Here’s a formula – and an app – to help you catch this easy-to-miss diagnosis
A 37-year-old man presented to the emergency department with severe
respiratory distress. He reported a history of hypertension, diabetes
and end-stage renal failure for which he received hemodialysis three
times per week. However, he admitted to missing his last two dialysis
A 39-year old female presents to our emergency department with
complaints of “worsening of heartburn”. The patient states that for
several months she has had episodic indigestion and chest discomfort.
She has been taking antacids for several weeks as prescribed by her
family doctor without improvement.
"I think my child has swan flu!” You pause and try your hardest to maintain that poker face you’ve perfected. “I saw it on the news,” she continues, “and then my daughter was at Disney World running around with all these swans yesterday. I think they were contagious!”
What does the EKG show? What should you do next?
Although these CDRs summarize what you should be looking for, regarding history, physical examination and diagnostic criteria that put your patients at risk for ACS, they come up short on real-world application. The value, in my opinion, is knowing what those risky elements are, as opposed to actually calculating a TIMI score.
Chest pain is a diagnostic dilemma for the emergency physician. Data
from the United States suggest that 2.1% of patients with acute
myocardial infarction and 2.3% of patients with unstable angina are
misdiagnosed. Information obtained from the history, the initial 12-lead
ECG, and a single set of cardiac markers does not have sufficient
sensitivity to identify those patients who are safe for early discharge.
A hemodynamically stable middle-aged male presents to your ED with
non-pleuritic chest pain and multiple cardiac risk factors. Your
diagnostic evaluation includes includes a Troponin-I which unfortunately returns at 0.5
ng/mL, although no ECG changes are noted.
A 40-year-old male presents to the ED after a syncopal episode. In his past medical history he relates a history of frequent debilitating “dizzy spells”. After reviewing his ECG your interpretation/advice is...