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LSU Internal Medicine Case ConferenceMay 1st 2012Courtney Austin MDLSU Internal Medicine Pediatrics Chief Complaint.
Abdominal Pain for 2 Weeks 46 year old man with significant past medicalhistory of TB treated in prison with RIPE x 6months and GSW abdomen and RLE 10 yearsago presents to the ED with complaints of.
nausea and abdominal pain for two weeks The patient describes the pain as sharp stabbing radiating to the back and associated with mildnausea but no vomiting He also states that thereare no identified alleviating factors for his pain .
He also complains of early satiety for the past twoweeks with a 15 pound weight loss over the past The patient denies any change in stoolconsistency hematochezia melena ordiarrhea but does note that his bowel.
movements are less frequent since theonset of his poor appetite He was evaluated for these complaints atOcshner Main Campus two weeks prior tohis presentation and he was prescribed a.
course of ciprofloxacin and metronidazolefor a presumed diagnosis of gastroenteritisversus small bowel ileus Past History Past Medical History .
Tuberculosis diagnosed in 2005 treated with6 months of RIPE therapy Surgical History RLE Fasciotomy 2 2 GSW in 2000 Exploratory Laparatomy 2000.
Family History Maternal Grandmother with Colon Cancer still living post resection initially diagnosedin her 60s Past History.
Recent completion of 10 day course ofciprofloxacin and metronidazole Denies NSAIDs Aspirin and Tylenol use Allergies Past History.
Social History Smokes marijuana cigarettes daily Denies tobacco abuse Drinks 1 2 6 packs of regular beer per week no Denies any IV drug abuse.
Has several homemade tattoos from prison Sexually active with women last HIV test twoyears ago that patient self reports as negative History of incarceration for one year from 2004 Unemployed.
Past History Health Maintenance Colonoscopy Not UTD Influenza Pneumovax Never Received TDaP UTD 2006 .
PCP None Endorses 15 Pound Weight Loss Denies Fever Chills Meningismus Dysphagia Epistaxis.
Chest Pain Dyspnea Diaphoresis Orthopnea PND Cough Wheezes Hemoptysis Vomiting Dysphagia Diarrhea Constipation Melena BRBPR Decreased Stool Caliber Dysuria Hematuria Urinary Urgency Flank Pain .
Penile Discharge Lesions Easy bruising bleeding Recent URI GI Illness Anesthesia Paresis Paralysis Dysarthria Ataxia additional Paresthesia Altered Sensory Perception Denies Recent Travel Sick Contacts.
Vital Signs Physical Vital Signs Temp 97 9OF Pulse 70 BP 106 76.
Pulse Ox 100 on RA BMI 21 3 Weight 70 kg Height 180 cm Physical Exam I.
General AAOx3 NAD thin male NCAT PERRLA EOMI Oropharynx clear noerythema or exudate No LAD no thyromegaly.
Cardiovascular Regular rate rhythm nomurmurs rubs gallops Physical Exam II Pulmonary .
CTA Bilaterally no wheezes rhonchi crackles Abdomen Decreased bowel sounds diffusely TTPthrough all four quadrants no HSM no Extremity .
2 peripheral pulses no edema no axillaryor inguinal lymphadenopathy Rectal Good tone no masses brown stool Hemoccult .
Physical Exam III Neurologic Motor 5 5 upper and lower extremity 2 CN PERRLA EOMI symmetrical facialexpression no dysarthria uvula midline .
tongue protrusion midline normal sensation Sensory intact light touch pain andproprioception in upper lower extremities Cerebellar Intact heel to shin bilaterally normal diadochokinesia no tremor no.
Normal plantar reflex bilaterally Laboratory DataDay of Admission Admit Laboratory Data I WBC 10 3 Segs70 .
Hgb 14 3 Lymphs 16 Hct 43 9 Monos 9 PLT 221 MCV 84 3 RDW 14 5.
Admit Laboratory Data II Na 141 Ca 8 9 K 3 7 Mg 1 9 Cl 110 Phos3 Bicarbonate 23.
Creatinine 1 08 GFR 60 Glucose 109 Admit Laboratory Data III Total Protein 6 4.
Total Bilirubin 1 2 Albumin 3 9 Alkaline Phosphatase 49 INR 1 2 Amylase 48.
Lipase 18 Admit Laboratory Data IV U A Micro Color Pale WBC 0 2 SG 1 029 Bacteria 0 2.
pH 6 5 Squam Epi 2 20 Protein Neg Blood Neg Urobilinogen 1 0 Ketones 15.
Leukocytes 25 Admission KUB Chest X Ray and KUBDay of Admission Hospital Day 1.
Initial Management Bowel Rest NPO with IV Fluids Held IV Antibiotics Symptomatic care with Nexium Colace Additional Laboratory Data.
Hepatitis Panel Negative HIV Negative Urine Culture Negative Urine GC Chlamydia Negative Hospital Course Day 4.
Unable to tolerate liquide diet Attempts to improve nutrition were made witha nasogastric tube which worsened thepatient s nausea and vomiting Repeat abdominal imagining performed 4.
days after admission prompting aninterventional radiology and GI consult Abdominal CT with Hospital Day 6 EGD and flexible sigmoidoscopy were done to.
evaluate the patient s diffuse stomachthickening that was seen on abdominal EGD Colonoscopy Report Esophagitis with slightly irregular Z line Nodular appearing body of the stomach.
Multiple biopsies taken Findings appear consistent with gastricCrohn s versus infiltrative gastropathy Pathology from EGD Invasive adenocarcinoma diffuse type .
Chronic active gastritis and intestinalmetaplasia Final DiagnosisStage IV Gastric Adenocarcinoma After Diagnosis.
On HD 10 the patient received hisdiagnosis and hematology and oncology wereconsulted to evaluate the patient Due to the mainstay of life saving therapybeing surgical resection surgical oncology.
was consulted and the patient was discussedat the ILH tumor board Careful review of the patient s imaging withradiology revealed likely carcinomatosis frommetastatic disease that spread from his.
stomach to the celiac plexus and head of the After Diagnosis Surgery to stage the cancer was tentativelyplanned however the patient decided againsta surgical staging procedure since it would.
not palliate his symptoms and the surgeonswere unlikely to perform a successfulresection of the cancer After another two days in the hospital thepatient went home with hospice .
Discharge Follow Up Home Hospice Oncology Clinic Discharge Diagnoses1 Stage IV Gastric Adenocarcinoma.
2 Malnutrition3 Chronic Nausea Thanks For YourAttention .
Courtney Austin, MD. PGY-4. LSU Internal Medicine & Pediatrics. LSU Internal Medicine Case ConferenceMay 1st, 2012

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