Rhythm Nation returns with another ECG from University Hospital of Brooklyn at SUNY Downstate Medical Center.
Case: 52-year-old man with past history of of Hypertension, Diabetes mellitus, and Hyperlipidemia who presented with chest pain.
HPI: The patient’s chest pain started two days ago, has been intermittent, and is present upon arrival in the Emergency Department. The pain is described as pressure, located substernally, and radiates to the left chest. At onset, the pain was severe but has been improving since the patient arrived. His symptoms are exacerbated by exertion and relieved by rest. He has experienced prior episodes, but they were shorter in duration, and the pain was less intense. He denies nausea, vomiting, shortness of breath, diaphoresis, abdominal pains, or history of trauma.
While in the ED, the patient has a second episode of chest pain, associated with nausea, vomiting, and diaphoresis.
ROS: No fever, chills, syncope, headache, sore throat, blurred vision, bloody or black stools, dysuria, rash, joint pains, lower extremity edema, or lymphadenopathy.
PMHx: As in HPI
SH: Denies Alcohol, Tobacco, and Illicit Drug Use.
Vital Signs: 98.2°F, 102/81 mm Hg, 90 bpm, 18 resp, 99% on RA.
General: Well Developed Male, Appears Stated Age, NAD
Eyes: PERRLA, EOMI, Normal Conjunctiva
Neck: Supple, No JVD
CVS: RRR, S1S2; No Murmurs, Rubs, or Gallops
Resp: CTA, No Wheezes, Rales, or Rhonchi, No Tenderness
Abd: Soft, NTND, No Guarding or Rebound
Back: Normal Inspection, No CVA Tenderness
Skin: No Rashes, Warm, Well Perfused
Ext: Normal ROM, No Calf Tenderness, No LE Edema
Neuro: AAOx3, CN II-XII Intact, Strength 5/5, Sensations Intact to Light Touch, No Dysmetria or Dysdiadochokinesia, Normal Gait
As the strong emergency physician that you are, you create a differential diagnosis of concerning cardiopulmonary, GI, and musculoskeletal pathology. With your differential in mind you order tests with the following results:
Trop I: 0.12 (Ref: <=0.15)
CXR: “Impression: No evidence of acute pleural or parenchymal pathology.”
This is Rhythm Nation after all, and the money is likely within the above ECG. To help crystalize your diagnosis, test your knowledge with the following questions.
- What ECG finding can be identified, and what is its pathophysiologic basis?
- What are the next steps in the treatment of this patient?
- What testing would be contraindicated given this presentation?