chbare Posted April 18, 2010 Share Posted April 18, 2010 I thought I would present an interesting case based on one of my Afghanistan experiences. I'll see what you guys think. You are pulling clinic duty out in the middle of nowhere when a 36 year old male presents to the clinic with complaints of sudden onset chest pain. Take care, chbare. Link to comment Share on other sites More sharing options...
spenac Posted April 18, 2010 Share Posted April 18, 2010 HX, Has this happened before? Meds? Vitals? EKG, 12 and 15 lead? Blood glucose level? Skin color, moisture, etc? Lung and heart sounds? Link to comment Share on other sites More sharing options...
chbare Posted April 18, 2010 Author Share Posted April 18, 2010 He is alert, awake, and oriented with a patent airway. Pmhx: appy about 5 years ago No allergies/intolerances, no meds, smoker about 10 pack years, 2-3 drinks a night, dad has DM HPI: Sudden onset chest pressure about 10 minutes ago while entering data on his computer, first time he's ever felt this way, no C/O stress or anxiety, "just started all the sudden." ROS: anxious, complains of chest pressure at about 7/10, otherwise unremarkable VS: p-94 rrr, 22 non laboured, 160/88, 97% RA, PE: Fairly unremarkable, lungs clear, S1S2, no JVD or edema, belly soft and non tender, neuro status intact, obese with a BMI ~ 30 Take care, chbare. Link to comment Share on other sites More sharing options...
DartmouthDave Posted April 18, 2010 Share Posted April 18, 2010 Hello, A BMI of 30. Must have been Chair Force (Air Force).... 2-3 drinks a night. Now, was that before he went overseas or while overseas? As for sudden on set chest pain I will go with: - PE (big guy sitting at a desk for long hours) - Thorasic Aortic Aneurysm - ACS I would do the work up as posted above. Plus, check BP in both arms and if possible, is there an iSTAT (Tn-I) available in the clinic. Cheers Link to comment Share on other sites More sharing options...
Kiwiology Posted April 18, 2010 Share Posted April 18, 2010 Does the pain go anywhere? ie back (AAA) or jaw/neck/arms/face (ACS) Does the pain get worse with inspiration? (pleuratic type) No SOB? What does our high quality Tom Bouthillet approved 12 lead ECG including V4R show? Heck lets try posterior leads too, we got time its the middle of nowhere! I would like to give 324mg ASA PO and try 0.8mg GTN SL up to say, 2 or 3 if it helps if not no point giving it anymore. Venous access (lock) and if we can pull some bloods for later analysis would be good. Can we do a chest x ray at the clinic? Link to comment Share on other sites More sharing options...
chbare Posted April 18, 2010 Author Share Posted April 18, 2010 Pressure in right arm ~ pressure in left arm. No military experience works a desk job for a logistics company. No radiation, does c/o "moderate dyspnea." BGL is 150 mg/dl. XII lead: No xray at the clinic. You can send labs out with a local and have them back in the afternoon, about 6 hours from now. Taking an ambulance trip to the military hospital is always a safety risk. Take care, chbare. Link to comment Share on other sites More sharing options...
Kiwiology Posted April 18, 2010 Share Posted April 18, 2010 (edited) Oh wow looks like RVH with right axis deviation but also looks like a bundle branch block (rabbits ears) in limb leads and V6 Man now thats making my chest hurt Edited April 18, 2010 by kiwimedic Link to comment Share on other sites More sharing options...
spenac Posted April 19, 2010 Share Posted April 19, 2010 Oh wow looks like RVH with right axis deviation but also looks like a bundle branch block (rabbits ears) in limb leads and V6 Man now thats making my chest hurt Actually looks more like pathological left axis deviation indicative of an anterior hemiblock and on top of that has left bundle branch block confirmed in lead V1. With two blocks this guy is a ticking time bomb. Link to comment Share on other sites More sharing options...
Kiwiology Posted April 19, 2010 Share Posted April 19, 2010 Wouldn't the horrendously exaggerated QRS complexes in V1-3 be indicative of RVH? I see what you are saying about a left BBBB now in V1. Anything outside of STEMI on a 12 lead I ain't so good at Link to comment Share on other sites More sharing options...
chbare Posted April 19, 2010 Author Share Posted April 19, 2010 So, we have a new onset or presumably new onset LBBB with his signs and symptoms. What do you want to do about it? Take, chbare. Link to comment Share on other sites More sharing options...
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