Rhythm Nation: Case 6 Answer

by mritchie • March 23, 2013 • Comments Off

History:
76 year old M with HTN, DM, HLD, Dementia BIBEMS via NH due to complaint of questionable syncope and possibly chest pain (poor historian even through speaking on Cyracom with him – ie Q: Have you ever had any surgeries? A: I worked in the circus and I always pay my taxes.”) Story we went with is he did not feel well and his chest hurt, called nurse, she called 911, when EMS came he states he passed out, Hypertensive, got ASA and Nitro and came to the hospital, no fall, was in bed the whole time. No fever, cough, nausea or diaphoresis. Was recently hospitalized with simiar complaint. Admitted to medicine for Syncope/ACS.

Official Resident Read:

Rate – between 4-5 large boxes – approx 62 bpm

Rhythm – sinus

Axis – Left axis

Intervals

PR – 6 boxes =240 ms

QRS – 4 boxes = 160 ms

QT – 410 ms

Complex Morphology – rSR – RBBB, LAFB because there is a Left axis with a RBBB (can argue for the finding rS in II,II, aVF)

ST Segments – no contiguous lead ST depressions or elevations

T wave Morphology – no TWI

Put it all together

Prolonged PR interval = First degree AV block

RBBB with Left axis = LAFB

Conclusion – Trifascicular Block

Thank you Dr. Bains for the EKG and congratulations to Dr. Terry!

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.