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ACS, GERD or both?

UnFiNiShEd CaSe CoMe BaCk LaTeR

“BRADY” DOWN FOR THE REST

EP History:  A 42-year-old male with a history of hypertension and polysubstance use presents with 3 months of intermittent central and left-sided chest pressure that is exertional and is associated with shortness of breath. Episodes occur after he walks a couple blocks and then resolve after resting for a couple minutes. In the past week these episodes are happening more frequently and are more severe

Hospitalist MDM: Patient is currently in drug and alcohol treatment center ordered by the law. Patient was evaluated emergency room with a negative troponin and EKG shows sinus rhythm without any ST-T changes. Patient was a smoker but quit.   Also reported symptoms of severe reflux disease. He is requesting specifically to have a prescription for PPI.    I do not believe patient has angina. I think patient symptoms related to his reflux disease. Patient also is some anxious side. I recommend the ER physician to repeat his a troponin. If negative discharge patient home with a PPI.

Exam: Vital signs are normal.   Exam is normal.

Initial differential diagnosis: Tachydysrhythmia, Electrolyte abnormality, Pulmonary Embolism, Acute Coronary Syndrome

Initial EKG: normal.  Repeat EKG after excercising until developing pain below

PLACE SCREEN SHOT HERE

PLACE HIGH DPI IMAGE IN BRADY-CARDIA WORD DOC

COMPUTER EKG READ:

  1. Atrial flutter with RVR
  2. minimal ST depression

Do you agree with the computer?  What should you do next?

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS: 

1) EKG analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): The computer read is

2) Case Conclusion:  tropoinin-i was >0.01 (99% URL <0.030: troponin-i immunoassay, Abbott laboratories).  The patient was admitted and had a very positive stress test

3) 1-Minute Consult (from the Emergency Medicine 1-Minute Consult Pocketbookon the topic for this case:

PLACE PAGE HERE

4) Case Lessons: 

  1. Always
  2. Never
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