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Oh, physical. So picture out to our sponsors and first big shout two MPs, one of our medical legal sponsors offer a lot of support in terms of medical indemnities You just heard from us and who just talked about Quest med. They have a lot of great services up there, like just talked about, especially for osteoporotic recently To make sure you check them out. Big child to med up metal who have support us with making feedback forms produce attendant certificates as well. Onda? Uh, yeah. Uh, you just said from us, and we have Ah, um, but this can occur as well. Ask easy. 24 20% off question subscription to make sure you take advantage of it. And he has, um we'll be very happy if you do. So, um, yeah, that's the code. We've also created Elasticity Community, a Facebook group. We plan on being more active on it, But if you have any questions, anything, clinical medicine, off skis, welfare research, integration, Feel free to leave it on the Facebook group. And we'll be happy to answer it or direct you to someone who is a pebble event and drink it and yeah, So we have a giveaway is going on with our our ski series. So if you share, it's and tigers on instagram stories will send you a free Oscars examinations, revision guides. So just make sure you tiger so that we can see it. Oh, if you have a private account, just send us a screen shark. A story on, Well, private message. You, uh, the sciatic examination Revision Religion guide. Uh huh. So I just throw the session. Just just take your picks and make sure you take us. We also an on saying that we are a fairly a sponsor on the eye next conference. So, cause you know, there's a big surgical conference happening in London this weekend, so march straight into March. Ask is, is one of the sponsors on the conference So we're going to be there to represent I'll be there to represent beginning. If you guys get your tickets for the conference, it should be really cool. Event a lot. Lots of cool workshops going on on day. Yeah. I mean, you guys that if you do get your tickets, so just a minute, I'll scrap ground holes, just as per usual. Okay, I'm not gonna spend too much time with this. This whole stuff you're hopefully very familiar with We'll send the feedback form for this slide and recordings during the break, which will have around at the halfway mark. Um, also, we really appreciate you guys can leave us a review on Facebook as well. So if you go on our Facebook page going to reviews tab on the Facebook page and if you conduct a positive review would really appreciate that it helps with our reach and engagement. A swell. And you guys have your finals or your or skis coming up soon. Good luck for them. Uh, you guys. You guys going to smash it? Just, um, and yeah, I hope you guys enjoy the session today as well. And here are socials as well, so make sure you follow them. All of them as well. For all the updates on our events. Sorry. It's just I don't We have a mailing list. A swell, um, and so I'll just put the mailing list in the chat. Well, uh, please sign up for the mailing list to keep updated with all our events, upcoming events, and, uh, any other opportunities, We might have just one clarification. I see a lot of you if you guys messaging the oh, Ski guide is for everyone who shares it. It's not only for the winner. Okay, good. Yeah. Yeah. So today is also session. Okay? It's ah, continuation of our car ski Siris. So it's all about, um ah. Practical aspects off the skis are with today is gonna be part to your cardiologist on pot one. Be mainly covered. Sort of focus history, taking in, formulating investigations, formulating of management plan, data interpretation, stuff as far $100 loads of different types of stations that come up in cardiology. But today we're gonna be focusing on the examination aspect of cardiology is Okay, so it's gonna be focusing on the focus cardiovascular examination. So we're gonna run through the cardiovascular examination, talk through physical findings you're looking for with the cardiovascular exam and explain all the explain how to do the exam Leave kind of methods of doing the examination techniques as well. I said two hours. Hopefully will. This session will last a bit shorter. This session will hopefully be a lot more fun than the part one. Okay, this examination that it's a lot more sort of interactive. It's all about there's a recognizing physical findings. It's it's gonna be loads of spot diagnosis. So stuff where I'll show you pictures. I've got videos as well of actual physical findings, and you guys need to be on it in the chat to tell me what the diagnosis is. I've got, um, the we've got clinical vignettes of different examination findings. I've got murmur sounds coming up a swell. So we're gonna do a full broad run through of the cardiovascular salmon and cover loads of different aspects off clinical medicine, which will hopefully be useful knowledge for your skis. So let's start up. So decision is within a cardiovascular combination. So we're in the cardiology outpatient clinic. Our patient is Doctor Bruce Pon, a 50 year old male who is short of breath when we've been osteo bi the Examiner to perform a focus cardiovascular examination on the patient. So, as always, I just want I just want to help with some general tips for physical examination before you go into the actual step. So the physical examination's it's always about general inspection of the starts. Okay, so, uh, after you've done the introduction and you talk to the patient, just spend a good few minute moments is looking okay? Even if you can't see anything, just show to the examiner that you're looking at the patient. You're looking around the bed for power. Often area off that specific to the examination. Okay, Just you make a show out of showing that you're looking around different places around the station. Okay, that's really important. Make sure you do spend a good couple of moments on general inspection. This is this. A lot of people get confused whether they should talk to you in the examination. Okay? I always prefer talking during the examination and explaining what I'm looking for. Okay. And rather than saying stuff like I'm looking for spent a hemorrhage is I'm looking for peripheral sinosis. I prefer saying stuff like there's no evidence off split hemorrhages. There's no evidence off truthful cyanosis. Okay. So rather than saying telling the examiner what you're looking for you showing the examiner that you found that there isn't evidence of a particular finding. Okay, that's how presents. That's how I would go about talking duty during the examination. If you do want to talk to reading examination. Okay, If you don't, it's you congest Explain all your examination findings at the end of the examination. Okay? It's personal preference, to be honest, but personally, I would talk during the examination, Okay? Just in case you run out of time and you don't cover everything. Always performed, like, but the starts. Okay, So, um, wash hands introduces out position the patient, explain what you're going to do. Uh, this hopefully something you're very familiar with. Examine from the patient's right side. Okay, this is a classic typical bedside manner. Okay? Always examine from the patient's right on site. Okay, this is just general tips for, um, physical examinations. And also, this is a big thing I think is really important. That skis. Okay, it's it's all about putting on a show for the Examiner. Okay, Oscar is is all about showing to the Examiner that you are competent that you have good clinical awareness and knowledge s So it's all about putting on a show on really flexing your knowledge. Okay. Ask is is ah, a lot about displacing what? You know. So, yeah, it should be a 7.1 it's all about. You should feel like you just want the Oscar after you've done your asking. So just really put on a show for the Examiner for the physical examinations as well. So let's do some spot diagnosis for cardiovascular examination cases. So I've got a serious of clinical the nets off different examination findings. And I want you guys to tell me what the likely diagnosis is based on the, uh, physical findings. So on examination, a patient as a high arch pallets and radio radio delay. There's evidence of a collapsing pulse. He has chest pain. Can you guys tell me what? What do you think's going on here? Marfan syndrome gets. I like the potential cause of chest pain and radio radio today. Correct? A shin. So I put a dissection so it could be a a tick dissection. Okay. Very common with Marfan syndrome. Okay, a degree of your station. Also, I dissected as well. It's very common in Marfan syndrome, but high arched palates sign of Marfan syndrome. It's like a connective tissue disease. Radio, radio today we'll talk about cause a radio radio delay. Okay. Collecting pulse is a sign off. Aortic regurgitation. and that can happen. Secondary to a a tick dissection and chest pain is also be job aortic dissection. Okay, that's the first one. Next one. On examination, a patient has a midline sternotomy star. She has multiple bruise marks on her arms. There are no graph stars on our arms or legs. A click sound is hurt on auscultation. What do you think about this case? You have a kind of yet mechanical valve. Um, why? Why is this a mechanical? So, yeah, this is a prosthetic. Both. Okay. Um what suggested prosthetic valve. Why? Why do you guys think this is a prosthetic bob click? Okay, so click sound is plastic. We'll talk about the prosthetic bodies times where click sound is classic for a classic audible sound for prosthetic puffs. Midline Stand up to me, Scott. Good. Can you tell me why? Why is this eso with midline? Still not Ms Cause there's you either be thinking about a coronary artery bypass graft or a prosthetic valve. But why do you think this is not a coronary artery bypass graft patients? Yeah. There's no grass goes. Okay, we'll talk about it. We'll talk about all of this okay if you're struggling. But if patients have had a CABG procedure, you in all skied. Likely you'd expect to see graphs cars on the legs. Okay. Or the arms. Okay, usually the legs for the softness. May. And what is this stuff about Bruce mucks? What does that suggest? And calculation. Good. Okay. I remember. With prostatic bulbs, patients will likely need to have long term anticoagulation. Okay, usually with warfarin. And as we talked about in on Tuesday with the warfarin counseling stuff, bruising is a very common side effect of warfarin. Okay, so bruise marks is classic for patients who found a prosthetic valve. Incentive. Good. Next one. So on examination a day if I go, man has an ejection. Systolic murmur heard loudest in the aortic area. Movement radiates to the cross. It's what do you think about this? Aortic stenosis is good. Uh, can you just tell me what is he likely cause of the aortic stenosis? Turn this patient, uh, rheumatic fever. Is there something else? That's a young young patient. What? What would I be thinking about? Bicuspid to bob. Ok, back bicuspid. Aortic valve. Most common cause of headaches, stenosis and younger patients. Okay, so this is a little stenosis, so we'll talk about aortic stenosis and detail. Okay, But this is a classic member for a little stenosis Ejection Systolic murmur loudest in the aortic area and radiating to the crop. It's okay. And And most the most common cause of a 16 OSIs is degenerative calcification. Okay. And older patients. But in younger patients, you think about bicuspid aortic wells. Okay, so it's really important to think about the age next one on examination, a patient has course, crackles on, but in both long basis, there's evidence off the bottom ugly peripheral edema and a third heart sound JVP is elevated. Uh, what do you think about this case? Yeah, half a liter. Okay. This is a patient with chronic heart failure. Okay, Congestive heart failure. Um so these are all hopefully features. You're familiar with these goals? Sort of features off fluid overload. Okay. Course crackles, you know, think about Palme Dema a patent ugly peripheral edema. Sign off, right sided heart failure and a third heart sound. We'll talk about this during ah heart murmur session, but third heart sound suggests sort of a volume overloaded ventricle. Okay, And it's classic for, um, heart failure and raised JVP again sign of, um, congestive heart failure. Right sided heart failure. Okay, good. Next one. So on examination patient has painful purple screen lesions as well as evidence off digital coming temperatures, 40 degrees on the rotation and members heard. And the mitral area. Do you think infective endocarditis get, um so we'll talk about in fact, if I look at I to signs in detail as well, But what is this stuff about? It's so remember with impact of endocarditis. The main things to think about, in fact, of endocarditis is is a patient with a new fever and a new murmur. Okay. And classically with impact of endocarditis that affects the mitral valve in particular. If you get classically mitral regurgitation, what is this stuff about painful purple skin lesions? Yeah. Good. Okay, we're gonna someone said Jane religions. It's not Jane religions, okay? It's also the nerves that are painful. Okay, So that this is a description off also knows, um, dishes clubbing again. We'll talk about cardiovascular cause of clubbing. But in fact, of endocarditis is one of the cardiovascular causes off each to bubbling last one. So, um, on examination, a patient has a midline sonata. Be scar with associated grafts. Go. He also has multiple finger prick marks. He has evidence off central obesity. What do you think? So this is this is different to the second one. Cabbage. Good. Uh, what else? What else would you be thinking about with this patient? What else does this patient likely have a history of diabetes gets? Which type of diabetes? Type two diabetes. Good. Okay. History of obesity strongly associated with type two diabetes. Okay, so this is but any case off a patient who's had a curry artery bypass graft. Okay, It's because of the med lines to not be scar within associated grafts car. And he also has likely has history of type two diabetes because off finger prick marks. Okay, because of, um, currently test finger pricking. And so Lucas measurements okay. And obesity is strongly should associated with type two diabetes. Okay, so that's a quick, warm about exercise for different cardiovascular cases. Let's run through the examination. So when you're starting off the examination, so start with your wife. Okay. So what's your hands? Okay. Especially important in Oscars and these days, especially with the time to code. Make sure you wash your hands before you enter the station. Introduce yourself to the patient. Okay. Position the patients where you want them to, um, explain what you're gonna do. Okay, So I've written out a paragraph about how I would go about introducing myself and explaining what I'm going to do to the patient. Okay, so I haven't really get the slides of how I would go about it, Okay? It's just think general things make sure you say what your name is, where your title is the age on. Explain what you're gonna do. Just general. Look, examine your face back. Gonna listen to your chest. Make sure you get that consent. Ask if they're in any pain, okay? And if they have pain, asked where they have pain on day. Always do some safety. Nothing. So say if if the examination shouldn't shouldn't be painful. But if you feel any discomfort, just let me know, and we can stop the examination. Okay? That's how I would go about introducing myself. Okay, we've got some most about diagnosis this time. We're going to start. So remember, with examinations, we start with General Inspection. So we're gonna talk about stuff. You're going to be generally inspecting with the cardiovascular examination. So I'm going to do some pictures now, So I haven't think What is this picture showing? Uh, STD, mostly. What's the machine? Generally? Yeah, it's a cardiac monitor. This is an example of a cardiac monitor. Good. Um, what about this one? What? Am I trying to get out with this picture? Yeah. Easy. G leads. Okay. Ah, the commonly patients will have EKG leads already attached them. Um, next one. What about this one? This is a pretty easy one. Walking aids. Okay, so you're all ski trying to look around for any type of mobility aids. Okay, Things like a walking stick, cause I hope so. Tell you what, The sort of if there's impairment and functionality from whatever condition they have. Okay? Working sick. Ah, this is an interesting one. What am I trying to get out with this Picture? Pillows. Get it. Okay, I just I tried to find a picture of bed with a bunch of pillows. So number of pillows is another important thing to look at a cake, especially in the context of heart failure. Thinking about orthopnea. Okay? You