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Um based on your previous feedback from who attended webinars as well as the other um what questions and whatsapp comments we've had. Um we thought we trial this out. So this is something completely new. Um It's what we call an interactive live question session where we'll go through some practice sessions and we'll be joined again by the fantastic Dan um to just as sort of pulling. So it's sort of to mix up your revision if you're getting bored, sitting in front of the screen doing questions by yourself though. I quite like that you've all started creating revision groups and um if you have any questions um or regarding the answers to the questions we're going through, you can then raise your hand and we can ask about it. And as I said, this is something completely new. So it's also we're learning from you as well. So, feedback is very important and we will really appreciate at the end. But for without further ado, please, can I hand over to the fantastic Dan. OK. Everybody. Super many thanks for coming here. I really love to present and I love the fact that you're here and thank you for um giving us the audience to do it and for trusting us to um help you a bit. It's, it's a great pleasure for both of us and we really enjoy doing that. Um So I think we can start what we'll do today is we'll um try a new format and we see how you feel about it. And hence, we also really ask you to fill out the feedback format and tell us exactly what do you think that could be better if you like it? If you don't like it? And um most importantly, if you don't like it, then why? Um so we can actually improve upon it. That's something that we would highly appreciate. Um So without further ado, let's just jump into it. What we will do today is we'll go through questions together and we'll see how to answer them. So we'll take not only the topic themselves and the high yield points from them, but we'll also do the test taking skills um while we go through the questions. So let me go and start presenting. Um You might be a chance that I would need you to do the poll because for some reason on the live version, I don't manage to press the buttons. So that's fine. Don't worry. Just let me know. OK, can you see that? Can you see the presentation? Yes. Can someone else comment to make sure we can also see it as Well, I am not having any issues seeing the presentation that right? Ok, fantastic. Um ok, so many approvals. Yes, thank you everyone. Ok. Um So my topic today would be congestive heart failure, C HF um associated with the other pathologies, the high yield points, the medication side effects and so on. Um let's go to the next slide. Ok. So I'm gonna give a minute for everybody to read the question and afterwards we can answer it together. Um You can do the first poll starting polling. OK. We have already one in there. Mhm. OK. We have two more uh eight. Nice. We're just gonna wait another 10 seconds. OK. Fantastic. So let's take a question before we answer it and break it into pieces. So how would be, what would be the optimal way to answer it? Um So in the M sra generally speaking, the questions stems are not that long, they're relatively short. Um But sometimes you do have long questions and it's important to know that this exam or generally speaking, every exam that you're going to take in your life. It's not only about knowing the knowledge and be able to apply, but it's also really about knowing how to go through the exam and answer the questions in an efficient manner. Um So that would be test taking skills. That's the concept that we're going to use in order to depict what we're going to do. Now, when we have such a very long, but it's also not very short. And the best way to do it would be to actually start from the last sentence. If I would have a very short question with a short questions, I wouldn't read the last sentence first. I would read all of it because there's no point in reading the last sentence first because it's only three sentences. But in this case, if you read the last sentence first of all, then you're going to have something that can orient the rest of your um reading. And by this, you can minimize the time that you're going to have. In order to read the question. When I've done the exam at the end of it, I had something like 13 minutes left in order to go back to all of the other questions that I wasn't sure of and I flagged them and then I could actually recheck them and redo them and invest more time in that. And that's because of test taking skills being optimized. Um So let's read the last sentence. What is the initial treatment plan for this patient? So we already know that they want us to um answer the treatment, they don't want us to answer. What's the disease? What's the pathology? What's the best next step they want us to focus on the treatment? Probably it's pharma or some procedure that you need to do. Now, in this specific question, direct, what jumps into our eyes directly. It's gonna be the 45% because it comes just before the last sentence and the test maker, they do it on purpose because there's an a to writing the question and this is part of the a they're gonna give you telltale signs that gonna orient you on how to answer it fast though. That's something that they want to see that you can do. Now, generally speaking medicine when you see something which is 45% you already know that it's gonna be one of two questions. It's either gonna be ejection fraction because that comes in percentage or whether it's gonna be pulmonary lung test. It's not gonna be anything else. There's hardly anything else that is being tested in the M SA with percentage. And therefore, we already know that it's one of those, we look quickly at the drugs and we know that we're speaking about medications and then we can go to the beginning and then read the rest of the answer and we have an 81 year old woman. Um So when I read that part, it basically spells for me in my brain. This transmit into an elderly lady, right? So we take the information that they give us and we transform it into what we can use in the exam itself. So we have an elderly lady, very elderly, comes to the cardiology clinic. All the rest of the sentence is not really relevant. So we're just gonna skim scan it. We're not really gonna read through it. And then again, she has a history we don't really need to read through that. Don't go deep into that part of the question. We know that she has ischemic heart disease three years already. So it's a chronic situation. Right. Then she denies chest pain. So we already ruled out angina, unstable, stable acs, she reports shortness of breath. So we already know that it's probably something with the lungs, all the ejection fraction, which is too low. But in this case, it's 45 upon examination, we see that she has good vital signs. So she's not, we know that it's chronic and it's not acute and she has mild ping edema. It doesn't matter until where it goes. It's written until the need bilaterally. But it's something that when you read the question, you can really ignore it in your mind when you go to the answer itself because it doesn't matter how much edema she has. We already know she has edema and that's what we need. So you can discuss the rest of the question, the rest of the information. OK. Now, the s here would be Bez and Ramipril. Um And why is that? Because when we're talking about congestive heart failure, we need to have, we need to have a concept in our mind that once you have this concept, you're going to answer all of the congestive heart failure questions correctly without a doubt and every single time get it correctly. There's no chance that you would fail any question with congestive heart failure. If you have this concept in your mind, the concept is the fantastic fall. And the sidekick, the fantastic fall would be the drugs that you give for congestive heart failure. The psychic is diuretic. So the fantastic fall, just remember it all the time in your brain. Fantastic fall also in the clinical scenario, this is something that you will see day in day out, it will be in your walls, in the A&E in the ICU. Those would be your or a inhibitors. We have three different classes. We have the ace inhibitors that in the UK, it's the first line, mostly Ramipril which to the best of my knowledge was also backed up by all the studies that it's the most efficient one. You have the Entresto, which is uh Sacubitril and Valsartan in the UK. I don't believe it's the first line, but in the US and in Germany, it would be the first line if you wish it is a cardiologist and you have the Saltans, right? The angiotensin receptor blockers. Now, Saltans are not the first line because if I'm not mistaken scientifically again, um according to studies, they were not proven to be as efficient as Ramipril. Ramipril has however, more side effects than the Saltan. So a lot of them, we have people with Ramipril, they have really chronic dry cough, right. It's one of the side effects of the pril. Um and we would switch them to saltans. The other are beta blockers. So we have bisoprolol and metoprolol that we usually use. Bisoprolol would be the oral pathway metoprolol. You can give orally and IV, bisoprolol is much more powerful than metoprolol also has a much longer half life. Um but we wouldn't be able to give it IV. Um So if you have a patient in the exam and that can happen and the patient is vomiting constantly, you cannot give Ozr right. You have to give her IV metoprolol. And that's something that actually happened to me a few days ago. Um I had a patient with thyroid stone that vomited constantly and therefore she had a type two mi because her heart is beating so fast. Um And then the coronary arteries, there's no issue with them, but the heart is just pumping so fast, it needs more oxygen. So the oxygen demands well, not met. And then we gave her, what do we do? We give her ACS treatment or we give her just beta blockers. Now we give her beta blockers, we gave her IV metoprolol. And in second, she stopped having the type two mi and you could see the changes in the ECG as well. Then we have the SGLT two inhibitor, the DAG Gliflozin, empagliflozin and so on. And then we have our corticoid receptor antagonist. So spironolactone and Lerone, usually the first line would be spironolactone again because it was again and again, by studies backed up to be with the most beneficient. Um And end of the sidekick, the sidekicks are loop diuretics. We have our um Bumetanide f Furosemide or Azam. Um And we don't use them according to the guidelines in order to treat the heart failure, we do, we use them for symptomatic control going to our next slide. Um what are the important points to, to keep in mind? And this is something that it's not only for the M sra I also checked the nice guidelines, the C KS when I've done the presentation um in the UK and especially in this exam, when you have the fantastic flow, you break it down into 33 different, three different peels. The first theory is the beta blockers and ace inhibitors. You always pick those when you have a patient with cardia with congestive heart failure. So in this question, we really wanted to click furosemide, we really wanted to click something with loop diuretic because in real life, if somebody comes through the A&E and he's, he has dyspnea and he desaturate and he doesn't breathe well, usually we would give him first of all furosemide and then when he stabilizes, then we would give him everything else in the exam. What you need to do is to click Ramipril and bisoprolol don't be tempted to click the furosemide unless if the patient is acutely decompensated and desaturate and you can also see it on his BP. Then they would want you to do something else. But generally speaking, rule of the thumb, it would always be the beta blockers and ace inhibitors afterwards would only come the allo antagonist, which would be the spironolactone and the SGL two inhibitors. Don't forget that with spironolactone and clarinol, you always need to watch the potassium and it will be in the exam again and again and again, they would want to test that if you have a patient with it, they would give you a patient, they would prepare the question for you to click on spironolactone and then they would give you you a host of flat values and one of them, those would be potassium and the potassium would be very high and then you wouldn't be able to click spironolactone. And that's because the potassium is very high and spironolactone is going to increase the potassium and it gives us the chance for arrhythmias. And we don't want to have that afterwards. We have all of our other drugs um that are the third line. This would also come in the exam but less common. What will come in the exam as a third line, which is very common is digoxin. Digoxin would come in a case where you have a congestive heart failure patient. Um and she is decompensated and she's having issues and she is already on bisoprolol and she is having as well atrial fibrillation and then they would want you to click digoxin. So patient with congestive heart failure already takes bisoprolol and is in af then you need to click digoxin in real life. Like we said, almost always, we also give diuretics. But for the example purposes, you need to remember the first line, the second line and the third line. So fantastic for and the side, let's have a seat. OK. Higher points regarding those drugs, um SGL T two inhibitors and this again will come in the exam in and out all the time. Very common common side effects a uti S uti uti uti. Why does it cause UTI S because the mechanism of action of SGL T two inhibitor is that it blocks the reabsorption of glucose in the glomerulus. And then you basically pee urinate glucose as well with the water. Um And it also causes uh it prevents remodeling of the myocytes via DNA mechanism, but we don't get into that right now. Um And my professor for cardiology in Germany, he used to say that if you want to know if the patient is actually compliant with the SGLT two inhibitor, you just need to taste the urine and you'll see that it has a flavor of Coca Cola the second side effect, which is not that common, but it is there is diabetes ketoacidosis, even though the patient will have more often than not type two diabetes. So those two side effects, right? UTI and DK A beta blocker, we need to know that bisoprolol is only orally. Metoprolol is orally an IV. And in the M SRA and that's a question that would come a lot. Um, is that you won't these bisoprolol or beta blockers to people with uncontrolled asthma in, in real life you do because the benefit a lot outweighed the side effects. But for the exam purposes, you would just check um you would, you wouldn't give them ber you wouldn't give beta blockers to people with asthma because it's contraindicated ace inhibitors, something that would come in the exam a lot and comes in all of the question bank when to check what to check for the pretreatment. So before you give the ace inhibitors, what do you need to check three parameters? And you don't need to memorize them, you just need to understand what stands behind this statement. This would be BP, electrolytes and G FL. So BP and electrolytes and so BP, electrolytes and G fl together with creatinine. So that would be just BP and U NE and you don't need to memorize it again. It's just making sense because ace inhibitors are gonna reduce your BP. So you want to check the BP before and after and they're going to influence your electrolytes, right? So, ace inhibitors are gonna slightly increase your potassium. They're not gonna really play with uh sodium, it doesn't happen in real life, even though theoretically speaking, they do influence it and they're going to decrease the G fr. And by that also increase the creatinine. So, decreased creatinine clearance, increased creatinine itself. The way they do it is that they basically vasodilate the efferent of the in the glomerulus and hence, they increase, they reduce the filtration that happens there. So you don't need to memorize it as long as you understand what stands behind it. Now, when to check it and want to recheck it, it's something that you do need to memorize and they will ask it. And it's very simple. You check it before you start the treatment, you check it 1 to 2 weeks afterwards and then you check it three months afterwards and then you check it six months afterwards. So two weeks, three months and then six months. Now another question that comes but not so often is with ace inhibitors, you're going to have endeavor and increase in the creatinine. And then when do you actually stop giving Ace inhibitors because it's too high? And in the exam, it's always gonna be the 30% number. And this is from the nice guidelines. So up to 30% you don't need to do anything, it's tolerable. And when it comes to above 30% you would need to do something practically speaking. According to nice guidelines, 30 to 50% it's a gray zone. So you can reduce the dose but you can so keep it as it is or you can even stop it. But for the exam in the exam, you would always have the 30% number. You would need to calculate it more or less yourself. And then the answers would be idle to do nothing or idle to do something. They wouldn't tell you, they wouldn't ask you to know what you need to do, but they would just want you to click. I don't need to do anything because the rice is not that potent. OK. We can go to the next slide. Um Until now, do we have any question? Wait, let's go backwards. So we don't see the question until now. Is there any question? Any point? Any remarks? OK. Seems that we can go on. OK. Um You can you pull the second question for me the second pull. Thank you very much. OK, let's give it a minute. Let's answer in the fall and then we can continue. OK. Fantastic. Let's continue. Um So let's read the question. It's a very short question. So I'm gonna read all of it again. We have an elderly lady, they already give us the diagnosis that she has heart failure. We know that she has reduced ejection fraction. They don't tell us how much. So we know that it's not so important and then they give us her BP, BP is really good. Why did they give us here, the BP, we'll come back to it in a second. Um She's currently on Lisinopril. So that's gonna be our Ace inhibitor and also the maximum dose, what agent would you give her? So we see that it's a very simple question. We know that we have a fantastic fall and the sidekick, we know that from the fantastic fall. She is only getting the ace inhibitors. We know that in the UK the fantastic fall being broken into different deals and we know that the false line was gonna be our beta blockers and ace inhibitor. So the answer is gonna be Bisoprolol. We don't have anything else that we can think about. We know that we need to follow the guidelines, we know what's gonna be there. We know that we have a fantastic fall going with this formula, we cannot get it wrong. Um Let's continue. I see that I have a question. Can patient without diabetes? Have your glycemic acidosis? Um Right. Very rarely. I II never clinically encountered a patient that never had um diabetes got SGL 22 inhibitors and then got DK A II never saw it. I don't think it's II don't know the studies about it. To be honest, I don't know what's the incident ratio but clinically speaking, I've never saw this. Ok, going to the next question. Um let's give it a minute, let's see the pool. Yeah. Can we pull in the third pool please Ok. So we have four responses. How people, well, 40 people, I would love to see more answers on the poll. Don't be afraid to get it wrong. It's anonymous. So nobody sees the answer. I just see the percentages. I don't know who clicked. What? Don't forget that you study more from your mistakes than what you get correctly. Ok. Fantastic. Let's continue. So, um, so here we have again another question with congestive heart failure as the source of the question, it's relatively short. Um Nevertheless, I'm gonna read the last sentence just because this is my perfer, um, which combination of medications would provide the greatest mortality benefit for him. So we need to focus on the question here and that would be greatest mortality benefit. That's what they wanna know. Um Reading the entire question, a 65 year old overweight man present with worse and shortness of breath and leg swelling due to advanced heart failure, his kidneys function is normal and his potassium is also normal. Right? Again, they gave us this because we need to know that if we do click spironolactone, it's fine. That's why they gave us this here. Um Then we have all of the questions, all of the answers, but I don't need to waste any time on the answers. I can only scan them and then I would already know the answer because again, they gave us a patient. He has a CHF and then they ask us which one will give us the greatest mortality benefit. So we know that we have the fantastic fall and we're just gonna go through this algorithm again. I know that already. Now, in the third question for you guys, it feels a bit dry because we already done it in the last two questions. But what I want to exhibit you, what I want us to, to take the silver lining would be that if you stick with a fantastic phone or a psychic, this specific topic, you will never ever, ever get it incorrect. You will always get that question. You would always get it correct. You would always get your points and you would always be able to answer it fluently and flawlessly correctly. And the answer is gonna be again, Ramipril and Bisoprolol going through the other answers just in order to take them out of the equation. Furosemide doesn't give us any mortality benefit. It was proven in many studies again and again in the US and in Europe, that doesn't matter if you give furosemide, it's not gonna increase the longevity, the lifespan of the patient. If he has congestive heart failure, those are gonna be Ramipril and bisoprolol. Now, um Thiazide on the same class as Furosemide Hill Atenolol is not a beta blocker that we would usually give in congestive heart failure. You would see patients in clinical scenarios that has also um gi issues due to liver cirrhosis with um viruses, sorry with esophageal viruses and then you would be able to click atenolol. But otherwise you need to pick bisoprolol furosemide. And b again, it means already that we cannot click. It. Aide is not related to congestive heart failure. We use it in order to reduce intracranial pressure usually. Um and E is the same, we have a Meite L so we could answer the question correctly. Um Yes, hello. Any chance you could repeat. Fantastic four thing. Sure. So fantastic. Four and the sidekick are ace inhibitors Bisoprolol. So beta blockers, Lanoc Corticoid receptor inhibitors, that would be a spironolactone or um Eplerenone. And you're going to have your SGL T two inhibitors. So those would be agli flazine and um empagliflozin by the way, another thing that I going back in the slides, something that I forgot to tell you about. Um a really good way to remember the dosages is that beta blocker bisoprolol, maximum dose 10 mg per day, ramipril biggest dose that you can give 10 mg a day dozine, aglycin. What you always give is 10 mg, always for congestive heart failure. So you just need to remember the number 10. If you have a patient that gets his SGLT two inhibitor, four diabetes mellitus, it could be 15 at times, but usually we do use 10 OK? Going forward right? This is what we have done just right now. The high yield point. Focus on the question they asked. So if we go backwards. We see that we have greatest mortality benefit if it would be written and it can be written in the exam. What do you give in order to relieve his dyspnea? What do you give in order to relieve his edema? What do you give in order to relieve his shortness of breath? Then you would click your fosamine, your bumetanide, your thiazide, but not in the case that they ask you where it is mortality benefit and not in the case where they ask you, what's the initial step that you need to do? Ok. Um Ace inhibitors come before the Albs. So Ramipril comes before the Saltans, Candesartan vasal diuretics that provide symptomatic relief, but they don't provide improved mortality. Again, this was back again and again and again in all of the studies, which is contra intuitive, right? Because you think that if a patient come to the A and A because of this FNA, then you should give him foz in order to improve his mortality and then he wouldn't die. But studies proved otherwise. Ace inhibitors and beta blockers are the one that gives us mortality benefit. It's almost like a click bite when you see mortality benefit and you see congestive heart failure, you can already click the answer without reading all of it afterwards, you would read it just in order to see that you didn't miss anything. So the way that I would do it in the exam is that I would flag it, I would click it without reading the entire question. I would flag it. And then when I would finish the exam, I would come back to it and then I would read all of it. Um I never had a mock exam in which I had less than 15 or 13 minutes in the real exam left to go back to my flag because to my flex questions. And that's because if you do use the method that I'm showing here, you are able to minimize the time loss. And by that, you will always finish the exam with extra time and you will be able to go backwards. And in this scenario, you basically, what do you do? You provide a scenario in which you are able to answer what you know, in seconds and what you cannot answer, you go forward and then you go backwards and some questions you would never be able to answer and therefore you don't waste so much time on that. Um And you don't use the questions that you could answer down along the line if that makes sense. OK? I see somebody asked a question and somebody else already answered it. Yes. Thank you very much, much appreciated. Let's go to our next question. Um And I think we can pull the third pole here. Let's see. Oh, no, we already did the third one. OK. So let's give it a minute here and you can read a question and see what you want to answer though. And then do you want me to start a poll for the fourth question? Um Yeah. Yeah, thanks. Yeah, that would be fantastic. Ok. Well, either 44 responses, all of them, correct. Either I have chosen very simple questions or either I, we, we got to the topic correctly. Ok. Fantastic. Let's continue. So, what did I want to do with this question? I didn't want to actually teach you any topic here. I wanted to go with you through the test taking skills. Why do I say that? Knowing what we already know, reading the last sentence because this is a midsize question. So why don't we do with questions about midsize or long size? We go through the last sentence. First of all, considering the probable diagnosis, which of the following medications has been proven to enhance long term survival. We know that in the M sra if you have this question, you know that it's congestive heart failure, there's nothing else except for some chemotherapy questions that would ask you about this. So we already know that Obama asked us about congestive heart failure. We don't even need to read the question itself. And I'm already gonna go and click Ramipril without reading the question. This is a classical scenario in my life where I would click flag continue. This would take me literally less than 10 seconds and then I would come back to it at the end just to make sure that I didn't get it incorrectly or that there was something there that I didn't do. Uh that I didn't pick up. For example, if it's written that she has Ramipril allergy, but generally speaking, I would click, I wouldn't read a question. I would click. Flag, continue, come back to it at the end because sometimes they would give us the Ramipril. But again, if you use this equation of how you're going to answer the questions, you're gonna always have some spare time. And with that spare time, you can make sure that you didn't miss anything. It's also a game of statistics. So yeah, it could be that with this method, you would miss one question that being said for all of the rest of the question, you would have much more time to answer. And I mean, those ones that you do need to invest time it and thought and thinking, OK. Um Reading through the question um not diving really deep into it. You see that we have a patient with a classical scenario of congestive heart failure. Again, they ask us about which one improve long term survival and that's gonna be about Ramipril and beta blockers. So ace inhibitors or, and beta blockers, we don't see it any beta blockers. So we're going to pick up our Ramipril. Um Somebody asked me about spironolactone. Um If it reduced mortality, to be honest with you, I don't have it on top of my head from the top of my head. But I do remember reading a study that spironolactone does decrease mortality um and has benefit but don't, don't take it with a grain of salt because I'm not 100% sure about this. Um OK. Going to the next second. OK. So again, somebody asked something and somebody answered, I love it. Thank you very much for being interactive. It's awesome. Um Now talking about this is not a question, it's just something that is very well. It's very good to know talking about heart failure, diagnostic criteria, which is something that we don't really use in clinical life. Um It's very good for the exam to know it because once you know those criteria, the major and the minor, when it appears in the question, you kind of, you can deduct, you can speculate kind of directly what's gonna be the pathology. Um So let's just give a second to go over the slide. If somebody has any questions, you can let me know and, and, and don't be shy in asking anything. So even though I'm already like, I'm, I'm, I'm already in medicine for three years when I saw the hepatojugular reflux, for example, I did need to go to Google and to check for how many centimeters, how long, what does it mean exactly. So if you have any questions, don't be sure about asking them, that's the reason why we're here to answer your questions and to make it easier for you to study, right? That that's the point of it. OK. So I think we can go on to the next slide. Now, this is an x-ray that will just depict us what we see in congestive heart failure in a very beautiful way. If we go to the next slide, we can see it here. So what do we see in the X ray? We have our cardiomegaly. So the heart is bigger, right? It's more than half of the side of the thoracic outlet, the cavity, we have our blunted diaphragm angles because there's fluids in the pleural fists. We have a A and B lines, we have our bilateral haziness. So the blood vessels are hazy. We don't really see the outlines and we see the bat wing distribution, the cephalisation. So the blood vessels are going towards the head, cephalisation, cephalus. Um And that would be a very classical pictures of congestive heart failure. It's just a picture that I really like. So I wanted to put it here. OK. And that was it from my side. Um If you have any questions, you can let us know. Um Was there any Yeah. Um Someone's posted the question. Actually, we've got quite a few. I'm just gonna quickly say Sarah, we won't be discussing S JT S Day today. It's only be clinical, but based on your feedback and if you think it might be useful we can try a similar format for the S JT section and then Dan, I think there's two more clinic. Ok. The first one is, does the M SS ra exam include imaging to supplement the questions? From my understanding, it's a possibility, but in reality, I don't think it happens very much. Exactly. I understand. Yeah, it's correct. They will describe it in vocabulary. So it would be in the text but they wouldn't necessarily give you a picture. They do give lab values. They give um pulmonary function test, they give you numbers. Um, they give you the findings in words, they won't necessarily give you pictures. Um I do think I had two ECG S, I'm not 100% sure anymore. Um But generally speaking, no. Oh, theoretically speaking, yes, it's possible. But I didn't experience it. Ok. And the next question is, does congestive heart failure automatically mean both sides of the heart are affected? Ok. Uh The answer to that is no, um, a lot of time it does happen because it's more common to have left-sided heart failure. And then we get pulmonary congestion and afterwards it goes into the right side and then we have right-sided heart failure and then we get all of our uh, well, you know, all of the hepatojugular reflux, the hepatomegaly, we get all of our edema, but generally speaking, no, the most common would be left-sided heart failure. And that could be because of um, valve pathology. So the heart cannot pump valve, a pump blood against the valve. It could be because of the arteries. We have increased BP. And again, the, the heart needs to pump a lot of blood against the BP and it doesn't manage. And that's how you get your concentric hypertrophy of the myocytes. You can have an enlarged heart in which um you don't have a concentric hypertrophy. But the the, the myocytes lining of the heart, the muscle l is becoming very thin and large and then you have increased feeling of the heart, but it cannot pump it forward and that would be your left side. But you can also have just right sided heart failure. So, for example, in the case of um CO PD, you have carpal monae and what does carpal monae means it just means that because you have any lung pathology that influence the oxygen exchange in the lungs and the alveoli. Therefore, you get um as a basic pathological physiological reaction of the human body, um constriction of the um blood vessels of the lungs. And then the right side need to pump a lot of blood against that and it doesn't manage. And therefore you have backlog backflow of blood from the right side. And that would be an isolated right side, heart failure. You can have left side, right side and biventricular, which is both of them and the left side usually start isolated and then it goes to the right side if that makes sense. Ok, let's go to the next one. Would we be able to see the earlier part on? Fantastic for uh shock? Let me go back down. Uh I knew that it would be a catchy thing. Actually, it's uh something that I picked up when I was in Berlin. Um There was a cardiology um convention there and someone in the hospital, he said he talked about the fantastic and he was raving about it. He was crazy about the fantastic film. He loved so much the, the film. Um If a patient has hypokalemia, is there an alternative to spironolactone or should it just be omitted and just a CBB and SGL T prescribed? Well, generally speaking, this is a very good clinical question. Um It wouldn't come in the exam, it wouldn't come in the M SRA in this case, um you can use a Lerone which is less potent um in my clinical experience than spironolactone. Um But you don't have another drug that can replace it. No, um you will just drop it and you will keep the other three. Ok. Um When M SRA questions, ask for most appropriate investigation or management, should we choose the initial investigation or the definitive gold standard? Right? So this is something that the M SRA loves to do and it's really annoying um because they do ask you those questions and there is no correct answer to give beforehand. It's very scenario dependent. So a question that is depicting that situation was, um, I had a patient with, um, in the exam with pulmonary embolism and they asked us what's the most appropriate or what's the initial investigation that you would do? And they gave me something like seven options and all of them will correct. But what I needed to click was most likely because I don't really know if what I clicked is correct. I just know my final score. What I clicked was BP because if I have a patient with pulmonary embolism, then I want to know if it's decompensated and we need to declot it now, right? If I need to give him anti, um if I need to give him um any drugs that would declotting right now. So even though I had the ECG um C TPA and saturation and so on, what I clicked was BP because that would mean for me clinically the most, what is happening there. So there was no saturation in that question. It was only BP because I think if you would have BP and saturation, it would be too difficult to answer between those two. Um So that's a very good question. It does come a lot in the exam. You don't need to click the definitive gold standard test. You need to click what is the most correct one for that scenario? So for example, if they give you a patient with pulmonary embolism and is decompensating clinically. You want something that will tell you now what would be the best initial management so that the treatment rather than what is the golden standard to actually tell him if he has it or not? Because you also have your clinical estimation of what is happening there. And next one, a low BP and a low saturating pe patient, would you encourage to go for a C TPA over D dimer? Right? For the M sra purposes, they would actually just want us to follow the algorithm and the algorithm, you can find it in the nice guidelines or you can find it in all of your question banks. And um this is a scenario that would come in your exam. It also came in my exam. You need to memorize the algorithm of what to do when you have a patient with a suspicion of pe and then you just need to follow the algorithm. They would actually ask you to um calculate even in some questions. Um how many points he has according to, you know, the well criteria, whatever you use. Um And they would ask you, they will tell you use this criteria, use that criteria. And then they would ask you, what is the best case? Uh what is the, the best uh next stage that you need to do? What's the next step that you need to um endeavor upon? So if you have the patient in the exam, um you need to follow the algorithm and then following the algorithm, you need to click the answer. It's very annoying because clinically speaking, it's not necessarily what you would do. Um And memorizing those algorithms also feel a bit like a waste of time because in real life you just have it on your phone. So you don't really need to memorize in, in that manner. But in the exam, you do need to memorize the algorithm, what I propose you to do. And it's something which is very helpful is to just get a piece of paper or a few 100s of them. And when you have an algorithm that is very high yield and that would be, for example, high yield, it would come in your exam um most likely. Um And if you don't know it by heart, you would need to know it, then start just writing the algorithm on the paper and write it again and again and again and make it a habit. So every time, every day that you sit for an exam have a list on the computer of what you need to memorize without faulting and then just memorize it. Um And memorize, I think it wouldn't necessarily be in your brain, it would be able to write it on the paper. Don't forget that they, in the real exam, you also actually get a white board and a pen to write on it. So when I got such question, I would actually, I would, I would do the algorithm on the paper really quickly and then I would get the results that I want and then you click the answer following the algorithm. Um And in the M sra sometimes there are scenarios that are exceptional. Well, you don't need to follow the algorithm. But again, doing um either in the next presentation that we do, we can talk about it or wider than your question bank, those scenarios would be explained. So they will tell you in which cases you don't follow the algorithm because the patient is deteriorating too quickly and you need to do something else. Um So it's something that is very difficult to answer when um it's a relatively fake scenario. So we need to have a scenario on the screen. Um But you would be able to answer that. Uh If you memorize the the algorithm in the exam. Yeah, I'm following from then I think who I would recommend is the chad Vas score of when to start anyone on the curb 65 the wells score. I think it's probably my second priority as well. Um Yes. So um thank you. Um A man, you're quite right. The smear test algorithm is another high yield one. We'll bear that in mind and we can look into doing one a flashcard for that. Um Oh Dan, what? That's a really, really good question. Spoke about reading long questions generally. Do you find questions often contain distractors, irrelevant info to throw you off tangent. Um Damaso specifically has more kind of rather have it rather has some points that are buried in the question stem um that you need to pick up then distract us. So for example, you would have a very, very long question about the patient. The answer would be very plea particularly penicillin, but then it was it would be written in one world or two worlds somewhere in the middle of the question that they had some reaction to penicillin in their childhood. And if you didn't pick that up, you would, um, get the questions incorrectly. Yes, you did. We read her distractors but not so often. Um It's more about some crucial information. They try to bury very deeply in the question. Um That would be the, um, sometimes you do have distractors but less often than those, those points that would be buried in the middle of the question. Um And again, if they don't usually come, but when they do come, if you use the, the method with the test, taking skills, you would be able to go back to the question and read through it. It's important to understand that you, you have less than one minute per question. So there's no chance that unless if you're an extremely fast reader and I'm a fast reader and I'm not that fast. Um, unless if you're an extremely fast reader, you cannot read all of the question properly and still finish the exam in time. So it's better to read them relatively. So better to use those test, taking skills that we talked about today. Again, that's my specific recommendation. And usually I see that it functioned, I never saw that it didn't function, but it might be that it wouldn't be for you specifically. Um If you use that method, you create a scenario where you have time in the end to go back to those questions that you didn't really read through and then to go through them at the end. And again, I just wanna say a very warm thank you to dad. Absolutely fantastic. Um Yeah. Any other feedback comment or else II think we should probably finish here.