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| No life ever grows great until it is focused, dedicated and disciplined." ~Harry E. Fosdick |
30th April to 30th May 2012
Learning objective: Basic lessons in ECG interpretation (Source: PhysioNet)
Sorry, the ECG is no longer available for viewing because of technical reasons.
Which of the statements below are 'True'?
- The axis is normal
- There is right axis deviation
- There is left axis deviation
- There is poor progression of R waves in the chest leads
- The R wave progression in chest leads is normal
- This patient may have had a recent anterior wall myocardial infarction
- This patient may have had a recent posterior wall myocardial infarction
Learning points during this semester:
- A blood pressure above 130/80mmg Hg is the trigger to initiate antihypertensive treatment in patients with diabetes. Hence this value can be considered to define hypertension in diabetics.
- As a screening test for diabetes, a fasting plasma glucose (or a fasting capillary blood glucose) or a glycosylated hemoglobin value can be used.
- The e-GFR in any clinical situation where there is an element of acute kidney injury should not be the basis for defining ESRF. The e-GFR must be estimated when the chronic kidney disease is stable in order to grade the severity of the chronic kidney disease.
- ACE inhibitors and ARBs can be used in patients with chronic renal failure to protect kidneys from rapid deterioration in function. They help to prolong the dialysis-free interval for these patients. These drugs reduce glomerular hyperfiltration and help to slow down nephron loss. This benefit must be balanced against the risk of hyperkalemia and worsening of renal function that can occur because of these drugs. Hence we tend not to use these drugs in ESRF because of the risk of hyperkalemia and we tend not to use these drugs also in people who experience a greater than 30 percent increase in serum creatinine in the first few weeks after their initiation.
- A crucial decision in managing diabetes is when to initiate insulin in patients with Type2 diabetes. The answer will generally be: Not too early, not too late. The HbA1c is a good guide for this purpose. As a rule of thumb we can say that insulin should be initiated whenever the glycosylated hemoglobin is more than 10 percent.
- When initiating insulin for a Type 2 diabetic, start with a basal insulin in a dose of 0.2units per kg body weight given subcutaneously once a day.
- Basal insulins come as "pure" basal insulins or as a pre-mixed combination (biphasic insulin). Biphasic insulins should always be given before food.
- Metformin should be discontinued a few days before any procedure that involves the use of an iodine-containing contrast medium. This is to reduce the risk of contrast-induced nephropathy.
Dr Vela Menon, MD
Faculty of Medicine, International Medical University, Malaysia
MedTutor is an online tutoring site for medical students and young doctors in Internal Medicine. Write to MedTutor at: moc.liamg|todikiwrotutdem#moc.liamg|todikiwrotutdem
3. Left Axis Deviation - True (I positive deflection, avF negative deflection. II negative deflection)
4. There is poor progression of R waves in the chest leads. - True (Normally R wave will progress from V1 to V6, Tallest at V5)
6. This patient may have had a recent anterior wall myocardial infarction. - True (Lack of R wave progression and Twave inversion in V1-V5)
You are correct Wei Sheng. Good interpretation.
Hi, these are my two cents on the ECG :
The TRUE statements are 3 & 4.
3. There is LAD - True, because Leads II & III are both negative
4. There is poor progression of R waves in the chest leads - True
Poor R wave progression can be present in previous anterior myocardial infarction (MI). However, a recent MI would should show pathological q-waves in the anterior leads V1-V4 which are not present in this patient. The average length of the complete disappearance of abnormal Q waves is 1.5 years (MacKenzie, 2005). After which, the poor R wave progression may be the only remaining evidence of the insult to the myocardium.
In conclusion, I think this patient has had an old anterior myocardial infarction.
(MacKenzie R. Poor R-Wave Progression. Journal of Insurance Medicine. 2005;37:58-62. (I can't post the link here, but if you google it there's free pdf)
Li Peng, your analysis is correct but I think the nature of the ST segment - with its slight convexity - should make us consider a recent MI rather than an old MI. I am sorry that the ECG is no longer available for viewing but I can send you a copy by email if you want.
Dear Dr Vela,
Thank you for your feedback! I'd appreciate having a look at the ECG again, if you don't mind? My email address is ku.oc.oohay|nat_gnep_il#ku.oc.oohay|nat_gnep_il. Thanks again.
Dr. Vela, can I have a copy of the ECG as well? I came across a sign saying bandwidth exceeded when i tried to view it earlier. My e-mail is moc.liamg|nvlanivla#moc.liamg|nvlanivla. Thanks a lot! :)