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JAS CPA Series: Cardiovascular examination

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Summary

This on-demand teaching session is ideal for medical professionals looking to prepare for the cardiovascular examination for the CPA exam. During the session, attendees will cover surface anatomy, murmurs and EKG's, as well as practice questions. They will learn how to properly introduce themselves and give consent to the patient, explain what points they need to check and differentiate between heaves and thrills. Attendees will also be shown how to determine the radio pulse and other palpate pulses, assessing for rhythm and rate and character and volume.
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Description

Register for Imperial Surgical Society's first CPA Series lecture on the Cardiovascular Examination!

We will cover the fundamental steps in the examination, interpreting essential ECGs with tips and questions at the end of each station.

Register with a free MedAll account to access the MS Teams link!

At the end of the tutorial, we will distribute the PowerPoint slides, a lecture recording, and an attendance certificate for those who complete the post-session feedback form.

Learning objectives

Learning Objectives: 1. Understand the surface anatomy of the cardiovascular examination for the CPA exam. 2. Learn the pulse points and palpation techniques necessary during the examination. 3. Differentiate between regular and irregular rhythm. 4. Demonstrate the ability to calculate the heart rate accurately by counting beats during a 15 or 30 second period. 5. Explain the difference between character and volume when evaluating the common carotid pulse.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay, There we go. It started. Go for Abdullah. All right. Fantastic. Thank you very much, Moe. And thank you very much for that, uh, lovely introduction. So today we're gonna be covering the cardiovascular examination for the CPA exam in for second years in Imperial. And we're gonna cover the main contents are cardiovascular examination. We're gonna look at surface anatomy because there is a possibility they ask about this. Um, but you definitely don't need to pull out marker and start drawing on people like you may have been doing before. Um, that's definitely gonna be happening in the c p. A. Um, we're also gonna be talking about murmurs and what to auscultate e c g s. And then a few practice questions because I can near guarantee CGs will definitely come up in the exam in some form. Uh, so the structure of the examination, Uh, before we do that, how would you guys sort of, um, introduce yourselves? How would you go about? Introduce yourself to a patient when you walk in to the c p. A. So he could you know, um um, meet yourself or type in the chat. I think that's about paid to us or something. So just how would you introduce yourselves? Anyone? No. All right. So the way that I would go about it is I walk in, wash my hands first thing with the antiseptic that they've provided you with, go through my introduction that, you know, you've probably been practicing since first year. Which is your name, Who you are, what you're doing. What's the purpose of you coming along and talking about consent and confidentiality? So that's the permission part. And then you're gonna talk about exposure. So for a car, you bust exam, you that you're gonna need the patient to be exposed from the waist up. So that's everything off, except for any sort of underwear for women or bras. Um, those are gonna be kept on for the CPA. There's no need to remove them, and then you're gonna reposition them. So most of the time, I remember when I did the CPA, the patient was already positioned in the correct place. But if they aren't okay, you need to have them lying on the bed at 45 degree angle. Okay? And you can always change the bed, uh, to the angle that you wanted to. Okay, But most of the time they're already in that position because that's the most comfortable position for them. Um, and you're gonna ask them two questions. So you're gonna ask them, Are you comfortable? And then you can ask them Are you in any pain? OK, so comfortable to make sure they're fine. They're happy. And if there any pain, they're just going to say no, OK, they're not really gonna say they are in pain. You don't It's not really gonna happen. They say they are in pain, okay? And it's a very quick acronym. And easy acronym for you to understand, which is wiper qq. Okay, now for this examination, this is the general list of position exposure inspection and palpation percussion auscultation that you need to go through when you're going through an examination for any station. Okay, but we've already covered position and exposure. Inspection doesn't really exist in the c. P. A. You're not gonna be asked to inspect anything. Percussion also doesn't really exist. You're not gonna be per cussing over the heart. Doesn't make sense. Not gonna tell you anything. So the only two things that we have left our power patient and auscultation, which we're going to discuss in detail today. So power patient. So in terms of our patient, there are a few pulse is you need to be able to pop it. And there's all the radio posts own the posts, break your pulse and common carotid pulse. What I would say is the radio pulse and break your pulse. Uh, radio pulse and the common Crossett pulse are the two that are most likely to come up. Okay, ulnar pulse and break your pulse. You need to know for second year, but they never come up again. Really? And they don't really come up again in our skis in third year. And in terms of chest power patient, you're gonna need to palpate the apex be you need to palpate for heaves, for thrills. Um, and it's very, very important that you understand the difference between them and how to do it differently, because I need to make it very, very clear to the examiner that when they ask you to examine for heaves that you know how to do this. And whenever you're going to go do something on a patient, you always need to explain. You need to always need to explain it before you do it on the patient. Okay, so they tell you to check the radio pulse. You need to go to the to tell the patient. Well, now, I've been asked to, um, check your radio pulse, which means I'm gonna have a feel of your wrist. Okay? Or if you're gonna check the common creditor pulses, I'm just gonna check one of the pulses in your neck, okay? Or I'm gonna need to check one of the pulse in your chest, okay? Something you always need to be able to explain it and different and tell it to the patient, cause they always always, really like that. So it started with the first pulse. The radio pulse. Where you're going to we're going to check. It is at the wrist between the distal end, okay of the radius and the lateral end of the 10 tendon of flex a copy radial radial list muscle. Okay, So around this area here, and if you can't feel it, what I would recommend is probably go a bit more lateral than medial because you may, um, end up going over the tendon and going into the central where you're not going to feel anything and get closer to the owner in reality. So you got enough to do this throughout the basically your entire career in medical school, it was going to be able to fill the radio pulse. So I would say, go more natural than medial. And through the radio pulse, you're gonna be able to assess the rhythm and the rate. Um, so the rhythm is the regularity of the beats. Do they come in regular rate or is it a fast rate and a slow rate, or is it a mix? Okay, so there's two ways we really describe them. We'll discuss that in a bit more detailed later on, and their rate as well. So that's the number of beats in one minute. But obviously, you're not going to stand there and count how many beats happen in one minute, okay? And you're definitely gonna need to have a watch on your person with you. Okay? Because the clocks don't really exist in the little cute in their little cubicles or separations or partitions that they have. Um, So what you're gonna do is you're gonna look at your watch, You're gonna hold their You hold their radio part, feel they're all your pulse is one hand Look at the watch, on the other hand, And then you're gonna count how many beats in 15 or 30 seconds, depending on how much you want. And then you just gonna multiply that number by four or two. Okay, Well, some people do sometimes is they just remember a number, Um, that's divisible by four or divisible by