Intern Report Inpatient Cardiology October 2023.pptx

Case on Endocarditis with evidence-based approaches and clinical decision making

1. AFTERNOON REPORT Jesse Medina Nabiha Khakoo 10/11/23

2. CHIEF COMPLAINT: 70-year-old female presents to the ED with left lower quadrant abdominal pain of 9 hours duration.

3. HISTORY OF PRESENT ILLNESS: 70-year-old female presenting with LLQ abdominal pain of 9 hours, she describes the pain as aching, radiating to the left flank, gradually worsening, intensity 8/10 abdominal which prompted her to visit the ED @15:00hrs on 9/24/23, associated with nausea but no vomiting. She also endorsed mild shortness of breath, dry cough, generalized weakness, anxiety and stress over the last few days. Lastly, she refers a slight intermittent constant dull chest pain located in the middle of her chest that radiates to her back, intensity 3/10, that alleviates with rest and increases on exertion.

4. PMH Medications Hypertension Diverticulosis Vertigo Prediabetes Psoriasiform contact dermatitis Tinea corporis Acetaminophen 325mg Betahistina 16mg Losartan 50mg Pantoprazole 40mg Vitamin C 500mg Hydroquinone topical cream 4% Ketoconazole topical 2%

5. PSH Family History Bartholin cyst removal – 1988 Hysterectomy and appendectomy-2002 Cholecystectomy - 2003 ORIF of left elbow- 2022 Father – stomach cancer Sister – lung cancer Brother – pancreatic cancer *No family history of CAD, MI, SCD Allergies: Ciprofloxacin Social history Originally from Venezuela, but has lived in Miami for 5 years Lives with husband and children. Rest of family back home. Denies tobacco/alcohol/drug use Employment: lawyer

6. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever, chills. Positive for fatigue, malaise, generalized weakness, HEENT: No vision loss or blurring. No sneezing, congestion, runny nose or sore throat. SKIN: rash and itching on left 4 th finger and left medial shin. CARDIOVASCULAR: Positive for chest pain. No palpitations or swelling of legs RESPIRATORY: positive for shortness of breath, dry cough. GASTROINTESTINAL: Positive for nausea, abdominal pain . No vomiting or diarrhea. GENITOURINARY: No hematuria or dysuria. NEUROLOGICAL: No headache, dizziness, syncope, numbness or tingling in the extremities. No history of previous head trauma. MUSCULOSKELETAL: No muscle pain, back pain, joint pain or stiffness. HEMATOLOGIC: No bleeding or bruising. LYMPHATICS: No cervical, axillary, or inguinal lymphadenopathy. PSYCHIATRIC: No suicidal ideation. No visual, auditory, or tactile hallucinations.

7. Additional Questions?

8. Differential Diagnosis?

9. Working through a Differential METABOLIC INFECTIOUS/IATROGENIC/INFLAMMATORY NEOPLASTIC TRAUMA/TOXIN SLE/STEROIDS/SOMETHING ELSE This Photo by Unknown Author is licensed under CC BY-SA

10. Working through a Differential

11. PHYSICAL EXAM

12. VITALS:

13. Changes in Differential? What’s your next step?

14. LABS: 8.3 13.9 42.6 215 123 (H) 140 4.1 104 24 18 0.7 Troponin: 0.107 (H) Alkaline Phosphatase: 132 (H) Lipase: 119 Lactic acid: 2.2 (H) 9/24/23 @ 16:55 Ca: 9.6 Mg: 2 Total protein: 7.5 (H) Albumin: 4.4 Total bilirubin: 0.6  AST: 32 ALT: 23 Alk Phos: 132 (H) PT: 14.5 APTT: 32 INR: 1.12

15. Urine Analysis Color - yellow Clarity- Clear USG- 1.017 pH- 6 Protein- negative Glucose- negative Ketones- trace Bilirubin- negative Blood- 0.2 Urobilinogen- negative Leukocyte esterase-25 WBC- 4 RBC-17 Squamous epithelial cells- 1 *Negative Urine culture Flu Panel Flu A- negative Flu B- negative RSV- negative Sars Cov 2 RNA RT PC- negative Viral Screening HCV- negative HIV- negative

16. EKG

17. Left ureterovesical junction 3mm stone with mild left hydroureter and mild hydronephrosis, associated with left pyelonephritis

18. 9/24/23 @ 23:25 = Troponin 3.720 9/25/23 @ 04:47 = Troponin 7.560 9/25/23 @ 11:00 = Troponin 6.090

