CPC CONFERENCE

1
CPC CONFERENCE

• Presented by Manavjyot S. Heer, MD (R2)
• Discussion James Ampil, MD
• Presbyterian Hospital of Dallas
• 11.20.2003

2
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

3
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
4
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
5
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/H10.8/30.7, 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 lt0.1, CK lt30, MB lt0.7
• UA 1.032, yellow, trace protein, trace blood, 2
  RBC, 5 fine granular casts, lt1 hyaline casts UCx
  negative
• Vit B12, folate levels normal Ferritin 289,
  Transferrin 229, Fe lt20, TIBC lt6
• 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)

6
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

7
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. . .