Chief Complaint With Question & Answer Guide (With Explanation)
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Original Question
CHIEF COMPLAINT SOB with diaphoresis and EKG en route to hospital showing 3-4 mm ST segment elevations in V4 through V6 with T-wave inversion in V4 through V6 and an inferior wall MI of indeterminate age. HISTORY OF PRESENT ILLNESS This is a 71-year-old female with a long-standing history of heart problems since the age of 48 who was admitted to the coronary care unit to rule out acute lateral wall myocardial infarction. She began developing chest pain, shortness of breath and diaphoresis about 5 days ago and was brought by ambulance, where an EKG showed ST elevation and T-wave inversion in V4 through V6 and an inferior wall MI of indeterminate age. She was started on nitrates and diltiazem with relief of her symptoms. PAST MEDICAL HISTORY Illnesses: Peptic ulcer disease, documented by endoscopy. She has a long-standing renal failure, although this has never been clearly documented in her prior hospital records, and her records from Japan are unavailable. She has an aortic aneurysm documented by abdominal CT in her most recent hospitalization, as well as previous cardiac catheterization at that time. There was no history of diabetes, cough, fever, paroxysmal nocturnal dyspnea or hypercholesterolemia. Medications: The medications she was taking at the nursing home include: Amphojel 30 mL p.o. q.i.d., Carafate 1 g q.i.d., FeSO4 325 mg t.i.d., Halcion 0.125 mg p.o. h.s. p.r.n., Pepcid 20 mg 2 q.h.s. Social history: The patient was born in the United States but lived in Japan most of her life. Family history: There is no family history of heart disease. REVIEW OF SYSTEMS Except as noted in HPI, noncontributory. PHYSICAL EXAMINATION VITAL SIGNS: Blood pressure: 130/90. Respiratory rate: 20. Heart rate: 95. Temperature: 98. HEENT: Normocephalic, atraumatic. PERRLA. Fundi positive for AV nicking and narrowing. No flame-shaped hemorrhages are seen. NECK: Supple. Jugular venous distention at 10 cm. No carotid bruits. HEART: Soft S1. Normal S2. S3 and S4 present. No murmurs. LUNGS: Coarse, wet rales to halfway up from the bases. ABDOMEN: Soft, nontender, without organomegaly. There is a 5-6 cm pulsatile abdominal mass in the right upper quadrant in the midclavicular line, just inferior to the umbilicus. NEUROLOGIC: No focal abnormalities. Cranial nerves 2-12 are intact. DATABASE The chest x-ray revealed pulmonary edema with a widened mediastinum consistent with a tortuous aorta, unable to rule out a dissection. A chest CT scan revealed evidence of dissection. She was transferred to the coronary care unit for hemodynamic monitoring and possible coronary catheterization. IMPRESSION 1. Coronary artery disease with evidence of new inferolateral wall myocardial infarction on electrocardiogram. PLAN We will restart nitrates and diltiazem and consider captopril for afterload reduction. A gated nuclear study is planned to look for focal areas of akinesia. We will continue her Lasix therapy as well.
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