History:
81 year old female with PMHx Hypothyroidism, HDL, dementia, and PE on Xarelto, presents to the ED today sent in from NH s/p fall. Patient is A&O x 2 and is unable to give full history or ROS. Denies falling, fever, or difficulty breathing; however, as per triage note, patient was sent in s/p fall with noted to have temp 39.2 of Patient was noted to be hypoxic on RA, then placed on 4L of O2 via NC. 

Physical:
SKIN: Warm, dry; (-) cyanosis; (-) rash.
HEAD: (-) scalp swelling, (-) tenderness.
EYES: (-) conjunctival pallor, (-) scleral icterus, (+) EOMI
ENMT: Pharynx: (-) erythema; airway patent: (-) stridor; mucous membranes moist.
NECK: (-) tenderness, (-) stiffness
CHEST AND RESPIRATORY: (-) rales, (-) rhonchi, (-) wheezes; breath sounds equal bilaterally.
HEART AND CARDIOVASCULAR: (-) irregularity; (-) murmur, (-) gallop.
ABDOMEN AND GI: Soft; (-) tenderness, (-) guarding, (-) rebound (+) slightly distended
EXTREMITIES: (-) deformity, (-) edema, (-) tenderness, (+) full range of motion, (+) equal pulses in upper and lower extremities
NEURO AND PSYCH: Mental status as above.

Steps to rule out cardiac differential diagnoses:
Labs: CBC, CMP, Lipid panel, Troponin, CK-MB, BNP, NT-proBNP, blood culture (possible endocarditis)
Imaging: ECHO (look at ejection fraction, abnormal blood flow), CXR (possible CHF, PE, Pneumonia)

Pertinent Findings:
Xray: Patchy ground glass opacities along the periphery with the largest in the right upper lobe. Although nonspecific this is suggestive of atypical pneumonia.

Treatment Plan:
Maintain 4L of O2 via NC
Administer 0.9% sodium chloride via IV over 2 hours
Treatment of atypical pneumonia: Azithromycin x 7 days (500mg on first day, 250mg from days 2-5)
Monitor for target urine output of 0.5-1ml/kg/hr
Check vitals and obtain serial labs Q 8 hours

 

Significance of troponins and proBNP, what is EF, HFrEF vs HFpEF
Troponin I
Significance: released when there is damage to heart muscle, cardiac specific, rises 3-12 hour after MI, peaks at 24 hours and can stay elevated for days
Normal range: 0.00 – 0.045ng/mL
Lab results: 0.045 > 0.031 >0.010ng/mL
Shows improvement over time, falling into normal range, suggesting less risk/chance of cardiac ddx
Also note: troponin can be falsely positive in renal failure

NT-proBNP (N-terminal-prohormone BNP)(non-active prohormone that is released from the same molecule that produces BNP)
Significance: BNP and this prohormone are produced when the heart is undergoing stress or stretch, they are released from ventricles, elevated in CHF, can help diagnose HF; helps in determining prognosis of patients with heart failure, coronary artery disease, and valvular heart disease
Normal range: <125pg/mL normal, >500 HF?
Lab results: 231
Note: other conditions that proBNP can be elevated are obesity, constrictive pericarditis, pericardial effusion, and flash pulmonary edema
Possible that theres elevated proBNP from pulmonary edema secondary to pneumonia

Ejection fraction: measures the amount of blood that is pumped out of the LV during each contraction, normal range is 55-75%, During HF, EF can either be reduced (HFrEF) or preserved (HFpEF)
In reduced (MC), <55% of blood is being pumped with each contraction, systolic dysfunction
Can be caused by enlarged LV (so big, heart cant pump normally), CAD or MI (limited blood flow to heart can damage/weaken it), HTN or Aortic stenosis (heart puts in more work to pump against pressure/valve, which weakens it), Mitral regurgitation (leakage of blood from LV to LA will stretch/weaken heart), arrhythmias (can affect amount of blood being pumped out)
In preserved, EF remains in normal range, diastolic dysfunction
Can be caused by enlarged LV (so big, heart fill normally), CAD or MI (limited blood flow to heart can damage walls and prevent relaxation for filling to occur), chronic HTN or Aortic stenosis (heart muscle thickened from working too much, now it cant fill); pericardial tamponade, or pericardial scarring can limit filling

Sources:
Diagnostic Studies (Laboratory Medicine) slides – Summer 2019 https://www.uwhealth.org/health/topic/special/heart-failure-with-reduced-ejection-fraction-systolic-heart-failure/tx4090abc.html
https://www.uofmhealth.org/health-library/tx4091abc
http://atm.amegroups.com/article/view/28884/html