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Just add on, quick, quick shout out to Dr Lewis Potter, founder of uh geeky medics. Uh He's in the chat. Uh Just a quick way of say hi to him. Yes, cool. So welcome everyone. Very exciting. So today is a very exciting session because it's the first session in our Oscar series. Uh So if you guys are new to ask easy, um Oscar is, is a medical educational platform that we set up around two years ago where we wanted to create an initiative initially to support students with the Oscar teaching, especially during the pressures of the COVID 19 pandemic. And since then, we've really branched out to all these different subdivisions of medical education from finals teaching, preclinical uh prospective medical students, surgical teaching to. Now we're doing loads of different stuff with med tech dental stuff, Oscar, the media research. So we really uh grown a lot in the last two years and we're really proud of what we've achieved. But Rosky series is what we've been most proud of since the start. It's what we've built our platform on and we are really excited about this series in particular uh for a number of reasons. We've really tried to level up if you guys watched last year's series. A lot of the recordings are still available on metal. You guys can check them out this new series with new content, different format to last year and we'll go through it as I'll go through how we're approaching it uh as we go along. Uh So today's session is on the cardiology station. As, as strangers said, my name is Nish, one of the co founders of. Uh So this is the cardiology station part one and very exciting for this series is that we are proudly in collaboration with geeky Medics. Uh So as soon as you mentioned, Geeky Medics huge medical education platform who have supported students, medical students all over the country, all over the world, you know, with, especially with the Rosky teaching content. So we're very proud and privileged to be um part of it up for them and using a lot of their materials to deliver the teaching content. Uh So in terms of this year's series, in terms of formats, it's going to be slightly different to last year. So those of you tuned in last year, uh what we sort of did last year is trying to build the sort of foundational knowledge for our skis, you know, uh sort of assume people had zero level of knowledge and clinical knowledge and really trying to make sure people got the basics of how to approach a Noski in general, you know, from basics of history, taking understanding um investigation plans, formulating management plans. Uh We really try to hone in on those basic principles with this year's series, we're really going to try and build on our clinical reasoning skills and try and do it in the format of different types of cases that can come up. So different types of uh ski stations that can actually come up in your, in your Oscar examinations. Uh So really try and make it as relevant to your learning as we can. We'll still be coming back to all those principles and make sure that no one's missing out on any learning. If, if you didn't watch last year series will always be making sure everyone's knowledge is uh is we're learning in the right way from history taking two investigation plans to management plans, but it's going to be very case orientated and specific to the presenting complaints. So today is I'm going to be on history taking okay, generally different types of histories that can come up in cardiology. Remember, we got another cardiology session on Thursday which is gonna be on examinations going to be delivered by three as well. Uh So in that session, she'll be going through different types of examination cases that can come up in cardiology Oscar stations, you know, and particularly she'll go through how to present findings in a, in a systematic manner. So let's get into it. Um I hope it's gonna be super attractive as well. And I want you guys to be really, really interacted with me in the chat and just give me as much feedback and bounce back as you guys can on the chat. I want this to be like, I'm having a conversation with you guys. Um So we were talking about cardiology. Uh We're talking about history taking in cardiology. Uh So I want you guys to just in the chat, give me some symptoms relevant to cardiology that you think could come up in a Noski what kind of things, what are the common cardio cardiovascular symptoms that you could be asked to take a history about? Yes, we're getting a lot of chest pain. Absolutely. When you guys start learning medicine, when you guys start learning history, taking chest pain is the thing that you're going to start learning about is the basics of medicine, chest pain, shortness of breath, ankle swelling, good syncope, good syncope. We're not covering syncope today. It's because Syncope has a, it's quite a broad differential, quite, not just cardio cardiology for syncope. It's quite a lot of differentials which will hopefully cover in a different session. Palpitations. Another one goods. Yeah. So you guys are you guys are gonna, so we're going to cover different, made the sort of broad presenting complaints and that come up in cardiology station. So chest pain is always a big, a big one. Uh palpitations is another big one which will go through how to, how to approach palpitation history, taking, how to formulate investigation plans. And we're really gonna nail down those are different ccgs as well and how to approach ccgs in, in all skis and present them in a systematic manifold on skis as well. Shortness of breath. OK. Broad differential for shortness of breath. But we'll go through um general important differentials in the context of chest pain, generally, uh syncope as well. We're not going to go through today, but it's important for any important cardiovascular differential for syncope and ankle swelling. Okay. And we'll cover ankle swelling, bit more detail on Thursday session when we go through heart failure. Okay. Today, we're going to focus mainly on the history, taking aspects of cardiovascular conditions. So we're gonna go through our first station, okay? And hope you guys like uh logo using a geeky medics templates. So today's first station, the first nation we're going to go through is on chest pain. Um In the chat soon. General want to hopefully going to be posting QR codes. Uh Sorry, sorry, you are else too geeky medics Rosky station templates that we've created. Um So just be on the lookout for that on the chat. Um So first station we're gonna go through is chest pain. So we're going to go through a 65 year old man who has presented with chest pain and we've been asked to take a history from them. So if you guys were tuned in last year, a lot of you enjoyed this sort of aspect of our session where we go through a spot diagnosis. Uh If you're new to it, essentially, the idea is we want to really try and make improve your differential diagnosis and diagnostic reasoning. So we're going to show you a series of clinical vignettes and you guys are just going to come up with what you think the most likely diagnosis is based on the key features of each vignette. So let's go to the first one and you guys just tell me what you guys think about it. So you got a six year old woman who is presenting with the chest pain that develops when she walks up the stairs. The pain resolves when she takes her GTM spray and five minutes and five minutes after she rests her B M I is 32 we'll get, we'll go through all the uh we'll go through these conditions in detail and Deborah just for now. I just want to test you guys knowledge. And yeah, most of you guys think this is stable angina is which it is. So based on what we know from this, what I've told you most likely diagnosis is stable angina. Um So stable angina, you guys know it's chest pain on exertion, okay, cardiac ischemic type, chest pain on exertion. So we got a woman chest pain on exertion. But key thing with, with that defines stable angina is that it's, it is highly responsive to G T N spray. Okay. The actual pain is very responsive to GTM spray and, and resting as well. Okay. And high B M I is obviously it's suggestive of her being at potentially having a metabolic syndrome but having a high cardiovascular risk. Okay. Cool. Let's go to the next one. 65 year old woman presents with pleuritic chest pain that improves when she sits up. The pain is sharp, doesn't last long recently had an upper respiratory tract infection and she still has a fever. Uh There are E C G changes. What do you think pericarditis um be be very specific when you, when you, when you, when you describe the condition, is this just pericarditis? Yes, acute pericarditis. Okay. Remember especially with pericarditis because there's loads of different types of pericarditis. You know, acute chronic constructive fibrinous, okay, be very specific when you describe a condition. Um So yeah, this is acute pericarditis. Okay. I I always I I've been lazy and having described here but you should call this acute pericarditis. Um So why is this pericarditis? What is the things you guys think that makes this pericarditis? Yep, pleuritic chest pain recent. In fact, infection history, okay, sharp pain, cute history better when sitting up good. Okay. So classically a paragard to die to Spain and the history they'll say that pain is improving when they lean forward. Ok. So when they're sitting up typically and the fever as well is very suggestive as well. Uh E C G changes, what do you, what do you guys think about the E C G changes? Yeah. So uh if you guys have ever seen E C G changes for acute pericarditis, uh typical things we see are the pr depression which you guys are talking about and the ST elevation, but it's global ST elevation, Okay. We'll talk about ST elevation in a bit but the pericarditis we typically we see we see global ST elevation changes. So it's not limited to any continuous, any particular coronary artery vessel territory, okay. Um So it's in multiple different leads and it's classically described as a saddle shaped ST segment. Okay. Cool. Next one, we have a 50 year old woman who is presenting with again, pleuritic left side of chest pain, not able to take a full breath history of right sided mastectomy for breast cancer a year ago. She also has uh palpitations. Uh huh Pete Good. Okay. So this is very suggestive of pommery embolism, okay. So a clot in the lungs. Um So in terms of the key features in the history, we're thinking this is a middle aged woman, uh unilateral pleuritic chest pain, uh not able to take a full breath. Okay. So that's again part of the pleuritic chest pain. But the key thing is this, this past medical history she she has, okay. So uh, what, what is this relevance of this mastectomy for breast cancer? What is the relevance of that? What do you think? Yeah. Good. So, um, so it's, it's a, it's a pretty, it's a bit of a vague statement. Okay. But the key thing to try and pick up on is if she's had a recent, it's a recent surgery. Okay. So it's a recent chest breast surgery and it's malignancy. Okay. So, both, both contributing to a hypercoagulable state, okay, increased risk of clots. Um So that's the thing to pick up on. Okay with people. Marie embolism. There's really, the history taking is really important. Pulmonary embolism. You really need to pick up on things that are going to be contributing to clot forming. Ok. Things that contribute to a hypercoagulable state and we'll go through some of these key risk factors. Uh One of these risk factors is recent surgery, active malignancy, okay. And that, that, and that would mean that you have an actual cause for the patient developing a clot. Okay. It's called a provoked pulmonary embolism. What about the, what about the palpitations? Why does the patient, why would a patient with pommery embolism have palpitations? It's a bit trickier. Uh What's the, what's the classic E C G change pattern in, in um primary embolism? What's the most common E C G pattern? Tachycardia? Good. Okay. So the most common E C G pattern that you get with, with the primary embolism is tachycardia. Okay, sinus tachycardia. So that can contribute to palpitations. Okay. Don't, if you guys have done your reading, you'll read about other things like S one Q three T three um uh right bundle branch block in for your strain patterns and things. Okay. But the most common E C G pattern you'll get with pottery embolism is sinus tachycardia. Okay, cool. Uh We got two more scenarios and then we're going to go into the uh bit more detail of the case. Next one, we have 50 54 year old man, severe crushing, chest pain at rest, paying into the radiating to draw an arm past medical history of diabetes, high cholesterol, heavy smoker as well. It's pretty pretty bog standard case. Uh huh. Yeah. Yeah, I'm sure most of you will be able to recognize this. This is uh this number one condition that you guys should be very familiar with. Being able to recognize the key features off. Okay. So this is an acute Coronary syndrome, okay. Um So this is ischemic, classic description of ischemic cardiac chest pain, okay, central severe crushing in nature, it's at rest, ok. Not just on exertion, it's at rest, it's radiating a joint arm, okay, classic cardiac chest pain and she has many cardiovascular risk factors, okay, diabetes, high cholesterol, um smoking, okay. Cool. Last 1, 2023 year old man has a sharp aching pain that is aggravated by movements such as deep inspiration, coughing or sneezing has tenderness on the side of the sternum as well. I I should say this is sharp, aching, chest pain that is aggravated by movement. Yeah. Good. Okay. So this is a bit more uh benign cause of chest pain. Okay. So remember with chest pain, there's there's so many differentials, okay. And the key with the history taking is being able to tell which one is the dangerous cause of chest pain, which is the more uh which is the type of chest when you can discharge patient's with. Okay. And this is the type of chest pain you can discharge patient's with. Okay. So this is a much more benign cause of chest pain, okay. We have a young man sharp aching, chest pain, but it's related to movement, okay. It's, it's musculoskeletal chest pain, okay. It's caused by, it's aggravated by movement like inspiration, coughing, sneezing. And the tenderness is the main thing that gives that that tells you this is more muscular, skeletal related, okay. Um So that's costalcondritis. So in terms of let's go through the some important principles of approaching chest pain in general, okay, not just for our skis, but local practice in general. Um I'm sure most of you guys will be very confident on all these things, especially for chest pain. This is the kind of stuff you get taught very early on in medical school. So we'll go through this pretty quickly and just mention some of the key things you guys know for your history of presenting complaints. The classic way to do it is to do your Socrates history. Okay. So sites onset character radiation's any associating factor factors, any if the, what's what the timing of the symptoms was? Anything that makes the pain worse? Okay. So, exacerbating factors, anything that makes that makes it better. So, relieving factors and the severity of the chest pain. Okay. So can you rate the pain from 0 to 10? Zero was the worst pain in the world? 10 was zero was no pain at all. And 10 was 10 is the worst pain in the world. How would you rate the pain? Okay. I'm sure I'm very confident you guys are familiar with these type of questions. Um Other things to think about. Okay. So with history taking Os Keys, you don't have that much time. Okay? So you really need to be very, once you get that open your, once you get your open questions down and get that key information initially, you need really need to make sure you make as, as much use of your time as you can, as best use of your time as you can. So I really find that the system review is one of the most important aspects of your history taking. Okay, because um one you can, you can do this pretty quickly, okay? If you know what if you know what you're doing, if you know what's the relevant symptoms to ask about and you can make sure you're not missing any important red flag symptoms. Uh, like important things that will help with your differential diagnosis. Okay. So a chest pain, important symptoms to always ask about in your systems. Review dyspnea, okay, shortness of breath orthopnea. Okay. Breathless with lying flat. Okay. Think about heart failure. PND I get ok. Practices in October dyspnea. So do you wake up short of breath? Think about heart failure, again, important uh palpitations we'll talk about but again, important, relevant to any cardiovascular history. Uh cough, always think about it, okay if sort of respiratory infection history, uh and always ask about constitutional symptoms, any weight loss, any general malaise, uh any sweating, any fever, um always important to ask about and musculoskeletal pain as well. Okay. Other parts of the history is generally pretty standard stuff that I'm sure you guys are familiar with. Always do your ideas concerns expectations. Um And I don't recommend doing that pretty early in your history. Okay. Don't leave it to the end because it's quite, it's generally something that examiners will be looking for you to ask about. It's a, it's a pretty important thing to pick up on uh like patients' concerns what they, what their perspective is on the condition. Um It's important, it's important question to ask, to demonstrate empathy as well. Um So I would recommend trying not to, to leave this to the end in case you forget it. Ok, so try and get, make sure you ask about it. Other things past medical history, surgical history, asking about your general cardiovascular risk factors, risk factors for pulmonary embolism. We talked about surgery. Okay. Cancer, uh, recent long haul flights. Another important risk factor if they have any clotting disorders. Um, and yeah, medications, family history, social history. Pretty standard stuff for any history taking. Okay. So that's your, that's your chest pain history. Um, I know it's quite a busy slide. Okay. I've made it quite detailed just so that when you get the slides, uh you can just review these the stuff in your own time. Uh, just have a read of the rest of it. I hope that's useful and in terms of general red flags in chest pain, um, these are the big things I always think about with chest pain. Okay, if it's sudden onset, if it's more than 10 minutes not relieved by G T N if there's any shortness of breath. Um, all these other things, these are the things I think about that make me think. Okay. This isn't just like costochondritis, this is, this is something that you need to do investigations for you need to actually be worried about. Okay. Cool. So we talked about so this is just a table highlighting um chest pain characteristics, okay, in terms of your differential diagnosis, this is what I think, I think you should be thinking about Ok, think about is this more of an ischemic type chest pain? So, uh you know, your angina type chest pain, your A C S type chest pain where it's very central, it feels heavy. Um, it's worsened by activity. Okay. Exercise stress, but it's getting better with rest or with G T N sprays. It's radiation to the arms, the jaw. Okay. That's your cardiac ischemic type chest pain. Okay. If it's more respiratory in nature will cover respiratory differentials next week in our respiratory station. But you know your pleuritic type chest pain, uh then it's typically more unilateral, it's more focal in origin. Uh The pain is typically, is described as more sharp stabbing type chest pain at a pleuritic chest pain means it's worse with breathing, okay. So it's worsened by deep inspiration or coughing might get better by patient's taking more shallow breaths. You don't get radiation with pleuritic type chest pain. And yeah, so this is your classic, you know, pottery embolism, pneumonia type, chest pain. Okay. And your musculoskeletal chest pain is, is obviously when they don't have these sort of scary features when it's more related to movements, postural change. If it's more about tenderness. Okay. That's your musculoskeletal type chest pain. Okay. Okay. So this is another important rosky skill um that I think a lot of people tend to struggle with. Okay. It's how to summarize a history. Okay. This is something that you guys need to practice to get to get good at. Okay. So what I mean by summarizing the history is once you've done your, once you've taken your history from the patient, um, the examiner will then ask you will usually ask you to just um summarize what you found, okay, present back your findings from your history taking from the patient. And this is, this is quite a difficult skill, okay. You got to actually be, you've got to practice this to get really um slick at doing it in a succinct manner if that makes sense. So I'm going to go through how I would approach presenting a history. Okay. There, it's not a one size fits all approach. It's, it's very, it's very much about personal preference, but this is what I think this is what works for me and I think is a logical manner in how to present your history. Okay. So the key thing with presenting history is that you're not just repeating back what the patient said, okay, you're, you're synthesizing all the information the patient has told you and you're trying to um put that all together in a compact manner, okay? In a very summarized manner that makes sense to the examiner and you're giving all the key information um that will help that tell, that tells the examiner that you've picked up on all the key features, but it's not too long. Okay. So it's, it's an important skill to be able to do so in terms of how, how, how I would start, I would start with just the key breaking news. Okay. Always start with the patient details. Uh If you can mention the occupation, I think it's useful initially as well and just the breaking news of what the presenting complaint is. So after that, I've then dude, my history of presenting complaint. Um so this would be, we'll go through a sample history, but the history presenting complaint is for chest pain would be your sort of Socrates type um template that you've done. Okay. So you just go through your Socrates relevant negatives. Can you guys tell me, what do you think? I mean by relevant negatives, you guys tell me in the chat, what do you think? I mean by talk about any relevant negatives in when you're presenting a history, what would, what would that, what is that referring to? Uh Yeah, good. Okay. So, so there's two ways to ways to think about it. Okay. Relevant negatives. It could be about red flag symptoms, okay. Um So anything in the history, any red flag features in the history which the patient doesn't have? Okay. So for example, if I think about back pain, okay, red flag features to think about with back pain would be things like um uh saddle anesthesia, urinary, incontinence, bowel, incontinence, okay? Because that those would be red flag features for things like quarter Equina syndrome, right? And so that's one thing it's red flag features other things. It's it's symptoms which are not necessarily red flag features, but it's symptoms that helped rule out other differentials. Okay. So for example, for chest pain symptoms like fever or pleuritic type chest pain or trauma, for example, would make you maybe point you more away from cardiac type chest pain, okay, maybe put you more towards a respiratory type chest pain, right? So it's two ways. Okay. Relevant negative. It's either you can either talk about the red flag symptoms or the symptoms that help you rule out other different relevant differential diagnosis. Okay, cool. Uh Then you mentioned this this when I say relevant, okay, I really mean relevant, okay. Your past medical history, past social history, past surgical history, social history, drug history. It's not this isn't where you just repeat back everything the patient said, okay. It's about giving the stuff that's really relevant to the patient's presented complaints. Okay. Um and we'll go through what we'll go through a sample history and go to what could be relevant. Go through ice. Okay, quickly. I think it's always good to mention what the patient's ideas concerns our expectations are when you summarize and finally um give you a top differential. Okay. Just go for it. Give just tell the example of what you think your top differential diagnosis is and try and give a good explanation to why you think it is. And then once you're given your top differential, just give a couple of other differentials that you think you would like to rule out. Okay, usually try and give 2 to 3 relevant differentials. Okay. Um So if I let's go through a sample history, okay, and um try and put this into context of an actual patient that we might see in a Noski. So in terms of the first place of patient details, occupation, keep presenting complaints. Uh I could say something like today. I had the pleasure of speaking to Roy Kent, a six year old taxi driver who presented with central crushing chest pain. And then I go into my history of presenting complaint. So he's been experiencing recurrent episodes of chest discomfort, which he feels is most prominent at the center of his chest. These episodes began approximately two weeks ago and have become more frequent recently. Uh The they typically last 5 to 10 minutes long. He described the pain as heavy discomfort that doesn't move anywhere. The attacks are triggered by activities like running and cycling. Okay. So this is basically you're, you're, you're described, you're going through the Socrates, okay. So for chest pain, it's pretty easy to do this, okay. You can just basically go through it in a Socrates approach. Uh So that's you're presenting complaint relevant negatives. Okay. Again, this is personal approach, okay. You can talk about whatever you think is relevant, okay, but make sure it's relevant to chest pain. So I could say something like there is no history of fever, weight loss or trauma. Okay. So they help rule out relevant differentials to chest pain and then the next bit. So relevant past medical history. So he has cardiovascular risk factors. Okay. So I'm making it relevant to the patient's differential diagnosis. Okay. So he has cardiovascular risk factors with a long standing history of hypertension. He's a significant smoker of 30 pack years. He's had, his father has had cardiac surgery in his late sixties sixties and he's taking Ramipril has no known drug allergies. His main concern is he is worried he might have a heart attack soon. Okay. So briefly mention what the patient's concerns are and then in terms of my top differential, so I would, I could say something like my top differential is stable angina based on the characteristics of this chest pain on exertion and his cardiovascular risk factors. Okay. And then to finish off, just briefly mention other differentials that you would like to reluct okay, such as A C S probably embolism, pneumothorax because that's, that's, that's a my sort of approach to how I would summarize the history. Okay. Again, it's personal preference. But I think by doing it this way, it shows to the examiner that you've not just repeated back what the patient said, you really thought about what you're summarizing in and you picked up on what the key features of the history are. Okay? Cool. So let's talk about, let's go onto investigation planning. Okay. And this is uh, this again is something you need to properly practice and read up on how you, how you would do it. So, well, in terms of your skis, can you guys give me an approach to how you would classify your investigation plans to an examiner? How would you categorize your investigations for our skis? Yeah. Yeah. So there's a couple of people mention different things. Okay. The one I prefer to do is bedside blood imaging and special tests. Okay? I know I can see some of you mentioning the boxes method. Um I personally I'm not, I'm not a fan of that, but if you, if it works for you, that's, that's great. Ok. But personally I prefer the bedside blood's imaging and special tests. Okay. So this, this is the way we we are generally going to be teaching it in uh teaching sessions, okay? But if you prefer other methods, that's fine. Ok. Just uh I just feel this is a very simple way of doing it and it's may may if you, if you do it this way, you're hopefully not going to miss any important stuff. Okay. So let's go through it and I want you guys to give me as many relevant investigations as you can for each bit. Um So in terms of bedside investigations, can you guys give me some things that would be relevant to mention to the examiner? Right? Yep, E C G BP, uh cardio examination. Good. Okay. So a lot of people forget about this. Okay. For a history station, uh you should always mention that you would do an examination. Okay. And for an examination station, when the examiner ask you to give investigations, you should always mention that you would take a formal history from the patient. Okay. Good. So E C G cardio examination observations. Yeah, that's, that's, that's pretty good. That's pretty good stuff. Blood tests. Can you guys give me some blood test? You do and try and explain why you do them as well? Okay. Don't, don't just listen, give me blood tests, just give me a blood test and give me an explanation for why you're doing it as well. Yep. So we got a lot of proponents. Okay for thinking about my card infection goods. Um BNP is a good one to mention for heart failure. Yep. Um Yes, a lot of the troponin ts any other blood tests you think you could do full blood counts? Yeah. For anemia. Good tired function test for arrhythmias. A pretty valid thing to mention. Yeah, cool. Um So we'll go, we'll go through the blood test and how and justifying each of them as well in terms of imaging uh any relevant image imaging you think you would do. Um someone said echo. So echo echocardiogram I would say is more of a special test. But yeah, so chest X ray. Okay. Why would you do it? What what's the point of doing? A chest X ray is chest X ray going to help you diagnose acute coronary syndrome? No, it's, but it's to help me, it's to help you rule out other differentials. Okay. Like a lot of you mentioned pneumothorax, pneumonia, goods. And finally, in terms of special tests, any special tests, what are the special tests that you would mention to examiner? Yeah, echocardiogram. Good echo to is pretty valid thing to do. Not necessarily the most, the most important one I would say is probably a CT Angio is coronary angiogram, which a lot of you're mentioning. Okay, angiogram. Okay. So let's go, let's go through it and uh hopefully will make sense. So these are all the different investigations that you could mention. Okay, I'm not saying that that you need to mention every single one of them. Okay. I've just included it for your own learning. But if you mentioned all of these are relevant things to mention what for your investigation plans. Okay. So in terms of bedsides, okay, you guys mentioned the three main things for chest pain, okay. So basic observations, cardio respiratory examination, E C G okay. Those are three main things to mention. Okay. Um in terms of blood tests, so let's let's let's try and justify each of them. Okay? And I've included a whole section here explaining how to justify them for each one. Okay. Um I'm not going to go through it okay. I'm going to leave it there for your own learning. But this table basically is is for your own reference to help you justify each of these blood tests. Okay. Um Things like full blood count, okay. It might not seem relevant but it is useful. Okay. Things like anemia and infection are relevant to chest pain as well. Um Other things, cardiac enzymes, troponin is you guys all mentioned. Okay. But don't forget other things like lipid profile, very relevant to cardiovascular stations, clotting screen. Okay. If they're going to be on anti coagulation, if they need blood products, for example, if if they have a dissection very relevant to mention uh blood gas, okay. So either A B G or BBg, uh most patients will get venous blood gas, okay unless the hypoxic for chest pain. Um So relevant they looking at hypoxia lactate any acid based disturbance always uh don't forget glucose, okay. It's similar to lipid profile, your HBO and see your glucose. Think about diabetes, okay. And again, important cardiovascular risk factor, okay. And this is a big one, okay. A lot of people forget about this with chest pain. Okay. But this is a big thing, examiners will look out for okay if you think the diagnosis is an aortic dissection, okay. So a tear in the major blood vessel which is leading to the chest pain. Then you have to mention that you would also do a group and save cross match. Okay. So a group and save cross match, if you don't know, it's a blood test to essentially, um, do the blood typing. Okay, so much to figure out what blood type you are so that you can be transfused, the correct type of blood. Okay. Key thing is because if you have an aortic dissection, you're most likely going to be taken to theater, okay, to have major cardio thoracic surgery. Uh So you, you need to make sure you've done the group and save across much. Okay? Um So that's just an important one to not forget. Okay, specifically for aortic dissection, any, any surgical condition in all skis, always remember to do a group and save cross match. Okay. Just uh because that's a big thing, examiners will pick up on, okay. And potentially you could fail the station if you don't mention you do a group and say across much. Okay. You guys mentioned most of these other investigations like chest X ray ct angiograms, um, echocardiograms as well, all relevant investigations, okay. You guys can have a read of this table when you get the slides. All it's, these are all the all valid investigations that you can mention. Okay, let's go onto CCGS now and uh talk about how to approach ccgs in our skis. What do you, so I've got, I'm giving you an E C G here and I want you guys to tell me how you would approach it. So I've got, so we've got an E C G here. We've also got a blood test and they've got some patient details. So, examiners handed you the E C G sheets and has asked you to interpret and present the findings. Can you guys tell me what's the first, what, how, how, how do you, how are you going to start your presentation? What's the first step? Yeah. Good. I'm glad no one, no one. Most of you didn't jump to try to tell me what the E C G is showing what the diagnosis is. Okay. There's a reason I've taken the effort to include the patient details, name, age date. Okay. So the key thing with Oscar, he's in terms of data interpretation in our skis is always showed the examiner that you've confirmed the patient details and you are familiar with what type of data you are looking at. Okay. So before you even think about presenting the data, always mention what the data is at. Okay. And whose data you are presenting? Okay. So for this one, if I was going to present it to the examiner before, I even even think about the E C G, I would say uh this is an E C G. Uh Roy Kent, a six year old 60 year old male who presented with chest pain. Uh This E C G was taken on the seventh of March 2023 at three PM. Okay. Um So always, that's, that's your opening statement for any data. Okay. It's always to just tell the examiner what the data is. Okay? Once you've done that, then you can talk about the data. Okay. So in terms of this E C G, um what do you think is going on here? What is this E C G showing? Can anyone tell me what, what they think of the C C G? Yeah, so we got a couple of different um answers coming through. But uh let's go through it. So in terms of E C G s, okay, we'll go through. Uh we got, I got a bunch of Mori cgs to go through, but I'm not going to go through the basics of E C G interpretation. Okay? Just because we don't have time today, I'm going to assume you guys have some basic level of E C G interpretation knowledge. Um So in terms of how I would go about reviewing, reviewing an E C G, uh this is how I would go about it. Okay. So we've, we've started it started with the patient details. Okay. Uh Then I'd start with the rate. Okay. What do you think about the rates? Is it fast, slow normal? Yeah, it's normal. Ok. This is a normal normal rate. Ok. So in terms of how we calculate rates, uh the easiest way to do it I find is just count the number of squares between. Okay. So it's about 33 and a bit squares. Divide 300 over that. So it's about 85. Okay. So rates rates about 85. Um So that, that's normal. Okay. It's not tachycardic rhythm. Is it, is it, what do you guys think about the rhythm? Is it regular? Irregular, irregularly irregular? What, what is the rhythm? Yep. It's a regular rhythm. Okay. Um You can, you can eyeball it and pretty easily see that this is regular. Okay. There's equal spacing between each QRS complex. That's a regular rhythm. Okay. Kodak access is um, what do you think about the access? Okay. Well, hopefully we'll do an E C G session sometime soon and go through access, how to interpret access. But what do you guys think about those of you do know how to look at access? Is there any evidence of access deviation? No? Okay. So there's no, there's no access deviation. Okay. So it's positive the QRS complex. It's positive there's a positive deflection and leads one and two. So there's no access deviation. Okay. Uh P waves and QRS complex is, what do you think about each P wave QRS complex? Is, is uh there are other P waves normal. Are they pressed other other P waves present? Yeah, P waves are normal. Okay. So the P waves are present and normal. Okay. Some people said they were absent, okay. They're not absent. Okay. They are, there's not that much. Um It's not that evident. Okay. It's not a big P wave but they are, they're okay. And curious complexes in terms of how you describe it? Okay. The curious complexes, they are narrow. Okay. So these are narrow, curious complexes with normal amplitude. Okay. So I should, I should the answer that. But yeah, those are not narrow, narrow, curious complexes with normal amplitude uh ST segments and T waves. Are there any uh any big ST segment changes or T wave changes that we can see of? Is there any ST elevation depression? No? Okay. Some people might, some people might be looking at this and thinking that's ST elevation, that's not okay. This is just slightly higher. Take off for the T wave but that's not ST elevation. Okay. Um T there's no T wave inversion. Okay. So um T waves are only inverted in a V R which is normal. Okay. T wave inversion is normal in a V R but in the other lead in the T wave is not inverted in your anterior chest leads or in your lead to um in your rhythm strip? Okay. So that's normal T wave morphology and QT intervals. Okay. QT interval is, it's quite, it's quite hard. I find to think about Q T interval. Okay. Usually the easiest way is to just look at the top of the E C G and check if it's normal. Okay, to see if the QT interval is prolonged. Uh it's fine here. Okay. Um So in conclusion. What, what do you guys after we've broken down the STD like that? How would you describe the, what is the diagnosis for the C C G? Yeah. So this is normal sinus rhythm. Okay. But you can see that by going through it the way I did that. Okay? Just going through each bit and just breaking it down all the aspects of an E C G. Okay. It's, it's, it's not as hard as you guys think it is. Okay. E C G interpretation doesn't have to be that hard if you just focus on each bit and go through it systematically, don't let, don't try and don't get distracted by different features. Okay. So we have a normal sinus rhythm, okay. And the troponin is normal. Okay. So if you put this together with the patient, okay. So the patient who had central central chest pain has a normal E C G normal troponin levels. If you say the chest pain is cardiac in nature, uh What would you guys think is the diagnosis? Yeah, possibly an genotype chest pain. Okay. So that would, that would potentially be what we think about stable, stable angina is what we think about. Okay. That's probably what the station is trying to get you to think about. Okay in our skis, generally, all the data is going to be relevant to what the patient is presenting with. Okay. So try and put it in the context of what the patient's presenting with okay, if it's cardiac type chest pain, but with normal E C G changes normal troponin levels. Okay. That's telling you it's most likely a stable angina, okay, fine. And so finally, how would you manage his patience? So this is the probably probably one of the last questions you get asked in the station. Um So formulate and management plan um in terms of management plans and how you describe it in an office key. Um How would you, how would you classify? How would you um structure your answer to an examiner? Like a lot of you are just giving, giving me management steps. I gave you G T N spray reassure. But like what, how is that? Is that where you're going to tell the examiner? How would you structure your answer? Yeah. So there's a lot of people saying different, really good, different things. So conservative or lifestyle measures, medical options, surgical options, okay, acute definitive. There's, there's different ways you can do it. Okay. I think I uh structure I find useful is for acute conditions. Okay. So conditions that patient's are acutely presenting with symptoms where you need to do uh an initial stabilization. Uh And then after that stable legislation, you need to think of follow up care. I like to think of it as immediate management and then ongoing care. Okay. So this is for your acute type stations. So stations where you need, you need to do mention an 8 80 assessment, uh sepsis six. Okay. Those type of stations I would think about management, structuring my answer as immediate management and ongoing management. Okay. For chronic conditions. Okay. So if it's more of a ongoing condition, that is more long term for the patient, I would like, I tend to prefer to go for the more conservative medical and surgical management. Okay. Um That's just my personal preference of how I would structure my answer. Okay, because I think with your chronic conditions, you really need to make sure you're thinking very holistically about the patient's care. Okay. So let's go through it. So we're thinking about stable Angina now. So what what do you guys, what would be important stuff to mention for stable Angina? A lot of you mentioned stuff already. So life, lifestyle modifications, G T N spray goods, uh safety netting. Yeah. Any other important stuff, medical management education. Yeah, good. Okay. Uh So in terms of stable Angina management, okay. These are all stuff I think is worth mentioning. Okay, as in how I would go about structuring answer. So in terms of conservative steps, uh I don't, I always like to mention an M D T approach for chronic conditions. Okay, because it is an MD T approach for chronic conditions. Um Charity, I always like to mention charities. Any support groups, okay, like British Heart Foundation, uh any cardiovascular condition, uh these kind of stuff kind of stuff is always relevant. Okay. Stop smoking, reduce alcohol modified diet. Okay. Maybe suggest a Mediterranean diet, advice on driving exercise, okay, aerobic activity and try to get, try to normalize the B M I medical therapy. Okay. So I've got a slide on the next showing the nice guidelines for stable angina management. Um uh secondary prevention. Okay. So for ischemic chest pain, the most patient will be on these type of drugs. Okay. Aspirin inhibitors, statins, um control of hypertension and diabetes. Okay. These are all sort of your part of your package of care for cardiovascular ischemic type patient's okay. And your surgical management, uh we'll talk about it okay. But you know PCI and cabbage are your main surgical options. Okay. Okay. So in terms of stable angina and these are the nice guidelines. So a lot of you talk about your G T N spray. Okay. So every, every patient with stable angina will be given a G T N spring and because the angina type pain is going to respond very well to G T N spray. How many when when should a patient with, with angina pain? Um call call emergency services. This might, this is a type of, this might be an examiner question. Can you tell me if, when should they call emergency services if the pain is not responding to a G T N spray? This is a, this is think about patient perspective kind of thing. Yeah. Good, good knowledge. So 55 minutes after their second dose. Okay. So if someone's angina pain, if they've taken one dose, okay. And it's not responding, they should wait another five minutes and then take a second dose. Okay. If, after the second dose, okay, after five minutes, if the pain still hasn't gone away, that's when they should call 999. Okay. So you, you, you counsel patient on that. Okay. When you prescribed DTN other things, um patient will be given either beta blocker or a non diary period in calcium channel blocker. Okay. Remember you don't give die hydro piperidine calcium channel blockers like Nifedipine, amLODIPine um with the beta blocker, okay because that's going to cause a V nodes suppression. Okay. So um one of the other, okay. So either bisoprolol or over a camel. If they are not responding, then you can combine them. Okay. But you can you combine beta blockers where they dihydrocodein calcium channel blocker. Okay. So something about Nifedipine, amLODIPine. And then after that, that's when you start thinking about other stuff, like either more medications or you think about revascularization therapy with things like PCI cabbage. Okay. Okay. So that was our first chest pain station that took a bit longer than I thought I would. But let's go into our next chest pain station. So this is uh more of a emergency type uh station, okay. More of an acute station. Um So let's go through it. So we've given some data again, um And I want you guys to go through the same approach to this data and tell me what you guys think. So again, first step, before, before, when you present, you always talk about patient details. Okay. So what, what is, what is this data here representing? What is this data here? What is this piece of data I've displayed to you? Yeah, it's a news chart, okay. Um So it's specifically it's a news to chart, but this is the digital version of it. So in terms of how first step, okay, always it's always the same for any type of data. Okay. The first step to presenting, go through the patient whose data it is okay. So this is a news chart for Ted Lasso, a 52 year old male. This news chart was done on the seventh of March 2023 at 10 AM. Okay? And then you can go through each bit. Okay. So what would you guys think about this patient's news? Um What's your interpretation of it? Yep. So patient's got a new score of three. Okay. So there's, there's not, not nothing too exciting going on here, okay. But the key thing with our skis is that it's not about picking up on there. They're not going to show you necessarily the most exciting data, but they want to show they want to see how you're going to approach going through the data. Okay. That's more on skis is all about your approach to things. Okay. It's not necessarily about getting the final diagnosis or getting the most perfect management plan. Okay. It's, or most perfect investigations. It's about showing that your approach is in the right, in a logical manner. Okay. And generally it's to just show that you're competent, okay. And that you're being safe in what you're doing. Okay. So, in terms of news chart and presenting it, okay, you can just go through each bit. So I can tell the examiner if it isn't normal, is it high? Okay. It might seem pretty simple. Okay. But it's just demonstrating um how to present your data. Okay. So in terms of this data, you can say the respiratory rate is high at 21 to 24 BPM, 21 24 breaths per minute. Uh The patient is has oxygen saturations of 96 9/96 percent on air patient is um has a BP between 111 to 219 millimeter. For mercury, patient's pulse is uh is 91 210. Patient is currently alert and the patient is apyrexia. Okay. Um So in in your actual Oscar, you'll, you'll be given actual values for it. Okay. I've just shown this digital version of it just for space to make it easier to see. Um But yeah, just go through it systematically and just present what you see. Okay. So that's how it presented So and then at the end you can give your new score. So this patient has a new score of three due to um tachypnea and tachycardia. Okay, fine. I've got another day bit of data interpretation for you guys. Uh What do you guys think about the C C G? We're not going, we're not going to go through it this the exact same way as we did for the last one. Ok? Just for the sake of time, we're just going to go straight to the, to the diagnosis now. Um So yeah, what do you guys think about this E C G? And again, you can go through the same um approach. Um Yeah, and so good stuff. Um So a lot of you are giving me um your answers and yeah, some of the answers I can see most of you have told me this diagnosis, anterolateral stemi again, I like someone still mentioned the first step, okay. You still always don't forget this, okay. I'm not going to repeat it again just for the sake of time, but always start with a patient information. This is a 12 lead E C G for Ted Lasso. A 52 year old male E C G was taken at on the seventh of March 2023 at 10 AM. OK. And then go into your E C G. Um So yeah, this E C G is showing an actual contralateral ST elevation myocardial infarction. Okay. So, why? Um So if you guys know your um territories for E C G S, um this is a disagree simple E C G if you know your territories. Okay. Um So we can see clear ST elevation in particularly particular leads. Okay. We can see ST elevation in um your chest, your chest leads here. Okay. B two V three before um B five V six. Okay. So that if you guys know your territories that's going to be corresponding to your anterior territories and your lateral territories. Okay. So B 12 before your anti anterior territories, V five V 61 of your lateral territories. Okay. So it's an anterolateral stemi. Is there anything else that tells you that? The, what else? What, what one of the other features on this E C G apart from the ST elevation? Is there anything else on this E C G? So we, we see ST elevation in the anterior and lateral chest leads anything else? Uh There's, there's, there's no atrial flutter here. Um That's, yeah, it's not flutter. Yeah. Yeah. ST depression. Okay. So remember whenever you see ST elevation in a particular territory of coronary artery vessels, okay. So you see ST elevation in a particular anterior and lateral territories, always look, think about what if there's any reciprocal changes. Okay. So for uh for ST elevation, you would often expect there to be some X ST depression in some leads. Okay? And those and so for anterior and lateral ST elevation, you expect risk, reciprocal changes in the inferior leads. Okay. And that's shown here. Okay. So it leads to uh at least three and aVF okay. There's clearly ST depression, okay. So there's ST depression in the inferior leads. Okay. So these are all, if you put them all together, it's clearly an anterolateral stemi. Okay. Uh So don't just look at the ST elevation and then give the diagnosis, okay, even though you got the diagnosis, okay, the examiner will be even more impressed by you if you're able to comment on the fact that there's reciprocal changes in other leads as well. Cool. So we've, we've got an anterolateral ST elevation, myocardial infarction patient in front of you. And then the and the patient that is acutely unwell examiner's now asked you, how would you initially manage this patient? Okay. So someone has, I'm glad someone has said this, someone has told me PCI. Okay. And if you, if you, if you sit, tell that to the examiner, I think you might lose some marks. Okay? Because I've specifically told you asked you how would you initially manage the patient's okay? You're not gonna as a junior doctor or F one doctor in emergency department, you're not going to be the one doing PCI. Yeah. Good. Okay. So we're gonna, we're gonna drill this throughout the series. Okay? But the thing you, you always mentioned in your first sentence for any acutely unwell patient is you're doing a two year assessment? Okay, A B C D assessment. And is it, are you going to manage this patient on your own? What else should you mention in your opening statement? Yeah, call for help. So get a call it gets calling for senior help. Okay? I think uh you should always mention it. Okay. I always like to mention it initially. Uh realistically it's not gonna be you doing most of the most of the important steps that's gonna dramatically save the patient's life. Okay? Like PCI um it's you need to escalate the patient to a senior. Okay. So a lot of you saying consult cardiology, could talk to the registrar and call, okay, whatever you need to tell the examiner that you're seeking some kind of expert senior help. Okay. So we call call for senior help 80 assessment. Okay. So then in terms of our uh stemi management, acute emergency management, what what would we do? Bone ac um give fluids? Okay, let's go through it. Okay. So in terms of how I would give my answer for it. Okay, I would talk like I said, I would say I would do an 80 year approach would escalate to a senior. Okay. Um I think it's always useful to mention some other practical stuff that you can do in the meantime. Okay. Repeat observations, repeat the E C G just to check establish intravenous access. Okay? Because you're gonna be giving them, a lot of IV drugs, okay. It's, it's just showing to the examiner that you're thinking practically about the patient. Okay. So, established intravenous access with too wide bore cannula. Um And then you can talk about the specific kind of um interventions or treatments that you're going to be doing okay. Um So a lot of people for acute coronary syndrome, they talk about mona, I'm going to give you another pneumonic that I think is a bit better. Okay? Because when mona, a lot of people forget the anti platelet drugs that you need to do. So I'm going to get you's the Pneumonic drama to help you guys remember the the key sort of steps for emergency management of acute coronary syndrome. Uh So dramas A D for dual anti platelet therapy. Okay. So typically we're going to be giving loading those aspirin 300 mg and another anti plate look okay. Things like something like um clopidogrel uh any uh or you can just mention anti platelets according to the local hospital guidelines. If you're not sure specifically about what anti platelet you need to give re profusion therapy. Okay. So PCIO fibrinolysis, okay, we'll talk about the guidelines, okay. But this is obviously your sort of main revascularization therapy that patient's need to get. Um uh then in terms of a psa analgesia. Um so your ana was the main types of animals using you to give. So, morphine is something most patients will get okay. IV morphine and GTM spray. Okay. So if patient's have their GTM spray, you can ask them to take them, see if that works. If not, you can give give IV nitrates as well, maintain auction saturation. So, so and I specifically in the news, try I showed you that the patient was not hypoxic. Okay. So are you gonna give oxygen to this patient? Even though the patient saturations was normal? No. Okay. So they're good. So uh there's a reason that I I specifically made, I made sure to emphasize that the patient saturations were normal. So don't, don't just tell the exam that you're gonna give oxygen to the patient. Okay? Because that could be dangerous. Okay. You only giving oxygen to someone who's saturations are already very high is potentially dangerous. Okay. Oxygen therapy on it in itself can be toxic. Okay. So don't inappropriately prescribe oxygen to patients', okay. If they're hypoxic then fine. But if they're not hypoxic, don't be very cautious in prescribing oxygen. Okay. So maintain auction saturations and then your antithrombin therapy. Okay. And we'll go through the guidelines for antithrombin therapy as well. And then once you've mentioned all that immediate steps, then you can say you can or you order a Cory angiogram, echocardiogram and discuss with the cardiology registrar as well to see if they're suitable for PCI or uh private thrombolysis. Okay. Whatever if they, whatever their criteria is for the patient. So I've just included this slide for your own learning. Okay. I'm sure most of you are familiar with acute coronary syndromes. Okay. So, um if you guys know you've got your stable angina, unstable angina and STEMI stemi and I've made this table here to make sure you guys are familiar with the key differences. Okay. Remember it's been, it's mainly based on the, if there's E C G changes and if there's troponin changes, okay, if you have E C G changes, okay. If there's ST elevation and the troponin is increased, okay, that's a stemi if there's E C G changes uh but not ST elevation and the troponin is raised, that's an end stemi okay if there's normally CG changes, but the troponin is still is high, that's an that's unstable angina. Okay. Um And as we discussed in the first case, normal troponin normally see G but cardiac chest pain responsive to G T N that's stable Angina. Okay. Uh This is the management, this is a diagram I made last year for the cardiology session. Okay. I've used it again here. Okay. But this, these are the nice guidelines for the definitive management of uh acute coronary syndrome. Okay. Specifically a stemi, okay. I'm not going to go through this. Okay. But this is the sort of algorithm which you guys can hopefully uh follow nicely with this visual diagram. Um Yeah, but remember your criteria for PCI in stemi patient's if a patient presents within 12 hours off their chest pain and the PCR is available in two hours. That's when, that, that's, that's when they're suitable for PCI therapy. Okay. Specifically, they, it's not 12 hours of when they come into hospital, it's 12 hours of when the chest pain started and the PCI center needs to be available to reach within two hours. Okay. And this is the management of N stemi and unstable angina. Okay. I'm not, I'm not going to go through this just because it's there's quite a lot of stuff going on here. But for your own references about the nice guidelines you can ever read in your own time. Okay. I've got another news chart here and I want you guys to quickly tell me what, what is what's changed, what's abnormal. And so it's the same patient. Um What do you think about this new stuck? It's the same patient. Remember. Uh you can see the last news chart it was done at 10 AM. Uh This news chart is done at so this should say six PM. Okay. It's six PM. Patient has seriously deteriorated. Good. Okay. But what what is deteriorated? What do, what have you seen? Mhm. Yeah. Good. Very nice detailed answers going coming here. Okay. So the patient deteriorated, their respiratory rate has increased, okay. Um Their sacks have decreased to 92 93 on but they're still on air. Okay. Their BP has decreased. Okay. So they've now become hypertensive um they're still tachycardic, okay. They become more tachycardic, there's still alert and a pyrexic, okay. But you can, as you guys have rightly said, this patient has clinically deteriorated based on the based on these news chart findings. Okay. So uh the patient's news score is now 10 if, if that's right. Um So yeah, the patient has clearly become more unwell, okay. And some people are talking about cardiogenic shock and things okay. You can't, you don't necessarily know what's going on. But if you described the findings, okay, you've shown the examiner that you've recognized that the patient has changed, okay. They've deteriorated and you need to investigate what's gone wrong. Okay. So I'm going to show you another E C G. Okay. It's the same patient and you've done an E C G now and this is what the E C G has shown. What do you think about the C C G? Yeah. Good. Okay. So remember we were still talking about this patient who initially had an a anterior anterior lateral stemi. Okay. And so six hours later, they've now got this, this E C G. Okay. Um So yeah, a lot of you have got the right diagnosis, okay. So this is a ventricular tachycardia, okay. Um So again, when you describe it to the examiner, always start a lot of you are talking about, you should again, start with the patient details. Again, acknowledge that this is the same patient. Okay, acknowledge that acknowledge the timeline that this is the E C G taken six hours later of a patient who had a anterolateral stemi. Okay, because it's obviously very relevant, okay. They, they've developed a broad complex tachycardia on a background of having a stemi. Okay, very relevant thing to mention. So why is this a ventricular tachycardia? Okay. So it's a pretty characteristic pattern. Uh These are the main thing you to see here is these broad QRS complex is okay with and there's no P waves to see it's a regular rhythm still. Okay. So it's a regular broad complex tachycardia and and the car in the context of an acutely unwell patient with chest pain. Okay. This is a ventricular monomorphic ventricular tachycardia until proven otherwise. Okay. So a lot of people are talking, someone mentioned S V T um with wide complex is so something like S V T if they have a bundle branch block could potentially cause an E C G pattern similar to this. Okay. And that's a pretty benign cause of this E C G pattern. But the main thing to recognize is that this is an emergency, okay. It's an acutely unwell patient who has chest pain, who has a background of ST elevation myocardial infarction. Uh So this is a monomorphic ventricular tachycardia, okay. Uh Now the examiner has then asked you now, how did you initially manage this patient's? So this is, it's the same patient acutely unwell. Had a stemi diagnose this morning now is deteriorated uh to developing a monomorphic ventricular tachycardia. Still in the, let's say this is coronary care unit, whatever. So I showed, I showed you the news charge has told you that the patient still has a pulse and everything okay there, still stable there. As in then they're not, they don't need necessarily basic basically BLS or a CLS algorithm. Um Yeah, get help okay. So the, the, the, the, the, the things I want to talk about here is the sort of prac practical steps steps you're gonna do as a junior doctor pads on. Good. Get senior help. Good pay arrest. Call, good a to assessment. Good, good, good, good, good. Yeah. So let's, let's go through it. So again, it's an acutely it's an acute emergency. Okay. So you talk about your, again, always, it's a standard statement you're gonna say for emergency. Okay. A to approach escalate to a senior of human, ironically unstable. Um I think it's, you can mention that you can follow the tachycardia algorithm by recess Council. Okay. Uh Stay calm, reassured the patient, okay. For as they're going to be if they got this rhythm, okay. They could become perry arrest very quickly. Okay. So reassure, stay calm, established, intravenous access with the cannula, uh potentially give oxygen, give morphine if they're in pain, uh move to a crash room. Okay. So whatever setting they're in, okay, they need to be moved to a crash room because they need to be started on cardiac monitoring acutely and they might use a portable chest X ray done as well in the meantime. Okay. And you need to get their pads on, get senior help. And, yeah, so it's about showing these practical steps that you need to do. Um, but yeah, that's how I would approach an initial, what I would say I would do too for a dangerous arrhythmia. Okay. Okay. We haven't got that long left where I have got a two stations left. I think I'll only have time to cover one of them. Um So I want you guys to, let's do a quick poll. Do you guys want me? I'm only gonna do one of you guys want me to go through palpitations or do you want me to go through hypertension? Because uh I'll go by your best interests. Do you guys want to go more into E C G stuff or do you guys want to go more about hypertension? Okay. Let's, let's do, let's do palpitations. Okay. Is a pretty, pretty over overwhelming majority gone for palpitations. Okay. Let's go through palpitations. Okay. So we got 54 year old woman who presents with palpitations. Um So history taking for palpitations can be very um wishy washy. Okay. If someone's just saying I can feel my heartbeat, I can feel uh some sensation in my chest. Okay. It can be quite difficult history to take. Okay in terms of what you need to ask. So I found this nice pneumonic to try and remember the key features to ask in the history for palpitations. Okay. So then you're Monica is flutter. Okay. Think about atrial flutter if you want for um arrhythmias, but the new monarchy is flutter. So f or feeling okay. So what does the palpitations feel like when do they occur? Okay. Do they, does your heart pound fast or slow? Okay. Is it more of a tacky tacky arrhythmia or bradyarrhythmia? And do they feel regular, irregular? Okay. They, these kind of things are pretty unreliable from a patient? Okay. But it's just important to ask in a history, um, length of the palpitations. Okay. So then it's sort of part of your Socrates type stuff? Okay, onset timing. But how long do the palpitations last for? Are they triggered by anything? Do they go away at all? Has it been constant since they started, uh, have they had any loss of consciousness with the palpitations? Okay. Very, very important. Okay. So, has there been any syncope episodes, uh, timing? Um So in terms of timing, so how frequently are they having palpitations? How long is each palpitation episode for? Do they comment on a particular time, like after drinking coffee, like caffeine or anything or is it after exercise? Can you tap out the rhythm? Okay. Again, this is a pretty unreliable thing to do? Okay, but it's worth, it's worth asking the patient to just tap. Is it, um, fast? Okay. Is it like, or is it more irregular, like? Okay. Uh, it might help you but, you know, it's just the kind of thing you need to just do in your Rosky just to show the examiner that you're really trying to ask, ask focus questions about what's happening with the palpitations, exacerbating, relieving factors. You guys know? And are there any related symptoms? So it's pretty, it's, it's I think it's a nice pneumonic to remember for your palpitations history taking. So with palpitations, we're gonna talk about investigations, palpitations and then we're going to go through some E C G S. Uh what would be some important investigations? Again, we're going to go through our bedside blood imaging special tests and you guys give me some relevant investigations. There's one big big thing you always, of course you have to do what, what, what is the most important investigation? Palpitations. Yeah, E C G. Okay. You have, you have to mention you do an E C G, okay? But that's, that's a given cardiovascular exam. Good. Okay. So again for all histories mentioned, you do a cardiovascular exam, for all examinations mentioned you would take a history. Okay. So mentioned you do a cardiovascular cardio respiratory examination. Okay. So that's your bedside investigations. What what about your blood tests? Any particular blood tests that you think are relevant electrolytes? Yeah, so good. Um So a lot of you think about arrhythmias. So a lot of arrhythmias can be triggered by electrolyte disturbances. Uh potassium BNP good one. Okay. Thyroid. Very good that someone mentioned thyroid. Okay, let's go through, let's go through them and try and justify some of them. So again, for cardio cardio stations, observations, examination E C G pretty standard for any cardio station to mention for bedside investigations. Uh then your blood test. So I mentioned a lot of these blood tests here. Um Let's go through some of that. So can anyone tell me why you do a bone profile for palpitations? What's the, what's the reasoning behind doing a bone bone profile for an examination for, for a palpitation? What what are you gonna get in your bone profile that could explain someone's palpitations, uh anemia. So, anemia. So you do your full blood count to check for anemia. Um But yeah, good, good to mention uh calcium, good. Okay. So calcium disturbances hypo or hyper calcemia can cause E C G changes particularly Q T Long Qt syndrome. Um So yeah, that's your bone profile. Things like phosphate as well can also cause arrhythmias. Uh Can you tell me why, why you do a clotting screen? What is the reasoning behind doing a clotting screen for someone with palpitations, uh, stroke risk? Um So does, does your clotting screen tell you that um, risk of embolism? Yeah. So it's, it's generally it's your risk of bleeding, right? That's your thing. You wanna. So yeah, I see what you mean. So it's a risk of embolism, risk of bleeding, which could influence you at the stroke risk. Okay. When you think specifically about embolism, you think about there's loads of other parameters. Uh and that's part of your sort of charge vasco for things like atrial fibrillation. But yeah, you're on the right track, you know, thinking about the bleeding risk. If you need to start anticoagulation for things like atrial fibrillation, you need to get the clotting screen, you need to know what the iron are is good. Um Yes, so that's, so that's, that's some of that, that's the major things to think about. Okay. And I've included uh my reasoning for justifying each of these different investigations. Again, you can have a read, a read of these justifying statements in your own time. But yeah, just the key thing in your or skis uh for you should for any investigation you mentioned, okay, try and justify its okay. You don't necessarily need to justify every investigation. Okay. But for any investigation that might seem a bit quite specific, okay. Things like a bone profile, thyroid function tasks or BNP. Okay. I would always try and justify it okay, just to show to the examiner why I'm doing it and really try and highlight to the examiner that I've uh got that clinical reasoning and put it in the context of what the patient is presenting with. Um So yeah, I always try and give a good justifying reason for your investigations if you, if you can. Okay. Um, okay, I've got a couple of slides on the C and how to do an E C G which I think I'm not gonna go through just because I'm just because of time, let's just go through some E C G s. Okay. I forgot to animate as well. Okay. Um, so this is an E C G of super ventricular tachycardia. I'm sorry, I I forgot to animate the answer. Um Get a little uh for this E C G. Can anyone explain why this is likely a super ventricular tachycardia? If you just just eyeballing the E C G quickly? I'm sorry, I'm sorry. I didn't give you time to have a look at it but just eyeballing it. What do you guys think? Yeah, good. Okay. So if you just eyeball a CCD quickly, okay. You can see that this is a Superman S V T, super ventricular tachycardia. It's base. Basically it's the features of narrow, complex, narrow curious complexes, zec tachycardia. It's, it's not necessary. It's not, it's not a sinus tachycardia because there's no P waves. Okay. You can't really see P waves anywhere on the rhythm strip. Okay. So it's not a sinus tachycardia. Okay. So there's no P waves, uh narrow complex tachycardia. Um That's, that's a super particular tachycardia. Okay. It's still a regular rhythm. Okay. Uh Those are the key features Um but in terms of if you got that E C G okay, and you picked up that this was a super ventricular tachycardia. And you're asked, and the examiner then ask you, how would you manage this patient? What would you say? Uh if I, if I tell you this is again, the patient who's presented quite acutely with chest palpitations is quite sweaty. Um Observations are not perfectly normal. What else? What would, what would be opening statement? Yeah, 88 to 80 S S. Okay. Generally with your arrhythmias, arrhythmias, okay. Palpitations, arrhythmia station. I was always worth mentioning the the 80 assessment. Okay, even if it's not necessarily a peri arrest type rhythm, okay. It's always a to assessment is relevant to mention IV access blood's E C G. Good senior help adenosine valsalva. Yeah. Okay. Yeah, good. You guys have got most of the things, okay. So for your acute situations, you can divide it into immediate management and ongoing management. So I'd mentioned things like 80 assessment escalated sr follow the guidelines by Research Council and then you guys have mentioned vagal maneuvers, okay. So things like valsalva maneuver, uh carotid sinus massage, okay. And then your medical therapy if that's not working okay. I've got, I've got a nice flow chart to that explains management of SPT uh but adenosine is your go to um for most patient's okay. Remember it, they might, they, it will be very harsh in an Noski to give an asthmatic patient. But just if they mentioned that they have asked me in the past medical history, just be very careful when you say you would give adenosine okay, because that could potentially be very dangerous. Okay. So if they asthmatic give verapamil because the denizen will cause uh broncho constriction. Okay. And yeah, you can also just mention that you would assess for any adverse features. Okay if they have, if they have chest pain, if they're shocked, if there's any evidence of heart failure, because then they might need, you might need to put some pads on and do a synchronized cardioversion. Okay. And in terms of ongoing stuff, um so you can mention just for arrhythmias in general ongoing stuff you can mention is any, if they need ablation therapy. Okay. So if they have um scar tissue in the heart or any ischemic areas that are contributing it, that might be treated with ablation, okay? Or if they have electrolyte imbalances that could be corrected, that will resolve the arrhythmia. Okay. Uh This general stuff that are pertinent to management of a witness. Okay. Uh Someone, someone, someone asked a very good question when you're asked to manage acute patient's. Do you include investigations? So, yeah, if, if, if you haven't mentioned investigations already to your examiner. Okay. And then, and they've asked you to describe how you manage them. Okay. You should, you should mention the investigations you would do in your management blood. Okay. Um, so at some point in your Oscar Station, you need to mention what investigations you need to do. Okay? Whether, whether that's whether if the examiner ask you why investing what investigations you would do? Okay, mention it then. But if they just ask you, how would you manage this patient? Okay. You should still mention the investigations you would do. Okay, because our skis, it's a, it's a simulated environments. Okay. So it's, it's not, you need to try and make sure you're thinking about how you would approach things in real life. Okay. So you need to mention that you, the investigations you would do at some point. Yes, cool. So this is just the algorithm for S V T management. Okay. That's just the logical steps in which you do it. Ok. So start with bagel maneuvers. If they have any adverse features. It's cardio cardioversion. Okay. If they don't respond to bagel maneuvers, then go on to your identity mean um uh bladder. Um Yeah, that's your standard management of SPT. Okay. We could, I'm afraid I'm, we're going to have to call it there just because I, I need to get to somewhere. Uh, soon I've included there, there's another state station on hypertension which you guys can have a read about. Um, but we're not going to go through that. Uh Now, unfortunately,