Old 11-21-2013, 14:02   #1
swatsurgeon
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New Patient

22 year old otherwise healthy recruit comes in to see someone with "chest pain".
The recruit has done escalating PT for weeks, is in 'great' shape so the medical someone exams him, finds a murmur which the recruit said he has always had and no other findings, tells him to take alleve and slow down on PT for 3 days then come back if no better.
It's better, all pain /discomfort gone so to catch up from no PT for 72 hrs, puts his pack on and runs the big hill, FAST. He is found 1/2 way up by someone on the ground, not breathing and no pulse.....
What happened?

ss
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The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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Old 11-21-2013, 14:24   #2
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He died.
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Old 11-21-2013, 14:26   #3
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The Aleve prescribed. NSAID's should not be taken by individuals with heart conditions, could lead to CHF.
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Old 11-21-2013, 15:22   #4
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Hypertrophic cardiomyopathy caused "Sudden Cardiac Death."

The NSAID may have "relieved" or "masked" the pain over the three days, but then hitting the PT as hard as he did after not doing any for those three days, put and enormous strain on his already enlarged heart and 1/2 way up the hill his heart said , "Nope, not today." then stopped.
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Old 11-21-2013, 16:36   #5
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Sounds like he saw an Army Doc.

Doctors practice medicine, they hopefully get better as time goes by, learning more and more as days pass by. A lot of the military docs I have seen come in as captains and are fresh from medical school.
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Old 11-21-2013, 17:11   #6
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How tall was he?
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Old 11-21-2013, 18:16   #7
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I got flagged on my retirement physical because the computer diagnostics said I showed symptoms of "Brugada (sp) Syndrome" ,otherwise known as "Sudden-Death Syndrome". I was told by the army's cardiologist that this is when young athletes (which I haven't been for many years, but thanks anyway, doc) either tear part of the heart tissue during intense contact sports, or the heart ruptures, develops an aortic tear, or succumbs to a whole slew of other possibilities. (5-finger death punch?) Examples given were: kid gets hit on the football field, gets up and walks a few steps and dies; kid goes up for a jump shot, lands, turns and dies.

I thought it was a pretty vague diagnosis when he listed the possibilities. Again, I'm no medic, but I thought it rather extreme that after 22 years in service I was suddenly prone to just keeling over if I sneezed too hard. Turned out I've had a 1st degree A-V node blockage for some time. My civilian doc said that's about as dangerous as having freckles on skin.
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Old 11-21-2013, 19:53   #8
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DDx

Sdiver nailed the easy #1, but I'll try to offer some additional options:

HCM is the most common etiology of sudden death in young athletes, and is consistent with the murmur. Increase index if he's African American. I bet the murmur got quieter when he squatted, or would have if the provider had tried it.

Nurse Tim is also on to something with Marfan's, which may lead to aortic dissection. Marfan's can also cause murmurs through a variety of mechanisms usually related to prolapse of valves or regurgitation.

Abnormalities of the coronary arteries are another possible structural etiology, although they don't explain the murmur quite as nicely.

Myocarditis is a possible infectious cause of sudden cardiac death by way of arrhythmia. Its always worth considering other treatable etiologies.

I'll throw long QT in as another congenital cause of SCD.

Brugada is an interesting thought, although the connection between that and exercise-induced SCD is unclear: usually Brugada kills you in your sleep.

Useful related note for medics in general:
Syncope DURING exercise is much more concerning than syncope AFTER exercise. Just a simple differentiator on whether to get your hackles up. Not saying syncope after exercise is always benign, but if it happens in the middle of exertion, you need to take it very seriously.
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Last edited by ender18d; 11-21-2013 at 20:00.
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Old 11-21-2013, 20:26   #9
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I'm happy to see this one got picked up quickly, good job. Keep the simple things in mind when you come across symptoms that add up to disaster ; it's not rocket science but there is doing good medicine and not taking signs and symptoms for granted, ie chest discomfort after a long PT, etc. any murmur an 'athlete' should be checked by an echo not some other non anatomic test.
ss
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'Revel in action, translate perceptions into instant judgements, and these into actions that are irrevocable, monumentous and dreadful - all this with lightning speed, in conditions of great stress and in an environment of high tension:what is expected of "us" is the impossible, yet we deliver just that.
(adapted from: Sherwin B. Nuland, MD, surgeon and author: The Wisdom of the Body, 1997 )

Education is the anti-ignorance we all need to better treat our patients. ss, 2008.

