Case 2:

Initial Impression: CHF NIF, Non-obstructive CAD, s/p Coronary Angiography, HCVD, T2DM, CKD,
Cardiac Dysrhythmia (High grade AV block)

F.B. a 73 year old female came in for Pacemaker insertion due to high grade AV block. She underwent
pacemaker insertion without complications. She was transferred to telemetry for post-procedural care.
Few hours later, she complained of chest discomfort and DOB. On physical examination, BP was 160/90,
HR 120, O2 sat 70%, distended neck veins,bilateral coarse crackles. Patient was hooked to O2 at
10LPM/NC. She was given Furosemide. ECG was done and revealed AF-RVR. She was started on
Amiodarone drip. Chest xray showed bilateral pulmonary congestion. Impression during that time was
Acute Pulmonary Edema secondary to Cardiac Dysrhythmia. Few minutes later, patients BP was noted
to be low hence, norepinephrine drip was started. ABG at 10LPM showed partially compensated
metabolic and respiratory acidosis w/ more than adequate oxygenation.
On the 2nd hospital day, CBC was done and showed leukocytosis and bandemia. Creatinine was also
elevated at 258 and potassium levels were elevated at 7.2mmol/L. With this result, and urine output was
noted to be decreasing, thus referred to Nephro service. Initial impression was Acute Kidney Injury
secondary to renal hypoperfusion. Nephro service titrated levophed to maintain BP > 120. Due to
decreasing UO, dopamine drip was started. BP was noted to be 90/60 despite dopamine and
norepinephrine drip, hence dobutamine drip also started. On that same day, discoloration of the right
hand was also noted. Doppler was done, no signal of right ulnar and radial artery noted. Patient was
referred to vascular cardilogy service. Impression was Acute limb ischemia category IIa of right hand
probably cardioembolic. She was started on Heparin drip. On the 3rd hospital day, patient was started on
dialysis due to continues elevation of creatinine level and decrease urine output. Arterial study of upper
extremities was done which revealed Atherosclerotic upper extremity arterial disease with no
hemodynamically significant stenosis bilaterally. DVT screening was also done which revealed positive for
superficial vein thrombosis of right cephalic vein of forearm, probably subacute. During HD, BP was 90-
100/40. Pitressin was started. After a few hours, BP became 70/40, inotropes were increased, standby
intubation. On the 4th hospital day, patient was unresponsive to painful stimulus, gasping, labored
breathing with desaturation. Relatives were undecided regarding intubation. Pitressin drip was tapered.
Cordarone drip was hooked. Patient was placed on DNR status. Patient was then referred to Infectious
disease due to fever, increased bands (22 on 3rd hospital day and 26 on 4th hosp day) and WBC (15.4
on 3rd hosp day and 26 on 4th hosp day). Impression was septic shock secondary to ischemic limb
gangrene. Infectious service suggested to start Vancomycin. However, patients relative opted to
discharge against medical advice.

Final Diagnosis: Cardiogenic shock secondary to acute decompensated heart failure s/p PPI (2/1/2017),
Acute Kidney Injury secondary to renal hypoperfusion & septic shock secondary to ischemic limb
gangrene, Acute Limb Ischemia IIa, right hand probably cardioembolic, DVT of the superficial vein of right
forearm, probably subacute, HCVD, Non-obstructive CAD s/p Coronary Angiography, T2DM