You are a practicing clinician taking care of the following patient. Based on the case details, please indicate your action.
History of Present Illness
A 51-year-old Vietnamese-speaking woman with HLD, HTN, CKD stage II (baseline creatinine 1.3), and cholelithiasis is admitted to the hospital for severe gallstone pancreatitis.
PMH/PSH
- Hyperlipidemia
- Hypertension
- Cholelithiasis
- CKD stage II
- History of positive PPD
FHx
- Heart disease
- Diabetes
SHx
- Former smoker
- Drinks 1-2 drinks of alcohol daily
- Lives with son and daughter-in-law
- Widowed
- Used to work managing in a textile factory
- Commercial insurance
Medications
- Atorvastatin 40mg qhs
- Lisinopril 5mg qD
- Ibuprofen 400-800mg qD PRN for joint pain
Physical Exam
T 101.3, HR 112, BP 98/52, SpO2 93% RA, RR 24
- Gen: Alert, oriented, in NAD, appears very fatigued
- HEENT: mild scleral icterus
- CV: tachycardic, regular rhythm, no m/r/g
- Lungs: crackles in the bases bilaterally
- Abdomen: soft, mildly distended, TTP in the RUQ/peri-umbilical areas
- Ext: no LE edema
- MSK: no joint swelling
Data
CBC show leukocytosis to 17.3K, decreased Hgb to 10.2, and platelet count of 345K.
BMP show elevated creatinine to 1.8, elevated BUN to 45.
LFTs show elevated AP to 102, elevated Tbili to 3.2.
Lipase is elevated to 603.
CT A/P shows peripancreatic stranding consistent with pancreatitis, cholelithiasis, and intrahepatic biliary ductal dilatation.
Hospital Course
The patient’s course is complicated by severe sepsis and ARDS requiring 6L supplemental O2, prompting transfer to the ICU and treatment with broad spectrum antibiotics and frequent electrolyte repletion. A chest x-ray obtained to evaluate for pneumonia shows a lung nodule, bilateral interstitial markings but no consolidation. After transfer out of the ICU, the patient has a follow up CT with contrast that showed improvement of the interstitial edema and reconfirms a single 2.5 cm nodule; the radiology report suggests either biopsy or repeat imaging in three months.
The course is further complicated by the development of a DVT, which requires a heparin drip with transition to apixaban, as well as respiratory failure requiring intubation. Despite a prolonged hospital course – 57 days – the patient gradually recovers. The lung nodule is forgotten during this prolonged course. The patient is severely deconditioned, and rehabilitation is recommended.
Discharge Medication List
- Atorvastatin 40 mg qHS
- Lisinopril 5 mg qD on HOLD until patient follows up with PCP
- Ibuprofen 400-800 mg qD PRN for joint pain on HOLD given mild AKI on CKD during hospitalization
- Acetaminophen 1000 mg q8h PRN for pain
- Potassium chloride 20 mEq daily
- Apixaban 5mg BID
Discharge Physical Exam
T 97.3F, HR 85, BP 142/75, O2 sat 95% RA, RR 18
- Gen: Alert, oriented, in NAD, appears weak
- HEENT: no scleral icterus, no oral lesions
- CV: RRR, no m/r/g
- Lungs: CTAB, no c/r/w
- Abdomen: soft, non-distended, non-tender to palpation
- Ext: no LE edema
- MSK: no joint swelling
Discharge Labs
CBC
- WBC 10.5
- Hgb 8.3
- Plt 473
BMP
- Sodium 137
- K 3.4
- Chloride 104
- Bicarb 21
- BUN 26
- Creatinine 1.5
Decision-making
As you prepare the discharge paperwork, you suddenly remember the lung nodule. There has been no plan in place for the biopsy but the patient does have a primary care provider and could have an outpatient follow up within 7 days. At rehab, the patient will have access to transport for appointments. During your conversation with the patient, you discussed the importance of the lung biopsy. Recognizing the potential barriers of deferring this, you discuss the possibility of staying in the hospital for the procedure. The patient expressed a preference for conservative management, but ultimately deferred to your recommendation.
Decision: Would you discharge the patient at this current time?