Internal Medicine Clinical Pathological Conference

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Internal MedicineClinical Pathological ConferenceJuly 18 2008 CPC FORMAT Presentation of case.
Medical student discussants 5 minutes each Radiology speaker 5 10 minutes Faculty discussant 10 minutes Pathology speaker 5 minutes Case wrap up.
Chief Complaint 55 year old male presents to BellevueHospital complaining of worsening diffusebody weakness dysphagia and cough for History of Present Illness .
The patient is a 55 year old Senegalese male cab driverwithout any medical problems who first complained ofbody weakness after a long day of driving 3 monthsprior to his presentation Over the next 3 months he noticed that his symptoms.
were progressively worsening and that he was unable totolerate driving for long periods of time He complainedspecifically of Bilateral shoulders and thigh weakness Symmetric diffuse arthralgia that was worse in the morning.
Arthralgia and joint swelling of his wrists and hands Difficulty getting up from a seated position History of Present Illness Approximately 3 weeks prior to admission his symptomshad become so severe that he quit his job as a cab .
During this time the patient also complained ofdysphagia to both solids and liquids The patient deniedany odynophagia The patient also complained of cough that was worse atnight The cough was productive of white yellow sputum.
without blood He denied fever chills or weight loss History of Present IllnessPast Medical History Latent TB treated in the pastChronic constipation for 40 years.
Past Surgical History noneMedication noneAllergy no known drug allergyFamily History Father and sister in Senegal described bodyweakness that was treated by medication with improvement No.
definite diagnoses were given Social History Moved from Senegal 20 years ago Works as a cabdriver No tobacco no alcohol and no drug use No recent travel HIV status unknown Physical Exam .
Gen lying on a stretcher appeared comfortable Vital signs T 98 9 P 104 BP 122 67 RR16 SaO2 98 on RA Neck no lymphadenopathy Lungs decreased breath sounds at the left base with bilateral Heart Regular rate and rhythm no murmurs no rubs.
Abdomen Soft non tender non distended normal bowel sounds Neurologic unable to abduct his upper extremities past 90 degrees unable to lift his knees off the chair Distal strength was normal normal reflexes Extremities normal joints no effusion no swelling.
Skin no rashes Laboratory Assessment TEST REFERENCE RANGE ON ADMISSIONSodium mmol liter 135 145 131Potassium mmol liter 3 4 4 8 5 1.
Chloride mmol liter 100 108 98Carbon dioxide mmol liter 23 0 31 9 26Urea nitrogen mg dl 8 25 16Creatinine mg dl 0 6 1 5 0 6Calcium mg dl 8 5 10 5 8 2.
Laboratory Assessment TEST REFERENCE RANGE ON ADMISSIONHEMATOLOGYHemoglobin g dl 13 5 17 5 13 6Hematocrit 41 0 53 0 41 1.
White cell count per mm3 4 500 11 000 14 900Differential Count Neutrophils 40 70 86Lymphocytes 22 44 7 3Monocytes 4 11 4.
Eosinophils 0 8 1 7Mean Corpuscular Volume m3 80 100 86Platelet Count per mm3 150 000 300 000 609 000Partial thromboplastin time sec 22 1 35 1 27INR 0 9 1 2 1 01.
Laboratory Assessment TEST REFERENCE RANGE ON ADMISSIONAspartate aminotransferase U liter 10 40 591Alanine aminotransferase U liter 10 55 456Total Bilirubin g dl 0 0 1 0 0 3.
Direct Bilirubin g dl 0 0 0 4 0 1Total Protein g dl 6 0 8 3 7 4Albumin g dl 2 6 4 1 3 2Alkaline Phosphatase U liter 45 115 74Creatine Kinase U Liter 45 245 10 217.
Lactate Dehyrdogenase U Liter 110 225 905Sedimentry Rate 0 15 50C Reactive Protein mg Liter 0 215 3 48 6 Laboratory Assessment TEST REFERENCE ON ADMISSION.
ANA Negative 1 40HIV Negative NegativeColor Clear ClearpH 4 5 8 0 6 0Bilirubin Negative Negative.
Protein Negative 2Blood Negative 3RBC 0 5 2 4WBC 0 5 0 1Leukocyte Esterase Negative Negative.
Nitrate Negative NegativeKetone Negative Negative Sinus Tachycardia RADIOGRAPHIC FINDINGS Chest X Ray.
Chest X Ray Lateral Decubitus Hospital Course The patient was triaged to a regular floorbed for further diagnostic testing A diagnostic procedure was performed .
Internal Medicine Clinical Pathological Conference July 18, 2008 CPC FORMAT Presentation of case Medical student discussants (5 minutes each) Radiology speaker (5-10 minutes) Faculty discussant (10 minutes) Pathology speaker (5 minutes) Case wrap-up Chief Complaint: 55 year-old male presents to Bellevue Hospital complaining of worsening diffuse body weakness, dysphagia, and cough for 3 months.

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