The final section of this textbook is a collection of 50 ECGs for review and self-assessment. These unknowns have been selected to challenge students and others who have completed the text or to serve as a stand-alone examination for clinicians who wish to take a board review–type “pretest.”
Each question comes with a short case description. (Helpful clues are sometimes provided.) Students are encouraged to write down their findings and compare their interpretations with the “official” answers given at the end of the section. Each question is worth 2 points. A perfect score is 100!
This section also gives answers to questions posed at the end of most chapters. Additional ECG questions and answers are freely available at a number of Internet sites including the ECG Wave-Maven: Self-Assessment Program for Students and Clinicians (http://ecg.bidmc.harvard.edu
). This site includes more than 250 practice ECGs.
Questions
TRIAGE TRYOUT
These patients arrive in your office at the same time. Both complain of severe chest pain. One ambulance and one taxicab are available for transporting them to the nearest hospital, which is five miles away. What do you do?
Case 6 50-year-old man with chest pain
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Case 7 50-year-old man with chest pain
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FOUR CASES OF MISTAKEN IDENTITY
The following ECGs are commonly incorrectly identified as shown. For each ECG, what is your correct diagnosis?
Case 8 “Left bundle branch block or left ventricular hypertrophy with inferior myocardial infarction”
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Case 9 “Complete heart block”
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Case 10 “Sinus (or ectopic atrial) tachycardia”
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Case 11 “Right axis deviation resulting from lateral wall infarction”
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SYNCOPATED RHYTHMS
Both of these patients are complaining of an irregular heartbeat. What are the diagnoses?
Case 12
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Case 13
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INCOMPLETE DIAGNOSES OF COMPLETE RIGHT BUNDLE BRANCH BLOCK
Right bundle branch block was correctly diagnosed in these two patients with chest pain. That is only part of the story, however. What else is going on?
Case 14
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Case 15
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MORPHING P WAVES
What subtle arrhythmia is present in this ECG?
Case 16
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TEARFUL PATIENT
Why is this very healthy female crying? (Clue: Consider QRS duration.)
Case 17
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TRICKY BUSINESS
An ECG is obtained in this 45-year-old businessman before he undergoes appendectomy. He complains of lower left quadrant pain. The ECG is unchanged from a previous one, at which time the workup revealed normal cardiac function. What is the diagnosis?
Case 18
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HEART FAILURE AFTER MYOCARDIAL INFARCTION
Two months after having a myocardial infarction, this 75-year-old man presents with rales on chest auscultation and an S3 gallop. His ECG is unchanged from a month ago and cardiac enzymes are negative. What does the ECG show?
Case 19
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COMMON THEME
These elderly women have heart failure, and both complain of nausea. What are the two arrhythmias? What is the probable common underlying problem?
Case 20 (Clue: Previous ECGs showed atrial fibrillation with a rapid rate.)
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Case 21 (Clue: Double-check leads II and V1.)
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DRUG DILEMMA
This ECG (from a patient with normal electrolytes) is most consistent with therapy using which one of the following drugs?
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a. |
Digoxin |
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b. |
Captopril |
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c. |
Amiodarone |
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d. |
Metoprolol |
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e. |
Verapamil |
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f. |
None of the above |
Case 22
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NARROWED-DOWN DIFFERENTIAL DIAGNOSES
The following patients both have narrowed heart valves. One has mitral stenosis, and the other has pulmonic stenosis. Can you tell which is which?
Case 23
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Case 24
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PAUSE FOR THOUGHT
A 72-year-old woman has intermittent light-headedness. What does the ECG lead show?
Case 25
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LOOK-ALIKE TACHYCARDIAS
The following patients both complain of a fast heartbeat. One has atrial flutter with 2:1 block. The other has paroxysmal supraventricular tachycardia (PSVT) due to atrioventricular nodal reentrant tachycardia (AVNRT). Can you tell which is which?
Case 26
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Case 27
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SILENT HISTORY
A 75-year-old man has an ECG before undergoing cataract surgery. He denies previous cardiac problems. What does his ECG show?
Case 28
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THREE PATIENTS WITH RECURRENT SYNCOPE
The following three patients (Cases 29-31) had recurrent episodes of fainting. Can you diagnose the cause in each case?
Case 29 21-year-old woman on no medications with normal serum electrolyte values
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Case 30 37-year-old man
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Case 31 75-year-old woman
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HEARTBURN
This 52-year-old man has indigestion, nausea, and an irregular pulse. What is the rhythm? What is the underlying problem?
Case 32
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HIDDEN P WAVE “ST-ORIES”
Can you diagnose these two arrhythmias?
Case 33
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Case 34
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MYOCARDIAL INFARCTION SIMULATOR
This 46-year-old man has chest pain and dyspnea. Initially, he was thought to have had a myocardial infarction. What alternative life-threatening diagnosis would account for all these findings?
Case 35
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IRREGULAR BEHAVIOR
The following highly irregular rhythms are often confused. What is the arrhythmia in each case?
Case 36
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Case 37
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QUICK CHANGES
These two rhythm strips show underlying sinus rhythm with abrupt changes in cardiac electrical activity and intermittent wide QRS complexes. What are the diagnoses?
Case 38
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Case 39
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MISSING BIFOCALS
A middle-aged cardiologist left his bifocals at home and missed the following diagnosis. (Clue: see arrow.)
Case 40
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LONG AND SHORT OF IT
Both of these patients have mental status changes. Can you diagnose the cause from the ECG alone? (Clue: The key to their treatable diagnoses relates to the beginning of the ST segment.)
Case 41 30-year-old woman
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Case 42 65-year-old man
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PACEMAKER PLUS
This 78-year-old man has a VVI pacemaker for complete heart block. He comes into your office with shortness of breath and evidence of pulmonary edema. In addition to the expected pacemaker pattern, what does his ECG show?
Case 43
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ECG/CORONARY ARTERIOGRAM MATCHUP
Which ECG (A to D) goes best with which story for these four middle-aged men?
Case 44 This man had chest pain 3 days ago. His creatine kinase level is now normal. He has an occluded large left circumflex coronary artery and a severe inferoposterolateral wall motion abnormality.
Case 45 This man has had chest pain for the past 4 hours. His creatine kinase level is 800 U/L (normal: less than 200 U/L). He has three-vessel coronary disease with 80% to 90% proximal stenoses and anterior wall hypokinesis.
Case 46 This man had chest pain 1 month ago, but his creatine kinase level is now normal. Currently, he is complaining of dyspnea. He has an occluded proximal left anterior descending coronary artery with an anterior wall aneurysm.
Case 47 This man has had chest pain for 12 hours with a normal creatine kinase level. His coronary arteries and ventricular wall motion are normal.
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CALCULATION LEADS TO DIAGNOSIS
A 40-year-old woman complains about feeling weak. She is not taking any medication. Based on the ECG, what laboratory values do you want checked?
Case 48
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INTEREST-PIQUING T WAVES
What underlying condition explains all findings? Additive clues: QRS voltage, P waves, and QTc.
Case 49
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FITTING FINALE
Case 50
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