1. 의식불명으로 내원한 57 세 남자환자

2. History

3. 송 O 효 (M/57) 12265054 Chief complaint altered mentality o/s:2012.3.15 07:00 Present illness M/57, HTN Hx. 이외에 특이병력 없이 지내던 자로 내원 당일 새벽 잠을 자 던 중 컥컥 거리면 숨을 잘 못 쉬는 증상 발생하였으며 보호자 들에게 관찰되 었다고함 그 후 불러도 반응 없는 상태로 오전 07:00 시 보호자에게 발견되 어서 자택에서 보호자들이 CPR 시행하면서 119 통해서 타병원 응급실 경유 하여 기관삽관 후 hypoxic brain damage 의심하에 본원 신경외과에 연락된 상태로 본원에서 Further evaluation 과 arrest management 위해서 본원 응 급실 경유 신경외과로 입원함 History

4. Past Medical History DM/HTN/TBc/Hepatitis(-/+/-/-) 진단 시기는 명확히 알 수 없고 건강검진상 혈압이 높다는 이야기 들었으나 medication 하지 않음. Op Hx(-) Medication Hx (-): none

5. Personal History Alcohol (+): 소주 1~2 병 2 회 /wks Smoking (+): 30pack year Family History None

6. Review of System 1. General Generalized weakness(-) fever(-) Fatigue (-) Chill(-) Myalgia(-)Weight change(-) general edema (-) 2. Skin Rash(-) Pigmentation(-) Itching(-) Bruise (-) 3. HEENT Headache(-) Dizziness(-) Otalgia(-) Otorrhea(-)PND(-)Nasal obstruction(-) Rhinorrhea(-)Sore throat(-)Swallowing difficulty(-) 4. Respiratory Dyspnea(+) Cough(-)Sputum(-) Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-)DOE(-) Palpitation(-)

7. 6. Abdominal A/N/V/D/C(-/-/-/-/-) Dysphagia(-) Bowel habit change(-) Abd. Pain(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) 8. Musculoskeletal Generalized myalgia (-) Muscle weakness (-) Swelling (-) Backpain(-) Myalgia(-) Numbenss(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) Weakness (-) sensory disturbance(-) Review of System

8. Physical Examination Height : 172cm Weight : 72 kg BMI : 24.3 kg/m 2 Vital Sign : 180/110mmHg - 120/min - 20/min – 36.5 ℃ 1. General appearance Semi-comatus consciousness 2. SKin Petechiae, purpura (-) 3.Head & neck Normocephaly, LN enlargement(-), Neck vein engorgement(-) 4. E/ENT Isocoric pupil c PLR(-/-) Pinkish conjunctiva, clear sclera Pharyngeal injection : uncheckble, PTH : uncheckble

9. Physical Examination 5. Chest Symmetric chest expansion Clear breathing sound without rale Regular Heart Beat without murmur 6. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness : uncheckble, Rebound Tenderness : uncheckble Palpable mass(-), Hepatomegaly(-) 7. Back & extremities CVA Td : uncheckble Pretibial pitting edema(-) pressure sore(-)

10. Physical Examination 8. N/Ex semi-coma(admission) -> stupor(3/15 13:00) -> alert (3/15 22:00) verbal communication intact cognition intact orientation intact PLR(-/-) -> PLR (++/++) (3/15 13:00) EOM full No facial palsy Motor grade I -> No motor weakness (3/15 22:00) Sensory grade I -> No sensory deficit (3/15 22:00) DTR(++/++) AC(-/-) Babinski(-/-)

11. Initial Lab Finding 1. CBC/DC 24520/mm² - 14.2 g/dl – 40.6% - 257K (seg 79.7%) PT (INR) 0.96 aPTT 35.9 2. Chemistry TB/DB0.58/0.22 mg/Dl Prot/Alb 6.2/4.6 g/dL AST/ALT92/71 IU/L ALP/GGT 49/78 IU/L BUN/Cr13/1.0 mg/dL Na/K/Cl 142/3.5/105mmol/L Ca/P/Mg/uric acid 7.8/1.8/2.0/2.9 mg/dL Glucose 90mg/dL TG/TC/LDL/HDL 51/117/65/47 CRP 0.32 mg/dL Total cholesterol 150 mg/dL LDL 101 mg/dL HDL 19 mg/dL TG: 239 mg/dL LD 642 U/L CK/CK-MB/TnI 242/11.8/0.80 U/L ProBNP 27.77 3. U/A RBC many/HPF WBC 2-4/HPF pH 5.5 SG 1.018 Blood (-) Protein (-) Glucose (-) Leukocytes (-) Nitrite (-) 4.ABGA(intubation fiO2=1.0) 7.314 – 40.9 – 179.2 – 22.7 (99.8%)

12. ECG(ED 3/15)

13. Initial Chest AP(ED 3/15)

14. #1. ROSC state s/p cardiac arrest, likely respiratory arrest, less likely #2. Altered mentality #3. Known HTN Initial Problem Lists

15. Initial ECG(119)

16. Initial Assessment and Plan #1. cardiac arrest d/t V-fib. d/t structural heart dis. (coronary a. dis, cardiomyopathy, valuar heart dis…) d/t primary electrical dis. (brugada synd.,longQT synd.,WPW synd…) diagnostic plan) Cardiac Echo, angiography spasm provocation test 24hr holter, treadmil test phamacologic provacation test, EPS

17. Initial Assessment and Plan #2. altered mentality d/t hypoxic brain damage d/t post cardiac arrest synd. r/o acute CVA r/o TIA diagnostic plan) neurologic finding pupil-light response, corneal reflex, motor response to pain after 24hr motor response after 72hr brain CT, CT angiography brain MRI, MRA

18. Brain CT,MRI,MRA

19. 24hr holter

20. Treadmil test

21. Isoproterenol test

22. Cadiac echo

24. Coronary angiography

26. PCI

27. Electrophysiologic test

28. Clinical Course 3/15 07:00 arrest 3/15 22:00 Mental recovery 3/19 TTE, 24hr holter 3/26 Treadmil test, isoproterenol test 3/26 CAG, EPS valproate acid(anti-convulsant) 3/28 discharge nifedipine 66mg qd isosorbide dinitrite 120mg qd 3/16 Brain MRI,MRA

29. Final Diagnosis #1. variant angina with coronary artery atherosclerosis #2. Transient brain hypoxia d/t post cardiac arrest syndrome