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NYU Medical Grand Rounds Clinical Vignette

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

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  1. NYU Medical Grand Rounds Clinical Vignette Pavan Bhatraju MD, PGY-II June 19, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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

  7. Working Diagnosis • Iron-Deficiency Anemia • Gastrointestinal • Dietary UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  8. Outpatient Course UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Patient was referred to gastroenterology for a diagnostic colonoscopy.

  9. 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

  10. 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

  11. 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

  12. 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.

  13. Final Diagnosis • Metastatic Adenocarcinoma of the Colon UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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