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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Benjamin Wu, MD PGY-2 May 15, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Benjamin Wu, MD PGY-2 May 15, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint • The patient is a 61 year-old woman, presents to an outside physician complaining of black colored stools for 1 week and dyspnea on minimal exertion. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  3. History of Present Illness • The patient had chronic, watery diarrhea related to past history of gastric bypass in the 1970s. • Patient reportedly with colonoscopy 5 years prior to admission with a “few” polyps with unknown biopsy results • 1 week prior to admission, had bilateral ureteral stents placed for nephrolithiasis, and at that time started on iron supplementation. Hemoglobin was noted to be 8g/dl • Since that admission, complained of dyspnea with slight exertion, and blackish stools, presented to PMD where a work up found a hemoglobin of 6g/dl • Referred to Tisch hospital for further evaluation UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  4. Additional History • Past Medical History: • Chronic Obstructive Pulmonary Disease • Chronic Watery Diarrhea • Past Surgical History: • Gastric Bypass Surgery in the 1970s • Social History: • Ex-tobacco smoker, 40 pack year smoker • quit 1 year ago • Denies alcohol use • No recent travel • Works as a pet driver • Family History: • Father had a MI • Mother with history of breast cancer UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  5. Additional History • Allergies: • Penicillin – rash • Medications • Ferrous Sulfate 325mg by mouth daily • Lomotil by mouth daily • Pancrease 2 tabs by mouth three times daily • Metronidazole 500mg by mouth three times daily UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  6. Physical Examination • General: Well appearing, well nourished female in no acute distress • Vital Signs: T: 97F BP: 156/64 HR: 108 RR: 20 and O2 sat: 98% on room air • Pale conjunctiva, tachycardia, regular rhythm, without m/r/g, no gum bleeding, no blood from rectal vault. Positive fecal occult blood. • The rest of the exam was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  7. Laboratory Findings • CBC: • Hemoglobin 5.7mg/dL MCV 82.7, Reticulocytes 8.6% • WBC 13.3 (N77%, L18%, M3%, E1%, B1%) • Basic Metabolic: Creatinine 1.7mg/dl • Hepatic: Albumin 3.4g/dl and Total protein 6.1g/dl • Ferritin 13ng/ml (12-150ng/ml) • Iron 17ug/dl (50-170ug/dl) • TIBC 522ug/dl (250-370ug/dl) • Transferrin Sat 3% (15-50%) • UA +large blood, protein 30, +small leukocyte esterase, moderate bacteria UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  8. Other Studies • ECG: NSR • Chest X-Ray: Clear, without consolidation, no pneumothorax or pleural effusion UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Differential Diagnosis • Acute gastrointestinal hemorrhage secondary to possible: • Colorectal cancer • Peptic ulcer disease • Infectious or ischemic colitis • Mesenteric ischemia UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  10. Hospital Course • Transfused blood products and remained hemodynamically stable without further evidence of hemorrhage. • CT Abdomen/Pelvis without contrasted significant for bilateral staghorn calculi, no evidence of retroperitoneal bleed UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  11. Hospital Course • Colonoscopy revealed “frond-like, villous, fungating, ulcerated non-obstructing medium-sized mass in the mid-ascending colon, and two smaller lesions in the proximal transverse colon and cecum.” UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  12. Hospital Course • CT of Abdomen/Pelvis and Chest with IV contrast performed after resolution of acute kidney injury: • hepatic flexure mass with adjacent lymph nodes. No evidence of metastatic disease. • 1 month after admission patient underwent right hemicolectomy which revealed a 2.5cm x 2.2 cm lesion with 3/15 positive lymph nodes UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  13. Final Diagnosis • Adenocarcinoma of colon, moderately differentiated with focal mucin production • Stage III UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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