56 y male C/o profuse vomiting since 30 mins Known DM /HTN On arrival BP - 170/110 Pupils b/l equal reacting to light . Patient settled with one dose of ondansetron. ABG /ECG attached below What can be probable diagnosis ?

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D/d 1. Acute coronary syndrome ( STE inferior leads and ST depression aVR) Diabetic ketoacidois ( high anion gap metabolic acidosis) Vomitting ( MI PLUS DKA) causing Metabolic alkalosis ( delta gap positive ) Compensated respiratory alkalosis Dehydration causing hypernatremia 2. Acute pericarditis (Slight diffuse upsloping of ST segment and ST depression of PR segment) Followed by the same sequence ECG: left atrial enlargement with prolonged PR interval with STE inferior leads and probably lateral leads with poor progression of R waves.

Hypernatremia. Sinus tachycardia, LAD, Q wave prominent in Inferior leads with T wave inversion suggestive of old Inferior Wall m i, poor r progression,. A .G. E ? Electrolyts imbalance, needed kft,sr electrolyts,cbc, BSR, HBA1c. ?

He is diabetic may not show classical pic of MI, Poor R wave progress ST uptake in 2 avf Only q wave in lead 3 ,looking like ACS bp also high, anyway admit send cardiac markers 2 sets, serial ECG, 2Decho ,start if bp still same after 10 min of no vomiting ntg ,lactate 2 hypoperfusion marker ,send cbc SE creat,loadibg dose of antiplatelets

AGE with hypernatremia

Water loss in AGE leads to relative hypernatremia Symptomatic tt with correction of electrolytes and volume loss will help

Low voltage in chest leads Poor R wave progression across the chest leads Old IWMI Hypernetremia Check S.creatinine,

Early ST elevations in inferior leads..

Hypernatraemia

Hypernatremia poor progression of R wave, ST elevation in inferior leads

Due to acute enterogastritis IV R.L inn piptaz and IV levoflox

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