01-08-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[01-08-2025 PPM 1: Afternoon session:
Courtesy yesterday's data shared by @PPM3
70F with acute cerebral stroke and acute posterior wall and inferior wall myocardial infarction. Discussion on ECG and echocardiography findings with images of handwritten history and progress notes for archival.
[01-08-2025 15.40] PPM 1: https://youtu.be/Q8qLXTe12ug?si=Cd5phLYsGUaQLXPW
[01-08-2025 15.41] PPM 1: 👆Also for @PPM4 's Web 3.0 system to process.
[01-08-2025 15.47] PPM 1: https://youtube.com/shorts/hIC-dz01vxQ?si=odzHwNJ16HybrHAK
[01-08-2025 21.31] PPM 1:
[01/08, 15:50] Dhu Pm: Sir
Ecg image quality reduced by whatsapp
[01/08, 16:05]cm: True but on checkin it appears sufficient to make the diagnosis
[01/08, 16:06]cm: Focus on the changes evolving in V1V2 and 2,3, aVF
[01/08, 16:15] Dhu Pm: i have this notes sir
I'm still under confident in understanding Ecg sir.
Attaching notes, please guide me via that recent reports you shared.
(wrote this notes myself by listening to Gmeet class 3 yrs ago)
[01/08, 16:37]cm: Keep practicing by seeing the real patient ECGs we posted in the group and keep asking us questions on it.
That's the only way to learn ECGs practically quickly and usefully.
[01/08, 16:41] Dhu Pm: okay sir
I saw 2d echo
I saw
some whitish appearance on the screen where you pointed to posterior wall and anterior wall
Hypokinesia /dyskinesia (reduced movement or abnormal movement)
I understood that part vi a 2decho
how does that interpret on ECG sir
[01/08, 16:42]cm: Good
So now you just need to know where are the inferior and posterior walls represented on the ECG
Ask google and or chatGPT
[01/08, 16:46] Dhu Pm: got this info from google sir
Inferior wall ischemia in an ECG is primarily represented by changes in leads II, III, and aVF, while posterior wall ischemia is indicated by changes in leads V1-V4, specifically ST depression and tall R waves, or by ST elevation in leads V7-V9. These leads correspond to the areas of the heart supplied by the right coronary artery (RCA) and potentially the left circumflex artery (LCx) for the inferior wall, and the RCA or LCx for the posterior wall.
[01/08, 16:48]cm: Now check what serial changes are visible in the patient's ECGs and let me know
[01/08, 17:04] Dhu Pm: On 30th ecg 7am
Lead II, III ,aVF - T wave inversion
on 30th 9.30 am
I could see a t wave inversion on lead III
and flat t wave in II and aVF
on 31st 6 am
II - flat T wave
III - depressed t wave
aVF - looks flat (doubtful)
on1st 1pm
II, III, aVF - flat T waves
[01/08, 17:04] Dhu Pm: Correct me sir still not sure 😅
[01/08, 17:11]cm: What about 28-29?
[01/08, 17:12]cm: What about V1, V2?
[01/08, 17:21] Dhu Pm: 28th 12.15 pm
II - flat T wave
III- no Proper pqrs waves
aVF - inverted T wave
V1- ST elevation
v2- slight ST elevation,R wave >5mm
v3 - Slight ST elevation R wave >5mm
29th 1.08 pm
II- T wave flat
III- p wave depression and st elevation
aVF T wave depression
V1-St elevation, R wave >5mm
v2-St elevation, R wave >5mm
v3 -St elevation, R wave >5mm
29th 8.30 pm
II -T flat
III- T depression
aVF- T depression
V1- ST elevated, S appears Deep
v2-ST elevated, S appears Deep
v3 - ST elevated, S appears Deep
[01/08, 17:32] Dhu Pm: 30th 7am
Lead II, III ,aVF - T wave inversion
V1, v2, v3 - ST SEGMENT ELEVATION AND s waves appear deep (doubtful)
30th 9.30am
I could see a t wave inversion on lead III
and flat t wave in II and aVF
v1,v2,v3 - ST elevation, R wave (>5mm)
31st 6am
II - flat T wave
III - depressed t wave
aVF - looks flat (doubtful)
V1,v2,v3 - st elevation
1st 1pm ecg
II, III, aVF - flat T waves
V3- Tall R wave (>5mm)
and T wave inversion
[01/08, 20:19]cm: In 2,3, avF the most important feature after the STEMI pattern on 29th is the appearance of Q waves suggestion an evolving inferior wall myocardial infarction
In V1, V2 it's ST depression, not elevation but if one holds it against a mirror then it can appear as an elevation and this is a hallmark of posterior wall myocardial infarction.
[01/08, 20:33] Dhu Pm: I remember that reverse interpretation is because of the direction of current
does that apply here sir.
[01/08, 20:34] Dhu Pm: and I vaguely remember we should cross check those v2 v3 leads from other v567 leads
[01/08, 20:38] Dhu Pm: Sir are these considered as Q waves?
[01/08, 20:38] Dhu Pm: I see a dip after p wave
[01/08, 20:39]cm: Yes
[01/08, 20:39]cm: Yes it's a qs pattern
[01/08, 20:41] Dhu Pm: Sir is this V tach
[01/08, 20:47]cm: Can't happen in a single lead alone
[01/08, 21:05] Dhu Pm: So what could it be sir
[01/08, 21:18]cm: Transient local lead 2 problem
[02-08-2025 11:31] PPM 4: For deidentification and archival purposes, here's the processed summary of the MRI brain report for the 70-year-old female patient, with all personal identifiers removed:
---
*🧠MRI Brain (Plain) – Deidentified Summary*
*Patient Demographics:*
* Age: 70 years
* Sex: Female
* Clinical Department: General Medicine
*MRI Protocol Used:*
* Axial T1, T2, FLAIR, DWI & SWI
* Coronal T2
* Sagittal T1
---
### *Key Radiological Findings:*
1. *Chronic Lacunar Infarcts*
* *Location*: Left thalamus
* *Etiology*: Likely secondary to chronic small vessel disease
2. *Bilateral Confluent Periventricular Hyperintensities*
* Suggestive of *chronic microangiopathic ischemic changes*
3. *No Acute Infarction*
* *DWI sequences*: No restriction (no acute infarcts)
4. *No Hemorrhage, Calcifications, or Vascular Malformations*
* *SWI sequences*: No microbleeds or vascular anomalies
---
### *Normal Structures Reported:*
* *Basal ganglia & right thalamus*
* *Brainstem and cerebellum*
* *Craniovertebral and cervicomedullary junctions*
* *Sella, pituitary, parasellar regions*
* *Hypothalamus, pituitary stalk, and posterior pituitary bright spot*
* *Orbital and globe contents*
* *Cortical gray/white matter differentiation preserved*
---
### *Final Impression:*
* ✅ *Chronic lacunar infarcts in left thalamus*
* ✅ *Chronic small vessel ischemic changes*
---
Let me know if you'd like this in a formatted PDF for upload to your case archive or integrated into the KIMS Hospital Syndrome CBBLE data set. I can also tag this for future reference under anonymized IDs.
[02-08-2025 11:34] PPM 4: Thank you,. Here's a deidentified and archivally formatted summary for the *MRI Brain Plain* report you shared for a 70-year-old female patient, suitable for inclusion in your KIMS Hospital syndrome CBBLE repository:
---
### *Case Summary: MRI Brain (Plain) — Elderly Female (70F)*
*Institution:* Kamineni Institute of Medical Sciences, Narketpally
*Date of MRI:* 28/07/2025
*Study Type:* MRI Brain Plain
*Sequences Used:* Axial T1, T2, FLAIR, DWI & SWI; Coronal T2; Sagittal T1
#### *Key Findings:*
* *Chronic lacunar infarcts in the left thalamus.*
* *Bilateral confluent periventricular hyperintensities*, consistent with chronic small vessel ischemic disease.
* *Normal findings* in:
* Right thalamus and basal ganglia
* Cerebral cortex (preserved gray/white differentiation)
* Brainstem and cerebellum
* Cranio-vertebral and cervico-medullary junctions
* Sella, pituitary and parasellar region
* Hypothalamus and posterior pituitary bright spot
* Orbit and globe contents
* *No acute infarcts* on DWI.
* *No hemorrhages, calcifications, or vascular malformations* on SWI.
#### *Radiological Impression:*
* Chronic lacunar infarcts (left thalamus)
* Chronic small vessel ischemic changes
---
Would you like me to link this summary with the clinical video file or generate a table entry format for CBBLE archival?
Also, let me know if you want to flag this for any neurology or geriatrics inputs on cognitive risk correlation (e.g., vascular dementia scale integration).
[02-08-2025 17.03] PPM 1: Patient's chest X-ray and HRCT done yesterday.
[02-08-2025 17:28] PPM 1: https://youtube.com/shorts/OiKgeJZb_48?si=uKsyvJg_DsdQyP0j
[02-08-2025 17:29] PPM 1: https://youtube.com/shorts/typ6afQWGoU?si=J4G-3kAjBjg-VCqq
[02-08-2025 17:30] PPM 1: https://youtube.com/shorts/4ctcT2p-9ZE?si=vh7TXxJs8kwOKUIw
[02-08-2025 17:30] PPM 1: https://youtube.com/shorts/bRnOljIVHQg?si=StBj2bGAvoMsR_yJ
