Moderator ventana Posted December 3, 2020 Moderator Share Posted December 3, 2020 routine annual on 48 yr old male health maintenance - like just about everyone stressed out with COVID, gained 10 lbs, has some calf pain with climbing ladders and some left flank pain for the past year that is not related to anything, works construction. EKG - sorry on the rotated view - Students and new grads - what do you think?? New File_1.pdf 1 Quote Link to comment Share on other sites More sharing options...
Aunt Val Posted December 3, 2020 Share Posted December 3, 2020 (edited) Let me try out my EKG reading skills . . . Rate: approx. 84 bpm Rhythm: irregularly irregular Axis: normal P waves are present before each QRS. QRS is narrow. T waves are present and not peaked. Normal R wave progression over precordial leads. I originally wanted to say A-fib, but it can't be because there are P waves. Calf pain could be related to possible DVT (although less likely if it's bilateral) or bad peripheral circulation. Left flank pain--kidney?? So I have some basic observations but am not sure how to put all this together. Please correct me and teach me more. Edit: I just reviewed some EKGs, and it looks like what you've presented may be a wandering atrial pacemaker, since it has at least 3 different morphologies for the P waves, is between 60-100 bpm, and has an irregularly irregular rhythm. Edited December 3, 2020 by Aunt Val 1 Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 3, 2020 Share Posted December 3, 2020 (edited) I think that's just sinus Arrhythmia. Looks like left axis devation and LVH (aVF has tall R wave)... Maybe atria enlargement (looks fuzzy and hurts my neck haha). Some of those ST segments don't look right either but could be the image and me looking on my phone. Any other sx? I'll take another look later tonight. _________________________________________________________________________ Edit after looking at a better picture: Normal axis. Still can't really tell about the atria...the P waves in v1 are still blurry for me. Does the patient take digoxin? The ST segments look slurred. Not sure about the flank pain or weight gain... Edited December 4, 2020 by TheFatMan Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 4, 2020 Share Posted December 4, 2020 1 Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted December 4, 2020 Share Posted December 4, 2020 Could you share the patient's vital signs, medical hx, and current meds? 1 Quote Link to comment Share on other sites More sharing options...
MediMike Posted December 4, 2020 Share Posted December 4, 2020 11 hours ago, TheFatMan said: I think that's just sinus Arrhythmia. Looks like left axis devation and LVH (aVF has tall R wave)... Maybe atria enlargement (looks fuzzy and hurts my neck haha). Some of those ST segments don't look right either but could be the image and me looking on my phone. Any other sx? I'll take another look later tonight. _________________________________________________________________________ Edit after looking at a better picture: Normal axis. Still can't really tell about the atria...the P waves in v1 are still blurry for me. Does the patient take digoxin? The ST segments look slurred. Not sure about the flank pain or weight gain... Thanks for reposting the rotated 12 lead! If I recall the esoteric criteria for LVH outside of the standard S wave in V1 or V2 + R wave in V5 or V6 being >35... aVL > 12 (remember this as the "l" and the "v" are both in the word twelve) aVF> 20 (Remember this as "Fo' Twenny", I wasn't the most responsible young man) aVR > 14 (I've got nothing fancy for this one) Doesn't quite seem to meet these limits. 1 Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 4, 2020 Share Posted December 4, 2020 11 minutes ago, MediMike said: Thanks for reposting the rotated 12 lead! If I recall the esoteric criteria for LVH outside of the standard S wave in V1 or V2 + R wave in V5 or V6 being >35... aVL > 12 (remember this as the "l" and the "v" are both in the word twelve) aVF> 20 (Remember this as "Fo' Twenny", I wasn't the most responsible young man) aVR > 14 (I've got nothing fancy for this one) Doesn't quite seem to meet these limits. Ah, yeah. Thanks! aVF looked taller with my head turned 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 4, 2020 Author Moderator Share Posted December 4, 2020 Vital stable look at the life threats first..... people are commenting on ST "looking funny" What looks "funny" any other findings that might go with the above??? Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 4, 2020 Share Posted December 4, 2020 8 minutes ago, ventana said: Vital stable look at the life threats first..... people are commenting on ST "looking funny" What looks "funny" any other findings that might go with the above??? In leads II, III, aVF, v5, and v6 there is a gradual downward curve of the ST segment with some very minimal ST depression. Looks like digitalis effect. The P waves aren't very distinct, but do II, III and aVF have significant Q waves? Possible inferior infarction? 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 4, 2020 Author Moderator Share Posted December 4, 2020 ok. so ST changes in 2,3,aVf, yes sig Q's - not on Dig, healthy 48 yr old male what part of the heart are we seeing? What next step? Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 5, 2020 Share Posted December 5, 2020 @Aunt Val you want to take a stab? Quote Link to comment Share on other sites More sharing options...
