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NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint • 49 year old man with progressive dysphagia, chest pain, and weight loss of 25 pounds for two months UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness •Difficulty eating solid food for six months, then progressed to difficulty swallowing liquid for the last two months •Lost 25 pounds in the last year •Ranitidine and omeprazole did not relieve symptoms •Severe odynophagia for the last month prompted presentation to the ED UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Past Medical History: •Psoriasis •Past Surgical History: •Tonsillectomy •Social History: •Former one pack daily smoker for thirty years, quit six months ago •Former heavy alcohol use, quit six months ago •Family History: •Father: deceased, kidney cancer, age unknown •Allergies: •No known drug allergies •Medications: •Clobetasol over affected area twice weekly •Omeprazole and ranitidine as needed UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination •General: Young well developed man in mild discomfort •Vital Signs: T: 98 BP: 127/64 HR: 89 RR: 16 and O2 sat: 97% on room air •Oral mucosa slightly dry •Mild temporal wasting •Mild tenderness to sternal palpation •Remainder of physical exam was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings •CBC: hemoglobin 11.9 g/dL •Remainder of CBC was within normal limits •Basic Metabolic panel: Sodium 134, Calcium 11.9 • Remainder of basic was within normal limits •Hepatic panel: within normal limits •Parathyroid hormone: <3 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies •Chest X-Ray: Masslike soft tissue density in the subcarina with proximal esophageal dilatation UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies •Chest CT: 6.7cmx5.2cx.10cm Large obstructing mid esophageal mass, involvement of the wall of the aorta can not be entirely excluded. Enlarged right paraesophageal lymph node. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Esophageal neoplasm UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: – Esophagogastroduodenoscopy was performed – Patient was placed on NPO and standing fluid for hypercalcemia – IV morphine standing and as needed for pain – Codeine as needed for cough UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2-7: – Palliative care was consulted for pain control, goals of care, social support in face of potential new diagnosis of cancer – Standing morphine was gradually transitioned to fentanyl patch with morphine prn for break through • Hospital Day 7: – Pathology results returned as Invasive squamous cell carcinoma, moderately differentiated – Family meeting with medicine team, palliative care, and oncology team UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 8: – Esophageal stent placement – Patient discussed at oncology and GI tumor board with surgical and radiation oncology • Hospital Day 11 – Patient discharged on fentanyl patch, oral morphine as needed, tolerating soft solid food – Plan to start chemotherapy followed by chemoradiation after discharge UNITED STATES DEPARTMENT OF VETERANS AFFAIRS