A 63-year-old man who developed severe abdominal pain after thrombolytic therapy.

Case History (Glenn McDonald, MD) A63-year-old white man with no significant past medical history presented to an outlying hospital with a chief complaint of substernal chest discomfort. The patient was in his usual state of health until ~1 to 2 months before admission, when he noticed generalized increased fatigue with exertion. One day before admission at ~5:30 PM, he developed a nonradiating substernal chest discomfort that was described as a severe pressure sensation with associated nausea, diaphoresis, and dizziness. He denied any vomiting or dyspnea. This discomfort persisted for %3 hours and was markedly decreased after taking two sublingual nitroglycerin tablets. He subsequently had similar intermittent episodes of substernal chest discomfort occurring every 45 to 60 minutes and lasting 10 to 15 minutes. These episodes were associated with diaphoresis but would spontaneously resolve. At 2:30 AM, he then had an episode of severe chest pain with associated nausea and diaphoresis that lasted for ~30 minutes and spontaneously resolved. He continued to have transient episodic chest pressure lasting :10 to 15 minutes, which would spontaneously resolve throughout the night. The morning of admission he called his physician and went to an outlying hospital. He specifically denied any history of orthopnea, paroxysmal nocturnal dyspnea, pedal edema, increased abdominal girth, fever, chills, cough, nausea, vomiting, diarrhea, melena, abdominal pain, or dysuria. He also denied any prior history of chest discomfort, bleeding disorders, headaches, visual changes, trauma, or preexisting illness. He had been told in the past that his cholesterol and triglycerides were elevated, but he denied any prior history of diabetes mellitus, hypertension, tobacco use, or family history of coronary artery disease. He has no drug allergies and was on no medication before admission. The patient's initial ECG was significant for nonspecific ST changes, and he was then admitted to the cardiac care unit. He was placed on continuous infusion of heparin and nitroglycerin, aspirin, and a calcium channel blocker. The patient was rendered pain free. Serial cardiac enzymes were not elevated, and his ECG