39 y/o male with no significant past medical history presents status post syncopal episode while getting a tattoo. Vitals and physical exam unremarkable. EKG, when compared to prior, notes new changes. Admit or discharge?

Prior and new EKG.  Click image to enlarge.

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Discharge after correcting left arm - left leg EKG lead reversal and obtaining a repeat EKG which will look exactly like the prior EKG, with no significant change noted.  The big tip off here for misplaced leads is the significant change in axis of the QRS complex in leads III and aVF.

Patient likely had vasovagal syncope from painful stimulus of tattoo.

Left arm - left leg lead reversal causes lead I and II to switch places, aVL and aVF to switch places and III to invert.  Click image to enlarge.

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