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Case 8-2007 A 48-Year-Old Man with Chest Pain Followed by

 投稿者:March 15, 2007  投稿日:2007年 3月24日(土)15時47分25秒
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  A 48-year-old man was admitted to this hospital in the early spring because of a 20-hour history of chest pain. The pain was substernal and was exacerbated when the patient was supine and inhaled deeply; it did not radiate and was not associated with shortness of breath, palpitations, nausea, or vomiting. The patient initially assumed that the pain was caused by heartburn, but it worsened overnight, and he visited his primary care physician in the morning. An electrocardiogram showed diffuse ST-segment elevation (2 to 4 mm) and PR-segment depression, and the patient was taken to the emergency department of this hospital.

He had hyperlipidemia but no history of angina, and he had previously been in good health, except for a 36-hour episode of nonbloody diarrhea 6 weeks earlier after he had eaten a chicken-salad sandwich purchased from a delicatessen. He worked in an office, was unmarried, did not smoke, and drank little alcohol. He had no recent history of travel or exposure to sick persons, pets, or other animals. He took no medications. He described the pain as 6 on a scale of 1 to 10, with higher numbers indicating worse pain.

On examination, the temperature was 37.1, the blood pressure 108/51 mm Hg, and the pulse 110 beats per minute. No cardiac murmur or pericardial rub was detected on auscultation, and the lungs were clear. The abdomen was nontender, without organomegaly. Repeated electrocardiographic examination showed the presence of diffuse ST-segment elevation and PR-segment depression (Figure 1). Aspirin, a single intravenous dose of 2.5 mg of metoprolol, and sublingual nitroglycerin were administered, and the pain decreased to 3 on the scale of 1 to 10. Results of laboratory tests are shown in Table 1. A transthoracic echocardiogram showed no pericardial effusion, left ventricular hypertrophy, or left ventricular segmental wall-motion abnormalities. The ejection fraction was normal. Treatment with ibuprofen, at a dose of 800 mg every 8 hours, was initiated, and the patient was admitted to the medical floor for observation and cardiac monitoring. Shortly after the patient arrived on the floor, specimens of blood were obtained and sent for culture.


Figure 1. Electrocardiogram Obtained at Presentation.
Widespread ST-segment elevations across the precordial and limb leads are concave upward, with PR-segment depression.

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