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Dyspnoea - This came on shortly after his chemotherapeutic treatments were started. He found that it happened only after he walked a few meters and he did not have any pain associated with this or Paroxysmal Nocturnal Dyspnoea (PND). This was also accompanied by an irritating non-productive cough and a husky voice. He also sometimes felt slightly light headed during the shortness of breath.
Palpitations - This occurred alone with the shortness of breath and there were no headaches or fainting associated with it. However when he got up from sitting to standing he found that he had a slight loss of vision described as darkening around the edges.
Tiredness - This tended to come and go also with the shortness of breath. There were no problems with sleeping.
Past Medical History
High Blood Pressure
Dukes C Bowel Carcinoma diagnosed November 2008
Ileostomy 2 months after that
2nd successful liver metastasis operation 6 months after diagnosis
No other relevant PMHx
Treatment of moderate to severe pain
Treatment of mild to moderate pain
Used for high blood pressure, increases fluid and salt output
Low Molecular Weight Heparin - DVT
Mother - Died of MI aged 64
Father - Stoke, also has high BP
Brother - Has angina
Worked as a joiner - Asbestos exposure unknown
Lives at home with partner plus two kids.
No support and is independent
Smoked 15/day "for as long as he can remember" up until about a year ago when he quit.
Drinks about 6 pints total per week.
General Appearance: Patient was alert and talking. Comfortable at rest and not breathless. Abdominal distention.
BP: 140/100 Pulse: 95 Temp: 36.8 Saturation: 95
Skin/Sores: Nil Urine: N
Respiratory Examination: Basal Crepitus and decreased breath sounds on the left side.
Cardiovascular Examination: Nil.
Abdominal Examination: Soft non tender. Active Stoma, two surgically induced hernias, two midline scars and a transverse abdominal scar.
These can be categorized into Pulmonary causes and other causes (most likely first based on risk factors):
Other causes of dyspnoea:
Ischemic heart disease
Full blood count + biochemistry -
Peak Flow - 460
CXR - Clear
ECG - Normal, SR, T-wave inversion (old)
CT chest - Clear
Full blood count and biochemistry
Double Contrast barium enema
His current management for prevention of cancer recurrence, control of high blood pressure and treatment of pain are sensible.
His DVT risk must be assessed as he is freely mobile. It may be prudent to take him off Enoxeparin.
Since he is suffering documented side-effects from his chemotherapy reducing his dosage or changing to a different type of agent may benefit this patient.
Chemotherapy related adverse effects
Reflective Commentary - Colorectal Cancer
Discussion on his differential diagnosis
This patient is interesting as he presented with shortness of breath and associated symptoms of a Pulmonary Embolus. He has some serious risk factors for a PE1. It has been noted that there is a four times increase in risk of developing PE in patients with previous malignancy. This risk is further increased if the patient is receiving chemotherapy. A study2 showed that the annual incidence of patients treated with chemotherapy was 10.9%. The actual percentages for cancer patients developing a PE is between 4 and 28% depending on tumor type and stage. This is quite high and was specifically noted for patients with colorectal cancer treated with a combination of fluorouracil and leucovorin. Due to these risk factors GP has been treated with a high index of suspicion, however, it is interesting to note that his dyspnoea is exertional and he did not have any other relevant clinical signs. This led the clinicians and myself to believe that there may have been another cause. Generally a PE will present with profound SOB and other clinical features which were not present. The standard procedure for a suspected PE is for the patient to undergo a CT scan. In the case of GP this came up negative which led the clinicians to look for other answers. I feel that adverse effects of chemotherapeutic agents were amongst the primary thoughts for his symptoms however this can only be diagnosed through elimination. The other main differential diagnoses to be considered are mentioned above, however, these were all excluded through the investigations ordered which came up negative in all cases. The side-effects of the chemotherapy were then documented and GP was then treated accordingly.
Colorectal Cancer (CRC) is the 2nd most common cancer cause of death in the UK3. This cancer is commoner as age increases with the average age of diagnosis being 60-65 years of age. Generally this condition is commoner in Western countries than in Asia or Africa.
Risk factors which increase the incidence of cancer are:
Diets low in fiber
High fat and meat consumption
Genetics (mutations in APC and inactivation of tumor suppressor gene)
Family history (familial adenomatous polyposis and Hereditary non-polyposis colorectal cancer) Table 14
Factors that decrease risk are:
Eating fruit and vegetables
Increasing the intake of fibers in the diet
Table 1 Lifetime risk of CRC relatives
1 in 50
1 in 17
One first-degree plus second-degree
1 in 12
One first-degree (<45)
1 in 10
1 in 6
Autosomal Dominant Pedigree
1 in 2
CRC is usually a polypoid mass accompanied by ulceration. This spreads by direct infiltration through the bowel wall. CRC then involves lymphatics and the blood vessels. It most often metastasizes to the liver. Histology of CRC is adenocarcinoma with moderately well differentiated glandular epithelium with mucin production. Characteristic features are the "signet ring" appearance in which the nucleus of the cell is displaced to the side due to mucin production.
Left sided colonic lesions typically present with an alteration of bowel habit with or without pain.
Rectal and sigmoidal cancer often bleed and this is mixed in with the stool.
Caecum and right sided colonic cancers are often asymptomatic and usually present with iron deficiency anaemia.
Change in bowel habit
FBC and routine biochemistry
Serum carcinogenic embryonic antigen level (for outcome)
Colonoscopy (for biopsies and polypectomies)
Double contrast barium enima (being replaced by CT)
Endoanal ultrasound and pelvic MRI (cancer staging)
CT and PET scanning (for tumour size, local and spread)
Faecal occult blood tests are of no value in hospital practice
Treatment involves a multidisciplinary team working in designated centers. Approximately 80% of patients with CRC undergo surgery though fewer than half survive more than 5 years. The operation depends mainly upon the site of the cancer and the long-term survival depends mainly upon the stage of the tumor and the presence of metastatic disease. Whilst Dukes classification is widely used it is now becoming more common to use the TNM classification (table 2)
Table 2 TNM Staging
Modified Dukes Classification
Stage 1 (N0, M0)
Tumor invades submucosa T1
Tumor invades Muscularis Propria T2
Stage 2A (N0, M0)
Tumor invades subserosa
Tumor invades organs direct
T1, T2 + 1-3 regional lymph nodes involved
T3, T4 + 1-3 regional lymph nodes involved
Any T + 4 Regional lymph nodes involved
Any T, any N + distant metastasis
Taken from Kumar and Clark 6th Edition
Long term survival can only be achieved if the cancer is completely removed. Total Mesorectal Excision is a surgical approach in which all the tissue surrounding the cancer is removed. This and chemotherapy reduces local recurrence rates of cancer to less than 5% and increases long term survival. Postoperative chemotherapy will improve disease free survival and overall survivability. The drugs used are 5-flurouracil and folinic acid. 5-FT plus oxaliplatin are also used together to increase survival and this is what GP has been given. This has increased his 5 year survivability from 5% to 40 to 45%.
In summary GP has been an interesting case since I have learned that often the most likely diagnosis is not the most likely cause. I have also learned the importance of exclusion as a use for diagnosis. GPs presentation was unique since he presented with some of the signs from different conditions (eg exertional dyspnoea without oedema, pain, tachypnoea etc - all signs of PE, heart failure etc) that could not be related to a simple cause. When dealing with cases like this it is always important to keep in mind all the differential diagnosis and how to exclude others to come up with a complete and accurate answer.