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Just wanted to get some people's opinions for a case I have later tomorrow afternoon. RElatively new attending at academic hospital.
Brief history...
26 yo M hx IVDA had some sort of trauma back in August with multiple facial and extremity fractures. Had hardware placed and eventually went to rehab.
He then came back to hospital about a week ago in septic shock and was in the ICU on pressors. AKI, Leukocytosis, thrombocytopenia, anemia and tranaminitis all linked to sepsis. So pretty much was seen by cards and ID initially and sepsis improved and was weaned off pressors and out of ICU.
However, they did a bedside ECHO which showed RV severly enlarged and hypokinetic. PFO via agitated saline, but no VSD. LVEF 45%. CXR back on the 4th showed increased bibasilar effusions and atelectasis, but no imaging since then. Cards recommended TEE, but because of his jaw fracutre and repair they were unable to do TEE so recommended cardiac MRI, however several notes say unable to perform due to "technical issues".
So tomorrow he's going for mandibular hardware removbal as a source of infection, but several notes also state possible RLE hardware and endocarditis as sources. His Hgb from the 5th was 7.6 and plt 87, none since then, but looks like they have CBC ordered. LFTs also elevated but imrpoving (they think from shock, but also Hep C Ab+ with no mention of chronic infection in chart). AKI improved Cr 3.1 --> 0.7
I figure I'm gonna talk to this kid and see what if any symptoms he's having. One cardiac note mentioned getting cardiac MRI as outpatient, so they don't seem overly concerned about his right heart fx despite elevated LFTS and effusions on CXR which were worsening but then not followed for a week...
Not sure what other workup I would do, besides check his morning labs to ensure his Hgb and Plts aren't completely in the toilet. Check for symptoms and if I'm really concerned have my goal to reduce PVR. Anything I'm missing? Outside of being a complete mess, the guy appeared to be otherwise healthy prior to his initial surgeries...
P.S. I'm very tired and going to bed soon, so preferably opinions with some constructive criticism.
Brief history...
26 yo M hx IVDA had some sort of trauma back in August with multiple facial and extremity fractures. Had hardware placed and eventually went to rehab.
He then came back to hospital about a week ago in septic shock and was in the ICU on pressors. AKI, Leukocytosis, thrombocytopenia, anemia and tranaminitis all linked to sepsis. So pretty much was seen by cards and ID initially and sepsis improved and was weaned off pressors and out of ICU.
However, they did a bedside ECHO which showed RV severly enlarged and hypokinetic. PFO via agitated saline, but no VSD. LVEF 45%. CXR back on the 4th showed increased bibasilar effusions and atelectasis, but no imaging since then. Cards recommended TEE, but because of his jaw fracutre and repair they were unable to do TEE so recommended cardiac MRI, however several notes say unable to perform due to "technical issues".
So tomorrow he's going for mandibular hardware removbal as a source of infection, but several notes also state possible RLE hardware and endocarditis as sources. His Hgb from the 5th was 7.6 and plt 87, none since then, but looks like they have CBC ordered. LFTs also elevated but imrpoving (they think from shock, but also Hep C Ab+ with no mention of chronic infection in chart). AKI improved Cr 3.1 --> 0.7
I figure I'm gonna talk to this kid and see what if any symptoms he's having. One cardiac note mentioned getting cardiac MRI as outpatient, so they don't seem overly concerned about his right heart fx despite elevated LFTS and effusions on CXR which were worsening but then not followed for a week...
Not sure what other workup I would do, besides check his morning labs to ensure his Hgb and Plts aren't completely in the toilet. Check for symptoms and if I'm really concerned have my goal to reduce PVR. Anything I'm missing? Outside of being a complete mess, the guy appeared to be otherwise healthy prior to his initial surgeries...
P.S. I'm very tired and going to bed soon, so preferably opinions with some constructive criticism.