Young Woman With Isolated Episode of Burning Chest Pain
A 23-year-old woman presents to the emergency department (ED) with left-sided burning chest pain that radiates to the epigastrium. The pain, which woke her from sleep 12 hours earlier, is intermittent and is not associated with eating or exertion. She had a single bout of nausea and emesis.
A 23-year-old woman presents to the emergency department (ED) with left-sided burning chest pain that radiates to the epigastrium. The pain, which woke her from sleep 12 hours earlier, is intermittent and is not associated with eating or exertion. She had a single bout of nausea and emesis.
Her medical history is remarkable for an episode of vertigo. She takes no medications and denies tobacco, alcohol, or illicit drug use.
Blood pressure is 101/95 mm Hg; pulse rate, 63 beats per minute; and respiration rate, 16 breaths per minute. The patient has no jugular venous distention. Heart rate and rhythm are regular, with a normal S1 and physiologically split S2; no murmur, rub, heave, or thrill is present. The lungs are clear. The abdomen is nontender.
A complete blood cell count, results from a metabolic panel, and lipase levels are normal. An ECG shows normal sinus rhythm with early precordial R wave transition and no ST-segment or T-wave abnormalities.
The patient's symptoms abate after treatment with antiemetics and a proton pump inhibitor. A telemetry rhythm strip is obtained and is shown here. The patient appears anxious but has no chest pain, diaphoresis, or dyspnea.
What abnormality is suggested by the tracing?
ANSWER: The telemetry rhythm strip shows "marching out" of the underlying normal sinus rhythm (
Figure 1
, arrows show the QRS complexes) on a background of
artifact, which resembles an episode of nonsustained ventricular tachycardia
.
In another dual lead tracing obtained during the patient's admission (
Figure 2
), the lower lead clearly shows normal rhythm with a narrow QRS complex and stable R-R interval. Although an artifact is also visible in this lead, it is less pronounced. A superimposed T wave is also apparent when the 2 leads are compared (arrows).
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