Presenter: R3 林聖哲 Supervisor: MA 周昱劭 Moderator: MA 邱德發 72小時返診- Nov. 2010 Presenter: R3 林聖哲 Supervisor: MA 周昱劭 Moderator: MA 邱德發

Case 1 吳X紘, 30y/o No. 10576465 診次 1st visit 2nd visit 到診時間 11/24: 19:56 11/26: 16:35 V/S 37.8/91/20, 144/86 40.5/106/20, 126/87 離開時間 11/24, 20:10 11/26, 17:52 C.C. 全身紅疹 全身紅疹,發燒 檢查治療 藥物 藥物,抽血,CXR Diagnosis Chicken pox 出院診斷 Varcella-zoster infection 返診原因 症狀持續

1st visit V/S: 37.8/91/20, 144/86 C.C.: Progressive multiple papule and pasture formation last night P.I.: Headache for 2 days Fever today No skin itchy P.H.: Nil

Physical Examination Cons: E4V5M6, Clear HEENT: grossly normal Chest: bil. Clear Heart: RHB, no murmur Abd: soft, no tenderness, normoactive bowel sound Ext: free movement

Medications: 1.Acetaminophen 2.Dexchlorpheniramine maleate 3.Sod. Fusidate cream 4.Fexofenadine

2nd Visit, V/S: 40.5/106/20, 126/87 C.C.: Fever for 2 days P.I.: Cough(+), Nausea(+) SOB and chicken pox was told No chest pain PH: Nil Allergy: NKA

Physical Examination Cons: E4V5M6, Clear HEENT: oral ulcer Chest: bil. Clear Heart: RHB, no murmur Abd: soft, no tenderness, normoactive bowel sound Ext: free movement

Admission Course Acyclovir use Moxifloxacin for suspected pneumonia

Final Diagnosis 1. Varicella-zoster infection 2. Suspected bronchopneumonia 3. Acute hepatitis, r/o varicella-zoster infection related 4. Thrombocytopenia

Varicella-zoster virus infection Intubation period: 14~16 days Airborne disease S/S: Myalgia, headache, fever, sorethorat, otogia, skin rash Dx: Tsanck smear Late complictions: shingles Tx: acyclovir within 24~48 hrs PO: 20mg/kg QID x5d, max: 800mg QID IV: 10mg/kg Q8H x7d

Complications Skin soft tissue infection Encephalitis Reye syndrome 1.Acute cerebellar ataxia children 2.Diffuse encephalitis adults Reye syndrome Pneumonia 1~6 days after skin rash, adult Hepatitis

Case 2, 黃x民, 34 y/o, No.10484375 診次 1st visit 2nd visit 到診時間 11/02, 09:28 11/03, 15:33 V/S 36.5/77/18, 92/73 36.2/87/20, 127/92 離診時間 11/02, 11:20 11/04, 16:23 C.C. 暈厥 門診轉入 檢查治療 抽血,CT, EKG 抽血,CXR,住院 診斷 Syncope r/o vasovagal reflex Syncope r/o Brugada syndrome 出院診斷 Syncope suspected vasovagal syncope, suspected Brugada syndrome 返診原因

1st visit, V/S: 36.5/77/18, 92/73 C.C.: syncope episode this morning P.I.: Sudden onset ILOC: seconds Headache/Dizziness Head trauma before syncope URI with nasal obstruction P.H.: B hepatitis Allergy: NKA

Physical Examination Cons: E4V5M6, Clear HEENT: neck stiffiness Chest: bil. Clear Heart: RHB, no murmur Abd: soft, no tenderness Ext: free movement

Lying BP: 157/85 Sit BP: 144/85 Stand BP: 122/58

CT report: No ICH Suspected paranasal sinusitis

EKG, 11/02

MBD CV OPD follow up

2nd visit V/S: 36.2/87/20, 127/92 C.C.: Refer from OPD as Brugada syndrome P.I.: No specific discomfor No chest pain, no dyspnea Family hx: Sudden cardiac death: his father

Physical Examination Cons: E4V5M6, Clear HEENT: supple Chest: bil. Clear Heart: RHB, no murmur Abd: soft, no tenderness Ext: free movement

EKG, 11/03, CV OPD

EKG, 01/03, ER

Echocardiography 11/03 EF: 65% Trivial MR, TR and adequate LVP

Admission Course Treadmill test: no VF induced Cardiac MRI: no remarkable findings Holter: sinus rhythm(65~145bpm) Isolated PAC only No isolated VPC, AV block, long pulse No syncope, chest pain or dyspnea episode during admission MBD and OPD follow up

Brugada syndrome: genetic disease with ST seg. Elevation. Syncope in male – let us think about Brugada syndrome! Presentation of 3 cases Kardiol Pol 2010; 68, 12: 1397-1400 Brugada syndrome: genetic disease with ST seg. Elevation. High risks of sudden death Diagnosis due to syncope and VT

Be aware of ST-seg elevation in ani. Precordial leads and VT/VF Sudden Cause of Cardiac Death- Be Aware of Me: A Case Report and Short Review on Brugada Syndrome Case Report Med. 2010; 2010:823490. Epub 2010 Dec 14 Be aware of ST-seg elevation in ani. Precordial leads and VT/VF

Brugada Syndrome Pseudo-RBBB and persisted ST seg. Elevation (V1~V3) Asian predominant Male > female Feature Type 1 Type 2 Type 3 T wave Negative Positive or Biphasic Positive ST-T configuration Coved Saddle ST seg (terminal portion) Gradually descending Elevated >1mm Elevated < 1mm

EKG

Type 1 BS EKG: ST seg. Elevation (coved type) 1 of the followings 1. documented ventricular fibrillation 2.self-terminating polymorphic VT 3.family hx of SCD < 45 y/o 4.type 1 ST seg in family hx 5.inducibility of VT by EP 6.unexplained syncope due to arrhythmia 7.nocturnal agonal respiration

Type 2 and 3 BS EKG: ST seg elevation (saddle-back type) >1 in V1~V6 1 of the followings 1. documented ventricular fibrillation 2.self-terminating polymorphic VT 3.family hx of SCD < 45 y/o 4.type 1 ST seg in family hx 5.inducibility of VT by EP 6.unexplained syncope due to arrhythmia 7.nocturnal agonal respiration

Exclusion of confounders Atypical RBBB LVH Early repolarization AMI Acute pericarditis Athletes

Risks factors for SCD Male sex 3rd-4th decades Family hx of SCD Previous SCA or syncope Fever SCD: sudden cardiac death SCA: sudden cardiac arrest

Take Home Messages Beware of chicken pox in adults Beware of EKG pattern in syncope patients