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A 27 year old man was hospitalised because of chest pain that had started eight hours earlier following an argument. On admission he was alert and his blood pressure was 120/80 mm Hg. Physical examination revealed no other abnormalities except for wounds on the thoracic wall and skull, presumably caused by entry of gunshot pellets. No exit wounds were found. Cranial computed tomography, magnetic resonance imaging, and EEG were normal. The ECG showed pronounced ST elevation in the inferior leads. Telecardiogram revealed radiopaque round foreign bodies, presumably the pellets, at the margin of the cardiac silhouette. Transthoracic echocardiography and aortography showed no signs of extravasated blood, but coronary angiography showed dissection of the right coronary artery by the pellet (see panels). Removal of the pellet, percutaneously or surgically, was not attempted because although the patient was haemodynamically stable, the risk of catastrophic haemorrhage was high.
The patient was discharged nine days later with no ongoing problems, having experienced an uncomplicated inferior myocardial infarction.