LSU Medicine Case Conference. Tuesday May 17, 2011 Gisella Tay, M.D.

Transcription

1 LSU Medicine Case Conference Tuesday May 17, 2011 Gisella Tay, M.D.

2 Chief Complaint I fell down on my porch.

3 HPI 60yo man with past medical history of HTN and recurrent sebaceous cysts was transferred from Lallie Kemp Medical Center for further evaluation. Patient initially presented to LKMC after having a syncopal episode 8 days prior to transfer to UH. Patient states he was on his front porch when he stood up and passed out. He denied any lightheadedness or dizziness prior to this episode. Per notes from LKMC, the patient was brought to the hospital by the his sisters after concern for his deteriorating health for the past few weeks. Patient has had decrease appetite with recent weight loss (at least a couple of pant sizes). He did have chills x 1 week but denied fever. He had increase fatigue and somnolence for 2 weeks and had been bedridden for one week prior to initial presentation.

4 ROS He admits to Edema of the feet for a couple of weeks Multiple skin nodules Sebaceous cysts on the face and neck Constipation

5 ROS He denies: Chest pain SOB Nausea or vomiting Abdominal pain Melena or hematochezia Hematuria Night sweats

6 Past History PMHx: HTN Recurrent sebaceous cysts (since teenager) Surgical history: I & D of scalp and neck sebaceous cysts

7 Past History Meds: No home medications Allergies NKDA

8 Past History Social History: 25 pack year history, quit 1 month prior secondary to bad taste. 20 year h/o EtOH use: one - fifth whiskey/day, quit 2 months prior. Denies any illicit or IVDU. Lives with his sisters and nieces. No children. Pt was in the Army for 10 years, now retired construction worker

9 Past History FMHx: Father deceased at 70 s of MI Mother deceased at 70 s of CVA HM: No PCP. Not up to date on flu or pneumococcal vaccine. Received Td booster 1 week prior. No colonoscopy

10 Physical Exam V/S: T 97.9 O F HR 99 RR 22 BP 120/70 Sat 98% on RA Ht 6 3 Wt 220lb BMI 29 Pain 0/10 Gen: A/O, NAD, flat affect, difficult to engage in conversation HEENT: PERRL, EOMI, OP clear, poor dentition, 3 non-purulent, tender open lesions with granulation on his posterior, occipital and frontal scalp measuring approximately 10cm, 6cm and 5cm in diameter. No bone exposure. 4cm firm subcutaneous nodule on right frontal scalp without any drainage.

11 Physical Exam Neck: Left sided nodule with a penrose drain in place with minimal malodorous serosanginous drainage. Right posterior 5cm nodule firm non tender CVS: RRR S1/S2. No murmurs or rubs. No carotid bruit. Pulmonary: CTA B/L Abdomen: Bowel sounds present. Soft, nontender, nondistended.

12 Physical exam Extremities: 3cm firm subcutaneous nodule on left forearm without any drainage. 2+ radial and dorsalis pedis pulses bilaterally. Palmar hyperkeratosis Skin: No rashes or bruises. Scalp and extremities lesions as described above Neuro: CN II-XII intact, no focal deficits, generalized 4/5 weakness, no dismetria finger to nose.

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17 Laboratory Data WBC 19.7 Hgb 12.3 Hct 39.7 Plts 422 MCV 72 RDW 16.9 Segs 95 % Bands 0 % Lymphs 3 % Monos 2 % Eos 0 % Microcytes 2 + Hypocromic 2 +

18 Laboratory Data Na 139 K 4.2 Cl 101 Bicarb 30 BUN 20 Creat 1.10 Glucose 112 TProt 6.4 TBil 0.8 Alb 3 AST 27 ALT 12 Alk Phos 84

19 Laboratory Data Ca 12.7 Ca (c) 13.5 Mg 1.8 Phos 2.5 PTH 8 Cardiac enzymes neg UA wnl PT 14.1 INR 1.2 HIV neg Acute hep panel NR ETOH neg Utox neg

20 Laboratory Data Iron 20 Transferrin 152 TIBC 198 Sat 10 Ferritin 50.3 UPEP and SPEP no M spike. Blood Cx: NGTD Wound Cx: heavy growth of MRSA ESR 32 CRP 4.6

21 LAK Hospital Course Multiple draining cysts/abscesses on scalp were I&D d in the ED Vancomycin and clindamycin were started upon admission General Surgery was consulted and performed a granulation tissue biopsy Hypercalcemia treated with fluids

22 LAK Hospital Course Initial CXR concerning for atelectasis vs mass CT of head/neck/chest/abd/pelvis was done with concern for spiculated mass in the superior segment of the LLL with probable lymphagitic carcinomatosis of LLL associated with mild pleural thickening and a small nodule in the superior segment of the RLL He was then transferred to University for pulmonary and hematology/oncology evaluation.

23 Admit ECG

24 CT head

25 Admit Chest X-Ray

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27 CT Chest

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31 Hospital Course While awaiting pathology slides done at LAK: Vancomycin and piperacillin/tazobactam administered Pulmonary was consulted Bronchoscopy planned Dermatology was consulted and performed punch bx of both scalp and forearm lesions Recommended continued wound care

32 Pathology

33 Anterior Scalp

34 Anterior Scalp

35 Anterior Scalp

36 Anterior Scalp

37 Left Forearm

38 Left Forearm

39 Diagnoses Skin, anterior scalp: Invasive squamous cell carcinoma Skin, left forearm: Trichilemmal (pilar) cyst Skin, frontal scalp: No significant microscopic abnormality.

40 Hospital Course Pathology from the scalp lesion => invasive squamous cell carcinoma Bronchoscopy cancelled Heme/Onc was consulted and complete staging work up was done Abd/pelvis negative; MRI c/w no definite extension of the lesions into the brain but there was restricted diffusion in some lesions in the right superior parietal area. Early metastatic neoplasm in the right superior parietal white matter could not be entirely excluded.

41 Diagnosis Stage 4 squamous cell carcinoma with poor prognosis. Hospice recommended.