CASE 4

Mr. Yoyo 46 years was admitted to the emergency room with palpitation and dyspnea. This was his second admission to this hospital. History of present illness Mr. Yoyo was admitted with palpitation and dyspnea. The alpitation started 1 day before admission, which was felt as rapid and irregular heart beats. He has also complaints of shortness of breath in the past few weeks, which worsened to dyspnea even at rest, after the palpitation occurred. He was hospitalized 2 months ago, due to dyspnea on mild exertion (he could only walk for 10-15 meters). Complaints of easy fatigability and shortness of breath was noticed about 2month previously. He was discharge after 10 day, was told to have heart disease and advised to continue medication and do routine follow up, which he denied for the last 3 weeks. The only medication he continuously took was a small white tablet which increased his urination. Examination The physical examination showed a dyspneic patient with orthopneu and cold sweat. The BP was 115/95. The pulse was irregularly irregular, unequal, with a rate of 128 BPM. The respiration rate was 32/min. the temperature was 36.7C. HEENT was normal except for a slight increase of the JVP (5+3cm H2O). The heart was enlarged; S1 was variable with normal S2 and no discernible cardiac murmur. The heart beat was irregular with a rate of 148 bpm. Rales were heard over both lungs, with harsh breath sound.

A tender and slightly enlarged liver was revealed, but the abdomen was otherwise normal. A bipedal edema was found in his lower ekstremities. Laboratory examination was performed, which revealed a normal CBC, RBS, liver and kidney function. The electrolytes showed a low normal sodium concertation 133mEq/L and low potassium concertation 2.5 mEq/L, hypoxemia with a normal pH was found in the blood gas analysis. The chest X-ray showed an enlarged heart with pulmonary congestion. The rhytm on the ECG showed an atrial fibrillation with rapid ventricular response (148-152bpm) and frequent premature unifoval ventricular beats with couplets and occasional nonsustained VT. The echocardiography showed LV dilatation with depressed LV function. LV wall motion was globally hypocinetic.

Course Patient admitted to the cardiac ICU. Cardiac monitor was hooked on O2 4l/min was given through binasal catheter. Digoxin 0.25 mg IV, furosemid 1 mg/kg BW was given. A bolus of 150 mg amiodarone IV given in 20 min, followed by 1mg/min drip was also istitude. KCL drip was institude to correct the hypopotasemia. During the course of therapy, sudden sozure occurred, the ECG monitor showed sustained VT degenerating into VF. Cardiac

resuscitation was immediately performed. The PF was converted to sinus rhythm after defibrillation of 200 J and 300 J. amiodarone drip was continued to prevent further recurrence of the arrhythmia. After the episode of cardiac arrest the patient was failed revived.