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