Case of The Week PCI replacing CABG R1 유태경

CASE 1

M/58 M/58 Chest pain o/s) 내원 2 시간전 Chest pain o/s) 내원 2 시간전 Present illness - 04 년 6 월부터 Seizure disorder 로 본원 신경과 외래 F/U 중 내원 2 시간 전부터 상기 증상 있어 ER 통해 내원 Present illness - 04 년 6 월부터 Seizure disorder 로 본원 신경과 외래 F/U 중 내원 2 시간 전부터 상기 증상 있어 ER 통해 내원 1st episode Substernum Pressing Continuous Radiation (+) : Lt shoulder a/w Sx(+) : sweating

Past medical history DM / HTN / Hepatitis / TB (-/-/-/-) Past medical history DM / HTN / Hepatitis / TB (-/-/-/-) Seizure disorder (+) Seizure disorder (+) Op Hx (-) Op Hx (-) Personal history Alcohol (-) Smoking (+) : 40 pack years Personal history Alcohol (-) Smoking (+) : 40 pack years

Review of system Cardiac Chest pain(+) Orthopnea(-) Palpitation(-) Review of system Cardiac Chest pain(+) Orthopnea(-) Palpitation(-) Physical examination V/S 120/70 mmHg - 68 회 /min -20 회 /min ˚C Thorax Clear breathing sounds without crackle Regular heart beat without murmur Regular heart beat without murmur B&Ext Pretibial pitting edema(-/-)

Lab findings CBC/DC 12,360 /mm 3 – 15.5 g/dl – 49.7 % K ( Seg : 63.6 % ) Chemistry BUN/Cr 18/0.9 mg/dL Na/K/Cl 141/3.5/106 mmol/L Glu 170 mg/dL BNP 19.9 pg/mL Cardiac Biomarker CK 68 U/L CK-MB 1.1 ng/mL TnI 0.05 ng/mL Lipid Profile T-chol 228 mg/dL TG 106 mg/dL HDL-chol 31 mg/dL LDL-chol 128 mg/dL

Chest X-Ray

ECG

Initial Problem List Initial Problem List #1. STEMI #2. Known seizure disorder Diagnostic & Therapeutic Plan Diagnostic & Therapeutic Plan #1. Echocardiography CAG CAG Primary PCI Primary PCI

Echocardiography

Coronary angiography

PCI

Post- PCI ECG

Final Diagnosis STEMI STEMI Known seizure disorder Known seizure disorder

CASE 2

M/67 Chest pain o/s) 내원 2 주전 Present illness - DM, HTN medication 중 - 2 주 전부터 상기 증상 발생하여 외래 통해 내원 Substernal Squeezing 5 분 – 10 분 On exertion Relieved by rest a/w Sx(-) Radiation(-) more severe and frequent

Past Medical History Past Medical History DM / HTN / Hepatitis / TB (+/+/-/-) DM / HTN / Hepatitis / TB (+/+/-/-) Op Hx (+) : Appendectomy, 30 년전 Op Hx (+) : Appendectomy, 30 년전 Personal History Personal History Alcohol (+) Smoking (+) : 30pack years

Review of System Cardiac Chest pain(+) Orthopnea(-) Palpitation(-) Review of System Cardiac Chest pain(+) Orthopnea(-) Palpitation(-) Physical Examination V/S 140/80 mmHg - 72 회 /min -20 회 /min ˚C Thorax Clear breathing sounds without crackle Regular heart beat without murmur Regular heart beat without murmur B&Ext Pretibial pitting edema(-/-)

Lab results CBC/DC 5,990 /mm 3 – 11.9 g/dl – 35.4 % K ( Seg : 58.3 % ) Chemistry BUN/Cr 22/1.1 mg/dL Na/K/Cl 140/5.0/106 mmol/L Glu 113 mg/dL BNP 96.5 pg/mL Cardiac Biomarker CK 62 U/L CK-MB 1.3 ng/mL Tn-I 0.01 ng/mL Lipid Profile T-chol 167 mg/dL TG 138 mg/dL HDL-chol 21 mg/dL LDL-chol 126 mg/dL

Chest X-Ray

ECG

Initial Problem List Initial Problem List #1. Unstable angina #2. Known HTN #3. Known DM Diagnostic & Therapeutic Plan Diagnostic & Therapeutic Plan #1. Stress Echocardiography CAG CAG PCI PCI

Stress Echocardiography

Coronary angiography

PCI

Final Diagnosis Stable angina Stable angina Known DM Known DM Known HTN Known HTN

CASE 3

F/73 F/73 Chest pain Chest pain Present illness - 05 년 8 월 unstable angina 로 PTCA( prox. RCA) 시행 한 환자로 상기 증상 악화되어 내원 Present illness - 05 년 8 월 unstable angina 로 PTCA( prox. RCA) 시행 한 환자로 상기 증상 악화되어 내원 Substernal <1min Squeezing On walking Relieved by rest Radiation (-) a/w symp (+) : Dyspnea NTG response(+)

Past medical history Past medical history DM / HTN / Hepatitis / TB (-/-/-/-) DM / HTN / Hepatitis / TB (-/-/-/-) Hypothyroidism(+) : 15 년전 진단 & 1 년간 medication Hypothyroidism(+) : 15 년전 진단 & 1 년간 medication Op Hx (+) : TKR d/t AVN, Rt hip Op Hx (+) : TKR d/t AVN, Rt hip Personal history Alcohol (-) Smoking (-) Personal history Alcohol (-) Smoking (-)

Review of System Cardiac Chest pain(+) Orthopnea(-) Palpitation(-) Review of System Cardiac Chest pain(+) Orthopnea(-) Palpitation(-) Physical Examination V/S 130/80 mmHg - 82 회 /min -20 회 /min ˚C H&Neck Neck vein engorgement(+/+) Thorax Clear breathing sounds without crackle Regular heart beat without murmur Regular heart beat without murmur B&Ext Pretibial pitting edema(-/-)

Lab results CBC/DC 5,340 /mm 3 – 12.2 g/dl – 37.6 % K ( Seg : 48.8 % ) Chemistry BUN/Cr 16/1.0 mg/dL Na/K/Cl 145/3.8/106mmol/L Glu 121 mg/dL BNP 12.8 pg/mL Cardiac Biomarker CK 70 U/L CK-MB 1.7 ng/mL Tn-I 0.03 ng/mL Lipid Profile T-chol 189 mg/dL TG 122 mg/dL HDL-chol 40 mg/dL LDL-chol 128 mg/dL

Chest X-Ray

ECG

Initial Problem List Initial Problem List #1. Unstable angina, s/p PTCA #2. Known Hypothyroidism Diagnostic & Therapeutic Plan Diagnostic & Therapeutic Plan #1. Echocardiography CAG CAG PCI PCI

Echocardiography

Coronary angiography

PCI

Final Diagnosis Unstable angina Unstable angina Known hypothyroidism Known hypothyroidism