sudar ima e book

FAMILY
the






DOCTOR











The Official Journal Of IMA Collage Of General Practitioners





















MESSAGES


UPDATES OF COVID-19


QUIZ



Dear Dr Yesodha,




It has been a great experience to work with you in the past two

years. Pure in heart in words and deeds you are an asset to IMA

and the fraternity. I should admit you worked under challenging

circumstances and carried the burden of the oldest institution of

IMA with dignity and poise.




r
Dr Hiranmay Adhikari added value to the chair and his ever bub-
D
bling enthusiasm, depth and intensity of involvement and the

vision gave a new dimension to the CGP movement.

The team led by both of you carried the responsibility adorably

during the Covid pandemic. I congratulate both of you and your

team for your dedication and hard work. I wish your e journal and

the National Conference all success







Dr. R. V. Asokan

Hony Secretary General IMA HQ

Greetings from IMA HQ.!




It is a matter of great pride that IMA College of General Practition-

ers is organizing virtual National Conference of IMACGP on 8th No-

vember, 2020




IMA College of General Practitioners has always undoubtedly been

one of the most active wings of IMA academically and also in re-

spect of member services.




We have been facing various professional problems in our day to

day practices in the form of litigations, attack on doctors, newer

diseases and so on. Collectively we have to face.




We should remember IMA is committed towards the betterment of

the healthcare of the deprived people.




I am con dent that the virtual National IMA CGP Conference would

be bene cial for all the General Practitioners.




I wish the conference a grand success.




With best wishes




Dr Ramesh Datta

o
Hony. Finance Secretary, IMA
H

As the Dean of Studies IMACGP, the academic wing of IMA-the prestigious or-
ganization, I am delighted to extend my warmest greetings to the delegates,
mentors and organizers of the GPCON 2020, the Annual National Conference,
IMACGP 2020 (Virtual Conference) which is going to take place on 8th Nov
2020.


I am very much thankful to all the Presidents & Secretaries of States and the
officials of State CGP Faculties in this Covid-19 pandemic situation, for their
cooperation by helping me to carry out the 4(four) numbers Zonal meeting
(virtual) of States(South Zone states on 18/6/20, West Zone States on 08/7/20,
Noth Zone States on 07/8/20 and East Zone States(Including Northeast States)
on 04/9/20) to have fruitful detail discussion between the IMACGPHQ officials
and the State officials including the officials of CGP Faculties on 6 points

AGENDA, which came out very successful one, with activation and
n
encouragement of the State Faculties.
e
I wish the conference all the success.




Dr Hiranmay Adhikary

Dean of Studies IMACGP

TO


DR. HIRANMAY ADHIKARI


DEAN, IMA COLLEGE OF GP


HQ CHENNAI


I I AM ELATED TO APPLAUD AND CONGRATULATE THE TEAM OF OFFICERS OF OUR IMA
COLLEGE OF GENERAL PRACTITIONER UNDER YOUR HEADSHIP AND THE DYNAMIC
STEWARDSHIP OF DR.YASODHA ,FOR THE PAIN TAKEN TO LEAD OUR MUCH AWAITED
NATIONAL CONFERENCE AMIDST THE CORONA PANDEMIC.


I WAS CONFIDENT OF YOUR POIGNANT PASSION AND UNQUENCHABLE HUNGER FOR
QUINTESSENCE OF UNITY AND PERSUASIVENESS IN UPBRINGING THE BLISS AND
ECSTASY OF OUR WING AND DELIGHTED TO GREET YOU FOR YOUR MIGHTY
B
S
T
E
S
S
C

N
ACCOMPLISHMENT ON THIS BLESSED DAY.
A C O M P I H M E T O N H I L S E A Y .
D
D
L
THE REJUVENATING, INVIGORATING AND REVIVIFYING 2019-20 LED WITH SALLY FORTH
AND OVERHAUL OF INCREDULOUS SARDINE HICCOUGHS DUE TO CORONA BY YOUR
SALMON SHINE VIRTUES, ALONG WITH THE VIGILANT HEADFUL OF PAST LEADERS WAS
A YEAR TO BE REMINISCED AS A SCINTILLATING PAGEANT ,AND SYMBIOSING UNITY IN
EVERY BIT OF EVENTS AND MEET, FLAMBOYANTLY THE FAMILY CONVENES .
THE TONE OF EXPECTATIONS ON YOUR TENURE WAS ATTIRE TO SOPRANO AND I AM
H
T E
HAPPY TODAY WITH YOUR TEAM OF ADEPT, PROFICIENT TEAMMATES AND
K
D
O
C
S
R
ROCK-SOLID HANDHOLDING OF ALL OF US AS ELDERS YOU HAVE MADE A GOLDEN ERA
-
O
L
I
IN THE CONQUERING EPITOMES OF THE ANNALS OF OUR IMA CGP. THE UNIQUE
ACHIEVEMENT OF CREATING THE STATE FACULTY UNIT IN MANIPUR, PUBLISHING THE
JOURNAL OF CME BY ASSAM IMA, ENHANCEMENT OF MEMBERSHIP IN NORTH EAST AND
YOUR UNIQUE INTERACTIVE ZONAL MEETS ARE PRAISEWORTHY JEWELS ON YOUR
CROWN.
I I FULLY ENDORSE AND APPRECIATE OUR LOVING AND AFFECTIONATE SECRETARY FOR
HER IMMACULATE PERFECTION, BLISSFUL PERSONAL INTERACTIONS WITH MEMBERS,
AND HOMELY ATMOSPHERE STEMMED BY HER AFFECTIONATE GESTICULATIONS IN THE
COLLEGE,
SUSTAIN THE UMBILICAL CORD WITH STATE HQ AND NATIONAL HQ AND ENSURE
EVERY ONE OF US FEEL HAPPY.


YOURS IN IMA SERVICE




PROF. DR. J. A. JAYALAL MS,FIGES,FIIOPM,FRCS,MBA,PHD
PROFESSOR OF SURGERY, TVMCH
MEU COORDINATOR
SENIOR NATIONAL VICE -PRESIDENT IMA 2019
NATIONAL COORDINATOR IMA UNESCO BIOETHICS

To

Dr.L.Yesodha

Hony. Secretary
IMA College of General Practitioners(HQs)

Chennai



Dear Dr. Yesodha,




I I am glad to know that you are organizing the virtual National Conference

of IMA CGP on 8th November 2020. Despite all odds and difficulties
created by COVID 19, you and your dynamic team continuously organized

several scienti c programs throughout the pandemic.



I congratulate your team for the same and wish you all the best.

D During my one year tenure as a Dean of IMA CGP we together worked hard

to spread the activities of CGP in northern states, where the branches are

not very active. I am very hopeful that coming teams will also concentrate
on the same. There is also a requirement to strengthen the research atmos-

phere among the general practitioners, which we had a plan but couldn’t

start during my tenure. Hopefully it can also be taken up further.





Best wishes

Dear Dr. Yesodha,




I am glad to know that you are organizing the virtual National

Conference of IMA CGP on 8th November 2020. Despite all odds

and difficulties created by COVID 19, you and your dynamic team

continuously organized several scienti c programs throughout the

pandemic.





I congratulate your team for the same and wish you all the best.
I


During my one year tenure as a Dean of IMA CGP we together

worked hard to spread the activities of CGP in northern states,

where the branches are not very active. I am very hopeful that

coming teams will also concentrate on the same. There is also a

r requirement to strengthen the research atmosphere among the

general practitioners, which we had a plan but couldn’t start

during my tenure. Hopefully it can also be taken up further.




Best wishes

COVID-19 IN CHILDRENS AND TEENS

Age Group:- Kids and teens (0-18 years) are less prone to disease. They become
asymptomatic carrier. There is less severing an fatality in this pandemic age group.
Usually kids and Teens are rare infective but certain under medical condition the illness may
be severe in nature.
Medical Conditions:-
 Asthma or chronic lung disease.  Weak immunity due to same medical
 Diabetes. conditions.
 Genetic, neurological or metabolic conditions.  Medical complexity.
 Heart disease since birth.  Obesity.
Symptoms:-
 Fever (100.4°F or higher).  Nausea or vomiting.
 Cough, sore throat.  Stomachache.
 Nasal congestion or running nose.  Tiredness, Headache
 Loss of taste or smell.  Muscle or body aches.
 Sore throat.  Poor appetite or poor feeding, especially in
 Shortness of breath or difficulty in breathing. babies under 1 year.
 Diarrhea.
Treatment plan:-
(A) If your child is asymptomatic but positive. Then you cure at home with rest. Take proper
consultation with your doctor and take care of (him/her).
 If you keep child at home.
(then)
 Keep other people, pets in the house away from your child.
 Try to have only one person care for the sick child.
 Provide them separate washroom.
 If the child is above 2 years, provide then mask (but don’t leave there alone).
 Use proper sanitization of doors, knobs & floor.
 Wash hands atleast for 20 sec.
(B) Some kids are having symptoms caused by inflammation through out the body, sometime after
several weak they were infected with virus called.
MULTI SYSTEM – INFLAMMATORY – SYNDROME
(In childhood) (MIS-C)
 Fever, belly pain.
 Vomiting, diarrhea
 Neck pain, rash, red eyes.
 Swollen hands, feats
 Swollen lymph nodes.
In this condition for better care they will shift to I.C.U. or special care in hospitals.
Prevention
As we all know prevention is always better than cure:-
 Wash hands
 Cover cough and sneezes.
 Avoid contact with other people those who are sick.
 Make sure kids get all recommended vaccinations like flue, measles etc.


Dr. Ravindra Singh Bhadhoria
M.B.B.S., D.C.H.
Secretary- IMACGP (U.P.)
E-mail: [email protected]

IMAGING IN COVID-19



DR.G.M.Vignesh Krishna.,MD.RD.,

Consultant Radiologist
Indian Scan, Chennai


INTRODUCTION TO COVID-19
 The official name of the illness is COVID-19 (a shortening of COronaVIrus Disease-

2019) and it is caused by the "severe acute respiratory syndrome coronavirus 2"

(SARS-CoV-2).
 WHO announced COVID-19 outbreak as a pandemic on 11 March 2020.
 As of October 2020, the number of confirmed case of COVID-19 globally is nearly 40

million affecting almost every territory and the number of deaths from COVID-19
exceeds 1.1 million globally.

 COVID-19 can either be symptomatic or asymptomatic. Symptoms can be systemic
and/or limited to respiratory system. Common symptoms are fever, anosmia, cough,

fatigue, sputum production and shortness of breath.
 Some also experience mild gastrointestinal or cardiovascular symptoms, although

these are less common.

RADIOLOGICAL FEATURES OF COVID-19

 Chest X-Rays are of less diagnostic value in initial stages, whereas CT findings may be
present even before the onset of symptom.

 Chest X-Ray may show diffuse bilateral coalescent opacities in the intermediate to

advanced stages of the disease.
 The characteristic patterns of COVID-19 on CT imaging are ground glass opacification
(GGO), airspace opacities, crazy paving pattern, vascular dilatation, traction

bronchiectasis and subpleural bands.
 The involvement is predominantly bilateral, peripheral distribution and multilobar

(more than one lobe).
 In majority of the affected patients, involvement of multiple lobes, particularly the

lower lobes with a peripheral or posterior distribution (or both) were reported.
 Bilateral lung involvement with a consolidative pattern is reported in patients with

moderate-severe symptoms and a predominantly ground-glass pattern is reported in
patients with mild symptoms.

Mild Moderate Severe


 Although chest CT has demonstrated high sensitivity along with RT-PCR testing for
COVID-19 diagnosis, it may not reveal distinct patterns for COVID-19 in all cases. This
can make it hard to distinguish COVID-19 from other causes of viral pneumonia.

For example, Influenza and COVID-19 both demonstrate GGO and consolidation on
chest CT.

 These imaging features also closely resemble those of MERS and SARS but bilateral
lung involvement on initial imaging is more likely to be seen with COVID-19.

 Pleural effusion, pleural thickening, pericardial effusion, lymphadenopathy,
cavitation, CT halo sign, and pneumothorax were less common.

 The severity of the lung involvement on the CT correlates with the severity of the
disease/symptoms.
 Visual assessment - the severity on CT can be estimated by gross visual assessment.

 Severity score - another method is by scoring the percentages of each of the five

lobes that is involved from 0-5. The total CT score is the sum of the individual lobar
scores and can range from 0 (no involvement) to 25 (maximum involvement). Another
variation of this scoring is based on individual segmental involvement (maximum 40).

 Few reports have however stated that in about 15% of individuals, initial imaging
might show normal findings, so a normal chest imaging does not exclude the

infection.
 In some cases with an initial false-negative reverse transcription polymerase chain

reaction (RT-PCR) screening test, CT findings have proven to be diagnostic.
 A combination of chest CT and repeat laboratory testing may be beneficial for COVID-

19 diagnosis in the setting of strong clinical suspicion, including individuals showing
typical clinical manifestations and those with a history of exposure.

Medicolegal Awareness In The Pandemic.
Dr. Dinesh Thakare,
8888129007; [email protected].
Member IMA HQs. SC For Legal Cell & Vice President IMA Maharashtra.

In Covid pandemic, you do not have the right to refuse the patient in an emergency.
In routine practice, each patient should be given a mask, sanitiser on hands and requested to keep a
physical distance of 2 meters. Keep distance while examining and wash your hands after each examination.
Look for flu-like symptoms. On suspicion of covid, refer to Covid hospital for testing.
If you are above the age of 55 years, you are exempted from treating patients having Covid like symptoms.
You are not allowed not to close your clinics without any written information sent and approved by the
authorities.
You should not consider yourself immune to litigation arising during a period of pandemic.
Though you are working in a difficult scenario, still don't skip any sort of documentation.

Following legal provisions are applicable....
Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002
1.9 Evasion of Legal Restrictions: The physician shall observe the laws of the country in regulating the
practice of medicine and shall also not assist others to evade such laws. He should be cooperative in
observance and enforcement of sanitary laws and regulations in the interest of public health. A physician
should observe the provisions of the State Acts like ……... and such other Acts, Rules, Regulations made by
the Central/State Governments or local Administrative Bodies or any other relevant Act relating to the
protection and promotion of public health.
2.1.2 Medical practitioner having any incapacity detrimental to the patient or which can affect his
performance vis-à-vis the patient is not permitted to practice his profession.
5.2 Public and Community Health: Physicians, especially those engaged in public health work, should
enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and
communicable diseases. At all times the physician should notify the constituted public health authorities of
every case of communicable disease under his care, in accordance with the laws, rules and regulations of
the health authorities. When an epidemic occurs a physician should not abandon his duty for fear of
contracting the disease himself
7.14 The registered medical practitioner shall not disclose the secrets of a patient that have been learnt in
the exercise of his / her profession except –i)in a court of law under orders of the Presiding Judge; ii)in
circumstances where there is a serious and identified risk to a specific person and / or community; and
iii)notifiable diseases. In case of communicable / notifiable diseases, concerned public health authorities
should be informed immediately.
The Epidemic Diseases Act, 1897
2(A). Powers of Central Government.—When the Central Government is satisfied that India or any part
thereof is visited by, or threatened with, an outbreak of any dangerous epidemic disease and that the
ordinary provisions of the law for the time being in force are insufficient to prevent the outbreak of such
disease or the spread thereof, the Central Government may take measures and prescribe regulations for
the inspection of any ship or vessel leaving or arriving at any port, in the territories to which this Act
extends, and for such detention thereof, or of any person intending to sail therein, or arriving thereby, as
may be necessary.
3. Penalty.—(1)Any person disobeying any regulation or order made under this Act shall be deemed to
have committed an offence punishable under Section 188 of the Indian Penal Code (45 of 1860).
(2)Whoever - (i)commits or abets the commission of an act of violence against a healthcare service
personnel; or (ii)abets or causes damage or loss to any property, shall be punished with imprisonment for

a term which shall not be less than three months, but which may extend to five years, and with fine,
which shall not be less than fifty thousand rupees, but which may extend to two lakh rupees.
(3)Whoever, while committing an act of violence against a healthcare service personnel, causes grievous
hurt as defined in section 320 of the Indian Penal Code to such person, shall be punished with
imprisonment for a term which shall not be less than six months, but which may extend to seven years
and with fine, which shall not be less than one lakh rupees, but which may extend to five lakh rupees.
4. Protection to persons acting under Act.—No suit or other legal proceeding shall lie against any person
for anything done or in good faith intended to be done under this act.
The Indian Penal Code 1860
IPC 188. Disobedience to order duly promulgated by public servant
-Whoever, knowing that, by an order promulgated by a public servant lawfully empowered to promulgate
such order, he is directed to abstain from a certain act, or to take certain order with certain property in his
possession or under his management, disobeys such direction, shall, if such disobedience causes or tends
to cause obstruction, annoyance or injury, or risk of obstruction, annoyance or injury, to any person
lawfully employed, be punished with simple imprisonment for a term which may extend to one month or
with fine which may extend to two hundred rupees, or with both; and if such disobedience causes or
trends to cause danger to human life, health or safety, or causes or tends to cause a riot or affray, shall be
punished with imprisonment of either description for a term which may extend to six months, or with
fine which may extend to one thousand rupees, or with both.
Explanation :-
It is not necessary that the offender should intend to produce harm or contemplate his disobedience as
likely to produce harm. It is sufficient, that he knows of the order which he disobeys, and that his
disobedience produces, or is likely to produce, harm.
IPC. 269. Negligent act likely to spread infection of disease dangerous to life.
-Whoever unlawfully or negligently does any act which is, and which he knows or has reason to believe to
be, likely to spread the infection of any disease dangerous to life, shall be punished with imprisonment of
either description for a term which may extend to six months, or with fine, or with both.
IPC. 270. Malignant act likely to spread infection of disease dangerous to life.
-Whoever malignantly does any act which is, and which he knows or has reason to believe to be, likely to
spread the infection of any disease dangerous to life, shall be punished with imprisonment of either
description for a term which may extend to two years, or with fine, or with both.

About tele consultation in short…
All registered medical practitioners intending to provide online consultation need to complete a mandatory
online course within 3 years of its notification.
Till that time, you can tele-consult, provided you follow the Telemedicine Practice Guidelines notified
under IMC Act, 1956.
The same ethical and professional standards should be practiced as in routine practice.
Do not opt for Telephonic Consultation, Telemedicine and Online Consultations, unless it can be proved
that it was the best option available in the given situation.
Ensure that proper security measures are in place to protect confidentiality of information shared with you
by the patient. Be very clear & well documented on that.
Maintain quality of instruments used. Keep back up.
Be available for follow-up procedures whenever necessary.
Maintain all records including how to identify the patient.
You may prescribe medicines via telemedicine ONLY when you are satisfied that you have gathered
adequate and relevant information about the patient’s medical condition and prescribed medicines are in
the best interest of the patient.
Patient consent is necessary for any telemedicine consultation. The consent can be Implied or explicit
depending on the following situations:

1.If the patient initiates the telemedicine consultation, then the consent is implied.
2.An Explicit patient consent is needed if: A Health worker, RMP or a Caregiver initiates a
Telemedicine consultation.
3.An Explicit consent can be recorded in any form. The patient can send an email, text or
audio/video message.
If a Medical condition requires a particular protocol to diagnose and prescribe as in a case of in-person
consult then the same prevailing principle will be applicable to a telemedicine consult .
You cannot prescribe medicines that have a high potential of abuse and could harm the patient or the
society at large if used improperly like medicines listed in Schedule X of Drug and Cosmetic Act and Rules
or any Narcotic and Psychotropic substance listed in the Narcotic Drugs and Psychotropic Substances, Act,
1985
Emergency consultations should be limited to directing the patient or caregiver to the appropriate site for
physical care and advice about first aid until reaching such a site.
Prescriptions should be provided in a standard format.
Medications are grouped as per the mode of consultation, feasibility and safety of telemedicine.
List O includes drugs which are available over the counter such as paracetamol, oral rehydration
solutions, etc. They may be advised by any mode of consultation.
List A includes drugs that can be prescribed only after video consultation such as eye drops for
conjunctivitis.
List B comprises of those drugs that are prescribed for the same condition as add-ons (Eg:
ondansetron for severe nausea in pregnancy which is not relieved by first line agents like doxylamine).
You have to maintain the following records/ documents for the period as prescribed from time to time:
-Log or record of Telemedicine interaction (e.g. Phone logs, email records, chat/ text record, video
interaction logs etc.).
-Patient records, reports, documents, images, diagnostics, data etc. (Digital or non-Digital) utilized
in the telemedicine consultation should be retained by you.
-Specifically, in case a prescription is shared with the patient, you are required to maintain the
prescription records as required for in-person consultations

References :- 1)Inputs from Dr.T.N.Ravisankar, Chairman, IMA HQs. SC for Legal Cell.
2)PPT presentation by Dr.Neelima Ardak-Thakare on telemedicine.
3)IMA Guidelines On Telemedicine

UPDATE ANSWERING THE QUIZ




1. HbA1c measurement may be affected by all the following EXCEPT

a) Iron deficiency anaemia

b) Haemolytic anaemia

c) Insulin administration prior to the test

d) Sickle cell anaemia

e) Massive haemorrhage
2. Regarding calcium channel blockers, all are true except..

a) LV Function should be assessed periodically.

b) Diltiazm is contra indicated in LV Dysfunction.

c) Better to combine DHP CCB with Beta blockers

d) Short acting Nifidipine is good in emergencies.


3. The differential diagnosis of fever with thrombocytopenia include all the following
except
a) Septicemia with DIC
b) Dengue
c) Bacterial endocarditic
d) Scrub Typhus
e) Leptospirosis

4. Which of the following viral infections can cause cirrhosis?

a) Hepatitis A
b) Hepatitis B
c) Hepatitis C
d) Hepatitis E


5. Acute Viral Hepatitis E is diagnosed by which of the following?
a) Anti HEV IgG
b) Anti HBcTotal
c) Anti HBs
d) Anti HEV IgM

6. What are tests to be sent when a HBsAg positive person comes with jaundice?
a) HBV DNA viral load
b) Anti Hbc Total
c) Anti HBc IgM
d) HBeAg
e) Anti HEV IgM


7. Which of the following tests indicate acute viral hepatitis B?

a) HBV DNA viral load
b) Anti Hbc Total
c) Anti HBc IgM
d) HBeAg
e) Anti HEV IgM


8. 40 /m ,Asymptomatic ,comes with a positive AntiHBS result? What are the
possibilities?

a) Vaccinated for Hepatitis B
b) Cleared previous infection with HBsAg in the past
c) Active infection with Hepatitis B

ECG 1


“ ECG of concealment”


This is the routine ECG of 84-year-old female.













































1.Describe all ECG changes

2.Why is this clue?


3.What are practical implications?




ECG CHANGES:


This ECG shows normal sinus rhythm, Right Bundle Branch Block

(RBBB) with Left Atrial Fascicular Block (LAFB) with upper limit of PR
interval. There are no typical secondary ST T changes of RBBB, and

they are replaced by primary horizontal ST segment and symmetrical

T inversion.

THE CLUE:


1. The V1 shows evidence of RBBB. But the RBBB is not typical.

The initial R in V1 is tall and Broad and almost equal to Terminal

R wave. The secondary ST T changes are replaced by primary ST

T changes. In uncomplicated RBBB this initial r wave is small
and sharp because it is due to septal activation occurring from

left to right. This initial R wave is tall and broad if it is

accompanied by Posterior Wall MI (PWMI). It is often difficult

to diagnose PWMI in the presence of RBBB as both of these

conditions produce Tall R in V1. The following points may help;
in uncomplicated PWMI there is tall R in V1 without QRS

widening. In uncomplicated RBBB, QRS is wide and initial r is

small and sharp. When both RBBB and PWMI coexist, there is

significant change in initial R wave in V1 which becomes Tall

and broad and secondary ST changes disappear (Fig 66A).
This is the first concealment of PWMI by RBBB, in this ECG.
















Fig. 66A


2.Now we shift our focus to limb leads. In RBBB, these is terminal S in
Lead I due to the terminal vector going towards right and away from

Lead I. But here there is no terminal S wave in this ECG and because
of widening of QRS, L I looks like LBBB. So here RBBB in chest leads

Masquerades as LBBB in limb leads due to absence of terminal S,

which is due to the dominant LAFB where terminal vector is going to
superior and left. So, this Masquerading Bundle Branch Block

(MBBB). Here RBBB is concealed in limb leads by dominant LAFB. So

this is second concealment.


3.The LAFB is also not typical here. The uncomplicated LAFB, shows
initial sharp r wave in L II, L III, avF due to the initial vector coming

towards inferior leads and terminal S wave due to dominant terminal

vectors which is going up and left,away from inferior leads.But in
IWMI there is initial Q. So,there is difficulty in diagnosing IWMI in the

presence of LAFB and vice versa. In this ECG, the initial r in inferior

leads is replaced by slurring of initial portion of QRS which is called
initial incident (Fig 66B). This occurs because of associated IWMI

involving only anterior portion of inferior wall (This is already
discussed). So here IWMI is concealed by LAFB. This is the third

concealment.




















Fig. 66B




4.In anterior chest leads, the ST T changes are not typical of
secondary changes because the ST segment is horizontal and

there is symmetrical T inversion. So it is likely these ST T changes

are most often mistaken for secondary ST T changes due to RBBB
and IHD may be missed. So here RBBB is concealing IHD. This is

fourth concealment.

As this ECG has all these features, the clue is given as “ECG of

Concealment”

PRACTICAL IMPLICATION:

So, if one is not familiar with above changes, inferior wall and

posterior wall infarction are likely to be missed and not treated. In

addition, MBBB usually has poor prognosis as it is most often
accompanied by LV dysfunction and further advanced conduction

system disorders, especially when associated with upper limit of

PR interval.

ECG 2


“Similar but not Same yet Saves Spending”


ECG of 60 y female; Guess her complaints apart from ECG

interpretation.

1.Describe ECG changes


1. Why is this clue and what is the complaint?

2. What are practical implications?
ECG CHANGES


ECG shows basic bradycardia with right bundle branch block (RBBB) with qR
pattern and Left Anterior Fascicular Block (LAFB). PR interval is normal and

fixed. There is Atrio Ventricular association. There seems to be ‘P’ in the ST
segment of all beats. There is horizontal ST with splayed deep T inversion, the

QTc is prolonged. The presence of S wave in V1 indicates RBBB is dominant.
The absence of initial r in V1 and initial q in V5,V6 suggest probable old septal
MI.


CLUES AND COMPLAINTS:


“Similar but not same” :


1. The regular P wave in ST segment in all beats looks similar to 2:1 AV
Block. So, in the presence of bifascicular block (RBBB+LAFB) it looks
similar to Trifascicular block. But, P wave in ST segment(P’) looks

different from sinus P especially in V2 (Fig.67A). In addition to this, sinus
P to P’ interval is shorter than P’ to sinus P interval indicating the P in ST

segment (P’) is premature. As the p wave in ST segment (P’)has different
configuration and prematurity, it is likely to be Atrial Premature

Depolarisation (APD) in bigeminy) rather than blocked sinus P. So, this P-
P’ sequence is similar to 2:1 AVB but not the same.

Fig 67 A: The P in ST segment (P’) is different from the previous P and P-
P’ interval is short in this expanded V2.


2. The deep T inversion is similar to ischemic deep inversion (Flat ST,

symmetrical T inversion). But here T wave inversion broad and splayed
with prolonged QTc. In the presence of conduction disturbance

(Bifascicular block), there deep broad T inversion indicates recent stokes
Adam Attack which is called “Stoffwechsel syndrome”. So here T

inversion is similar to CAD but not same.
3. The qR in V1 is similar to RVH and RAE. But here the QRS is wide and it is

accompanied by loss of initial q in V5V6. There is no right axis deviation.
So qR pattern in RBBB is due to loss of initial septal q due to old ASMI.

The qR in V1 is similar to RVH, RAE but not the same.
4. In the presence of bi or trifascicular block, the broad splayed T inversion
with prolonged QTc indicates recent SA attack. So, this patient needs

early permanent pacemaker implantation with this ECG itself without
undergoing any costly investigation such as EP studies. So, this ECG has

saved the spending of the patient.
5. The complaint is likely to be syncopal attack because of these typical T

changes.
Because of these findings, the clue of “Similar but not Same yet Saves

Spending” is given.

PRACTICAL IMPLICATION


The immediate Permanent Pacemaker Implantation is needed in this patient,

from this ECG itself. If the APD is misdiagnosed as 2:1 AV Block, administration
of cardiac stimulants will further aggravate atrial arrhythmias. If the T wave
inversion is misdiagnosed as CAD, the investigations and management will be

going in a completely wrong direction.

ANSWERS TO QUIZ





1. Insulin administration prior to the test

2. Short acting Nifidipine is good in emergencies.

3. Bacterial endocarditic

4. Hepatitis B and C


5. Anti HEV IgM

6. All of the above

7. Anti HBc IgM

8. 1&2