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Giving a Case Presentation in English
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Mr. Smith is a 62 year old man with coronary artery disease, diabetes, and hyperlipideamia who is transferred to our hospital for further evaluation of 3 weeks of episodic chest pain.
Mr. Smith has a long history of coronary disease, originally diagnosed 5 years ago when he presented with crescendo angina was found to have 3 vessel disease and underwent 3 vessel CABG. A myocardial perfusion scan 2 years ago revealed no evidence of ischemia.
He was in his usual state of health, without angina or other chest symptoms, until 3 weeks ago when he noticed the gradual onset of episodic chest pain and dyspnoea. He describes his chest pain as a "tightness" or "vise-like" sensation, 3-5/10, occurring once or twice daily, usually lasting minutes at a time, located deep in his left chest without radiation, mostly occurring during exertion but also occurring at rest and waking him at night, and associated with dyspnoea. This morning, while eating breakfast, he experienced a more severe version of the identical pain, 8/10, which did not resolve until 30 minutes after lying down and taking 3 nitroglycerin tablets.There is no history of fever, weight change, cough, sputum production, heamoptysis, dysphagia, or edema. The patient is a diabetic and has a strong family history of coronary disease. He does not smoke and his ldl cholesterol 6 months ago was 82.
The patient went to an outside emergency department this morning for evaluation. Although he was pain-free, his electrocardiogram revealed T wave inversion in leads 1, L, V5 and V6 which was new when compared to a tracing 1 year ago. His creatinine kinase and troponin levels were normal and he was transferred to our service for further evaluation.
His other problems include a 10 year history of diabetes mellitus, without retinopathy, neuropathy or nephropathy. An A1c 6 months ago was 6.8. His current medications include his NPH insulin, glyburide, isordil, aspirin, metoprolol, lisinopril, and simvastatin. He does not drink alcohol and has no allergies.
On physical examination, he appeared in no distress and was pain free. His blood pressure was 120/80, pulse 80 and regular, respirations 18, temperature 98.4 and oxygen saturation is 98% on 2L. There is no goiter. His lungs are clear. Estimated central venous pressure is 8 cm water. There is no precordial pulsation or chest wall tenderness. There is a left ventricular S4 but no murmurs or rubs. His abdominal examination is normal and there is no edema.
On laboratory testing, his chem 7 is normal except for a glucose of 160 and creatinine of 1.4 (his creatinine 6 months ago was 1.3). CBC was normal. CPK and troponin at admission and 8 hours later are normal. CXR revealed wires from his CABG, normal heart size, and clear lungs. ECG revealed the inverted T waves in the antero-lateral leads as previously described.
In summary, the patient has progressive episodic chest pain that is classic for crescendo angina because of its exertional nature and the patient’s known coronary disease. Pericarditis is less likely because of the absence of characteristic rub, pleuritic pain and ECG of pericarditis. Dissecting aortic aneurysm is unlikely because the pain is episodic and there is no pulse differential on examination and no widened mediastinum on CXR. Pulmonary embolism is unlikely because he has no risk factors and we have a better alternative diagnosis.
We treated him overnight as unstable angina, using enoxaparin, aspirin, and metoprolol. He had no further pain and overnight telemetry revealed only sinus rhythm. This morning’s ECG is unchanged from admission. We plan to obtain cardiac catheterization later today to better define the etiology of his pain.
Mr. Smith has a long history of coronary disease, originally diagnosed 5 years ago when he presented with crescendo angina was found to have 3 vessel disease and underwent 3 vessel CABG. A myocardial perfusion scan 2 years ago revealed no evidence of ischemia.
He was in his usual state of health, without angina or other chest symptoms, until 3 weeks ago when he noticed the gradual onset of episodic chest pain and dyspnoea. He describes his chest pain as a "tightness" or "vise-like" sensation, 3-5/10, occurring once or twice daily, usually lasting minutes at a time, located deep in his left chest without radiation, mostly occurring during exertion but also occurring at rest and waking him at night, and associated with dyspnoea. This morning, while eating breakfast, he experienced a more severe version of the identical pain, 8/10, which did not resolve until 30 minutes after lying down and taking 3 nitroglycerin tablets.There is no history of fever, weight change, cough, sputum production, heamoptysis, dysphagia, or edema. The patient is a diabetic and has a strong family history of coronary disease. He does not smoke and his ldl cholesterol 6 months ago was 82.
The patient went to an outside emergency department this morning for evaluation. Although he was pain-free, his electrocardiogram revealed T wave inversion in leads 1, L, V5 and V6 which was new when compared to a tracing 1 year ago. His creatinine kinase and troponin levels were normal and he was transferred to our service for further evaluation.
His other problems include a 10 year history of diabetes mellitus, without retinopathy, neuropathy or nephropathy. An A1c 6 months ago was 6.8. His current medications include his NPH insulin, glyburide, isordil, aspirin, metoprolol, lisinopril, and simvastatin. He does not drink alcohol and has no allergies.
On physical examination, he appeared in no distress and was pain free. His blood pressure was 120/80, pulse 80 and regular, respirations 18, temperature 98.4 and oxygen saturation is 98% on 2L. There is no goiter. His lungs are clear. Estimated central venous pressure is 8 cm water. There is no precordial pulsation or chest wall tenderness. There is a left ventricular S4 but no murmurs or rubs. His abdominal examination is normal and there is no edema.
On laboratory testing, his chem 7 is normal except for a glucose of 160 and creatinine of 1.4 (his creatinine 6 months ago was 1.3). CBC was normal. CPK and troponin at admission and 8 hours later are normal. CXR revealed wires from his CABG, normal heart size, and clear lungs. ECG revealed the inverted T waves in the antero-lateral leads as previously described.
In summary, the patient has progressive episodic chest pain that is classic for crescendo angina because of its exertional nature and the patient’s known coronary disease. Pericarditis is less likely because of the absence of characteristic rub, pleuritic pain and ECG of pericarditis. Dissecting aortic aneurysm is unlikely because the pain is episodic and there is no pulse differential on examination and no widened mediastinum on CXR. Pulmonary embolism is unlikely because he has no risk factors and we have a better alternative diagnosis.
We treated him overnight as unstable angina, using enoxaparin, aspirin, and metoprolol. He had no further pain and overnight telemetry revealed only sinus rhythm. This morning’s ECG is unchanged from admission. We plan to obtain cardiac catheterization later today to better define the etiology of his pain.