Chest Case Conference Presented by R3 張筱桾

Basic Data Name: 蔡 ○ 遠 Chart No.:425○○09 Gender: male Age: 72 y/o Date of birth: 01/28/1933 Marital status: married Occupation: 無 Education: 國小 Date of admission: 09/25/2006

Chief Complaint Left lower chest pain for three days.

Present Illness This 72-year-old man has DM, HTN, vavular heart disease (MR, TR), coronary artery disease post stenting, and a history of ischemic stroke; he receives medical control from 國泰 Hospital. He suffered from persistent left lower chest pain for three days. The chest pain aggravated on deep inspiration. The patient had just been discharged from 省立 Hospital because of pneumonia in about 2 weeks ago.

Present Illness Short of breath was noted since last hospitalization, and it persisted thereafter. He also complained of cough with blood-tinged sputum since 4 days ago. There was no fever, no radiation of the chest pain, or recent trauma. Pneumonia was suspected initially, he was admitted for advanced treatment.

Personal History Allergy to drug: nil to food: nil Smoking: denied Alcohol consumption: denied Betelnut chewing: denied Recent travel history: nil Family history: not contributory

Past History 1. Hypertension, essential 2. Type 2 diabetes mellitus 3. Valvular heart disease (mitral regurgitation and tricuspid regurgitation) 4. Coronary artery disease post stenting in 7~8 years ago 5. Sick sinus syndrome post pacemaker implantation 6. History of ischemic stroke

Physical Examination - I Vital signs: T: 36.2/ ℃ P: 69/min R: 20/min BP:151/80/mmHg 身高 : 177CM (2005/09/30) 體重 : 82KG (2005/09/30) GENERAL APPEARANCE: Fair Consciousness: Clear / Coma scale: E4V5M6 HEENT: Grossly normal structure / Sclera: anicteric / Conjunctiva: pale / Nasal: normal / Tongue: papilla atrophy (-) NECK: Freely movable / Tenderness: (-) / Thyroid enlargement: (-) / Lymphadenopathy: (-) / Mass (-) / Jugular vein engorgement (-)

Physical Examination - II CHEST: No kyphosis or scoliosis Breath pattern: smooth; symmetric expansion Breath sounds: crackle on left middle and lower chest Wheezing(-), rhonchi (-), stridor(-) Heart: regular heart beat ABDOMEN: soft and flat Bowel sounds: normoactive Tenderness (-), rebounding pain (-), muscle guarding (-) Shifting dullness: (-) Liver and spleen: not palpable EXTREMITIES: Freely movable No pitting edema

LAB 09/24 BUN13 Cr1.1 AST23 Na134.6 K3.03 CK-MB4.9 Trop-I /24 WBC10400 Seg80.6 Lym10.6 Mono6.4 Eos2.2 Bas0.2 Hb9.6 Hct30.1 MCV89.9 MCH28.7 MCHC31.9 Platelet329 D-dimer0.415

CXR 09/24/2006

Complete EKG

Impression 1. Left lower chest pain, suspect pneumonia, R/O pulmonary embolism 2. Type 2 diabetes mellitus 3. Hypertension, essential 4. Vavular heart diseases 5. Coronary artery disease post stenting 6. Sick sinus syndrome status post permanent pacermaker implantation

HOSPITAL COURSE

2D echo Moxifloxacin Chest echoV/Q scan Tazocin + Teicoplanin Fraxiparin

Chest CT Fraxiparin MICU IVC filter placement Tazocin + TeicoplaninCefepime + Clindamycin

Chest ward Fraxiparin

2D echo Fraxiparin Ceftriaxone

Fraxiparin Tazocin Wafarin

Tazocin

LAB DATA – Biochemistry 09/2410/0310/12 BUN13106 Cr AST ALT2428 Alk-P71 Bil-T0.7 Na K Ca7.3 P2.6 A/G1.7/2.5 Uric acid4.6

LAB DATA – Pleural effusion 09/28 Glucose299 LDH207 Total protein2.5 09/27 AppearanceTurbid, orange SpG1.024 ProteinPositive Neutrophil24 Lymphocyte21 Monocyte52 Eosinophil1 Mesothelial2 Gram’s stainNo bacteria seen AFBNegative * Fibrin clot, cell cannot count

LAB DATA - Urinalysis 10/02 COLORYellow TURBIDITYTurbid SP.GRAVITY1.015 PH6.0 Leukocytetrace Nitritenegative Protein(mg/dL)75 Glucose- Keto- UBG (EU/dL)0.1 Bilirubin- Blood / RBC4+/ >100 WBC0-2 Squamous0

LAB DATA - Hematologic 09/2410/0110/0310/12 WBC Seg Lym Mono Eos Bas Hb Hct MCV MCH MCHC Platelet D-dimer /3010/0210/1210/1910/24 PT (11.3) INR aPTT (30.1)

CXR 09/27/2006

CXR 10/11/2006

CXR 10/13/2006

CXR 11/14/2006

Final Diagnosis 1. Deep vein thrombosis, complicated with pulmonary embolism, status post IVC filter placement on 10/04, anticoagulant therapy with Fraxiparin (3,800U Q12H, 09/27-10/19) and Warfarin (5mg) 1# QD (10/17) 2. Nocturnal hypoxemia

2D Echo Pulmonary hypertension (PG= 56.6mmHg) with dilated LA, RA and IVC Mild to moderate TR, MR and mild MR No significant asynergy Adequate LV performance (LVEF = 64.7%)

Ventilation/Perfusion scan Multiple segmental defects of bilateral lungs, high probability of pulmonary embolism.

Chest CT Bilateral pulmonary embolism. Partial thrombosis of the IVC below the infrarenal level and completed Occlusion of the left common iliac vein. Bilateral pleural effusion.

2D Echo Severe pulmonary hypertension (PG = 70mmHg) Moderate TR, mild MR Adequate LV and RV contractility Dilated LA and RA LV hypertrophy Pacemaker lead in RV apex