MONTHLYCASE PRESENTATION :MONTHLYCASE PRESENTATION ORGANIZED BY DEPARTMENT OF CARDIOLOGY APOLLO HOSPITALS DHAKA


Slide 2:BY DR. SUMANTA KUMER SAHA MBBS, FCPS-II (MEDICINE) RMO APOLLO HEART CENTRE WELCOME


Slide 3:Resuscitated Cardiac Arrest (Polymorphic VT) DCM HTN TYPE-2 DM (ON DIET) Renal Impairment DIAGNOSIS


CONTENTS… :CONTENTS… HISTORY DEMOGRAPHIC DETAILS PRESENTING COMPLAINT HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY PERSONAL HISTORY DRUG HISTORY FAMILY HISTORY SYSTEMIC ENQUIRY PHYSICAL EXAMINATION CLINICAL DIAGNOSIS OR IMPRESSION INVESTIGATION DIAGNOSIS MANAGEMENT PLAN INFORMATION


DEMOGRAPHIC DETAILS :DEMOGRAPHIC DETAILS NAME OF THE PATIENT : MR. MIZANUR RAHMAN AGE : 55 YEARS SEX : MALE


DEMOGRAPHIC DETAILS :DEMOGRAPHIC DETAILS MARITAL STATUS : MARRIED ADDRESS : PRESENT :H-86, R-10, ZIGATOLA, DHAKA PERMANENT : MYMENSING DATE & TIME OF ADMISSION : 18 TH APRIL, 2007; AT 1.00 PM


DEMOGRAPHIC DETAILS :DEMOGRAPHIC DETAILS DATE & TIME OF DISCHARGE : 24TH APRIL, 2007; AT 5.25 PM SOURCE OF REFERRAL : FROM NICVD, DHAKA SOURCE OF HISTORY : FROM PATIENT HIMSELF


PRESENTING COMPLAINT :PRESENTING COMPLAINT SHORTNESS OF BREATH GENERALIZED BODY WEAKNESS


HISTORY OF PRESENTING COMPLAINT :HISTORY OF PRESENTING COMPLAINT THE PATIENT, MR. MIZANUR RAHMAN, 55 YEARS OF OLD, HYPERTENSIVE, DIABETIC, EX-ALCOHOLIC (10 YEARS), EX-SMOKER (SINCE SCHOOL LIFE), DIAGNOSED CASE OF DCM, CAME TO CARDIOLOGY-OPD WITH THE COMPLAINTS OF SOB AND GENERALIZED BODY WEAKNESS. HE ALSO STATED THAT HE WAS REPEATEDLY HOSPITALIZED (INCLUDING NICVD) WITH THE SAME COMPLAINTS PREVIOUSLY FOR 6 TIMES.


HISTORY OF PRESENTING COMPLAINT :HISTORY OF PRESENTING COMPLAINT HE HAD A H/O EPISTAXIS, YEARLY DEVELOPED, AGGRAVATED BY TRAUMA AND HE ADDED HE HAS BEEN SUFFERED FROM RHEUMATIC FEVER SINCE HIS SCHOOL LIFE, STATING THE SYMPTOMS LIKE JOINT PAIN, ESPECIALLY LARGE JOINTS, AND SWELLING AND INABILITY TO WALK.


PAST MEDICAL HISTORY :PAST MEDICAL HISTORY DCM, HEART FAILURE FOR WHICH REPEATEDLY (6 TIMES) ADMITTED INTO THE HOSPITAL HTN (ON REGULAR ANTI-HTN) DM (ON DIET CONTROLLED) ? H/O-RHEUMATIC FEVER/ RHEUMATIC VALVULAR HEART DISEASE


PERSONAL HISTORY :PERSONAL HISTORY SMOKER SINCE SCHOOL LIFE (ABOUT 30/35 YEARS) ALCOHOLIC FOR ABOUT 10 YEARS * BUT NO H/O DRUG MISUSE (LIKE COCCAINE)


DRUG HISTORY :DRUG HISTORY DIURETICS FRUSEMID 40 MG + SPIRONOLACTONE 50 MG; 1+1+0 SPIRONOLACTONE 100 MG; 1+0+0 ANTI-ARRHYTMIC DIGOXIN 0.25 MG; ½ +0+0 AMIRODARONE 100 MG; 1+0+1 ANTI-LIPID ATORVASTATIN 10 MG; 0+0+1 NITRATE GTN 2.6 MG ; 1+0+1 ANTI-PLATELET ASPIRIN 75 MG 0+0+1


FAMILY HISTORY :FAMILY HISTORY HIS FATHER DIED OF STROKE (ACCORDING TO PATIENT’S LANGUAGE) ONE OF BROTHER IS DIABETIC


SYSTEMIC ENQUIRY :SYSTEMIC ENQUIRY CVS- EXERTIONAL DYSPNOEA HAEMOPTYSIS (DURING ADMISSION PERIOD) ALIMENTARY- HEART BURN UROGENITAL- NIL OF NOTE NS- NIL OF NOTE LMS- H/O JOINT PAIN AND SWELLING ENDOCRINE- DM


CASE SUMMARY :CASE SUMMARY MR. MIZANUR RAHMAN, 55 YEARS OF OLD, HYPERTENSIVE, DIABETIC, EX-SMOKER, EX-ALCOHOLIC BANGLADESHI GENTLEMAN--


Slide 17:………CAME TO CARDIOLOGY-OPD WITH THE COMPLAINTS OF SOB FOR LAST FEW DAYS GENERALIZED BODY WEAKNESS FOR LAST FEW DAYS ON 18TH APRIL, 2007


Slide 18:KNOWN CASE OF … DCM HTN (ON REGULAR ANTI HYPERTENSIVE) DM ON DIET ON 18TH APRIL, 2007


Slide 19:ECG SHOWED LBBB ECHO REVEALED ***EF < 20 % ON 18TH APRIL, 2007


Slide 20:THEN HE WAS MONITORED IN ER & DURING, SUDDENLY, HE COLLAPSED ECG SHOWED POLYMORPHIC VT WITH TORSADES DE POINTES ON 18TH APRIL, 2007


Slide 22:ABG *PH - 7.197 PaCO2 - 42.2 mmHg PaO 2 – 108.7 mmHg SO2 - 94.8 % HCO3 - 16.5 m mol/L ON 18TH APRIL, 2007


Slide 23:ELECTROLYTES Na – 144 m mol/L K - 4.1 m mol/L Cl - 102 m mol/L HCO3 - 21 m mol/L ON 18TH APRIL, 2007


Slide 24:MANAGEMENT DC SHOCK WAS GIVEN FOR 2 TIMES CPR WAS PERFORMED INJ. AMIODARONE, 300 MG INTRAVENOUSLY GIVEN AS A STAT DOSE AND MAINTENANCE DOSE WAS ALSO ADMINISTERED. ON 18TH APRIL, 2007


Slide 25:2ND ECG


Slide 28:EVEN AFTER THAT, PATIENT BECAME HAEMODYNAMICALLY UNSTABLE AND OXYGEN SATURATION WAS ALSO GRADULLY FALLEN DOWN ON 18TH APRIL, 2007


Slide 29:THEN, THE PATIENT WAS PUT IN VENTILATOR IMMEDIATELY IN CCU, PT WAS PUT IN SIMV MODE AND CV LINE & ARTERIAL LINE WERE ENSURED HIGH BP, (200/90 MM-HG), MANAGED BY GTN INFUSION ON 18TH APRIL, 2007


Slide 30:THE PATIENT WAS EXTUBATED SUCCESSFULLY WITHOUT ANY EVENT WITH SPONTANEOUS RESPIRATION ON 19TH APRIL, 2007


Slide 31:S. CREATININE WAS FOUND 2.3 MG/DL; THEN SEEN BY NEPHROLOGIST THEN URINE RME WAS DONE, REVEALED NUMEROUS RBC/HPF AND HB-9.5 GM/DL. MX—FLUID 1 L/DAY -CALORIE 2000 KCAL/D -PROTEIN 50 GM -SALT 5 GM -POTASSIUM 60 MEQ ON 20TH APRIL, 2007


Slide 33: ON 21ST APRIL, 2007


Slide 34: ON 21ST APRIL, 2007


ON 21TH APRIL, 2007ECHOCARDIOGRAM :ON 21TH APRIL, 2007ECHOCARDIOGRAM 2D-M-MODE/MEASUREMENTS IVS (d) – 10.5 MM (06-12) IVS (s) – 13.8 MM (09-18) * LVID (d) - 82.5 MM (35-55) * LVID (s) - 63.7 MM (20-40) LVPW (d) -12.7 MM (06-12) LVPW (s) -17.2 MM (09-18) FS – 10 % (30-45 ) * LVEF - > 20 % (50-85) AORTA – 34.3 MM (20-40) * LA – 47.1 MM (20-40) ACS – 22.7 MM


ON 21TH APRIL, 2007ECHOCARDIOGRAM :ON 21TH APRIL, 2007ECHOCARDIOGRAM Doppler study- AR moderate MR mild Conclusion- Dilated LA & LV Global hypokinesia AR- Moderate, MR- mild Spontaneous LV Echo contrast Global LV EF > 20 %


ON 24TH APRIL, 2007 AT 5.24 PM :ON 24TH APRIL, 2007 AT 5.24 PM AT DISCHARGE, HIS PULSE-60 B/MIN BP-120/30 MM-HG S1 + S2 +0 LUNGS- FEW BASAL CREPS


ON 24TH APRIL, 2007 AT 5.24 PM :ON 24TH APRIL, 2007 AT 5.24 PM MEDICATION AT DISCHARGE ANTI-PLATELET- ASPIRIN + CLOPIDOGREL 75/75 OD DIURETICS- FRUSEMIDE 40 MG +20 MG+0 BETA-BLOCKER- CARVEDILOL 6.25 MG ½+0+½ ARB- CANDENSARTAN 16 MG ½+0+½ ANTI-LIPID- ATORVASTATIN 10 MG 0+0+1


Slide 39:NEXT PLAN……… ICD IMPLANT CRT (CARDIAC RESYNCHRONIZATION THERAPY) ADVISE ON DISCHARGE


Slide 40:THANKS A LOT


POLYMORPHIC VT/ TORSADES DE POINTES :POLYMORPHIC VT/ TORSADES DE POINTES ECG Criteria- QRS-wide, bizarre, irregular of different or changing amplitude from upright to


Slide 42:NEXT PLAN……… ICD IMPLANT ( BUT PT DOESN’T FULFILL THE CRITERIA & HAS AR) CRT (CARDIAC RESYNCHRONIZATION THERAPY) ADVISE ON DISCHARGE


Slide 53: ON 21ST APRIL, 2007


Slide 54: ON 21ST APRIL, 2007


Slide 55: ON 21ST APRIL, 2007