Okay, the answer is that she has hisperkinesia disease. Why is that? Well, if we trace where her P waves are here, you can see in her baseline tracing that she actually has a second P wave deforming the end of the T wave here. Little bit unusual looking T wave, pretty broad here. And she's plugging along in two to one block here with right bundle branch block. Let's look back at her baseline ECG. She has right bundle branch block, a little bit of left axis deviation, not terrible. A normal PR, so not likely to be avian nodal disease. And here you can see these P waves that are deforming the end of the T wave here during sinus rhythm. During anxious, she increases her sinus rate appropriately. She doesn't have chronotropic incompetence, at least from a sinus perspective. And that's what the distractor was, number one. So she has these P waves that are now popped on top of the T wave. And it's very different looking T wave than it was before. And she maintains her PR interval as it was. Avian nodal disease is not present. It is in the hispokinesis system. So these red dots indicate where her P waves are with her normal PR interval and right bundle branch block. It's more than likely in the hispokinesis system as to the site of her conduction problem. Her heartbeat during exercise fails to increase not because of sinus node problems, but because of persistent conduction in the hispokinesis system. Thank you for your attention. ♪♪

hisperkinesia

ECG

right bundle branch block

conduction issues

two-to-one block