ECGS AT BEDSIDEDR.PRAVEEN NAGULA

ECGs at bedside

DR.PRAVEEN NAGULA

Please help me out ?

Patient history • A 55 yr old male was presented in the ED in a

confused ,irritable ,dyspneic state.• The patient is a known case of DM2,HTN,?

COPD,h/o anterior wall M I hospitalised for it…• He had tachycardia,spo2 –50% ,bp—130/80 mm

Hg..• He was ventilated..• But the ECG …?• 2d echo---EF—23%

Have a look at the ecg?

•What is the ecg diagnosis?

•What is the rhythm?

•What is the diagnosis?•Is it a AV dissosciation?•Are P waves are there?•Is so where?•Reason for negative p waves in lead II

regularily ? •HOW IS ventricular bigeminy expalined…

ECG 2---What does the ECG show?

2

The PR interval is shortened…

WPW SYNDROME

•diagnosis

HISTORY

• Patient had sustained RTA.• He was admitted in ortho ward• Diagnosis was made after ECG ..• He was asymptomatic pertaining to cardiac status.• No h/o palpitations,syncope attacks• No h/o admission with heart failure.• He is 27 yr old and lorry driver by occupation.• He was taken up for surgery with due risk of post

operative ARRYHTHMIAS.• He should be sent for RF ablation..

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Just help me out ..What is the axis?

• What is the ECG diagnosis? What is the axis?

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•Earlier ECG of the same patient?

Axis?

What is the diagnosis/7

Make it out8

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IMAGE CHALLENGE

1.WHAT DOES THE CHEST X RAY SHOW ?

• There is left ventricular aneurysm with calcification in the rim of aneurysm

Image2

•What is the diagnosis

Ans—calcinosis cutis• A 74-year-old man presented for evaluation of severe calcinosis

cutis. He had a 16-year history of systemic sclerosis, which had been treated with high-dose prednisone, intravenous immune globulin, and penicillamine.

• Despite these therapies, calcinosis had progressed to involve his fingers, hands, toes, right thorax, and right thigh, resulting in clinically significant functional limitation. Surgical debulking procedures provided brief periods of pain relief but were followed by recurrent calcinosis.

• Physical examination revealed extensive soft-tissue calcification involving both hands and all the fingers, with bilateral flexion deformities and unhealed ulcers of the distal digits that drained calcific deposits (Panel A).

• Extensive calcinosis cutis was also observed on plain radiographs of the hands (Panel B) and on axial computed tomographic images of the chest (Panel C).

• Calcinosis cutis results from deposition of calcium hydroxyapatite crystals and other calcium salts. The patient continues to be treated with physical therapy, analgesia, and medications for systemic sclerosis.

Image3

•What is the lesion called?

Ans—VILLAR’S nodule• The woman's medical history was significant for

dysmenorrhea and two recent laparoscopic resections of endometriomas. Histologic examination after resection of the nodule revealed the presence of endometrial glands and stroma. Endometriosis of the umbilicus, also called Villar’s nodule, is a rare presentation of extrapelvic endometriosis

IMAGE 4

•WHAT IS IT IS?

ANS –DIFFERENTIAL CLUBBING• A 30-year-old woman with known congenital heart disease presented to

our clinic with a 1-year history of fatigue, hemoptysis, and progressive exertional dyspnea.

• On examination, the toes had mild cyanosis and marked clubbing, but the fingers had subtle clubbing only. She was noted to have a left parasternal heave, a palpable second heart sound, and a systolic ejection murmur audible in the pulmonic area.

• Contrast echocardiography showed right atrial and right ventricular dilatation, an elevated mean pulmonary-artery pressure of 68 mm Hg, and bidirectional flow through a patent ductus arteriosus.

• IN Eisenmenger's syndrome, a long-standing systemic-to-pulmonary circulatory shunt results in pulmonary hypertension and eventual bidirectional or pulmonary-to-systemic shunting of blood. When Eisenmenger's syndrome occurs in concert with a patent ductus arteriosus, deoxygenated blood from the right ventricle is delivered to the aorta distal to the left subclavian artery.

• The upper extremities are thus spared the effects of the shunt, whereas the lower extremities are not, resulting in differential clubbing and cyanosis.

Image5

Ans :Facial Angiofibromas Associated with Tuberous Sclerosis•The yellow-orange papules on the

patient's nose and cheeks are characteristic of tuberous sclerosis, an autosomal dominant disorder in which mutations in tumor suppressor gene TSC1 or TSC2 result in the formation of benign hamartomas throughout the body. Almost all patients with this condition have at least one characteristic dermatologic feature…

Image6

Erythromelalgia

• The patient's presentation is typical of erythromelalgia, in which an increase in temperature triggers attacks of acute pain and red, swollen hands and feet. Symptoms are relieved by exposure to cold.

• Erythromelalgia can be seen in association with myeloproliferative disorders, connective-tissue disorders, vasculitis, diabetes, gout, multiple sclerosis, thrombotic thrombocytopenic purpura, and the use of certain drugs. 

Image7•What is

the diagnosis?

•What is elevated in this condition?

Ans—cotton wool appearance,paget’s disease,ALP • The skull radiograph shows thickening of the

outer and inner tables of the cranial bones, widening of the diploë, and a "cotton wool" appearance caused by irregular areas of sclerosis.

• This is consistent with the mixed osteolytic and osteoblastic phases of Paget's disease.

• Alkaline phosphatase is typically elevated in patients with this disease. 

Image 8

•What is this characteristic lesion called as?

Cutaneous anthrax –black eschar• A 17-year-old girl presented to the emergency department with a

black necrotic lesion on her left cheek and periorbital edema. She had been well until 15 days before presentation, when she noticed a small, painless, pruritic papule on her face that quickly enlarged and developed a central vesicle.

• The vesicle burst, leaving a painless necrotic ulcer with a black, depressed eschar. Extensive edema of the eyelids developed and progressed over a period of 7 days.

• At presentation, she was afebrile, and there was no lymphadenopathy. A diagnosis of cutaneous anthrax was made and confirmed by Gram's staining of the ulcer, which revealed gram-positive spore-forming bacilli consistent with Bacillus anthracis.

• The patient was from a northern Iranian village where exposure to contaminated soil and livestock products is common; no bioterrorism was suspected. Intravenous penicillin G (at a dose of 6 million units given every 6 hours for 10 days) was administered. On follow-up, the patient was well, and the eschar was healed, with very little skin atrophy.

Thank you