Case presentation raa

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By Saud Al-Sulimani

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Case presentation raa

  1. 1. Case presentation<br />Suad Al-Sulimani<br />
  2. 2. outline<br />Case presentation<br />Case discussion<br />Topic review<br />
  3. 3. 23 years old male<br />sudden onset of SOB <br /> & palpitation <br />1 day duration <br />
  4. 4. Primary survey<br />
  5. 5. Generally:<br />A:patent<br /> no secretion<br />Anxious , Irritable , sweaty<br />Contious , orianted<br />
  6. 6. B:<br />Dyspnic<br />RR:22/min<br />spo2 100% in RA<br />Chest : clear <br />Generally:<br />Anxious<br />hyperventilating<br />Contious , orianted<br />A:<br />patent<br /> no secretion<br />
  7. 7. B:<br />Dyspnic<br />RR:22/min<br />spo2 100% in RA<br />Chest : bilaterally clear<br />Generally<br />Anxious<br />hyperventilating<br />Contious , orianted<br />A:<br />patent<br /> no secretion<br />C:<br />Pr:140/min<br />(regular , good volume)<br />bp164/90 mmhg<br />
  8. 8. B:<br />Dyspnic<br />RR:22/min<br />spo2 98% in RA<br />Chest : clear <br />Generally:<br />Anxious<br />hyperventilating<br />Contious , orianted<br />A:<br />patent<br /> no secretion<br />C:<br />Pr:140/min <br />( regular , good volume)<br />Bp 164/90mmhg<br />D:<br />Reflow:6.8<br />Pupils: bilaterally reactive<br /> GCS: 15/15<br />
  9. 9. B:<br />Dyspnic<br />RR:22/min<br />spo2 98% with 100% o2<br />Chest : clear <br />Generally:<br />Anxious<br />hyperventilating<br />Contious , orianted<br />A:<br />patent<br /> no secretion<br />E:<br />No obvious external injuries or bleeding <br />Temp:afebrile<br />C:<br />Pr:140/min<br />(regular , good volume )<br />bp150/60<br />D:<br />Reflow:6.8<br />Pupils:bilaterally reactive<br /> GCS: 15/15<br />
  10. 10. history<br />= young male , unmarried , work as water tank driver <br />= after stressful event at home, was driving his car , suddenly has sob , palpitation , became dizzy <br />= stopped the car , call for help <br />= associated chest pain :unspecific , left sidedchest , burning , withsweating <br />
  11. 11. Since 3 mounths , have onn/off chest pain , mainly after stress , not related to excertions , associated with sweating & palpitation <br />
  12. 12. No cough or fever<br />No GI symptoms<br />No h/o contact with sick person<br />No recent travel.<br />Never smoke or drink alcohol.<br />Denying h/o drug intake <br />No FH of sudden death or CAD<br />
  13. 13. Examination:<br />Hyperventilating <br />Not ecteric , no skin rash , not dehydrated , no neck stiffness <br />Fundoscopy : no papilodema<br />JVP:not raised, no pedal edema<br />Chest:, clear<br />CVS: normal s1s2, no added sounds <br />Abdomen is soft, no hepatomegaly.<br />
  14. 14. Differential diagnosis<br />Cardiac :Arrhythmias ,ACS ,Cardiomyopathy<br />Pericarditis <br />Respiratory :Pulmonary embolism <br />Endocrine : Hyperthyrodism ( thyroid storm ) , Phyochromocytoma<br />Drug overdose : sympethatomimatic , anticholenergic<br />Psychological :Hyperventilation , anxiety disorders <br />
  15. 15. ECG<br />
  16. 16. Chest x-ray<br />
  17. 17. Trop T < .014, repeated Trop T <.014<br />
  18. 18. Action taking<br />Midazolam total of 13 mg <br /> ABG : Po2 118 , PH 7.4 , Pco2 22 <br />
  19. 19. Bedside Echo ( done by cardiologist ):<br />Normal , good EF , no evidence of pericarditis<br />
  20. 20. <ul><li>Hb is 14.7,hct:46.2,plt202, wbc:4.5,neutrophile 1.1,lymphocyte:2.5
  21. 21. Urea:3.8, creat:68, K: 4.3, Na:143
  22. 22. Salicylate level :normal
  23. 23. TSH < .003 (.35-4.9 )
  24. 24. Free T4 42 .6 (8.2 – 22.6 )
  25. 25. LFT : normal , CK : normal , bone profile WNR </li></li></ul><li>
  26. 26. Admitted in HiDe , monitored for 48 hrs<br />Remain tachycardia ,PR 128/min , high BP 180/70 , maintaining sat , c/o sweating <br />His BP controlled with IV Labetelol <br />Started on Propranolol Carbimazol & lugol’s iodenine solution 1 ml tid for 1 week<br />
  27. 27. BP controlled , PR improved 100/min , 80/min<br />24-hour urine catecholamines and metanephrines was done , came as normal<br />Discharged home after 4 days on Carbimazol &n Propranolol with f/u appointment in Endocrine clinic <br />
  28. 28. Thyroid Storm<br />
  29. 29. Thyroid Storm<br />The overall incidence of hyperthyroidism is estimated between 0.05% and 1.3%<br />Thyroid storm is a rare disorder. Approximately 1-2% of patients with hyperthyroidism progress to thyroid storm <br />Mortality approximately 10-20%, but it has been reported to be as high as 75% in hospitalized populations. Underlying precipitating illness may contribute to high mortality.<br />
  30. 30. <ul><li> thyroid hormones in Pt with hyperthyrodism…</li></ul>symptoms get worse<br />One major sign of thyroid storm that differentiates it from plain hyperthyroidism is a marked elevation of body temperature, which may be as high as 105-106 ºF<br />a life-threatening emergency<br />
  31. 31. Thyroid Storm Causes<br />Untreated hyperthyrodism<br />Infections, especially of the lung  <br />Thyroid surgery in patients with overactive thyroid gland<br />Stopping medications given for hyperthyroidism <br />Too high of thyroid dose <br />Treatment with radioactive iodine<br />Pregnancy<br />Heart attack or heart emergencies <br />Emotional stress  <br />
  32. 32. Thyroid Storm Symptoms<br />Rapid heart beats <br />Greatly increased body temperatur<br />Chest pain<br />Shortness of breath <br />Anxiety and irritability <br />Disorientation <br />Increased sweating <br />Weakness <br />Heart failure<br />
  33. 33. Fever ranges from 100.4-105.5.  The pulse rate may range between 120 and 200 beats per minute but has been reported as high as 300 . . . sweating so profuse  as to lead to dehydration from insensible fluid loss . . . <br />
  34. 34. Medical Treatment<br />A complete evaluation to determine the cause of thyroid storm <br />Intravenous fluids and electrolytes<br />Oxygen if needed  <br />Fever control with antipyretics (fever-reducing medications) and if needed cooling blankets <br />Intravenous corticosteroids such as hydrocortisone<br />
  35. 35. Defenitivetratment<br />Medications to block the production of thyroid hormones, such as propylthiouracil (PTU) or methimazole<br />Iodide to block thyroid hormone release <br />Block the action of thyroid hormones on the cells by drugs called beta-blockers, such as propranolol (Inderal) <br />Treatment of heart failure if present <br />
  36. 36. Next Steps<br />Following the start of treatment, careful monitoring, usually in the intensive care unit, is necessary. <br />Following recovery from thyroid storm, options for definitive treatment are radioactiveiodine or antithyroid medications; surgery is rarely needed.<br />
  37. 37. Rescue PCI<br />Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI<br />It is reasonable to perform rescue PCI for patients with one or more of the following: <br />a. Hemodynamic or electrical instability<br />b. Persistent ischemic symptoms. <br />

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