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Arm Pain & SOB

UnFiNiShEd CaSe CoMe BaCk LaTeR

History: A smoker in his mid 60’s presents for left arm and left neck pain with mild SOB that started on waking.  He  denies syncope, palpitations, chest pain, fever, cough or other complaints.

Exam: Vital signs are normal as is the physical exam

An EKG is done

Computer Read: rate: 68, QRS: 98, QTc: 429 .   Junctional rhythm, abnormal ECG

What is the most likely cause of the EKG findings?

  • A) Hyperkalemia
  • B) Pulmonary Embolism
  • C) Acute coronary syndrome
  • D) COPD exacerbation

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

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

1) Quiz Answer:

  • A) Hyperkalemia: can cause junctional rhythm and maybe SOB/weakness, but not left arm pain
  • B) Pulmonary Embolism: can cause SOB, but not junctional rhythm
  • C) Acute coronary syndrome: CORRECT – can cause all 3: SOB, junctional rhythm and left arm pain
  • D) COPD exacerbation: can cause SOB but not arm pain or junctional rhythm

2) EKG/Echo analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): there are inverted P-waves in the inferior and lateral precordial leads consistent with a junctional rhythm.  There are nonspecific ST changes in lead V3.

3) Case Conclusion:  Troponin-i was <0.03  (99% URL <0.030: troponin-i immunoassay, Abbott laboratories).  The patient was admitted and had a stress test that was positive and went on to have a cardiac stent.

4) 1-Minute Consult from the Emergency Medicine 1-Minute Consult Pocketbook & Smartphone app on the topic for this case: See highlighted areas of sample page below.

5) Case Lessons: 

  1. Always
  2. Never

6) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should.  It’s long but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from emergent reperfusion and how you can pick up those patients and get them the care they need. for more information CLICK HERE

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