OK, Pop Quiz!

[AngelfireRN, MSN, RN, APRN]

A friend's daughter is in nursing school, and she called me last night with this question.... I wanted to see what y'all's take was...

A stable 20-something female presents for a yearly physical and as part of her exam, an EKG is done. The results are as follows:

NSR rate 95.

Rightward axis

Borderline EKG

PR interval 162

QRS duration 82

QT/QTc 338/424

P-R-T axes 56-103-19

Medications:

Nexium 40 mg per day

OCP

Phentermine 37.5 1/2 tab daily

fluoxetine 20 mg daily

Question: What could be the reason for the rightward axis?

I suggested lead placement, as there are no changes mentioned in the tracing. Changes in lead V1 would make me think about an enlarged right ventricle, but there are none. PPH came to mind, but there are no s/s. I looked up all the meds, thinking that the phentermine might cause it, but it does not cause PPH ( I was thinking about the other half of Phen-fen, fenfluramine).

Any other ideas? This is a bonus question on a take home quiz, she's allowed to look things up. This one just sparked my interest. Thanks, all!

[MedSurgeMess]

you know, reading over this, my first thought was the Nexium, but I haven't been able to find anything that would suggest why--just something in my head said that this was the problem, like I've heard something like this before. The only thing that I would think on that line would possibly be that she doesn't take the Nexium correctly, causing absorption issues with the other meds, which in turn could cause the right shift on the EKG. I'm very curious about this question as well.......

[NRSKarenRN, BSN, RN]

Moved to student assistance forum.

Take another look at your drug book as Phentermine does cause PPH.

Phentermine Side Effects - for the Professional

Phentermine

Cardiovascular: Primary pulmonary hypertension and/or regurgitant cardiac valvular disease, palpitation, tachycardia, elevation of blood pressure.

http://www.drugs.com/sfx/phentermine-side-effects.html

[AngelfireRN, MSN, RN, APRN]

Thanks.

From what I had read, I was under the impression that it caused the problems when it was combined with another drug. Good to know.

Thanks for moving this. Had no idea there was a student assist forum.

[AngelfireRN, MSN, RN, APRN]

Valvular heart disease has been reported in patients taking phentermine in combination with fenfluramine or dexfenfluramine, but not in patients taking phentermine alone. Analysis of available data suggests that fenfluramine and dexfenfluramine are the causal agents, and both drugs have been withdrawn from the market as of September 15, 1997.

Saw this on there as well. This is a good site. I'll have to bookmark it.

[AngelfireRN, MSN, RN, APRN]

Phooey, y'all, I take phentermine! I'll have to call my doc and see if I need to stop. You know, you'd think he might have mentioned that when he put me on it. I think that falls into the category of "Information You Need".l