1. Case I

2. Chief complain : dyspnea o/s) 2 days ago Present illness : a 67 years old man with hypertension, MVP and atrial fibrillation had taken medicine. He noticed recently that his both hands and legs swelling 4 weeks ago, this symptom has been getting severe since 2days, and nausea, vomiting and dyspnea was developed. So, he visited ED.

3. Past Medical History HTN (+) : 10 years ago Dx DM(-) / Hepatitis(-) / Pulmonary TB(-) CVA (+) : 10year ago, no sequelae Personal History Alcohol (-) Smoking (-) Family History Unremarkable

4. General Fatigue(-) Febrile sensation(-) Chill(-) Skin Rash(-) Pigmentation(-) Itching(-) H&N Headache(-) Sore throat(-) Dysarthria (-) Respiratory Cough(-) Sputum(-) Hemoptysis(-) Cardiac Chest pain(-) Orthopnea(+) Dyspnea(+) Edema(+) dyspnea on exertion (+) : NYHA IV G-I Postprandial abd. discomfort (-) Anorexia(-) Nausea(+) Vomiting(+) Abd. pain(-) Renal Dysuria(-) Urgency(-) Frequency (-) Hematuria(-) B/Ext. Upper back pain(-) Lower back pain (-)

5. V/S 120/70mmHg – 126/min – 22/min – 36.4°C General Appearance Alert mental status Acutely ill-looking appearance Head & Neck No cervical LN enlargement Neck vein engorgement (+/+) No thyroid enlargement Eye & ENT Isocoric pupil with PLR(++/++) Pinkish conjunctiva with icteric sclera

6. Chest Coarse breathing sound with crackle on both LLF systolic murmur (Gr I) at apex Irregular heart beat with systolic murmur (Gr I) at apex Abdomen Soft & flat abdomen Normoactive bowel sound Tenderness(-) Rebound tenderness(-) Shifting dullness(-) No Hepatosplenomegaly Back & Ext. CVA tenderness (-/-) Pretibial pitting edema(+/+) Neurologic examination Babinski (-/-) motor/sensory : intact

7. CBC/DC 7,610 /mm 3 –14.3 g/dL – 44.6 % – 172 k/mm 3 (Seg. 70.1%) Chemistry T. Bilirubin/D. Bilirubin 3.47/1.15 mg/dL Prot/ Alb 5.6 / 3.3 g/dL AST/ALT 28 / 32 U/L ALP/ GTT 71/ 67 U/L CRP < 0.5 mg/dL BUN/ Cr 69/2.5 mg/dL Na/K/Cl 139/3.7/101 mg/dL Ca/ P /Uric acid 8.1/ 5.4/2.4 mg/dL

11. #1. Congestive Heart failure #2. Atrial fibrillation #3. Mitral valve prolapse #4. ARF (FeNa : 0.03) #5. r/o biliary obstruction #6. old CVA

13.  Echocardiography 시행이유 For evaluation of cardiogenic pulmonary edema Known atrial fibrillation Known Mitral valve prolapse

14. #1. Congestive Heart failure #2. Atrial fibrillation #3. Mitral valve prolapse #4. ARF d/t CHF #5. old CVA