mdwannabe
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68 yo male come to office with substernal CP since last night, radiating to both arms and back. BP 100/60, HR 60, RR 22, T-100.2
EKG Q's in II, III, AVF and prominent Ts in V1 and V2. CXR clear.
Probable dx:
A. Aortic disect.
B. Constrictive Pericarditis
C. Acute MI
D. Myocarditis
E. GERD
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| orthodromic
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A.aortic dissection :roll:
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| 2bmd
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I agree with A.
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| orthodromic
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mdtobe, could u post the right ans?
thnaks
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| mdwannabe
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I d rather have a discussion. Why don't you guys rationalize your answers. I was waiting for more people ti join in... I guess its just us then :-)
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| Ahab
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C. Acute MI
Dont allow the non-classical chest pain to confuse, all other signs point to an AMI such as the Q waves
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| mdwannabe
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Ok Ahab... discuss the other choices and the reasons why they are not correct. I think that is the way to do questions. :-)
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| Ahab
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Ill play  have a party to go to in a few mins so excuse the brevity.
Rule out A because of the lack of sudden onset, clear CXR and no textbook signs of dissection, i.e. different bps in both arms, signs of aortic regurg.
Rule out B, for some reason doesnt sound right but is a possibility, BP is low but not too low, history is too acute, temp high, resps high, lack of exacerbation by movement. Most difficult to rule out, unsure of ECG changes in pericarditis but the localisation in this history would rule it out i would imagine.
Rule out D, probably again due to the ECG changes present.
E. Distractor, history not consistent with GERD and again pointing to the ECG changes in ruling out.
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| mdwannabe
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Also ...I was hoping for you to point out normal pulse...Low BP and normal pulse... In any one of the choices the pulse should be up, weather due to low b/p as in A or stress as in others. Amongst the choices only 2 can have low pulse rate... Acute Miocarditis and Inferior MI. Now, Acute Miocarditis usually presents with fever and some prodorm. Acute MI does not have either one. (well, some fever can be there)
That was my reasoning... I think it is shorter.
Your opinion!?
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"Life not lived for others, is not worth living" Uncle Einstein
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| orthodromic
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hello mdwannabe
i was thinking q waves indiacte old MI.(may be he had that in past).also in the stem patient has the pain radiating to back indicating aortic dissection????.
please correct me if i am wrong.
thanks
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| mdwannabe
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not wrong at all. Q waves indicate scarring...however, they are in essence just dead myocytes, in Inf MI they appear after only 12 hrs. Pain from Inf MI can radiate anywhere and down the back as well. It is similat to disection, however, in disection the pain is described as tearing and it moves as the disection progeresses. Mostly though, the pressure plummets...in this case it is rahter stable...and pulse stays low, due to intrinsic cardiac disfunction.
Hence the dx is either MI or Myocarditis...and there is no evidence of infection or prodorm smx.
Also..in regards to Pericarditis, which is usually present in Myocarditis, the ECG changes are ...diffuse ST elevation.
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| orthodromic
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thanks mdwannbe.
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| mdwannabe
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my pleasure :-)
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