Genitourinary Pathology Case 7
Part 1
A 59 year old previously
healthy man presented to the emergency department with abdominal pain which
began several hours earlier. The pain began in the lower quadrants and
intensified throughout the day. He denied hematochezia,
melena, or change in bowel habits. An
abdominal CT scan showed free air, inflammation near the cecum, a right renal
cyst and a left renal mass.
1. What is your
differential diagnosis?
Part 2
The patient was taken to the
operating room where he was found to have a cecal mass with perforation. He
underwent a right colectomy and ileostomy. Pathologic evaluation of the tissue
revealed an adenocarcinoma of the colon.
Microscopic section of the colon at medium
power
2. Is it likely
that the renal mass is associated with the colon cancer?
Part 3
The renal mass was
considered to be highly suspicious for renal cell carcinoma. Since it was peripherally located the
surgeons felt it could be resected with a partial nephrectomy. After adequate healing of the colectomy wound
the patient underwent a left partial nephrectomy.
Review the surgical
pathology specimen:
Partial nephrectomy specimen bisected through
the tumor
Low power microscopic view of the tumor with
cystic structures
Medium power view of the renal tumor
High power view of the cystic areas of the
tumor
Medium power view of the more solid area of
the tumor
High power view of the solid area of tumor
This is another case of a total nephrectomy
for the same type of tumor; in this case there was hemorrhage into the tumor.
1. What is your
diagnosis?
2. How was your
diagnosis made?
3. Why might a
patient with RCC have erythrocytosis or anemia?
Part 4
Using all of the information you
have gathered from the chart, prepare a presentation about this case as you
would for attending rounds with a concise summary of the history, physical
findings, labs and x-rays. Your presentation should be about 5 minutes long. A
copy of your presentation needs to be handed in to your facilitator by the end
of the lab on
Incorporate the following basic
questions/answers/points into your report:
- What are the different types of renal cell
carcinoma?
- What are treatment options for renal cell
carcinoma?
- What is the prognosis for clear cell RCC?
- What are the paraneoplastic endocrine syndromes
associated with RCC?
Anatomic Pathology Reports
Admission H&P
CC: Abdominal pain
HPI: The patient is a 59 year old previously healthy male who
began having abdominal pain around
PMH: meningitis 30 years ago
PSH: none
Medications: none
Allergies: NKDA
FH: HTN – father, stroke – mother
SH: no tobacco, no ETOH
ROS: no fever/chills, no CP, no SOB, no vomiting, minimal nausea,
no melena, no hematochezia, no dysuria
PE:
T: 38.2, BP: 134/73, HR: 82, O2 sats:
99% on RA
Gen:
WDWN male, NAD
HEENT: PERRL, EOMI, op clear
CV: RRR, no m/r/g
Lungs: CTA bilat
Abdomen: soft, obese, minimally distended, bilat
LQ tenderness, positive guarding
Extremities: no c/c/e
Labs:
WBC 9.0, Hct 28.4, Plts
471, 62% PMNs, 29% Bands
Na 138, K 4.2, Cl 109, Bicarb 25, BUN 25, Cr 1.1, Glucose 133, Ca
8.2
PT 15.7, PTT 25, INR 1.2
Total protein 5.7, Alb 3.0, T. bili 0.5, Alk
phos 65, AST 17, Alt 8
CT scan: free air, inflammation near cecum, no appendix
visualized, multiple diverticula, mass in left kidney (suspicious for RCC).
Lesion in pelvis, possible met.
A/P: 59 y/o male with perforated viscus, likely diverticula vs.
appendix v. ulcer. Possible RCC.
-hydration
-Cefoxitin
-to OR for perforated viscus resection
-evaluate for RCC and prostate CA
Post-Op Note
Pre-op Dx: perforated viscus
Post-op Dx: s/p ileostomy for cecal mass
Procedure: ileostomy
Anesthesia: GETA
Estimated blood loss: minimal
IFV: 3000 crystalloid, 3 units PRBCs
UOP: 350cc
Condition: Stable
SICU Admit Note
HPI: 59 yo male s/p right colectomy with ileostomy for perforation
of cecum with mass. Had acute onset of abdominal pain on
5/17/03. No n/v/f/c or blood in stool. Htn in
OR, required 3 units PRBS for Hct of 20.
PE:
T: 37.0, P: 82, R: 14, BP 177/84, NAD
Psych: no anxiety/agitation
Neuro: motor intact, sensory intact
Eyes: PERRL, sclera white/conjunctivae clear
ENT: NCAT, mmm, nasal/oropharynx clear
Neck: supple, trachea midline
Respiratory: CTA, non-labored, intubated (PC vent settings 14/5,
14, .4 O2)
CV: RRR/no m/r/g, rt. pulse 2+, left pulse 2+
GI: s/nt/nd, no hsm,
new ileostomy, healthy, some serosanguineous staining of dressing
Skin: warm, dry, no rashes/lesions
Extremities: digits w/o clubbing or cyanosis
Labs:
ABG: 7.33/38/242/20/-5, K 4.4, Na 137, Lactate 1.5, Glucose 191,
HCT 28
A/P:
Neuro: minimize sedation, pain control PRN
CV: hydralazine PRN for BP control
Resp:
wean to extubate as tolerated
GI: NPO, follow wound and stoma
R/F/E: Foley , follow UOP
H/ID: follow for loss, replace PRN, remain
on broad-spectrum antibiotics
Discharge Summary 5/21/02
HOSPITAL COURSE: He was
admitted with a diagnosis of a perforated viscus with free air on CT. He was given IV cefoxitin and taken to the
operating room. An exploratory
laparotomy, a right colectomy, ileostomy, and Hartmann pouch were
performed. Intraoperative findings
revealed a cecal mass concerning for carcinoma and lymph nodes were also
biopsied at the time. He did extremely
well postoperatively, having bowel activity beginning on postoperative day two
from his ileostomy. His stoma continued
to mature and was pink and healthy at the time of discharge. He continued having ileostomy output and was
advanced to a regular diet with no difficulties. He and his wife underwent
ileostomy care teaching, which they handled extremely well.
Urology was
consulted regarding the mass in his kidney, and a contrast CT was performed the
day prior to discharge. The CT scan revealed
that the two masses on the right kidney likely represented simple cysts, and
the mass on the superior pole of the left kidney was categorized as a Bosniak
III lesion. This categorization means
that this mass has a 50% chance of being renal cell carcinoma. Therefore,
urology recommended that he return to see them in three to four weeks for
consultation and possible biopsy.
DISPOSITION: He has a
follow up in three weeks for consultation on his renal mass. Pathology of the colon mass revealed moderately
differentiated adenocarcinoma that had eroded through the colon wall. He had three of 11 positive lymph nodes. He
will return to see the surgeon in one week and have his staples removed.
|
CBC |
|
|
|
|
|
|
|
WBC |
9.02 |
12.04 H |
11.96 H |
11.76 H |
7.20 |
8.89 |
|
RBC |
4.23 L |
4.55 L |
4.44 L |
4.11 L |
5.17 |
3.96 L |
|
Hemoglobin |
7.7 L |
9.3 L |
9.0 L |
8.3 L |
11.3 L |
8.8 L |
|
HCT |
28.4 L |
32.2 L |
31.0 L |
29.2 L |
37.9 L |
27.8 L |
|
MCV |
67.1 L |
70.7 L |
69.8 L |
71.0 L |
73.4 L |
70.2 L |
|
MCH |
18.1 L |
20.3 L |
20.2 L |
20.1 L |
21.8 L |
22.3 L |
|
MCHC |
27.0 L |
28.8 L |
29.0 L |
28.3 L |
29.7 L |
31.8 L |
|
Red cell
distribution width |
17.7 H |
19.3 H |
19.2 H |
19.3 H |
20.9 H |
19.1 H |
|
Platelets |
471 H |
373 |
385 |
342 |
326 |
255 |
|
MPV |
6.8 |
7.7 |
|
|
|
|
|
Poly % |
62 |
|
|
|
|
|
|
Band % |
29 H |
|
|
|
|
|
|
Lymph % |
3 |
|
|
|
|
|
|
Mono % |
6 |
|
|
|
|
|
|
Chemistry |
|
|
|
|
|
|
|
Sodium |
138 |
139 |
139 |
137 |
139 |
136 |
|
Potassium |
4.2 |
4.6 |
4.3 |
4.3 |
4.5 |
4.1 |
|
Chloride |
109 H |
113 H |
112 H |
109 H |
110 H |
108 H |
|
Carbon Dioxide |
25 |
22 |
22 |
27 |
24 |
26 |
|
Anion Gap |
5 L |
4 L |
4 L |
1 L |
5 L |
1 L |
|
Urea Nitrogen |
25 H |
24 H |
21 |
16 |
23 H |
16 |
|
Creatinine |
1.1 |
0.9 |
0.9 |
0.9 |
1.0 |
1.2 |
|
Glucose |
133 * H |
216 * H |
223 * H |
157 * H |
85 * |
115 * |
|
Alkaline
Phosphatase |
65 |
|
|
|
|
|
|
Aspartate
Aminotransferase |
17 |
|
|
|
|
|
|
Alanine
Aminotransferase |
8 L |
|
|
|
|
|
|
Calcium |
8.2 L |
7.4 L |
7.6 L |
8.1 L |
9.3 |
7.9 L |
|
Total Protein |
5.7 L |
|
|
|
|
|
|
Albumin |
3.0 L |
|
|
|
|
|
|
Bilirubin, Total |
0.5 |
|
|
|
|
|
|
Bilirubin, Direct |
0.2 |
|
|
|
|
|
|
Magnesium |
|
1.7 |
1.9 |
2.2 |
|
|
|
Phosphorous |
|
139 |
2.1 L |
2.3 L |
139 |
136 |
TOP
Radiology Reports
History: Severe abdominal pain,
evaluate for ruptured abdominal aortic aneurysm.
Technique: C. T. of the abdomen
was performed without intravenous or oral contrast. A helical technique was
utilized to generate 6.5 mm axial images from the lung bases to the iliac
crests. Images are reviewed in soft tissue and bone windows. There were no
immediate complications reported.
Findings: There is
pneumoperitoneum with small foci of gas present throughout the abdomen. There
is extensive free fluid surrounding the liver and within the pelvis. These
findings are consistent with a perforated viscus. There is extensive
inflammatory and phlegmonous change within the right lower quadrant,
surrounding the cecum. An appendix cannot be identified however; there are
innumerable diverticula throughout the colon. Therefore, the favored diagnosis
is a perforated diverticulum and diverticulitis.
There is a large exophytic lesion associated with the superior
pole of the left kidney. There is coarse peripheral calcification within this
exophytic lesion. This lesion measures 4.2 x 5.3 cm in transverse dimension.
There is mild stranding in the perinephric fat. These findings are most
indicative of a renal cell carcinoma. An additional hyperdense exophytic lesion
is present at the superior pole of the right kidney. This is less pronounced
and may represent a hyperdense cyst or an additional focus of renal cell
carcinoma. This lesion measures 2.1 x 2.0 cm in transverse dimension. This is
an indeterminate lesion.
Impression:
1
Pneumoperitoneum with free fluid predominantly within the pelvis. Findings are
consistent with a perforated viscus.
2. Inflammatory and phlegmonous change within the right lower
quadrant in the setting of numerous diverticulum. The appendix is not
visualized. The favored diagnosis is thus diverticulitis with perforation.
3. Exophytic left renal mass with peripheral calcification most
indicative of a renal cell carcinoma.
4. Indeterminate exophytic region at the superior pole of the
right kidney.
Addendum # 1
There are two sclerotic foci
within the osseous structures of the pelvis, one is
located within the left sacrum and one with the left ilium. These may represent
small bone islands however, the characteristics are more indicative of a
sclerotic metastasis such as prostate neoplasm. Correlation with a PSA is
recommended. The prostate is normal in appearance by CT.
Abdominal CT with
Contrast
Clinical information: Perforated viscus
Technique: A routine CT of the abdomen was performed with
intravenous and oral contrast. The patient tolerated the procedure without
complication.
Findings: There is been interval appearance of small bilateral
pleural effusions. There is adjacent parenchymal opacity consistent with
compressive atelectasis. Again demonstrated are small pockets of free
intraperitoneal gas. Postsurgical changes related to interval right lower
quadrant ileostomy are demonstrated. The
liver demonstrates a normal appearance without evidence of mass. There is no
intra or extrahepatic ductal dilatation. The gallbladder wall is thickened
measuring 5 mm. No calculi are demonstrated. The spleen and pancreas are
normal. The adrenal glands are normal.
The kidneys enhance promptly and symmetrically. Again demonstrated
is a the exophytic mass arising off the superior pole of the left kidney of
heterogeneous attenuation with both fluid and soft-tissue components and
containing coarse calcification. No definite enhancement is demonstrated after
intravenous contrast. Again demonstrated are two exophytic lesion arising from
the superior anterior pole of the right kidney consistent most consistent with
simple cysts. A small amount of fluid is present in the right paracolic gutter.
No lymphadenopathy is demonstrated.
Impression:
1.
Postsurgical changes related to interval right lower quadrant ileostomy. Again
demonstrated is free intraperitoneal gas.
2. Exophytic
mass arising from the left kidney as described above. Although contrast
enhancement is not definitively demonstrated, this is a Bosniak category 3
lesion and is concerning for renal cell carcinoma.
3. No other
abdominal masses are demonstrated.
4. Thickening
of the gallbladder wall. No calculi are demonstrated.
Chest X-Ray
HISTORY: Renal mass, left partial nephrectomy.
FINDINGS: Comparison
Bibasilar atelectasis. Small bilateral pleural effusions. The
lungs are otherwise clear. Degenerative changes of the spine.
IMPRESSION:
BIBASILAR
ATELECTASIS. BILATERAL PLEURAL EFFUSIONS. FREE INTRAPERITONEAL AIR AND SURGICAL DRAIN, RELATED TO PARTIAL
NEPHRECTOMY.
