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Medical Grand Rounds Clinical Vignette

09-12-2008. Medical Grand Rounds Clinical Vignette. Matthias C. Kugler, M.D. Internal Medicine Resident. Chief Complaint. 53 year old Caucasian male with Hepatitis C and cirrhosis, who presented to Bellevue Hospital with 8 days of abdominal pain and increasing girth.

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Medical Grand Rounds Clinical Vignette

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  1. 09-12-2008 Medical Grand Rounds Clinical Vignette Matthias C. Kugler, M.D. Internal Medicine Resident

  2. Chief Complaint • 53 year old Caucasian male with Hepatitis C and cirrhosis, who presented to Bellevue Hospital with 8 days of abdominal pain and increasing girth

  3. History of Present Illness • Right Upper Quadrant pain for 8 days, up to 8/10 intensity, aching, non-radiating, intermittent, lasting several hours, no association with nausea or vomiting. • Increasing girth and abdominal swelling. • He denied fever or chills

  4. History • Past Medical History: Hepatitis C diagnosed 15 years ago, cirrhosis since 2003, awaiting transplant Esophageal varices with endoscopic banding 2006 • Past Surgical History: none • Family History: non-contributory • Allergies: Penicillin – rash • Medications: Esomeprazole 40mg daily, Furosemide 40mg daily, Aldactone 25mg daily, Lactulose 30ml bid, Propanolol 20mg tid, Acetaminophen 500mg q6h prn pain, Docusate 100mg tid • Social History: no toxic habits, married, 2 children, no intravenous drug use • ROS: otherwise negative

  5. Physical Examination • General: Ill-appearing white male in mild distress, alert and oriented x 3 • Vital Signs: BP-113/80 HR-65 RR-20-22 O2-sat 93% (room air) Temp-37.0°C • Head/Neck: + scleral icterus • Lungs: breath sounds decreased b/l bases, upper lungs clear to auscultation • Abdominal: + tense, distended, diffusely tender to palpation, + fluid wave, no guarding or rebound, bowel sounds hypoactive in all 4 quadrants • Extremities: 1-2+ pitting edema of the legs bilaterally • Skin: + jaundice • Remainder of physical exam normal

  6. Laboratory Values Basic: Na 132 (140-145) CBC: WBC 4.2 (N53%, L26%, M15%, E5%) Hb 11.1 (13-18) Hct 31.6 (35-50) MCV 112 (86-98) plt 81 (150-350) Hepatic: AST 100 (7-27) ALT 43 (1-21) AP 112 (13-39) Tbili 7.7 (<1.0) DBili 5.1 (<0.4) Prot 10.3 (6.0-8.4) Alb 1.6 (3.5-5.0) Paracentesis: WBC 45 (N10%, L57%, M2%,) RBC 3350 Alb 1.0 LDH 49 Gram stain: gram-negative rods Coags: INR 2.5 (<1.15) PTT 52 (25-38) ABG: pH 7.43, pCO2 39, pO2 87, HCO- 26, O2-sat 92% (room air), Lact 1.2

  7. Imaging Data • PA/Lateral chest radiograph: small pleural effusions b/l, no infiltrates, + ventral hernia

  8. Working Diagnosis • Bacterial peritonitis and decompensation of cirrhosis secondary to infection.

  9. Hospital Course HD#1: • Therapeutic paracentesis with 1.5 liter fluid femoval • Ceftriaxon initially, when paracentesis fluid grew out pansensitive Escherichia coli, the antibiotic was switched to Ciprofloxacin • Forced diuresis using intravenous furosemide with monitoring of the electrolyte status • Patient continously afebrile HD#4: • Despite improving ascites, patient noticed to be more short of breath, tachypnic and hypoxic

  10. Hospital course HD #5: • ABG: pH 7.37, pCO2 43, pO2 62, HCO- 24, O2-sat 88% (room air) • PA/Lateral chest radiograph with increased diffuse patchy infiltrates b/l • Patient was placed on CPAP with supplemental O2 and transferred to the intensive care unit

  11. Hospital course HD #7: • ABG: pH 7.39, pCO2 43, pO2 48, HCO- 26, O2-sat 77% on FiO2 50%, PaO2/FiO2 96 • Patient was intubated for severe hypoxemia. • Portable AP chest radiograph with worsening diffuse patchy infiltrates throughout both lungs

  12. Hospital course HD #8-10: • Ventilation using low tidal volumes, PEEP, and permissive hypercapnea • Setting VT 400 cc, FiO2 70-80%, PEEP 7-10 mm H2O later increased to maximum of 14 mm H2O • Over the next days the team was able to decrease PEEP to 8, FiO2 to 50%, VT 400 cc, with improving hypoxemia on ABG (pH 7.38, pCO2 31, pO2 84, HCO-18, O2-sat 96% • Sputum cultures remained all negative

  13. Final Diagnosis • Bacterial peritonitis and decompensation of cirrhosis secondary to infection. • Acute Respiratory Distress Syndrome (ARDS)

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