28 YO F with CP... what would you do?

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How would you dispo this patient?


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waterski232002

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So... I saw the following patient the other day. My attending and I disagreed on the management/disposition.

28 yo F was sent in from the PMD office for intermitent CP and HA x 3 wks. HA was mild and constant, but relieved with tylenol prn. Kind of a poor historian. Pt said CP was getting progressively worse over last 3 weeks, not exertionally related, and today lasted 8 hours so she went to her PMD office and had an EKG done. It was NSR w/ TWI in the inferior leads & V1-V3 with TW flattening in V4/V5. She was then sent to the ER for an evaluation. Our repeat EKG showed the same thing. There was no old EKG, and she had never had a stress test.

In the room she was non-toxic, vitals stable, CP was somewhat reproducible with movement & palpation. She denied any risk factors for CAD or PE/DVT, and no family hx of early CAD.

Her work-up was totally normal including CXR, basic labs, cardiac enzymes, CT Brain. What would you do with her?

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Was she a "big girl?" I might admit her if she's obese.

Otherwise...send out with follow up.
 
concerning for PE, with inferior and anterior TWIs. would duplex US and CT PE scan, and if that's negative, obtain delta set of cardiac enzymes. if neg and CP free, outpt stress test if she has good followup, but if still having pain and poor social situation, admit for obs and stress/coronary CTA vs. cath.
 
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I would admit this for a work up. I don't necessarily think anything you do in this situation is "wrong" but you have to be able to argue your case.

There are a few things that argue for admission, or to put it another way, there are things that would make this case difficult to defend if she left and died. Pt was felt to be enough of a risk that the PMD sent her to the ED.
The patient has an abnormal EKG.

Other things that make her riskier are that she's young which increases the value of any real damages they could get out of you. If she has children they can put in front of the jury they'll get sympathy cash.
 
concerning for PE, with inferior and anterior TWIs. would duplex US and CT PE scan, and if that's negative, obtain delta set of cardiac enzymes. if neg and CP free, outpt stress test if she has good followup, but if still having pain and poor social situation, admit for obs and stress/coronary CTA vs. cath.
Was thinking the same thing, although would probably admit for serial enzymes and then they could arrange the outpatient stress once three sets are normal (hopefully stress echo).

Is the delta enzymes supported by strong evidence yet? I know there is some evidence to support it, but I wasn't aware there was enough evidence to support it being a standard.
 
This is a good learning point for a student (me). To what extent does the "correct" answer on a test diverge from the reality? DocB brings up some medicolegal points that certainly get one's attention.

Before I read past the first post, I wanted to schedule the stress test in the AM and let her go home. Now I like this serial enzymes idea a lot, and start to think D-Dimer as well.
 
What would you do with her?

You're painting the picture of a very low risk patient with atypical chest pain. Her ECG changes are very non-specific, especially as she is this low risk with a low risk story. 10% of the population has these. There is a reason that ischemia studies don't uses T-wave inversions or flattening as inclusion criteria. They might mean something in the right scenario, but are usually meaningless. Unless she can give me something to change her risk group, I don't think I would have even bothered to get enzymes. I can see why you might, so if you start the process, you are pretty much obligated to get a repeat set to rule her out.

Stress Echo? Heck no. There is just a slightly higher than zero percent chance that she has a tight lesion. In the extremely unlikely event that she has positive stress test, it is more likely to be a false positive than a true positive. And, in the extremely unlikely event that she does have a tight lesion, she is very likely to have a false negative due to her age and functional status. Cath is more likely to cause an adverse event than it is to find a lesion.

Regular Echo? Maybe, if you are looking for pericarditis. The ECG doesn't really support it. Given that she is 3 weeks into this, I have to seriously doubt that she will develop life-threatening tamponade.

PE is possibility and probably the highest risk scary diagnosis for her. So I probably would get a CT PE protocol with venous run off if I was worried. As it has been 3 weeks, a D-Dimer can give a false negative.

As for other diagnoses that are scary --> pneumonia, pneumothorax, and dissection: as she seems low risk for all of these, your work up is likely sufficient to rule these out. Same with esophageal rupture.

Given all this, if I were in your shoes and I was worried, I'd get the CT, the second enzymes, and start her on an NSAID with follow up to her doctor.

Unless she is dissecting up her carotids and having atypical symptoms for both, the duo of headache and chest pain in a 28 year old without risk factors sounds more somatic than the result of physical pathology. I certainly wouldn't risk a cath over her chest pain with some non-specific ECG changes. As for inpatient admission for "workup," I'm not sure what is getting worked up, except our us over our fear of lawyers.
 
I would probably admit. I'd do so because her PMD was concerned enough to send her to the ED. The ECG is also troubling.

I think we could pretty easily rule out MI with a single negative set of markers b/c the pain had been going on for >8 hours. That isn't really the entire question, though. We want to know if she has unstable angina. We need some flavor of provocative testing for that.

Because of her concerning ECG, I think I'd have a strong case for doing the testing as an inpatient. If the admitting MD felt strongly about doing it as an outpatient and could arrange for it within 2 days, I'd probably be OK with that as well, assuming we ruled out MI (it sounds like we did based on > 8 hour markers).

Take care,
Jeff
 
Stress Echo? Heck no. There is just a slightly higher than zero percent chance that she has a tight lesion. In the extremely unlikely event that she has positive stress test, it is more likely to be a false positive than a true positive. And, in the extremely unlikely event that she does have a tight lesion, she is very likely to have a false negative due to her age and functional status. Cath is more likely to cause an adverse event than it is to find a lesion.

I've seen quite a number of 30 year olds who have had MI's or coronary stenosis, including one of my own family members.

Nonetheless, stress echo also evaluates for valvular abnormalities accentuated with stress.

It can also identify things that may suggest coronary problems, such as an anomalous coronary artery.
 
I've seen quite a number of 30 year olds who have had MI's or coronary stenosis, including one of my own family members.

Sure. I've seen a few too. Give me a family history. Give me a good story. Heck, give me a story. Give me a risk factor. Otherwise, the pretest probability is so low that any result from a functional test can't be interpreted.

Nonetheless, stress echo also evaluates for valvular abnormalities accentuated with stress.

It can also identify things that may suggest coronary problems, such as an anomalous coronary artery.

The rest portion maybe. But she is young, with an atypical story. There is no reason to suspect that she is having a valvular problem and certainly not that it is contributing to her chest pain. Fatigue with exercise? Shortness of breath? I think you'll have a hard time explaining a valvular abnormality causing intermittent, non-exertion linked chest pain. Sure, women get "atypical" symptoms, but she doesn't even have those.

She is also outside the zone where anomalous coronaries are going to cause her an issue. Young...healthy...no risk factors...not growing...atypical story. You might find an anomalous coronary. 1% of the population has them. Is this the cause of her chest pain? Unlikely.
 
BADMD-

Our VA ER is hiring. Can you pretty please with sugar on top come work here?

Thank you.

In our ER this patient would have been admitted to cards before labs were drawn and a CXR done. Seriously.
 
I am going to go with BADMD here. (of course, like BADMD I would like more history... This is a patient that needs more sorting out. Prior to this, has she ever had any hx of exertional CP or equiv sx. Does she have a family hx? recent travel? I would get a thorough CP hx. When she came from her dr's office to the ED, did it get worse? has it gotten better laying in the stretcher?)

Although we have all had that 'one patient', there is extensive evidence regarding low risk CP. She is low low risk. with an atypical story. presumably no family hx. or risk factors. She has a stable, unchanged EKG. I might repeat it again. If there are no dynamic EKG changes and my further hx reinforced her low risk, AND I had thought about other causes of her CP (dissection, pna, PE ) and decided if they needed to be addressed, then I would go talk to her: (assuming all the other causes of cp are not the cause)

Here is the chance that you might actually have something. Here are a few things that might need to be done. Here is what will be done in the hospital (in my hospital, its not a stress or an echo.) I personally think you are okay to go home, but there is a small chance you could have something going on. We can start you on an ASA a day and you can see your doctor in the morning to have further work up done. If you are really worried, we can admit you. What would you like to do?

I document this discussion as well (we also have 'low risk' cp discharge instructions)


I use a similar approach with syncope (and the SF syncope rule).
 
This is a great thread. I think 60% of admitting docs are going to have a fit over admitting this. Looking back over discharge summaries of similar patients, admitting docs invariably don't stress this patient as an inpatient (I admitted them with the intention of them getting stressed and they weren't).

One third of physicians at baseline are complete butt holes. Those one third of physicians will not only have a fit about trying to admit this patient, but will actively work to made your life miserable by spreading rumors, and airing out your dirty laundry to the rest of the staff. In an academic center, where you have residents who don't know the patient, and usually don't care about the patient, maybe the right thing to do is sell it as an admission and make them set up out-patient follow-up before they heavily push to send them home.

With a private physician, who is experienced and says, that patient needs to go home, I'll see them in follow-up, I think I would use Roja's thinking and involve the patient in the decision. If the patient feels uncomfortable going home and thinks something serious is wrong (is saying things like, "I think I'm having a heart attack." I'd use that patient input to sway the decision of the admitting doc. If your gut tells you on this specific patient that they need to be admitted, and the patient wants to be admitted and the admitting doc is giving you crap, put them on the phone with the patient and let them convince them to go home.

I know, I know, we do what is right for patients, not what is politically correct in our institution. However, admitting BS uses up a lot of resources, plugs up the hospital, and increases the likelihood of unnecessary tests and false positive test leading to invasive procedures. It also uses up large amounts of your bargaining power as a department. You might win this particular battle, but each victory over admitting docs trying to get out of work, decreases your likelihood of winning the next battle down the road. You've got to pick your battles.

I think that the ambiguous results on the poll prove that there is no right answer in this case. I could honestly stand up in court and tell a jury that I thought this patient was at very low risk for heart disease and therefore, didn't need emergent stress testing and I would testify in court defending a physician using this same logic.
 
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What about cocaine induced chest pain? Usually every 20-30 something year old that comes to the ED with chest pain and EKG abnormalities=cocaine use.
 
Any h/o depression, recent intense stress, bulbous heart on US, exertion? (Takotsubo's?)
 
I would probably admit. I'd do so because her PMD was concerned enough to send her to the ED. The ECG is also troubling.

I think we could pretty easily rule out MI with a single negative set of markers b/c the pain had been going on for >8 hours. That isn't really the entire question, though. We want to know if she has unstable angina. We need some flavor of provocative testing for that.

Because of her concerning ECG, I think I'd have a strong case for doing the testing as an inpatient. If the admitting MD felt strongly about doing it as an outpatient and could arrange for it within 2 days, I'd probably be OK with that as well, assuming we ruled out MI (it sounds like we did based on > 8 hour markers).

Take care,
Jeff

I'm really lost on this line of thinking. What makes you think she has UA? She has one thing in her history (at least the history that's given) that is concerning for UA...chest pain at rest. How many people come in and out of the ED on a daily basis with CP at rest? They have to have something else...like a h/o angina, CAD, dyspnea...that pushes you towards unstable angina.

And if you decide she has UA....then you're not putting her through a stress for a while, or at least until she's pain free for a while. So, if you do think she has UA and she's having CP for 8 hours then you're getting on the horn to nearest cardiologist and making the case that this person 1. Needs maximal medical management right now 2. Likely needs to go to the cath lab.

Oh...and by they way, they're 28 with a squirrelly story and non-specific EKG.

UA just doesn't make sense to me...
 
I'm really lost on this line of thinking. What makes you think she has UA?

My point on the UA was more generic than this situation and I probably merged two different thoughts into one conversation.

On this specific situation, the main argument for admission is that her PMD sent her to me. He'd already evaluated her yet he felt the need to send her to the ED. He either felt she was moderate to high risk (and thus needed further risk stratification) or he was dumping. Since I'm sure the PCP would NEVER dream of using the ED for clinic overflow, I must assume it was because he was worried about this patient.

In the general case of patients with chest pain, I was pointing out that we need to look for UA as well as MI. Sorry for blending the two points.

Take care,
Jeff
 
My point on the UA was more generic than this situation and I probably merged two different thoughts into one conversation.

On this specific situation, the main argument for admission is that her PMD sent her to me. He'd already evaluated her yet he felt the need to send her to the ED. He either felt she was moderate to high risk (and thus needed further risk stratification) or he was dumping. Since I'm sure the PCP would NEVER dream of using the ED for clinic overflow, I must assume it was because he was worried about this patient.

In the general case of patients with chest pain, I was pointing out that we need to look for UA as well as MI. Sorry for blending the two points.

Take care,
Jeff

you're assuming the pcp was a guy, and assuming the pcp felt that the pt was moderate to high risk. while i'd agree that there are times when pt's get sent for mod/high suspicion, i'd like to think we know of pts who have been sent "just because". :laugh:

a low risk patient with a non specific ekg clearly not showing stemi, negative cardiac biomarkers, she's a low probability patient who could reasonably get the work up (a non invasive stress test) as an outpatient.

of course we could also think about non-cardiac causes for her complaints, ask about her home/job situation, etc.
 
Thanks for all the good discussion....

There's really not much more to her history. No symptoms suggestive of PNA, PE, Depression, AD, GERD, etc. She wasn't pushing to be admitted. She just had the CP that was getting progressively worse and after 3 weeks of dealing with it, she saw her PMD who did the EKG.

So... My thought was that this patient is a shoe-in for a stress. My attending was like "get this patient outta here". Here are my thoughts:

1) The patient has new onset CP, progressively worse, PMD was obviously concerned enough to have the patient sent directly to the ER thus he must have thought she was mod-to-high risk. If he thought it was low risk, he would have given her a script for ibuprofen and sent her home himself. If he thought an outpatient stress was appropriate, he would have arranged it in clinic after he did the EKG, right? But he didn't... he sent her to the ER.

2) There was really no way for me to say that an EKG with clear TWI in the inferior & anterior leads is normal in a 28 year old with CP. I would argue.... if you're not going to act on clear EKG changes in 2 anatomic distributions... why get the EKG in the first place. I mean... what would it take on the EKG to get her admitted? STE? That seems a little extreme. We would be suggesting that young patients either go to the cath lab or go home. If I changed the thread to a 60 yo F with no risk factors, those EKG changes would probably get her admitted without much fuss. Although the patient in the case above has no risk factors for CAD including no family history for early CAD, there's always a first family member who suffers an MI to "create the family history"... and who's to say her cholesterol isn't through the roof and she doesn't eat big macs for every meal since age 3. Not that this is my mode of logic for all young atypical CP patients, but I felt the compelling factor was her EKG. I also had this discussion with my attending who said that we get EKG's in young patients with CP to look for pericarditis (which I've heard so many times before). But I would argue that I don't really care about pericarditis... I only care about myocarditis. If a patient had EKG evidence of pericarditis and they were non-toxic, I'd do the same thing I was going to do for them if the EKG was normal... send them home with ibuprofen and f/u with PMD in 2-3 days. Although I'd check a set of CE's and put the US probe on their heart to make sure there was no effusion.

3) If this girl goes home and dies 3 days later, I really believe that you are screwed as a physician. What defense do you have? Being young and healthy just means that you are even more f*#ked in a lawsuit. The PMD established that she was high risk (too high to be evaluated in clinic). She has clear EKG abnormalities which may be consistent with ischemia (which is the reason for checking the EKG in the first place). Her chief complaint is new onset, worsening CP. You sent her home not knowing if her TWI happened 2 years ago or 2 hours ago. You did nothing to further evaluate her abnormal EKG except check 1 set of CE's (which only tells us that she did not have an NSTEMI up to 8 hours ago).

