ECG Solving & Cardiac Cases Mangement in Family Medicine DR Ihab Suliman MBBS , MRCP, Diplomate Certification Board of Nuc...
28 years old school teacher, Mother of 3 children visited Family medicine clinic with Chest pain & Palpitations
<ul><li>Normal  </li></ul>
Lead Position <ul><li>A typical ECG report shows the cardiac cycle from 12 different vantage points (I, II, III, aVR, aVL,...
QRS waveform nomenclature R r qR qRs Qrs QS Qr Rs rS qs rSr’ rSR’
Millivolts Milliseconds 0 200 400 600 -0.5 0 0.5 1.0 QRS The width of the QRS complex should not exceed 110 ms, less than ...
The QRS complex should be dominantly upright in leads I and II I II III aVR aVL aVF
QRS and T waves tend to have the same general direction in the limb leads I II III aVR aVL aVF
V 1 V 2 V 3 V 4 V 5 V 6 The R wave in the precordial leads must grow from V1 to at least V4
Question <ul><li>An 8 years old boy presents with history of chest pain that gradually worsened while he was watching tele...
Answer <ul><li>Administer salbutamol and check peak flow </li></ul><ul><li>Discharge home with primary care followup </li>...
<ul><li>Administer Salbutamol  and check peak flow </li></ul><ul><ul><li>Not indicated by the history </li></ul></ul><ul><...
53 years old male with Previous history of pontine Hemorrhage , visited the clinic with Chest Pain, 2 sets of cardiac Enzy...
 
<ul><li>NSR, LVH + LV Strain Pattern </li></ul>
Exertional Syncope case  <ul><li>49 years old male healthy looking , does regular exercise at home using treadmill testing...
Answer <ul><li>Aortic stenosis </li></ul><ul><li>Pulmonary embolus </li></ul><ul><li>Mitral incompetence </li></ul><ul><li...
Answer <ul><li>Aortic stenosis </li></ul><ul><ul><li>Fits the age group for congenital bicuspid valve </li></ul></ul><ul><...
Aortic Stenosis <ul><li>Bimodal distribution </li></ul><ul><ul><li>Under 65: bicuspid aortic valve </li></ul></ul><ul><ul>...
<ul><li>35  years old , Lady seen in Family Practice Clinic for Vague Sx , including Chest Pain. </li></ul>
 
<ul><li>NSR, First Degree AV Block </li></ul>
<ul><li>50 years old lady with Rheumatic Heart Disease & Open Heart Surgery 15 years ,triple valve replacement , came to t...
 
<ul><li>AF with Controlled Ventricular rate . </li></ul>
<ul><li>65 years old male with Recurrent Heart Failure & non-ischemic Cardiomyopathy was admitted Electively to CCU . </li...
 
<ul><li>NSR , LBBB </li></ul>
<ul><li>16 years old female admitted to HDU for elective cardiac procedure. </li></ul><ul><li>H/O rheumatic Heart Disease....
 
<ul><li>Sinus Tachycardia , Bi atrial Enlargement. </li></ul>
 
<ul><li>Left Atrial Enlargement  </li></ul>
<ul><li>40 years old male , hospital staff , LDL is  3.5, strong Family history of IHD, occasional Chest Pain. </li></ul><...
 
<ul><li>Normal , next step is stress Test  </li></ul>
 
 
65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy an...
65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy an...
A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided chest pain and she is short of...
<ul><li>Pulmonary Embolism </li></ul><ul><li>Why ? </li></ul><ul><li>Young female </li></ul><ul><li>Pegnancy  hypercoagula...
50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril
<ul><li>Hyperkalemia,tall tented T-wave & bradycardia. </li></ul><ul><li>Why ? </li></ul><ul><li>Chronic renal failure </l...
26  Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no histo...
<ul><li>Acute Pericarditis </li></ul>
26  Old army officer had flu last week, felt chest pain while driving his car, pain increased by deep breath, ECG after 5 ...
<ul><li>Resolved Pericardtis.  </li></ul>
<ul><li>47 years old lady mother of 5 children , visited Family Practice  Clinic with Palpitations , ECG oredered </li></ul>
 
 
<ul><li>S Tachycardia , LVH + LAE </li></ul>
<ul><li>Thank You Very Much  </li></ul>
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Family medicine presentation1120111final

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  • QRS waveform nomenclature The ECG consists of a small deflection called the P wave, arising from the atria, a more complicated deflection called the QRS complex due to ventricular depolarisation and a final T wave resulting from repolarisation of the ventricles. The QRS complex of waves is the largest deflection of the ECG and is always spiky in shape. All sharp deflections resulting from electrical activation of the ventricles are called QRS complexes. However, these waves can vary immensely in size, and arrangement. The QRS complex is very important when diagnosing myocardial infarction. In order to be able to describe these complexes, a nomenclature for the waves is needed. This can be done using combinations of the letters q, r, s, Q, R, S, lower case letters denoting small waves and upper case larger waves. The first positive wave is labelled with r or R Any second positive wave is labelled r´ or R´ A negative wave which follows an R wave or r wave is labelled S or s A negative wave that precedes an R or r wave, is labelled a q or Q wave Any wave that is entirely negative is labelled qs or QS. Using these rules and nomenclature all QRS complexes can be described, enabling more accurate diagnosis.
  • Rule 2 The QRS complex is due to depolarisation of the ventricles. The width of the QRS complex should not exceed 110 ms (less than 3 little squares). A wider QRS is sometimes seen in healthy people, but may represent an abnormality of intraventricular conduction.
  • Rule 3 The QRS complex should be dominantly upright in leads I and II. Slight disparities are likely to be acceptable.
  • Rule 4 The QRS and T waves tend to have the same direction in the standard leads.
  • Rule 6 The normality of QRS complexes recorded from the precordial leads is dependent on both morphological and dimensional criteria.
  • Family medicine presentation1120111final

    1. 1. ECG Solving & Cardiac Cases Mangement in Family Medicine DR Ihab Suliman MBBS , MRCP, Diplomate Certification Board of Nuclear Cardiology(USA)
    2. 2. 28 years old school teacher, Mother of 3 children visited Family medicine clinic with Chest pain & Palpitations
    3. 3. <ul><li>Normal </li></ul>
    4. 4. Lead Position <ul><li>A typical ECG report shows the cardiac cycle from 12 different vantage points (I, II, III, aVR, aVL, aVF, V1-V6), like viewing the event electrically from 12 different locations (like a 3D perspective).BUT only 10 electrodes are used. </li></ul><ul><li>Lead I represents activity that is going from the right arm to the left arm </li></ul><ul><li>Lead II represents activity that is going from the right arm to the left leg </li></ul><ul><li>Lead III represents activity that is going from the left arm to the left leg </li></ul><ul><li>aVL is placed on the left arm (or shoulder) </li></ul><ul><li>aVF is placed on the left leg (or hip) </li></ul><ul><li>aVR is placed on the right arm (or shoulder) </li></ul><ul><li>V1- 4th intercostal space to the right of sternum </li></ul><ul><li>V2- 4th intercostal space to the left of sternum </li></ul><ul><li>V3- halfway between V2 and V4 </li></ul><ul><li>V4- 5th intercostal space in the left mid-clavicular line </li></ul><ul><li>V5- 5th intercostal space in the left anterior axillary line </li></ul><ul><li>V6- 5th intercostal space in the left mid axillary line </li></ul>
    5. 5. QRS waveform nomenclature R r qR qRs Qrs QS Qr Rs rS qs rSr’ rSR’
    6. 6. Millivolts Milliseconds 0 200 400 600 -0.5 0 0.5 1.0 QRS The width of the QRS complex should not exceed 110 ms, less than 3 little squares P R T Q S
    7. 7. The QRS complex should be dominantly upright in leads I and II I II III aVR aVL aVF
    8. 8. QRS and T waves tend to have the same general direction in the limb leads I II III aVR aVL aVF
    9. 9. V 1 V 2 V 3 V 4 V 5 V 6 The R wave in the precordial leads must grow from V1 to at least V4
    10. 10. Question <ul><li>An 8 years old boy presents with history of chest pain that gradually worsened while he was watching television with his mother. The pain lasted 2 hours and then resolved without intervention. There was no associated dyspnea or syncope. He has no significant past medical history. Family history includes a grandmother who died of a heart attack. Physical exam, ECG, and CXR are normal. What is the most appropriate next step in the emergency department? </li></ul>
    11. 11. Answer <ul><li>Administer salbutamol and check peak flow </li></ul><ul><li>Discharge home with primary care followup </li></ul><ul><li>Laboratory evaluation, including cardiac markers </li></ul><ul><li>Observation admission for treadmill testing </li></ul><ul><li>Outpatient echo and Holter monitor </li></ul>
    12. 12. <ul><li>Administer Salbutamol and check peak flow </li></ul><ul><ul><li>Not indicated by the history </li></ul></ul><ul><li>Discharge home with primary care followup </li></ul><ul><ul><li>Reasonable for 1 st episode with reassuring story </li></ul></ul><ul><li>Laboratory evaluation, including cardiac markers </li></ul><ul><ul><li>No clear evidence for trops in kids </li></ul></ul><ul><li>Observation admission for treadmill testing </li></ul><ul><ul><li>Evals for CAD, very rare in kids </li></ul></ul><ul><li>Outpatient echo and Holter monitor </li></ul><ul><ul><li>May be indicated for recurrent episodes </li></ul></ul>
    13. 13. 53 years old male with Previous history of pontine Hemorrhage , visited the clinic with Chest Pain, 2 sets of cardiac Enzymes are Normal <ul><li>A 49 yo M presents after he fainted while running on his treadmill at home. He has been having exertional dyspnea and angina for the past several months. Which of the following disease is most likely to cause these symptoms? </li></ul>
    14. 15. <ul><li>NSR, LVH + LV Strain Pattern </li></ul>
    15. 16. Exertional Syncope case <ul><li>49 years old male healthy looking , does regular exercise at home using treadmill testing , last Night had syncope after 5 minutes on treadmill , no fits. </li></ul><ul><li>Visited today Family Practice Clinic , ECG showed LVH , NSR , BP 120/70 </li></ul>
    16. 17. Answer <ul><li>Aortic stenosis </li></ul><ul><li>Pulmonary embolus </li></ul><ul><li>Mitral incompetence </li></ul><ul><li>Pulmonary stenosis </li></ul><ul><li>Tricuspid incompetence </li></ul>
    17. 18. Answer <ul><li>Aortic stenosis </li></ul><ul><ul><li>Fits the age group for congenital bicuspid valve </li></ul></ul><ul><li>Pulmonary embolus </li></ul><ul><ul><li>Usually more acute, not exertional </li></ul></ul><ul><li>Mitral incompetence </li></ul><ul><ul><li>SV maintained -> exertional SOB but not syncope </li></ul></ul><ul><li>Pulmonary stenosis </li></ul><ul><ul><li>Dyspnea and Easy Fatigability </li></ul></ul><ul><li>Tricuspid incompetence </li></ul><ul><ul><li>Causes JVD and peripheral edema (right sided) </li></ul></ul>
    18. 19. Aortic Stenosis <ul><li>Bimodal distribution </li></ul><ul><ul><li>Under 65: bicuspid aortic valve </li></ul></ul><ul><ul><li>Over 65: calcific degeneration </li></ul></ul><ul><li>Outflow tract obstruction with LVH </li></ul><ul><li>Crescendo-decrescendo systolic murmur </li></ul><ul><li>Classic symptoms </li></ul><ul><ul><li>DOE </li></ul></ul><ul><ul><li>Syncope </li></ul></ul><ul><ul><li>Angina </li></ul></ul><ul><li>This is the classic AS question </li></ul>
    19. 20. <ul><li>35 years old , Lady seen in Family Practice Clinic for Vague Sx , including Chest Pain. </li></ul>
    20. 22. <ul><li>NSR, First Degree AV Block </li></ul>
    21. 23. <ul><li>50 years old lady with Rheumatic Heart Disease & Open Heart Surgery 15 years ,triple valve replacement , came to the clinic with SOB , ECG & CXR were done </li></ul>
    22. 25. <ul><li>AF with Controlled Ventricular rate . </li></ul>
    23. 26. <ul><li>65 years old male with Recurrent Heart Failure & non-ischemic Cardiomyopathy was admitted Electively to CCU . </li></ul><ul><li>ECG oredered </li></ul>
    24. 28. <ul><li>NSR , LBBB </li></ul>
    25. 29. <ul><li>16 years old female admitted to HDU for elective cardiac procedure. </li></ul><ul><li>H/O rheumatic Heart Disease. </li></ul><ul><li>ECG ordered showed </li></ul>
    26. 31. <ul><li>Sinus Tachycardia , Bi atrial Enlargement. </li></ul>
    27. 33. <ul><li>Left Atrial Enlargement </li></ul>
    28. 34. <ul><li>40 years old male , hospital staff , LDL is 3.5, strong Family history of IHD, occasional Chest Pain. </li></ul><ul><li>ECG ordered </li></ul>
    29. 36. <ul><li>Normal , next step is stress Test </li></ul>
    30. 39. 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has vomited twice .
    31. 40. 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has vomited twice . <ul><li>Anterior (extensive) Myocardial infarction. </li></ul><ul><li>Why ? </li></ul><ul><li>Male 65 years. </li></ul><ul><li>H/O DM+HTN( remember INTERHEART study) </li></ul><ul><li>Crushing chest pain. </li></ul><ul><li>Associated sweaty,clammy,vomiting. </li></ul>
    32. 41. A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided chest pain and she is short of breath.
    33. 42. <ul><li>Pulmonary Embolism </li></ul><ul><li>Why ? </li></ul><ul><li>Young female </li></ul><ul><li>Pegnancy hypercoagulable state </li></ul><ul><li>Occurrence one week post partum </li></ul>
    34. 43. 50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril
    35. 44. <ul><li>Hyperkalemia,tall tented T-wave & bradycardia. </li></ul><ul><li>Why ? </li></ul><ul><li>Chronic renal failure </li></ul><ul><li>Patient on lisinopril </li></ul>
    36. 45. 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/ L
    37. 46. <ul><li>Acute Pericarditis </li></ul>
    38. 47. 26 Old army officer had flu last week, felt chest pain while driving his car, pain increased by deep breath, ECG after 5 days .
    39. 48. <ul><li>Resolved Pericardtis. </li></ul>
    40. 49. <ul><li>47 years old lady mother of 5 children , visited Family Practice Clinic with Palpitations , ECG oredered </li></ul>
    41. 52. <ul><li>S Tachycardia , LVH + LAE </li></ul>
    42. 53. <ul><li>Thank You Very Much </li></ul>
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