Section 1: Initial Presentation

You and your crew mate are dispatched at 07:10 to a private residence for a 63-year-old female complaining of ‘generally unwell’ and ‘just not feeling right’. She lives alone, and it was her daughter – who visited for breakfast – that called 999. The patient is alert, appropriately dressed, and initially tries to downplay her symptoms.

On first contact:
- GCS: 15
- HR: 87 regular
- RR: 20
- SpO2: 96% on air
- BP: 132/78
- Temp: 36.9°C
- Blood glucose: 5.7
- Cap refill: 2s
She says she’s just been ‘off her food’, has slept poorly, and felt a bit breathless after bringing in the bins last night.

Reflective Prompts:

- What’s your initial impression and working differential?

- What further questions do you ask?

- What might be easy to overlook here?

- Would you consider doing an ECG? Why or why not?

Section 2: Developing Picture

During your interaction, the patient mentions she had an episode of indigestion yesterday after lunch, which she treated with Gaviscon. She also reports intermittent mild shoulder ache (right side), which she assumed was from gardening. She denies chest pain.

She’s still a little breathless while speaking, but remains lucid and alert. There is no nausea or vomiting. No swelling or signs of DVT. You decide to perform a 12-lead ECG.

You notice subtle ST depression in the inferior leads and a borderline Q wave in lead III.

Reflective Prompts:

- What are your concerns now?

- How do you explain your reasoning to your crew mate? To the patient?

- Does this meet criteria for PPCI or does it warrant transport with monitoring?

- What role does patient age, sex, and atypical presentation play in your judgment?

Key Takeaway:

Silent MIs or atypical presentations are more common in older adults, women, and patients with diabetes. Breathlessness, fatigue, indigestion, or general malaise may be all you get. This scenario isn’t about the obvious – it’s about what we nearly missed.