Case 07

54 yo M with h/o atrial fibrillation (on Pradaxa), aortic coarctation repair (1975), and bicuspid aortic valve, sent in by his cardiologist for admission for nonsustained ventricular tachycardia. Patient was seeing his cardiologist today for evaluation of his aortic valve and recent fit for a holter monitor. While in the office today he was found to have brief episodes of nsvt. He was sent to the ED for admission and EP consult. Patient denies dizziness, palpitations, chest pain, diaphoresis and any other symptoms. He does state that he was usually running or doing something active when episodes occurred. Patient had no complaints at presentation. 

PHYSICAL:

VS: T 96.2,  BP 132/90,  HR 64,  RR 18,  O2 sat 99% on RA

CONSTITUTIONAL: NAD. WDWN, alert.
CARDIOVASCULAR: Regular rate, regular rhythm, no gallop. Systolic murmur.
RESPIRATORY: No respiratory distress. No wheezing, rales, rhonchi. Breath sounds equal and symmetrical.
GI/ABDOMEN: Normal bowel sounds. Soft, non-tender, no guarding or rebound. No organomegaly or pulsatile mass.
NEURO: Oriented x3. Cranial nerves II-XII within normal limits. No motor or sensory deficits. 

LABS:

CK 91
CK MB 1.2
Troponin <0.06

BNP 39

CMP within normal limits

EKG normal sinus rhythm at 67 bpm, Q waves inferior leads (old) 

1. What abnormalities do you see on this image?  What further questions might you have about this image?

2. What is the normal size of this abnormality?  What follow up studies would you consider ordering?