ECG, XR, Chest Pain, SOB

1. ECG, XR, Chest Pain, SOB

2. Shortened AP less plateau phase  shortened segments Less Ca2+ influx superslow Ca2+ influx  prolongs plateau phase  prolongs ST segment  prolong QT segment Clues: Metabolic situation, look at QT segments

3. Hyperkalemia: more positive outside  RMP is more +  phase 0 in presence of high K+, the number of Ca2+ decrease  less Ca2+ in to cell  slowing of impulse conduction  QRS widening

4. Hypertrophy: LVH = tall R wave in leads V4 or V6 RVH = dominant R waves in V1 Axis: + in lead 1, + in lead aVF = normal Infarction: ST elevation in lead 3 = inferior infarction Rate: 300/3 = ~100 Rhythm: regular sinus

5. MI Anterior infarction: changes classically in leads V3-V4 (but also V2 and V5) Inferior: changes in lead III and aVF Lateral infarction: changes in leads I, aVL, V5-6.

6. AV node is continuously bombarded with depolarization waves Conduction into ventricles is normal therefore QRS is normal however irregular Rate: 300/ 3-2 = 100-150 Rhythm: no P wave Irregular Atrialfilbrillation

7. Rate: no relationship between P waves and QRS complexes Rhythm: sinus with complete heart block and AV junctional type escape rhythm

8. Escape junctional beat or rhythm occurs when there is failure of impulse generation from the sinus node or atrial myocardium. The 4th and 5th beats of this tracing are junctional beats that are not preceeded by a P wave and occur after a pause that is longer than the underlying sinus cycle length

9. Axis: RAD Hypertrophy: RVH – lead V1 R wave is larger than S wave Lead V6, S wave is larger than R wave Answer: Right ventricular hypertrophy Rate: 93 Rhythm: sinus

10. The most likely diagnosis is A. congestive heart failure. B. pericardial effusion. C. intracardiac shunt. D. expiratory phase of respiration. E. pulmonicstenosis. This case represents an apparent "enlarged heart" due to an expiratory phase of respiration in an uncooperative patient. Note the decreased lung volumes and the elevation of the hemidiaphragms. The resultant crowding of vessels obscures much of the cardiac border. The technique of inspiratory PA radiograph is preferred to avoid "diagnosing" diseases that a patient does not have.

11. 60-year-old alcoholic man with shortness of breath. The most likely diagnosis is A. mediastinal mass. B. intracardiac shunts (ASD and VSD) C. pericardial effusion or cardiomyopathy D. combined aortic and pulmonary arterial disease. E.technical aberrations. The most likely diagnosis is A. mediastinal mass. B. intracardiac shunts (ASD and VSD) C. pericardial effusion or cardiomyopathy D. combined aortic and pulmonary arterial disease. E.technical aberrations.

12. 53-year-old woman examined in the emergency department for chest pain, tachycardia, and shortness of breath with normal ECG. The most likely cause of the patient's symptoms is A. pneumonia. B. pulmonary edema. C. interstitial lung disease. D. panic attack. E. pneumothorax.

13. Panic attack In this case the chest radiograph was normal in a 53-year-old woman seen in the emergency department for left-sided chest pain. The electrocardiogram was also normal, and there was no obvious cause for the patient's pain. Note the well-defined pulmonary vessels in the perihilar region and normal branching of these vessels into the lungs. There is a gradient of pulmonary vascular markings from the bases to the apices on an upright radiograph due to the increased perfusion to the lower lobes. No pulmonary parenchymal abnormalities are present to support the other diagnoses.

14. 50-year-old woman with acute shortness of breath. A. cardiac failure with pulmonary edema. B. pulmonicstenosis with pneumonia. C. pulmonary embolism. D. pneumomediastinum. E. pneumothorax. This case is an example of a pulmonary edema due to fluid overload and congestive heart failure. Note the increased size of the cardiac silhouette, the ill-defined reticular perihilar air-space opacities, the enlargement of the vascular pedicle, and the redistribution of blood flow to the upper lung zones.

15. Chest pain

16. Probability Dx of Chest Pain 3 of them Musculoskeletal (chest wall)     Psychogenic     Angina

17. Serious not to be missed -what are the systems/ categories? • Cardiovascular • myocardial infarction/unstable angina     • aortic dissection     • pulmonary embolism • Neoplasia • arcinoma lung     • tumours of spinal cord and meninges • Infection • pneumonia/pleurisy     • mediastinitis • pericarditis • Pneumothorax

18. Pitfalls (often missed) Mitral valve prolapse Oesophageal spasm     Gastro-oesophageal reflux     Herpes zoster     Fractured rib (e.g. cough fracture)     Spinal dysfunction

20. Probability dx of dyspnoea Bronchial asthma     Bronchiolitis (children)     Left heart failure     COPD     Obesity     Lack of fitness

21. From ‘how to treat’ paper (on wiki) 2. Bob, 50, is anxious and presents with chest pain. Which TWO aspects of the clinical history would be most helpful in deciding if the pain is cardiac in origin? a) His pain worsens while walking from the car park to your rooms and eases while sitting b) He describes sweating accompanying the pain c) He describes the pain as like a feeling of pressure d) His pain is relieved by nitrates given to him by your practice nurse

22. Case study Peter, 47, A&E with left-sided chest pain Diagnosed with MSK condition Now returns to emergency few days later Same pain (central), pain in left side of neck and shoulder History of asthma, and now complains of slight SOB

23. During ex – leaned back, winced in pain Changing position affected his pain, better when he sat up and leaned forward Lungs were clear and peak flow was normal DDX??

24. Intense, grating sound of a pericardial friction rub, confirming the diagnosis of pericarditis.