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Challenges in Clinical Electrocardiography |

Finding Needles in a Haystack—Quiz Case

Daniel Jurewitz, MD; Ezra A. Amsterdam, MD
JAMA Intern Med. 2013;173(10):849. doi:10.1001/jamainternmed.2013.128a.
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A 92-year-old woman was brought to the emergency department by ambulance after experiencing a fall. She was confused and speaking incoherently. Family members indicated that she had hypertension and hyperlipidemia with no history of cardiovascular disease.

Physical examination revealed a blood pressure of 131/87 mm Hg; heart rate, 99/min and regular; and oxygen saturation, 98% on room air. She had a 2-cm laceration over the right forehead, normal cardiopulmonary findings, and a Glasgow Coma Scale score of 13. Noncontrast computed tomography of the head showed a subarachnoid hemorrhage and multiple large intraparenchymal hemorrhages with surrounding edema. Serum troponin I level peaked at 0.31 ng/mL (reference, <0.04 ng/mL). Cardiology was consulted because of the patient's elevated troponin level. The patient's telemetry record revealed the electrocardiogram (ECG) strip shown below (Figure 1).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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