Case presentation

50 year old female with past medical history of hypertension, chronic kidney disease receiving dialysis three times a week and congestive heart failure reported to the emergency room with chief complaints of palpitations for almost half an hour. She also complained of chest discomfort and mild shortness of breath. She was receiving lisinopril, amlodipine digoxin, darbopoietin and calcium acetate. Her examination revealed a regular heart rate of 150 beats per min, respiratory rate of 18, and blood pressure of 160/95 mm Hg. She had an AV fistula in left arm. Her chest examination revealed few crackles in the bases. Cardiovascular examination revealed normal S1 and S2. She had a grade II/VI murmur at the base. Abdominal and neurology examination was normal. An ECG was done in the ER (Figure 1). She was ruled out for an acute coronary syndrome with three negative sets of cardiac enzymes. After reading the ECG we decided to check her digoxin level, which was 2.4 ng/ml.

1) What is the diagnosis of an arrhythmia seen in the EKG in Fig 1?

2) In what conditions do you see such arrhythmias?

Figure 1

Figure 1: ECG showing wide QRS tachycardia with alternating axis with each beat.

Answer

Correspondence to

Mohammad Khalil kanjwal MD. Khalil.kanjwal@utoledo.edu Clinical Instructor of Medicine. University of Toledo Medical Center Toledo OH 43614 Tele: 4193835388 Fax: 4193836252