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CPC
#4: Tuesday, December 17, 2002
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Chief
Complaint: History
of Present Illness: Figure
1 On 11/27/01, the patient underwent orthotopic heart transplantation. His post-transplant course was complicated by wound dehiscence, sepsis, aspiration, gastritis, pleural effusions, acute renal failure, and an upper gastrointestinal bleeding requiring embolization of a branch of the gastroduodenal artery. His post-operative echocardiogram (12/26/01) showed an ejection fraction of 70-75% with mild left ventricular hypertrophy. Multiple cardiac biopsies demonstrated only mild grade IA rejection (12/17/01, 12/27/01, 2/1/02, 2/14/02). The biopsy from 2/14/02, demonstrating mild (ISHLT grade 1A) rejection and Quilty type B infiltrates, is shown in Figure 2. He was discharged for rehabilitation on 2/2/02. An echocardiogram on 2/16/02 showed a decreased ejection fraction of 35-40%, along with mild concentric left ventricular hypertrophy, inferoseptal and anteroseptal hypokinesis. Figure
2a Figure
2b The patient completed rehabilitation on 3/5/02. On 3/17/02, he had an episode of syncope in his bathroom along with intractable nausea and vomiting. He was taken to an outside hospital. At the outside hospital, his arterial blood gas revealed a pH 7.06, pCO2 14 mmHg, pO2 160 mmHg, and bicarbonate 4 mmol/l. Blood cultures were drawn and the patient was given broad-spectrum antibiotics (Levoquin) and intravenous fluids. He was transferred to JHH for further management. Past
Medical History: Social
History: Family
History: Allergies: Physical
Examination: Laboratory
Studies: CBC: WBC 18,240/mm3, Hgb 12.3 g/dL, Hematocrit 41.6%, Platelets 294,000/mm3. Hospital
Course: What is the most likely cause of the patient's demise?
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