R3 이정훈 Echo Conference

History 임 O 수 (M/45) adm. Via OPD Chief Complaint dyspnea of exertion o/s) 1yr ago dyspnea of exertion o/s) 1yr ago Present illness A 45 - year-old man with no significant medical history was admitted A 45 - year-old man with no significant medical history was admitted to the KMC via department of cardiothracic surgery O.P.D after hearing to the KMC via department of cardiothracic surgery O.P.D after hearing there is “something wrong with the lung and the heart” at local check-up. there is “something wrong with the lung and the heart” at local check-up.

Past Medical History Past Medical History DM / HTN / Tbc / Hepatitis ( - / - / - / -) DM / HTN / Tbc / Hepatitis ( - / - / - / -) Personal History Personal History Alcohol (-) Alcohol (-) Smoking (+) : 38 pack - years Smoking (+) : 38 pack - years Family History Family History Unremarkable Unremarkable History

Review of System General Fatigue(-) General weakness(-) Febrile sensation(-) Chill(-) Wt. change (-) Chill(-) Wt. change (-) Skin Rash(-) Pigmentation(-) Itching(-) H&N Headache(-) Sore throat(-) dizziness(-) Respiratory Cough(+) Sputum(+) Hemoptysis(-) Cardiac Chest pain(+) : stressful state Orthopnea(-) Dyspnea (-) Palpitation(-) D.O.E(+) : 1yr ago, 1~2 time/wk Palpitation(-) D.O.E(+) : 1yr ago, 1~2 time/wk G-I Anorexia(-) Nausea(-) Vomiting(-) Diarrhea(-) Renal Dysuria(-) Urgency(-) Frequency (-) Hematuria(-) Constipation(-) Abd. pain(-) Constipation(-) Abd. pain(-) Musculoskeletal Back pain(-)

Physical Examination V/S V/S 120/80mmHg – 76/min – 20/min – 36.5 ℃ - 96% 120/80mmHg – 76/min – 20/min – 36.5 ℃ - 96% General Appearance Alert consciousness Alert consciousness Not so ill looking appearance Not so ill looking appearance Head & Neck Normocephaly Normocephaly No NVE, No cervical LNE No NVE, No cervical LNE Eye & ENT Eye & ENT Isocoric pupil c PLR(++/++) Isocoric pupil c PLR(++/++) White sclera, Pinkish conjunctiva White sclera, Pinkish conjunctiva

Physical Examination Chest Chest Symmetric chest expansion Symmetric chest expansion Clear breath sound without rale or wheezing Clear breath sound without rale or wheezing Regular heart beat without murmur Regular heart beat without murmur Abdomen Abdomen Soft and obese abdomen Soft and obese abdomen Normoactive bowel sound Normoactive bowel sound Tenderness(-), Rebound tenderness(-) Tenderness(-), Rebound tenderness(-) Back & Ext. Back & Ext. CVA tenderness (-/-) CVA tenderness (-/-) Pretibial pitting edema(-/-) Pretibial pitting edema(-/-) Neurologic examination Neurologic examination Motor – IV+ IV+, Sensory – Motor – IV+ IV+, Sensory – IV+ IV IV+ IV

Initial Lab. Findings CBC/DC CBC/DC 7,700/mm 3 – 14.3 g/dL – 43.0% - 182K/mm 3 (Seg. 61.6%) 7,700/mm 3 – 14.3 g/dL – 43.0% - 182K/mm 3 (Seg. 61.6%) aPTT 26.9 sec PT (INR) 12.9 sec (1.01%) aPTT 26.9 sec PT (INR) 12.9 sec (1.01%) Chemistry TB 0.56 mg/dL TB 0.56 mg/dL Prot/ Alb 6.9 / 4.1 g/dL Prot/ Alb 6.9 / 4.1 g/dL AST/ALT 20 / 15U/L AST/ALT 20 / 15U/L ALP 73 U/L ALP 73 U/L BUN/ Cr 31 / 1.0 mg/dL BUN/ Cr 31 / 1.0 mg/dL Lipid Profile TC 158 mg/dl Lipid Profile TC 158 mg/dl TG 137 g/dl TG 137 g/dl

Chest X-ray ( )

EKG ( )

Initial Assessments #1. r/o ACS r/o pul. thromboembolism r/o pul. thromboembolism r/o aortic dissection r/o aortic dissection r/o aortic aneurysm r/o aortic aneurysm

Echo 시행 이유 #1. r/o ACS r/o pul. thromboembolism r/o pul. thromboembolism r/o aortic dissection r/o aortic dissection r/o aortic aneurysm r/o aortic aneurysm  cardiac function ( pul. HTN, wall motion, chamber size …)  cardiac function ( pul. HTN, wall motion, chamber size …)

History 최 O 준 (M/61) adm. Via OPD Chief Complaint altered mentality altered mentality Present illness A 61- year-old man who has problems of CKD was admitted to the A 61- year-old man who has problems of CKD was admitted to the hospital for alterd mentality and decreased heart rate (28/min) during hospital for alterd mentality and decreased heart rate (28/min) during performing dobutamin echocardiograpfy for evaluation of dyspnea. performing dobutamin echocardiograpfy for evaluation of dyspnea. The patient is on hemodialysis three times a week. The patient is on hemodialysis three times a week.

Past Medical History Past Medical History DM / HTN / Tbc / Hepatitis ( - / + / - / -) DM / HTN / Tbc / Hepatitis ( - / + / - / -) ESRD on HD : 05’ ESRD 진단 (prof. 임천규 f/u) ESRD on HD : 05’ ESRD 진단 (prof. 임천규 f/u) 07’ HD start !! 07’ HD start !! Personal History Personal History Alcohol (-) Alcohol (-) Smoking (-) Smoking (-) Family History Family History Unremarkable Unremarkable History

Medication Aspirin 100mg qd Efonidipine 40mg qd Nifedipine 66mg bid Irbesartan 150mg bid Cilazapril 2.5mg bid Atenolol 50mg bid Doxazosin 4mg bid Minoxidil 5mg qd Ferrous sulfate 256mg bid Hydroxyzine (ucerax) 10mg bid Diazepam 2mg bid Ca polystyrene sulfonate (Kalimate) 5g bid

Review of System General Fatigue(-) General weakness(-) Febrile sensation(-) Chill(-) Wt. change (-) cyanosis (+) Chill(-) Wt. change (-) cyanosis (+) Skin Rash(-) Pigmentation(-) Itching(-) H&N Headache(-) Sore throat(-) dizziness(-) Respiratory Cough(-) Sputum(-) Hemoptysis(-) Cardiac Chest pain(-) Orthopnea(-) Edema(-) D.O.E(+) Palpitation(-) Dyspnea(+) : 수개월전부터 지속적으로 있어오던 증상 Dyspnea(+) : 수개월전부터 지속적으로 있어오던 증상 G-I Anorexia(-) Nausea(-) Vomiting(-) Diarrhea(-) Renal Dysuria(-) Urgency(-) Frequency (-) Hematuria(-) Constipation(-) Abd. pain(-) Constipation(-) Abd. pain(-) Musculoskeletal Back pain(-)

Physical Examination V/S V/S 120/60mmHg – 28 /min – 22/min – 36.8 ℃ - 96% (Room air) 120/60mmHg – 28 /min – 22/min – 36.8 ℃ - 96% (Room air) General Appearance Alert consciousness Alert consciousness Acute ill looking appearance Acute ill looking appearance Head & Neck Normocephaly Normocephaly No NVE, No cervical LNE No NVE, No cervical LNE Eye & ENT Eye & ENT Isocoric pupil c PLR(++/++) Isocoric pupil c PLR(++/++) White sclera, anemic conjuctiva White sclera, anemic conjuctiva

Physical Examination Chest Chest Symmetric chest expansion Symmetric chest expansion Clear breath sound without rale / wheezing Clear breath sound without rale / wheezing Irregular heart beat without murmur Irregular heart beat without murmur Abdomen Abdomen Soft and flat abdomen Soft and flat abdomen Normoactive bowel sound Normoactive bowel sound Tenderness(-), Rebound tenderness(-) Tenderness(-), Rebound tenderness(-) Back & Ext. Back & Ext. CVA tenderness (-/-) CVA tenderness (-/-) Pretibial pitting edema(-/-) Pretibial pitting edema(-/-) Neurologic examination Neurologic examination Motor – IV+ IV+, Sensory – Motor – IV+ IV+, Sensory – IV+ IV IV+ IV

Initial Lab. Findings CBC/DC CBC/DC 4,630/mm 3 – 10.0 g/dL – 30.0 % K/mm 3 (Seg. 71.6%) 4,630/mm 3 – 10.0 g/dL – 30.0 % K/mm 3 (Seg. 71.6%) aPTT 39.2 sec PT (INR) 14.8 sec (1.15%) aPTT 39.2 sec PT (INR) 14.8 sec (1.15%) Chemistry BUN/ Cr 59 / 9.7 mg/dL BUN/ Cr 59 / 9.7 mg/dL Na/K/Cl 134 / 6.9 / 98 mg/dL Na/K/Cl 134 / 6.9 / 98 mg/dL Ca/P/Mg 7.3 / 2.2 / 3.0 mg/dL Ca/P/Mg 7.3 / 2.2 / 3.0 mg/dL CRP 0.40 mg/dL CRP 0.40 mg/dL Lipid Profile TC 126 mg/dl TG 56 g/dl Lipid Profile TC 126 mg/dl TG 56 g/dl LDL 75 mg/dl HDL 39 mg/dl LDL 75 mg/dl HDL 39 mg/dl Cardiac biomarker CK 110 U/L Cardiac biomarker CK 110 U/L CKMB / TnI 0.5 / 0.01 ng/mL CKMB / TnI 0.5 / 0.01 ng/mL pro BNP pro BNP 45439

Chest X-ray ( )

EKG ( :08:10)

Emergency CAG & femoral pacemaker insertion  CAG : normal.  CAG : normal.

EKG ( :36:23)

Emergency CRRT 시행.

EKG ( :59:53)

EKG ( :52:39)

Initial Assessments #1 Complete AV block d/t hyperkalemia #2 ESRD on HD #3 HTN