Tuesday, March 18, 2008

EKG Du Jour #3

It seems it's a slow news day in the field of Cardiology, so continuing the "EKG Hall of Fame" series, here comes the toughest diagnosis yet...

A 17 year old high school senior presents to the Emergency Room with intermittent shortness of breath and lightheadedness unrelated to exertion. He has never lost conciousness. He is otherwise "healthy" and is new to the health care system. He denies any recent illness, fever, cough, or history of lung disease. He has no family history of heart disease or unexpected death. His physical examination is completely normal and are the usual cauldron of ER blood tests. An EKG is obtained and you are called to review the EKG because the ER staff is "concerned." The EKG is shown below:

Click to Enlarge

So, what's the diagnosis? If you're unsure, what other history, exam findings, test(s) would you order?

Finally, would you send him home or admit him?



Anonymous said...

Brugada Syndrome?

Patrick said...

I'm going to keep answering WPW until it's the right answer.

To the EP lab with him, for a little Dr Wes workup.

Anonymous said...

I was going to guess WPW as well. There looks like there are some delta waves--particularly in III, and aVF

Possibly some elevation in the ST in leads V2 to V6...so anterior/lateral MI.

Some of those T waves look pretty darn peaked. Hyperkalemia?

That all just seems too easy though! :)

DrWes said...

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?

I realize the facts given in the brief history and physical exam descriptions are limited compared to what one could garner in person, but there is a point to be made here (believe it or not).

So, if you're the one there in the ER, what should be done next?

Anonymous said...

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.
i don't think they need to be admitted. echo and event monitor.
i don't think brugada is high on my list either, given the symptoms, ?nationality, lack of family history, and the ekg.

DrWes said...

Thanks again to all who've ventured a guess about this EKG. This EKG represents all that challenges ER physicians today.

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 ischemia? (In reality, this is most consistent with early repolarization.) We look very carefully and see the slight slurring of the onset of the QRS in lead III and aVF and wonder, could this be Wolff-Parkinson-White syndrome? Yes adenosine could be administered to be absolutely sure that it doesn't exist, but need this be done in the ER? The patient's symptoms really don't support it. Certainly, the T waves anterolaterally look a bit peaked, could this be hyperkalemia (I guess the labs said no.)

But it is interesting to me that noone, not one who commented nor the over 150 people who viewed this tracing, said "normal EKG." It's a tough diagnosis to say, isn't it? It seems with the fear of litigation and the overwhelming fear that we could be wrong, we aren't allowed to say that anymore in the Emergency Rooms. We must consult, do a million tests, and be absolutely sure we're not wrong, lest we get it wrong. It's the climate in which we work. But seriously, doctors must make extrapolations about the clinical scenario with the data we are given. It is not perfect and certainly, each of those findings discussed above exist on this EKG, but the environment is one that limits sound deductive reasoning.

So yes, ladies and gentleman in the ER's of today, this is the toughest EKG diagnosis in medicine: normal.

Anonymous said...

dr wes
the v1 certainly looks like an incomplete right bundle branch block. does that fall within your scope for normal ekg?

DrWes said...

anony 10:06 -
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."

The Happy Hospitalist said...

I would say this looks like a normal EKG

The Happy Hospitalist said...

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"

Thanks for reminding us that some times a symptom is just that.

Jay said...

Thanks Wes for this case.

You fooled me too. I was ready to do a Procan or Flecainide challenge for Brugada.

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.

I think even on a board exam, I would have been more inclined to let this patient go without workup. I certainly have done so many times in general clinical practice.

Now that it is perfectly clear to me how much of a jacka** you are, I don't plan to be fooled again. :)


DrWes said...

Jay -
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.

This is the last normal I'll show... promise...

At least for a while...

Robert W Donnell said...

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.

Anonymous said...

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 also become dizzy." When you are short of breath, dizzy/lightheaded is fairly common, I think. Not my fault that the person listening to my lungs noted a lot of what turned out to be frequent PVCs.

Granted, I'm two decades older than this patient, but otherwise the descriptors fit. In any case, I also had negative/normal labs - for I assume everything. TSH, electrolytes, CBC, no TB. I hadn't been ill, but my kids had.

After the negative cardiac eval (Holter, echo, thallium stress test) and finally I was accidentally hooked up while I was experiencing breathing difficulty. The printout said normal. Kind of pointed to a pulmonary issue, even if I wasn't wheezing. No history of asthma either. No recent illness that I noticed. No fever, no night sweats.

Anyway, albuterol worked great, except that I started coughing. Within a day I noticed I was couging up nasty green stuff. I received antibiotics, and all seems to be ok. I was not coughing before.

Now, I'm not sure why no one asked me to blow in a simple tube until AFTER all the expensive, radiation emitting tests were done, but it seems like a cheap, easy thing to do...I know it's my fault as much as the practitioner's.