ECG, XR, Chest Pain, SOB

Clues: Metabolic situation, look at QT segments

Less Ca2+ influx superslow Ca2+ influx prolongs plateau phase prolongs ST segment prolong QT segment

Shortened AP less plateau phase shortened segments

Hyperkalemia: more positive outside RMP is more + phase 0 in presence of high K+, the number of Ca2+ decrease less Ca2+ in to cell slowing of impulse conduction QRS widening

Rate: 300/3 = ~100

Rhythm: regular sinus

Axis: + in lead 1, + in lead aVF = normal

Hypertrophy: LVH = tall R wave in leads V4 or V6RVH = dominant R waves in V1

Infarction: ST elevation in lead 3 = inferior infarction

MI

Anterior infarction: changes classically in leads V3-V4 (but also V2 and V5)

Inferior: changes in lead III and aVFLateral infarction: changes in leads I, aVL,

V5-6.

Rate: 300/ 3-2 = 100-150

Rhythm: no P wave Irregular Atrial filbrillation

AV node is continuously bombarded with depolarization wavesConduction into ventricles is normal therefore QRS is normal however irregular

Rate: no relationship between P waves and QRS complexes

Rhythm: sinus with complete heart block and AV junctional type escape rhythm

Escape junctional beat or rhythm occurs when there is failure of impulse generation from the sinus node or atrial myocardium. The 4th and 5th beats of this tracing are junctional beats that are not preceeded by a P wave and occur after a pause that is longer than the underlying sinus cycle length

Rate: 93 Rhythm: sinus

Axis: RAD

Hypertrophy: RVH – lead V1 R wave is larger than S waveLead V6, S wave is larger than R wave

Answer: Right ventricular hypertrophy

The most likely diagnosis is

A. congestive heart failure. B. pericardial effusion. C. intracardiac shunt. D. expiratory phase of respiration. E. pulmonic stenosis.

This case represents an apparent "enlarged heart" due to an expiratory phase of respiration in an uncooperative patient. Note the decreased lung volumes and the elevation of the hemidiaphragms. The resultant crowding of vessels obscures much of the cardiac border. The technique of inspiratory PA radiograph is preferred to avoid "diagnosing" diseases that a patient does not have.

60-year-old alcoholic man with shortness of breath.

The most likely diagnosis is

A. mediastinal mass.B. intracardiac shunts (ASD and VSD)C. pericardial effusion or cardiomyopathyD. combined aortic and pulmonary arterial disease.E.technical aberrations.

The most likely diagnosis is

A. mediastinal mass.B. intracardiac shunts (ASD and VSD)C. pericardial effusion or cardiomyopathyD. combined aortic and pulmonary arterial disease.E.technical aberrations.

53-year-old woman examined in the emergency department for chest pain, tachycardia, and shortness of breath with normal ECG.

The most likely cause of the patient's symptoms isA. pneumonia.B. pulmonary edema.C. interstitial lung disease.D. panic attack.E. pneumothorax.

Panic attack

In this case the chest radiograph was normal in a 53-year-old woman seen in the emergency department for left-sided chest pain. The electrocardiogram was also normal, and there was no obvious cause for the patient's pain. Note the well-defined pulmonary vessels in the perihilar region and normal branching of these vessels into the lungs. There is a gradient of pulmonary vascular markings from the bases to the apices on an upright radiograph due to the increased perfusion to the lower lobes. No pulmonary parenchymal abnormalities are present to support the other diagnoses.

50-year-old woman with acute shortness of breath.

A. cardiac failure with pulmonary edema. B. pulmonic stenosis with pneumonia. C. pulmonary embolism. D. pneumomediastinum. E. pneumothorax.

This case is an example of a pulmonary edema due to fluid overload and congestive heart failure. Note the increased size of the cardiac silhouette, the ill-defined reticular perihilar air-space opacities, the enlargement of the vascular pedicle, and the redistribution of blood flow to the upper lung zones.

Chest pain

Probability Dx of Chest Pain 3 of them

Musculoskeletal (chest wall)    Psychogenic    Angina

Serious not to be missed -what are the systems/ categories?

Cardiovascular myocardial infarction/unstable angina     aortic dissection     pulmonary embolism

Neoplasia arcinoma lung     tumours of spinal cord and meninges

Infection pneumonia/pleurisy     mediastinitis     pericarditis

Pneumothorax

Pitfalls (often missed)

Mitral valve prolapse    Oesophageal spasm    Gastro-oesophageal reflux    Herpes zoster    Fractured rib (e.g. cough fracture)    Spinal dysfunction

Probability dx of dyspnoea

Bronchial asthma    Bronchiolitis (children)    Left heart failure    COPD    Obesity    Lack of fitness

From ‘how to treat’ paper (on wiki)

2. Bob, 50, is anxious and presents with chest pain. Which TWO aspects of the clinical history would be most helpful in deciding if the pain is cardiac in origin?

a) His pain worsens while walking from the car park to your rooms and eases while sitting

b) He describes sweating accompanying the painc) He describes the pain as like a feeling of

pressured) His pain is relieved by nitrates given to him by

your practice nurse

Case study

Peter, 47, A&E with left-sided chest pain Diagnosed with MSK condition Now returns to emergency few days laterSame pain (central), pain in left side of neck

and shoulder History of asthma, and now complains of

slight SOB

During ex – leaned back, winced in pain Changing position affected his pain, better

when he sat up and leaned forward Lungs were clear and peak flow was normal DDX??

Intense, grating sound of a pericardial friction rub, confirming the diagnosis of pericarditis.