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A case study….what happens when you don't examine the patient, and when 'pathways' for raised troponin take over
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Introducing...Prof Montage
Cardiology Roundswww.profmontage.com.auwww.cardiologyrounds.com.au
DISCLOSURE
Over the years Prof Montage has taken lot$ of money from pharmaceutical companies.
He would prefer this was not widely publicised.
meet the characters
troponins
Case history
84yo female, 45 kg
Past history:hypertension
Renal artery stenosis Cr 115
Polymyalgia on steroids
Macular degeneration
March 2014
Peri-trochanteric #NOF
‘just twisted’ while bending
Medical review
I-V hydrocortisone
Theatre: gamma nail
12 hrs postop
Rapid response, low BP
Acute AF, preexisting LBBB
d/w Cardiology ‘could be nonSTEMI’
Transfuse 1 unit
6 hours later
1300ml I-V so far
Fast AF, give Mg infusion
80 ml/hour
Now sats <90%
JMO: ‘not fluid overloaded’
Coronary perfusion pressure
3 days later
Cardiology review re: raised troponin
Raised venous pressure
d/w Cardiologist: give aspirin & clopidogrel
Supply / demand
4th post-op day
Sudden abdo pain
Laparotomy: perforated gall bladder, biliary peritonitis
Postop: low BP, fluid bolus…etc
Days 7-11 post-admission
Rapid AF; i-v amiodarone
Fever ?sepsis
low BP, desaturation ?PE
Echo dilated hypocontractile LV
‘consolidation’
Pleural tap
15-18 days post admission
Transudate
‘CCF’ :Diuretics and digoxin
Fast AF: amiodarone, K, Mg
Waiting for rehab
Home day 22
Late July 2014
Still on bisoprolol / amiodarone
Bradycardia 35/min
Isoprenaline 4 days
Chest pain, troponin rise
Queue for pacemaker and cath
Day 5
Angio 2 vessel disease, no ventriculogram
Permanent pacemaker
Postop hypertension & bleeding
Transfused, stopped clopidogrel
Day 6
Sudden visual loss
Retinal artery occlusion
Aspirin. “Consider warfarin”
Discharged for GP care
8 days later
Chest pain, ambulance
Raised troponin
Diagnosis ‘nonSTEMI’
….and so on
End August 2014
Heart failure treated
Near-blindness
Adrenal insufficiency
Heading home…..
Right ventricle
3 minute Cardiology
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