27990013 Visualization

A 73 Age - year Age - old Age Hispanic Personal_background male Sex with a history of stage Detailed_description IV Detailed_description chronic Disease_disorder kidney Disease_disorder disease Disease_disorder and three Detailed_description - vessel Detailed_description coronary Disease_disorder artery Disease_disorder disease Disease_disorder was admitted Clinical_event for coronary Therapeutic_procedure artery Therapeutic_procedure bypass Therapeutic_procedure graft Therapeutic_procedure surgery Therapeutic_procedure and mitral Therapeutic_procedure valve Therapeutic_procedure repair Therapeutic_procedure .
On post-operative day Date two Date , the patient developed cardiac Sign_symptom tamponade Sign_symptom and subsequently progressed to a cardiac Disease_disorder arrest Disease_disorder while temporary Therapeutic_procedure pacing Therapeutic_procedure wires Therapeutic_procedure were being removed.
Advanced cardiovascular Therapeutic_procedure life Therapeutic_procedure support Therapeutic_procedure and emergent exploratory Detailed_description sternotomy Therapeutic_procedure were performed, and the patient was transferred Clinical_event to the intensive Nonbiological_location care Nonbiological_location unit Nonbiological_location ( ICU Nonbiological_location ) for further care.
During the patient’s ICU Nonbiological_location admission Clinical_event , his renal Disease_disorder failure Disease_disorder progressed, requiring hemodialysis Therapeutic_procedure .
A nasogastric Therapeutic_procedure tube Therapeutic_procedure was placed on post-operative day Date two Date for establishing early enteral Therapeutic_procedure nutrition Therapeutic_procedure .
PEG Therapeutic_procedure tube Therapeutic_procedure insertion Therapeutic_procedure was suggested given his cognitive Sign_symptom impairment Sign_symptom and poor Lab_value swallowing Diagnostic_procedure function Diagnostic_procedure on the Modified Diagnostic_procedure Barium Diagnostic_procedure Swallow Diagnostic_procedure test Diagnostic_procedure .
His coagulation Diagnostic_procedure profile Diagnostic_procedure prior to the procedure revealed an international Diagnostic_procedure normalized Diagnostic_procedure ratio Diagnostic_procedure of 1.04 Lab_value and partial Diagnostic_procedure thromboplastin Diagnostic_procedure time Diagnostic_procedure of 36 Lab_value seconds Lab_value .
A complete Diagnostic_procedure blood Diagnostic_procedure count Diagnostic_procedure showed a hemoglobin Diagnostic_procedure of 11.6 Lab_value grams Lab_value per Lab_value deciliter Lab_value , a hematocrit Diagnostic_procedure of 34.9% Lab_value , and 281×103 Lab_value platelets Diagnostic_procedure per Detailed_description microliter Detailed_description .
His blood Diagnostic_procedure urea Diagnostic_procedure nitrogen Diagnostic_procedure was 55 Lab_value milligrams/deciliter Lab_value , and his serum Detailed_description creatinine Diagnostic_procedure was 5.22 Lab_value milligrams/deciliter Lab_value .
The patient was taking aspirin Medication 81 Dosage mg Dosage per Dosage day Dosage due to recent cardiac Therapeutic_procedure surgery Therapeutic_procedure , but was not on any anticoagulant Medication agents Medication .
He also did History not History have History a History history History of History coagulopathy Disease_disorder .
PEG Therapeutic_procedure tube Therapeutic_procedure insertion Therapeutic_procedure was performed on post-operative day Date eight Date under intravenous Administration anesthesia Medication .
The esophagogastroduodenoscopy Diagnostic_procedure ( EGD Diagnostic_procedure ) was accomplished without difficulty Other_event , revealing diffuse Detailed_description moderately Severity erythematous Sign_symptom mucosa Biological_structure without bleeding Sign_symptom in the gastric Biological_structure antrum Biological_structure .
While attempting PEG Therapeutic_procedure tube Therapeutic_procedure placement, a rapidly Severity expanding Severity hematoma Sign_symptom (Figure 1) developed at the needle Biological_structure insertion Biological_structure site Biological_structure .
The procedure Coreference was stopped and the patient was sent Clinical_event back Clinical_event to the ICU Nonbiological_location with a nasogastric Therapeutic_procedure tube Therapeutic_procedure .
A single Dosage dose Dosage of intravenous Administration desmopressin Medication ( 0.3 Dosage microgram/kilogram Dosage ) was administered under the suspicion of uremic Sign_symptom bleeding Sign_symptom .
No further gastrointestinal Biological_structure bleeding Sign_symptom events were noted.
To assess platelet Diagnostic_procedure function Diagnostic_procedure , a platelet Diagnostic_procedure function Diagnostic_procedure assay Diagnostic_procedure ( PFA Diagnostic_procedure ) was ordered after desmopressin Medication injection Administration .
PFA Diagnostic_procedure collagen/epinephrine Diagnostic_procedure closure Diagnostic_procedure time Diagnostic_procedure was 195 Lab_value seconds Lab_value (normal <174 seconds), and collagen/ADP Diagnostic_procedure closure Diagnostic_procedure time Diagnostic_procedure was 76 Lab_value seconds Lab_value (normal <120 seconds), indicating platelet Disease_disorder dysfunction Disease_disorder due to either aspirin Medication or uremia Disease_disorder .
Aspirin Medication was discontinued, and he was monitored Therapeutic_procedure with a daily Frequency complete Diagnostic_procedure blood Diagnostic_procedure count Diagnostic_procedure and metabolic Diagnostic_procedure panel Diagnostic_procedure .
Three Date days Date later Date the patient underwent a second attempt at PEG Therapeutic_procedure tube Therapeutic_procedure placement Therapeutic_procedure .
PFA Diagnostic_procedure collagen/epinephrine Diagnostic_procedure closure Diagnostic_procedure time Diagnostic_procedure prior to this procedure Coreference had gone Lab_value down Lab_value to 141 Lab_value seconds Lab_value , possibly due to withholding aspirin Medication and an improvement Lab_value in renal Diagnostic_procedure function Diagnostic_procedure .
EGD Diagnostic_procedure showed an area of flat Texture , bluish Color gastric Biological_structure submucosal Biological_structure bruising Sign_symptom at the site of the previous hematoma Sign_symptom (Figure 2).
The PEG Therapeutic_procedure tube Therapeutic_procedure was placed successfully at an adjacent Biological_structure site Biological_structure .
Over the course of the following Duration month Duration , the patient continued to undergo feeding Therapeutic_procedure through the PEG Therapeutic_procedure tube Therapeutic_procedure with no adverse Sign_symptom events Sign_symptom .