Follow up Note 5/28/02
HISTORY: The patient is a 59-year-old gentleman who returns to clinic today after being discharged from the hospital on 5/26 of this year. He underwent a right colon resection with ileostomy followed by complication of abdominal wound infection. He has done well since being discharged from the hospital a couple of days ago. He is packing his wound twice a day with wet to dry saline dressings. He comes to clinic today for follow up and placement of a KCI wound vac.
PHYSICAL EXAM:
VITAL SIGNS: BP: 155/90, P:
96, T: 98.9
ABDOMEN: Abdomen is packed,
there is a fair amount of soupy material in the base of the wound, otherwise, and
he appears to be doing fairly well.
PLAN: The plan was to have a KCI wound vac placed in clinic,
however, the ostomy nurses informed us that the paper work had not yet been
completed and thus the arrangement was made to have the wound vac placed at his
house by home healthcare when it was available.
In the meantime, we will change his dressing changes to three times a
day. He will continue that until the
wound vac is in place. He will follow up
in two weeks.
Follow up Note 6/11/02
The patient returns to clinic in follow up of an ileostomy status
post colectomy for a perforated cecal cancer and probable renal cancer noted on
CT scan. The patient is doing reasonably
well although his wound pack system has come undone and apparently there are
some problems with the KCL system and having the patient seen at his home by
outpatient visitors. Our stomal
therapist saw him today and presumably, cleared that problem up. His wound is healing nicely and I trimmed
some Prolene out of the base. He is
having some problems with his ostomy, which will also be addressed by the
ostomy nurses.
He has an appointment to see the urologist regarding the renal
lesions, which were noted incidentally on his CT scan. He will be back to see us in two weeks so
that we can review the plans for his ileostomy takedown and workup of his colon
cancer.
Follow up Note
HISTORY: The patient returns to clinic today approximately one
month status post exploratory laparotomy with right colectomy and ileostomy and
Hartman's pouch. The patient's only
complaint is that he has recently had trouble with skin breakdown around his
ileostomy. He came into the hospital on
Sunday after he ran out of colostomy bags and could not get any of the
colostomy bags to stick during the day.
They kept on falling off due to the skin breakdown. His skin was cleaned and DuoDERM was placed
around the ostomy and colostomy bag was then placed over the DuoDERM. He went home but the colostomy bag fell off
once again. They re-tried doing it in a
similar fashion and it stuck overnight.
The next day wound care saw him and was able to get the ostomy bag to
stay in place. Otherwise, the patient has no new complaints. He has no fevers or chills. He reports no new abdominal pain. He is eating well.
PHYSICAL EXAM:
VITAL SIGNS: T: 98.1, P:
72, BP: 134/82
ABDOMEN: soft, nontender
and nondistended. His midline abdominal
wound is granulating in well. There is
no purulence seen. The wound was
explored and there was a small tract that was open without any drainage. His ostomy is intact and is well healed. There is some skin breakdown that is
improving around the ostomy. The ostomy
nurse and wound nurse came and saw the patient's wounds and agree that they are
doing well.
Urology
H&P
HPI: 59 year old white male, with recent right colectomy and
ileostomy for adenocarcinoma of the colon with three positive nodes. CT scan
revealed a complex upper pole mass of his left kidney. No pain or hematuria. Now admitted for left partial nephrectomy.
Allergies: none
Meds: none
PSH: colon resection
Medical history: none
FH: breast CA – father
PE: HEENT: normal, chest: clear, CV: RR, no murmurs, Abd: ilestomy, GU: normal male,
rectal: 30 g benign, ext: no edema.
Impression: complex upper pole lesion of left kidney, very
suspicious for renal cancer.
Plan: Left partial nephrectomy.
Operation
Report
PREOPERATIVE DIAGNOSIS: Left renal mass.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION PERFORMED: Left partial nephrectomy.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 300 cc.
INDICATIONS: The patient is
a 59-year-old gentleman who had difficulty with colon cancer and as part of
that workup was discovered to have a left renal mass consistent with renal cell
carcinoma involving the upper pole of the kidney about 3.5 to 4 cm in size. He presents today for a partial nephrectomy
as the tumor seems to be peripherally located and amenable to such an approach.
PROCEDURE: The patient was
prepped and draped in the usual sterile fashion in the left flank
incision. An 11th rib skin incision was
made with a scalpel. Cautery was used to
divide the subcutaneous tissues to the fascial layers down onto the rib. Periosteal elevators were used to separate
the rib from the surrounding tissue, and a bone cutter was used to excise the
11th rib. The retroperitoneal space was
then opened. A Balfour retractor was
then placed. We took great care to
separate the diaphragm off of the ribs to prevent a pleural injury. Blunt dissection was used to create posterior
to Gerota's fascia and then also anteriorly. The tumor could easily be palpated. The vessels were identified. The renal vein was identified with a
right-angle clamp and electrocautery, and then the renal artery was identified. There were three branches of the renal artery
coming off of the aorta. Each of these
was dissected with the right-angle clamp and cautery.
We then identified the tumor and excised some fat off of the lower
pole of the kidney for cooling purposes.
We left a large amount of fat overlying the tumor. The tumor also appeared mainly to be
posterior on the CT scan, but there was also an anterior nodule that was
identified, and we saved the fat around that.
We then incised the capsule circumferentially around the tumor to help
mark it. We placed bulldog clamps, two
each, across each of the renal arteries and the renal vein. We then had placed
a plastic bag around and cooled the kidney for 10 minutes.
We then used Penfield elevators to dissect the renal parenchyma
and Metzenbaum scissors to excise the tumor.
The specimen was sent to pathology, and a 1 cm margin was noted. The tumor appeared to be renal cell carcinoma
on gross examination.
We noticed a rather large vein that was closed with a #4-0 Prolene
continuous stitch. A series of
figure-of-eight sutures using #3-0 Vicryl were used to isolate bleeding
arterials or segmental arteries. Once
this was accomplished, hemostasis appeared to be adequate. We had two areas of the collecting system
that were opened. These were closed with
continuous #3-0 Vicryl sutures. We then
released the clamp and examined for hemostasis.
There appeared to be some small amount of bleeding, although it was not
significant. Fibrin glue was applied to
the defect, and thrombin soaked Gelfoam was also applied. We mobilized some lower pole fat over the
defect and bolstered our defect with that fat using interrupted #3-0 Vicryl
sutures.
At that point, hemostasis appeared to be adequate. We did note that there appeared to be a small
hole in the pleura we could not identify. We placed a red rubber catheter and
brought it out through the skin and applied suction. It appeared to reduce the pleural space. We also placed a Jackson-Pratt drain in a
normal fashion out the inferior portion of the wound.
We then closed the flank incision in two layers, taking great care
not to injure the intercostal nerve or artery to either the 10th or 11th rib.
The JP drain was sewn in with a #2-0 silk tie.
Note that we identified a small little pleural tear, and that was closed
with #3-0 Vicryl suture material in a continuous
fashion.
We then reduced the pneumothorax by applying suction to the red
rubber catheter as the anesthesiologist provided large inspirations and then
removed the catheter under suction. The
wound was irrigated with saline and closed with staples. The wound was covered with 4 x 4 dressings
and ME fix. The patient tolerated the
procedure well with no intraoperative complications. He was taken to the recovery room in good
condition.
