1. Chest Case Conference Presented by R3 張筱桾

2. 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

3. Chief Complaint Left lower chest pain for three days.

4. 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.

5. 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.

6. 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

7. 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

8. 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 (-)

9. 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

10. LAB 09/24 BUN13 Cr1.1 AST23 Na134.6 K3.03 CK-MB4.9 Trop-I0.03 09/24 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

11. CXR 09/24/2006

12. Complete EKG

13. 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

14. HOSPITAL COURSE

15. 2D echo Moxifloxacin Chest echoV/Q scan Tazocin + Teicoplanin Fraxiparin

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

17. Chest ward Fraxiparin

18. 2D echo Fraxiparin Ceftriaxone

19. Fraxiparin Tazocin Wafarin

20. Tazocin

21. LAB DATA – Biochemistry 09/2410/0310/12 BUN13106 Cr1.11.00.9 AST233922 ALT2428 Alk-P71 Bil-T0.7 Na134.6136.0137.9 K3.034.543.61 Ca7.3 P2.6 A/G1.7/2.5 Uric acid4.6

22. 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

23. 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

24. LAB DATA - Hematologic 09/2410/0110/0310/12 WBC10400770096006400 Seg80.676.178.468.2 Lym10.615.111.017.3 Mono6.44.35.88.4 Eos2.24.44.65.9 Bas0.20.10.2 Hb9.67.88.28.1 Hct30.124.925.726.4 MCV89.989.288.389.2 MCH28.728.028.227.4 MCHC31.931.331.930.7 Platelet329270298399 D-dimer0.415 09/3010/0210/1210/1910/24 PT (11.3)14.214.013.913.119.3 INR1.241.231.221.151.68 aPTT (30.1)37.037.933.6

25. CXR 09/27/2006

26. CXR 10/11/2006

27. CXR 10/13/2006

28. CXR 11/14/2006

29. 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

30. 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%)

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

32. 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.

36. 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