NYU Medical Grand Rounds Clinical VignetteNYU医学查房临床小插曲.pptVIP

* NYU Medical Grand Rounds Clinical Vignette Todd Cutler, MD 12/18/12 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS The patient is a 61 year old woman with three days of weakness and shortness of breath. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS The patient has a history of severe pulmonary hypertension, previously treated pulmonary TB and MAC, cor pulmonale (on home oxygen), bronchiectasis and diabetes. Three days prior to admission she began having fevers, productive cough and shortness of breath. The day prior to admission she had difficulty walking across her living room and presented to the ED. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History Social History: Lives with son, no smoking, alcohol or illicits Medications: Lisinopril 20mg daily Digoxin 0.125mg daily Lasix 20mg daily Lantus 20 Units at night Novolog 10 Units with meals UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination General: Frail, chronically ill-appearing, short of breath, difficulty completing sentences Temp: 100.4 BP: 138/85 HR: 100 RR: 22 O2 sat: 95% on 4L NC, 87% on room air UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination Head and Neck: distended neck veins Heart: tachycardia, palpable pulmonic valve, loud S2 Lungs: tachypnea, diffuse rhonchi with bronchial breath sounds UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies Chest CT: stable fibrotic left lung and severe right middle lobe bronchiectasis with small nodular opacities in the anterior right upper lobe consistent with airway impaction versus infection UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Pneumonia Bronchiectasis Working or Differential Diagnosis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings Her labs were most remarkable for: - Arterial Blood Gas: 7.22/83/80/33 A repeat arterial blood gas after 15 minutes of bilevel at 18/5 was unchanged. UNITED STATES DEPARTMENT O