always were You taking history? Always ask number of pillows patients patient is sleeping with. So you do the same thing, but they you have a good examination, Okay? If they're sitting upright, okay, try and pick up on that. If they have a bunch of pillows to help with the ORTHOPNEA, just try and pick up on things like that. What about this one? Yeah, and they're be okay. Auction mosque. Um, simple base mass? Yep. We'll talk about auction the different types of auction mosques in detail next week. Okay. With the respiratory examination next Tuesday, Okay. We'll talk about different types of auction. Must. Okay, but yeah, this auction mosque. Uh, what about this one is here. This is again, pretty obvious one. What are you trying to look at here? Yeah, sweating diaphoresis. Okay, give it. Uh, what about this one? Yeah, GTs very good. Uh, see the the comp. Okay, sir. GTs Very important for patients with angina symptoms. Okay, Always look around for any type of medication. A GI cancer is a very common one that will come up in your cardiovascular ski on last one Ah. Those of you know, your clinical skills will hopefully recognize this. Yeah, it's capital. Good after urinary catheter. Good. Okay, so these are all different stuff to pick up on on general inspection. Okay. Looking at the growth. The patient on around the beds. Okay, so let's run through the steps, Okay? This is basically the diagram we're gonna come back to. Okay, So we're going to discuss a couple of the different steps of the examination and then do some spot diagnosis and then come back to this slight. Okay, so we'll draw. The session was slowly going to fill in this slide with the steps of the cardiovascular examination. So we started off with the general inspection. So he looks for things in the patient, and we looked at things around the bedside. So the patient you want to look if they're comfortable at rest. Okay, uh, track of their sweating check. There's obvious changes in habitats. Okay. If they're a beast, evidence of respiratory distress or cachexia around the bedside. Look for the look around for things like medications like the GT and spray, which we talked about. Look for oxygen masks. Okay. Mobility is like a walking stick. Number of pillows. Easy leads if they have. If they have a cannula in Okay, on DA if they have a catheter inserted as well. Okay, Okay. Now we're gonna move on to their hands and our guess, That stuff you want to be looking at in terms of the hands. So again, we've got a bunch of pictures, so I want you guys to try and recognize the physical finding. What is this physical finding here? Uh, some said ma funds. So this is a sign of more funds. But remember, when you're describing physical findings, you don't describe the diagnosis. Okay? You describe what you're seeing? What What is the physical finding? Long fingers. Yeah, it is long fingers. What's the technical term? Yeah, I recommend. Actually, someone's got it. Okay, so it's this is arachnodactyly. And, like someone said very long fingers sign off. Marfan syndrome. Okay, um, on a similar tone. Uh, what is this picture showing here again? Still looking at the hands. What do we do? What is this picture showing here? No edema. This is a fist. But what is what's happening with the fist? Why? This is showing a particular type of sign Some signs. Someone's gotta Yeah, this is some sign. Okay. Again, If you guys don't know, Thumb sign is basically you get a patient. If you bring 100 you're faced with your thumb. If you wrap your fingers on your thumb and you your thumb crosses the older margin of your list, that means your thumb is really Long day. This this is just a thumb sign. It seemed in Marfan syndrome again. It's a sign of patients having really long fingers. Okay, that's your thumb sign. Um, this isn't, you know, your actual osteo. You don't need to actually get them to wrap the fingers around the thumb. Okay. I'm just talking about general physical findings to pick up with the hands. Uh, what about this one? It's hopefully be easier. Ah, this is just purple Sinus. Like a birth full sinosis. Um, yeah. This is just so this sinosis means bluish discoloration off the arms. Okay, this is a classic. I'm sign of proof. Will sinosis. Uh, what about this one? Clubbing. Okay, this is a place. It's something you might have seen on the warts. Okay. Pretty common disease, stroke, digital clubbing Okay. Remember you always participations to look for digital troubling observation to put the needle best together. Okay? It can be a bit of our house hassle sometimes to explain how to put their nail beds together. Okay, But you're looking to see if this when they put the nail beds together, if you can't see a gap between the nail beds that suggests clubbing. Okay, Um, what about this sign here? Okay, whoever says nicotine staining I'm not happy with you. Okay? Never say nicotine staining if you if you see this, okay? Nicotine doesn't cause this type of standing. It's tart stating that causes it. Okay, toss the thing that causes discoloration, not nicotine. Okay, so if you see this in your osteo bi, you describe it as a fasting, okay? Ah, yes. And then finally, um, itch zero. Listen, if you say this is the back of the elbow, what's this little bump? Ah, good. Ah. Thinking about lipid stuff. What we think about Yeah, it's a It's a tendon, xanthoma. Okay, this is for one of the best image of it. Okay, It's a lipid deposit, typically on the extensive show says, but yeah, this is a xanthoma. Good. Okay, so we've talked about hand stuff. So I'm gonna ask you guys What? Uh, the cardiovascular causes of clubbing. And I want three different answers. In fact, if under God, I just get what else? Congenital heart disease. Specifically. What type of congenital heart disease. So, yes, I am not a heart disease and atrial myxoma get Okay, So cancer basically So there's three closes off the vascular. There's three cardiovascular causes of clubbing. So, um and you can remember it with the three c. So cancer. Okay. So atrial myxoma. Ah, effective. And oh, card. I just is another important cause off clubbing and cyanotic heart disease. Okay, on these all college basketball's is troubling. Good. Okay, we've got some more signs for you guys. Uh, what is this sign here? Yeah, track mark. Track marks. Good. Think about IV drug use if you seeing this kind of track Marketing needle six months. Okay. Uh, what about this? If you say this is the, um ah, last cholitis. So what? How do you describe this kind of rush, Pepe? Good. Okay. And keppra has lows of different causes. But in your cardiology station, I would think about anticoagulation use. Okay? Particularly warfarin. Eso things like if patients might be I have things like atrial fibulation. Or they might have a prosthetic both. Okay, that's with your cardiology station. I really think about anticoagulants use if they have evidence off. Sort of bruising Popara again. Good. Uh, what about Okay, So who is still on the hands? Okay. What is this sign here? Splinter hemorrhages. Good. Uh, what about this one here? I see that even even my brain knows that this isn't Raynaud's. I'm talking about the Oslo notes. Okay. These painful, um, nodular appearances. Okay. It can be something you typically palpate more than a C on inspection, but these are also notes. Onda. Similar are similar to that. What was this image showing here? One of these spots here, Jane, release is good. Okay, So can you tell me which off? Also notes And generally Jin's, Which of bees are painful? Which one's painful out of these two? Yeah. Oslo notes. Okay, if you guys could drop your best ways of remembering which ones were Charleston get mixed up on them. He's leave it in the chat and share with people I often just remember over Ouch. Because that helps him remember. Yes. I said over our just remember positive nodes are painful. What? We're all these. What are all these signs suggestive? All in your cardiology examination? Yeah. In fact, if under God, I just get okay. These are all important signs of impact it and about itis. So my next question to you guys is Can you list me all the examination findings off? Effective and I called Actis. This is the next exam in a question for you guys. We talked to a bunch of them. Can you guys let me any other ones? Yep. Murmur Good members would be big one. Temper. Take. It's we've talked about over the hand ones. What else? On inspection? On examination of the abdomen. What else might you find? Rough spots is good. That's a good, important Sinus. Well, poor dental hygiene is a good one. What? What you find on examination of the abdomen guys? Splenomegaly. That's another. A useful examination. Finding it's well, very get S O is a quick, less stuff. A lot of the examination finding for infective endocarditis. Okay, just make sure you congested many as you can okay, Because these are This is a very topical thing, even though in reality, in clinical practice, infective endocarditis is very, very rare. Okay, but has very classical examination findings that you often get tested on. So good. Yes. Okay, this one's a video. So hopefully this video place. Okay, So have a watch of the video and tell me what you guys think. Be physical finding. It's, uh, really focus on the nails. You guys able to see that I play it again? In case you were. Look at the what's happening? That there's something happening inside the nail bed. Yeah, something that some of you. Got it. This is quickie sign. Ah, this's quickie sign, eh? So what we're looking at there was visible post stations underneath the nail bed. Okay? And this is like someone said, this is a sign off a little vegetation. Okay? It's a purple finding off a little leakage. Okay, so we just talk about what? Just stuff we're looking at with the hands. Okay, That's a lot different. Physical findings were looking at with the hands and arms. Now we're gonna move on to talk about pulse and quickly when you're palpating pulse. Um, I recommend using your three fingers. Okay, so your 2nd, 3rd and 4th fingers have helped your post. The key thing is, when you're palpating a post, don't use your thumb. Okay? Can you guys tell me why don't you use your thumb for palpating posts? Yeah. You often if you pop your radio posts with your own thumb. Your thumb has its own policy. It can confuse you. Okay, Uh, they record use your 2nd, 3rd and 4th fingers on when you're helping the pulse. Worry that three different things you're commenting on you're trying to think about. Yeah. Great rhythm volume. Okay, those are the three things to comment on. Okay, Volume character is the same thing that's worth thinking about. Okay, um, in terms off, uh, actually calculating rates. Okay. For your skis, I recommend just palpating for about 15 seconds on Ben. Just multiply. However many beats you come by four. Okay. Don't spend I don't spend more than 15 20 seconds palpating post. Okay, Because it's just honestly, it's not worth your time on. And make sure when you actually say your answer, make sure the the actual value of pulse that you say to the examiner is a multiple of four. Okay, make sure you say numbers like 72 or 76 or 80. Okay, um, just just to show you the example will be if you say if you help it for 15 seconds and you say, post of 75 then that might look a bit suspicious. Okay, So just make sure your, um, quote, you're saying your answer and multiples afford you're if you're palpating for 15 seconds. Um, okay, I got another video for you guys, and you guys are gonna tell me what this video is trying to describe. He's got this stick it, and it's very good. I'll say, this is very like he placed on the radio post, but it's still moving up and down. What is that suggesting? Yeah, it's a bounding posts. Okay, So when you're palpating your radio pulse, this is one of the things you want to be looking out for. You want to look checking it? It's a pounding pulse. So if it has a very, very strong volume, it's ah, hyperkinetic posts. That's a bounding pulse. Um, good. Ah, And have a list. Have a watch of this video. This is a very interesting one. So we can see that there's different probes placed, um, have a watch and let me know what you guys think the physical finding is. Oh, oh, oh. So the so this program place on the radio calls on the femoral pulse. Okay. And the probes picking up the sounds on do? Yeah. A lot of you're going. It's so the if you're able to hear the sound. So there's basically two sounds happening right there was. So if we think about it, if this separate sounds happening that suggesting there's a delay somewhere. Okay, there's a delay in the family post. Okay, this is signing off. Ah, a D o femoral delay. Okay. I couldn't find any images on any videos of radio. Radio delay. Okay, so you're all ski. You be checking for radio radio where your radio delay. So palpate pulse off one arm and palpate the radio host of the other arm at the same time. And check of that still a day. Okay, but and you can offer to check radio family delay. Um, but yeah, this is the physical finding off radio family delays. Okay, so I got some more spot diagnosis that you guys just in terms off the pulse abnormalities. So you guys are really confident and understanding what the difference apologies you can get with the post. So on PALPATIONS. And 85 year old man has a slow rise in karate pulse with a low volume. BP is 1 20 by 100 ejection systolic members had Can you tell me what city? Likely diagnosis. Yeah, It takes the nose is good. Okay, well, come on to the murmur. You guys know the murmur? Ejection? Systolic murmur. Uh, can you tell me what's the technical term for this pulse? How do you describe this pulse? In a technical way? Yeah. Pulses Pappas at target. Okay, so this is a classic pulse finding for aortic stenosis. You get a slow rising carotid pulse is okay. Or radio pulse on that task. You got a low balling with aortic stenosis. Okay. Particularly if it's severe. Um, so that's it. Extend ASUs next one on probation. A patient has an irregularly irregular radio post. There's evidence off. Prepare on the forearms. He's hypertensive and tachycardia. Yes. Good. This is This is the This is a very common pulse abnormality you should be able to pick on. Pick up on. Um, you need to work out if the rhythm is regular. So an irregularly irregular radio pulse is very suggestive off atrial fibrilation. Good. Um, we talked about that purple on the forearms, were thinking about anti coagulation, which will be common in patients with atrial fibulation on dive. Just added in hypertensive in turkey Codec suggesting this is, um f with this is fasting. Okay, so this is a patient who is potentially hemodynamically unstable. Which what? Which won't happen in your osteo. Okay, you're not gonna get a patient to our chemo, dynamically unstable in your osteo. Okay, but remember to pick up on your irregularly irregular pulse. Next one on palpations, a patient has a bounding pulse with shop upstrokes on down strokes. This is essential ated by lifting the patient's arm from breast, There's evidence off arachnodactyly. His BP is 1 40 by 40. What you guys think about the diagnosis? Yeah, I get it. Mostly. Got a little regurgitation. Okay, so we'll talk about the murmur for a degree. Good. But you that again, do you You're able to you can diagnose every gate station just from these powerful findings. Okay, you can assume that the likely diagnosis is the anterior station, just from the referral findings on the cardiovascular exam. But he thinks of bounding posts with shop upstrokes and down stroke. So that's a classic pulse finding for aortic regurgitation. So it's this type of post is called a walk with a hammer pulse essential ated by lifting the patient's arm from rest. What do you call this type? Of course. What is this called? What are you checking for here? Yeah, a collecting pulse. Okay, so I recommend watching videos on how to do how to properly do a collapsing pulse. But remember, what do you have to tell the patient before you check for a collapsing pulse? Yeah. So always this. This is Ah, big marking 0.3 ml skis. Okay. Before you check for a collapsing post, ask if the patient is in pain. If they have any type of shoulder pain before you check for collapsing posts, Okay? Essentially, and lifting the shoulder up on your trying to essentially eight the aortic regurgitation and feel for that, uh, water hammer pulse. Okay. Evidence of record, actually. So again, that sign of Marfan syndrome a degree of station is very common in Marfan syndrome. Um, BP of 1 40 by 40. What is that indicative all. What is this sign? What is this BP telling you? Yeah, this is a very wide what's called pulse pressure. So this patient has a big difference in the systolic and diastolic BP. Okay, that's a pulse pressure of 100. That's very high. Okay, if you have a big difference in your systolic and diastolic BP again, that's a suggestive off a little regurgitation in this patient. Yeah. Good. Okay. Next one on palpations. A patient has a normal pulse that becomes unpalatable during deep inspiration. Heart sounds are muffled and JVP is elevated. Uh, what do you think? Yeah. Yeah, Good. I think mostly you got it. So this is ah, likely cardiac tamponade. Okay. Again, You're not going to get this in your osteo, okay? You're not gonna get a patient cardiac tamponade in your skin, but we're gonna We're just talking about physical findings that you're looking for the examination. Um, So what is this? What's the classic triad? You get with cardiac tamponade. Yeah, someone's got it. Backs try it. Okay, so, um, that's a place on your familiar with hae percent hypotension, muffled heart sounds and an elevated JVP. Okay, I haven't mentioned BP here. Okay, but this patient has muffled heart, sir. That's okay. Sorry for the type of and elevated JVP as well. Uh, can you know, Tell me what this pulse is describing here. It pulse becomes unpalatable during inspiration. What is that called? Yeah, pulses paradoxus Good. Okay, pulses. Paradox says so. You're basically Either your pulse is becoming unpalatable or your systolic BP is dropping by more than 10 during inspiration. That's a sign off. That's called pulses. Paradoxes. It's a feature off guard. Actemra not okay to explain the physiology of That's quite complicated. Okay, but that's a physical finding off. Cardiac company up. Um, last one on palpitation A patient has evidence off lady. Oh, femoral delay. Femoral pulses are weak. There is neck webbing, and she has a very short stature. Yeah, gets Ah, yeah, I think mostly you got it. So this is describing cooptation of the older. Okay, So are narrowing off the aorta, which is suggested by the radio femoral delay and week femoral process. Okay, with classically with coarctation of the aorta, you get the narrowing after the branches off the aorta, too classically with coarctation of the aorta, you get, um, difference in pulses in your upper limbs and your lower limbs, okay. And difference in blood pressure and your upper limbs and lower limbs. And so classic, classic finding and cooptation is radio family delay. Uh, what is this stuff about neck webbing and a very short stature? Yeah. Turn this syndrome. Very good. So Turner syndrome, it's ah, type of genetic syndrome. Um, monosomy X. Okay, so and classically features alternate syndrome is neck webbing and short stature. Okay, amongst other features. And coarctation of the aorta is very, very common internist syndrome. Okay, one of the common. It's one of the common genetic causes off cooptation off the aorta. Uh, good. Uh, can you tell me any other features of Turner syndrome? One of the other clinical features of Sinus syndrome? Yeah. Wide space nipples streak, ovaries, infertility, bicuspid, antibody, a cystic hygromas. Um, amenorrhea horse horseshoe kidneys get There's a lot of clothes, beaches with them, tennis and room again Ah gets okay. This is I've got another activity for you guys. So this is basically a table describing all the different things you're looking for with the pulse. Okay. And I've blocked some words out with the with the Oscars, the logo. Just a bit of shameless plugging at the same time. But I want you guys to tell me what I've covered with the locus. So let's start with the first ones that bradycardia is ah, heart rate. Less than what? Yeah, heart rate, less than 60 goods. Um, tachycardia is a hurry. Greater than what? 100 goods. Um, have described some stuff for a regular, regularly regular rhythm. Uh, what's another cause? Often irregularly irregular rhythm on the post? Yeah, it atrial fibrilation goods. Okay, we're slowly getting rid of all all the all ski See logos. Um, hyperkinetic pulse. What is this describing here? What's the hyperkinetic pulse describing? Yeah, it's a pounding pulse. The case of a positive, they're very fast. Strong volume, um, and abounding pulse, which has a very quick up stroke and a rapid down stroke again. Rapid collapse of vessel. What is that called, uh, collapsing postal. Collapsing pulse is how you is. I can accept that. What was the other main thing to describe? Their collapsing posts? Yeah. Water hammer posts. Okay, I'll accept collapsing pastas. Well, because basically, you're looking for a water hammer pulse at the same time. Um, but yeah, we'll have a post on. Okay. Next one. There's an abnormal decrease in post volume and systolic BP during inspiration. What is that called? Most Paradox is good. We just talked about it. Okay, So pulses fired. Ox is classically seen in cardiac tamponade as well as other things. Um, and last one radio, radio delay were on radio family delay. What else? What my gonna take out? Yeah, Cooptation gets very good. Okay. And this is a summary table off the different rate abnormalities. Okay, Hopefully, this is useful for your revision on hope. You guys sort of enjoyed that activity. Um, also with the we're coming to the end of the arms. Now, remember, with your exam meaning the patient's arms always offer to measure the patient's BP in both arms and standing and sitting as well. Okay, You won't be. You typically won't be asked to actually measure BP in your in your cardiovascular examination, but just offer it to the Examiner, and the example might tell you what the BP is. Okay? And you might be able to pick stuff up from that bed. Always remember to offer it in your skin. Okay, so we just talked about the hands and arms. Okay, so let's talk. Let's quickly review what we talked about with the hand stuff you're looking for. So, inspection. You're looking for all of these different things. Okay, You also want to check the capillary refill time. Um, can you tell me, how long do you press on the thumb? The finger to check for Hillary. Refill? Yeah. Press for five seconds. Good on. Do you check it? Very returns in Less than in less than two seconds. Okay, that's there. That's important to check for confusion, check radio posts. Okay. We said check for rate with volume. Check for radio radio DeLay again both arms and offer to check radio family delay, uh, then in terms off the actual arm on inspection of the arm, check for things like track marks and bruising. Check for the collapsing pulse. Okay. And remember, when you're checking for collapsing pulse Your asking if the patient has any pain and always offer to check BP in both arms as well. A standing and sitting. Okay, okay. We're gonna fit Once we finish with the neck aspect will take a break and then we'll move on to the chest s o I I've got to videos which are gonna be playing side by side, and one video is gonna be showing the corrupted pulse and the other video is going to be showing a patient's JVP I want you guys to tell me which one is the protein post and which one is the JVP? Okay, good. This is very people find it's very, very hard again to differentiate Carlton balls and JVP So you guys are going to tell me which one's which. So let's play them at the same time. Actually Ever played one by one. You guys are gonna tell me. Okay, I'll say that again. What do you think this is that this is very difficult? Yeah, this is the cross. This is the carotid pulse. Get it. Um, can you tell me what? Okay, so Okay, play this video again and then we'll talk about it so I'll show you this one. What is this showing? Yeah, So this is the JVP Okay, this video showing JVP okay. Um so again this this video was showing multiple cysts on this video was showing be JVP Um that's not off with the carotid pulse Why did you guys think this was the current patients cultic post that I was moving? What was suggesting that that that was a carotid pulse rather than a JVP right again Good A single pulsation Good Is that what else? So there's one that you only get one pulsation with a carotid post Okay, so if I played again look closely there's only one pulsation more Upper medio Another thing I like to notice With the cardiac process I it's typically more outward Okay with a carotid post the actual movement is outward Okay Competitive to JVP where the movement is more inward Okay, so played again Movement is more outward right? And it's one pulsation Okay, that's the current it post JVP uh Let's have a look at it. Why? Why do you get Why did you guys think this was the JVP? Yeah, double This is double pulsation good. Okay. This if you look really closely there's, like, double pulsations happening. Okay, Um two waves. Um, like you said. And