Physical Examination as a Helpful Aid in Decision-Making in Challenging ECGs

Discussion continuedThe absence of pace spikes suggests this is not a pacemaker/ICD-related rhythm in this patient with an ICD.The presence of thinned myocardium and known large amount of scar tissue makes for a nidus for VT. Thus VT is very probable.A wide native QRS can be expected in a patient with a dilated heart and a history of heart failure, even if it is sinus rhythm. so the question of whether those are P-waves is critical.Additionally, the qR morphology, particularly in a patient with right bundle branch block (RBBB) type wide QRS complex tachycardia (WQCT), lends further support for VT.Furthermore, a pertinent physical examination finding to consider is:Intermittent cannon waves, indicative ofatrioventricular dissociation, emerged during the assessment, further supporting the diagnosis of ventricular tachycardia (VT). This finding, while reliable and sensitive, requires a focused search for its identification.Simultaneously, a programmer device was employed, and the programmer ECGs revealed notable distinctions between the atrial and ventricular channels. The atrial channel displayed considerably less activity (atrial sense, AS) compared to the ventricular channel (ventricular sense, VS), reinforcing the diagnostic likelihood of VT. Following administration of midazolam for sedation, the patient underwent successful cardioversion with an internal energy of 15J.The subsequent ECG, taken 5-10 minutes post-shock, depicted a soothing of ST deviation. The patient r...
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