CPC for November 2002

The patient noted abdominal pain that was initially like a band across his abdomen, but eventually progressed downward and became localized in the right lower quadrant. There was no nausea, vomiting, or melena, but he did report rare hematochezia. There was some bilateral flank pain without dysuria, hematuria, or other urinary symptoms. The patient also noted red-brown irregular macular lesions on the dorsal and palmar surfaces of both hands and the dorsal surfaces of his left foot. These were not painful at first, but over several days the second digit on the left foot became dark red and then purple, and very painful.

The patient saw his internist for abdominal pain. Routine labs (Chem 14, CBC) were normal except for a platelet count of 437,000. Sedimentation rate was 70, and ANA was negative. Abdominal sonogram did not demonstrate a cause for his pain. Upper GI series demonstrated a hiatal hernia. The patient was referred to a gastroenterologist.

The gastroenterologist found heme positive stool on exam, scheduled a colonoscopy, and sent the patient for a CT of the abdomen. CT revealed a 2.1 cm ill-defined, heterogenous mass in the right kidney showing diminished attenuation, and the question of a renal cell carcinoma. There was also a triangular-shaped area of diminished attenuation in the spleen measuring 2.5 cm in maximum dimension, which was interpreted as being a subcapsular hematoma related to old trauma. The patient was then referred to a urologist.

The patient saw a urologist, who recommended obtaining an MRI to further evaluate the renal lesion.