Holiday Heart

8/2/2019 Holiday Heart

1/31

Presented ByMeNursing 630

The Case of A Little Too Much


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HISTORY AND REVIEW OFSYSTEMS PERTINENT TO THE

CASE


3/31

CC is a 24 year old Caucasian

female who presents with aChief Complaint ofheadaches and chest

discomfort.

Chief Complaint


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HPI

The headaches started this AM when patient woke up

Describes the head as heavy; not unilateral; nophotophobia; Not the worse head of her life. She states thatthe headache is mainly at the back of her head.

States her heart was fluttering this morning and lasted forabout 2hrs.; but is now improving;

Denies chest pain; no radiation of pain; denies shortness ofbreathe.

She states that she has never experienced her heart flutteringbefore

She denies the use of any medications. She states that she had a couple of drinks yesterday duringthe day while out with friends; she couldnt quantify the intake.

Had several episodes of nausea and vomiting last night.


5/31

Past Medical History

Adult illness: Asthma Childhood illnesses: Recurrent ear

infections,

Psychiatric illnesses: Anxiety Surgical History: Tonsillectomy


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Current Health Status

Allergies: No Known Drug or Food allergies

Immunizations: MMR, Varicella, TD all less than 10 years; Yearly Flu shot.

Screening Test: Last Physical Examination over a year ago, last Pap

test 3 years ago

Safety Measures: Uses seatbelt, helmet on bicycles, no firearms in the

home.

Exercise: Does not exercise

Sleep Patterns: Sleeps well at night

Diet: Regular diets

Habits: Smokes ocassionally, occasional alcohol use, no use of

street drugs.


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Family History

Father: CVA

Mother: HTN

No Siblings


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Social History

Housing: Lives with her boyfriend.

Support Systems: Boyfriend

Recently started a new job.

Sexual History: Sexually Active with her

boyfriend only.


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Review of System (Pertinent)

General:

No weight loss or gain;

Generalized fatigue;

No Fever.

Skin and Hair: No Rash

HEENT

No loss of vision, occasionalheadaches;

Cardiac: no dizziness

Respiratory/CV:

No Shortness of Breath, orhemoptysis.

GI:

No diarrhea, no hematemesis

No jaundice

Hematology:

No abnormal bleedingOB/GYN:Normal Pap smear 1 yr.ago; .

Neurological:

No change in mentalstatus

Endocrine:Fatigue .

Musculoskeletal:

Occasional joint pain.

Mental Health:Stressed, nodepression.


10/31

PERTINENTPHYSICAL

EXAMINATION

What Systems Should we focus on?


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Thin white femaleAlert and OrientedNAD

VSBP: 145/80 RR:18 O2 Sat: 100%on RAT: 98.2 HR: 110

SkinNails without clubbing or cyanosis.

HEENT:Dry mucosaThroat: No goiter, thyromegaly;barely palpable, no lymphadenopathy.

Lungs:CTA, No Wheezes

GI/GU: Soft, slightly tender. LMP: 1 week ago

Cardiac:+ Orthostatic BPNormal S1, S2;No murmurs;No rubs; No gallops.No JVD

M. System:FROMNo deformities

Peripheral VascularSystem

No peripheral edema ofLEs

Neuro: Alert and oriented,CN I VII intact; no confusion

noted

Physical Examination


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What is Missing from the Physical Examination

CAGE Question

Cut back

Annoyed

Guilty

Eye Opener

Psych


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Physical Examination

Panic Disorder Questionnaire

Have you experienced brief periods, for seconds or minutes, of an

overwhelming panic or terror that was accompanied by racing heartbeats,shortness of breath, or dizziness?

Abbot A.V (2005). Diagnostic Approach to Palpitations. Retrieved from

http://www.aafp.org/afp/2005/0215/p743.pdf


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Lab

Normal Chest X-ray

EKG: ST

Glucose 95U/A dip

Specific Gravity >1.025

RBC +3


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Chest X-ray


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ECG


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What are the Possible DifferentialDiagnosis?


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Palpitations are secondary to underlying

problems such as anxiety, medications, cardiac

or pulmonary origin.

Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company


19/31

Differential Diagnosis

o Dehydration

o Holiday Heart Syndrome (Paroxysmal SupraventricularTachycardia or Atrial Fibrillation or Atrial Flutter)

o Hyperthyroidism

o Anxiety/Panic Disorder

o MI

Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care37(2).

Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape


20/31

Pathophysiology

The term Holiday Heart Syndrome was coined in

1978. Benign in nature

It is an acute cardiac rhythm and/or conductiondisturbance, most commonly supraventriculartachyarrhythmia, associated with heavy ethanolconsumption in a person without other clinicalevidence of heart disease.

Modest Alcohol Intake can act as a trigger in

some people.


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Pathophysiology

Alcohol Mechanism Theorized

Increased secretion of epinephrine andnorepinephrine.

Increased sympathetic output

Decreased Sodium current (leading to altered pH

level: with low dose=acidosis; high dose = alkalosis) acetaldehyde, the primary metabolite of alcohol, or

fatty acid ethyl esters, a cardiac alcohol metabolite

Arrhythmia resolves within 24hrs of , even

without any treatmentDirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care37(2).



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A Standard Drink Contains

12 fluid ounces of beer (about 5% alcohol)

8 to 9 fluid ounces of malt liquor (about 7%

alcohol)

5 fluid ounces of table wine (about 12%alcohol)

1.5 fluid ounces of hard liquor (about 40%

alcohol)


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How Would You Manage Ms.CCs Case?


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Therapeutic Plan

Diagnostics TherapeuticsPatient

Education andFollow Up


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Evaluating Palpitations

http://www.aafp.org/afp/2005/0215/p743.html


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Therapeutic Plan

1. Holiday Heart Syndrome:

Diagnostic:o Additional Lab: Cardiac Enzymes, CBC, Chem Panel, TSHTherapeutics: none

(beta blockers or calcium channel blockers) if dyspnea or sustained palpitations or chest pain. Holter Monitor: If symptom persists.

Patient Education: Alcohol abstinence, Eliminate other triggers like caffeine, ephedrine, stimulants like cocaine. Teach Valsalva maneuver or carotid massage or hands in cold water. Call 911 if symptoms recur and persist. Avoid exertion for the next 48 hours

Follow Up: In 2-3 days for lab work.Cardiologist Referral (Especially with syncope or near

syncope)


Cash, J., & Glass, C. (2011). Family practice guidelines (2nd ed.). New York: Springer Publishing Company


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Therapeutic Plan

2. Dehydration

Diagnostic: + Orthostatic BP

Therapeutics: 1 liter NS via IV infusion.

Patient Education:

Maintain hydration.


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Headache

Tension headache

Diagnostic: None

Therapeutic: Tylenol 650mg Prn headaches.Patient Education

Stay hydrated


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Role of the Nurse Practitioner

Partnership with the pt.

Support care for pt.

Referral and consultation(Cardiologist)

Follow up

Patient and Family education


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Follow Up & Case Summary

Reports no use of alcohol since last visit

No recurrent palpitations

EKG: Sinus Rhythm.

LAB: WNL

No Myopathy found on echo


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Reference

ACC/AHA/ESC Guidelines for the Management of Patients WithSupraventricular ArrhythmiasExecutive Summary. Retrieved from

http://circ.ahajournals.org/content/108/15/1871 Abbott A.V (2005). Diagnostic Approach to Palpitations.American Family

Physician. 71(5).

Budzikowski A.S (2012).Holiday Heart Syndrome. Medscape.

Cash, J., & Glass, C. (2011). Family practice guidelines(2nd ed.). New York: Springer Publishing Company Dirks J. (2007).Supporting Your Patient through Holiday Heart. Critical Care

37(2).

Pittman H. (2004). Recognizing Holiday Heart Syndrome. Nursing34(12).
http://circ.ahajournals.org/content/108/15/1871http://circ.ahajournals.org/content/108/15/1871http://circ.ahajournals.org/content/108/15/1871http://circ.ahajournals.org/content/108/15/1871

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Holiday Heart

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