ECG Challenge

Up the Creek Without a Provider

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A 40-year-old man presents to establish care with you as his primary care provider; he was recently forced to make this change because his prior network stopped accepting his insurance policy. He works as an electrical engineer and is a competitive rower. He began rowing at age 14; he was on his university’s team and now rows in a competitive, age-matched league.

He has never had any health-related issues, apart from sprained ankles and a fractured right clavicle in childhood. He exercises daily at an exclusive men’s club. He has no history of hypertension, diabetes, hyperlipidemia, chest pain or discomfort, shortness of breath, or exertional dyspnea. He has no surgical history.

The patient is single and has never been married; after some contemplation, he states that he is gay. He and his most recent partner separated six months ago. He denies having multiple partners, currently or previously. He reports that he is HIV-negative and was tested just three months ago. He has one alcoholic drink per day and uses marijuana recreationally with friends on the weekends.

He is not taking any medications and has no known drug allergies. The review of systems is remarkable only for recent rhinitis, which is resolving.

Vital signs include a blood pressure of 124/60 mm Hg; pulse, 110 beats/min; respiratory rate, 14 breaths/min-1; and temperature, 98.4°F. His weight is 194 lb and his height, 75 in.

The physical exam reveals a mildly anxious male in no acute distress. When asked if he is nervous, he says yes, because he’s “used to having someone else examine him.” His HEENT exam is normal, as is his thyroid exam. He has no jugular venous distention. The lungs are clear bilaterally. His heart rate is 110 beats/min and regular with no murmurs, rubs, or gallops. The abdomen is soft and nontender, with no palpable organomegaly. Peripheral pulses are strong and equal bilaterally, and there is no peripheral edema. The neurologic exam is grossly intact.

Routine blood tests are performed, and an HIV titer, ECG, and chest x-ray are ordered. The ECG reveals a heart rate of 112 beats/min; PR interval, 132 ms; QRS duration, 76 ms; QT/QTc interval, 326/444 ms; P axis, 59°; R axis, –8°; T axis, 26°. What is your interpretation of this ECG?



The ECG is remarkable for sinus tachycardia and left ventricular hypertrophy. Equal numbers of P and QRS complexes with a consistent PR interval indicate sinus tachycardia. High voltages in the limb leads (R in lead I and S in lead III ≥ 25 mm) or precordial leads (S in lead V1 and R in lead V5 or V6 ≥ 35 mm) constitute left ventricular hypertrophy.

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