Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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