Welcome to the best time of the year (hello social house!). An odd appearing ECG with a new answer format this week, the most correct answer with lowest level of training (including med students) wins one of these (best chocolate in the northwest).
Case: 65yo man pmh CAD, HFrEF (EF 30%), HTN and DM2 admitted for abdominal pain, Cr 2.5 (baseline 1.2) on BMP has this ECG rhythm strip. Your fellow has left for the day and it’s up to you
We are so excited about this case we bring it to you a day early
Case: Alexandra Monrovia is a 38yo cross-fitter with minimal past medical history who presents “feeling tired” with palpitations for the last hour. Notably she finished her third deep fried oreo at onset of symptoms. In the ED she is afebrile, BP 90/50 (baseline BP 125/70s from recent yearly gyn visit), and breathing 22 times a minute with 95% saturation on RA. She appears uncomfortable, slightly diaphoretic, but is conversing in full sentences. her ECG is below
Check back for the answer on Monday
Thanks for all the great submissions, if you have interesting ECGs or other images please de-identify and submit with a one-liner to firstname.lastname@example.org
Great case and write-up below by: Drs. Allison Lange + Anurag Mehta (@anuragmehta09)
37yo previously healthy man presented with pleuritic chest pain, subjective SOB, hemoptysis. Found to be tachycardic to the 130s with EKG showing sinus tach, tachypneic to the mid 20s, BP 120s systolic on arrival. CXR with Westermarks sign and Hamptons hump.
Props to our stellar Resident Bryan Park and Intern Shawn Simek, Wards-Team-Extraordinaire!! They received a written letter of thanks and compliments from the spouse of one the patients under their care on the CUH Wards Eisenberg Service! Way to go guys!! Thank you to Dr. Rubin for sharing this note with us!🙂
Shout out also to our rising Superstar Jessy Barnes!! Words of praise from her attending: “She did a phenomenal job. Despite being an intern, I would say the best resident I’ve ever had on service since I became an attending. Very proactive. Read up on stuff. She critically evaluated patients and didn’t just go by what she was told by the ER or other services. I was very happy and very impressed.” We are IMPRESSED!!🙂
Well done! The answer to our #FridayImage was Myopericarditis.
We picked this case to discuss a differential for ST elevation on ECG. From a great NEJM paper from 2003 (ST-segment elevation in conditions other than acute myocardial infarction. Wang K, Asinger RW, Marriott HJ)
And then! What’s the difference between….
Myocarditis: inflammation of the heart muscle Pericarditis: the inflammation of the lining outside the heart. Myopericarditis: elevated troponin in the setting of pericarditis without new onset of focal or diffuse depressed LV function by echo or MRI Perimyocarditis: with new onset of focal or diffused depressed LV function
Remember: Acute pericarditis: dx by the presence of 2 or more: chest pain, pericardial friction rub, ECG changes (diffuse ST-segment elevation or PR depression) and pericardial effusion.
Typical ECG:initially diffuse ST elevation and PR depression, followed by normalization of ST and PR segments, and then diffuse T-wave inversions
Well done on your answers! The chest xray that you saw showed a L sided hiatalhernia – the left diaphragm is not visible while the right is. The bowel loops have crossed the midline (with an air bubble on top of the right heart border) and can be seen extending into the R hemithorax as well. You all probably wanted to get a Lateral xray…great though to differential an anterior/middle/posterior mediastinal mass.
The patient had further imaging done, a CT which revealed multiple loops of bowel that were located posterior to the heart and had filled the space normally occupied by the lungs. See image below:
Thank you Anurag Mehta for the great case and images.
Our Pulmonogist and ICU director, Dr. Kershaw gave us a lecture on July 18 discussing mediastinal masses on imaging giving us a nice list. He says: “remember that lateral chest xrays can help you differentiate middle mediastinal masses, one of which is a hiatal hernia.”
Excerpt from his slides:
And for BONUS: remember the 2 types of Congential Diaphragmatic Hernias (CDH)?
CDH is usually 95% posterolateral (Bochdalek hernia), but may be anterior retrosternal or peristernal (Morgagni hernia), or rarely central. ***mnemonic: Bochdalek is back and to the left***
80 year old healthy hispanic lady who presented to the ED with gradually worsening SOB for the past 6 months. Her only other complaint was reflux symptoms that were not improving after almost a year of of treatment with pantoprazole.