clinical correlations the nyu internal medicine blog a daily dose of medicine
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Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine. http://clinicalcorrelations.org. Medical Grand Rounds Clinical Vignette October 8, 2008. Sabina Berezovskaya, M.D. Chief Complaint. - PowerPoint PPT PresentationTRANSCRIPT
Clinical Correlations The NYU Internal Medicine Blog
A Daily Dose of Medicine
http://clinicalcorrelations.org
Medical Grand RoundsClinical Vignette
October 8, 2008
Sabina Berezovskaya, M.D.
Chief Complaint
• 49 year old male presents with early satiety for three months and one day of red blood and clots mixed with stool one week prior to presentation.
History of Present Illness
• He was in his usual state of health until three months prior to admission when he began experiencing frequent early satiety and subjective weight loss.
• One week prior to presentation patient noted bright red blood per rectum with clots which spontaneously resolved after one day.
• One day prior to admission, he had routine labs drawn at his cardiology clinic appointment.
• He was recalled for admission when his hemoglobin returned significantly decreased from his baseline.
Further history• Past Medical History:
– GERD– Diabetes Mellitus Type II – Hypercholesterolemia– Hypertension – Coronary artery disease (CAD) with prior STEMI (10/07) requiring percutaneous stenting
of the RCA
• Past Surgical History: Denies
• Social History: – Prior history of alcohol abuse (20 beers per day). Last use 2 years ago– No tobacco or illicit drug use
• Family History: Non-contributory
• Medications: – Aspirin 81 mg daily– Clopidogrel 75mg daily– Metoprolol 50 mg twice a day– Lisinopril 20 mg daily– Simvastatin 40 mg daily– Metformin 1g twice a day– Pioglitazone 30 mg daily– Esomeprazole 40 mg daily
• Allergies: no known drug allergies
Physical Exam
• General : Well nourished and well developed male; in no acute distress
• Vital signs: T- 98º F BP: 99/75 HR: 62 RR: 18 O2 sat: 100% RA– Orthostatics were negative
• Abdomen: mildly tender at the right lower quadrant
• Rectal: no masses or tenderness; black guaiac + stool
The physical exam was otherwise entirely normal.
Laboratory Findings
• WBC: 7.7, normal differential• Hgb: 7.9 g/dl, MCV 65.6, RDW: 15.8
– Prior baseline hgb 13-14g/dl• Platelets: 384• Iron: 16 mcg/dL (nl: 42-146)• TIBC: 462 mcg/dL (nl: 250-450)• Ferritin: 4.8 ng/mL (nl: 22-322)
• Basic metabolic panel, liver function tests, amylase, lipase & coagulation profile were all within normal limits
Imaging
• Chest x-ray: no cardiopulmonary disease
• EKG: normal sinus rhythm with q waves in II,III, aVF; unchanged from prior baseline.
Working diagnosis
Lower Gastrointestinal Bleed
Colonoscopy
• A single sessile polyp measure 6mm in size was found in the hepatic flexure.
• The polyp was removed with a hot snare
• There was a friable non-obstructing circumferential tumor in the ascending colon immediately distal to the IC valve
Colonoscopy
Pathologic Diagnosis
Poorly Differentiated Invasive Carcinoma+ for Cytokeratin 20 and Neuron Specific
Enolase (NSE)
- for Cytokeratin 7, Synaptophysin or Chromographin
Clinical Staging Evaluation
• Abdomen & Pelvis CT:
Ascending colon tumor with multiple enlarged adjacent mesenteric lymph nodes
• Chest CT:
No evidence for intrathoracic metastatic disease
• CEA <0.5 (nl <=5)
Abdominal / Pelvic CT Scan
Hospital Course
• Patient was transfused with 1 Unit of packed red blood cells and started on Iron supplementation
• He remained hemodynamically stable and had no recurrent episodes of bleeding
• Patient was evaluated by surgical consult and a right hemicolectomy was scheduled
Final Diagnosis
Lower Gastrointestinal Bleed due to
Poorly Differentiated Adenocarcinoma of the ascending colon and the hepatic flexure