narrow complex tachycardia rhythmn strip. Student needs help.



K

Kingmonekey

Guest
Hi, Im a third year medicial student. And I have a question in my
coursework that I am a bit stuck on. The history is:

Mr Llewellyn is 60 yr old l.7 metre 60 kg publican who reports being a heavy smoker and drinking 0.5
bottle of whiskey 2-3 times a week. He is diagnosed with COPD and has right atrial and ventricular
hypertrophy. In the winter he develops worsening dyspnoea and cough productive of yellow/green
sputum is feverish and unwell. His GP treats him at home with a 7 day course of amoxicillin. He
gradually begins to improve and 2 weeks after starting antibiotics his sputum has cleared to his
usual pattern. He then suddenly becomes more breathless and complains of chest pain on coughing and
deep inspiration. His GP admits him to hospital for further investigation.

The ECG rhythmn strip can be found at:

http://homepage.ntlworld.com/douglas.heatherington/Fig_4a.jpg

The question is: What abnormality does the ECG rhythm strip show? and List FOUR possible causes of
the ECG rhythm abnormality in this patient.

My friends think its AF but Im not sure because I can see p waves there so I was thinking it was
multifocal atrial tachycardia? -however there arent p waves in front of every QRS complex -so Im a
bit confused!

Any help will be greatly appreciated.

Thank you Leon
 
Leon, Sometimes when you look at a short rhythm strip it is not possible to tell for sure what you
are seeing. The differentiation of these two rhythms is often misdiagnosed because of inadaquate
rhythm strip. I agree that it appears that there are what could be P waves in this strip. One is
inverted, one is upward, etc. I also see artifact in part of the strip. Because it is a COPD patient
it could very well be multifocal atrial tachycardia. However as your friends have stated it might
also be atrial fibrillation. On the basis of the strip and few complexes given I would certainly try
to get another strip.
 
Sorry, I just went back to the strip and found I could see more. For some reason the first time I
arrowed over nothing mover. I think that it is atrial fibrillation in viewing more complexes. Lets
see what Dr Chung says.
 
On 22 Feb 2004 09:54:01 -0800, [email protected]
(KingMonekey) wrote:

>anyone please?

Sorry was using google groups - now using proper software.

Thanks for your replies. More information is that on the next day he has an echocardiogramme that
shows atrial fibrillation, the left ventricular ejection fraction is 50%, the right ventricle
appears dilated. Tricuspid regurgitation is present and the estimated mean pulmonary arterial
pressure is 35 mmHg.
 
On 22 Feb 2004 13:41:39 GMT, [email protected] (Complex592) wrote:

>Sorry, I just went back to the strip and found I could see more. For some reason the first time I
>arrowed over nothing mover. I think that it is atrial fibrillation in viewing more complexes. Lets
>see what Dr Chung says.

Thanks for your help.

Why do you think it is AF? Im not convinced by the irregular baseline, however the QRS complexes are
irregular but normaly shaped.
 
[email protected] (Complex592) wrote in message news:<[email protected]>...
> Sorry, I just went back to the strip and found I could see more. For some reason the first time I
> arrowed over nothing mover. I think that it is atrial fibrillation in viewing more complexes. Lets
> see what Dr Chung says.

Looks like atrial fibrillation to me too, Complex.

A 12 lead EKG would have been helpful for more definitively excluding MAT.

Servant to the humblest person in the universe,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

**
Who is the humblest person in the universe?
http://makeashorterlink.com/?W1F522557

What is all this about?
http://makeashorterlink.com/?G5EF42A77

Is this spam?
http://makeashorterlink.com/?N69721867
 
[email protected] (Dr. Andrew B. Chung, MD/PhD) wrote in
news:[email protected]:

> [email protected] (Complex592) wrote in message news:<20040222084139.20529.00000189@mb-
> m24.aol.com>...
>> Sorry, I just went back to the strip and found I could see more. For some reason the first time I
>> arrowed over nothing mover. I think that it is atrial fibrillation in viewing more complexes.
>> Lets see what Dr Chung says.
>
> Looks like atrial fibrillation to me too, Complex.
>
> A 12 lead EKG would have been helpful for more definitively excluding MAT.

Agreed. There were too few distinct P wave morphologies to call it MAT. The overall underlying
rhythm looks chaotic.

As has been mentioned before, posting to answer homework questions on Usenet is frowned upon.
Posting to settle bets is okay, though. =)

- TC, md Pediatric cardiology and electrophysiology
 
Some causes of atrial fibrillation in this patient could be: Alcohol related non ischemic
cardiomyopathy, atrial hypertrophy, COPD. I do not think this is an MI, pericarditous, or
myocarditisThe S-t segments are too normal. Again a 12 lead EKG would have been benificial.
 
I personally have learned quite a bit from this user group. While I understand your point of view I
disagree with it. Especially when it involved something called "Interpretation". Three Dr's may look
at one rhythm strip and have different outlooks. Is it atrial fib.? Is it atrial fib flutter?Or is
one part of the atrium fibrilating and another part fluttering as one electrophysiologist has
described. While a student shouldnt do his homework on the usenet there is nothing wrong with
conversation and sorting thus information. Please.... we all could profit from these questions and
we many of us enjoy the challenge. I work for an electrophysiologist who has taught me much by
providing this type of challenge. Have a good evening.
 
"Terrence Chun, MD" wrote:

> [email protected] (Dr. Andrew B. Chung, MD/PhD) wrote in
> news:[email protected]:
>
> > [email protected] (Complex592) wrote in message news:<20040222084139.20529.00000189@mb-
> > m24.aol.com>...
> >> Sorry, I just went back to the strip and found I could see more. For some reason the first time
> >> I arrowed over nothing mover. I think that it is atrial fibrillation in viewing more complexes.
> >> Lets see what Dr Chung says.
> >
> > Looks like atrial fibrillation to me too, Complex.
> >
> > A 12 lead EKG would have been helpful for more definitively excluding MAT.
>
> Agreed. There were too few distinct P wave morphologies to call it MAT. The overall underlying
> rhythm looks chaotic.
>
> As has been mentioned before, posting to answer homework questions on Usenet is frowned upon.
> Posting to settle bets is okay, though. =)

:)

Servant to the humblest person in the universe,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

**
Who is the humblest person in the universe?
http://makeashorterlink.com/?W1F522557

What is all this about?
http://makeashorterlink.com/?G5EF42A77

Is this spam?
http://makeashorterlink.com/?N69721867
 
Complex592 wrote:

> I personally have learned quite a bit from this user group. While I understand your point of view
> I disagree with it. Especially when it involved something called "Interpretation". Three Dr's may
> look at one rhythm strip and have different outlooks. Is it atrial fib.? Is it atrial fib
> flutter?Or is one part of the atrium fibrilating and another part fluttering as one
> electrophysiologist has described. While a student shouldnt do his homework on the usenet there is
> nothing wrong with conversation and sorting thus information. Please.... we all could profit from
> these questions and we many of us enjoy the challenge. I work for an electrophysiologist who has
> taught me much by providing this type of challenge. Have a good evening.

Complex,

Don't take it personally when doctors frown :)

Servant to the humblest person in the universe,

Andrew

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com/

**
Who is the humblest person in the universe?
http://makeashorterlink.com/?W1F522557

What is all this about?
http://makeashorterlink.com/?G5EF42A77

Is this spam?
http://makeashorterlink.com/?N69721867
 
It seems to me I heard somewhere that Leon wrote in article
<[email protected]>:

>On 22 Feb 2004 09:54:01 -0800, [email protected] (KingMonekey) wrote:

>Sorry was using google groups - now using proper software.

Off topic, but you might be better off using the current version, Free Agent 2.0, with many bugs
killed and some functions added. The company's URL is www.forteinc.com, and the same install file
works for Free Agent, a 30-day trial, and the registered version.
--
Don [email protected]
 
You want four causes?

A-fib is the obvious rhythm. Is A-Fib a cause or a result? A result, I think.

On the surface, it does not look like flutter. However, without calipers, is there a relationship
between p-waves and wanna-be p-waves on this strip? I seem to think so on the first several beats.

A chronic lack of 02 due to smoking could cause either. You did not state about the overall heart
size. I suspect that this patient is in mild failure. From experience - not education- it is clear
to me that many alcoholics do just fine with cardiac function while others do not fare as well.
Perhaps someone more educated than I can provide a reason for that.

One thing I know for sure. He will not do better unless he wants to. My question is how are
you going to motivate him? Diagnosing a rhythm strip is going to do precious little for him in
the long run.

j "KingMonekey" <[email protected]> wrote in message
news:[email protected]...
> Hi, Im a third year medicial student. And I have a question in my coursework that I am a bit stuck
> on. The history is:
>
> Mr Llewellyn is 60 yr old l.7 metre 60 kg publican who reports being a heavy smoker and drinking
> 0.5 bottle of whiskey 2-3 times a week. He is diagnosed with COPD and has right atrial and
> ventricular hypertrophy. In the winter he develops worsening dyspnoea and cough productive of
> yellow/green sputum is feverish and unwell. His GP treats him at home with a 7 day course of
> amoxicillin. He gradually begins to improve and 2 weeks after starting antibiotics his sputum has
> cleared to his usual pattern. He then suddenly becomes more breathless and complains of chest pain
> on coughing and deep inspiration. His GP admits him to hospital for further investigation.
>
> The ECG rhythmn strip can be found at:
>
> http://homepage.ntlworld.com/douglas.heatherington/Fig_4a.jpg
>
> The question is: What abnormality does the ECG rhythm strip show? and List FOUR possible causes of
> the ECG rhythm abnormality in this patient.
>
> My friends think its AF but Im not sure because I can see p waves there so I was thinking it was
> multifocal atrial tachycardia? -however there arent p waves in front of every QRS complex -so Im a
> bit confused!
>
> Any help will be greatly appreciated.
>
> Thank you Leon
 
Once again Juli you are adding an nasty negative which adds noting to the group. The question is one
of diagnostics and interpretation not a phycological evaluation of a cardiac patient. We are dealing
with abnormalities, whether congenital or acquired. Understanding the diagnostics is a skill. Sure
you want to treat the patient. Treating the patient includes patient education. The medical student
was learning to assess. Maybe you should work on assessing topics in a more positive way.
 
"Complex592" <[email protected]> wrote in message
news:[email protected]...
> Once again Juli you are adding an nasty negative which adds noting to the group. The question is
> one of diagnostics and interpretation not a
phycological
> evaluation of a cardiac patient. We are dealing with abnormalities,
whether
> congenital or acquired. Understanding the diagnostics is a skill. Sure
you
> want to treat the patient. Treating the patient includes patient
education. The
> medical student was learning to assess. Maybe you should work on assessing topics in a more
> positive way.

I do not understand what you mean by adding a nasty negative which adds nothing to the group. The
fact is that we had one short strip in one unidentified lead which could have been A-Fib or A-
Flutter. Regardless of the cause, we told of a history that included excessive alcohol intake and
COPD. Since the patient was easily stabilized, my question was not about the limited strip but
rather the future treatment of the patient.

There are numerous EP docs who might have made more sense out of the strip posted but the ones I
have worked with would have wanted to see more than the sic second strip which was posted online.
Meanwhile, which is more important:: an accurate interpretation of the strip or a plan to treat the
patient? j
 
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