Transcript Hospital Day 3

NYU Medical Grand Rounds
Clinical Vignette
Ramin S Hastings, MD
PGY-3
September 8, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 47 year old male presents with chest pain for
two days
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Mr. R is a 47 year old male with asthma and
hypertension who was in his usual state of good health
with a baseline exercise tolerance of fifteen blocks, until
two days prior to admission when he developed new
onset chest pain while lying down before going to bed.
•The patient stated the pain was a substernal pressure,
as if “someone was trying to push my heart through my
back.”
•The pain was non-radiating, and associated with mild
shortness of breath, nausea, and diaphoresis. It
resolved on its own after ten minutes.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• He went to sleep, and the following day was free of
symptoms until that night when a similar attack of chest
pain occurred, again lasting about ten minutes.
• On the day of admission he was at work, again not
exerting himself, when he developed similar chest pain.
• The pain lasted fifteen minutes, and he was drenched
in sweat. He then decided to present to the emergency
room for care.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•On arrival to the emergency room, he was chest pain
free, without complaint
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
• Asthma – diagnosed in childhood, never intubated, approximately two
exacerbations per year
• Hypertension – diagnosed 5 years ago poorly controlled
•Past Surgical History:
• Right hand fracture repair after motor vehicle accident (10 years ago)
•Social History:
• Smokes one to two packs of cigarettes per day for the past 30 years,
previously heavy alcohol and cocaine abuse, quit three years ago
• Currently homeless and living in a shelter, works at a deli
•Family History:
•Adopted and does not know family history well
•Allergies:
• No known drug allergies
•Medications:
• Albuterol metered dose inhaler, 2 puffs as needed
• Fluticasone 220 mcg 1 puff every 12 hours
• Nifedipine 30 mg three times a day (however patient was not taking)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Obese African American male lying in stretcher
in no acute distress
•Vital Signs: T: 97.1 BP: 198/112 HR: 94 RR: 16 and O2
sat: 98%
•Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: White Blood Cell Count 11.5
•Remainder of CBC was within normal limits
•Basic Metabolic panel: Glucose 106
•Remainder of basic was within normal limits
•Hepatic panel: within normal limits
•Troponin 0.170 (normal 0.08)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial EKG
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Electrocardiogram: Normal sinus rhythm at 70 beats
per minute, normal axis, normal intervals, T-wave
inversions in leads II/III/Avf and V3-V6, Left Ventricular
Hypertrophy, no ST segment changes
•Chest X-Ray: no consolidations, no pulmonary
edema
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Acute coronary syndrome
• Demand ischemia in the setting of uncontrolled
hypertension
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 1:
– Patient was started on aspirin, clopidogrel,
heparin, and simvastatin
– His blood pressure was controlled with calcium
channel blockers
– Trans-thoracic echocardiogram was performed
showing:
• Concentric left ventricular hypertrophy
• Normal left ventricular ejection fraction
• Normal left ventricular wall motion
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 2:
– Nuclear pharmacologic stress test was
performed showing:
• No evidence of vasodilator-induced ischemia
or decreased coronary artery flow reserve
• No evidence of prior myocardial infarction
• Normal wall motion and thickening with left
ventricular ejection fraction of 54%
– Given the normal echocardiogram and stress test
the plan was to obtain a coronary computerized
tomography angiography on the following day
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3:
– The patient had been chest pain free until this
day, when he developed severe chest pain much
like his prior episodes
– Electrocardiogram was repeated
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Repeat EKG
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3 Continued:
– He was treated with nitroglycerin with relief of the
pain and normalization of the findings on
electrocardiogram
– He was admitted to the Coronary Care Unit and
emergently brought to the catheterization laboratory
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Cardiac Catheterization
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• Hospital Day 3 Continued:
– Cardiac catheterization revealed:
• A 90% lesion was noted in the proximal left
anterior descending artery
• A Promus stent was placed
– Post-catheterization care was performed in the
coronary care unit where he remained chest pain
free
• Hospital Day 5:
– The patient was discharged from the hospital
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Atherosclerotic heart disease with acute
coronary syndrome
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS