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What’s the Diagnosis #16

A nursing home patient is brought by ambulance with a cough. Nursing home staff believe the patient may have aspirated lunch 30 minutes ago. The patient’s workup is normal except for his EKG which is shown below (you can click on it for a much larger/printable version).

What’s the diagnosis? What needs to be done with the patient? Does it make any difference whether this was a new finding or an old finding?

I’ll provide the answer in the comments section in a couple of days.

EKG Scenario


  1. 3rd degree A-V block. If new, would probably warrant an evaluation of reversible causes. If old and the patient is asymptomatic, nothing need be done.

  2. I agree, 3 degree heart block, RSR’ in V1 suggestive of intraventricular conduction delay and concomitant with heart block shown. Does patient have prior history of dysphagia or neurological deficit causing difficulties in swallowing? Is this cough syncope (valsalva induced?)

  3. > If old and the patient is asymptomatic, nothing need be done.

    Is “old” referring to the patient (as in old and sick and something else is gonna kill him real soon so it’d be unnecessary cruelty to do a lot of stuff unto him) or the block? This guy IS having 2-second pauses. If new/reversible then pacing pads on and machine by bedside, or possibly a temp wire.

  4. I don’t think it’s 3rd degree heart block… the R-R interval should be more regular in that case. My best guess is Mobitz II AV block with a prolonged PR interval, but that’s not a great fit either. The cough could potentially be related to pulmonary edema from heart failure, and the patient likely needs a pacemaker. If it’s a new finding, you could look for drugs causing the conduction delay. But I don’t know how the management would differ if it was a new vs. old finding.

  5. looks like 2nd degree AVB, Wenckebach to me.
    pretty slow
    make sure no nodal agents on board, no dig
    depends on who’s on call as to what they get
    doc A – leave em alone if asx
    doc D – get a pacer even if asx

  6. I prefer to provide a diagnosis in the form of a YouTube video.

  7. Wenckebach, no treatment.

  8. very subtle P-P lengthening

  9. NSR w/type I AV block, variable conduction, and RBBB. He’s certainly got a sick AV node if he’s not able to handle an atrial rate of 60 bpm w/o dropping beats, but no immediate treatment is necessary unless the patient is symptomatic.

  10. I agree with the later comment, 2nd degree block not 3rd degree block. If it’s new I would probably admit him, because I’m not 100% convinced its a mobitz 1 although I think it is. If it’s old and his electrolytes are ok he can go back.

  11. Good case.
    We know there is some type of block.
    Since there are QRS complexes dropping, it isn’t a first degree AV block.
    Third degree block is AV dissociation where atria and ventricles beat at their own rhythms. While the P waves are regular, the QRS complexes are not. Third degree block therefore isn’t likely. I made a markup EKG showing P waves here.
    So the block is a type 2. We just have to figure out whether there is elongation of the PR interval before the dropped beats. This is an important determination. If there is elongation of the PR interval, then it is a Wenckebach and no treatment is needed. If there is no elongation of the PR interval, then it is a Mobitz 2 and a pacemaker is indicated.
    Lead V1 on the rhythm strip does show a progressively lengthening PR interval before the QRS drops. Note how the first PR interval is long, then a beat drops, then the PR interval shortens on the following beat and becomes progressively longer over the next 3 beats before dropping again.
    Those who said Wenckeback were correct.
    The patient had the same rhythm on his previous EKGs and was clinically stable, so he was sent back to the nursing home.

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