Here's a great case submitted by a faithful reader who wishes to remain anonymous. Some details have been changed to ensure patient confidentiality.
You are called to the local ER to transfer a 17 year old male to a large metro hospital for evaluation. Your patient presented to the local ER with chest pain and palpitations following mild exertion. He was alert and oriented, and other than his elevated heart rate, his vitals were within normal limits. Upon presentation to the ER:
- O: Discomfort began during exertion
- P: Exertion makes it worse
- Q: Dull pain, substernal
- R: non-radiating
- S: 3/10
- T: about 20 minutes prior to ER arrival
- S: Chest pain/palpitations
- A: NKDA
- M: N/A
- P: No previous medical hx
- L: Unknown
- E: Mild exercise
As far as vitals go, all i can tell you is that they were within "normal limits" with the exception of heart rate. The patient is given trials of adenosine, lidocaine, digoxin, and cardizem, without successful conversion. In fact staff noted that the rhythm seemed to "speed up a bit" after the adenosine. He is put on an Amiodarone drip, which slows the rhythm a bit. They then elected to cardiovert, and after three attempts he converted to a sinus rhythm. Here is one of the rhythm strips and a 12 lead they acquired:
At the time you make contact, the patient has no complaints and is still in sinus rhythm. You apply your cardiac monitor and acquire your own rhythm strip and 12 lead:
Your trip to the metro hospital is uneventful, and he remained stable in your care.
What do you think is going on with this patient?
What is your interpretation of the ECGs?
Is there anything further you want to do for this patient?