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Chest Pain and Cardiac Dysrhythmias

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A 36-year-old woman presents to the ED with sudden onset of left-sided chest pain and mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that worsens with a deep breath. She walked up the stairs at home and became very short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling.

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What is the most common electrocardiogram (ECG) finding for this patient's diagnosis?

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a. S1Q3T3 pattern

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b. Atrial fibrillation

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c. Right-axis deviation

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d. Right bundle branch block

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e. Sinus tachycardia

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The answer is e. The patient most likely has a pulmonary embolism (PE) originating from a thrombus in her left calf. The diagnosis of PE is usually made with a CT angiogram or less commonly a ventilation-perfusion scan performed in nuclear medicine. The most common ECG abnormalities in the setting of PE are sinus tachycardia and nonspecific ST-T–wave abnormalities. Other ECG abnormalities may be present and suggestive of PE, but the absence of ECG abnormalities has no significant predictive value. Moreover, 25% of patients with proven PE have ECGs that are unchanged from their baseline state.

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With a large PE, the right heart becomes strained. Classic ECG findings of right heart strain and acute cor pulmonale are tall, peaked P waves in lead II (P pulmonale), right-axis deviation (c), right bundle-branch block (d), a S1Q3T3 pattern (a), or atrial fibrillation (b). The finding of S1Q3T3 pattern is nonspecific and insensitive in the absence of clinical suspicion for PE. Unfortunately, only 20% of patients with proven PE have any of these classic ECG abnormalities.

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A 36-year-old woman presents to the ED with sudden onset of left-sided chest pain and mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that worsens with a deep breath. She walked up the stairs at home and became very short of breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling.

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Which of the following is an indication for the administration of t-PA in the previous diagnosis?

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a. Bilateral proximal clot

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