-7192137

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-7192137

  1. 1. AUTOPSY CONFERENCE June 2009 Department of Medicine Chief Residents
  2. 2. Chief Complaint <ul><li>53 yo F who was originally admitted for elective L ureteral stent placement </li></ul>
  3. 3. History of Present Illness <ul><li>Patient was diagnosed with R breast CA in 2002 (T2N1M0, er/pr+, her2/neu neg). </li></ul><ul><li>Patient had a R. lumpectomy in 12/02 and was given chemo ( initially cyclophosphamide x 8, methotrexate, flourouracil). Patient was not found to have metastatic disease at this time. </li></ul><ul><li>After initial chemo, she was switched to anatrazole 5/05 </li></ul><ul><li>In 2006, the patient began losing weight and was anemic requiring multiple blood transfusions and darbopoieten. No clear etiology was determined and patient had negative mammograms at this time. </li></ul>
  4. 4. History of Present Illness <ul><li>In 2008, a new palpable lesion was found in the R breast. </li></ul><ul><ul><li>Breast biopsy showed bilateral invasive ductal CA with moderate differentiation </li></ul></ul><ul><ul><li>Bone biopsy showed infiltrative carcinomatosis </li></ul></ul><ul><li>Patient was switched to zoledronic acid. </li></ul><ul><li>In 2/2009, PET/CT scan showed </li></ul><ul><ul><li>increased uptake in multiple vetebral bodies and ribs </li></ul></ul><ul><ul><li>Axillary and hilar LN </li></ul></ul><ul><ul><li>L hydronephrosis </li></ul></ul><ul><ul><li>Ascites </li></ul></ul><ul><ul><li>Tumor compression of L ureter </li></ul></ul>
  5. 5. History of Present Illness <ul><li>Given that the patient had tumor compression of the L ureter, the patient was admitted for an elective stent placement. </li></ul>
  6. 6. History of Present Illness <ul><li>PMHX: as above, HTN, CRI, anemia </li></ul><ul><li>PSurgHX: L ankle fracture s/p ORIF 2/09 </li></ul><ul><li>MEDS: Acetaminophen, Darbopoetin, Diphenhydramine, Dyazide 37.5/25 mg daily, Exemestane 25 mg daily, Hydrocortisone, MVI </li></ul><ul><li>ALL: PCN </li></ul><ul><li>SOCHX: no history of drug or alcohol use </li></ul><ul><li>FH: mother and 3 aunts had breast cancer </li></ul>
  7. 7. Physical Exam <ul><ul><li>Gen: No apparent distress, well nourished </li></ul></ul><ul><ul><li>VS: T 96.8 BP 122/80 HR 81 RR 18 O2 sat 98% RA </li></ul></ul><ul><ul><li>HEENT: dry MM, PERRL </li></ul></ul><ul><ul><li>Neck: Supple, no JVD, nl LAD </li></ul></ul><ul><ul><li>Heart: RRR –m, -g </li></ul></ul><ul><ul><li>Lungs: CTA b/l </li></ul></ul><ul><ul><li>Abdomen: +distended, dull to percussion </li></ul></ul><ul><ul><li>Ext: R ankle and foot closed fracture in cast </li></ul></ul><ul><ul><li>Neuro: grossly intact </li></ul></ul>
  8. 8. Laboratory Assessment: 131 70 - 110 Glucose (mg/dl) 8.5 8.5 – 10.5 Calcium (mg/dl) 2.0 0.6 – 1.5 Creatinine (mg/dl) 66 8 – 25 Urea nitrogen (mg/dl) 20 23.0 – 31.9 Carbon dioxide (mmol/liter) 100 100 – 108 Chloride (mmol/liter) 6.4 3.4 – 4.8 Potassium (mmol/liter) 132 135 – 145 Sodium (mmol/liter) CHEMISTRY ON ADMISSION REFERENCE RANGE TEST
  9. 9. Laboratory Assessment: 0 2-8 Bands 1.48 11.3 – 13.3 INR 34.5 22.1 – 35.1 Partial-thromboplastin time (sec) 106 150,000 – 300,000 Platelet Count (per mm 3 ) 8 4 – 11 Monocytes 7 22 – 44 Lymphocytes 86 40 – 70 Neutrophils Differential Count (%) 13.2 4,500 – 11,000 White-cell count (per mm 3 ) 25.7 41.0 – 53.0 Hematocrit (%) 8.5 13.5 – 17.5 Hemoglobin (g/dl) HEMATOLOGY ON ADMISSION REFERENCE RANGE TEST
  10. 10. Laboratory Assessment: 6.6 6.3-8.2 Total Protein 3.5 3.5-5.0 Albumin 29 8 – 50 ALT 162 15-46 U/L AST 264 39-117 U/L Alk phos 0.2 0 – 0.3 mg/dl Conjugated Bili 0.3 0.2-1.0 mg/dl Total Bili Liver Function Test ON ADMISSION REFERENCE RANGE TEST
  11. 11. Hospital Course <ul><li>The first day of admission, the patient had an uncomplicated procedure and was weaned off of sedation with no complication </li></ul><ul><li>On POD #2 – patient became unresponsive and hypotensive and hypoxic (bp 98/54, p 130, 85% RA) </li></ul><ul><ul><li>ABG was 7.1 | 43.6 | 82 | 12.2 | lactate 8.4 | K 7.1 </li></ul></ul><ul><ul><li>Patient had a paracentesis which was significant for WBC 512 PMN 6% Lymph 69%, ascites alb <1 </li></ul></ul><ul><ul><li>Patient was treated with kayexelate ans started on broad spectrum antibiotics vancomycin, pip/taz, and metro </li></ul></ul>
  12. 12. Hospital Course <ul><li>On HD #3, patient remained hypotensive and unresponsive to fluid boluses. Patient was started on 2 pressors and intubated. </li></ul><ul><li>The patient had a CT scan without contrast that was significant for bowel ischemia with pneumotosis and likely hemoperitonium related to bowel ischemia. </li></ul><ul><ul><li>Surgery was consulted, but patient was deemed not to be a surgical candidate </li></ul></ul><ul><li>Also, ascitic cultures were positive for gram positive rods and cocci in pairs </li></ul>
  13. 13. Hospital Course <ul><li>On HD #4, the patient was made comfort care. Patient eventually went into asystole and passed away </li></ul>

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