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front, we'll come to part to off the cardiology talk. Um, we're gonna be going through a few more conditions. That's very, very relevant to the pre clinical undergraduate curriculum. Um, if you haven't had the first, we ask easy. Uh, but we do not only specialize in ask easy or or skis this year, we do many other serious. We launched our pre clinical seriously yesterday. Thank you for all those who turned up. We have a pre med division, a surgical division as well as a final division on you guys are currently doing in to our final stocks, which we are giving on a weekly basis. It would be either on a Tuesday or Thursday, depending on the amount of content that we wish to cover. So if there's loads of content will be both on a Tuesday and Thursday, otherwise it will be just on a Thursday. Uh, that just makes it easier for you guys. Um, one question is just come up part one lecture. 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And they have all the lectures that we do our recorded. And so everything is uploaded on med. Also, all those who attend elections can reviewed as many number of times. It's possible on as much as they want. That's why I'm feeling the feedback from and a quick shot anastomosis. They help provide connections between healthcare professionals. Um, just I missed one in the previous letter here. This quest mint are amazing question, but we all use them and, uh, they provide amazing questions, really tough stimulated mind, and they provide very in depth answers. Um, So if you if you think that, uh, the subscription is something that you fancy the news on skis 20 for 20% off the scale, 20 for 20% off their service. Um, right. So we have a new ask you sick community Shinji, one of our team members who posted in the chat. We do almost daily questions that on these questions have said to be really, really stimulating. And we're trying to create a community where everyone can ask us many questions as they want in this open space. And we are more than happy to come and help and discuss why. Ah, questions wrong. Why? Quite question is right. Uh, or it doesn't even have to be about medicine again. You can literally ask us about anything. Advice, career advice, any advice? Um, we're not expense, but we'll direct your list in there in the right direction if we know. Um I'll skip this and finally a few. A few point us. So please keep your microphone and a camera on mute. If you guys do done on your microphones and cameras, it will be recorded and it will be put in the session to attending. The session is consented. You agreed to this terms of do ask questions and interact on the chat engaged in the pools. This is S be a section, so it's very key that you engage in the polls. Be respectful on the chat, the session is going to be recorded. 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If you enjoy the sessions and if you find it beneficial, please share it on a social so that we can give him a traction on. We can provide this free service for a longer period of time because we we work with, uh, sponsors. And so that's the only way to find out is you because we don't keep any of the profits. It also it's all to fund the larger volume off people that come to our sessions. So thank Thank you. And, uh, today's speaker is gonna be Sharma. Uh, I'm sure many of you guys would have pretended the lecture last year by his brother. So she he has a wonderful lecture. We've helped him. We've worked with him at the Amazing questions on tall cardiology related. So I'm sure it'll keep you on your toes. We've made it harder to um, so it's not straightforward. It's not. It's not easy enough gas. Last session. Lot of people were getting everything right. And so it because we were intellectually, intellectually stimulating toe, um, so charming is a medical student. 15 medical student in you see up. And he has an interest in cardiology and medical education, so I will just hand it over to him. Sherman, you're ready to continue a decision. I saw You're on metformin. Oh, yeah, Just I'm just saying. Okay. You guys see my screen, okay? Yep. Relates Hi. My name is sharper. Be speaking of the Apostle. Great part two of the cardiology talk. Um, so let's get right into it Is the first question we have a 35 year old lady with the background off s Sorry, just looking that if I really the back are asked my presents An emergency department with sudden onset palpitations. She denies any chest pain or loss of consciousness. ECD shows a regular tachycardia to our restoration 110 milliseconds. A current BP 120 over 90 mean me? Just mercury vagal NuvaRing have been tried multiple times. But you know of you, what is the single most appropriate management? This patient that's going to be cake gonna ended in 54, three to I hope this thing work. Tell him there's times it's kind of drains a doll and pulling out. So majority of you could see 6 mg idea Tennessee, which is a very fair guess. But the answer is at 5 mg IV verapamil over two minutes. So congratulations of those deep. The reason being is because this is visitation is presented with super ventricular tachycardia. Just a narrow, complex tachycardia mediated by the QRS duration off less than 100 20 milliseconds. The first line treatment is indeed the gum numerous, such as Barcelona Numa, the maneuvers and character Sinus. Besides, Or you can even did the patient stays in the high school bucket. But these maneuvers do they activate the vagus nerve, causing a parasympathetic overdrive to decrease the heart rate and tell meeting with me in a stable patient with narrow, complex tachycardia which is refractory to vagal maneuvers such as this patient, you would initially give 6 mg IV Tennessee However, this station has a background of asthma, hence agonizing. Adenosine is contraindicated due to the risks off Bronco spasm. And