Transcript Journal Club - NYU Langone Medical Center

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