Medical Grand Round 순환기 내과 R2 송 란

박 0 돌 (F/70) Adm C.C. : chest pain onset - 일주일 전 duration – 10 분이내 site – substernal area frequency - 3~5 회 /day character – squeezing ass. symptom – dyspnea,sweating radiation – back, both shoulder NTG response – unknown P.I. : 내원 1 주일 전 chest pain 발생하여 3 일간 안동 병원 입원하여 치료 받았으나 증상 소실 없어 본원 순환기 내과로 전원. PMHx. : HTN (-) DM(-) Tb(-) Hepatitis(-) Op. Hx.(-) Allergy(-) FHx. : unremarkable PHx. : alcohol (-) smoking (-)

Review of System General : fatigue(-) fever(-) chills(-) sweat(-) weight loss(-) Skin : rash(-) pigmentation(-) Itching(-) Head & Neck : headache(-) trauma(-) stiiffness(-) Eye & ENT : sore throat(-) dry mouth(-) visual disturbance(-) Respiratory : cough(-) sputum(-) hemoptysis(-) Cardiac : chest pain(+) dyspnea(+) palpitation(-) orthopnea(-) PND(-) Gastrointestinal : A/N/V/D/C(-/-/-/-/-) abdomial pain(-) Urinary : dysuria(-) nocturia(-) frequency(-) Endocrine : polydipsia(-) heat intolerance(-) Musculoskeletal : myalgia(-) weakness(-) numbness(-) joint pain(-) Neurology : dizziness(-) tremor(-)

Physical Examination V/S : 140/90 mmHg-96 회 /min-20 회 /min-36.3°C height: cm body weight: 50 kg BMI: kg/m 2 General apperance alert conciousness Acutely ill appearance Skin no rash or pigmentation, skin turgor : normal Head & Neck normocephaly no neck vein engoregement no cervical LN enlargement no Supraclavicular LN enlargement no thyroid gland enlargement

Eye & ENT isocoric pupil with PLR(+/+) pinkish conjunctiva clear sclera Pharyngeal injection(-) paratonsilar hypertrophy(+/+) Thorax symmetric chest expansion clear breathing sound without crackle regular heart beat without murmur Abdomen soft and flat abdomen normoactive bowel sound no hepatosplenomegaly no tenderness, no rebound tenderness Back / Extremity CVA tenderness(-/-) pretibial pitting edema(-/-) dorsalis pedis artery pulse : palpable Neurologic examination unremarkable

Impression Acute myocardial infarction r/o unstable angina r/o aortic dissection

Diagnostic Plan Heart enzyme Chest X-ray, EKG Echocardiography If need, coronary angiography If need, Chest CT

Initial Lab Finding I (‘ ) CBC/DC 5970/mm g/dL-34.7 % /mm 3 INR :1.08 % a-PTT : 42 C 33 sec Chemistry TB/DB 0.7/0.1 mg/dL AST/ALT 31/31 IU/L ALP/GGT 77/26 IU/L Prot/Alb 6.4/3.4 g/dL Glucose 131 mg/dL Ca/P/Mg 8.5/4.1/2.4 mg/dL BUN/Cr 13/0.7 mg/dL Na/K/Cl 135/3.5/104 mmol/L

Initial Lab Finding II (‘ ) Heart enzyme CK / CK-MB 36 U/L/1.1ng/mL (CK-MB/CK ratio : 3.05%) Myoglobin 22.0 ng/mL TnI 0.01 ng/mL BNP 43.5 pg/mL (NL <100 pg/mL) Lipid Profile Total cholesterol 132 mg/dL TG 45 mg/dL HDL cholesterol 29 mg/dL LDL cholesterol 87 mg/dL UA RBC 0-1/HPF WBC 0-1/HPF O.B.:- Ketone(-) Glucose(-) Protein(-) SG: pH: 7.0

EKG (‘ )

Chest X-ray (‘ )

Echocardiography (‘ ) –Thickened aortic valve –Moderate amount of pericardial effusion –MR, PR : minimal –AR : mild to moderate –TR: mild Coronary angiography(‘ ) –<20% stenosis at Distal-RCA. –<20% stenosis at Mid-LAD. – Normal LCx.

