holiday heart
TRANSCRIPT
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Presented ByMeNursing 630
The Case of A Little Too Much
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HISTORY AND REVIEW OFSYSTEMS PERTINENT TO THE
CASE
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CC is a 24 year old Caucasian
female who presents with aChief Complaint ofheadaches and chest
discomfort.
Chief Complaint
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HPI
The headaches started this AM when patient woke up
Describes the head as heavy; not unilateral; nophotophobia; Not the worse head of her life. She states thatthe headache is mainly at the back of her head.
States her heart was fluttering this morning and lasted forabout 2hrs.; but is now improving;
Denies chest pain; no radiation of pain; denies shortness ofbreathe.
She states that she has never experienced her heart flutteringbefore
She denies the use of any medications. She states that she had a couple of drinks yesterday duringthe day while out with friends; she couldnt quantify the intake.
Had several episodes of nausea and vomiting last night.
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Past Medical History
Adult illness: Asthma Childhood illnesses: Recurrent ear
infections,
Psychiatric illnesses: Anxiety Surgical History: Tonsillectomy
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Current Health Status
Allergies: No Known Drug or Food allergies
Immunizations: MMR, Varicella, TD all less than 10 years; Yearly Flu shot.
Screening Test: Last Physical Examination over a year ago, last Pap
test 3 years ago
Safety Measures: Uses seatbelt, helmet on bicycles, no firearms in the
home.
Exercise: Does not exercise
Sleep Patterns: Sleeps well at night
Diet: Regular diets
Habits: Smokes ocassionally, occasional alcohol use, no use of
street drugs.
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Family History
Father: CVA
Mother: HTN
No Siblings
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Social History
Housing: Lives with her boyfriend.
Support Systems: Boyfriend
Recently started a new job.
Sexual History: Sexually Active with her
boyfriend only.
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Review of System (Pertinent)
General:
No weight loss or gain;
Generalized fatigue;
No Fever.
Skin and Hair: No Rash
HEENT
No loss of vision, occasionalheadaches;
Cardiac: no dizziness
Respiratory/CV:
No Shortness of Breath, orhemoptysis.
GI:
No diarrhea, no hematemesis
No jaundice
Hematology:
No abnormal bleedingOB/GYN:Normal Pap smear 1 yr.ago; .
Neurological:
No change in mentalstatus
Endocrine:Fatigue .
Musculoskeletal:
Occasional joint pain.
Mental Health:Stressed, nodepression.
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PERTINENTPHYSICAL
EXAMINATION
What Systems Should we focus on?
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Thin white femaleAlert and OrientedNAD
VSBP: 145/80 RR:18 O2 Sat: 100%on RAT: 98.2 HR: 110
SkinNails without clubbing or cyanosis.
HEENT:Dry mucosaThroat: No goiter, thyromegaly;barely palpable, no lymphadenopathy.
Lungs:CTA, No Wheezes
GI/GU: Soft, slightly tender. LMP: 1 week ago
Cardiac:+ Orthostatic BPNormal S1, S2;No murmurs;No rubs; No gallops.No JVD
M. System:FROMNo deformities
Peripheral VascularSystem
No peripheral edema ofLEs
Neuro: Alert and oriented,CN I VII intact; no confusion
noted
Physical Examination
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What is Missing from the Physical Examination
CAGE Question
Cut back
Annoyed
Guilty
Eye Opener
Psych
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Physical Examination
Panic Disorder Questionnaire
Have you experienced brief periods, for seconds or minutes, of an
overwhelming panic or terror that was accompanied by racing heartbeats,shortness of breath, or dizziness?
Abbot A.V (2005). Diagnostic Approach to Palpitations. Retrieved from
http://www.aafp.org/afp/2005/0215/p743.pdf
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Lab
Normal Chest X-ray
EKG: ST
Glucose 95U/A dip
Specific Gravity >1.025
RBC +3
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Chest X-ray
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ECG
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What are the Possible DifferentialDiagnosis?
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Palpitations are secondary to underlying
problems such as anxiety, medications, cardiac
or pulmonary origin.
Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company
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Differential Diagnosis
o Dehydration
o Holiday Heart Syndrome (Paroxysmal SupraventricularTachycardia or Atrial Fibrillation or Atrial Flutter)
o Hyperthyroidism
o Anxiety/Panic Disorder
o MI
Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care37(2).
Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape
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Pathophysiology
The term Holiday Heart Syndrome was coined in
1978. Benign in nature
It is an acute cardiac rhythm and/or conductiondisturbance, most commonly supraventriculartachyarrhythmia, associated with heavy ethanolconsumption in a person without other clinicalevidence of heart disease.
Modest Alcohol Intake can act as a trigger in
some people.
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Pathophysiology
Alcohol Mechanism Theorized
Increased secretion of epinephrine andnorepinephrine.
Increased sympathetic output
Decreased Sodium current (leading to altered pH
level: with low dose=acidosis; high dose = alkalosis) acetaldehyde, the primary metabolite of alcohol, or
fatty acid ethyl esters, a cardiac alcohol metabolite
Arrhythmia resolves within 24hrs of , even
without any treatmentDirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care37(2).
Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape
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A Standard Drink Contains
12 fluid ounces of beer (about 5% alcohol)
8 to 9 fluid ounces of malt liquor (about 7%
alcohol)
5 fluid ounces of table wine (about 12%alcohol)
1.5 fluid ounces of hard liquor (about 40%
alcohol)
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How Would You Manage Ms.CCs Case?
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Therapeutic Plan
Diagnostics TherapeuticsPatient
Education andFollow Up
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Evaluating Palpitations
http://www.aafp.org/afp/2005/0215/p743.html
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Therapeutic Plan
1. Holiday Heart Syndrome:
Diagnostic:o Additional Lab: Cardiac Enzymes, CBC, Chem Panel, TSHTherapeutics: none
(beta blockers or calcium channel blockers) if dyspnea or sustained palpitations or chest pain. Holter Monitor: If symptom persists.
Patient Education: Alcohol abstinence, Eliminate other triggers like caffeine, ephedrine, stimulants like cocaine. Teach Valsalva maneuver or carotid massage or hands in cold water. Call 911 if symptoms recur and persist. Avoid exertion for the next 48 hours
Follow Up: In 2-3 days for lab work.Cardiologist Referral (Especially with syncope or near
syncope)
Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape
Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company
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Therapeutic Plan
2. Dehydration
Diagnostic: + Orthostatic BP
Therapeutics: 1 liter NS via IV infusion.
Patient Education:
Maintain hydration.
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Headache
Tension headache
Diagnostic: None
Therapeutic: Tylenol 650mg Prn headaches.Patient Education
Stay hydrated
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Role of the Nurse Practitioner
Partnership with the pt.
Support care for pt.
Referral and consultation(Cardiologist)
Follow up
Patient and Family education
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Follow Up & Case Summary
Reports no use of alcohol since last visit
No recurrent palpitations
EKG: Sinus Rhythm.
LAB: WNL
No Myopathy found on echo
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Reference
ACC/AHA/ESC Guidelines for the Management of Patients WithSupraventricular ArrhythmiasExecutive Summary. Retrieved from
http://circ.ahajournals.org/content/108/15/1871 Abbott A.V (2005). Diagnostic Approach to Palpitations.American Family
Physician. 71(5).
Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape.
Cash, J., & Glass, C. (2011). Family practice guidelines(2nd ed.). New York: Springer Publishing Company Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care
37(2).
Pittman H. (2004). Recognizing Holiday Heart Syndrome. Nursing34(12).
http://circ.ahajournals.org/content/108/15/1871http://circ.ahajournals.org/content/108/15/1871http://circ.ahajournals.org/content/108/15/1871http://circ.ahajournals.org/content/108/15/1871