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* What is the best initial diagnostic test for her? Answer is ECG. Why not pH
monitor or upper endoscopy? To rule out the most dangerous thing first.
* Which of the following is the most accurate test for her? Well then it might be
pH monitor or upper endoscopy.
* 47yo woman now suddenly remember she has had diabetes since she was a
child and has been taking insulin for 30 years. She also remembers hypertension
and hyperlipidemia with low HDL. She forgot to mention she smoked three packs
of cigarettes a day. Oh yea also most of her family members had heart attacks in
the 40s and she is a high-stress type A person. Now, what is the most likely
diagnosis in this patient? Answer is ischemic heart disease.
* Correcting which of the risk factors will improve her long term survival? Answer
is correcting all of them. Correcting which of the results in the most immediate
improvement in outcome? Tobacco smoking. But what kind of question is that,
its not like a managed care plan would only allow for you to correct a single
problem so you would need to choose the best one to correct. In real life you try
to fix all of the risk factors.
* What is the most common risk factor for coronary disease and myocardial
infarction? Hypertension. What is the most common cause of hemoptysis?
Bronchitis. Not TB, mitral stenosis, cancer, Wegener, Goodpasture, etc. What is
the most common cause of atrial fibrillation in the United States? Hypertension.
* Smoking related deaths are about 2/3 COPD and 1/3 lung cancer.
* In real life, you can have an MI with no chest pain and with a normal ECG. But
for a board exam, if they want you
to know an answer they have to tell you something. Otherwise no one can know
the answer. 4% of the time
myocardial infarction pain is pleuritic. For boards, that is too small a chance so if
a patient has pleuritic pain on a
board exam question it is not an MI.
* Pleuritic chest pain (worse with respiration) causes include viral pleurisy (i.e.
pleurodynia, Devils grip, Bornholm
disease), pneumothorax, pneumonia, pericarditis, pulmonary embolism. They all
start with Ps.
* Pneumothorax and pulmonary embolism are different from the other pleuritic
chest pain in that they are associated
predominantly with shortness of breath. Patient complains of not being able to
breath, with a little chest pain.
Myocardial infarction patient complains of crushing chest pain, with a little
shortness of breath.
* Myocardial infarction chest pain changes with position 4% of the time. Most of
the time, it is not positional.
Pericarditis chest pain is positional, better when leaning forward or worse with
leaning back.
* Chest wall is non-tender in myocardial infarction. Chest wall is tender in
costochondritis (Tietze syndrome).
* Anything that can give pleuritic pain can simulate shortness of breath. The
patient is splitting and does not want to
take a deep inspiration.
* Fever is not specific enough to differentiate between causes of chest pain.
Fever seen in infections and
inflammation like pneumonia and pleuritis as well as others like MI, PE,
pneumothorax (any form of atelectasis).
* Any clot or collection of blood can give fever; like DVT clot, MI clot,
hemarthrosis in the knee, subdural
hemorrhage, subarachnoid hemorrhage, ruptured ectopic pregnancy.
- 92 -
* 47yo woman with chest pain being treated and LDL is 191. What do you do
next? Answer is statins, not
cholestyramine, niacin, or fibric acid derivatives. Statins are first. All of those
drugs lower total cholesterol and all
raise HDL. All lower triglycerides as well. Statins are first because they lower
mortality.
* Which raises HDL the most? Niacin. Which lowers triglycerides the most? Fibric
acids like gemfibrozil.
* 47yo woman with positive stress test but no risk factors and LDL is 171?
Answer is statins. 141? Statins. What is
most important, risk factors or individual presentation? Again, individual
presentation. She has disease. Once you
have disease, it does not matter how many risk factors you have.
* Diet and exercise only prevent the disease. So when disease is present, diet
and exercise is not primary treatment.
* Risk factors <=1, start diet at 160 LDL and drugs at 190 LDL.
* Risk factors >=2, start diet at 130 LDL and drugs at 160 LDL.
* Disease, start diet at 100 LDL and drugs at 130, get LDL < 100.
* Patient with coronary artery disease (or MI, angina, unstable angina) who has
LDL > 130, start statin.
CABG & PCI
* 47yo woman with positive stress test, why do angiography? To determine if she
needs a coronary artery bypass
graft (CABG) or percutaneous coronary intervention (PCI) with medications.
* For every 100 people who undergo CABG, 1 person dies; Surgical mortality is
1%, which seems small when it is
someone elses mortality. Its better to be alive with chest pain.
* Bypass if severe disease, meaning 3 vessel disease or left main affected.
* PCI (angioplasty, stenting) if 1 or 2 vessel disease.
* This is why you hear he had triple bypass or she had quadruple bypass or
David Letterman had quintuple
bypass. You do not hear yea, he had single bypass.
* CABG is not done for single or double vessel disease because there is no
benefit in mortality. Let the mortality
difference drive you.
Unstable Angina & Myocardial Infarction Management
* How can you tell now to give heparin or thrombolytics? Answer is ST elevation
or not.
* If ST segment elevation present, give thrombolytics. If no ST segment
elevation, give heparin.
the CK-MB is up with ST segment elevation, you will still give aspirin, beta
blockers, thrombolytics. If CK-MB not
up, maybe it is just not up yet since they begin to rise at 4-6 hours and take 1224 hours to reach peak.
* Also, thrombolytics can be given up to 12 hours from the onset of chest pain (3
hours for stroke).
* CK-MB last 1-2 days, troponins last 1-2 weeks. CK-MB (97-99%) is specific, but
troponins are even more specific
(99.9%). Troponin I is the most sensitive and specific. Uterus can still make a
little CK-MB but no troponins.
* LDH is no longer used in the diagnosis of myocardial infarction. LDH is not
abnormal from 12-24 hours.
* When a patient comes in with chest pain and ECG abnormalities, do not wait
around for enzyme changes. The
mortality benefit with thrombolytics is enormous in the first 1-2 hours, up to a
50% reduction in mortality within the
first hour. Overall reduction in mortality with thrombolytics is 25%.
* Efficacy is the same with tPA (tissue plasminogen activator) and streptokinase.
Use tPA if patient previously got
streptokinase, because streptokinase can produce antibodies resulting in
anaphylaxis.
Post Myocardial Infarction Management
* 65yo man in the coronary care unit (CCU) after having an inferior wall
myocardial infarction last night. He
received all the appropriate therapy. You are called by the nurse because he is
confused. Patients blood pressure
is 70/40, pulse is 40, has cannon a waves, a chest that is clear to auscultation.
Heart exam reveals 3/6 murmur.
Which of the following is the most likely diagnosis?
* Right coronary artery feeds the right ventricle, AV node, and inferior wall. 40%
of inferior wall MIs also have RV
infarcts. This is not the right answer though.
* Myocardial wall rupture with cardiac tamponade would lead to hypotension and
confusion. But no.
* Think about what it could be. We could go to sermons all day long to become
saints, but it doesnt work that way.
* Valve rupture with chordae tendineae rupture (after a week) could cause a
murmur and hypotension. Nope.
* What about extension of the MI with cardiogenic shock? Not that either.
* Cardiogenic shock would give rales. Valve rupture would regurgitate into the
lungs, causing rales. This patient has
a clear lung auscultation exam. RV infarct and cardiac tamponade could give
clear lungs, but the heart would beat
faster to compensate (here the patient has bradycardia).
* Complications of an MI can all cause hypotension and hypotension can cause
confusion.
* Answer is third degree complete AV heart block, described first in 1826 by
Stokes and in 1846 by Adams near the
University of Dublin. Wait, they didnt have ECG back then. Stethoscope invented
shortly before by Laennec in
France (1816). They saw lightheadedness, syncope, cannon a waves,
bradycardia. No hypotension because the blood
pressure cuff did not exist then.
* What is the best initial diagnostic test? ECG, showing complete heart block.
* What is the best initial management? Atropine. This blocks the
parasympathetic, allowing the sympathetics to
work without inhibition and thus speeds up the impulses through the AV node. It
is like a car that has an accelerator
(sympathetics) and brakes (parasympathetics). Atropine cuts the brake lines for
a while.
* Transcutaneous pacer makes the heart beat with capture, but it also makes all
the chest muscles contract.
* Transvenous pacing cannot be setup fast enough and requires an invasive
procedure.
* If cardiac tamponade, do a pericardiocentesis or a cardiac window then repair
the hole.
* If valve rupture, may need to go in and emergently replace the valve.
* If cardiogenic shock and extension of the MI, may need emergency bypass
surgery.
* Many years ago before IV furosemide was around physicians did phlebotomy
and rotating tourniquets.
* Loop diuretics are used because they are intravenous and work fast on the
ascending loop of Henle. Loop diuretics
are furosemide, bumetanide, ethacrynic acid, torasemide.
* Nitrates also work at pre-load reduction because they dilate both arteries and
veins, but dilate veins more.
* Morphine can reduce pre-load as well.
* 67yo woman with CHF and now acute pulmonary edema. Give her medication
for her shortness of breath and to
reduce preload: oxygen, loop diuretics, nitrates, morphine. 80-90% of patients
will get better with this therapy.
* CXR would show enlarged heart with congestion, pulmonary vascular
redistribution, effusions, Kerley B lines, but
we know all this. A CXR does not change our management in this patient. Patient
comes in short of breath saying
they feel like they are filled up with fluid. You do a CXR and tell her that her lungs
are filled with fluid. Thats great
doc, but she already knew that and she doesnt care. What are you going to do
to help her is the question.
* ABG would show hypoxia and low CO2 (hyperventilating). But you know this, it
does not change management.
* Say you give this patient oxygen and preload reduction but she is still short of
breath. This is dilated
cardiomyopathy, also known as systolic dysfunction. The goal now is to decrease
afterload.
* Why not use digoxin now since it is a positive inotrope? It takes time, weeks to
fully take effect.
* Dopamine and dobutamine are both positive inotropes. Which do you give for
this patient though? Dobutamine.
They will both increase contractility (positive inotropes) and myocardial oxygen
consumption.
* Dopamine increases the afterload. Dobutamine decreases the afterload, and
thus does not change blood pressure.
* Dopamine is only used if you need to raise the blood pressure. It is only used as
a pressor here.
* Afterload reduction is best achieved with ACE-I (-pril drugs). Most common
adverse reaction to ACE-I is cough
and hyperkalemia. If you have an intractable dry cough, give an ARB (-sartan
drugs, like losartan or valsartan).
* ARB drugs are angiotensin II receptor blockers.
* Most accurate way to measure ejection fraction is MUGA scan.
* Catheterization and angiogram is less accurate, but more accurate than an
echocardiogram.
* The least accurate method to assess ejection fraction is an echocardiogram.
Echo is the best initial method of
measuring ejection fracture. They are cheap, clean, easy, but not the most
accurate test.
* MUGA scan is a nuclear ventriculogram (radionuclide ventriculography).
Nuclear isotope is injected into the body
and the scan measures the amount of nuclear energy emitted from the heart in
diastole and systole. The difference in
this measurement corresponds to the ejection fraction, stroke volume to be
precise. Since it is nuclear energy, it is
not based on a cross sectional diameter like an echo or catheterization. You could
look at a soda bottle and take a
cross sectional diameter to get an estimate of the amount of soda inside. But the
better way is to pour fluid into the
bottle and measure how much actually comes out, and that is what a MUGA scan
is about.
- 96 * 67yo lady with pulmonary edema and CHF was treated with oxygen,
furosemide, nitrates, morphine. She feels all
better the next day, what is the most important medication to discharge her on?
Answer is ACE-I, diuretics, and beta
blockers. Sometimes you may need digoxin.
* ACE-I can raise potassium and help offset diuretics. You give potassium if the
patient is only on diuretics and
digoxin, as the diuretic would make you hypokalemic and the digoxin would then
become toxic.
* Diuretics and digoxin have not been show to lower mortality. ACE-I has been
shown to improve mortality.
* Aspirin has been shown to decrease mortality in coronary disease but not
congestive failure.
* But wont beta blockers worsen ejection fraction? Actually, they increase
ejection fraction and cardiac output.
Basic sciences in medical school will tell you over and over that beta blockers are
negative inotropes that worsen
ejection fraction and worsen cardiac output. That was because beta blockers had
not been studied in congestive
failure because everyone thought it would make things worse.
* There is an interesting thing that happens to patients with congestive failure
who are on beta blockers and they like
it quite a bit. That thing is that they do not die.
* Beta blockers lower mortality more than ACE-I in congestive failure.
* What is the bigger problem in cardiac failure with systolic dysfunction, the
weak heart or the ischemia? Ischemia,
and that is why beta blockers are good as they lower heart rate and cardiac
contractility, because they are antiischemic.
Going back to stress testing, what is the major determinant of exercise? Heart
rate. When you lower the
heart rate you reduce ischemia and the patient is less likely to die.
Valvular Heart Disease
* Valvular disease is organized into stenosis and regurgitation, more than by
valve location.
* Fundamental symptom of all valve disease is CHF (rales, S3 gallop, edema).
* The ease of availability and use of the echocardiogram has led to a decline in
our ability to auscultate murmurs.
The echo has greater sensitivity and specificity than the stethoscope.
* What is the most common cause of mitral stenosis? Rheumatic fever, but it can
cause any valvular disease.
* What else causes mitral stenosis? Congenital, but it can cause any valvular
disease.
* Calcification can cause mitral stenosis and aortic stenosis, but not a regurgitant
loose/floppy lesion.
* Infections (e.g. endocarditis) can cause regurgitant lesions from vegetations,
but not stenotic lesions.
* When your heart dilates, the valve leaflets do not change in size. Anything that
dilates the heart has to cause
regurgitation because the leaflets separate. Infarction can cause regurgitant
lesions through this mechanism.
Quincke sign (pulsation of the capillary bed in the nail), Traube sign (a double
sound heard over the femoral artery
when it is compressed distally), Duroziez sign (systolic and diastolic murmurs
described as 'pistol shots' heard over
the femoral artery when it is gradually compressed). Dont forget the even less
common Lighthouse sign, Landolfi
sign, Becker sign, Mller sign, Mayen sign, Rosenbach sign, Gerhardt sign, Hill
sign, Lincoln sign, Sherman sign,
and Ashrafian sign. None of these have utility in making a diagnosis. Hearing a
diastolic murmur is more reliable.
* These exotic findings are usually only seen in longstanding non-treated
disease. We replace the valve before these
patients join the American Iatrogenic Association.
so it pushes the valve open earlier. Murmur will increase with more blood in heart
(leg raise, squatting). Decreases
with preload reduction (standing, Valsalva).
* Aortic stenosis (AS): crescendo-decrescendo murmur, upper right sternal
border. Murmur will increase with more
blood in heart (leg raise, squatting). Decreases with preload reduction (standing,
Valsalva).
* Mitral regurgitation (MR): S1 and S2 are obscured by constant murmur,
pansystolic or holosystolic murmur.
Decreases with preload reduction (standing, Valsalva).
* Aortic regurgitation (AR): decrescendo murmur because blood gets shot up out
of the aortic valve and you do not
hear anything, then you hear the blood crashing down on the ventricle.
Decreases with preload reduction (standing,
Valsalva).
* Do not give beta blockers to AS, MS, AR, MR because it would make the
murmur/problem worse.
* Hypertrophic obstructive cardiomyopathy (HOCM): crescendo-decrescendo
murmur, lower left heart apex. Most
common presentation is dyspnea. It is the most common cause of sudden death
in healthy young athletes. Unlike the
other murmurs of the left heart, there is more murmur with less blood and less
murmur with more blood.
Asymmetric septal hypertrophy is in the way, so anything that makes the heart
larger (more blood) pushes away the
obstruction and decreases the murmur. When a patient exercises, the heart
contracts more completely causing more
obstruction. When dehydrates, the heart empties more fully causing more
obstruction. Digoxin, diuretics, and ACE-I
would thus cause more obstruction. Do not give HOCM or MVP patients diuretics.
Best initial therapy for HOCM is
beta blockers because it decrease the heart rate thus more filling and thus less
obstruction.
* Occasionally a myomectomy is needed for HOCM to remove the obstruction.
* Mitral valve prolapse (MVP): mid-systolic click due to leaflets stopping short.
Most common cause is congenital.
Presentation is most commonly pain (atypical chest pain), palpitations, panic
attacks. Mnemonic: Prolapse, Pain,
can bundle any one of the causes into these main topics. Try to do this for any
disease with a long list.
* Cancer causes include...yea no point, its any cancer near the heart. Lungs,
breast, esophagus, mediastinal lymph
nodes are all near the heart.
* Symptom of pericarditis is pain that is positional and pleuritic.
* ECG shows ST elevations everywhere. Pathognomonic ECG finding is PR
segment depression.
* Treatment of pericarditis is to correct the underlying etiology. If no etiology
(mainly viral), NSAIDs. If NSAIDs
do not work, then use prednisone.
* Causes of pericardial tamponade are pneumonia, pleuritis, pleural effusion.
* What are the causes of pneumonia? Anything, pneumococcus most often.
* Which connective tissue disorders have pulmonary involvement? Any
connective tissue disorder.
* What cancer can affect the lung? The ones that are anatomically near the lung.
* Can trauma cause a pleural effusion? Yep. And pulmonary contusion with
atelectasis leading to pneumonia.
* Causes of pericardial tamponade are the same as pericarditis. Infections,
inflammatory, trauma, cancer.
* What about peritonitis? Yep, same causes there too.
* Chronic pericardial tamponade becomes constrictive pericarditis from fibrosis.
* Presentation is jugular venous distension (JVD), tachycardia, and hypotension.
But that could be pulmonary
edema, so how do you distinguish? Answer is pulsus paradoxus and clear lungs.
* First test of choice is echocardiogram.
* Treatment of choice is needle pericardiocentesis.
* The problem with the pericardiocentesis is that the fluid can keep reaccumulating. So what do you do to treat a
chronic pericardial effusion? Pericardial window, a hole in the pericardium and
fluid drips into pleural space.
* Constrictive pericarditis symptoms are JVD, ascites, enlarged liver.
* What occurs in constrictive pericarditis that does not occur in CHF. Pericardial
knock.
* CXR or CT for diagnosis.
* Treatment is to remove the pericardium.
Arrhythmia Management
* The type of arrhythmia management that you need to know is the first hour of
management, what you would be
expected to managed as a physician intern at a hospital.
* 47yo man comes to the office seeking advice about diarrhea prophylaxis prior
to going to a vacation to Thailand.
You notice that he feels alright but his heart rate of 47. What is the next best
step in management? This patient does
not have symptoms so ECG. If he did have symptoms, give atropine acutely to
increase the heart rate then a
pacemaker later on.
* Side note, pulse rate is not the same as heart rate. Heart rate is seen on ECG,
pulse is palpated.
* Normal heart rate of 60 to 100 is based on thousands of military recruits
between the ages of 18 and 24, two hours
post prandial in the supine position.
* Sinus bradycardia at a rate of 47 in an asymptomatic man, next step is leave
him alone. What if the heart rate was
37 without symptoms and ECG showing sinus bradycardia? Do nothing. It does
not matter how low it gets because
he has no symptoms.
- 99 * First degree AV block without symptoms do nothing. This does not progress to
second degree AV block.
* Mobitz type I AV block (Wenckebach) without symptoms do nothing. This does
not usually progress and is part
of the normal aging of the conduction system.
* Mobitz type II AV block is the dividing line, this can progress to complete block
and ischemia.
* Mobitz type II AV block and type III complete AV block get a pacemaker even
without symptoms. We do not
wait for the patient to have their first syncopal episode while they are driving
down the road.
* 28yo female medical student who has been preparing for an exam and using
the four basic food groups, alcohol,
nicotine, caffeine, chocolate. She comes in complaining of palpitations. ECG
shows supraventricular tachycardia
these? ECG. Thus, you better call for help to get the equipment there so you can
distinguish these.
* After calling for help, then you do ABCs. Open airway, check breathing, give
two breaths if not breathing, check
pulse, start compressions if no pulse.
* Say ECG shows up and patient is in Vfib with no respirations. Now what?
Defibrillation. Not intubation, how long
would it take to intubate in the field? Maybe 3-4 minutes with getting equipment
out, suction, and get the tube in. In
that time, 40% of your patients just died since 10% are lost per minutes.
- 100 * If defibrillation did not work, do a cycle of CPR then shock again. Epinephrine
can be given between each cycle as
well. So shock, drug, CPR, shock, drug, CPR, etc. After three cycles with
refractory VT or Vfib, you can give
amiodarone or lidocaine.
* Intracardiac medication has not been show to have greater efficacy so it is not
an answer.
* Thoracotomy with direct cardiac massage is also not an answer, it will not help.
* Magnesium is given for Torsades de Pointes only.
* Precordial thump is like a little defibrillation, 10-20J of energy. The amount of
energy needed for successful
defibrillation is little at the very beginning. Thus, precordial thump used in
witness arrest only with no defibrillator
present. If you have a defibrillator, use that instead.
* What about the dosing of these drugs and shocks? Drug dosing is not asked on
board exams. Exception may be the
advanced cardiac life support (ACLS) drugs here. Epinephrine is 1mg, atropine is
1mg for cardiac arrest and 0.5mg
for bradycardia, lidocaine is 1mg/kg, adenosine is 6mg to start, amiodarone is
300mg.
* Resuscitation of patients beyond 10 minutes only in hypothermia or induced
hypothermia. CO2 production of each
cell and oxygen consumption is directly proportional to body temperature.
* For asystole or PEA, atropine and epinephrine can be given between CPR
cycles.
* Do not shock asystole. It may be important to know the most common wrong
answer in situations like this because
both will be listed on the exam and likely they are the two answer choices you
narrow down to. Defibrillation stops
the heart with the hope that it will reboot normally. Defibrillating asystole will do
nothing because the electrical
system is already stopped; its not like jumper cables for a car, its more like
rebooting an electronic device when it
is not functioning well. Side note: always confirm asystole in a second lead.
* Say youve given epinephrine and atropine through several cycles of CPR and
the patient is still dead. You can
consider a pacemaker. For true asystole, this does nothing. You consider
pacemaker because it could possibly be
very slow bradycardia and you may have missed a beat. Algorithm says consider
because beyond that you are
considering burial or cremation, there is nothing else to do, the patient is dead
anyway.
Electrocardiograms
* There are very few ECGs on USMLE Step 2, maybe two or three.
* Each small box is 40ms. Each large box is 200ms.
* PR interval should be less than 5 small boxes (200ms). QRS should be less than
3 small boxes (120ms).
* Counting rate is done by the 300 method. Count the number of large boxes
between QRS complexes and divide
300 by that number. So if there were 5 large boxes between QRS complexes it
would be 300/5 = 60bpm.
* 300 method points are 300, 150, 100, 75, 60, 50. You can differentiate
tachycardia from bradycardia this way.
* Arrhythmia associated with digoxin toxicity is bigeminy, trigeminy, any
arrhythmia. The most common
arrhythmia seen in digoxin toxicity is SVT with variable block.
* Bigeminy is every other beat being a PVC. Couplets are two PVCs, not
uncommon.
* Supraventricular can be differentiated from ventricular by the width of the QRS
complexes. Wide complexes
always comes from the ventricles. Wide complexes are > 120ms.
Supraventricular impulses follow the normal
conduction pathway through the AV node, which makes them narrow on the QRS.
* Ectopic beats originate from an ectopic focus. One is PVC. Two is couplet. Three
is triplet. Four or more is
ventricular tachycardia.
* ECG showing flat line. Dont think something like the leads came off the
patients chest. This is asystole. There is
some biological variability, so it might not be perfectly flat line. What is the best
next step in management? CPR,
then epi and atropine for a few rounds, then consider a pacemaker, then
consider the patient dead.
* You are at the bedside for a patient with chest pain. They become unconscious
and the ECG shows flat line.
Should you do a precordial thump for the witnessed arrest? No. Precordial thump
is like defibrillation and you do
not defibrillate flat line.
* Consistent wide complexes is ventricular tachycardia. What do you do next if
the patient is conscious and stable?
Give lidocaine.
* What if ECG shows Vtach and patient is unconscious? Defibrillation.
* Know what ventricular fibrillation looks like and do not expect Torsades.
Irregular waves with no consistency
across the rhythm strip. Patient is always pulseless. What do you do? Defibrillate.
* ECG shows Vfib and youve gone through cycles of CPR with defibrillation. Now
you intubated the patient and
give epinephrine during the cycles. How much time do you have to save this
patient? 10 minutes. What medication
can you give for refractory VT or VF? Amiodarone.
* Important Note: There is no minimum and no maximum for running a
resuscitation.
* You get called into a room by a nurse because the monitor shows the patients
rate at 140 per minute. She has the
defibrillator ready and is asking you what to do. You feel a pulse and note that it
is 70 per minute. The patient states
- 101 she missed her dialysis treatment this week. What could it be? Hyperkalemia.
The peaked T-waves are so high that
the monitor is reading them as QRS complexes.
* When talking about peaked T-waves, the size does not matter as much as the
shape. The pointier the worse.
* The most important ECG to know is regular sinus rhythm.
* Keep in mind when you are studying for the exam, if your highest point to
attain is the exam it will feel painful. If
you are conscious of the goodness that comes from the knowledge after that and
what it can do to be of service, then
the exam will feel smaller and your process will be filled with more joy.
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