The ECG with caption below was shared with the 8th semester students group even while seeing the patient in real time yesterday:
ECG figure 1
Seeing this patient right now in OPD complaining of 20 days of continuous chest pain for few days and asking him to get admitted in AMC for observation although I am 99% certain his pain is unrelated to his ECG. How?
The first 8th semester student response arrived shortly in pm closely followed by other students and following is the active learning discussion with them:
Student 1:
5/27/20, 10:00 AM – UG 2016: Monomorphic P wave preceding each QRS complex tells that that there is sinus rhythm. Normal PR Interval. Normal QRS complex. Though, there appears to be tachycardia, but I don't know how to count/decipher without the boxes. Regular R-R interval. Axis is normal - (0 - 60 degrees), With a normal R wave progression in V1-V6
5/27/20, 10:01 AM – UG 2016: Though there appears to be a wave before P wave in lead ll
5/27/20, 10:01 AM – UG 2016: Sir what else do i look for ?
5/27/20, 10:03 AM – UG 2106: Sir V4, V5, V6 donot appear normal
5/27/20, 10:03 AM – GM Dept: Which ECG are you describing?
5/27/20, 10:04 AM – UG 2016: Sir the one you sent on the group
5/27/20, 10:05 AM – GM Dept: Good. Yes what is wrong here.
5/27/20, 10:06 AM – UG 2016: ST depression ?
5/27/20, 10:08 AM – GM Dept : And T wave?
5/27/20, 10:08 AM – UG 2016: Inversion
5/27/20, 10:10 AM – UG 2016 : T wave inversion is symmetrical or unsymmetrical sir ? Also sir, will the amplitudes of R wave in V5 and V6 added up to more than 35mm ? If they do, it could be LVH.
5/27/20, 10:12 AM – GM Dept: Yes he has coronary artery disease and yet it's stable angina or even silent angina.
Why? Because the ECG is not a resting ECG but taken after six minutes of exercise signifying a coronary artery blockage but he was never symptomatic due to it.
His current 20 days of chest pain is on the right side and I just pressed on his right chest where he pointed to the pain and found it to be very tender suggesting a musculoskeletal chest pain
5/27/20, 10:18 AM – UG 2016: Yes sir, stress ECG is a must as, at rest, the heart's compensatory mechanisms would be in action. Sir, is there a past history to any chronic disorders, in this patient ? And any finding in the blood tests ?
5/27/20, 10:20 PM – GM Dept: Ecg taken today
5/27/20, 10:20 PM – GM Dept: <Media omitted>
5/28/20, 8:33 AM – UG 206: Good morning Sir, this ECG and 2D ECHO are of the pt with chest tenderness on rt side ?
5/28/20, 9:01 AM – GM Dept: Yes
5/28/20, 9:13 AM – UG 2016: Sir there is ST depression, T inversion and left Ventricular hypertrophy (as the sum of amplitude of R wave in V5, V6 > 35mm ). Other than that, i cannot seem to see anything wrong, HR = 70 b/m
5/28/20, 9:14 AM – UG 2016: And ST depression doesn't seem that significant. But since we saw it in the stress ECG, it becomes clearer.
5/28/20, 9:14 AM – UG 2016: And sir, I am not being able to understand the 2D echo.
5/28/20, 9:19 AM – GM Dept: The main feature in that echo is the gross LVH which alone accounts for the ECG findings. In the absence of any significant hypertension this would be labeled as hypertrophic cardiomyopathy.
5/28/20, 9:24 AM – UG 2016: Thank you sir. Does he have a h/o any chronic medical condition or medications which might have caused Hypertrophic Cardiomyopathy ?
5/28/20, 10:20 AM – GM Dept : No. Didn't get a chance to document that.
Student 2:
"[5/27, 10:57 AM] MBBS 2016 UG 5: Good morning sir!
[5/27, 10:57 AM] MBBS 2016 UG 5: Maybe the pain and the ECG are unrelated because he has the pain since 20 days
[5/27, 10:58 AM] MBBS 2016 UG 5: And usually pains related to the heart don't last that long or goes away when they take medications or deep breaths
[5/27, 10:17 PM] Post residency PG1:Yes he has coronary artery disease and yet it's stable angina or even silent angina.
Why?
Because the ECG is not a resting ECG but taken after six minutes of exercise signifying a coronary artery blockage but he was never symptomatic due to it.
His current 20 days of chest pain is on the right side and I just pressed on his right chest where he pointed to the pain and found it to be very tender suggesting a musculoskeletal chest pain
[5/28, 9:13 AM] MBBS 2016 UG 5: Sir so due to the ischemia he might've developed a muscle pain?
[5/28, 9:14 AM] MBBS 2016 UG 5:Also sir. The fire accident is very disturbing. I hope no one was injured.
[5/28, 9:18 AM] Post residency PG1: No ischemia to myocardium can't cause chest muscle pain.
However if you check out the Echo then our initial assumptions of ischemia may not be true in accounting for his Ecg findings. The anatomic localization for those Ecg findings may shift from coronary disease to elsewhere in the heart
[5/28, 9:23 AM] MBBS 2016 UG :Okay sir.
Sir any chance we can maybe suspect any costochondritis?
[5/28, 9:24 AM] MBBS 2016 UG 5: Did he have any history or trauma or muscle strain?
[5/28, 10:01 AM] Post residency PG1:Yes that was the number one diagnosis for his pain due to the extreme tenderness noted in the right side of his chest.
So this case illustrates that the patient can have Ecg findings due to a completely different reason whereas the chest pain symptoms could be due to a different reason"
28/05/20, 10:06:27 AM] MBBS 2016 UG 5: Okay sir.
Sir, I wanted to know, why was his initial ECG without the normal squares? Like why is that done?
[28/05/20, 10:06:51 AM] MBBS 2016 UG 5: Okay sir.
[28/05/20, 10:07:45 AM] Post residency PG1: That was a print out where they managed to blur the squares
[28/05/20, 10:10:36 AM] MBBS 2016 UG 5 : 28/05/20, 10:11:09 AM] :Why is that done sir?
Isn't it better to interpret with the squares? 🙈
[28/05/20, 10:15:12 AM] Post residency PG1:ECGs are done on heat sensitive paper and are more of heat lines that can quickly vanish with time. Print outs as photocopies in regular paper are taken to increase the longevity of the ECG information and these print outs may miss the squares?
[5/28, 11:30 AM] MBBS 2016 UG 5: Sir. Has the patient been discharged or is he undergoing any confirmatory tests?
[5/28, 11:31 AM] MBBS 2016 UG 5
: Because to confirm Costchondritis, the CRp should be raised
[5/28, 11:31 AM] Post residency PG1: He had just come for an OPD. Stays nearby
[5/28, 11:32 AM] Post residency PG1: CRP is a non specific marker of inflammation
[5/28, 11:33 AM] MBBS 2016 UG 5
: Sir in this blog there are many patients who inspite of having HOCM have always been diagnosed with costochondritis
[5/28, 11:34 AM] Post residency PG1: Excellent find. Share the blog link so that it's easier to put on the active learning blog 👍👏👏
[5/28, 11:34 AM] MBBS 2016 UG 5:
https://messageboard.4hcm.org/forum/hcma-general-forums/hcma-discussion/2918-costochondritis
[5/28, 11:35 AM] MBBS 2016 UG 5:
: So was the patient given anti inflammatory medication sir?
[5/28, 11:35 AM] Post residency PG1: Yes
Student 3:
[5/27, 1:31 PM] MBBS 2016 UG1: Does he have a history of fever?
[5/27, 1:33 PM] MBBS 2016 UG1: What is the character of his Chest pain? Does it vary with respiration? Is it relieved on sitting and leaning forward?
[5/27, 10:19 PM] POST RESIDENCY PG1: Didn't ask
[5/27, 10:20 PM] POST RESIDENCY PG 1: Ecg taken today : (image)
[5/27, 10:27 PM] MBBS 2016 UG1: In V3, there appears to be an ST elevation and a U wave?
[5/27, 10:29 PM] MBBS 2016 UG1: Yes. Have you looked at the Echo? Just your knowledge of anatomy and physiology should be enough to interpret it
[5/27, 10:33 PM] MBBS 2016 UG1: Mitral regurgitation?
[5/27, 10:36 PM] POST RESIDENCY PG1: No prominent left ventricular hypertrophy and that is the reason for his ECG changes even more than possibility of coronary artery disease. Even mild ST elevation that you pointed out is indicative of LVH
[5/27, 10:36 PM] MBBS 2016 UG1 What is the reason sir?
[5/27, 10:45 PM] POST RESIDENCY PG1: Didn't check his BP. If not hypertension then HOCM
[5/27, 10:45 PM] MBBS 2016 UG1: Oh okay. Thank you.
[5/28, 10:03 AM] MBBS 2016 UG1: Could this patient also have mitral regurg and/or SAM. Patients with HCM frequently have systolic anterior motion (SAM) of the mitral valve, which positions the mitral valve within the LVOT.
[5/28, 10:05 AM] MBBS 2016 UG1: And in this ECG, there appear to be some Deeply inverted T waves (so-called "giant negative T waves") - seen in V4 - V6 in patients with the apical variant of HCM.
[5/28, 10:10 AM] POST RESIDENCY PG1: Possible. I shall have to do the echo myself to confirm that.
However even if the patient doesn't have all that it would still be HCM if not HOCM.
Even without the LVOT obstruction, HCM can be equally problematic in terms of morbidity causing heart failure
[5/28, 10:17 AM] MBBS 2016 UG1: 👍
