# Differential Dx??



## Kendall (Dec 31, 2008)

I had a patient this evening and I'd like to run it by the panel for a differential dx. 

Pt is a 61 y/o f/m, c/c of weakness, feeling cold and shaking, general malaise and shortness of breath.

HxC/C pt was enjoying spectating a sporting event at onset of symptoms

Baseline Vitals:
Pulse 78, Resps 12, SpO2 90% (room air), BP 156/90, BGL 11.8 mmol/L, 3-Lead ECG showed normal sinus

PMHx: MI in 1994, history of unknown arrhythmia, previous stomach cancer, insulin dependent diabetic. Pt is pharmaceutically gifted and could not provide details.

Vitals q5 mins Pulse 140, Resps 10, SpO2 96% (o2 @ 4 Lpm), BP 160/100, BGL 13.0 mmol/L, 3-Lead ECG showed atrial tachycardia 

The patient continued to go in and out of the atrial tachycardia. It is important to note that the ECG had *a lot* of artifact and was only 3-lead so it is hardly diagnostic. Having looked at some sample ECG's online I'm second guessing my original interpretation of the tracing.I'm thinking now it might have been more characteristic of hypokalemia. There was a diminished T wave, prominent U wave and ST-segment depression. I wish I was able to provide a copy of the tracing but I forgot to grab it before I left work. 

Thoughts?


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## daedalus (Jan 1, 2009)

I think you mean sinus tachycardia or SVT. I am not sure you can differentiate atrial vs junctional tachycardia with a 3 lead EKG. Second, 78 bpm is not tachycardic. 

Questions: How goes your H&P? Do you have a more detailed hx of present illness? Also, was this acute onset or got worse over a few days/weeks?


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## Veneficus (Jan 1, 2009)

quick and dirty,

with a previous MI, depending on where it was, the heart over time could morphologically change and some CHF patients go into afib, particularly during angina attacks, with the pulse going from 78-140 in 5 minutes, you either scared hi very badly, or the rate may have been irregular. This guy shouldn't be SVT till ~159. (going by the criteria of 220 - age in years) but even the basic is 150.

I would stipulate that the rate for junctional tach would have no p waves or possibly inverted ones. Atrial tach may have morphologically abnormal ones, but not inverted, even on a 3 lead with a rate slow enough to not get it lost in SVT.

I will have to put some more thought into it to give you a decent answer, more info would help and I admit I really don't care much for cardiology.


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## mycrofft (Jan 1, 2009)

*Missing VS: temp*

I have atrial tach and occasional fib but could go down from, say, a sepsis or pneumonia and the techs could get "tach happy" and miss the differential. 
(Isn't it "Some atrial fib patients go into CHF"?)


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## MSDeltaFlt (Jan 1, 2009)

If your pt c/o SOB and has a low SpO2, then your stethescope needs to be on their chest front and back.  Without that you can't rule out pulmonary involvement.

Did she cough anything up?  If so, what color was it?  Any color other than no color at all is a bad color.  You can also have them cough for you to hear how loose it is.


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## Outbac1 (Jan 2, 2009)

If you are working on that truck again you should be able to go into the monitors archives and print that ECG. 

  What meds does the pt take and did they take them? Allergies? Lastmeal, eat anything different? Why was he cold? Was he dressed appropriatly for the environment he was in? Results of pulmonary investigation?


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## maxwell (Jan 31, 2009)

U waves are the least helpful ECG finding...ever!  Atrial Tachycardias require a more careful gander.  A rate of 140 is legit for some automatic atrial tachycardias - but - a bread 'n butter SVT (AVNRT are 90% of the cases) starts 160s-190s...and above 190s start thinking weird pathways like WPW, LGL, etc.  However, their problem doesn't seem all that cardiac to me...but I wasn't there.  Pleuritic pain?  Psyche?  Too much drinkie drinkie?


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## Wyoming Medic (Feb 3, 2009)

I have to agree with some of the respones here.  It does not qualify as SVT IMO.  

Your description as "pharmaceutically gifted" was an eye opener.  That is where I would turn my attention and try to drag any medications or PMH out of her.  There is some PMH that you listed but it is kind of vague.

Did you just stick her with the IV?  was she scared of needles?  Cold? Booze? Was the 5 mins AFTER she walked out of whatever spectating are she was in?  Was she lying down at the initial vitals then standing the next?  Was she watching an equine event and all of the horses broke wind at the same time?     

I would do orthostatic tests.  I know that it would not explain all of the symptoms but this may be a multitude of problems and the more that you can rule out the better. 

I would also be inclined to perform a 12-lead and get a better look.

Maybe that would help but that is what I would be looking into. 

So did you figure out what was up ever?


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## Veneficus (Feb 3, 2009)

mycrofft said:


> I have atrial tach and occasional fib but could go down from, say, a sepsis or pneumonia and the techs could get "tach happy" and miss the differential.
> (Isn't it "Some atrial fib patients go into CHF"?)



I have seen it go both ways.


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