Morning Report. With Miller and Dr. Polite. MKSAP.
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The primary anatomic location of metastatic colon cancer is the liver. Between 20% and 30% of patients with metastatic disease following curative surgery will have isolated hepatic metastases.
Morphine SR 15mg BID
Aranesp causes flushing
PhD candidate of philosophy, married with three children.
No TOB, EtOH, or Illicits
First cousin and two second cousins died of breast ca < 40 yo.
Metastatic Breast Ca
-T2N2Mx ER/PR +, HER-2 –
2000 dx’d with infiltrating ductal carcinoma
11/2000 modified radical mastectomy with adjuvant chemo-XRT.
2003-2009 she had recurrence to disease involving bilateral ribs, thoracic spine, lumbar spine, marrow involvement, liver, and lung. She received multiple chemo regimens at an OSH during this time.
Her last chemo regimens included bevacizumab and abraxane, followed by Doxorubicin 3 weeks prior to admission.
H/o neutropenia in 1/08
R/O mimmickers of Sz, most commonly Syncope, Pseudoseizure, alcoholic blackouts, hypoglycemia, migraines, TIA’s narcolepsiy.
Trauma or intracranial abnormality
Tumor or Metastasis with or without bleed.
Getting bonked in the head
Stroke (hemorrhagic, large size, or cortical involvement)
Intracerebral hemorrhage, subarachnoid hemorrhage, subdural hematoma, hypertensive encephalopathy, global hypoxic damage, cerebral vascular dz
hypoglc, nonketotic hyperglc, hypoNa, hypoCa, Uremia, hepatic encephalopathy, thyroid dysregulation
Meningitis, encephalitis, abscess
Etoh withdrawal, illicit drug use
(local anesthetics, meperidine, tramadol [Ultram])
Antibiotics (e.g., beta-lactam antibiotics, isoniazid [INH; Nydrazid], quinolones, some HAART meds)
Immunomodulators (e.g., cyclosporine, interferons, tacrolimus,)
Psychotropics (e.g., antidepressants, lithium, stimulants)
Vented, moving air well throughout
No rebound or gaurding
Grossly normal upper and lower extremity strength
+ gag, PERRLA
No passive neck stiffness.
Upper and Lower extremities with 2+ reflexes, Bilaterally downward babinsky. Nl Rectal tone.
VitalsT 36.9, BP 101/40, HR 80, RR12, O2 satting 98% on AC
Intubated and unresponsive
Optic disc sharp bilaterally, PERRL, no nystagmus or preferential gaze.
No cervical, supraclavicular, axillary, or cervical LAD
RRR, without murmurs, rubs, nl S1 S2, warm and well perfused with no JVD, no LE edema
139 105 25
4.2 22 0.9
8.9 MCV 108
N 86 L6 M8
+ Left Shift
CK – 198
3cm mass in the left frontotemporal junction, 5 x 2.3 cm mass in the posterior lateral left frontal parietal junction, multiple 1-2 cm lesions in the frontal lobes, diffuse edema in the Left temporal lobe, mild edema in the right temporal lobe, posterior left frontal lobe. No midline shift or herniation. Mild para-nasal sinus disease. MRI suggested
The cortical sucli ventricles cisterns are prominent for patients stated age, and c/w cerebral and cerebellar atrophy. Edema in left temporal lone and R parietal lobe, most c/w metastases.
Dural metastases along the left temporal bone w surrounding edema and multiple lesions in the inner left frontal bone with hyperdensity c/w hemorrhage vs calcification. No midline shift or herniation.
Spinal portion: Diffuse bony metastatic disease involving the entire spine vertebral columns, sacral ala, and iliac wings. There is no evidence of intra-spinal metastasis.
New onset seizure or seizure within past week
Altered mental status
Focal neuro findings
h/o CNS dz
Finding of elevated ICP (papilledema)
Opening pressure was not performed
Decadron, and Dilantin had been initiated by the OSH.
Treatment for bacterial meningitis with Vanc, high dose Ceftriaxone (2g) is initiated based on CSF pleocytosis.
Diff Quik Stained x 1, Cytospin Slide - Papanicolaou Stained x 1
Meningitis 2/2 malignant infiltration from SOLID TUMOR progression (as apposed to leukemic or lymphomatous meningitis)
1) Hematogenous spread via arachnoid vessels
2) Metastasis to the choroid plexus and from there into the CSF
3) Direct extension from brain parenchyma, or from vertebral, subdural, epidural metastases
4) Retrograde neural invasion (peripheral or cranial nerves)
5) rarely, tumors arise within meninges
6) Post-surgical resection of a brain tumor
(highly specific but sensitivity is 40% with 1st LP, 80% with 2nd)
LP findings (opening pressure >20cmH2O), Leukocytes>4/mm3, elevated protein >50mg/dl, glc <60 mg/dl, tumor antigens
MRI with gadolinium is preferred to look for enhancement/any meningeal irritation and characterize CNS lesions. (cranial and spinal)
Radionuclide studies to evaluate CSF flow
1)Decrease bulky disease
(intra-CNS chemo only penetrates 2-3mm into tumors)
2)Correct CSF flow abnormalities
(shown to improve patient outcome)
3)Palliation of symptoms
(i.e. cauda equina syndrome, Cranial neuropathies)
24 hrs post indium-111 administration, good flow was seen throughout the ventricles
(LP does not guarantee drug delivery)
Know indications for imaging prior to tap
Know how to diagnose Carcinomatous meningitis and when to suspect it
Know importance of diagnosis of carcinomatous meningitis
Indications for XRT in the setting of carcinomatous meningitiss
Be familiar with Ommaya delivery system