Case Presentation

[Hani]

38 yr old gentleman, Indo-Pak origin, presented to ER c/o 2 days Hx of diffuse dull chest pain that radiates to his back. few hours before he came the pain became retrosternal and severe, increases with respiratory movements and gets better by sitting, it was associated with palpitation. his past medical Hx was insignificant, his father is a cardiac patient and he smokes around 10 cigarettes per day for the last 15 yrs

O/E
HR 98
BP 100/60
Temp: 38.1 C

CVS: S1 + S2 + 0
chest: clear
others: NAD

His labs were WNL and ECG was



The ER physician was thinking about inferior wall MI, he gave him sublingual nitrates and morphine which relieved his pain, the on-call cardiology registrar was informed, who admitted the patient and directly he was taken to the Cath Lab for primary intervention but his coronaries were all normal. patient was sent to CCU with an order to do an ECG every 6 hours.

[salahabusin]

the case is classic for acute pericarditis
the initial ECG shows minimal ST elevation in inferior leads with Q waves
subsequent ECGS unravel acute pericarditis with diffuse ST elevation in chest leads, and lateral leads with no reciprocal changes,
there is no PR depression that is sometimes seen and points to acute pericarditis

Comments about the ECG case;
the inital presentation of the patient was atypical for ST elevation MI due to 1) relatively young age, 2) pain worse with inspiration, 3) T 38
activation of the Cath lab is reasonable with the inital ECG, if Cath lab was not available thrombolytic therapy would have been disastrous. in such a situation where Cath lab is not availabe, transfer to the nearest Cath facility is required.

in the presence of normal coronaries as mentioned, acute MI is unlikely except in the context of cocaine use which we see more of in USA, another cause of MI with normal coronaries is takstubo cardiomyopathy which can be diagnosed on Left ventricular angiogram in the Cath lab, or on echocardiogram

this is an excellent case, well done

I would also like to invite you to read some of the cases we have been writing in SAMA E-clinic
http://sama-sd.org/sama-e-clinic/case1-q1
http://sama-sd.org/sama-e-clinic/ecg-1
http://sama-sd.org/sama-e-clinic/ecg-2
http://sama-sd.org/sama-e-clinic/ecg-3

AGAIN WELL DONE AND KEEP THESE CASES COMING

Salah Abusin, MBBS, MRCP
Cardiology Fellow
Chicago, IL
USA

PS a small suggestion; delete the patient's personal information

[Hani]

thanks doc .. wonderful unpacking

i'll work on editing the ECGs to remove personal information inshalla .. many thanks

[Hani]

pt data has been removed ... thanks doctor Abusin

[SudaMediCa]

Very useful discussion ... Keep such things up please