tag:blogger.com,1999:blog-549949223388475481.post8988875615954360954..comments2024-03-28T14:02:08.119-05:00Comments on Dr. Smith's ECG Blog: A 50-something with left shoulder pain and diffuse ST elevationUnknownnoreply@blogger.comBlogger4125tag:blogger.com,1999:blog-549949223388475481.post-53953303078593176912019-11-22T22:29:49.344-06:002019-11-22T22:29:49.344-06:00THANKS for your comment Felipe. If I understand yo...THANKS for your comment Felipe. If I understand your question correctly — my understanding of Dr. Smith’s formula is that IF there is clear evidence elsewhere on the ECG of acute OMI — then the formula should not be used because the formula wasn’t studied under these circumstances — and because you ALREADY have your answer (ie, if there is definite T-QRS-D = Terminal QRS Distortion) — then you KNOW this patient with symptoms has acute OMI. It’s possible you sent in your question in before I wrote My Comment — Please take a look above at my Figure-1, which hopefully clarifies your understanding of how to recognize T-QRS-D. I’ll pass on your Question to Drs. Smith & Meyers to see if they would add anything to my answer. Gracias otra vez por tu pregunta! (Thanks again for your question) — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-78923253928676527822019-11-20T18:53:37.271-06:002019-11-20T18:53:37.271-06:00Great case!, I have a question regarding terminal ...Great case!, I have a question regarding terminal QRS distortion and the subtleSTEMI formula. I understand that with terminal QRS distortion on V2 AND V3, the formula should not be used, is this correct? or the correct thing would be that with terminal QRS distortion on V2 OR V3 to not use de formula?. The app SubtleSTEMI literally says: "Is terminal QRS distortion (absence of both A-wave and J-wave) in V2 AND V3?" I am confused. Hope to get help from you, and btw thank for creating such an incredible ECG blog (sorry for the english, it is not my mother tongue)Felipe Muñozhttps://www.blogger.com/profile/00997178057271092593noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-53455886136146773482019-11-17T17:41:25.088-06:002019-11-17T17:41:25.088-06:00THANKS (as always!) for your comment Jerry. My big...THANKS (as always!) for your comment Jerry. My biggest “plea” regarding an ED history of “pain” (be it chest, arm, neck, etc) — is brief indication of when symptoms began, and IF symptoms were truly concerning for possible acute coronary disease. Unfortunately, with cases that are passed on — this essential information is often lacking (as it is here). Despite the appearance of a repolarization variant — IF the history was that of new-onset left shoulder pain that was felt to be potentially indicative of acute coronary disease — my approach to this patient would be different (ie, Was this ECG truly needed? — or was the clinician team “sorry” after ordering it and seeing what it showed …?). Otherwise — I also saw that peculiar P wave notching in the inferior leads (albeit without associated significant negative component to the P in V1) — but I chose not to comment on this. Sensitivity and specificity of the ECG for atrial enlargement is wanting — and this might be another example of an ECG finding (if this was an otherwise healthy 50-year old) that I would have preferred not knowing about. THANKS again for your input! — :)ECG Interpretationhttps://www.blogger.com/profile/02309020028961384995noreply@blogger.comtag:blogger.com,1999:blog-549949223388475481.post-48028086481447001702019-11-17T09:22:17.748-06:002019-11-17T09:22:17.748-06:00Interesting case...
(My comments are based on the...Interesting case...<br /><br />(My comments are based on the assumption that the patient did not appear in a lot of distress.)<br /><br />I'm wondering what the indication was for the ECG to be done? Was the patient also having other signs or symptoms of an OMI? Was the left shoulder exam so equivocal that it was felt prudent to look further?<br /><br />Did the exam of the left shoulder not reveal any tenderness or pain with active ROM? The likelihood of having an acute OMI AND acute onset of musculoskeletal pain of the left shoulder at exactly the same time is profoundly low.<br /><br />As far as the ECG itself is concerned - I agree with you 100%. It's a textbook case of early repolarization (or now, normal variant) - one of those diagnoses (along with benign T wave inversion) that has to be studied again and again until one has the self-confidence to make the diagnosis.<br /><br />Also there is another very interesting finding on the tracing: there is a P-mitrale in the inferior leads, yet the P-terminal force in V1 is quite normal. This man has an interatrial delay within Bachmann's bundle and is at risk for future atrial fibrillation if the delay progresses.Jerry W. Jones, MD FACEPhttps://www.medicusofhouston.comnoreply@blogger.com