By ZEESHAN TARIQ MD 66 yr old black American with lower abdominal and back pain for the last 3 months. On and off pain with acute exacerbations. 6/10 intensity. Dull pain. Worsened by movements. Review of symptoms: H/o Constipation, no weight loss, anorexia or fever No H/o Numbness, tingling or urinary or fecal incontinence. Diabetes mellitus (Recently diagnosed) Hypertension Obstructive sleep apnea. Psoriasis on steroids. Lumbar spine # S/p Trauma Transplantation of ureters. Hernia repair Bilateral cataract removal Family History: Hypertension Lives with his wife. No h/o Smoking No h/o Alcoholism No h/o illicit drug use. Allergies: NKA Middle age black American lying anxiously in bed well oriented in time space and person with vitals of: BP: 143/86 Pulse: 93 R/R : 18 Afebrile Ox Sat : 95% on RA Soft abdomen Minimal abdominal tenderness. No visceromegaly Audible bowel sounds. CVS: S1 + S2 + 0 Resp : NVB no added sounds CNS : Grossly Intact Spinal tenderness +ve Rash both lower extremities below both knee. Hb 12.7 WBC 6.9 Ht 39.9 Platelets 185 BMP: Normal Amylase 296 Lipase 79 UA: Normal Bilirubin 0.9 ALT 22 AST 23 Alkaline phosph 120 Albumin 2.9 Total Protein 5.8 PT/INR 12.5/ 0.9 PTT Lactic acid 1.6 20.0 Abdominal X ray. Unremarkable Abnormal gas pattern CXR: No acute changes. Doppler LEX: Chronic DVT in distal femoral and popliteal veins. CA 19-9: 48 CEA: 3.9 Glucagon: 67 PSA: 0.9 66 year old came with lower abdominal and back pain. Recently diagnosed DM 2 Psoriasis on steroids Spinal tenderness on percussion H/o Trauma Slightly elevated pancreatic enzymes. Left lower ext DVT Area of low attenuation 17 x 9mm in the tail of pancreas with adjacent pancreatic duct dilatation. Multiple renal cysts. Multiple vertebral body compression fractures Diverticulum along the lesser curvature of the second portion of the duodenum . Subacute compression fractures in the vertebral bodies of T10, T11 and T12 most likely due to osteoporosis. Old L3 vertebral body compression fracture. Mild-to-moderate spinal canal stenosis seen at L2-3 level Severe left-sided neural foraminal narrowing and moderate right-sided neural foraminal narrowing with impingement of the left L3 nerve root seen at L3-L4 level . 5. Severe bilateral neural foraminal narrowing seen at L4-5 level. Periampullary diverticulum Dilated pancreatic duct more around tail of pancreas 2.6mm Mutimicrocystic leisons at the tail of pancreas. Each cyst measured 5-6 mm in size 12x 19.4 cm whole collection of cysts. CEA in fluid 278 Amylase in fluid 499155 Units /L Pancreatic aspirate: cystic mucinous neoplasm Celiac lymph node biopsy: Inflammatory changes , no malignancy. Newly diagnosed DM 2 Trousseau s Syndrome.( DVT) Necrolytic Migratory Erythema. (Psoriasiform eruption) Slightly elevated pancreatic enzymes. An association between venous thrombosis and malignancy was first suggested in 1865 by Trousseau. Unexplained deep venous thrombosis, followed a year later by the development of gastric carcinoma In one review of patients with Trousseau's syndrome, the following associated tumors were seen : Pancreas — 24 percent Lung — 20 percent Prostate — 13 percent Stomach — 12 percent Acute leukemia — 9 percent Colon — 5 percent Common in mucin secreting adenocarcinoma. Transient weeping eczematous or psoriasiform eruption 70 percent of patients with glucagon-secreting pancreatic islet cell tumors. Less frequently it has been seen with no glucagon-producing tumor, a condition termed pseudoglucagonoma syndrome. Reported associations include celiac disease (from malabsorption), cirrhosis of the liver, inflammatory bowel disease, and various extrapancreatic malignancies, such as hepatocellular, lung, and duodenal cancer, and tumors that secret insulin or insulin-like growth factor II .