Give me a detailed history taking list in proper order for general medicine with systemic examinations

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I have enough foundational knowledge from Harrison's and my comprehensive medical training to give a thorough answer. Let me now compile the complete, detailed history-taking guide with systemic examinations.

Complete History Taking in General Medicine with Systemic Examination

Based on Harrison's Principles of Internal Medicine (22nd Ed., 2025) and standard clinical medicine framework.

STRUCTURE OF CLINICAL HISTORY TAKING

1. BIOGRAPHICAL / IDENTIFICATION DATA

Recorded first to establish the patient's identity and demographic context.

Item	Details to Record
Name	Full name
Age	Date of birth / actual age
Sex	Male / Female / Other
Occupation	Current and past (relevant to exposure history)
Address	Permanent and current residence
Marital status	Single / Married / Divorced / Widowed
Religion / Nationality	(relevant for certain genetic disorders, dietary habits)
Date and time of admission	-
Referred by	GP / specialist / self
Informant	Patient / relative / bystander (and reliability of history)

2. CHIEF COMPLAINT (CC)

State the main presenting symptom(s) in the patient's own words
Record duration alongside each complaint
List in chronological order if multiple complaints
Avoid using diagnostic labels - use the symptom itself (e.g., "chest pain for 2 days", not "angina")

Example: "Fever, cough, and breathlessness for 5 days"

3. HISTORY OF PRESENT ILLNESS (HPI)

This is the most critical part. Explore the chief complaint(s) in detail using the SOCRATES mnemonic (or equivalent):

SOCRATES Framework for Each Symptom

Letter	Aspect	What to Ask
S	Site	Where exactly? Does it move?
O	Onset	Sudden or gradual? What were you doing at onset?
C	Character	Nature/quality of the symptom (dull, sharp, burning, colicky, throbbing)
R	Radiation	Does it spread? Where to?
A	Associations	Other symptoms occurring with it (nausea, sweating, dyspnea)
T	Time course	Constant or intermittent? Getting better / worse / same?
E	Exacerbating / Relieving factors	What makes it better or worse?
S	Severity	0-10 scale; effect on daily activities

Additional HPI Details

Sequence of events - how the illness evolved from first symptom to present
Prior episodes - any similar illness in the past?
Treatment sought - any medications or interventions already tried, and response
Functional impact - effect on work, sleep, appetite, activities of daily living

4. PAST MEDICAL HISTORY (PMH)

Systematic review of previous illnesses, surgeries, and relevant medical events.

Medical Illnesses

Previous diagnoses: hypertension, diabetes mellitus, asthma, TB, rheumatic fever, epilepsy, jaundice/hepatitis, peptic ulcer, renal disease, thyroid disease
Previous hospitalisations (when, where, reason, outcome)
Known allergies (drug, food, environmental) - always document

Surgical History

Operations with dates, type of procedure, and any complications (including anaesthetic reactions)

Obstetric/Gynaecological History (in females)

LMP (last menstrual period)
Menstrual cycle: regularity, duration, flow, dysmenorrhoea
Number of pregnancies (G), deliveries (P), abortions (A)
Complications of pregnancy (pre-eclampsia, gestational diabetes)
Menopausal status

Immunisation History

Childhood vaccinations
Adult vaccines (influenza, hepatitis B, COVID-19, pneumococcal)

5. DRUG HISTORY

Current medications: name, dose, frequency, duration, route (include over-the-counter drugs, herbal remedies, supplements, oral contraceptives)
Compliance: is the patient taking medications as prescribed?
Drug allergies and adverse reactions: nature of reaction (rash, anaphylaxis, GI upset), not just "allergy" label
Recent changes to medications

6. FAMILY HISTORY

Health status of parents, siblings, children (alive/dead - cause of death if deceased)
Hereditary / familial conditions: ischaemic heart disease, hypertension, diabetes mellitus, cancers, epilepsy, mental illness, haemophilia, sickle cell disease, thyroid disease, autoimmune conditions
Consanguinity (especially relevant in populations where this is common)
Pedigree chart if needed for complex family patterns

7. PERSONAL / SOCIAL HISTORY

Lifestyle

Smoking: current/ex/never - type (cigarettes, bidi, pipe, chewing tobacco), pack-years (packs/day × years)
Alcohol: units per week, pattern (binge vs. regular), duration, type
Recreational drugs: type, route of use, duration
Diet: vegetarian/non-vegetarian, special dietary restrictions, caloric intake if relevant
Exercise: level of physical activity

Social Context

Occupation: current and past, workplace exposures (dust, chemicals, radiation, asbestos, noise)
Living conditions: housing (cramped, overcrowded), sanitation, water supply
Marital status and domestic relationships
Recent travel (international or to endemic areas - malaria, TB, typhoid, parasites)
Sexual history: relevant when evaluating STIs, HIV, hepatitis B/C (asked sensitively)
Financial / insurance status: affects treatment compliance
Education and literacy: affects communication strategy

8. REVIEW OF SYSTEMS (ROS) / SYSTEMIC ENQUIRY

A systematic screen for symptoms in body systems not covered in the HPI. Ask specifically - do not rely on the patient volunteering these.

General / Constitutional

Fever, chills, night sweats
Weight loss or weight gain (quantify: how many kg over what period)
Fatigue, malaise, lethargy
Appetite change (anorexia)
Sleep disturbance

Cardiovascular System

Chest pain / discomfort (character, radiation, relationship to exertion)
Palpitations (onset, duration, regularity, associated symptoms)
Breathlessness / dyspnoea (at rest vs. on exertion, how many flights of stairs)
Orthopnoea (number of pillows used)
Paroxysmal nocturnal dyspnoea (PND)
Ankle / leg oedema (bilateral vs. unilateral, pitting, time of day)
Syncope / pre-syncope
Claudication (leg pain on walking, distance)

Respiratory System

Cough (dry vs. productive, duration)
Sputum (colour, amount, consistency, blood-stained)
Haemoptysis (amount, frequency)
Dyspnoea (grading: MRC scale 1-5)
Wheeze
Chest pain (pleuritic - worse with breathing)
Snoring / sleep apnoea

Gastrointestinal System

Dysphagia (to solids, liquids, or both; progressive?)
Heartburn / regurgitation / waterbrash
Nausea and vomiting (content - blood / bile / faeculent)
Haematemesis
Abdominal pain (site, character, radiation, relation to meals, bowel habit)
Change in bowel habit (constipation, diarrhoea, alternating)
Stool character: colour (melaena, fresh blood, pale/steatorrhoea), consistency
Flatulence, bloating
Jaundice (skin/eyes/urine/stool changes)
Pruritus (with or without jaundice)

Genitourinary System

Dysuria, frequency, urgency
Nocturia (how many times)
Haematuria (frank vs. microscopic, at beginning / end / throughout stream)
Incontinence
Hesitancy, poor stream, terminal dribbling (males - prostatic symptoms)
Loin pain
Frothy urine (proteinuria), dark urine
Urethral / vaginal discharge

Nervous System

Headache (location, character, timing, associated nausea/photophobia/phonophobia)
Dizziness / vertigo (true rotatory vs. light-headedness)
Syncope / transient loss of consciousness
Seizures / fits (type, frequency, post-ictal state, aura)
Memory problems / confusion
Weakness (focal vs. generalised, upper vs. lower limb)
Sensory disturbance: numbness, tingling, paraesthesiae
Visual disturbance (diplopia, blurring, visual field loss, amaurosis fugax)
Speech disturbance (dysarthria, dysphasia)
Tremor, coordination problems
Gait disturbance
Hearing loss, tinnitus

Musculoskeletal System

Joint pain (which joints, bilateral/unilateral, migratory/fixed, morning stiffness duration)
Joint swelling, warmth, redness
Back pain (site, radiation to leg, relationship to posture)
Muscle pain / cramps / weakness
Bone pain

Endocrine System

Heat/cold intolerance
Excessive sweating
Polydipsia, polyuria (diabetes)
Skin/hair/nail changes
Changes in libido or sexual function
Growth abnormalities

Haematological System

Easy bruising or bleeding
Petechiae / purpura
Prolonged bleeding from cuts
Recurrent infections
Lymph node enlargement (painless vs. painful, duration)
Pallor, fatigue (anaemia symptoms)

Psychiatric / Mental Health

Mood (depression, elation)
Anxiety
Hallucinations, delusions
Sleep patterns
Memory and cognition

Skin

Rashes (site, character, spread, relationship to sun)
Itching
Changes in moles
Hair loss, nail changes

PHYSICAL EXAMINATION

9. GENERAL PHYSICAL EXAMINATION (GPE)

Performed before systemic examination. Assess the patient from the end of the bed first ("end of the bed diagnosis").

General Appearance

Level of consciousness: AVPU or GCS
Apparent age vs. stated age
Built: thin, average, obese; well-nourished vs. malnourished
Well / ill / toxic / distressed
Comfortable at rest vs. in obvious distress
Posture and gait (if ambulant)

Vital Signs (MUST document all)

Parameter	Detail
Temperature	Oral / axillary / rectal; normal: 36.5-37.5°C
Pulse	Rate (per minute), rhythm, character, volume, vessel wall (right radial first)
Blood pressure	Both arms; lying and standing (for postural hypotension)
Respiratory rate	Breaths per minute (counted for 1 full minute)
Oxygen saturation (SpO2)	By pulse oximetry on room air
Weight	In kg
Height	In cm
BMI	Weight (kg) / Height² (m²)

Anthropometric Measures

Waist circumference (metabolic syndrome)
Waist-to-hip ratio

Skin and Nails

Pallor (conjunctival, palmar, mucosal)
Jaundice / icterus (scleral first)
Cyanosis: central (tongue, lips) vs. peripheral (fingertips)
Clubbing (grades I-IV: Schamroth's sign, loss of angle, drum-stick appearance)
Koilonychia (iron deficiency)
Leuconychia (hypoalbuminaemia)
Pigmentation: hyperpigmentation (Addison's, haemochromatosis), depigmentation (vitiligo)
Spider naevi (>5 significant, upper body distribution)
Palmar erythema
Xanthomata / xanthelasma
Purpura, petechiae, ecchymoses
Oedema (pitting vs. non-pitting, bilateral vs. unilateral, sacral)

Head and Face

Facial puffiness (myxoedema, nephrotic syndrome, superior vena cava obstruction)
Malar flush (mitral stenosis, SLE)
Facial asymmetry
Periorbital oedema

Eyes

Conjunctival pallor (anaemia)
Scleral icterus
Xanthelasma
Exophthalmos / proptosis (thyroid)
Corneal arcus (dyslipidaemia, especially if < 50 years)
Kayser-Fleischer rings (Wilson's disease)

Oral Cavity

Lips: pallor, central cyanosis, angular stomatitis (B12/iron deficiency)
Tongue: glossitis (B12/folate/iron), geographical tongue, macroglossia
Teeth and gums: dental hygiene, gum hypertrophy
Tonsils
Palate: high-arched (Marfan's)
Breath (uraemic fetor, hepatic fetor/foetor hepaticus, ketotic)

Neck and Lymph Nodes

Lymphadenopathy: cervical (anterior/posterior), submandibular, submental, supraclavicular (Virchow's node - left side), axillary, inguinal
- Size, consistency, tenderness, mobility, matting
Thyroid: goitre (size, consistency, nodularity, bruit, tracheal deviation)
JVP (jugular venous pressure): height from sternal angle, waveform (a, c, v waves), hepatojugular reflux
Carotid pulse: character

Hands

Temperature, moisture (hyperthyroidism = warm moist; hypothyroidism = dry)
Tremor: fine (thyrotoxicosis), coarse (liver flap / asterixis)
Thenar/hypothenar wasting
Dupuytren's contracture
Peripheral cyanosis

10. SYSTEMIC EXAMINATION

A. CARDIOVASCULAR SYSTEM (CVS)

Inspection

Precordial bulge (childhood cardiac enlargement)
Apex beat visible?
Visible pulsations (aortic, carotid)
Surgical scars (median sternotomy, lateral thoracotomy, pacemaker site)

Palpation

Apex beat: location (normally 5th ICS, midclavicular line), character (heaving, thrusting, tapping, diffuse), double impulse
Parasternal heave (right ventricular hypertrophy)
Thrills (systolic / diastolic; grade ≥4 murmur)
Palpable P2 (pulmonary hypertension)

Percussion

Cardiac dullness (rarely done in modern practice; can detect massive cardiomegaly or pericardial effusion)

Auscultation (in 4 areas + additional)

Area	Location	Best hears
Aortic	2nd ICS, right sternal border	Aortic valve
Pulmonary	2nd ICS, left sternal border	Pulmonary valve
Tricuspid	Lower left sternal border (4th ICS)	Tricuspid valve
Mitral (apex)	5th ICS, midclavicular line	Mitral valve

Heart sounds: S1, S2 (intensity, splitting), S3 (volume overload, heart failure), S4 (stiff ventricle)
Murmurs: timing (systolic / diastolic / continuous), grade (I-VI), character, location, radiation, behaviour with manoeuvres (Valsalva, standing, squatting)
Pericardial friction rub
Additional: carotid artery auscultation (bruits), aorta and renal arteries

Additional CVS Examination

Peripheral pulses: radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis
Radio-femoral delay (coarctation of aorta)
Ankle-brachial index if peripheral vascular disease suspected
Fundoscopy for hypertensive / diabetic retinopathy

B. RESPIRATORY SYSTEM

Inspection

Shape of chest: barrel chest (COPD), pigeon chest (pectus carinatum), funnel chest (pectus excavatum), kyphoscoliosis
Respiratory rate and rhythm (Cheyne-Stokes, Kussmaul, Biot's)
Depth and symmetry of chest movement
Use of accessory muscles (scalene, sternocleidomastoid)
Intercostal / subcostal / suprasternal recession (in children)
Tracheal position (central vs. deviated)
Scars (thoracotomy, drain sites)

Palpation

Tracheal position (fingers in suprasternal notch)
Chest expansion: upper, middle, lower zones bilaterally (normal >5 cm)
Tactile vocal fremitus (TVF): increased (consolidation), decreased (pleural effusion, pneumothorax)
Apex beat position

Percussion

Systematically front and back: resonant (normal), dull (consolidation, effusion, collapse), stony dull (effusion), hyper-resonant (pneumothorax, emphysema)
Liver and cardiac dullness on right side as reference points

Auscultation

Breath sounds: vesicular (normal), bronchial (consolidation, upper lobe collapse), diminished / absent
Adventitious sounds:
- Crackles (fine = pulmonary oedema / fibrosis; coarse = bronchiectasis / pneumonia)
- Wheeze (expiratory = asthma, COPD; inspiratory = stridor = upper airway)
- Pleural friction rub (pleuritis, PE, pneumonia)
Vocal resonance / whispering pectoriloquy / aegophony

C. GASTROINTESTINAL SYSTEM (ABDOMEN)

Inspection (patient supine, arms at side, abdomen fully exposed)

Contour: flat, scaphoid (hollow), distended (generalised or localised)
Visible peristalsis
Pulsations (epigastric - aortic aneurysm)
Dilated veins: caput medusae (periumbilical, portal hypertension), inferior/superior vena caval obstruction pattern
Herniae: umbilical, inguinal, incisional, epigastric
Scars (previous surgery)
Stria (stretch marks - pregnancy, ascites, Cushing's)
Skin discolouration: Grey-Turner's sign (flank bruising - haemorrhagic pancreatitis), Cullen's sign (periumbilical - intraperitoneal haemorrhage)
Visible masses

Palpation (light then deep; watch patient's face for pain)

Systematic 9-region or 4-quadrant approach
Tenderness: site, severity, guarding (voluntary / involuntary), rigidity
Rebound tenderness (peritoneal irritation)
Organomegaly:
- Liver: lower edge in mid-clavicular line; size (cm below costal margin), consistency (soft / firm / hard / nodular), surface (smooth / irregular), tenderness, pulsatility
- Spleen: enlarges towards right iliac fossa; Traube's space dullness; spleen notch palpable
- Kidneys: bimanual palpation; ballottement; palpable in thin patients normally
- Bladder: suprapubic dullness when full
- Aorta: epigastric pulsation, expansile vs. transmitted
Murphy's sign (cholecystitis)
Masses: site, size, shape, surface, edges, consistency, mobility, pulsatility

Percussion

Liver size (upper and lower borders by dullness)
Splenic dullness in Traube's space
Ascites: shifting dullness, fluid thrill (for large ascites)
Tympany over gas-filled bowel

Auscultation

Bowel sounds: normal, increased (obstruction, gastroenteritis), decreased / absent (ileus, peritonitis)
Arterial bruits (renal artery, aortic)
Friction rubs (liver / spleen)

Rectal Examination (when indicated)

Perianal inspection: haemorrhoids, fissures, fistulae
Digital rectal exam: sphincter tone, rectal mucosa, prostate (males), masses, blood on glove

D. NERVOUS SYSTEM

Higher Mental Functions

Level of consciousness (GCS: E+V+M)
Orientation: time, place, person
Attention and concentration
Memory: immediate recall, short-term, long-term
Language: fluency, comprehension, repetition, naming (dysphasia types)
Praxis, visuospatial function, executive function
Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) if cognitive impairment suspected

Cranial Nerves (CN I to XII)

CN	Name	Test
I	Olfactory	Coffee / vanilla recognition each nostril
II	Optic	Visual acuity (Snellen), visual fields (confrontation), fundoscopy (optic disc, retina)
III, IV, VI	Oculomotor, Trochlear, Abducens	Pupil size/reactions, PERLA, extra-ocular movements (H-pattern), nystagmus
V	Trigeminal	Corneal reflex, facial sensation (3 divisions), jaw muscles, jaw jerk
VII	Facial	Facial symmetry at rest and on movement (raise brows, close eyes, show teeth, puff cheeks)
VIII	Vestibulocochlear	Gross hearing, Rinne and Weber tests, Romberg's
IX, X	Glossopharyngeal, Vagus	Gag reflex, palate movement, voice (hoarseness)
XI	Accessory	SCM and trapezius strength against resistance
XII	Hypoglossal	Tongue protrusion (deviation to weak side), fasciculations, atrophy

Motor System

Inspection: muscle bulk, wasting, fasciculations, involuntary movements
Tone: normal / hypotonia / spasticity (clasp-knife) / rigidity (lead-pipe / cogwheel)
Power: MRC grade 0-5 for each muscle group (proximal and distal, upper and lower limbs)
Reflexes:
- Deep tendon reflexes: biceps (C5/6), brachioradialis (C5/6), triceps (C7), knee (L3/4), ankle (S1/2)
- Grade: 0 (absent), 1+ (diminished), 2+ (normal), 3+ (brisk), 4+ (clonus)
- Plantar response (Babinski): flexor (normal) vs. extensor (UMN lesion)
- Abdominal reflexes, cremasteric reflex

Sensory System

Light touch (cotton wool)
Pain (pinprick - use neurological pin)
Temperature (cold/warm tubes)
Vibration sense (128 Hz tuning fork at bony prominences - great toe, malleolus, knee, ASIS, sternum)
Proprioception / joint position sense (fingers and toes)
Cortical sensations: two-point discrimination, stereognosis, graphaesthesia

Cerebellar Function (DANISH)

Dysdiadochokinesia (rapid alternating movements)
Ataxia (gait - tandem walking, broad-based)
Nystagmus (horizontal - fast phase to side of lesion)
Intention tremor (finger-nose test, heel-shin test)
Scanning speech (dysarthria)
Hypotonia

Gait Assessment

Normal gait
Hemiplegic (circumduction)
Spastic scissor gait
Parkinsonian (shuffling, festinant, reduced arm swing)
Cerebellar (wide-based, ataxic, staggering)
Steppage gait (foot drop)
Antalgic gait (pain avoidance)
Waddling gait (proximal myopathy)

E. MUSCULOSKELETAL SYSTEM

General

Gait (as above)
Posture and spinal alignment (scoliosis, kyphosis, lordosis)

For Each Joint (LOOK, FEEL, MOVE)

Look

Swelling (bony vs. soft tissue), deformity, muscle wasting, skin changes (redness, rash, tophi)

Feel

Temperature (warm = inflammation)
Tenderness: joint line vs. periarticular
Crepitus on movement
Effusion tests (e.g., patellar tap, bulge sign for knee effusion)

Move

Active range of motion (patient moves)
Passive range of motion (examiner moves)
Resisted movement (tests muscle/tendon strength)

Special Tests by Region

Shoulder: Hawkins, Neer, empty can (rotator cuff)
Elbow: golfer's / tennis elbow tests
Wrist/Hand: Tinel's, Phalen's (carpal tunnel)
Hip: FABER/FADIR, Thomas test (flexion contracture), Trendelenburg sign
Knee: Lachman, anterior drawer (ACL), McMurray (meniscus), valgus/varus stress
Ankle/Foot: anterior drawer, Thompson test (Achilles)

F. ENDOCRINE SYSTEM (Targeted)

Examine based on clinical suspicion:

Thyroid

Goitre: size, consistency, surface, mobility with swallowing, bruit
Features of hyper/hypothyroidism: pulse, skin, hair, eyes, reflexes, weight

Adrenal

Cushing's: moon face, buffalo hump, central obesity, purple striae, skin fragility, hypertension
Addison's: hyperpigmentation (buccal mucosa, skin creases, scars), postural hypotension

Pituitary

Acromegaly: enlarged jaw, hands, feet, frontal bossing, macroglossia, widely spaced teeth
Hypopituitarism: pale, fine wrinkled skin, loss of secondary sexual characteristics

Diabetes

Signs of complications: peripheral neuropathy, retinopathy, foot changes, lipodystrophy at injection sites

G. RENAL SYSTEM

Ballottement of kidneys
Renal angle (costovertebral angle) tenderness
Bladder palpation and percussion
Blood pressure (hypertension in renal disease)
Oedema (periorbital in nephrotic syndrome, peripheral)
Signs of uraemia: asterixis, encephalopathy, pericardial rub, pallor, sallow complexion, scratch marks

11. CLINICAL SUMMARY AND FORMULATION

After completing the history and examination, synthesise your findings:

Working diagnosis / differential diagnosis (in order of likelihood)
Relevant positive and negative findings that support or refute each diagnosis
Investigations required: bloods, imaging, special tests
Initial management plan

QUICK REFERENCE: ORDER OF HISTORY TAKING

1. Biographical Data
2. Chief Complaints (with duration)
3. History of Present Illness (SOCRATES + sequence)
4. Past Medical/Surgical History
5. Drug History + Allergies
6. Family History
7. Personal and Social History
8. Review of Systems (Systemic Enquiry)
----------- PHYSICAL EXAMINATION -----------
9. General Physical Examination (Vitals + General signs)
10. CVS Examination
11. Respiratory Examination
12. Abdominal / GI Examination
13. Neurological Examination
14. Musculoskeletal Examination
15. Endocrine / Other Targeted Examination

Sources: Harrison's Principles of Internal Medicine, 22nd Edition (2025, McGraw-Hill); Goldman-Cecil Medicine; standard MBBS/MD clinical medicine training framework.

Give me the chart of wcg changes in different heart condition

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Give me the result buddy

Here is the complete chart of ECG changes in different heart conditions, drawn from Rosen's Emergency Medicine, Braunwald's Heart Disease, Harrison's 22nd Ed., Frameworks for Internal Medicine, and Tintinalli's Emergency Medicine.

ECG CHANGES IN DIFFERENT HEART CONDITIONS

STEMI EVOLUTION - Timeline

The image below from Frameworks for Internal Medicine shows the classic ECG evolution of STEMI:

ECG evolution of STEMI - hyperacute T waves → ST elevation → Q wave formation → T wave inversion → normalization

MASTER REFERENCE CHART

1. ACUTE CORONARY SYNDROMES (ACS)

Condition	ECG Changes	Leads Affected
STEMI	Hyperacute tall/broad T waves (earliest) → ST elevation (convex/tombstone) → Q wave formation → T wave inversion → ST normalises → Q waves persist	Depends on territory (see localisation table below)
NSTEMI / UA	Horizontal or downsloping ST depression ≥0.05 mV in ≥2 contiguous leads; T wave inversion ≥0.1 mV with prominent R wave	Diffuse, or territory-specific
Posterior STEMI	ST depression in V1-V3 (mirror image); ST elevation in posterior leads V7-V9	V1-V3 (reciprocal), V7-V9 (direct)
Right ventricular MI	ST elevation in V1, V3R, V4R	V3R, V4R
Wellens Syndrome (critical LAD stenosis, pain-free)	Type A: Biphasic T waves in V2-V3; Type B: Deep symmetric T wave inversion in V2-V3	V2-V3
de Winter T-wave pattern	Upsloping ST depression at J point + tall symmetric T waves; no ST elevation	V1-V6
Hyperacute T waves	Tall, broad, asymmetric, peaked T waves	Territory-specific

2. STEMI LOCALISATION BY LEAD TERRITORY

MI Territory	Leads with ST elevation / Q waves	Artery Occluded	Reciprocal Changes
Anterior	V1-V4	LAD	III, aVF (ST depression)
Septal	V1-V2	Septal branches of LAD	-
Lateral	I, aVL, V5-V6	LCx or diagonal	V1-V2 (ST depression)
Anterolateral	V1-V6, I, aVL	Proximal LAD	III, aVF
Inferior	II, III, aVF	RCA (80%) or LCx (20%)	I, aVL (ST depression)
Posterior	V7-V9 (elevation); V1-V3 (depression)	RCA or LCx	V1-V3
Right Ventricular	V1, V3R, V4R	Proximal RCA	-

3. PERICARDITIS

Feature	ECG Finding
ST elevation	Diffuse, saddle-shaped (concave upwards), in multiple leads (I, II, III, aVF, V2-V6) - does NOT follow a coronary territory
PR depression	Classic hallmark - PR segment depression in most leads (especially II, V4-V6); PR elevation in aVR
T wave inversion	Occurs late, after ST normalises
No reciprocal ST depression	Unlike STEMI (except aVR and V1)
No Q waves
Sinus tachycardia	Common (pain, inflammation)
Low voltage / electrical alternans	If pericardial effusion develops

Key differentiator from STEMI: PR depression + diffuse concave ST elevation not localised to one territory.

4. MYOCARDITIS

Feature	ECG Finding
ST elevation (diffuse, mimics pericarditis)	Common
T wave inversion	Widespread
Bundle branch block (new)	May occur
AV block (1°, 2°, 3°)	Can develop
Ventricular arrhythmias	PVCs, VT
Low QRS voltages	If myocardial oedema severe

5. LEFT VENTRICULAR HYPERTROPHY (LVH)

Feature	ECG Finding
Increased QRS voltage	S in V1 + R in V5 or V6 ≥35 mm (Sokolow-Lyon); R in aVL ≥11 mm
Left axis deviation	Common
ST depression + T wave inversion	"Strain pattern" in lateral leads (V5-V6, I, aVL) - downsloping ST depression with asymmetric T wave inversion
Left atrial enlargement	Broad, notched P wave (P mitrale) in II; biphasic P in V1
Prolonged QRS	Mild widening, not frank BBB

6. RIGHT VENTRICULAR HYPERTROPHY (RVH)

Feature	ECG Finding
Right axis deviation (>+100°)
Dominant R wave in V1	R > S in V1
Deep S waves in V5-V6
ST depression + T wave inversion	Right precordial "strain" in V1-V3
Right atrial enlargement	Tall peaked P wave >2.5 mm in II (P pulmonale)
rSR' pattern in V1

7. ATRIAL FIBRILLATION (AF)

Feature	ECG Finding
No P waves	Replaced by irregular fibrillatory baseline (f waves), 350-600/min
Irregularly irregular RR intervals
Narrow QRS (if no aberrant conduction)
Variable ventricular rate	Uncontrolled: 100-180 bpm
Fine or coarse f waves	Best seen in V1, II

8. ATRIAL FLUTTER

Feature	ECG Finding
Sawtooth flutter waves	250-350/min, best seen in II, III, aVF
Regular atrial rate ~300/min
Regular ventricular rate	Usually 2:1 (150 bpm), 3:1, or 4:1 block
No isoelectric baseline	Continuous flutter activity

9. AV BLOCK

Type	ECG Finding
1st degree	PR interval > 200 ms (>5 small squares); every P conducts
2nd degree Mobitz I (Wenckebach)	Progressive PR prolongation until one P wave is not conducted (dropped QRS); cyclical
2nd degree Mobitz II	Fixed PR interval with sudden non-conducted P waves; more ominous
3rd degree (Complete)	P waves and QRS completely dissociated; P rate > QRS rate; escape rhythm (junctional = narrow, ventricular = wide)

10. BUNDLE BRANCH BLOCKS

Left Bundle Branch Block (LBBB)

Feature	Finding
QRS duration	≥120 ms
Broad notched R in lateral leads	I, aVL, V5-V6 ("M" pattern)
Deep broad S in V1	"W" pattern in V1
No septal Q waves in I, V5-V6
ST/T discordant	ST depression + T inversion opposite to main QRS deflection
New LBBB + chest pain	Treat as STEMI equivalent (Sgarbossa criteria apply)

Right Bundle Branch Block (RBBB)

Feature	Finding
QRS duration	≥120 ms
rSR' in V1-V2	"M" or "rabbit ears" pattern
Wide slurred S wave in I, V5-V6
ST depression + T inversion	V1-V3 (discordant)
Can be normal variant

11. WOLFF-PARKINSON-WHITE (WPW) SYNDROME

Feature	ECG Finding
Short PR interval	<120 ms
Delta wave	Slurred upstroke of QRS
Widened QRS	>120 ms
Secondary ST-T changes	Discordant to delta wave
Risk	AF with very rapid ventricular rate → VF

12. BRUGADA SYNDROME

Feature	ECG Finding
Type 1 (diagnostic)	Coved ST elevation ≥2 mm with T wave inversion in V1-V2 (sometimes V3); "shark fin" or "coved" pattern
Type 2	Saddle-back ST elevation ≥2 mm in V1-V2
Type 3	ST elevation <1 mm
PR prolongation	May be present
RBBB-like pattern	V1-V2

13. PULMONARY EMBOLISM (PE)

Feature	ECG Finding
Sinus tachycardia	Most common (>40% of cases)
S1Q3T3 pattern	Deep S in lead I + Q wave in III + T inversion in III (classic but only ~20% of cases)
Right axis deviation	New
New RBBB
T wave inversions in V1-V4	Right heart strain; correlates with severity
Right atrial enlargement	Peaked P wave in II
Sinus tachycardia or AF
Low voltage	Occasionally

14. HYPERKALAEMIA

Serum K⁺	ECG Finding
5.5-6.5 mmol/L	Tall, peaked, narrow ("tented") T waves - earliest sign
6.5-7.5 mmol/L	PR prolongation, P wave flattening/disappearance
7.0-8.0 mmol/L	Widened QRS (sine wave appearance)
>8.0 mmol/L	VF / asystole

15. HYPOKALAEMIA

Feature	ECG Finding
U waves	Prominent U wave (follows T wave), best in V2-V3
T wave flattening or inversion
ST depression
QT(U) prolongation	Risk of torsades de pointes
PR prolongation

16. HYPERCALCAEMIA vs HYPOCALCAEMIA

Condition	ECG Finding
Hypercalcaemia	Short QT interval; short ST segment; J-wave (Osborn wave in severe cases)
Hypocalcaemia	Prolonged QT interval (specifically QTc); prolonged ST segment; T waves normal; risk of torsades

17. HYPOTHERMIA

Feature	ECG Finding
Osborn wave (J wave)	Positive deflection at J point, best in V4-V6 and II; pathognomonic
Bradycardia	Progressive
Prolonged PR, QRS, QT	All intervals prolonged
AF/Junctional rhythm	Common
VF	At core temp <28°C

18. LONG QT SYNDROME

Feature	ECG Finding
QTc prolonged	>440 ms in males, >460 ms in females (>500 ms = high risk)
Abnormal T wave morphology	Notched, bifid, or late-appearing T waves
Risk	Torsades de Pointes → VF

19. HYPERTROPHIC CARDIOMYOPATHY (HCM)

Feature	ECG Finding
LVH pattern	High voltage
Deep narrow "dagger" Q waves	II, III, aVF, V5-V6 (septal depolarisation abnormality) - NOT infarction Q waves
ST depression + T wave inversion	Lateral leads
Left axis deviation
AF	Common

20. DILATED CARDIOMYOPATHY (DCM)

Feature	ECG Finding
Low QRS voltage	Or paradoxically increased
LBBB	Common
Left axis deviation
ST-T changes	Non-specific
Atrial and ventricular arrhythmias
Intraventricular conduction delay

21. DIGOXIN EFFECT vs TOXICITY

State	ECG Finding
Therapeutic (Digoxin effect)	Scooped/reverse tick ST depression ("Salvador Dali moustache"), shortened QT, T wave inversion in lateral leads
Toxicity	Bradycardia, AV block (any degree), PAT with block (classic), bidirectional VT, multiple arrhythmias simultaneously

22. ACUTE COR PULMONALE / CHRONIC PULMONARY DISEASE

Feature	ECG Finding
Right axis deviation
P pulmonale	Peaked P > 2.5 mm in II
RVH pattern
Low voltage	In COPD (hyperinflation)
Multifocal atrial tachycardia (MAT)	COPD-specific: ≥3 different P wave morphologies with irregular rate
S1S2S3 pattern

QUICK-REFERENCE SUMMARY TABLE

Condition	Key ECG Signature
STEMI	ST elevation (convex), Q waves, in territory
NSTEMI/UA	ST depression, T inversion, no Q waves
Pericarditis	Diffuse saddle-shaped ST elevation + PR depression
PE	S1Q3T3 + sinus tachycardia + T inversion V1-V4
LVH	High voltage + lateral strain (ST dep + T inv)
LBBB	Wide QRS, M-pattern V5-V6, W-pattern V1
RBBB	rSR' V1, wide S in I/V5-V6
WPW	Short PR + delta wave
Brugada	Coved ST elevation V1-V2
Hyperkalaemia	Peaked T → wide QRS → sine wave
Hypokalaemia	U waves + flat T waves + ST depression
Hypothermia	Osborn (J) wave + bradycardia
Long QT	Prolonged QTc >440/460 ms
HCM	Deep dagger Q waves II, III, aVF, V5-V6
Digoxin effect	Scooped ST depression + short QT
AF	No P waves + irregularly irregular
3rd degree AV block	P-QRS dissociation

Sources: Rosen's Emergency Medicine (9e), Braunwald's Heart Disease (Vol 1-2), Harrison's Principles of Internal Medicine (22e, 2025), Frameworks for Internal Medicine, Tintinalli's Emergency Medicine (9e)

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