two. And they just say that, Okay, but it But the problem with that is just going to feel like it's a bit off If everyone else is saying one number and you're saying something else, um, and normally populate you would need to palpate the right arm only because you can palpate it on one arm. You can calculate it on the other arm. You don't really need to palpate both. Okay, because this isn't a full examination. This is all more guided examination. So they're going to tell you exactly what to do. Very different to how a Noski is. Uh, and what about character and volume? Well, for character and volume, you are unable to talk about character and volume with the radio pulse. Okay. You cannot comment on character and volume. So do you not say anything about the character of the volume that you feel in the radio pulse? Because you we can't comment on it. The only place that you can comment on, um, on character and volume is in the common carotid pulse. Okay, so in the neck. And obviously, please don't feel both pulses at the same time, okay? Because then you're just gonna suffocate the patient. The patient's brain. Okay. And that's going to be a big red flag. And again, most of the time, they're just they're just gonna ask you to feel one side, Okay, But if they don't stop, you just feel the other side as well. Okay, So now I'm just gonna feel both pulses in your neck, go for one side, and then go for the other side. By the time when they when you when they see you go for the other side, they'll probably stop your that. Okay, um, so I said its palpating the neck between the medial ahead media end of the sternocleidomastoid to a stern employed mass story right there. medial to it. So in the middle, Uh, and natural to the thyroid cartilage right here. Okay. And make sure the patient's head is straight. So not like this. Okay, make sure they're staring straight at you, because if the neck is twisted, you will not be able to feel that pulse. Okay, So if you're trying to feel the right common carotid and they're looking to the left side, you're not really gonna be able to feel it because the sternocleidomastoid pretty much covers it and goes over it. Okay. And in this area, I said before you can comment on the character in the body and then other palpable pulses. So the owner and the brachial these are less asked about, but they still could possibly come up. So with the owner, it's just the other side of the wrist. So if I go back to that diagram, it's just here on the other side, on the other, on the medial side of the arm, if you're looking at it on in terms of anatomical position, okay? And I said the wrist over the distal under the forearm lateral to the tendon of the flexor Carpi ulnaris. This time and then the break here. You can feel it in two positions. So either in the cubital fossa down here, okay? Or you can feel feel it on the medial side of the tendon of the biceps braking. I okay, and you have to keep the elbow fully extended. Okay, This one is a bit more. Needs a bit more practice to feel it on this side. But the cubital fossa is much easier. And I definitely recommend practicing both. And then this is just the diagram. Just showing you all the different pulse is they can ask you all the different positions they can ask you. So, owner, Uh, sorry. Radial ulnar break your pulse. Uh, same break your pulse and then auxiliary. They're not They're not gonna ask you to do auxiliary, but it's just including the diagram here. And then in terms of the apex beat. So the apex be is the main pulsation due to the apex of the ventricle beating against the anterior chest. Uh, anterior chest wall. Okay. During its contractions. Um, it's not always powerful, depending on the person in front of you in some patient's. I've been able to actually just see it, OK, that's so thin and frail that you can just see the apex be happening right in front of you in other patient's. It's not as okay, but this is what you're generally meant to. This is generally where it is, okay? And this is where you're meant to start looking for it. So obviously, you start by the exposition in the fifth intercostal space in the mid clinically line. But you can't just go straight into where you think the fifth intercostal space looks like. OK, in the CPA, they prefer you to actually find the ribs and then look like you're counting the ribs down to the fifth one and then finding that intercostal space, okay, And in the mid clinical line. So you can either start from, uh, the sternal angle here. Okay, which is most of the time, Quite easy to find on most people. Or you can start from the first rib. You can feel okay, because the first rib is never palpable. Okay, You can never ever feel the first rib. So you always know the first rib that you can palpate is the second is the actually the second rib. Okay, and then once. So that's just easier if you if you're finding it difficult to work out where the sternal angle is. Okay, After this year, you probably will never need to find the sternal angle again unless you're teaching someone and how to do this. Um, so with the second from the second rib, you're going to count down so second rib and then feel the third rib and then fill the fourth rib and then you feel the fifth rib. And then once you feel the fifth rib, you're gonna look at the mid clinical line and then you're going to place your hand pretty much flapped on by that, and you're trying to feel the apex beat with this sort area of your fingers because it's more sensitive. Okay? And what I would say is I would say, Start, quite you can either start quite medial and work your way out words, or what most people do is they start on the lateral side and then they work their way towards this towards the mid clinical line, and that's what I would recommend as well. OK, start on the sort of on the lateral side in the mid, Probably the midaxillary line, and then work your way towards the mid clinically line because then it just shows that you you're looking for it. Okay? You're searching for it. You know the technique to do this. Okay, because the whole point of the CPA is just to check that you know how to do it. Okay. You don't need to start talking about pathologies or identifying them or anything like that. So, mentally, with your line, and that's where the apex be is and then heaves and throats. So heaves. Okay. Most people get very worried and very confused about heaves and throws, but heaves are just abnormal character of a beat. Okay, So we're gonna do is you're gonna place the hand vertically, okay? Adjacent to the sternum and two to the left and to the right of the heart of the of the sternum. So you get your hand, place it this way, and then this way on either side. Exactly like that vertically. Okay. Now, a positive sign is that you will see the heel of your hand lift up with each hobby. Okay? And that could be on the left side or the right side and the main causes mostly hypertrophy of the left or the right ventricle. It's not clear cut how you know, if you feel a heave on the right side of the patient, then that means it's right ventricular hypertrophy, because the left ventricle hyper tree could be quite large to cause a heave everywhere, uh, on both sides. So it's not quite click up, but it's going to tell you that that heart is definitely hyper treat. Okay, And that could lead to a more pathological finding of something like hock or something, okay. Or even just HCM and then thrills. So thrills are palpable mums. So the murmur murmurs are just valves that have sort of that have stopped working okay properly. They either don't close properly or they don't open problem. So what happens is the murmur is just the vibrations or the sound waves created because of it. So you use your stethoscope okay to normally auscultate the murmurs. But if the murmur is so bad, if the valve is dysfunctioning so much, then you can actually feel it. Okay, you can feel the thrill. So what happens is you palpate you can you can do this with again the top part fingers of your hand. And what you're gonna do is you're gonna place your hand horizontally across the chest at the same sites that you're auscultate for. Okay, exactly the same site, Okay. And then you're gonna feel this sort of vibration, and you're gonna be able to feel the actual murmur. So that will tell you what valve is dysfunctional. But it's not going to tell you if it's d nosed or if it's regurgitate, int or regurgitating. But you're just going to tell you if it exists, okay? And it also tells you how bad it is because you can feel the thrill. Then that means it's quite a bad position. And it might be the main problem of the patient. And then in terms of auscultation so ostentation used telescope to auscultate all four heart valves. So the aortic valve pommery valve by, uh, the mitral valve and the TriCor hospital valve. And normally what you're looking to hear is normal s one and s two heart sounds. So s one. Heart sounds are due to the atrium drink a valve closing, um, and s two heart sounds due to the semolina valves closing this time. Um, and the moment are any added heart sounds between s one and s two or around s one and s two. Okay. And you also have accentuating maneuvers to try and make them allowed. And you also have sound radiating okay and accentuating maneuvers are very, very important. And you need to do them even if they don't ask you to do them okay with with ostentation. So if they tell you, just listen to all four heart sounds. You still need to do the accentuating maneuvers, even if they don't specifically ask for it. And then these are the four half ups. So can anyone tell me what each of the letters where? Where you'd auscultate for that? You'll take the Pommery, the tricuspid and the mitral valve either in the chat or just shout them out. So that's not with aortic. Where am I? Oscar taking for that one. Just type it in the chat or we're gonna just shout out. Wait, Is this chart even working for everyone? Yeah, it is working out. Any ideas? Anyone? Yes, So I know it's Yeah, we know it's the aortic valve, but where are my Oscar taking for it. What position? Sabah, If you wanna on meat, maybe you could just tell me So the right second intercostal space? Yes, that's correct. Perfect Second score space on the right. Sternal edge. And then what about the pulmonary? So over here, literally. I've literally given you the ribs as well, so you can literally count. Where is Uh huh. Come on, you'll know it. So someone just type in the chat. Mo, you want to nominate anyone? Uh, let's see who was first on the list. Jan It Do you want to give it a go? Sorry. Hello. Because that did someone say something And he's someone, um, you'd but we can't hear them. No, you've got a tough crowd. You might as well we want. Okay, fine. So Paul Henry is second intercostal space and the left sternal edge Tricuspid then is the fifth intercostal space at the left sternal edge. And then finding the metro is in the fifth Intercourse space in the mid clinically line in exactly the same position that you that you used to palpate for the apex beat. And again, these are just the same ones. This is what the diagram they they've included. It's not amazing. It's quite confusing. All this is showing. Is that really in reality? The areas you auscultate for are not the areas where the bumps exist. And the reason for that is because where you can hear them loudest is not where they actually exist. So you can hear them loudest in the positions that we actually oscal take for them. Indeed, And then these are just again the locations. So the aortic problem. We try to go to the mitral valve locations to, um oscal take them. And what area of the of the, uh, of the stethoscope that you use, I think about my stethoscope here. So hopefully by this point, you've had your stethoscope for, like, a year, and you've remember to remove the baby diaphragm from it, Um, and actually put the belt on it, OK, It's It can be quite embarrassing going around on the wards, having a baby diaphragm and calling it a bell, uh, from experience. And then you've also got the diaphragm, which is the big one. Okay, so for the aortic, the pulmonary, the tricuspid, you definitely use the diaphragm. Okay, But for the mitral. You need to use the bell. Okay, We need to be able to utilize the bell, okay? And this little you could just literally just take this off. And then this little ring comes with the box and is increasing the box with the stethoscope. One thing with the mitral, I would say, Okay, it's better to get into the habit of using the diaphragm first and then using the bell. We're going to auscultate them, because that's what you're going to be expected to do in your rosky. And it just looks a lot more professional because, yes, we know it's the bell, but the science behind it is a bit wishy washy. Okay, so there's no really well, mama, that you're going to hear with a bell that you can't hear with the diaphragm. It's just clearer with a bell rather than a diaphragm. Okay, so I would say use the diaphragm for all of them, and then for the mitral, just remember to switch to the bell as well. Okay, next surface anatomy and key anatomical landmarks. So again, others said before, you're not gonna be expected to draw these on the patient's or draw them on paper or anything, but you are. You could be expected to describe them. Okay, I remember it wasn't for my cardiac station, but I remember maybe for my neurological, um station or maybe the gastro station. Uh, they asked me, but Oh, yeah, there's the gastric station. They asked me about surface anatomy for the for the liver so it can come up okay and also came up with my respiratory stuff so it can come up. OK, that's why we're going through. And you'll just be asked to describe it in words, No drawing. So if you go through the sternal angle on the intercostal spaces So the sternal angle is the, uh is the manubrium sternal joint and is at the level where the 2nd 2nd costal cartilage joins the sternum. And it's used to find the first, uh, intercostal space and the second costal space. And then you can relocate the rest of the relevant intercostal spaces as well and then talking about the aortic arch. So the aortic arch starts and ends at the level of the sternal angle at the second intercostal space. Okay, so it's just literally where you've where you found the sternal angle. That's also where the aortic arch exists. Okay, And that's where the three main three branches that come out before it becomes the descending aorta come out of it. So you've got the breaker Catholic artery, the break your artery and the, uh, my current room in our but those are the three main arteries. Okay, Okay, you're not gonna be asked about them, but you're just gonna be asked where the aortic arch is. So four borders of the heart. This is a bit more complicated, and this is more likely what you could get asked because they're not really gonna waste time on something as simple as the aortic arch. So there are four borders that you're going to need to be able to describe. So the fourth border. So it's already the upper border. We start there. So it's from the third costal cartilage, one centimeter from the sternal border to the second intercostal space on the left. And then the right border is the sixth cost of the cartilage. One sent me to run the sternal border to the third intercostal space. One centimeter from the sternal board, and you've got the lower border which is the fifth intercostal space to the apex. Beat at the mid Clerics line to the sixth intercostal. Sorry, the sixth costal cartilage from the sternum border. And then you've got the left. So second, uh, and cost of space to the fifth intercostal space. Okay, to the apex beats in the midclavicular line. All right. Those are the four portions of the heart. Okay, The slides, I'm pretty sure will be available to you afterwards. Um, this is probably gonna be one of the most important slides, okay? And you can actually just add these into an Ankie flashcard and just go through it. That's probably the best way to try and remember them. So now that we've covered our basic surface anatomy that we need to cover now let's look at murmurs. So we're gonna look at the etiology of murmurs. We're gonna look at aortic murmurs and micro numbers because those are the main focus in 1st and 2nd year, and you don't really need to touch on. Try accosted and Pommery murmurs, to be honest, because they are more covered in third year. And they're also rarer to be honest. And I've covered trick hospital and and the problem, er probably, um, Pommery murmurs in the, uh, summary of this lecture or tutorial. So etiology of the murmurs. So murmurs could occur due to lots and lots of reasons. Many, many reasons. Okay, so they could occur. Do. And they The reason why murmurs exist is because of the abnormal blood flow across the valve. So I say before, either the valve isn't closing properly, so it's regurgitating or the valve isn't opening fully. So it's stenosed, okay, And this obviously cause an abnormal or more abnormal blood flow across the valve, leading to a vibration that we hear a sound right or leading to the murmur so they just could be due to structural issues could be due to surrounding structures problems, or it could be congenital or it could be infection. So looking at this, this valve here as an example, which is the mitral valve. So either there could be a problem with the, uh, leaflets themselves. So that's a lot more common in the aortic valve, where you've got to leaflets instead of three. There could be a problem with the cord. I attend any because remember the corner tendency also connected to the period period, the muscles and the muscles. If there's something like a stemi or a heart attack and the puree muscles have infarcted and died, then obviously that this is gonna shrink and it's going to pull the cord identity, and it's going to cause more, most likely a regurgitation valve. Okay, Um, also, if there's atrial enlargement, that could also lead to, uh, regurgitation, because it's gonna basically, instead of the atrial opening being this large, it's going to open it up into a bigger window. Um, and also left ventricular enlargement. So if the if the not hyper trees, But if it dilates and expands, okay, due to a cardiomyopathy, Then again, the primary muscles are also going to get moved down and pulled down, which again is going to lead to a more regular GIs involve. Okay, aortic Sorry. Stenosis are more likely due to calcifications. Okay, Most that's the most common reason for s stenosis. Okay. And the most common stenosis is an aortic stenosis. That happens if so, if if you ever come across a patient who has aortic stenosis or has a murmur, and they're in their sixties and it's in the aortic region. Most likely, it's aortic stenosis. Okay, because they're very common in their sixties and seventies because they've lived for so long that the valve has started to calcify. Okay, if they're in their forties and they have an aortic murmur, it's most likely due to a congenital bicuspid valve instead of a tricuspid valve. So they've got two leaflets instead of three leaflets out there. Uh, are they oil take valve in terms of chaotic murmurs. So for aortic stenosis, idiotic regulation, this is how we describe them. And this is how you must describe or this is how you must understand the murmurs. So with aortic stenosis, it's an injection systolic murmur. So it happens between s one and s two. It radiates to the carotid arteries, and it's loudest on expiration. And in terms of accentuating maneuvers, you get the patient to lean forward and get them to breathe out. Okay, All murmurs on the left side of the heart are loudest on expiration. All murmurs on the right side of the heart allowed us on inspiration. So for your accentuating nervous, you're again. You're gonna lean forward, you're gonna get them to lean forward whilst you still have the stethoscope on the aortic valve or at the site of auscultation for the aortic valve, and you're gonna get them to breathe out as much as possible and hold it, and then you're gonna listen to the valve. Obviously, don't let them hold their, uh, stop breathing for too long, okay? Because then the Examiner is not gonna be happy about that. And the patient is not gonna appreciate that. And the patient Do the patient's do score you as well? No, it's not just the examiners. You score you, um and then in terms of able to regurgitation, it's an early diastolic murmur. There's no radiating sound and its largest on expiration. Okay. And the accentuating numerous again. You get the patient to lean forward and get them to breathe out and hold it for a few seconds whilst you're listening. Okay? And you always do this hot using the bell. So next, in terms of the mitral moments, you've got mitral stenosis and mitral regurgitation again there on the left side of the heart. So again, they're going to be largest on exploration. Micro stenosis is a It's called a low rumbling mid diastolic with opening snap murmur. Okay, it radiates to the left axilla and its largest on expiration. As we said before and in terms of accentuating news because you're listening to the apex the way that you're going to get the heart to be closer to your stethoscope so you could listen to them better is by getting the patient to lean to the left and getting them to breathe out as much as possible. All right, so basically, if the patient's lying on their back, what you're going to get them to do is whilst the stethoscope is still on them, you're gonna get them to turn and lie to their left and again in terms of mitral regurgitation. It's a pansystolic murmur, and it radiates to the left axilla OK, pansystolic. That means you basically hear the murmur all the way through s one and s two. If it gets really bad, you may not even here s one and s two. That because the murmur just covers everything. Um, all you're gonna here is just the murmur and then a gap of no noise. And then the murmur again and again accentuated believer Exactly the same again to leave them and left and breathe out as much as possible and stay there and then e c g s e c G s is very likely to come up, and it's very likely that they're going to give you a 12 lead E c g, and ask you what is this? Um, And to interpret it, Tell me, what's the what's wrong with it and then tell me a diagnosis from it. Okay. And these are the steps that you need to cover. You need to cover calculating the Hari. You need to cover the rhythm. Is it regular? Is it irregular? Is it regularly irregular? You need to maybe mentioned the cardiac access if it's important, if it's not normal. But I wouldn't worry too much about the cardio axis. And there's a quick way of actually calculating it without having to do some trigonometry. Um or, you know, get a calculator already that rubbish, because you're never gonna be able to do that on a ward. Okay? It's just not feasible to do to do that on a ward, Um, and then PR intervals as well. So we're looking at heart blocks and rhythm irregularities and ST segments, So calculating the hurry. There's two main methods to calculate the hurry, so either it's a regular carjack rhythm. Okay, then that way we just divide 300 by the number of large squares between the R waves and then irregular cardiac rhythm, which is the number of our waves multiplied by six. So for this first one, as I can see, there's 1234 boxes. I would say that the Hari is about 75 because that's just 300 divided by four, which is 75 then in terms of this irregular one, because you can see that the gap isn't the same between them. I would have to multiply the number of our waves. I would see in this rhythm strip because remember the rhythm strip accounts for 10 seconds. If you're looking at the small, um, uh, each lead independently, then that's only for I think it's like five through two seconds, um, or three seconds. So you're gonna need to look at the rhythm strip and you just count the number of our waves in the rhythm strip and then multiplied by six. So this patient, if they only had four r waves, they would have a heart rate of, uh 24 okay, which is very, very low and very worrying, unless s. There's some super athlete, because they because you always have to take into account the patient's own normal. So is it normal for the patient to have a read really a heart rate? Then you wouldn't worry so much about it because some patients have heart rates of 30 or something because they're incredibly incredibly. They're called you, leave it and then rhythm, so the main point is to compare if it's regular or an irregular rhythm. And then, if it's an irregular rhythm that's gonna tell you it's either. It depends on how fast it is that can tell you if it's attacked cardio brachycardia or if it's fibrillation. Okay, and you can feel atrial fibrillation can feel fibrillation in terms or in somebody's radial pulse. Okay, obviously we're talking about atrial fibrillation. Okay, not venture defibrillation. If the patient's in venture confabulation, you and somebody's feeling their radio post to tell that, then that's a big problem. Okay, then you they're basically wasting time. They need to treat and shock the patient very, very quickly. Um, and again, these just a few rhythms. Okay, I wouldn't worry too much about these atrial rhythm. The main one you need to know about is the main one is atrial fibrillation in terms of no do or junctional rhythms. I'd stay clear of that until you get to third year. Then you can learn about the nodal reentry tachycardia is and all that fun stuff and then ventricular rhythms again stick to the basics. So you've got V T or or which is ventricular tachycardia or ventricular population. But you can I can tell that on an E c g quite easily because all you see is our waves, and it's just gonna be shaking all over the place. Uh, and then in terms of cardiac access, Okay, these are the different axes they could have. So it could either be a normal axis, a left axis, deviation or right axis deviation, and all it does. All it tells you is it tells you the overall direction of the deep polarization and the magnitude. Okay. Normally, it's between 30 minus 30 degrees to 90 90 degrees. That's a normal person's, um, cardiac axis. If it's left axis deviation that mean it means it's less than 30 to minus 30 degrees. It was right axis deviation. It means it's more than 90. Okay, And then if it's in between this range of minus 9200 and 80 or yeah, minus 9, 280. That means then you've got extreme axis deviation, and something is incredibly, incredibly wrong. And you're probably only gonna write this if you're doing a case report or something or writing up the case afterward, you're not gonna sit there and look at the C G. Um, notice that there's an extreme axis deviation is probably gonna be something more, um, pressing and more important because it is not really used. Diagnostically like it just because they're in left axis deviation doesn't mean we're going to change anything in terms of their management plans. All it does is it probably tells us, you know, they've got left ventricular hypertrophy, or if it's the right activation, they've got right ventricular hypertrophy, so it leads us to the right lines. But I'm not going to make a diagnosis just because they're cardiac accesses screwed up because it can also change if the person is really, really tall or if the person is really, really short. I think that can also skew it as well, because the heart sits in different positions. So the person is really, really short. The heart is more likely to sit in a horizontal position if the person is really, really lot tall. Um, and really big and bulky like think like Arnold Schwarzenegger, then their heart is gonna be more vertical, so the college access is going to be very different, and this is how we do it. So the easiest way to calculate a cardiac access on award Okay, when you don't have a lot of time and you don't really want to be thinking too much, okay? And you're not gonna there's no point calculating a specific number because it's not going to change if there if they've got normal access, not gonna matter if they're normal access is just about or that it's completely okay. It's not going to change any. So it happens. You will look at lead one, and we look at a V F. And we look at how much positive or negative deflection is in the QRS. So if it's overall more positive than it's in this half of minus 92 90. If it's more negative, then it's in this half where it's the other side, crossing over 1 80. Really so and then in aVF again, we're looking at it. If it's a positive or negative deflection, if it's more positive, then it's in this bottom half. If it's more negative, then it's in the top half and then we basically overlap them together. So here we can see this lead. One is more positive. So we're looking at this blue light blue science's or color and then aVF. It's more positive as well. So we're looking at this one, and the only area that these two overlap is in this quarter of 0 to 90. So therefore, it has a normal axis because, remember, normal axis is minus 32 90. So this way, we've estimated there, um, cardiac access. And we don't need to, you know, calculate a specific number because Catholic spacing number is not going to tell us anything. And then what about this one? Does anyone have a Does anyone want to have a good rashy? Let me let me do this one and then people can have a go the next one. So again, we're gonna look at lead one, and we're gonna look at lead. Look at Abia. So lied. One is more positive. So again, we're in the same, uh, half of the circle aVF on the other side. That looks a lot more negative to me. There's a lot more of a negative deflection pointing down than pointing up. So that means we're looking at a negative QRs. So again, the only two quart the only two the only quarter these two overlapping is going to be between zero to minus 90. So what that means if you go back zero to minus 90 it could mean that they're in. It could mean that they're in a possible left axis Deviation. It's possible. Okay, because again, we said normal access is up to minus 30. So if they are in this range of minus 30 then they've got normal access. Okay, but again, just because we were, you know, in a real life situation, you're gonna keep that in the back of your mind. But it's not gonna you're gonna determine your end diagnosis for it. And if it determines your end diagnosis, then it's going to be a very um, it's not gonna be a really problematic diagnosis, because if the only thing wrong with them is that they have a left axis deviation, then either it's up to minus 30 and they've got normal access or it's probably they just got left ventricular hypertrophy. And that could be just due to a lack of fix, OK or due to obesity, which then leads to a lack of fitness and poor diet and then leading to hyper hyper tree left interest hyper tree. And then what about this one? So lied? One is more negative. aVF is more positive. So the only area that they split in they cover is 90 to 100 and 80. So what? What sort of access are we? Are we in normal access to you, or do we normal access, or are we in left axis deviation or right axis deviation and I'll give you a hint. We've covered no more access and we've covered left access. So there's only one left. Um, this will be right. Axis deviation. Yes, Perfect. Correct. Thank you very much. So this is right axis deviation. So just looking at lead one and aVF and looking over all the QRs, if it's more positively deflected or more negatively deflected, will be able, you'll be able to calculate a access deviation very, very quickly. Okay, in a minute, rather than getting a calculate around, doing some trigonometry and doing it How, uh, I mean, that's that's the way they try to teach us anyway. Okay. But there's no point of teaching that because no one is going to do that. No one sits there and does that, Um, and if they do, they, you know, maybe have too much time and again, if you're worried about always it negative. Is it positive? Just counting the number of squares above the ice. Electric point. Okay, All the above the ice electric line. All right. If it's if they're very close, then one of them is definitely gonna be more positive. Definite. It's either gonna be positive or negative. It's not going to be equal on both sides. I've never seen it equal on both sides. OK, is everyone happy with cardiac cardiac access to them? If anyone's got any questions, just type them in the chart or just shout out okay. And you, You can do that all the way through this lecture. So the next thing we're going to cover RPR intervals. Okay, We'll try. Hopefully should have covered by now. Maybe we learned about a few heart blocks. Um or at least it can be an introduction then. So this is just the interval between the P Wave and the R wave and a normal PR interval is 0.112 seconds to 0.2 seconds. Okay. Or if you're looking at many seconds, it's 100 20 minutes seconds to 200 milliseconds. And if you go back to an E, C g 11 square on the E C G is zero point. Sorry. It's 40 minutes seconds. So normal. PRN tool should be between 3 to 4 squares. 3 to 5 scores. Okay. Should be between 3 to 5 squares. If it's any longer, then you're looking at Braddock Heart here and most likely a heart block. So a larger PR interval is brad a card or a heart block. So let's have a look at a few different, um, bright ecologies. So the first one okay. And the most normal one. You. It's odd. Thing is first degree heart block. So in this one, you've just got p a prolonged PR interval. So again, you can see this. This is obviously clearly more than four or five squares. Okay, so this is definitely more than 200 milliseconds long. Okay? So you can clearly determine that this is first degree heart block, and there's nothing else wrong that we can see with the C C G. Okay. QRS looks normal. T waves are fine. Um, he may might be an, uh, no, he's not tachycardic. Um, and it's just a normal P r. It's just a PR interval that's a bit extended. Okay. And this causes something called first degree heart block. And it's normally caused if his pathological caused by an abnormally slow conduction through the avian. Uh, when When I say abnormally slow here in this case, it's just abnormal to what we normally see. But first degree heart block exists in lots and lots of athletes. Okay? It can be very, very normal to have first degree heart block, okay. And it's often a accidental finding or an incidental finding that they just did an e C. G and they just find that they're in first degree heart block. Okay, It usually presents with zero symptoms, and the patient normally feels perfectly fine, okay? And it doesn't really require treatment. And there's very few cases that I've ever seen that actually have symptoms or any symptoms with this. And you probably think, you know, you try to investigate if their symptoms are coming from something else first, before coming to a conclusion that their symptoms are arising due to the first degree heart block. Okay, Because if they're coming in with crushing chest pain, then I'm going to be there and first and I do an e c g. And I see first degree heart block. Then, you know, I'm almost gonna think there's a stemi and I'm going to try and investigate that more Tito. Okay, so that's first degree heart block. It can be normal. It's not always abnormal, right? And then second degree heart block. This, on the other hand, is is a path or is a is a pathology. This is not meant to occur. Okay? This means something wrong has happened. So what second degree heart block is and lobe is type one more specifically is a gradually prolonging PR interval until a P wave is not followed by a QRS complex. So if we look at this example, you can see the in the P wave here and the Q r s over here. And then if you look at the next one the p with the difference between the P wave and the QRS, the distance is much longer. And then if you look at the next P wave or there's now, there's no QRs complex that follows it, Okay, The P wave has not reached or has not crossed the avian to reach the ventricles to cause a contraction. And then again, you can see the P wave in the QRS very close to each other, and then it gets longer and longer and longer and longer until eventually the P wave has no QRs complex that follows it, okay. And this is due to a conduction issue across the avian across the 80 of particular note and they normally present with no symptoms, okay, or a mild dizziness or faintness. Okay, if they present with no symptoms, they get no treatment. Okay, you know, it's been shown through research and especially that back up on all these guidelines that treating patients' with second with mobiles type one with no symptoms doesn't improve. Eight. Okay, and there's no point doing it, so we don't treat them unless they come in with symptoms. Okay, that's the only point. And that's the only time we actually go into treating. Now there's lots of different treatments that you can that you can look at. But again, my worst type one is quiet. It's not one of the most dangerous ones, so, and it's also called Bank You back as well. Okay, so that's movies type one, and then you've got movies. Type two. So movies type two. You've got P waves that are regular but not always followed by a Q. R s conflicts. So you normally for, uh, normally for an E C G, you'd see a ratio of 1 to 1 of one P wave to one curious inmobilize type two. That ratio gets a bit, uh, skewed. Okay, so you can see ratios of 2 to 1 or 3 to 1 of P waves to Q R. S s. And if we look at this, e c g you can see this P wave is followed by curious. This one isn't this P wave is followed by curious. This one is this one isn't sorry. This one is This one isn't. And then p Q r s p Q R S P Q R s. And then we got P wave here and then another p wave isn't followed. And we got a P wave here that's been happening at the same time as the ventricles are re polarizing. So therefore, it looks It looks, uh, like a very long T wave. And then again, no QRs okay. And it follows the same pattern again and again and again. Okay, it's it's quite regular, so that's why we call it regularly. Irregular. So our regular irregular ratio between the number of P waves and Q. R s complexes and this is normally quite symptomatic and requires treatment so you can cause chest pain. You can cause shortness of breath or dyspnea, and it could also cause postural hypertension. So that's where they come to stand up or they stand up normally and our BP falls and they faint. Okay, It's a big, big problem in elderly populations that take lots and lots of medications for their BP. Okay, well, you're trying to lower their BP too much that it causes postural hypertension and then because they're elderly, then also more likely to be frail. And that causes a big lots of big problems. And it's a big cause. Big pressure on on A and e s. Okay, I remember I was on placement. I saw it a lot. So a ton of people come in with postural hypertension, and then this is the final and the most important and the most dangerous heart block, third degree heart block, also called complete heart block. The reason why it's called complete heart block is because there is absolutely no relationship between the P waves and the QRS complex is. And you can clearly see that with the P waves donated by arrows pointing up, and the QRS complex is donated by arrows pointing down Okay, there is absolutely no relationship between the P waves and the Q R S s. Now this obviously clearly looks like a bradycardia, but it doesn't always look like a bradycardia. Sometimes you can look like a normal heart rate, and it can catch people out. Okay, But you just need to be able to look at the rhythm strip and count the P waves and the R waves. Do they look regular? Do they look like there's a relationship between Does it look like the P wave has actually caused that TRS or has the QR has just happened on its own? Because what happens is that there is no conduction of electoral activity between the atria and the ventricles, um, through the atrioventricular node. So what happens is that the p waves they start, obviously they obviously still contracting through the action of the sinoatrial node and the ventricles because the heart muscle is the only muscle that's myogenic i e. It starts its own contractions. If there's no if it's not stimulated at all, then the ventricles start stimulating themselves, okay? And they start contracting by themselves, okay? And therefore the P waves and the cure the atria and the ventricles do not contract, uh, succinctly. Together, they don't. They're not coordinated. It's just a complete mess of uncoordinated contraction. So you can clearly see that that is going to cause big, big problems for the patient. Okay, so it's gonna cause faith thing. It's gonna faint. Sorry. It's gonna cause shortness of breath. It's going to cause extreme tiredness, confusion, chest pain and it's a big problem, Okay? And if you if the patient has the degree heart block, then most likely they're going to need some sort of pacing. Okay, depending on how Hemodynamically stable they are, it is going to depend on what treatment they get If they're completely, uh, not hemodynamically stable, then they're gonna get pushed with some drugs to try and stabilize this and eventually they're gonna need some sort of pacing, OK, to be able to coordinate the P waves and the Q r s s, which is called cardiac resynchronization therapy. And then I'm gonna get I c d. Okay, because I see D is more to do with with, um a systole and particularly cardias and VF. Okay, they might get a CRT device with an I C. D. But again, that's gonna be up to the medical team looking after them and two, And if they have a risk, any other risks of getting a V T or or a V f so like if they have heart, heart failure, for example. Um, and then we're gonna look at finally the ST segment. Okay, so when you're looking at the ST segment in year two, the main two things you should be looking for are a stemi and an end stem. Okay, you're going to be looking for ST Elevation. If there is ST Elevation, then you obviously can think of s to me. So that's a ST elevated myocardial infarction. And in ST Depression, on the other hand, normally signal signals. And instead, Okay, so a non ST elevated m I. And obviously this is gonna have to be on a background of a raised troponin. Okay, So if the troponin is raised, then most likely the you're you're gonna be looking at a, um n stimulus stemi. Okay, if both are present, then suspect to stemi because the stem is more dangerous. Okay. And that's also why a stemi needs to be, um, treated within 24 hours of presentation. Because basically, um, the time is, uh, muscle is time. Okay. The longer you wait, the more muscle that's gonna die. The worst the prognosis is, and the worse the outcome is for the patient with an n stemi. You can wait up to 72 hours. Okay, so they're not as rushed, and it's not as an emergency, but again, if you can, you get them into the cath lab as fast as possible. And you put that stent in or you assess them as fast as possible and you do a coronary angiogram, Okay, because the coronary angiogram is going to tell you exactly which part of the artery is blocked. And then you can think about doing a coronary artery bypass graft. Or you can think about doing a stent. And most patient's these days get stents ready. Um, and the way that you know that this ST elevation is related to a myocardial infarction is because of the pattern of ST Elevation. The pattern of ST Elevation is going to happen in specific leads because those leads are looking at the specific areas of the heart, and that specifically, the heart is going to be supplied by blood by a specific artery. All right, So, for example, the left anterior descending artery supplies heart to the left ventricle. So if there's an l. A D. In fact, which can be quite common, then you're gonna see problem. We're gonna see problem with the leads that are looking at the left ventricle. Same thing with the current right coronary artery. If you see problems with, uh, leads that looking at the right side of the heart, then probably the problem is at it is in the right coronary artery. If you just see diffuse ST Elevation or diffuse ST Depression, then think of something else, then a stemi. Okay? And also So this is this is what I'm what? This is what I mean. Okay, if the if the ST Elevation is in lead to three and aVF, then it's an inferior stemi. Okay, if the infarct is in V uh, V four v two v t three and t four, then it's an anterior stemi. Okay, learn this. Please. Please learn this. Okay? Because if it's an because most likely the e c g will be a stemi and they will ask you where is it? Okay, so I would say 100% learn this. Okay, this is one of the This is probably the second important slide from this power point. Okay, so I take photos of it. Look it up. Do whatever you want. Okay, but learn it, please, because it's an incredibly, incredibly bored Okay? And if we just cover the pathophysiology of why they ever Mm, I Why does it happen? Most likely, the most common reason is it occurs due to a scheme of the car, that tissue due to occlusion of the supplying blood vessel. Okay. And most of the time, this is due to atherosclerosis. So what happens? You've got plaque formation under, uh, the endothelial layer or the endothelium. And then that plaque grows and you got phone cell formation, and it grows and grows until the actual, uh, plaque ruptures. Okay, because it becomes more and more unstable. Okay. And then finally, all this underneath the endothelium is very very, um uh, it's basically causes a clot formation. Okay. And then that clot formation, Then finally occlude the rest of the blood vessel. Okay. So because this plaque formation is a very, very slow process, often times it doesn't lead to any, uh, symptoms maximum. It leads to Well, most of the time. Where the max, the maximum it leads to is that it causes, um, stable angina. Okay, so it causes them chest pain when they're going through some sort of high level of physical activity. I mean, and then it goes away afterwards. Okay, In rare cases, it's also been known to cause unstable angina. But that's because you've included the plaque is very, very stable. And it's occluded, you know, probably about 80 or 90% of the artery. Okay. And if the plaque ruptures, it causes a blood clot because it's very, very atherogenic. Okay, all the material underneath the underneath the endothelium is very, very atherogenic. Okay. It causes lots and lots of blood. Clot formation, including the entire artery and depending on where the artery is, will cause, uh, will cause different problems. So if the artery is very, very distal okay, and down here, it's not gonna cause is big symptoms. But if it's, for example, in the left coronary artery, then pretty much half the heart is not going to get any blood supply. And that's going to cause big, big symptoms. Okay, you know, cause your classic like collapse. Okay, if it's down here, then it's more likely gonna cause, like you're crushing chest pain. Patient still gonna be able to walk. It's gonna cause a bit of shortness of breath. Still gonna cause them problems, but not as big. And, I said before in stem ease are normal. Normally, partial occlusions and stem ease are complete occlusions. So if there's complete occlusion, that means there's no blood movement, so there's no option getting to that muscle. So the longer you wait, the more muscle that will die. And the more muscle that dies, the worse the outcome is for the patient and the worse the outcome is for the heart and again, other said, Um, definitely. I would say, Spend some time learning this, Okay, because this also tells you if that ST Elevation is due to an M. I okay, the one thing I would say two maybe look out for is if there is diffuse ST Depression. If there's diffuse ST Depression, then that probably means that you're looking at a posterior M. I and you need to get the other leads. So you need to get the other three leads and you need to do a 15 lead E C G instead of just a 12 lead, E C G. So you need to get V 78 and nine did they which basically go on the back of the patient to look at the posterior aspect of the heart. Okay, but that's a special case. Okay, so and sometimes they might throw in an exam question to catch people out. But I wouldn't expect in a CPA and then practice questions. So can anyone tell me what this is? Don't tell me what's on the what's on it. Just tell me what it is. Just just describe what it was for me. I'm just trying to get the teams try to open again. So can anyone tell me what is? Just shout out. It's not your question. It's as simple as you know. Uh, there's ST Elevation and some of the pickle relief Most of them are. Yeah, so that that's that's fine. But what is this? So I could have given you exactly the same thing without any ST Elevation that record your leader or anything like that. But what is this actual thing? What's it called? Anyone have any event? Is Hello. Let's see. Maybe Tola can give it to tell us. Did you guys is just say what you see whole ago. Yeah. You can also put your honest in the chair. I just literally I've got I've got, like, maybe three or four more practice questions. So if no one says anything, then I don't know how useful they're gonna be. So we know this is an E c G. But what type of e c g. They don't have any ideas? No, no. Maybe you can answer this one. It's been a long time since we've seen any C d. What did he say? Meet you. Yeah. Oh, gosh. Just just tell us what? What type of e c g. This is so 2 12 lead E c g. Yes, Thank you to 12 lead E c g Exactly. Okay, literally as simple as it gets. Because this is exactly the same question that they're going to ask you in the c p. A. They're going to hand you a piece of paper and they're gonna ask you what is this? Okay, that's normal. That was normally their first question. And that's what I've been hearing about the CPK. Okay, so now what is the main pathology exhibited here? Type in your answers in the chat. Anything wrong? You see, with this e c g type it in. Okay. Just tell me what leader is and what's wrong with it. Anything wrong with this? See? See you. If you think it's normal type bit if you don't think it's normal type in literally type in whatever you want, right? And literally it doesn't matter what you type, as long as it just doesn't necessary Upset anyone. So everyone thinks this is a normal E c g. Then, um, the one abnormality is there's ST Elevation in the recording leads. Yeah. So which can you tell me which specifically? What leads? Those are, um, the two. The three before, uh, the five. And be successful? Yep. Perfect. Thank thank you. Fantastic. And then all the other ones are normal. Okay, if you could say you could look at a V R and say it looks upside down, but a VR always looks upside down. Okay, most of the time, so I wouldn't comment on it. I wouldn't say that anything is abnormal with it. Lead one. You know, there's a bit of ST elevation. Maybe it could. You could argue that, but I would say it doesn't really look that elevated outside the ice electric line because when I say ST Elevation, it has to be. The area between the QRS and the T wave is also elevated. Okay, It's not just the T Wave is pointing up. It's also the area, um, between them and then lead to again. I wouldn't say there's any ST Elevation Lee three. You might argue there's ST Depression, and that ST Depression could be due to ischemia of the surrounding tissues, because what's happening is that an area of muscle has become infected. It stopped working. When that happens, the other areas of the heart basically have to pick up the slack. Okay, they have to do the extra work to, um, to pick up from or to try, as best, they as best they can to maintain the cardiac output, even though an area of muscle is basically dying and not working properly anymore. Okay, so that's why if and if a stemi goes on for long enough, you could see ST Depression as well as ST Elevation. Okay, But the biggest things that has has been correctly mentioned is that, uh, someone's correctly mentioned. Sorry. Um, is that V two and V three Massive ST Elevation V four Massive ST Elevation V five also massive ST Elevation. Okay, so I think back to that diagram where it was all the little cutups of which ones which leads correspond to which areas of the heart of infarcted. Okay, so what area of the heart is affected? So we said V two V three and the four and V five a little bit in V six. Maybe, but most main ones are V two V three and the four. So what area of the heart is that? Um, that would be the anterior part B two b three and before? Yeah, perfect. Exactly. So as we said, there's ST Elevation need 12 a V l v one V four. And there's a reciprocal ST Depression, so we probably think this is a stemi most likely. Okay, But always whenever you're looking at e. C. G most of the time, you should. If you're on a ward, you want to interpret it in the context of the patient. And the patient is there, clutching his chest, looking sweaty, difficult breathing, saying that he's got crushing chest pain. It's radiating to his arm. Then you know, even without looking the the E C g. You know, it's a stemi. You just look at the e t us to know which area of the heart is being affected. Okay, but if the patient is sitting there perfectly normal, then it may dissuade you from a stomach. But it could be, um it could basically fake you up. Okay, Because especially in females, it's been known that the patient could have no symptoms or very mild symptoms, but they're but they actually have a very large infarct, and they actually have a very large inclusion. So the symptoms do not always correlate to how much, Um, how much infarction there is. Okay. In males, it does. And there's been lots of research to show it's been done in females on your hand. It's a bit more shaky. Okay, unfortunately, historically, most research has always happened in white Caucasian males. Okay, so obviously, we need more research into that area. And as you said, it's a lateral, an anterior lateral area of the heart, which is most likely an l a. D. Occlusion. And you want to be whisking this patient off to the cath lab as fast as possible. Okay, Okay. So What about this one? So you examine the patient and you find they have a midsystolic crescendo decrescendo murmur. There's a grade three are six and radiates to the neck. What is your differential diagnosis? What do you guys think it is? Um, this would be a aortic stenosis, mama. Because of radiation and the type of mom. Yes, exactly. Perfect. So even if you stood there in your c p a. And you completely forgot, uh, everything that we went through this, uh, through this tutorial, or you completely completely drew a blank, which can happen because of the stress. As long as you, when you start hearing radiates to the neck, only one murmur radiates to the neck. Only one and that is aortic stenosis. Okay, All this other stuff, they may tell you just to put you off just to confuse you. Okay. Grade three out of six. You don't need to know where it is, and then no one uses grading systems. To be honest, I've never seen grading system to being used for a murmur on award. Now that also the cardiology ward for about night a month, I think two months. Okay? I never heard about this crescendo. Decrescendo. That's great. The describing the sound with the sound that it makes. Yep. Midsystolic probably should have, you know, been able to identify that, but radiates to the neck is your smoking gun. That is your biggest clue. Okay. And it tells you that it's an aortic stenosis. Okay, what about this one? Then you examine a patient and find a pansystolic high pitched murmur that is loudest on expiration that radiates to the axilla. What is your differential Diagnosis? Mitral regurgitation? Yes. Perfect. Exactly. Mitral regurgitation. And what told you it was mitral regurgitation? Uh, since the mama was pansystolic one and it was relating to the mainly the radiation. Yes, exactly. Perfect pansystolic and radio to the exit. Er, those are your two biggest, um, telltale signs that this is mitral regurgitation. Radio to the axilla. Tells you it's mitral. Pansystolic tells you it's regurgitation. There are other pansystolic murmurs, but not of the mitral valve. Mitral stenosis is not pansystolic if you go back, OK? Mitral stenosis is a rumbling midsystolic mid diastolic mob. Okay. And you can listen to these are there's tons of videos on YouTube. Uh, there's Professor Mehran even has a website that he has lots of heart murmurs and lots of breathing sounds on there. So you can look that up as well. Ok, there's tons of resources out there for you to go listen to them. Okay, But the reason why I don't have the I haven't included the actual, um, sounds of them is because you're not gonna be You're not gonna be hearing them in the c p. A. They're not gonna tell you to listen to heart sound already. So I haven't heard about them ever doing that for the CPA. What's most likely gonna happen is that they're going to describe it to you Exactly how I've described it to you as well. Okay, so and then this is the final question Describe to features of this E c G. It could be anything anything you want from the from the list of five things that we went through about this E c g. So you can talk about the rate, the rhythm, cardiac, at sit cardiac access sorry, or anything else? All right. Just describe me two features as e. C. G. And I think everyone can at least give me one. So anyone have any ideas? Okay. What? What's the rhythm? Is it regular or irregular? Going in three. I can see. 3.5 squares. 3.5 squares. 3.5 squares. 3.5 squares. So we say regular or so. Sorry. So I say that again. Regular? Yeah. Perfect. Regular. Anything else you can tell me about C C. G? Um, the heart rate, I guess, would be, uh, a little over 100. Yeah, Exactly. Perfect. Probably were under 100 because 3.5 squares, I would say, Uh, one second. Sorry, mother. Um, anything else we wanna describe? Other, C, c, g. And again, you see, a BR here is upside down, which is perfectly normal. Be one. Being upside down is a bit abnormal. So these things I came up with So there's ST Depression needs 12 V five and V six. Okay. And we're comparing that to the ice of electric line, which is around here is also ST Elevation in V one. Yeah, I would say ST elevation in B one, and there's also ST Elevation in V two has a rate of about 86 BPM, which I calculate before, and I believe that is it. So if anyone has any questions or anything they want to ask about now is your time or anything that seems unclear. Okay? Please don't leave here modeled up. If you have any questions, just shoot and fire away and not answer them as best I can. Uh, and here's the QR code feedback. So if everyone can please please fill in this QR code, um, Mohammed's also kindly paste it in the chat for us. Please fill this in. Mohammed's worked really hard organizing this, um, and the slides. I've made the slides and hopefully, you know, tell me if the slides look amazing. Tell me the slides to look rubbish. Uh, too fast. Too slow. Whatever feedback you have for us, okay? And thank you very much, guys, for listening to me, and that is all I'll hand back to you, Mohammed. Yeah. Thank you so much, Abdullah. And just to reiterate what Abdullah said, please, please do fill in the feedback form. He spent quite a lot of time on these slides and a lot of effort to go through this lecture so it would mean quite a lot for him to have this feedback. And yeah, if once you fill in the feedback as well, you'll get access to these slides and the recording of this lecture as well. So thank you very much for attending guys. And I'm gonna stop the recording now. And if you have any questions, Abdullah and I will stay around for a bit as well.