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Kornhauser Health Sciences Library

Harvey Mason: The Case

 

The Case

 

The Case

HPI:

Mr. Harvey Mason is a 50-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:

  • GERD
  • Angina

PSH: None

Medications:

  • Omeprazole 20 mg po daily
  • Ibuprofen 400 mg po prn severe pain

Allergies: NKDA

Family history:

  • Father passed away suddenly at age 54.
  • Mother is 80 years old and healthy.

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 Data
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 labwork STAT.

The ECG is performed 8 minutes after triage and demonstrates 3 mm of ST segment elevation in leads II, III and AVF.

The physician tells the unit clerk to alert the cardiac cath lab and anticipate emergent referral for 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.

  • Aspirin 325 mg is given to the patient for him to chew
  • Sublingual NTG 0.4 mg every 5 minutes for 3 doses as needed
  • Morphine 4 mg IV q 10 min prn severe pain
  • Unfractionated heparin 4000 units IV x 1
  • Clopidogrel 600 mg po x 1
  • Portable CXR

The chest x-ray comes back reading: Normal cardiac silhouette, no widening of the thoracic aorta.

Test Data
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 report from the interventional cardiologist is available in the EHR after the procedure.

Cardiovascular Catheterization Report

Summary Primary Indication

  • Chest pain (786.50)

History

  • A 50-year old man with a history of angina and a positive family history who presents with chest pressure with radiation to the right shoulder.

Procedures

  • Left heart cath, ventriculogram, coronary angiography (93458)
  • Percutaneous coronary intervention: prox LAD, prox-mid LCX (92928, 92929)
  • Intra-aortic balloon pump (33967)

Vascular Access

  • Location: right radial artery, right femoral artery
  • Sheath: 5Fr (right radial), 6Fr (right femoral)

Diagnostic Findings

  • Coronary arteries
  • Left dominant
  • Prox LAD: 90%
  • Prox-mid LCX: diffuse 80% OM3: 60%
  • RCA: normal

Interventions

  • Prox LAD: Brand X 3.0mm x 18mm (drug eluting) stent: 90% pre to 0% post
  • Prox-mid LCX: Brand Y 3.0mm x 28mm (bare metal) stent: diffuse 80% pre to 10% post

Left ventricle

  • EF: 61%
  • MR: 1+ mild
  • Wall motion: mild anterior hypokinesis, moderate apical hypokinesis

Impressions

  • 2 vessel coronary artery disease
  • Successful PCI x2

Recommendations

  • Risk factor modification
  • Routine post-PCI care
  • Refer for cardiac rehab
  • Aspirin 81 mg lifelong
  • P2Y12 inhibitor for at least 6 months
  • Avoid elective surgery while receiving a P2Y12 inhibitor

FMC-device time was 80 minutes. "Percutaneous

He spends the night in the hospital and is prepared for discharge the following day. He is having some mild pain at the right femoral artery catheterization site but not enough to warrant narcotics. He elects to resume his home ibuprofen as needed.

The patient is started on a beta-blocker, an ACE inhibitor, an aldosterone antagonist and a statin medication. His care team assembles his paperwork for discharge home with his wife. 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 is referred for cardiac rehabilitation to guide his physical recovery and a nutritionist for diet and weight loss recommendations. He is instructed to call his primary care physician and a local cardiology office for follow up.

Two months after discharge he presents in follow up to see his primary care doctor. He appears well and is proud to talk about the positive lifestyle changes he has made to improve his health. He is being consistent with his cardiac rehab and is regularly seeing the nutritionist. His insurance provided him with an electronic scale and fitbit to help him monitor his weight and activity level; he visits with an online coach once a month regarding his progress. He feels like this heart attack was a real wake-up call for him.

He has returned to work and resumed driving, but he is going easier on himself and his schedule. He is making time for exercise and eating a healthier diet.

He reports that this health scare has taken a bit of a toll on his family life. He asks if it is time that his heart could handle being physically intimate with his spouse again.

 

Clinical Librarian

Vida Vaughn

Vida Vaughn

Clinical Librarian / Assistant Director

Kornhauser Health Sciences Library

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