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come over here is a pretty nice for you guys were going to be Let's go through. So obviously this is what we're going to be covering the main topics that we're going to go through today. It's high potential. Valvular disease is rheumatic fever, infected, infected endocarditis and hokum. Um, just to let you know I if you are at the end, if there's anything that's confusing you exceptional, pop it in the chat on, you know we'll do our best to be able to answer that question there and then, um, on also, if you have any, I know there's gonna be a wide variety of people here, perhaps from people who just started clinical medicine. Did that you are coming up to where, but one on diaper silly, out of help when I was going through this entire process. I understand that it's tough, it's scary, but I'm really happy to stay behind, and we can have a bit of a matter after just to give a little bit of advice. If it's useful, control this organ. Other people that this group can actually help with that as well. So also to get excited and talk a little bit quickly. Sometimes. If that is the case, please just go ahead. Still be down to say That's a big quick Can you slow down a little bit? Mirrors? I think you're, ah, think you're Michaels on it off that fantastic. Without any further ado, let's get started so we'll stop some SPF. There's an 83 year old gentleman who's coming to Gtuss for the results of his ambulatory BP readings. The average BP is 145 over 87. He's got no other presenting on his past medical history Is interferon appendectomy when he was 40. Basically above information. What is the best management of this patient's hypertension? A moldy peen Be the stop blow or well done. You can decide I'm a pro or a monitoring, so I will give you a few seconds to be able to just answer those questions for me on. We'll see what we come up with. So let's give you about 30 seconds from now sort of point out and and, uh and it is it going so soon? Yeah, will get me. It's really exciting watching this guy. Okay, well, there is a bit of feedback, I think. Gosh, you might you might hear right. So you might want to set off. That's okay. Thank you. Um, okay, cool. So that is one minute on. So the majority of the Earth's is gone for a on there's a few for it's the correct answer for this patient is okay, uh, basic over how we manage hypertension and the and the algorithms that we use for that little bit later on. But effectively, for this patient, the answer is monitoring them. They're eight. The reason why is because they're 83 will find out later. That threshold is above eight with an average BP, which is just a little bit hyper intensity is otherwise got no other problems. So basically, the logic is that as they're a bit older, the anti hypertensive sorry is going to be causing a bit more harm than it would do them good for this sort of BP. As a cording, we would just monitor this patient. Lot of peanut disapproval kind of started around April. They're all different kinds that we could use if we're going to be treating this patient. But obviously we're not going to be doing it in this in this particular scenario, and I'll go into a little bit as well, uh, and go into the actual, uh, the albums no further. Um, so let's go over hypertension. So first of all, what is it means the hypertension means high BP. It's fun. It's a clinic BPH above 40/90 or an ambulatory BP of above 13 5/85. In terms of what causes it or etiology, it can be idiopathic, so don't know something. It can be an endocrine course. So there's these things called your crime aside. These are these are tumors on the adrenal glands on. They release catacholamines, and you remember adrenaline. That's what have they been recently into the blood system, And that's causing your BP to rise up. King syndrome, which is a increased reduction of increased productive sensory off cortisol, can also increase your stress response on that. Also, Teo, um, the risk of you getting high BP. There's also the renal system as well. So renal artery stenosis, stenosis of the arteries going towards the kidneys that causes effectively an increase in the rast synced um, Serena and you tense in the story and you're tense and system which acts to increase your BP. I'm just a sort of beside, by the way, something that does come up. SBA is quite a lot. Is a patient who's got They've got their absolutely fine, generate a little bit older, and usually you start them on an ace inhibitor and that EDS are absolutely plummets. The reason why they ask you what's the reason why? And it's actually one of the things that could it could be, is renal artery stenosis. The really I can go into the pathophysiology a little bit later of people are interested, but it's a because of this. If someone's got bilateral renal artery stenosis, you are asymptomatic contraindicated, so that's just their sort of SP a little point that you might want to know or show up a little bit with on the words if you need to. Obviously, if someone's in pain, where if they're emotionally stressed, your BP gets a little bit higher. We can all relate to that. I'm sure clinical features so often it's actually an incidental finding, and there's not anything specific going on, but you can have headaches, visual disturbance on further on, kid, the injury and heart failure associated with high BP is Well, all right, so that's just a few of the things on then. The next thing is, how do we actually go about? Like nosing that Sure that you guys are all medical student. So you're very familiar with this lovely website past medicine dot com, which covers it really, really well. Use. That's That's one of your premium. Your premiere remission resource is what we would do. One of GPS. We want to be taking like, a panic pressure. It's above 140 over 90. Well, I mean, that's a bit higher, but is this thing is just happening here in the clinic where opening at home as well. So we'll be offering them ambulatory BP, a home BP monitoring If when that that's basically they're taking this BP consistently over a period of a few days to just see what the average is when they're at home. If the average is fairly late, then they're not hypertensive, so script doesn't matter, you know? Just monitor them all goods. That's fine. If the BP is fairly high above 100 50/95 then any patient, regardless of age or anything else going on more started on treatment for the hypertension. Okay, if it's between these two values, then we start thinking about it a little bit more under have to meet certain criteria. So if they're below 80 years old on, they've got any of the following things. Target organ damage, established cardio vascular disease needs, renal disease, diabetes or a 10 year cardiovascular risk equipment to 10% or greater. What does that mean in English? That means that you use your two risks school, which is an online calculating you type in the patient's details. It pumps out a number on if that number is above 10% which means 10% risk of this patient dying from a cardiovascular causes in the next 10 years, and you start them on treatment. I was also remember when I was a med student. I was always heard this term end Organ damage being thrown around didn't really know what it means, but it just the organs right at the end of the system that could be damaged by the high BP. So one of the things is the heart. So you could have a ski nick into GI changes happening on the heart because it's just struggling to pump that blood around. And it's getting a bit tired and lethargic, and it's becoming a skin. Because of that, the renal system can be affected. So if you could if you could just imagine a lot of pressure on that kidney having or laugh of better even on the kidney, then that's gonna there's gonna reduce the amount of blood flow to the kidney or increasing the blood flow to the kidney on that can use the kidney damage. So you'll be thinking about things that the urine albumin creatinine ratio and also checking the you use. It needs a swell to see if there's any protein urea or if this patient's developed in a K. I have kidney disease, secondary to the high BP and also very important. You want to be checking the eyes as well. So we're looking for signs of papilledema or retinal hemorrhage, and you can just imagine that if that BP is really high, you just caught bursting off those off the off the arteries and granddaughters regimen the eye cause of these hemorrhages to occur. Um, interesting thing is, you have a blood clinic, BP above 180 over 120. You're a little bit worried by this, understandably, and you decide not to you being a GP would be deciding whether or not this patient is to come into the hospital for a specialist review on. But we the indications for that would be if this pain it's got any problems with their eyes to the papilledema retinal hemorrhages talked about before. Or there's anything else that's real life resting that you would be concerned about, such as heart failure, AKI chest pain, indicating that this is progress. Kenya were a new onset confusion. Or if you're thinking about the oh, chromosome times of palpitations, headaches and abdominal pain system the symptoms that you can get with that if you don't have any of these things and you just want to be investigating that end organ damage. So if you know, by doing all of this stuffy CG albumin creatinine ratio, taking some blood tests if it is present than you would after you obviously you've not sent them home, you're gonna be assessing exactly what's happening and send them home with ambulation BP monitoring along with the other investigations to be done within the next one or two days. Find one of these these issues you would be treating offering drug treatment immediately before waiting for the unrelated BP readings to come back if they're not present in what Nice said. It's due to repeat the BP with a day that's a to summer. So that is in terms of hypertension. Diagnosis. Um, are there any questions at this point that people are a little bit confused about? Okay, cool. I'm going to assume that, you know, and I'm gonna move on, all right? If there is anything that comes up, just go ahead. The second SBA than 73 year old Caucasian gentleman comes into the GP practice for the results of this ambulatory BP monitoring average BP at home is 170 over 105 minutes. Past medical history includes hypertension, anemia and type two diabetes. He has no known drug allergies. What is the most appropriate management of this patient's hypertension? Ramipril, candesartan, bisoprolol and lot of pee or well done time. We tried this something. Okay? And that's coming up, and I'm smashing it. May I'll give it about 10 more seconds. End this poem. See what that does. Fine, Doctor. Oh, good. Right, sweetie. So a lot of people have gone for a We're going to be d seems to be about corruption. And he is, well, you know, well done. But majority of you, you have that correct. It is a ramipril. Um, if you if you haven't gotten correct, absolutely fine. That's the reason you're here in this place. Well, okay. In this patient, the main thing vesicle you approach a situation. Always look the demographics because that's always important reason or another. In this case, it's a bit of a red herring. So he this guy has come in. He's had the gp practices, had an ambulatory BP. Monitoring on his BP at home is is still high. His past medical history includes we're and type two diabetes mellitus. The important learning point from this question is, if a patient's got type two diabetes than the first hypertensive agent that they start is ramipril, Which is why I ramipril is the correct answer. Candesartan is a ARB, which you would start it on. The computer isn't tolerated. The bisoprolol is a little bit further down the line. I'm not a pain. It's a calcium channel blocker, which would start if they don't have type two diabetes. There are about 55 or their Africa. Being on the rapid mill is a cardio selective calcium channel blocker which you don't really use our managing hypertension. Um, just a sort of know a really good way of remembering how to differentiate least two types of blockers. You've got your house, internal blockers, you've got the ones act on the heart and the ones that act Restoril e the ones that act on the heart off the rapid mill on DILTIAZEM. Right. You may or may not know that there's a dating up for the South Asian community called Gilbert So diltiazem and verapamil I for the heart. Whereas peripherally acting agents are your Peens, you die Higher group pyridine is right. So you've got your, um not a peon orphan with peeing are peripherally acting agents and that's what you use for BP. So that's just a quick would we get. Would we give? We still give amlodipine. If the patient didn't have diabetes, we'll find out when the next slides. Okay, so if they're above 55 this is good. So you would go for I'm not a first line, if that was the case. Yeah, yeah, thanks. Any further questions that All right, sweet question, then. 58 year old African be a gentleman comes into the GP practice, as his BP is still know appropriately controlled is a past medical history of aspirin and is currently on ramipril and ap a minute, and we'll opinion on a rescue salbutamol. Inhaler is ambulatory. BP is 143 over 90. And his re do you need a shot below? What is the next most appropriate step in this patient's management? The start on this up, the doxazosin spironolactone or bendroflumethiazide and give you a few minutes give you about 30 45 seconds. Try and get not room because the pores are all anonymous. So you guys printed without being afraid. That's really five seconds is my sort of limit. I reckon you I just like on pole, right? Cool and pole results. Right so the majority gone for a the answer. And then there's B, C, D and E. So let's look at what the correct answer is for this patient. Okay, that's just draw your attention to a few things here. First of all, 58 year old African would be a gentleman. Okay, Fine comes into the GP practice and is not well controlled. He's got a past medical history of asthma that's really important. A scarring is currently on ramipril and doctor Mind I'm not appeared. I've been salbutamol inhaler, but his BP is still not controlled because this we need to go to 1/4 line. Therapy on the answer here is actually see doxazosin. Remember how many people got back? So let's go through it together. So I was going through the next cycle. Go through the management off the moment levels of my BP thanks. The management levels off high BP and what we use 1st and 2nd and 3rd and all of that stuff. Basically, this patient's had the three line therapies that reduce as the Foot has the first had had the first three strips of the therapies that we would use would be a niece and a bitter a thighs of like diuretic on a calcium channel blocker. Because of that, the next step is to look at patients. Potassium of the potassium is less than 4.5. Then we can safely give a potassium sparing diuretic like spironolactone. If it's above 4.5, then they go for an alpha blocker or we go for a beat. A blockage on the decision is really made us to what's probably the cheapest. But also what other co morbidities that this patient have. So in this patient we know that they've got Asper on in asthmatics. Beater blockers are contraindicated. Now the reason why that occurs is that remember what a beach block it is blocking be two receptors. I remember the main medication that we used to treat asthma or one of them, especially the rescue is so beautiful, which is a beater to agonists, right? So if you block those beater two receptors, talk yourself beautiful where and you can also risk bronchospasm. Therefore beforehand you left with the choice of our the blocker beater blocker, You've no longer got beat. A blocker is an option. Therefore you've got to go for your alpha blocker, which is why I see is the correct answer. Let's go through the other options as well. So this patient's already on an ACE inhibitor, and the start on is an ARB. So we would use an ace inhibitor, reduce the side and if they're not tolerating the ace inhibitor, usually because a consistent coughin and explore the pharmacology with the later as well if you need to. But basically you don't given a senator and and they are being the same time we've talked about this open or being a beater blocker and why we wouldn't use it in an asthmatic spironolactone. So if the potassium is less than 4.5, then we would go for Spiro. In this case, it's 4.7. So we wouldn't get the spiral, because if we gave the taxi, um, gave the potassium channel blocker Sorry if we gave the potassium sparing diuretic as a risk that potassium to go higher than needed to go on the bendroflumethiazide. We've already got the thighs. I'd like diuretic in in place here with the doctor Might s so we wouldn't need to go and repeat that again. So I hope everyone's happy with that. If you do, you have any questions? Problem in the chair, and that's okay if you just let me know what's going on. So in terms of management of high BP, first of all, standard stuff, lifestyle changes don't eat so much. So loose. Um eight. Weight. Go for around. Do one of that stuff. I'm going after that. Working to this, this is again. Let's take from past bad sick use on we'll get, you know if they're below 55 years old or their Type two diabetic and also not Africa. Robien. Then we would start off with a which is an ace inhibitor or angiotensin two receptor blocker. So the ramipril enalaprilat stuff losartan a kind of start and stop. All right. That would be a if they're above 55 years old and know Type two diabetes or their Africa from the Africa have been continued. Then you would start off by going with C, which is which is your calcium channel blockers. Remember, this is the peripherally acting house channel blockers, your pizza, the ones. So I'm being a lot of if after this stage you it's still not controlled. Then you would then add on I the castle marker or thighs. I'd like diuretic if you started up on announced half of a nation hepatic or you would add on a ace inhibitor or thighs. I'd like diuretic if you just started up with a calcium channel blocker on the Step three three drugs and then step towards as we've discussed before. So if the potassium is less than 4.5 a spiro, if it's above 4.5 outfits out the blocker or a beta blocker, if it's still not controlled, then after it would be really very by by the methadone, just cardio, just to be able to look up a little bit further. What if their Type two diabetic plus 55 on Black African be in? In that case, it's about 55 type two diabetic I after a Caribbean. So, in my opinion, what I understand it to be. Obviously, that's what we want to check it out and make sure that's not correct, then I think, because the renal protective effects of of the ace inhibitors and type two diabetic too so much my understanding is that you would go and give him a some computers. That's my understanding of it. And it's okay if you want to check that back. Check me. Absolutely perfect. But that is my understanding is that you would go for the ace inhibitors Is being the first like that population of the helps. Um, any other questions regarding that? Cool. Let's move on. So I tend to So this is just thinking that can go wrong with high BP. And why were important that we need to control it. So cardiac, I like spitting up a system so cardiac causes cardiac problems. Sorry. Cardiac hypertrophy, my cardio infection, heart failure, sort of section or walls. Or got increased risk. If you are hypertensive, you've also got an increased risk of stroke TIAs basket, a dimension, a retinopathy. And you've also got an increased risk of kidney disease. Is I found it. Um, on it was made students lovely. Monix a doctor's s. So therefore see, you could remember for hypertension. Is your coronary artery disease? Congestive heart failure. Chronic renal failure Would cerebrovascular accident PSAs Well, so it's drugs. So that is That's tension. Yeah. Yeah, I'm pretty certain. Just because of the, uh, just because of the renal protective effects are so good for 18 temperatures. They really like them in diabetics. Uh, the reason why that they don't use them in Africa or being populations. You you got to reduce amount of ASIS, just a zoo background. But from what I remember having us a similar question back in when I was a med student is that despite this, be still good for the ace inhibitors. Um, they're in. They're in either population when they when they got diabetes, because it's just that good of diabetes. And the evidence base is just that strong in that population as well, Which is why we go for evidence based medicine. So let's go next one s before 62 year old man who comes in for review recently. He has several excited be the reports, feeling groggy for only a few seconds after the episodes and, frankly, breakfast with occasional chest pain on examination. Pulse is 90 regular BP 110 over 86. Lungs are clear as a systolic murmur, loudest in the aortic region, which radiates to the carotid area. What is the likely cause of his symptoms. Aortic stenosis, Motrin, good station, aortic sclerosis, paroxysm, atrial fibrilation or he aortic regurgitation. I will give you a minutes to be able to answer this question. Yeah, straight in. I did say Give everyone a minute and we've got 15 more people who have a baby. I have a guess Has got nothing to lose, even keep. Do you get it wrong? You know, one will never is Yeah, it's worth going for. And the evidence actually does say that if you do give it a try, you're probably gonna Yeah, you get more out of the session. The ones that keep themselves themselves. So that is a minute. Um, so the results Ah, as follows. The majority of people have gone for a I'm I would for a So this is coming. Isn't something slightly older Festival. Excuse me on. He's had several episode of syncope or fainting. Uh, he's recovering fairly quickly after, and he's but breathlessness in the cage chest pain. This is the fact that he's really quickly means that this is sounds this to me anyway, sounds a lot more like a non neurological or epileptic cause because usually after, if you had a full secondary epilepsy. You're usually getting pretty rubbish for a while after where is in this patient game? Just obviously, this is a relevant to this question. But just when you were thinking of your black out, West is acceptable. Your histories. That could be something to think about, right? He's feeling slightly breathless with occasional chaps. Okay, fire has got BP 186 So it's not wide. Dolich murmur loudest in the aortic regions, which radiates to the keratosis. I just let you know if it's Ah, systolic murmur and the aortic region, and it radiates of the credit that is a lot Extenders is, whereas if it does not radiate to the corrected than it is aortic sclerosis. How you actually tell that upon a is on auscultation? If you're able to really do that fantastic view, I still struggle, so don't worry if you're in that position, but just like you know so much vegetation. That's a pant astomic murmur, taking place predominantly in the mitral region that radiates over to the Exelon paroxysm. Nature of the relation could definitely be a course of syncope, but classically, the symptoms describes of palpitations. You might be expecting an irregular pulse by this pulse has been described as regular apologies. Skipped a slow and there's no yeah, moments of seven associate with it. And if we described a member of the question, there's a reason we put it in there. It's because we want to pick up on it, usually on about the reason why you're sick regurgitation in the diastolic member. And it's associated with a wide pulse pressure on multiple eponymous signs as well. So let's talk about about disease and moments. In my opinion, once you get I feel like bad really diseases, I can understand why that could be a little bit tricky. You're trying to memorize them is a list of things, but for me will help really help just to try and understand mechanisms of what's actually happening. So you understand the blood flow through the heart on that? What points the valves are going to be shutting on opening depending upon sisterly diastole, you can kind of get a little bit more of an idea of exactly what the murmur is going to be taking the point. There's really two types of the main off. How is that you get having about there are the stenosed, which means it been a turbulence and opening about. Or they can regurgitate, which means that they are just a bit leaky and they start the room. And it's not meant to be there right in real life for me, because I'm aware for me and I probably I'm sure for whatever you guys as well, because I have a decent idea in my head off what the systolic murmur would be and like members would be. I just go. Okay, it's loud, is in this region, and it's systolic. Therefore, it has to be this member, or it's it's diastolic and in this region. So therefore, it has to be that murmur as this goes through what it means. The systolic murmur is in the left side, the heart, most common ones, which is why they've been highlighted here. That's your aortic stenosis. Um, mitral regurgitation. Remember on your palm restenosis and tricuspid regurgitation for the right side of the heart, right? And again, if you're interested in ventricles, a current tracking the Bloods trying to push it's way through the aortic valve in the Palm rebel. So if they're a bit rubbish. Then it's the state, you know. The murmur would be off. It would be because they're struggling to open. So therefore the member would be of the stenosis of those welts. Where is if it's off the track hospital or the mitral valves? Then if there's a murmur there, these girls should be closing in Systole. And therefore, if there is a member there, it's likely because the valves of UTI or something. So that's the regurgitation aspect, Um, exact opposite for the diastolic murmur. So the left side, this famous one is three aortic regurgitation and the other one that you can think about may expect as well is. And my trust in a cyst on the right about you got regurgitation tricuspid stenosis on demonic that you. So I'm sure the junior cardio exam. So if you're not covered cardio exams that one of the things that you asked to do is to be able to exacerbate a particular murmur. And you ask that by pushing a patient in different positions and out and breathe and breathe out. S o n ammonic the right sided members get loud or an inspiration. The left side of my step ladder expiration. So the pneumonic there is a royal. I eat metal about old sound, really clunky. So when you're doing, your examination's like we'll be looking for on if you're stuck romantically brewing back to conduct our latest course. Any murmur, all right, And these in different regions and how I see a question. The attack last year. Seconds the Imitrex The nurses doesn't disappear. So basically, like what's happening is that the patients trying to exert themselves a little bit whatever reason eso at the baseline. That about the cardiac output of that valve is sufficient to be a cardiac output of the heart. When you have blood coming out, that heart is sufficient to be able to provide the blood supply to the brain and everything else is going to do. And it's absolutely fine when the patient's trying to move about it. Just go up or something, and you're gonna have a change in where that blood blood volume going. So maybe it's going out to the legs or they're trying to be able only little bit quicker, and the blood's try to go to the muscles, never less blood, just going over to the to the brain because of that now, about cardiac output isn't sufficient to be able to reach the brain in there for to go. And is that what's your question? You're very, very welcome. Anything else? I I'll take that as a no. So this is a little cheat sheet, common valvular issues. I will talk through it. But if you want me to hurry up and just move through the entire thing, then you know, just put me a message. Um, so aortic stenosis. The moment that we talked about injection systolic loudest in the order region radiated the keratosis of what we just discussed. The majority reasons where you get that is because you're just and when you get older stuff calcified in your arteries, everybody, unfortunately on. But you know, that's just becoming so nose and calcified. And that's the reason why you're getting this problem. If you're a little bit younger, so say that you're in your thirties, your forties, you start developing this member. Then it could be because there's a problem with that valve in the first place. So patients have got bicuspid heart valves there. That valve, if you think about it, is going through more trauma, then the tricuspid valve would be going through right. So accordingly that valve is is going to be. That was gonna be more likely to get some more earlier than the tricuspid one would on. Accordingly, the's patients may get aortic stenosis. Owner Your age. There's also a note. There's a characteristic parts of paralegal, low rise and belts. No idea what back means in real life. Less be a thing. Be aware of it. You be similar, but no radiation to the correct. It's mitral valve prolapse. So this is when the mitral valve insistently is going is going up and then opening. It's going to blow up and then opening right so that what that you're hearing is that Midsystolic Clicks is going on. That's the That's a classic, uh, auscultation off a much of a prolapse fairly common, and it is also associated with connective tissue diseases. That makes sense, because if that valve is a little bit floppy, then it's going to prolapse easier and go. But he's here as well can also need to regurgitation. Much regurgitation is a pansystolic flowing where blue pansystolic blowing murmur. Now this in the mitral region in radiating over to the exit. It's associated with prolapse, papillary, muscle rupture and heart palpitations. But remember rupture. So if so, that could be coming up in SBA like this patient had a heart attack. Now you listen and you've got a you've got a member with going on. What's a lot MRI? Because of this thing particularly, this may be an SPH thing and heart validation. So if you've got a petrified or whatever, it may be that you may have that ventricle becoming bigger and bigger and bigger and therefore allow the leaflets about valve is coming out out there for you Cooperative station happening because you may see stuff on a chest X ray just kind of regular because of the atrial enlargement. Reason why that's happening is because, as the ventricles trying to pump blood into the aortic valve and that way, it's got to be going through the mitral valve and expanding the left ventricle a little bit more, and that might be picked up just X ray on that PCG can show that classic M shaped big feeds P wave or P might try it on the on the e. C. G which I'm sure your EKG Lectures of coverage previously as well on the aortic regurgitation early diastolic, which is heard loudest and, uh, connective tissue diseases also has got a classic collapse in pulse finding what you pick up on on, uh, when you do the whole raising your raising the patient's arm when you're doing a whole cardiovascular examination, a wide pulse pressure is classically, I've been fixing meals. 60 millimeters of mercury. That's the difference between the systolic and diastolic reading. You're Scot dance in carotid on the head bobbing DiMasa sign. I've got silly ways of remembering stuff. If this were exploding fantastic, they must've kind of sound like dumps stuff to me and from Ryan sending dump step music Just go like this and they bang their head. So that's the way that I rub it with that one. Um, my interest in OSIs and mid to late diastolic murmur with an opening snap. They also this particular member is associated with Ah, a bit of a mile a flush because you've got reduced amount of blood flow through the entire system, basically in a bit of a backup so clogged up really off the the OT, which is building up in the body that can debate the dilatation. Especially prominent in the face. That's classic micro uh, Mala face is associated with micro stenosis, so that's just something to be to be aware of as well. Um, from an SBA point of view. So management wise, it's an echo for diagnosis and really, really simply, this's not absolutely perfect, but it's a good, you know. I know there's people who maybe could see the stuff before. So as a sort of good overall overview, if the patient's asymptomatic, then you don't really go in there and try and, you know, be a hero with them. You just understand and see how they do. We only really go in there if the patients actually symptomatic. And actually that's really performed surgery. We've got various different options, but with surgery types that would actually do metallic valve biological valves of the main valve replacement things that we can do, we make the choice between which, which one we're going to do, based upon how old the patient isn't, how long we've got. They re think they've got to live. If they're fairly young, then we're probably going to go more like you to go for a metallic valve because these are much more longer lasting. Where is the biological pig? Well, you know the big bottles of both right belt. They are more likely to counsel bye the issue with the metallic pounds. They require lifelong into regulation because of the sharing forces around in the when the flow is slowing down past the metallic valve on that increases your throat got a risk effectively so they do require. Mentally they do require anti coagulation. So that's kind of the decision. Those with biological valve make house by fairly easily eso you know, if the patient's older than that's probably going to be all right, because they're not going to make it for that long anyway. Um, but obviously, if they're a little bit young, we'll go from the type of. If they're pretty rubbish on, do they con sustain a full valve replacement surgery? Then we may consider a balloon valvuloplasty Kristen OSIs. I just go in when they're blow up a balloon to be able to help shake obstinance of calcifications that maybe on the on the bowel, for example, obviously the risk risk of that is to turn a stenosis and your regurgitation, so it depends upon the patient. How about there? Yeah, uh, and just let me to treat any complications that may arise from that point is it's like heart failure and written anywhere from maybe is that fairly? Is that very clear? Going? Assume That's all right. So then next for SBA, 5 30 year old Bangladesh sugar is brought into any profusely unwell, their father tells you, have a sore throat three weeks ago and yesterday complained a joint pain in her arms and legs. You noticed there is a wide spread rash on her skin, and she appears to be made restrained rhythmic movement as you approach the bed. She is currently Pyrex. Your EKG shows a first degree heart block. She has no known drug allergies. Given the most likely diagnosis, Which of the following is the most appropriate treatment option? IV Cough Enemy IV. A rhythm icing IV fluids. Lots of seven PM Dr Cyclen or IV Benzyl Tennis Center. Thank you very much. Okay, Sweet. That's one minute and pole and share results. All right, sweetie. So the majority of us have gone for a and then option. But there's a few. There's a few few in there for B C and D. Um, so that's absolutely fine. Okay, cool. So the answer this is? Well, first of all, can I just ask people to put in the chart what they think is going on in this particular patient? If you're feeling brave or even if you're not, just go for it. And guess it's absolutely fine. Yep, my card itis can't disease cool, rheumatic fever and okay, Rightist? Yeah, Group B strep yet. Cool. Well, thank you very much. Those guys for answering. So this is rheumatic fever, which is secondary to group B. Strep is people have mentioned on the answer to this patient for this particular patient is IV benzylpenicilloyl. Let's go through the Let's go through What's going on here? So 13 year old Bangladesh, you gotta soon as they give you a demographic with the world country where a developing country, then they probably going to be something that that's that's meant to him, that this patient, for some reason, is not going to necessarily have the same level of, um, I may not have had the same level of vaccination or hygiene in the past is, we're quite, you know, used to within the A or within Europe. So it is just a sort of thing that they made a new when you come up with with exam questions. Sore throat three weeks ago. So in whenever I see that on the half strep throat, um, now complaining of joint pain. Okay, arms and legs wide spread rash on her skin. So this is a thema. Sure, I get this one right. I think it's everything and margin Artem on your strained arrhythmic movements as you approach the bed. So this has been to be something called Citizens Korea. All right. She's currently Pyrex notions about temperature in a PCG sugar first degree up with no no drug. So as people correctly said, the things going on here is this patient had a strep group B strep infection or strep allergies, infection against the body's development of a hypersensitivity or autoimmune reaction. Just needing to all of these problems that bring it, the first thing we want to do is trying to make sure we get rid of all of that nasty bug on scrapped a caucus. It's particularly susceptible to benzylpenicilloyl, which is why he is our first option. So chlorpheniramine, that's an antihistamine. So if we were thinking that this was a carrier rash caused by, you know, allergy or anaphylactic reaction or an emerging reaction, and that's maybe what we're thinking off. But given the other history, probably not thinking with this is this. Every three myson could be given if the patient's penicillin allergic New cloxacillin is standardly the static October infections staphylococcal infections on oral doctor cycling could be used for strep throat, but obviously this pain pretty second. So we'll be going from the IV Bad boys in this one, right? Let's talk about about magic fever. So as we discussed Group B strep strep project is infection into a type two like a sensitivity, Actually. Now what does that mean? It's probably question, and you might be asking. Some people will be already know the answer, in which case could be fantastic. What's brought? That means that the you know you have this bug that's coming along, and the bone has got proteins on it. And as you probably remember, the body tries to deal with this book by targeting the protein to run the book on their four brecca guys ing it and eating it, getting rid of the boat now if it was strep protein. Is that the protein that you're on this particular bug? A very similar to certain proteins that found sellable of ourselves. So as soon as the body develops antibodies against this particular bug, it also is developing out antibodies against different parts of the body as well. And therefore it's attack, which is obviously probably the diagnosis and investigation that's in the investigations that you would use it in order to make a diagnosis. Obviously, the diagnostic criteria that we use is something called the Jones Quite area to the Jones criterion. Want to make a diagnosis called rheumatic fever? Need to have evident to destruct. A crackle in a factory from either from antibodies, a throat swab or a racket damaged in rapid Group A strep test, probably a group a strep group, a strep for this one might be on Jones and Jones criteria of what you want me to major or one major and to minor. This could be about remembered by help on the monitor, so you've got a major criteria with Jones and mining criteria with fail so major criteria. So J u joints. So if you got swollen and painful, drink them an arthritic arthritis that to me, Obviously that and carditis pictures are peri cardio Rub would be indicative that these nodule is the rheumatoid nodules that you're getting. Can also is also going to be a major criteria everything margin Artemus We described in sitting in his career that we described as well for the minor criteria. You've got a fever after al. Just painful joints not necessarily swollen. Pulling the quite sure of arthritis inflammatory markers raised on a lengthened PR interval as long as we don't have pancarditis is being the major criteria just so that we understand. If we're saying that the patients got arthritis, we can't then use a bike right here of Arthralgia. And similarly, if we've said the patients got pancarditis, we cannot use the length NPR Interval as being a minor criteria, you need to have another one of the minor criteria. That's what you're looking for in terms of the management antibiotic starting up and I've been paying the movement of penicillin on analgesia like insides, which is aspirin was quite commonly used on then. Also Haywood, if you've got some black systems career that we may need to use sometimes Dad's opinions like diazepam as well you want to be able to help with those problems used. It's quite, say, improved diagnosis on treatment. Which NSAID to Children under six? Honestly, no. But a clue. Um, I would I don't know the answer. That particular question. I would be very surprised if they ask you. It's a swell. If I was faced with that particular scenario, I would definitely be asking up chain as to exactly what they want me to do in this particular patient, because actually, very rightly said, giving it giving us bring, for example, in a car with kiddies on this it's could lead to race syndrome, Which is exactly what you asked that question, which is very good holiday. Uh, I don't know the answer, but I had I'm really sorry. Sorry if you've got if you've got a way to be able to find out that really, really sore, but it's people get from that. Sorry, I see any other questions. Hey, welcome. Cool. Um, anyway, next question, that 47 year old IV drug user comes into an E with seven day history of a fever and fatigue on Oscal. Take one of his chest. You notice he has a power and systolic murmur, which has not been documented before. He has had no previous surgical history. His observations rest fire BP, which is a bit low. Heart rate with 100. Oh, temperature 38.2 A respiratory rate, 23 infarction saturation of 97% room air. Even the most likely diagnosis in which location is the murmur likely to be the loudest a number we'd mount A B C D e. I'm not being rude. I'm going to try and look up into being after I see is questionnaire lier. That's exactly what I'm gonna do. That right now, I find in this area here, if you're on that and that's fantastic, and I'll continue on with my talk, Um, so I'm gonna end up, hold back so and share the results. Fantastic. Okay, cool. So it's actually a fairly even spread. Which jet really means that none of us have any idea what's going on with this particular with this particular doctor? Oh, which is absolutely fine and the reason you have probably turned up to this lecture. All right, so the answer is this question. Okay, let's go through it. Festival. We've got 47 year old IV drug user coming in with a seven day history of fever and fatigue. Okay, He's got a panic systolic murmur, which is not being documented before. No surgical history on is everyone in agreement. Just put in the chart that this patient doesn't look great at the moment. He's got BP, which is a bit low. Heart rate, uh, is a bit high temperature, which is a bit high. The respiratory, which is bordering on a little bit higher but is maintaining is option saturations everyone in agreement that he doesn't look great. Sweet. Okay, cool. Can we put in what we think the diagnosis might be in this patient? Don't worry. If you just put it in, don't worry about endocarditis, okay? Yeah, I see one just We're thinking it. Don't know, but don't know what you find. I e infected and a car right is under control. Itis sweet. It's weak, right? I agree. It has got ineffective. And writers? Yeah, The key thing in here is that this patient's an IV drug user. So the most likely thing that's happened is that this patient has been injecting again. We have to be quite when especially less. Be a question. You notice that they stereotype quite a bit on the stereotype is that they're going to be injecting. They're not going to necessarily be cleaning everything as they go through, so they're going to be injecting things through the skin. I'm gonna go through the skin, is going to be going to the Venus roots. Obviously, it's gonna be feeding into the inferior vena cava on then, going into the right atrium. Any bugs are going through obviously are going from the influence going through the skin into your Penis. Persist, um, into the interferon, be in a car for on then into the right atrium. And then the first valve that they hit is gonna be the tricuspid about which is a believe fourth intercostal, which the tricuspid side is the fourth intercostal space left sternal edge. Which is why that is the correct answer. Um, than the usual most common sites in a patient hasn't any other risk factors. Is the my actual area. But in this patient, cause the IV do you use it's gonna be the track hospital everyone happy with. Why that's the case on the mechanism behind her. If you could just put a little bit of a yes, then we can move on quickly. And it's no good. Yes, thank you. Straightly. Fantastic. Good stuff. Um, yes, sweets. And then the other. So then the other area second intercostal space, right? Sternal edge is going to be It's going to be the aortic area. Oh, yeah, sure. No worries. So with so let's go back. So we've got we've got an IV drug user on the stereotype is that this patient may not be using their injections or their needles very safely. Should we say so? You imagine that there is. You know, you've got a bunch of skin commensalism your skin. You're going to be injecting drugs. Hopefully not. But you know, these people, unfortunately, would be injecting their drugs. It's going through the being a system. Then it's going to go back into the inferior vena cava is going to go to the right atrium and the first valve that that blood is going to hit is going to be the Tricuspid valve, which on the space associated with the tricuspid read That's tricuspid area. When you're listening is the fourth intercostal space left sternal edge, which is why the Tricuspid area is. It's just why that's why you would hit here. They hear the murmur because the blood, the the organisms, have gone through the blood going to the first valve that it's hit with tricuspid valve and then seeded in that area and causing the colitis of that particular area. Does that make sense? Miro's okay, Absolutely fine. Thank you very much for asking question. I'm sure that you have the only one who was struggling. Um, so that's absolutely fine. Very happy to do all of that stuff. Yeah, Cool. A 58 year old gentleman comes into and you with a seven day history of a fever and fatigue in the skull. Take one of his check. You know, he's got pansystolic murmur despite normal echo. Three weeks ago, I had a valve replacement surgery. Isn't the questionnaire on the right sternal edge know it's just their laps. Dental edge. The right state alleged got the aortic area that's on the right side. So the patient's right. Then you've got the pulmonary area. Second crosses, base left, Little edge. Fourth intercostal space left. That alleged strike us bed and midclavicular. Fifth intercostal spaces. Mitral. Cool. I'm hoping that's okay. I see. I'm going to continue on with my explanation. Okay? Not absolutely fine. It's easy to get confused or get 58 year old gentleman comes into any with a seven day history of a fever and fatigue on auscultation of its trash. You know, he's a parent. Systolic murmur, despite a normal echo three weeks ago. Said valve replacement Surgery for a tricuspid valve four months ago. Observations as follows. BP 97 56. Heart rate of 114. Temperature. 38.4. Respiratory rate of 22 on oxygen of 90%. Given the most likely diagnosis, which is the most likely cut organism Staph epidermidis staff warriors Strep pyogenes strep very dance or strep Bovis. Okay, sweet. Thanks so much. I don't know if it's my bnfl or not, but every time I take also the just comes with a blank page on what you have to be in that happens down or not by hunger you could also with the if you guys weren't ammonic for the Oscars. A shins. A nice one island. While it's more physicians take money, yeah, works. Yeah, I'll just say you look. It's been about a minute in terms. That previous question is Well, I think was I saw you. Not sure they seem to what they seem to be happy enough in kids. Generally, I don't know about specific in there inspector robotic fever, but generally they seem to be happy with the approximate a potential option as well. So in terms of NSAID mean when you're worried about his aspirin, which is what I remember is well. But on the other, Thea, the other, the other end says, I think you you can get away with them kids, right? So let's end the pole right there. Good response rate, by the way. Good, good job, everybody, Um, And again, it's a fairly spread out. None of us want to go for Bovis, which is a bit sad, but you know is where it is on again. It's a bit spread out, which indicates that you know, we're not 100% sure what's going on. Sorry, I just shared the pole now, which is again absolutely fine. Whole reason you come here. So hopefully we're happy that this history's fairly similar to the previous eye. Guys got a fairly on specific fever, fatigue history, and it's got a new murmur. New murmur and fever is back to Benicar, right? Isn't it pretty? Otherwise, he's had a valve replacement surgery for his truck last about four months ago. Now the relevance of that is that if a patient's got an indwelling line in or if they've had valve replacement surgery, for example, then usually within two months of that surgery happening the most likely organism to infect if they get infected endocarditis after most likely organism to cause that is going to be stabbed every dermatis. However, after that two month period is passed, it then goes back to the usual floor of being most likely. And then that takes it, Um, staph aureus, which is my B is the correct answer. Okay, so as I mentioned step happy Terminus with the most common for prostatic bells within two months of surgery outside that window, chillin staph aureus is generally the most common cause of impact of endocarditis strep priority. Knees is the one that was associated with graphic fever. Strep very down used to be the most common one, but now it's going back to stop warriors associated with dental work as well. On strep Bovis, that's interesting. It's got association of colorectal cancer for So if you see your question, which is? This patient has got been diagnosed with infected and their card itis there. Blood cultures have grown. Trip Bovis Water's the next most appropriate investigation. The answer is, after you stabilize the patient, the answer is actually a colonoscopy on. The reason why is because of strep Bovis have got flora commence away, sickly on in a patient who's got colorectal cancer. What's happening with the preservation of that is the best. An invasion or breaking down of that barrier between the got slower and then your blood stream so you got four is now getting into your bloodstream. One of the biggest ones in there is going to be struck. Bovis eso basically strep Bovis makes its way into the blood stream. Then it goes over to the heart. Of course, the fact of endocarditis to happen. The reason why that's going is because of the colorectal cancer being there in the first place anyway. So the point being is that if you're faced with that question, what patients grow? Instruct very this. You just look for colonoscopy in the answers and just click that, you know, that's all right. Unless there's something else just, you know, screw you over. But that's how I used to do it. Yeah, that's it. Cool. So that's infected. Undercut that this is now. In fact, I think arthritis. So it's What does it mean? It's an infection of the of the leaflets starting off most commonly mitral valve and then aortic bar on a combination of the two men tricusp bed. Unless it's an IV, do you on the moment? Because it of organisms eso status or is is the most common that followed by extract various bands. If they've got a line which is in situ, or being there in the last two months or they've got a prosthetic lower than staph epidermidis would be the would be the course. The problem is, you've been worried about instructing me a message we talked about in colorectal cancer as a bunch of organisms called the Hack hack organisms and as well as Coxiella, which can also cause strep. All right, so I can also cause impact of endocarditis, the clinical features generally, when they presented my own specific, It's this left a gee fever. But they start on the heart for years, so sometimes they can go in. And people may think that had a chest infection, heart failure will actually happen. It's going back to the car. I just The important thing to remember is that if you've got a fever and a new murmur that's impacted interchronitus and it's proven otherwise, all right, some of the chemical we just you can get these Jane relations had spent a hemorrhage is a reason why those come up. The reason why those happen is because you've got the effectively. This colony of bugs live big on the on the vow to the patient, and sometimes these little bug crawling is going to fly off course embolize in the in the palms or in I can see, but it really, but specifically when that's in the hands and the palms, the painless ones of Jane religions on it's been two hemorrhages in the fingernails. If you've got an immune complex. I you've got a lift and I g antibodies or whatever it may be with along with a bit of bug, then these can kind of put them. These could be quite painful when they when they hit um, when they hit the peripheral system on compressant us what's called Oslo's notes and the way that I used to remember that they use remember generalizations and most of them which one's which always listen nodes. I remembered something like Somebody told me our our Oslo, on some reason that stuck about something work to make. So if it works for you, fantastic, it doesn't That's absolutely fine, this one. So there is also a diagnostic criteria for back to get the colitis. That's what the Dukes criteria again. There you need. There's a major and minor stuff involved. So in order to make a diagnosis, you either need to two major one major and three minor five minor criteria on the and the pneumonic is be liver. So major criteria is one of blood cultures on echo. So the blood coaches actually showing organisms present we need either to or a typical is and is, um one for a positive Coxiella, usually in clinical practice, were asked to take three blood cultures from separate sites. They also think about an echo showing vegetations indicative off a colonization of that particular about again. This makes sense, right, because it's an infection off the endocardium, usually valves. So it makes sense that these two the infection markers and that, you know, is it one about are the two major criterias here and liver is the lab lab stuff the blood cultures not meeting the major criteria? Immunological findings like those those numbers in arthritis vasculitic bone Is that embolize Jamie's lesions? Are they extremely hot with a fever above 38? And do they have risk factors like a previous car cardiac surgery? Or are they in IBD you, for example? So that's interactive card endocarditis in a slide effectively with some hopefully useful Know Monix Any questions on that? Yeah. Who? Oh, IVG you means intravenous drug user. Sorry about that. That mean using, uh, uh gravy A shins without without saying anything, without explaining that which is a bit wrong with me. Happy with that Casey know where it's actual? Any other questions? Can you explain how cackled medicines. There's a heart attack is actually I don't remember each individual one. I think him off. The less is one. And maybe I got remember the other ones to be honest, So they're just the hack hack. It takes a C e k. I think klebsiella is another one. Um on effectively, Each one of those letters is another effectively genus, effectively a back of bacteria that's could potentially cause, in fact, of endocarditis. There's just something that seems to come up when it goes to this particular diagnosis. I didn't remember every single one of those things on. I was fine. So that's why I just put it in there is a sort of letting, you know that is, if you want to go in and learn a little bit more about them, go ahead. Absolutely. So Oh, this is fantastic. King Geller. I was close, Um, but yeah, so that's just a It's just a bunch of different. It's just a bunch of different organisms that can potentially cause these infections. I just didn't want to mess up the slide and make it, you know, put them all in there basically, but I didn't remember that if that makes any difference to you guys. Um, so we'll get any further questions. Cool. That's wrong. So this is being taken him to be enough. Um, I'm this is just the antibiotic therapy is that you can use to be able to manage impact of endocarditis. This wouldn't be my first thing that I would necessarily go in and learn. But, you know, if you've got you know, you don't know what MRI is. For example, probably you don't need to know this stuff, but if you want to just build up a little bit more knowledge so this is what this is for. So there's a few things that generally coming up the steam. So initial treatment for a native bowel amoxicillin plus minus gentamicin depends on how serious infection is if their septic you go vancomycin meropenem to the real big boys. If they're paying allergic Vankin gent. And if they're gonna prosthetic. There you go. Thanks, gentle added inside. More fun percent as well. If they've got staphylococcal infection, then and it's a native valve, you just go for flu clocks. But if it's a prosthetic barbers, you know, a bit more uncertainty. Exactly how that valve is going to respond, and it's going to see it a little bit better, so you need to hit it with some bigger drugs, like a person in gentamicin. As you mentioned streptococcus particularly sensitive to penicillin, penicillin? If they're not for this, that's standard adults and gentamicin. If there any of the high tech organisms and you might go for our A marks and gent on, then with the resistance and you go for Catherine gyn as well. Obviously, the arts do any antibiotic therapy when you're asking and asking is that I would check with my local guidelines and prescribe accordingly. Responding to some stimulation goes cultures that we've got it. But that's just something from the be enough. It's the one put in there in case you want to do it for completeness, and you make you need to consider surgery on in situations due. So it's either when the valve has become completely incompetent or, if actually, for antibiotic benefit you to remove and replace about. So if they've got cardiac failure, for example, or if there is an aortic abscess, which is their infection isn't responding to the antibiotics that you're giving or that's still AM. But I after the antibiotics have been given, then that would be indications, then, for replacement of that after invented indacarditis situation. Okay, So, um, sorry. Is there any other questions about I e Are we happy Enough of that. Okay. Oh, okay. Very happy. That's very nice of you. Cool sp 8 24 year old man's come into a needs passed out in middle of playing football. Fourth time. This has happened on our sport. A shin You here in ejection Systolic murmur loudest in the left. No external border. His mother comes in in terms of his patients patients. Father died age 32 following a similar presentation. Given the most likely diagnosis, which investigation findings would be most likely on echo showing mitral regurgitation and asymmetric hypertrophy. And the C G showed right ventricular hypertrophy and fbc showing h b of 76 the c g during ST elevation or an echo showing aortic regurgitation on symmetrical hypertrophy. Do you have apartments or not? Yes. So we're gonna go let it run for a minute? Uh huh. We'll kind of get to 50%. Oh, no. Okay, that's fine. Well done. For all those who voted on These are the answers. A majority of us have gone for a on. Then there's if you spread between the other options as well. Okay, so 24 year old guy Young, that's the first thing is young. It's come to anything passed out in the middle of playing football. Now if can people put what they think the diagnosis is in the in the chaps. Okay, some people, it's a hokum. So other people have said something. How you came as well. Okay, cool. Yeah, I agrees. This's hypertrophic obstructive cardiomyopathy. Um, so it will hokum so well done for. Those guys were thinking about that so immediately Suit to see that, I think. Okay, that's immediate. First thing I think about other ways well played. Football suddenly collapses. Bang. That's what I'm thinking about. Always been hit in the head and it may be, ah, middle Mingeon. Artery lesions have loosened or something like that. But you know, Doctor has been hit in the head of the football. But in this case, absolutely hope. Miss My first, like my thinking injection system murmur. Yes, this fits, and his mother comes in and tells the patient's father died age 30 to 40% of presentation. Now we're going to discuss the same in the latest like, but just let you know. Okay, um has gotten older, someone dominant inheritance. So if you've got a family history and you've got sort of presentation, you almost got diagnosed, right? Associate it with on Echo with a symmetric hypertrophy on a Montreal regurgitation. And therefore, those who voted a were absolutely correct. This is predominantly left side. It s so you have the left in particular hypertrophy and hopefully as opposed to right ventricular hypertrophy Intrasite be is incorrect. See, So he could be anemic. That's true. Like that's chemicals murmurs and can cause the fainting episodes. But it's really, you know, he doesn't have any particular reason to be in on. Also, we've got this family history of pointing us into this direction. Okay, ST Elevation and the C G. So it's true you have the skin changes on X G associating the hokum. They turned speedy raven version. Predominantly, they're not ST Elevation. We don't have this patient that it's stemming which the other thing we could be thinking about on a article gurgitation symmetrical hypertrophy. So usually it's, um, our and a senator black option with the Echo findings. So let's go over Hogan Epidemiology one and 500 or 27 dot inheritance we talked about before. What's going wrong in this condition is you've got a defect in the genes creating some contract are proteins and that leads there hypertrophy off the left side of of the left septum on the the Internet trickle a septum predominately on the left side. Exactly wise, and that's, I don't know, 100% sure, but it's this is the pathophysiology behind. Okay, What happens then is that you've got, as you can imagine, when this heart so the heart contracts you've got an obstruction, which is preventing proper blood flow through the side of the heart on That leads to your murmur on because you have to push a little bit harder and there's muscles get work on that they get bigger. That's why you get the left ventricular hypertrophy you're carrying secondary to that as well. This because you're getting this that ventricle getting bigger and bigger. This mitral valve leaflets were getting further and further apart on becoming more on, and you've got this particular thing called systolic country movement of the anti relief of the Byetta valve, which is just a sort of SP a sort of thing that you may want to paradox one of the cardiologists or something to look smart on. Go also, because of the the hypertrophy that securing you can have a description of the mechanisms, the heart as well needing to use the cardiac deaths in terms. The presentation. It can, as with high potential, be asymptomatic but obviously can lead to these collapse. So ejection systolic murmur loud run valsalva me there and also the sudden cardiac death. And if people remember the Fabrice move around the case, the guy who passed out in the middle of your picture few years ago, this was three said virus, because of oh, come on, I know you guys might know a little bit better, but I'm pretty sure now that when it comes to professional athletes, they usually do a little screening to make sure that they don't have this underlying conditions as well. Uh, I don't know. Anyone else knows a bit more about that, but it's something that I remember here. I can't independently verify that. But it would make complete sense if that was the case. Okay. Any other questions about that? Que. I just want to show you the CCG. So this is the CD from a patient who's got hokum. Other thing that I wanted to point out to you guys, Is this left ventricular hypertrophy on and the T wave inversion which is going on here? Yes, that happened four times in a common for that to be that recurrent. Uh, I think the idea I was trying to go with here is that he's had these episodes before, which is just getting worse and worse. I'm haven't actually had a case of by I'm not actually seen a case present this such, but it wouldn't surprise me if they had these episodes that, you know, actually thinking back he had these funny things happen before. I'm not quite certain about it a little bit better, and they've moved on. Um, so the answer is I'm not 100% sure because I've not seen in clinical practice. Um, the main thing I would remember from your guy's perspective, they got a young person with a sudden collapse. Definitely think about this is being in differential. Um, I wouldn't worry, necessarily if it's happened with the work. It's, you know, the first presentation. Because it could be a lot of you. Is that okay? Is that since that question, Casey Sweet. So I just want to know from the question, you know where it's sweet. So three is so versatile. T wave inversion. It's very obvious here. You've got your pee waves. You're curious complexes, which is just coming on on top of each other and your T waves. Number six is going down, right? Thea? Other thing is well, is that can reappraise gates now if we go back to our EKGs Festival. S o N e C G is basically a measure of the electrical activity off the heart right now. If we remember all chest needs So we've got a factory. Be 123456. From here across Hit, the one is going to be predominantly looking at the right side of the heart. Be six is gonna be predominately looking at the left side of the heart. I just to reiterate that stuff I'm sure you've been told before is that when you see electrical activity going upwards. It means that electricity is going towards that particular lead or that that particular lead. But it's going away. It means it's going further away from that, particularly in this case, the V one, which is the right side and be too as well, which is a predominantly right side of things. And the cure s complex is predominately going away. Where is in the five and the sex is predominantly going towards. So this points to the left side of the heart having that big muscle mass on that side. Because that's predominant new left sided. And you've got these deep. You got these deeper s waves here. Sorry. And he's really tall. Are waves? Are there certain director criteria which could make a diagnosis of electrical perfectly based upon this on this is something that you may see, for example, in a patient who's got hokum. Um, people relatively happy with that explanation of the CDs and the reason why this is a poke, um, related e c g or anything. Further questions based upon that, any other changes in this particular condition? No way I can have a rib musical exactly, too. So I think the actual common reason why this the people actually have the death at the current. It's because you've got such bad conductance they end up going into the attack and b f Um, just because the conduction is so messed up. Um, but obviously in this case, those the main changes that I didn't see and this particular a surgeon cool. Any other questions? Cool. I'm going to assume that that's a resounding no. So in terms of the hope of investigations of management, ECD showing some particular signs, they can have a F and they can have deep two waves as well associate it with, obviously, a normal conduction part ways of dealing with the Heart. There's echo findings that could be remembered to this demonic Mr Semashko. Drug vegetation, systolic anterior motion of the interiors have to leave that on asymmetrical septal hypertrophy on the main way that we manage. It is to try, and suddenly with these occurring, so amiodarone and beat of luck is being spent some relief on. Then we can consider pacing or defer, having implanting a defibrillator as well to be able to restart the heart in the case that it does go into a pretty horrible arrhythmia. Okay, On at the same time, if it's patients developing any undue terms, like half and we sort of pictures, then we might need to be able to at Accord and as well, um, that is my