NYU Medical Grand Rounds Clinical Vignette Francesca Montanari, MD PGY 2 6/12/2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

The patient is a 75-year-old man presenting with generalized weakness. Chief Complaint The patient is a 75-year-old man presenting with generalized weakness. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

History of Present Illness Three weeks prior to admission, the patient experienced progressive dysphagia and was diagnosed with metastatic squamous cell carcinoma of the tongue. Four days prior to admission, the patient was in a motor vehicle accident and suffered a left frontal subarachnoid hemorrhage. He was hospitalized for two days for observation. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

History of Present Illness After discharge, he experienced generalized weakness and recurrent falls at home. His son took him back to the Emergency Department. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Additional History Past Medical History: Past Surgical History: Metastatic squamous carcinoma of the tongue extending to the left side of the neck and involving the left carotid space Hypertension Past Surgical History: Cataract surgery Social History: 8 oz of Vodka daily (no history of alcohol withdrawal or seizures), not a smoker, denies illicit drugs use Retired, lives with his son Family History: No family history of cancer Allergies: Penicillin (skin rash) Medications: Losartan/hydrochlorothiazide 100/25 mg by mouth once daily Aspirin 81 mg by mouth once daily UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Physical Examination General: chronically ill-appearing, elderly man, in no acute distress Vital Signs: T: 98.5, BP:135/70, HR: 79, RR:16, Oxygen saturation: 99% in room air Neck: left posterior cervical adenopathy, hard, non mobile, and firm mass at the left angle of the jaw with no elevation of the jugular venous pressure Remainder of physical exam was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Laboratory Findings Complete Blood Count: within normal limits Basic Metabolic Panel: Blood Urea Nitrogen 37, Creatinine 1.5 Remainder of the basic metabolic panel was within normal limits Hepatic Panel: AST 98, ALT 18, total bilirubin 2.1 Remainder of hepatic panel was within normal limits Coagulation: within normal limits UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Other Studies Electrocardiogram: Normal sinus rhythm Non-contrast head CT: Improved left subarachnoidal hemorrhage and stable bilateral frontal intraparenchymal hemorrhages compared to 2 days prior UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Emergency Department Event In the Emergency Department while having an IV placed, the patient was noted to be bradycardic (HR 29) and hypotensive (BP 70/40), with no change in mental status. The heart rate and blood pressure returned to baseline without any intervention approximately 20 minutes later. An electrocardiogram during the episode showed a junctional escape rhythm at 29 beats per minute. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Working and Differential Diagnosis The transient episode of bradycardia and hypotension associated with a noxious stimulus observed in the Emergency Room was thought to be the likely cause of the patient’s recurrent falls at home Differential diagnosis included: Vaso-vagal reflex Carotid hypersensitivity (tumor encasing the left carotid body/space) New intraparenchymal cerebral hemorrhage (although unlikely given CT scan findings) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Hospital Course The patient was admitted to the Intensive Care Unit for monitoring with a temporary transvenous pacemaker. He received a permanent pacemaker on hospital day four. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Hospital Course The hypotensive and bradycardic events were attributed to the extension of the squamous cell carcinoma into the left carotid space. The patient remained asymptomatic but with labile blood pressure. He was transferred to a regular floor bed with the plan to start radiation treatment to palliate the tumor. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Hospital Course Initially agreeable to the radiation plan, the patient’s mental status deteriorated during the hospital stay. He refused further interventions repeatedly stating “there is no hope.” UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Hospital Course A psychiatric evaluation was performed as the patient appeared profoundly depressed, disorganized, tangential, and at times paranoid. The patient was found to lack capacity to make medical decisions. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Discharge plan Given the side effects of the radiation treatment, limited life-extending benefit and patient’s previous beliefs, his son (his health care proxy) decided to take the patient home with hospice services, without pursuing further treatment. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Diagnosis Carotid hypersensitivity secondary to metastatic squamous cell carcinoma of the tongue encasing the left carotid artery UNITED STATES DEPARTMENT OF VETERANS AFFAIRS