New York University Medical Center Department of Medicine Clinical Pathological Conference

Friday, April 11th, 2008 at 11:30 AM Bellevue Hospital 17W Conference Room
Moderator: Anthony Grieco, MD Discussant: Radiologist: Maria Shiau, MD Pathologist: Rosemary Wieczorek, MD Wrap-Up: Alana Choy-Shan, MD The clinical pathological conference is a teaching exercise in which the students integrate their understanding of pathophysiology and the clinical manifestations of disease with their ability to interpret information provided by a case record. The case is one in which careful consideration of the information available can lead to a correct diagnosis and an insight into the disease process. The students must submit a complete diagnosis indicating the entity, as well as the manifestations in the patient. All infectious diagnoses must include reference to the etiologic agent by genus and species. Malignant diagnoses must contain enough specificity of cell type to eliminate ambiguity. Cardiac diagnoses must be complete and conform to the New York Heart Association criteria. If a diagnostic procedure was performed, the diagnosis must include the proposed procedure. Selected students will present their diagnosis and reasoning at the CPC on Friday, April 11th, 2008. A review of the literature is not expected, but pertinent references should be used. Student presentations are limited to five minutes.

Chief Complaint: 26 year-old woman who presents with productive cough for two weeks. History of Present Illness: The history begins seven years prior to presentation when the patient had her first episode of pneumonia. She was treated as an outpatient with oral antibiotics and improved. Several months later, she developed a second pneumonia that again responded to oral antibiotics. The patient was well until four months prior to admission when she contracted another pneumonia. Her symptoms resolved with oral therapy, as they had in the past. Two weeks prior to admission, the patient noted a minimally productive cough and subjective fevers. She presented to the emergency room of an outside hospital where she had a chest radiograph which revealed a right lower lobe consolidation. She was treated with a five day course of azithromycin. Her cough improved, but was still present when she was supine or inspired deeply. She had no breathlessness and did not use tobacco. She had no skin changes, sick contacts, pets, recent travel or history of incarceration. She presented to the emergency room with these symptoms. Past Medical History: Per history of present illness Past Surgical History: Lasik surgery 2001 Medications: None Allergies: NKDA Family History: Patients father is alcohol dependent and a diabetic. Her mother has borderline hypertension. Her siblings are healthy. Social History: Born in the United States, resides on Long Island. Single with no children. Served in the Army in Kuwait. Currently works as an administrative assistant. Occasionally drinks alcohol, denies any tobacco or illicit drug use. Sexual history is unknown.

Physical Exam: General: Tall, thin young woman in no acute distress. Pleasant and conversant. Vital Signs: T 99.30F, Pulse 81 bpm, BP 113/66 mmHg, RR 18 breaths/min, SaO2 97% on room air HEENT: Pupils equal, round and reactive to light, extraocular muscles intact, moist mucus membranes Lymph: No cervical, submandibular or axillary lymphadenopathy Pulm: Decreased breath sounds in right lower lung field with dullness to percussion and egophany CV: Regular rate and rhythm, nml S1/S2 no murmurs, rubs or gallops Abdominal: Soft, nontender, nondistended, normal bowel sounds, no organomegaly Extremities: Warm, 2+ distal pulses, no clubbing, cyanosis or edema Neuro: Non-focal Laboratory Data: MCV 80 Na 137 K 4.2 Cl 107 HCO3 27 BUN 8 Cr 1.0 46 34 19 1 AST 29 AP 60 ALT 23 Alb 3.9 INR 1.2 Tbili 0.5 TP 7.8
N L M E

Hgb 10.0 Glu 92 Wbc 4.6 Hct 30.5 RDW 12 Plt 233

PT 13.6

PTT 26

U/A: SG 1.015, pH 7, no protein or nitrites, wbc 1-4/hpf Radiology: Please see attached Powerpoint file ECG: Please see attached Powerpoint file

Hospital Course: The patient was admitted to the hospital and treated with gatifloxacin for a presumed right lower lobe pneumonia. Computed tomographic images of the chest were obtained (see Powerpoint file) and a procedure was performed.