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em photo quiz( occasional series)


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Beats the heck out of me.

 

What I do see:

P/P, R/R regular, p wave for every qrs. Rate approx 75 bpm

PR, QRS, QT intervals all appear to be WNL at casual perusal.

ST segment, J point WNL. R wave progression in anterior leads appears to be WNL but V3 is a faint trace probably lost in scanned reproduction

 

Low amplitude in lead III, aVF is notched yet still narrow QRS.

T wave in V2 seems amplified, perhaps a bit peaked but if this was a K problem, I'd expect to see peaked T's in multiple leads, wouldn't I?

 

Given the chief complaint and the fact I am on safari hunting zebras, I'd seek the counsel of those wiser than me before I streeted the patient.

 

On the previous pt with the beta blocker OD...did you find the OD via history/ROS or is the T wave inversion in multiple leads a pretty reliable indicator?

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dx by hx on prior case.

for current case look at avf, v2 and v3. you normally see this finding in multiple leads but it was subtle here(in fact I missed it). the consultant picked it up and it showed up better during the acute phase(when pt was symptomatic) on a holter monitor later prior to his ablation....this current ekg is baseline without sx.

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Ok....this morning I read your hint, went back and thought "aha, nice to see "U"...Very subtle at casual glance, but there does appear to be U waves. aVF has fine baseline artifact that would preclude me from hanging my hat on using just that tracing but sure enough, in V2 and V3, there appears to be a second hump.

 

How was his thyroid and calcium levels? Ever have any bouts of CP that points you in the direction of prinzmetals?

 

Then I re read your hint...you mention ablation. I say to myself "self, there is thyroid ablation but there isn't a whole lot in the very initial patient description to give a hint that his thyroid is acting up" and "if it was a U wave abnormality and he suspected thyroid, he probably wouldn't mention a holter"... so I start wondering about WPW.

 

I go back and start staring at the ECG looking for a delta wave and a shortened PR and to be honest, at this point, my eyes are crossing. I go back and forth if it's there or not. aVF with it's fine baseline artifact and all making the best case. Without the tracing in my hand, I'd be hard pressed.

 

We haven't gone over ECGs yet in class so I'm in the weeds here a bit now but I appreciate the learning exercise. Thanks

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  • 1 year later...

Please interpret the following studies on this gentleman who just got off a plane from Japan. click on thumbnails to enlarge

 

Dislclaimer: Never read imaging/haven't started school yet.

 

Left sided pneumothorax. But it can't be that simple...

I've done the long flight to/from Japan several times, so I was going to suspect lung infarction due to pulmonary emboli from DVTs. But idk what to look for... teach me!

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Right pneumo. You look at ct imagining you are at the feet looking up to the head. Plus you can kinda see some tracheal deviation away from the side of the pneumo.

That makes so much more sense now. :P Feet to head. Thanks!

 

 

Sent from the Satellite of Love using Tapatalk

 

 

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The CT finding of R PTX is correct. pt was tall/skinny/young. I was thinking spontaneous PTX as I walked in the room. pretty staright forward exam with dec. BS on the R.

There is a subtle finding on the CXR which I missed and my md partner who is double boarded FP/EM suspected.

any takers on the subtle finding on cxr?

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I've got a guess but I'll see if students want to go first. Hint, if I'm correct, is to look at other mediastinal structures.

I'll add a hint. it's a tipoff to the CT finding.

another statement/ question to lead to the answer: the PTX on CT is 10-15%. why don't we see it well on cxr? what subtle finding on cxr suggests a PTX in this location?

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if you are looking at the little line on the L (your r) diaphragm, it looks a bit like free air but isn't.

not the finding I am looking for.

That's just a little line of gas in the stomach correct? (pt. left, right of image) That little divot marked on pt. right is something I didn't see searching for normal cxr pics. I'm out of my league, but I'm acutely interested. :)

 

 

Sent from the Satellite of Love using Tapatalk

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another statement/ question to lead to the answer: the PTX on CT is 10-15%. why don't we see it well on cxr?

This was actually covered this afternoon in a lecture at SEMPA. The short answer is, because CXR kind of sucks in terms of finding pneumothoraces.

 

Back in the days of diagnostic peritoneal lavage (there's one for the students to look up!), they knew there was air in there (because they put it there), and yet CXR proved to be somewhere between 38 and 80% sensitive compared to CT.

 

The rest, I'll wait and see. I have a theory.

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this is what I was looking for:

http://en.wikipedia.org/wiki/Deep_sulcus_sign

 

I missed it. the doc I was working with saw it and the rads confirmed it. I knew clinically that the guy had a PTX which is why I proceeded to CT.

he was admitted for obs on high flow o2, worsened overnight, and got a chest tube.

I still don't really see it, personally. I would miss that everyday and twice on Sunday. I knew of the deep sulcus, just seems really subtle here. I thought those striations were just lines from a reflection or something, but when you mentioned another sign I thought maybe it could be subq air not seen on CT. Good case. Thanks.

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I thought it was mediastinal air along the right heart border edge as seen on CT, i.e.-mediastinal ptx.  It may just be the variance between the vascular structures, lung, and right ventricle, but to me, there appears to be a lucency consistent with possible air along the ventricular margin.  Can't see clearly without larger image.  Heck, without my readers, that probably wouldn't help either.  :-(

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