***Update: The conclusion for this case is now posted here.***
This is the second in our occasional series of Masters Cases. These are some of the toughest ECG’s we have seen and that is reflected in both the level of responses that are expected along with the depth of the discussions that will entail. For a taste of how these play out check out the conclusion to the Case #01.
As with the first case, this one was also submitted by Dr. Bojana Uzelac from Serbia. Her country, along with much of the Balkans, recently experienced flooding on a scale that has not been seen in anyone’s lifetime. In an email she described it to me as:
“For my 34 years I have seen war, bombing, earthquakes, fires, political revolutionâ€¦We had regional floods in past and we managed to recover from them. But something like this – no one has ever seen in Serbia! I canâ€™t explain you with words about size of our disasterâ€¦”
Please keep the people there in your hearts.
A 60-year-old female presents with a chief complaint of chest pain.
The pain started at rest one hour prior and was associated with shortness of breath, nausea, and weakness. At present the pain has subsided substantially although she still appears exhausted and admits: “There is some mild discomfort, but it’s not pain.”
She can’t quantify the pain, but based on your experience you would assume it started off at maybe an 8/10 (she’s the stubborn type who would never admit to 10/10 pain) and is now a 1 or 2/10.
Her past medical history is significant for type II diabetes, hypertension, and “chronic bronchitis.”
Importantly, she was hospitalized almost a year ago for exudative pericarditis and her husband is worried that she could be experiencing that again. He is unsure of the etiology of the prior pericarditis but it doesn’t sound like it was secondary to tuberculosis, so at least that’s good.
Physical exam shows a well-nourished, slightly overweight, middle-aged female. Lung sounds are mostly clear with some scattered wheezes bilaterally. Heart sounds are a bit quiet but audible. Pulse is strong and regular at the radial arteries and her skin is warm and dry, though a bit pale.
Vitals: HR 61 bpm, RR 14 /min, SpO2 97% on room air, BP 150/90 mmHg, and temp 37.2 C.
You perform the following ECG in the field:
Because of an error in the electronic medical record you are unable to pull up a scanned copy of her old EKG, but the report is available and states there was a right bundle branch block and left-anterior fascicular block.
The patient is hesitant to go to the hospital as she feels much better. In-fact, she looks a bit better than when you first arrived.
How would you manage this case? Is this pericarditis? Does she have a coronary culprit? What is the likely clinical course?
Please remember that the Masters Series is designed to push the abilities of experienced ECG readers. Responses are expected to be detailed and supported by your understanding of the complex interplay of ECG findings. One sentence replies will simply be deleted. With that, happy reading, and good luck!