NYU Medicine Grand Rounds Clinical Vignette

1. NYU Medicine Grand Rounds Clinical Vignette Helene L. Strauss, MD PGY-2 3/26/2014 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 78 yo man presents with generalized malaise and shortness of breath x 1 week

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Patient has chronic cough productive of yellow, non-bloody sputum for years which he attributes to prior heavy smoking • Chronic dyspnea, no acute worsening but now more noticeable at rest • EMS called by his friend after noticed to be increasingly lethargic lying in bed for 12 hours

4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • None • Past Surgical History: • Right knee arthroscopy 15 yrs ago • Social History: • h/o “heavy” tobacco use, quit 7 years ago • Occasional EtOH, mostly beer • No illicits • Divorced and has 11 children, not in contact with them • Family History: • Unknown • Allergies: • No Known Drug Allergies • Medications: • None

5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: elderly man, in no acute distress, breathing comfortably, disheveled and malodorous • Vital Signs: T:97 BP:110/80 HR:140 RR:12 and O2 sat:98% on 2L NC and 94% on RA • HEENT: poor dentition, dry mucus membranes • CV: tachycardic • Pulm: bronchial breath sounds in left lower lung field • Ext: +2 pitting edema bilateral lower extremities up to knees • Remainder of Physical Exam was normal

6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: WBC 21.3 (95% N), Hgb 17.5/ Hct 53.9 • Remainder of CBC was within normal limits • Basic Metabolic panel: BUN 59 • Remainder of basic was within normal limits • Hepatic panel: AST 434, ALT 1237, AlkPhos 184, T Bili 1.9, D Bili 1, Prot 6, Alb 3.4 • INR 1.83 (0.8-1.13) • PTT 54.5 (23.6-35.8) • BNP 2080 (0-100) • Venous Lactate 3.1 (1-2.5)

7. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: atrial flutter at 146 bpm • Chest X-Ray: interstitial pulmonary edema, left pleural effusion • CT chest PE protocol: small right lower lobe peripheral PE without evidence of pulmonary hypertension, left lower lobe atelectasis and Left upper lobe atelectasis/consolidation

8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Sepsis • Pneumonia • CHF exacerbation vs new-onset CHF • A flutter • Pulmonary embolism • Transaminitis: secondary to transient hypotension vs sepsis vs shock liver

9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Emergency DeptartmentCourse • ED course: • 1 dose of Vancomycin and Piperacillin/Tazobactam given • Attempted rate control for a flutter with 2 doses of IV diltiazem but BP dropped to systolic in 90s and HR only briefly decreased to 120s • Enoxaparin 80mg SQ prior to admission to ICU

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1-2: • Aggressive IVF resuscitation with improvement in BUN • TTE: EF 20%, LV thrombus, RV dilatation and hypokinesis

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 3-5: • Antibiotics narrowed to ceftriaxone • LFTs continued to downtrend • On Day 5 converted to normal sinus rhythm

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 6: • 2 episodes of melena, hemoglobin dropped 14.6 -> 10.6, transfused 1unit PRBCs, anti-coagulation held, GI consulted, and given the patient was hemodynamically stable, EGD was planned for the morning

13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 7: • EGD: • Z-line 37cm • Large clean-based distal esophageal ulceration from 33-37cm and occupying approximately 30% of esophageal lumen with adherent clot distally w/o active bleeding  no intervention performed • An approximately 8mm adherent clot with an exposed visible vessel and slow active oozing was noted in the distal duodenal bulb. 6cc of 1:1000 epinephrine was injected around the clot and cauterization with successful hemostasis • Given erythromycin 250mg IV and started on PPI drip and sulcralfate

14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 10-12: • Transferred to the floors, Heparin converted to enoxaparin with bridge to coumadin • H Pylori Ab: Negative

15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 13: • Hgb dropped from 9.6  7.5 without overt bleeding then later in the day dropped further5.9 and melena; GI re-consulted and anti-coagulation held • EGD findings: • Healing distal esophageal ulceration without active bleeding • Active bleeding in the duodenal bulb with loosely adherent clot, no discrete ulcer visible—no endoscopic intervention pursued • IR consulted for embolization

16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 14: • IR embolization of gastroduodenal artery • Hospital Day 15: • Restarted anti-coagulation with heparin drip • Hospital Day 16-18: • Transferred back to floors • Transitioned PPI drip to 40mg PO BID • Switched to enoxaparin and coumadin bridge

17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Patient ultimately discharged on HD #41 to subacute rehab center

18. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Upper GI bleed (esophageal and duodenal ulcers)