Discharge
Summary
DISCHARGE DIAGNOSIS: Left kidney mass.
PROCEDURE: Left partial nephrectomy.
HISTORY/PHYSICAL EXAMINATION:
Please see the chart for the complete H&P, but briefly, this is a
59-year-old male status post recent right colectomy with ileostomy with three
positive nodes. He had a CT scan that
revealed a complex upper pole mass that was consistent with a renal cell
carcinoma.
PHYSICAL EXAMINATION: His
chest was clear. His heart was regular
rate and rhythm. Abdomen was soft,
nontender. Ileostomy was present on the
right lower quadrant. Normal
male genitalia. Rectal exam
showed a 30-gram benign prostate, and no lower extremity edema.
HOSPITAL COURSE: The
patient was admitted to the hospital following an uneventful left partial
nephrectomy. His postoperative course
was essentially routine. He had an
epidural catheter for the first three days and then was started on oral diet on
postop day two. Once he was able to
tolerate oral diet, he was switched over to oral pain medication which he
seemed to tolerate well.
He was eventually discharged on postoperative day four with an
uneventful postoperative course. His
hematocrit remained stable at about the level of 29, and his JP drain output
decreased to minimal output and was removed prior to discharge. He was afebrile throughout the hospital
course. He was able to tolerate his pain
on oral pain medications. He was able to
ambulate independently, and he was breathing regularly on room air.
Of note, the patient did have some mild erythema of his skin
incision prior to discharge. His staples
were removed, and he was started on Keflex on the day of discharge for a
seven-day course.
Oncology Note 8/11/02
CHIEF COMPLAINT: The patient is a 59-year-old man with recently
diagnosed stage III colon cancer and recently resected stage I renal cell
carcinoma who was referred for recommendations regarding further treatment.
HISTORY OF PRESENT ILLNESS: He was in his usual state of health
until May of 2002. He had just been laid off from his job and developed
dyspepsia and increased gas which he thought was related to an ulcer due to
stress. In May, he went "four-wheeling" and developed sudden
abdominal pain. This subsided, but periodically became more intense so that he
was seen in the emergency room and then transferred immediately to the hospital
for fears of a ruptured aortic aneurysm. CT scan was obtained on
He therefore underwent exploratory laparotomy. They discovered
purulent fluid within the abdomen, and the cecum was adherent to the
retroperitoneum. Multiple perforations of the cecum were noted. Mesenteric
lymph nodes were hard and abnormal. The kidneys were not explored. A right hemicolectomy and ileostomy was performed.
Lymph node dissection was also performed. A total of 28 cm of ileum and colon
were removed. An ulcerated carcinoma at the very proximal right colon was noted
measuring 6.5 x 3.5 cm. The tumor was far from the margins.
Moderately-differentiated adenocarcinoma of the proximal right colon with full
thickness invasion and extension into pericolonic tissues was noted.
Perforation was noted and localized peritonitis was seen. Three
of 11 lymph nodes were positive for tumor and two tubulovillous adenomas were
noted, one with high-grade dysplasia. Margins were free.
His postop course has been relatively unremarkable except that on
7-07-02, he underwent left partial nephrectomy for a 5.0 cm clear cell renal
cell carcinoma. Margins were negative.
This was felt to be a T1b lesion.
Currently, he feels well. He has no pain. His wounds are well
healed. He notes no weight loss. He appears to be dealing with his ostomy
relatively well, but he wonders if this can be taken down prior to beginning
any further treatment.
FAMILY HISTORY: His father had breast cancer, but died at age 85
of an infection. His mother died at age 81 of a stroke.
SOCIAL HISTORY: He quit smoking 25 years ago. He drinks no
alcohol. He was recently laid off from work with some increased stress
reported.
ROS:
GU: No known renal abnormalities, hematuria, dysuria,
pyelonephritis, or nephrolithiasis.
PHYSICAL EXAMINATION:
General: well-appearing middle-aged man in no acute distress.
Vital Signs: Weight is 95.8 kg, temperature 37.3 C, blood pressure
153/82, pulse 65, respiratory rate 22, and KPS 80%.
HEENT: Normocephalic, atraumatic, PERRLA, EOMI, sclera anicteric,
conjunctivae are pink, fundi are normal.
Throat: Clear, tongue midline, no oral or lip lesions are noted.
Neck: Supple, full range of motion, no carotid bruits, and no
thyromegaly.
Back: Spine is straight, no spinal tenderness, no CVA tenderness,
and no pre-sacral edema.
Chest: Lungs are clear with no wheezes, rhonchi, rales, and no
dullness to percussion.
Heart: Regular rate and rhythm with no murmurs, gallops, or rubs.
PMI is non- displaced.
Lymph Nodes: No peripheral lymphadenopathy palpated including no
cervical, supraclavicular, axillary, or inguinal lymph
nodes.
Abdomen: He has a well-healed left flank scar from his nephrectomy
as well as well-healed exploratory laparotomy scar. His ileostomy is intact.
Extremities: No edema, clubbing, or cyanosis. No joint swelling or tenderness.
Skin: No petechiae, ecchymoses, or rash.
Rectal exam:
GU: Prostate is without nodules or tenderness. No testicular masses.
Neurologic exam: The mental status is intact. Cranial nerves are intact. Motor is 5/5 throughout. Sensory is intact to light touch. Reflexes are 2+ throughout and symmetric. Toes are down going. Gait is normal.
Laboratory Data: The white blood cell count is 7.5 with 66% polys,
17% lymphs, 6% monos, 11% eosinophils, hemoglobin
10.5, hematocrit 34.6%, MCV 76, and RDW 12.2%. Of note, his hemoglobin on 5-17
was 7.7 with an MCV of 67. No previous
differential including eosinophils has been performed. BUN is 21, creatinine
1.2, sodium 139, potassium 4.1, calcium 8.9, glucose 86, LDH 386, alkaline
phosphatase 82, AST 13, ALT 7, total bilirubin 0.4,
albumin 3.5, and total protein 7.0. CEA was 1.0 today.
ASSESSMENT:
This is a 59-year-old man with stage III cecal adenocarcinoma with
three positive lymph nodes who presented with perforation and peritonitis as well
as a synchronous clear cell carcinoma of the kidney status-post resection with
a pathology stage of T1 and clinical N0, M0 tumor measuring 5.0 cm.
We discussed the nature of his diagnosis of these two synchronous
cancers. Fortunately, the renal cell carcinoma has been completed resected and
he should have a 95% of a 5-10 year disease-free survival from this malignancy.
Therefore, we spent most of our time discussing his colon cancer
which is stage III. Unfortunately, he is at relatively high-risk of recurrent
disease. This risk of 50% can be decreased to about 30-35% with the use of
adjuvant chemotherapy. Standard chemotherapy for stage III adenocarcinoma
remains 5-fluorouracil plus leucovorin either given weekly or for five days in
a row every month for about six months. The addition of additional medications
such as oxaliplatin or irinotecan is under study now. Unfortunately, we
currently do not have a protocol for which he is eligible, especially given his
recently diagnosed additional malignancy.
