a curious case of heart rhythm: a report on brugada syndrome abad....
TRANSCRIPT
A Curious Case of Heart Rhythm:A Report on Brugada Syndrome
Abad. Imperial.Javate.Palma.Uy,R.Valencia19 November 2010
The Medical City
General Data
General Data
MS 25 years old Male Filipino Roman Catholic Pasig City Informant: Self Reliability: Very Good
Chief Complaint:
Loss of Consciousness
History
History of Present Illness
30 minutes PTA Riding a motorcycle with companion Chest discomfort described as tightness, diffuse, non-
radiating, 6/10 severity with associated dyspnea lasting 30 seconds
Stopped bike on sidewalk where vision dimmed Loss of consciousness lasting 2 minutes No headache, vomiting, dizziness, weakness, numbness No stiffening of extremities or drooling
History of Present Illness
28 minutes PTA Pt regained consciousness, was diaphoretic Chest pains continued Was picked by a serendepititiously located RedCross
van and rushed to TMC
Review of Systems
General◦ (-) Fever, (-) Weight changes, (-) Fatigue
Musculoskeletal/Dermatologic◦ (-) Itching, (-) Muscle/joint pains, (-) Rashes
HEENT◦ (-) Vision/hearing problems, (-) Epistaxis/gum bleed,
Respiratory◦ (-) Hemoptysis, (-) Cough, (-) Wheezing
Review of Systems
Cardiovascular◦ (-) Orthopnea, (-)PND
Gastrointestinal◦ (-) N/V, (-) Dysphagia, (-) Heartburn, (-) Change in
bowel habits, (-) Rectal bleed, (-) Jaundice Genitourinary
◦ (-) Nocturia, Dysuria, Frequency, Hematuria Endocrine
◦ (-) Heat intolerance, (-) Polyuria, (-) Excess thirst, (-) Cold intolerance
Past Medical History
Nonspecific abnormal ECG, 2008 For pre employment Initially diagnosis unrecalled ECG repeated which turned out normal
Head trauma, January 2010 Sustained while lifting machinery Causing bleeding, necessitating stitches No loss of consciousness, vomiting, or neurological
sequelae
Family History
(+) Asthma, father's side (+) Hypertension, father's side (+) Myocardial infarction, father's side (+) DM, mother’s side (+) Stroke, mother’s side (+) Leukemia, mother's side (-) PTB, Kidney Disease
Personal and Social History
College graduate Systems developer Cohabiting, no children Current smoker (2 pack years) Occasional alcohol beverage drinker (3 / month
max 3 bottles) No history of illicit drug use
Physical Examination
Physical Examination
General◦ Alert, coherent◦ Height 166 cm, Weight 68 kg, BMI 24.7
Vital Signs◦ BP 110/80, HR 88, RR 19, T 37.1 C
Skin◦ pink, no rashes/scars/lesions
Physical Examination
HEENT◦ Normocephalic◦ Anicteric sclerae, Pink palpebral conjunctivae◦ Moist pink lips, pink buccal mucosa◦ (-) Nasal discharge, (-) facial tenderness◦ (-) TPC, (-) CLAD, non distended neck veins
Physical Examination
Respiratory◦ Symmetric chest expansion◦ Resonant chest wall◦ (-) Rales, rhonchi, wheezes
Cardiovascular◦ PMI 5th ICS LMCL◦ Normal rate, regular rhythm◦ Distinct S1 and S2, (-) Murmurs
Physical Examination
Abdominal◦ Flat abdomen◦ Normoactive bowel sounds◦ Tympanitic on percussion◦ No tenderness on light and deep palpation◦ No organomegaly
Extremities◦ Full and equal pulses◦ CRT <2s , no cyanosis
Physical Examination
Neurologic◦ Cranial Nerves intact◦ Motor 5/5 on upper and lower extremities◦ Sensory - no deficits
Salient Features
Differentials
Atypical Right Bundle Block Branch
Rule In
• Loss of consciousness• Usually asymptomatic
Rule Out
• Chest Pain usually not present
Pulmonary Embolism
Rule In
• Chest Pain• Dyspnea• Loss of Consciousness• Syncope
Rule Out• Chest pain usually begins or
worsens with deep breath or cough
• Cough which has bloody or blood streaked sputum usually present
• Usually presents with tachycardia
• Usually has unilateral leg swelling
• After 24-73 hours, lung findings should be present
• Family history not suggestive• No known risk factors such as
recent surgeries
Prinzmetal Angina
Rule In
• Chest tightness• Loss of consciousness
Rule Out
• Pain radiates t the neck, jaw, shoulder, or arm
• Occurs in cycles• Attacks usually lasts from
5-30 minutes
Brugada Syndrome
Rule In
• Chest pain, diffused and non-radiating
• Loss of consciousness• Unknown ECG
abnormality in 2008
Rule Out
• Usually presents with irregular heartbeats
• Usually presents with palpitations
Diagnosis
Brugada Syndrome
High Risk
In TMC ER
TMC ER
• Oxygen at 2L/min cannula• Aspirin 325 mg/tab, crushed [hold after coro-angio]• Clopidogrel 75 mg/tab, 4 tablets loading dose [hold
after coro-angio]• Pantoprazole 40 mg/tab • Atorvastatin 80 mg/tab, 1 tab STAT [hold after
coro-angio]• ISDN 10cc in PNSS 90cc [hold after coro-angio]• Betadine for abrasion in Left Knee
Diagnostics: TMC ER
CBG: 118 Pulse Oximetry: 97% aPTT
PT
Control 13.3
Patient 13.4
% Activity 0.99
INR 1.01
Control 31.2
Patient 28.8
Complete Blood Count
PARAMETER RESULT NORMAL VALUES
Hgb 162 115-135 g/L
Hct .49 0.36-0.47
RBC 4.2-5.4
WBC 10.2 4.5 - 10 x 10^9/L
PC 253 140 - 400 x 10^9/L
Differential
Neutrophil .71 .56-.66
Lymphocyte .26 .22-.40
Monocyte .04-.08
Eosinophil .01-.04
Blood Chemistry
PARAMETER RESULT NORMAL VALUES
Na 141
K 3.0 3.5-4.9
Mg 0.75
Ca 1.25
Creatinine 0.73
• Given Kalium Durule
Blood Chemistry
PARAMETER RESULT NORMAL VALUES
CK Total 337.2 24-204
CK MM 304.7 24-179
CK MB 32.5 0-25
Trop T Negative
Chest Xray
ECG
2D Echo
Coronary Angiography
In CCU
Blood Chemistry
PARAMETER RESULT NORMAL VALUES
Uric Acid 0.39
SGPT
SGOT
TSH 3.4
FT3 3.01
FT4 1.22
ECG
Course in the Wards
Case Discussion
Brugada Syndrome
Pathophysiology
Epidemiology
Diagnostics
Treatment
Public Health Perspective
PEFR Measurements
Nebulization Best PEFR Percent Best (350)
Pre 250 200 200 71 %
1 250 240 250 71%
2 250 250 250 71%
3 300 250 300 86%