34 yo female "abnormal labs"

[pbruss]

34 yo female told to come in by her PCP for "abnormal labs".  yesterday she was in a hot tub had acute onset of palpitations, chest pain, and near syncope. lasted apron 2 hours and resolved. she went to an urgent care while still symptomatic. they did an keg, cxr, labs and DC her home. she called here pcp the next day who checked the labs, K was 3 so she was told to go to the ER. In the ER she is symptom free and has a normal exam. she smokes but exersizes daily and is in good shape. her vitals and exam are all normal.

she has a copy of all the test from the urgent care including the EKG attached. (sorry abut the quality- its a copy of a copy)

What is you interp and treatment?

Attachments:

ekg.jp2 (269.43 KB)

[hackman]

Giant t-wave inversion in the mid precordial leads in otherwise young healthy female. If vitals are stable, I would lean towards this indicating possible apical hypertrophy. Pt needs a cards consult and echocardiogram at minimum. Pt does smoke, but I would also inquire about other PE risk factors (BC, travel, etc) as PE has been reported with these findings.

[hackman]

Actually on closer look, I am concerned for Wellens here. Cards should come down and see patient for possible cath. The biphasic t wave in V2 concerns me

[Bjs04f]

cant open file, but I disagree with scott, because hes scott

[pbruss]

stransky is correct. see if this attachment works better

Attachments:

[pbruss]

wellens is what i called it. STEMI activated but not taken to cath because she was symptom free. cards did bedside echo which was normal. they were concerned for type one brugada as well. which initially i was kind of on board with but when looking at EKG that we did in the ER (see attached) i think the t waves in v 4 5 and 6 are more consistent with a subendocardial infarction / ischemia then with brugada. talked to amal mattu who agrees wellens most likely and brugada less likely so that seals it for me.

but the plan was for EP to see, asa heparin and probably cath in 24 hours. on side note her trop at the urgent care was 1.2 and normal in or ED. this was just yesterday so we'll see what EP and cath says. and forgive the circle, i got excited and circled the original while explaining it to someone.

Attachments:

[Bjs04f]

Not too keen on type 1 brugada, which to me has that higher J point and coved st, not just bam inverted deep T

[kemple]

Hackman FTW, btw nice to have another person on here!

[pbruss]

for follow up she had a cath 2 days later - 95% proximal LAD that was stented.

[tyson]

while she was in icu, before the cardiac cath. they had hard time figuring out whether it was a wellens or brugada. i think their suspicion was pretty low that anything would come back, but pretty neat case. saving lives!

[kemple]

Definitely young for that kind of disease. Wonder what her genetic anomaly is.