ECG, XR, Chest Pain, SOB
Less Ca2+ influx
 superslow
Ca2+ influx 
prolongs plateau
phase 
prolongs ST
segment 
prolong QT
segment
Clues: Metabolic
situation, look at QT
segments
Shortened AP
less plateau
phase 
shortened
segments
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
Axis: + in lead
1, + in lead
aVF = normal
Infarction: ST
elevation in lead 3
= inferior
infarction
Hypertrophy:
LVH = tall R
wave in leads
V4 or V6
RVH =
dominant R
waves in V1
Rate:
300/3 =
~100
Rhythm:
regular
sinus
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.
AV node is
continuously
bombarded with
depolarization
waves
Conduction into
ventricles is normal
therefore QRS is
normal however
irregular
Rate: 300/
3-2 = 100150
Rhythm: no P
wave
Irregular
Atrial
filbrillation
Rate: no
relationship
between P waves
and QRS
complexes
Rhythm: sinus with complete
heart block and AV junctional
type escape rhythm
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
Axis:
RAD
Hypertrophy:
RVH – lead V1
R wave is
larger than S
wave
Lead V6, S
wave is larger
than R wave
Rate: 93
Answer: Right ventricular
hypertrophy
Rhythm: sinus
The most likely diagnosis is
A. congestive heart failure.
B. pericardial effusion.
C. intracardiac shunt.
D. expiratory phase of respiration.
E. pulmonic stenosis.
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
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.
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.
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.
50-year-old woman with acute shortness of
breath.
A. cardiac failure with
pulmonary edema.
B.
pulmonic
stenosis 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.
Chest pain
Probability Dx of Chest Pain
3 of them
 Musculoskeletal (chest wall)
 Psychogenic
 Angina
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
Pitfalls (often missed)
 Mitral valve prolapse
 Oesophageal spasm
 Gastro-oesophageal reflux
 Herpes zoster
 Fractured rib (e.g. cough fracture)
 Spinal dysfunction
Probability dx of dyspnoea
 Bronchial asthma
 Bronchiolitis (children)
 Left heart failure
 COPD
 Obesity
 Lack of fitness
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
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
 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??
 Intense, grating sound of a pericardial friction rub,
confirming the diagnosis of pericarditis.