Determining the Cause
a. EKG: Normal
Differential Diagnosis
Myocardial Infarction, Pneumothorax, Aortic Dissection, Esophageal Rupture, Pneumonia, Gastrointestinal Reflux, Perforated Ulcer, Aortic Insufficiency
| Pivotal Assessments one after the other | Finding | |||
|---|---|---|---|---|
Serial EKGs over short intervals should be performed in patients with a high suspicion of ACS.
|
ST Segment Elevation | Non ST Elevation | Indeterminate | Remains Normal |
| Transthoracic echocardiograph for assessment of wall motion for patients with suspected ACS but a nondiagnostic ECG. | Abnormal wall motion | Normal wall motion | ||
Troponin Level
|
Elevated | Normal | ||
| D-Dimer Level | Less than 500ng | |||
| CT Scan | Intimal Flap | Hyperlucent area in the hemithorax | ||
Great — here's a clear breakdown of how specific wall motion abnormalities on echocardiogram correlate with coronary artery territories. This helps in localizing the infarct and understanding which artery may be involved:
Supplies the anterior wall, anteroseptum, and apex of the left ventricle.
Anterior wall hypokinesis/akinesis
Septal wall abnormalities
Apical wall motion abnormality
🧭 Echo Segments Affected:
Anterior septum (basal, mid)
Anterior wall (basal, mid)
Apical septum
Apical anterior
Apex
Usually supplies the inferior wall, posterior septum, and right ventricle. It also supplies the inferior part of the LV in right-dominant circulation.
Inferior wall hypokinesis/akinesis
Possible RV dysfunction
May see tricuspid regurgitation if RV is involved
🧭 Echo Segments Affected:
Inferior wall (basal, mid)
Inferoseptal wall (basal, mid)
RV free wall (in some cases)
Supplies the lateral wall and often part of the posterior wall.
Lateral wall hypokinesis
Posterior wall motion abnormality
🧭 Echo Segments Affected:
Lateral wall (basal, mid)
Posterior wall (basal, mid)
Possibly apical lateral
This is harder to visualize directly on TTE, but may be inferred from:
Basal inferolateral hypokinesis
Increased echogenicity or wall thinning
Use of posterior views (or contrast echo, if needed)
| Coronary Artery | Wall Segments on Echo | Common Location |
|---|---|---|
| LAD | Anterior, septal, apical walls | Anterior MI |
| RCA | Inferior wall, RV | Inferior MI |
| LCx | Lateral, posterior wall | Lateral/Posterior MI |
Would you like a visual diagram or a sample echocardiogram segmentation chart?
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Here’s a simplified decision tree for diagnosing esophageal reflux (GERD):
+-----------------------------+ | Typical symptoms of GERD? | | (heartburn, regurgitation) | +-----------------------------+ | v +----------------------------+ | Trial of PPI (e.g., omeprazole) | | for 4–8 weeks | +----------------------------+ | v +-------------------------------+ | Symptoms improve with PPI? | +-------------------------------+ | | v v +--------------------+ +-----------------------------+ | Diagnosis: GERD | | Atypical or refractory case | | (Clinical diagnosis)| +-----------------------------+ +--------------------+ | v +------------------------------------+ | Alarm symptoms or risk factors? | | (dysphagia, weight loss, bleeding) | +------------------------------------+ | | v v +---------------------------+ +------------------------+ | Upper endoscopy (EGD) | | Ambulatory pH ± impedance| | +/- biopsy | | monitoring (off PPI) | +---------------------------+ +------------------------+ | | v v +-------------------------------+ +----------------------------------+ | Findings confirm GERD, | | Acid/non-acid reflux confirmed? | | Barrett's, esophagitis, etc. | +----------------------------------+ +-------------------------------+ | | | v v +--------------------------+ +----------------------------+ | Treat accordingly: | | Diagnosis: Non-erosive | | lifestyle + PPI, etc. | | reflux disease (NERD) | +--------------------------+ +----------------------------+
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