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  1. 1. Clinical Pathological Case Conference February 13, 2008
  2. 2. Chief Complaint <ul><li>52 yo F presents with one month history of cough and fevers </li></ul>
  3. 3. History of Present Illness <ul><li>Patient’s medical history begins eight months prior to her current admission when the results of a routine mammogram found a four mm span of microcalcifications in the right breast . </li></ul><ul><li>Subsequent biopsy revealed right sided high-grade comedo-type ductal carcinoma in-situ. </li></ul><ul><li>As such, right breast partial mastectomy with excision of retroareolar tissue and axillary lymph node dissection was performed with no complications. </li></ul><ul><ul><li>Final path showed Ductal Carcinoma In Situ (DCIS), high grade, estrogen receptor negative, and intraductal papilloma sclerosing type. Lymph node dissection was negative for malignancy. </li></ul></ul>
  4. 4. History of Present Illness <ul><li>Patient underwent multiple rounds of radiation treatment which ended approximately five months prior to admission. </li></ul>
  5. 5. History of Present Illness <ul><li>Three weeks before admission, the patient began experiencing fevers (measured to 101.7 °F ), dry cough, loss of appetite, and generalized arthralgias. </li></ul><ul><li>Approximately 16-days prior to admission, patient was started on moxifloxacin for a presumed pneumonia. </li></ul><ul><li>Patient finished a 10-day course of moxifloxacin, but continued to have fevers and cough. In addition, the patient also began experiencing shortness of breath and new onset orthopnea. </li></ul><ul><li>Patient was switched to amoxicillin/clavulanate and azithromycin six days prior to admission, after which, she developed diarrhea. </li></ul>
  6. 6. History of Present Illness <ul><li>Two days, prior to admission, the patient reported to have measured fevers as high as 100.3. Patient was switched to levofloxacin. </li></ul><ul><li>In addition, the patient’s shortness of breath worsened and she began experience a decrease in exercise tolerance to one flight of stairs. Previously, she had unlimited exercise tolerance. </li></ul><ul><li>Patient also reported that her fevers occurred at night. She reported feeling better during the day. </li></ul>
  7. 7. History of Present Illness <ul><li>The day of admission, the patient had an outpatient CT scan which prompted admission. </li></ul>
  8. 8. Past Medical History <ul><li>Past Medical History: as above, hypothyroidism, osteoporosis </li></ul><ul><li>Past Surgical History: as above </li></ul><ul><li>Social History: ex smoker, quit one year ago. Smoked 3-4 cig / day for over 20 years. Drinks 2-3 glasses of wine per week. Denies drug use. Works as a lab technician at an academic medical center. She has lived in New York all her life. Currently, lives with her elderly mother. She travelled to Canada 10 months prior to admission. </li></ul><ul><li>Family History: Father died at 86 years old of lung cancer (was a non smoker). Mother has Rheumatoid Arthritis </li></ul>
  9. 9. Past Medical History <ul><li>Allergies: NKDA </li></ul><ul><li>Medications: Levothyroxine 100 mcg daily, Ibandronate 150 mg monthly, Levofloxacin 750 mg daily </li></ul><ul><li>Review of Systems: Patient denies any rhinorrhea, chest pain, dysuria, headache, visual changes, numbness/weakness. Patient reports a ten pound weight loss over the past month and occasional ankle swelling </li></ul>
  10. 10. Physical Exam <ul><li>Gen: Well appearing, speaking in full sentences </li></ul><ul><li>Vital Signs: 99.6 103/67 110 16 97% RA </li></ul><ul><li>HEENT: PERRLA, no sinus tenderness </li></ul><ul><li>Neck: supple, no JVD </li></ul><ul><li>Heart: nl S1, S2, RRR, -m, -g, -r </li></ul><ul><li>Lung: +rales on R middle and upper lung field with bronchial breath sounds </li></ul><ul><li>Abd: soft, NT, ND +BS, liver span 7 cm </li></ul><ul><li>Ext: 1+ pitting edema bilaterally, distal extremities cool </li></ul><ul><li>Neuro: 5/5 strength bilaterally </li></ul>
  11. 11. Laboratory Assessment: TEST REFERENCE RANGE ON ADMISSION HEMATOLOGY Hemoglobin 13.5 – 17.5 g/dl 13.3 Hematocrit 41.0 – 53.0 % 41.9 White-cell count 4,500 – 11,000 per mm 3 14.7 Differential Count Neutrophils 40 – 70 % 84 Lymphocytes 22 – 44 % 7 Monocytes 4 – 11 % 8.1 Eosinophils 0 – 8 % 1 Platelet Count 150,000 – 300,000 per mm 3 643 Partial-thromboplastin time 22.1 – 35.1 sec 33.3 INR 0.8 – 1.2 1.4
  12. 12. Laboratory Assessment: TEST REFERENCE RANGE ON ADMISSION CHEMISTRY Sodium 135 – 145 mmol/liter 138 Potassium 3.4 – 4.8 mmol/liter 4.0 Chloride 100 – 108 mmol/liter 98 Carbon dioxide 23.0 – 31.9 mmol/liter 26 Urea nitrogen 8 – 25 mg/dl 11 Creatinine 0.6 – 1.5 mg/dl 0.8 Calcium 8.5 – 10.5 mg/dl 9.2 Erythrocyte Sedimentation Rate Female: 1-25 mm/hr Male: 0-17 mm/hr 58
  13. 13. Laboratory Assessment: 3.3 3.5-5 g/dL Albumin 7.0 6 – 8.3 g/dL Total Protein 0.0 8 – 25 µmol/L Direct Bilirubin 0.7 2 – 14 µmol/L Total Bilirubin 357 30 -120 IU/L Alkaline phosphatase 48 10 – 40 IU/L Aspartate transaminase 68 5 – 40 IU/L Alanine transaminase Liver Function Test ON ADMISSION REFERENCE RANGE TEST
  14. 14. Other data <ul><li>Urine Analysis - negative </li></ul><ul><li>Chest Xray – see attachment </li></ul><ul><li>Chest CT - see attachment </li></ul><ul><li>EKG – NSR, rate 90, nl intervals, no ST changes </li></ul>
  15. 15. Hospital Course <ul><li>On admission, the patient was started on vancomycin and cefepime. </li></ul><ul><li>On Hospital Day 2, the patient spiked a fever to 102.3 °F. Patient also began complaining of R sided chest pain. </li></ul><ul><li>On Hospital Day 3, the patient continued to spike fevers. Patient was negative for C. difficile toxin. Blood and urine cultures were negative for growth. Sputum cultures were positive for gram positive cocci in clusters. </li></ul>
  16. 16. Hospital Course <ul><li>On Hospital Day 4, the patient underwent a bronchoscopy with a transbronchial biopsy. </li></ul><ul><li>Bronchial lavage returned blood-tinged fluid and final cultures were negative. </li></ul><ul><li>The final pathology from the transbronchial biopsy showed a lymphocytic inflammatory infiltrate. </li></ul><ul><li>The results of the transbronchial biopsy were inadequate to make a definitive diagnosis. </li></ul>
  17. 17. Hospital Course <ul><li>On Hospital Day 5, the patient underwent a diagnostic test/procedure. </li></ul>