also, if you noticed that the actual movement is happening in words. Okay. Compatic carotid balls. Which the movement was happening outwards. JVP the movements more inwards. Okay. Really Like if you really could look closely the actual double pulsation, it's happening in words rather than outwards. Okay, so that's your JVP again. This is it can be quite challenging to pick up. Okay, Usually it's quite obvious and we'll talk about the differences But I'm gonna ask you guys one of the main differences between the JVP and carotid pulse of an examiner asks you in the Oscar How do you differentiate? It's what's the main differences in characteristics off the JVP and the carotid post? Yeah, JB is collapsible. Good. So, um, you can't palpate the JVP Okay? That's one thing to realize you can't actually palpate the JV observe the J P wave form. Um, carotid can be correlated with radio poster. That's a good one to comment on what else? How If you're really struggling to differentiate between JVP and Carlton Pulse, what else can you do? Yeah, Yeah. You guys got a patio juggler reflex. Okay, so and I'll show you a video of a pattern Regular reflexes, reflux reflexes. Well, but that's a good way to differentiate between the JVP and the carotid. Pulse is okay, So I just listed some important differences. So did karate. Pulse is palpable. Okay, but it doesn't change with position. Unlike the JVP, crowded pulse is not compressible. Okay, but JVP if you put pressure on it that stopped the pulse okay? And the key thing with the JVP is the hepatojugular reflux as well If you do if you apply abdominal pressure that elevates the JVP Okay, but it doesn't actually do anything with the carotid pulse and I'll show you a video off the hepatojugular reflux now. So this is a look closely and follow the arrows and see what's happening with the JVP after abdominal pressure is placed so look closely. Okay, So you see, if you really look closely that you can see they're JVP started that But as soon as abdominal pressure was applied, the JVP moves to about there and I haven't have a different video of that. Um so again. Have a look closely at the neck so you can see the DPP started there. But it's ended up there. Okay, after the about the jugular reflex. Okay, so that's a good way to tell about the JVP, okay? And your actual osteo bi you you can you can either do it, okay? Or you can offer it to the offer to do it to the Examiner. Um, but that's the batter jugular reflex. Can I pay the first one again yet? Um okay, the first one again Don't know pressure. So there's a There's a clear movement in the JVP after you put abdominal pressure. Okay. Ah. Okay. So yeah, I was about to juggle a reflex on. I've got another question for you guys. So can you guys tell me what are the causes off a raised A VP on, um t clinically tell to determine a race EVP You're looking at the political distance between the sternal angle and the highest point of the posts and you're looking at That's great to them. Four centimeters. But can you send me one of the different causes off elevated? JVP If an examiner ask you that right side a half. Really? Helping his big one. I can make sure you say that is any any other medical causes you can think of. Tricuspid regurgitation. Good pneumothorax. Yeah. Tension. Your mother your ex Potentially good, um, superior. Be in a cave. Obstructions. A good one to mention. Yeah, So there's a useful pneumonic that people like to use. It's called the new Monica Is P Q R s D s a p for probably hypertension and other primary stuff. Ah, do you, for quantity of fluids of fluid overload. So if you've, uh, given the patient too much too much fluid, okay? Or the patient has, uh, renal failure and that fluid overloaded that can cause the race JVP off for, right, right. Heart failure. Okay. Really, really common one, uh, as far superior vena cava obstruction on D for Sorry, you're ST So I got up to you can change the letters a t far cardiac tamponade and tricuspid regurgitation. I'll change that when I send the slides. Ah, good. I've got another neck examination. Finding was slowly. We'll take a break after we finished with the neck. Ah, What do you guys think about this? Play that again. So this is a difference in the day VP with excellent shin and inhalation. Okay, so have a look. So follow. Look at where the movements happening. So with excellent shin, it's around here, so I'll take it again. Excellent. They're inspiration. It's moving up to the UC and then with excellent shins moving back down. Does anyone know what? That what? The Sinuses with the JVP is moving up with inspiration. What's the basic finding called? What? Not the diagnosis. Ah, yeah, cause most breathing. It's not because most not christmas breathing because most sign. Okay, pressman breathing is ah is sign off. Uh, diabetic ketoacidosis. Okay, this is called Small's Sign. Okay. Uh, can, you know, tell me which condition cause small sign plastic. We seen him. Yeah. Company gets. Don't know. Not not Not tamponade, not tamponade. Know specifically you don't you don't get cosmos signed with cardiac tamponade. Yeah, constricted pericarditis. Okay. Um, yeah. So you don't get course most times with cardiac tamponade, typically. Okay, you get it. Commonly with constrictive pericarditis. Okay. Again to explain the physiology of this is a bit outside the scope of today, but this is the course. Small sign? Uh, another neck finding. Can you guys have a watch of the video? And what do you guys think? Update again? Look at that. Look. The patient's carotid pulse dancing corrupted is good, but what's the technical term for that? Dancing corrupted? What's the technical term for Danks dancing? Karate? It's guys know Adoree. So the technical term is Corrigan's false. Okay, so I'm sorry. Corrigan. Sign. Okay, so it's a similar thing with quickie sign, which happens in the nail bed. Okay, Corrigan sign is basically the same thing as quickly sign, but it's happening in the neck. Okay. With the carotid posts. Okay, that's card and sign it. Seen an aortic regurgitation. Okay. With a little creative station, there's a bunch of examination findings, but Corrigan sign is another physical finding of a little regard. Ah, this is another sign of taking regurgitation. Have a look. Yep. Head bobbing. But what's the technical term for that? What's the what's the Impala? Ms. Name for that. Yet? The mustard signed. Good. Yes. So this is the muscle signs of head bobbing again. Seen in a article. Vegetation. Okay. So quickly. I just want to talk quickly about how painting the carotid pulsation. Your palpating carotid pulse. Uh, what's the big thing not to do with when you're palpating Karate pulse? What am I doing very wrong right now when I'm palpating? Yeah. Okay. Don't do this. When you do it in your osteo. Don't help both carotid pulses together again. Risk off big is a genuine risk of syncope to do that. Okay, Make sure you palpating one at the time. And I always recommend when you do before you do the palpations auscultate the corrupted. So Okay, so I always recommend auscultate and propped up a current is wanted to time. Uh, what are you looking forward when your auscultated the corrupt? It's what? Yeah. What? One thing is that you're looking for a bruit. What else could you be? What else could be auscultation of the carotid is tell you you one thing. Is he looking for across it? Bruit? Yeah. You have radiation off aortic stenosis is another thing. Okay, so you if you hear a little stenosis, you should listen to the carotid again on check if they have radiation. Okay, But that's it's two big things. You're looking forward. Um, auscultate in the carotid arteries. Okay, those two. So I want to see corrupted bruit the other Is the radiation off? A lot extent. ASUs Okay? Yes, I remember. Don't do it bilaterally. Um Okay, well, we'll quickly talk about the face findings as well, and then we'll take a break. Uh, what is this finding? Hear what you're looking for about in the ice contract title? Pollock goods Sign of mine deficiency anemia. Uh, what is this I finding here? Okay. Yeah. Good. I'm glad. I'm glad. Okay, Someone said cornea lockers. Okay, this isn't cornea lockets, okay? This is a case. Apply sharing. I try to trick you guys. So whenever you're learning examination findings, I know a lot of people just they read of something about the cardiovascular exam, and they know that in the eyes, you want to look for cornea arcus, but it's about it actually. Know what the physical findings look like. So this is not corny, Lakis. This is a case of fluttering. Uh, which condition is case applies during seeing it? Yeah, Wilson's disease. Okay. Wilson disease, which I which is a condition that affects the liver. Okay, which has nothing to do with cardiology. okay. But I just wanted to emphasize that when you're learning physical findings, try and learn what the physical finding actually looks like. Okay, so this is a case of flights during it's sort of brown green. I'm bringing on the periphery of the virus again. This is Connie Lakis. Okay, this is a thing. Actual physical finding for cornea Lakis. Okay, so it's ah, more blue Grey appearance. Uh, the bottom of the eye. Okay. Uh, what is called the Lakis associated with had hyperlipidemia. Okay, so we called. The lock is It's actually usually benign. Okay, It's usually a thing that can happen as you get older. Okay, But if you see it in younger people, you want to be thinking about Hae Libertes, okay? Things like have familial hypercholesterolemia or they have some condition that leads to high levels of lipids in the body. That's when you think about that's when the cornea Lakis is significant. Ah, what about this one? Yeah. Example. Asthma. Good. Um, this sign of Ah, um cholesterol. Okay. Um, last one, this is so this is just a fundoscopic image. Okay? This isn't something you actually look for. You don't do for endoscopy, and I have asked them about What's the finding here? Yeah, raw spots against Ah, this's raw spots of these retinal hemorrhages with the pale center. That's the classic appearance of rough spots. And the scene in infective endocarditis is which we discuss. Okay, Um, okay, I just talked to this one, So this is a sign off A lot. Flushed face is seen in mitral stenosis. Okay, so erythema around the cheeks. Okay. Is physical finding off Michaelson? Oh, says this is one we talked about before. So this is a physical finding off a high arched palates seen in Marfan syndrome. Okay, so, um, that's a classic high arched palates on Lost li. This is What do you guys think? I'm trying to get out with this image? Yeah. In fact, if under God, I says, basically, I'm trying to get a poor dental hygiene. Okay, that could be a sign off. Uh, infective endocarditis. Okay. Ah, yeah. Um, I've got this bit on one of the clinical features off Marfan syndrome. I'll just let you guys read through it, Okay? These you can use this little and ammonic to remember the different features off Marfan syndrome. uh, let's talk about the next examination. So what we did with the neck and face. So this is the thing you were doing with the next. So when you examine them back, make sure that position about 45 degrees today, especially when you're examining the jpp. Um, when you remember to auscultate and then palpate the carotid actress okay with the eyes. Um, these are the different things you looking for on with the face and mouth. The's are the different beaches were looking for a swell. Okay, okay, let's take a break for five minutes. Okay. Lets come back at 8. 16. then we'll talk about the rest of the examination, that chest examination and the rest of the cardiovascular examination. Um, you guys were enjoying it. It's like you guys having fun with the sport. Diagnosis. Um, there's a lot of physical findings. Um, we have a break. We'll come back in five minutes if you guys have any questions. Yes, it's on. If you could post to be back from, be good. Yep. I was gonna wait. Wait 30. But she just don't know. You can just you know Oh, I love the videos. By the way, I think it's like the best way of learning force keys. Just kind of sticks in your brain. Um, you don't need to measure JVP this gun senior all ski, Okay, You don't you don't you don't need to get get out the ruler and or anything If you didn't. If it looks levetiracetam, then comment on it. Okay? Yeah, We're going to talk tomorrow. If you feel in the slides metal form and you remember to take a request catch up content, you'll get the slides and the recording. Okay, Some of the images I'll have to remove on these slides. Just It's a copyright stuff, but, um, you'll get the recording with all the videos. Why do you also take cards quoted before palpating? Um, it's just Ah, it's just good practice to auscultate before palpating, I think just to auscultate for bruit, um, you know, if they have a bruit carotid bruit, you won't you won't be very careful with with the palpating that area. Okay. You know, we talked about this in ah, on Tuesday. You like if you do, if the patient has a crowded bruit Your boy doing a carotid Sinus massage if they have a super ventricular tachycardia because you don't wanna dislodge any amble I into the brain. So that's why that's the That's what it's always. It's always good practice to auscultate that crosses before you palpate it. Okay, is it's safe practice to do that. These videos proper. Take the charge out of my left eye was a charge before this. I'm more worried about your wife. I I'm surprised it hasn't, um, take up yet. I mean, touch wood, but I would have to palpate a break. Your pulse. Um, not typically for, ah, typical for, um, cardiovascular examination. You don't necessarily need to do a compulsive is no harm in doing it. Okay, break your pulse. Um, if you check it, If you're checking BP you use, you should always do use breakaway lows. Um, if you're doing a newborn examination room, you want to be used checking the break or close rather than real close. Um, should be able be able to do all this in the allotted time. So honestly, honestly, kind of acid is, um, nation is something you can fly through. Okay, This stuff with everything that that comes before the chest examination you should be doing relatively quickly. Okay. I just spent all that time talking about stuff that you're that you can see. Okay? Not stuff that you're likely to see in your actual osteo. Okay? I'm just talking about all the different physical findings you're going to be picking up with the hands, arms and neck. Um, but in reality and your osteo, you should be flying through all that part of the examination. A bit of a random question. What's better? What's better for the skis and placement when in your three on analog or a digital watch? Uh, Sana, what do you think? You know, like a digital watch. I just get one of those, like nurse for watches, which you can like six. Your scrubs, and then it's already upside down, so you can just, like, five it up and look at her. It's an amazon. It's really cheap on, but it's also you can't You can't have anything on your wrists in an exam. Anyway, um, you could have a watch. Do you have one of those four bushes? I don't know. I just, uh would you use my, uh, frontal lobe? Okay, Ah. Do you actually take the time to find the pulse rates? Ah, yeah. So I don't You just come for If you ever watch, just put a time it for 15 seconds and, um, just multiply whatever you hear by four. Okay? I know some people. They just they don't actually even listen to the actually feel for the pulse of it. They just make up a couple of multiples of full and then answer that. Yeah. So we should do a spot that I know succession. It's a good idea, actually. Just a just a session of pictures, and you guys just don't we all the answers, we have a date, and you're wondering that's that's the for watch thing. You can't just like it's upside down. So you gonna just take it to your scrubs and then, like, when you're doing it, you can just come flip it up and look at the time. Um, yeah, it's called the nurse. How much feeling Emotion. Have this? Yeah. If you guys have any other ideas, particular stations. You want us to try and cover? Let us know. Okay. If you have a look in a facebook and you see all the stations coming up, which we tried to organize it to try and cover as much of be undergraduate curriculum as we could. Okay, that can common specialty stations that come up. But if you guys want us to cover particular type of station weaken aimed to cover it some day. Green olives, that's in Ah, 233 weeks. Um, way. Definitely. Especially being a little examination in a couple of weeks. SED interpretation that you had a session on that. It's been hot. It's gonna be delivering it focusing really exam again. It's coming in two weeks. Mskube. All coming, guys. If you look at that Facebook events, we've got, um, stations plan for all these different specialties. Um, yeah. Any