he had to give IV verapamil. And there's two options are the DMV. As the VNF states? The answer is 5 mg IV verapamil over a period off two minutes. So well done. Those those d So just a bit more about checking Cardia. So the first thing when you're stressing a patient with tachycardia is you want to performer General Assessment off the patient's current status. So you do this using the doctors ABCDE approach. I'm sure all of your very familiar. And if there's evidence off, no pulse this you need to follow the cardiac arrest ls algorithm. So tachycardia is defined as, um, more than 100 beats a minute, and it brought competitive guy ages. And the cure is more than 100 20 milliseconds in duration. Your next after assess for adverse life threatening features, including shocked just defining, defining the systolic BP. Less than 90 mean most mercury clamminess sweating this sweating sorry to be setting and signs or syncope myocardial ischemia. So just just been scheming changes in the CD. So it's hot it can present with progressive dyspnea severe nature, any of the signs of present. We would then up for synchronized DC cardioversion up to three times. Importantly, you have to sedate the patient that conscious and we're still unsuccessful. Then you you confused the patient with IV, um, uterine, 200 mg over 10 to 20 minutes. So if they if there's no adverse features and then you need to decide is the QRS narrow was abroad. So brought your regular arrhythmia is one of two options either an age of formulation with a bundle branch block or a just regulation with Wolff Parkinson White syndrome. And he treated the irregular, narrow, complex yellow offenses. It could be a polyp, more feet ventricle, tachycardia especially. So start the points, and this is treat that using IV may need himself it to grams over 10 minutes. It is regular and abroad, complex tachycardia, and he could either be VT, and in that case, you give them your urine. If you're uncertain, you also still treat and Bt and you give your urine or, if you know, there's a previous diagnosis off super ventricle tachycardia bundle branch block, then you treat as a regular narrow, complex tachycardia for a narrow, complex tachycardia. That's regular nature for so you can terminate, as we discussed using vehicle nervous and then giving IV adenosine 6 mg IV and 12 mg IV and finally, 18 museums. I It's important know these were recent changes to the guidelines, and you can read more about this indeed. Resuscitation Council UK Pdf Doctor. Very nice chart that beach. Is it fun? It's irregular. It's most likely to be if and we'll talk a bit more about age of for relation later on. So just having a look at the categories of broken plastic it cardio In the first PCG, you can see chaotic, irregular deflections off hearing amplitude, and this is in keeping with ventricle left fibrillations. Ideally, you shouldn't be diagnosing ventricular fibrillation. Yeah, G that the patients probably in a rest, So you want to perform the left Easy below that shows brought complex cure assess their uniforms in nature. This is in keeping with ventricular tachycardia how they can be difficult to distinguish ventricular tachycardia from super ventricular tachycardia with a parent. See, be to bundle Branch Block or Wolf Parkinson White Center. There are some criteria is on lines that state such a sed criterias that won't go over that for days. Talk last sed shows the curious, complex cyst almost twisting along the eyes or electrolyte. This is in keeping polymorphic ventricular tachycardia specifically to Assad points. And as we talked about you treat it with my knees himself. It So this is the next question you asked me a 50 year old man on the war because of a reduction in classical my scale if you're feeling clammy. He was recently started on an antibiotic for a chest infection. Nose hand you the easy tracing here to show you our X QRs complex is twisting around the eyes or electric lines. Which of the following is not a known precipitants for this condition? This patient is currently having a Muslim be Claritin. My zing, CNN strong d methadone and the hype. Okay, so I can't see the pool eyes. Okay, I'll give you about five seconds left. 54321 and most of you could be, which is the right answer. So that's very good. So the answer is indeed amoxicillin and the patient has to Saudi points, which is indicated by the SED showing a QRS complex there twisting around the eyes or electric lines. And this is invariably secondary to prolonged QT interval. So it seems that George of you did 7% of you know, the main drug called us off long QT syndrome, which is really good and they are often just in yesterday. So they are very high is going back. Um, yeah, This is the second question you've got. A 12 year old boy is seen by cardiologist for the evaluation off palpitations. His father passed away the age of 30 you to an unknown heart condition. His current observation stable S e g demonstrates acut interval corrected for heart rate off for for for under 80 milliseconds. Based on the likely diagnosis which is following the next most appropriate a such a law be making himself eight See a dentist. Do you prevent a low? You referrals! I planted a cardioverter defibrillator. It's been interesting. And the bulls five? Yeah, Nice. Be answer. The majority of you put his referral for an implantable cardioverter defibrillator. But the actual answer is D. So I think most of the recognize that the underlying diagnosis is This boy has long QT syndrome, as indicated by easy findings, and it's also important to know day the family history off his father passed away from heart condition. And this further increase our possibility that this is a long pretty syndrome, so administration start along. Although the first line treatment for long QT syndrome is indeed a bitter blocker, Sotalol is a beta blocker as well as a Class three and here with me so it can precipitate the Saudi points they've given to patients with long QT syndrome. So there's not cancer. Magnesium sulfate is given for two sides points, and this patient is not has have any evidence of that as he's stable, and there's no findings of that at anything is using Serevent Cardia as we've talked about and referral for an implantable cardioverter defibrillator. It's interesting most people. This is the answer. This is indeed the definite of answer for high risk patients with long QT syndrome. High risk patients with lung disease typically have qd intervals off more than 500 milliseconds. Oh, recurrent episodes of cardiac events such as syncope cutting arrest. We don't do not know the question is then what this is the case for this boy and renew. For fact, it's regionals less than 500 seconds. So that is not and so are just, uh, yeah, just to go back on this question, I didn't explain the answers very well there. It's not Claritin, my zing or density on methadone, because it was all drug causes off long to disinter, Um, and his hypergly mirror, Oakland. I broke the mall, so persistence purchased precipitates long distance. Yeah, so let's just talk a bit about long QT syndrome So long QT syndrome is a wreck and gentle or quiet general disorder, which predisposes patients to ventricular arrhythmias specifically to assign points. Hence, these patients are at a higher risk of cardiac events such a single bit and caressed. So it's an important condition to remember is often picked up in since 20 or after family screening and is characterized by prolonged QT interval more than 430 milliseconds, meals more than 100. I mean, it's and just a refresher memory. The Arctic duty interval is calculated by dividing the beauty, um, duration over the square off the r R. Interval. It is not. The visits formula is showing images left in questions them to really long QT syndrome, we might see mention off particular triggers, and these can often precipitate or 30 points such as exercise, especially assuming patient feeling, startle a telephone alarm clock or even happy and rest are bradycardic states. I read recently about Case report off a student who had undiagnosed long QT syndrome, who passed away because he was having a lot of stress because of the exams and his long distance when you picked up after this type of really so just the golfing a bit deeper regarding the cause is of long QT, as mentioned, that could be congenital causes or a quiet causes. There's only a few facts you know about the congenital causes. There is this specific congenital cause called JaVale and lunch meals and syndrome, and this is associated with sensory sensory neuro hearing loss, and the disease is inherited in the autosomal recessive manners. That's important. The other one is called Romana Want Syndrome, and there is no association with hearing loss, and it's inherited in the autosomal dominant. Quiet causes are not just drugs. It also includes heart conditions that you have heart disease. So is my good itis an electrolyte imbalance as you saw previously or Gilenya, I pulled magnesium for magnesium ear and hypocalcemia CNS agent such as Supper at Night Hemorrhage. This is a new morning because I've always found it difficult medical school, and he's deciding which drugs for long duty interval you have to name on it. I came across for Santa Assad's on Have Highlighted and yellow the common, um, drug causes the commonly seen in SBS. So if you can have a look at this on your own time, I think very useful and the other ones also monitor. This was taken from the US Emily Step one, also just useful movie run got next question. Now a 66 year old woman is referred to pee any by GI be following a three day history of palpitations. She has never experienced this before. She's the background, diabetes and asthma. She appears well, easy, easy review and irregularly irregular heart rate of 120 minutes on a BP of 1 to 5/75 millimeters of mercury. Echocardiogram reviews mixed mitral valve issues, which is believed cause on drying time. Most medical team has decided to call you about using medications in three weeks' time rather than DC given the diagnosis was the best management strategy to start. So we just launched a pool, please. Okay. Okay. You going? Interesting. Spread again. Off answer choices among our participants today. Yeah, and pull 54321. It's majority of you. Put a a fix a ban and verapamil with, um, uterine treatments. Late Vega. Guess the answers actually see, And this is a tough question. There's a lot to account for, and I highly doubt you'll get a question like this in your actual exams. But I think it's a good question just to highlight some of the difficulties in, um, as the is related with each other for relation when I choosing particular trucks. So let's go. Let's dissect this question further. You can treat this patient Chad. Best score should definitely need a card here for anticoagulation. So we need to choose an appropriate anticoagulant. The first line is indeed no AC and a lot of your problem because of that, However, in this patient is case she has what's called valvular a f, which is secondary to either artificial, um, artificial valves or velvet conditioning in her case with mixed mitral valve, which is stage in the question. Then that's causing underlying diagnosis, which is yes, and the evidence for why warfarin is preferred over. No wax in valvular here came from a study called The Realign Study, and you guys can have a look at that in your own free time. I think it's interesting. So the next thing to decide on is, What are we gonna rate controller in the interim while she receives his anticoagulation, this can either be a bit of blocker or rate limiting council channel blocker such a verapamil. However, we are told that she has a background off Asmat. So beat up blockers, especially atenolol, which is a non cardiac selective beta blocker, is contraindicated due to the risk off bronchospasm. That's why we choose the verapamil. And a good way, I recently found out, is to decide whether, um, beat a block. It's cardioselective, or non cardiac selective. Generally, if the betablocker begins with the letter a toe and it is non cardio selective, so atenolol non cardiac selective and those from M, Z and Z are cardio selective. So example propanolol is kind of selective. So the next thing to decide is we have told that she needs medical electrocardioversion of pharmacology. Electrocardioversion choose an improvement drug. For that, we are told that you have mixed much of our disease and this constitutes structural heart disease. And this contra indicated for use of flecainide. So that's why um, your drinks answer three weeks later. That's why sees the Royals warfarin plus verapamil with, um, your urine treatments later is another question. Um, a 63 year old woman has episodes off irregular palpitations, which started two weeks ago. She has a history of type two diabetes and scheming heart disease. A PCG confirms a chair for relation. The patient wishes to discuss the risks of starting anticoagulation with you. What is the most likely lifetime risk of having a stroke related to at each of relation? 83% be 15 cent, see 20 cent. DHA sent 60% go another very healthy spread off responses. Okay. And the pool 54321 Also be there split 50 50 half view of a 7% of you and see And I understand you've been t Okay, so let's go through this question together. So every couple A champ. Basco, child Basco three. Just because number one, she's a female, she has a history of diabetes well, as it's giving heart disease, which constitutes vascular disease, which funds the part of the scoring of the chest or in criteria. So, using this table, we know that her her annual stroke really wrists and the key with his annual trip on 2% the question wants to know what a lifetime risk of having a stroke related to it. Efforts. To do this, you need to kind of have estimation off. The average life expectancy expectancy off people in the UK is about 82 years in 2020 and mine is that with her age 62 82 miles 2020 and times it by 3.2 and you get about 64%. And the closest answer here is about 60%. So that's the answer. So age of formulation is our next topic. It's a job. It is a very busy slide. I do appreciate that, and here's your from religion is quite confusing topic to get your head wrapped around the first time so it afibrillation can be classified according to can start here. And firstly, it's contrast that, um, has proximal age of relation, which means written, that terminates spontaneously within seven days. Assistant Age of Formulation means last seventies and more, but it's still immediate cardioversion and permanent heavens, it last. Similarly, yes, however, it's not amenable to cardioversion. So this state, the doctor and patient, agrees that you know the patient's life life would lifelong arrhythmia will be eight years fibrilation because there's no way to call you right back. Sinus You might have heard in the world's People call it called people mentioning something along the lines of fast Yes or F the rapid ventricular response. This just means that the patient has a sudden onset of symptoms that partition and breathlessness breathlessness, and I found a technique out of age of relation. The triggers are off a tree for a relation is numerous, but it can be remembered usefully with the pneumonic pirates. I'll have I'll let you read that anyone from time and the clinical features of the F Most of the time it's asymptomatic and start incidentally, or SED readings. Patients who have symptoms and have a palpitation shortness of breath, chest pain. So it's focal neurological deficits. If associated with embolic phenomenon as well, probably know the main complication of it. Your fibrillation's is development trouble embolic phenomenons such as strokes and our scales in my field. Patient's pulse could be irregularly irregular. Well, I was mentioning often apical to really a positive deficit. What? That just means if you measure the patient's apex deep as well as they're really a pulse, it won't be the same. Um, hot right. You'll be a deficit, anything in variation intensive. So in terms of the different just looking at the CD and you think he could be age of fibrillation, something else just know that concentration is it could be age of flatter over that presents with salt to baseline was multifocal atrial Tachycardia don't need to know a lot about this. Just a few key fax. One of it is it's presents on Easy judy. Very morphology off the Pier IV, specifically three or more different shapes of people and in SBS, it's commonly associated with patient with pulmonary disease specific issue. So that's that's and the management of this is also very complicated. The first thing you want to assess it patient whether they have until able Yeah, off stable. Unstable. Yes, is noted by President or Advil. It's science, as we talked about. Yeah, shock can present a little pressure like a ski me out to be a heart failure syncope. That is because we do a little TV and synchronized easy shot three times, and that's an unsuccessful. They give you the order as you stop breathing now moving on to the management of stable. Yeah, if the answer was less than 48 hours, you can start the patient on heparin and then up to choose between great with, um, control, um, rhythm control. You can either use DC cardioversion or medications that, um, you know, in fact, pregnancy is, and we saw previously recognize contraindicated in structural heart disease. If the answer is more than 40 hours or you're unsure when the nature of revelation actually started, you have two options. First, you try to do a transesophageal echocardiogram. It's