Case report-A 79 y/o male with dyspnea

for 2 daysCV intern 吳易儒

Basic dataChart number: 5239588Age/Sex: 79/MaleEducation: Junior highOccupation: Business(塑料工廠, 鐵線加工)Marital status: Married

Past medical historyCHFCAD, TVD, s/p CABG on 2014/2Atrial fibrillationHypertensionDM

Present illnessThis 79 y/o Male with past history of CHF, CAD s/p CABG, Atrial fibrillation, Hypertension, DM.

He was admitted to our ER due to dyspnea for 2 days.

Present illnessAccording to his statement, he had dyspnea since one year ago. He came to our OPD where triple vessel CAD was diagnosed and CABG was done 4 months ago. Dyspnea was relieved at that time.

But these 2 days, he started to have progressive dyspnea and orthopnea with palpitation which often woke him up at night while sleeping.

Present illness

The symptoms may relieved by sitting up and won’t happen at day time.

Also, he noted about bilateral leg edema for about 3 days.

He denied URI symptoms, fever, cold sweating, nausea, vomiting, dizziness, chest pain or dysuria.

Present illness

In our ER, CXR revealed cardiomegaly and LLL pleural effusion. EKG reported 2-to 1 atrial flutter. Lab data showed elevated BNP and D-Dimer.

Under the impression of heart failure and atrial flutter, he was admitted to our ward for further evaluation and treatment.

Social historyAllergy: No known allergyAlcohol drinking: DeniedBetelnut chewing: DeniedCigarette smoking: 1PPD for 10 years , quitted for 40+ years

Family HistoryFather: Gastric cancerMother: CVA

Review of systemsGeneral：Recent weight change：-Fever/Chills：-　Change in appetite：-　Fatigue：-　Generalized weakness：-　　

Respiratory：Lung disease：-　Cough：-　Sputum：-　Hemoptysis：-　Shortness of breath：+Wheezing：-

Review of systemsCardiovascular：Heart trouble：+　Chest pain：-　Dyspnea on exertion：+　Orthopnea：+　Palpitation：-　Intermittent claudication：-Varicose veins：- Edema：-

Endocrine：Polyuria or polydipsia：-Thyroid disease：-　Heat or cold intolerance：-

Reveiw of systemsMusculoskeletal：arthralgia：- Myalgia：- Back pain：-

Neurological：Syncope：-　Seizures：-　Focal weakness/paralysis：-Numbness/paresthesias：-Tremor：-　　

Psychiatric：Irritability：-　Difficulty concentrating：-Memory loss：-　Depression：-　Anxiety：-　Psychiatric treatment：-

Physical ExaminationHeight：168 cm;　Weight：62 kg;　Vital signs:T/P/R: 36.3/18/144BP：120/74General Appearance：Consciousness: clear, alert, fair lookingGCS: E4M6V5Heart：Regular heart beats with GrII systolic murmur

Physical ExaminationChest：Symmetric expansion

No focal tendernessNo chest wall lesionBS: crackles over LLL

Abdomen：Soft, no focal tendernessLiver and spleen: not palpableBowel sound: normally activeCV angle: no knocking pain

Skin：No cyanosisNo focal erythemaExtremities：mild leg edemaFree movement with full ROMNo clubbing fingerNeurological：No flapping tremorMuscle power: full

Cardiac echo(6/9).LA and LV enlargement..Impaired global contractility of left ventricle..LVEF by M-mode is 18.1 %..Regional wall motion abnormality, suspect coronary artery disease ( multi-vesselterritory)..Impaired diastolic function of left ventricle.

Cardiac echo(6/9).Calcification of aortic valve..Mild pulmonary regurgitation..Calcification of mitral valve apparatus with miild-to moderate mitral regurgitation..Mild-to-moderate tricuspid regurgitation..Moderate pulmonary hypertension.

EKG 6/9 1400

EKG

EKG

EKG

EKG

Lab data

CK CKMB BNP D-Dimer pH pCO2 pO2

74 2.3 955 478 7.5 21 145

PT INR APTT Glucose AC

Total Bilirubin BUN Creatinin

e

14.9 1.42 41.8 254 1.5 23 1.9

Diagnosis

Congestive heart failure

Atrial flutter

Coronary atherosclerosis

Pulmonary edema

Plan1. Arranged ablation on 6/92. Furosemide, Carvedilol, Captopril, Spironolactone for heart failure3. Amiodarone, Clopidogrel for atrial flutter4. Sitagliptin, Acarbose and insulin for DM

Respiratory system

Cardiovascular system

Metabolic/endocrine system

Hematologic system

Neuropsychiatry system

Differential diagnosis

DiscussionWhat caused the patient heart failure?CardiomyopathyAtrial flutter

Thanks for your attention