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2014 중부지회 증례발표

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Hyelim lee

on 21 April 2014

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Transcript of 2014 중부지회 증례발표

Plan
Syncope
반복적인 의식 소실로 내원한 36세 남자
이 O 일
M / 36

Chief complain>
“의식을 잃었어요.”
Onset> 2013. 11. 17 13:00



2014 중부지회 증례발표
ABGA 7.30 - 29.5 - 108 – 14.3
Lactic acid 5.7
CBC 16,130 – 14.5 – 40.0 – 210K

Electrolyte 134 - 4.0 – 106 -14
Serum osmolality 294
Mg / i-Ca 1.8 / 4.12

AST/ALT 102 / 108
Glucose 141
CPK 183
CRP 0.09
Ammonia 47
Laboratory test
Holter monitoring
Basal ECG : Sinus rhythm
1. VPB : once / 24 hrs
2. Sx : ( - )


Echocardiography
Normal echocardiographic findings
Ejection fraction = 65 %

Cardiac Work up
Laboratory test including CPK, ammonia

Routine EKG, Echocardiogram, Holter monitoring
Consult to cardiology specialist

Brain MRI, EEG
Neuro Work up
Provocation Test
Flecainide 400mg loading
Syncope
Abrupt, transient, and self-limiting loss of consciousness
Loss of postural tone
Sudden fall in cerebral perfusion

Symptomatic
Convulsive vs non-convulsive

Mechanism
Brugada Syndrome
Treatment
Drug in BS
Conclusion
Cardiac arrhythmias and epilepsy can be misdiagnosed.

The most specific features of cardiac syncope were loss of consciousness while supine or during effort, blurred vision, palpitation, and
convulsive syncope
.
-Progress in cardiovascular diseases, 55 (2013)

In discriminating among patients with syncope to identify those with cardiac syncope, a history or physical signs of cardiac disease can be
95% sensitive
for a cardiac aetiology.
-Lancet Neurology, 8 (2009)

History and physical examination is the most important!



Clinical investigations should include the role of a
screening EKG
in all people with epilepsy or syncope, and other methods to identify those at risk of arrhythmias.

Further
genetic investigation
is needed, especially genes coding for the numerous channels that are dually expressed in heart and brain.
Lessons from cases
Present illness>
1. 1990.(14세), 자고 일어나 소변 보다가 어지럽고 눈앞이 아득해지면서 쓰러져 의식을 잃는 일이 두 번 정도 있었으며 수분 후 깨어남.

2. 2013. 4.(36세) 맥주 한 캔 마시고 컴퓨터 하던 중, 속에서 무언가 올라오는 듯한 느낌과 함께 흉부 불편감, 호흡 곤란 발생하였으나 의식 소실 없어 과호흡에 의한 증상으로 생각하고 집에서 경과 관찰함.

3. 2013. 5. 흉부불편감, 호흡곤란을 주소로 정신과 진료 후 R/O Panic Disorder 로 약물 처방 받아 1회 복용 후 중단.

4. 2013. 11. 17 오후 1시 경 침대에서 낮잠을 잤으나 깨어나 보니 바닥이었으며 자리에서 일어나면 어지럽고 토할 것 같은 느낌, 가슴 답답함 등 발생하였고 이후 2, 3 분간 의식을 잃었음.
5. 수분 후 의식 회복하여 일어나서 움직일 때마다 반복적으로 의식을 잃음. 총 3 회 정도, 수 분 씩 반복되었고 구급대원이 도착하여 문을 열어주면서도 다시 의식을 잃어 근처 병원으로 이송. 당시 목격자는 없었고 두부 및 사지에 외상은 없었음.

6. 이후 타병원에서 진료하면서 누워있던 중에 흉부불편감 호소하면서 의식을 잃었고 타병원 소견서에 의하면 General tonic clonic movement, eyeball deviation, urination 동반되었고 BP 80/60 mmHg, HR 200 bpm, EKG : sinus tachycardia 였음.

7. 2-3 분 후 의식 회복 되었으나 confuse mentality, mild dysarthria 보여 추가적인 검사 위해 본원 전원하여 내과 진료.
Prodromal symptoms
Chest discomfort
Epigastric discomfort with uprising sense
Dizziness with nausea

Attack

> 3rd attack
Loss of consciousness (+)
Generalized tonic clonic movement
Duration : 2-3 minutes
Eyeball deviation / Neck deviation (+/-)
Urination (+) / Defecation (-) / tongue bite (-) / Drooling (-)
Vomiting (-) / Speech (-)

Post - attack
Confuse mentality
Mild dysarthria
Epilepsy and Cardiac Arrhythmias Genes
Convulsive Syncope
장 O 복 F/80

1. HTN/DM (-/-)

2. 4년 전부터 간헐적인 Dizziness로 Dimenhydrinate 100mg per day 복용

3. 최근 1개월 간 3 회의 syncope 있었음.

4. 2014. 4. 15 right eyeball deviation 동반한 general tonic clonic seizure attack 발생하여 타병원에서 carbamazepine, valproate 복용 시작함.

5. 입원 중 seizure attack 과 함께 8초 간의 sinus pause 보여 본원 전원.
Inherited arrhythmogenic disease
Coved-type ST-segment elevation in right precordial leads
Mutations in SCN5A genes on chromosome 3
Encoding for the α-subunit of the
cardiac Na+ channel
Autosomal dominant incomplete penetrance

Increased risk of sudden cardiac death (SCD)
Ventricular fibrillation (VF) or ventricular tachycardia (VT)
25% of the total population with BS will experience SCD or VF during lifetime

M >> F
Mean age of 40 years
Problem and Assessment
Past Medical History
HTN/DM/Hepatitis/Tb (-/-/-/-)
Operation/admission (-/-)
Current medication (-)

Social History
Alcohol : 주 3 회, 맥주 1~2 캔
Smoking : About 15 Pack-year current smoker
Occupation : 회사원

Family History
Sudden death (-)
At ER
NR : 내과 선생님, 이 환자의 EKG는 괜찮나요?

IM : 잘 모르겠는데... 괜찮은 거 같아요.
신경과로 입원하세요.
Neurologic exam
Vital sign > 84/50 mmHg - 85 bpm - 22/min - 36.8 'C

Mental status > alert

Speech > mild dysarthria -> within normal (after 30minutes)

Cranial nerve exam >
Isocoric pupil with light reflex (++/++) afferent pupillary defect(-)
Primary eyeball position neutral
EOM : full without diplopia, nyagmus
Facial palsy (-) Facial sense symmetric intact

Motor >
No weakness

Sensory >
Symmetric intact

Deep tendon reflex >
Within normal limits

Plantar response >
Both flexor pattern

Meningeal irritation sign > Negative
#1. Recurrent syncopal episode
Prodromal symptoms
Dizziness, chest and abdominal discomfort, dyspnea
Supine position and during activities
General tonic clonic movement with eyeball deviation, urination
Transient dysarthria with confuse mentality

#2. Familial history of syncope


R/O Convulsive syncope
R/O Cardiogenic syncope >>

R/O Localization related symptomatic epilepsy

R/O Panic attack (less likely)
Problem list
Assessment
Brugada syndrome (type I)
Implantable
Cardioverter - Defibrillator
Avoidant Drugs
Proventable Drugs
What Is Your Opinion ?

Convulsive Syncope
R/O Sick sinus syndrome




Pace maker insertion
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