first question | choose another case | Epharnet
A 60-year-old man, J. P., was admitted to hospital because of short-term unconsciousness.
Patient's history:
1 year ago he was admitted to hospital for an acute myocardial infarction (the anterior type of MI, complicated by a monomorphic ventricular tachycardia). He was short of breath if doing mild exercise (going up-stairs). He has been treated with Moduretic (amiloride) and Cordarone (amiodarone) since.
5 days before the admission to hospital, the patient was diagnosed with atrial fibrillation (in another medical institution) for which he was prescribed quinidine sulphate orally in addition to the previous medication. 2 days before the admission he suddenly fainted for a short period (10 min) twice within 7 hr. The first syncope occurred while watching TV in the morning. The second episode occurred while the patient was shopping in the afternoon. It resulted in mild injury to the patient´s head.
The prescribed medication at admission was as follows: quinidine sulphate (Kinitard) 250 mg 4 times/ day (for 5 days), hydrochlorothiazide 25 mg coadministered with amiloride 2.5 mg (Moduretic 1/2 tabl)/day, and amiodarone 200 mg (Cordarone - 1 tabl)/day.
Physical examinations:
The patient was pale. Jugular filling was adequate, there were no signs of dehydration,
acral congestion was normal.
Lungs: sonorous percussion, clear, vesicular breathing, no rales in basal parts.
Heart: heart action is accompanied with presystolic beats, followed by long post-systolic
pauses, neither 3rd sound nor murmurs are present. BP 110/70 mmHg, and heart rate 50/min.
Abdomen and lower extremities: the findings were adequate to the age of the patient.
The weight of the patient was 60 kg, height 170 cm.
Electrocardiogram (ECG):
the sinus rhythm of 50 beats per minute, QT interval ( 0.61s. A premature ventricular beat
is followed by a pause and a subsequent supraventricular beat. Then a premature ventricular
beat appeared followed by the episode of polymorphic ventricular tachycardia showing a
peculiar electrocardiographic pattern characterised by a continuous twisting in QRS axis
around an imaginary baseline ("torsade de pointes" - TdP) occurred during monitoring (these
episodes disappeared spontaneously).
RTG:
the border size of the heart shadow, there are no more distinct signs of lung congestion
|
sodium potassium magnesium chlorides total calcium creatinine urea AST ALT LDH glucose |
140 mmol/L 3.7 mmol/L 0.9 mmol/L 103 mmol/L 2.17 mmol/L 89 µmol/L 11. 4 mmol/L 0. 6 ukat/L 0. 4 ukat/L 0. 5 ukat/L 6 mmol/L |
Serum quinidine was 2 ug/L at 1.5 hour after the drug administration.