How to manage a patient with NSTEMI, atrial fibrillation, impaired LVEF, acute kidney injury, diabetes, and hypertension, presenting with intermittent left upper quadrant tightness relieved by bowel movements?

From the Guidelines

The patient's management should prioritize stabilization of NSTEMI, rate control of atrial fibrillation, and careful management of acute kidney injury, with a multidisciplinary approach addressing both cardiovascular and gastrointestinal issues. Given the complexity of the patient's condition, including impaired left ventricular function (LVEF 45%) and acute kidney injury, it is crucial to balance the need for aggressive management of cardiovascular risk factors with the need to protect renal function.

The patient is already on aspirin and Eliquis for anticoagulation, and metoprolol for rate control of atrial fibrillation, which is appropriate given the impaired LVEF and need to manage symptoms of atrial fibrillation 1. For the management of NSTEMI in the context of acute kidney injury, an invasive strategy may be reasonable, but careful consideration must be given to the risk of contrast-induced nephropathy, and the use of low-osmolar contrast agents and hydration to minimize this risk is recommended 1.

Given the patient's diabetes, avoiding metformin due to kidney injury and considering insulin therapy with blood glucose targets of 140-180 mg/dL during hospitalization is a prudent approach. The left upper quadrant discomfort relieved by bowel movements suggests splenic flexure syndrome or constipation, and initiating polyethylene glycol 17g daily and increasing dietary fiber while monitoring bowel movements can help manage these symptoms.

Arranging for cardiac catheterization within 24-48 hours, but first ensuring kidney function stabilization with IV hydration (careful volume management considering heart failure), is a key step in managing this patient. Monitoring electrolytes, renal function, and cardiac enzymes closely will also be crucial in the acute management phase. After discharge, transitioning to long-term management with cardiac rehabilitation, optimized heart failure therapy, and follow-up with both cardiology and gastroenterology to address the abdominal symptoms if they persist is essential for improving outcomes.

The patient's current medications, including aspirin, Eliquis, metoprolol, Jardiance, and glipizide, should be reviewed and adjusted as necessary based on the patient's response to treatment and any changes in renal function or other clinical parameters. Regular follow-up with the nephrologist (Dr. Patel) and cardiologist (Dr. Strefling) will be important for managing the patient's complex medical conditions and adjusting the treatment plan as needed.

Key considerations in the management of this patient include:

• Balancing the need for aggressive cardiovascular risk factor management with the need to protect renal function
• Careful management of atrial fibrillation and NSTEMI in the context of impaired LVEF and acute kidney injury
• Monitoring for and managing potential complications, including contrast-induced nephropathy and worsening heart failure
• Coordinating care with multiple specialists, including cardiology, nephrology, and gastroenterology, to ensure comprehensive management of the patient's complex medical conditions.

From the Research

History of Present Illness (HPI)

The patient is a 52-year-old with a past medical history (PMH) of:

• NSTEMI (non-ST-elevation myocardial infarction)
• Atrial fibrillation with rapid ventricular response
• Impaired left ventricular function (LVEF 45%)
• Acute kidney injury
• Diabetes
• Hypertension

Current Symptoms and Concerns

The patient reports feeling good and has been lifting weights. However, he has been experiencing intermittent left upper quadrant tightness for 2 months, which is relieved by bowel movements. The pain is sharp and intermittent, worse in the morning, and better at night. He denies any radiation of the pain and does not need medication for constipation.

Management and Follow-up

The patient is currently managed with:

• Aspirin, Eliquis, and metoprolol for his cardiac history
• Jardiance and glipizide for his diabetes
• He has a scheduled cardiology appointment with Dr. Strefling
• He has a scheduled nephrology follow-up with Dr. Patel
• He has been non-compliant with an ophthalmology referral for a diabetic eye exam due to financial constraints

Digital Tools for HPI

Studies have shown that digital tools can be used to obtain the HPI from patients, improving efficiency and quality of care 2. These tools can be used to collect patient symptoms and generate a narrative HPI, which can be transferred directly into the electronic health record 3.

Organization of HPI

The organization of the HPI is crucial in improving verbal case presenting and clinical diagnostic reasoning skills of medical students 4. The use of a structured, timeline-based format, such as the Chronology of Present Illness (CPI), can improve physician cognition and communication 5.

Therapeutic Potential of HPI

The HPI has therapeutic potential, as it helps patients make cognitive sense of their illness and serves as a vehicle for sharing the affective burden with the physician 6. The effective clinician joins the patient in coprocessing the illness experience, conveying a sense of safety, sensitivity, affective competence, and cognitive competence.

Key Points

• The patient's HPI is complex and requires careful management of his multiple medical conditions
• Digital tools can be used to obtain the HPI and improve efficiency and quality of care
• The organization of the HPI is crucial in improving verbal case presenting and clinical diagnostic reasoning skills
• The HPI has therapeutic potential and should be used to help patients make cognitive sense of their illness and share the affective burden with the physician.