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Wednesday, 19 June 2013

#ECGclass Case 32 - A 13yr old with chest pain?


#ECG Class is an educational blog which runs alongside Twitter.
A new ECG "quizz" is launched most Wednesday evenings, in term time. 

Cases are generally aimed at Primary Care.  All scenarios are completely fictitious, but based on commonly occurring presentations in General Practice. 
This is an educational site, intended for healthcare professionals and shouldn't be construed as patient advice. 

Please use the Hashtag #ECGclass on Twitter, if you want to ask the patient any questions, or request any further investigations. Alternatively, please join in discussion and leave comments below.

Remember there are no right or wrong answers!  

ECG interpretation is often open to debate, and will usually evolve and change as new information becomes available.  Everyone's opinion is valid, and useful for others, as the evolution process takes place.  Together we will try and form an interpretation based on the trace, and information, we have in front of us.  Don't worry if you disagree - shout up and share your thoughts - the diagnosis is often arguable on the basis of a 12 lead trace, and may only become more obvious when a longer rhythm strip is available. 

Please feel free to join in, but most important of all, have fun! :-)

If you feel confident enough to join in, that's fantastic, but equally its great if you just prefer to watch and learn quietly.

Please feel free to leave any comments at the end - It's really helpful to know how many people are 'out there', finding this class useful.

Here goes then....

#ECGclass case 32.

An anxious Mum, re-presents her 13yr old son, for the second time, with chest tightness on exertion. 
You last saw him 8 weeks ago, when he described breathlessness and chest tightness, often on exertion (during football and running), but occasionally at rest as well. 

Despite there being no family history, you were fairly convinced this was asthma, and suggested a trial of inhaled bronchodilator, and a Peak Flow diary. 

The peak flow diary is unremarkable, and he reports no symptomatic benefit from salbutamol.

You remain unimpressed by this tall, thin and healthy looking, active teenager, but mum seems unduly concerned.
Under a little pressure you agree to do an ECG to reassure.
After all, 13yr olds can't get angina.... Can they?

You have planned to review him in a couple of weeks, but as soon as your practice nurse has done the ECG she brings it in for you to see:

What are your thoughts now?

Does it look normal?

Which features worry you?

Any more questions you want to ask?


Having seen the ECG, you call the patient and his Mum back in, and establish that there is no signifcant family history of heart disease. You specifically ask about sudden young deaths in the family, and Mum is aware that a paternal uncle drowned in his teens whilst swimming. 

You are a little more concerned now, and want to know more about his symptoms.  He describes the chest discomfort as a tight band when he exerts - he feels like he can't breathe. It also occurs at rest. very rarely he had noticed a brief awareness of his heart beat but had thought nothing of it. There is no history suggestive of sustained palpitations.

You revisits your examination. He is normotensive with BP the same in both arms. 
You think he may have a soft ejection systolic murmur and notices this is amplified on valsalva manoevre. It is quieter on held expiration. You know that the murmur of Aortic stenosis is usually louder on expiration so you find this odd.
It's now 5pm on Thursday. You'd like a CXR - or better still an ECHO - but you know there is no way of getting an out-patient one this evening.
Your practice nurse went home straight after doing the ECG so the only way you could get Mum's ECG is to do it yourself....and there are still more patients waiting to be seen.

He's smiling as he sits in front of you, pain free and relaxed. 

Does anyone want to call the on-call cardiologist to chat?

Does anyone want to admit him?

Does anyone want to give him a CXR card to attend for a walk in CXR in the morning and refer to a paediatric cardiologist once the report is back?


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


  1. Heart sinks - this is clearly not right. My reaction is refer immediately to local paediatric service for further evaluation. Suspect aortic dissection in teenager with marfan's syndrome (or other elastase disorder) CXR may clinch diagnosis, though MRI angiography may be required at specialist centre to grade the disease.

  2. Thanks David. ECG looks worrying doesn't it. I think I'd call for advice straight away too! I don't think we can't even get a CXR result back within a reassuring time frame.... Updated information now added.

  3. Thanks for your post, the contents are informative.. I will be waiting for your next post.