Interesting Case Rounds. Mark Boyko EM Resident. REDIS ‘Reason For Visit’. “Penis caught in the net”. CASE. 30-year old middle-eastern woman presents to the ER with complaints of a bilateral, throbbing headache, located in the occipital region. “Heart rate 34” on REDIS.
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“Penis caught in the net”
HR 34, regular
BP 170/105 right arm
O2 96% on RA
HR fluctuating between 32-40 BPM
General:Sweaty, but A/O
PERL, EOM normal, fields normal
able to flex/extend neck, not objectively stiff
no pronator drift
symmetrical movements UL & LL, power 5
reflexes 1 in UL & LL
JVP not elevated
N S1 S2, II/VI mid-systolic murmur LUSB
pulses equal R & L radial
normal A/E, equal, no crackles
incision looks okay
bulky mass left side of midline just above incision, verytender
Otherwise no peritoneal signs
4 puncture wounds near site of epidural, tender near area, no cellulitis or mass
no calf tenderness or swelling
pedal pulses present
About that heart rate…
Uric Acid 410 (140-360)
LDH 336 (100-235)
Urinalysis – “I don’t have to pee”
Mobitz I – block within the AV Node, progressive lengthening of PR interval
Mobitz II – block below the AV Node, presumed to be healthy. Most often, QRS is wide. A narrow QRS essentially excludes infra-nodal heart block.
Our patient was a perfect 2:1 block with a narrow QRS… hard to figure out!
*Only way to truly differentiate is intra-cardiac EPS. All Mobitz Type II’s get a pacemaker, regardless of whether or not they are asymptomatic.