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1Really overwhelming at first but with practice becomes a lot easier!! Good to look at images online Links at the end– look at 100s until you are used to reading them and noticing the patterns Going over structured approach and how to approach OSCE station Some ECG features/rhythm that are important to be able torecognise Lots of cases 2In an OSCE station (if in person) if shown anecg and asked to tell the examiner what it showed I would do this and speak through all of it 3Very easy 456Bifid P waves look like an M– so makes me think of mitral valve which is on the left (so left atrial hypertrophy) Peaked p waves makes me think of pulmonary which is on the right side (so right atrial hypertrophy) ^ no cases on this as simple so don’t forget to check Heart blocks– more in a couple of slides but varies from first degree with prolonged PR interval to no relationship between p andqrs SVT AND VT No P waves, tachycardia Qrs narrow in SVT And broad in VT ( 7Example of normal https://thephysiologist.org/study-materials/the-normal-ecg/ Work out rate in chat Answer = 300 / 4 = 75 8https://litfl.com/atrialfibrillation-ecg-library/ AF - Irreg irreg - No P waves - Fibrillating baseline 910https://litfl.com/atrialflutter-ecg-library/ 11https://www.shutterstock.com/search/atrial+flutter 12https://litfl.com/sinus-tachycardia-ecg-library/ Sinus tachy P and T waves are squished together so looks funny 131415First degree heart block https://litfl.com/first-degree-heart-block-ecg-library/ 16Mobitz type I block https://itfl.com/av-block-2nd-degree-mobitz-i-wenckebach- phenomenon/ 17https://www.medscape.com/answers/161919111884/which-ecg-findings-are- characteristic-of-mobitz-ii-second-degree-atrioventricularav-block 2:1 ratio Regular 18https://litfl.com/av-block-2nd-degree-mobitz-ii-hay-block/ https://www.proacls.com/wiki/ekg-rhythms/atrioventricularblocks/ No fixed ratio here Still fits Mobitz II Irreg irreg 19https://litfl.com/av-block-3rd-degree-complete-heart-block/ No relationship between P and QRS 20Quite a lot with QRS complex 2122Lead I, lead II, lead III Not V1/2/3! 2324Image shows LVH (calculatesokolow-lyon index) 25https://litfl.com/supraventricula-tachycardia-svt-ecg-library/ Tachyregular, no P waves, narrow QRS SVT 26https://litfl.com/supraventricula-tachycardia-svt-ecg-library/ This ECG shows same thing but even faster (around 300 bpm or just under) so squished together more 27https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/ VT - very obvious Broad complex tachy, no P waves 2829https://litfl.com/ventricular-fibrillation-vf-ecg-library/ 30https://litfl.com/ventricular-fibrillation-vf-ecg-library/ 31Skip if little time 323334Questions/answers in chat Diagnosis? - STEMI From looking at the history and examination, how do you know it is an MI and not stable angina? 1. Came on at rest and not relieved by GTN spray (stable angina is typically precipitated by exertion/emotion and relived by rest or GTN in 5 minutes) 2. Associated nausea and clamminess – autonomic features are present in ACS but not stable angina What is the location of the STEMI / which coronary artery is affected - Anterior STEMI (LAD) Modified case frompassmedicne.com 35Question/answer in chat: Diagnosis and location? Inferior STEMI (usually RCA) I, II and AVF Case modified fromPassmedicine.com 36Question/answers in chat: What is the diagnosis Anterior STEMI 37Table fromassmedicine.com 38https://www.physoc.org/magazine-articles/trigonometry-of-the-ecg/ https://litfl.com/ecg-lead-positioning/ This is how I localize MI 39404142431 – normal 2 – RAD C = correct answer Use these websites!!! 44451. PVT (polymorphic VT looks like VF– if VF then patient would not have a pulse) 2. Posterior MI (reciprocal changes in V-1) 3. Unstable angina (normal troponin levels with ECG changes and clinical features of ACS) 4. Posterior MI (as above) (all cases fromassmedicine.com) 5. Left circumflex (lateral MI) 4647https://www.ebmconsult.com/articles/radiologchest-xray-normal 4849505152Tracheal displacement No patient rotation- the spinous processes (red line) are central between the medial clavicles (blue lines) Tracheaasterisk) shifted to the left of the midline Soft tissue mass mainly to the right of the trachea Diagnosis Mediastinal thyroid enlargement The patient had a CT scan- see below https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page1 53Tracheal displacement No patient rotation- the spinous processes (red line) are central between the medial clavicles (blue lines) Tracheaasterisk) shifted to the left of the midline Soft tissue mass mainly to the right of the trachea Diagnosis Mediastinal thyroid enlargement The patient had a CT scan- see below https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page1 54555657https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page7 LLL pneumonia Cant see inferior or left heart borders 58https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page7 LLL pneumonia Cant see inferior or left heart borders 59Left middle lobe pneumonia https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page3 60Left middle lobe pneumonia https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page3 61https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pneumothorax (left upper zone) Not a tension pneumothorax as no displacement of trachea or mediastinum 62https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pneumothorax (left upper zone) Not a tension pneumothorax as no displacement of trachea or mediastinum 6364https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pleural plaque (bilateral) 65https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pleural plaque (bilateral) 66https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Unilateral pleural thickening 6768https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page5 Right upper lobe collapse (due to lung cancer obstructing the RUL bronchus) 69https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page5 Right upper lobe collapse (due to lung cancer obstructing the RUL bronchus) 7071https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pleural effusion secondary to lung cancer Uniformly white left lower zone Meniscus sign Cannot see left heart border, costophrenic angle Also slight blunting oc costophrenic angle on RHS 72https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pleural effusion secondary to lung cancer Uniformly white left lower zone Meniscus sign Cannot see left heart border, costophrenic angle Also slight blunting oc costophrenic angle on RHS 73https://www.medcomic.com/medcomic/pleurae lffusions-transudate-vs-exudate 74Diagnosis Left ventricular failure with pulmonary oedema Signs of heart failure Cardiomegaly CTR = 18/30 (>50%) Upper zone vessel enlargement (1) – a sign of pulmonary venous hypertension Septal (Kerley B) lines (2) – a sign of interstitial oedema– see next picture Airspace shadowing (3) – due to alveolar oedema– acutely in a peri-hilar (bat's wing) distribution Blunt costophrenic angles ( ) – due to pleural effusions https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page8#top_1st_img 75Diagnosis Left ventricular failure with pulmonary oedema Signs of heart failure Cardiomegaly CTR = 18/30 (>50%) Upper zone vessel enlargement (1) – a sign of pulmonary venous hypertension Septal (Kerley B) lines (2) – a sign of interstitial oedema– see next picture Airspace shadowing (3) – due to alveolar oedema– acutely in a peri-hilar (bat's wing) distribution Blunt costophrenic angles ( ) – due to pleural effusions https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page8#top_1st_img 767778https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page8 79https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page8 808182https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pneumoperitoneum secondary to duodenal ulcer 83https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page4 Pneumoperitoneum secondary to duodenal ulcer 8485https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page6 Hyper-expansion causing flattening of the diaphragm (this causes blunt costophrenic angles – not due to an effusion) Dx = COPD, pt also has an alpha-1-AT deficiency 86https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page6 Hyper-expansion causing flattening of the diaphragm (this causes blunt costophrenic angles – not due to an effusion) Dx = COPD, pt also has an alpha-1-AT deficiency 8788https://medschool.co/tests/chestray/costophrenic-angles 8990https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page011 91https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page011 92Clinical information Road traffic crash Chest pain, shortness of breath and marked clinical surgical emphysema Diagnosis Multiple rib fractures complicated by left hemidiaphragm injury, left pneumothorax (treated by drain) and widespread surgical emphysema (tracking subcutaneous air) urgical emphesyma AP erect chest X-ray Left chest drain (orange) Raised left hemidiaphragm ( rrow) Stomach/bowel bubble (asterisk) Multiple irregular areas of low density within the chest wall soft tissuesa( rowheads) due to surgical emphysema Multiple rib fractures ( ) https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page010#top_3rd_img 93Surgical emphysema Clinical information Road traffic crash Chest pain, shortness of breath and marked clinical surgical emphysema Diagnosis Multiple rib fractures complicated by left hemidiaphragm injury, left pneumothorax (treated by drain) and widespread surgical emphysema (tracking subcutaneous air) urgical emphesyma AP erect chest X-ray Left chest drain (orange) Raised left hemidiaphragm ( rrow) Stomach/bowel bubble (asterisk) Multiple irregular areas of low density within the chest wall soft tissuesa( rowheads) due to surgical emphysema Multiple rib fractures ( ) https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page010#top_3rd_img 9495https://geekymedics.com/ches-t-ray-interpretation-a-methodical-approach/ 9697https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page2#top_2nd_img 98https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page2#top_2nd_img 99https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page2#top_2nd_img 100https://www.radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_path ology_page2#top_2nd_img 101https://www.bir.org.uk/media/258608/mark_rodriguez_ _philips_trainee_for_excellence_-_unofficial_guide_to_radiology.pdf 102103104105106107