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Morbidity and Mortality Conference. Stephen K. Liu, M.D. February 27, 2002. Initial Presentation - Feb 2001. A 76 y/o male presented to his physician’s assistant at the VA Medical Center in WRJ with a chief complaint of a dry cough for several months. Initial Presentation.

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morbidity and mortality conference

Morbidity and Mortality Conference

Stephen K. Liu, M.D.

February 27, 2002

initial presentation feb 2001
Initial Presentation - Feb 2001
  • A 76 y/o male presented to his physician’s assistant at the VA Medical Center in WRJ with a chief complaint of a dry cough for several months
initial presentation
Initial Presentation
  • The pt believed that the cough improved after getting a course of amoxicillin for a dental infection
    • ROS: negative for fever, chills, night sweats, shortness of breath, or weight loss
    • PE: decreased breath sounds at the right base
    • CXR: bilateral (R>L) pleural effusions
  • Followup was difficult
history
History
  • Two months later-
    • CT scan (without contrast) : large left mediastinal mass encasing the aorta
  • Over the ensuing months, the pt canceled multiple follow-up appointments, an enhanced CT scan, and a planned diagnostic thoracentesis.
    • It was difficult to reach him by phone
    • Letters were sent regarding his results
history1
History
  • Pt had avoided further work-up and treatment of his pleural effusions for the past nine months due to anxiety, denial, the recent death of his ex-wife, and a desire to try herbal remedies first.
presentation to the drop in clinic november 2001
Presentation to the Drop-In Clinic - November 2001
  • On presentation, the patient was significantly SOB with minimal effort, including talking
  • The patient agreed to admission for a diagnostic and therapeutic thoracentesis
  • Advance directives: full-code
history2
Past Medical History

HTN

Basal Cell Carcinoma

DJD

Medications

None

ALL: Erythromycin

SocHx:

Quit smoking over 50 yrs ago, no alcohol misuse

Six children

Retired insurance agent

Previously enjoyed racquetball and rowing.

FHx:

father - lung CA

brother - prostate CA

History
physical exam
Physical Exam

Gen: Somnolent but arousable, ill appearing, cachectic

VS: T 97.5 BP 150/84 HR 86 RR 30

SpO2 85% RA 96% 4L NC

HEENT: PERRL, EOMI, OP-dry MM, no erythema

Neck: Supple, no LAD, JVP < 5 cm

CV: RRR, no S3 or S4

Resp: Decreased BS L>R, dull to percussion 2/3 up lung fields, minimal air movement in apices , decreased tactile fremitus at both bases

Abd: ND, +BS, Soft, NT, no palpable masses or HSM, no palpable inguinal LN

Ext: No edema, no palpable axillary adenopathy

Neuro: Arousable with some difficulty, oriented to date but not to place

laboratory data
Ca- 9.7

T.Bili - 0.7

Alk Phos - 52

AST - 34

ALT - 30

GGT - 38

Laboratory Data

14.4

8.5 252

41.8

89%Gran 7%lymphs 3%monos

0.1%eos 0.1% baso

130 90 23

119

4.5 32 0.7

ABG 7.255/84/82.5

PT - 12.8

INR - 1.0

PTT - 49.2

admission to wrj vamc
Admission to WRJ VAMC
  • Thoracentesis performed
  • Pleural Fluid Analysis:
    • pH 7.350
    • Glucose 120
    • LDH 131
    • Protein 3.8
    • RBC 5800
    • Nucleated Cells 450
      • 10% segs
      • 22% macrophages
      • 5% mesothelial
      • 63% lymphs

Gram Stain:

