Case Discussion

History of Present Illness

A 63 year-old male presents to the emergency department after resolution of a 20minute episode of chest pain, which began while he was raking leaves. The pain was
described as a "pressure" sensation. The pain radiated down his arms and into his jaw
and was associated with palpitations and dyspnea. The pain resolved shortly after
resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10
minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or
any other associated complaints, nor is there change in the pain with inspiration or
movement. He has had no recent illnesses. His past medical history is significant for diet
controlled diabetes and hypertension. He hasn't smoked in "many years" and denies
drug use. He presently takes HCTZ and states that he is compliant. Family history is
significant for a sister who had an acute MI at age 55. He has no known allergies.
On physical examination he is an anxious, thin male who looks appropriate for age. His
vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen
saturation 94%, and temperature 37.3. His external jugular veins are not distended. He
has basilar crackles up bilaterally and his chest is nontender to palpation.
Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and nontender. His skin is dry and pink. He has equal bounding pulses in all four extremities.
The rest of his examination is unremarkable.
While in the emergency department he says that his pain is returning.
Decision Point 1
What is your differential diagnosis at this time?
a) Pneumonia
b) Pulmonary Embolism
c) Acute MI
d) GERD
e) Unstable angina
Decision Point 2
Which of the following are high-risk indicators in patients with Acute Coronary
Syndromes?
a) Diabetes Mellitus
b) Hypercontractile left ventricle
c) Lateral wall involvement
d) Pulmonary Edema
e) ST depression

Decision Point 3
Which of the following cardiac markers levels are indicated at this time?
a) Creatine Kinase
b) Myoglobin
c) Troponin
d) LDH
Decision Point 4
Which of the following tests should be performed initially on this patient?
a) D-dimer
b) Liver function tests
c) Electrolytes
d) Renal profile
e) CXR
Decision Point 5
Which pharmacotherapies are indicated at this time?
a) Oxygen
b) Nitroglycerin
c) ACE inhibitors
d) -blockers
e) Calcium channel blocker
f) Aspirin
Decision Point 6
Which of the following are used in patients with acute unstable angina?
a) Heparin (unfractionated)
b) Low molecular weight heparin (LMWH)
c) Coumadin
d) Thrombolytics such as TPA/Retivase/streptokinase
Decision Point 7
Which of the following is the mechanism of action of LMWH?
a) Prevents platelet aggregation
b) Blocks thrombin
c) Depletes factor VII
d) Activates tissue plasminogen

Decision Point 8
What is/are the possible disposition/s of this patient?
a) Home
b) CCU
c) Catheterization lab
d) Stress test
e) Observation unit