CARDIOVASCULAR CASE-BASED SMALL GROUP DISCUSSION

Transcription

1 MHD I, Session 7, STUDENT Copy Page 1 CARDIOVASCULAR CASE-BASED SMALL GROUP DISCUSSION MHD I SESSION 7 OCTOBER 16, 2015 Helpful Resource McPhee, SJ, Hammer GD. Pathophysiology of Disease: An Introduction to Clinical Medicine, 6 th edition. p (available as e-book though Loyola Health Science Library) STUDENT COPY

2 MHD I, Session 7, STUDENT Copy Page 2 CASE HISTORY Chief Complaint: Shortness of Breath getting worse x 5 days Mr. Bridges is a 71-year old gentleman who has been under his physician s care for a variety of medical problems during the past 5 years. He has been treated for two myocardial infarctions, hypertension, diabetes mellitus type 2 and stasis dermatitis of the left leg. He had 3 vessel aorta-coronary bypass surgery one year ago. He presents to his physician s office with shortness of breath which has been progressive over the past five days. In addition, he has experienced episodes of shortness of breath during the past four months, especially when exerting himself. He fatigues easily and has lost all my energy to do anything. He also complains of anorexia. Despite not eating well he feels that his weight has been going up. Last night he awoke suddenly from sleep because he couldn t catch his breath and developed a dry cough. The breathing problem improved when he sat on the edge of his bed for an hour. He generally sleeps with two, and recently with three pillows. He has not experienced chest pain, leg pain or syncope. Mr. Bridges states that he is taking all of his medications as prescribed however he forgot to bring them to the office visit today. Mr. Bridges stopped smoking after his first myocardial infarction. Prior to that he smoked 1 pack of cigarettes per day since the age of 20. He has a glass of red wine with dinner every Friday night. Mr. Bridges worked as a car salesman and retired after his second myocardial infarction. He is married and his wife has been having some health problems. Examination in the office reveals a man who appears depressed and older than his stated age. He is unshaven. His shoes are untied. His breathing is labored and his lips have a blue tinge. Vital Signs: Blood Pressure 98/82mmHg in the right arm, 100/82 in the left arm; Heart Rate 110/min; the pulse is irregularly irregular. Respiratory Rate 26/min; Temperature 98.4 ºF. Weight 92kg (weight four months ago: 84kg). Pulse oximetry on room air demonstrates oxygen saturation of 86%. Examination of the lungs reveals dullness to percussion in both bases. Coarse rhonchi and moist, inspiratory crackles are heard bilaterally in the lower lung fields. Examination of the cardiovascular system: Neck veins are prominent and distended to the mandible when the patient is sitting upright. The apical impulse is displaced lateral to the midclavicular line. S 1 and S 2 are diminished. S 3 is heard at the apex. A grade 3/6 holosytolic murmur is heard best at the apex and radiates to the left axilla. Examination of the abdomen: The abdomen is soft and not distended. Bowel sounds are normoactive. The liver edge is palpable and tender. The spleen is not palpable. Examination of the extremities reveals diminished peripheral pulses. There is pitting edema of both lower extremities to the knees. His distal extremities have a blue tinge. Mr. Bridges is hospitalized.

3 MHD I, Session 7, STUDENT Copy Page 3 ADMISSION LABORATORY TESTS Heme Final - T0897 Complete Blood Count (Hemogram) RBC 4.01 [ ] M/ML WBC 8.4 [ ] X 10/MM Hemoglobin 14.6 [ ] gm/dl Hematocrit 40.0 [ ] % MCV 88.1 [85-95] fl MCH 29.4 [ ] pg MCHC 34.0 [ ] gm/dl RDW 14.0 [ ] % Platelet Count 290 [ ] K/ML Chem Final - T0897 Complete Metabolic Panel Glucose 112 H [70 100] mg/dl Blood Urea Nitrogen 39 H [7-22] mg/dl Creatinine 1.6 H [ ] mg/dl Calcium 8.9 [ ] mg/dl Sodium 132 L [ ] mmol/l Potassium 4.0 [ ] mmol/l Chloride 93 L [98-108] mmol/l Carbon Dioxide 23 [20-32] mmol/l Albumin 3.1 L [ ] gm/dl Protein, Total 5.8 L [ ] gm/dl Alkaline Phosphatase 200 [25-215] IU/L AST 75 H [5-40] IU/L Bilirubin, Total 1.9 H [ ] mg/dl B-Type Natriuretic Peptide 337 H [< 100] pg/ml Urin Final - T1111 Urinalysis Color YELLOW [YELLOW] Clarity AMBER [CLEAR] PH 7.0 [ ] Specific Gravity [ ] Protein 1+ [Negative] Blood NEG [Negative] Glucose NEG [Negative] Ketones NEG [Negative] Bilirubin NEG [Negative] Urobilinogen 0.2 [ ] eu/dl NITRATE NEG [Negative] LEUKOCYTES NEG [Negative] RBC 0 [0-2] /hpf WBC 0 [0-5] /hpf Nonrenal Epith Cells 0 [0-5] /hpf Hyaline Casts [0-2] /hpf

4 MHD I, Session 7, STUDENT Copy Page 4 EXAM: PORTABLE AP CHEST COMPARISON: NONE AVAILABLE AT TIME OF EXAM FINDINGS: THERE IS INCREASED TRANSVERSE DIAMETER OF THE HEART. THERE IS MARKED PROMINENCE OF THE PULMONARY VASCULAR SHADOWS BILATERALLY. THERE IS INCREASED HAZINESS AND DECREASED RADIOLUCENCY OF THE LUNG PARENCHYMA BILATERALLY. THERE ARE MODERATE BILATERAL PLEURAL EFFUSIONS. METALLIC SUTURES AND CLIPS FROM PREVIOUS SURGERY ARE SEEN. EDUCATIONAL OBJECTIVES 1. Define all unknown terms. 2. Cite the primary clinical problem (not the diagnosis). 3. Develop a differential diagnosis for this clinical problem. 4. What is your diagnosis? Describe the data from the history and physical examination which supports your diagnosis. 5. In terms of the pathophysiology, explain the mechanism for the following findings: fatigue, anorexia, labored breathing, blue lips, lowered blood pressure, distended neck veins, diminished S 1 /S 2, palpable liver edge and pitting edema. Comment on the patient s appearance, including untied shoelaces.

5 MHD I, Session 7, STUDENT Copy Page 5 6. Explain the pathophysiology of the holosystolic murmur, S 3 and the irregular, irregular pulse. 7. Correlate the laboratory data in terms of the diagnosis. 8. Correlate the results of the chest x-ray (structural changes) with the clinical findings. 9 Interpret Mr. Bridges EKG. Mr. Bridges physician formulates a treatment plan. An echocardiogram is also ordered (the report is included at end of case). 10. Diuretic therapy is indicated. What class of diuretic would you initiate in this patient? What is the most widely used drug in this class? How do patients benefit from diuretic therapy? List the most relevant potential adverse effects.

6 MHD I, Session 7, STUDENT Copy Page Which 2 classes of drugs are indicated for treatment of any New York Heart Association class of systolic heart failure, including asymptomatic patients? What treatment objectives do these drugs help achieve? 12. Is there a role for digoxin in this patient s medical management? If so, what? 13. Compared to normal, how do you think Mr. Bridges illness has altered his ventricular function curve (the relationship between LV end-diastolic and cardiac output)? Would his ventricular function curve be further altered by digoxin, vasodilator therapy or diuretic therapy? 14. Mr. Bridges physician believes patient education is very important. What issues should be addressed with Mr. Bridges during this hospitalization by his physician and other members of the health care team? UNKNOWNS QUESTIONS 15 and 16 STUDENTS WILL NOT HAVE THESE QUESTIONS UNTIL THE SESSION MEETS

7 MHD I, Session VII, Case 1 - EKG MHD I, Session 7, STUDENT Copy Page 7

8 MHD I, Session 7, STUDENT Copy Page 8 Measurements (Normal Values) Echocardiogram Report 2D ECHO LV Diastolic Diameter Base LX 7 cm ( ) LV Systolic Diameter Base LX 5.3 cm ( ) Fractional Shortening BASE LX 0.24 ( ) IVS Diastolic Thickness 1.3 cm ( ) LVPW Diastolic Thickness 1.2 cm ( ) LA Systolic Diameter LX 4.6 cm Aortic Root Diameter 3.9 cm LA Ao Ratio 1.2 LVOT Diameter 2.6 cm Ascending Aorta Diameter 4.2 cm LA Volume 106 cm³ LA Volume Index 46.2 cm³/m² LA Area 4C View 27.7 cm² LA Length 4C 6.8 cm LA Area 2C View 30.1 cm² LA Length 2C 6.7 cm DOPPLER LVOT Diameter 2.6 cm FINDINGS LV Ejection Fraction: 35 % Left Ventricle: Right Ventricle: Severe left ventricular enlargement. Akinesis of the anterior septum, inferior septum and the apex of the left ventricle. Anterior wall is not well visualized. Moderate reduction in left ventricular ejection fraction is present. Normal right ventricular size and function. Right Atrium: Normal right atrial size. Dilated inferior vena cava with less than 50% collapse during inspiration Left Atrium: Mitral Valve: Aortic Valve: Left atrial enlargement. The visualized portions of the atrial septum are normal. Normal mitral valve. Moderate mitral regurgitation. No mitral stenosis. Thickened aortic valve leaflets with normal opening in systole. Mild aortic regurgitation. No aortic stenosis. Tricuspid Valve: The tricuspid valve leaflets could not be visualized adequately. Pulmonary artery systolic pressure could not be estimated.

9 Pulmonic Valve: Pericardium: MHD I, Session 7, STUDENT Copy Page 9 Pulmonic valve leaflets could not be visualized adequately. No significant pulmonary regurgitation or stenosis. No pericardial effusion. Aorta: Dilated aortic root (4 cm). Sinotubular junction 3.1 cm. Ascending aorta 4.2 cm. CONCLUSIONS Technically limited study. Severe left ventricular enlargement. Akinesis of the anterior septum inferior septum and the apex of the left ventricle. Left atrial enlargement. Moderate mitral regurgitation.