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Short answer question: a distracting ECG
  1. K Lyddon1,
  2. M Thevendra2
  1. 1Department of Medicine, Countess of Chester Hospital, Chester, UK
  2. 2Emergency Department, Countess of Chester Hospital, Chester, UK
  1. Correspondence to Dr M Thevendra, Emergency Department, Countess of Chester Hospital, Chester CH1 2UL, UK; mthevendra{at}nhs.net

http://dx.doi.org/10.1136/emermed-2014-204359

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    Part 1

    A 76-year-old man with a past medical history of chronic obstructive pulmonary disease is brought to the emergency department (ED) with suspected sepsis. He is a smoker of 15 cigarettes per day who has an exercise tolerance of approximately 30 m.

    He saw his general practitioner who treated him with antibiotics and steroids.

    He has rung for an ambulance complaining of increasing shortness of breath and back pain. His initial vital signs were: BP 100/87 mm Hg, HR 120 bpm, RR 24 breaths per minute, oxygen saturations 100% on room air and normal temperature. He appeared sweaty and clammy, but his heart and chest were normal on examination.

    An ECG is done (figure 1).

    Figure 1

    Twelve-lead ECG at initial presentation.

    Questions

    1. What is the differential diagnosis?

    2. What is your initial management?

     

    1. The differential diagnosis would include acute ST-elevation myocardial infarction (STEMI), pericarditis, dissecting thoracic aneurysm, pneumonia and pneumothorax.

      Pneumonia is unlikely given the absence of a cough or fever, normal lung examination and normal room air oxygenation. An acute pneumothorax is unlikely given the history and normal lung examination. Both, however, could be assessed with a chest radiograph. An aortic dissection should be considered in the setting of back pain with …

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    Footnotes

    • Collaborators Dr Timothy Jang.

    • Contributors The article was conceived and written by KL and MT.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; internally peer reviewed.