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Wednesday, 20 March 2013

#ECGclass Case 27 - A young man with palpitations

#ECGclass case 27

Back to the wonderful world of everyday-GP-land tonight.

A 19 yr old man comes to see you in surgery. He's worried about some short-lived palpitations he had in the early hours of Sunday morning.

He's usually fit and well with no significant family history of IHD, or sudden unexplained death. He is on no medication. On further questioning he admits the palpitations were an isolated episode after a rather 'heavy' night of alcohol, caffeinated energy drinks, smoking.  He denies any use of recreational drugs.

After a thorough history and examination, you are completely happy that this was lifestyle induced, and educate him appropriately. You reassure him that no further investigations are necessary, but to call you again if problematic symptoms return.

He appears to remain anxious and unconvinced, and doesn't seem to want to leave.

What now? 

Do you:
a) Smile, stand up and open the door for him? 
b) Turn back to your computer and sip your coffee, waiting patiently for him to leave?
c) Explore his concerns?

Update 1

OK. You are feeling benevolent, so you opt for c.

He tells you that he is in the process of applying to the RAF as he hopes to be a fighter jet pilot. He's worried that these recent symptoms may mean something more sinister, which may need 'dealing' with before he attends for his interview/medical.  He asks if he could have 'a heart trace or something'.

Do you :
a) Agree to his request and book him for an ECG? (It goes against your clinical judgement, but if it will help reassure him - it's going to be normal after all...).
b) Do you stand your clinical ground and offer more firm reassurance? (if the RAF are interested, surely it's up to them to investigate)

Update 2

You do the ECG, and this is what you get:

Is it normal?

Rate:  Atrial (P-wave rate) and Ventricular (Q-wave rate)?
Pwaves: Present? Regular? Consistent?
PR Interval: consistent?
QRS:normal shape? size? Duration? Consistently preceeded by a P wave?
ST segments - Are they isoelectric?
QT interval - is it normal duration?

Q1. Does this man's ECG fulfil this definition for sinus rhythm?
       (Check the definition of sinus rhythm if you are unsure).

Q2. What about the QRS - does it look normal? Is the duration normal?
       (see normal interval values if need)

When you've had a go,  you'll find the full discussion on the next blog!

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