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The ECG shows sinus rhythm with normal axis and intervals. The two notable findings are 1) inferior Q-wave myocardial infarction (MI) of indeterminate age and 2) diffuse ST elevations in anterior and lateral leads, with PR deviations (up in aVR, down laterally) c/w with pericarditis. The story was of prior MI with pericarditis post-coronary artery bypass graft (CABG) surgery. If you know anyone who got this right (the first time), drop us a line so we can sign them up for a Cardiology Fellowship!

? Answer Case 34 ?
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? Case 34 ?*?**?*??

Sinus rhythm with left atrial abnormality. Most striking are tall right precordial R waves with pathologic inferior and lateral Q waves giving a "reverse" type R wave progression. There are also ST-T abnormalities in I, aVL, V6. Thus the patient has coronary artery disease (CAD), s/p large infero-(postero)-lateral myocardial infarction (MI) accounting for congestive heart failure (CHF) findings. Recall that differential diagnosis of tall right precordial R waves includes: 1) Normal/positional variants, 2) Right ventricular hypertrophy (RVH) (look for right axis deviation, P pulmonale), 3) Posterior/lateral MI (usually signs of inferior MI, too), 4) hypertrophic cardiomyopathy/idiopathic hypertrophic subaortic stenosis (HCM/IHSS), 5) right bundle branch block (RBBB), 6) Wolff-Parkinson-White (WPW ) variants with posterior/lateral pre-excitation 7) Duchenne muscular dystrophy (young men with myopathy).