tag:blogger.com,1999:blog-18943510.post8823108348819658913..comments2023-08-21T02:57:37.362-05:00Comments on Dr. Wes: EKG Du Jour #3DrWeshttp://www.blogger.com/profile/17438019699222125477noreply@blogger.comBlogger14125tag:blogger.com,1999:blog-18943510.post-29685093030207007252008-03-21T18:15:00.000-05:002008-03-21T18:15:00.000-05:00I think someone should check the lungs before he i...I think someone should check the lungs before he is dismissed. As the patient in this case - seriously, I just got a full work-up and lots of probably unnecessary radiation for shortness of breath and palpitations (which I didn't feel). Bear in mind that the main complaint when I went to the doctor was SHORTNESS OF BREATH. Ok, what I said is "I seem to be having problems breathing sometimes. I Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-18943510.post-5598539612751948712008-03-21T09:03:00.000-05:002008-03-21T09:03:00.000-05:00An R prime in V1 is often a normal variant. When ...An R prime in V1 is often a normal variant. When you see an R prime in V1 always look for Brugada. But, I agree, this tracing doesn't really fit that. But could it be an epsilon wave? Admission or discharge decision would be based on close questioning about his symptoms. How acute, how vague, etc.If I was really worried I guess I'd get an echo.Robert W Donnellhttps://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-39889127771740301882008-03-19T14:19:00.000-05:002008-03-19T14:19:00.000-05:00Jay -Heh. I guess this is a classic case of "pimp...Jay -<BR/>Heh. I guess this is a classic case of "pimping" that used to be done on rounds. But I did it not to really skewer those who made great obervations, but to make a point about how hard it is to just call things "normal" in the ER.<BR/><BR/>This is the last normal I'll show... promise...<BR/><BR/>At least for a while...DrWeshttps://www.blogger.com/profile/17438019699222125477noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-19704925036268407282008-03-19T12:27:00.000-05:002008-03-19T12:27:00.000-05:00Thanks Wes for this case. You fooled me too. I wa...Thanks Wes for this case. <BR/><BR/>You fooled me too. I was ready to do a Procan or Flecainide challenge for Brugada.<BR/><BR/>I wonder however, what mine and other doctors responses would be in the "real world." The mere fact that you put this up on your blog implies that there is some interesting twist or wrinkle. It is very difficult to get past this bias.<BR/><BR/>I think even on a board Jayhttps://www.blogger.com/profile/10897176780069403370noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-1424298034357294662008-03-19T12:06:00.000-05:002008-03-19T12:06:00.000-05:00nice, That's the oldest trick in the book. Almos...nice, That's the oldest trick in the book. Almost as bad as changing the speed of the EKG paper or the amplitude, or the ever popular, "teeth brushing vfib artifact"<BR/><BR/>Thanks for reminding us that some times a symptom is just that.The Happy Hospitalisthttps://www.blogger.com/profile/14392872203166584371noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-66874319145393708172008-03-19T12:04:00.000-05:002008-03-19T12:04:00.000-05:00I would say this looks like a normal EKGI would say this looks like a normal EKGThe Happy Hospitalisthttps://www.blogger.com/profile/14392872203166584371noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-67228861851717780562008-03-19T11:56:00.000-05:002008-03-19T11:56:00.000-05:00anony 10:06 - I agree that the "incomplete bundle ...anony 10:06 - <BR/>I agree that the "incomplete bundle branch" pattern exists on this EKG, but this is essentially a normal variant. As such, I would describe this finding in my reading, but leave my assessment as "normal."DrWeshttps://www.blogger.com/profile/17438019699222125477noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-74800419553184473552008-03-19T10:06:00.000-05:002008-03-19T10:06:00.000-05:00dr westhe v1 certainly looks like an incomplete ri...dr wes<BR/>the v1 certainly looks like an incomplete right bundle branch block. does that fall within your scope for normal ekg?<BR/>thanksAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-18943510.post-9707020144519032972008-03-19T09:05:00.000-05:002008-03-19T09:05:00.000-05:00Thanks again to all who've ventured a guess about ...Thanks again to all who've ventured a guess about this EKG. This EKG represents all that challenges ER physicians today.<BR/><BR/>We look carefully at this EKG and we note the R-S-r' pattern in V1 and wonder - could this be a Brugada patient? (Just doesn't fit the look nor clinical scenario - see Case 1 in this series). We see the slightly elevated ST segments and wonder - could this be DrWeshttps://www.blogger.com/profile/17438019699222125477noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-58317041019198154532008-03-18T22:33:00.000-05:002008-03-18T22:33:00.000-05:00there is a q wave in v6 which theoretically rules ...there is a q wave in v6 which theoretically rules out wpw. i agree the pr interval looks short and there is a suggestion of a delta wave in iii. you could give adenosine as we discussed in the previous case to sort out whether there is conduction to the ventricle outside the av nodal system.<BR/>i don't think they need to be admitted. echo and event monitor.<BR/>i don't think brugada is high Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-18943510.post-90701308069852208752008-03-18T22:11:00.000-05:002008-03-18T22:11:00.000-05:00First, let me congratulate the folks above who hav...First, let me congratulate the folks above who have offered their ideas about this tracing. If Brugada - what should we do? How do we sort out if there is WPW on this EKG? Is this something we'll do in the ER? Should we admit the patient to sort this out? Any other tests or ideas?<BR/><BR/>I realize the facts given in the brief history and physical exam descriptions are limited compared to DrWeshttps://www.blogger.com/profile/17438019699222125477noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-87368626053458461982008-03-18T20:12:00.000-05:002008-03-18T20:12:00.000-05:00I was going to guess WPW as well. There looks like...I was going to guess WPW as well. There looks like there are some delta waves--particularly in III, and aVF<BR/><BR/>Possibly some elevation in the ST in leads V2 to V6...so anterior/lateral MI.<BR/><BR/>Some of those T waves look pretty darn peaked. Hyperkalemia?<BR/><BR/>That all just seems too easy though! :)Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-18943510.post-57908256707335669302008-03-18T17:52:00.000-05:002008-03-18T17:52:00.000-05:00I'm going to keep answering WPW until it's the rig...I'm going to keep answering WPW until it's the right answer.<BR/><BR/>To the EP lab with him, for a little Dr Wes workup.Patrickhttps://www.blogger.com/profile/10681011337931740108noreply@blogger.comtag:blogger.com,1999:blog-18943510.post-47253280445827648942008-03-18T17:08:00.000-05:002008-03-18T17:08:00.000-05:00Brugada Syndrome?Brugada Syndrome?Anonymousnoreply@blogger.com