Download Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Verity Schaye, MD
PGY-3
September 15, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 66 year old female who presented
with malaise, chills, muscle aches, productive
cough, shortness of breath and wheezing for one
week.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient’s past medical history includes moderate persistent
asthma, poorly controlled, but without recent hospitalizations.
•Notably, the patient was not up to date on her vaccinations,
including influenza.
•She was in her usual state of health until one week prior to
admission with the above complaints, and was treated for a
presumed asthma exacerbation with a high dose steroid taper.
• A chest x-ray obtained at that time was within normal limits.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient’s symptoms did not improve after one
week of therapy, at which time she was directly
admitted from the outpatient clinic for treatment with
intravenous steroids.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Hypertension
•Hyperlipidemia
•Type II Diabetes diagnosed 2004
•Past Surgical History:
•None
•Social History:
•No history of tobacco, alcohol or drug use
•Family History:
•noncontributory
•Allergies:
•No Known Drug Allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Medications:
•Albuterol inhaler as needed
•Theophylline 300mg twice a day
•Fluticasone 500mcg and Salmeterol 50mcg inhalation powder twice a day
•Metformin 500mg twice a day
•Simvastatin 40mg nightly
•Omeprazole 20mg daily
•Prednisone taper
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: well developed, well nourished, elderly
female, in mild respiratory distress
•Vital Signs: T: 97.6 BP:146/88 HR:96 RR:26 and O2
saturation:95% on 3 liters nasal cannula
•Diffuse inspiratory and expiratory wheezes, egophony
at right lung base
•The remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: white blood cell count 8.8, 85.7% neutrophils
•Remainder of CBC was within normal limits
•Basic Metabolic panel: glucose 316
•Remainder of basic was within normal limits
•Hepatic panel: within normal limits
•Arterial Blood Gas: 7.42/38/70.5/93%
•Influenza swab: negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Admission Chest X-Ray
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working or Differential Diagnosis
• The patient was initially admitted for a
presumed asthma exacerbation.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– The patient was placed on high dose
intravenous steroids and initially improved.
• Hospital Day 2:
– The patient continued to improve and a
steroid taper was begun.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
– The patient was febrile to 102.
– The patient was pan-cultured and a chest xray was repeated which showed new bibasilar
opacities.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chest X-Ray Hospital Day 3
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
– Laboratory work was significant for an
increasing white blood cell count to 12.3, with
51% neutrophils, 29% bands.
– Sputum Cultures and Blood cultures were
positive for Methicillin-resistant
Staphylococcus aureus.
– The patient was placed on Vancomycin and
Piperacillin/Tazobactam with clinical
improvement.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 7:
– The patient was discharged with a course of
oral linezolid for the treatment of Methicillinresistant Staphylococcus aureus pneumonia.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Influenza complicated by Methicillinresistant Staphylococcus aureus
pneumonia super-infection
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS