Renal cell carcinoma (RCC) accounts for approximately 80% of all primary renal neoplasms in United States causing approximately 65 000 new cases of RCC and 14 000 deaths each year. Symptoms of RCC typically include weight loss and night sweats but may also feature paraneoplastic phenomena in advanced stages as well as flank pain, gross hematuria, scrotal varicocele, inferior vena cava pathology, and a palpable abdominal mass. In this article, we present the course of a patient with advanced RCC, from initial presentation through workup and to eventual diagnosis. The case features late-onset symptoms, extensive paraneoplastic phenomena, and significant physical examination findings. We also review the literature available on RCC and critically analyze inefficiencies of the workup retrospectively.