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SOB & Cough

“BRADY” DOWN FOR THE REST

History:

A 72-year-old male with a history of CAD and COPD presents to the ED for 24 hours of worsening SOB with mild cough. He denies fever, phlegm, syncope, palpitations, chest pain or other complaints.

Exam:

Vital signs are normal. Exam is normal except for mildly diminished breath sounds without rales or wheezes.

Initial differential diagnosis:

  • COPD
  • CHF
  • Pulmonary Embolism
  • Acute Coronary Syndrome

Initial EKG (click TWICE if you want to enlarge):

COMPUTER EKG READ:

  1. Sinus Rhythm
  2. Indeterminate Axis
  3. Intraventricular Conduction Delay

Do you agree with the computer?

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

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EKG ANALYSIS, CASE CONCLUSION & 1-MINUTE CONSULT: Peer Reviewed by Dr. Stephen W. Smith of Dr. Smith’s ECG Blog

  • EKG Analysis: The computer read is correct but incomplete, as it does not include that there are both concordant ST depressions and excessively discordant ST depression (two of the Smith-modified Sgarbossa criteria).  These changes were new compared to the prior EKG.  The cardiologist was paged urgently but a code STEMI was not called due to the duration of symptoms and the fact that there was no chest pain and there was cough.
  • Case Conclusion: Cardiology saw the patient and saw the patient and felt there was no indication for emergent cath.  The troponin came back undetectable after 24 hours of constant symptoms.  CXR and D-dimer was also normal.  The patient was admitted for observation and possible COPD exacerbation.  A nuclear perfusion study showed no reversible defects.
  • 1-minute Consult: See highlighted area of sample page below and Case Lessons below that.

1-Minute Consult on the EKG topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

 

 

Source: The Emergency Medicine 1-Minute Consult Pocketbook   

Case Lessons

  1. Look for Smith-modified Sgarbossa criteria with LBBB, paced rhythm and non-specific intraventricular conduction delays.
  2. Clinical presentation is key.  When the clinical presentation is less consistent with ACS then concerning EKG findings are equally less likely to be caused by ACS.  The pretest probability of coronary occlusion in any chest pain patient (whether LBBB, paced rhythm, or normal conduction) is about 2%.  Given this, if the Smith modified Sgarbossa criteria are 99% specific, then the positive predictive value is less than 50%.  The pretest probability of coronary occlusion for patients with cough and SOB is far lower. Therefore, the positive predictive value of a very specific ECG is far less than 50%.

Peer Review: Dr. Stephen W. Smith of Dr. Smith’s ECG Blog

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