February 2018 Tracings

Transcription

1 Tracings Tracing 1 Tracing 4 Tracing 1 Answer Tracing 4 Answer Tracing 2 Tracing 5 Tracing 2 Answer Tracing 5 Answer Tracing 3 Tracing 6 Tracing 3 Answer Tracing 6 Answer Questions? Contact Dr. Nelson wpan747@gmail.com Visit the web site!

2 Tracing 1 54 Year old woman Remind me: Kussmaul Art & Venous Signs? Kussmaul-Griesinger sign?

3 Tracing 1: Answer 54 Year old woman Remind me: Kussmaul Art & Venous Signs? Kussmaul-Griesinger sign? The tracing shows sinus rhythm at 100/min. with remarkably low QRS voltage, RBBB, right axis of the preblocked forces, and possible septal M.I. Dr. Kussmaul was obviously a careful observer and skilled bedside diagnostician. Kussmaul s arterial sign is the exaggerated variation in the peripheral pulse volume (AKA - paradoxical pulse ). It is seen in pericadial effusion and constriction as an abnormal decrease in blood pressure with inspiration. It is due to an increase in the normal respiratory septal shift which varies the volume of the ventricles -- increased RV volume with inspiration at the expense of the LV capacity (and the opposite with expiration). Kussmaul s venous sign is due to decreased volume capacity or compliance of the RV, resulting is an increase in jugular venous distention with inspiration. It is seen in RV infarction or pericardial effusion/ constriction. The Kussmaul-Giesinger sign is seen in patients with constrictive pericarditis. The compressed ventricle demands an increased venous filling pressure. When the AV valve opens in early diastole, the venous column abruptly falls -- exaggerated Y descent. This lady was being followed with a diagnosis of cardiomyopathy but had constructive pericarditis. The illustrations are examples of these valuable bedside signs.

4 Tracing 2 What type of AV block??

5 Tracing 2: Answer What type of AV block??

6 February Tracing 3 82 Year Old Woman Her complaint is dizzy spells. What are your observations?

7 February Tracing 3: Answer 82 Year Old Woman Her complaint is dizzy spells. What are your observations? The basic rhythms is sinus, with Lt. axis deviation due to Lt. Ant. Fasc. Block. The lack of waves V1-V3 are consistent with septal M.I. there is marked increase in QT interval with diffuse T wave inversion. In older literature, this repolarization pattern was identified with strokes-adams attacks (ie- syncope in the setting of complete heart block)... However, the pattern is seen with a variety of CNS abnormalities (Hemmorhage, Meningitis, protracted seizures... as well as ongoing myocardial ischemia. The interesting pause seen at the end of the recording is due to Sinoatrial Exit Block The interval of 3 P Waves (A) Is the same as that with the missing P Wave (B) Indicating the SA node fired but the discharge did not exit to the atria. Unfortunately, no subsequent EKG is available...

8 80 year old man. Weak and dizzy Tracing 4 Bedside observations? S 1? S 3? S 2? JVP?

9 80 year old man. Weak and dizzy Tracing 4: Answer Bedside observations? S 1? S 3? S 2? JVP? P 1 P2 P 4 P 3

10 20 Year old woman Tracing 5 Her problem may be? The outcome may be?

11 20 Year old woman Tracing 5: Answer Her problem may be? The outcome may be?

12 Tracing 6 61 Year Old Man Your observations please The EKG 4th Commandment is? Normal sinus rhythm, rate 85 Left bundle branch block Left atrial enlargement - ABNORMAL ECG - 3 Weeks Earlier...

13 Tracing 6: Answer 61 Year Old Man Your observations please The EKG 4th Commandment is? Normal sinus rhythm, rate 85 Left bundle branch block Left atrial enlargement - ABNORMAL ECG - Remember the 4th EKG Commandment: Thou shalt not interpret an EKG tracing as other than normal without reference to prior tracings 3 Weeks Earlier... Comparing the two tracings, there is an evident difference in the morphology of the QRS-ST-T in leads AVLand V 5-6 indicating an acute lateral wall myocardial infarction. A minor under-call on the part of the reviewer?