Chief Complaint: “fall and weakness in my legs”

HPI

71 y.o. male, full code, PMH chronic hypotension on midodrine 15mg TID, s/p bioprosthetic MVR, AVR 2010, afib on warfarin, ascending thoracic aneurysm, ESRD on hemodialysis since 2012 (M/W/F), HLD, right lower extremity limb ischemia s/p embolectomy and fasciotomy in 06/2019 who presented to the ED BIBEMS s/p witnessed mechanical fall at home. At the time of presentation, the patient denied any head trauma, LOC, or dizziness, CTH negative. Patient states that after the fall he was unable to get up secondary to lower extremity weakness prompting family to call EMS. Patient reports that he uses a walker at baseline and is proficient with his ADLs. In the ED patient was found to be hypotensive with systolic BP in the 60s and endorses a history of chronic hypotension at home with readings in 70/50s. Patient admitted to medicine for workup of altered mental status with systolic BP in the 60s and subsequently admitted to MICU for acute hypercarbic respiratory failure requiring NIV & presumed cardiogenic shock requiring vasogenic support.

MICU COURSE

Patient lethargic, however arousable, alert and oriented x2 on MICU admission. Left IJ TLC placed patient subsequently started on levophed and vasopressin to maintain MAP 50-60. Right shiley placed and patient underwent CVVHD with negative balanced removed. Overnight (11/1) patient noted to have oozing from shiley and TLC sites, DDAVP administered. Repeated Hgb stable and INR 2.8 s/p 1 FFP at that time. Overnight patient weaned off of NIPPV to HFNC, tolerating well. Patient evaluated this morning with the MICU team at bedside appears to be more awake and alert to person, place and time. Patient noted to be tachycardic to 130s, amnioderone drip started with decrease in heart rate. Will continue to titrate vasogenic agents as tolerated.

PMH

Biosynthetic mitral and aortic valves

ESRD on dialysis

Chronic hypotension

Ascending thoracic aortic aneurysm

Atrial fibrillation

HLD

Right lower leg ischemia

PSH

Biosynthetic mitral valve and aortic valve replacement (2010)

Left AV fistula creation (2012)

Right lower extremity embolectomy with fasciotomy (2019)

MEDS

Cyanocobalamin 1000mcg PO qd

Famotidine 20mg PO qd

Midodrine 15mg PO TID

Acetaminophen 650mg PO prn

Norepinephrine DRIP 10mcg/min

Docusate-Senna 2 tablet PO at bedtime

Polyethylene glycol PO 1 packet qd

Vasopressin DRIP 0.04UNIT/min

Heparin 1200UNIT/hr

FHx

Father: heart disease, diabetes, deceased at 74

Mother: diabetes, deceased at 81

Brother: MI, diabetes alive 67

Children: alive and well

SHx

Patient is married with two children is a retired MTA employee and lives at home with his wife. He denies any past tobacco or illicit drug use and admits occasional social alcohol use with 1-2 drinks per week. He denies any recent travel or known sick contacts.

ROS

• Constitutional: negative for fever and chills, but admits weakness x 2 days, appetite is unchanged
• HEENT:
• Eyes: no recent changes in vision, photophobia, glasses used for reading
• Ears: hearing intact
• Nose: no epistaxis or obstruction
• Mouth and throat: no ulceration, hx of candidiasis, denture use
• Neck: no lumps, localized swelling or stiffness
• Respiratory: exertion SOB, occasional dry cough, denies wheezing, hemoptysis, PE, pneumonia, TB or TB exposure
• Cardiac: there is a known heart murmur with b/l LE edema (R>L) no recent CP, palpitations, or syncope
• GI: denies abdominal pain, constipation, diarrhea, nausea or vomiting
• GU: denies urinary frequency, urgency, dysuria, or hematuria
• Musculoskeletal: denies myalgias
• Skin: reports RLE wound secondary to embolectomy performed in 06/2019, denies rash
• Neurological: negative for headaches or visual changes

PE

• VS: BP 67/48 right arm, supine; pulse 128 irregularly irregular; O₂ sat 97% HFNC; respirations 22/min; temp 98.7°F oral
• Patient awake, alert and oriented x3, conversive, more awake than 1 day prior
• HEENT: normocephalic atraumatic, EOMI, anicteric sclera, face symmetric, oropharynx clear and moist, HFNC
• Neck: FROM, trachea midline, no palpable cervical adenopathy, no stidor
• Heart: tachycardic, irregularly irregular rhythm, murmur appreciated at left upper sternal border
• Lungs: distant lung sounds, no wheezing, ronchi, crackles
• Abdomen: soft, nontender, bowel sound active, no rebound/guarding, no CVA tenderness
• Extremities: 2+pitting edema in RLE, 1+ in LLE, distal LE and UE cool to touch, distal pulses intact bilaterally
• Skin: right medial and lateral lower extremity wound s/p embolecomy 06/2019 with clean margins, no purulence or wound drainage noted, clubbing and cap refill > 2sec throughout
• Neuro: grossly intact, moving 4 extremities, follows commands, AO x 3, diffusely weak

LABS

CBC: WBC 11.09, Hgb 10.3, Hct 32.2

CMP: Na⁺ 134, Cl^– 96, K⁺ 5.0, BUN/Cr 28.1/3.90, Anion gap 18

LFTs: direct bili 0.5

ABG: pH 7.301, PCO₂ 47.7, PO₂ 125.0, HCO₃ 22.8

IMAGING

FINDINGS

Left Ventricle: Normal LV systolic function. Estimated EF 60-65%.Concentric LV remodeling.

Right Ventricle: Markedly dilated right ventricle with reduced systolic function. Interventricular septal flattening during systole and diastole consistent with RV pressure overload.

Left Atrium: Severely dilated left atrium.

Right Atrium: Dilated right atrium.

MISCILLANEOUS

The aortic root and proximal ascending aorta are markedly dilated, measuring approximately 6.5 cm and 6.2 cm, respectively.

The aortic arch is markedly dilated, measuring approximately 6.8 cm.

Aortic Valve: There is a bioprosthesis in the aortic position. It is not well seen on short axis views. There is no obvious paravalvular or central aortic regurgitation. Doppler suggests a non-obstructive prosthesis.

Mitral Valve: There is a bioprosthesis in the mitral position. In PLAX views, the posterior leaflet appears thickened with at least mildly restricted opening. At least mild-moderate mitral regurgitation (origin not well seen). Mean mitral gradient 12 mmHg and peak velocity 2.6 m/s at a heart rate of 79 bpm, concerning for an obstructed mitral prosthesis.

Tricuspid Valve: Tricuspid valve appears grossly normal. Severe tricuspid regurgitation.

Pulmonary artery pressure was estimated to be at least 53 mm HG which is consistent with moderate pulmonary hypertension.

Pulmonic Valve

Pulmonic valve not well seen.

DDX

• Acute aortic or mitral valve insufficiency
• Dissection of the ascending aorta
• Pulmonary embolism

ASSESSMENT: 71 y/o M from home PMH of chronic hypotension, HLD, ESRD on HD M/W/F via right AV fistula, s/p bioprosthetic MVR and AVR, a.fib on warfain admitted to MICU for the management of acute hypercarbic respiratory failure and cardiogenic shock requiring vasogenic support.

PLAN

1. Neuro:

• No active issues.
• CTH: no acute intracranial abnormality.
• Maintain fall and aspiration precautions.
• Neuro checks q2h

2. CVS:

• Cardiogenic shock requiring Norepinephrine and Vasopressin.
• Titrated as tolerated to maintain MAP 50-55.
• CTA Chest A/P: Aneurysmal aortic root/proximal ascending thoracic aorta (6.7 cm).
• Proximal right femoral artery occlusion/severe stenosis. Vascular consulted, recommended no acute surgical intervention.

3. Pulm:

• Acute hypercarbic respiratory failure requiring Bipap, now transitioned to Hiflo.
• Trend ABG and titrate FIO2 as tolerated.
• CXR: Bibasilar atelectasis with interval prominence of the pulmonary vasculature suggestive of edema. Increasing small bilateral pleural effusions.

4. GI:

• No active issues.
• Advance diet as tolerated.

5. Renal/Electrolytes:

• Acute on chronic CKD.
• Continue on CVVHD via right femoral shiley to maintain negative balance.
• Replete electrolytes PRN

6. Endocrine:

• Hemoglobin A1C 5.8.
• Monitor FS, insulin sliding scale PRN to keep glucose less than 180mg/dL.

7. Infectious Disease:

• Afebrile, WBC 11.09, lactate 1.5, all cultures negative, no signs of infection.
• Monitor off antibiotics.

8. DVT prophylaxis: On Coumadin for A.fib/Bioprosthetic MVR.

• Dose Coumadin daily based on INR to keep level 2-3.