I/NF CASE #8 (34 y/o F with anxiety/palpitations)

[sozme]

I/NF CASE #8

Will ask for help from our favorite cardiology fellow @Instatewaiter
====================================================================
Links to previous:
Case 1 Case 2 Case 3
Case 4 Case 5 Case 6 Case 7
====================================================================
You are paged about a 34-year old female admitted with fever, elevated WBC, diarrhea, and abdominal pain after returning from a business trip to Kathmandu. On the night of admission, she complains of anxiety and palpitations. Her vitals: 101.3 degrees F; 130/70; 150 bpm; RR 14; SpO2 99% on room air.

She is currently on 125/cc/hr 0.90% NS. Other meds include Fluoxetine 40mg PO QD and Atenolol 25mg PO QAM prescribed by her Nurse practitioner for anxiety. Both of these were stopped on admission (but she took them the morning before being admitted).

The nurse ordered an EKG and gives it to you at the bedside.

What do you want to do, senpai?

Source: Klamen, DL, Hingle ST: Resident Readiness: Internal Medicine: www.accessmedicine.com.

UPDATE 1 (Initial E.D. H&P and labs)
UPDATE 2 (Follow-up Nurse page and D-dimer)

---

Members don't see this ad.

 

[WheezyBaby]

How high's her fever currently? How's her pain control? Onset of palpitations before or after anxiety? Palpitations or anxiety more prominent? Instantaneous onset of palpitations (like flicking a switch on and off) or gradual? How's the patient look (general appearance, perfusion, respiratory)? I'm on my phone but ekg looks like a regular atrial-driven tachycardia around 150. Narrow complex normal axis, normal axis p's of consistent morphology, no major st changes, appropriate r wave progression. Either an impressive sinus tach or SANRT? Don't know a lot about the latter. If she doesn't look sick, vagal maneuver and see if it breaks.

Not getting into the sepsis from rare Kathmandu tsetse fly acquired bleed out your eyes virus aspect of the scenario. Don't have the energy for that while working NYE

 

[cbrons]

Looks like narrow-complex atrial tachycardia. Is this SANRT?

 

[Instatewaiter]

What was the HR on admission? Is she on the tele? What was the initiation like?

HR is more like 156- 162 (26-27 beats in a normal 12 lead EKG) which for a 34 year old could be within the range you could expect for sepsis if this weren't paroxysmal. So if she came in tachycardic at a different rate, this is likley sinus tach. If not, probably pAT, SANRT. Not sure what to make of the tibit about Kathmandu

With regard to the initiation of electricity, the p wave axis appears to come from the high right atrium which could be be sinus but could be an A-tach, SANRT or a few others.

Interesting almost pre-excitation in V1 and interesting R wave amplitude through the precordium. Furthermore P wave size is large enough to suggest RAE. QT is also long. So sure, do your carotid sinus massage and then adenosine. It is probably fine despite the borderline pre-excitation. But I suspect based on the EKG, this is not a structurally normal heart.

How about a bedside echo?

 

[Instatewaiter]

Also check for C diff since she appears to be septic and do the normal diarrhea workup but honestly who cares about that stuff... it is pretty crappy

 

[sozme]

UPDATE #1
EMR Data for the admission (from ED):

HPI:
This is a 34 y/o F history of bipolar II disorder presents with N/V. Pt is a dutifully employed individual for a tech company who returned home from Nepal 2 days ago. Early today, she developed fever with three episodes of non-bilious, non-bloody emesis. Pt Ate seafood the day of departure in Kathmandu at an airport restaurant.

Reports no history of sexual activity past year. No recent use of antibiotics. Reports no smoking, alcohol use, or other drug use. No significant PMH other than bipolar, for which she does not take medications.

1930 Update
Receive call from bedside RN. Pt HR went from 90 to 150 suddenly. EKG ordered (see initial post).

Exam (significant parts only):
VS: 132/89 HR 96 Temp 101.8 RR 14 SpO2 100% on R.A.
Abdomen: Non-distended, diffusely tender to palpitation with hyperactive BS
Psychiatric: Pt is clearly anxious

Initial Tests ordered by ED:

• CMP: normal
• CBC: moderate leukocytosis with left shift, otherwise normal.
• Venous blood gas: Unremarkable
• Serum Beta-hydroxybutyrate: negative
• Urine beta-hCG: negative
• Serum lactate: normal
• Procalcitonin: normal
• Noncontrast abdominopelvic CT: essentially unremarkable

 

[GadRads]

Some ddx include infectious causes (e.g. hepatitis A, gastroenteritis, c. diff colitis, UTI, STD, etc), serotonin syndrome (history of SSRI use, need other medication history), inflammatory causes (e.g. vasculitis, pancreatitis, cholecystitis, etc), endocrinologic causes (e/g pregnancy (normal vs ectopic), thyroid disease) . Mesenteric ischemia is less likely given history and EKG which appears to be sinus tach.

Most likely diagnosis is gastroenteritis given leukocytosis with left shift and otherwise normal labs. Normal BMP and lactate is reassuring for now. So unlikely to be hypercalcemia or DKA

Plan: Continue IV fluids. Add hepatitis panel (low yield given normal CMP), TSH, serum/urine beta HCG (I would imagine this was done for a 34 year old female before CT even though she claims no sex). If positive pregnancy test, get ob/gyn consult and rule out ectopic preg with pelvic ultrasound (useful in a woman with abd pain).

Also get amylase and lipase labs. Blood culture, chest xray, stool culture, stool WBC's, urine culture, urinalysis. After culture and sepsis work up, I will start metronidazole and moxifloxacin after ruling out pregnancy and then monitor. Tylenol for fever. zofran for nausea/vomiting. Re-assess q1h for now. Consider surgery consult.

Happy new year.

 

[TooMuchResearch]

QT looks long.
Could be SSRI related.

CT should have showed evidence of ruptured ectopic if present.

Give a bolus and see what happens. Cover with appropriate gut source antibiotics per local protocol.

Airport seafood is probably important.

 

[WheezyBaby]

I still say vagal and try to break her. Tele. Neuro exam for serotonin syndrome, question patient for SI / OD. I'm not seeing sepsis accounting for that level of worsening tachycardia with a real but not very impressive fever, not immunocompromised, perfusion well on exam with normal / elevated pressures, normal lactate, normal procalcitonin, normal CT. I'd put her on tele, bolus, see if she breaks with vagal. If she doesn't have anything consistent with serotonin syndrome and doesn't break with vagal, I think you're obligated to treat empirically for sepsis. Myocarditis and PE both also at least cross my mind as differential but probability seems very low for either

 

[W19]

Some ddx include infectious causes (e.g. hepatitis A, gastroenteritis, c. diff colitis, UTI, STD, etc), serotonin syndrome (history of SSRI use, need other medication history), inflammatory causes (e.g. vasculitis, pancreatitis, cholecystitis, etc), endocrinologic causes (e/g pregnancy (normal vs ectopic), thyroid disease) . Mesenteric ischemia is less likely given history and EKG which appears to be sinus tach.

Most likely diagnosis is gastroenteritis given leukocytosis with left shift and otherwise normal labs. Normal BMP and lactate is reassuring for now. So unlikely to be hypercalcemia or DKA

Plan: Continue IV fluids. Add hepatitis panel (low yield given normal CMP), TSH, serum/urine beta HCG (I would imagine this was done for a 34 year old female before CT even though she claims no sex). If positive pregnancy test, get ob/gyn consult and rule out ectopic preg with pelvic ultrasound (useful in a woman with abd pain).

Also get amylase and lipase labs. Blood culture, chest xray, stool culture, stool WBC's, urine culture, urinalysis. After culture and sepsis work up, I will start metronidazole and moxifloxacin after ruling out pregnancy and then monitor. Tylenol for fever. zofran for nausea/vomiting. Re-assess q1h for now. Consider surgery consult.

Happy new year.

My thought process was similar to yours... It's kind of reassuring to know that I am learning something as a 3rd year student . Why surgery consult? (anyone can answer)...

 

[WheezyBaby]

My thought process was similar to yours... It's kind of reassuring to know that I am learning something as a 3rd year student . Why surgery consult? (anyone can answer)...

