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Location:
University of Louisville ER
HPI:
Mr. Harvey Mason is a 44-year-old gentleman who comes in complaining of chest pressure, shortness of breath and fatigue.
The pain began 2 hours ago when he awoke in the morning. The pain is substernal and radiates to the right shoulder. It has been coming and going for the last 3 months. Previously the pain resolved with rest for a few minutes, but now is not going away. Pain is exacerbated with activity, no alleviating factors. He has had some nausea but no vomiting. He reports no unusual activity today; he had a busy day yesterday at work. Today he awoke with the pain, so he took his medicine and started getting ready for work. When the pain was unrelieved, he decided to get evaluated.
PMH:
PSH: None
Medications:
Allergies: NKDA
Family history:
Social history: Married, has 2 grown children. He works for UPS during the daytime and as an Uber driver during his off hours. He doesn’t get much exercise, just helping people with their luggage in and out of the trunk. Mostly eats fast food while in his car. No smoking or alcohol use. No illicit drug use.
Review of systems: No sweating, fever, chills, vomiting or diarrhea. No abdominal pain or back pain. No changes with voiding or bowel movements. No skin changes. He has gained 10 pounds in the last year.
Physical Exam:
| Test | Result |
|---|---|
| T | 98.5 |
| HR | 100 |
| BP | 170/90 |
| RR | 20 |
| SpO2 | 91% |
| VAS | 9/10 |
| Height | 6'0" |
| Weight | 250 lbs |
| BMI | 34 |
Gen: Awake and alert, appears uncomfortable and mildly diaphoretic.
HEENT: NCAT. Oropharynx without erythema or exudate.
CV: Regular rate and rhythm. Possibe S3 present. No murmurs, rubs or gallops. No JVD.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended. Positive bowel sounds in all four quadrants. No epigastric tenderness
Extremities: No edema bilaterally. He has equal pulses in the radial arteries bilaterally.
MSK: Normal shoulder range of motion. No tenderness to palpation over the sternocostal margins.
The ER physician orders a 12-lead ECG and lab work STAT.
The ECG is performed demonstrates 3 mm of ST segment elevation in V2, V3 and V4 as well as ST segment depression in leads II, III and AVF.
The physician places a consult to cardiology and tells the unit clerk to activate the cardiac catheterization lab STEMI team to prepare for emergent cardiac angiography.
While coordinating with the cardiac cath team, the physician is also placing STAT orders for the following and relaying these orders to the nurse as well.
CXR report: Normal cardiac silhouette, no widening of the thoracic aorta.
| Test | Value |
|---|---|
|
WBC |
5000 |
| HgB | 14 |
| Hct |
40 |
| Platelets | 200,000 |
| Sodium | 140 |
| Potassium | 4 |
| Glucose | 89 |
| Calcium | 9 |
| Chloride | 105 |
| Bicarbonate | 24 |
| BUN | 18 |
| Creatinine | 1.1 |
| PT | 13 |
| PTT | 20 |
| Troponin | 5 |
The patient is emergently transported to the cardiac cath lab for a diagnostic angiogram/PCI.
The following images and report from the interventional cardiologist are available in the EHR after the procedure.
WATCH VIDEO CLIPS BELOW
Cardiovascular Catheterization Report
Summary Primary Indication
History
Procedures
Diagnostic Findings
Interventions
Left ventricle
Recommendations
(Avoid elective surgery while receiving a P2Y12 inhibitor)
He spends the next couple of days in the hospital learning about his heart disease and is prepared for discharge on post-procedure day 4. He is having some mild pain at the right radial artery catheterization site but not enough to warrant opiates. He elects to resume his home ibuprofen as needed.
The patient is started on a beta-blocker, an ACE inhibitor, and a statin medication. His care team assembles his paperwork for discharge home with his wife. He is referred for cardiac rehabilitation to guide his physical recovery and a registered dietician for diet and weight loss recommendations. He is instructed to call his primary care physician and a local cardiology office for follow up.
As the physician and the nurse give him his discharge instructions, he and his wife have many questions about what he should and should not be doing in the next couple weeks and how his diet and lifestyle should change following his heart attack. He asks when his heart could handle being physically intimate with his spouse again.
