MEDICAL CHALLENGE

CV F1 黃邦碩 Department of Internal Medicine

National Taiwan University Hospital

ChiefComplaint

•  A 80-year-old man with acute onset of dyspnea for one day

Ques1on1

•  Differen1aldiagnosisofacutedyspnea

Past History

•  Medical history: HTN, CHF •  Current medication: Bokey, Aprovel, Inderal,

Urief •  TOCC: non-contributory •  Cigarette: Nil •  Family history: CVA

Personal

Present Illness

D-30 •  Progressive exertional dyspnea

D-7 •  Traffic accident, left lower leg injury •  Progressive left lower leg swelling

Present Illness

D-5 •  Visit NTUH CV OPD •  Arrange UCG and Thallium scan

D-1 •  One episode of acute dyspnea •  Relief after rest

Present Illness

D0 •  Complete Thallium scan at morning

D0 •  Another episode of acute dyspnea

accompany with chest tightness at afternoon

•  Came to ER for help

Physical Examination Generalappear.:acuteillnessCons:GCS:E4V5M6T/P/R:37.4/98/22BP:149/79mmHgSpO2:92%

LymphnodeNeck(-),axilla(-),inguinal(-)

Height:158cmWeight:62kgBMI:24.8

HeartRegularheartbeat Murmur(-),Heave(-),thrill(-)

AbdomenDisten1onovoidbutso\Bowelsounds:normoac1ve Shi\ingdullness(-)Tenderness(-)Reboundtenderness(-) Hepatosplenomegaly(-)

HEENTConjunc1va:pinkSclera:anictericPupils:R/L3mm/3mmLightreflex:+/+,promptNeck:supple,JVE(-),goiter(-)

ChestPercussion:bil.resonantBreathsound:bil.clear

BackCVanglepercussionpain(-)

ExtremityPicngedema(-)

Laboratory Study

Hemogram WBC(k/μL)

Seg.(%)

Band(%)

Eos.(%)

Baso(%)

Mono.(%)

Lym.(%)

RBC(M/μL)

Hb(g/dL)

MCV(fL)

Plt(K/μL)

9.15 78.7 0 0.5 0.1 7.1 13.6 5.27 16.3 88.6 113

Biochemistry CK(U/L)

CK-MB(U/L)

Tn-T(ng/L)

NT-proBNPpg/mL

ALT(U/L)

BUN(mg/dL)

CRE(mg/dL)

Na(mmole/

L)

K(mmole/

L)

79 2.11 43.42 4732 19 21.7 0.9 138 3.8

EKG

Chest X-Ray

Ques1on2

•  What’sthetenta1vediagnosis

ChestCT

ChestPerfusionCT

Ques1on3

•  Howtheclassifytheseverityofthisdisease

Ques1on4

•  Howtotreatthisdisease

Angiography

Ques1on5

•  Whatelsework-upshouldwedo

Follow-upAngiographyD+12