ECG

1.1) A 27yr old bank executive came with an

ECG taken at a health insurance screening.
I. What’s the ECG diagnosis?
II. What’s the next investigation you would
perform and write 3 findings you will seek.
III. His girlfriend is concerned that you are
performing additional Ix and she’s asking you
what’s wrong with him. What’ll be your
response to her.
 ECG Answers

1. 1
1. Dextrocardia
2. CXR –
Dextrocardia
Gastric air bubble – situs inversus
Bronchiectasis
3. Confidentiality, autonomy, further Ix, ethical
issues
 ECG
1.2) A 58yr old male driver, previously healthy,
presents with epigastric burning chest pain,
sweating and vomiting for 1hr duration.
On Ex: PR 50bpm and BP 120/70mmHg.An
ECG was taken at ETU.
I. What are your ECG findings?

II. What’s the diagnosis?

• Within next few minutes he becomes faintish,
Pulse Rate drops to 30bpm and BP is
78/44mmHg.

III. 3. What’re your immediate next steps in

management?

IV. 4. Patient becomes haemodynamically stable

with your above interventions. What would
you be doing next?
1.2
1. 2. Inferior STEMI with II0 Heart block, Mobitz
type II

3. Symptomatic bradycardia with

haemodynamic instability; needs IV
Isoprenaline, Temporary/Transcutaneous
pacing.
4. PCI/Thrombolysis
 ECG
1.3) A 75yr old female with a history of DM,
HTN and past Hx of 2 x TIA’s presents to
ETU with chest tightness and palpitations
for 2 days duration. O/E her PR 155bpm
irregular, BP 148/74mmHg and No cardiac
Murmurs and Lung Bases clear.

i. What’s the ECG diagnosis?

ii. What’s your initial Mx of this patient?
iii. What’re the next 2 Ix you would
perform on her?
iv. How would you decide on her further
Mx?
v. What’re the advices and issues you
would discuss with patient/relatives?
 Answers
1.3
1. AF with rapid ventricular response
2. Rate Control – IV/O β - Blocker
3. 2D Echo, TFT
4. Asses risk of thromboembolism
CHADS2
5. Warfarin Advice
2. A 22 year old previously healthy female is brought
to ETU with one day history of abdominal pain and
vomiting.
She is ill looking, tachypnoeic & dehydrated. Her blood
pressure is 85/55mmHg with a pulse rate of 104bpm.
Her ABG is shown below
pH 7.3

pO2 98mmHg

pCO2 30mmHg

HCO3 - 13mEq/L

Na+ 136.5mEq/L

K+ 3.5mEq/L

Cl- 107mEq/L

Lactate 1.1mmol/L
2)
i. Calculate anion gap.

ii. What is the acid base disturbance seen in this

report?

iii. Name 2 investigations useful in narrowing

down the differential diagnosis.

iv. What is the likely diagnosis?

v. List 3 principals of management of above

condition.
 2) Answers

1. (136.5+3.5)-(107+13) = 20 mEq/L
2. High anion gap metabolic acidosis with
respiratory compensation
3. Capillary blood sugar, Urinary ketones
4. Diabetic ketoacidosis
5. Fluid resuscitation, Intravenous soluble
insulin infusion, Potassium replacement
• 3)A 34-year-old woman with an no significant past medical history
presents with intermittent headaches for the past 2 weeks. She has
a temperature of 36.8°C, blood pressure of 168/102 mmHg, heart
rate of 96 beats per minute, respiratory rate of 16 breaths per
minute, and oxygen saturation of 98% on room air. One year prior to
this episode, her recorded blood pressure was 134/86 mmHg.
Physical examination was unremarkable except for a faint bruit on
the left side of the abdomen.
Na+ 148 mEq/L
K+ 2.8 mEq/L
S.Cr 0.6 mg/dL
2D echocardiogram Normal

i. Give 2 differential diagnoses

ii. Suggest one endocrine and one radiological test that you will
perform in this patient.
iii. Fill the relevant form requesting the radiological test that you
suggested above.
iv. Write a referral letter to the relevant authority requesting the
endocrine test that you suggested.
 3) Answers
1. Renal artery stenosis/ fibromuscular
dysplasia
2. Primary hyperaldosteronism
3. Endocrine test: plasma aldosrerone to
Renin ratio
4. Radiological test : Renal artery duplex
scan
4). A 60 year old female with bronchial asthma
with recurrent exacerbations presents to you
with a complaint of recurrent falls. She comes
with the following investigation report.

i. What is the investigation that she has

undergone
ii. What is your interpretation
iii. What is the specific therapy?
iv. You decide to start her on an oral
preparation of the specific therapy. How
would you advise her?
 4) Answers

1. DEXA scan
2. Osteoporosis
3. Bisphosphonates
4. Administer prescribed dose in the morning
at least 30 min before the first food,
beverage (other than water), or medication
of the day.
5. Swallow the tablet with a full glass of plain
water and remain sitting or standing for at
least 30 min.
5) This is the chest radiograph of a 56 year
old male with rheumatoid arthritis.
1. List 2 x-ray findings
2. He underwent clinical spirometry. Which
one of the following curves can be his
result?
3. Write a referral to the relevant consultant
to arrange above investigation
4. Fill the form for the next relevant
investigation
 5) Answers
• 5.1
– B/L reticular shadows (Lung fibrosis)
– Traction bronchiectasis in left lower zone
• 5.2 B
• 5.3 Respiratory physician/physiology/or
relevant section dpt refferal
• 5.4 HRCT form
6)
56 yr old chronic ethanol user came with
altered behavior, loss of appetite and loss of
weight for 3 months
1. Comment on chest radiograph
2. Give 2 differential diagnosis
3. List 2 further investigations you would do
to confirm his diagnosis
6)
4. He underwent CSF analysis. Interpret his results
and give the most likely diagnosis
Protein : 110mg/dL
Glucose: 26mg/dL
Microscopy: PMN 37
Lymph 90 RBC 05

5. List management steps of this patient

 6) Answers
6.1 B/L miliary shadows with multiple
nodules
6.2 Miliary TB
Carcinomatous deposits
6.3 Sputum for AFB/TB PCR
CECT Chest
6.4 TB meningitis
6.5 ATT for 9months
IV steroids followed by oral steroids
7) 64 year old patient with Diabetes Mellitus and bipolar affective disorder came with
altered behaviors nausea, diarrhea and reduced level of consciousness for 5 days
duration. In hospital, patient developed one episode of generalized tonic- clonic seizures.
2 week prior to the admission, patient was started on treatment for bilateral ankle oedema
by a GP. On examination he is afebrile, no neck stiffness and GCS 12/15, BP
-150/100mg/dL, PR – 100bpm and had coarse tremors.
These were his initial investigations
• WBC – 10570/mm3
• N-90%, L- 8%
• Hemoglobin – 10.8g/dL
• PLT – 306 x 103/mm3
• Na + = 125,
• K+ = 3.7
• CPK - 311 ( <195 )
• Serum Creatinine – 410 micromol/L
• RBS - 180mg/dL
1. What is the most likely explanation for above clinical history
2. What is the investigation you do to confirm your diagnosis
3. List 2 therapeutic steps in management of this patient.
 7) Answers
7.1 Lithium toxicity precipitated by diuretic
therapy
7.2 Serum Lithium level
7.3 HD
Hydration
8) 44 year old female came with generalized weakness, difficulty
in walking, muscle aches and drowsiness for 1 week duration. On
examination, she is febrile(104 F) dehydrated, sweating ,
tremulous and confused. There was B/L exophthalmoses.
No neck stiffness, BP – 130/90mmHg, PR – 130bpm. Lower limb
muscle power is grade 3 in proximal and grade 4 in distal.
• WBC – 15600/mm 3

• N- 90%, L-6%
• HB – 12g/dL
• PLT – 348 x 10/mm
3 3

• ESR – 56mm
• CRP – 60g/dL
• K+ - 2.1, Na - 129
• Creatinine – 140micromol/L
1. What is the most likely clinical diagnosis of this patient.
2. List 3 other investigations you would like to request for this
patient. 
3. Name 3 management steps for this patient.
 8)Answers
8.1 Thyrotoxic crisis
8.2 Thyroid function tests (TSH,T4,T3)
ECG
Serum calcium
8.3 Beta blockers
Hydration
Electrolyte correction
Anti-thyroid medication
 BLS/ALS Station
• A 45 yr old medical officer presented with
retrosternal tightening chest pain lasting for 30 mins.
The pain was radiating to the neck and left arm. A 12
lead ECG was taken in A & E unit following which he
was given stat doses of Aspirin, Clopidogrel and
Atorvastatin & GTN sublingually. Pain slightly
improved but was complaining of dizziness 10 mins
later. You are called upon to see the patient by a
nursing officer.
• 1st ECG taken in admission
– Inferior STEMI
• He was not responding when you saw him.
Demonstrate how would you proceed.
 Counseling Station
• Miss Perera is a 29-year-old English teacher who first
admitted 6 weeks ago, feeling generally unwell with
a fever and weight loss. She was found to have
bilateral cervical lymphadenopathy. The consultant
did not discuss the diagnostic possibilities, but he
arranged a lymph node biopsy which was performed
10 days ago. Your consultant is away today and Miss
Perera has come back for the biopsy result.
Unfortunately, the histology report is of a Hodgkin’s
lymphoma.
• Your tasks are to: Break the bad news to Miss Perera
and deal with her concerns and questions.
 CVS 2
1. Check the radial pulse and comment
2. Auscultate the apex and comment on
your findings
3. What is the diagnosis
CVS 1
Respiratory
Neurology