We recently encountered a 78-year-old male with past medical history notable for atrial fibrillation, chronic kidney disease, ischemic heart failure, diabetes and coronary artery disease who was scheduled to undergo a radical open nephrectomy for an enlarging tumor in his right kidney. The patient went to the anesthesia pre-operative clinic two weeks prior to his surgery and was given written and oral communication regarding perioperative management of his medications. On the day of surgery, the patient presented with shortness of breath associated with increased work of breathing. His room air oxygen saturation was noted to be 88 percent (baseline of 95 percent). He reported weight gain of 10 lbs and bilateral lower-extremity edema with dyspnea and chest pain for the past three days. Further questioning revealed that he had discontinued all of his medications five days prior to surgery....

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