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

2. Chief complaint Present illness
Admission 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
~ 5.10 #1 admission ~ 5.30 #2 admission

3. 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 (-)

4. 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 (-)

5. 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

6. 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(+/+)

7. Lab Findings
CBC/DC
6,320 /mm3 – 10.2 g/dl – % - 268K (seg: 76.0 %)
PTT sec INR 1.23 %
Chemistry
AST/ALT 51 / 27 U/L TB/DB / 0.48 mg/dL
Prot/Alb / 3.7 g/dL CRP mg/dL
BUN/Cr / 0.4 mg/dL
Na/K/Cl / 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%

8. Initial Chest X-Ray
Cardiomegaly, pulmonary congestion

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

10. T wave inversion

11. Initial Problems
#1. DOE

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

13. 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

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

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

20. Chest CT ( )
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.

21. 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!!!!!

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

23. 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 /mm3 – 8.7 g/dL – 28.9 % /mm3 (Seg. 84.0%)
CK/ CK-MB/ Myoglobin/ Tn –I 42/ 1.4/ 18.3/ 0.05 ng/mL
CRP mg/dL BNP 4970 ng/L
aPTT sec INR %
환자 DOE 증상은 ?

24. F/U Chest X-ray ( )
Cardiomegaly, mild pulmonary congestion

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

26. F/U ECG ( )

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

28. 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

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

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

32. 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

33. 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

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

35. 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 ( ) Protein S Ag – 2.47ng/dL ( ) Blood culture – No growth after 5 days

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

37. 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