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PQRST Morphology Continued

• ST segments

• ST elevation = myocardial injury

• ST depression = myocardial ischemia

• T wave

• T waves usually in the same

direction as the largest deﬂection of

the QRS (normally the R wave)

• Normally upright in I, II, V3–V6

• Normally inverted in aVR

• Flattened or inverted T waves may

indicate ischemia

• Tall T waves seen following

myocardial infarction (MI)

• Peaked T waves suggest

hyperkalemia

• Hypertrophy

• Left ventricular hypertrophy

• aVL >11 mm

• S in V1 + R in V5–V6 >35 mm

(7 big boxes)

• Right ventricular hypertrophy

• R:S ratio >1.0 in V1

• Dominant R wave >5 mm in V1

ST segments examined for

elevation or depression against

the TP segment (the true

isoelectric line)

Post-MI, persistent ST

elevations associated with

ventricular aneurysm

https://t.me/med1917

Example of Normal EKG Morphology

I aVR V1 V4

III

aVL

aVF

V2 V5

V3 V6

Blocks

• 1st-degree AV block

• PR >0.20 s

• 2nd-degree AV block

• Type I (Mobitz I/Wenckeback)

increasing PR interval until a QRS

complex is dropped

• Type 2 (Mobitz II) QRS dropped

without any progressive increase in

PR interval (i.e., PR interval is

constant but >0.20 s)

• 3rd-degree AV block

• Atria and ventricles are electrically

dissociated. P waves and QRS

complexes will occur independent of

each other. As always, use the QRS

complexes to determine heart rate.

“Longer, longer than a drop

then you have a Wenckeback”

1st-degree and 2nd-degree,

Mobitz type I are usually

benign; other blocks are not

https://t.me/med1917

Blocks Continued

• Left bundle branch block (LBBB)

• QRS >0.12 s

• Dominant S (W-shape) in V1

• Broad or notched R wave in I, aVL,

V5, and V6 (M-shape)

• Prolonged R wave in V5 and V6

• LAD <30 degrees

W-shaped

dominant S

M-shaped

broad R

• Right bundle branch block (RBBB)

• QRS >0.12 s

• Large R wave in V1, large S in V4

• Wide slurred S in lateral leads: I,

aVL, V5, and V6

• Possibly RSR′ (M-shaped QRS

complex) in V1–V3 with ST

depression and T wave inversion

M-shaped

QRS

Slurred S

https://t.me/med1917

30 Chest Radiograph

Chest Radiograph (CXR) Reading

(ABCDEFGHI)

A. Assessment of technical quality and

airways

B. Bones and soft tissues

C. Cardiac silhouette

D. Diaphragm

E. Effusions (i.e., pleura)

F. Fields/ﬁssures (lungs)

G. Gastric bubble, great vessels

H. Hila/mediastinum

I. Instrumentation (lines, tubes, devices,

and surgeries)

Normal Posteroanterior CXR (Female)

Normal Left Lateral CXR (Female)

Assessment of Technical

Quality

• Rotation: T3 spinous

process equidistant to both

medial ends of clavicles

• Inspiration: the

diaphragm between 8–10

posterior ribs or 5–6

anterior ribs

• Penetration: visualize

peripheral pulmonary

vasculature and thoracic

vertebrae through heart

Radiographic Densities

• Air (black)

• Water (dark grey)

• Fat (light grey)

• Metal and bone (white)

Silhouette Sign: Pathological

loss of a border between

two objects of different

radiographic density (e.g.,

pleural effusion, pneumonia,

mass)

https://t.me/med1917

Usually posteroanterior (PA)

view. Anteroposterior (AP)

view reserved for patients

unable to stand: critically ill

(intensive care unit [ICU])

Normal cardiac silhouette is

<50% maximum thoracic

diameter

Left hilum is slightly higher

than the right hilum to

accommodate the heart

If edges of heart

and diaphragm are

hazy = inﬁltration

RALS (Right Anterior, Left

Superior): Right pulmonary

artery anterior to bronchus,

left pulmonary artery superior

to bronchus.

Posteroanterior CXR—Cardiac Structures

Left Lateral CXR—Cardiac Structures

R. clavicle

R. sterno-

clavicular

joint

Spinous process

First rib

Aortic

window

Aortic

arch

L. hilum

R. hilum

L. ventricle

R. ventricle

R. atrium

R. pulmonary

artery

Breast

shadows

Thoracic

vertebra

Manubrium of

sternum

Aortic

arch

Body of

sternum

L. pulmonary

artery

L. ventricle

ventricle

R. atrium

L. atrium

Inferior

vena cava

R. pulmonary

artery

https://t.me/med1917

Costovertebral angle (CVA): If

not sharp, think effusion

Can see the right

hemidiaphragm from anterior

to posterior; the anterior part

of the left hemidiaphragm

silhouette is not seen because

the heart rests on it (the same

way an inﬁltrate obscures)

Posteroanterior CXR—

Respiratory Structures

Left Lateral CXR—Respiratory Structures

L. main

bronchus

Posterior

ribs

R. main

bronchus

Horizontal

fissure

Trachea

Carina

R. hemi-

diaphragm

L. hemi-

diaphragm

CVA

Gastric

bubble

L. main

bronchus

(superior)

Trachea

R. main

bronchus

(inferior)

Horizontal

fissure

R. oblique

fissure

L. oblique

fissure

R. hemi-

diaphragm

Gastric

bubble

L. hemi-

diaphragm

Esophagus

https://t.me/med1917

Lung Lobes—PA CXR

Right upper

lobe

Middle

lobe

Left upper

lobe

Right lower

lobe

Left lower

lobe

Right Lung Lobes—Lateral CXR

Right upper

lobe

Middle

lobe

Right lower

lobe

Left Lung Lobes—Lateral CXR

Left upper

lobe

Left lower

lobe

https://t.me/med1917

31 Screening Physical

Full Screening Physical Exam

This is an example of a full annual physical

of a primary care physician

• Vital signs

• Blood pressure

• Heart rate

• Respiratory rate

• Temperature

• General

• General appearance

• Level of consciousness

• Orientation

• Weight/height/body mass index

(note but do not perform)

• HEENT

• External inspection of eye

• External ear

• Tympanic membrane

• Nasal septum/turbinates

• Pupillary reaction to light

• Inspection of oropharynx and

dentition (“Say, ‘Ahh’ ”)

• Neck

• Lymph node palpation (cervical,

supraclavicular)

• Thyroid palpation

• Cardiac

• Carotid artery auscultation

• Cardiac auscultation diaphragm and bell

at four areas

Consider examining cranial

nerves while doing HEENT

exam for choreography

https://t.me/med1917

• Lung

• Inspect thorax

• Lung auscultation

• Anteriorly: 2 spots

• Posteriorly: 6 spots

• Abdomen

• Inspect

• Auscultate

• Palpate 6 areas

• 4 quadrants

• Epigastric

• Suprapubic

• Liver palpation and/or percussion

• Vascular

• Dorsalis pedis/posterior tibial artery

palpation

• Assessment of lower extremities for

edema

• Skin

• Inspection

• Extremities and musculoskeletal

• Inspection of extremities

• Inspection of joints

• Neurologic

• Assessment of speech

• Cranial nerves (II–XII)

• Motor exam of upper and lower

extremities

• Deep tendon reﬂexes

• Sensory exam

• Cerebellar exam

https://t.me/med1917

32 Write Up

Sample of Normal Physical Examination

Patient Note

Vital signs

• T: ____, RR: ____, HR: ____, BP: ____

(sitting), POx ____ on RA

General

• WD/WN male in NAD, appears stated

age, AO (×4), and cooperative

Skin

• (−) rashes; (−) lesions; (−) hyper/

hypopigmentation

HEENT

• H: NC/AT; (−) temporal wasting. Note

any lesions/rashes

• E: conjunctiva pale; (−) scleral icterus;

(−) injection; EOMI; PERRLA; fundi

benign; acuity grossly intact—or speciﬁc

number such as 20/20 if using Snellen

• E: external canals normal w/ cerumen;

(−) exudate or d/c; TM nl w/good LR

bilaterally; (−) erythema. Note if TM

bulging or retracted

• N: septum w/o deviation; (−) rhinorrhea;

nares clear B/L; (−) polyps/masses;

maxillary, frontal sinuses nontender B/L

• T: MMM; pharynx w/o erythema;

(−) exudate; dentition good

Neck

• Trachea midline; supple, (−) masses;

(−) cervical adenopathy; (−) JVD; no

thyromegaly; (−) nodules; (−) carotid

bruit B/L

Cardiovascular

• RRR; nl S1/S2; (−) S3/S4; (−) M/R/G,

PMI at L 5th intercostal space

Respiratory

• CTA/P B/L; (−) W/R/R

Remember this varies with

abnormalities and changes in

the exam. Only write what you

see and do.

Abbreviation List

• AO (×4): alert, oriented to

person, place, time, and

situation

• B/L: bilateral

• BS: bowel sounds

• C/C/E: cyanosis/clubbing/

edema

• CN: cranial nerves

• CTA/P: clear to

auscultation and

percussion

• CVA: costovertebral angle

• d/c: discharge

• DP/PT: dorsalis pedis/

posterior tibial

• EOMI: extraocular

movements intact

• GU: genitourinary

• HEENT: head, eyes, ears,

nose, throat

• HSM: hepatosplenomegaly

• JVD: jugular venous

distention

https://t.me/med1917

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