Case Study

Aivi Phung

EOR 5
May 5, 2016

Identifying Data
Patient ID:
Name: Mr. Patient
Age: 48 years old
Race: White
Sex: Male
MRN: 112233
Date(s) Seen: Feb 2016-March 2016

CC & HPI
CC: Worsening abdominal pain and distention x 2 months.
HPI: The patient is a 48-year-old Caucasian male with no significant past medical history,

who notes he was well up until approximately 2 months ago when he began to notice
increasing abdominal distention. He says it became worse approximately 1-2 weeks ago. He
was seen by GI a week ago and had an upper endoscopy and colonoscopy. He says biopsies
were taken and were normal. GI advised him that he was just very gassy and needs to try
passing gas. His complaints persisted so he elected to come to Urgent Care for symptom
relief. He states that he feels constipated and his last bowel movement was 4 days ago with a
very small loose stool. He feels nauseous and has a hard time keeping food down. He states
his pain is constant and non-radiating at a level of 6-7/10 and is worsened by eating, but
improved with burping and with flatulence. Pain is described as aching and dull. Denies
blood or mucous in emesis or stool. Denies fevers, chills or sweats.

Patient Records
Pathology Report

History
PMHx: No significant past medical history. Pt denies any history of inflammatory bowel

disease.
PSHx: Notable for tonsillectomy at age 7. Pt denies any history of any abdominal surgeries.
FMHx: Father had hypertension. No other significant family history.
SHx: He smokes PPD of tobacco. Occasional alcohol. No drugs. He is divorced and
works as a card dealer at the casino.
Allergies: No known drug allergies. No known allergies.
Medications: Patient denies taking any medications.
Immunizations: Up to date.

ROS
Const: Thin Caucasian male

Integ: No rash, no itching, no pruritus

Eye: No eye pain, no visual changes, no

Resp: No tachypnea, SOB

discharge

HENT: No ear pain, no sore throat, no nasal

discharge

GI: Abdominal pain, nausea, vomiting,

constipation, bloating, no skin changes

GU: No hematuria, no painful urination, no

polyuria

Musc: No back pain, no neck pain, no leg pain

Cardiac: No palpitations, no chest pain, no leg

edema

Psych: No anxiety, no depression

Endo: No weight loss, no polyuria
Heme: No painful lymph nodes, no bruising,
no bleeding

Neuro: No weakness, no numbness, no

tingling

Physical Exam
Objective
Vital Signs: Ht: 72, Wt: 210 lbs., Temp: 98.2F tympanic, P: 86, RR: 24, BP: 132/78, Sp02: 97%
RA (adequate), Pain: 7/10

Gen: Alert, middle-aged man in no acute distress.

Skin: Appears to be well hydrated, no rashes in his trunk or extremities. No evidence of cyanosis,
clubbing, or jaundice. Normal skin coloration. No visible masses or lesions noted.

HEENT: Normocephalic and atraumatic. Sclera is white, conjunctiva clear, pupils are equal,
round and reactive to light. Mucous membranes are moist. The neck is supple without any
evidence of thyromegaly or lymphadenopathy. No JVD.

Resp: Thorax is symmetric. No use of accessary muscles of respiration. The lungs are resonant
with vesicular breath sounds and clear to auscultation bilaterally. No rales, wheezes, or ronchi.

Physical Exam (contd)

CV: He has good S1, S2, no S3 or S4. Heart rate and rhythm are regular with no

murmurs, rubs or clicks.

GI: The abdomen is firm, protuberant, distended, with hypoactive bowel sounds.
Diffuse tenderness to palpation in all quadrants. He has no organomegaly. No
masses. No rebound or guarding. No skin changes or rashes.
GU: External genitalia normal male, no testicular/scrotal/epididymal masses or
TTP, no inguinal bulging.
Extremities: Without cyanosis, clubbing or edema.
Neurologic: Grossly nonfocal.

Diagnostic Studies

CBC w/diff
CMP
PT-INR/PTT

ESR/CRP
Abdominal and Pelvic CT w/contrast

Diagnostic Studies

CBC w/diff WNL

CMP WNL
PT-INR/PTT WNL
ESR/CRP mildly elevated
Abdominal and Pelvic CT 1. Small bowel obstruction with heterogenous
congestion of omentum 2. mild ascites 3. neoplasm cannot be completely
discounted 4. observed changes could be seen with severe infectious and/or
inflammatory changes

Differential Dx/Assessment
1.
Small bowel obstruction
r/o Neoplasm of colon
r/o Inflammatory bowel disease

2.
Ascites

Treatment/Plan

Admit to Med/Surg
NPO status
IV Dilaudid and Zofran

Surgical consult for exploratory laparotomy and biopsy of omentum for

definitive diagnosis

Follow-Up
Procedure: Exlap with loop ileostomy.

Surgical findings consistent with diffuse abdominal carcinomatosis. Frozen section came
back as adenocarcinoma.

Follow-Up
Post-operatively, patient became septic and underwent acute respiratory
failure/PE.

Patient was intubated for 2 days.

Successfully extubated and transferred to MedSurg.
GI performed EGD, bx negative for H.Pylori. No safe window found for
PEG placement. Pt is not a candidate for G tube placement.

Unable to take food orally and will be discharged on TPN.

Follow-Up
Long discussion with the pt, his family & case management regarding poor
prognosis & treatment options. Given estimate of ~3 month life expectancy.

Pt feels he is not ready for hospice care but would like to be discharged
home with home health.

PCA pump has been ordered and pt will be discharged on Fentanyl patches
until pump is delivered. Pt will also be discharged home on IV Pepcid, Lasix,
Zofran and Ativan.

Discharge Diagnoses

SBO
Ascites

Shock
Protein calorie malnutrition
33-lb weight loss in 30 days

Abdominal carcinomatosis

Wound dehiscence
Pulmonary embolism
Acute respiratory failure
Sinus Tachycardia

AKI
Ileus
Omental Metastasis
Encounter for palliative care

Carcinomatosis
A condition in which multiple carcinomas form simultaneously, typically after
dissemination from a primary source.

Almost always implies that there is spread to regional nodes and even more
than is seen in just metastatic disease.

Term is usually taken to mean that there are multiple secondary malignancies
in multiple sites.

Carcinomatosis
Peritoneal carcinomatosis is spread of metastases into the peritoneum,
usually from colorectal and ovarian cancers.

Can present as progression of known disease, recurrence of known disease,

or may be the primary presenting feature.

Usually no realistic hope of curative therapy, although chemotherapy and

radiotherapy may have a palliative effect.

References
Sadeghi, B., Arvieux, C., Glehen, O., Beaujard, A. C., Rivoire, M., Baulieux, J.,
... & Porcheron, J. (2000). Peritoneal carcinomatosis from nongynecologic
malignancies. Cancer, 88(2), 358-363.

Chu, D. Z., Lang, N. P., Thompson, C., Osteen, P. K., & Westbrook, K. C.
(1989). Peritioneal carcinomatosis in nongynecologic malignancy. A
prospective study of prognostic factors. Cancer, 63(2), 364-367.