Rounds on a sick young man

I entered the ICU prepared to visit our patient. He is 24 years old and was acutely ill. As I entered his room he had apprehension plastered on his face. He was using accessory muscles to breath. He looked sick.

Now for those who have never done a residency, one of the most important things that we learn is the difference between sick and not sick. This patient was sick.

As I went to the bedside, I first felt his pulse – a bit tachycardic, but strong. I then felt his scalene muscle on the right, checking for how hard he was working to breath. He was working fairly hard.

I saw that he was receiving pressors through his IV, but his BP was 106/70 with a pulse of 112. The most remarkable part of his physical exam was his loud, grade III/VI holosystolic murmur which I could hear throughout his chest. He had a loud P2 heard in the 2nd -4th ICS on the left. He had wet rales to the scapula bilaterally.

I asked him if he knew that he had a heart murmur. He told me that he had been told about the a murmur 5 years previously prior to a deviated septum repair. He had no other past medical history.

THE STORY

The patient had come to the emergency room 2 weeks previously with non-specific complaints. He had a CBC and a monospot test. CBC – hemoglobin 11.6 with hematocrit of 35.9%. WBC 10.2 with 76% neutrophils and 18% lymphs. His monospot test was positive. The ER physician made a diagnosis of infectious mononucleosis and discharged him.

The next week he had cough and dyspnea. He went to his primary care physician who gave him a Z-pack and 10 mg of prednisone daily. 3 days later he returned to the ER with severe abdominal pain.

At this time they repeated his CBC – hemoglobin 9.1 with hematocrit of 29%. WBC 14.4 with 85% neutrophils and 12% lymphs.

On physical exam, in addition to the murmur described above, his abdominal exam was abnormal. He had guarding and rebound tenderness. Because of the fear of splenic rupture, he had an abdominal CT scan. It showed a splenic infarct and a right renal infarct.

Additional laboratory tests included a normal troponin, but an proBNP of 16,000. His CXR showed an enlarged heart and pulmonary edema.

Tomorrow I will provide the resolution of this patient’s illness. Please comment on the likely diagnosis and the tests you would need.