Newly diagnosed colorectal cancer

Patient: Mr C.R, 70 y.o. presents with newly diagnosed colorectal cancer in the setting of steriod treatment for his giant cell arteritis and repeated episodes of collapse.

HOPC:

He was diagnosed with colorectal cancer 2 weeks ago in the general ward. A CT scan showing a rectal cancer with mets to both the liver and lungs. A colonoscopy and biopsy was also done on him to confirm the diagnosis. (rememeber to ask!!) His symptoms of colorectal cancer are a 6 week history of fecal incontinence, blood in his stools and SOB. With regards to his fecal incontinence, this tends to come on particulary when he goes to the toilet to urinate and he would soil his pants. He therefore consciously sits on the toilet seat before urinating to prevent soiling his pants. (getting worse? agg/reliefing factors? concerns? previously had this problem?) His bowel motions are unchanged( know how many times?), no diarrhoea or constipation, no abdominal tenderness, bloating or vomiting or fatigue reported. His stools are solid although he reports occasional bright red blood in the stools(quantify?) or black coloured-stools. He also reports recent weight loss but is unable to quantify it for me. (still get the baseline). His SOB gradually came on over the last 6 weeks, previously fit and was not physically inhibited from SOB but now currently is only able to walk about 10m before feeling SOB. Exertion makes the SOB worse and rest makes it better. No chest pains, palpitations. No sputum, cough, fevers, rigors. No orthopnea, PND, lies flat when he sleeps.

Current treatment for his cancer is palliative chemotherapy which he started 3 days ago and during the course of the chemo he was feeling unwell and nauseated. Currently he is feeling well. (what chemo?)

Related medical hx:

He was diagnosed with GCA by a biopsy 6 weeks ago at the eye and ear hospital. His symptoms were bitemporal pain (U WANT TO KNOW MORE!). He was then started on high dose steriods(how much?) to prevent vision loss. As a result of his treatment, he developed steriod induced DM and is currently on novorapid sliding scale for it. He claims that it was the steriods that made him feel nauseasted and unwell. And that his symptoms coincided with the steriod treatment. Currently, his vision is still intact.

4 weeks ago, he had an episode of collapse due to muscle weakness. This happened in the morning when he got up to urinate and when he exited the toilet he actually collapsed with associated sweating. There was no other neurological deficit, no LOC, loss of vision, no speech impairment, confusion, abnormal muscle jerks. He was unable to get up and his wife called the ambulance, he slowly regained strength 2 hours later at the ED. He was drowsy but otherwise alert after the attack. There was no post-ictal confusion, residual neurological deficits such as sensory or muscle strength deficits. Before the attack there were no warning signs, no changes to his vision or feeling of impending doom or being unwell, no palpitations. Never reported having signs of a postural drop. he had never had an episode of collapse before this. Over his stay in hospital he had 3 more episodes of similar nature and currently goes to the toilet only under supervision. Increasing in frequency? Currently he is under specialist care for his collapse episodes and is having a 24hr bp monitor.

• spine operation + laminectomy done for an accident during work in 1983.
• double heart bypass in 1997. Since then he has not complain of anymore chest pains.
• He has a few broken ribs and bones as a result of his occupation.
• No HT, cholesterol, has smoked 10 pack years from age 18-28. No diabetes.

Medication: paracetomol, caltrate, cholecalciferol, pantoprazole, nilstat, pethidine, oxynorm, metoclopramide, novorapid.

Family Hx

• Father died at 70 due to lung cancer which he thought was due to his father's excessive smoking habits.

Social Hx

• Living - wife,66
• No problems with ADLs - previously very fit. Learnt to live healthily after the heart operation and the spine surgery
• Not depressed
• Financially stable
• Exercise - very often, mountain bikes daily to give out pamphlets and walks his dog often
• occupation-carpenter
• Diet- eats healthy lots of greens. Doesnt drink.

Physical exam: abdo, heart, lungs normal

In summary, Mr R is a 70 year old gentlemen with newly diagnosed colorectal cancer in the setting of steriod treatment for his GCA and unexplained episodes of collapse. His main issues are diagnosis and managment of his collapse, managment of his colorectal cancer along with symptomatic treatment for his SOB, blood in his stools and fecal incontinence, managment of the treatment for his GCA which involves altering the dose of steriods that balances between GCA disease activity and the development of steriod use complications such as steriod induced DM. And discharge planning for him such as a personal alarm, social support, occupational therapy and community help.

What are the differentials for his SOB?

1. pleural effusion - hypoalbuminaeima
2. lymphangitis carcinomatosis
3. PE-from hypercoaguable states.
4. infection
5. bronchial obstruction leading to collapsed lung
6. pericardial effusion
7. cardiac tamponade.

Consider concurrent illnesses: CCF, COPD.

What investigations would you order?

1. CXR
2. ABG
3. ECG(silent infarct)
4. CT(lymphangitis?)

What are your differentials for his episodes of collapse?

1. Micturation syncope - less likely due to no LOC
2. cardiogenic - arrhythmia? no palpitations?
3. neurogenic - brain mets causing seizures? no prodrome or post-ictal phase. ictus was also atypical.
4. postural hypotension - no history of dizziness when he changes posture
5. vasovagal, effort cough syncope to be considered
6. metabolic? (NO!!!)

ECOG performance status. If 2 or below we treat cancer, if 3-4 treating with chemo does not provide benefits to QOL. Some cytotoxics are reserved for 1. Extensive small cell carcinmoa is an exception, 6 weeks death without treatment. Cancers are very chemosensitive.