NYU Medical Grand Rounds Clinical Vignette

Pansy Tsang MDPGY-2

January 31, 2012

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• 38 year-old male presents with chest pain for 1 hour

Chief Complaint

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History of Present Illness

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• 2 years ago Mr. A developed chest pain and was found to have a myocardial infarction.A bare-metal stent was placed in hismid-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

• 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.

History of Present Illness

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Additional History

•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

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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

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Physical Examination

•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

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Laboratory Findings

•CBC: Hgb 9.9. MCV 68.7•Remainder of CBC was within normal limits

•Basic Metabolic panel was within normal limits

•Hepatic panel was within normal limits

•Troponin <0.012

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Other Studies

•ECG: Sinus tachycardia 109, otherwise unremarkable

•Chest X-Ray: no acute cardiopulmonary findings

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• Acute coronary syndrome

• Pulmonary embolism

• Non-Hodgkin’s lymphoma (mass effect, necrosis)

• Anxiety

Differential Diagnosis

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• 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.

Hospital Course

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• 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.

Hospital Course

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• 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

Hospital Course

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• Chest pain of unknown etiology vs. • Malingering, drug seeking behavior vs.• Factitious disorder

Final Diagnosis

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