A large R-wave in lead V1

This 20-something male presented with alcohol withdrawal, alcoholic hepatitis, and alcoholic steatosis.  There was no chest pain or syncope, but an ECG was recorded as part of his workup.What is it?I received this message about it:Steve,I was just looking back at this patient and noticed that he was diagnosed with WPW based on his ED EKG, and I certainly did not pick up on it. I was thinking it looked like an incomplete right bundle pattern.  I'm curious about the EKG - the admitting IM resident notes "wide QRS and delta wave with short PR" but his PR is 152 and 145 on both EKGs. Looking at it, I see the delta wave, but thought a short PR was a requirement for WPW diagnosis. Any thoughts on how I can spot this next time? Any other thoughts on his somewhat odd-looking EKG?Dr. _______My answer:Dear _____I saw this ECG and knew instantly it was WPW.  I actually put the formal interpretation into the system.  How did I know?  By pattern recognition.How can I make the diagnosis if I don't recognize the pattern?There are only a few causes of large R-wave in V1:1. Right Ventricular Hypertrophy (RVH) [on first glance, that could be etiology here, since there is also a deep S-wave in lead I (a requirement -- right axis deviation)].2. WPW3. Posterior MI (at first glance, this could be posterolateral MI: there is STE in aVL and ST depression in V1-V4).4. Lead placement5. RBBB (this requires an rSR' in lead V1, and deep S-wave in V6, which are not present here). ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs