LAUSR

ACCOMPANIED by her husband, Mrs. J, 64, arrives in the ED via ambulance. At the scene, her husband reported that he woke at 0430 to find his wife confused. Mrs. J was last seen in her usual state of health at 2300 the night before, when she said goodnight to her husband. Mrs. J’s husband states that she was recently diagnosed with heart failure (HF) and started on enalapril, metoprolol, and furosemide. He adds that because the furosemide was causing urinary frequency, she stopped taking it several days ago. He also says he’s unsure of her adherence with the other prescribed medications and states that her last weight was 144.5 lb (65.7 kg) 2 days ago. Her weight today is 149.5 pounds (67.9 kg). He also shared concerns over her nonadherence to her prescribed low sodium diet. Mrs. J is confused to place and time, and complaining of a frontal headache (5/0-10) and nausea. Her vital signs are as follows: oral temperature, 97.9 ̊ F (36.6 ̊ C); heart rate, 115 beats/minute and regular; respirations, 28 regular and slightly labored; SpO2, 98% on supplemental oxygen at 2 L/min via nasal cannula; and BP supine, 102/58 mm Hg. She’s placed on continuous cardiac monitoring, which shows sinus tachycardia. Physical assessment findings include 1+ bilateral lower extremity pitting edema, bibasilar inspiratory crackles, and bilateral neck vein distension at 30 degrees. Her lab results include: random plasma glucose, 89 mg/dL (normal, less than 140 mg/dL); cardiac troponin T, <0.01 ng/mL (normal, <0.2 ng/mL); serum sodium, 126 mEq/L (normal, 135-145 mEq/L); serum osmolality, 265 mOsm/kg (normal, 280-300 mOsm/kg); urine osmolality, 115 mOsm/kg (normal, 300-900 mOsm/kg); and urine sodium 18 mEq/L (normal, >20 mEq/L).1-3 Mrs. J’s ECG demonstrates sinus tachycardia without signs of ischemia or infarction. The chest X-ray shows