Dana Wells - St. John's University



Case Presentation

CC: “I have chest pain shooting down to my left arm”

HPI: FM is a 53 yo male who came to the ER with chest pain 7/10. Chest pain occurred on way to detox clinic, patient pulling large luggage with him. Pain described as radiating pain to left arm, numbness in left hand and sharp lower back pain. Days prior to incident FM noticed intermittent chest pain lasting from 1-1.5 minutes and decrease in exercise tolerance from several months ago. FM positive for nausea, sweating, SOB and negative for vomiting. NTG relieved chest pain. FM has a history of cocaine abuse, last used 5 days prior and last drink few hours prior to ED.

PMH:

• Hypertension

• DM- Type 2

• Hypercholesterolemia

• MI x 2 in 2000 & 2003

• Bipolar

• Depression

• Anxiety

PSH:

• s/p CABG 1/2006

• s/p pericardial window 2007 cardiac tamponade

• PCI with 4 stents

SH:

• + IN cocaine use (last used 2 grams 5 days ago)

• - tobacco

• + EtOH 1 beer/day

• construction worker

• currently homeless, mom kicked out of house due to drug use

FH:

• Mother has HTN & DM-2

Allergies: NKDA

Meds on Admission:

• Abilify 30mg QD

• Nexium 40md QD

• Lisinopril 10 mg QD

• Metformin 500mg BID

• ASA 81mg QD

• Gabapentin 200mg TID

• Sertraline 25 mg QD

• Lipitor

• Novolin

• Ultram 50mg (as per patient)

PE:

VS: Ht: 6’2 ABW 96.7kg IBW 82.2kg T: 97.9 P 79-81, RR 16-18, BP 106-111/69-70, O2 98-100%

Gen: Patient easily aroused, fully cooperative.

VS: BP 130/82, HR 62, T 37.6◦ C, RR 22, Wt 71 kg, Ht 177.8 cm

CV: RRR S1 S2 no murmur, midline sterniatomy scar

Chest: Clear to auscultation

ABD: Soft, NT, ND + BS 4 quads, no organomegly

EXT: Clubbing BUE and BLE

Neuro: A & O x 3

Vitals:

| |6/11 5:18am |6/11 8:02am |6/12 8:00am |

|Na |141 |139 |139 |

|K |3.2 |3.6 |4.2 |

|Cl |101 |98 |103 |

|CO2 |24 |33 |25 |

|Glucose |138 |154 |110 |

|BUN |15 |15 |19 |

|Cr |0.8 |0.8 |0.9 |

|Ca | |7.8 |8.4 |

|Mg | | |1.9 |

|CrCl |123ml/min |123 ml/min |110 ml/min |

|WBC |6.8 | | |

|Hgb |12.8 | | |

|Hct |37.8 | | |

|Plt |272 | | |

Medications:

|Medication/Dose/Schedule |Start |Stop |Indication |

|Gabapentin 200mg TID |6/11/07 | |Diabetic neuropathy, tingling sensation hands |

|Lisinopril 10 mg QD |6/11/07 | |HTN |

|Metformin 500mg BID |6/11/07 | |DM-2 |

|Sertraline 25 mg QD |6/11/07 | |Depression |

|Simvastatin 40mg Q6pm |6/11/07 | |Hypercholsterolemia |

|Protonix 40mg QD |6/11/07 | |Ulcers |

|ASA 81 mg QD |6/11/07 | |CAD prophylaxis, anticoa |

|Abilify 30 mg QD |6/11/07 | |Bipolar, voice in head |

|Lantus 28 units Qam |6/11/07 | |DM-2 |

|NISS |6/11/07 | |DM-2 |

|Potassium 40 mEQ QD |6/11/07 | |Hypokalemia |

|Magnesium Oxide 400 mg QD |6/12/07 | |Hypomagnesium |

|Plavix 300mg x1 |6/12/07 |6/12/07 |Catherization load |

|Plavix 75 mg QD |6/13/07 | |Anticoagulant |

|Lantus 14 units Qam |6/13/07 |6/13/07 |DM-2 |

|MOM 30ml prn |NG | |Laxative |

|Maalox 30ml prn |NG | |Indigestion |

|Tylenol 60mg Q4H prn |NG | |Temp >101 |

Hospital Course/Progress Note:

6/11: Admitted from ER; stable with no more complaints of chest pain. Echo completed

with findings: EF 60%, normal LV function, trace tricuspid regurgitation, dilated aortic root.

6/12: Pt has no new complaints, denies chest pain overnight. Telemetry shows NSR and no changes on EKG. Rehab evaluated patient and addressed pts desire to detox: bed available 6/18 pt was instructed to bring list of meds to detox and not to use any EtOH or drugs. Catherization scheduled for tomorrow as recommended by cardiologist to evaluate pt cornaries- cath note: NPO midnight, gave ASA 81 mg and plavix 300 mg load and D/C metformin temporaily.

6/13: No new complaints. Pt denied any CP or SOB at rest however mild SOB upon exertion. Pt Lantus insulin reduced to 14 units. Catherization result: LHC with RCA 50-60% stenosis, mild diffuse disease.

6/14: Pt denies any groin or chest pain. Metformin still held and Lanuts resumed to normal dosing of 28 units Qam. Cardiologist placed patient on Plavix 75mg QD.

Problem List:

1. Chest Pain

2. Cocaine Use- Detox

3. Hypokalemia

4. Diabetes

5. Hypercholesterolemia

6. HTN

7. Depression

8. Bipolar

9. Anxiety

Problem #1 Chest Pain

Findings:

- Chest pain 7/10

- Radiation of pain to left arm and back

- Nausea

- SOB and diaphoresis

- Neg troponin x 2

- + cocaine use 5 days ago

- hypokalemia

- extensive cardiac history

- relief w/ NTG

Assessment: FM is a 53 yo male who presents to ED with chest pain and positive cocaine use 5 days ago and presentation of ACS symptoms. Chest pain could be secondary to cocaine use, however patient has CV risk factors and prior history. R/O MI as troponin negative. Goals of therapy is to relieve chest pain, assess cardiac function, restore potassium.

Recommendation:

- Assess cardiac function with follow up test

- Provide Sublingual Nitroglycerin 0.4mg every 5 minutes x 2 prn CP if no relief contact call 911.

Monitor:

- Chest pain symptoms resolving or worsening

- Blood Pressure & HR

- Patient wellness

- Pt initially symptoms subsiding ( N, SOB, diaphoresis)

Problem #2 Hypokalemia

Findings:

- K 3.2

- EtOH use

Assessment: FM is a 53 yo male who has asymptomatic hypokalemia which needs to be corrected to avoid cardiac events. Goal of therapy restore potassium and prevent cardiac events.

Recommendation:

- Potassium Chloride 40 mEQ po x1 dose and assess lab values for subsequent doses. 10mEQ = 0.1 raise in K+

- Advise to include in diet foods rich in potassium to prevent hypoK if lacking

Monitor:

- Potassium levels

Problem #3 Cocaine Use

Findings:

- Urine + cocaine

- Pt admits 2 grams 5 days ago

Assessment: FM is a 53 yo male who admits to intranasal cocaine abuse. Pt seems to require high doses to achieve drugs pleasurable effects and past medical history indicate long term substance abuse. Drug abuse attributed to patient significant cardiac history. Pt speaks of desire to quit.

Recommendation

- Avoid beta blocker use increases chance of MI

- Provide information and resources to aid in quitting.

Monitor:

- Cocaine withdrawal symptoms (depression, fatigue, decrease appetite)

- Pt behavior and motivation

- Heart rate & blood pressure

- Drug test periodically

Problem #4 Diabetes

Findings:

- Type-2

- Metformin 500 bid

- Lantus 28 units qam

- Gabapentin 200mg TID

- Novolin

- FBS 138

Assessment: FM is 53 yo male with history of diabetes with questionable control on DM. Average fingerstick reading of 190 however no recent Hg A1c available to assess glucose control. Goals of therapy to achieve HbA1C less than 7. Prevent macrovascular and microvascular complications of diabetes. Pt’s gabapentin dose is sub therapeutic.

Recommendation

- Order HgA1c

- Continue patient on lantus 28 units qam.

- Increase metformin to 750 bid

- Increase Gabapentin dose to 300mg TID

- Assess HgA1C if not at goal consider changing to rapid acting insulin, humalog 6 units TIDAC to cover post prandial glucose.

- DC metformin when SrCr exceeds 1.4

- Encourage lifestyle modifications (↑ physical activity and change diet)

- Implement footcare, visit podiatrist

- Implement eye care visit ophthalmologist

Monitor:

- Daily fngersticks

- Hb A1c Q 3-4 months

- Hypoglycemia symptoms: shaking, tachycardia, sweating, dizziness, hunger, headache, irritable.

- Hyperglycemia symptoms: extreme thirst, polyuria, dry skin, hunger, blurred vision, nausea, drowsiness

- Serum creatine

Problem #5 Cholesterol

Findings:

- Zocor 40 mg

- PMH

Assessment: FM is a 53 yo male with hypercholersterolemia. At this time no current lipid panel available to assess course of disease. However due cardio history (stents, MI, PCI) and likely cocaine induce arthrosclerosis tight control of cholesterol is needed.

Recommendation

- Order lipid panel

- Provide nutritional information on diet- restriction of saturated and trans fat and cholesterol intake.

- Take additional steps to achieve goals LDL50 TG 3x uln

- Muscle pain/pain & rhabdomyalysis

Problem #6 HTN

Findings:

- Lisinopril 10mg

- PMH

Assessment: FM is a 53yo male with history of hypertension that is well controlled on his current regimen and is appropriate. Patient is at goal achieving BP less than 130/80. Goals of treatment maintain a lifelong control of blood pressure to preserve renal function and prevent further cardiovascular events.

Recommendation:

- Continue lisinopril

- Implement low salt diet

Monitor:

- K levels

- BP readings

- Angioadema and cough

- Hypotension

- Renal function-CrCl ................
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