A 70 yo woman presents to the emergency department with a 3 month history of intermittent dizziness.
Her only past medical history is hypertension, for which she is on an ACE inhibitor. There are no other medications and she has no allergies.
On arrival the patient's vitals are BP of 190/95, pulse rate of 48bpm and sats of 99% on room air. She is seen by the registrar.
Her examination is normal. Dual heart sounds, nil extra sounds, normal respiratory exam, abdomen is soft and the neurological exam is normal. She is stable on her feet and walks around the department with no assistance.
Blood tests including FBC and UEC and Troponin are reported normal. The ECG is reported as normal.
The patient is to be discharged, when you review. What did the doctor miss?
To solve this case, we need to be suspicious as to why the patient has bradycardia, when they are not on a beta blocker.
The money is in the ECG. This is a MOBITZ II with a 2:1 Block
The problem with Mobitz II blocks like this is that they can deteriorate into a complete heart block.
The patient had a pacemaker inserted.
In last week's EMQA we spoke about a 2:1 block where the p waves were hidden in the T waves. These are not hidden.
CAUSES OF MOBITZ BLOCKS