Faithful Bloggers!
Rhythm Nation returns for another installment of critical analysis of the ECGs seen at King’s County. Onwards!
87 year-old male, history of HTN, dyslipidemia, DM, Stage III CKD, Prostate cancer s/p radiation presents with syncope.
Two weeks ago, he noted urinary frequency and saw a doctor in Brooklyn who gave him tamsulosin. While taking this, he felt lightheaded. He stopped the medication 3 days ago, but the lightheadedness continued. This morning, he went to pick up the newspaper, felt lightheaded, and fell backwards. He was saved from any injury by his home health aide who is at bedside. The patient has no symptoms presently.
ROS: Denies recent illness, tongue biting, or micturition during episode, as well as seizure, fevers, chills, chest pain or dyspnea in the last 2 weeks, abdominal pain, N/V/D, or changes in BM
PMH: No history of coronary artery disease, history of PE or DVT
PSH: Denies
SH: Lives alone in Brooklyn, home health aide visits daily from 9a-5p
FH: Father died of MI at 57
Meds: Atorvastatin, metformin, lisinopril, tamsulosin
NKDA
Physical Exam:
Vitals: 97.8, 79, 198/124, 18, 100% on RA, not orthostatic
Gen: Well appearing, awake, alert, NAD, non-diaphoretic
HEENT: NCAT, EOMI, no conjunctival pallor
Neck: Supple
CV: Irregular rhythm, no m/r/g, good pulses in b/l UE, LE
Resp: CTAB no w/r/r, good effort
Abd: Soft, NTND, +BS, no masses, no HSM
Ext: Nl ROM, inspection in b/l UE, LE
Skin: No rashes or lesions
Neuro: CN intact, intact motor, sensation in b/l UE, LE, able to stand without ataxia
Discuss the ECG findings. What is the pathophysiology? What complications may arise? How would you manage this patient?
Yours Truly,
Rhythm Nation
BK in BK
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3 Comments
mr · January 23, 2017 at 11:54 am
RBB with 2nd degree HB type1 3:1 ratio. you could call this symptomatic since he had an otherwise unexplained syncopal event. i’d want cards to see him with at minimum a tele admission, EP study, evaluation for a pacer.
edenkim · January 23, 2017 at 2:41 pm
this is a good one! looks like an incomplete trifascicular block. there’s a RBBB + LAFB + mobitz type i (looks like progressively prolonged PR interval until DA BEAT DROPS). usually due to ischemia or HTN, senile degeneration, can be seen in hyperkalemia. with this ekg and a cc of syncope, he should be admitted to tele, cards consult for possible pacemaker because he may be intermittently having a complete trifascicular block.
cp · February 7, 2017 at 1:14 pm
this is a bifascicular block with rbbb and lafb with nsr with mobitz I pattern ; given his syncopal event evidence of infrahisian disease and age it is likely he had a prolonged pause as a cause of syncope. Dual chamber PPM would be considered. EPS study would not add much as he already has evidence of infra His conduction disease with symptoms. BP management as well.