1. ECG Practice Cases: Part 4—More Practice Cases
Megan Chan, PGY-1
UHCMC 2015
Torsades picture:

2. 71 y/o female with CAD DIAGNOSIS? #34 Afib with PVC at left, HR 100
LBBB (no Q waves in aVL) 2/2 ischemic heart disease

3. DIAGNOSIS? Afib with PVC and LBBB PVC #34
Afib with PVC at left, HR 100
LBBB (no Q waves in aVL) 2/2 ischemic heart disease
Afib with PVC and LBBB

4. 68 y/o male with COPD DIAGNOSIS? #5 Mulifocal atrial tachycardia?
Sinus tachy (HR 110) with PAC
Right superior axis deviation (axis opposite direction with I)
Pulmonary disease pattern
RSR’ or QR pattern in V1 suggest RV conduction delay
Septal infarct?

5. DIAGNOSIS? Multifocal atrial tachycardia Right axis deviation#5
Mulifocal atrial tachycardia?
Sinus tachy (HR 110) with PAC
Right superior axis deviation (axis opposite direction with I)
Pulmonary disease pattern
RSR’ or QR pattern in V1 suggest RV conduction delay
Multifocal atrial tachycardia
(Irregular rhythm w/ varying P wave morphology & PR intervals)
Right axis deviation
RSR’ in V1 suggests RV conduction delay
Poor R wave progression

6. 49 y/o male with pulmonary edema
DIAGNOSIS? #7
NSR, HR 70
LVH
Causes: uncontrolled HTN

7. (R in Lead I >14, R in aVL > 11)
DIAGNOSIS? #7
NSR, HR 70
LVH
Causes: uncontrolled HTN
R in aVL > 11mm
R in V5/V6 + S in V1/V2 > 35mm
R in I + S in III > 25 mm
R in aVF > 20mm
S in aVR > 14mm
Ortiz:
Lead I: R > 14
Lead aVL: R > 12
S in V1 + R in V5/V6 > 35
NSR with LVH
(R in Lead I >14, R in aVL > 11)

8. 81 y/o male with Dyspnea on Exertion
DIAGNOSIS?
#40
Aflutter with variable AV block, HR 75
Tx: ablated
LBBB

9. Aflutter with variable AV block
DIAGNOSIS?
#40
Aflutter with variable AV block, HR 75
Tx: ablated
LBBB
Aflutter with variable AV block
LBBB

10. 73 y/o female with GI bleed
DIAGNOSIS?
#19
Coarse Afib, HR 75

11. DIAGNOSIS?
#19
Coarse Afib, HR 75
Coarse Afib

12. 76 y/o male with CAD DIAGNOSIS? #25
Sinus rhythm with 1st degree AV block (PR interval 228 ms), HR 60
Possible LAE
Left axis deviation
LVH with QRS widening and repolarization abnormalities
Old inferior infarct

13. DIAGNOSIS? NSR with 1st degree AV block Left axis deviation
#25
Sinus rhythm with 1st degree AV block (PR interval 228 ms), HR 60
Possible LAE
Left axis deviation
LVH with QRS widening and repolarization abnormalities
Old inferior infarct
NSR with 1st degree AV block
Left axis deviation
Old inferior infarct (Q waves in II, III, aVF)
Possible LAE

14. 51 y/o female with Chest Pain
DIAGNOSIS?
#30
NSR, HR 95
Possible LAE/RAE
LVH with repolarization abnormality
T wave inversions in I & aVL
J point elevations in V1
ST depressions in aVL, V5, V6 (lateral leads)
-J point = junction b/w the end of the QRS and the start of the ST segment

15. DIAGNOSIS?
#30
NSR, HR 95
Possible LAE/RAE (Tall P > 2.5 mm in lead II, Large diphasic P with large initial phase in V1)
LVH with repolarization abnormality
T wave inversions in I & aVL
J point elevations in V1
ST depressions in aVL, V5, V6 (lateral leads)
-J point = junction b/w the end of the QRS and the start of the ST segment
LVH:
R in aVL > 11mm
R in V5/V6 + S in V1/V2 > 35mm
R in I + S in III > 25 mm
R in aVF > 20mm
S in aVR > 14mm
Ortiz:
Lead I: R > 14
Lead aVL: R > 12
S in V1 + R in V5/V6 > 35
NSR with LVH (R in V6 + S in V2 > 35, R in lead I >14 )
J point elevations in V1 & V2
ST depressions in lateral leads aVL, V5, V6
T wave inversions in I & aVL
Possible atrial enlargement

16. 57 y/o male with hx of MI s/p stents
DIAGNOSIS?
#35
Sinus Brady, HR 55
Prolonged QTc 500ms (but R—R ok)
Inferior infarct + Tall R waves in V2 = posterior infarct

17. Sinus Bradycardia (HR 55)
DIAGNOSIS?
#35
Sinus Brady, HR 55
Prolonged QTc 500ms (but R—R ok)
Inferior infarct + Tall R waves in V2 = posterior infarct
Sinus Bradycardia (HR 55)
Old posterior infarct = Inferior infarct (Q waves in II, III, aVF) + Tall R waves in V2
Prolonged QTc 500ms

18. 84 y/o male with lightheadedness
DIAGNOSIS?
#32
Afib with idioventricular escape rhythm (LBBB)
HR 35

19. Afib with idioventricular escape rhythm (LBBB pattern)
DIAGNOSIS?
#32
Afib with idioventricular escape rhythm (LBBB)
HR 35
Afib with idioventricular escape rhythm (LBBB pattern)
HR 35

20. 41 y/o female on antipsychotics
DIAGNOSIS?
#37
NSR, HR 60
Nonspecific intraventricular block
T wave inversions in anterior leads
Prolonged QTc (646ms) 2/2 psych meds

21. NSR with nonspecific intraventricular block T wave inversions in V1-V4
DIAGNOSIS?
#37
NSR, HR 60
Nonspecific intraventricular block
T wave inversions in anterior leads
Prolonged QTc (646ms) 2/2 psych meds
NSR with nonspecific intraventricular block
T wave inversions in V1-V4
Prolonged QTc 646ms

22. 67 y/o male with chest discomfort
DIAGNOSIS?
#41
AVNRT with intraventricular block, HR 100
Tx: Ablated, pacemaker placed

23. Ventricular pacemaker
DIAGNOSIS?
#41
AVNRT with intraventricular block, HR 100
Tx: Ablated, pacemaker placed
Ventricular pacemaker

24. 73 y/o female with CAD DIAGNOSIS? #4 NSR, HR 75 Low voltage
Old inferior infarct—Q waves in II, III, aVF

25. DIAGNOSIS? NSR with low voltage QRS#4
NSR, HR 75
Low voltage
Old inferior infarct—Q waves in II, III, aVF
NSR with low voltage QRS
Old inferior infarct (Q waves in II, III, aVF)

26. 80 y/o female with CAD DIAGNOSIS? #13 NSR, HR 75 Left axis deviation
Incomplete RBBB (RSR’ but no deep S)
T wave inversions inferior and anterolateral ischemia

27. DIAGNOSIS? NSR with Left axis deviation Incomplete RBBB
#13
NSR, HR 75
Left axis deviation
Incomplete RBBB (RSR’ but no deep S)
T wave inversions inferior and anterolateral ischemia
NSR with Left axis deviation
Incomplete RBBB
Inferior & Anterolateral T wave inversions

28. REFERNCES
Agabegi SS, Agabegi ED. Step up to Medicine, 3rd ed Lippincott Williams & Wilkins. Philadelphia, PA.
Gomella LG, Haist SA. Basic EKG reading. In: Clinician’s Pocket Reference. McGraw-Hill; Accessed Nov 18, 2014.
Longo DL, Fauci AS, Kasper DL, et al. Electrocardiography. In: Harrison’s Principles of Internal Medicine, 18th ed McGraw Hill. New York, NY.
University of Illinois at Chicago. Online ICU Guidebook ver_442934/Image/1.1/residentguides/final/icuguidebo ok.pdf. Accessed December 1, 2014.