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NYU Medical Grand Rounds
Clinical Vignette
Francesca Montanari, MD
PGY 2
6/12/2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 75-year-old
man presenting with
generalized weakness.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Three weeks prior to admission, the patient
experienced progressive dysphagia and was
diagnosed with metastatic squamous cell
carcinoma of the tongue.
• Four days prior to admission, the patient
was in a motor vehicle accident and suffered
a left frontal subarachnoid hemorrhage.
• He was hospitalized for two days for
observation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• After discharge, he experienced
generalized weakness and recurrent falls at
home.
• His son took him back to the Emergency
Department.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
• Metastatic squamous carcinoma of the tongue extending to the left side of the neck and
involving the left carotid space
• Hypertension
•Past Surgical History:
• Cataract surgery
•Social History:
• 8 oz of Vodka daily (no history of alcohol withdrawal or seizures), not a smoker, denies
illicit drugs use
• Retired, lives with his son
•Family History:
• No family history of cancer
•Allergies:
• Penicillin (skin rash)
•Medications:
• Losartan/hydrochlorothiazide 100/25 mg by mouth once daily
• Aspirin 81 mg by mouth once daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• General: chronically ill-appearing, elderly man, in
no acute distress
• Vital Signs: T: 98.5, BP:135/70, HR: 79, RR:16,
Oxygen saturation: 99% in room air
• Neck: left posterior cervical adenopathy, hard,
non mobile, and firm mass at the left angle of the
jaw with no elevation of the jugular venous
pressure
• Remainder of physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• Complete Blood Count: within normal limits
• Basic Metabolic Panel:
• Blood Urea Nitrogen 37, Creatinine 1.5
• Remainder of the basic metabolic panel was
within normal limits
• Hepatic Panel:
• AST 98, ALT 18, total bilirubin 2.1
• Remainder of hepatic panel was within normal
limits
• Coagulation: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Electrocardiogram: Normal sinus rhythm
• Non-contrast head CT: Improved left
subarachnoidal hemorrhage and stable
bilateral frontal intraparenchymal
hemorrhages compared to 2 days prior
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Emergency Department Event
• In the Emergency Department while having an
IV placed, the patient was noted to be
bradycardic (HR 29) and hypotensive (BP
70/40), with no change in mental status.
• The heart rate and blood pressure returned to
baseline without any intervention approximately
20 minutes later.
• An electrocardiogram during the episode
showed a junctional escape rhythm at 29 beats
per minute.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working and Differential Diagnosis
• The transient episode of bradycardia and hypotension
associated with a noxious stimulus observed in the
Emergency Room was thought to be the likely cause of
the patient’s recurrent falls at home
• Differential diagnosis included:
– Vaso-vagal reflex
– Carotid hypersensitivity (tumor encasing the left
carotid body/space)
– New intraparenchymal cerebral hemorrhage
(although unlikely given CT scan findings)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient was admitted to the Intensive
Care Unit for monitoring with a temporary
transvenous pacemaker.
• He received a permanent pacemaker on
hospital day four.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The hypotensive and bradycardic events were
attributed to the extension of the squamous cell
carcinoma into the left carotid space.
• The patient remained asymptomatic but with
labile blood pressure.
• He was transferred to a regular floor bed with
the plan to start radiation treatment to palliate
the tumor.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Initially agreeable to the radiation plan, the
patient’s mental status deteriorated during
the hospital stay.
• He refused further interventions repeatedly
stating “there is no hope.”
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• A psychiatric evaluation was performed as
the patient appeared profoundly
depressed, disorganized, tangential, and
at times paranoid.
• The patient was found to lack capacity to
make medical decisions.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Discharge plan
• Given the side effects of the radiation
treatment, limited life-extending benefit
and patient’s previous beliefs, his son (his
health care proxy) decided to take the
patient home with hospice services,
without pursuing further treatment.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Diagnosis
• Carotid hypersensitivity secondary to
metastatic squamous cell carcinoma of the
tongue encasing the left carotid artery
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS