NYU Medical Grand Rounds Clinical Vignette

Justin Simmons, M.D.

Class of 2012

3/27/2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient is a 69 year-old Spanish speaking woman with an extensive history of coronary disease and systolic heart failure who presents with complaint of intermittent lightheadedness for one day.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

•The patient was in her usual state of health when she was hospitalized two-weeks prior for hypotension and acute renal failure secondary to over-diuresis.

•The patient’s medications were adjusted during her hospitalization. She achieved euvolemia, and was discharged home with outpatient follow-up.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Previous Medications Discharge Medications

Furosemide 160mg BID Furosemide 80mg BID

Lisinopril 40mg daily Lisinopril discontinued

Carvedilol 3.125mg BID Carvedilol 3.125mg BID

Spironolactone 25mg daily Spironolactone 25mg daily

•The day of readmission, the patient presented to outpatient clinic for scheduled follow up with a complaint of lightheadedness but denied any other complaints.

• Review of medications with the patient and one of the caretakers revealed a potential lack of understanding of the adjustments made to pre-admission medications during her prior hospitalization.

•Her vitals signs were notable for hypotension to 83/47 and the patient was referred to the adult emergency services for an urgent evaluation.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:•Hypertension•Coronary Artery Disease•Rheumatic Heart Disease•Tachy Brady Syndrome•Systolic Heart Failure• Iron deficiency Anemia•Erosive Gastritis

•Past Surgical History:•Coronary Artery Bypass Graft•Mitral Valve Replacement•Permanent Pacemaker•Atrioventricular Nodal Ablation•Cholecystectomy

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Social History:

•Former smoker. No alcohol or illicit drug use

•Lives with daughter.

•Has a home health aid 3 hours daily 7 days a week.

•Family History:

•Non-Contributory

•Allergies:

•NKDA

•Medications:

•furosemide 80mg twice daily sucralfate 60mg three times daily

•carvedilol 3.125mg twice daily esomeprazole 40mg twice daily

•spironolactone 25mg daily ferrous sulfate 325mg twice daily

•simvastatin 20mg nightly calcium carbonate twice daily

•warfarin 2mg nightly

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

•General: well appearing in no acute distress.

•Vital Signs: T: 96.9 BP:85/57 HR:76 RR:16 and O2 sat:100% on room air

• regular rate and rhythm with 3/6 systolic murmur heard best at apex, pronounced S1.

•Remainder of Physical Exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

•CBC:•Hemoglobin 8.5 (at baseline). •Remainder of CBC was within normal limits

•Basic Metabolic panel:•BUN 107, Cr 2.4 (1.1), K 7.6•Remainder of basic was within normal limits

•Hepatic panel: within normal limits•INR 3.6•Urinalysis: within normal limits

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•ECG: paced at 72bpm.

•Chest X-Ray: stable cardiomegaly without evidence of focal consolidate, volume overload, or cardiopulmonary pathology

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Iatrogenic hypovolemia complicated by hypotension, acute kidney injury and hyperkalemia.

Working Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Hospital Day 1:– Spironolactone, lisinopril, and lasix were held– The patient was given fluid boluses with improvement in blood

pressure.– Calcium gluconate, IV insulin, and kayexelate were administered

for treatment of hyperkalemmia– Potassium downtrended to normal range.

• Hospital Day 2-6:– Creatinine downtrended toward baseline– Medications were slowly titrated back on– Extensive conversation with caretaker regarding correct

discharge medications and dosing regiment.• Hospital Day 7 - The patient was discharged with close medicine and heart

failure follow up.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Iatrogenic hypovolemia with acute kidney injury and hyperkalemia.

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS