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OK, guys, we'll make a start in just one second. I'm just about to share the slides. Um And then you guys can tell me if you can see them. Ok. Can someone just confirm in the chat that you can see the screen? Um as soon as you can, we'll get going. Yeah. Ok, cool, perfect. So thanks for coming out guys. I know that Monday evening is not the most fun time to be doing this, but we'll try and make it as enjoyable as possible. Um So yeah, like I said, the first half of the session will be respiratory um and then the second half will be cardiology with sciatica. Um And you guys can drop any questions in the chat as we go. Um And just a disclaimer that this is not gonna replace any formal teaching by the university. Um Code blue are an independent platform. Um We're partnered with I FM Sas and also GKI Medics. Um and you can use this discount code to get 10% off on geeky quiz if you want to. Um And it's a really good resource. So I would definitely recommend um and just a quick overview of the session. Um So obviously it's quite a lot to try and cover all of respiratory. So I've just picked the most common things that if you're on call you're gonna get leaked about. Um Or if you're working on a ward doesn't really matter. Um The specialty, these are quite common things that you're gonna see. Um And it's kind of clinically focused because by now in fifth year, you kind of know the theory and the content behind things. So I guess the focus now is a bit more if you were the F one on call or if you were the F one and you were asked to see this patient, what would you actually do? Um OK. The mic is buzzing out. Let me two. Ok. Um We'll try is has that worked? Has that fixed it at all? Yeah. Ok. We'll continue for now. Um and also AQ tips. Um So I'm in F one, I'm currently on general surgery. Um and I went to Manchester. Um, so in terms of, ok, it's not still not working. Mm. Ok. Um Hopefully it's better now. Um, so any ay questions that you have, um I can answer any but specifically Manchester ones are probably able to give a bit more detail. Um So we'll cover pneumonia, we'll cover peas, we'll cover asthma and we'll cover pneumothorax. Um And then the main focus of the session really is data interpretation. Um So ABG S and chest x rays because invariably whatever specialty you're on pretty much every day, you're either gonna have to review a chest X ray, um, or if the patient's deteriorating, you're gonna have to do an ABG. Um, so we'll talk about how to kind of do an ABG and how to interpret them. Um And then also how to interpret chest x rays. Um, ok, so we'll start off with the kind of theory side of it. This is just a recap, to be honest. Like I said, you guys will probably know most of the stuff already. Um But it's just to contextualize things really. And like I said, it's more kind of things to look out for for when you actually start work that you don't necessarily get told at uni um but you kind of just learn on the job, um which I think are important to know. Um So first of all, in terms of pneumonia. So in terms of what it actually is, so it's when your lung tissue becomes infected and then your alveolar space gets inflamed. Um And in terms of different types, you can split it up into different classifications. Um So you can either split it up into where it's actually happening. So you've got community acquired pneumonia if it happens outside a hospital, um, hospital acquired pneumonia, if you've been in hospital more than 48 hours and they'll have pneumonia, um, ventilator associated pneumonia. I mean, it's only really for people who, as the name suggests are ventilated. So, I mean, it's less common but it can still happen. Um, and then aspiration pneumonia. So things like food, vomit, choking on them. So it tends to be people that have either had a stroke or got dementia. Um, and it's more common than you think actually. So it's an important one to remember as well. Um And then you can also classify it based on the type of microorganisms that are involved. Um So you've got typical atypical and fungal, um and the difference between them is that with typical microorganisms, you can culture them just normally gram, stain them and then you can see what the patient's gonna be sensitive to, to decide antibiotics. Um, whereas atypical, you can't do that. So the antibiotics that you're gonna use are gonna vary. And to be honest in real life, you just call micro to see what they want you to give. Um because every trust has different guidelines about which antibiotics they want you to use. Um And in terms of fungal pneumonia. So really it's PCP. Um and this is really only applicable to patients who have HIV and low CD fours. Um, but I mean, they'll usually present with the usual symptoms of kind of like cough. Um, but it's a dry cough specifically and they also tend to have night sweats. So for that, you just give them Co Triox, you don't really need to do anything else you just monitor. Um, and see, um I don't know how to fix the mic, I can try plugging in some earphones and use that and see if it's better. Ok. Is this better at all? Someone let me know if it is or not? Ok. Um So we'll continue. Um So in terms of how it presents, so patient's gonna be short of breath, they'll have a cough. Um, they'll probably be producing sputum if they are, it's always worth culturing it. Um, they might have hemoptysis as well. Um, and just general malaise feeling unwell. Um, and if they're gonna have chest pain, it's gonna be pleuritic. Um, and on examination, pneumonia is quite noisy. So you're gonna hear bronchial breath sounds, you'll also hear crackles in the chest, sometimes focal and sometimes a bit more general. Um, and they'll also usually be dull to percuss. Um, so it's really important when you kind of get this presentation to have a list of your differentials and to also think about what you're actually expecting to find on examination because usually that's the kind of turning point for what you think is going on. Um So in terms of causes, I won't go through this in massive detail, cos the slides, if you fill out the feedback form will get sent out later. Um But in terms of knowing kind of common things for MC Qs in exams, um, you've got kind of these common organisms, um, and they all present slightly differently. So for, for example, your most likely organism for any type of pneumonia is gonna be streptococcus pneumonia. Um, but you can also have different types. Um So some only affect immunocompromised patients. Um, it's also worth learning the ones that focus on cystic fibrosis patients because it's really easy to set empty Qs on them. Um And then the atypical ones all kind of have their own little thing. Um That's really easily identifiable in MC Qs. So for example, if a question mentions um that someone recently came back from somewhere with not clean water supplies, um or air conditioning, then you're thinking more legionella. Um Or as if it's kind of talking about animals, um or people that have pet parrots, that's the one that they always use. You can start to think about other organisms. Um And if you've got any skin changes, it's most likely gonna be mycoplasma. Um So just in the interest of time we'll kind of move on. Um But that's how to really distinguish between the different types of causes of pneumonia. Um So in terms of assessing it, if you're in the community, you're gonna use CRB 65 because you're not gonna be doing your levels in the community. Um But if you're in hospital, you can use C A 65. Um Yeah, so to answer the question slides, um are gonna be uploaded to the medal platform um on completion of feedbacks. Um So if you score a 0 to 1 using the C 65 then you'll probably just be fine to be treated in the community. Um above that, if you're scoring the two, you usually get admitted um to be treated. Um and anything above a three, really, you wanna be reaching out to critical care itu seeing if there's anything that can be done. Um because if you're scoring highly on all these parameters, it's also probably likely that you're septic, which is also something to look out for. Um If you go and review a patient, don't get so distracted with your differentials that are rasp focus, that you forget to look at the bigger picture. Um Because more often than not, you'll have to start doing blood cultures, B GS. Um And also considering whether oxygen and antibiotics are needed depending on what you find on your review. Um So, yeah, I've kind of discussed most of this before. Um But you wanna do bloods, you wanna be looking at your white cell count, your C RP. Um And also blood cultures um to see if a patient is infected, what specifically they're going to respond to antibiotics wise, you don't just wanna keep loading them with antibiotics that aren't specific for their micro. Um You also wanna do a chest X ray um which we'll talk a little bit more about later. Um And you can also do urinary antigen tests if you're thinking pneumococcal lesion. Um, but I mean, that's more of a side point. Um, and then management is quite simple. Um, you're just gonna start them on antibiotics. Uh, like I said, depending on your local trust guidelines, if it's a mild case you can get away with oral, but otherwise you're gonna be giving them IV antibiotics. Um, and if they're still not responding to that, then they might require ventilation intubation, et cetera. Um, But that's not something you're gonna be doing on the ward if you escalate that. Um So yeah, that was a whistle thought for of pneumonia. Um We'll quickly go through P ES as well. Um So this is when you've got a thrombus and it gets lodged in the pulmonary arteries. Um and risk factors look out for these in MC QS. Um And also they do happen in real life, especially on surgical wards because after surgery, patients are immobilizing. Um So it's really, really common. Um So other things, long haul travel and also hormone therapy. So estrogen containing things like contraceptives, H RT. Um and also pregnancy because you're in a hypercar state. Um So it presents once again with shortness of breath, you're also gonna usually see hemoptysis and a cough, chest pain. Um And then on examination, you'll find that the tachypneic probably tachycardic. Um And you also might find clinical signs of DVT. So it's always worth looking at the calves as well because in terms of how peas arise, you usually have a thrombus in your calves and then it travels and becomes an embolus. Um an embolus is just a thrombus that is moving through the blood and then it gets lodged. Um And then it presents these symptoms. Um ok, so in terms of how you assess it, so you're gonna wanna do a chest X ray just to rule out any other kind of respiratory pathology. I mean, things like pneumonia, uh always gonna be in your differentials clearing a pneumo sometimes as well. Um But the mainstay of your initial diagnosis is gonna be doing a well score. Um because if your well score is high, then you'll just crack on and do a C TPA as your first line. Um But if not, then first of all, you're gonna do ad dimer. Um and then your D dimer is not the be all and end all, but it's usually a good indication of whether a patient has a pe or not. Um And if your D dimer is high, then you can go on to do a C TPA. Um And if it's low, if you look at it in the greater clinical picture with some just regular blood, so full blood count LFT S bone profile, you might be thinking pe is not as likely. Um So C TPA S are first line. Um but you might have to do a VQ scan if a patient can't have C TPA S Um, so if they're renally impaired, if they're allergic to contrast, um, or if they're pregnant, then you're gonna have to do a VQ, but it's still ok, it'll give you the same end result. Um, and then in terms of management. So, I mean, I guess the biggest, most obvious one is that you want to make sure patients are anticoagulated. Um, and that's usually fine for a normal pee. Um, but if it's a massive pee, you're gonna have to give a continuous infusion of unfractionated heparin and also consider thrombolysis. So stuff like ola streptokinase. Um And then in terms of follow up what you keep them on is gonna depend on whether you know what the cause was. Um So usually if you know what the cause of their pee was, then you can just keep them um on a doac for three months or you can start them on Warfarin low molecular weight heparin, whatever is gonna fit with their comorbidities and meds that they're already on. Um If you don't know what the cause was, then you keep them on it for about six months. Um And then if they're on quality patients, then you'll have a more tailored regime, but it's usually about 3 to 6 months um so quickly just touching on asthma. Um So, I mean, this is more kind of a GP based condition to be honest, but I mean, lots of patients do have asthma and if they come in and then they exacerbate, then it becomes a big problem. Um So it's worth just knowing about. So it's atopic and it basically gives you chronically inflamed airways and it causes variable airway obstruction. So your smooth muscle becomes hypersensitive and it causes bronchoconstriction and then your end result is shortness of breath. Um, and a wheeze. Um, and usually a dry cough and patients also report their chest feeling very tight. Um And the big thing about asthma is that it also shows that a variation. So you usually find that it's worse at night and it fluctuates. Um And in terms of MC Qs as well, so asthma does present with a wheeze, but the most important thing is that the wheeze is widespread, it's also polyphonic and it's expiratory. So if in an M CQ, they're talking about wheeze, don't just necessarily assume it's asthma, but if they specify any one of these characteristics, then you can be more sure. Um And the same goes for real life as well. Um But usually if you examine an asthmatic, they'll be fine um unless they're having an acute exacerbation. Um and then if they are, then you'll see use of accessory muscles, um tachycardia, tachypnea. Um and also depending on how severe it is sometimes struggle to actually talk to you. Um And then in terms of triggers, so there's lots of different things. Um So you can have occupational asthma, which the kind of key question especially in Aussies to ask patients is whether it's better when they're not at work because if it is, then you can be pretty sure they might just be kind of having uh exacerbations based on dust or fumes. Um, but if not, then it's just general asthma. So things like cold weather infection allergens from pets, um and also strong emotions. Um, so in terms of how to investigate it, um, so you can do spirometry. Um and you can also do bronchodilator reversibility testing. Um You can also have a look at feno because that's gonna give you an idea of how much stress the respiratory systems under. You can also get patients to keep a peak flow diaries. So usually about two entries from 2 to 4 weeks. Um And if you need to do one, this is more kind of an exacerbations than you can do an ABG. Um And in terms of management, so I'm not gonna go into this too much. Um because it's basically just a ladder of drugs you start at the bottom. Um And then you can increase it as you need to. Um as an F one, you're not really gonna be starting any of these medications. Um if patients come in and you have to prescribe the regular medications, that's as much as you really need to do. Um But otherwise it's something to just be aware of because there are so many exam questions. Um, that kind of require you to know this. Um, and also in an sy, it's a really easy situation for them to set up someone who's coming to talk about that asthma. Um, and to talk about medications that they can have, um, and can't have as a side note, does anyone know two types of medications that you wouldn't wanna give to an asthmatic? You can just pop it in the chart if you do. Yeah. Yeah. Good. So beta blockers and Nsaids, um, so if you're clocking someone and you're gonna start them on analgesia, um, or you need to kind of give them a beta blocker, always think twice because you're just gonna cause a bronchospasm and probably make everything worse. So it's just being worth being aware of. Um, and it's also important for people to kind of have lifestyle changes. Um, so making sure they don't smoke if they do you continuing to have regular exercise. Um, and also going to their asthma review appointments at the GP. Um, and everyone in theory should have a personalized asthma plan as well. Um, it doesn't always happen in real life. Um, but especially if you're in an AK and you have things to counsel on asthma. It's a really good thing to say because it shows that you're going that extra mile and not just focusing specifically on medical management. Um, so this slide, you'll probably have seen something of the sort before. Um, so it's how we quantify different types of exacerbations of asthma. Um because there's a massive difference between someone who's having like a moderate attack um compared to someone who's got life threatening features. Um And it's just a case really of these, to be honest. Um because there's so many different types of question they can give you, but one that comes up literally every year um is kind of classifying what type of asthma attack someone's having. Um, and basically the worse the symptoms, the worse the asthma attack. Um and we'll talk a little bit about the management of severe and life threatening asthma. Um And it's yeah, just worth being aware of. Um So you can monitor a real life patient as well. Um So if it's a severe exacerbation, then you can give them oxygen, you can give them salbutamol, you can also give them steroids. Um And then if they're still not getting better, then you can add in some tropium, you can also consider amio um and also magnesium sulfate. But at this point, if you're having to step up to those, then you're gonna escalating the situation anyway. Um And if it's a life threatening situation, then they need to be escalated really straight to critical care because they'll probably need some form of intubation um or ventilation or just close monitoring. Um because giving all of these drugs together, you don't just wanna give them and then leave the patient to their own devices. Um So then the final thing we'll talk about before we go on to the osk side of things is pneumothorax. Um So it's when you've got air in the pleural space and then it makes the lungs separate from the chest wall. Um So there's once again, different types. So, um you can have spontaneous pneumothorax is um, so primary um are just when there's no underlying pathology, it just happens one day secondary is when you've got some kind of underlying pathology that you think might have precipitated it. Um You can also have traumatic pneumothorax. So usually if the victims have kind of been in collisions or experienced trauma um or kind of just yeah, had a greater episode of something happening. Um You can also have iatrogenic incidences. So in hospital or even in the community, um things that happen. So like lung biopsies or insertions are central line sometimes. Um And then you can also have tension pneumothorax, which are just a completely separate thing in terms of management. Um But also the most concerning like if you've got a patient presenting with a tension pneumothorax, then you're gonna be more worried than some of the others. Um And in terms of presentation, so once again, it presents with shortness of breath. Um and you might also have a patient complaining of chest pain, but already for a pneumothorax, you're gonna go based on history and imaging um because there's not anything else that you can really gain from symptoms. Um But in terms of examination, it's really important as well. So you want to percuss them, you also wanna have a listen to breath sounds. Um And if you do a chest x ray, you also want to have a look for whether there are lung markings present or not. Um, because pneumothorax is uh very distinct on chest x rays. Um So it's worth if you're not familiar with them just having a look at one because once you see how one presents, you won't forget it and you'll be able to recognize it because they come up in acies quite frequently. Um And if it's a tension pneumothorax, you might actually see tracheal deviation away from where your tension pneumothorax is. Um And then you'll also see kind of more systemic symptoms. So they might be tachycardic and present with hypotension as well. Um So, in terms of how you're gonna investigate it, so pulse oximetry is important um and also getting some bloods just to kind of rule out everything else. Um So maybe if you're clearing an infection as well, checking CRP white cell count can help you. Um And an ABG once again, um so you can get a chest X ray. The only thing with those is sometimes pneumothorax is can be too small to see on chest x-rays. So if you're still thinking that that's your main diagnosis, but chest X ray is not really showing anything, you can do a CT as well. Um But it's not as common. Um So there's also this little flow chart um that I've put up, it's probably a bit small to see on here. Um But your management really is gonna depend on how big the pneumothorax is. Um So it's gotten a little bit cut off here. But I mean, if it's two centimeters or less, then usually you just go with conservative management. Um as long as the patient's well, and the patient's happy to do that. Um, you can kind of just keep monitoring it and safety net them to come back in. Um, if it's over two centimeters you can decompress it. Um, patients sometimes have a preference whether they wanna just kind of go and see whether it gets better, um, or whether they want to have that. Um, but if you've got kind of a patient that's presenting with something more severe, you're gonna have to do an emergency decompression. Um, does anyone know where you decompress where you'd insert the needle? You can pop it in the chart otherwise we'll go through it. Ok. That's fine. Um, so, I mean, oh, ok. Yeah, exactly. So in terms of inserting needles and chest drains, people kind of get a bit concerned about this. But I mean, for a chest drain in particular, you wanna go in your triangle, the safety. So that's gonna be w you're not really gonna hit anything. Um, if you go in there because obviously the warriors hitting a neurovascular bundle. So it's gonna be your fifth hostel space and then your latissimus dorsi the lateral edge of that. Um And then also your lateral edge of your pec major. Um But I mean, it's worth just learning your triangle of safety because every year questions come up about the borders. Um And it's also just good to know in real life if you ever actually have to do one. Um So yeah, it's just important to make sure patients also come back for follow up. If you send them home with a pneumothorax, then make sure they actually come back to be reviewed if they need to make sure they actually follow the safety netting advice. Um And you can, if you need to go down the surgical route, um this is more for kind of really severe cases. Um but you can either just remove the pleura um or you can stick them together so nothing can get trapped. Um And a patient won't repent, but that's really if people keep on having pneumothorax and you can't really do anything else about them. Um OK, so we'll focus on the osk side of rasp now um because this is probably more applicable for coming up to finals. Um So just in terms of how to do ABG S. Um So this is something that hopefully you'll have gotten the chance to do it at least once throughout fifth year Um, but if you've not, definitely I'd recommend doing at least one. because if you're the f one, and you're on call or you're the only one on the wards and someone needs an ABG, you're gonna have to do it. Um, and yeah, they're not as bad as people think. Um, they're not too different to kind of just normal venipuncture. Um, but obviously it is slightly different. Um, so I've just included a picture here as well. Um So first of all, the most important thing to do is to check the id of the patient, you don't wanna be doing an ABG on the wrong person um because they are quite painful, but if a patient needs one, then they need one, you can also check for any contra indications or allergies. Um So, I mean, in terms of contraindications, is there anything that anyone can think of that would maybe stop you doing an ABG? Once again, you can pop it in the chat if there's anything you can think of. Yeah. So, um if the patient's got a history of like peripheral vascular disease, you don't really want to be doing it. Um Also if you look around the site of insertion, if you've got kind of a cellulitis looking picture, um And also if they've got an ad fist, um I mean, most of the time if the patients are sick enough to need an ABG, you'll do it anyway. But those are kind of your contraindications. That's the point where you step back and say, ok, let's think if there's something else we can do. Um, because you don't want to make things worse. Um And then obviously it's also really important you consent them. Um, sometimes patients are skeptical. Um But I mean, you only really do your ABG S in well, either rest patients or the sickest of patients. Um So usually they're quite amenable. Um And then it's time to do Alan's test. Does anyone know what Alan's test is? Once again, you can pop like a brief overview of it in the chat and then we'll go through what it is. Ok. So basically as an overview of Allens, it's when you're gonna occlude the arteries one by one, and just check that you've basically got reperfusion. Um So you get them to kind of clench and then you can occlude one, whichever one you want to start with and then you're gonna switch to the other one. And usually that Allens test will be fine, but obviously, if there's not enough circulation and you've occluded one artery and there's not anything coming back, then you might want to rethink whether you actually need to do it or not. Um In terms of the position of the patient. Um So it really depends on who you're doing an ABG on. Um If they're well enough, they can sit up, you want their arm at about 20 to 30 degrees and it's easier for you and for them if you just prop their arm on a pillow, um, but if they're really sick and they're really unwell, then they can lie down as well. It's not really gonna make that much of a difference. Um, and then the most important thing to do really is to palpate the artery, um, and make sure that you can actually feel it. Um, because the last thing you wanna do is insert the needle in the wrong place. Um because they are quite painful even when they're inserted in the right place. So it's just important to be confident that, you know, you're in the right place. Um And nothing's ever that urgent. If you feel like you need to take the time to make sure, then that's fine. You don't have to rush. Um So in terms of preparing everything, uh make sure you've got the right needle, um flush the heparin through the needle and also make sure you've cleaned the wound site. Um And then you can just pop the needle in. Um So you, you put it in at like 30 degrees um kind of like you're throwing a dart. Um And once you're in the syringe should just self fill. Um And then when you've got enough, you can withdraw. Um And then make sure patient's ok. Um And then you just go um analyze it, you just pop it in a machine and it will give you the results. Um And then the most important thing to do as well is to always document the results because there's no point doing an intervention. If you don't put in the notes, what actually happened. Um And then it's useful because you can start to create a management plan. Um Once you know what the picture of the patient is. Um So, in terms of how to actually go about interpreting ABG S, um this is also just the picture of the machine that you put the syringe in. Um Because if you never found one in a hospital before and tell someone tells you to go run an ABG or a VBG, it's the same machine. Um It's useful to just know what one looks like. Um So, the first thing to do is to think about the clinical context of the ABG when you're interpreting the result. So, was it taken with the patient on oxygen or was it taken with a patient on room air? Um because that's gonna dictate whether you're more or less concerned about your oxygen. Um And just ensuring that the sample taken was appropriate. So making sure that it's not at that point, coagulated, making sure it's taken with the right needle, et cetera. Um And obviously you want to check the patient's ID. Um And then in terms of a systematic way to go through doing ABG S, um different people have their own ways um, but if you're kind of sat there in an ay, um, or in real life and they give you an ABG, the first thing to do, um, is to check the ph cos, if you've got an idea of whether they're gonna be acidotic or alkalotic, that can help a lot because you can think about what's gonna cause an acidotic picture, what's gonna cause an alkalotic picture. Um, and then that will help you figure out what's going on. Um And then you can check the oxygen and the CO2. Um if one of them is deranged or looking at type one breast failure, if your oxygen's deranged. Um but if they're both, then it's gonna be type two. which once again is useful to kind of know. Um So that's kind of the respiratory side of things. And then it's also just important to check whether you've got compensation or whether you've actually got a more metabolic picture. Um So you can do that by checking the bicarb and the base excess because if they're also deranged, then you're thinking that there's either a compensatory picture going on or actually the rasp might be fine and it's more of a metabolic picture. Um So same thing you can use this to create a management plan. Um So, what we will do is we'll do a practice ABG. Um So just trying to see um if I try and share my screen, um let me just see if not, I'll just carry on with the presentation. Um And we can do it after Ska's um talk. The only thing we've got left is chest X rays. Um So, yeah, I'll sort it while she's doing her presentation. Um So just in terms of chest x rays, um so in terms of a systematic way to go about having a look at them, first thing you always wanna do is check the patient ID. Um And it's also really important to check when it's actually done and whether they've got any previous imaging because it's really useful to compare different images. Um And especially in an osk, if they ever give you an image of anything, it doesn't have to be an X ray of the chest. Um It's always worth just asking whether there's anything you can compare it to. And even if there's not, it's shown that you've at least thought about what you want to do in terms of checking for differences to see whether a patient has gotten better or worse. Um And then you also want to check whether it's AP or PA um most of them will be pa you only really use APA. A patient is unstable because it doesn't really give you that good a picture. Um But if a patient is not well enough for APA, there's nothing you can really do. Um And then you can check for the quality of the X ray because there's no point trying to read an X ray that's not gonna show you anything. Um So for example, I want to make sure that your clavicles are equidistant from your spinus processes. Um If not, and you've got a rotated image, everything's gonna be distorted. Um You also want to have a look at whether you've got adequate penetration. Um So you don't wanna be able to see all of the vertebral bodies really easily, but you also don't really wanna be able to not see anything around the heart. Um And then it's also important to check that there's adequate exposure. Um And then in terms of inspiration, you wanna check that you're not seeing too many or few ribs. Um So posteriorly about 10, anteriorly about six, it's, it's just important to check. Um The only caveat to that is if they've got say COPD and their chest is hyper inflated, you might kind of think, oh, this chest X ray is not very good to look at, but actually, that's just the pathological picture of the patient at that time. Um And then you can start off by talking about any obvious abnormalities you see. Um because even though you want to have a systematic structure, if there's something glaringly obvious that just looks wrong, you can point it out. Um So it's important to think about what it actually is, is it like a bronchogram? Is it consolidation? Is it a pacification? Is it a mass? Is it lymphadenopathy. It's important to specify what um and also where it is. So usually for chest x rays, you can just use zones. Um don't need to talk about lobes because it becomes confusing to do, but you can if you want to. Um and then also the size of it and the shape of it as well. Um Basically the more detail you can give the better. Um and then in terms of chest X rays, you can just follow once again an A to E structure. Um So in terms of your airway, you wanna have a look, is the tracheal central, is it deviated, anything going on at the Corina? Um in terms of breathing, just making sure to have a look at the AP CS and the Hila um and also having a look for any hilar lymphadenopathy, which if you see it on a chest X ray, you'll know straight away because it will just be everywhere. Um But it's important to just check for um in terms of cardiac things. So checking for cardiomegaly. So, I mean, if the heart's taking up more than like half of your kind of space, you know that the heart is enlarged. Um and also just checking the cardiac borders um in terms of the diaphragms, this is one of the most useful things to do. Um So it's important to always check whether you've got any air, you might be thinking pneumoperitoneum. Um and also just checking your costophrenic angles, are they blunted? Are they not if they are, are you thinking there might be fluid in the chest? Um Kind of just thinking also about your hemidiaphragms. Um And then also just extra things. So anything bony, but you can see say, for example, if you know the patient had a fall, you can see some broken ribs, um anything to do with soft tissue or gas that you think potentially shouldn't be there. Um and also some objects. So like say if a patient's got a pacemaker um or an NG, then it's important to kind of pick up on that. Um and still note even though it might not actually change anything that you do at all. Um So yeah, we were gonna do the geeky me stations whilst I work out how to actually get them to share. Um I'll hand it over to Sada to start cardio. Hi guys. Um my name is Sica. I'm one of the F ones in Bolton. I'm gonna go through some cardio um acies. I'm just gonna pull up my presentation. Mhm. Ok. I hope you can see this. This is actually the end of my presentation. Let's start at the beginning. Um Can I just check that you can, you guys can see that I don't really get any like feedback as to whether I do. Yeah, you guys can see it. I'm assuming you can. All right. Um So the main things that I wanted to go over was more um practical stuff. So obviously with these types of presentations, um, there's quite a large volume of content that we can go through. So I thought it would be useful to go through, um, kind of abnormal signs that you'd usually see in a cardiology exam. Um, go through at e examinations and kinda chat through that as well and then look through the pa guidelines. Um, so I've got three main topics that we're gonna co like four main topics that we're gonna cover. But I would say that um there is quite a large breath of all of um content to cover. So things like EC GS um and that aren't in your power guidelines and in your emergencies and aren't um sties um it would be good to go over in that sense. I think I went over the main ones, but it's just good to um I'm just clarifying that this is not um like a complete um visualization. If you just give me one second, I'm actually just gonna stop sharing my screen because I don't think, yeah, hopefully you guys can still. Ok, perfect. Ok. So um just starting off with um clinical signs on your cardiovascular exam. So um anytime you're doing your cardio exam, you all know, um we're gonna inspect palpate and auscultate. Um precaution doesn't play as big of a role in um a cardio exam compared to a respiratory exam. Um or maybe an abdominal exam with your inspection, a top tip that I like to do is always go general and then you're targeted. Um But don't forget to look at the patient. Um So first of all, I would like to take a step back, have a look at the room. Are there any charts, meds, instruments or paraphernalia? Um So charts could be news charts or fluid charts or anything that might give you an indication of how the patient's doing, um, meds. So that could be, um, for a patient who's a cardiovascular patient, things like insulin, things like, um, inhalers. Um, any, um, what's called things like BP, medications and things like that. If there's any just lying around the room to give you a clue as to what, um, this patient might, um, just to give you a clue about the patient really, um, instruments. So that could be things like catheters very, very important, very easily missed. Um, because they're usually hanging at the bottom of the bed. Um, always go look good to look at catheters, BP cuffs. Um, do, are they on invasive, um, are they on 24 hour, um, cardiac monitoring? Um, things like that, then you do a ta general examination of the patient themselves? Are they co uh comfortable at rest? Are they feeling, um, are they, are they looking cyanotic, are they looking pa pale? Do they look quite flushed? Um, do they look like, um, they're extremely Disick and, um, short of breath. Um, and then you're gonna go closer and then examine the chest. Um, so what I like to do with my closer inspection with a cardiovascular and with any exam really, um, some people get taught this, some people have their own system, follow your own system, but the way I like to do it is going up the hands, um, having a look at the hands, going up the arm, um then up into the neck, looking at the face, the eyes and then going down into the chest and that just makes sure that I don't forget anything. Um So hands and arms, you can look at your capillary refill time. Um uh You can look at peripherally or centrally. Um It's just always a good thing to um have and it's a very quick thing to do pulse. Um really, really important with your cardiovascular exam. Main things you're looking for is rate, rhythm, volume, character and symmetry. So rate is it, are they tachycardic? Are they bradycardic um rhythm? Are they in sinus rhythm? Is it irregular or is it irregularly irregular or is it sinus irregular um volume? So there's a bounding is a very, very high volume pulse or is a very thready and low volume that kinda um leans into character as well character. You can think about your collapsing pulse, things like your Carin sign, um not Carin sign, sorry, your um water hammer pulse where you're like lifting their arm up and you feel their um pulse slowly collapse in volume. Um And then also symmetry, symmetry is really important when you're thinking about things like aortic dissection. Um then you can move on to getting a BP in a osk scenario. You can either mention it and they'll usually give it to you or they'll just tell you to move on because you don't have enough time in a real cardio in an osk setting to get through that. But things to look out for is um are they hypertensive hypotensive symmetry as well? Again, in that classification of um aortic dissection and um coarctation and then longstanding BP can be um something you could mention if there's a prompt that, that they presented with recurrent falls or um something like that, you can also look for your dewy sign, which is nail bed pulsation in aortic regurgitation. Um And then I've got a couple of hand signs to look at here as well. Um So sorry, I'm gonna sneeze. I didn't. Um So this picture here um would be more your nicotine staining. So very, very common. Lots of patients are smokers, lots of patients go out to smoke while they are in hospital. So very easy um for them to bring in a patient with um nicotine staining in their hands. Um finger clubbing more common in um more congenital um cyanotic um heart disease, but also something to look out for, especially if you're thinking of something more respiratory um cych and anemia, palmar erythema in CO2 retention. And then all the below three seen in infective endocarditis. Um So the way I'd like to just differentiate between osler nodes and Janeway lesions is um one is raised. So the o nodes are raised and Janeway lesions are flat. Um Any questions so far? Oh You guys can all hear me. That's great. Um If you guys do have any questions, feel free to put them in the chat. Um And I'll answer them as we um go along. Um We'll move on to um your face, neck and eyes. So you move up the arm and then you're going into, first of all the neck, you're looking at your JVP um and making sure you distinguish that with your carotid pulse. So, um J BP has uh two pulsations, your A and V wave and your carotid pulse is just one. Usually your carotid pulse isn't visual unless um you've got Corrigan sign which is seen in aortic regurgitation as well that you like dancing carotids. Um And then also your JVP um response to your hepatojugular reflux. So that's when you ask the patient to take a deep breath in um deep breath out. You, you press a hand on the right upper quadrant where the liver would be and you press down and you're gonna see their um J BP rise. So the main thing that um would m make you look for something like this or look for signs like this is your um heart failure. You can also see it in constrictive pericarditis, which is um basically like chronic pericarditis um seen um and presents in a ki a similar manner to heart failure. Um So you're gonna look at that and then you're also gonna assess the carotid pulse. So you want to, first of all, assess the character, um the carotid pulse is a larger um artery. So it's a lot easier to assess the pulse, the character of the pulse with that artery. And then again, Carrigan sign, then other things to look for in the face, you can get malar flush, seen in mitral stenosis. Um All of your signs of um hypercholesterolemia. So your corneal arcus, your xanthe asthma, um uh conjunctival pallor, central cyanosis and poor dentition generally seen in smokers. Um So again, uh when you're doing an exam, if you don't see this, um you don't have to mention every single one just mentioning like maybe two or three and just being like, OK, I'm just looking at the eyes just to assess for any corneal arcus, any um conjunctival pallor or any xantho xantho assma, that's more than enough. So don't kind of um force yourself to just list all these things off. Um Just for the points. Um Make sure that you kind of have a um like give yourself a limit and move on. So you're not wasting time. Um All right. So next we go on to the chest. So big things with a um uh with looking at the chest. So main things would be your um chest wall deformities. So things like your pactus carinatum and excavate the way I like to think about excavatum and carinatum, excavatum has the word cough in it and in my head that thinks of like cave. And so you're like ca caving into the chest and then carinatum is the opposite of that. Um So you're looking at your chest wall deformities and then you're looking at scars. So, um it's really make a big deal out of this. Um You probably know by now, but you need to show that you're actually inspecting the patient and um you could get patients who do actually have abnormal clinical signs. You could have a patient who's had a pre cabbage and they've got a midline sternotomy. So it's just really important to show that you're looking um make a point of um having a look at the chest, lifting each arm up. Um This would be the same in your peripheral vascular exam when you're looking at um uh the, the feet and looking at the toes and you're assessing for any ulcers or any um uh like arterial venous ulcers between the toes, um make a point to look between each toe and you're actually showing that you're um you're mo you're looking for this, you're not just kind of mentioning it for the point. Um It's good to have an idea of what these um surgical scars might indicate. So things like sternotomy, meaning a cabbage, um or if they've got a um like a sub uh left subclavicular, we had a patient with a left subclavicular um scar and she had a pacemaker inserted. So it's good to have an idea. You could also just ask the patient as well. So just kind of build that um patient rapport and say, oh, I can see that you got a scar there. Did you have a previous surgery? And they might give you an idea as well? Um Then you're gonna go on to your palpation. So three main things you're palpating for is your apex beat, your heaves and your thrills. Um So your apex beat. Um Do we all know where it's supposed to be if you want to answer in the chat? Oh, yeah. Um So when you're inspecting, do you say it, for example, no previous sign of sign of previous surgery just vocalize your thoughts. So, um it shows the um the examiner that you are thinking, oh, they're looking for scars, they're looking for this. So definitely um verbalize as you go while you're doing your examination for sure, because you could very much just look at the te the chest and then um the examiner is kinda like, ok, they're just looking at the chest. They're not really saying what they're looking for. So I'll just verbalize what you're saying. Um Yes, fifth intercostal space, midclavicular line. Perfect. Um So I will say what you need to do. First of all is when you're palpating, go to palpate for the apex beat, try to find it once you locate it. Um count up. So go up and you're saying, OK, this is um sorry, count down, sorry. So go um find your angle of bluey, go to the side and say, OK, this is the second, this is the third, this is the fourth and this is the fifth intercostal space. And I can see this is the midclavicular line. So make it a point that you're actually measuring it and don't kind of just say it's in the fifth intercostal space, mid clavicular line because um you will get an extra point um or you might just lose out on a very easy point. Um For noting where the apex beat is, if it's difficult to feel the apex beat, you can have, you can turn them onto their left lateral side or you can just say, I can't feel the apex beat. I would expect to um see it in um the fifth intercostal space, midclavicular line. Once you feel the um the apex beat, you go on and feel for um heaves and so heaves are basically you're feeling the heart push up against your hands. So it's kind of like if the, if you're feeling the chest wall there, it feels like we like that. And that the reason for that is because heaves are a consequence of hypertrophy. So um more, more commonly in stenosis, um stenosis is obviously a narrowed valve. So you've got your chamber that's put working really, really hard to push the same amount of blood um through a stenosed valve so that it can meet the requirements for stroke volume um for an adequate stroke volume. Um But obviously, once it's working really, really hard, it's gonna start growing bigger because um it's a muscle and it's working harder than it should be. So it grows bigger. And so that means it's gonna, it's more likely to just push up against the chest wall. Um Once you feel for heaves, then you're gonna move up and you're gonna feel for thrills. Um and thrills are basically just a palpable murmur. So that's when you go above a, a grade four or above which we'll talk about um murmur and that's um secondary to some sort of valvular insufficiency. I can show you how to assess heaves and thrills. It's a bit difficult. It's I think it's really, it's quite difficult to show on um on obviously video. But if you're, if you're feeling for uh heaves and thrills, if you were so I can move this back. If you were feeling for the apex beat, I like to go feel for heaves. So palm on the center vertically and then feel for thrills. So you're um assessing with the side of your hand and um horizontally, placing that on the top of the chest. I hope that makes sense. Um Again, thrills will feel like a vibration cause that's a palpable murmur. Um Another thing to point out a patient could have a displaced apex beat, which is again, why it's really important to show that you're counting where the um apex beat is placed. This is more common regurgitation. Um Again, if you think about it, when you've got um your chamber is pushing um to get blood through a valve that isn't adequately closed. Um There's gonna be inevitably black backflow and that backflow once it becomes um a lot more chronic is gonna cause dilatation of the chamber and that cause that causes the um apex beat to be dis displaced. Um Does that make sense? Any questions or comments or concerns or I'll move on if you have any questions, feel free to um put it in the chat. Next is the big part of um your examination, which is your auscultation. So I've put an image here um of the different um areas where you auscultate. So that's your aortic, your pulmonary, your um tricuspid and your mitral and this is herbs point which we'll talk about as well. Um So what you wanna do when you're auscultating, listen to each um point with the diaphragm and your diaphragm looks at your higher pitched sounds. So that's usually your systolic murmurs, um and your higher frequency murmurs. Um then you're gonna listen to Tricuspid and mitral um locations with the bell of the diaphragm because you're gonna find lower pitched murmurs, especially your kind of um early diag diastolic um like mitral stenosis type murmurs. Um Then you're gonna get them to go on to their left lateral position, listen with the diaphragm and listen into the axilla and you can hear radiation of mitral regurg into the axilla. So it's important to, so if you're um considering a um a mitral valve insufficiency, that would be um a uh ex extenuating maneuver to do another extenuating maneuver to do is herbs point. So you go into the right upper sternal edge and you're gonna get them to lean forward, take a deep breath in and a deep breath out and hold their breath and that's gonna make the murmur more prominent. Um And then you, you can listen to the carotids um with your diaphragm as well um to listen for any ra radiation of an aortic stenosis murmur. Um So, what I will say is your auscultation is the um um the most prominent, prominent um part of your examination. So, um this is the part that's gonna be obviously assessed um the most because there's more to do. Um So there's more points to get here. Um I will say even if you do um hear something, it's ok to just mention. Um like I wouldn't lie and say it's normal if that makes sense, never lie. Always say that you found something if you have because then um it shows that you're actually listening and you're actively thinking. So you could always say like if you hear something, you could say, I hear a murmur um in, I don't know the aortic um and describe it, describe how it sounds to you, even if it's wrong, it shows that you are listening and you are trying to actively think and it's always safe to say I would like to escalate to the se to a senior or ask someone else to have a listen as well just to confirm um any questions about that, I'm gonna swiftly move on just cause there's quite a bit to go through. But this is a mind map that I made um when I was in uni to help me um revise for the different types of murmurs. Um I'm not gonna kind of read through every single one. Your main ones would be your mitral regurge and your aortic stenosis. They're gonna be your most common ones. Um So, um here's your mitral regurge your aortic stenosis and these are like the causes and then these are other um signs that you might see as well. So, um again, as you can see with your stenosis, you're gonna get heaving apex beats because you get hypertrophy and with your regurgitation, you're getting displaced apex beats um because of your regurgitation um because of dilatation. Um mm excuse me. Um two important um pneumonics that really helped me. One is mister traps. Um When I was stuck in figuring out what s what systolic murmur, I think this patient has um mister traps was really useful. So, uh M RTR um is my true and tricuspid regurgitation A PS is aortic pulmonary um stenosis. And so all of those are systolic murmurs. So, um that's a useful mnemonic if you're struggling. Um whether the as to which um um murmurs are systolic or diastolic, that's a good one to know. Um and then Ryle as well. So Ryle is basically right-sided murmurs will um be more prominent on inspiration and left-sided murmurs on aspiration. So, things like your tricuspid and your pulmonary murmurs will be more prominent when a patient takes a deep breath in and holds whereas with your aortic um murmurs, for example, with herbs point, especially when you get them to take a deep breath in and a deep breath out and hold, um it causes more, um it, it causes more prominence and it's just relating to how your breath and your um ventilation coincides with your cardiac cycle. So when you're taking a deep breath and there's gonna be more blood flow going towards the lungs, which is why it's going towards the um the right side and with expirations going more towards the system in very layman's terms. Um Again, if you have any questions, please feel free to ask. Um But yeah, um zero to finals and um med sounds on youtube are really good to have a listen and just listen to normal heart sounds as well. Cause a lot of the times in an ay you can kind of convince yourself that there is a murmur. Um Just because you're kind of panicking and you're in your head and you're like, oh, what if there is? And I'm missing something. So have a listen to as many like normal chest as you can and um like obviously practice on your friends and things. Um So then when you do hear a murmur, you kind of know that there is something wrong. Um And in terms of your assessment of a murmur, zero to finals is really, really good for this. So know your script, mnemonic. So then you can sound quite slick when you're presenting it. So, um on auscultation, I found a murmur at the site of the aortic loudest in the aortic valve, it sounded like a crescendo, decrescendo murmur. Um And then um it radiated to the carotids. Um It was, I don't know, grade two in intensity and it was high pitched um and it was a systolic murmur. So, um it made me think of aortic s um aortic stenosis. So, um those are all um that just obviously in a more um kind of concise manner. That is a really good way to describe, um, a, a murmur without missing anything. Um, and I'm getting quite a few questions in the chat, so I will, I will get to them. I promise. Um, so that's kind of a good mnemonic to, to, to learn in terms of, um, being a little bit more slick and concise and presenting what your murmur is in terms of murmur grade. Um, It's again, very subjective, but it's good to kind of get an idea as to how loud it is and how severe this valvular insufficiency might be. Um the way I was taught to think about it, um The way I was taught to think about it was um relating the murmur to heart sounds. So grade one is you can't really hear um the murmur over the heart sounds, it's like super, super loud. Grade two is you can hear the murmur but um the heart sounds are louder. Grade three is the heart sounds are about equal volume to the to the murmur. Um Grade four is obviously louder. You've got a palpable thrill. Grade five. You have the stethoscope off the chest and you can still hear it in grade six. You're on the other side of the room and you can hear the murmur. Um So again, a good way to kind of show that you're thinking and your slick um is knowing how to grade this murmur. Um So decrescendo crescendo is basically, yeah, it's getting increasing CRE it's crescendo, decrescendo. So getting louder in volume and then getting quieter. So you hear, you hear that a lot in your ejection, systolic murmur and aortic stenosis where it's um crescendo, decrescendo. Um Let me send a link to the med sounds I can. Um But yeah, it sounds um like you can kind of hear it um increasing in volume and then decreasing. It's kinda like it goes up and down. Um I will find a link to send you guys um um so that you guys can get a um I'm trying to find uh oh yeah, it's this one. Let me copy and paste this. Yeah, it's that one. Sorry, let me send it to you now so you guys can have a listen. Is it that it is that whoosh type of sound? Um All right. Um I'll make sure to send it in the um slides for some reason the chat isn't working for me, but I will send it um in terms of the grading of the heart sounds. So um it's the grading of murmurs. Um you're relating the murmurs to the heart sounds. So in terms of volume, how does the the murmur compared to the volume of the heart sounds? So in terms of grade one, you can't really hear, it's very difficult. The heart sounds are really, really loud and you just kinda hear something in the background that might be wrong. Grade two, heart sounds are louder than the um than the murmur, but you can still hear the murmur. Um Grade three is there about equal in volume? Grade four is the murmurs louder and you've got a palpable thrill and then grade five is the audible without the stethoscope touching the chest. And grade six is your across the room? Um I hope that makes sense. I will. So the if you Google meds, cool. Um Me DZ Cool Coo L um they're really good for um heart sounds and then zero to finals as well is really good for um those heart sounds as well. I don't know why the chatting, the chat isn't working, but I'll put it at the end of my slides as well. Um If we're sending them out, um next part. So obviously you've done your auscultation part of the examination, you're probably um questioning all of your life choices. Um So next thing you're gonna do just for completeness, always auscultate the base of the lungs and assess for pedal or sacral edema. Um It's really good for completeness because if you're getting someone who has valvular insufficiency that comes hand in hand with heart failure. Um So it's always important to assess that. Um And then it's always good to just summarize. Oh, thank you. Abigail s so nice. Um But yeah, so it's always good to summarize. Um think concisely when I think about summarizing, you can kind of think about it in an sbar fashion. So um situation, I examined a pa like a 54 year old patient um or 50 year old four year old woman um who presented with blah, blah, blah, blah blah. Um on inspection, I noticed this or an expression I inspection. It was completely normal. Um on palpation, same thing on auscultation. Um You can use your script mnemonic. Um Overall, this gives me an impression of like heart failure or whatever. Um To complete my examination, I would like to take a full history, do a respiratory exam, do a 12 lead E CG and do a peripheral vascular exam. So it's always good to just think about other things that you could do for this patient. Um If a patient has heart failure or your worried about heart failure and fluid overload, you could do a fluid assessment, you can get um A PRO B and P, you can um refer them for an echocardiogram. And um in GP land, the easiest thing is just do a cardiology referral, very nice and easy thing. And it shows that you're thinking about the ne next step for this patient because that is something that are gonna be asking you about in um in a final year. OS, does that make sense? Um That is our m main kinda um summary of a cardiovascular exam. It's a very large run through and I know it's, it was quite fast. But um if you guys have any questions, feel free to ask it in the chat and we can run through them again. Um So let's go. Let's, we're gonna move on to our A to E examination. We're gonna make it cardio focussed. So this is just an overview of our um at E examination. So you've got your sample history. So, symptoms, allergies, medication, past medical history, last meal and events leading up to now. So this is basically the really important questions that you need to ask. So, um just so that you don't, um you have a full picture of the patient and you know what you're giving them and what you're giving them will help um airway. So, are they talking any additional sounds, any angioedema, respiratory distress, um breathing. Um So, so obviously with your airway, you've got your airway maneuvers and your airway adjuncts that are interventions, breathing, you're gonna look at the tea, is it central equal chest expansion changes in percussion auscultation and then just their s in terms of um respiratory rate and um sp O2 interventions could be starting 15 L through a non rebreather mask, a practical tip. Um Whenever you are starting F one is um you need to inflate the bag in the non rebreather mask. So you need to hold that down when you start the oxygen, let it inflate. Um So that's on the inside of the mask. So if this is the mask, you've got a little like hole there and then you've got the bag important to reinflate that um other interventions to think about. So, if you're worried about fluid overload in a cardiac patient, if you're worried about respiratory distress, a chest x-ray and an ABG would be entirely reasonable um to get um circulation. So you're looking at your peripheral and your central cap refill your pulse, blood pressure, heart sounds and then this is just a key point for any um acute abdomen patient. If they've got ab abdominal pain, do your abdomen exam and your circulation because that is your main priority and you don't wanna miss anything um acute that might um that might save you time by bringing it forward to escalate and to manage. Um and then always look at the CS to be doing an E CG catheterize the patient, um or strict fluid input output, get IV access, get bloods and IV fluid boluses. Um in terms of your um what's it called in terms of your circulation as well? That is usually when you start intervening and start treating something, but it's important to not kind of skip over your disability and exposure because that will give you a better idea of, first of all the important parts um of their management that might um influence or important parts of the patient that might influence your management such as their glucose, their medications. And also just, it might just give you an idea into what is going on with the patient. So if you go, sometimes you might have a SIM or you might have an OS station where you actually go to exposure and you see that they've just had a massive pr bleed and they just covered it with a blanket. So it's really, really important to um complete your, complete your at e other things that are really important in your at E assessment is always escalate to the relevant senior early. Don't feel bad about doing that, stabilize the patient and um give you relevant management and escalate. Um So if that's a um acute M I, you wanna refer to cardiology slash med reg slash PCI. If it's an acute abdomen, refer to surgery, um things like that. Um So always escalate and always reassess. So, if you've given an intervention, you've given them 15 L through a non rebreather and their um saturations are improving. Great, make sure their saturations are improving and you can start weaning off the oxygen. Um If you've gotten a chest x-ray, check the chest x-ray, is there anything in there that might give you an indication of what further treatment they might need? Um So specifically, we're gonna start off with acute coronary syndrome. So, um acute Coronary syndrome is specifically your unpredictable pain. So you've got your predictable pain, which is stable angina where you have demand ischemia in um your coronary blood vessels, you get a normal E CgA normal troponin and it's predictable chest pain on exertion, you start going into your A CS where you um have your unstable angina from to yours and your stems, um unstable angina is when you get plaque rupture and um that's gonna start causing supply ischemia. So basically, your um coronary arteries aren't able to supply enough blood flow to um to the heart just randomly. Whereas demand ischemia is um when it needs more blood flow, it's not able to get it. Um So on your E CG, you can, I'm sorry, on an E CG, you can get normal EC GS or you can get E CG changes in keeping with an NSTEMI but your troponins remain normal. Um uh That's because there's no infarction there. So, because there's no damage to the cardiac tissue, your troponins stay normal once you start getting into your Nstemi and your semi, that's when you start getting elevated troponins. Um So your plaque rupture causes um some infarction. So it just depends on how severe the infarction is. Whether it's subendocardial or if it's transmural, that's when you get your specific types of E CG changes. So in an end sty, you've got ST depression or you've got inverted T waves in your stemi, you've got your hyperacute T waves and your t elevation um in an ay usually they give you something quite obvious and it's really important to just um uh to, but it's really important to look through a whole E especially if it's just an E CG reading station to look through the whole E CG um and make sure you've come to your diagnosis and um are pretty sure of it. We had an oscopy where um we had an E CG and it was hyperacute T waves. And so some people actually diagnosed it as hyperkalaemia and a lot of patient, a lot of people um lost quite a few points because they got the diagnosis wrong. And then they got all the questions wrong because they were treating it differently. So, it's um with that, I would say it's really important to look at the base level of where that P wave is and where the Q wave is. And if that's elevated, that's a stemi if it's not, but you've got your T waves tenting, that's hyperkalaemia. Um So your presentation of your um acute Coronary syndrome, you got your classical chest pain, um chest pain. So, in an acute patient, it's chest pains, suddenly, sudden onset, central chest pain, radiating to the left arm or to the jaw or to the tongue. Um they describe it as c crushing, chest tightness or a dullness or heaviness. So, like someone's sitting on their chest, um it's often associated with dyspnea, nausea and they feel very sweaty and clammy. Those are very classical symptoms. Um in patients who are older and in patients who are women, um they often present with dyspnea nausea sweatiness and calms without the chest pain, um, in atypical M I. So it's important to keep an eye on out on that as well. Um, family history and past medical history is really, really key here to understand this patient's, um, um, a risk for an M I and we'll give you an idea as to whether, um, and we'll give you a better idea as to how, how much further you should investigate or if you should kinda go to another route of what chest of what this patient's chest pain might be. Um, so very much you're going off of the history and you're going off of um, how they feel. Um, in terms of chest pain, um, in any acute patient, I just thought it was important to cover that you might, it might, it doesn't necessarily have to be an M I. It could be acute coronary syndrome, but it could also be pu a pulmonary embolus. It could be aortic dissection, a pneumonia, pneumothorax, pancreatitis. Um, you can get quite a broad range of differentials there. So that's why again, it's really important to think about your full at e assessment and keep a broad range of differentials in mind. Um So your main investigations with a, um, acute coronary syndrome is your E CG and your troponins, um, depends on the trust, but you can, in, in my trust of Bolton, we do zero and three hourly troponins. But in my old trust in Belfast, we did zero and six hourly and then 12 hourly troponins. And you're looking for more than a 50% increase in um a rise in your troponin to um confirm that it is an acute coronary event. Um in terms of E CG leads, it is very, very variable how people learn it. I'm a visual learner. So I kind of focused on this bottom right um image and I was like, OK, this is anterior, this is lateral. Um what's it called? This is inferior. Some people work better by just memorizing it. And your anterior is your led, your ant um la your lateral is your left circumflex. Antra lateral is your left coronary artery inferior. Is your right coronary artery and posterior is right coronary and left circumflex. But some people work better with understanding why. And if you look at the way the way that the leads are placed, you can see that um B1, b2 and B3 are slowly going more lateral to the heart. Um And then with your um leads 23 and A VF these are all kind of more inferior to the heart. So um there is the actual reasoning behind why each lead um gives you more of a um what's it called? Um gives you more of a um a change compared to others. Um So with a to E stations. Um oh yeah, Karen nicely um answered but yeah, usually you're given a scenario, it can be a mannequin. It can also be a patient we had patients in, in Belfast, um, as well. So you work through your at examination a lot of times they'll give you your findings as well if it's like respiratory findings or heart sounds. Um, and you can just kind of verbalize as you go. Um, and you can get asked the examiner for investigations as you go along and make sure you, you're explaining management that you'd like to give them. Um, but it does, um, at the end, they usually ask you a couple of questions and that's usually like Karen said, your differentials and your management plan. Um All right. So I just had a couple of EC GS that I thought we could look through. So, um, if anyone wants to answer in the chat, what this could be, um, we don't have to, if not. Um, but I thought it would be useful to just look through some common EC GS. Um, of what this could be. It might give you a clue that we just talked about this as well. Um Yes, ST depression wear. So, um, it's important to notice the E CG change first of all and then also know w which leads it is. Um, so what kind of idea might? Yeah, 100%. So it's ST depression in the lateral leads. So this patient is having an enemy in their left circumflex artery. Um So again, as you can see, um I hope you can see my mouse, but basically, you're looking at that base of where the R wave starts and you can see that that is significantly less than where that um s wave is gonna start. Um And that ST interval is gonna start. So that's how you can get an idea that this is ST depression. It's specifically in B um V 5 B6 1 and two, you can kind of see it in V four as well. So it is leaning towards getting some L ad involvement as well, but mainly predominantly it is a lateral um and sty. Um All right. So next one, if anyone wants to try this one out, it's OK. No stress. Um So this patient is having a anterior stemmy. Um Oh yes, ST ST elevation, correct, correct. Um Amazing. Um Maybe my wife has just poor. Um But yeah, it's an anterior stemmy. You can see again, we're looking at that base of where the um RWA starts and for this one, it's really, really, really high up. Um But you can see it predominantly in V one, V two, V three and V four. One thing I'm actually just gonna go back quickly and clarify. Oh yeah, here, um T wave inversion is normal in a VR. So if you see T wave inversion in a VR um but nowhere else that could, that's normal, that might not be indicative of uh anemia. Um So it's just important to know what's normal and what's not. Um But yeah, I just thought I'd quickly clarify that this one's difficult. Um I didn't really go over this but I thought I'd quiz you and see what you guys were. Um, if your brain was switched on. But does anyone want to tell me what this E CG is? I'll give you like a minute cause it is, it is difficult. Yeah. Um Left bundle branch block. So new, left bundle branch block in a patient is being treated as a semi no matter what. So it's important to keep an eye out for that. Um So yeah, yes, they do have left axis deviation as well. Um Well done. Um So uh the main things you're looking for is that William Morrow, I don't know if you've heard of it, but basically that deep Q wave um or sorry, Deep QR S complex in V one and V six, you're getting that bi FT R wave. Um So that's indicative of your left axis deviation when you're oh sorry, your left bundle branch block when you're thinking about your axis deviation. I was taught something by this really cool A&E consultant of a hack um of how to distinguish between right and left. Um I know some people look at the 12 and three, but I look actually at one and a VF. So if you're looking at one and a VF here one is positive and um, a VF is negative. So they're leaving each other. And so that's left axis deviation. Um If it was the other way around, they're reaching for each other. And that's right. Axis deviation. If they're both positive, that's what you want and that's good. And if they're both negative then I don't know what's going on and you should call cardiology. Um But yeah, I thought that would be, uh that's, WW was really useful for me to kind of wrap my head around um axis deviation along with obviously understanding it, which I don't remember as much as I did before when I was in medical school, but that mnemonic I do. Um So it's something quick and easy to kind of just um have a look at left axis deviation. Um So obviously, if you got an acute Coronary syndrome patient, you're gonna do your full at e assessment. Um And a lot of times you're gonna find out that. Um, well, first of all, if, if the history is kind of pointing in that direction of, um this actually seems really like an M I you can start off and give them analgesia because this patient is gonna be in a lot of pain. So the way I remember it is mona some people think about moan or have different pneumonics in their head. Um As long as it all includes morphine, oxygen, nitrates and aspirin. Um So if the patient is not hypotensive um you can always start off with some GTN spray two puffs. Sometimes the patient might have angina and they actually might have that diagnosed already. Um So they will have GTN spray that they've tried and it's not worked. Um Then you can step up to morphine in terms of doses. It depends. Um The way I remembered it as a medical student was 10 and 10. So 10 of morphine, 10 of metoclopramide milligrams. Um in terms of now you the, the, the realistic way to do it clinically is to like slowly work your way up. Um So if you're giving it or, or you can do, I would do like five and then see how that works and then give them another five so that it's total 10. Um If you're giving IV um nurses will legally, at least in my trust only give 2 mg weight and then give another 2 mg. Um So it just depends on how you wanna go. Um And then metoclopramide, you just always wanna give an antiemetic, you don't have to give metoclopramide. I just remembered it because it was M and M. Um but you can give cyclizine Ondansetron as long as you're giving them something because they will be extremely nauseous. Um Oxygen um is only given if their po two is less than 94%. If it's more than 94% you're actually increasing their mortality by giving them oxygen. So it's really important to um consider that if the patient is um uh has got acute Coronary syndrome. Um And then the next thing you want to do is you wanna load them with antiplatelet therapy. So you give them 300 mg of aspirin stat. And that's when you start pulling up the guidelines and thinking about um uh transferring to PCI or whether they need fibrinolysis, depending on their indications. So, um depending on the trust, um different trusts work differently just logistically if a patient um needs PCI and it's within the same department, a lot of the times you fax or email or you do something to send that E CG to the PCI department. Um If like in my trust, you actually don't have a PCI and they need to go for us, we, they need to go to Manchester. Um You need to organize, basically fill out a performa and organize them, being transferred with the Northern Ambulance service. This is not something you're gonna have to do in an AK but it's just something to consider if once you do start. Um because um it is something very real and if you're on call and you've got a patient and they got um an acute Coronary syndrome and you suddenly realize you actually, it's very easy to say, oh, this patient needs PCI. And that's another thing actually being like, oh, let me transfer them and get them to the hospital so they can get their PCI. Um it's important if for antemi and unstable Angina to think about their grace score. So, are they high risk um of recurring events or low risk? Um If they're high risk, usually they will get PC and if they're low risk, they get font paranox and um their secondary prevention. Um when you're thinking about dual antiplatelet therapy, um uh you always go for aspirin, they get that lifelong. Um and then they get tag tag or clopidogrel. Clopidogrel serves a lower bleeding risk compared to Tegre. Um So the dose would be clopidogrel 300 tag 180. Um So usually with like your older patients, your more co comorbid patients, they're high risk of bleeding, you'd go for clopidogrel, but it's also very trust dependent. So you'd always look at your guidelines and escalate to the medical reg or the cardiology consultant who would be leading um the further management of this patient. Um You then also will be giving them secondary prevention through an ace inhibitor, a beta blocker and a statin. Um I hope that all makes sense. Um repeat what to do in high and low risk for grade scores. So, um with ante and an angina, so their grade score is basically their six month mortality rate of um um a Anstey. So if they're high risk with their high grade score, um and they're clinically unstable, you go for PCI immediately if they're high risk and they're stable, you wanna give them PCI within 72 hours. Um If they're low risk, then you're gonna give them, um, Fonda PA or they don't have an immediate PCI risk PCI planned, you're gonna give them Fondaparinux. Um, and that's gonna be given in uh conjunction with dual antiplatelet therapy. Does that make sense? But again, this is all very um in an AK setting, they're more likely gonna ask you these kind of broader, broader range of questions in terms of um when will you give the PCI, can it be delivered in, in two hours, et cetera? Um And knowing kind of when, how to assess whether the patient needs PCI and how to um assess whether they don't and what you would do in that setting, acutely really important. The main treat, things are treating mona as well. Um No problem, acute heart failure. So this is the next at e that um I was gonna cover, it's something very common, at least that I've seen. So I thought it would be really high yield for you guys to look at. Um And basically, in terms of your history and examination, pitting edema, shortness of breath, um Pax, if this happens overnight, things like paroxysmal nocturnal dyspnea and orthopnea. Um and then also on your examination by basal crackles um for pulmonary edema or reduced basal breath sounds if they got like pleural, bilateral pleural effusions, um and past medical history is also important here. So, if they've got a history of heart failure, you know, you, it can kind of clear you in that they're short of breath and they might be having an exacerbation. MRI S. Um A common complication can be heart failure as well. CO PD if they're, um they can get right rightsided heart failure or some patients just might be given way too many um IV fluids and um they get, they develop heart failure. Um So sometimes this can be a new presentation, it can be an exacerbation. Um Either way, it's very, very important to treat as patients can get unwell very quickly. Um Again, with your shortness of breath, um there's many, many things that could be going on. So it's important to create um have a broad range of differentials and keep those in mind so that you're not missing um something because you've kind of pinpointed on one specific diagnosis. Um So reasonable um investigations to do. Um getting a chest x-ray, obviously, there's a breathing problem. So getting a chest X ray and an ABG would be entirely reasonable. Um So with your chest X ray, this is a very, very classical like heart failure x-ray. It's really nice. It's from radio pia. Um I really recommend using radio pia for your um kind of radiology revision. Um So there's a Pneumonic ABCD E, I'm not sure if you guys are aware of it. Um So you've got your alveolar edema, which is basically around the hilar regions where you're um starting to get your branches into your alveoli. Um You just get a lot of congestion and it just gets, it just starts getting very filled with fluid and it looks like bat weighing opacities. Um If you see like the movement of my um of my mouse, you've also got curly bee line. So if you see it's more prominent here, but if you see just like here, you just get kind of random li horizontal lines um near the bases of the lungs and those are all um interlobular septa in the lungs, filling with fluid. Um You can also get cardiomegaly only assessed in apa um x-ray. Um but you have the cardiac, the the heart is more than 50% of the um thoracic width and then you get dilated upper lobe vessels as well, um which is just congestion around the upper lobe vessels due to fluid. And you can get um fluid lines, either fluid in the horizontal fissure or fluid lines which cause blunting of the cost phrenic angle, which is indicative of a pleural effusion. Um then when you kind of move on, it's really important to get an E CG because you can look for um heart strains. So that would be like high voltage QR S complexes. Um um Most predominantly you can also get a BNP and if it's raised, that's also gonna clue you in that this patient will need a cardiology referral, get an urgent echo to assess for their ejection fraction, to assess for any valvular insufficiency as well. Um Does that make sense so far? I hope so. Um acutely um in any patient that is short of breath, there's quite a few kind of basic things that you can do. So things like lift the bed up um stop the precipitating factor. So if they're an anaphylaxis, stop the precipitating factor for that. If they're um fluid overloaded, stop their IV fluids, they're desaturating. So you wanna put them on oxygen and their fluid overloaded. So you wanna assess their fluids and give them loop diuretics. Usually it's like a 40 mg stat dose of IV frusemide. Sometimes it's 20. It depends on the patient and their renal function. Um patients can get cardio genically shocked as well with um acutely unwell patients. So it's important to have senior staff in ICU or critical care be involved early in case they need vasopressors, vasodilators, um CPAP or an IV. Um Again, you're constant, constantly monitoring and reassessing. Um You want senior like medical reg or kind of cardiology um reg to, to see this patient um in terms of long term after you've kind of stabilized them, you wanna get daily weights. Um and that's really important so that you're um uh assessing how the um if you, if you're offloading the fluid well, daily you and if they're gonna be on regular fursemide, you wanna make sure that their electrolytes and their renal function doesn't go bonkers. Um And again, a cardiology referral. Um So I know we're um running through really quickly. I've just got um this one last um per rest guidelines to go through. Um And then we'll be done. Thank you so much for your time. Um So these are the guidelines for your adult tachycardia and your adult bradycardia. I would say your adult tachycardia is a lot more high yield. Um But it's important to know your bradycardia guidelines as well. I had both of these posters up on my wall when I was revising for my final exams. I think it's just really useful to constantly be looking at something and then you're repeatedly thinking about um the pathway and like the guidelines um specifically with your tachycardia. Um you're um important to think about his. So your lifethreatening features. Um I think about it in the mnemonic. Hi H Iss. So that would be heart failure, ischemia, shock and syncope. So, heart failure, are they fluid overloaded ischemia? Do they have chest pain, syncope? Have they had any episodes of syncope and shock? Are they hypotensive? Um If they have life threating features, you will give three up to three synchronized DC cardioversion shocks and then give some amiodarone 300. Um If not, um You're then asking, OK. Is this a narrow QR S complex or a broad QR S complex? And then you're asking, is this irregular or regular rhythm. So in a narrow QR S complex with an irregular rhythm, you've got P AF and usually that needs treated with a beta blocker. A lot of the times that's 2.5 to 5 mg. If you don't know the doses don't panic, always refer to B NF. Um because that is the safer route to do. Um If you don't know, um if they've got heart failure, you'd go for digoxin or amiodarone. And then if this, um, phosphate has been going on for more than 48 hours, um, you want to consider anticoagulation as well. If it's regular and A N QR S complex, they are an S VT which is supraventricular tachycardia. We're gonna, I'm gonna show you the EC GS in a bit as well. You start off with vagal maneuvers, which I'll show you here. So usually the more common one is just getting them to blow into like a syringe and getting them to push the back of the syringe out. Um You can also do carotid massage as well. So the maneuver where you get them to pinch their nose, um, and, um, pinch their nose, close their glottis and try to take a deep breath in and with kids, you put ice to the neck, that's usually the best way to go. Um If vagal maneuvers don't work, you're giving adenosine, um, adenosine usually makes the patient feel absolutely crap and they feel like they're gonna die. So it's important to warn them before you give it to them. Um You give basically 6, 12 and then 18 and you're, they're on continuous cardiac monitoring. Um adenosine is contraindicated in asthma. So you'd give verapamil if in those, in those patients um if ineffective, um you then give synchronized um DC cardioversion, then you're gonna go on to your broad QR S complex um side of the algorithm. If it's regular, that is VT ventricular tachycardia and you're gonna give them amiodarone 300. Um If it's irregular, you're thinking of um complex af or polymorphic VT. So torsades, de pointes, which you'd give magnesium sulfate 2 g um to treat that adult bradycardia again, less, less um high yield in terms of an OSK scenario, but you could get it. Um So, again, always ask for the guidelines. Um uh You're the main thing that you're giving is your atropine and you're also looking at your risk, high risk of asystole. So that's your thing. It's like recent Asystole Mobitz type two A B block, complete heart block or ventricular pause of more than three seconds. If atropine doesn't work, you can give it up to six times to 3 mg and then you're starting to think about basically transferring them to CCCU and doing transcutaneous um pacing. Um So, again, just become familiar with these algorithms and also whenever you've, you've got a patient and you're worried about per arrest, you would uh first of all pull up the guidelines, call for help and call for the crash team. Um And uh what's it called? Um Always check if they have a pulse because if they're per arrest, for example, if they're in VT, you always wanna check if they have a pulse because pulseless VT is an indication for sh um for the shock side of the algorithm for A LS. So that's your vagal maneuvers. Um So I thought we just go through some common EC GS. Um And what we do um just kind of spot diagnosis. Um Does anyone know what we do for this? What this is and what we do for this in terms of the algorithm, it's so fair if, if you guys are like super, super tired cause it is late. Um And we have been running um quite long. Yeah, this is VT. So um so you would shock if they've got high-risk signs. So, life-threatening features such as um heart failure, ischemia shock or syncope. So you're gonna give up to three synchronized um shocks and then give up um amiodarone. If they don't have those features, you're just gonna go for um amiodarone. Um So yeah, it's ventricular tachycardia, correct. Um Next one, if anyone wants to put it in the chat. Mhm mhm mhm Yeah. S VT um Correct. So, unless they have his symptoms, you go back to that side of the algorithm. If they don't, you're gonna start off with your vagal maneuvers and then if that doesn't work, does anyone know what we would give? We give adenosine? Um, yes. Correct. Well done. Um, so we'd give adenosine and that's, um, 612 and then 18. So you can give it three times. Um, next one, is this ECG if anyone knows what it is or what we would do for this? So then again, um, just when we're looking at this EEC G, it's important to think. Um Is there, first of all, is there electrical activity? Is it broad complex or narrow complex tachycardia? And then is it regular or irregular? And you guys are exactly right. It's atrial fibrillation. Um So we're gonna give this patient a beta blocker, consider digoxin or amiodarone if they're in heart failure and consider anticoagulation as well. Um Another important thing is with any of these patients you always wanna think is there a root cause for this? Um I had a patient who was, um in S VT for quite a while and um it was really difficult cause it wasn't going away with the vehicle maneuvers. Um, she was completely stable and the cardiologist actually didn't think it was S VT, they just thought it was tachycardia. So they didn't want to give adenosine. And um we finally decided to um C TPA her because we were worried, ok, could this tachycardia be a pe and we found a, um pylori perforation, um, a new collection, I'm on surgery. So that's something that we would expect. But again, it's really important to think. Could there be an underlying cause for this patient um to suddenly develop this? Um Yes. Uh Next one would be this one. This one is a little bit difficult. It doesn't even look like an E CG but it is. Um does anyone know what it is and what we would give? Yeah. So it's Torsade de pointes. You give magnesium sulfate 2 mg 22 g. Um Perfect. Um We had a OS station like this where we had um basically a patient sitting there and they're like, oh, you know, I'm feeling like terrible, I feel my heart beating out of my chest. Um And you had to take a history and then um interpret the E CG and explain your management to the patient. So important key aspects in the history for would be what is the underlying cause? So, could there be an infection going on? Could there be uh could it be drugs causing them to be super tachycardic or um some sort of underlying um past medical history that would cause this? So like thyroid, et cetera, um really important to ask about your, his symptoms because that's gonna obviously affect your, which side of the algorithm you're getting uh which, which side of the algorithm you're moving into. Um And then obviously um with your E CG, it'll give you um a, a better idea of what is actually going on and then you can kind of follow through with your, with your management plan. Um I just thought I'd show you guys heart block as well. I never really understood it until final year. Um, because I just always would get mixed up between the different ones. Um, so first-degree heart block is, you've got a fixed prolonged pr interval and that's it. If it's asymptomatic, you usually do nothing about it. Um Second degree heart block is split into Mobitz type one and type two. So Mobitz type one or Wky back. So Wky back is the weird one. So um you get a prolong, slowly prolonging pr interval and then it prolongs so much that um there's not enough space for um there to be a QR S complex before the next P wave. So, um atrial re repolarization, sorry, there's not enough time for the ventricular depolarization and repolarization. Um So you get prolonging pr interval and then suddenly a dropped beat. Um Your second degree Mobitz type two is you have a fixed pr interval and a dropped beat. So that's where you start getting into your ratios of um 2 to 1 A V block or 3 to 1. And that's literally just, you've got a fixed pr interval and you've got for every three QR S complexes you got um sorry for every three P waves, you've got one QR S complex and then your third degree A V block is just it's all chaos and it's not. Um there's no kind of rhyme or rhythm to it. Um So that's me, basically me done just basics for Aks. I would know I've listed some common ec um EC GS and um uh Kara nicely went through chest x-ray ation as well. Um Always clean your stethoscope, um things like consent, hand washing, empathy, offering a management management plan after seeing um after um um doing an examination, so kind of conservative medical surgical, um if they're asking you for um treatment, take your time, um don't kind of rush through it. Um always take your time so that you feel like you're calm. The examiner thinks you're calm, the patient thinks you're calm because that will give you more patient points. Um Always with ec gs chest x-rays, always identify the um um always check the identity of the of the scan, ask for any previous scan. And also ask, is this the most recent scan cause they could have had like a previous um or they could have had a new chest x ray that was done 10 minutes ago. So always double check. Um And it's always really important. Have they had a previous scan to compare it to cause we had a patient who had like sudden onset shortness of breath and um they had these really weird markings on their lungs which we diagnosed as pleural plaques. Um and they were seen on a previous x-ray, but never followed up because they had just been discharged and stuff like that, which is, um, obviously its own thing, but it's important to look back and see. Ok, they've been having this for a long time. This is not a new change. Um, so when we're looking for something where they're, where they're in acutely unwell, um, the new change we'd be looking for would not really be related to the pleurops. Um, but yeah, um in terms of useful resources, especially for cardiology, life and the Phos Lane would be, would be for ec gs um geeky medics um is really, really good, especially kind of for your um for to have a good structure and just for like general information as to why you're looking for different things. Zero to finals, especially for heart failure and murmurs. I found it really useful. Um B MJ breast practice was kind of my best friend in medical school because it gives you really good differentials to think about and it just kind of follows you through the um a specific diagnosis. Osk stuff is really good for your ay and posed obviously is really, really good. Um Good luck if you could give feedback, I could, I would love to, if we're sending this um form, I'll send you the link for feedback that would be really useful for me. Um And yeah, good luck for your um akie. You guys will be amazing. You already know a lot And so I hope this was helpful. Yeah, I don't know what um I'm just gonna finish the rest of my talk. Um I just had an ABG and a chest X ray to practice. Um This was what I was gonna do before we had the tech issues. Um You guys will also be sent a feedback form from Medal um and just to plug our series, um we've got every specialty being covered um on Code blue. So every Monday at seven we'll be rotating through specialties and trying to get you guys ready for finals. Um So next week it's going to be gastro same time, same day. Um So I'm just gonna quickly share my screen. Um If you guys have to go, that's fine. Um But it's just talking through an ABG and a chest X ray, how you would in an Ay because it's quite good practice. Um So I'm just gonna share. Um And then you guys are free to get off. Um And also if you have any questions um especially about kind of any ay um or anything like that, then that's fine too you can ask. Um So I'm just going to load it up. Um And then we'll go through, but yeah, any questions feel free to pop them in the chat. Ok. So I'll start sharing in a second and then hopefully you guys will be able to see it. Um So I just screenshot the geeky medics um slides that we were gonna use. Um So the first one, I'll just give you guys literally a couple of minutes um to look at an ABG. Um Sorry if it's a little bit small, let's just go back. Um But at the top it's telling you, um, who the patient is. So it's an 83 year old woman who's been admitted with shortness of breath, a cough and a wheeze. Um And she's drowsy and tachy, tachypneic even on oxygen. Um So literally just a couple of minutes to interpret the ABG. Um And then we'll talk through it how you would in an actual osk scenario. Um And if you've got any questions or any thoughts on what this is showing, then just drop them in the comments. Ok. So we'll give it maybe like 10 more seconds and then we can go through. Um It's also worth thinking if you know what's going on with the ABG, what the most likely diagnosis is because that's also something we'll discuss. Um So just have a think about what you think is going on with this patient based on the history um combined with the ABG. Um And then we will discuss it. There's no right or wrong answer in terms of most likely diagnosis, but just in terms of differentials, if you're in an ay um that you would go with because in your ay you get this amount of information, um they'll give you age gender and then a little bit about the clinical findings, but not a huge amount because they want you to interpret it in conjunction with the ABG. OK. So we can start to go through it. So obviously, here, they've not given us like patient details, but in a ay they would, so the first thing that you would start to kind of say is I can see that this is the ABG of say their name and then say the hospital number NHS number, whatever you've been given. Um And then it's important to once again just interpret it with a clinical context. Um So the first thing to do is to have a look at the ph um So you can see here that it's an acidotic picture. So that's good because you know what's going on. Um And as soon as you know that there's acidosis that kind of narrows down a little bit what you might be thinking. Um And then the next thing to do is have a look at the O2 and the CO2. Um So here you can see that the O2 is low and the CO2 is high. Um So yes, it is type two respiratory failure. Um So well done to everyone that said that. Um So you're also thinking that this is respiratory in nature. Um So, you know that you've got acidosis, you know that it's respiratory in nature. So it's respiratory acidosis as well. Um And then it's time to look at the bicarb and the base excess um to see whether there's any compensation to see whether there's anything metabolic. Maybe it's a mixed picture, maybe it's not. Um But here, when we have a look, the bicarb is within range and so is the base excess. Um So here it's rasp acidosis. Um it's type two rasp failure. Um but nothing's going on metabolically. Um So that brings us to the next kind of thoughts about what could be going on with this patient. Um So yeah, the differentials in the chat are really good. Um So yeah, the most likely diagnosis here is probably an infective exacerbation of CO PD. Um If we had more time, we would go through it kind of properly, but I still want to do the chest X ray as well. Um So, I mean, here you can kind of pick it up from the age, obviously, they've not really shown you that much. Um But they've also not really given you any kind of past kind of medical history. Um So it's interpreting what things are gonna affect elderly people, um, compared to younger people. Um So yeah, we've got the wheeze as well. They've not specified what type of wheeze it is. So, asthma is a very good guess as well. Um And then in terms of pneumonia, yes. So, I mean, we've not got any blood. Um So that's something we want to get to kind of rule out pneumonia as well. Um, so all very good differentials. Um, and for your osk you'll need about three differentials. But in finals, they always ask you for your top one as well. Um, because they want to make sure that you've actually thought about it and to come up with what you think is the most likely one, not just named three, pretty safe bets. Um, so, yeah, that's kind of how you'd summarize your ABG. Um You couldn't work through it logically and then whatever kind of differential you give is your top differential for finals, you have to come up with a management plan for that as well. Um And obviously most respiratory things kind of be doing the same types of things. Um But just remember that if you're thinking of something that has a slightly different management plan, for example, pneumothorax don't have the same management plan as quite a lot of other things to just kind of make sure that you've thought about which one you're going to put as your top differential. Um and go with something that you're confident with the management plan of as well. Um And then the final thing um So the stem got cut off. Um But this is a 54 year old man who's come in um with a three day history of coughing. Um and just general malaise. So have a look at the chest X ray and think about how you describe this if you're in an ay and then we'll go through together. Um And then this is the final bit of the talk. I promise obviously any questions, feel free to drop them in the chat. We'll do the chest X ray and then you guys can enjoy the rest of your Monday. And also with this, what the most likely diagnosis is gonna be, I'll just give it maybe 20 more seconds and then we can go through but really good things coming through in the chat so far, so well done guys, ok. So we can start going through. So you get really good suggestions in the comments. So we'll just run through how you would in a natural sy. So same thing obviously here, we've not got any patient details, but you start going through and having a look. Um And at this point, you could also ask if you've got any previous imaging that you could look at nine times out of 10, you won't, but you never know sometimes in the oscopy, they might give you something um which would probably show a clear chest X ray. Um Compared to this one. as a side note, I put one up in the slides earlier, but just make sure you know what a normal chest X ray looks like because if you don't know what a normal one looks like, then you can't decipher things that are wrong on an abnormal chest X ray So if we go through, um so just for the purposes of time, we'll say um that kind of the quality is fine um in an OSC, they're not gonna give you a bad quality um chest X ray. So that would be mean, but it's always good to just comment on it that, you know, it's not overly rotated, that you can see suitable inspiration and that you can see that the penetration and exposure are OK. Um And then in terms of obvious abnormalities, so something that jumps out, which quite a lot of you picked up on is the consolidation. Um So it's good that you're using zones as well. It's kind of straddling the upper and middle zone, but I mean, you've picked out the right place, um which is good. Um So that's your big obvious normality. Um And it's kind of taking up the whole of that diameter of the lungs. So it's quite a big patchy area. Um And if you're not sure consolidation is kind of a blanket term that you can use. Um So then in terms of just going through the A to e so, yeah, there's no tracheal deviation, Corina looks OK. Um And I mean, judging by the stem, obviously, there was just a really small snippet of the case. Um They'd give you maybe some examination findings. Um but everything looks all right. Um Really, unless you're dealing with a tension pneumothorax or maybe a massive effusion effusion, the tia will be ok and it'll be central um in terms of the lungs. So, I mean, the ap look. Ok. So does the hila there's no like lymphadenopathy that you can see. So that's fine. Um There's no cardiomegaly. So once again, that's ok. Um And the cardiac borders, there's nothing too abnormal about them. Um But then when we actually kind of get down to the nitty gritty, we've already discussed the consolidation diaphragm is looking OK as well. It doesn't seem to be any pneumoperitoneum. Um and then just finishing up. So I mean, it doesn't appear to be any kind of fractures within the ribs, not really any masses at all. Um And there's nothing in situ, there's no pacemaker. Um There's no NG um which I mean, an NG in this patient, you probably and expect that to be in place. Pacemaker is always worth asking. Um So yeah, overall, right, mid zone consolidation um and it's most likely gonna be pneumonia. Um So, yeah, very good abigail. Um So yeah, usually we talk about it in zones inside of lobes just because it's easier to kind of visualize. Um You can just split it up into 123 with the lobes in the way that they're actually anatomically in the body. It can be difficult. Sometimes you might think it's in one lobe, but it's actually in another one based on how the chest X ray has been taken. Um But Yeah, so very good. Um, and we've already kind of covered how you would manage the pneumonia. It's quite simple. It's just antibiotics, screened for sepsis. Um, and obviously if they're still not kind of feeling better then you can escalate to either your sho your reg or critical care if you need to. Um, so yeah, that was just finishing off the first bit of the rest talk. Um, so I'll stay on for a bit if there's any other questions, otherwise if you guys could fill in the feedback, that would be great. Um And yes, stay tuned for more of our blue light of final session. So, thank you guys. No worries, guys. Have a good evening and if there's any other questions, you have, feel free to contact us.