Middle of nowhere

[chbare]

Had his appendix removed.

This is actually not a zebra case.

Take care,

chbare.

[Mateo_1387]

I am getting the impression from all the information being given so far that the gentleman has heart disease.

Walk with me here, please...

Patient present with hypertension, causing stress and probably some degree of ischemia on the heart.

The EKG shows left bundle branch block and strain pattern.

After the patient receives anti hypertensive agents, Metoprolol and Nitroglycerin, his symptoms of chest pain, Left Bundle Branch Block and Strain pattern disappear.

I am assuming the abnormal EKG finding for this patient is the lack of hypertrophy of the heart after the treatment is provided.

Although the coagulation panels are normal, this patient still has risk factors for clots, those being sedentary, overweight, and a smoker. I think pulmonary embolism could still be a possibility, even in the face of a normal coagulation panel, but sudden onset C/P, Shortness of Breath, and transient LBBB (seen during ischemia). Of course, for pulmonary embolism, the interesting EKG finding is the lack of tachycardia.

I think the treatment provided by the health care provider and the findings afterwards points more towards heart disease rather than pulmonary embolism.

Just my thoughts, eat me alive ! LOL

Matt.

[DartmouthDave]

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.

Hello,

I like you thought. It could be LV strain from the patient's HTN.

According to the LIFE study that I found on Google LV strain is defined as, "...as a downsloping convex ST segment with inverted asymmetrical T-wave opposite to the QRS axis in leads V5 and/or V6."

The T-waves are opposite the QRS axis in V5 and V6. However, the concave ST is missing. Still, a solid thought.

However, can strain cause conduction delays? Could. I don't know. Maybe, coronary perfusion is limited during diastole? My CCU/CVICU experience is limited.

Cheers....

Cheers...

[chbare]

Possibly, think about a few key points;

1) The signs and symptoms started suddenly while at rest.

2) The signs and symptoms resolved suddenly with treatment.

3) Substitute the LBBB with ST elevation and would you consider other differentials?

Take care,

chbare.

[Mateo_1387]

What does a coronary angiography show?

[jonas salk]

Possibly, think about a few key points;

1) The signs and symptoms started suddenly while at rest.

2) The signs and symptoms resolved suddenly with treatment.

3) Substitute the LBBB with ST elevation and would you consider other differentials?

Take care,

chbare.

prinzmetal's angina....?

[chbare]

What does a coronary angiography show?

Unremarkable.

Take care,

chbare.

[Mateo_1387]

prinzmetal's angina....?

That was my next conclusion too. Since the angiography is unremarkable, I assume we can rule out angina caused by atherosclerosis.

[chbare]

prinzmetal's angina....?

That was my next conclusion too. Since the angiography is unremarkable, I assume we can rule out angina caused by atherosclerosis.

Yep, he was eventually diagnosed with variant angina.

Take care,

chbare.

[spenac]

Good scenario. Thanks.