History of Present Illness:
This is a 70-ish-year-old female who presents with 45 minutes of having pain in her jaw bilaterally a little bit more on the right followed by spread to her chest bilaterally and a little bit to the back of her neck and maybe her upper back associate with nausea which has resolved but no shortness of breath. No arm pain, leg pain or other symptoms. She has a history of a-fib with ablation 10 years ago but no history of coronary disease. Pain was 5 out of 10 at peak and now is down to 3 out of 10 after nitroglycerin.
Vital Signs & Physical Exam:
Vital signs are normal except for BP in the 160’s bilaterally. The rest of the exam is normal
Initial Diagnostic Testing:
Computer read: LBBB
ANSWER: What should you do next?
- A) Activate cath lab
- B) Blood work including troponin.
- C) Repeat ECG
- D) Admit after troponin results
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ANSWERS:
- A) Activate cath lab – CORRECT. Concerning story and though not quite Sgarbossa positive in leads II and aVF at least concerning in these leads. Repeat ECG below showed dynamic change with pain improving from 5/10 to 2-3/10 and ST changes also improving
- B) Blood work including troponin.
- C) Repeat ECG
- D) Admit after troponin results
CASE CONCLUSION: cath lab activated. 99% obtuse marginal stenosis treated with one stent. Troponin was 4 then 9 then not rechecked.