1 / 17

NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Audrey Pendleton, MD PGY2 November 29, 2011. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

oliver
Download Presentation

NYU Medical Grand Rounds Clinical Vignette

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. NYU Medical Grand Rounds Clinical Vignette Audrey Pendleton, MD PGY2 November 29, 2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Patient is a 66 year-old man who presents with a one-day history of substernal chest pain

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient was in his usual state of good health until 1996 when he developed progressive typical anginal symptoms and was diagnosed with multi-vessel coronary artery disease. • He underwent three-vessel coronary artery bypass graft.

  4. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Over several years, the patient had multiple • re-admissions for typical chest pain in the setting of poor adherence to anti-platelet medications. • He was found to have 100% occlusive disease in two grafts and diffuse obstructive coronary disease in 2006. • In 2009, he underwent percutaneous coronary intervention with drug-eluting stents to the proximal left circumflex and obtuse marginal 2, and maintained on aspirin and clopidogrel.

  5. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Three months prior to presentation, he was admitted to an outside hospital for an upper gastrointestinal hemorrhage requiring blood transfusion. • A diagnostic upper endoscopy was performed showing evidence of chronic gastritis. • He was discharged in stable condition with instructions to discontinue aspirin and clopidogrel.

  6. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient returned to his baseline of good health with unlimited exercise tolerance when on the morning of presentation while at rest, he developed substernal pressure-like chest pain, radiating to both shoulders and with associated dyspnea. • He took two sublingual nitroglycerin without relief, and subsequently called an ambulance and reported to an outside hospital.

  7. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History • Hypertension • Coronary Artery Disease • Peripheral Artery Disease • Diabetes Mellitus, Type 2 • Chronic Kidney Disease, Stage 3 • Gastritis, Upper Gastrointestinal Bleed • Past Surgical History • Three-vessel coronary artery bypass graft • Percutaneous coronary intervention with drug-eluting stents

  8. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Family History • Mother: Died of myocardial infarction, age 80 • Father: Died of myocardial infarction, age 70 • Social History • Tobacco: 22 pack year history, quit 16 years ago • Denies alcohol and illicit drugs

  9. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Medications • Ramipril 2.5mg by mouth daily • Spironolactone 25mg by mouth daily • Furosemide 20mg by mouth daily • Atenolol 50mg by mouth twice daily • Amlodipine-Benazepril 5/50mg by mouth daily • Simvastatin 20mg by mouth at night • Lansoprazole 30mg by mouth daily

  10. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Well-appearing middle-aged man in no acute distress • Vital Signs: list T:98.7 BP:155/90, HR:83, RR: 15, and O2 sat: 100%RA • Physical exam was otherwise normal

  11. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: • Hemoglobin-11.9 g/dl, hematocrit-35.9% • Chemistries: • Cr 1.7mg/dl (normal 0.1-1.4mg/dl) • Troponin-15.5 ng/ml (normal <0.059ng/ml) • CK- 545 u/L (normal 45-245u/L) • The remainder of the lab values were within normal limits

  12. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS ECG: NSR at 80bpm, flattened T waves in I, aVL, and V6 CXR: normal

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • Non-ST-elevation myocardial infarction

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 1: • At the outside hospital he was treated with aspirin, clopidogrel, metoprolol, sublingual nitroglycerin, heparin drip and normal saline. • The patient was then transferred to the Coronary Care Unit at Bellevue Hospital.

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 2-3 • The patient underwent transthoracic echocardiogram which revealed a depressed EF of 40% and hypokinesis in the inferior and lateral walls. • A cardiac catheterization was performed showing an acute 70% occlusive thrombus within the proximal left circumflex stent. • The patient was changed from heparin to bivalirudin gtt.

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Hospital Course • Hospital Day 4 to Discharge • The patient underwent repeat coronary artery catherization showing complete resolution of acute thrombus with an underlying 40% re-stenosis lesion within the proximal left circumflex artery stent. • The patient remained stable without evidence of hemorrhage on anti-platelet agents. • He was ultimately discharged home on aspirin and clopidogrel.

  17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Non-ST-elevation myocardial infarction due to acute in-stent thrombosis in the setting of discontinued anti-platelet agents

More Related