Cairo University – Faculty of Medicine

Cardiology Department

Examination of the MD in Cardiology

May,  2000.

Commentary Case

  - A 67 year-old retired teacher presented to the emergency room for diffuse pericardial ache radiating to both shoulders that started after supper. He underwent coronary artery bypass grafting 3 years earlier, after an anteroseptal myocardial infarction. He is diabetic, has controlled hypertension, and had stopped smoking since his heart attach 3 years ago. Examination revealed a distressed obese elderly white male with a heart rate of 82/min and regular. BP was 140/100 supine, he was a febrile and cardiac examination revealed a normally located apex, S3 gallop and soft late systolic apical murmur. The electrocardiogram revealed old anteroseptal myocardial infarction with flat T and down sloping ST segment in leads I, aVL and V6.

- In hospital the pain improved after the administration of morphine sulfate, nitroglycerine infection and low molecular weight.

- The next morning, coronary angiography was performed. This revealed a patent vein graft to the left anterior descending coronary artery. there was a vein graft to the circumflex branch with multiple critically stenotic segments. Angioplasty was performed and three stents were placed. The patient was discharged (clinically compensated and angina-free) two days later. Four days after discharge the patient came back with recurrent chest pain. Examination revealed a temperature of 38.4C. cardiac physical findings and ECG abnormality were not significantly different from the findings at the previous admission. Inspection of the femoral puncture site and examination of the neck.