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NYU Medical Grand Rounds
Clinical Vignette
Jennifer Lue, MD
PGY-2
9/11/2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
Mr. Y is a 64 year old Chinese Male who
presents with chest pain for 24 hours.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• One day prior to presentation, the patient began
to experience 8/10, non-radiating, substernal chest
pressure associated with diaphoresis and
shortness of breath.
• The pain initially improved with Tylenol, however
over the following 24 hours, his symptoms
worsened
• The patient went to his primary physician, where
an EKG was performed which showed ST
elevations in leads V2-V6.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• He was given Aspirin 325mg and Nitroglycerine spray
and his symptoms improved.
• EMS was called and the patient was taken to the
Bellevue ER where a STEMI alert was called
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Past Medical History: Osteoarthritis
• Past Surgical History: None
• Social History: Denies tobacco, alcohol and other
illicit drug use
• Family History: Denies early MI, sudden cardiac
death, DM, HTN, HLD
• No Known Drug Allergies
• Medications: None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• General: Chinese Male, laying in a
stretcher, in mild distress
• Vital Signs: T: 98.6 BP:106/76 HR:67
RR:18 and O2 sat:100% on 2L NC
• Remainder of the physical exam was
normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC: WBC 10.9 (77% neutrophils)
Remainder of CBC was within normal limits
• Basic Metabolic panel: within normal limits
• Hepatic panel: AST 252, ALT 52
Remainder of hepatic panel was within normal
limits
• INR, PT, PTT within normal limits
• Troponin >50
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
ECG: Normal Sinus Rhythm, Normal axis. Q w
in I, avL, V2-V6. ST elevations in V2-V6.
Other Studies
• Chest X-Ray: no infiltrates, effusions,
consolidations
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• Acute Coronary Syndrome
• ST Elevation Myocardial Infarction
Hospital Course
• Hospital Day 1:
– The patient was started on Plavix 75mg, ASA
81mg, Crestor 40mg
– Cardiac Catherization demonstrated a complete
occlusion of mid- Left Anterior Descending Artery,
with a 50% proximal Right Coronary Artery lesion.
Drug Eluting Stent was placed in mid Left Anterior
Descending Artery
– A transthoracic echocardiogram showed an ejection
fraction of 30%, apical anterior wall akinesis, apical
lateral wall akinesis, dyskinesis of LV apex and
apical septum akinesis.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
•
Hospital Day 1 cont.
–
•
Due to a depressed ejection fraction and
significant anterior wall hypokinesis, the
patient was started on heparin drip and
bridged to coumadin
Hospital Day 2-3
–
•
The patient was started on metoprolol
succinate 25mg daily and lisinopril 2.5mg
daily
Hospital Day 4
–
The patient was discharged home
Final Diagnosis
• ST Elevation Myocardial Infarction
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS