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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 nephro...
Subjective
• PMHx: HTN (onset 2004), stroke (2004), 5
  episodes of heart attack, severe HF class C
• PSHx: 5 cardiac sten...
Subjective (cont)
• Meds: (upon transfer from LAC-USC)
  Doripenam 500mg IV q 8º, ASA 81mg PO
  daily, Tamulosin 0.4mg PO ...
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,...
Assessments and Plans
• L nephrouretolithiasis and subsequent L
  pyelonephritis - minimal sx (L flank pain),
  øhematuria...
Assessments and Plans
• H/o MI x5 - pt has øcardiopulm complaints/sx
  – 12 lead EKG
  – Echo
     • Eval LV EF and wall m...
Assessments and Plans
• HF Class C - pt compensating well
  – CXR - PA and lateral
  – B-natriuretic peptide
  – Correg - ...
EKG Discussion
• Inferior infarct in II, III, aVF
   – Pathologic Q waves and evolving ST-T changes
   – T wave inversion
...
CXR Discussion
• Cardiomegaly
• Perihilar congestion
Discussion Topics
• HF
  – Stage A
       • Ø structural HD or sx, but RFs: CAD, HTN, DM, cardiotoxins,
         familial ...
Discussion Topics

• Automatic Implantable Cardioverter-
  Defibrillator (AICD)
  – Implanted in chest to correct episodes...
Cardiology Case Presentation
Cardiology Case Presentation
Cardiology Case Presentation
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Cardiology Case Presentation

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Cardiology Case Presentation

  1. 1. Cardiology Case Presentation Candice Reyes, MS III Friday, July 10, 2009 Cardiology at Rancho Los Amigos
  2. 2. 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”
  3. 3. 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.
  4. 4. 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
  5. 5. 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.
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. CXR Discussion • Cardiomegaly • Perihilar congestion
  11. 11. 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
  12. 12. 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

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