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Interactive Case Presentation

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)

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Interactive Case Presentation

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  1. Interactive Case Presentation Doug Kutz MD

  2. 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: Occluded RCA, L with 40% distal Dz, EF 45% Paroxysmal AFIB – Clopridogel instead of coumadin due to pt. pref Multiple CVA’s (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 Clonazepam “Mononucleolis” with hepatitis while serving in Vietnam

  3. Medications 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 QD Phenelzine 30mg po BID

  4. 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

  5. Admission 12/04 • CC: Lightheaded and weak • HPI: Progressive nausea, some emesis, weakness, and chills. Not using his insulin 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 • Skin no jaundice or rashes • CNS nonfocal but slightly confused

  6. 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

  7. Imaging/Other Studies 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

  8. RN: “He is becoming hypotensive”

  9. 5-HT agonists Buproprion, SSRI, mirtazapine Alpha 2 agonists Decongestants Dextromethorphan Ginseng Hydralazine Most sedatives Linezolid (14 days) Licorice Metoclopramide Promethazine SAMe Sulfonylurea Sympathomimetics Trazodone Drug Interactions: Phenelzine

  10. Hospital Course • Aggressively rehydrated • Oliguria and Azotemia resolved after 3 days • Liver function normalized over 3-4 days • Hepatitis serology negative • AFIB did not recur, not a candidate for anticoagulation

  11. Discharge Diagnoses • Severe dehydration due to severe hyperglycemia/medication noncompliance and possible viral GE • Acute Tubular Necrosis • Ischemic Hepatitis • Cardiac “Enzyme Leak” • Pericardial Effusion, Incidental/? viral • Paroxysmal AFIB

  12. 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 occur • Chronic congestion can lead to “cardiac cirrhosis” with fibrosis of liver on biopsy

  13. 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 • No specific marker for Dx, but typically the transaminases drop >50% in first 72hrs of onset

  14. 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 diffusely, BS absent in right lower ½ w/ dullness • CV: RRR distant, no murmur • ABDM: NABS, NT, Soft • Ext: slight increase edema (now 1+)

  15. 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

  16. Outpatient Thoracentesis 3/05 • Red Hazy fluid with many RBC’s • 500 nuc cells (4% seg, 22% lymphs, 74% mono’s) • Glucose 238 • LDH 82 • Protein 1.4 (serum 7.7) • GS + Cx neg • Cytology neg

  17. Outpatient Imaging 3/05 Echocardiogram LVH with no wall motion abnormalities, nearly resolved pericardial effusion.

  18. Admission 4/4/05 • CC:Worsening edema, 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 lightheadedness. 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”.

  19. 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 not visible due to habitus and edema • Lungs: Absent R base to ½ 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, pitting up to costal margins • Ext: 3+ pitting edema bilaterally, pos sacral edema

  20. 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, BNP 2800 • Other: D-dimer 3000, U/A 2+ prot

  21. 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

  22. Fluid Studies 4/05 • Pleural Fluid: almost identical to outpatient • Ascitic Fluid: • Yellow, clear, moderate rbc’s • 500 nuc cells (20% segs, 15% lymphs, 61% mono’s) • Glucose 177 • Amylase 20 • Alb 1.9 (serum 3.9) (s:a gradient 2.05) • GS and Cx neg

  23. Diuresed 30# JVP now visible to 10cm

  24. “A Diagnostic Study was Obtained” “Doctor I have to get out of here !”

  25. Heart Cath 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) • Kussmaul’s 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

  26. Tissue Diagnosis: • Fibrotic Pericardium, up to 5mm thick.

  27. Pericarditis • Can present in 4 ways: • Acute pericarditis • Incidental effusion • Tamponade • Constriction

  28. 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 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%

  29. Tamponade • Occurs in 15% idiopathic, but up to 60% with Tb, bacterial or neoplastic etiology • Presents with “Beck’s triad” • Hypotension • Quiet heart sounds • Increased Jugular venous pressure • Can also note compensatory tachycardia and pulsus paradoxus (fall in SBP >10 during insp)

  30. Constrictive Pericarditis • Chronic fibrous 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

  31. Constrictive Pericarditis….. • Clinical findings: • Pulsatile hepatomegaly • Pericardial knock (early diastole) • Kussmaul’s 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

  32. Constrictive Pericarditis….. Differential Diagnosis • 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 channel, minoxidil, steroids, “glitazones”, NSAIDs,)

  33. 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”

  34. Constrictive Pericarditis…. • Treatment: Pericardectomy • Use caution with diureses pre-op

  35. 1 month follow up

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