#FridayCaseChallenge

A case challenge for you on this rainy Thursday.

I will present the case step by step with additional information provided  every ~24-72h. Please leave your thoughts in the comments, or can submit to the anonymous link.

CASE: A 59yo with severe ischemic CM (most recent EF <20%) presents to CUH ED with DOE, orthopnea, bendopnea, and PND. He has had 3 hospitalizations in the last 4 months for heart failure exacerbations. His initial lab work is notable for normal K, CO2, AG, and creatinine, CBC is wnl, normal lactate, TSH. He is afebrile, BP 140/75, HR paced at 70, and satting well on RA. he has 2+ pitting edema b/l, JVP 15cm, +HJR, his extremities are moderately cool to touch. Overall he appears chronically ill but stable for the floor.

his EKG is belowADHF

His home medications are as follows

amiodarone 400 qday, furosemide 40mg BID, carvedilol 25mg BID, clopidogrel 75mg, pravastatin 10mg, diltiazem 30mg q6h, ranolazine 1000mg BID, ISMN 30mg BID, digoxin 125mcg qday, pradaxa 150mg BID

He is taken to RHC on HD1 with numbers below.

Hemodynamics:

Right atrium: 14 mmHg
Right Ventricle: 40/8 mmHg
Pulmonary Artery: 39/18/26 mmHg
PCWP: 20 mmHg

NIBP: 114/ 75/ 88 mmHg
Heart Rate: 60
PA sat: 47 %
Pulse Ox: 96%
Hgb: 14.6 g/dL

Assumed Fick: cardiac output 2.8 L/min, index 1.37 L/min/m2
Thermodilution: cardiac output 2.8 L/min, index 1.36 L/min/m2

Day 1 questions- What Stevenson profile is this patient? What are your treatment options and how do his RHC numbers inform your decisions? What would you do with his home medicines? What conditions make thermodilution less accurate? What kind of device does have in place?

If you have further questions of the patient’s history or initial presentation please ask as well