# Unexpected find



## GorillaMedic (Sep 10, 2012)

We had a call tonight for a fall—92 y/o F who slipped and fell. Pretty straightforward, right? Well, assessment revealed hip pain with no other injuries; pt has no medical history at all (and overall, seems to be in good shape). Gave her some pain medication and as part of our pain management protocol, placed her on a 4-lead monitor. Surprisingly, she was in sinus arrhythmia with 1st degree AVB! (When we took vitals earlier, her pulse was regular; throughout care, rhythm went back and forth from normal sinus to sinus arrhythmia). Well, i thought that seemed a little odd, so I did a 12-lead and found a significant q-wave in leads V2-5 + aVL, left ventricular hypertrophy, left atrial enlargement, and the previously mentioned rhythm abnormalities.

Reported it to the ED doc and he said he'd let her PCP know that maybe she needs a cardiac workup done.

Not at all what I expected to find, though.


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## Brandon O (Sep 10, 2012)

GorillaMedic said:


> Surprisingly, she was in sinus arrhythmia with 1st degree AVB!



Why was this surprising?


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## VFlutter (Sep 10, 2012)

92? Not really surprised by any of that. Sinus arrhythmia is bening and fairly common.


B/p? HTN?


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## NYMedic828 (Sep 10, 2012)

Pathological Q waves aren't a common finding but sinus arrhythmia certainly is.

92 years old if you didn't have LAH/LVH id probably think something was wrong. 

What are you considering a significant Q wave? I think the criteria for patho Qs is something like 1/3 the R wave of greater? I forget.

If she has no complaints and the cause of her fall was purely mechanical I wouldn't consider a cardiac event outside of her norm.


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## VFlutter (Sep 10, 2012)

Something like this?


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## zmedic (Sep 10, 2012)

Also what are you going to do about it if she has serious cardiac disease? Maybe start her on ASA and a ACE inhibitor, but she's pretty unlikely to get a stent, or a bypass given her age. I wouldn't even do a stress test. She's 92.


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## Emtpbill (Nov 26, 2012)

I think he just was surprised by the fact that he was called for one thing and found an underlying, totally non related issue.

I think he should be commended, nice catch. I know I probably
Wouldn't have hooked em up to the monitor for a straight forward fall with no LOC or other contributing factors to the fall(dizzy prior, doesn't know why fell)


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## usalsfyre (Nov 26, 2012)

Being surprised by this is particularly concerning to me. What is concerning is the OP claims to be an FP-C yet is surprised by odd EKG findings in a 92 year old.


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## Christopher (Nov 26, 2012)

usalsfyre said:


> Being surprised by this is particularly concerning to me. What is concerning is the OP claims to be an FP-C yet is surprised by odd EKG findings in a 92 year old.



Hell, I've got sinus arrhythmia (and sinus pause on occasion too) and I'm the convolution of 92 years (read: 29 years)...


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## Anjel (Nov 26, 2012)

My normal PR interval is around .24 so technically I have a 1* AV block. 

I hate to see the OP do a 12 lead on me. I also have physiological t wave inversion and left axis deviation. 

The patient wasn't complaining of a cardiac problem, so no need to be alarmed.


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## mycrofft (Nov 26, 2012)

They not infrequently find people in their eighties and nineties with radiographically significant back disorders who have not had complaints, and in one case where a 70-plus year old WWI vet reported in to the VA about back pain, they found an old machine gun slug he had forgotten about which had migrated into a position of discomfort. We adapt and sometimes are ignorantly accepting of stuff others wold have been screaming about years before.


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## socalmedic (Nov 26, 2012)

I am 24 and have sinus arrhythmia, 1*AVB, LVH, left atrial enlargement, left axis deviation, and BER. 

this was all found during my annual physical with Bruce criteria. I got 16 minutes in final step was 6.4mph @ 24*grade. max heart rate was 204. I would say without cardiac complaint don't look for zebras, you wont like what you find. I shouldn't have to tell an "FP-C" this.


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## NYMedic828 (Nov 26, 2012)

Whats a 4 lead :unsure:


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## Christopher (Nov 26, 2012)

NYMedic828 said:


> Whats a 4 lead :unsure:



The colloquial name for a limb lead system with a separate common ground cable (i.e. RA-white, LA-black, LL-red, and RL-green/common ground).


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## NYMedic828 (Nov 26, 2012)

Christopher said:


> The colloquial name for a limb lead system with a separate common ground cable (i.e. RA-white, LA-black, LL-red, and RL-green/common ground).



<_< I hate you.


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## mycrofft (Nov 27, 2012)

I remember five-leads with the "gearshift" Burdick machine.





PS: $300 on Ebay


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## Clare (Nov 27, 2012)

I can't say this surprises me; half the population probably has an undiagnosed arrhythmia, of which I would bet half have AF and the other half have some sort of atrial or atrioventricular conduction abnormality.

I have seen people with AV block, sinus bradycardia, atrial hypertrophy, runs of SVT, PVC's etc and they are for all intents and clinical purposes totally benign.  

I recall one young woman who had benign LAH, since we were not transporting her we gave a copy of the 12 lead ECG to give to her GP.


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## mycrofft (Nov 27, 2012)

My atrial fib went undiagnosed for five years because my MD depended on the software in his machine and despite my worsening condition and complaints. I accepted it ("Occasional PVC", no rhythm strip) and just thought it was part of getting older and out of shape.


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## Clare (Nov 27, 2012)

mycrofft said:


> My atrial fib went undiagnosed for five years because my MD depended on the software in his machine and despite my worsening condition and complaints. I accepted it ("Occasional PVC", no rhythm strip) and just thought it was part of getting older and out of shape.



Not sure which is more concerning; the fact your GP did not interpret your ECG or that your GP's ECG software was not able to pick up AF.


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## irish_handgrenade (Nov 27, 2012)

NYMedic828 said:


> Pathological Q waves aren't a common finding but sinus arrhythmia certainly is.



In a 92 y/o they are not common? Well they are here...


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