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NYU Medical Grand Rounds Clinical Vignette Matthew Johnson MD, PGY-2 May 5, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint A 54-year-old man with diabetes presents with watery diarrhea for 5 days. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • The patient was in his usual state of health until several months prior to admission when he noted an ulcer on the lateral aspect of his right foot. • Though he is unsure exactly when it developed, the ulcer persisted over several months. • When associated swelling and drainage developed, the patient sought medical attention, and eventually underwent surgical debridement. • Additional wound care and antibiotics were continued and the patient was eventually discharged home. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • Two weeks after discharge, the patient began to experience 10-15 episodes of profuse, non-bloody diarrhea. • The diarrhea persisted over the next several days, and the patient began feeling increasingly weak. • Concerned, he sought further care in the emergency room. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History Past Medical History • Diabetes mellitus Past Surgical History • Ulcer debridement • Right foot UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Family History • Mother: Diabetes • Father: Prostate cancer Social History • Lives alone • Currently unemployed • Denies tobacco use • Denies alcohol use • Denies illicit drug use Outpatient Medications Glipizide 5mg Daily Pioglitazone 15mg Daily Metformin 1000mg BID Allergies: NKDA UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination General: Well-appearing middle-aged man in no acute distress Vitals: T 98.4F, BP 101/52, HR 107, RR 16 O2 saturation: 99% on room air Abdominal: Mildly distended, non-tender, hyperactive bowel sounds Extremities: 3 x 4 cm ulcer with a clean base and margins on lateral aspect of the right foot The remainder of the physical exam was normal. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Initial Studies • CBC: • WBC 39,300 with 35% bands • The remainder was within normal limits • Basic Metabolic Panel: • Sodium 130 • BUN 37, Cr 1.7 • The remainder was within normal limits • Hepatic Panel: Within normal limits UNITED STATES DEPARTMENT OF VETERANS AFFAIRS CT Abdomen and Pelvis • Diffuse marked symmetric pan-colonic wall thickening up to 1.3 cm involving the entire colon • Thickened haustral folds with associated free fluid in the paracolic gutters UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis Clostridium difficile Colitis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Treatment was initiated with metronidazole and oral vancomycin, but without significant clinical improvement. • The patient’s WBC count continued to rise over the next several days, and peaked at 58,800. • Vancomycin per rectum was added, but the patient’s diarrhea persisted. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • The patient was transferred to the ICU for several days after developing hypotension, acute renal failure and increasing oxygen requirements, concerning for sepsis due to his colitis. • The patient’s diarrhea slowly improved and he was eventually transferred back to the medical ward. • He is currently in the process of being discharged to a rehabilitation facility. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis Pan-colitis secondary to a severe, antibioticassociated Clostridium difficile infection UNITED STATES DEPARTMENT OF VETERANS AFFAIRS