ID Case Conference ID Case Conference 4/23/084/23/08

Gretchen Shaughnessy, MDGretchen Shaughnessy, MD

Clinical FellowClinical Fellow

Dept of Infectious DiseasesDept of Infectious Diseases

CC: chest painCC: chest pain

19y/o Native American woman s/p OHT at 19y/o Native American woman s/p OHT at age 12 who presents with chest pain.age 12 who presents with chest pain.

She was admitted for chest pain on 4/4/08, She was admitted for chest pain on 4/4/08, CXR, echo, EGD, and cardiac w/u all stable. CXR, echo, EGD, and cardiac w/u all stable.

Finishing her second course of TMP/SMX for Finishing her second course of TMP/SMX for sinusitis (prescribed by PMD as outpt).sinusitis (prescribed by PMD as outpt).

Requesting large amts of pain medication, Requesting large amts of pain medication, exhibiting drug seeking behavior. exhibiting drug seeking behavior. Psychiatry involved. Workup negative, Psychiatry involved. Workup negative, d/ced with outpatient followup.d/ced with outpatient followup.

HPI (cont)HPI (cont)

Discharged from UNC 4/8/08.Discharged from UNC 4/8/08. Went home and continued to have Went home and continued to have

pain. Went to outside hospital pain. Went to outside hospital 4/13/08 and admitted for chest pain.4/13/08 and admitted for chest pain.

Multiple studies negative including Multiple studies negative including VQ scan, CXR, Echo, abd u/s all VQ scan, CXR, Echo, abd u/s all unchanged from prior studies.unchanged from prior studies.

HPI (cont)HPI (cont)

4/15/08 patient develops epistaxis, ENT 4/15/08 patient develops epistaxis, ENT consulted. D/ced Allegra, recommended consulted. D/ced Allegra, recommended saline, vasoline, afrin spray.saline, vasoline, afrin spray.

The patient was transferred to UNC The patient was transferred to UNC 4/19/08 but since admission has had a 4/19/08 but since admission has had a fever and now worsening infiltrates on fever and now worsening infiltrates on CXR. She has also started coughing up CXR. She has also started coughing up blood.blood.

ID was consulted for assistance.ID was consulted for assistance.

PMHPMH

Heart transplant in 10/19/2000, secondary Heart transplant in 10/19/2000, secondary to Idiopathic dilated cardiomyopathy, now to Idiopathic dilated cardiomyopathy, now with graft vasculopathy with graft vasculopathy – Cath in 2/2008 showed 30% LM, 40% LAD, Cath in 2/2008 showed 30% LM, 40% LAD,

70% LCx, 40% RCA70% LCx, 40% RCA– TTE in 4/2008 showed LVEF of 65-70%, TTE in 4/2008 showed LVEF of 65-70%,

diastolic dysfunction, mod AI, and mod dilation diastolic dysfunction, mod AI, and mod dilation of RA of RA

– Recent increase in immunosuppression Recent increase in immunosuppression because of vasculopathybecause of vasculopathy

PMH (cont)PMH (cont)

DyslipidemiaDyslipidemia Chronic abdominal pain/GERD.Chronic abdominal pain/GERD.

– EGD done during 4-08 admissionEGD done during 4-08 admission History of two sinus surgeries, which History of two sinus surgeries, which

included tonsillectomy and included tonsillectomy and adenoidectomy in 1997, and with adenoidectomy in 1997, and with recurrent sinusitisrecurrent sinusitis

EndometriosisEndometriosis AnxietyAnxiety MDDMDD elevated ANA 1:640, rheum workup 9/07elevated ANA 1:640, rheum workup 9/07

MedicationsMedications

Allergies: PCN – hives, Allergies: PCN – hives, ceclor- hives, levofloxacin – ceclor- hives, levofloxacin – itching, vancomycin – itching, vancomycin – Redman’s, morphine - Redman’s, morphine - itchingitching

ABX history: ABX history: Levofloxacin started 4/17/08 Levofloxacin started 4/17/08

aztreonam and clindamycin aztreonam and clindamycin 4/19/08 4/19/08

aspirin 81 mg po q dayaspirin 81 mg po q day lasix 40 mg po q daylasix 40 mg po q day pravastatin 20 mg po q daypravastatin 20 mg po q day norvasc 5 mg po q daynorvasc 5 mg po q day neurontin 600 mg po q dayneurontin 600 mg po q day

Singulair 10 mg po q daySingulair 10 mg po q day Ferrous sulfate 325 mg po Ferrous sulfate 325 mg po

q dayq day colace 100 mg po q daycolace 100 mg po q day prozac 40 mg po q dayprozac 40 mg po q day magnesium oxide 800 mg magnesium oxide 800 mg

po bidpo bid sirolimus 2 m po q daysirolimus 2 m po q day tacrolimus 2 mg po bidtacrolimus 2 mg po bid nexium 40 mg po q daynexium 40 mg po q day

ROSROS

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

otherwise negative.otherwise negative.

