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NYU Medical Grand Rounds Clinical Vignette. Pavan Bhatraju MD, PGY-II June 19, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. 72 year old male who presented with dyspnea on exertion and fatigue for the last 3 weeks. U NITED S TATES

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nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Pavan Bhatraju MD, PGY-II

June 19, 2012

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

chief complaint

Chief Complaint

  • 72 year old male who presented with dyspnea on exertion and fatigue for the last 3 weeks.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

history of present illness

History of Present Illness

  • Prior to this presentation he had not seen a doctor for the last 5 years.
  • He first noticed his symptoms of dyspnea on exertion and shortness of breath 3 weeks prior and the symptoms have continued to progress.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

additional history

Additional History

  • Past Medical History:
    • DM
    • HTN
    • Stage II CKD
  • Social History:
    • 40 pack tobacco smoking history, no alcohol
  • Family History:
    • No family history of cancer
  • Allergies:
    • None
  • Medications:
    • Aspirin 81 mg daily
    • Glyburide 2.5 mg daily
    • Lisinopril 40 mg daily
    • Simvastatin 10 mg at night

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • General: thin adult male, lethargic
  • Vital Signs:
    • T:38.6 BP:130/90 HR:90 RR:12
  • HEENT – pale conjunctivae, dry mucous membranes
  • Remainder of Physical Exam was Normal.
laboratory findings

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • CBC:
    • Hemoglobin – 8.5 g/dL,
      • Mean corpuscular volume 76 fl.
      • Red blood cell distribution width 16.5%
    • Remainder of CBC was within normal limits
  • Basic Metabolic panel
    • BUN 45 mg/dL, - Creatinine 1.8 mg/dL
    • Remainder of BMP was within normal limits
  • Hepatic Panel:
    • Within normal limits
slide7

Working Diagnosis

  • Iron-Deficiency Anemia
    • Gastrointestinal
    • Dietary

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide8

Outpatient Course

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Patient was referred to gastroenterology for a diagnostic colonoscopy.
outpatient course

Outpatient Course

  • Colonoscopy biopsies were positive for adenocarcinoma. Kras mutation positive.
  • CT scan of the abdomen and pelvis with IV and oral contrast
    • Cecal mass with mesenteric lymphadenopathy and hepatic metastases

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide10

Outpatient Course

Immediately after diagnosis the patient was started on palliative chemotherapy with FOLFOX

    • Leucovorin Calcium
    • Fluorouracil
    • Oxaliplatin
  • After 4 cycles of chemotherapy with FOLFOX the patient had a repeat CT scan of the abdomen that showed disease progression.

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

slide11

Disease Course

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Chemotherapy was changed to FOLFIRI with bevacizumab:
    • Leucovorin Calcium
    • Flurouracil
    • Irinotectan Hydrochloride
    • Bevacizumab
  • After 5 doses of chemotherapy, a repeat CT scan of the abdomen showed further progression of disease.
  • Chemotherapy was changed to FFG
    • Leucovorin Calcium
    • Flurouracil
    • Gemcitabine
slide12

Disease Course

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

After 2 cycles of FFG the patient was admitted to the medical intensive care unit with neutropenic sepsis.

He died 8 months after diagnosis.

slide13

Final Diagnosis

  • Metastatic Adenocarcinoma of the Colon

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS