more hoofbeats, more zebras

have we mentioned to keep a wide differential?

17 y.o. with CP for 2 days

Right out of the gate we see a young patient.  At 17 we’re probably looking at a different differential than if he’s 67.  We’ll have to see how we work through it later.  This case was seen by one of our graduated residents.

Rate looks to be in the 80’s.  I see P waves throughout so it looks to be sinus.  I think there is a suggestion of PR depression.  The QRS is narrow.  What to do with the ST waves.  There is elevation in I and aVL, less so in II.  There is depression in aVR and V1.

So what to do with this?  The first differential for ST elevation obviously is ischemia.  He’s 17 so it’s very unlikely, but cocaine and methamphetamine can change that risk profile by inducing vasospasm; always remember to ask about this.  Pericarditis or myocarditis would probably be my first differential for this patient; he’s young and the STE is upcoving.  There is a suggestion of PR depression.  Early repol is commonly seen in young patients, however that is more frequent in the chest leads.  He certainly doesn’t have LBBB.  LV aneurysm crops up frequently on the written boards, usually couched as an essentially asymptomatic patient a couple weeks after an MI.

What happened to the patient?  Despite the young age, you really can’t rule out an MI and he was indeed taken to cath … where he was found to have takotsubo like ballooning of the heart. I think there’s no way that in retrospect you could make any kind of definitive case from the original EKG that that would be the ultimate finding, but it does reinforce the idea that we have to maintain wide differentials as we approach patients in the ED.

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