NAME:PADILLA, LEANDRO LUIS R.
SCORE: _________________
Month of IM Rotation: FEBRUARY 2021 Group: _RA______________
Program:X INTERN ___ CLERK
ECG AND CHEST XRAY INTERPRETATION
Instruction: For each of the following items below, a sample ECG tracing and chest xray is given. Please review
each ECG tracing and chest xray, and answer the variables needed according to the structure in ECG and chest
xray.
Case 1: ( 10 pts) A 31 year old, Kargador for 2 years in a rice mill consulted at ER level due to chest pain,
pleuritic in character. Upon physical examination there is point tenderness on the right chest and left chest
area, other physical examination are all normal. But still the ER resident requested for 12L ECG further work up
was done. Patient was sent home with Celecoxib 200 mg/capsule 1 capsule every 12 hours for 3 days then as
needed for pain, Vitamin B complex 1 capsule once a day, and advised for follow up after 1 week.
Rhythm Regular sinus Rhythm QRS Duration < 0.12 sec
Atrial rate 75 QT interval 0.36 sec
Ventricular Rate 75 QRS Axis ( Compute) Lead I: 8 aVF:4
90xaVF = 60
8+ 4= 12
=60/12= 5
=+5 degrees normal
axis deviation
PR Interval 0.12sec
Interpretation: Acute Pericarditis
ST elevation on leads I, II, aVL, aVF
Depression in aVR and P wave and R wave depression in leads II,V2 and V3
Clinical Impression:
T/C Pericardial Effusion
Case 2: ( 15 pts) 50 year old female, known case of Type 2 DM, on Metformin 500 mg/tab 1 tab 3x a day for
almost 6 years, came in at the ER due to epigastric pain radiating to the left chest area.
Rhythm Sinus Tachycardia QRS Duration 0.08sec
Atrial rate 110bpm QT interval 0.24sec
Ventricular Rate 110bpm QRS Axis ( Compute) Lead I: 7 aVF:7
90x7=630
7+7=14
630/14= 45
=+45 degree normal
axis deviation
PR Interval 0.12sec
Interpretation:
Antero-septal wall Myocardial Infarction
Clinical Impression:
Ischemic Heart Disease, STEMI-ACS T/C Congestive Heart Failure
If you are the ER resident who saw this patient what medications are you going to give? ( please
include the dose, duration and frequency of the medication)
1) Oxygen supplementation
2) Metformin 500mg/tab PO TID
3) Metoprolol 50-200mg PO BID
4) NTG 0.3-0.6mg SL up to 3 doses 5 minutes apart or ISDN 5mg SL
5) Simvastatin at maximum tolerated dose of 80mg/day
6) Aspirin 80-160mg/day
CASE 3A: ( 20 pts), A 45 year old female diagnosed with hyperthyroidism since 2015 on Methimazole 20 mg/tab
1 tab once a day and Propanolol 40 mg/tab 1 tab once a day however patient stop her medication for 1 week
due to financial constraints, came in at the ER due to palpitation and chest pain. 3 days prior to admission
patient experienced LBM 6 episodes accompanied with vomiting, non-projectile approximately ¼ cup per bout
and epigastric pain, aggravated by walking, cramping in character, 5/10 in severity non radiating, patient took
HNBB 10 mg/tab 1 tab every 8 hours as needed for abdominal pain and continued her maintenance
medication. Upon Physical examination pt was noted to have exophthalmos, crackles on both lung fields
bibasal, irregular rhythm, PMI at 6th ICS Anterior Axillary line, no murmur noted. Patient was also noted to have
bipedal edema, grade 1 pitting.
Rhythm Sinus Tachycardia QRS Duration 0.08 sec
Atrial rate ( 13 QRS 130bpm QT interval 0.12 sec
in 30 large boxes)
Ventricular Rate 130bpm QRS Axis ( Compute) Lead I: 3 aVF: 21
90x21= 1890
3+21=24
1890/24= 78.75
=+78.75 degrees normal
axis deviation
PR Interval 0.16 sec
Interpretation:
Incomplete Left Bundle Branch Block
Clinical Impression:
T/C Congestive Heart Failure
Compute for Burch and Wartofsky Score ( Please enumerate the criteria that is present and not
present in your patient and the appropriate scoring)
BURCH AND WARTOFSKY’S CRITERIA
Present in patient:
Tachycardic 130bpm- 20
Diarrheric episodes with non-projectile vomiting with epigastric pain-10
Pitting bipedal edema grade 1- 5
Bibasilar Crackles-10
History of anti thyroid medication for a week-10
◦ Score of 55=Highly suggestive of Thyroid storm
Not Present in Patient:
Thermoregulatory dysfunction
Neurologic Disturbances
If you are the ER resident who saw this patient what medications are you going to give? ( Please
include the dose, duration and frequency of the medication)
1)Initial fluid resuscitation: 1L PNSS at 80ugtts/min for 12 hours
2) Propanolol 20-40mg every 6 hours TID-QID
3) Acetaminophen 500mg PO every 4-6 hours as needed for pain
4) Methimazole 10-20mg PO every 8-12 hours
CASE 3B. (10 pts) In relation to the case above (case 3A) the ER physician also requested for Chest Xray. Please
interpret the chest xray by ABCDEGHI approach.
Interpretation ( ABCDEFGH approach)
Trachea in midline
No ribcage fracture
No pulmonary nodules
Obscured CPA of both side Left diaphragm
Consolidation on the entire right lung and left lower lung fields
Gastric bubble visible
Clinical impression ( Please refer to case 3A and 3B for a complete clinical Impression)
Community Acquired Pneumonia- Moderate Risk
T/C Congestive Heart Failure
CASE 4: ( 15 pts) A 48 year old male came in at the OPD due to cough, productive with yellowish sputum for 4
weeks accompanied with back pain, 5/10 in severity aggravated by coughing, hemoptysis, occasional DOB and
weight loss.
Interpretation ( ABCDEFGH approach)
Trachea in midline
No ribcage fracture
No pulmonary nodules
CPA not obscured for both side
Pulmonary infiltrates on the mid to upper zone of both lungs with cavitation on the mid- zone of
right lung field
Gastric bubble visible
Clinical impression ( Please refer to case 3A and 3B for a complete clinical Impression)
Presumptive Pulmonary Tuberculosis
Laboratory Examination to be requested ( Please prioritize) and give the rationale
1.) Complete blood Count- to check for active inflammation and to rule out possible hepatitis
B
2.) Urinalysis- to check for blood (hematuria) and presence of protein in the urine, to screen
for Urinary tract infections
3.) Direct Sputum Smear Microscopy /AFB Stain Microscopy
Presumptive screening if patient can expectorate sputum sample
As initial for faster confirmation of result compared to TB culture
4.) GeneXpert- to confirm TB in smear negative and determine rifampicin resistance
5.) Kidney function test: BUN Crea to asses for kidney involvement
6.) Liver Function test: AST/ALT to asses baseline level of hepatic enzymes before starting
antimycobacterial theraphy
Medical Management ( Include the dose, frequency, and duration)
1) If Fixed Dose Combination (FDC) available, or
a) First 2 months HRZE: 3 tablets/day
b) Following 4 months HR: 3 tablets/day
2) If Single Dose Formulation (SDF) available
a) First two months (Intensive Phase)
Isoniazid 250mg/day
Rifampicin 500mg/day
Pyrazinamide 1.25grams/day
Ethambutol 750mg/day
b) Following 4 months (Continuation phase)
Isoniazid 250mg/day
Rifampicin 500mg/day
For Isoniazid-related neuropathy: Pyridoxine 10-25 mg/day
To efficiently monitor adherence to regimen, subject patient to facility or communitybased
TB Directly Observed Treatment programs
DSSM screening after 3 months of treatment to determine treatment failure. However,
DSSM screening should be ideally done monthly throughout the treatment.
PART 2: ABG INTERPRETATION: For each of the following items below, a sample ABG result is given. Please
review each result, and interpret the acid base and oxygenation status.
CASE A: ( 10 pts) A 46 year old male, known case of CKD secondary to DM nephropathy on HD 2x per week,
came in at the ER due to DOB. The ER physician requested for ABG stat which revealed the following result?
Weight: 68 kgs
pH 6.90
pCO2 24
pO2 79
Bicarbonate 8
BE -2.3
FIO2 40
Interpretation:
Partially Compensated Metabolic Acidosis with Mild Hypoxemia
Compute for Bicarbonate Deficit
=(Desired HCO3 ̅ - Actual HCO3 ̅) x BW in kg x 0.4
=(15-8) x 68 x 0.4
=190 mEq
How much Sodium Bicarbonate are you going to give to your patient and How will you give?
190mEq x 0.5 = 95mEq
first dose is 95 mEq Na HCO3 be given as slow IV push
Second dose is 95 mEq Na HCO3 be incorporated in 1L PNSS 40ugtts/min for 24 hours
CASE B: ( 5 pts). A 45 year old male, known chronic smoker came in at the ER due to DOB. Upon physical
examination patient is in respiratory distress and noted to have subcostal retraction and wheezing on both lung
fields. The ER physician requested for ABG and Chest Xray.
pH 7.0
pCO2 68
pO2 74
Bicarbonate 28
BE 1.0
FIO2 38
Interpretation:
Acute Respiratory Acidosis with mild hypoxemia
3 differential Diagnosis Based on History and ABG result and give the rationale?
a) Asthma
b) Chronic Bronchitis
c) Chronic Obstructive Pulmonary Disease
Acute respiratory acidosis is present when an abrupt failure of ventilation occurs. This failure in ventilation
may result from depression of the central respiratory center by one another like COPD causing airway
obstruction related to Asthma and chronic bronchitis
Medical management ( Include the dose, frequency and duration?
1. Start with Short-acting Beta 2 Agonist
Salbutamol 4-10 puffs by pMDI
Repeat every 20 minutes for 1 hour
If improving, continue use of this reliever
2) Low dose ICS
Methylprednisolone 80mg IV q8h
If no relief with SABA
3) Supplemental oxygen if O2 saturation<90%
