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Teo for 55 main points in a position exposure, which we already looked up. So we expose them from the waist up on feel cardiovascular. Same position them at a 45 degree angle, laying on the bed. So we dealt with position and exposure in the 1st 30 seconds to a minute of our station on. Then we have inspection. So generally, when your inspection at this level for an intermediate cardiovascular some there is a much inspection going on. Okay, on, then. Fine. And then we got power. Patient was going to lost our patient going on because you need to be able to for pulses, feel the chest feel in their neck, be able to do without, so that stays percussion. We don't do any of that. This isn't a respiratory exam, too, because the chest you're not gonna get, you know there's no pathology that you're gonna find from costing over the area where the heart is so that one drop off and then we've got auscultation. So always, we're gonna be listening over the heart valves and listening to the heart it's auscultation is they keep on. So your cardiovascular outcome really be split up into two sections. How patient on this quotation. Okay, so if we look up our patient first there are a few posters the weeds palpates or the radio calls All the pulse break a post and common carotid pulse on. There's also some chest palpations need to be able to do so. Eight me to palpate the apex beat. We palpate the heaves you to palpate for throat and a lot of people get hung up on what you've been through is on How do we exactly go about this? But hopefully through this let you know that whole mist will be dispelled radio calls. So it's probably for the radio pulse we need to palpate at the wrist between the distal end of the range is on the lateral to the lateral to the end of Lexicomp. You're a journalist muscle. So hopefully if everyone not not to do this last night. So if everyone can see, that's the radial are true right there on the on the radial radial bones runs right right behind it. So what you're gonna be feeling is trying to be feeling it on the boat. If you can't feel it. The first time when you're adjusting, try and go more laterally than medially. Because if you go more immediately, then you definitely be able to feel anything in what you'll be feeling. Um, or tendons? No, They said it's for the radio calls on their tooth key things they need to be able to assess at the radio policy to be able to assess the rhythm on the right. Okay. Most importantly, the rate. So what normal happened in your CK examine? Examine. I'll tell you. Please participate The radio artery on the radio pulse on calculate heart rate. Okay, so we need to reduce to find the always introduces. Tell you what the patient we're gonna do, find the radio post, feel it, and then calculate a rate for about 50 to 30 seconds. In terms of rhythm you're gonna be looking at with the regularity off the beat, you know, Is it regular, which is normal? Is it regularly irregular, or is it originally okay on readily really means that there is some sort of a reality, but it happens at a steady, steady rate. Okay, And that could be something like second degree heart block. If it's completely irregular, and there's no pattern to it at all that something like a tree for bridge. Okay, but again, these are just things. Things will come in later in your CK exam. You aren't really required to be able to find pathologies from your examination. It's all guided. So they will tell you what stage of the of the examination to do. And then you just performed examination. But they won't be expecting some sort of summary off. You know, I found this. So the patient's completely normal. Regular pulse there, but they will expect you toe tell them a wrecked heart rate. Okay, so this is always the number of beats in a minute, but you don't have a minute. Okay? So spare waste on on doing this because you only have five minutes and total for this examination. So what you'll be doing it is measuring it for you. The 15 to 30 seconds it's up to you. How long you want to do it? Okay, but don't forget to multiply. Okay? So if you're doing it for 15 seconds, don't get too much by by 4. 30 seconds is by two. And normally in your CPA exam, you only palpate the right arm. Okay? Because in your CPA exam in on, Expected to look for differences between the left and right arm, which is called radio radio today. So normally only palpate the right arm. Because if you think about it logistically, if you're you always approach the patient from there right side. So if you're gonna try and pop it there, left arm, you're gonna be leaning over the patients, and that's gonna be good for you. It's going to work with the patient. Is gonna be a little bit uncomfortable is Well, okay, so just stick to the right on now. What about character on volume? The road about character building before Can we talk about it? A music about the radial pulse. Come here. Says character in volume using the region pulse. Any ideas? Any ideas in the chart? Anyone was shot are? Yep. So I got here no use quarter pulse. And I was exactly what know exactly the right ones. You're the pro propose is that you feel you cannot comment on their character body. Okay, So the radio post on the pole, she kind of comment on character. You can use the break a pulse, but I would highly unlikely are no one would really recommend that. What we will be prefer you to use is the cross A pulse? If we look at the common carotid pulse gets here, my diagram there, um, power for you. It's palpated in the neck. Medial to the sternal. Great. A master of muscle. So you can see here on the model. There's the stone. Quite a mastery. So where you would be placing your fingers is in the middle here on whenever you're feeling for a post. Always use your what I use normally use is your, um your index finger on your middle finger, okay. And sometimes the ring finger as well to feel but in in somebody's neck and might be uncomfortable to use all three special. You've got quite large hands. So normally, use those two things to feel for the pulse. Okay on. Obviously, when you're feeling for the post, make sure this patient is facing head on. So not like this. Okay, because if you try to feel for their common carotid pulse here, you wouldn't be able to feel that. Okay, because the basic the stone quite mastered muscle is covering it over, and you won't be able to feel the post. Our nature of the artery okay, it does is it's partial, some sort of partial creation going on there, and he we can come and comment on correct correction volume, but a year to level. And for the CPA exam, it is only required that you understand what character for him isn't where you can comment on it. But you aren't expected to be able to do that, okay? And you there is very unlikely that we are there were asking about pre continuing to the other palpable pulses. So we go the only pulse, okay, which is if we go back to this diagram is right here. It is basically palpable on the medial side of the arm for looking at this from the anatomical position on. It's exactly the same as the radio pox again. Use your two fingers and make sure you don't use your thumb to measure any pulse because your thumb has a pulse of its own. So what you probably be feeling is your pulse on the patients post together. Okay. Which is not gonna give you an accurate representation of what the patient's pulse is now. In addition, there's also the break. Your pulse. Okay, All the brachial artery pulse. And you can feel that in two areas you can feel it in the cubital fossa, which is around here, medial to the head or just to the tendon off by such a break, I can see the biceps break there. It does come over it, but it's an open your sister's Know that thicken that strong? Um, you could see the biceps bake break or a tendon there. And the owner of the break your artery is media to it. Okay, so what you can often do is get the patient to flex their flex their voices. Okay, so you can feel the tendon often times you can feel the tendon without any flex inflection on you just feel medial to it of it and again using two fingers or three fingers to feel in that area. Okay, And normally the best method to feel for a post is to get the pay. The patients aren't to be completely extended, so don't try and feel for the pulse when the patient's arm is bent. Okay, it's gonna be you're gonna feel it much weaker than if their patients almost completely extent. And they said if the patient's elbows extended like my now you can also feel for it in the medial side of the tent so you can see here buys break it, comes across and break your arteries Just medial toe underneath it. Okay, So if you can feel for the your biceps break I and you feel medial on underneath, know inferior to it. You'll be able to also feel the the artery and noted the break your pox and normally you try and feel that around halfway off the off. Okay, all more down in this bottom one third of the okay, onda. Often times it is be easier to feel it in the medial side in the cubital fossa. But to be honest, it's your choice. Okay, then. I don't need the going to specify which site you have to measure it in. And I'm very unlike it's very unlikely that we're gonna ask you to palpate the break your clothes. There is one of the less important once and the more important ones are your radio on your comma crowded and again he's just summary of all the areas you can pop it courses. You've got Rachel over here. Owner on the other. Other media cite you got the break of post, uh, in both areas on exhilarated. There again, you know, gonna be feeling, for example. No, I don't think we need to be able to copy. Is the apex beat? Okay, the apex be is just post station on the beets created by the apex of your left ventricle hitting against the anterior chest wall. It's just a vibration that's passed along from the apex of your heart towards the anterior chest wall. It is very normal, that feeling on a patient, and it's also very normal to not feel it on the patient, depending on the patient. And sometimes if the patient is thin enough, you can actually see it. Okay, Which makes it very much. Makes it much easier to find a pop later on. The normal area that we palpate this in is the fifth intercostal space at the midclavicular line. And we're gonna talk about how do you get to the fifth Intercostal spaces? And it could become a little bit later on. We're looking at the surface and actually but normally whenever the my top tip whenever palpating the apex peak is normally use your entire hand if you've got small to medium hands like I am on your trying to place them in between the ribs. Okay, on the left side of the patient in the exhilarate region and you started exit a region and working award. You work your way immediately towards the middle clinical line. Just make sure that you know if the apex is displaced and make sure that you will definitely feel or definitely feel where that where it should be. Okay. And you can get this place for many reasons. For example, uh, left ventricular hypertrophy will displace it to the left, but it's ah, sometimes it is displaced. Elected anyone Okay, so it could be normal. Could be a So now he keeps is another thing meter properly and he's our basic just out of the abnormal character of a beat. So basically, there's some sort of hypertrophy or the heart is using. There's too much force being created on. It's hitting too much against the chest wall. You can actually feels so you do. This is you get your hand and you place it vertically like wandering. So here, hopefully ever conceive. Let me know if you can't adjacent to the stone, which is the middle in the midline it on. Did you place on the left? You try on the left. Any place on the rights on a positive sign is where you when you place your hands, you'll feel the heel of your hand left with each heartbeat, so you'll feel the heel of your hand. Just lift off you have your fingers will still be in place, But you'll feel, um, he'll lift off. And the million reasons some sort of cardiomegaly Okay, which could be hypertrophy left or right. And again, if anyone has any questions, let me know in the chair or Sharma now for throws. A lot of people get confused about Those are okay. Thrills are literally just palpable murmurs. So there is some sort of valvular dysfunction occurring that's gotten so bad. Okay, that you can actually feel it. You can feel that there is turbulent blood flow going through the bowel, but they which shouldn't be happening. Thank you on the best way to the best area to use here is has been demonstrated on this diagram is basically this bottom of this most bottom area of your hands and also your first fill out these. Okay, those are the best areas to feel them. Your fingertips aren't the greatest because there there is pulsation happening in this. And then they are the most sensitive. But it's ah, it's a balance there. Okay. And you and the areas where you place your answer this time, instead of placing a vertical place a horizontal in the areas where you place your hand, you place them in the same areas you would you would use for scored a shin off the valves, but we're going to talk about those specific areas in a little bit now are Scottish. So we've finished all of our power patient sections on you know, your examining Your CPK could ask you any of those, um, to do any of those things that we just talked about, but it's very unlikely they're asking to you all of them because of just you've only got five minutes to cover this heavily. Should you please your hand on the chest? He's okay. So when you're placing your your hand on on the chest for heaves. It should be firm, but no pressing that. Okay, so So you keep your hand firm. But if you shouldn't be pressing down purposely on the chest on for throws again, it's a very light touch. Okay? No, you know, pressing on somebody chest and trying to gave it in or trying to feel feel trying to get to the heart itself. It should because, you know, he has it made. It depends on how bad it's been for the patient that he may be very easy to feel. Maybe very hard. Okay, but the more you the hard you pressed, unless you're gonna feel if it's a very light one or it's a very light through on again, the patient may have some sort of valvular issue about the dysfunction, but you may not feel a thrill. That's because the valvular dysfunction divide issue hasn't become so bad that you can feel it. There isn't enough turbulent blood flow that the there it creates vibrations that you can actually feel. Or so, in terms of our auscultation, we will. We need to use our steps script okay, and the auscultate a lot four valves. The base of those your your take your pulmonary valves, your said which are your semilunar bulbs and your atrial particular valves, which is your mitral on tricusp it. Try and stay away from bicuspid it because you can sometimes get be born with, like a by by cost it aortic valve. So my true is a better term than bike hospital. Okay, now, normally, when you're listening over, you should hear s one s two sounds. So s one. Sounds are created by your h aortic and your pulmonary valves. Sorry. Your mitral and tricuspid valves cruising and s to sound should be created by your aortic and pulmonary bulbs cruising. Okay, So if there is any bother, dysfunction will happen around now. Sometimes you can also get added heart sounds, which is your s three s four. But those are not caused by valvular issues, but all they're going to be second. Treat a vibration. So Barbara issues on the room or not cause s three s four socks, they can create issues such as, um, um, atrial thinning. Okay, Which will then? Or some sort of increased compliance of love of the Ventura, which will then creating estrogen. Okay. And so murmurs Any added heart starts. And sometimes we can also accentuate the monks. And when that means is basically make the moment allowed really well on the way we do this is we try and get the heart closer to our stethoscope or collision to the anterior chest wall, which is where we place in our stethoscope on. Basically, make it louder for us to hear. Okay, on sometimes the sound can Also, the vibration can also radiate to other police so they can go to other places. Okay? And we're gonna see that exactly right now. So I'm going to focus on four mean Barbara dysfunction. Because those are four main ones according to the Ampyra respect specifications you need to worry about. But before we do that, let's have a look at where we're gonna be oscal d So either in the chat or shouting. Now, where would you pay? Sure. So it's good to feel for the aortic? Well, at a yes. So So? So where is that located? So describe to me. If I couldn't see this diagram, where would I be placed myself? Any ideas from anyone? Second intercostal space to the right of the sternum. Yeah, perfect. Second is Course right. Sternal edge. Want about your pulmonary in red? So start with what? Rib space or intercostal space you're in Going? Doesn't matter if you're wrong. Showing up. I couldn't intercostal space left yet. Exactly. Perfect. Same coast leftism. And what about you? Try custody anyway. This both into hostels. Best the left of the stone. So no dragging. It's not the fourth into. Okay, so this started intruders forth intercourse space. But technically, should be the fifth intercostal space, so it should be a little bit low, But it doesn't really matter that some people say forth. Some people say fifth. Okay, but the one I would stick with this fifth intercostal space. And then finally your mitral, okay, is 15 to cost a space at the midclavicular. Okay, so it's a bit further away, and you can see what the spaces there are on the right page. And again, Same thing. It's so if you go through, run through the move quickly, you'll take a second knuckle space, right? Sternal border. A pulmonary left upper sternal border, second course space. And then you're trying to spit is your left fifth into a treatment course? Still space. The sternal edge on the left on mitral is midclavicular lined up on the fifth intercostal space. Now, what this diagram highlights really well is that these are not the locations or whether valves actually are okay. This is just the areas where we best here. There's where the areas where we where the aortic valve is the loudest, so we can hear if there's any developed, a dysfunctional. Okay, so these do not correlate to the actual areas where the box, All these. Just the areas where the create allowed to sound for those vials. Okay, so here's another quick diagram. So then we got aortic formally tricuspid mitral. Learn all of this on. Then. We need to talk about the diaphragm and the belt. So if your aortic palm it, there's There's two main way to think of your aorta component. Tricuspid. Use the diaphragm, and then, for the might treat, confuse the bell. Okay. The other way of thinking is used the diaphragm for all four valves on you and then use the belt for all four bottles and it's up to you. Which one you decide to go with a personal. If I was in this in exam, I would use the diaphragm for the top three and then the mitral for the last one. Because I don't want to be spending time. Okay? Especially if the Examiner's and expect me to find any pathologies. We will find any abnormalities going on, but I just want to see my technique of the superior. So now that we've gone a quick one through off the cardiac of an intermediate cardiovascular exam for the CPK, now we'll go some surface and at me in key anatomical landmarks, which they could be asked about a very, very important when covering the call you back. So first thing we'll look at is the sternal angle on the intercostal spaces. When we were palpated to the apex beat, we said it should be the fifth intercostal space. Okay, in the clinic line, how do we find the fifth intercostal space? The main method is to find the stone or angle first, so the stone or angle is a little protrusion. Okay. Between the manubrium on this body of the sternum at the menu, bridgestone or joint okay, on, you can feel it on yourself right now. Okay, On some people, it's it's a bit more difficult on others. It's it's easier. So getting practice of feeling for these is very, very important. And then once you finally found that you know your level off the second. Okay, Now that you know, you're in the level of the second group, the area underneath it is the second intercostal space. So now you can start counting down the rips to find the fifth intercostal space. Okay. And in your CPA exam, they want they want to see you do this. They want to see you when you're trying to find your sites of auscultation. Wanted to see you do this. When you're trying to find the site of feeling for the apex beat, they want to see you try and find the stone or angle the second rib and then moved your weight down. Okay. Now, another method you could use is you could, because another method that you could use if it you find it very, very difficult to feel for the stone or angle is you can try and locate the second rib when you say on the way to do This is because the second rib is the first palpable rib. Yeah, okay. You're never on on a normal person gonna be able on any person gonna be able to palpate the first room because you as you can see that it sits underneath the clock. Okay, So unless you want to, um, you you go out the way and stuff you're never gonna feel for the first trip where you are going to feel is the second and then is the first palpable regular food. So you can you can orient it yourself that way by feeling for the second rib, and then you can work your way down to the third rib. 4th, 5th rib. And now you know your fifth intercostal space down here. Okay. Over that all makes sense to run. Let me know if it was confused on anything, or if there's any questions, keep them coming in. And then this is the way you can find the areas for your auscultation sites and your expenses. It's okay. Carry on the artery, the aortic arch. So the aortic arch is very, very important, and it is a little bit of a requirement to understand and to know the surface marking off where the aortic start arch starts and ends. And thankfully, it is very, very simple. Aortic arch starts at the stone or angle on ends on the stone. Where because because you can see here, it's hardship. So it starts at this second intercostal spaces sternal angle, and it ends. There is well giving or three main branches of the break It chronic artery, the left common crossed artery on the left break. Urology really get so and again whenever you're doing the surface markings are surface it out to me and your CPA exam. You do not need to draw them on to a paper you don't need to draw. Start drawing them on two people of your patients. Okay? These were going to be answers that you provide verbally. So there's no there's not gonna be any drawing like you've had in your clinical school sessions or any other sections. Okay, You're not gonna be with taking out a marker pen and start jury. Okay, now, another thing that is very, very important to you know how to service month is the borders of the heart. Really, it is hot it in My opinion is very unlikely that it comes up, but that there is still a possibility. Okay? And it is a little bit because there are lots of different borders one star on to remember. So you have the upper border, which is from the third cost of cartilage. One sentence from the sternal border to the second intercostal space. We have the right border here, which is a six cost a cartridge. One sentence from the sternal border to the third intercostal space. We have the lower board, which is the fifth intercostal cartilage. Because the spacer to the apex beat at the Midclavicular line or to the sixth costal cartilage. One said switch from the sternal boat. Okay, those are the two. Those are two options. I'm fine with the left ball. Do it for the second intercostal space to the fifth intercostal space to the apex. Be two of them, including and those Either four borders are the heart. Now there there are two possibilities of the asking them. They could ask you for two of the borders or just one of the borders. Or they could ask you for a while. Four borders of the heart Okay, so it's very importantly, either your, um the best way I recommend is get him into a flash card and just practice practice parts. So now that we've completed are surface and at me for cardiovascular system. As you can see, it's very limited. Now we're gonna get onto the more interesting things of murmurs. And then finally talking about the CDs ago, which is probably more than more than likely to come up. So terms of understanding murmurs murmurs occurred G two abnormal blood flow across the valve. They there is some sort of turbulent blood flow occurring across the valve. Okay, do to some sort of some reasons that we're gonna explore right now on that is the sound your hearing? So your hearing is blood flowing in the wrong direction or either flowing in the wrong direction or flowing through a very small and tight. Okay, because there are two main perfect follows use of fouls. There's either, um, stenosis, stenotic valves or regurgitating powers. Okay. And there are many, many reasons these good, huh? So this could be a structural reason. So if the ventricular war, if the bench for starts thinning, um, the but very muscles that are connected to you. The leaflets will start moving away from each other. So therefore, you just pulled the way the other muscles that keep them that help keep them closed and help them open. So now they're just going to open all the time and you're gonna lead to some sort of regurgitation occurring. Okay. In addition, it could be congenital. So as we said before in your aortic valve, sometimes people are born with a two with to leaflets. Fairer. There was a lot of instead of three leaflets. Okay on that, with time will cause some sort of aortic regurgitation on it could be infection. Okay. Ineffective endocarditis loves to sit around the valves and cause some sort of stenosis on. That's without even starting to think about the MBA. Like that's infected. Endocarditis can start. Very okay. But these religious reasons of four moments. Okay, there are many, many more out there, and it's just full main categories, But again, it's just to give you some background. So what we're going to talk about? We're gonna talk about aortic moments. I'm going to go and talk about mitral notes. So if you start with aortic numbers, The aortic murmurs and your mitral moments are the most common ones to come. Okay, so if we talk about this in terms of figures, mitral regurgitation is the most common valve dysfunction, followed by a or decrease go station and then followed by a what extent? Okay, also, it doesn't have to be very severe to cause issues for the patient, So a patient could sit there with some sort of tricusp it pulmonary rehabilitation or stenosis on Be perfectly normal. Go about their day to day life very, very normal. And then all over the time, these are found on echocardiograms. Incidentally, have your aortic and mitral valve dysfunction are a lot more city, and they Well, they don't have to be as the valve dysfunction has to be a severe to course, symptoms for the patient, okay. And cause issues for the patient is why we're fixing on these mean for today. So pretty good able to extend isis aortic stenosis is normally referred. You referred to as an ejection systolic murmur. What that means is it's a murmur that occurs during sister introduce system on. We know this because we know that s to sound is created by the aortic valve closing and the India on the pole. Me about crazy. And if the OT about it isn't open to start with, that's going to create problems for the bench court to try and force that blood through a valve that doesn't worry when I open is not letting the blood three, but they. That's why it's called an injection story on Normally, these a lot extensive radiates to the cross doctors, and it is the only murmur that will radiate to the courts, Doctor. Okay, so if you listen over somebody who has a what extent saying Listen over there carotid artery in their neck. Okay, if you hear some sorts of washing some okay, also for the murmur instantly start thinking it was extensive or if anyone mentioned that there is a fabulous barbell. Its function that radiates their prices are instantly think it'll take Celexa Now. All aortic murmurs are loudest on expiration. They allow mom is off, the left side of the heart allows just on expiration, and all murmurs on the right side of the heart are allowed just on inspiration. That is a rule. Okay, so how do we use this in our X Century Two news. So in our accentuated, anywhere we try and make it louder for us to hear better. Because I know often times you're doing this on a water and a ward can be very, very loud and very, very busy. Okay, you got the patient to lean forward and you couldn't take a deep breath in and then breathe ALS a way out, okay? And hold it. And that is the optimum time for you to listen for your aortic stenosis, okay? And that is when it will be the lapse. The reason why we get them to lean forward is because naturally you listen to for a trickster nose is at the top here. So if you get get this area closer to a certain group of close to the anterior chest wall, it will be a little make a creative, louder sound. You can do this even on a no absolutely normal person, and you listen to their listen over the aortic valve. You get them to sit forward and breathe all the way out. You will hear s one and s too much loud to the okay. Now they're able to pre good. It's an early diastolic action, because what happens in it was a real agitation. The valve doesn't close all the way, doesn't close properly away. And they're still on basic blood. Starts to leak back from the aorta. Okay, on the order of regurgitation has no radiating sounds on is again loudest. An expiration on decreased. Exactly the same accentuating. So if anyone describes a mama with their location or any of these things, they you should be able to identify what type of members or be able to tell them what type of bridges and what your viral dysfunction. Now your mitral valve. Okay, mitral stenosis is a low rumbling mid diastolic okay, with an opening snap. So that means this happens in the middle of diced. All okay, because what happens in diastole is that there is passing feeling off the bench, girls. But your mitral valve is meant to be all is meant to be open, but, um, I just notice it's not very, uh okay is much smaller surface area for the blood to get them on. That creates a low rumbling on the reason why it's low, rumbling or not, very loud rumbling is because a very passive process and I still that's when the heart is going to Richard, Relax, Asian face. In addition, Microcytosis radiates there left exhibit and obviously because that's where we normally so we looked normal is for mitral valve in the midaxillary line in the middle. Clinical Fine. So if you live over the left axilla, you may hear microcytosis loud as well on again. It's loudest on expiration now for mitral, um, to make mitral about mitral dysfunction Marshall about is louder. Have any accentuating uber it together patient to lean on their left. Okay, and breathe all the way out. Okay, Now, obviously, should, you know, logistically try and put your stethoscope there before they start leaning on the left because it can be very difficult for you to get in between the bed and the patient after that point because a lot of these patients are not very not the most mobile special awards. But in your CK, you're gonna be examining very normal people. So they should be incredibly mobile Now for mitral regurgitation. It's a pansystolic month. What pansystolic means and you hear this about you. If you hear this about different moments as well is it means it. You can hear it away through s one s two. Okay? And it radiates left to fix it again. And it's loudest on expert. And the reason why mitral regurgitation is all the way through your present s one. It doesn't close on an s two when the when the ventricle is contracting blood goes back into the wrong direction back into the atrial and cause the actual agent to start filling. And again, it's the same extent creating new, but as my trust in Texas. Okay, so what we're gonna look up next is interpreting a 12 lead easy. Okay, so when you're looking at calculating heart rate from any CT rhythm of a knee surgery Codec access PR into walls in ST said I'm gonna be trying to understand each other is looking at common pathology is that you might have come across in your to, um, in you two medicine and also in general. Why would the ventricle was get thinner books? So the walls, the ventricles could get in for multiple reasons. Okay. Many memories about them. One of the main reasons is that there is that initially, if after load has been increased on the heart, so the force, the heart the Levitra has to pump against, it gets bigger, the ventricle will start to hypertrophy and get sick or in the car and thicker. And that's up to a certain point they. If that continues, the ventricle will start to get thinner. Okay, now, often times patients don't reach that stage because we try and manage the MS best we can by lowering that they're normal BP with lots of BP medications. But if it continues on on the BP is massively high for a long period of time, the ventricle walking start to get thinner. Injectable thinning is very, very uncommon. It's more common to happen with the H, especially if you've got mitral regurgitation. The blood is fourth back into the atrium, causing the agents in a structurally on. Also regular wars thinning is more likely to happen in the right ventricle. They right ventricular heart failure and then eventually will eventual normal hyper trees and the right ventricle normally thins. And that's because just of how the myositis and the project, my sites are added to try and create a bigger force. Okay. Uh, what's your question? Yeah, Doors. So what causes the open some cereal? So the opening snack is trying to actually open the mitral valve. Okay, that's the mitral valve trying to open to the computer muscle contracting, trying to open about that. That's what's causing that opening stuff on this often happens in is turned midsystolic. But you can also hear it during during the stages of Sistol because it was so just before eswar. That's what my diastolic means. It's between. It's just before s one starts, and that's when the trees contracting on pushing blood into the into the through the bowel. Okay on. So if you can imagine lots of lots of pressure through a very tight area, eventually or the mitral valve will start to give way and actually open. And that's causing that. But they should look any more questions. All right, See, this time, Mr Fiance's. But there are rumors, lots and expression. No, they're not. Okay, so only your left sided. So your mitral and your aortic valve murmurs allows the expiration on you're, um your primary and tricuspid valves are loudest on inspiration. What? This pansystolic pansystolic means that happens away throughout system. Okay, It's also turned hollow. Systolic A swell. Yes. So when you're listening to heart sounds, okay, trying time. So try and find the first love on the lab and then the doctor. Okay, so the love is when the labs are closing. So the atrioventricular hours are closing on. The dog is when the seven, you know, valves a close. So if you think of it that way, then atrial sister was happening before the lab on. But, um ventricle sister was happening between the lump on the top and after the dog urine die still. Okay, what I would recommend about these murmurs is a wraps are recommended. The end, but go Look at it. Look at it online on D. Listen to it. Okay? And when you were listening to it torrent time the murmur with between s one and ST so between the love on the dock. Okay, again, if there's any questions I've missed, just talk them into the try again. I think my teams must have not refreshed on defy. I didn't get to them. Now I get them at the yet. So if we want to 12 lead EKG calculating Hori. So when you're the two main methods of calculating heart, there's a fast method. Okay? And there's a bit of a longer method or one that you're more used to it. Okay, so the fast method is use is using this formula here for a regular cardiac rhythm. So, as you can see in the first CT here, it's a very regular contact with, um, the always on the eastern. The waves are spaced out even. Okay? And they have been after the same intervals. So what you could do is you become the number of large squares. So this is one of square here between each always right on. Then use that number on do 300 divided by. So who were doing this for this ECD at the top here. What would be our heart rate or that we work? Actually, you know, they shot him out. Yeah. 300 divided by four, which is five beats. Exactly. Perfect. Exactly. Now for an irregular cardiac rhythm. Okay, if you you can see the one of the bottom here. This is very Eric on. What we do is we count the number of always in the rhythm strip at the bottom. Okay, We only use the rhythm strip of the bottom because the rhythm strip basically is records the heart the easy is an easy to monitor for over 10 seconds. Okay, if you try and use the smaller sections less food? Sure. Your knee CG. You know she'll show you to you later. Use with some of the smaller views of the heart you That doesn't measure it for 10 seconds. Okay, so use the red in rhythm strip at the bottom on. Do you measure? Count the number of our ways you can see here. This is obviously in that rhythm. Strip fives. Using this, I would say 1234 and most like by six. Okay, now, obviously, if I got 24 that I'm thinking something is wrong with the EKG and not really something wrong with the picture. I'm probably something's wrong with my machine or I'm not using the rhythm strip. Okay, so the next thing to look up when you're looking at the CT is rhythm, okay? And the main point is to compare if it's regular or irregular, and if it's irregular, then you can start start to think about different tachycardia is on Bradley carriages. And if there's any sort of fibrilation happening depending on what the rhythm is, okay, so you can get there's a few. There's lots of different ones that we talk about few rhythms. Not now, but the main ones you should probably know about are things like ventricular fibrillation, um, atrial fibrilation, atrial flutter. And they just have a some sort of idea of what they are. But again, not the most important point to comment on, especially for your CPA exam. And when interpreting the CT now colitic access. This is no the the most relevant about, um, CK. But I still wanted to include it because I feel like a lot of people are confused about how to calculate carbs. It access, you know, we're going to go through. It was good. The river very quick and easy way you can use when you're if you're doing this in your CPA exam or if you're on the water meter, see if there's some sort of deviation happening on very quickly without starting to get calculate around, start calculating angles, but basic concept access is the sum depolarizations on of the direction and the magnitude generated curing a complete cardiac cycle. So it's a vector. It shows you the direction. So where is Thedy're polarization of the hot occurring? Um, overall on How large is it? So it's a vector course. He has 22 values. That's actually now a normal access is between minus 30 degrees, 90 degrees left axis deviation is less than minus 30 degrees, and right axis deviation is more than 90 degrees. What left axis of my tax situation means is that there is more depolarizations happening to the left side, or there's more depolarizations happening to the right side. So common things that could cause left axis deviation, I think is like left ventricular hypertrophy, okay. Or on common things that cause right excavation is normally right ventricle, where there's basically been big, creating more muscle on the left side or more most on the right side, creating that, um, creating more deeper. Right now, the quick way that I'm going to show you is to use lead one and a V f. Okay, if you use lead one Avia, that is the fastest way to try and estimate the accident. Vacation Okay. This is the common way that is used when you're on the water. Need to do this very, very quickly. Okay, We're in Your CPS are more urine. Any examine your tight for time, do they? And it's incredibly accurate for how quickly it's So we've got lead one in a V F up here. Now we can see a lead. One is overall, a positive deflection up If I count the number of squares I can see. 1234567 squares up on 1234 square stuff. So overall there is a positive three squares up in a V F. I can see it's also mostly opposed to what puts deflection. So there's another five. Another probably 67. You probably ate, ate squares up on one square dot So again, that's a overall positive deflection. I mean, if there's an over a positive election, we're in this belief section here. Any foreign over posted reflection ABF were in this red section when we're looking at the view of the hot. So the only quadrant where they both crossover is this blue magenta sort of section it and this is where you exist that normal access. Okay, because that is between zero and 90 degrees. Okay, So simpler way of even doing this is if they're both pointing up, then you're in normal access. Okay, So lead one and a V f r overall pointing up there in your normal access right now. Let's have a look. Another example. Hopefully, you guys can, uh, help me do this one. So lead one again. Overall. Positive. But a V F on this, on the other hand, is overall negative. So which quarter? Until we in during this blue card in here. And we're in this red quarter in it. And where did they overlap? Give me a range where they would overlap. So last time I was between 0 90 degrees. Hey, where would it be? Yeah, exactly. 02, minus 90 on exactly as, um caught country sort of start from saying that room a scar. You said it is possible left axis deviation because we were in the serotonin minus 90 degrees. And remember, normal access is a lonely going to go up to minus 32 results. So if it's between minus 30 and 90 minus 90 then we're in um left axis deviation. So it's possible Left axis deviation. Okay, most of time if it looks like this. And look at how large of a negative it is. Okay, this is probably left Extavia taken sorts of nearly estimate. Okay, what about this one? Nothing here is if lead one and a V f appointing away from each other, then we're in left. Axis deviation wasn't even simpler methods to use, so they're pointing away from each other. So lead one's pointing up. AVS pointing down and urine left axis. What about this one you got lead one pointing down, and we got a V of pointing up. What section or you you were in this So go in this negative resection and it's possibly section. But which quadrant? Ninety, two hundred eight. Exactly. Perfect. So 90 to 180 is definitely going to be some sort of excessive a shin. And are, as everyone has get correct as told me correctly, it is right access to get okay, because we we know that a normal access only goes two plus night. So anything after 90 is, um is some sort of deviation is happening. So again, if you need 1.5 a pointing towards each other. Then it's right access. They're pointing away from each other. And this one, as we say as we saw then it's left axis deviation. If they're both pointing up, then it's no. Max is okay. And that's just a quick method that you can use Teo Count to try and find some sort of accidentally a shin very, very quick on Axid. A vacation is no big toe on it. So it's not gonna tell you the most amount of information about the patient. So don't get too hung up on trying to doctor activation. I know it's a lot of people get confused, but if you use this method, it's very, very simple, Okay? And this is often the method you know. Doctors use, and we have used on the warts before as well. So P r intervals. The next thing to look up is P R n. So the PR interval is between the interval between the P Wave on the R wave or the start of the key we've, and it's normally shows The P wave normally shows atrial depolarizing um, actually, normally be when the atrial contracts. Today, a normal PR interval is between 0.12 to 0.2 seconds, or between 201 120 milliseconds. Because, remember, if you're looking at a normal E C G, every single small square is about 40 milliseconds. So anything bigger than about three or four uh, 3 to 5 small squares is gonna be abnormal. So anything bigger than five squares, you're gonna look at a very large p r n on gonna fix on larger PRN tours for this session. So we're gonna be a large PR interval are going to create some sort of brad ecology and a bread called you just when the heartbeat has slowed down. Okay. And we can see it slow down because it's physically taking longer for one heart rate. Heart beat happen and you get, um, dysfunctions called heart blocks, which we're going to explore now, The first heart block. I'm gonna talk about our first degree Heart looks okay. First degree heart block means that there is just a prolonged PR interval. But there are still regular p waves and there is still a regular QRS complex. For me, the only thing is There's just a bigger gap between the way the PR interval is bigger between, and this is caused by abnormal slow conduction through the Atrioventricular eight or the Aviane Me on this usually presents with no symptoms and is normally left untreated. Okay, lots of people have first degree heart block without even knowing, and it's normal and incidental finding when you go to Costco and get an e c treater. Did you see here? Here's our P wave. His are always and you can see there's a massive gap in between. Now it's definitely bigger than five. Um, small squares. That's about six squares large has a massive PR interval. Definitely first degree heart block and we can see they're all regular. Each P wave is followed by a cure. It's complex every single time, and these are T waves here, which is the report or is Asian. You agree Heart block, which is gonna yourself going up in severity is a gradually prolonging PR interval until the P wave is not followed, followed by a QRS complex, and we turn this to be a regularly irregular. So what we if we look at this diagram in the bottom here, you can see there's a P wave. You are a complex tear wave P wave, another QRS complex, but not can you see how it's further away from each other now? Okay. And then again, you are is complex T wave. But then hang on. You got P r P P wave. No cures complex. So that cures complex has been dropped. Okay. And again, peewee, A furious, complex p wave Curious, complex p word cures complex. And we'll continue on this until it gets longer and longer. And then it finally drops. So there's API way on, no more purest complex. And that's why we turn it regularly. Irregular. Okay, because it's a it is irregular. Something wrong is happening, but it's happening at regular intervals. There's a pattern for me, okay on. But this is again normally do to conduction issues across the Aviane. But it's more severe conduction issues now, okay, and then normally present with no symptoms or mild dizziness or face of a faint in extreme cases on obviously under exertion on move second degree heart block movies, Type one is also known as Vanke back or however you on a pretty pictures that pronounce that they are the same thing. Thank you dot com movies type on are exactly the same thing. And normally, movie cyclen is left untreated. Okay, unless it's causing severe symptoms for the patient's. Okay. And the way we treat this is a few different ways. But we can try ablation or we can actually no, no ablation. Well, you know me to fit in and, um uh, pacemaker. But it's pretty extreme, too. Fair piece make for movies, type of for movies. Talk to. On the other hand, we have peewee aves a regular, but they're not always followed by two hours complex, so we no longer have a longer and longer PR interval, and then one drops. Now what we have is we have a few a few people with curious complexes on, then A P way without. So if you look at this P wave, you're a complex tear wave pee with a P wave, their QRS complex. You were there QRS complex, another one there. And then look at this page here. No cure. It's complex. And then it comes back and again and again. And then until we get to think about this point here where we could see the T wave in the P wave combining together and again no cure is complex. There on again, we turned. This is regularly irregular. On this time can I should work out a ratio between the number of people, waves and curious complexes, and it can cause chest pain, shortness of breath and postural hypertension. If it's also taken it taken with, um, anti hypertensives can. Definitely. It's postural third degree heart block, which is the where you got complete dysfunction between the atria and dick you're on do Eventually. There's no coordination between a tree in the bedroom to the 80 and eventually can contract on their own Separate rabbits and third degree heart block is there isn't a coordination between and remember a lot of cardiac muscle cells or cardiac monocytes. They're all myogenic. Well, that means they can initiate their own contractions. But what happens with the essay and on the Aviane is that they coordinate those contractions. What happens with in 33 heart blockage? There was no coordination. So what you'll find you'll get peewee Aves happening at their own rate, and you'll get curious Complex is happening at their own rate, as you can see here in this diaper, and it's gonna often cause faints, Shortness of breath, extreme cart tired. This confusion and chest pain. A third degree heart. Look, we are probably definitely looking at fitting in a pacemaker for that person to artificially coordinate those people waves. And you're curious complexes. Any questions? Again, Any questions? Took them in the child, but fine. I'm going to look at ST Seconds now. This is one of the big ones is probably definitely come up in your CPA exam is some sort of question, right? We look at ST segments for Elevation, if you're not sure, you ST elevation in a second. But that considered if I a step stemi sounds for ST elevated myocardial infarction as the Depression is a normal sign off non ST elevation myocardial infarction, right? If both of present, then you're probably going to suspect to stemi. And the ST Depression is due to some sort of ischemia of the minor sites and is a reciprocal change. Okay, So, ST segments, what we think when we're looking at ST segments were thinking Has this person had a heart attack? How is this person had an m I okay. And we can tell them you could tell from the because we place about 10 different electrodes and they produce 12 different leads on 12 different views of the heart. We can distinguish which area of the heart has infarcted and actually which blood vessels, in fact, it Okay, well, which blood vessel has basically been blocked or isn't supplying the heart with that option? And with that, um, with that, there's nutritional Lucas that it needs. If there were resets on your mind, So if there was left side, Am I okay? And you left? It happened for long enough. Where the my sites have actually died on the left side of the heart, you would get right axis deviation, but I'm pretty sure that would be the least of your concerns for that patient. Um I mean, the first question would be why, if you left, why did they leave the MRI to go on for so long? Where the the left side is actually died so much that the right side just taken over a lot more. And sometimes you can also got collateral blood vessels opening up to supply the the that area of the heart that's being affected. That and take over from that blood vessel that's been blocked. But again, that takes time, so you may not get right Extavia a good question. Yep. So with Mobic, start to. If you go back quickly, you find a pattern where each where. You'll find a ratio between number of people ways followed by a cure. It's complex on a P wave that isn't for so for Hey, we can see a pattern of about 321 because the three p waves followed by a QRS complex and then one being dropped. Okay, where is uncurious? In a third degree heart block. There is absolute disregulation. So Kiwane will happen at their own rate, which you can see here. It's it's It happens at the same. If you look at the gaps between the P waves, they happen very regularly at the same time. But on the R waves, they happen at their own rate as well. That's how I would define the difference. So with seconds we can see a ratio and there is coordination with the degree there isn't a coordination at all. Very. Keep the questions coming guys Very good questions on so ST elevation that we're talking about. And again, as we saying from the leads we can I can distinguish what level the infection happened. I'm going to get a little bit of the pathophysiology. How does an M I normally have really? So normally an m I or a heart attack on my card infection. However, you wanna, um, define it or terminal a term. It is due to ischemia off the cardiac tissue due to some sort of occlusion off the supplying blood vessels. So let's say this is this is the artery. This is the let's say, the left coronary artery or the right coronary artery. We're looking inside the corner and we can see a plaque forming. And this is often do two hours after, right, Sclerosis, where you got this plug? This plaque forming on what happens sometimes is the plaque can actually block the artery itself. Okay. And maybe make the radius off the the blood vessel smaller and smaller and smaller. Okay, so therefore, your artery cannot supply the same volume of blood in the same amount of auction to your heart. So what can often happen is that you can get pain on exertion, so that's called unstable and joint. No. So that's quite stable. Enjoying okay, stable and join us when you get pain on exertion because there is some. There is partial occlusion. Unstable angina on the ground is when there is occlusion, but it's causing you pain when you're at rest. So on Jonah is just the pain. Not really. If it's an MRI or not. Okay. And as we said before and instead me is partial occlusion. There's still some oxygen and still some blood getting to that heart tissue. But with a stemi, there is complete blockage, complete closure of this blood vessel. Nothing is getting in or out. Okay, No more option is get to get to that muscle tissue. So stemi is a very, very big emergency way. We normally in Hostel try and do some sort of indifferent intervention between in the 1st 2024 to 48 hours. Patient presents with an instant, you can wait about three or four days. Okay? And they will still be able to recover, borrow, see where we we don't want to do that. But that's just when you have to triage patients. Just a little bit of the pathophysiology. Okay, if you have any more questions about that, I can cover it. More detail. At the end of that. This is what I really want to get onto. Okay? Because one thing you take away, take away this This graph, okay. This this, um, image. Okay, this is incredibly incredibly important, because this will tell you which area of the heart is affected, so each lead will show you a certain area of the heart. Okay. A VR doesn't We don't really use it to show any any areas. A lateral is when you use lead one and a via a veal on V five and B six in for review of the heart is lead to lead three and a V f set to his V one and B to anterior is V to be three and people. Okay, so there's one thing on screen shot from this is Electra. Is this very, very important? Okay, because this is if if you get ST Elevation, let's see in lead to three and a V f. Or, you know, there's an M I in the inferior area of the heart okay, if you get a ST Elevation like this here, you see ST Elevation Biggest the elevation of view to be three and 34. Okay, on be five. And in B six, you can say that anterior lateral. So it's happening in two areas. Anterior area on natural area of the heart. Okay, anything to even say possible septal. It's not that great, Big and V one and you can see their ST Depression a VR, but a B or sometimes you see ST Depression A be on not natural, okay? And that brings us to the end off our SED rate, which is a quick rundown, A be off the important aspects of interpreting you should you should be able to do for a CPA exam. And again if anyone wants to, any more details or any more things about that, I'm more than happy to stay after election and go through. So let's go to some practice questions. So anyone know or don't have a definition of what this is? What is this shot? You know, write them in the chart, however you want. Okay. If I say what imaging modalities, this imaging modality, I forget what it is, but what it's showing anyone Tell me what imaging My diet has been used. SCG, Can I get any more detail on the surgery? What's like a B C D? How many leads on exactly 12 Lead STG. This is a 12 lead. Easy. Gee, you That level of diesel is required. Okay? For your suitcase, I mean, also, just if you know the detail idea, because sometimes you can also get the really need the CDs. Okay? And he goes to get five extra four or five extra leads added on to in the exhilarate area where it shows you the inferior aspect of the heart, which is a known as like a 15 or 17 g tcg. Okay, so it just because this is the main one that you know, you see, it doesn't mean it's the only one that exists on it. So this is a 12 lead, the CT. So what is the main pathology exhibited under? Some people mention this a little bit again, but giving everyone the opportunity. So what is the main pathology exhibited? What's the main problem that you can see start basic. What can you see? The c g What is it? Where you What leads you seeing this on? Give you 30 more seconds just to make sure everyone's had an opportunity to answer. And again, if you want to show them out, you can. All right? Yeah. ST Elevation. Yeah. I'm seeing a lot correct things for the right things in the in the chat. Perfect. Fantastic, guys. I know it was, You know, I mean, most of your ready Answer this worried about the heart is affected. So I did make a plan. This for a two step a question. But everyone is been bit to be more advanced than I am. So let's get there so we can see ST Elevation and need one Avio on V one to V for lead one in a V O. It's very subtle, but hopefully everyone should have seen that there is massive ST elevation in V to be three the for the five and B six on. There is also ST Depression in view one. Okay, Which you can see that? Yes, exactly. Reciprocal changes. Fantastic. Were super genius in lead to, um it's already in V t o v t. Um, yeah, we support changed in 23 on a V A fantastic give you so receptor changes are basically ST Depression. That happens. So basically what happens is that you just cut off The blood supply to a area of the heart was functioning completely, perfectly fine. So that area of the heart can't function as well anymore. So something has to take over and pick up the slack. Essentially. So what you get is the other areas of the heart working extra heart and working a bit more than they They should. They working overtime basically on because they can't sustain that for bring on time. So then they start to become a scheming and they start to also get problems. And that's what causes those reciprocal changes. Do you go to support ST Depression in the three and A V F. And this is always the. Hopefully everyone was able to identify this systemic on. It's in the natural anterior lateral areas. Okay, so please, please, please. That diagram that I showed you before I could go back to the end of lecture from once very, very important on possibly could about it in that there is left anterior descending artery occlusion. So What about this question? So your exam in a patient and find they have a midsystolic crescendo. Decrescendo mother has a grade three of six on radiates to the neck. What is your differential? Diagnosis? What's everything? Give you 30 more seconds Being sitting a few ounces. Just just want to give everyone you're beginning to answer. All right, look. Look at yours is fantastic. Everyone is correctly identified that this is your six doses perfect. The key give away should have been radiates to the next they now some murmurs are awesome. Mentioned as Christian do decrescendo months. What that means is they get loud and then he's become quiet. Some murmurs just get quiet and summer mistrust get loud. Okay, so aortic stenosis is known as a crescendo decrescendo most. There are many, many ways of classifying and of describing murders. But there are certain key things that you should look out for a certain things that you, if you want you here, you should be able to instantly recognize with certain pathologies of the month on a Grade three. Up six just means how easy it is for you to listen to it. So grade one means that. You know, it's very difficult to hear it. A great six means that you can hear it with the stethoscope hovering over the chest or even on the chest. But we start very, very bad for every loud means. Very ah, large dysfunction. Now again, you examine a patient, find Pansystolic high pitched moment. It's loudest on expiration that radiates to the exit. What is your differential diagnosis? This one's a bit harder. Anyone have any ideas? So I'm seeing a few months is in the child. You know it. 10 more seconds. Yeah, exactly. Fantastic eyes. You will. You will pick this up really, really quickly. It is mitral regurgitation. You should be able to tell it's mitral because it radiates to the exit. I mean, it might was the only one that will radiate with eggs. Easier on. It's a pansystolic. All right, Mama. Okay. That should tell you both. Those are the two area too important parts that we should tell you too much. We go station. They could again. This is just more description. It's a high pitched murmur. Loudest. An expiration that you tell you it's on the left side on radiates to the exit to tell you it's the mitral. Pansystolic retorts, regurgitation or stenosis. Remember, Michael stenosis is an open snap hum. So I think this is our final question. Could you describe two features off this ECD Any two features that any features of this of this city could be abnormal could be normal features Any of the steps that we talked about before. When you're interpreting easy tree, I've seen lots of a lady lady don't know what that means. Fine. Six Peaks ST. Depression. So if you want to say there's ST Depression is in a lead to resistance. Certainly it's always have to be specific. What means you're talking about the way president too. Start normal tap. Yeah. Prime P Wave person left axis deviation. Fantastic. We're gonna use to lead one. And a video more. Is the left axis deviation. Was he of AB? If anyone in your fantastic they could say is left axis deviation Very reasonable. Very, very small. ST. Depression. Need to be 4 to 6. You know, I don't agree with that. So these are things I came up with. So there's ST Depression lead one to be five to be six. There's ST Elevation in V one and be two on a video. And there's a heart rate of 86 BPM because again, it's a regular heart rate, so I can just look at how many large question between them on estimated that way off. This is an estimation. There's Oh, there's different ways. And again, this is an exhaustive list or things you guys have come up with are a perfect okay are exactly the things that I was thinking about is well, I think that brings us to the end of our electric. So you got any other questions or comments? Let me know. Now what's the diagnosis? So this one, the diagnosis is, is, um, step. Really? Where is it? So it's in V one and be too. So it's a septal step of a possible occlusion of the left anterior descending depending on if it's left dominant. All right, Dominant or left. Circumflex. You could be hard Scarlett. Irregular heart. So it's a calculated regular heart rate. You should use the rhythm strip of the bottom here. Okay, add up all the always let's do here. 1234567. So there's 14 are waves of the bottom here. And then you multiply it by 10 as a red mark by six. You know, so 15 most road by six should give you a rest. No worries. You're welcome. Any other questions you guys got? Keep them.