People who are crazy enough to think they can change the world, are the ones who do. -Rob Siltanen Welcome back to Roshcast Episode 33! This episode marks an incredible milestone for Roshcast. Exactly 365 days ago, Roshcast was born (Apgar’s 7 and 9). It is wild to look back and think about how much we have covered – hundreds of questions, thousands of pearls, dozens of test-taking strategies, regular tweets, etc. We couldn’t be more excited about where Roshcast has been or where it is going. In honor of hitting one year, we are doing another trauma ring tone competition. During episodes 34 to 38, listen for a trauma ring tone, and tweet the exact time to us or e-mail the time to us. A few weeks ago, we also launched a new partnership with the EM Clerkship podcast as a core EM corollary for selected topics. This week, we are doing another crossover episode, in which we return to cardiac arrhythmias — specifically, bradycardia. Let’s get the episode started with a rapid review of some essential vitamins, which were recently covered on the Rosh Blog. * The fat-soluble vitamins are A, D, E, and K. * Vitamin D deficiency can lead to rickets in children and osteomalacia in adults. Vitamin D deficiency is classical seen in the elderly, those with insufficient sun exposure, malnutrition, malabsorption, breastfeeding infants, and those who take anticonvulsants. * Vitamin E deficiency can present with areflexia, peripheral neuropathy, gait abnormalities, ophthalmoplegia, and decreased proprioception. * Vitamin A deficiency is associated with night blindness, xerosis (dryness of the skin, mucous membranes, and conjunctiva), as well as Bitot’s spots (white patches on the conjunctiva). Now onto this week’s podcast Question 1 A 66-year-old woman presents with generalized weakness and dyspnea on exertion for 2 weeks. Vital signs are BP 80/45, HR 40, RR 16, and pulse oximetry 97% on room air. Her ECG is shown above. There are no other ST-segment abnormalities. Which of the following is the most appropriate next step in management? A. Administer aspirin, heparin and admit for acute coronary syndrome B. Cardiac catheterization laboratory activation C. Observation and arrange for follow up with cardiology D. Place a transcutaneous pacemaker Teaching Image Question 2   A patient has the above ECG shown above. Which of the following findings is likely to be present on exam? A. A harsh crescendo-decrescendo systolic murmur B. A swollen and tender right lower leg C. Decreased core body temperature D. Elevated jugular venous distension Teaching Image Question 3 Which of the following organisms is associated with pneumonia and bullous myringitis? A. Bordetella pertussis B. Haemophilus influenzae C. Streptococcus bovis D. Streptococcus pneumoniae Teaching Image Question 4 A 52-year-old man presents from his primary care physician’s office for evaluation of an abnormal electrocardiogram. His ECG is seen above. He has no symptoms. What is the appropriate intervention? A. Measurement of cardiac enzymes B. No intervention C. Telemetry observation D. Transcutaneous pacer pad placement a href="https://www.roshreview.