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Case presentation

新光吳火獅紀念醫院

急診醫學科 R3許哲彰

指導者:VS林立偉

102.06.18

Triage

DAY1 02:26

Vital signs: T/P/R: 36.1/ 114/ 20

BP: 175/109 mmHg, SpO2: 100%

Triage II

GCS: E4V5M6

47 year-old female

Chief complaint: 噁心嘔吐

Present illness

今天覺得心臟痛，肚子痛，吐了好幾次

no diarrhea, no fever

男友表示：平常低血壓，沒特別病史

Denied AP, denied alcohol use

Past history

有在看精神科，恐慌？ Panic disorder ?

mitral valve prolapse ?

GCS: clear, ill looking

HEENT: not pale

Chest: clear breathing sound, RHB

Abdomen: no obvious tender, pain intermittent, 壓會想吐

Extremities: warm

Physical examination Impression

• Acute gastritis with dehydration

• Phobia ? Panic ?

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OrderECG

NPO

CXR, KUB

WBC/DC/Hb/PLT

Panel-I, Lipase, T-bil, Troponin-I

N/S 500cc challange st then 100cc/Hr

primperan 1 amp V st

Morphine 5 mg v st

ECG

X-ray03:49

still felt abd pain, epigastragia, tenderness with guarding

=> Peritonitis, cause? arrange CT without contrast r/o PPU

Bain 1/3 amp iv st

護理記錄 03:25時 HR 133, SpO2 94%

03:59 Lab data03:59 Order

Impression: 1. pericarditis or myocarditis, 2. r/o Aortic dissection (pain, high BP, irritable mood)

補CK/CKMB

Consult CV & 總值

Bedside echo: no pericardial effusion

DC abd CT, arrange Aorta CT c/s contrast

on monitor

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CT04:21 SOB, desaturationKeto 1amp iv st

O2 NRM 15L/min

改IV lock

B/C x II, ABG(G6), Cl, CK/CKMB/Troponin-I, CRP, Ketone, Lactate

F/S (Hi)

N/S 500cc + RI 50u run 40cc/hr

RI 10u iv st

Flumarin 1g iv st

04:31

on ETT, NG decompression, Foley

CXR (p)

succinylcholine 60mg iv st

Etomidate 1/2 amp iv st

sputum culture x II

on critical

Next

f/u ABG (G6)

Lasix 2 amp iv st

NaHCO3 4 amp iv st

Admission to ICU

ICU

DAY1 Consult CV, Heart echo: EF around 15~20 %, Global-hypokinesis => arrange Cath: patent CAD; on ECMO & IABP, levophed and Dopamine due to shock

DAY1 Consult Endocrine: can’t r/o pheochromocytoma, check urine VMA (But p’t sufferred from ARF without urine )

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ICU

DAY3 sign DNR due to persist shock and unstable vital sign

DAY4 expired

Final diagnosis:

Acute myocarditis with HF and ARDS, multiple organ failure

Right adrenal tumor r/o pheochromocytoma or meta

Breast CA s/p op

Discussion:

•

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Dyspnea, Chest pain, arrhythmia

Lympocytic, necrotizing eosinophilic, giant cell (worst)

Tachycardia, soft S1, S3 or S4 gallop, Lymphadenopathy(sarcoidosis), rash(hypersensitivity), polyarthritis, erythema marginatum (acute rheumatic fever)

ECG sensitivity is low

About myocarditis

Echo: evaluate LV function, r/o other problem. Classic finding include global hypokinesis c/s pericardial effusion（in some case can mimic AMI）=> 但是specificity is low

MRI: T2 can see tissue edema/T1-weighted MR with contrast will showed tissue enhancement (myocyte rupture)

Biopsy: Steroid or not

About myocarditis

About myocarditis

Conclusion: Mostly supportive treatment except Giant cell myocarditis or Hypersensitive myocarditis or systemic disease induced(ex. SLE)

About myocarditis

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Pheochromocytoma • 心跳加快、心悸、血壓飆升 (可導致頭痛、中風、及腎

臟損傷)、盜汗、皮膚蒼白 (因為表皮血管收縮導致血流減少)、易怒、焦慮、和恐慌發作 (panic attack) 的症狀

• Epinephrine 與 Norepinephrine 可將肝醣與脂肪轉變成葡萄糖，並釋放至血液中，故嗜鉻細胞瘤的患者可能出現血糖偏高、甚至葡萄糖不耐

• 診斷：urine vanillylmandelic acid (VMA)

• => 和病人的症狀有許多雷同, 開刀會不會有機會?

unknown

• Thanks for your attention