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Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine. http://clinicalcorrelations.org. Medical Grand Rounds Clinical Vignette December 17 th , 2008. Anjali Grover, M.D. Chief Complaint. A 45 year old Hispanic male presents with chest pain for 45 minutes.

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Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

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  1. Clinical Correlations The NYU Internal Medicine BlogA Daily Dose of Medicine http://clinicalcorrelations.org

  2. Medical Grand RoundsClinical VignetteDecember 17th, 2008 Anjali Grover, M.D.

  3. Chief Complaint • A 45 year old Hispanic male presents with chest pain for 45 minutes.

  4. History of Present Illness • The patient was well until the evening of admission when he had the sudden onset of non-radiating, sub-sternal chest pressure while walking. • The chest pain was associated with shortness of breath, light-headedness, palpitations, diaphoresis and nausea without vomiting.

  5. Additional History • Past Medical History: • Hyperlipidemia • Depression • Past Surgical History: none • Social history: • Current smoker with a 25 pack year history • Denies ethanol or illicit drug use • Family History: • Mother died of a myocardial infarction at age 76 • Allergies: • No known drug allergies • Medications: -- Simvastatin 40 mg daily -- Aspirin 81 mg daily -- Fluoxetine 20 mg daily

  6. Physical Exam General:In mild distress appearing anxious secondary to chest pain, appeared his stated age. T:97.1oF BP:159/82 HR:84 RR:16 O2:97%RA The remainder of the physical exam was normal

  7. Laboratory • Basic Metabolic Panel normal • Complete Blood Count normal • Hepatic Function Panel normal

  8. Imaging • ECG: Sinus rhythm with rate of 63, 2 mm ST elevation in V2, 1 mm up-slanting ST depression in II, III, aVf. • Chest X-Ray: No evidence of pulmonary congestion, infiltrate or effusions.

  9. Working Diagnoses • Acute Coronary Syndome: ST Elevation Myocardial Infarction (STEMI) • Brugada Syndrome

  10. Hospital Course • Emergency Room course: • Treated with: • Aspirin 325mg • Clopidogrel 300mg • Lopressor 5 mg IVP x 3 • Morphine 4mg IVP • Sub-lingual Nitroglycerine 0.4mg x 3 • Heparin drip • Lipitor 80 mg • The patient remained hemodynamically stable, EKG changes were stable and his chest pain resolved.

  11. Hospital Course • Hospital Day #1: • Cardiac Catheterization revealed clean coronary arteries • Transthoracic Echocardiogram showed no abnormalities • Hospital Day #2: • Procainamide challenge performed to evaluate for possible manifestations of Brugada Syndrome on EKG. • With procainamide, the patient’s 2mm “saddle-back” ST segment elevation in V2 converted to a “coved” ST segment elevation pattern. • These findings represented a positive procainamide challenge.

  12. Hospital Course • Hospital Day #3: • Electrophysiology Study performed for further risk stratification revealed no inducible ventricular arrhythmias. • Intracardiac defibrillator placement was recommended to the patient, but he refused. • He was discharged on Aspirin and Zocor. • 6 months later on follow-up in Cardiology Clinic, the patient agreed to ICD placement. It was placed shortly thereafter.

  13. Final Diagnosis • Type 2 Brugada Syndrome

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