Thursday, May 01, 2008

EKG Du Jour #5

Alright. It's gettin' near the weekend, and it's been a pretty slow week for cardiovacular news here, so I'll put up a chip-shot EKG for the clever observer from the "EKG Hall of Fame."

What's the diagnosis of this 74 year old asymptomatic man?

Click to enlarge image


Other earlier fun EKG's and rhythm strips:
EKG Du Jour #1
EKG Du Jour #2
EKG Du Jour #3
EKG Du Jour #4


Eric, AKA The Pragmatic Caregiver said...

I got lucky on the Holter for sleep apnea. . . I'll take my amateur stab here.

The rate looks reasonably periodic, so I discounted arrythmia, and looked instead to post-infarct changes. I'm sure I missed something, but in looking at the P-wave in V1, I couldn't help but notice it looked awfully negative, which would tend to suggest some sort of left atrial enlargement.

Feel free to mock me.

Jay said...

Yo Eric! Dude!

What about all those funny sharp spikes in leads II, III and aVF?? Did you miss the click to enlarge button??

Ya think maybe some kinda funky flutter or something??

(trying my best to sound mocking, but probably just sounding stupid)

Anonymous said...

Retired Paramedic here...

I'm going to go with pacemaker malfunction, probably the lead wire coming loose.

Anonymous said...

The Barbed Wire phenomenon?

Appears that there is lack of sensing, but also no capture either. With an underlying NSR.

Lead dislodgement? Implanted in infarcted/fibrotic tissue?

Cardio NP

Eric, AKA The Pragmatic Caregiver said...

I saw all the little choppy bits, but I'm willing to chock low-amplitude stuff up to either measurement artifact or something subsequent to the larger structural abnormality.

Again, this is why I don't practice medicine. ;0)

DrWes said...

Clue time:

#1: The patient has never had ANY surgery.

#2: Which leads are those funny things noted in? Might that predict the patient's disorder?

Jay said...

Some form of periodic electromagnetic interference is present. I vote for a TENS unit.

Anonymous said...

Essential tremor or PD?

DrWes said...

Once again, the power of the many on the blog-o-sphere is demonstrated.

Besides the underlying sinus bradycardia and incomplete right bundle branch block, the curious finding on this EKG was the strange "barbwire"-like signals seen in many of the limb leads. These findings were not found on the precordial leads (V1-V6). Note there are approx 6 or 7 such signals per second and these do NOT appear to correlate with the underlying P waves, suggesting that this is, indeed, artifact.

But what is that artifact from?

It was suggested possibly a TENS (Transcutaneous Electrical Nerve Stimulator) unit. (Great guess, by the way.) But these usually stimulate the nerves much faster than seen here.

In 1817, James Parkinson characterized the tremor in his essay on The Shaking Palsy as the "involuntary tremulous motion in parts not in action." The frequency of the "pill-rolling" Parkinson tremor is usually 6-12 cycles per second (Hz) and usually worse at rest(as opposed to intention tremor where the tremor is typically worse with exertion).

This, then, was an EKG of an elderly patient demonstating the artifact caused by the resting tremor of Parkinson's disease. (Nice work Anony 2:38PM...)