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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)

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