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NYU Medicine Grand Rounds Clinical Vignette

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Title: Journal Club Author: Helene Strauss Last modified by: admin Created Date: 5/22/2007 12:58:19 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: NYU Medicine Grand Rounds Clinical Vignette


1
NYU Medicine Grand Rounds Clinical Vignette
  • Helene L. Strauss, MD
  • PGY-2
  • 3/26/2014

2
Chief Complaint
  • 78 yo man presents with generalized malaise and
    shortness of breath x 1 week

3
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

4
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

5
Physical Examination
  • General elderly man, in no acute distress,
    breathing comfortably, disheveled and malodorous
  • Vital Signs T97 BP110/80 HR140 RR12 and O2
    sat98 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

6
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)

7
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

8
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

9
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

10
Hospital Course
  • Hospital Day 1-2
  • Aggressive IVF resuscitation with improvement in
    BUN
  • TTE EF 20, LV thrombus, RV dilatation and
    hypokinesis

11
Hospital Course
  • Hospital Day 3-5
  • Antibiotics narrowed to ceftriaxone
  • LFTs continued to downtrend
  • On Day 5 converted to normal sinus rhythm

12
Hospital Course
  • Hospital Day 6
  • 2 episodes of melena, hemoglobin dropped 14.6 -gt
    10.6, transfused 1unit PRBCs, anti-coagulation
    held, GI consulted, and given the patient was
    hemodynamically stable, EGD was planned for the
    morning

13
Hospital Course
  • Hospital Day 7
  • EGD
  • Z-line 37cm
  • Large clean-based distal esophageal ulceration
    from 33-37cm 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 11000
    epinephrine was injected around the clot and
    cauterization with successful hemostasis
  • Given erythromycin 250mg IV and started on PPI
    drip and sulcralfate

14
Hospital Course
  • Hospital Day 10-12
  • Transferred to the floors, Heparin converted to
    enoxaparin with bridge to coumadin
  • H Pylori Ab Negative

15
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 visibleno
    endoscopic intervention pursued
  • IR consulted for embolization

16
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

17
Hospital Course
  • Patient ultimately discharged on HD 41 to
    subacute rehab center

18
Final Diagnosis
  • Upper GI bleed (esophageal and duodenal ulcers)
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