nyu medical grand rounds clinical vignette han na kim pgy-3 february 7, 2012 u nited s tates d...

NYU Medical Grand Rounds Clinical Vignette

Han Na Kim

PGY-3

February 7, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient is a 43-year-old Chinese man who presents with fatigue and weakness for 3 weeks.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Over the past month, he has been feeling weak and lightheaded. He has had decreased appetite and 4 lb weight loss.

• A week prior to presentation, he was diagnosed with pneumonia when he presented to the Gouverneur clinic with fevers and cough. He was treated with 5 day course of azithromycin.

• One day prior to admission, he presented to clinic for follow-up of his symptoms. During the visit, labs were drawn and results were notable for white blood cell count of 8 with 38% blasts, hemoglobin of 6.4, and platelet count of 63.

•The patient was sent to the Bellevue emergency department for further inpatient workup and management.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:• Hypertension

•Past Surgical History:• None

•Social History:• Denies use of tobacco and drinks alcohol occasionally• From China, lives with wife and three children, works as food deliverer

•Family History:•Father: Gastric Cancer

•Allergies: •No Known Drug Allergies

•Medications:• None

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

General: pale Asian man lying in no acute distress

Vital Signs:

T 98.0 ºF BP126/87 HR 78 RR 16 O2 sat 100%

HEENT: pale conjunctiva

Guaiac was negative

Remainder of the physical exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

• CBC: 7.8 > 5.8/16.9 < 62 diff : Neut 31%, Band 5%, Lymph 21%, Mono 3%, Meta 1%, Myel 2%,

Promyel 4%, Blast 33% smear: Auer Rods

• Basic Metabolic panel: within normal limits

• Hepatic panel: within normal limits

• PT/INR: 1.15 PTT: within normal limits• Haptoglobin: 292 (30-200) Fibrinogen: 443 (152-427)• LDH: 468 (110-225) Uric Acid: 6.8 (3.6-7.7)

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The working diagnosis at this time was acute myeloid leukemia.

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient was transfused and bone marrow biopsy was performed revealing acute myeloid leukemia. He was immediately started on induction chemotherapy.

• On hospital day 7, he developed neutropenic fever to 104 ºF thought to be from pneumonia and possible phlebitis.

• He was started on broad spectrum antibiotics with vancomycin/cefepime and blood cultures later grew out gram negative rods.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The next day, he further decompensated with new hemoptysis, persistent high fevers, tachycardia, tachypnea and severe hypoxia with arterial blood gas of 7.48/27/55/20/2.0.

• He was transferred to the intensive care unit and intubated for hypoxic respiratory failure.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Imaging Study

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• His chest x-ray was concerning for acute respiratory distress syndrome and he was ventilated with lung protective strategy on volume control of 450 ml, RR 20, PEEP 12, FiO2 of 70%.

• He was further treated for septic shock with vancomycin/imipenem/metronidazole and norepinephrine.

• Gram negative rods on blood cultures were finalized as pansensitive Klebsiella pneumoniae and his antibiotics were narrowed.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• By hospital day 12, ARDS dramatically improved requiring minimal PEEP and FiO2. Sepsis improved and he was weaned off of norepinephrine.

• The next day, he was successfully extubated after a week of intubation and on hospital day 15, he was transferred to the Hematology service for further care.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The final diagnosis of the patient is acute myeloid leukemia complicated by neutropenic fever and septic shock secondary to pneumonia, phlebitis and Klebsiella bacteremia leading to acute respiratory distress syndrome.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS