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(Insert Witty Title Here). PBL 12 Grant Coleman, Kirstie Foster, Fathema Johura, Nam Nguyen, Jonathan Penny, Charlie Sheen, Rachel Smith. Presenting Complaint. 30 ♀ GP Practice Manager “Collapsed”. Cardiac “Syncope”. Neurological. Differentials of “Collapse”. Neurological Vascular:

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  1. (Insert Witty Title Here) PBL 12 Grant Coleman, Kirstie Foster, Fathema Johura, Nam Nguyen, Jonathan Penny, Charlie Sheen, Rachel Smith

  2. Presenting Complaint • 30 ♀ GP Practice Manager • “Collapsed” Cardiac “Syncope” Neurological

  3. Differentials of “Collapse” Neurological • Vascular: • Cerebrovascular disease (rare) • Subclavian Steal Syndrome • Migrane • Other: • Seizure • Drugs – Medicinal / Recreational • Metabolic • Phycogenic / pseudo seizure Cardiac • Obstructive: • HOCM, AS, ?MS • PS, PE, Pulmonary Hypertension • MI, Tamponade • Arrhythmias: • Brady: Heart Blocks • Tachy: VT, SVT (only in Wollf-Parkinson-White) • Other • Adams-Stokes • Sick Sinus • Aortic Dissection • VasoVagal • BP • Drugs

  4. 1st episode of Collapse • Some memory loss – exact events hazy • Feeling hot and SOB prior to episode • Sitting down on toilet – Not actually using loo • Husband heard collapse – <1 minute • Looked pale / clammy • After regaining consciousness – Lethargy and chest pain 30 mins later

  5. Feeling generally unwell since December 2010 • Central, squeezing chest pain, 3 – 4 times a night, lasting 5-15 mins • Sudden onset • No aggregating or alleviating factors • Increasing in severity • Other • Increasing SOB - “Made it difficult to care for kids” • Sweating at night, nausea • Palpitations • Increasing temperature • 5 lb Weight loss (9st5 → 9st)

  6. Family Hx • Mother: Hypertension • Social Hx • Non smoker, moderate alcohol • Lives with husband / 2 children • PM/SH • Congenital Heart Disease – Surgical correction at 8 • Drug Hx • Paracetamol • Co-codomol • Depo-Provera IM injection

  7. Nicolas Steno 1672 Edward Sandifort 1773 (not accurate photo) Étienne-Louis Arthur Fallot 1888

  8. Increasing pressure on the left side of the heart

  9. A diagnosis of tetralogy of Fallot is usually based on: • Cyanotic • High systolic pressure in the right ventricle – Pressure Studies • X ray • Echocardiography

  10. Treatment – Surgical Average life expectancy after repair increases from only 3 to 4 years, to 50 or more years.

  11. Shaun White Beau Casson

  12. C. Walton Lillehei 1918 -1999 Lillehei's brilliant surgical career was marred by a flamboyant personal style, reckless relations with women, and a conviction for income tax evasion.

  13. Fallots Risks • RBBB • Leaking Pulmonary valve • Ventricular arrhythmia • Infective Endocarditis • Sudden cardiac death

  14. On Examination Temp: 39.6oC Pulse: 119 BP 90/63 mmHg RR: 18 GCS 15 O2 sat: 98% EWS 4 • Pale and diaphoretic • Digital clubbing • OLD ejection systolic murmur • NEW Early diastolic murmur

  15. ? Differentials

  16. U&E’s FBC CRP ESR Troponin D-Dimer ECG CXR Investigations Added later: • MSSU • TOE BLOOD CULTURES

  17. Abnormal Results Anaemia Raised CRP: 118 (0.3-5) Raised ESR: 68 (0.7) Raised D-Dimers: 735 ng/ml (0-250) MSSU- Enterococci positive Vegetation on Pulmonary Valve seen on TOE Awaiting Culture Results

  18. Management Antibiotics total 6/52 via central line Vancomycin and Gentamicin. 2) Culture results: Gram +ve Streptococcus viridans 3) Benzylpenicillin and Gentamicin continued

  19. Infective Endocarditis Incidence: 1.7-6.2 cases / 100,000 patient years Risk factors Previous IE with valvular damage Invasive vascular procedures Recreational IV drug abuse Rheumatic heart disease  Elderly patients with calcific aortic stenosis Congenital heart disease Prosthetic Valve implants

  20. Classification Acute vs. Sub acute Right sided vs. Left sided Hospital vs. Community – acquired Native – valve vs. Prosthetic - valve

  21. Causes In order of incidence: Staphylococcus aureus Streptococcus viridans

  22. Diagnosis Symptoms E.g. Fever, night sweats, weight loss Signs New murmur; early diastolic Emboli; Splinter haemorrhages, Janeway lesions Duke’s Criteria…

  23. Dukes Criteria IE definitive: 2 major, 1 major +3 minor, 5 minor • Major: • Positive BC • Other tests: e.g. Echo • New valve regurgitation • Minor: • T >38oC • Predisposition • BC +ve (but not major) • Vascular abnormalities; Janeway lesions • Oslers nodes

  24. Treatment Treatment will depend on the organism implicated. For example, with Streptococcus viridans:

  25. The plot thickens.... Developed Right sided pleuritic chest pain Apyrexial, Right sided basal crackles Impressions: septic emboli (likely) or PE, CNS KIDNEYS LUNGS SPLEEN

  26. Inflammatory markers

  27. Discharge summary 30 Y.O Female with surgical correction of Fallots Endocarditis + Secondary PE Blood cultures positive for Gram +ve Streptococcus 6 weeks IV antibiotics (Teicoplanin and Rifampicin) at home, and warfarin (for PE)

  28. So … Why the Syncope?!

  29. Thankyou I Cardiology PBL 12 Grant Coleman, Kirstie Foster, Fathema Johura, Nam Nguyen, Jonathan Penny, Charlie Sheen, Rachel Smith

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