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ECG QUIZ

ECG QUIZ. The ECGs here show a variety of common abnormalities

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ECG QUIZ

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    1. ECG QUIZ By Dr Hashim Ahmed, FRCGP (UK) MRCP (UK), MRCPCH (UK) DCH (Dublin) Senior Family Medicine Consultant

    2. ECG QUIZ The ECGs here show a variety of common abnormalities & some traces have more than one. Report on each ECG & then answer the clinical question. Remember that an ECG report should contain a description & a conclusion.

    3. The description should include: The rhythm The ventricular rate The conduction intervals (PR, QRS duration & QT) The QRS axis The QRS complexes (what is the height, width & are Q waves present?)

    4. The ST segment (is it raised, normal or depressed?); and The T wave (is it inverted in leads that should be upright?) Following this description the conclusions indicates the diagnosis based on the ECG.

    5. CASE ONE A- 22- YEAR OLD MEDICAL STUDENT CAME TO SEE YOU , TOLD YOU HE IS FEELING HIS HEART IS JUMPING. ON ENQUIREY HE TOLD YOU THAT HE WILL HAVE HIS FINAL EXAM. IN A COUPLE OF DAYS. YOU EXAMINE HIM & REQUEST ECG.

    6. QUESTION 1 Report on this ECG. What would the patient complain of & what would the treatment be?

    8. REPORT – QUESTION 1 Sinus rhythm with ventricular extrasystoles Ventricular rate about 100 per minute Normal conduction intervals Normal QRS complexes Normal ST segments Normal T waves

    9. CONCLUSION – QUESTION 1 Normal ECG with ventricular extrasystoles. The patient will complain of palpitations, which will take the form of the heart “jumping”, “turning over” or “stopping”. This will be particularly common on lying down at night. The palpitations may well be related to smoking, alcohol, coffee or tea.

    10. TREATMENT –QUESTION 1 Stop any of the things that might make the problem worse & reassure the patient that the symptom is not an indication of severe heart disease. Ventricular extrasystoles are best left untreated, but ?-blockers can be used if the patient insists on medication.

    11. QUESTION 2 This patient was a 60 year old man who had had a heart attack 3 years previously & now presents with sudden chest pain. What does the ECG show? What would you do?

    13. REPORT – QUESTION 2 Sinus rhythm 100 per minute Normal conducting intervals Q waves in leads 3 & VF Raised ST segments V1-V6 Inverted T waves leads 2 & V3-V6

    14. CONCLUSION – QUESTION 2 Old Inferior , Acute Anterior& Lat. Myocardial Infarction.

    15. TREATMENT – QUESTION 2 Pain relief [ Morphia] Oxygen Nitroglycerine Aspirin [ MONA ] B-Blocker, ACE-I & Statin Immediate hospital admission Thrombolysis or immediate PTCA [ IF NO C/I]

    16. QUESTION 3 This patient has had occasional attacks of palpitations & this is the first time an ECG has been recorded during one. What does the ECG show & what would you do?

    18. REPORT – QUESTION 3 Narrow complex rhythm, probably junctional (“SVT”) Rate about 200 per minute, normal axis Normal QRS complexes, ST segments & T waves

    19. CONCLUSION – QUESTION 3 Supraventricular tachycardia, probably junctional (AV nodal re-entry).

    20. TREATMENT – QUESTION 3 Vagal stimulation by carotid sinus pressure, Valsalva maneuver, or face immersion. If these fail, IV adenosine. DC cardioversion if this fails or if the patient is haemodynamically compromised.

    21. QUESTION 4 This ECG was recorded from a 56 year old man with chest pain. What is the diagnosis & is any special treatment necessary?

    23. REPORT – QUESTION 4 Sinus rhythm, rate about 50 per minute Long PR interval – about 280 ms Normal axis Small Q wave in lead 3, but not elsewhere ST segment elevation in 2, 3 & VF; ST depression in 1, FL & possibly V5-V6.

    24. CONCLUSION – QUESTION 4 Acute inferior myocardial infarction & first degree heart block.

    25. TREATMENT – QUESTION 4 As for acute myocardial infarction, the first-degree block does not require specific treatment.

    26. QUESTION 5 This ECG was recorded from a 65 year old woman who complained of palpitations, breathlessness & chest pain. What is the problem & how should it be treated?

    28. REPORT – QUESTION 5 Atrial fibrillation (diagnosed from the marked irregularity of the QRS complexes) Ventricular rate about 180 per minute Normal axis QRS normal width Q wave in 3 but not elsewhere (and therefore not important) Horizontal ST segment depression leads V5 & V6

    29. CONCLUSION – QUESTION 5 Atrial fibrillation with uncontrolled ventricular rate & ischaemia.

    30. TREATMENT – QUESTION 5 The breathlessness is probably due to heart failure & the chest pain is angina. Rate control is essential & in the 1st instance digoxin is the drug of choice. Cardioversion by DC shock may have to be considered.

    31. QUESTION 6 The patient here was a 70 year old woman who complained of dizzy attacks for the previous 6 months. What is the diagnosis & how should be be treated?

    33. REPORT – QUESTION 6 Sinus rhythm 2:1 heart block with ventricular rate about 45 Left axis Widened QRS with RSR pattern in V1

    34. CONCLUSION – QUESTION 6 This is right bundle branch block & the left axis is due to block of the anterior fascicle of the left bundle branch (left anterior hemiblock. This combination is called bifascicular block. The 2:1 (second degree) block indicates conduction delay in the remaining fascicle of the left bundle branch & this pattern can, therefore, be called “trifascicular” block.

    35. TREATMENT – QUESTION 6 Permanent pacemaker.

    36. QUESTION 7 This patient, who was discharged from hospital a week previously after a myocardial infarction, now complains of chest pain & dizziness. What is the problem & how should it be treated.

    38. REPORT – QUESTION 7 Broad complex tachycardia Rate about 200 per minute No other features can be described

    39. CONCLUSION – QUESTION 7 Ventricular tachycardia.

    40. TREATMENT – QUESTION 7 The arrhythmia may be due to a further infarction, or may result from the previous one & the rapid heart rate may be the cause of the pain. The treatment is IV lignocaine, emergency hospital admission & cardioversion if necessary. If the patient becomes collapsed & pulseless, cardiopulmonary resuscitation must be instituted.

    41. QUESTION 8 This ECG was recorded at a routine medical exam of a black footballer. What are the possible diagnoses?

    43. REPORT – QUESTION 8 Sinus rhythm, rate 60 per minute Normal conducting intervals Normal axis Normal QRS complexes Normal ST segment T wave inversion V2-V5 & T wave flattening in 1, 2, V2 & V6.

    44. POSSIBILITIES – QUESTION 8 The main abnormality is T wave inversion in the anterior leads. This is sometimes seen in black people with perfectly normal hearts. The alternative possibilities are a non-Q-wave infarction or hypertrophic cardiomyopathy. An exercise test & an echocardiogram were both normal.

    45. CURRENT & FUTURE ASTHMA THERAPIES By Dr Hashim Ahmed, FRCGP (UK) MRCP (UK), MRCPCH (UK) DCH (Dublin) Senior Consultant in Family Medicine

    71. Thank You

    72. DYSLIPIDAEMIA BY : DR. HASHIM AHMED MRCGP/ FRCGP [ LONDON] MRCP [ EDIN] MRCPCH [ LONDON] DCH [ DUBLIN ] CONSULTANT FAMILY PHYSICIAN

    73. DYSLIPIDAEMIA TYPES OF CHOLESTROL : LOW DENSITY LIPOPROTEIN [LDL ] HIGH DENSITY LIPOPROTEIN [HDL ] TRIGLYCERIDE [ T.G]

    74. WHO / PANEL III RECOMMENDATIONS RULE OF [ 30 ] 130 mg/ dl 100 mg / dl 70 mg /dl

    75. PROBLEMS OF [DYSLIPIDAEMIA] CAD D.M METABOLIC SYNDROME LIVER PROBLEMS

    76. FAMILIAL HYPERCHOLESTROLAEMIA PROBLEMS : 1-YOUNGER AGE GROUP 2-NOT RESONDING TO TREATMENT 3-INCREASE MORBIDITY & MORTALITY 4- LATE DIAGNOSIS

    77. CASE ONE A- 58- YEAR OLD MALE PATIENT , CAME TO CHECK THE RESULT OF HIS ANNUAL CHOLESTROL SCREENING. T.C = 236 LDL ? HDL 24.6 T.G

    78. CONT, HOW TO CALCULATE HIS LDL? HOW ARE YOU GOING TO MANAGE SUCH A PATIENT ?

    79. CONT,

    81. CASE TWO A- 50- YEAR OLD MALE SMOKER P.H S.H [ INSIGNIFICANT ] F.H P.E : B.P, WT, HT, & BMI WITHIN NORMAL LIMITS SYSTAMATIC EXAM. NAD HIS LDL WAS 256 mg/ dl

    82. CONT, WHAT IS YOUR TARGET FOR LDL ?

    83. CONT, THE TARGET [ 130 mg /dl] ONE RISK FACTORS

    84. CASE THREE A- 60- YEAR OLD LADY , KNOWN CASE OF HTN & OBESE . COME FOR ROUTINE CHECK- UP P.H , S.H & F.H INSIGNIFICANT P.E : B.P 155 /95 , BMI 34 SYSTAMIC EXAM. NAD HER LDL WAS 267 mg /l , HDL & T.G [NORMAL]

    85. CONT, WHAT IS YOUR TARGET OF LDL ?

    86. CONT, THE TARGET OF LDL [ 100mg/ dl] TWO RISK FACTORS

    87. CASE FOUR A- 68-YEAR OLD MALE PATIENT WHO IS AKNOWN CASE OF HTN , SMOKER & F.H OF IHD. COME TO SEE YOU FOR HIS ROUTINE VISITS P.H NO H/O IHD P.E : B.P 170/98mmHg , BMI 30 THE REST OF PHYSICAL EXAM . O.K HIS LDL WAS 300mg/l

    88. CONT, WHAT IS YOUR TARGET LDL LEVEL? & WHY

    89. CONT, LDL TARGET [ 70mg/l ] HAVING THREE RISK FACTORS

    90. CASE FIVE A- 57- YEAR OLD FEMALE PATIENT , KNOWN CASE OF TYPEII D.M FOR THE LAST 5- YEAR ON [ OHD] + ACE-I + ASPRIN] COME TO SEE YOU WORRIED ABOUT [ IHD] P.H TYPEII DM S.H NON- SMOKER F.H +VE FOR IHD

    91. CONT, HER %HBAIC WAS 10 FBS 12 mmol /l LDL 170 mg/l HDL & T.G [NORMAL]

    92. CONT, WHAT IS YOUR TARGET OF LDL FOR THIS PATIENT ? & WHY ?

    93. CONT, THE TARGET LEVEL OF LDL [ 70mg/l] D.M. IS[ M.I] EQUIVELANT BUT IT IS DIFFICULT TO ACHEIVE

    94. CONT, WHAT OTHER MEDICATION YOU WANT TO ADD ?

    95. [ CONT, INSULIN [ NPH 10 UNITS] AT BED TIME STATIN 40 – 80 mg LIPITOR DIETARY ADVICE EXERCISE LIFE STYLE MODIFICATION

    96. CASE SIX [ CLINICAL TRIAL] A -70- YEAR OLD FEMALE , NO MEDICAL PROBLEMS , COME FOR HER ANNUAL CHECK-UP P.H, OK S.H NON- SMOKER F.H INSIGNIFICANT P/ E BP, WT,H T,BMI OK

    97. CONT LAB. INVESTIGATION WITHIN NORMAL LIMITS EXCEPT [ CPR 2mg]

    98. CONT HOW ARE YOU GOING TO TACKLE SUCH A PROBLEM?

    99. CONT, STATIN IS BENIFICIAL [ EVID. JAMA NOV. 2008 ] IT WAS RCT.

    100. [ CASE EIGHT ]ACS A- 65 – YEAR OLD MAN CAME WITH H/O CHEST PAIN , SUGGESTIVE OF MYOCARDIAL INFARCTION HIS CHOLESTROL LEVEL WITHIN NORMAL LIMITS. HOW ARE GOING TO MANAGE SUCH A PATIENT ?

    101. CONT, STATIN IN A HIGH DOSE IS INDICATED [ 80 mg] ALTHOUGH HAVING NORMAL CHOL. LEVEL. WHY ? IT ACTS AS ANANTI-INFLAMATORY AGENT.

    102. TYPES OF LIPID LOWERING DRUGS FIBRATES STATINS NICTONIC ACID NIACIN AZT COMBINATION OF [STATIN+ AZT] COMBINATIO OF [STATIN + AMLOR]

    103. STATINS ATROVOSTATINS [ LIPITOR 10, 20, 40 & 80 mg ] ROVUSTATIN [CRESTOR 10 mg] PRAVASTATIN [ LIPOSTAT 20 &40 mg] SIMVASTATIN [ZOCOR 10, 20& 40 mg ] FLUVASTATIN [LESCOL-X 40 & 80mg ]

    104. RULE OF [ 6 ] IF A PATIENT HAVING LDL LEVEL OF 270 mg / l , and he on lipid lowering drugs [ LIPITOR 40mg ] ,but showed no response for six months. What is your next step ?

    105. CONT, YOU HAVE TO ADD ANOTHER DRUG FROM OTHER GROUP e.g. FIBRATE. DOUBLING THE DOSE OF LIPITOR WILL DECREASE[ LDL] LEVEL BY ONLY 6% , ON THE OTHER HAND WILL ADD MORE SIDE- EFFECTS

    106. PRECAUTIONS BASE LINE [ LFT ] BASE LINE [ C.K ]

    107. ADVANTAGES

    108. CONT,

    109. DISADVANTAGES

    110. CONT,

    111. ASPRIN / +/- STATIN IS IT COST - EFFECTIVE ?

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