lsu internal medicine case conference may 1 st , 2012
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Courtney Austin, MDPGY-4
LSU Internal Medicine & Pediatrics
LSU Internal Medicine Case ConferenceMay 1st, 2012
“Abdominal Pain for 2 Weeks”
Chief Complaint
46 year-old man with significant past medical history of TB (treated in prison with RIPE x 6 months) and GSW (abdomen and RLE >10 years ago) presents to the ED with complaints of nausea and abdominal pain for two weeks.
The patient describes the pain as sharp, stabbing, radiating to the back, and associated with mild nausea but no vomiting. He also states that there are no identified alleviating factors for his pain.
He also complains of early satiety for the past two weeks, with a 15 pound weight loss over the past month.
HPI
The patient denies any change in stool consistency, hematochezia, melena, or diarrhea, but does note that his bowel movements are less frequent since the onset of his poor appetite.
He was evaluated for these complaints at Ocshner Main Campus two weeks prior to his presentation, and he was prescribed a course of ciprofloxacin and metronidazole for a presumed diagnosis of gastroenteritis versus small bowel ileus.
HPI
Past Medical History:Tuberculosis, diagnosed in 2005, treated with
6 months of RIPE therapy
Surgical History:RLE Fasciotomy 2/2 GSW in 2000Exploratory Laparatomy, 2000
Family History:Maternal Grandmother with Colon Cancer
(still living post-resection)-- initially diagnosed in her 60s
Past History
Meds:Recent completion of 10-day course of
ciprofloxacin and metronidazoleDenies NSAIDs, Aspirin, and Tylenol use
Allergies:NKDA
Past History
Social History:Smokes marijuana cigarettes dailyDenies tobacco abuseDrinks 1-2 6 packs of regular beer per week, no
h/o DTsDenies any IV drug abuseHas several homemade tattoos from prisonSexually active with women, last HIV test two
years ago that patient self-reports as negativeHistory of incarceration for one year from 2004
to 2005Unemployed
Past History
Health Maintenance:Colonoscopy Not UTDInfluenza, Pneumovax Never
ReceivedTDaP UTD (2006)PCP None
Past History
Endorses: 15 Pound Weight Loss
Denies: Fever, Chills, Meningismus, Dysphagia, EpistaxisChest Pain, Dyspnea, Diaphoresis, Orthopnea, PND,
SyncopeCough, Wheezes, HemoptysisVomiting, Dysphagia, Diarrhea, Constipation,
Melena, BRBPR, Decreased Stool CaliberDysuria, Hematuria, Urinary Urgency, Flank Pain,
Penile Discharge/LesionsEasy bruising/bleeding , Recent URI/GI IllnessAnesthesia, Paresis, Paralysis, Dysarthria, Ataxia;
additional Paresthesia & Altered Sensory PerceptionDenies Recent Travel, Sick Contacts
ROS
Vital Signs & Physical Exam
Temp 97.9OF Pulse 70 RR 16BP 106/76 Pulse Ox 100% on RA BMI 21.3Weight 70 kgHeight 180 cm
Vital Signs
General:AAOx3, NAD, thin male
HEENT: NCAT, PERRLA, EOMI, Oropharynx clear, no
erythema or exudateNeck:
No LAD, no thyromegalyCardiovascular:
Regular rate & rhythm, no murmurs/rubs/gallops
Physical Exam I
Pulmonary: CTA Bilaterally, no wheezes/rhonchi/crackles
Abdomen: Decreased bowel sounds; diffusely TTP
through all four quadrants; no HSM, no masses
Extremity: 2+ peripheral pulses, no edema, no axillary
or inguinal lymphadenopathy Rectal:
Good tone, no masses, brown stool, Hemoccult® (-)
Physical Exam II
Neurologic: Motor: 5/5 upper and lower extremity, 2+
DTRsCN: PERRLA, EOMI, symmetrical facial
expression, no dysarthria, uvula midline, tongue protrusion midline, normal sensation
Sensory: intact light touch, pain, and proprioception in upper & lower extremities
Cerebellar: Intact heel to shin bilaterally, normal diadochokinesia, no tremor, no dysmetria
Normal plantar reflex bilaterally
Physical Exam III
Laboratory DataDay of Admission
Admit Laboratory Data IWBC 10.3Hgb 14.3Hct 43.9PLT 221MCV 84.3RDW 14.5
Segs70%Lymphs 16%Monos 9%
Admit Laboratory Data IINa 141K 3.7Cl 110Bicarbonate 23BUN 22Creatinine 1.08GFR >60Glucose 109
Ca++ 8.9Mg++ 1.9Phos3
Admit Laboratory Data IIITotal Protein 6.4 Total Bilirubin 1.2 Albumin 3.9 AST 17 ALT 12 Alkaline Phosphatase 49
INR 1.2Amylase 48Lipase 18
Admit Laboratory Data IVU/A
Color PaleSG 1.029pH 6.5Protein NegBlood NegUrobilinogen 1.0Ketones 15Leukocytes 25
MicroWBC 0-
2Bacteria 0-2 Squam Epi 2-
20
Admission KUB
Chest X-Ray and KUBDay of Admission
Hospital Day 1
Bowel Rest, NPO with IV FluidsHeld IV AntibioticsSymptomatic care with Nexium, Colace
Initial Management
Hepatitis Panel NegativeHIV NegativeUrine Culture NegativeUrine GC/Chlamydia Negative
Additional Laboratory Data
Unable to tolerate liquide dietAttempts to improve nutrition were made with
a nasogastric tube, which worsened the patient’s nausea and vomiting.
Repeat abdominal imagining performed 4 days after admission, prompting an interventional radiology and GI consult.
Hospital Course: Day #4
Abdominal CT with Contrast
Hospital Day #6EGD and flexible sigmoidoscopy were done to
evaluate the patient’s diffuse stomach thickening that was seen on abdominal imaging.
EGD/Colonoscopy Report
Esophagitis with slightly irregular Z-lineNodular-appearing body of the stomach
Multiple biopsies takenFindings appear consistent with gastric
Crohn’s versus infiltrative gastropathy
Pathology from EGD
Invasive adenocarcinoma, diffuse type. Chronic active gastritis and intestinal metaplasia.
Stage IV Gastric Adenocarcinoma
Final Diagnosis
On HD #10, the patient received his diagnosis, and hematology and oncology were consulted to evaluate the patient.
Due to the mainstay of life-saving therapy being surgical resection, surgical oncology was consulted and the patient was discussed at the ILH tumor board.
Careful review of the patient’s imaging with radiology revealed likely carcinomatosis from metastatic disease that spread from his stomach to the celiac plexus and head of the pancreas.
After Diagnosis
Surgery to stage the cancer was tentatively planned; however, the patient decided against a surgical staging procedure since it would not palliate his symptoms, and the surgeons were unlikely to perform a successful resection of the cancer.
After another two days in the hospital, the patient went home with hospice.
After Diagnosis
Home HospiceOncology Clinic
Discharge Follow-Up
1. Stage IV Gastric Adenocarcinoma2. Malnutrition3. Chronic Nausea
Discharge Diagnoses
Thanks For Your Attention!
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