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Case #25

You are about to end your shift on the wards. Your page goes off and it is the ER. Your next admission is ready and waiting. You go through your H & P and she is basically a 79 year old female who came in with fever, cough, productive sputum and some mild shortness of breath. She says she has no other medical problems and she forgot what medications she takes. She says, " I take three red pills, one brown pill and of course a purple one, you know those right?". You tell her of course and continue with the H & P. The x-ray is on the view box and she has a lobar consolidation. You ask if an EKG was done and this is what they hand you. What is your interpretation?

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Here is a woman who tells you she has no medical problems, which often happens. So as you can tell from this EKG, she has a history of AFib and one of those pills must be coumadin. When the old chart comes, you confirm the finding.

What is interesting is the Rhythm strip with v1. There seems to be some atrial activity when there is a long enough pause. This may make us hedge towards saying atrial flutter. However, there is no evidence of this activity in the other leads, if they were to march out, the p-r interval of some of this "atrial activity" is too short to be conducting down to cause the ventricular contraction. So based on this, we could safely assume this is a-fib with rapid response. In the end the treatment is the same so in a clinical sense it doesn't really matter.

The rest of the findings are self explanatory. The Axis is around 120 with AvR being the most iso-electric lead which is Right axis deviation. There is a small S wave in lead I and a small q wave in lead III, which gives us the three needed to diagnose Left Posterior Fasicular Block and the findings in v1 with an RsR' giving the diagnosis of Right Bundle branch block. Hence bi-fasicular block. The t-wave inversions are in the expected leads when some one has a Right bundle.