CPC Case for September 12, 2003

Discussant: Ed Goodman, MD

Case presented by:Sonya Merrill, MD, PhD

CC

 

HPI 78 yo WM presents to the ER with dyspnea and fatigue. Over the week prior to admission he reported increasing exertional dyspnea and fatigue. He also complained of palpitations, paroxysmal nocturnal dyspnea and orthopnea to the point that he started sleeping upright in a recliner. He denied any chest pain or lower extremity edema. He had recently seen his cardiologist who increased his furosemide and scheduled a nuclear stress test (not yet completed at the time of presentation).
KDA None
MEDICATIONS

Metoprolol 50 mg qd, Furosemide 40 mg bid, KCl, ASA 81 mg qd, Sulfasalazine 500 mg qd, Folic acid, Hydroxychloroquine 200 mg bid, Prednisone 5 mg qd

PMH
  1. CAD (s/p stent 6/02, MI @55)
  2. HTN
  3. Rheumatoid arthritis
  4. Sigmoid diverticulitis
  5. Left colon resection and temporary ileostomy (10/02)
  6. Takedown of ileostomy (1/03)
  7. Prostate cancer s/p XRT
PSH  

SH

 Married, 3 adult children. Retired restaurant kitchen manager. 15-pack-year tobacco history but quit 30 years ago. 3-5 alcoholic drinks per day in the past but quit 4-5 years ago. No illicit drug use. History of perioperative blood transfusions in 10/02 & 1/03.
FH

Father deceased from MI and mother deceased from CVA.

ROS Positive only for anorexia.
PHYSICAL EXAM:

T 97.4 P 150 and regular BP 130/70 R 22 O2 sat 96% on 5L nasal cannula
Gen: elderly WM, AO x 3, NAD
HEENT: NCAT, PERRL, anicteric sclerae, moist mucous membranes.
Neck: supple, no bruits or JVD
CV: tachycardic S1 S2, distant
Pulm: decreased bibasilar breath sounds
Abd: obese, soft, non-tender, non-distended, normal bowel sounds
Ext: warm, 1+ pedal pulses, trace edema


LABS:
142 102 20 132 10.7 42P            
5.6 14 2.7 25.1 74 33B 31.3 4L 14M      
Ca 7.5 Mg 2.3 P 9.6          
AP 69 AST 6570 ALT 4120 TB 1.9        
TP 7.6 ALB 3.5 GLOB 4.1 Amylase 64 Lipase 187 INR 6.2 PT 84  
CK 95 MB 2.1 TropI 0.2 BNP 1950        
UA: 1.016 5.5 >300 Protein Lg blood trace glucose, trace ketone, trace leukocytes RBC 339
Blood CX: neg x 2            


STUDIES:


EKG : Aflutter with 2:1 AV block, R150 Brief Hospital Course:

HOSPITAL COURSE (Short)
DAY 1-2:
 

 

. 		Cardioverted in ER via carotid massage followed by Amiodarone. RBC’s given. Hypotension and bradycardia develop. Pressors started and moved to ICU where S-G catheter placed. TTE: LV dysfxn with EF ~30-35% + inferopost and inferoseptal akinesis. Surgery consulted for LFT’s. RUQ sono: acute cholecystitis without stones. Gen surg consulted and recommends percutaneous drainage of gall bladder done by IR. Cx’s negative of drainage. Steroids plus antibiotics started. Resp failure develops requiring mechanical ventilation. Nephrology consult started Bumex drip for low urine output.
DAY 3-4: CXR reveals small pleural effusions, right > left, with mild vascular congestion. CT abdomen shows pleural effusions, small ascites, thickened stomach lining and possible infrahepatic abscess. Thromboctyopenia worsens. INR still elevated, treated with vitamin K and FFP. CVVHD started. Wedge up to 30. Persistent coagulopathy.
DAY 5-7: Still oliguric and hypotensive. Pressors restarted. CT abdomen reveals worsening pleural effusions, ascites but no abscess. Later weaned pressors. Pleural effusions decreased on CXR and vent weaning trials begin. Now on TPN.
 
DAY 8-9: Heparin-induced thrombocytopenia diagnosed and Heparin D/C’ed. Swan-Ganz removed. Becoming more responsive. CXR clearing and vent stable
DAY 10-11:
Pleural effusions smaller. Hypotensive again and norepinephrine restarted. Blood cultures x 2 negative. Requiring increased ventilatory pressure support secondary to tachypnea. CVVHD continued.
DAY 12-13: Vent difficult to wean. Now on low-dose norepinephrine . Less responsive. Chest clear on exam and subsegmental atelectasis and effusion noted at right base on CXR. Blood cultures and catheter tip cultures still -ve. Stool guaiac positive. CT abdomen repeated without evidence of liver abscess; right pleural effusion and atelectasis persist but some clearing at left base noted. Pressor requirement increasing to maintain BP despite being off CVVHD.
DAY 14: Asystole at 4:50 am, unable to resuscitate.
An autopsy is performed.
HOSPITAL COURSE (abbreviated chart)
DAY
Temp, F
WBC
Antibiotics
Creatinine
ALT
AST
  
1-2
97.4
25.1
Ceftriaxone started
2.7
4120
6570
  
3-4:
96
10.2
Pip-taz and metronidazole started
5.2
4031
5265
  
5-6:
96.4
14.5
3.7
 
7-8:
97.9
14.2
3.7
748
96
  
9-10:
99.1
20.3
3.3
495
69
  
11-12:
100.2
40.8
4.2
295
61
  
13-14
102.2
86.2
7.5