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Monday, 10 December 2012

#ECGclass Case 19

#ECG Class is an educational blog which runs alongside Twitter.

A new ECG "quizz" is launched most Monday evenings, in term time. 
Cases are generally aimed at Primary Care. 
All scenarios are completely fictitious and theoretical, but based on commonly occurring presentations in General Practice. 
This is an educational site, intended for healthcare professionals and shouldn't be construed as patient advice. 

Please use the Hashtag #ECGclass on Twitter, if you want to ask the patient any questions, or request any further investigations. Alternatively, please join in discussion and leave comments below.

Remember there are no right or wrong answers!  

ECG interpretation is often open to debate, and will usually evolve and change as new information becomes available.  Everyone's opinion is valid, and useful for others, as the evolution process takes place. 
Together we will try and form an interpretation based on the trace, and information, we have in front of us. 
Don't worry if you disagree - shout up and share your thoughts - the diagnosis is often arguable on the basis of a 12 lead trace, and may only become more obvious when a longer rhythm strip is available. 

Please feel free to join in, but most important of all, have fun! :-)

#ECGclass Case 19

Today's case is adapted from old ECGclass, from the early (pre-blog) days. 
So those of you who were in from the beginning have no excuses! ;)

A 74yrs gentleman comes to see you with funny turns. His wife describes him as having brief episodes of transient 'faint-like' attacks, when he seems unresponsive for a moment, and looks very pale. On one occasion he actually collapsed, but came round moments later. 

Obviously - you want an ECG - this is #ECGclass after all!
So here it is:

Q1. Is the rhythm Regular or Irregular? 

Q2. Can you see P-waves? 

Q3. What is the rate? (Atrial? and Ventricular?)

Q4. Does the P-QRS morphology look normal, or abnormal?

Update 1

So far, having answered Questions 1 to 4, you can already make the following comments (Remember the art of ECG bluffing - July blog) :

This is a 12 lead ECG, on which electrical activity can be seen.
The gain calibration is noted and normal, but no paper-speed is noted. For calculation purposes, we will assume standard paper speed of 25mm/sec.

When mapped out, the ventricular rate is regular at 50 beats per minute. (6 large squares between complexes = 300/6). The Atrial rate is also regular at around 85 beats per  minute. (somewhere between 3 and 4 large squares between complexes = 300/3.5)

P waves, which are usually best seen in V1 and V2 , are not clearly seen in these leads, but can be clearly seen in other leads.

Morphology and amplitude:
The P and QRS morphology both appear normal in shape. 
There are large R wave amplitude deflections in Lead I and the chest leads, consistent with voltage criteria for left ventricular hypertrophy (LVH).
The P waves, where seen, are normal in duration (2-3 small squares) and height (<3mm high), and consistency (same appearance throughout). 

That all sounds like quite impressive banter, and not bad at all, considering you haven't even had to plump for a diagnosis yet! 
All you've done so far is 'describe what you see". 

So now let's concentrate on something else...

Q5. What is the relationship between the P waves and the QRS? Can you calculate the PR interval? Does it alter? (Should be 3-5 small squares)

When you've had a go,  you'll find the full discussion on the next blog!
Thank you. :)

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