1. 순환기내과 R1 윤경한 / Prof. 한미영 Medical Grand Rounds Case Presentation

2. Chief Complaint Dizziness onset : 2months ago Present Illness 55/F, Uterine myoma 로 subtotal hysterectomy hx 있는 자로 (2003 년 본 원 OBGY prof. 김승보 ) 내원 두달 전 의자에 앉아 있던 중 발생한 fainting type 의 dizziness 로 본원 신경과 방문하여 Neurologic exam. 정상 소견 및 Echocardiography 이상 소견 보여 순환기 내과로 refer 후 입원함. 11075778 신 O 희 55/F Adm : 2011.08.10

3. Past Medical History DM/HTN/Tb/Hepatitis (-/-/-/-) Op Hx (+) : 2003 uterine myoma s/p subtotal hysterectomy c adhesiolysis Familial History Heart disease familial Hx(-) Cancer Hx(-) Personal History Smoking (-) Alcohol (-)

4. Review Of Systems General F atigue (−) Wt loss (−) Febrile sensation (−) Chilling (−) Myalgia (−) Night sweat(−) Edema (-) Skin Rash (−) Itching (−) Pigmentation (−) Head & Neck Headache(−) Diplopia(−) Tinnitus(−) Respiratory Cough (−) Sputum (−) Dyspnea (−) Tachypnea (−) Hemoptysis(−) Cardiac Palpitation (−) Orthopnea (−) Chest pain (+) : 평소 운동시 왼쪽 가슴 intermittent pain 호소함 Lt. chest wall, 1~2 분, squeezing type, no resting pain, no radiating pain, no associated symptom

5. Review Of Systems Gastrointestinal Swallowing (−) Jaundice (−) Abdominal pain (−) Melena (−) Hematochezia (−) A/N/V/D/C (−/ −/ −/ −/ −) Urinary Dysuria (−) Frequency (−) Oliguria (−) Flank pain (−) Musculoskeletal Pain (−) Weakness (−) Cramp (−) Neurologic Syncope (−) Seizure (−) Dizziness (+) : abrupt onset, 30~60 초, fainting type, no aggravating & associated factor

6. Physical Examination Vital sign 110/80mmHg - 64 회 /min - 20 회 /min – 36.8°c - 99%(R/A) Pulse pressure : 30mmHg General A lert mentality Not so ill looking appearance Skin No rash No pigmentation Head & Neck No neck vein engorgement Cervical LN enlargement ( − ) Eye & ENT Isocoric pupil w/ PLR (++/++) PI ( − ) PTH ( − / − )

7. Physical Examination Thorax Bilateral symmetric expansion Clear breathing sound without R or W Irregular heart beat with continuous murmur at upper Lt sternal area, Grade 1-2/6, P2 accentuation (-) Abdomen Soft & flat, Normoactive bowel sound Tenderness ( − ) Rebound tenderness ( − ) No palpable mass No abdominal bruit Back & Extremity CVA tenderness ( − / − ) Pretibial pitting edema ( − / − ) Neurology Motor V V Sensory 100 100 V V 100 100

8. Initial Lab Findings CBC/DC 4530/mm² -13.0 g/dl – 36.6%- 193K(seg : 58.5%) aPTT 33.1 sec PT(INR) 12.5 (0.97) Chemistry AST / ALT 23 / 19 U/L BUN / Cr 17/0.6mg/dL Total bilirubin 0.67 / 0.09 mg/dL Total CO2 25.3 Na / K / Cl 141 / 3.9 / 106mmol/L Protein / Alb 6.5 / 3.5 g/dL Ca / P / Mg 9.0/ 3.3 / 2.2 mg/dL U/A RBC 0-1/HPF WBC 0-1/HPF Protein (-) Nitrite (-) Glucose (-) PH 5.0

9. EKG

10. Chest X-ray

11. Initial Problem Lists #1. Dizziness #2. Chest pain #3. Uterine myoma s/p subtotal hysterectomy c adhesiolysis

12. Initial Assessment & Plan #1. Dizziness S) Dizziness – fainting type O)EKG –sinus rhythm Neurologic exam - normal A) Cardiac arrhythmia Cardiac structural disease Diagnostic Plan> TTE, Stess test 24hr-holter monitoring Therapeutic Plan> Anti arrhythmic drug If structural disease -> Intervention

13. Initial Assessment & Plan #2. Chest pain S) Lt. chest pain that occurs during exercise O) EGD(2011.03) – Reflux esophagitis, minmal change A) Coronary heart disease, most likely stable angina GERD Diagnostic Plan> Cardiac enzyme, Treadmill test TTE, Cardiac angio CT CAG Follow up EGD Therapeutic Plan> Antiplatelet agent, Proton pump inhibitor If needed, PCI

14. Initial Assessment & Plan #3. Uterine myoma s/p subtotal hysterectomy c adhesiolysis Plan> Observation

15. Clinical course

16. HD #2 S & O) CK / CK-MB / Tn-I – 73 / 2.3 / 0.01 TTE(2011.06.15) Coronary Angiography Transcatheter device closure A) Patent ductus arteriosus s/p transcatheter PDA closure P) Follow up echocardiography

17. Clinical course HD #3 S) None specific symptom O) Follow up TTE A) PDA s/p transcatheter PDA closure P) Discharge & OPD follow up

18. Clinical course OPD (2011.08.19) S) No significant symptom O)EKG A) PDA s/p transcatheter PDA closure P) OPD follow up

19. Ecocardiography

20. 2011.06.15 Echocardiography(TTE)

24. Qp:Qs  1.31

25. Cardiac Catheterization Pre TCO FA 96% LPA 75% MPA 87% SVC 70% RA 71% IVC 68% Qp: Qs: 96(%)(A)- 69(%) (mixed venous saturation ) / 99(%)(PV)- 75(%)(LPA)  1.125

26. 2011.08.12 Echocardiography(TEE)

27. Final diagonsis Patent ductus arteriosus(small type)