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So, I'll just start by introducing myself and I'll get sabrina to introduce herself as well, So, I'm william, I'm an academic foundation doctor working at the Rbi in freeman. Um We'll be covering cardiology and respiratory medicine. I've posted some links to the three other sessions, we're hoping to do um with a quiz session um the day before your s. P. A. Um So feel free to register for those events. Um Sabrina do you wanna yes Hi, I'm sabrina, I'm a final year medical student, and I integrated last year um and I'll be running the session on sunday at half five on endocrinology and some non communicable diseases and if you have any questions just pop them in the chat um and I'll try to answer them during wills presentation, a cardio, yeah sorry, I apologize, I was on me uh so I'll probably get started now Cardiology, respiratory can be quite daunting um and there's a lot to learn about the increasingly rare conditions um. So from what I've been told these are the core conditions you have for cardiology and respiratory medicine. Um I remember when I did this in fourth year and it was an incredibly dense block with a lot of highly complex conditions, but you're probably you're gonna here In this talk, me say high yield a lot there's probably about 13 or 14 concepts that will go through that may uh that are commonly asked on exam papers um and modelers, so I just want to give you that material so some of the things we'll go through um that I think our high yield or in red um we probably won't go through asthma and copd um that's even though is very commonly asked, um I think it's something we go through a lot in 1st and 2nd year in, in something you can learn quite well on your own, um so let's get started so with the case, so chest pain, six year old man with a medical history of hypertension, diabetes, dyslipidemia, smoking, and a family history of premature carney. A artery disease presents with retrosternal crushing chest pain, which radiates down his left arm and left side of his neck. He feels nauseated, lightheaded in a short of breath. Examination reveals hypertension, diaphoresis. Iss in considerable discomfort with diffused bilateral crackles on chest auscultation, um So there's probably an obvious uh diagnosis that comes to mind um Would anyone want to put in to differential diagnosis they might think of. I guess the second one might be a bit harder to think about and if it's seven o'clock after a long study that I understand if no one wants to respond um okay, great, so we've got p down there other things, yeah, so we're thinking about an mri, at the moment, so our general approach, I won't make you guys say a two e, but in third year, you've had that drill down um into your big time, but just going through the approach here, so we're obviously going to do any in and any model we're going to do an 80 reproach, um but particularly important here is B and C, so we want to make sure we're auscultated bilaterally especially at the basis and I want you anytime you think or here or presented with some with chest pain. I want you when you're at be to make sure you think of a chest x ray um and we'll go through wide a minute but um I just want that to ring a alarm bell on your head, so moving on to see, we'll do our fluid status jvp cat refill, um temperature and e. C. G. As well as blood tests um so for blood count using these LFTS and then high sensitivity troponin tS. We also want to get a blood glucose measurement cause that's important for diabetics with a key coronary syndrome and then check if there's any bleeding or anemia as well, this can precipitate chest pain, so you do an e. C. G. And here we've got the c. G. Can anyone point out any abnormalities in the e. C. G. Or maybe there aren't any yeah perfect so st elevation in bit in v one but definitely in v two, v 32 v four, so anteroseptal st, elevated myocardial infarction, So the first point I want to stress is chest pain. I want you to obviously start with an 80 approach, but I want to make sure you don't forget an e. C. G. In a chest x ray because if you miss those out in a muzzle er that's just like you're missing out on the diagnosis essentially, um so e. C. G. You don't even have to do it. Yourself. You just ask the healthcare assistant or nurse hi, can you please get an e. C. G. For this patient and then chest x rays um and e. C. G. Will tell you potentially if they have a. P. As well, cause sinus tacky is the most common sign um in PE, and then check sex ray you always want to rule out a pneumothorax uh as far as the CGS in a mother station, uh Yes, you can um it tends to be more common in final year muzzle ear's, so it would be less likely to happen in fourth year, but it can happen in the long sessions, so you it would be quite uh it would be harsh to give you to interpret e. C. G. In 14 minutes station, so first question of the day, which of the following risk factors is the biggest contributor to this patient's presentation, so if you guys want to answer and then we'll okay, so we've got d any so it is quite a difficult question, but this is high your point number two if in doubt always go for smoking, so all of these risk factors are actually nearly identical um In conferring risk to um acute coronary syndrome um and they often like to ask about you know lifestyle factors that contribute to vascular disease or acute coroner's, but if ever you're faced with this, I want you to just go for smoking, smoking is the highest sealed answer um and if you're faced with between diet, obesity, poor exercise, smoking will always trump that uh. The only time you might want to go for hypertension is in the case of an aneurysm because hypertension is a bigger risk factor um for aortic aneurysm, but so this is high, old point number two always go for smoking um So that will make sure you get a lot of points um on the sba, so we've had this patient, they've been admitted um and then we've you probably know this fairly well But initially managing an acute coronary syndrome and st, uh elevated myocardial infarction, you want to use the Mona acronym so morphine and clo promide um to control the pain. Um We need oxygen, so oxygen saturations vary. Um Some trust only require that you need it up to 95%. Um You want to give them a g. T. N. Spray. Um You can give iv nitrates but you have to be careful in cardiogenic shock. You want to give aspirin 300 mg stat and then the t, part of the Mona acronym is um variable by trust, um so I wouldn't worry about T, specifically, I would just say I would refer to my local trust guidelines for choice of anti platelet agents, so our patient is transferred to say they presented to the RBI They've been transferred to the Freeman um for primary carney um intervention um and then these are the indications for PCI. So if they're presenting within 12 hours, if pc I can be done within two hours of the time, fiber analyst, this could have been given cardiogenic shock um even if it's been greater than 12 hours, but there's still evidence of ongoing ischemia essentially it's in most cases of stemi, um but now so they've done PCI. The patient's you know relatively stable um on the cardiology ward at the freeman um Can anyone name some complications of an acute m. I. And this is quite high yield from muslim hours um and sBS as well yep, death dress, alors, arrhythmia, darth, vader brilliant heart failure all right that that's that's good and a few of you've got onto the acronym. I learned which is quite well dressler, also brilliant brilliant um So a lot of you have learned this acronym Darth vader um So you have death arrhythmia rupture, but that tends only to happen when there's a full thickness transmural infarction, tamponade or thrombus, heart failure, valve disease, aneurysms, another m. I. Dressler, simba syndrome, embolism, and regurgitation, so three of these are particularly high yield for examinations and I'm going to go through them now, um but yeah, arrhythmia, heart failure, and dresser syndrome, and I would learn this acronym. If you haven't learned already because in a monster station, you may be asked this and you know if you're actually dealing, it might not be this year but in future years and you you're fluster dealing with acute coronary syndrome. Um This acronym is an easy way to remember the important complications, so you're called to see the patient um as a nurse, thinks his most recent e. C. G. Seems odd and then so this goes to our next high yield point number three, so heart block is nearly always um examined or can be examined, um So it's something you learn early on in medical school, but it's really important to refresh um and so we'll briefly go through the different types of heart block um. I find it simplest to remember first degree in third degree separately, so first degree is just a prolonged PR interval greater than 200 milliseconds, whereas third degrees when there's complete a. V. Uh disassociation with the P waves and q. R. S. Is not um having any relationship um And then as far as the second degree, I think of it, I remember by learning more bits, Type two is sort of when the nonconducted P waves um march through um march through. The qRS is without prolongation of the PR interview interval, so I just remember to legs is marching um and so the P waves are just steadily marching through, whereas second degree type one move it's one is just when you have progressive prolongation of the PR interval, which culminates in a nonconducted P wave, so I'll get you guys to look at some e. C. G. S. They are kind of they are really poor quality say as far as like the quality of the image on the PdF, but if anyone has any idea, so there are all types of heart block to make it easier for yourself okay. We got third degree, anyone else, no, it's too okay all right first degree okay. We'll take first degree, so it's really it's in an exam you would have the e. C. G. A lot more clear, um, but perhaps I can convince you that this red line, so they're both the same length and if you went through the whole of lead three, it's staying at the same length and there is the qrs. So uh I understand if you think that the T wave is a P wave so that there's a missed qRS, but it's actually just the T wave is quite small and space apart. Um So this is first degree heart block, um but that is a it's not great because you don't have the bottom rhythm strip to look at that more complex is okay. Next one any guesses brilliant. Yeah, I'm I'm just got that correct so perfect yeah exactly so we have our red lines here, which are the same length, but you can sort of see the gap between the p. And the qrs is lengthening as we're going um along um. And finally there's a completely dropped grs, later on in the, in the complex, perfect Yusef's got it so um second degree type two. So here unfortunately my little men have been moved to the side, um but we can see here the P waves are marching through um so we we know this is 2nd 2nd degree heart block type two and finally this image is not the best either to be honest, so this one shows third degree heart block. Um The P waves and q. R. S. Is um don't really have any relation to each other. Um mhm, you could be convinced that this is second degree um type one because it looks like the p. R. Intervals getting prolonged progressively and then there's drop beats, but um if you look at the star and the end, there's just no real relation between the P waves and the qRS complex is and it's difficult as well because third degree heart block is just a continuation of second degree um so it can be a bit confusing right so high you'd point there, so we need to know are types of heart block because if that comes up on an exam that's just easy marks were looking at uh e. C. G. And we can determine that very quickly. So our patient has returned to any four weeks after his mri, reporting of severe chest pain, which is worse when lying down, ambassador, sitting forward is worse when he breathes in and he describes as a jaggi pain, does anyone have any ideas of differentials for a patient. Yeah yeah people people on it, so it may seem like you know this is obvious, but people will get this wrong in an exam um and then so here we have the e. C. G. Of the patient, but a lot of you have said pericarditis um so here's a classic e. C. G. So if you can see there's unfortunately it hasn't come through oh here, we go, so we've got this classic you like saddle shaped, we have some uh pr depression and then concave saddle st elevation um and that's classically seen in pericarditis. So you absolutely if you don't know this already, but you actually have to know and be aware of someone's had a recent mRI, and they're coming back with those sort of symptoms. Um The answer is gonna be Dressler syndrome every time, but seems a lot of you guys are on that, which is good right, so moving on, so another complication of a q. M. I. Is heart failure and this is another high yield topic because they love to ask about heart failure. Um It requires you to differentiate between other lung pathologies, cardiac pathologies. Um So our patient has returned, they've got increasing shortness of breath. They've got all the same risk factors and smoking, which you mentioned before, which will remember. Um So he underwent his successful primary angioplasty um For his m. I. Two months ago, his bp is 1 80/80 his heart rates 1 10, respirator 30 elevated neck veins prominent s three, e. C. G. Shows sinus tachycardia and a trans thoracic trans thoracic echocardiogram reveals impaired left ventricular systolic function with an ejection fraction of 20% so he's not doing too well at the moment. Um So going through some investigations, we obviously want to do r. E. C. G. We want to do our chest x ray um For reasons stated, so we want to see if there's cardiomegaly, pommery dema plural fusion. We want to get a full blood count and n. T. Pro BMP and then another potentially obvious um investigation, but we need to get a transthoracic echocardio gram because this is like the first line investigation for heart failure um and it's definitely can be asked on exams even though it seems like a simple first line investigation, um but you just you absolutely have to know this um form Osler's and for sbs um and then something that probably won't be um examined for you guys, but I think something that's just really useful going forward especially when you go through your infections, chronic infections um later on after christmas um is the difference between trans thoracic echo and transesophageal echo, So until I saw this picture didn't really make sense to me, but if you have a look so transesophageal echo is going down through the esophagus and the way the heart structured is that the left atrium sits sort of really close to the esophagus um and then when you have infective endocarditis, it's the mitral they valve that's often affected um and so that's why often um to get definitive diagnosis of infective endocarditis, you need to do this trans esophageal e, because it really visualize is that valve really well um and then it's important to remember that right sided valve lesion's. An iv. D. Uh Iv drug users um is more common because the bacteria from use needles enters the venous system and then travels to the right side of the heart, which is where the tricusp it is right, so Question number two. This question is a bit weird but um it will be quite useful, so our patient has presented as we stated before with a high bp tacky cardia, signs of heart failure which of the following medications should be given first and feel free to answer, so WAlton's gone with a okay, so a. N. C. R. Predominant answers okay, so high your point number six is bizarre. Prell offers mortality benefit and heart failure so um I could completely understand why you would go for sarah samide because although um this patient could have chronic heart failure, he sort of got an acute presentation um of heart failure and that's often managed with oxygen, sitting them up, Cpap and furosemide. Um However, because this patient is tachycardic and has high BP um and this is a result of sympathetic activation, so it's heart is working really really hard to try and maintain that output um So in this case um and normally he would be on bisoprolol anyway after his admission, but in this case if he's not on bisoprolol that that is the first thing you should give because it will help with sympathetic tone um and reduce BP in the tachycardia, whereas for frusemide, doesn't actually have a symptomatic benefit, uh mortality benefit. So um if you're faced with this, definitely go for bisoprolol if their BP is high and they're tacky cardiac, however, if it's the opposite and the BP is low um or they've got a low heart rate, then you might go for reuse mind first because a beta blocker obviously would reduce their cardiac output to a point where it's far too low um but yeah just keep in mind bisoprolol. And then yeah we talked, I talked a bit about heart failure management, so in acute um it tends to be oxygen diuretics such as furosemide and see pat, whereas chronic we have um these medications which we've learned um about frequently. Um So ACE inhibitors and beta blockers have the mortality benefits, whereas the loop diuretics, thiazide, diuretics, and digoxin in um only give symptomatic benefit um There are other medications you would have been um taught in your c. D. M. Lectures, um which are important to learn, but I've just put the ones that you absolutely have to know um. And then this is like one of the most common exam questions is you know the patient's been started on a medication and now they have a dry cough. You absolutely have to know that it's an ACE inhibitor um that's like a gimme, a gimme point that you have to have um does anyone know the reason why a sin hip bitters uh lead to a dry cough. Sometimes anyone know like the molecule or substance that leads to the cough yeah brilliant um so bradykinin, so this is something you'll come across um in your immunology lectures as well after christmas, um so you can get hereditary angioedema, which is where you get um sporadic just swelling for no apparent reason um And this is due to um a lack of uh ACE enzyme and so a sin hitters um inhibit, ACE, and ACE, converts bradykinin into sort of non active substances, so when you have a build up of brady kind and it leads to swelling um and this when this happens into the lungs that leads to a bit fluid build up in a cough, um but you'll come across that more in your immunology, so our patient so he's gone through a lot and unfortunately he's deteriorated in hospital um and it's put on end of life care, so we'll now go on to our next question, so the patient is acutely short breath with signs of heart failure, has by basal crackles on auscultation in and is a dermatitis from his ankles to his mid calves, which of the following is the most appropriate therapy to treat his breathlessness. If anyone has okay, we've got d. C. C, see see okay, so this is higher point number seven, so because we've quickly shifted to this patient being end of life um The most important thing uh to do end of life is to make patient's comfortable so you have the care of the dying sort of package and medications that you would give so morphine's included in that um along with high seen midazolam um and so morphine is really important to know that morphine is used to treat breathlessness especially when someone's end of life um so it will um reduce the respiratory rate um and yeah so it's it's just an incredibly important thing to to know. Um So if a patient's end of life for any reason, perhaps they have cancer, but they have signs of acute heart failure um The management option would be morphine and it wouldn't be frusemide or Cpap, so some final few quick hits with cardio, um So we have a 25 year old male collapses playing football and, and he also has a systolic ejection murmur that decreases in intensity when squatting and this is his e. C. G. I. Understand that cardiomyopathy might not be perfect. Hokum, yes exactly um brilliant. So again hokum, um it's definitely something that can be examined. Um You have these really um large QRS complex is and V 45, and six um and the murmur decreases when squatting, so basically hokum, the murmur gets louder as there's less blood in the heart, so um when the patient is squatting that increases peripheral vascular resistance, um which increases um the amount of blood that's in the heart, so the um the more blood that's in the heart, the less loud the murmur is um so we got that hogan ok ulcers. Uh There's usually some sort of question about an ulcer um on an exam, so it's mostly important to know the difference between arterial and venous ulcers um So arterial ulcers are punched out and deep, So it's this second image here with sort of the black shr, in the middle. Um There's usually underlying peripheral arterial disease, so they may have symptoms of claudications or pale feet um and it's often happens in patients with diabetes and a smoking background. Whereas venous ulcers. If you look on the left, they usually have sort of uh sloughing in the skin, they'll have a dema pigment deposition and some granulation tissue, so it's just quite important to um understand the differences between these two types of ulcers because they like to ask about that. Another high your point is hypertension management um This is absolutely must know um and I think sabrina will go through this more in her endocrinology and non communicable disease lecture um but yeah, so on the left, we have anyone with type two diabetes whose under 55 not of black african or african caribbean family origin, Although this is kind of the nysc islands are quite simplified and the genetic um causes of hypertension um This is what we've got currently, So this is the guidelines we follow um whereas first line for anyone over 55 or black black african or caribbean family origin has started on a calcium channel blocker um So it's really important to know like the stages of this and be able to talk about it um Obviously in a muzzle er, with any hypertension, you want to talk about lifestyle modification first, um but these you need to know um this for sBS for sure so another question for you guys. Um 56 year old patient of african caribbean descent has been taking amlodipine for the past two years, however, his average home bp measurements the past two weeks have been 1 65/85. What is the next appropriate treatment for this patient, so we've got c, any others see okay all right, so we've got sees there, which I actually can't fault. Um However, the answer will most likely be a um because uh ACE inhibitors are cheaper than um uh alpha receptor block uh rBS um and for that reason, they're given first uh in the combination with the calcium channel blocker, um but you're not wrong to say losartan um but they will it's lisinopril will be prescribed first um okay so quickly moving on to respiratory medicine, there's not that much more of the lecture, so um If you're still with me and your brain is still working, we've got a few more things to just put into our brain that we won't forget for the s. P. A. So Aksaray changes. Um you guys may have come across um these acronym before, but um even for exams going future like in fifth year, or if you're doing g. P. Exams or um you know um further doctor exams later on just knowing this acronym can help you so much in lung pathology. Questions, so TV space are usually lesion's that occur in the apical zone, so we have TB, sarcoid slash silicosis pneumoconiosis, ANK, spond, cF and then extrinsic allergic alveolitis, whereas um the middle and lower zones are acid and AMN, so you've got esp, osteosis, connective tissue disease, Ipf so you've got no ipf is in the lower zones and then you have these drugs, so amiodarone, methotrexate or got derivatives and nitrofuran tone. Um walton's mentioned is in our case of listener do it because um the sBA s are based on like current best practice guidelines, um so I would pass med may put arb um and I may be wrong in the guidelines have since changed, but there, the question banks usually don't update um that frequently so I would definitely go for an ACE inhibitor first because that's what's prescribed in practice, it's cheaper um and that's what they want, they probably wouldn't be harsh enough and put both an ARB in an ACE inhibitor anyway. Um The point of that question overall was just that you need to know. Um yeah no that's a fair point um yeah, so I may have to get back to you guys on that, but as far as what I faced before, um they don't put the rBS and ACE inhibitors together, but you need to know that it's yeah either ACE inhibitor or Arb, is the next thing you would add to a calcium channel blocker, so I'll accept that that question actually was not the best written um but yeah back to x ray changes learn this acronym and then you won't have to worry if you ever come across, um They mentioned you know there's a finding the lower upper zones, so really important acronym to learn. So this is our second case of the day. Our first case was our acute coronary syndrome man, um and now we've got a case of fatigue, so 41 year old obese man presents with on refreshing sleep, multiple awakenings, morning headaches. He has excessive daytime sleepiness, which is interfering with his daily activities and he was nearly an m, over vehicle accident. His memory is affected and he's got a few risk factors which are being treated such as hypertension, gourd, type two diabetes. Ucf Ucf is already fast on a potential diagnosis um So this is really high yield even though it seems like quite a simple question um slash condition to understand, but it commonly comes up in on exams. So common risk factors are obesity being male, middle age, alcohol because alcohol is a CNS depressant um and like abnormalities of the jaw um and this can lead to premature death, cvs disease um in daytime accidents um yeah that's that's fair enough um So you absolutely have to know have to know so on investigations, they, they'll ask you what is the definitive test to diagnose obstructive sleep apnea and the answer is polysomnography. Um So the app worth sleeping is scare is um just basically um like your phq nine. It's just like a little survey that you can use in general practice. It is very useful tool, um but it's the polysomnography that actually is the definitive test um. So you would also make sure you're going to check any cardiovascular risk factors such as BP e. C. G, um people with hypothyroidism are increased risk as well um for us a, um and then you need to know that it's the apnea hypopnea index um and you need at least 15 episodes um within an hour um So they take you into sort of a sleep center and monitor your sleep or you can have five episodes within an hour or, and you have symptoms or co morbidities and the management's often cpap, but weight loss and bariatrics or bariatric bariatric surgery and avoiding sedatives can be really helpful, so we're nearly done what have we got here, so we've got a cough. Um 65 year old man presents with gradually progressive decision exertion and a non productive cough. No medications. He's a nonsmoker, know environmental exposures um to organic allergens, he has fine crackles over his lungs bilaterally. No extremity edema elevation, no elevations in JVP. No findings of volume overload, and he has clubbing of his fingers okay, so we've got pulmonary fibrosis so far any others okay, yeah, so hi o point number 10 i. P. F, so you just always think Ipf first um they love to go after it, um So it's going to show a restrictive picture on pulmonary function tests, so it could also be Ipf with. Like you know a c, copd type picture um someone who's been smoking um a long time in their life, but then they're put on uh steroids and um salbutamol um or copd treatment and then don't really improve and then when they're doing spirometry, which they should have done initially, um you can see a restrictive sort of picture. Um If they give you an ace level, If this is normal, then it's you're still on Ipf. Um If this is raised, then you you would shift to sarcoidosis and then it's important to know about prevented own um which is an anti fibrotic um for the treatment of Ipf, although it's not super effective, so that's the final um uh second to last point so moving on to pulmonary hypertension, so this is a quite a difficult um condition to get your head around slash understand slash it's not always obvious with the clinical vignette that it's pulmonary hypertension and so you'll learn there's like multiple subtypes of pulmonary hypertension even beyond like what I've put, which is primary and secondary um but just as important with primary to know that b m p r two is the most common gene affected. Um You probably won't even need to remember what that gene is, but just remember it's sort of a genetic cause. Um young middle aged female with shortness of breath, dry cough, and a murmur um and this is often try custard regurgitation on the left lower sternal border um and this happens because there's increased uh so, essentially this gene results in increased resistance in the pulmonary vascular chair, which leads to increased pressure and then increased back black backflow through the right side of the heart leading to tricuspid regurge um So it's really important so you might come across a patient who's had a collapse or they've come in short of breath um and you're not sure maybe you think maybe it's a piece maybe it's pommery hypertension. If they've got a murmur, you want to go for pulmonary hypertension overpay, um just because it's just it's something they love to ask about. Um secondary pommery hypertension, is usually due to preexisting lung disease and leads to eventual court pulmonale e, um and this condition is often treated with pd five inhibitors, um but they very rarely ask about the medications used to treat pulmonary hypertension. It will be more like you have a case and you need to determine you know what is causing this patient's collapse or what is causing this patient's shortness of breath um So if you've got that murmur that might point you in the right direction um. So that's the end of my talk apologies. If it's a bit basic or if I've completely put you to sleep at 7 45. I know you guys will be studying hard um but if you learn the points on this slide, you will absolutely get at least 10 marks um additional on the, on the sBA or do well in your muscles so that I've got the dates for additional sessions that we've got going on. Um Please let me know in the chat. If this conflict with anything, I think you have a muslim on wednesday um and then your SBA is on the friday with your risky as far as I understand, so we're hoping to do a quiz on the thursday night um Around 20 to 30 questions that should be um really useful um but please fill in the feedback form, and if you have any other questions, I know, there's some discussion's over ARB and ACE inhibitor um so that was really good of you guys to talk about that, but if there's any other questions or anything, please send them over, but otherwise have a good night you guys are you're getting there, you're you're you just got to keep powering on.