What Do You Think 11

32-year old elephant trainer with flat feet.

Clue: sinus rhythm with 12-lead ECG, but P waves hard to see.  

What do you think?

It isn’t hard.

Again dissect it down to its basics.

• Sinus rhythm 60 bpm (red vertical arrows). Yes 60 bpm!
• Alternate beats are premature; bigeminy.
• Interpolated atrial ectopics (red highlight).
• Some ectopics are conducted with aberration(yellow highlight).

Sinus rhythm with bigeminal interpolated atrial ectopics and aberration