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NYU Medical Grand Rounds
Clinical Vignette
Luz E. Liriano-Ward, MD
PGY3
January 3rd, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 75 year-old man complaining of two weeks
of bloody stool.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
Physical Examination
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•ECG: Normal sinus rhythm with first degree
AV block
•Chest X-Ray: normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
•
•
•
•
Colorectal cancer
Diverticulosis
Arterial-venous malformation
Internal hemorrhoids
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• An evaluation for metastatic disease including CT
Chest/Abdomen/Pelvis revealed multiple subcentimeter hepatic lesions, and several bilateral
pulmonary nodules up to 1.6cm.
• Palliative Care and Oncology were consulted
Hospital Course
• Chemotherapy was initiated on hospital day 9 with 5folinic 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.
Final Diagnosis
• Stage IV rectal cancer with metastases to
the lung and liver
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS