Something's not right

Diagnostic Challenge

Andrew Healey, MD;* Tia Renouf, MD†

*Assistant Professor, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Nfld. †Emergency Medicine Resident, McMaster University, Hamilton, Ont.

CJEM 2005;7(4):283

Case history

A 59-year-old gentleman awoke from sleep in the morning and attempted to get out of bed. He immediately began to experience chest pain and took some of his wife's nitroglycerine with minimal relief. At this point, his wife called an ambulance.

On arrival to the emergency department, his vitals signs were as follows: pulse 80 beats/min; respiratory rate 20 breaths/min; blood pressure 180/100 mm Hg and 160/100 mm Hg in the right and left arms, respectively; temperature 35.6°C, oxygen saturation, 100% on room air. He complained of chest pressure radiating to the back, abdomen and flanks. He also described weakness, shortness of breath and diaphoresis. His past medical history included a remote cholecystectomy, previous non-bleeding peptic ulcer disease and sleep apnea. He was recently diagnosed with hypertension and started on an angiotensin converting enzyme inhibitor. He had a heavy smoking history and considered himself a social drinker.

On examination, this obese gentlemen was pale, diaphoretic and in obvious discomfort. There were no focal neurological findings, and physical examination of the heart, lungs and abdomen was unremarkable. The jugular venous pulsation was within normal limits and radial, femoral and pedal pulses were symmetric. Results of his chest x-ray (Fig. 1) and ECG (Fig. 2) are shown below. The next steps in management would include: