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  1. Case review for the forum. Good learning/teaching case Saw this guy Friday afternoon. (HPI below cut-n-pasted from my Epic ASAP note) 51 yo M c/o of low blood pressure, slow heart rate, lightheadedness. Two evenings ago he noted onset of chest pressure - "like someone sitting on my chest" with radiation to L shoulder. He attributed this to "bursitis when it gets cold" The pain/pressure lasted ~ 3 hrs and was NOT associated with any diaphoresis, SOB, lightheadedness, nausea or vomiting. Took a couple aspirin and went to bed. The next morning (yesterday) after he awoke and took his morning meds he noted some lightheadedness with slow heart rate ("in the 40s") and low BP (has home BP monitor and noted SBPs in 80s) This has persisted and although he has not had any frank syncopal episodes he states "I feel like I could pass out sometimes but I lay down and put my feet up" He currently has NO chest pain or pressure, and no shortness of breath - just occ lightheadedness Checked BG this morning @ 190 No recent illness. No recent drug additions or dosage changes Interestingly he states that "something like this occurred a couple years ago and Dr [cardiologist] did a Holter on me for a month and then a tilt table and said he couldn't find anything. Told me maybe someday I'd need a pacemaker but not right now." PMHx: HTN, DM - w/poor control & neuropathy, dyslipidemia, hypothyroid, obesity, OSA, gout, bilat knee DJD, Vit D deficiency Exam pertinent Neg & Pos: AOx3, WDWN. No distress (resting comfortably on gurney - good color) Triage VS: 126/73, P56, R20, nl temp and sats 96% Cardiovascular: RRR bradycardia (P44 on exam) S1/S2 normal wo murmur. 2+ bilat radial/DP, no JVD Pulmonary/Chest: Effort & BS normal. No respiratory distress Abdomen: soft, NTND + BS Musculoskeletal: Normal AROM. Skin: mild 1+ pitting edema BLE Neurological: AOx4, CNs grossly intact, nl gait Labs ordered & pending: CBC, BMP, Troponin Imaging: CXR AP was unremarkable So I'm wondering - as I'm sure you are - with this HPI, PMHx and exam findings, whether he had ACS (inferior/posterior MI?) two nights ago with involvement of the conduction system. He is not on a β-blocker (just nifedipine for his HTN). Obviously this guys getting admitted - and will likely get a permanent pacemaker. In the meantime I slapped him on the monitor, put pacer pads on him and had the crash cart outside the room, and while I'm doing the evaluation the nurse does the 12-lead and you can see the two attached files Something had probably gone on (2 nights previously) and something is probably going on now. Brady @ 39 and Ps marching out (CHB). Large "humpy" Ts in II, III & aVF, but with ≤ 0.5mm ST elevation (if that), and some impressive flipped Ts in I and aVL (especially in aVL) Attending (18 yr EP) & I looked at it and were impressed, but unimpressed it was a STEMI (yet) Called Cards and reviewed everything and he agreed to admit (labs still pending) and asked if I'd fax the EKG. "No problemo." 2 min after I faxed it he called - "This gentleman is having a STEMI right now so fyou should fly him up to [Mothership Memorial] for PCI right away!" We (attending and I) gave each other a quizzical look, while we looked at the EKG again, but - not wont to argue with the cardiologist on call Got him heparinized, Lipitor'ed, Plavix'ed and aspirin'ed and had the helo launched. BMP comes back with his 405 glucose and Cr of 2.34 (AKI I figure from decr renal perfusion form the decr CO), and troponin of 11. Got up to the cath lab and they found - "Subacute thrombotic occlusion (late presentation) of distal RCA/PDA and PLB. S/P successful PCI with DES (Xience 4.0x32 mm) in distal RCA and DES (Xience 2.5 x23 mm) in rPDA. Unsuccessful revascularization of the rPLB. Moderate disease in mid LAD" He's doing well so far, but I have to wonder - did I/we undercall the STEMI?
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