1. Medical Grand Rounds Clinical Vignette October 15 th, 2008 Srikant Duggirala, M.D.

2. 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

6. Physical Exam General: In no acute distress, appeared stated age. T:98.8 o F BP:147/70 HR:76 RR:18 O:98%RA T:98.8 o F BP:147/70 HR:76 RR:18 O 2 :98%RA 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

7. Laboratory WBC of 15.13 AST of 73 (Normal 0-40) Basic Metabolic Panel normal Urine Toxicology negative for opiates Time 0 hoursTime 8 hours Troponin0.9352.363 CK392611 CK-MB3777.8

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.

9. Working Diagnosis Non-ST Elevation Myocardial Infarction (NSTEMI)

10. 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.

11. 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.

12. Hospital Course On HD#2, 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 HD#3, he was started on a beta-blocker and ACE-inhibitor and titrated off the nitroglycerine drip.

13. 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

14. 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.

15. Final Diagnoses NSTEMI from coronary artery disease.