Computer generated transcript

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

And it is very likely that some element of the cardiology history or the cardiology examination will come up in your s. So it's an important one just to, to nail down and for it to become second nature. So we're going to start off with a simple case. We have that you are a foundation, you one doctor in the emergency department. We've Mr Bruce Wayne, uh no similarity to Superman here and he's 64 year old and he's come in with chest pain. What you want to do is take a focus history and initiate a management plan including pertinent investigations. So this is very classic of an osce particularly in the Cardiff f whereby you'll get the spinet of maybe four or five sentences. And you'll have a minute to think of how am I going to structure this history going forward? Chest pain is a classic one. I've only done the classic histories here. The ones that are most likely to come up chest pain, you need to be thinking in the back of your mind, what are your differentials and what is your structure for taking this history? So with regards to your differentials for chest pain, you're going to be thinking the likes of acute coronary syndrome. Number one, and you need to make that clear to the examiner from the start that this is something that's, that's on the back of your mind. So, a simple vignette here would be a 54 year old man presents with severe crushing, chest pain at rest, the pain radiates to the jaw and arm and he has a past medical history of type two diabetes and high cholesterol. So your risk factors are in there as well. And he's also a heavy smoker. This would be very classic SBA. But what you'll find is that your S pa vignette will be very similar to your os vignette in that they really want you to become experts at passion recognition in terms of the most likely situation, given the few sentences that you're provided with. So the second one would be a 24 year old woman presents with pleuritic left sided chest pain. She's not able to take a full breath. She's currently on the combined oral contraceptive pill and has recently traveled again your risk factors and she also has palpitations. So here with regards to chest pain, you'd be thinking more along the lines of a pulmonary embolism. And then a 54 year man presents with very severe sudden onset is a tearing chest pain. Once you hear the word tearing chest pain, you want to be thinking the likes of aortic dissection, the pain radiates to a scapula again, very classic. And he has a significant history of hypertension and smoking. Then moving on, a 65 year old woman presents with pleuritic chest pain that improves when she sits up. It is that that change in the nature of the chest pain, altering the position that makes it quite likely to be acute pericarditis. Here. The pain is sharp and it does not last long and she's recently had an upper respiratory tract infection and still has a fever. So when you're thinking fever as well with chest pain, it's quite likely to be an acute pericarditis. And there, there are ecg changes, we can go through the ECG changes of acute pericarditis in, in another station as well. But you'd classically have pr depression and widespread ST elevation. And then a six year old woman presents with chest pain that develops when she walks up the stairs. The pain resolves when she takes her GTN spray and five minutes after she rests, her BMI is 32 at this stage. It's the fact that it's, it is the chest pain on exertion and the relief with GTN spray or arrest that you'd be thinking you're stable angina. And then finally, a 26 year old man presents a pleuritic chest pain in the middle of his hockey game. There's no history of trauma and, and oh, he has no venous embolism, risk factors and no significant medical history So it's this young patient with sudden onset pleuritic chest pain. It is often in the middle of a hockey game or in the middle of a football game as well as what they'll say. You're going to be considering your primary spontaneous pneumothorax, especially considering this patient has no underlying risk factors. So that's just a general overview of what you'd want to be thinking in the back of your mind when you're seeing the words chest pain in your cardiology history. So to go through it, these are your more focused questions. So start off, you'd want to introduce yourself, ask their full name, date of birth, their age. I wouldn't necessarily say what the their occupation is or symptom screening at the very beginning. But it's definitely something you'd want to integrate throughout your history as well. Again, to consider your underlying risk factors with regards to your history of presenting complaint for your chest pain, you'd want to go through your simple Socrates as you would for any element of pain. And then you can even say things like, oh, just show me where you feel the pain just to make it a bit more natural for them to. You usually suffer from chest pain or is this new? It's very important to get the timing of the onset of this pain. And, and if you think it is something to do with more angina pain or a CS, you'd want to ask, are you taking GTN spray is the pain relieved by this and again, is the pain relieved by rest. And how long does it take for the pain to go away? Because if it is something that's relieved by Angina, this will be a more long term history as opposed to an acute history. And you'd want to be getting a general overview of how well this Angina is managed. Then again, you're going through the differentials that I went through before these are why you're asking these specific questions. So you want to know, is this pain worse when you breathe in? As again, we're going back to our pleuritic chest pain and then is the pain worse when you cough, is the pain worse when you lie down? And is it tolerated related to worse after meals? And sometimes gord can actually mimic an acs and vice versa? And then was the pain at its worst when it started? Or has this been, has this elevated as, as the pain has evolved? And how far can you walk before you get this pain? If that's in the case of something like Angina, then I suppose with any, with any history, you'd want to go through your past medical and surgical history. If you simply ask the question, do you have any past medical history? And they say no, it, it depending on time in the Os situation, sometimes you can kind of show off to the examiner by thinking what other risk factors you want to consider here. So you could simply ask to, is it likely you have high BP diabetes or high cholesterol that said, I find in the Os, the, the actors are fantastic in that they have you a if you ask, do you have any past medical history? And they say no, it's unlikely then by prompting them further that they're going to suddenly come out with. Yes, I have type two diabetes. Um So it's very much dependent on you and how much time you have in the station, how much you want to prompt that further. But these are very important elements of patients past medical history that you want to consider in the cardiology history, any previous heart attacks, history of calf swelling that is important, um particularly if you think this is likely to be a pe that's something they're not going to tell you directly. Um So it's important to ask about calf swelling as well. If this is acute heart failure, you'd want to consider that as well. Periods of immobility, long haul flights and recent surgery, malignancy of pregnancy and history of previous surgeries, eg cabbage procedure. Again, even if these things don't directly lead you to your diagnosis, they're kind of showing off to the examiner as well that you know what you're talking about here, then you do your systems review. So you would want to consider palpitations as this is a presentation. A lot of cardiology, cardiology presentations. You don't want to consider your shortness of breath, cough, swelling, nausea, vomiting, and sweating fever, any element of unexplained weight loss. Again, it might not be that relative to a cardiology history in the very, very unlikely situation of potential atrial myoma or something really, which is very unlikely to come up in your exams. But you also want to consider for things like in fact, by endocarditis as well. So you have your night sweats, yours could be and dizziness with regards to social history. You'd want to obviously consider any family history of cardiovascular disease and get used to asking that question as well with any of the systems because you don't want to come in and day and ask them, do they have any family history of a cardiovascular disease? So for this one, simply any, do you know of any people in your family who have had any issues with their heart? You could ask the same for gastro and for resp and so on, but just have that in the back of your mind. How are you going to ask that question? Are they a smoker current or ex smoker? You have to be sensitive? Just ask them how many pack years again, you can say the words pack years. Just how long have you been smoke for? And how much would you say a day? Do you drink alcohol, particularly in terms of atrial fibrillation? Have they just had an alcohol intake acutely in this past 24 hours, you consider it as a precipitating factor. Do you take any recreational drugs over the counter medication? Any allergies, of course, are going to be asking that and with regards to social history, what's their house situation like? Are they independent? This is particularly pertinent in terms of acute heart failure or in stable angina when you want to gauge how well supported these people are at home. And of course, if it is a longer history and if this is something that's going on a long time, you don't want to be asked, how is this, how is this making them feel? Um I know Cardiff loves that. You do get a lot of marks for just exploring the wider aspects of the patient's presentation. And again, if you do ask these questions and if you ask these, um honestly, and if there actually is a sense of sincerity there, I do find the actor or actress in that situation will very much open up to you because that's what they are there for. They really want that kind of um connection and when they want to see that you care about what they're presenting with, so just things like that will actually really help you even if you don't think they're going to directly relate to the um into the differentials or to the management. So again, we just have a general overview of our differentials in the cardiac history here. So you have your A CS, this is going to be your essential crossing chest pain, worsen exe radiation to the jaw or shoulder, which is associated with shortness of breath, nausea or sweating. And you have your underlying cardiovascular risk factors again or aortic dissection. We have that tearing chest pain and I wish it wasn't as classic before the exams. They are most likely to give you the barn door presentation. It's not going to be like real life where it's a bit more, um, bit more niche and hard to get out the patient. You'll have that tearing chest pain will be sudden onset and they'll say that it's going to the back and they're also really short of breath. They might be nauseous, they might be sweating, they will most likely have a history of hypertension if this comes up in your oy. And as well, you also want to consider, does this patient have something like Marin Syndrome or that will put them at an increased risk? Um, then with your acute pericarditis, you have again, this pleuritic chest pain and it's going to be relieved by sitting up or leaning forwards and it's going to be worsened by lying flat. That would be classic. And you'll have the shortness of breath, they might have an associated fever or this might come later in the, in the station whereby you're getting set of observations, turns out they actually have a fever as well. And they may have had an illness in the past week or so. Um, I can put in the chat here. What is the most classic, um, underlying ati of C per carditis? Like this is a very niche ba question and not likely to come up directly. And your was one to consider. Um, and as well with myocardial infarction, sometimes they do get acute pericarditis. It's most likely to be Dressler syndrome which presents more chronically about two weeks later. But it's a very similar presentation and they might have underlying risk factors such as rheumatoid arthritis, which is a risk factor for acute pericarditis. You have your pe again, classic, your pleuritic sharp chest pain, it will come on suddenly there'll be associated shortness of breath. And again, this is why you want to ask about the calves, any underlying risk factors as well. Um, pneumothorax, again, chest pain will be sudden onset as I went through before in here. And yet it's most likely to be a younger patient. If this was a primary spontaneous pneumothorax, they might be out for a run, playing a football game or something. Come on all of a sudden and then it's most classically in your SB as young teenage male. Of course, when you're working in clinical practice, anyone who comes in with this pain, you want to be considering it not just going with going with a stereotype. Then with regards to pneumonia, you'll again have this pleuric chest pain, they will also have a productive cough. So that will be covered more in the respiratory station. But it's really important to kind of go gauge. Um and as about the nature of the cough, what they're bringing up as well, um any shortness of breath, fever, history of viral illness. Um because again, you're just narrowing your differentials and you're showing the examiner most importantly that you are thinking of the wider differentials as well. COPD exacerbation. Again, this can present with chest pain. However, again, it would be most likely going down the respiratory route. But just some things to consider, they will have chest pain because it's not a nice thing to experience for them. They'll also have productive cough associated with this shortness of breath, wheeze fever and they'll be using their inhalers more. And it's quite likely as well that if this patient has not already been diagnosed with COPD, that they will have a significant smoking history as well if they are um as a diagnosed COPD patient. Again, asthma exacerbation, we're really going down more of the respiratory here. But it just to show you how broad different um different presentations present and what you have to consider. So chest pain, patients will be in pain, they have, again, chest pain, this will be more with the shortness of breath. And you'll have, they'll probably say things like they're wheezy because they will want to give you the answers. It won't be long before you find out they are an asthmatic patient. They may have a fever. Sometimes an underlying illness can precipitate an asthma exacerbation. And again, they'll just be saying that they've been using their inhalers back to back and that nothing's been happening. Gourd, as I said, it comes up in ps quite a bit but a patient that comes in with go like symptoms and particularly the OS, you want to show that you're safe. Um So you also want to consider that if patients coming in with what you think is gord, you say, oh, an atypical presentation of this may be a CS. So I want to be considering why differentials is the pain, radiation to the jaw. But with gord, it's classically this burning epigastric pain, it's going to be worse after meals or when they're lying flat, they may also have a metallic taste in their mouth. I think that's more classic when b um I can't imagine the actor getting too much information with regards to that, but they might also have a cough as well. Um With peptic disease, again, it's more abdominal pain, but sometimes it can present with chest pain. So you'll have this burning epigastric pain. It improves or worsens with meals. They may also have associated dyspepsia hematemesis. They might be feeling a bit nauseous and they'll have these risk factors as well such as underlying Ibuprofen or NSAID, use ruptured esophagus. Again, I think if this would be quite a niche one to come up in your is just one to consider. It's most likely if patients present with central chest pain, sudden onset a history of violent vomiting and history of recent endoscopy. Um I know of something like this. Um, sudden onset central chest pain. You'd want to be considering more ACS and perhaps aortic dissection higher on the list, which is something to consider and costochondritis. Um I think it's unlikely to come up in a Cardiff station because it's we only have eight stations and they don't really want you to go into the management of some kind of costochondritis to in too much detail. That said it's a lovely one to be able to say in your list of differentials that you know, chest pains for some acute pericarditis. You could also say this is a young patient, new onset, sharp, localized chest pain and particularly if there's point tenderness, you'd want to consider costochondritis, which is often associated with a patient saying that when they're going to the gym that they're experiencing this pain on exertion, which you could consider angina, but it'll usually be a younger patient. And sometimes they might say that taking Ibuprofen or Nsaids relieves the pain as well. So again, just to kind of make it more succinct, you'll have your patient details your key presenting complaint, your history, presenting complaint, your relevant negatives in this case, and you'll get that by ruling in and ruling out stuff by asking the important questions, your relevant past medical history, social history and drug history as well, what the patient thinks might be going on and what's really concerning them about the situation, then you go into the heart of it and you're saying what you really think this is why you think that however your other differentials as well. And for me, this is something I really struggled with for my OSC. And that's probably what I spent so much time actually practicing. And that's where a lot of my revision kind of went into was just learning to be able to just turn and face. Remember absolutely everything important from what you've just been speaking to the patient about and really just kind of nailing why you think this is what it is. And then that really puts you down a nice path for the next two minutes where you'll essentially just be talking about. This is what it is. This is the investigations now that I'd like to do. And then from there, depending on the nature of your university station, you'll be guided then to talk to the manager, next element of mutation, which is where you go through your investigations and management. So, onto the investigations part, I think it will be very much dependent on what the patients presenting with. You know, if you think this is acute, you really want to be going down the more a CS route and So with any of it, if it is acute, you want to say initially, if you want to do your at assessment, I know with Cardiff, any time I was prompted, do you want me to go through the AC SAT E presentation? They would say absolutely not because we don't have that time, but it's something you'd want to have in the back of your mind that you are able to go through and again, you can rattle it off from most stations, um, very similarly and it's just something you want to have on the unlikely harsh situation that they make you go through in ae, then if the patient is coming into the emergency department, you would naturally be doing a set of basic observations. You'd also want to be doing serial ecgs and a cardiology examination, which will also feed into respiratory examination. You'd also want to be doing a urine dip and a glucose. The bloods will be a full blood count. LFT SE you'll be absolutely sick of seeing, saying these over and over. By the time your A CS come around X ray, the patient really unwell or can this be something that's done, done less acutely? Um But you'd also just still want to say that you want to do a chest X ray, then the investigations from here will be most likely dependent on what you think your um most likely differential is. So if it's acs, you'll be wanted to look at underlying risk factors. So you'd also want to throw on a lipid profile clotting screen and HBA1C on your blood. And naturally, you'll be considering a coronary angiogram and you'd say in these situations, this will be guided by my seniors. But these are the investigations that I'd like. Um, I'd like to consider requesting stable angina. Again, this is going to be less acute, but you, you want to be doing the same bloods. And again, considering a coronary angiogram aortic dissection. If the patient does come in with this and you're getting the observations and they're very unwell, this would be something that would be much more acute and you really want to, you'd want to convey that urgency to the examiner. Um You'll be saying this is very much dependent on the patient's hemodynamic stability. If they come in and their BP, similarly, with the likes of an abdominal aortic aneurysm rupture. If their BP is like 90/50 through the floor, then you'd want to be saying that you'd want to be prioritizing this patient's management. However, other, other investigations at this stage, you'd want to be getting a group and saving cross match as this patient will most likely need to be transfused blood. Um If, if there is a very severe dissection and the gold standard is a CTA orgran, but again, this will be dependent on the patient's hemodynamic stability. Um If they have a pe you can mention things like your well score. And do the patient, does the patient need a DDIMER or can they go straight to a CTPA acute pericarditis against C RP? Because this is most likely to be an inflammatory disorder. And you also want to consider an echocardiogram as well. So again, I touched on the ad earlier for me personally, I didn't usually prioritize wrapping off the at because I know that's a huge element of a lot of universities exam stations. I just know personally with Cardiff, no one's ever been actually, um, when prompted that they've had to go through thoroughly. And I think it'd be quite mean to do that because we don't have that much time that said it is something that you want to be able to do confidently on the day. So just spend a bit of time knowing how to go through your at E and then tailoring that specifically for the different conditions just in case on the day they say, yeah, I'll go through the whole at E and it's very similar to what you'd be doing in terms of your investigations and management anyway, so you can kind of feed that in first off airway, you're going to check the airways patient. I like to say something simply like I'll begin by introducing myself and asking the patient to simply repeat their name and date of birth that in that case, you've confirmed their identity, which is something you have to do anyway. And you'd be saying that you're simultaneously assessing the patency of the patient's airway. So it's just a nice way to make it a bit more natural. And then you, if you say that you think there's any evidence of potential airway compromise, um such as snoring stridor, um, any rashes or edema around the mouth, the more than anaphylaxis route, you'd want to perform some simple airway maneuvers and adjuncts of signs of airway compromise. Again, with the caveat, if you think there is airway compromise, you'd be fastly the Anestis immediately for more definitive airway management. However, we'd hope on something like an ac situation. This would not be your top priority here. Moving on to be, you'd want to check their oxygen saturations on a pulse ox. It's quite nice in this situation as well to mention who you'd be using on your MDT team at the situation. If you're an F one doctor, you simply say things like what's actually going to happen in real life. Oh, I'd ask one of my colleagues to get the most recent set of observations. I simultaneously um assessing the patient's chest movements. Looking um looking to assess for any evidence of cyanosis, feeling for any events of tracheal deviation, check the respiratory rate and auscultate chest again and perform an ABG if their oxygen saturations are less than 92%. If there's any evidence of compromising their oxygen, you don't want to start delivering 15 L of pipe of oxygen to be a non rebreath mask and again, maintain their oxygen saturation between 94 and 98%. Then you'd say simply moving on to see you'd want to assess their fluid balance. And ask again, you could say, ask one of your colleagues um for a most recent up to date um a fluid balance assessment. And if you think it's quite necessary at this stage, you could also say, I'd also like to ask one of my colleagues to insert a catheter and would start monitoring this patient's fluid output. Simple things like that are just very realistic to what goes on in the environment. And it just shows the examiner that you're thinking we'd also want to check their pulse, their BP and capillary refill time. Check the heart sounds all that auscultate, the pericordium, obtain an urgent ecg and start treated cardiac monitoring. If you think this is necessary again, you don't want to be saying this. If you don't think it's going to be something that's going to be pertinent to the patients management, you don't want to get IV access with a wide or peripheral cannula and you want to take your bloods, the bloods that I mentioned before and you'd want to start fluid resuscitation. If you think this is appropriate. If the patient is in pain and this is acute Coronary syndrome, you want to give IV morphine to start off at five and then titrated the patients pain, give your GTN spray again unless there is significant hypotension as this can make this the patient further hypotensive. And you'd also want to give them aspirin at this stage as well. So this is 300 mgs and you also want to consider giving the patient an antiemetic. So this would be I BCLI but it would be very much dependent if the patient is nauseous to begin with. Then Mr GERDs D D is not a hugely significant component of your A CS. But you have to say this in your, in your at assessment, check a po level, you'd hope that they're still aware at this stage, check the pupils equal reactive to light, check blood glucose. This is important because if their blood glucose is sky high, then you'd want to be considering we'll be sending them on for a type two diabetes or a type one diabetes screen after you've managed your A CS and you check your ketone levels as well. Again, less, less important for something like a CS, but something you'd want to consider and then you'd want to with e you can show off to the examiner here and you'd say you'd want to inspect the patient from head to toe to look for any signs of cardiovascular disease and any, you don't want to check your temperature form your analysis. And then as I mentioned before, if you think it's relevant at this stage, I like to throw this in to see. But it's very much up to you where you'd like to put it in, insert a catheter and closely monitor the patient's urine output. And you can also get chest x- here as well. Again, I like to throw that into be, but it's up to you how you like to, to structure it. Importantly, you want to say this to the examiner, you want to be safe. So then you can say that the patient becomes unresponsive with no signs of life at any stage. Then you begin CPR and you discuss with the on call interventional cardiologist for urgent PCI. And as you're going through your a assessment, I like to throw on at some stage that as you're making these interventions, you would go back to a and um you'd want to assess how your patient is tolerating your intervention at least each stage. So the SBAR approach, I know this is an important one for the Cardiff as they do throw sbar into one of the acute stations. So it is again, as I said before, when I was revising for the OS, a lot of it was just being able to turn to the examiner and go through how you're presenting your patient. The SBAR approach is another thing that I have to practice regularly because it's something that doesn't come to naturally. And it's something that can get you a lot of easy marks if you just know in the back of your mind, what you're going to say to the examiner. And again, what you believe is most important because it just makes a really good impression that you're going to be a good f one who's going to make, um, a good handover that's going to be clear, it's going to be concise and it's going to demonstrate to them that you've good idea of what's going on and importantly what needs to be done. So just to begin, you'd like to introduce yourself where you are, who you're talking to. And I always just ask as well, is it ok if I speak to you about a patient who I think is really unwell with XYZ and just get their intention immediately. So then you can go a bit more into the situation, why you're concerned and why you've called them a bit more about their details where you are. And again, the most pertinent problem because you want to sell your patient to the med or the consultant, whoever you're calling in the situation, then you can go a bit more into the background, the admission details if they're an inpatient in the hospital. Like for instance, if this is a three day post surgical patient who just had a knee operation, suddenly they have pleuritic chest pain, that's going to be important that they are an inpatient um summarize the clinical presentation and what you think your diagnosis might be any past medical history. That's relevant risk factors and red flags again, as we spoke about things like fever and night sweat, sweat, weight loss, that is going to be important, um, in other presentations, any relevant medications they're on, um, any investigation results that you've already been given, um, any allergies, important. I would always say that and if you've been given their news score, that, that's fantastic. You can just, for me personally, I just remembered the important ones that I thought were outside the parameters and why I thought the patient was scoring. Um So that might be a BP. Um Again, that might be on the floor, a really high pulse rate. They might have um a really high or low respiratory rate, what their oxygen saturations are and temperature. If it's unlikely at this stage, you'll be given quite a thorough examination finding. But you might do, you might have been told they have a new onset of a new onset murmur or you might find it by basal crackles. Again, these are important things that you'd want in your hand over what investigations you've requested. Um So that will be very much dependent on what you've said to the examiner and the important things that you thought were that needs to be requested and just kind of where you can again show off to the examiner and to the person that you're presenting to what you've done so far. Um What you think overall is going on and importantly what other things you might think might be going on and what you might need to rule out at this stage because you are only an F one. It's not really fair of you to, to come up with one diagnosis and manage that only. So you want to say to the reg, what you think other things might be going on from there, it's up to them to be able to tell you that. Yeah, that's quite likely or no, it's, it's um it's less likely that we can kind of rule that out. And then this is kind of again where again, you can show off, you can say this is what I think needs to happen. Um This is what's urgent and this is what I've done already and importantly, is there anything else that I can do in the meantime? So we just go through it here. Um I give you an example situation from earlier. We have Bruce Wayne, a 64 year old male who come in with severe crushing, central chest pain, it's radiation to the left arm and the jaw. He's come in, he's also shortness of breath and sweating. We have his past medical history. He's hypertensive type two diabetes. He's osteoarthritis. So again, you're thrown in stuff that's less relevant and stuff that's very relevant. So his afib with regards to his drugs, he's on a Statin, Warfarin, Ramipril, omeprazole, Ibuprofen, Metformin, I'm allergic to penicillin. So with his family history. His father had a heart attack at age 60. So there is cardiovascular risk factors there and he's a heavy smoker. He is a sedentary job. And with regards to observations, he has high respiration, his oxygen saturations are low, high, high pulse and very low BP. He's alert and he doesn't have a fever. So with our classic sbar approach here, you just simply begin by introducing yourself. So hello, in my case, I'm F one F one doctor on call here in the emergency department and then just simply ask who I'm speaking to. Um And if it's the me reg to say fantastic, I'd like to throw in. Thank you for answering my call as well because I don't often um have the time to be listening to, to every F one's um concerns. So just again, just go straight in with why you're concerned and just, that's really good as well because I chose the examiner that you're thinking and you're in the emergency department, you're not wasting time here. I'm calling. So I'd like to speak to you urgently um to review a patient who is presented acutely and well, again, be cautious what you're worth doing. I like to be on the backside of things and just be asking these questions about, be asking as opposed to um making direct statements I'd say, is it OK? If I talk to you about this patient who is, I would like to urgency review who's presented acutely unwell. Um, he's called XYZ and then you come in part of the matter that you think this is an A CS, once they hear that they're not going to ignore you, um, they'll want to get further information. So I need to talk about what they've presented with. Again. We've gone through their symptoms, cardiac risk factors, his significant history, that's really good as well. Just shows to both the examiner and to the med regiment situation are really thinking and you've done your ECG who've been really organized and you have your classic ST elevation in the anterior and lateral leads in real life. Does this always happen? Not always, but in the situation, it's great because they will feed you with this information that will be very bar in door and it allows you to make a really good handover chest X ray and ABG were normal as they would be. Then again, you've assessed the patient. This has all been done really quickly and they're scoring a really high news um for all the reasons that we've said before and you've, you've given them a stop bolus of 500 mils as well. Um Again, it was really showing to the patient to the med patients really acutely unwell. You've started them on cardiac monitor, you the Dream F one and you've also given them an anti in the stage as well. Um You've given them aspirin and you started on clopidogrel as well and morphine and then you've said that you've taken your bloods, you probably marked them with urgent in this situation, but you're still awaiting the results. Then this, when you come in again, show off, you can say, oh, this patient has suffered an anterolateral stem and that you require urgent assessment. You can also say something as well as I like to do. Um just be humbled to say, I recognize this is completely beyond um the limitations of my, of my current management as an F one, which is why I thought it was really important to give you a call and to see um what additional investigations or management is required. I think it's really nice and it isn't always um so to us for excuse just to be able to demonstrate what you know, are the limitations of your competency. Um So that's where you can get that across here. So this is what you think recommend need to be done, but be humble as well and say, is there anything more that you think needs to be done or is there anything else that I can do? Um I would like to ask if there's anything else you would like me to do for this patient, would you? And is it possible that you could come and review them as soon as possible as again, I am very concerned about this patient. And then thank you very much if you can remember all of that then. That's been absolutely fantastic. I know on the day for me, I would say I left out about half of it. But once you get across it, you know, this is an urgent situation and you've got the really most important stuff then that's all they want to see. So, with regards to management, um for these sessions, I don't go too much into detail with regards to management because I feel that very much correlates with your written examinations. And it's something that you can be learning in the background before A CS management. It's a classic. Once you suspect your A CS, you want to say you're going through ae assessment, it's really nice just to say that you address the patient's pain requirements at this stage. So IV morphine 2.5 to 5 mgs, you'd also want to be starting them on oxygen if their oxygen saturations are less than 92%. And you'd also want to be giving GTN. Unless there's any of the contraindications that I mentioned before, you'd want to be getting an urgent ECG and you'd want to also be giving them Aspirin 300 MGS. Once it's confirmed as a semi from your ECG, it goes down a bit more of a niche route. You think about your timing. So it's really nice actually to think about that and your history when this come on. Um And then you can just again showing off the examiner, this patient has had this pain for eight hours. This means he's still a potential candidate for a PCI procedure. And then again, I love to kind of not wasting time, but it just gives you that moment to think. Um when you say to the examiner, just be like, I recognize that I am in a emergency department. But I also want to consider um the the facilities available in the center. Is this a tertiary center? Is this ad GH or are we in a teaching hospital? And do we need to organize transfer to a PCI center or is this something that we have available on site? If you say stuff like that, I'm telling you like there's no knowledge in that, but it's just like two sentences. It will give you 30 seconds to really glad your thoughts and it just shows to the examiner that you're really thinking like an F one in this situation. And again, there's no real knowledge required in that. Um So it's just stuff like that that you can, I think, I remember even just like pointing to the vignettes in the cord and I was like, we're in a GP here. This patient needs to be urgently moved to the emergency department. And just things like that if you're in the emergency department, does the patient need to be transferred to a PCI center? This will be very much dependent on there's a PCI center in, in the vicinity. It's very likely that there will be an OS situation. So if they're within two hours and this is confirmed stemi, then again, you'd say I'll be liaising with my registrar and situation. As I recognize this patient needs to be transferred in the interim period, you'd want to be giving them a second antiplatelet agent. So it would be pros unless they're on an oral anticoagulant. In which case, you'd be changing this clopidogrel. And they also want to be given an antithrombotic agent prior to coronary angiography. So this is your unfractionated heparin with a glycoprotein bailout inhibitor. Um And then you obviously, within your investigations, you're considering your angiogram and they'd be referred for a PCI. If it's the case that they didn't present within the window or you can't get them to a PCI center. Again, this is more niche ba stuff and you say no, um you go on to giving them a second antiplatelet, which is your T or an an thrombotic agent and they'd be an eligible candidate for fibrinolysis. You'd want to repeat your ECG. It's really important just to say that. And if fibrinolysis hasn't been effective, then you're really just pushing again for this PC because that is the gold standard management here. Um So again, in the e you'd really hope this is going to be um a center with a PC um available within two hours would just be cautious of the other route. You might need to go down as well, really important at this stage as well to say that I touched on it before you said this, this management would be likely guided by my seniors. You don't want to say who this is going to be guided by you. So you want to make a direct referral to cardiology. I think that's where you're going to get the majority of your marks in the I know for me anyway, that was, it's so beyond the knowledge component of um niche guidelines. It's about knowing who you're going to call and when you're going to call them, just say, ultimately, I'm in the emergency department. I've contacted my registrar in the emergency department. If this, if the patient, if the reg wasn't available at all to be getting the consultant involved, as I recognize this is going beyond my competency as an F one and would want to be getting cardiology involved as soon as possible for the definitive management of this patient, which is the PC, stuff like that just have in the back of your mind because it's really easy marks on the day and it really gives you time to gather your thoughts as well while showing off to the examiner that, you know, you're an F one, you're not a consultant in this situation, despite you knowing what the ultimate management is, that's not going to be done by you. You're just keeping this patient alive in the interim period before definitive management then suspected a A CS and if you dont and it's ente or unstable Angina less acute, so it's slightly different in this situation, you give them an antithrombotic agent, you want to calculate again, your grace score. Honestly, they're not going to ask you what the components are of a grace score are unless they're really mean or unless they think you're doing really well and they just want to give you an opportunity to show off even further. But in that situation, if you don't know the components of a grace score fine, if you do brilliant, show them off um and be very much dependent on the risk here. So I think like 3% risk less is considered low risk. In which case you just give them or clopidogrel. Um If they're high bleeding risk and you'd consider um your ongoing management to be ischemia testing, you're going to do te or tt stress echo MRI, they're very niche. And again, it's not going to be instigated by you. Just something to consider. Um If they are high risk, you want to give like before and they'll want their angiography within 72 hours. If they're unstable, of course, you're going to say get you fast, you can even put out a call if they're really unstable. They like to hear that if you, you recognize this is really a well patient that I know as an F one, you will probably get a call. If they're ning above above nine or 10 depending on the hospital protocol. And he wants to do an immediate coronary angiography and she'd want to give something like pursue girl as well. So with regards the ongoing management, um again, it would be very much dependent on your university. I just know what car if they really like you to say, um break it down into initial and ongoing management and even just being able to say things like that as well as I said, the is, is all about working fast. So having those feeder sentences um just gives you that initial time to think. So, I'd say this is the initial management and then with regards to the ongoing management, again, cardiff love this. They really like the you knowing the ongoing management and how we're going to make this patient centered. So this is where your conservative measures come in. Initially. You'll have your MDT approach. Again, they love when you mention the MDT who's that's going to involve, it's going to involve the patient's GP as they're going to be discharged. Now, patient, we want to ensure there is adequate follow up there, consider a physiotherapist as part of a cardiac rehabilitation program. You'd also want to get their cardiologist involved. You want to do a full functional assessment to assess for any comorbidities they have, how well supported this patient is the charity society thing was definitely something I kind of threw in dependent on the situation. Um but it is kind of a lovely thing to throw in. Oh yeah, the British Heart Foundation because in real life it is something that you would be saying to the patient, you know, like, oh, there's information available here. So you might only have 10 minutes with them. And so you can mention the British Heart Foundation are fantastic and they really support their patients. Um, lifestyle changes. Again, just considering your modifiable risk here, you want to consider sending them or referring them to the necessary smoking cessation services. Driving advice will be dependent on their management and it's quite niche. They're not going to expect you to rattle off one week for angiography or one month if not successfully treated, you know it so that if you know from PT or whatever, just feed it in there and then sexual activity device as well, it just shows you're considering the wider aspects of the patient's consider and condition. And then medical management, you dual antiplatelet therapy, beta blocker ace inhibitor statin and aldosterone antagonist. Again, this is stuff you probably know from PT and you just rattle it off on the day. So on to the next one, you've your history here. This is Mr Tony Stark, 54 year old male. He's been recently diagnosed with angina secondary to coronary artery disease. Please have a discussion with the patient regarding diagnosis and answer any questions you may have. So this is um a typical, it's an information giving station. I know this used to be quite popular in the Cardiff when they had longer days and it was over three days, they'd classically have an information giving station. And the reason I included it is that I know it's quite popular still in a lot of other universities, what I would say for a Cardiff students, I think, if SP spend too much time preparing for these stations, then I didn't even spend that much time, but it was still too much time because they're not that common and be really mean for them to spend a whole eight minute station on information giving when they really want to know that you're good at taking histories. So that said it's good to have a knowledge of it and it's good to have a bit of a practice on how to give information to patients in a nonmedical um language. So for the likes of Angina, you just introduce yourself again, get a brief history. It's really tough because you only have eight minutes but just get a general overview. The actor really isn't going to go into too much detail. Um And it's nice at this stage just to ask, what's your current understanding of, of Angina or what have you been told so far? What's really worrying you about this? You know, they could say, oh, I'd like to look after my grandkids. So I want you want to know is that going to limit them. Um But then you just quickly two sentences is what we're gonna talk about the introduction. What is Angina? Which again, as you can imagine, it's something that's good to practice because I'm really bad personally at explaining um conditions to patients in a nonmedical environment or nonmedical language. So, Angina, you know, just go through, you know, it's this chest pain just related back to the patient because you've already got information from them. You say you've been experiencing this chest pain when you've been walking to the shop. So that's what we'd call Angina. It's um it's when you're the arteries in your heart get a bit stressed when you're putting it under pressure and that's what's causing this pain. Then you establish the patient's risk factors as well. You'd want to know at this stage, how was it diagnosed for them? And then just say that's really typical. This is why we do these scans or investigations just so that we can get to the heart of the matter and just say something as well. Just something like so that we can treat you best. Um importantly, they really want you to be safe in these situations. So you'd want to say the complications of angina. So you are at increased risk of unfortunately, potentially developing a heart attack, which is why we want you to know that if you have been taking your GTN spray and it hasn't worked after two puffs we want you to give you call an ambulance immediately. There's also going to be a red flag feature in these information giving stations. Such is about knowing that and just saying that to the patient. Um, again, we like to bring in our support and education. So usually just say we followed up by your GP or there's a cardiac specialist nurse we have here, talk to your lifestyle changes, medications, potential surgery, very unlikely in your Angina and driving DB. It's quite um broad with Angina. It's like if symptoms are occurring at rest. Um, and then any follow up as you can see here, that's a lot to go through in eight minutes, which is why Cardiff don't really tend to do it and that often just to consider and have in the back of your mind. So on to the next one, you are a foundation doctor in the emergency department. M Romanoff is a 45 year old woman and she has an ECG taken so review the patient's ECG and we'll consider an appropriate management plan from here. So, do you have any suggestions in the chat as to what this might be? Yay. Yeah, exactly. Um So this actually came up in my, it was supraventricular tachycardia. Um I think patient infective endocarditis. So, you know, SVT is a classical presentation of many things. Um which is why I just want to cover tachycardia more broadly because it is very likely situation to come up if the patients really unwell, um you'd want to go down your approach, as I said, oxygen IV access as I went through before and it's unlikely any of these things will happen. But you, I just simply say to the examiner, if there's any life threatening features such as shock syncope, myocardial ischemia or severe heart failure, just drop them off. And then you'd want to get your seniors involved as soon as possible. Stable, hopefully. And then from here, you'd want to be assessing the cure restoration. So if it's narrow, lessen up at 12, then you narrow QS, supraventricular tachycardia more regularly. Again, you can just go down the management for use bagel maneuvers initially, then you'd go on to adenosine. You can give up to 18 MGS and you'd be continuously monitoring the ECG and then more niche stuff is for optimal or beta blocker. It's unlikely that you will be required to instigate that management. Then irregular atrial fibrillation. This would be a lovely station to go up in your ski and it's very common one too. Um Then you go down your I have this in more detail, but you'd be going down your, this is your rate or rhythm control if you'd be considering things as well like your anticoagulant. Um So it's very much just gauging what type of, yeah, management here is amiodarone 300 mgs over 10 to 60 minutes followed by um an ongoing bonus. Then um over 24 hours. Again, you'd be saying this is done by the cardiologist. It's not going to be done by you as next one. And then an irregular broad complex QR S is very unlikely to come up. It's just, it's in the algorithm. So just something to consider, but they would hopefully not be that mean to you at all. Then Bradycardia, this is a nice one to come up because if it's kind of come up in your oy, more than likely the patient will be very acutely unwell. So it is something that you could say to the examiner. So you'd want to consider your at assessment um and make any interventions as necessary and then get your life threatening signs in if the case is not, then you'd want to consider if there's any things like risk of Asystole Mobi type two A B block, complete heart block with a broad QR S complex and vicar pause. I remember II did have this in the back of my mind for the excuse me thinking back like that would just be very, very niche to come up. Um So I wouldn't worry about it too much. It's just something to consider and it's handy to notice stuff for you written exams as well. Um So if that is the case, then you move on as if the patient had life threatening signs. So you'd consider your atropine 500 mcg up to a maximum doses 3 mg and then from here, it most likely be guided by I to would you want to be considering your isoprenaline 5 mcg adrenaline? But again, this is not going to be done by you. And it's important for you to say that and to recognize that as well, but it's nice to be able to show off if you do know the management. Then from here, do we have a suggestion as to what any of these might be anything in the charts? Indeed. So this is monomorphic ventricular tachycardia. The reason I say monomorphic is that it is an important differentiation to be able to make. If this is monomorphic, this is your classic ventricular tachycardia. If it's polymorphic, we'd be considering more the line along the line of torsades de pointes. I think that is again a very niche thing to come up in your is they like to just show you or burn or presentations. So this is if this is monomorphic VT again, you want to be expressing the urgency of the situation to the examiner. So again, this is a potential per for them. So I'll be going by how the patient is presenting symptomatically as well. Um So this will bring us on to the next one. Can anyone say what this might be any suggestions? So, yeah, this is our a um and it's just important to be able to recognize these as, again, there'd be lovely ones to come up in your a ski as it brings you on to our final one here. Um Which and again, any suggest. Yes. So this is VF the reason I've done those three is I did spend a bit of time in the run up to my excuse, being able to recognize those three. And for the very important reason that they bring you on to your adult advanced life support. So it's, it is really important to just be able to know your shockable and nonshockable rhythms. And beyond that, to be able to recognize them on an ECG as well. I think they'd be quite tough stations to put in or like quite tough um data interpretation. But for that reason, it's just nice to be able to know them. Um So if you are seeing any of the previous ecgs, so if the patient is unresponsive, they're not breathing normally. And you can see that it's a BF, it's important to be able to recognize that the advanced life support guidelines is I could do a whole station on that on its own and it's unlikely to come up, but it's a very um very plausible station to come up at the same time. And there's probably no harm for you just to practice with one of your friends going through a potential cardiac arrest situation. The beauty of that is that you're an F one. So you're never going to be the person ultimately um guiding the entire cardiac arrest situation. But in this environment, it's simulated. So you will be and you have to demonstrate the examiner that you know what procedure to follow. So if they are unresponsive and not breed, normally this is where you'd say you'd call for help. Um And again, I mentioned before, um I don't think it's something that's talk to us that much, but it's about recognizing in a real life environment who's going to be with you to say, I'll be asking one of my nursing colleagues to put out an immediate me call for a cardiac arrest and say that where we are again, as I said, it's nice to have these filler sentences just to allow you to gather your thoughts as well. So you'd be saying you'd be asking one of your colleagues about an immediate arrest called, say where we are and when they're on their way back to bring the cardiac arrest, Holly, if you can say that again, there's no knowledge there, but it's just very, um it's just very similar to what actually happens in a real life situation. And it shows the exam that you're thinking from here. You'd say that in the interim period, I'd like to consider this as a, as a full ae approach and I'd like to initiate CPR in the interim period. And I'd like to ask another one of my colleagues to start a timer and start documenting. So this is very much what happens in a real life situation. So then you'd be attaching your defibrillator and this is why I brought up the ecgs. You have your shockable and your non shockable rhythms. If this is a shockable rhythm by your ventricular fibrillation or your pulseless VT, as you very much pointed out, you'd be initiating with one shock and then you'd be considering resuming your CPR for two minutes and you'd be reassessing your rhythm. If this is a non shockable rhythm, you'd be, um, you'd, at this stage, you'd be giving an immediate um, adrenaline and you'd be repeating this every 3 to 5 minutes and then you'd be resuming your CPR thing with cardiac arrest and why it's, it's a tough one to come near. Excuse that management just tends to go on and on and on um, until you achieve a return to spontaneous circulation or in real life until um your reg or yours comes and takes over. But it's nice to be able to say what you'd be doing in the interim period. You'll be gaining IV access and you'd be giving adrenaline every 3 to 5 minutes. If this is a shockable rhythm, you'd also be giving amiodarone um after three shocks and then you can kind of show off again any opportunity to show off. You think about your reversible causes. So you'd want to be monitoring the patient's oxygen saturations. You'd want to be looking for hypoxia. You'd want to be looking at their BP to consider if this is hypokalemic and you'd be giving them um a fluid bots in that stage. And then you'd also want to be considering getting an ABG or a VBG as this gives you a really quick indication of the patient's metabolic status and you can get their um potassium levels um very quickly. Then, so you'd be considering if this is hypo or hyperkalemia that needs to be corrected immediately again, within your basic observations, you'd recognize if this patient is hypo or hypo hyperthermic. And do we want to consider if this is a potential thrombosis? So that could be through a massive pe or is this potential ACS which we've touched on before? And you'd want to consider if this is a cardiac tamponade, that'd be really mean to come up in a station if it was a cardiac tamponade causing um a uh a unresponsive patient, but you never know. And it's nice to be able to show off again that you're considering this at least. So then with regards to your ongoing management, you'd want to consider your investigations. This is your angiography with potential PCI. If this is an A CS and mechanical chest compressions are um a common thing in bigger hospitals. So you get a machine to come. Um It depends on the hospital, what they call a new machine, but they just do mechanical chest compressions because it's exhausting. And then from here, if the patient achieves a return of spontaneous circulation. You go right back to your at assessment and you're maintaining your oxygen saturations between 94 and 98%. So, as you can see, like there's quite a lot to get through. Um which is, it definitely didn't come up in my ski cardiac arrest situation, but it's important to be able to know as well and it will help you for your written exams as well. So, moving on to the next station, you are a med student in A&E. So Miss is incredible here. She's come in 36 year old female and she's come to palpitations. Um So take a concise history from the patient regarding his or her presenting symptoms. And then at seven minutes, the examiner will stop you ask you to summarize your findings and present a differential diagnosis. So the reason I've done seven minutes here is that palpitations, um it can be a more of a chronic one. and like a CS is going to be very four minutes in the door. You want them managed as soon as possible. You'd hope it's something like palpitations. The patient won't be that acutely unwell, but you never know and something you have to consider, but it might be more of a chronic history. Um So hence why they might give you a bit more time to explore what might be going on um in the lead up to the presenting complaint. So palpitations just like chest pain palpitations is a history that is good to be able to have focused questions for and to show off again to the examiner that you know what your differentials are here and you want to be ruling in and ruling out as you go with the patient who will have a lovely script and they will have all the information that you need. It's just about being able to get it out from them within your time, pressure environment as well. So you have full name date of birth, classic age, as I said, occupation, symptoms screening will come later on. These are just the basic things to get out of the way with regards history of presenting complaint. So Socrates is less relevant here. I always do ask, is there any pain associated with this? Um In which case, you kind of have to explore that a small bit more, you'd hope that they won't be in pain because it opens kind of a tin of worms in terms of palpitations. So then it's unlikely the patient will say palpitations. They will just say something like I have a funny feeling in my chest. And if they say that you mirror that back, you're not going to be using the word palpitations and that's not a word you're going to be saying again until you're presenting this to the examiner. Do you usually suffer from this or is this new onset again? That's really important? And it just shows the examiner that you're thinking in the back of your mind. How are we going to manage this patient? Um, I've seen it before. I've heard, can you tap the rhythm on, on the desk or, um, on the chair in front of you less important? But it's something you can consider, if that's something you feel natural asking. And is there anything that triggered this, um, is there anything that's happened in the last 24 hours that caused the palpitations and then they might go down the street of Yeah, but you feeling really nervous or? Oh yeah, I went on a massive night out last night and um it's just then I woke up this morning. I had this really funny feeling in my chest. Again, the actor has the script, they have all the information so they are going to feed it to you just about asking the right questions and then yeah, have you experienced any anxiety, any change in your mood at all? Because again, you're showing to examine it, we're going to be thinking of thyroid screening here. Um Any stress or sleep changes. Then with regards to medical surgical history, surgical history is less important to hear, with regards medical history. Do they have any underlying cardiovascular risk factors? So, hypertension diabetes and cholesterol, have they had any previous heart attacks? It's always going to be important to ask, it's less relevant to AFIB. Um But you know, any bowel disease is really important because you're thinking just as patient potentially have mitral stenosis and mitral regurgitation. Just again as I mentioned before, get comfortable asking these questions in a nonmedical environment. Just if you ask the question, have you any issues with your heart? Previously, they're going to mention if they have a valve disorder and you don't have to ask that question specifically. Um and similar with thyroid disease, it's an important one to consider with atrial fibrillation. And again, they're going to most likely tell you if they have any past medical history in terms of their mental health, then systems review is really important in the cardiovascular history. So, do they have any chest pain, shortness of breath, calf swelling? Um Again, less important with um, a palpitations, which is something you want to consider nausea, vomiting, sweating change in their periods at all. Because again, this feeds into your um potential thyroid disorders, any fevers, unexplained weight loss, night sweats, syncope and dizziness. Then you can feed more into your social and family history. Again, cardiff love this. Any family history of cardiovascular disease, any history of sudden death. Again, it's unlikely. Um or it's not that important in the situation that are the smokers. Um Again, I mentioned before, just get the extent of the smoking history similar in alcohol or recreational drugs. Have they? You could just simply ask the question, do, how's your caffeine intake? And again, it's not really going to open anything. You'd hope it shows the examiner. Do you know what you're talking about? And it's important question that you feel you need to ask, then any medications are on importantly, any allergies. And again, this is less, um, important than it was for the chest pain history. But you can simply ask, how is, how are they functioning independently at home to have someone looking after them and importantly, psychological impact. I'd like asking this in any history because it just allows you to fill that report with the patient and if you can do that, they will open up for you. Um And that is the magic of an situation is just getting the, the actor or the patient in that four minutes to tell you as much information as possible. So do just try and explore why they're concerned what brought them to the GP or the A and in the first place. So once you've cover that in character of land anyway, you will be given a piece of data to interpret. So, does anyone want to have a go at what they think might be going on here? Any suggestions? Oh, ok. So this is your atrial fibrillation. Um This would be a very classic station. I know I go through stuff that's unlikely to come up. Atrial fibrillation would be a nice one to come up and it came up my mock. Definitely. Um It's just something they really want you to be able to recognize. So with your atrial fibrillation. So with anything you want to go through your differentials and why you're ruling stuff in and ruling stuff out with AFIB. It's quite like to be an elderly patient. They'll have cardiovascular disease. I went a bit about valve disease before. Um or they may have had a precipitation factor like a recent infection. A younger patient again might come in and say they've um had an acute history of excessive alcohol intake. SVT. Um These episodes are terminated by bagel maneuvers and they might have a history of COPD or multifocal atrial tachycardia. As you can see, it's a bit more niche and there's not much to kind of go through in a station which is why it's less likely uh VT as I touched on before is a lot more severe and it's going to be more likely your four minute history. So, symptoms of hemo instability, systemic compromise, history of recent mi or ischemic heart disease, thyrotoxicosis. If the patient is coming in with AFIB, you have to mention thyroid if you're going to get investigations done. Um and just think about your wider differentials. So you'll have your symptoms of hyperthyroidism, history of thyroid disease. Potentially, they may not. And this is something you might have to just explore a bit further and they may have a history of autoimmune disease if you've been touched on stuff like that, that like oldest patients also diabetic. Um which may feed into the fact that they might have some graves disease and they come in atrial fibrillation. I know that's kind of basic knowledge when it comes to your written exams. But if you can gather your thoughts like that in this situation and present that back to the examiner, like that's really showing off and they will be very impressed with stuff like that. Even though it is quite basic knowledge when it comes to fourth year, it's just about being able to consider your wider differentials and how it's feeding into the patients presenting complaint. Um, hypoglycemia. Again, hyperglycemia feeds into a lot of things. Um, atrial fibrillation is one of them. They might have a history of diabetes. You consider what medications they're on if that's insulin or sulfurea. Um, are they coming in? Sweating, hunger, dizziness, the classic ones. And then your other differentials, if you really mean if these came up with your pheochromocytoma, um, it's something you just mentioned. I really hope they wouldn't bring that into it. Um, patients just simply quite anxious. It's something you can consider. Um, ventricular top is very niche and then you consider what medications they've been taking or what they've told you from the history. So, what are the causes of afib, um, if you can have this in the back of your mind, I'm a person that I don't like to just learn off lists for the sake of it. But if you just have in the back of your mind. What are the potential causes and what you need to rule out and rule in then in terms of your investigations. So it could be P EC O PD pneumonia. They might have ischemic heart disease. It might be idiopathic rheumatic heart disease, valve, heart disease again, as I touched on before your alcohol anemia is an important one as well. And it just happen at advancing age, thyrotoxicosis and any potential toxins, an elevated BP and atrial fibrillation also tends to present quite acutely if the patient has an underlying infection as well. So you would want to be getting a basic set of observations if there's any potential um even like a mild elevation of the temperature you'd want to consider, is there a potential infection going on here? Sepsis would be quite severe. Um And it'd be really niche for them to make the jump from to bedside bloods and imaging. I know I did personally as well. Um It just gives you that 10 seconds to kind of think about what you need to do for this patient going forward. Is this patient really acutely unwell? And in which case, you say that's the examiner or can they be managed slightly more conservatively doing simple set of basic observations in ECG, which you've already done a cardiovascular examination, which will also feed into your respiratory examination, urine dip and your glucose. Then with regard to specific bloods for atrial fibrillation, you'd want to do your full blood count, HBA1C. You want to see your Tup Unis and then your BMP because you want to look for underlying heart failure, potentially and your lipid profile. Then more niche tests you'd consider for um potential atrial fibrillation, you'd want to get a chest X ray. Um because you don't want to assess if there's any evidence of cardiomegaly. You don't want to get an echo for this patient. Importantly, I'll touch on that later and you'd want to get 24 hour ECG because particularly if it's um patient comes into a, into the e and they have one onset of atrial fibrillation, you want to assess, is this more of a long term thing? And do they need to be managed ongoing or is this just once off? So they'd be getting a 24 hour ECG to assess from paroxysmal af then with regards to management, I can go through this here, but it's something that you'd want to just know for your written exams anyway. So patients really keep feeling well, you do your full assessment. Um If they're hemo unstable against, we really mean in your ac situation but have this rattled off your shocks and could be heart failure, chest pain. Those four just know those off and then just say if there any of those, I'd be fast weep my register immediately. And um I'd consider pa me call as this patient may need to be urgently sedated for electrode synchronized DC cardioversion. Again, this is where you get in as well. This would be going on the limitations of my own competency and this man should be guided by my seniors. Those things. 10 seconds allows you to gather your thoughts and you've shown the examiner you're safe as well. That's in terms of hemodynamic instability, which again, we really mean, but it's just something to consider. The more likely situation you'd hope is the patient's hemodynamic be stable and you'd want to check their anticoagulant status if they're on any anticoagulants at this stage. If they're not, again, get mentioned things like your child's vas score um with regards to their anticoagulation, I'll cover this a bit further. But with regards to the actual atrial fibrillation, you'd want to consider, does this patient need to be rate or rhythm controled? Um If this was onset less than 48 hours, if it's more than 48 hours, then there will be anticoagulated for three weeks um and rate controlled simultaneously before elective cardioversion. So, anticoagulation um again, I'll touch on it here, but it's quite a common one for written exams. Anyway, you'd want to um do a stroke risk assessment using a patient's child's vas score. Um like the grace score I mentioned earlier with regards scoring systems, it's really up to you whether or not you want to just show off the examiner and you have the time to come through like personally, for me, on the day, I would not have been able to list off all the components of these scoring systems, nor do they expect you to, if they ask you specifically. As I said, this is probably a good sign that it means you're doing well and they just want to give you the opportunity to get your extra marks. Um Please don't feel you need to be um being able to rattle this off. But at the same time, if you've taken a history and you can go back to the examiner and say they've had these risk factors like their age is this, they have hypertension, they have diabetes. So then you could instantly just be like their child's vas score is automatically one or more, then they will be anticoagulated. If you can say stuff like that. It looks fantastic. Um So then your child vas score, you know this, if it's less than or equal to two, then you offer oral anticoagulation, it's equal to one in men, then you consider your oral anticoagulant and then your DOAC is offered first line. Um And then your warfarin, if it doac is contraindicated, that's less likely. And then you assess your bleeding risk as well using the orbit score. I couldn't tell you much like, like I don't have the specific criteria in my back of my mind and nor will they expect you to and things like hemoglobin. Um They have any renal dysfunction if you could mention one or two. And that looks good, but don't be expected to learn it all off by heart because you'll have plenty of other things to think about on the day. Um Again, with her as management, you have your rate control of her first line unless it has a reversible cause. Unless the patient has heart failure, it's thought to be caused by the af new onset af atrial flaughter. And the condition is suitable for ablation or with a controlled strategy is more suitable based on clinical judgment. If they meet these criteria, then fantastic. And if they don't, then you'll be moving on to rhythm control. In which case, it's pharmacological with fide or amiodarone. If the patient has underlying structural heart disease, synchronized cardio D CDC cardioversion and yeah, amiodarone is considered four weeks before and up to 12 weeks after 12 months after electrocardioversion. So for symptomatic af that is refractory to drug treatment to consider left atrial ablation or pa ablation. Again, that's really neat. You'd be saying you'd get the cardiologist involved and all of this is just, it's up to you in terms of how much time you have at this stage and how much you just kind of want to show up to the examiner dependent on what the patient is presented with. So next station is, you are a med student in the GP setting. You have Mr Dumbledore here, 76 year old male with a history of heart failure. So please take a focus history regarding his symptoms. Again, it's unlikely that they'll say heart failure explicitly. They might say, um Mr Dumbledore has been experiencing shortness of breath or he has reduced exercise tolerance, you know, things like that, that will allow you to think about your differentials at this stage. What I like to do as well is make it really clear from the start to the examiner or when you're presenting back to the examiner that you say you recognize you're in the GP environment here because that really influences what investigations you're going to be doing your management and the acuteness of the situation as well. If you're in a GP session, you would really hope they're not coming in with acute flash pulmonary edema, but it's just something to consider as well. So with regards to the management heart failure, reduced ejection fraction, you have management here, it's an ace inhibitor and a beta blocker. And then you add your spironolactone. I think I use ABA L to remember it. So um ace inhibitor, beta blocker aldosterone antagonist, which is your spironolactone or um Nerone, if they are intolerant of spironolactone and they're loop diuretic. If they continue to be symptomatic, then from here, this is really niche and they'd be quite mean to ask you this. But again, if you have it in the back of your mind, you can consider mentioning it, your additional medication would be guided by your cardiologist, um A bra or digoxin hydrALAZINE as well. Valsartan, I've never really seen this in clinical practice, but then your intervention, implantable cardio, cardiac defibrillator or resynchronization therapy and transplant. Again, I've never come across this. But again, it's just um this is the ongoing management in terms of the algorithm. So focus questions for your patient coming in with query, heart failure, short of breath, when lying down or sitting forward again, you can make these more open questions. You know, is there anything that makes you don't need? It's not going to be a pain in this situation. So you can kind of incorporate Socrates into that. It is anything that makes the shortness of breath worse or better. It's really important to ask about the whole um shortness of breath at night. Um because that really allows you to gauge how severe this is. How many pillows do you sleep well at night? Difficulty walking? And then in the back of your mind, you can be thinking of your New York heart heart failure assessment if you can mention that back to the examiner, an amazing um difficulty walking, recent illness or surgery which may have precipitated this. And yeah, it's about gauging as well. How has this changed to their baseline? Why if they presented to their GP now? Um And how far can you walk before getting shortness of breath again? Gauge these that these are open questions because you have however many minutes the actor has the scripts, they have all the information and if you can really facilitate open questions from the beginning, they will just give you all of the information and it makes your life so much easier. Um So with regard to heart failure, and specifically, you'd want, you've covered shortness of breath or apnea, paroxysmal nocturnal dyspnea. Please do not mention any of these words when you're speaking to the patient because they will just, they might know what this is, but it just looks really badly. Um And then just things like fatigue as well. You're going to be considering how this is impacting their activities of daily living, how it's impact on their life. And if you, they might mention this, but you mentioned, have they noticed any change in their ankles as well? In which case, they will probably say that they're swollen. So I touched on it before. If this patient is in, it's much more likely to be, um, your acute pulmonary edema. Um, actually be a great station to come up because it's very much like bar and door management and stuff you probably know from your written exams anyway. But for a full at assessment, I've touched on the full a previously. Um, and it's really nice one just to be able to ruffle off again. I mentioned how to assess their airway. You consider performing airway maneuvers. If the signs of airway compromise, an important one in acute pulmonary edema is you just start off by simply sitting the patient up and ask and assessing if there's any relief. Um particularly if the patient has low oxygen saturations, you'd want to initiate the patient on oxygen therapy and remember to be using the team around you. So this is a hypothetical situation, but you will have a nurse or a healthcare assistant and you have to show to the examiner that you know that you can use these people in the situation that you're not going to be trying to manage this patient on your own, then check oxygen saturations, check respiratory rate, just talk really quickly through your your respiratory examination, pre and osculate the chest. And if you want to show off the stage, you'll be set for bi basal crackles, check for trochal deviation, perform an ABG start um 15 L of high flow oxygen. Most likely this patient will be very hypoxic. And um if they are refractory to your initial oxygen therapy again, this is what you're saying you're getting involved, this will be it or getting your med reg involved. They may be a potential candidate for CPAP or invasive ventilation. You're assessing their fluid balance, check their pulse, blood pressure, capillary refill time again. So you auscultate, important to get this, this um here first off, take your bloods, but also to have that IV access because the ongoing management of this patient will involve IVF freeze initially. 40 MGS. And I think the most important element of any acute osk situation it's about and knowing who to call and when to call them. If you know your patient is a coupon or edema, you'll be given a set of observations. If they're using like a nine or a 10 in the back of your mind, it's so appropriate in that situation just to turn to the examiner and say I'm going to be putting out a call and I'll be managing this patient with a full at assessment in the interim period. You'd be getting on to the cardiologist, critical care. You might begin fluid resuscitation. Um I wouldn't say that unless they're very hypertensive because as we all know for any a situation and then um for e with regards exposure, it's really nice just to stay here. Did you assess the ankles for pushing edema? And you do your classics like c there actually is really important because you do want to monitor your urine output and you can also get their daily weights as well. Again, none of this is like uh none of this has to be said, which is nice if you do know this just to be able to, to say to the examiner and you'd request your chest X ray. That's really important. You do a portable chest X ray and you'd get an echocardiogram as well. So management of chronic heart failure, again, we like to break this down into your initial management and then your ongoing management. So with regards to your ongoing management, try and mention as soon as possible who is going to be in the team of this patient's ongoing management. They love to hear you mention that they love to know that you're thinking of the wider aspects of this patient's management. So it's going to be their GP, they're going to be discharged as an outpatient. They are going to require follow up with their GP. There's also going to be a physiotherapist and a cardiologist involved. They will want a full functional assessment. Again, these words, give you five seconds to think, um they are going to be applicable to every management situation. So saying things like a full functional assessment, then you can kind of click on the back of your mind, what will this patient actually need? So they will be required to be assessed for comorbidities and until the patient is diabetic, if they're immobile, again, we love our charities and societies here. So British Heart Foundation is again the one for um ongoing heart heart failure. And again, it's just a point of contact for the patient who may be um concerned about this new diagnosis and any lifestyle changes. And again, cardiff loves that depends on your uni but they do like you to consider the wider aspects of the patient's management. So what lifestyle modifications might be required and if there's any other modifiable risk factors that we can intervene here such as sending the patient to smoking cessation services, medical management. We've touched on before it's per the flow chart you have your able. Um And then the other things to consider here, which is also nice to consider for things like COPD and a lot of chronic conditions. They'll want their annual influenza vaccine and a one off pneumococcal vaccine. And you'd want to consider fluid restriction. Again, that's quite niche and it'll be guided by the cardiologist. So that is a general overview of the cardiology history. I think what I tried to do was cover the three most pertinent um complaints on what you're most likely to get in cardiology.