Morning Report 042209 Jad Skaf 87 y o

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. • Patient knows it’s cooper and obama is president but thinks it’s 1996

PMH • • CKD (Baseline 1. 4) HTN OA Gout MEDS • • Aricept Allopurinol celebrex Catapres asa pentoxifylline Tylenol-Codeine#3 Metoprolol

96. 6 • • 44 139/67 16 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, Ox 1 (persons). Non focal exam 97

“Oh and by the way she dropped her HR to the low 30’s once…”

Sp. O 2>98% 155/68 175/72

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…

CCU day#1: • Atropine 80 • Glucagon 60 • Cutaneous Patches • No indication for PPM at this time • Hallucinations resolved

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

PCU day # 1: BP 138/96 HR 200 RR 22 97. 6 Metoprolol 5 IVP HR 120

PCU day # 2: Pt. is transferred to Medicine with EP consult

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.

Discharge Meds • Sotalol 40 BID • Metoprolol 25 BID • …

SSS – Lown (1967)

SSS Patients 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; Mc. Anulty J; Ellenbogen K; Ehlert F; Freedman RA; Estes NA 3 rd; 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.

SSS - ETIOLOGY • Tachy-Brady Syndrome (50%) • Sinus Node Fibrosis • Disease of SA Nodal artery • Familial disease (rare – SCN 5 A, HCN 4 mutations) • Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria, Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies… • Drugs: Parasympathomimetics sympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB) Cimetidine Digoxin CCB Amiodarone …

SSS - ETIOLOGY • Tachy-Brady Syndrome (50%) • Sinus Node Fibrosis • Disease of SA Nodal artery • Familial disease (rare – SCN 5 A, HCN 4 mutations) • Other: Amyl, Hemochr, Scl, Pericarditis, Rheum fever, Diphteria, Chagas, Lyme, Hypothyroidism, Hypothermia, Muscular dystrophies… • Drugs: Parasympathomimetics sympatholytics (reserpine, guanethidine, methyldopa, clonidine, BB) Cimetidine Digoxin CCB Amiodarone …

SSS - ETIOLOGY http: //images. google. com/imgres? imgurl=htt p: //library. med. utah. edu/kw/ecg/pics/thum bs/ecg_0374_modth. gif&imgrefurl=http: //li brary. med. utah. edu/kw/ecg_outline/Le sson 6/index. html&usg=__RYOml. Ql_ygpyp 4 sb 70 b 7 Yie. DKg. Q=&h=53&w=120&sz=4& hl=en&start=19&tbnid=p 8 wx. BPLVqhn. PBM : &tbnh=39&tbnw=88&prev=/images%3 Fq %3 Dsinus%2 Bexit%2 Bblock%26 gbv%3 D 2 %26 hl%3 Den