Case 2

The patient is a 67 year old man with a past history of alcohol abuse, bipolar disorder, paroxysmal atrial fibrillation, reflux oesophagitis, chronic obstructive lung disease and iron deficiency anaemia secondary to small bowel telangiectasia. 

He presents with a 4 day history of multiple loose bowel motions, intermittent vomiting, reduced oral intake and weakness.

On arrival his:

  • Heart rate was 80 beats per minute
  • Blood pressure was 128/68 mm Hg
  • SaO2 was 95% on room air
  • Jugular venous pulse was not visible.
  • Examination of the heart and lungs was normal.
  • Abdominal examination was normal, and there was no blood on rectal examination. There was no peripheral oedema

Investigations were:

  • Chest Xray: Lungs fields clear, no free gas under the diaphragm. 
  • Abdominal Xray: Normal
  • Blood tests:
    • Arterial blood gases:
      • pH 7.65 (normal 7.36-7.44),
      • pCO2 35 mm Hg (normal 35-45 mm Hg),
      • pO2 60 mm Hg (normal 80-100 mm Hg),
      • base excess 13 mmol/L ( normal -3 to +3mmol/L)
    • Serum electrolytes:
      • Na concentration 134 mmol/l (normal 135–145 mmol/L),
      • K concentration was 2.2 mmol/L (normal 3.5–5.2 mmol/L),
      • Bicarbonate concentration 30 mmol/L (normal 22–32) mmol/L),
      • Cl concentration 77 mmol/L (normal 95–110 mmol/L),
      • Creatinine concentration 157 μmol/L (normal 60–110 μmol/L),
      • Mg concentration 0.62 mmol/L (normal 0.70 - 1.10 mmol/L)  
      • phosphate concentration 0.71 mmol/l (normal 0.75–1.50 mmol/L)
    • Haemoglobin concentration was 97 g/L (normal ≥ 130 g/L).
  • Twelve lead electrocardiogram shown below

Describe the main ECG changes in Case 2