Geographic Tongue

Geographic tongue is a benign, chronic condition of unknown cause. It is present in around 13% of the population and is more common in females.

As the name suggests in this condition there is a map-like appearance on the upper surface and sides of the tongue. It may occur in other areas of the mouth, as well.

Although geographic tongue may look alarming, it doesn't cause health problems and isn't associated with infection or cancer.

Clinical Features

• Erythematous areas with a white grey border (the irregular, smooth red areas are said to look like the outline of a map).
• The patches may vary in size, shape, and color.
• These patches come and go or change very quickly in days, weeks, or months
• Some patients report burning after eating certain food.
• Many people with geographic tongue have no symptoms.

A 60 year old woman with a h/o Rheumatic heart disease and recently being treated for heart failure...

This ECG was recorded from a 60-year-old woman with rheumatic heart disease. She had been in heart failure, but this had been treated and she was no longer breathless.

What does the ECG show and what question might you ask her?

The ECG shows:
• Atrial fibrillation with a ventricular rate of 60-65/min
• Normal axis
• Normal QRS complexes
• Prominent U wave in lead V2
• Downward-sloping ST segments, best seen in leads V5-V6

Clinical interpretation
The downward-sloping ST segments (the 'reverse tick') indicate that digoxin has been given. The
ventricular rate seems well-controlled. The prominent U waves in lead V2 could indicate hypokalaemia.

An 18-year-old woman presents to your office complaining of tender nodules that have developed on the lower extremities.

An 18-year-old woman presents to your office complaining of tender nodules that have developed on the lower extremities.

She has no other symptoms. She continues with her oral contraceptives but has not started any new medications. She denies any fevers and has no history of recent trauma.

The likely diagnosis is
A) Erythema multiforme
B) Erythema nodosum
C) Lyme disease
D) Pyoderma gangrenosum
E) Rheumatoid arthritis

Answer:

Left Posterior Fascicular Block - ECG

ECG Findings
• QRS complex widening to 90 to 120 ms.
• Right axis deviation must be beyond 100 degrees and must have no other cause (such as lateral myocardial infarction).
• Small R wave and large S wave in the high lateral leads, I and aVL.
• Slurred S wave in V5 and V6.
• This example also contains unrelated ST changes.

 Clinical Pearls
1. The signal exiting the AV node is carried rapidly to the upper aspect of the LV and all of the RV through the intact left anterior fascicle and right bundle, where depolarization is rapid. However, conduction to the inferior portion of the left ventricle is slower and must proceed cell-to-cell
due to the blocked left posterior fascicle. Therefore, the latter portion of the QRS depolarizes toward the inferior myocardium, manifesting as strong right axis deviation.

Meconium Aspiration Syndrome - X ray Chest

This X ray is of a one day old baby who had difficulty breathing.

X-ray chest shows right upper lobe consolidation and rest of the lungs show patchy to streaky areas suggesting meconium aspiration syndrome

Explanation: In meconium aspiration syndrome (MAS) the newborn breathes a mixture of meconium and amniotic fluid into the lungs around the time of delivery.
Meconium is the early feces passed by a newborn soon after birth, in some cases; the baby passes meconium while still inside the uterus. This usually happens due to lack of enough blood and oxygen.
Once the meconium has passed into the amniotic fluid, the baby may breathe meconium into the lungs. This condition is called MAS. It causes breathing difficulty due to inflammation in the lungs after birth.
Meconium aspiration syndrome is a leading cause of severe illness and death in newborns. However, in most cases, the outlook is excellent and there are no long-term health effects provided the infant is placed in newborn intensive care unit for close observation and treatment

Traumatic Cataract

Introduction: 
Any trauma to the eye that disrupts the normal architecture of the lens may result in the development of a traumatic cataract—a lens opacity.
The mechanism behind cataract formation involves fluid infiltration into the normally avascular and acellular lens stroma. The lens may be observed to swell with fluid and become cloudy and opacified. The time course is usually weeks to months following the original insult. Cataracts that are large enough may be observed by the naked eye. Those that are within the central visual field may cause blurring of vision or distortion of light around objects (eg, halos).

               This acute traumatic cataract is seen as a milky cornea at the time of injury

Clinical Pearls: 
1. Traumatic cataracts are frequent sequelae of lightning injury. Advise all victims of lightning strike of this possibility.
2. Cataracts may also occur as a result of electric current injury to the vicinity of the cranial vault.
3. Leukocoria results from a dense cataract, which causes loss of the red reflex.
4. If a cataract develops sufficient size and “swells” the lens, the trabecular meshwork may become blocked, producing glaucoma.

Some Common Deformities of the Pinna (The External Ear)

The pinna is formed from the coalescence of six tubercles, and development abnormalities are common. Also deformities could be seen later on in life following trauma or infection.
Some of the common deformities are shown here with brief description.

1. Duplication of the lobule: It is of of little clinical importance, other than cosmetic worry mostly in females.

2. Hillocks (or accessory lobules): These are commonly found anterior to the tragus, and are excised for cosmetic reasons. A small nodule of cartilage may be found underlying these hillocks.

3. Darwin’s tubercle: A deformity of the pinna of phylogenetic interest. It is homologous to the tip of the mammalian ear and may be sufficiently prominent to justify surgical excision.
Although Darwin’s name is used for this tubercle, Woolmer gave the first description.

4. Microtia: Absence of the pinna or gross deformity is often associated with meatal atresia and ossicular abnormalities. Faulty development of the 1st and 2nd branchial arches results in aural

deformities which may be associated with hypoplasia of the maxilla and mandible, and eyelid deformities

Structural Abnormalities Of the Uterus

1. Arcuate uterus: 

• The cavity has an indentation at the fundus.
• This is probably the mildest form of uterine abnormality.

2. Septated Uterus: 

• The uterus appears normal externally, but the cavity has a septum.

Stress (Exercise Tolerance) Testing - Learning Flash card

Congestive Cardiac Failure As Seen On Chest X ray

An elderly male presents with a history of exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.

His chest x ray is shown below:

Diagnosis : Congestive cardiac failure

Discussion: The Chest X Ray shows classic evidence of left ventricular failure, i.e.

• cardiomegaly (cardiothoracic ratio >50%), 
• upper lobe pulmonary venous diversion, and 
• Kerley B lines (which indicate distension of lymphatics). 

In addition, there is evidence of sternotomy wires, suggesting previous coronary artery bypass surgery (CABG).

Followup Of this Patient: Following diuresis, the pulmonary infiltrates have cleared . (X ray shown below).

Right Ventricular Hypertrophy with Strain - ECG

ECG Criteria
Tall R wave in V1 > 7 mm (also deep S in V5 or V6).

Other Criteria
• R/S ratio in V1 > 1 (R is > S in V1).
• R in V1 + S in V5 or V6 is equal to or > 10.5 mm.
• R in aVR > 5 mm.
• S in V1 < 2 mm.
• Incomplete RBBB (rSR in V1).
• QRS-wide.
• Small q in V1.
• Right axis deviation (between + 90° and + 180°).

Causes Of  Right Ventricular Hypertrophy:
• Chronic cor pulmonale.
• Mitral stenosis with pulmonary hypertension.
• Pulmonary hypertension (due to any cause).
• Pulmonary stenosis.
• Eisenmenger’s syndrome.
• Fallot’s tetralogy.
• ASD.
• VSD.
• Tricuspid regurgitation.

Erythema ab igne

Erythema ab igne (EAI, also known toasted skin syndrome) is a skin condition caused by over exposure to infrared radiations. 

Initially, the skin in erythema ab igne patients is often mildly erythematous; however, after repeated heat exposures, the classic blue, purple, or brown reticulated hyperpigmentation develops.

A history of prolonged or repeated skin exposure to mild-to-moderate heat or infrared radiation that is below the threshold of thermal burn (less than 45°C) should raise suspicion. The duration of exposure varies from weeks to years. 

Examples include: 

• local application of hot water bottles or heating pads used for pain relief, 
• Direct exposure to the optic drive, battery, or ventilation fan of computers. Resting a laptop computer on the thigh (laptop computer-induced erythema ab igne).
• Repeated exposure to heated car seats, space heaters, or fireplaces. 
• Repeated or prolonged exposure to a heater is a common cause of this condition in elderly individuals.
• Occupational hazards of silversmiths and jewellers (face exposed to heat), bakers and chefs (arms)

                        Erythema ab igne as seen on the thigh after prolonged resting of laptop 

Clinical features: 

Erythema ab igne (EAI) is generally localized and usually well-demarcated, presenting with a reticulated macular pattern of erythema and hyperpigmentation . Cutaneous lesions are commonly asymptomatic, although patients may complain of pruritus or a slight burning sensation.

A 50-year-old man is seen in the Emergency department with severe central chest pain...

A 50-year-old man is seen in the Emergency department with severe central chest pain which he says is present for about 18 hours.
His ECG is shown below:

Question:
What does this ECG show and how would you manage this patient?

Answer:

Tinea versicolor - Clinical Presentation And Treatment

Tinea versicolor is a common skin infection caused by the organism Pityrosporum orbiculare (also known as Malassezia furfur, Pityrosporum ovale, or Malassezia ovalis). The condition usually affects adolescents and young adults in tropical environments. The organism is a yeast that is a constituent of the normal skin flora.

Predisposing factors: A number of factors may trigger conversion to the mycelial or hyphal form that is associated with clinical disease, including

• hot and humid weather, 
• use of topical oils, 
• hyperhidrosis, and 
• immunosuppression. 

Clinical features: Tinea versicolor usually responds to medical therapy, but recurrence is common, and long-term preventative treatment may be necessary. Versicolor refers to the variety and changing shades of colors present in this condition. Lesions can be hypopigmented, light brown, or salmon-colored macules. A fine scale is often noted, especially after scraping. Individual lesions are typically small, but frequently coalesce to form larger lesions. Typically the lesions are limited to the outer skin, most commonly on the upper trunk and extremities, and are less common on the face and intertriginous areas. Most patients are asymptomatic; however, some may complain of mild pruritus.

Left Anterior Fascicular Block - ECG

Left anterior fascicular block (LAFB), also known as left anterior hemiblock is an abnormal condition of the left ventricle of the heart, related to, but distinguished from, left bundle branch block (LBBB). It is caused by only the anterior half of the left bundle branch being defective. It is manifested on the ECG by left axis deviation.

ECG Findings
• QRS complex widening, usually 90 to 120 ms
• Left axis deviation beyond minus 45 degrees with no other cause (such as inferior myocardial infarction)
• Small R wave and large S wave in the inferior leads
• Slurred S wave in V5 and V6

Points To Remember:

1. The signal exiting the AV node is carried rapidly to the inferior aspect of the LV and all of the RV through the intact left posterior fascicle and right bundle, where quick depolarization occurs. However, conduction to the high lateral and upper portions of the left ventricle is slower and must proceed cell-to-cell due to the blocked left anterior fascicle. Therefore, the latter portion of the QRS

depolarizes toward the upper lateral myocardium, manifested as strong left axis deviation.

A 60 year old man presents with cough not responding to antibiotics...

The x ray shown in the picture above is of a 60 year old man who presented with a history of cough that was not responding to antibiotics and cough syrups.

X Ray Description: X-ray chest shows a mass lesion measuring 6 cm in diameter in left lower zone of which the margins are not smooth, finding suggestive of carcinoma lung, however, needs confirmation on CT chest.

Case Follow Up : The patient was subjected to CT chest (see the picture below) shows moderately
enhancing irregular mass lesion measuring 5 × 6 cm in the superior segment of Left lower lobe and lingula. Feeding vessel is also seen. Multiple areas of necrosis are seen within. There is central cavitation and air fluid level. Surrounding lung shows infiltration. Multiple pretracheal, carinal, and subcarinal lymph nodes are seen measuring 11–17 mm.

Lens Dislocation

Introduction
Lens dislocation may result from blunt trauma to the globe. As the anterior surface of the eye is struck, there is compression in the anteroposterior dimension with resultant stretching of the globe along its equator in the medial-lateral plane. As this occurs, it stretches the zonule fibers, which suspend the lens in place, and they along with the lens capsule may become disrupted.

Lens Dislocation. Lens dislocation revealed during slit-lamp examination. Note the zonule fibers, which normally hold the lens in place.

Clinical Features
The patient may experience symptoms of monocular diplopia or gross blurring of images, depending
on the severity of the injury. Occasionally there can be dramatic visual fluctuations caused by the lens changing position with resultant phakic and aphakic vision. There is generally a lack of pain except if secondary angle closure glaucoma occurs from the lens causing pupillary block.

Neonatal Dermatoses - Different Types Explained with Pictures For Better Understanding.

Skin disorders are one of the most common problems in pediatrics. Never underestimate parental concerns about their child’s skin. Unlike many disease processes, the skin is visible and noticeable to parents and others. Examination of the skin requires observation and palpation of the entire skin surface under good light. Do not forget to look at the eyes and mouth for mucous membrane involvement. Examination should include onset, duration, and inspection of a primary lesion. It is also important to note secondary changes, morphology, and distribution of the lesions.

Neonatal Dermatoses

1. Cutis Marmorata

• Transient, blanchable, reticulated mottling occurs on the skin exposed to a cool environment.
• No treatment is necessary; the condition generally resolves by 1 year of age.
• If it persists, consider hypothyroidism, heart disease, or other associated abnormalities.

2. Erythema Toxicum Neonatorum

• Scattered erythematous papules and pustules may occur anywhere on the body .
• This self-limited condition generally appears in the first week of life and resolves within 1 month.

Ruptured Liver Abscess.

A 50-year-old male presented to the Emergency Room with shock and a four-day history of a febrile illness. He required intubation and was started on inotropes.
His Chest X ray is shown below:

Case Discussion: It is important to look at the “blind areas” of the Chest X ray in order not to miss important clues. These areas are under the diaphragm, behind the heart, the hilum, and the soft tissues. This Chest X ray shows a lucency over the liver density. The lucency does not conform to the usual bowel configuration. In this clinical context, an important differential diagnosis to be considered is a ruptured liver abscess. This can be confirmed either by bedside ultrasound or CT,

A CT scan was done in this patient which is shown below:

Left Ventricular Hypertrophy (LVH) - ECG Study

ECG criteria of LVH (voltage criteria):
• S wave in V1 + R wave  in V6 or V5 is > 35 mm (S V1 + R V6 > 35 mm).
(This criteria is applicable only above 25 years of age).

Other criteria of LVH:
• R in V5 (or V6) > 26 mm.
• R in aVL > 11 mm (or 13 mm).
• R in aVF > 20 mm (also in LII and LIII).
• R in LI + S in LIII > 25 mm.
• R in LI > 15 mm.
• R in V6 is equal to or greater than R in V5 (normally R in V5 is taller than R in V6).
• S in V1 or V2 > 25 mm.
• Sum of all QRS in all 12 leads > 175 mm.
• Left axis deviation (QRS between –30° and –90°).

                                         Left ventricular hypertrophy with strain

It is important to note that: In young and thin person, this voltage criteria is not diagnostic (in younger person, S in V1 + R in V5 or V6 should be greater than 40 mm).

Q. How to confirm the diagnosis of LVH?
Ans. By echocardiography (M-mode).

Q. What are the causes of LVH?
Ans. As follows:

Drug Induced Lupus Erythematosus

Drug-induced lupus erythematosus is a disorder that is brought on by a reaction to a medicine. In drug induced lupus not all the typical features of systemic lupus erythematosus are seen, with renal and nervous system involvement being unusual. It usually resolves on stopping the drug.

The most common medicines known to cause drug-induced lupus erythematosus are:

• Isoniazid
• Hydralazine
• Procainamide

Other less common drugs may also cause the condition. These may include:

• Anti-seizure medications
• Capoten
• Chlorpromazine
• Tumor-necrosis factor (TNF) alpha inhibitors (such as etanercept, infliximab and adalimumab)
• Methyldopa
• Minocycline
• Penicillamine
• Quinidine
• Sulfasalazine

Symptoms tend to occur after taking the drug for at least 3 to 6 months.

Case Study - Complete 3rd Degree Heart Block

An 80-year-old woman, who had previously had a few attacks of dizziness, fell and broke her hip. She is  found to have a slow pulse, and her ECG is shown below. The surgeons want to operate as soon as possible but the anesthetist is unhappy.

What does the ECG show and what should be done?

The ECG shows:
• Complete heart block
• Ventricular rate 45/min

Clinical interpretation
In complete heart block there is no relationship between the P waves (here with a rate of 70/min)
and the QRS complexes.
The ventricular 'escape' rhythm has wide QRS complexes and abnormal T waves.

What to do

A sexually active 24-year-old woman presents to your office complaining of vaginal discharge.

A sexually active 24-year-old woman presents to your office complaining of vaginal discharge. Findings from a wet prep are pictured here.

The most likely diagnosis is
A) Yeast vaginitis
B) Gardnerella infection
C) Trichomonas infection
D) Gonorrhea
E) Chlamydia

Answer is

Left Bundle Branch Block - ECG

ECG Findings
• Wide QRS complex, at least 120 ms (three small blocks).
• T wave appears on the opposite side of the baseline from the QRS complex.
• The QRS precordial axis is normal or deviated to the left.
• QRS complex deflection is predominately downward in lead V1 and upward in lead V6.

Points to Remember
1. The signal exiting the AV node does not proceed through the left ventricular conduction system. It must propagate more slowly cell-to-cell through the myocardium, starting in the septum. Therefore, the QRS is wider and the bulk of the depolarization signal is deflected toward the far lateral aspect of the heart.

A 2 year old child with Bronchopneumonia

A 2 years old child was brought to radiology department for X-ray chest with cough and high fever over last 3 days. His X ray is shown below:

X-ray chest shows soft small ill-defined opacities scattered in both lung fields partially sparing the lower zones.

Comments And Explanation
On X-ray bronchopneumonia appears as small fluffy ill-defined acinar nodules, which coalesce and enlarge with time and may develop into segmental and lobar densities with volume loss from airway obstruction secondary to mucus plugging and bronchial narrowing.

Diagnosis: Bronchopneumonia.

Clinical Discussion
Bronchopneumonia is a combination of interstitial and alveolar disease.
In bronchopneumonia the insult begins in airways, involves bronchovascular bundle and trickles into alveoli, which may develop and contain edema fluid, blood, leukocytes, hyaline membranes and organisms.

Traumatic Iridodialysis.

Traumatic iridodialysis is the result of an injury, typically blunt trauma that pulls the iris away from the ciliary body.

The resulting deformity appears as a lens-shaped defect at the outer margin of the iris.

Traumatic Iridodialysis. The iris has pulled away from the ciliary body as a result of blunt trauma. A traumatic cataract is also seen. The rosette pattern is classically seen after contusion injuries. It is due to separation of lens fibers around lens sutures. 

Patients may present complaining of a “second pupil.” As the iris pulls away from the ciliary body,
a small amount of bleeding may result. Look closely for associated traumatic hyphema.

Consider etiologies such as

• penetrating injury to the globe, 
• scleral rupture, 
• Intraocular  Foreign body and 
• lens dislocation causing billowing of the iris.

Primary Spontaneous Pneumothorax - Chest X ray

This X ray is of a 25 year old male patient who presented with sudden onset of left sided chest pain.

X ray Description: The CXR shows the visceral pleura separated from the parietal pleura by air which now occupies the potential space in the pleural cavity. The visceral pleura must not be mistaken for skin-fold shadows which usually occur in supine or obese patient CXR. In addition, the line from skin folds can be seen to cross the chest wall.

Understanding Cardiac Axis In ECG

Cardiac Axis Definition: It is the sum of all the depolarization waves as they spread through the ventricles as seen from the front.

Axis Determination
• Axis can be derived most easily from the amplitude of QRS complex in LI, LII and LIII.
• The greatest amplitude of R wave in LI or LII or LIII indicates the proximity of cardiac axis to that lead.
• The axis lies at 90° to the isoelectric complex, i.e. positive and negative deflections are equal in any of the lead LI, LII, LIII, aVL, aVR and aVF.

Normal axis is between –30° to +90°.

Quick and Simple Way of Determination of Cardiac Axis
• Positive QRS in both LI and LII means axis is normal.
• Positive QRS in LI and negative in LIII (tall R in LI and deep S in LIII)—means left axis deviation.
• Negative QRS in LI and positive in LIII ((tall R in LIII and deep S in LI)—means right axis deviation.

Left Axis Deviation
When the cardiac axis is between –30° to –90°.
Causes are :

Discoid lupus erythematosus - A Brief Discussion

Discoid lupus erythematosus is a benign disorder generally seen in younger females. It very rarely progresses to systemic lupus erythematosus (in less than 5% of cases).

Discoid lupus erythematosus is characterized by follicular keratin plugs and is thought to be autoimmune in etiology.

Clinical Features

• erythematous, raised rash, sometimes scaly
• may be photosensitive
• more common on face, neck, ears and scalp
• lesions heal with atrophy, scarring (may cause scarring alopecia), and
• pigmentation

Management

A 60 year Old Man Presenting With Vague Chest Pain On Exertion..

A 60-year-old man was seen as an out-patient, complaining of rather vague central chest pain on exertion.  He had never had pain at rest.
ECG was done and is shown in picture below:

What does this ECG show and what would you do next?

The ECG shows:
• Sinus rhythm
• Normal axis
• Small Q waves in leads II, III, VF
• Biphasic T waves in leads II, V6; inverted T waves in leads III, VF
• Markedly peaked T waves in leads V1-V2

A 12-year-old boy presents with a crusted honey-brown lesion that affects his face

A 12-year-old boy presents with a crusted honey-brown lesion that affects his face. The rash began as red macules 3 days earlier. The best treatment is

A) Intramuscular ceftriaxone
B) Topical hydrocortisone cream
C) Oral ciprofloxacin
D) Topical mupirocin ointment
E) Oral acyclovir

Answer:

Right Bundle Branch Block - ECG

ECG Findings
• Wide QRS complex, at least 120 ms (three small blocks).
• QRS complex has sR’ or rsR’ in leads V1 and V2.
• Slurred S wave leads V6 and I.

Important Points:

1. The signal exiting the AV node is carried rapidly to the LV through the intact left bundle, but is delayed into the right ventricle, where depolarization must propagate cell-to cell. Since the RV myocardial mass is much smaller than that of the LV, this delay in depolarization is best seen in the leads overlying the right ventricle, leads V1 and V2.

2. Acute right heart strain, as may occur with pulmonary embolism, may result in new onset right bundle branch block (RBBB).

A 70 years old male patient with a long history of cough and general weakness.

A 70 years old male patient with a long history of cough and general weakness. His Chest X ray is shown in the picture below:

X-ray chest shows a mass lesion in right upper lobe (arrow), likely a bronchogenic carcinoma.

To confirm the diagnosis, CT chest was performed. CT chest (shown in the picture below A&B) shows ill-defined rounded opacity abutting the chest wall with radiating strand seen in right upper lobe with minimal necrosis within, seen in mediastinal window.

Intraocular Foreign Body

The most important consideration with any eye injury is the possibility of a penetrating globe injury with residual intraocular foreign body (IO FB). Patients may report FB sensation, but subtle presentations occur. A meticulous history about the mechanism of injury (grinding or metal on metal) must be elicited.

Anterior Chamber Foreign Body. A shard from a nail is seen embedded in the anterior chamber. A “teardrop” pupil is present, indicating perforation

Clinical Pearls : 
1. Always maintain a high index of suspicion for penetrating globe injury. Be particularly wary in mechanisms involving use of “metal on metal” such as grinding or hammering. A positive Seidel test demonstrates corneal microperforation.
2. If ocular penetration is suspected, a diligent search for a retained FB is indicated, beginning carefully with bedside ultrasound using a high-frequency transducer. Computed tomography (CT) is the diagnostic study of choice (avoid magnetic resonance imaging [MRI]) with indeterminate results or when confirmation is desired.

Interpreting Chest X ray Of A Patient Diagnosed With Pneumonia

A 35-year-old male presented with fever, cough, and purulent sputum for one week. His Chest X ray is shown below: 

The CXR shows a focal shadow in the right lower lobe with air bronchograms suggestive of pneumonia. It is clearly in the right lower lobe because the right hemidiaphragm is effaced. Right middle lobe shadows would efface the right heart border.
The presence of air bronchograms indicates pathology in the alveoli, as the conducting airways remain patent with air.
Water or blood can also occupy the alveoli as a result of pulmonary edema or pulmonary hemorrhage respectively. There should be other supporting signs such as cardiomegaly, upper lobe diversion, and
Kerley B lines with pulmonary edema.

The differential diagnoses of a focal shadow with air bronchograms include 

• bronchoalveolar cell carcinoma and 
• lymphoma. 

Causes Of Hyperkalemia - Charts

Causes Of Hypokalemia - Charts

Understanding A Normal ECG - Details about The Waves And Intervals.

Characteristics of a Normal ECG:
• Normal ECG recording consists of P wave (atrial beat), followed by QRS, ST and T wave (ventricular beat).
• Capital letter P, Q, R, S, T—indicates large wave (> 5 mm).
• Small letter p, q, r, s, t—indicates small wave (< 5 mm).

TYPES OF WAVES IN ECG
• P — Deflection produced by atrial depolarization.
• QRS — Deflection produced by ventricular depolarization.
• Q (q) — First negative deflection produced by ventricular depolarization. It precedes R wave.
• R(r) — First positive deflection produced by ventricular depolarization.
• S(s) — Negative deflection after R wave produced by ventricular depolarization.
• T — Indicates ventricular repolarization.

OTHER WAVES
• J — At the beginning of ST segment.
• U — Not always seen. When present, it follows T wave, preceding the next P wave. It indicates repolarization of interventricular septum or slow repolarization of the ventricles.

INTERVALS IN ECG
• PR interval — Distance between the beginning of P to beginning of QRS (Q), ideally called PQ interval.
• PP interval — Distance between two successive P waves. In sinus rhythm, P-P interval is regular.
• RR interval — Distance between two successive R waves. In sinus rhythm, R-R interval is regular.
• QT interval — Distance interval between the beginning of Q wave and the end of T wave.

SEGMENT IN ECG
ST—Distance from the end of QRS complex to the beginning of T wave. It indicates the beginning of ventricular repolarization. Normally, it is in isoelectric line, but may vary from – 0.5 to + 2 mm in chest leads.

Discoid Eczema (Nummular Dermatitis)

Eczema or Dermatitis is a term used to describe conditions in where there is inflammation of skin. There are several types of eczema and Discoid eczema is one type which causes round or oval red patches of inflamed skin. It is also known as Nummular dermatititis which means coin shaped lesions. 

Discoid eczema is usually seen in adults with dry skin although it can affect teenagers and young children, but this is rare.

Clinical Features

• typically present as round or oval plaques on the extremities
• the lesions are extremely itchy
• central clearing may occur giving a similar appearance to tinea corporis

Some other symptoms might include: