1. NYU Medical Grand Rounds Clinical Vignette Todd Cutler, MD 12/18/12 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 61 year old woman with three days of weakness and shortness of breath. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient has a history of severe pulmonary hypertension, previously treated pulmonary TB and MAC, cor pulmonale (on home oxygen), bronchiectasis and diabetes. Three days prior to admission she began having fevers, productive cough and shortness of breath. The day prior to admission she had difficulty walking across her living room and presented to the ED. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Social History: Lives with son, no smoking, alcohol or illicits Medications: Lisinopril 20mg daily Digoxin 0.125mg daily Lasix 20mg daily Lantus 20 Units at night Novolog 10 Units with meals U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Physical Examination General: Frail, chronically ill-appearing, short of breath, difficulty completing sentences Temp: 100.4 BP: 138/85 HR: 100 RR: 22 O2 sat: 95% on 4L NC, 87% on room air U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination Head and Neck: distended neck veins Heart: tachycardia, palpable pulmonic valve, loud S2 Lungs: tachypnea, diffuse rhonchi with bronchial breath sounds U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Other Studies Chest CT: stable fibrotic left lung and severe right middle lobe bronchiectasis with small nodular opacities in the anterior right upper lobe consistent with airway impaction versus infection U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Pneumonia Bronchiectasis Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Laboratory Findings Her labs were most remarkable for: - Arterial Blood Gas: 7.22/83/80/33 A repeat arterial blood gas after 15 minutes of bilevel at 18/5 was unchanged. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. She was intubated for hypercarbic respiratory distress and transferred to the MICU. She was started on vancomycin, cefepime and azithromycin. She was extubated on hospital day #4 and discharged from the MICU to the seventh floor on Monday. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. That same day, Hurricane Sandy hit the medical center and power to the hospital was lost. That night, supplemental oxygen was carried up to the seventh floor by the National Guard. She continued to receive IV antibiotics by gravity drip. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. On Thursday, the National Guard carried the patient down the stairwell to the ground floor. She was taken by ambulance to St. Luke’s Hospital in Manhattan. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. She completed her course of antibiotics at St. Luke’s Hospital. Discharge to subacute rehabilitation was delayed as facility vacancies were limited after the storm. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. On Thanksgiving, after 10 days at St. Luke’s Hospital, she was discharged home where she has been receiving physical therapy. She still feels week, has difficulty walking across the room and remains on continuous oxygen therapy. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Her home physical therapy and nursing visit benefits end today. She will follow up with me in the newly reopened Bellevue outpatient clinic next week. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Pneumonia versus Bronchiectasis Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS