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Harvey Mason: The Case

The Case

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:

  • 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 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.

  • Aspirin 325 mg  PO
  • Sublingual NTG 0.4 mg every 5 minutes for 3 doses as needed
  • Morphine 2 mg IV q 10 min prn severe pain
  • Unfractionated heparin 5000 units IV x 1
  • Clopidogrel 600 mg PO x 1
  • Atorvastatin 80mg PO x1
  • Portable CXR


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

CLIP 1: https://louisville.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=dbb31e3a-c749-45de-8e23-ac36010cdfdf

CLIP 2: https://louisville.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=eccf83b8-d872-4388-8f56-ac36010ce613

CLIP 3: https://louisville.hosted.panopto.com/Panopto/Pages/Viewer.aspx?id=567e2292-627a-4293-9450-ac36010ceb29

 

 

Cardiovascular Catheterization Report

Summary Primary Indication

  • Chest pain

History

  • A 44-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 Percutaneous coronary intervention: prox LAD, mid LCX

Diagnostic Findings

  • Left dominant
  • Prox LAD: 90%
  • mid LCX:  80%
  • OM3: 40%
  • RCA: normal

Interventions

  • Prox LAD:drug eluting stent
  • mid LCX: bare metal stent

Left ventricle

  • EF: 61%

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)


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.

Clinical Librarian

Profile Photo
Ansley Stuart
Contact:
Health Science Campus
Kornhauser Library, Rm 204
502-852-8534

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