Physical ExamPhysical Exam

Vital 38.5 - 35.6 - 89-103 - Vital 38.5 - 35.6 - 89-103 - 18-20 - 109-121/63-75 18-20 - 109-121/63-75 94% on RA94% on RA

INAD, frequently coughing INAD, frequently coughing during exam. coughed up during exam. coughed up small amount of yellow small amount of yellow sputum streaked with sputum streaked with blood during examblood during exam

EOMI, PERRLA, nonictericEOMI, PERRLA, nonicteric no JVD, no LAD no JVD, no LAD

appreciated in cervical, appreciated in cervical, supraclavicular, or supraclavicular, or inguinal regionsinguinal regions

RRR III/VI systolic murmurRRR III/VI systolic murmur

no e/e on OPno e/e on OP coarse breath sounds B, coarse breath sounds B,

rhonchi worse on L, rhonchi worse on L, crackles on Rcrackles on R

no rash or lesionsno rash or lesions a&ox3, pleasant and a&ox3, pleasant and

cooperative. asking for cooperative. asking for more dilaudidmore dilaudid

soft NT nabs, no HSMsoft NT nabs, no HSM no c/c/eno c/c/e nl tone, full ROM presentnl tone, full ROM present no focal defecitsno focal defecits

Diagnostic Tests from Diagnostic Tests from OSHOSH 4/13 Labs: CBC 11.7>9.4/27.8<245, BNP 4/13 Labs: CBC 11.7>9.4/27.8<245, BNP

600. PT 11.5, INR 1.1, PTT 26.7. CK 85, 600. PT 11.5, INR 1.1, PTT 26.7. CK 85, CKMB1.4, Trop <0.1 (repeat x2 unchanged).CKMB1.4, Trop <0.1 (repeat x2 unchanged).

4/13 CXR clear lungs, stable cardiomegally.4/13 CXR clear lungs, stable cardiomegally. 4/13 VQ scan normal.4/13 VQ scan normal. Utox negative, TSH 4.8, Upreg test negative, Utox negative, TSH 4.8, Upreg test negative,

u/a negative. D-Dimer 2.2.u/a negative. D-Dimer 2.2. ABG 7.42/36/102/23.3/98 on 0.21 O2ABG 7.42/36/102/23.3/98 on 0.21 O2 4/14 Echo - LV systolic low normal, EF 55%, 4/14 Echo - LV systolic low normal, EF 55%,

RV systolic elevated at 40-50mmHg RV systolic elevated at 40-50mmHg concerning for pulm HTN, mild valvular aortic concerning for pulm HTN, mild valvular aortic stenosis with moderate aortic regurg.mild stenosis with moderate aortic regurg.mild mitral regurg. No pericardial effusion.mitral regurg. No pericardial effusion.

OSH Diagnostic testsOSH Diagnostic tests

4/14 CBC 11.1>10.4/31.8<222. ESR 334/14 CBC 11.1>10.4/31.8<222. ESR 33 4/15 CBC 7.1>8.8/26.7<231. Amylase 4/15 CBC 7.1>8.8/26.7<231. Amylase

49, Lipase 19, Mg 1.5, Ca 8.9, Cr 0.9.49, Lipase 19, Mg 1.5, Ca 8.9, Cr 0.9. 4/15 Abd U/S done with small vol of 4/15 Abd U/S done with small vol of

perihepatic ascites, left pleural effusion.perihepatic ascites, left pleural effusion. 4/15 PCXR no acute cardiopulm 4/15 PCXR no acute cardiopulm

disease, stable findings.disease, stable findings. 4/15/08 ENT consulted for epistaxis4/15/08 ENT consulted for epistaxis

4-19-08

Previous Rheumatologic Evaluation – 9/07

4-4-08

4-19-08

4-21-08

4-22-08

4-20-08

Discussion