1. Echo conference R1 하 상 진

2. 11087130 박 * 순 (F/69) Admission date 2005.08. 23 Patient’s history Chief complaint : chest pain onset) 내원 30 분전 Character: sqeezing Aggravating factor: (-) Location: substernum Relieving factor: (-) Duration: continous Associated sx: nausea,dyspnea Radiation to back NTG response : (-) Rest pain: (-)  Present illness : 3 년전 CVA 로 본원 한방병원 추적 관찰중인 환자, 약 9 일전부터 간간히 chest pain 반복적으로 호소하여 본원 외래 방문 검사 예약후 귀가. 오전 1 시경부터 chest pain 지속되어 응급실 방문하여 입원

3. Medical history DM/HTN/TBC/Hepatitis (-/+/-/-) Old CVA Hx.(+) : Lt. facial palsy 로 2002 년 12 월에 진단받고 본원 한방 신경과 에서 medication 중임 Family history Unremarkable Personal history Alcohol(-), Smoking(+) : 1pack /d * 40years Patient’s history

4. 1.General : fatigue(+), fever/chilling sense(-/-) 2.Skin : itching sense(-), easy bruisablitiy(-) 3.H & N : headache(+), neck stiffness(-), sore throat(-) 4.Breast : discharge(-), lump(-), pain(-) 5.Resp. : cough(-), sputum(-), dyspnea(+) 6.Cardiac : chest pain(+), orthopnea(-), palpitations(-) Review of systems

5. 7.G-I : anorexia(-), nausea(+), vomiting(-), abdominal pain(-) 8.Urinary : dysuria(-), hematuria(-), incontinence(-) 9.M-S : back pain(+) trauma(-), 10. Endo. : weight change(-), temperature tolerance(-) 11. Neurology : syncope(-), seizure(-), dizzness (+) memory disturbance(-), Review of systems

6. *V/S 120/80 mmHg-64 회 /min-20 회 /min-36.5 ℃ *Body weight 59 kg Height 151.5 cm BMI 25.7kg/m2 1.General appearance Alert consciousness Acutely ill-looking appearance 2.Skin No rash or pigmentation, skin turgor : intact 3.Head & neck Normocephaly No neck vein engorgement No cervical lymph node enlargement 4. Eyes & ENT Isocoric pupil with PLR (++/++) pinkish sclera, whitish conjunctiva Physical examination

7. 5. Chest Symmetric chest expansion Clear breathing sound without crackles or wheezing Regular heart beat without murmur 6. Abdomen Soft & flat abdomen Normoactive bowel sound No abdominal tenderness or rebound tenderness 7. Back & extremities No CVA tenderness or rebound tenderness No pretibial pitting edema 8. Neurologic signs Lt. facial palsy(+), dysarthria (-), motor &sensory : intact Physical examination

8. 1.CBC/DC 7,900/mm 3 – 13.3g/dL – 38.9% - 267,000/mm 3 (Seg. 59.1%) 2.Blood chemistry Total bil./Direct bil. 0.7/0.2 mg/dL Total cholesterol 179 mg/dL Protein/Albumin 6.7/3.8 g/dL AST/ALT 45/21 IU/L BUN/Creatinine 10/0.7 mg/dL Na/K/Cl 141/3.7/105 mmol/L 3.U/A : RBC 0~1/HPF, WBC 0~1/HPF lab data

9. 4. Heart enzyme : CK / CKMB 355/ 50.8 U/L TnI 2.18 ng/mL BNP 984 pg/mL 5. Lipid profile Total cholesterol: 179 mg/dl TG: 118 mg/dl HDL: 26 mg/dl LDL: 109 mg/dl

10. EKG

11. CHEST

12. Clinical course 8/23 tPA (I-TNA metalyse 35mg iv) 8/23 chest pain 지속  echocardiography 시행 (MI with VSD)

13. Clinical course 8/25 dyspnea aggravation & decreased Bp & O2 saturation  f/u echo 시행 & 응급 op 시행 (VSD repair)

14. Clinical course 8/27 CRRT 시행 ( I/O imbalance, U/O = 0, diuretics 반응 없음 (40mg/hr) 8/29 re-op 시행 (sternal closure)