8. Patient Presentation
• Mr. Smith is a 60-year-old Caucasian male, who presents
with 8/10 chest pain after working out. He just quit smoking
and started a new workout and diet program after recently
retiring. He has noticed some chest and shoulder discomfort
with working out that usually resolves with rest,but decided
to come to the emergency department because this episode
was unrelenting and more severe.
9. • Mr. Smith describes his current pain as severe and sharp, and
also complains of nausea and shortness of breath. Vital signs
are HR: 110 BP: 150/90 RR: 30 Temp 97.6 O2 Sat: 92% on
2L nasal cannula, EKG shows ST segment elevation in leads
II, III and AVf. Labs were drawn, including an elevated
troponin (4.23 ng/ml), and slightly elevated white blood cell
count (13.6 × 109/L).
10. Past Medical History
Type II diabetes (age 47), dyslipidemia (age 33), atherosclerosis
(age 52), hypertension (age 49), obesity (age 33), viral
pneumonia (age 29), hiatal hernia (age 28), peptic ulcer disease
(age 41)
11. Family Medical History
• Mother (deceased) – atrial fibrillation (diagnosed at age 45),
died of MI (age 65)
• Father (83) – obesity, type II diabetes (diagnosed at 50), COPD
(diagnosed at 55)
Social History
• Smoker (20 pack years), worked in an office sitting at a desk his
whole career (35 years), recently began working out at his local
gym since retiring this year.
12. • What is the probable diagnosis?
• What are the points that helped you reaching diagnosis?
• What will be your outline of management?
13.
14. Location of MI Leads Affected Vessel Involved ECG Changes
Anterior wall V2 to V4
Left Anterior Descending artery (LAD)
– Diagonal branch
•Poor R-wave progression
•ST-segment elevation
•T-wave inversion
Septal wall V1 and V2
Left Anterior Descending artery (LAD)
– Septal branch
•R-wave disappears
•ST-segment rises
•T-wave inverts
Lateral wall I, aVL, V5, V6
Left Coronary Artery (LCA)
– Circumflex branch
•ST-segment elevation
Inferior wall II, III, aVF
Right Coronary Artery (RCA)
– Posterior descending branch
•T-wave inversion
•ST-segment elevation
Posterior wall V1 to V4
Left Coronary Artery (LCA)
– Circumflex branch
Right Coronary Artery (RCA)
– Posterior descending branch
•Tall R waves
•ST-segment depression
•Upright T waves
ECG Changes during Myocardial Infarction (MI)
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43. Differential Diagnoses
1. Acute Pericarditis
• Acute pericarditis is inflammation of the pericardium.
• Symptoms in case history consistent with clinical manifestations
of Acute pericarditis-
• Sharp chest pain
• Tachycardia,
• Elevated troponin
44. • Absence of friction rub upon auscultation
• No positive history for connective tissue disease or other reason
leading to believe he is experiencing an infectious process.
