NYU Medical Grand Rounds Clinical Vignette

1. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS NYU Medical Grand Rounds Clinical Vignette Roy Mukku, MD PGY-2 1/15/13

2. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint • Mrs. W is a 49 year old Chinese woman who presents with 2 weeks of hemoptysis.

3. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • Two weeks prior to presentation, the patient began experiencing a productive cough with flecks of blood in the sputum. • During the same time period, the patient also began experiencing fatigue, dyspnea on exertion and a decreased exercise tolerance.

4. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • The patient regularly undergoes hemodialysis secondary to lupus nephritis. • On the day of admission, she was referred to the ED from dialysis after being found to have a hemoglobin of 7 g/dL, down from her baseline of 11 g/dL.

5. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History • Past Medical History: • Lupus Nephritis • Social History: • Denies tobacco, ethanol, or illicit drug use • Immigrated from China 20 years prior • Medications: Methotrexate 7.5 mg PO q weekly, Iron Sulfate 325 mg PO TID

6. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination • General: Chinese woman, sitting in stretcher, appears comfortable • Vital Signs: list T: 98.4 BP: 105/57 HR: 88 RR: 18 and O2 sat: 96% on room air • III/VI systolic ejection murmur heard throughout precordium • Remainder of the physical exam was normal

7. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings • Complete Blood Count: • Hemoglobin 7.2 g/dL • Remainder of CBC was within normal limits • Basic Metabolic Panel: • Creatinine 3 mg/dL • Remainder of basic was within normal limits • Coagulation panel within normal limits • Ferritin 1245, Iron 46, TIBC 269

8. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies • ECG: Normal Sinus Rhythm • Chest X-Ray: bilateral opacification at bases, new from previous images • CT Chest: diffuse ground-glass opacities

9. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working or Differential Diagnosis • Methotrexate Toxicity • TB • Diffuse Alveolar Hemorrhage

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Patient was transferred to the MICU for closer monitoring given concern for diffuse alveolar hemorrhage • Patient underwent hemodialysis with concomitant blood transfusion • Bronchoscopy was scheduled for the same day

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • Signout was given that Rheumatology Consult was already contacted and was awaiting bronchoscopy results prior to leaving official recommendations. • Underwent bronchoscopy, the results of which were consistent with diffuse alveolar hemorrhage, likely the effect of a capilleritis secondary to lupus vasculitis. • Results were discussed on rounds and the decision was made to start high dose steroids while awaiting formal recommendations from Rheumatology. 11 11

12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2: • Patient appeared quite well, yet it was noted on rounds that Rheumatology had not yet left formal recommendations • Housestaff stated that Rheumatology was aware of patient • Patient was stable for transfer out of MICU, but decision was made to hold off on transfer until recommendations from Rheumatology had been documented in chart 12

13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2: • Rheumatology was re-consulted, at which point consult service was completely unaware of patient • Rheumatology service subsequently made recommendations on steroid dose and duration • Patient did well, and was discharged a few days later 13 11

14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Diffuse Alveolar Hemorrhage