Medical%20Grand%20Rounds%20Clinical%20Vignette%20October%2015th,%202008

1
Medical Grand RoundsClinical VignetteOctober
15th, 2008

• Srikant Duggirala, M.D.

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Chief Complaint

• 57 year old male presents with chest pain for 12
  hours

3
History of Present Illness

• On the evening prior to admission, the patient
  reports the sudden onset of sub-sternal chest
  pain while doing housework. The pain radiated to
  the jaw and left arm. The chest pain was
  associated with mild shortness of breath,
  diaphoresis and nausea with no vomiting. He
  denied any palpitations or prior episodes of
  similar chest pain.
• He denied any recent cocaine use.
• He recalls a normal exercise stress test several
  years ago done at another hospital.

4
History

• Past Medical History
• Depression
• Asthma
• Past Surgical History
• No prior surgeries

5
History

• Social Hx
• 44 pack year history of smoking, current 1ppd
  smoker
• Smoked Cocaine for 40 years, quit 2 months ago
• Drank 5 12-ounce beers daily for 10 years. Quit 2
  months ago after completing a 10 month in-patient
  rehab program.
• Family Hx
• Father died of MI at age 65
• Allergies
• No known drug allergies
• Medications
• MVI

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Physical Exam

• General In no acute distress, appeared stated
  age.
• T98.8oF BP147/70 HR76 RR18 O298RA
• HEENT No JVD or carotid bruits noted.
• CV Normal S1 and S2. No murmurs, rubs or
  gallops.
• Pulm Clear to auscultation bilaterally
• Ext No clubbing, cyanosis or edema. 2 dorsalis
  pedis pulse and 2 femoral pulses bilaterally
• The remainder of the physical exam was normal

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Laboratory

• WBC of 15.13
• AST of 73 (Normal 0-40)
• Basic Metabolic Panel normal
• Urine Toxicology negative for opiates

Time 0 hours Time 8 hours
Troponin 0.935 2.363
CK 392 611
CK-MB 37 77.8
8
Imaging

• ECG Sinus rhythm with rate of 66, LAFB, Left
  Atrial enlargement, TWI in V4-V6
• Chest XR No evidence of pulmonary congestion or
  effusions.

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Working Diagnosis

• Non-ST Elevation Myocardial Infarction (NSTEMI)

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Hospital Course

• ED course
• Treated with
• Aspirin 325mg
• Clopidogrel 300mg
• Enoxaparin 70mg
• Morphine 4mg IVP
• Sub-lingual Nitroglycerine 0.4mg and Nitropaste
• The patient remained hemodynamically stable and
  his chest pain resolved.

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Hospital Course

• The patient was taken for a Diagnostic Cardiac
  Catheterization showing
• Mid RCA 40-50
• Distal RCA 75
• Proximal LCx of 70
• OM2 with 99
• Ventriculogram showed EF of 55 with moderate
  posterior- lateral wall hypokinesis.

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Hospital Course

• On HD2, the patient transferred to Bellevue
  Hospital CCU for rescue Percutaneous Coronary
  Intervention (PCI) of the proximal left
  circumflex and obtuse marginal lesions.
• Upon transfer, the patient developed a BP of
  190/100 and was started on nitroglycerine drip.
  He remained chest pain free.
• On HD3, he was started on a beta-blocker and
  ACE-inhibitor and titrated off the nitroglycerine
  drip.

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Hospital Course

• On HD 4, he had rescue PCI of his lesions with
  Endeavor stents.
• He remained CP free and was discharged on a
  beta-blocker, ACE-Inhibitor, Clopidogrel and
  Aspirin

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Follow-up

• He is scheduled to return to the Bellevue
  Hospital Catheterization lab in 4-6 weeks for
  elective PCI of his distal RCA lesion.
• He was also educated about smoking cessation.

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Final Diagnoses

• NSTEMI from coronary artery disease.