Elderly male with Chest Pain | Figure 1

Elderly male with Chest Pain

77 year old Male. Complaining of CP (at rest), 8/10, substernal, radiating to left arm, ongoing x 15min. No cardiac hx. Recent left knee replacement x 1 mo prior with no complications. Stopped all prescribed meds one week ago per orders. Pt was on diclofenac, famotidine, and meloxicam. Now off all and not on any additional meds. No recent trauma, illness, or lifestyle changes.

Initial HR 140, BP 200/143, RR 16 , spo2 98%, temp normal.

Tx: asa, cardizem 10mg, 250cc fluid bolus.

Result: HR decreased to 90’s, resolution of CP, but bigeminy noted, as well as, couplets. PVCs resolved for the most part within 10 min and pt remained stable.

What rhythm is this?

Junctional tach? P waves appear to be inverted in lead 2 in the first ekg. We did a Lewis Lead to tease out the p waves but looking at lead 1 I’m not sure it gives much help.

Aflutter with 2:1 block was considered. As well as atrial tachycardia.

Thoughts?

Similar cases

Case 1: HR 70s, SR 1 degree AVB; top strip: HR 120s, rhythm unsure of. Looking for possible interpretations.

Case 2: 50ish male called 911 for mild SOB x 4 hours.

Case 3: HR between 45-55 , pt A+O, no chest pain/ SOB at this time.

Case 4: Analysis of rhythm in patient with heart failure.