Case - AMI & complications

Mr T, is a 64 year old gentlemen admitted to hospital 5 days ago with a cough and SOB on a b/g of a recent AMI 6 weeks ago and subsequent pleural effusion with a background history of DM.

HOPC

He first developed dry Cough and SOB 5 weeks ago. Day 1 after being discharged from hospital for his AMI. He also had fevers, sweating. No sputum production, chest pains, palpitations at that time. 4 days later he went to his GP. Had a CXR done which showed left-sided pleural effusion. Then admitted to hospital and started on oral doxycycline and amoxicillin and observed. He was subsequently discharged with the following medication. He was feeling unwell throughout. 6 days ago in the evening he suddenly developed chest pains that radiated on the left side from the front to the back. He was unable to tell whether it was of a similar nature to his previous AMI pain. There was associated coughing and SOB, no sputum production. no palpitations, nausea, vomiting or sweating. Relieved by panadeine fort and GTN. 2 days later the GP sent him to the hospital where he was managed both for his respiratory and cardiac problems. For his respiratory, had his antibiotics switched to IV ceftriaxone, U/S of the chest and CXR showed resolution of the effusion. In terms of his cardia problems, put on a holter monitor that showed a tachycardia and an abnormal rhythm. He had DC cardioversion last night and he reports feeling well and he noticed better perfusion of his fingers and better skin tone.

Had a recent AMI 6 weeks ago during the evening with symptoms of vomiting, pain to his right shoulder tip, cheeks, chest, sweating and general sense of unwell. No meleana or fresh blood, he vomited only his food contents. His pain was 4/10 chest, 6/10 left cheek and 5/10 in his right shoulder tip. It was described as a dull aching pain. No agg/reliefing factors at that time. Unable to lie in bed and had to sit in his chair and slept fitfully the rest of the night. The next day he went to the GP who sent him to the ER and was diagnosed with a AMI with raised cardiac enzymes and ECG changes. He was subsequently investigated with an angiogram and a echocardiogram. 5 days post-admission he developed a sharp pain that radiated from his shoulder to the face with no other associated symptoms. It was an 8/10 in severity. Came on suddenly and was constantly there. He was diagnosed with pericarditis. Treated with morphine and oxygen. This pain subsided 48hrs later and he was discharged.

Medical history
CVD RF: No HT, no chol, smoked a pack a week for 3 years during his university days, drinks socially, has DM.

His type II diabetes was diagnosed 5-6 years ago on routine blood screen. Currently managed on diet and exercise control. He avoids sugary food, takes low fat and lean meat. Walks his dog 4 times a week/ 30min each time. Has lost 30kg from 134-104kg. After his recent admission to hospital his blood sugars were not well controlled and was put on insulin. currently on 3 times novorapid and one evening bolus of glargine. His current average blood glucose is 6mmol/L on insulin. No macro/microvascular complications of DM.

Non-active medical conditions: gall bladder removal, recently diagnosed carpel tunnel, hayfever and asthma when he was a kid, appendicitis.

Medications:
Novorapid, glargine, ceftriaxone, fruesemide, atenolol, atorvastatin, perindopril, aspirin, clopidogrel.

FH:
Father lung cancer, 79. Mother, diabetic.

Social: Live/family, support, depresion, financial, depression, exercise/drinking/diet/smoking, insight.

Physical examination:

Peter is a well-looking man, orientated in time/place. Not in any pain or respiratory distress.
V/S: HR 60bpm, regular. RR18bpm. BP110/70. Oxygen sats on room air was 94%. On general inspection. He had no supplemental oxygen, a venous cathether in the dorsum of this right hand. Scars??

On cardiac examination:
No pale palmar creases, no manifestations of IE. On inspection of his face, no central cyanosis or jaundice. JVP was not elevated. Carotid pulse felt normal. Apex beat was not displaced. No palpable heaves or thrills. Dual heart sounds with no murmers.

On respiratory examination:
No deviation of the trachea, No palpable LN. Chest expansion was equal and normal. Stony dullness to percussion on mid to lower region on his left side. On asculation, there was decreased breath sounds and decrease vocal resonance.

In summary, Mr T is a 64 y.o gentlemen who was admitted to hosptal 5 days ago with cough and SOB on a b/g of a recent AMI. The SOB began 3 weeks ago and was treated with IV ceftriaxone. His current physical examination findings are consistent with a left sided pleural effusion. His issues are.

1. managment of his pleural effusion - which requires organized follow up with the GPs + continued Antibiotics. CXR to monitor the current pleural effusion.

