Transcript Medical Grand Rounds Clinical Vignette

09-12-2008
Medical Grand Rounds
Clinical Vignette
Matthias C. Kugler, M.D.
Internal Medicine Resident
Chief Complaint
• 53 year old Caucasian male with Hepatitis C and
cirrhosis, who presented to Bellevue Hospital with
8 days of abdominal pain and increasing girth
History of Present Illness
•
Right Upper Quadrant pain for 8 days, up to 8/10
intensity, aching, non-radiating, intermittent, lasting
several hours, no association with nausea or vomiting.
•
Increasing girth and abdominal swelling.
•
He denied fever or chills
History
• Past Medical History:
Hepatitis C diagnosed 15 years ago, cirrhosis since 2003, awaiting
transplant
Esophageal varices with endoscopic banding 2006
• Past Surgical History: none
• Family History: non-contributory
• Allergies: Penicillin – rash
• Medications: Esomeprazole 40mg daily, Furosemide 40mg daily,
Aldactone 25mg daily, Lactulose 30ml bid, Propanolol 20mg tid,
Acetaminophen 500mg q6h prn pain, Docusate 100mg tid
• Social History: no toxic habits, married, 2 children, no intravenous
drug use
• ROS: otherwise negative
Physical Examination
• General: Ill-appearing white male in mild distress, alert and oriented x 3
• Vital Signs: BP-113/80 HR-65 RR-20-22 O2-sat 93% (room air)
Temp-37.0°C
• Head/Neck: + scleral icterus
• Lungs: breath sounds decreased b/l bases, upper lungs clear to
auscultation
• Abdominal: + tense, distended, diffusely tender to palpation, + fluid
wave, no guarding or rebound, bowel sounds hypoactive in all 4 quadrants
• Extremities: 1-2+ pitting edema of the legs bilaterally
• Skin: + jaundice
• Remainder of physical exam normal
Laboratory Values
Basic:
Na 132 (140-145)
Hepatic:
AST 100 (7-27)
ALT 43 (1-21) AP
112 (13-39)
Tbili 7.7 (<1.0)
DBili 5.1 (<0.4)
Prot 10.3 (6.0-8.4)
Alb 1.6 (3.5-5.0)
Coags:
INR 2.5 (<1.15)
PTT 52 (25-38)
CBC:
WBC 4.2 (N53%, L26%, M15%, E5%)
Hb 11.1 (13-18)
Hct 31.6 (35-50)
MCV 112 (86-98)
plt 81 (150-350)
Paracentesis:
WBC 45 (N10%, L57%, M2%,)
RBC 3350
Alb 1.0
LDH 49
Gram stain: gram-negative rods
ABG: pH 7.43, pCO2 39, pO2 87, HCO- 26, O2-sat 92% (room air), Lact 1.2
Imaging Data
• PA/Lateral chest radiograph: small pleural effusions b/l, no
infiltrates, + ventral hernia
Working Diagnosis
• Bacterial peritonitis and decompensation of
cirrhosis secondary to infection.
Hospital Course
HD#1:
1. Therapeutic paracentesis with 1.5 liter fluid femoval
2. Ceftriaxon initially, when paracentesis fluid grew out
pansensitive Escherichia coli, the antibiotic was
switched to Ciprofloxacin
3. Forced diuresis using intravenous furosemide with
monitoring of the electrolyte status
4. Patient continously afebrile
HD#4:
•
Despite improving ascites, patient noticed to be more
short of breath, tachypnic and hypoxic
Hospital course
HD #5:
•
•
•
ABG: pH 7.37, pCO2 43, pO2 62, HCO- 24, O2-sat 88% (room air)
PA/Lateral chest radiograph with increased diffuse patchy infiltrates b/l
Patient was placed on CPAP with supplemental O2 and transferred to the
intensive care unit
Hospital course
HD #7:
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ABG: pH 7.39, pCO2 43, pO2 48, HCO- 26, O2-sat 77% on FiO2 50%,
PaO2/FiO2 96
Patient was intubated for severe hypoxemia.
Portable AP chest radiograph with worsening diffuse patchy infiltrates
throughout both lungs
Hospital course
HD #8-10:
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Ventilation using low tidal volumes, PEEP, and permissive
hypercapnea
Setting VT 400 cc, FiO2 70-80%, PEEP 7-10 mm H2O later
increased to maximum of 14 mm H2O
Over the next days the team was able to decrease PEEP to 8, FiO2 to
50%, VT 400 cc, with improving hypoxemia on ABG (pH 7.38,
pCO2 31, pO2 84, HCO-18, O2-sat 96%
Sputum cultures remained all negative
Final Diagnosis
• Bacterial peritonitis and decompensation of
cirrhosis secondary to infection.
• Acute Respiratory Distress Syndrome
(ARDS)