Cough 를 주소로 내원한 32 세 여자환자 심장 내과 R3 김민제 /Prof. 김우식 MGR

정 O 진 (F/32) Chief complaint –Cough onset : 2 days ago Present illness F/32, 2 년 전부터 MVP with Severe MR 로 진단받고 본원 심장내과 외래 진료 받으며 2013 년 6 월까지 외래 진료받던 자로 이후, 추적관찰 되지 않았다가 내원 2 일 전부터 상기도 감염증세 있어 근처 병원 진료받았으며, 심잡음 청진되어 큰병원 권유받고 순환기 내과 외래 방문함. History

Past Medical History DM / HTN / TBc / Hepatitis (-/-/-/-) MVP with severe MR(EF=70%, LVESd=40.18mm) Op Hx (-) Medication (-)

Personal History Alcohol (-) Smoking (-) Family History N/S

Review of System 1. General Generalized weakness(-) Fatigue (-) Chill(-) Weight change(-) 2. Skin Rash (-) Pigmentation(-) Itching(-) Bruise (-) 3. Head & Neck Neck mass (-) Swelling(-) Tenderness (-) 4. Respiratory Dyspnea(-) Cough(+)Sputum(-) Pleuritic pain(-) 5. Cardiac Chest pain(-) Orthpnea(-)Palpitation(-) DOE(+) : 계단 3 층 이상을 한번에 오를 경우. “ 일상 생활에 제약은 느끼지 않습니다.”  NYHA II (Newyork Heart association functional classification)

6. Abdominal A/N/V/D/C(-/-/-/-/-) Bowel habit change(-) Abd. Pain(-) Hematochezia(-) Melena(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-)Hematuria(-) 8. Musculoskeletal Arthralgia(-) Myalgia(-) Backpain(-) Numbness(-) 9. Nervous Dizziness(-) Seizure(-) Syncope(-) Review of System

Physical Examination Height : 151.6cm Weight : 64.6 kg BMI : 21.8 kg/m 2 Vital Sign : 110/70 mmHg - 80/min - 16/min – 36.5 ℃ 1. General appearance Alert consciousness Not so ill looking appearance 2. Skin Petechiae, purpura (-) Rash (-) 3.Head & neck Palpable neck mass (-) Tenderess (-) 4. E/ENT Pinkish conjunctiva, clear sclera Pharyngeal injection(-), PTH(-/-)

Physical Examination 5. Chest Symmetric chest expansion Clear breating sound without rale/wheezing Regular Heart Beat with murmur : systolic m. (IV / IV) at apex 6. Abdomen Soft / obese abdomen Normoactive bowel sound Tenderness(-), Rebound Tenderness(-) Palpable mass(-) Hepatomegaly(-) 7. Back & extremities CVA Td(-/-) Pretibial pitting edema (-/-) Pressure sore(-) Tenderness (-) Swelling (-) Redness (-)

Initial Problem Lists TTE Chest Xray, EKG CBC/DC, CRP 1.Cough (dry) 2.DOE (NYHA II) 3.Known, MVP with Severe MR Known, MVP with Severe MR Pulmonary Edema Acute pharyngitis

Initial Lab Finding 1. CBC/DC 5130/mm² g/dl – 38.9% - 179K (seg 57.8%) PT (INR) 1.04 aPTT Chemistry TB/DB 0.75/0.18 mg/dL Prot/Alb 7.6/4.5 g/dL AST/ALT20/14 IU/L ALP/GGT 74/12 IU/L BUN/Cr10/0.6 mg/dL Na/K/Cl 138/3.9/105 mmol/L LD/CK350/60 U/L Uric acid 4.9 mg/dL Ca/P/Mg/ 8.6/3.3/2.3 mg/dL CRP <0.3 mg/dL 3. U/A RBC 2~4 /HPF WBC 0~1 /HPF pH 5.0 SG Blood (-) Protein (-) Glucose (-) Leukocytes (-) Nitrite (-)

Chest Xray (2014 / 3 / 12)

EKG (2014 / 3 / 12)

TTE (2014/03/04)

TEE (2014/03/17)

Echocardiography 년 12 월 2013 년 6 월 2014 년 3 월 MVP with Severe MR 1. LAVI = 56.14/m2 2. LVEF = 70.82% 3. LVESd = 40.18mm 4. RVsp = 37.57mmHg DOE (NYHA II) MVP with Severe MR 1. LAVI = 85.18/m2 2. LVEF = 68.35% 3. LVESd = 40.9mm 4. RVsp= 40mmHg MVP with Severe MR 1. LAVI = 93.8/m2 2. LVEF = 60.18% 3. LVESd = 41.8mL 4. RVsp = 52.31mmHg

TS consultation for MVR

#1. MVP with Severe MR Diagnosis

Clinical Course

OP finding (2014/03/18)

f/u TTE (2014/03/24)

#1. MVP with Severe MR Final diagnosis