Case Discussion
|
This 21- year- old man was admitted due to sudden onset of
chest tightness and shortness of breath at PM 7: 45 on May
28
This 21- year-old man was robust
in the past without known major systemic diseases. He said
that he had two episodes of cold sweating in teenage but
neither one was associated with chest tightness. No family
history of heart disease was known. In the past one year, he
began to experience chest discomfort and palpitations after
exercise and the symptoms were relieved 2- 3 minutes after
taking a rest. Neither chest pain nor dyspnea was noted and he
didn’t pay much attention to the discomfort. However, he
suffered from sudden onset of chest tightness, palpitations
and shortness of breath while he was sitting and reading at PM
7: 45 on May 28. Cold sweating, dizziness, tinnitus and near
fainting sensation were also noted. He was then escorted to
our ES at PM 8: 16 while the discomfort subsided slightly. On
arrival at emergency room, BP was 147/93 mmHg, and HR 75/min.
ECG (05/28 20:29) showed ST depression over leads II, III, aVF
(Figure
1, 2)
and the blood test revealed serial elevation of
cardiac enzyme (CK/CKMB 5/28: 236/16.4, 5/29: 341/28.8, 5/29:
441/38.6). Under the impression of non-Q myocardial
infarction, he was transferred to our CCU.
On examination, his consciousness was clear.
The blood pressure was 133/73 mmHg, pulse, 84/min;
respirations, 20/min; temperature 36.5°C. The breath sounds were clear and
the heart sounds were regular without tachycardia. No pitting
edema was noticed over extremities.
Aspirin and heparin were administered
on May 29 and the chest discomfort improved subjectively.
Enzyme peaking was achieved at 4AM on May 29 (9hrs post chest
tightness). Cardiac catheterization (Figure
6)
performed
on May 29 demonstrated patent coronary arteries and good LV
contractility with normal LV size. Localized myocarditis at inferior wall was
considered and anti-platelet agents, NTG and Heparin were discontinued
since May 30. He was transferred to general ward on
May 31 and then discharged on June 2.
Another episode of chest tightness
along with palpitations and shortness of breath happened at PM
5: 00 on June 13. He visited our emergency room within 5
minutes where ECG (Figure
3) was taken immediately. Cardiac enzyme was also checked
and elevated troponin I was found. Adenosine 18 mg was given
intravenously and the tachycardia was terminated. The ECG
followed 2 minutes later showed ST depression over leads II,
III and aVF (Figure
4). Two hours after the tachycardia stopped, the ECG (Figure
5)
showed normal sinus rhythm without
any ST-T change. He was followed at NTUH OPD and will receive
EPS later.
Laboratory data: [Hematologic laboratory values]
CBC |
WBC |
RBC |
Hb |
Hct |
MCV |
MCHC |
PLT |
|
K/uL |
M/uL |
g/dL |
% |
fL |
g/dL |
K/uL |
90/5/28 |
8.4 |
4.94 |
14.4 |
42.8 |
86.6 |
33.6 |
172 |
90/6/01 |
7.08 |
4.97 |
14.6 |
44 |
88.5 |
33.2 |
241 |
DC |
Band |
Seg |
Eos |
Baso |
Mono |
Lym |
|
% |
% |
% |
% |
% |
% |
90/5/28 |
0 |
81.9 |
1.3 |
0.7 |
4.0 |
12.1 |
PT/PTT |
PT (sec) |
INR |
PTT (sec) |
90/5/29 |
13.4/12.4 |
1.1 |
78/35.5 | [Blood biochemical valves]
BCS |
LDH |
UN |
CRE |
UA |
Na |
K |
Cl |
Ca |
Mg |
|
U/l |
mg/dl |
mg/dl |
mg/dl |
mmole/l |
mmole/l |
mmole/l |
mmole/l |
Mg/dl |
90/5/28 |
- |
12 |
1.21 |
- |
141.3 |
3.81 |
- |
- |
|
90/5/29 |
- |
- |
- |
- |
- |
- |
108 |
2.25 |
0.89 |
90/5/30 |
- |
- |
- |
- |
- |
3.64 |
|
|
|
|
5/28 |
5/29-1 |
5/29-4 |
5/29-11 |
5/29-16 |
5/30 |
6/1 |
6/13-18 |
6/13-20 |
6/14 |
CK |
236 |
341 |
441 |
423 |
334 |
197 |
108 |
162 |
150 |
156 |
CKMB |
16.4 |
28.8 |
38.6 |
32 |
20.5 |
7.8 |
5.6 |
25 |
7.9 |
8.1 |
Troponin I |
0.5 |
8.45 |
12.8 |
- |
- |
- |
- |
0.004 |
0.222 |
1.35 |
病例分析 這是一個二十一歲的年輕男性胸痛病人,有心悸及冷汗暈眩之伴隨症狀,但無明顯冠狀動脈疾病危險因子.在急診時之鑑別診斷需考慮如氣胸,肺炎,心肌炎,心律不整等等.精神官能症在年輕人雖很有可能,但不可作為唯一之考量.簡易的心電圖,胸部X光及心臟酵素檢查仍必須完成.
以本病例而言,一開始之心電圖在下壁有ST
段低下的情況,X光並無肺炎及氣胸之情況,故心臟之問題仍需優先考慮.此時系列的心電圖和酵素之追蹤是最重要的.當酵素上升時而心電圖有系列變化時,在心肌受損的診斷下給予急性冠狀動脈症候群的處理是合理的.進一步血管攝影檢查是有必要的.
關於心律不整的部分,發病時的心電圖是診斷時最重要的,有時單從臨床症狀是無法作確實診斷.故在門診遇到這種病人,應建議於症狀發作時盡快至最近的醫療院所或檢驗所取得十二導程心電圖,以為診斷之工具.
|
|
繼續教育考題
|
|
1.
(D) |
For the chest
pain in this young man in emergency room, which management is not
suitable? |
A | Give O2 supplement |
B | Take chest x-ray |
C | EKG study |
D | Discharge |
2.
(D) |
For chest pain in this
young man, which one should be considered
initially?
a.pneumonthorax
b.myocarditis c.coronary spasm d.arrythmia e.mitral valve
prolapse |
A | a,c,d |
B | a,c,d,e |
C | b,c,d |
D | a,b,c,d,e |
3.
(A) |
What are the possible
causes of cardiac enzyme elevation?
a.myocardial infarction
b.myocarditis c.shock with poor perfusion d.DC shock |
A | a,b,c,d |
B | a,c,d |
C | a,b,d |
D | a,b |
4.
(C) |
Which is the most
likely diagnosis of EKG rhythm in Fig.3
? |
A | Ventricular
fibrillation |
B | Atrial fibrillation |
C | Paroxysmal supraventricular
tachycardia |
D | Sinus tachycardia |
5.
(A) |
How to manage
the rhythm mentioned in question 4 if the patient has stable
hemodynamic condition in emergency room? |
A | Carotid massage |
B | Atropine |
C | Synchronized DC shock |
D | Amiodarone |
6.
(C) |
If the patient is
pulseless in emergency room as question 5, which one is
appropriate? |
A | Carotid massage |
B | Atropine |
C | synchronized DC shock |
D | Amiodarone |
7.
(A) |
Which one is not
characteristic of paroxysmal supraventricular tachycardia? |
A | Bizaar QRS morphology |
B | Regular RR interval |
C | Narrow QRS |
D | Paroxysmal attacks |
8.
(C) |
For regular widened
QRS tachycardia, which one of the followings favors the diagnosis of
ventricular tachycardia? a.atrioventricular dissociation
b.rsR' in V1 c.fusion beats
d.QRS duration >0.14 sec |
A | a,b,c |
B | a,b,c,d |
C | a,c,d |
D | a,d |
9.
(D) |
Which one of the
followings is the EKG pattern of WPW syndrome in antegrade
conduction? a.short PR interval b.delta wave c.PR
prolong d.wide QRS
e.slurred S wave |
A | a,b,c,d |
B | a,b,e |
C | b,c,d |
D | a,b,d |
10.
(A) |
In pre-excited
paroxysmal supraventricular tachycardia in patients with WPW
syndrome, which drug is most suitable? |
A | Procainamide |
B | Digoxin |
C | Propanolol |
D | Verapamil |
答案解說:
1. ( D
) Discharge is not suitable if diagnosis for chest pain
is not certain, even in a young man. Life threatening
condition such as pneumothorax, myocarditis or coronary syndrome should
be ruled out before discharge.
2. (D
)
3. (A
)Cardiac enzyme
上升表示心肌細胞受損,在四種情況都可能發生.
4. (C
) Fig 2 shows regular wide complex EKG
with RBBB pattern. Heart rate is about 300 per minute. Response to
adenosine favors paroxysmal supraventricular tachycardia.
5. (A ) Carotid massage
should be
tried first for suspected paroxysmal
supraventricular tachycardia in hemodynamic stable condition.
6. (C) DC shock is indicated for
hemodynamic unstable tachyarrythmia.
7. (A
) Bizaar
QRS favors ventricular tachycardia.
8. (C
) Atrioventricular dissociatioin, capture beats, fusion
beats and QRS duration > 0.14 second
皆為Ventricular tachycardia之表現
9. (D
) Harrison's principles of internal medicine, 14th
edition. P.1270
10. (A ) Digoxin, propanolol, and
verapamil will delay atriovenntricular node conduction
and increase conduction over bypass.
| | |
|