NYU Medicine Grand Rounds Clinical Vignette Jamie Osman, MD MPH RD PGY2 April 2, 2013 U NITED S...
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NYU Medicine Grand Rounds Clinical Vignette Jamie Osman, MD MPH RD PGY2 April 2, 2013 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS
Transcript of NYU Medicine Grand Rounds Clinical Vignette Jamie Osman, MD MPH RD PGY2 April 2, 2013 U NITED S...
NYU Medicine Grand Rounds Clinical Vignette
Jamie Osman, MD MPH RDPGY2
April 2, 2013
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Mr. D is a 39-year-old Chinese man who presented with progressive bilateral lower extremity edema, dyspnea on exertion and fatigue for five weeks.
Chief Complaint
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Five weeks prior to arrival the patient noted bilateral lower extremity swelling which advanced to his thighs and abdomen over the next 1 - 2 weeks.
Three weeks prior to arrival he began having intermittent palpitations, weight loss, fatigue and shortness of breath with minimal exertion.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
He also recalled feeling anxious during this period
On the day of arrival he was “hanging out” in Penn Station when he was noted hunched over with leg pain by police officers who called EMS.
History of Present Illness
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Additional History
PMH/PSH: None Meds: None Allergies: NKDA Social History: Drinks $1000 of vodka
per month with friends with the last drink 1 day before admission.
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Physical Examination
Gen: cachectic, jaundiced Asian man in no acute distress
Temperature: 97.3F Heart rate: 118 Blood Pressure 120/68 Respiratory Rate: 20 Oxygen Saturation: 97% on room air
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Physical Examination HEENT: scleral icterus, no
exophthalmos, mild thyromegaly, no lid lag
Cards: PMI displaced to anterior axillary line; tachycardic, irregularly irregular with jugular venous distention
Abd: distended with hepatomegaly Ext: 3+ pitting edema up to scrotum
and abdomenUNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Remarkable Laboratory Findings
CBC: Hgb 7.1 g/dL Hepatic: panel AST 41, ALT 31, alk phos
149, total bili 4.9, direct bili 4.0, total protein 7.9, albumin 2.9
Coagulation Panel INR 1.96, aPTT 33.1 Brain Natriuretic Peptide: 640 TSH undetectable, Free T4 3.42, FT3 7.0
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
EKG
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Atrial fibrillation with rapid ventricular response
Chest X-ray
Cardiomegaly with increased interstitial markings consistent with pulmonary edema
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
CT Abdomen/Pelvis
Heterogeneous liver with engorgement of hepatic veins and IVC; diffuse anasarca and moderate abdominopelvic ascites
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Working Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
Thyrotoxicosis
Alcoholic cardiomyopathy
The patient was admitted to the CCU where beta blockers and lasix were given for rate control and diuresis, respectively.
Transthoracic echocardiogram showed four chamber dilatation with severe MR, severe TR and paradoxical flattening of the septum consistent with right ventricular overload.
The patient was started on methimazole and coumadin.
Hospital Day #1
Thyroperoxidase antibody (TPO) returned positive with thyroid stimulating immunoglobulins elevated to 345
A thyroid ultrasound showed increased vascularity.
Hospital Day #10
The patient was successfully diuresed with improved heart rate and symptom control and he was discharged.
Hospital Day #19
Thyrotoxicosis due to Graves’ Disease
Final Diagnosis
UNITED STATES
DEPARTMENT OF VETERANS
AFFAIRS
