1. Q1. (i) What are the rate and rhythm? (ii) What is the QRS pattern?

2. Q1. - Answers A nice easy one to start!
The rate is 300/4.5 = 66(67)bpm.
The rhythm sinus rhythm with extreme first degree heart block
There is a broad, dominant RV1 consistent with RBBB
Note – the T-wave inversion in leads V1 to V3 may be part of the RBBB or may represent ischaemia or right heart strain.

3. Q2. List five ECG abnormalities

4. Q2 - Answers
This is another good ECG to test whether you are using the ECG checklist correctly Rate: 300/2.5 = 120bpm i.e. tachycardia Rhythm – Sinus (thus sinus tachycardia) P wave and PR interval - normal Axis – Going towards the RIGHT but is actually normal as lead II is strongly positive QRS – Broad with Dominant RV1 – i.e. RBBB T waves inverted V1 – V4 (Part of Right heart strain; also T wave inversion II, III and aVF The famous S1Q3T3 This ECG has almost every feature of an acute pulmonary embolism – in most cases only sinus tachycardia is present.

5. Q3. What are the abnormalities in (i) The inferior leads
Q3. What are the abnormalities in (i) The inferior leads? (ii) The anterior leads? (iii) The high lateral leads?

6. Q3. - Answers
This is a good test of whether you know the territories represented on the ECG
Inferior leads (II, III and aVF) – Gross ST elevation
Anterior leads (V1 – V4) – ST depression, gross in V2 and V3
High lateral leads (I and aVL) – ST depression
This ECG represents an Inferoposterolateral STEMI; There is also Third degree (complete) heart block. The important thing is that you spotted the ST elevation in II, III, aVF!

7. Q4. Excluding the changes in leads V4 and V5, list three abnormalities of the ECG

8. Q4. Answers
Rate: 60 – 88 bpm Rhythm: Irregular and there are no discernible P waves (i.e. you can’t see any obvious P waves) Atrial fibrillation Axis – This is quite difficult to work out! All three leads are almost iso-electric so the axis is normal (Just!) QRS complexes – broad with Dominant RV1 and RV2 i.e. RBBB Twave inversion in leads II, III and aVF, V1 – V3 Answer: Controlled atrial fibrillation with RBBB and T-wave inversion in the inferior and anterior leads.

9. Q5. List five abnormalities of the ECG

10. Q5. - Answers
Another one to sort out your ECG checklist!
Rate: 55 – 88bpm
Rhythm: Irregular with no P-waves i.e. atrial fibrillation
Axis: Lead I and II are slightly positive thus the axis is normal
QRS: Broad with dominant V1 and V2 i.e. RBBB
ST elevation with Q waves III and aVF, V1 and V2
ST depression I, aVL and V6
T wave inversion V1 to V6
This is an acute inferior STEMI with anterolateral ischaemia; There is also controlled Atrial fibrillation and a RBBB pattern!

11. Q6. What is the axis and the QRS pattern?

12. Q6. Answers There is left axis deviation and Left bundle branch block
Axis – note leads I and III are ‘LEAVING’ one another; lead II is just iso-electric.
This is a very characteristic LBBB pattern with large negative complexes anteriorly and dominant positive complexes laterally
The combination of LAD and LBBB is most commonly seen in patients with IHD.