ID Case Conference 4/23/08 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases.

Slides:



Advertisements
Similar presentations
Case History 1 : Sorting out chest pain in general practice Dr Albert Ko / GP Panel.
Advertisements

CC Pt is a 48 yo AA male who presents with SOB..
VSD Case Discussion. Patient Data 23 y/o female 23 y/o female Underline Disease: Underline Disease: 1. Large VSD 2. Pulmonary hypertension, secondary.
Hemoptysis Mentioned in the Review of Systems… Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases.
Case Presentation Linda White, PA-S. Chief Complaint n “ I am short winded and tired. Also when I eat it feels like the food sits in my chest.”
NYU Medical Grand Rounds Clinical Vignette Roy Mukku, MD PGY-2 1/15/13 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
HPI A 35 yo female presents to the ED with chest pain that started this morning. She had cold- like symptoms earlier in the week. She has an important.
Melioidosis case report of a pediatric patient in Cambodia with extrapulmonary findings of mastoiditis and visceral abscesses Yos Pagnarith MD Angkor Hospital.
NYU Medical Grand Rounds Clinical Vignette Rennie Rhee MD, PGY-2 January 13, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
LEMONS OR LYMES?. Learning Objectives 1. Participants will be able to identify symptoms of Lyme Disease 2. Participants will be able to determine if further.
Trileaflet Aortic Valve. Management strategy for patients with chronic severe aortic regurgitation. Preoperative coronary angiography should be performed.
18/10/ Mostafavi SN. MD Pediatric infectious disease departement Isfahan University of Medical Science 18/10/13902.
Atypical Presentation of MI Johnna Walker PA-S. The case… 59 year old woman presents with chief complaint of persistent cough and chest congestion for.
Dyspnea and Rash Andres Quiceno, MD Rheumatology PHD.
Intracardiac Shunts.
Valvular Heart Disease Dr. Raid Jastania. Valvular Heart Disease Congenital or Acquired Part of congenital heart diseases May involve any valve: Aortic,
Case #1 Bicuspid Valve Dilated Aortic Root Mod AI/Mild AS - RW
Clinical Pathological Conference Kartikya Ahuja, M.D. Resident Physician Department of Medicine NYU School of Medicine July 20 th, 2007.
PROBLEM BASED LEARNING
Medical Grand Rounds Clinical Vignette Jessica Lambert, MD Third Year Resident April 8, 2009.
NYU Medical Grand Rounds Clinical Vignette Jacqueline Lonier, PGY2 November 3rd, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
IgG4-related Disease Jen Ng, MD PGY-2 June 18, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Should there be air there? Elizabeth M. Regan November 22, 2013 Dr. Cameron; Dr. P.Smith, Dr. Ebersole.
NYU Medical Grand Rounds Clinical Vignette Jennifer Lue, MD PGY-2 9/11/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
Acute Renal Failure Cases. Case 1- HPI 71 yo mw/ fever and dysuria for 2 days Decreased UOP but increased frequency Yesterday vomited 3-4 times and developed.
Acid/Base Conference 11/3/09 Saleem Bharmal. Case HPI: 43 y/o AAF with PMHx of SLE, ESRD from lupus nephritis on HD, interstitial lung disease on 4L home.
Patient presenting with altered mental status
HYPOXIA Maroun Matta, M.D..
HPI A previously healthy 33 year old male complaining of progressive nonproductive cough for 2 months. He became more short of breath with exertion in.
Peri-rectal Abscess Snehalata Topgi, M4 January 2014.
Coding Tips and Other Strategies to Increase Practice Revenue Cynthia W Denmark, FNP-BC, Wesley Primary Care-Leakesville Wesley Medical Center.
MORBIDITY & MORTALITY CONFERENCE
Heart Failure: Interactive Fundamental Clinical Reasoning Activity
Medical Grand Rounds Clinical Vignette October 15 th, 2008 Srikant Duggirala, M.D.
APPROACH TO CHEST PAIN. OBJECTIVES  1. Establish a differential diagnosis for chest pain  2. Know what clues to obtain on history to rule-in or out.
Sickle Cell Pain Crisis and Fever Management
Generic Case Review Chief Complaint.
Congestive Heart Failure ADOPTED FROM: Jarrod Eddy, PGY2 Internal Medicine Sub-I Lecture Series ADOPTED FROM: Jarrod Eddy, PGY2 Internal Medicine Sub-I.
NYU Medical Grand Rounds Clinical Vignette Andy Levy, MD PGY-2 March 26, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
71-year old male Admitted with worsening shortness of breath PMHx: Severe COPD, A.Fib, CHF/ischemic, PE On long term anticoagulation with Pradaxa 150.
NYU Medicine Grand Rounds Clinical Vignette David Altszuler, MD PGY-2 December 11, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
NYU Medical Grand Rounds Clinical Vignette Justin Simmons, M.D. Class of /27/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.
SACGR June 15, 2005 Ann Chen. History of Present Illness 31 yo male, residing at West Seattle Psychiatric Hospital, brought to HMC for fevers, chills,
Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine
Tri-leaflet Aortic Valve. Aortic Stenosis Nishimura, RA et al AHA/ACC Valvular Heart Disease Guideline.
Excluding the Diagnosis of Pulmonary Embolism: Is There a Magic Ball? COPYRIGHT © 2015, ALL RIGHTS RESERVED From the Publishers of.
November 26, HPI 14 month old male seen by PCP intially for fever and nasal congestion with purulent nasal discharge and cough. At initial visit.
MUNEZ. 3 months PTA, patient had fever, cough and colds. Consult done at a local health center where she was given amoxicillin for 1 week with noted resolution.
– Dr. J. Satish Kumar, MD, Department of Basic & Medical Sciences, AUST General Medicine CVS Name:________________________________________ Congestive Heart.
HARVEY®Simulation Exam VCU Internal Medicine M3 Clerkship IMSPE Exam.
Morbidity and Mortality Rounds Dr. Shounak Das July 27, 2007.
A Case of Hypertension Dr. Susan Poe, case presentation Dr. Paul Kellerman, topic discussion October 10, 2007.
TID Case Nicole Theodoropoulos, MD, MS The Ohio State University.
Scleroderma Associated Pulmonary HTN August 13 th /03 Wael Batobara.
우연히 발견된 폐결절환자 증례 호흡기내과 R1 최윤영/ Prof. 박명재
Echo-Conference R2 조경민. History 박 O 화 (F/31) Chief Complaint Chief Complaint Fever.chilling & Chest discomfort O/S) 10 days ago Fever.chilling.
Angio Conference 김 O 동 (M/50) Admission: Chief complaint - Chest Pain (recent o/s: 내원 2 주전, remote o/s: 내원 1 년전 ) squeezing type Ant.
EOL care Closing the Gap 2b.
Background Information
Pulmonary Thromboembolism
Guide on how to manage atrial fibrillation in the office
Chest Pain & Shortness of Breath
7/18/07 Gretchen Shaughnessy, MD
Intern Case Report Scott Le, DO 11/14/14.
Hannah Jones, PGY-1 Pericarditis.
Thursday, August 23rd 2018 VAMR Team 3
Patient Presentation History of Present Illness (HPI)-
What is the relative risk reduction of ACEi’s/beta blockers for HFrEF?
CLINICAL PROBLEM SOLVING
Khalid AlHabib Professor of Cardiac Sciences Cardiology Consultant
Presentation transcript:

ID Case Conference 4/23/08 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

CC: chest pain 19y/o Native American woman s/p OHT at age 12 who presents with chest pain. 19y/o Native American woman s/p OHT at age 12 who presents with chest pain. She was admitted for chest pain on 4/4/08, CXR, echo, EGD, and cardiac w/u all stable. She was admitted for chest pain on 4/4/08, CXR, echo, EGD, and cardiac w/u all stable. Finishing her second course of TMP/SMX for sinusitis (prescribed by PMD as outpt). Finishing her second course of TMP/SMX for sinusitis (prescribed by PMD as outpt). Requesting large amts of pain medication, exhibiting drug seeking behavior. Psychiatry involved. Workup negative, d/ced with outpatient followup. Requesting large amts of pain medication, exhibiting drug seeking behavior. Psychiatry involved. Workup negative, d/ced with outpatient followup.

HPI (cont) Discharged from UNC 4/8/08. Discharged from UNC 4/8/08. Went home and continued to have pain. Went to outside hospital 4/13/08 and admitted for chest pain. Went home and continued to have pain. Went to outside hospital 4/13/08 and admitted for chest pain. Multiple studies negative including VQ scan, CXR, Echo, abd u/s all unchanged from prior studies. Multiple studies negative including VQ scan, CXR, Echo, abd u/s all unchanged from prior studies.

HPI (cont) 4/15/08 patient develops epistaxis, ENT consulted. D/ced Allegra, recommended saline, vasoline, afrin spray. 4/15/08 patient develops epistaxis, ENT consulted. D/ced Allegra, recommended saline, vasoline, afrin spray. The patient was transferred to UNC 4/19/08 but since admission has had a fever and now worsening infiltrates on CXR. She has also started coughing up blood. The patient was transferred to UNC 4/19/08 but since admission has had a fever and now worsening infiltrates on CXR. She has also started coughing up blood. ID was consulted for assistance. ID was consulted for assistance.

PMH Heart transplant in 10/19/2000, secondary to Idiopathic dilated cardiomyopathy, now with graft vasculopathy Heart transplant in 10/19/2000, secondary to Idiopathic dilated cardiomyopathy, now with graft vasculopathy –Cath in 2/2008 showed 30% LM, 40% LAD, 70% LCx, 40% RCA –TTE in 4/2008 showed LVEF of 65-70%, diastolic dysfunction, mod AI, and mod dilation of RA –Recent increase in immunosuppression because of vasculopathy

PMH (cont) Dyslipidemia Dyslipidemia Chronic abdominal pain/GERD. Chronic abdominal pain/GERD. –EGD done during 4-08 admission History of two sinus surgeries, which included tonsillectomy and adenoidectomy in 1997, and with recurrent sinusitis History of two sinus surgeries, which included tonsillectomy and adenoidectomy in 1997, and with recurrent sinusitis Endometriosis Endometriosis Anxiety Anxiety MDD MDD elevated ANA 1:640, rheum workup 9/07 elevated ANA 1:640, rheum workup 9/07

Medications Allergies: PCN – hives, ceclor- hives, levofloxacin – itching, vancomycin – Redman’s, morphine - itching Allergies: PCN – hives, ceclor- hives, levofloxacin – itching, vancomycin – Redman’s, morphine - itching ABX history: Levofloxacin started 4/17/08 aztreonam and clindamycin 4/19/08 ABX history: Levofloxacin started 4/17/08 aztreonam and clindamycin 4/19/08 aspirin 81 mg po q day aspirin 81 mg po q day lasix 40 mg po q day lasix 40 mg po q day pravastatin 20 mg po q day pravastatin 20 mg po q day norvasc 5 mg po q day norvasc 5 mg po q day neurontin 600 mg po q day neurontin 600 mg po q day Singulair 10 mg po q day Singulair 10 mg po q day Ferrous sulfate 325 mg po q day Ferrous sulfate 325 mg po q day colace 100 mg po q day colace 100 mg po q day prozac 40 mg po q day prozac 40 mg po q day magnesium oxide 800 mg po bid magnesium oxide 800 mg po bid sirolimus 2 m po q day sirolimus 2 m po q day tacrolimus 2 mg po bid tacrolimus 2 mg po bid nexium 40 mg po q day nexium 40 mg po q day

ROS positive for cough, sore throat, chest pain, DOE, SOB, hemoptysis, weight loss (since increasing her lasix dose - but has not noticed any weight loss other than that related to fluid), brown nasal discharge, fatigue, occasional diarrhea. positive for cough, sore throat, chest pain, DOE, SOB, hemoptysis, weight loss (since increasing her lasix dose - but has not noticed any weight loss other than that related to fluid), brown nasal discharge, fatigue, occasional diarrhea. otherwise negative. otherwise negative.

Physical Exam Vital / % on RA Vital / % on RA INAD, frequently coughing during exam. coughed up small amount of yellow sputum streaked with blood during exam INAD, frequently coughing during exam. coughed up small amount of yellow sputum streaked with blood during exam EOMI, PERRLA, nonicteric EOMI, PERRLA, nonicteric no JVD, no LAD appreciated in cervical, supraclavicular, or inguinal regions no JVD, no LAD appreciated in cervical, supraclavicular, or inguinal regions RRR III/VI systolic murmur RRR III/VI systolic murmur no e/e on OP no e/e on OP coarse breath sounds B, rhonchi worse on L, crackles on R coarse breath sounds B, rhonchi worse on L, crackles on R no rash or lesions no rash or lesions a&ox3, pleasant and cooperative. asking for more dilaudid a&ox3, pleasant and cooperative. asking for more dilaudid soft NT nabs, no HSM soft NT nabs, no HSM no c/c/e no c/c/e nl tone, full ROM present nl tone, full ROM present no focal defecits no focal defecits

Diagnostic Tests from OSH 4/13 Labs: CBC 11.7>9.4/ /27.8<245, BNP 600. PT 11.5, INR 1.1, PTT CK 85, CKMB1.4, Trop <0.1 (repeat x2 unchanged). 4/13 CXR clear lungs, stable cardiomegally. 4/13 CXR clear lungs, stable cardiomegally. 4/13 VQ scan normal. 4/13 VQ scan normal. Utox negative, TSH 4.8, Upreg test negative, u/a negative. D-Dimer 2.2. Utox negative, TSH 4.8, Upreg test negative, u/a negative. D-Dimer 2.2. ABG 7.42/36/102/23.3/98 on 0.21 O2 ABG 7.42/36/102/23.3/98 on 0.21 O2 4/14 Echo - LV systolic low normal, EF 55%, RV systolic elevated at 40-50mmHg concerning for pulm HTN, mild valvular aortic stenosis with moderate aortic regurg.mild mitral regurg. No pericardial effusion. 4/14 Echo - LV systolic low normal, EF 55%, RV systolic elevated at 40-50mmHg concerning for pulm HTN, mild valvular aortic stenosis with moderate aortic regurg.mild mitral regurg. No pericardial effusion.

OSH Diagnostic tests 4/14 CBC 11.1>10.4/ /31.8<222. ESR 33 4/15 CBC 7.1>8.8/ /26.7<231. Amylase 49, Lipase 19, Mg 1.5, Ca 8.9, Cr /15 Abd U/S done with small vol of perihepatic ascites, left pleural effusion. 4/15 Abd U/S done with small vol of perihepatic ascites, left pleural effusion. 4/15 PCXR no acute cardiopulm disease, stable findings. 4/15 PCXR no acute cardiopulm disease, stable findings. 4/15/08 ENT consulted for epistaxis 4/15/08 ENT consulted for epistaxis

Previous Rheumatologic Evaluation – 9/07

4-4-08

Discussion