1. Medical Grand Round 순환기 내과 R1 이윤정

2. Chief complaint Chest pain onset) 내원 30 분전 양상 : 2nd attack ( 1 st : 2000 년, 2 nd : 내원 30 분전 ) character – squeezing type, radiation (-) associated sx. (-) duration — 30 분 이상 location – substernal area, NTG response (-) Present illness 평소 특이병력 없는 72 세 남자환자로 2000 년에 급성 심근 경색으 로 아산병원에서 PTCA ( mid-RCA stent insertion state ) 시행받고 이후 medication 하면서 지내다가 내원 30 분전에 커피마시다가 흉 통을 주소로 본원 ER 통해 입원함 Patient’s history 이 0 길 (M/72) Adm.2005.08.24

3. Medical history DM/HTN/TB/Hepatitis ( -/ - / - /- ) OP Hx. (+) : 2004 년 TURP d/t BPH ( 위생병원 ) PTCA ( mid-RCA drug eluting stent insertion state ) – 2000 년 시행, aspirin 100mg qd, po Family history Unremarkable Personal history Alcohol(-) Smoking(+) : 1pack x 50 years – 50 pack / years Patient’s history

4.  General : fatigue(-) fever(-) chills(-) sweat(+) weight loss(-)  Head & Neck : headache(-) trauma(-) stiiffness(-)  Eye & ENT : sore throat(-) dry mouth(-) visual disturbance(-)  Respiratory : cough(-) sputum(-) hemoptysis(-)  Cardiac : chest pain(+) dyspnea(-) palpitation(-) orthopnea(-)  Gastrointestinal : A/N/V/D/C(-/-/-/-/-) abdomial pain (-)  Neurology : dizziness(-) tremor(-) Review of System

5. Physical Examination  V/S : 100/60 mmHg-91 회 /min-24 회 /min-36°C  General apperance alert conciousness Acutely ill appearance  Skin no rash or pigmentation, skin turgor : normal  Head & Neck no thyroid gland enlargement no neck vein engoregement no thyroid gland enlargement  Eye & ENT isocoric pupil with PLR(++/++) pinkish conjunctiva clear sclera Physical Examination

6.  Thorax symmetric chest expansion course breathing sound with rale of Rt. Lower lung field 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 Physical Examination

7. Initial EKG

8. Chest x-ray (‘05.08.24)

9.  CBC/DC 15820/mm 3 -14.6 g/dL- 43.6 %- 421000/mm 3 (seg.:43%) INR :1.00 % a-PTT : 36 C 33 sec  Chemistry TB/DB 0.6 / 0.1 mg/dL AST/ALT 24 / 19 IU/L ALP / rGT 73 / 43 IU/L Prot/Alb 5.6 / 3.4 g/dL Glucose 150 mg/dL BUN/Cr 21 / 0.9 mg/dL Na/K/Cl 137 /4.0 /106 mmol/L  Heart enzyme CK / CK-MB 174 U/L / 23.0 ng/mL (CK-MB/CK ratio : 13.2 %) Myoglobin ( 17.4 – 105.6 ) 615.4 ng/mL TnI ( <0.04 ) 1.39 ng/Ml  Lipid profile TG/Total cholesterol 100 / 175 mg/dl HDL / LDL Cholesterol 12 / 115 mg/dl Initial Lab Finding

10.  Acute myocardiac infarction  Pulmonary edema Impression

11. Diagnostic Plan  Echocardiography  Coronary angiography, PTCA 고려  Heart enzyme F/U  Chest X-ray, EKG F/U Diagnostic Plan

12. Echocardiography (‘05.08.24)

14. Coronary angiography (05.08.24)

17. PTCA (05.08.24)

18. F/U EKG Heart enzyme F/U CK/CK-MB 571/ 92.7 ( ratio 16.23 ) 05.08.24 20 :00 CK/CK-MB 573 / 44.7 ( ratio 7.8 ) 05.08.25 6 : 00 CK/CK-MB 397 / 9.6 ( ratio 2.41 ) 05.08.26 6 : 00 05.08.25 am 7:00

19. F/U Chest PA

20.  Acute MI – Restenosis of stent insertion site - Total occlusion at Mid-RCA Final diagnosis