ID Case Conference 4/23/08

1. ID Case Conference 4/23/08 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

2. CC: chest pain • 19y/o Native American woman s/p OHT at age 12 who presents with chest pain. • She was admitted for chest pain on 4/4/08, CXR, echo, EGD, and cardiac w/u all stable. • Finishing her second course of TMP/SMX for sinusitis (prescribed by PMD as outpt). • Requesting large amts of pain medication, exhibiting drug seeking behavior. Psychiatry involved. Workup negative, d/ced with outpatient followup.

3. HPI (cont) • Discharged from UNC 4/8/08. • Went home and continued to have pain. Went to outside hospital 4/13/08 and admitted for chest pain. • Multiple studies negative including VQ scan, CXR, Echo, abd u/s all unchanged from prior studies.

4. HPI (cont) • 4/15/08 patient develops epistaxis, ENT consulted. D/ced Allegra, recommended saline, vasoline, afrin spray. • The patient was transferred to UNC 4/19/08 but since admission has had a fever and now worsening infiltrates on CXR. She has also started coughing up blood. • ID was consulted for assistance.

5. PMH • Heart transplant in 10/19/2000, secondary to Idiopathic dilated cardiomyopathy, now with graft vasculopathy • Cath in 2/2008 showed 30% LM, 40% LAD, 70% LCx, 40% RCA • TTE in 4/2008 showed LVEF of 65-70%, diastolic dysfunction, mod AI, and mod dilation of RA • Recent increase in immunosuppression because of vasculopathy

6. PMH (cont) • Dyslipidemia • Chronic abdominal pain/GERD. • EGD done during 4-08 admission • History of two sinus surgeries, which included tonsillectomy and adenoidectomy in 1997, and with recurrent sinusitis • Endometriosis • Anxiety • MDD • elevated ANA 1:640, rheum workup 9/07

7. Allergies: PCN – hives, ceclor- hives, levofloxacin – itching, vancomycin – Redman’s, morphine - itching ABX history: Levofloxacin started 4/17/08 aztreonam and clindamycin 4/19/08 aspirin 81 mg po q day lasix 40 mg po q day pravastatin 20 mg po q day norvasc 5 mg po q day neurontin 600 mg po q day Singulair 10 mg po q day Ferrous sulfate 325 mg po q day colace 100 mg po q day prozac 40 mg po q day magnesium oxide 800 mg po bid sirolimus 2 m po q day tacrolimus 2 mg po bid nexium 40 mg po q day Medications

8. ROS • positive for cough, sore throat, chest pain, DOE, SOB, hemoptysis, weight loss (since increasing her lasix dose - but has not noticed any weight loss other than that related to fluid), brown nasal discharge, fatigue, occasional diarrhea. • otherwise negative.

9. Vital 38.5 - 35.6 - 89-103 - 18-20 - 109-121/63-75 94% on RA INAD, frequently coughing during exam. coughed up small amount of yellow sputum streaked with blood during exam EOMI, PERRLA, nonicteric no JVD, no LAD appreciated in cervical, supraclavicular, or inguinal regions RRR III/VI systolic murmur no e/e on OP coarse breath sounds B, rhonchi worse on L, crackles on R no rash or lesions a&ox3, pleasant and cooperative. asking for more dilaudid soft NT nabs, no HSM no c/c/e nl tone, full ROM present no focal defecits Physical Exam

10. Diagnostic Tests from OSH • 4/13 Labs: CBC 11.7>9.4/27.8<245, BNP 600. PT 11.5, INR 1.1, PTT 26.7. CK 85, CKMB1.4, Trop <0.1 (repeat x2 unchanged). • 4/13 CXR clear lungs, stable cardiomegally. • 4/13 VQ scan normal. • Utox negative, TSH 4.8, Upreg test negative, u/a negative. D-Dimer 2.2. • ABG 7.42/36/102/23.3/98 on 0.21 O2 • 4/14 Echo - LV systolic low normal, EF 55%, RV systolic elevated at 40-50mmHg concerning for pulm HTN, mild valvular aortic stenosis with moderate aortic regurg.mild mitral regurg. No pericardial effusion.

11. OSH Diagnostic tests • 4/14 CBC 11.1>10.4/31.8<222. ESR 33 • 4/15 CBC 7.1>8.8/26.7<231. Amylase 49, Lipase 19, Mg 1.5, Ca 8.9, Cr 0.9. • 4/15 Abd U/S done with small vol of perihepatic ascites, left pleural effusion. • 4/15 PCXR no acute cardiopulm disease, stable findings. • 4/15/08 ENT consulted for epistaxis

12. 4-19-08

17. Previous Rheumatologic Evaluation – 9/07

18. 4-4-08

19. 4-19-08

20. 4-21-08

21. 4-22-08

22. 4-20-08

33. Discussion