leg pain, swelling, and near-syncope

67 yo Caucasian male was hospitalized for 4 weeks in the Middle East (Dubai) after presenting there with a hemorrhagic CVA on 2/15/03.
His stroke was complicated by aspiration pneumonia treated by IV Abx. MRI and MRA of head in Dubai showed no obvious source for bleed. He was treated with phenobarbital and gabapentin for seizure prophylaxis.

He returned to United States and on 4/3/03, he presented with chest pain and dyspnea. CT angiogram revealed bilateral pulmonary emboli. IVC filter was placed without anticoagulation given his recent CVA.

He was discharged 4/6/03, but returned 4/13/03 with leg pain and swelling. He also complained of lower abdominal tenderness. Doppler ultrasound revealed thrombosis of the right popliteal, right posterior tibialis, and left peroneal veins below the knee.

He was then discharged again and readmitted 2 days later with worsening leg pain, swelling, and near-syncope with balance problems.

Gabapentin 400 mg PO TID, phenobarbital 60 mg PO qD

SH

+CVA, MI, congenital valvular disease, HTN, CAD

Positive for mild dyspnea, occasional nonproductive cough; chest pain; short-term memory and gait problems; left-sided facial weakness; 8 lb weight loss since CVA

VS: T 98F (max 101.6F), P 98, R 18, BP 100/60,

Oxygen Sat 98% on 1-2 liters

Gen: WDWN Caucasian male in mild distress from leg pain

HEENT: NC/AT, EOMI, PEERLA, oropharynx clear

CV: RRR, no m/r/g

Resp: CTA bilaterally

Abd: soft, mild tenderness in lower quadrants; non distended, no masses palpable, no hepatospenomegaly, normoactive bowel sounds

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

Neuro: Left facial weakness; cranial nerves intact; symmetric and bilateral U/LE strength 5/5; normal sensationL

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 5 x 3.4cm of subacute to chronic intensity with mass effect on left frontal horn, smaller than in 2/03. No edema or contrast enhancement to suggest tumor.

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

Abdominal Sono: Solid 3 cm exophytic lesion mid pole left kidney (3.1 x 3.1 x 3); Right kidney 10 cm, Left kidney 11 cm; no hydronephrosis or perinephric fluid collections

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

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

He did well and had no neurological events. PET was done which revealed no evidence for intracerebral metastases as cause 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…