Electrocardiographic clue for a mid-LAD lesion.

ECG is still the first diagnostic tool for coronary artery disease. It is possible to predict the localisation of affected vessel(s) through ST and T changes on ECG. Sometimes, reciprocal changes may be the only marker of acute myocardial ischaemia, as single T-wave inversion in lead aVL may represent a coronary artery lesion in the left anterior descending (LAD). A 49-year-old woman presented to the emergency department, with left-sided chest pain. Her initial ECG showed no ischaemic changes. On the third hour ECG there was T-wave inversion in leads aVL and V2, and troponin turned positive. Coronary angiography showed 90% mid-LAD occlusion. The importance of this case is that patients with ischaemic chest pain should be followed with serial ECG. Also, emergency physicians should be alert to identify new changes on ECG, as isolated T-wave inversion in lead aVL can be the only finding to take the patient into the catheterisation laboratory.

Asymptomatic pneumocephalus after head trauma: case report.

A 66-year-old man was brought in to our emergency department (ED) with head trauma and was diagnosed with frontal located pneumocephalus based on a cranial computed tomography (CT) scan. At the time of arrival, he was alert and his Glasgow Coma Score (GCS) was 15. A neurological examination revealed no deficit and during follow-up in the ED his GCS did not deteriorate. Cranial CT scan demonstrated nasal fracture. On maxillofacial CT examination, we detected a nasal bone fracture, air loss and fluid was seen in the maxillary and ethmoid sinuses. In our case, pneumocephalus is assumed to be the result of ethmoid bone fracture. Despite the large amount of air in the subdural area, our patient had no symptoms. He was admitted to the intensive care unit for close monitoring and was discharged from hospital without neurological deficit on the fifth day of follow-up.

Spontaneous rupture of hepatocellular carcinoma presented as low back pain to an emergency department: a case report.

INTRODUCTION: Spontaneous haemoperitoneum due to rupture of hepatocellular carcinoma (HCC) is a surgical emergency and may have catastrophic outcomes. CLINICAL PICTURE: A 62-year-old male presented with nausea, dizziness and low back pain. There was no history of malignancy. Physical examination revealed a surgical abdominal emergency, but there was no physical finding that pointed towards a specific diagnosis. Laboratory studies revealed decreased haematocrit (27.6%) and increased INR (2.8) levels. A computed tomography scan showed a tumoral lesion within the fourth segment of the liver and fluid collection (haemoperitoneum) with normal vascular and intra-abdominal structures. TREATMENT: Exploratory laparotomy was performed; the appearance of the liver was cirrhotic and nodular. Actively bleeding tumoral lesion was confirmed in fourth segment of the liver, "packing" applied with sponges to stop bleeding. On the post-operative day 22, the patient was discharged. CONCLUSIONS: Spontaneous rupture of HCC is rare and should be considered in the differential diagnosis of non-traumatic spontaneous haemoperitoneum.