1. NYU Medical Grand Rounds Clinical Vignette Benjamin Wu, MD PGY-2 May 15, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 61 year-old woman, presents to an outside physician complaining of black colored stools for 1 week and dyspnea on minimal exertion. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient had chronic, watery diarrhea related to past history of gastric bypass in the 1970s. Patient reportedly with colonoscopy 5 years prior to admission with a “few” polyps with unknown biopsy results 1 week prior to admission, had bilateral ureteral stents placed for nephrolithiasis, and at that time started on iron supplementation. Hemoglobin was noted to be 8g/dl Since that admission, complained of dyspnea with slight exertion, and blackish stools, presented to PMD where a work up found a hemoglobin of 6g/dl Referred to Tisch hospital for further evaluation History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: Chronic Obstructive Pulmonary Disease Chronic Watery Diarrhea Past Surgical History: Gastric Bypass Surgery in the 1970s Social History: Ex-tobacco smoker, 40 pack year smoker quit 1 year ago Denies alcohol use No recent travel Works as a pet driver Family History: Father had a MI Mother with history of breast cancer U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Allergies: Penicillin – rash Medications Ferrous Sulfate 325mg by mouth daily Lomotil by mouth daily Pancrease 2 tabs by mouth three times daily Metronidazole 500mg by mouth three times daily

6. Physical Examination General: Well appearing, well nourished female in no acute distress Vital Signs: T: 97F BP: 156/64 HR: 108 RR: 20 and O2 sat: 98% on room air Pale conjunctiva, tachycardia, regular rhythm, without m/r/g, no gum bleeding, no blood from rectal vault. Positive fecal occult blood. The rest of the exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings CBC: Hemoglobin 5.7mg/dL MCV 82.7, Reticulocytes 8.6% WBC 13.3 (N77%, L18%, M3%, E1%, B1%) Basic Metabolic: Creatinine 1.7mg/dl Hepatic: Albumin 3.4g/dl and Total protein 6.1g/dl Ferritin 13ng/ml(12-150ng/ml) Iron 17ug/dl(50-170ug/dl) TIBC 522ug/dl(250-370ug/dl) Transferrin Sat 3%(15-50%) UA +large blood, protein 30, +small leukocyte esterase, moderate bacteria U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Other Studies ECG: NSR Chest X-Ray: Clear, without consolidation, no pneumothorax or pleural effusion U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Acute gastrointestinal hemorrhage secondary to possible: –Colorectal cancer –Peptic ulcer disease –Infectious or ischemic colitis –Mesenteric ischemia Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Transfused blood products and remained hemodynamically stable without further evidence of hemorrhage. CT Abdomen/Pelvis without contrasted significant for bilateral staghorn calculi, no evidence of retroperitoneal bleed Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Colonoscopy revealed “frond-like, villous, fungating, ulcerated non-obstructing medium-sized mass in the mid-ascending colon, and two smaller lesions in the proximal transverse colon and cecum.” Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. CT of Abdomen/Pelvis and Chest with IV contrast performed after resolution of acute kidney injury: –hepatic flexure mass with adjacent lymph nodes. No evidence of metastatic disease. 1 month after admission patient underwent right hemicolectomy which revealed a 2.5cm x 2.2 cm lesion with 3/15 positive lymph nodes Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Adenocarcinoma of colon, moderately differentiated with focal mucin production Stage III Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS