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who? No, it's accurate, isn't it? Is the feedback better and sleepy? But that's it. Yeah. Good point, but state. Okay. Hi. I'm sorry for technical issues. My chat isn't working, so I had another laptop to try and chat with you guys, but it seems like that causes some feedback. So, um, I'm gonna have to rely on you guys to talk to me a bit if there's anything going on in the chat. Thank you. Hmm. Okay. Hi. My name is so I'm a foundation year. One doctor working at William Harvey and Ashford. I've been working with Jamal, who's organized these lectures for you guys. Um, I studied at ST Georges in London. So, um, I don't know everything about what you guys are going through, but hopefully, you know, hopefully this can help you with your exams. Busy. Can This might be seen. Nothing. No. Okay. No. Should be. Yeah. Nice. Okay, fine. So, uh, CGs, um electrocardiogram. Thank you. Nice. I can see the chat as well. So and please chat on that to interact. So on a scale of 1 to 10, with one being not confident at all and 10 being on the ward round. If a consultant asks me to present a BCG, I can present it confidently. Could you guys rate yourself out of 1 to 10? But it's there. Okay, Chance of it's like, Okay, this will take a while, so I'm going to just run with it. Stop me if you need, so I'll give you an example. The rate is about 72 BPM. It shows a regular Sinus rhythm with no axis deviation. The P waves appear to have a normal morphology, as does the QRS complex. And the T waves looks normal as well. There are no signs of a ski me A or myocardial infarction. I was looking for these signs, particularly due to the presenting complaint. Therefore, this is a normal EKG with no acute concerns. Okay? No. Okay. Um, is it better now if I have I stopped? I'll go again. Let me know if I freeze. Thank you. So this if I got the CCG in an Oscar station, I have one minute to have a look through. And then I'd say this is a 12 lead electrocardiogram of Mr John Smith. A 50 year old man was presented with chest pain. This HCG was taken today at three. PM I can't see any major signs of concerns, but I'd like to present this E c g systematically. Okay, I have to turn my video off because apparently the audio is okay. Just to find more comfortable to me. Same. Let me. Okay. Can you guys still hear me and see the screen? Nice. Okay. I think you got the gist. Right. Um so that was basically a normal EKG is not hard. You're just going through right rhythm access and then going through the you're going through the C D complex starts with a P wave PR interval if needed. Two rs and then the weight. So this one does the pathology. So if I was given the CCG, I'd say this is a 12 lead electrocardiogram of Mr John Smith, a 50 year old man presented with chest pain. The CCP was taken to stay at three PM As a brief glance at the CCG, I can see ST Elevation and I'm worried about this patient hae well presented BCG systematically, the rate is about 84 BPM. It shows a regular Sinus rhythm with no axis deviation the P ways abnormal morphology. And the PR interval is normal. The QR as an insulin needs one and a b l overshoot three and ABF. The T waves are normal. So overall, this is a 12 lead electrocardiogram, which has features indicative of an acute extensive anterior lateral stemi. Is that roughly what you guys are expecting? Yeah. What is that? So that's what we were expecting on. Yeah, we went out. You don't really know what to expect, Okay? From Jamal. Is that roughly what you you would have done in your breast exam? Okay. And then for okay, perfect. And then to complete it if you're expected to manage as well, I'd say, since this is a stemi with any stemi, the management is pretty much the same. So I would ensure that this patient is assessed quickly and started on morphine treatment Is aspirin, clopidogrel, nitrates and oxygen, if necessary. After checking for allergies and contraindications, I would consider them for a percutaneously coronary intervention or from both thrombolysis based on the services at the hospital. And escalate my senior urgently. Cool. So now I'm going to try and make this as interacting as possible Because I don't like talking at you guys, Um, one on the chat, right? One if you know your SED and you want to practice presenting cases right, too. If you're not that confident with the CVS and would like to go over the thing over the theory okay to they gave the theory. Okay. Okay, great. So we'll go over the theory. So I wanted this to be interactive, but the there's a delay between me talking in the chat. So if it gets too slow, just let me know and I'll try to move through, Okay? When you look at an EKG, the first thing you do is look at patient details. You usually always, really. It should be on the EKG, so you see their name, date of birth, the hospital number. The nurses or clinician might write the indication for the EKG as well, and you'll see the date and time it was taken. Another thing you should look at, if possible, is the collaboration. So the normal speed the ECP should be taken is 25 per second. Okay, So what we're going to do is we're going to quickly run through the theory because I think you should know it. But I might need more confidence in it, and then we'll run through some cases at the end. Um, this session was supposed to be EKG, chest X ray and abdominal X ray. So what we'll do is we'll go through, you know, like, go through it properly. So you guys do understand, and then try and get through as much as possible. If we don't finish and you guys would like to do the rest of it, then we can arrange another session. So after looking at the patient details, you know that rate for the access. So first we're starting with rate on the chat. Could you write which heart rate is considered normal? Right. Mhm. Nice. Perfect. Nice. Well done, guys. And what term is used when the heart rate is below 60 BPM? So some good stuff? Yes. Okay, good. And when it's above 100 BPM and move on to the next question. As soon as you see right, Answer. Yes, Exactly. Tachycardia. And how do you calculate route? So there's various ways to calculate rate you could be told to do 300 divided by the number of large squares between each are complex, but the one I use, which is, I think is more reliable because if you have an irregular rhythm, it's quite hard to use. That method is just to count the number of curious complexes and times that by six, if you're calibration, is 25 ml per second. So on the chat, what's the rate for the CCD? Nice and this CCG. So that one was 72 BPM because it had 12. QRS complex is time plie six, which is 72 for this next patient, Mr J. Patel, a 32 year old patient who has come in with loss of consciousness. Well, if you guys want to shout out, that's fine as well. I just feel like I'm waiting on the chat and I don't want to waste your time. Nice. Well done. So this one is 42. So you've got one if you count the QRS complex with me starting from the left 1234567 times it by 6 42. So it's roughly 42 BPM. Um, so if you want to present. This would say, this is this is Mr Capital, a 32 year old gentlemen presenting with loss of consciousness. Um, looking at the rate this BCD shows bradycardia because the rate is about 42 BPM, therefore slower than normal. This next patient, Mrs Martin. What's her right? Good. So if you count, there's 123456789, 10, 11, 12, 13, 14, 15, 16, 17 times six 100 and two. Nice. Um, we get the disk now moving on to rhythm. What is a Sinus rhythm? Because cardiologists I love this time. So So, in simple terms, Sinus rhythm is just when the conduction of the heart rhythm is going through the normal pathway. So it's starting at the SA node going through to the ab node down the bundle up. It's through the bundle branch branch bundle branch is and the community fibers. And to see that on an E, C. G. You just need to see a P wave in front of every QRS complex. Nice. Thank you. Oh, that's exactly it. So, on the chat type all the different types of rhythms you can get so one example is a regular rhythm. Yes. Good, Good. Nice. Regular rhythm and irregular rhythms. And with irregular rhythms you can get irregularly irregular rhythms. And you can also get an irregularly irregular with a nice good luck. Okay, so this patient mhm. Are you guys able to turn your mix on, or would you be happy to practice presenting the like bits of the CT? Uh huh. Yeah. So this one. So the rate last time we said was about 40 to 45 BPM, focusing on the rhythm. Is it Sinus or not? Sinus. And then, is it regular regularly? Irregular. Irregularly. Irregular. Yeah. Nice. So Sinus and regular. Um what the CCG. So a clue. It's that this isn't a regular rhythm. So with irregular rhythm, there's two types. There's regularly irregular and irregularly irregular. Which one? This one. You're right about the irregular. So it's hard on the computer when you have it in front of you on the walls, You can I feel like everyone's been showing this tip where you get a piece of paper, you mark where they are, wave hits, and then you move the paper across. So if you were able to do that. You see this rhythm is actually irregularly irregular, and it's the perfect example of the atrial fibrillation. Cool this one. So the rate is approximately 54 BPM because there's 123456789 QRs complex is times that by six is about 54 on the chat. Could you tell me which rhythm this is? Is it regular? Is it regularly irregular or irregularly irregular? So it's regularly irregular because you can see that this at the beginning there's one QRS complex. And then there's of pause and then to curious complexes that are evenly spaced apart. And then that pattern just repeats. There's a break to curious complexes, a break to curious complexes, a break to curious complexes. So if you had a piece of paper and you marked the first three QRS peaks, and then if you moved your paper along, you'd see that that was the same each time. That's why it's regularly irregular rhythm, Um, technicalities. There's like the technical term is that there's 22 QRS complex is with every three p waves, So this BCG would show a hot look. We can practice more later, moving on to access to access. I find I've always found really difficult as a student. I still find it difficult. Now, Um, you on the chat? Could you write what the different cardiac accesses? And he says you can show. So when you're looking for the project access, what are you trying to work out? Nice. Nice. Perfect. So you've got three. You've got normal project access. You've got left axis deviation and right axis deviation. Do you know what? So if you so we'll go through how to identify it. Um, if you saw right axis deviation, what have you learned that that could be a sign of if you can write on the chat with the different conditions. It could be. Yeah, so am I. Can definitely corporate axis deviation. Tacky. Depends what the cause of it would be. So how I simplified it for myself. Is that right? Access? I consider more to be a lung pathology. So things like pulmonary hypertension, uh, chronic lung disease, pulmonary emboli, embolus. You can also get conceptual defects. So atrial septal defect and curricula septal defect. And you can get it where you have, um my eyes. Yeah, nice. So you can get it in, um, Myocardium functions and heavy books. Cool. Next question. What causes the left axis deviation to be like you? I don't think like we really saw right axis deviation in med school. I doubt it's going to come up, but it's just good to know that it's, uh, you'll see a conduction Abnormalities, um, as well as the left anterior hemiblock. You'd see it in with Parkinson's white syndrome if it's the right sided accessory. Partly, um, cool. So this is my shortcut. It's not reliable, but, uh, it's not always accurate, but it's pretty reliable. So there's a complex where that is, I find cardiac axis deviation quite complex, and there's loads of really good videos, online or lecture series where they talk about how you work it out. Away I've been taught is you. Look at on the left side of the ECU. Look at lead one. Not everyone need one. And you look at a V F or need three. So can you see the QRS complex and need One is going up. Okay. And you see the QRS complex in the three going up as well that's normal. So if the curious in one as well as the three or A B F is going up, that's the normal project. Access deviation. Let's say the cure is complex and need one now faces down, so the top left is facing down and the bottom left is facing up. Then the QRS complex is are reaching towards each other. So, since they're reaching, is the right axis deviation. Okay, and then next for left axis deviation. If you imagine need one, the QRS complex is going up, and then the QRS complex need. Three is going down. Then the QRS complex is are leaving each other. They're going away from each other, and since they're leaving, that's left axis deviation. It's not the most accurate way to work out cardiac axis deviation, but if you're in a rush, then it's pretty reliable. Okay, say some more examples. What's the rate of the CCD? If you could write on the chat? If you could write the rate as well as how you describe the rhythm, as well as whether there's any access deviation, what's the project access? You don't have to do it all together. You can do just write one by one or whatever you feel most confident with. Excellent rate. 19. So there's 15. 123456. Yeah. So 15 times six is 90. Excellent. So, with the rhythm. Oh, perfect. So you've got left axis deviation? That's correct. With rhythm, different clinicians respond differently. Um, but particularly the cardiologists. Quite picky. They really want you to tell the methods, Sinus or not. And whether the rhythm is regular regularly, irregular or irregularly. Irregular. So good. Nice. Everyone's got the right, right? Yeah. The rhythm is regular. Is the rhythm Sinus or not? Yeah. Okay, so this is Sinus rhythm. So this is a 12 lead electrocardiogram of oil albuterol. Who Who is a 40 year old lady? Uh, this is the CT taken today at three. PM Looking at the I'd like to present the BCG systematically looking at the rate, it's approximately 90 BPM. The rhythm is a regular Sinus rhythm. And then there is a left axis deviation. Next, EKG. So Dennis peel, if you can write the rate, the rhythm and the cardiac axis. Okay, Anyone able to type the rate in the chat or what? How you describe the rhythm? Nice. Yes, exactly. Right. Axis deviation. I should have gone through. Uh, so here, if you look at, uh, things in the way. Sorry. So if you look at lead one Mm hmm, it's coming down. And then if you look at least three, the complex is going up. You can see right. It's almost as if the two peaks are reaching towards each other. And that was for axis deviation. I've got some rates exactly 78 beats a minute. Perfect is regular nice and also get used to mentioning whether, um also used to mentioning whether it's a Sinus rhythm or not. Cardiologists like that a lot of cool. So we've done rate rhythm access. Let's move on to the actual PCG. So P wave. Honestly, there's really anything that comes up. Um, but just for your information, um, the most important thing is whether it's present or not, whether the rhythm is Sinus or not. So if it's present, it's Sinus. It's not. It's not Sinus. That's all you need, really, But to go through it systematically, you then think about, um so that's followed by normal QRs complex as part of the Sinus, and then you think about the normal shape. So with shape, you have to think about height, width and shape. So a normal height is 2.5 squares. So if it's bigger than that, it's peaked. Or it's too. Um, if and the width should be three squares wide, so three small squares. So if you can see the dark lines and then inside this fainter lines, so you want three of those faint lines as the width, and then you're thinking about the shape so abnormal P waves at this point, like all I've learned and going to need, if if anything is more than what you need is whether it's bifida or if it's a peek shape. So if it's been, if it's it's an M or it's like a wave. And that suggests Micro Uh uh, So that's, um so that's mitral. So that's left axis late. Sorry, left atrial enlargement, and that's usually due to mitral stenosis if its peak. So if it's small and it's peaked, that suggests right atrial enlargement, and that's usually due to pulmonary hypertension. So how I remember it, it's just using the alphabet, so a B C d E f g h i j k l m and m. So if it's been, if it looks like an M So that's L for left atrial enlargement. And then, uh, l m n o p Q r. So if it's peaked, it's the right atrial enlargement. And, as you know, the liver is for the atrial depolarizations moving on. Uh, this isn't I mean, I was going to go through it, but it's not that common this. You can see the P wave has an M shape. So that would be m four l m left h um, management. And this has a peak shaped PQ. All right. Atrial enlargement call PR interval. This was quite important. What's on the chat? Could you write the normal PR interval? I like to use squares, but whatever you've learned just because I feel like squares, you can counts it easier. I'm going to count to five and then continue. Oh, nice. He used seconds. Nice. Yes. Fine. Good. So pr interval normal. Yeah, I like to use squares. So as long as it's less than five squares or less than one big square. Nice. Good, nice. You guys know your things News. Okay, so well done. Well, uh, so a short interval. Does anyone know what can cause it? It's quite complex stuff, and I highly doubt it's going to come up, but it's just very simply put, is any congenital conduction issues so, like wolf Parkinson syndrome or Oh, nice, You guys nice. Nice. Um, learn the normal even syndrome. You can also get injections, muscular dystrophy as well as, uh, welcome. So what's more important is what causes a long PR interval, because that's more likely to come up for you guys. So what could cause a long P R N two nice hot block? Um, so mainly first degree heart block. But you can also get it in, make sure ventricular delay or try the singular blocks. So now here's a pole. I haven't used metal much before. So, Jamal, if you can help me with the pole So here's a quiz for you guys. I have four uh, P uh, four. He said He said, Which one? Choose the PR interval. Uh, thank you. Nice. Look. Good set. Uh, right Answer is de de shows the PR interval, and it's the time of onset from the p wave to the start of the QRS complex. Cool. So hot blocks because this may come up for you guys. So there's lots of different types that there's a first degree second degree, which is the type one and type two and third degree. So has a, um, quest for you guys, right? Your answers on the chat. Which time? Which hot look is this is it? First degree is it's second degree type two, uh, type one or type two Or is it a fair degree? Help a lot. And if you're not sure, let me know, and then I can go through it because nice. Exactly. So it's Ah, I see. Cool. So the answer yeah, is second degree type one. So it's difficult because they are so similar. Uh huh. Type one versus Type two. I was taught quite a. I think it's quite a mean way of remembering, but it's helped me remember, So I'll share with you guys. So with second degree you've got so first degree is just, uh, PR prolongation, and that's equal with each QRS complex, right? It's just more than, um, 0.2, or it's more than five squares or it's more than one big square. That's very simple. Second degree. You've got a PR interval that changes right and the difference between type one and type two. Type two. I think it's simpler because there's P Q R s and then it continues, continues. And then there's a drop in the QRS complex. I'll show you the example later in type one. How I was taught it. Is that the cure? Uh, this is really rude. The QRS complex. This is how I started it. The curious complex has survived. That's cheating on his wife, who is the key wave. Every night he comes back later and later. That's what happened, and and later, until he doesn't put them. Whereas Type two, they come regularly and then, Okay, type one doesn't have the drug. I was it. Sorry. Did I say that the long way around? So this one, which is type one, is the one with is where they it gets longer and longer. Sorry, because I was doing the order with me longer and longer, and then it drops and then type two, which is this one is when it's equal facing, and then a drop Okay, what's this one? So just to clarify and make that very confusing at one is the one that gets progressively longer than drops. Type two is the one that steady, steady, then drops. What's this one? Nice. So this one is the degree. So it looks like how I recognized that degrees is the curious complex is very regular, and the P wave is very regular, but they just don't match. So it's it's both are very regular, but they didn't mention that could be helpful. Exactly. No association. Perfect. Hey, moving onto the QRS complex again, There's not much I think this is You need to know, and I'm I'm sure you do know it, but in terms of the conditions that you're likely to come up with, I don't think this would be that relevant. So it's small. If the height is less than five millimeters or less than five small squares and the limb leads, uh, which are the ones on the left or if it's less than 10 minutes mm or 10 small squares and the chest beats, which is the ones on the right. It's too, is it? There's the cycle of lien criteria which is where, which is where you see the some of the deep wave deep, deepest part of the S wave in the one to the other decline and then the tallest R wave height and 85 6 if you add up the squares or the length. If it's more than 35 or seven large squares, then it's considered to be a tall, curious complex. But I'm sure you guys move from experience with this, too, or you can tell this to cool in terms of the width you have. Narrowing board, which is more likely to come up narrow, is if it's less than 0.12 or more than 0.12, or if it's less than three. Small squares are larger than three. Small squares give you one for the morphology. You've got the Q part that are part of the S, starting with the key part, um, abnormalities that can come up is the Delta wave. So the Delta wave, uh, indicates that the venture cause so if the ventricles are being activated earlier than it should be because it should be quite a rhythmic, um, movement along the um activation. If it's a bit earlier, then you get this, um, early activation that spreads slowly across the myocardium. And that's what causes the slurred upstroke. And you see from the p que off There's a slut. Um, and that's Do you know what that's you know? That's sort of associated with this Delta wave. Which condition? Yeah, exactly with Parkinson White. Okay, cool. Um, and for it to be wolf Parkinson White, you have to have Delta Wave and tacky arrhythmias so pathological. Q Wave is also something that can come up. So it's pathological if it's more than 25% of the following R wave, or if it's more than two mm in height, or more than 40 or less in width. So I like to use squares. So if it's, it's 221. So if it's, uh, deeper than two small squares, or if it's why didn't want to go back moving on to all so all you need to know about the progression. So you look at the chest needs to be 123456 and the ER should slowly get bigger. Yeah, and then in terms of s, um, so our should be bigger than us towards the end. But if S is bigger than our, it needs to be five and C six. That suggests that there's poor progression, and that can be a sign of a previous myocardial infarction. So ST segment, I think this is the part that this is quite commonly, um, reviewed, but you've got either elevated or depressed. So elevated S F. It's greater than one small square in two or more adjacent limb needs. Or if it's more than two small squares and two adjacent chest beats, it's depressed. If it's more than half a small square and two adjacent leads, whether that be the chest beats or the limited T wave, same looking at the T wave. In particular, there's four abnormalities that can come up. It can either be tall. You can either be flat. It can either be inverted or it can be by basic. So if it's to, it's usually due to tall tinted T waves in hypercholesteremia can also get in. Hyper acute stem is flattened, is usually due to ischemia or electrolyte imbalances like hypochelemia inverted. That's various. It's quite non specific. It could be an ischemia could be a bundle branch block. It can be in P e s or even generalized illness. And biphasic is if there's ischemia or hyperglycemia last week. Um, the waves are quite uncommon, and they follow the T wave and the indicate electrolyte imbalances or hypothermia. Hypo So called Hermia. Um, and it can be secondary to anti arrhythmic therapies like digoxin or amiodarone. That's the only way. Okay, so here's where we practice the c g. Sorry, this took a lot longer than I thought. Um, I am not used to the medicine, so I don't know. Um, can you raise hands on this bit or how would I get someone to practice? So if you look at the CD and have a look at how how you present it looking at the patient details, looking at the rate rhythm access as well as the P Q. R s T complex, I think we have to get mhm. Mhm. Mhm. Okay, I've got no someone else. Okay. Thank you. Yes. So we had to hide this long because I was trying to work out how to call people up. Um, Rahamim, could you present this CCG for me, please? I can't hear anything yet. I can't see. Thank you. Give me a second. Uh, uh huh. Okay. If we choose someone else. Uh huh. Yeah, Well, hello. Um, yeah. Can you hear me? Well, I can do Yes. Okay. So, uh, hello, my like I should start with introducing myself or just go with it. Mhm. How would you do it in your Oscars for me? I'd introduce when I was clocking the patient. Actually, not do it into yourself and then present the CT. Okay. Hello. My name is, um, one of the junior doctors here. Uh, and I'll be presenting the BCG, uh, John Smith. Um, date of birth. The first of, uh, July 1972. Uh, he came presenting with chest pain. Uh, the E c g is. Oh, great. Uh, just a minute. The sug is regular. Uh, the just a minute. You're doing really well that the rate is, um I'm counting. Yeah. Okay. There is no axis deviation that there is a left axis deviation, and it's Sinus rhythm. Uh mm. I got a book and then now go through p. Whether it's normal, if there's anything abnormal. P r Q r s ST T The P looks normal to me. The PR interval. Uh, PR interval, I guess. Normal as well there. And the Q r s. They're narrow and curious in a row. Uh, there there is a tall tented p wave, um, T wave, which suggests hyper cutting me, I guess, like in the four or five and six. Like it just leaks much, so I just really bad. Sorry. Sorry. That's good. Keep going. Um, what about ST the S t? Oh, there's there is ST Elevation in lead one to, uh, which might indicate, uh, infection. Mm. Myocardial infarction. Okay. And then at the end of the BCG, you should always give a one sentence summary. Okay, so, uh, this is, uh, the ECU of John Smith, uh, born in June 1919, 72. Uh, the, uh, Sinus rhythm. Uh, I couldn't really detect the right story, So there was a left axis deviation. And, uh, with long PR interval That indicates to make all the infection. No. Sorry. What'd you say long What? So I didn't catch the bathroom, Get really well done. Really? Well, just, um really well done and so brave of you. I was very impressed. It's really hard because when you're trying to count, but also you're thinking, Oh, I need to be talking like the rate is very hard to calculate. So with more practice, you'll get it. Don't worry, rhythm. Excellent. You got that? It was regular, and you got that. It was Sinus and then access. Good. Um, slight left axis deviation. So that But you see you've got and the rate is about 78. So you've got all the right stuff. You're recognizing the rate rhythm acts as well. Just get used to presenting it in a systematic manner. So, looking at the rate that I am counting the QRS, you can count with them. You know, if if you're really struggling, I get counted. 123456789, 10, 11, 12, 13. QRs complex is which suggests that the rate is approximately 78 BPM. Looking at the rhythm, I can see that the rhythm is regular and that it is Sinus. And looking at the access, I believe this shows left axis deviation. You got all that excellent pee. You're right. Absolutely fine. Pr. You're right. I'm pretty sure it's a normal. It's fine. QR yeah is slightly narrow is two squares. Um, but the big thing is is the ST Elevation. So ST Elevation? It's in leads V two, V three and t four. And like you said, there's also a slight elevation in need. One and a B l. Yeah, And then there's a reciprocal ST Depression and need three say, don't worry about the Depression. The elevation is in the 234. Okay, that's anterior. There's also elevation in one, and l. So there's slight lateral movements as well. So you're right. It is myocardial infarction. And then we'll slowly get to the point where we can recognize it's an anterior lateral. You mentioned the tea, which is peak, which it looks too absolutely correct. That is a result of the ST elevation, So Okay, it looks like it could be hypochelemia. Absolutely correct. But you recognize that with the elevation of the S T, the T will rise as well and nice. The summary. You got it. Um, I, um just what you did. Which, um, we'll do at the beginning. And we learned how to summarize. You went right to the top. And you did another quick summary, which was all correct. How I would summarize is that, as you said, this is a 12. This is an E c g of John Smith. If if your old man who's coming with chest pain every one of these features indicate a hyper acute anterior septal, uh, anterior lateral stemi. So what we've recognized is that you can see all the different parts is now just making that all pretty for the Examiner's. Okay? Yes. Well done. Well done. Really? Well, well, I was just putting my four month old child to to bed. That's why I was, like, all messed up and stuff. Honestly, that was the case. You did so, uh, like I'm sitting and, you know Good. Well done. Um, just got something I'm very bad at all. So I'm just going to read the messages. Can say Okay. This way. Yeah. Sorry. It's anterior Steptoe. Um, yeah. 234 is anterior and then one and l sector. So these features indicate a hyper que anterior septal stemi. Do we have to, like, specify anterior lateral anterior? Acceptable or like it? Absolute high points? Yes. At least we were sorry. I I really don't know what you guys are expected, but for us, Yes. If we wanted high schools, we should, um And to be fair, it's something we can do. But in terms of passing, the big thing is not missing that. This is an am I, um And then saying in your presentation after, um, the speech is indicated hyperacute entering stemi. I am worried about this patient, and I would like to escalate them immediately to my senior, but also for management for my so morphine, aspirin, clopidogrel, nitrates, oxygen if necessary. But PCI or thrombolysis. Okay. We should, like, create the the BCG and then with the management just, uh, one goal, right? We should not like, Yeah, I missed that. Yeah, but at this point, we just need to get used to presenting the BCG nicely. I've got extra points. You have the summary, and you have the management. Um, I've got a question on the chat. Do you vocalize that you can find this ECCP cancer the right patient or something of that sort? So, for me know, in our we'll see, you know, one because the time, too, because you would have had the history with the patient. You would have checked their name. Checked the age. Um, so you should know it's the right patient, but I'm not sure what it is like for your times. Nice. Thank you, Jim. All that ran a lot longer than I thought. Sorry. I have some technical issues and just getting used to it all. Um, there are There were quite a few more examples. I don't know whether it would be better to schedule another and just go through, like so maybe instead of going through the theory, which I think you guys are really good. Actually, um, if it's better just to But you just go over the theory in your own time and then just the the practices, because from, um hum, I can see that you guys know your stuff is just getting into the fluency of presenting. Um, so I think the CVS Yeah, okay. I think I'll end this session here because it's time. And then we'll let me update you guys about what to do next. Because it was also, um, chest X ray. An abdominal x ray. Yeah. Yes. So I think there's a feedback just let me know in the feedback. What you guys would like or do you want me to? I think I'll end here unless you guys are eager to continue. Because for me, I'd be tired, like as a listener, I'd be tired, and I want to do other stuff. But you guys let me know on the chat. You want to continue? Wow. Yeah. No, I'm okay. You guys have a great attention spans. All right? How would you say the summary? Okay, so, uh, I can I am sharing my screen. Okay? We'll do maybe two more examples and then call it a day. So So for the one, this one. Thank you for letting me see John Smith, the 50 year old man who came in with chest pain. I have reviewed his E c G, which was taken today at three. PM and I can see on a brief look that there are signs of ST elevation. So I'm worried about this patient. I'd like to present this PCG systematically to make sure I don't miss anything else. Looking at the rate there is, I would say it's approximately 78 BPM. The rhythm is regular Sinus rhythm, and there's a slight left axis Deviation. P wave and PR are normal. The QRS complex is slightly narrow, but not a major concern. There is. ST Elevation in leads me to be three and t four as well as elevation in V needs one and a v e l This along with the reciprocal ST Depression and need three, um, make me concerned of an anterior septal S t elevated myocardial infarction. So, in summary, this is a 12 lead electrocardiogram of a 50 year old man presenting the chest pain that has features that indicate a hyper acute anteroseptal stemming to manage this patient. I would like to escalate them immediately to the senior and start them on the A. C s critical with morphine treatment is aspirin, clopidogrel, nitrates and oxygen. If they're saturations are low. I'd also like to for them for percutaneously coronary intervention or thrombolysis based on what's available. You like it. Let's do another. So give yourselves time to look through this. And also, if someone would like to very breezy present CCG Uh huh. He's probably use it. Why do you Why do you have to take those first probably use abbreviations and given the summer. So do you mean the breathing is my estrogen? So the electrocardiogram or PCI instead of, uh, coronary intervention? Can you hide the board bar, High bar down the screen. Oh, I see. Thank you. Um, so you can use abbreviations? That's absolutely fine. But just to sell, it's just an exam technique. Um, where you can instead of saying e c g u c 12 lead electrocardiogram. One is more specific to it. Just sounds a lot better, but you don't have to. It's just exactly week. I think that's your question. Who? Who wants to present another John Smith I got I couldn't be asked to change the names and stuff. If we don't have a volunteer, I'm gonna I'm going to choose someone. Okay? I'm gonna check the anyone. Fine. 4321. Okay. Um, Jamal, just because I don't want to close my screen, um, could, you know, um, do the stage thing for Oh, uh um for Jenny, please. Do you? Yeah, a good place. So you don't have to vocalize while studying the EKG, But, I mean, it depends on how you like to present if you like. My brain is really slow, so I need to vocalize. So I'm doing the right thing. If you can do it without vocalizing go ahead. It sounds It sounds so much better. Okay. Anyone want to volunteer? I'll give you five seconds before choosing someone. All right? Yeah, right. True. Okay. Jamal, could we invite Oh, chat. Mhm. Um, could we invite Can contact contact content to the floor, please? I love that attitude is really good. This is how we get better. And it's best to practice here when it doesn't help or anything. Okay. And practice during the exactly nice officially by Melinda to the stage. Yeah. I'll let you know if I can hear anything. I can't hear anything yet. Oh, no. We could, um, eat. Yeah. No, don't be sorry. It's quite difficult. Technical issues. You hear me? Yes, I can Woman. Um, yeah. Could you say something again? I said, can you hear me? Yeah, you can. I can hear You're a little quiet, but it should be okay. Okay. Yeah. So I don't know what I'm doing, but I'm going to try. Excellent. That's how that's how we do it all right. So, um, I'm currently looking at the BCG for John Smith. Uh, date of birth first of January 1972 Who has presented with palpitations. And this CCG was a 12 lead EKG that was taken at three. PM I'm now going to interpret this CCG in a systematic way. Uh, first, I'm going to look at the rate Uh huh. Which is irregularly irregular, I would say, Um, but sorry. That's the rhythm. The rhythm, which is irregularly irregular. The rate is 78 which is normal. Um, yeah. Um, I wouldn't say this is Sinus rhythm, because I can't see the p waves before Curis. Um, and the access is maybe left axis deviation. Possibly, Um, I would say that the p I can't see the p but like, mhm you got the Q waves are of the, uh, QRs complex is our small Maybe, um and there's possibly poor progression. Looking at the leads, the chest leads that there's, like, poor progression of the cure are and the S in the in lead V five and V six are larger than the r. So possible, uh, am I or like, previous and I can see I think, as the elevation in leads V is that V two and the three? Yes. Uh, So I would say that this patient is in an acute state. Also, uh, has myocardial infection in the septal regions, except I think, uh, and should be administered. Uh, so morphine, oxygen, nitrates, uh, and aspirin and clopidogrel and, uh, should be, uh, referred immediately to the CCU. So the cardiac care unit for PCI, uh, and I will inform my seniors for proper management, if that's okay. Yeah. Yeah, I think that sucked, but yes, I'm done. Excellent. Well done. Really good. Well done. Okay. Um, just right, so I'll give some feedback. Um, so systematic. You're getting the structure, uh, and you're going through and you're recognizing where there's differences. Um, now, in terms of correlating, these differences to the correct diagnosis will go through. So from the beginning. Excellent introduction. Yes. You mentioned the patient's details, their name, date of birth and what they presented with you. Did all this start excellently rate correct? 78. Um, and rhythm correct. Irregularly irregular. Uh, and then access. Yeah. It's quite difficult time. Like I said, I really don't like access either it looks maybe left borderline or I guess it is leaving. But I think the down is rather than the r. It's the s, which is what it looks like it's leaving, but it's technically both pointing up. So I would say it's normal. Yeah. Um, well, for recognizing that P. Yeah. So it s a P is absent. This is not a Sinus rhythm, which is why, you know, you're looking for it, but he is absent. There's no evidence of a tree activity. Can you see that? Like like fibrillation? Yeah. Now that I'm looking at the two, I can see. Yeah. So there's fine prolactin the waves throughout. Really? Um, use a Q R s was small. Fair enough. Um, it is, I think it's Plus, I think it's actually okay, because if you look at the on on, like, from where the complexes start, and then it's roughly three, it's on the small side. But it's not considered. I wouldn't consider it narrow. Uh, and you're right. There is poor progression as well as the S waves. And five is bigger. Um, but also, you mentioned you saw S C elevation in, uh, leads me to be three so good. So you can see that there is an elevation now, in terms of whether that's an M I. So can you see before that ST Elevation, you've got that massive s wave? Yes. Yes. So that's why there's that elevation. It's a result of that Deep s and it's coming up. So it looks like And, uh, yeah, exactly. Yeah, it's a normal variation as a result of the way. So that's not ST Elevation. Your summary. I like it. You said an acute state of my Fair enough. Um, and you tried to localize it as well. Um, but we'll get to that later. And your management for if it wasn't in my great you talked about going to see see you about escalating to your seniors, getting the ACL protocol in. And that's important. That's an exam thing where even if you get the diagnosis wrong, as long as the management matches the diagnosis, you're still at least for us again. Um, I'm not sure about that, but for us, as long as the management matches the diagnosis, we won't fail. But we won't get a high school. Um, so good. Um, as you recognize now it's an atrial fibrillation. So this is a copy of the actual project. Done. You did really well. I've done with the year old man who's coming with palpitations, the great to 78 BPM. The rhythm is regular regular and the cardiac axis is normal. There are the the waves are absent with no evidence of organized a church activity. And I can see some fire fine for a luxury fibra littering waves, which is suggestive of an atrial fibrillation. Right over all these features suggesting atrial fibrillation. Therefore, I would like to urgently admit this patient for management as this would be an acute onset, I would check if they are hemodynamically stable, which would affect my management, and I'd like to take a thorough history to see if there are any underlying conditions which would have caused this atrial fibrillation. I'd also like to assess. You can do other stuff to assess the stroke risk of the bleeding risk, but first line management for a F is great control, so whether that be a beta blocker or rate limiting calcium channel blocker. But I kind of I'm sorry, I kind of got confused because, like, maybe I'm wrong. But isn't there supposed to be like, uh, tachycardia with It's not necessary. So, uh, so usually, yes. So with the f u c. But the main is absolute. Pa is with relations. It usually is presents differently. Um, but this one is f and then as well as if you see the normal way you get the like, really fast, irregularly irregular. Absolute key wave. That's also the if, from my understanding, let me know if that's wrong. Who, Uh so basically, you're saying that the, um well, I know for sure. Uh, absent P wave is like the most important factor, I guess. And then, um so absent P wave and irregular rhythm take precedence over the, uh, fast heart rate. Yeah, because atrial fibrillation is the atrial part. If you have a ventricular response to it where you get tachycardia that's associated with it, I think so, Um, on the it says, it looks like a third degree heart block. So that's it's so with the third degree heart block, you need no association with the atrial activity and the ventricular activity. But here you've got no atrial activity or no organized activities, so it can't be a That could be happening. Nice. Really? Well done. Thank you very much for volunteering. Um, so I I have the last question because I know you explain the reason why there's like, uh for, uh, ST Elevation in those chest leads. Yeah, but, like, how can you really tell? Like, this is only one of the variations where you have, like, the, uh, the ST Elevation as a consequence of the very deep s wave in these leads, So are there, like, other variations Where, uh, there could be an ST elevation due to something else. Like I mean, the most common or the most, um, possible or likely? Yeah. So this one is, like, normal variation, uh, normal variations. Uh, so I think so. What I thought of when you were asking the question was You can also get widespread, ST Elevation, which isn't. Am I in pericarditis? So that's when you see ST and you think Oh, are they having an MRI? But it's actually more likely to be pericarditis in terms of what else would there be? ST. Elevation. That's normal. I'm not sure. Um, I've just seen this one quite a bit, which is why I recognize it. I don't know if anyone in the chat can share one else. We'd get ST Elevation this morning, but definitely a question to ask the cardiologists. Cool. I think I think that's I don't know about you guys, but I think that's enough for today. Thank you so much for your patients. Um, despite all my technical issues, um, I'm staying after as well. Hopefully we can do more practice, and I'll talk to you more and more about you know what, exactly what you guys are expected, like and give better. Thank you. Thank you. Mhm. Let's go. Uh, can you guys hear me? Okay. I'm just checking once more. Can you hear me right now? Okay. Brilliant. Um, yes. Thank you for attending. So I just wanted to say Yeah, it's good to just keep it simple. So, um, you know, if there's going to be a case with ST Elevation, you will recognize that you know, some things up. You know that It's an M. I, um So, of course we were This was quite detailed today, which is good, so you can have a bit more knowledge because sometimes the Examiner's may ask you questions because they want to assess just how much you, you know. Okay, um, in terms of recognizing that there is a stemi, for instance, that could be that could be enough. Now, if you're able to localize where that in fact could be, then obviously that's another level where you score even higher. Um, but that might not be the difference between passing and failing. So I think it's a good strategy to focus your energy on presenting the BCG with a great structure on doing it in the style that Doctor John was telling us, because that's how local UK graduates do it. So if you haven't studied that, it's quite evident that, okay, this person hasn't done this before. So if anything, it's something you take away from today. I think it's the structure because even if you were unsuccessful in getting the exact diagnosis, if you have a great structure and you're actually able to, um, take away some of the useful points from the BCG, Um, it's possible that you could still pass. Okay, Sorry. Any questions before we wrap it up? Sorry. I was invited to this stage. Uh, and like there is a part of the conversation wasn't like I couldn't hear it. So just to make this clear, are you talking about this The, uh, the one that I did? Um, no, I'm talking about the the other one. Uh, I took, um because I think the general level of this this talk has been a bit higher than what I expected in clinical assessments. So I just don't want you guys to think that you have to really study so hard. All of these different CCGs when really it's about just having a very clear structure, and they're not going to try and catch you out. So you will. You will need to, like, be able to recognize atrial fibrillation, for example. But it's much better use of your time to practice presenting an e. C. G and being able to talk about it. And then I mean, if you can reach to the diagnosis So this is atrial fibrillation. Brilliant. But the examiner mite then take you on a completely different tangent and say, Okay, so talk to me about atrial fibrillation. What will you do for this patient? Right, So or maybe they'll ask you. You know, um, in terms of atrial fibrillation, what are the risks of unmanaged atrial fibrillation? So you might have to read around the the subject as well. So, um, yeah, I just wanted to kind of let you guys know that it's not going to be so complicated, but it will be, uh you will be judged on your presenting skills and whether you are methodical enough, basically, Does that make sense? I'm not sure if you can still hear me. Does that make sense, guys? Yeah, Yeah, exactly, because it was quite high level. And I think in the UK, the local graduates, they're expected to to know this information, But actually, when they go to the mosque, it's not going to be so complicated as well. So I was discussing that with Dr John before we started that you would have to study these things, but actually, the ski was a little bit easier. So, um, yeah, I don't want you guys to get stressed and start studying like all these e c gs. It's not a good use of your time. It's much better to pick out the key presentations. So HL fibrillation I would expect you to practice reporting that and being able to pick out the BCG features, Um, hypokalemia and M I, for instance. But you're not going to be. I mean, I'm not saying heart Block wouldn't come up, but what I'm saying is that that's probably the highest difficulty that you're going to encounter. So if you are going to get something that's going to be a textbook case for that rather than trying to catch you up, so yeah, don't over complicate it. When you go into the station, keep it simple, have your structure and that lets examine and know that you you've studied this before. It's not your first time reporting any CG. Okay, cool. Any last questions before we go. Okay, so we were going to do chest X ray and abdominal X ray. But there's a lot of content there, and, um, I went through the slide a little bit earlier. So Doctor, um, has got some really good slides for those as well. So hopefully that should be more than enough to prepare you for the exam in terms of from a knowledge perspective. And then it's just again the whole idea of presenting and being able to do that effectively to the Examiner. So, yeah, So, guys, if you can fill out the feedback form for us, that would be great. And once you do that, you have access to the recorded content so you can watch it back in your own time and also we will be adding more.