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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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