ECGs in the ED

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A 7-year-old boy was brought to the emergency department for evaluation of left ear pain. During the evaluation, he was noted to have an irregular cardiac rhythm. The ear pain started 2 days prior and has been associated with a low-grade fever of 100.3 ° F. His parents deny having been told about an irregular rhythm in the past. He is an otherwise healthy boy. He denies a history of palpitations, chest pain, shortness of breath, dizziness, syncope, or exercise intolerance. There is no history of cyanosis. He has no other medical problems and has had no prior hospitalizations or surgeries. There has been normal growth and development throughout childhood. He takes no medications regularly, but took acetaminophen earlier today for the pain. He has no known drug allergies. The family history is noncontributory for congenital heart disease or sudden death. There is a healthy brother. He attends second grade.
In the emergency department, the boy is acyanotic and in no distress. He is well-developed and alert. The temperature is 38.2 ° C. The heart rate is 68 bpm and the respiratory rate is 18 per minute. The blood pressure is 100/64. The mucous membranes are moist and the oropharynx is clear. The right tympanic membrane is normal. The left tympanic membrane is erythematous and bulging. The neck veins are nondistended. The chest is clear to auscultation. The cardiac exam reveals a normally active precordium. There is a regularly irregular rhythm with a normal first heart sound and a soft, physiologically split second heart sound. There is no gallop or click. There is no murmur. The pulses are full and equal without brachial-femoral delay. The abdomen is soft with the liver edge palpable at the right costal margin. The extremities are warm and well-perfused. The neurologic exam is nonfocal.
An electrocardiogram was performed (Fig. 1).
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