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, essential2. Type 2 diabetes mellitus3. Valvular heart disease (mitral regurgitation

and tricuspid regurgitation)4. Coronary artery disease post stenting in

7~8 years ago5. Sick sinus syndrome post pacemaker

implantation6. 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

BUN 13

Cr 1.1

AST 23

Na 134.6

K 3.03

CK-MB 4.9

Trop-I 0.03

09/24

WBC 10400

Seg 80.6

Lym 10.6

Mono 6.4

Eos 2.2

Bas 0.2

Hb 9.6

Hct 30.1

MCV 89.9

MCH 28.7

MCHC 31.9

Platelet 329

D-dimer 0.415

CXR 09/24/2006

Complete EKG

Impression

1. Left lower chest pain, suspect pneumonia, R/O pulmonary embolism

2. Type 2 diabetes mellitus3. Hypertension, essential4. Vavular heart diseases5. Coronary artery disease post stenting6. Sick sinus syndrome status post

permanent pacermaker implantation

HOSPITAL COURSE

2D echo

Moxifloxacin

Chest echo V/Q scan

Tazocin + Teicoplanin

Fraxiparin

Chest CT

Fraxiparin

MICUIVC filter placement

Tazocin + Teicoplanin Cefepime + Clindamycin

Chest ward

Fraxiparin

2D echo

Fraxiparin

Ceftriaxone

Ceftriaxone

Fraxiparin

Tazocin

Wafarin

Wafarin

Tazocin

LAB DATA – Biochemistry

09/24 10/03 10/12

BUN 13 10 6

Cr 1.1 1.0 0.9

AST 23 39 22

ALT 24 28

Alk-P 71

Bil-T 0.7

Na 134.6 136.0 137.9

K 3.03 4.54 3.61

Ca 7.3

P 2.6

A/G 1.7/2.5

Uric acid 4.6

LAB DATA – Pleural effusion

09/28

Glucose 299

LDH 207

Total protein

2.5

09/27

Appearance Turbid, orange

SpG 1.024

Protein Positive

Neutrophil 24

Lymphocyte 21

Monocyte 52

Eosinophil 1

Mesothelial 2

Gram’s stain No bacteria seen

AFB Negative

* Fibrin clot, cell cannot count

LAB DATA - Urinalysis10/02

COLOR Yellow

TURBIDITY Turbid

SP.GRAVITY 1.015

PH 6.0

Leukocyte trace

Nitrite negative

Protein(mg/dL) 75

Glucose -

Keto -

UBG (EU/dL) 0.1

Bilirubin -

Blood / RBC 4+/ >100

WBC 0-2

Squamous 0

LAB DATA - Hematologic09/24 10/01 10/03 10/12

WBC 10400 7700 9600 6400

Seg 80.6 76.1 78.4 68.2

Lym 10.6 15.1 11.0 17.3

Mono 6.4 4.3 5.8 8.4

Eos 2.2 4.4 4.6 5.9

Bas 0.2 0.1 0.2 0.2

Hb 9.6 7.8 8.2 8.1

Hct 30.1 24.9 25.7 26.4

MCV 89.9 89.2 88.3 89.2

MCH 28.7 28.0 28.2 27.4

MCHC 31.9 31.3 31.9 30.7

Platelet 329 270 298 399

D-dimer 0.415

09/30 10/02 10/12 10/19 10/24

PT (11.3) 14.2 14.0 13.9 13.1 19.3

INR 1.24 1.23 1.22 1.15 1.68

aPTT (30.1) 37.0 37.9 33.6

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