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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 2months 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 • Dismal • Very high mortality rate

  30. 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

  31. End of Life Care

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. Thank you~!

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