CASE HISTORY
EXAMPLE
PATIENT HISTORY: The patient is a 71 year old male with right flank pain radiating to the back for 3 weeks, with an unintentional ten pound weight loss. A recent bout of melena and vomiting of coffee-ground material caused him to seek care at an outside institution. His work-up revealed a single gallstone and extrahepatic bile duct dilatation to 14 mm on ultrasound, with a total bilirubin of 2.8 mg/dl and an alkaline phosphotase of 293 IU/ml. The patient had been maintained on Coumadin for pulmonary embolism prophylaxis, and had an INR of 4.5. His hematocrit was 26% at the outside institution. Cholecystectomy was performed, and the patient developed a post-operative bile leak. A JP-tube was placed, and the patient transferred to a second outside facility. This hospital performed an upper endoscopy and found a friable periampullary mass causing biliary obstruction. The patient was then sent to a local medical center for evaluation. Computed tomography revealed a 5 cm periampullary mass and periaortic lymphadenopathy. Upper endoscopy revealed a circumferential mass, around which the endoscope could not be passed. Biopsies were obtained.
Past medical history is significant for seminoma in 1999 with orchectomy and chemotherapy complicated by
peripheral neuropathy. He was "told he had a recurrence" in
2002, with unclear follow-up. The patient had not received adjuvant therapy in three years prior to
presentation. In addition, the patient had deep venous thrombosis with pulmonary embolism with pulmonary thrombectomy, lifelong Coumadin prophylaxis, and
Microscopic examination revealed an
infiltration of the duodenal mucosa by large cells with abundant clear to
slightly foamy cytoplasm, well-delineated cell
borders, with irregularly shaped nuclei with granular chromatin, and prominent,
irregular nucleoli.
FINAL DIAGNOSIS: Metastatic seminoma in the duodenum
Source: Internet: USCMC Case Studies in
Medicine