64 y/o male presents to ED ℅ lower back pain and lower abdominal pain x 3 months
CC: “My back hurts” x 3 months
O- gradual
L- left lower back/ lumbosacral area and LLQ abdominal pain
D- 3 months
C- dull
A- walking makes it worse, sitting makes it better
R- non-radiating
T- constant
S-6/10
Did you take any medications for the pain? No
Have you ever felt this type of pain before? No
Any recent travel? No
Any recent weight loss? Yes, about 10 pounds over 3 months
Pertinent positives/ negatives
- Admits to non-bloody diarrhea for the past few months- about 7 times a day and throughout the night
- Is the diarrhea malodorous? No
- Admits to generalized fatigue/ weakness
- Admits to dyspnea/ SOB on exertion
- Admits to occasional lightheadedness
- Admits to loss of appetite over past few months
- Denies chest pain, nausea, vomiting, constipation, fever, headache, urinary symptoms- urgency, frequency, hematuria
PMH: none, hasn’t seen a dr in 5 years, has no PCP
PSH: none
Allergies: NKDA
Family History: father died of unknown type of cancer at age 90, mother had diabetes
Social History:
Divorced, lives alone, works as an accountant
Diet- eats coffee for breakfast, makes a sandwich for lunch and often eats fast food for dinner
Exercise- patient does not exercise regularly
Habits- patient smokes 20 pk/yrs and drinks alcohol occasionally. Denies illicit substance use.
Sleep- states he doesn’t sleep well because he wakes up to go to the bathroom (diarrhea) multiple times a night
PE:
Vital Signs:
Pulse- 88
BP- 118/70, seated
RR: 16 breaths/ minute, unlabored
Temp- 98.6 deg F
O2 sat- 96% on room air
Ht: 68 in Wt: 180 pounds BMI: 27.4 (overweight)
General- alert and oriented x4, of average build, good posture, good hygiene, in no acute distress
HEENT: conjunctival pallor noted bilaterally,
Heart and lungs: normal S1/S2, no murmurs, bruits, lungs clear to auscultation and percussion bilaterally
Abdominal exam: tender to palpation along LLQ, no guarding, normoactive bowel sounds/ tympanic throughout, soft, non-distended abdomen, no guarding/ rebound noted, no CVA tenderness
Musculosketal: Tender to palpation across left flank L4-L5, spinous processes and paravertebral muscles non-tender to palpation, full passive and active range of motion of spine, hips, and all extremities, muscle strength 5/5 in all extremities, straight leg raise negative bilaterally
Genitourinary- uncircumsized penis with no erythema/discharge/blood at urethral meatus, no masses/ lesions on penis/scrotum, testes nontender, no masses/ swelling
Rectal Exam- blood in rectal vault, no masses noted, positive FOBT
Differential Diagnosis:
1.Colorectal Cancer– has diarrhea, fatigue, recent weight loss, loss of appetite, lower abdominal pain, positive FOBT suggesting occult blood loss
2. Inflammatory Bowel Disease- -has diarrhea, lower abdominal pain, positive FOBT, weight loss and fatigue.
3..Diverticulosis-has LLQ abdominal pain/ tenderness, and diarrhea. However, no nausea/vomiting, constipation, or fever.
4. Celiac Disease– has diarrhea, fatigue, weight loss, lower abdominal pain, and anemia. Also has back pain which could be caused by celiac due to inflammation. However, denies nausea, vomiting, constipation.
5.Nephrolithiasis– has one sided lower back and abdominal pain. However, timeline is slightly long for this (3 months) and diarrhea is not so common (more common is urinary symptoms, nausea)
Testing:
Chemistries
Sodium 144 [135-145 mmol/L]
Potassium 5 [3.5-5.3 mmol/L]
Chloride 105 [96-108 mmol/L]
Carbon dioxide 23 [22-31 mmol/L]
Anion gap 17 [5-17 mmol/L]
BUN 20 [7-23 mg/dL]
Creatinine 1.11 [0.5-1.3 mg/dL]
Calcium, total serum 9.7 [8.4-10.5 mg/dL]
eGFR 62 [>60 mL/min/1.73M2]
Troponin T 20 [0-51 ng/L]
Hematology
WBC count 8 [3.80-10.50 K/uL]
RBC count 2.75 [308-5.20 M/uL]
Hemoglobin 5.1 [11.5-15.5 g/dL]
Hematocrit 17 [34.5-45%]
Mean cell volume 76 [80-100 fl]
Mean cell hemoglobin 21.1 [27-34 pg]
Mean cell hemoglobin conc 27.8 [32-36 gm/dL]
Red cell distribution width 14.4 [10.3-14.5%]
Platelet count – 288 [150-400 K/uL]
Hepatic Panel
Albumin-3.3
Total Protein-6.4
Total Bilirubin-.08
Alk Phos-100
ALT-17
AST-30
Assessment:
Low hemoglobin and positive FOBT concerning for occult blood loss
CT abdomen with contrast- mild wall thickening and some small polyps
Colonoscopy with biopsy- polyps that were positive for cancerous tissue
Secondary Labs:
Type and Screen- B+
Serum CEA- positive
Diagnosis- Stage 2 non-metastatic colorectal Cancer 🙁
Treatment:
- Urgent RBC transfusion
- Partial Colectomy to remove portion of cancerous tissue and surrounding lymph nodes. Oncology consult to determine potential need for neoadjuvant chemotherapy.
Patient Counseling:
- Explain that unfortunately we found cancer on the biopsy of the colon- this explains his symptoms of diarrhea, left abdominal and back pain, and weight loss- the good news is it is only stage 2 and has not spread to other areas of his body, so he has a good chance of survival (75% even without chemotherapy)
- Explain that his hemoglobin is low as he has been slowly losing blood due to the cancer- this explains his fatigue and SOB, and get consent to perform an urgent RBC transfusion
- Explain that he will need surgery to remove the cancerous portion of his colon, and depending on how much colon they remove, he may need a colostomy bag, which is a bag that will remove his feces through an opening in his abdomen called a stoma. He also might need chemotherapy after surgery, depending on what the oncologist recommends, based on certain factors, such as if the cancer has grown to nearby blood vessels, if it is near the margin of removed tissue
- Explain that he will have to follow up frequently after surgery to ensure that the cancer has gone away and everything is going smoothly
- Advise on quitting smoking, as well as losing weight and trying to exercise more- these are all risk factors for colon cancer, and can increase the risk of dying from the disease as well
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