morning report 04/22/09
DESCRIPTION
Morning Report 04/22/09. Jad Skaf. 87 y.o. F. admitted for Change of Mental Status. HPI. History obtained from EMS, patient lives alone, called 911 claiming that there were people walking through her walls. Vitals stable during transportation. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/1.jpg)
Morning Report 04/22/09
Jad Skaf
![Page 2: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/2.jpg)
87 y.o. F. admitted for Change of Mental Status
![Page 3: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/3.jpg)
![Page 4: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/4.jpg)
HPI• History obtained from EMS, patient lives
alone, called 911 claiming that there were people walking through her walls. Vitals stable during transportation.
• Patient knows it’s cooper and obama is president but thinks it’s 1996
![Page 5: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/5.jpg)
PMH
• CKD (Baseline 1.4)• HTN• OA• Gout
MEDS• Aricept• Allopurinol• celebrex• Catapres• asa• pentoxifylline• Tylenol-Codeine#3• Metoprolol
![Page 6: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/6.jpg)
96.6 44 139/67 16 97
• Drowsy, opens eyes to verbal stimuli• No ecchymosis or evidence of trauma• R eye cataract• Decr. BS bibasilar• HS reg, no murmurs• Abd Soft NTNDBS+• LE: trace edema• AA, Ox1 (persons). Non focal exam
![Page 7: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/7.jpg)
“Oh and by the way she dropped her HR to the low 30’s once…”
![Page 8: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/8.jpg)
HR
0
20
40
60
80
100
14:30 15:00 15:30 16:00 16:30 17:00 17:30 18:00 18:30 19:00
HR
155/68 175/72
SpO2>98%
![Page 9: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/9.jpg)
![Page 10: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/10.jpg)
![Page 11: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/11.jpg)
Bradycardia
• SSS• Increased Vagal Activity• Myocardial Ischemia• Increased Intracranial Pressure• Athletes• OSA• Meds (BB, CCB, Digoxin, AA)• Idiopathic Degeneration (Aging)• Others: Hypothy, hypothº, K, CVD, Amyloidosis,
Sarc…
![Page 12: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/12.jpg)
CCU day#1:
• Atropine 80
• Glucagon 60
• Cutaneous Patches
• No indication for PPM at this time
• Hallucinations resolved
![Page 13: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/13.jpg)
CCU day#2:
HR reversed off metoprolol/clonidine/Aricept
Will continue to observe
May not need a PPM
UTI: E coli susc. to levaquin
Stable for Tx to PCU
![Page 14: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/14.jpg)
PCU day # 1:
BP 138/96 HR 200 RR 22 97.6
Metoprolol 5 IVP HR 120
![Page 15: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/15.jpg)
PCU day # 2:
Pt. is transferred to Medicine with EP consult
![Page 16: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/16.jpg)
Med day # 1:
Atrial Chamber PM implant via L cephalic vein cut down without complication. Converted to sinus during procedure, suggest Sotalol to maintain in sinus.
![Page 17: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/17.jpg)
Discharge Meds
• Sotalol 40 BID• Metoprolol 25 BID• …
![Page 18: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/18.jpg)
SSS – Lown (1967)
![Page 19: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/19.jpg)
![Page 20: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/20.jpg)
SSSPatients with symptomatic SSS are primarily older, with frequent co morbid diseases and a high mortality rate. In three major trials of pacing in this disorder, the median or mean age was 73 to 76 years.
Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. Lamas GA; Lee KL; Sweeney MO; Silverman R; Leon A; Yee R; Marinchak RA; Flaker G; Schron E; Orav EJ; Hellkamp AS; Greer S; McAnulty J; Ellenbogen K; Ehlert F; Freedman RA; Estes NA 3rd; Greenspon A; Goldman. N Engl J Med 2002 Jun 13;346(24):1854-62.
• Chronic, inappropriate, and often severe bradycardia • Sinus pauses, arrest, and exit block with and often
without, appropriate atrial and junctional escape rhythms.
• AV conduction disturbances in over 50 percent of patients
• Alternating bradycardia and atrial tachyarrhythmias in over 50 percent of cases. AF is most common, but atrial flutter and paroxysmal supraventricular tachycardias may also occur.
![Page 21: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/21.jpg)
SSS - ETIOLOGY
• Tachy-Brady Syndrome (50%)• Sinus Node Fibrosis• Disease of SA Nodal artery• Familial disease (rare – SCN5A, HCN4 mutations)• Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria,
Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies…
• Drugs: Parasympathomimeticssympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB)CimetidineDigoxinCCBAmiodarone
…
![Page 22: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/22.jpg)
SSS - ETIOLOGY
• Tachy-Brady Syndrome (50%)• Sinus Node Fibrosis• Disease of SA Nodal artery• Familial disease (rare – SCN5A, HCN4 mutations)• Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria,
Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies…
• Drugs: Parasympathomimeticssympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB)CimetidineDigoxinCCBAmiodarone
…
![Page 23: Morning Report 04/22/09](https://reader035.vdocument.in/reader035/viewer/2022062803/568146a6550346895db3c278/html5/thumbnails/23.jpg)
SSS - ETIOLOGY
http://images.google.com/imgres?imgurl=http://library.med.utah.edu/kw/ecg/pics/thumbs/ecg_0374_modth.gif&imgrefurl=http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson6/index.html&usg=__RYOmlQl_ygpyp4sb70b7YieDKgQ=&h=53&w=120&sz=4&hl=en&start=19&tbnid=p8wxBPLVqhnPBM:&tbnh=39&tbnw=88&prev=/images%3Fq%3Dsinus%2Bexit%2Bblock%26gbv%3D2%26hl%3Den