ECG Practice Cases: Part 4—More Practice Cases Megan Chan, PGY-1 UHCMC 2015 Torsades picture: http://thepracticalpsychosomaticist.com/2013/04/01/qtc-interval-prolongation-and-antipsychotics-by-elysha-elson-pharm-d-mph/ http://thepracticalpsychosomaticist.com/2013/04/01/qtc-interval-prolongation-and-antipsychotics-by-elysha-elson-pharm-d-mph/

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

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

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?

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

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

(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)

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

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

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

DIAGNOSIS? #19 Coarse Afib, HR 75 Coarse Afib

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

REFERNCES Agabegi SS, Agabegi ED. Step up to Medicine, 3rd ed. 2013. Lippincott Williams & Wilkins. Philadelphia, PA. Gomella LG, Haist SA. Basic EKG reading. In: Clinician’s Pocket Reference. McGraw-Hill; 2007. http://flylib.com/books/en/2.569.1.27/1/. Accessed Nov 18, 2014. Longo DL, Fauci AS, Kasper DL, et al. Electrocardiography. In: Harrison’s Principles of Internal Medicine, 18th ed. 2012. McGraw Hill. New York, NY. University of Illinois at Chicago. Online ICU Guidebook. 2013. http://chicago.medicine.uic.edu/UserFiles/Servers/Ser ver_442934/Image/1.1/residentguides/final/icuguidebo ok.pdf. Accessed December 1, 2014.