case of

Introduction

A 72 yo woman presents to the emergency department with a 4 day history of sharp, left-sided substernal chest pain. The pain is worse with inspiration & is relieved by sitting up. 3 weeks ago she had an ST-segment elevation myocardial infarction involving the anterior wall for which she had a drug-eluting stent placed

History

• hypertension
• depression
• diabetes mellitus type 2
• GERD
• recent myocardial infarction

Physical examination

• temperature: 38.3 C
• heart rate: 70/min
• respiratory rate: 20/min
• blood pressure: 140/70
• lungs: clear
• heart regular rate & rhythm without murmurs
  • a faint rub synchronous with the heart beat
• abdomen: benign
• no peripheral edema

Dosage

• metoprolol 25 mg PO BID
• clopidogrel 75 mg PO QD
• aspirin 81 mg PO QD
• atorvastatin 40 mg PO QD
• hydrochlorothiazide 12.5 mg PO QD
• lisinopril 10 mg PO QD
• metformin 500 mg PO BID
• glipizide 10 mg PO QD
• sertraline 100 mg PO QHS
• omeprazole 20 mg PO QD

Laboratory

• serum troponin-I is normal

Diagnostic procedures

• electrocardiogram: diffuse ST-segment elevation
• echocardiogram: small pericardial effusion

Radiology

• lungs clear, no pleural effusion

Differential diagnosis

• pericarditis
• Dressler's syndrome

Management

• colchicine (as per gout) 1.2 mg PO followed in 1 hour by 0.6 mg, then 0.6 mg PO QD + aspirin 2-4 grams/day*

* It is unclear that aspirin 2-4 gram/day is prudent in a patient on clopidogrel. Additionally, SSRIs increase risk of GI bleed, but this is allegedly mitigated by proton pump inhibitors. Hemorrhagic pericardpharmaceutical insulinitis is a complication of Dressler's syndrome in anticoagulated patients. Risk with high-dose aspirin + clopidogrel is unknown.

• Immunizations:
  • Herpes zoster vaccine
  • PCV13 & PPSV23
  • Tdap
  • influenza vaccine annually

More general terms

• case presentation