So.... I definitely take the conservative approach. I'm not saying that I think she had UA by any means (in fact I'm almost positive it was somatic). But I think that if you get an abnormal EKG like that one in a patient complaining of CP then you have to evaluate it and assume it is real (unless you can prove that it's not... old EKG or recent stress). If I could get her a stress from the ER, that would be my ideal approach. Unfortunately, the patient presented at 6pm. If I had an obs area where I could redraw CE until morning and get her a stress then, that would have been my next choice, but that option wasn't available either.

Lastly.... I told a small fib for the sake of discussion. The girl's troponin came back at 0.04 (normal is <0.03). So my attending finally agreed to admit her "rolling eyes". The CK and CK-MB were normal.... tons of patients at that hospital have mildly elevated troponins b/c they use such a low cut-point for normal.
 
I'm curious, and as a mere student I might be missing an obvious one, but why did she have a head CT?
 
I'm curious, and as a mere student I might be missing an obvious one, but why did she have a head CT?

Along with heart rate, blood pressure, respiratory rate and temperature, in the US, head CT is the fifth vital sign.
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Probably due to the unusually persistent headache.
 
Rotating at an urgent care place every friday for three weeks in a row I saw a different 21yo male with CP. They all described it as crushing sub-sternal CP, and one made the fist and said it radiated to the left shoulder. Either they were all watching the same movies or something was wrong. It was a well-run little clinic and we did EKGs and basic cardiac labs on these boys. They were all normal except one was a little tachypneic with a h/o anxiety.

I had a long talk with each of them about certain recreations that kill young men -- i.e., cocaine. They all denied drugs, etc, and their drug screens were negative. We decided they were each likely anxiety driven. But, if they were even 20 yrs older we would have shipped them off to the local ER. To send them to the ER would have been wimpy, and we referred them to their PCP with very precise DC instructions.
 
Easy case....RESTING SESTAMIBI. I love this test for this population of low risk patient's with some concern for cardiac etiology.....the caveat being she must have pain within two hours of tracer injection, but she probably was. This allows for a set of enzymes and EKG number 1 on arrival, Mibi taking about 1.5 hrs to obtain and read, then a second set of enz and EKG post-mibi and d/c to home. Does anyone else here use sestamibi scans like we do?
 
Interesting case, in terms of the potential for discussion it generates. My meager clinical instinct would be that this was a dump and to send her home with close follow-up, as well, unless my spidey-sense went off. But this would be based on statistics/data. I would be interested in seeing any follow-up.

What is sad is how the litigious nature of our society causes us to change the threshold for inpatient and detailed workups from "greater good" to zebra level. From a macroeconomic and distribution ethics perspective, this is a disaster. The American health care system simply cannot sustain itself this way. :(
 
Easy case....RESTING SESTAMIBI. I love this test for this population of low risk patient's with some concern for cardiac etiology.....the caveat being she must have pain within two hours of tracer injection, but she probably was. This allows for a set of enzymes and EKG number 1 on arrival, Mibi taking about 1.5 hrs to obtain and read, then a second set of enz and EKG post-mibi and d/c to home. Does anyone else here use sestamibi scans like we do?

Most EDs are not set up to have ready access to the tracers. It requires having nuke-med people in house at all times. Plus, as there is a shortage of radioactive thallium and the stuff has a fairly short halflife, you have to be willing to either lose product or have limited access to the test.

It is a pretty slick test and you can do the gamma scan many hours post injection.
 
waterski - you're giving the PMD too much credit IMO. We get stuff sent to us the time by PMDs. A lot of it is legit, but a lot of it is "admit for....." or "rule out...."
I take a look at the patient, examine then, get whatever appropriate studies and if I disagree with the PMD I'll give them a call and tell them why I think we should follow this up as an outpatient. If they adamantly disagree...I admit.

I can't tell you how many times we get, "rule out tenosynovitis," from PMD's. I've yet to see a true case.
 
Most EDs are not set up to have ready access to the tracers. It requires having nuke-med people in house at all times. Plus, as there is a shortage of radioactive thallium and the stuff has a fairly short halflife, you have to be willing to either lose product or have limited access to the test.

It is a pretty slick test and you can do the gamma scan many hours post injection.
The Canadian plant was brought back online, so to my knowledge there isn't a shortage anymore. At least where I am there doesn't appear to be a shortage. We do resting nuclear imaging all the time in our chest pain center. It's difficult to arrange from 10p-6a though, so it's usually only during the day and evening hours.
 
The Canadian plant was brought back online, so to my knowledge there isn't a shortage anymore. At least where I am there doesn't appear to be a shortage. We do resting nuclear imaging all the time in our chest pain center. It's difficult to arrange from 10p-6a though, so it's usually only during the day and evening hours.

In retrospect, it has been quite sometime since the plant shutdown, so I would hope it was back online. Though the plant had some serious issue and I suspect it will be an issue in the future.

I'm curious how you guy work the injection. My understanding is that you want to inject while the patient is actively having chest pain. Is there a dose sitting in the ED? Does someone from Nuke med come running when you call? Where I am, it would likely take an hour plus from the time we call to the time a dose of thallium appeared.
 
I'm curious how you guy work the injection. My understanding is that you want to inject while the patient is actively having chest pain. Is there a dose sitting in the ED? Does someone from Nuke med come running when you call? Where I am, it would likely take an hour plus from the time we call to the time a dose of thallium appeared.

We have an active chest pain center where we do nuclear imaging within the department. It is readily available from 8-6p as there is a nuclear tech down in the ED. After 6p we have to page someone to come in from home.
 
Another interesting case...

We just had a 24 yo F @ 7 wks gestation (hx type II DM, HTN) come into the ER last week with a STEMI. ER resident triggered a cath lab alert & cards fellow didn't buy it... even after her troponin came back at 0.50. They called it myocarditis and admitted her to the CCU. When the cards attendings came in at 7am then cath'ed her and she had a 70% circ lesion and 90% LAD lesion. Utox was neg.

Of course... this is a different animal. The patient here had type II DM x 10 years. But still!!! Crazy to think a 24 yo pregnant chick had an MI.
 
Another interesting case...

We just had a 24 yo F @ 7 wks gestation (hx type II DM, HTN) come into the ER last week with a STEMI. ER resident triggered a cath lab alert & cards fellow didn't buy it... even after her troponin came back at 0.50. They called it myocarditis and admitted her to the CCU. When the cards attendings came in at 7am then cath'ed her and she had a 70% circ lesion and 90% LAD lesion. Utox was neg.

Of course... this is a different animal. The patient here had type II DM x 10 years. But still!!! Crazy to think a 24 yo pregnant chick had an MI.

Do you know if the elevations resolved on the later ECGs or if she Q'ed out? Either she recannulated her vessels or she actually had myocarditis. A 90% shouldn't give you ST elevations at rest (in theory). NSTEMI I'd buy, but STEMIs usually implies complete occlusion.
 
We had a similar experience in a 29yo...
 
waterski - you're giving the PMD too much credit IMO. We get stuff sent to us the time by PMDs. A lot of it is legit, but a lot of it is "admit for....." or "rule out...."
I take a look at the patient, examine then, get whatever appropriate studies and if I disagree with the PMD I'll give them a call and tell them why I think we should follow this up as an outpatient. If they adamantly disagree...I admit.

I can't tell you how many times we get, "rule out tenosynovitis," from PMD's. I've yet to see a true case.

we frequently get pts sent from pmds for a variety of reasons legit and not so legit. however, my personal philosophy is if the pmd was concerned and thought that outpatient mgmt was not enough and sent the pt to the ED---then medicolegally that pt should almost always be admitted. if you think the pmd is FOS and you send that pt home and he has an negative outcome, (even if its a fluke) you are F--ked. period. there are many times when I disagree with the pmd's assessment (especially the hypertensive urgency..bp 220/115 at the office and 170/100 in the ED). but if the pmd wants to admit them anyway, there's no point in wasting time arguing with them. i'll give them the benefit of the doubt since they've known the pt for years.

if it's for a rule out flexor tenosynovitis---and it absolutely clearly is nothing, then thats a different story
 
We have nuc med people in house during the daytime that come down and inject when we call. At night the radiology residents reading overnight films come inject the radioactive goods made up by the tech before he/she leaves. If there is no tracer at night then the tech gets called in to mix it up which happens every so often when we go mibi/vq crazy. Sometimes overnight we have to wait until 5am to get the test performed and read, but this is always done by 7am so we can dispo before shift change. It really is a great test. I'm going to miss it a lot if I end up somewhere without it.
 
Another interesting case...

We just had a 24 yo F @ 7 wks gestation (hx type II DM, HTN) come into the ER last week with a STEMI. ER resident triggered a cath lab alert & cards fellow didn't buy it... even after her troponin came back at 0.50. They called it myocarditis and admitted her to the CCU. When the cards attendings came in at 7am then cath'ed her and she had a 70% circ lesion and 90% LAD lesion. Utox was neg.

Of course... this is a different animal. The patient here had type II DM x 10 years. But still!!! Crazy to think a 24 yo pregnant chick had an MI.

We had a similar experience in a 29yo...

We had an 18 yo F type I DM with cc: neck pain have a STEMI. For some reason the triage nurse wrote down CP, which the patient repeatedly strongly denied. Attending ordered an EKG and bingo. :eek:
 
we frequently get pts sent from pmds for a variety of reasons legit and not so legit. however, my personal philosophy is if the pmd was concerned and thought that outpatient mgmt was not enough and sent the pt to the ED---then medicolegally that pt should almost always be admitted. if you think the pmd is FOS and you send that pt home and he has an negative outcome, (even if its a fluke) you are F--ked. period. there are many times when I disagree with the pmd's assessment (especially the hypertensive urgency..bp 220/115 at the office and 170/100 in the ED). but if the pmd wants to admit them anyway, there's no point in wasting time arguing with them. i'll give them the benefit of the doubt since they've known the pt for years.

if it's for a rule out flexor tenosynovitis---and it absolutely clearly is nothing, then thats a different story

I disagree. If I call them and document the conversation I think I'm covered, even if something bad happens. As I said, if I talk to the PMD and they really want the patient admitted, I put them in for a bed.
 
man, you could never blow off someone with chest pain, costochondritis in an absolutely healthy teenagers, sure. 28 yr old..... CP not always cardiac, pulmonary causes presents a lot of time with just CP (and SOB i). 28 yr old.... PTX, PNA, Peri/myo/endocarditis, PE, all kinds of stuff. We had a 20 yr old cocaine user who had a STEMI, chronic cocaine use accelerates atherosclerosis disease.
 
Do you know if the elevations resolved on the later ECGs or if she Q'ed out? Either she recannulated her vessels or she actually had myocarditis. A 90% shouldn't give you ST elevations at rest (in theory). NSTEMI I'd buy, but STEMIs usually implies complete occlusion.

I just reviewed the chart from the 25 yo STEMI for our upcoming M&M.... And I was wrong about her being 7 wks pregnant... she was actually 17 wks pregnant. It was a confirmed STEMI.

Her initial EKG's showed boarderline 1mm STE in V2/V3 with convex morphology and a troponin of 0.5. Her overnight repeat EKG showed dynamic increase in anterior STE and an interval increase of her troponin to 0.83. The am TTE prior to cath revealed apical akinesis with an EF of 35%, at which point she was started on a heparin gtt and taken to the cath lab. The cath report documents 90% occlusion of her mid-LAD, and 70% occlusion of her circ. She did not develop Q waves on any of her EKG's; however, her STE resolved after placement of her bare metal stent in the cath lab. Her troponin peaked at 2.00 on hospital day #3.
 
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