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Morbidity and Mortality Conference

Morbidity and Mortality Conference. Jennifer Y. Lee February 6, 2002. Which of the following is NOT an upper motor neuron sign?. Babinski Sign Kehr’s Sign Strumpell’s Sign Hoffman’s Sign Stransky’s Sign. Presentation to Primary Care Physician, 3/28. CC: chest pain

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Morbidity and Mortality Conference

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  1. Morbidity and Mortality Conference Jennifer Y. Lee February 6, 2002

  2. Which of the following is NOT an upper motor neuron sign? • Babinski Sign • Kehr’s Sign • Strumpell’s Sign • Hoffman’s Sign • Stransky’s Sign

  3. Presentation to Primary Care Physician, 3/28 • CC: chest pain • HPI: 70 year old female presents with c/o R sided chest pain x 4 days. • Mild in intensity, but worse with deep respirations. • Not exertionally-related. • No associated fever, cough, SOB, leg swelling. • Pt. is concerned that this pain is related to a newly-discovered R breast nodule found on routine exam.

  4. Past Medical History • Rheumatoid arthritis, dx 1986 • RF+, currently on methotrexate alone • Pernicious anemia • Hashimoto’s thyroiditis • Benign thyroid nodule • Hx of methotrexate-induced pneumonitis in 1988 • fever, cough, dyspnea, bilateral alveolar infiltrates • Newly-discovered right breast nodule, mammogram pending

  5. Medications • Methotrexate 2.5 mg PO q week (restarted in 1989 without complications) • Vitamin B12 1000 mcg SQ q month • Levothyroxine 0.088 mg PO qd • Flurbiprofen 100 mg PO qd • Pt has NKDA

  6. Never been a smoker No alcohol or illicit drugs Married x 44 years Retired secretary without significant occupational exposures Mother died at age 57 of ovarian cancer Father died at age 86 of “leukemia” No early CAD No HTN, DM No breast, colon CA Social History Family History

  7. Physical Examination Vitals: T-36.8 BP-126/70 HR-98 RR-18 O2 sat not recorded Gen: Well-appearing elderly female HEENT: Anicteric sclera, oropharynx clear, JVP 6 cm Lungs: Diffuse rales bilaterally, right>left; no friction rub; good air movement; no wheezing Heart: RRR without m/r/g Abd: Soft NT/ND without HSM Ext: No c/c/e; good peripheral pulses in all 4 ext.; nodules in Achilles tendon, fingertips, olecranon

  8. Physical Examination (cont) Joints: Nontender, + synovitis of bilateral MCPs and PIPs Breast: 1 cm firm, round, smooth, mobile nodule 2” lateral to right nipple Node: No abnormal lymph nodes palpable in occipital, cervical, submental, supraclavicular, axillary or epitrochlear regions

  9. Primary Care Physician Appointment (cont) • Respirophasic chest pain - ? Etiology • Plan to get CXR in the next few days when patient scheduled for mammogram

  10. F/U Appointment with Primary Care Physician, 4/2 Interval history: • Respirophasic chest pain resolved spontaneously after 24 hours • New mild non-productive cough x several days • Mild decrease in appetite x few weeks • Reduced energy level x several months • No fevers, SOB, sputum production, night sweats, weight loss No changes in physical exam

  11. F/U appt. with PCP (cont.) • 3/31/01 mammogram and U/S – 1 cm nodule in the right breast, suggestive of benign cyst • Impression: Metastatic cancer to lungs from unknown primary • Plan: Share unfortunate news with patient; Routine labs, CT C/A/P, bone scan, referral to DHMC Pulmonary for possible bronchoscopy

  12. Pulmonary clinic appt., 4/11/01 Interval history: • Severe non-productive cough and profound DOE x 4 days • Anorexia x 4 days • Much worsened fatigue x 2 days • Disorientation x 2 days • Denies F/C, chest pain, LE pain or swelling

  13. Pulmonary clinic appt (cont.) Gen: Moderate respiratory distress, AAO x 2 (confused about date/time) Vitals: T-36.8 BP-98/62 HR-113 RR-28 O2 sat 68% on RA, 89% on 100% NRB Lungs: Diffuse rales bilaterally Heart: Tachycardic, but regular rhythm; no m/r/g Abd: Soft NT/ND BS+ Ext: No c/c/e; warm and well-perfused

  14. Pulmonary clinic appt. (cont) Review of outside labs/studies (4/2/01): 20 11.0 138 100 84 4.6 275 4.9 NP 1.0 32.0 Ca 9.6 84S 8 L 5 M 2 Eo 2 Ba TP 6.5 Alb 3.1 T bili 0.6 AST 118 ALT 92 Alk P 423

  15. Pulmonary clinic appt (cont) • Impression: 70 y/o female with hypoxemia and multiple pulmonary nodules, presumably metastatic cancer • Plan: Admission to the ICU for further evaluation/management

  16. Admission to ICU DHMC lab data (4/11) : Ca11.6 (12.9) 12.3 134 96 35 318 10.8 Mg 1.03 Phos 3.7 1.1 4.8 17 34.3 75S 15B 3L 6M 0Eo TP 6.3 AST 176 Alb 2.4ALT 56 T bili 1.1 Alk P 266 D bili 0.6 PT 15.3 INR 1.3 PTT 23 D-dimer 5040 7.44/29/53 on 100% NRB

  17. Assessment/Plan • Hypoxia – 20 to metastatic CA, but ? complicated by PE • Supplemental O2 to keep sat > 90% • Trial CPAP if needed • Verify pt’s wishes regarding intubation • Doppler LEs for DVT • CT scan for PE • Methylprednisolone 125 mg IV qd • Treat underlying disease

  18. Assessment/Plan (cont) • Pulmonary/Liver nodules – metastatic disease from unknown primary, most likely breast CA • Breast biopsy ASAP • Consult Oncology Service • Volume depletion/hypercalcemia • Hydration with NS • End of life issues • Discuss prognosis with patient and family • Verify Code Status

  19. ICU Day #1 • Prognosis/Code Status discussed - pt. made DNR/DNI • LE dopplers obtained - negative for DVT • CT chest for PE - multiple bilateral nodules throughout lungs, c/w metastatic disease; no intravascular filling defect • Placed on CPAP, saturating 89%

  20. ICU Day #2 • O/N, pt. subjectively much improved. • CPAP D/C’d, changed to 100% NRB, saturating 88-91%. RR decreased to 22. • Breathing comfortably; PE otherwise unchanged. • Breast biopsy obtained, tumor markers sent. • Arrangements made for transfer to M3 - Oncology service.

  21. Tx to M3-Oncology Service, HD #2 • Chart reviewed, pt. interviewed and examined • Medication list: Methylprednisolone 125 mg IV qd, Pepcid 20 mg IV bid, Heparin 5000 U SQ bid, Morphine IV prn • VS: 35.3 114/64 75 24 95% on 100% NRB • No significant change in PE • Labs: 10.2 133 99 39 Ca 8.9 CA 19-9, CA 15-3, CEA, CA 27.29 all pending 4.1 218 4.7 24 0.9

  22. M3-Oncology Service, HD #2 (cont) • Assessment/Plan: • Hypoxia - secondary to diffuse pulmonary nodules; continue methylprednisolone 125 mg IV QD • Pulmonary/Liver nodules - most likely metastatic CA from unknown primary; F/U breast biopsy and tumor markers • Hypercalcemia -PTH and PTH-RP; IVFs, Pamidronate 90 mg IV x 1 • Volume depletion - IVFs

  23. M3-Oncology, HD #3 • Pt’s respiratory status stable overnight, but still requiring 100% NRB to keep sats greater than 92%. • Breast biopsy • Fat necrosis • Plan: U/S-guided liver biopsy for definitive tissue diagnosis

  24. M3-Oncology, HD #4-10 • Pt. feeling better each day. No SOB/DOE. Got hair done at Split Ends. • Weaned from 100% NRB to 2L NC, saturating 96%. • Lungs: CTA bilaterally • Steroids weaned to Prednisone 60 mg qd. • Alternative diagnoses to solid tumor considered. • Still awaiting report from Pathology on liver biopsy.

  25. What’s the diagnosis? • 1. Metastatic cancer from unknown primary • 2. Sarcoidosis • 3. Lymphoma • 4. Methotrexate-induced lung/liver toxicity • 5. Extra-articular rheumatoid arthritis

  26. Core biopsy - Liver

  27. CD 3 T cell marker

  28. CD 79a B cell marker

  29. M3-Oncology, HD#11 • Tolerated bone marrow biopsy well • Pt. feels wonderful, now saturating 96% RA • Awaiting bone marrow biopsy results

  30. Bone marrow - low power

  31. Bone marrow - high power

  32. CD 3 T cell marker CD 79a B cell marker

  33. M3-Oncology, HD#12 • Pt. doing well, no need for continued inpatient stay. • Plan: Wean steroids; plan for open lung biopsy when underlying disease re-emerges

  34. Discharge medications, 4/24 • Prednisone taper over two weeks • Levothyroxine 0.088 mg PO qd • Famotidine 20 mg PO bid • Docusate sodium 100 mg PO bid • Benzonatate 100 mg PO TID prn • D/C Methotrexate

  35. F/U with Heme/Onc and Rheumatology, 5/01 • Pt doing wonderfully, is glad to be alive and well. Undergoing steroid taper. • Saturating well on RA • Lungs are CTA bilaterally • Assessment/Plan: Continue steroid taper. F/U closely with primary care physician. • Final Liver Path: Clonal TCR gamma rearrangement  c/w lymphoproliferative disorder

  36. Lane 1 - liver 2 - bone marrow, tissue from flow 3 - bone marrow, formalin-fixed tissue 16 - positive control 1 2 3 - - - - - 16

  37. F/U with Primary Care Physician, 5/25/01 • Doing well. Off steroids x 2 weeks. C/o mild discomfort in her hands bilaterally. • O2 sat 97% RA, lungs CTA bilaterally • F/U labs: 10.8 TP 7.2 Alb 3.2 T bili 0.4 AST 19 ALT 27 Alk P 189 137 103 16 349 6.1 4.2 22 1.1

  38. F/U with Rheumatology, 6/27 • C/o worsened bilateral hand pain, despite recent addition of flurbiprofen 100 mg bid • PE shows synovitis in wrists, MCPs, PIPs, ankles, and feet. • Assessment: Symptomatic RA, off prednisone and methotrexate • Plan: Start Prednisone 5 mg PO QD

  39. F/U with Primary Care Physician, 7/2001 - present • Pt. doing wonderfully. Arthritis well-controlled with low-dose prednisone. • Labs: CBC, lytes Bun/Cr, Ca, LDH all WNL LFTs WNL except for Alb 3.3 • PFTs: well preserved lung volumes, normal spirometry, mod-severe diffusion defect with DLCO 48%

  40. Work in Progress…What would you do next? • 1. Bone marrow biopsy • 2. Bronchoscopy with biopsy • 3. Open-lung biopsy now • 4. D/C steroids, then open-lung biopsy • 5. Initiation of chemotherapy • 6. Watchful waiting

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