Acebecker Posted April 18, 2014 Share Posted April 18, 2014 Mid 50s white male comes in not feeling well. Had a URI 12 days prior to presentation. That resolved without intervention. Two days later developed n/v/d with fever up to 101.5F for 3-4 days. That resolved the day before presentation. He just doesn't feel right, so comes to urgent care. Still coughing a little bit, productively. Feeling a little weak. Mild chest discomfort across the upper chest, mildly worse when he takes a deep breath but not stabbing or point specific and not radicular. No cardiac risk factors. No fevers. VSS other than BP which is just shy of 110 systolic (normally 130 systolic). Lungs with R lower rales. Ears with a little fluid, nose draining a little bit. CXR is clear. EKG ordered "just to be thorough - it's probably nothing" and it is definitely not clear - ? inferior STEMI, but there is a lot of precordial ST segment elevation as well. Only reciprocal change is aVL with T wave inversion. Sent to ER and Troponin markedly elevated. Link to comment Share on other sites More sharing options...
primadonna22274 Posted April 18, 2014 Share Posted April 18, 2014 Flulike illnesses can be a significant strain on the heart. Guy could have had myocarditis also...which might also bump the troponins and cause funky EKG changes. Would certainly make the guy feel like crap. The diagnosis isn't clear here but the hospital is the best place to sort it all out. Link to comment Share on other sites More sharing options...
Febrifuge Posted April 18, 2014 Share Posted April 18, 2014 I love how every time I see one of these stories, I'm convinced I've killed somebody in the past 6 months. Link to comment Share on other sites More sharing options...
Guest Paula Posted April 18, 2014 Share Posted April 18, 2014 ^^^^^^^ my greatest fear. Link to comment Share on other sites More sharing options...
Maverick87 Posted April 18, 2014 Share Posted April 18, 2014 Mid 50s white male comes in not feeling well. Had a URI 12 days prior to presentation. That resolved without intervention. Two days later developed n/v/d with fever up to 101.5F for 3-4 days. That resolved the day before presentation. He just doesn't feel right, so comes to urgent care. Still coughing a little bit, productively. Feeling a little weak. Mild chest discomfort across the upper chest, mildly worse when he takes a deep breath but not stabbing or point specific and not radicular. No cardiac risk factors. No fevers. VSS other than BP which is just shy of 110 systolic (normally 130 systolic). Lungs with R lower rales. Ears with a little fluid, nose draining a little bit. CXR is clear. EKG ordered "just to be thorough - it's probably nothing" and it is definitely not clear - ? inferior STEMI, but there is a lot of precordial ST segment elevation as well. Only reciprocal change is aVL with T wave inversion. Sent to ER and Troponin markedly elevated. I've been working in family medicine for 1.5 years now (my first job). Right when I saw the bolded, I thought "EKG". No matter what my patient is complaining about, if they even mention chest pain (and, of course, I ALWAYS ask), they get an EKG. Maybe this will change when I'm more experienced, but, for now, this is how I practice lol. Haven't found an MI yet, but I've diagnosed an atypically presenting pericarditis a few times. Link to comment Share on other sites More sharing options...
physasst Posted April 18, 2014 Share Posted April 18, 2014 That'll change, or hopefully it will. I've seen many people over the years with chest pain. If it seems warranted I get an EKG, and most of them do, but if it appears predominately chest wall related pain, I don't. I tend to be super conservative though. Have I missed something in my career? I'm sure I have. I still sleep fine, because I know that rare things are rare, and I'm not going to test everyone up the hilt for a rare thing. When I worked ER, I once had a patient with classic gastroenteritis symptoms and some mild LUQ tenderness and some mild left shoulder discomfort.. Did labs, fine, gave her fluids and zofran, and she was happy. Mid 20's female. What was the problem you ask? Well, at that ER, and at that time, I needed to staff all ESI Level III patients, which she was. The physician noted the shoulder discomfort and told me to order a CT, which I refused. He said, "there have been some rare case reports of splenic infarct presenting like this"....I was like "what? seriously?, she does not have a splenic infarct"....I told him he could order the CT himself, I wasn't going to. The point is...you can get too wrapped up in the "RULE OUT EVERYTHING" stuff. My basic rule in EM, was, we would rule out the life threatening (often only with exam and VS) and common stuff, and if things got worse...well, guess what, we were open 24/7, come on back. I work in a complicated spine practice, and I find much of my day is spent explaining to people that I don't really care that much about what is on their MRI that their primary doctor ordered that they didn't need. I usually tell people that 70% of people walking around with NO symptoms will have disc pathology and abnormal findings on MR. The MR only matters in how it correlates with my exam findings. OR, the lower lumbar spinal stenosis that has no pseudoclaudicatory features, but they complain of axial back pain. Their PCP tells them that they have spinal stenosis, and that's their problem. I end up spending 45 minutes trying to explain to them that yes, they have spinal stenosis, no it's not causing their pain, and we wouldn't do anything about it, and it's the facet arthropathy that's causing their pain. The joys of my world. Link to comment Share on other sites More sharing options...
Acebecker Posted April 18, 2014 Author Share Posted April 18, 2014 physasst: very much agree. We can't be part of the problem of spending too many healthcare dollars on unnecessary stuff. EKGs are a gray area - a cheap, noninvasive test that shows a lot of information. I don't have a problem ordering this test as therapeutic - Pt is worried something is wrong so you pull out the normal EKG and their worry improves. In the case above, the physiologic stress of his illness with atypical CP warrants further w/u. Link to comment Share on other sites More sharing options...
physasst Posted April 18, 2014 Share Posted April 18, 2014 physasst: very much agree. We can't be part of the problem of spending too many healthcare dollars on unnecessary stuff. EKGs are a gray area - a cheap, noninvasive test that shows a lot of information. I don't have a problem ordering this test as therapeutic - Pt is worried something is wrong so you pull out the normal EKG and their worry improves. In the case above, the physiologic stress of his illness with atypical CP warrants further w/u. Sorry, wasn't speaking about your case, but the post above mine where the poster noted that even they even mention chest pain they get an ECG. I would have ordered an ECG in the case based on the symptoms and information you provided. Link to comment Share on other sites More sharing options...
Guest Paula Posted April 19, 2014 Share Posted April 19, 2014 Sorry, wasn't speaking about your case, but the post above mine where the poster noted that even they even mention chest pain they get an ECG. I would have ordered an ECG in the case based on the symptoms and information you provided. Physst: I tried to send you a pm and your box must be full. It is not about anything on this thread....just an idea I had about your career. Link to comment Share on other sites More sharing options...
physasst Posted April 19, 2014 Share Posted April 19, 2014 Physst: I tried to send you a pm and your box must be full. It is not about anything on this thread....just an idea I had about your career. Should have some room now. Had to delete 279 messages.....LOL. Link to comment Share on other sites More sharing options...
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