Clinical History 41

Forty-eight year old woman with insulin requiring diabetes mellitus and end stage renal disease who presents for an outpatient nephrology follow-up examination. Her medications included prednisone, azathioprine.furosemide, nifedipine, quinine, metolazone and warfarin. A serum calcium level was not drawn at the time of this electrocardiogram.
Comment on this ECG ?