42 yo female with SOB

[pbruss]

42 yo femal, smoker, COPD, presents with productive cough and SOB for 5 days. denies any CP, DOE, Orthopnea or edema. does not wear O2 at home.

HR - 60, BP - 135/90, T - 38.5, O2 - 85% on room air

AAOx3 mild resp distress
Lungs - mild tachynepia, rales and rhonic in right base
CV - RRR no MRG
ABD - WNL
EXT - no CCE, rashes or edema

attached is her KEG and previous EKG.

Based on your EKG interpretation, what would be your diagnostic/therapeutic treatment of choice?

A. ASA, heparin, cath lab activation
B. Labs, CXR, O2
C. CTA chest
D. ABG
E. Echo

Attachments:

[Bjs04f]

after staring at these for awhile, taking a break and staring again all I see is the 2nd shows sinus tach, and possibly some electrical alternans, but the baseline sucks, so the best I see it is v4-6. If thats the case and shes febrile with pericardial effusion, leaning towards pericariditis picture I would E. get an echo

[pbruss]

Sorry I was not clear. The first EKG is the one in the er the second EKG is a previous one

[Bjs04f]

From the new on what im not seeing is P waves, except in the lateral lead where they look really non conducted. So with the history im getting could this be an infiltrative disease causing her to have a junctional escape rhythm? Perhaps a CTA would be helpful to look for hilar lymphadenopathy, pericardial fuid or enhancement, masses in lung tissues?

[pbruss]

correct. there are some retrograde P waves that you can see if you look close. see attached with them marked. thus she has a junctional rhythm secondary to the hypoxia. turs out if was from bad pneumonia which is indicated from the history. I was looking for CTA because I do think PE needs to be ruled out.

Attachments:

[kemple]

Good example of wandering baseline and don't think it's ST changes as well.