A woman in her early 60's came to the ER with complaints of "stomach pain" for the last six months. She localizes her discomfort to the epigastric and left upper abdomen, and a very discreet association with food. "It hurts mainly when I eat greasy foods." She reports some relief in the early weeks with Tums antacid and occasional use of OTC Omeprazole, but admits that she has taken these only sporadically. "I have a lot of burping," she tells me, "and when I do burp a lot, the pain gets a lot better." She also told me that her symptoms were worse when she was lying down at night. Though the patient had her symptoms for six month, she did not have health insurance and did not report them to her doctor "because I can't afford to have any tests done."
She denies and complaints of chest pain, weakness, diaphoresis, shortness of breath or other symptoms of concern. She also has noted no association of this illness with any physical exertion. "It's just really when I eat."
Her medical history is remarkable only for hypertension and high cholesterol. She takes medication for both, but tells me she can't take statins because they cause a lot of muscle weakness. Unfortunately, she does smoke cigarettes. She has had no surgery in the past.
On exam she is an alert, refreshingly non-obese and generally healthy-appearing lady. She is in no acute distress, but does have some complaint of her upper abdominal discomfort on exam. Her area of focal pain is mildly tender, but without peritoneal findings. Bowel sounds are normal and the aorta is not appreciated on exam. Her vitals signs are within normal limits.
I performed a bedside abdominal ultrasound and noted a normal aorta and IVC. Her liver was unremarkable, but she did have gallbladder wall thickening (5mm) with no stones, sludge, or significant edema. The common bile duct was 3-4mm. There was no sonographic Murphy's sign. I felt it likely that she had some chronic cholecystitis.
I ordered IV Zantac and Protonix and during treatment her pain subsided and she tolerated clear fluids well. Laboratory analysis showed a normal CBC and differential, essentially normal Chem 7 except for a mildly elevated glucose of 121. Liver functions showed normal bilirubin, but the AST, ALT, and Alkaline Phos. where modestly elevated. UA was normal. A cardiac profile and EKG were also ordered, the CK was normal, with a pending Troponin. I reviewed the EKG and noted inferior and lateral ST/T-wave abnormalities, Unfortunately, this was the patient's first visit to the ER, and no old EKG was available for review. Eventually, the Troponin resulted at 0.893 (MI threshold is 0.125). Chest Xray was normal.
I consulted with the hospitalist service and arranged to admit the patient for further workup. The first repeat Troponin was 0.769. I suspect that since the patient had a normal CK, this had peaked and return to normal before that patient came to the ED, and her MI was subacute. Still the extent of her coronary disease needed to be investigated and managed before a more serious event occurred.
We are taught that many MI patients will present with atypical symptoms. The higher risk groups are women and diabetics. The biggest point of liability in emergency medicine remains the missed MI. Even in a patient with clear-cut signs, symptoms, laboratory, and ultrasound findings of a compelling GI condition, you have to consider coronary disease in those with risk factors (age, HTN, hyperlipidemia, smoking). This case cannot punctuate that lesson enough.
Always consider and investigate the potential of a cardiac origin in any patient with upper abdominal complaints with coronary risk factors.