Case Based Decision Making: A Critical Review of Interventions

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Case Based Decision Making A Critical Review of
Interventions

• Eckhard Alt, M.D.
• Robert Smith, M.D.
• Cardiac Catheterization Conference
• March 30, 2004

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Case Presentation
LC is a 94 yo white male with PMHx significant
for HTN, DM who presented on 2/18/04 with c/o
severe retrosternal chest pain. He reported that
the chest pain began approximately 4 hours prior
to presentation to the ER and awakened him from
sleep. The chest pain was initially mild but
gradually increased in severity over time,
prompting him to call EMS for transport to the
emergency room. He described the chest pain as
crushing and with radiation to the left arm.
He reported associated SOB, diaphoresis, and
nausea.
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Past Medical History

• HTN
• DM
• CRI (1.4 1.6)
• Remote h/o colon cancer s/p resection
• BPH

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Medications

• ASA 81mg
• Protonix 40mg
• Diltiazem 120mg
• Lisinopril 5mg
• 70/30 insulin

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Physical Exam

• 154/56 81 18 36.0
• NAD
• No JVD
• Normal S1S2, no murmurs
• Few basilar crackles
• Benign Abdomen
• No edema

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Labs

• Na 133
• K 4.6
• Cl 101
• CO2 24
• BUN 23
• Cr 1.8
• TP 5.9
• ALB 2.9
• AST 28
• ALT 30
• Troponin 0.13

• WBC 7.8
• HGB 12.4
• HCT 38.2
• PLT 249

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Case Presentation
KD is a 62 yo male with PMHx significant for HTN
and hyperlipidemia who presented to his primary
care physician in February of 2004 with c/o chest
discomfort. He described the chest discomfort as
retrosternal, pressure like, and without
radiation or other associated symptoms. He
reported that the discomfort had been occurring
approximately once every 2 weeks for the last 3
months and that it was not related to exertion.
Subsequently, he had an adenosine cardiolyte
stress test which showed an inferolateral
reversible defect. Because of this, he was
referred for elective LHC.
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Past Medical History

• HTN
• Hyperlipidemia

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Medications

• ASA 81mg
• Lopressor 25mg BID
• HCTZ 25mg
• Lisinopril 10mg
• Simvastatin 40mg

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Physical Exam

• 142/80 70 12 36.8
• NAD
• No JVD
• Normal S1S2, no murmurs
• Chest clear
• Abdomen benign
• No edema

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Labs

• Na 138
• K 3.9
• Cl 105
• CO2 28
• BUN 18
• Cr 0.8
• Glu 96
• Mg 2.4
• Troponin lt0.01

• WBC 4.9
• HGB 11.3
• HCT 34.0
• PLT 299

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Case Presentation
WL is a 72 yo male with PMHx significant for CAD
s/p CABG several years previously who presented
to his primary care physician with c/o chest
pain. Pt. Reported that the chest pain had begun
4-5 months prior to presentation and had been
increasing in frequency since onset. He reported
that the chest pain was squeezing in nature and
with radiation to his left arm. He reported that
it was unrelated to exertion and was not relieved
with SL NTG. He reportedly had some type of
stress test which was positive (details not
available) and was referred to the VAMC for
elective LHC.
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Past Medical History

• CAD s/p 2V CABG in the early 1990s
• HTN
• Hyperlipidemia
• S/P right CEA

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Medications

• Diltiazem 120mg
• Simvastatin 40mg

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Physical Exam

• 170/84 70 18 36.2
• NAD
• No JVD
• Normal S1S2, 2/6 SEM LUSB
• Chest clear
• Abdomen Benign
• No edema

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Labs

• Na 142
• K 3.9
• Cl 111
• CO2 25
• BUN 15
• Cr 1.2
• Glu 107
• Alb 4.0
• TP 7.9
• AST 13
• ALT 38
• Troponin lt0.03

• WBC 6.4
• HGB 13.2
• HCT 40.2
• PLT 247

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Case Presentation
RT is a 57 yo male with PMHx significant for HTN,
Hyperlipidemia, tobacco abuse who presented in
February of 2004 with c/o chest pain. He
reported that the chest pain had begun 5 days
prior to presentation and had been progressive in
frequency and severity since onset. He described
the chest pain as burning in nature with
associated tingling in his left arm. He
reported that it occurred with exertion and at
rest and was often associated with nausea. He had
tried antacids without relief of his symptoms.
On the day of his presentation, he experienced
approximately 2 hours of chest pain prior to
coming to the ER. In the ER, the chest pain was
relieved with SL NTG.
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Past Medical History

• HTN
• Hyperlipidemia
• Lower Back Pain

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Medications

• Atorvastatin 40mg
• ASA 325mg
• Atenolol 50mg

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Physical Exam

• 112/62 67 14 36.8
• NAD
• No JVD, no bruits
• Normal S1S2, no murmurs
• Chest clear
• Abdomen benign
• No edema

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Labs

• Na 140
• K 5.1
• Cl 104
• CO2 30
• Glu 156
• BUN 16
• Cr 0.9
• Alb 4.4
• TP 7.7
• AST 26
• ALT 33
• Troponin 0.23

• WBC 7.1
• HGB 16.4
• HCT 48.7
• PLT 219

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Case Presentation
JL is a 54 yo AAM with PMHx significant for DM,
HTN who presented to his primary care doctor in
January, 2004 with c/o chest discomfort. He
described the discomfort as pressure like and
with radiation to his left arm. He reported
associated SOB. He reported that the discomfort
did not occur at rest but was reliably reproduced
with walking approximately 1 block. He was
referred for exercise stress test, during which
he developed severe retrosternal chest pain with
3mm ST segment depressions inferiorly and 2mm ST
segment elevations in V1-V3. ECG returned to
baseline with rest and SL NTG. Pt was sent
upstairs for LHC.
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Past Medical History

• Poorly controlled DM
• HTN

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Medications

• HCTZ 50mg
• 70/30 insulin
• Metformin 1000mg BID
• Ramipril 10mg

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Physical Exam

• 156/82 88 20 37.0
• NAD
• No JVD, n o bruits
• Normal S1S2, no murmurs
• Chest clear
• Abdomen benign
• No edema

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Labs

• Na 137
• K 4.0
• Cl 101
• CO2 27
• Glu 146
• BUN 13
• Cr 0.9

• WBC 16.8
• HGB 15.5
• HCT 46.2
• PLT 293

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