Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Pavan Bhatraju MD, PGY-II
June 19, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
• 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
•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
•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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Iron-Deficiency Anemia
– Gastrointestinal
– Dietary
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
• Patient was referred to gastroenterology for a diagnostic
colonoscopy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
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
Disease Course
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Disease Course
• After 2 cycles of FFG the patient was
admitted to the medical intensive care unit
with neutropenic sepsis.
• He died 8 months after diagnosis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Metastatic Adenocarcinoma of the Colon
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS