An 80 year old woman with Left Bundle Branch Block (LBBB) and pleuritic chest pain
This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System.The patient presented to an outside hospitalAn 80yo female per triage “patient presents with chest pain, also hurts to breathe”PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB.HPI:
Abrupt onset of substernal chest pain associated with nausea/vomiting
30 min PTA. She reports associated SOB but no dizziness or LOC. She
was given NTG
at home before coming to the hospital. This was the ECG obtained at triage.This ECG was recorded and was reviewed remotely by a...
Source: Dr. Smith's ECG Blog - March 19, 2024 Category: Cardiology Authors: Steve Smith Source Type: blogs
Infection and DKA, then sudden dyspnea while in the ED
To learn more about Occlusion MI, join us in thisFree Webinar on November 27 12 noon US Central Time:Sign up at this link: https://zoom.us/webinar/register/2216945975176/WN_7HuMRHNxREKifGgQvy70lg#/registrationInfection and DKA, then sudden dyspnea while in the EDA 63 year old male with a PMH of CAD and peripheral vascular disease from type 1 DM presented to clinic and was found to have a very high blood sugar and so was sent to the emergency department.Patient stated that he has had glucose over 400 even though he has not missed any doses of insulin. He also endorses fatigue, upset stomach, frequent urination, i...
Source: Dr. Smith's ECG Blog - November 22, 2023 Category: Cardiology Authors: Steve Smith Source Type: blogs
What do you think of this " Ventricular Bigeminy " ?
Written by Bobby Nicholson MD, with edits by MeyersA woman in her 50s with past medical history of heart failure, prior stroke, atrial fibrillation on Eliquis, lung cancer in remission, and CKD, presented to the emergency department for evaluation of cough and shortness of breath. EKG was obtained in triage and read as ventricular bigeminy. What do you think?On my first read of the EKG, I agreed with the initial interpretation. Pendell Meyers then recommended that I take a second look at the morphology of the QRS complexes. I think it was easiest for me to see in the rhythm strip, but there are clearly P waves in front of ...
Source: Dr. Smith's ECG Blog - November 19, 2022 Category: Cardiology Authors: Pendell Source Type: blogs
Bradycardia with a Wide Complex. Sometimes 2 pathologies are present. Which?
An elderly woman was found to be bradycardic. She was awake with a BP of 120/70.Here is her prehospital ECG:What do you think?I thought this was likely due to hyperkalemia. I do not see P-waves. It appears to be sinus arrest with ventricular escape. The ST deviations could be ischemia, but are very often the result of hyperkalemia.First ED ECG:Pretty much the sameShe was given multiple doses of Calcium gluconate. 6 grams as I recall. And another ECG was recorded 9 min later:3rd 2.5 hours laterThere are some possible P-waves here, but if they are, there is complete AV block as well, ...
Source: Dr. Smith's ECG Blog - December 12, 2021 Category: Cardiology Authors: Steve Smith Source Type: blogs
We Use Too Many Medications: Be Very Afraid of Interactions
By HANS DUVEFELT
I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.
This is only today’s example of an interaction I didn’t have at ...
Source: The Health Care Blog - October 21, 2021 Category: Consumer Health News Authors: Ryan Bose-Roy Tags: Medical Practice Physicians Primary Care Hans Duvefelt Medical Ethics medication pharmaceuticals Pharmacy Source Type: blogs
Can gout be prevented?
To many people, gout seems like a disease of the past. Cartoons from 200 years ago depicted it as a condition afflicting the wealthy (“the disease of kings”), whose gluttonous consumption of food and drink was thought to bring on the attacks of debilitating arthritis.
All these years later, much about gout is still misunderstood. Shame, derision, and the belief that the gout sufferer deserves the condition linger. And rather than being a disease of the past, gout is quite common — and rates are rising. Estimates suggest gout affects nearly 4% of the adult population in the US, an increase from prior decades. And it...
Source: Harvard Health Blog - January 8, 2021 Category: Consumer Health News Authors: Robert H. Shmerling, MD Tags: Arthritis Bones and joints Health Men's Health Source Type: blogs
New Onset Heart Failure and Frequent Prolonged SVT. What is it? Management?
This middle-aged man with no cardiac history but with significant history of methamphetamin and alcohol use presented with chest pain and SOB, worsening over days, with orthopnea.BP:143/99, Pulse 109, Temp 37.2 °C (99 °F), Resp (!) 32, SpO2 95%On exam, he was tachypneic and had bibasilar crackles.Here was his ED ECG:There is sinus tachycardia (rate about 114) with nonspecific ST-T abnormalities.There is a large peaked P-wave in lead II (right atrial enlargement)There is left axis deviation consistent with left anterior fascicular block.There are nonspecific ST-T abnormalities.There is no evidence of infarction or ischemi...
Source: Dr. Smith's ECG Blog - March 5, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
40 years of ward attending
January 1, 1980 I walked onto the 7th floor of the old North Hospital at the Medical College of Virginia to make rounds as the attending physician. I had spent much time there as an intern and resident, but now I had a new role.
As I reflect on 40 years and probably between 12 and 15 years of total time making rounds, I first feel fortunate that I quickly discovered that my vocation was also my avocation. Now while I have retired from administrative responsibilities, I still devote 3.5 months each year to rounding with students, interns and residents. And each rotation still brings out the same excitement of going to t...
Source: DB's Medical Rants - January 2, 2020 Category: Internal Medicine Authors: rcentor Tags: Medical Rants Source Type: blogs
Severe shock, obtunded, and a diagnostic prehospital ECG. Also: How did this happen?
A middle-aged woman was found down in her apartment unconscious. She was in shock with thready pulses.A prehospital ECG was recorded:Limb leads:Precordial LeadsWhat is the therapy?This is pathognomonic of hyperkalemia (I suppose it could be due to a massive overdose of a sodium channel blocking drug, maybe).Is it ventricular tachycardia (VT) due to hyperK or is it a supraventricular rhythm with hyperK? ---I don ' t think that it is possible to say for certain, and it does not matter. The rate is not fast enough to be causing shock, so if it is VT, the priority is still to treat hyperK and secondarily to cardiove...
Source: Dr. Smith's ECG Blog - November 29, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
MKSAP: 38-year-old woman with primary membranous glomerulopathy
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 38-year-old woman is evaluated during a follow-up visit for primary membranous glomerulopathy. Diagnosis was made by kidney biopsy 4 months ago, and she was found to be positive for anti–phospholipase A2 receptor (PLA2R) antibodies. Medications are furosemide, losartan, and simvastatin. […]Find jobs at Careers by KevinMD.com. Search thousands of physician, PA, NP, and CRNA jobs now. Learn more. (Source: Kevin, M.D. - Medical Weblog)
Source: Kevin, M.D. - Medical Weblog - November 16, 2019 Category: General Medicine Authors: < span itemprop="author" > < a href="https://www.kevinmd.com/blog/post-author/mksap" rel="tag" > mksap < /a > < /span > Tags: Conditions Nephrology renal cell renal cell carcinoma Source Type: blogs
Unusual: Troponin Trajectory to Help Determine Ongoing/Recurrent Infarction vs. Completed Infarction.
A 40-something male with no PMH of any kind presented to urgent care on a weekend (cath team is at home) with cough starting 2 weeks prior and SOB one week prior.He underwent a chest x-ray:As this was consistent with " pulmonary edema vs. viral infection, " and he was transferred to the EDThe faculty physician did an immediate cardiac and lung ultrasound:Many B lines (probable pulmonary edema)Parasternal short axis cardiac ultrasound:The anterior wall is closest to the transducer and shows an obvious wall motion abnormalityFurther history:The patient denied chest pain but stated that he had had about 3 epis...
Source: Dr. Smith's ECG Blog - September 16, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Magnum, P.I.
An 11-year-old boy with cerebral palsy presented to the emergency department unresponsive. His mother said the child was in his normal state earlier that morning, but was blue and unresponsive when she tried to wake him from his morning nap. A home pulse oximeter reported an oxygen level of 55%.The mother placed the child on oxygen and called 911. He was still unresponsive on arrival, and his physical examination demonstrated flaccid paralysis and a GCS score of 3 with fixed dilated pupils. He was tachycardic with shallow respirations. His initial vital signs were a temperature of 36.9°C, a heart rate of 136 bpm, a res...
Source: The Tox Cave - June 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
I Can’t Hear You!
A 50-year-old man presented to the emergency department complaining of ringing in his ears and difficulty understanding what people were saying. He was concerned that he was having a stroke. A full neurological exam was unremarkable aside from decreased hearing, but his hearing deficits appeared to be equal bilaterally. Otoscopic exam demonstrated a normal tympanic membrane, and the rest of his physical exam was unremarkable. The patient's past medical history was significant for hypertension and hypercholesterolemia, for which he took lisinopril and atorvastatin. He was recently treated with a 10-day course of doxycycl...
Source: The Tox Cave - April 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Right sided heart failure and tachycardia.
A middle-aged male presented with tachycardia, dyspnea, and 4+ bilateral leg edema.What is the rhythm?There had been an ice storm, and it was the busiest day in the history of our emergency department because of falls. I reduced 12 fractures that evening and was in constant motion. I looked at this and saw the negative component of the P-wave in V1, and immediately diagnosed sinus tachycardia.I did a bedside echo:There was good LV functionYou can see a very large RV (closest to probe) and RA (on far right).Lungs were clear to auscultation and there were no B-lines.Volume overload was confirmed with this:Th...
Source: Dr. Smith's ECG Blog - February 9, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
A Caregiver ’ s Perspective on Patient Engagement
The following is a guest blog post by Michael Archuleta, Founder and CEO of ArcSYS, where he shares his experience as a caregiver for his father trying to navigate the healthcare system.
My dad is 99 years old. Having moved him to Utah 6 months ago into a retirement home, our first step was to get an appointment with a new primary care physician. I brought along a list of his medications and watched the nurse tediously look up and enter each into the EHR. Dad and the doctor got along great on that first visit. She assured us that she could help manage his medications. There was nothing realistically that could be done to r...
Source: EMR and HIPAA - August 20, 2018 Category: Information Technology Authors: Guest Blogger Tags: Health Care Healthcare Healthcare Interoperability HealthCare IT Patient Advocacy Patients ArcSys Michael Archuleta Patient Stories UpDox Source Type: blogs
