Epigastric pressure and nausea for four hours

Type 2 diabetes on metformin, hypertension on ramipril and indapamide. Ex-smoker. Seen at an out-of-hours clinic two hours ago and given omeprazole for indigestion; no ECG was recorded there.

Stage 1 of 2

Dilys Morgan came back because the pressure under her ribs had not settled and she had started to feel sick. She is uncomfortable rather than distressed and can talk in full sentences. The abdomen is soft with no tenderness, the chest is clear and the heart sounds are normal. This twelve-lead was recorded four minutes after she arrived, while the pressure was still there.

Tracing 1 of 2 for the quiz “Epigastric pressure and nausea for four hours”. — Twelve-lead recorded at triage, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What is the acute abnormality on this tracing?

AAcute injury to the posterior wall Correct answer Your answer
BFrequent atrial ectopy with no acute ST change Your answer
CLeft ventricular strain from long-standing hypertension Your answer
DSubendocardial ischaemia of the anterior wall Your answer

Which additional recording settles that reading?

ALeads V3R and V4R across the right praecordium Your answer
BThe same twelve leads repeated in fifteen minutes Your answer
CA Lewis lead arrangement across the upper sternum Your answer
DLeads V7 to V9 across the left posterior chest Correct answer Your answer

Stage 2 of 2

The registrar reviewing the first tracing reads it as strain from long-standing hypertension and asks for a repeat before anyone is referred. Posterior leads recorded while she waits show ST elevation in V7 to V9. Forty minutes have passed since she arrived, the pressure is unchanged and she has vomited once. The first high-sensitivity troponin T is 310 ng/L. The primary PCI centre is twenty-five minutes away and takes direct referrals.

Tracing 2 of 2 for the quiz “Epigastric pressure and nausea for four hours”. — Twelve-lead repeated forty minutes after arrival, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 84
SpO₂ (%): 96
Respiratory rate: 18
Temperature (°C): 36.7
Systolic BP (mmHg): 138
Diastolic BP (mmHg): 80

Bloods

Haemoglobin (g/L): 132
Troponin T (ng/L): 310
Potassium (mmol/L): 4.3
Creatinine (umol/L): 92

What does the second tracing commit you to?

ARefer now for primary percutaneous coronary intervention Correct answer Your answer
BWait for the three-hour troponin before referring Your answer
CStart fondaparinux and book angiography within 72 hours Your answer
DRepeat the twelve leads after a further thirty minutes Your answer

Epigastric pressure and nausea for four hours

The case

On arrival

Observations

Bloods

Diagnosis

Discussion