He has microcytic anemia which is probably due to previous blood
loss. He probably would benefit from iron supplementation. He also has an
eosinophilia of unclear etiology. I do not know if this has been noted
previously. This may be related to his malignancy, and certainly this would be
concerning. His CEA is now normal and his staging evaluation including all CT
scans were normal. At this point, he has no additional symptoms and I do not
think that repeat staging evaluation is warranted. We will follow the
eosinophilia for now.
PLAN:
1. I will discuss his ileostomy takedown with the surgeons.
2. Labs as noted above were obtained today.
3. He will return to clinic in 1-2 weeks to begin treatment if he
does not go for ileostomy takedown.
FOLLOW-UP
Hematology/Oncology Division
The patient has begun treatment with adjuvant 5-FU and Leucovorin
on a weekly basis. He has had two weeks of this therapy, and comes today for
follow-up. He states that he is doing quite
well. He had no problem with the first two weeks of chemotherapy. He notes no
paresthesias, nausea, vomiting, or mouth sores.
PHYSICAL EXAMINATION: VS: Weight is 95.8 kg (stable), temperature
36.8? C, blood pressure 146/92, pulse 70, respiratory rate 20, oxygen
saturation on room air is 96%. General:
He appears quite well. HEENT: Normocephalic, atraumatic. The sclerae are anicteric. Conjunctivae are pink. Pupils are equal and
reactive. Throat is clear. Tongue is midline. No oral or lip lesions. Neck: Supple, full range of motion, no
carotid bruits, and no thyromegaly. Back: Spine is straight, no spinal
tenderness, no CVA tenderness and no pre-sacral edema. Lungs: Clear with no
wheezes, rhonchi or rales. No dullness
to percussion. Heart: Regular rate and
rhythm with no murmurs, rubs or gallops.
PMI is nondisplaced. Lymph nodes:
No peripheral lymphadenopathy is palpable including no cervical, axillary,
inguinal or femoral lymph nodes. Abdomen
is flat, soft, and non-tender with no hepatosplenomegaly or abdominal
masses. Bowel sounds are normal. Extremities: No edema, cyanosis or
clubbing. No joint swelling. Skin: No rashes, petechiae or purpura. Neurologic: Muscle strength is intact. Gait
is normal.
Laboratory Data: WBC 9, with 78% polys, 13% lymphs, 4% monos, 6% eos,
0.4% basophils. Hemoglobin 12.6, hematocrit 40%, platelets
317. His MCV is 75.4 (up from 74.5), RDW 15.9%. BUN 19, creatinine 1.1,
sodium 143, potassium 4.8, calcium 9.4, glucose 84, LDH is normal at 511, alk phos 70, AST 20, ALT 4, total bilirubin 0.5, albumin
3.7, total protein 7.1, and CEA is 1.2.
ASSESSMENT: 60-year-old man with stage III colon cancer, receiving
adjuvant 5-FU and Leucovorin weekly. He also has a history of renal cell
carcinoma.
PLAN:
1. He will continue with weekly 5-FU and Leucovorin for the next
two weeks. He will continue with a four-week on two-week off cycle.
2. He will return to Clinic in four weeks prior to cycle #2.
Hematology/Oncology
Division 1/20/03
The
patient is a 60-year-old man with stage III colon cancer and stage I renal cell
carcinoma, which has been completely resected. He is receiving weekly 5-FU plus
Leucovorin, given 6 out of 8 weeks for a total of six months. He came in today
to get week #6 of cycle #3 of chemotherapy. He reports that he has not eaten
any food for the last three days, but he is drinking lots of water and
Gatorade. He is complaining of severe mouth soreness and extreme fatigue. He
was quite dizzy this morning, and was pre-syncopal in the lobby of the clinic,
and therefore was brought up in a wheelchair. When asked, he admits that his
urine output is markedly decreased to about one time per day. He states that he
called on Friday night and spoke to a covering physician, complaining of
diarrhea and decreased oral intake. He apparently was taking Imodium only once
every 4-6 hours, and complains that this does not work. Unfortunately, although
his symptoms persisted over the weekend, he did not call again.
PHYSICAL
EXAMINATION: VS: Weight was not obtained. His temperature was 36.1 ? C, blood pressure was 90 palpated,
and unobtainable with this sphygmomanometer? (not sure
about this sentence) Heart rate was about 80 and somewhat difficult to palpate.
His respiratory rate was 12. Oxygen saturation was unable to be obtained.
General: Patient appeared extremely drowsy, but was arousable.
HEENT: Severe conjunctivitis was noted, with marked tearing of his eyes. He did
have some oral ulcers and diffuse mucositis. His abdomen was soft and
non-tender. Extremities revealed no edema. Decreased skin turgor was noted.
Laboratory
data: WBC is 2.3, with 11% bands, 4% polys, 8% lymphs, 2% monos,
and 75% variant lymphocytes. Hemoglobin 19.6, hematocrit 54%,
and platelets 306,000. BUN is 103, creatinine 5.0, sodium 121, potassium
3.4, calcium 8.8, glucose 232, alkaline phosphatase 80, AST 16, ALT 15, total
bilirubin 1.1, albumin 3.6, and total protein 6.3. INR is 4.5.
ASSESSMENT:
This is a 60-year-old man status-post partial colectomy and partial left
nephrectomy for stage I renal cell carcinoma and stage III colon cancer, with
marked dehydration, acute renal failure, and hyponatremia, as well as
neutropenia, arising in the setting of weekly 5-FU and Leucovorin. He was
recently started on hydrochlorothiazide for hypertension, which is his norm. It
is possible, since he is continuing to take the hydrochlorothiazide,
that this, plus his previous nephrectomy, plus diarrhea, all contributed
to his marked dehydration. This in turn probably led to acute renal
insufficiency. He has hypovolemic hyponatremia, which will probably correct
with re-hydration. He is afebrile at this time, and has no signs or symptoms of
infection. Certainly, infection could be contributing to his renal failure.
This will be watched more carefully.
PLAN:
1. He
will be admitted today.
2. He
received one liter of normal saline in the Infusion Room, and his mental status
improved remarkably. The infusion rate was decreased to 250 cc for one more
liter. His blood pressure upon leaving the Infusion Room rose to 152/107.
3. He
will return to clinic after discharge.
Hematology/Oncology
Division Admission 1/20/03
CC: Diarrhea
The
patient is a 60 yo male with Stage III (T3,N1,M0)
colon cancer plus Stage I RCC (s/p resection) who is followed by Oncologist. He
finished his 5/8 course of chemo one week ago (getting weekly 5FU plus
leucovorin) and since that time has had loose diarrhea x 5 days. He has a
colostomy bag and normally empties it about once every 2.5h but over the last
week has had to empty it about every 1-1.5 hours. With this diarrhea (which he
states normally happens after chemotherapy) he has had some nausea, one episode
of vomiting, decreased PO intake x 3 days, decreased urination (no urination
for 48 hours), and severe generalized weakness. He denies any recent travel,
exposure, new medications (except HCTZ started one week ago), unusual foods,
sick contacts, recent antibiotic use, recent hospitalizations, pets in the
home, camping. He has had no F/C.
