CPC Case for October 3, 2003

Discussant: Benjamin Levine, MD

Case presented by: Kara Prescott, MD

CC

“My legs are swollen”

HPI This is a very pleasant 47 year old African-American woman with no significant past medical history who presented to the emergency room with bilateral lower extremity edema becoming progressively worse over the past 2 weeks. She has noticed some dyspnea only on exertion. She denied PND or orthopnea. She is usually sedentary and sits at home. Of note, she states she has been eating a lot of ice, because it seems to make her feel better.
KDA Codeine
MEDICATIONS

Vitamin E, Cod Liver Oil, Centrum

PMH Unremarkable except for “heart murmur” diagnosed in the 1970’s
PSH Hysterectomy in 1986 for fibroids and metromenorrhagia

SH

 No bad habits
FH

Her mother is alive and well with hypertension. Her father drowned in a fishing accident.

ROS

ROS: General : no weight change, fever, chills or night sweats.

Cardiac : She states she has a history of heart murmur and was told in the past that she may have had rheumatic fever as a child. No chest pain or palpitations.

Pulmonary : dyspnea on exertion only.

Gastrointestinal : Frequent constipation. No abdominal pain, nausea or vomiting. No melena, hematochezia or hematemesis.

Genitourinary : no dysuria or hematuria.

HEENT : hair loss over the last several years. No change in vision or headaches.

Heme : no bleeding.

Psyche : no depression or anxiety.

Endocrine : fatigue, no polydipsia, polyphagia or polyuria.

PHYSICAL EXAM:

GEN: Overweight, alert in no acute distress.

Vital Signs: BP 107/63, afebrile, pulse 106, respirations 24-28 - unlabored, saturation on 100% non rebreather 77%, weight 99 kg, height 5’7”

HEENT: poor dentition, jugular venous distention to the angle of the jaw at 45 degree

Chest: clear with slightly diminished breath sounds in the left base

Heart: tachycardic with regular rhythm; soft systolic ejection murmur at the left sternal border; no rubs or gallops.

Abdomen: Soft, nontender, nondistended, normoactive bowel sounds. No hepatosplenomegaly.

Extremities: Bilateral lower extremity edema to her groin; flattened nailbeds, clubbed with slight bluish discoloration

Neuro: grossly nonfocal


LABS:
WBC 4.6 HGB 15.3 HCT 47.9 PLT 110 MCV 91.7 RDW 16.7 normal differential
Sodium 141 Potassium 3.8 Chloride 111 CO2 14 Glucose 154 BUN 30 Creatinine 1.6
Calcium 5.4 Magnesium 5.2          
Alk Phos 70 AST 86 ALT 31 TP 10 Alb 3.4 Total Bili 1.4  
TSH 2.41            
Coagulation Studies Protime 22.6 INR 1.8a PTT 24 Fibrinogen 218.5 D Dimer >1050  
BNP 3310 CK 141 to 87 MB 5.7 to 2.4 troponin 34 to 23.9
ABG on 4 liters NC: pH 7.427, pCO2 20.8, pO2 35, O2 sat 71.9%, HCO3 13.8
ABG on NR with 5 liters NC O2 flush: pH 7.42, pCO2 24, pO2 42, O2 sat 82%


STUDIES:

EKG: sinus tach at 111, PR 0.14, questionable S1 Q3 T3 pattern with RBBB
 
CXR:cardiomegaly, no evidence of pulmonary vasculature engorgement, minimal atelectasis along the left lower lung periphery
 
Echocardiogram: severe left hypokinesis, severe right atrial and right ventricle enlargement, severe pulmonary hypertension, severe TR ,moderate pericardial effusion, but no tamponade
 
CT angiogram: no evidence of pulmonary embolus, pruned pulmonary vasculature in the periphery, marked right atrial enlargement, biventricular dilatation, a low density enhancement either in the LV wall or against its wall, engorged liver with dilated hepatic veins, small pericardial effusion, and an area of subtle, patchy infiltrate in the right middle lobe of the lung.

HOSPITAL COURSE

The patient was placed on maximal O2 and moved to the ICU. She had a Swan-Ganz placed with the following recordings: pulmonary capillary wedge (left atrial) pressure 43, RV 70/15, PA 70/40, cardiac output 3 L/min with an index of 1.3-1.5.

The patient proceeded to the catheterization laboratory for right heart catheterization which revealed: pulmonary capillary wedge pressure 45, cardiac output 2.8 liters per minute and right sided pressures over 70

Early in the morning of her second hospital day the patient was noted to have systolic pressures in the 70’s, was apneic and in PEA. ACLS protocol was initiated, but the patient expired.
 
An autopsy was performed and a clinical diagnosis was made…