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Reminder of important clinical lesson
The importance of an ECG: back to basics
  1. Golaleh Haidari1,
  2. Kirsty Gray2,
  3. Senthil Kirubakaran3
  1. 1Department of Genitourinary Medicine, St Thomas’ Hospital, London, UK
  2. 2Department of Acute Medicine, St Thomas’ Hospital, London, UK
  3. 3Department of Cardiology, St Thomas’ Hospital, London, UK
  1. Correspondence to Dr Golaleh Haidari, ghaidari{at}


A 48-year-old man presented to accident and emergency with syncope on a background history of 3 weeks of increasing shortness of breath. He collapsed at home prompting admission. He was a smoker with a 30-pack-year history. On examination, he was found to be tachypnoeic and hypoxic, with a raised JVP and quiet heard sounds. He was haemodynamically stable and a chest x-ray showed right upper-lobe collapse.

His resting ECG demonstrated electrical alternans prompting urgent referral to the cardiologist for echocardiography. This revealed a large pericardial effusion with evidence of right ventricular diastolic collapse. In view of this, he underwent urgent pericardiocentesis.

A subsequent CT scan showed bilateral pleural effusions and multiple lung nodules. Both pericardial and pleural fluid cytology were reported as metastatic non-small cell adenocarcinoma. The pericardial fluid continued to reaccumulate requiring a pericardial window. He was referred to the oncology team for palliative chemotherapy.

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