more specific than trans thoracic echocardiogram to rule out the president's promise left atrial appendage, and there is no promise you happen to give low molecular heparin anticoagulant patient, and then you can call you with the patient. The other option is you anticoagulated patient for three weeks, and in the interim period you give a rate control medication at the bisoprolol, or rate limiting calcium channel blockers. Diltiazem never together because of risk of asystole and heart block has moving cover last lecture, and then you can go on to proceed to your electrical cardioversion and nice state that DC cardioversion is more appropriate than Medicare diversion after this treatment window. Importantly, after that, the patient has to remain arrangeable beautiful in the cotton in the likelihood that the patient's refractory to medications or does not want medication, you can offer something called catheter ablation. I wouldn't go too much into it. Um, suffice to say, that's another option for terminating Yes, that can be used. It's next. I'm sure you're all her. The chat best score, Which is this scoring cysts scoring criteria to assess the stroke risk, and any patient that's caused two or more. You offer them anticoagulation. The first line was in Iraq such a difficult, um, that kind of thing. And however, as you saw in the previous question, if they have valvular a f and you give them warfarin Importantly. No. There's a new scoring criteria of a building risk, which has superseded. He has blessed, for it's called the orbit, and the reason why it's called or bit is that she comes from the short hand off the registry. Use off the population of patients and they were investigating the what risks what constitutes a higher risk for bleeding. So the registry is call outcomes Registry for better and from treatment. And see the first letter of each of their forms or bit is not useful. Has has that got that? Made it easy. The room, remember? But you still have to pay for exact. So this is the next question you have a 40 year old man presents to the emergency department fever in general malaise. We're also stationed precordium a new woman looking good. Easy on this admission and an e c g. Two days before it's GP practice. I should be. Which of the following next program that a city be urgent. Brightman here to root replacement involved. See cardiogram, dear. Routine observation and he discharged. Pigeonhole our restart the pool, please. Thank you very much. Okay. I think this is question of the great discontents is he had so far. That's good. Just chat. I'll end up on five for three. To what? Okay. Yes, it is, indeed. See, um, you do an echocardiogram. Um, but yeah. Show me to stop. Does anybody know why? What? What? The diagnosis here is you get those down and chat endocarditis. Okay, I even stations, okay? And it's very, very villa access. Ah, probably due to infection. Meningitis. Okay, so the online diagnosis is integrated, but there's a complication, which is the aortic root abscess. And the reason for that is if you look at if you look at, um so so why is the effect of endocarditis in the first place? That sounds that question patients, fever and a new onset. Mom s BLN. This most always gonna be infective endocarditis. Next, if you look at the EKG on the right, which is be that was initially see Gee, And if you look comparative, his agent's left, which is this current STD. You can see that the prolongation of the PR interval, if I can, if you can kind of see it's slightly prolonged in the first image. Competitive second, the first image, the more recent one. And what you need to do in that case is, um, you want to investigate further, but this is highly suggestive off aortic root access. The contacts, in fact, of endocarditis. Just a repeat that point again, someone has prolongation of PR interval, especially in such a shot on on set like Judy's. That's very specific for here to abscess. And, um, this is because of the anatomic relation of the year to group and the cardiac conduction system and slowing and aka infection spreads transmural across the aortic group. So be will be what a Yeah, You don't need to see you under something more. Step up, step up the treatment game or your investigation. Be adjusting your primary vein replacement off the valve is the treatment of choice. If it's confirmed here, do abscess. You are. You would like to do an echo first to confirm whether they're actually abscesses in the aortic root. This is best done using that card you want just routine. You observe. The patient was very, very efficacious again. We're cause the 30 to rupture, and that can last reading and he definitely wants and okay, ready? Cardio uh, cartia, another point about that question was a lot of people. Yeah, well, this is one the red instances where a first degree heart block where this for long version of the Androgel is serious need for further evaluation. So that's why I put the question that that's nice. Remember that fact? Okay, this is the adult predatory. A guidelines. Come. You all seen this? This is a resuscitation UK Council website, and I would highly advise everyone to read this stuff off skis and for exams always comes up and I won't go over it down or you can bring your time. And so now I'm just talking a bit more about heart blocks. There's three types of tablets as the first degree heart block which affected prolongation of PR interval two more than 200 milliseconds or five small squares. It could be second degree heart block type. One more bids. One Eliza, go bring you back whether it's progressive prolongation of PR interval until a drop to be. And after that a PR interval shortened from the previous for the preceding beat. So, he said, she looks that goes back to normal, right, indicating a second degree heart block Mobitz Type two is where you have a constant PR interval with intermittent drops off drawers. Complex is almost as if you have as if it happens randomly and second degree every block in a specific pattern. So just to 203 to 1 drop is predictive, so it's constantly are intervals with drops they're knocking to meeting. There's a specific pattern to it, so you get to be five to pee raises even one cures complexes been seen here. Third degree heart block, um, refers to the complete association between the P Wave and QRS complex is the BTP. Interval is constant and the art of our interval is constant, but there's no relation between the P wave in the drawers complex. So that's 33. Heart doctor and patient often had severe. Very hard is important to categorize the patients that use classification because it changes how you treat them so before where the treatment on the causes include hum for 33 heart block increased vehicle toe. Still young Asian population as well athletes as well as certain medications. Getting there across the holes works off whole span off heart blocks is includes beta blockers calcium channel blockers die, Got sing and your room. I'm a good new monitor that I came across that a b c d. So drugs that affect the Aveeno is, um, you're on the beta blocker. C hasn't broken. Indeed, I got and inferior. Um, I scan also pretty supposed to heart blocks because it affects the fair. Um affects the artery that supplies the evening as well as myocarditis. They're going to treatment now. First degree heart block often don't need to treat you can just monitor them in the position to find accepting the case we saw just now That's also similar to what? How you treat patients secondary heart block movies. Type one of the human element. And you have no other problems patients and mobitz time, too. And the MRI heart block. However, by a pacemaker in persons, because the higher risk off developing station that's just I ended the context of STD's really know the passions off the heart, Doctor. Almost always come cool. Got another question here, um, a 30 year old men presents to the emergency department with sudden onset central. Just be that I think that improves on meaning forward, he complains of a low grade fever and malaise We started a few days ago. Past medical history includes trips is on a project beating, and I'll stop this to review scratching eyes over the less than what it what The most common side effect of medication that will be used to treat Ms patients condition You go help him itself. I says That's our goal. And the bull? No. Okay, the majority off you put See, um, we'll get if I going to dance. Is, um what do you think is the medication that you use to treat this patient in? Someone talks and checked colchicine and said, Yep. Okay. Um, protein. Yep. So okay, the answers between cultures in or inside and the answer's not ends it because it was past medical history. Off two episodes up, a job eating. You read the VNF that a contract indication off ends. It's so then you have to use colchicine and the most common side effect off colds thing is gastrointestinal disturbances, especially diarrhea. Cancer is a Yes. Yeah. Nice moving on. Another question here, a 55 year old men who is recovering three days post heart ball surgery. It's found to be less responsive. Is observation on a respirator, for instance, of Barrett's per minute oxygen saturation, 90% on two liters of oxygen. That pressure 80/55 millimeters of mercury. Heart rate 100 community piece of well, auscultation recording reviews. Quiet. Heart sounds show. Um, peace to us conferences. Cardiogram is currently doing which of the following immediately management or his vision issue. I think this is the, uh Yeah, yeah. Everyone should never get yet. Okay. You guys know your emergency medicine. Very well. That's good. Okay. Um, yeah. Okay. Just okay. Ending full in 321. And the whole. The answer. Most people put it very cutting. Jesus. Um, Okay. Cool. Yes, that's the answer. And can someone to help me? Why? The answers? Pericarditis and pieces. What's the diagnosis here first? All right. I'm not good. Okay. Can someone tell me what's why do you think of temporal? What? In the STDs 10 is revealing to them that this is a temporary okay next Friday. Cool. Um, I always found, like, these tribes difficult to remember and and you might They came across the program from stop was the three DS, which is distant heartsong um, drop in blood pressure. And, um what drop in blood pressure, distant heart sound And, um, and distended drug living. Especially here. You think I should I should have known that. So there's the street. He's off correct. Just to repeat distended JVP distant heart sounds and drop in blood pressure. And yep. Youngsters temple not and extra. So you do emergency Herget. Very kind of Jesus to remove the fluid from the pericardial. Cool. Talking a bit more about pericardial diseases. Now, can anyone tell me what this Easter dish? Oh, so not the diagnosis. What does the recent issue someone posted? Checked some three. D is distended, um, neck veins, which is raised dvt. Sorry. Um, distant heart sound and drop in blood pressure. Belgians. Okay. Um yeah. Good. Yes, I think I got it. I haven't got it yet. It's electrical horse nuns, and it actually often is a beat. To be variation with altitude off QRS complex is and it's it's almost always seen cart temple in because the heart is swinging and the paragard and sacrifice full of food. Yeah, Michael Bolton. I'm assuming that means yeah. No, amplitudes were very good and low. Amplitude complex. Good. Okay. Okay, now testing a bit more spot diagnosis questions. Oh, no. What's the first image? And what's the image? Blow that. What? What can you see? Okay. What is it? More indicative in terms of pericardial diseases can just put a check, please. Got a fusion. Good. What's what? What sign is the first one? Did you know it's just a big name sign squeezing things? Yeah. Okay. And what's the one below that? What's the abnormality, then? What is that? Most sensitive to it? Contribute regard is yes. Okay, fine. I'm assuming you saw the So those dance of the calcification around the outline of the cardiac morning. So, yes, that's what about assigning it often CDs in large pack of fusions. This can produce supposed to cut it temporarily. So the thing is, it is It is a lot chronic pregnant infusion. We often see this in conditions of malignancies. In conditions such as trauma. You don't have to have a large effusion to cause Tampa. That's an important distinction for me. So someone's come in with symptoms of back stria. They might do a chest X ray. You might not see this glass of this huge global heart at in by a stroke of the temple. And the second one is pregnant constipation. And this is very indicative off. Um, cardio constrictive pericarditis Question. So this is a table off beer, high yield stuff. They need, you know, a very kind of disease and comes SPS. So for pericarditis or some acid osteo, the first thing you see is like 90% of the causes of market decided a dramatic or viral image and many other causes that drug causes hardening causes uremia both terrorism and so on. Thank clinical features. A very bad in the morning. You should be someone young, 30 to 50 year old man comes in shops and you'll just pain and better sitting for worse Lying in bed, you might get viral prodrome such a low grade fever myalgia If the etiology is viral in nature and on oscal vision, you can hear pericardial frictional. Um, does anybody know how you can difference? She a pericardial friction rub and a pure rub on oscal vision imposed in charge of you. Yeah, well, you have to stop inspiration. That's good. Um, cool. So very good idea. of friction Rub. Yeah, he still had happens during, um expression expert. An expiration. You hold your breath, period. Friction disappears a CG You can see a global conclave as the elevation. In contrast to this chemo cause off the elevation is normally in certain churches g in a very specific science pr depression management as it as we talked about previously constrictive pregnant itis. Um, it's a condition where the heart is. In case, you know, rigid, very hard. It is often seen any visions of repeated inflammatory process that affect the pericardium or repeat it. Corning pericarditis causing calcification of the Valium, the most common cause that has to be something to TV. And because it's this diastolic dysfunction ready heart is in this region kings. It has difficulty in relaxing and you can get symptoms. Right. Heart failure such as societies, people Dema hepatosplenomegaly take anything classically and is very stable cause for the hepatitis, a sign called can get osculate osculate Therese time called peri cardio Knock. Um, is he sent? It is a lot of three. Um, the exact mechanism is quite hard to explain all with you, but you can read about it in time it's interesting and he also get this phenomenon as small sign is that abnormal, abnormal raising supplements president during inspiration so inspired. Normally, the lower intrathoracic pressure pulls the blood into the right heart. Cause a decrease in JVP in country, The back of my record itis because there's increased pressure in the right part. The fact of the heart, you know, relax properly. There's back flow of blood to the internal jugular vein, which is reflected on, was reflected as an increase and JVP drink inspiration. Chest X ray is you can do a bigger than calcification. We talked about the SoMa just now, and management involves a surgical procedure where you can remove the calcification part of the body. It's got a fusion back of the infusions and give you that there's fluid, either blood, passing some other fluid within the back of the space of the paragard, Um, through it in, please cut it out. But this guy is that card in temperature. A life threatening conditions is very important to recognize that quickly. Small, pericardial effusion is tend to be a symptomatic, but large effusions can predispose to 10. The key features identify as we discussed previously. Our eyes, we just have to previously. And there's also a phenomenal policies. Paradoxes where there's an exaggerated decreased insist on a BP off more than 10 millimeters per month during spirit. So the patient we feel that really a pulse you might not be able to feel and emitted deep breath in. And this, I think, was in the osteo easy community SP. It's just a really good question. Um, just extra signs of talked about in the most important thing is urgent management. Urgent Management institute very urgently is pericarditis and pieces to drink from it. Cool. Okay, next question. You were asked to see an 80 year old patient who has presented with just being on further questioning. He tells you they suffered more episode of collapsed and shortness of breath on auscultation, you know, injections. A solid murmur that really is the character which is the most, which is the most appropriate investigation to make no sense. A an e c g be a transthoracic gram. See my head, the fasting glucose. He chest nice. You're not taking these, right? Yeah, And the pool in 54, three, 21. Yep. The answer is indeed okay. Transthoracic echocardiogram? Yes, because there's evidence for Mama, and the best way to investigate that further is by using transfers. It also showed the severity off, the yes on and the other investigation appropriate are not diagnosis type won't help. Diagnose is off. Yes, it's much. It's just moving on to valve the lesions and specifically talk about two s. And yeah, because I think most you ones aortic stenosis is it causes more than fight often said that it was due to a counselor degeneration involved. If it's less than 65 it's like a hospital. See medications such as those with Turner syndrome single features. I'm sure you've heard of demonic sed. Just seemed to be angina just here. So get anyone. Tell me among syncope, angina and dyspnea, which feature Pretend the worst problem Nuisance for visiting. Yes, you know, think of it. Think the basic basic today. Cool. The answer that your dyspnea and it's because that the media the Bible is much less competitive, Better China. I also want to see you first when someone first told me that, and that was study that was done that showed that the Disney years that keeping the heart failure and that actually pretended the worse Prognosis is as a fact, Keep in mind you can also get narrow pulse. Presently systolic president of diastolic pressures are. There's not much difference between them. You get this, um, and you get this other policy calls Positive part is a target was a week and dilate files. And because aortic stenosis is what we call a a pressure pressure overload letter than the volume over As because of the calcified narrowing of the aortic valve, the heart has to work harder on my card. It has the work harder. So hypertrophy is get this pressure a little bit. Deceiving is nondisplaced and severe calcifications get quiet as to some. And you can also get, um, s four stuff as far additional hot. The classic Everybody knows that rejection. Just a moment, really, in the carotids. So if you do have in the question from an injection, but it's not really eating the patient's interview. Well, do you have any other heart sounds? This could be a a tick. Sclerosis is just counseling the generation, the low end of the spectrum, you normally just have been wanting to these patients. And, yeah, that's just an important thing to remember. So I'm, you know, hospice. Um, and see what the differential for an aortic stenosis. Mama, you can mention aortic sclerosis and investigations. Do this for all the belt religions. Just extra. A PCG left ventricular hypertrophy does that. And gardening management division. He's intermitting much reserves patient. He's symptomatic, developing more than 40 millimeters mercury and any evidence of left ventricle. Systolic dysfunction defined the injection fraction less than 50% in consider surgery. They're symptomatic you consider about our surgeons? Well, I got involved. Replacement tabby Orange Surgical place. I don't know. There's a shift in paradigm about how best to treat the aortic valve aortic stenosis. And there's a shift towards Tabby because it's shown to have non inferior outcomes come about the surgical aortic valve replacement and Chevy done percutaneously. Of course, people prefer pocketings see gyn resident procedure that you have to go. So you had done the surgery for, uh, if there's a critical aortic stenosis vision office, five places from whatsoever reason, then you up for balloon valvular plus a valve you're blasting blue. Lovely, fast white in aortic regurgitation causes you going to buy them to put Q causes and chronic cause you cause group infectivity part itis He ordered that section drama morning cause isn't by custody of evolved rheumatic fever, connective tissue disorders, ankylosing spondylitis, spondylitis and syphilitic your titers. So the last three, Um okay, um any him more computerized petite girls to divide it takes regurgitation, causes those ever fell. And does that affect affect the root? It's the latter Trina crime section Affecting your route features patients often the reason diabetic in the US And then the heart sensitive heart failure taught me and PND this white pants projects We want to have a pulse and in this state is a volume overload. We get displaced, trusting it back Speak with an early diastolic murmur In severe er you might get something called Austin Think more is this soft, I think mitt diastolic murmur And it's a differential for someone with my trains, the nurses and what essentially happens because the UTI regard to use it yet shoots down when they might just the nose is My just involved wants to open doing guys when the mitral valve wants to open doing isolated regard station just prevents the mitral valve from opening. So Effective X is a functional use of mitral stenosis. Hope that makes sense and, um, is important number eponym assigns. As you know, Oscars are going more and more virtual, especially with Pandemic hopefully empty. It's up to get easily. Show you and him in jail, for example, Quickies, Sign and Gasol and ask you what what is the issue and then use. It is nearly a pulsation, and the kind of a syndrome, even a Sinus quick are they besides depressive side, which is his body will indulge me. Sign people in construction and dilation. Mullah Cycle, which is a new bill, a pulsation Corrigan sandwiches, character pulsation. So is Trump. Son. Is the shots done over there? Femoral hospitalization investigators. Same thing has discussed previously. And management in acute a r A. To regurgitation. Who would want it? Urgent Surgery to speech often presented a cute family. Dema and the quite urgent repair Honey Um, you're regarded Asian. You can give medication that he's a dilators and his individuals with the goal off reducing after load so less blood gets pushed back into the left ventricle consistently after his height is more resistant. Yeah, monitor Echo six and one of the base of the Echo every 6 to 12 months, and, you know surgery for 85% has indication management for this. I don't think it's that important, but knowing the one of the signs causes genital features are definitely more important now. In the city echoes diagnostic is the most. So there's a key moments summary that just compiled I was on it difficult Don't want to do for what murmur So you can have a read of this in your own time and hopefully it'll help your revision. Official Boston. Uh, how long trip to go over it? Right now? These are my references on, and that's the end of the talk. Thank you very much.