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CASE PRESENTATION

CASE PRESENTATION. DATE: 94/11/24 REPORTER: Int. 陳冠任. Case Profile. Name ：黃洪 X 纏 Gender ： female Age ： 80y/o Chart no. ： 00159689 Bed no. ： ICUB12 9A17(94/10/31) Admission date ： 94/10/26 Discharge date ： 94/11/07. Chief Complaint. Left chest pain noted this morning (94/10/26).

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CASE PRESENTATION

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  1. CASE PRESENTATION DATE: 94/11/24 REPORTER: Int.陳冠任

  2. Case Profile • Name：黃洪X纏 • Gender：female • Age：80y/o • Chart no.：00159689 • Bed no.：ICUB129A17(94/10/31) • Admission date：94/10/26 • Discharge date：94/11/07

  3. Chief Complaint • Left chest pain noted this morning (94/10/26).

  4. Present Illness (I) • The 80y/o female is a case of hypertension with regularly OPD follow up. Left chest pain developed this morning and she was then sent to our ER. The pain character was as following: • Location: left anterior chest wall • Pattern: sharp pain • Duration: 20+ mins • Radiation: nil • Aggravating factor: nil • Relieving factor: nil

  5. Present Illness (II) • Other associated s/s: cold sweating(+), palpitation(+), tremor(-), headache(-), nausea/vomiting(+)/(-), dizziness(-), fever(-) • No URI symptoms dyspnea(-), cough(+/-), sputum(-) • No UTI symptoms dysuria(-), frequency(-), urgency(-) • No GI symptoms diarrhea(-), abdominal pain(-), tarry stool(-)

  6. Present Illness (III) • The initial cardiac enzyme was normal, but the serial cardiac enzyme was elevated. The EKG also revealed inverted T in V1-V4. Acute coronary syndrome was then diagnosed.

  7. Previous EKG (94/7/12)

  8. EKG in ER (I) 94/10/26 09:54

  9. EKG in ER (II) 94/10/26 12:56 (pre-NTG)

  10. EKG in ER (III) 94/10/26 14:12 (post-NTG)

  11. EKG in ER (IV) 94/10/26 16:55

  12. Present Illness (IV) • NTG, Bokey, Plavix, Clexane were prescribed. However BP dropped after NTG was given. Due to the reason above, she was sent to our MICU for further evaluation and care.

  13. Past History • (1) Hypertension with regularly OPD • follow up • (2) Dyslipidemia • (3) Old pulmonary tuberculosis s/p • complete treatment • (4) Soft tissue tumor s/p excision • (5) DM(-) • (6) other systemic disease: denied

  14. Personal History • 1. Smoking(-) • 2. Alcohol(-) • 3. Betel nuts(-) • 4. Other systemic disease: denied • 5. Herbal drug history: denied • 6. Drug allergy history(-) • 7. OP history: • (1)soft tissue tumor s/p excision while young • (2)bilateral cataract s/p surgery

  15. Family History

  16. Physical Examination (I) • BP: 122/46 mmHg, BT: 35.8 C, • PR: 56 /min, RR: 10-24 /min • Consciousness: clear, E4V5M6 • HEENT: Conjunctiva: not pale Sclera: not icteric • Throat: not injected • Neck: supple; Lymphadenopathy(-), • Jugular vein engorgement(-) • Chest: left chest pain,symmetric expansion • Heart sound: regular heart beat, no murmur • Breathing sound: bilateral basal crackles

  17. Physical Examination (II) • Abdomen: soft, no tenderness • Bowel sound: normoactive • Liver/ spleen: impalpable • Rebound pain(-), muscle guarding(-) • no Murphy’s sign, no Cullen’s sign • Extremities: freely movable, no pitting edema • Skin: no rash nor wound was noted

  18. Lab Data in ER (I)

  19. Lab Data in ER (II)

  20. Tentative Diagnosis • 1. Acute coronary syndrome, non-ST • elevation myocardial infarction, • complicated with shock • 2. Shock, DD cardiogenic, hypovolemic due • to NTG used vasodilatation • 3. Hypertension • 4. Dyslipidemia

  21. Plans • 1. Anti-platelet drugs (Plavix, Bokey)and • anti-coagulation drugs (Clexane) used • 2. Follow up cardiac enzymes and EKGs • 3. Hydration by central venous catheter • 4. Close observation vital signs

  22. Admission medications • Clexane (60mg) sc q6h x5 • Bokey 1# 1x/ampc • Lescol XL 1# 1x/pmpc • MgO 6# 3x/pc • Through 2# 1x/hs • Isordil 1.5# 3x/pc • Zestril 0.5# 1x/om • Plavix 1# 1x/om • Phyllocontin 2# 2x/bid • Sigmart 2# 2x/bid

  23. Lab Data in ward (I)

  24. Lab data in ward (II)

  25. Cardiac enzyme curve

  26. Lab data in ward (III)

  27. Lab data in ward (IV)

  28. EKG in ward (I) 94/10/26 18:49

  29. EKG in ward (II) 94/10/26 18:51

  30. EKG in ward (III) 94/10/27 15:54

  31. EKG in ward (IV) 94/10/29 14:38

  32. EKG in ward (V) 94/10/30 05:38 (pre-NTG)

  33. EKG in ward (VI) 94/10/30 05:45 (post-NTG)

  34. EKG in ward (VII) 94/11/01 21:25

  35. Cardiac catheterization • Coronary catheterization was done on 94/11/1 • Report was as follow: • 1. 3 vessel disease, culprit lesion of STEMI is RPD branch of RCA with total occlusion • 2. Inferior and posterior STEMI • 3. Congestive heart failure

  36. Chest PA (94/10/26)

  37. Chest PA (94/10/30)

  38. Chest PA (94/11/02)

  39. Renal echo (94/11/02)

  40. Renal echo (94/11/02)

  41. Impressions • 1. Inferior wall STEMI with posterior wall • involved • 2. Shock episode, NTG related, recovered • soon • 3. Hypertension • 4. Dyslipidemia • 5. Asymptomatic urinary tract infection • 6. Suspect left upper lobe pneumonia, r/o • COPD

  42. Plans • 1. keep Bokey used for STEMI • 2. NTG was hold due to low BP • 3. add Plavix 1# qd for post-MI unstable • angina • 4. check Mycoplasma and chlamydia titer for • pneumonia survey • 5. keep current treatment and follow up vital • signs

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