Cardiology Case Presentation

Candice Reyes, MS III

Friday, July 10, 2009

Cardiology at Rancho Los Amigos

ID and HPI• 56 y/o Hispanic male w/hx of HF 2º to ischemic

cardiomyopathy EF=14%, MI x 5, and HTN p/w blood in nephrostomy bag to LAC-USC on 5/5/09.

• After L PCNT was placed, he was discharged on 5/6/09. On 5/9/09, he represented to LAC-USC with blood in bag again and SOB worsening x 5d. He was Dxed w/UTI and CHF exacerbation.

• On 6/24/09, he was transferred to RLA “for outpatient IV antibiotics and to see cards in house”

Subjective• PMHx: HTN (onset 2004), stroke (2004), 5

episodes of heart attack, severe HF class C• PSHx: 5 cardiac stents, AICD guidant pacemaker• FHx: Dad is 90y/o and healthy (living in Mexico),

Mom died when pt was 4y/o-he does not know why. Pt had 1 brother who died bc of kidney stones

• SocHx: He works as a security guard in the City of Commerce. He lives with his daughter who is 20y/o. He has 2 sons, who are 26 and 22y/o. He denies drinking EtOH, smoking or tobacco produts, and recreational drug use.

Subjective (cont)

• Meds: (upon transfer from LAC-USC) Doripenam 500mg IV q 8º, ASA 81mg PO daily, Tamulosin 0.4mg PO daily, Plavix 75mg PO daily, Simvastatin 40mg PO daily, Tramadol 50mg PO q 8º, Correg 3.125 mg PO BID, Lasix 60mg PO BID, Ferrous sulfate 300mg TID c orange juice, Colace 100mg, Pepsid 20mg daily

• Allergies: NKDA, pt denies allergies to environment

Objective

• Vitals: BP range 92-123/60-99 P 67-97 T 96.0-97.8 O2Sat 98-100% Wt 72.6-75.8kg

• PE: – CV - RRR. Ømurmurs, clicks, rubs auscultated.

Øbruits. JVD +2cm. Ø cyanosis, clubbing. Cap refill <2s. Peripheral pulses +2/4 B/L UE, LE. Pacemaker palpable in upper left chest.

– Resp - LCTA B/L, post and ant, unlabored breathing. Chest movement symmetrical. Post chest wall @ level of L2 - L nephrostomy tube intact and draining yellow urine.

Assessments and Plans• L nephrouretolithiasis and subsequent L

pyelonephritis - minimal sx (L flank pain), øhematuria, afebrile, WBC wnl– Doripenam - Carbepenem beta-lactam

• Complicated UTI/pyelo

– KUB– U/A– Vicodin => Acetaminophen

• Intermittent flank pain

Assessments and Plans

• H/o MI x5 - pt has øcardiopulm complaints/sx– 12 lead EKG – Echo

• Eval LV EF and wall motion

– BP management• Correg, Lasix, Captopril/Lisinopril

– Lipid management• Simvastatin

– Antiplatelets• ASA and plavix

Assessments and Plans

• HF Class C - pt compensating well – CXR - PA and lateral– B-natriuretic peptide– Correg - nonselective B-adrenergic blocking agent with

selective a1-adrenergic• Titrate up as tolerated

– Lasix• Loop diuretic

– KCl• To replete K

– Captopril => Lisinopril• Suppress RAA, decr pre and after load

EKG Discussion

• Inferior infarct in II, III, aVF– Pathologic Q waves and evolving ST-T changes– T wave inversion

• LVH using Estes Criteria (5pts is diagnostic)– S in V2 > 30 mm (3pts)– ST-T Abnormalities without digitalis (3pts)– LAE (1pt) in III

• P wave duration > 0.12s• Notched P wave

– QRS duration > 0.09s

CXR Discussion

• Cardiomegaly

• Perihilar congestion

Discussion Topics• HF

– Stage A• Ø structural HD or sx, but RFs: CAD, HTN, DM, cardiotoxins,

familial cardiomyopathy• Tx: Lifestyle modification - diet, exercise, smoking cessation; tx

hyperlipidemia and use ACEI for HTN

– Stage B• Abnml LV systolic fxn, MI, valvular HD, but no HF sx• Tx: Lifestyle mod, ACEI, B-adrenergic blockers

– Stage C• Structural HD and HF sx• Tx: Lifestyle mod, ACEI, B-adrenergic blockers, diuretics, digoxin

– Stage D• Refractory HF sx to maximal medical management• Tx listed under A,B,C and mechanical assist device, heart

transplantation, continuous IV inotropic infusion, hospice care

Discussion Topics

• Automatic Implantable Cardioverter-Defibrillator (AICD)– Implanted in chest to correct episodes of rapid

heart beats - reduces risk of SCD d/t arrhythmias– Cardioversion - corrects rhythm or pattern by

sending small electrical charges to heart to “reset” when it goes too fast

– Defibrillation - stops potentially fatal quivering of heart (Vfib) by sending stronger charges to “reset” heart if it quivers, instead of beats

– Bradycardia pacing - like artificial pacemaker