MosaicED Brain Teaser!
You're in the ED contemplating little being a doctor is like it was depicted in scrubs, no matter how many taxidermied dogs you buy. A 44 year old women comes in with epigastric pain and the nurse in charge assigns her to you. You deliver your best quip to her but instead of zinging you back she looks at you and says "Doctor that comment was inappropriate and I feel like you're making this an unprofessional workplace. I'm afraid I have to go to talk to HR."
The pain came on when the patient got to work this morning, it is right sided and heavy. It was preceded by a unilateral headache and is associated with nausea and sweating.
She returned from an overseas holiday three weeks ago.
Her past history is notable for breast cancer 4 years a go for which she had a double mastectomy and 1 course of radiotherapy and type 2 diabetes myelitis controlled with metformin.
She has 20 pack years and is a social drinker.
BP 130/70, HR 70, RR 18, O2 sat 98% on RA, T 36.7
Obese woman, not in any respiratory distress, talking in complete sentences, DHS NM, chest clear, abdomen soft non tender.
ECG shows sinus rhythm.
Which of these is the most useful test for this patient?
- A-Atypical pneumonia screen
- C-Beta HCG
- H-Faecal occult blood test
- I-Fasting lipids
- L- LFT
- N-Peak flow
- O-Troponin T
Answers:O-Troponin T. It would be an unusual AMI presentation but it is not improbable and a NSTEMI definitely needs to be ruled out. She is a diabetic, obese and a smoker. Women and diabetics are prone to less typical AMI presentations. A d-dimer is not needed as her PERC score is 0, and clinical suspicion should be low she travelled overseas three weeks ago not yesterday.