CASE 1: Left sided heart failure leading to pulmonary edema and CAP We have a case of a 66 year old female

patient with a chief complaint of Difficulty of Breathing and Chest Pains. History revealed the patient complained of difficulty of breathing accompanied of mild to moderate chest pains, and easy fatigability aggravated once patient uses 1 pillow on supine position and relieved if in semi-high fowlers position, and unable to do common house choirs such as walking on 6-7 stair case steps. She mentioned that she had experienced awakening at night 1 am or 3 am due to difficulty of breathing and cough. The patient denies that she had swelling on the feet or weight gain. She also mentioned that she strictly followed doctor orders such as medication, diet, activity and clinical visit schedules. Confirmed non-cigarette smoker and non-alcohol beverage drinker by registered private RN in the household. 8 years prior to admission the patient had elevated blood glucose and was diagnosed with Diabetes Type 2 and was maintained on Metformin, and well compliant to medications and clinical visitation achieving normal HgB 1AC results done Routinely every 3 months. 4 years prior to admission the patient had CAD diagnose by cardiologist and was maintained on Aspirin, Nifedipine, and Nitrates and diabetic regimen. 2 years prior to admission the patient was diagnosed ST-Elevated Anterior Wall Myocardial Infarction and subsequently admitted PCI was not done because she responded to anti-thrombolysis therapy with streptokinase and stable. She was maintained with Digoxin, Aspirin and Nitroglycerin, Metoprolol, Captoril and Nifedipine. Few months Prior to admission the patient visited cardiologist and she was diagnosed Heart Failure stage C, Old MI 2010, NYHA III. She was advised to seek for possible heart transplant and negosations for possible donor is underway. She was maintained with Captopril, Low dose Metoprolol, Digoxin, Spirinolactone, Nitrates SL and Aspirin. Few days prior to admission the patient mentioned that she visited a relative with a respiratory tract Infection probably viral and upon reaching home she experienced runny nose and eventually coughing. No medication was taken for the common flu. She had Flu Vaccine H1N1 given last year. Vital Signs: HR = 90 RR = 22 T = 37.5 BP = 130140/90. Physical Examination revealed, Dyspnea on exertion with ordinary physical activity, Parosysmal Nocturnal Dyspnea (after four hours sleep, relieved when the patient sits for 15-30 minutes), (+) Orthopnea (immediately after on supine position change for 5 minutes post), Cardiac Asthma with Cheyne-Strokes Respiration, (+) S3 gallop on heart sounds and Feverish. At the ER she was diagnosed Heart Failure stage C, Old MI 2010, NYHA III, DM Type 2, CAP, Pulmonary Edema Here are the Admission Orders: Admission Orders Diagnosis: Admit: Condition: Order Heart Failure stage C, Old MI 2010, NYHA III, DM Type 2, Community Acquired Pneumonia and Pulmonary Edema Coronary Care Unit with Telemetry (ICCU) with Isolation Serious Watch out for Changes of Sensorium, Difficulty of Breathing

and Chest Pains Vital Signs: BP = 130/90, HR = 91, T = 37.8 C , RR = 22- with apnea-20 Monitor Vital Signs q4 hours until stable Activity: Bed Rest on semi-fowlers x 12 hours with bedside commode, thereafter if stable may resume light activity. Weigh the patient every AM and record. Diet: NPO except with sips of water and medications until pain free and stable for 24 hours Sodium Restriction <2g/Sodium per 24 hours, heart healthy diet, no salt on cooking and processed foods. Laboratory Test: CBC with Platelet Count WBC Blood Culture (STAT) Serum Digitalis Determination aPTT and PT/INR Serum Sodium, Magnesium, and Calcium Serum Potassium every AM Urinalysis and Culture LDL, HDL, Cholesterol, SGPT, SGOT FBS (Tomorrow AM after Fasting) Random Blood Glucose STAT x every 4 hours BUN & Creatinine Other Diagnostic Test ECG with 2D Echocardiography thereafter ECG/24 hours (AM) Plain Field Chest PA (X-ray) Hook to Pulse Oximetry & Cardiac Monitoring STAT Arterial Blood Gas STAT Medications 1. Nasal O2 at 2L-4LPM x 6 hours 2. 0.9 NaCl with D5W Target Management: 3. Urine Catheter Insert 4. Low Dose Carvidiol a. Heart Failure 5. Morphine Sulfate 10mg IM q 2- 4hours (-ANST) b. CAP Infection 6. Furosemide (Lasix) 20mg IV Bolus or Spirinolactone c. Hypertension PO STAT, thereafter PO AM only. d. Pulmonary 7. IV Nitroglycerin Drip for 24 hours Edema 8. Lactulose PO as stool softener e. Stress Ulcer 9. Diazepam PRN only for severe anxiety Prophylaxis 10. Digitalis PO f. Anxiety 11. Captopril 6.25mg x 8 hours g. Hypovolemia 12. Lipid Lowering Agents once result available h. Correction of (Simvastatin 40mg OD) Electrolytes 13. Piperacillin-Tazobactam 2.25g/IV to run 8 hours after (i. Manage DM ANST) j. Determine 14. Ipratropium HBr 20mcg +Salbutamol 120mg Digitalis Toxicity (Salbutamol) Aerosol STAT = 12 puffs/24 hours in divided doses. 15. Paracetamol 500mg PO q 4 hours (>37.5). Do not give if (<37C) 16. Dobutamine IV Drip (10mcg/kg per minute) 17. Hydrocortisone IV blous 18. Ranitidine 90mg IV bolus and Sucralfate PO 19. Insulin Bolus with Potassium IV- Side Drip via infusion pump. Thereafter Insulin Scaling APIDRA 20. Aspirin 325mg OD PO

