Arjun Khadilkar, MD Profile picture
Feb 5, 2023 7 tweets 3 min read Read on X
One of the most important diagnostic tests in Cardiology to interpret is the EKG.

Here are my thoughts and notes. Will continue to this thread. Let me know what you think!

Thread #3: ECG Leads

#arjuncardiology #medtwitter #CardioTwitter #MedEd #IMG
ECG Leads:
- Body act as a conductor of electricity; the recording electrodes in the arms, legs, and chest wall show the differences in voltage (potential) among electrodes
- Different views of the same event leads to different ECG patterns
ECG Limb Leads:
- 6 Limb leads (extremity leads) and 6 chest (precordial)
- 3 bipolar limb leads: I, II, III
- 3 augmented unipolar: aVR, aVL, and aVF
- 6 precordial leads: V1-V6
Einthoven’s Triangle:
Lead I: LA - RA
Lead II: LL - RA
Lead III: LL - LA

Remember: Lead I + Lead III = Lead II

Should double check if the R-lead in lead II = sun of the R-waves in lead I and lead III (1 + 3 = 2)
ECG Leads:
- Unipolar leads record the electrical voltage at one location relative to an electrode with close to 0 potential
- aVR + aVL + aVF = 0
ECG Limb Leads
-  V1: 4th intercostal space (right)
-  V2: 4th intercostal space (left)
-  V3: Mid-way b/w V2-V4
-  V4: Mid-clavicle line in 5th intercostal space
-  V5: Anterior axillary line
-  V6: Mid-axillary line
 
*Placement is key, but can be highly variable*
Let me know what you think and stay tuned for the next ECG thread!

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More from @akhadilkarMD

Jul 15
Pre-Rounding Tips 3d: How to think about Troponin? (
(Bookmark or Like/Retweet, will be high-yield for future reference)

If helpful, check out my other threads or join my newsletter (starting on Friday - 7/19/24) for more in-depth insights and Internal Medicine and Cardiology notes:

Pro-Tip: If you can print out a pre-rounding sheet with the labs auto-populated, that is always helpful.

Let's Dive in!
#arjuncardiology #medtwitter #cardiotwitterarjun-cardiology.ck.page/fec5d1458aImage
One of the most common consults from the Emergency Room to Cardiology is 'elevated troponin.'

Yes, elevated troponin can be scary, but here is the framework that I use to analyze / consider troponin.

1. Patient Presentation?
2. Patient's risk factors and prior cardiac history?
3. What is the troponin trend?
4. What does the ECG look like?
5. What are some non-cardiac reasons troponin may be elevated?
1. Patient Presentation?

In Cardiology, the clinical presentation is the most important part of the story when determining the significance of an elevated troponin! In many situations, clinical decisions (whether to pursue a LHC) may be made in the absence of having a troponin available.

Key Questions:
1. If the patient presents with chest pain, how does he/she describe it?
- Some common worrisome symptoms associated with angina. Elevated troponin in the setting of these symptoms should always be taken seriously.
a) Chest pressure, constant, sub-sternal.
b) Radiation of pain to the neck or jaw
c) Diaphoresis
d) Numbness to the left arm
e) New onset dyspnea
f) Worse with exertion, better with rest

2. What makes the pain better?
- If the patient got improvement with nitroglycerin more likely to be consistent with cardiac chest pain.
- If patient's pain improves with muscle relaxers, IV toradol, IV PPI, IV Ativan, less likely to be a cardiac etiology.

3. Has the patient had this type of pain before?
- If similar recent presentation with a negative work-up, this might be reassuring. However, you don't want to have anchor bias and should keep an open perspective.
Read 6 tweets
Jul 10
When I was an intern, pre-rounding was one of the most stressful parts of the day. I would take too long and be inefficient. Part 1.

Now as a PGY7 (long-time, right?), here is 3 parts of my system that I use for new patients.

If you liked this thread, be sure to subscribe to the newsletter in my bio.

On Twitter, I will provide a more condensed version for easier reading. In the email format, I will expand on my thoughts to provide more detailed insights. I will walk you through my thought process and make sure they are concise but helpful.

Future direction will be ECG/Echo/General Cardiology Topics!

#arjuncardiology #cardiotwitter #MedTwitter
1) Why is the patient here / chief concern?

- This seems like the most basic question that is often overlooked. What made the patient decide to leave his/her house to come to the hospital?

- When reading the overnight H&P, the abundance of clinical documentation can create confusion.

- Simplicity is key. What is the chief concern? Is it chest pain? Is it dyspnea on exertion? Knowing this information will help frame your thoughts.
2) What are the relevant past medical problems?

- Most patients will have chronic medical problems that will contribute to the current presentation.

- It is easy to get lost in the weeds of this presentation. In Cardiology, I typically focus on (but not limited to) coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, diabetes mellitus, history of CVA. Again, this is not all inclusive but it is a start.

- Although patients may present to the hospital with a new diagnosis, it is more likely that the presentation may be an exacerbation of a previous problem.
Read 5 tweets
Jun 6, 2023
As an intern, chart checking new patients was intimidating and time-consuming.

Even as a cardiology fellow, I continue to refine my system.

Here are 7 tips and tricks to help you out!

#arjuncardiology #MedTwitter #MedEd #Cardiotwitter #IMG Image
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Read 10 tweets
Jun 4, 2023
Studying for the IM Boards and Step 2 CK can be challenging.

Here are some of my notes that can help you.

Part #24: Ophthalmology : 5 High-yield facts!
#arjuncardiology #medtwitter #MedEd #IMG Image
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Read 7 tweets
Jun 1, 2023
During my Internal Medicine training, I wrote 100s of History and Physicals (H&Ps).

Now as a Cardiology fellow, I read every single H&P for a new consult.

Here are 7 tips and tricks for effective H&Ps. #arjuncardiology #MedTwitter #MedEd #Cardiotwitter #IMG Image
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Read 10 tweets
May 31, 2023
Studying for medical exams can be challenging.

Here are some of my notes I used to study for the IM Boards. Also high-yield for Step 2 CK!

Part #23: Dermatology: 5 High-yield facts! #arjuncardiology #medtwitter #MedEd #IMG Image
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Read 7 tweets

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