This excellent case comes to us from our friends in the UK. The author wishes to remain anonymous, but we thank him for his contribution.
It is about 8am on a gorgeous Wednesday morning, when your Paramedic unit is dispatched to a 49 year old male, "chest pain".
You arrive at the bungalow of a summer resort and are greeted by an elderly couple.
"They don't look too bad", you think, but you are not that lucky.
"Our son has been complaining of chest pain and vomiting for a couple of days".
You are led back to a room where you find your 49 year old patient lying in bed.
His parents say they found him like this and called 911. They tell you he seemed ok when he went to bed last night.
Your patient is lying supine in bed, responds to verbal stimuli only, and it is difficult for you to make sense of his answers.
You note that he appears anxious and uncomfortable, with dried vomit on his shirt.
His airway seems clear, but his respirations seem quick and a bit shallow, although clear bilaterally. You put him on a non-rebreather.
The rest of the vitals are as follows:
- Pulse: 85 and regular
- RR: 27, shallow
- BP: 86/62
- Pupils: equal and reactive
- Skin: cool and slightly diaphoretic
While he is not adequately answering your questions, you are able to determine from his parents that he is an insulin dependent diabetic. You are unable to determine any other past medical history, medications, or allergies.
You check his blood glucose while your partner puts him on the monitor. The BGL reads "High".
Here is the 12 lead:
You are 15 minutes from the local community hospital, and 30 minutes to the PCI center by ground. Air transport to PCI is a possibility.
What's your differential diagnosis?
What does the ECG show?
What do you want to do about it?