Case 1: 79 year old male with epigastric pain
Written by: Omer A. El-Amin, MD, FACC. Interventional Cardiologist, Yakima, WA, USA Reviewed by: Seif El-Jack, MD, FRCP, FRACP, FCSANZ. Interventional Cardiologist, Auckland, New Zealand Khidir Osman, MD, FACC. Interventional Cardiologist, Yuma, AZ, USA Farouk Belal, MD, FACC. Interventional Cardiologist, FL, USA Ahmed A. Suliman, MD. Interventional Cardiologist, Khartoum, Sudan Eltahir Mohamed, MD. Interventional Cardiology Fellow, Nashville, TN, USA
History of Present Illness: A 79 yr old male presented to the Emergency Department (ED) with 1 hour history of epigastric pain . The pain came on at rest, was of moderate to severe intensity and not associated with any other symptoms. It did not radiate anywhere and was intermittent in nature. He did not notice any precipitating or relieving factors. On arrival in the ED, his pain had faded away. Physical Examination in the ED did not reveal any significant abnormalities . Investigations done in the ED included complete blood count (CBC) , basic metabolic panel (BMP); includes Na, K, urea, creatinine, HCO3, chloride; liver function test, amylase, lipase, troponin and ECG were all within normal limits. Consequently, he was discharged home after continuing to remain pain free for another hour. He then drove to another city around 2 hrs away, for scheduled business the next day. While in the hotel room, he started experiencing the same pain again, this time associated with nausea and sweating. He decided to go down to the reception in order to not be alone, and when the receptionist noted that he looked very sick, an ambulance was called to take him to the nearest ED.
Systemic Review: Negative for vomiting, melena, fever, malaise, urine discoloration.
Past History: Insignificant coronary arterial disease by angiography 15 yrs ago.
Social History: He is a physician who works in labor and industries claims at various locations. He did not smoke cigarettes or other tobacco products.
Family History: Notable for diabetes, but no history of premature heart disease or sudden death.
Drug History: Aspirin 81mg daily.
Physical Examination: Vital signs: Pulse: 55/min Respiratory rate: 16/min Blood Pressure: 118/70 mmHg. Otherwise unremarkable.
Labs: notable only for Troponin I 0.06 ng/mL (normal range 0.00 – 0.05 ng/mL)
ECG (click to enlarge)
