This is an electrocardiogram from a man in his 80's. The patient has severe lung disease, has mitral regurgitation secondary to bacterial endocarditis , and is taking digoxin, Lasix and potassium. The electrocardiogram shows sinus rhythm and a QRS with a left axis deviation, a QRS duration of 118 milliseconds and a tall are wave in the first precordial lead V1 with an R wave height of approximately 21 mm. The prolonged QRS duration and the S waves that are seen as lead one and lead the six suggest a right on the Branch block and the a left axis deviation suggests a left anterior hemi-block . Finally the tall R wave in V1 lead suggests right to ventricular Hypertrophic.