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Case 2

Case 2. Salient features. General Data. Mr. L 70/M Jehovah’s witness. High risk for certain cancers Transfusion issues. Chief Complaint. Abdominal pain of 9 months duration. History of Present Illness. 9 months PTC. Vague epigastric pain unrelated to food intake

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Case 2

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  1. Case 2

  2. Salient features

  3. General Data • Mr. L • 70/M • Jehovah’s witness • High risk for certain cancers • Transfusion issues

  4. Chief Complaint • Abdominal pain of 9 months duration

  5. History of Present Illness 9 months PTC • Vague epigastric pain unrelated to food intake • VAS 3-5/10 (moderate pain) • No triggering factors • Disappears spontaneously • Occuring once a week • No consult • Moderate visceral pain • R/O cholelithiasis/ choledocholithiasis

  6. History of Present Illness 3 months PTC • Undocumented weight loss • Decrease in appetite but able to eat the same amount of food • Increased frequency of abdominal pain, 2-3x/wk, same VAS score • Prompted consult resulting to a diagnosis of Gastric ulcer • Esomeprazole (40mg 1x/day), no relief • Consider another diagnosis

  7. History of Present Illness 2 months PTC • Persistence of symptoms • Steatorrhea • Continued esomeprazole, to 2x/day, 1 month • Domperidone10mg 3x/day, 1 month • Laboratory results • FBS: seemed high • Stool: positive fat • Urine: WBC 8-9 per high power field • Unremarkable abdominal ultrasound • Questionable indication for both medications, esomeprazole and domperidone.  • One FBS result is not enough to diagnose DM (repeat test on another day to confirm).  • To r/o pancreatic disorder • Start low go slow: initial dosage is supposed to be 2.5-5mg PO QD then titrate later on  • At risk for sever hypoglycemia • Caution in patients with infection • Interaction with ofloxacin

  8. History of Present Illness 6 Weeks PTC • Diagnosed with DM • Glibenclamide, 5mg, BID • Metformin, 500mg, TID • Diagnosed with UTI • Given ofloxacin 400mg BIDx 5 days • Vivid and horrifying nightmares upon start of antibiotic intake • Became restless and disoriented • Repeat urinalysis showed PC 0-1 • Antibiotics discontinued ultrasound • Advised low fat diet • Metformin should be BID and then titrate later on. The patient should have started with monotherapy before 2 drugs.  • For ofloxacin, this can be given to the elderly patient with a starting dose of 200 mg (lowest dose possible). 

  9. History of Present Illness • Due to significant weight loss, consider malignancy.  • Wt loss continued (10-15 kg) in 3 months • Oily stools continued • Daily abdominal pain despite medication

  10. Review of Systems • Jaundice • Blurring of vision • Difficulty hearing • Easy fatigability less than 20 m • Palpitations • Prolonged urination • Sleep disturbances: initiating and maintaining • Work up for eye disorders • Work up for sensorineural or conductive hearing defects • Work up for anemia and cardiac problems • Work up for depression • Work up for BPH

  11. Past Medical History • BP 150/80 (Type 1 hypertension) • Vasectomy • Multivitamins and Calcium Carbonate • No allergies or vices  • Interaction with medications • Complicated surgical procedure • Poor health seeking behavior • Work up for osteoporosis and osteopenia • Osteoporosis – contraindicated for surgical procedures • At risk for hypercalcemia due to calcium carbonate

  12. Social History • Sea farer • Children working over seas • Living with wife and youngest daughter • Occupation at risk for STD’s (denied) • Exposure to chemicals and oil • Screen for HepB and HIV • May lack social support

  13. Physical Examination: Positive

  14. Physical Examination: Negative

  15. Laboratory and imaging findings

  16. Laboratory Findings

  17. Laboratory Findings

  18. Laboratory Findings

  19. Imaging Findings

  20. Differential Diagnoses

  21. Malignancy (i.e. Liver Cancer) • Weight loss, BMI 16.67, continued to lose weight 10-15 kilograms in the past 3 months • Anorexia • Epigastric pain • Jaundice and/or pallor; slight icterisa • Pale conjunctivae or anemia • Steatorrhea • Shows side effects of drug intoxication which are excreted through liver • Possible Hepatitis B from sexual contact (sea farer occupation) • Abnormal LFTs, bilirubin, KFTs • No palpable neck nodes or CLAD • No palpable mass in the abdominal area • No history of hepatitis • No history of alcohol abuse • No history of drug abuse • Denied sexual contact • No fever • No chills • No malaise • No arthralgia • No maculopapular or urticarial skin rash • No vomiting • No RUQ pain • No palmarerythema • No signs of portal hypertension • No ascites • Imaging results

