1. Internal Medicine Clinical Pathological Conference July 18, 2008

2. 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

3. Chief Complaint: 55 year-old male presents to Bellevue Hospital complaining of worsening diffuse body weakness, dysphagia, and cough for 3 months.

4. History of Present Illness: The patient is a 55 year-old Senegalese male cab driver without any medical problems who first complained of body weakness after a long day of driving, 3 months prior to his presentation. Over the next 3-months, he noticed that his symptoms were progressively worsening and that he was unable to tolerate driving for long periods of time. He complained specifically 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

5. History of Present Illness: Approximately 3-weeks prior to admission, his symptoms had become so severe that he quit his job as a cab- driver. During this time, the patient also complained of dysphagia to both solids and liquids. The patient denied any odynophagia. The patient also complained of cough that was worse at night. The cough was productive of white-yellow sputum without blood. He denied fever, chills, or weight loss.

6. History of Present Illness Past Medical History: Latent TB treated in the past Chronic constipation for 40 years Past Surgical History: none Medication: none Allergy: no known drug allergy Family History: Father and sister in Senegal described body weakness that was treated by medication with improvement. No definite diagnoses were given. Social History: Moved from Senegal 20 years ago. Works as a cab driver. No tobacco, no alcohol, and no drug use. No recent travel. HIV status unknown

7. 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 crackles 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

8. Laboratory Assessment: TESTREFERENCE RANGEON ADMISSION CHEMISTRY Sodium (mmol/liter) 135 – 145131 Potassium (mmol/liter) 3.4 – 4.85.1 Chloride (mmol/liter) 100 – 10898 Carbon dioxide (mmol/liter) 23.0 – 31.926 Urea nitrogen (mg/dl) 8 – 2516 Creatinine (mg/dl) 0.6 – 1.50.6 Calcium (mg/dl) 8.5 – 10.58.2

9. Laboratory Assessment: TESTREFERENCE RANGEON ADMISSION HEMATOLOGY Hemoglobin (g/dl) 13.5 – 17.513.6 Hematocrit (%) 41.0 – 53.041.1 White-cell count (per mm 3 ) 4,500 – 11,00014,900 Differential Count (%) Neutrophils 40 – 7086 Lymphocytes 22 – 447.3 Monocytes 4 – 114 Eosinophils 0 – 81.7 Mean Corpuscular Volume (µm 3 ) 80 – 10086 Platelet Count (per mm 3 ) 150,000 – 300,000609,000 Partial-thromboplastin time (sec)22.1 – 35.127 INR 0.9 - 1.21.01

10. Laboratory Assessment: TESTREFERENCE RANGEON ADMISSION Aspartate aminotransferase (U/liter)10 – 40591 Alanine aminotransferase (U/liter)10 – 55456 Total Bilirubin (g/dl)0.0 – 1.00.3 Direct Bilirubin (g/dl)0.0 – 0.40.1 Total Protein (g/dl)6.0 – 8.37.4 Albumin (g/dl)2.6 – 4.13.2 Alkaline Phosphatase (U/liter)45 – 11574 Creatine Kinase (U/Liter)45 - 24510,217 Lactate Dehyrdogenase (U/Liter)110 - 225905 Sedimentry Rate0- 1550 C-Reactive Protein (mg/Liter)0.215 - 348.6

11. TESTREFERENCE RANGE ON ADMISSION Others ANA Negative1:40 HIV Negative UA Color Clear pH 4.5 - 8.06.0 Bilirubin Negative Protein Negative+2 Blood Negative+3 RBC 0 - 52 - 4 WBC 0 – 50 - 1 Leukocyte Esterase Negative NitrateNegative Ketone Negative Laboratory Assessment:

12. EKG Sinus Tachycardia

13. RADIOGRAPHIC FINDINGS

14. Chest X-Ray

15. Chest X-Ray: Lateral Decubitus

16. CT CHEST

19. Hospital Course The patient was triaged to a regular floor bed for further diagnostic testing. A diagnostic procedure was performed.