phuluong2k
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A 68-year-old man is admitted to the medical service for chest pain. The patient has an 80 pack-year smoking history and is known to have an elevated total cholesterol but unknown LDL and HDL components. He is a known insulin-dependent diabetic with a recent hemoglobin A1c fraction of 8.3%. He has a history of chronic, stable angina precipitated by exertion and relieved by rest. During the examination, he is free from chest pain. His blood pressure is 160/90 mm Hg, pulse is 90/min, and respirations are 22/min. He is mildly diaphoretic. On physical examination, he has an S3 gallop, bibasilar course rales, and an abdominal bruit. A chest radiograph shows mild pulmonary edema. On ECG obtained on arrival to the floor shows ST segment depressions in leads V3, V4, V5 and V6. Which of the following is the most likely diagnosis?
A. Costochondritis
B. Pulmonary embolus
C. Musculoskeletal chest pain syndrome
D. Myocardial ischemia
E. Myocardial infarction
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| nisha
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D
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| mani
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D. Myocardial ischemia
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| DrS
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E. Myocardial infarction
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| kabu
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D.
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| ARJ
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D. Myocardial ischemia
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| phuluong2k
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ST depression, so D
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| DrS
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How do you explain pulmonary oedema in myocardial ischaemia?
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| frontal
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Ischemia, on the basis of ECG.
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| DrS
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But subendocardial infarction can cause ST depression too?
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| nisha
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From stable angina I think he's more likely to progress to unstable angina (myocardial ischemia) rather than directly to an infarction..
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| frontal
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Good point DrS. In subendocardial infarcts, ST elevation is not prominent (NSTEMI). About ST depression I'm not sure...I get the impression that it can occur (with subendo. infarct).
Added info: Infarction of the posterior wall of the left ventricle can be diagnosed by ST depression and a tall R wave in leads V1 to V4 (reciprocal changes).
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| DrS
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Yes, going from the ECG changes with history of chest pain only the diagnosis would have to be Unstable angina, but is it possible to get pulmonary edema in unstable angina?
Regarding ST deps in MI to quote from Concise Oxford Textbook of Medicine:
"ST segment depression occurs in leads facing the infarct when it is subendocardial. ST segment depression also occurs as a reciprocal change in leads opposite to those showing the primary changes of acute infarction"
And from emedicine.com (http://www.emedicine.com/med/topic1567.htm)
"ST depression and T-wave changes may also indicate evolution of NSTEMI."
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| ibraheem
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E. Myocadial infarction.
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