c c c c c BY: MEJILLA/PURA/MINDUENETO/ROXAS c ? ë hav a cas of a 66 y ar old f al pati t with a chi f coplait History r v al d th pati t coplai d of difficulty of br athi accopai d of ild to od rat ch st pais, ad asy fatiability aravat d oc pati t us s 1 pillow o supi positio ad r li v d if i s i-hih fowl rs positio, ad uabl to do coo hous choirs such as walki o 6-7 stair cas st ps. Sh tio d that sh had p ri c d awak i at iht 1 a or 3 a du to difficulty of br athi ad couh. Th pati t d i s that sh had sw lli o th f t or w iht ai. Sh also tio d that sh strictly follow d doctor ord rs such as dicatio, di t, activity ad cliical visit sch dul s. Cofir d o-ciar tt sok r ad o-alcohol b v ra drik r by r ist r d privat RN i th hous hold. 8 y ars prior to adissio th pati t had l vat d blood lucos ad was diaos d with Diab t s Typ 2 ad was aitai d o M tfori, ad w ll copliat to dicatios ad cliical visitatio achi vi oral HB 1AC r sults do Routi ly v ry 3 oths. 4 y ars prior to adissio th pati t had CAD diaos by cardioloist ad was aitai d o Aspiri, Nif dipi , ad Nitrat s ad diab tic r i . 2 y ars prior to adissio th pati t was diaos d ST-El vat d At rior ëall Myocardial Ifarctio ad subs u tly aditt d PCI was ot do b caus sh r spod d to ati-throbolysis th rapy with str ptokias ad stabl . Sh was aitai d with Dioi, Aspiri ad Nitrolyc ri, M toprolol, Captoril ad Nif dipi . F w oths Prior to adissio th pati t visit d cardioloist ad sh was diaos d H art Failur sta C, Old MI 2010, NYHA III. Sh was advis d to s k for possibl h art trasplat ad osatios for possibl door is ud rway. Sh was aitai d with Captopril, Low dos M toprolol, Dioi, Spiriolacto , Nitrat s SL ad Aspiri. F w days prior to adissio th pati t tio d that sh visit d a r lativ with a r spiratory tract If ctio probably viral ad upo r achi ho sh p ri c d ruy os ad v tually couhi. No dicatio was tak for th coo flu. Sh had Flu Vacci H1N1 iv last y ar. Vital Sis: HR = 90 RR = 22 T = 37.5 BP = 130140/90. Physical Eaiatio r v al d, !"# $ %$ & $ !' ( ) %$'"
* At th ER sh was diaos d + * & ,-.# # /+--- ,0 . 1
u u
! Coroary Car Uit with T l try (ICCU) with Isolatio c S rious ëatch out for Cha s of S soriu, Difficulty of Br athi ad Ch st Pais BP = 130/90, HR = 91, T = 37.8 C , RR = 22- with ap a-20 Moitor Vital Sis 4 hours util stabl !"# B d R st o s i-fowl rs 12 hours with b dsid cood , th r aft r if stabl ay r su liht activity. ë ih th pati t v ry AM ad r cord. NPO c pt with sips of wat r ad dicatios util pai fr ad stabl for 24 hours Sodiu R strictio <2/Sodiu p r 24 hours, h art h althy di t, o salt o cooki ad proc ss d foods. $ # CBC with Plat l t Cout ëBC Blood Cultur (STAT) S ru Diitalis D t riatio aPTT ad PT/INR S ru Sodiu, Ma siu, ad Calciu S ru Potassiu v ry AM Urialysis ad Cultur LDL, HDL, Chol st rol, SGPT, SGOT FBS (Toorrow AM aft r Fasti) Rado Blood Glucos STAT v ry 4 hours BUN & Cr atii ! ECG with 2D Echocardioraphy th r aft r ECG/24 hours (AM) Plai Fi ld Ch st PA (X-ray) Hook to Puls Oi try & Cardiac Moitori STAT Art rial Blood Gas STAT %! 1. Nasal O2 at 2L-4LPM 6 hours 2. 0.9 NaCl with D5ë % 3. Uri Cath t r Is rt 4. Low Dos Carvidiol a. H art Failur 5. Morphi Sulfat 10 IM 2- 4hours (-ANST) b. CAP If ctio 6. Furos id (Lasi) 20 IV Bolus or Spiriolacto c. Hyp rt sio PO STAT, th r aft r PO AM oly. d. Puloary 7. IV Nitrolyc ri Drip for 24 hours Ed a 8. Lactulos PO as stool soft r . Str ss Ulc r 9. Diaz pa PRN oly for s v r ai ty Prophylais 10. Diitalis PO f. Ai ty 11. Captopril 6.25 8 hours . Hypovol ia 12. Lipid Low ri A ts oc r sult availabl h. Corr ctio of (Sivastati 40 OD) El ctrolyt s 13. Pip racilli-Tazobacta 2.25/IV to ru 8 hours aft r (i. Maa DM ANST) j. D t ri 14. Ipratropiu HBr 20c +Salbutaol 120 Diitalis Toicity (Salbutaol) A rosol STAT = 12 puffs/24 hours i divid d dos s. 15. Parac taol 500 PO 4 hours (>37.5). Do ot iv if (<37C) 16. Dobutai IV Drip (10c/k p r iut ) 17. Hydrocortiso IV blous 18. Raitidi 90 IV bolus ad Sucralfat PO
