NYU Medical Grand Rounds Clinical Vignette

Jennifer Lue, MD

PGY-2

9/11/2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Mr. Y is a 64 year old Chinese Male who presents with chest pain for 24 hours.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

History of Present Illness

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 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.

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• 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

Hospital Course

• ST Elevation Myocardial Infarction

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS