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Cardiac assessment at the cutting edge (PowerPoint)

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									Cardiac assessment at the
      cutting edge

             Joanne Smith
           Nurse Practitioner
           Maureen Coombs
    Consultant Nurse in Critical Care
 Southampton University Hospitals Trust
                   Case study 1
67 year old female
Attended pre-assessment clinic for mitral valve
  surgery for mitral regurgitation

Past Medical History
   Diabetic - Type 2 on Insulin
   Hypertension
   Renal impairment
   R & L Varicose Veins Stripped 1990
   R cataract surgery 1998
History of Presenting Complaint
   Diagnosed with ‘murmur’ in 1998, during
    admission for cataract surgery
   Referred to Cardiologist – for Echo
   Complains of breathlessness when doing
    housework and climbing stairs
   Intermittent chest pains on exertion, radiation to
    L breast
   Reviewed 6/12 in outpatients
        Recent History of Illness
   Breathlessness on minimal exertion
   Feeling tired and lethargic
   Chest discomfort occurring at any time
   Coronary angiogram – October 2005 – normal
    coronary arteries
   Referred for Elective MVR
                Pre-assessment
   Short of breath on arrival at clinic
   Evidence of weight loss – ill fitting clothes
   Generalized pallor
   ECG – RBBB, HR 59bpm
   BP – 155/70, RR 16 min, O2 Sats 95% air
   States 3 episodes of collapse in previous 6
    months
                Review of Systems
   Respiratory
    RR 16 min, equal lung expansion, bi-basal crackles, resonant


   Cardiovascular
    Apyrexial, pitting oedema to ankles, heaving apex, thrill present
    throughout. Loud bilateral carotid bruits. Loud systolic murmur in
    aortic region (grade 4). Loud pansystolic murmur radiating to axilla
    (grade 3 in mitral region), bilateral femoral bruits.
    Hb 98g/L, JVP 5cm at 45 degrees
                Review of Systems
   Renal
    Urea 17.8, Creat 181 (Under c/o Nephrologist)


   Neurological
    Evidence of peripheral neuropathy, secondary to diabetes

   GI
    Generalized tenderness over whole abdomen, recent
    unintentional weight loss (10 Kg in 2 months), loss of appetite,
    states recent episodes of fresh blood whilst having bowels open,
    BMI < 20
                 Review of Systems
   Social
    Lives with husband and 2 daughters in Portsmouth.
    Usually independent with activities of daily living

   Drugs
    Bisporolol
    Ramipril
    Amlodipine

   No known allergies
Clinical Investigations and Outcomes
   Admitted to unit for further investigations
   Repeat transthoracic echo
    – Moderate / severe aortic stenosis
   CXR
    – Evidence of cardiomegaly, pulmonary oedema, no
      major lung pathology
   Abdominal USS
    - ? Lower abdominal mass / referred for colonoscopy
                  Case study 2
   63 yr old male
   Married with 2 sons and a daughter
   Lives in Spain and on south coast

   E/A from renal unit for cardiac surgery
   Intubated, ventilated, sedated and on inotropic
    support
    Recent history of current illness
   Aug 2006    Diarrhoea – 3 weeks
   Sept 2006   ICU admission for E. coli sepsis
                6 day hospital stay
   Oct 2006    SOB, anaemia, renal failure
                (BE -7.4, HCO3 18.7)
   Nov 2006    Re-admitted with pulmonary
                oedema, metabolic acidosis,
                haemofiltered
                Cardiac investigations
                      PMH
   Adult polycystic kidney disease
        normally good u/o, creat. 300
   Hypertension
   Intracerebral haemorrhage (1995) – full recovery
   Gout
   Active and independent until Aug 2006
                Review of systems
   RS
     Intubated and ventilated. Pressure Controlled Ventilation 500 x
       15. FIO2 0.6%, PEEP 5. PaO2 6.92. Air entry all zones.
       Bi-basal crackles

   CVS
     SR 105/min, B/P 105/46 (MAP 70) on Noradr. 13, Dopamine 6.
       RA 14. Electrolytes within range. Lactate 1. Cool peripheries.
       Apyrexial. WCC 8.9. CRP 66. Nil on blood cultures. Clotting
       NAD. Splinters left hand. Bounding short carotid pulses.
       Heaving Apex. Diastolic murmur 2/6 Aorta and SM 3/6 Apex
       and LSB
CXR on admission
              Review of systems
   Renal
    CVVH via Lt. femoral vascath. Last filtered 24 hours
    ago
    u/o 10mls/hour. Achieving 100 mls/hr off filtre
    Negative 2L bal achieved. Ur 13.3, Creat. 442
   Neuro
    PERL size 4, Sedated Alfentanil and Propofol
   GI
    Abdo soft. Massive ballottable kidneys. 3-4cms smooth
    liver edge. Bowel sounds present. LFTs NAD.
    Albumin 23. BM 6.8 on Insulin sliding scale
               Review of systems

   Hygiene
    All areas intact. Eyes/mouth clean and moist. All lines
    clean and dry. No obvious inflamed joints

   Social
    Wife and family aware of t/f and plan for surgery
    Consent to be obtained

   Drugs
    On Ben-pen QDS IV for suspected IE
Clinical Intervention and Outcomes

   AVR (Bovine Pericardial bioprosthesis)
   Valve triscuspid, structurally normal

   Slow recovery requiring respiratory, cardiac and renal
    therapy support. Tracheostomy day 10
   Haemofiltration d/c day 20, u/o with diuretic support
   Slow wean onto CPAP and trachy mask
   Discharged from CICU day 29. Discharged home day 42
In conclusion, have we
 achieved what we set
        out to?

								
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