What is the workup and management for a 53-year-old male with a history of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), presenting with mental status changes, left upper extremity (UE) weakness, and chest pain while on Dapt (prasugrel)?

Differential Diagnosis for 53 yo Male with CABG and PCI

Single Most Likely Diagnosis

• Acute Coronary Syndrome (ACS) or Stent Thrombosis: Given the patient's history of CABG and PCI, and current presentation of chest pain while on DAPT (Dual Anti-Platelet Therapy), the most likely diagnosis is a new coronary event, either an acute coronary syndrome or stent thrombosis, which could also explain the mental status changes and left upper extremity weakness due to potential decreased cardiac output or embolic events.

Other Likely Diagnoses

• Cerebrovascular Accident (CVA): The patient's left upper extremity weakness and mental status changes could be indicative of a stroke, which is a common complication in patients with a history of cardiovascular disease.
• Cardiac Arrhythmia: Patients with a history of CABG and PCI are at increased risk for arrhythmias, which could lead to decreased cardiac output, resulting in mental status changes and weakness.
• Pulmonary Embolism (PE): Although less directly related to the patient's history of CABG and PCI, PE could cause chest pain and, in severe cases, lead to decreased cardiac output, resulting in mental status changes and weakness.

Do Not Miss Diagnoses

• Aortic Dissection: This is a life-threatening condition that could present with chest pain and could lead to decreased cardiac output or direct compression of cerebral vessels, causing mental status changes and weakness. It's crucial to consider this diagnosis due to its high mortality rate if missed.
• Cardiac Tamponade: This condition, which can occur post-CABG, would lead to decreased cardiac output, potentially causing the patient's symptoms. It is critical to diagnose promptly due to its high mortality rate if untreated.
• Subdural Hematoma or Intracranial Hemorrhage: Given the patient's use of DAPT, there is an increased risk of intracranial bleeding, which could explain the mental status changes and weakness.

Rare Diagnoses

• Vasculitis or Arteritis: Conditions such as giant cell arteritis or other forms of vasculitis could potentially cause the patient's symptoms, although they are less common and would require specific diagnostic testing to confirm.
• Spinal Cord Infarction: This is a rare condition but could explain the patient's weakness and mental status changes if the spinal cord is involved.