CPC for 10/11/02
Discussant: Dr. Mark Feldman
CC: Abdominal pain, ascites, and fever
History of Present Illness:
Mr. E. S. is a 56 y/o Spanish speaking male transferred from an outside hospital in Decatur for further evaluation of persistent fever, ascites, and abdominal pain. His medical history dates back as follows:
· Aug 2001: admitted to JPS Fortworth for SOB, severe lower extremity edema, and increased abdominal girth. Diagnosed with right-sided heart failure. The patient had a therapeutic paracentesis and was diuresed. He was discharged home on diuretics. He did well until May 2002 when he was readmitted to JPS for recurrent symptoms of right heart failure, increased abd girth, LE edema, and shortness of breath. He was diagnosed with OSA and a traheostomy was performed in order to correct his hypoxia. He had two therapeutic paracentesis, was diuresed and discharged home on medical therapy.
· June 30th, 2002: admitted in Decatur for fever, abdominal distension, and abdominal pain. Abdominal CT showed increased ascites in the abdomen & pelvis and a loculated pocket in the right lower quadrant. CT guided percutaneous drains were placed in RLQ loculated fluid collection. Pocket fluid that was sent for analysis was negative for cytology but showed acute inflammatory infiltrate and necrotic cells c/w peritonitis. The patient was started on antibiotics for ³spontaneous bacterial peritonitis² and transferred to our institution for further management ten days after admission.
The patient complained of left-sided abdominal pain. He denied anorexia, weight change, nausea, vomiting, hematemesis and diarrhea. The patient denied a history of cirrhosis. He denied a history of hepatitis or blood transfusions. He quit etoh intake 6 yrs ago, but used to drink 2-4 beers each weekday & a 24 pack on the weekends for 8-10 years. No medical problems until Aug¹ 01 visit to JPS.
Medications (inpatient):
aspirin 81 mg qd, diltiazem SR 120mg qd, isosobide monoinitrante 20 mg qd, furosemide 80mg qd, potassium 20mg qd, cefepime hydrochloride 2 grams IV bid, metronidazole 500mg tid
Allergies: NKDA;
Past Medical History:
1); HTN, diagnosed in Aug ¹01
2); Ascites x 1 year
3); Obstructive sleep apnea
Past Surgical History:
1); Paracentesis x 4 (once in 8/01, twice in 5/02, once in 7/02)
2); s/p tracheostomy placement in 5/02
Social History: no tobacco, quit drinking alcohol 6 years pta, no high-risk sexual behaviors. Travel to Mexico 6 months pta for 10 days.
Family History: noncontributory
ROS: In addition to HPI, +orthopnea, +PND, otherwise negative
Physical Exam: VS: 99.0, 96, 24, 113/80, Tmax 101.0
Gen: obese Hispanic male, awake, alert, Spanish speaking only, in NAD
HEENT: at/nc, PERRL, anicteric sclera, oropharynx clear
Neck: obese, no bruits, no JVD, no adenopathy, no thyromegaly
Heart: regular rate, S1, S2 normal, loud 2/6 SEM at Left sternal border, no radiation, no S3, no S4, no rub
Lungs: coarse lung fields bilaterally, poor inspiration
Abd: asymmetric abdomen, drains in RLQ, distended but soft, tender to deep palpation in LUQ & LLQ, bulging flanks, +dullness to percussion in flanks, +fluid wave, no shifting dullness
Extrem: trace edema
Neuro: negative
Skin: no spider angiomata, palmar erythema, gynecomastia, caput medusa.
Rectal: not performed
Pertinent Labs:
1.; Chem 8: Na 135, K5.0, Cl 98, CO2 26, BUN 7, Cr 0.8, Glu 107, Ca 8.3
2.; CBC: WBC 12.8, Hgb 11.6, Hct 35.1, Plts 607, MCV 82.9, Neutra 78%, Lynph 13%
3.; LFTs: Total Prot 6.8, Alb 2.7, Glob 4.1, Alk phos 538, AST 44, ALT 58, Total bili 1.1
4.; BNP 143
5.; INR 1.4, PT 16.0
6.; ANA: <1:40, ds-DNA neg, RF neg
7.; Bedside diagnostic paracentesis (done on 7/11/02): 20cc of cloudy fluid drawn from left abdomen with results as follows:
RBC 1700 cmm, WBC 8775 cmm, 75% polys, 20% lymphs, 5% monos, tot protein 4.8, Alb 2.0. Serum Ascites Albumin Gradient 0.7 (<1.1)
Preliminary Impression:
1.; 56 y/o Hispanic male with persistent febrile episodes, abdominal distension, and ascites s/p RLQ drainage of loculated fluid.
2.; Right Ventricular Failure due to pulmonary hypertension from OSA
Hospital Course:
· 7/11/02: Blood culture x 2 negative
· 7/12/02: CT abdominal/pelvis + fistulgram in Interventional Radiology:
CT: multiple loculations of fluid, largest in left abdomen with air fluid levels; the right pelvic collection w/o air fluid levels but with 2 drains in it.
· 7/14/02: fluid from bedside paracentesis grew Streptococcus bovis (1 of 2 sets)
A diagnostic procedure was done.