A woman in her 40s with intractable nausea and vomiting, dyspnea, and lightheadedness

 Submitted and written by Oriane Longerstaey MD, peer reviewed by Meyers, Smith, and McLarenA woman in her 40s with diabetes and HLD presented with nausea and vomiting x3 days. She was seen on day 1 of symptoms at an outside ED, no ECG performed, and sent home with return precautions and zofran, which she had been taking around the clock for persistent nausea and vomiting. She presented on day 3 of symptoms because of new onset dyspnea, tachycardia, lightheadedness, and heart palpitations. She had a " burning " sensation in her chest but no " pain " .A 12 lead EKG was obtained at triage: - Sinus rhythm at 96 bpm - Narrow, normal QRS - ST depressions in V3-V6, II, III, and aVF, with reciprocal STE in aVR, V1, (and potentially reciprocal in aVL) - Extremely long QT interval due to both prolonged ST segment and prolonged T wave, concerning for acquired long QT, drug induced long QT, hypokalemia, hypomagnesemia, or Takotsubo cardiomyopathy. Long QT can be subdivided by ECG into cases with long long QT due to long ST segment (hypocalcemia), long QT due to T wave (meds, takotsubo, etc.) and long QU (usually due to hypokalemia).The computer QT/QTc was 486/540 msec (heart rate 96 bpm).My quick QT interval measurement is at least 520 msec, with Bazett QTc 658 msec.Given the long QT, she was given 2g magnesium.Her initial high sensitivity troponin I was markedly elevated at 1950 ng/L.Repeat ECG was performed about an hour after the first:Mostly similar.Several ...
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