Page 1 This is the third hospital admission for Mr. Hotma, a 65 year old man.

Chief Complaint: Severe chest pain for 1 hour. History of Present Illness: In 200 , the patient started to have episodic !urnin" pain located in the retrosternal area and radiatin" at times to the nec# and left arm. It occurred only $ith e%ertion, after eatin" or $ith e%citement. The pain $as not influenced !y turnin", !reathin", or s$allo$in" an antacid. It never lasted lon"er than 10 minutes. It $as relieved in 2 or & minutes !y su!lin"ual nitro"lycerin or sometimes after restin" for a $hile. 'ver the course of the years, the pain attac# !ecame steadily more severe, appearin" $ith less e%ertion, up to the point of his first hospital admission, $al#in" one(half a !loc# or !rushin" his teeth $ould !rin" on the pain. The patient denied syncope, dyspnea on e%ertion, orthopnea, edema, or pain at rest. In )pril 200* he $as admitted for evaluation of these symptoms. The pertinent findin"s at that time included a normal heart !y physical e%am and %(ray. His !lood pressure $as 1+0,+0 mmH". -a!oratory data reveal a random !lood su"ar of 1 & m",dl and serum cholesterol of &2+ m".dl. ./. and urinalysis $ere normal. The electrocardio"ram demonstrated sinus rhythm, normal 01S comple%es, and chan"es consistent $ith ischemia. The patient under$ent coronary an"io"raphy $hich demonstrated si"nificant lesion in !oth ri"ht and left anterior descendin" coronary artery. In May 200*, the patient under$ent coronary an"ioplasty and a stent $as placed in the left anterior descendin" coronary artery. The post an"ioplasty course $as uneventful and the patient $as dischar"e t$o days later. He $as referred to a dietician at that time and $as advised to modify his diet. 2ollo$in" a complain of chest pain, the patient under$ent symptom(limited treadmill test in )u"ust 200+. The test $as ended in + minutes and 32 seconds !ecause of muscle fati"ue $ith ma%imum heart rate of 150 !eat per minute. He did not complain of chest pain durin" the test. The 4.5 did not sho$ any ischemic chan"es.

Page 2 He $as completely asymptomatic for the su!se6uent 1 year until one month a"o $hen he noted the return of an"ina pain $hich $as lo$ in the chest and at times in the su!%yphoid re"ion. This mornin" he developed severe effort dyspnea and today he e%perienced crushin" chest pain, perspiration, $ea#ness, and dyspnea at rest. His $ife too# him to the emer"ency room $here !lood $as dra$n for serum en7yme analysis. He had dia!etes mellitus, controlled !y oral medications, for the past & years. He still smo#in" 12 cloves ci"arettes per day. Family History: ) sister died at the a"e of 60 and a !rother died at a"e of 53 of sudden 8heart attac#9. Present Physical Examination: Temperature & o.: /lood pressure 1*0,100 mmH": ;ulse 120 !pm and re"ular: 1espiration 2*%,min. He present a moderately o!ese man complainin" of 8$ei"ht9 on his lo$er !reast !one and shortness of !reath. S#in H44=T =ec# .hest Heart )!domen < Moist < =o a!normality found < >eins not distended < ?iffuse 1ales < 4nlar"ed $ith left ventricular impulse. )n S& $as audi!le @5allop rhythmA. The first sound $as soft. =o murmurs. < -iver and spleen $ere not palpa!le

4%tremities < =o edema Routine Laboratory: B/. +,300,mm& $ith *0C polys: Hct 3 C: =aD 1& m46,-: ED 3.& m46,-: .l( 105 m46,-: H.'&( 20 m46,-: Frine< =o si"nificant findin"s. Serum .holesterol< total cholesterol 2*0 m",dl: H?- cholesterol 2 m",dl: -?- cholesterol 1*0 m",dl: tri"lyceride 2 m",dl. 2astin" /lood 5lucose< 110 m",dl

Serum 4n7yme< .E,.EM/ & hours after onset $as less than 2% normal limit, * hours after onset $as more than 2% normal limit. Chest !Ray .ardiac enlar"ement and pulmonary con"estion. EC" )n 4.5 ta#en in the emer"ency room sho$ed a sinus rate of 100 !pm. There $as "ross elevation of ST se"ment in the leads facin" the inferior surface of the heart @II, III, and a>2A. The ;(1 interval measured 0.23 seconds.

Page # He $as "iven strepto#inase 1.5 million units in the emer"ency room and immediately transferred to the coronary care unit @..FA. In the ..F, he $as treated $ith rest, elevation of the head of the !ed, nasal o%y"en 6 lt,min, morphine, aspirin, dia7epam, and furosemide inGection 0.5 m",/B. His ;(1 interval remained prolon"ed for t$o days. 1uns of three premature !eats $ere suppressed !y amiodarone inGection 150 m" follo$ed !y I> drip. He improved "radually and $as removed to the intermediate care unit on the third day.