ECG dilemma
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"A 48-year-old white male presented to the emergency room (ER) with 5-day history of fever and chills. He also reported chest pain, which he described as heaviness and radiating to the left arm. He reports generalized weakness. He has no significant past medical history. He was told to have a murmur since childhood. He does not have orthopnea nor paroxysmal nocturnal dyspnea. Vitals on examination were: Heart rate 30 bpm, blood pressure 100/60 mm Hg. Physical examination: Ejection systolic murmur grade 3/6 heard at the right upper sternal border and radiating to both carotids, lungs were clear to auscultation, skin and extremity examination was normal. Laboratory studies obtained in the ER: WBC 26, 900 /[mu]l, hemoglobin 12.2 g/dl, BUN 23 mg/dl creatinine 0.97 mg/dl, troponin I 0.3 ng/ml, hemoglobin A1c 9.2[percent]. Blood culture results obtained the next day showed 4 of 4 cultures positive for Gram positive cocci in chains. Electrocardiogram obtained is shown below. Transthoracic echocardiogram was performed – valves were not adequately visualized due to poor imaging windows but showed mild mitral and tricuspid regurgitation, aortic valve was calcified with moderate stenosis."
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