The
diarrhea persisted and he saw his doctor in clinic today for his 6th course of
chemo but was noted to be markedly weak, dehydrated, hemoconcentrated, and in
ARF. He was admitted for diarrhea with dehydration.
Pertinently,
he denies any cough, SOB, dysphagia, blurry vision, hematemesis, hematochezia,
blood from the colostomy bag, dysuria, myalgias, arthralgias, chest pain, slurred speech.
ONC
HISTORY:
Patient
had an abdominal CT scan on 5-17-02 for persistent abdominal pain which
revealed a left renal mass, inflammatory changes, and
two sclerotic foci were seen in the osseus structures within the pelvis. He underwent
exploratory laparotomy. They discovered purulent fluid within the abdomen, the cecum was adherent to the retroperitoneum,
multiple perforations of the cecum and unusual, hard mesenteric lymph
nodes. A right hemicolectomy and
ileostomy wand lymph node dissection was performed and an ulcerated carcinoma
at the very proximal right colon was found (far from the margins).
Moderately-differentiated adenocarcinoma of the proximal right colon with full
thickness invasion and extension into pericolonic tissues was noted. Three of 11 lymph nodes
were positive for tumor and two tubulovillous adenomas were noted, one with
high-grade dysplasia. Margins were free. On 7-07-02, he underwent left
partial nephrectomy for a 5.0 cm clear cell renal cell carcinoma. Margins were negative. This was felt to be a
T1b lesion.
Past
Medical History:
1.
2. RCC
3. HTN
(recently started on HCTZ)
4.
History of Hepatitis
5.
DVT. Found on US 10/03
Current
medications:
Coumadin
2.5mg po qd
HCTZ
25mg qd
Compazine
PRN
MV a
day
Allergies:
No known drug allergies.
REVIEW
OF SYSTEMS
Positive
for chronic runny eyes and conjunctivitis from chemo, otherwise negative except
as described in HPI.
PHYSICAL
EXAMINATION
VS: 36.8 146/90 18
94 99% 3L NC
Orthostatics
- could not get standing BP but patient c/o dizziness when standing
GEN:
A&Ox4, lethargic, GCS 15, white male who appears very weak, accompanied by
wife and daughter
HEENT:
Dry MM, OP without lesions, eyes erythematous with red lids b/l, PERRL, EOMI,
No LAD, no alopecia, no icterus, red conjunctiva b/l, sunken cheeks
NECK:
Supple, no TM, JVP flat
LUNGS:
CTAB, no W/C/R, symmetric expansion
CV:
RRR, no M/R/G, Nl s1/s2, PMI
normal in location and character, no RV heave
ABD:
S/NT/ND/NABSx4, colostomy bag on right side intact without drainage, brown
stool in bag, midline scar well healed, no bruits, no CVAT b/l
EXT:
Cool, DP/PT 1+ b/l, radial 2+ b/l, no CCE, no calf
tenderness
SKIN:
Pale, no rashes or lesions, poor turgor
Neurologic
exam: Cranial nerves II-XII intact.
Motor is 5/5 UE and LE. Sensory
is intact to light touch. Reflexes are
2+ throughout and symmetric. Toes are
down going.
LABS:
CBC 2.27/20/54/306 (MCV
88, 11%B, 4%P, 8%L)
BMP
121/3.4/76/26/103/5.0/232/8.8
Alk Phos
80
AST 16
ALT 15
TB 1.1
TP 6.3
Alb
3.6
Coags
41/4.5
ECG:
Rate 88, NSR, nl axis
ASSESSMENT:
60 y/o male with colon cancer and diarrhea with significant dehydration as
evidence by orthostasis, hemoconcentration (HCT 54), ARF (high BUN and
creatinine with ratio 103/5.0 = 20, c/w prerenal state), poor skin turgor, and
dry MM.
PLAN:
HEME/ONC.
Was planned to get 6th course of chemo today but will hold off until stable and
discharged from hospital. Current diarrhea likely side effect
of chemo.
-F/U
with Dr. upon d/c
-H/O
DVT on Coumadin but supra therapeutic today, will hold
Coumadin for now and restart when trending back down between 2-3, Lovenox if
necessary to bridge
-Last
HCT around 40 - currently hemoconcentrated
FEN. Hyponatremia likely due to increased ADH release secondary to
volume depletion and also with recent start of HCTZ as possible contributing
factor. DDX also includes adrenal insufficiency, RF, thyroid disorders
(but all less likely).
-Will
follow Na levels closely
-Give
NS to correct slowly
-Check
serum and urine osmols
-Will
not free water restrict at this point because his underlying d/o is likely
dehydration and we want to encourage
-Consider
serum cortisol
RENAL. ARF, decreased UOP likely due to dehydration secondary to
diarrhea and poor
-Will
place PICC (unable to get good IV access) for aggressive rehydration
-Check
UA to evaluate other causes of ARF
-Consider
urine lytes if creatinine doesn't correct
-No
nephrotoxic drugs
ID.
Diarrhea likely due to chemo but will r/o infectious
etiologies with C. Diff, Stool O&P, culture.
Consider further w/u if warranted. No abx until
source identified. WBC low today (last WBC WNL) - possibly side effect of
chemo, currently AF. Will follow.
GI. Diarrhea as above. Will rehydrate and w/u.
ENDO. Hyperglycemic today, all previous BS normal. Etiology unclear - ? chemo, DM,
stress?, decreased
-Will
follow
DISPO.
Will d/c to home once stable.
FULL
CODE
Surgical Pathology Reports
Pathology of the colon
SP GROSS DESCRIPTION
The specimen is received in a small container with a small amount
of formalin labeled "terminal, ileum, cecum, ascending colon". The specimen consists of an unopened segment
of gut to include the terminal 16.0 cm of ileum in continuity with a deep cecum
and short proximal segment of right colon measuring 12.0 cm in length. A vermiform appendix with a glistening serosa
measures 7.0 x up to 0.8 cm, showing a small amount of
exudate at its face, continuous with a larger thin plaque of exudate over the
lateral anterior cecum over an area of 4.0 x 2.5 cm. On the anterior surface of the serosa of the
very proximal right colon at the junction of the cecum there is a surgical
stitch through an area of serosal puckering and slight dullness, and a small
transmural, 3.0 mm perforation in an area of slight serosal puckering. Sections
show a circumferential, centrally ulcerated carcinoma of the very proximal
right colon beginning right at the ileocecal valve,
and actually tunneling beneath the ridge of the ileocecal valve into the distal
ileum by way of an internal colo-ileal fistula up to
1.5 cm in diameter. The tumor shows
rolled, raised, indurated margins and a central, irregular ulcer, measures
approximately 6.5 cm in circumference by 3.5 cm in length. Just distal to and separated from the
ulcerated tumor is an irregular lobulated, plaque-like sessile polyp, 1.5 x 1.1
x 0.6 cm. Deep in the cecal recess
surrounding the ostium to the appendix is another broad, sessile, lobulated
polyp, 3.0 x 2.2 x 1.0 cm. The ulcerated
tumor approaches to within 7.0 cm of the distal surgical margin, and 15.0 cm of
the proximal surgical margin. Deep in the
cecal recess adjacent to the sessile polyp is a broad, punched out, full-thickness
mucosal ulcer, 1.8 x 1.5 cm, associated with a stitch through the serosa in the
area of serosal exudate near the base of the appendix and showing a possible
pinpoint transmural perforation to the serosa.
