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Patient Case 01 Cardiac Arrhythmias

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					                           Patient Case 01: Cardiac Arrhythmias PBL


Patient Case 01                                        The Arterial Pulse
                                                       Pulse rate – 60 – 80 bpm
Hugh Proctor, 51 Male
                                                               Slight quickening – early inspiration
Banker
                                                               Slight slowing - expiration
                                                       Irregular rhythm: due to premature beats,
                                                       intermittent heart block, AF
History
History of Presenting Complaint                        With AF: pulse is irregular and fast
Presented to ED with irregular rapid palpitations,
chest discomfort, mild presyncope                      Slow rising – large stroke volume
Afebrile                                               Collapsing – Aortic regurg, persistent ductus
Irregular pulse 130bpm                                 arteriosus
BP 105/70                                              Pulsus alternans – LV failure
Carotid pulse – variable wave form                     Pulsus bigeminus – Premature ectopic beat
JVP – not elevated
Clear S1S2 (heart sounds), no murmur
Lung fields clear

First presentation of palpitations
Previously had occasional “flutters”
         Llasting few secs, over past 10yrs.
         Never sought advice


Medical History
No past medical history

Workload is heavy
Exercise: fit, goes to the gym                                                                     th
                                                                  Kumar & Clark. Clinical Medicine 6 ed.


Investigations
ECG: shows atrial fibrillation
Atrial fibrillation terminates spontaneously
Resume normal sinus rhythm 80 bpm                            ECG: Diagnosis of AF
BP 135/80                                                     1. Irregularly irregular R-R intervals
ECG 2: confirms normal sinus rhythm                           2. Absent P waves
Patient is well and discharged home                           3. Fibrillatory waves b/w QRS
                                                                 complexes (irregular in timing,
                                                                 irregular in morphology)
As an outpatient
Thyroid function test: normal
Echocardiography: normal
Treadmill exercise test: normal


2 months later
Sudden onset, rapid palpitations
Persistent and associated with pre-syncope and chest discomfort


                                                                                                           Page | 1
                           Patient Case 01: Cardiac Arrhythmias PBL
Palpitations described as “faster and regular”

On arrival at ED, regular tachycardia     180 bpm
BP 95/65 mmHg
Oxygen sat: 98%
ECG: shows SVT

SVT terminates with 12 mg IV bolus of adenosine
Resume: normal sinus rhythm
Vitals: normal


Patient Case 02
Mr X, 86 Male                                                                     Admission date: 09/02/10
Retired food business
From Italy, has been living in Australia for 60 years


History
History of Presenting Complaint
Was at the GP for a prescription (metaformin) when he felt dizzy.
BP and pulse rate was checked. Profound sinus bradycardia and was referred to the hospital immediately.

At ED, extremely low BP. Drs mentioned the cause to be his age

On the 11/02, is scheduled for a pace maker

Pt recalled feeling “funny” for the past 2 weeks. (including little short blackouts, however not enough for
collapse)

Systems review
Nil chest pain
Nil dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea
Nil palpitations
Nil fatigue
Nil syncope
Nil claudication
Nil swelling

Past Medical History
Diabetes – well controlled, BSL monitored every day, on medication
Aspirin – Daily dose (due to angioplasty)

15 years ago - repaired Left inguinal hernia
               Angioplasty – no stent, site of entry: left groin

Nil HT
Nil hyperlipidaemia
Nil respiratory / abdominal / renal / GIT complaints
Nil allergies


                                                                                                      Page | 2
                              Patient Case 01: Cardiac Arrhythmias PBL
ET: Can’t walk more than 1 km w/o SOB. Able to climb 13 steps at home comfortably.
Nil mobility aids

Family History
Parents death unknown due to loss of communication
Nil heart disease or HT
Mother is known to have diabetes

Siblings – nil diabetes, heart disease, HT

Social History
Nil smoking
Nil ETOH
Nil illicit drugs

Lives at home with wife
Enjoys gardening and regards it as a form of exercise
Wife cooks at home
No fast food
Sleeps well
No stress


Examination
General appearance
Well, alert and responsive
Comfortable, no signs of distress
Nil breathing difficulties
Nil signs of cachexia
Body habitus: overweight

Hands
Present:            Splinter haemorrhage (left thumb)
                    Good capillary refill

Pulse rate – 36 bpm        regular with good character (but slow)
Nil radial-radial, radial-femoral delay

Brachial pulse regular with good character

Nil clubbing, palmar erythema/ creases, arthropathy, xanthomata

Face
Present:            Xantholesma
                    Central cyanosis

Nil anaemia, jaundice, dental carries

Neck
Present:            Cervical chain lymph nodes slightly enlarged


                                                                                     Page | 3
                                Patient Case 01: Cardiac Arrhythmias PBL
Carotid pulse      regular with good character
                   Is palpated lateral to the expected position – may indicate tortuosity
                   Nil bruits

Trachea midline
Nil JVP elevation

Chest
Cardiac monitor on
Nil scar                                                           JVP
Unable to visualise the apex beat                                  2 positive waves
Apex beat not palpable                                             A wave – due to atrial contraction
Distinct S1S2 sounds however extremely soft                        V wave – due to atrial filling
                                                                   Other
Back                                                               X descent – atrial relaxation
Lungs Breath sounds unable to be heard                             C Point – due to transmitted carotid pulsation
Nil sacral pitting oedema                                          Y descent – Due to rapid ventricular filling (tricusp opens)

Legs
Loss of Right 2nd toe nail
Loss of hair on both legs

Post tibial pulse R – can be felt but vague
                  L – can be felt but vague
Dorsalis pedis R – can be felt but extremely weak
                  L – can be felt but extremely weak
Cold feet
Nil oedema


Charts
Medication
Aspirin
Diabex – Metformin hydrocholoride
Gliclazide – Oral hypoglycaemic
Lantus – 24hr insulin
Micardis – HT (terminated)
Pantoprazole – Gastroesophageal reflux disease
Atorvostatin

Observations
                                                    On admission 09/02                                     11/02
           Temperature                                      36.4                                            36.2
            Pulse rate                                       34                                              45
                BP                                      R – 150/80                                         120/47
                                                         L- 180/70
         Respiratory rate                                    18                                              18
              SaO2                                          96%                                             97%
      Blood glucose (mol/L)                                  9.9                                            14.6

References: Mr X, Kumar & Clark, Clinical Medicine ; Talley & O’Connor, Clinical examination, NCBI (online), Merck
manual (online)
                                                                                                                     Page | 4
Came across this site for JVP: http://www.blobs.org/science/article.php?article=50

				
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posted:1/11/2012
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