1. NYU Medical Grand Rounds Clinical Vignette Justin Simmons, M.D. Class of 2012 3/27/2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Previous MedicationsDischarge Medications Furosemide 160mg BIDFurosemide 80mg BID Lisinopril 40mg dailyLisinopril discontinued Carvedilol 3.125mg BID Spironolactone 25mg daily

4. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. 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 dailysucralfate 60mg three times daily carvedilol 3.125mg twice dailyesomeprazole 40mg twice daily spironolactone 25mg daily ferrous sulfate 325mg twice daily simvastatin 20mg nightlycalcium carbonate twice daily warfarin 2mg nightly U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Other Studies ECG: paced at 72bpm. Chest X-Ray: stable cardiomegaly without evidence of focal consolidate, volume overload, or cardiopulmonary pathology U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Iatrogenic hypovolemia complicated by hypotension, acute kidney injury and hyperkalemia. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Iatrogenic hypovolemia with acute kidney injury and hyperkalemia. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS