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NYU Medical Grand Rounds Clinical Vignette

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

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  1. NYU Medical Grand Rounds Clinical Vignette Jennifer Lue, MD PGY-2 9/11/2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. 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.

  3. 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.

  4. 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

  5. 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

  6. 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

  7. 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

  8. ECG: Normal Sinus Rhythm, Normal axis. Q w in I, avL, V2-V6. ST elevations in V2-V6.

  9. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Chest X-Ray: no infiltrates, effusions, consolidations

  10. Working Diagnosis • Acute Coronary Syndrome • ST Elevation Myocardial Infarction

  11. 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.

  12. 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

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • ST Elevation Myocardial Infarction

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