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NYU Medicine Grand Rounds Clinical Vignette Jamie Osman, MD MPH RD PGY2 April 2, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Mr. D is a 39-year-old Chinese man who presented with progressive bilateral lower extremity edema, dyspnea on exertion and fatigue for five weeks. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Five weeks prior to arrival the patient noted bilateral lower extremity swelling which advanced to his thighs and abdomen over the next 1 - 2 weeks. Three weeks prior to arrival he began having intermittent palpitations, weight loss, fatigue and shortness of breath with minimal exertion. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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He also recalled feeling anxious during this period On the day of arrival he was “hanging out” in Penn Station when he was noted hunched over with leg pain by police officers who called EMS. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Additional History PMH/PSH: None Meds: None Allergies: NKDA Social History: Drinks $1000 of vodka per month with friends with the last drink 1 day before admission. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Physical Examination Gen: cachectic, jaundiced Asian man in no acute distress Temperature: 97.3F Heart rate: 118 Blood Pressure 120/68 Respiratory Rate: 20 Oxygen Saturation: 97% on room air U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Physical Examination HEENT: scleral icterus, no exophthalmos, mild thyromegaly, no lid lag Cards: PMI displaced to anterior axillary line; tachycardic, irregularly irregular with jugular venous distention Abd: distended with hepatomegaly Ext: 3+ pitting edema up to scrotum and abdomen U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Remarkable Laboratory Findings CBC: Hgb 7.1 g/dL Hepatic: panel AST 41, ALT 31, alk phos 149, total bili 4.9, direct bili 4.0, total protein 7.9, albumin 2.9 Coagulation Panel INR 1.96, aPTT 33.1 Brain Natriuretic Peptide: 640 TSH undetectable, Free T4 3.42, FT3 7.0 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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EKG U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Atrial fibrillation with rapid ventricular response
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Chest X-ray Cardiomegaly with increased interstitial markings consistent with pulmonary edema U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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CT Abdomen/Pelvis Heterogeneous liver with engorgement of hepatic veins and IVC; diffuse anasarca and moderate abdominopelvic ascites U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Thyrotoxicosis Alcoholic cardiomyopathy
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The patient was admitted to the CCU where beta blockers and lasix were given for rate control and diuresis, respectively. Transthoracic echocardiogram showed four chamber dilatation with severe MR, severe TR and paradoxical flattening of the septum consistent with right ventricular overload. The patient was started on methimazole and coumadin. Hospital Day #1
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Thyroperoxidase antibody (TPO) returned positive with thyroid stimulating immunoglobulins elevated to 345 A thyroid ultrasound showed increased vascularity. Hospital Day #10
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The patient was successfully diuresed with improved heart rate and symptom control and he was discharged. Hospital Day #19
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Thyrotoxicosis due to Graves’ Disease Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS
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