Medical Grand Rounds Clinical Vignette by olk11750

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									          09-12-2008




Medical Grand Rounds
  Clinical Vignette


    Matthias C. Kugler, M.D.
   Internal Medicine Resident
             Chief Complaint

• 53 year old Caucasian male with Hepatitis C and
  cirrhosis, who presented to Bellevue Hospital with
  8 days of abdominal pain and increasing girth
      History of Present Illness

•   Right Upper Quadrant pain for 8 days, up to 8/10
    intensity, aching, non-radiating, intermittent, lasting
    several hours, no association with nausea or vomiting.
•   Increasing girth and abdominal swelling.
•   He denied fever or chills
                            History
• Past Medical History:
    Hepatitis C diagnosed 15 years ago, cirrhosis since 2003, awaiting
  transplant
    Esophageal varices with endoscopic banding 2006
• Past Surgical History: none
• Family History: non-contributory
• Allergies: Penicillin – rash
• Medications: Esomeprazole 40mg daily, Furosemide 40mg daily,
  Aldactone 25mg daily, Lactulose 30ml bid, Propanolol 20mg tid,
  Acetaminophen 500mg q6h prn pain, Docusate 100mg tid
• Social History: no toxic habits, married, 2 children, no intravenous
  drug use
• ROS: otherwise negative
             Physical Examination
• General: Ill-appearing white male in mild distress, alert and oriented x 3
• Vital Signs: BP-113/80 HR-65 RR-20-22 O2-sat 93% (room air)
  Temp-37.0°C
• Head/Neck: + scleral icterus
• Lungs: breath sounds decreased b/l bases, upper lungs clear to
  auscultation
• Abdominal: + tense, distended, diffusely tender to palpation, + fluid
  wave, no guarding or rebound, bowel sounds hypoactive in all 4 quadrants
• Extremities: 1-2+ pitting edema of the legs bilaterally
• Skin: + jaundice

• Remainder of physical exam normal
                  Laboratory Values
Basic:                            CBC:
Na 132 (140-145)                  WBC 4.2 (N53%, L26%, M15%, E5%)
                                  Hb 11.1 (13-18)
Hepatic:                          Hct 31.6 (35-50)
AST 100 (7-27)                    MCV 112 (86-98)
ALT 43 (1-21) AP                  plt 81 (150-350)
112 (13-39)
Tbili 7.7 (<1.0)                   Paracentesis:
DBili 5.1 (<0.4)
                                   WBC 45 (N10%, L57%, M2%,)
Prot 10.3 (6.0-8.4)
                                   RBC 3350
Alb 1.6 (3.5-5.0)
                                   Alb 1.0
Coags:                             LDH 49
INR 2.5 (<1.15)                    Gram stain: gram-negative rods
PTT 52 (25-38)

ABG: pH 7.43, pCO2 39, pO2 87, HCO- 26, O2-sat 92% (room air), Lact 1.2
                     Imaging Data
• PA/Lateral chest radiograph: small pleural effusions b/l, no
  infiltrates, + ventral hernia
           Working Diagnosis
• Bacterial peritonitis and decompensation of
  cirrhosis secondary to infection.
               Hospital Course
HD#1:
1. Therapeutic paracentesis with 1.5 liter fluid femoval
2. Ceftriaxon initially, when paracentesis fluid grew out
   pansensitive Escherichia coli, the antibiotic was
   switched to Ciprofloxacin
3. Forced diuresis using intravenous furosemide with
   monitoring of the electrolyte status
4. Patient continously afebrile

HD#4:
•  Despite improving ascites, patient noticed to be more
   short of breath, tachypnic and hypoxic
                   Hospital course
HD #5:
•   ABG: pH 7.37, pCO2 43, pO2 62, HCO- 24, O2-sat 88% (room air)
•   PA/Lateral chest radiograph with increased diffuse patchy infiltrates b/l
•   Patient was placed on CPAP with supplemental O2 and transferred to the
    intensive care unit
                   Hospital course
HD #7:
•   ABG: pH 7.39, pCO2 43, pO2 48, HCO- 26, O2-sat 77% on FiO2 50%,
    PaO2/FiO2 96
•   Patient was intubated for severe hypoxemia.
•   Portable AP chest radiograph with worsening diffuse patchy infiltrates
    throughout both lungs
                 Hospital course
HD #8-10:
•   Ventilation using low tidal volumes, PEEP, and permissive
    hypercapnea
•   Setting VT 400 cc, FiO2 70-80%, PEEP 7-10 mm H2O later
    increased to maximum of 14 mm H2O
•   Over the next days the team was able to decrease PEEP to 8, FiO2 to
    50%, VT 400 cc, with improving hypoxemia on ABG (pH 7.38,
    pCO2 31, pO2 84, HCO-18, O2-sat 96%
•   Sputum cultures remained all negative
            Final Diagnosis
• Bacterial peritonitis and decompensation of
  cirrhosis secondary to infection.

• Acute Respiratory Distress Syndrome
  (ARDS)

								
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