A guy in his early 30’s came to my ER recently. As had several other people that day, he complained of vomiting and diarrhea.
He was also diabetic, and triage recorded a glucose level in the 300’s.
He looked very comfortable: not particularly dehydrated and a normal respiratory rate but his heart rate was in the 110’s and he seemed to have some sort of gastrointestinal illness so I thought I better evaluate him for DKA.
Among other tests, that includes an EKG. I wrote the orders and went into another room to drain an abscess. A few minutes later the nurse brought me this…
It’s a pattern consistant with an inferior MI, a heart attack.
I asked the nurse to get an aspirin, and quickly went back into the patient’s room to ask a few more questions. Any chest pain? Only some vague, fleeting, mild pain across his lower rib cage. Certainly not the pain people typically describe with a heart attack.
Then a call to the cardiologist and we gave him some more medicines and arranged a trip to the cath lab.
Early 30’s with GI type symptoms and no chest pain. Sometimes you figure out a tough diagnosis, and sometimes you just get lucky.
June 25, 2007 at 4:23 pm
You know how it is…those diabetics can fool you every time.
June 25, 2007 at 10:23 pm
Take home: inferior MIs can present as abdominal pain, especially in diabetics, and if right sided EKG shows posterior involvement, they become preload dependent and nitrates and opiates must be used very carefully.
June 25, 2007 at 10:31 pm
Just curious–diarrhea…related or unrelated to the MI?
June 26, 2007 at 12:56 am
[...] to be an ER doctor from Shadowfax and Why to get EKGs by 10 outta [...]
June 26, 2007 at 4:46 am
Re Nurse K’s comment, symptoms of MI can include nausea, and he did complain of nausea and diarrhea. Tachycardia, nausea, and history of diabetes would tell me that this patient was to be seen right away. Many MI’s are silent, or the patient did not feel much chest pain, however was displaying some unusual symptoms.It was not mentioned in the patient’s history, however I bet that he was also diaphoretic which is another symptom of AMI.
June 26, 2007 at 6:58 am
I’m just wondering why diabetics are more likely to present with the vague symptoms than the typical Levine’s sign. Neuropathy?
June 26, 2007 at 8:22 am
Nurse K, ultimate generic nurse:
Maybe from catecholamine release from the MI, maybe just random. Who knows?
Christine:
yes
Sue & Pal
The whole point of this post is that nobody is clinically diagnosing this guy with an acute MI. Trust me. He looked well, (by defination no diaphoresis) he was young, and he came with symptoms of an alternative diagnosis that I had already seen several times that day.
If you want to put on your retrospectroscope and say oh well he is diabetic and has nausea and AMI can present atypically blah blah blah that is all true but I will see variations of this patient again and again, daily, and it’ll be nothing but garden-variety gastroenteritis 99% of the time.
Also, FWIW, if there’s one finding you want to hang your hat on for the diagnosis of MI it’s this: these patient’s tend to get this far-away, glazed kind of look. They sit fairly still, and you can tell that they can tell that something is definitely not right. If they’re real dramatic about the pain or if they look completely at ease, it’s probably not a heart attack. Except, of course, when it is.
10/10
June 26, 2007 at 9:49 am
I agree with you. MIs tend to have that weird greyish kind of look. I love the retrospectoscope…perfect instrument.
And yes, diabetics tend to have neuropathy that prevents traditional CP, and in general inferior MIs can present as abdominal discomfort. I teach all my students and residents to be especially careful of diabetics with abd pain, because they can fool you every time. They still fool me.
June 26, 2007 at 11:30 am
I FULLY agree with your assessment of the ones who look really bad…
I’ve recently redefined my criteria for who’s high risk and who’s not, and it has nothing to do w/ TIMI risk.
85 year old, NO MEDICINES, 2 am “I’ve just got a little heart burn, sweetie. Are you old enough to be a doctor?” LBBB, no old EKG, pain free. Let’s sit on her for a little while. Pain’s back, repeat EKG, no LBBB. Uh oh. Cath – 100% LAD.
