I thought the ECG diagnosis was obvious. But many missed it. So I'm showing it.

I was reading ECGs in the system and came across this one:

What do you think?

Computer diagnosis: 

--ST DEVIATION AND MARKED T-WAVE ABNORMALITY, ANTEROLATERAL ISCHEMIA 

--ST DEVIATION AND MODERATE T-WAVE ABNORMALITY, CONSIDER INFERIOR ISCHEMIA 

I thought the ECG diagnosis was obvious, but no comment was made by the providers who ordered it.  That could be because they never saw it, as the patient eloped before full evaluation.  

But then I showed it to multiple smart providers and not a single one saw it.  So I thought it would be good to show it to blog readers.

Everyone went straight to the ST-T abnormalities, and came up with diagnoses such as pulmonary embolism, or subendocardial ischemia.

However: whenever you see ST-T abnormalities (abnormal repolarization), first look to see if they are secondary to (as a result of) abnormal QRS (abnormal depolarization).

Read the ECG systematically: Rate, rhythm, intervals, axes, voltages (QRS, ST, T), ratio of ST-T to QRS, morphologies

Here, the QRS is definitely abnormal.  The most obvious abnormalities are a large R-wave in V1 (and also V2, V3...) and also high voltage.  And also wide QRS interval -- so the QRS (depolarization) is clearly abnormal. But look more closely still: there is a short PR interval.  This should make you look for a delta wave.  

And there it is, pretty clearly evident in nearly all leads!!

This is WPW with typical repolarization abnormalities.  All of these ST-T abnormalities are expected, as they are secondary to the abnormal depolarization of pre-excitation.

I went to the chart:

This 20-something woman presented after smoking marijuana. She believes that it may have had some other drug added to it because she has had no similar reactions from past marijuana smoking. She reports that everything feels slow and distant. Endorses chest pain and auditory hallucinations. Denies EtOH/other drugs.

She had an ECG recorded and was put in the waiting room.  The wait was too long and she eloped.

After seeing this ECG, I called her back and made an appointment in Cardiology clinic.

Here are a number of interesting WPW cases:

WPW mimicking and obscuring acute MI (5 Cases)

(Case 5 is an amazing case that Pendell sent me when he was still an undergraduate)