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Hello. Hi, everyone. Can you hear my voice? I didn't see the slides. I share. Thank you. So, um, let's start. Uh, I think a few people joined already. So before we start, um, uh, are you, are all of you guys uh, uh foundation year or, or any other grade? Uh, can you type in the chat box that so that I can see which, um, who are, which grade and where we, um, is it like uh foundation year or other grade? Just, um, just type your uh, grade in the check box? Oh, I'm T two. That's nice. I'm, I'm, I'm T one, by the way, working in uh da for hospital. A friend. Yes. Yeah. All right here. Ok. 11. Ok. Ok. I will start sharing my slides then. Sorry? Ok. You guys can stay right? Ok. Medical student. Very hardworking. Ok. My name is Yi Yi. I'm currently, I'm T one working in Lyme, um, just started this year. So today I will talk about at assessment for common uh cardiovascular cases that you might come across on your own call shift. So, so the major aim that uh we do the A two E assessment is to just to buy time to improve our patients clinical outcome by performing like a clinical assessment. What we do A two E assessment and do the investigation that are needed to give intervention and regular reassessment so that we we we you know, we can improve the patient's uh condition while we are waiting for the seniors to come or itu to come and assess uh before they come, we are the first line uh doctors to assess the patient and improve the clinical outcomes by doing some basic investigations and all the things that, that we need to do to present to the seniors. So today I will talk um case by case so that uh you are, it will be more interesting and II would like all of you guys to, to put your opinion and thinking into the chat box. So they would be more interactive rather than I only speaking to you guys. So let's say you are at foundation year one overnight on the medical take. And, and 76 year old lady has been having a history of worsening breathlessness and increasing leg swelling over the last week. And uh functional data is that she is only able to walk a short distance and then she becomes very short of breath. But uh she at the moment she denies any chest pain. Uh her BP is 1 55/90 heart rate is 97 respiratory rate. Is 24. NSAID is 91% on air and she, her temperature is 37.3. So by looking at this, uh, what kind of diagnosis or what, uh, what kind of things, uh, come across to your, your thoughts before you go to, you go and see that patient you, you can put in the chat box. Ok. Pe any, any, any other differentials? Let's see. Um, um, my scenario is a bit, you know, let's is bilateral and she is having shortness of breath previously and this is becoming worse and worse over the last week. So first thing is before you go and see, you have to think what are your differentials and how you assess the patients. Yeah, Achille conversated heart failure, congestive cardiac failure. Yes. So, so by by having those uh differentials in your mind because uh you have to think of cardiac causes and respiratory causes also because in the in the on, on the on course, you, you have to see all sort of patients and shortness of breath pregnant could be anything. So, uh, so first of all, how would you assess this patient? Uh like you will go through a two E assessment and just type it in what you would do. I know it's a bit, you know, uh difficult to type everything, just mainly focus on what, what, what assessment you would do and what you will look for, particularly for this patient, like from a to assessment. What would your focus mainly on and what are the things that, that would help you to get the diagnosis and other clinical features that you would like to find and examine? Yes. Um First, uh you have to do a three assessment first and then we will talk about the investigation. Uh After our assessment first, you will go to go to the patient to, to assess their airway first. Like if they can maintain their airway on their own, like by talking to them or you can listen to their breathing. Is there any airway obstruction or you can look at in their mouth by seeing any about air obstruction and like with secretions or is there anything that is blocking their airway? So uh a to the assessment first, um and then you can move on to breathing. Uh the nurses have already done the ops and uh you know, the respiratory rate and saturations. Um The saturation is 91% of air and respiratory rate is 24. And then what we do is you listen to the uh you examine the chest and look at the chest recordia and also uh listen to their breath sounds, any uh palpitations or any localized. So uh edit sounds so that you can check the patient is having any chest infection or reduced a entry on either side of the lungs and in circulation. Can anyone tell what would you look at? Uh look for. And what would you assess? Yes, couple of refill. Yes. Any other thing. Yes. BP. Yes. Yes. Yes. If the patient is morbidly uh like cardiovascular uh diagnosis that you, you suspect most you can start with circulation first. So you check the BP. Yeah. J BP is a must uh if you think of heart failure and ccf as a differential heart rate. Yeah. So in heart rate, how would you uh assess other other things about heart rate? You, you're just not content with the rate. What we, we, what would you assess other uh in, in the heart rate? I mean, yes, rhythm. So uh heart failure patient, they can sometimes precipitated by the atrial fibrillation. So rhythm is very important whether they have uh irregular rhythm or regular rhythm or a two base. So you can check by listening to the heartbeat and also uh checking their pulse rate. And in the precordium, you can also look at their apus fee is displaced or not or any previous cardiac surgery scar on the precordium of the chest. Uh Sometimes they have other like a vi uh replacement, they might have some scar over the chest so that these are the things that you need to look for in the uh circulation assessment. So you check um generally you check the neck for J BP and BP, heart rate. And also you look at the chest wall and assess the apus feet and listen to the heart sounds and edit, sound like murmurs. And also the main thing is over the, you know, back of the chest uh uh oh at the back you listen to the palpitations uh to see whether it's a, it's a, it's a fluid overload like pulmonary edema. And, and then you, the main thing is you need to assess the fluid status of the patient. Also, uh these are done by the J BP and then you look at their leg for the leg swelling and the liver of the edema. Sometimes they have edema of the thigh or up to sacrum. So you have to look for sacral edema also by uh you have to assess the severity of the fluid overload. So we'll go to next slide to show the first of all um on the on call shift when the patients acutely deteriorated. Uh One of the other tasks is to check the patient research status so that we Yeah. Yeah, I II haven't uh you, do you go, do you see now? Assessment A two E? Yeah. So uh we have to check the recent status. Oh, no, let me go through uh I don't know why a full cream. Ok. Start again. Can you all see now? So I didn't know that you guys cannot see the slides. Really? Sorry. Can you see it now? I just like movie now? No. OK. OK. Right. Oh How about now? Can you see now? Oh, thank you. Oh, is it blank? Uh it's not blank. Can you see the scenario page now? Case one? Ok, sorry, sorry guys. So this is a scenario 76 year old lady with worsening breathlessness and increasing leg swelling over the last week. And also uh she has uh become very short of breath even to a short distance. And the BP is 1 55/98 and heart rate 97 SV rate 24 and sets 91 on a. So what are the differentials? You guys already talk about the respiratory causes like pulmonary embolism and heart failure? CF acute decompensated heart failure, sometimes the patient might already have a heart failure and they are fine and unless there is a prescription or any risk that causing them to have a acutely decompensated state, we need to look for that and treat that. So how would you assess this patient? Is first of all A two E and on, on call as a sho you have to check the patient's recess status also because if they are for full recess, uh we have to, if they are like acutely deteriorating and ra rapidly deteriorating, we need to alert the ITU and get the senior involvement early. So uh sometimes they are for inotropes for an IV or we we that are, that are to be given in the ITU so that we need to check the reset status and then we start the A ta assessment get involved, the whole thing. The nursing staff are really helpful in telling you all the history that you need rather than because the patient might be very, you know, sometimes very bound, they cannot talk to you or cannot tell you anything about their, their symptoms that nurses can. Um So the main focus is on, on circulation and the you need to assess their fluid status uh in airway and breathing, they could be the kidney with reduced saturation. So we need to give the supplementary oxygen if needed. Uh Because of the fluid overload uh in circulation, we need to check the G VP D VP and also any acute change in BP, heart rate, as I say, rhythm is important and we need to check the A a speed is displaced or not and we listen for the heart, sounds like murmurs or any um the heart sound, muffle, heart sound and yes, schedule a refill time for um any breaker perfusion reduced as. And so that we know the patient is in shock and we need to assess. Very important thing is urine output because we are going to treat and the the treatment is uh we need to check the urine output to see the response. And also uh I'm sorry, in uh in disability, the patient might be confused and we need to check their G CS level in exposure. Um If we suspect DVT, we need to check for the anti signs of DVT and assess the flu, uh, fluid overload status by looking at the sacra and PTO edema. So, uh, next step, uh, you assess clinically and you, um, next step is you need to do some investigations. Let's talk about investigation. Uh, what investigation will you do? Like, let's say you are seeing the patient. Now, what will you ask the nurses to do and what kind of thing you would do? Because all are in the team and you all, we all have to work together. Yes. 1st, 1st of all, tell the nurses to do the 12, the ECG and at the same times, um so in ECG, what will you look for? Yeah, blood test also uh in blood test. Uh can you tell me more specifically rather than like full blood count C RP? And what else you would like to know also? Ok. And in ECG, what would you assess for? Look for? Yes, guard markers. Yeah. Aces. So let's say you are seeing the patient, you ask the nurses to do the ECG and you are doing the bloods and you, first of all, you need to give the IV assess uh if they, they're not already have a cannula and you do the blood test like a full blood count, basic plus in the heart failure, what would you ask specifically for it? It is correct BNP. And also what else uh is more than full blood count. And C RP. That is one thing, 11 in 11 thing, one main thing is left, it's a visit. Every patient, we usually check CK hm CK some. Uh we, we could check, yeah, we need to check the renal function and the electrolytes because uh in the treatment we are going to give the diuresis. And so that uh yeah, E BG also uh so that we need to know the renal function and also the electrolyte status. Um because uh first of all, uh as, as for the thinking process, uh we, we must find out why this patient got decompensated heart failure. What are the causes? So we divide into cardiac and non cardiac causes like in cardiac, we, the patient must have like like she might have uh arrhythmia like atrial fibrillation or she might have any uh worsening of her var heart diseases or she might have a heart attack like a CS. That's why we need to do the ECG to see any atrial fibrillation, any S TT wave changes. And in the blood test, we need to check the cardiac markers like troponin. And also BMP is more, more likely for the prognosis. And sometimes they, we, we don't acutely check if the patient already have a diagnosis of heart failure. And eb is a must because um we can know whether the patient have a type one or type two respiratory failure. And uh it will help the, it team to decide whether the patient needs the N IV or CPAP. So these things can help them. So these are our tasks to prioritize to get the um basic information from the patient while we assess and chest X ray, that is very correct. Uh uh And I will suggest if the patient is very breathless and is unstable, we can't let them go down and it will take lots of time. So you, you you it would be very helpful. You call the Portugal chest X ray to call to, to tell them the patient uh unstable, they can come down and they will quickly come and do the chest X ray. You can quickly assess whether the patient is uh very overloaded or any infusions. You can already check on their screen before they go. You don't need to look at into the system because they sometimes they show you are you happy with that and if you're not, they will take another another picture. Yeah. E sr we can do and mm what else you would do? Also? Sometimes um we could check the patient already had an echo or not. Uh like previous echo findings might help us how severe the patient heart failure was like, let's say the patient already have a ejection fraction, less than 30. So this this kind of information we need to know. Um sometimes we could do the bear echo. But if you're trained in ed, sometimes they have a portable echo machine so that they could see uh any recent uh ischemic changes. Like they could see the hypokinesia or ech in the heart or mo uh wall and the heart is not, not contracting very well, they could look at it. So I'll go to next slide then. So first of all, as I say, IVS says blood for full blood count to see any anemia because sometimes an patient might have anemic heart failure and use any, this is uh to see any uh electrolyte imbalance causing atrial fibrillation and that precipitate the heart failure and also renal function. We because we are going to use uh IV through some mice to get the di uh uh uh a diuresis. If the renal function is not good, we can't do, we can't give high doses. And in is to check if the patient had a recent heart attack or not. And E BG to see type one or type two respiratory failure as ECG also, we could check any S TT with changes and any arrhythmias that the patient is having and portable chest x-ray, you could see pulmonary edema. So um on the right hand side, II, put a small, small x-ray findings for the pulmonary edema. So you will see the bad winds appearance, alveolar shadowing and the diversion of the upper lobe veins. So it would be more prominent upper lobe veins on the LMS feet and K BL and sometimes they might have lower e fusion. Also. Uh you could check the patient's previous echo findings to see if the patient has uh any severe valvular heart diseases like aortic stenosis and whether they have a pul hypertension. And we could check their ef uh for the ed some, some of the registrar, they, they have, they have been trained for echo so they could do the best echo and they could see any reversible causes like large pericardial effusion and any signs of recent ischemia. As I say, they, we could check like uh uh echina movement in uh Ekins in the heart field. Um So nice. How would you manage? So, what you guys gonna do now get up anything, what you would do on the resetting? Let's let's think of yourself. You're now seeing a patient and you think the patient is having a heart failure. Yes, we could give fide uh you can check your patient red chart first. Uh Sometimes they already yeah, supplemental oxygen, depending on the patient ops. We have to stabilize the patient's condition before the senior comes. And if the patient is desaturating, we could give supplemental oxygen. Uh make sure they have a, they don't have a past medical history of COPD and then already on this K two and you, you get the uh not over oxygen to them. Uh but they might already have a type two respiratory failure and you make them worse by giving uh too much oxygen uh and then we have the IBS so we could get, get the IV fluide but sometimes the patient is already on the cruise might and then we could switch to IV and increase the dose if the patient renal function allows. And yeah, CPAP and, and IV, usually they are to be decided by the registrar and the ICU team. We could, we could uh tell them that this patient is for full recess and they will have to come and see, assess the patient also. And then what we, what you will tell the nurses to do because you are giving the fro right now, then what, what you will instruct the nurses to do. Sometimes you know, the the patient might have a chest infection and then causing the decompensated heart failure. So uh there could be any infection uh like COVID, you could tell the nurses if they have suspect COVID, you have to tell them to do the swab COVID swab. Um I don't know uh in my uh in my, in my class, they don't do the COVID regularly now. So if you suspect you have to specifically ask the nurses to do your BP monitoring. Uh One main thing, if the patient is not already on catheter, you have to tell them immediately to get twice and then you have to tell them we need a straight inter home monitoring and daily body weight so that we could see our uh treatment is adequate or not or too much. Uh But basically, we aim for uh weight loss of 1.5 kg over 24 hour, not more than that or negative balance or one in the urine in the output. You mean, I mean, if you over diuresis, the patient would go into the EK because all these patients, sometimes they already had a CKD and if you can't balance the intake output by carefully, they gone too, too, too dehydrated and got the AKI again and can't give the fluid too much again. So is, is the balance that you tell the nurses and the patient. Sometimes you need a flu restriction but you, you must tell them, you must at least drink that liter a day to keep your kidneys hydrated. Yeah, if you suspect chest infection, you could start antibiotic. But uh if you suspect chest infection or any infection, sepsis, you would have to do the sepsis bundle. Uh like you have to take blood cultures, urine culture before you start antibiotic. OK. I would go for next slide. So as you say, as we say, if the patient hypoxic, we can start oxygen and also we start IV diuresis change to IV if they're already on oral, if, if they are having uh if you assess their heart rate and they are in fast ef you could use a dent because uh to control the rate for heart failure patient. Um for the, for the heart patient. If they, if you think the patient has AAA fast ef with rapid ventricular response or any arrhythmia causing the decompensated heart failure, they might need to be on the cardiac monitors. So you need to escalate to your senior nurses or um uh registrar to get the cardiac monitor. Sometimes they don't have on the wards, we have to ship the patient to M AU or the cardiac wards to get the monitors and catheterization is a very important thing. Uh so that we could monitor the urine output. We need the negative balance of 1 L, daily body weight and daily use any monitoring to check the renal functions. And if the patient become more stable and out of, you know, acute heart failure, we can add on the heart failure medications to optimize the treatment. Like we, we can use uh increased m um improve the mortality medications like beta blocker aci spironolactone. And nowadays we use the SC LT two inhibit inhibitor like topically, Flosin, usually in the trust they have a heart failure nurses so that next day they could come. And as, as a patient, if they, if their criteria meets and, and good thing about heart failure is they educate the patient very well. And when the patient got discharged, they have a community heart failure team, they, they contact them and the patient is follow up in the, in the community and they, they didn't, they, they didn't get lost you know, so the heart team is usually helpful in in that aspect. Um ok, so this is for heart failure. So another case, this is case two, you are again, you are fy one overnight on the medical take, you've been asked to see a 75 year old lady on M AU who is scoring on news eight with tachycardia. And the nurse said the BP is slightly on low side, 106 100/60 heart rate is 140. So it says 92 respiratory rate, 824 and temperature is 38. So past medical history includes hypertension type two diabetes. I uh ischemic heart disease and hypothyroid. She was being treated for pneumonia uh for, you know, um uh the the main reason she came to hospital is for pneumonia and the nurse told you that she already put her on the oxygen. So first of all, um what differentials do you think of? Can you please type in the checkbox and, and uh and then how would you assess as usual? Just uh give any opinion you think of and from this scenario? And and your kind lovely nurses has already done ECG for this patient because the patient is going mainly for tachycardia. So, I mean, you necessarily go there sometimes they already assess and they, if they think they need the patient needs ECG they already done it and they will show it to you. So this is the ct of that patient. That's any idea about what do you think? Why do you think m I uh just look at the ECG and tell me what you see and what else do you find on this? Ed? Mhm So, first of all, when you look at the rhythm, is it regular or irregular? Yes, irregular rhythm. It's not sinus, uh it's not sinus because it's irregular rhythm and some, it, when you look at it, some of the uh in lethal rhythm strip P wave are missing. So in this case, it is um atrial fibrillation. I would say that with this patient because II copied this easily from Google. It's not from the, this uh I don't do telly. Um this patient has ST depression in one el also depression tova also. So the this, this is another finding that I find. So what are the differentials that you think of if the patient is having AFM? What would you do if the patient is having ef what other differentials you think of? What causes this patient? Ef she came in for being treated for uh pneumonia? Yes, atrial fibrillation. That is correct. I want to show atrial fibrillation mainly in this ECG but unfortunately, this also has a one in a BLT press antiar. So this is a, yeah, the patient is also high temperature. So let's say um we have to think of why these patients got atrial fibrillation. Again, whenever we saw one patient with atrial fibrillation, uh usually divide the causes into cardiac and noncardiac. Uh because af can be caused by the cardiac dis uh diseases like uh var lesions or congenital heart disease or either ventricular dilatation or they might have um sick sinus syndrome or WBW syndrome. These are the cardiac causes that we might need to screen. Yeah, I used the history. Yes. And noncardiac causes for this scenario. For me. I was uh think of fate as a sepsis causing atrial fibrillation. There's other clues that that might cause um as as in the past medical history, she already had ischemic heart disease and this time she could have another heart attack and cause having ef and she also had a hypothyroidism and thyroid diseases can also cause atrial fibrillation. So the all sort of things we need to find out and at the, at the, at the moment, what I'm concerned is by looking at the patients, the patient is slightly hypertensive in the in the ef if the if the blood pressures and everything is stable, you still have time to manage and it's not urgent. But when the when the BP start to get lower, we it could be uh a bit concerning and we have to think uh first and manage first. So yeah, sepsis is the main causes over the on course shift. Usually the patient spike fever having infection which has been treated, but I uh somehow the antibiotic cannot cover the, completely cover the infection and they went into sepsis. So whenever we saw the sepsis patients, we have to do all everything to cover up the, to manage the sepsis, uh sepsis bundle, uh we have to give IV fluids, IV antibiotic, get the cultures, every, every cultures that you suspect of SUA infection. And we have to treat uh anti uh escalate the antibody if they are already on the antibiotic. So let's start how would, how we will assess this patient? So it would be mainly um airway breathing circulation and we will focus on the circulation. Uh We have to think of the investigation mainly focus on the the scenario. Can anyone's uh just type in what would you assess in this patient focusing on the circulation? But this patient also been treated for pneumonia. So we definitely think of other respiratory causes also in the rare scenario because I'm today, I'm telling you all the C vs cases that you guys would will only think of the C VS courses. But in real setting, you have to be broad minded at every differential you need to think of and cover for the uh everything. Yes. Yes. Yes. Heart rhythm and BP. And, and now we have to assess a couple of refills on whether the patient is now in shock. Yes, E GG. Uh The good thing about E BG and B PG, we can as clearly quickly assess the uh electrolytes and also the late level. Because if the late is very high, we can maybe say it's this a degree ses and somehow we can check the potassium levels uh very quickly. So I'll go to next slide. So again, the same thing, we uh check the GPP uh whether the patient is, is uh having a heart failure again or not. And or in shock and heart rate is it, it is already known that on the ECG it is irregular and any murmurs. Uh we have to check and the same things as a heart failure assessment. So in the investigation, what would you do? As we already said, we would do the EB GS uh we would give I VSS and blood tests. What, what, what blood tests you would do too for this patient. Yes, because we, we know that the patient is being treated for pneumonia and now she is spiking the break. So we have to take blood cultures, urine cultures. And if she is coughing up with phlegm, we could send the sputum cultures and then we review the patient's chart. And if she is, you know, uh if, if we think the patient needs to escalate uh antibiotic, you can still discuss with the seniors or on call microbiologist if you have time. Um If you think HEP, you can order the repeat chest X ray and you can give the tazo in for hep. Yes, blood full blood counts, blood differential Yeah, we can check s electrolytes. Why? Because uh electrolytes, uh we have to check extended electrolytes including magnesium and calcium because uh these, these uh all the electrolytes can, can give the arrhythmia and chest X ray. So in for this patient, I would add on to and thyroid function test also because uh she, she already had her back on I HD and also hypothyroid. Um So we need to find out uh those, those things also and E CG for any acute acu changes and chest xray to see any heart failure or pulmonary edema. And let's say we have we, if we have uh assessed the patient and if we are going to look at the patient's background, we can check the previous echo finding to see if, if they have any mitral valve diseases and you, you can do best I go if you're trained also, these all will be the same just only a blood test. Uh I would think of uh adding on the magnesium and calcium also. Uh And also, yeah, plus blood cultures and all sort of cultures that you suspect of for the infe infection. So how would you manage this patient at the moment? The patient is having a fast e with rapid ventricular response and the BP is kind of low side if you can't, if you don't treat um the patient got a crush very soon. So how would you manage? Yes. Yes. IV fluids and anything else you think of uh the patient's uh it, it do assessment also because uh in the reset it would be, it wouldn't be like this, you know, step by step, you all assess and you tell the nurses give oxygen and you continue assessing the things. Uh it will go the, you know, all, all the same time. Yes. Beta blocker. Yes. Yes. If not contraindicated, that's correct. A control. Yeah. So, first of all, we need to think of is how we will because the main thing is we need to identify why the this this patient go into atrial fibrillation. And like this, this patient, she already had an infection. And we, we have to optimize that treatment by escalating the antibiotic and giving IV fluids and all the subs of treatment. And for the F EF if the patient, BP goes further down, we, we will have to alert seniors and she might need urgent um DC cardiovas because the patient BP is start to lo lo down lower down. And uh with he hemodynamical instability, we have to shock the patient to get emergency rate control. And also if the patient is stable and we don't know if it's already there or rein or onset, we, we, we could control the rate with biopro or autism. So, uh for heart failure, I checked the EE ESC guideline and they said um with preserve ef uh if the EF is preserved, uh we could use the beta blocker dilTIAZem and digoxin. Uh if the renal function is fine and vision is a heart failure, we could use the IV digoxin loading dose and we could give the or a beta blocker also uh for reduced e they say beta blocker digoxin can be, can still be used. Uh ione can be used but uh I Metra it could be used only after the consultation with the cardiology rash and they will, they will give you the what doses they sh should be given in AQ setting. So aurone could be used in both forms of heart failure in AQ setting. Yeah. So for anticoagulation, um it, it is um you do, you don't, you don't have to do it overnight to decide if they are not already on, you have to stabilize the patient first with the BP and you know, other things. Uh but for, for the ef we need to think of anticoagulation and with the school uses a school as you all know, uh see first uh got it. Uh congestive heart failure for uh hypertension and age is 65 to 74 and more than 74 is two. And we have other uh uh vas uh diabetes and other vascular problem like ti a or stroke before. And also uh if the patient is female or male, we can assess those things and we have to uh assess the bleeding risk. Also, usually we, we use a has at school but now they changed it to orbit. Um This is a new school. Uh more or less the same. Uh uh uh I think it's a uh like a uh reduced uh hemoglobin, insufficient renal function, antiplatelet treatment with antiplatelet, any bleeding, uh history, things like that. And that is for later. But in sometimes uh you might see the atrial fibrillation patient, the, the consultant, uh they came in with the four and the consultant stopped the antico they say the patient is already 90/90 they have a recurrent four risk. And uh the they have to weigh the risk and benefit and that, that is the consultant decision to stop or to continue the anticoagulation. But this is a a case setting. You don't need to think of all these things first. Uh We have to stabilize the patients uh vital sign first. So that's it. So another case is case three. you again uh fy one overnight on medical, take a 58 year old gentleman attends the E NE with chest pain. It started a day ago when he was walking up a hill and settled down when he rested today. He reports having a central chest pain at rest lasting an hour associated with um nausea and sweating. BP is stable 1 40 90 heart rate 97. So that's 97 respiratory rate, 19 and temperature 37. So, uh and again, the sis is already done the E CG. Please look at the E CG and tell me what do you think of that E CG? And what do you find? Yes. Uh Can you specify which M I anterior lateral, inferior? Yes, if UO om I Yes, cause there's ST elevation in 23 and a VF So how about uh when you guys look at a VLA VR, what do you think of that? Des E CG? There's also as the depression E VR and VL. Any idea why that is? Mm Yes. Reciprocal changes. Yes. So uh in the lease uh limb leaves and precordial leads, uh there are some reciprocal changes. Uh if we have to see like uh in the, in the plane for the limb leaves, most of the inferior leaves are reciprocal to the Avil and IVR is uh reciprocating with the leak two. So this, that's why they have a depression in a VR and a BL. So if you think of endy in like a lateral ABL because you see the, the depression in Avil, there's no changes in the one. It should be one, a VL five basis for later M I but this is only a V and VR and this is the reciprocal changes 42 and three. And what else? There is another, another thing that you should be aware of in the EC D. That's why I choose that one. There is another changes in the ECG just in the precordial lease. Look at the precordial lease. Sorry, I think this one is, yeah, any idea. This is the last case it. So when you look at the V one and V two, there's SD depression. What do you think of that? And they have a reciprocal changes in V five and V six also? So this means the patient also has a Yes, yes, Gabriel, you're excellent. Uh The patient also has a posterior M I. Uh we have to be aware of the inferior wall Mr because usually posterior wall M I doesn't comes alone. They are usually the extension of the inferior M I or lateral M I. So that means that infarct area is so large. So we need to be very careful if we see inferior M I. That's another thing that we need to be aware of inferior M I. Do you know what is that when you, when you see infection with inferior Mr, you have to be aware of something because of the artery supplying that area. Any idea about inferior M I? So inferior area of the heart is uh usually supplied by the Yes HL because it's supplied by the right coronary artery. So it it will, it will later complicated by the patient having a heart block, complete heart block and they might need uh pacing by temporary if it is uh acutely deteriorated with bradycardia. So let's go on to the next slide. So you guys are good this patient have inferior M I and also the posterior M I. So whenever you come across a chest pain, patient, you have to ask thoroughly about the chest pain. Most of the time, most of the time, it is not the acute Coronary syndrome, it's either musculoskeletal or either bid chest pain or other causes. So do the because why we have to be very brief and quick physical examination in M I because time is muscle, we have if you are in the pri uh center, if you have a primary uh PC, if you, if your, if your hospital can do the primary PCR, you have to do very quick or if uh sometimes they have to transfer the patient with blue lights also. So uh everything needs to be a bit quick. So as usual, a two assessment, we do uh BP, heart rate rhythm, murmurs, any scar from the previous surgery. Uh some acute aortic stenosis can also come with the chest pain if they are on too much exertion. So they might have other symptoms like syncope or prins cope symptoms. You have to ask, ask them and sometimes uh if they say heart uh chest pain is radiating to the back, you also suspect that you have a dissection and you have to do the bilateral BP measurement. And one last thing is uh if you are confirmed that the patients have M I have to ask any, is there any contraindication for PCI or thrombolysis, like they have a recent major surgery or recent major bleed recently. So you have to assess those things. It's mainly for the cardiology because the other main decision makers. Uh so investigation wise, uh as usual, we need to check the blood test troponin. And here I would specify about clotting screen also. And if