Transcript Physical Examination

GS II PRECEPTORIAL
DR. MANUEL ROXAS
FEBRUARY 29, 2012
REYES | RIVERA A | RIVERA K | RIVERA M | ROGELIO
SAGAYAGA | SEE | SIY | SANTIAGO | SOTALBO
Patient History
General Data
 EC, 49/M, from Pasay
 CC: weight loss
History of present illnesses
 3 months PTA
 (+) weight loss
 (+) bowel movement changes
 BMs would happen immediately following food intake.
 (+) black stools
 (-) hematochezia
 (+) episodes of watery stools.
 1 episode of vomiting
 yellow-green in color, containing partially digested food
 (-) fever, dyspnea, easy fatigability and weakness
 Patient was apparently well enough to work.
History of present illnesses
 2 month PTA
 Bowel movement changes persisted
 Noted loss of appetite
 2 weeks PTA, patient had vague RLQ pain
 “kumikirot”
 VAS 2/10
 Intermittent, not associated with food intake
 non-tender
 no medications taken
History of present illnesses
 Weight loss was quantified to be around 10 kg at
this time.
 Patient recalls passage of goat dung-like stool,
light brown in color.
 Persistence of symptoms prompted consult
History of Present Illness
 Pt was told that he might have an infection.
 The physician palpated an RLQ mass.
 Ultrasound: no significant findings
 CT findings revealed signs of fatty liver, and a
colonic mass on the ascending segment, no
hepatic nodules or retroperitoneal
lymphadenopathies
 Patient was referred to PGH Ward 4 for
immediate admission. He was admitted on
February 19, 2012.
Course in the Wards
 Scheduled for operation, but deferred due to
pneumonia
 1 week ago
 He presented with afternoon fever of 38oC, 4
day duration.
 Given antibiotics and advised to wait for 1 week
until the infection resolves before the operation
Review of Systems
 (-) dizziness, palpitations
 (+) cough, productive of whitish to yellowish sputum
 (-) colds, chest pain, dyspnea
 (-) dysuria, nocturia, polyuria, increased frequency of





urination
(-) hematemesis or coffee-ground vomitus
(+) goat dung-like stool
(-) constipation
(-) joint pains
(-) pallor, jaundice
Past and Family Medical History
 PMH:
 (-) DM, HPN, TB, BA, allergies, thyroid
disease, blood disorders
 FMH:
 (+) father reported similar RLQ pain, and died
of unknown cause
 (-) DM, HPN, TB, CA, BA, allergies, thyroid
disease, blood disorders
Personal Social History
 Roman Catholic, married, with 3 kids
 Finished 2 years of high school
 Works as maintenance personnel at a golf course
 37 pack-year smoker
 Hard alcoholic beverage drinker, thrice a week
 No illicit drug use
 1 promiscuous sexual partner
 Diet:
 fond of fatty foods like chicharon, and likes isaw, atay ng baboy,
grilled meat
 eats 1-2 cups of rice per meal, with vegetables and fish
Physical Examination
Physical Examination
 Awake, ambulatory, conversant, not in cardiorespiratory distress
VITAL SIGNS
 BP: 125/80 HR: 80
Ht: 157.5
BMI:19
RR: 18 Temp 36.2
Weight: 48
HEAD AND NECK
 (-) skin lesions, (-) acanthosis nigricans
 Pink palpebral conjunctivae, anicteric sclerae, 4mm pupils both
briskly reactive to light
 (-) anterior neck mass, (-) tonsillopharyngeal congestion,
 (-) cervical lymphadenopathy, (-) supraclavicular lymph nodes
 (-) carotid bruits
Physical Examination
CHEST AND LUNGS
 Equal chest expansion
 (+) 4x2 cm hypertrophic scar dissecting left nipple
 (+) 1x1 cm doughy non-tender carbuncle located on the
midline of the dorsal lower thoracic portion
