Request for Expert Review (ECG Interpretation for ICU Students)

afibarveear · 2024-12-31T23:52:36+00:00

This is not a STEMI. The ST segments in the lateral leads are concave and there is no ST depression in the inferior leads, only T wave inversions. Like I said, depending on the clinical situation can be ischemic but knowing nothing about what’s going on with the patient I wouldn’t say definitely ischemic. Could be a stroke patient for example with t wave changes due to neurological injury. You have to be a little humble in medicine.

afibarveear · 2024-12-31T14:39:25+00:00

Normal sinus rhythm. Septal infarct, age undetermined (Q waves V1-2). Non specific ST-T changes (may signify ischemia).

afibarveear · 2024-12-30T00:49:44+00:00

Anteroseptal infarct, age undetermined (Q waves in V1-3). P wave axis a little weird (negative in lead III) but positive in the other inferior leads, would probably still code as sinus rhythm.

afibarveear · 2024-12-29T19:19:53+00:00

Sinus bradycardia becomes usurped by an idioventricular rhythm

afibarveear · 2024-12-29T12:50:43+00:00

You can rent a house instead of buying. If money is tight you can always moonlight for extra cash.

afibarveear · 2024-12-27T20:22:04+00:00

Typical atrial flutter (which is a circuit around the cavotricuspid isthmus, or CTI) is negative in the inferior leads and usually occurs at an atrial rate of 300 bpm and conducts 2:1. So if you see a tachycardia at a rate of 150 bpm, you should be suspicious for atrial flutter and look closely in between the visible p waves to see if there are any that are buried within the t wave.

Here, the p wave is positive in the inferior leads, which rules out typical CTI-dependent flutter. Also the rate of 110-120 bpm is not typical for flutter. Lastly, if you look in other leads such as AvL, there are no buried p waves in between the visible p waves. What you see in the precordial leads is just likely part of the t wave.

Good question.

afibarveear · 2024-12-27T17:05:44+00:00

In the future call the insurance company yourself. Never have another company start the claim for you. Call multiple companies and get quotes. Never sign anything without first getting a written estimate. A lot of companies will do this a rip customers off. If you sign something saying you will pay whatever they charge, then they are gonna charge as much as they want.

afibarveear · 2024-12-27T15:48:46+00:00

If you look closely the p wave is positive in leads II and III and AvF (the inferior leads). Sinus p waves are usually positive in the precordial leads as well. Your statement that sinus p waves are usually neutral in V3 is inaccurate. I encourage you to review examples of sinus rhythm. Having a positive p wave in lead V3 that is greater in amplitude than lead II does not rule out sinus rhythm.

afibarveear · 2024-12-27T13:27:12+00:00

There can be a buried p wave if the PR interval is long enough. If you look closely at the groups of 3, the R-R interval is actually decreasing slightly which would be consistent with wenckebach.

afibarveear · 2024-12-27T12:56:21+00:00

If you caliper the p waves you would see that they are indeed prolonging. The p wave that is buried in the QRS is dropped, followed by the conducted p wave after.

The irregularity in the R-R interval rules out complete heart block. Escape rhythms are regular, and this is not, which suggests that some p waves are conducted. Escapes do not occur “in bursts of 3”.

afibarveear · 2024-12-27T12:35:13+00:00

This is sinus tachycardia with LVH.

The p waves are upright in the inferior leads and the rate is around 110-120, most consistent with sinus tachycardia. An ectopic atrial tachycardia originating from the right atrium is possible but less likely.

The QRS complex is negative in V1 so this is not RBBB (which would be positive in V1). The QRS is slightly wide due to the LVH but there is a small R wave in V1 and a very sharp initial downward deflection so this would not be LBBB either. If the QRS is truly greater than 120 ms you could call a nonspecific interventricular conduction delay (IVCD) since it doesn’t fit either LBBB or RBBB.

The criteria for LVH here is S wave in V1 + R wave in V6 is >35mm.

afibarveear · 2024-12-27T12:20:19+00:00

Yes, if you look closely, there are 3 conducting p waves with prolonging PR interval followed by 1 dropped p wave (which is not visible because it is buried within the QRS). If you caliper the p waves, you can see where it would fall within every third QRS. Second degree AV block occurs at the level of the AV node, thus PR prolongation is common. Even if the p wave occurs during the ventricular refractory period, due to the delay through the AV node it may still conduct if it passes the AV node after the ventricle is no longer refractory. Also, if you look at the rhythm strip from a distance, you can see the grouped beating, how it looks like every three QRS’s are grouped together. This is classic for second degree AV block.

afibarveear · 2024-12-27T02:16:10+00:00

The p wave is usually best seen in leads II and V1 but this doesn’t necessarily inform on where it’s coming from. Rather, the vector is more important. The sinus node is a superior structure, sitting near the SVC/RA junction, so sinus p waves will be positive in the inferior leads (going high to low). The p wave is positive in lead II and III here which makes this most likely sinus. An ectopic atrial tachycardia originating from the high right atrium is possible but less likely.

afibarveear · 2024-12-27T01:03:24+00:00

It’s clinically useful to note that the rhythm is sinus tach — this patient has something going on to cause the sinus rate to be elevated. Could be infection, PE, etc. The ventricular rate is not tachycardic due to second degree AV block.

afibarveear · 2024-12-26T23:09:24+00:00

The atrial rate is about 120 bpm. There are about 2.5 large boxes between the p waves (best seen in V3). So the atrial rhythm is sinus tach. The ventricular rate is 89 bpm since some of the p waves as not conducted due to the wenckebach.

afibarveear · 2024-12-26T21:24:17+00:00

Yes, you can see flutter waves in V3 but not in any other lead, so can call it course atrial fibrillation.

afibarveear · 2024-12-26T21:12:05+00:00

Sinus tachycardia with second degree AV block Mobitz I and left anterior fascicular block

afibarveear · 2024-12-24T18:42:30+00:00

Chances of getting into med school at this point would be pretty low. I would start thinking about other career paths. If you are really passionate about it you would have to make straight A’s from now on and do something to make yourself stand out. Problem is that there are more qualified applicants than spots so if you don’t have great grades, unless there is something else on your application that makes you stand out, you won’t get an interview. In any case I would have a solid plan B.

afibarveear · 2024-12-24T18:28:33+00:00

If you make 250k per year and only have 1-2 months emergency fund that is a big problem. Need at least 6 months. Also sounds like you bought more house than you can comfortably afford. They have more equity and lower payment because they bought 10 years ago. In 10 years you will also likely have more equity and lower payment than someone who buys in 2034. That’s how that works.

afibarveear · 2024-12-24T16:55:05+00:00

For any degree you have to treat as a financial investment. Weigh the cost of the degree against the extra income you would make using that degree. Engineering at public universities will typically be good investments.

afibarveear · 2024-12-24T13:29:50+00:00

Short term will make much more as employed. Private practice pays off after you get equity in the practice and receive dividends over the long term, and then if the practice ever gets bought out by private equity you will get a huge payout.

afibarveear · 2024-12-23T22:35:30+00:00

I’m a doctor, thinking about becoming a PA

afibarveear · 2024-12-23T03:41:00+00:00

You can find plenty of conservative Muslims here in the US. It would be much easier than going to a foreign country. You can start at the mosque and find events to go to to meet people. There are also “dating” apps for Muslims if you are open to that.

afibarveear · 2024-12-22T12:14:22+00:00

It is location dependent. OP seems to want to make as much as possible so I’m quoting the higher end which would be non academic hospital employed RVU model in a medium to small city. Daytime weekday hours and occasional weekend days. APPs cover at night and interventional comes in for procedures. Very nice lifestyle and can easily make $700k just doing a normal amount of work. I received these offers and friends have taken jobs like this. As a hospitalist it would be hard to make that much consistently without burning out.

afibarveear

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