Mr. Smith is a 62 year old man with coronary artery disease, diabetes, and hyperlipidemia who is transferred to our hospital for further evaluation of 3 weeks of episodic chest pain.

Mr. Smith has a long history of coronary disease, originally diagnosed 5 years ago when he presented with crescendo angina was found to have 3 vessel disease and underwent 3 vessel CABG. A myocardial perfusion scan 2 years ago revealed no evidence of ischemia. He was in his usual state of health, without angina or other chest symptoms, until 3 weeks ago when he noticed the gradual onset of episodic chest pain and dyspnea.

He describes his chest pain as a “tightness” or “vice-like” sensation, 3-5/10, occurring once or twice daily, usually lasting minutes at a time, located deep in his left chest without radiation, mostly occurring during exertion but also occurring at rest and waking him at night, and associated with dyspnea. This morning, while eating breakfast, he experienced a more severe version of the identical pain, 8/10, which did not resolve until 30 minutes after lying down and taking 3 nitroglycerin tablets.

There is no history of fever, weight change, cough, sputum production, hemoptysis, dysphagia, or edema. The patient is a diabetic and has a strong family history of coronary disease. He does not smoke and his ldl cholesterol 6 months ago was 82. The patient went to an outside emergency department this morning for evaluation. Although he was pain-free, his electrocardiogram revealed T wave inversion in leads 1, L, V5 and V6 which was new when compared to a tracing 1 year ago. His troponin level was normal and he was transferred to our service for further evaluation. His other problems include a 10 year history of diabetes mellitus, without retinopathy, neuropathy or nephropathy. An A1c 6 months ago was 6.8. His current medications include glargine insulin, isosorbide mononitrate, aspirin, metoprolol, lisinopril, and atorvastatin. He does not drink alcohol and has no allergies. On physical examination, he appeared in no distress and was pain free. His blood pressure was 120/80, pulse 80 and regular, respirations 18, temperature 98.4 and oxygen saturation is 98% on 2L. There is no goiter. His lungs are clear. Estimated central venous pressure is 8 cm water. There is no precordial pulsation or chest wall tenderness. There is a left ventricular S4 but no murmurs or rubs.

His abdominal examination is normal and there is no edema. On laboratory testing, his metabolic panel is normal except for a glucose of 160 and creatinine of 1.4 (his creatinine 6 months ago was 1.3). CBC was normal. Troponin at admission and 8 hours later is normal. CXR revealed wires from his CABG, normal heart size, and clear lungs. ECG revealed the inverted T waves in the anterolateral leads as previously described.

Mr. Smith is a 62 year old man with coronary artery disease, diabetes, and hyperlipidemia who is transferred to our hospital for further evaluation of 3 weeks of episodic chest pain.

Mr. Smith has a long history of coronary disease, originally diagnosed 5 years ago when he presented with crescendo angina was found to have 3 vessel disease and underwent 3 vessel CABG. A myocardial perfusion scan 2 years ago revealed no evidence of ischemia. He was in his usual state of health, without angina or other chest symptoms, until 3 weeks ago when he noticed the gradual onset of episodic chest pain and dyspnea.

He describes his chest pain as a “tightness” or “vice-like” sensation, 3-5/10, occurring once or twice daily, usually lasting minutes at a time, located deep in his left chest without radiation, mostly occurring during exertion but also occurring at rest and waking him at night, and associated with dyspnea. This morning, while eating breakfast, he experienced a more severe version of the identical pain, 8/10, which did not resolve until 30 minutes after lying down and taking 3 nitroglycerin tablets.

There is no history of fever, weight change, cough, sputum production, hemoptysis, dysphagia, or edema. The patient is a diabetic and has a strong family history of coronary disease. He does not smoke and his ldl cholesterol 6 months ago was 82. The patient went to an outside emergency department this morning for evaluation. Although he was pain-free, his electrocardiogram revealed T wave inversion in leads 1, L, V5 and V6 which was new when compared to a tracing 1 year ago. His troponin level was normal and he was transferred to our service for further evaluation. His other problems include a 10 year history of diabetes mellitus, without retinopathy, neuropathy or nephropathy. An A1c 6 months ago was 6.8. His current medications include glargine insulin, isosorbide mononitrate, aspirin, metoprolol, lisinopril, and atorvastatin. He does not drink alcohol and has no allergies. On physical examination, he appeared in no distress and was pain free. His blood pressure was 120/80, pulse 80 and regular, respirations 18, temperature 98.4 and oxygen saturation is 98% on 2L. There is no goiter. His lungs are clear. Estimated central venous pressure is 8 cm water. There is no precordial pulsation or chest wall tenderness. There is a left ventricular S4 but no murmurs or rubs.

His abdominal examination is normal and there is no edema. On laboratory testing, his metabolic panel is normal except for a glucose of 160 and creatinine of 1.4 (his creatinine 6 months ago was 1.3). CBC was normal. Troponin at admission and 8 hours later is normal. CXR revealed wires from his CABG, normal heart size, and clear lungs. ECG revealed the inverted T waves in the anterolateral leads as previously described.

Mr. Smith is a 62 year old man with coronary artery disease, diabetes, and hyperlipidemia who is transferred to our hospital for further evaluation of 3 weeks of episodic chest pain.

Mr. Smith has a long history of coronary disease, originally diagnosed 5 years ago when he presented with crescendo angina was found to have 3 vessel disease and underwent 3 vessel CABG. A myocardial perfusion scan 2 years ago revealed no evidence of ischemia. He was in his usual state of health, without angina or other chest symptoms, until 3 weeks ago when he noticed the gradual onset of episodic chest pain and dyspnea.

He describes his chest pain as a “tightness” or “vice-like” sensation, 3-5/10, occurring once or twice daily, usually lasting minutes at a time, located deep in his left chest without radiation, mostly occurring during exertion but also occurring at rest and waking him at night, and associated with dyspnea. This morning, while eating breakfast, he experienced a more severe version of the identical pain, 8/10, which did not resolve until 30 minutes after lying down and taking 3 nitroglycerin tablets.

There is no history of fever, weight change, cough, sputum production, hemoptysis, dysphagia, or edema. The patient is a diabetic and has a strong family history of coronary disease. He does not smoke and his ldl cholesterol 6 months ago was 82. The patient went to an outside emergency department this morning for evaluation. Although he was pain-free, his electrocardiogram revealed T wave inversion in leads 1, L, V5 and V6 which was new when compared to a tracing 1 year ago. His troponin level was normal and he was transferred to our service for further evaluation. His other problems include a 10 year history of diabetes mellitus, without retinopathy, neuropathy or nephropathy. An A1c 6 months ago was 6.8. His current medications include glargine insulin, isosorbide mononitrate, aspirin, metoprolol, lisinopril, and atorvastatin. He does not drink alcohol and has no allergies. On physical examination, he appeared in no distress and was pain free. His blood pressure was 120/80, pulse 80 and regular, respirations 18, temperature 98.4 and oxygen saturation is 98% on 2L. There is no goiter. His lungs are clear. Estimated central venous pressure is 8 cm water. There is no precordial pulsation or chest wall tenderness. There is a left ventricular S4 but no murmurs or rubs.

His abdominal examination is normal and there is no edema. On laboratory testing, his metabolic panel is normal except for a glucose of 160 and creatinine of 1.4 (his creatinine 6 months ago was 1.3). CBC was normal. Troponin at admission and 8 hours later is normal. CXR revealed wires from his CABG, normal heart size, and clear lungs. ECG revealed the inverted T waves in the anterolateral leads as previously described.