CASE
REPORT This 66-year-old man , a heavy
smoker, complained of chest pain for two days, which was
characterized as compressive over retrosternal area, and
relieved spontaneously after resting for few minutes. He did
not pay attention to it initially, but the pain still bothered
him on the following day. He visited LMD, the symptom was
slightly improved after unknown medication injection.
Unfortunately, he felt that chest pain became progressive and
was radiated to the back six hours prior to admission; dyspnea
and cold sweating were happened subsequently. He was brought
to local hospital for consultation. However, he was referred
to our hospital immediately due to critical condition.
He does not have any systemic disease such as DM,
hypertension, or hyperlipidemia. He took three cups of herb
wine (藥酒) per day for half a year. No sickness was mentioned
recently.
At ER, his consciousness was clear,
BP-86/48 mmHg, heart rate- 82 beats/min, respiration rate- 16
cycles/min, and body temperature- 36.8°C. Oxygen saturation
was 96% by Oxymeter measurement Neck was supple. Jugular vein
was not engorged. Symmetrical chest expansion with clear
breath sound, regular heart beat without heart murmur, soft
abdomen without bruit sound, and intact symmetrical pulsation
over all extremities were found Also, neurological examination
was normal. EKG(Fig.1)
was performed.
CBC:
WBC(K/μL) |
RBC (M/μL) |
HB( g/dL) |
HCT( %) |
MCV( fL) |
10.37 |
3.62 |
11.1 |
30.6 |
84.5 |
MCH (pg) |
MCHC(g/dL) |
PLT(K/μL) |
Blast(%) |
Promyl(%) |
30.7 |
36.3 |
60.0 |
0.0 |
0.0 |
Myelo(%) |
Meta(%) |
Band(%) |
Seg(%) |
Eos(%) |
Baso(%) |
7.0 |
5.0 |
6.0 |
65.0 |
0.0 |
1.0 |
BCS:
Alb (g/dL) |
D-BIL(mg/dL) |
T-BIL(mg/dL) |
LDH(mg/dL) |
UN(mg/dL) |
3.1 |
1.1 |
1.7 |
445 |
22 |
CRE(mg/dL) |
Na(mmol/L) |
K(mmol/L) |
Mg(mmol/L) |
P(mmol/L) |
1.3 |
142 |
4.7 |
1.32 |
6.2 |
CK(U/dL) |
CK-MB |
Troponin-I |
|
|
1113 |
127 |
30 |
|
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CASE ANALYSIS
66歲男性病人,因持續胸痛兩天,合併呼吸困難及盜汗,被送至醫院急診室。到院時,病人意識清楚,血壓86/48 mmHg,頸靜脈平坦,肺部無囉音;心電圖顯示lead I, aVL, and
V2的ST升高併LBBB pattern,同時生化學檢查心肌酵素亦升高(CK: 1113 U/dL, CK-MB: 127
U/dL, Troponin I: 30)。所以,馬上診斷是急性心肌梗塞。除給予normal saline and
Dopamine infusion 外,還裝置intra-aortic ballon counterpulsation
(IABP)
來維持血壓的穩定。然而,病人持續感到胸悶,且血壓仍不穩定,立即安排緊急心導管檢查。在心導管檢查中,發現冠狀動脈是正常的;另外,心電圖亦出現不同的 interventricular conduction disturbance( LBBB
→RBBB)。就急性心肌梗塞的心電圖變化若合併正常冠狀動脈攝影時,應高度懷疑是急性心肌炎(acute
myocarditis)。此時,需做右心室切片檢查來確定診斷。若病況仍持續惡化,就需裝置extracorporeal
membrane oxygenation (ECMO)來降低心肌的病變,同時給予Intravenous
Immunoglobulin (IVIG) 1 mg/Kg/day來治療acute
myocarditis。如果,上述治療失敗,唯有換心一途。
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