The Shortness Of Breath Biology Essay

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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

High Cholesterol

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

Drug History

NKDA

Drug Name

Dose, Frequency

Indication

Tramadol

100mg/4hrs

Treatment of moderate to severe pain

Paracetamol

1g/4hrs

Treatment of mild to moderate pain

1mg

Bendrofluezide

2.5mg daily

Used for high blood pressure, increases fluid and salt output

Enoxeparin

40mg daily

Low Molecular Weight Heparin - DVT

Family History

Mother - Died of MI aged 64

Father - Stoke, also has high BP

Brother - Has angina

Social History

Worked as a joiner - Asbestos exposure unknown

Lives at home with partner plus two kids.

12 stairs

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.

Examination

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.

Neurological

Wears glasses

Differential Diagnosis

These can be categorized into Pulmonary causes and other causes (most likely first based on risk factors):

Pulmonary:

PE

Pneumonia

Bronchitis

Emphysema

COPD

Lung CA

Sarcoidosis

Other causes of dyspnoea:

Chemotheraputic agents

Heart Failure

Ischemic heart disease

Cardiomyopathy

Laryngeal CA

Adrenal insufficiency

Investigations

Full blood count + biochemistry -

Blood Test

Result

//2009

Normal Range

FBC:

Hb

RCC

Haematocrit

MCV

WBCC

Platelets

Neutrophils

Lymphocytes

MCHb

15

85

10

255

7

2

28.6

13-18g/dl

3.9-5.6x1012

0.35-.5

79-100fl

4-11x109fL

150-400x109L

1.5-7.5 x109L

1.5-3.5

25-32

LFT

bilirubin

alk phos

AST

ALT

total protein

albumin

globulin

19

80

28

35

74

39

35

3-17umol/L

33-117iu/L

8-60

3-35iu/L

62-82g/L

37-50g/L

21-35g/L

G-GT

+76

U&Es:

urea

creatinine

sodium

potassium

chloride

bicarbonate

4.9

2.5-7.5mmol/L

44-125umol/L

135-145mmol/L

3.5-5.0mmol/L

97-107mmol/L

23-30

Glucose

5.3

(3.5-5.5 mmol/L)

CRP

2-10mg/L

Cortisol random

Nmol/L

eGFR

>60

60-999

Peak Flow - 460

CXR - Clear

ECG - Normal, SR, T-wave inversion (old)

CT chest - Clear

Management plan

Full blood count and biochemistry

Colonoscope

Double Contrast barium enema

Pelvic MRI

CT scan

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.

Diagnosis

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

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

Exercise

Table 1 Lifetime risk of CRC relatives

Number

Population risk

1 in 50

One first-degree

1 in 17

One first-degree plus second-degree

1 in 12

One first-degree (<45)

1 in 10

Two first-degrees

1 in 6

Autosomal Dominant Pedigree

1 in 2

Aetiology

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.

Presentation

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.

Red flags:

Change in bowel habit

Rectal bleeding

Anorexia

Weight Loss

Tenesmus

Faecal incontinence

Passing mucus

Investigations

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

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

5-year survival(%)

Stage 1 (N0, M0)

Tumor invades submucosa T1

Tumor invades Muscularis Propria T2

A

80-95

Stage 2A (N0, M0)

Tumor invades subserosa

T3

B

72-85

Stage 2B

Tumor invades organs direct

T4

B

65-66

Stage 3

T1, T2 + 1-3 regional lymph nodes involved

N1

C

55-65

Stage 3B

T3, T4 + 1-3 regional lymph nodes involved

N2

C

35-42

Stage 3C

Any T + 4 Regional lymph nodes involved

N2

C

25-27

Stage IV

Any T, any N + distant metastasis

M1

D

5-7

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%.

Summary

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.

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