19. Isuli Bolus with Potassiu IV- Sid Drip via ifusio pup. Th r aft r Isuli Scali APIDRA 20. Aspiri 325 OD PO DIAGNOSTIC TEST
c % % cc % % % &'c ' ' c( ( $ ) c ( ' c %' ' PaCO2 = >50 PaO2 = <89 c
c
c*c c
RESULT (Toorrow AM) (Toorrow AM)Y Noral Liits
(Toorrow AM) 135 5.4 (Toorrow AM) (Toorrow AM) <4,500 >120 R sult Ud rway aft r 3 Days 2.0 INR 150,000 Noral Liits Noral Liits 126 R spiratory Acidosis with Cop sat d M tabolic Alkalosis Cardio aly ad L ft V tricular Hyp rtrophy, Old At rior-S ptal ëall MI V1V3. Cardio aly, Ath roscl rotic Aorta with siificat puloary co stio, (+) It rstitial Ed a with loss of puloary arkis. (+) K rl y A & B Li s with subpl ural fluid. No at l tasis s . Dilat d Cardioyopathy, with Coroary Art ry Dis as , L ft V tricular Systolic Dysfuctio (S tal), with od rat Riht V tricular Dysfuctio ad D pr ss d Ej ctio Fractio L sid .
RANGE 3.5-5.5 5 ,000-10,000 >120 2-3.0 INR 150,000 Noral Liits Noral Liits 80-100 -
-
-
c + + ) ' ë hav a cas of 50 y ar old al pati t ca to th ER du to 2 ? 1 '
History r v al d that th pati t has a lo stadi Hyp rt sio pisod s sic 5 y ars prior adissio ad pati t is o-coplait to diatios ad s ldo visits dical cosults. H tio d that his usual BP was (130-160/90-100) ad o ait ac dicatio. H d i d that h has o faily history of HPN but tio d his par ts di d du to coplicatios DM. Two y ars prior to adissio th pati t visit r ular cosult ad foud out that th pati t was havi Ipair d Blood Glucos o FBS but fail d to follow subs u t tr at ts ad follow-ups. F w days prior to adissio, th pati t p ri c d asy fatiability, Low r tr ity sw lli ad accopayi w iht ai fro 86lbs to 100 lbs. H also tio d havi asy sati ty, ad Riht upp r uadrat discofort. H d i d havi dysp a o rtio ad ch st pais. Physical Eaiatio r v al d, l vat d juular v ous pr ssur , H pato-spl o aly upo palpatio, Ascit s, Low r Etr ity Ed a. At th ER h was diaos d + * /+-3 ,0 . + . c
u u" u # Coroary Car Uit with T l try (ICCU) S rious ëatch out for Cha s of S soriu, Difficulty of Br athi ad Ch st Pais BP = 140/100, HR = 98, T = 37C , RR = 22 Moitor Vital Sis 4 hours util stabl !"# B d R st o s i-fowl rs 12 hours with b dsid cood , th r aft r if stabl ay r su liht activity. ë ih th pati t v ry AM ad r cord. NPO c pt with sips of wat r ad dicatios util pai fr ad stabl for 24 hours Sodiu R strictio <2/Sodiu p r 24 hours, h art h althy di t, o salt o cooki ad proc ss d foods. $ # CBC with Plat l t Cout ëBC aPTT ad PT/INR S ru Sodiu, Ma siu, Potassiu,ad Calciu Urialysis LDL, HDL, Chol st rol, SGPT, SGOT , FBS (Toorrow AM aft r Fasti) Rado Blood Glucos STAT v ry 4 hours BUN & Cr atii ! ECG with 2D Echocardioraphy th r aft r ECG/24 hours (AM) Plai Fi ld Ch st PA X-ray Plai Fi ld Abdoial X-ray Ultrasoud of th abdo Hook to Puls Oi try & Cardiac Moitori STAT
Art rial Blood Gas STAT %! 1. Nasal O2 at 2L-4LPM 6 hours 2. 0.9 NaCl with D5ë % 3. Uri Cath t r Is rt 4. Low Dos Carvidiol a. H art Failur 5. Furos id (Lasi) 20 IV Bolus or Spiriolacto b. Hyp rt sio PO STAT, th r aft r PO AM oly. c. Str ss Ulc r 6. IV Nitrolyc ri Drip for 24 hours Prophylais 7. Lactulos PO as stool soft r d. Ai ty 8. Diaz pa PRN oly for s v r ai ty . Corr ctio of 9. Diitalis PO El ctrolyt s ad 10. Captopril 6.25 8 hours Ed a 11. Lipid Low ri A ts oc r sult availabl f. Maa DM (Sivastati 40 OD) . D t ri 12. Dobutai IV Drip (10c/k p r iut ) Diitalis Toicity 13. Hydrocortiso IV blous 14. Raitidi 90 IV bolus ad Sucralfat PO 15. Isuli Bolus with Potassiu IV- Sid Drip via ifusio pup. Th r aft r Isuli Scali APIDRA 16. Aspiri 325 OD PO
DIAGNOSTIC TEST
c % % cc % % % &'c ' ' c( ( $ ) c ( ' c %' c c
c*c c
c , ! !,-
RESULT (Toorrow AM) (Toorrow AM)Y Noral Liits
(Toorrow AM) 135 5.4 (Toorrow AM) (Toorrow AM) <4,500 >120 R sult Ud rway aft r 3 Days 2.0 INR 150,000 Noral Liits Noral Liits 130 Cardio aly ad Riht V tricular Hyp rtrophy Cardio aly, Ath roscl rotic Aorta with o puloary co stio. No at l tasis s . Dilat d Cardioyopathy, with Coroary Art ry Dis as , with Riht V tricular Dysfuctio od rat L ft V tricular Dysfuctio ad D pr ss d Ej ctio Fractio R sid .
RANGE 3.5-5.5 5 ,000-10,000 >120 2-3.0 INR 150,000 Noral Liits Noral Liits 80-100 -
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ë hav a cas of a 33 y ar old al pati t ca to th ER with th chi f coplait of . History r v al d that th pati t coplai d of ch st pais that is d scrib d as poudi ad stabbi o th ch st that was pr cipitat d wh th pati t do tra ous work-outs such as joi ad if h p ri c d otioal ups ts 6 oths prior to adissio. H d i d that h us d ciar tt soki ad r fus d that h is alcoholic b v ra drik r. H lov s to at proc ss d at ad oth r pork products. H d i d that h was hyp rt siv . H tio d that h was o di ti 6 oths ao ad took a pill call d - . ' !/ ( $$ % %% & % ' ) for 2 pills/24 hours for thr oths. H stopp d th pill aft r h coplai d ck pais, palpitatios ad isoia ad th syptos r li v d radually. H visit d a it rist ad h was diaos d with CAD or ath roscl rotic typ of aia, ad HPN sta 2 ad was su st d that h ust ud ro coroary aioraphy with st ti to visualiz ad r ov possibl blocka o th coroary art ry, ad stop th dru that h was taki (Lipo6 Black), but th pati t r fus d to ud ro diaostic t sts du to fiacial costraits. Pati t was aitai d to Propraol OD, Nif dipi , Raipril, Aspiri OD ad if ch st pais occurs Isosorbid Diitrat ayb iv SL. H was advis d to visit th cardioloist 1 w k aft r th iitial visit to ud ro oth r t sts lik str ss t st with ECG ad 2D- cho ad Chol st rol with HDL-LDL d t riatios but fail d to coply sic th pati t has o isurac to cov r th s work-ups. F w hours prior to adissio, whil th pati t is o his r ular routi y work-ups h p ri c d ch st pais, that is accopai d with dizzi ss ad pai lat raliz s to riht ar. H i diat ly took Isosorbid iitrat pill SL for 2 ti s with 3-5 iut it rvals but o affordi r li f. Th pai b co s or it s ad h was s t to ar st hospital Makati-M dical C t r. Physical Eaiatios r v al d, %$ 4 ) 5 #6 ## +) 5 #$ '( ( - 1) 7 Acut ST-S t El vatio, At rio-S ptal ëall Myocardial Ifarctio, Killip Class 1, Forr st r Cass 1, HPN Sta 2. Coroary Car Uit with T l try (ICCU) c S rious ëatch out for Cha s of S soriu ad Ch st Pais BP = 150/100, HR = 108, T = 37C , RR = 21 Moitor Vital Sis 4 hours util stabl !"# Strict B d R st 12 hours with b dsid cood , th r aft r if stabl liht activity. NPO c pt with sips of wat r ad dicatios util pai fr ad stabl for 24 hours 2/Sodiu, h art h althy di t (aft r Cardiac Cath rizatio) $ # Tropoi I or T, CK-MB v ry 8 Hours CBC with Plat l t Cout ëBC aPTT ad PT/INR S ru Sodiu, Ma siu, Potassiu ad Calciu
!
