Aaron Turner: The Case

Physical exam: 

Test	Result
T	98.1
HR	72
BP	185/100
SpO2	94%
Weight	245 lbs (up 30 lbs compared to 3 months ago)
BMI	30

Gen: Ill-appearing but not distressed.
HEENT: + JVD to angle of jaw at 60 degrees elevation. Mucous membranes moist and pink. 
CV: S3 heard at lower sternal border, rhythm regular. Pulses strong in all 4 extremities.
Pulm: Rales at the lung bases bilaterally. No dyspnea with ambulating to the exam room or conversation.
Abd: No bruits, no organomegaly appreciated. Bladder not palpable. Bowel sounds present. No pain with palpation. Rectal exam shows normal tone, normal prostate and brown stool. 
Ext: 2+ pitting edema to knees bilaterally.
MSK: No muscle tenderness with palpation.
Back: No costovertebral angle tenderness with percussion.
Skin: No lesions noted.

 

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His primary care physician orders a basic metabolic panel and says she will call the patient with the results in a day or two.

These test results return in the evening, and the on-call physician is notified of the following results:

Lab Results 9/9 @ 1445

Test	Value
Sodium	146 mEq/L
Potassium	6.7 mEq/L
Chloride	118 mEq/L
Bicarbonate	16 mEq/L
BUN	85 mEq/L
Creatinine	5.1 mg/dL
Glucose	78

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The on-call physician checks the patient's electronic health record.

Comparison of Lab Results from 7/9 and 9/9

Test	9/9 @ 1445	7/9 @ 1400
Sodium	146	145
Potassium	6.7	4.1
Chloride	118	119
Bicarbonate	16	25
BUN	85	30
Creatinine	5.1	1.1
Glucose	78	90

She calls the patient and tells him to go straight to the ER. The patient asks if he can just be seen in the morning, but the physician is not comfortable waiting due to the elevation of his potassium and insists he go to the ER immediately. She then phones ahead to the ER to tell the ER physician that the patient is coming in and the reason for referral as well as to report his baseline labs several months prior.

 

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The ER physician sees Mr. Turner after he has been triaged and repeats the physical exam, with no notable changes from the examination performed by the primary care physician earlier in the day. 

He orders several additional laboratory tests, an EKG and imaging.

The EKG comes back first:

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Lab Test	9/9 @ 2130	9/9 @ 1445	7/9 @ 1400
WBC	11,000
Hgb	9.1
Hct	27.3
Platelets	331000
MCV	83
RDW	14.1
Sodium	146	146	145
Potassium	7.1	6.7	4.1
Chloride	116	118	119
Bicarbonate	14	16	25
BUN	90	85	30
Creatinine	5.0	5.1	1.1
Glucose	89	78	90
ESR	8
CRP	3
C3	66
C4	20
BNP	530
Troponin I	0.061
CK	Normal
Myoglobin	Normal
Urinalysis
Specific gravity	1.015
pH	6.3
color	yellow
Protein	3+
Occult blood	negative
Nitrate	negative
Leukocyte esterase	negative
RBC	0
WBC	0, occasional granular casts seen
Urine creatinine	100 mg/dL
Urine urea	700 mg/dL
Urine sodium	100 mg/dL
Urine microscopy	Renal tubular cells and renal tubular cell casts

 

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The ER physician places the following orders IV calcium gluconate 6.8 mmol, iv sodium bicarbonate 50mEq, and IV insulin and dextrose, and places the patient on telemetry.

An ultrasound of his kidneys and bladder is ordered.  The US demonstrates normal-sized kidneys without hydronephrosis and, as the patient can void without difficulty, a bladder post-void residual is measured and found to be low.

The ER physician then calls the ICU team for admission.

The critical care team admits him to the ICU for hypertensive emergency and holds all of his home medications. 

Intravenous nicardipine and esmolol infusions are started while nifedipine, isosorbide dinitrate, and hydralazine are titrated for blood pressure control.

During the night, Mr. Turner develops dyspnea and his oxygen saturations drop to 88%.  He is placed on oxygen and nephrology and cardiology are consulted.  They recommend adding IV furosemide, which is started.

8 hours after the initiation of treatment in the ER, his potassium is 6.0, his BUN and creatinine are 37 and 3.1, respectively and his EKG changes are trending towards normal.

His telemetry continues to be normal.

His input/output is monitored and he has a net negative fluid balance of 2 liters per day.

His intravenous medications are converted to PO.

 

Selected labs are shown below:

Lab Results 9/11 @ 1400

Lab	Result
Sodium	140
Potassium	4.8
Chloride	100
Bicarbonate	25
BUN	31
Creatinine	2.9
Glucose	85

His follow up chest x-ray is shown below:

He is transferred out of the ICU, but will continue to have telemetry monitoring.

A 2D echocardiogram shows left ventricular hypertrophy and dilation with a decreased ejection fraction and impaired diastolic function. 

The cardiologist tells Mr. Turner that he has a form of heart failure most likely due to his longstanding hypertension. 

The nephrologist tells him that he appears to have underlying kidney disease from hypertension and that he got sick because he had a worsening of his kidney function due to multiple factors. 

He is advised to receive vaccinations before leaving the hospital and told he will need regular monitoring by his kidney doctor and cardiologist every 3 months for the foreseeable future. 

He is discharged on oral nifedipine, hydralazine, isosorbide dinitrate, and furosemide with follow-up in one week with cardiology and nephrology.  He is also made an appointment to see a nutritionist and follow up with his primary care physician regarding his desire to resume exercising, lose weight and alternative ways of managing his back pain. For now, acetaminophen is recommended.