Case 1

Patient presented with symptoms of…

• 21 year old male (college student)

• Felt Heaviness in chest after walking a slight incline
• Extremely short of breath, collapsed
What are all the differentials you
are thinking of at this stage?
 D/D

• ECG
• Chest X-ray
• Cardiac enzymes
What additional information
would you ask for?
 Information

• Blood Pressure= 151/99 mmHg

• Pulse= 97 bpm
• Respiration =20/minute
• Temperature= 36.60c
• Oxygen Saturation = 98%
• Regular rate & rhythm without murmurs s3 and s4
• Lungs clear of auscultation
What details will you like to
elicit in the history?
History

• Smoking history (3 years)

• Family history of CHD (maternal aunt & great
grandparents)
What follow up tests would
you like to suggest
Follow up tests

• Exercise stress testing

• ECG
 What Physical Findings are
you looking for and what will
you expect to find?
Physical Findings

• Normal sinus rhythm

• BP of 136/84 mm Hg
• Pulse 81 bpm
• Peak phase BP reached 196/80 mmHg, Pulse 176 bpm
• Exhibited chest pain, dypnea and lightheadedness
ECG
• Non sustained ventricular tachycardia
• Chest pain & dyspnea decreased during recovery phase
• ST segment depression in V5 and V6
• T wave inversion shown in aVL
• Unremarkable remaining recovery phase with normalization of ECG
What is the most important
Test you will order first and
why?
 Test
• Coronary arteriogram
• Computed coronary tomography angiography
What are your findings?
FINDINGS

ECG Findings
• Mild concentric LVH
CTA findings
• Large soft plaque in the distal LMCA extending
into the LAD coronary artery (80-90% occluded)
and LCX coronary artery (70-80% occluded)
What is your final differential
diagnosis and your most
likely diagnosis?
Coronary Atherosclerosis
Patient management and Outcome

• Left Cardiac Catheterization

• Left Ventriculography
• Due LMCA & progressive anginal symptoms, Patient had
to under go coronary bypass surgery
• Medical therapy