45/F presented to ER with c/o Right upper & lower quadrant severe abdominal pain since 12.30 midnight a/w vomiting - 6 episodes h/o right flank pain radiating to lower abdomen. h/o palpitation+ no h/o fever/decreased urine output / burning micturition. ECG done showed this changes diagnosis and treatment?

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Signs and symptoms are overlapping between abdominal cause of symptoms like acute appendicitis, acute cholecystitis, a perforated peptic ulcer considering the right sided pain . Also considering the ECG changes of sinus and bradycardia and inferior/ anterolateral myocardial ischaemia- patient needs to be thoroughly evaluated and managed .Investigations needed are 1.An X- ray abdomen standing to see gas under right dome of diaphragm 2.An ultrasound scan of abdomen to rule out acute cholecystitis- CHOLELITHIASIS and acute appendicitis besides pancreatitis. 3.A Trop - T test to evaluate Acute M.I 4.Echocardiography for cardiac evaluation

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NSR, sinus bradycardia Anterior wall ischemia ECHO, electrolytes, TFT Clinical picture is suggestive of right ureteric colic , gall bladder disease, appendicitis . Bradycardia in such as situation is due to increased vagal tone .

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ECG=SINUS BRADYCARDIA ADV DO USG OF WHOLE ABDOMEN TO RULE OUT APPENDICITIS. ?CHOLECYSTITIS RX START ANTIBIOTICS. CONSERVATIVE MANAGEMENT.

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RT UPPER & LOWER ABD PAIN VOMITING++ O/ E MUSCLE GUARD ? MURPHEY'S SIGN ? RENAL ANGLE TENDERNESS ? MC BURNES TENDERNESS ? 45 YRS F = MENSTRUAL HISTORY = POSSIBLY = MENOPAUSE USG = ABDOMEN BLOOD = CBC URINE = ROUTINE C & S ECG = SINUS BRADICARDIA ST T ZCHANGES V3 ----V6

Sinus Bradycardia Inferolateral wall ischemia Ad2 D ECHO Cardiac enzymes

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From the ecg it's sinus bradycardia and anterolateral ischemia. Holter monitoring. Inj atropine IV SOS. Analgesics. Antiemetic. Cardiology opinion. Need trop I, abg, RBS , usg w/a.

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SINUS BRADICARDIA WITH ANTERIOLATERAL ISCHEMIA

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Except Bredycardia no significant conclusion can be derived from ECG. Other systemic involvement like Hepeto billary system and Renal system functioning should be taken in considerations.

S.Bradycardia St t changes in Inf leads & v2 to v6 Need old ecg to confirm changes NEW/OLD Otherwise Echo, Troponin

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Sinus bradycardia, inferolateral wall ischemia.cardiac enzymes,2d echo, serial ecg's should be done.

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