Wouldn't consult surgery for a tender but benign abdomen neg CT with good reason to have abd discomfort (likely infectious gastroenteritis per hx)

 

[GadRads]

My thought process was similar to yours... It's kind of reassuring to know that I am learning something as a 3rd year student . Why surgery consult? (anyone can answer)...

It's low yield IMO given normal CT abd. But I have seen people still consult surgery. I would consult surgery if the abdominal pain was refractory to medical management.

 

[Zebra Hunter]

Evidence of right heart strain on EKG (S1Q3T3 and RAE), any previous EKGs? I've seen PEs present w/ anxiety and/or palpitations alone, and she does have the recent long flight, and the gastroenteritis symptoms could definitely be distractors; however, no hypoxia and does not sound like pt is dyspneic or tachypneic. I would start with fluid bolus and continue to treat like sepsis from GI source. Evaluate patient and look for evidence of DVT. Repeat CBC, cmp, lactate, add on troponin and order CTA because if she ends up dying from a PE, you're going to look like a ***** for glossing over the S1Q3T3, intercontinental flight, severe tachycardia, and fever while explaining in your M&M that you wanted to save her from unnecessary radiation.

 

[WheezyBaby]

Evidence of right heart strain on EKG (S1Q3T3 and RAE), any previous EKGs? I've seen PEs present w/ anxiety and/or palpitations alone, and she does have the recent long flight, and the gastroenteritis symptoms could definitely be distractors; however, no hypoxia and does not sound like pt is dyspneic or tachypneic. I would start with fluid bolus and continue to treat like sepsis from GI source. Evaluate patient and look for evidence of DVT. Repeat CBC, cmp, lactate, add on troponin and order CTA because if she ends up dying from a PE, you're going to look like a ***** for glossing over the S1Q3T3, intercontinental flight, severe tachycardia, and fever while explaining in your M&M that you wanted to save her from unnecessary radiation.

Good points. What's a typical turn around time on high sensitivity ddimer / what're your thoughts on it? I'd give her moderate risk wells, and she's not 1000 years old with a hundred comorbidities. Seems like you'd have a fair shot at sparing a young septic patient the contrast and radiation

 

[Zebra Hunter]

Good points. What's a typical turn around time on high sensitivity ddimer / what're your thoughts on it? I'd give her moderate risk wells, and she's not 1000 years old with a hundred comorbidities. Seems like you'd have a fair shot at sparing a young septic patient the contrast and radiation

Never been evaluated for inpatients, so would be inappropriate (IMO) in this setting, as there is no good literature to guide care. I could see doing b/l lower extremity DVT studies, but it still would not effectively rule out a PE. I don't think many would fault you (of course some always will) for jumping straight to CTA with that EKG and that story.

 

[TooMuchResearch]

I still say vagal and try to break her. Tele. Neuro exam for serotonin syndrome, question patient for SI / OD. I'm not seeing sepsis accounting for that level of worsening tachycardia with a real but not very impressive fever, not immunocompromised, perfusion well on exam with normal / elevated pressures, normal lactate, normal procalcitonin, normal CT. I'd put her on tele, bolus, see if she breaks with vagal. If she doesn't have anything consistent with serotonin syndrome and doesn't break with vagal, I think you're obligated to treat empirically for sepsis. Myocarditis and PE both also at least cross my mind as differential but probability seems very low for either

If she's tachy to the 150s and not getting better with fluids, she still might be septic but you'll need to consider why. Perhaps her squeeze is no good in this thread in which a cardiology fellow was summoned.

 

[GadRads]

Evidence of right heart strain on EKG (S1Q3T3 and RAE), any previous EKGs? I've seen PEs present w/ anxiety and/or palpitations alone, and she does have the recent long flight, and the gastroenteritis symptoms could definitely be distractors; however, no hypoxia and does not sound like pt is dyspneic or tachypneic. I would start with fluid bolus and continue to treat like sepsis from GI source. Evaluate patient and look for evidence of DVT. Repeat CBC, cmp, lactate, add on troponin and order CTA because if she ends up dying from a PE, you're going to look like a ***** for glossing over the S1Q3T3, intercontinental flight, severe tachycardia, and fever while explaining in your M&M that you wanted to save her from unnecessary radiation.

This is a great point. So do you start empiric heparin drip or therapeutic lovenox? I feel you are almost obligated to start it given the presentation in association with long flight and S1Q3T3.

I don't want to jump to a CT pulmonary angiogram. There are alternate diagnoses for what is going on: gastroenteritis and hyperthyroidism can cause these symptoms, although not sure whether these pathologies can cause S1Q3T3. Her Wells score = 3, so if the chest xray is clear, I would add a d-dimer, do a v/q scan and ultrasound of lower extremities. I would move on from there based on this.

But excellent point not to forget PE in a patient with tachycardia.

 

[TooMuchResearch]

My thought process was similar to yours... It's kind of reassuring to know that I am learning something as a 3rd year student . Why surgery consult? (anyone can answer)...

For a tender belly with a CT that didn't show anything in a patient without a good reason to suspect dead gut, I am unlikely to call a surgeon. And they are unlikely to want to operate on pain.

 

[WheezyBaby]

If she's tachy to the 150s and not getting better with fluids, she still might be septic but you'll need to consider why. Perhaps her squeeze is no good in this thread in which a cardiology fellow was summoned.

I agree with getting cards on board and evaluating with at least a bedside echo in that situation, but I'd still be more thinking the failure of HR to improve is related to tachyarrhythmia that just didn't respond to vagal maneuver (at which point cards is still the right place to go regardless) or PE as previously mentioned

 

[TooMuchResearch]

Good points. What's a typical turn around time on high sensitivity ddimer / what're your thoughts on it? I'd give her moderate risk wells, and she's not 1000 years old with a hundred comorbidities. Seems like you'd have a fair shot at sparing a young septic patient the contrast and radiation

I get the dimer back in about 30-40 minutes.

I only know the literature from the ED perspective, if she is Wells < 4, you could use the d dimer. Unless you look at her and decide you need to scan her regardless, then don't bother with the dimer.

Now...do you want to scan this young lady with (was it sudden onset?) tachycardia, strain pattern on ECG who maybe has something who isn't a PE? Maybe. Is she improving clinically from anything we've done so far? No one (who matters) will fault you for scanning her chest, though didn't she just get a contrast load a few hours ago for her belly/pelvis scan?

 

[TooMuchResearch]

This is a great point. So do you start empiric heparin drip or therapeutic lovenox? I feel you are almost obligated to start it given the presentation in association with long flight and S1Q3T3.

I don't want to jump to a CT pulmonary angiogram. There are alternate diagnoses for what is going on: gastroenteritis and hyperthyroidism can cause these symptoms, although not sure whether these pathologies can cause S1Q3T3. Her Wells score = 3, so if the chest xray is clear, I would add a d-dimer, do a v/q scan and ultrasound of lower extremities. I would move on from there based on this.

But excellent point not to forget PE in a patient with tachycardia.

It's just a strain pattern on ECG. It happens only in 15% of PEs, happens with other things too. It shouldn't guide your management if you're working the patient up appropriately and think you have more likely alternate diagnoses.

 

[Zebra Hunter]

This is a great point. So do you start empiric heparin drip or therapeutic lovenox? I feel you are almost obligated to start it given the presentation in association with long flight and S1Q3T3.

I don't want to jump to a CT pulmonary angiogram. There are alternate diagnoses for what is going on: gastroenteritis and hyperthyroidism can cause these symptoms, although not sure whether these pathologies can cause S1Q3T3. Her Wells score = 3, so if the chest xray is clear, I would add a d-dimer, do a v/q scan and ultrasound of lower extremities. I would move on from there based on this.

But excellent point not to forget PE in a patient with tachycardia.

I never start therapeutic lovenox prior to CT, and Jeff Kline doesn't either, despite what the textbook states (he did recently give tPA prior to CT though). Also, why are you ordering an inferior study that will take several hours longer to obtain results for? If you order what you listed, you are looking at probably >5 hours to result the V/Q and DVT studies whereas the CTA would be resulted within an hour and a Half. Not saying what you listed off is wrong as there are multitude of other diagnoses on the differential, but I think time to diagnosis is an important consideration. You have to weigh out the very small increased lifetime risk of cancer vs the immediate concern of making the diagnosis of PE.

 

[Instatewaiter]

Long flight and tachycardia, by well's criteria for PE she has a score of 1.5 (tachycardia), which is low risk but should get a D-dimer . With a negative D-dimer you rule out PE and can forgo your CT scan in your young woman (who needs a pregnancy test of note). You can then get your echo to look for other causes of RV strain.

If DD is positive, go directly to PE protocol CT. And get your echo afterwards for guidance of lyrics if CT is positive or other causes of RV strain and structural heart disease if negative. .

In my hospital D-dimers in the ED come back in less than an hour.

In parallel she needs a workup for sepsis and her diarrhea.

 

[sozme]

UPDATE #2

Intern orders D-dimer. It's negative.

I'll remind you of the other labs ordered by the E.D.: UPDATE 1

Nurse paging you again, asking to do something about her heart rate, which is currently hovering around 160, EKG is essentially the same as above. Other vitals normal save for temp of 101.3 deg F.

 

[nlax30]

Ideally would want to see on tele the progression of her tachycardia. Did it start suddenly or gradually ramp up? That may help tease out a diagnosis of just sinus tach vs an atrial tachycardia or SA nodal rentry and then could decide on a further tx as far the rhythm goes.

Agree with concurrent infectious work-up.

Also, just to throw this out there. Any he of thyroid disease? Could also send a TSH.

 

[sozme]

Ideally would want to see on tele the progression of her tachycardia. Did it start suddenly or gradually ramp up? That may help tease out a diagnosis of just sinus tach vs an atrial tachycardia or SA nodal rentry and then could decide on a further tx as far the rhythm goes.

Agree with concurrent infectious work-up.

Also, just to throw this out there. Any he of thyroid disease? Could also send a TSH.

Ideally would want to see on tele the progression of her tachycardia. Did it start suddenly or gradually ramp up? That may help tease out a diagnosis of just sinus tach vs an atrial tachycardia or SA nodal rentry and then could decide on a further tx as far the rhythm goes.

Agree with concurrent infectious work-up.

Also, just to throw this out there. Any he of thyroid disease? Could also send a TSH.

I'll update UPDATE #1. Her HR essentially went from 85-90 to 150 suddenly.

(I would google search another EKG but it'll invariably end-up with confounders)

 

[cbrons]

This is a great point. So do you start empiric heparin drip or therapeutic lovenox? I feel you are almost obligated to start it given the presentation in association with long flight and S1Q3T3.

I don't want to jump to a CT pulmonary angiogram. There are alternate diagnoses for what is going on: gastroenteritis and hyperthyroidism can cause these symptoms, although not sure whether these pathologies can cause S1Q3T3. Her Wells score = 3, so if the chest xray is clear, I would add a d-dimer, do a v/q scan and ultrasound of lower extremities. I would move on from there based on this.

But excellent point not to forget PE in a patient with tachycardia.

I agree with getting cards on board and evaluating with at least a bedside echo in that situation, but I'd still be more thinking the failure of HR to improve is related to tachyarrhythmia that just didn't respond to vagal maneuver (at which point cards is still the right place to go regardless) or PE as previously mentioned

I never start therapeutic lovenox prior to CT, and Jeff Kline doesn't either, despite what the textbook states (he did recently give tPA prior to CT though). Also, why are you ordering an inferior study that will take several hours longer to obtain results for? If you order what you listed, you are looking at probably >5 hours to result the V/Q and DVT studies whereas the CTA would be resulted within an hour and a Half. Not saying what you listed off is wrong as there are multitude of other diagnoses on the differential, but I think time to diagnosis is an important consideration. You have to weigh out the very small increased lifetime risk of cancer vs the immediate concern of making the diagnosis of PE.

Long flight and tachycardia, by well's criteria for PE she has a score of 1.5 (tachycardia), which is low risk but should get a D-dimer . With a negative D-dimer you rule out PE and can forgo your CT scan in your young woman (who needs a pregnancy test of note). You can then get your echo to look for other causes of RV strain.

