Sinus rhythm with long PRI mimicking junctional rhythm


Vignette: Elderly patient with history of chronic smoking, DM, HTN and dyslipidemia was brought in due to  weakness and fall. Patient is being worked-up for possible CVA.

What is the rhythm?

Image 1



This is a regular, wide QRS complex rhythm with left anterior fascicular block (LAFB) and right bundle branch block (RBBB). Our differential are: junctional rhythm or a SR with a long PR interval with P hidden from view as it merges with the T wave. 

Image 2



The rhythm strip revealed the P waves and the long PR interval.

Going back to the 12 lead, if you look closely in lead II you see distortions at the descending portion of the T waves.

For the case, it was found that it was indeed stroke. Managed as that and later sent for rehab and risk factors addressed.

#142 

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