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Before I start, I'm gonna have to be that guy. But um this is gonna be a Pacers focused session and to get the most out of it, it's gonna be very interactive and you're gonna be completing parts of the history and exam and then I'm gonna be giving you signs that you need to interpret. So if you guys can turn your cameras on, it would be extremely helpful because I genuinely think you will get more out of the session if you have your camera on and unmute. Um What ends up happening sometimes is like only a few people do that and they tend to be the ones who remember the most from the session. Um So I will say that if you don't want to turn your camera on at least, um It would be great if people uh just unmutated and spoke and gave some answers in the um, like by their voice. Um because this session doesn't really work that great if people don't. So, yeah, help me out to deliver it. Ok. So what we're gonna do is we're gonna spend an hour and 10 minutes um going through different paces stations almost it's going to be history slash examination stations that aren't in this order that will be covering this content. So whenever you revise cardiology, I always divide it into the cardiac specialties. So you have structural stuff like valves, you have coronary disease, you have heart failure and you have arrhythmia. So typically cardiologists will be one of these specialties when they super specialize. So I always like to divide my revision into these, into these um into these groups. Ok. So we're gonna do some stations, some of them will be history, some of them will be exams and um just a bit the same with the IM and F one and this is just to help you for your exams. It's not been reviewed by a consultant for clinical practice or anything like that. So, um, let's start with this one. So let's say you're on the AM U and somebody has developed shortness of breath. Uh, and maybe your, your colleague calls you over and so the doctor of this patient is quite short of breath. Um So it can I please have someone volunteer to start off the history and I will be the patient. You don't have to do the whole thing. But who wants to get in with the history of presenting complaint again? You'll get the most out of it if you volunteer. Hi, I'm happy to do history. Brilliant. So I'm a, yeah, I'm a 65 year old male. So please go ahead. Yeah, I got your name and date of birth already. Uh Can you tell me why you're here today? Yeah, of course. Um I am quite short of breath. I've been on the ward for a couple of days. Um, yeah. Right. Um, a couple of days. So you're already in the ward when this happened suddenly, was it? Yeah. So let's say you're on the ward right now, you're in the hospital and, yeah, I was already on the ward. I see. Uh, can you tell me what you want to work for? Yeah. Um, I was admitted with, um, a pneumonia. Ok. It's already been treated. I see. It's, it's not like any operation or anything. No, no, I was meant to go home today. I see. I see. Fine. Um, so this breathlessness, right? Is it there all the time, I imagine? Is it like, uh, worse on any when you're lying down or worse when you're? Yeah, it's probably, it's probably worse when I'm lying down. I can't sleep because of it. I see. And do you need like lots of pillows too? I think so. Yeah. Fine. Um, this breathless. Is it al also at rest? Uh, or is it only when you're walking? Um, probably a bit worse when I'm walking, but I haven't really noticed. Ok, it's fine. Uh, how far do you think you can walk before you need to stop to take a breath? Uh, not far? Just a few meters fine. And you have never been, like, breathless before, like, two days ago. Well, I've had breathlessness in the past sometimes but it's never been this bad. Right. Uh, how far could you usually walk before that? Probably about 100 m or so. I'm not very fit. Right. I see. Uh, do you have any, um, uh, do, do you have any problems with the heart, um, before, like, diagnosed any problems with the lungs? No, just got some lung infection that I'm here for, but it was only like one day of antibiotics and I think it's sorted now. I see. I see. Fine. Um, other than breathlessness. Do you have any, like, cough or any chest pain? No. So that's good. Well done. Um, just that, that's pretty good. We won't do the whole history, but I think you start off really well. Um, you've been asking me some important questions now, my history of taking tips. Uh, this is your main part and so I'm going to get you all the marks. Just use Socrates for everything. Like this is kind of controversial, but I just, I just like to keep things simple. It's very difficult to find the site of shortness of breath. So just ignore the ones that don't apply. But onset character associated symptoms, timing, worsening and severity are all going to apply to any patient. So you did well in getting some of these, just use Socrates for everything and ignore the ones that don't apply. That's honestly how I did most of my history presenting in places and it's quick and dirty, but it works. So, can someone else tell me what, how do you guys classify acute shortness of breath in your head? Let's say this is a pace. This is your finals. You're outside the door, I mean, actually outside the door these days, you don't get told, but the patients has told you that they're short of breath. What do you guys think of when you classify it, you won't be able to memorize a list of all of the causes. Respiratory cardiac. Yeah. Yeah. So I think respiratory cardiac is the probably the best way there's also systemic. So that way you don't miss uh severe anemia but yeah, um respiratory and cardiac and systemic. So Chelsea was also gonna answer. I think. So, what are the, what are some of the respiratory causes? Can you that you can think of? Oh asthma and COPD restrictive lung disease like IPF Sure. Um more, more acute things that you would, that might kill the patient if you're not careful. Pe Yeah. Good. Yeah. So I always start with my life threatening causes. The reason being I would fail for not saying the life threatening causes, but I wouldn't fail for saying the ones that you might not be so acute. So pe pneumothorax, acute exacerbation of asthma anaphylaxis, that kind of thing. And then because this is a cardio lecture. Someone else want to tell me the cardiac differentials for shortness of breath are the most important. Generally, heart failure. Yeah. Can you name any others? Heart failure is really good. And probably the one that we're gonna deal with here. But yes, anything else, I guess if they had like, some kind of acute infective picture, like infected appendicitis, if they were having like a stem, I guess they could be a bit. Yeah, exactly. So when, whenever you think this is the thing about cardiology, which makes it nice and straightforward when you're thinking about cardiac causes of anything, divide it into the four cardiac specialties, structural coronary, arrhythmias and heart failure. So it could be a structural cause like an acute valvular lesion plus minus infective endocarditis. It could be a um um coronary cause like a stemi. It could be a arrhythmic cause, right, acute af worse rhythms and it could be um what was the last one? Heart failure? OK. What made you say heart failure first in this case? And we'll stick with you just last question. Yeah. Um I guess maybe like the age, the fact that like they've been in the hospital for a while, um heart failure just seems like quite a common cause. Fair enough. Cardiac. Yeah. Yeah, it is certainly very common. I would say one of the main things here as well is the um orthopnea so very rightly asked me like is it worse when laying flat? Do you have to use pillows? That's quite classic for heart failure. Because why, because the pulmonary edema accumulates in it. It's position dependent. It's gravity dependent. Um, yeah, so let's say this person's observations look like this and you listen to their chest and you hear some crackles. Um, why are they hypoxic? Uh, anyone, it got impaired like exchange because, yeah, they probably have like fluid on the lungs. Exactly. So you're, you're um ventilator, you're um you're not ventilating but you are perfusing that area. And that's obviously that's gonna lead to um the hypoxia. So that's why they have it. Um And so this is what I already said and this is what I think is the reason for um this person being ignore this part. Uh But yeah, these are the reasons. It's probably ADH in this patient. So, Viber, ok. So let's, let's just start with um some basic classification. So what do you guys think of when you think of heart failure? How are we classifying heart failure? What type of heart failure do you think this patient has? You can classify anywhere you want if you know a kid chronic, you know, a heart failure? Yeah. Which side, let's say he has, let's say he has really bad leg swelling and he has um poroma as well. Yeah, both sides. So the right sided heart, remember the right sided heart failure is going to be very much your elevated JVP and your peripheral edema. Why? Because it's blocking the inflow of blood into the heart because the right side receives the blood. So then all of this peripheral stuff starts to get blocked up. But equally the most common cause of right sided heart failure is left sided heart failure. Because when you have left sided heart failure, the fluid backs up in the lungs. And so you get pulmonary hypertension and you transfer that back pressure to the right heart and start um injuring the right heart. So this guy probably has both if he has all of these findings and you can classify the right or left low output or sorry, preserved ejection fraction, reduced ejection fraction. But really in a case of acute stage, they're going to have acutely compensated heart failure, usually left and right sided. We usually like presumed reduced ejection fraction. Um So how do you guys want to work up this patient? So you're on your pages, you've taken the history, you said, ok, you think this is acutely compensated heart failure? What investigations would you like to do? We won't do an exhaustive list. But what are the kind of key investigations that you guys want? Like a BNP? An echo maybe? Yeah. Do you have? Yeah. Yeah. So like bedside bloods imaging at that side, I think you've already got all the other. So maybe like an ECG and then bloods would be like your BNP. Um if you're worried about like an cause you might do like trop cardiac. Agreed. Very good. Um And then what about imaging? Probably an echo. Um And then I guess you might do other things like guided by that. Yeah. Sure. Um A chest X ray as well. Yeah. So my chest x- Yeah. Um What other uh so someone else want to tell me the signs of acute heart failure on her chest. Actually, it's fine. We don't have time. Look up the ABCD E stuff for the chest X ray findings of pulmonary edema. Um Anyway, echo. Ok. So Echo is going to tell you if this person has a kind of acute heart failure um fine. And then for management, you know, always ABCDE because these sorts of these cases in your exam are going to be acute cases, which means you're going to be doing an A really. So airway make sure they are not having oxygen because they are hypoxic. And then really, it's diuresis and fluid restriction, isn't it? With weight? That's how you manage heart failure because they are fluid overloaded. Um What's the um what's the most common diuretic we use? Anyone wanna want to pitch in most common diuretic samide? Yeah. Um Does anyone one tell me how fluide works? I think it's a loop, it's a loop diuretic. So uh in the kidneys um loop diuretic stops the ions from the triple transporter and the pen. So you have osmotic um losses of water. So that's good. Um And then does anyone want to tell me what are we monitoring for in this patient? So I've already said, wait, start them on IV foods. What you're gonna monitor point? So, so can say that again. Oh I said fluid balance. Yeah. Yeah. Input output, charting daily weight in their bloods. What are you gonna look for? The sodium and the other electrolytes? Yeah. And, and potassium as well like um you said other electrolytes. But yeah, potassium is the one I would name first because it's the most dangerous if it's low. What happens when you have a low potassium? Like what are the cardiac consequences of a low potassium? I call the ECG changes like broad cure in particular, I think and then that can lead to other arrhythmias. Sure. I think the broadening and the sine wave and stuff is hyper but you can get ECG changes. Um But what is the like, what's the difference between the ar between the rhythm problems when you have a low potassium versus high potassium? Because they both cause rhythm disturbance. All right, let's let's not put so much pressure on, on the guys who've already spoken. Does anyone else want to have a go? It's honestly fine. Like um II feel like you'll remember more if you if you suggest an answer. Um Is it Asystole? OK. Cool. So Asystole is what happens if it's too high? Um Yeah, so Exactly. So that is one, it's too high. If it's too low, you start getting hyper excitation, to be honest. So you can get fibrillations and, and stuff. Um So yeah, it's because of the way potassium is involved in repolarisation. If you've got too much, I think you areolaris but not depolarizing. Hence, asystole. If you've got too little, your repolarisation kind of isn't happening. So you have fibrillation, it's kind of a crude way of thinking about it, but that is what happens. So you need to monitor the potassium, you need to monitor input output, etc et not exhausted. But if you say these things in your, in your exam, you will pass the station. Um you know, I'd like to get ecg you know, bloods, fluid balance and echo to confirm and then I'd like to, you know, treat this patient with oxygen IV diuretics, strict weight monitoring, fluid restriction, sodium restriction in the long term guideline, directed medical therapy for heart failure. So there are some drugs that reduce mortality, beta blockers, ace inhibitors, MS SGLT two inhibitors and then um monitor the patient as an inpatient for electrolyte disturbances and weight. Nice job guys. All right, it's gonna have to be someone else you're doing. You guys are doing really great but someone else because there's plenty of people. Um Can you guys run me through a, a kind of mock CV exam on this 50 year old lady? Someone just um tell me like the order of examining and tell me what they're looking for and I'll, I'll throw you some examination findings very good way of revising your exam, preferably someone other than the people already because they have been very good contributing at this rate. The poor lady is not gonna get a cardiovascular exam. Um I don't mind giving it a go. All right then. Um, so like I'll just start off at the hands. Um Yeah. Uh like do capillary refill time. Um If it's like an acute scenario, then maybe just move on to the pulse, it's not on a case. Yeah. Ok. Um Yeah, so look at the hands, check for sort of clubbing capillary refill time if there's any sort of uh sort of like stigma of smoking and nicotine use around fips. Um any sort of cyanosis. Um You're doing pretty well. Um Yeah, I can't think of anything else. Um Apart from that um check the pulse good. Yeah, we'll, we'll pause there and I'll give you some findings. You're doing great. Um um Thank you for pitching in. So your hands are, I'd say warm hands. Um Cap four is less than two. I don't expect you to recognize this immediately but you see um you see some pulsation of the capillaries in the nails. Ok. Um And let's say you're not really sure what that means is fine or you might know and then your pulse you say is very easy to feel and a very strong pulse, you're almost surprised how strong the pulse is given the patient's BP is completely normal. Um, so what's next? Keep going. Um, I'd offer like to do like a, a BP reading. Ok. Um, and then check for, I forgot what it's called from third year. But when you lift the arm up, something pass like something like a, um, no, no, no, like the water hammer pulse thing. I don't know. Ok. That's good. So you're already thinking along the, yeah, you're already thinking along the right and then move on to the, then you'll have a look at the JVP and then move on to their face um in the eyes. You just want to check for conjunctival pallor or sort of corneal arcus. Um move on to the mouth to check for like central sinois good. Um Yeah, and a little bit of anemia. Yeah. Yeah. Doing very well and then we'll skip to auscultation. Um So I take the four yes heart valves. Um Yeah, and then like check for sort of like murmurs and radiation of murmurs. So you might do sort of the leaning to the left for good idea. So I think, I think let's focus on that. I think you've said some really great things. So here are your findings. The nail bed is pulsating with every heartbeat. Ok. The patient has these conjunctival petite. Yeah. And you hear this murmur. So be very correctly checked for all this stuff. So I'm gonna give you all the, can you guys hear the moment? Uh Not really? Ok. It's not continuous. Like I don't know if that's my internet connection. It's not continuous. It's right. Let me, let me play it one more time. If you guys still can't hear it, I'll tell you what the murmur is. Any lump like middiastolic. Yeah. So I would definitely say it's a diastolic murmur. Can you? So let's go with you and so well done. You did really great. Um And we'll come, we'll come back to you for the last bit of this. Um But you said it was diastolic murmur. So let's let's forget like mid or early because it's hard to hear over the computer. What is going through your head for this patient's diagnosis at the moment? So I'm thinking it's probably like a complicated aortic regurgitation um because she's got Rey sign in the nails pss. Um And so because it's complicated, probably because of the pneumonia um that's causing the heart failure um because of the reg um And so you've got like the left sided heart failure, but that's complicated to become more congestive, which is given the um right heart side failure signs. That's very fair. II meant for this to be a different patient. But um that's completely fine. Um You, yeah, you would probably get acute heart failure if you had a really bad regurg um but let's say this is a new person. What do you think of the eye findings? Could that just be something else? Yeah, it is something else. What is your concern when you hear a new murmur in a patient? Like this is a 50 year old lady who isn't feeling well. She's come to the GP and she has no cardiac history. So, of like infective endocarditis. So, or being to do some blood cultures and maybe consider doing a transesophageal. Exactly. So, so well done. That's pretty good. All right. Let's bring it back to care for a second. So well done. That's very good. Um So, ok, your exam was, was great. You didn't miss stuff and I made you skip to stuff. So you did well, if you um, would have heard um, a diastolic murmur, what are your differentials for a diastolic murmur? Like, what do you think of? And, um, just like two is fine. So you can have one free. I might be really wrong because I don't remember. It's from vio cardio. But yeah. Yeah, it's fine. Um, is aortic regurg. Yeah. So, I think that's probably what this patient has. And then there's one more, it's