EKG Heart Sounds Workshop Notes

Questions on D2L

 Question 1 - EKG
o II, III, aVL, these leads have small repetitive P waves – sawtooth waves
o That makes this atrial flutter
o But no consistent number of P waves preceding QRS – it’s variable
o NOT a-fib because a-fib is “irregularly irregular” and this is “regularly irregular”
o Answer: atrial flutter with variable block
 Question 2 - EKG
o Look at rhythm strip – it’s sinus rhythm (1:1 P:QRS)
o V1, V2, V3 – “bunny ears”, double peak with widened QRS complexes
o Bunny ears on right side – suggests RBBB
o S waves in V5, V6 (and V4?) – also suggests RBBB
o Answer: sinus rhythm with RBBB
 Question 3 - sound
o Murmur – does not change with respiration
o Localized to left sternal border
o Listening to it – it’s a systolic murmur
o Patient is 72 years old
o Answers: aortic stenosis, tricuspid regurg, mitral regurg, VSD, PDA
o Answer: VSD
 Question 4 - EKG
o Look at rhythm strip
o QRS waves are narrow
o Narrow QRS = supraventricular tachycardia
o Answer: supraventricular tachycardia
 Question 5 - sound
o Murmur does not change with inspiration (not right-sided)
o Right upper sternal border
o Systolic murmur
o A crescendo can be heard – allegedly a decrescendo is also there but I couldn’t hear that
o Crescendo-decrescendo pattern = aortic stenosis
o Answer: aortic stenosis
 Question 6 - EKG
o Tachycardia
o Giant, wide QRS complexes
o No other waves present
o Definitely V-tac
o How to differentiate this from WPW syndrome – this doesn’t have delta waves
o Also clinically: patient is mid-50s presenting with syncope – WPW is congenital, he
would have presented earlier
o Answer: Ventricular tachycardia
 Question 7 - Sound
 o Baby
o Continuous, whooshing sound
o “Like a dishwasher”
o Answer: Patent ductus arteriosus
 Constant mechanical sound is a buzzword for PDA
 Question 8 - EKG
o Check rhythm strip – tachycardia
o V2, V3, V4 – prominent Q waves, ST elevation
o Also in lead III, there are Q waves
o V2-V4 = anterior
o Answer: sinus tac with anterior STEMI
o In order to say there’s a Q wave, you have to see the downward deflection in two leads
that are anatomically adjacent to each other
 Question 9 - sound
o There are three sounds
o Clinical info: sound is heard at apex, heard with bell
o S4 is not an answer choice
o Answer: S1, S2, S3
o S3 is the sound of early ventricular filling – vibratory sound that occurs after S2
o We also googled a split S2 – sounds more like a blurred long S2 because the time
between split sounds is still really short – that’s how you tell split S2 from S3 – S3 will be
clearly a separate soun
 Question 10 - EKG
o Look at lead 2
 There’s a P wave, then a prolonged PR, then a QRS
 Then another P wave – dropped
 Then P wave with normal QRS
 Then P wave with prolonged PR
 Then P wave with dropped QRS
o Pattern is hard to see here IMO but it depicts Wenkebach (2nd degree Type I)
o How do you know it’s not premature atrial contraction? The P waves look the same all
the way through and they have dropped QRS. In PAC there is not progressive elongation
of PR interval, that’s how you know this is Wenkebach
o Answer: Sinus rhythm with type I 2nd degree AV block
 Question 11 - EKG
o Check rhythm strip – normal rate, sinus rhythm (1:1 P:QRS)
o V1-V6 – really big magnitude peaks = left ventricular hypertrophy
o T waves inverted in II, V4, V5, V6
o Answer: Sinus rhythm, LVH, T wave inversion consistent with strain or ischemia
 Question 12 - EKG
o Tachycardia (150bpm)
o There are multiple atrial waves between QRS complexes
o 2:1 waves before QRS
o Answer: 2:1 atrial flutter
 Question 13 - sound
o Dyspnea on exertion
o Sound heard at apex, with bell
o Patient is an immigrant
o Listening: Diastolic murmur per Dr. Brickner, with a diastolic click (I thought it was an S4)
o The hx of an immigrant is important because it suggests the patient did not have good
access to abx as a kid (more likely to have rheumatic disease) (wowwwww)
o Hx of rheumatic disease, diastolic murmur with click  mitral stenosis
o Answer: mitral stenosis
 Question 14 - EKG
o Normal rate
o Q waves with ST elevation in V1, V2, V3
o V5, V6 = rabbit ears
o Answer: normal sinus rhythm with LBBB
o HIGH YIELD – V1, V2 – RBBB; V5, V6 – LBBB
o LBBB has rabbit ears in V5, V6 AND Q wave with ST elevation in V1, V2, V3
 Question 15 - EKG
o Regular rhythm but waveforms look weird
o Wide QRS complexes – suggestive of ventricular originating rhythm
o The broad, wide QRS complexes are preceded by extremely narrow spikes
o Extremely narrow spikes = ventricular pacing
o Answer: normal sinus rhythm with ventricular pacing
o What would ventricular escape rhythm be: would be slow/bradycardic with broad, wide
QRS – this is normal rate
 Question 16 - sound
o Clear third sound – occurring very shortly before S1
o Answer: normal S1, S2 with S4
 Question 17 - EKG
o Older patient, sudden syncope
o V1 is a good lead to look at here
o There are P waves and QRS complexes, but they are random – not associated with each
other at all
o Answer: Third degree (complete) heart block
 Question 18 - Sound
o Patient has dyspnea on exertion
o Listening at right upper sternal border
o *symptoms since childhood*
o Sound: seems like a fixed split – VERY short time interval between 2 of the sounds
o Answer: Normal S1 with fixed split S2
o The fixed split is caused by congenital atrial septal defect (explains symptoms since
childhood) and consistent with right upper sternal border location
o Fixed split S2 occurs due to delayed pulmonic valve closure – you would hear that in
right USB – in contrast to S3 which you would hear at the apex of the heart
 Question 19 - EKG
 o Incredibly slow
o But there’s 1 P to 1 QRS
o Answer: Sinus arrest with slow escape rhythm
o This could be caused by severe hyperkalemia (this is what happens after the EKG gets
“wavy” if K+ continues to rise)
 Question 20 - EKG
o ST elevation V2-V4
o Answer: Anterior STEMI
 Question 21 - EKG
o II, III, aVF – ST elevation
o Answer: Bradycardia with Inferior STEMI
 Question 22 - Sound
o Listening at apex
o This is the same patient from Q21 who had an MI
o Whooshing sound – holosystolic murmur
o VSD and mitral regurg could both cause whooshing sound
o Clinical context helps answer this: this is mitral regurgitation because the patient is
having this sound while he is having an MI – if it were VSD from acute myocardial
rupture, it would occur 3-7 days after the MI
o Answer: Mitral regurgitation
o Different reasons you can have mitral regurg after MI
 Papillary muscle rupture
 Papillary muscle ischemia – if there’s ischemia, the papillary muscle can’t
contract as well, and the valve won’t close, and that can happen concomitantly
with the MI – muscle rupture (papillary OR ventricular wall) would take days to
develop b/c they result from necrosis of the muscle after prolonged ischemia
 Question 23 - EKG
o Sinus rhythm
o Q waves and ST elevation in V2/V3, aVF
o Answer: sinus rhythm with inferior Q waves
 Question 24 - EKG
o Irregular rhythm, 120bpm
o Answer: A fib with rapid ventricular response
o How to differentiate from AV nodal supraventricular tachycardia?
 AV nodal SVT is tachycardic but regular rhythm
 This is irregular with bizarre, irregular small waves – A fib
 Question 25 - sound
o 55yo M
o Family hx of sudden cardiac death
o Listening at left sternal border
o Systolic murmur
o Must watch video not just listen – murmur intensity decreases when patient squats –
this is due to the increased venous return to the heart
 o Murmur decreasing with increased heart filling volume = either MVP or Hypertrophic
cardiomyopathy
o Answer: This is HOCM
 Question 26 - EKG
o Answer: torsades de pointes
o Classic torsades de pointes – looks like string twisting around an axis, then unwinding,
then twisting again
o Recall TdP is a polymorphic ventricular tachycardia
 Can be caused by congenital long QT syndrome, or drug-induced
 Clinical case in this question – patient was in a motor vehicle accident. Most
likely he was given some drug during post-accident eval that caused his TdP
 Question 27 - EKG
o Answer: V fib
o Classic V-fib
o No discernible rhythm
 Question 28 - sound
o Patient is uncomfortable when supine
o Sounds like sandpaper rubbing, played over his heart sounds
o Answer: pericardial rub
 Question 29 - EKG
o Severe bradycardia, 36bpm
o Very long PR interval – and regular length – that’s 1st degree AV block
o Other answer choices include bradycardia with inferior Q waves (not present)
o And bradycardia with peaked T waves (not present)
o Answer: sinus bradycardia with 1st degree AV block
 Question 30 - sound
o 49yo M with chest pain radiating to back
o Listening at Right USB and left USB
o Very difficult to make out (to me) but it sounds like a diastolic murmur
o Diastolic murmur at upper sternal area = aortic regurgitation
 More info: pain radiating to back – type A Stanford aortic dissection
 Type A aortic dissection can cause aortic regurgitation
o Answer: aortic regurgitation
 Question 31 - EKG
o We’re not given complete rhythm strip
o Around 80bpm
o EKG starts with narrow QRS but progresses to wide QRS complexes
o Starts with normal EKG but then you get “inserted” ventricular-originating QRS
complexes – those are premature ventricular contractions
o Answer: sinus rhythm with PVCs
 Question 32 - EKG
o Bradycardic ~55bpm
o Small, “weird” atrial waves
o Answer: Atrial fibrillation with slow ventricular response
 Question 33 - EKG
o Extremely tachycardic, >200bpm
o Looks like high-magnitude peaks but it’s unclear what that means here (LVH not in
answer choices)
o ST depression in virtually all leads
o ST depression = global ischemia
o Answer: diffuse ST depression consistent with global ischemia
 Question 34 - EKG
o Normal rate ~80bpm
o V1, V2, V3 – huge Q waves
o There is prolonged PR interval in multiple leads – 1st degree AV block
o T wave inversion in lateral leads (V5, V6)
o Answer: sinus rhythm with 1st degree AV block, T wave inversion in lateral leads
 Question 35 - EKG
o Normal rate, 84bpm
o Looks like minor ST depression in V4, V5, V6 – lateral (that is incidental)
o Major finding – this is shortened PR interval wide “ramp-up” to the QRS complex –
delta waves
o This is WPW
o The answer choice is: sinus rhythm with shortened PR and delta waves
o Delta waves in WPW syndrome come from use of the accessory pathway which is faster
than the normal pathway – you get ventricular contraction before the AV nodal
conduction occurs – that’s why there is sloping of the QRS complex
 Question 36 - EKG
o Normal rate, 66bpm
o Sinus rhythm
o But – QT intervals are long
o Normal T wave should be <halfway between 2 QRS complexes, always closer to first QRS
complex
o These are prolonged QT intervals
o Answer: Sinus rhythm with prolonged QT interval