History: A man in his mid 30’s with a history of spontaneous pneumothorax x 3 presents with chest pain and lightheadedness starting around 7 AM. The pain is in the central chest and is pleuritic. He also endorses bilateral leg swelling for the past 4 days. He has no other complaints and says this pain is different from his pneumothorax pain because it is central.
Exam: Vital signs are normal except for a pulse in the 120. Physical exam is notable for tachycardia, diminished breath sounds on the left and mild symmetric leg edema
An ECG is done
Computer Read: ST at 112, possible RAE
What is the most likely cause of ECG findings in this patient?
- A) MI
- B) pericarditis
- C) PE
- D) GERD
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ECG interpretation: Sinus tachycardia with incomplete RBBB and nonspecific ST changes. No PR depression. (CXR showed scarring on the left from prior pleurodesis)
QUIZ ANSWER:
- A) MI – can rarely cause pleuritic pain. Rarely causes tachycardia
- B) pericarditis – can cause central pleuritic CP but not typically these ECG changes
- C) PE – CORRECT – there tachycardia an incomplete RBBB and nonspecific ST changes
- D) GERD – shouldn’t cause ECG changes but rarely can cause T wave inversion. A diagnosis of exclusion
Outcome: troponin 30 then 120, repeat ECG better with HR 90 and similar ST and QRS but read by computer as NSSTE and IRBBB. Started on empiric heparin and once more stable sent to CT which confirmed extensive bilateral PE’s
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