Transcript NYU Medical Grand Rounds Clinical Vignette Justin Simmons, M.D. Class of 2012

NYU Medical Grand Rounds
Clinical Vignette
Justin Simmons, M.D.
Class of 2012
3/27/2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
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
Working Diagnosis
• Iatrogenic hypovolemia complicated by
hypotension, acute kidney injury and
hyperkalemia.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Iatrogenic hypovolemia with acute kidney
injury and hyperkalemia.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS