1. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. Admission Course
Acyclovir use
Moxifloxacin for suspected pneumonia

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

14. 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

15. 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

17. 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

18. 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

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

20. Lying BP: 157/85
Sit BP: /85
Stand BP: 122/58

21. CT report:
No ICH
Suspected paranasal sinusitis

22. EKG, 11/02

23. MBD
CV OPD follow up

24. 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

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

26. EKG, 11/03, CV OPD

27. EKG, 01/03, ER

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

29. 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

30. 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:
Brugada syndrome: genetic disease with ST seg. Elevation.
High risks of sudden death
Diagnosis due to syncope and VT

31. 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: Epub 2010 Dec 14
Be aware of ST-seg elevation in ani. Precordial leads and VT/VF

32. 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

33. EKG

34. 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

35. 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

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

37. 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

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