64 yom CC: Chest Pain

Here's another great case submitted by a faithful reader who wishes to remain anonymous.

The patient is a 64 year old male with a chief complaint of substernal chest pain.

Onset: Sudden onset at rest.
Provoke: Nothing makes the pain better or worse.
Quality: Patient describes the pain as "sharp".
Radiate: Pain radiates to right arm.
Severity: Patient gives the pain a 15/10.
Time: 10 minutes prior to EMS activation.

Skin is cool, pale, and diaphoretic.

He denies shortness of breath. He admits to nausea but has not vomited.

Past medical history: CVA with right side deficit. IDDM with below knee amputation. Electric wheelchair bound.

Allergies: No known drug allergies

Medications: Vicodin

Vital signs:

Resp: 18
Pulse: very rapid, weak
BP: 103/81
SpO2: 99 on RA

BGL: 283

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

 

A 12-lead ECG is captured.

 

And another.

 

What's next?

*** Update 02/13/2010 ***

A rhythm change is noted on the monitor.

An additional 12-lead ECG is captured.

 

And another.

 

Does this shed some light on the situation?

50 yom (Asian) CC: left-sided chest and arm pain/weakness.

Is this patient having an Acute Myocardial Infarction at this present time or did he have the infarct 2 weeks ago when the patient first had central chest pain?

This is an interesting case... The story here is:... an good friend and colleague of my recently got a call for a immediate transfer from one hospital to another to take a patient for PCI... My colleague was stuck in the middle of 3 consultant cardiologist's aurguing whether the patient was having an AMI at the present time or is the ECG changes from 2 weeks ago when the patient actually had the first chest pain.

Outcome was 2 cardiologists decided that the patient was having an AMI now, and the 3rd cardiologist thoughts were these events are from when the patient first infarcted 2 weeks ago. In the end the outcome was they decided NOT to PCI this patient.

Sorry I have not much clinical information on this patient whether he has any cardiac history, I understand the patient's english was very poor... Observation's were recorded as follows:

HR: 89

BP: 110/69

SPO2: 99% O2

RR: 22

SKIN: No details: just my colleague stated that this patient did not present like he was having a AMI.

No other info on this patient regarding blood results...etc.

My Questions are:

1) What your opinion on this case study?

2) After looking at these ECG's, do you think present events or is the infarct 2 weeks old?

3) Would you PCI ?

4) Give evidence and your reasons from the features on the 12 lead ECG, whether this is 2 weeks old or AMI?

Lead II taken from the rhythm strip

Hospital captured 12 Lead ECG 

This is a interesting case to hear from cardiologists with their opinions on this case study, or any other health care professional's sharing their views... Look forward to all your comments...:-)