Case Study(CSI): Stomach flu? Anxiety? What's Going on Here?
A new case study in which the patient, A.W. a 65-year-old African American woman presents to her primary care clinic with unspecified complaints. She told the scheduler, "Something’s just not right. I want to come in and talk about it."
"My son died a month ago. He was stationed in Afghanistan. I think I'm still in shock. For the last few weeks I haven't slept well. I keep waking up in the middle of the night, my heart pounding, out of breath, and now on top of that I've been feeling nauseated. I even threw up yesterday. I wonder if I have the stomach flu. I'm just praying I don't have another migraine coming on.”
History of Present Illness
A.W. began to experience shortness of breath and racing heart approximately two weeks ago, primarily at night. Nausea began two days ago with two episodes of emesis yesterday. Admits to burning pain in her throat that she attributes to heartburn. Ms. W. has been depressed and anxious since learning of her youngest son's death. Ms. W. states she has been feeling more tired than usual, but attributes it to lack of sleep and stress over her son's death. Most recent migraine was over a month ago.
General Appearance
Looks anxious. Eyes wide, blinks a lot, shoulders tense, diaphoretic, occasionally rubs stomach just under sternum. Pt appears female, skin is brown in color, appears stated age, looks slightly overweight with weight carried around the middle.
Okay super sleuths, what's going on here? What information do you need? What would you do first? What labs do you want? What other diagnostic tests should we run? Ask me some questions!
Specializes in Education, Informatics, Patient Safety.
On 11/20/2019 at 6:13 PM, 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.
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.
Specializes in Education, Informatics, Patient Safety.
On 11/20/2019 at 7:14 PM, 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.
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.
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?
Specializes in Education, Informatics, Patient Safety.
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
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.
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.
Specializes in Education, FP, LNC, Forensics, ED, OB.
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.
Guest219794
2,453 Posts
Well?