48 year old, htn only. “Just a little indigestion, but it won’t go away this time.” No other symptoms. Stone cold normal EKG. postive troponins (not cath’d at time of post)
65 year old, looks like death warmed over, diaphoretic, tachy, hypertensive – one of two things. BIG freakin STEMI. Or, if not – nothing. Neg enzymes. Neg stress. Clean cath (if he gets one.)
I so wish the Medicine/Family residents would see some of this, so I wouldn’t have to continuously argue the point that no, this patient cannot go home and come back to have his stress test.
June 26, 2007 at 11:50 am
We’re lucky, we have a good USAROMI system…even if they don’t get admitted, they usually stay overnight in the CP clinic and get stressed. Still, they miss ‘em.
June 26, 2007 at 1:33 pm
yeah, having and ED chest pain unit would be nice, and solve some of that problem.
I had a cardiologist tell me one “why don’t you stop trying to make things more than they are, and when are you guys going to take responsibility for your own f-ing patients?”
He was forgetting that it was cardiology that didn’t want us to have the ED rule out unit. I’d LOVE to “take responsibility” and get the income for it (or at least, have my attendings get the income for it…)
June 26, 2007 at 3:37 pm
The ED in the hospital I work at has a chest pain center. I have nothing to do with it though, and no experience what so ever with how good it is.
June 26, 2007 at 10:39 pm
Nice case, and good job! This patient was lucky. If he was having a NSTEMI, it probably would not have been picked up, unless your ED does routine cardiac enzymes as part of a panel. Having a ED chest pain unit is nice, but irrelevant for this patient.
June 27, 2007 at 4:37 am
You’re right…this is easily the guy you can miss. You’ve got to have a low index of suspicion and low threshold to check an EKG. Especially in the elderly, and diabetics, and people with multiple “vague” symptoms that could be ANYTHING…I sometimes think of an EKG in those people as a “6th vital sign”
June 27, 2007 at 6:28 am
and that was supposed to say “high” index of suspicion…
June 27, 2007 at 7:31 am
ID,
I completely agree, as rare as a 30 year old STEMI is, at least it’s diagnosible. If he had come in 4-6 hours earlier, when his clot was still forming, I almost certainly would have sent him home (probably wouldn’t have drawn enzymes, probably would have been negative anyway.)
Then I might very well be blogging about the young guy with gastroenteritis who came back coding instead of the above. Yikes.
10/10
June 28, 2007 at 8:27 pm
To nurses and the ‘curious’:
1. take MCAT, go to med school, train at least 8 more years, get licensed, take professional liability, start your doctoring inclinations
2. if u cannot handle #1, stop pestering your doctors for your continuing education; they have jobs to do aside from justifying every test they decide to get for every case they have with you; educate yourself, on your own time, effort, and dime! go drain yourself too, instead of sucking more life out of your docs!
3. especially for Nurse K: constellation of symptoms cannot be treated like a multiple choice exam, nor can they be placed in a box that you check off, to be related every time! docs get this ability from putting in training time, much more than nurses, mid-levels, and high horse riding arrogant nth guessers, are willing to get or capable of handling!
June 29, 2007 at 4:55 am
The initial case was interesting, the rest of the banter is lame; Great everyone explaining to nurses and the like how to diagnose a MI. Keep up the great blog, Trismus1.
June 30, 2007 at 10:18 pm
Trismus,
What made you get this guy’s EKG in the first place? I’m not sure I would have.
(although, now that I think about it, I had a similar case in residency: 40 yo woman with diarrhea for 3 days, came in feeling “dehydrated”. NO chest pain ever. My super-conservative attending made me get an EKG and she had HUGE tombstones all across the anterior leads.)
July 1, 2007 at 8:25 am
Hallway Four,
I do it for anyone I’m evaluating for DKA to look for peaked-T’s before the chemistry comes back, even though I was 99% sure this guy wasn’t in DKA.
With your lady I doubt I would have gotten one unless her heart rate was like 130 or something and I just wanted to make sure it was sinus. I don’t really care about hypokalemia/U waves since it’s obviously not as life threatening and I’d wait for the number to come back before treating anyways.