Case StudyAivi Phung

EOR 5

May 5, 2016

Identifying Data

• Patient ID:

• Name: Mr. Patient

• Age: 48 years old

• Race: White

• Sex: Male

• MRN: 112233

• Date(s) Seen: Feb 2016-March 2016

CC & HPI

• CC: Worsening abdominal pain and distention x 2 months.

• HPI: The patient is a 48-year-old Caucasian male with no significant past medical history, who notes he was well up until approximately 2 months ago when he began to notice increasing abdominal distention. He says it became worse approximately 1-2 weeks ago. He was seen by GI a week ago and had an upper endoscopy and colonoscopy. He says biopsies were taken and were normal. GI advised him that he was just “very gassy” and needs to try passing gas. His complaints persisted so he elected to come to Urgent Care for symptom relief. He states that he feels constipated and his last bowel movement was 4 days ago with a very small loose stool. He feels nauseous and has a hard time keeping food down. He states his pain is constant and non-radiating at a level of 6-7/10 and is worsened by eating, but improved with burping and with flatulence. Pain is described as aching and dull. Denies blood or mucous in emesis or stool. Denies fevers, chills or sweats.

Patient Records

• Pathology Report

History

• PMHx: No significant past medical history. Pt denies any history of inflammatory bowel disease.

• PSHx: Notable for tonsillectomy at age 7. Pt denies any history of any abdominal surgeries.

• FMHx: Father had hypertension. No other significant family history.

• SHx: He smokes ¾ PPD of tobacco. Occasional alcohol. No drugs. He is divorced and works as a card dealer at the casino.

• Allergies: No known drug allergies. No known allergies.

• Medications: Patient denies taking any medications.

• Immunizations: Up to date.

ROS

• Const: Thin Caucasian male

• Eye: No eye pain, no visual changes, no

discharge

• HENT: No ear pain, no sore throat, no nasal

discharge

• GI: Abdominal pain, nausea, vomiting,

constipation, bloating, no skin changes

• GU: No hematuria, no painful urination, no

polyuria

• Musc: No back pain, no neck pain, no leg pain

• Integ: No rash, no itching, no pruritus

• Resp: No tachypnea, SOB

• Cardiac: No palpitations, no chest pain, no leg

edema

• Psych: No anxiety, no depression

• Endo: No weight loss, no polyuria

• Heme: No painful lymph nodes, no bruising,

no bleeding

• Neuro: No weakness, no numbness, no

tingling

Physical Exam

• Objective

• Vital Signs: Ht: 72’’, Wt: 210 lbs., Temp: 98.2°F tympanic, P: 86, RR: 24, BP: 132/78, Sp02: 97% RA (adequate), Pain: 7/10

• Gen: Alert, middle-aged man in no acute distress.

• Skin: Appears to be well hydrated, no rashes in his trunk or extremities. No evidence of cyanosis, clubbing, or jaundice. Normal skin coloration. No visible masses or lesions noted.

• HEENT: Normocephalic and atraumatic. Sclera is white, conjunctiva clear, pupils are equal, round and reactive to light. Mucous membranes are moist. The neck is supple without any evidence of thyromegaly or lymphadenopathy. No JVD.

• Resp: Thorax is symmetric. No use of accessary muscles of respiration. The lungs are resonant with vesicular breath sounds and clear to auscultation bilaterally. No rales, wheezes, or ronchi.

Physical Exam (cont’d)

• CV: He has good S1, S2, no S3 or S4. Heart rate and rhythm are regular with no murmurs, rubs or clicks.

• GI: The abdomen is firm, protuberant, distended, with hypoactive bowel sounds. Diffuse tenderness to palpation in all quadrants. He has no organomegaly. No masses. No rebound or guarding. No skin changes or rashes.

• GU: External genitalia normal male, no testicular/scrotal/epididymal masses or TTP, no inguinal bulging.

• Extremities: Without cyanosis, clubbing or edema.

• Neurologic: Grossly nonfocal.

Diagnostic Studies

• CBC w/diff

• CMP

• PT-INR/PTT

• ESR/CRP

• Abdominal and Pelvic CT w/contrast

Diagnostic Studies

• CBC w/diff – WNL

• CMP – WNL

• PT-INR/PTT – WNL

• ESR/CRP – mildly elevated

• Abdominal and Pelvic CT – 1. Small bowel obstruction with heterogenouscongestion of omentum 2. mild ascites 3. neoplasm cannot be completely discounted 4. observed changes could be seen with severe infectious and/or inflammatory changes

Differential Dx/Assessment

• 1.

• Small bowel obstruction

• r/o Neoplasm of colon

• r/o Inflammatory bowel disease

• 2.

• Ascites

Treatment/Plan

• Admit to Med/Surg

• NPO status

• IV Dilaudid and Zofran

• Surgical consult for exploratory laparotomy and biopsy of omentum for

definitive diagnosis

Follow-Up

• Procedure: Exlap with loop ileostomy.

• Surgical findings consistent with diffuse abdominal carcinomatosis. Frozen section came

back as adenocarcinoma.

Follow-Up

• Post-operatively, patient became septic and underwent acute respiratory failure/PE.

• Patient was intubated for 2 days.

• Successfully extubated and transferred to MedSurg.

• GI performed EGD, bx negative for H.Pylori. No safe window found for PEG placement. Pt is not a candidate for G tube placement.

• Unable to take food orally and will be discharged on TPN.

Follow-Up

• Long discussion with the pt, his family & case management regarding poor

prognosis & treatment options. Given estimate of ~3 month life expectancy.

• Pt feels he is not ready for hospice care but would like to be discharged

home with home health.

• PCA pump has been ordered and pt will be discharged on Fentanyl patches

until pump is delivered. Pt will also be discharged home on IV Pepcid, Lasix,

Zofran and Ativan.

Discharge Diagnoses

• SBO

• Ascites

• Abdominal carcinomatosis

• Wound dehiscence

• Pulmonary embolism

• Acute respiratory failure

• Sinus Tachycardia

• Shock

• Protein calorie malnutrition

• 33-lb weight loss in 30 days

• AKI

• Ileus

• Omental Metastasis

• Encounter for palliative care

Carcinomatosis

• A condition in which multiple carcinomas form simultaneously, typically after

dissemination from a primary source.

• Almost always implies that there is spread to regional nodes and even more

than is seen in just metastatic disease.

• Term is usually taken to mean that there are multiple secondary malignancies

in multiple sites.

Carcinomatosis

• Peritoneal carcinomatosis is spread of metastases into the peritoneum,

usually from colorectal and ovarian cancers.

• Can present as progression of known disease, recurrence of known disease,

or may be the primary presenting feature.

• Usually no realistic hope of curative therapy, although chemotherapy and

radiotherapy may have a palliative effect.

References

• Sadeghi, B., Arvieux, C., Glehen, O., Beaujard, A. C., Rivoire, M., Baulieux, J.,

... & Porcheron, J. (2000). Peritoneal carcinomatosis from non‐gynecologic

malignancies. Cancer, 88(2), 358-363.

• Chu, D. Z., Lang, N. P., Thompson, C., Osteen, P. K., & Westbrook, K. C.

(1989). Peritioneal carcinomatosis in nongynecologic malignancy. A

prospective study of prognostic factors. Cancer, 63(2), 364-367.