CPC CONFERENCE Presented by: Manavjyot S. Heer, MD (R2) Discussion: James Ampil, MD Presbyterian Hospital of Dallas

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 (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 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...