Work up for esophageal mass – which tests first and are there different approaches based on what the expected Dx is?

 

Laboratory Tests

• Anemia related to chronic disease or occult blood loss
• Elevated aminotransferase or alkaline phosphatase suggest hepatic or bony metastases
• Hypoalbuminemia

Imaging:

• Chest x-ray may show adenopathy, a widened mediastinum, pulmonary or bony metastases, or signs of tracheo-esophageal fistula such as pneumonia.

 

• While researching the topic most common way the work up was described, “maybe, most of the time, sometimes” barium swallow is the first study obtained to evaluate dysphagia
• Barium coats the surface of the esophagus, making a tumor or other unusual changes easier to see on the x-ray.
• A barium swallow test can show smooth inner lining of the esophagus, which can show even small, early cancers.
• Early cancers can look like small round bumps or flat, raised areas (called plaques), while advanced cancers look like large irregular areas and can cause narrowing of the inside of the esophagus.
• The cancer can appeare polypoid, obstructive, or ulcerative lesion and this appearance suggestive of carcinoma and requires endoscopic evaluation.
• However, even lesions believed to be benign still a endoscopic evaluation is warranted.

 

Perforation is the major complication during endoscopic submucosal dissection (ESD) of esophageal squamous cell carcinoma. If the carcinoma is larger than 75% of the luminal circumference there is risk of perforation during endoscopy. So, it would be beneficial to due the barium swallow before the endoscopy since its less invasive can be used to prevent perforation

 

• Upper endoscopy with biopsy
  • Endoscopy with biopsy establishes the diagnosis of esophageal carcinoma with a high degree of reliability. In some cases, significant submucosal spread of the tumor may yield nondiagnostic mucosal biopsies. Repeat biopsy may be necessary.
• Contrast CT of the chest and abdomen to look for evidence of pulmonary or hepatic metastases, lymphadenopathy, and local tumor extension
• Endoscopic ultrasonography with guided fine-needle aspiration (FNA) of lymph nodes is superior to CT for evaluating local extension and lymph node involvement
• Bronchoscopy may be required to exclude tracheobronchial extension
• Laparoscopy to exclude occult peritoneal carcinomatosis should be considered in tumors at gastroesophageal junction
• Positron emission tomography with fluorodeoxyglucose (FDG-PET) or integrated PET-CT imaging is indicated to look for regional or distant spread in patients thought to have localized disease after other diagnostic studies

 

Sources:

1. American cancer society
2. American society of clinical onchology
3. Current Medical Diagnosis and Treatment chapter 39 on esophageal cancer
4. https://onlinemeded.org/spa/surgery-general/esophagus/acquire
5. https://www.giejournal.org/article/S0016-5107(04)00665-0/fulltext
6. https://www.cancer.org/cancer/esophagus-cancer/detection-diagnosis-staging/how-diagnosed.html
7. https://www.cancer.net/cancer-types/esophageal-cancer/diagnosis
8. https://www.medscape.com/answers/277930-38146/what-is-the-role-of-a-barium-swallow-in-the-diagnosis-and-staging-of-esophageal-cancer

 

Preclass Assignments: Feedback for the HPI

History of Present Illness #1

72 y/o female with a PMHx of HTN, HLD, CAD s/p CABG, GERD was admitted to NYPQ from 3/17/19 to 3/20/19 with chief complaint of left hip pain s/p mechanical fall. Pt slipped while going down stairs in her house. Admits to having pain in the left hip that radiates to her left groin with a severity of 6/10. Patient describes the pain as being sharp in nature and impairs ambulation. Patient denies any chest pain, SOB, syncope, dizziness, diaphoresis, headache, palpitations. Pt deemed stable and transferred to MTC for restorative rehabilitation.

Good

1. Includes patient age, PMHx and the chief complain for admission
2. The OLDCARTS was well elaborated

Missing

1. When did the patient experience the mechanical fall
2. What is the living condition for this patient meaning does she lives alone or with other family members?
3. When did the patient get admitted to the long term care
4. What medications were given in the hospital course
5. Was there any imaging study run during the hospital course
6. How is patient balance?
7. How is the patient doing now in the LTC
8. The name of the LTC and what day was she accepted

Needs better order

1. I would put the description of the patient’s pain before describing the severity score because it helps the reader to digest the information easily
2. Overall, the order is good but more details need to be added that is necessary to provide care to the patient in the a LTC facility.

