QI Rounds SPH

3 Cancer Cases

• Unusual complications of cancer
• Usual complication of cancer
• Section 51BC Evidence Act

57 M

• July 9/22 @ with delirium likely secondary to polypharmacy (including cannabis gummies)
• NSCLCA w mets to liver/bone and malignant L P effusion (Pleur X)
• ER note-new onset of binocular blindness
• CT(A) no infarct, dissection
• Worked up for back pain w MRI

July 11 abnormal EEG

MRI/Neuro

• punctate infarcts in frontal, parietal, occipital, cerebellum=embolic shower
• no dissection
• Enox 1mg/kg BID>Apixaban
• Recommend ECHO W bubble study
• July 18

Thrombosis July 20

• ESUS (Embolic Stroke of Unknown Source)
• Remained on Enox (discussed Apix)
• Stated limited evidence for efficacy of DOAC v. ASA in this population
• DC July 25 on Apix
• Found to have DVTs during workup

Aug 1 Acute Stroke

sudden blurry vision 1400
ED note 0100

New CT=multiple maturing infarcts in multiple territories>embolic

Neuro

• Hold anticoagulation>fear hemorrhagic transformation
• IVC filter
• DDX included PRES (carboplatin/pemetrexed)

ECHO Aug 2

• aortic valve cusp thickening, progression of regurgitation
• suggestive of endocarditis

Marantic Endocarditis

Constipation

37 M

• dx with met rectal CA July 2022 (liver, nodes, lungs, peritoneum)
• @ to MSJ for cough, pleural effusion, constipation
• Initially @ with concerns over pneumosepsis and pleural effusion
• Seen by IM and DC same day
• Thora drained 1.5 L

RTER 3 days later

• Persistant cough despite drain
• Reaccumulation of fluid
• Noted to have a 'distended abdomen' on admission

US day 7

• 'limited US' to assess for paracentesis-not enough fluid
• no comment on bowel

Day 8 Discharge

• Multiple notes from PC
• Constipation described as 'severe'
• No comment on obstipation
• Upped constipation regimen

Next Day

• Port-a-Cath placed at UBC
• Presented to SPH ED that evening in severe abdominal pain
• MBO on CT
• Gen Surg/PC consult

Diverting Colostomy

What could have been done?

• Was he obstipated?
• DRE?
• AXR
• POCUS
• Relying on 'limited US'

Dyspnea

Nov 21/22

• SOBOE,
• recent presumed prostate CA
• started on Degarelix (GnRH antagonist)
• CT P Angiography=no PE, no PCE, multiple nodules, T spine bone mets

Nov 22/22

• Worsening hypoxia @home
• Met criteria for home O2
• Resp and PC referral placed
• Query pneumonitis. Started Prednisone 50 mg x 5 days with Symbicort
• NO HF, COVID, INFX

Nov 23/22

• Cyanosis, hypoxia at home with o2 (67%)
• CXR n/lactate 2.7/ALKP 1037
• methemoglobinemia?
• Admitted to IM/Resp

Dec 3/22

• Worsening o2 needs-BiPAP>intubation
• Echo, PASP 107 mmHg=new Pulmonary Hypertension
• Diagnosis?

PTTM

• Pulmonary tumour thrombotic microangiopathy
• Most often diagnosed at autopsy