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NYU Medical Grand Rounds Clinical Vignette Pansy Tsang MD PGY-2 January 31, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Chief Complaint • 38 year-old male presents with chest pain for 1 hour UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • 2 years ago Mr. A developed chest pain and was found to have a myocardial infarction. A bare-metal stent was placed in his mid-circumflex with resolution of chest pain. • 1 month ago, chest pain returned. Mr. A had instent restenosis and a drug-eluting stent was placed. • 2 days prior to presentation, Mr. A travelled via plane from Canada to NYC for a business trip UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • On the day of presentation, the patient reports sudden sub-sternal chest pain at rest with associated diaphoresis, shortness of breath and a 30-second syncopal episode. • Pain was relieved with 3 sublingual nitroglycerin, but pain returned within a few minutes. An additional 3 sublingual nitroglycerin provided no relief. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Past Medical History: •Coronary artery disease •Non-Hodgkin’s lymphoma •Doxorubicin induced cardiomyopathy •Past Surgical History: •Anterior cruciate ligament graft •Bone marrow transplant •Social History: •10 pack year tobacco history, quit 4 years ago •Social alcohol use, denies drug history •From Montreal, Canada. Works as an attorney. •Family History: •Father-MI and sudden death, age 54 •Paternal Grandfather-early sudden death UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional History •Allergies: •Contrast/Iodine: urticaria •Morphine: urticaria •Medications: •Aspirin 81mg daily •Clopidogrel 75mg daily •Metoprolol tartrate 25mg every 12 hours •Simvastatin 20mg at bedtime •Nitroglycerin Sublingual tab, 0.4mg sublingual as needed •unknown chemotherapy, unknown dose or schedule UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Physical Examination •General: well groomed, extremely anxious middle-aged white male in moderate distress •Vital Signs: T:36.6 BP:131/72 HR:108 RR:22 and O2 sat:98% on room air •Mild tachycardia, smelling of tobacco •Remainder of physical exam was normal UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Laboratory Findings •CBC: Hgb 9.9. MCV 68.7 •Remainder of CBC was within normal limits •Basic Metabolic panel was within normal limits •Hepatic panel was within normal limits •Troponin <0.012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies •ECG: Sinus tachycardia 109, otherwise unremarkable •Chest X-Ray: no acute cardiopulmonary findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Acute coronary syndrome • Pulmonary embolism • Non-Hodgkin’s lymphoma (mass effect, necrosis) • Anxiety UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: – Aspirin, clopidogrel, heparin drip, and nitroglycerin drip were initiated for ACS. – IV Hydromorphone repeatedly dosed for chest pain – Pain persisted. Premedication for contrast given in preparation for cardiac cath. – Serial EKGs unchanged. Troponin (-) x 3 – Mr. A was found repeatedly out of his room, off drips, smoking in the stairwell. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2: – Cardiac catheterization deferred for low suspicion for ACS – CT chest pulmonary embolism protocol ordered, patient agreeable – On arrival to radiology, patient refused CT, refusing 20 gauge IV. – Patient agreed to ventilation/perfusion scan, but on arrival to radiology, he again refused. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2 (continued): – Contact numbers for next of kin not in service – Patient is unable to provide his cardiologist’s or oncologist's contact information – Repeated elopements off the floor to smoke – Patient left against medical advice UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Chest pain of unknown etiology vs. • Malingering, drug seeking behavior vs. • Factitious disorder UNITED STATES DEPARTMENT OF VETERANS AFFAIRS