Transcript Case Conference #1

Case Conference #1
Mark Randolph
Setting the stage
Sheila Jones is a 66 year old retired nurse,
chief complaint is cough for about 6 weeks.
Cough is none productive. No chest or
back discomfort, palpitations,
lightheadedness, or syncope. Her cough
was treated with azithromycin without
benefit by family doctor.
Past Medical History
• Myocardial infarction 3 years ago. After
an angiogram, "They told me that I had
a blocked vessel, and that surgery was
not necessary."
• No history of hypertension.
• No history of serious infectious disease.
• No history of heart murmur.
• No known allergies.
• Random blood glucose intermittently
elevated for 5 years
Medications:
• ASA 325 mg QD/ Metoprolol 25 mg
bid. Both were started after Her
MI.
• She has never used nitroglycerin
products
Family History
• Father died of a myocardial
infarction at age 72.
• Mother died of colon cancer at age
70.
Personal and Social
History
• Sedentary since she retired from her
job as a nurse at age 60.
• Avoids red meat whenever possible and
observes no other dietary restrictions.
• No drug abuse. Occasional alcohol
intake.
• No history of exposure to cardiotoxins.
Thirty-five pack-year smoking history
(stopped at the time of her MI).
Conversation with the patient
• Doctor: What's bothering you?
• Mrs. J .: I've had a bad cough for about 6 weeks. And I've
been waking up at night coughing.
• Doctor: Are you bringing up any phlegm?
• Mrs. J.: No, doctor. It's a dry cough.
• Doctor: When you awake at night, are you short of breath?
• Mrs. S.: Sometimes. I am usually nervous, too. But after I sit
on the side of the bed for a few minutes, I begin to feel better.
• Daughter: she's tired all the time. She watches soap operas
all day long and hardly ever gets up. And when we do go for a
walk, I notice her gasping for air.
• Mrs. J: I get short of breath easily. I also have to go to the bathroom to pass
water a lot at night. My last doctor thought I had a bladder problem
Review of Systems
• Appetite ok, but she eats very
little, but the patient notes that
she has been gaining weight.
• Occasional ankle swelling,
particularly after standing or
sitting for prolonged periods
“Shoes too tight, usually”.
Lung
exam
Patient- Sheila Jones
Extremities
Neuro
Neck
exam
Abdominal
exam
Precordial
Exam
Vital
Signs
Vital Signs
• 135/85.
• Pulse 90, regular.
• Afebrile.
• Respiratory rate 18/minute
Neurological Exam
• Alert and oriented.
• Speech fluent and appropriate.
• No focal deficits
Precordial Exam
Inspection
Inspection
• Cardiac apex
displaced
laterally.
Auscultation
Neck Exam
• Normal carotid pulsations.
• No carotid bruits.
• JVD estimated at 10 cm H2O (nl:
<9 cm H2O).
Extremities
• Distal pulses are 2+ throughout
Lung Exam
• Resonant to percussion bilaterally.
• End-inspiratory rales audible at the
lower 1/3 of both lung fields
Abdominal Exam
• Active bowel sounds.
• Liver palpable at the right costal
margin;the liver edge is smooth,
non-tender, without nodularity.
• The aorta is not palpable
Labs- Which ones?
• BUN and
•
Creatinine
• Electrolytes and •
Glucose
• Liver Function •
Tests
•
• Thyroid Function
•
Tests
• Urinalysis
Complete Blood Count
CPK (Creatinine
phosphokinase)
Blood Cultures
Immunoelectrophoresis
Ferritin
BUN and Creatinine
• BUN: 10 mg/dl Creatinine: 1.3
mg/dl Within the normal range
• Why?
– Necessary for several reasons. Severe renal
insufficiency can lead to volume overload.
Diuretics and ACE inhibitors, common
therapies for CHF, may adversely affect
renal function. In addition, if renal
insufficiency is advanced, medication dosing
adjustments may be necessary.
Electrolytes; Glucose
• (Na,K,Cl,HCO3):137/4.2/100/25
• Glucose: 140 mg/dl Within the
normal range, except glucose
• Why?
– An essential test. Diuretics can cause
hypokalemia which may predispose to
ventricular arrhythmias. For this reason, the
serum potassium should be maintained at a
level greater than 4.0. In chronic congestive
heart failure, hyponatremia has grave
implications.1 This glucose is high. Given this
patient's reported history, it might be prudent to
check the Hbg A
Liver Function Tests
• Alkaline phosphatase is mildly elevated.
Otherwise within the normal range.
• Why?
– A reasonable choice. Liver function can be
adversely affected by congestive heart
failure. In addition, peripheral edema
secondary to hypoalbuminemia should be
ruled out.
Thyroid Function Tests
• Within the normal range
• Why?
– This test is a reasonable choice. Hypothyroidism
may present without its usual signs and
symptoms and may manifest as CHF, especially
in the elderly. Hyperthyroidism can cause CHF,
and can provoke CHF in patients with intrinsic
heart disease. The Agency for Health Care
Policy and Research (AHCPR) Guidelines2
suggest that thyroid function tests be routinely
checked in patients over 65 years of age, those
with atrial fibrillation, and those with symptoms
of thyroid disease.
Urinalysis
• Specific Gravity: 1.020
Neg. Protein: Neg
• Why?
Blood:
– This test is also recommended by the
AHCPR guidelines2, as a screen for
nephrotic syndrome or
glomerulonephritis, both of which
may coexist with CHF.
Complete Blood Count
• Hematocrit: 43%
• WBCs: 8,000/mm3
• Platelets: 304,000/mm3
• Within the normal range
• Why?
– This test is useful, as anemia may
aggravate congestive heart failure.
Lipid Profile
• Total cholesterol: 190 mg/dl
LDL Cholesterol: 120 mg/dl
HDL Cholesterol: 30 mg/dl
Triglycerides: 110 mg/dl
• Why?
– A reasonable choice in a patient with
a history of ischemic heart dis
CPK
(Creatine phosphokinase)
• Not necessary! The history and
physical do not suggest active
ischemia.
Blood Cultures
• This test is not necessary. It is true
that endocarditis with valvular
damage can cause heart failure,
and that any infection can
precipitate heart failure in a
predisposed individual. However,
this patient's history, vital signs,
physical exam.
Immunoelectrophoresis
• Not indicated. While amyloidosis
can cause heart failure,
immunoelectorphoresis should not
be used as a screening test.
Ferritin
• Not indicated. This is a valuable
test when hemochromatosis is
suspected, but that is not the case
in this instance.
Other Tests
• A recent 12 lead ECG is a necessary
component of the evaluation.
• X-ray
Rhythm: Sinus. Normal intervals and axes. Nonspecific
ST-T wave changes. Q waves are present in leads V1V5 and are consistent with an anterior infarct.
The issue of arrhythmias
This patient has a heightened likelihood of developing atrial
fibrillation and ventricular arrhythmias. Symptomatic
arrhythmias merit investigation. Symptomatic, non-sustained
ventricular tachycardia in patients with prior infarction and EF
0.35 should lead to consideration for an electrophysiological
evaluation
The electrocardiogram shows normal sinus rhythm and Q waves
in V1 to V5 indicative of an extensive anterior myocardial
infarction of indeterminate age. In addition, the broad P wave in
lead II and terminal negative P wave forces in lead V1 indicate
interatrial conduction abnormality.
The issue of arrhythmias:
continued
• The finding of abnormal P waves in
this patient's electrocardiogram
would most likely indicate?
Significant left ventricular dysfunction is
indicated
Why- is significant left
ventricular dysfunction indicated
• In patients with coronary artery disease, the finding of
interatrial conduction abnormality is a good indicator of
significant left ventricular dysfunction. Only 20% of patients
with coronary disease and this abnormality have normal left
ventricular function.4 The patient's presenting symptoms and
physical exam along with the ECG findings of an anteroseptal
myocardial infarction and interatrial conduction abnormality
certainly would indicate significant left ventricular dysfunction.
• Although LA abnormality is seen in LVH, the ECG and past
history (no known hypertension) don't support a diagnois of left
ventricular hypertrophy. Also, as there is no diastolic murmur,
mitral stenosis is not a likely diagnosis. Finally, idiopathic dilated
cardiomyopathy is incorrect because the history of MI and ECG
is consistent with prior MI, as is the history of CAD at
catheterization.
X-ray
Information
Cardiomegaly and pulmonary vascular congestion are noted
Information
• The chest X-ray plays an essential role in the evaluation of
suspected heart failure. It is useful in distinguishing pulmonary
from cardiac causes of dyspnea. Left atrial size and ventricular
enlargement, as well as valvular calcification, can often be
discerned on routine chest X-rays. The lateral view can provide
additional information on chamber size and valvular calcification.
In patients with ischemic cardiomyopathy, cardiomegaly is usually
associated with an EF 35%. 5
• Based on the history, physical exam, preliminary labs, ECG, and
CXR, this diagnosis is possible. Further evaluation is required to
determine the degree to which valvular dysfunction, on-going
ischemia, or the consequences of ventricular remodeling following
an infarction are each contributing to the patient's heart failure.
Continuing evaluation is clearly indicated; however, treatment
should be initiated at this juncture.
• At this point the patient has been found to have a history and
physical exam suggestive of congestive heart failure. His CXR
supports this diagnosis. The ECG shows evidence of previous
infarct.
What should we do with the Mrs.
Jones?
• Admit
• Treat out patient
You are wrong
Go back and find out why!!
Treat out patient
According to the AHCPR guidelines on
CHF, indications for admission include:
•
•
•
•
•
•
•
•
Clinical or ECG evidence of acute ischemia
Pulmonary edema or severe respiratory distress
O2 saturation less than 90%
Severe complicating medical illness
Anasarca
Symptomatic hypotension or syncope
Heart failure refractory to outpatient therapy
Inadequate social support for safe outpatient therapy
Which outpatient treatment
would you first recommend?
• ACE inhibitor
• Digoxin
• ß blocker
• Loop diuretic
Correct
• A loop diuretic should be administered
– Loop diuretics are indicated for the signs and
symptoms of volume overload. Their potency is
preferred to relieve symptoms. Milder fluid
overload can be treated with thiazides.
– The starting dose should be 10-40 mg of
furosemide (or the equivalent dose of another
loop diuretic). Since loop diuretics interfere with
renal handling of Mg++ and K+, hypokalemia and
hypomagnesemia are potential problems. Such
electrolyte disturbances can predispose to
serious arrhythmias..
Correct- Continued
• Supplementation of K+ and sometimes Mg++ is
often required, but, as a general rule,
treatment should not be delayed while labs
are pending. Given normal renal function and
K+ in the low end of the normal range, K+
supplement would be started.
• ACE inhibition full dose ß blockade and digoxin
may be indicated, but not yet. ACEI and ß
blocking drugs have proven to be of most
certain benefit in cases where the EF is
depressed (as determined by echocardiogram,
radionuclide scan, or contrast
ventriculogram).6-8 Digoxin may be indicated,
but only if he remains symptomatic after
diuretics, ACEI, and ß blocking agents. 9
Thank you for your time.