doc_clotaire
Forum Guru
Topics: 159
Posts: 1,274
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A 35-year-old man comes to the hospital after an episode of syncope.
There were no preceding symptoms, and the patient recovered rapidly
and completely with no residual effects. The patient did not have
seizure activity during the episode. There is no history of heart
disease and no previous episodes of syncope. The patient lives in
rural Connecticut. His only previous medical problem was bilateral
facial palsy several months ago. Currently, the physical examination
is normal, except for a heart rate of 52/min. His blood pressure is
normal. An EKG shows a sinus rhythm with Mobitz II second-degree heart
block with a PR interval of 0.34 seconds. Echocardiogram is normal. He
has a positive VDRL and a negative FTA. What is the most appropriate
management of this patient?
(A) Doxycycline in addition to electrophysiological studies
(B) Ceftriaxone in addition to pacemaker
(C) Ceftriaxone in addition to prednisone
(D) Ceftriaxone
(E) Doxycycline in addition to permanent pacemaker
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| snowdrops
Forum Senior
Topics: 6
Posts: 149
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No very clear question. My guess is B.
Mobitz II second degree needs pacemaker for the treatment. ceftriaxone for the late stage of Lyme disease.
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| nadiabarati
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E
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| muna
Forum Senior
Topics: 17
Posts: 126
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B
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| sprint123
Forum Guru
Topics: 129
Posts: 870
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I would go with B...Since,myocarditis-a complication of LYME should be treated with ceftriaxone and since the patient is symptomatic on type ii block,I think we must add a pacemaker....
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| nadiabarati
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yes answer is B!!
for CNS symptoms except for Bell's palsy and also heart blocks higher than first degree we must choose ceftriaxone instead of doxycycline.
I'm just wondering that if we need to know so much details for step 2.
How you guys knew it? Is it in kaplan?
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| snowdrops
Forum Senior
Topics: 6
Posts: 149
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I checked TN.
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| doc_clotaire
Forum Guru
Topics: 159
Posts: 1,274
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Answer:
(B) Ceftriaxone in addition to pacemaker
Explanation:
This patient seems to have second-degree heart block secondary to Lyme
disease. He lives in Connecticut, which is an endemic area. (The city
of Lyme is in Connecticut.) Facial palsy is the most common
neurological manifestation of Lyme disease. The false positive VDRL is
characteristic as well. Besides, the patient is very young and has no
other reason to have heart block, such as ischemic heart disease. In
Lyme disease, high-grade AV block with a PR interval of >0.3 seconds
is an indication for intravenous therapy with either ceftriaxone or
penicillin. A pacemaker should be placed at least temporarily in those
with a Mobitz II heart block because of the risk of progressing on to
third-degree block. This patient is also severely symptomatic from his
heart block and has had syncope. Prednisone was used in the past but
is inferior to an antibiotic alone. Steroids would only be used in
those for whom the heart block does not improve with antibiotics. More
minor forms of Lyme disease can treated with oral doxycycline.
Doxycycline can be used with those who have just the rash, joint
symptoms, facial palsy, or first-degree heart block.
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The elevator to succes is broke ,you must take the stairs
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