Patient A is white, 60 years of age, and works as a cab driver. While driving home after work, he develops an aching in his chest and slight, regular palpitations. The ache is still present when he goes to bed, when he wakes several times during the night, and when he gets up in the morning, seven hours after retiring. He drinks some soda water, but when the aching does not improve, he decides to go to the emergency department.

At the hospital, Patient A complains of chest pain accompanied by diaphoresis, slight shortness of breath, and nausea. Relief of pain is obtained with IV morphine sulfate. When the patient is admitted to the critical care unit (CCU), his symptoms are generally unremarkable except for recurrent pain.

Patient A experienced the usual childhood illnesses without rheumatic fever. As an adult, he has a history of hypertension (documented on discharge from the Army at 45 years of age and when hospitalized two years ago) that has not been treated. Past surgery includes tonsillectomy and adenoidectomy as a child. A cataract was removed from his right eye two years ago.

Patient A’s father died of an MI at 55 years of age. His mother is alive and well, although the patient does not know her age. Two brothers, 65 and 58 years of age, are alive and well. The patient lives alone and works approximately 72 hours per week. He has been married and divorced twice; the last divorce was four years ago. He has no children.

Upon admittance to the CCU, a full physical exam is conducted (Table 4). An ECG is done and shows ST elevation. Several laboratory tests are ordered, with the following results:

Based on the results of the assessment, Patient A is diagnosed with:

Patient A’s vital signs are stable for the remainder of the day, with a sinus bradycardia of 56 bpm. Early in the morning the next day, the patient awakes with nausea and diaphoresis. His blood pressure has decreased to 90/60 mm Hg with sinus bradycardia of 40 bpm. PVCs are present. The patient is treated with 0.5 mg IV atropine sulfate twice, after which his heart rate increases to 70 bpm and his blood pressure increases to 130/68 mm Hg. Unifocal PVCs are then treated with 150 mg of amiodarone IV over 10 minutes followed by an amiodarone drip at 1 mg/minute for 6 hours, then 0.5 mg/minute for 12 hours.

Later in the day, Patient A’s vital signs are:

The patient has no further chest pain, but he reports that his nausea persists after meals.

Two days later, Patient A’s LDH value rises to 310 IU/L; other enzyme levels remain essentially the same as the admission values. ECG shows ST elevation diminishing from previous levels. The amiodarone is discontinued without return of the PVCs. His vital signs remain stable, no further arrhythmias are noted, and his nausea is resolved. On day three, Patient A is moved out of the CCU and started on cardiac rehabilitation.

On day four, a treadmill test is done at 50% effort with negative results. Patient A is discharged on day seven. The medical plan is to continue treatment of his hypertension with propranolol. The patient plans to return to driving his cab, but for fewer hours per week.