Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Juliette Provenzano-Gober, MD
PGY 2
November 15, 2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
GP is a 64 year old man presenting to Rusk
Institute for rehabilitation following a right
below-the-knee amputation nine days prior
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•GP’s History of Present Illness began more
than twenty years earlier when was he was
found to have slowly progressive renal failure
with persistent proteinuria and hypertension
thought possibly to represent post-streptococcal
glomerulonephritis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•His renal disease progressed and he was
treated with hemodialysis for twelve years until
he received a cadaveric renal transplant in 1991
•The next 15 years were marked by the
development of atrial fibrillation and
symptomatic aortic stenosis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•In 2006, GP underwent an aortic valve
replacement, which was complicated by
rejection of his renal transplant
•A subsequent placement of a left upper arm
arteriovenous graft was complicated by the
development of gangrene of his left hand,
necessitating partial amputation of digits 2-5
•Later that year, he received a living unrelated
renal transplant
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•Five years later, GP began experiencing
claudication of his right leg and underwent
right superficial femoral artery stent
placement, right anterior tibial atherectomy,
and right popliteal angioplasty, all without
improvement
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•He consequently developed gangrene of
the right toes and underwent a right
transmetatarsal amputation and eventual
right below-the-knee amputation nine days
prior to his transfer to Rusk
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•End stage renal disease
•Hypertension
•Paroxysmal atrial fibrillation
•Renal cell carcinoma
•Thyroid cancer
•Gout
•Colonic polyps
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Surgical History:
•Partial nephrectomy
•Parathyroidectomy
•Renal transplant x 2
•Left arteriovenous graft
•Aortic valve replacement
•Amputation of left digits 2-5
•Right transmetatarsal amputation
•Right below–the-knee amputation
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Social History:
•Patient is a lawyer and lives with his wife
•Patient has remote tobacco use, denies
alcohol or drug use
•Family History:
•Non-contributory
•Allergies:
•Sulfa
•Warfarin
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Medications:
•Allopurinol 100 mg daily
•Pantoprazole 40 mg daily
•Calcitriol 0.25 mcg daily
•Pyroxidine HCl 50 mg daily
•Nystatin suspension 500,000 units four times daily
•Linezolid 600 mg twice daily
•Acetaminophen/oxycodone, 2 tabs every 4 hours PRN
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Medications:
•Furosemide 40 mg daily
•Clopidogrel 75 mg daily
•Simvastatin 40 mg every evening
•Darbepoetin Alfa 100 mcg weekly
•Levothyroxine 200 mcg daily
•Tacrolimus 2 mg daily
•Mycophenolate acid DR 720 mg twice daily
•Docusate sodium 100 three times daily
•Senna 2 tabs daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Well developed, well nourished, in
no apparent distress, conversant and
cooperative
•Vital Signs: T: 98.8 F, BP: 143/31 HR: 80
bpm RR: 18/minute and Oxygen saturation:
100 % on room air
•Abdomen: surgical scar in the left and right
lower quadrant, right inguinal hernia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•Extremities: Right below-the-knee
amputation stump with sutures and mild
erythema, left hand with partial amputation
of digits 2-5, decreased left posterior tibialis
pulse, left great toe ulceration
•The remainder of the physical exam was
normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: White blood cells 12, hemoglobin 9.2
•Remainder of CBC was within normal limits
•Basic Metabolic panel: BUN 25, creatinine 1.4
•Remainder of basic was within normal limits
•Hepatic panel: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• End stage renal disease
– Status-post 2 renal transplants
– Severe aortic stenosis, status-post aortic
valve replacement
– Gangrene of the left hand and right lower
extremity, status-post digit and right belowthe-knee amputations
– Extensive vascular calcification
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS