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Nine. Let no, I do chemo services. Did you come in? I right. Everyone ready. Uh ok. So um thanks for everyone coming this afternoon. Sorry, I looked a bit rough. I've just come from Kingston. So apologies for my late appearance. So as I mentioned this week is on cardiology. So as I remember if you weren't here, last time, each week we go do a theme on an acutely ill patient. We're gonna go through a history exam questions and then an a toy at the end all just shouting out answers, the more you get involved, the more you'll get from it. There's chocolate this week. So shout out you get some prizes. How does everyone feel about cardiology? Yeah, I watch orthopedics. So any medical always makes me feel funny but everything with medicine, if you stick to the basics, stick to the steps, you will get through it. So this is your first case. You've got Barry, a 53 year old male who was presented to Amy with central chest pain. The triage nurses asked you if you could kindly see them next. So we have pain. How do we address pain? Lovely. So it's pain in the middle of his chest. It started 30 minutes ago. What else do you want to know about the pain radiation? Yeah. It's going in, into, up, into all of my chest up here. It feels like someone's sitting on my chest. Um, when did it start, as I say, about a half an hour ago? Yeah. I feel really clammy and sick. I just don't feel right doc, any other kids, as I said, I feel really sick. Ok. And is there anything that makes the pain worse? No, I did have the spray that I have at home that I put under my tongue and it did help at first, but now it's not getting any better. I think that makes it better. So you mentioned the spray makes it better. Um, so nothing else. No. Ok. Uh Have you had some more pain before? Uh, yeah, I have but usually as I say with the spray, it settles immediately. 10 out of 10 worst pain I've ever felt doc. Can you give me some painkillers, please? Uh, we will look at, we just need to know which ones are the best for you. Um So, so thinking of other symptoms, like, is he feeling dizzy or losing consciousness? No, I haven't lost consciousness. No, I feel like a bit heavy but I just feel really generally unwell. No. Do you feel palpitations? Right? Any changes to your vision? No. Sorry. What did you say? The, the answer to the question about radiation was it's kind of going up into my chest, going up like up here. All right. Then I'm guessing, then you just move on to the, no, no, no. We do a full history. Always. Are you aware of any other medical conditions? Oh, that I have. All right. We'll just recap. So, yeah, this is your presenting complaint just r through that. So you got rid of this. He's a bit short of breath, but he has no cough, no difficulty in breathing, no fever. And this is what we're all getting at. So this is helping with your differentials in cardiology. Where is this pain? Where did it start? Where is it going? Helping you build up your differentials? So, yes. Any other medical conditions? Yeah, I have high BP and the doctor says I need to lose some weight. I do, but it's not diagnosed. The doctor just gave me the spray and the ambulance and I've had it at the GP recently, but it's not a regular prescription. Ok. Does the pain come on, uh, when you exercise or does it come on when you're just at any point? Sitting relaxing? So today it was, it just came on when I was sitting there at rest usually. Yeah, sometimes I feel a bit short of breath with exercise, but I've been trying. Ok. Uh, are you on, uh, what medications are you on at the moment? Excess Ramipril. Anything else? No. And with the spray, how often do you have to use it? As I say, it was just, I spoke to the GP about it the other day so I haven't really used it. Yeah, I do. Yes. Ok. And is your BP still high? But it's on the Ramipril? I haven't been measuring it. Really? Ok. Uh, any allergies? No. Ok. Um, family history. I know my dad had a lot of issues with his heart. Do you know which ones? No, is still? No, you just did. He died of a, um, heart failure? You, how old is the patient? Uh, Barry is 53. Um, any other conditions that run? Um, no, any history of heart attacks? No. Um, and do you? No, I have my wife, two kids, pet dog. Try and walk it. Uh, yeah. No, I'm working, I'm a lorry driver. Not that good back in COVID when I lost all the work. I just gained all the weight and I haven't been able to keep it off since II, know it's in the red zone in the doctors. Uh, apart from walking your dog. Do you get any form of regular exercise? Not really. I just try and, you know, get my steps and that's what I do. Um, and just asking about questions we ask everyone. Do you smoke at all? Yeah. No, I do. And what do you smoke? Uh, 10 roll ups? Ok. And how long have you been smoking 10 roll ups for? Oh God, since I was, since I was 18. And do you drink alcohol? Yes. Yeah. How often do you drink can, or two a night? Yoga? And do you use any recreational drug? Mhm. I'd tell you. Smash that. I'd say there's nothing else you missed absolutely nothing. Like it's all in there. The main things you're getting for smoking. What is family history? We all know cardiovascular conditions do run in the family allergies. Well done. I can't handle at home enough. Especially for those nearing your exams. It's really, it's a simple question but people forget it and it's an easy tick box. But yeah, quite a simple one. So you've got your history. What differentials are in your head? Yeah. Yeah. What does that all come under? Yes. So we've got that. So, I'd say that is your one beginning one before you can have your three differentials because that's all within that step. So we've got a CS as one. Anything else. Anything else? Like something? Yup. Um, anxiety. Yeah. No, don't laugh a bit. Genuinely. You would not believe you have people. You have young people and he's only 53 coming into A&E someone sitting on their chest feeling short of breath, the pain, it just happened out of nowhere could definitely be anxiety. It's definitely one differential. The other one I was put in as well is costochondritis rib pain comes in the same kind of thing. That is my usual differential when I was coming to my examinations. So, cardiovascular exam, how do we all feel about doing that? Quite confident? I murmurs. But the, the exam itself you can flow through it in seven minutes. Um, yes, you're holding it. So, you know, your pulse. So you're always going with, is it a systolic or diastolic murmur? So, you know, if it's, you're here at the same time as you're holding it, that's when you know it's systolic. Otherwise, it's diastolic and that's how you can also vary if it's end or pan. So by holding that pulse, you're always gauging your sign. To be honest, it's to orientate yourself as well because you're in your exam, you're stressed. If you're holding the pulse, you feel it, close your eyes, listen for it. You will hear it. I just, I II struggle to identify and systolic systolic and then all those things like I find it really tough. So I had it in my third year. Oy, and the looking back at my feedback, it was just identifying where I heard a sound. Was it with the pulse? Saying sic, panic is great. But the main thing is identifying if there is something abnormal and presenting it as if what you do after. So the best people obviously is to hear a cardiologist on a ward round and say this is what this is because you will hear it and it will be that classic waveform where it would be the, or the very different things. Snapshot, you have to listen to them. It's never that bundle. And you've got to have someone introduce it to you. But for your exam purposes and for me as someone who is just a surgical trainee, it's where did I hear it? With? What pulse did I hear it? And that is sophisticated enough to know that you were understanding that pathology. So if you get too muddled up in your words, where you're presenting as someone who has like sat in exams and helped. It's the people who are just very clear and factual with what they heard. People try and say what they think they're meant to be saying are the ones who stumble on it because then we pick apart and go, we'll ask you on it or what does that mean? Well, actually, if you stick simple, we build and that gets you more marks. So just stick with the pulse. But yeah, peripheral exam is what I feel. People stumble up on. You're quite happy with starting up from the hand going up. What, what are the extra things that in a cardio exam that you want to be doing with? Starting from the hand clubbing? What is the full sign you look for in the fingers? I Janeway lesions Osler's nose, which are all four signs of perfect. That's the first one you start with. Then you still you're gonna feel the hand. Barry said he's clamming. This is what I don't think you'll get, hold the hand, just feel it. Then what do we get to? What do you want to, what do they want to tell you with the pulse rate and rhythm? Then you're holding the radial pulse. What do you do next? Yes, perfect. So you then go up, you also can mention at this point if you want to do blood is what I remember in the exam, then you go up again, you can do radiofemoral delay as well. We then go to brachial. And so what else can you do at brachial? Technically, you can do character and volume as well. You can mention that, but you can also do that with carotid which you're going to feel. No, you cannot do character and volume with your radial. It has to be a central pulse for you to see how much blood's going around the body. So rate rhythm, character volume. So you can feel if it's a strong or a thready pulse, you can barely feel it. And the reason you can barely feel it is because their pulse pressures are low because they're shutting down. You'll feel that if you ever go to Greece and see someone who's lost a lot of blood, you'll feel this kind of thrill and that not a thrill. That's the wrong word because you have to use real thrill. You feel kind of this little flutter under your fingers and that is a thready pulse. So going up your arm, done your collapsing pulse. Then you've got to say you do manual BP, manual being the key word. Going up again, we're at the neck carotid pulse you're gonna feel at this point, this is your family character JVP. Then we go to the face, we look at Ma ma Mala, Mala Thrush. However you say that, open their mouth, look at the palate tongue up cyanosis. It's a lot to do in peripheral and I think people really underestimate it and like, obviously you get to the chest. I think everyone's happy with palpation and auscultation. Never forget the lungs and always go back down to the legs at the end are the main things I think you can get to. But that is the main things for like getting through an exam that I found I got quite slicker. By the time I graduated was getting through the periphery, any questions about any of that? No happy. So in Barry, to this case, I'm gonna give you real life what you found on a general exam from the end of the bed? He's gray, he's clammy, he's anxious. His pulse is regular at a rate of 90 BPM. He has no signs in his nails and his cap refill is normal. His BP is 100 and 75/100 and 10. He has a raised JPP, no new murmurs and a potential fourth heart sound, but you're not sure. Sorry, sorry. End of the bed, he's grave clammy, anxious. His pulse is regular with a beat of 90 BPM. There are no peripheral signs in his nails and his capillary ro time is normal. His BP is raised at 100 and 75/100 and 10 with a raised JVP with no new murmurs, potential fourth heart sound, but I'm not sure. Ok, so you've done your cardio exam. We've mentioned 12 lead E CG over the back there and bloods any bloods you want in particular? Yep. Mhm. Yeah. Why would you want to use these um electronically? I don't, sorry, I'm just thinking of not, no, no, but we said it was regular but why he's got a Rage JPP. He's on Ramipril. Why do we want to use these? Yeah, he could have kidney issues. He could have an acute kidney injury if he's shutting down and he's on Ramipril. Always gotta think why you're having a blood test always be ready to justify it. Why would you do an LFT in him? Oh, because it's a major organ. It could be, if he's got cardiomegaly, he could have hepatomegaly. If he's got a cardiac thing, it's all justifiable. The main things I think in this are doing the full blood count. I would do a renal profile, troponin T and a, a DDIMER because we said pe being one of our differentials, he's got J BP. Do you do if I was in GP? Yes, I've never done it in any. I've seen it on the system but I've never requested it in a, as an acute test. It's justifiable. But in the acute setting with an acute onset of a 30 minute, I'm putting a rest in the chest, get an echo. This is something else that some of you may or may have not heard of the heart score. Anyone seen this before? No. So this is something I used back when I worked in A&E different trusts, different places, different policies. But this is what my cardiology department advised me to do to help work out what we do, whether we can send them home. Obviously, different departments don't use this for exams. But this teacher program is also about like get you to use your brains as an F one F two. Seems to be in A&E it's very justifiable. All of these things about. Can I send them home starting off with? Is it a suspicious history? Yes, he's got two points. So automatically he's probably already gonna get him. We haven't done an E CG. We haven't done a, he's 45 to 50. He gets three points with at home. That's got risk factors. Yes, he's got probably three. He's at four. So we're already admitting him for clinical observation and it's just in the B of your head. Would I feel comfortable sending this patient home? Is it anxiety? Is it a 23 year old girl who he's got a history of U PD? Yeah, maybe I'll just send that home. But if this is someone who's overweight smoker, new onset of chest pain at rest with some signs on his cardio exam definitely wouldn't be sending him home. But this is just a thing to help you get through that. This is something I find helpful. This is uh oh yeah, sorry. Usually I go straight to his E CG but someone mentioned last time that they were a bit unsure about interpreting EC GS. Is everyone quite happy with going through EC GS or would you like the recap? Go for it? Right. This is how I go through an E CG as I say, I am no expert. This is someone who just safely goes through this. And basically, if I see something abnormal, I will be calling someone. This is the first that I start at. What am I looking at in these leads? Deviation, reaching, leaving. That's where I start. I just like to go round the page. So these they're normal, they're not reaching to each other or leaving away. So Barry, we could be worried about left access deviation and then move on to the rhythm strip at the bottom. So first off, I want to make sure I've calculated my rate, big squares 300 divided by big squares. If it's irregular, how do you calculate the rate six? Perfect. And then we want to know if his brother is the same regular, are the same big squares in between them. This one is regular, there's four in between all of them, then you want to work out. Is it I if it is irregular, is it regularly irregular or irregular, irregular? And that all helps with your pr interfere? So that is the next that I go to working out? Is this a normal length? Because that helps with your degrees of heart block? That's also looking at that a bit, extending it where I'm looking more at my Mobitz one, Mobitz two, then I go to these two bits. What am I looking for on these two leads? Exactly that you William Marrows. That's the next stage you go to, then you're moving on to your ST segments. So it's William Marri. So in your QRF segment. So this bit William is left bundle. So it looks like a W and the other one looks like an N vice versa for a right bundle branch block is quite obvious that for my learning for my exams. Have you all heard of their website? Life in the Fast Lane? Use that it's just really clear and then I obviously look at my ST segments looking for elevation and depression working out whether these are anterior, inferior or lateral leads. So in this one, I've got blue as inferior, green, as anterior and purple, as lateral leads everyone. Quite happy going through EC GS. You'll find your own ways. But that is just the way I step through it. Happy expiry CJ. Oh, what's wrong with it? Inferior LC. There are, it's regularly sinus. They are uh each other. So sorry. I'm just looking at one. Would you look at me? One and three or one and two? So one and 31. Mm I'd say so. So that's perfect access deviation. 65. Mhm. Yes. Um No that pr s three lips twice. It's all right. OK. So is not right that. Ok. And then six it so be specific because there's lots in this and this is why I want to. Oh the William Marrow. Yeah, that's all right. That's all right. Ok. ST elevation. Yes, sir. Elevation 12 12. Potentially af as well. A reciprocal I depression 1234. There's also some elevation is there, is there elevation in V four? That's what you said. Depression. So you're saying depression and b1 b2 b3 P four elevation and P five P 612 and aVF Yeah, everyone agreed. OK. So I gave you the colors. What does this mean then? Inferolateral 10 T elevation systemic? But we've got depression as well. Is that normal? Could it be posterior as well? It could be. So what do you want to do? Poster leads? And it's OK. Ok. So it's an infra cluster posterior, the other, his heart's a mess. So you've seen this g while you're interpreting this because you're in year four and you're just getting through things, the nurse runs to you with this blood test result. What do you do? We're admitting him. Definitely. So if he, so if he's in pain, we're gonna give him more. Correct. If he's got low oxygen oxygen, we'll give him nitrate so that he's already had GTN give him a loading dose of aspirin. Mhm And then we also wanna give him so. Ok. Yeah. What's the other thing? Yes, we do want to. There's another thing it's within, he's coming to the hospital within 30 minutes. Yeah. P CS. Does every hospital have a primary PCI center? No, that the probability of you all working here where this is like the only hospital where everything's inside. It is very, very rare. So you'll be muggins like me in Southend having to fax an E CG to baton. This is what's going to be your lives and this is why it's really important to get the faces barrier. Come to you. You've been managing him. It's been now an hour since you saw him. So he's an hour and a half. Nan, he's in pain. Morphy, morphy, morphine can help moving on oxygen. People don't really give oxygen. His packs were actually fine. It's more if he's feeling symptomatically short of breath, nitroglycerins as you said, we've already got. And then this is the pack. So in my day and I sound so old saying this, we would talk clopidogrel. But in real life, these are the three drugs you're going for. Heard of all Aspirin. Obviously, loading dose to Alor is the same principle and your Fondaparinux, but do not give that. If they are going to go for primary PCI or thrombolysis, you want to check them first before you give this because then they'll be too thin and you've got to bear in mind with PCI. You're going in through the groin, you're going to be, you give. So firstly, a classic medical answer, I would be contacting cardiology urgently and acting as per my trust guidelines in my local trust. We give a loading dose of aspirin and gag and then, and then discuss whether we want to give the fondaparinux or transfer them for a primary PCI I or discuss thrombolysis because you're an F one, they just want you to be safe, which is saying I'm aware of the drugs, which I'd be escalating to my senior and real life. There is always a performer. So just to check, we'd give them aspirin, then we'd give them and then we'd contact cardiology and be in discussion with them about whether yes, because we're not sure whether they, if they meet the PC uh qualification categories or they meet PCI qualification, we do give them, we do not, we do not give them funder unless they tell you to, but you don't because you've got to bear in mind if you thin the blood too much, you're about to take them to a procedure through the groin. You don't want them to bleed too much. So this is why you want to before you thin them too much. If you're going to directly deal with that clot, don't thin them out too much cos it is a form of intervention. So, always check first. But the first thing for your exams, this a star your life. If they're gonna be from your life, would they then receive the to death? I've never seen someone thrombo. They do get older places because that is the thrombolysis drug. So when do you give that if you're not gonna do anything, if you've missed the window, say any how many, what the, what the, what the, the 2412 to 24 contraindicated past 24. Well, PC is less than 12, 6 to 12, but usually six again, it depends on trust and it depends on transfer times because you've got to bear in mind real life again. What this teacher program is also about. You're in Ad GH by the coast, you've had a patient waiting nearly four hours, but they've got E CG changes that heart score, they're meeting every criteria. It takes an hour to get to the local P PCI center. It will still be the best option. He's got an inferolateral posterior ST elevation. He's got most of the, his heart is ischemic. It will be his best option. You have to let seniors decide whether they do it. You would be surprised how often we end up with medical management. But for your exams, take out what set of real life, give the drugs, call cardiology have that in your back pocket. That my three options of this primary PCI thrombolysis fonix. It, that one. He that one. Yeah. Yeah. Is PCR the same as a prime PCR. Yes, it's the first. It probably just means it's the first. It's percutaneous, but it's just the first. So we would just say this and contact, you would say yes. So in your, so you've done your assessment, you give antiplatelets. So that is your aspirin and ticagrelor analgesia anti ischemic drugs, which is your GTN. Consider your low molecular weight heparin discuss with cardiology and make sure they're on continuous cardiac monitoring. That would be what I would expect you and what? To be honest, I would do as a nonmedical trainee. Yes, they weren't going to PC. Do they still get a CT on your B? Depends what they've asked for when I was an F two again. Very different if we didn't. Um It would mainly be admitting the next day they would get an echo first thing and then we'd also get the CT Angio because we may be looking at caps and other things down the line sorry. Just again, you wouldn't outside of 6012, I'd say is the limit and that's where you, then you thromb and it's thrombo. Uh, do, do you with no old place? All stripped car things are, I have both of those. There was another question at the back or is it all all right. I was gonna say, um, have the guideline changed over the last couple of years for ps wouldn't surprise me. I feel like I remember it being two hours, but I might have just II, if it is two hours, I would be shocked. I'd say less than six is probably where it's gone to. But as I say, with all of this, my notes, I have been a doctor for four years and I'm a surgical trainee. This is more for you getting your brains working. This is why I don't send out lectures because don't use my word verbatim. I want you to use your mind and I am not a medical doctor. I started the teacher program when I was an F two very different now, II do hips. It's much more. But yeah, still what I would do in this day and age as a genuine doctor when I saw that E CG these drugs including your aspirin and, and I would be checking my trust guideline for Terrel and calling cardiology and in real life, they make the decision. They'll be the ones saying you need to call the primary PCI I center. You will never be making this decision. Someone has paid a lot more to make this decision for you. Your main thing is escalating safely getting the patient safe, giving them the pain relief, giving them the anti ischemic drugs, antiplatelets. That is what will help them. Yeah, sorry if II probably am wrong. My notes are, as I say from my med school days which were a long time ago, 2020. So, yeah, he would have gone for that long term management. There's a lot you need to tell Barry everyone happy with these kind of plans. So the, yeah, have you never had that? It's um, yeah, it's what I was talking about raising the heart rate. There's, you can't after a hip replacement. Yeah. Genuine. It's in the leaflets. No, the hip replacements is because of the immobility that pops out. But, um, there's always advice, you know, it's life. Yeah, this is your long term management. It's getting the GP involved, getting the exercise, getting the right medications on and decreasing the risk factors. Clopidogrel. Is it only with ST or is it again? I'm not sure on that question. Sorry. Right. I feel I've been talking enough. It's your turn ready. You blow it first question. Yeah. Pericarditis. Everyone agrees. Yeah. Why is it Pericard? You are correct? Ok. We're doing well. What type of, um, flu like illnesses can cause it apart from the, obviously the flu, any other viruses, you know, associated with it. Ok. EBV Coxsackie are the ones that are usually associated with it. But yes, this is someone who has got a pain that's radiating off to the left shoulder but it's more lying flat. So, if they have a pain which is relieved by sitting forward, that is classically a pericarditis. ECG change. You'd see in pericarditis. Yep. Over which segment like spread. Yeah, it's widespread. But, yeah, ST with some associated to pr depression is your E CG changes. You'll hear the friction rub, which is kind of, I've never heard it, but it's described to be widespread as well when you're listening down. But the main thing is your clinical history. Yeah. This one. Yeah, everyone was happy with that next question. What does this ECG demonstrate? I'm thinking it's true. Sorry. Are we meant to say it out? Yeah. Yeah. Out. All relaxed. No, no, no. This is safe space. No one ever feel you get an egg if you get it right? Type two. Two lowest one. I don't expect it. Which one is it? When it gets like longer, longer, longer, which one? This one, this one go it to the one where it's normal, normal, normal, then randomly drops one oh where like it's normal. But then one like as in you have normal ECG and then you're close. So who said type one? Starving chocolate? It's type one because it's the one you said it slowly keeps getting longer and then it drops, which is type one. So you break it out into it. So look at all your options because you're in an exam is stress. OK. These are all rhythm. So what do I want? I want the rhythm strip start off. Is there ap wave? Yes. Is it regular irregularity or irregular irregularity? So we've already ruled out air. We also can look quickly and rule out left on the branch block because I can't see her. And also it's not really past the question. There's a clue as well, but everything else is about heart block. That one is an easy cross out answer. Then you are looking at your other types of heart block. So type one is just with Apr greater than 200 Mobitz. One is a slowly increasing pr before and non conduction. Mobitz two is a constant pr with the dropping the third degree being it's a mismatch. Yes. So type of first degree. Uh the pr and third is more increase, first one, more than five years. I can't remember. It's more than 200 milliseconds. It depends on your rhythm maybe. Yeah, that's why I'm 200. It's all I have written down. So that is what I think because uh the reason I've written it down in my notes back in the day is because they used to in my med school put on different rates on the speed of the ECG. So that's why it's really important to check your patient demographics and the speed and rate of the E CG. And that's why I was put down to 100. Um You wanna see it be B1 and B6 in the Q RSI. I'll bring it up in here. That might be easier on your chest. Morbid type one is slowly getting longer dropped off mes two constant pr drop three mismatch. OK? And life and the last, sorry. So this is your William Marin. So this is your left arm around. Look, let's see. So will and then the pr get longer and longer and longer and dropping. Ok. So mm one shorter. So this is about 356 take longer even more longer. Thank you. It what? Yeah. So next question. Stable. Correct. Yeah. Anything that is brought on by the excessive exercise is where it's unstable. People can get esophagitis out exercise but this is just a bar or stable Angina. Next question he said they liked mamas. Yeah. Mhm Yeah, everyone happy. So you know your signs of aortic regurgitation apart from the ones I've put in here. Mm mm mm Collection. Sorry. Just add some chocolate. So your signs or your weird and wacky things were able to regurge Corgan's post which is collapsing pulse Corgan's s which is a carotid pulsation demus which is the head. No, with the pulse Quincas which is the capillary pulsation in the nail beds. Tras which is the pistol shot sounds over the femorals and your austin flip murmur, which is a rumbling mid diastolic, which is severe. A they are weird and wacky signs for all regurgitation, enddiastolic murmur being the key one here. Aortic stenosis. What type of murmur is that? Yes. Mhm. Then what about tricuspid regurge? Ok. What type of murmur is it in? Tricuspid regurge? I don't know the answer to this in real life. I is pansystolic murmur. I wouldn't have known that. So, don't worry. Your main ones, you need to know they atic stenosis and your mitral regurge. They're the most important ones you need to learn for your exams. Talking of mitral regurge. What is that? What type of murmur? Hi. Systolic me that one. You good. You know where it peaks and then goes. But you can hear it all the time. Mitral stenosis. Wait. Oh, I don't. Mm. And, um, so it's a s stenosis. So you can always say it's at point. So it's mid daral mamma again. I learnt these, I don't know them. Now, the only ones I know are your aortic stenosis and you might go cos that is what you need to know because that is common. Um, mitral regurge. Mm. To mama. Is that one? And stop it? Was he there? Push, push, push, push, push, right? Got it all about your pressures where it's going through which chamber of the heart during that part? Aortic and mitral they are the most important one today. The other ones of the MC QS. Nothing more. Yeah. Final question. It hasn't. Mhm. How much am I doing? Cool. Not nice. Any form of volume overload because if you get left you usually end up having. Right. Yeah. Yeah. What is K sign is that the, um, GDP is raised? And what do you get that in or any form of use? The constriction of the pericardium? So, T Yeah, that's the main thing. So you look at back, try out Pulsus paradoxus and co sign your main things when you have your M CQ of um tamponade. All the other questions. So, coughing up pink, frothy sputum. What is that? A sign of? Yep. And then what are your x-ray signs in left sided heart failure? Some action. Uh What are the x-ray signs that you find of ventricular failure left is, do you know an acronym? Oh And there's another one there's like, isn't it? All right, let me just print it out. Thank you. So ABCD is what I use used up because as I say, it's been a while there we are. Keep up. C what do you find on your chest X ray? I lost it. I had it. So sorry. ABCD alveolar shadowing, curly bee lines, cardiomegaly, upper lobe diversion, effusions and fluid in the fissures. That is the acronym for remembering what you find in a chest X ray back when your size. But you see like in the horizontal and blue fissure you see fluid coming in, so it separates it. But the main thing, honestly, you'll measure the damage of the heart as long as you've got a true film there. So it's not projectional and then you'll see some signs of pulmonary edema is what I look for. Uh But for your exams, the ABCD is a good way to remember it. So that alveolar shadowing, curly bee lines, cardiomegaly upload diversion, effusions, fluid in the fissures, weight loss because they're not very well. So they're gaining just fluids, hepatomegaly mainly just because they can't, they go from left, they do get right and then we were discussing the wrong answer. Yeah. All right. This A two A is one that genuinely happened to me as an F one. So this is definitely real life. This is you getting your brains working. This is not just exams. This is me as an F one with one renal red. We've got 40 patients. What are you going to do? The nurses go. Can you review this patient? We've got um Lee Lee's been on the ward for a week now. He's a 72 year old man who came onto the ward because he's got an infected leg ulcer. He was, he's been tachycardic since he came in. But we've done another E CG cos it's just not getting right. The E CG when he came in was sinus tachycardia driven by sepsis. But we've done it again. His new score has been persistently 56. We're just really worried about him. Cos you've got some time on the wall today. Would you mind reviewing him? Doc? Ok. New six. Happy. Not happy, not happy. So what do we wanna do? Do an A to a. So how do we start? And Lee's like, hi Doc, why are you here? I just, I'm just, I'm fine. I'm just a bit sweaty. You put me on this ward? Yeah. 89% what he said? Oh, we discussed this last week. You were listening to me doesn't matter. 15 L will titrate it down. Remember, the hypoxia will kill them earlier than the, the C ot retention. You can fix that after, but the hypoxia will come back. Yeah. Whack on the oxygen. He's already got nasal specks on of uh, 4 L. And you're still maintaining 89 worried. Not worried. We're worried. Ok. So we're in breathing. What else do we need to do in breathing? It's raised. It's about 16 ABG. Yeah, we'll send that off to the lab. Doc. Ok. So he's breathing quite fast. He's equally expanding and he's got reduced air entry at the basis. Both, both bases. The cushion can't have much. Yeah, we'll call the port now, but it's a bit of a wait. Um, anything else you need? Anything you want to do? And resp just, yeah, we've done that reduced air entry. The only thing I'll harp on at and again, the more you se the more you'll get used to it and you, I won't have to chime and you'll just be like, yeah, a to e, you've given some medication which is oxygen. You've done a change. So, I want you to reassess you never move on to c, until you're happy with the first one. So we've redone A SAT. So they're now 94. So always when you do something and even in your Aussies, say to the person who's playing the nurse, oh sister, once you've given those fluids, would you mind recirculating that BP and letting me know the BP, cos it shows I'm already thinking ahead. You've already ticked that box that I am thinking. Are they re fluid responsive? Have they responded to this? Oxygen? Oxygen is a drug? We're meant to prescribe it. I haven't, but then I don't think I've needed to since I've worked here, but still it's a drug, prescribe it. So we've done, we're happy with breathing as that are coming up. What's next? Ok. How do we stop the circulation? Just not sure we start to move up because he's really clammy, really sweaty and he's gray. Um, two seconds. Yeah, we are. What kind of cannula in, in both. I want it to reel off the tongue. It's gonna be so natural by the end of it. And you're gonna say, well, I'm putting the cannula and I want to blood cultures and blood, blood. Would you like? What bloods would you like doctor? And let's see, this coagulation. What's his BP? Oh, his BP. It is low. It's 90/60. Yep. See, I just, would you take, she doesn't have to, what do we? Ok. You're to query. Anyone else wants something in circulation that I have said is really, really important that you do in every single one. We haven't mentioned it. Not even in the bloods in circulation. We've done a BP. It's low, listen to the heart. Um Can't hear much going up the arm JVP. It's fine. Can't see it's not elevated. Yeah, we we can feel the pulse, it's really fast and it's a bit fe CG. We would like an E CG. Every single A to E please get an E CG and attach cardiac cardiac monitoring. We're gonna get there. It's gonna be this every single one. This is ba er sorry Lee's E CG and I was an F one reading this and I was told they were admitted with sinus tachycardia driven due to sepsis is the sinus tachycardia if I'm not cure the altern hands. Mm mm. Quite different. OK. So that's, that's is that, I don't know. Yeah. Yeah. Yeah. I said yeah, I don't know. I think, II think I think like I don't know, you know the right. Yeah. So then, so there's P waves. So an elevation it's regular but it's very fast. It's about it. It, it's, hm, not so 70 blood. So, we've done the P ri can't really see. I can't, honestly, it's narrow, it's narrow and it's fast. So it's a narrow, complex tachycardia, which by definition is, it is. And this had been misdiagnosed for a week. You'd come in with S VT. I've put this up because what is your step wise management of S VT? Mhm. Which is a form of a bagel. So, Valsalva is in stimulating your vagus nerve. Exactly. So, yeah, valsalva. But this is where you just get someone to blow into a syringe. See if that helps drive them down doesn't work. Mhm. How much? Uh Yep. Then it, it hasn't worked. 12 and then 12. Close, 6, 1212. And what should you have? So, when you're given this drug, this is what it is important. You have to have the defibrillators on and continuous cardiac monitoring. I was in f form of one reg panicking out my life worrying that we were gonna stop this person's heart because you've got one, you see it finally go on the monitor where they slip back into sinus. It is a very scary thing, but you have to have them with the pads on monitoring, on continuous trace going through and you give the drugs and it works. If they, we've said his BP is low. If it is less than 90 what would we do? Cos he's now if he's, he's holding his BP at the moment and he boosted up after he gave it, it was 90/60. So he's boosted up. Now he's 95/100 over, what is it? 80 whatever. But if he goes to 60/40 if he's still in SV two, yeah, synchronized cardio version, and then you can also go to amiodarone. But that is if they're hemodynamically unstable, if they are stable on the ward, which he was, he was only using 56, then we go on to doing your veg maneuver first and then your adenosine. That's your basic management. So this is the bit where I'm saying, this is how we did it, attach the pads continuous, give him the drugs and then if you're cardioverting, move on to that with synchronized shopping. So you got through C what must do? You always do at the end of it, recheck everything we're gonna carry on and do his disability and exposure. His BM is raised, his pupils temperature are all a bit raised. He's also got this in exposure on the end of his foot, which is what drove him in. Lee was not a well man, but he left hospital unfortunately with one left leg. But this was really bad that the person who'd clocked him in which had been checked by a med and an AM U consultant had been in S VT since the commission and it had been misdiagnosed as sinus tachycardia. And then the nurses come to me again with a new E CG and I went to my reg the same, right? And Kashif said, no, it's not Charlotte and we panicked and went to dealt with them. But that is the basic thing. So the main things I want you to take away with this is this E CG because people looked at that and just when that's fast, it's regular. I'm not worried. We've seen their bloods. His CRP came back as 300. His white cells were 18. This is a sepsis sinus tachy because most of the time this is the ECG you're handed and as an FT you'll be signing off these EC GS. But it's going yes, it's regular. But can I see those P waves? Is this normal and breaking it down and going that QR S is one square that is not normal and his heart rate is way too high. It cannot be sinus at this point. And that is the main thing I want you to take away from that. A to a reassessing and this and that's it. Sorry again. But Oh yeah, sorry. No, it's not. This is obviously where you will base everything. When you graduate. You, you're all done, your B LS and I LS you take home and have to do your A LS you card. This is what you stick to. This is back when I did it in 2015, they, it may have changed. But this is the basic thing you're gonna go through as it all starts. Each main thing IV. Access oxygen because as the F one is someone in S VT, your job is to get that green Cannula in at least and getting the pads on and being there for your r because you're not getting these drugs. Yeah. Any questions, see you back again, please. Just to say someone came and that's it. That's all right. Don't worry about that. Ok.