Download Clinical Vignette - Clinical Correlations

Medical Grand Rounds
Clinical Vignette
Jessica Lambert, MD
Third Year Resident
April 8, 2009
Chief Complaint
• A 75 year old female complains of
progressively worsening shortness of breath
and lower extremity edema that developed
over the past month.
History of Present Illness
• The patient‘s 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 betablocker 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.
Additional History
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Past Medical History
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Past Surgical History
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30-pack year smoking history, quit several years ago
Denies alcohol and illicit drug use
Lives alone without home services
Family History
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Lumpectomy
Social History
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Diastolic Heart Failure
Atrial Fibrillation
Hyperthyroidism
Osteoarthritis
Breast Cancer treated with Trastuzumab therapy
Non-contributory
No Known Drug Allergies
Medications (Non-Compliant with all medications listed below)
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Furosemide 40 mg twice daily
Lisinopril 5 mg daily
Metoprolol 50 mg twice daily
Aspirin 81 mg daily
Propylthiouracil 100 mg three times daily
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
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)
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:
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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
Working Diagnosis
• Acute Coronary Syndrome
• CHF Exacerbation secondary to medication noncompliance
• Atrial Fibrillation with a rapid ventricular rate
causing demand ischemia
• Hyperthyroidism, untreated
• Metastatic Breast Cancer with pulmonary
metastasis
• Pulmonary Embolism
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 patient’s 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 patient’s medication orders.
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 patient’s 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.
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 patient’s 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.
Final Diagnosis
• CHF Exacerbation in the setting of medication
non-compliance.