You are seeing a 25 year old woman in clinic who presents with a chief complaint of palpitations. She states that she occasionally feels "like there's an extra very large beat" in her heart, and she first noticed this about two months ago. She describes an increase in the frequency of these episodes during the past 4-6 weeks. She is pregnant with her first child at 25 weeks gestation (G1P0), has a negative past medical history, no prior surgeries, takes only prenatal vitamins, and has no allergies. She is married, a third year law student, a 25 mile/week runner, takes no OTC medications, does not smoke, and while frequently had a glass of wine with her husband with dinner before the onset of pregnancy, now is not using alcohol. Her vitals signs are 132/82, 96, 18, 98.6, pOx-99%, BMI-22. She is alert in no distress and appears healthy and younger than her stated age. Lungs are clear. No JVD. HRRR with occasional extrasystoles auscultted. Normal S1, S2, no S3/S4, although a faintly audible soft systolic murmur is noted. FHTs are 140. Uterine fundal height correlates w/24-26 week gestation. The remainder of the examination is within normal. Her EKG is attached.

Dx: Premature ventricular contractions

This ECG tracing is from a 24 year old woman who presented to the emergency department complaining of palpitations with lightheadedness. Her symptoms began one hour prior to her visit, at which time she was attending a symphony at Hill Auditorium. She had been seen for the same complaint on two prior occasions in the ED during the past six months, although she admitted to resolution of her symptoms just prior to arriving at the ED. Clinical evaluations performed during those prior visits did not disclose any evidence of arrhythmias or other abnormalities. EKGs which were performed during both of those visits noted the presence of a normal sinus rhythm without ectopy or other abnormalities, and a heart rate in the 70s. The patient had been referred to her primary care physician, and in concert with a cardiology consultation, had an outpatient Holter monitor performed, which was read as normal. Physical examination of today notes the patient to be in no distress. Vital signs note a BP of 110/70, with a heart rate of 180/minute and a respiratory rate of 20. She is afebrile and the pulse Ox is 99%. Physical exam notes an anxious appearing 24 year old woman who does not appear to be in any distress. Her lungs are clear. Cardiac examination notes a tachycardia, but otherwise is essentially within normal. The remainder of the physical examination is otherwise unremarkable. What does this EKG show, and what would you do?

Dx: Supraventricular tachycardia

This EKG is from a 60-year old man that you are seeing in outpatient clinic for the first time. He complains of rather vague central chest pain on exertion, first noticed two weeks previously while cutting his lawn. He has never had pain at rest. His vital signs are 132/78, 50, 18, 98.6, 95%. What does this EKG show and what would you do next??

Dx: Anterior/septal MI

This EKG came from a 40-year old woman who complained of palpitations, which were present when the recording was made. She first noticed these about one week previously. She denies chest pain, dyspnea, syncopal episodes, lightheadedness, or exertional dyspnea. Her past medical history is unremarkable, and she takes no medications. She is a non-smoker and drinks one glass of wine daily with dinner. Her vitals signs note a BP of 120/78, HR of 55, RR, 16, T-98.6, Pulse Ox 99%. - what abnormality does this EKG show?

Dx: Premature atrial contraction

These two segments of a continuous rhythm strip are from the same patient, taken minutes apart. It is copy of a tracing from a 62-year old literature professor who presented to the emergency department via EMS following a syncopal episode which occurred while waiting in line to buy movie tickets at the Michigan Theater, accompanied by his wife. As he was heavily surrounded by other individuals in line, he was supported in his fall to recumbency, and sustained no injuries. Upon admission to the ED, the professor was alert and oriented, mildly diaphoretic, and in mild distress secondary to central chest pressure (pain described as 2/10). His blood pressure was 70/50, with an obvious palpable bardycardia correlating to the first tracing, with a RR of 22 and pulse ox of 92%. His physical exam was otherwise non-contributory (to our discussion here). His initial cardiac evaluation was begun immediately upon his presentation to the ED, and during the course of his ED stay he was treated - just prior to the second tracing. His serial EKGs, cardiac markers and enzymes were not diagnostic of an AMI. His CXR was unremarkable. He was admitted.

A: 3rd degree AV block with left ventricular escape rhythm
B: Right ventricular pacemaker

This EKG is from an elderly woman whom you saw in clinic, complaining of a three week history of increasing central chest discomfort with climbing stairs. She also admitted to "dizziness," and had stated that she had "fainted" on one occasion while stair climbing one week ago. She is alert and oriented in no distress. She has a slow rising pulse and a blood pressure of 100/80, with cardiomegaly noted on physical exam.

Dx: Left ventricular hypertrophy, left bundle branch block

This EKG is from a 75 year old woman you have just seen in clinic. She complains of occasional attacks of "dizziness," without syncope, chest pain, nor dyspnea. Her vital signs are 90-120/80-18-98.6-POx97%. Her physical exam is generally unremarkable.

This tracing shows a single abnormality - what might be its significance?

Dx: 1st degree AV block

This is an EKG of a 60-year old gentleman you are following in clinic for the careful outpatient management of moderately advanced congestive heart failure. What does this EKG show, what might be the underlying heart condition, and what might you consider in maximizing his cardiac potential?

Dx: Atrial fibrillation with rapid ventricular response

This ECG was recorded from a 23 year old pregnant woman (G1P0, 32 weeks), complaining of palpitations, who had been found to have a heart murmur. What does it show and what might be the problem?

Dx: Possible atrial septal defect

This EKG tracing is from a 62 year-old man, whose heart and preoperative EKG had been normal, but who developed cough with pleuritic chest pain and dyspnea three days following an open cholecystectomy. In light of this clinical history, what does this tracing show, and what would you do?

Dx: Atrial fibrillation with irregular ventricular response

This ECG was recorded from a 32 year old woman who complained of palpitations. Her past medical history is unremarkable, and she has had no prior surgeries. She has no allergies, takes no medications, does not smoke, and rarely drinks alcohol. She is employed as an orchestral musician, and is a competitive long distance runner. She is not pregnant. Her physical examination was unremarkable, with the exception of her heart rate. - Can you think of five conditions which can cause this rhythm?

Dx: Sinus tachycardia

This tracing is taken from a 48 year old gentleman. He is a clinic patient of yours whom you had not seen the past year, who presented to the ED with complains of one hour of sustained chest pain which began while he was pulling a deer through the woods (assume this is hunting season). He admitted to first noticing chest pain beginning one year previously, but at that time exacerbations generally came on only with strenuous exertion (snow shoveling, wood chopping), but which always went away withing a few minutes following rest. He is anxious today, although his physical exam is normal. His vital signs are 120-22-140/92-98.6-96%. His pain is relieved with nitroglycerin sublingually x 2.

Dx: Anterior NSTEMI (or acute coronary syndrome)

This EKG was recorded from a student in the University of Michigan Medical School. While on a cardiology rotation, as a teaching subject, an EKG was performed on him. Two days previously he had just completed his final 14-mile training run for the Detroit Free Press International Marathon to be held this Sunday, October 21st. He was concerned over his own tracing, and made an appointment to see his own physician. His physical exam is completely normal. - What do you think?

Dx: Left ventricular hypertrophy (by voltage criteria)

This tracing is from a 69-year old woman, a retired college professor whom you admitted from the emergency department with an acute exacerbation of congestive heart failure.

Dx: Atrial flutter with variable conduction

This is an ECG taken from a 55-year old lady seen in the emergency department due to severe central chest pain which radiated posteriorly into the mid thoracic region. The pain began four hours earlier when she had been pushing a cart filled with fall leaves which she had been raking. Vital signs are all within normal.

Dx: Acute inferior MI

This EKG is from an asymptomatic 28 year old, performed as part of a health screening exam for a life insurance policy.

Dx: Dextrocardia

It is August 23rd of 2005, and you are in your eighth week as a first year internal medicine resident on the inpatient medicine service at Charity Hospital of Louisiana in New Orleans, during the peak of the Atlantic hurricane season. The evolving flood has just damaged one of the local nursing homes, and you h ave been reassigned to the ED on an emergency basis to assist with the excessive influx of patients. Three patients, all in their late seventies, are transferred in and arrive simultaneously, each complaining of dyspnea. What are their EKG (rhythm strip) diagnoses, and what might they likely benefit from, based on only this tiny bit of information?

Dx:

This ECG tracing was taken from a 65 year-old diabetic gentleman who presented to the ED due to the rather sudden development of pulmonary edema with progressively worsening dyspnea at rest.

Dx: Atrial fibrillation with RVR, acute anterolateral MI

This patient is a 34 year-old woman who is two months post-partum (G3, P2204). She presents to your clinic complaining of intermittent breathlessness beginning three weeks ago. Vital signs are stable. She has a soft systolic murmur on physical examination.

Dx:

This is an ECG of a 16 year-old young man referred to your clinic because of a heart murmur. He is asymptomatic and his vitals are normal. What do you think? - What physical findings might you look for??

Dx: Atrial septal defect (PE findings - fixed splitting, pulmonary flow murmur, tricuspid murmur)