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Can you see it? Take that? Yeah. Ok. Um So in terms of electrical conduction in the heart, we have the sinoatrial node and that kicks up the conduction with um generating its its own impulse. Um from there, the conduction spreads across the atria that causes contraction of the atria and it arrives at the ATRIO ventricular node. So here, the electrical impulse stops very briefly. It just allows the atria to fully contract before the ventricles start contracting. You have a ring between the atria and the ventricles called the annulus fibrosis. And that basically stops any, any electrical activity going over into the ventricles prematurely. Um So at the AVN, uh when it's ready to fire, that sends the impulse down a bundle of nerve fibers called the bundle of this. From there, it splits into the left and right bundle branch. So essentially, they're just two tracks and they take the electrical activity to the left and right um ventricles uh respectively. So this come all the way down septum, they go around the septum wall and it, they turn into what's called purin fibers, which are basically just the, the nerve endings. And, and that causes contraction of the whole ventricle. Um So again, just summarize standard atrial node, atrioventricular node down septum back and around the ventricle wall. And that causes contraction of, of the atria and the ventricles in terms of the actual uh electrodes and leaders themselves when you set up an E CG. So we have 10 electrodes in total for a 12 B DCG. They go on the, you've got the right arm, left arm, right leg and left leg electrodes and then you've got electrodes on the chest wall. So you've got V one to V six. So by, by the way, the exact locations are sort of on the next slide. So don't it, it's just something you're gonna have to sort of memorize um by yourselves. But um don't worry about that right now. So we have um the right arm electrode. It can go anywhere from the shoulder to the wrist. Uh Same with the left arm, but the only thing is make sure you keep them symmetrical. So if you go for the shoulders, go for shoulders on both sides, if you go for the wrist, go for wrists on both sides, same with the legs, um they can go from like the hip down to the ankle. Um The right leg electrode doesn't play it, it doesn't, it doesn't form part of a lead. Um The way it acts as is something called an earth. So basically the earth acts to reduce electrical interference So it takes the electroactivity from the rest of the body and just takes it out of the E CG. So anything coming up in the E CG is just to the heart itself. Um So that doesn't really form part of the, the electrodes. So you won't really hear much talk about the, the right leg electrodes because of that. And then again, we've got V one to V six. So these all go on the chest wall. They V one goes in the fourth intercostal space on the right side of the sternum, V 2/4 intercostal on the left. Then we have V four which goes in the middle of the clavicle fifth intercostal space, we have V three going between V two and V four. V six goes in the mid axiliary line. Uh So middle of the armpit, basically in the fifth intercostal space and V five sits between V four and V six. So again, that sounds like a lot of information. It's just you just got to memorize the placements. Um And again, they're all written there. OK? Cool. So in terms of the actual leads themselves, so you have three D DCG s and you have 12 D DCG S. So three leads are the, are the basic ones that you see in sort of A&E and stuff. Um They give you quite a, they, they, they give you like a basic overview of the heart. You don't get all the information that you, you'd get in a 12 DCG, but it still does, it tell, it tells you enough to see if there's something big going on. Um So we have lead one, lead, one is made of the right arm electrode going to the left arm electrode. Lead two going from the right arm to the left leg, lead three, going from the left arm to the left leg. Now, you can see there's negative and positive electrodes and that without making it too confusing, essentially, if an electrical impulse is going towards the positive electrode, it forms an upward deflection on the E CG. If it's going away from the positive electrode ie towards a negative, it forms a negative deflection on the E CG. So it goes downwards. Um If you can remember that the, the rest of the, when you come to talking about the actual cardiac cycle and how that plays into the ECG, it'll all become quite, quite sort of simple. Um OK. So we've talked about lead one lead, two lead, three. So these are, these are called the limb leads. They, they're the basic leads that you get in a three lead E CG and the rest of them. Uh So the chest leads and the augmented limb leads, you get these extra leads in a 12 lead E CG. By the way, I speak quite quick and I can't see the chart. So if you do wrong with anything in the chart just let me know. Um OK. Cool. So next, we've got the chess leads. Um The chest leads don't have a physical negative electrode. Somehow. I don't remember how exactly it's calculated, but the E CG works out that the negative electrode is in the center of the heart and then the electrode that's on the sur uh skin, uh the skin surface I UV one V two all the way to V six, they act as the positive electrode. So basically, it's detecting impulses going from the middle of the heart outwards. So these give quite a detailed view of the like health of the ventral wall from, from different angles. So from this kind of angles all the way to around the side into the armpit. Um So that's B1 to B6 and then we have augmented limb leads. So these, when I was doing EC GS, it took me a while to get my head around these. But essentially, again, just imagine the negative electrodes in the center of the heart and the positive electrode is whichever one the last letter uh indicates. So for aVF for example, I just think F feet. So the positive electrode is the left leg electrode, um A V LL for left arm. So the positive electrode is the left arm electrode and A V RR for right arm positive electrode being the right arm electrode. So again, as I said before, um if the electrical impulse is going towards the the positive electrode, you get a upward deflection on the E CG and if it's going away from that, you get a nega uh downward deflection on the E CG. OK. Let me stay for here. Cool. Has anyone got any questions on that before we move any further? I mean, just do drop them into the chat if you've, if you've got anything. OK. Cool. OK. OK. So in terms of how an actual E CG um pattern maps out, um whenever we see this kind of pattern, it's normally in lead two. And the reason why it's in lead two is because if we imagine we've got the body, you've got the heart sitting in the body and it's in, it's in that kind of that kind of plane, it's slightly angled and lead two falls roughly in that direction. So as I said before, lead to his right arm to left leg. And if you look, it falls roughly parallel to where the electrical conduction runs uh in the heart. So you've got like vi node, intraventricular node down the septum of the ventricle wall. So, so it gives quite a good overview of that, of that impulse going down and up. So if you look a little bit closer at that, so as I said before, we've got the sinoatrial node firing and that spreads impulses across the atria. So you get this P wave here. So as I said before, if it's going towards the positive electrode, you get an upward deflection, then we have that brief uh pause that we talked about before we um send the impulse down the ventricles. So you get a flat line and then you get firing of the atrioventricular node that sends impulses down the septum and back up the ventricle wall. So you get this whole QR S complex. OK. So in terms of the individual components of the QR S complex, the Q wave, normally, you can't, you won't really be able to see it on, on an ECG. And if you can, it's, it's normally a sign of some sort of abnormal pathology. Um but it indicates impulse is going across the septum as in side to side, then you have the R wave which is impulse is spreading from the top of the septum all the way down to the bottom. So again, it's going towards the positive lead. So you'll get an upward deflection of the E CG. And then the S wave represents the conduction going back around the ventricle wall back to the negative electrode. So again, it shows a downward deflection. And then we have, there's some arrows indicating with that. Then again, we have, we have another flat line that just indicates the time taken for the ventricles to contract. And then we have at wave, which is basically just repolarization of this, of all this muscle. So the ventricle muscle just resets ready for the next impulse to to be fired down. Um Cool. I hope that all make sense to everyone. Ok. So again, just to summarize. So we've talked about where the physical leads and electrodes go, um the electrical activity in the heart and how that maps onto a normal sort of E CG pattern. Um Are you Rama? I just remember, I forgot the. Ok. So I'm gonna, um, I was supposed to ask this at the beginning. Uh OK. Can anyone just indicate how much cardiology they've done? Done? So I know I know how quickly to go through it. OK. OK. So it's split between people that have done the content and the placement and not done anything. OK. Fine. So for people that have done the placement on the content, the last few slides are probably gonna be quite useful because it's just a recap through all the conditions the for the people that haven't done anything yet. The first, the first bit should be quite good. Um because it's going from the basics. OK. Fine. OK. So moving on from there. So we have some, some normal values that you have to learn for, for what normal E CG looks like. I've tried to condense it as much as I can. Um Just because there, there's like a few more values you can learn, but II don't think they're that useful for interpreting EC GS. So when you get an E CG paper, it's normally this sort of yellow. Um not yellow, red paper, uh red slash pink paper. Um It has small squares and big squares. Essentially each small square indicates um naught point naught four seconds. Big square indicates naught 0.2 seconds. So if you join five big squares, you get, you get one second. So a normal P wave should be less than naught 0.12 seconds, which is three small squares strength together. Um The QR S complex. So beginning of the Q wave to the end of the S wave, that should be uh again, less than 0.12 seconds. So less than three small squares, the pr interval. So from the beginning of the P wave, all the way to the uh end of the flat line, that should be less than naught 0.2 seconds. So one big square and then the QT interval. So from the beginning of the QR S complex, all the way to the end of the T wave should be less than naught 0.44 seconds. So that should be less than two big squares plus one little square. OK. Um Again, we, we're rattling through all this quite quick. Um The recording will be available with all the slides. So hopefully, um later on, if you do need to memorize it, you can always come back and, and revisit it. OK? Cool. So you, you've set up your E CG, you've, you've connected to the machine and you've got a printout essentially this is what the printout looks like. So you've got lead one, lead, two, lead three. They're the basic limb leads that we talked about a VRA VLA VF, they're the augmented limb leads that we talked about. Then you have V one to V six, which is basically the chest leads. And like I said before, they give quite a good view of ventricle walls and then along the bottom of the E CG, if you look here, it says lead two and it has what's called a rhythm strip. So it gives, it gives a really long view of just that one strip. And it's quite handy for checking whether a rhythm is regular or irregular because because with these scripts, it's just sometimes they're just too short to see whether the QR S complexes are the same distance apart. So having said that if you do wanna check how to see if the rhythm is regular, just count the number of big squares between the QR S complexes. So here it is roughly three big squares between the Qs complexes. And if you follow that forward again, it, it stays similar maybe like three and a big squares, I think. Yeah. So it's a, it's a regular plan. OK. So one thing we need to have a quick look at is the blood supply of the heart. Um Just because so as I mentioned before, the leads give views of different sides of the heart. Um like certain leads will give a good view of the inferior aspect of the heart. Certain leads will give a good view of the anterior aspect of the heart. So as in the uh left and right ventricles, and then certain leads will give a good view of the side of the heart. Um But before we go into that, we just need to know how like the roof blood supply in the heart. So when it comes to the heart, you've got the aorta, you've got the left coronary artery and the right coronary artery coming off of it. Um With the right coronary artery that supplies the right atrium, sinoatrial node, the atrioventricular node and a little bit of the inter ventricular septum. The the main thing to know with that is they supply the, the nodes. So if there's a problem with, uh for example, say someone's had a heart attack, um There's a blockage in the right coronary artery that's taken out the blood supply to the sino atrial and the atrioventricular node. So, if you realize there's some issues with the heart rate that's too slow, for example, and that's a good indication that it could be like a RCA infarction. Um And then if we look at the left coronary artery, so you've got that coming off, you've got the left anterior descending, which is the led here and you've got the left circumflex artery. So the left anterior descending supplies quite a, a decent chunk of the heart. So it supplies the right ventricle, left ventricle and the intraventricular septum and the left circumflex supplies the left atrium and a bit of the left ventricle. So again, if there's something that's wrong in the left anterior descending artery, that takes out a decent chunk of the heart. So you might notice pathology in, in quite a few different leads. Ok. Um So that's what this is showing here. So basically, the leads can be split into groups. So leads 23 A VF which is the one shown in red here. They give a very good view of the inferior aspect of the heart and normally that's supplied by the right coronary artery. It says all left circumflex. I think that's like a like a normal variant in some people. Um But for simplicity, you can just ignore that for now, then we have the left anterior descending artery that supplies the anterior aspect of the heart. So V one to V four will give you a, a good, good idea of what's going on in the, in the artery. And then again, we have the blue lead. So one FV five V six that's normally supplied by the left circumflex. Um Again, you can ignore the of L AD um And that gives a good view of the, of the side of the heart, the lateral aspect of the heart. So the, the main time that they're, this is useful is for semis and well, semis by, I mean, ST um elevated myocardial infarction. So, if there's a blockage in the left anterior descending artery, you'd expect to see ST elevation linked, linked to V one to V four. Again, likewise, if there's someone in the RCA, you'd see ST elevation in these 23 AVIA. And then one thing to bear in mind is if you go back to this, if there's a big blockage that comes on the, that blocks the left coronary artery prior to the left anterior descending artery coming off. And the left circumflex, you'd expect to see ST elevation in all of the green and of the blue leads because it's taken out the blood supply um for, for both of them together. II do remember that coming up past me a couple of times actually. Um OK, cool. So we've discussed the by the heart, the different leads and the different territories as well. Ok. Cool. So axis axis is one of the things that II, remember when I was going through EC GS, it took me, it took me quite a long time to sort of get my head around it. And in hindsight, a lot, a lot of it was unnecessary um because you just need to know how to calculate it and how to tell whether there's left or right axis deviation, um which I'll go into in a second, but essentially what axis refers to is. So, as I said before, you got electrical impulses starting at the SA N, they go across the atria, they arrive at the atrial ventricular node down the septum back of the ventricle walls. Now, because the left ventricle has slightly more muscle than the, well, a lot more muscle than the right, because it's pumping uh, blood across the whole body rather than just to the lungs. Um, it takes, it takes some more of the electrical impulse. Is that oh, it has more fiber on that side. So if you plan the net direct net net movement of electrical activity, there should be more of it going to the left ventricle in the right ventricle because there's more nerve tissue on that side. So if you plot a point from like the beating of the impulse to roughly where most of it goes, it should be going in that kind of direction there. I'm sorry. Um And if you look, if, if you look behind the heart diagram there, you've got pink um which shows that that's where normal access should be. So if the neck movements anywhere within that pink, the the electrical activity is fine in the heart, the issues arise when you have um what's called left or right bundle branch block. So if you have an issue which cuts off the nerve supply or the conduction down the left side of the heart, more of the electrical activity goes towards the right side of the heart because of that this net movement of electricity, the arrow might be pointing. So this in this direction here towards the blue and that's what's called right axis deviation. Um So again, all that means is there's an issue with the conduction on the left side of the heart. So electrical activity is going down the right and that's right axis deviation and you get same the same on the left. So if you have what's called right bundle branch block, so this, this conduction down this way of the ventricles, all cut off, more of the electricity goes towards the right uh Sorry, left and the net movement of electricity goes roughly in that direction and that's called left axis deviation. OK. I hope that will make sense to everyone. Does anyone need me to go over that again? Just because it's something that took me a while to get my head around. I think it was NPO that's very efficient. That is, yeah, using technology, you know what? It's what to be fair. I think, I think mine's blo mine's, mine's just like it. There you go. I'll be fine good. OK. Um So that's what access when let me just check is updated. OK. I think so. 90% of people said yes. OK. So um basically access refers to the net movement of electricity through the heart. The the way to calculate it is if you look at lead one and you look at ABF. Um So some people also use, I think it's lead one and lead three. I've always stuck with lead one and ABF. So if you look at the QR S complex, we've got a QR S here for lead one and a QR S here for ABF. Um If you draw a rough line on like the EEC GS baseline, so where the E CG should return to after impulse. So it's roughly around here and the same against ABF if more of the QR S is above that line than below, it's called a net positive deflection. So for it, for lead one here, for example, a lot of it goes above and below, that's net positive, it's the same with a VFA lot of the QR S goes above and below. Again, that's net positive. So if both of them are positive, that's that's normal axis. So left axis deviation is the QR S is positive and need one as it is here, but lead VF is negative. So more of that QR S complex will go below rather than above. So if you see that, that, that just means left axis deviation and right is the opposite. So if you see the QR S is more, so you've got a positive QR S in a VF as you do here and a negative in lead one. So more more of this is going below than above the line that'd be right after deviation. So a bit in terms of access all you need to remember is how, how to calculate access and what leads you're using as aside from that, you don't need to sort of think, think of it in any more detail than that. So again, for that, you just need to me memorize these three lines. Ok, cool. So that's a ok. So in terms of how to interpret an E CG, um all the physiology you need to know about an E CG was in the previous slides, anything more than that, you don't really need to know for the, for the purposes of your OS or, or, or a KT. Um So say, say you've got an OS station and you've been told to do your EKG, um you've set it up, you've done it on the patient and you've got your print out. So anytime you get results in an OSC, always make sure to check the name and date uh date of birth of the patient and make sure you've got the right scan uh in front of you for that patient, check the date and time the ECG was done and then ask for any previous ECG S to compare to because if there is some sort of some sort of abnormality on the E CG, you want to see if that's new or whether that's, that's longstanding or, or previous. So after you've done that again, that's the same for any investigation, you look at rate rhythm axis and the individual components of the CD. So in terms of how to calculate the rate. So if you go back a little bit to hear, so I think there's a method where you can do like 300 divided by the number of big squares between the QR s. Um The only issue with that is it only works if the rate is regular. So the way I normally do it is this big strip along the bottom represents 10 seconds. So I'll just count all the big spikes, all the big Qs complexes between them 10 seconds and times it by six. So here, for example, it's, I think it was 13 if I've got that right. Um So 13 times six should be 78. Uh And that's your rate in terms of how to calculate the rhythm or look at the rhythm. Um Just look at the number of big squares between each player as complex like I said before, if, if they're all the same. So roughly here, it's like 3.5. If they're all 3.5, which it is, that's regular, then it could also be irregular. So if you notice sort of three big squares followed by two big squares followed by two big squares, three big squares that's irregular, but then that breaks down into regularly irregular and irregularly irregular. So what I mean, so regularly irregular is if there's a pattern to the irregularity, so you might notice three big squares, 22 big squares, three big squares, two big squares, there's a regular pattern. So that's regularly irregular, irregularly irregular is where there's no pattern at all. So you might notice sort of three big squares, 22145. That's irregularly irregular. OK. So we talked about how to calculate rate, which is a big square times by six. We talked about how you how to calculate rhythm and the differences between sort of regular and irregular. Next, we have access which we've talked about. So again, you just look at leads one and avia both of which are positive here. And that means that's normal axis, then we look at individual components. So for the individual components, all you really need to talk about is these here. So talk about the P waves. Can you see P waves talk about the QR S? Is it less than naught 0.12 seconds or more than 10.12 seconds? If it's less, it's called a narrow complex, which is normal. If it's more than, than three small squares, it's called broad complex which is abnormal. Um Talk about the pr interval, is it prolonged? Is it, is it normal and talk about the QT interval? Now, the only issue is in certain types of pathology, you might not be able to talk about all of the um different types of um individual components because they might not be there. For example, atrial fibrillation there's no P wave for you to talk about. So you can't talk about P waves or the pr interval. Um, and if you do spot any abnormalities, just, just sort of check whether it's in a certain lead group as we talked about before here or whether it's widespread, whether it's on every single lead. Ok. Cool. So, interpreting E CG is great rhythm, access individual components and then just sort of figure out whether it's on every lead or whether it's specified to a certain number of leads. Ok. II know I've flown through that in like half an hour. I hope that's made sense to everyone. If it hasn't, there's some resources that I've got on the last slide which I found quite useful, a couple of youtube videos and a couple of um links to different websites. Um So they're always there to refer back to. So we're gonna talk about some ECG plans. The next um these are sort of bit diagnosis that you should be able to spot from, from just the seeing the ed. Obviously your always get like a clinical context as well, which will help. Um So the first one, what we'll do is so the first one we'll work through uh by doing these polls and after that, I might just quickly run through some of the ba diagnosis base of science for you to look, look at, look for sorry um in different conditions. Cool. So we have OK, So I've also grouped all the pathology. So we've got tachyarrhythmias where the heart goes too quick. Brachy arrhythmias is like heart block where the heart rate is too slow. We've got sort of myocardial damage. Um, so stuff like heart attacks and uh angina and left and right branch block, which we'll talk about at the end. And then I've also got some, some random patterns that you should be able to recognize. So, starting off with the first one, so tachyarrhythmias as I mentioned before, they normally characterized by either being narrow complex or broad complex. So if the QR S as we talked about before is more than three uh three small squares is broad complex. If it's less than three small squares, it's narrow complex. So as soon as you, as soon as you figure that out, you're either talking about these four or these three conditions over here. Um OK, let's have a look at these on the next slide. OK. So here's an E CG, I'm gonna set some polls. So this is the first one. So can someone calculate the rate of that, by the way, the politics are a bit on the screen? So you might wanna say it on a full screen so you can see, still see the E CG in the background. Oh To be fair, you can click answer later and then later see the rest of the flood. Yeah. To be, I think everyone's right. Yeah, you got, you got 100% or nine people responded. So, yes, move on. Ok, bye. Um So again, you just count the QR S which is 12 times it by six. That's 72. Fine. Let's do rhythm. Uh Yeah. Fantastic, irregularly irregular. Let's do axis. So left axis deviation, right, axis deviation are normal. Yeah. Fantastic. And then let's do if somebody has a normal QR S is that kind is narrow or is that just? Yeah. So normal is less accurate. Yeah. And narrow complex is normal. Yeah. Yeah. It should be less than 120 milliseconds. So three small squares. Yeah. Ok. Yeah. Fantastic. Everyone's got now. Ok. Cool. Um So after this I II won't be doing the polls just for the sake of time. Uh I don't wanna take too much of the evening off as well. Um So we'll just talk about the, the big signs to look out for. So this is irregularly irregular and this narrow complex. And as soon as you see that you should be looking for, if, if there's any P waves here, these sort of oscillations are P waves. Um It's just sort of like a fibrillation in the baseline. So this is atrial fibrillation again, that's not, you can see that the absent P wave is regularly irregular. OK. Can you just go through how you went through figuring out there was no access to deviation? OK. So if we look at the lead one So we, you can see where the baseline of the E CG is. It's, it's roughly quite flat over the um over that ST uh lead one strip, more of the QR S complex goes above that line than below. So you've said that's a net positive deflection in the QR S. Does that make sense? Probably you get that. Yeah, that makes sense. Yeah. So, so, so more of the QR S is spiking up and spiking down. Yeah, if you look at a VF, it's, it's similar as well. It's a bit harder to draw the baseline here because it's going up and down. But more of the QR S is going above than below. So again, you chance a positive reflection. OK. So you're looking at lead one and a VF. Yeah, I think you can also use one and three, but I normally just stick with one and a VF. Um So because they're both positive. So if you look back at the rule that we learned before this one here, secure deflection, positive and lead one ABF is normal axis, does that make sense? Yeah, that makes sense? Cool. So that's afib. So next, let's look at um this one here. So again, you do the whole whole sort of business of rate rhythm, access individual components. So the most salient finding here would be these sort of big, big waves. Um Now these here are periods and they've got this quite characteristic. It's called a suor uh not su so tooth. Um and what that means, um anytime you see that it's quite characteristic of a condition called atrial flutter. So you've got a saw tooth pattern, you've got variable um in this condition, you can have like a variation between the number of P waves to the QR S complexes. So in this one, you've got like three P waves before a QR S, you could also have four, you could have two by, in this condition, the atria old is fire at roughly of 300 BPM. That's why you get a really regular um So tooth pattern. Um So again, if you see that and it's not a complex, it's gonna be atrial flutter. Um Next, we have, so this one here is OK. So again, there, there's, there's quite, quite a bit going on, but the more salient finding here would be if we look at the lead two strip at the bottom, you can see you've got AP wave and then normally you'd expect that flat segment that we talked about between the atria and ventricles contracting. Here. It's not really a flat segment, it kind of goes the fewer finishes and straight away, you start getting like an incline for the QR s and then it go goes even steeper. So th this is a condition called Wolf Parkinson White that um finding here is called the delta wave or a slowed up stroke. And basically in wolf Parkinson white, there's a extra bundle of uh nerve fibers that go from the atria to the ventricles. So basically, rather than stopping um between the atria and ventricle a contraction, the the nerves sort of bypass uh that fibrous ring that we talked about. So you start getting like early depolarization of the ventricles and that's the reason why the QR S starts a bit earlier than it should. Um OK. Hope that makes sense. OK. So this one here. So again, we just wanna look at lead to for the, for the sake of time. So you can't really see, you can see this wave here. We don't know whether it's APR T you've got quite a flat interval, then you've got a narrow PR S complex and then you've got a flat ST segment and then you've got another wave. So basically, this wave here is at wave, there's no P waves and you can tell from the sort of tense rhythm strip that there's loads of QR S complexes. Um So actually, if I just calculate it really quickly in 36, so it's 24 times um six, which is like 100 and 50 or something. Um So again, this is, this is super ventricular tachycardia um because there's no P waves, that's how you differentiate it from Sinus tachycardia. And this narrow PR S complex is OK. I went through that quite quick. Let me just make sure that makes sense to me. These poles are cooking, man. Yeah, I know, man. Ok. Fantastic, cool. So let's move on. Um So we have Brady arrhythmias. So basically this is where the heart's just going too slow. So the the other name for it is heart block. The more common name you've got first degree heart block, second degree heart block, and third degree heart block, which is basically sort of complete heart block. Um Now on the in secondary heart block, you can also split it down into two types of heart block. So you have Mobitz one and Mobitz two. Um OK, I'm not gonna explain that. Now, we'll go, we'll explain it as we, as we go along. So in, in this one here, again, if we just look at lead two, so you've got, you've got a small wave here, which we'll assume is AP wave, you've got quite a flat segment, then you've got a QR S complex and then you have the T wave. Now, if you compare it to um the strip at the beginning, so let's quickly go back. If you compare it to these, you can see here like the P waves are quite close to the QS complexes. But if you go back to this one, the, the P waves are miles away from the PO is complex. So I said before, the pr interval should be less than one big square. And here you can tell that's way more than one big square from the beginning of the P wave to the end of the uh flat flat area. So this is first degree heart block. Um In this one, it's about 300 milliseconds. Uh It's common in it, it doesn't always indicate pathology. It's also common in athletes. It can be common in people that are on drugs like uh beta blockers, calcium channel blockers and digoxin. Um But it's basically defined as having apr interval of more than uh 200 milliseconds, which is one big square. But that, that's why it's important to know the rough sort of um normal time for APR interval. OK. So that's first degree heart block. Next, we have this here. So if we look at lead to, if, if we start here, so you've got P flat area Q RST wave, then again, P flat Q RST and progressively the difference, the distance between the P and the QR S is getting bigger. So here it's quite small here. It's a bit bigger. Here's even bigger. Here is huge. And then here you've got AP wave here and then you haven't got a QR S and then you've got another P wave and then a QR S and at wave. So basically the P wave, the PR interval is getting longer until you get one dropped QR S complex. And then it restarts again and it does it again down here. So this is what's called. OK. I don't know how to pronounce this, the when when came back phenomenon, um this is second degree heart block, morbid type one. OK. So with this, this isn't immediately dangerous. So if they're asymptomatic, they don't need self pacing. But then anything after this, they, they do need pacing even if it's a asymptomatic because it can get quite dangerous. So the next one, for example, so if we look here, it's, it's quite similar to the last one. You've got AP QR S complex. QR STP Q RST. But there's the pr interval is staying the same. And then you've got this one dropped beat with um no QRS after it. And this is second degree heart block morbid type two. So just to compare Mobitz type one, you've got that uh elongation in the Pr interval, Mobitz type two, there's no elongation, it just drops. So these guys need pacing even if they're asymptomatic because they've got a high risk of going into a complete heart block, which is this here. So II could not find like a normal E CG for these. So all of this is lead to the way I normally identify complete heart block is if you look at the, so the P waves are normally slightly bigger than the. So the T waves are normally slightly bigger than the P. If you compare the distance between like all the, all the P waves, it's roughly like here is about four squares. Here is about four about four, about four. And the QR s has roughly seven squares difference between them. Now, the QR S to QR S distance stays the same about seven squares and the P to P distance stays the same about four squares. So what that means is the P waves and the QR S complex is they're, they're beaten completely independently of each other. They, they're not linked to each other at all. Um So that, that's basically a third degree heart block and, and this is, this is really dangerous. So they need sort of immediate pacing and, and sorting out. Ok. Again, I feel like I'm rushing through it, but that's, that's all of heart block done. And next, we have conditions which damage the heart. So we've got acute coronary syndromes where um you've got some, some kind of ischemia, so unstable angina. Um It's not a complete blockage. It, it's reversible at that point. It's only on exertion or sorry, it's at rest. Um Entei where you've got a blockage of the artery, but it's not completely occluded, occluded. And you've got STEMI where you've got a complete blockage of the artery and then you've got a left and right bundle branch block, which is what we talked about before where conduction to one side of the heart gets cut off. Um And that causes like massive like conduction abnormalities and, and it struggles and the ventricle struggles to contract properly. Ok. Right. So locked up, then OK. So now we, we're starting to talk about sties. So we need to, rather than just looking at lead two, we need to be looking at all of the, the leads to identify where, where the problem is. So here, if you look at sort of lead two, the ST segment looks looks normal here. Um Lead sort of three. ABL, you can argue, it still looks pretty normal. But then if you look at lead one to lead V one to V four, there's massive ST elevation and there, there is a little bit in V five, V six, but not as much as V one to V four. So you can like quite easily limit it down to them, them thingies, them um leads and as I mentioned before, lead V one to V four is actually put more slides in. They, they're all, they're all anterior. So they're all supplied by the left, left anterior descending arteries, artery and that indicates a blockage in that. Basically, let's go back here. Ok. So it's anti, has anyone got any questions with it? Cos I feel like I'm up front to that again. Ok. No. Yeah. Ok. Ok. So next here we have a Nstemi. If you look at sort of leads 23 A VF um V two V three, V five V four, there's all, there's slight ST depression in all of them. Um and there's no no real ST elevation in any of the leads. So again, and STEMI and it's quite widespread as well. It's not linked to elite territory that finally we have here. OK. So we're gonna talk briefly about bundle branch block. There's quite a lot of um like physiology behind it and understanding like how it relates to the E CG. But I remember trying to learn it and it just, it was just too much for the sake of the OSK or the A KT. Basically, there's like an acronym on, on par me. Um I think there's Marrow and William. So this one is if you see some kind of notch in the QR S complex like you do in most of the leads here that normally indicates bundle branch block. So if you look at V one and if there's AM pattern in V one, that's normally right, middle branch block and if there's AM in V six, that's left branch block. So here you can, you can kind of make out the M in V six and that indicates left middle branch block and just to get a better view of that, there's, there's some here. So I think the technical term for this is like RSR. So you, you this, this depiction down here should, should look look more like this. So if you see AM and V six, it's left middle branch block and then going on to Redwood branch block if you see AM and V one, that's right. OK. And as I explained before. Um, all, all that mean right bundle branch block means the electrical impulse to the right side of the heart is being cut off. So electricity is only going to the left and this vice versa as well. Same for left and right. Ok. Cool. Sorry Roma, I'm going into your time. I'm just gonna make one more call really quick just to make sure that makes sense. No, I think the C DS are the harder it, so it's good to, it's good to get it done properly. Yeah, and that this is recorded. Um So if you guys feel like it's gone a bit too quickly, just feel free to watch it back. Yeah. Um And by the way, at the end, I do have um links to some videos that I found really useful. Uh and they go through it quite slowly as well, like I think it's like an hour and a half per video and there's two videos. Um So they, they explain it from scratch and really well as well. Ok, I think we've got most, most people understanding it. Um OK, we're gonna, we're gonna do some polls now for the people that have done um cardio. So let's start with this one. So does anyone know what's in figure one? And again, like I said before, the, these should be sort of findings where you see the pattern and you can sort of instantly recognize it as being a condition I, I'll let it get to about 910 and then we'll no fun. OK. We got a decent mix. OK. So this is do anymore. I believe that. So this is hypokalemia. The reason why is because, so you've got, you've got T wave inversion. So directly after the QR S complex, the T wave is going upside down which you shouldn't be. And after that, you've got another wave going up. This is a, the, the P wave, by the way, because the P wave is down here, it's a lot smaller. Uh and the next T wave after that should be a lot smaller as well. This is what's called AU wave. And then if you, if you look at this entire pattern here and you think back to sort of G CSE A level maths, it's got like a sign wave pattern to it. So if you see that, that's that, that's sort of uh indict of hypokalemia. Now, the next one is here. So just to help everyone, just look at the T waves. This, this large peak here is at wave. It's a premixed picture. Um OK. So again, normal P wave, it flattens out. You've got a QR S the, there's no ST elevation here because it more or less comes back to baseline. But if you look at the T wave, it's huge. It's, it's bigger than the, the QR S complex. So normally tall tented, um T wave, sorry, tall tented T waves indicates hyperkalemia. Um And normally if you see, if you see a sign like that on the EC GS, you got to implement like the emergency hyperkalemia protocol, um which you guys should also know as well. Um, ok, fine. Next one is OK. By the way, if you're not getting any of these, don't worry at all because these are the kind of things where when you're doing, you'll see it again and again, it'll get to the point where as soon as you see the E CG, you'll be able to recognize it straight away. Ok? To be fair. This one you could do with seeing the entire E CG. Um, it might have made it a bit easier. I mean, to be fair, half of you guys got it. So this is pericarditis. Um, the thing that indicates that is so the blue line is supposed to represent the baseline of the E CG. Um, after the P wave, there's like there's pr depression. So the E CG goes slightly below the baseline here. You've got the PR S complex, but then you've got this, it looks like ST elevation, but it's quite curved as well. And that's called saddle shaped ST elevation. It's kind of like a horse saddle. Um And the reason why I was saying it, it'd be good to see the entire E CG is you'd see this ST elevation, the, the saddle shaped ST elevation on every single lead. So it's not tied down to one specific um territory or like a semi. Um Yeah, and then final one is OK, we've got a next picture here. OK. So this little deflection here is what's called AJ wave. Um And that's not the T wave, the, the actual T wave is down here. So if you look at the E CG, the, I think this is supposed to be the P wave here. It's, it's really flat and the pr interval is quite long and then the QT interval is, is pretty huge. Um So this J wave plus a long pr interval and a long qt interval indicate hypothermia. And the way I think of it is everything's going really slow because you're called so long pr long QT. Um again, if you do get any of those, don't worry at all. Um these, these would be shown for. So all of these should be widespread across the E CG. It is not like a, a stem you where uh because you've got a infarction in one artery, you'd see um is ischemic changes in a certain territory? These are two sort of with the, the like systemic circulation, hypokalemia, hyperkalemia, and hypothermia. So you should see a widespread across the entire thing. Does that make sense? Yeah. Fantastic. Cool. OK. I think that's my section. Oh, yeah. So these are the resources that I was talking about. So there's a ninja. Er he, he was really good for EC GS and arrhythmias. Um Life in the Fast Lane have a lot of good E CG patterns and Gee medics has like a good um interpretations or readthrough things. Ok. I'm gonna hand over to Rama now that's my section done. Um Probably you need to follow your slide. So, yeah. No, that should be, should be good. Right. Yeah. Ok, perfect. Thank you guys for, for sticking on. Um We've been there an hour, nearly an hour. So I'll try and keep this so like 2025 minutes. Um I would definitely say ec GS are one of the harder parts or hardest parts of clinical years in terms of the content you need to know. Um So definitely go through that, go through the recording if you find it difficult and just keep it consistent and you will get there. It did take me a while as well. We're gonna talk about chest X rays. Now um I'm gonna start with some pulse and some rapid fire diagnoses just before we do that. I did want to ask um just to gauge your knowledge. So how much do you know about chest x rays? Um so far and your medical training just so I can see what level everyone's on? Ok, good. So most people sort of know what they're doing, which means I can get through this in a decent amount of time and you guys should find something that's helpful. Ok. So we're gonna start off with some rapid fire diagnoses on the spot. So, first one have a look at that chest X ray and I'll start this pulp. So what are we looking at? Are we looking at TB cancer asthma? Is this a normal chest X ray or is it a condition called alpha one antitrypsin deficiency? Perfect. All right, most people seem to know what they're doing. So, as you can see and can you see my um mouse on screen? You can't, can you? No, no. OK. That's fine. Um If you see that mass on the right hand side, that circle that is a lung cancer. So we need to be aware of that. Um Just remember on a chest X ray, the right hand side is the left lung and the left hand side is the right lung. So next one, what are we looking at here? Is it something called interstitial lung disease? It's a COPD. Is it a normal chest X ray or is it a pneumothorax or is it asthma? And just to know when we wrap this up, I will send a feedback form. We'd really appreciate if you guys fill that out um because it just helps us direct our learning and and how we can better teach you in future tutorials. Ok. So we've got eight responses. So we got somewhat overread, but the majority of people are getting this right. So the answer is CO PD because these lungs are hyperinflated. So there is way too much, way too much lung space going on here. And we can tell that by how many ribs we can count. And we can also tell that because the diaphragm is quite flat and we call that a flat hemidiaphragm. So those are two key findings on a chest X ray for CO PD. It's hyperinflation, but the log fields are too big and a flat hemi diaphragm and we'll go through that in a bit later. That one, what are we thinking? Is it interstitial lung disease? Is it a pneumonia? Is it alpha one antitrypsin deficiency? Are we looking at lung metastases or is this a normal chest X ray? Ok. We've got a good amount of responses. So the majority of you again, going for the right answer. This is a normal chest X ray. I apologize for trying to trick you guys, but there's absolutely nothing wrong with this chest X ray. It's perfectly, perfectly normal and this is a good chest X ray. OK. Number four. This is the second to last one. What are we looking at? Pneumothorax, atelectasis, a pleural effusion, sarcoidosis or is this a normal chest X ray? So again, you get to smashing it. Most of you are getting the right answer. This is a pleural effusion. So the main finding here is if you look at the right lung, which is on the left side of the chest X ray, there's what we call a meniscus sign, which is where most of that lung is taken out. And it's sort of got a curved, a curved bottom side. And that's what we call a meniscus sign. And it's very, very key finding in a big pleural effusion and a pleural effusion is when there's fluid within the sort of barriers of the lung. Last one, what are we looking at? Are we looking at interstitial lung disease and pneumonia? Alpha one antitrypsin deficiency lung metastases or is this a normal chest X ray? Again, most of you getting the right answer, this is pneumonia. Again, this is on the right lung, which is on the left hand side of the chest X ray, specifically in the lower zone. We've got a lot of what we call consolidation. Um and that's something we can go over in a second. So chest X rays are they easy or not to sort of look at and present some things stored in those spot diagnoses are quite easy to diagnose. For example, that first one on lung cancer that was a massive mass. Um and with a bit of practice, you should be able to see that quite easily. However, some other chex rays, chest X rays can be quite dubious and difficult to interpret. Ano an annoying thing with respiratory medicine is that one condition can lead to another condition. So when you look at a chest X ray, it can have multiple pathologies on it that you have to sort of figure out, for example, a common cause of a pleural effusion can be cancer. Um And uh lung cancer can also be secondary to smoking. And a lot of smokers have CO PD. So with chest X rays, when you look at them, you have to have a structure to go through because that makes things a lot easier. And it allows you to pick the little, the little minute details um that you might miss if you just went for looking at a rapid fire diagnosis. So how do we go about doing that? But before we do that, let's talk about why we might do a chest X ray. So uh let's break this down into symptoms, signs and any other reasons. So, symptoms are, what is the patient complaining about signs are what do you see on an examination if you were to do a respiratory examination on a patient? And are there any other random reasons you might think about as to do a chest X ray if you just unmute and speak or put them in the chat? Um we can go through them. Ok, ra ra so me give me some reasons why I do a chest X ray. I'll put you on the spot, persistent cough, nice breathlessness, shortness of breath. A so chest pain perfect. So signs, um patient might complain about having a cough, a fever, something called hemoptysis is which is when you're coughing up blood and symptoms. So what would you find on a respiratory exam? My answer to that is pretty much anything that's abnormal on a respiratory exam can in some ways warrant a chest X ray because it's an easy noninvasive thing to do. Um especially in adults and then you have random reasons. So let's say patients uh go into theaters and we put an NG tube in to give them food um because they're n by mouth, we need to do a chest X ray to make sure that it's in the right position. If someone has pneumonia after six weeks, we need to do a chest X ray to make sure there's no severe underlying cause of the pneumonia. And if someone's had a pneumothorax, um you also do a follow up chest X ray to make sure that they're fit to fly. So moving on to how we actually interpret a chest X ray. We have a nice Pneumonic called Doctor Wright ABCD. E, I'm sure you've probably heard of this. Um And it's a very healthy pneumonic for learning how to interpret chest x rays. The first half of the mnemonic. Doctor Wright assesses the chest X ray quality. So that answers the question is this chest chest X ray worth me interpreting because some chest X rays are not actually that good and they can lead you down the track of getting your wrong diagnosis. So you need to make sure it's the right quality before you even bother looking at it properly. And in order to look at it properly, we've got the mo mnemonic ABCD E. So when you're beginning your practice, it can take a while to go through the first half of the Pneumonic to make sure that chest X ray is adequate for you to look at from a clinical perspective. But once you get to your later stages of your education, and hopefully by the time you get to your Aussies and your CP SAS, you should be able to rattle that off in 20 to 30 seconds because is essentially something you can do very, very quickly. So let's start with d first step is details. The first thing you wanna do is make sure you've actually got the right patient. Ideally, you have three different identifier before you look at any, any sort of patient data. And that's very important for your C PSAs to state. So first thing is the name, the second thing is the patient's date of birth. And the third thing is their hospital number or M RN or NHS number, anything that's unique to the patient. The second thing you wanna say is that you would compare to any previous x rays if possible. So this is because we can look at sort of chest x rays from a longitudinal perspective. And that can give us a good idea as to whether there's any changes happening within the patient and looking at a chest X ray from six months ago to now can help us look at the progression of a known condition and also, and also can help us look at any changes that have happened that are abnormal to help us diagnose a new condition. And then the third thing you want to do is is quickly spot out anything that you see that sticks out to you. So if you see there's consultation, if you see there's a mass, if you see there's um hyperinflation, just say it straight away because there's nothing wrong with doing that. So in terms of actually assessing whether the chest X ray is adequate, the first thing we wanna do is look at the rotation of the chest X ray. So rotation refers to whether the chest X ray is hitting the patient at a straight angle straight on or if it's at an angle. So what we wanna have is the medial aspects of both clavicles to be the same distance from the spinus process. So if you can see in that diagram, the spinus process is smack bang in the middle and the clavicles are an equal distance to it. You also want the chest X ray to be sort of as vertically oriented as possible. So not twisted to the side or anything, but again, that's never gonna be perfect in a real life situation. So if we look at these chest X rays in the top left, we've got a good quality chest X ray in terms of rotation because the spinus process is equidistant from the medial sides of both clavicles. And in the top right, we've got that same diagram again. But in the bottom right, that dia is a bit small. But we can see that that chest X ray is slightly rotated to the right, it's rotated to the right because you can see the right clavicle which is on the left side of the photo takes up is much closer to the spinus process. So that means this, this chest x-ray is bad in terms of its rotation, but it doesn't mean you should write it off entirely. It's just something you should comment on. The next thing we want to look at is inspiration. So how good was the patient's inspiratory effort when the chest X ray was done? In order to comment properly on a chest X ray, you should be able to see 5 to 6 anterior ribs. So the anterior ribs are the ribs are in front of you um on the side of your pectoralis muscles or at least seven posterior ribs. So your posterior ribs are the ribs on your back essentially. So as we looked at CO PD earlier, I to I told you that one of the chest X rays was high power inflated and that's because there were too many posterior ribs um visible. So that's over 10. And you can also count the anterior ribs and if you can see over six anterior ribs, that also indicates hyperinflation. So the first thing we wanna do is look at the rotation, we wanna look at how many rows we can count. And then we also wanna make sure the costophrenic angles. So that's the angles between diaphragm and the lungs um are included in the film itself. So we've got some photos to go through here. So as I said, this is the co PD chest X ray or just another CO PD chest X ray, I think. But you can tell that that is hyperinflated. Now, in terms of making sure you know which rib you're counting, I want you all to just think about your own anatomy. If you feel the ribs on your, on the front of your chest, you can feel them all sort of diagonally going downwards towards your sternum because that's where they all meet. Whereas if you feel like ribs on your back, you can realize that they're sort of much more horizontally orientated and go around like a coat and we can see this on a chest X ray. So if you look at the photo on the right, the front side of the ribs, the anterior side, all sort of diagonally orientate down, and we can actually count how many there are in this chest X ray. And we can do the same for the back where they look sort of more horizontally oriented and are more or less straight. So moving on again, if I'm going too quickly, just let me know and I'll slow down. So moving on to P so P stands for two things. One is position and two is penetration. So physician is very, very important in the chest x-ray. There are two ways of doing a chest X ray. One is pa and one is AP and this refers to how the projection of the chest X ray hits the patient. Is it going from their back to their front or the front to their back, back to the front is more common. And this is called a posterior anterior chest X ray. And this is a better way of looking at chest X rays. Um We can, and we can talk about that later in terms of how you differentiate the two. The main thing I always look at is the scapula. So the scapular is the bone that connects your arm muscles to your chest. Um And in a pa X ray, it's sort of flatter and it's more out of view. So it's more lateral on the, on the image of the chest X ray. Whereas on an AP on an AP view, the scapula are much more visible and are more central, centrally located. Another thing is penetration. So you just wanna ask yourself, can I see the virtual bodies behind the heart? Because you wanna see every single bone that's possible to see on a chest X ray. So just a quick poll here just to make sure we're all on the same page is this pa which one is APA chest X ray? And which one is it? AP chest X ray. Just wait for like 10 people to respond. OK. So most of you again getting it right. So the left chest x-ray is APA X ray and the right is an AP. So going over why? Um so going over white, the scapula on the left side is not as visible, whereas on the right side, we can see it a lot more. So if you look at the AP x-ray, you can sort of see that shadowing that gets a lot lighter on the lateral aspects. I apologize. You can't see my cursor because that would make it a lot easier. But you can sort of appreciate the fact that the the scapular is much more visible in that image. And secondly, and most importantly, the heart is a lot bigger on the A PX ray. This is very important clinically because heart size is something that's very important for our cardiovascular systems and a lot of conditions cause your heart to become bigger. So chest X rays can be good to sort of help diagnose this. However, because your heart looks bigger naturally on a chest X ray. In an AP view, we cannot use an AP view to comment on heart size. That's why I said a pa X ray is more common and is better to use. And this is a big reason why it's more commonly used because in patients who have something called cardiomegaly, which is when the hearts are bigger. Um We can't comment it, we can't comment on it on a ap chest X ray. Um Someone said they think they both look the same which I do appreciate and it did take me a while when I first um started, but I hope you can at least appreciate the c the, the difference between the scapula in both images and oh, you mean the M CQ? OK, never mind. Um But the heart side is also something you want to figure. You want to have a look at. This is essentially why um if we're looking at a pa a chest X ray, look how far away the source is from the heart. Whereas with an ap projection, the projection is much closer to the heart. So as a result, the heart looks bigger, but this is not reliable. So if you see an AP chest X ray and you're given it, the heart looks too big, don't comment on it. So, e um for e you want to comment on whether or the patient is there? So can I see the top of the lungs? And can I see the bottom of the lungs? And that's all you need to do. Do those doctor Ri Pe do those five steps, you can comment on whether a chest X ray is adequate or not. So now we actually have to look at the X ray itself and try and figure out what's going on and if there's anything wrong with it. So we're starting with a, a stands for airway, which is very nice and convenient. The first thing we wanna look at is, is the TKA central. If it deviates, then something might be pushing it and something might be pulling it. The common things that p that polar chest X ray or a collapsed lobe and a lung and the most common causes of collapsed lobes and lungs are cancer being the most common caused by far. And also asthma. And that will pull the, that will pull the trachea towards it. Other things can push the trachea away from it. One of them being a pleural effusion and the other one being a pneumothorax and those are the most common causes of something pushing um a trea away. Then what we want to comment on is the carina. So if you look in the top right, we can see the bifurcation of the tea into the bronchi and the carina is basically the middle point of where they split and you wanna comment on it if you can see that and that can help you understand whether there's some deviation or not. The one thing we want to comment on after that is the hilar region. So the hilum of the lung is where all your pulmonary vasculature is all the arteries and the veins, et cetera. Sometimes there can be lymphadenopathy in those areas and that can show up on a chest X ray where they become more visible. So some causes of lymphadenopathy can be split into unilateral slash bilateral asymmetry or bilateral sy is equal on both sides. So if something's unilateral lymphadenopathy, so it's only more proval on one side or it's, it's got lymphadenopathy on both sides. But it's asymmetrical. The most common causes you want to remember are TB uh and cancer and the most common cause of bilateral symmetrical or BHL bilateral high lymphadenopathy is a condition called sarcoidosis, which will come come across quite a lot when you study your resp um and it comes up a lot, a lot and past. So just looking at these chest x rays on the top, we can see there's a collapsed lung uh and the right, it's the right upper lobe or the right upper zone that has collapsed. And in order to compensate the pressure differences, the trick here is pulled to that side. Whereas at the bottom photo, there's too much fluid on the left hand side of the lung due to the pleural effusion, which is physically moving the trichia to the other side. And it's also lead to something called mediastinal shift, which is when the contents of the um mediastinum move over to another side of the body and this is just a, a comment on high low lymphadenopathy. So if you look at the top x-ray, we have BHL, which is most likely associated with sarcoidosis. Ok. So we've done doctor, right? We've done a, let's go on to B so we wanna comment on breathing. This is why we look at the lungs themselves properly and in detail, we split the lungs into zones. So the apical zone, which is just above where your clavicles are the upper zone, the middle zone and the lower zone. The one thing you want to focus on is not saying lobes. I know we all know our pulmonary anatomy, the right lobe has the right lung has three lobes and the left lung has two lobes. However, you cannot differentiate those on a chest X ray and you need to talk about zones. Lobes are not visible on a chest X ray. And I've made that mistake quite a few times and you will just embarrass yourself in front of the consultant. If you say lobes, when you're going through your chest X ray, you want to compare like for like. So what that means is you want to compare the upper side of one lung and the upper side of the other lung and the middle of one lung and the middle of the other lung. And as you go through, you wanna compare like for like and that will help you differentiate any clinical abnormalities. If you don't see any lung markings and it just looks black and empty, that could suggest something called a pneumothorax, which is an sort of empty cavity within the lung. Um, and that can be quite dangerous as you compare. Like for like, you also want to note any consolidation, any areas of blackness, um and any appearances of heart failure. Um We won't go through those in specifics today, but I have a list at the end that you can sort of go through and study manually if you want to after you've done compared the lungs, like for like you wanna make sure the lungs go all the way to the edge of the lung field and you wanna make sure the plural borders are not visible. And this is just a reminder to comment what you go and verbalize what you say and that makes it a lot easier for the examiner. So these are the zones I was talking about the upper middle and lower zone, they've not added the apical zone in there. And I guess that's optional, but just make sure you split the lungs roughly into those criteria when you're presenting and assessing. So there's sort of a bit of a mishmash with regards to how people present breathing. And one thing that people say is a pacification and some people say consolidation, what is the difference between the two pacification is just a general term? Whereas consolidation is an actual clinical finding caused by veo alveolar linting with fluids, cells or other material. This is a really common finding in pneumonia. So if you remember that pneumonia that we saw earlier on the right lower lobe, on the right lower zone, sorry, not lobe, um there was consolidation if you see something that you think is a pacification or consolidation and you're not sure what to say, always say a pacification because that's a general term, many things can cause a pacification. Whereas only veo alveolar fluid alveola filling can cause consolidation. So you wanna be careful with that and just don't use, don't just say consolidation whenever you see something patchy on a chest X ray and this is just something to look at um in your own time. But this is just to help appreciate the differences between a consolidation and and the pacification going on to C. So C is for cardiovascular and that's looking at the heart. Remember the chest X ray has to be pa cannot be ap if the cardiothoracic ratio is over naught 0.5. So what that means is, does the heart take up over half the space in the mediastinum? This indicates cardiomegaly and cardiomegaly is just a fancy word for heart. That's too big on top of commenting on the heart side. You want to be able to comment on whether you can distinguish the right atrium and the left ventricle on the chest X ray. If there's other pathology such as consolidations or pleural effusions or lots of fluid building up that can make the hard borders really difficult to distinguish between each other. So, in this chest X ray, we can see the left a left atrium or left ventricle sorry and the right atrium quite easily. And the heart takes up less than 50% of the space in the thorax, which is good. And we can say the cardiothoracic ratio is under naught 0.5. So can anyone list some causes of cardio? So we can see in this chest X ray which we know is pa so we can comment on it. This heart is way too big and it's taken up over half the space in the Thax. Does anyone know any causes? So yeah, heart failure is a good one. A cardiac tampon. Not OK. Yeah. You think, yeah, I want you go, I guess it would but it would be very acute, wouldn't it? Actually, I definitely would. Um Yeah, some causes congenital heart disease, cardiomyopathies, but mainly heart failure is the one you want to remember. And there are distinct signs of heart failure. Um Again, I don't, we don't really have time to go over all of them, but they will be in a in a table at the end of this presentation. So we've done ABC. That's most of the hard work done. D stands for diaphragm. Remember because of your liver, uh the right side of your diaphragm will be slightly higher, then the next thing we wanna comment on are the costa friend angles. So those are the angles sort of on the bottom, left and bottom, right of where the lungs are. They should be nice and well defined. Um So you should be able to see a nice sharp margin, but if they are sort of lost and blurry, that is something called costophrenic blunting. And that indicates that there has been either hyperinflation or there's a sign that fluid has settled in that space, for example, in a pleural effusion. Um Yeah. So having a look at this chest X ray, we can see at the top, we've got some really nice sharp costophrenic angles on both the left side and the right side, they're a bit clearer on the left side, which represents the right lung. Whereas at the bottom, we've got some really, really blurred margins and that's something you definitely want to comment on. So, again, some causes of costophrenic, blunting, uh pleural effusions, atelec atelectasis, which is um common postoperative complication where the alveoli get blocked up and also can be a complication of asbestos exposure. Another thing you want to comment on is if, if there's anything underneath the diaphragm. So again, I wish I had my car, but you can see on the right lung which is on the left side, there's a clear outline of the diaphragm, but somehow there's still air underneath it. This is not good. This is called pneumoperitoneum. And it's a sign of gas under the diaphragm itself. There are many causes of it. But the main one you want to remember is perforation. So that means there's basically a hole somewhere in the usually gi anatomy and that's leading to air, being released into the, into the cavity of the body. And this is what we call a surgical emergency because it needs to be urgently investigated and urgently treated because it can be very dangerous. Once we've done that we can move on to E so e is where we just focus on everything else. So we've looked at whether the chest X ray is good. We've commented on whether there's any issues with the airway, any issues with the lungs is the heart a normal size? Is it, are the diaphragms normal? Is it at the right level? E is everything else? So are there any pacemakers? Are there any EG leads? Is the patient in any trauma? Are there any rib fractures? Can I see any damage to any of the bones? Can I see bright shadows normally? Hopefully, in most chest X rays, you won't be able to see any abnormalities at the very most. You'll see a pacemaker or an E CG lead. And if it's a female patient, you might see breast shadows. So an easy way to just say that and get out of the way quickly. Is there are no abnormalities with regard to bony structures or soft tissues in this chest X ray. This is a bit of a hard question. But can anyone see any everything else abnormalities with this chest X ray? It's pretty, pretty difficult. So if anyone gets it, I'll be quite happy. Any taker. What do you mean? You got any ideas? No. So, so there's a rib fracture you see on the right hand side, chest X ray, which is the left lung. Um I'm gonna count that the 12346. Um Was it anti AIP? Yeah, because it's coming diagonally. Uh There's a fracture there. But again, that's quite hard to see and I should have made that a bit bigger. So I do apologize. Uh This is only for you to practice in your own time. So I've made a station here where you can just present it. I've given you some patient details and some history. Um And if you just practice presenting that chest X ray to a friend or to yourself, and there's a bit of little, little mark scheme here um which I won't go through chest X rays. And how did they come up in your exams um in your spas, you'll, you'll likely to get at least one photo of a chest X ray. Um And that can either be for like a gastro question, but most commonly a respiratory question. And these are quite common for examples to pick in, especially now that a lot of exams for SBA S are done online. Um It's a lot easier to add things like imaging in them and then your practical exams. Um It's very likely that you'll get, be asked to interpret a chest X ray. Um or in more of an integrated station, you might have to do an examination of a patient for the respiratory system and then have a look at a chest X ray after that and interpret it and then in sort of more sinister conditions such as interstitial lung disease and lung cancer, which unfortunately, we didn't have time to cover in depth. Today, you might have to interpret that on the spot and then break those, break the news of the condition to the patient and obviously your counseling to that patient is entirely dependent on whether you can interpret that chest x-ray or not. So it's very, very important that you sort of nail this skill down. CT scans are worth just giving a quick mention to. These are often the gold standard in diagnosing certain respiratory conditions, namely bronchiectasis, interstitial lung disease, lung, lung cancer, and rib fractures. So, whilst chest X rays are good, very portable, very easy and accessible methods of imaging. They aren't the best and CT scans give you a much more in depth look and you wanna learn the spec significant findings specifically for bronchi interstitial lung disease as they do come up quite a lot in your SBA S I made this table to sort of just explain all the main respiratory conditions that I could remember. And I've put all the personal clinical findings that you should see on those chest x rays. So I've just created that as sort of AAA revision resource for you to use. But I won't go through that um today because we've taken up enough of your time in terms of resources. I find helpful this um chess show tutorial if you need sort of more resources to go through is very helpful and the websites are even more helpful, especially a website called Radio Pia. If there's any, if there's any conditions that you find, um you don't know or you wanna have a look at a chest X ray just type in any condition. So pleural effusion and then radio pia and you'll find a multiple chest x rays explaining the findings as well. So it's very, very helpful. And radiology master class helps you sort of figure out what you're looking at basically. Otherwise that is it? Thank you for watching. If you guys could fill out this feedback form, it will literally take a minute. Um If you have any questions, put them in the chat and we can try and answer them now. Um But otherwise I really for sticking with us throughout this time, please fill out the feedback. Um And let us know if there's anything we can improve on, I will stop the recording. Now, if that's OK. Yeah. Actually just wanna mention we'll be here every Thursday 6 p.m. Um, again, one sort of general medicine tutorial and one specialty specialty medicine tutorial. Um, so you can pick which one you go to, but we do appreciate you guys coming. 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