Download Clinical Vignette - Clinical Correlations

Medical Grand Rounds
Clinical Vignette
October 15th, 2008
Srikant Duggirala, M.D.
Chief Complaint
57 year old male presents with chest pain
for 12 hours
History of Present Illness
On the evening prior to admission, the patient reports the
sudden onset of sub-sternal chest pain while doing
housework. The pain radiated to the jaw and left arm.
The chest pain was associated with mild shortness of
breath, diaphoresis and nausea with no vomiting. He
denied any palpitations or prior episodes of similar chest
pain.
He denied any recent cocaine use.
He recalls a normal exercise stress test several years
ago done at another hospital.
History
Past Medical History:
– Depression
– Asthma
Past Surgical History:
– No prior surgeries
History
Social Hx:
– 44 pack year history of smoking, current 1ppd smoker
– Smoked Cocaine for 40 years, quit 2 months ago
– Drank 5 12-ounce beers daily for 10 years. Quit 2
months ago after completing a 10 month in-patient
rehab program.
Family Hx:
– Father died of MI at age 65
Allergies:
– No known drug allergies
Medications:
– MVI
Physical Exam
General: In no acute distress, appeared stated age.
T:98.8oF BP:147/70 HR:76 RR:18 O2:98%RA
HEENT: No JVD or carotid bruits noted.
CV: Normal S1 and S2. No murmurs, rubs or gallops.
Pulm: Clear to auscultation bilaterally
Ext: No clubbing, cyanosis or edema. 2+ dorsalis
pedis pulse and 2+ femoral pulses bilaterally
The remainder of the physical exam was normal
Laboratory
WBC of 15.13
AST of 73 (Normal 0-40)
Time 0 hours
Time 8 hours
Troponin
0.935
2.363
CK
392
611
CK-MB
37
77.8
Basic Metabolic Panel normal
Urine Toxicology negative for opiates
Imaging
ECG: Sinus rhythm with rate of 66, LAFB, Left Atrial
enlargement, TWI in V4-V6
Chest XR: No evidence of pulmonary congestion or
effusions.
Working Diagnosis
Non-ST Elevation Myocardial Infarction
(NSTEMI)
Hospital Course
ED course:
–
Treated with:
Aspirin 325mg
Clopidogrel 300mg
Enoxaparin 70mg
Morphine 4mg IVP
Sub-lingual Nitroglycerine 0.4mg and Nitropaste
The patient remained hemodynamically
stable and his chest pain resolved.
Hospital Course
The patient was taken for a Diagnostic
Cardiac Catheterization showing:
– Mid RCA 40-50%
– Distal RCA 75%
– Proximal LCx of 70%
– OM2 with 99%
Ventriculogram showed EF of 55% with
moderate posterior- lateral wall
hypokinesis.
Hospital Course
On HD#2, the patient transferred to Bellevue
Hospital CCU for rescue Percutaneous
Coronary Intervention (PCI) of the proximal left
circumflex and obtuse marginal lesions.
Upon transfer, the patient developed a BP of
190/100 and was started on nitroglycerine drip.
He remained chest pain free.
On HD#3, he was started on a beta-blocker
and ACE-inhibitor and titrated off the
nitroglycerine drip.
Hospital Course
On HD #4, he had rescue PCI of his lesions
with Endeavor stents.
He remained CP free and was discharged on a
beta-blocker, ACE-Inhibitor, Clopidogrel and
Aspirin
Follow-up
He is scheduled to return to the Bellevue
Hospital Catheterization lab in 4-6 weeks
for elective PCI of his distal RCA lesion.
He was also educated about smoking
cessation.
Final Diagnoses
NSTEMI from coronary artery disease.