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EKG Potpourri
Jen Carlquist PA‐C, ER CAQ
Is this EKG normal?
Rate: 60 – 100 BPM
PR: 120‐200 MS
QRS: under 120 MS
QTc: 460 MS
Axis: 0 ‐ 90
70 year old male with Palpitations
Palpitations for 4 hours: 47 y/0 female
37 y/o “ I feel weak”
Look at that PR interval
Courtesy of EKGtools.com
Courtesy of EKGtools.com
First: T wave flips in early ischemia.
Then: ST elevation either flat or tombstoning
Finally: We see Q waves.
Courtesy of The Art of 12 Interpretation
Anything else this could be?
Labs
TC: 155 TRI: 103 HDL: 52 LDL: 82
DX: stress kills
45 y/o F with dyspnea with exertion x 1 month
Used to ride bicycle at higher speeds Now dyspneic with walking across hall Labs: HGB 14.0, CR 1.0, TSH 2.0, Glucose 113, ESR, CRP ‐ Calcium score zero four years ago
What does she need?
38 y/o female school teacher –“weak”
56 year old male “Chest pain”
More on him
• Dizzy? Lightheaded? Dyspnea? • Was your pain like it was before you had a stent?• Alleviating/Aggravating? Tx prior to arrival?
• Were you feeling ok earlier in the day?
• “He was really sweaty and pale so I made him come in…”
His vital signs
RR 20, pulse ox 99% RA, HR 54, BP 90/60
What’s wrong with this patient?
Lisinopril Liptor CoregLasix
Metformin
DM, HTN, CHF, Hyperlipidemia
Syncopal last night Left sided chest pain, HA HX: HTN, Hyperlipidemia VS: 98%, 50, 18, 114/91 Trop 12.3 >7.9 Glucose 173
He’s admitted…
• Nurse calls: His sats are 76 when he sleeps and he “stops breathing” sometimes.
Diagnostics
Echo showed EF of 37% ‐What is normal? Had temp pacer placed – why did he need it? Had angiogram: LAD: 100%, LCX: 99, RCA: 100
What does he need?
Final disposition
1. NSTEMI 2. S/P DES RCA 3. Hyperlipidemia ‐ uncontrolled 4. Probable sleep apnea
Follow up with cardiology Cardiac rehab 30 Day heart tune up BP log
The Cardiology “Happy Meal”
BB ACEI Statin ASA/Antiplatelet
“FixIt All”
Discharge meds:
Coreg 6.25 mg bid Brilinta 75 mg qd ASA 81 mg EC qd Crestor 40 mg qd
The Happy Meal: Not so happy?
“I feel dizzy now” “I don’t want to be on all these medications” Phase II Cardiac Rehab
Refractory Angina
Ranexa Imdur Amlodipine
ASAACEIStatin
Coreg
Plavix $
Effient $$
Brilinta $$
+If stent
BB
Metop
rolol
Crestor 4
0 Atorvastatin 80
Simvistatin
81Ramipril
Lisin
opril
Urgent care visit Chest pain:
64 year old male who presented for a nurse visit for chest pain that was unrelieved with 5 nitro. He has had chest pain for one week that initially was better with NTG.
HX: 1. PTCA with stent placement was done 7/30/12, 1/9/14 (LCircwith stent/DES, DES median ramus) 2. ( s/p renal transplant ).
Stress test 4 months ago…never followed up
LV: Large, severe lateral infarct with mild peri‐infarct ischemia extending
distally in the LCx territory LVH Lateral wall hypokinesis. sEF: 41 % // rEF: 50 %
IMPRESSION: 1. Abnormal myocardial perfusion study. Large, severe
lateral infarct with mild peri‐infarct ischemia in the LCxterritory.
2. Segmental wall motion abnormalities. Mild LV enlargement without transient
ER Labs
Troponin 0.183 –0.6 – 8.2 GFR 39 CBC normal No lipids done
Post‐Operative Diagnosis:
Acute myocardial infarction. Coronary atherosclerosis.
Successful PCI of LAD (95%) using DES . Successful PCI of CIRC (100%) using DES .
Next day…”I have chest pain”…
Reoccludes both stents…only LAD can be opened.
Echo: severe left ventricular systolic dysfunction consistent with ischemic heart disease; LVEF 20‐25%.
Case conclusion
Had VT with collapse in heart center Got Lifevest Has contrast induced renal nephropathy Prognosis: Guarded
36 year old male “palpitations”
54 y/o female chest pain
Went off her Lexapro and synthroid “I forgot to take them” Went to the gym earlier and a long walk earlier in the day.
While walking uphill was slightly dyspneic. “It was normal, I thought.”
Her EKG
Chart note
. She is very busy all the time taking care of a household.
She noticed that she felt a little "lightheaded" that morning. This was different for her. No chest pain until she ate a bowl of cereal. She had a sharp pain in her chest. She started walking around, she felt it wasn't going away. She told her daughter to call 911. They called. She was defibrillated before she went inside the ER.
She remembers "coming to" when they cut her clothes off.
Labs
TC: 155 TRI: 103 HDL: 52 LDL: 82
DX: stress kills
“When can I start ironing again?”
45 y/o male with chest pain
“My pain woke me up”
“I was feeling bad for 5 days” “ I thought I had a flu” No sick contacts.
“Oh my throat hurts…”
Myalgias + malaise + ST + positive strep = tonsillitis
Diagnostics:
ESR: 61 WBC 6.1 CXR – Troponin ‐ Cardiac cath –
DX: Strep throat, Pericarditis
T Wave Mugshots
87 y/o BIBA for possible STEMI
0400 sudden onset c/p P – unprovoked Q – pressure/discomfort R – bilateral arms S – 5/10 T –½ hr 2010 EKG was normal
“EKG done yesterday was normal.” ‐ ERMD
EMS
No nitro – he was hypotensive Was noted to be diaphoretic “Noted dyspnea” by medics BG chem normal at 80 Took ASA before EMS arrived
SH: occ etoh useMeds: Plavix, ASA, Simvistatin
54 y/o male: chest pain
P – unprovoked Q‐ pressure R – Left arm, jaw, neck, head S – 8/10. Dyspnea, diaphoresis at home T – Intermittent for four days
History
PMH: None Meds: None SH: Lives with girlfriend, wife lives in Mexico. Drives a tractor Hasn’t seen a doctor in 20 years + Former smoker, drinks 12 beers a day
75% stenosis on LAD
56 year old male c/p x 2 d
Pressure radiates to his throat HX: Hypertension, not on medsMeds: ASA 81 mg qd SH: Drinks 2 beers a day and more on weekends
EKG #1 door time
Labs
11/28: 0134 – 0.2 Lipase 980 11/28: 0635 – 0.19 11/29: 1700 ‐4.2 11/30: 1800‐ 3.2
“He was sweaty so I got an EKG…”
Diagnostics
What happened?
CABG s/p NTEMI with triple vessel disease
Has an ICD: Palpitations for 4 hours
What is the cause?