A Stressing Situation

A 64-year-old woman presented to the emergency department with two days of severe nausea, numerous episodes of vomiting, and progressively worsening right upper quadrant/epigastric abdominal pain. She was continuously spitting clear secretions into an emesis bag on arrival in triage. Her 8/10 dull ”ripping” pain originated in the right upper quadrant and radiated in a band-like pattern to her epigastrium. She was not experiencing any chest pain or shortness of breath. Her medical history included hypertension, type 2 diabetes mellitus, recurrent acute pancreatitis secondary to hyperglycemia, peripheral artery disease, and gout. She smoked a pack of cigarettes daily.   Vital signs were blood pressure 123/79 mm Hg, pulse 86 bpm, respiratory rate 20 bpm, temperature 36.8°C, and SpO2 100%. She appeared quite uncomfortable. Her cardiac and chest exams were unremarkable. Her abdomen was soft but tender to palpation maximally in the epigastric region without rebound. Laboratory studies were ordered. An ECG is shown in Figure 1.   Figure 1. Presenting ECG.   This is a regular sinus tachycardia. The QRS axis is normal, but notable biphasic deep inverted T-waves are seen in the anterior precordial leads. The QTc is also very long at approximately 580 ms. These findings were noted to be different from a previous ECG obtained about three weeks earlier. (Figure 2.) The differential diagnosis of deep inverted T-waves is shown in Table 1.   Figure 2. Previous ECG.   ...
Source: Spontaneous Circulation - Category: Emergency Medicine Tags: Blog Posts Source Type: blogs