1. The HyperGram EKG programs are designed to help guide Third Year Medical Students in using a 10 item system for rapidly interpreting “real” EKGs using the “Yellow Card”. This card is based on a simple approach to EKG Interpretation that traces the sequences of depolarization and repolarization of the heart and asks: 1) “Is this step normal?” If the answer is no, It asks “What is the abnormality?” Because of its simplicity it is of necessity incomplete. However it covers all the common important problems. More importantly, it helps the student avoid missing obvious abnormalities. As it is used, the students develop confidence in their ability to interpret EKGs systematically, and they begin to fill in gaps not covered on the Yellow Card. To learn EKG interpretation, nothing is a substitute for practice. The Yellow Card makes practice easier. The more EKGs a student interprets, the more proficient he/she becomes. The card is laminated and designed to fit easily into a shirt/jacket pocket. If one is not available, slides 3 and 4 can be printed as a handout, 2 slides per page, cut and folded. This should produce a compact paper version. The 3 second lines on the original may not be correct on a printed version. To correct for this, make two marks, 75 mm apart (@25mm/sec = 3 sec along the x axis). Abbreviations from the card are defined on the next slide. HyperGram* EKG Programs “Yellow Card” *HyperGram© is a teaching program created originally by Robert Zelis, M.D. for the Macintosh computer using the HyperCard program. Copyright 1996 & 2010. 3/14/2010

2. List of abbreviations – Yellow Card.04QsQ wave width ≥ 0.04 sec (one little box)NSRnormal sinus rhythm 1°, 2°, 3°1st, 2nd, 3rd degree AV blockPJCpremature junctional complex AbnlabnormalPostPosterior wall (reference to MI site) AntAnterior wall (reference to MI site)Precordprecordial (leads) Bradybradycardia. HR < 50PWRPpoor R wave progression c/oconsiderR>SR wave height > S wave depth digdigitalisRADright axis deviation (>+ 90°) InfInferior wall (reference to MI site)RR R wave to R wave interval measurement intintervalRV6R wave height in V6 LABFBlock of anterior fascicle of left BundleSeptSeptal wall (reference to MI site) LADleft axis deviation (>- 30°)subendosubendocardial (reference to MI site) LAEleft atrial enlargement or hypertrophySV1S wave depth in V1 LatLateral wall (reference to MI site)SVTsupraventricular tachycardia nl/NLnormalTachytachycardia. HR ≥ 100

3. If a step is abnormal, turn the card over to see the most common causes POCKET GUIDE FOR THE SYSTEMATIC INTERPRETATION OF EKGs 10 ElementsNORMAL FINDINGS 1. HR 50; RR interval 3-6 big boxes; 3 sec. marks above (=75mm) 2. RhythmRegular, All QRSs preceded by a normal P (vector~+60°) 3. EctopyNo Early Beats 4. PR Interval≤.2, >.1 sec. (.2 is NORMAL), All Ps followed by QRS 5. QRS Interval<.12 (<3 little boxes) (.12 is ABNORMAL) 6. QRS AxisQRS upright in BOTH lead I & lead II (-30° to +90°) 7. QRS TransitionAfter V2, Before V5; R waves increase from V1 to V4 8. HypertrophyNo RAD; RV5,6 + SV1,2<35mm, RaVL<12,ST-T nl, NoLAD 9. InfarctionNo Q waves =.04 in 2 contiguous leads, No "PRWP" 10.RepolarizationFrontal: T Upright where QRS upright; QRS down,T down © 1996, 2010 Precord: T always upright V4 to V6; T V1 can be + or - Robert Zelis ST within 1 mm of isoelectric; QT < 50% of RR interval SUMMARY:Normal EKG=NSR@___,No ectopy, NL PR & QRS intervals, NL QRS Axis & Transition, No Hypertrophy or MI, NL Repol; NORMAL EKG Question #1. “Is this step normal or abnormal ?”

4. Question #2. “What is the problem ?” Big 10ABNORMALITIES 1.HRTachy/Bradycardia; // Irregularly Irregular RR = Atrial Fib. 2.RhytmP@300&QRS@150=A.Flutter with2:1AVBlock;SVT@180=reentry 3.EctopyEarly Beats( Abnl QRS&noP=PVC) (Nl QRS:abnl P=PAC; noP=PJC) 4.PR int.PR>.2=1°AVB;Some Ps&noQRS=2°AVB; Independent Ps&QRSs=3° 5.QRSint≥.12:Note terminal QRSvector(LBBB=RV6,SV1;RBBB=SV6,RsR'V1) 6.Axis(+aVL) = LAD = -30 to-90° (DDx: LBBB, Inf.MI, LVH, LAHB) I- or II-(+III) = RAD = +90 to+180° (DDx: RVH, RBBB, R&L reversed) 7.Trans.Late/PRWP (LBBB,As/AntMI,LVH,rvh); Early (RVH,Post.MI,RBBB) 8.HyptroLVH=Incr.LV Volts+repol.(orVolts+LAD+LAE);RVH=RAD+R>S inV1 9.MI.04Qs: II,III,F=Inf; V1,2=Sept; V3-4=Ant; I,L,V5,V6=Lat;wide RV1=Post 10.RepolAbnl T Vector: Secondary to Hypertrophy, BBB, Drugs (eg.dig); Penn StateOR Primary (ischemia=labile Ts); OR Nonspecific T abnormalities; CV Center ST elevation (Acute Injury-localized; Pericarditis-most leads) Zelis-GuideST depression (subendo ischemia OR secondary);long QT c/o drug 3/15/2010 SUMMARY - ABNORMAL or BORDERLINE EKG