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A 51-year-old security officer had an electrocardiogram recorded because of a strong family history of coronary arterial disease (Figure (Figure11). His medical history was significant for a gunshot wound to the left side of his chest in the line of duty 25 years earlier.
The electrocardiogram shows sinus rhythm and prominent R waves in leads V1 to V3 and otherwise is normal. The Table lists many of the causes of tall R waves in the right precordial leads and confirming clues to their diagnoses (1).
In this patient, the chest radiograph makes the diagnosis (Figure (Figure22). Eventration of the left hemidiaphragm, the result of left phrenic nerve damage from the gunshot, allows upward displacement of the gut that pushes the heart far enough to the right that leads V1 to V3 lie over the left ventricle and record complexes resembling those usually recorded from the left precordial leads. A similar appearance may occur when atelectasis of the right lung causes a rightward displacement of the heart (2).