Sections of tumor show full thickness, destructive invasion of the
muscular wall at the base of the ulcer, with tumor extending grossly at least
0.8 mm into the mesenteric/pericecal fat.
Multiple lymph nodes up to a grossly positive, 1.8 cm lymph node are identified
SP MICROSCOPIC EXAMINATION
SP
DIAGNOSIS:
TERMINAL ILEUM, CECUM, AND ASCENDING
1. LARGE (6.5 CM) CIRCUMFERENTIAL MODERATELY DIFFERENTIATED
ADENOCARCINOMA OF PROXIMAL RIGHT
Pathology of the partial nephrectomy
SP CLINICAL HISTORY left kidney mass
SP GROSS DESCRIPTION:
Received fresh in a container labeled with the patient's name,
medical record number, and "left partial nephrectomy" is a partial
nephrectomy encased in thick perinephric fat, in aggregate weighing 230 grams,
and measuring 17.0 x 9.5 x up to 6.0 cm including the mass. The exposed raw surgical margin of the kidney
measures 8.0 x 5.0 cm. Sections show a
complex solid and predominantly cystic mass bulging from the capsular surface
of the kidney, measuring approximately 5.0 x 4.5 x 5.0 cm, showing mostly a
white parenchyma containing multiple cysts, 0.5-2.0 cm, several of which
contain solid nodules of mottled, yellow-red tumor from 0.6 up to 1.5 cm. The outer surface of the nodule has a
variably circumscribed to more complex, bosselated, multinodular appearance
which in some areas are clearly outside the contour of the kidney and renal
capsule. Focally, bulging nodules of
tumor are covered only by a very thin membrane of pseudocapsule, which, by
verbal description from the surgeon were in fact covered and encased with thick
perinephric fat and do not represent tumor at a true surgical margin. Tumor grossly approaches to within 1.0 cm of
the raw surgical margin of the kidney tissue itself.
SP
DIAGNOSIS:
KIDNEY,
LEFT; PARTIAL NEPHRECTOMY:
- RENAL CELL CARCINOMA, CONVENTIONAL CLEAR
CELL TYPE, FUHRMAN NUCLEAR GRADE 2
- THE TUMOR IS AN ESTIMATED 5.0 CM IN GREATEST
DIMENSION
- NO EXTENSION INTO PERINEPHRIC FAT IS
IDENTIFIED
- NO EVIDENCE OF LYMPHOVASCULAR INVASION IS
IDENTIFIED
- THE TUMOR IS WIDELY EXCISED
- pT1bNxMx
ADMISSION DIAGNOSIS:
1. Acute renal failure
2. Hyponatremia
3. Dehydration
4. Diarrhea
5. Stage 3 colon cancer.
6. Stage 1 renal cell carcinoma.
DISCHARGE DIAGNOSES:
1. Stage 3 colon cancer.
2. Stage 1 renal cell carcinoma.
3. Cerebellar cerebrovascular accident.
4. Diarrhea and dehydration.
5. Hypertension.
6. Deep venous thrombosis.
7. Acute renal failure, resolved
8. Hyponatremia
9. Gastrointestinal hemorrhage
HISTORY: The patient was a 60-year-old male with stage
3 colon cancer and stage 1 renal cell carcinoma status post resection. He finished his fourth cycle of chemotherapy,
which consisted of 5FU plus leucovorin, approximately one week prior to
admission and since that time had had loose diarrhea. He had a colostomy and reported having to
empty it much more often than normal.
With this diarrhea, he had had some nausea, some vomiting, but significantly
decreased p.o. intake, essentially eating nothing for the last three days but
drinking fluids, along with decreased urinary output.
The diarrhea persisted, and on
the morning of admission, he saw Dr. in clinic for his planned last weekly dose
of chemotherapy. He was noted to be
markedly weak, confused and moderately hypotensive. Labs revealed acute renal failure and severe
hyponatremia, so he was admitted. He was
given about 1 liter normal saline in the clinic with immediately improvement in
his blood pressure and mental status.
ONCOLOGY HISTORY: The patient had an abdominal CT scan on
05/17/2002 which revealed a left renal mass, inflammatory
changes, and two sclerotic foci in the osseus structures over the
pelvis. He underwent exploratory laparotomy,
and the surgeons discovered purulent fluid within the abdomen, the cecum was
noted to be adherent to the retroperitoneum, he had multiple perforations of
the cecum, and unusual hard mesenteric lymph nodes. A right hemicolectomy, ileostomy, and lymph
node dissection was done, and he was found to have a moderately differentiated
adenocarcinoma of the proximal right colon with full-thickness
invasion/extension into the pericolonic tissue, and 3/11 lymph nodes were
positive for tumor. The margins were free.
On 07/07/2002, he underwent left
partial nephrectomy for a 5-cm clear cell renal cell carcinoma with negative
margins.
PAST MEDICAL HISTORY: 1.
MEDICATIONS: Coumadin 2.5 mg a day, hydrochlorothiazide 25
mg a day, Compazine p.r.n., and a multivitamin a day.
ALLERGIES: None.
PHYSICAL EXAMINATION: VITAL SIGNS:
Temperature 36.8, blood pressure 156/90, respiratory rate 18, heart rate
94, saturating 99% on 3 liters. GENERAL: He was alert and oriented times four, but
very lethargic. He appeared very
weak. HEENT: His mucous membranes were dry. His oropharynx was clear without
lesions. His pupils were equal, round, reactive
to light. His extraocular movements were
intact, and he had no icterus.
NECK: Supple without any
thyromegaly. His neck veins were flat. LUNGS:
Clear to auscultation without any wheezes, crackles, or rhonchi. HEART:
Regular without murmurs, rubs, or gallops. ABDOMEN: Soft, nontender, nondistended with normal
bowel sounds and a colostomy bag on the right side that was intact. EXTREMITIES:
Cool. His dorsalis pedis and
posterior tibial pulses were 1+ bilaterally.
He had no clubbing, cyanosis, or edema, and no calf tenderness. SKIN:
Very pale without any rashes or lesions and with poor skin turgor. NEUROLOGIC: Cranial nerves II through XII were
intact. His motor strength was 5/5 in the
upper and lower extremities. Sensation
was intact to light touch.
LABORATORY DATA: On admission his white count was 2.3 with 11%
bands, 4% polys, and 8% lymphocytes. His
hemoglobin was 20, his hematocrit was 54%, and his platelets were 306. His sodium was 121, potassium 3.4, BUN 103, creatinine
5.0. His LFTs
were normal. His INR was 4.5.
An ECG demonstrated a
ventricular rate of 88 with normal sinus rhythm and normal axis.
HOSPITAL COURSE: The patient was admitted to the
Hematology/Oncology Service and felt to be severely dehydrated secondary to diarrhea. He was aggressively rehydrated. His diarrhea was controlled with a
combination of Lomotil and octreotide, and he initially responded well. His creatinine started to decrease down
towards baseline, and he felt better. However, on the day following admission, he
became neutropenic with a white blood cell count of 1.07 of which 49% were
neutrophils. His hematocrit was
acceptable at 39%, and his platelets were slightly low at 128.
Although he initially was
afebrile within several days, he became febrile, and a chest x-ray demonstrated
a right lower lobe consolidation consistent with pneumonia. For this pneumonia, he was started on antibiotics,
but did not markedly respond.
Concomitant with this, he developed a urinary tract infection with
greater than 100,000 colony forming units of E. coli. The ceftazidime which was one of the antibiotics
he was started on for his pneumonia also covered with urinary tract infection.
He developed septic physiology
requiring transfer to the ICU and support with vasopressors. The vasopressors were quickly weaned, and he
was transferred back to the floor in stable condition. He was continued on antibiotics and continued
to do fairly well with the exception of continued intermittent delirium. A head CT was done to evaluate him for possible
intracranial hemorrhage, but this was negative for any bleed or any other
masses.
Slowly, his sensorium cleared,
and it was felt that his confusion was secondary to his recent infection, and
that he would continue to do well. A
lumbar puncture was considered, but his INR remained elevated above 1.6 despite
vitamin K and FFP, and it was felt that since he was clinically doing better
and had a high INR, it was not safe to do a lumbar puncture.
His general clinical condition
was improving although he developed a recurrent oxygen requirement after being
weaned to room air. The clinical
impression was that of pulmonary edema due to fluid overload, and he was
diuresed with furosemide. His temporary
central venous line was removed. Soon
thereafter, he became more short of breath and
developed a new left hemiparesis. A "brain
attack" was called, and he was taken to CT scanner emergently. Although
the CT scan was negative for any hemorrhagic stroke or other masses, he was
then taken to MRI for diffusion weighted scan.
The results of the diffusion weighted MRI demonstrated a small abnormal
region in the cerebellum. He was
transferred to Neuro critical Care and underwent cerebral angiography which was
without evidence of any focal vascular occlusions. Therefore, the possibility of an air embolism
from removal of his line was raised. His
heparin anticoagulation was continued during this time. During this work-up, which continued into the
evening, most of his neurological deficits resolved. He did remain somewhat confused, however, and
no etiology was evident.
On the evening of 01/29/2003, he
suddenly decompensated, becoming very tachypneic, hypotensive, and
hypoxemic. He did not become
tachycardic. A stat ABG was drawn which demonstrated
a sudden drop in his hematocrit to 19% from 28% earlier that morning, and an NG
tube was passed and returned reddish-brown substance, approximately 200
cc. His PTT had increased to 112, up
from 67 obtained earlier that afternoon.
He had no evidence melena, bright red blood per colostomy
nor hematemesis during the day or evening as an indication of severe GI
bleeding however.
He subsequently and suddenly
suffered a cardiac arrest, and the code team was unable to resuscitate him. His
family was contacted by the night team.
Laboratory
ACTH 9
- 52 pg/mL
Alpha-fetoprotein 0
- 15 ng/mL
Alanine
aminotransferase (ALT) 6
- 50 U/L
Albumin 3.5
- 4.6 g/dL
Alkaline
phosphatase 45
- 150 U/L
Ammonia 7
- 27 micromol/L
Amylase,
serum (adult) 30
- 110 U/L
Aspartate
aminotransferase (AST) 15
- 50 U/L
Bilirubin,
total 0
- 1.5 mg/dL
Bilirubin,
direct 0
- 0.3 mg/dL
Calcium 8.8
- 11.0 mg/dL
Carbon
dioxide 20
- 29 mmol/L
Catecholamines,
urine free
Epinephrine 0 - 25 microgm/day
Norepinephrine 0 - 100 microgm/day
Chloride 101
- 111 mmol/L
Cholesterol,
total 100
- 200 mg/dL
Cholesterol,
HDL 0
- 35 mg/dL
Cortisol
(
(
Creatine
kinase 20
- 200 U/L
Creatinine 0.8
- 1.4 mg/dL
Erythrocyte
sedimentation rate 0
- 20 mm/Hr
Estradiol,
female <73
pg/mL (postmenopausal)
30
- 400 pg/mL (normal hormonal cycle)
Ferritin 7
- 340 ng/mL (male)
7 - 75 ng/mL (female)
Gastrin 0
- 100 pg/mL
Glucose 64
- 128 mg/dL
HCG,
serum, quantitative
Male 0 - 5 IU/L
Female 2
- 8 IU/L
Homocysteine,
plasma 4
- 12 micromol/L
Homovanillic
acid (HVA), urine 0
- 15 mg/day
Iron,
serum
Male 50 - 170 microgm/mL
Female 30
- 160 microgm/mL
LDH 105
- 230 U/L
Lipase,
serum 16
- 63 U/L
Metanephrins, urine, adult
Metanephrine 0 - 300 microgm/gm of creatinine
Normetanephrine 0 - 400 microgm/gm of creatinine
Phosphorus 2.4
- 4.1 mg/dL
Plasma
renin activity (upright) 0.5
- 3.3 ng/mL/hr
Potassium 3.7
- 5.2 mmol/L
Prostate
specific antigen 0
- 4 ng/mL
Rheumatoid
factor 0
- 20 IU/mL
Sodium 136
- 144 mmol/L
Thyroglobulin
antibody 0
- 2 IU/mL
Thyroid
peroxidase (TPO) antibody 0
- 2 IU/mL
(antimicrosomal
antibody)
Thyroid
stimulating hormone (TSH) 0.4
- 5 mU/L
Thyroxine 4.5
- 10.9 microgm/dL
T4,
free 0.9
– 2.3 ng/dL
Total
Protein, serum 6.3
- 8.2 g/dL
Total
Protein, CSF 15
- 45 mg/dL
Troponin
I <0.4
ng/mL; >2 ng/mL consistent with myocardial injury
Urea
Nitrogen (BUN) 7
- 20 mg/dL
Uric
Acid 2.7
- 6.6 mg/dL
Hgb 12 - 16 g/dL
female
13 - 18
g/dL male
Hct 37 - 48 % female
42 - 52
% male
MCH 28 - 33 pg/cell
MCHC 32 - 36 g/dL
MCV 86 - 98 fL
RDW 11.5 - 14.5%
Platelets 150,000 -
300,000/microliter
WBC
count 4300 -
10,800/microliter
PT 12.5 seconds
PTT 26.2 seconds
Fibrinogen 150 - 350 mg/dL
Lymphocyte
subsets
CD4 cells (absolute) 440 - 1600/microliter
CD8 cells (absolute) 180 - 850/microliter
Quantitative
Immunoglobulins
IgA 68
- 378 mg/dL
IgG 768
- 1632 mg/dL
IgM 60
- 263 mg/dL