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NYU Medicine Grand Rounds Clinical Vignette

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Title: Journal Club Author: Louis Miller Last modified by: admin Created Date: 5/22/2007 12:58:19 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: NYU Medicine Grand Rounds Clinical Vignette


1
NYU Medicine Grand Rounds Clinical Vignette
  • Cindy Fang
  • PGY2
  • 5/28/2014

2
Chief Complaint
  • 49 year old man with progressive dysphagia,
    chest pain, and weight loss of 25 pounds for two
    months

3
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

4
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

5
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

6
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 lt3

7
Other Studies
  • Chest X-Ray Mass-like soft tissue density in the
    subcarina with proximal esophageal dilatation

8
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.

9
Working or Differential Diagnosis
  • Esophageal neoplasm

10
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

11
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

12
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
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