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Hello, good afternoon, everyone. Welcome to Cracking the Code E C G workshop, webinar myself, Logica sing Talk. I'm one of the co founders and coaches of Jim Saw and I'm thrilled to have all of you all here for this amazing E C G webinar. We have Doctor Sophie to officially here with us. She's MD PhD Medicine and she is also currently the professor at New Vision University and we also have Kiara Maxwell. She is are amazing workshops director from Gym Sock. So here fourth, we'll begin the workshop uh webinar. The webinar will consist about the basics and the criteria that we follow in the E C G after this webinar. Well, also have a workshop on 29th. The details for the workshop will be shared soon and the chat will be enabled soon for you guys to ask the questions. But we request you guys to ask any doubt, any questions that you have during the last 15 minutes, you will have a chance to interact with Doctor Sophie and you can discuss all your doubts in all your questions regarding SCG over to you Dr Sophie. Thank you so much for joining us. Today. Thank you very much to give me such opportunity. Okay, can we start now? Yes, doctor, I remember. Hello, everyone. I'm very happy to be with you and to make some little bit introduction of our work. So we are doing the CGM webinar. So today I will talk only about the general and basics of the E C G because the main aim of our project do is to do is to to we have to do E C G closer. So all students will participate in today's webinar. So they will start to work on a Z glossary. Uh This is easy glossary visual present during our session which will be held on April 29. Is it OK. Tough. Yeah. Yes doctor. Yes, there was the format of the glossary. So we shall uh maybe maybe be a Google account. I don't because that will help us to do the glossary, but each student should present its own case. Uh For example, uh to make the whole grocery all theoretical grocery okay clear. So now let me to usually start with a little cartography. I will usually turn off my video and I will go to the slides. Okay. Can I start? So, no, I guess most of students, of course they are say no C E C G. But today we are starting from the usual beginning, we have to talk today about the basics or the electrocardiogram. Okay. But it it is that that really coming. It's a problem just second. So I cannot really love this love show. Can you help me? Uh huh uh guys, can you? Yes. Uh can I continue? So? Sure, sure, go ahead. So this is this. Yes. So now I guess usually now are the basics all of you, of course, know what the E C G. So we are taking the C D in order to record all L activities which are happening in Jakarta muscle. Yes, you know that's a cardiac muscle is autonomous organ saying heart is usually able to generate and conduct imposes okay. Therefore, uh we have to record E C G in order to understand whether we have uh cardiac ischemia, my granny faction corner syndrome or whether we have the healthy type psychotic ever to me is okay. And all of this information we can obtain through the recording of this message. Okay. So now in order to record the SCG, initially, we have to also use a specific device which is the recorder. And while the ECG recorder, we have to attach these different electrodes onto the body in order to make the the COPTIC like here, you can see, see differently. So and now let's speak about the leep uh lead production, okay. So usually in the E C G, we have these 33 bipod elites which is the first, the second week settle it. Also we have the usual three additional leads from the leaves it will be area a yes, as well as finally, we have the six because their lead from even to six, they are usually in generally in our routine test. It is a 12 lead ECG because by the 10 electrodes which are attached to the patient's, but we, we are taking the 12 lead ECG. So we have the six leads from the list and here we have the six limp from extremes. Okay. So now let's see how we should arrange the defendant style. It's for example, if he has a lead bank lead one, it is usual is um uh it is a lead and it's composed. So what elephant should be placed on the right arm and second director should be located on the left arm. Okay? And as you see in four throws the right hand, which is a negative pole is directed towards the left hand, which will be in this case, it will be the positive Pope. Okay. And in special direction, this orientation of the sleet director coincides with the horrid total access. And if you see here on this panel, how does this, this corresponds the angle of zero? Okay. So usually see uh angle for the first treated for visit zero. Okay. So in order to make the second lead, we have to put what Ellicott on the patient's right are and second elephants you have to put on the left leg, okay? And as you see, it's, it's a negative pole. Here it is the right art and the positive oh It is in the left leg directed from the right arm to the left leg before it has some type of usually leftward direction. In order to assess the special, special orientation of the second week, coincide with the angle of 60 degrees you see here, they're fours this this usually access of the second week. It is a 60 degree okay. And finally, in order to usually obtain and record the said league, the negative elector should debate on the left arm and the positive electrode should be placed on the left leg. Therefore, the the lead access direct from the left turn towards the left leg. It has some kind of right for direction in it's specially it's concert with the uncle. Also I had a drink. OK. This as uh to summarize specially it is it's usually elite access which is placed in which coincides with the uncle of the zero. Secondly, access and corresponds to Angelos plus sick, sadly corresponds to Angelos plus 120. Okay. Taking concentration. Usually that when we are taking the limb beliefs, we are making so called ain't harvest triangles. You see ain't over the anger, which is the usual triangle, which is made by the usual is the link electrodes. You can see here's the electron uh in toti ago. It should be composed by the writer by the left hand, by the left length. This is it's usually typical and harvest the angle okay. But the question will built about the right and my food, right food usually is used as a reference electrode. Okay. Therefore, uh from the right foot, we are not taking the impulses, but we have to put here's the electrode in order to record, usually say to in order to make the whole secret, it is used usually to Rico otherwise tick on it real like okay. Okay. So for the right food is considered as a reference electrode. Okay. So the 0.8 having three anger is the first week. It is the usual cedo. Secondly, it will be the usual as a plus 60 and send it will be the plus uh had it went, please note usually the least blows. It is a horizontal line it's called are located in the deposited the area and and then an obstacle is the light. Uh it's considered it's a negative area. Okay. Realage recorded. Augmented lead key are usually VSE augmented lead. It's for this A V R A V E L L A V F. Okay. So how we are making usually see this dogmatic late if you're specialist this area area. AVF are usually Junik elaborates here, we do have to post like in case of the increase. Yes. So well, to make, for example, every year we have to put the active electrode on the night are and impulse will be directed to the right side is into the beckford position, okay. This will be a heavier and from this point of view, you can see this usually see algal for the area, it was a minus 150 because as I told you, the leads after horizontal line, it's obviously negative area there for the angle for the night area elite, it will be the minus 150. Okay. So similarly, so two other electrodes from eight hold surrender will be use this reference electrodes. Therefore, active electrode in case area, it will be the uh usual place on the dry car and left and left foot are used as a very select. Oh okay. Similar evil makes the active are even makes active electrodes on the left arm, I can obtain the uh the elite you see in every elite he has active electrode, which is put on the left arm. But the right arm and left foot are usually connected as they're usually used as a reference electrode. Okay. The angle for the HDL also is oriented to the left side but also into paid for direction. Okay. Therefore, here I got good with the mindset. Okay. And finally, if our American usually active electorate on the late food, so that with the impulse will be directed into the vertical position, you can see here it is a vertical position. So therefore angle here will be plus nine. Okay. So in order to mix the summary, you can see the first week is Horizant Line. It is the usually zero uncle here, second little elected to over to the left and here we have the other plus 60. Sadly, it usually the orientations. Victor died a little bit on the right before angle will be 100 plus 120 area usually is nega materialists angle will be minus 150. It's usually coming from the right arm. AVL also is only into the left side from the left are set for the ankle with minus one minus 30 and aVF usually it is a vertical lines. Therefore, angle will be class nine. Please note as you see from this usual circle here. Firstly, now every f little orthogonal it's sets me that angle between these two leads equals 29. Why we have to know because when we are calculating the access, we have to use these two orthogonal lease in order to estimate the car Takacs. Okay. So I guess you understood uh this one. Now I will go to the usual next slide. All the next slide you will see from the presentation description, all of this lease which I already told you because here it's brief description of this thing which I have told and now I will go to the final slide. So after sometimes in certain uh usually normally we are taking the 12 lead the city to describe the Caddick events. But how in certain condition conditions we have to to take additional reads. For example, sometimes if you have signs of the right medical infection, we have to use the right side because they're electrodes in order to usually use to describe usual is um events which are happening into the right ventricle. But what I skipped here because I think it's correct to put a slight, let me to explain the six record. Well, it's because I skipped, sorry because his right was that usually uh was that put collectors? Therefore, after recording to the 1st 23, heavy aviate and Aviall Risk, we have to record. He has a six probably. Well, it's, it's the this record to record six because they're late. We have even to the three before we find the six leads. Okay. So please know that here's if we called their leads are also unicorn. Let's what does it mean? So we are attaching elected into spa particular areas of the thorax. Okay, into the Precordium is that we can also record the city to, in order to record the even we have to put the usual is sick. We elected on the fourth intercostal space into the right side of Paris tunnel line. In order to record the usually V two, we are putting the active electro it onto the red side for senticosus space into the Paris tunnel line. Okay, we four corresponds to affects the four correspondent. We are putting usually the electrodes on to the fifth intercostal space on mid clinical line and the three will be usually locate, the state will be located between the B two and before. So we far in order to record the V five leads. So we have to also put here the electrode onto the fuse intercostal space into the anterior axillary line. And we six. In order to record the V six fleet, we have to put the active elected and to say uh midaxillary line infusing Kolkata Space. So four consecutive the B four V five V six always. Is this A, this elector should be placed on stiff hips, intercostal space but in different lines, yes, V four should be at the meteorological life. It's the intercoastal space V six will be verifiable busy until accident line. Here's Intrakota Space and B six will visit media to the line 50 intercourse. A space. Okay. Here, this fusion electrodes usually are the beautiful electrodes. But here also we have the reference electrodes. Uh electrode is paid by the eight homes triangle here and here's the effort uh focus the center of this usually in to Vestry and here it is the usual reference. Uh Okay, so you go here we are taking the usually by this elected. We are taking the usual is um S G M s which are usually happening into uh traditionally rooting, rooting traditional routinely we are taking the 12 with TCG. We have these three. I know that the stomach make some three limber electrodes fresh which are usually uh firstly, second and settle it. It will be vital electrodes. In addition to this, we have the three documented electrodes area every L N A B F. And finally, we have a six because they're electrodes from everyone has to be six. Okay. These are also closeted as a unipolar electric. Okay. So in our daily activities in the uh our daily routine were taking 12 with TSH. Okay. But however, as I told you, sometimes we may have some extra conditions, some usually some special conditions which require to use additional leads, additional leads in. We are making in some particular conditions. For example, if it has a size also right ventricle infection. Okay. So especially how we should assess the signs of right typical infection. Initially, we should have the ovary of sciences because if a little Michaela faction and you should have the hemodynamic and stability if patient will present with chest pain and easy defined. Because if the world my Kanye faction together with hemodynamic instability always is in this condition, we have to rule out the possibility of the right practical infection. And therefore, in this condition, we have to put additional beads, it will be very nearly. History are before R and D five are sometimes we are also putting statistics are but maybe let's hear these three are before R and B five R. As you see these electrodes, this uh history are before that we five other trace on the right side of the thorax, but in the same area as the V two history and before bath on the right side. Okay. Therefore, it's usually it's a stable location. What we have to also assess here visit, we have the statement elevation is this place in particular in Israel before uh before. Uh if it has the second elevation, this makes diagnosis, rights and equality faction. Because from this patron, from traction SCG can estimates the signs of the right friends call infection. Okay. This is very important to understand. Also sometimes also we are using so called just like. So sometimes we are also using the additional electrodes which is usually well received the seven V eight and V nine V seven V eight and V nine to record. This leads, we have to put the additional electric on the back of this patient. Okay. In fifth intercoastal, it is a V 72 visit, posturing accident, life is intercourse. A space V eight will be usually the scapular else sir, Paul Benign will be usual is in paraventral life in 50 to cause a space in which in addition, we are recording additional in your back foot leads with seven through T nine. If we speak presence of posted about Michael infection, we have to also put the erected of the Pecos patient in order to record the SCG in this particular worries. And if you observe here as a segment elevation, this will indicate it one of those if possible. So okay. But also how we should make the suspicion about the considerable magritte faction from the surface. Very TCG you will do your for your sed glossary because since we are making the Z glossary, while I will explain your E C G, I will also suggest some particular test which we have to do for you. Usually for closer, for example, you can present one well visit a our letter are it could be for example, the right ventricle infection you can also present here's one E C G which will indicate to say right, thank oh infection. Also you will do some convert in which condition we have to suspect because a little right went for infection as I told you, yes, if you have the Coumadin as the key and we have the signs of infec A ble infection, yes. Consequently, if you will also do, for example, was it related p for example, possible Michael infection? Yes, you will find the appropriate E C G and you will make the comment in which condition we've got to also put it helps the suspicion that we have the possible Michael defection because it would be more interesting to usual present. And by this usual specific condition, we can make the whole ECG clustering according to the letters iconic Tuesday after the particulars. Okay. So now before a successful about the lead access, okay. So now and you see usually about the access, I guess you, it was usually enough. So I guess you don't have the question. If you question, you have additional questions. I will give uh re explain. It's yet also. Now let go to see and now let's proceed and now let's think how to make the interpretations easy. Okay. So usually too big, the usual interpretation easy. G so initially, we have to take it okay. And we have to also take the CT and so record it and then we are analyzing usually is what we have on the E C G paper. Okay. So initially, baseline is E G assessment and requires usually accepted the cardiac, right? Whether it's right, it's coming from the S A note whether we have usually we have to also count the legs of iron interval. Us, we have to also see whether periods are present on loads. This indicates that we have the usual is um sinus, right? Also based on estimation means that we have to count all intervals, peon interval, we'll have to assess the better, okay or as complex as well as we have to assess as a submitted changes. So for these basic things I will explain today, but particular abnormalities you will present in your ECG closer because the specific comment in order to precise everyone that construct the whole ecg glossary. Okay. So now before I will talk to description to, before I will start uh talking about the particular and waves like a cues of you. Chrissy can tell, tell you about it. Raj type of information we have to obtain here. We have to obtain very many TV, Cuban our way s way TV. And you pay okay. But usually if you will do sometimes we entertaining the, basically because it's five ways this previous cure, you are uh very TV. Yes. But since the cardiac cycle is continues, these views are usually connected to each other as their composing the cardiac cycle. Yes, for example, p very correspond to Atras history cure. This complex mainly corresponds to ventricular systole and TVL corresponds to recovery about the appeal into a segments little bit lately. But usually this image in order to seal both, we have to look to the city. And also we have to usually recall the SCG every week. And finally, we have to assess what we hear so on the CT, in order to usually make the initial interpretation. Okay. So in this actually what we have to do, we have to also count the cardiac, right? Okay, because we have, of course, you know, we very well how to assist the heartrate. You can count the heartrate through the past. You can count the heartrate from the telescope race and usually the your telescope, it's the appliques, it's your choice. But also we can use CCD in order to estimate the heartrate. Okay. So what we have to do and how to come, I guess I'm absolutely sure that you know it because you know traditional box methods which are using, which we are using every day in order to estimate the heartrate. Yes. But now let me to explain how um why we are using the, what is it Music Box methods usually traditionally, when we are usually making the E C G, we are, we are in specific, we have to record. Is it on the specific paper? You can see this is the mill emetic paper here, Mila Matic paper. As you see here, we have the small contracts and as well. And we have also the big contracts. Yes, five small contracts are making this one big contracts. Okay. Also, it's very important to understand the whole uh align all the mathematic paper charism and the vertical line corresponds to amplitude. You see that was this line, it is the time and since. Okay. So in order to understand the uh the account the interrupt, so we have to also now no value of the smallest and biggest contract. Okay. And in order to estimate the value of the contract, we have to know the speed of the paper because usually we are recording sec is it is moved into the device and therefore we have to know the speed of the paper. Yes, generally in more than is it the device is the speed of paper? It's usually 25 millimeter spend second. This means that the permanence I can't the speed of paper is 25 millimeters if I know this, so I can estimate the value of the one smallest contract because one smallest contracts corresponds to one millimeter said. Well, in order to estimate the value of the one smallest contract, I have to divide one by the 25 it will visit point point four. Otherwise in milliseconds, it will visit 400 milliseconds said usually. So therefore, if the HVAC follow the smallest contracts, point point four, since the five quadrants I'll make exist won the contract the value of the one because it will be 10.2. Okay. So four by this approach, I can usually know the calculate the time. So afterwards, I have to take the legs or two other interval. And by this approach, I can calculate the heart rate. For example here, sorry example, if I'll take the distance between this second set are in cover it accounted to beef contracts to be value of the rand because that I already know it is a point to the eye. So consequently, is it too because that will be the time of the 0.0.4? Yes. So traditional formula potential equation is to to calculate the heartrate, we have to also use a television liquid Asian Asian which is written in old books. This equation equals it states hearted equals is 60 divided by the length of tarantella. So therefore, if I know the length of two because that which will be in this case 20.4. So uh put this variance equation because your heart it will be six divided by the 60.8. How much to 16? No, not pointed to 0.4. Yes, 60 should be divided by the 600.2. It will be 60 to do advise the 600.2. It will usually sorry, not 2.222 times 0.2 60 should be developed as a 600.4. Sorry, it will be 150 because value of the one quote that it's the 10.22 of them are bridging 0.4. The process divided by the 0.4, it will be 150 correspondent. It's usually if we have the only to conduct between two consequent other intervals. So it will be usually the heartrate here will be seen 150. Okay. So if I have only one conduct between 202 level 16, this is the 160.2. Yes, 60 divided by the 600.2, it will be 300 before boluses once ordered, it will be 300 is permitted. I said, well, I guess you understand why usually how, why these boxes have led to see 305 115 100. Yes, for example, in third case, we have three because that's between two other men tables. So because here is 20.2 point two and 20.2 300.2 and 40.6. Yes, 60 divide visit. And in 6 41 150. Okay. So, so this is usual social estimation. So, so it's your choice how you do it. You can also use so called box method. But also first with me, I most like to usually calculate Smith uh bigger contracts because sometimes usually are an interval, not coincide, not always busy, bigger conditions. Sometimes the distance between a rental can include not always a bigger quarters, but also it can include the smaller contracts. It well it's not that makes the more accurate estimation, heartrate. You can usually use the equation 60 divide by the legs of two other intervals. Okay. But problem is that usually store here you just sometimes this equation. So this box method or otherwise usually traditional method we have to use in case of the irregular heartbeat because this usually this method needs a 300 methods. Needs a traditional equation doesn't work if it has irregular heart rate. Okay. So, so in case of irregular heart rate, we have to use the 12th method, 12th method. So it will be your tasks. So you can do to the HZ Grocery. For example, 12th methods will be for example, usually 10 at ski. Okay. Uh For example, you can do for the heart rate calculation, heart rate calculation, you can upload how you're using the 12th method uh okay. So irregular heart rate, for example, traditional is a 12th admitted we are using in case of astra tribulation, okay. Because classically it's access tribulation is related with irregular heart rate. Therefore, of course, in the cities, we cannot use. The traditional equation is the 300 method need to usually classical equation. Okay. So now after estimation of the heartrate, so then we have to assess it usually can't access okay. So in order to assess the card that access, we have to take this six basically. So which case we have to do? We have to have on the CT. We have to look on the first week. Secondly, started with a year aVF Alien leads. Okay. We don't to estimations cardiac access. We don't music record elites, we only need these six leads which we are taking from the extremes. Okay. In order to estimate the cardiac access, we can, we can use two equations to approach is that we can use, use the quadrants. We thought either we can dialectic, calculate the anger to estimated cardio ax more easiest way to estimate the cardiac accesses, the quadrant mitt what we are taking, I guess you remember I told you yes. So firstly, every fleet are sorta gone elite. What does it mean? So the angle between these two leads is because the ninth. So in order to make easier the calculate the cardiac access, we are taking the two oughta gone elites first in the end, usual every athlete okay and looking. So whether we were positive or negative wave things, the sleet if in both first fleet, as well as every athlete because the positive are berries, this means the return to normal acts. Okay if in both settings in first week and every because the negative are ways that we, that we cannot determine zacks. Okay. So if it goes, we have negative, it is the first fleet. Usually we have the positive our business. But in every, if we have the negative space, see which means that we have the left access Tabish, okay because access is or into the left food. But if into the person, we have a negative s fair. But in every if he has positive arbit this in the is that because the higher taxes deviation because vector is only into the right side. That wise you see by looking at the director is simply on the right direction because what is the direction to see individually? We have a higher argue and individuals we have a big as well. We can do simply so we can easily estimate access okay. Because usually traditionally, so in normal heart, we have the normal access. Therefore may lessen need vector also can be affected. It's okay, enthusi it's concert. This is the country's for maximal barrier of sleet, maximum amplitude possibly over the vase will be in second device because Mary normally heart access is located into the second tree. Okay. But in certain cases where we are have suspicion about the hypertrophy of the less medical, we may have also left axis deviation, okay. But in case of usually the right hand full of problems, we can also have the high taxes stabilization. Why I did not position this year because it will be get your trust. Yes. Uh So you can do the uh letter left access devolution. So you will upload your E C G and you will make some comments what we have to take into the consideration in case of the left axis deviation. Yes. Similarly right access donation letter are you can also make your usually little piece it together with little comment in order to make usually closer to force it right? Access division. Okay. Okay. But usually as you already understand by the U quadrant method, you cannot calculate the ankles. But sometimes in order to make this very accurate estimation of the E C G, we have to calculate here's the ankles. Okay. Now, I guess and from the beginning which has the 6 may reads which, which has, which has, which has a special orientation. Yes, for example, first, it is zero second plus 60 said it's plus 120 AVR minus 150 area uh minus 1 50 80 or minus safety and A B F plus 70. Okay. And by C six usually lead, we can estimate the exact angle of this cardiac access. Okay. What we have to do is this is the methodist know or known as echo opposite approach. To use acrobatic approach. First step here to find the lead where we have the usual mm equality of the RNS. So it is the equipment, the grades when R N S well, app little this equal. Afterwards, we have to find the reeds. Well, we have the maximal, our visit will be the positive read. And finally, we have to also assess it where he has a maximum negative rates when we have the maximal deep s well. Okay. So act is always open equal to echo of a secret in direction of the positively. For example, if you have a secret zero access will be usually accessible, busy but prevent equal to zero in the direction. Also maximally, for example, if the maximal positive reason okay toward to the at least set for here, sorry. So access will be practical that which will coincide with it if you had. For example, if now let's see if here, for example, let's take the hundreds, let's imagine usually is in second grade. It is equal physically that way if you look on the E C G R S U equal into the second right here we have the angle 00. But after other words, we have to look in which leads we have the maximal amplitude, those RV. For example, if on the standard STD, we have the maximum amplitude into the state leave. So we have to also go to the right for direction because there's the Oriental is oriented right side. Yes, since I know the second before it was two plus score is supposed to plus 60 I'm going to perpendicular to plus 16 to be close to the 150. Here we are adding 1982 16. Other two usually cesic a access for because why, because E M C maximum, our bases looking said with that we, we have to go to the right side directions that for t access. Well, if a plus 150 but imagine if we have also the everybody read into the second lead, but maximal amplit those are better is located over to the every elite. Yes, it's opposite direct. It's visit left for directions before I'm going to the left direction. Tober to the every elite and pay particular to the 60 it will be minus thirties. So correspondingly access will be located close along with the elite before it's all busy left up. Okay. So you can see always when we're using to this equivocal approach. So always initially, we have to do see well, in which because the equality of the island as well and then you have to find which is the most positive lease and you are going in direction of the most positively because access always auto going up to the Prevacid quit in the direction of the highest army before this is usually most simple approach. Okay. So now now in China, let's go and see and talk about the practical er intervals. Yes. So what else we have to see, we calculate the Codec access, we calculate the heartrate. But now we have to also look to each way and count the internals. Yes. So we have eyesight. All the basic ways here are are waves. So P wave to Q A R Y S and tvs, sometimes we also, as you can see the Jewish also there because they are usually connected to each other. Because cardiac cycle, this one usually one moment before all these uh integrative their first year. Also we have to count the interval. So so appear interest is a basic interred vaso which corresponds to time of this usually conductions in postion is kind of snow to the EDI note. Okay. There's obviously P an internal before, if it's in la increase, it means that we have a delay of the conduction from a same note to see any note. Okay. Afterwards, we have to access the best of curious complex whether we have the vitamins or security complex because in which condition we may have the Vicodin nonsecurity community which has for the band average blockages. Yes. And you can all also presents LBBB in letter L. You do everything in case our it will be our BBB letter are corresponds to our BBP. Therefore, you can also oppose E C G T because then I mean, is it the example of our BBB? And you can make some comments, what is uh which type of conditions could be? The Lasix is that these are B B B is RBC LBBB. Okay. Then we have to assess and look at S S F and tvs whether they're positive or not because usually maybe we should have the usually positive tvs. Right? Well, activity, no one should be always positive because you know what is usually, all right. Now, let's see why the proposed because you know cardiac cycle increase it phase of the polarization and depolarizations. Yes, deep polarization always thought it's the level of endocardium and it usually it's goes towards us. Epicardium. Yes. But repolarization starts on the induced epicardium and goes back to the endo condoms. Therefore, the various of popularization popularization are different but that that will be safe. Okay. As a result, you have to always have the positive race because variable depolarizations is from endo too epic cartoons that for it to be positive. But where was the re polarization of a pea to endocardium? It's opposite direction but very self say a similar but because always vectors from minus 2/2 plus yes, from negative to positive before usual TV should be always positive FTV. It's negative. This may indicate to Michael the ischemia. Okay. Also, once we have to take its considerations that we have to also access it shooting Toral about the beauty, integral little, we shall talk a little bit lately, but it's the time it's got exposed to the factory carry. And if it's increase, this may indicate it can also indicate to risk of those a day. The point uh semesters and the point at Christmas, we can also do T rex 30. You can make sports at the point medical address me and you could will oppose the CT and you'll make some comments. What does it mean and why we should, in which condition we have to take is this interest concentration? Okay. Now, let's see, usual is um normal C G. And now let's go by the people. I would usually start by the available. Let me remind from an A to me, I guess you already know. But a little bit, let me to remind about how impulse is usually conducted from a say no to the usually conduction system. Yes, you know that in heart, we have that done pacemaker which is S a note and this nominal pacemaker is located into the right actions. Yes, you can see here and from the S A note in for uh for the right to the rep that comes to the bomb uh route, but also merely the impact should reach to every note, which is the second right pacemaker, usually normal heart dominant pacemaker is always a same note. Therefore, normally all imports should be started from the same note and they are the same conducted to the imposed actually. And finals, they're reaching every note which is his second line pacemaker but it's not active activation of second line pacemaker occurred only if it has a failure, also faced line pacemaker. For example, you can do such type of uh sea sick sinus syndrome. You can do a letter S six kind of syndrome, six kind of syndrome. You can present C E C G as it reduces comments. Sometimes in case of sick sinus syndrome being you may have not always, but we may have activation of the second degree pacemaker. And you can also do so for example, in which condition we have escaped junctional, right? Also you can do for example, escape junctional right. So this also will be junctional right, but escape interesting mutually to see in which condition we have the activation of the second degree pacemaker. Okay. Finally, from the junction impulses conduct was essay know to the junction and from the junction it conduct impulse should be condemned to the his bundle and his battle will be should be split it. You know, it's very well from an atomic, it split into, into the right and left testicle, right and let branches. Yes and let that should be split it in uh uh terrible positive testicles. Okay. Uh Finally, uh particular my card um he has a look in your fibers and this is usually finally, usually it is really in lock it in uh medical um are cartoon uh look in your fibers are considered as a state line pacemaker for the improvement the apply bors. We may have also uh for the putting the fibers we help, we have also usually escape it over is correct. But he said like pacemaker is active in special conditions that you can make the letter later. It will be I don't correct. And you can use your present E C G and final. You can also estimate in which condition we will have usual is um activations in the ideal and declare, right? Okay. So let me take some break. Okay. And after a couple of weeks of break, I was usual continue to talk about how to usually they say analyze the message. I will help to analyze each way. Okay. Sure. Thank you so much. Doctor. We'll have a short break of 10 minutes and I would request everyone if you have any questions related to the topics that we have covered so far, you can put them in the chart box and we'll make sure we asked them during the question answer session. Thank you so much. We'll begin by five PM again. So, so can we continue? Okay. Yeah, Doctor Sophie, if you'd like to continue to have five minutes because the participants would join back in five minutes. Ok. From break. Doctor. Okay. So yes. Uh afternoon, Doctor Sophie, we can begin, I think. Okay. So can we proceed now? Yes, sure. We can proceed now? Okay. So guys, now let's continue. So we'll usually finally we usually stop. We're talking about the conduction system here, mainly we have three dominant, three pacemakers and dominant pacemaker. Pacemaker is always s A note usually is the minute activity. Unusual exposes the emphasis from the 60 to 90 imposes per minute because it's normal cartia. If the S A note produces more than 19 positive with the tachycardia. If it's in the process imposes less than 60 BPM, it will be the practicality. Okay. Therefore, it is a normal pace maker which overdress as a pacemaker, it's dominant pacemaker in normal conditions. But for example, if it has activations, every note, every note cannot makes it faster in process. Generally, it cannot makes if it's escaped, not the right. This means that we have more slower, harsh it no more than 60 BPM, but sometimes it can accelerate it and sometimes we may have a junctional delicate okay. So you can also make it usually junk Chua writing letter J what we have here, for example, Joshua, right, we can do escape Jiaxuan, right. Right. You can do the usual accelerated junction, right? You can do also Joshua to Alicante. Also please note that when you do this glossary, you have to take Mr makes these three different patterns of the sexual violence. Yes, because so when right is coming from the junction, we have to see the relation business, the periods and curious complex whether negative periods are positive periods complex where the negative periods are follows if yours complex or whether periods are barrett, even the periods complex, that's where you present. It makes the glossary about functional, right? Always take these products in your considerations and make some comments. Okay. So also in from the set line pacemaker which has the cooking the fibers, he has idea vet school, right, which is very slow so fall. Uh Madonna, it's very unstable because it's very slow, okay. But sometime we may have the acceleration of together with polite and we have also made for a country. Of course, you know, the event is what Carter lives, certain conditions that music because it gives usually can't do a defibrillation to made cessation of the cart. He also, we can usually such as they relate. Er, for example, I've idea what's correct and you can also raise patterns. Yes, escape either what's correct, accelerate it uh critical, right? Or for example, ventricle country. Okay. You can also describe these patterns and you can describe in which in comment you can put in which condition we have such type of usual activation state line pacemaker. You know, it's usually it's dangerous considerations that well in glossary, you could usually make your suggestion what we have to take its consideration. Okay. So, but mainly we have a normal heart in normal heart because the dominant pacemaker, which is a same note. Okay. So right now, let's see, usually stage the, the Parlodel, let's go to the deep polarization and deep depolarizations. These are usually spaces of psychotic activity. Yes, deep polarization, you know, from the facility, it is usually exceeds potential, but the polarization is the recover okay. And I usually just reminds you usually that usually cardiac cycle, it's usually conscious for basic phases. Yes. So you know, so it is usually we have here plateau in muscle, we have only two faces just we have deep polarization polarization. Yes. But in cardiac cycle, in addition to deep polarization polarization, it has a plateau. Yes. Because why we have the plateau because it relates to the uh deals of costume from the uh mycoplasma critical uh cause it has a plateau okay about this also. So you don't need to usually make it closer. But if you wish to states and make some letters of course, but it's not, it's it's general pretty fizzles is that you don't need to usually makes it correspondent letters supposed duplicity, deep polarization. Okay. So now let's see. So cardiac cycle it starts with the answer. People that ization here you can see it's came out it right here. So it's coming across every note. So, so sorry, it's coming. Uh s a note. So okay. And so as usually it's main pacemaker and France essay. No, it should be reached to the any note. Close it every know if we have the you can tickle activation otherwise it went particular cyst ori and the ventricular deep association is the is curious complex period corresponds that'll systole and went to assist elite will visit usually curious complex. And afterwards we you know, he will, which is always positive in normal condition. I told you right? Because the depreciation start in point where deposition was finished. Yes, I foresees the people start always from the endocardium goes towards epic cardio. The polarization will be starting, epicardial will go come back to the endocardium as well. TV. Usual direction will not be changed. So waves are different but vertical direction direction is similar. Therefore, normal TV should always positive. Okay, it will be recovered. Now, let's see usually how usually uh let's talk about the practical of years. Now, let's start from the PD. Yes P well, as we already know, correspond to actor system, okay. And always all TV should be come across a say note because you know all the say no, this is a dominant basement. Okay. So, so from the dominant pacemaker, it goes to the letter to activate the letter to through the parliament Bandel. Okay. But finally, it should reach to the every note from this usually uh here, here's Evie here's appear internal. Yes pr intel correspond to usually the time of conduction from S A note to the any note. This is usually usually there is some conduction from the back here to the uh assume to the uh the usual conduction. So they say no to see any note, okay, take his contributions that if in certain conditions, we have the prolongation of the peer into more. But in other conditions, we have usually the shortening as appear in terms of for we have to precise. For example, if the WPW syndrome, you can do the letter W and they send the WPW syndrome. Also, we have L G O system which is related with the short appear interval and you can do that later. L and describe what so busy L G O syndrome. Okay, generally. But in case of every blockages, you know, it's very well, we have the problem Gatien appear into uh well, you can do the letter A and every blockages and you can put the information about it, peer in cover. Let me do also, you know that most in most condition pivotal should always positive unless in a beer lead, it's always negative because you know the now let's see the video where because every every this here it's very far from the heart and heart is locate main here and area is here. It was the right side in work for directions said for all positively, all positive negative in every elite, it's very important to understand. Said, well, the va normal should be negative in just a little area. Okay afterwards, maximal amplitude uh correspondent Kartik access since the normal access okay into this this area. That basically is a second let we should have the maximal amplitude on the previous. Okay. So, but uh the leads which are far from the cyst in leeds is just that we have more decrease tablet of the previous, for example, in area as well as in central, we have a little bit decreased uh Victoza periods but period should be negative always increase of usually a fairly okay. In precordial, it's for even from the six, mainly we have the positive periods but sometimes you may have a bike as periods you least given and be too. So, so it should not be considered this battle because sometimes we have a positive to negative deflections periods for use these conditions, usually it should not be estimated this patent. Okay. So for example, uh now let's see, the usual, it's a time or time of the peak corresponds with the links of PV. It's usually corresponds to 120 millisecond. It's a time, you know, whatever and Africa, it it should be less than 1200.25 million votes because because it's a vertical axis. Okay. So usually it's this is the normal P veins. Okay. So please. Uh so now let's see, schematically what we has depolarizations at you. You can see. So it's say no, then you can see how the emphasis usually spreading how the impulse circulating the actress. This is another deep polarization. But usually normally we are not talking about the utter depolarizations because after the polarization, usually uh we are not estimating general and usually we are not making its estimation. Yes, you can see here the other day politician called is supposed to ta did we usually for those superior you see period is applied usually because it should be positive but after a deep uh should be negative. Is it conditional? I've because after the polarization usually started also into the endocardium? Okay ST for Ta they will because I'd to the pubic, do I understand clearly? Because liberalizations actually a same as depolarizations ask because if okay, if you remember, but usually, so if you remember the ventricular depolarizations was started once and the cardio when was going to the epicardium. Yes. And particular deep polarization was started was uh cardio, it was coming back to the endocardium. Not clear, it's not the same. And when we are in which point, what is that if actually politization starts was in the cardio deep polarization, it is starting to look at the depolarizations also will be studied in the same place. So for she usually the population is a value of TV, which follows the same direction as people realizations. Therefore, consequently, ct anyway, since this is this, the places should be opposite to superior, it's very important to understand. But this is very minimal, it has a minimal impact usually due to Libya, not usually even well, especially big attention to city, but in case of pedicle diet, ease of all uh particle, we have seen this invisible tea. So this is it okay. That's what it's just we really looking at this reality, of course, you can do usually your glossary. So after a recommendation letter A, you can put E C G and you can put also your comment. What does it mean in which condition it's it's more visible? For example, if you have some every blockage or if it has many less is it pericarditis? So actually, tarcher, this T A will become more prominent before this may give some additional information. Okay. Other by scrutiny, of course, and you think even uh because it's 300 basics enough, usually interest to this usually event. Okay. So afterwards, usually, so take this conservation, we talked about the dominant pacemaker. Yes, it was s a note. Yes. S a note usually. But you already know from the physiology, the hardest artoms organ. Yes, it's, it's able to compose and, and conduct impulses. But also please never forget it. Also hard innovation. Yes, because here we have a sympathetic input as well as he has a parasite to put the OK inputs. Therefore, due to sympathy paris and activity which usually has sickle their cycle cycle changes, heart rate also should be changed. So for during the surgical, your cycle, of course, normally heartrate's varies. It should be. So why? Because in Monica our thread, we are actively help more increased sympathy activity while we're spending our heart beats are better alone because you to activation bankers uh usually the heart rate valve, it is normal, phenomenally, it should be present. But in certain conditions because the usual decreased heart rate variability, especially if it's a desert data process and which process. Adelaide degeneration. For example, mainly in elderly patient, it has a limited heart rate variability. It's late is a theological aging process or sometimes it because the decreased heart rate variability. Invention with diabetes medic because you remember is in the diabetic patient because it happened in Europe which also affects you tions, heart rate variability. OK. All in if you have city a congestive heart failure, this destruction of S A note. And usually we have many neurohormone disruption in case of conscious heart failure, we have also decreased heart rate variability said for this. Also in the case to an federal talk to step, you can do the age later age heart rate variability. You can describe the event you can describe that. Usually we have sit at the unusual change of heart rate variability. And with each condition, we have to take usually more uh more information. For example. Well, we have to take its consideration if we have the adult patient or pace every severe heart failure or maybe that patient, we could have the decrease has variability. This explained by the underlying conditions as well. You can also make it you're closer okay. So after P R segment, P M P R segment, I will tell you just to remind about pr interval, pr interval, you already know it is the length of the conductions, the emphasis of the S A notice every note and we suggested about some glossary considerations. Now, let's talk about the P R segment. I will show what is I get, you know, because I'm, I'm trying not to show many teachers because you already know saying that it would be interesting for you just to specifically important dishes. Pure said is this segment and it's used in order to estimate this, that we have a credit card tax. Yes, because when we have a down slope, because the pure segment, it can defend the pericar that is made sometimes if you have the uh great uh we may have also counseled because the pure segment but really we are using pure segment is in case uh it should be downside, of course, the main. But how is the baby's type easy define this. We do have a case of headache attacks but also never, usually you'll forget about P R segment. You can P P R segment and what does it estimate? Of course you can do and you especially uh closer. Okay. So afterwards, so let's now start with Mexico's history as otherwise known as curious conference. Okay. Curious Compal is, you know, it's very well, this corresponds to the medical assist Ary, this is is this phase okay. And usually it's uh also Maxwell's company is no more the point. Well, for a second, yes, that usually if we don't have interventional blockages So usually we should have, you should not have the biting curious conflicts. Also taking considerations that in a very elite. So since ever little copper is mostly fact point from the heart. Oh uh they shouldn't be negatives that well. Are they will be negative? Okay. So if you look at a violet are should be negative, it's normal conditions before uh we are usually we are not most of, you know, we are not looking a view. Yes, if you have some following the right ventricle, for example, if he has right and co infection or uh right, Mint cross train in every a what has upright argue with this indicates that we have some problem because generally in every risk, in terms of negative are ways if they become upright. Of course, is this indicate easy to write and for problems is a displacement of electrodes because sometimes everyone makes mistake and put the yellow a little the right side and developed to their elections before this will be this. Therefore, it will give you really okay. Besides please avoid have the vice versa conditions, you can also see misplacement of elected and which have the ct we have a case of misplaced with electrodes. So if you will become the upright and first, it will be the opposite, right? Because due to usually inappropriate putting or elected, all these upper rings okay before you can uh ready. So now let's usually continue. Can you um procure it's complex. And you know, I am telling always every day I mentioned many times depolarizations stuff always goes endocardium. I go through this epic cardio and the politician will be vice versa. Okay. It starts always epicardium. It goes back to the endocardial said, well, finally are getting positive tea leaves. Okay. So for if it has a ski me or manufacture, of course, we'll have the TV Universe so you can do the close of TV University Vallin version, which type of condition put a bitter taste visit TV. Universe. Okay. So now let's see the usual see the faces of a tickle activation. Let's see in the initial phase, what we have here initially as you see the main victor from the left, there's a medical activation goes for the left to right. OK. As a result, you know you are obtaining birth, little bit curious. Yes, especially interesting left. For example, left side, it's a C B five V C's and facing area. Why is it mainly from small cube? Because initial activation is of course from the sector from the left, right. This is you know, initial activation. Therefore, because here we can see small Cuba's but we know that uh legs occupational be great. It has a one for so yes, because if it has a deep Q you know what it is this card before you get Cubans or scars, that type of group that you can do. And you can describe what does it Miss Car and what we have to look where we have uh we're looking at where we have the deep cubes. What does it estimate? You can describe your uh Tikosyn? Okay. So phase two of the deep polarization here, we have the activation also usually goes 20 concept as you see here in process to cover effects. You can see here okay here from the end according to the epicardial okay. Uh mainly so critical, mainly the left hand conceptive Ated Singapore. This means vector is placed into the hardest plane because there is it will call response to the the six. Uh but it was the front thing interested that we therefore corresponds to usual. Second for maximal apple does the main better correspond to the second rate. Okay. This is because mainly activation those postman tickles okay. But because we have the usual is um and that's critical because main event because before it has the usual such type of direction. So what does this secondary? Okay. And finally, so finally, we should if you notice so initial phase, it was he acceptance that it was left at five activation also basil part of the ventricles uh in final usually phase, we had aspirational based basil part of the ventricles for Shia will have the coating s way s very expensive because the negative S waves okay you can see here okay. This especially because it's a wrist oriented to the backward of this patient okay, you can see here to serve it. It's obvious. Okay, seat. Okay. Let's see. So it's related to the activation bustle segment of the of the micro. Okay, schematically, you can see the usual uh place of activation together, initial activation. So sense usually uh initial cures and we have the curious complex and finally becomes s so obsessed because due to activate shouldn't bother part of the both medicals. And finally, after this, of course, the face of the people realize they should be finished. Just to remind you of the orientation Victor different starts was endocardium goes towards epic cardio. The pro Victor is positive because this endocardium is uh minus the deputized, epicardial positive that projector will be positive and the popularization well visit vice uh vice versa. So and look at it becomes positive. People, I say look at it because positive but and look at them still reminds negative, therefore work that will be safe but it will be different. Okay. So of course, this issue shins came out of representation of post faced a polarization and regularization. Okay. So now let's see. And now let's talk about the patterns of the Surest complex. As I told you, normally, it should not be it should be narrow normal than 0.12 milliseconds. But in certain conditions of helps you, we have invited per Securest Complex. Okay about the model, this blockage if we talked. But here we have to precise some phenomena which is known as our uh yes, our surveys, you know, mainly related, you see right by the French book before you'll do the rubric about the right. But the block and you can describe this event also sometimes on the especially the real sudden leads, you can see the QS complex US complex indicated we could have the massive necklace this car. Okay. So before you can also make the everybody's cure, cure is complex. Usually it's correspond similarly to this car but sometime we are doing more equals imaging test like we are doing the cardiac and we write to see the volume wasn't advertise my condoms as well. If you see secures complexes, you cannot estimate by the ho sometimes we have to do some imaging test, not better estimate volume necrotizing my country because uh not always shows you falling also damage my card because sometimes you may have absolutely normal conductivity in case of Syria Micatin necklace. It also happens because you know that the better estimates severe to the market of damage, we have to do more advanced imaging test. For example, we are doing the usual cardiac and you know, okay. So you can know, so you don't need to upload the MRI notes and but you can also present is this condition, please usually suggest to do some card acheivement. Okay. So all also, so Cuban, why I just told you just include besides if he has a prominent Cuban to this indicate to scar said. Well, we have to also see in the beach leets we have a cube a uh he has a possible Micardis necrosis, please. No, the cube correspond to scar is doesn't and corresponds to active equity corner syndrome because active every corner syndrome should be estimated by ST segment Italy but not with the cure, cure with scar because if you have the cure it because if we should consider the older my Kanye faction notes active FT Maiken refraction and 50 micron risky mean we could consider if it has a TV or a statement change. Okay. So afterwards, now let's see, finally, what's the TV? You know, I guess in a second changes, I already told you usual to you, you should be always positive unless we have a beard lease. Yes, because area reads since it's very far from the heart. So on the right side and back back for here in area TV, should be negative because area in these areas. Therefore, it's very hard far from the heart. Therefore, normally give people should be negative in a year. Okay. I guess, you know, also key compact upright, it's very tolerant we can indicate is um I've had ischemia is a hypokalemia. I said, oh, please, when you make it, usually you're closer to, please usually always takes a hype of Columbia. Which condition we have to also see the suspect hyper column if you have very tall, a proactive. Oh, so if the va is negative or also it could be really eczema either with a hipaa Callum. Yeah. But if you have rituals, the hip academy also. So if you uh you, you were each a reasonable sometimes, so you can reflect also state of hyper coming. I said, well, usually you have to also making you weigh as a lubricant you guys are from, from, usually it's related hypochelemia. Okay. So afterward s a segment, as a segment usually should be placed on the isolated life because as a segment indicates this is, is this part, let's see, compressive S A segment, this this whole cardiac muscle will stay polarized and there is no potential different spaces in my country. So who is, the segment should be placed along with the eyes a little line but as a segment is shooted, of course, if it's elevated, it first indicates it in my car damage uh if you wanna Cinda, but also if it's down sloped, also it's indicated start with the heart risk. Yes, savoys essentially tickets national because it is no. But also if he has the issues that segment elevation in every lead it's called maybe indicate to equip medical doctor before you can see a quick pericarditis, we will have a deep segment elevation issues and segment elevation in almost every lead. This concomitant pure segment depression's, this indicates to hysterical times. Yes. Also uh about a vice ST elevation we can judge Russell because this time by almost. Um I'm not going to function. Yes, if you have the stem, I it's a definite second elevation afterwards. We have to look in a which particular list we have a similar election. And according to this, we can classify see Michael infection. Yes, we can see how he has a we may have, we can have here as an extra two in federal infection too, anterior infection, lateral cost. So we have to as a judge it by two looking as a as a segment revelation because if we had a second depression, no localization should be done localization. So factor should be done in case of the same elevation in which particular least it's elevated. Okay. So, but in case if he has a second depression here, also it's this phenomena also may indicate to michael ischemia, especially in these chemicals and the cardio. But also it may indicate to let's spend cross train is that we'll further, you can make a rubric lessons to strain. In this case, you can usually to put easy cheap which indicate which will show let's and cross train. And in each condition, we have a restaurant question maybe 22. Let's send hypertrophy. First of all, hi Patrick orderup optimally or as a type of condition which have related to the hypertrophy also less ventricles that we can see. This. Usually you can do if your throat looks. Yes. No. So and also what else we have to also takes consideration G joint, G joint. Once again, let's see here. What is the joint he joined? Why it's important because we have to count. Usually that is the joint. It's, it's usually it's, it's joints uh after s wave, this is usually this area. And by the G joint, we can also call the specific internals. Yes, because we are music, especially if we have the only nebulizer yet because sometimes you may have a matter that's um an elevation in part of it. And we have to define measures. There is a benign or whether it can't relate with certain particle addict. Yes, just a second. Okay. So uh uh usually a political sometimes the joint maybe usually it's the applet maybe increase because in different people in different racist or sexist or ages, we may have a different pathology and a plate of the ji joint. Okay. So for many reasons, upper limit of the G joint, it should not be elaborated, for example, no other 0.2 million maltin's millig off in May or 0.25 million more seamen. But here elevation should not be in usually except also be too and mysteries in Vitacin and it's the legs. Usually we have to also see what is the usual type of elevation. Yes. So, but also usually, so we have to also higher levels are commonly normal percent especially. Um And uh you can also see athletic heart, which type of usual considerations we make uh we may have in a tragic heart. Sometimes we have the some uh joint from in in G joint. So it should not be considered the uh pathology. Okay. So, but problem is, is sometimes even have severe written, for example, just sickened. So for example, if for example, sometimes we have some type of G joint relate syndromes. It is included also Brugada syndrome. That's why we have to usually use look at the G joint. We have to see whether some circum pathologies could be related to visit usual G joint elevation. Okay. Okay. So for example, in case you broke at the syndrome, you can present a look at the syndrome. Okay. You can also describe the steps but you showing why what's important as the joint in case of Brugada syndrome. Okay. And also usually take this consideration. Sometimes we have the rep polarization period. Every polarization syndrome represent symptom also is replace this elevation, you join. But we have to also see in which condition G joy elevations you joint is, is a benign condition is can be lately. Second attack everything. Yes. Yes. So far what we have to here, we have a specific right career which is given by the American Heart Association and you can see here. So normally we may have the usual G joint prominence, okay, at least view. So in particularly, but it for example, in most, if it has a D joint into the usual is um to at least 2 30 every IV. And so you will do it your own in your grocery. This may indicate to usually it's pattern is not always benign. And this, this condition can predict that uh expensive for you can present in which condition G G G joint to not be usually elevated because this can decay to the sources, even like event life dedicated spears at four. It's not uh patterns that you can describe. For example, for example, representation them individually, it's called the benign and which in which this is considered as usually risky. Okay. And finally, we can also talk about conspiracy. I talked about cutting in terrible shooting. Incredible. I will show you. So this is the interval which core is called uh close the beginning going to kills it and usually the end of the TV, this is shooting internal. Yes. And I told you this corresponds. So the factor. Okay. Okay. That's message usually. So if it's enlarged that Mr because it's usually affected, rest of credit is enlarged. Uh it has a high possibility lives and then 20 for medical use it. Well, I thought that you can suggest the cause of the point that it takes a bit relationship with. Uh so let's acute intro also please know that usually any type of grass um drugs but for some special drugs, you can also criticizes drugs. Can also, for example, tricycle antidepressant, yes, can contribute to increase the rest of your interest as well. Is this condition? We have to take caution. Well, there are usually different drugs because it can also uh the pointed type of uh okay. So also what's important thing that to dental changes with the heart rate? So we'll absolutely equal. Put the internet possible before we have the changes in the interval. Said always when we are estimating the blocks of the interval, we have to take into consideration the heart rate. If he has a has a heart rate to, to acquitaine gets shorter, usually we have the usually uh lower heart rate cuter in so should be large. Okay. But problem usually is also from the bit too bit. We have also the usually dispersion of the container because even two things may body from the bit too bit because this is not shruti discretion. And in order to calculate the between correctly, we are doing the Q T correction. But because this estimates he has a less of cute intro but also heart to to take uh the heartrate a special collection in order to, to preside usually the correct usually got also corrected between terabyte because if it's prolonged for the, we have to say why it's prolonged. Whether it's look at the syndrome, whether it's uh drug induced you to enter prolongation, for example, and uh anti arrhythmic drugs in an amiodarone, which is mostly just drugging cardiology to know why. So, okay, sometimes contributor prolongation, Peter in the process. Of chance of uh in terms of the uh hired feel also to be increased. Well, you can precise it a long qt interval syndrome. And here you can also upload information which type of considerations are great visit. Long cuter in Tracinda. Okay. So and so I guess we told okay, also take its concentration say in officially Children sometimes because that negative tibial Symbicort, they're very Tsepo you should have considered it's pathology because in Children maybe because it be touristic sometimes it may help also negative, usually serious. Okay. So I guess usually I covered, I thought about most of the anesthetic. So now I usually I will give you the answers to your questions. Okay. Now let's do particularly in particular relations in particular questions if you to precisely and precise talk about how you should do because what is dedicate of the seminal I'm not teaching because I guess you already know this. Okay. Uh There is nothing usually use it for you. By the way, I see it too. It's a dedication to make as active as possible that we'll I will not do that. I think because it's your task, you will do your own. It will be your for data students closer. Uh I guess it will be more interesting. It will do your own, your boss. Okay. Uh huh. Hello everyone. I'll be taking your questions now. Uh Doctor. Okay. Okay. Well, the first question uh okay. If some of the questions are not answered today. They will be adjust on day two. So don't worry. Okay. Uh So the first question doctor is uh during access deviation, what happens if it shows extreme deviation? Yes, I see this question during the break. I know this question. Let's because usually come back. And now usually uh now, once again, always we have to look all this usually uh yes. Every six sugar based, all this red card. Yes. OK. Uh The visual doesn't mean it said usually this area this is that we can determine is the correct angle, these access this angle. But because both uh in February of 50 has a negative. Yes, for example, extreme deviation will be system. But because he here inefficient, we have uh we should not have the positive are very similar cholesterol. Also we have seen as far as the army. So these are all these octagonal is we don't have the positive upright armors. This means that we cannot determine access other rights. It's not extreme axis deviation. In some books, it's written as undetermined double access. But in other books, you can see extreme access or extreme delusions. This is usually causes in animals usually. Yeah, we cannot define this access. That of course you can do extended vacation which conditions. So it's the the regulator is which condition could be related with the X axis tribulation. Okay. And you're closer and you can also put this condition okay. Yes, doctor Thank you so much for answering that question. The other one uh the other, the next question is how do we get 12 lead E C G while using nine or 10 leads? Uh nine or 10 weeks we are doing here routinely brutally. We are putting before electors the right. Um It's the director left of the yellow electricity grid that we're putting the let food and break. The rules were putting the right foot and buy the support. We are making the whole uh Europe. Yes. Afterwards we are using six because the electric women or support into the space on the right side be too same level but on the left side, people corresponds are takes it for it will basically 15 because of space in the mid clavicle line, we will be located between the two and before the five will be fish intercostal space into the uh to relax a little line. And we see. So the locating the middle, extra light into the use the space that for finally by the 10 electors. Because further because I have on the oh four extremities, right? And later left foot and the right foot, we have only four. Yes. In addition because these electrodes with me too, if successful uh by 10 electors, I can compose 12 ethnicity. But because I'm making arrangement, combination of the electorate years for the president's, you already know right to lift up. And so vices combination, we can physicality city because the routine start of the city. But if you have some considerations, for example, if you have the signs of right, when Collie faction, you are putting the additional electrodes, this referral, probably this three we are putting on the right side before putting on the right side and we five interested usually same level, but on the right side too, records, it is uh fine because as a second elevation, yes, similarly five basics we said we are putting on the back of situation. You see you can replace these electrodes and because no additional because needs a device you have seen, you know, this divide these uh usually additional. Yes, but we can do the combination and prices usually electrodes in order to record, of course, these are based maybe 70 89. These are right, settling on the truth and electors. We are doing all the specific considerations to usually confident all rule out the possibility of right ventricular infection in case of right, because the let's all to assess whether we have possible possible infection in case of we've had me seven meet in the night before. It's not a routine. Usually it is additional electorates. Okay. Okay, doctor. Thank you so much. Uh Our next question is, can you tell us more about the characteristic sed changes in regard a syndrome? Uh I can give the clue because I want to make you your own because I if I get basic is, is you know, because all of you started, I suppose, you know, make see here why we're doing the same thing to make you active as possible. If I will tell you, of course, you tell me it's not to be interesting for you because if someone will do it, it will be very good. Of course, I can tell me, but I'm not telling now because to make you a executive as possible. Okay. Look at the symptom again. Uh this, this was discovered in, at the end of the 12th and he is in 20 century uh is still alive. Usually here we have the brothers of Brugada. It's Peter and Joseph, Brugada. Uh usually Pedro, not Peter, but Pedro and Joseph uh brothers who are coming from Spain. But Joseph, I guess he lives in after no looking uh in Belgium and the Federalist, I guess impossible. Anyway, usually they have the big cardiac centers and the artistic, they are usually main archaeologists in support. Therefore, if you want to continue and study arthrology, I suggest to go is I use a and work with the Joseph, you gotta is a work with usually in petrobras go to which is in Barcelona. So, and they discovered the skin do it is Brugada syndrome is related, is it from your stroke uti interval? We have a specific system, material change. You will find we have street after Brugada syndrome and you will see it's usually the bypass six. So I will give you some cream biophysics as a segue material changes, bypass sick, you will find your own. But why it's the work that you underestimate Brugada syndrome. Because since it's too late, this longer qt interval, we may have the high risk or uh sometimes even little conditions because it's sometimes let's see some genetic consideration, especially if he has abnormal uh depolarizations interest due to, for example, genetic mutations therefore existed since it was discovered passes this present Brugada. It was known after some cases which Brugada syndrome. It's also so uh so sudden cardiac this because if patient is, if on the for example, if he has a patient, you will see in business in physical terrorists specific changes which could correspond to break up the syndrome. You have to always think that you said that there is high risk of use a sudden cardiac this okay. So that's what we're talking this. Okay. Thank you so much doctor for the answer. Uh One last question that I would like to ask you is I'm so sorry. Yes. Uh Why are we using right sided precordial leads only during suspicion of right ventricular pathologies? Why is it not used in routine ccgs? Because uh why? Because uh not all patient uh patient with Chester may have the right thing for infection? Yes, simply because more the right medical infection. Why? Because if he has a closure, all right corner active. Yes. Because right from the apple supplies the right 20. Okay. Right. Problem here. Now, let's see, it was a part of his ability would spend if he has the right clinical infections. That means that he has a severe decrease contract of the right tragical and you know, the north valid i clinical contracting is depend on the pre load that for if he has the right clinical infection due to decrease severe contracting film, right like that where the clear road will be decreased. And therefore both of the center of the shock, similar condition occurs in patient has permanent and boards. But in Parma Edwards, we have putting the guys charity list because in family members, you know what is the main test? Something? Not always because the ct manifestations sometimes we have to see to uh Cuban uh Q S T phenomenal. Yes. Whether we have deep us 2 to 3 S one S T T wave inversion to see versus there's a family member is what problem is that even for it? From my own experience, I have seen many patient with uh without any changes. So forgot the standard here. You're busy city angiograph. So when we are usually talking about the parliamentary able split, please know if he has a quick chest pain at Hamilton deterioration. Okay. This uh this means that we have usually see uh some uh some dysmetria chest pain and initially we have to take it easy. Yeah, initially what we have to uh corner since initial, yes, afterward, we have to look for uh usually conditions which could be related to the chest pain. Sometimes we have absolute normal SCG. But if your expenses that for, if you are suspected still about the presence of the permanent limbo, you should to start with the CT angiogram because you should not lose time for the dye Merisi D dimer essay is usually given if you have the lower and your information likelihood of the pulmonary embolus. But if because during the your diagnostic World Cup, you have to always assist like wrote of particular events. Just if we have a highlighting hotels, palmer embers, you aren't including time for the rest of you are taking patient city and you are doing this city and you to see whether we have the clock in parliament happen because you know pulmonary embolism, life, certain conditions. For example, if you have different trembles, if the patient signs of different trembles is really in pain. And so this clear and patient's have suggestion this could increase the light level also for family angles. Well, of course, you will not spend this time for the right ventricle electrons or forcible forces usually did I initially, you have to do the second test to make the diagnosis as soon as possible. And it gives the antichol coalition as soon as possible to rectus a patient, you understand clear. But if you had spent square closure for story right at the at the closure of the right coronary artery or somebody here's the right mental infection due to closure, x closure, right, uh right corner artery that the the patient will have the chest pain and we'll have since right corner actors supplies not on it. Right. 20 but also it supplies some. Uh So, you know, the positive descent the battery is coming to sometimes through the right phone after sometimes coming from the people of Zachary. but somehow it comes from the right corner. Actually, it's the place, the dominance of the rich actor is dominant. Uh imagine we have the dominant right corner actors. That's where the pedia is coming close it right from the rattles that's with. So these areas which is supplied advice and cause uh this an active will be also compromised. So we'll new startle intradural CCS segment elevation, which is typical too in federal because PTS area, but of course, these the some possible part of the right thing. So when there is what it's about some, usually the right ventricle arts also supplied, that's why it's coronary active, we can put the little on the right side. Okay. Because to estimate whether we can usually signs of right ankle infection also take consideration. Sometimes we may have also possible. My contraction due to closure is a surgical places that are connected because it because which grants surprise which person's mic talking. Okay, but we'll see it. But if traditional artist is a Tuesday, it's elevated. There is no doubt there is infallible Maiken infection. I said, well, here we have to rule out the possibility where I can go involvement. Why we have to rule out because if you have the signs, that was the right thing for you is going to give you a nitrous, you know, diet, treat and issues in case of right and for infection because that's again, I I tend to contracted. It depends on the clear. Oh, they're going to use your nitrates. You're severe because the pillow and the patient will have the hemo dynamic shocks that probably would have had a unique shock. So well, is this case, we have two main condition in which we should not give the nitrate is a, it is, it's a patient takes a few, you know, Viagra, it's the usual male patient doing this. Either we have the signs of right friend Colin function in other cases. Of course, we are GNC tonight. This too. Is it relieves the pain and usually usually start uh manager was uh okay. Yes. Thank you so much doctor for the explanation. And thank you so much for this session today. It was so informative and we cannot wait for our day two of the workshop where we'll have the quiz competition and we'll we'll get to interact one on one with you. So, thank you so much for today. Thank you so much for the lecture. Thank you at the Fashion. I would also like to remind everyone to fill out the leader forms for day too. So if you are an internal medicine five student or if you've cleared internal medicine five, then uh we highly encourage you to fill out the form and uh be a team leader. So that on the day too, when we have the competition, uh it would be more interactive and we can have better uh understanding of the, of the subject. Um Thank you so much. I hope everyone has filled the forms and uh if there are any further questions, I believe all the questions of Aunt have been answered. Thank you for listening guys. I guess you will be more motivated and you're on your, is it closer? It's increase your motivation? Seppo I suggest to do it. It's very, very nice. Your product which is done by the students itself. Okay. Thank you so much, Doctor. Thank you so much. Uh Everyone's thanking you doctor um from the half of them. I Yes, yeah. Thank you so much, Doctor Sophie for joining in for today. I would like to remind everyone that the feedback forms would be deactivated 15 minutes after the session ends. So make sure all of you all fill your forms in order to receive your certificate of attendance. And please to provide any suggestions and feedback, we considered our top most priority to go through all these suggestions and your feedback. Thank you so much to all the attendees for joining in for today and we can't wait to host you for the workshop on 29th. Thank you. See you, you have the workshop and you'll do your own product. Okay. Thank you for listening. This you next Saturday, I guess around two o'clock, it's good for you exited. Yes. Uh You finally convince you details and we shall do good conduct it on next Saturday. Okay. Thank you. Thank you. Thank you. Okay. Uh huh.