! 0 -#
%!
Urialysis LDL, HDL, Chol st rol, SGPT, SGOT FBS (Toorrow AM aft r Fasti) Rado Blood Glucos BUN & Cr atii ECG with 2D Echocardioraphy th r aft r ECG/24 hours Plai Fi ld Ch st PA (X-ray) Hook to Puls Oi try & Cardiac Moitori (ëatch out for Cardiac Tachy-arrhythias or abs t P wav s) ABG S cur E r cy Drus ad Cardiac D fibrillator PRN E r cy priary coroary aioraphy withi 90 iut s ad fibriolysis Str ptokias IV 1.5 MU bolus i 30-60 iut s For Priary P rcuta ous Coroary It rv tio (PCI) 1. Nasal O2 at 2L 6 hours 2. D5ë IV 3. Uri Cath t r 4. Aspiri 325 ch w d o Adissio th 162 PO D ( t ric coat d) 5. IV H pari 60/k bolus (12/k/hr) 6. M toprolol 12.5 PO v ry 6 hours (Hold SBP <100, Puls <50, Astha/Crackl s) 7. IV Nitrolyc ri Drip for 24 hours 8. Morphi Sulfat 4/IV Bolus th r aft r 5-15/i PRN for ur li v d pai 9. Lactulos PO as stool soft r 10. Diaz pa PRN oly for s v r ai ty 11. Captopril 6.25 8 hours 12. Lipid Low ri A ts oc r sult availabl (Sivastati 40 OD) 13. S cur Lidocai PRN ad Dioi IV PRN for Suprav tricular Tachycardia. 14. C furoi 500/IV aft r (-ANST) 15. Hydrocortiso IV blous 16. Raitidi 90/IV STAT with Sucralfat PO
c DIAGNOSTIC TEST TROPONIN I (TI)
CK-MB
SGPT SGOT LDL HDL CHOLESTEROL SODIUM POTASSIUM
RESULT POSITIVE (>20 fold) " $ POSITIVE (El vat d) " $ El vat d El vat d (Toorrow AM)Y (Toorrow AM)Y (Toorrow AM) 137 5.6
RANGE NEGATIVE (Trac )
NEGATIVE
3.5-5.5
CALCIUM MAGNESIUM ëBC HB Blood Cultur Prothrobi Ti & INR Plat l t Cout BUN CREATININE RANDOM BLOOD SUGAR ECG
CHEST PA
ECHO-CARDIOGRAPHIC FINDING
(Toorrow AM) (Toorrow AM) >14,000 149 R sult Ud rway aft r 3 Days 2.0 INR 150,000 Noral Liits Noral Liits 110 ST-S t El vatio, Cardio aly ad Tachycardia, At riorS ptal ëall MI (L sid d) V1-V3 Cardio aly, Ath roscl rotic Aorta with o siificat puloary fidis Dilat d Cardioyopathy, with Coroary Art ry Dis as with acut yocardial ifarctio o r sti chocardioraphy, ad P ricarditis
5 ,000-10,000 >140 2-3.0 INR 150,000 Noral Liits Noral Liits 80-100 -
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