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  • 1. NEJM: CLINICAL PROBLEM-SOLVING Kurdistan GEH Board journal club:
  • 2. History:  A 55-year-old man with a history of heart failure presented to the emergency department with pain and swelling in his right foot and leg.  Three days beforepresentation, he noted a sudden onset of swelling in the right foot and calf, without any prior trauma.  The swelling worsened progressively, extending to the upper leg&was accompanied by pain in the foot and calf.  He doubled his usual dose of torsemide, with no effect.  On the day of presentation, he noted new dusky discoloration of the toes on his right foot.
  • 3. History:  The patient’s medical history was notable for obesity, paroxysmal atrial fibrillation, hypertension& heart failure with a preserved ejection fraction.  Medications included warfarin, sotalol, torsemide, and lisinopril.  There was no personal or family history of arterial or venous thrombosis.  The patient had a 30-pack-year smoking history but had quit smoking 5 years earlier. He drank about four beers every weekend.  He reported an intentional weight loss of 22.7 kg (50 lb) over the preceding 6 months, which he attributed to a combination of diet and exercise.
  • 4. On physical examination  The patient’s temperature was 36.1°„C (97°„F), with a heart rate of 80 beats per minute and a blood pressure of 96/50 mm Hg; the oxygen saturation was 95% while he was breathing ambient air.  The oropharyngeal examination was notable for poor dentition.  The lungs were clear on auscultation bilaterally.  The heart sounds were regular, with a normal S1, a physiologically split S2, and no murmurs, rubs, or gallops.  The jugular venous pressure was 8 cm of water.  The abdomen was obese, soft, and nondistended, with normal bowel sounds and no hepatosplenomegaly or masses.  The legs were markedly asymmetric, with 4+ pitting edema of the upper right thigh& 2+ pitting edema of the left calf. The right leg&foot were dusky and cold, & distal pulses were detectable only on Doppler ultrasonography.
  • 5. On physical examination  On the right ankle and sole of the right foot, there were discrete hemorrhagic bullae on a purpuric base with central, dusky discoloration  The bullae were confluent over the dorsomedial aspect of the foot and toes.  The entire right lower extremity was edematous but without eczematous change or scaling.  There was no purpura other than that associated with the bullous lesions.  Pulses in the left leg were easily palpable, and there was no edema.  Muscle tone and strength and sensation of pinprick and light touch were intact and equal in both legs.
  • 6. Lab tests:  Na136 mmol per liter, K 4.6 mmol per liter, chloride 110 mmol per liter, bicarbonate 23 mmol per liter  BUN 62 ,cr 2.1 , glucose 114,1 month earlier, BUN 18 mg , cr 0.8  ALT 31 U, AST 34 ,TSB 0.5 ,SAP 630 ,albumin 3.1.  WBC 16,900,PCV 37.1%, platelet 283,000  A peripheral-blood smear was negative for schistocytes.  PT 42.3 seconds (INR, 4.3), PTT 89 seconds , fibrinogen 215 mg/ dl  An U/S of the right leg showed noncompressibility of the deep veins, consistent with thrombosis, extending from common femoral vein to the popliteal vein.
  • 7. Actions:  IV VK administered, after INR decreased to 1.5.  IV UF heparin was initiated.  Leg venography revealed complete occlusion of the right common femoral vein, femoral vein &popliteal vein.  After pulse-spray thrombectomy with a rheolytic catheter, a large thrombus burden remained, prompting overnight catheter-directed thrombolysis with tissue plasminogen activator (t-PA).  The following day, a repeat venogram showed restored patency of the venous system .
  • 8. Actions:  The t-PA catheter was removed, and systemic anticoagulation therapy was resumed.  Laboratory testing before the initiation of heparin therapy was notable for a normal homocysteine level,normal results of an antithrombin III functional assay & activated protein C resistance testing.  Results of testing for the prothrombin G20210A mutation were negative, and antiphospholipid antibodies were not detected.
  • 9. Imagings:  The γ-GT 295 IU per liter (normal range, 0 to 40).  Computed tomography of the abdomen and pelvis without the IV contrast showed multiple hypodense liver lesions, up to 3 cm in diameter&extensive periportal/ gastrohepatic retroperitoneal lymphadenopathy& diffuse omental nodularity & caking & irregular, masslike thickening of the greater curvature of the stomach.
  • 10. Endoscopy:  OGD/EUS revealed a large, infiltrative, & centrally ulcerated mass on the greater curvature of the stomach.  Pathological exam revealed poorly differentiated, invasive adenocarcinoma.  Progressive hypotension&renal failure developed, both of which were unresponsive to fluid resuscitation.  Treatment with IV dopamine / vasopressin was initiated.  The vascular-surgery service was consulted for consideration of right-leg amputation, but the patient declined the procedure, given his poor overall prognosis.  At his request, vasopressor therapy was withdrawn&comfort measures were initiated; he died 10 days after admission.
  • 11. Diagnosis:  Gastric cancer-induced Hypercoagulable state