Chest Pain, Palpitations, Seizure in an Elderly Woman

An 89-year-old woman with a history of hypertension presents to the ED with one day of severe pleuritic left-sided chest pain radiating to her back, palpitations, and left-sided twitching. She denies syncope, dyspnea, fever, or history of any of these events in the past. She takes 3 medications for her hypertension.

On physical examination she is screaming in pain, begging for pain medicine. Vital signs are normal except for a blood pressure of 172/75 mm Hg with similar blood pressure in both arms. The rest of her exam is normal except for an irregular heart rhythm and mild twitching of the left arm.

Her ECG is shown in Figure 1, below. The computer ECG read is: atrial fibrillation with ST and marked T-wave abnormality. 

Figure 1. Initial ECG tracing. What’s your ECG read? 

What’s in your differential diagnosis? 

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