Recording267 · Current educational rationale notes
These are authored educational rationales, not copied source-page text, a diagnosis or certification. Source document: ABIM_ECG_Complete_531_Case_Master.pdf; source73 page232. The private source PDF is not served. Source access and commercial rights are not granted by these notes.
Machine-readable finding references · Scoring method · Practice app
1. Normal ECG
incorrect
Premature atrial beats and anterior inverted T waves preclude normal ECG.
2. Normal variant
incorrect
At age82, anterior T inversion with premature atrial beats is not established as a listed benign variant; no narrow rSRprime or early-repolarization pattern.
3. Incorrect electrode placement
incorrect
Positive I P/QRS and preserved precordial progression do not show limb reversal or precordial transposition.
4. Artifact
required
Full raw/native trace has abrupt non-QRS limb notches and steps, e.g. II/III near3.62 and5.94s, with much cleaner precordial baselines; real acquisition/movement noise, not flutter or pacing. Terminal export hold is separately censored.
5. Right atrial abnormality or enlargement
neutral
Premature P near4.70s reaches about3.2mm in III on paired references, while II is1.66–2.48mm and aVF2.38–2.69mm across actual preP/latePR references. Source inferior-lead distribution and aVF threshold are uncertain; no ectopic-inferior exclusion invented. V1/V2 premature P overlaps prior T and is not a reliable RA amplitude baseline. Full PDFp2014 additionally excludes RA based on ectopic V1 P specifically; not extended to inferior leads or source6.
6. Left atrial abnormality or enlargement
neutral
V1 sinus terminal negative lobes are generally0.5–0.9mm deep; beat4 approaches0.99mm on latePR with baseline/noise sensitivity, not a robust >1mm result. PAC preP overlaps previous T and is not usable terminal-P proof. Inferior notching is noisy, with no secure >120ms notched P. Neutral rather than false certainty near boundary.
7. Sinus rhythm
required
Actual V2 atrial apices establish underlying sinus PP mostly.618–.656s (91.5–97.1/min), with corresponding positive I/II P; two different premature P and post-PAC reset intervals are reported separately. No RR surrogate used.
8. Sinus arrhythmia
neutral
Ordinary sinus PP variation is below10%, but premature atrial/reset intervals markedly alter total PP. Low-amplitude atrial onset/apex uncertainty and ectopic-reset attribution prevent assigning independent sinus-arrhythmia credit; no persistence requirement imposed.
9. Sinus bradycardia
incorrect
Underlying actual sinus PP rate about92–97/min, not<60.
10. Sinus tachycardia
incorrect
Underlying sinus PP is not>100/min; short coupling intervals belong to two differently shaped premature P, not sinus tachycardia.
11. Sinus pause or arrest
incorrect
No >2s observed P-free pause. Terminal small P is followed by export hold, not proof of arrest.
12. Sinoatrial exit block
incorrect
No PP-multiple dropped-P pauses or grouped SA-exit-block pattern; isolated premature atrial/reset events account for timing changes.
13. Premature atrial complexes
required
Premature altered P in II/III/aVF/V1/V2 near4.70 and9.10s precedes unchanged narrow QRS at4.834 and9.218s. Coupling RR.434 and.484s is shorter than ordinary.618–.634s; first is followed by.760s reset interval.
14. Atrial tachycardia
incorrect
Two isolated premature P, not at least three successive ectopic atrial beats.
15. Multifocal atrial tachycardia
incorrect
No three established P morphologies with sustained atrial rate>100; recorded sequence is mainly sinus with two similar premature atrial events.
16. Supraventricular tachycardia
incorrect
Ordinary ventricular rhythm is below100/min; two isolated shortened coupling intervals do not form the source regular rhythm>100. No invented nonsinus or persistence prerequisite.
17. Atrial flutter
incorrect
Discrete low-amplitude P separated by quiet segments rather than organized continuous flutter activity; no typical240–340/min atrial train.
18. Atrial fibrillation
incorrect
Organized P precedes each fully acquired QRS, including premature P, not absent-P fibrillation.
None. Premature AV-junctional complexes
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
20. AV-junctional escape complexes
incorrect
No late junctional escape after pause or block; premature complexes have antecedent ectopic P.
21. AV-junctional rhythm or tachycardia
incorrect
Sinus-axis P before ordinary QRS, not retrograde/junctional train.
22. Premature ventricular complexes
incorrect
Premature complexes are preceded by altered P and retain native QRS morphology; no premature ventricular-origin wide complex.
None. Ventricular parasystole
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
24. Ventricular tachycardia
incorrect
No three consecutive ventricular-origin premature beats>100/min.
25. Accelerated idioventricular rhythm
incorrect
Linked P/QRS sequence and unchanged narrow morphology, not ventricular-origin rhythm; rate in90s alone does not establish AIVR.
26. Ventricular escape complexes or rhythm
incorrect
No20–40/min ventricular escape train.
None. Ventricular fibrillation
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
28. First-degree AV block
incorrect
Measured global P/QRS envelopes give PR98–172ms, well below200ms; lead-specific P feet measured rather than formula offsets.
29. Second-degree AV block: Mobitz I / Wenckebach
incorrect
No progressivePR followed by nonconducted acquired P. Terminal expected beat lies in censored export hold.
30. Second-degree AV block: Mobitz II
incorrect
No intermittent nonconducted P with PP-multipleRR; premature P is present at short intervals.
31. Two-to-one AV block
incorrect
One observed P per acquired QRS, not twoP perQRS.
32. Third-degree AV block
incorrect
P and QRS linked rather than independently marching atrial/ventricular clocks.
33. Wolff-Parkinson-White pattern
incorrect
Some PR bounds are short, but there is no delta-wave slurred upstroke with adult QRS>120ms; short PR alone is insufficient.
34. AV dissociation
incorrect
Recorded P-to-QRS associations persist, not AV dissociation.
35. Low QRS voltage in limb leads
incorrect
II and I QRS excursions exceed5mm, contradicting all-limb low voltage.
36. Low QRS voltage in precordial leads
incorrect
V3–V6 QRS excursions exceed10mm, contradicting all-precordial low voltage.
37. Left-axis deviation
incorrect
Frontal peak-net and integrated methods span+12…+69degrees across paired baselines, not−30…−90.
38. Right-axis deviation
incorrect
Both axis methods remain far below source100degree right-axis boundary.
39. Electrical alternans
required
Paired-baseline III R varies.183–.637mV and ordinary-beat variation also exceeds local quiet noise; V5 amplitudes vary as well. Full source permits broad beat-to-beat amplitude/direction variability, not mandatory alternating big/small pattern. Noise and ectopy separately documented; no effusion causal credit.
40. Left ventricular hypertrophy
incorrect
Female82 Cornell12.8–14.6mm below20, Sokolow maximum25.2mm below35, and aVL R below11mm; no source LVH voltage route.
41. Right ventricular hypertrophy
incorrect
No right axis and lateralR remains dominant; right-precordial T inversion alone does not establish RVH.
None. Combined ventricular hypertrophy
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
43. Complete right bundle-branch block
incorrect
No complete RBBB morphology: V1 terminal forces negative and lateral terminalS is not broad>40ms; adult global duration envelope does not establish≥120ms.
44. Incomplete right bundle-branch block
incorrect
Specific RBBB morphology not met, regardless of near110ms conservative duration bounds.
45. Left anterior fascicular block
incorrect
Axis is positive, not−45…−90; no LAFB pattern.
46. Left posterior fascicular block
incorrect
Axis is not90…180 and I/aVL not predominantlyrS; no width-only exclusion used.
47. Complete left bundle-branch block
incorrect
No broad notched lateralR with delayed>60ms intrinsicoid deflection or meanQRS≥120ms.
None. Incomplete left bundle-branch block
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
50. Aberrant conduction, including rate-related aberrancy
incorrect
No rapid-rate QRS>120ms normalizing at slower rate; premature atrial QRS retain morphology.
49. Nonspecific intraventricular conduction disturbance
neutral
Manual global QRS mean envelope78.7–109.7ms approaches strict>110ms within sampling/endpoint uncertainty. No specificBBB; neutral rather than pretending endpoint precision rules out every borderline estimate.
51. Anterolateral MI: recent or probably acute
incorrect
No contiguous anterolateral qualifying pathologicalQ/QS or truepostJ injury elevation.
None. Anterolateral MI: indeterminate or probably old
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
53. Anterior or anteroseptal MI: recent or probably acute
incorrect
Anterior smallinitialR precedesS and no contiguous female1.5mm truepostJ elevation.
54. Anterior or anteroseptal MI: indeterminate or probably old
incorrect
Preserved initialR inV1–V4 rather than qualifying contiguous pathologicalQ/QS.
55. Lateral MI: recent or probably acute
incorrect
No qualifying lateralQ pairs or contiguous truepostJ lateral injury elevation.
56. Lateral MI: indeterminate or probably old
incorrect
I/aVL initialnegative deflections are not paired qualifying≥30ms/.1mV pathologicalQ.
57. Inferior MI: recent or probably acute
incorrect
No contiguous inferior truepostJ elevation; III earlynegative deflection alone is not acute inferior injury.
58. Inferior MI: indeterminate or probably old
incorrect
III initialnegative deflections occur, but no second inferior lead has qualifying≥30ms/.1mV pathologicalQ; II predominantly initialR.
59. Posterior MI: recent or probably acute
incorrect
V1 initialR is small with terminalS and invertedT; no pairedV1/V2 broad dominantinitialR with concordantpositiveT.
60. Posterior MI: indeterminate or probably old
incorrect
No pairedV1/V2 posterior-infarct broadinitialR/concordantpositiveT morphology.
61. Early-repolarization normal variant
incorrect
No elevated concaveJ takeoff with uprightT/notchedR; anteriorT inversion is not earlyrepolarization.
None. Juvenile T-wave normal variant
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
63. Nonspecific ST or T-wave changes
required
V3/V4 mildly inverted or flattenedT and mild postJ displacement meet nonspecific morphology. Supported descriptive alternatives63/64/66 count once.
64. ST or T-wave changes suggesting ischemia
required
V1 negative T on beat11 is2.06–2.30mm across preP/latePR/postT references, and beat13 is2.02–2.21mm; meets≥2mm inversion criterion without adding lead restrictions. Other beats straddlethreshold because baseline evolves. Educational ischemia-suggesting morphology only, not coronary cause confirmation. OR63/64/66 once.
None. ST or T-wave changes suggesting myocardial injury
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
66. ST or T-wave changes suggesting an electrolyte disturbance
required
FlattenedT and mildST depression meet complete source descriptive electrolyte-associated pattern without mandatoryU or lab proof. No biochemical diagnosis; OR63/64/66 once.
67. ST or T-wave changes secondary to hypertrophy
incorrect
Neither LVH nor RVH source criteria met; repolarization changes not credited as hypertrophy-associated.
68. Prolonged QT interval
neutral
Earliest global QRS foot and pairedRR give PAC8 early anterior QTc440–510ms, but V5 later component if terminalT gives683–768ms. Its first valley is not a proven isoelectric plateau. Similar V4/V6 late small humps support possible smallU/evolvingbaseline, not definitive exclusion of terminalT. Source68 is neutral on actual T-vs-U/baseline ambiguity, not ectopic-beat exclusion, persistence, or an assertion that allboundsstraddle460. PAC15 early candidate446–497ms also remains documented.
69. Prominent U waves
incorrect
No distinct U>1.5mm. A smaller late component near5.12–5.16s could be U versus fused/bifid terminalT or evolvingbaseline; it is not the nextP, whose globalfoot is5.428s. No prominentU credit, and no claim that everylatewaveisP.
70. Brugada syndrome
incorrect
No pseudoRBBB with coved/saddleback persistentV1–V3 ST elevation.
71. Digitalis toxicity
incorrect
No≥3beat atrialtachycardia, AFcompleteblock, advancedAVblock orbidirectionalVT. Atrialtachycardia would not requireAVblock under source.
None. Torsades de pointes
neutral
Null source mapping preserved; no invented golden criterion or point. Neutral0/0.
73. Hyperkalemia
incorrect
Incorrect for the recorded ECG pattern after morphology review. Native and focused QRS9–12 show compact main QRS with small initial/terminal deflections, not convincing generalized widening or BBB; upper uncertainty bounds116–120ms alone do not establish the separate widening component. Anterior T waves are broadly inverted and laterals low/broad, not tall narrow peaks; actual longest-T/PAC alternatives are normal-to-long or unresolved later termination, not convincing short QT combined with ST-T depression. Underlying sinus92–97/min with atrial premature beats has no bradycardia/arrest or ventricular tachyarrhythmia. Isolated ST depression is insufficient. No numeric short-QT cutoff or all-features-mandatory rule is used; this does not exclude biochemical hyperkalemia.
74. Hypokalemia
neutral
FlattenedT/STdepression overlap fullsource hypokalemia; no mandatoryU or lab prerequisite, but biochemical cause unestablished.
75. Hypercalcemia
incorrect
QT is not demonstrably shortened; some Bazett envelopes are prolonged-borderline, not hypercalcemicshortQT.
76. Hypocalcemia
neutral
SomeQT envelopes crossprolonged boundary, but no certain interval or biochemicalcause; neutral0/0.
77. Mirror-image dextrocardia
incorrect
PositiveI P/QRS and preserved precordial progression contradict mirror-imagedextrocardia.
78. Acute cor pulmonale, including pulmonary embolism
neutral
NonspecificSTT is an overlapping listed pulmonaryembolus manifestation; no acute pulmonarycause established, no mandatoryS1Q3T3 requirement.
79. Pericardial effusion
neutral
Broadsource39 amplitudevariation overlaps sourceeffusion and/or criterion, but does not identify pericardialcause; highvoltage doesnot itselfexcludeeffusion.
80. Acute pericarditis
incorrect
No diffuseST elevation with aVRPRelevation/otherlimbPRdepression pattern.
81. Hypertrophic cardiomyopathy
neutral
NonspecificSTT overlapfullHCMsource; noLVH/Q/RVHpattern and no apicalV4–V6 deepT morphology. No invented giantTthreshold or HCM causalcredit.
82. Central nervous system disorder
neutral
AnteriorT inversion and uncertainQT overlap portions of fullCNSsource; not proof of CNSdisease. No requirement that all listed manifestations coexist.
83. Hypothermia
neutral
QT-duration uncertainty overlaps one sourcehypothermia manifestation, without establishedbrady/AF orOsbornJ. No temperaturecause credited.
84. Atrial or coronary-sinus pacing
incorrect
No trueatrial pacingstimuli; limbnotches are noncardiactransients.
85. Normally functioning VVI demand pacing
incorrect
No ventricular pacingstimulus/different pacedQRS.
86. Normally functioning DDD dual-chamber pacing
incorrect
No pairedatrial/ventricularstimulus DDDpattern.
87. Pacing capture failure, atrial or ventricular
incorrect
No actualpacingstimulus withoutcapture; terminalexporthold is notpacingfailure.
88. Pacing sensing failure, atrial or ventricular
incorrect
No truepacemaker firing at inappropriate intervals.
89. Paced QRS morphology compatible with biventricular pacing / CRT
incorrect
No dualventricularstimuli within80ms orCRT morphology.