History of Present Illness: A man in his late 60’s with a history of valvular heart disease, BPH and bipolar disorder presents to the ED for 5 days of gradually worsening dizziness, shakiness and generalized weakness with multiple falls.  He denies any injury from the falls.  He denies any fever, nausea, chest pain, SOB or other complaints

Vital Signs & Physical Exam: Vital signs are normal.  Physical exam is otherwise normal except for the oropharynx, which seems somewhat dry.  He also has some teeth grinding and just seems a bit odd

Initial Diagnostic Testing:

  • CBC: white count of 12, stable hemoglobin of 11.8 with macrocytic indices
  • Chem 7: BUN and creatinine are 46 and 2.8, which are new. Troponin slightly elevated at 12.
  • Imaging: Brain CT normal
  • EKG: see below

Computer Read: NSR at 76, first degree AV block, IVCD, NSTWA

What is the most likely cause of ECG findings in this patient?

  • A) Acute coronary occlusion
  • B) Blood clot (PE)
  • C) Cardiac tamponade
  • D) Drug toxicity
  • E) Electrolyte issue

SCROLL DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

<<<<<<<<<<<<<<<<<<<<< ADVERTISEMENT & SPACER >>>>>>>>>>>>>>>>>>>>>

THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA

Emergency Medicine 1-Minute Consult, 5th edition

A-to-Z EM Pharmacopoeia & Antibiotic Guide, NEW 5th edition

8-in-1 Emergency Department Quick Reference, 5th edition 

******************************************************************************

Check out our weekly Wednesday EM Case Challenge

We’re currently posting on Facebook (ERpocketbooks.com) & Twitter (@EM1MinuteGuru) twice a month

 

<<<<<<<<<<<<<<<<<<<<<<<<< END SPACER >>>>>>>>>>>>>>>>>>>>>>>>>

My ECG interpretation: Computer interpretation is correct.  Unusual that patients HR is only 76 given degree of dehydration.

ANSWERS:

  • A) Acute coronary occlusion – good thought
  • B) Blood clot (PE)
  • C) Cardiac tamponade
  • D) Drug toxicity – CORRECT – he forgot to tell anyone he was on lithium
  • E) Electrolyte issue

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

CASE CONCLUSION: Lithium level was critical at 1.6 (normal 0.6-1.2).  Was admitted and treated with NS and lithium was held.  Symptoms gradually improved

CASE LESSONS:

  1. Always consider medication toxicity in drugs where levels are monitored.  Also, consider medication side effect after ruling out other causes
  2. Ask patient’s with bipolar if they are taking Lithium even when it is not listed in their medications