Transcript NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds
Clinical Vignette
Todd Cutler, MD
12/18/12
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 61 year old woman with
three days of weakness and shortness of
breath.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient has a history of severe pulmonary
hypertension, previously treated pulmonary TB
and MAC, cor pulmonale (on home oxygen),
bronchiectasis and diabetes.
• Three days prior to admission she began
having fevers, productive cough and shortness
of breath.
• The day prior to admission she had difficulty
walking across her living room and presented
to the ED.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Social History:
• Lives with son, no smoking, alcohol or illicits
• Medications:
• Lisinopril 20mg daily
• Digoxin 0.125mg daily
• Lasix 20mg daily
• Lantus 20 Units at night
• Novolog 10 Units with meals
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• General: Frail, chronically ill-appearing,
short of breath, difficulty completing
sentences
• Temp: 100.4
• BP: 138/85
• HR: 100
• RR: 22
• O2 sat: 95% on 4L NC, 87% on room air
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• Head and Neck: distended neck veins
• Heart: tachycardia, palpable pulmonic
valve, loud S2
• Lungs: tachypnea, diffuse rhonchi with
bronchial breath sounds
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• Chest CT: stable fibrotic left lung and
severe right middle lobe bronchiectasis with
small nodular opacities in the anterior right
upper lobe consistent with airway impaction
versus infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• Pneumonia
• Bronchiectasis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• Her labs were most remarkable for:
- Arterial Blood Gas: 7.22/83/80/33
• A repeat arterial blood gas after 15 minutes of
bilevel at 18/5 was unchanged.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• She was intubated for hypercarbic
respiratory distress and transferred to the
MICU.
• She was started on vancomycin, cefepime
and azithromycin.
• She was extubated on hospital day #4 and
discharged from the MICU to the seventh
floor on Monday.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• That same day, Hurricane Sandy hit the
medical center and power to the
hospital was lost.
• That night, supplemental oxygen was
carried up to the seventh floor by the
National Guard.
• She continued to receive IV antibiotics
by gravity drip.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• On Thursday, the National Guard
carried the patient down the stairwell to
the ground floor.
• She was taken by ambulance to St.
Luke’s Hospital in Manhattan.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• She completed her course of antibiotics at
St. Luke’s Hospital.
• Discharge to subacute rehabilitation was
delayed as facility vacancies were limited
after the storm.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• On Thanksgiving, after 10 days at St.
Luke’s Hospital, she was discharged home
where she has been receiving physical
therapy.
• She still feels week, has difficulty walking
across the room and remains on
continuous oxygen therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Her home physical therapy and nursing
visit benefits end today.
• She will follow up with me in the newly
reopened Bellevue outpatient clinic next
week.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Pneumonia versus Bronchiectasis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS