Best Cases of Curofy 2

Rare, complicated and intriguing cases

come across the career of a doctor not more than
once in a lifetime. These cases are often the
stepping stone of learning and evolution in
medicine and healthcare.

These interesting cases broaden the

perspectives of a doctor not just in medicine
but in overall patient healthcare.

Curofy, brings to you a concise compilation of

such top cases in the field of ECG
contributed by various doctors across the country.
Best Cases of Curofy 3

Case 1:
45 yr old make patient presenting with palpitations and dizziness to
ED, What does the ECG show?
Dr. Shivaji Mallampati
Top Emergency Medicine Practitioner of September

Best Helpful Answer

This ECG shows a regular broad complex tachycardia with an RSR pattern in
V1. The differential diagnosis could include: Ventricular tachycardia. SVT with
aberrant conduction either due to RBBB or WPW. On closer inspection, the
ECG demonstrates some classic features of ventricular tachycardia: Northwest
axis QRS is positive in aVR, negative in I and aVF. The taller left rabbit ear sign
There is an atypical RBBB pattern in V1, where the left rabbit ear is taller than
the right. Negative QRS complex (R/S ratio < 1) in V6. These findings indicate
VT rather than SVT with aberrancy. Taller left rabbit ear Taller left rabbit ear =
VT RBBB typical morphology Taller right rabbit ear = RBBB Clinical Pearls Other
factors that increase the likelihood of VT in patients presenting with regular
broad complex tachycardia include: Age > 35 (positive predictive value of 85%).
Structural heart disease e.g. IHD, CCF, cardiomyopathy. Family history of
sudden cardiac death or arrhythmogenic conditions such as HOCM, Brugada
syndrome or ARVC that are associated with episodes of VT. In any patient with
a broad complex rhythm, also consider the possibility of toxic / metabolic
conditions such as hyperkalaemia or sodium-channel blockade.
- Dr. Shivaji Mallampati

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Best Cases of Curofy 4

Case 2:
68 y/o man comes in feeling weak and describes pre-syncope
episodes for the past week. ECG attached. Takes metoprolol but was
not taking for several days due to not feeling well. Echo: normal LV
function with significant calcifications of the mitral annulus and aortic
valve. Your diagnosis and management?
Dr. Manish Malhotra
Cardiology

Best Helpful Answer

Tpm followed by ppm. stop metoprolol meanwhile. has severe mac

and sclrotic mitral vakve. has a high chance of conduction tissue
disease. ecg shows mobitz type 2. cad also needs to be ruled out for
confirmation of sclerodegerative disease. angiography before or
after ppm
- Dr. Amit Gulati

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Best Cases of Curofy 5

Case 3:
20 year old male brought by his roommates with history of two
episodes of seizures since 30min prior to arrival to ED, on arrival
patient was in altered sensorium with HR of 130/min . BP 80/50 .RR
26/min,spo2 92%in RA,, CNS, GCS E2v3M5, pupils dilated but reacting
to light, RS conducted sounds present, rest of systemic exam was
normal, Describe the ECG and management
Dr. Shivaji Mallampati
Top Emergency Medicine Practitioner of September

Best Helpful Answers

This looks like a tough one ecg shows wide qrs tachycardia with rate
around 130-140 bpm, lbbb morphology with discordant axis, right
axis deviation I can see a slur on the downslope of t wave favouring
sinus tachycardia there is tall R wave in lead avr lbbb morphology
with right axis is very rare and patient has presented with seizures
possibility TCA toxicity needs to be ruled out because of tall R in AVR
what is the potassium of this patient.
- Dr. Shafiq Zargar
Best Cases of Curofy 6

Main Abnormalities in ECG Broad complex tachycardia, rate ~ 130

bpm. The rhythm is likely sinus tachycardia with a 1st degree AV
block note the camel hump appearance to the T waves indicating a
hidden P wave. Interventricular conduction delay (QRS duration >
100ms, not typical LBBB / RBBB morphology) Right axis deviation.
Secondary R wave in aVR > 3 mm. Diagnosis In the context of a
patient presenting with seizures and hypotension, the combination
of QRS broadening > 100 ms R wave in aVR > 3 mm is highly
suggestive of poisoning with a sodium-channel blocking agent e.g.
tricyclic antidepressant. The sinus tachycardia may be due to the
anticholinergic effects of the TCA. Clinical Pearls : In the context of
sodium channel blockade: A QRS duration > 100 ms is predictive of
seizures. A QRS duration > 160 ms is predictive of cardiotoxicity. This
patient is already manifesting life-threatening toxicity and needs
aggressive resuscitation, including: Serum alkalinisation with
NaHCO3 to reverse pH-dependent toxicity. Intubation and
hyperventilation aiming for alkaline arterial pH (e.g. 7.45 to 7.55).
Seizure management with benzodiazepines. BP management with
fluid boluses +/- pressors.
- Dr. Shivaji Mallampati

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Best Cases of Curofy 7

Case 4:
A 55yrs.lady having normal preop investigations underwent cholecystectomy
under spinal anaesthesia . After about 20hrs. she became drowsy & disoriented.
Vitals were normal.Pt. has passed only 75ml. urine in last 4 hrs. investigation: tlc-
16000, BL urea -32,s.creatinine-1.2, BL.sugar-408(preop-102, no h/0 DM). ECG
enclosed. Comments for management invited
Dr. Manish Malhotra
Cardiology

Best Helpful Answer

looks like she is landing into multi organ failure.now patient is in altered
sensorium. Renal tests are normal at present , repeat it again as urine output
gas reduced. there is hyperglycemia also it can also cause altered mental
status.you have not mentioned electrolytes , pls look for
hypercalcarmia,hypo/hypernatraemia.do one ABG , for
hypoxia/hypercapnia.TLC raised indicating sepsis.ECG showing STD in
precordial & inferior leads.do cardiac enzymes. see if hyperkalaemia is there.
All routine investigation including RFT,LFT,thyroid profile,echo. if possible CT
brain to r/o any brain pathology. Treat with higher antibiotics , control Sugar
with insulin(~180). correct hypoxia/hypercapnia if there.any serum electrolyte
imbalance, thyroid abnormality(unlikely).depending upon the investigations
,determine further course of management.if cardiac enzymes positive start on
iv heparin or LMWH( will also take care of DVT/PTE risk).
- Dr. Jairam Patil
Top Emergency Medicine Practitioner of September

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Best Cases of Curofy 8

Case 5:
68 y/o man comes in feeling weak and describes pre-syncope
episodes for the past week. ECG attached. Takes metoprolol but was
not taking for several days due to not feeling well. Echo: normal LV
function with significant calcifications of the mitral annulus and aortic
valve. Your diagnosis and management?
Dr. Shivaji Mallampati
Top Emergency Medicine Practitioner of September
Best Cases of Curofy 9

Best Helpful Answer

The patient presented with acute pulmonary edema This ECG demonstrates
the classical pattern of left main coronary artery (LMCA) occlusion:
Widespread horizontal ST depression, most prominent in leads I, II, avl, avf,
and V2-6 ST elevation in aVR 1mm ST elevation in aVR V1 However, ST
elevation in aVR is not entirely specific to LMCA occlusion. It may also be seen
with: Proximal left anterior descending artery (LAD) occlusion Severe triple-
vessel disease (3VD) Diffuse subendocardial ischaemia e.g. due to O2
supply/demand mismatch, following resuscitation from cardiac arrest Some
authors argue that using the term LMCA occlusion is inaccurate, as most of
these patients have at least some flow in their LMCA (i.e. incomplete LMCA
occlusion); whereas a complete LMCA occlusion would rapidly lead to STEMI,
cardiogenic shock and death. Lead aVR is electrically opposite to the left-sided
leads I, II, aVL and V4-6; therefore ST depression in these leads will produce
reciprocal ST elevation in aVR. Lead aVR also directly records electrical activity
from the right upper portion of the heart, including the right ventricular
outflow tract and the basal portion of the interventricular septum. Infarction
in this area could theoretically produce ST elevation in aVR. ST elevation is aVR
is therefore postulated to result from two possible mechanisms: Diffuse
subendocardial ischaemia, with ST depression in the lateral leads producing
reciprocal change n aVR (= most likely). Infarction of the basal septum, i.e. a
STEMI involving aVR. The basal septum is supplied by the first septal perforator
artery (a very proximal branch of the LAD), so ischaemia / infarction of the
basal septum would imply involvement of the proximal LAD or LMCA. In the
context of widespread ST depression + symptoms of myocardial ischaemia: STE
in aVR 1mm indicates proximal LAD / LMCA occlusion or severe 3VD STE in aVR
1mm predicts the need for CABG STE in aVR V1 differentiates LMCA from
proximal LAD occlusion Absence of ST elevation in aVR almost entirely excludes
a significant LMCA lesion In the context of anterior STEMI: STE in aVR 1mm is
highly specific for LAD occlusion proximal to the first septal branch In patients
undergoing exercise stress testing: STE of 1mm in aVR during exercise stress
testing predicts LMCA or ostial LAD stenosis Magnitude of ST elevation in aVR
is correlated with mortality in patients with acute coronary syndromes: STE in
aVR 0.5mm was associated with a 4-fold increase in mortality STE in aVR 1mm
was associated with a 6- to 7-fold increase in mortality STE in aVR 1.5mm has
been associated with mortalities ranging from 20-75%
- Dr. Shivaji Mallampati
Top Emergency Medicine Practitioner of September

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Best Cases of Curofy 10

Case 6:
A 62 years k/c DMT2 old chronic bidi smoker male patient admitted with c/o
diffiulty in breating , cough,coryza since last 2 days. Also having sever
constipation since past 5 days. o/e BP 110/70, PR-78,RR-20 SPO2-92% ON
R.A LUNGS- left side AE decreased with B/l fine corse crepts rest systems
are WNL LAB INV'N serum K level 2.0 rest CBC & Biochen was WNL 2 DAY
OF ADMKSSÌON PATIENT DEVELOPED HORSENESS OF VOICE further
s.electrolyte shows K level 1.7 ENT specilest opinion taken S/O partial left
vocal cord palsy and advice oral steroids . K suplimented but horseness
does not improved . so what next ????
Dr. Javed Khan
Emergency Medicine

Best Helpful Answer

Left hilar lymphnodes are enlarged...look for..?Ca lung. ECG shows st

depression in almost all leads..persistance of S in V5, 6 ...global Ihd
with Rvh
- Dr. Sharad Pore
Top Cardiologist of September
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Best Cases of Curofy 11

Case 7:
20 year old male brought by his roommates with history of two
episodes of seizures since 30min prior to arrival to ED, on arrival
patient was in altered sensorium with HR of 130/min . BP 80/50 .RR
26/min,spo2 92%in RA,, CNS, GCS E2v3M5, pupils dilated but reacting
to light, RS conducted sounds present, rest of systemic exam was
normal, Describe the ECG and management
Dr. Praveen Kumar
Emergency Medicine

Best Helpful Answers

Ecg shows sinus Bradycardia with left axis and LVH with sec st /t wave
changes
- Dr. Shafiq Zargar
Top Cardiologist of September
Best Cases of Curofy 12

Ecg shows sinus bradycardia, Left axis deviation Marginal Left

ventricular hypertrophy, old inferolateral ischaemia. The cause of
above Ecg finding is hypertension with old inferolateral ischaemia of
long duration. The cause of leg cellulitis is severe infection, it is not
related at all with ischaemic changes.There is no changes seen of
hypokalemia in Ecg.The infection of leg cellulitis may be caused by
MRSA or other organism.Antibiotic,antiinflamatary and b complex is
treatment. CBC ,URINE examination complete, Serum plasma
glucose, Serum TSH.Serum electrolytes and blood culture should be
done.
- Dr. MR Chhipa

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Best Cases of Curofy 13

Case 8:
70years male c/o chest discomfort HR:148/min BP:110/80
Pulse:palpable but not able to count as rate is his,low volume
Previously had gone for stains 8years back they missed those files
Know case of DMtype2, hypothyroidism Currently now on:metoprolol
50 Amiodarone 100 Ecosprin gold 20 Cardace 2.5 Thyrox 25
Rabeprazole 20 Pregabalin(75)+methyl cobalamin (1500) Tab zoryl
m2forte Dx and rx ??
Dr. Pankaj Garg
General Practice

Best Helpful Answer

ecg s/o SVT mostly AVNRT with HR around 150/min ..... Treat with IV
Diltiazem or IV verapamil in this case.... After conversion to sinus
rhythm, analyse the ecg for short pr or any other st-t changes
- Dr. Sandeep Pemira

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Best Cases of Curofy 14

Case 9:
80 yr old female presented with syncope...Haemodynamically
stable....non HTN and non diabetic...k 3.1 mg 1.6
Dr. Sandeep Pemira
Internal Medicine

Best Helpful Answer

old age pt syncope. haemodynamically stable. . ecg shows giant t

wave inversion in antero lateral leads. ? complete heart block. DD .
1.CVA.LARGE INFARCT OR ICH 2. HCM 3. hypokalemia. 4.CHB. 5.
NSTEMI RARE POSSIBLITY. .
- Dr. Suresh Narayanan

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Best Cases of Curofy 15

Case 10:
Identify the typical ECG pattern in a 35 y/o male with c/o palpitations
and h/o syncope
Dr. Manish Malhotra
Cardiology

Best Helpful Answer

progressive increase in PR interval followed by dropped qrs complex

and p wave not conducted. . Second degree heart block. . MOBITZ
TYPE 1..wenchebach phenomenon. . USUALLY self resolving. . Wait
and watch. .zzzzzz
- Dr. Suresh Narayanan

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Best Cases of Curofy 16

Case 11:
60yr male Patient came with complaint of chest pain, exertion, profuse
sweating. Patient is Hypertensive and taking telmisartan as
antihypertensive. What are the findings in ECG. What is the diagnosis
and what will be further treatment plan.
Dr. Aashish Madhar
Undergraduate Student

Best Helpful Answers

J point raised in leads v2 v3v4 it can be taken as acute coronary

insufficieny so admit the pt in ICU for observation Bed rest O2 tab
sulingual sorbitrate Asprin tab Metaprolol 25 mg Bd Cardace 1,25 mg
Bd & sedative continued monitering cardiac enzyme study repeat
ECG after 24 hrs or sos
- Dr. Jaiprakash Lalwani

this is ecg does not look typical ST elevation MI . blood pressure is

not mentioned. at present give supportive Rx . watch for cardiac bio
markers and renal function and electrolytes .. and serial ecg at 1 and
2 HR to watch for ST changes
- Dr. Ravi Thakkar

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Best Cases of Curofy 17

Case 12:
68Yrs Male with Typical chest pain Undergone TURP 25 days back H/o
suffering from Dengue fever with sevre thrombocytopenia last yr.
Platelets on follow- up < 1.5lac. Trop Positive; Platelets 1.64 lacs Pt.is
nondiabetic / non- hypertensive No major bleeding during TURP But
Urine showing plenty of RBCs How to tackle???
Dr. Hameed Chaudhari
Emergency Medicine

Best Helpful Answer

Very intresting ecg Following findings wide qrs with lbbb morphology
St elevation seen in V1 to V5 and avl AV dissociation seen
Interestingly sinus rate appears low I think hyperkalemia has been
ruled out I think the only diagnosis I currently could think of is AIVR
With likely cause Awmi
- Dr. Shafiq Zargar
Top Cardiologist of September

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Best Cases of Curofy 18

Case 13:
55 yrs old hindu male patient working as a security guard started
feeling breathless at rest while on duty in afternoon. Known case of
DM with HTN with no h/o Ischaemic Heart Disease. No h/o Fever or
Cough. O/E - BP - 90/40 mm of Hg, Pulse - 150+ bpm SpO2 - 94 % on
room Air Chest - bilat Crepts + Hb - 12.5 TLC - 23000/cumm Plt -
2.76L/cumm Sr. Creat - 1.6 Electrolytes - WNL
Dr. Ajitkumar Yadav
Emergency Medicine

Best Helpful Answer

probably pt is in cardiogenic shock, chek peripheral pulse, temp if cold,

clinicaly coconfirm shock, it is unstable VT, if bp is 90/40 probably VT with
pulse, inj amiodatone 150 stat. satrt NIv, lasix 20 mg, after amiodaron no
responce as per ACLS protocol Broadcomplex tachy DC shock but give
fentanil 50 mg n then only shock the pt. call for cardiologist, plan for
PAMI, send serum K, loding dose of antiplatlets
- Dr. Gautam Kulkarni

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Best Cases of Curofy 19

Case 14:
71 y/o male with CKD presented with palpitations. ECG image
attached. His serum K was 5.6 on admission and urea - 78 and s creat
- 1.9. What are your views about the case
Dr. Diksha Bhardwaj
Emergency Medicine

Best Helpful Answer

in my experience i have seen hyperkalemia induced Vt mostly 7 n above,

but any way recheck k it may behigher any way, fastest way ti decrease k
is dialysis, 2nd GI drip, k bind (k binding resins), b2 agonist is last n
slowest, in this case i will start with if vt with pulse amiodarone 150 mg
stat, blood sugar check GI drip 50% dex with 8 units actrapid, or u can
start insuline drip if pt is diabetic, k bind sacchet 30g TDS, check K 30 min
apart keep ready bed side defibrillator, simultaneously send trop I and
cpk MB not ti miss ischemia induced VT, keep dialysis cannula ready ,.find
out casue for hyperkalemia most common pottasium spering diuretics
,ace inhibitor, end stage CKD
- Dr. Gautam Kulkarni

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Best Cases of Curofy 20

Case 15:
Diagnosis and management of ECG
Dr. Hemanth Harish Ponnana
Internal Medicine

Best Helpful Answer

Looks like SVT Revert with adenosine In view of very fast rate, high
suspicion of AVRT Needs to compare it with NSR ecg
- Dr. Shafiq Zargar
Top Cardiologist of September

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Best Cases of Curofy 21

Case 16:
18 yo male with history of mitral rheumatic heart disease. Is it an
junctional rhytm with quadrigeminy PVC or an idioventricular rhythm?
How can we differentiate it?
Dr. Diksha Bhardwaj
Emergency Medicine

Best Helpful Answer

This is atrial fibrillation.The rhythm is irregular and P waves are

completely absent.In both junctional and idioventricular rhythm P
waves will be present but they will not maintain synchronicity with
the QRS complexes.Physiologically both idioventricular and
junctional rhythm are essentially the same,the difference is only in
the nomenclature and the place of origin.An junctional rhythm
occurs from very high up near the AV node and QRS is narrow.As the
origin moves down the QRS widens and when the impulse originated
from the ventricular wall it is known as idioventricular rhythm.
- Dr. Nabarun Guha

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Best Cases of Curofy 22

Case 17:
A 21 year old man in the Emergency Department complaining of chest
pain of 2 days duration, worse on deep inspiration. Whats the
diagnosis?
Dr. Satyam Mohan
Top Emergency Medicine Practitioner of September

Best Helpful Answer

Hyperkalemia
- Dr. Bharat Pamnani

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Best Cases of Curofy 23

Case 18:
Plse diagnose case and advice treatment needed..55 yr female pt
chest pain non diabetic non htn
Dr. V S S
General Practice

Best Helpful Answers

S.tachycrdia S1Q3T3 T wave inversion in v1, v2 Persistent S wave in

v6 Although criteria is not very specific for P.E but can be used as a D
/ D Need serial ecg & more evaluation
- Dr. Iliyas Sheikh

sinus rythm, normal axis, No significant ST-T changes except q in III

(isolated q in III not very significant , may seen in normal person too)
Approach - If ongoing typical Angina - TnT if TnT positive than treat
like NSTEMI , CAG sos Revascularization may require if TnT negative
than TMT to rule out inducible ischemia
- Dr. Ankur Thummar

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Best Cases of Curofy 24

Case 19:
A 47/f presented with syncope. what is the diagnosis?
Dr. Rini Thakur
General Practice

Best Helpful Answer

First Ecg s/o Prolonged QTC which as precipitated in to NON

SUSTAINED POLYMORPHIC VT most probably Torsades de pointes as
their is prolonged Qtc is documented (second Qrs complex in long
lead 2), appearing in second Ecg. Some R on T Ventricular
extrasystoles are also appearing in second Ecg. So, may be LONG QT
SYNDROME and also check out electrolytes like K,Mg,Ca If
electrolytes are normal, start the patient with Betablockers like
Bisoprolol. Corrected Qtc in 1st ecg is almost 470 msec and is
significant in females to call it as Long QT syndrome.
- Dr. Sandeep Pemira

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Best Cases of Curofy 25

Case 20:
50 yrs old female repeated episode of palpitations and sob no no no
dm no CAD comment ECG and treatment
Dr. Ramesh Kumbhkar
Cardiology

Best Helpful Answer

It's a regular narrow Qrs tachycardia with alternation of voltage of Qrs complexes. The
apparent st depression in many leads are intact P waves. The negative P waves in lead I
suggest atrial activation occurring from left to right since Lead I records difference in
potential between left and right arm. This suggest that either it's a left atrial tachycardia or
AVRT with retrograde conduction over a left sided accessory pathway. AVRT is much more
common and is hence the likely mechanism. QRS alternans was earlier thought to be
suggestive of AVRT but now we know that it is because of fast rare and has nothing to do
with tachycardia mechanism. The acute treatment of avnrt and AVRT is same - vagal
maneuver, adenosine or iv beta blocker/ diltiazem The ECG during sinus rhythm after
terminating SVT may or may not show ventricular preexcitation. About 50% of accessory
pathways conduct both antegradely and retrogradely whereas other 50% are concealed and
conduct only retrogradely

- Dr. Kartikeya Bhargava

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Best Cases of Curofy 26

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