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NYU Medical Grand Rounds Clinical Vignette

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

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Pansy Tsang MD PGY-2 January 31, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 38 year-old male presents with chest pain for 1 hour

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS History of Present Illness • 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.

  5. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  6. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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

  7. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  8. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: Hgb 9.9. MCV 68.7 • Remainder of CBC was within normal limits • Basic Metabolic panelwas within normal limits • Hepatic panel was within normal limits • Troponin <0.012

  9. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • ECG: Sinus tachycardia 109, otherwise unremarkable • Chest X-Ray: no acute cardiopulmonary findings

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Acute coronary syndrome • Pulmonary embolism • Non-Hodgkin’s lymphoma (mass effect, necrosis) • Anxiety

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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.

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • 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

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Chest pain of unknown etiology vs. • Malingering, drug seeking behavior vs. • Factitious disorder

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