lsu medicine case conference - lsu health new orleans · conference tuesday may 17, 2011 gisella...
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LSU Medicine Case
Conference
Tuesday May 17, 2011
Gisella Tay, M.D.
Chief Complaint
“I fell down on my porch.”
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.
ROS
• He admits to
– Edema of the feet for a couple of weeks
– Multiple skin nodules
– Sebaceous cysts on the face and neck
– Constipation
ROS
• He denies:
– Chest pain
– SOB
– Nausea or vomiting
– Abdominal pain
– Melena or hematochezia
– Hematuria
– Night sweats
Past History
• PMHx:
– HTN
– Recurrent sebaceous cysts (since
teenager)
• Surgical history:
– I & D of scalp and neck sebaceous cysts
Past History
• Meds:
– No home medications
• Allergies
– NKDA
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
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
Physical Exam
V/S: T 97.9OF 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.
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.
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.
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 +
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
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
Laboratory Data
• Iron 20
• Transferrin 152
• TIBC 198
• Sat 10
• Ferritin 50.3
• ESR 32
• CRP 4.6
• UPEP and SPEP no
M spike.
• Blood Cx: NGTD
• Wound Cx: heavy
growth of MRSA
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
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.
Admit ECG
CT head
Admit Chest X-Ray
CT Chest
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
Pathology
Anterior Scalp
Anterior Scalp
Anterior Scalp
Anterior Scalp
Left Forearm
Left Forearm
Diagnoses
• Skin, anterior scalp: Invasive
squamous cell carcinoma
• Skin, left forearm: Trichilemmal (pilar)
cyst
• Skin, frontal scalp: No significant
microscopic abnormality.
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.
Diagnosis
• Stage 4 squamous cell carcinoma with
poor prognosis.
• Hospice recommended.