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NYU Medicine Grand Rounds Clinical Vignette

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Title: Journal Club Author: Louis Miller Last modified by: glennc03 Created Date: 5/22/2007 12:58:19 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: NYU Medicine Grand Rounds Clinical Vignette


1
NYU Medicine Grand Rounds Clinical Vignette
  • Elizabeth Park PGY2
  • Oct 16th 2013

2
Chief Complaint
  • Mr. M is a 67 year-old male with a past medical
    history of melanoma who presented to an urgent
    care center with confusion, mental "cloudiness,"
    left hand weakness and clumsiness for 3 days.

3
History of Present Illness
  • The patients melanoma was originally diagnosed
    in 1998 by excisional biopsy.
  • He had stable disease until 2008 when he had a
    second lesion resected measuring 0.8 mm (pT1a
    (0.8) N0 M0 Stage 1A).
  • He then presented again in April 2013 with a
    large lesion on the right upper back with fine
    needle aspiration demonstrating malignant
    melanoma, BRAF mutation.

4
History of Present Illness
  • CT chest and brain MRI revealed metastatic
    disease in June and the patient was begun on
    vemurafenib with good systemic response.
  • However the treatment was stopped at the end of
    July secondary to skin rash and transient
    transaminitis.
  • He was then transitioned to ipilimumab systemic
    therapy in August.

5
History of Present Illness
  • The day after his first infusion he began
    experiencing confusion, mental "cloudiness," and
    left hand weakness.
  • After his second ipilimumab infusion, he was
    referred to urgent care for his neurological
    symptoms.

6
Additional History
  • Past Medical History
  • Melanoma
  • Hypertension
  • Hyperlipidemia
  • Asthma
  • Obstructive sleep apnea
  • Benign prostate hypertrophy
  • Past Surgical History
  • Uvulopalatopharyngoplasty and septoplasty in
    2011
  • Soft palate reduction 2008
  • Skin excision 1998

7
Additional History
  • Social History
  • No history of smoking. Drinks about 4 glasses of
    wine per week.
  • Family History
  • No family history of melanoma
  • Allergies
  • No known drug allergies
  • Medications
  • simvastatin 40 mg daily
  • losartan 50 mg daily
  • tamsulosin 0.4 mg daily
  • albuterol MDI as needed

8
Physical Examination
  • General alert and oriented to person, place and
    time. In no acute distress.
  • Vital Signs list T 98.4 BP 156/99 HR 74 RR
    16 and O2 sat 97
  • Left pronator drift
  • Finger to nose movement dysmetric LgtR
  • Rapid alternating hand/foot movements and fine
    finger movements slower on L
  • Remainder of Physical Exam was normal

9
Laboratory Findings
  • CBC Hgb 12.5 Hct 37.5
  • Remainder of CBC was within normal limits
  • Basic Metabolic panel glucose 121
  • Remainder of basic was within normal limits
  • Hepatic panel
  • Hepatic panel was within normal limits

10
Other Studies
  • MRI brain demonstrated multiple supra-and
    infratentorial enhancing lesions in the bilateral
    frontal, parietal, occipital and right temporal
    lobes, as well as bilateral cerebellum. There was
    apparent interval progression of disease
    manifested by new lesions and increase in size of
    the previously demonstrated lesions as well as
    hemorrhage conversion of multiple lesions with
    local vasogenic edema and mass effect.

11
Working or Differential Diagnosis
  • Metastatic melanoma with acute hemorrhages of
    brain metastases

12
Hospital Course
  • Hospital Day 1
  • The patient was started on dexamethasone 4 mg
    every 8 hours and levetiracetam 500 mg twice a
    day
  • Hospital Day 2
  • The patient was restarted on vemurafenib at the
    recommendation of his primary medical oncologist

13
Final Diagnosis
  • Stage 4 Metastatic Melanoma
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