Faithful Bloggers!
Rhythm Nation returns for another installment of critical analysis of the interesting ECGs from Kings County. Batter up!
63F h/o HTN, HL, DM, CAD, AFib (warfarin) CHF (EF 35%) presents to King’s County for “high blood pressure”.
Lucky for you, the patient brings a large bag of all her medicines that she dumps on the stretcher, mentioning “there are some others I have at home” before informing you of her difficulty taking “the right ones”. However, she is insistent that she has been taking “her water pill” and that “she never misses that one”. Yesterday she was cooking at home when she realized “there was salt” in her favorite chicken bouillon recipe. Immediately she “felt her pressure rise” and got “a touch of headache” which caused anxiety and prompted the immediate call to EMS. She currently has no symptoms and is requesting a “full exam”.
ROS: Endorses anxiety and headache. No cough, recent illness, CP, SOB, abd pain, N/V/D, changes in urination, BM, blood from mouth or rectum, recent medication changes per her PMD; rest of ROS unremarkable.
PMH: As above
PSH: “Bunionectomy” (as per pt…)
FH/SH: Father who died of MI at 52; lives in Brooklyn, retired, often mixes knitting with drinking tea.
Meds: (on stretcher) Amlodipine, HCTZ, metformin, aspirin (At home…?)
Allergies: NKDA
Physical Exam:
Vitals: T 97.6, BP 115/76, HR 94, RR 14, O2 Sat 97% on RA,
Gen: NAD, elderly F, speaking in full sentences
HEENT: NCAT, PERRLA, no JVD
CV: Irregularly irregular, no m/r/g, nl S1/S2
Resp: CTAB no w/r/r, good effort
Abdomen: Obese, soft, NTND, +BS
Extremities: 1+ edema to mid shin
Neuro/Psych: Anxious affect, AAOx3, CN intact, intact motor/sensation in b/l UE and LE, no cerebellar signs, nl gait.
Before you can discharge this asymptomatic patient with “high blood pressure” and a resolved headache, the nurse walks over to you and hands you the ECG that they obtained quickly at triage. “A quick signature, thanks Doc” she smiles…
Faithful bloggers! Please discuss the findings in this ECG as well as how it would change management. Thank you.
Yours Truly,
Rhythm Nation
BK in BK
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2 Comments
edenkim · November 27, 2016 at 10:43 am
narrow complex irregularly irregular rhythm without clear p waves. st depressions in I,III, aVF, V2-V6. afib @ about 120 bpm. qt is either short or prolonged… don’t have my calipers handy unfortunately.
i mustache if she is on digoxin, cause it looks like the dig effect aka salvador dali mustache
Situasian · November 29, 2016 at 3:39 pm
Looks like digoxin effect.
Rhythm is afib with rate of 90’s, QT interval is shortened with U waves at the end. There are ice cream scoops and salvador dali mustaches everywhere. I guess dig can cause whatever arrhythmia it wants but afib is definitely up there.
Her headache and anxiety could be neuro signs of dig toxcity as well.