Pharmacology Case #6

University of Alabama at Birmingham
Pharmacology Case #6
School of Medicine
December 10, 2002
Mr. B, a 71 year-old veteran and widower, is being followed for the medical diagnoses
listed below:
1. Stage 3B squamous cell cancer of the right lung (2001)/status post XRT and
2. Chronic obstructive pulmonary disease.
3. Peripheral vascular disease.
4. Hypertension.
5. Degenerative joint disease.
6. History of alcohol abuse (abstinent since 1999).
Current Medications
1. Darvocet N-100 po q6-8h prn pain.
2. Combivent metered dose inhaler 2 puffs qid.
3. Ibuprofen 400 mg po tid with meals.
4. ASA 81 mg po qd.
5. Multivitamen tablet, one po qd.
6. Lactulose syrup, 30 cc po qd prn constipation.
7. Acetaminophen 650 mg po tid prn pain.
Interval History
Mr. B complains of increasingly severe aching, rated 8/10, involving the right chest
wall associated with cough productive of thick, white, occasionally blood-tinged
sputum and worsened dypsnea at rest. This pain is worsened by deep breathing and
coughing and has increased to the point that Darvocet and ibuprofen are no longer
effective. He also describes a similar, though less severe, pain and fullness involving
the right side of the upper abdomen. Mild nausea, loss of appetite, tea-colored urine,
yellowing of the skin and generalized pruritis are also noted, particularly in recent
weeks w/o diarrhea, vomiting or abdominal bloating. The patient complains of
inability to sleep because of his symptoms, and he has grown progressively weaker to
the point that he is barely able to perform self-care Activities of Daily Living
(ADL’s). Mr. B’s sister, who is his primary caregiver since the death of his spouse 2
years ago, visits the patient daily and provides his meals and medications, but finds
his care demands overwhelming and beyond her abilities.
Physical Examination
Mr. B is a thin, acutely ill-appearing older man complaining of pain.
BP 170/60, P 100, T 98o, Wt 133 lbs (minus 30 lbs from appointment of 10/14/02)
HEENT: (+) Scleral icterus.
Skin: Jaundiced w/ reduced skin turgor and dry mucus membranes.
Neck: Supple with flat jugular veins w/o lymphadenopathy.
University of Alabama at Birmingham
School of Medicine
Chest: Increased AP diameter with decreased breath sounds throughout. Dull w/
increased fremitus, bronchial breath sounds and e-to-a changes in the right anterior
Heart: Point of maximum impulse not palpable with an increased S1 and a
physiologically split S2 w/o murmurs or gallops
Abdomen: Soft, protuberant with normoactive bowel sounds. Liver is firm, tender
and 18 cm in span w/ an irregular, nodular edge 5 fingerbreadths beneath the right
costal margin. W/o splenomegaly, shifting dullness, guarding.
Extremities: Trace edema at the ankles w/o clubbing or cyanosis. Absent pedal
Neurological: W/o asterixis.
 Chemistry panel: Na 147, K 3.4, Cl 110, CO2 38, Glu 100, BUN/crea 8/0.9.
 CBC: Hct/hgb 30%/10.2, wbc 11, plts 140,000.
 LFT’s: Alk phos 438, SGOT 225, SGPT 199, LDH 400, total bilirubin 4.4,
direct bilirubin 3.0, albumin 3.4.
 Right upper quadrant abdominal ultrasonogram: Numerous nodules,
consistent with metastases, are noted in an irregularly enlarged liver. Nondilated intra- and extra-hepatic bile ducts are seen, as is a normal-appearing
spleen, gallbladder and pancreas.
 Chest radiograph (AP and lateral views): An enlarging lung mass abutting the
mediastinum and involving the right middle lobe and the chest wall is seen.
Boney lesions of the adjacent ribs, most likely due to direct spread of tumor,
are appreciated. Enlarged ipsilateral and contralateral mediastinal lymph
nodes are noted. The chest x-ray is otherwise remarkable for changes
consistent with COPD and a normal cardiac silhouette.
Supported by a grant from the Association of American Medical Colleges and the John
A. Hartford Foundation.