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    Hypotension and Near-syncope in a 66-year-old Woman

    A 66-year-old woman presents to the ED with a 3-day history of generalized weakness, malaise, recurrent near-syncope, nausea, and occasional vomiting. She denies chest pain, fever, difficulty breathing, diarrhea, and fainting. Her history includes diabetes, end-stage renal disease, coronary disease, and complete heart block after pacemaker implantation.

    She is afebrile. Pulse is 126 beats/min; blood pressure, 81/53 mm Hg; and oxygen saturation, 100% on room air. She appears adequately hydrated as evidenced by a moist oropharynx. There is no jugular venous distention or thyroid mass. Heart rate is regular and rapid without murmur, and lungs are clear. She has weak peripheral pulses and mild bilateral pitting edema, which she states is of recent onset. Other physical findings are unremarkable.

    Laboratory results, including a CBC count, metabolic panel, and troponin I level, are normal. Urinalysis shows 25 white blood cells per high-power field with few bacteria.

    Her ECG is shown below.

    What is your ECG read?

    Answer and discussion on next page>>

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