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NYU Medical Grand Rounds Clinical Vignette. Jennifer Lue, MD PGY-2 9/11/2012. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Mr. Y is a 64 year old Chinese Male who presents with chest pain for 24 hours.

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nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Jennifer Lue, MD

PGY-2

9/11/2012

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

chief complaint

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

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

history of present illness

History of Present Illness

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 illness1

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
additional history

Additional History

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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
physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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
laboratory findings

Laboratory Findings

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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
other studies

Other Studies

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • Chest X-Ray: no infiltrates, effusions, consolidations
working diagnosis
Working Diagnosis
  • Acute Coronary Syndrome
  • ST Elevation Myocardial Infarction
slide11

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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.
slide12

Hospital Course

  • 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
slide13

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Final Diagnosis

  • ST Elevation Myocardial Infarction