Osce ecg

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Osce ecg

  1. 1. OSCE- ECG Phase IIIa sienmingoat
  2. 2. Dizziness
  3. 3. Ventricular tachycardia <ul><li>Describe? </li></ul><ul><ul><li>regular widen/bizarre QRS (> 0.14 s or 3.5 small squares) </li></ul></ul><ul><ul><li>QRS rate: 140-200 beats/min </li></ul></ul><ul><ul><li>P not present/dissociated/retrograde (AV dissociation) </li></ul></ul><ul><ul><li>Indeterminate QRS axis </li></ul></ul><ul><ul><li>Concordant pattern (all +/- polarity) in lead V1-V6 </li></ul></ul><ul><ul><li>Sinus capture/fusion beats (different morphology) </li></ul></ul><ul><ul><li>LBBB pattern (also SVT w aberrant ventricular conduction) </li></ul></ul><ul><li>Causes: </li></ul><ul><ul><li>CAD/IHD/MI </li></ul></ul><ul><ul><li>Cardiomyopathy (hypertrophic, dilated), mitral valve prolapse </li></ul></ul><ul><ul><li>Digitalis intoxication </li></ul></ul><ul><li>CX? </li></ul><ul><ul><li>V fibrillation </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><li>Rx (avoid VF) </li></ul><ul><ul><li>Amiodarone - DC cardioversion </li></ul></ul><ul><ul><li>IV lignocaine - pacing </li></ul></ul><ul><ul><li>IV procaineamide </li></ul></ul><ul><ul><li>Cardioversion </li></ul></ul><ul><li>S&S? </li></ul><ul><ul><li>Hemodynamic instability: hypotension, pul edema, cardiac arrest </li></ul></ul><ul><ul><li>Presyncope/dizziness or syncope (dizziness, palpitation, syncope, cardiac arrest) </li></ul></ul>
  4. 5. 64yo man, A&E with syncope. Admission ECG.
  5. 6. Inferior MI <ul><li>Dx? </li></ul><ul><ul><li>Acute Inferior MI (with posterior infarction) </li></ul></ul><ul><li>Describe/List abnormalities? </li></ul><ul><ul><li>II, III, aVF changes (IMI) </li></ul></ul><ul><ul><ul><li>Q waves present </li></ul></ul></ul><ul><ul><ul><li>ST elevation </li></ul></ul></ul><ul><ul><li>I, aVL (hyperacute transmural IMI) </li></ul></ul><ul><ul><ul><li>tall T </li></ul></ul></ul><ul><ul><ul><li>Reciprocal ST depression </li></ul></ul></ul><ul><ul><li>V1-V4 (PMI) </li></ul></ul><ul><ul><ul><li>Reciprocal ST depression </li></ul></ul></ul><ul><li>What artery? </li></ul><ul><ul><li>R coronary artery </li></ul></ul><ul><li>Risk Factors (modifiable) </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Hypercholesterolemia </li></ul></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>HPT </li></ul></ul><ul><li>MI- Presentation? </li></ul><ul><li>symptoms: acute central chest pain, SOB, sweatiness, palpitation </li></ul><ul><li>signs: anxiety/distress, pallor, abn pulse/BP, hear failure/murmur </li></ul><ul><li>MI- complication? </li></ul><ul><li>Cardiac arrest </li></ul><ul><li>Cardiogenic shock </li></ul><ul><li>Heart block </li></ul><ul><li>DVT/PE/thromboembolism </li></ul><ul><li>Valvular heart dz </li></ul><ul><li>Cardiac tamponade/pericarditis </li></ul>
  6. 7. Posterior MI <ul><li>Reciprocal changes in leads V1-V3 </li></ul><ul><li>Dominant R in leads V1-V3 </li></ul><ul><li>ST segment depression in leads V1-V3 </li></ul><ul><li>Tall, upright T wave in leads V1-V3 </li></ul>
  7. 8. 38yo lady, SOB palpitation 1 week
  8. 9. Atrial fibrillation <ul><li>What is the rhythm? </li></ul><ul><ul><li>Irregularly irregular: Atrial fibrillation </li></ul></ul><ul><li>2 abnormalities? </li></ul><ul><ul><li>Disorganized indistinct P </li></ul></ul><ul><ul><li>‘ f’ wave (irregular/undulating baseline) </li></ul></ul><ul><ul><li>Rapid/slow ventricular rate? </li></ul></ul><ul><li>4 causes </li></ul><ul><ul><li>IHD </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>HPT </li></ul></ul><ul><ul><li>Thyrotoxicosis </li></ul></ul><ul><ul><li>Mitral valve dz (MS/MR) </li></ul></ul><ul><ul><li>Idiopathic </li></ul></ul><ul><li>1 complication </li></ul><ul><ul><li>Stroke (systemic thrombo-embolism) </li></ul></ul><ul><li>Mnagement: </li></ul><ul><ul><li>Digoxin (B-blocker)/verapamil: if high ventricular rate </li></ul></ul><ul><ul><li>Anti-coagulant </li></ul></ul>
  9. 10. Palpitation, X organic HD
  10. 11. SVT (AVNRT) <ul><li>Describe? </li></ul><ul><ul><li>Regular narrow complex tachycardia (>170) </li></ul></ul><ul><ul><li>P absent </li></ul></ul><ul><ul><li>P inverted @ II(b4/aft/in QRS) </li></ul></ul><ul><li>Why neck massage? </li></ul><ul><ul><li>Carotid sinus massage (vagotonic stimuli) </li></ul></ul><ul><ul><li>Transient increase AV block </li></ul></ul><ul><ul><li>Unmask u/lying atrial rhythm </li></ul></ul><ul><ul><li>Alternative: adenosine/valsalva maneuver </li></ul></ul><ul><li>Components: </li></ul><ul><ul><li>AV nodal re-entrant T </li></ul></ul><ul><ul><li>AV reciprocating T (WPW syndrome) </li></ul></ul><ul><ul><li>Atrial T </li></ul></ul><ul><ul><li>Junctional/nodal T </li></ul></ul>
  11. 12. 70y/o chest pain
  12. 13. Left ventricular hypertrophy <ul><li>3 abnormalities? </li></ul><ul><ul><li>S @ V1-V2 + R @ V5-V6 > 35mm </li></ul></ul><ul><ul><li>V5-V6 & I: ST depression & T inversion (L wall ischemia) </li></ul></ul><ul><li>S wave > 25 mm in V1 or V2 </li></ul><ul><li>R wave > 25mm in V5 or V6 </li></ul><ul><li>The sum of R wave in V5/6 and S wave in V1/2 > 35mm </li></ul><ul><li>Diagnosis/cause? </li></ul><ul><ul><li>Angina 2nd to IHD </li></ul></ul>
  13. 14. Ventricular hypertrophy with strain <ul><li>ST segment depression </li></ul><ul><li>T wave inversion </li></ul>
  14. 15. Right ventricular hypertrophy <ul><li>Dominant R in V1 </li></ul><ul><li>Deep S in V5 and V6 </li></ul><ul><li>RAD </li></ul><ul><li>RBBB </li></ul>
  15. 17. Anterior MI <ul><li>Abnormalities? </li></ul><ul><ul><li>Pathological Q @ V1-V3 </li></ul></ul><ul><ul><li>ST segment elevation V1-V6, I, aVL </li></ul></ul><ul><li>Diagnosis? </li></ul><ul><ul><li>Acute extensive anterior MI </li></ul></ul><ul><li>Artery involved? </li></ul><ul><ul><li>L anterior descending artery </li></ul></ul><ul><li>Risk factor? </li></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Elderly </li></ul></ul><ul><ul><li>Hypercholesterolemia </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul>
  16. 18. 58yo female, hip fracure + recurrent syncope/dizzy
  17. 19. Third degree AV block <ul><li>Atrial rate? </li></ul><ul><ul><li>300/3.5= 85 bpm </li></ul></ul><ul><li>Ventricular rate? </li></ul><ul><ul><li>300/10= 30 bpm </li></ul></ul><ul><li>Relationship btw A-V? </li></ul><ul><ul><li>Complete atrio-ventricular dissociation (3 rd degree) </li></ul></ul><ul><li>Reson for syncope? </li></ul><ul><ul><li>Bradycardia d2 3 rd degree AV block (Stokes-Adams attack) </li></ul></ul><ul><li>Physical signs? </li></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Cannon a wave </li></ul></ul><ul><ul><li>Dizziness/syncope/SOB (exertion) </li></ul></ul><ul><ul><li>Postural hypotension </li></ul></ul><ul><li>Causes? </li></ul><ul><ul><li>IHD/post-MI </li></ul></ul><ul><ul><li>idiopathic fibrosis </li></ul></ul><ul><ul><li>Drug toxicity (digoxin/B-blocker) </li></ul></ul><ul><ul><li>Infiltrative process (amyloidosis, sarcoidosis) </li></ul></ul><ul><ul><li>Connective tis dz (SLE/RA) </li></ul></ul><ul><ul><li>Endocarditis/Myocarditis </li></ul></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>NM disorders (Duchenne MD) </li></ul></ul>Adams-Stokes syndrome slow or absent pulse, vertigo, syncope, convulsions, and sometimes Cheyne-Stokes respiration; usually as a result of advanced A-V block or sick sinus syndrome
  18. 22. Acute Pericarditis <ul><li>Description? </li></ul><ul><ul><li>ST elevation @ II (max), V1-V6 (saddle-shaped/concave upward) </li></ul></ul><ul><ul><li>ST depression @ aVR, ST iso @ aVL (ST vector directed to lead II) </li></ul></ul><ul><ul><li>PR depression @ II (max), V1-V6 (acute) </li></ul></ul><ul><ul><li>Normal QRS voltage & T </li></ul></ul><ul><li>Diagnosis? </li></ul><ul><ul><li>Acute pericarditis </li></ul></ul><ul><li>DDX ST elevation? </li></ul><ul><ul><li>Transmural infarct </li></ul></ul><ul><ul><li>Early repolarization syndrome (Grusin pattern II) </li></ul></ul><ul><ul><li>Acute pericariditis </li></ul></ul><ul><li>S&S? </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><ul><li>sharp retrosternal </li></ul></ul></ul><ul><ul><ul><li>Worse on inspiration </li></ul></ul></ul><ul><ul><ul><li>relieved by sitting fwd </li></ul></ul></ul><ul><ul><ul><li>Radiate neck + shoulder </li></ul></ul></ul><ul><ul><li>Pericardial friction rub </li></ul></ul><ul><li>Rx? </li></ul><ul><ul><li>NSAIDs </li></ul></ul><ul><li>VS chronic: </li></ul><ul><li>low voltage </li></ul><ul><li>low/isoelectric T (all except aVR) </li></ul>
  19. 24. Mitral stenosis <ul><li>3 findings: </li></ul><ul><ul><li>RAD </li></ul></ul><ul><ul><li>P mitrale @ II (bifid P) </li></ul></ul><ul><ul><li> RVH </li></ul></ul><ul><li>Causes? </li></ul><ul><ul><li>MS </li></ul></ul><ul><li>Cx </li></ul><ul><ul><li>AF </li></ul></ul><ul><ul><li>Lung ifx </li></ul></ul><ul><ul><li>Cor pulmonale/pul HPT </li></ul></ul><ul><ul><li>IE </li></ul></ul><ul><ul><li>Thromboembolism </li></ul></ul><ul><ul><li>RVH/TR </li></ul></ul>
  20. 25. 56yo palpitation 1 day
  21. 26. Atrial flutter <ul><li>Cardiac rhythm? </li></ul><ul><ul><li>Atrial flutter with variable degrees AV-nodal block </li></ul></ul><ul><ul><li>sawtooth/F waves </li></ul></ul><ul><li>2 other abnormalities? </li></ul><ul><ul><li>Reverse tick = digitalis use </li></ul></ul><ul><ul><li>Regular tachycardia (if 2:1 block) </li></ul></ul><ul><ul><li>narrow QRS </li></ul></ul><ul><li>3 causes? </li></ul><ul><ul><li>CVS: IHD, HPT, chronic rheumatic valvular dz </li></ul></ul><ul><ul><li>Others: sepsis, atrial enlargement, digoxin, thyrotoxicosis </li></ul></ul>
  22. 28. Atrial tachycardia <ul><li>Describe? </li></ul><ul><ul><li>Tachycardia (regular narrow QRS) </li></ul></ul><ul><ul><li>Clear visible P wave precedes each QRS </li></ul></ul><ul><ul><li>RP interval longer/equal PR interval (VS: AV reciprocating tachycardia) </li></ul></ul><ul><ul><li>(criteria: heart rate >100, abnormal p wave) </li></ul></ul><ul><li>Causes? </li></ul><ul><ul><li>Digoxin toxicity </li></ul></ul><ul><ul><li>IHD, RHD, cardiomyopathy </li></ul></ul><ul><ul><li>Sick sinus syndrome </li></ul></ul><ul><ul><li>COPD </li></ul></ul>

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