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Washington University Experience | NEURODEGENERATION | Hippocampal Sclerosis of Aging | 6A0 Case 6 History
Case 6 History ---- The patient was a 91 year old woman with chronic combined CHF due to severe mitral valvular regurgitation leading to cardiomyopathy, sick sinus syndrome s/p pacemaker placement, and CKD.. The patient developed mild to moderate dementia and was admitted, after presenting to ER, with a complaint of seeming "out of sorts" and "had tremors" on the evening in August 2018 when her daughter noted her to be confused. She started talking about deceased relatives as though they were alive and family events which had occurred several decades ago. Sometime later, she attempted to stand up independently but was too weak to do so. Her son-in-law assisted her to a standing position, but once upright, the patient began "shaking" and developed "tremors that wouldn't stop." She did not lose consciousness and "was staring off into space." The patient's appetite and energy level had declined in the past few days; she had been spending more time in bed/chair than previously. She had lost about 20 lbs over the past 10-14 days, some presumably due to dehydration. As a result adjustments were made to her diuretic regimen. In the ER, she was afebrile with normal vital signs. Her examination suggested volume depletion. Routine lab work in the ER revealed evidence of contraction alkalosis and hemoconcentration leading to acute metabolic encephalopathy. HCO3 was 44 mmol/L (up from 30 on 8/3/2018) and chloride was 77 mmol/L. BUN was double what it had been 10 days previously (43 --->89) though creatinine was slightly lower. NT-proBNP was ~16000 pg/mL (down from >19000 at the end of July and >34000 in early July). Head CT revealed no acute intracranial pathology. She failed to improve clinically with hydration. Due to her multiple comorbidities and failure to thrive her daughter requested transfer to home hospice care. In early October 2018 the patient became out of breath, her urine output started decreasing and she patient eventually died.
