Transcript Journal Club - NYU Langone Medical Center

NYU Medicine Grand Rounds
Clinical Vignette
Helene L. Strauss, MD
PGY-2
3/26/2014
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 78 yo man presents with generalized
malaise and shortness of breath x 1 week
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• 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, Alk Phos
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)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•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
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Emergency Deptartment Course
• 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
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
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 6:
– 2 episodes of melena, hemoglobin dropped
14.6 -> 10.6, transfused 1unit PRBCs, anticoagulation held, GI consulted, and given the
patient was hemodynamically stable, EGD
was planned for the morning
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 7:
– EGD:
• Z-line 37cm
• Large clean-based distal esophageal ulceration from 3337cm 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
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
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
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Patient ultimately discharged on HD #41 to
subacute rehab center
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Upper GI bleed (esophageal and duodenal
ulcers)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS