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does mention this. So this is this the osteo bi Siris? Okay, this is ah, lot different from finals Easy series. If you guys have to go into our final Siris, the form that is a lot different. Okay, with finals easy, it was all about sort of SPF single sounds of questions. And then we rapidly review a condition. Okay, Aussies are a lot different, okay? In terms of the actual knowledge you need to know for Oscar, it's a bit different to final say it's all but also he's It's all about sort of structured, clinical thinking, having good clinical reasoning, being having thinking through things in a logical way. It's a lot more practical. Okay? It's not necessarily about having the most knowledge, medical knowledge in the world. Okay, is having a decent level of knowledge about the most important stuff and being having good practical skills as well. Okay, so that's what we're going to focus more on. But the Oscar Siris okay, there's not. There's no sort of SPS that's all sort of interactive learning about important common conditions that can come up you'll see in clinical practice, okay, because all skis, it's all about preparing you guys for the stuff that's common in clinical practice. Okay, You don't It's not about the nation niche medical stuff. Okay, so let's get into so today, the first part of our series. So this is our cardiology. Okay, so it's the cardiology station, Heart one. Okay, so we've split up some of the specialties into two parts because they're quite hefty specialties. So part one of cardiology. So today, we're gonna be covering, uh, basically, most of the clinical aspects of his focus history taking data interpretation, Um, just technical investigations, formulating a management fine and sort of more niche osteo stations that can come up. So things like explaining a diagnosis as far hand over. Um uh, we'll do a lot of the CD practices well, and then about two on Thursday. So second part of cardiology will talk through the cardiovascular examination and talk through physical findings and how you sort of present physical findings. And so that's only Thursday session. Okay, so today is more about sort of focus history, taking investigations, management plan, data interpretation. Okay, so let's get into it. Um, so we got our first case. Okay, this is cardiology. So We need to be very confident with this presentation. So our task is we've been assigned the role of being a foundation year. One doctor were in the emergency department, and we've been asked to see Mr Bruce Wayne, who is a 64 year old male who presents with chest pain. And we've been asked to take a focus history on initiate a management plan with pertinent investigations. Okay, so this is, ah, pretty standard Oscar station. Okay, we're We've been asked to take a focus history from a patient with acute chest pain. Okay, Okay. So if you guys students are series last year, you'll know that we like to do these spots diagnosis sessions. So basically will present you with a clinical vignettes off a patient with chest pain. And I want you guys to come up with what? The likely diagnosis this. Okay, so this is a This is an activity basically trying to test your ability to come up with a differential diagnosis and trying Think about what the likely diagnosis is. This. Okay, So, first scenario, we have a 54 year old man who presents with severe crushing chest pain at rest. The pain radiates to the drawer and on. He has a past medical history. Off type two diabetes and high cholesterol is a heavy smoker. So can you guys tell me, what do you guys think going on? Okay. You guys saying am I? I'll accept that My But can you guys give me a better term than saying Am I at this point a C s good? Okay. Acute coronary syndrome. Okay, so I want I'm clarifying that it's better to stay a C s at this point. Because if you're seeing a patient is having a my college myocardial infarction, you ideally want to be very specific and say ST Elevation myocardial infarction or non ST elevation myocardial infarction. Okay, but I haven't given you any ECD features here. Okay, so at this point, you don't know. So it's best to just classify this as an acute coronary syndrome. So why acute coronary syndrome? This is a patient is presented acutely with severe crushing chest pain at rest. Okay, so it's a it's chest pain at rest that differentiates it from just normal, stable angina. Okay, pain radiates to the drawing on classic for ischemic chest pain, ischemic cardio cream and has a history of type two diabetes and high cholesterol. Okay. And he has a significant smoking. History is a big cardiovascular risk, but this. Okay, since that this is a classic been yet off acute coronary syndrome next in a row. So we have a 24 year old woman presents with pleuritic left sided chest pain. She is not able to take full breath. She is currently on the combined oral contraceptive pill and recently traveled. Jones has palpitations. Good. You guys, you guys are you guys get good? Yeah. So it's a P, probably embolism. Um, can you tell me why is this a p? What suggest ski in this patient? Yeah. The risk factor is good. So probably embolisms or clot in the lungs. So classic symptoms probably embolism. Pleuritic chest pain. Uh, you know, I will take a full breath. Okay. So impaired ventilation as well. And the key thing that gives the makes it more likely to be a pa in this case. Is there risk factors for is a probiotic risk factors. Okay, Like someone said Virgos, try it. Very good. So this patient has risk factors for thrombosis. She's on the pill, and she's recently traveled. Okay. So recently traveled That suggesting potential potentially disease had a deep vein thrombosis. Okay. And then that's cause their primary embolism. Okay, so also the palpitation. So why is it why is this patient have palpitations? What's that like Because of palpitations? Age of regulation, yet did what's But what's the most common arrhythmia you get with communism? Yeah. Sinus, Sinus tachycardia. Okay, we'll go through the CTS, but it's Sinus. Tachycardia is the most common. The CT future you get with family embolism. Don't say things like s one, Q three t three or t. Uh uh, um, a fib. Okay. It's not as common as Sinus tachycardia. Okay, but it can't happen. Okay, next one. So we have a 55 year old woman man who presents with very sudden onset tearing chest pain ain't really it's to scapular has a significant history of hypertension and smoking. What do you think you have you guys know aortic dissection that we're starting pretty basic. Okay, we're gonna go into some, uh, hardcore clinical stuff now. We're just trying to warm everyone up. So this is classic scenario for dissection. Okay. Classic description for dissection. Pain is central, sudden onset, tearing chest pain. Okay, that sudden onset suggested. Generally, it's a vascular cause of pain, and it's tearing in nature. That's classical dissection. Pain radiates to the scapula. Okay, so it's going through to the back again. Classical dissection on hypertension and smoking are very common. A very clear risk. Factors for dissection is, well, next one. So we have a 65 year old woman who presents with pleuritic chest pain that improves when she sits up. The pain is sharp and does not last long. She recently had another respiratory tract infection, and she still has a fever. There are SED changes, Harry Carditis. Good. Is this a key Pericarditis? So chronic pericarditis are constricted pericarditis. So what were you saying? Yeah, so remember, be specific when you say pericarditis. This is a coupon card. Itis okay, so why pericarditis? So the There's a lot of classic things they say about pericarditis. The chest pain improves when she sits up. Okay. And it's shop. It doesn't last too long. Okay? You have episodes of chest pain. That's classic for pericardial chest pain. Okay. On the history of infection fever, that's also a typical history for acute pericarditis. A swell in terms of the e. C. T. Changes one of the classic ECD changes you get with pericarditis. Diffuse ST Elevation. Good. And what kind of ST Elevation? Yeah, saddle shaped ST Elevation and er PR depression. Break it. You guys are on it. 60 year old woman presents with chest pain that develops when she walks up the stairs. The pain results when she takes a GTs gray and five and five minutes after she rests be in my study, too. Good. So this is This is different to the first one. This is just stable angina. Good. So the key thing that makes this stable angina rather than acute acute coronary syndrome is that the pain resolves is responsive to detail, and it's resolving up to she rest. Okay, that's the key. Different difference between acute coronary syndrome and stable angina. Last one last differential for chest pain. So we have a 26 year old man presented paretic chest pain in the middle of a hockey game. No history of trauma. She has no venous thromboembolism risk factors and no significant medical history. Yep. Pneumothorax. Can you guys be more specific. And when you classifying the pneumothorax? Yeah. So it's spontaneous pneumothorax. Specifically, it's a primary spontaneous pneumothorax. Good. Okay, so you want their exes is classic for a pneumothorax picture. Okay, a young man pleuritic chest pain? No, there's no history of trauma, no history, no risk factors or venous thrombosis thromboembolism. Okay, so it's unlikely to be a P, and there's no significant medical histories. Okay, so there's no underlying lung disease, so that means that's not you. It's not a secondary pneumothorax. Okay, this is primary spontaneous pneumothorax. Okay? It's just no history of lung disease. So it's the primary, and it's no associative a trauma or ventilations of spontaneous pneumothorax. Okay, so I was a little activity just warming up our minds on chest pain. Now we're gonna go into some more of the cost. So this is like, basically trying to cover the sort of keep focused questions you want to be asking in chest pain histories. Okay. Um so in terms of the focus question, So you guys know for chest pain histories, you do your Socrates okay. And I'm hope you got hopefully you guys are very confident in doing Socrates. I just go through some of the good focus questions to ask about chest pain. It's always good to ask where exactly they feel the pain. Okay, ask if this is a new chest pain. Okay? So if they if they're suffering normally from angina pain, they might say that this pain is a bit different. Okay, It's new. Okay? And that's important to clarify. Ask about the alleviating factors. Is it relieved by G 10 alleviated by rest on. Always ask how long it takes for the pain to go away. Okay, If it's more than five minutes, that's pretty significant. Um, and ask about stuff like, Is it worse when you breathe anything about pleuritic chest pain? Worse when you cough worse when you lie down. Okay. So things like pericarditis. Uh, is it related to our worst two meals? Okay, so things like reflux, the pain can actually worsen with meals. Okay, on was the pain at its worst when it started? Okay, Classically, with aortic dissection is the pain is very significant. Assumes that starts okay and always ask How far can you walk before you get this big? Okay. It's an important functional question. Okay? Trying to get a good functional assessment. It was a past medical history. You want to ask about a bunch of risk factors for the chest pain? Okay, so hypertension, diabetes, high cholesterol, a cardiovascular risk about this history of previous heart attack. So these are again risk factors for heart disease. History of cough swelling, long haul flights, immobility. So these are all risk factors for sort of venous thromboembolism risk factors Risk factors for developing a pulmonary embolism, recent surgery, malignancy, pregnancy again. Risk factors for from, er thromboembolism Ms Copy, uh, risk. And it's also good to clarify if they've had any previous surgeries. Like a CABG procedure. Okay, so a coronary artery bypass always do a good system review. Okay, Just make sure they don't have any other of these associative peaches and do a good social family and broke history as well. Okay, so make sure you're getting a good assessment of all of these. Different back is okay. Always ask about allergies, okay? And a lot of what history you're taking. No. One of what type of focus history you're taking. Make sure you're you've asked about allergies. Okay? Because you could potentially failed that station if you if you haven't asked about allergies. Okay, Um, And with smoking, if they if they have a smoking history, always clarify how long they smoked for and how many cigarettes a day they've been smoking, cause that's gonna help you calculate the number off smoking Pakis. And also good too. If you get if you have enough time on your social history, ask about the housing status, okay? And how much independent functionality they have. How able to that How capable How, um how much? How, how they can do that. The activities of daily living activities of daily living, how effectively they're able to do those and ask about any psychological impact of a Okay, so that's the sort of chest pain history that sort of fundamental principles are doing. A focus chest pain history. Okay, so this is something. Hopefully you guys will have practice. Okay, but make sure you can do this. Focus. History really, really Well, Okay, good. So now we're gonna talk to some of the differentials quickly. Okay? This is stuff you hopefully based primarily weight. So the big cardiovascular differential for chest pain. We're thinking about things like acute coronary syndrome, Aortic dissection. A few pericarditis as well. Okay. And I've listed some of the key things you want to be picking out in the history to have a read. When you had the slides, just go through it. And this is This is stuff. Hopefully a very uncomfortable clip. There's some of the respiratory differentials. Okay, So things like pulmonary embolism, pneumothorax, new pneumonia can cause chest pain as well. Uh, patient have about a COPD exacerbation. Okay, so all of these also spiritually differentials for chest pain will talk about this more in the Risperdal station next week. Okay, Today we're gonna be mainly focusing on the acute coronary syndrome, and I've got some other differential. So again asked me. Exacerbation is Well, it can cause chest pain. There's a lot of gastroenterology g I differential for chest pain. Okay, Particularly reflux. Reflux is a super common cause of chest pain. Okay, to make sure they're not that, it's not just simple reflux. Okay, Ask about meals. Peptic ulcer says ruptured esophagus is another big emergency cause of chest pain on so also known as boerhaave syndrome. So again, you just make sure you're ruling out all of these other systems in terms of because of the chest pain. Yeah, but the big one we're gonna focus on is the acute coronary syndrome as well. Okay, cause the contractors as well composed chest pain. So, as I said, we're gonna be focusing on acute coronary syndrome. Okay. The sort of approach to acute coronary syndrome. Um, so this is just a little picture, too. It's just a little picture to highlight the distribution of pain classically seen in a C s. Okay, so it's you particularly Central. Okay, that radiates to the jaw. Ready? It's still a shoulder. Okay. So, guys get your void on a taking place. Okay? So we're going to talk about so that we just talked about the differentials. Now, now I'm going to talk about it. Very specific skill. Okay. Presenting the history, um, hair and also easy. We like to teach the present presentation of history of a specific way. Ah, a little the animations up. So this is a sort of approach we want to do. Two presenting a history. So you've taken the history, and then the examiner asks you to present the history to them. This is the kind of approach that I think works best to make sure you're hitting the key points. So the key thing you want to remember when you're presenting histories to be examining is that you want to make sure that you're not just repeating back the patient's history, okay? You're not just regurgitating what the patient said to you and telling that back to examine her. You're presenting history to the Examiner. You're trying to show the Examiner that you've really thought about what the important relevant stuff is in the patient's history and that your articulating it properly. Okay, so when you presenting history, so always start with patient details again what their keep resenting complaint was. Okay, so in this face, this case today I spoke to Mr Bruce Wayne, a 64 year old man who presents with central crushing chest pain. And then we're going to history of present company. Okay, so you congest go through your sokrati. So the chest pain started two hours ago. It's radiating to this shoulder and down to his job. Um, associated symptoms include shortness of breath, dyspnea. Um so again, just go through the Socrates. Is it responding to GTM spray That's another good thing to include relevant. Negative. So can you just tell me, what do you think I mean by relevant negatives? When you're presenting a history, what do you guys think I'm talking about when I say relevant negatives? What? What would relevant negatives mean? Yeah, good. So things that rule out conditions, Yes, that relevant, active things. So things that the patient doesn't have that would make you think of other differentials and also things red flag symptoms as well. Okay, so that's what I'm getting out with the relevant actives, their symptoms that rule out other differentials off that presenting a plate. And it's also red flag symptoms that the patient doesn't have. Okay, for example, with back pain. A big one, to always mention, is that a patient doesn't have saddle anesthesia or and loss of yeah, about bowel incontinence or urinary continents. Okay, because the big red flag with back pain is thinking about quarter quite a syndrome. Okay, so a similar thing, but chest pain rather than negatives, so you can say things like the patient doesn't have a history of fever. There's no history off recent viral illness. There's no history off being a stronger embolism. Risk factors. Okay, so this the symptoms that's helping you rule out other differentials off the chest pain. Okay, so that's what relevant actives mean on again. This is a This is something you could practice for a lot of common presenting complaint. Okay, you can practice saying relevant negatives that I don't I just that are specific to representing a great. Okay, So the classic one with chest pain is saying there's no venous thromboembolism risk factors because that helps to rule out a pulmonary embolism. Okay, in terms of the other stuff so well, a vint past medical history, past surgical history, social history, drug history. So this is really important. So the key thing is, you don't want to just repeat the entire history back to the Examiner, okay? You just want to be able to pick out the stuff that's really important. Okay. For example, if they have a history off, talk to diabetes history off it's chemical disease, that that would be very relevant. Okay. To present, um also mention if they have any allergies as well. That's a big thing to remember to present as well. Mention what the patient says in the terms of their ice. Okay. In terms of what they're ideas, concerns, expectations are okay. That's a good ones. Always include. And then finally, you want to come to your top differential and why? Okay, so you you have a differential diagnosis in your mind. But first present where your top differential is, So you could say something like my top differential is acute coronary syndrome, based on the patient's presenting features off acute cardiac chest pain radiate into the shoulder on draw on. Because of a significant history of cardiovascular risk factors, that would be my top differential. Other differentials that I would like to exclude include aortic dissection on do a pneumothorax. Okay, you start with your top differential, okay? And you give explanation for it, okay? And then you present some other differentials that you would like to rule out. Okay? That's how I would go about presenting the history. And then you can start talking about investigations for the chest pain. Okay, so we're going to about chest pain investigations. Can you guys tell me what is the approach to classifying investigations? How do you split up the investigations you're gonna perform? That's Yeah. Bedside bloods imaging. Good. Okay, that you can also use the boxes approach. Okay, but because I prefer the bedside bloods imaging and special tests approach, okay, because I think that's a good, systematic way of going through it. Okay, So going to talk about the investigations with chest pain on here, we So with these asking sessions we like the way we tend to teach investigations is that we'd teach investigations for the broad presenting complaint first. Okay, so in this case, chest pain. So we teach the investigations that you would do for any chest pain. Okay, No matter what the cause of the chest pain is, there's There's a set of investigations that you would do just because it's chest pain in your ski. And then if you haven't idea of what the pop differential is, So if you think the diagnosis is acute coronary syndrome, then you can add some specific investigations based on that. Okay, but we're going to first talk about investigations that you would do for any different any chest pain complaint. Okay, so for any chest pain you mentioned, you do it and 80 assessments. Okay, this is ah, gold standard statement for any acute emergency to say mentioned you could do basic observational. Get a new shot you mentioned. You do Cereal CGs okay? Yeah. Monitoring. I mentioned that you do a cardiovascular examination. A respiratory examination. Do a urine dip. Okay. Checking particularly checking for glucose. And you also mentioned that you do a glucose blood glucose measurement in terms of blood test. So you mentioned doing a full blood counts. Okay, So, typically checking white cell count. That's high LFTs. A useful to check for liver function you need so check renal function. Okay, second safety check. It gives it on medications. ABG is always useful to mention for the acutely unwell patients. Okay, Just because if they're keeping a unwell, you want to get an accurate value off their oxygen. Okay, Okay. You might argue that you can just say BBg. Okay, I would argue that it's it's in your skin. You can just say you would do an arterial blood, Gus. And to get an accurate value off their oxygen levels and inaccurate, accurate evaluation off the acid base status, someone said why you're in depth. So urine dipsticks can be very useful. Okay, basically, you want to check glucose for diabetes. Uh, BMP for heart failure. Yeah, you can mention BMP for heart failure. That that's a reasonable thing to check is, well, chest X ray as well. Super crucial, too. Mentioned that you had a chest X ray. Even if you think the likely diagnosis is a cardiac cause of chest pain like acute coronary syndrome, I always say that you do a chest X ray because you want to show the Examiner that your ruling out differentials like you're thorax. Um, that's a big difference. You want to be ruling out with the chest pain pneumonias as well looking for Consul it consolidation. So always mention that you do a chest X ray for anyone with chest pain. Okay, The big thing with osteo is is that you don't need to worry about doing too many investigations. Okay, as in, you don't need to worry about sort of health economics on straining resource is on the hospital or anything. You just you just need to be a You can do as many investigations as you want, as long as you're able to justify all the investigations. Okay, so that's the sort of investigations I would do for anyone with chest pain Now, in terms of specific conditions, Um, let's talk about some specific extra investigations you can do. So this is some other differentials of chest pain that I've included. So, for a C s, I'd recommend saying that you can check lipid profile. Okay, get a good but measurement off the cholesterol and lipids levels. Crawling screen would be useful as well. If you're going to start prescribing antibiotic Lintz hate to even see for diabetes. Okay, as someone asked, Why glucose? So it's it's always good to check. Do coz levels. Typically, you know DK's Well, it's a good differential to realize it's just good to get accurate measurement off that glucose in case that diabetic, um oh, so you could mention you do a coronary angiogram. Okay, so corny angiogram. This isn't something that you would perform by. You can just mention that you would consider referring them for a coronary angiogram. Same investigations for angina, stable angina on. So that's the sort of major cardiovascular differentials. A little section. So big thing to remember with aortic dissection is that always mention that you do a group and save and cross match. Okay, Because a lot of most patients with aortic there sections will need to be taking for cardiothoracic surgery for treatments on. So always for any patient you think is going to need to have major surgery mentioned that you do a group and save and cross match. Okay, So that you really you thinking proactively for the patient because, you know, the patient's going to need to have surgery. So you're you're actively organizing blood products for them and mentioned that you, uh, go sounded investigation to diagnose dissection is to do the CT aortogram. Okay, uh, probably embolism. So do this because this is quite a common situation. So you need to be able to determine if you need to admit to patient with me and is, um and that the main way you can do that by using the scoring system so well, it's going to pick school. So well, school. Is that pretty much the gold standard for investigating? If a patient needs to have a ct pa with the primary embolism so well, school is ah, I have a patient has their high Well, scores are a score above four. That means that it's likely that they have a P. And you can take them straight to have a CT pa done. Which is the gold standard investigation for Conrad embolisms if they have a low well score, But but you still think that they have a program Bliss. Um, then you can check that d dimer levels. And if the d dimer level is high, then you could do a CT. Okay, so the well score basically helps determine how if they need to have a seat be done immediately. Okay, perks goes, What is it? What is it? The use of one to measure a swell. Okay to calculate. So her score. If someone has a perk school off zero that basically rules out a pulmonary embolism. Okay, so these are the really important scores that I would recommend you mentioned in your Aussies. And again, you can talk through how you would use the D dimer and CTP a based on the patient's well school. Okay. And for pericarditis mentioned CRP for because inflammatory marker and you can also mentioned that you consider an echocardiogram in case they have developed an effusion. So that's the sort of investigations for chest pain. Okay, That's how I would go about learning investigation. So I'd recommend just learning investigations for broad presented complaints. Okay. To learn investigations for chest pain, shortness of breath, abdominal pain. Okay, the broad presenting complaints, and then for specific conditions you can add on certain investigations. Okay, Because you want to make sure that you're showing the Examiner that you're being really safe and really thoroughly thinking about the differentials. Okay? Okay, Now we got a blood test for you, so we're going to start some data interpretation now on. I want you guys to just present this, interpret this blood test for me. Uh, take some time to think about what? The abnormal findings up. Yeah. We haven't think what the positive findings on what they indicates. Yes. Someone said proponent so yet? So let's go. Let's talk about this. So you're positive. Rise in Poland. Four hours yet. Increased reporting. White blood cells increase increased white cells. Proponent, get Okay, so we're gonna I'm gonna talk a little bit about how you presented data in your osteo. Okay. First, can you guys tell me what is the first step in presenting data in your osteo? Any type of data. What's the first thing you always start with when you're presenting data in your house? Key? Yeah. Good patient details. Okay, so that's the first thing with any kind of data. We're gonna stress this throughout the series. Okay? First step is always patient. Details, date of birth. Um, and if you know what, The patient's presentation, it's okay. So when you presenting data to the Examiner? Always mentioned. So this is a blood test it off. Mr. Bruce Weighing a six score. You're a man who presented with chest pain. Okay, first sentence for any data interpretation, and then you can talk about what the blood test is showing. So this is a blood test, which has values for various different parameters, including proponent, including creatinine kinase levels and including electrolytes. Okay, So again, if you're just talking through the data, okay? I haven't even come to any of the abnormalities. I'm just talking through the data to the exam, not to show them I've actually read through the daytime. Understood what the date is representing, Okay. And then you can talk about what the positive findings are. Okay, So in this case, I've put in red, but the sort of abnormal findings. Also, this patient has a an elevated white blood cell count's okay, It could be a sign of infection. Or And this patient has an elevated troponin T level at four hours. Okay, compared to admit at admission when it was normal, uh, so increase Scripture opponent could be a sign of cardiac to skip stomach damage. Increased cramping kind is a swell is another important marker off the stomach damage and increased cholesterol as well. So this is in keeping with the patient's abnormal lipid profile. So again could be a contributing factor to the patient's ischemic chest pain. Okay, so again, it's it's not just about be able to say which blood test values are abnormal. Okay? It's about just talking through the blood test in a systematic manner, always starting with the patient details and hh. Okay, Uh, so remember that approach for any type of data I'm going to present you guys? Okay, now we're gonna talk through some easy gs, and I just put this light in, in case you wanted some revision on how you play CCG least cause that can commonly get asking us up and you're asking. You can be asked to put on the CT leads for the on the patient. Okay, so I've just put this, like to help you guys. Remember where all the different needs go so you can use it for your revision on how the Examiner has given you an HCG and as asked you to interpret it. So can you guys please interpret these? Present this easy to me on DA. Let me see. See what you guys think. Good. I like that. Someone said patient details. Very good. So that's the first thing. Okay, get good that you're listening. When was the EEG done? Good. So that's another important information that you want to be getting. Okay, so once you once you've done the basic you found the basic you presented the basic patient information, then you can talk about the specific G BCG. Okay. Remember, you also want to mention what the calibration off the CT is a swell. Um, so yeah, So that yeah, let's first talk to you. The different things you want to be talking through. So? So the first thing I mentioned is patient information ECD information. Okay. And then you can if there's any obvious abnormalities, you convention it, Okay, But I'd recommend just going through the EKG in a systematic manner. Okay, so first thing I mentioned is the rate. Okay, calculate the rate. So if there were, we go by the rate here. So the easiest way to calculate rates is I see is that the rates you just, um, cuddly the difference. The number of squares between the cure is complex, and then divide 300 over that. Okay, so the rate here would be about sort of 90. Okay, Um, so this is the sort of three and a bit square, So if you divide 300 so that's about 100 to 90. Okay, then you can go. Then you move on to rhythm. Okay. Rhythm. How do you determine rhythm? So rhythm is basically that ah, number of the space between tourist complexes is the same. Okay. And then you're Oscar. You can demonstrate that this by taking another piece of paper and then drawing on during to curious complexes and then checking the the distance matches between each correct complex. Okay. So, again, it's just showing to the examiner that you actively trying to figure out if the rhythm is regular. Okay, so the rhythm is regular here. Uh, then you can move on to, uh, be ways. So anyways, so is the P waves before every single curious complex s. So there is a P way before each curious complex here. I'm looking at the rhythm strip, okay. And your ski. If you can't figure out anything that's wrong with the CT, just go to your rhythm strip. Okay, so there's three ways before every single curious complex P waves are operates their upright in lead to, uh, operating lead one and that inverted in a via Okay, so that's a That's a normal finding in a V A. Uh, if you guys are struggling with the seeds, Remember, we have a CT station and a couple of weeks as well, where we'll talk through some of the basics off your SED interpretation and some more complicated cases. But I'm just trying to give you some of the basic guide. Um, so we talked about the waves soapy right. P waves normal. Um, then you can move on. Then you want you can mention the PR interval. PSA PR interval is normal is well okay. It's not prolonged. Then you can mention the curious complexes. So with us complexes, you want to mention if they're narrow. Okay, so these are narrow. QRS complex is normal amplitude. Okay on. So that's a cure. It's complexes. Then you can talk about ST segments. So is that evidence of ST Elevation or depression or any abnormal? Um, no abnormal feature features off the ST segments like a saddle shaped elevation. Okay, there's no evidence of ST Elevation on this CCG. Uh, then you can talk about, uh, t waves S o T waves. So in this E c T T waves are normal. Okay, They're upright and, uh, inverted in a via Okay, that's normal. I'm sorry. I think I might have said P waves inverted a navy as mobile. I'm sorry if you should be up. Up, right. Um, so yeah, that's that's so you talk about at T waves. Uh, then you want to mention the cardiac access. Okay. So? Well, if you don't know how to work out the access again, we'll talk about that in the CT station. But in this patient, be access is normal. Okay, so we have positive deflections in lead one me to lead three and a BF. Okay, so the road positive deflection, that's that's a normal cardiac access. Um, so yeah, that's that's how you break down the CT into its components. Okay, So for any CD, I would just present it in that way. Okay? Just going through each different components off the CD. And then finally, after you've done that, then you give what you think. Then you give them, you interpret the CT. Okay? What? The findings are from the CT. So can you guys tell me what is the diagnosis from the CCD? But if someone presented you the CCD Well, it was the final diagnosis. Yeah, it's normal. Okay, this is a normal E C g. Okay. This patient is in normal Sinus rhythm. Okay, But that again, even though it's a normal even though this patient's in normal Sinus rhythm, I'm just talking through the entire ECD. Okay? It's all about your skin. It's all about talking. Okay? You should feel like you. Just when you're Oscar after just one. The Oscar after you've done your skis. Okay? Yeah, because just talking through everything. Okay, so let's go into some abnormal EKGs now. Okay, We're not We're not gonna We're not gonna go to the systematic approach for you a CT CT, Okay, We'll just talk about the likely diagnosis. So can you guys interpret this easy for me and tell me what the likely diagnosis is? Yeah, a antihistamine. Very good on the anterior lateral stemi. Okay, so there's ST Elevation in the anterior leads on in the lateral leads as well. Okay, so as the elevation and B one B two B three before before I V six ST elevation and lead one and a V L, um, reciprocal changes in the inferior leads as well. I guess that there's ST Depression and leads to lead three. And a BF Okay is a classic easy gi for Antara. Lateral stemi. Okay, um so hopefully you guys were able to pick that up. If you don't. If you If you're struggling with that, remember your SED territories. Okay, so I've I've just put on the well, each lead corresponds to in terms off the coronary artery vessel territory. So remember, your B one to be four is your anteroseptal. It's okay. We won't be too. Is septal be three before is bit more anterior aspect. Need one. Um, a video on D V five b six are your lateral leads. Okay, um, on your inferior leads are your leads to three and maybe a. Okay, uh, can can you tell me which coronary artery corresponds to the anteroseptal? It's a lady Goods. Which coronary artery corresponds to the lateral leads? Typically circumplex good on your inferior leads. Typically, which ones are we thinking about with your inferior leads? Yeah, you're right. Right. Coronary artery. Get, uh, yes, I remember your coronary artery vessel territories. Okay, if you're doing a cardiology station in your ski on your skin, you're almost You be pretty confident in that you're asked to interpret a patient with ST Elevation. Okay, so you need to be pretty confident in knowing your sed territories. Um, I got another similar case. We If you know your territories, you should be able to interpret this. What do you think? Inferior ST MI. Good. Okay. So again, learn your territories. Okay. This is ah, inferior stemi. Um, so this is these are what you call hyper cute t waves. Okay. The classics, classically seen you see a patient very early on in there if they got stomach. Okay. And but in terms of the leads, remember at least 23 and a VFR your inferior leads. Okay, So least 23 and a BFA are inferior leads on this patient also has a reciprocal ST depression and lead 1 80. Oh, Lieberman. Avia. Okay, the lateral beats again. There's also some ST Depression B one B, two years old, So that's an inferior stemi on. I've also got this ECCP This is ah, bit more slightly tricky virus sed. What do you guys think is going on here? So it's not a heart block, remember? With heart blocks, you'd expect bradycardia. It's remember, if you remember, go for your rate. Um so great ears, um, out of hundreds of remember hot box for bradycardias. Ah, yeah, I think a couple of you got it. So LBBB good. So left bundle Branch block created this. That's the diagnosis in this patient. So, um, we'll talk to you. Why can you tell me what's the classic SCG? We'll see Manisa. The abnormalities that points towards the left bundle branch block. Here you go. Did that some people saying marrow. Sorry. Um, William so, Yeah, you can look at the w shape and B one and ah, um, shape and B six. Okay, I don't find that particularly helpful, but to be honest, the easiest way I think to look for a left bundle branch block is to look for broadened curious complexes and B one. Okay, So remember, with a bundle branch block, you'll get widened. QRS complex is because it's taking longer for ventricular depolarizations happen. So you're correct. Complex has been a wider, and the classically with a left bundle branch block, you'll get a primarily a negative deflection and be one. Okay, So a negative deflection with a broad, curious complex and B one, but a positive deflection in B six. Okay, that's a key thing you want to be picking up with a left bundle branch block. Okay, um, also, uh, also in the left bundle branch block. You can. There's classically you'll see left axis deviation. Okay, but, uh, there's not significant left axis deviation. This patient okay, this upright and beat one down right in a V f only three, but they're really to is bit by physics, so it's got the access. Isn't that disrupted here, but yeah, this is a left bundle branch block. Okay? Can you tell me I'm in the context off ischemic cardiac chest pain? Why is a left bundle branch block clinically significant? Why am I talking about left bundle branch blocks here? Yeah. Good. Okay, so a new a new left bundle branch block in the context off acute chest pain. You treat that systemic? Okay, if they have a new LBBB, you put them down. These stemi popery. Okay, that's so examines my trick. You into into Mike Tricky and your skis by showing the CCD. And you might not think this is Ah, steam, a cardiac chest pain. Okay, but if they presented, they're features often acute coronary syndrome. And this is a new left bundle branch block. You're gonna put them down the standard popery. Okay, some of that's what would be the finance. All right, bundle, Branch block. I was talk about that later. Okay, Dorie, but yeah, those are the sort of we talked to some key CDs of a skin testing. Uh, now we're gonna talk. Move on to management. Okay. We've covered Are investigations. Let's move on to the acute management can you guys tell me, what is the approach to the management off the acutely unwell patient? What is the approach? Ah, the moans. Moaning specific for a C s. But what's the general approach? 80. We approach good. So let's talk about the ABC The assessment off acute coronary syndrome. So we're going to go through this systematically. Okay. Know is this is not This is just anything you do for a to assessment, but we'll add in some specific things you would do for a C s. So, in terms of your airway, what you going to do for the patients? Check patency. Okay, check of they're responding. What else? As the oxygen. That's that's for that's breathing. Okay. Auction giving auction. It's part of the breathing aspect. If there's any noises, Yeah, you might need to do airway maneuvers and things. So that's the key things with airway. Okay, check of the patients talking. You might need to perform. Area maneuvers are used adjuncts like nasal pharyngeal tubes or found your tubes if there's compromised. Okay. In terms of breathing, what are you guys gonna be doing in terms of the breathing? Yep. Check for trickle deviation. Give auction. If they have low sats, check respiratory rates. Check oxygen on a pulse. Oximeter, check. Chest expansion. Ah, yeah. Percussion get. Remember, you always remember percussion cause we're thinking man pneumothorax so good. There's a cousin likes turkey, things we're going to be picking up Check. SATs check. Respiratory rates Accustomed auscultate. So okay, check the tracheal deviation. Doing a BG. Okay. Remember your ABG score your breathing aspects and give oxygen and 50 needs is by a non b beat musk. Okay, so some of that's what this beast I'm supposed to be. So, in terms of a B c, the assessments that this is a ways reading circulation, disability exposure. Okay. Sorry, buddy. So we just did breathing. So in terms of see circulation, uh, what do you guys gonna be doing? There's a couple of steps you need to be doing specifically for a C s in. See? What do you think? Sed good. Okay. Yes, it is very important to mention BP. Heart rate couple refill. Get IV access. Good. Ah, give gtm spray aspirin. Yeah, not pressure. Good. Okay. I think you guys got almost of them. So let's talk through it as yet. Good. Good. Assessment off the fluid status. Okay. Uh, Chek Pulse. Blood pressure cap Refill. Check. Heart sounds. Okay. Uh, you have to mention you get any CT. Can you start cardiac monitoring? Established intravenous access with a big cannula. Okay. Ah, wide board cannula. Take bloods again. We've talked through these bloods before. Uh, start fluid resuscitation of it's appropriate. Okay, if the hypersensitive the signs off, um, fluid, like of fluid in the body stop fluid resuscitation. Okay. And then you want to do your Mona. Okay, so remember we classically with a C s, we're gonna start the give Mona. Okay, so give morphine. Um, 5 to 10 mg give a gt and spring. Okay. And, ah, especially if they have angina. They might already be carrying Indy chance Brace that. Advise them to take that. Give aspirin, loading those 300 mg on given anti emetic. Okay, usually something like cycles me. Okay, so that's the sort of circulation aspect. Uh, in terms of disability, what do you guys gonna be doing? GCS pain instead of GCS. What else could you use? Yeah, after I recommend using after you and your osteo. Okay. Just because It's a lot quicker, and it's it's a lot easier to do than checking about the actual GCS. Um, yeah. So check alcohol level check of peoples are equal and reactive to light, chap, the capillary glucose and keeps on level inspect for signs of cardiovascular disease. Check temperature. Uh, I I should have asked you guys. So in terms of ee. So you want to be inspecting for signs of cardiovascular disease? Okay, so, um, so check if they things, like if they've had a CABG start, that would be very relevant. Okay, check that temperature. Okay. So, um, get an accurate measurement of that temperature. Do your analysis. Okay, Um, dipstick, get a catheter in, okay, Offer it to instead of catheter and so that you can closely monitor urine output and also request the chest sexually. Okay, because this is really important. Make sure some people like to mention they do a chest X trait during the breathing assessments. Okay, It I don't think it matters too much. Okay, but make sure you mentioned that you'd risk press request the chest X ray because you want to make sure you're ruling out a pneumothorax and pneumonia. Okay? So that's the sort of a B C. The assessment of an acute coronary syndrome. Okay, hopefully, you guys are pretty confident in that. Okay? You guys need to You need to be able to manage a heart attack. Okay, You're going to see it some day, so make sure you're very confident in these different steps. Okay, Um, so in terms of other steps, so if patient becomes unresponsive with no signs of life, because begin CPR, Okay, after that, you want to discuss with you? Tell the Examiner that you discussed with the on call interventional cardiologist for urgent PC. I okay, if they're suitable for PCI on, you can you should always offer to reassess a B c d. Especially if there's any sort of changes during the assessment. Always offered to reassess to re do the restart, the ABC, the assessment. Okay, okay. We're gonna quickly cover Esposo. This is we're gonna go through this a bit quickly because I want to make sure. Sure, you guys get a good, decent break. So, Esfahan of us that this is the approach, Teo communicating information. So we're gonna go over this quickly. Hopefully this is something you might have come across but s far is basically the standard of care approach to communicating information to patients and as far basically stand school situation, background assessment and recommendation. Okay. Um, I'll just we'll just go over the sort of keep principles you're thinking about with spots with the introduction. You want to clarify what your name is? Okay. Clarify where you're calling from. If you're calling from the emergency department, Uh, what, your greatest. Okay, if you're a foundation one doctor And also clarify who you're calling if you're calling a medical registrar and clarify what? Their greatest Okay, um, so that's with the introduction, then the situation. You're basically giving the breaking news off. The patient's okay. You're giving the reason for calling them. So again, you're giving the reason for concern of cool. You're giving the patient details and where they are currently. Okay, if it's so, we'd be talking about Bruce Wayne, who is currently in the mostly department on what their most pertinent problem is. Okay, So the actual most important reason why you need that person to come to that area. Um, so that's the situation aspect now, with background. So the background aspect of exposure. Background is basically where you're giving objective information. Okay? Stuff that you know about the patient to be true. Okay, So things like admission details. Okay. If when they were admitted, Want to summarize what the clinical presentation is and they're working. Diagnosis. Any relevant past medical history, risk factors of red flags, any relevant medications, any relevant investigation results. Okay, if any investigations that you've done want to mention that with the background. And also they have had any allergies as well. Mention that all in the background of aspect until the assessment. So this is what you've just done for the patient's okay? In terms of your examination observations, anything that's changed. Okay, that's what you're doing with the assessment. So give them the news what their new score is. Okay. Any relevance examination findings? What investigations? You're still waiting for, uh, what you've done for the patient so far? What type of medications you've already given to the patient. And what you think that your what your overall clinical impression of the patient is okay, if the patient is clinically deteriorating or they're stable, Okay. Just mentioned that as part of your assessment and finally in terms off recommendation. So, commendation. Is that what you're suspected? Diagnosis is, and you might want to give some differentials. You can also mention what you what you want the person to do. Okay, What needs to happen and when it needs to happen, so always qualified. Both of them. Okay, How urgently you need stuff to be happening on. This is a big statement to mention with any esposed a shin always mentioned to the other person you're calling. Ask them if there's anything else that you should do. Okay, Because it might have been stuff that you missed out. So always make sure that you ask, Is there anything else that I should do? And you can also ask if you want the patient to be transferred to another place. Okay. The register. I might ask you to transfer them teo I to you or transfer them to a different word, for example. So again mentioned that in your recommendation. Okay, so that's your s your hand over. Now we're gonna gonna give you a sort of a template for espada. Um, I made this table with this example patient brief with a bunch of information about a patient. I'm basically going to try and summarize that information in the form of SVR. Okay, You can have a read off the actual information when you get slides. I'm just gonna give you a Ah, a template for how I would go about presenting an SPF on this patient. So I start off with saying hello. I'm asking is eat the f I One doctor on call in the emergency department. Is this the medical registrar and then in terms off situation? So then I could say I'm calling because I would like you to surgeon the review. A patient who has presented acutely unwell the patient is called Bruce Wayne, a 64 year old man, and I am concerned that he has developed an acute coronary syndrome. Um, so that's your situation. And there's a background. So you're giving objective information about the patient so you could say his symptoms started one hour ago, including central just pain radiating to the left arm and draw with associated dyspnea. He has multiple cardiac risk factors, including hypertension, which is managed with ramipril and type two diabetes management metformin. He also has a significant smoking history and he said he was performed and showed ST elevation in the anterior lateral leads. Chest X ray and a BG were normal. Okay, so that's your background. So I've given objective information that hot that I know is true about the patients and then in terms of your assessments s Oh, you could again some of the new school. So the patient currently has a new score off their team due to being tachycardia at 140. Hypotensive with the BP off 90/50 despite a 500 mL. Crystalloids stop us Rough respiratory rate is 28 ends. Saturations are 92% on hundreds and auction by a 15 beats and non rebreather mask. Okay. Always clarify what type of auction there is receiving. He's currently a little and a fibro. I have started cardiac monitoring and have given an antiemetics. I've also given aspirin. You're on the milligrams clopidogrel, 300 mg on morphine, 5 mg okay on by am still awaiting the results of blood tests, including troponin levels, and then finally recommendations or what? You want the patient What you want the registrar to do? So I mentioned this patient suffered an entre lateral stemi and needs an urgent assessment and should be transferred to the cath lab for PCI. I would like to ask if there is anything else that you would like me to do for the patients. Would you be able to come and review him as soon as possible? These. Thank you. Okay, So that's how I would do the s far 100. Okay. Um, so again, it's about presenting in a systematic manner. If you know, the basic principles are each aspect of the s far, it should be a lot easier. Okay, but that's the SVR handover. I hope that tempting is useful. Okay, we're gonna wrap up with ways to break now. So this is just the summary off the night skyline, some managing a C s. Okay. Haven't really when you get the slides, but I'm gonna go through it. But remember, with Stanley's, the criteria for PCI is if they present within 12 hours, and if PCI is available within two hours on, I'm gonna ask you this question. So the examine you presented the management off a. C s. Now the examiner's asked you one of the contraindications to figure in a license. Can you guys tell me, what would you answer? So this is a viable question. The Examiner's just ask you subarachnoid hemorrhage. Intracranial bleed. Good. What else? Recent head trauma of GI bleeds. Good recent stroke. Yeah, I I like to remember pneumonic. So bathtubs. Um, so I buffed Lance back on. So this is the sort of different contraindications that you can remember. Okay. Big things to remember if they have history of bleeding dissections. History of allergic to it. Um, history of CNS neoplasm. These are big contraindications. I like to remember, but if you prefer a sort of actual table Ah, this is a table to off the different contraindications. Okay, So absolute contraindication Zar listed here mellitus contraindications are listed here. Okay, So a relative contraindication means that you basically need to balance the risk off giving fibrillation since and wait. Sorry. The balance. The benefits of giving February license against the risk off harm to the patient. Okay, that's what a relative contraindications means, but yeah, those are the contraindications, the fibrillation. Since so, if a patient is not suitable for PCI therapy and you're considering figure it'll isis, these are the different things you want to be thinking about, Uh, this is basically at the algorithm for, and stem is an unstable angina. Okay. Haven't really been together slides. It's a bit different. Teo Stannis. Okay, remember, with estimates and angina unstable angina, you wanna be calculating Decrease school. Ah, and yet so we're going to wrap up the A C s bit, but we're just talking about the chronic management of a C s. And then we'll take a break. So remember, when you presenting management's, you always want to be thinking about conservative management, medical management and surgical management. Okay, uh, conservative management always talk about the MBT approach. Okay, so they'll be input from GPS physiotherapists. Cardiologists mentioned that you would do a full functional assessment, so assess and manage. And he called my abilities that they have. Whenever you're presenting management. I always like to present talk about charities and societies, Okay, because it shows that you're really thinking holistically about the patient. So a good one for cardiovascular disease to mention is the British Heart Foundation. Uh, conservative again. Lifestyle changes, exercise, dietary changes. But you can mention cardiac rehabilitation programs that are available to patients who have separate M I C offered to tell them to stop smoking. Okay. Offer smoking cessation services, nicotine replacement and things like that, Uh, driving advice. Uh, this is interesting. Can you guys tell me, uh, when conditions who have had a how the tax start driving. Who have had a you had in the CS When can they start driving? Ah, so someone someone's got someone's absolutely nailed that. So one week Postangioplasty on four weeks if they haven't had an angioplasty. Okay, so if they've had a stent and it's successful, they can start driving after one week. Okay, if they haven't had a stent or it was if they understand, but it wasn't successful than it's four weeks, okay? And so Yeah, good knowledge. Their sexual activity advice. Uh, again, this is interesting. Can you step? So if you're asking if the if the actor asked you when can I start having sex again? So they just had an m. I They're about to be discharged. When would you say When Would you advise them to wait before they can start having sex? One month? Yeah. So, basically, you should get done. We advise them to wait a minimum off sort of four weeks. Okay, before you, they can start taking burning sexual activity. Okay, that's the sort of minimum waiting period generally. So that's your conservative management in terms of medical management. So remember stool antiplatelet therapy. So, um, is usually continued for about a year. Uh, southern butter blockers. It's inhibitors statins on. If there's evidence off, well, be dysfunction. You can start them on aldosterone and tightness at something like spring locked. Um, okay, So these are this is your sort of chronic long term management after the A. C. S. Okay, I'm going to skip over this bit. Okay. Uh, just because I wanna take a little break, but this is basically slide about explaining angina to patients. Okay, This is basically how I would go about structuring consultation about explaining enjoyment for patients on. I read when you get it on down, I basically presented the management off angina to these are the nice guidelines for the management off stable angina, remember? Start them on a GTM spray. Oh, patient should be given G 10 spray if first line medical agents of things like Peter blockers or a non diary period and calcium channel blocker for stable angina. Um, second line you can combine beat the blockers and a dihydrocodein calcium channel blocker. Okay. Remember, you never combined beater blockers where things like Barack. Um oh, okay, cause that can cause significant ab note suppression. So you combine beats blockers with a dihydrofolate in, cast it on a blocker, and then third line. You can use other agents like Nick around. Oh, I've abrading all refer them for revascularization therapies like PCI. Okay. Oh, yeah. I'll talk about GTM sprays a little bit, and it's actually I was thinking about this because of the sexual activity. If someone has a GT and spray, what else did you need to advise them on? If there have a history off erectile dysfunction in your skin, this might be a common thing that you can come across. Yeah. Good to avoid till then, if. Okay, so you might be asked to sort of counsel patients on cardiovascular drugs. A big thing to mention with D 10 sprays to avoid, um, drugs like sildenafil. Okay. Biography. Okay. Or if they are taking gets, you shouldn't be taking your GTM spray within 24 hours off your, um Viagra. Okay, that's a big thing to think about with GTM sprays. Um, yeah. Okay. I'll leave it that it'll take a break. I think that I was gonna heavy hour, and then we'll start moving on to other things. Let's take a 23 minute break there. And if you guys have any questions, we're gonna move on to talk about a rhythm, ears and heart failure. Okay? You don't send the feedback from now. Yeah, Yeah. Send it. Send people from now. You got it. But the others light in quest. Mint know. Say they're in mental question. It is a, um, using question. Banks. Guess lights and recordings will all be on metal. Oh, fine. Okay, So we're gonna move on to talk about a rhythm years and heart failure. So we've got a bunch of the CDs coming up on you guys. I'm going to present you the CD. You guys are gonna come up with the diagnosis, and then I'm gonna ask you guys to present your management plan for that patient. Okay, So the roles were a foundation doctor again, Still in the emergency department. Okay on. But we've been asked to see Ms Romanoff, a 45 year old women who has heart and electric cardiogram taking me in the CT. Take it. Please review the patient's e c d and make an appropriate management. But okay, so that's the station we're gonna work through now. So we got a bunch of STD's coming up. So can you guys tell me what is the diagnosis off the CCD again? Remember, your actual osteo you guys are going to systematically present it. It's starting with patient information and then working through the different aspects. But for now, we're just gonna go through the diagnosis now in our complex tachycardia. Good. But you need to be more specific what you can. What do you guys think about the It's different cause of now a complex tachycardia, right? What do you think this isn't? This isn't ventricular tachycardia with remember? Well, I'll show any city of be tag with v-tach You get Broadcom flexes. Yeah, you're gonna SPT Yeah. Super ventricular tachycardia. Okay, so with SPT so classically with SPT you get narrow, complex, narrow QRS complex is, uh because conduction atria does conduction through the ab note. There's, uh is regular rhythm. Okay, there's no p waves. Okay, Um, I can't see any p waves. Okay, if there are any ways, they they're either blurry. Buried in the cure is complex. Are sort of inverted just after it. Okay, But they're keeping with SED. You don't get you can't really see Peewee. It's too narrow. Complex talk tachycardia. Um, that's the classic description off SPT. Okay. Again in your actual osteo. Just talk through all the different aspects. Rate rhythm, P waves, the waves, course complex ST segments and cardiac access. Okay, but this is a CT again. Yes. Tell me, how you going to manage this patients? What kind of things would you be talking about? To the Examiner. What's that? Was the first step. Okay, what's the first step before you start talking about vagal maneuvers and everything? If this is a patient presented acutely on Well, what's the first step? Good. Always. I'm going to stress that. Always states start with a B C. Always start with a B C D assessments. Okay, for when you're presenting management for these conditions. Okay, Um and that you want to You want to check your best stable or unstable? Okay. If you when I work out if the hemodynamically stable or hemodynamically unstable because that's going to determine which what type of management you did. Okay, so let's talk through the management of STD. So this is basically a flow chart off the way we do things and SPT so again start with the ABC the assessment and then work out if they have out of her speech is okay if the human anti stable or unstable. So if they he didn't even definitely unstable it, if they have these out of a speech is, then you go straight for DC cardioversion. Okay? If they have, if they're stable and they don't have any of these speeches, then you start with bagel maneuvers. So things like cross it's Sinus for such are salve a maneuver. Okay, you get a common way they do. It is they get people to blow into a syringe on to try and increase able to him. And that often does help resolve the arrhythmia. Uh, with CrossFit Sinus beside you, when would you be very hesitant in doing across his Sinus? Besides, when would you avoid doing it? Yeah, they have a bruit. That's the big one. Okay, that if you also take to them. And they have evidence of a carotid bruit. Oh, are you know they have You know that they have evidence off big. If they have a risk of embolize from the cross your artery, then you gonna avoid doing cross to sign. It's been such okay, because, you know, you don't want to dislodge any embolize and cause a I'm a stroke. Okay. What is that? Bruit So bruit. So it's when you also take it. And you hear that murmur over the carotid artery because of stenosis there. Okay, Yeah. That's the sort of a cognitive issue. That's where you got to start with. If they don't respond to make a maneuvers, then you move on to giving policies of identity. Okay, so we started 6 mg. If that doesn't work, go to 12 mg, then go to 18 mg. Uh, you're asking what do you What? What would you advise the patient if you're gonna give them a dentist in what you need to warm the patient? Yeah, that Yeah, the feeling of impending doom. Okay, that's a big thing. You mentioned it. You get this sensation of impending doom. Okay. When you flush adenosine through patient. Um, also, make sure when you're doing it. Make sure you you have you're flushing the adenosine down as quickly as possible and you're giving a saline flush straight after it's okay. And make sure you've got the CT ct monitoring happening at the same time. Yeah, that's how you give a damn is een. Um, but yeah, that's the sort of approach to do it. And remember, if they have a when is that Energy and Contra indicated When When would you avoid giving adenosine? Yeah, asthma. Okay, It's a lot of it. They have very brittle, like non not significant aspect often is given, but they have a significant of significant asthma. Avoid identity. Okay, because the risk of bronchoconstriction So that's SPT management. Okay. Again, Just talk through it systematically. Next one, the next CCD here. Okay, this is this is a challenging, you see, GI, But I've included it just to sort of talk about a bunch of different abnormalities. This will be a very harsh easy to get in your osteo. Okay, I'll admit that, you know, unlikely to get this STD in your all ski. But I haven't got it. Yeah, it is. Um, right. Cuando branch block. Get what else? Good. It's a by physical block. Good. There's another abnormality that here, if you can get if you can pick it up, look in the rhythm strip like this pr interval. But, um, I think what do you think about with the PR interval? Yeah. Good first degree. Heart block. Okay. There's three different abnormalities going on here. Okay, So summarize that this is a by physical block with first degree heart block. Okay? Some people, clinically, they cause they just call this try particular block. Okay? But technically, it's a by physical block with a first degree heart block, so let's talk to it's a biophysical. A block means that there's two blocks. Okay, One of the blocks is a right bundle branch block, and the other block is a left anterior particular block. Okay, so right. Bundle. Branch block. So what? See? Which one's the right bundle? Branch block. What are you looking for with the right bundle? Branch block? Yeah. Good. So broad. You're a sin B one B B one, B two. Okay, so this is a special has a broad curious and be one again. Is that primarily It's a positive deflection of the one. Okay, remember, with a left bundle branch block, it's primarily negative defection, and but But it's still a broad, clear rest. So broke arrest, but with a positive reflection. That's a right bundle. Branch block. Okay. Is this classic our s our pattern, Which with the right bundle branch block. Uh, the second one is the left anterior particular block. And that's hinted because this patient has left axis deviation. So this patient has positive reflection and lead one negative deflections in leads. Three and a V f. Okay, on negative and lead to a swell. So that's a left axis deviation. So that's again. That's a sign off left. Anterior particular block on decision also has a prolonged PR interval. Okay, so that's a first degree heart block. Okay, so there's three abnormalities there. Okay? You, you know, unlikely to get this STD in your osteo. But I just include it to try and talk through a bunch of different abnormalities. Okay? But hopefully you guys are clear on that. Remember? With the right bundle branch block, it's a positive deflection. Okay? And also, you get probably negative. You can get a negative deflection in the sex ago. Okay, again, I got another. Use it if you guys, this is hopefully bit easier if you can. You talk to me. The diagnosis body cardiogram. That again. Make sure you comment. This patient has bradycardia and your osteo, but we'll see. Diagnosis? Yeah, complete heart block. Okay. Or also known as third heart blocks. So with a complete heart block, remember, You're basically your atrial rhythm and you're ventricle. Rhythm is your activity is completely independent of each other. So this patient's having peewee waves, but there's no cure us complexes. Okay, so there's people that just the issue activities is not going down to event ventricles. Okay. The ventricles basically and beating on its own. There's independent ventricular activity. That's this is a complete heart block. Okay, Um, so and also there's broaden your s complexes because the ventricles taking a lot of time to try and contract. Okay, because ventricles don't contract very well on the room. Can you tell me what? How did you manage this patient's? So we're gonna talk about management Answer. Can you guys tell me the management off Friday, Cardia? Yeah, there's a too fat with complete heart block. Most patients were will need a pacemaker in terms of bradycardia in general. How would you manage that? Get good ab CD assessment. Okay, I'm glad someone saying it. So it's always a B C D assessments. Um, yeah. Stable. Unstable. Good. So a testing if they're have adverse features. Good. And then some atropine pacing or good. Okay. So this is the sort of algorithm for bradycardia management's. Okay? Always talk about the ABC. These assessment burst, then mentioned any adverse speeches if they have, if they have any of these adverse peaches, that's when you give treatments. Okay? Remember a lot of patients. A lot of people will just be bradycardic. Okay, You only treat them if they have symptomatic bradycardia. So you get atropine initially, 500 IV. If they respond well to that, um, it's our If they don't respond to that, then there's different things you can do. I have to give atropine again, or you start you refer them to cardiology to stop pacing. Okay. Um, but yeah, that's the sort of management if they have symptoms, if they have a risk of a system as Well, so some of these features which have listed here, then you also want to do some of these treatment options. Okay, but yeah, that's the sort of management approach to Broady called IUs. Next one. Next ECD have ago. This one. Okay? Yes. Good. This is this is a super important ECD that you need to be able to recognize. Okay? You You should have to You have to just be able to see this and act on it quickly. Okay. So let me, uh most post said this is a likely likely to be a ventricular monomorphic ventricular tachycardia. Okay, eso why we talk. So whenever you see this broad, complex, regular tachycardia the first top differential, the only thing you really should be thinking about is is this patient having Is this a monomorphic ventricular tachycardia? Okay, so again, brought to us complexes. Um uh, Legler rates. Okay, extreme right. Axis deviation. This is all this is likely a monomorphic ventricular tachycardia. Um, any family. What else? What other differentials could cause this sort of pattern? What else potentially might cause Broadcom plex? Regular tachycardia is yes. I was going SPT yeah, someone has SPT with aberrant conduction. So if someone has a super ventricular tachycardia, But if they have a bundle branch block, Brundle, branch block at the same time, that can also cause a broad complex that regular tachycardia. Okay, but if you see this pattern, you always think I think it's monomorphic ventricular tachycardia until you're you're confidently able to prove that it's not okay, So that's the key thing. Can you tell me what is? Actually we'll we'll talk about this in a better but can Yes. Tell me the management. We're sorry. Diagnosed this E c t for me. What is this, E c t shirt? Yeah. What's happening here? Yeah, I got a sister that good. Okay, so that death s so we can assume that patient. This is what we're seeing. So it's a Sicily. Um Okay, so you're a systole. So there's no electrical activity happening here on last one here. This is absolutely crucial ECD that you after the most important ECD that we'll ever after that you have to be able to recognize that V fib. Okay, this is the fifth. We'll get this straight of the ventricle if it relation fibrillating eventual activity. This is ventricular fibrillation. Okay, if you see this sort of squeeze the patterns, that's this ventricle population. Okay. Um, good. So can you, uh Okay, well, I'll just talk threat. So we get We basically just talked to a bunch of emergency A redness, okay? That sort of different rhythms that would immediately that can cause immediates deterioration. Okay, so we're gonna talk about the for the originals, and basically, with those arrhythmias, you wanna be sort of taking the a less approach. So if they are, this is a less approaches where basically, you do it for patients who are unresponsive. No breathing. Okay. And then this is in hospital, so it's unresponsive, not breathing. Call the recess T. Okay. Put out across school, start CPR 30 compressions attached the defense, and then the defibrillator is going to tell you the river. Okay. And this is where stuff in here bit complicated. So, with the rhythm, we basically tells you if it's a shock about rhythm or a non talk about liver, Okay, your cycle rhythms are your ventricular fibrillation, and you've been trickling tachycardia is your non shock about rhythms? Are is your pa so post lis electrical activity and your asystole. Okay, those are those are the non talk about rhythms. If they have a shock, a bowl rhythm and you're gonna give them a shock. Okay. And then after that, you start CPR, okay? And then do that again. Uh, the key thing is, with a shock or with them, you give adrenaline 1 mg only after the third shot. Okay, so you give three shocks, and then you can give adrenaline 1 mg IV, and you can also give you your drug 300 mg IV after third shock. Okay? And then subsequently, you can keep giving adrenaline. But if they have a non shock all rhythm, that means you don't shock them. Okay? Obviously, but if they have a non stick with what are called with them, that means you give adrenaline immediately. Okay? That's the key difference you want to be thinking about with a shock. Will rhythm adrenaline's givens after the third shot. That's a non chock full rhythm. Gave adrenaline straight away and start CPR. Resume CPR. Okay. That's the sort of approach that's the sort of adults out of advanced life supports algorithm. Okay, this is something you probably have come across more when you start working in the emergency departments pee. So some of the sports, pa pa is pulseless electrical activity. Okay, if they haven't got a pulse, but they have some electrical activity, That's what he is. Okay, Okay, so let's move on. Okay. And I also listed some of the reversible causes off calling arrest. Okay, so remember that. Remember, the four h is on the forties for the reversible cause of cardiac arrest. You might get asked that in your ski. Okay, just remember the four pages and forties. Okay, so we've covered a redness. Okay, Now we're basically going to move on to some palpitations, history taking and talk about a particular condition and a bit more detail. So with palpitations history, I'm not gonna talk to the slide. So the patient presented with palpitations these type of type off focus history questions you want to be asking. Okay. So clarify what they mean by palpitations. Awesome to talk the rhythm. Okay, just stop. If it's going fast, it's slow of its abnormal rhythm. Okay? Do you? So for them to talk about the rhythm, uh, then you got all stems. Like just associative peaches off the palpitations if they have anxiety. If they had mood changes, if there's any obvious triggers, okay? Things like caffeine and things that might be triggering the palpitations. Also important to have to ask about in a palpitations history. Okay, Your past medical history and system's really is pretty similar to the stuff we talked about with your chest pain. Remember to ask about Bayreuth disease because, um, hyperthyroidism can trigger set in arrhythmias on, but important to clarify And in terms of your social family drug history, Big one. I always like Teo. Remember to ask is ask about certain medications like caffeine eat Agnes and nicotine because they can also trigger palpitations as well. Okay, the rest is pretty much the same for the chest industry. Um, so let's talk about some palpitations now. And I've got another EKG for you guys. Um, what do you think's happening here? Yeah. Yeah. Someone said this is That's what This isn't That's not ST Elevation. Okay, this is just slow at get. Okay, So this is atrial population. Um, yeah. So, again, remember your ski. Please always follow that process. Okay? Started patient information go through each different aspects of the CD. Okay, on. But then when you come out when you would start coming on to the rhythm, you'll notice that this patient's rhythm is completely irregular. Okay, It's irregularly irregular. Okay. It's not the same disparity between each curious complexes. It's it keeps changing. So this is atrial fibrilation, But specifically it's slow. Yeah. Okay. This is not tachycardic, okay? This isn't atrial fibrilation. Um, this isn't passed a f Okay. Um, yeah, that's what the CT is. So let's talk about a F now. Um, basically listed some differential for palpitations. Okay, with you guys can have a read about in your own time. I just want to talk through some of the investigations for a f The again always talk through bedside bloods, imaging special tests. Okay. With any presentation and your skis. So again, start with a B C. The assessments and all the other other things are pretty much the same. It's chest pain. Uh, all these blood tests are pretty much the same. A stress pain as well. Okay. They may make sure you mention BMP because you want to check for heart failure. Uh, check for do a crawling screen. Okay, Because you're going to start anti coagulation on most patients? Uh, yes. Tell me what? Why? Why would we check lefties? What would be used for? To check elegies Party congestion. Statin? What? What could we put? What might be prescribed that might harm the left hand? Deliver in atrial fibulation. Good. Establish a baseline for investing drugs. Good hypothyroid can goes partition. Yes. So it would be good to mention a thyroid function tests as well, if you want it. Okay. That's another good blood test dimension for atrial fibrillations. Um, you're doing good. I can reorder the big one that can cause liver injury. So that's that's That's a potential justification to do LFTs with atrial fibrilation. Okay, again, it doesn't matter what investigation you do as long as you're able to adequately justify it. Okay, In terms of imaging special tests, a chest X ray is useful because ah, lot of atrial fibrilation is caused by infections. Okay, like pneumonia. Uh, in terms of diagnosis of easy for a F, patients can do 24 hour east. You monitoring on You should consider doing echocardiography because a lot of a F is caused by valve abnormalities. Okay, babble a heart disease so you can do an echo to check for that. Okay. Now, the examiner's asked you to discuss what the cause is off. Atrial fibrillation's. So can you guys let's, um, causes of atrial fibrilation from it. Okay. I wouldn't start with you. Can you can start with idiopathic to be doing a lot of efforts. Did your part of it, but yeah, uh, a thyroid disease. Hypertension bottle up these hypothyroidism. Coffee and drugs. Good. Electrolyte. The seventies. I like it's alcohol. Get there's a There's a whole list, Of course, is that I like to use in your Monica pirates. Okay. It's a pretty common one that's used. I guess the key thing is, being able to list a man is you can okay. Pulmonary causes team called disease, rheumatic heart disease and barbara Heart disease, Alcohol, thyroid disease, hypertension, sepsis, sleep apnea. Okay. The whole list, of course, is okay, So try and remember as many of them as you can. Okay. Make sure you're remembering common ones like bottle of heart disease. Idiopathic cause idiopathic is a cause. Probably closes. Ischemic are disease. Those are the sort of common stuff. Okay, but try and remember as many as you can. Okay, now, I wanted I spend some time going over this. So warfarin counseling. So this is quite a difficult station for a lot of people to explain how warfarin is given how to take warfarin. So I'll spend a decent time explaining this. So the station is We've been asked to explain to patients how to take warfarin and how do what to do when they're on the drug. Um, so it's a counseling type of station, so it's a bit different to your focus. History, taking consultations, structured a bit differently. But let's don't do the key stuff. Eso always thought with the introduction, even though it's a counseling station, I recommend doing a brief history to establish the events off the consultation. Okay, so establishing what led to that consultation. Okay, but remember, this is primarily a explaining station. Okay, So you want to get to some of the other stuff, then established patients understanding, Okay. So establish what they already know about war, friend. Okay on. And then that's gonna help guide you the rest of your consultation, cause your with these explaining stations, you always refer back to what the patient already knows. Okay, You're just building about the patient already understands. Okay. And when you're doing it, always just encourage the patient on saying yet. Yep. That's right. Warfarin is a blood thinner. Yep. That's right. Warfarin. Does this okay? Just always encourage patients as well. Uh, then just do a quick ice. Okay? So ideas concerns expectations. And when you're doing ice, I I'm not a fan of just asking. What are your ideas? What are your concerns? What? Your expectations. Okay. You can face it. Stuff like, um, what do you know about your friend? Uh, what concerns you about warfarin? What do you hope to discuss today? Okay, that's how I would go about discuss discussing it, okay? And I don't With this consultation, I also recommend just checking that they're not pregnant is welcome. Okay. Before, because it's showing to the Examiner that you know that warfarin is a big territory. Teratogen. Okay, so you discectomy that they're not going to pregnant as well. Uh, and then with this explaining station, then you outline your discussion. Okay? So discuss what you're going to do for what you're gonna do with the consultation going to discuss the what warfarin is why you need warfarin. How you're going to take warfarin and side effects of warfarin Going to discuss at certain things that you might be worried about when you're walking therapy on certain lifestyle advice when you're on warfarin. Okay, just outline what you're gonna be talking about when with this consultation, um, and then we're gonna move up so specific stuff. Okay, So talk to patient about what will furnace. So you can say warfarin is a blood thinner, okay? And it's gonna help thin the blood so it reduces the risk off clots. Be informed on. Explain why that patient needs warfarin. Okay, so in the context of a f, you can say because of your atrial fibrilation, it means that your blood is ah, a bit at a higher risk of prodding. And that means you might have a increased risk of stroke. Okay, so that's why you need warfarin to help thin the blood to reduce the risk of stroke. Uh, then you can talk about the dose of warfarin. Okay, so with war friend, if you explain that to tablets. Okay. Take it once in the evening, okay? And take it at the same time each evening. Uh, and then this is a big thing of the consultation. Okay, There's a major aspect. Want to make sure that they know what that what you mean by you know, so explain that the ana is basically a way we used to monitor your warfarin. Okay. How effective your wall furnace. The in our basically tells us how long it takes for your blood to clot and then mention, and then you start to talk about, um the specific target ranges for for your eye and also and healthy people I know is typically one. But if they're going to be starting warfrin, you should explain to them that your blood's going to take a bit longer to clot. So your target I and I would like to be between 2 to 3. Okay, um and then you and then you mentioned that you adjust the dose of warfarin based on your you know? Okay, whatever. I another patient has the might increase the dose or lower the dose, depending on on the I know on. Then you want to talk about side effects, okay? And he has left me some side effects of warfarin therapy, but big side effects you got to be thinking about. What do you gonna advise the patient about? Bruising. Bleeding is the big one, right? Pull the egg. It's bruising. Uh, cold, um, beatings, the big one. Okay, so you mentioned that because warfarin is thinning your blood, you elaborate this risk of bleeding, and you can mention there's a lot of common, non serious courses of bleeding. Okay. Things like if they're brushing their teeth, you might They might notice there comes a bleeding. Okay, um, they might notice slightly heavier periods. If they have a cut, there might bleed for a longer than usual. Okay, If I have nosebleeds, use often with warfarin therapy, they get nose bleeds, which lost less than 10 minutes. Okay, if it lasts more than terminus, and that's a bit worrying. Um, but yeah, that's the sort of common ones. More serious cause of bleeding in terms of warfarin therapy, things that you would advise the patient to call nine and nine is if they start seeing blood in the urine, but it blood in the stools. Okay, they start seeing red P or read or black stools. okay. Did you see blood in the bomb? It or blood in the sputum? Okay, all things that you should advise them to call, See medical attention. So that's the sort of bleeding aspect, this other other things You mentioned that patients often get a rash with warfarin therapy. Uh, often you might notice your skin's get yellow if that. If that happens, so they might get jaundice. Um, advise them to seek medical attention if that happens, Okay. Ah, yeah. That's the sort of side effects that aspect. Okay, so it's all about explaining stuff that's common. Okay, that you can expect to see with your friend therapy and side effects that are bit more serious, that you should seek urgent medical attention on. So you're always doing the safety net thing. Okay. So always with these explaining stations, it's always about safety. Nothing. You know, things like, if this happens, do this. Okay, give leaflets. Um, explain went to seek medical attention. That's the key stuff with these dp gp sort of consultations. It's all about safety. Nothing. Um, then talk about diet advice. Okay, So with warfarin therapy, what do you advise them about? Diets. What do you gonna tell them? Eso Someone said avoid high okay between K containing foods, so I wouldn't say Avoid them. Okay, so a lot of it. A lot of people say, avoid vitamin K containing foods. I say it's important to just reduce intake. Okay. And be careful. Okay. Um so advise allowed to take too many green vegetables, which contain a lot of vitamin K that can potentially affect their affect the efficacy of warfarin. But I wouldn't. You don't necessarily need to say to just stop taking it because a lot of green vegetables can be healthy for you. Just have a good balance. And make sure to inform people if you're doing if you're making drastic changes in your diet, Okay. Someone said cranberry juice. Good. Avoid any type of problem. Reduce. Okay, reduce alcohol intake as well. Okay, so no binges while you're on warfarin therapy. Okay? That's a big no, no for warfarin therapy. Um, that's a That's a big stuff with diet lifestyle or by. So what are you gonna advise? Generally in terms of lifestyle advice when they're on warfarin? What kind of stuff would you be advising them on? Yeah. Good. No, contact sports? Um, yeah, that's a That's a big thing to dust. Also, if they're planning on, they need to make sure that they're on effective contraception as well. Okay, because, ah, you know, there are child bearing age. Make sure that they're on effective contraception. That's big. There's some big lifestyle advice. Um, also, if they admit another thing to mention with the dosings if they missed a dose of warfarin, make sure you tell them to not double dose of warfarin. Okay, you don't don't over anticoagulated. So if it that's a big thing, if they miss a dose of warfarin one day, make sure that they not double dosing on the next day. Okay, that's a That's a big no no as well. Next, things of warning. So again, things like we already talked through a lot of them. Okay, things that they should seek. Urgent medical attention about okay. Ah, and finally anti coagulation book. This is a big thing. Okay, so anyone preside. Warfarin will be given this sort of yellow booklets. Okay. Were you know, they can fill in there in our level filling what tablets they're taking and dose of tablets each day that's really important for them to engage in, fill in regularly. Good. And then follow up. So remember, but always talk about when you follow up with patients. So read more, friend. There be. You could give a leaflet about warfarin therapy off of follow up appointments. Tell them that they will have regular monitoring off the eye on our levels. Okay, so it's all about safety netting patients, but yeah, that's how I would go about structuring your consultation. Okay. And this sort of keep content. You want to be getting out with the Wolfram counseling station, uh, in terms of some other stuff. So address patients concerns throughout. Okay. So patients might have questions, so always address them chunk and shots. So this is a type of communication approach for explaining stuff. So give a little bit of information and then check their understanding. So I would say stuff like, can you just repeat back what I said about the warfarin dosage so that I know that you've understood it. Okay. So again, the patient too refer to explain back where you just said on offer leaflets, good websites, the routes and jack up throughout. Okay, so it's all part of that safety net thing. Okay, That's the big stuff with these DP counseling stations. It's all about safety net thing. It's offering follow up, offering leaflets offering support services and things. Okay, good. Okay, So this is somebody of the management off. So anti coagulation for a f. Okay, I'm not going to go through it. But remember, you use things like the chance of our score the orbit school to determine the need for anticoagulation and a half. Uh, this is somebody off read Control, this is rhythm control and episode. Well, okay. Haven't read when you get the slides. And this is a summary off the management of acute A f. Okay, So if they're human, anti unstable, remember, you go to DC cardioversion. If they're stable, then follow this algorithm. Okay, there. It's been different, depending on when they presented. If you go for rhythm control, rate control or when you do cardio vision, Okay, so follow this algorithm. Ah, yeah. That's the atrial Fibrillation's station of you guys are pretty clear on f. Now. Now we're gonna quickly wrap up with heart failure, okay? I'm not gonna spend too much time, Anus. I've made the slides pretty brief for heart failure, but I'm gonna try and cover some key clinical aspects of heart failure to remember. So with heart failure, the key symptoms to be thinking about with heart failure is dyspnea orthopnea part is more lock turn or dyspnea. Okay, waking up short, short of breath, fatigue and ankle swelling. Okay, so these are the big things to be picking up in the history of someone with decompensated heart failure. Okay. Sort of, um, pulmonary edema type symptoms on desire. Some focus questions that you can Oscar the patient. So are you short of breath when you lie down? Do you wake up at night short of breath, abstracting about PND? How many pillows do you sleep with at night? Okay. So, again, asking about orthopnea difficulty walking. So that's a big thing. Might be because because of ankle edema, recent illness or surgery is important to ask about. Important to ask about what that previous exercise tolerance waas on eso getting a good functional assessment. How far can you walk before getting short of breath? So, uh, this is a important to get a good functional assessment. Can anyone else tell me. Why is this an important question to ask in heart failure. What does this question help? Tell you about a patient? How far they can book? Yeah. Good. It helps tell you there and wipe the chase cool again. We'll we'll talk about that briefly. That the level of function impairment helps determine, uh, anyway and white Newark Health Association. 70 of heart failure And how the symptoms affected that David of it. Okay, so just general assessments are functionality. Gentle investigations by heart failure. Okay, these again, Pretty standard investigations for cardiac, but with ologist similar bedside investigations. Similar blood test. Make sure you're mentioning BMP for heart failure. Okay, there's a big GPO blood test to check for heart failure on in terms of imaging, a special test so mentioned you do a chest X ray looking for pictures of heart failure on you got your A B C D features or part billions. Uh, would you guys be able to disturb me all the A B C D. Pictures are part of this. What are the ab CD? Peaches on a chest X ray. Pa Pa. Have you'll edema? Good. Really Be lines. Good. Cardiomegaly Good dilated up a low airway. Best old script. So get your diversion to the upper lips. That's another important extra finding and e for curl infusions. Good. And always mention you do echocardiography. There's a couple of things you want to be doing with the Echo. The main thing is, you want to check the ejection fraction, okay, cause that's gonna help you diagnosed at level of heart failure and also check bowel function. And for any regional wall abnormalities as well. Okay, uh, I forgot to put a slight an actual CBC finding. So remember, these are the actual a b c d. Finding so heart failure again. This is a classic chest X ray appearance with a lot of these findings. Okay, so remember these findings commonly tested in your skin is Onda. Here's the summary off the NIH. A system okay for classifying heart failure. Okay, so remember, that's why it's very important to ask about all those functional questions that we discussed to classify the severity of the heart better. And this is summary off the management of heart failure. Okay, so it's something we've discussed before. First line Eastern, every 10 beats a block us Okay. If then you move on to things like spironolactone, and then you start, you can either start moving on. You can either add other medical therapies. Okay, If if the cardiologist thinks that's gonna benefit them or you consider certain interventions such as an I C D. Okay, implantable cardiac defibrillator, cardiac resynchronization therapy. So CLT So this is if they are symptomatic a particularly low ejection fraction, and they have broadened curious complexes on some patients might be suitable for transplant. Remember, this is for chronic heart failure management. If they're presenting acutely with, um, heart failure symptoms with a coupon redeemer than the mainstays to give you rose a mild to try and drink some fluid off. So this is, um we have been managing sort of the osteo presentation off management of heart failure. Okay, So similar things for conservative management. Talk about the MBT approach. Talk about the functional assessment. Talk about charities and societies. Okay. Such as the British Heart Foundation. Any lifestyle changes. Okay, so, exercise changing diet, reduced alcohol intake, stop smoking, okay. And then your medical and surgical therapies. So we've described him in that flu shot. Okay. Um, always It's only if you can remember. It's mentioned that you should make sure that they're getting their annual vaccinations. Okay, so the annual flu vaccine annual pneumococcal vaccine. Okay. And ideally, if they're fluid overloaded, I really did want to make sure that they're fluid restricting. Okay, So not drinking too much fluid throughout the days to avoid aggravating the edema symptoms. I just added in this echocardiogram in because this might get tested in your osteo. Okay, um, I ask you to label this echocardiogram. Um, so just I put this image in for reference. Just remember how to label an echocardiogram. Remember this This big wall, this big, muscular ball is what's gonna be separating your left ventricle from your right ventricle and your atrial A lot smaller than your ventricles. Okay, that's again. This this is probably a pretty harsh state. Pretty harsh activity to get in your skin. But it might be it might be done as that. It's interpretation question. Okay, so I just included this for your reference on this is the last night. I think I just filled in the ABC The assessment for acute pony, A Dema um, so it's pretty similar a B C D assessments are pretty. It's always the same approach. Okay, in terms of a coupon, redeem a some excess, some extra stuff you want to be thinking about is, uh, doing seep giving, See back, okay. Or starting invasive until a shin at the sort of breathing aspect. Okay, So mention to the Examiner that you'd consider CPAP and investigate basic ventilation that their hypoxia does not improve in terms of circulation. Some additional stuff. Make sure you say that you checked being the levels. Make sure that you'd, uh, urgently see critical care and cardiologists input. Okay, Because if they're presenting acutely with pulmonary edema, they ever I rest off deteriorating very quickly. If they have a background of heart failure so urgently see critical can critical cardiologists. And because they might need to be moved to I to you very quickly. Ideally, you want to be fluid restricting them. Okay, But if they're hypertensive, if they look seem fluid depleted, then and you need to get fluids, and you should be very cautious with how you get fluids. Okay? Because you don't wanna fluid overload them. Guess would be very cautious on also, you should consider giving furosemide to try and pull some of the blue it away IV fluids might remember on all the other stuff is pretty much the same. Remember, you'd recommend you requested echocardiogram as well for patients with a coupon edema. Yeah, I think that's it. Uh, thank you guys may be pretty much finished on at the nine PM, Mark. Thank you. That was our first Oscar session. I hope you guys enjoy that. We covered a huge amount of cardiology content. That's ah, relevant for your skis. Um, I hope you guys enjoy. That was after a session, and I lost the series. Make sure you come in on Thursday for part two, or I'll be talking through the physical examination, okay? The and talk about relevant physical findings and presenting the examination, I'm actually turned in for the other OsteoSet ones as well. I think I've really enjoyed this one, um, way a lot of cool stations plan for you guys, so make sure you guys keep tuning in. Um, yeah, thank you. Um, parties And Thursday, right? Yeah. Just Thursday. Yeah, is there. And don't forget to enter the give away as well to get your, um, ski revision guide. Um, recording and the size. And we put up a medal very soon