Download CPC Answer - Clinical Correlations

Clinical Pathological Conference
Marshall Fordyce, M.D.
Department of Medicine
NYU School of Medicine
August 17th, 2007
Chief Complaint
A 44 year old woman presents with nausea,
vomiting and diarrhea for one week.
History of Present Illness
• The patient had a history of hypertension,
peripheral vascular disease, and poorly
controlled Type 2 diabetes mellitus, complicated
by chronic renal insufficiency and chronic foot
ulcers.
• One week prior to admission she presented to
another hospital complaining of nausea,
vomiting, diarrhea, and dyspnea for one week.
She also reported one month of subjective fever.
Two days prior to admission, she developed
hypotension, hypoxia and decreased urine
output.
History of Present Illness
• She was started on broad spectrum antibiotics
for presumed sepsis. An echocardiogram was
performed and the patient was transferred to this
hospital for further care.
• On review of systems she denied weight loss,
headache, visual changes, syncope or chest
pain. Her baseline exercise tolerance was more
than ten blocks, not limited by dyspnea or chest
pain.
Other History
• Past Medical History: hypertension, peripheral
vascular disease, Type 2 diabetes mellitus,
chronic renal insufficiency.
• Past Surgical History: Right great toe
amputation.
• Medications: the patient reported taking insulin,
unknown dose.
• Allergies: none
• Family History: Father unknown, Mother with
diabetes
• Social History: Born in New York City. No travel.
No history of tobacco, alcohol or drugs.
• Review of Systems: otherwise negative.
Physical Exam
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General: obese woman in no acute respiratory distress, diaphoretic and
jaundiced.
Vitals: BP 96/58, HR 76 and regular, RR 24, Temp 96.5, O2 saturation 97%
on 3L NC, CVP 18.
HEENT: scleral icterus.
Neck: obese neck, no masses.
Cor: regular rate and rhythm, normal S1, S2, no S3 or S4.
Pulm: crackles at bases bilaterally, decreased breath sounds at right base.
Abd: +bowel sounds, soft, non-tender, non-distended.
Extr: cool lower extremities; bilateral pitting edema, 1+ left, 3+ right; chronic
venous stasis changes; decreased hair growth; minimal pedal pulses
bilaterally; right foot with erythematous ulcer on plantar surface with
serosanguinous drainage, no bone visualized.
Lymph: No lymphadenopathy.
Neuro: Alert and oriented to person, place, time, and situation. Cranial
nerves II-XII intact. No focal motor or sensory deficits. No asterixis.
Laboratory Data
Na 133, K 3.9, Cl 103, CO2 16, BUN
50, Cr 2.8, Glu 218
WBC 18.4, Hgb 8.4, HCT 25.2, Plt 28
Ca 6.8, Mg 1.7, Phos 2.6
AST 36, ALT 18, Alk Phos 168, total
bili 5.8, direct bili 4.2, total protein 6.2,
albumin 1.6
PT 13.5, INR 1.1, PTT 31
UA: 3+ blood, 2+ protein negative
nitrites, small leukesterase.
Labs from 6/05: Hgb 10.4, Plt 339
ECG
Radiology
CXR: mild interstitial edema and cardiomegaly.
Transthoracic echocardiogram (TTE): large 6.5
x 2.0 cm pedunculated mass attached to the
lateral free wall of the right atrium separate from
the tricuspid valve leaflets, with prolapse of the
mass across the tricuspid valve and associated
severe tricuspid insufficiency.
A diagnostic procedure was performed…
Student Discussants
Jessica Finn: Atrial Myxoma
Etin-Osa Osa: Right atrial thrombus
Eleza Golden: Pancreatic Cancer with cardiac
metastases
Daniel Asay: Cholangitis
Echocardiography
MRI Images
T1-pre
T1-post
T2-pre
T1-IR-delay post
T1-pre
T1-post
T2-pre
T1-IR-delay post
Faculty Discussant:
Dr. Martin Kahn
NYU Medical Center
Department of Pathology
PATHOLOGY
Mariela Losada, M. D.
TRICUSPID
INDENTATION
ATRIAL CUFF
Final Diagnosis:
Subacute bacterial endocarditis
Giant endocardial vegetation
due to Vancomycin Resistant
Enterococcus faecium
DDx : Intracardiac Mass
80% of myxomas
are left sided
Primary cardiac tumor
Benign – 75%
Malignant
Either
!
Secondary tumor
Thrombus
Vegetation
Evaluation of cardiac mass
On cardiac MRI, avascular masses (thrombus)
can be differentiated from tumors as they appear
hypointense in T2 weighted images and do not
enhance with contrast.
Differentiating between thrombus and vegetations
from tumors using noninvasive means is crucial
as it may determine the need for and timing of
resection.
Diabetes mellitus Type 2
Medication non-adherence
Hyperglycemia
Neuropathy, Vascular compromise, Immunodeficiency
Chronic foot ulcer
Cellulitis, Osteomyelitis
Right atrial free wall vegetation, sepsis
Septic emboli
Case follow-up
Acknowledgements:
Martin Kahn, M.D.
Martin Blaser, M.D.
Mariela Losada, M.D.
Monvadi Barbara Srichai-Parsia, M.D.
Joshua Olstein, M.D.
Andrew Zinn, M.D.
Timothy J. Vittorio, M.D.
Juan B. Grau, M.D.
Pey-Jen Yu, M.D.
Samyra El-ftesi, B.S.