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NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF...

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NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
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Page 1: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

NYU Medicine Grand Rounds Clinical Vignette

Cindy Fang

PGY2

5/28/2014

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 2: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

• 49 year old man with progressive dysphagia, chest pain, and weight loss of 25 pounds for two months

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 3: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

•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

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 4: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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

Page 5: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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

Page 6: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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

Page 7: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

Other Studies

•Chest X-Ray: Mass-like soft tissue density in the subcarina with proximal esophageal dilatation

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 8: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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

Page 9: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

• Esophageal neoplasm

Working or Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 10: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 11: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Page 12: NYU Medicine Grand Rounds Clinical Vignette Cindy Fang PGY2 5/28/2014 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

• 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

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS


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