Gastroscopy ( ) –1. Marked atrophic gastritis –2. Reflux esophagitis(LA-M) –3. Duodenitis Abdominal Sonography ( ) –common duct dilatation. no stone or mass –liver, GB, bile duct, pancreas, spleen, both kidneys 에 이상 소견 없음

Chest CT (‘ )

Intramural hematoma Final diagnosis

Case 2

전 0 환 (M/55) Adm C.C. : chest pain onset – 내원 3 시간 전 duration – continuous site – restrosternal area ass. symptom – sweating character – 뻐근하게 aggrevation & relieving factor - none radiation – back NTG response – unknown P.I. : –15 년전 colon cancer 로 op. 받음 ( 강남 성모 병원 ) – 당시 HTN 진단 받았으나 medication 없이 지냄. – 내원 3 시간 전 낚시 하던 중에 갑자기 chest pain 과 함께 back pain 발생하여 응급실 통해 내원. PMHx. : HTN (+)  15 년 전 진단. No medication DM(-) Tb(-) Hepatitis(-) Op. Hx.(+) : Lt. hemicolectomy (15 년 전, colon cancer)  당시 한차례 chemotherapy 시행. Allergy(-) FHx. : unremarkable PHx. : alcohol (+) : 소주 4 병 X daily X 10 년 smoking (+) : 2 pack / day x 11 년  22 pack / year

Review of System General : fatigue(-) fever(-) chills(-) sweat(+) weight loss(-) Skin : rash(-) pigmentation(-) Itching(-) Head & Neck : headache(-) trauma(-) stiiffness(-) Eye & ENT : sore throat(-) dry mouth(-) visual disturbance(-) Respiratory : cough(-) sputum(-) hemoptysis(-) Cardiac : chest pain(+) dyspnea(+) palpitation(-) orthopnea(-) PND(-) Gastrointestinal : A/N/V/D/C(+/+/-/-/-) abdomial pain(-) Urinary : dysuria(-) nocturia(-) frequency(-) Endocrine : polydipsia(-) heat intolerance(-) Musculoskeletal : myalgia(-) weakness(-) numbness(-) joint pain(-) back pain(+) Neurology : dizziness(-) tremor(-)

Physical Examination V/S : 210/130 mmHg-90 회 /min-24 회 /min-36°C height: cm body weight: 50 kg BMI: kg/m 2 General apperance alert conciousness Acutely ill appearance Skin no rash or pigmentation, skin turgor : normal Head & Neck normocephaly no neck vein engoregement no cervical LN enlargement no Supraclavicular LN enlargement no thyroid gland enlargement

Eye & ENT isocoric pupil with PLR(+/+) pinkish conjunctiva clear sclera Pharyngeal injection(-) paratonsilar hypertrophy(+/+) Thorax symmetric chest expansion clear breathing sound without rale regular heart beat without murmur Abdomen soft and flat abdomen, op scar (+) – LLQ normoactive bowel sound no hepatosplenomegaly no tenderness, no rebound tenderness Back / Extremity CVA tenderness(-/-) pretibial pitting edema(-/-) dorsalis pedis artery pulse : palpable Neurologic examination unremarkable

Impression Aortic dissection r/o Intramural hematoma r/o Unstable angina r/o Acute MI

Diagnostic Plan Heart enzyme Chest X-ray, EKG Chest CT Echocardiography If need, coronary angiography

Initial Lab Finding I (‘ ) ABGA – 35.7 mmHg – 82.0 mmHg – 24.8 mmol/L (96.5%) : O2 2L VNP CBC/DC 15160/mm g/dL-40.8 % /mm 3 (seg.:76.4%) INR :1.11 % a-PTT : 35 C 33 sec Chemistry TB/DB 1.0/0.1 mg/dL AST/ALT 19/12 IU/L ALP 74 IU/L Prot/Alb 6.9/3.6 g/dL Glucose 144 mg/dL Ca/P/Mg 8.6/3.5/2.1 mg/dL BUN/Cr 17/1.6 mg/dL Na/K/Cl 135/3.1/102 mmol/L UA RBC 0-1/HPF WBC 0-1/HPF O.B.:- Ketone(-) Glucose(-) Protein:100 mg/dL SG: pH: 6.5

Initial Lab Finding II (‘ ) Heart enzyme CK / CK-MB 84 U/L/1.9ng/mL (CK-MB/CK ratio : 2.26%) Myoglobin 37.0 ng/mL TnI 0.03 ng/mL Lipid Profile Total cholesterol 246 mg/dL TG 219 mg/dL HDL cholesterol 27 mg/dL LDL cholesterol 83 mg/dL 24hrs urine urine volume: 3200 mL creatinine: 1324 mg/day protein: 352 mg/dL CrCL: 54.1 ml/min

EKG (‘ )

Chest x-ray (‘ )

Chest CT(‘ )

Final Diagnosis Intramural hematoma

Case 3

최 0 길 (M/62) Adm C.C. : chest pain onset – 내원 5 시간 전 duration – continuous site – restrosternal area ass. symptom – sweating character – squeezing aggrevation & relieving factor - none radiation – back NTG response (+) P.I. : – 평소 간간히 exertional dyspnea 있었음. –HTN 있다는 얘기 들었으나 특별한 manage 없이 지냄. – 내원 전날 초상 치룬 뒤 오후 8 시경 부터 갑자기 chest pain 발생하여 녹색 병원 내원  Urokinase 150 만 unit 2 회 – 본원으로 전원. PMHx. : HTN (+)  no medication DM(-) Tb(-) Hepatitis(-) Op. Hx.(-) Allergy(-) FHx. : unremarkable PHx. : alcohol (+) : 소주 4 병 X daily X 10 년 smoking (+) : 2 pack / day x 11 년  22 pack / year \

Review of System General : fatigue(-) fever(-) chills(-) sweat(+) weight loss(-) Skin : rash(-) pigmentation(-) Itching(-) Head & Neck : headache(-) trauma(-) stiiffness(-) Eye & ENT : sore throat(-) dry mouth(-) visual disturbance(-) Respiratory : cough(-) sputum(-) hemoptysis(-) Cardiac : chest pain(+) dyspnea(-) palpitation(-) orthopnea(-) PND(-) Gastrointestinal : A/N/V/D/C(-/-/-/-/-) abdomial pain(-) Urinary : dysuria(-) oliguria(+) nocturia(-) frequency(-) Endocrine : polydipsia(-) heat intolerance(-) Musculoskeletal : myalgia(-) weakness(-) numbness(-) joint pain(-) back pain(+) Neurology : dizziness(-) tremor(-)

Physical Examination V/S : 160/90 mmHg-63 회 /min-24 회 /min-36°C height: cm body weight: 50 kg BMI: kg/m 2 General apperance alert conciousness Acutely ill appearance Skin no rash or pigmentation, skin turgor : normal Head & Neck normocephaly no neck vein engoregement no cervical LN enlargement no Supraclavicular LN enlargement no thyroid gland enlargement

Eye & ENT isocoric pupil with PLR(+/+) pinkish conjunctiva clear sclera Pharyngeal injection(-) paratonsilar hypertrophy(+/+) Thorax symmetric chest expansion clear breathing sound without rale regular heart beat with diastolic murmur on Lt. sternal border Abdomen soft and flat abdomen normoactive bowel sound no hepatosplenomegaly no tenderness, no rebound tenderness Back / Extremity CVA tenderness(-/-) pretibial pitting edema(-/-) dorsalis pedis artery pulse : palpable Neurologic examination unremarkable

Initial Lab Finding (‘ ) CBC/DC 17500/mm g/dL-48.0 % /mm 3 (seg.:85.9%) INR :5.88 % a-PTT : 97 C 33 sec Chemistry TB/DB 1.7/0.4 mg/dL AST/ALT 30/25 IU/L ALP 67 IU/L Prot/Alb 7.3/4.2 g/dL Glucose 131 mg/dL BUN/Cr 15/1.1 mg/dL Na/K/Cl 140/3.6/105 mmol/L UA RBC 0-1/HPF WBC 0-1/HPF O.B.:- Ketone(+/-) Glucose(-) Protein:30 mg/dL SG: pH: 5.5 Heart enzyme CK / CK-MB 134 U/L / 2.5 ng/mL (CK-MB/CK ratio : 1.86 %) Myoglobin 50.2 ng/mL TnI 0.03 ng/mL

Impression Aortic dissection r/o Intramural hematoma r/o Unstable angina r/o Acute MI

Diagnostic Plan Heart enzyme Chest X-ray, EKG Chest CT Echocardiography If need, coronary angiography

EKG (‘ )

Chest x-ray (‘ )

Chest CT(‘ )

Echocardiography (‘ )

Clinical Course TS 전과 –Total arch & ascending & proximal descending artery replacement

Final Diagnosis Aortic dissection DeBurkey type I