  22. Pancreatitis • Epigastric pain • Intermitted attacks of severe pain • May occur with or without taking of meals • Weight loss • Patients with severe disease may present with fatty stools or steatorrhea • Often radiates inabandlike fashion or localized to the midback • Patient is not alcoholic

  23. Cholelithiasis/Cholecystitis • Tenderness • Anorexia • Jaundice • Holoabdominal ultrasound cannot totally rule out liver parenchymal disease • Common bile duct is dilated • Epigastric pain unrelated to food intake • No fever

  24. Giardiasis • Fatty stools or steatorrhea • Reactive arthritis, enlarged DIP and PIP of both hands • Anorexia • Diarrhea • Abnormal LFTs, KFTs, electrolytes • Acute diarrhea • More common in children. • Imaging

  25. Cardiomegaly/CHF or possible valvular disease • (+) Grade 3/6 systolic murmur at the apex radiating to the precordium • Normal ECG and 2D-echo

  26. Primary clinical impression

  27. Complete Diagnosis • Type II diabetes secondary to pancreatic tumor with biliary duct obstruction, to consider pancreatic malignancy, to rule out liver disease. • Hypertension (Stage I) with Atherosclerosis to consider aortic sclerosis Osteoarthritis • Benign prostatic hyperplasia • Post-vasectomy

  28. Prognosis

  29. Prognosis for Pancreatic Cancer • Clinical course of pancreatic cancer is very rapid. • The patient is classified in the locally advanced stage already since the tumor has already grown into nearby arteries and nearby organs, though no evidence of distant spread in the body were seen. • Mean survival is 6-10 months  for patients with locally advanced disease and 3-6 months for those with metastatic disease.

  30. Prognosis for Pancreatic Cancer • Surgery is also the only curative treatment, with outcome related to tumor stage. • Unresected: the mean survival for patients is 4-6 months, with a 5-year survival rate of less than 3%. • Resected: survival rate is approximately 12-19 months, with a 5-year survival rate of 15-20%.

  31. Prognosis for Diabetes Mellitus • Diabetes has been theorized to be both a risk factor for and a consequence of pancreatic cancer. • The study of Wang, Gupta and Holly found that recent-onset diabetes, but not diabetes of more than or equal to10-years duration, was associated with increased risk for pancreatic cancer.

  32. Prognosis for Diabetes Mellitus • However, according to a study conducted by Olowukureet al., patients with stage I-IV pancreatic cancer with associated diabetes mellitus had significantly higher median survival. • Diabetes has been implicated in development of optic, renal, neuropathic and cardiovascular diseases.

  33. Prognosis for Hypertension • Organs that are affected are the brain (intracerebral hemorrhage, encephalopathy, thrombotic stroke and infarcts), cardiovascular system (congestive heart failure, angina pectoris, myocardial infarction), eyes (retinopathy), kidneys (renal artery stenosis). • 30% increase in the risk of having atherosclerosis and a 50% increase in the risk of having organ damage in the span of 8-10 years.

  34. Prognosis for Atherosclerosis • Prognosis systems affected, the vascular beds involved and the degree of flow limitation. • Complications: myocardial infarction, peripheral arterial occlusive disease, coronary artery disease and cerebrovascular disease.

  35. Prognosis for Osteoarthritis • Disease progression is typically slow occurring several years. • Pain is the principal morbidity in OA. This may cause the patient to become less active thereby causing morbidities due to weight gain. • disability is correlated with impairment of joints essential for activities of daily living

  36. IMPORTANT • Give the patient and his family an estimate of how long he has left • Be truthful about the graveness of the situation and avoid giving false hope

  37. End of Life Care

  38. Best option: Palliative Care • Will help ease any physical pain from the disease • Should be focused on: • Making the patient comfortable • Making sure he receives all the medications and treatment to control pain and the other associated symptoms brought about by condition

  39. Palliative Care • Patient should also decide whether he wants to live out the rest of his days in the hospital or at home • Hospital – health care professionals always available to monitor and attend to any complications, but it may be a financial burden • Home – constant emotional support from family members but may be a delay in treatment of arising complications

  40. Caregiver Briefing • Proper briefing about signs that indicate worsening of the patient’s condition • Should be able to understand patient’s situation • Should be able to cope and get help from others to prevent burnout

  41. The Family • Refer family to a psychologist or cancer support groups to help the family deal with emotional aspect of losing their loved one • Family meetings are necessary and become even more important as the cancer progresses • Health care team can explain goals for care and let the family state their wishes for care • Serve as an open forum • Clarify caregiver tasks • Plan the next steps in intervention

  42. Preparing for Death • Advanced directives • Legal papers • Funeral wishes • Living arrangements • Counselling for unresolved issues among members (Individual sessions for children) and to allow them to share their feelings and emotions

  43. Thank you~!

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