Welcome to the channel where medical topics are made easy.
In this video, we’re going to walk through a clinical case.
You’ll first be given a scenario, and then as we go through the case
try to figure out the diagnosis and how you would manage it.
This is good practice for nursing, medical, and healthcare students,
and is also good practice for licensure or board exams.
Comment down below if you want more videos like this.
And make sure to watch until the end to see if you diagnose and manage the patient correctly.
There will be some high-yield learning points at the end too.
And as always, all of the notes for this video can be found on the website linked below.
So turn on the captions and read along, and let’s get right into it!
The initial triage information you have on the patient is they’re a 68-year-old
male presenting with epigastric abdominal pain.
Their vital signs on arrival are a blood pressure of 117/78, a heart rate of 67,
a respiratory rate of 22, a temperature of 37.2 Celsius or 98.9 Fahrenheit, and a O2 sat of 96%.
Now hit pause in the video and start to think about a broad differential diagnosis,
and what other questions you would have for the patient to help figure out what’s going on?
We’ll show you the differential diagnosis at the end, so we don’t ruin the case.
You might ask more questions about the location of pain, whether the pain radiates,
what the pain feels like, how severe the pain is, does anything make the pain better or worse,
has he tried anything for his symptoms, and does he have any associated symptoms.
As you get more information you learn the patient is a 68-year-old male with a history
of hypertension and diabetes presenting with 3 days of localized epigastric abdominal pain.
The pain is intermittent and he describes it as a “burning” sensation.
Today’s episode began while raking the leaves. The pain is currently a 7/10.
He reports nausea without vomiting.
And he denies dyspnea (shortness of breath), fevers, cough, congestion, urinary symptoms, or changes to stool.
You also obtain more information about his general history.
He has a past medical history of hypertension and type 2 diabetes.
He has no surgical history.
He was a former smoker and quit 5 years ago. He used to smoke 1 pack of cigarettes per day.
He has a family history of hypertension in his father.
He has no allergies, and he takes lisinopril and metformin.
When you walk in the room you see a 68-year-old man who is alert and oriented,
is in mild distress due to pain, and appears pale and clammy.
You then look at his ABCs.
Airway is intact and he is speaking in full sentences.
His breathing shows no significant respiratory distress,
but does have an increased respiratory rate.
His circulation shows cool and clammy skin, pulses and capillary refill are normal.
His head and neck exam is normal.
He has no reproducible pain to palpation to his chest and no signs of chest trauma.
His heart is regular rate and rhythm without rubs, gallops, or murmurs.
His lungs are clear to auscultation bilaterally.
And his abdomen is soft, non-tender, non-distended, and without signs of trauma.
Bowel sounds are present. There are no masses. No rigidity, rebound tenderness, or guarding present.
His extremity, back, and neurological exams are normal.
His skin is cool, clammy, and pale without edema or clubbing.
Stop the video again. What is your differential diagnosis now?
And what are your next steps in management.
Again, we’ll show you an example differential diagnosis at the end once the case is revealed.
The patient should be hooked up to cardiac monitor, continuous pulse oximetry,
and 2 large-bore peripheral IVs placed.
Given the patient has a history of diabetes and is cool, clammy, and nauseous after raking
the leaves, a quick point of care glucose should be obtained to get his blood sugar.
Based on the information you have,
stop the video and decide what your work up and next steps would be?
Let’s go through work up considerations and why they should be ordered.
Hopefully you thought of an EKG to assess cardiac etiologies
given the patient is a 68-year-old male with cardiovascular risk factors like hypertension,
diabetes, is a former smoker, and is presenting with epigastric abdominal pain.
Labs should also be ordered including
a CBC or complete blood count.
Although non-specific, the white blood cell count
may be abnormal with infectious or inflammatory causes of his symptoms.
Based on your differential diagnosis, there were likely conditions that may require intervention,
anticoagulation, reversal of bleeding,
or associated with bleeding so it’s good to have hemoglobin and platelets as well.
A chemistry should also be ordered, especially with his abdominal pain and history of diabetes.
This will contain electrolytes, renal function, and glucose.
Given his epigastric pain, you should consider a liver function test to look
at hepatobiliary causes or a lipase to assess the pancreas such as pancreatitis.
As mentioned before, cardiac etiologies should be considered
given his risk factors and epigastric pain, so a troponin should be ordered.
Finally you can consider coagulation studies. This is good to have especially if the patient
requires procedures, or anticoagulation, or reversal of bleeding for any reason.
These are the main labs to consider, but that doesn’t mean there can’t be others.
For example, you may have thought of lactate, urinalysis, blood gas, d-dimer, and others.
What about imaging?
You could consider a chest x-ray as part of the cardiac work up given his presentation,
increased respiratory rate, and the cardiac reasons mentioned for the EKG and troponin.
You could also consider a quick bedside ultrasound if concerned for a AAA (abdominal aortic aneurysm).
And even though he has epigastric pain, an abdominal x-ray for an
acute abdomen or a CT abdomen and pelvis are probably not necessary at this time,
especially given his very benign abdominal exam and other things needing worked up first.
But remember you can always adjust the plan as you get more information.
As you finish putting in orders and are considering what medications to
give the patient for his pain and symptoms, you’re handed this EKG.
Pause the video and think through how you would
manage the patient and what you would do next.
We can see we have ST elevations in leads II, III, and aVF and reciprocal ST depressions in lead aVL.
Leads II, III, and aVF are inferior leads,
so this EKG is concerning for an acute inferior myocardial infarction.
Hit pause in the video. How would you manage this and what medications would you administer?
You should follow your institutional protocols for a STEMI.
STEMI protocols can change over time so make sure you follow current guidelines.
You should activate the cardiac catheterization lab for intervention
and potential coronary stent placement for his MI (myocardial infarction).
The top priority is to restore blood flow to the heart as quickly as possible.
You should consult and communicate with the
interventional cardiologist or appropriate provider.
The patient should receive medications including aspirin, and most facilities recommend dual
antiplatelet therapy with aspirin and a P2Y12 inhibitor such as clopidogrel or ticagrelor.
Remember many STEMIs are caused by coronary artery plaque rupture.
This then causes platelet adhesion, activation,
and aggregation, as well as activation of the coagulation cascade to form a thrombus,
which can occlude the coronary artery and reduce blood flow to the heart.
By inhibiting platelet function, you’re trying to reduce and minimize thrombus formation
and worsening of that coronary artery occlusion.
You want to try to improve blood flow through the artery.
Likewise, many protocols will include an anticoagulant such as heparin.
This again is to help reduce thrombus formation from the coagulation cascade.
You can decide which medications to give in conjunction with the cardiologist
because they might be giving medications too as the patient goes to the cath lab.
Finally, you might need to treat the patient’s
symptoms as long as there are no contraindications.
This might include pain control with analgesics and nausea control with antiemetics.
Some analgesics may interfere with anti-platelet effects,
so be aware of that. Again you can discuss additional medications with cardiology.
What about nitroglycerin? When you were thinking about your management,
did you say if you would give that? And then what about fluids, are they safe?
Starting with nitroglycerin.
Should you give it to the patient?
Remember nitroglycerin is often given for angina or acute MIs because it causes vasodilation.
And coronary artery dilation increases blood flow to the myocardium.
Inferior STEMIs are different. They can involve the right ventricle,
and the right ventricle relies on preload for adequate cardiac function.
Nitroglycerin reduces preload through its vasodilation,
so it should be avoided in patients with an inferior STEMI, especially if right ventricular involvement
is unknown or suspected.
The vasodilation from the nitroglycerin can decrease preload, which we said the right ventricle needs.
This can cause hypotension and hemodynamic instability.
For an inferior STEMI, you can consider getting a right-sided EKG.
This is where some or all of the V1-V6 leads are
placed in a mirror-image on the right side of the chest.
If there are ST elevations or changes in the right-sided leads,
then that could suggest a right coronary artery occlusion and right ventricular involvement.
And this can lead to hypotension if there is inadequate preload.
What about fluids, are they safe?
If the inferior STEMI involves the right ventricle,
then the patient may require sufficient preload to maintain adequate cardiac function.
So if the blood pressure is low, then giving small fluid boluses might help
up to a certain point as long as there are no contraindications.
Let’s go over the key learning points.
This was a case of acute coronary syndrome (ACS), specifically an inferior wall
myocardial infarction with ST elevations in the inferior leads II, III, and aVF.
Be aware of atypical ACS presentations,
especially in populations involving the elderly, diabetics, and females.
They may not present with the classic exertional crushing chest pain.
Instead they could present with epigastric pain, nausea, dyspepsia, or fatigue.
This case was an example of that where we had a patient with a history of diabetes
presenting with epigastric abdominal pain that actually turned out to be an MI.
Consider getting a right-sided EKG with inferior STEMIs.
If you had ordered a right-sided EKG in this case, it would have shown ST elevations in the right
sided leads suggesting right coronary artery occlusion and right ventricular involvement.
Avoid giving nitroglycerin with inferior STEMIs,
especially if right ventricular involvement is unknown or suspected.
The vasodilation from the nitroglycerin can decrease preload which the right ventricle relies on,
and this can lead to hypotension and hemodynamic instability.
The other results would have come back with a positive troponin
and the other labs and chest x-ray were overall unremarkable.
Here is an example differential diagnosis for the case.
This is not necessarily a complete list and you may have thought of others.
Hopefully this case gave you good practice for an atypical presentation of an MI.
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As always, you can find all of the notes and pictures for this video on
the website linked down below in the description.
Thanks for watching and hope you check out future videos.