History: A 73-year-old man presents to the emergency department (ED) in the evening after a day of progressively worsening shortness of breath and dyspnea on exertion that began when he woke at 7:00 am. He has had a cough for about a week with a lot of green phlegm, but states that neither is any worse today. His dyspnea became significantly worse this evening so he had his wife drive him to the hospital. His past medical history is notable for CHF, CABG, COPD, and glaucoma. He denies any fever, chest pain, leg swelling, or other complaints.
Examination: Vital signs are normal except for a pulse of 104, and a respiratory rate of 22. Physical exam results are normal except for ronchi and coughing with a lot of pale yellow phlegm, which the patient insists on showing the ED staff. There is no JVD on neck examination or rales or wheezing. The heart is tachycardic without murmurs. There is no peripheral edema or calf tenderness.
• Pulmonary embolism
• Acute coronary syndrome
• Congestive heart failure
• Chest x-ray: Clear
• EKG: See Figure 1 (Please click to enlarge)
1. What does the case EKG show?
2. What’s the next step?
3. Where can I get a quick refresher on this topic?
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