 (+) right basal crackles, (-) rales/ ronchi/ wheezes
 (+) decreased vocal fremiti on right lower lung field
 Equal on tactile fremitus
 (-) chest shifting dullness for pleural effusion
Physical Examination
CARDIOVASCULAR SYSTEM
 Adynamic precordium
 Normal rate, regular rhythm, (-) murmurs
 (-) heaves / thrills
 good S1 and S2, PMI at 5th intercostals space left mid
clavicular line
Physical Examination
ABDOMEN
 Flat and lean abdomen
 (-) visible organomegaly, (-) caput medusae, (-) enlarged
vessels, (-) skin lesions
 (+) hyperactive bowel sounds
 (-) abdominal bruits
 (+) right lower quadrant tenderness on light palpation
 (-) rebound tenderness
 (-) palpable masses
Physical Examination
ABDOMEN
 7 cm liver span percussed along the right anterior
axillary line
 (-) CV angle tenderness
 (-) fluid wave test
 (+) Succusion splash test – patient just ate a slice of
water melon and a drank a glass of water <10 minutes
ago
Physical Examination
DIGITAL RECTAL EXAMINATION
 Prostate is not enlarged, doughy and non-tender
 Intact empty rectal vault
 (-) palpable polyps, (-) intraluminal masses
 (-) blood per examining finger
Physical Examination
EXTREMETIES:
 (+) multiple hypertrophic and hypotrophic scars scattered along
both legs of the patient
 Pink nailbeds, (-) cyanosis, (-) jaundice, (-) clubbing,
 Full equal pulses, (-) edema
 Normal GALS
NEUROLOGIC EXAM
 Intact cranial nerves
 (-) sensory deficits for pain, temperature, vibratory and light
touch
 MMT 5/5 on all extremities
 DTR +2 on all extremities
Primary Working Impression
GI pathology, probably malignant
Plan: Diagnostics
Workup
 Colonoscopy/flexible sigmoidoscopy, barium





enema
Contrast CT of chest, abdomen and pelvis
Histopathology of lesion
CBC, platelets, chemistry profile
CEA
For pneumonia:
 Chest x-ray
 Microbiologic studies (blood culture and gram stain)
Endoscopy
 Without major comorbidity
 Colonoscopy – high sensitivity and specificity
 With major comorbidity
 Flexible sigmoidoscopy then barium enema
 Alternative: CT colonography
 Suspicious lesion → biopsy
*unless CI (e.g. bleeding disorder)
Endoscopy
Incomplete colonoscopy:
 Inadequate bowel preparation
 Poor tolerance of the procedure
 Intra-operator variation in completion rate
 Obstructing lesion in the distal colon
If patient had incomplete colonoscopy:
 Repeat colonoscopy or
 CT colonography or
 Barium enema
Histopathology
 Malignant polyp – invades through muscularis mucosae
and into submucosa
 Pathological stage parameters:
 Grade of cancer
 Depth of penetration
 Number of lymph nodes evaluated and number
positive
 Status of proximal, distal and radial margins
 Lymphovascular invasion
 Perineural invasion
 Extranodal tumor deposits
Staging
 Contrast-enhanced CT of the chest, abdomen and
pelvis
 No further routine imaging recommended (NICE
2011)
RESULTS OF DIAGNOSTIC WORKUP
Urinalysis (2/20/12)
color
Specific gravity
Transparency
pH
Protein
Sugar
Epithelial cells
Bacteria
Mucus threads
Casts
Crystals
Bilirubun
Urobilinogen
Ketones
Leukocytes
Nitrites
Hemoglobin
Light yellow
1.015
Clear
6.5
Negative
Negative
Negative
Rare
Negative
Negative
Negative
Negative
Normal
Negative
Negative
Negative
Negative
Blood chemistry, electrolytes
(2/20/12)
TEST
RESULT
NORMAL VALUE
Glucose
4.92
4.1-5.4
BUN
4.30
2.9-9.3
Creatinine
61
57-113
Albumin
28 (LOW)
35-48
Sodium
139
136-144
Potassium
4.5
3.6-5.1
Chloride
101
101-111
