Hello bloggers! Time for another segment of the Rhythm Nation where we look at interesting cases and critically analyze difficult ECGs from our department. Here is the first case of the year:
46 year-old man with history of “some heart failure,” longstanding, uncontrolled HTN, NIDDM, HLD who was sent to the ED by cardiology for admission for right and left heart catheterization. The patient reports chronic dyspnea on exertion, reporting that he had been able to walk 10 blocks, but in the past 4 months he cannot walk more than 2. Pt denies dyspnea at rest and doesn’t report any chest pain. Otherwise, he has been well; no acute URI symptoms, recent travel, surgeries, or trauma.
PSH: denies
NKDA
Meds: amlodipine, HCTZ, metformin, atorvastatin
ROS: Denies abdominal pain, nausea, vomiting, diarrhea, constipation; no fever/chills; no dizziness/headache
Physical Exam
V/S: BP 138/84, HR 99, R 16, O2 Sat 98%, Temp 98.1
Gen: NAD
HEENT: NCAT, PERRLA, MMM
Neck: no JVD
CV: RRR, -MGR
Resp: Diffuse rales
Abd: soft, NTND
Extrem: 2+ edema to mid-shin bilaterally
Question: The most likely cause of this patient’s dyspnea is:
a) total occlusion of a coronary vessel
b) pulmonary fibrosis
c) deconditioning
d) thyrotoxicosis
e) tamponade
f) pulmonary embolism
Please offer an explanation, including evidence from the ECG, to support your answer.
carmellig
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1 Comment
edenkim · August 11, 2016 at 9:56 pm
looks like cor pulmonale given the peaked p waves in lead II. V1 looks like it might show some LAE so maybe biatrial enlargement? does have some STD in inferior leads, but no STE or concerning TWI, and no chest pain so unlikely to be coronary occlusion. patient also has incomplete RBBB and RAD.
C and D unlikely given clinical picture. no evidence of tamponade on ecg – no decreased QRS amplitude and no electrical alternans, also patient not hypotensive. PE unlikely given lack of other risk factors although pulmonary HTN could also present with a similar ecg, which could be sequela of PE.
but given the diffuse rales, i would say pulmonary fibrosis fits best. any history of amiodarone use?