Case Study(CSI): Stomach flu? Anxiety? What’s Going on Here?

8 hours ago, SafetyNurse1968 said:

Thank you for reading and commenting! Here are the pertinent labs and vital signs:

Vital signs:

BP 160/98 RA sitting

HR 105

RR 18

T 98.2oF

HT 5’6”

WT 170 lbs

BMI 27.4

 

Laboratory Test Results:

Na 133 meg/L

K 4.3 meq/L

Cl 101

HCO3

BUN 14 mg/dL

Cr 0.9 mg/dL

Glucose, fasting 264 mg/dL

Mg 1.9

PO4 2.3

Cholesterol 213

Triglycerides 174

LDL 143

HDL 34

CPK 99 IU/L

CK-MB 6.3 IU/L

Troponin I 0.3 ng/mL

Hb 12.2 g/dL

Hct 40%

WBC 4,900/mm3

Plt 267,000/mm3

HbA1c 8.7%

 

Arterial Blood Gas

pH 7.42

PaO2 90 mm

PaCO2 34 mm

SaO2 96.5%

You got it (and thanks for reading and asking!)

Electrocardiogram:  4 mm ST segment elevation in leads V2-V6

Well?

2 minutes ago, hherrn said:

Well?

I'm sorry,  I don't have an actual ECG I can send you...Only the description: 4 mm ST segment elevation in leads V2-V6. Also there's tachycardia, and an occasional premature beat. 

I hope that will work for you!

 

This patient is a walking advertisement for an atypical MI, and had ST elevation in multiple contiguous leads.  I am not clear why she isn't on the cath table.

Also- the trop- there are different scales.  Our cut off is 0.045, so that trop would be positive.

Am I misreading something here?

 

1 hour ago, hherrn said:

This patient is a walking advertisement for an atypical MI, and had ST elevation in multiple contiguous leads.  I am not clear why she isn't on the cath table.

Also- the trop- there are different scales.  Our cut off is 0.045, so that trop would be positive.

Am I misreading something here?

 

I’m not sure what you mean by missing something, it’s just supposed to be for fun. It sounds like your level of cardiac diagnostic skills is potentially higher than mine. 

The reason I asked if I missed something is-

Even without the history, ST elevation is the hallmark sign of an MI. Chest pain, nausea and palpitations are hallmark symptoms. While there can be other causes, none seem obvious.

65 y/o overweight female experiencing high stress levels with chest pain, palpitations and nausea with ST elevation is a STEMI, barring any other convincing explanation.  The elevation could be a repolarization abnormality, but nothing points that way.  The trop is a bit confusing- there are different reference scales- Absolutely positive on 1, negative on the other.

So- since nobody else offered STEMI on this pt with ST elevation and MI symptoms, I thought maybe I was missing something.

Agree with a previous request for an echo. 

Where I work, a patient with pain/symptoms that are plausibly cardiac in nature and substantial st elevations on 12 lead ecg would likely be whisked away to the cath lab, even if the overall picture suggests... something else. Where is that echo tech anyway?

54 minutes ago, hherrn said:

The reason I asked if I missed something is-

Even without the history, ST elevation is the hallmark sign of an MI. Chest pain, nausea and palpitations are hallmark symptoms. While there can be other causes, none seem obvious.

65 y/o overweight female experiencing high stress levels with chest pain, palpitations and nausea with ST elevation is a STEMI, barring any other convincing explanation.  The elevation could be a repolarization abnormality, but nothing points that way.  The trop is a bit confusing- there are different reference scales- Absolutely positive on 1, negative on the other.

So- since nobody else offered STEMI on this pt with ST elevation and MI symptoms, I thought maybe I was missing something.

Oh I see now why you were confused, we’re actually asking folks to not post their guesses here but to put them on the admin site

Got it.

No guess here.

Send this PT to the cath lab, let me know how it works out.

Unless there is an interpretation of this EKG showing an explanation for ST elevation other than MI, she needs a cath and probably a stent.

OTOH, if the 0.3 trop is negative, and the ST elevation is read by a qualified clinician as early repolarization, or something else non-clinical, we are back to guessing.

Hi hhern,

I definitely agree with your suggestion. I had another idea for dx, so I posted in the Admin area....not sure if I'm right or wrong...lol

31 minutes ago, hherrn said:

Got it.

No guess here.

Send this PT to the cath lab, let me know how it works out.

Unless there is an interpretation of this EKG showing an explanation for ST elevation other than MI, she needs a cath and probably a stent.

OTOH, if the 0.3 trop is negative, and the ST elevation is read by a qualified clinician as early repolarization, or something else non-clinical, we are back to guessing.

There are some conditions that can at times cause significant st elevation thats neither an mi nor benign early repolarization. 

I do agree that whether or not an mi is actually the most likely diagnosis, most symptomatic patients with significant precordial st elevation would wind up in the Cath lab. 

How do you post an answer in the admin help desk? Just make a new topic and then it disappears or something?

As I recall, you click the Admin Link at the very beginning of the Case and post your dx there. You need to be signed in to do this. Good Luck! I don't want to say what I'm thinking here as we are not supposed to post the dx in the discussion area.

42 minutes ago, Cowboyardee said:

There are some conditions that can at times cause significant st elevation thats neither an mi nor benign early repolarization. 

I do agree that whether or not an mi is actually the most likely diagnosis, most symptomatic patients with significant precordial st elevation would wind up in the Cath lab. 

How do you post an answer in the admin help desk? Just make a new topic and then it disappears or something?

We replied to you in the thread you started in the Admin Office, @Cowboyardee. Thanks.