This document presents a cardiology case of a 56-year-old Hispanic male with a history of heart failure, ischemic cardiomyopathy, myocardial infarctions, hypertension, and strokes who was transferred for outpatient IV antibiotics and cardiology consultation. The patient's medical history, medications, physical exam findings, assessments, and treatment plans are summarized. Discussion topics include the patient's heart failure stage, electrocardiogram and chest x-ray findings, and automatic implantable cardioverter-defibrillator.

1. Cardiology Case
Presentation
Candice Reyes, MS III
Friday, July 10, 2009
Cardiology at Rancho Los Amigos

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. 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. 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. 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. 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

8. 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

9. 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

11. 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

12. CXR Discussion
• Cardiomegaly
• Perihilar congestion

13. 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

14. 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