Circling back

It’s always good to review, right?  We’ll have to see how people do with a little more spacing between posts.

40’s y.o. man with pleuritic CP worse when lying down

Worse when it’s lying down.  That must mean it’s GERD right?  Trial of prilosec and move on to the next patient?  Maybe not so fast.  Because the opposite of worse when lying down is better when sitting up, the trigger for the attending who shared this EKG with me to add another item to the differential.

Rate is just under 100 with a little more than 3 big boxes spacing the RR interval.  P waves are fairly easy to see; it appears to be sinus.  PR interval is normal though there looks to be a little down-sloping of the PR in some leads.  Axis appears normal, up in I and up in aVL.  QRS looks to be nice and narrow.

Let’s zoom in on the ST waves, looking inferiorly


There is the suggestion of ST elevation in II, however this is equivocal if you compare the ST segment to the TP segment.  It’s elevated relative to the PR segment, but again this week, this represents PR depression rather than ST elevation. We see the same pattern looking laterally as well.

20180319_lat zoom

Some of you commented that the patient does have at least most of an S1Q3T3 pattern, and you’re not wrong;  but the PR depression causing the appearance of ST elevation is consistent with Pericarditis, which is what this patient had.

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