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A lady with acute SOB Sammi Pe. Case Presentation 54/F Cat II BP 129/69mmHg P 128 Temp 36.9 SpO2 78% ( 100% O2) Triage : SOB since afternoon, cough with.

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Presentation on theme: "A lady with acute SOB Sammi Pe. Case Presentation 54/F Cat II BP 129/69mmHg P 128 Temp 36.9 SpO2 78% ( 100% O2) Triage : SOB since afternoon, cough with."— Presentation transcript:

1 A lady with acute SOB Sammi Pe

2 Case Presentation 54/F Cat II BP 129/69mmHg P 128 Temp 36.9 SpO2 78% ( 100% O2) Triage : SOB since afternoon, cough with sputum, mild chest discomfort

3 What will you do ? What further history need?

4 What further Hx Good Past Health Domestic helper SOB since ~2 hrs ago Mild cough with yellowish sputum xdays become blood stained on AED No fever Chest discomfort today ( tightness) Palpitation +ve

5 More hx from employer Mild exertional SOB x several days Need resting after her work No fever all along No Travel hx Work in HK x ~17yrs No GI upset/ abd pain Not on regular medication Non-smoker, non-drinker

6 P/E Alert GCS 15/15 BP 139/78 P 120 RR 48 Sit up for breathing SpO2 80% on 100% O2 Recheck Temp 37.2 H ’ stix 13.2

7 P/E Chest: AE fair with bilateral basal crep, occ wheeze Abd soft HS dual, no murmur No ankle edema

8 What will you do next ?

9 ABC 100% O2 mask HB set Blood x CBC, L/RFT, Trop I, Clotting ECG i stat ( arterial) CXR

10 ECG x 2

11 i stat (arterial, on 100%O2) pH pCO kPa pO2 5.8 kPa BE 0 HCO mmol/L SO2 79% Na 141 K 3.5 i Ca 1.21 Hb 14.6

12 Our Patient Problem: Sudden onset SOB Desaturation even on 100% O2 Type I Resp Failure What is yr DDx?

13 Type I Resp Failure Typically due to V/Q mismatch PaO2 low (< 60 mmHg(8.0 kPa)) PaCO2 normal or low PA-aO2 increased Parenchymal disease (V/Q mismatch)V/Q Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism right-to-left shuntpulmonary embolism interstitial lung diseases: ARDS, pneumonia, emphysema.ARDS pneumoniaemphysema

14 Patient was still in distress even on 100% O2 What will you do then?

15 Patient was put on CPAP Lasix 40mg iv BP 110/70 Clinically improved CXR film A/V ….

16 CXR What is yr Diagnosis?

17 APO …. ? Other drug(s) to be considered ? Underlying cause CCU was consulted

18 Medications… Nitrates –Vasodilation –Reduced preload and afterload –Improved CO –Rapid effect –Not prescribed likely due to BP on low side Diuretics –Reduced plasma volume / preload –Pulmonary vasodilatation ACEI –Reduced afterload –Improved CO

19 Underlying Causes ACS HT Aortic/mitral valve disease Arrhythmias VSD Cardiomyopathy Acute myocarditis Pericardial disease Atrial myxoma Echo was performed…

20 Our case What is show in the Echocardiogram?

21 CCU input ECHO: LA mass ~4cm Likely atrial myxoma Trivial MR/AR Normal LV size and EF

22 Our Patient APO secondary to large atrial myxoma Transfer to CCU then CTSU for further Mx.

23 Progress Emergency excision of atrial myxoma –6x5cm encapsulated LA tumour attached to inter-atrial septum. –Causing obstruction & pul edema –Bi-atrial exploration + excision of tumour Extubated on D1 Post-op echo: EF 70% no PE

24 Day 0 Day 1 Day 2

25 Day 3 Day 4 Day 20 Patient was discharge on D8 and SOPD FU On Day 20 Good Recovery, Class I II, ET 3-4 FOS

26 Atrial Myxoma

27 Background Most common 1° Heart tumour (40-50%) 90% solitarty and pedunculated –Multiple tumours occur in 50% of familial case 10% familial ( autosomal dominant) 75-85% occur in LA ~25% RA Attach to fossa ovalis Symptomatic ~ 70g 140g

28 Myxoma- –polypoid, round, oval in shape –Smooth / lobulated surface –White/ yellow/ brown –Produce numberus growth factors and cytokines e.g. interleukin-6

29 Histology lipidic cells embedded in a vascular myxoid stroma In a series of 37 cases, 74% of tumors showed immunohistochemical expression of interleukin-6 while 17% had abnormal DNA content

30 Epidemiology US ~ 75 case / million autopsies 75% sporadic – Female Mean age – 56 15% present as sudden death – tumour embolism, HF, mechanical obstruction

31 History Asymptomatic (20%) symptomatic sudden death (15%) Mechanical interference with cardiac fx embolization LHF RHF systematic (L) Pulmonary (R) Exertional SOB fatigue infarct / haemorrhage PE Orthopnea peripheral edema of viscera Pul infarction PND ascites e.g. CVA Pul HT Pul edema visual loss Postural dizziness Constitutional symptoms : fever, Wt loss, arthralgias, Raynaud ~ 50% of patient due to interleukin-6 overporduction

32 Physical ↑ JVP Loud S1 ( delay mitral valve closure) Early diastolic sound (Tumor plop) tumor hit against the endocardial wall Diastolic atrial rumble ( obstruction in MV) MR/ TR ( valvar damage/ prolapse)

33 DDX Mitral Regurgitation Mitral Stenosis Pul Embolism Pul HT, primary Tricuspid Regurgitation Tricuspid Stenosis

34 Ix Lab: ESR, CRP, CBC, serum interleukin-6 CXR ECHO need to differentiate thrombus from myxoma – Thrombus ( in posterior portion, in layers) –Myxoma ( presence of stalk and mobility) MRI (point of attachment ) CT scan

35 Treatment Medical treatment for CHF and arrhythmia Surgical excision is the definitive tx Safe and curative Recurrence is possible if incomplete excision

36 Thank you


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