※1－5）については「脳の心配（肺）が肝腎」と覚えます。

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　ICU Presentationの例（米国医学部３年生のICU症例提示より）

[History]
15 months ago, the patient got a diagnosis of dilated cardiomyopathy by myocardial biopsy. Beta-adrenergic antagonist therapy had been initiated. During the following months, he could work 40 hours per week on his job, although he had chest oppression when walking on slope and nocturnal dyspnea one or two times a week. No hemoptysis, chest pain, palpitation, or syncope. One month before the referral to our hospital, productive cough and shortness of breath developed with fever. He had been admitted to another hospital. Supportive care by nitrate, diuretics, and inotropes in cardiac care unit made his condition improved. However, his cardiac function remained poor, ejection fraction（EF）＜20％ on echocardiography. Two days before the transfer, severe hypoxemia with acidosis developed, which required IABP and artificial ventilation. He was referred to our hospital for the indication of left ventricular assist devices（L-VAD）.
The patient didn't have hypertension, diabetes mellitus, or hyperlipidemia. He has no family history of heart disease and sudden death. He didn't drink alcohol and smoke cigarettes. No history of allergy and blood transfusion.

[By-System]
General: 175cm and 61.4kg with mild generalized edema. The rectal temperature for the last 24 hours ranged between 37.9 and 37.2. Skin: normal but cold.
#1 Central nervous system: Sedated by midazolam. Pupils are round, isocoria. Reaction to light is prompt. Fundi: normal.
#2 Respiratory: The patient is orotracheally intubated and on pressure control ventilation. SIMV: MV 2／min., PEEP 5cm H₂O, PS 10cm H₂O, and FiO₂ 0.4. The respiration is 10-14／min. Sounds: clear. ABG revealed pH 7.35, PO₂ 110, PCO₂ 38, BE＝－4, O₂ saturation 98％. Chest X-ray revealed pulmonary edema on bilateral hilar regions, pulmonary vessel's cuffing sign, atelectasis of left lower lobe, and cardiomegaly.
#3 Circulatory: IABP with dopamine（DOA）and dobutamine（DOB）, 10 microgram／kg／min., respectively. Systolic blood pressure 70－90mmHg and diastolic 30－50 over the last 24hours. The pulse was 80－100／min, regular. Neck veins were dilated three fingers above from clavicles. CK and MB: normal. An electrocardiogram showed sinus rhythm with first-degree AV block, left and right atrium enlargement. STAT cardiac ultrasonography revealed four-chamber enlargement, generalized severe hypokinesis, EF 20％. Central venous pressure: 20cm H₂O. IABP is placed from the right femoral artery. Dorsalis pedis and posterior tibial pulses are weak but palpable bilaterally.
#4 Hepato-renal function: Sclerae were slightly icteric. No hepatomegaly or splenomegaly. BUN 19, Cre 0.6. AST 102 and ALT 87, elevated. LDH and ALP: normal. T-Bil 3.5mg／dl, elevated. Abdominal ultrasonography revealed dilated hepatic veins without ascites. Hepatitis B and C are negative. A urine sample is normal.
#5 Electrolytes, fluid & nutrition: Potassium ranges between 4.2 and 4.7mEq／l. Blood glucose 110－150mg／dl. Na, Cl, Ca, and Mg are normal. TPN: 40ml／hr with sodium restriction. Urine output: 720 ml for 24 hours. Body weight is constant for the last two days.
#6 Others: Occult blood was negative. WBC 12,500, Hb 10.1, Hct 28.9, Plt 155,000. PR-INR 1.1, aPTT 41 seconds.

[Case Mapping]
The key issue of this patient is low output syndrome. It is a result of acute exacerbation of dilated cardiomyopathy. The condition has been refractory to inotropes and IABP, with the ominous signs of sustained hypotension, acidosis, and congestive liver. CNS, respiratory: intact. No sign of infection.

[Summative Plan]
The patient is on the list awaiting cardiac transplant. For bridging, we will implant L-VAD, while discontinue IABP. We are going to wean the patient from mechanical ventilation and taper catecholamines, once the condition is stabilized after operation.