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NYU Medicine Grand Rounds Clinical Vignette

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imaran
18 diapositives · 307 Views · Aug 23, 2014

A 78-year-old male presents with generalized malaise and shortness of breath. He has a history of chronic cough, attributed to heavy smoking, and recent changes in his condition, with increased lethargy noted by a friend. Physical examination reveals tachycardia, pulmonary findings indicating bronchial breath sounds, and evidence of fluid retention. Diagnostic studies indicate acute renal failure, metabolic abnormalities, and signs of pulmonary embolism. The clinical course involves aggressive resuscitation, management of atrial flutter, and complications leading to gastric hemorrhage and eventual gastroenterological intervention.

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  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)