Table 1.
Correlation of the relevant clinical findings, laboratory data and therapeutic interventions
| Clinical sign/ investigation/intervention |
Admission time line (days after admission) | |||||||||
| Days after admission | 0 | 2 | 3 | 4 | 5 | 9 | 11 | 14 | 27 | 88 |
| Metolazone | 2.5 mg one time a day | 2.5 mg one time a day | 2.5 mg one time a day | 2.5 mg one time a day, last dose. | ||||||
| Furosemide | 20 mg intravenously three times a day | 20 mg intravenously three times a day | 20 mg intravenously three times a day, extra 40 mg intravenously was given for acute overload. | 20 mg intravenously three times a day | 40 mg intravenously two times a day | 40 mg intravenously two times a day until day 13 | 80 mg PO two times a day until day 15 | 40 mg PO two times a day | 20–40 mg PO PRN | 20–40 mg PO PRN |
| Spironolactone | Held | Resumed 25 mg one time a day | 25 mg one time a day | 25 mg one time a day | 25 mg one time a day | 25 mg one time a day | 25 mg one time a day | |||
| D5W | 80 mL/h for 8 hours, stopped due to overload. | Held | 80–120 mL/hour | 80–120 mL/hour | 80–120 mL/hour stopped day 12 | |||||
|
Sacubitril/ valsartan |
Held | Resumed 24/26 mg two times a day | 24/26 mg two times a day | |||||||
| Bisoprolol | Held | Resumed 2.5 mg one time a day | 2.5 mg one time a day | 2.5 mg one time a day | 2.5 mg one time a day | 2.5 mg one time a day | 2.5 mg one time a day | |||
| NYHA | IIIb | IIIa | IV | IIIa | IIIa | IIIa | II | II | II | II |
| Extremity oedema | +++ | +++ | ++++ | ++ | ++ | ++ | + | – | – | – |
| AJR* | ++ | + | +++ | + | + | + | + | + | -/ND | -/ND |
| Walking test | Frail, unable. | Frail, unable. | Frail, unable. | Frail, unable. | Frail, unable. | Exertional desaturation | ++ | ++ | +++ | +++ |
| Weight (kg)** | ND | ND | ND | 73.2 | 75 | 76 | 69.9 | 69.5 | 69.5 | 70 |
| O2 saturation | 94% | 98% | 95% | 92% | 92% | 90% | 90% | 92% | 95% | ND |
| Oxygen (L/min) | 4 | 2 | 1 | RA | RA | RA | RA | RA | RA | RA |
| Days after admission | 0 | 2 | 3 | 4 | 5 | 9 | 11 | 14 | 27 | 88 |
| Serum BNP (pg/mL) | 469 | 148 | 76 | 106 | ||||||
| Serum Cr (μmol/L) | 225 | 259 | 258 | 221 | 210 | 199 | 207 | 183 | 160 | 153 |
| Serum Na (mEq/L) | 138 → 147 on day 3 | 152 → 150 post D5W | 154 after stopping D5W | 156 | 152 → 145 on day 8 | 146 | 145 | 147 → 142 on day 18 | 139 | 141 |
| Serum osmolality (mmol/kg) | 361 | 342 → 336 on day 9 | 347 | 340 | ||||||
| Serum K (mEq/L) | 6.2 | 5.1 | 4.9 | 4.6 | 4.5 | 5.3 | 4.3 | 4.4 | 4.2 | 4.1 |
| Serum Cl (mEq/L) | 115 | 122 | 119 | 125 | 118 | 104 | 100 | 102 | 101 | 104 |
| Serum bicarbonate (mmol/L) | 22 | 24 | 25 | 28 | 28 | 30 | 34 | 32 | 27 | 24 |
| Venous pH | 7.27 | 7.50 | 7.36 | |||||||
| Serum urea (mmol/L) | 41 | 34.4 | 33.9 | 21 | ||||||
| Urine Na (mmol/L) | 19 | 101, 9 hours post MTZ | 105 | 108 | 15 | |||||
| Urine Cr (mmol/L) | 6.2 | 3.9 | 3.7 | 4.1 | 8.8 | |||||
| Urine K (mmol/L) | 4.9 | 18.9 | 20.9 | 19.2 | 54.8 | |||||
| Urine Cl (mmol/L) | 118 | 100 | 105 | |||||||
| Urine urea (mmol/L) | 159 | 150 | 289 | |||||||
| Urine osmolality (mOsm/kg) | 434 | 411 | 391 | |||||||
Some of these data are also presented in figure 3.
*AJR was used instead of jugular venous distention as the patient has severe pulmonary hypertension and severe tricuspid regurgitation with a large cv wave.
†Baseline weight 1 year before presentation was 68.3 kg.
AJR, abdominal jugular reflex; Cl, chloride; Cr, creatinine; D5W, dextrose 5% water; iv, intravenously; K, potassium; MTZ, metolazone; Na, sodium; ND, not documented; NYHA, New York Heart Association classification of dyspnoea; PO, peroral; PRN, as required; RA, room air.