1. NYU Medical Grand Rounds Clinical Vignette Pansy Tsang MD PGY-2 January 31, 2012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 38 year-old male presents with chest pain for 1 hour Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 2 years ago Mr. A developed chest pain and was found to have a myocardial infarction. A bare-metal stent was placed in his mid-circumflex with resolution of chest pain. 1 month ago, chest pain returned. Mr. A had in- stent restenosis and a drug-eluting stent was placed. 2 days prior to presentation, Mr. A travelled via plane from Canada to NYC for a business trip

4. On the day of presentation, the patient reports sudden sub-sternal chest pain at rest with associated diaphoresis, shortness of breath and a 30-second syncopal episode. Pain was relieved with 3 sublingual nitroglycerin, but pain returned within a few minutes. An additional 3 sublingual nitroglycerin provided no relief. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: Coronary artery disease Non-Hodgkin’s lymphoma Doxorubicin induced cardiomyopathy Past Surgical History: Anterior cruciate ligament graft Bone marrow transplant Social History: 10 pack year tobacco history, quit 4 years ago Social alcohol use, denies drug history From Montreal, Canada. Works as an attorney. Family History: Father-MI and sudden death, age 54 Paternal Grandfather-early sudden death U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Allergies: Contrast/Iodine: urticaria Morphine: urticaria Medications: Aspirin 81mg daily Clopidogrel 75mg daily Metoprolol tartrate 25mg every 12 hours Simvastatin 20mg at bedtime Nitroglycerin Sublingual tab, 0.4mg sublingual as needed unknown chemotherapy, unknown dose or schedule U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination General: well groomed, extremely anxious middle-aged white male in moderate distress Vital Signs: T:36.6 BP:131/72 HR:108 RR:22 and O2 sat:98% on room air Mild tachycardia, smelling of tobacco Remainder of physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: Hgb 9.9. MCV 68.7 Remainder of CBC was within normal limits Basic Metabolic panel was within normal limits Hepatic panel was within normal limits Troponin <0.012 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Other Studies ECG: Sinus tachycardia 109, otherwise unremarkable Chest X-Ray: no acute cardiopulmonary findings U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Acute coronary syndrome Pulmonary embolism Non-Hodgkin’s lymphoma (mass effect, necrosis) Anxiety Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hospital Day 1: –Aspirin, clopidogrel, heparin drip, and nitroglycerin drip were initiated for ACS. –IV Hydromorphone repeatedly dosed for chest pain –Pain persisted. Premedication for contrast given in preparation for cardiac cath. –Serial EKGs unchanged. Troponin (-) x 3 –Mr. A was found repeatedly out of his room, off drips, smoking in the stairwell. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Hospital Day 2: –Cardiac catheterization deferred for low suspicion for ACS –CT chest pulmonary embolism protocol ordered, patient agreeable –On arrival to radiology, patient refused CT, refusing 20 gauge IV. –Patient agreed to ventilation/perfusion scan, but on arrival to radiology, he again refused. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Hospital Day 2 (continued): –Contact numbers for next of kin not in service –Patient is unable to provide his cardiologist’s or oncologist's contact information –Repeated elopements off the floor to smoke –Patient left against medical advice Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. Chest pain of unknown etiology vs. Malingering, drug seeking behavior vs. Factitious disorder Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS