Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hey guys, we're just gonna give it a couple of minutes for people to tune in. Hey, hi, everyone. So we just thought we'd give a quick introduction before we start. So we're a group of three final year medical students. I'm Emma and Yan and Brian are also here. And after setting our finals last year, we were really keen to come up with and online revision series with the aim of providing some useful and relevant content tailored to passing your outcome and final exams. So we'll be running these sessions roughly weekly or fortnightly and covering a different specialty. Each time it will adopt an SB sale approach and will be run by an experienced doctor. This time today is joining us who is also there to run through the questions and also answer any questions that you guys may have. So we hope you enjoy these sessions and keep a look out for the next one. We'll be posting on our social media, Instagram, Facebook, things like that and moving on to the format of these sessions. So we put in three rounds of questions starting off with easy, then moving on to me, then moving on to hard questions. So the best way to keep up to date with everything that we post is through our social media pages. We have Instagram, Facebook, things like that, et cetera. Cool. So, um yeah, we've got six questions for sort of difficulty and are sort of guide us um through these questions. Yeah, that makes sense. Um So just some general thing there it goes to load up um that are sort of social wants to follow that and keep updated. Um General housekeeping, please stay on mute. Uh Any questions that you guys have put it in the chat and, and one of us will respond to it um and just be respectful, I suppose. Yeah, cool. So I think this is a good time for us to give a the opportunity to introduce her yourself. Um Hi guys. Um I'm I am one of the um fy twos working in NHS Grampian. Uh I did a one year of um training in Ari and there was a cardiology rotation I quite enjoyed. So Brian Yan and Emma have been kind enough to invite me to go through some exam questions with you guys. So if everyone's happy, shall we start? So, I guess we're going into the first round which is easier questions. Um The first one should be on your screen. Um A 65 year old male with a history of hypertension and diabetes presents to clinic with newly diagnosed atrial fibrillation when deciding the patient's management GP adopts use of chad vas score. Uh The question is, what's the purpose of using the score in assessing patients with atrial fibrillation before starting anticoagulation therapy? I think a pool should come up on your screen. Um Is that right young? It should be come that well. So it, it the poles kind of block the screen but if you click, enter later, um you can, it moves it away and then you can click. OK? It looks like most people have answered so far. Uh If we can go to the next slide, the correct answer is d to evaluate the patient's risk of developing thrombo embolic events such as stroke. Um atrial fibrillation is when your atria are not contracting um in a regular fashion, it's quite an erratic sort of a heart rhythm which is quite a thromboembolic in nature, which means that you're more likely to develop um clots and this can increase the risk of stroke. So the chart vas score is nicely summarized on the left where it takes into account heart failure, BP, age past medical history um and gender. And that's sort of the scoring system we use to predict the risk of stroke before starting on anticoagulant therapy. It's quite a factor recall question. So yeah. Uh B is the right answer. 85%. Got it correct. So well done. OK. Hold on, Missus Johnson has presented to her GP with shortness of breath worse on exertion and at night requiring three pillows to sleep, she feels chest tightness and notices her ankles are more swollen, which baseline blood test will support the most likely diagnosis. Ok. Seems like most people have answered. Shall we reveal the answer? Y BNP is the right answer. It is a hormone that is released by the ventricular myocardium due to stretching and volume overload, which is why it's quite a good indication of heart failure. This was the likely diagnosis in this patient's case with the shortness of breath, which was exertional in nature. The orthopnea and the fluid overload indicated by ankle swelling, troponin levels can be quite useful for chest tightness to rule out an ACS. But the question was most likely diagnosis which was heart failure. Creatinine clearance is useful for kidney function indications to treat the heart failure because we would be using nephrotoxic like furosemide and things, but it's not really supportive of the diagnosis itself. And CRP is more of a marker of inflammation. Right. Next question. So we have a 53 year old African Caribbean male present for a follow up appointment with a high BP of 1 60/100 and two. He has no past medical history, which medication should be used to treat his hypertension. First line. I think we'll keep 30 seconds to answer each question. Ok. Shall we move on to the next slide? So, amLODIPine is the first line antihypertensive to use for this patient. It is quite a guideline based question which is summarized quite nicely on the table in on the left side. Um Given that this patient is Afro Carribbean descent, uh we automatically move to the right side of the pathway, uh which says the first line is a calcium channel blocker. Ramipril is an ace inhibitor. Um and indapamide and Candesartan are um not calcium channel blockers. They are alpha receptor blockers and potassium sparing antihypertensives. OK. Which of the following medications is most likely to cause hyponatremia and your time starts. Now, there we go. That's bendroflumethiazide. It is a thiazide like diuretic which acts on the sodium uh chloride channels on the distal convoluted tube of the Nephron. It prevents the reabsorption of sodium into the bloodstream, which is why it can cause hyponatremia. Ramipril is more, more likely to cause. Um It's a rare side effect of Ramipril, but it's um more common in bendroflumethiazide and bisoprolol. Um doesn't really have uh hypotonia as a side effect. Neither does amLODIPine. OK. Next question. A 63 year old presents with shortness of breath and chest pain. An echo was performed where her ejection fraction was 33%. She was immediately started on IV furosemide and her symptoms were improved past medical history is given, what is the next add-on medication to improve outcomes for this patient? Ok. Shall we review the answer please? The correct answer is Ramipril which most people, 50% got correct. Um The most common answer to that was Candesartan. Um I guess this is in keeping with the nice guidance for treatment of reduced ejection fraction and heart failure. The first line would be to either offer an ace inhibitor and um a beta blocker. But given the clinical scenario, we're more likely to start with Ramipril. Um As this patient has asthma and you'd be more cautious with that. Ok, an 82 year old is admitted to hospital after feeling faint, having palpitations and have experiencing syncope. The consultant has described a murmur as an ejection systolic best her in the right upper sternal border. What is the most likely diagnosis and your time starts? Ok. Um So the answer here is aortic valve stenosis. It is uh due to an ejection systolic murmur which is quite characteristic of aortic valve. Um stenosis, a mitral stenosis is more likely to be a rumbling middiastolic murmur with an opening snap. While mitral regurge is more of a pansystolic radiating to the left axilla. Aortic regurgitation is an early diastolic murmur which is best heard on expiration with the patient sitting forward. So it's a quite a factual recall question. You either know it or you don't. Ok. We're going to the medium difficulty questions just now. A 65 year old male with a history of coronary artery disease presents to ed with dizziness, weakness and a heart rate of 40. The BP is 90/60. And ECG shows sinus brady, which of the following interventions is first line treatment for a Perret rhythm characterized by bradycardia. Time starts now. OK. So IV atropine is the right answer for this rhythm. I can see the ne that's so most of you answered it correctly. So well done. The second most popular answer was actually a which is IV adenosine, that's more most likely to be used in supraventricular tachycardia kind of a situation rather than a Brady um arrest rhythm. We've got a nice summary of the flow chart by the A LS um group uh which summarizes the whole thing quite well. This patient had a background of myocardial ischemia and was showing symptoms of shock. So the first line would be atropine, they were not in cardiac arrest. So chest compressions would be a bit premature. Ok. 65 year old presents to ed with minor epistaxis. He has a past medical history of AF for which he takes Warfarin. And lab results show an inr of 7.2 which is the most appropriate management strategy for this patient. OK. Um So the correct answer would be to withhold Warfarin and administer 1 to 3 mg of IV Vitamin K I guess um the main thing would be to classify this patient's bleed into major or minor and it's a nose bleed. So I would think it would be a minor one. So as per the protocol give IV Vitamin K1 to 3 mg. A 55 year old male has had three days of sharp central chest pain that radiates to the back and is worse on lying flat. His observations are given he has normal heart sounds, his brachial pulses can be felt in both arms and are synchronous. There's a list of investigations given CRP is a bit raised and an ECG is shown below. What is the most likely diagnosis? I think that's most people answered. So shall move to the next slide. The correct answer is actually acute pericarditis. I can see why most people answered. Um A CS. The, the question is trying to test the concept of widespread ST elevation versus that in specific um, coronary artery territories. Um If we go back to the ECG, is that ok? Yeah. Can we move back? All right. Ok. Yeah. So if we have a look there, um, the SST elevation is in most of the leads and there are no reciprocal changes either. So we're more likely to think of acute pericard a acute pericarditis rather than ACS. Um I guess aortic dissection. Um The clue here was brachial pulses can be felt in both arms and are synchronous, which you wouldn't expect in aortic dissection making that less likely and M SK pain unlikely to have ECG changes either. So, yeah, that was a bit of a tricky one, a 50 year old, 58 year old male presents to A&E with chest pain and shortness of breath for the last two hours with a background of hypertension and AF an ECG was carried out which is confirmed a sty and the patient is suitable for PCI and has been started on aspirin which medication should also be given along with aspirin. Mm, so the next medication that should be given along with aspirin is clopidogrel. Um Usually patients in this situation need dual antiplatelet therapy And the guidelines have been summarized on the left where Rivaroxaban would be inappropriate. It's an anticoagulant and this patient is already on one. Risug would have been given had they not been on an anticoagulant already and agre or is usually if PCI is deemed inappropriate. So that's for more of a medical management side of things as per the guidance. So, clopidogrel is the correct answer. A 56 year old underwent a valve replacement surgery and was admitted to the ward for POSTOP on the seventh day. They developed myalgia and fatigue vitals are given below where the bit pyrexial, what investigation would support the most likely diagnosis. So given the stem recent valve surgery, um pyrexia, all those kind of things point to a more of an infective endocarditis which we want to rule out. So because the most common cause would be a bacteremia, um We want to do blood cultures to see what exactly is growing. An ECG would be useful. Um but not really point to the correct diagnosis, BP monitoring would need to be done anyway. But again, it's quite nonspecific as is a chest x-ray um with the lack of respiratory symptoms that won't be very helpful to diagnose infective endocarditis. Ok. Moving on. So a patient is presented to the GP surgery for a blood workup. Her reports were a bit abnormal and they've been summarized below. Her ECG is shown as well and her stats are given, what is the first line management for this patient? Ok. So IV calcium gluconate is the correct answer. This is in keeping with a hypokalemia as given by the results. I've forgotten the number actually on the stem but I know it's quite high and there are marked ECG changes. Oh, there we go. Thanks. 6.7. Yeah. And there's marked ECG changes as well. That indicates that the myocardium is in distress. So IV calcium gluconate is protective and should be administered in the first instance. Yes, we will also be giving IV insulin and dextrose cause that does lower potassium. But IV calcium in this situation is the most important. Yeah. Blood test can be repeated but yeah, not the first line. OK. So at this point, is there, does anyone have any questions or any? Yeah. Doubts at all. Yeah, maybe we'll just give people if anyone has any questions, put it in the chat, we'll give you guys like 30 seconds or so. Um And if not, we can just move on. Ok. So a 72 year old male presents to Ed with epigastric pain and nausea. His medical history includes af for which he's been taking digoxin for the past year. Patient is stable but a baseline ECG was done as below which of the following findings is most consistent with digoxin toxicity in this patient. So the correct answer was down sloping ST segment um or the reverse t sign some, some descriptions of it also refer to it as resembling Salvador Dali's mustache. So that's a fun fact. But this is the most common feature. A 62 year old male presents with a known abdominal aneurysm to ed with complaints of headache and blurred vision. Imaging studies reveal an aneurysm of those dimensions as per nice guidelines. What is the most appropriate management strategy? Yes. So we've got the answer down here as a two week referral to vascular surgery for E ri know this is more of a vascular based question, but um it's still, I guess useful to know. Um The guidance is sort of summarized on the left hand side here, a 62 year old male with sudden onset tearing chest pain which radiates to the back. He has a past medical history of hypertension and weak brachial and femoral pulses. His observations are given which investigation is most appropriate for this patient. So, so we've got here the answer as transesophageal echo. Now, I guess it's important to note that the gold standard for an aortic dissection diagnosis would be CT. So that's a key concept here which I'm glad most people have kind of recognized. I think this question is a bit cheeky really. It's trying to sort of bring home the idea that sometimes patients can be a bit too unstable to take to CT. In which case, even at E can be appropriate. But I just wanna stress that CT angio is um sorry CTA aorta. Uh CTA aorta is the gold standard. Um A chest X ray is useful um in the sense you can check for a widened mediastinum. Um And an ECG, I think you would do that anyway, with this kind of a picture. But yeah, they're both not very diagnostic of an aortic dissection. A 59 year old man presents with central chest pain which radiates into his left arm on examination. He is clammy and his SATS are given the fy one performs an ECG to rule out an M given this clinical picture which coronary artery is most likely to be occluded. OK. Sorry guys, I think there was a, a problem, there was supposed to be an ECG on this um this slide. Um But if for some reason, sorry about that. Uh No, no, I think um yeah, I there wasn't gonna be an ECG. Um I think this was a harder sort of question. I'll explain at the end why there's no reason. All right. Ok. Good. Yeah. So, um, the correct answer here is right coronary artery. I know a lot of people have put left anterior descending. I'll explain the reason why. Um, I think it's quite a common fact in past med and those kind of uh question banks where they want you to know that the right coronary artery supplies the AV node. And, um, in cases of right coronary artery occlusion, um, if your blood supply to the AV node is um reduced, then you can go into bradycardia, which is why his heart rate is 40. Um It's a bit of a harder question, but I think that was the concept we were trying to test here. Um The left anterior descending supplies the anterior septum and left ventricle. Um The left circumflex supplies the lateral wall of left ventricle and the right marginal is mostly supplying the a portion of the right ventricle. Um So yeah, right coronary artery supplies the AV node. And if there's any sort of stenosis or occlusion, you run the risk of bradycardia as a complication. I hope that makes sense. Ok. 78 year old being assessed by stroke. Team upon assessment, he's short of breath, tachypneic and chest X ray showed a straight left heart border with an ecg as below sodium mitral valve. Stenosis is the most likely diagnosis. So, mito stenosis is when the atrium is unable to, how do I mean it's unable to contract against? Um The impaired valve into the left ventricle. So the amount of blood entering the left ventricle um is reduced. This um increases causes an increase in left atrial pressure because it has to work much harder to pump that blood into the ventricle. Leading to hypertrophy as a compensatory mechanism that reflects as a left hard border, straightening on a chest x-ray, this high pressure in the atrium um also causes backflow of blood into the pulmonary circulation, causing dysnea and fluid overload. So that's sort of the logic behind this question. There was an ECG showing af because when the Atria can go into spasm like that, you can go into af with mitral valve, stenosis. A 20 seven-year-old man was admitted to hospital after falling unconscious. An ECG was done which showed below and his vitals are given which of the following options is the most appropriate form of management. So y most of you got it right. Well done. Synchronized cardioversion. This patient is unstable um And showing signs of shock. Um As per the ALS algorithm, they need to be given a shock before any of the IV amiodarone or IV fluids or anything like that. Thanks so much guys. I hope that was clear. Is there any questions? Cool. Thank you so much Arya for, for running that session. It was, it was really good. Um Could I please ask everyone that attended to fill out the feedback form that we're about to um send out I think you guys should have got it. Now, it's under the feedback session in, in the chat. Um It's useful for us and useful for a so we can sort of build up our portfolios as well as improve these sessions for you guys. Um As well as you know, join us for more of the sessions that we're gonna run. So we're planning on running these sessions weekly, um and or biweekly running up to the finals. Um So again, thank you guys so much for joining. Thank you guys. Uh Thank you a for coming along. Um Yeah, any questions please put in the chart. Hm So our next session is respiratory. We've got a rest session next week, uh run by another F two down in leeds that will be running the session. So stick around for that scan the gear record to sort of follow us on social media and things like that to keep updated. Yeah, cool. Thank you, everyone. Thank you. Thanks everyone for coming. Sorry, I forgot to mention as well that um everyone gets everyone who fills out the f the feedback form gets a certificate as well. So please make sure to fill out the form and you get the slides as well. Cool. Thank you. Hey guys. So just to um talk a bit about um the session and whether it'll be recorded, so we, we will not be recording any of our sessions um But on completion of the feedback form. We can send you guys the slides with the correct answers on it. Hope not.