54 year-old male with history of granulomatosis with polyangiitis (GPA), end-stage renal disease, myelodysplastic syndrome, and hypertension presents to the emergency department with fevers, chills, and myalgias x 1 day. The symptoms have worsened since his dialysis session this morning. The patient admits that he has actually been feeling this way for about a week. He originally had large amounts of bloody sputum that has now been decreasing over the past few days. He endorses a decrease in exercise tolerance: 3 months ago he was able to walk 3-5 blocks and now walks less than a block. The patient denies weight gain or weight loss, chest pain, nausea, vomiting, diarrhea or constipation, rashes or skin changes. He was admitted to the hospital one week ago for fever. An echocardiogram was done that showed a small pericardial effusion, an ejection fraction of 50%. The rheumatology consult did not believe that this was a GPA flare, and he was discharged on his maintenance dose of prednisone.

 

PSH: AV fistula

Allergies: None

Meds: Prednisone 10 mg qd, aspirin, carvedilol, hydralazine, rosuvastatin, valsartan, cinacalcet, calcium acetate, calcium-vitamin D

Social: No drugs, alcohol or tobacco. No recent travel or sick contacts. The patient was born in Guatemala but immigrated here when he was 3 months old.

 

PE:

VS: BP: 176/105, HR: 111, RR: 19, SpO2: 96% RA, Temp: 100.8

GEN: No acute distress, comfortable

Eyes: Conjunctiva and sclera normal

PULM: Breathing comfortably. Speaking full sentences. Rhonchi present, Rales present, No accessory muscle use.

CV: Tachycardia, 2/6 systolic ejection murmur right 2nd intercostal space. Murmur does not radiate to neck

ABD: Bowel sounds present, soft, non-tender, non-distended.

Skin: Warm dry, normal color, no rashes, normal turgor.

Extremities: No edema, cyanosis. Joints normal.

 

Labs:

Na: 140, K: 4.2, Cl: 99, HCO3 28, BUN: 38, Creatinine 5.2, Glucose 75

Protein: 4.6, Albumin: 2.9, AST 10, ALT 11, Alk Phos 126, Tbili: .4

WBC: 70, Hb: 7.5 (at baseline) Hct: 21.4, Plt: 108, MCV: 95.9 RDW: 18.7

INR: 1.0, PTT: 26.8, Trop: 0.14, BNP 1316

VBG: pH: 7.4, PCO2: 51.3, PO2: 44.1. Lactate 1.6

 

EKG: Sinus tachycardia, normal axis/intervals, no ST-T abnormality.

 

CXR: Vascular congestion, diffuse opacities

Bedside Sonogram : Diffuse B-lines. Normal wall motion, small pericardial effusion present. Normal chamber size.

CTA: Infiltrates present, no evidence of pulmonary embolism.

 

 

What is a differential diagnosis?

Does the BNP level help with the diagnosis? How?

How would you treat this patient?

 

 

Post your answers for a possible shout out in next week’s answer.

 

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Steven Greenstein

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1 Comment

ablumenberg · October 9, 2016 at 10:26 am

Vanc, zosyn, bipap, 2 units prbc on hold, admit to medicine.

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