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

General Data

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

Chief Complaint: Loss of Consciousness

History

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

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

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

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

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

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

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

Physical Examination

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

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

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

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

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

Salient Features

Differentials

Atypical Right Bundle Block Branch Rule In Loss of consciousness Usually asymptomatic Rule Out Chest Pain usually not present

Pulmonary Embolism Rule In Chest Pain Dyspnea Loss of Consciousness Syncope Rule Out Chest pain usually begins or worsens with deep breath or cough Cough which has bloody or blood streaked sputum usually present Usually presents with tachycardia Usually has unilateral leg swelling After hours, lung findings should be present Family history not suggestive No known risk factors such as recent surgeries

Prinzmetal Angina Rule In Chest tightness Loss of consciousness Rule Out Pain radiates t the neck, jaw, shoulder, or arm Occurs in cycles Attacks usually lasts from 5-30 minutes

Brugada Syndrome Rule In Chest pain, diffused and non-radiating Loss of consciousness Unknown ECG abnormality in 2008 Rule Out Usually presents with irregular heartbeats Usually presents with palpitations

Diagnosis Brugada Syndrome High Risk

In TMC ER

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

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

Complete Blood Count PARAMETERRESULTNORMAL VALUES Hgb g/L Hct RBC WBC x 10^9/L PC x 10^9/L Differential Neutrophil Lymphocyte Monocyte Eosinophil

Blood Chemistry PARAMETERRESULTNORMAL VALUES Na141 K Mg0.75 Ca1.25 Creatinine0.73 Given Kalium Durule

Blood Chemistry PARAMETERRESULTNORMAL VALUES CK Total CK MM CK MB Trop TNegative

Chest Xray

ECG

2D Echo

Coronary Angiography

In CCU

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

ECG

Course in the Wards

Case Discussion

Brugada Syndrome

Pathophysiology

Epidemiology

Diagnostics

Treatment

Public Health Perspective

PEFR Measurements NebulizationBest PEFRPercent Best (350) Pre % % % %