Download - Cardiology Case Presentation
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