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act confident with whatever you're doing. Um, it's also important to find a balance between taking your time and rushing. Um, it may sound quite basic, but it's a good place. Start if you want to maximize your marks. Uh, manners will always be polite, empathetic and honest to your patient. Listen to them carefully and just let them speak. Thank them and the examiner at the end of the station. So a significant amount of marks are just often awarded for demonstrating these generic communication skills, so make sure you don't neglect them, lastly, so keep calm. And don't worry about making mistakes during the Yassky. Like stay calm, we all make mistakes. Take a deep breath and continue where you were, because at the end of the at the end of the day, the aim is to maximize your marks. And if you start panicking, it's it's not gonna make it any better. So let's move on to the cardio cardiac examination. So once you read your instructions, you know you have to be performing in cardiovascular examination. You step into the room. What's the first thing that you have to do? Any takers, um, just pop onto the chart. What do you think? It's the first thing we should do whenever we go into when we step into the room when we're performing a cardiovascular examination. Yeah. So great. Um lovely. So a lot of answers on the chat. So as we discussed it. So why? So wash your hands, introduce yourself, gain the patient, gain patient details and then explain what you're going to be doing. So the main thing I'd like to focus on this side is the explanation. Say what you're going to be doing. So I would like to perform a cardiovascular examination on you that involves me having a look at your hands, your face, your neck, your chest feeling for your pulse and heartbeat and then also listening to your chest. Is that okay? Normally they'll say yes. And that's the consent bit, actually, So I have to explain the procedure patient. Ask them if they're happy to proceed. An important thing to do generally before starting an examination is ask the patient if they're in any pain, because this can give you a clue about what the problem is. But it can also make you aware of any pain before you start asking the patient to move around position. So for the whole cardiovascular examination, the patient is generally, um, lying down at 45 degrees. And that's the position you would, uh, need to ensure the patient is in. In some scenarios, they leave the patient flat on the bed, and it's your responsibility to ensure there's lying down at 45 degrees. So make sure you do that before you start your examination the next. The last bit is, before you start, your examination is exposed to patient adequately, so in most scenarios, the patient will already be exposed. But if they're not, you would need to ensure that they are. This means that there bear above the waist if their mail and they're wearing only their bra if they're a female, so that their arms, neck and chest are all exposed. Oh, now moving on to the next stage. So that is your general inspection now, does anyone know what we're looking for when we are having a when we're doing when we're doing our general inspection of the patient? So what are we looking at? Um, anything that would stand out to you, especially cardiovascular examination Yes, a cyanosis. Yeah, I've seen that. That's a good sign. Anything else that you'd like to look for? Edema, Pallor, Distress? Yes. Perfect, Yes. Sweating. Good. Yeah. I mean, great answers. So far. Really good. Yeah. Yeah. I mean, really all really good onto shortness of breath. Yeah. Breathlessness. Yeah, right. Yeah. So those are all really, really good answers. So first thing that we want to look at, as we've, uh, first you can look at is the patient. So first, look at the patient. Are they? Do they appear breathless? Does the patient appear pale, Which could be a sign of anemia. Do you notice that? Their fingers a little bit blue, which means that they're cyanosed. I think someone a few people mentioned cyanosis. Um, scars, edema, distress. Um, I think these are all really good signs. Especially like, um, cyanosis can be a sign of hypervolemia inadequate oxygenation such as COPD patient's. Um, scars can give you idea about surgery. Dema can give you a sign about other, like heart failure conditions. So these are all important information before you actually really even touched the patient. Now everyone's given me a really good response. Is about what to look for in the patient. But there's also other things to look about when you're doing a general inspection. Um, it's quite it's quite easy to get focused in on the patient, but not look around the room. Can you think about other things that you'd be looking at around the room? That would be really useful. Yeah. Lighting? Yeah. Cool. Yeah. You don't want the room to be really dark equipment? Yeah. Equipment A bit vague while we're thinking in terms of equipment. What type of equipment? Yeah, oxygen. Oxygen is one of them. Definitely 100% 02 sats. Yeah. Yeah. Great. Medications. Room temperature? Yeah, past medication, walking AIDS inhalers. Great. Yeah. This is really good stuff. Um, yeah. So really good stuff. So things that we want to look at around the bed are we? There are sometimes quite obvious things. Like oxygen IV drips, E C G machines, and patient's are often attached to them. So be aware of them. Um and it's important to notice them at the start, as it can give you a clue about what's actually going on with the patient before you've even started examining them. um, pillows. Pillows can be used to shut off up near, and that's also a sign of congestive heart failure. Other things are like news charts prescription their medications now. These things are quite small in general, and they're quite they're not as obvious. So you do need to make sure that you look carefully around the room. You can also ask the patient if they brought anything with them, and they'll usually point any of these and medications such as G T N spray, statins, blood pressures but BP tablets. Um, it can give you invaluable information about the patient so you can have an idea about your differential diagnosis. Cool. Now the next step involves looking at the patient's hands. So the way that you do that is first, you start by examining the back of the hands, followed by the front of the hands. Then you assess for clubbing, assess, assess the temperature in both arms and then assess the cap refill. So these are the steps that you need to follow When, uh, when performing a cardiac examination, um, of the hands so start with back of the hands front of the hands clubbing temperature and then cap refill. Now I'm going to show you how what to look for in each of the stages. Um, for when you're examining back of the hands front of the hands clubbing how to assess the temperature and how to assess cap refill. So I'm going to bring up a series of pictures, and I just like you to tell me either. What are we examining? What we doing or what sort of abnormality can you see? So what do you think is happening in either of these three pictures? And the first two were testing something. We're examining something. Third one is some sort of abnormality. Yeah. So we we already got James James. Uh, Abigail. He's already got peripheral cyanosis, which is perfect. That's what you've seen. That one? Yeah. Cap refill. That's what we're doing. They're really good. Yeah, And that can be caused by inadequate blood supply. So the cap refill will be really long. If there is inadequate blood blood supply, we can also see cyanosis sometimes. Um, if the there is inadequate oxygenation, what do we think we're doing in the first one? Why are we touching? Yeah, perfect temperature. Great. So That's how you dis Estep richer. You'd, um, use your hands and use the back of your hands and move along the patient's for arms and see if the pain if the temperature is, um, if they feel warm, do they feel cold in their peripheries? Great cap refill is generally less than two seconds. That's normal. That's a normal cap. Refill. You normally press on their finger and normally become turn red, um, within two fingers, which shows the blood supply is adequate. Peripheral cyanosis is a sign of co oxygenation to the peripheries. Looking at the patient's nails. We've got a few things that we're looking that we can see here. So what are we assessing for here? And what can we see in these scenarios? Yes, the splint to hemorrhage is great. That's what we see over there. Blubbing? Yeah, that's what we're assessing for their Great. Yeah, And can anyone tell what this is? This is quite difficult. Think smokers and not quite a January lesion. January lesions are a lot. Yeah, tossed, ending. Great. Perfect. Um, yeah. So that's what we see over there. To spend time with you is they can be caused by trauma and they can be caused by infective endocarditis. Yeah, so here we're looking for the that window. I can never know how to pronounce the name. I think it's called Scammell. Scammell. Scammell. Scammell. Okay, I'm not sure, but I know that it's a window. You're looking for that window, and that is to assess for clubbing. Clubbing can be a sign of several different medical conditions. Um, so, heart failure, Uh, infectivity products. It's a loaded, loaded things that can cause, um, clubbing. Tar saving is generally a sign of smoking. Especially someone who smokes quite a bit. That's what you'd see last year. Looking at the palms. There's three things that we can see here. What do you think? You either any of these things are. Does someone mentioned one of them? Yeah. January lesion. Well done. Um, So which one is a Janeway lesion? Yeah. Okay. Oslo knows we've got Oslo nose and Jane relations. Good. Oh, perfect. You guys are great. You guys are great. Those anthem otta, um, Austin nodes of genuine lesion. So Austin's are generally really big, bright purple ones, which are very painful. Um, January lesions are really smaller and red um, they are often less painful, but Australia is generally really painful. Xanthum onto is yellow deposits of cholesterol, which are generally seen in the hand. So those are the things that you're looking for when you're looking at the hands. Essentially, now we move on to the arms, and the first thing to do is inspect to see if there's any obvious abnormalities. The next thing that we want to do is palpate the radio pulse, which is located on the radio side of the wrist. You use your middle, uh, your index and middle fingers to that. And once you've located the radio pulse, assess the rate and rhythm. You can measure this for 20 seconds and then multiply that by three or 15 seconds and multiply by four. The normal range is between 60 and 100. If it's below 60 it's a sign of bradycardia greater than 100. Is tachycardia an important thing to also assesses the rhythm? So is it regular or not? If it's irregular, it can be a sign of atrial fibrillation. The next thing to assess is assessing for radio radio delay, and to do this, you want to palpate both radio Sorry both radial pulses simultaneously and in healthy individuals. The pulses should occur at the same time. So if the pulses are out of think that you'd see here that will be described as radio radio DeLay and that can be caused by aortic dissection or aortic Caucasian. The next step involves assessing the collapsing pulse. And to do that, we want to palpate the radio pulse and the break your pulse and then raise the arm above the head. Now it's important to ask if the patient's in any pain, especially in the shoulder, before you do this. But a positive, collapsing pulse would be seen as a tapping sort of sensation that would happen in the bulk of the muscle, and that's normally a sign of aortic regurgitation. It's quite uncommon to see it, but it's quite uncommon that you'd get this in your ski. But it's something that you need to be aware of. BP down. Um, in most areas, you need to just mention to the Examiner that you'd like to measure the BP in both arms while the patient is lying, lying down and standing. It's not something that you would be asked to do, um, in a really, um, os key because you're performing a cardiovascular examination. So one of the one of the attendees wanted Why? What the causes of radio radio delay. Yeah. Okay. So, uh, so someone has, um, answered it for me. So mainly, the main two ones are aortic dissection. Aortic qualification are the main two things that would cause radio radial delay. I hope that helps. Um And then, yes. So BP and measuring the break your pulse. Um, normally, these are things that you can offer to do. But normally, the examiner will tell you to carry on with your examination, and you won't have to. Once you examine the hands and arms, the next thing is to examine the head and neck. And these are general steps that you'd have to do. So first, have a general inspection on their face. Look at their eyes. Ask the patient to pull the eye eyelids down. Once you've had a look at their eyes, then you move on to their mouth. And to do so, you have to ask them to open their mouth and stick their tongue out. You then want to look under their tongue. So you'll ask them to raise their tongue to the roof. Their mouth. Finally, you'd like you'd have to look at their neck. She'd ask the patient to turn the neck away from you and assess the JVP. And then finally you auscultate and palpate the carotid pulse located in the neck. So once again, we're going to go. I'm going to show you some pictures and have feel free to tell me what you think is going on in each of these patient's. So, firstly, looking at the eyes, what do we see in each of these scenarios? Yeah, Anemia. Okay, Yeah. Pala Pala. So the main thing that we're looking for is conjunctival pallor. Yeah. So that's what we've seen the first one and conjunctival pallor is a sign of anemia. Um um I see lots of corneal arcus. Yes. Great. So everyone's noticing the ring outside the eye there, which is perfect. And then yeah, I see xanthelasma as well. So perfect. You guys are doing really, really well, so yeah, conjunctival pallor is, um, something that you'll notice when a patient pulled down there eyelid and it's normally very, very, very light pink essentially, whereas a normal person, a pests, a lot darker and that's suggestive of underlying anemia. Corneal arcus is a blue a pic ring normally associated um, located in the peripheral cornea. Um, you will see it quite commonly in patient over the age of 60 and in older patient is quite benign. But in younger patient's, this is a sign of hypercholesterolemia and xanthelasma. As you can see, here is also these yellow deposits, um, around the eyes, which we can see here and here. And now all of that is a sign of hypercholesterolemia. Cool. Um, what we're seeing in any all of these scenarios, central cyanosis Lovely. I'd like to see that. Yeah, the central cyanosis we can see here because the lips and the tongue have become a bit blue. That's clearly a sign of severe, um, hypoxia normally, um, and it can be seen in COPD Patient's Yes. So Kaiser Fleischer rings and corneal arcus. That's also, um, it's quite, um uh, like a very subtle difference. And I've been I I asked a one of the ST doctors one day, and they were like they find it really difficult to tell the difference. So I would I wouldn't actually, uh, obviously be able to say, like, Oh, one of them is clearly a lot more obvious than the other. Um, I'm thinking of a way. How do I describe the difference? I guess the only real way I can really tell is like a Kaiser Fleischer ring is a bit yellower, whereas a, um, corneal arcus is a bit more bluish. Um, they generally both rings around the eyes, but it's not particularly obvious is what I would say. Um, so if you see a ring around the eye, they generally both are indications of um um, sorry. This is generally an indication of hypercholesterolemia, but it's very subtle to find a difference between the two of them. I'd say Sorry, I didn't really help that much. Um, I guess if you if you Google pictures, it tells you can vaguely see a slight different um, so you'll be able to tell like I think, um, the Kaiser flashes a bit more yellow er and the corneal artists a bit bluer, but yeah, I see loads of good answers support, dental hygiene, Anglos, dermatitis and central cyanosis. So we talked about central cyanosis, especially being? It's blue disco discoloration in hypoxemia. Um, commonly seen in COPD angulus dermatitis is an inflammatory condition around the corner of the mouth. Um, normally a sign of iron deficiency anemia and poor dental dental hygiene. Now, that's just a risk factor for infective endocarditis. No, it's just a risk factor. Doesn't mean that everyone with endocarditis infected and the product is has to have for dental hygiene. Um, it's one of the risk factors for it, but something that you can look out for. And what can we see in these Larson hours in the neck? Yeah. So JVP raised JVP great. And what are we assessing for in this scenario here? Yeah, palpating carotid pulse Perfect. Yeah. So the main thing to do in the cardiac examination and make sure you auscultate the carotid pulse first before you palpate it. And then in this scenario here we can see a race JVP which can be a sign of venous hypertension. Main causes of that are right sided heart failure and tricuspid regurgitation. Oh, and now we move on to the chest. So the first thing that we want to do is inspect the chest and this can give a clue about patient's medical and surgical history, and the main thing we want to look for is cars. Let's look at some of the scars that you may expect to see in a patient. Um, now the names are a bit complicated sometimes, um, but it's important to remember what type of surgery is associated with which car rather than the names. So that's what I would probably, uh like you to take from this. Firstly, we have the midline Sonata Me scar, which we can see here, Um, and that's associated with patient's who have had a cabbage so coronary artery bypass graft or patient's who have had cardiac valve replacements. The next type of scar we have is the anterolateral thoracotomy scar, which you can see right there now that can be on either side. It could be here or here, and it's normally seen in Lobectomies, but it's also used for minimally invasive cardiac valve surgeries, so it's important to look for it, especially in females. So make make sure you lift the breast and look underneath. If there's any scars, a common scar that you may see in Oscar these are is your pacemaker scar what you're seeing here, and that's generally use for pacemaker insertion. You generally may might be able to see it or feel the pacemaker as well when you're palpating the chest. So generally that's one to look out for the last one that sometimes misses a left mid auxiliary scar. So make sure you ask the patient to lift their arms and look under, um, need their arm sort of sort of in the armpit region, um, near the axilla, Um, and this is normally used for insertion of, um, and I see d so implantable cardioverter defibrillator. And so in most cases you will see a midline Sonata Me scar or a pacemaker scar in Oscar the scenarios. And if patients are quite old, the scars maybe less visible, visible because their skin is a bit less stretchy. So it's quite important to look quite carefully at the chest in these scenarios. Once you're done with the inspection, the next thing to do is palpitation, so the first thing that you want to palpate is the apex beat. The apex beat is mainly located, is usually located in the midclavicular line, which means the middle of the clavicle So this is that bone there and in the fifth intercostal space, which you can generally go by counting intercostal space. 12345 and you're there. So mid clavicle, fifth intercostal space. That's where you'll find your apex beat. To do this, you want to position your fingers horizontally, so sort of in that direction, fingers generally facing this way. And that's how you would, um, palpate the apex speed. Generally, your fingers, the edges of your fingers will be on the apex right there. The next thing you want to palpate for is heaves, and to do so, you want to keep your hand parallel to left sternum. So sort of there is where you want to keep your hand for to measure heat and you keep your hand flat on the patient's chest. If he is the present, you will feel the heel of your hand being lifted off the chest. Um, each time the heart beats, and that's generally a sign of right ventricular hypertrophy. Thrills are palpable vibrations that you should assess for over each of the Codec valves, so the cardiac valves in general we can see them highlighted in that image right there. So you got your mitral tricuspid chaotic and pulmonary valves, So it's important that you feel over each of them. And if you feel small vibration, that's generally the presence of a thrill. One thing to note is that he's and thrills are quite unlikely to be felt. Um, patient's have to have quite severe disease before you can actually feel them. So most scenarios you really won't feel them unless you have severe disease, which is unlikely to ask you scenarios. The apex beat is something that you do need to feel for. And if you do not feel it here, move laterally. And that's a sign of a displaced apex beat, which could happen in contact and acknowledgement. The next thing we want to do is auscultate all cardiac valves. So after power patient, you want to auscultate them using the bell? Sorry. Using the diaphragm, which is over here, Over here, over here and over here. So a good way to find out where you're examining is find them, uh, the mitral valve right here in the fifth intercostal space. Move to left sternal edge. Um, and you will find your tricuspid valve right here. and that's normally the fourth intercostal space on the left stone ledge. Then you want to move up to your second intercostal space, and here you'll find your aortic one. And then finally, you'll go into your, uh, final valve and you'll get your you'll finally get your primary valve, and that is on the right side of your sternum. You cool? And now one thing to remember is always palpate the carotid pulse when you're doing so. Uh, it's a common mistake to do, but you want to make sure that the heart sounds are at the same time as your, um auscultation. Okay, now the next thing I'd like to do is to perform the accentuation maneuvers, and I don't know. You can probably see all of this, but hopefully it works. Um, it's the last bit of cardiovascular examination, and these are the accentuation maneuvers, and these are done in order to hear the cardiac murmurs. Clearly, we generally focus on the left sided, um, cardiac murmurs. So those are aortic stenosis, regurgitation, stenosis and, uh, mitral regurgitation to assess. For all of these murmurs, we always ask the patient to breathe out and hold as that's when left sided heart murmurs are at their loudest, Let's hear what a normal heart sounds Sounds like. So if I play that, I hope the sounds are coming through. But that's what the sound would sound like. Is the sound coming through. Okay, great. Thank you, James. So yeah, here. You can clearly see two distinct heart's out, which is clear to see, And this is a normal heart. So with aortic stenosis, what you'd like to do is a position the patient at 45 degrees, as they normally are and use the diaphragm. In this case, they've shown using the bell, but usually use the diaphragm of the stethoscope and auscultate in the carotid artery area here. And this is the kind of a murmur that you'd expect to hear. So this is an ejection Systolic murmur. And this is what an aortic stenosis murmur sounds like. Thank you before moving onto aortic regurgitation. So for this one, you want to sit the patient forward, use the diaphragm, and listen to the, uh, the aortic area, as we can see over here. And the sound that you expect to see here is something like this. Now, this type of murmur is called an early diastolic murmur. Note that you can clearly hear the first sound, which is your your your first sort of, um, art contraction. There's sort of like a little wish between them, which is your early diastolic amendment. Next one is your mitral stenosis. And for to do this, we want to roll the patient on to our left side and use the bell to examine the patient. This is done in the mitral area. So your fifth intercostal space midclavicular line, and this is the type of murmur that you'd expect here. This type of moment is called a mid diastolic moment. There you are, and the last type of murmur is your mitral regurgitation. So this is a pansystolic murmur, and it's generally seen when you rotate the patient the left side, using the diaphragm. Now this kind of moment radiates the axilla, so it's important you move your stethoscope along this line to re add elicit, really, Listen for it. Uh, it's quite hard to show these accentuation maneuvers, um, in a power point, So I would really recommend you watch a video for this, and the one I recommend is the geeky medics video because it's a lot easier to visualize when you watch the video rather than me sort of presenting on a slide. But I wanted to show you what the actual sounds actually sound like and what the difference is. It's quite difficult to tell differentiate between the two, especially as a medical student. Um, but if you can clearly say that there is definitely a murmur there, that that's a great that's a really good start in itself. Oh, and then finally concluding the examination. One thing you want to do is Oscar Oscar take the lung basis, so make sure you sit the patient forwards and listen to the base of the lungs in the back, because if you hear any course course crackles, that can be a sign of left ventricular failure. Make sure you palpate the sacrum, which is the lower back for any signs of edema and make sure you look at the legs and also help pay the ankles, um, to look for any signs of edema, which could be caused by congestive heart failure or right sided heart failure. Um, yeah, and then thank the patient and ask if there's like any help getting dressed. Now you've done your examination. Your examiner says right. Can you present your findings to me? And sometimes a lot of people find this quite stressful. But the best way to do this is break it down into steps and just say exactly what you've done to just start by saying, Who did you examine? So this is this is James. He's a 55 year old male, etcetera, etcetera. Um, what do you see on general inspection? Where they Any of the signs that we discuss? How is the patient? What were his surroundings like? Um, and then a quick little line that you can use. Um, if there was no obvious signs in his arms, face, neck, hands. Um, you can summarize that by saying, um, were there any signs any peripheral stigmata of cardiovascular disease? Um, because your head, neck, arms, hands, that's all peripheries. Um, and if there's no signs in any of those areas, you can say there is no peripheral stigmata of cardiovascular disease, and that sort of summarizes all of that aspect for you. It's important to describe his pulse and JVP because, um, that can give that can give quite, um, an important sign for, um, cardiovascular examinations. Um, and also important describe if there are any scars. The apex beat was a displaced, so we said Normal. It's the midclavicular line. If it's if it's displaced more laterally, then we have to obviously mention that describe the heart sounds, uh, before summarizing key findings. Finally, you need to say what other tests would you like to do to complete the examination? So here is an example of a cardiovascular examination that I probably performed on Mr Morgan Freeman, which you can see right there. Um seems quite happy. So he so I performed the cardiovascular examination on Mr Morgan Freeman, an 84 year old man. Um, on general inspection, he was comfortable sitting upright in on the on the bed and seemed alert and orientated. There was no signs of any peripheral stigmata of cardiovascular disease. His pulse was 80 regular and had strong volume. His JVP was not elevated. Um, on closer inspection of the chest, there were no scars to suggest any previous surgeries. His apex plea beat was not displaced, so it was located in the fifth intercostal space midclavicular early. They're normal heart sounds with no added sounds. So, in summary, this was a normal cardiovascular examination. Normal tests that you would do to complete your cardiovascular examination include taking a full cardiac history, conducting a 12 lead, E c g, and performing a peripheral vascular examination. And yeah, so that's my sort of summary for cardio examination. These are three really good resources, and I would really recommend you use them. Which is the geeky medics, the Rosky stop and the simple Loski cardio exam. Uh, geeky medics, Probably my favorite one. Because every video and a checklist for cardio exam, I'd say Go over that. And that is your best shot into first. Your first sort of steps into looking through a cardio exam, But yeah. So before we move into onto CCGs, do we have any questions? I feel free to pop anything on the chart. If you do. Okay, I'm going to assume that there isn't any, But if you have any questions, just feel free to better pop them on the chat. All right, Now, moving on to E. C G interpretations. So this is what a normal E t G would look like. So you have your P wave here, which is your sign of atrial contraction. Then you have a small gap, which is known as your P R segment. And then you have this big, sharp contraction right here. And this electrical signal here is called your QRS complex. And that's the sign of the ventricles contracting. Finally, you have a bit of a gap between your QRS complex and your T wave, which you can see right here. And the T wave is what happens during, um, diastolic to sort of relaxation of the ventricles. That's what you see here. Now it's quite important to understand that with every e c g that you interpret, each small box is equal to 40 milliseconds, which we can see right here. And the General. Uh, it's generally important to remember a few key figures which are highlighted here in red. So your PR interval, which is the time between the start of the P wave and the start of the QRS complex. And that's generally between 1 22 100 milliseconds or between 3 to 5 boxes. Really, the cure is complex. Is this whole sharp region, So from beginning to the end, that's generally less than 100 milliseconds, or generally less than three small boxes is what we like to say. The last thing we want to know is the ST segment, which is the distance between the end of the curious and the start of the T wave, and that's normally about 1 2020 seconds. So, as we said about three boxes as well. And that's generally a brief summary of what an E. T. G is and what exactly you should be looking for. So that's how we should start with it. So, firstly, moving onto E. C G. Interpretation. If you're giving an E c g like this, um, how would I go about interpreting it? What do I do? It's quite confusing. There's a lot to look at. Um, so let's go through it. So this is a normal P C G here and, uh, in an e c g. There's 12 lead. This leads 123. Got a V, R a, V l and aVF. You've got these V one v, two v, three, V four, V five and V six, and in total, there's 12 leads, and that's why the 12 lead E. C G. So your first step when, uh, interpreting an E C G is check the patient's name, paper, hospital number, check patient details. Um, with most documents that you'd be interpreting, that's the first step. So it's important you do you do that? The second thing is to check the date and time that the E C. G was taken. So in this scenario, the date is written here. The time is written here, So that's sort of what we're looking at. Um uh, in this scenario so we can see the date. We can see the time we've checked the patient details. We're moving on to the next step. And the third step is actually checking the calibration, which is generally seen at the bottom over here. And we want it to be 25 millimeters per second. Um, so 25 millimeters per second ensures that we get the figures, um, that we previously discussed of one small box per 40 milliseconds in most hospitals, the E. C. G s will be calibrated to that automatically. Now, what that means is the entire e c G page equate to 10 seconds exactly the next step that you want to perform involves calculating the rate of your TTG. So what is the heart rate if you're given the e T. G? Now this is another normally see G, and the way to interpret the rate there's two ways to do it. It's either, um, 300 divided by the number of big boxes between two QRS complex is so here we have 1234. So about four, I'd say, like half on each side. So four so 300 divided by four is about 75. Yeah, 75. I see that. Yeah, Perfect. And then another way to do that is, um probably count all the QRS complex is here. So we've got 123456789, 10, 12, 12 times six. Um, and that gives you about 72. So that's another way to calculate the, uh, number of curious complexes. Now, if the rate is irregular, it's important to use the second method because it might be really small between two curious complexes and really, why between two others. So then just count all the number of curious complexes you see, and then multiply by six, your fifth step is noting the rhythm. Now, the way you know the rhythm is by checking. If curious complexes are evenly spaced or irregularly spaced and this scenario, we can see that each QRS complex occurs every four boxes. So this is a regularly spaced E t g. Um, and the rhythm is regular. Now, the next thing to look at is access. And this is probably one of the most confusing bits of an E C G, which is left access and right axis deviation. A simple way to tell if a e c G is showing left access or right axis deviation is to look at Leeds One and aVF to need one which we can see up here and aVF, which you can see down here if lead one and aVF boat show positive curious complexes. That is a normal E c g. If there's left axis deviation lied. One will be positive, But lead aVF will generally show a negative curious complex like that. Right axis deviation is generally the opposite where, um lied. One will be negative as shown here, and aVF will be normal like that. Like that. Um, like that one right there. And that's generally a quick, easy way to tell if there's left or right axis deviation. The seventh step is looking at the P waves, which is just before the curious complexes. So as you can see here, there's a P P wave before every QRS complex, and I'm quite happy that they're They're they're before each and every curious complex. Then we want to look at the cure is complex itself and see. Is it narrow, or is it broad? So, as we said before, the curious complexes generally supposed to be less than three small boxes. So in this scenario, we can see that they're all narrow, which is a sign of Sinus rhythm. Now certain types of tachycardia is such as atrial or super ventricular. Tachycardia will also have a narrow, complex and narrow QRS complex. But it's important to know that narrow, curious complex can mean either a normal Sinus rhythm or there could be other forms of tachycardias which are atrial or super ventricular in origin. The next thing I want to see is if they're broad, which means that the greater than 33 boxes, it means that the origin of this electrical activity is further down or more likely in the ventricular region, so it could be a sign of ventricular fibrillation or ventricular tachycardia. Cool. Now I'm just going through the final few steps of interpreting an E c G. So the first thing you want to then we want to look at the P. Q. R s relationship. So initially we discussed the PR interval, which was the time between the P. The start of the PAS and the start of the cure is complex, and we want to make sure it is less than five um, small boxes, which is normal. So if it is increased, it'll be greater than five boxes. In this scenario, we could say it's 1234 boxes, which is completely normal. Now, a common thing that we generally see on E. C. G. S is ST Elevation and I can't lie to you. It took me forever to get my head around, uh, finding out what does ST Elevation mean? What is it? How do I tell that this sug shows ST Elevation? Um and it took me quite a while to figure it out before I actually got explained it quite carefully. The key thing to look at is the P Q and P Q. Line here and the S D line right here. Now, if the PQ line is here and the SD line is on the same level, there is no ST Elevation present, whereas in this example we can see the PQ line is up down here. But the ST line is all the way up here, and it's clearly that different. And that's a sign of ST Elevation. ST. Depression, on the other hand, means that this ST line is below that initial PQ PQ segment which we saw right here. Um, and this E C G shows an example of that, and the last one that we want to see is T wave inversion to normally, it's positive wave, but it can also be a negative sign here. And that's also a sign of abnormalities. Uh, please note that in, um Avr and leads a V R and B one the two areas normally inverted. It's not a sign of anything sinister. Um, it's just quite common occurrence in those in those two leads. Cool. And that's how to interpret an E c. G. So I'm just going to go through a few e c g s that you'd commonly expect to see. Um, I'll quickly run over what we've just quickly discussed. So as a quick summary, the first thing check Patient's name, details check the time and date the EC do is taken. Check the calibration. Look at the rate by counting number of boxes between Q r s s or the whole number Time swing by six. Um, the rate, uh, the rhythm story. Um, are they regular or irregular access deviation followed by P waves if they're present or not, and then the QRS complex is if they're narrow abroad. Finally, we're looking at a PR intervals ST Elevation ST Depression and T wave inversion. Um and, yeah, that's what we've got so far. So before I move on to, um e c G findings, do you have any questions I'm going to assume? Not because there's nothing that's popped up on the chat so far. Cool. So here's an E C. G. Can anyone tell me what they think is going on and what they think is a diagnosis? Um or do you have any idea or if you're completely confused, you can also say, Completely confused. Okay, so we've got stemi. We've got ST Depression. Yeah. Anyone else want to give it a go? You can say basic stuff as well. Talk about the rate, the rhythm access, anterior lateral stemi. Oh, okay. Got an anterior lateral Septra. Okay. Yeah, lovely. So, I mean, we've got lots of us have here. Have got an idea of what could be going on here. So let's break it down. Step by step. Yeah, Lovely James. 75 BPM. That's what I like to see. So yeah, regular rate. This is good. So yeah, exactly when you interpreting your ttg start by saying all of those stuff, Um, that's what we like to see. But yes, a lot of people said that this is a stemi. Um, there is ST Elevation between Leeds V one to V four, and that is generally seen here, here and here. It's more predominant in Leeds V one and V two. Now, someone also mentioned ST Depression, and that is correct because you can see ST Depression in Leeds, Leeds, Leeds two and three. Um, but that's a common occurrence in stem ease. Uh, there is a reciprocal um, ST Depression in the alternate leads. Um, so in this case, the alternate leads are leads two and three. Um, so yeah, so in this case, this is a stemi. Most commonly, this is an anterior. Am I? Because it's mainly seen in V one v two v three V four, which a lot of everyone, a lot of people in the comments did suggest which is well done to a lot of you. So what do you mean by alternate leads? Um, so there, this is on my next slide. So I will explain that to you, Um, in the next slide. So moving on, let's move on to it. In fact, so here we are. Um, this slide sort of tells you which type of myocardium is supplied by which artery and therefore which area on the E. C G. Are you likely to see elevation corresponding to these points? I'll break it down. So the V one and V two region generally shows a septal or an anterior. Am I so? Especially the V one to V four Region shows a septal and anterior part of the myocardium and that is supplied by the left anterior descending artery. Now what this means is the reciprocal or alternate leads for this are generally the right are generally or leads to three and aVF. Now it's not something that is straightforward. I'd say it's something that you just sort of have to learn. Um, because the the the the alternate or the reciprocal leads aren't really straightforward for mis um What the key thing to look out for is, is there ST Elevation in one portion of an E c G. And is there ST Depression on, um, on another session on another section of the E C g. The section where there is ST Elevation, which is the area where the step meat is occurring. And generally to compensate for this There's ST Depression in the alternate leads. I don't know if that makes sense. Okay, Perfect. Great. So I see a question. Is it not raised in lead one and aVL? Let's go back. Yeah, I know. It is raised slightly in a in one and aVL as well. Yeah, you're right. It is also raised in one and aVL. Um so I guess this is not the best example, because this, um, example shows a bit of elevation in the lateral regions, the, um, the anterior regions and also your, um one and aVL. Now why is it raised in lead one in aVL as well? Because we've got to think about the anatomy in this, in this case, then and it's not the most fascinating thing, but where does the left anterior left anterior descending artery and left circumplex artery come from? And they both originate from a very similar place. So the key thing to note is because they originally from the same place, um, you will. You might tend to see this, um, kind of scenario. And this generally means that the stem is much higher up in the artery, which means it's more serious. Um, but yeah, that's the reason why you would see raised in those two leads as well. So as a lot of people said, this is an anterior laterals. The stem is where I'd probably class that one has. This is generally a very useful table to have in mind. So I know you will get the slides at the end of this. But if you want to take a picture of this, keep in your notes probably really, really useful. Um, as it tells you, which area that my card you miss supplied by which artery and where you can look up for ST Elevation on which type of in which part of the C d. Cool now moving on to another E C G. Um, what can we see you right here? Um anyone want to post? Post your answer on the chart? Feel free. Mhm. Lovely. Good. 75 BPM. Regular left axis deviation. Great. Great left axis deviation. I see that here. Because lead one Here is positively aVF is negative. Perfect. Yes. Left axis deviation is present. Anything else we can see? Okay. Oh! Oh, Bundle. Branch block. Yay! Perfect. And someone tell me what type? Yes, left bundle. Branch block. Perfect. Yeah, it's a left bundle branch block. So how do we know this left bundle? Branch block, left bundle. Branch blocks generally tend to appear with a curious that is widened. And you can generally see that quite clearly in all of these leads The curious complex. Although the images quite small, it's larger than three. Small. Yes, W s and M s. Um, I really I really like people who are showing me the W and M's because that's perfect. That's the best way to interpret them. Um, so widened QRS complex is, um, which we can see here. So the W is what we will see in a in a left bundle branch block. Um, what that means is the curious complexes widened, and it's a massive downward deflection in the V one lead. Um, now, if we remember, there's two e c g changes that can diagnose, um, and that can diagnose a stemi. One of them is ST Elevation, or the other one is a new onset left bundle branch block. So in this scenario, we have a left bundle branch block as we can see these e c G changes. You also note that there is some ST elevation in lead two and three. So that's sort of like, um, certifies that this is, uh, an interior m I Oh, now this is a bit faint, but does anyone tell me what they think is occurring here? I'm not sure if you can see it, but if you can't, no worries hypertrophy. Okay. Where are we getting hypertrophy from? ST Depression? Yes, the ST ST Depression. Okay, what else have we got? Yeah, B one V to ST Depression. Okay, lovely. OK, so we've got some ST Depression left, um, left hypertrophy as well left hypertrophy. So the left hypertrophy hypertrophy generally associated with left axis deviation. So this and this would both be positive, So it's less likely. Um, there's left hypertrophy in this case. But what we can see as James said that there is ST Depression in Leeds V one and V two. Um, ST Depression is a sign of n stemi or unstable angina. And what? Another thing that we can see in this scenario is the T wave inversion in these leads right here. And those are all signs of ends Demis or Unstable and China. Now, one thing to note is in the previous slide, we noticed that some leads, they're also had ST Depression. Now, how do we know that someone and stemi well, in this e. C. G. There is no ST Elevation in any other lead. And that's a key way of differentiating between the two of them. We will note that there's no ST elevation in any of the lead. Why is the amplitude of the QR so big, um, that could just be dealing with calibration And where the e c G. D's are placed. It's nothing that should, um, there's nothing really that's making the QRS complex leads that much. So it's not something I'd say that's worrying me, um, at all. Um, the amplitude generally isn't something that were quite concerned about. Um, but yeah. So here we can see ST Depression in these three leads mainly, um, but there's no ST Elevation and there's also T wave inversion, and these are clear signs of end stem ease or unstable angina. And does anyone know How do we differentiate between Yes, No, we can definitely have n stemi and hypertrophy together. Um, that's definitely possible. I'm just struggling to see hypertrophy from this e c g. If that makes sense, um, and most likely there will be hypertrophy. I they probably will be, um, but, uh, in the c c g. It's quite not it's not obvious to tell that there is hypertrophy. Um, does anyone know? How would we differentiate between end stemi an unstable angina? In this scenario, troponin great Zara was already like, um, straight straight on my case. Um, she had the answer ready before I even mentioned it. Um, so is the right access deviation. So if the right access deviation we would there is slight, I'd say maybe slight, because this is, um, slightly negative, you're saying and this is more positive. I guess you could say that. But generally there is still a positive element of this and a positive element of here. So I wouldn't say there's any sort of deviation, Really? Wire leads one and two's ST segment More of a curb shaped than than a straight line. Um, you mean is it? This element is more curved. So there is a straight line at the bottom here, in needs one. I mean, one is very difficult to see, but lead, um, to especially here. That's a flat line. There is what I'd say there is flood there. There is flood there. So I wouldn't say it's curved. Essentially, um, in some scenarios. As I said, um, it depends where the e. C G leader placed and the calibration settings, but I'd say that's fairly normal in this scenario. Um, you would see this. You tend to see this kind of curve. Um, on these leads, um, in a normal e c g as well, that's what I would say. Hopefully that answers everyone's questions, but yes, troponin loads. People said, um, and that's how you differentiate between ends day me to announce table and I Oh, now, what is going on in this scenario? We've got a question here. How does troponin help differentiate between, um and stemi and unstable angina? Right, So troponin will be massively elevated in and stem ease, but it's only mildly, Or maybe not at all. Elevated in unstable angina. Does anyone have an idea of what they think could be going on here? Okay, um, I know we were running quite over, so I'm gonna quickly skim through these, Uh, stemi is a good idea. The low diversity elevation, But what this is is a pericarditis. And what you can notice is a widespread ST elevation in this case, in this case, So you see, ST Elevation needs one too. A V f v uh, V two v 345 and six. Yeah. So there's I mean, um is quite irregular. But the point is that, um and there's widespread ST Elevation. What you're seeing across all the leads over here. ST Depression can be seen indeed, Avr And these are all signs of pericarditis is the P way present. That is a very good question. Now you can notice that there's a very sort of rough kind of period here, a rough kind of like bit here. So it's very difficult to clearly dis discern the P wave. I would say this is a small P wave we can see here, but yeah. I mean, in some situations like here, that looks like a P wave to me that there looks like a P wave to me. Mm. Now, maybe it's type two. Uh, we're coming on to move it side to, actually. So hang on to your horses. We will get to that one. But there's I don't think in this situation there's more of its type two now. In the interest of time, I'm gonna skim through these a bit quickly, quicker. So, um, this example here, we can see that the rate and rhythm are regular, I'd say, probably a bit tachycardic because the number of BPM is probably a bit higher, but the key thing to notice here is that the PR interval is longer than five small boxes, and you will see that for each QRS complex. And that's a sign of first degree heart block. Because the PR PR interval is greater than 200 milliseconds now, this in itself is not normally harmful. Um, and some athletes can have first degree heart block. Um, it's not pathological, and some, um, some medications can also cause it, but it's just something to be aware of. Now, in this scenario is where we have our second move. It's type one degree heart block, where we see there's a constantly increasing PR interval before a dropped beat occurs due to a nonconducted p way. As you can see, the gap here is quite small, bigger, bigger, given more bigger, and then a drop beat. And that's what we call a morbid type one, uh, second degree heart block. Now here is your mobile is type two. So you're mobile's type two involves, um, one p wave being conducted a one p wave, um, not being conducted into curious, followed by a few that are are, and then one that is not no longer conducted and usually this occurs know ratio. So 221321 or 4 to 1. In this example, it's 2 to 1. That means that too curious complexes are conducted. And then there's one dropped beat. Two are conducted, and then there's one drop beat and so on and so forth, and that's what we call a Mobics type two second degree heart block. Note that the PR interval remains constant, though there is no prolonging of the PR interval in a type two second degree heart block. Lastly, we have a. In this scenario, we have a complete or third degree heart block, and what we see is that there is bradycardia and a V dissociation. Now what does that mean? That means the P waves can become completely dissociated from the QRS complex is, And we can see that in this scenario, because the P waves happen every three boxes. So here's 1123. There's another P wave. 123. You have another P wave 123 So on and so forth. So P wave happens every three boxes, whereas a curious complex happens every 10 boxes, and there's no sort of relationship between the pew s and the cure a space. And that's what we call a complete or third degree heart block. Now, the next scenario is a fast atrial VT here. So the only difference between a first degree this is second degree type two. Um, Okay, So, as you said, the first degree heart block is like this. This means that the PR interval is greater than five small boxes, but all P waves still conduct them into cures are still conducted into curious complexes. Whereas in a second degree, um, second degree Mobic's type two the PR interval is normal. It's not raised as in a first degree. Uh, but every every so often there comes a P wave which isn't conducted into a QRS complex. Hopefully, that makes sense. Moving on this is an example of atrial fibrillation. Now, how do I know that this is atrial fibrillation? Um, this is because the atrial rate is very fast and you can't really tell. But the atrial area, which is sort of this area between the curious complexes, seems very sort of zigzag e. Another way to note it is more or less. In most cases, if the rate is irregular. It's generally a sign of atrial fibrillation. Yes, it's an irregular baseline. Perfect. Thank you, Richard. That's what That's the word I was looking for. Um, so an irregular baseline plus an irregular sort of QRS complex rate is a good indication that this could be atrial fibrillation. Um, and there's a non smoothness in the P wave area or an irregular baseline. As we've discussed here, it's quite impossible to descend one exact p way before each QRS complex as well. And these all give you signs of this is an atrial fibrillation. Now, this is very similar to age of fibrillation. But can anyone tell me what they think this is? Yeah, Great April flutter. Perfect. So the key differential between the two of them are there's a sort youth appearance between, uh the QRS complex is especially the P wave region, which we can see here and in atrial flutter. The QRS complex is our regularly spaced, as opposed to atrial fibrillation, which they're irregularly spaced right now. Here we we've got two more CCGs to interpret. Um, does anyone know what this looks like? It's quite it looks quite scary. Yeah, ventricular tachycardia. Someone's got s V T. Then there's got also ventricular fibrillation. Okay, so you got s V t. Which is super ventricular tachycardia. Uh, ventricular tachycardia or ventricular fibrillation? Okay. Any other gasses or educated guesses or people who know? Okay, we're gonna stick with these, Um oh, VT, we've got another VT. So loads of BTS and yeah, you guys are correct. So it is a V t. Um, the reason why you know this is because it's a ventricle. Um, because the QRS complex is wide. It's likely to be ventricular in or origin. So, James, I think you had mentioned soup s V t. So super ventricular tachycardia. Now, those are present with narrow, complex, uh, so narrow QRS complex is so atrial fibrillation. Atrial flutter. Those are examples of super ventricular tachycardia is as they are, Um, have this narrow, curious complex now ventricular fibrillation. Why is this not ventricular fibrillation? Um, the reason for that is the amplitude generally remains quite constant with ventricular tachycardia. Um, whereas in ventricular fibrillation, the amplitude varies, like fluctuates massively. Um, so that's how you know that this is a ventricular tachycardia one, the wide QRS complex. Um, and the amplitude remaining quite constant, and we've kind of given away. But what do we think this last one is? There we go. The F Yeah, ventricular fibrillation. So, yeah. Here we have the irregular amplitude. Generally, the baseline keeps on moving as well. Um, and you can see the QRS complex is quite wide, which generally, which suggests a ventricular or origin so cool. Those are the most common issue gs that you're likely to see. Um, hopefully I've covered, if covered quite a bit, and I hope you've enjoyed it. But just before you go, I've just got a few quiz questions. Hopefully, you test your knowledge, see how you're feeling. Um, this is generally the script that you'd get outside your rosky station. So Mr Morgan Freeman, 78 year old man presents with chest pain. Please perform cardiovascular examination and he'll stop you after your examiner will stop you after six minutes. So here we have a 78 year old man. The idea of this is that I'll be sharing four. I think four more slides and I just want you guys to tell me what you think is wrong with each of these. Patient's, um tell me what you think your diagnosis would be. Um, Now it's important to have a wide range of diagnosis. But please tell me if you have a feeling like, you know what is going on. So here we have a 78 year old man Sharp sided left, uh, left sided pain. Um, sudden onset two hours ago. No signs of peripheral cardiovascular disease. Normal heart sounds past medical history of prostatic lung cancers. Hmm. OK, so James said stemi Do we have any other spot diagnosis than what? This could be Sinus tachycardia. Great. Yeah. So supraventricular tachycardia. Okay? Yeah. Good. Okay, so we've got three answers there. We've got stemi. Okay, so So someone's changes the Sinus tachycardia. Okay, so two scientists and one stemi. Yeah, I mean, so you guys are correct. It is a Sinus tachycardia that we can see here. Um, there is no sense of ST Elevation. I know you can kind of think that that might be a sign of ST Elevation, but the baseline is very similar to, um right here, where as the baseline would be much higher if this was an ST elevation, and, um, there are no other leads that kind of suggest that this could be It's very unlikely that you would just see ST Elevation in one lead only Generally, it's quite a two of the two leads, at least. So this is Sinus tachycardia. But what is the diagnosis, then? What is causing the site of the pain? Why is it not s v t? Um, so S V t. The super ventricular tachycardia is, um what the what those mean is that there is a sort of an abnormal some sort of abnormality that's occurring So atrial flutters. Um, atrial fibrillations. Those are examples of super ventricular tachycardia. So super ventricular tachycardia, an umbrella term for all of those abnormalities. In this case, there's nothing wrong with the C c. G. Um, it's just that the rhythm is just a bit fast. So we've got Sinus. So the rhythm is normal, Which means Sinus tachycardia is just a bit quick. But yeah, 22 people have said pe and that's exactly what we've got here. So the person got pe sharp, sharp chest pain, breathlessness, um, and the and the prostatic a lung cancer. That's a risk factor for pe. Oh, so here we have another patient. What do we think this patient has? 54 year old man Chest pain, breathlessness, central chest pain radiating left shoulder. Yeah, loads of stem ease load of stemi that we've got loads of stem ease. Yeah, so we've got here. We've got lateral ST Elevation. Um, stemi. I gave it away before I really wanted to. Anyway, um, why is it lateral now? A lot of people are saying that this ST elevation in Leeds Yeah. Good. Okay, Yes. There's loads of people saying ST elevation before v five v six. If we look quite carefully, Um, there is some aspect of ST elevation in lead 456. so that is also, um, could indicate a what type of am I? Yeah, it's a more lateral kind of m I, um But there's also this ST Elevation that you can see in Leeds One and aVL. Yeah, perfect. So that's also a sign of a lateral stemi as well. Yeah. Are you good job, guys. Well done. Now what do we see here? 31 year old ban presents a chest pain three day history of shop. Severe shop chest pain paint. Worse than lying down the febrile have a friction Rub Heart's on the normal tra preneurs Slightly raised pericarditis. Good. Good. Any other answers? Pericarditis. Everyone seems quite set on pericarditis. Great. Oh, wow. I guess it looks pericarditis. This is definitely pericarditis. This great. Well, gave it away. Was the friction rub. I feel, um normally that does it. Yeah, but this is what you'd see on pericarditis. Widespread ST Elevation. All the leads here have ST Elevation, Uh, which is what you generally tend to see. Cool. And this is the last one I've got. Um, does the e c g not necessarily need to show right access deviation of right on the ball book. Okay. Yeah. So this is a really good question. Um, with a pulmonary embolism, there are loads of STDs that can that can take place. And it depends on the size of the palm Marie embolism. Really? Um, especially larger pulmonary embolisms will have right axis deviation right on the branch block. But most pas are quite small. And then those ones generally present with just normal Sinus tachycardia. So it's important to look at eggs and also include the entire history as well, because um, the e c g might not give you all the information that you need. So we've got an example here of aortic dissection. Okay. Cool. Yeah. I mean, that tearing chest pain definitely sounds like it could be a aortic dissection, but do we think anything else could be causing this? Yeah, given their age. Sorry, Sisi. Jesus. Not I don't think I'm sorry. I think I've taken the C c g. But it's not a very good E c g a tall, short, curious complex. Yeah, it could be short. Yeah. Yeah, my part. I test short. Yes. Yeah, I see. That's why I thought you meant by short. Um, yes. So there's definitely a narrow, narrow, curious complex. Um, my priorities is a good child, but the key thing there is with aortic dissection and my card itis the troponin will be slightly raised. It will be next. It will be. This one is basically negative as a normal. Yeah. I'd say the T waves could be bit taller. They're a bit taller. I wouldn't That wouldn't surprise me. Yeah. Is there ST Elevation? So the issue is the avr sort of finish is here, so this is where you think the baseline is, but it's important to look at this E c g here. So you see, the baseline is actually here, and the ST segment starts here as well. So I wouldn't say there's ST Elevation in those areas, especially because here, and we see that here. Okay, well, it's something to look at, which you see a lot in the, uh in any, actually. Patient just has anxiety. Um, what gives this away is generally the, um who first degree heart block. No, because this P wave is here, and it's right before the curious complex. It's not increased. If it was increased, that would be a first degree heart block. So, um, this patient has anxiety. The T waves are a bit taller. I will agree. So that could be a sign of, um, potassium disorders. But more or less, this patient is just normal. The troponin is also a key thing. And also, the history of chronic fatigue and restlessness means that they generally are more predisposed to those kinds of medical conditions. Cool. And that's a summary of what we've sort of done today. Thank you every much. Yeah, E c G is normal. The C D was normal. Um, thank you, everyone, for being there today. Um, have some recommendations. These are some. Anyone wants to have a Noski? Um, these are the two books I recommend. I really use them a lot. I swear by them best Toschi books. Ever use them for your skis? Brilliant. These three websites again. Great for your skis. Um, if you have, would you be able to post onto the chat How confident you feel about cardiovascular stations now? And also, please fill back, fill the feedback, So yeah, two things to do post on the chat. Um, how confident do you feel about the cardiovascular stations? And also, please fill out the feedback form the books? I will just send them to you. Um, hopefully you can fill out the feedback with a link on the group chat on the chart as well. But here at a quick look at what the books are probably what I take