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ECG Abnormalities_Part 17

Sunday, December 12, 2010

A 21 year old healthy female comes to the clinic with complaints of intermittent palpitations. These episodes can last from seconds to minutes and are associated with lightheadedness, diaphoresis, and occassionally chest pain. Her ECG is below:

What is the Abnormality in ECG 1?

In the clinic she has one of these episodes and an ECG is performed:

What is the Abnormality in ECG 2?

ECG Abnormalities_Part 16

Friday, November 26, 2010

An 87 year old male with a history of coronary artery disease has the below ECG:

What is the Abnormality?

ECG ANSWER

The ECG findings include:

1) Normal sinus rhythm with first degree AV block
2) Right bundle branch block (RBBB)
3) Left anterior fascicular block (LAFB or left anterior hemiblock or LAHB)
4) PVC

ECG Abnormalities_Part 15

Sunday, November 21, 2010

A 58 year old male with a history of  DM, hypertension, and dyslipidemia presents with substernal chest pressure for 30 minutes. The pain began at rest,severe in nature, was mild to begin with then increased in intensity, is worse with exertion, radiates to his left arm, is not pleuritic or positional, and is associated with diaphoresis, shortness of breath, and nausea.
His temperature is 37.2, blood pressure 90/50mmhg, heart rate 100/bpm, respiratory rate is 16/min. No jugular venous distension is present, he is tachycardic and an S4 heart sound is present. No murmurs are heard. His lungs are clear to auscultation. The rest of his exam is normal.


What is the diagnosis?

ECG ANSWER

The ECG findings include:

1) Normal sinus rhythm
2) Poor R wave progression (possibly indicated an anterior wall infarct - age undetermined)
3) Old inferior wall infarct (indicated by Q waves in inferior leads)
4) Biphasic T waves in leads V1 - V4 possibly consistent with ischemia

ECG Abnormalities_Part 14

Wednesday, November 17, 2010

A 72 year old male receives a routine ECG which is below. His electrolytes are normal.

Identify the Abnormality in this ECG strip?

ECG ANSWER

Normal sinus rhythm with a first degree AV block

The PR interval in this ECG is very long, about 380 milliseconds (normal is 120 - 200 ms or 0.12 - 0.20 seconds). A P wave preceeds each QRS complex, thus this is 1st degree AV nodal block.

ECG Abnormalities_Part 13

Saturday, November 13, 2010

An 82 year old male with a history of hypertension presents to the clinic with a complaint of generalized weakness for 3 days. No chest pain, shortness of breath, dyspnea on exertion, lower extremity edema, paroxysmal nocturnal dyspnea, orthopnea, palpitations, or dizziness. He takes lisinopril and hydrochlorothiazide for his hypertension.

His temperature is 37.0, blood pressure 100/50 mmHg, heart rate 155 bpm, respiratory rate is 16/min. No jugular venous distension is present, he is tachycardic and irregularly irregular on cardiac exam without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is below

What Is the Abnormality in this ECG?

ECG ANSWER


The ECG findings include:

1) Atrial fibrillation with rapid ventricular response
2) PVC(Premature ventricular contraction)

Atrial fibrillation occurs when the atrial conduction becomes chaotic and very fast. The atrial rate increases to around 400-600 beats per minute. When this occurs, the amplitude of the P waves markedly decrease. Frequently, the P waves are not able to be detected at all, however at times a coarseness of the baseline of the ECG occurs reflecting the fibrillatory atrial activity. Not all of the 400-600 atrial action potentials per minute are conducted to the ventricles otherwise ventricular fibrillation would occur. Instead, the AV node is able to block a good number of beats usually resulting in a ventricular rate between 120-180 in the absence of AV blocking medications. Due to the chaotic atrial activity, varying block of the atrial action potentials at the AV node occurs resulting in an irregularly irregular rhythm.

ECG Abnormalities_Part 12

Sunday, November 7, 2010

A 68 year old male with a past history of chronic atrial fibrillation presents to the emergency room with a complaint of nausea, vomiting, generalized abdominal pain, and generalized weakness. No fevers or chills. No diarrhea, constipation, melena, or other signs of gastrointestinal bleeding. He does not know his medications. He states his vision has been slightly yellow tinged recently.

His temperature is 37.0, blood pressure 90/50, heart rate 55, respiratory rate is 16. No jugular venous distension is present, he is bradycardic and irregularly irregular on cardiac exam without any murmurs. His lungs are clear to auscultation. His abdominal exam is completely normal. The rest of his exam is normal.

His ECG is below:

 Identify the Abnormality?

ECG ANSWER

The ECG findings include:

1) atrial fibrillation with bradycardia
2) ST segment depression consistent with digoxin effect

The ECG shows a downsloaping ST segment depression in multiple leads that are shaped like the "reverse check mark sign" or a "scooped out" appearance. This pattern is typical of digoxin. This may occur at normal digoxin levels in some people, but becomes more common as the digoxin level increases.

ECG Abnormalities_Part 11

Friday, November 5, 2010

A 38 year old female presents to the emergency department with a complaint of palpitations for 2 hours. She complains that she has intermittently had palpitations for years, but always lasting for minutes only. These palpitations are associated with mild dizziness and shortness of breath. No chest pain occurs.

Her temperature is 37.0, blood pressure 90/50, heart rate 190, respiratory rate is 16. No jugular venous distension is present, she is tachycardic and regular on cardiac exam without any murmurs. Her lungs are clear to auscultation. The rest of her exam is normal.
Identify this ECG rhythm?


ECG ANSWER

The ECG findings include:

Narrow complex tachycardia - most likely AV nodal rentry tachycardiaa (AVNRT)

The ECG shows a narrow-complex tachycardia that is regular.No flutter waves are seen. In leads V3 - V6 a P wave can be seen just after the QRS complex making this rhythm a "short-PR" tachycardia. Remember the most common short-PR tachycardia is AV nodal rentry tachycardia.

ECG Abnormalities_Part 10

Sunday, October 24, 2010

A 86 year old male with no significant past medical history to clinic with a complaint of generlized weakness, dizziness, and dyspnea on exertion. Mild lower extremity edema, paroxysmal nocturnal dyspnea, and orthopnea are present. No chest pain has occured. He is not taking any medications.

His temperature is 37.0, blood pressure 80/40mmHg, heart rate 40/BPM, respiratory rate is 16/min. Mild jugular venous distension is present, he is bradycardic and regular without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is below:

Identify the Abnormality in this ECG strip?


ECG ANSWER

The ECG findings include:Junctional rhythm

A junctional rhythm occurs when the SA node is not able to generate an action potential and AV node acts as the main pacemaker of the heart. In this instance, the P wave morphology (normally generated when the SA node fires causing atrial depolarizaion) will be altered since its origin is no longer at the SA node and is instead at the AV node. The direction of conduction to the atria in a junctional rhythm is considered "retrograde" since it is traveling up the atria from the AV node instead of down the atria from the SA node. This results in an inverted P wave in lead II (normally upright in sinus rhythm) and an upright P wave in aVR (normally inverted in sinus rhythm).
Depending on the exact location of the pacemaker in a junctional rhythm, the P wave location may vary. If it occurs slightly above the AV node (low atrium), then the P wave will actually occur slightly before the QRS complex is seen. This will result in the P wave appearing just before the QRS, but PR interval will be short (< 0.12 ms). If the pacemaker occurs at the junction, the P wave and QRS complex may be exactly overlying and you may not be able to identify any P waves at all. If the pacemaker occurs lower in the junction, the QRS complex may actually occur before the P wave (the P wave will be seen after the QRS complex). In this case a retrograde P wave can be identified just before the QRS complex with a short PR interval, thus the pacemaker is located high in the AV node or perhaps in the low atrium. Causes of a junction rhythm include chronic degeneration of the SA node (termed "sick sinus syndrome"), hypoxia, myocardial ischemia, hyperkalemia, digoxin toxicity, elevated vagal tone, and medications known to supress the SA node (beta-blockers and non-dihydropyradine calcium channel blockers).

ECG Abnormalities_Part 09

Monday, October 18, 2010

A 50 year old male with no past medical history presents to the emergency room with sudden onset severe chest pain. The pain is 10/10, substernal, sharp in nature, worse with deep inspiration, not positional or reproducible, and associated with shortness of breath and dizziness but no excessive sweating , nausea, or vomiting.

His temperature is 37.0, blood pressure 80/40, heart rate 110, respiratory rate is 28. His oxygen saturation is 88% on room air. He appears in mild distress, no jugular venous distension is present, he is tachycardic and regular without any murmurs. His lungs are clear to auscultation. The rest of his exam is normal.

His ECG is given below:

What is the Abnormality in this ECG Strip


ECG ANSWER

The ECG findings include:
1) Sinus tachycardia
2) S1Q3T3 pattern consistent with acute cor pulmonale (acute right ventricular strain) a.k.a. the "McGinn-White sign"

The diagnosis is pulmonary embolism
The patient's clinic scenario of pleuritic chest pain, tachycardia, and hypoxia should raise a high clinical suspicion for pulmonary embolus. Also, his chest pain was sudden onset and severe unlike that of myocardial ischemia. Aortic disection can cause sudden-onset severe chest pain as well, however usually the patient is hypertensive and not necessarily hypoxic.

ECG Abnormalities_Part 08

Wednesday, October 13, 2010

A 53 year old male with a history of uncontrolled hypertension is found unresponsive at the side of the street and is brought to the emergency room.

His temperature is 37.0, blood pressure 190/100, heart rate 50, respiratory rate is 8. He is unrepsonsive on physical exam. Heart and lung exams are normal. Laboratory studies including electrolytes and troponin levels are all normal.

His ECG is below:

What is the abnormality in this ECG strip?

ECG ANSWER

The ECG findings include:
1) Normal sinus rhythm
2) Marked T wave inversions and prolonged QT interval

Answer: A CT scan of the brain is needed. His clinical picture and ECG findings are consistent with an acute central nervous system abnormality. Patients with subarachnoid hemorrhages, intracranial hemorrhages, and less commonly severe ischemic strokes have ECGs that reveal deep, symmetric T wave inversions and QT prolongation. Less commonly, carotid endarterectomy can result in this ECG pattern chronically.

ECG Abnormalities_Part 07

Monday, October 11, 2010

A 27 year old female with a history of HIV infection presents to the emergency room with a complaint of increased dyspnea on exertion and lower extremity edema over the past 6 months. She denies chest pain, paroxysmal nocturnal dyspnea or orthopnea.

Her temperature is 37.0, blood pressure 90/50, heart rate 110, respiratory rate 20. She has large V waves in her jugular venous pulsations, a III/VI pansystolic murmur at the left lower sternal border which gets louder with inspiration, and a right ventricular S4 heart sound is heard. A pulsatile liver is palpated.

Her ECG and chest x-ray are given below:

What are the ECG findings and the abnormality in the chest Xray?


ECG ANSWER

The ECG findings include:
1) Sinus tachycardia
2) RVH with strain pattern

Chest XRAY ANSWER

The patient's clinical presentation is consistent with severe pulmonary hypertension. Her ECG revealed RVH which results from pulmonary hypertension. Her chest x-ray shows enlarged pulmonary arteries and an enlarged right ventricle in the absence of pulmonary edema. Her physical exam showed findings consistent with severe tricuspid valve regurgitation which included large jugular V waves, the pansystolic murmur at the tricuspid listening post that increases with inspiration (Carvallo's sign), the right ventricular S4 heart sound indicating RVH, and a pulsatile liver indicating severe regurgitation into the hepatic venous bed.

ECG Abnormalities_Part 06

Sunday, October 10, 2010

A 23 year old female  medical student presents to the emergency room with altered mental status. Her friends say she has been drinking hard liquor non-stop for 1 week after her final exams and has not been eating well for months. She was recently started on erythromycin for a upper respiratory tract infection.
Her temperature is 37.0, blood pressure 90/50, heart rate 70, respiratory rate 10. She is thin and cachectic appearing. She is arousable but unable to answer questions or follow commands. Her heart and lung exam are normal.
Her laboratory studies reveal a potassium level of 2.1 (normal 3.5-5.0), a magnesium level of 0.9 (normal 1.8-3.0), and a calcium level of 5.0 (normal 9.0-10.5). Her ECG is below:

After a few hours in the emergency room, she becomes completely unresponsive and the monitor reveals the below rhythm:


Identify the abnormalities in 1st and 2nd ECG strips?



ECG 01 ANSWER

The ECG findings include:
1) Normal sinus rhythm
2) Prolonged QT interval
She was pre-disposed to a long QT due to hypokalemia, hypomagnesemia, hypocalcemia, erythromycin use and female gender.

ECG 02 ANSWER

Polymorphic ventricular tachycardia (Torsade de Pointes)

ECG Abnormalities_Part 05

Sunday, April 11, 2010

A 66 year old female with a history of hypertension, TYPE 2 Diabetes mellitus, and End stage renal disease requiring hemodialysis presents to the emergency department with increasing shortness of breath and dizziness.
On arrival she was confused and her GCS was 13/15 and her BP was 110/70mmhg and pulse was 83bpm.HerRespiratry rate was 32/min.
Immediate ECG was taken and it is given below.


Identify the abnormalities in this ECG???
What is the Condition???

Pregnant Woman with Vaginal Bleeding

Tuesday, March 30, 2010

 41 years Old  Pregnant Woman who married for 10 years, admitted to the ward complaining of vaginal bleeding and severe nausea and vomiting for 3 days duration.
Parity  - 00 Gravida - 01
Her Last Menstrual Period - 3 1/2 months prior to the onset of vaginal bleeding.
Menarche - 14 years
She had regular periods of 32 days Cycle with normal Bleeding for 3-5 days.No Hx of Intermenstrual Bleeding or Dysmenorrhagia.
No significant past medical,surgical or contraceptive history.

On examination 
Not pale, Not ill- looking or Not in pain
Regular pulse of 76bpm
BP - 130/80 mmHg
Abdominal Examination
  • No Striae Gravidarum
  • Symphisio Fundal Height is greater than the Gestational Age

 hCG  level was Markedly increased

What is the Diagnosis?

4 year Old Boy Stares Vacantly

Saturday, March 27, 2010

Here shows an abnormal behavior of a  4 year old boy  who was having a positive family history epilepsy.
This Child was brought to the pediatric ward by mother as she was told that this child was staring vacantly in the nursery.This has been happened several times a day and short lasting.Immediately after the event, the child will usually resume whatever he  was doing prior to its onset.No history of falls during that Event.






His EEG(Electroencephalography) is given below


What is the Diagnosis?
What are the EEG changes?

8-year old male,has a long history of progressive weakening of his muscles.In the first year of his life, He reached many gross motor skill milestones, such as holding his head up, rolling over, sitting, and standing, at normal times. But he did not walk until age 16 months.During last 5 years he suffered progressive muscle weakness and Frequent falls when trying to walk, most notably in the proximal musculature of the arms and legs.He has has a younger sister in good health.



What is your diagnosis?
What are the important physial signs that you would expect in this Child?
How would you confirm the Diagnosis?

Man with Abdominal Pain and Jaundice

Tuesday, March 16, 2010

32 Years old man was admitted to the medicine ward complaining of feeling tired for last 3weeks associated with yellowish discoloration of eyes.And he also complained that he had on and off abdominal pain for about 1week duration.There  is no history of fever,nausea,vomiting,loss of weight or loss of appetite.He has undergone appendectomy when he was 5 years.There was no significant past medical history or drug history.

On General Examination he looked well but mildly icteric.
Abdominal Examination - Mild tenderness in the upper quadrant of the Abdomen and there was a palpable mass in the upper left quadrant felt 3cm below the costal margin. 

  • What  are the differential diagnosis???

FBC,Blood Picture,Biochemical tests  were done


Full blood Count
  • HB        11.8g/dl
  • MCV     103fl
  • MCH     30pg/cell
  • MCHC   36g/dl
  • RBC      6x1012/l
  • WBC     10.5x109/l
  • Reticulocyte count  130x109 /l

Biochemical Tests
  • Bilirubin 25umol/L (0-17umol/L)
  • LDH 680IU/L(220 - 450 IU/L)
  • Coombs' test was negative 

Blood Picture




  •  What are the abnormalities in this blood picture??
  •  What further tests that you would need to do for a defenitive diagnosis??
  •  What is your diagnosis??


32 year Pregnant Mother Came to the ENT Clinic Complaining of right sided hearing loss especially for low freaquency sounds and hearning of ringing, roaring and  buzzing like sounds.Examination of her Tympanic membranes are normal on both sites.
Interpret this Audiogram???

ECG Abmormalities_Part04

Sunday, March 7, 2010

A 58 year old male with a history of hypertension, dyslipidemia, and diabetes mellitus presents to the emergency department with substernal chest pain radiating to his left arm and shortness of breath. He has vomited twice and now is intermittently feeling lightheaded.

His temperature is 37.4, heart rate 70, blood pressure 110/70, and respiratory rate 24.  His heart sounds are regularly irregular, and an S4 heart sound is present.


What are the ECG abnormalities you can see?
How would you expalin these ECG changes with the clinical presentation ofthe patient?


4 1/2 years old child presented with marked abominal distension which was more prominent on the left side of the abdomen which was associated with abdominal pain and haematuria.There  was no family history of any significant diseases or any malignancy. On examination of  this child it was found that he was pale and abdomen was tender.

His CT Scan was given below.

What is the Diagnosis?
What are the biochemical tests that you would do to conform the  Dx?
What arethe Management options available and How is the Prognosis of this Disease?

Lady with Right Sided Lower Abdominal Pain

Thursday, February 18, 2010



32 year old lady who married for 10 years presented with Right Sided lower abdominal pain since 22nd of January.She had intermittent type of pain lasting for 15-20 minutes.In between that ,there were pain  free periods.Pain was radiating to the to the Thigh and Buttocks.During the painful period she also had Sweating and and faintishness.There is no vaginal Bleeding associated with lower abdominal pain.
There was No fever and No vomiting.

Menstrual History 
She attend the Menarche at the age of 14 years.
She had 25 days regular cycle with normal bleeding with is usually lasting for about 4 days.
She also complained that she had experienced  pain 2 day before menarche and lasting it for about 3 days.
That pain felt in both sides of the Lower abdomen but more prominent in the Left side of the Abdomen.
Her last menstrual period in  02nd of January of which due date was 15th of January.

Obstetrics History
Her 1st pregnancy was in 2000 and she has no history of Abortions.She did not have any antenatal complications.She has only 1 child.She used contraceptive pills for 1 year after the delivery and then withhold treatment for 4-5 years.And again she used pills since 6 months back and stopped in the 18th of January.

There is no significant past medical,surgical or drug history.

Trans Vaginal Ultra sound Scan was done and the report is given below.
Antiverted Uterus
Small irregular Sac in Uterine Tube
No fetal pole
Bilateral ovaries are normal
No free  fluids

Urinary hCG was positive.

Only the history and the investigations are given in this case.
What would be the possible diagnosis?


Chathur 5 year old Boy,Known patient with Ventricular Septal Defect , brought to the hospital by his mother complaining of  Sudden Weakness of the Right Leg and fallen on the ground 2days back.This was happened four times on that day.There was no loss of Consciousness,Sudden loss Of Vision,Fits and Vomiting associated with that above  event.
This child did not have any significant past surgical history and child was regularly followed up by a  cardiologist

On examination of this Child

He was not Febrile,not pale and not Icteric.There was no finger or toe clubbing.No facial  Puffiness or pitting ankle Odema
Cardio Vascular System - Pan Systolic Murmur best heard at the Left sternal Edge
Cenral Nervous System - No abnormality Detected
Other System Examinations also uneventful

What are the differential Diagnosis?
What are the other relevant things that you would  ask in the history?
What are the Investigations you would like to do for confirmation of your Dx?


 

ECG Abnormalities_Part03

Friday, January 8, 2010

79 year old woman complaining of attacks of dizziness for the past.These Attacks are infrequent but come on any time, without obvious precipitating events And the attacks could occur  in any posture.She had never had Chest pain.Apart from these attacks she was very well.
But her Physical examination reveal that she was having a regular heart with a rate of 40bpm.
And there were no murmurs or signs of cardiac  enlargement.


  1. How would you explain her attacks of dizziness with the aid of the ECG given above???

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