ID Case Conference 4 .

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ID Case Conference 4/23/08. Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases. CC: chest pain. 19y/o Native American woman s/p OHT at age 12 who presents with chest pain. She was admitted for chest pain on 4/4/08, CXR, echo, EGD, and cardiac w/u all stable.
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ID Case Conference 4/23/08 Gretchen Shaughnessy, MD Clinical Fellow Dept of Infectious Diseases

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CC: mid-section torment 19y/o Native American lady s/p OHT at age 12 who presents with mid-section torment. She was conceded for mid-section torment on 4/4/08, CXR, resound, EGD, and cardiovascular w/u all steady. Completing her second course of TMP/SMX for sinusitis (recommended by PMD as outpt). Asking for extensive amts of agony prescription, displaying drug looking for conduct. Psychiatry included. Workup negative, d/ced with outpatient followup.

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HPI (cont) Discharged from UNC 4/8/08. Went home and kept on having torment. Went to outside healing center 4/13/08 and conceded for mid-section torment. Numerous studies negative including VQ check, CXR, Echo, abd u/s all unaltered from earlier studies.

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HPI (cont) 4/15/08 persistent creates epistaxis, ENT counseled. D/ced Allegra, prescribed saline, vasoline, afrin splash. The patient was exchanged to UNC 4/19/08 however since confirmation has had a fever and now exacerbating penetrates on CXR. She has additionally begun hacking up blood. ID was counseled for help.

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PMH Heart transplant in 10/19/2000, auxiliary to Idiopathic widened cardiomyopathy, now with unite vasculopathy Cath in 2/2008 demonstrated 30% LM, 40% LAD, 70% LCx, 40% RCA TTE in 4/2008 indicated LVEF of 65-70%, diastolic brokenness, mod AI, and mod enlargement of RA Recent increment in immunosuppression in light of vasculopathy

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PMH (cont) Dyslipidemia Chronic stomach torment/GERD. EGD done amid 4-08 affirmation History of two sinus surgeries, which included tonsillectomy and adenoidectomy in 1997, and with repetitive sinusitis Endometriosis Anxiety MDD hoisted ANA 1:640, rheum workup 9/07

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Allergies: PCN – hives, ceclor-hives, levofloxacin – tingling, vancomycin – Redman\'s, morphine - tingling ABX history: Levofloxacin began 4/17/08 aztreonam and clindamycin 4/19/08 headache medicine 81 mg po q day lasix 40 mg po q day pravastatin 20 mg po q day norvasc 5 mg po q day neurontin 600 mg po q day Singulair 10 mg po q day Ferrous sulfate 325 mg po q day colace 100 mg po q day prozac 40 mg po q day magnesium oxide 800 mg po offer sirolimus 2 m po q day tacrolimus 2 mg po offer nexium 40 mg po q day Medications

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ROS positive for hack, sore throat, mid-section torment, DOE, SOB, hemoptysis, weight reduction (since expanding her lasix dosage - however has not saw any weight reduction other than that identified with liquid), chestnut nasal release, weariness, infrequent the runs. generally negative.

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Vital 38.5 - 35.6 - 89-103 - 18-20 - 109-121/63-75 94% on RA INAD, habitually hacking amid exam. hacked up little measure of yellow sputum streaked with blood amid exam EOMI, PERRLA, nonicteric no JVD, no LAD acknowledged in cervical, supraclavicular, or inguinal districts RRR III/VI systolic mumble no e/e on OP coarse breath sounds B, rhonchi more awful on L, crackles on R no impulsive or sores a&ox3, wonderful and helpful. requesting more dilaudid delicate NT seizes, no HSM no c/c/e nl tone, full ROM display no central defecits Physical Exam

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Diagnostic Tests from OSH 4/13 Labs: CBC 11.7>9.4/27.8<245, BNP 600. PT 11.5, INR 1.1, PTT 26.7. CK 85, CKMB1.4, Trop <0.1 (rehash x2 unaltered). 4/13 CXR clear lungs, stable cardiomegally. 4/13 VQ filter ordinary. Utox negative, TSH 4.8, Upreg test negative, u/a negative. D-Dimer 2.2. ABG 7.42/36/102/23.3/98 on 0.21 O2 4/14 Echo - LV systolic low typical, EF 55%, RV systolic raised at 40-50mmHg worried for pulm HTN, gentle valvular aortic stenosis with direct aortic regurg.mild mitral regurg. No pericardial radiation.

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OSH Diagnostic tests 4/14 CBC 11.1>10.4/31.8<222. ESR 33 4/15 CBC 7.1>8.8/26.7<231. Amylase 49, Lipase 19, Mg 1.5, Ca 8.9, Cr 0.9. 4/15 Abd U/S finished with little vol of perihepatic ascites, left pleural emanation. 4/15 PCXR no intense cardiopulm infection, stable discoveries. 4/15/08 ENT counseled for epistaxis

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Previous Rheumatologic Evaluation – 9/07

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