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Washington University Experience | NEOPLASMS (METASTASES) | Meningeal | 13A0 Case 13 History
Case 13 History ---- The patient is a 54 year old male with past medical history of COPD, heavy smoking, hypertension, coronary artery disease status-post stent, history of back and knee surgery who presented with complaints of personality changes since two months, and history of weakness in his left upper extremity and left lower extremity, progressive for the past two weeks to the point that the patient needed assistance even for minimal activity. The patient had occasional falls in the past two weeks. He denies any numbness or tingling in his extremities. He also denies any bowel or bladder disturbance. He has occasional headaches and has had one episode of vomiting. He denies any visual changes. There is no history of slurred speech or choking. There is a history of chronic cough, occasionally associated with mucus. He also complains of having decreased appetite and decreased energy levels; however, his weight has been stable. The patient denies any fevers or chills. He has dyspnea on exertion and occasional chest pain with exertion. He has a history of tobacco smoking, two packs per day for thirty to thirty-five years. Occasional intake of alcohol. No IV drug abuse. On his neuro exam, 4/5 power noted in his left upper extremity and left lower extremity. However, 5/5 in his right upper extremity and right lower extremity. Intact sensations. MRI of the brain shows diffuse T2 hyperintense lesions throughout the cerebral and cerebellar parenchyma, fluid/fluid levels and distribution throughout the gray-white matter junction are most consistent with metastatic disease. Chest CT findings compatible with primary bronchogenic carcinoma (small cell carcinoma) with mediastinal, gastrohepatic, and right inguinal nodal metastases. Neurosurgery was consulted in the emergency department and recommended dexamethasone and Keppra to decrease cerebral edema and for seizure prophylaxis related to his coronary artery disease. The patient's home aspirin, Plavix, and Pletal were held, with concern for bleeding risk. The cytology of the bronchoscopy lymph node biopsy demonstrated small cell lung carcinoma. On the morning of August 12, the patient reported an episode of rhythmic jerking of his left arm. He did not lose consciousness during this episode and was alert and oriented throughout, with no confusion afterwards. A repeat head CT demonstrated no hemorrhage. The patient's pulse was no longer palpable and cardiopulmonary resuscitation was initiated. Extensive resuscitation was performed and failed.
