1. NYU Medicine Grand Rounds Clinical Vignette Jamie Osman, MD MPH RD PGY2 April 2, 2013 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. Mr. D is a 39-year-old Chinese man who presented with progressive bilateral lower extremity edema, dyspnea on exertion and fatigue for five weeks. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3.  Five weeks prior to arrival the patient noted bilateral lower extremity swelling which advanced to his thighs and abdomen over the next 1 - 2 weeks.  Three weeks prior to arrival he began having intermittent palpitations, weight loss, fatigue and shortness of breath with minimal exertion. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4.  He also recalled feeling anxious during this period  On the day of arrival he was “hanging out” in Penn Station when he was noted hunched over with leg pain by police officers who called EMS. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History  PMH/PSH: None  Meds: None  Allergies: NKDA  Social History: Drinks $1000 of vodka per month with friends with the last drink 1 day before admission. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination  Gen: cachectic, jaundiced Asian man in no acute distress  Temperature: 97.3F  Heart rate: 118  Blood Pressure 120/68  Respiratory Rate: 20  Oxygen Saturation: 97% on room air U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination  HEENT: scleral icterus, no exophthalmos, mild thyromegaly, no lid lag  Cards: PMI displaced to anterior axillary line; tachycardic, irregularly irregular with jugular venous distention  Abd: distended with hepatomegaly  Ext: 3+ pitting edema up to scrotum and abdomen U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Remarkable Laboratory Findings  CBC: Hgb 7.1 g/dL  Hepatic: panel AST 41, ALT 31, alk phos 149, total bili 4.9, direct bili 4.0, total protein 7.9, albumin 2.9  Coagulation Panel INR 1.96, aPTT 33.1  Brain Natriuretic Peptide: 640  TSH undetectable, Free T4 3.42, FT3 7.0 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. EKG U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Atrial fibrillation with rapid ventricular response

10. Chest X-ray Cardiomegaly with increased interstitial markings consistent with pulmonary edema U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. CT Abdomen/Pelvis Heterogeneous liver with engorgement of hepatic veins and IVC; diffuse anasarca and moderate abdominopelvic ascites U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Thyrotoxicosis Alcoholic cardiomyopathy

13.  The patient was admitted to the CCU where beta blockers and lasix were given for rate control and diuresis, respectively.  Transthoracic echocardiogram showed four chamber dilatation with severe MR, severe TR and paradoxical flattening of the septum consistent with right ventricular overload.  The patient was started on methimazole and coumadin. Hospital Day #1

14.  Thyroperoxidase antibody (TPO) returned positive with thyroid stimulating immunoglobulins elevated to 345  A thyroid ultrasound showed increased vascularity. Hospital Day #10

15.  The patient was successfully diuresed with improved heart rate and symptom control and he was discharged. Hospital Day #19

16. Thyrotoxicosis due to Graves’ Disease Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS