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Initial Presentation. A 52-year-old Caucasian female was admitted to the hospital 2 days ago with complaints of unexplained weakness and fatigue. She also reported irregular menstrual periods and weight loss of 10 lbs over the past 6 months. Hx. Medical history:

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Initial presentation

Initial Presentation

  • A 52-year-old Caucasian female was admitted to the hospital 2 days ago with complaints of unexplained weakness and fatigue. She also reported irregular menstrual periods and weight loss of 10 lbs over the past 6 months.


Initial presentation

Hx

Medical history:

  • Patient reported chronic constipation and hemorrhoids, mild dyspnea on exertion, and chronic arthritis in her knees and hands.

  • Normal mammogram 8 months ago; has had no screening colonoscopy or sigmoidoscopy.

  • Currently taking diuretics, furosemide, ibuprofen, and oral contraceptives (10 years).


Hx cont d

Hx Cont’d

Family History:

  • Mother (83 year-old) has type 2 diabetes since the age of 35.

  • Father died at age 60 due to acute myocardial infarction.

  • Brother is alive at age 61 with hypertension.


Hx cont d1

Hx Cont’d

Social history:

  • Owner and manager of interior design firm

  • Divorced with 2 grown children

  • Lives alone

  • Non-smoker; rarely drinks alcohol

  • Avid tennis player


Physical examination

Physical examination

  • BMI: 15

  • BP: 132/86 mmHg

  • HR: 84 beats/minute

  • RR: 22 breaths/minute

  • Temperature: 37 °C


More examination

More Examination

  • Karnofskyperformance status was 90%

  • No palpable adenopathy

  • Lungs were clear to ausculation

  • Normal cardiac examination

  • No hepatosplenomegaly

  • Normal rectal examination

  • Abdomen was soft w/o distention or tenderness

  • Normal bowel sounds


Initial presentation

DDx

  • What test should we order?

  • What organs should we check for?


Blood test

Blood test

  • WBC: 5200 cells/mm3

  • Hgb: 7.5 g/dL

  • Hematocrit: 26%

  • Reticulocyte: 1.5%

  • Creatinine: 1.1 mg/dL

  • Total bilirubin 0.9 µmol/dL

  • Blood urea nitrogen 15 mg/dL

  • Glucose 124 mg/dL

  • Sodium 134 mEq/L

  • Potassium 4 mEq/L

  • Magnesium 1.8 mEq/L

  • Total calcium 9.2 mg/dL

  • Serum ferritin: 8 ng/mL


Initial presentation

By now, what can we conclude about the diagnosis of the patient?

What other tests can indicate the underlying cause of this problem?


Guaiac stool test

Guaiac Stool Test

  • Results indicate a positive guaiac stool test

  • What does this indicate?


More examination1

More examination

  • Colonoscopy

  • Exploratory surgery

  • CT scan

  • MRI

  • PET Scan

  • Xray


Results

Results

Results of colonoscopy and CT scan revealed:

  • Proximal ascending colon, mass, biopsy: poorly differentiated invasive adenocarcinoma with ulceration

  • Transverse colon, biopsy: tubular adenoma


Diagnosis

Diagnosis

???


Treatment

Treatment

  • Surgery?

  • Iron supplement

  • Erythropoietic therapy

  • chemotherapy


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