If DD is positive, go directly to PE protocol CT. And get your echo afterwards for guidance of lyrics if CT is positive or other causes of RV strain and structural heart disease if negative. .

In my hospital D-dimers in the ED come back in less than an hour.

In parallel she needs a workup for sepsis and her diarrhea.

Ideally would want to see on tele the progression of her tachycardia. Did it start suddenly or gradually ramp up? That may help tease out a diagnosis of just sinus tach vs an atrial tachycardia or SA nodal rentry and then could decide on a further tx as far the rhythm goes.

Agree with concurrent infectious work-up.

Also, just to throw this out there. Any he of thyroid disease? Could also send a TSH.

I'm curious about the issue of HR. Does anything need to be done about it?

I've seen a few times the intern get paged about a fast HR in a patient who was hemodynamically stable.

One case was PSVT which resolved on its own after patient coughed. The other was just a panic attack so far as I could tell. Similar situation - woman on the obs unit for what appeared to be gastroenteritis. She was the kind that was hypersensitive to her internal mileau (had a diagnosis of OCD) and her elevated HR freaked her out (we had to order the telemetry monitor turned off in her room). Anyway, she ended up getting a small dose of Lopressor. The attending was displeased about that the next morning.

 

[WheezyBaby]

I'm curious about the issue of HR. Does anything need to be done about it?

I've seen a few times the intern get paged about a fast HR in a patient who was hemodynamically stable.

One case was PSVT which resolved on its own after patient coughed. The other was just a panic attack so far as I could tell. Similar situation - woman on the obs unit for what appeared to be gastroenteritis. She was the kind that was hypersensitive to her internal mileau (had a diagnosis of OCD) and her elevated HR freaked her out (we had to order the telemetry monitor turned off in her room). Anyway, she ended up getting a small dose of Lopressor. The attending was displeased about that the next morning.

You need to determine if it's sinus or a tachyarrhythmia. If it's sinus, you should identify the underlying cause and treat it; if you don't and the patient's underlying disease has bumped their HR from 100 to 150 in a few hours, they're on a bad trajectory. If it's a tachyarrhythmia, it depends, what's the patients presumed cardiac reserve? A 21 year old should be able to tach away at 150 for quite some time that monitoring it for spontaneous resolution for a bit is ok. An 80 year old, chf exac, CAD patient, etc taching away at 150 is going to decompensate much quicker.

 

[tantacles]

Ideally would want to see on tele the progression of her tachycardia. Did it start suddenly or gradually ramp up? That may help tease out a diagnosis of just sinus tach vs an atrial tachycardia or SA nodal rentry and then could decide on a further tx as far the rhythm goes.

Agree with concurrent infectious work-up.

Also, just to throw this out there. Any he of thyroid disease? Could also send a TSH.

Thyroid disease is also what stood out to me as a possibility. I would do TSH and free T4 given the clinical description.

 

[tantacles]

You need to determine if it's sinus or a tachyarrhythmia. If it's sinus, you should identify the underlying cause and treat it; if you don't and the patient's underlying disease has bumped their HR from 100 to 150 in a few hours, they're on a bad trajectory. If it's a tachyarrhythmia, it depends, what's the patients presumed cardiac reserve? A 21 year old should be able to tach away at 150 for quite some time that monitoring it for spontaneous resolution for a bit is ok. An 80 year old, chf exac, CAD patient, etc taching away at 150 is going to decompensate much quicker.

I've seen the SICU have a standing order for metoprolol for tachycardia, which made no sense to me. It was odd.

 

[cbrons]

I've seen the SICU have a standing order for metoprolol for tachycardia, which made no sense to me. It was odd.

Reminds me of a common non-sensical one I see on medicine floors a lot: IV hydralazine PRN for Psystolic >160. Very Lol.

 

[tantacles]

Reminds me of a common non-sensical one I see on medicine floors a lot: IV hydralazine PRN for Psystolic >160. Very Lol.

160? Come on, now.

 

[cbrons]

160? Come on, now.

160 or 180. DOesn't matter, I've seen both. Just yesterday I saw an 82 year old with Parkinson's admitted for some rule-out bull**** was given hydralazine overnight for 190 over something per the standing order. Next check it was 89/45. Oops.

 

[762513]

Send her to the ICU.

 

[Rendar5]

2:1 A.flutter is my first thought with buried p-waves. I always like to give adenosine and see the underlying rhythm when the rate is a steady ~150bpm. Won't hurt at least.

 

[cbrons]

2:1 A.flutter is my first thought with buried p-waves. I always like to give adenosine and see the underlying rhythm when the rate is a steady ~150bpm. Won't hurt at least.

Isn't that extremely uncomfortable for the patient though?

 

[TooMuchResearch]

2:1 A.flutter is my first thought with buried p-waves. I always like to give adenosine and see the underlying rhythm when the rate is a steady ~150bpm. Won't hurt at least.

That's interesting. I haven't seen a case where they are completely buried on the entire ECG. (At least not that I've noticed!)

 

[Rendar5]

Isn't that extremely uncomfortable for the patient though?

You should always warn the patient that they'll feel very weird like their heart is stopping prior to giving. As long as you prepare them psychologically for the 5-6 seconds of it they're fine. If you don't prepare them though...

 

[Rendar5]

That's interesting. I haven't seen a case where they are completely buried on the entire ECG. (At least not that I've noticed!)

I've had 2 cases out of like 20 2:1flutters where you don't notice the 2:1 block until you slow it down. Only clue is a locked rate without variability at 150bpm (as the flutter wave itself is usually around 300bpm and is very fixed). Still I'd say it's more often sinus tach, ectopic atrial tach or some other rhythm I usually speak with an ep cardiologist on.

 

[Radetzky]

Am I the only one unconvinced by the q3t3? In any case the negative d-dimer is 99% reassuring.

There's not much other than the tachycardia to point to sepsis as a cause and it would be unusual for it to be so paroxysmal.

Not sure Kathmandu is malaria endemic or not but in any traveler to an exotic area want to rule out malaria and typhoid in these kinds of patients.

Probably an investigative job for the next morning, but what is the history of this so called diagnosis of anxiety? Did she present initially with palpitations? Possibility is some preexisting supra ventricular tachycardia (exactly what I am not sure) which got better with atenolol and has now been unmasked with acute illness and cessation of drug.

Tell the nurse to stop worrying about the number.

 

[Instatewaiter]

That's interesting. I haven't seen a case where they are completely buried on the entire ECG. (At least not that I've noticed!)

While I have, it is when the 2nd P is buried in the middle of the QRS (not the beginning or end) or directly in the middle of the T wave. Based on the EKG given, the 2nd P wave should be in the beginning of the T wave which should be visible as a hump in at least 1 lead (which it isnt). Given the sudden onset and the paroxysmal nature, it is probably an A-tach.

I do agree with giving adenosine to see what the underlying rhythm is...

 

[Rendar5]

Am I the only one unconvinced by the q3t3? In any case the negative d-dimer is 99% reassuring.

There's not much other than the tachycardia to point to sepsis as a cause and it would be unusual for it to be so paroxysmal.

Not sure Kathmandu is malaria endemic or not but in any traveler to an exotic area want to rule out malaria and typhoid in these kinds of patients.

Tell the nurse to stop worrying about the number.

I agree about the malaria, though typhoid would cause. A relative "bradycardia" compared w/ the temp, Be weird to be tachycardia at that temp in typhoid

 

[Radetzky]

I agree about the malaria, though typhoid would cause. A relative "bradycardia" compared w/ the temp, Be weird to be tachycardia at that temp in typhoid

Interesting. Is that a ubiquitous finding?

Out of interest read up a little about relative bradycardia- turns out lymphoma and drug fever can be two common non infectious causes.

Also off topic can remember several instances on nights of being called regarding fast atrial flutter that hadnt responded to ccb/bb given by day team- turned out monitor was picking up some flutter waves as qrs and when you counted pulse was actually fine. Potential trap cos there's the temptation to trust what the monitor says!