Medical Grand Rounds Clinical Vignette

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Medical Grand RoundsClinical Vignette

• Jessica Lambert, MD
• Third Year Resident
• April 8, 2009

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Chief Complaint

• A 75 year old female complains of progressively
  worsening shortness of breath and lower extremity
  edema that developed over the past month.

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History of Present Illness

• The patients history begins several years prior
  to admission when she was diagnosed with
  diastolic heart failure. Despite appropriate
  medical management, the patient has had
  approximately 3 hospitalizations per year for the
  past 4 years.
• Her most recent admission occurred 4 months prior
  to admission.
• Approximately one month prior to admission, the
  patient stopped taking her medications regularly.
  She completely stopped taking her beta-blocker
  and only took her furosemide every few days.
• Over the past month, the patient began to notice
  shortness of breath at rest and with minimal
  exertion that was progressively becoming worse.
• She also noticed worsening edema that developed
  in both of her lower extremities and mildly
  increased abdominal girth during the same time
  period.
• After relaying these symptoms to her primary
  medical physician in Geriatrics clinic, she was
  referred to the Emergency Room for evaluation and
  admission.

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Additional History

• Past Medical History
• Diastolic Heart Failure
• Atrial Fibrillation
• Hyperthyroidism
• Osteoarthritis
• Breast Cancer treated with Trastuzumab therapy
• Past Surgical History
• Lumpectomy
• Social History
• 30-pack year smoking history, quit several years
  ago
• Denies alcohol and illicit drug use
• Lives alone without home services
• Family History
• Non-contributory
• No Known Drug Allergies
• Medications (Non-Compliant with all medications
  listed below)
• Furosemide 40 mg twice daily
• Lisinopril 5 mg daily
• Metoprolol 50 mg twice daily

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Physical Exam

• General Elderly female, oriented to person,
  place and time, in mild respiratory distress
• Vital Signs T 97.3 F BP 130/60 HR 120 RR 16
  O2 sat 92 on room air
• Eyes Scleral icterus
• Neck Elevated jugular venous pressure to
  approximately 8 cm above the sternal angle
• Lungs Bibasilar crackles
• Heart Irregularly irregular heart rhythm with a
  III/VI systolic ejection murmur best heard at the
  apex
• Abdomen Distended abdomen with evidence of
  hepatomegaly
• Extremities 2 pitting edema of bilateral lower
  extremities approximately 1/3 way up both legs
• Remainder of physical exam was normal

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Laboratory Values

• CBC Hgb 16.3, Hct 48.2, platelets 128
• Remainder of CBC was within normal limits
• Basic Metabolic Panel within normal limits
• Hepatic Panel alkaline phosphatase 259
• Remainder of hepatic panel was within normal
  limits
• Troponin 0.238 (0-0.2)
• TSH 0.029 (0.3-4.5)
• Free T4 1.50 (normal), Free T3 3.7 (normal)

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Imaging Findings

• EKG Atrial Fibrillation with a rate of 115, left
  anterior fascicular block, q-waves in V1-V2
• Chest X-Ray cardiomegaly, low lung volumes, mild
  pulmonary vascular congestion
• Transthoracic Echocardiogram
• moderate left atrial dilatation
• severe right atrial dilatation and right
  ventricular dilatation
• ejection fraction 55
• severe mitral insufficiency and tricuspid
  insufficiency
• pulmonary hypertension with a PA systolic
  pressure of 55 mmHg
• probable patent foramen ovale
• dilated IVC and hepatic veins

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Working Diagnosis

• Acute Coronary Syndrome
• CHF Exacerbation secondary to medication
  non-compliance
• Atrial Fibrillation with a rapid ventricular rate
  causing demand ischemia
• Hyperthyroidism, untreated
• Metastatic Breast Cancer with pulmonary
  metastasis
• Pulmonary Embolism

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Hospital Course

• Hospital Day 1
• The patient was admitted in the early evening by
  a resident called in to assist with the large
  volume of admissions to the Internal Medicine
  service that day
• The resident who admitted the patient was
  expected to admit several other patients, then
  leave the hospital for the night in anticipation
  that his/her services would be needed the next
  day
• After the resident completed the admissions, they
  were handed off to one of the regularly scheduled
  night float admitting residents. This case was
  not thoroughly signed out because of time
  constraints.
• The admission was handed off again the next
  morning to the daytime admitting resident, who
  received six new admissions. There was very
  little exchange of information between the two
  residents regarding the patients history of
  medication non-compliance and symptoms.
• The day team did not have adequate time in the
  morning to obtain a full history on each of their
  six new overnight admissions. They also did not
  thoroughly review all this patients medication
  orders.

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Hospital Course

• Hospital Day 2
• The patient had been started on oral Metoprolol
  the night of admission because of her rapid
  ventricular rate. She was also started on her
  outpatient oral Furosemide dose.
• The patients heart rate was down to 70 bpm when
  the day team evaluated the patient. She was now
  requiring 2 L nasal cannula to maintain an oxygen
  saturation of 96. She had crackles mid-way up
  both lung fields on exam.
• Several hours later, the team was called to
  evaluate the patient for worsening shortness of
  breath and hypoxia, with an oxygen saturation of
  70.
• The patient was placed on a 50 facemask, and her
  oxygen level improved to 93.
• Stat CXR revealed interval development of a
  moderate right sided pleural effusion and
  worsening pulmonary vascular congestion.
• The patient was switched to IV Furosemide, with
  adequate diuresis and improvement in symptoms.
• The Metoprolol was stopped immediately.
• The patient was moved to the observation unit for
  close monitoring.

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Hospital Course

• Hospital Day 3
• The patient continued to received IV Furosemide
  with appropriate diuresis.
• She no longer required a facemask for
  supplemental oxgyen.
• She was moved out of the observation unit.
• Hospital Day 4
• The patients shortness of breath significantly
  improved, and she was able to ambulate without
  developing dyspnea.
• She was started on oral Furosemide.
• Her beta-blocker was restarted at a lower dose.
• Hospital Day 5
• The patient was discharged home. She was
  instructed to adhere to her medication regimen
  and was scheduled for close outpatient follow-up.

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Final Diagnosis

• CHF Exacerbation in the setting of medication
  non-compliance.