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At the minute in oncology. Um but my first rotation was in the oral on cardiology. So, um one of the girls has asked me to do a presentation for you and hopefully you will find it useful. It feels like for that. I did my finals and I know there's a wee bit different now used to them is our fourth year. Is that right? Yeah. Yeah. Um And when are your finals? They're in June, I think like maybe end of June. Oh, so, so I definitely know that. Yeah, you have, you have loads of time anyway. Um So I'll just crack on, obviously I can't see you. Sorry, but um feel free to just like jump in with questions or whatever. Um I don't mind in the middle of it. Um So I'll just get started. Hopefully this will work. So um I'm just gonna go through sort of the main um cardiology diseases that I thought would be relevant for you. And so just sort of their presentation and management and of just mainly based on like what I think might go up on M CQ because I know that's sort of your main focus at the moment. Um, ok, so we'll just get started. So we're starting off with ischemic heart disease. So that sort of entails your angina up to your A CS. So we'll start off just with stable angina. So, as I'm sure, you know, this is sort of just central chest pain or heaviness. Um, and it's on exertion. So that's the important bit. Um, it may radiate into the neck, jaw, arms and that sort of thing. And it's often associated with nausea, sweating, tirs, shortness of breath. And it's really important sort of in your history taken to distinguish if those sort of things are there cause then they are pointing towards more of like a cardiac cause of someone's chest pain. People come in all the time, chest pain that is in cardiac and sometimes you don't really get to the bottom of it. But, um, it's important to try and take really good history, um, to, to get that out of them. And then the important thing as well is that it's always relieved by rest and it's always relieved by GTN when it's still angina and this is normally within a few minutes. So sometimes you'll have people come in that've been diagnosed with angina, um, and they'll have GTN and stuff and you say so when you take your GTN, how long does it take to go away? And they'll say, oh, like 30 minutes or an hour. So that's, it's really unlikely that they actually do have angina and it's probably something else causing their, their chest pain or the symptoms. Um, so then just looking at management for stable angina, so everybody should get aspirin and a statin and then GTN spray to relieve their symptoms as needed. Um And then here sort of the first line treatments as part of the nice guidelines are beta blocker or calcium channel blocker. Um And then obviously that's dependent on like people's other past medical history, any contraindications and it says person's preference. Um So as you're going through that, you're gonna titrate whatever you start them on to the maximum dose possible. And if their symptoms aren't controlled and then if that's still not working, you're gonna add in the other one. Um So say you start them on a beta blocker and it's not working, then you're gonna add in a calcium channel blocker. But you have to remember, we can't use the rate limiting calcium channel blockers such as verapamil or dilTIAZem. They should not be given with a beta blocker um because of the risk of heart block, incomplete heart block um with the combination of the two. Um so you can give amLODIPine, for example, he said, um feel free to jump in if that doesn't make sense or if you have any questions. So I'm gonna move on to a CS. So um three main conditions under A CS is sort of like the umbrella term, I suppose for unstable Angina, um sty and stemi. So your unstable Angina um is essentially when someone has Angina like stable Angina before this and then it starts to get progressively worse. Sometimes it's called like crescendo Angina where it comes on on less and less exertion. Um and it's more severe and then eventually it comes on at rest. So that's your unstable Angina. Um And technically they have normal tropes. So it is important then, you know, the history really comes into play then cause a lot of people will come in with some sort of chest pain that started at rest. But if they don't have a history of stable angina or any sort of heart disease, you know, it's unlikely then that it is gonna be unstable angina. Um So then obviously, if the troops are raised at all, then you're looking at and sty or sty sty is just diagnosed purely on the E CG. Um So if the troops are raised and there's no s TL incidence sting, obviously, there's other reasons that the, the troops can be raised. But I suppose in someone who's got classical CHSP raised troops, um you're worried about an an so you need to rule out um the sort of changes that you can have with an ante on the CG would be TB in or ST depressions and sometimes there's no changes on the ECG anyway. Um So then as well, I've just mentioned you, I hear people talk about you. We have something. So they're sort of representative of an infarct that's already happened. Um, an old infarct. Um, and then I found this, which I actually didn't realize it says it typically can appear six or more hours after the onset of symptoms. So, um, it's actually a lot more, you know, so not for them. I thought so. Um, it could be the same day and they're developing, I suppose. Um I put a picture there of the coronary arteries just in terms of questions that can come up as CQ si think it's important just to try and get your head around the anatomy of those. And that makes it a little bit easier to understand sort of the, you know, like the A CG regions and areas um unblocked vessel is supplying those in which vessel is likely um affected if there are a CG changes in that area. So I'll move on from this side. And so this, we table again, just sort of showing you um which, which artery corresponds with which regions of the E CG. Um So I feel like it's something that can definitely come up in MC Ks and ask sort of which artery you think is, is blocked. Um And then this, we picture on the right has always sort of help me to visualize um which, which area you're looking at on the ECG strips. So you can see sort of the red arrows there um are your chest leads and they're also sort of looking at the front of the heart and the side of the heart whenever you get to V five V six. so V one to V four are very much looking at the front of the heart. So you're thinking anterior and then that's gonna be obviously your left anterior descending artery. So the word anterior, so that's a, that's, that's helpful. Um So you're gonna be one to V four for that artery and then looking at your lateral weights, um like V five, V six. And then you can see there as well. A VL and one are sort of looking at that side of the heart. Um So if those are affected um on the E CG, then you're thinking the lateral areas affected on the full back, just to here, you can see it's the circumflex artery that's sort of going around the lateral aspect of the heart. Um And then your right coronary artery, I feel back, it's sort of looking um posteriorly at the heart and um it sort of at the inferiorly as well on the inferior aspect of the heart. Um And then just that we diagram on the right, I suppose it's showing you that leads to and three and VF for looking at the inferior aspect of the heart. Um So it's gonna be your right coronary artery. I haven't put it in here, but I suppose it's worth mentioning as well, posterior mis. Um So you'd be suspicious of that if you've got ST depression in your anterior leads like V one to V four. And then you check that by putting leads on the back, um they're called like V seven to V nine. And if they show s TL vision, then that confirms a posterior M I. Um And it's sort of if you look at that red digram again, um your circumflex artery and your right coronary artery are both supplying the posterior aspect of the heart. So it could really be either one of those and that's causing posterior M I. Does that make sense? Ok. Yeah. Well, nobody's probably gonna hurt themselves but feel free to jump in and with any questions. So then sort of your management um of your I CS. So all three of those unstable Angina, um your stemming your and stemming all kind of get the same initial management. Um Well, actually stam they normally just go straight to the Cath bab. Um But for the other ones, so I always remembered Mona, um it's quite basic. So you've got your morphine for your pain relief, you're probably gonna give them IV morphine um oxygen if required. So it's only really if they're hypoxic that you put oxygen on them now, um And then you've got your nitrates. So GTN if, if the sublingual like the sprays aren't working, sometimes people can go on like a GTN infusion, if it's gonna be a while before they can get to the, the cab for PCI. And, and then everybody gets loaded with 300 mg of aspirin. And so if we were sort of in someone who we thought it was like an ans or unstable angina, you'd be loading them with 300 of aspirin, load them with a second antiplatelet um and therapeutic and oxy. So that's gonna be like your 1.5 megs per kg and dose of klax in. Um And then obviously, those people are gonna go for a PCI and um well, they'll go to the CB and then maybe get a stent. So in terms of the second antiplatelet, most of the time now people use re um clopidogrel is only kind of used if someone's a high bleeding risk, if you've had like a previous hemorrhagic stroke or something like that. Um If they've got af and if they're old physically is the main times that would use clopidogrel. Um And then I believe that there. So for secondary prevention. So it was after all that and you know, they, they have their stents and things. Um people tend to go to an ace inhibitor on a beta blocker um and a high dose statin. So normally 80 mg of atorvastatin. Um and then they're gonna be on aspirin lifelong. And the second do that normal is continue for about a year, but it kind of depends the consultants sometimes have their own ways of doing things. Um And the other thing then is if someone's in af sometimes they go on to triple therapy, but it's always sort of the consultant that decides how long each of those lasts, lasts for. And sometimes it's, it's always different. So I wouldn't get too bogged down with that sort of um aspect of it. But ace inhibitor, beta blocker and hydrostatin and aspirin lifelong, um, are the main things to remember and some of it, um complications follow an M I and others that like do the and I saw this woman it's shorter and I mean, it's short and sweet. So you've got obviously death and then rupture. Um So a few things can rupture. So the, the ventricular septum