Colorectal Cancer

HPI

Dr. H.U. is a 53 yo old Asian American male, who was diagnosed with colon cancer 18 months ago. He had been completely asymptomatic until the onset of RLQ discomfort. Four days after the initial onset of symptoms, he experienced severe abdominal pain (9/10 on the standard pain scale) and presented at the emergency room. An abdominal CT scan revealed a mass in the RLQ involving the colon. A 4.5-cm tumor was surgically resected and all signs of visible disease were cleared. There was no sign of liver or lung involvement on CT scan or upon gross examination by the surgical team. Abdominal lymph nodes were biopsied to determine the extent of the disease. The pathology report revealed that the colon tumor was a poorly differentiated adenocarcinoma. The tumor had penetrated deep through the entire width of the wall of the ascending colon and perforated the visceral peritoneal membrane. Extent of the cancer was consistent with stage IIB.

Colorectal Cancer

HPI

Serum CEA was 15.9 ng/mL. The patient underwent six cycles of fluorouracil (425 mg/m² IV QD X 5 days) plus leucovorin (20 mg/m2 IV QD X 5 days) administered every 4-5 weeks as the patient was able to tolerate. After adjuvant chemotherapy was completed, chest and abdominal CT scans were negative and serum CEA was 3.4 ng/mL. The serum CEA level indicated that the patient had achieved a remission.

Colorectal Cancer

HPI

Last month, however, the patient noticed bright red blood on the surface of the stool and immediately contacted his oncologist. He reported that he was not experiencing any pain, fatigue, bloating, vomiting, constipation, or diarrhea. His serum CEA had increased to 23.2 ng/mL and exploratory laparotomy revealed recurrent cancer in the terminal ileum and a large segment of the descending colon that extended into the rectosigmoid colon. There were no signs of disease in the rectum. A chest CT scan was normal, but an abdominal CT scan and ultrasound revealed evidence or multiple (12-15), small, hepatic metastases. All regions of tumor involvement in the ileum, descending colon, and rectosigmoid colon were resected and a colostomy was performed.

Colorectal Cancer

PMH

• Chickenpox at age 6
• Asthma x 35 years
• Crohn disease X 8 years
• Portion of jejunum resected 6 years ago (scarring and stricture from Crohn disease ⟩ obstruction)
• Type 2 DM X 6 years
• Bilateral osteoarthritis of the knees X 3 years
• Intra-articular cortisone injection, both knees, 5 months and 2 months ago
• Negative for serious injuries or bone fractures

Colorectal Cancer

FH

• Father, age 75, is alive but has type 2 DM, CAD, and several episodes of severe depression with suicide attempts
• Mother, age 72, has traits of OCD but has not been diagnosed or treated
• Patient has 7 siblings-two sisters with HTN, one brother with Addison disease, one brother with type 2 DM and hypothyroidism, one sister with Down syndrome
• No family history of cancer
• He is married with one son, age 35, who is alive and well

COLORECTAL CANCER

SH

• Patient is a university professor of pathology and primate research
• Has smoked 3-4 cigars/day for 20 years
• Drinks 2-3 cans of beer and 1 glass of sake daily
• Sedentary lifestyle

COLORECTAL CANCER

Meds

• Metformin 500 mg po BID
• Budesonide 9 mg po OD
• Vitamin B12 1000 μg IM Q month
• Albuterol inhaler PRN (recently less than 1 X/week)

All

• Adhesive tape and latex (rash)

COLORECTAL CANCER

ROS

The patient lost weight, but he is finally getting his strength back after his second surgery. No chest pain, headaches, SOB, DOE, weakness, fatigue, or wheezing. Complains of mild irritation around the colostomy site but states that the "bag is working well" with no current malodorous problems. He has had some diarrhea with fluorouracil and leucovorin therapy in the past but took loperamide and tolerated side effects "fairly well." He still has a few aches and pains in his knees.

COLORECTAL CANCER

PE and Lab Tests

Gen

• Middle-aged Asian American male
• Appears stated age of 53
• Cooperatively but mildly anxious, oriented, attentive, and NAD

Vital Signs

See Patient Case Table 19.1

Patient Case Table 19.1 Vital Signs
BP                        120/65 (sitting, L arm)	RR                        17 and unlabored	HT                         5’10½”
p                            70 and regular	T                            98.3°F	WT                        179 lbs.

COLORECTAL CANCER

Skin

Warm with normal turgor and no lesions

HEENT

• PERRLA
• EOMI
• Mildly icteric sclera
• Fundi Benign
• TMs intact
• OP clear with moist mucous membranes

COLORECTAL CANCER

Neck/LN

• Neck supple
• (-) cervical or axillary lymphadenopathy

Thorax

• Lungs are clear to auscultation and resonant throughout all lung fields

COLORECTAL CANCER

Heart

• RRR
• Normal S1 and S2
• (-) murmurs, rubs, or gallops

Abd

• Colostomy in LLQ
• Tender at both costal margins
• Hepatomegaly prominent
• Mild distension with some ascites

COLORECTAL CANCER

Genital/Rectal

• Normal male genitalia
• Slightly enlarged prostate with no distinct nodules
• Heme-negative stool
• No rectal wall tenderness or masses

Ext

• (-) CCE
• Pulses intact throughout

COLORECTAL CANCER

Neuro

• Speech normal
• CNs II-XII intact
• Motor: normal strength throughout
• Sensation normal Reflexes 2 + and symmetric throughout
• Babinski negative bilaterally
• Rapid movements, gross and fine motor coordination are normal
• Good sitting and standing balance

COLORECTAL CANCER

Neuro

• Gait normal in speed and step length
• Alert and oriented X 3
• Able to do serial 7's
• Able to abstract
• Short-and long-term memories intact
• No peripheral neurologic deficits secondary to DM

COLORECTAL CANCER

Laboratory Blood Test Results

See Patient Case Table 19 .2

Patient Case Table 19.2 Laboratory Blood Test Results
Na                 140 meq/L	Hb                14.2 g/dL	ALT                169 IU/L
K                   4.0 meq/L	Hct                44%	LDH                479 IU/L
Cl                  101 meq/L	RBC              5.3 X 106/mm3	Total bilirubin              1.9 mg/dL
HCO3             26 meq/L	Plt                  429 X 103/mm3	Alb                    2.9 g/dL
BUN               9 mg/dL	WBC              6.5 X 103/mm3	Total protein     4.5 g/dL
Cr                   0.7 mg/dL	CEA               16.1ng/mL	Ca                     9.2 mg/dl
Glu, fasting    161 mg/dL	AST                78 IU/L	PO4                   3.5mg/dl

COLORECTAL CANCER

Clinical Values for Case Study Problem-Solving

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations

Reference for digestion (or gastrointestinal)

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Gastrointestinal system diseases