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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Daniel Diaz, MD Class of 2014 September 4, 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.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Daniel Diaz, MD Class of 2014 September 4, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 48 year-old woman complaining of epigastric abdominal pain for 6 months

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Burning in character • Duration: six months • Radiated upwards to the chest • Not associated with exertion • Exacerbated by large meals, caffeine and supine position.

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History • Generalized Anxiety Disorder • Major Depressive Disorder • Nephrolithiasis, 2009 • Preventative Care • PAP Smear: 2 years prior, normal • Mammography: 2 year prior showing R benign cyst • Past Surgical History: none • No Known Drug Allergies • No Medications

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Social History • Active smoker, 10 pack-year history • Two alcoholic drinks per week • No history of illicit drug use • Family History • Multiple first degree relatives with diabetes and hypertension • No history of early MI or CVA • No common history of malignancy

  6. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Well-appearing, no apparent distress • Vital Signs: T:98 BP:150/113 HR:88 RR:12 • Remainder of physical exam was normal

  7. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Complete Blood Count, Basic Metabolic Profile and Hepatic Panel all within normal limits • Thyroid Stimulating Hormone: 13.4 (0.35-4.8) • Free T4: 0.79 (0.9-1.9) • Hemoglobin A1c 6.0 (4-5.9) • Fasting Lipid Panel • LDL: 81 • HDL: 40 • Triglycerides: 293 • Total Cholesterol: 182

  8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnoses • Presenting complaint • Gastroesophageal Reflux (GERD) • Gastritis • PUD • Malignancy • Secondary Diagnoses • Hypothyroidism • Uncontrolled Hypertension • Impaired Glucose Tolerance

  9. Outpatient Management UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Epigastric Pain: trial of a proton pump inhibitor • Hypertension: anti-hypertensives • Hypothyroidism: levothyroxine • Impaired glucose tolerance: dietary counseling • Tobacco use: smoking cessation counseling • Screening: ordered for mammogram and PAP smear

  10. Outpatient Course UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Epigastric pain: resolved on esomeprazole. • Hypertension: improved on lisinopril • Hypothyroidism: became euthyroid on levothyroxine • Tobacco use: able to quit smoking • Screening: abnormal findings on mammography

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Abnormal Mammogram • Right breast nodule consistent with a benign cyst. • Abnormal left breast micro-calcifications were noted in the upper outer quadrant that were suspicious for malignancy.

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Follow-up Testing • A core biopsy of the lesion showed lobular carcinoma in-situ (LCIS) • A 1.3cm mass adjacent to the LCIS site was also biopsied, showing atypical mammary cells on cytology and atypical lobular hyperplasia on histology

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Treatment Course • The left breast mass was excised and surgical pathology showed atypical lobular hyperplasia. • The patient was started on Tamoxifen and was scheduled for a follow-up mammogram.

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnoses • Gastro-esophageal Reflux • Lobular carcinoma in-situ, Left Breast • Hypothyroidism • Hypertension • Impaired glucose tolerance

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