Fall 2014 OSM II Block 3 Bonus Doc (Unabridged)

Fall 2014 OSM II block 3 Bonus Doc (Unabridged)

Symptom = patient’s subjective experience of illness

Sign = clinical finding of illness

Example = Anorexia is a symptom, Cachexia is a sign

Case 1– Congestive Heart Failure

http://emedicine.medscape.com/article/163062

CC: 52 y/o African American M with worsening SOB at rest ~3 weeks

FACT: Heart failure is the fastest-growing clinical cardiac disease entity in the United States, affecting 2% of the population. [We have treatments for heart disease that would have otherwise killed people]

Signs and Symptoms of Heart Failure include:
·  Exertional dyspnea
·  Orthopnea = SOB when laying flat, relieved with elevation of head (Sleeps on many pillows, number of pillows is significant clinically)
·  Paroxysmal nocturnal dyspnea = Waken with shortness of breath, severe anxiety, and feeling of suffocation. [In contrast to orthopnea, which may be relieved by immediately sitting up in bed, paroxysmal nocturnal dyspnea may require 30 minutes or longer in this position for relief]
·  Dyspnea at rest
·  Acute pulmonary edema (cough with white sputum)
·  Chest pain/pressure (“Tightness” around his chest “like a band”)
·  Palpitations
·  Weak, rapid, and thready pulse
Common noncardiac signs and symptoms of heart failure include:
·  Anorexia
·  Nausea
·  Weight loss
·  Bloating
·  Fatigue
·  Weakness
·  Exophthalmos and/or visible pulsation of eyes
·  Distention of neck veins
·  Hepatojugular reflux
·  Ascites, hepatomegaly, and/or anasarca
·  Central or peripheral cyanosis, pallor
·  Rales, wheezing
·  S3gallop and/or pulsus alternans
·  Increased intensity of P2heart sound
·  Oliguria
·  Nocturia [Recumbency reduces the deficit in cardiac output in relation to oxygen demand, renal vasoconstriction diminishes, and urine formation increases.]
·  Cerebral symptoms of varying severity, ranging from anxiety to memory impairment and confusion.

Our guy:

Feet swelling improves when he’s in bed, puts feet up to relieve swelling (peripheral edema= right sided heart failure)

Denies claudication. Claudication is a symptom of in peripheral vascular disease, like atherosclerosis.

Left vs Right sided Heart Failure

Right Sided (Cor Pulmonale) signs:

Congestion of the hepatic and gastrointestinal venous circulation

·  Ascites (can be difficult to distinguish right-sided heart failure from hepatic failure clinically)

·  Congestive hepatomegaly [Nutmeg Liver]

·  Anasarca (generalized edema) and Dependent Edema

·  Increased abdominal girth

·  Epigastric and right upper quadrant (RUQ) abdominal pain

·  Anorexia, bloating, nausea, and constipation (GI Distress)

·  Distended Jugular veins

·  Kussmaul’s sign

Dyspnea, prominent in LV failure, becomes less prominent in isolated right-sided heart failure because of the absence of pulmonary congestion.

$$$- The most common cause of R-sided heart failure is L-sided heart failure -$$$

Also (less commonly) may be due to chronic pulmonary conditions.

Left sided signs:

·  Pulmonary congestion: Cough, Crackles, Wheezes, Blood-tinged Sputum, Tachypnea

·  Orthopnea

·  Paroxysmal Nocturnal Dyspnea

·  Elevated Pulmonary capillary wedge pressure (indicates increase in Left Atrium pressure)

SOCIAL HX:

·  Smokes 1 ppd x 20 years : 20 pack year history (quit when noticed sx)

·  Drinks a crap ton (Alcohol is toxic to the myocardium, associated with dilated cardiomyopathy)

CAGE questions asked: [Previous BONUS]

· Felt need to CUT DOWN

· Have people ANNOYED you by criticizing your drinking

· Have you ever felt bad or GUILTY about your drinking

· Have you ever used alcohol or a drug as an EYE OPENER first thing to steady your nerves or to get rid of a hangover?

Each positive response provides a 35-40% chance or drinking or drug problem being present. 2 positive responses provide an 80% chance of alcoholism being present. (Our pt had 2 positive responses)

FAMILY HX: Father passed from an MI at age 49

[Carefully assess the patient's medical history as well as that of asymptomatic first-degree relatives, with special focus on heart failure symptoms, arrhythmias, presyncope, and syncope]

Case 1 - Block 3 Fall 2014 / Common PE findings in (Right/Left - Sided) CHF
Vitals
·  BP: 110/70
·  Pulse: 90 with irregular beats (ectopy)
·  Respirations: 28 and labored
·  Temp: 99F
·  Pulse Ox: 96% on room air
HEENT:
Orbits show slight puffy tissue (anasarca) and conjunctiva is pale in color (pallor). No hemorrhages/exudates
Darkened mucosa around gumlines, caries
CHEST:
Rales (aka crackles and crepitation) were heard ½ way up back bilaterally. Dullness to percussion, bilateral in basal areas. Some use of accessory muscles in inspiration. Vocal fremitus noted in basal areas [Vocal fremitus increases in areas of lung consolidation]
CARDIOVASCULAR:
●  Jugular veins were distended to the angle of the jaw with the patient sitting at 90 degrees.
●  Carotids demonstrate no bruits but decreased in amplitude.
●  Apex impulse displaced to left anterior axillary line and enlarged at 4cm with patient in left lateral decubitus. [Indicative of left ventricular hypertrophy]
●  First and 2nd heart sounds soft, grade 3/6 pansystolic murmur [a regurgitant murmur heard throughout systole] heard both at apex and lower left sternal border. Intensity of the murmur does not change with inspiration.
○  You can exaggerate right sided sounds w/ inspiration
○  Remember that a thrill isn't heard until Grade 4/6
●  S3 Gallop (overfilled ventricle- can be heard in young and athletic people or can be sign of cardiac failure or pulmonary edema) [“Kentucky”]
●  S4 Gallop (stiffened ventricle, always pathological) heard at apex [“Tennessee”]
ABDOMEN: Liver palpable 2cm below the costal margin w/ slight tenderness, 13 cm. (@ MC line= 6-12 is normal) Hepatomegaly
EXTREMITIES: there is 2-3+ pitting edema 14cm above the medial malleolus bilaterally. (Pulses/ROM normal)
NEURO: 3+ reflexes / VITAL SIGNS:
HR: >100 (tachycardia)
R: >20 (tachypnea)
GENERAL: cyanosis, pallor, generalized edema (anasarca)
HEENT: Exophthalmos and/or visible pulsation of eyes.
Signs of cyanosis and pallor are best assessed by looking at the conjunctiva and gums.
NECK: Distention of neck veins (JVD).
LUNGS: Rales heard over the lung bases are characteristic of heart failure of at least moderate severity. With acute pulmonary edema, rales are frequently accompanied by wheezing and expectoration of frothy, blood-tinged sputum.
CARDIOVASCULAR:Weak, rapid, and thready pulse, S3gallop, Jugular venous distension, pulsus alternans. Increased intensity of P2heart sound. Regurg and new murmurs can appreciated due ventricular dilation.
ABDOMEN: Ascites, hepatomegaly, Hepatojugular reflux, RUQ tenderness/pain
SKIN: Cyanosis, pallor
EXTREMITIES: Edema (esp. lower extremities), Cyanosis
NEURO: May see impairments
* If isolated right-sided less pulmonary manifestations, and more edema.
* If only Left-sided heart failure dsypnea (pulmonary rather than peripheral edema)
Side Note:
Pansystolic Murmur means a murmur occupying the entire systolic interval, from first to second heart sounds.
Grade III: you can hear it clearly with stethoscope ON chest (No thrill, that's a grade IV)
Grading a Murmur
·  Grade 1: A quiet murmur that can be heard only after careful auscultation over a localized area.
·  Grade 2: A quiet murmur that is heard immediately once the stethoscope is placed over its localized PMI.
·  Grade 3: A moderately loud murmur.
·  Grade 4: A loud murmur heard over a widespread area, with no thrill palpable.
·  Grade 5: A loud murmur with an associated precordial thrill.
·  Grade 6: A murmur sufficiently loud that it can be heard with the stethoscope raised just off chest surface.
* If it changes with inspiration, more likely to be a right-sided murmur.
Labs In suspected CHF
Useful: / Our Guy
CBC / Aids in the assessment of severe anemia, which may cause or aggravate heart failure.
Leukocytosis may signal underlying infection.
Otherwise, CBCs are usually of little diagnostic help.
Serum Electrolytes (including Ca2+ and Mg2+) / In cases of severe heart failure, however, prolonged, rigid sodium restriction, coupled with intensive diuretic therapy and the inability to excrete water, may lead to dilutional hyponatremia.
Potassium levels are usually within reference ranges, although the prolonged administration of diuretics may result in hypokalemia.
Hyperkalemia may occur in patients with severe heart failure who show marked reductions in glomerular filtration rate (GFR) and if they are receiving potassium-sparing diuretics and/or ACE inhibitors (ACEIs). / Ca, Mg, Phosphorous: WNL
Why look for these? Hypocalcemia can cause cardiac tetany, extreme hypercalemia can cause arrhythmias. both hypo and hyperkalemia can cause arrythmias and ECG changes. Phosphorous also binds calcium and could have an effect on blood levels.
Renal Function Tests / Patients with severe heart failure, particularly those on large doses of diuretics for long periods, may have elevated BUN and creatinine levels indicative of renal insufficiency because of chronic reductions of renal blood flow from reduced cardiac output.
Liver Function Tests [AST, ALT, Alk Phos, T. protein, Albumin, T. Bilirubin, Consider running LDH and GGT] / [R-sided] Congestive hepatomegaly and cardiac cirrhosis are often associated with impaired hepatic function, which is characterized by abnormal values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactic dehydrogenase (LDH), and other liver enzymes.
Hyperbilirubinemia secondary to an increase in the directly and indirectly reacting bilirubin is common. In severe cases of acute RV or LV failure, frank jaundice may occur.
Can result in severe jaundice, with a bilirubin level as high as 15-20 mg/dL, elevation of AST to more than 10 times the upper reference range limit, elevation of the serum alkaline phosphatase level, and prolongation of the prothrombin time.
The impairment of hepatic function is rapidly resolved by successful treatment of heart failure.
In patients with long-standing heart failure, albumin synthesis may be impaired, leading to hypoalbuminemia and intensifying the accumulation of fluid. / AST high at 96 (0-60) [AST> ALT in alcoholic hepatitis 2:1 ratio]
GGT high at 159 (5-159)
B-type natriuretic peptide (BNP) / <200 is not likely HF
>500 HF likely
BNP levels greater than 100 pg/mL have a specificity greater than 95% and a sensitivity greater than 98% when comparing patients without heart failure to all patients with heart failure.Even BNP levels greater than 80 pg/mL have a specificity greater than 95% and a sensitivity greater than 98% in the diagnosis of heart failure
ANP and BNP are elevated in chronic heart failure. ANP and BNP are endogenously generated peptides activated in response to atrial and ventricular volume/pressure expansion. ANP and BNP both promote vasodilation and natriuresis.
The major source of plasma BNP is the cardiac ventricles, and the release of BNP appears to be in direct proportion to ventricular volume and pressure overload
In urgent care setting can be used to establish the diagnosis of heart failure, clinical presentation is ambiguous etc… / BNP: 1050 (4-40)
Indicative of sympathetic stimulation / ENDOCRINE TESTS
Plasma epinephrine 180 (0-110)
Plasma norepinephrine 1103 (70-750)
Dopamine 806 (0-136)
LIPID PROFILE
HDL: 25 (high risk <35)
Cholesterol/HDL ratio: 6.5/1 (<4.5/1)
Triglycerides: 200 (<150)
Acute MI? / Cardiac Enzymes: Troponin, CKMB, LDH-> WNL
ABG measurements / Hypoxemia and hypocapnia occur in stages 1 and 2 of pulmonary edema because of V/Q mismatch. In stage 3 of pulmonary edema, right-to-left intrapulmonary shunt develops secondary to alveolar flooding and further contributes to hypoxemia.
In more severe cases, hypercapnia and respiratory acidosis are usually observed.
ABG values in isolation are rarely useful, but they may add to the entire clinical picture / ABG’s
·  pH 7.59 (7.35-7.45)
·  pCO2 20 (35-45)
·  pO2 69 (80-95)
·  HCO3 19 (22-26)
·  O2 Sat 96
Uncompensated metabolic alkalosis!
Imaging/Procedures In suspected CHF
Chest Radiography
(PA and Lateral) / 2 principal features of chest radiographs are useful in the evaluation of patients with heart failure: (1) the size and shape of the cardiac silhouette and (2) edema at the lung bases.
Up to 50% of patients with heart failure and documented elevation of PCWP do not manifest typical radiographic findings of pulmonary congestion. / CXR: shows marked cardiomegaly. Lungs show pulmonary venous congestion and Kerley B Lines [indicative of L Heart Failure] and prominent vasculature. Fluid is present in the fissures.
2D ECHO and Doppler flow / Doppler and 2-D echocardiography may be used to determine both systolic and diastolic LV performance, cardiac output (ejection fraction), and pulmonary artery and ventricular filling pressures. In addition, echocardiography may be used to identify clinically important valvular disease / ECHO: Shows a severely dilated left ventricle, global systolic dysfunction with an EF of 25% (normal EF is ~55%) and a dilated left atrium. Other chambers are normal.
Doppler: Grade 4 Mitral Regurgitation [usually high pitched. explains pansystolic murmur]. No LA, LV clot noted [Clots have a tendency to form where ever there is wall motion abnormality; can lead to stroke].
Coronary anteriography / Coronary arteriography in patients with a history of exertional angina or suspected ischemic LV dysfunction, which may reveal coronary artery disease / Cineangiography - enlarged LV with diffuse dysfunction, EF 24% (normal 55-75%), moderate mitral regurg; mild plaque but no significant obstructive disease in coronary arteries.
· 
EKG / The presence of left atrial enlargement and LVH is sensitive (although nonspecific) for chronic LV dysfunction.
It is unlikely that an ECG would be completely normal in the presence of heart failure.
Electrocardiography may suggest an acute tachyarrhythmia or bradyarrhythmia as the cause of heart failure. It may also aid in the diagnosis of acute myocardial ischemia or infarction as the cause of heart failure or may suggest the likelihood of prior MI or the presence of coronary artery disease as the cause of heart failure / ·  Lead I had a + QRS vector
·  Lead AVF had a negative QRS vector-> Left Axis Deviation
·  Sinus rhythm (we saw p waves!) with frequent premature atrial contractions (we saw lots of P waves!)
·  HR = 94
·  PR interval = 176 ms (over 200 ms would be indicative of AV block)
·  QRS duration = 100 ms (Over 120 would be a wide QRS, meaning a ventricular-driven rhythm that could predispose you to Torsades de points)
·  QRS -20
·  Nonspecific ST-T wave changes
Holter monitoring / May reveal arrhythmias or abnormal electrical activity (eg, in patients with heart failure and a history of MI who are being considered for electrophysiologic study to document ventricular tachycardia [VT] inducibility)
Wearable heart monitor, usually 24h
CARDIAC CATHETERIZATION: / Pressures in all chambers elevated; PCW = pulmonary capillary wedge pressure (estimate of left atrial pressure)

Admitted directly to the hospital, orders: