LSU Internal Medicine Case Conference - School of Medicine

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LSU Internal MedicineCase Conference RAPID RESPONSE 11 06 2012Mallory Smith MD PGYI Internal Medicine Pediatrics .
Scott Laura MD PGYI Internal Medicine Chief Complaint SOB x 3 days History Physical9 16 2012 .
77 yo women with past medical history significant forstage IV lung CA status post right lobectomy chemotherapy and radiation presented to the ED withdaughter for 3 day history of SOB at rest The shortness of breath had gotten progressively worse.
and was aggravated by exertion Per patient sdaughter the patient experienced chest pain of rightside that was intermittent and without radiation Patient denied diaphoresis vomiting lower extremityedema orthopnea or PND but did endorse recent.
history of nausea and diarrhea Past Medical History PMHx Lung Cancer Stage IV s p Rlobectomy chemotherapy and radiation GERD Depression Neuropathy.
PSHx Right Lobectomy 6 months prior Soc 1pk day for many years quit 2 yrs ago occasional alcohol use denies illicit drug use FmHx Non contributory PMHx Continued.
Home Meds Neurontin 300mg TID Vicodin 7 5 750 q6 PRN Meclizine 32mg TID PRN Prilosec 40mg Daily Ambien CR 6 25mg PRN.
Allergies Adverse Rxn Codeine N V Health Maintenance No PNA Flu vac ROS as above plus general fatigue andsome light headedness Vitals Physical Per ED.
Vitals T 98 F 37 2 C HR 124 BP 80 60 RR 30 Sat 97 on NRB GENERAL Oriented x 3 appears distressed HEENT NCAT PERRLA EOMI NECK No carotid bruits JVP UTA secondary to body habitus andcentral line.
CV Regular rate and rhythm no murmurs rubs gallopsappreciated LUNGS Respiratory Distress Decreased breath sounds rightupper mid lower lung zones ABDOMEN Soft NTTP BS no masses or organomegaly.
EXTREMETIES No lower extremity edema moves all extremities no clubbing or cyanosis VASCULAR 2 radial pulses in BUE 2 DP pulses in BLE SKIN Warm and Moist Laboratory Data.
Complete Blood Count with Diff WBC 20 000 N 47 Bands 27 L 14 M 10 E 2 H H 15 6 48 3 Platelets 320.
MCV 88 RDW 16 Laboratory Data Complete Metabolic Panel Na 145 TP 8 1.
K 4 5 ALB 3 7 Cl 109 AST 51 HCO3 15 ALT 18 BUN 36 AP 143 Crea 1 89 Bili 1 2.
Glucose 144 Calcium 9 3 EKG 9 16 12 CT Chest W O Hospital Course.
During the ED stay patient was found to behypotensive with systolic BP into the 70s and80s but responded well to fluid and pressorsbefore she was admitted to ICU Chest tube was placed for drainage of.
Hospital course 9 17 9 20 Quickly stabilized off vasopressors Continued on empiric antibiotics Vanc Pip Tazo Ciprofloxacin .
Echocardiogram ordered by MICU team Echo 9 17 Hyperdynamic LV with EF 75 Mild AR Hospital course.
9 20 12 Patient transferred to floor under the care of LSU Was awaiting transfer to West Jefferson perpatient s request as she is well known to herprimary care physician and oncologist there.
Vitals Physical Vitals T 99 F 37 2 C HR 118 BP 162 95 RR 19 28 GENERAL Obese Intubated Sedated Arousable to voice andtactile stimuli HEENT NCAT PERRLA EOMI.
NECK No carotid bruits JVP UTA secondary to body habitus andcentral line CV Distant heart sounds no murmurs rubs gallops appreciated LUNGS Decreased breath sounds at bilateral bases norhonchi rales wheezing.
ABDOMEN Soft NTTP BS no masses or organomegaly EXTREMETIES No lower extremity edema moves all extremities no clubbing or cyanosis VASCULAR 2 radial pulses in BUE 2 DP pulses in BLE SKIN Warm and Moist.
Laboratory Data 9 20 Complete Blood Count with Diff WBC 12 000 N 68 L 21 M 10 E 1 B 0 H H 9 8 30 1.
Platelets 208 MCV 87 5 RDW 17 Laboratory Data Complete Metabolic Panel.
Na 141 TP 5 7 K 3 6 ALB 2 1 Cl 112 AST 56 HCO3 19 ALT 27 BUN 26 AP 98.
Crea 2 0 TP 0 9 Glucose 153 Calcium 8 1 Laboratory DATA Coagulation Studies.
PT 13 6 INR 1 3 PTT 26 8 Cardiac Profile BNP 165.
Troponin 0 02 0 08 CK 429 CKMB 36 6 LA 2 1 Laboratory DATA.
Lipid Profile TC 116 TG 149 HDL 21 LDL 65.
Hospital course Approximately one hour after transfer to floora rapid response was called due to SOB BP stable HR 140.
ABG 7 12 54 76 17 91 sats on 100 Intubated Cardiac enzymes 9 16 12 Troponin 0 02.
9 20 12 CPK 429 412 687 679 CKMD 36 27 33 28 Troponin 0 08 8 09 9 72 7 85 Cardiac cath 9 20.
LM patent LAD diffuse plaque 30 stenosis LCx diffuse plaque 30 stenosis RCA 50 ostial Ventriculogram Severe hypokinesis of the.
mid and apical segments The basalsegments are hyperkinetic Hospital course 9 21 12 Remained in ICU intubated.
Pressors weaned Diuresed with IV furosemide Echo repeated Echo 9 21 Severely decreased EF 20 29 .
Distal 2 3 anteroseptal wall motionabonormality with hyperdynamic function at New findings since 9 17 12 Hospital course 9 22 10 2.
Continued to have complicated ICU course Eventually extubated on 10 2 Echo repeated on 9 24 Stepped to the floor placed on beta blocker Echo 9 24.
Good LV function EF 50 Final DiagnosisCardiomyopathy THANKS FOR YOUR.
LSU Internal Medicine Case Conference “RAPID RESPONSE” 11/06/2012. Mallory Smith, MD PGYI ( Internal Medicine & Pediatrics)/ Scott Laura, MD PGYI (Internal Medicine)

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