ECG: Prolong PR interval with Generalized Up sloping ST Depression in Hypokalaemia Patient.

This is the ECG of 23 years old lady, post partum D24 who presented with generalized body weakness for 3/52 duration and unable to ambulate for 2/7 duration. Otherwise, no diarrhea or vomiting, no fever, no PV bleeding or foul smelling discharge.

She also has similar presentation during her last post partum but did not seek medical attention and claim that the problem resolves spontaneously.

On examination, patient is conscious and alert, hydration and perfusion status is good, CRT less than 2 second, good pulse volume. Examination of heart, lung and abdomen are normal. Neurological assessment revealed generalized body weakness with power of 2/5, hypotonic, hyporeflexia and intact sensation. Patient also have weakness of the right Sternocledomastoid and trapezius muscle weakness ?Accessory nerve involvement.

ECG shows sinus rhythm with prolong PR interval and generalized up sloping ST depression.

His potassium level is 1.6 mmol/l with other electrolytes are normal. VBG shows metabolic acidosis and random blood sugar is 5.5.

ECG: A Challenging Inferior MI ECG due to Interference

54 years old gentleman who is a smoker and co morbid of diabetes mellitus and hyerlipidaemia presented with left sided chest pain that radiate to the back. It is compressive in nature with pain score 10/10. Pain is associated with diaphoresis and nausea.

On examination, patient is conscious and alert, anxious and restless and in severe pain. he otherwise pink, good hydration and perfusion status, good pulse volume. No murmurs, no basal crepitation or tender hepatomegally.

ECG was obtained and full of interference as patient in pain. Left sided ECG shows sinus rhythm with Right bundle branch block, ST elevation at lead II,III, AVF and AVR. No reciprocal changes.

Right sided ECG shows no right wall involvement.

A diagnosis of Left main coronary artery stenosis with acute inferior MI was made.

Pain management is achieved with frequent small bolus of IV Morphine and patient was given IV streptokinase 1.5 Mu/ 1 hour.

Repeated ECG post streptokinase shows return of ST Elevation to the baseline

ECG: Third Degree Heart Block

This 70 years old gentleman who is a smoker but no known medical illness presented with severe giddiness for 4 days associated with epigastric discomfort, shortness of breath, orthopnoea and paroxysmal nocturnal dyspnoea.

On examination, he is conscious and alert, pink, hydration and perfusion status is good. pulse volume is low. Blood pressure is 100/70, Pulse rate is 34, respiratory rate is 28, SPO2 is 100% under room air.

No murmurs or basal crepitation heard.

ECG shows sinus bradycardia with atrial rate is about 70. Ventricular rate is about 33. There is AV dissociation (atrial impulse is not conducting to ventricular impulse). Occasional ventricular impulse are seen.

A diagnosis of symptomatic bradycardia secondary to complete heart block was made and the aetiology could be due to underlying ACS in view of risk factor (Age, smoker, male)

ECG: Left Main Coronary Artery Disease

42 years old lady with known case of skin vitiligo, stroke with right hemiplegic unsure of type and hypertension was referred for right elbow abscess. She otherwise denied typical chest pain, no nausea and vomiting, diaphoresis or syncopal attack

On examination, vital signs are normal. heart S1S2 with PSM at mitral region grade 4, no basal crepitation, no raised JVP or ankle edema.

ECG taken shows generalized down sloping ST depression with ST Elevation >1 mm at lead aVR

CXR shows minimal cardiomegally with no APO changes.

Patient remain asymptomatic and repeated ECG no dynamic changes.

Impression

Generalized ST depression with ST elevation at the lead AVR is indicative of left main coronary artery disease and not necessarily means ischemia as patient do not have typical chest pain.

Other differential such as systemic illness like anemia or electrolyte imbalance should be seek. Serial cardiac enzyme would be very useful to exclude myocardial ischemia.

ECG OSCE Quiz 1

A 60 years old Malay lady with underlying chronic renal failure presented to Casualty because of generalized muscle weakness and lethargy for 1 day duration. Below is her ECG strip.

Questions

1) Comment on the ECG

2) What is your provisional diagnosis based on history and ECG findings

3) What is the causes of condition associated with the ECG findings

4) How do you manage this patient?

For answer to this question, click [here]