82 year old female CC: "Flu-like" symptoms

EMS is called to the residence of a 82 year old female complaining of “flu-like” symptoms, including vomiting x 4-5 hours.

On arrival, the patient is found sitting on her bed alert and oriented to person, place, time, and event.

The patient’s skin is pale but warm and dry.

Past medical history: Breast CA, double mastectomy, HTN, hyperlipidemia

Meds: Unknown antihypertensives

The cardiac monitor is attached.


The patient is relocated to the ambulance.

Upon questioning the patient admits to chest discomfort and mild dyspnea.

Onset: 4-5 hours ago
Provoke: Nothing makes the pain better or worse
Quality: Described as “discomfort” and “rock-like”
Radiate: The pain does not radiate
Severity: Patient gives the pain a 8/10
Time: No previous similar episodes

A 12-lead ECG is captured.


An additional ECG is captured en route to the hospital.


And upon arrival at the emergency department.


Your thoughts about the case?

10 Comments

  • Christopher says:

    Pretty cool look at an evolving MI. By the last ECG, it appears there is involvement almost everywhere. However, aVL and V6 still don't show elevation. Pretty extensive anterior MI. Dominant LCA occlusion?Hemodynamics and the possibility for SCA are my top concerns with the amount of involvement.

  • Anonymous says:

    Drive fast.

  • Tom B says:

    C. Watford – I agree, the changes on serially obtained ECGs are always interesting to me! I'm pretty sure this was an LAD occlusion (so left side for sure) but hopefully I'll get the angios on this one! Also, from what I understand this patient crashed on the cath table, so very perceptive about the level of risk! @Anonymous – Touche'! :)Tom

  • Patrick Hoket says:

    Ahhhhh….. What’s our ETA

  • ZTM says:

    I'm not seeing any recip-changes, what am I missing?

  • Brian H. says:

    Almost a pure anterior, ZTM, so any reciprocal changes would have to come from posterior leads.  Just goes to show, 3 leads = no leads.  Nice pickup on moving to the next step and getting the 12. 

  • CB says:

    The first clue was 87 go female, the second was vomiting. In elderly females vomiting is number one in suspecting a MI. Always do a 12 lead as soon as possible and you will pick up many MI’s that others miss.

  • Kate says:

    Elderly female with acute vomiting is anginal equivalent until proven otherwise in my book. Possibly a good background of history, medications, previous events might be the more obvious red flags. I can imagine how easy it is for EMTs and medics to discount these symptoms especially in winter or when we’re tired. Suspicious medics make for better pt care.

  • DJ says:

    hey guys good case. im a new paramedic and new to this site so its good to see cases and learn. i will admit that cardiology is a weakpoint for me being new so its nice to have a place like this i can come to and ask questions and see actual cases. thanks!

  • Benjamin says:

    Well, all the years of service……chest pain + ST Elevation = Possible MI, so treat as an Mi and rapid transport to an appropriate medical faciclity….otherwise till is ruled out by more extensive lab work…..
     

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