June 2006         

ADMISSION DIAGNOSIS:  Chest pain.

DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Uncontrolled hypertension.
3. Noncompliance with medications.

PROCEDURE(S):
1. EKG.
2. Chest x-ray.
3. PCST - Pharmacologic Stress Test

HISTORY:
The patient is a 52-year-old African-American man, with a known history of hypertension and CHF, who is followed by his primary care physician (PCP), who presented to the emergency room with chest pain, associated with shortness of breath. He had had chest pain for the last two to three weeks and the pain was " achy" and had radiated to both of his shoulders and was constant and was not related to any specific aggravating or alleviating factors. He denied any lower extremity edema. He did complain of some shortness of breath with exertion, but denied any nausea, vomiting, diarrhea or abdominal pain. Denied any
fever or chills. His blood pressure in the emergency room was elevated. He also complained of generalized malaise and weakness.

PAST MEDICAL HISTORY:  Hypertension and congestive heart failure.

PAST SURGICAL HISTORY:  Right hip replacement, left knee replacement.

MEDICATIONS:  Lisinopril, Aldactone and Lasix. The patient was unsure of the dosages and also was not taking them regularly.

FAMILY HISTORY:  Noncontributory.

SOCIAL HISTORY:  Married, lives in a small town. Denied tobacco abuse, but does drink beer frequently, plus marijuana and cocaine.

PHYSICAL EXAMINATION:  blood pressure 199/111

LABORATORY DATA:  Creatinine of 1.2.; The first set of cardiac enzymes was normal.

DIAGNOSTIC DATA:  The EKG showed a normal sinus rhythm, with no acute ST or T-wave changes.
Chest x-ray was negative for any acute process. There was a question of pulmonary edema.

HOSPITAL COURSE:
The patient was admitted to the hospital and placed on telemetry. He was ruled out for an acute MI by three negative sets of cardiac enzymes. However, given the patient's past medical history, he underwent a PCST. The PCST showed an ejection fraction of 35%  (normal >50%) and it was negative for any reversible ischemia, but did show an old inferior infarct. The patient was started on metoprolol and lisinopril for his hypertension. In addition, Lasix and aldactone were restarted. The patient was counseled about medication compliance. He was given prescriptions for all his medications. Social worker was consulted for financial assistance. He was discharged home in a stable condition. A 2-D echocardiogram was scheduled for the patient to be done. The patient will follow up with his PCP in one to two weeks.

MYOCARDIAL SPECT STRESS/REST TESTING

HISTORY: 52-year-old male patient with chest pain.

INTRAVENOUS PERSANTINE STRESS/REST: The resting heart rate was 66 beats per minute and the resting blood pressure is 152/109mmHg. The resting EKG demonstrated V5, V6 leads demonstrating inverted T-waves. Otherwise normal sinus rhythm was identified. Under rest conditions the patient was injected with 57mg of intravenous Persantine. Following Persantine injection the patient's heart rate was 81 beats per minute and blood pressure was 160/113mmHg. EKG did not demonstrate any significant changes and patient reported tingling in his arms and pressure in his head and chest. At 7 minutes into the Persantine stress dose, the patient was injected with a stress dose of radiotracer and at 8.5 minutes the patient was injected with 100mg of intravenous aminophylline.

IMPRESSION: NORMAL PHYSIOLOGIC RESPONSE TO INTRAVENOUS PERSANTINE WITH NO EVIDENCE OF ISCHEMIA.

MYOCARDIAL PERFUSION IMAGING: 10.4mCi Tc 99m sestamibi was infused at rest. SPECT images of the myocardium were obtained at approximately one hour delay. At seven minutes into the Persantine stress test, patient was injected with 35.3mCi Tc 99m sestamibi and imaging sequences repeated.

FINDINGS: There is minimal decreased uptake of the radiotracer in the anterior and inferior myocardium best identified at rest. This could be related to apparent decreased uptake secondary to attenuation from the diaphragm. However, the stress images demonstrated better uptake when compared to the rest images.

IMPRESSION: INTRAVENOUS PERSANTINE MYOCARDIAL PERFUSION STUDY DEMONSTRATING NO MYOCARDIUM AT RISK.

QUANTITATIVE FUNCTIONAL IMAGING: Quantitative gated SPECT imaging demonstrated end diastolic volume of 243ml and the ejection fraction of 33%.

IMPRESSION: DECREASED LEFT VENTRICULAR EJECTION FRACTION AT 33% AND END DIASTOLIC VOLUME OF 243ML.