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This 58-year-old man had
hypertension for more than 5 years without medical control. He
began to suffer from palpitation, dyspnea and chest tightness
while escaping from his house during the 9-21 earthquake in
1999. The chest tightness ususally last about 10-20 minutes
with radiation to the back, and was related to emotional
change and exertion. It could be relieved by rest. Besides, he
also has exercise intolerance and could only climb up to the
2nd floor. His symptoms deteriorated in recent six months.
Bilateral leg edema developed 3 weeks before this admission.
No orthopnea or paroxysmal nocturnal dyspnea was noted. Some
heart disease was told outside, so he came to our hospital for
further evaluation. <PHYSICAL Examination>showed: Consciousness: clear; T/P/R: 36.7/84/20;
BP: 170/90; HEENT: grossly normal; Eye: conjunctiva: not pale;
sclera: icteric; pupils: isocoric; L/R: +/+; Neck supple;
LAP(-), JVE(+/-), goiter(-), carotid bruits(-); Chest:
symmetric expansion; BS: clear; Heart: RHB, PMI at left 5th
ICS on LMCL, a Gr IV/VI continuous murmur over left upper
sternal border, thrill palpable,
No LV or RV heave; Abdomen: soft & flat, No tenderness or rebounding
pain, Liver/spleen: impalpable, No shifting dullness, Bowel sound: normoactive; Ext: freely movable, clubbing(-),
cyanosis(-), edema(-); Back: no knocking pain;
Pulse:
| |
Carotid |
Brachial |
Radial |
Femoral |
Post. Tibial |
Pedis Dorsalis |
| L't |
++ |
++ |
++ |
+~++ |
+ |
+ |
| R't |
++ |
++ |
++ |
+~++ |
+ |
+ |
Four limb BP:
| R't arm |
R't leg |
L't arm |
L't leg |
| 185/108 |
107/80 |
176/89 |
96/85
<LAB> |
<Lab>
| 項 目 |
WBC |
RBC |
HB |
HCT |
MCV |
MCH |
MCHC |
PLT |
| |
K/μL |
M/μL |
g/dL |
% |
fL |
pg |
g/dL |
K/μL |
| |
10.05 |
3.67 |
11.7 |
35.1 |
95.6 |
31.9 |
33.3 |
211.0 |
| 項 目 |
UN |
CRE |
Na |
K |
Cl |
| |
mg/dl |
mg/dl |
mmole/l |
mmole/l |
mmole/l |
| |
20.6 |
0.9 |
135 |
4.5 |
103 |
 Course
& Treatment
A supine
Chest PA view (圖一)
initiated serial noninvasive tests including echocardiograpgy
and MRA (圖二). Cardiac
catheterization (圖三
) and coronary angiography were performed
later to establish the diagnosis. ECG showed sinus rhythm and
LVH without ischemic ST-T change. Anti-HTN agents including
Trandate (200) 2# bid, Sorbitrate 1# tid, Lasix 1# qd, Isoptin
SR 1# bid and Adalat (5) were administered. Unfortunately, his
BP dropped suddenly with bradycardia after taking stat
Tenormin 2# for poorly controlled BP and he was transferred to
CCU. Intubation was performed due to drowsy consciousness,
shock, and respiratory failure. Temporary pacemaker was also
inserted. Inotropic agents including dopamine and Levophed
were prescribed. S-G data suggested cardiogenic shock (CI=
1.78; SVRI= 2423; PAWP=
35). Emergency chest and abdominal CT did not disclose rupture
of DAA. However, sudden onset of paraplegia and numbness of
his lower extremities developed and spinal cord infarction was
impressed. Vascular duplex showed bilateral small vessel
disease and patent flow of the arteries below the knee. Fever
flared up during the admission and antibiotics with unasyn was
given (claforan+anegyn) under the suspicion of abdominal
infection but was later changed to PCN-G+GM for the result of
blood culture (Streptococcus oralis). He was extubated
smoothly 2 days later under the stabilized hemodynamic
condition. SSEP showed prolonged scalp SEP latencies from
Peroneal nerves, which was compatible with a spinal cord
lesion. He is still staying in the hospital for
rehabilitation.
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Case Discussion