Feeling unwell

[SpecialK]

This is an interesting case, a real case, for you to think about.

You are responded at 3 a.m. to a 64-year-old female who is "feeling unwell". She has been feeling this way for many hours and now cannot sleep. Her husband is significantly concerned enough to call an ambulance.
She has a history of diabetes but is not on insulin and has no other specific medical history.
She takes no regular medications.
She was previously a smoker but quit earlier this year.

She is unable to describe her feeling in greater detail other than "feels very sick and tired". She has no pain that can be localised anywhere, there are no abnormalities with her physical examination and she is euglycaemic.

A 12 lead ECG is taken:

You are 45 minutes from a regional base hospital but her GP is two streets away and open at 9 a.m.

1. What further specific information do you want?
2. What is your diagnosis?
3. What treatment do you provide (if any)?
4. Does she need to be referred to another health profession? Who? When? How should she get there?

 

[chaz90]

This EKG is almost textbook for Wellen's Syndrome (sometimes called Wellen's Warning). Anterior precordial leads show significant t-wave inversion/biphasic t waves.

I don't remember the exact numbers, but Wellen's Syndrome has a very significant predictive value for proximal LAD occlusion pre-infarct.

In this case, I would try quite hard to convince the patient to allow me to transport her to the hospital. She's female, elderly-ish, a diabetic, and a former smoker, so falls into several categories of patient population that often present with vague cardiac symptoms. I would explain my reasoning based on her EKG findings and typically unremarkable health history. At 0300 for a non frequent flyer, a close family member calling because he "doesn't feel right" is concerning to me, particularly when the patient admits to feeling "very sick and tired."

Locally, I would transport this patient and provide IV access and a lab draw along with serial 12 lead EKG monitoring. I'd also administer 324 ASA due to the concerning EKG changes. In the absence of any chest pain, I'd avoid NTG, but this could change based on the preference of the ED doc, and I may at least apply some NTG paste.

EDIT: And yes, a cardiology referral is in her future.

 

[PotatoMedic]

Wellens! Off to the er with her!

Full set of vitals.
IV
325 of asa
Cardiac monitoring and serial 12 leads.

There is no St elevation but wellens is indicative of an occlusion that will soon cause major issues.

No to her to yes to the major hospital with a cardiologist.

 

[Tigger]

For once something here the same time I see it in class! Keep her away from treadmills and other stress testing...

But even without the knowledge of Wellen's Warning, the inverted and flattened t waves combined with a female patient fitting several risk factors and a minimal history would suggest to me that her GP is probably not the correct care destination for her. Here we would certainly bypass the local community access ED and head somewhere with cardiac services.

 

[Alan L Serve]

This is an interesting case, a real case, for you to think about.

You are responded at 3 a.m. to a 64-year-old female who is "feeling unwell". She has been feeling this way for many hours and now cannot sleep. Her husband is significantly concerned enough to call an ambulance.
She has a history of diabetes but is not on insulin and has no other specific medical history.
She takes no regular medications.
She was previously a smoker but quit earlier this year.

She is unable to describe her feeling in greater detail other than "feels very sick and tired". She has no pain that can be localised anywhere, there are no abnormalities with her physical examination and she is euglycaemic.

A 12 lead ECG is taken:

You are 45 minutes from a regional base hospital but her GP is two streets away and open at 9 a.m.

1. What further specific information do you want?
2. What is your diagnosis?
3. What treatment do you provide (if any)?
4. Does she need to be referred to another health profession? Who? When? How should she get there?

Source for the ECG is from Wikipedia. https://en.wikipedia.org/wiki/Wellens'_syndrome#/media/File:Wellens'_Syndrome.png

 

[SpecialK]

You guys are too good!

I hadn't heard of Wellens truth be told. For this lady I was initially leaning to referral to the GP since there were no signs of STEMI and the general clinical scenario was not strongly indicative of myocardial ischaemia. I was however quickly proven wrong!

She had 95% stenosis of her LAD and did well with one stent.

Yes, ECG is from Wiki, not the ambulance one.

 

[StCEMT]

I hadn't heard of Wellens either, this was a good read.