Needs to be expanded

1. Expand on the OLDCARTS meaning address if there is an alleviating or worsening factor
2. A more detailed inquiry into their neuromusculoskeletal because if there are concern for future fall the management in LTC might be different.
3. If any new diagnosis were made because I have no idea if the patient has a fracture or just bruises
4. What medication did the patient receive in the hospital and how did the patient respond to the treatment?
5. What imaging study was conducted and what is the differential diagnosis
6. Needs to add more pertinent negatives and positives

 

Write a brief summary of the feedback you would give this student

Good job in the first attempt in writing an HPI for LTC which differs a little from general HPI. Overall, the HPI does an effective job in highlighting aspects of OLDCARTS but more details regarding hospital course and current condition in the LCT facility is necessary to paint a full picture of the patient circumstances. The differential diagnosis, imaging, medication and the patient’s response of the treatment need to be part of the HPI in order for LTC providers to assist the patient effectively. Additionally, patient living condition should be mentioned because that might determine the discharge condition of the patient from the LTC.

 

History of present illness #2

83 yo female with a PMHx of DMII, HTN, CAD, CVA x 2, Afib on Coumadin, MI x 2, RA, scleritis was hospitalized at NYPQ from 03/22/19 to 04/10/19 presenting with syncopal episode associated with polydipsia, polyuria, and lethargy. Pt was found by family member passed out on kitchen floor. Upon EMS arrival pt had a tonic clonic seizure and lethargic and was given 5mg midazolam and intubated to protect airway on ED arrival. Pt was transferred to MICU sedated, intubated, and on insulin gtt. Pt treated with loading dose of Dilantin and keppra and transitioned to Keppra and Vimpat due to transient hypotension. MRI brain showed possible SAH in left temporal, occipital, and parietal lobes and lovenox for afib was discontinued. Hosp course c/b fever, dxed w MSSA in nares and treated with Abx therapy. Pt extubated on 3/27/19 and noted to be stable under Keppra and Vimpat. Pt became increasingly dyspneic and repeat CXR showed new perihilar edema. Lasix started and breathing improved. Gram negative PNA was presumed and treated with IV cefepime x 7 days, doxy x 4 days, vanco x 7 days. Pt’s seizure med dose adjusted due to increased somnolence by neuro. Pt found to be normocytic anemic 2/2 to hydroxyurea. Heme/onc consult for essential thrombocytopenia and recommended to dec dose of hydroxyurea due to anemia.

 

Good

1. Includes patient age, PMHx and the chief complain about admission
2. Through list of the medication that was administer in the course of hospital stay
3. What medication need to be adjusted in the patient care
4. Includes the competency of the patient
5. Includes the source of information which is a important aspect of HPI

Missing

1. When did the patient start to take the hydroxyurea medications because this information was mentioned earlier and presented at the end of the HPI.
2. What is the living condition for this patient meaning does she lives alone or with other family members
3. When did the patient get admitted to the long term Care
4. How is the patient doing now in the LTC
5. The name of the LTC and what day was she accepted

 

Needs better order

1. Order was manageable but it was very detailed and wordy which made it difficult to follow the course of the patient hospital stay. I think it is imporatan to deciding what materials should be added into the HPI and what information need to be leave out.
2. The HPI only describes the ER arrival to the discharge but it’s missing the transition to the LTC which is essential to establish patient current status. The order of arrival to ER to the discharge to a LTC facility

Needs to be expanded

1. Her living condition need to be explained to have a picture of amount of dependence
2. Expand on the OLDCARTS meaning address if there is an alleviating or worsening factor
3. How did the patient respond to the antibiotics?
4. Why did the patient is on hydroxyurea?

 

Write a brief summary of the feedback you would give this student

Overall, this HPI was a detailed and good attempt in capturing the journey ER arrival to the hospital course management. I appreciate that the HPI was detailed and it included imaging, medication name and dose that was administer in the hospital. However, since it was very detailed oriented, it was little difficult to keep up with so I think if it is broken into paragraph with dates then it might be easier for the reader to understand. Providing the story with specific date helps the reader to follow along better. The purpose of the HPI is to provide a full journey of patient from hospital admission to the day of LTC to another provider in order ensure proper treatment. So, I think this HPI need not inform the reader how the patient is currently doing in the LTC which is a fundamental aspect of the patient care. Furthermore, Try not to present a new idea at the end of the HPI such as a medication name if it was not discussed throughout the HPI because that confuses the reader because he/she is not aware if the patient was already on the med or the course started in the hospital or need to be started in the long term care. Regardless of the small issues, I thought this was a very detailed and well attempt HPI.