David here, posting my first case on the blog… hope you enjoy, and Happy Father's Day! Here's an interesting case submitted by "Mike from Mass". Some minor details have been changed to preserve patient confidentiality.
EMS is dispatched to a residence for a 63 year old male with chest pain. Dispatch advises that a different crew had responded about 30 minutes earlier, but the patient refused transport against medical advice.
Upon arrival, the crew finds a 63 year old male walking towards them, in no apparent distress. There is a moderate language barrier, but the the crew is able to understand that the patient began experiencing right back pain while taking a shower about an hour ago. He may also have experienced shortness of breath and chest discomfort, but the crew is less certain of this due to the language barrier. Patient is alert and oriented X 4, with clear lung sounds. The crew obtains the following vital signs:
- BP: 142/70
- HR: 52 bpm, regular
- RR: 14
- SpO2: 98%
- BGL: 137
While trying to obtain the patient's medical history, the crew learns that the patient has not received regular medical care until one year ago. The patient is able to deny any allergies, but regular medications and any past medical history are unclear. The patient is given 324 mg baby ASA, but nitrates are withheld due to unclear PDE5 inhibitor (ED drugs) status. Prior to transport to a PCI capable hospital, IV access is established and the following 12 lead is acquired:
Enroute, another 12 lead is acquired:
Upon arriving at the hospital, the patient becomes acutely anxious and tremulous. The crew observes that the patient now appears to be in moderate discomfort, with a rising heart rate. A third 12 lead is acquired by the crew:
What do you think is going on?
What do you think about the change in the patient's presentation?
How would you treat this patient?