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The eyes see only what the mind knows1
The Journal of Emergency Medicine, Vol. 19, No. 3, pp. 275–276, 2000 Copyright © 2000 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/00 $–see front matter
PII S0736-4679(00)00237-7
Visual Diagnosis in Emergency Medicine
THE EYES SEE ONLY WHAT THE MIND KNOWS Umesh C. Jairath,
MD
and David H. Spodick,
MD, DSc.
Cardiology Division, Saint Vincent Hospital/University of Massachusetts Medical School, Worcester, Massachusetts Reprint Address: David H. Spodick, MD, Cardiology Division, Saint Vincent Hospital, Worcester, MA 01604
A 50-year-old male presented who complained of retrosternal and epigastric pain described as 8/10 in severity and 3– 4 h in duration. The patient had multiple coronary risk factors, including history of longstanding diabetes, hypertension, and family history of premature coronary artery disease. He was on maintenance hemodialysis for chronic renal insufficiency. Figure 1 shows the electrocardiogram (EKG). On the basis of this EKG, the patient was considered to have acute ischemia and given aspirin, a -blocker, and intravenous nitrate and heparin. The patient was
fortunate that no thrombolytic treatment was given. During morning rounds, reevaluation of EKG interpreted it as classic findings of acute pericarditis, i.e., ST elevation with PR depression in appropriate leads with tall T waves suggesting acute hyperkalemia (another mimic of the hyperacute phase of MI). Upon close questioning, he described respirophasic pain; auscultation revealed a two component pericardial rub. The review of laboratory data revealed elevated potassium, BUN, and creatinine with a normal CPK. With an EKG like the one shown in Figure 1, it is
Figure 1. EKG showing ST segment elevation in multiple limb leads (except aVr) and V2–V6 with PR depression in leads 1, 2, aVf and V2-V6.
Visual Diagnosis in Emergency Medicine is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California
RECEIVED: 13 August 1999; FINAL ACCEPTED: 8 February 2000
SUBMISSION RECEIVED:
29 December 1999; 275
276
tempting to diagnose acute evolving myocardial infarction (“hyperacute” T waves and ST elevation), and therefore increased likelihood of giving thrombolytic treatment. Herein lies the importance of a good history (i.e., the respirophasic nature of pain), physical examination (demonstration of a pericardial rub rather than a murmur), knowledge of comorbid conditions (chronic renal
U. C. Jairath and D. H. Spodick
insufficiency with hyperkalemia), and a careful analysis of the EKG (PR depressions and absence of reciprocal ST-T changes in acute pericarditis). Also, when encountering this kind of problem, it is wise to obtain a twodimensional echocardiogram, which might reveal a (small) pericardial effusion in pericarditis or regional wall motion abnormalities in ischemia.
PII S0736-4679(00)00237-7
Visual Diagnosis in Emergency Medicine
THE EYES SEE ONLY WHAT THE MIND KNOWS Umesh C. Jairath,
MD
and David H. Spodick,
MD, DSc.
Cardiology Division, Saint Vincent Hospital/University of Massachusetts Medical School, Worcester, Massachusetts Reprint Address: David H. Spodick, MD, Cardiology Division, Saint Vincent Hospital, Worcester, MA 01604
A 50-year-old male presented who complained of retrosternal and epigastric pain described as 8/10 in severity and 3– 4 h in duration. The patient had multiple coronary risk factors, including history of longstanding diabetes, hypertension, and family history of premature coronary artery disease. He was on maintenance hemodialysis for chronic renal insufficiency. Figure 1 shows the electrocardiogram (EKG). On the basis of this EKG, the patient was considered to have acute ischemia and given aspirin, a -blocker, and intravenous nitrate and heparin. The patient was
fortunate that no thrombolytic treatment was given. During morning rounds, reevaluation of EKG interpreted it as classic findings of acute pericarditis, i.e., ST elevation with PR depression in appropriate leads with tall T waves suggesting acute hyperkalemia (another mimic of the hyperacute phase of MI). Upon close questioning, he described respirophasic pain; auscultation revealed a two component pericardial rub. The review of laboratory data revealed elevated potassium, BUN, and creatinine with a normal CPK. With an EKG like the one shown in Figure 1, it is
Figure 1. EKG showing ST segment elevation in multiple limb leads (except aVr) and V2–V6 with PR depression in leads 1, 2, aVf and V2-V6.
Visual Diagnosis in Emergency Medicine is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California
RECEIVED: 13 August 1999; FINAL ACCEPTED: 8 February 2000
SUBMISSION RECEIVED:
29 December 1999; 275
276
tempting to diagnose acute evolving myocardial infarction (“hyperacute” T waves and ST elevation), and therefore increased likelihood of giving thrombolytic treatment. Herein lies the importance of a good history (i.e., the respirophasic nature of pain), physical examination (demonstration of a pericardial rub rather than a murmur), knowledge of comorbid conditions (chronic renal
U. C. Jairath and D. H. Spodick
insufficiency with hyperkalemia), and a careful analysis of the EKG (PR depressions and absence of reciprocal ST-T changes in acute pericarditis). Also, when encountering this kind of problem, it is wise to obtain a twodimensional echocardiogram, which might reveal a (small) pericardial effusion in pericarditis or regional wall motion abnormalities in ischemia.