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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Rachel Shur PGY-2 October 16, 2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. 56 woman who presented with 2 weeks of right foot numbness and weakness.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Rachel Shur PGY-2 October 16, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 56 woman who presented with 2 weeks of right foot numbness and weakness

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient was in her usual state of good health until approximately 1 month prior to presentation when she started experiencing intermittent headaches with associated nausea and vomiting. • Headaches became more frequent, occurring almost daily, worse in the morning • 2 weeks prior to presentation, pt noted right foot numbness and weakness. • Presented to NYU after she had difficulty driving with her right foot.

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Gastroesophageal reflux disease • Past Surgical History: • none • Social History: • Lived with husband and 2 children, worked as real estate agent • No smoking or drug use, drank 2 glasses of wine per week • Family History: • No family history of cancer or heart disease • Allergies: • No Known Drug Allergies • Medications: • Omeprazole 20mg daily

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: anxious, well appearing, no acute distress • Vital Signs: T: 97.8ºF BP:133/86 HR: 87 RR:14 and O2 sat: 99% on room air • Right foot: decreased sensation to light touch and pin prick on anterior and posterior aspect up to ankle, 4/5 strength on flexion and extension • Remainder of Physical Exam was normal

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: Hemoglobin 11.8 gm/dL / Hematocrit 34.2% • Remainder of CBC was within normal limits • Basic Metabolic panel: within normal limits • Hepatic panel: within normal limits

  7. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CT and MRI brain revealed frontal lobe masses with edema and mass effect, but no herniation

  8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • The working diagnosis at this time was Gliobastoma Multiforme (GBM)

  9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course Hospital Course • Hospital Day 3: • Pt underwent resection of the right sided lesion (pathology was consistent with glioblastoma multiforme) • Hospital Day 10: • Pt developed deep vein thrombosis and was started on Lovenox/Coumadin

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Pre and post contrast MRI obtained 1 week post craniotomy revealed post-operative changes +/- residual tumor • Pt was discharged on Hospital Day 15

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS UNITED STATES DEPARTMENT OF VETERANS AFFAIRS UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Disease Course • Within one month of surgery, she started focal external beam radiation therapy with concurrent temozolomide chemotherapy for a six week course (6480 cGy). • Post radiation MRI revealed increased surrounding edema.

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Disease Course • The patient completed 6 cycles of adjuvant temozolomide prior to having progression of disease. • She then had once cycle of BCNU chemotherapy complicated by anemia requiring transfusion. • She was offered participation in a clinical trial with bevacizumab, after an IVC filter was placed and coumadin was discontinued.

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Disease Course • She had a dramatic response to bevacizumab therapy, maintained for 6 cycles.

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Disease Course • A new lesion was detected, but additional treatment had to be interrupted in order to place a ventriculoperintoneal shunt for communicating hydrocephalus.

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Disease Course • The patient had further treatment delays for shunt related complications and intractable seizures. She was treated with enzyme-inducing antiepileptic drugs (EIAEDs). • She developed clinical and radiographic progression of disease.

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Disease Course • Since her tumor over-expressed epidermal growth factor receptor (EGFR) and intact phosphate and tensin homolog gene (PTEN), she was treated with erlotinib despite being on EIAEDs. • There was no response to erlotinib and she died several months later of progressive disease (~18 months from initial hospital admission).

  17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Gliobastoma multiforme

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