Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 1: Heart Failure, CKD, and Diabetes with Competing Treatment Priorities
Clinical Presentation
Patient Demographics: 74-year-old male
Chief Complaint: "My legs are swelling and I'm short of breath"
History of Present Illness: Mr. Rodriguez is a 74-year-old male with a complex medical history who presents with 1 week of progressive bilateral lower extremity edema, orthopnea requiring 3 pillows to sleep, and dyspnea on exertion now limiting him to walking only 1 room before needing to rest (previously able to walk around the block). He also reports a 6-pound weight gain over 10 days despite "trying to take his water pill." He denies chest pain, fever, or cough. He notes he has been eating more salty foods recently due to poor appetite for his usual low-sodium diet.
Past Medical History:
- Heart failure with reduced ejection fraction (EF 30%, ischemic cardiomyopathy)
- Chronic kidney disease stage 4 (baseline creatinine 2.8 mg/dL, eGFR 22)
- Type 2 diabetes mellitus (A1c 8.2%)
- Atrial fibrillation on anticoagulation
- Hypertension
- Gout
- Moderate aortic stenosis
- Peripheral vascular disease
- History of falls (2 in past 6 months)
Medications (18 medications total):
- Carvedilol 25 mg BID
- Lisinopril 20 mg daily
- Furosemide 80 mg BID
- Spironolactone 25 mg daily
- Apixaban 5 mg BID
- Metformin 500 mg BID (should be stopped given CKD)
- Glipizide 10 mg BID
- Insulin glargine 20 units nightly
- Atorvastatin 80 mg daily
- Aspirin 81 mg daily
- Allopurinol 100 mg daily
- Amlodipine 10 mg daily
- Omeprazole 20 mg daily
- Iron sulfate 325 mg daily
- Calcium carbonate 500 mg TID
- Vitamin D 1000 IU daily
- Gabapentin 300 mg TID
- Oxycodone 5 mg PRN
Social History:
- Retired mechanic
- Lives with wife (also elderly with mild dementia)
- Daughter visits weekly
- No longer drives
- Uses a cane for ambulation
Physical Examination:
- Vital Signs: Temperature 36.8C, HR 78 bpm (irregular), BP 142/86 mmHg, RR 20/min, SpO2 93% on room air, Weight 98 kg (baseline 92 kg)
- General: Elderly male in mild respiratory distress when lying flat
- Cardiovascular: Irregularly irregular rhythm, III/VI systolic ejection murmur at RUSB, JVP 14 cm H2O, positive hepatojugular reflux
- Lungs: Bibasilar crackles to mid-lung fields
- Abdomen: Soft, mildly distended, no tenderness
- Extremities: 3+ pitting edema to thighs bilaterally, cool feet with diminished dorsalis pedis pulses
- Neurologic: Alert and oriented, no focal deficits
Problem Prioritization Framework
Life-Threatening/Urgent:
- Acute decompensated heart failure with volume overload
Symptom-Causing (High Priority):
- Dyspnea and edema affecting quality of life
- CKD with potential worsening from diuresis
Potentially Reversible:
- Hyperglycemia management
- Medication optimization (polypharmacy)
Chronic/Stable (Lower Priority for Acute Visit):
- Atrial fibrillation (rate controlled)
- Gout (not currently flaring)
- Aortic stenosis (moderate, monitoring)
Inpatient Workup
Laboratory Studies:
- BNP 2,840 pg/mL (significantly elevated)
- Sodium 132 mEq/L
- Potassium 5.4 mEq/L
- BUN 68 mg/dL, Creatinine 3.4 mg/dL (baseline 2.8)
- eGFR 18 mL/min
- Hemoglobin 9.8 g/dL
- A1c 8.2%
- Glucose 186 mg/dL
- INR 1.1 (subtherapeutic - patient admits missing apixaban doses)
- TSH 2.4 mIU/L
- Iron studies: Ferritin 42 ng/mL, TSAT 15%
Imaging:
- Chest X-ray: Cardiomegaly, bilateral pleural effusions, pulmonary vascular congestion
- Echocardiogram: EF 25% (decreased from 30%), moderate MR, moderate AS (unchanged)
Competing Treatment Priorities Analysis
| Condition | Optimal Treatment | Conflict |
|---|---|---|
| Heart failure | Aggressive diuresis | Worsens CKD, causes AKI |
| CKD | Avoid nephrotoxins, limit diuretics | Limits HF treatment |
| Diabetes | Tight glycemic control | Hypoglycemia risk with CKD |
| Hyperkalemia | Hold spironolactone/ACE-I | These are key HF medications |
| Fall risk | Reduce sedating medications | Pain control needed |
| Anticoagulation | Continue for AFib | Bleeding risk with CKD |
Goals of Care Discussion
Eliciting Patient Values:
- "What matters most to you right now?"
- Patient response: "I want to be able to breathe and spend time with my grandchildren. I don't want to be in the hospital all the time."
Function-Focused Goals:
- Able to walk to the bathroom without stopping
- Sleep lying flat
- Maintain independence at home
Treatment Limitations Discussed:
- Patient does not want dialysis if kidneys fail
- Would want CPR attempted but not prolonged ICU stay on ventilator
- Willing to accept some decline in kidney function for better breathing
Treatment Plan
Immediate Management (with attention to competing priorities):
- Diuresis: IV furosemide 80 mg BID with close creatinine monitoring
- Accept some worsening of creatinine for symptom relief
- Goal: net negative 1-2 L/day
- Potassium management: Hold spironolactone temporarily, low-K diet
- Diabetes: Stop metformin (contraindicated with eGFR < 30), continue insulin, reduce glipizide (hypoglycemia risk with CKD)
- Anticoagulation: Resume apixaban (renal dose 2.5 mg BID given eGFR < 25)
Medication Reconciliation - Deprescribing Opportunities:
- Stop metformin (CKD contraindication)
- Reduce gabapentin dose (renally cleared, contributing to fall risk)
- Stop omeprazole (no clear indication, contributes to hypomagnesemia, CKD risk)
- Stop aspirin (on anticoagulation, no recent ACS - discuss with cardiology)
- Consolidate calcium/vitamin D timing
Care Coordination:
- Social work consult for home safety assessment
- PT/OT evaluation for fall prevention
- Home health referral for medication management
- Palliative care consult for goals clarification and symptom management
Clinical Image
Image Description: Chest radiograph demonstrating marked cardiomegaly with bilateral pulmonary vascular congestion and small bilateral pleural effusions, consistent with decompensated heart failure.
Image Source: Wikimedia Commons - "Congestive heart failure x-ray"
- URL: https://commons.wikimedia.org/wiki/File:Congestive_heart_failure_x-ray.png
- License: Public Domain