Transcript Journal Club

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