A Curious Case of Heart Rhythm: A Report on Brugada Syndrome Abad....

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%