1
NR570 — Common Diagnosis & Management
in Acute Care Practicum Comprehensive
Original Study Resource (2026–2027 Edition)
SECTION 1: CLINICAL REASONING CASES (5 Cases)
CASE 1: Acute Decompensated Heart Failure with Renal Compromise
Patient Presentation
HPI: 78-year-old male with known HFrEF (LVEF 30%), CKD Stage 3b (eGFR 38), presents with
progressive dyspnea over 3 days, orthopnea, 8-lb weight gain, and decreased urine output. He
ran out of furosemide 5 days ago.
Vitals: BP 168/94, HR 112 (irregularly irregular), RR 26, SpO2 88% on RA, T 36.8C
Exam: JVP elevated to angle of jaw at 45 degrees, bilateral basilar crackles to mid-lung fields, 2+
pitting edema to knees, S3 gallop, hepatomegaly. No chest pain.
Labs: BUN 68 mg/dL, Cr 2.8 mg/dL (baseline 1.9), K+ 5.6 mEq/L, Na+ 132 mEq/L, BNP 2,840
pg/mL, Hgb 9.8 g/dL, lactate 2.4 mmol/L. ABG: pH 7.28, PaCO2 48, PaO2 58, HCO3- 22.
Imaging: CXR — cephalization, bilateral pleural effusions, cardiomegaly (CTR 0.62). Bedside
echo: severe LV dysfunction, no pericardial effusion.
Guided Questions
Q1. What is your differential diagnosis (minimum 3)? Q2. What diagnostic studies would you
order immediately? Q3. What is your management plan (pharmacologic + non-pharmacologic)?
Model Answer with Clinical Reasoning Walkthrough
Differential Diagnosis:
1. Acute decompensated heart failure (ADHF), cardiorenal syndrome Type 1 — Most
likely. Volume overload + acute kidney injury from forward failure and venous
, 2
congestion. BNP >400 supports diagnosis. Cardiorenal syndrome is bidirectional: renal
congestion worsens GFR; AKI worsens volume retention.
2. Acute coronary syndrome precipitating decompensation — Must exclude. Elderly
patients often have "painless" ischemia. New AF with RVR may be secondary to ischemia
or cause of decompensation.
3. Pulmonary embolism — Dyspnea out of proportion, tachycardia, hypoxemia. Risk
elevated in HF and immobility.
4. COPD exacerbation / pneumonia — Crackles could represent infection; however, fever
absent and infiltrates not described.
Immediate Diagnostic Studies:
• 12-lead ECG (within 10 min) — Rule out STEMI, assess rhythm (AF with RVR confirmed),
evaluate for ischemic changes
• Troponin I/T (serial x3, 6-hour intervals) — Detect Type 2 MI from demand ischemia
• BNP/NT-proBNP (already obtained; trend if diagnosis uncertain)
• Chest CT angiography ONLY if PE pre-test probability intermediate/high AND patient
stable enough for transport
• Bedside lung ultrasound — B-lines profile confirming pulmonary edema; pleural
effusions quantified
• Urinalysis and urine sodium — Assess prerenal vs. intrinsic AKI (FeNa <1% supports
prerenal)
• LFTs, coagulation panel — Baseline before initiating GDMT
Management Plan:
Non-pharmacologic:
• Continuous telemetry, pulse oximetry
• Strict I&O, daily weights
• Sodium restriction <2 g/day, fluid restriction 1.5 L/day (hyponatremia present)
, 3
• Head-of-bed elevation 45 degrees, legs dependent to reduce venous return
• Consider CPAP/BiPAP if respiratory distress progresses (this patient is borderline)
Pharmacologic — Tiered Approach:
Tier 1: Decongestion (first 24 hours)
• Furosemide IV — Give 80 mg IV push (2x oral home dose). Given Cr 2.8 and concern for
diuretic resistance, consider furosemide infusion 10-20 mg/hr after initial bolus OR add
metolazone 2.5-5 mg PO daily for sequential nephron blockade. Monitor urine output
hourly; target >0.5 mL/kg/hr.
• Goal: Net negative 1-1.5 L/day. Avoid over-diuresis given AKI.
Tier 2: Afterload Reduction & GDMT Optimization
• Nitroglycerin IV — Start 10-20 mcg/min, titrate to SBP >110. Reduces preload and
afterload. CAUTION: Avoid if RV infarct, severe AS, or SBP <100.
• ACEi/ARB — HOLD initially due to AKI and hyperkalemia (K+ 5.6). Reassess after diuresis.
• Hydralazine/isosorbide — Consider if persistent hypertension and ACEi contraindicated.
Tier 3: Rhythm & Rate Control
• Diltiazem IV — 0.25 mg/kg IV push (15-20 mg) then 5-15 mg/hr infusion for AF with RVR.
AVOID in HFrEF if possible; amiodarone 150 mg IV over 10 min preferred if
hemodynamically stable but symptomatic. Beta-blockers CONTRAINDICATED in acute
decompensation.
• Anticoagulation per CHA2DS2-VASc once stabilized.
Tier 4: Renal Protection & Electrolyte Management
• Sodium zirconium cyclosilicate (SZC) 10 g TID or patiromer 8.4 g daily for K+ 5.6. If ECG
changes or K+ >6.5: calcium gluconate 1 g IV, insulin 10 U + D50 50 mL, albuterol neb.
• Avoid NSAIDs, contrast, nephrotoxins.
Tier 5: Escalation if Refractory
, 4
• Inotropes — Dobutamine 2.5-5 mcg/kg/min if persistent hypoperfusion (lactate >4, MAP
<65) AFTER diuresis. Milrinone avoided in AKI (renal clearance).
• Ultrafiltration — If diuretic resistance and volume overload persists despite above.
• Consult cardiology/heart failure team for advanced therapies.
Red Flags / Warning Signs That Change Management
Table
Red Flag Implication Immediate Action
SBP <90 mmHg Cardiogenic shock Stop vasodilators; start inotropes;
activate cath lab if ischemic
Altered mental status Cerebral Intubation, invasive monitoring,
hypoperfusion possible IABP/Impella
K+ >6.5 or ECG peaked T Life-threatening Calcium stabilization, insulin/glucose,
waves hyperkalemia emergent dialysis
Lactate >4 mmol/L with Peripheral Escalate to ICU; consider dobutamine;
cool extremities hypoperfusion rule out sepsis
New ST elevations STEMI Cath lab activation; management
shifts to ACS protocol
Oliguria <0.3 mL/kg/hr x Severe cardiorenal Nephrology consult; consider CRRT if
24 hr syndrome refractory
Common Pitfalls Students Make
1. Giving home dose furosemide PO in acute setting — Bioavailability is 50% PO vs. 100%
IV. Always convert to IV and increase dose in decompensation.
NR570 — Common Diagnosis & Management
in Acute Care Practicum Comprehensive
Original Study Resource (2026–2027 Edition)
SECTION 1: CLINICAL REASONING CASES (5 Cases)
CASE 1: Acute Decompensated Heart Failure with Renal Compromise
Patient Presentation
HPI: 78-year-old male with known HFrEF (LVEF 30%), CKD Stage 3b (eGFR 38), presents with
progressive dyspnea over 3 days, orthopnea, 8-lb weight gain, and decreased urine output. He
ran out of furosemide 5 days ago.
Vitals: BP 168/94, HR 112 (irregularly irregular), RR 26, SpO2 88% on RA, T 36.8C
Exam: JVP elevated to angle of jaw at 45 degrees, bilateral basilar crackles to mid-lung fields, 2+
pitting edema to knees, S3 gallop, hepatomegaly. No chest pain.
Labs: BUN 68 mg/dL, Cr 2.8 mg/dL (baseline 1.9), K+ 5.6 mEq/L, Na+ 132 mEq/L, BNP 2,840
pg/mL, Hgb 9.8 g/dL, lactate 2.4 mmol/L. ABG: pH 7.28, PaCO2 48, PaO2 58, HCO3- 22.
Imaging: CXR — cephalization, bilateral pleural effusions, cardiomegaly (CTR 0.62). Bedside
echo: severe LV dysfunction, no pericardial effusion.
Guided Questions
Q1. What is your differential diagnosis (minimum 3)? Q2. What diagnostic studies would you
order immediately? Q3. What is your management plan (pharmacologic + non-pharmacologic)?
Model Answer with Clinical Reasoning Walkthrough
Differential Diagnosis:
1. Acute decompensated heart failure (ADHF), cardiorenal syndrome Type 1 — Most
likely. Volume overload + acute kidney injury from forward failure and venous
, 2
congestion. BNP >400 supports diagnosis. Cardiorenal syndrome is bidirectional: renal
congestion worsens GFR; AKI worsens volume retention.
2. Acute coronary syndrome precipitating decompensation — Must exclude. Elderly
patients often have "painless" ischemia. New AF with RVR may be secondary to ischemia
or cause of decompensation.
3. Pulmonary embolism — Dyspnea out of proportion, tachycardia, hypoxemia. Risk
elevated in HF and immobility.
4. COPD exacerbation / pneumonia — Crackles could represent infection; however, fever
absent and infiltrates not described.
Immediate Diagnostic Studies:
• 12-lead ECG (within 10 min) — Rule out STEMI, assess rhythm (AF with RVR confirmed),
evaluate for ischemic changes
• Troponin I/T (serial x3, 6-hour intervals) — Detect Type 2 MI from demand ischemia
• BNP/NT-proBNP (already obtained; trend if diagnosis uncertain)
• Chest CT angiography ONLY if PE pre-test probability intermediate/high AND patient
stable enough for transport
• Bedside lung ultrasound — B-lines profile confirming pulmonary edema; pleural
effusions quantified
• Urinalysis and urine sodium — Assess prerenal vs. intrinsic AKI (FeNa <1% supports
prerenal)
• LFTs, coagulation panel — Baseline before initiating GDMT
Management Plan:
Non-pharmacologic:
• Continuous telemetry, pulse oximetry
• Strict I&O, daily weights
• Sodium restriction <2 g/day, fluid restriction 1.5 L/day (hyponatremia present)
, 3
• Head-of-bed elevation 45 degrees, legs dependent to reduce venous return
• Consider CPAP/BiPAP if respiratory distress progresses (this patient is borderline)
Pharmacologic — Tiered Approach:
Tier 1: Decongestion (first 24 hours)
• Furosemide IV — Give 80 mg IV push (2x oral home dose). Given Cr 2.8 and concern for
diuretic resistance, consider furosemide infusion 10-20 mg/hr after initial bolus OR add
metolazone 2.5-5 mg PO daily for sequential nephron blockade. Monitor urine output
hourly; target >0.5 mL/kg/hr.
• Goal: Net negative 1-1.5 L/day. Avoid over-diuresis given AKI.
Tier 2: Afterload Reduction & GDMT Optimization
• Nitroglycerin IV — Start 10-20 mcg/min, titrate to SBP >110. Reduces preload and
afterload. CAUTION: Avoid if RV infarct, severe AS, or SBP <100.
• ACEi/ARB — HOLD initially due to AKI and hyperkalemia (K+ 5.6). Reassess after diuresis.
• Hydralazine/isosorbide — Consider if persistent hypertension and ACEi contraindicated.
Tier 3: Rhythm & Rate Control
• Diltiazem IV — 0.25 mg/kg IV push (15-20 mg) then 5-15 mg/hr infusion for AF with RVR.
AVOID in HFrEF if possible; amiodarone 150 mg IV over 10 min preferred if
hemodynamically stable but symptomatic. Beta-blockers CONTRAINDICATED in acute
decompensation.
• Anticoagulation per CHA2DS2-VASc once stabilized.
Tier 4: Renal Protection & Electrolyte Management
• Sodium zirconium cyclosilicate (SZC) 10 g TID or patiromer 8.4 g daily for K+ 5.6. If ECG
changes or K+ >6.5: calcium gluconate 1 g IV, insulin 10 U + D50 50 mL, albuterol neb.
• Avoid NSAIDs, contrast, nephrotoxins.
Tier 5: Escalation if Refractory
, 4
• Inotropes — Dobutamine 2.5-5 mcg/kg/min if persistent hypoperfusion (lactate >4, MAP
<65) AFTER diuresis. Milrinone avoided in AKI (renal clearance).
• Ultrafiltration — If diuretic resistance and volume overload persists despite above.
• Consult cardiology/heart failure team for advanced therapies.
Red Flags / Warning Signs That Change Management
Table
Red Flag Implication Immediate Action
SBP <90 mmHg Cardiogenic shock Stop vasodilators; start inotropes;
activate cath lab if ischemic
Altered mental status Cerebral Intubation, invasive monitoring,
hypoperfusion possible IABP/Impella
K+ >6.5 or ECG peaked T Life-threatening Calcium stabilization, insulin/glucose,
waves hyperkalemia emergent dialysis
Lactate >4 mmol/L with Peripheral Escalate to ICU; consider dobutamine;
cool extremities hypoperfusion rule out sepsis
New ST elevations STEMI Cath lab activation; management
shifts to ACS protocol
Oliguria <0.3 mL/kg/hr x Severe cardiorenal Nephrology consult; consider CRRT if
24 hr syndrome refractory
Common Pitfalls Students Make
1. Giving home dose furosemide PO in acute setting — Bioavailability is 50% PO vs. 100%
IV. Always convert to IV and increase dose in decompensation.
