# 36YOM - Chest pain



## Melclin (May 27, 2013)

Case taken from another crew, presented for your opinion on the ECG particularly in regards to the elevation in II. 


Prehospital ECG





Hospital ECG approx 40 mins later.






36 YOM

3-4 day hx of cellulitis for which the pt is taking a course of abx. Nil other medical hx.

Increased stress in recent weeks. 

Sudden onset of heart burn type pain, nausea, pallor and diaphoresis. Had similar pain last night which self resolved.

HR 95, BP 149/96, SpO2 98% RA. Other obs apparently "normal".


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## VFlutter (May 27, 2013)

Interesting EKG. A subacute PE would be on my Ddx. 

On my phone it looks like a prominent R wave in lead I with some STE vs Early repolarization and inverted P&T waves in lead III. Also developing Q waves in I&aVL


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## chaz90 (May 27, 2013)

I do see S1 Q3T3, which is indicative of right ventricular strain. Curious as to the follow up.

Any old EKG for the hospital to compare?


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## NomadicMedic (May 27, 2013)

I'd also look at PE. Curious about his D-Dimer.


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## Melclin (May 27, 2013)

chaz90 said:


> I do see S1 Q3T3, which is indicative of right ventricular strain. Curious as to the follow up.
> 
> Any old EKG for the hospital to compare?



You see s1q3t3? Thats news to me. 

No old ECGs.

Will post followup when I get back to the hospital.


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## chaz90 (May 27, 2013)

Melclin said:


> You see s1q3t3? Thats news to me.
> 
> No old ECGs.
> 
> Will post followup when I get back to the hospital.



Let me take back S1. No S waves in either EKG, so I don't really know what I was looking at earlier. I do see small Q waves and inverted Ts in III though. 2/3 of a sign rounds up to a whole sign right?


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## Melclin (May 28, 2013)

chaz90 said:


> Let me take back S1. No S waves in either EKG, so I don't really know what I was looking at earlier. I do see small Q waves and inverted Ts in III though. 2/3 of a sign rounds up to a whole sign right?



Again, news to me. What are you calling a Q wave?


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## chaz90 (May 28, 2013)

I've got nothing. Upon further evaluation, I don't know how I originally saw S or Q waves in either EKG.


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## VFlutter (May 28, 2013)

I see Q waves in I and AvL? They are borderline for being pathological in EKG #1


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## chaz90 (May 28, 2013)

Yeah, but not in lead III like I initially thought.


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## Melclin (May 28, 2013)

Anyone have an opinion on lead II?


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## Ecgg (May 28, 2013)

Melclin said:


> Anyone have an opinion on lead II?



That is has no clue?  Bob Paging on you!


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## Ecgg (May 28, 2013)

Melclin said:


> Case taken from another crew, presented for your opinion on the ECG particularly in regards to the elevation in II.
> 
> 
> Prehospital ECG
> ...



Look at your leads in prehospital EKG I and AVL along with recip changes in inferior leads







Ill also leave this here






How long is duration of pain until you arrived?
History of HTN?
Smoker?
Family HX for CAD/MI?

What you give meds wise?


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## Christopher (May 28, 2013)

If there was an LA-LL swap, this ECG would look less LWMI and more pericarditis (it is odd that II and V6 look alike and I and V6 do not; but it persists from prehospital to inhospital, so it was likely obtained correctly).

Either way III is really suspicious in light of the elevation present.


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## Melclin (May 28, 2013)

Ecgg said:


> Look at your leads in prehospital EKG I and AVL along with recip changes in inferior leads
> 
> 
> How long is duration of pain until you arrived?
> ...



Not sure about the extra hx. I wasn't at the job. 

Aspirin..obviously. Pain free after 2 x 300mcg nitro. 



Christopher said:


> If there was an LA-LL swap, this ECG would look less LWMI and more pericarditis (it is odd that II and V6 look alike and I and V6 do not; but it persists from prehospital to inhospital, so it was likely obtained correctly).
> 
> Either way III is really suspicious in light of the elevation present.



The bloke who did it is pretty quick between the wickets and less likely not to notice such an error. The hospital does a completely different ECG, ie replacing the electrodes we place. So, as you say, unlikely.


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## Melclin (Jun 1, 2013)

So... sort of a disappointing follow up. Might be able to follow up again in coming days assuming anyone on the unit remembers him.

The attending paramedic called a code STEMI, but O/A at the hospital there was   some discussion about a reduction in the ST elevation and they didn't send him straight to the cath lab. Initially they were going with coronary artery spasm, but they did cath him at some stage in his ED stay. 

Angio was as clean as they come. Last I heard of him he was in CCU and everyone was shrugging their shoulders.


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## Ecgg (Jun 1, 2013)

Melclin said:


> So... sort of a disappointing follow up. Might be able to follow up again in coming days assuming anyone on the unit remembers him.
> 
> The attending paramedic called a code STEMI, but O/A at the hospital there was   some discussion about a reduction in the ST elevation and they didn't send him straight to the cath lab. Initially they were going with coronary artery spasm, but they did cath him at some stage in his ED stay.
> 
> Angio was as clean as they come. Last I heard of him he was in CCU and everyone was shrugging their shoulders.



Prinzmetal's angina for a nice zebra.

Negative on cardiac enzymes?


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## Melclin (Jun 3, 2013)

Ecgg said:


> Prinzmetal's angina for a nice zebra.
> 
> Negative on cardiac enzymes?



Perhaps. But I suppose we wont be finding out any time soon. Nobody on the unit was aware of the case when I returned a week or so later. Looks like there won't be any answers. 

No enzyme rise as far as I know, but I wouldn't hang my hat on the idea. 


Has anybody got any theories on the STE in II?


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