The blade is so sharp that the incision is perfect. They don't realize they've been cut until they're out of the fight: A Surgeon Warrior. I use a knife to defend life and to save it. ss (aka traumadoc)
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Old 11-21-2013, 20:30   #10
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Quote:
Originally Posted by swatsurgeon View Post
I'm happy to see this one got picked up quickly, good job. Keep the simple things in mind when you come across symptoms that add up to disaster ; it's not rocket science but there is doing good medicine and not taking signs and symptoms for granted, ie chest discomfort after a long PT, etc. any murmur an 'athlete' should be checked by an echo not some other non anatomic test.
ss
Appreciate your taking the time sir.
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Old 11-21-2013, 20:33   #11
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Quote:
Originally Posted by ender18d View Post
Sdiver nailed the easy #1, but I'll try to offer some additional options:

HCM is the most common etiology of sudden death in young athletes, and is consistent with the murmur. Increase index if he's African American. I bet the murmur got quieter when he squatted, or would have if the provider had tried it.

Nurse Tim is also on to something with Marfan's, which may lead to aortic dissection. Marfan's can also cause murmurs through a variety of mechanisms usually related to prolapse of valves or regurgitation.

Abnormalities of the coronary arteries are another possible structural etiology, although they don't explain the murmur quite as nicely.

Myocarditis is a possible infectious cause of sudden cardiac death by way of arrhythmia. Its always worth considering other treatable etiologies.

I'll throw long QT in as another congenital cause of SCD.

Brugada is an interesting thought, although the connection between that and exercise-induced SCD is unclear: usually Brugada kills you in your sleep.

Useful related note for medics in general:
Syncope DURING exercise is much more concerning than syncope AFTER exercise. Just a simple differentiator on whether to get your hackles up. Not saying syncope after exercise is always benign, but if it happens in the middle of exertion, you need to take it very seriously.
Great dDx Bro. But Scooter answered the asked question. Q: What happened? A: He died.
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Old 11-21-2013, 22:06   #12
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Quote:
Originally Posted by swatsurgeon View Post
I'm happy to see this one got picked up quickly, good job. Keep the simple things in mind when you come across symptoms that add up to disaster ; it's not rocket science but there is doing good medicine and not taking signs and symptoms for granted, ie chest discomfort after a long PT, etc. any murmur an 'athlete' should be checked by an echo not some other non anatomic test.
ss
Doc,
Thanks for the brain tickler. It's always appreciated when you and the others on the board throw these up.

Hypertrophic cardiomyopathy has been a study of mine since I was Dx'd with it several years ago. Had a bad case of bronchitis and had a chest x-ray done of my lungs to r/o pneumonia, the ER doc showed me the pics, (he knew me from when I was on the ambulances) and showed my enlarged heart. Last physical I had, was told I have a slight murmur on the left side (probably mitral valve), so I started doing research on this condition. So I'm always aware of not "over doing it" when working out or doing too much strenuous activity.

Here's a couple of pictures I've collected about HCM along with a cool picture of the vessels of the heart.

Thanks again SS
Attached Images
File Type: jpg hypertrophy.jpg (42.2 KB, 24 views)
File Type: jpg Normal heart (A) vs. Enlarged heart (B) Cardiomegally.jpg (50.3 KB, 25 views)
File Type: jpg vessels of the heart.jpg (82.0 KB, 21 views)
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