NYU Medical Grand Rounds Clinical Vignette

Pavan Bhatraju MD, PGY-II

June 19, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 72 year old male who presented with dyspnea on exertion and fatigue for the last 3 weeks.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

History of Present Illness

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

• Iron-Deficiency Anemia– Gastrointestinal – Dietary

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient was referred to gastroenterology for a diagnostic colonoscopy.

Outpatient Course

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

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.

Outpatient 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

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.

Disease Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Metastatic Adenocarcinoma of the Colon

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS