CPC CONFERENCECPC CONFERENCE

Presented by: Manavjyot S. Heer, MD (R2)Discussion: James Ampil, MD

Presbyterian Hospital of Dallas11.20.2003

HISTORY AND PHYSICAL

CC: Leg pain, swelling, near syncope

HPI: 67 yo Caucasian male

• Was in the Middle East (Dubai) and presented there with hemorrhagic CVA 2/15/03 and in hospital x 4 wks; course complicated by aspiration pneumonia and treated by IV antibiotics

• Head MRI and MR angiogram in Dubai showed no obvious source for bleed

• Was treated there with phenobarbital and neurontin for seizure prophylaxis

• He returned to United States and on 4/3/03 presented with CP, SOB, and subsequent CT Angiogram revealed bilateral pulmonary embolus

• IVC filter placed without anticoagulation given recent CVA

• Discharged 4/6/03 but he returned 4/13/03 with increased leg pain, swelling, and abdominal pain; Doppler ultrasound revealed DVT on right popliteal and posterior tibialis, left peroneal vessels below the knee also

• Discharged again and readmitted 2 days later with worsening leg pain, swelling, and near-syncope with balance problems

HISTORY AND PHYSICAL CONTINUED

ROS: Negative for fevers, chills; + for mild SOB, nonproductive occasional cough, CP, short-term memory and gait problems, left-sided facial weakness; no headaches, n/v/d/BRBPR; 8# weight loss since CVA

PMHx: CVA as above, memory problems since CVA

PSHx: Negative

Allergies: NKDA

Medications: Gabapentin 400 mg po TID, phenobarbital 60 mg po qd

SHx: Married, engineer, remotely Hx of smoking (quit 30 yrs ago), no IVDA, 2-3 drinks/day prior to his stroke

FHx: +CVA, MI, congenital vavular disease, HTN, CAD

PHYSICAL EXAM

VS: Tc 98F (Tm 101.6F), P 98, R 18, BP 100/60, 02 Sats 98% on 1-2 liters

Gen: In mild distress from leg pain, WDWN Caucasian male, irritable mood

HEENT: NC/AT, EOMI, PEERLA, O/P clear

CV: RRR, (-)m/r/g

Resp: CTA bilaterally

Abd: soft, mild tenderness in lower quadrants; ND, no masses palpable, no HSM, NABS

Ext: 1-2+ edema of his thighs; pulses 2+, no rash, clubbing, or cyanosis

Neuro: Left facial weakness; other CNs intact symmetric and bilateral U/LE strength 5/5; normal sensation

LABORATORY DATA

• Chem 8: Na 140, K 4.3, Cl 105, HCO3 25, BUN 13, Cr 0.8, Glucose 109

• CBC: WBC 6.4, H/H=10.8/30.7, Platelets 243K; Differential: N62.8, L20.6, M8.0, E7.9, MCV 93.9, RDW 13.9; Blood cultures negative

• Calcium 9.2, Mg 1.9, Phos 5.2, TP 6.9 Albumin 3.4

• Coags: PT 12.2, PTT 26.9, INR 1.0

• LFTS: Alk Phos 57, AST 28, ALT 41, Tbili 0.3

• Trop I <0.1, CK <30, MB <0.7

• UA: 1.032, yellow, trace protein, trace blood, 2 RBC, 5 fine granular casts, <1 hyaline casts; UCx negative

• Vit B12, folate levels normal; Ferritin 289, Transferrin 229, Fe <20, TIBC <6%

• Hypercoagulable Panel: Homocysteine 10.12 (4-12); Protein C functional normal (148%), Protein S 84% (82-177), Antithrombin III 136% (73-125), Factor V Leiden (-), Lupus Anticoagulant (-), Cardiolipin Ab IgG, IgM (-), Prothrombin 20210A mutation (heterozygous)

OTHER DATA/IMAGING

• EKG: Sinus tachycardia, HR 103, no acute ST/T-wave changes;

• CXR: LLL infiltrate (? +/- left pleural effusion); normal cardiac silhouette

• MRI of brain w/wo contrast: Left basal ganglia intracerebral hemorrhage of subacute to chronic intensity with mass effect on left frontal horn but is smaller than the one in February 2003. No edema or contrast enhancement to suggest tumor; hematoma is 5 x 3.4 cm; no acute bleed

• CT Chest and Abdomen: Left exophytic renal mass (3.5 cm); small splenic cyst

• Abdominal Sonogram: Solid 3 cm exophytic lesion mid pole left kidney (3.1 x 3.1 x 3.0 cm); right kidney 10 cm, left kidney 11 cm; no hydronephrosis or perinephric fluid collections

• Ultrasound of LE extremities (repeated): clot extension to level of his Greenfield filter; bilateral obstruction

HOSPITAL COURSE

• Patient was started on IV Heparin, then Lovenox, and finally Fragmin subcutaneously despite he had a recent CVA given his risks of further organ compromise (renal, GI, etc) from his massive DVT

• He did well and had no neurological events or decline

• The MRI as described confirmed no tumor and PET was done which revealed no convincing evidence for intracerebral metastases as agent for CVA; there was no focal accumulations of tracer in either kidney as well

• Patient was discharged home after 2U PRBCs for mild anemia.

• He was then readmitted and underwent partial left nephrectomy where a diagnosis was made. In addition, he was referred to another institution for a second opinion regarding his stroke.

• An additional diagnosis was made. . .