Interactive Case Presentation.ppt

1、Interactive Case Presentation,Doug Kutz MD,Past Medical History 58 yo male Adult onset DM on Insulin for 18 yrs. Last HBA1C 10.2%, Mild proteinuria and CRI (30/1.7), Macrovascular disease HTN w/ dias dysfunction COPD FEV1=1.0 liter/FVC=2.1 liter (little response to B-agonists) ASCVD Heart Cath 03: O

2、ccluded RCA, L with 40% distal Dz, EF 45% Paroxysmal AFIB Clopridogel instead of coumadin due to pt. pref Multiple CVAs (L cerebellar, R pontine, L caudate) Prostate CA s/p prostatectomy age 49 Dyslipidemia 80+ pack year Tobacco Abuse (Ongoing) Depression/PTSD intolerant of anything but MAOI Rx and

3、Clonazepam “Mononucleolis” with hepatitis while serving in Vietnam,Albuterol 2.5mg unit dose via nebulizer QID Clopidogrel 75mg QD Clonazepam 1mg TID Furosemide 120mg po BID NPH and Lispro Insulin Metoprolol 25mg po bid Pantorazole 40mg QD Spironolactone 25mg QD KCL 40meq po BID Prednisone 10mg po Q

4、D Phenelzine 30mg po BID,Medications,Family History Mother died age 45 of Uterine CA Father died age 76 sudden death Brother died 67 lung CA and COPD 3 Healthy children ages 24 - 36,Admission 12/04,CC: Lightheaded and weak HPI: Progressive nausea, some emesis, weakness, and chills. Not using his ins

5、ulin or taking his meds for 5 days Exam: Vitals Afeb, 148/82 supine, 108 irreg, 22, P.O. 96% (ra) HEENT anicteric slcera, dry mm, neck “thick” no obvious jvd Lungs diffusely diminished breath sounds CV distant, irreg irreg, no murmur, no rubs Abdm soft, nontender, nabs Ext trace edema both ankles Sk

6、in no jaundice or rashes CNS nonfocal but slightly confused,Labs 12/04,WBC 15.2k, H/H 9.0/26.9, Plt 293k Bun/cr 2.9/63 Nml lytes Glucose 390, Slight pos serum ketones Ast 6098, Alt 1601, Alb 2.8, Alk 386, Bili 0.9, Nh3 51 Coags nml Troponin I 1.94 ECG: AFIB w/RVR, LVH, nonspecific ST,Imaging/Other S

7、tudies 12/04,CT chest: COPD and pericardial effusion U/S Abdm: nml liver and GB, no masses Echocardiogram: Large pericardial effusion without tamponade, LVH with diastolic relaxation abnormality,RN: “He is becoming hypotensive”,Drug Interactions: Phenelzine,5-HT agonists Buproprion, SSRI, mirtazapin

8、e Alpha 2 agonists Decongestants Dextromethorphan Ginseng Hydralazine Most sedatives,Linezolid (14 days) Licorice Metoclopramide Promethazine SAMe Sulfonylurea Sympathomimetics Trazodone,Hospital Course,Aggressively rehydrated Oliguria and Azotemia resolved after 3 days Liver function normalized ove

9、r 3-4 days Hepatitis serology negative AFIB did not recur, not a candidate for anticoagulation,Discharge Diagnoses,Severe dehydration due to severe hyperglycemia/medication noncompliance and possible viral GE Acute Tubular Necrosis Ischemic Hepatitis Cardiac “Enzyme Leak” Pericardial Effusion, Incid

10、ental/? viral Paroxysmal AFIB,Heart disease and Hepatic dysfunction,Hepatic congestion Typically due to exacerbation of chronic CHF Liver enlarged and firm on exam Modest elevations in ALT, AST, LDH, GGT and sometimes alk phos, total bili, and slight decrease in albumin Mild transient jaundice can o

11、ccur Chronic congestion can lead to “cardiac cirrhosis” with fibrosis of liver on biopsy,Cardiogenic Ischemic Hepatitis More acute and severe fall in cardiac output (such as with an acute MI or Severe CHF) Enzyme levels often 10x normal Coagulopathy and Functional renal impairment can be associated

12、No specific marker for Dx, but typically the transaminases drop 50% in first 72hrs of onset,Outpatient Visit 3/05,Dyspnea and pallor, cough.“Considering Hospice” Exam: Vitals 110/76, 68 reg, Afeb, 22, Wt. up 4# in 1month, pulse ox 93% on room air HEENT dry mm, JVP not visible Lungs: Diminished diffu

13、sely, BS absent in right lower w/ dullness CV: RRR distant, no murmur ABDM: NABS, NT, Soft Ext: slight increase edema (now 1+),Outpatient Labs 3/05,WBC 9.3k, H/H 10/34.3, Plt 220 BS 248, Bun/Cr 27/1.3, Nml lytes Lfts nml except alk 346 TSH 1.70 BNP 467 (nml) EKG unchanged,Outpatient Thoracentesis 3/

14、05,Red Hazy fluid with many RBCs 500 nuc cells (4% seg, 22% lymphs, 74% monos) Glucose 238 LDH 82 Protein 1.4 (serum 7.7) GS + Cx neg Cytology neg,Outpatient Imaging 3/05,Echocardiogram LVH with no wall motion abnormalities, nearly resolved pericardial effusion.,Admission 4/4/05,CC:Worsening edema,

15、dyspnea and falls HPI: Despite increasing doses of furosemide, fluid build-up in legs has extended up to chest wall, now distended and bloated abdomen, weight is up 30#. Positive orthop and PND. Dyspnea continues and is now associated with a cough. Cough is associated with dizziness and lightheadedn

16、ess. Cough produces yellow sputum 1-2 tbsp per day. Fell yesterday after a coughing spell and hit his R orbit; now has a “black eye”.,Physical Exam 4/05,Vitals: 156/97, 94, 22, 97.8 Wt up 24# from 12/04 Pulse Ox: 90% RA, 94% on 2L NC HEENT: New circular ecchymosis R orbit, R scleral hemorrage, JVP n

17、ot visible due to habitus and edema Lungs: Absent R base to way up, w/ dullness to percussion, BS otherwise diminished diffusely, no wheeze CV: Irr Irr w/no murmur, distant, no gallups or rubs Abdm: Distended with no localized tenderness, NABS, prominent liver, no splenomegaly, ? Shifting dullness,

18、pitting up to costal margins Ext: 3+ pitting edema bilaterally, pos sacral edema,Initial Laboratory Data 4/05,Heme: Wbc 11.2, H/H 10.3/32.3, Plt 295 Renal/Lytes: Bun/Cr 36/1.3, Gluc 131, Ca 9.2, Na 141, K 4.8, Mg 2.3 Hepatic:Alt/Ast 40/52, AlkP 368, Alb 3.9, Ammonia 26 Coags: nml Cardiac: Enz neg, B

19、NP 2800 Other: D-dimer 3000, U/A 2+ prot,Imaging 4/05,CXR: R effusion, mild PVC CT chest: No PE, R pleural eff, some obstructive changes Head CT: no change U/S abdm: normal except ascites Echo: Nml wall motion, LVH w/ dias dysfunction, trace effusion,Fluid Studies 4/05,Pleural Fluid: almost identica

20、l to outpatient Ascitic Fluid: Yellow, clear, moderate rbcs 500 nuc cells (20% segs, 15% lymphs, 61% monos) Glucose 177 Amylase 20 Alb 1.9 (serum 3.9) (s:a gradient 2.05) GS and Cx neg,Diuresed 30# JVP now visible to 10cm,“A Diagnostic Study was Obtained”,“Doctor I have to get out of here !”,Heart C

21、ath 4/05,Arterial press 139/86 LV end-dias pressure 29mmHg (3-12) Pulm arterial pressure 51/25 (15-30/4-12) Wedge pressure 34 (2-10) Kussmauls sign noted on right atrial pressure trace, mean pressure RA 26 (2-8) Equalization of LV and RV dias press, as well as LV and RA dias pressures,Tissue Diagnos

22、is:,Fibrotic Pericardium, up to 5mm thick.,Pericarditis,Can present in 4 ways: Acute pericarditis Incidental effusion Tamponade Constriction,Acute Pericarditis,85-90% idiopathic, 1-4% viral Remainder of cases are post MI, other infx, AAA, trauma, neoplastic, post surgical or XRT, uremic, connective

23、tissue disease or drug induced Classic ECG changes: diffuse ST elevation Pericardial rub pathognomonic (85% develop) Pericardiocentesis indicated for tamponade, or if strong suspicion of bacterial infx or neoplasm Serologic studies not very helpful (10% dx) “Troponin Leak” occurs in 35-50%,Tamponade

24、Occurs in 15% idiopathic, but up to 60% with Tb, bacterial or neoplastic etiology Presents with “Becks triad” Hypotension Quiet heart sounds Increased Jugular venous pressure Can also note compensatory tachycardia and pulsus paradoxus (fall in SBP 10 during insp),Constrictive Pericarditis,Chronic f

25、ibrous and/or calcific thickening of the pericardium that leads to abnormaly elevated diastolic filling pressures Most commonly idiopathic after acute or sub acute pericarditis (Tb still most common in undeveloped countries) Post cardiac surgery and radiation therapy becoming more common,Constrictiv

26、e Pericarditis,Clinical findings: Pulsatile hepatomegaly Pericardial knock (early diastole) Kussmauls Sign: JVP rises (or at least fails to fall) during inspiration, due to separation of the cardiac pressures from the thoracic pressure changes in respiration,Constrictive Pericarditis,Differential Di

27、agnosis Other causes of right heart failure Restrictive Cardiomyopathy PE or Pulm HTN Right ventricular infarction Mitral stenosis or Tricuspid Disease Cirrhosis or Hepatic Vein Thrombosis Acute Renal Failure or Nephrotic syndrome SVC obstruction or Lymph obstruction Myxedema Drug Induced (Ca channe

28、l, minoxidil, steroids, “glitazones”, NSAIDs,),Constrictive Pericarditis,Diagnosis Unfortunately clinical findings not very specific Key echo findings are that of a thickened pericardium, a septal “bounce”, inspiratory decrease in pulmonary venous flow, and normal relaxation indices. MRI is 88% sens, 100% specific using same criteria above Cath findings that are most specific are equalization of RV and LV end dias pressures. No widely accepted “gold standard”,Constrictive Pericarditis.,Treatment: Pericardectomy Use caution with diureses pre-op,1 month follow up,