Laennec Student Report

1. Laennec Student Report

2. Admission H&P 61-year-old gentleman with a history of hypertension, COPD, and aortic aneurysm repair (2006) for aortic dissection type A. All was well until day of admission, when he felt chest pain. He notes that he had temperatures above 98.6 at home. • What kinds of questions do you want to ask when someone comes in with chest pain?

3. Chest Pain Chest pain: One day of sharp pain, continuous, associated with SOB, located substernal and epigastric as well as upper back, radiates towards back, positional in that it improves lying down and with thorax elevated, some relation to meals, nocturnal component to pain. Patient is light-headed, and fatigued.

4. Admission H&P • PAST MEDICAL HISTORY: HTN, Emphysema, BPH, aortic dissection type A, COPD, recent hospitalization for UTI • PAST SURGICAL HISTORY: Aortic aneurysm repair (2006) • ALLERGIES: NKA • FmHx: Father – died at 56 of “heart problems” • Mother – died at 69 of “natural causes” • SH: Tobacco – ½ ppd X 30 years, quit in 2006 Neg Alcohol, Drugs Employment – retired government employee • Medications at Home: Metoprolol 50 mg BID, Lisinopril 40 mg QD, Flomax 0.4 mg daily

5. Physical Exam • VITAL SIGNS: On examination, he was afebrile since his stay here. • Temperature 36.5, his blood pressure 132/89, pulse 100 • GENERAL: He was resting comfortably and had a Foley in place. He no longer • was reporting chest discomfort or abdominal discomfort. According to the • chart, he put out 1600 mL of urine. • LUNGS: Clear to auscultation. His PMI was displaced approximately 1-2 cm • laterally from the midclavicular line but no murmurs, rubs or gallops • appreciated. • ABDOMINAL: Positive bowel sounds, nontender, nondistended, no hepatosplenomegaly, no evidence of an aortic pulsations in the abdomen, no palpable abdominal masses, • Extremities: 2+ dorsalis pedis and posterior tibial pulses bilaterally, no cyanosis, no edema, 2+ strength throughout, no peripheral edema

6. Throughts? • Problem List • Further Questions about H & P? • Diagnostics?

7. Labs on Admission Labs: • 22.9 / 9.2 / 30.1 / 1142 • 89.9% PMN • 6.3% Lymphocytes • 20.6 Abs. PMN • 1.2 Abs Lymphocytes • RBC, platelet morphology normal • 133 96 31 83 • 4.9 26 1.24 • After hydration  BUN/Cr  15/1.03 • Negative Cardiac enzymes • EKG normal

8. Diagnostic Tests • 6/17 CXR: emphysematous changes in lung – more on right • No focal consolidation/pulm edema • No pleural effusion/no pneumothorax • Evidence of apical pleural thickening • 6/18 • CT Abdomen – to evaluate aneurysm – no evidence of endoleak/stable aortic dissection within abdominal aorta • CT Chest - • 1. Thoracic endovascular stent graft, as described above. There has been interval enlargement of the caliber of the descending aorta when compared to prior study from 1 month prior without evidence of endoleak, however delayed images were not available. Within the excluded portions of the descending aorta, there are small pockets of air which raises concern for the possibility of a graft infection. Further evaluation with Indium 111 tagged white blood cell recommended for further assessment. • 2. Unable to distinguish a separation of descending aorta and esophagus. Given the presence of air within the descending aorta, as described above, the possibility of a fistulous connection between the esophagus and excluded portion of the aorta cannot be excluded. • 3. Bilateral emphysematous lung disease with large apical bullae. • 4. Stable-appearing sub centimeter nodules in right middle lobe.

9. Thoughts? • Patient continues to have intermittent chest pain throughout hospital stay, same in character as when admitted. WBC increasing day by day. Periodic fevers. Negative blood cultures, resolving UTI. Notable thrombocytosis. Notable gas around aortic graft on CT, which is concerning for either infection, or esophageal-aortic fistula.

12. Progress Note • HOD 2: CP continues  CT angiogram done. Abx begun and WBC scan conducted to further explore possible infectious etiology of bubbles seen on the CT angio. • UGI series with gastrograffin ordered – to evaluate for esophageal-aortic fistula • Hematologic cause being explored for elevated WBC and thrombocytosis – Heme/Onc consult • IV Vancomycin and Zosyn begun for possible graft infection

13. Further Studies • 6/22: UGI Series with Gastrograffin: No esophageal-aortic fistula seen • 6/23: WBC scan: No scintigraphic evidence of active inflammatory/infectious process (special attention was paid to the region of the thoracic aorta). Of note, patient is on antibiotics, which can diminish the inflammatory response and therefore decrease ability to localize such a process.

14. Progress Note • 6/23: Neg UGI series for fistula. Neg WBC scan. Neg blood cultures. Periodic fever spikes, and increasing elevation of WBC count. Heme/Onc consulted for malignancy workup. Not a surgical candidate. Possible reactive thrombosis.

15. Progress Note • HOD 8 : Now constant chest pain and pain in his back. Propped on pillows and leaning on right to improve pain. Worse with meals, but also awakens him in the middle of the night. Same description of chest pain as on admission. Requires Dilauded now for pain. C/O dyspnea as well. No cough. • What do we do?

16. Further Studies • HOD 8 CXR - • New moderate to large left sided pleural effusion with a left base opacity representing atelectasis or consolidation. • HOD 9 : CT chest: • 1. Thoracic aortic aneurysm with an endovascular stent graft appears grossly unchanged with a stable small high density focus seen just distal to the arch which may represent a hematoma versus a slow leak which cannot be further evaluated on this non contrast scan. There are foci of gas within the excluded portion of the aneurysm which suggests graft infection versus an aortoenteric fistula. • 2. Interval development of a large left-sided pleural effusion which appears to be mostly fluid density. • There is associated collapse of the left lower lobe. Underlying left lower lobe consolidation cannot be excluded. • 3. Small pericardial effusion which demonstrates somewhat increased tissue density may indicate a hemopericardium. Recommend correlation with cardiac ultrasound. • 4. Diffuse emphysematous lung disease with large biapical bullae and stable appearing subcentimeter pulmonary nodules in the right lung.

17. Thoracocentesis Results • Thoracocentesis: • Cloudy, 250 RBC’s, 6850 WBC, 1.3 albumin, 6 glucose, 23, 259 LDH, 7.56 pH • Pleural fluid: evidence of cellular inflammation, no malignant cells • Rare gram negative rods on gram stain and WBC’s • AFB stain on pleural fluid – negative; fungal stains - negative • Pleural culture – no growth

18. Further Studies and Diagnostics • HOD 9: U/S Chest: A large loculated pleural effusion is seen with numerous hyperechoic septations. No significant effusion is seen on the right. • HOD 10: U/S guided 8-French pigtail catheter placement into left chest for purpose of diagnostic and therapeutic thoracocentesis and drainage of effusion

19. Resolution and Discharge • HOD 15: CT chest s/p 3 TPA tx and drainage of empyema: • Interval improvement in the loculated pleural collection of the left superior posterior thorax and periaortic fluid collection previously described. Also decrease in the free component of the left pleural collection at the left base. • 2. Improved aeration in the left lower lobe.