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![Page 1: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/1.jpg)
NYU Medical Grand Rounds Clinical Vignette
Daniel Diaz, MD
Class of 2014
September 4, 2012
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
![Page 2: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/2.jpg)
48 year-old woman complaining of epigastric abdominal pain for 6 months
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
![Page 3: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/3.jpg)
•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
![Page 4: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/4.jpg)
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
![Page 5: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/5.jpg)
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
![Page 6: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/6.jpg)
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
![Page 7: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/7.jpg)
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
![Page 8: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/8.jpg)
• Presenting complaint– Gastroesophageal Reflux (GERD)– Gastritis– PUD– Malignancy
• Secondary Diagnoses– Hypothyroidism – Uncontrolled Hypertension– Impaired Glucose Tolerance
Working Diagnoses
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
![Page 9: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/9.jpg)
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
![Page 10: 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.](https://reader035.fdocuments.net/reader035/viewer/2022072016/56649ee65503460f94bf5c54/html5/thumbnails/10.jpg)
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
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• 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
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• 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
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• 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
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• Gastro-esophageal Reflux
• Lobular carcinoma in-situ, Left Breast
• Hypothyroidism
• Hypertension
• Impaired glucose tolerance
Final Diagnoses
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS