NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Luz E. Liriano-Ward, MD PGY3 January 3rd, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 75 year-old man complaining of two weeks of bloody stool.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient was in his usual state of good health, receiving intermittent care from several community-based providers. • He had never previously agreed to undergo screening colonoscopy.

4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Two weeks prior to admission, he noticed a small amount of blood on the toilet paper. • Five days prior to admission, he had an episode of fecal incontinence with a large bloody bowel movement with visible clots. He presented to an outside hospital, and was discharged after receiving IV fluids. • After discharge, he continued having bloody bowel movements for which he presented to the Manhattan VA for evaluation

5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Benign Prostatic Hyperplasia • Glaucoma • Osteoarthritis of the knees • Post operative DVT • Peripheral Neuropathy • Osteoporosis and severe kyphosis • Past Surgical History: • Prostatectomy 1995 • Internal Fixation of L1 transverse vertebral fracture 2003 • Social History: • Denies smoking, alcohol, or drug use

6. Additional History • Family History: Denies any history of colorectal cancer • Allergies:No known drug allergies • Medications: • Alendronate 70mg weekly • Calcium Carbonate 1.25 g three times daily • Cholecalciferol 200 unit daily • Amlodipine 2.5mg daily • Dorzolamide/timolol eye drops twice daily • Travoprost eye drops at bedtime • Review of systems: Negative

7. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: well developed, well nourished elderly man in no acute distress • Vital Signs: T:96.8 BP:128/84 HR:97 RR:16 O2 sat:99% room air, +orthostatic vital signs • Heart: regular rate and rhythm, II/VI systolic murmur in the right upper sternal border • Skin: anicteric, dry • Rectum: brown stool with small amount of red blood. No hemorrhoids • Remainder of Physical Exam was normal

8. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: Hemoglogin 12.1, hematocrit 36.8, mean cosposcular volume 93.5 • Remainder of CBC was within normal limits • Basic Metabolic panel: BUN 34, creatinine 1.2 • Remainder of basic was within normal limits • Hepatic panel was within normal limits

9. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: Normal sinus rhythm with first degree AV block • Chest X-Ray: normal

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Colorectal cancer • Diverticulosis • Arterial-venous malformation • Internal hemorrhoids

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • The patient received IV fluids with improvement in orthostasis, and on hospital day 3, underwent a colonoscopy which revealed a large, fungating partially obstructing mass in the distal rectum and small-medium diverticuli throughout the colon without bleeding. • The pathology revealed a well differentiated colonic adenocarcinoma with K-ras mutation

12. Hospital Course • An evaluation for metastatic disease including CT Chest/Abdomen/Pelvis revealed multiple sub-centimeter hepatic lesions, and several bilateral pulmonary nodules up to 1.6cm. • Palliative Care and Oncology were consulted

13. Hospital Course • Chemotherapy was initiated on hospital day 9 with 5-folinic acid, fluorouracil and oxaliplatin (FOLFOX) • On hospital day 13, the patient received one dose of filgrastim and was discharged home. • He would return in 10 days for his second cycle of FOLFOX.

14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Stage IV rectal cancer with metastases to the lung and liver