41y/M CP

FLMedic311

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SO you are dispatched to a 41y M pt and on arrival of a fairly clean appearing home you find the pt just past the front door, sitting on the floor half in the jacket/shoe closet. He is clearly pale cool and diaphoretic. He is a/o x4 and complains of chest and side pain. The pt sts that 4 days ago he got home from surgery where half of one of his kidneys was removed. As to why his best explanation is that it was damaged. Initial vitals are P-102 irregular, R-38 and shallow, SPO2- 91%RA, BP-90/48 BGL-112.. Feel free to ask for any additional info and of course here is your first 12 lead..
 

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captaindepth

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So the obvious to begin with.... search for any prescribed medications in the house and what are they? Is the pt on home oxygen? what is the pts diagnosed medical history? How long has the pt had chest/side pain? any other associated symptoms (i.e. dizziness, L.O.C. , extremity pain/swelling, or N/V)? Ge the pt on the stretcher w/O2 and into the ambulance. Once in the ambulance grab a 12 lead - which appears to show sinus tach around 100 bpm with frequent PVCs and other ectopy, significant ST depression throughout the anterior/lateral leads and elevation in the septal/ R sided leads.... shoot a V4R as well as posterior leads V7-V9. At this point i'm good with O2, ASA 324mg PO, ETCO2, starting a line w/ fluids running, and completing a secondary physical exam. Any significant findings on exam (lung sounds, subcutaneous air, positional discomfort, extremity edema.... etc)?

With recent surgery, chest pain, and hypoxia, P.E. is high on the list... also considering M.I. and pericarditis.
 

Eden

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In addition to what he ^ said, the ecg is very worrying. Imma jump the gun and say it seems like a significant lmca lesion.
 

SpecialK

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Oh dear, this bloke looks very sick. He needs to go to STEMI centre quickly and let the experts determine what the cause of his ticker badness is.
 

VFlutter

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Takotsubo Cardiomyopathy. Boom
 

StCEMT

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On top of what Captain asked, take a quick peek at the surgical site before strapping him in. While looking, get v7-9 back there then move to v4r. 324mg asa. Bilateral 18's and hang some fluid. Nasal cannula 2L. Go from there based on the history, physical exam, and rest of the EKGs.
 

EpiEMS

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VFlutter

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I was mostly joking since it would be rare, but not unheard of, in a younger male patient but possible with recent surgery/stress and possibility of adrenal issues presenting with what sounds like acute cardiogenic shock and global ST changes. Either that or a coronary vasospasm.
 

medichopeful

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What's the surgical site look like? Bruised? Hot? Tender/swollen? I'm a bit concerned about re-bleeding and don't necessarily want to just give this guy ASA until we dive further into this, even with the chest pain.

Left-sided EKG?
 

jaeems

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What's his LOC? Any known allergies as well? Seizure history?

Good scenario, though. Is he in pain, maybe an NSAIDS.
 

StCEMT

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Unrelated and ultimately doesn't change my treatment, buuuut...Interpretation of wenkeback yet it recorded a PRI? Que?
 

FLdoc2011

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What's the surgical site look like? Bruised? Hot? Tender/swollen? I'm a bit concerned about re-bleeding and don't necessarily want to just give this guy ASA until we dive further into this, even with the chest pain.

I agree, good pickup about possible bleeding. Post-op patient who appears in some short of shock state, bleeding always high on list.

Kidneys are retroperitoneal structures so bleeding there could cause a significant RP bleed and would certainly focus some of my exam on that area.
 
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FLMedic311

FLMedic311

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Hey all! Sorry for the late reply! Some great stuff so far. I am going to open up the door on this case now for a bit more discussion. So after further investigation you find the pt's surgical site appears to be healing appropriately, no obvious signs of infection, and the pain does not localize to the area Further PMHx includes HTN, Hyperlipid, Aortic stenosis (Not repaired), NIDDM, Hypothyroid. NKDA, medications are appropriate for Hx ( I don't have them available, and honestly don't think it is pertinent to the DDx) The pt is afebrile A/O x4 GCS-15 but as earlier stated significantly pale and diaphoretic. Further head to toe assessment does reveals JVD and lung sounds with basilar rales bilaterally. No pedal edema and good PMS. The CP is substernal non-radiating, and also sts that he feels extremely weak, and that exertion has made it worse which is why he says you found him on the floor, he says he nearly passed out. Further BP is 82/P and repeat 12 lead is as follows... Further thoughts? What do you think is going on? if I didn't clarify something well or just have additional questions fire away!!
 

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FLMedic311

FLMedic311

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The pt is also noted to be breathing rapid and shallow and sts that the pain is increased upon deep inspiration.
 

E tank

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My DD....evolving perioperative MI v. PE v. delayed post op bleed v. ascending aortic dissection v. post op pneumonia. All of which can be ruled out by CT and cath if necessary.
 

StCEMT

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I think Eden was on the right track with LMCA occlusion. I had to go dig up the other signs besides AVR elevation and that ekg is hitting them all.

  • Widespread horizontal ST depression, most prominent in leads I, II and V4-6
  • ST elevation in aVR ≥ 1mm
  • ST elevation in aVR ≥ V1
 

Eden

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Hey all! Sorry for the late reply! Some great stuff so far. I am going to open up the door on this case now for a bit more discussion. So after further investigation you find the pt's surgical site appears to be healing appropriately, no obvious signs of infection, and the pain does not localize to the area Further PMHx includes HTN, Hyperlipid, Aortic stenosis (Not repaired), NIDDM, Hypothyroid. NKDA, medications are appropriate for Hx ( I don't have them available, and honestly don't think it is pertinent to the DDx) The pt is afebrile A/O x4 GCS-15 but as earlier stated significantly pale and diaphoretic. Further head to toe assessment does reveals JVD and lung sounds with basilar rales bilaterally. No pedal edema and good PMS. The CP is substernal non-radiating, and also sts that he feels extremely weak, and that exertion has made it worse which is why he says you found him on the floor, he says he nearly passed out. Further BP is 82/P and repeat 12 lead is as follows... Further thoughts? What do you think is going on? if I didn't clarify something well or just have additional questions fire away!!
Okay so now im more confident in my inital diagonsis. This guy is in cardiogenic shock due to lmca lesion.
What i would do
Asa o2 heparin put the pads on him and hang a pressor (in my case dopamine ). full throttle to closest stemi center

Bleeding, ascending aortic dissection and such can also cause these kind of changes in the ecg. But with the patient symptoms and this specific ecg, which is very imperssive and like stcemt said it nails every point for lmca lesion, It seems to me that this is the most probable dx.
 
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