Download - Case report- Atrial flutter
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Case report-A 79 y/o male with dyspnea
for 2 daysCV intern 吳易儒
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Basic dataChart number: 5239588Age/Sex: 79/MaleEducation: Junior highOccupation: Business(塑料工廠, 鐵線加工)Marital status: Married
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Past medical historyCHFCAD, TVD, s/p CABG on 2014/2Atrial fibrillationHypertensionDM
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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.
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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.
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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.
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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.
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Social historyAllergy: No known allergyAlcohol drinking: DeniedBetelnut chewing: DeniedCigarette smoking: 1PPD for 10 years , quitted for 40+ years
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Family HistoryFather: Gastric cancerMother: CVA
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Review of systemsGeneral:Recent weight change:-Fever/Chills:- Change in appetite:- Fatigue:- Generalized weakness:-
Respiratory:Lung disease:- Cough:- Sputum:- Hemoptysis:- Shortness of breath:+Wheezing:-
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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:-
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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:-
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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
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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
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Skin:No cyanosisNo focal erythemaExtremities:mild leg edemaFree movement with full ROMNo clubbing fingerNeurological:No flapping tremorMuscle power: full
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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.
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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.
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EKG 6/9 1400
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EKG
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EKG
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EKG
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EKG
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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
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Diagnosis
Congestive heart failure
Atrial flutter
Coronary atherosclerosis
Pulmonary edema
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Plan1. Arranged ablation on 6/92. Furosemide, Carvedilol, Captopril, Spironolactone for heart failure3. Amiodarone, Clopidogrel for atrial flutter4. Sitagliptin, Acarbose and insulin for DM
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Respiratory system
Cardiovascular system
Metabolic/endocrine system
Hematologic system
Neuropsychiatry system
Differential diagnosis
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DiscussionWhat caused the patient heart failure?CardiomyopathyAtrial flutter
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Thanks for your attention