LSU Internal Medicine Case Conference

1. LSU Internal Medicine Case Conference “RAPID RESPONSE” 11/06/2012 Mallory Smith, MD PGYI ( Internal Medicine & Pediatrics)/ Scott Laura, MD PGYI (Internal Medicine)

2. Chief Complaint: • SOB x 3 days

3. History & Physical HPI: 9/16/2012 : • 77 yowomenwith past medical history significant for stage IV lung CA status post right lobectomy, chemotherapy, and radiation presented to the ED with daughter for 3 day history of SOB at rest. • The shortness of breath had gotten progressively worse and was aggravated by exertion. Per patient’s daughter, the patient experienced chest pain of right side that was intermittent and without radiation. Patient denied diaphoresis, vomiting, lower extremity edema, orthopnea, or PND but did endorse recent history of nausea and diarrhea.

4. Past Medical History • PMHx: Lung Cancer Stage IV s/p R lobectomy, chemotherapy and radiation, GERD, Depression, Neuropathy • PSHx: Right Lobectomy 6 months prior • Soc: 1pk/day for “many years”, quit 2 yrs ago, occasional alcohol use, denies illicit drug use • FmHx: Non-contributory

5. PMHx Continued • Home Meds: Neurontin 300mg TID, • Vicodin 7.5/750 q6 PRN • Meclizine 32mg TID PRN • Prilosec 40mg Daily • Ambien CR 6.25mg PRN • Allergies/Adverse Rxn: Codeine (N/V) • Health Maintenance: No PNA/Flu vac • ROS: as above plus general fatigue and some light-headedness

6. Vitals/ Physical – Per ED • Vitals: T 98 °F (37.2°C) HR124 BP 80/60 RR 30 Sat 97% on NRB • GENERAL: Oriented x 3, appears distressed • HEENT: NCAT, PERRLA, EOMI • NECK: No carotid bruits, JVP UTA secondary to body habitus and central line • CV: Regular rate and rhythm, no murmurs/rubs/gallops appreciated • LUNGS: Respiratory Distress, Decreased breath soundsright upper, mid, lower lung zones • ABDOMEN: Soft, NTTP, + BS, no masses or organomegaly • EXTREMETIES: No lower extremity edema, moves all extremities, no clubbing or cyanosis • VASCULAR: 2+ radial pulses in BUE, 2+ DP pulses in BLE • SKIN: Warm and Moist

7. Laboratory Data • Complete Blood Count with Diff • WBC 20,000 • N 47/ Bands 27 / L 14/ M 10/ E 2 • H/H 15.6/48.3 • Platelets 320 • MCV 88 • RDW 16

8. Laboratory Data • Complete Metabolic Panel • Na 145 TP 8.1 • K 4.5 ALB 3.7 • Cl 109 AST 51 • HCO3 15 ALT 18 • BUN 36 AP 143 • Crea 1.89 Bili 1.2 • Glucose 144 • Calcium 9.3

9. EKG – 9/16/12

10. CXR

11. CT Chest W/O

12. Hospital Course • During the ED stay, patient was found to be hypotensive with systolic BP into the 70s and 80s, but responded well to fluid and pressors before she was admitted to ICU. • Chest tube was placed for drainage of effusion

13. Hospital course • 9/17 – 9/20 : • Quickly stabilized off vasopressors • Continued on empiric antibiotics (Vanc, Pip-Tazo, Ciprofloxacin) • Echocardiogram ordered by MICU team

14. Echo – 9/17 • Hyperdynamic LV with EF 75% • Mild AR

15. Hospital course • 9/20/12 • Patient transferred to floor under the care of LSU Medicine • Was awaiting transfer to West Jefferson per patient’s request, as she is well known to her primary care physician and oncologist there

16. Vitals/ Physical • Vitals: T 99 °F (37.2°C) HR 118 BP 162/95 RR 19-28 • GENERAL: Obese, Intubated, Sedated, Arousable to voice and tactile stimuli • HEENT: NCAT, PERRLA, EOMI • NECK: No carotid bruits, JVP UTA secondary to body habitus and central line • CV: Distant heart sounds, no murmurs/rubs/gallops appreciated • LUNGS: Decreased breath sounds at bilateral bases, no rhonchi/rales/wheezing • ABDOMEN: Soft, NTTP, + BS, no masses or organomegaly • EXTREMETIES: No lower extremity edema, moves all extremities, no clubbing or cyanosis • VASCULAR: 2+ radial pulses in BUE, 2+ DP pulses in BLE • SKIN: Warm and Moist

17. Laboratory Data – 9/20 • Complete Blood Count with Diff • WBC 12,000 • N 68/ L 21/ M 10/ E 1/ B 0 • H/H 9.8/30.1 • Platelets 208 • MCV 87.5 • RDW 17

18. Laboratory Data • Complete Metabolic Panel • Na 141 TP 5.7 • K 3.6 ALB 2.1 • Cl 112 AST 56 • HCO3 19 ALT 27 • BUN 26 AP 98 • Crea 2.0 TP 0.9 • Glucose 153 • Calcium 8.1

19. Laboratory DATA • Coagulation Studies • PT 13.6 • INR 1.3 • PTT 26.8 • Cardiac Profile • BNP 165 • Troponin 0.02-> 0.08 • CK 429 • CKMB 36.6 • LA 2.1

20. Laboratory DATA • Lipid Profile • TC 116 • TG 149 • HDL 21 • LDL 65

21. Hospital course • Approximately one hour after transfer to floor a rapid response was called due to SOB • BP – stable • HR 140 • ABG : 7.12 / 54 / 76 / 17 91% sats on 100% NRB • Intubated

22. EKG 9/20

23. EKG 9/20

24. Cardiac enzymes • 9/16/12 • Troponin 0.02 • 9/20/12 • CPK 429 – 412 – 687 – 679 • CKMD 36 – 27 – 33 – 28 • Troponin 0.08 – 8.09 – 9.72 – 7.85

25. Cardiac cath 9/20 • LM : patent • LAD : diffuse plaque, <30% stenosis • LCx : diffuse plaque, <30% stenosis • RCA : 50% ostial • Ventriculogram : Severe hypokinesis of the mid and apical segments. The basal segments are hyperkinetic

26. Hospital course • 9/21/12 : • Remained in ICU, intubated • Pressors weaned • Diuresed with IV furosemide • Echo repeated

27. Echo 9/21 • Severely decreased EF 20-29% • Distal 2/3 anteroseptal wall motion abonormality with hyperdynamic function at base • New findings since 9/17/12

28. Hospital course • 9/22 – 10/2 • Continued to have complicated ICU course • Eventually extubated on 10/2 • Echo repeated on 9/24 • Stepped to the floor, placed on beta blocker

29. Echo 9/24 • Good LV function • EF 50%

30. Final Diagnosis Takotsubo Cardiomyopathy

31. THANKS FOR YOUR ATTENTION