1+ WBC

No orgs

hospital day 3
Hospital Day 3
  • Patient awoke with dyspnea and tachypnea
    • Increased O2 requirements
    • ABG 7.18/104/79/29
    • CXR showed an increased effusion on the left without a pneumothorax and the persistent effusion on the right
  • Transfer to the MICU
  • Therapeutic left thoracentesis performed at the bedside
hospital day 31
Hospital Day 3
  • Increased somnolence, then became unarousable
  • Emergently intubated
  • Propofol gtt begun
  • Chest tube inserted on the right
  • 2-3L of pleural fluid filled the Pleura-Vac in minutes before the chest tube was clamped
  • Pt became hypotensive and tachycardic requiring a dopamine gtt to maintain pressures
hospital day 4
Hospital Day 4
  • Pt remained hypotensive and on dopamine
  • The blood pressure was extremely sensitive to propofol
  • Additional labs returned
    • LDH 170
    • uric acid 2.5
    • albumin 1.9
  • Swan placed :
    • RA 25/16 RV 49/15 PA 44/17 PAOP 20
    • CO 4.4 CI 2.3 SVR 1417
      • Dopamine gtt - 6
hospital days 5 7
Hospital Days 5-7
  • Pt continued to require numerous fluid boluses in addition to maintenance IVF to maintain Urine OP and BP
  • Left sided pigtail catheter placed
  • CT of the chest/abd/pelvis obtained
  • Platelets begin trending down to 70 - all non-essential meds including heparin flushes discontinued
hospital day 8
Hospital Day 8
  • A CT guided biopsy of the mediastinal mass was performed by interventional radiology
  • A trans-thoracic echo was performed
slide20

Homogeneous population of lymphocytes with a scant to moderate amount of vacuolated cytoplasm.

slide22

Poorly cohesive small lymphocytes with irreg. hyperchromatic nuclei, some with eosinophilic cytoplasm; rare plasma cells.

By flow cytometry:

Monoclonal kappa light chain, CD19+, CD20+, slight CD23, CD10-, CD5-. C/w B-cell lymphoprolif. disorder.

Diagnosis: B-cell lymphoma

hospital days 9 14
Hospital Days 9 - 14
  • Extubated, then re-intubated after only two hours for respiratory failure
  • Extubated again two days later
  • Both chest tubes drained a liter of fluid/day
  • Massive anasarca
  • Platelets began to rise
  • First round of CHOP given at 67%
hospital days 15 19
Hospital Days 15-19
  • Pt developed rigors
  • Pleural fluid sent for culture
    • Initial Gram stain showed GPC/GNR
    • Started on pip/tazo
    • Culture grew out coag neg Staph and Providencia rettgeri
  • Pt re-intubated for worsening respiratory status
    • Etiology thought to be due to failure of the left chest tube
  • Platelets fell to a low of 36
platelet count
Platelet count

11/13 - heparin flushes and allopurinol d/c’d

11/20 - first dose of CHOP

hospital days 20 29
Hospital Days 20-29
  • Extubated, given platelet transfusions, and pressors weaned off
  • Repeat echo showed improved hemodynamics
    • s/p one cycle of CHOP
  • Chest tubes continued to drain a liter of fluid a day
    • Pleurodesis planned when drainage decreased
hospital days 30 35
Hospital Days 30-35
  • G-tube placed by interventional radiology
  • Platelets began to rise again
    • trial of heparin
    • CT drainage down to 60 cc on the left and 430 cc on the right
    • planned pleurodesis canceled as the drainage was greater than 50 cc/24hr
hospital days 36 43
Hospital Days 36-43
  • Chest tubes continued to have minimal drainage bilaterally
    • left chest tube pulled, right side remained on water seal
  • Second cycle of CHOP given
  • Pt pulled out G-tube during the night
    • Re-inserted at the bedside, tube feeds held
hospital day 44
Hospital Day 44
  • Pt developed a worsening lung exam
    • ABG 7.1/146/64.6
  • Pt once again agreed to re-intubation
  • A portable CXR was obtained post-intubation
hospital day 45
Hospital Day 45
  • Patient decided to be DNR
    • Self extubated overnight
  • Three hours after extubation, the patient told the nurses that he wanted to die
  • Withdrawal of support
issues discussed
Issues Discussed
  • Patient decision making and the role of physicians
  • Management of pleural effusions
  • Re-expansion pulmonary edema
  • Lymphoma and CHOP
  • Thrombocytopenia
  • Volume status, hypoalbuminemia, and nutrition
ad