MediMike Posted December 5, 2020 Share Posted December 5, 2020 6 hours ago, TheFatMan said: In leads II, III, aVF, v5, and v6 there is a gradual downward curve of the ST segment with some very minimal ST depression. Looks like digitalis effect. The P waves aren't very distinct, but do II, III and aVF have significant Q waves? Possible inferior infarction? Criteria for significant Q waves? Go! Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 5, 2020 Share Posted December 5, 2020 (edited) 7 minutes ago, MediMike said: Criteria for significant Q waves? Go! I'm sure it's more nuanced than this but off the top of my head >1mm wide (that's what I think I'm seeing but it's hard for me to see where the p waves end and the q waves start in this ecg), and >2mm deep. I believe if they're only seen in v5 and v6 its a normal variant. Appreciate the pimping! Edited December 5, 2020 by TheFatMan 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 5, 2020 Author Moderator Share Posted December 5, 2020 Next step? Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 5, 2020 Share Posted December 5, 2020 3 minutes ago, ventana said: Next step? Was going to see if anyone wanted to chime in. Okay so I did a little looking. I'm thinking inferior ST depression and ST changes in v2/3. Hes asymptomatic right now but concerning for old anterior MI. I'd get a trop and chest xray, look for old ecgs and repeat the ecg in an hour. Full disclosure - we haven't had cards yet and it's Friday so I'm having a Brandy. Quote Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted December 5, 2020 Share Posted December 5, 2020 Can an old medic share a hint? Consider moving lead 4 to the right side of the chest and repeating the 12 lead. 1 Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 5, 2020 Author Moderator Share Posted December 5, 2020 ok so this was a routine EKG as part of an annual PE he feels fine no + ROS except the calf pain when on ladders..... next step? Quote Link to comment Share on other sites More sharing options...
MediMike Posted December 5, 2020 Share Posted December 5, 2020 20 hours ago, ohiovolffemtp said: Can an old medic share a hint? Consider moving lead 4 to the right side of the chest and repeating the 12 lead. What would you be looking for here? V4R has great sensitivity/specificity for identifying RV involvement in an RCA OMI but I'm not seeing an acute process occurring here or STE? Asking out of curiosity, not snark Quote Link to comment Share on other sites More sharing options...
Aunt Val Posted December 5, 2020 Share Posted December 5, 2020 22 hours ago, TheFatMan said: @Aunt Val you want to take a stab? You're good. I've been busy the last couple days with my unfortunately-non-PA temp job. So my first observations on the EKG apparently weren't quite right. I'm enjoying looking over other people's discussion though. Not sure what else to offer at this point besides comparing past EKGs and maybe getting a repeat. Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 6, 2020 Share Posted December 6, 2020 (edited) 6 hours ago, ventana said: ok so this was a routine EKG as part of an annual PE he feels fine no + ROS except the calf pain when on ladders..... next step? At this point I'm just kind of guessing... But my next guess is compare to old ekg...check electrolytes, consider scheduling outpatient stress test. Can someone steer me in the general direction or give a resource to look at. Kind of busy with finals the next two weeks but I want to figure this out. Edited December 6, 2020 by TheFatMan 1 Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 6, 2020 Share Posted December 6, 2020 And as the fat man I'm tempted to do as much nothing as possible for this patient. 1 1 Quote Link to comment Share on other sites More sharing options...
PACali Posted December 6, 2020 Share Posted December 6, 2020 (edited) HOCM? Dagger like Qs, LVH Edited December 6, 2020 by PACali Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 6, 2020 Author Moderator Share Posted December 6, 2020 So. ST changes and Q waves are a concern old EKG about 4 yrs ago did not have these. they are not ST elevations. what next?? remember I am the PCP and he has zero cardiac red flag symptoms. Quote Link to comment Share on other sites More sharing options...
TheFatMan Posted December 7, 2020 Share Posted December 7, 2020 I'm still thinking we need to look to see if he had a previous silent MI and current silent ischemia (from what I've read 1/4 patients with CAD has had a silent MI). I want to check his lipids and set him up with an exercise ECG and an echo. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted December 7, 2020 Author Moderator Share Posted December 7, 2020 BINGO - ETT Came back inconclusive NUC study done for more info EF was far lower (10-15%) after stress then before CARDS freeked out URGENT cath set up - likely GLOBAL CAD or even worse is HUGE LAD lesion...... time will tell Quote Link to comment Share on other sites More sharing options...
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