Cardiovascular Case Study

Introduction

Steven, a 48-year-old male, presents to the office with mild-to-moderate chest pressure with radiation to his back.

Review Steven’s history, vitals, and office notes taken by your practice’s RN.

Office Notes

Steven reports that he was awakened from sleep at 7:00 a.m. with chest pressure, initially described as soreness across his anterior chest and through to his back.

His wife drove him to the office to be here when it opened at 9:00 a.m. She tried to convince Steven to go to the emergency room, but he emphatically refused, insisting on going to the office first.

Patient History

Past medical/surgery history: He was diagnosed with type II diabetes last year.
Family history: He has a family history of premature coronary artery disease. His father died of acute myocardial infarction (AMI) at age 45. One brother died of AMI at age 49.
Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother’s death 2 years ago. He has put on 25 pounds in the past 2 years and is generally sedentary.

Medications

Steven has been fairly controlled with his diet.

Metformin, 500 mg daily. His last hemoglobin A1c 2 months ago was 7.4.

He took an oral aspirin on the way to the office.

Allergies

Latex

Vitals

He is anxious and shows Levine’s sign. He is slightly diaphoretic.

Vital signs

BP: 192/96, P: 102, R: 22, T: 97.8. His SpO2 is 90%.

Diagnostic Tests

ECG

Analyze Steven's ECG to confirm his diagnosis.

Physical Exam

You enter the room after reviewing the RN’s notes in Steven’s record. You greet Steven and then ask him some questions before you begin his physical.

Now, begin Steven’s physical.

Confirming the Diagnosis

Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis? Select all that apply.

Feedback:

Here are Steven’s test results:

ECG: His stat ECG shows ST segment depression and T wave inversion in leads II and III

Troponin: 6 ng/dL

Chemistry panel:

Na, K, Cl are within normal limits (WNL);
creatinine: 0. 8;
BUN: 20;
serum glucose: 189

Differential Diagnosis

After completing Steven’s physical and diagnostic testing, what is the most likely differential diagnosis?

Feedback:

Acute coronary syndrome (ACS): Probable non-ST elevation myocardial infarction (NSTEMI): The patient has positive family history, history of diabetes mellitus, and a long smoking history, which are all risk factors for ACS. The symptoms are consistent with ACS and the ECG changes are reflective of myocardial ischemia (II, III, and aVF) lateral (V5 and V6) leads.

GERD: Steven reports feeling the need to belch. GERD can often cause chest pain or pressure; a positive smoking history and being overweight are risk factors for GERD. However, the presence of ischemia on the ECG makes a diagnosis of GERD unlikely.

Review the information and try again.

Pulmonary embolism: The sudden onset of chest pain is a hallmark sign of PE. The patient also demonstrated tachypnea, hypertension, and neck vein distension, all of which may be seen with PE. Pulmonary embolism is generally associated with more dyspnea and seldom presents with epigastric distress.

Review the information and try again.

What is your immediate plan of treatment?

Type your answers in the following text box. When you have finished, select the Submit button.

Feedback:

The immediate plan of treatment should be to call 911. Urgent transport by the EMS system to the nearest interventional cardiology service is required. The ECG demonstrates myocardial ischemia, and coupled with Steven’s symptoms, indicates a medical emergency.