Internal Medicine Clinical Pathological Conference

1
Internal MedicineClinical 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
9
Laboratory Assessment
10
Laboratory Assessment
11
Laboratory Assessment
12
EKG

• Sinus Tachycardia

13
RADIOGRAPHIC FINDINGS
14
Chest X-Ray
15
Chest X-Ray Lateral Decubitus
16
CT CHEST
17
CT CHEST
18
CT CHEST
19
Hospital Course

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