Download ID Case Conference 10-10-07

ID Case Conference
4/23/08
Gretchen Shaughnessy, MD
Clinical Fellow
Dept of Infectious Diseases
CC: chest pain
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19y/o Native American woman s/p OHT at
age 12 who presents with chest pain.
She was admitted for chest pain on 4/4/08,
CXR, echo, EGD, and cardiac w/u all stable.
Finishing her second course of TMP/SMX for
sinusitis (prescribed by PMD as outpt).
Requesting large amts of pain medication,
exhibiting drug seeking behavior. Psychiatry
involved. Workup negative, d/ced with
outpatient followup.
HPI (cont)
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Discharged from UNC 4/8/08.
Went home and continued to have
pain. Went to outside hospital
4/13/08 and admitted for chest pain.
Multiple studies negative including VQ
scan, CXR, Echo, abd u/s all
unchanged from prior studies.
HPI (cont)
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4/15/08 patient develops epistaxis, ENT
consulted. D/ced Allegra, recommended
saline, vasoline, afrin spray.
The patient was transferred to UNC 4/19/08
but since admission has had a fever and
now worsening infiltrates on CXR. She has
also started coughing up blood.
ID was consulted for assistance.
PMH
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Heart transplant in 10/19/2000, secondary
to Idiopathic dilated cardiomyopathy, now
with graft vasculopathy
– Cath in 2/2008 showed 30% LM, 40% LAD, 70%
LCx, 40% RCA
– TTE in 4/2008 showed LVEF of 65-70%, diastolic
dysfunction, mod AI, and mod dilation of RA
– Recent increase in immunosuppression because
of vasculopathy
PMH (cont)
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Dyslipidemia
Chronic abdominal pain/GERD.
– EGD done during 4-08 admission
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History of two sinus surgeries, which
included tonsillectomy and adenoidectomy
in 1997, and with recurrent sinusitis
Endometriosis
Anxiety
MDD
elevated ANA 1:640, rheum workup 9/07
Medications
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Allergies: PCN – hives, ceclorhives, levofloxacin – itching,
vancomycin – Redman’s,
morphine - itching
ABX history:
Levofloxacin started 4/17/08
aztreonam and clindamycin
4/19/08
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aspirin 81 mg po q day
lasix 40 mg po q day
pravastatin 20 mg po q day
norvasc 5 mg po q day
neurontin 600 mg po q day
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Singulair 10 mg po q day
Ferrous sulfate 325 mg po q
day
colace 100 mg po q day
prozac 40 mg po q day
magnesium oxide 800 mg po
bid
sirolimus 2 m po q day
tacrolimus 2 mg po bid
nexium 40 mg po q day
ROS
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positive for cough, sore throat, chest
pain, DOE, SOB, hemoptysis, weight
loss (since increasing her lasix dose but has not noticed any weight loss
other than that related to fluid), brown
nasal discharge, fatigue, occasional
diarrhea.
otherwise negative.
Physical Exam
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Vital 38.5 - 35.6 - 89-103 18-20 - 109-121/63-75
94% on RA
INAD, frequently coughing
during exam. coughed up
small amount of yellow
sputum streaked with blood
during exam
EOMI, PERRLA, nonicteric
no JVD, no LAD appreciated
in cervical, supraclavicular,
or inguinal regions
RRR III/VI systolic murmur
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no e/e on OP
coarse breath sounds B,
rhonchi worse on L,
crackles on R
no rash or lesions
a&ox3, pleasant and
cooperative. asking for
more dilaudid
soft NT nabs, no HSM
no c/c/e
nl tone, full ROM present
no focal defecits
Diagnostic Tests from
OSH
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4/13 Labs: CBC 11.7>9.4/27.8<245, BNP 600. PT
11.5, INR 1.1, PTT 26.7. CK 85, CKMB1.4, Trop
<0.1 (repeat x2 unchanged).
4/13 CXR clear lungs, stable cardiomegally.
4/13 VQ scan normal.
Utox negative, TSH 4.8, Upreg test negative, u/a
negative. D-Dimer 2.2.
ABG 7.42/36/102/23.3/98 on 0.21 O2
4/14 Echo - LV systolic low normal, EF 55%, RV
systolic elevated at 40-50mmHg concerning for
pulm HTN, mild valvular aortic stenosis with
moderate aortic regurg.mild mitral regurg. No
pericardial effusion.
OSH Diagnostic tests
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4/14 CBC 11.1>10.4/31.8<222. ESR 33
4/15 CBC 7.1>8.8/26.7<231. Amylase 49,
Lipase 19, Mg 1.5, Ca 8.9, Cr 0.9.
4/15 Abd U/S done with small vol of
perihepatic ascites, left pleural effusion.
4/15 PCXR no acute cardiopulm disease,
stable findings.
4/15/08 ENT consulted for epistaxis
4-19-08
Previous Rheumatologic Evaluation – 9/07
4-4-08
4-19-08
4-21-08
4-22-08
4-20-08
Discussion