Richard A. Harrigan, MD

A 44-year-old man presents to the emergency department (ED) with light-headedness, nausea, and vomiting of 1 day's duration. He has also had intermittent palpitations but denies chest pain, dyspnea, and weakness.

A 68-year-old woman with hypertension complains of intermittent dyspnea and light-headedness. She is asymptomatic during the evaluation. Vital signs are normal, but an irregularly irregular pulse is noted on examination as well as on the telemetry monitor. The 12-lead ECG is shown here; the ECG machine printout reads "atrial fibrillation." The patient has no history of this arrhythmia.

A 24-year-old woman presents to the emergency department (ED) withgeneralized weakness, headache, and muscle cramping that have progressivelyworsened over the past week. Recently, she has also had nauseaand vomiting. She denies chest pain, palpitations, dyspnea, cough, fever,chills, diarrhea, and urinary symptoms. She has a history of type 1 renaltubular acidosis.

An 80-year-old man presents to the emergency department (ED) with intermittent dyspnea and chest pain. He has hypertension and osteoarthritis but no known cardiac disease. Vital signs are normal. No jugular venous distention is noted. The lungs are clear with equal breath sounds, and the heart rate is regular, without murmurs, gallops, or rubs. The chest wall is not tender. No edema or asymmetry is evident in the extremities.

In cases of PEA, a rapid, narrow-QRS-complex rhythm is associated with an improved chance of survival.

A56-year-old woman with chest pain and emesis is brought to the hospitalby ambulance. En route, the pain resolves after nitrates, morphine,and aspirin are administered.

Rapid, accurate diagnosisof acute myocardialinfarction(MI) in patientswith chest pain isa formidable challenge.

A 54-year-old man with a history of type 2 diabetes, hypertension, and coronaryartery disease with angina presents to the physician’s office withchest pain. The pain began 3 hours earlier and is associated with diaphoresisand dyspnea. Examination results are unremarkable, except for diaphoresis.A 12-lead ECG reveals normal sinus rhythm with large R waves and horizontalST-segment depression in leads V1 through V3. The patient is given nitroglycerin,aspirin, heparin, morphine, and a &#946-blocker for noninfarction acutecardiac ischemia and transferred to the local emergency department (ED).

An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.

A42-year-old man with a history of hypertension presents to an outpatientclinic with chest pain that began the day before, after he had worked outat his health club. The discomfort increases when he walks and worsenssomewhat with inspiration. No associated symptoms are noted. Results of aphysical examination are normal; no chest wall tenderness is evident. Becausecertain features of the presentation suggest an acute coronary syndrome, a12-lead ECG is obtained, which is shown here.

A 76-year-old woman presents with chest pain-which she describes as“muscle tightness”- that began when she awoke in the morning. Thepain is constant, exacerbated by deep inspiration, and accompanied by asubjective sense of slight dyspnea; she rates its severity as 3 on a scale of1 to 10. She denies pain radiation, nausea, diaphoresis, palpitations, andlight-headedness. Her only cardiac risk factors are hypertension and a distanthistory of smoking.

A30-year-old man complains of chest pain, dyspnea, fever, and nonproductivecough that began earlier in the day. The pain is constant and does notdiminish with rest; it worsens somewhat with deep inspiration and has localizedto the left chest. The patient has had no nausea, vomiting, or abdominal pain.He has been immobile for several years secondary to spinal cord disease buthas no history of cardiopulmonary disease.

When your patient presents with chest pain and other symptoms of an acute coronary syndrome (ACS), yet a standard 12-lead ECG shows no evidence of ST-segment elevation myocardial infarction (STEMI), you may face a diagnostic dilemma. The patient could have a non-STEMI ACS for which conservative treatment will suffice--or he could have a STEMI in an electrocardiographically "silent" area and need acute reperfusion therapy.

When your patient presents with chest pain and other symptoms of an acute coronary syndrome (ACS), yet a standard 12-lead ECG shows no evidence of ST-segment elevation myocardial infarction (STEMI), you may face a diagnostic dilemma.

An 82-year-old man presents with shoulder pain resulting from a fall the day before. He has had intermittent episodes of light-headedness, chest pain, and "flutterings in the chest" over the past week--including one this morning.

56-year-old man presents with substernal chest pain, diaphoresis, and weakness of 1 hour's duration. He had taken a sublingual nitroglycerin tablet that had been prescribed for his wife.

An 86-year-old woman complains that she has felt "not at all well" for the past day. Her symptoms include diffuse generalized weakness and nausea; she denies chest pain, shortness of breath, abdominal pain, leg swelling, palpitations, and light-headedness. Five years earlier, a pacemaker was implanted as therapy for sick sinus syndrome and atrial fibrillation.

35-year-old woman presents to the emergency department with palpitations and chest pain. She is aware of her heart beating fast but not irregularly. She notes associated discomfort in the center of her chest.

56-year-old man with a history of diabetes mellitus and hypertension presents with chest pain, emesis, pallor, and diaphoresis.

A 66-year-old woman with a history of coronary artery disease, hypertension, diabetes mellitus, and end-stage renal disease presents to the emergency department 1 week after a coronary artery stent was placed to treat ischemic heart disease.

56-year-old woman presents for evaluation of several syncopal episodes that occurred during the past 2 weeks. These episodes were associated with various activities--eating while seated, walking slowly, and standing upright--and rendered her briefly unconscious.

A 34-year-old man presents to the emergency department with progressive, generalized weakness and shortness of breath that began 2 weeks earlier. He has no history of cardiac disorders, and he denies chest pain, palpitations, and abdominal pain. He admits to recent methamphetamine use.

A 60-year-old woman with hypertension, diabetes mellitus, and intermittentatrial fibrillation presents with nausea, diaphoresis, dizziness, and globalweakness that has lasted 1 hour. She denies chest pain, dyspnea, syncope,vomiting, diarrhea, blood loss, and headache; there is no vertigo. Medicationsinclude acetaminophen, digoxin, diltiazem, glipizide, hydrochlorothiazide,irbesartan, metformin, pioglitazone, and warfarin.