can rupture or the papillary muscles can rupture. Then we've got edema with an A. So it's obviously a bit American. Um But you basically go into heart failure then from um following an M I. So everybody normally gets an echo before discharge um after they've come in with an M I and then you can get arrhythmias from it or aneurysm. So it's a ventricular aneurysm that can be caused and then D Dressler syndrome. So it could probably come up in your M CT S easy enough. Um I mean, things with it, it's basically pericarditis and it's caused by a localized immune response and it normally happens about 2 to 3 weeks. Um after the M I, so if they're putting all those sort of things in the, in the question, you know, you're thinking Dresler syndrome pancreatitis. Um, and then this is just a nice we graph of, sort of like when the, the complications um can tend to happen. So it's very useful for MCD just to have a rough idea. It's mainly sort of the arrhythmias and the brown arrhythmias in like the first day or two, cardiogenic shock. So, if someone has had like a really big M I, um they're probably not gonna do too well and sometimes when the cardiogenic shock and they're kind of in trouble then, um and then sort of all your ruptures like your um papillary muscle rupture and your septal rupture, um or sort of like a week to two weeks after. Um And then after that is sort of your Dresler syndrome, your pericarditis. Um And then obviously there are, there are risk of um arrhythmias further down the line as well. Um So I've just done a wee bit on some of those complications. Um just in case the two come up and then see occasion a little bit more about them. So the left ventricular aneurysm, it will present with persistent ST elevation um and often left ventricular failure, some that have symptoms of heart failure and then your E CG and they've got persistent ST elevation and obviously they're at risk of stroke. So the leaf or on the top sort of, we can see blood could sort of gather in there and um clot and then makes them more at risk of, of a stroke following that. Um And then you've got your sometimes left ventricular free wall rupture. So that's definitely not good. We'll come in sort of in acute heart failure and to not um and they need urgent uh pericardiocentesis and then your VSD, your uh septal rupture. So I suppose it does just, you know, it gives them a VSD. Then technically, they can also come in in acute heart failure and they need surgical occur and your papillary muscle rupture as well and it will cause acute mitral regurg if you can see sort of the way maybe these things covered it. I don't know if you can see the for um sorry. So if they rupture, you know, the they're sort of holding the valves in place. So if they rupture, then you're gonna get mitral regurg as the the valves sort of um the back closer, it pushes them upwards and, and they can come in acute pulmonary edema as well. So it for all the heart failure symptoms and um they also need surgery. So just a wee bit on pericardial disease then. So main thing sort of as supposed to be aware of is your pericarditis. Um So it's gonna be sort of central chest pain worse on line flat. Um And pruritic are sort of the key things with, uh, pericarditis and it's often sharp as opposed to like an MR, which might be like a dull or heaviness or crushing chest pain. And then your A CG is, um, the signs that got for pr depression and the sort of saddle shift ST elevation or global ST elevation, those are things that you're gonna be thinking, um, pancreatitis and then they're probably gonna wanna get an echo to see if they have an effusion or not. Um Just on the right here, I've just taken sort of from the E SA guidelines, the management. So the management is um always either Aspirin or Brufen. Um And then you want them to be on a PPI for that as well. Um Just for that gastroprotection and then also colchicine. So colchicine is for three months. Um And those two, that's the two sort of mainstays of management for pericarditis. Um I don't really advise steroids um in pericarditis unless it's like a sort of like a autoimmune cause or something like that. Um So this is just sort of the timeline for the treatments um of the E SA guidelines. So most people I can go on person. Um and then it's sort of like a tapering dose and it's just sort of guided by like her bloods and her symptoms and things like that. And then the colchicine is for three months. Mhm. And then obviously with uh if I have an infusion, the main thing that you don't wanna miss is tamponade. Um So it cause it's bex triad and I don't know if this is on your screen as well as we, I kind of otherwise. Sorry. But um so the three things to remember that are hypertension, distention of the jugular veins in, in the neck and the chest, um and muscle tartans and then I put there as well, pulse as paradoxus. So, um if there's mentioned, you know, in about a drop in BP and inspiration and you're thinking post as Partox and you're thinking to not. And so I think that's enough on that. Um Does anybody have any questions so far? Oh, good. So move on sort of the valvular heart disease. I think it's um oh straight on with the question. I think it's sort of ha uh easy for them to put that in an M CG and, and try to make it work out to know what the, the M is based on the, the signs and symptoms that are typically um associated with, with that. I have a question here. So an 82 year old man is referred to cardiology by his GP with um increasing shortness of breath. That's often um how those sort of problems present with like fatigue, shortness of breath, um dizziness, syncope, that sort of thing. So he has a systolic murmur um and his BP is a little bit on the low side and he's got a slow rising pulse. And so I suppose if you know what, you know, classically slow rising pulse is associated with and you're gonna know what the valvular problem is. So, uh what is the most likely cause of this underlying condition? So, we've got bicuspid aortic valve, VSD, posttraumatic fever, calcification, um or hooking and just anyone feel like a short night, I see, have an idea. Ok. I'll just move on to the answer. So it's calcification. So I suppose this is because of his age. Um and the slow rising pulse is pointing towards aortic stenosis. Um So, in younger patients, it's normally a bicuspid valve and then with age, the valve just gets calcified. And so stenosis is quite common in older people. So this is just a wee bit about the murmurs um and their causes. So if they say in question, like what's pan systolic murmur or the las a murmur or something like that to kind of have an idea of um what might be going on. So, ejection systolic is cause of your aortic stenosis and your pulmonary stenosis. Your pound systolic is more sort of your tricuspid mitral regurge. And also there's a few other things there. But those are just the main things. And then if they say late systolic, you're thinking mitral valve prolapse and sometimes coarctation. So I suppose those are good just to have in the back of your mind. Um And then it's kind of hard to remember. So there was a pneumonic R but I just remembered as there's an I in right for inspiration and there's an e left for expression. So, um right-sided valvular problems. So that's gonna be like your pulmonary valve and your tricuspid valve. If there's a problem there, the murmur will be worse on inspiration and then the same sort of for the, the left-sided. So if it's aortic or um mitral, then the murmurs gonna be worse on Asper. And so I feel like I can put that in questions and it's good just to remember. And, and then so, and your diastolic murmurs, early diastolic is cause your aortic regurge or your pulmonary regurge and then mid late diastolic is your mitral stenosis. So it's good. Just sort of having your head and you know, where the valves are and, and what they're supposed to be doing during, um, cysto. Um, and then it's easier to sort of work out, you know, um, what sort of m it is in your head. But I find it just, you just kinda have to learn those off. There's, there's no real easy way about it, you know what the already does? It does do. I probably just had it in my head for like MC Qs and then have like totally forgotten about it. If you hear a murmur in practice, you're doing well and they're gonna get an echo and figure out what's going on anyway. Um, but I suppose it's good just to sort of maybe have a, we look at before your M CQ. So it's fresh in your head. Um And then again, let's just be a little bit of like the main murmurs and like classically what they might cut um in an M CK for, for association with each of them, each of the problems. So, aortic stenosis is your rising pulse. Um You say you have a narrow pulse, pressure, your heaves and thrills or that's associated with your aortic stenosis. Um and it radiates to the carotids and it's also can be associated with complete heart block. Um and then your aortic regurge, that's your collapsing pulse or your water h pulse. Um and it has a wide pulse pressure and they might describe it as having a displaced apex bait and then we already said it's your early diastolic murmur. Um And then mitral va as well also potentially have a displaced apex bait and it's your posy murmur and it radiates to the axilla. Let's get rid of that and then your mitral stenosis. Um It sometimes described as having a large um first heart sound, um low pulse volume, malar flush. So it's associated with your mitral stenosis. Um It's mentally a diastolic murmur and it can be associated with af and then in that case, because it's valvular um af they would go on warfarin instead of a walk. So, just remember those treatments and I'm gonna move on to heart failure. I know that was a lot to those, uh, the valve ones you just gonna have to earn them off and they're not. Um, and you probably won't really need to remember much faster exams. But, um, it's good to have in your head if you know it often it's, it's an easy mark, so we'll move on to your heart failure. So, I suppose your symptoms, um, are your shortness of breath, um, orthopnea, swollen land flat and your P ND waking up in the middle of the night, asking for leg swelling and then signs that you're gonna see peripheral edema, particularly um in ankles and edema and by basal cramps, ation and a classically third heart sound is associated with heart failure. So it's called like a gallop rhythm. Um And then you're gonna be H IVP as well. I wrist and so that another question. So sorry. So 74 year old lady presents to her GP with breath in his legs swollen. She has heart failure and low ejection fraction and some other that's going on. So she's on a beta blocker, she's on an Ace inhibitor and she's on a diuretic and on examination, she's got a little bit of fluid in the lungs. Heart sounds are normal. She's got peripheral edema and her abs there look normal and I think her bloods are normal as well. So in terms of medications to start and so it's good to know, sort of the powers of medication for heart failure. So, she's already on a beta blocker and she's on an ace inhibitor and she's on a diuretic. And so these are the options. What do you think? Um We should add in? So, Amiodar spironolactone, Digoxin Vain or amLODIPine does anybody like if they, if they know the answer, would it be the spironolactone? It would. Yes. Thank you for speaking out. Um So yes, Spiro cancer there. So after the A and beta blocker, you're gonna add in sort of uh um an MRI and especially you have a reduced ejection fraction as well. So hold on. And so yeah, I've just got sort of the four pillars here of so your ace and your beta blocker and your MRI is so spiral. But remember it can cause uh I think it spells around there with gynecomastia. So sometimes in the end, you might be looking more para um it's important to monitor their U because if you're putting them on an ace um and an MRI, you know, the potassium can go up. So um you need to monitor the U and then more commonly now people are being put on SGL T two inhibitors, topical Flosin. So there's a lot of evidence now showing that it's actually really good in heart failure. And even, and obviously, there's the different types of your reduced ejection fraction, your preserved ejection fraction. But it's um recommended. Now for both So, I suppose it wasn't an option in my question, but if it was, then you could, you know, that could have been the answer to you. Um And then obviously we're gonna put you on for aside on their diuretic. But it's important to remember. It's more just for symptom management. It, it doesn't really tend to um affect their prognosis long term. Um, obviously in the acute statin as well. If someone's in acute pulmonary edema, it's um it's gonna be really useful, but um it's those other meds, the four pillars that are sort of um linked to your, your better outcomes long term in terms of prognosis and things. Um So does anyone have any questions? I feel like I'm just talking mats. Yeah, that's good. And so we move on to arrhythmias. I think this might be sort of come up to the end. Um I've just sort of done briefly on this. I don't think you need to get to sort of all on the gritties, but the main things that I would say are your algorithms. So um your Bradycardia al algorithm and your tachycardia one. So and sorry. So the main things I suppose are if somebody is unwell with this, if they're unstable, you know, shock syncope, um M I heart failure sort of symptoms, then you're going for atropine IV. And um I remembered atropine uh just cause there's at in it and it will make you tachycardic. So if you're cardic, you want atropine to make you tachycardic. Um And then obviously, there's the um if that's not working, you know, you could like that somebody might need some um a renaline to for your BP and things. Um And then you're looking at transcutaneous pa and transvenous pacing. But the main thing I also remember is your atropine if somebody is on all of it and then your tachycardia, so it's a little bit more complex. Um But if someone's unwell, it's easy, they're gonna get shocked. Um So that's fine. But then if they're not, you know, he unstable, then you have to sort of look. It, is it uh broad complex? Is it narrow complex? What do you think is causing it? So it's good just to take a little bit of time to sort of go through all of those in the management. Um And obviously remembering, you know, if, if it's giving the magnesium um, amiodarone then sort for your broad complex. Um And then for your narrow one, you're sort of thinking what term like S PT S. So your, your, um A VRT and your A VN RT s, um And you're thinking, you know, a thing for them and your vehicle maneuvers and stuff like that. So it's good just to take a bit of time, go through them and make sure um, that, that, you know what you're doing at, at each step cause the could, we could throw that in. Um And then to finish, I'm just gonna throw in a wee bit on atrial fibrillation cause I think it's probably the most common thing that is gonna come up for you is, you know, you know, so obviously it's your irregularly irregular um pulse and on the A CG, there's no pubs um on the CSS are irregularly spaced out. So it's good to, to know the causes. And so we've got hypertension is actually the most common cause and alcohol infections also some septic that could be an, an AF sorry. Um like I said, you know, your MRI S can lead to um arrhythmias in af heart failure, thyroid problems. So if anyone comes in with an AF it's important to send um their T FT and take a good history and stuff, make sure their electrolytes are OK as well and, and make sure they don't have a pee, you know, if they're short of breath, uh tachycardic, that sort of thing. Um It's important to remember as well if it's a reversible cause you say somebody septic and they got af and that you really just wanna treat the cause. So, um as well as sort of, if it's a thyroid problem instead of, you know, getting involved on with R control for AF, you just wanna treat the cause and then hopefully it should resolve. And so as I'm sure there's no complications from AF is um may not be a stroke you also can have tachycardia induced cardiomyopathy. So you can end up with heart failure and your was running fast. Um So then it also decompensation of preexisting disease. So, if you've got heart failure already, um or if you've got valvular disease, um it can sort of tip you over the edge in the pulmonary edema and then you can actually get cardiac ischemia from the high rate. So we sort of call that like a type two M I um cause it's to do with the um sort of mismatch in perfusion and demand um as opposed to like uh atherosclerosis of the, the vessels and then up a tier, I suppose, um cause you're clock risk, obviously, you're gonna wanna anticoagulate them. And so the main thing is to look after their child vas score um and then bounce that up to affect their orbit and has that score. I don't think you need to get too bogged down with like learning the nitty gritty of these and, and actually the, the child vas score um has actually changed recently. They've taken out gender now uh as part of the E SE guidelines. So I don't know if they would really throw this in your exam because there's like a lot of changes and stuff that have happened. Um And it's, it's probably a bit um so to be put that on your exam, but in case you're interested, they've taken out gender and the guidelines say if their child V score or CH two ba score um is two and they recommend anticoagulation and if it's one consider anticoagulation and that's really a and female. So, um and then it's always really gonna be like consultant decision, like weighing up the the benefits of putting somebody on anticoagulation. Um Anyway, so then we're looking at your management for af outside your anticoagulation. And so most people just get birth control beta blocker. It's sort of the main one for that. You can use digits quite helpful as well in heart failure, especially if you're worried that you're gonna send someone into pulmonary edema from their heart failure. You definitely don't wanna give them a beta blocker down. So you might give them digits but safer in heart failure. Um If they're in f um and then you can use a calcium channel blocker as well. Um So then if you know, see as you're deciding this person would be suitable for rhythm control, um You can do rhythm control if you are certain that it was less than 48 hours of onset, which is very rare to be very certain of that. Um Unless somebody was on like a cardiac monitor or something. Um And then if you're gonna do rhythm control outside of that, they have to be anticoagulated for three weeks. So you can send someone home on anticoagulation and bring them back to the clinic for um electrical cardioversion after they've been anticoagulated for three weeks. That's just to do with the risk of stroke and when you cardiovert them, then it's a high risk of like, should not um an emboli or a clot. And so of note, probably for the MC QS, it's useful to know that the, your general synchronized shock then for that and its own, it synchronizes with the airwave and that's just to avoid sending them into like the F or something like that, if you don't do it on the airwaves, so it has to be synchronized. Um And I suppose the main reasons that you'd be doing that is if they were hemodynamically unstable. Um Or if, say you've had someone and you've put them on be lockers, stitch everything and their heart rate is still going away, then you might just stop them if they've already been anticoagulated. Um And then you can have pharmacological methods as well. And so there's flecainide and amiodarone are sort of main ones and you can't use flecainide in structural heart disease. So like heart failure and involving problems and stuff. So you're gonna look at your, your amiodarone then and those people um but most people do just get controlled unless they're like really struggling with symptoms and things. So I have another question. Um oh, that was actually the end of af so this question wasn't related to a, so I have a few questions here um at the end, if anybody wants to in like sh night. So, um we've got a 75 year old mom comes under ed with shortness of breath and um shortness of breath lying flat. He's got ischemic heart disease. He's on aspirin, a beta blocker and ace and spironolactone and his bulbs there. His respites up a wee bit, his oxygen shots are a wee bit low. Um, he's got bibasal cramps, uh no murmurs and no peripheral edema based on the likely diagnosis, which of the following is an early sign of the condition. So I think I mentioned this earlier and if anyone that's an idea, so I suppose 12, those are your heart songs. So one is like your first heart song. That's your second heart sound. And P two is to do with the pulmonary valve. Um and then three starts one that first four heart. So does anybody have any of those? Ok. Um So maybe just the way I type that up was a bit sorry, my presentation isn't good but um S3. So that's like your third heart. So, so that's like the gallop rhythm and that, that you I see in heart failure. So it's just cause they were that back up and associated with heart failure. And does anyone have any questions? No. Um So with another question, so a 26 year old female um comes in with chest pain. It's sharp, it's left side, it's worse on inspiration and um it's worse on lying flat she has no past medical history. Um, on her abs is we tend to tachycardic and, um, other s look, ok. And her ECG shows widespread ST elevation and pr depression in all plates and her bloods are, I think pretty normal. And so what? Oh, so we've got her echo shows a pericardial effusion. What is the most appropriate immediate management? Now, that's just a small pericardial effusion and she's pretty stable. So, does anyone have any ideas? Is it the nsaids? I'm not sure if you'd use colchicine or not? Yeah. So you actually would. So um I suppose from the ASC guidelines, they say a combination of uh nonsteroidal and colchicine. So, in this case, but yeah, you know, I was afraid someone would say per pericardiocentesis or something. But um yes, you're just gonna go medical management cause it's only a small infusion and it's just very stable. Um So NSAID and colchicine sort of the main standard of treatment for pericarditis. Does that make sense? Ok. So I don't have any questions. And so we've got another question. So I try my best to otherwise. Um So we've got a 64 year old mom um who comes in, he's got pulmonary hypertension and, and his comorbidities are diabetes and heart failure. And he's on busin Metformin, SITagliptin Rail and Bisoprolol. And on examination this probably name it and he has some peripheral edema. His lungs are clear. He's got a high pitched pansystolic murmur and heard a lot of the lower left sternal edge which is lowest on inspiration. So, which underlying pathology do you think is most likely to explain his murmur? And so I suppose if I remember, you know, which side we're thinking there's a lot around in person. Um, and he's got a pass. So mower and high pitch. And does anybody have any idea? The Tricuspid regurge? Yes, it is. Thank you. And is that right? Yeah. Tricuspid regurge daughter inspiration. And unlike my, I think I wanna go have one more. So I'll have another one. Sorry. So I've got a 56 year old man brought in. Um he fainted this morning and he has not regained consciousness. So he is unstable. Um On examination, his heart rate is 37. So he bradycardic and his respirate is OK. His BP is a wee bit low. So you get an ECG and it shows a prolonged pr interval. What would be your initial management? So if you think about your, your, your bradycardia algorithms, is there anyone? Oh, it's maybe tricky because of an office said earlier that it's IV. But um so it's gonna be your IV atropine. So because he's had like a collapsed syncopes, you know, part of the, the algorithm where you're gonna just go for um aping. So it's IV atropine. Um That's what we would do for him. And so that's all the questions finished. I've just put in a slide on acies, you know, I don't know if you still have acies in fourth year or if you just do your final on your OSC next year. Um, but I suppose in terms of cardiology, things that will probably come up and on the day that they bring in, if they still do this mask is to bring in like real patients and we have aortic stenosis. So if it's gonna be a murmur, it's gonna be one that you can hear. So it's gonna be a systolic murmur. It's very hard to hear, diastolic murmurs. And so it's either gonna be aortic stenosis or mitral regurge. So if you're stuck, you can just say it's a systolic murmur which is either aortic stenosis or modular regurg. And that's probably good enough and you get most of your marks for like examination anyway, too down on not getting the right diagnosis. Um But just know sort of how to examine for murmurs. I suppose we could do like a heart failure thing. So make sure you look at a few sort of chest x rays with those signs on it and like your pleural effusions, your cardiomegaly, your currently bic and like your fluid and the fissures and stuff like that they can do if they're gonna do ECG S, it would probably be something obvious. I don't, I know one of the previous years had like an Mr and I don't know if he's already maybe had that, but if it's, if it's gonna be an ECG, it'll be something obvious on it. Um, like that or, um, I don't know if they would do a heart block they could do. So, it's probably good to be familiar with the types of heart block just in case. Um, and the af I could do af, um, and make it into sort of like a counseling station maybe. And I did a practice Husky on constant for anticoagulation for starting somebody on a door. And so it's good to sort of go through with that to even look up online, you know, like patient leaflet information on do walks and stuff and just make sure you have a few points in your head um to go through and they could do counseling on the condition. So maybe af or heart failure or something. Um and then no attack and body al algorithms just in case I to throw something like that in. Um But honestly just um just try and, you know, stay calm, be nice, be friendly. Just remember the basics like walking in hand hygiene, you know, um just like manage your basic history stuff. Um You'll get like all the points for that. Um And I like totally bombed loads of my stations and still managed to pass. So it was a way absolutely fine. And so if I have any questions or anything, you want me to like go back through, you probably catch you long enough and the, the, the car sent me, she's asked me to put this in and if you wouldn't mind doing some feedback and I suppose it's good for them. You know, they've organized this and to see how everybody's, um, find it. Is it, I don't know. Is it working for you? Yeah, it's grand. Yeah. Thanks Steve.