Case Presentaion R3
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Transcript of Case Presentaion R3
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Case presentationCase presentation
KHALID ALRASHDIKHALID ALRASHDI
R3R3
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--case studycase study
--diagnosisdiagnosis
--home massagehome massage
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Seen at 8:20 amSeen at 8:20 amMiddle age male presents with h/o Middle age male presents with h/o
chest pain since 3 dayschest pain since 3 days..
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Primary surveyPrimary survey::Oriented , alert with some chest painOriented , alert with some chest pain
A- patentA- patentB- good b/l air entry, rr:20/minB- good b/l air entry, rr:20/min
C- bp:137/76 pr:114/min spo2:96%C- bp:137/76 pr:114/min spo2:96%D- GCS:15/15 RBS:6.2D- GCS:15/15 RBS:6.2
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Middle age laborerMiddle age laborernot known to have any medical problemsnot known to have any medical problems not a smoker or ethanol consumernot a smoker or ethanol consumer..no family history of heart diseaseno family history of heart disease..Referred from Rusayl health center with Referred from Rusayl health center with ====================================================Gave a 3 day hGave a 3 day h//o of on and off pricking o of on and off pricking chest pain that is alternates between the rt chest pain that is alternates between the rt and lt side of the chestand lt side of the chest. . Is not associatd with Is not associatd with sweating, nausea or dizzinesssweating, nausea or dizziness. . no particular no particular radiation or relation to exertion or restradiation or relation to exertion or rest..
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The pain was particularly severe starting 11 The pain was particularly severe starting 11 pm last nightpm last night. . He went to LHC in the early He went to LHC in the early hours of the morning hours of the morning . . He received aspirin He received aspirin 81 mg and and s81 mg and and s//l GTN after which the l GTN after which the pain somewhat subsided and he was pain somewhat subsided and he was reffered to SQUHreffered to SQUH..
Denies hDenies h//o fever, dizziness, SOB, orthopnea, o fever, dizziness, SOB, orthopnea, PND or coughPND or cough no urinary or gastroinestinal complaintsno urinary or gastroinestinal complaints..
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Secondary surveySecondary survey::Head and neck:nadHead and neck:nad
CVS:S1S2CVS:S1S2P/A:softP/A:soft
CNS:NADCNS:NADECGECG
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Lab investigationsLab investigations::
--CBC; hb 14, plt 355, WBC 12.2, ANC:9.7CBC; hb 14, plt 355, WBC 12.2, ANC:9.7
--U&E,LFT,BONE PROFILE:NADU&E,LFT,BONE PROFILE:NAD
--TROPONIN:NEGATIVETROPONIN:NEGATIVE
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The ECG was shown to and dThe ECG was shown to and d//w Drw Dr. . MeharMehar. . since the patient is pain free and currently since the patient is pain free and currently stable, he opted for thrombolysing the stable, he opted for thrombolysing the
patientpatient.. - -
--thrmbolyse with reteplase 10 units ad thrmbolyse with reteplase 10 units ad repeat another 10 units after 10 minrepeat another 10 units after 10 min - - -enoxaprin and continue aspirin 81 mg -enoxaprin and continue aspirin 81 mg and clopidogrel 75 mg odand clopidogrel 75 mg od - - Admit to CCUAdmit to CCU--
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repated ecg still showed st elevation in repated ecg still showed st elevation in anterior leadsanterior leads..
PlanPlan::
For angio+/-ptcaFor angio+/-ptca
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Angio NORMAL CORONARIES GOOD LV Angio NORMAL CORONARIES GOOD LV FUNCTIONFUNCTION..
Impression Impression : : Chets pain with Normal Chets pain with Normal Coronaries with good LV function and Coronaries with good LV function and normal serial troponinsnormal serial troponins
? ?PericarditisPericarditis-- -Possible pneumonia left upper zone-Possible pneumonia left upper zone
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PlanPlan --stop all antiplatelets and heparinstop all antiplatelets and heparin
-Continue augmentin and -Continue augmentin and azithromycinazithromycin-Check repeat CBC ESR Blood -Check repeat CBC ESR Blood cultures and CRP and ESRcultures and CRP and ESR-respiratory review-respiratory reviewECHO routineECHO routine--
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PericarditisPericarditis
Pericarditis can be classified according to Pericarditis can be classified according to the composition of the inflammatorythe composition of the inflammatory exudateexudate..Types includeTypes include::serousserous purulentpurulent fibrinousfibrinous caseouscaseous hemorrhagichemorrhagic Post infarctionPost infarction
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ClinicallyClinically: : Acute (<6 weeks), Acute (<6 weeks), Subacute (6 weeks to 6 months) Subacute (6 weeks to 6 months)
Chronic (>6 months). Chronic (>6 months).
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CausesCauses::
--infectionsinfections
Viral 1-childrenViral 1-children coxsackieviruscoxsackievirus
22--adults adults cytomegaloviruscytomegalovirus, , herpesvirusherpesvirus, , andand HIVHIV..
Bacteria Bacteria PneumococcusPneumococcus or tuberculous or tuberculous
FungalFungal histoplasmosishistoplasmosis
in immunocompromised in immunocompromised AspergillusAspergillus, , CandidaCandida, and, and CoccidioidesCoccidioides..
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IdiopathicIdiopathic : :No identifiable etiology found after routine No identifiable etiology found after routine testingtesting . .
ImmunologicImmunologic conditions including conditions including lupus erythematosuslupus erythematosus (more common among (more common among
women) orwomen) or rheumatic feverrheumatic fever Myocardial InfarctionMyocardial Infarction( ( Dressler's syndromeDressler's syndrome ) )
TraumaTrauma to the heart, e.g. puncture, resulting in to the heart, e.g. puncture, resulting in infection or inflammationinfection or inflammation
UremiaUremia( ( uremic pericarditisuremic pericarditis ) )MalignancyMalignancy( ( as aas a paraneoplastic phenomenonparaneoplastic phenomenon ) )
Side effectSide effect of some of some medicationsmedications, e.g, e.g . .isoniazidisoniazid , ,cyclosporinecyclosporine , ,hydralazinehydralazine
RadiationRadiation inducedinduced Aortic dissectionAortic dissection TetracyclinesTetracyclines Postpericardiotomy syndromePostpericardiotomy syndrome
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ComplicationsComplications::
--Pericardial effusionPericardial effusion
--Constrictive pericarditisConstrictive pericarditis
--Cardiac tamponadeCardiac tamponade
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TreatmentTreatment::
- -NSAIDNSAID
--pericardiocentesispericardiocentesis
--antibioticsantibiotics
--steroidssteroids
--colchicinecolchicine
in rare cases, surgeryin rare cases, surgery
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HOME MASSAGEHOME MASSAGE::
- -there are more than ten causes for ST there are more than ten causes for ST elevationelevation
--MI -pericarditisMI -pericarditis--LVH -hyperkalemiaLVH -hyperkalemia
--myocardium disorder -acute cor pulmonalemyocardium disorder -acute cor pulmonale--post cardiac injury syndromepost cardiac injury syndrome
--cadiac truma -myocardial contusioncadiac truma -myocardial contusion--dresslers syndrome –aortic disectiondresslers syndrome –aortic disection
--early repolarization ECG syndromeearly repolarization ECG syndrome