Stage Iv Adenocarcinoma Case Study

History of Present Illness: The patient is a 27-year-old male complaining of right lower-quadrant abdominal pain, nausea, and

Peripheral pulses posterior tibial and dorsalis pedis 2+ bilaterally. No edema on legs. Apical pulse regular rate and rhythm; s1, s2 noted. No murmurs, rubs or gallop rhythms. Denies dizziness, and fainting. Resp RR between 36-40 SpO2 85% per oximetry on 2 liters oxygen by n/c. Difficulty breathing and complaints of chest tightness. Patient unable to lay flat. Lung sound bilateral wheezes and crackles in right lower lobe. All other lobes clear A&P. Cough with yellow sputum. Tachypnea. Head of bed 45 degree. GI Last bowel movement 2 days ago, hard, long brown stool. Complains of constipation related to medication. Bowel sound are WNL in all 4 quadrants. Abdomen is soft, with no palpable masses. Poor appetite. Like sweet foods. Does not like vegetable or fruits. Like sodas, beer, scotch. Little water intake. GU Urinates every 2-3 hours. Yellow. No odor of urine. No history of UTI. One vaginal infection 2 years ago. No abnormal periods, last menstrual period 3 weeks ago. No pain or discharge. Skin Hair poorly groomed, dirty and oily. Nail are dirty and appear to be bitten. Skin clammy and moist with flushed color. IV IV of D5W at 125 mL in left forearm with 18

HEENT: No thyroid enlargement, masses or adenopathy, JVP was 5 cm above sternal Angle, carotid pulse was strong and regular

PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.

She converses appropriately. Blood pressure 92/60 supine. Blood pressure decreased to 72/50 standing. Pulse is 90 and regular. Weight 113 pounds. She has a normal appearance of her face and does not have a masked appearance of her face. She has good strength throughout her face. She has good strength of her extremities. She has only minimal cogwheel rigidity at the left wrist, but no cogwheel rigidity at the right wrist. She has no tremor of her hands. She moves her extremities freely and with normal speed. She is able to rise on her own from a sitting to a standing position, only minimal bradykinesia of standing. She walks fairly freely and there is a normal cadence of her gait. She did not have dyskinetic movements of her extremities. She is able to walk, including turning without losing her balance. She does not shuffle her feet when walking. She does not have en bloc turning. She has good posture stability

Generally, this is a well-developed man sitting comfortably in no acute distress. Skin is warm and dry. HEENT: Head is normocephalic, atraumatic. Pupils equal, reactive to light and accommodation. Sclerae are anicteric. Oral mucosa is moist without lesions. No JVD. No thyromegaly. Lymphatics: No cervical, supraclavicular, axillary, or inguinal adenopathy appreciated. Respiratory: Lungs are clear to auscultation bilaterally. Heart: Regular rate and rhythm. Abdomen: Soft, nontender. Positive bowel sounds. Liver and spleen not palpable. Strength is 5/5 throughout. Neurological exam is

Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetric chest expansion. Breathing nonlabored. Diminished breath sounds in all lung fields. Resonant to percussion.

On assessment today, blood pressure is 140/66, pulse 78, weight 249 pounds, down 2 pounds from previous. The neck is supple. Short stature without adenopathy, (thyromegaly), nodules, tenderness.

States that it started 3 days back and uses oxygen at home. States that he is a former smoker and laying on his back feels better. Also says he has a list of medication, more than 20. Pt has a history of COPD, CHF, DM,morbid obesity, HTN, HLM, hypothyroid, and sleep apnea. Has no accessory muscle use. CC is shortness of breath. Assessment is that there is no deformities or trauma of the head or neck area. Chest shows no signs of deformities or trauma. The abdominal area is tender and warm to the touch. Pelvis and back was not assessed. The upper and lower extremities show signs of low circulation and swelling. PMS=4. I helped with placing the BP cuff on the left arm and attaching it to the monitor. First vitals were recorded. O2 was given by the Nurse and then Albuterol by nebulizer. After 30 minutes, I assisted the Nurse and other hospital workers in moving the PT to a bigger bed. Second set of vitals were recorded. After becoming stable the Pt was moved up to the floor.

His past medical history is pretty benign. He smoked only in his youth probably quit before he was 30 years old. There were no chronic diseases. His past history included an appendectomy, cataract extraction in the distant past. He did see Mike Pike at Cary GI for esophageal problems and apparently had a couple of dilatations of esophageal strictures. He had been followed by the neurology clinic by Dr. Perkins for sleep apnea and used CPAP for the last several years. He does have glaucoma. His most significant past history was that he had some type of a follicular lymphoma treated by Ken Zeitler. He took a pill which apparently put it in remission and took no radiation therapy or chemotherapy. Apparently, he was living very independently in all his ADL's. He drove, took care of all the finances, could complete all his ADL's and instruments of daily living. He was actually still working buying produce at the farmer's market and distributing it and selling it to various restaurants. All this came to an abrupt ending on 10/13, when he presented to the hospital with an acute stroke was there for a week. He had some abnormal liver findings. They thought it might be a recurrence of the lymphoma but these were biopsied and turned

He started seeing doctors last December, but nothing serious was diagnosed until two weeks ago, when a gastroenterologist spotted "something very concerning," which after four days was confirmed as stage IV stomach cancer with a grim survival prognosis.

In general he is a not acutely ill appearing male. His neck veins were elevated to the angle of the jaw. He had no thyromegaly or lymphadenopathy. His lungs were clear to auscultation. His heart was regular rate and rhythm with an S3 and an S4. His PMI was laterally displaced by 1 cm. His abdomen was (full), slightly distended and had a positive fluid wave. He had no pitting edema in the abdominal exterior wall. His rectal exam was heme-negative. His extremities showed 4+ pitting edema up to his knees and in his feet

ABDOMEN: The lung basis appeared unremarkable. The liver, spleen, gallbladder, adrenals, kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened. Dilated appendix seen constant with acute appendicitis. Osseous structures of the abdomen appeared unremarkable. No free air was seen.

Neurological system. Upon inspection, Mr. Fedora has a high level of consciousness, as he was awake, and alert. He has a strong cough that is producing yellow sputum. His gag reflex is present and reports feeling nauseous. The pt. has been dry heaving, but not actively vomiting. Mr. Fedora’s motor function is adequate. Pt. reports pain to his chest and abdomen.

We have seen 70 years old, right handed, independently mobile gentleman who woke up at 06:45hrs and went into en suite bathroom. Suddenly wife heard a thud who found him collapsed & disoriented appeared he