NYU Medical Grand Rounds Clinical Vignette

Daniel Diaz, MD

Class of 2014

September 4, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

48 year-old woman complaining of epigastric abdominal pain for 6 months

Chief Complaint

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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

• 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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•Well-appearing, no apparent distress

•Vital Signs: T:98 BP:150/113 HR:88 RR:12

•Remainder of physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Presenting complaint– Gastroesophageal Reflux (GERD)– Gastritis– PUD– Malignancy

• Secondary Diagnoses– Hypothyroidism – Uncontrolled Hypertension– Impaired Glucose Tolerance

Working Diagnoses

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Outpatient Management

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Outpatient Course

•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

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Abnormal Mammogram

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Follow-up Testing

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

Treatment Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Gastro-esophageal Reflux

• Lobular carcinoma in-situ, Left Breast

• Hypothyroidism

• Hypertension

• Impaired glucose tolerance

Final Diagnoses

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS