Presented by CHAE JUNGMIN M G R Division of Cardiology, Department of Internal Medicine Presented by CHAE JUNGMIN

Chief complaint Present illness Admission 2008-05-06 11216515 고o남 (F/72) Chief complaint Dyspnea remote onset) 내원 2개월전 recent onset) 내원 1주일전 Present illness 96년 LC 진단받고 본원 소화기내과 F/U 중인 72세 여자로 내원 2개월전 Ischemic colitis with colonic perforation으로 S-D colectomy and loop T colostomy 시행하고 퇴원후 DOE 발생하였고 내원 1 주일전부터 febrile sense와 함께 DOE 악화되어 응급실 통해 입원 2008.5.6~ 5.10 #1 admission 2008.5.13~ 5.30 #2 admission

Past medical history Personal history DM / HTN / TB / Hepatitis (-/-/-/-) unknown origin LC with portal vein thrombosis, esophageal varices s/p EVL #3 본원 소화기내과 F/U med Op Hx (+) Appendectomy d/t appendicitis 96년 Devascularization with Splenectomy, 2001년 6월 S-D colectomy with Loop T colostomy, 2008년 3월 Drug Hx (+) propranolol 10mg bid aspirin 100mg qd gabapentin 300mg qd Personal history Alcohol (-) Smoking (-)

Review of System General Febrile sense (+) Chill (-) Fatique (-) Wt loss(-) Skin Itching (-) Pigmentation (-) Rash (-) Head & Neck Headache(-) Sore throat(-) Respiratory Cough(+) Sputum(-) Dyspnea(+) 내원 2개월전부터 발생, 내원 1주일전 악화, DOE NYHA class Ⅱ Cardiac Chest pain (-) Orthopnea (-) Palpitation (-) GI A/N/V/D/C(-/-/-/-/-) Abd pain(-) Renal Dysuria(-) Frequency(-) Hematuria (-)

Physical Examination Vital sign 80/50mmHg – 109회/min – 28회/min – 36.9°C – SaO2 94% Body weight 54 Kg Height 160 cm BMI 21.0 kg/m2 General appearance Alert mentality Acutely ill-looking appearance Skin No rash & pigmentation No palpable LN enlargement Head & Neck No neck vein engorgement v/s unstable

Physical Examination Chest Coarse breath sounds with wheezing on BLLF Regular heart beats without murmur Abdomen Soft and flat abdomen Normoactive bowel sound Abdominal tenderness/rebound tenderness(-/-) Colostomy state at RLQ (+) Back & Extremity CVA tenderness (-/-) Pretibial pitting edema(+/+)

Lab Findings CBC/DC 6,320 /mm3 – 10.2 g/dl – 32.6 % - 268K (seg: 76.0 %) PTT 38.1 sec INR 1.23 % Chemistry AST/ALT 51 / 27 U/L TB/DB 0.94 / 0.48 mg/dL Prot/Alb 7.1 / 3.7 g/dL CRP 1.4 mg/dL BUN/Cr 22 / 0.4 mg/dL Na/K/Cl 140 / 3.8 / 115 mmol/L Cardiac biomarkers CK/CK-MB 59/2.5 U/L ng/mL, Myoglobin <0.05 ng/mL, Tn-I 0.09 ng/mL BNP 794 ng/L UA RBC 2-4/HPF WBC 10-29/HPF glucose (-) protein (2+) ABGA (RA) 7.529 – 18 mmHg – 70.7 mmHg – 14.7 mmol/L– 93.8%

Initial Chest X-Ray Cardiomegaly, pulmonary congestion

Initial ECG HR 96회 이며 RR interval regular 하며 v1-6까지 t wave inversion 소견 나타나고 있으며 특별한 st change 보이고 있지 않았습니다.

T wave inversion

Initial Problems #1. DOE

Initial Assessment #1. Acute Pulmonary Embolism r/o Rt Heart failure r/o IHD r/o DVT

Initial Plan Diagnostic plan Therapeutic plan 1. Cardiac biomakers F/U 2. ECG F/U 3. Echocariography, Chest CT, Extremity doppler ultrasound Therapeutic plan 1. Anticoagulation 2. If needed, thrombolysis or thrombectomy 3. If needed, IVC filter

Echocardiography (2008-05-06) Enlarged RA & RV, RV wall motion 저하, D-shape, severe TR, dilated IVC respiratory change,

Enlarged RA & RV, RV wall motion 저하, D-shape, severe TR, dilated IVC respiratory change,

Chest CT (2008-05-06) Pulmonary thromboembolism involving both pulmonary artery and segmental branches Subcarinal lymphadenopathy Scanty pericardiac effusion Large ascites and infiltration in mesentery with colostomy state -> 중요 image cut 2-3장 넣고 애니메이션 효과로 넘어가도록~~~ !!!! (30->32 ->34->37) Right 와 left main pulmonary artery에 low attenuation이 관찰되며 right 는 upper, middle, lower모두 thrombus를 보이고 left upper와 lower bifurcation level에서 low attenuation이 양쪽에 걸쳐있으며 그이하의 segmental pulmonary artery내부에도 thrombus가 관찰되고 pulmonary artery의 diameter가 증가되어 있음. Mediastinum에 collateral formation이 있으며 subcarinal lymph node enlargement가 있으며 scanty pericardiac effusion 이 있음. Both lung에 abnormal finding은 보이지 않음. Abdomen의 organ은 enhancement가 delay되어 있으며 ascites와 mesenteric infiltration이 있음.

Extremity Doppler US (2008-05-08) Mild atherosclerosis, both femoral and distal arteries. Deep vein thrombosis with obstruction, right popliteal and distal veins. Both femoral and distal arteries show diffuse wall irregularities, but no significant flow disturbances are noted. The right popliteal vein shows obstruction with thrombus and distal veins show dilation with thrombus. -- 이에 해당하는 사진 2장 넣으세요!!!!!

Acute Massive Pulmonary Embolism Clinical Course Acute Massive Pulmonary Embolism With RV Dysfunction DVT Heparinization Warfarin DOE HD1 HD2 HD3 HD4 HD5 Discharge Actilase IVC filter Successful insertion of IVC filter at infrarenal IVC. HD1

Readmission after 3 days #1 Both leg swelling S) Both leg swelling with pain (+) 3일전부터발생 ambulation 어려운 상태, Lt >Rt Febrile sense (+), Fatique (+), DOE(+) Cough(+) O) V/S 140/90mmHg – 98/min – 24/min – 38.4°C Both Leg tenderness with heat sense(+) Lt > Rt Pretibial pitting edema (+/++) – 좀 더 proximal CBC/DC 16420 /mm3 – 8.7 g/dL – 28.9 % -377000 /mm3 (Seg. 84.0%) CK/ CK-MB/ Myoglobin/ Tn –I 42/ 1.4/ 18.3/ 0.05 ng/mL CRP 16.17 mg/dL BNP 4970 ng/L aPTT 48.4 sec INR 1.41 % 환자 DOE 증상은 ?

F/U Chest X-ray (2008-05-13) Cardiomegaly, mild pulmonary congestion

F/U ECG (2008-05-13) INITIAL EKG 와 비교하여 T WAVE INVERSION AT V1-6 있는 차이 없는 소견

F/U ECG (2008-05-13)

A) DVT aggravation r/o Postphlebitic syndrome P) Extremity doppler US F/U, Echocardiography F/U, Anticoagulation, antibiotics, if needed, thrombolysis, thrombectomy

F/U Extremity Doppler US (2008-05-14) Deep vein thrombosis, involving left common femoral vein and its branches and right popliteal vein and its branches. a/w superficial edema, left>>right lower extremities. Atherosclerosis, both lower extremities. a/w no evidence of significant flow disturbance. Lt CFV1,2 Lt SFV1, Rt PV Lt superficial femoral vein Lt common femoral vein

Echocardiography (2008-05-16) Enlarged RA & RV, RV wall motion 저하, D-shape, severe TR, dilated IVC respiratory change,

Enlarged RA & RV, RV wall motion 저하, D-shape, severe TR, dilated IVC respiratory change,

Clinical Course HD2 F/U Extremity Doppler US -> Heparinization DVT, involving Lt common femoral v. and br. and Rt popliteal v. and br. -> Heparinization HD 7 Extremity Doppler US Aggravation of DVT, right lower extremity HD 8 Thrombectomy of Lt Supf. Femoral V. UK treatment (10만 UI)into Lt common iliac v. by multi sideport catheter 약자 풀어서 써주세요 ~~~!! 사진 한장 씩 넣고 나타 났다가 사라지게 해주세요

HD 9 UK treatment (10만 UI) into Rt Common Iliac V HD 9 UK treatment (10만 UI) into Rt Common Iliac V. by multi sideport catheter Addisional thrombectomy of Lt Supf. Femoral V. HD 10 Stent insertion into Lt Common Iliac V. 재입원시에 Anticoagulation 스케줄 확인하세요

HD 18 F/U Extremity Doppler US Before After Marked improvement of deep vein thrombosis, both lower extremities. Insertion of stent, right iliac vein.

Laboratory finding Anti cardiolipin Ab Ig G - normal Anti phospholipid Ab Ig G - normal Lupus anti coagulant – negetive Factor V – 88% (66-126) Protein C activity – 63% (70-130) Protein S activity – 58% (55-123) Protein C Ag – 0.26ng/dL (0.17-3.32) Protein S Ag – 2.47ng/dL (0.94-2.53) Blood culture – No growth after 5 days

Acute Massive Pulmonary Embolism Clinical Course Acute Massive Pulmonary Embolism With RV Dysfunction DVT Lt CIV stent anticoagulation First admission Readmission HD 1 4 6 8 12 16 Discharge Thrombectomy UK treatment Anticoagulation Successful insertion of IVC filter at infrarenal IVC. IVC filter Ceftriaxone 2g qd iv

Final Diagnosis #1. Acute Massive Pulmonary Thromboembolism with DVT #2. Postphlebitic Syndrome #3. Unknown origin LC with Esophageal Varices s/p EVL #4. Known T colostomy State d/t Ischemic Colitis with colonic perforation