X ray bone and ECG revision

1. ECG revision
Dr. Abdelrahman Ahmed Ewais
Assistant lecturer of internal medicine
Faculty of medicine – Fayoum university

2. Normal ECG
Height : ↓ 2.5 small squares
Width : ↓ 3 small squares
Leads: II – V1 (+ve then –ve)
P wave
Duration: 3-5 small squares
P wave + PR segment
PR interval
Duration: ↓2.5 small squares
Amplitude: L1- L2- L3 ↑ 15 small
squares
Q wave: Small ↓ 1mmX 1mm
Deep ↑ 1mm X 1mm
Transitional zone: V3-V4
QRS complex

3. Srarts by the end of QRS at J poin
Isoelectrical ± 1mm
ST segment
+ve except in aVR- V1
Amplitude : ≤ 1 big square in limb leads
≤ 2 big squares in chest leads
T wave
Height 1/10 T
Direction as T
U wave
Starts by: beginning of QRS
Ends by: end of T wave
Duration: ½ RR interval
QT interval

4. Abnormal ECG
1- Atrial enlargement
• P Mitrale:
Lead II: broad ↑3mm ± notched
Lead V1: negative deflection is broad ↑1mm and
deep ↑1mm
• P pulmonale:
Lead II: tall ↑2.5 mm + peaked
Lead V1: +ve deflection ↑1.5 mm
• Biatrial enlargement:
Lead II: tall ↑2.5 mm + broad ↑3mm
Lead V1: +ve deflection ↑1.5 mm and : negative
deflection is broad ↑1mm and deep ↑1mm

5. Left ventricular enlargement
1- R in V5 or V6 (the taller) ≥ 25mm
2- R in V5 or V6 (the taller) + S in V1 ≥ 35mm
3- R in V5 or V6 (the taller) + S in V2 ≥ 45mm
4- R in V6 > R in V5
5- R in avf > 20 mm
6- R in avl > 13 mm
Strain pattern: inverted ST segment and/or
inverted T wave in V5 and V6  LVH

6. • Right ventricular enlargement
Lead V1: R > 7mm or R/S ratio ≥ 1
Lead V6: deep S
Strain pattern: inverted ST segment and/or
inverted T wave in V1 and V2  RVH
• Biventricular enlargement
Signs of LVE + tall R in V1
Or Signs of LVE + Rt axis deviation

7. 3- Low voltage ECG
• QRS amplitude in I+II+III is < 15 mm

8. • LBBB:
Width: 2.5-3mm → incomplete LBBB
≥3mm → complete LBBB
Shape:
V1 and V2: Qs or rS
V5 and V6 and I: monophasic ± notched R
T wave: 2ry inversion in V5 and V6
• IVCD
Wide QRS but the pattern is not consistent with
RBBB or LBBB

9. 4- Bundle branch block
• RBBB:
Width: 2.5-3mm → incomplete RBBB
≥3mm → complete RBBB
Shape:
V1 and V2: rsR (wide R) or RR (monophasic
notched tall R)
V5 and V6 and I: qRs (slurred S)
T wave: 2ry inversion in V1 and V2

10. Pacemaker pattern
• As LBBB or IVCD but a spike precedes each
QRS  Ventricular pacemaker
• If a spike precedes each QRS and each P wave
Dual chamber pacemaker

11. Hemiblock
• Left anterior hemiblock  left axis deviation +
deep S in II-III-aVF
• Left posterior hemiblock  Rt axis deviation +
deep S in I-aVL
• Bifascicular hemiblock  RBBB + hemiblock
• Trifascicular hemiblock  bifascicular + 1st
degree heart block

12. ECG comment
• Rhythm
• Rate
• P
• PR
• QRS: amplitude – width – axis – waves
• ST
• T
• QT
• Diagnosis

40. Bone radiology revision

41. • Hand and foot
• Skull
• Spine
• CT brain

42. Hand
• RA
• Acromegaly
• Gouty arthritis
• OA
• Hemolytic anemia
• Hyperparathyroidism
• scleroderma

43. Normal hand

44. RA
Plain X ray hand (both hands) PA view showing:
• Bilateral symmetrical arthritis affecting……..
• Affected joint showing:
Periarticular osteopenia – narrow joint space –
joint erosions – subchondrial sclerosis
• Sublaxation
• Deformity…….
• Rarefaction (osteoporosis)

50. Acromegaly
• Plain X ray hand (both hands) PA view
showing:
• Bulky sized bones
• Increased soft tissue shadow
• Tufting of terminal phalanges
• ± Big sesamiid
• ± Bone rarefaction

55. Gouty arthritis
• Plain X ray hand (both hands) PA view
showing:
• A symetrical arthritis affecting ………….
• Irregular articular lines of bones
• Extra-articular punched out bone erosions
• Soft tissue shadow of tophi

61. Hemolytic anemia
• Plain X ray hand (both hands) PA view
showing:
• Boxing of bones and loss of waist
• Thin cortex and wide medulla
• Lattice pattern due to trabeculation of bones
• Decrease bone density

64. Osteoarthritis
• Plain X ray hand (both hands) PA view
showing:
• Bil symmetrical arthritis affecting………….
• Narrow joint space
• Periarticular osteopenia
• Joint erosions
• Subchondral sclerosis
• Osteophytes

68. Hyperparathyroidism
• Plain X ray hand (both hands) PA view
showing:
• Resorption of terminal phalenges
• Subperiosteal phalangeal bone resorption
• ±Osteolytic lesions

71. Scleroderma
• Plain X ray hand (both hands) PA view
showing:
• Resorption of terminal phalenges
• Calcification in soft tissue of fingers

75. Skull
• Acromegaly
• Hemolytic anemia
• Filling defect

77. Acromegaly
Plain X ray skull lateral view show:
• Big skull
• Increased frontal and maxillary air sinus
• Prominent orbital margin
• Bossing of forhead
• Prognathism
• Prominent external occipital protuberance
• Big soft tissue shadow
• Thick cortex
• Increase thickening and widening of skull diploic space
• Teeth widely separated and falling
• Silver beaten apperance

79. Hemolytic anemia
Plain X ray skull lateral view show:
• Big skull
• Increase thickening and widening of skull
diploic space
• Generalized rarefaction
• Hair on end appearance

81. Filling defect
• Single defect
• Salt and pepper skull
• Multiple defect

82. Single defect

83. Salt and pepper

84. Multiple filling defect

85. MM

86. Spine
• Ankylosing spondilitis
• Osteoporosis of the spine

88. Ankylosing spondilitis
Plain X ray LSS PA view showing:
• Square shaped vertebrae
• Calcification of lateral longitudinal ligament
• Calcification of posterior ligament giving
dagger sign
• Bony bridging between vertebral bodies
• Obliteration of sacroiliac joint

91. Osteoporosis of the spine
• Plain X ray LSS PA view showing:
• Osteopenia
• Biconcave vertebral outline cod fish spine
• Widened spaces
• Deformity

93. CT brain
• Hge
• Infarction
• Abcess

95. Lateral ventricle level

96. 3rd ventricle level

97. 4th ventricle level

98. Haemorrhage
Plaint CT brain ventricular level ……
• Hyperdense lesion site…………..
• Mass effect
• diagnosis

99. Fronto parietal He + lat vent + mass
effect + brain edema

100. Parietal He + lat ventricle + mass effect + brain
edema

101. Epidural Hge + lat ventricle+ mass effect + brain
edema

102. Subdural He + lat ventricle + mass
effect + brain edema

103. Lat vent+ hypodense parieto occipital
+ mass effect+ brain edema

105. CT brain with contrast + lat vent hypodense
area + ring enhancement + fronto parietal
abcess