a 57 y/o male s/p percutaneous intervention

1. Case Presentation-
A 57 y/o male with chest
tightness for 2 months
Intern吳易儒

2. Basic data
Chart number:9180565
Age/Sex: 57/Male
Education: University
Occupation: Business
Marital Status: Married

3. Past medical history
Hypertension- regularly f/u in MMH
DM- regularly f/u in MMH
Hyperlipidemia-recently diagnosed

4. Present illness
This 56 y/o male with past history of
hypertension and diabetes mellitus type 2
for 10 years under our OPD medical control
was admitted here due to frequent chest
tightness for two months.
chest tightness often woke him up at night
and could be relieved soon by taking NTG. It
located around 4th intercostal area at left
anterior chest. The pain didn’t last more
than 5 minutes.

5. Present illness
There was no radiation pain, no dyspnea, no
nausea, no vomiting, no dizziness nor
indigestion accompanied with the chest
tightness. The pain was not related to
position change or meal taking. Also,
exercising won’t exaggerate his chest
tightness.
As a buisnessman, he has not developed
symptoms at day for he was sitting all day
long.

6. Present illness
He went to our OPD for help, where
treadmill was done 2 months ago and
revealed ST-segment depression.
Heart echo found EF=57.1%, mild AR and
mild MR.
Thallium scan showed suspected large
extent of myocardial ischemia in the
anteroseptal, apical anterior, apical, inferior
and inferiolateral walls of left ventricle.

7. Present illness
Then he was admitted to receive CAG 2
weeks ago. CAG reported CAD with TVD.
This time, he was admitted to our ward to
receive PCI for RCA and LCX.

8. Social History
Allergy: none
Alcohol drinking: social drinking
Betalnuts chewing: no
Cigarette smoking: previously 1 PPD, quitted
for 2 months(due to chest pain)

9. Family History
Father died of Hypertension.
Mother died of Leukemia
One of his brother living with previous stroke.
(four elder sisters and two elder brothers)

10. Patient’s Risk Factors for CAD
DM
Hypertension
Age
Male
Smoking
Family vascular
disease history
Less exercise

11. Review of systems
General：
Recent weight change：-
Fever/Chills：-
Change in appetite：-
Fatigue：-
Generalized weakness：-
Cardiovascular：
Heart trouble：+
Chest pain：+
Dyspnea on exertion：-
Orthopnea：-
Palpitation：-
Intermittent claudicate：-
Varicose veins：+
Edema：-

12. Review of systems
Musculoskeletal：
arthralgia：-
Myalgia：-
Back pain：-
Neurological：
Syncope：-
Seizures：-
Focal weakness or
paralysis：-
Numbness/paresthesias：-
Tremor：-
Psychiatric：
Irritability：-
Difficulty concentrating：-
Memory loss：-
Depression：-
Anxiety：-

13. Physical Examination
Height：166 cm; Weight：72 kg
Vital signs:
T/P/R : 36.9/79/17
Blood Pressure：132/77
General Appearance：
Consciousness: clear, alert, Ill-looking
Chest：Symmetric expansion
No focal tenderness
No chest wall lesion
BS: clear, no wheezing or crackles

14. Physical Examination
Lymph Nodes：No LAPs
Pulses：intact and strong, symmetric
Abdomen：
Soft, no focal tenderness
Liver and spleen: not palpable
Bowel sound: normally active
CV angle: no knocking pain
Extremities:
No leg edema
Free movement with full ROM
No clubbing finger

15. Physical Examination-3
Heart：Regular heart beats with continuous murmur
Neurological：
No flapping tremor
Muscle power: full
GCS: E4M6V5
Skin：No cyanosis
No focal erythema

16. EKG

17. Treadmill

18. Treadmill Conclusions
1.Target heart rate:163 bpm
2.Exercise capacity:
(1) Maximum heart rate:146 bpm (89 % predicted rate)
3.Resting ECG:NSR, NSTTC
4.HR recovery time(bpm):1min(121);3min(103);6min
(83)
5.Exercise ECG:Sinus tachycardia, further horizontal
ST-segment depression =1mm at lead II,III,aVF, V4-6
since stage 1 .
6.Cause of termination:SOB
7.Conclusion:Possiable positive.

19. Cardiac echo
Ventricles
.Impaired diastolic function of left ventricle.
.Mild aortic regurgitation.
.Mild mitral regurgitation.
.Increased thickness of left ventricular
walls.
.Prolong isovolemic relaxation time..
.E/E'(Lateral) : 18.

20. Cardiac echo (05/05)
Valves
.MR jet area is <20% of LA area.
.AR jet width is <25% of LVOT diameter.

21. Thalium scan

22. CAG report
CAG showed CAD with TVD.
LM-d and LAD-p 95% stenosis with calcification
LAD-d 70% stenosis
LCX-m 70% stenosis
LCX-d 100% stenosis
RCA-p 99% stenosis
RCA-m 95% stenosis
PLV 85% stenosis.
LVG demostrated preserved LV systolic function
without significant regional wall motion abnormality .
MR,AR,LV aneurysm was found.

23. Lab data
Glucose
AC
AST ALT BUN Creatinine GFR Na
159 18 30 16 0.9 87.2 141
TG Hb WBC PLT PT aPTT K
277 13.9 5.2 152 10.4 26.7 4.4

24. Diagnosis
CAD with TVD s/p CAG on 2013/5/22
Hyperlipidemia
Hypertension
Diabetes mellitus type 2

25. Plan
Plan for PTCA on 6/9
Lifestyle control, quit smoking
Under Aspirin, NTG and Colpidogrel control

26. PTCA on 6/9
1.At first
RCA-P-M-PLV lesion was dilated with Hiryu 2.5*15 mm
balloon at 6-18 atm
2.then
Resolute 3.0*38mm stent was placed at the RCA-P lesion
across RCA-M vessel and deployed at 14-16 atm
In RCA-P-M stent post dilatation with nc Sapphire 3.75
*12mm balloon at 10-25 atm
-> The lesion was dilated with the same balloon
-> Final coronary angiography showed successful stent
implantation