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NYU Medical Grand Rounds Clinical Vignette Todd Cutler, MD 12/18/12 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint • The patient is a 61 year old woman with three days of weakness and shortness of breath. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • The patient has a history of severe pulmonary hypertension, previously treated pulmonary TB and MAC, cor pulmonale (on home oxygen), bronchiectasis and diabetes. • Three days prior to admission she began having fevers, productive cough and shortness of breath. • The day prior to admission she had difficulty walking across her living room and presented to the ED. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History • Social History: • Lives with son, no smoking, alcohol or illicits • Medications: • Lisinopril 20mg daily • Digoxin 0.125mg daily • Lasix 20mg daily • Lantus 20 Units at night • Novolog 10 Units with meals UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination • General: Frail, chronically ill-appearing, short of breath, difficulty completing sentences • Temp: 100.4 • BP: 138/85 • HR: 100 • RR: 22 • O2 sat: 95% on 4L NC, 87% on room air UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination • Head and Neck: distended neck veins • Heart: tachycardia, palpable pulmonic valve, loud S2 • Lungs: tachypnea, diffuse rhonchi with bronchial breath sounds UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies • Chest CT: stable fibrotic left lung and severe right middle lobe bronchiectasis with small nodular opacities in the anterior right upper lobe consistent with airway impaction versus infection UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Pneumonia • Bronchiectasis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings • Her labs were most remarkable for: - Arterial Blood Gas: 7.22/83/80/33 • A repeat arterial blood gas after 15 minutes of bilevel at 18/5 was unchanged. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • She was intubated for hypercarbic respiratory distress and transferred to the MICU. • She was started on vancomycin, cefepime and azithromycin. • She was extubated on hospital day #4 and discharged from the MICU to the seventh floor on Monday. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • That same day, Hurricane Sandy hit the medical center and power to the hospital was lost. • That night, supplemental oxygen was carried up to the seventh floor by the National Guard. • She continued to receive IV antibiotics by gravity drip. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • On Thursday, the National Guard carried the patient down the stairwell to the ground floor. • She was taken by ambulance to St. Luke’s Hospital in Manhattan. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • She completed her course of antibiotics at St. Luke’s Hospital. • Discharge to subacute rehabilitation was delayed as facility vacancies were limited after the storm. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • On Thanksgiving, after 10 days at St. Luke’s Hospital, she was discharged home where she has been receiving physical therapy. • She still feels week, has difficulty walking across the room and remains on continuous oxygen therapy. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Her home physical therapy and nursing visit benefits end today. • She will follow up with me in the newly reopened Bellevue outpatient clinic next week. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Pneumonia versus Bronchiectasis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS