Simple and Complex

A CLINICAL PROBLEM-SOLVING article by Siyang Leng from University of Pittsburgh Medical Center, Pennsylvania.
A 43-year-old man presented to the emergency department with chest pain that had started 1 hour earlier and had awakened him from sleep. The pain was severe, substernal, burning, radiating to the left arm, and accompanied by nausea and vomiting.
On physical examination, he appeared to be in considerable distress, clutching his chest. Cardiac examination revealed a regular rhythm without extra heart sounds, no jugular venous distention, and no lower-extremity edema. The fasting serum glucose level was 192 mg per deciliter. An electrocardiogram showed an acute injury pattern in the anterolateral wall of the heart that was consistent with ST-segment elevation myocardial infarction (STEMI) in the territory of the left anterior descending coronary artery.
The patient underwent left-sided cardiac catheterization. Percutaneous coronary intervention of the left anterior descending artery was performed, and two drug-eluting stents were placed.
On recheck the day after the cardiac catheterization, the white-cell count was 13,800 per cubic millimeter, the hemoglobin level was 15.6 g per deciliter, and the platelet count was 610,000 per cubic millimeter. A peripheral-blood smear showed an increased number of platelets and occasional giant platelets.
This case illustrates that even a seemingly straightforward presentation of a common illness may involve a more complex underlying disorder, which, when recognized, changes the approach to the patient. [Original Article]

Further Reading

• Kardasz I, De Caterina R. Myocardial infarction with normal coronary arteries: a conundrum with multiple aetiologies and variable prognosis: an update. J Intern Med 2007;261:330-348