2. Managment of his MI - start him on ACS medication and continue to watch for SE. and monitor complications. Optimise the control of his risk factor particularly his diabetes.

PUO- endocarditis

Intro:
Peter is a 80 y.o gentlemen who came to the hospital via ambulance due to an episode of uncontrollable rigors and SOB. This is in the setting of a previous pacemaker infection in October 2008.

HOPC

6 days ago, he had an episode of rigors that lasted about 20min. He was at home at that time and he started shaking uncontrollably with involved all of his limbs there was associated SOB, increase RR and feeling cold. No chest pains, palpitations. There was no associated neurological deficits- muscle weakness, numbness, visual changes. There was no LOC. During this episode he called the ambulance and was sent to the hospital. He recovered in the ambulance and was feeling tired but otherwise not confused. Prior to this episode he had two similar episodes while at home and while in hospital he developed a similar episode. The total number of attacks is 4.

Patient has no recent

· Fevers ( spiking (malaria), high swinging( abscesses), constant ( gen. bacterial/ neoplasia/CTD), intermittant fever (viral especially in paediatrics) ( (has chills and rigors)
· Fatigue, LOW(despite eating a lot), night sweats.
· Localised symptoms:
1. Cough, sputum(blood? Colour? Amt?), (SOB)
2. Chest pain, palpitations, PND, orthopnea, pillows used, peripheral odema (if HF)
3. urinary – freq, urgency, nocturia, dysuria, and incontinence
4. diarrhoea, constipation, abdominal pain, blood in stools
5. Neck stiffness, photophobia, Head ache
6. Arthralgia (backpain – epidural abscess), myalgia and skin rashes.
7. ear pain, face pain (sinusitis).
8. wounds/bites.

· Dentition
· Immunization – was up to date with both his pneumococcal and flu vaccine
· Contact – no contact with anyone that’s sick recently or anyone with TB
· Travel – gone to alice springs and NT but nothing too adventurous like swimming in rivers
· Occupation – purchasing manager
· Animals – No
· Drugs – later
· Sex- Nil.

Medical conditions

· Heart failure with AF was diagnosed in 2002. He presented with APO and was unable to sleep at night his wife had to send him in ED. A pace maker was then inserted in December 2002. Since then he does not complain of PND, orthopnea, uses 1 pillow, has occasional leg swelling well controlled by diuretics. His exercise tolerance is about 50m.
· October last year he noticed a rash on his skin overlying the pacemaker. Prior to this he developed a boil on his head when he bumped his head on the shower. His GP sent him to the hospital for further investigations and he was treated for a pacemaker infection with 1/12 of antibiotic treatment and the infection was presumed cleared.
· He had no other admissions for exacerbations for HF. His current HF meds are carvedilol, spironolactone, lasix.

Non-active medical conditions
· 2 hernia operations (1980)
· Right knee replacement (80’s)
· Backpain caused by lumber sacral spinal stenosis, which is getting worse recently. Still able to drive, no muscle weakness or numbness
· OSA(04’)- used to be on CPAP but doesn’t need to use it now.
· Bilateral varicose veins

CVD risk factors – HT, high cholesterol, No DM, smoked 16 pack/yrs and quit when he was 35.

Medications-
Carvedilol, spironolactome, lasix, lipitor, irbesatan, warfarin.
Was treated on ceftriaxone, flucoxicillin and vancomycin 3 days ago for empirical treatment of sepsis.

FH- NIL
Social – live, occupation, depression, financial, support, exercise, diet.

On physical examination

· Alert, well-orientated, no signs of fevers, rigors or sweats.
· V/S – 120/80 bp, 72 HR regular, sats 98%, temperature 37.7 at 0600hrs but previously afebrile.
· CVL in for 3 days – area of insetion not oedematous or red.
· Cannula on right arm.
· Pacemaker area not oedematous, no rash.

CVD exam – normal. Looking specifically for signs of IE – Janeway, oslers, splinter haemorrhage. Petechiae in the conjunctivae. Roth spots. Splenomegaly.

Resp- Normal

Abdomen – normal

Mx issues-
Identify source of infection – septic screen - sputum, stool, urine culture. CSF? CXR. Ideally 3 samples of bloods spaced at least 30min apart.
Empirical treatment for sepsis – antibiotics ( gentamycin+ ceftapine) + supportive therapy. This treatment does not cover for gram +ve -staphs aures, enterococci. [ use ampicillin or vancomysin], TB, PCP (co-trimaxazole, if allergic to sulphur meds use pentamidine), anaerobes(metronidazole). Consider fungal causes. If less sick ceftriaxone + stat dose of gentamycin is enough.