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Just Palpitations

UnFiNiShEd CaSe CoMe BaCk LaTeR

“BRADY” DOWN FOR THE REST

A woman in her 20s presents to the ED for 1 week of intermittent palpitations lasting hours.  She feels it still.  She denies syncope, chest pain, SOB, fever, stimulants, triggers or other complaints.

Exam: Vital signs are normal.  Exam is normal except for a regularly irregular pulse and heart rate .

An EKG is done

PLACE HIGH DPI IMAGE IN BRADY-CARDIA WORD DOC

What is the most likely primary diagnosis?

  • A) Hypokalemia
  • B) Pulmonary Embolism
  • C) PVC’s
  • D) PAC’s

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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EKG ANALYSIS, CASE OUTCOME, 1-MINUTE CONSULT & CASE LESSONS: 

1) EKG analysis (check out more great EKG’s from Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): The diagnosis is PJC, premature junctional complexes, in a trigeminal pattern.  There are premature junctional beats every third beat.  The PJCs are unifocal with a slightly wide QRS that is quite different than the sinus beats.  There is also a P-wave after the PJC and also a compensatory pause, which would be very unusual if these were PAC’s

2) Case Conclusion: Metabolic panel, CBC and magnesium were normal; troponin-i was <0.01 (99% URL <0.030: troponin-i immunoassay, Abbott laboratories).  Cardiology was consulted by phone and recommended office follow-up for an echo and a Holter.

3) 1-Minute Consult (from the Emergency Medicine 1-Minute Consult Pocketbookon the topic for this case:

4) Case Lessons: 

  1. Always
  2. Never

5) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should.  It’s long but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from emergent reperfusion and how you can pick up those patients and get them the care they need. CLICK HERE

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