1. Medical Grand Rounds Clinical Vignette Jessica Lambert, MD Third Year Resident April 8, 2009

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

3. 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 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.

4. 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 Aspirin 81 mg daily Propylthiouracil 100 mg three times daily

5. 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

6. 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)

7. 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

8. 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

9. 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.

10. 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.

11. 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.

12. Final Diagnosis CHF Exacerbation in the setting of medication non-compliance.