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Interpreting Investigations Part A CARI O’ROURKE + LUCIE AYLIFFE-DALYImages: https://litfl.com/wp-content/uploads/2018/08/ECG-right-sided-pulmonary-embolus.jpegObjectives ◦ To learn systematic approaches to interpreting ECGs, CXRs, urinalysis and MSUs. ◦ To use these systematic approaches to identify important pathological investigation findings. ◦ To practise applying this learning to tackling common clinical scenarios.ECG Interpretation Systematic Approach 1. Confirm patient identity 2. Check ECG details 3. Identify obvious abnormality 4. Any previous ECG for comparison? 5. Systematically review: ◦ Rate ◦ Rhythm ◦ Axis ◦ P waves and PR interval ◦ QRS complex ◦ ST segment and T waves ◦ QT interval 6. Consider clinical question Images: https://www.cvphysiology.com/Arrhythmias/A009; https://ecg.utah.edu/lesson/1RA TE A 33 year old woman presents to ED with SOB. Her ECG shows: ◦ Rate – 132 bpm ◦ Rhythm - Regular ◦ Axis - Normal ◦ P waves and PR interval - Normal ◦ QRS complex - Normal ◦ ST segment and T waves - Normal ◦ QT interval – Normal Sinus tachycardia Images: https://commons.wikimedia.org/wiki/File:ECG_Sinus_Tachycardia_132_bpm.jpgRHYTHM An 89 year old woman presents to ED with SOB and palpitations. Her ECG shows: ◦ Rate – 102 bpm ◦ Rhythm – Irregularly irregular ◦ Axis - Normal ◦ P waves and PR interval – No P waves ◦ QRS complex - Normal ◦ leads III, aVF, V1-2es - TWI ◦ QT interval – Normal Atrial fibrillation Images: https://commons.wikimedia.org/wiki/File:ECG_Atrial_Fibrillation_98_bpm.jpgAXIS A 79 year old man is admitted following a collapse. His ECG shows: ◦ Rate – 150 bpm ◦ Rhythm – regular ◦ Axis - LAD ◦ P waves and PR interval – P waves not visible ◦ QRS complex - broad (400ms) ◦ assessment and T waves - unable to ◦ QT interval – unable to assess Ventricular tachycardia Images https://litfl.com/wp-content/uploads/2018/08/trifascicular-3-2.jpgP WA VES AND PR INTERV AL A 73 year old woman is admitted following a fall. Her ECG shows: ◦ Rate – 90 bpm ◦ Rhythm – Regular ◦ Axis - Normal ◦ P waves and PR interval – Prolonged (>200ms) ◦ QRS complex - Normal ◦ ST segment and T waves - Normal ◦ QT interval – Normal First degree heart block Imageshttps://litfl.com/wp-content/uploads/2018/08/ECG-1st-degree-AV-block-2.jpgQRS COMPLEX A 79 year old man had an ECG as part of pre-op assessment. His ECG shows: ◦ Rate – 96 bpm ◦ Rhythm – Regular ◦ Axis - LAD ◦ P waves and PR interval – Normal ◦ QRS complex – LBBB ◦ ST segment and T waves – ST elevation depression in leads I, aVL, and V5-6 ◦ QT interval – Normal LBBB Images: https://litfl.com/wp-content/uploads/2021/01/ECG-Left-Bundle-Branch-Block-LBBB-2-2-1024x428.jpgST SEGMENT AND T WA VES A 68 year old man presents with central chest pain. His ECG shows: ◦ Rate – 84 bpm ◦ Rhythm – Regular ◦ Axis - Normal ◦ P waves and PR interval – Normal ◦ QRS complex – Normal ◦ ST segment and T waves – ST elevation in leads I, aVL and V2-6 leads III and aVFT depression in ◦ QT interval – Normal Acute anterolateral STEMI Images: https://litfl.com/anterior-myocardial-infarction-ecg-library/QT IntervaL A 24 year old man presents to ED following a suspected overdose. His ECG shows: ◦ Rate – 78 bpm ◦ Rhythm – Regular ◦ Axis - Normal ◦ P waves and PR interval – Normal ◦ QRS complex - Normal ◦ ST segment and T waves – TWI lead III ◦ QT interval – Prolonged Prolonged QT Images: https://commons.wikimedia.org/wiki/File:Lqts3_(CardioNetworks_ECGpedia).pngCXR Interpretation Systematic APPROACH 1. Confirm patient identity 2. Check CXR details and quality 3. Identify obvious abnormality 4. Any previous CXR to compare? 5. Systematically review: ◦ A – Airway - Trachea and bronchi ◦ B – Breathing - Hilar structures, lung zones, and pleura ◦ C – Circulation – Heart and mediastinal borders ◦ D – Diaphragm – Diaphragm and costophrenic angles ◦ E – Everything else – Bones and soft tissues 6. Consider clinical question REMEMBER THE COMMONLY MISSED AREAS: 1. Lung apices, 2. Hila 4. Below the diaphragm Images: https://upload.wikimedia.org/wikipedia/commons/1/1b/Implantable_cardioverter_defibrillator_chest_X-ray.jpg AIRWA Y A 57 year old man is admitted with a worsening cough and SOB: His CXR shows: ◦ Airway – Right-sided tracheal deviation ◦ Breathing – Large left-sided opacification ◦ Circulation – Normal right-sided heart borders, obscured left-sided heart borders ◦ Diaphragm - Normal right-sided costophrenic border, obscured left-sided costophrenic border ◦ Everything else - Normal Large left pleural effusion Images: https://commons.wikimedia.org/wiki/File:Pleural_effusion_-_Left_lung_(7471755836).jpg BREA THING A 67 year old man presents with a fever, cough and SOB. His CXR shows: ◦ Airway – Normal ◦ Breathing – Right-sided middle zone opacification ◦ Circulation – Normal ◦ Diaphragm – Normal ◦ Everything else - Normal Right middle lobe pneumonia Imaghttps://commons.wikimedia.org/wiki/File:X-ray_of_lobar_pneumonia.jpg CIRCULA TION An 86 year old woman presents with severe SOB and peripheral oedema. Her CXR shows: ◦ Airway – Normal ◦ Breathing – Widespread patchy opacifications mainly in middle and lower zones bilaterally ◦ Circulation – Cardiomegaly ◦ Diaphragm – Obscured costophrenic borders bilaterally ◦ Everything else - Normal Severe pulmonary oedema Images: https://commons.wikimedia.org/wiki/File:PulmEdema.PNG DIAPHRAGM A 87 year old man with a background of dementia is admitted with an acute deterioration of his cognition and behaviour. His CXR shows: ◦ Airway – Normal ◦ Breathing – Normal ◦ Circulation – Normal ◦ Diaphragm – Subdiaphragmatic gas bilaterally ◦ Everything else - Normal Pneumoperitoneum Imaghttps://commons.wikimedia.org/wiki/File:34-01-Freie_Luft_nach_LH-OP.png EVERYTHING ELSE A 32 year old man is admitted to ED following an RTA: His CXR shows: ◦ Airway – Normal ◦ Breathing – Reduced lung markings in right-sided upper and middle zones ◦ Circulation – Obscured right-sided heart border ◦ Diaphragm – Normal ◦ Everything else – Multiple right-sided rib fractures Large right-sided pneumothorax Imaghttps://commons.wikimedia.org/wiki/File:RtPneumo.pngUrinalysis Interpretation URINAL YSIS 1. Confirm patient identity 2. Check urinalysis details 3. Identify obvious abnormality 4. Systematically review: ◦ Leucocytes ◦ Nitrites ◦ Protein ◦ Blood ◦ Ketones ◦ Glucose ◦ hCG if indicated 5. Consider clinical questionMSU ◦ Make sure to send an MSU as part of your septic screen, ideally before administering antibiotics if possible ◦ Urinary incontinence can make sending an MSU hard, but not impossible ◦ A positive MSU does not always mean infection ◦ Use the MSU sensitivities and resistances to guide antibiotic therapy in clinically unwell patients – if no IV option is given then talk to MicroClinical ScenariosSCENARIO 1 Mrs Christie is an 87 year old woman who was admitted following a fall with a right NOF fracture, for which she underwent a hemiarthroplasty 2 days ago. History: ◦ Central chest pain and SOB at rest Examination: ◦ NEWS 6: RR 22, SpO2 95% on 2L, BP 106/87, HR 111, Alert, Temp 37.7 ◦ Appears unwell. ◦ WWP. Pulse reg, good volume. HR >100. HS normal. ◦ Chest clear. Good AE throughout. ◦ Calves SNT. Mild bilateral oedema. No erythema.SCENARIO 1 Images: https://upload.wikimedia.org/wikipedia/commons/5/5b/E000584_%28CardioNetworks_ECGpedia%29.jpg;SCENARIO 2 Mrs Dhavala is a 62 year old woman who was admitted to ED following a collapse at home. She was seen by her GP 4 days earlier with fever, cough, and SOB. History: ◦ Very drowsy and confused Examination: ◦ NEWS 11: RR 30, SpO2 96% on 15L, BP 98/62, HR 105, Confused, Temp 38.3 ◦ Appears unwell. ◦ WWP. Pulse reg, thready. HR >100. HS normal. ◦ Right-sided basal course crepitations. ◦ Calves SNT. Mild bilateral oedema. No erythema.SCENARIO 2 https://www.flickr.com/photos/iem-student/29969903188s/8/87/118_%28CardioNetworks_ECGpedia%29.jpg;SCENARIO 3 Mr Jones is a 81 year old man with a background of HTN and a previous MI who was admitted with recurrent falls and a UTI. History: ◦ Intermittent cough and SOB at rest Examination: ◦ NEWS 4: RR 22, SpO2 96% on 1L, BP 124/89, HR 132, Alert, Temp 37.2 ◦ Appears unwell. ◦ WWP. Pulse irregular, thready. HR >100. HS normal. ◦ Widespread course crepitations throughout. ◦ Calves SNT. Severe bilateral oedema. No erythema.SCENARIO 3 Images: https://upload.wikimedia.org/wikipedia/commons/3/32/ECG_Atrial_Fibrillation.jpg; https://commons.wikimedia.org/wiki/File:AP_portable_CXR_of_a_patient_in_acute_pulmonary_oedema.jpgSummaryKey Learning Points ◦ Familiarise yourself with how to actually perform an ECG and urine dip ◦ Make sure you get access to image requesting and viewing software ASAP ◦ ALWAYS stick to your system! ◦ Practise looking at as many ECGs and CXRs as possible ◦ Take a look at these resources: ◦ LITFL - https://litfl.com/ecg-library/ ◦ ECG Library - https://ecglibrary.com/ecghome.php ◦ Radiology Masterclass - https://www.radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_start ◦ Geeky Medics - https://geekymedics.com/urinalysis-osce-guide/ ◦ If in doubt, just ask for help- escalating something you’ve recognised as abnormal is the important part, not knowing the exact pathology!Questionshttps://app.medall.org/feedback/feedback-flo w?keyword=7753d414ec89d37228ab9051& organisation=prepare-for-practice