you are suspecting uh like uh myocarditis or pericarditis, they are screening blood tests also, uh those that you could add on and E CG, you have to do the SE E CG and as regular assessment of the patient and, and some, you know, uh the patient might have a uh chest pain, but they have a pericarditis and then that, that would be easy to change this or pericarditis or pulmonary embolism. I just want to ask, um can can any anyone of you tell me what is the um findings ecg findings of pulmonary embolism? Yes, sinus tachy. And what else? Yes. Usually they said S one Q three T three is very rare to see. We will see Sinus Dey and a strained uh like right on the branch block, things like that you will see first. Um And as I say, we have uh we have to be vigilant for evidence of posterior M I in any patient who came with, who have inferior or laters stomy. Uh so that we could um ask the cardiology to assess really quick if they are having large M I and other, other things are the same as previous cases like chest X ray echo and everything. So how would you manage this patient? Oh These are just for revision of the recent uh arteries. That's what J has I. OK. So how would you manage this patient? Yes. Uh It says deviation. Yes. So first of all, you need to treat the patient pain first, chest pain, treat the pain first and then contact the cardiology. And for uh before you contact, you can start the platelet or aspirin for to grow and for the anticoagulation. That makes a decision from the cardiology because depending on whether they're gonna do the re very uh urgent uh primary PCI or whether they will manage medically or these also a decision comes from the cardiology and then we can choose the anticoagulin. Yes. Morphine. That's Brittan. Yes. Correct. So I would go to show for next slide. So at the moment just they uh we have to stabilize the patient according to their ob if they are short of breath and desaturated, we could give supplemental oxygen. And definitely we would need this patient wouldn't need the cardiac monitors. You have to, to be very sure because the, these patients have an inferior Mr plus posterior and are very high risk of having uh ventricular dysfunction and BT and BF. So they should be on cardiac monitors and do antiplatelet. Uh And first of all, we need to treat the pain with morphine and antiemetic and your antiplatelet and contact cardiology for an plan. Whether they're gonna do the urgent PCI or, or if the patient is quite frail, sometimes they said no for invasive procedure, they would manage medically. Uh So the twice an gland is depending on their decision because if they're doing, doing the invasive surgery very quickly, we have to use the injectable anticoagulin so that it could be short acting and it could be, you know, uh flexible with the timing of the procedure. And if not, uh if a patient is for medical management and going to the cardiology, we could use it for the perox or low, low low molo heparin. Uh we could use a beta blocker and thus it is contraindicated and we can use it as an alternative also. Yes, a statin oxygen. That's it. Any questions I know it's not covering for all the C vs cases. There will be a lot, a lot more you could see on the on call shift, but I just mainly focus on the, the most common cases you should come across on the on call shift. Oh I will send feedback form. Uh The, the organizers are telling me not to forget to send the feedback form you have to fill in so that you will get the certificate for attendance. And also there will be another uh uh webinar uh on the res uh common, common causes of respiratory cases, a two assessment, you asked to see the patient but uh mainly for respiratory causes. Uh it will be on seven of September. The minor bleed will send out the uh information and also thank you all for attending. 07 of September. Are you involved in a new? Mm sorry, I don't know what is S LR means. Sorry. The next session is will be on seven of September. We have planned system by system. Uh This is AC vs uh previously it was four and now C VS and next session will be on seven of September respiratory system. And then we will do gastro neuro and we were announced in advance. Oh, literature review. Yeah. No, I'm not involved. I'm trying to learn those uh reading uh those uh research papers and you know, uh previously we we uh I don't, I don't usually learn about these channels and now they in the training, they do the channel club, reading research and a paper analysis and things like that. I started to read. Not really involved yet myself in the research. Uh You are the it two right? Three V crumb. Yeah, thank you also. Yeah, thank you. So please do attend next uh session on seventh of September or so I think this will help you, you know, uh refresh all your knowledge and it will helpful for your on call shift. Also when you are doing the cover shift or on call shift in the hospital. Thank you everyone. Thank you. Don't forget to fill in the feedback also so that you guys can claim your uh certificate for attendance. Um ok, so I will stop. Bye-bye. Mm How to stop.