LSU Internal Medicine amp Pediatrics LSU Internal Medicine Case Conference May 1 st 2012 Abdominal Pain for 2 Weeks Chief Complaint 46 yearold man with significant past medical history of TB treated in prison with RIPE x 6 months and GSW abdomen and RLE gt10 years ago prese ID: 931199
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Slide1
Courtney Austin, MDPGY-4LSU Internal Medicine & Pediatrics
LSU Internal Medicine Case Conference
May 1
st
,
2012
Slide2“Abdominal Pain for 2 Weeks”Chief Complaint
Slide346 year-old man with significant past medical history of TB (treated in prison with RIPE x 6 months) and GSW (abdomen and RLE >10 years ago) presents to the ED with complaints of nausea and abdominal pain for two weeks.The patient describes the pain as sharp, stabbing, radiating to the back, and associated with mild nausea but no vomiting. He also states that there are no identified alleviating factors for his pain.
He also complains of early satiety for the past two weeks, with a 15 pound weight loss over the past month.
HPI
Slide4The patient denies any change in stool consistency, hematochezia, melena, or diarrhea, but does note that his bowel movements are less frequent since the onset of his poor appetite.He was evaluated for these complaints at Ocshner Main Campus two weeks prior to his presentation, and he was prescribed a course of ciprofloxacin and metronidazole for a presumed diagnosis of gastroenteritis versus small bowel ileus.
HPI
Slide5Past Medical History:Tuberculosis, diagnosed in 2005, treated with 6 months of RIPE therapy
Surgical History:
RLE
Fasciotomy
2/2 GSW in 2000
Exploratory
Laparatomy
, 2000
Family History:Maternal Grandmother with Colon Cancer (still living post-resection)-- initially diagnosed in her 60s
Past History
Slide6Meds:Recent completion of 10-day course of ciprofloxacin and metronidazoleDenies NSAIDs, Aspirin, and Tylenol useAllergies:
NKDA
Past History
Slide7Social History:Smokes marijuana cigarettes dailyDenies tobacco abuseDrinks 1-2 6 packs of regular beer per week, no h/o DTsDenies any IV drug abuseHas several homemade tattoos from prison
Sexually active with women, last HIV test two years ago that patient self-reports as negative
History of incarceration for one year from 2004 to 2005
Unemployed
Past History
Slide8Health Maintenance:Colonoscopy Not UTDInfluenza, Pneumovax Never ReceivedTDaP
UTD (
2006
)
PCP None
Past History
Slide9Endorses: 15 Pound Weight LossDenies: Fever, Chills,
Meningismus
,
Dysphagia
,
Epistaxis
Chest Pain,
Dyspnea
, Diaphoresis, Orthopnea, PND, SyncopeCough, Wheezes, HemoptysisVomiting, Dysphagia, Diarrhea, Constipation, Melena, BRBPR, Decreased Stool CaliberDysuria, Hematuria
, Urinary Urgency, Flank Pain, Penile Discharge/Lesions
Easy bruising/bleeding , Recent URI/GI Illness
Anesthesia, Paresis, Paralysis,
Dysarthria
, Ataxia; additional
Paresthesia
& Altered Sensory Perception
Denies Recent Travel, Sick Contacts
ROS
Slide10Vital Signs & Physical Exam
Slide11Temp 97.9OF Pulse
70
RR
16
BP
106/76
Pulse Ox
100% on RA BMI 21.3Weight 70 kgHeight 180 cm
Vital Signs
Slide12General:AAOx3, NAD, thin male
HEENT:
NCAT, PERRLA, EOMI,
Oropharynx
clear, no
erythema
or
exudate
Neck: No LAD, no thyromegalyCardiovascular: Regular rate & rhythm, no murmurs/rubs/gallopsPhysical Exam I
Slide13Pulmonary: CTA Bilaterally, no wheezes/rhonchi/cracklesAbdomen: Decreased
bowel
sounds; diffusely TTP through all four quadrants
;
no HSM, no masses
Extremity:
2
+ peripheral pulses, no edema, no
axillary or inguinal lymphadenopathy Rectal:Good tone, no masses, brown stool, Hemoccult® (-)Physical Exam II
Slide14Neurologic: Motor: 5/5 upper and lower extremity,
2
+ DTRs
CN: PERRLA, EOMI, symmetrical facial expression, no
dysarthria
, uvula midline, tongue protrusion midline, normal sensation
Sensory: intact light touch, pain, and
proprioception
in upper & lower extremitiesCerebellar: Intact heel to shin bilaterally, normal diadochokinesia, no tremor, no dysmetriaNormal plantar reflex bilaterallyPhysical Exam III
Slide15Laboratory DataDay of Admission
Slide16Admit Laboratory Data IWBC 10.3
Hgb
14.3
Hct
43.9PLT 221 MCV 84.3RDW 14.5
Segs
70
%
Lymphs
16
%Monos 9
%
Slide17Admit Laboratory Data IINa 141
K
3.7
Cl
110
Bicarbonate 23 BUN 22 Creatinine 1.08
GFR
>60
Glucose
109
Ca
++
8.9
Mg
++
1.9
Phos
3
Slide18Admit Laboratory Data IIITotal Protein
6.4
Total
Bilirubin
1.2
Albumin 3.9 AST 17 ALT 12
Alkaline
Phosphatase
49
INR
1.2Amylase 48
Lipase
18
Slide19Admit Laboratory Data IVU/AColor
Pale
SG
1.029
pH
6.5
Protein NegBlood Neg Urobilinogen
1.0
Ketones
15
Leukocytes
25
Micro
WBC
0-2
Bacteria
0-2
Squam
Epi
2-20
Slide20Admission KUB
Slide21Chest X-Ray and KUBDay of Admission
Slide22Hospital Day 1
Slide23Bowel Rest, NPO with IV FluidsHeld IV AntibioticsSymptomatic care with Nexium, ColaceInitial Management
Slide24Hepatitis Panel NegativeHIV NegativeUrine Culture NegativeUrine GC/Chlamydia Negative
Additional Laboratory Data
Slide25Unable to tolerate liquide dietAttempts to improve nutrition were made with a nasogastric tube, which worsened the patient’s nausea and vomiting.Repeat abdominal imagining performed 4 days after admission, prompting an interventional radiology and GI consult.
Hospital Course: Day #4
Slide26Abdominal CT with Contrast
Slide27Slide28Slide29Slide30Slide31Slide32Slide33Hospital Day #6EGD and flexible sigmoidoscopy were done to evaluate the patient’s diffuse stomach thickening that was seen on abdominal imaging.
Slide34EGD/Colonoscopy Report
Slide35Esophagitis with slightly irregular Z-lineNodular-appearing body of the stomachMultiple biopsies takenFindings appear consistent with gastric Crohn’s versus infiltrative gastropathy
Slide36Pathology from EGD
Slide37Slide38Slide39Slide40Slide41Invasive adenocarcinoma, diffuse type. Chronic active gastritis and intestinal metaplasia.
Slide42Stage IV Gastric AdenocarcinomaFinal Diagnosis
Slide43On HD #10, the patient received his diagnosis, and hematology and oncology were consulted to evaluate the patient.Due to the mainstay of life-saving therapy being surgical resection, surgical oncology was consulted and the patient was discussed at the ILH tumor board.Careful review of the patient’s imaging with radiology revealed likely carcinomatosis from metastatic disease that spread from his stomach to the celiac plexus and head of the pancreas.
After Diagnosis
Slide44Surgery to stage the cancer was tentatively planned; however, the patient decided against a surgical staging procedure since it would not palliate his symptoms, and the surgeons were unlikely to perform a successful resection of the cancer. After another two days in the hospital, the patient went home with hospice.After Diagnosis
Slide45Home HospiceOncology ClinicDischarge Follow-Up
Slide46Stage IV Gastric AdenocarcinomaMalnutrition
Chronic Nausea
Discharge Diagnoses
Slide47Thanks For Your Attention!