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HISTORY:
PRINCIPAL DIAGNOSIS:
Dyspnea.
PROCEDURE(S):
PCST - Pharmacologic Stress Test
HISTORY OF PRESENT ILLNESS:
The patient is a 58-year-old white man with a history of
hypertension
for seven years, dyslipidemia, not on any meds who presents to the
ER
with complaints of sudden onset of shortness of breath last night
while watching TV. Reports that he started coughing and acutely
became dyspneic last night while watching TV, cough nonproductive,
shortness of breath not associated with chest pain/wheezing. Patient
came to the ER where he was given sublingual nitroglycerin times
three
and 40 mg of IV Lasix. Reports a similar episode about a week ago
lasting for two hours that relieved spontaneously. No history of
chest pain in the past. No history of MI/coronary artery disease in
the past. Reports being easily fatigued for the past week. No
complaints of dyspnea with exertion, no complaints of pedal
edema/dysuria/cough productive of sputum/nocturia. No history of
syncope/PND/orthopnea/palpitations. No history of wheezing. No
complaints of weight gain/weight loss. No complaints of
heartburn/dysphagia. History of PCST four years ago was normal. As per EMS, the patient was diaphoretic
at the scene, was given albuterol updraft times one, and placed on
100% nonrebreather. Blood pressure was found to be 160/100 with a
heart rate of 132, respiratory rate of 35, pulse oximetry 97% on
100%
nonrebreather, monitor showed sinus tachycardia.
PAST MEDICAL HISTORY:
Hypertension, dyslipidemia.
PAST SURGICAL HISTORY:
Vasectomy with reversal.
HOME MEDS:
Toprol XL 25 mg?
SOCIAL HISTORY:
Lives with wife, works as a sales person History of 50-pack
years of tobacco abuse.
ADMISSION CHEST X-RAY: Cardiomegaly with diffuse interstitial
infiltrates.
ADMISSION EKG: Sinus tachycardia, occasional PVCs with LVH, poor R
wave progression, left atrial enlargement, no previous EKG available
for comparison.
HOSPITAL COURSE:
The patient was admitted to Team 1 Cardiology and ruled out for MI
with serial cardiac enzymes. He was started on aspirin, Toprol XL 25
mg daily, an ACE inhibitor due to his LVH, and Lasix. He began to
clinically improve on these medications. Patient had a PCST
performed, which showed a fixed defect and an ejection
fraction of 23% (Normal >50%). His simvastatin was increased to 80
mg a day due to his uncontrolled hyperlipidemia and his Toprol XL
was
increased to 50 mg daily due to uncontrolled hypertension. since the
patient clinically improved, he was discharged home with close followup
in PCP's office, as well as the
cardiology clinic in four weeks. Along with an ACE inhibitor and an
increase in his metoprolol and simvastatin, spironolactone 12.5 mg
daily was also added for management of CHF to his discharge
medications.
Nuclear Medicine Report:
HISTORY: 58-year-old male with shortness of breath. Patient also
reports hypertension, congestive heart failure, smoking, and family
history of heart disease.
IV PERSANTINE STRESS: Resting heart rate was 85 beats per minute and
blood pressure was 149/100. Resting EKG showed normal sinus rhythm
with left ventricular strain. Under rest conditions, the patient was
injected with 48 mg intravenous Persantine. Post-Persantine
injection heart rate was 105 beats per minute and blood pressure was
107/102. EKG showed no significant changes, and the patient reported
no symptoms during the examination. At 7 minutes into the Persantine
stress test, patient was injected with stress dose of radiotracer.
At 9 minutes, the patient was injected with 100 mg intravenous
aminophylline.
IMPRESSION:
1. NORMAL PHYSIOLOGIC RESPONSE TO INTRAVENOUS PERSANTINE WITH NO
EVIDENCE OF ISCHEMIA.
MYOCARDIAL PERFUSION STUDY: 10.9 mCi Tc 99m Sestamibi was injected
at rest. SPECT images of the myocardium were obtained at
approximately 1 hour delay. 7 minutes into the Persantine stress
test, the patient was injected with Tc 99m Sestamibi. The imaging
sequence was repeated. There was noted a fixed defect in the
inferior wall of the myocardium. This is likely secondary to scar.
There is also noted evidence of ischemia in the anteroseptal region
and lateral wall of the myocardium.
IMPRESSION:
1. FIXED DEFECT IN THE INFERIOR WALL OF THE MYOCARDIUM, LIKELY
SECONDARY TO SCAR.
2. EVIDENCE OF ISCHEMIA IN THE ANTEROSEPTAL AND LATERAL WALL OF THE
MYOCARDIUM. THIS DEFECT IS REVERSIBLE.
QUANTITATIVE GATED SPECT: Gated SPECT imaging was performed during
the stress acquisition. The end diastolic volume was calculated at
52 cc. Left ventricular ejection fraction was calculated at 23%.
Review of CINE shows hypokinesis of the inferior wall of the
myocardium.
IMPRESSION:
1. LEFT VENTRICULAR EJECTION FRACTION CALCULATED AT 23% WITH
HYPOKINESIS OF THE INFERIOR WALL OF THE MYOCARDIUM.
DISCHARGE MEDICATIONS:
1. Lisinopril 20 mg p.o. daily.
2. Toprol XL 50 mg p.o. daily.
3. Simvastatin 80 mg p.o. nightly.
4. Spironolactone 12.5 mg p.o. daily.
5. Aspirin 81 mg p.o. daily.
FOLLOWUP:
1. Follow up for echo ASAP.
2. Follow up in PCP's office in four weeks.
3. Follow up in UAMS cardiology clinic in four weeks.
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© 2005 Nuclear Education Online
- Images courtesy of UAMS Dept of
Nuclear Medicine.
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