Clinical Images
Wide QRS Complex
Melinda B. Tanabe, MD and Rami Doukky, MD, MSc, FACC
A 77-year-old female presented to the emergency department with confusion. She had a history significant for hypertension, stage IV chronic kidney disease, papillary thyroid carcinoma, and status-post thyroidectomy maintained on levothyroxine. She reported left-sided chest pain which was exacerbated with touch. She denied any orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema. Her exercise tolerance was three blocks, stable from before.
On admission, her blood pressure and heart rate were 190/100 mmHg and 71 beats per minute, respectively. There were no other remarkable physical exam findings. Chest x-ray showed no acute changes. Laboratory work was remarkable for creatinine 4.6 mg/dL (baseline 3.5 mg/dL), blood urea nitrogen 101 mg/dL, calcium 16.0 mg/dL, albumin 3.1 g/dL, and TSH 66 μIU/mL. Her 12-lead electrocardiogram (ECG) at presentation is shown in Figure 1.
How do you explain her ECG findings?
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Hypothyroidism
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Hypercalcemia
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Digoxin toxicity
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ECG artifact
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References:
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Schutt, Robert C. et al. "Severe Hypercalcemia Mimicking St-Segment Elevation Myocardial Infarction." Methodist DeBakey Cardiovascular Journal 10.3 (2014): 193-97.
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Gardner, Jonathan et Al. "ECG Diagnosis: The Effect of Ionized Serum Calcium Levels on Electrocardiogram." The Permanente Journal 18.1 (2014): 119-20.
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Vecht, Romeo, Michael A. Gatzoulis, and Nicholas S. Peters. "Pericarditis, Myocarditis, and Metabolic Disorders." ECG Diagnosis in Clinical Practice. London: Springer, 2009. 187-94. Print.
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Kusumoto, Fred. "Orphans." ECG Interpretation from Pathophysiology to Clinical Application. New York: Springer, 2009. 259-75. Print.
Author Biography:
Dr. Tanabe is a current PGY3 and future Chief Medical Resident of the Internal Medicine program of John H. Stroger Jr. Cook County Hospital.
Dr. Doukky is the Chairman of Cardiology at Cook County Health and Hospitals System and a Professor of Medicine, Preventive Medicine and Radiology at Rush Medical College.