A woman in her 60s with a history of hypertension, seizure disorder, and polysubstance use was brought to the hospital because of altered mental status. On arrival to the emergency department, she demonstrated nonpurposeful lower extremity movements and was nonresponsive; her Glasgow Coma Scale score was 6. Vital signs were notable for normal body temperature, normal heart rate (85 beats/min), and markedly elevated blood pressure (220/122 mm Hg). Physical examination findings revealed an ill-appearing, normocephalic woman with asymmetric pupils—the left pupil was 4 mm in diameter and her right pupil was described as pinpoint. Stroke was suspected, and she was intubated because of concern for inability to protect the airway. Computed tomography of the head did not demonstrate hemorrhage, herniation, large-vessel occlusion, or perfusion mismatch. Initial laboratory workup findings were largely unremarkable, with lactate, creatinine, glucose, and high-sensitivity troponin levels all within normal limits. Serum electrolyte levels, including potassium and magnesium, were grossly normal. An electrocardiogram (ECG) was obtained (Figure).
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Salazar JW, Goldschlager N. The Negative U Wave: The Company U Keep. JAMA Intern Med. Published online October 12, 2020. doi:10.1001/jamainternmed.2020.5024
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