DIAGNOSTIC TEST LDL HDL DIGITALIS ASSAY CHOLESTEROL SODIUM POTASSIUM CALCIUM MAGNESIUM WBC HgB Blood Culture Prothrombin Time & INR Platelet Count BUN CREATININE RANDOM BLOOD SUGAR ABG PaCO2 = >50 PaO2 = <89 ECG

RESULT (Tomorrow AM) (Tomorrow AM)

Normal Limits

RANGE 3.5-5.5 5 ,000-10,000 >120 2-3.0 INR 150,000 Normal Limits Normal Limits 80-100 -

CHEST PA

ECHO-CARDIOGRAPHIC FINDING

(Tomorrow AM) 135 5.4 (Tomorrow AM) (Tomorrow AM) <4,500 >120 Result Underway after 3 Days 2.0 INR 150,000 Normal Limits Normal Limits 126 Respiratory Acidosis with Compensated Metabolic Alkalosis Cardiomegaly and Left Ventricular Hypertrophy, Old Anterior-Septal Wall MI V1V3. Cardiomegaly, Atherosclerotic Aorta with significant pulmonary congestion, (+) Interstitial Edema with loss of pulmonary markings. (+) Kerley A & B Lines with subpleural fluid. No ateletasis seen. Dilated Cardiomyopathy, with Coronary Artery Disease, Left Ventricular Systolic Dysfunction (Segmental), with moderate Right Ventricular Dysfunction and Depressed Ejection Fraction L side.

CASE 2: Hypertension and Right Sided heart failure We have a case of 50 year old male patient came to the ER due to Abdominal and Lower Extremity Swelling. History revealed that the patient has a long standing Hypertension episodes since 5 years prior admission and patient is non-complaint to mediations and seldom visits medical consults. He mentioned that his usual BP was (130-160/90-100) and no maintenance medication. He denied that he has no family history of HPN but mentioned his parents died due to complications DM. Two years prior to admission the patient visit regular consult and found out that the patient was having Impaired Blood Glucose on FBS but failed to follow subsequent treatments and follow-ups. Few days prior to admission, the patient experienced easy fatigability, Lower extremity swelling and accompanying weight gain from 86lbs to 100 lbs. He also mentioned having easy satiety, and Right upper quadrant discomfort. He denied having dyspnea on exertion and chest pains. Physical Examination revealed, elevated jugular venous pressure, Hepato-splenomegaly upon palpation, Ascites, Lower Extremity Edema. At the ER he was diagnosed Heart Failure stage C, NYHA IV, DM Type 2, HPN stage 2. Here are the Admission Orders: Admission Orders Diagnosis: Admit: Condition: Order Heart Failure stage C, NYHA IV, DM Type 2, HPN Stage 2 Coronary Care Unit with Telemetry (ICCU) Serious Watch out for Changes of Sensorium, Difficulty of Breathing and Chest Pains Vital Signs: BP = 140/100, HR = 98, T = 37C , RR = 22 Monitor Vital Signs q4 hours until stable Activity: Bed Rest on semi-fowlers x 12 hours with bedside commode, thereafter if stable may resume light activity. Weigh the patient every AM and record. Diet: NPO except with sips of water and medications until pain free and stable for 24 hours Sodium Restriction <2g/Sodium per 24 hours, heart healthy diet, no salt on cooking and processed foods. Laboratory Test: CBC with Platelet Count WBC aPTT and PT/INR Serum Sodium, Magnesium, Potassium,and Calcium Urinalysis LDL, HDL, Cholesterol, SGPT, SGOT , FBS (Tomorrow AM after Fasting) Random Blood Glucose STAT x every 4 hours BUN & Creatinine Other Diagnostic Test ECG with 2D Echocardiography thereafter ECG/24 hours (AM) Plain Field Chest PA X-ray Plain Field Abdominal X-ray Ultrasound of the abdomen Hook to Pulse Oximetry & Cardiac Monitoring STAT

Medications Target Management: a. Heart Failure b. Hypertension c. Stress Ulcer Prophylaxis d. Anxiety e. Correction of Electrolytes and Edema f. Manage DM g. Determine Digitalis Toxicity

Arterial Blood Gas STAT 1. Nasal O2 at 2L-4LPM x 6 hours 2. 0.9 NaCl with D5W 3. Urine Catheter Insert 4. Low Dose Carvidiol 5. Furosemide (Lasix) 20mg IV Bolus or Spirinolactone PO STAT, thereafter PO AM only. 6. IV Nitroglycerin Drip for 24 hours 7. Lactulose PO as stool softener 8. Diazepam PRN only for severe anxiety 9. Digitalis PO 10. Captopril 6.25mg x 8 hours 11. Lipid Lowering Agents once result available (Simvastatin 40mg OD) 12. Dobutamine IV Drip (10mcg/kg per minute) 13. Hydrocortisone IV blous 14. Ranitidine 90mg IV bolus and Sucralfate PO 15. Insulin Bolus with Potassium IV- Side Drip via infusion pump. Thereafter Insulin Scaling APIDRA 16. Aspirin 325mg OD PO

DIAGNOSTIC TEST LDL HDL DIGITALIS ASSAY CHOLESTEROL SODIUM POTASSIUM CALCIUM MAGNESIUM WBC HgB Blood Culture Prothrombin Time & INR Platelet Count BUN CREATININE RANDOM BLOOD SUGAR ECG CHEST PA

RESULT (Tomorrow AM) (Tomorrow AM)

Normal Limits

ECHO-CARDIOGRAPHIC FINDING

(Tomorrow AM) 135 5.4 (Tomorrow AM) (Tomorrow AM) <4,500 >120 Result Underway after 3 Days 2.0 INR 150,000 Normal Limits Normal Limits 130 Cardiomegaly and Right Ventricular Hypertrophy Cardiomegaly, Atherosclerotic Aorta with no pulmonary congestion. No ateletasis seen. Dilated Cardiomyopathy, with Coronary Artery Disease, with Right Ventricular Dysfunction moderate Left Ventricular Dysfunction and Depressed Ejection Fraction R side.

RANGE 3.5-5.5 5 ,000-10,000 >120 2-3.0 INR 150,000 Normal Limits Normal Limits 80-100 -

CASE 3: CAD-Angina- MI We have a case of a 33 year old male patient came to the ER with the chief complaint of Chest Pain. History revealed that the patient complained of chest pains that is described as pounding and stabbing on the chest that was precipitated when the patient do extraneous work-outs such as jogging and if he experienced emotional upsets 6 months prior to admission. He denied that he used cigarette smoking and refused that he is alcoholic beverage drinker. He loves to eat processed meat and other pork products. He denied that he was hypertensive. He mentioned that he was on dieting 6 months ago and took a pill called Lipo6 Black (Caffeine Anhydrous, Methylhexaneamine, and Yohimbine) for 2 pills/24 hours for three months. He stopped the pill after he complained neck pains, palpitations and insomnia and the symptoms relieved gradually. He visited an internist and he was diagnosed with CAD or atherosclerotic type of angina, and HPN stage 2 and was suggested that he must undergo coronary angiography with stenting to visualize and remove possible blockage on the coronary artery, and stop the drug that he was taking (Lipo6 Black), but the patient refused to undergo diagnostic tests due to financial constraints. Patient was maintained to Propranol OD, Nifedipine, Ramipril, Aspirin OD and if chest pains occurs Isosorbide Dinitrate maybe given SL. He was advised to visit the cardiologist 1 week after the initial visit to undergo other tests like stress test with ECG and 2D-echo and Cholesterol with HDL-LDL determinations but failed to comply since the patient has no insurance to cover these work-ups. Few hours prior to admission, while the patient is on his regular routine gym work-ups he experienced chest pains, that is accompanied with dizziness and pain lateralizes to right arm. He immediately took Isosorbide initrate pill SL for 2 times with 3-5 minute intervals but no affording relief. The pain becomes more intense and he was sent to nearest hospital Makati-Medical Center. Physical Examinations revealed, (+) James Reflex (BP= 150/100, HR = 110), Cold Clammy Skin, No Cyanosis, No crackles, and was Apprehensive, Anxious and Diaphoretic. In ER Admission orders given to the patient: Admission Orders Diagnosis: Admit: Condition: Vital Signs: Activity: Diet: Order Acute ST-Segment Elevation, Anterio-Septal Wall Myocardial Infarction, Killip Class 1, Forrester Cass 1, HPN Stage 2. Coronary Care Unit with Telemetry (ICCU) Serious Watch out for Changes of Sensorium and Chest Pains BP = 150/100, HR = 108, T = 37C , RR = 21 Monitor Vital Signs q4 hours until stable Strict Bed Rest x 12 hours with bedside commode, thereafter if stable light activity. NPO except with sips of water and medications until pain free and stable for 24 hours 2g/Sodium, heart healthy diet (after Cardiac Catherization) Troponin I or T, CK-MB x every 8 Hours CBC with Platelet Count WBC

Laboratory Test:

Other Diagnostic Test

Recanalization Therapy

Medications

aPTT and PT/INR Serum Sodium, Magnesium, Potassium and Calcium Urinalysis LDL, HDL, Cholesterol, SGPT, SGOT FBS (Tomorrow AM after Fasting) Random Blood Glucose BUN & Creatinine ECG with 2D Echocardiography thereafter ECG/24 hours Plain Field Chest PA (X-ray) Hook to Pulse Oximetry & Cardiac Monitoring (Watch out for Cardiac Tachy-arrhythmias or absent P waves) ABG Secure Emergency Drugs and Cardiac Defibrillator PRN Emergency primary coronary angiography within 90 minutes and fibrinolysis Streptokinase IV 1.5 MU bolus in 30-60 minutes For Primary Percutaneous Coronary Intervention (PCI) 1. Nasal O2 at 2L x 6 hours 2. D5W IV 3. Urine Catheter 4. Aspirin 325 mg chewed on Admission then 162 mg PO qD (enteric coated) 5. IV Heparin 60mg/kg bolus (12mg/kg/hr) 6. Metoprolol 12.5 PO every 6 hours (Hold SBP <100, Pulse <50, Asthma/Crackles) 7. IV Nitroglycerin Drip for 24 hours 8. Morphine Sulfate 4mg/IV Bolus thereafter 5-15/min PRN for unrelieved pain 9. Lactulose PO as stool softener 10. Diazepam PRN only for severe anxiety 11. Captopril 6.25mg x 8 hours 12. Lipid Lowering Agents once result available (Simvastatin 40mg OD) 13. Secure Lidocaine PRN and Digoxin IV PRN for Supraventricular Tachycardia. 14. Cefuroxime 500mg/IV after (-ANST) 15. Hydrocortisone IV blous 16. Ranitidine 90mg/IV STAT with Sucralfate PO

DIAGNOSTIC REPORT DIAGNOSTIC TEST TROPONIN I (TnI) RESULT POSITIVE (>20 fold) (3 hours from chest discomfort) POSITIVE (Elevated) (3 hours from chest discomfort) Elevated Elevated (Tomorrow AM) (Tomorrow AM) (Tomorrow AM) RANGE NEGATIVE (Trace)

CK-MB

NEGATIVE

SGPT SGOT LDL HDL CHOLESTEROL

SODIUM POTASSIUM CALCIUM MAGNESIUM WBC HgB Blood Culture Prothrombin Time & INR Platelet Count BUN CREATININE RANDOM BLOOD SUGAR ECG

CHEST PA

ECHO-CARDIOGRAPHIC FINDING

137 5.6 (Tomorrow AM) (Tomorrow AM) >14,000 149 Result Underway after 3 Days 2.0 INR 150,000 Normal Limits Normal Limits 110 ST-Segment Elevation, Cardiomegaly and Tachycardia, AnteriorSeptal Wall MI (L sided) V1-V3 Cardiomegaly, Atherosclerotic Aorta with no significant pulmonary findings Dilated Cardiomyopathy, with Coronary Artery Disease with acute myocardial infarction on resting echocardiography, and Pericarditis

3.5-5.5 5 ,000-10,000 >140 2-3.0 INR 150,000 Normal Limits Normal Limits 80-100 -