It's 12:00 midnight and you are on your third admission of the night. The patient is a 63 yo male with significant medical history of HTN, Osteoarthritis, DM who came in with fever, right leg rash, tenderness and warmth which seemed like a typical cellulitis. Review of systems is negative except for his complaints above. He denies any other symptoms and claims to walk 2 miles a day with no problems as he has been health concious since he was diagnosed with DM. You continue through the H & P and reach the part where it's time to get an EKG. You put the stickers on and this is what prints out. What is your interpretation and what do you do next

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This is classic Wanchebach phenomenon with gradual increase in the P-R interval and eventual dropped nonconducted P wave. If you take calipers and look at just the p waves, they march out and are regular. What is changing is the AV node conduction time due to various causes, giving the increase in PR. As each sinus node depolerization happens, it takes longer for the impulse to pass through the av node. Eventually the delay to pass through is so long that the next sinus node impulse arrives at the AV node wich is still in the Absolute refractory period and does not conduct, hence the non-conducted p wave.

In this patients case, considering he was not admitted for any cardiac related symptoms, gives no history of any symptoms such as syncope, near syncope palpitations, etc. there is no intervention needed. Turns out from an EKG from his PMD, the patient has been living in Wanchebach for 2 years with out any impact on his daily life. As long as a Second Degree Type I Wanckeback is asymptomatic, there is no need to intervene.