Morning Report 04/22/09
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Transcript of Morning Report 04/22/09
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Morning Report 04/22/09
Jad Skaf
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87 y.o. F. admitted for Change of Mental Status
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HPI• History obtained from EMS, patient lives
alone, called 911 claiming that there were people walking through her walls. Vitals stable during transportation.
• Patient knows it’s cooper and obama is president but thinks it’s 1996
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PMH
• CKD (Baseline 1.4)• HTN• OA• Gout
MEDS• Aricept• Allopurinol• celebrex• Catapres• asa• pentoxifylline• Tylenol-Codeine#3• Metoprolol
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96.6 44 139/67 16 97
• Drowsy, opens eyes to verbal stimuli• No ecchymosis or evidence of trauma• R eye cataract• Decr. BS bibasilar• HS reg, no murmurs• Abd Soft NTNDBS+• LE: trace edema• AA, Ox1 (persons). Non focal exam
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“Oh and by the way she dropped her HR to the low 30’s once…”
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HR
0
20
40
60
80
100
14:30 15:00 15:30 16:00 16:30 17:00 17:30 18:00 18:30 19:00
HR
155/68 175/72
SpO2>98%
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Bradycardia
• SSS• Increased Vagal Activity• Myocardial Ischemia• Increased Intracranial Pressure• Athletes• OSA• Meds (BB, CCB, Digoxin, AA)• Idiopathic Degeneration (Aging)• Others: Hypothy, hypothº, K, CVD, Amyloidosis,
Sarc…
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CCU day#1:
• Atropine 80
• Glucagon 60
• Cutaneous Patches
• No indication for PPM at this time
• Hallucinations resolved
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CCU day#2:
HR reversed off metoprolol/clonidine/Aricept
Will continue to observe
May not need a PPM
UTI: E coli susc. to levaquin
Stable for Tx to PCU
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PCU day # 1:
BP 138/96 HR 200 RR 22 97.6
Metoprolol 5 IVP HR 120
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PCU day # 2:
Pt. is transferred to Medicine with EP consult
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Med day # 1:
Atrial Chamber PM implant via L cephalic vein cut down without complication. Converted to sinus during procedure, suggest Sotalol to maintain in sinus.
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Discharge Meds
• Sotalol 40 BID• Metoprolol 25 BID• …
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SSS – Lown (1967)
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SSSPatients with symptomatic SSS are primarily older, with frequent co morbid diseases and a high mortality rate. In three major trials of pacing in this disorder, the median or mean age was 73 to 76 years.
Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. Lamas GA; Lee KL; Sweeney MO; Silverman R; Leon A; Yee R; Marinchak RA; Flaker G; Schron E; Orav EJ; Hellkamp AS; Greer S; McAnulty J; Ellenbogen K; Ehlert F; Freedman RA; Estes NA 3rd; Greenspon A; Goldman. N Engl J Med 2002 Jun 13;346(24):1854-62.
• Chronic, inappropriate, and often severe bradycardia • Sinus pauses, arrest, and exit block with and often
without, appropriate atrial and junctional escape rhythms.
• AV conduction disturbances in over 50 percent of patients
• Alternating bradycardia and atrial tachyarrhythmias in over 50 percent of cases. AF is most common, but atrial flutter and paroxysmal supraventricular tachycardias may also occur.
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SSS - ETIOLOGY
• Tachy-Brady Syndrome (50%)• Sinus Node Fibrosis• Disease of SA Nodal artery• Familial disease (rare – SCN5A, HCN4 mutations)• Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria,
Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies…
• Drugs: Parasympathomimeticssympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB)CimetidineDigoxinCCBAmiodarone
…
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SSS - ETIOLOGY
• Tachy-Brady Syndrome (50%)• Sinus Node Fibrosis• Disease of SA Nodal artery• Familial disease (rare – SCN5A, HCN4 mutations)• Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria,
Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies…
• Drugs: Parasympathomimeticssympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB)CimetidineDigoxinCCBAmiodarone
…
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SSS - ETIOLOGY
http://images.google.com/imgres?imgurl=http://library.med.utah.edu/kw/ecg/pics/thumbs/ecg_0374_modth.gif&imgrefurl=http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson6/index.html&usg=__RYOmlQl_ygpyp4sb70b7YieDKgQ=&h=53&w=120&sz=4&hl=en&start=19&tbnid=p8wxBPLVqhnPBM:&tbnh=39&tbnw=88&prev=/images%3Fq%3Dsinus%2Bexit%2Bblock%26gbv%3D2%26hl%3Den