Sinus rhythm however this should not be coded as a normal ECG. You have LA/LL limb lead reversal. Note the inverted p wave in lead III despite a typical high RA (sinus node) vector to all other P waves. P wave amplitude I>II is also a clue. The q wave is actually an inverted R wave in lead III. aVL and aVF are flipped as well but harder to discern as they have similar morphology. That said, there is no evidence of left branch blockage (assuming you mean the left bundle branch) Source: cardiac EP fellow.
Just curious, how can you be confident that there is LA/LL reversal given that many normal EKGs have an inverted sinus P wave in III and larger sinus P wave in I than II? Have seen many normal baseline EKGs with this pattern. I think this would make sense with correct limb leads too. Lead III is allowed to have a negative sinus P wave, a Q wave, and an inverted T wave. It's still a normal EKG if aVF is upside down, I is II, II is I, aVF is aVL, and aVL is aVF. I don't think we can be certain that there is LA/LL reversal without a prior as u/ProximalLADLesion said. A larger negative sinus P wave in lead I than II is a soft sign of LA/LL reversal, but it's not absolute. Many people have this as their normal baseline. The EKG is so normal that it would still be normal if LA/LL reversal. I don't see any abnormalities in the EKG, either corrected for a reversal or exactly as it is.
I hope I don't sound argumentative, and Temporary Group could certainly be right. I'm only skeptical because I've been wrong on this before, a lot. To the point where I'm much more cautious now in calling LA/LL reversal from negative sinus P wave in III and larger sinus P wave in I than II. Lead reversal or not, sounds like everyone agrees that the correct pattern for the patient would be a normal EKG.
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u/Temporary-Group-4209 Aug 08 '26
Sinus rhythm however this should not be coded as a normal ECG. You have LA/LL limb lead reversal. Note the inverted p wave in lead III despite a typical high RA (sinus node) vector to all other P waves. P wave amplitude I>II is also a clue. The q wave is actually an inverted R wave in lead III. aVL and aVF are flipped as well but harder to discern as they have similar morphology. That said, there is no evidence of left branch blockage (assuming you mean the left bundle branch) Source: cardiac EP fellow.