1. ID 279 – This 57 year old woman who had rheumatic fever at age 17 has been suffering from severe dyspnea and fatigue during the past year

2. ID 279 – Normal sinus rhythm, 80/min Yes: The P waves originate from the sinus node– The rhythm is regular , the rate is 80/min. – Each P is followed by a QRS - The PR interval is normal – NORMAL SINUS RHYTHM, 80/min

3. ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement There are signs of left atrial enlargement

4. Let’s now look at the QRS complexes: There is Right axis deviation ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation

5. Let’s now look at the QRS complexes: There is Right axis deviation ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation

6. The QRS duration is normal : There is no right bundle branch block, left bundle branch block or non-specific block ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation

7. There is right ventricular hypertrophy ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation Right ventricular hypertrophy

8. There are no QRS signs of myocardial infarction ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation Right ventricular hypertrophy

9. There is ST depression in II, III, aVF and the right chest leads (V1-V3) may be due to RVH – There are negative T waves in V4-V6. Diffuse T changes are not uncommon in patients who are in heart failure. They may be due to ischemia ID 279 – Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation Right ventricular hypertrophy

10. There is ST depression in II, III, aVF and the right chest leads (V1-V3) may be due to RVH – There are negative T waves in V4-V6. Diffuse T changes are not uncommon in patients who are in heart failure. They may be due to ischemia ID 279 – Final diagnosis: Normal sinus rhythm, 80/min – Left atrial enlargement – Right axis deviation Right ventricular hypertrophy with ST-T abnormalities