Case 21 — Hospitalization

One Day After Presentation

Problem #1 (HCM): Freckles is more depressed. Knuckling on right front leg; right front paw cool and painful — consistent with a new right subclavian thromboembolus. Chemistry: mild azotemia (Cr 2.5, BUN 49); ALT 539, AST 399 (likely muscle necrosis from thromboembolism, not hepatic damage). Spontaneous contrast in LA indicates ongoing risk. Plan: continue ICU monitoring, passive range of motion (now including right front), continue heparin, discontinue Lasix this evening.

Problem #2 (saddle thrombus): Femoral pulses now palpable bilaterally. Voluntary movement of hind limbs and tail; limbs warmer. The saddle thrombus is being broken down. Plan: continue passive ROM and heparin.

Problem #3 (right subclavian TE): Small clots often embolize to the right front leg (brachiocephalic trunk is the first branch off the aorta). Plan: passive ROM and heparin.

Two Days After Presentation

Freckles is much better — eating, drinking, walking normally. Femoral pulses present. Saddle thrombus and right subclavian TE both resolved. Temperature spiked to 104°F overnight but now 102.1°F. Moved back to wards. ECG: atrial fibrillation with PVCs. Repeat echo: large amount of spontaneous contrast in LA.

Plan: Start warfarin 1 mg PO SID; continue heparin 1000 U SQ for 3 more days (cover initial hypercoagulable phase). Start atenolol ¼ of 25 mg PO. Continue Lasix 6.25 mg PO BID and enalapril 1.25 mg PO BID.

Three Days After Presentation

Bright and alert. Eating well. Walking normally. HR 140, irregularly irregular (still in AF but rate has slowed). No new thromboembolic events. Plan: send home this afternoon.

Discharge Instructions

  • Freckles has severe HCM, systemic thromboembolism, and atrial fibrillation. He lysed his saddle thrombus but continues to produce more clots.
  • Medications: Lasix 6.25 mg PO BID; enalapril 1.25 mg PO SID; atenolol 6.25 mg PO BID; warfarin 0.5 mg PO SID; heparin 1000 U (1 ml) SQ q8h for 3 days.
  • Monitor for respiratory difficulty, coughing, extreme pain, drastic changes in mentation, or overt bleeding.
  • Warfarin carries risk of severe bleeding complications. Return Monday evening for clotting time recheck 2 hours after warfarin dose.
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