19. 2nd EKG on 9/25/23 @ 1:02 am

20. NICM Nonobstructive coronary disease Findings: LM: angiographically normal LAD: mild luminal irregularities LCx : small atrial branch with questionable SCAD. Remainder of LCx and OM are normal RCA: normal

21. LABS: WBC DIFFERENTIAL: Segmented neutrophil (%): 66.0 Band neutrophil (%) - Lymphocyte (%) 24.7 Monocyte (%) 6.2 Eosinophil (%) 1.8 Basophil (%) 0.6 Atypical lymphocytes (%) - Myelocyte (%) - Metamyelocyte (%) - Absolute Neutrophil 5.5 Absolute Lymphocyte 2.1 Absolute Monocyte 0.5 Absolute Eosinophil 0.15 Absolute Immature Granulocyte 0.04 18.6 (H) 13.2 38.5 161 118 (H) 138 3.7 105 25 19 0.7 Troponin: stop trending 9/25/23 @ 14:25 9/26/23 @ 03:41 9.4 12.2 36.75 150 109 (H) 137 3.6 105 24 18 0.6

22. LA LV Ao

23. LA LV Ao * * EF 35-40%

24. 3rd EKG on 9/25/23 @ 16:12:15

25. 4th EKG on 9/26/23 @ 6:24 am

26. CHANGES IN DIFFERENTIAL?

27. DIAGNOSIS Mid-Ventricle variant Takotsubo induced by Urolithiasis

28. TREATMENT GDMT for HFrEF Metoprolol 12.5mg PO BID Candesartan 8mg Titrate rest of GDMT outpatient ACC cardiology clinic Rosuvastatin 20mg Tamsulosin 0.4mg + hydration + pain meds Cefepime 2g every 12 hrs from (9/24/23 to 9/27/23) then converted to Augmentin 875/125 mg PO BID x 7 days

29. HOSPITAL COURSE On arrival to the ED, pt was hypertensive but otherwise with stable vitals. Initial EKG and troponin were normal. Pt underwent CTA to r/o acute intraabdominal pathology which found a left sided kidney stone. On return from CT, pt developed worsening chest pain with pressure in the mid-sternum. EKG showed ST depressions in anterolateral leads and troponin increased to 3.7. Pt was started on ACS protocol and admitted to CCU for further evaluation. Interval History: 1. Underwent Echocardiogram and report Takotsubo with EF of 35-40%. 2. Underwent PCI that described - LM: Angiographically normal - LAD: Mild luminal irregularities - LCx : small atrial branch with questionable SCAD. - Remainder of LCx and OM are angiographically normal - RCA: Angiographically normal 3. Transferred to CCU post PCI for observation. 4. Downgrade to cardio wards for continued ATB tx and GDMT initiation.

30. Teaching Points

31. Takotsubo Cardiomyopathy (TTC) Syndrome characterized by transient systolic and diastolic LV dysfunction that mimics MI but does NOT have angiographic evidence of obstructive CAD or acute plaque rupture Occurs in 1-2% of pts presenting with suspected ACS Predominantly affects elderly women Often preceded by an emotional or physical trigger Classic regional WMA described as “apical ballooning” Mid and apical segments of the LV are hypokinetic or akinetic Hyperkinesis of the basal walls Pathogenesis not fully understood: Catecholamine excess Microvascular spasm  myocardial stunning Direct toxicity myocardial injury Coronary artery vasospasm Co-existing non-obstructive CAD

32. Clinical Presentation Postmenopausal women*** Inciting stressor*** Prevalence of physical stressors exceeds that of emotional stressors Absence of stressor does not exclude diagnosis Association seen in acute or chronic neurologic & psychiatric disorders Chest pain*** Most commonly substernal Associated dyspnea or syncope Signs of decompensated HF (e.g., volume overload, pulmonary edema, congestive hepatopathy) Arrhythmias (tachy & brady) Cardiogenic shock +/- TIA or stroke (2/2 embolization of LA thrombus)

33. Diagnostic Evaluation troponin Elevated in all pts with TTC Median initial troponin was 7.7x ULN (International Takotsubo Registry) EKG changes ST elevation Occurs mostly in the anterior precordial leads T-wave inversions Coronary angiography Required to rule out ACS Serial assessment of LV systolic function Initial ventriculography or ECHO Subsequent ECHO or cardiac MRI  

34. THANK YOU!