Teaching & Learning Conference Cardiology Division i i Severance Cardiovascular Hospital
신 O 준 M/49 C.C. : Dyspnea & General weakness D. : 2 months P.I. : 본 49 세남자환자는 2003 년 6 월 DOE 증상으로개인의원에서시행한 chest x-ray 결과 cardiomegaly 소견보여본원내원하여심장초음파시행한결과 severe AR (GIV/ IV), annuloaortic ectasia 소견보여 2003.11 aortic valvuloplasty & graft replacement of ascending aorta 시행받았다. 이후 f/u echo상 AR(GII/IV) 관찰되었으나약물치료하며외래추적관찰하던중 2개월전부터의 dyspnea 증상을주소로외래경유하여 2008년 10월 15일입원하였다.
신 O 준 M/49 PHx : DM/ HTN/ Hepatitis/ Pul Tbc (- /+ / - / - ) Severe AR (GIV/ IV), annuloaortic ectasia s/p Annuloplasty & Ascending aortic graft replacement (03.6) Smoking : 1pack * 25yrs = 25pyrs (Quit 5yrs ago) Alcohol : 소주5병 * 3회 / 주 * 30yrs FHx : none
신 O 준 M/49 ROS General weakness(+) / Easy fatigue(+) Dyspnea / DOE (+/+) Chest pain/discomfort/ palpitation ( -/+/+) Fever/Chill (+/+) Cough/Sputum/Rhinorrhea (-/+/-) : whitish sputum Hemoptysis(-) Abdominal pain(-) Constipation/Diarrhea(-/-) Anorexia/Nausea/Vomiting(-/-/-) /V iti / / Hematochezia/Hematemesis/Melena(-/-/-) Poor oral intake(+)
신 O 준 M/49 P/Ex : BP 80/50 mmhg, PR 100 /min BT 38.1 o C, RR 18 /min Acute ill looking appearance & Alert mental status Slightly pale conjuntiva / Not icteric sclerae Dried Lips & Tongue/ Not enlarged tonsil & Not injected throat Neck stiffness(-) Neck vein engorgement (-) Coarse breathing sound with rales, Wheezing/Ronchi(-/-) / PMI at 5 th ICS * LMCL RHB with murmur (to and fro murmur) Thrill/Heaving(-/-) No pitting edema CVA tenderness(-/-)
신 O 준 M/49 WBC / Hb / Plt 6200 (poly 76%) / 8.0 / 277k BUN / Cr 16.3 / 1.04 mg/dl AST/ALT T.bilirubin T.pro / alb 15 / 15 IU/L 0.5 mg/dl 5.6 / 2.8 g/dl Electrolyte 132 / 3.4 / 102 / 21 S-Iron / TIBC / Ferritin 15 ug/dl / 167 ug/dl / 826 ng/ml CK / CK-MB / Tn-T 63 / 2.15 / 0.144 PT / PTT 1.28 / 30s ESR/CRP 61 / 7.11 ABG 7.49 / 29 / 87 / 97%
Chest AP (HOD #1)
EKG
Echocardiography
Impression Infective endocarditis, subacute Severe MR(GIV/IV) AR(GII/IV) s/p Aortic valvuloplasty l l s/p Graft replacement of ascending aorta HTN
HOD #5 I/O negative로유지하였으나, Fever(39.7도 ) Tachycardia(170bpm EKG:S.tachycardia, BP150/60) 로인해Heart failure aggravation 되면서폐부종악화됨, 환자 Dyspnea 심하게호소하였으며 Mask ventilatoin O2 15L/min 유지함에도 SpO2 60% 정도로 Elective Intubation 시행함
Chest PA (HOD #5)
HOD #11 negative I/O (-1000ml/daily) 유지하면서 pulmonary edema 호전되어 ventilator weaning 시행하였으며, ventilator care 7일째 extubation 함
Chest AP (HOD #11)
Blood cultures 신 O 준 M/49 (10.15) 3쌍 /3쌍 Streptococcus sanguis (Clindamycin S / Erythromycin S / Cefotaxime S / Penicllin G S) (10.19) No growth for 5days (10.26) No growth for 5days (11.1) No growth for 5days
신 O 준 M/49 Antibiotics Initial antibotics : Empirical therapy Vancomycin2g#2/Gentamycin180mg#3/Rifampin600mg#1 Streptococcus t sanguis isolated (HOD#5) Vancomycin2g#2/Ceftriaxone4g#2 Drug fever (HOD #20~22 22 ; BT > 38 C, no leukocytosis, CRP 3) Ceftriaxone4g#2 >> Claforan6g#3
Impression Infective endocarditis Severe MR(GIV/IV) AR(GII/IV) s/p Aortic valvuloplasty l l s/p Graft replacement of ascending aorta HTN
Brain MRA
Brain MRI
Brain MRI 1. No mycotic aneurysm on MRA 2. Multifocal tiny embolic infarcts in the right pons, right external capsule, both frontal lobes, and left occipital lobes on DWI. 3. Multifocal small old ischemic lesions in the cerebral WM.
Operation note 1. Aortic valve replacement (ATS #21) 2. Mitral valve replacement (ATS #27) - severe adhesion around RA & aortic vascular graft. - AV: NCC, fibrosisi 에의해 retraction ti 되어있고 vegetation ti 이 있어 ATS 21mm 로 replacement 함. - MV: AML 에 huge vegetation ti 및 destruction ti 에의한 perforation 소견보임 -> ATS 27mm 로 replacement 함.
Operation note OP pathology(08.11.13) A. Mitral valve: Acute suppurative inflammation and myxoid degeneration B. Aortic valve: Myxoid degeneration and dense fibrosisi Vegetation cultures (11.10) No growth for 48hours
Final Diagnosis 1. Bacterial endocarditis 2. MR (GIV/IV) 3. AR (GII/IV) 4. s/p AV Annuloplasty & Ascending Aortic graft replacement 5. s/p AV replacement & MV replacement