Blood AB culture (2/20/12)
No growth after two days of incubation
Sputum microbiology (2/27/12)
PMNs
>25
Squamous epithelial cells
<25/LPF
Gram (-) diplococci
None
Yeast cells (hyphal elements)
3-5/OIF
Gram (+) cocci in pairs
10-15/OIF
Gram (+) cocci in chains
None
Gram (-) bacilli
5-10/OIF
Gram (+) bacilli
5-10/OIF
Complete blood count (2/27/12)
TEST
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Platelet
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
RESULT
13.9 (HIGH)
4.26
123
0.376
88.2
29.0
328
14.6
491 (HIGH)
0.640
0.164
0.120
0.074
0.003
NORMAL VALUE
5-10
4-6
120-170
0.38-0.48
80-100
27-31
320-360
10-16
150-450
0.50-0.70
0.2-0.5
0.02-0.09
0.01-0.04
0.02-0.05
12-Lead ECG (2/20/12)
Regular sinus rhythm, normal axis within normal
limits
Other labs to request
 Chest x-ray
 Contrast-enhanced CT of the chest, abdomen,
and pelvis
 Histopathology
Assessment
Ascending Colon Mass, probably
malignant
Plan: Therapeutics
Goals of Management
 Achieve total cure
 Prevent recurrence
 Early detection of recurrence
Stage I and Stage II Colorectal Cancer
 Surgical resection
 Adjuvant Chemotherapy may be needed
 Radiotherapy has no role in treatment
 If stage II and obstructing, stents can be used
prior to colectomy
Surgical Resection
 Remove primary tumor and lymphovascular
supply
 At least 12 lymph nodes should be included to
establish N stage
 Partial vs Total Colectomy
Colectomies
 Ileocolic
 Left
 Right
 Extended Left
 Extended right
 Sigmoid
 Transverse
 Total and subtotal
Right hemicolectomy
 For curative intent
 Proximal colon carcinoma
 Included vessels: ileocolic, right colic, right
branches of middle colic
 Anastomosis: Primary ileal – transverse colon
Adjuvant Therapy
Adjuvant Therapy
 46% of patients with resected stage II tumors will
die of colon CA hence the need for adjuvant
chemotherapy
 However, benefit of adjuvant chemotherapy does
not improve survival by more than 5%
Adjuvant Therapy
Regimen
 FOLFOX
Notes
 Oxaliplatin
 85 mg/m2 over 2 hours, day
1
 Leucovorin
 400 mg/m2 IV over 2 hrs,
day 1
 5-FU
 400 mg/m2 bolus on day 1
 1200 mg/m2/day for 2 days,
continuous infusion
 Repeated every 2 weeks
Adjuvant Therapy
Regimen
 FLOX
Notes
 Leucovorin
 500 mg/m2 IV weekly x 6
 Each 8 week cycle x 3
 5-FU
 500 mg/m2 IV bolus weekly
x6
 Each 8 week cycle x 3
 Oxaliplatin
 85 mg/m2 IV
 On weeks 1, 3 and 5 of each
8 week cycle x 3
Adjuvant Therapy
Regimen
Notes
 CapeOx
 Capecitabine
 1000 mg/m2 twice
daily, days 1-14 every 3
wks for 24 wks
 Oxaliplatin
 130 mg/m2 over 2
hours, day 1
Adjuvant Therapy
Regimen
Notes
 Clinical Trial
 Bevacizumab
 Cetuximab
 Panitumumab
 Irinotecan
Surveillance
Procedure
Frequency
 Follow-up (History &
 First 2 years
PE)
 Every 3 to 6 mos
 Thereafter ‘till 5 years
 Every 6 mo
Surveillance
Procedure
Frequency
 CEA
 First 2 years
 Every 3 to 6 mos
 Thereafter ‘till 5 years
 Every 6 mos
Surveillance
Procedure
Frequency
 Chest / abdominal /
 5 years
pelvic CT
 annually
Surveillance
Procedure
Frequency
 Colonoscopy
 In 1 year
 If no pre-op colonoscopy due
to an obstructing lesion
 In 3 to 6 mos
 If advanced adenoma
 Repeat in 1 yr
 If no advanced adenoma
 Repeat in 3 years
 Then every 5 years
Surveillance
Procedure
Frequency
 PET-CT scan
 NOT routinely
recommended
Prognosis
Stage
I
II
III
IV
5-yr survival
70-95
54-65
39-60
0-16
Function post-surgery
 Generally excellent
 Frequency or diarrhea is not expected