Transcript Journal Club

NYU Medicine Grand Rounds
Clinical Vignette
Jamie Osman, MD MPH RD
PGY2
April 2, 2013
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
Mr. D is a 39-year-old Chinese man who
presented with progressive bilateral lower
extremity edema, dyspnea on exertion and
fatigue for five weeks.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
 Five weeks prior to arrival the patient
noted bilateral lower extremity swelling
which advanced to his thighs and
abdomen over the next 1 - 2 weeks.
 Three weeks prior to arrival he began
having intermittent palpitations, weight
loss, fatigue and shortness of breath with
minimal exertion.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
 He also recalled feeling anxious during
this period
 On the day of arrival he was “hanging out”
in Penn Station when he was noted
hunched over with leg pain by police
officers who called EMS.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History




PMH/PSH: None
Meds: None
Allergies: NKDA
Social History: Drinks $1000 of vodka per
month with friends with the last drink 1 day
before admission.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
 Gen: cachectic, jaundiced Asian man in no
acute distress
 Temperature: 97.3F
 Heart rate: 118
 Blood Pressure 120/68
 Respiratory Rate: 20
 Oxygen Saturation: 97% on room air
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
 HEENT: scleral icterus, no exophthalmos,
mild thyromegaly, no lid lag
 Cards: PMI displaced to anterior axillary
line; tachycardic, irregularly irregular with
jugular venous distention
 Abd: distended with hepatomegaly
 Ext: 3+ pitting edema up to scrotum and
abdomen
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Remarkable Laboratory Findings
 CBC: Hgb 7.1 g/dL
 Hepatic: panel AST 41, ALT 31, alk phos 149,
total bili 4.9, direct bili 4.0, total protein 7.9,
albumin 2.9
 Coagulation Panel INR 1.96, aPTT 33.1
 Brain Natriuretic Peptide: 640
 TSH undetectable, Free T4 3.42, FT3 7.0
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
EKG
Atrial fibrillation with rapid ventricular
response
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chest X-ray
Cardiomegaly with
increased
interstitial
markings
consistent with
pulmonary edema
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
CT Abdomen/Pelvis
Heterogeneous liver
with engorgement of
hepatic veins and
IVC; diffuse
anasarca and
moderate
abdominopelvic
ascites
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Thyrotoxicosis
Alcoholic cardiomyopathy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Day #1
 The patient was admitted to the CCU
where beta blockers and lasix were given
for rate control and diuresis, respectively.
 Transthoracic echocardiogram showed
four chamber dilatation with severe MR,
severe TR and paradoxical flattening of
the septum consistent with right ventricular
overload.
 The patient was started on methimazole
and coumadin.
Hospital Day #10


Thyroperoxidase antibody (TPO)
returned positive with thyroid
stimulating immunoglobulins elevated
to 345
A thyroid ultrasound showed increased
vascularity.
Hospital Day #19
 The patient was successfully
diuresed with improved heart rate
and symptom control and he was
discharged.
Final Diagnosis
Thyrotoxicosis due to Graves’
Disease
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS