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

2. 48 year-old woman complaining of epigastric abdominal pain for 6 months Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination Well-appearing, no apparent distress Vital Signs: T:98 BP:150/113 HR:88 RR:12 Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Presenting complaint –Gastroesophageal Reflux (GERD) –Gastritis –PUD –Malignancy Secondary Diagnoses –Hypothyroidism –Uncontrolled Hypertension –Impaired Glucose Tolerance Working Diagnoses U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Gastro-esophageal Reflux Lobular carcinoma in-situ, Left Breast Hypothyroidism Hypertension Impaired glucose tolerance Final Diagnoses U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS