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Brooks Walsh
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53 followers
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27 y.o. male, palpitation and exertional dyspnea, increasing over past few months. Exam unremarkable.

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27 y.o. male, palpitation and exertional dyspnea, increasing over past few months. Exam unremarkable.

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59 y.o. male complained of worsening dyspnea, lower extremity edema, a nonproductive cough, and night sweats.

Hx coronary sinus fistula, with a percutaneous attempt at closure 2 months ago.

(I have follow-up!)

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50 y.o. male, no medical history, seen 3 times in last month for cough and SOB. No improvement despite albuterol, steroids, a fluoroquinolone.

Seems like we've all seen a few of these recently.

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This is a continuation of the case I introduced yesterday (https://plus.google.com/105960568675610612527/posts/ZRfBvhrWLBs).

I misspoke when I wrote she was 27; she was actually 37. Still young, true, but not quite as impressive.

After discharge from the ED, she went to her PMD the next day. (Monday) There, the APRN obtained a second ECG (#2 below) and sent a CPK. She was again felt to be having a URI-type illness.

On Tuesday, however, the primary MD over-read the ECG, and also received notice that the CPK was elevated,. The patient was sent to the ED, where ECG #3 was recorded. A CPK and CPK-MB were found to be very high. At the time I saw the patient in the ICU, the cardiologist was contemplating transfer for angiography.

When I wrote about this case for my medic class, I evidently thought that the ECG on the first day was essentially normal, while #2 was "non-specific." Fast-forward to today, where my junior residents were able to immediately identify the concerning signs in aVL and the inferior leads!
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2013-12-20
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This case dates back to my clinical rotations for paramedic school, in '97.

A 27 y.o. female described aches in her neck and arms for the prior week. On the day of her ED visit (ECG #1) she had been carrying laundry up some stairs, when she had acute chest pressure radiating to both arms, and sweating "so bad it fogged my glasses." A CPK-MB was normal, but her WBC was 19,000.

She was diagnosed with flu-like illness and discharged. She had an appointment the next day with her PMD. At that appointment on day #2 she had another ECG...
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I posted a day ago about a possible STEMI brought in by EMS (https://plus.google.com/105960568675610612527/posts/WUmQwiettuW).  I've added the post-conversion ECG.

The patient had a fairly extensive cardiac history (ischemic cardiomyopathy, CABG, AVR), but despite that I did not have access to any prior ECGs. During the hospitalization no catheterization was performed.
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2013-12-13
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79 y.o. male, acute onset SOB, mild chest discomfort. Normal BP.

Cath lab?
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Before & after - what did we give the patient in the ED?
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2013-10-11
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38 y.o. male with no medical history c/o 1 day dyspnea on exertion and right-sided chest pain. Pleuritic, no change with movement or palpation. While walking to the car to come to the ED he passed out, injuring his face and teeth.

In the ED he has a HR of 118, and exam reveals crackles in the left lung base. I started IV fluids for possible sepsis, but stopped the infusion when I noted JVD, and grabbed the ultrasound. He had a distended IVC, but clear lungs. The RV was distended and akinetic.

This is the question - when I discussed the ECG with my resident, she stated that, although there was an S1Q3T3, she would discount the precordial TWI since the QRS axis was concordant.

Interestingly, after we looked at a number of examples of ECGs associated with large PEs (e.g. http://lifeinthefastlane.com/ecg-library/pe/), I noted that many of them had significant PRWP, i.e. had R-waves in V1-V3 that were concordant with the inverted T-waves.

Has everyone else always noted this? Is this a novel observation, or have I just been oblivious?
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2013-10-04
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