1. A Curious Case of Heart Rhythm: A Report on Brugada Syndrome Abad. Imperial.Javate.Palma.Uy,R.Valencia 19 November 2010 The Medical City

2. General Data

3. MS 25 years old Male Filipino Roman Catholic Pasig City Informant: Self Reliability: Very Good

4. Chief Complaint: Loss of Consciousness

5. History

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Physical Examination

14. 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

15. 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

16. 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

17. 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

18. Physical Examination Neurologic ◦Cranial Nerves intact ◦Motor 5/5 on upper and lower extremities ◦Sensory - no deficits

19. Salient Features

20. Differentials

21. Diagnosis Brugada Syndrome High Risk

22. In TMC ER

23. 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

24. Diagnostics: TMC ER CBG: 118 Pulse Oximetry: 97% aPTT PT Control13.3 Patient13.4 % Activity0.99 INR1.01 Control31.2 Patient28.8

25. Complete Blood Count PARAMETERRESULTNORMAL VALUES Hgb162115-135 g/L Hct.490.36-0.47 RBC4.2-5.4 WBC10.24.5 - 10 x 10^9/L PC253140 - 400 x 10^9/L Differential Neutrophil.71.56-.66 Lymphocyte.26.22-.40 Monocyte.04-.08 Eosinophil.01-.04

26. Blood Chemistry PARAMETERRESULTNORMAL VALUES Na141 K3.03.5-4.9 Mg0.75 Ca1.25 Creatinine0.73 Given Kalium Durule

27. Blood Chemistry PARAMETERRESULTNORMAL VALUES CK Total337.224-204 CK MM304.724-179 CK MB32.50-25 Trop TNegative

28. Chest Xray

29. ECG

30. 2D Echo

31. Coronary Angiography

32. In CCU

33. Blood Chemistry PARAMETERRESULTNORMAL VALUES Uric Acid 0.39 SGPT SGOT TSH3.4 FT33.01 FT41.22

34. ECG

35. Course in the Wards

36. Case Discussion

37. Brugada Syndrome

38. Pathophysiology

39. Epidemiology

40. Diagnostics

41. Treatment

42. Public Health Perspective

44. PEFR Measurements NebulizationBest PEFRPercent Best (350) Pre250 200 20071 % 1250 240 25071% 2250 250 25071% 3300 250 30086%