one of the atrioventricular valves. It's one of the diseases that affect D no. Uh Did you say it was the valve, one of the, it's one of the, like tricuspid stenosis or like mitral stenosis. Yeah. One good. That's, that's you very done. Very Well, um, so mitral stenosis is a diastolic murmur. Why? Because it's when the ventricle is spinning from the atria, it's diastolic aortic really goes is diastolic because it's the, the ventricle back filling from an incompetent aortic valve. Um, nice job, systolic murmurs. We normally talk about left sided murmurs because the right ones are very soft and not there. But remember, in cases you should always list the right sided ones of differentials. So you should say tricuspid stenosis and you should say pulmonary regurge, it's just rarer, but we usually talk about left sided ones because they're louder and more like common. Don't quote me on that mitral regurge and aortic stenosis would be your systolic murmurs. Ok, great. So Harro said, um that she's concerned about ie which I agree with. So infective endocarditis has lots of peripheral signs. Does someone want to name some of the peripheral signs of infective endocarditis? Jane ray lesions, splinter hemorrhages, Oslo nodes, rough spots in the eyes. Very nice. Yeah. Ouch nodes because they're the painful ones. Um, very good. Um Yeah, and then does someone does someone else so well done? You guys, you did really? Great. Thank you. Um Does someone else want to tell me what will happen? Let's say she gets treated for her infective endocarditis? We're not worried about that. What will the aortic regurgitation do to this lady's heart over time? This can be anyone but, or even, yeah, I've had the like they fulfilled their contributions. So, but it cause like left ventricular dysfunction. Yeah. Can you be more specific by any chance um could cause decent heart failure because of end volume like increase because of regurgitation. And so eventually over time, um you just get heart failure because of reduced cardiac output. Yeah. So very good. So structurally, she's gonna get eccentric hypertrophy is literally gonna dilate. You can see how this wall dilated into this picture. Concentric is different. Concentric is when the heart looks similar from the outside, but hypertrophy inwards and that happens when you have pressure loading from like a stenotic aortic valve. This person's heart is volume overloaded because she keeps having reflux of blood from the aorta. So the left ventricle is taking on too much blood volume. So this lady's heart would acentric hypertrophy and you should see dilation if she is untreated. Um And then you, I mean, the treatment this this person needs a uh urgent aortic valve repair, um a replacement for regurg because it's like quite a bad condition. Um She's gonna get heart failure. Um And can anyone tell me why we get the Quins Corrigan? What's the path? What's the uh mechanism? The wide pulse pressure? Oh Because essentially I think from what I remember your systo looks relatively big and your diastolic pressure is low because during diastole, it regurgitates back into the left ventricle. So the pressure kind of decreases in that massive because you've got like an increased EDV and your initial upstroke during cysto is quite big. Um, there's that massive difference where in such a short period of time causes that massive pulsation in water and a pulse. All right. So let's say this is normal and someone suddenly gets a systolic diastolic and someone suddenly gets aortic regurge. The diastolic is going to drop. Why? Because every time there's dias the heart is refilling with blood that it already ejected. So your BP fours, your diastolic BP fours at the same time. Now that the heart has got loads more volume in the LV. Every time it ejects blood, your systolic increases. So your pulse pressure widens and that's why you like blow out your arteries and that's where you get the massive pulses and um massive pulses and uh all the other pulsations, lots of eponyms, greenies, corals, um Muller sign. So many signs think about murmurs logically. Um You know, remember your auscultation areas. I always go from A to A to M um And remember logically, so remember that this is going to be systolic like this because they happened during Sicily. Um Do you have a question or was it just like a hand by accident? Yeah, I do. Um Could you explain why the diastolic pressure falls? I get that. Yeah. Sure. So, thank you. No, of course, I can, I can do that. Um What, so what determines, let's go with this? So it tells you what determines the systolic pressure? Like what do we mean by systole and systolic function? It will be just any answer, you know about that. I guess the pressure generated when the ventricle contracts. That's it. Perfect. Ok. So ventricle squeezes and then the aorta gets a rush of blood systolic. Right. Do you know what determines the diastolic? So there's, yeah, I was gonna say there's blood still in the heart after the contraction. So the pressure of that blood once it's contracted. Yeah. So I'm gonna do a slight correction there, right? The BP we measure here is not cardiac pressure, it's in the vessels, it's in the aorta. Yeah. So it's not really the blood that's resting in the heart. It's the blood resting at high pressure in the arteries. Yeah. So it's always like 80 then it gets hot, hot. Yeah, it like receives uh a load of blood from the heart every time the heart beats. So that's your di and systolic, right? And this is in the AORTA. So the DYO is kind of like the constant basal pressure and the system every time that basal pressure gets another 40 mmhg from the ventricle contracting, right? If you have aortic regurge, the reason the diastolic falls is because every time the systole happens, it doesn't go back to being this level of 80. It goes further because the heart is wrongly receiving backflow of blood from the aorta. Ok. So you're like reducing the amount of blood there is in the aorta every time. And so your thing will look like this when you have aortic regurg, right? That makes sense. The blood leaves the aorta and goes back into the heart, which is why your diastolic falls. Yeah, thank you so much. No worries. And it and it shouldn't be doing that, it should be staying in the aorta because the aortic valve is supposed to be very tightly sealed. Um So yeah, it's a good question. So I just had a follow up question today. Um Why, why does systolic rice stand? Well, the systolic rises as a follow up to the diastolic decreasing because once the diastolic, the diastolic decreases because the blood is leaving the aorta and filling the ventricle backflow. Right now, the ventricle has more blood in it than it normally does. And so when it ejects the blood this time, there's going to be more blood ejected into the aorta. And therefore, the systolic is gonna be higher like it's higher because the heart is ejecting its normal volume plus the back flow volume. So that means the stroke volume is high also. Yes. OK. Thank you. All right. So bedside blood, I don't know. Wait. So what was my actual case? Oh, yeah, in fact, OK. So bedside bloods, imaging cultures and echo you'll pass if you say cultures and echo management. IV antibiotics, surgical valve repair. OK. Ok. So I think we're doing really well. You guys are doing great. Um Can someone else want to sign up to do a history of palpitations, please? 35 year old woman comes to the emergency department palpitations. You, your paces, your final year paces. You've entered the room as a lot of people to choose from, but I obviously I am not gonna pick people but have a go at it. Worst. That can happen is you just earn a couple of extra points. I can do it. It's just that I'm not that good at the conversation history. It's all good. It's all good man. Like even if you just Yeah, just go for it. Ask me some questions. Um ok. So when did it start? Yeah, so Socrates, right. Beautiful because I just use it for everything. So onset nice. Uh It started about an hour ago. I was just sat on my sofa and would you be able to talk about what it feels like? Yeah, it feels really quick. My heart isn't, it doesn't feel like it's supposed to go that quick. And um have you had any, any other symptoms or any sort of fainting? So I've not had fainting, which is a great question. I've not had fainting. It's a very good question. Um But no, uh what other symptoms would you like to know about doctor? Um any sort of pain anywhere? No, II haven't had chest pain. Um Anything else? Any shortness of breath? Good. Uh, a little, I'm a little short of breath. Yeah. Um, and how, how long, uh, how long do these palpitations last? Yeah. I mean, it's always there. Um, and it's been there for an hour now and I've never had it before. Ok. Does anything make it better? No. Does anything make it worse? No. Um, and I guess then have you noticed any sort of nausea or vomiting or any, um, any feeling of fainting? Yeah, you can say that, I mean, severity in this case is probably like, what? Um, so tell me the reasons like, or tell me what it stopped you from doing, you know, are you able to walk around or were you brought in by an ambulance or like, do you, how long do you think you could live, like, go like this? And then the patient would probably say like, really not long. Yeah. So severity is not always going to be pain. So you can, you can use less good, nice job. Yeah, Socrates. It's just, it's just easy. Um, what will happen is when you do some mocks, you will realize that Socrates didn't cover these quite important questions that I need to ask for this particular presentation and then you can just, you can just memorize that. Um, if that makes sense. Um But I just always do Socrates. Ok, nice job. Um, so in a 35 year old woman, like, what do you think would be the common causes of these fast palpitations with no chest pain. And so just like a reflex, if you have any thoughts first would probably be anxiety. That's like, it's like a transient thing. Probably anxiety actually really important to consider anything else. Um If she has other, other characteristic symptoms or findings um or any other underlying conditions like heart failure uh or sorry, um ischemic heart disease or atrial fibrillation. Yeah. So exactly af could be af could be anxiety. So sinus tachycardia, it could be af nice job you do really? Well, I will, I'll, I'll, I'll let, I'll let you off there. So it's really good. Um Thank you. Um All right. So what one investigation is gonna be quite important? Assuming she's still having these uh palpitations? An ECG. Yeah. So wait, who was that was? Ok again? Yeah. Ok. Hi. Do you want to have a go interpreting an ECG or would you like me to do, pass it on to someone else? Um I don't mind. All right. Nice job. Can you see that? Yeah. Is it too small? I, it lets me in which is fun. Brilliant. Ok. So just take it nice and easy. II don't, I don't worry too much about the diagnosis. Um Just go through your like systematic ECG thing you let's say you've not revised was sure. Yeah. Um Right. Ok. So just starting off with the rhythm. It appears to be regular. Um Yeah, regular. Um at a rate of around 150 BPM. Um, looking at the P waves in sort of all the leads. I don't think I see any clear P waves, um, which makes pr interpretation a little bit tricky. Um The QRS complexes are narrow. Um And the ST, there's no elevation of the ST segment. Um, I don't know if that's a true depression in lead two. Ok. Um, so it's not. Ok. Um And the T waves also seem to be OK. They don't seem to be like tall 10 or in V one. They are inverted though. OK. I don't know if, yeah, they're inverted in B1. Sure. Um And the QRS complex is uh I forgot to mention this but in aVL, it looks like they're also inverted time. They're doing great. So um axis I'm really bad at this. I don't know what I'm going to set this straight, right? For everybody here because this is the same problem I had and I just didn't understand like why there wasn't one method. So of course, feel free to not use what I'm saying and use like a different resource, but I have a way of doing this. OK. And I'm going to explain why. So here is the thing, right? That can you see a white screen, you need it to draw something. So when you do your, when you place your ecg electrodes and you create the leads, remember that they have different places they are pointing and there is like this diagram of the chest where you can see which, which way each of the ECG leads are going. Remember that lead one, let's say this is the person's head, they are facing, you lead one is facing right and lead. AVF meaning floor is facing to the floor. OK. So if these two are the best leads for access because they are, they are perpendicular to each other and they are facing completely right and completely bottom. So when you have a lead one positive and an aVF positive, you're in this quadrant, you've got a normal axis. OK. So from here on, you can use your leaving and reaching rules. So remember if it's reaching, if one is pointing down and F is pointing up, they are reaching. So it's a right axis deviation. And if they're leaving each other like that was pointing up and that was pointing down, it's the left side. So I always do this method and it has always been correct because by definition, I'm using the correct leads. So OK. Do you want to finish off by telling me the access for this patient? Um Right axis. Yeah. Right axis deviation. Good diagnosis. To finish your interpretation. You've done so well. Regular rhythm. 150 BPM, no P waves. Oh afib. So if it, if it were afib, oh it be irregularly irregular. Sorry. Yeah, exactly. That's fair. Um No, it's fine. It's fine. Um, so what do you know of any others, any other fast arrhythmias? Oh, SVT. Yeah. Uh, why did you say SVT instead of like VT? Um, purely because the QRS complexes are narrow? Yeah, nice one. And again, I'm gonna take a bit of a, um, quick digression here. Why, um, do SVT S have narrow QRS S and ventricular ones have broad ones? Um, the answer actually you might know, do you know, um is it just to do with like the anatomy of it? Because obviously SVT it suggests that it's above the level of the ventricles. So it's to do with the atria as opposed to dysfunction of the ventricles, it's close, it's close. I will quickly explain it. Um Essentially the, remember the QR S is what the part of the cardiac conduction the PRS complex is showing is ventricular depolarization, right? That's the part of it, it's showing you the P wave shows the atrial bit. So the reason an a supraventricular rhythm has a narrow cures is because it's narrow because it's quick, it's efficient. You're going here, you're going here down, the bundle appears very efficient. If you stop there, you're gonna have to traverse like a really odd path from that random point to the bottom of the heart. You don't get your lovely conduction system to help you, which is why the all go really broad because it's inefficient conduction. Um So it's slower ventricular depolarization. That's why but yes, you've done really well. This is SVT. Nice job. Um, definitely you would have passed that. Um, but just be careful with AF because, um, yeah, it's always irregular, by the way. Um, ok, I'm not going to go into it now. But yeah, there is another point here which is that you can actually see P waves that are retrograde P waves because of the way the SVT works. Um, we'll talk about it at the end if we have time. But yeah, this is essentially no P waves before the PSS regular rhythm. 150 is a very typical heart rate for SVT. So always ask people if they fast or slow. Um And when we say SVT, in this case, we actually mean AVNRT, AV node, reentrant, tachycardia probably don't have time to talk about it today, but just look up what avnrt is. It's um specific name for this. Um But yeah, um, how do we manage it? So someone else, thank you. You've done really well. I have someone else want to tell me the management of an SVT, forget the investigations. It's fine. Um I think you initially do some, um you can do some maneuvers. So you like do you can massage the across the sinus or you can get them to blow into like what was it blow into a straw? Um, or like bump their head in cold water? Yeah, nice job. Why do those work? Uh blocks the AV node. Yeah. So actually the reason SVT happens because some people have an AV node that can form a reentrant loop. Um like this and that loop is going up and down and it keeps going down at a rate of 150 just autonomously like throws down electrical impulses towards the base of the heart. Um So by giving the vagal maneuvers, you are blocking this Avio, it's a vagal tone, isn't it? So blocking it? Nice job. And then Joshua, what do you do if that doesn't work? Um, you probably give a, that also works in the node. Ok. Um, via kind of biochemical pathways, it will reduce the um, conduction speed at the AV node. Um What's like Josh, do you know that the main symptom people will describe if you give them IV adenosine? Oh, yeah, they might get chest pain. Yeah. And there's another one as well along with that chest pain psychologically what happens to them? Like impending fear of doom? Yeah, it's like a very, um, I think it's like a very disturbing feeling. Not, I've never experienced it myself, but that's what the classical teaching. You did. Great. Thank you so much. Um, let's do another um examination station. So 75 year old gentleman comes to the GP surgery for a follow up and we're not told following up what, um, right, someone else, please, um, please give me a cardiovascular exam starting with the hands and I'll throw you some findings I can leave this out. So like you might start looking at the nails. Yeah. OK. Um Let me think. What was my case with this? OK. Nothing on the nails. So then you move up to like the hands themselves do like a cap refill. Check their pulse. Excellent. Um move up their arms, check for collapsing pulse, feel the brachial pulse at the same time. Um And then um a neck. So J BP. Yeah. Hepatojugular reflux. OK. Um And then face. Mhm Yeah. All normal keep going. OK. Um And then, so uh look in the eyes, look for any like cholesterol deposits. Um Yeah, there are. Yeah. OK. Yeah. Um cholesterol deposit uh pallor um like conjunct type. OK? Um And then look in the mouth um see any like ulcers, angular colitis, um bursitis, anything like that um down the chest. So examine any scars. Um and then have a feel for that apex. Yeah. OK. Um And then have a listen. Yeah. So that sounds, yeah, that's fine. So you listen, OK. Um And then um you would also have a listen to the back. Good. OK. So yeah, you listen to the lungs, legs. OK? And then, and then you look at the legs. OK. Nice drop ped edema. Yeah. Yeah. Yeah. Very good. Very good. So let's say you didn't find anything, remember? Um But you did say scars, right? So this patient has some scars. These are all just images from Wikipedia. Um So what's the, what's the first one? Do you know there's a midline Steny? Yeah. Yeah. Let's say um let's say like ignore this one different patient. But what, what is that uh uh potentially a pacemaker scar? Very good. And then what's this? I'm struggling to tell. Is that a leg? Is it sorry? Is it from like a like a venous harvest? Yeah. So let's so this. Yeah, really good. So this is a different patient, but these two are the same. Um And you're very correct uh in saying that this is a median soot toy. Uh And this is a sinus brain harvest. So that's really good. What operation do you think this man had cabbage? Absolutely. Um So can I just say guys, scars are really important because it's very easy for medical schools to find patients with scars as it is a recognizable sign for medical students. And the patient is not acutely unwell. Um So, you know, just think about that. It's important. Um Nice job cabbage. Why do you think this gentleman had a cabbage? Probably ischemic heart disease because you had the cholesterol deposits. Yeah, probably um cholesterol would be a risk factor for the ischemic heart disease. Nice job. And remember when you're examining people with this kind of a scar, have a palpate over here to see if there's a pacemaker, you can feel them underneath the skin. Um sometimes and then this is your me and your pain. It's very good, nice job. Um This is a really good link by Gy medics on cardiothoracic incisions. Um So have a look at that and kind of understand the different types of thoracic scars. Very, very important. Yeah. So, all right, you've done great. I will, I will let you go. Now, someone else. Let's now, this is a vi now. So let's say this patient um is, is, is before being operated on. Um how would you, how would you classify chest pain? So, you know, you can do a Socrates and stuff, but, but how would you actually classify it when you're presenting a patient? Does anyone have any ideas? I'll tell you that he's not having acute coronary syndrome. But still, how would you classify chest pain? Any ideas are welcome. There's no real wrong answer to this because you could argue classification. Anyway, do you say like cardiac sounding chest pain if it was like crushing and like whether it's stable or unstable, if you're thinking like acs? Yeah. So there's actually a, that's absolutely right. And there's a more specific um system than saying it's cardiac or noncardiac. So anyone aware of what that is like um the classification of angina of, of chest pain, like whether it's angina or not, there's like three sort of criteria to meet an I think it's let me think. I know it's like maybe it's crushing, chest or chest pain. I know one of them is relieved to unrest and relieved by nitrates. Um I've forgotten. I know there's a classification you're doing really well. If one of them is relieved by rest and what do you think the other one is brought on by exertion? It makes sense. It's very cardiac, right? Because exertion is a very great way of increasing cardiac demand. So, if you are getting pain when you are doing that, it's quite worrying. And then the first one, I'll give you a hint is about location. Where should the chest pain be as like central chest pain? I think it's like central substernal, that sort of area. And then if you have all three, you call it typical. If it's two out of three, it's atypical and if it's 01, it's a non angina. So this is how you should present your, if you get a chest pain patient, you might do. So. This is a 75 year old gent been presenting with, sorry, how old is he? 75 year old g has been presenting with typical chest pain and they're like, ah, this person knows the three things that they need to look for in chest pain. It also helps your history because if you run out of questions, you can just be like, oh, is it brought on by a surgeon? Is it relieved by rest? And have you tried a nitrate spray brilliant investigations? I mean, you should do some basic investigations with ecg bloods, risk stratification, structural and functional investigations. What is a definitive structural investigation for coronary disease? Anybody? Yeah, angiogram. So the angiogram can be accompanied by an angioplasty but not always like a stent. Uh uh you know, um even angioplasty just means dilate like a dilation of the. Uh um so, but yeah, you can just do a diagnostic on it. Uh and the management. So you need to know this. So management of stable Angina, let's say you have stable Angina. Um then you know, um nitrates um beta blockers, calcium channel blockers and then other ones, Nando and all sorts of, of, of, of important stuff. But remember, lifestyle modification paces always go lifestyle conservative medical surgical. Should we stent people with stable Angina? Does anyone want to have kids? Yeah. Um Yes. One of the lecturers from did the Orbiter trial and not too good. Yeah. Did you do the cardio BSE? No, I just went to one of her tours back in the second year. So very good. So basically there was some evidence that PCI stenting doesn't help people with stable Angina. But then they did the Orbiter two trial which kind of got some evidence against the first trial. Um essentially um stable Angina should um you, you won't get penalized for saying either in the exam but cabbage or PC. You can just say that in your final year. Um This is just that because um we've gone through all of them, but one case and I'm just a reminder that please stick around at the end to fill out this feedback form. I won't make people do it now in between the lecture, but it would, it would be really great if you guys would just hang back for like two minutes and fill out the QR code comes back up at the end. OK. This is the last one you guys will be relieved to know. Oh, Did you, did you have a question? Um Would you just be able to repeat the medication that's used for it? Yeah, I mean, so you can use, you should use the nitrate nitrates for symptomatic relief stuff that helps, you know, symptoms in the long term would be beta blockers and calcium channel blockers. Long acting nitrates is another one. And then there's other ones, the one I mentioned was called Nicorandil which has, you know, I honestly can't remember exactly the mechanism. It's either calcium or phosphodiesterase or something, but these are just bonus marks and Survivor. If you say these three, it's fine. Ok. Um All right. So what was I going for with this one? Yes. OK. I remember. All right. So last opportunity um for a lovely um his uh mock history. Um Does anyone want to give it a good, it's chest pain. 50 year old gentleman presents at the ed with chest pain. You guys have actually been very, very, um, you've contributed really well, just one more. Anyone wanna have a go. No, I'll, I'll, I'll tell, I'll, I'll have a game. Ok, for it. Hello? Hi. Um, how are you doing? Yeah, not too bad. Thank you. I've just got this really bad chest pain. Ok. And can you tell me where that is? Yeah. It's like right in the middle of my chest. Ok. And when do you start, um, feeling that, that chest pain? Yeah. Um, I would say it just started about three hours ago and it's been getting worse. Ok. And how would you describe that pain? Like someone sitting on my chest, like someone sitting on your chest? Ok. And does that pain spread anywhere, um, to my jaw, to your jaw? Ok. Any sweating? Yes. Ok. And did that start on three hours ago when you first felt that pain? Yeah. Ok. Um, and any kind of shortness of breath? Um, I'm a bit breathless. Yeah, a bit breathless. Ok. And does it feel like your heart's beating very quickly? Um, not really? Ok. Fine. Um, and since three hours ago, how would you just, um, how has the pain changed? It's just becoming kind of unbearable now. I mean, initially I was kind of gonna sit, sit through it. Um, yeah, but, uh, it's just, you know, I can't do anything around the house, it's just really painful. Sure. Um, and does anything make it better? Um, well, I mean, it's certainly worse when I'm walking around. Ok. So that's making it worse. Yeah. Ok. And on a scale of 1 to 10, uh, where with one being not very painful and 10 being the most pain you've ever had. Uh, where do you put that pain right now? Nine. Great job. So, do you want to present that, uh, history to me? So, I'm the examiner and you've done a great history so live presentation. Um, I know in front of 15 other people. Let's, let's leave that then let's leave it later. That's fine. That's fine. I would just say keep it simple. A 50 year old gentleman. Um, 10 out of 10 central chest pain that's been getting worse, associated with mild breathlessness. That sounds like typical angina. All right. Um, it's fine. You did. Well, that's the only reason I asked. Um, ok, so someone else, what have you got for these, um, what have you, what do you gain from these observations? Does anyone have any ideas about what you gain from learning from reading this? What's the, what's the abnormality? Bradycardic? So, it suggests maybe a rightsided, oh, no, uh, blockage of the right coronary artery, potentially. Um, um, yeah, possibly so. That's good because the artery that supplies the anode comes from the right side. Um, I probably won't be able to tell you this. You won't be able to hear anything. But let's just say the examination is generally normal. Other than this. All right, somebody else. Um, what do you think this ECG shows you don't need to do the whole interpretation thing. Just tell me a, if you can see anything that suggests a diagnosis, a, a, anyone feel free to jumping. Actually, if you see anything abnormal on it just, uh, just yell it out. It's like a bit of ST elevation and bleed three and then depression and RL, yeah, nice job. That's brilliant. Um And can you see any other ST elevations? Mhm. So in LA three. Yeah. And then there's just, and then maybe like a little bit and aVF it's kind of hard to tell. Yeah, you're right, you're right. So 23 and aVF, do you know the distribution like where is the infarct in inferior? Yeah. And so that's the Joshua is kind of on the right lines with the right side of thing because in most people, the descending artery that supplies the inferior comes off the right coronary artery. Um Nice. So we'll just finish off by me going through the management and classification of acs. So you guys are all done. Thank you very much for contributing. Um I really feel that by doing that um exercise even though it might be a bit nerve wracking, it's the best preparation you can have for a Pacer style. Um But for this last part, I would just lecture on a little bit on a CS so acute Coronary syndrome. Um are unstable angina and stemmy and stemmy. That one has ST elevation and these two don't, the difference between these two is they have differences in troponin N seven have raised drops and unstable Angina has normal drops. Just remember that very important. This patient is having a stemi. So I personally am not a major fan of mona bash and I know it's really popular and it probably, it does cover the important ones, but, you know, there's a little bit of, it's a bit questionable, the morphine and the nitrates, especially when you're dealing with right side infarctions. And I just, I also think the order of it isn't particularly helpful because in the cases, they'll say, you know, what's the first thing you want to do or um you know, what is the most urgent thing? And I don't think it helps much with that. So I like to use different types of treatment. So the first thing is antiplatelets because aspirin is something um you know, most people are aware needs to be given in a so antiplatelets, aspirin plus another, another agent, usually clopidogrel or something like that and then anticoagulants. So a lot of people will get some sort of heparin. So antiplatelets and anti should make sense because it's just thinning the blood uh to prevent more infarction from the clot. And then you should also give them some anti ischemic. So that's gonna be your ace inhibitor, the beta blocker unless they're like in cardiogenic shock, then he wouldn't give the beta blocker to drop the BP. But in this guy as well, he's got a right sided uh you know, and he's kind of got um bradycardia. So you might want to be careful. But ace inhibitor beta blocker um and nitrates anti ischemic um reduces the, the, the strain on the heart and then statin. So I always use this classification when answering this question, like a, I'd like to do an at assessment and then um manage the medical side by giving some antiplatelets to prevent platelet clots, giving anticoagulants to prevent um thinning. Uh sorry to thin the blood um antiischemic such as ace inhibitors, beta blockers and um nitrates to reduce the uh kind of strain on the heart and then a statin for uh lipid management and then definitive management PC. They go in with a catheter angioplasty, usually with stent. That is how we do it. So, thank you very much. Um I hope you guys enjoyed that start of the year. So you guys have got ages and you're actually doing really well. Um So thank you so much for um contributing and making the session interactive. It's just so hard to run a Pacer station uh station session um in like a Didactic style. It's really hard to do. Thanks so much. Um And yeah, uh if you guys could fill out that feedback form, that would be incredible. Helps with portfolio stuff. Um and just generally a good record of teaching as an effort and then if anyone has any other questions, I'm happy to take them.