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Published byKelly Deborah Cain Modified over 7 years ago
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Angio Conference
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11175155 김 O 동 (M/50) Admission: 06-06-07 Chief complaint - Chest Pain (recent o/s: 내원 2 주전, remote o/s: 내원 1 년전 ) squeezing type Ant. chest wall area Radiation to neck Aggrevated by exertion Duration: 5 min. Ass. Sx : nausea Relieved by rest Present illness -M/50, 2 년 전부터 local clinic 에서 HTN medication 중이었으며, 1 년 전부터 1km 정도의 보행시 chest pain 이 있었음. 내원 2 주 전부터 500m 정도의 거리를 걸을 때에도 2-3 차례의 chest pain 이 생길 정도로 Sx. 심해져 외래 통해 입원함.
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Past medical history DM / HTN / Hepatitis / TB (-/+/-/-) Op Hx (-) Personal history Alcohol (+): 회식시 소주 반 병 Smoking (-) :3 개월전 stop (20pack-years)
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Review of systems General : fatigue (-) fever (-) chills (-) Skin : rash (-) itching (-) pigmentation (-) Head / Neck : headache (-) hoarseness (-) sore thraot (-) Respiratory : cough (-) sputum(-) dyspnea(-) Cardiac : Chest pain(+) orthopnea(-) palpitation(-) edema(-) GI : A/N/V/D/C (-/-/-/-/-) abd pain(-) hematochezia (-)
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Physical examination Vital sign 130/80 mmHg – 80/min – 18/min – 36.0 °C General appearance - Alert mentality - Well looking appearance Skin - No rash & pigmentation - Intact skin turgor Head & Neck - No cervical lymph node enlargement - Neck vein engorgement (-/-)
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Eyes and ENT - Isocoric pupils with pupilary light reflex (++/++) - Whitish sclera - Pinkish conjunctivae Chest - Clear breath sounds without crackle or wheezing - Regular heart beats without systolic murmur Abdomen - Soft and flat abdomen - Normoactive bowel soud - Abd tenderness or rebound tenderness (-/-)
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Lab results CBC/DC 6780/mm3 – 15.2 g/dl – 44 % - 277k ( seg: 63.2 % ) Chemistry TB/DB 1.22 / 0.25 mg/dL T-chol/Glu 229/90 mg/dL AST/ALT 26 / 19 U/L LDL-chol 165 ALP 73 U/L TG 206 Prot/Alb 6.1 / 3.4 g/Dl HDL-chol 28 BUN/Cr 18 / 1.1 mg/dL Na/K/Cl 141 / 4.3 / 104 mmol/L CK 176 CK-MB 2.3 Troponin I 0.01 Myoglobin 38.4 UA RBC 0-1 WBC 0-1
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Chest PA
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ECG
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Treadmill Echocardiography(06-6-2)
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CAG AND PTCA
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