other questions? Guys? Gastro next week. Okay, Okay. Let's Let's get started. Doesn't down here on me. Sorry, I don't think I'm just finding the link that Facebook page people can look up the, um, skinny side. Yeah, that Yes, we saw. I think it's been five minutes. Right? Come. All right, guys. You guys enjoy your break idea. So I did. We do have a bit of a longer break, but with the chest examination that again. Quite a lot of stuff to get through. So hopefully finish my nine. PM might finish bit later, but we'll do our best. So we're gonna talk about chest examination now. And the big thing you want, It's sort of inspection of the chest. And the big thing we're gonna be inspecting initially with the chest is surgical scars. Okay, so we have a bit of a quiz on cardiothoracic surgeon starts now. You guys going to tell me the what the scar is and what the indications for that scar is? So can you tell me what is this scar here? Midline sternotomy scar. One of the indications for med lines to not risk us. One of the what procedures have likely had they had done. Yeah. CABG bother placements. Okay, those are two big ones. Open outside. Reasonable toe. Open heart surgery to do things like a CABG procedure or above replacement. Um, what about this guy here? So just under the Pravachol left Tropical. What is so Yeah, it's ah subclinical Esca again. Like mostly said it's most usually done. Two instead. Devices such a pacemaker is such a zeiss. EDS. Okay. I'm comfortable cardiac device is Oh, uh, I'll also, um, loop recorder. So that that's the subclavicular scarred main thing to think about is the pacemaker's with this type of Scott. Ah, what about this guy here? Breast breath. If you think about the cardiovascular examination, what? Definitely the mattress factory started. That definitely looks like this. But if you think about cardiovascular, uh, respiratory type stuff So this is an anterolateral recall to Miska. Okay, um, so indicated for things like lobectomies New minute to need elective. He's single of lung transplants. Okay, but this is an anterolateral thoracotomy scar. So if you see this on the anterior, but usually with these starcraft me scars, you see them posterially and also you talk about that in a bet. We'll talk about this guy in detail next week with the respiratory examination. Uh, what about this guy here? So this is a ah, continuous bilateral star rooftop. Um, if you're not not talking about, um, abdomen surgery here what? What do you think about it? If it thinking about the chest Cardio thoracic surgery. What kind of Scott? Yeah, it's a clamshell incision. Okay. It's a bilateral thoracotomy. Scott. Okay. It's indicated for lung transplants. Okay, That's a typical guy. Thoracotomy bilateral clamshell incision. That's what it's called. Okay, cause it's crossing both sides. Um, what about this guy here again? It's a mini thoracotomy. Okay, So, again, you know, depending on whatever valve is involved in, So this would be a mini aortic valve replacement, Scott. Okay, Um, so from minimally invasive cardiothoracic spells, you can get a tiny horizontal scar like this on last one. So they purposely showed you the the posterior off the patients, and we got a scar here. What is that kind of risk? Uh, what is this scar go? Yeah, it's a poster electoral store. Got me get. Okay, this is the bigger scar for lobectomies. Pneumonectomy is black knees. Okay? And this is a procedure that's done most common before these indications. Okay, compared to the anterior thoracotomy. Okay, this is the what big thing to think about which we'll talk about in a lot of detail with the respiratory Dominic next week. Okay, but these are important cardiothoracic scores. Teo scars to pick up on again. Still sticking with the chest s. So this is the I'm just showing you actually images of starts that this is that subclavicular scar commonly used for pacemakers. And this is the midline sternotomy scar. Commonly, you typically for CABG procedures or pacemaker. Sorry. Or four bowel complaints Mints. Okay, So can you tell me what are the potential indications for a CABG procedure for a coronary artery bypass graft? This could be this said Typical. Examined my question. What? What are the different indications for a CABG? Triple vessel? Disease is a big one. What else? What else we might you consider doing a CABG? And I say particularly indications for when you do it with, um, I failed Primary PCI. Okay, so they've had a piece, Adam. It's failed. And that's still hemodynamically unstable. And your other indications that you know off. But it's one of the when. What if they're having what other type of procedure? If having another procedure planned? What other one? Sorry, I don't I I'm starting to go with that. Let's just let's just talk through the indications. So the big one is, uh, just list, um, all out. So these are the main indications. Okay, So it's not a significant left main stent stenosis. Okay, That's affecting a bunch of the branches. That could be. That's an indication. Triple vessel disease old if even if they have two best of disease on a very low ejection fraction about that's an indication as well. Like someone said, if they have failed PCI or they're not suitable for PCI therapy, then that's a potential indication as well. If they develop complications like a ventricular septal rupture or a papillary muscle rupture, that could also be an indication to have to do open heart surgery. And it's a really important one if they if they If you know that they need to have a valve replaced at the same time, then you can do the CABG procedure on the ballot placement at the same time. Okay, because you're already doing the open heart surgery to open the chest so you can access both areas at the same time and saves, um, say saves Resource is where they have for HS, and it's much more convenient for the patient as well. Um, yeah, those are the different indications. Uh, but generally, patients should be discussing an empty tea meeting on Decision for Cabbage is based around the corner artery vessel involvement, redness for surgery and patient choice is well, okay. And you should mention that when you're talking about indications for a CABG. Okay, I've just been I want to talk about cabbage in a bit of detail. So classically with a CABG in procedure and Oscar, they use a vein from the leg. Okay. Can you guys tell me which vein classically do they use for a CABG procedure? Yeah. Ah, long saphenous vein goods. Um, so that's what that's typically, what to use for a CABG procedure with a staff lose bone graft. What's the other artery that's more commonly being used these days? Which other artery typically gets used? You're really a lot, for it can be used. The internal mammary artery is the big one that's kept use for CABG procedure. Okay, that's the internal mammary artery. Because you can just, um, it's, um quite quite convenient for cardiothoracic surgeons. And it has good patency as well. To the internal mammary artery is the big one. But always check the we'll talk about this. Always check the late legs for a, um, softness vein graft, because that helps you. That really tells you that the patient has had a CABG procedure. Um, um Okay. So, again, this is just a schematic diagram off the CABG procedure. Okay, so this is a venous crafts. Okay. Usually the long saphenous vein graft is useful if you're using a vein, but the arteriographic do you typically use And in the internal thoracic artery, typically the mammary artery. Okay. Ah, yeah, I got another image. Okay, so we were talking about pacemaker, so I just want to explain some concepts. Says so. Can you tell me what? How do you describe this pacemaker here? What type of pacemaker is it? I just wanted to make sure people are really clear on the difference devices. Yeah, This is a dual chamber pacemaker. Okay, so there's Ah, dual chamber. So it's two chambers, so there's two leads, one going to the 80 right Atria and one going to the right ventricle. Okay, so that's a dual chamber pacemaker on. I just got a chest X ray to show that as well, cause a lot of people get confused looking at pacemakers in a chest X ray, but this is a dual chamber chest X ray, and you can match it up with the diagram here So we got the one of the leads here on one of the leads here. Okay, so that's a dual chamber pacemaker. Uh, can anyone tell me what this just x ray is showing? But this is different to the dual chamber pacemaker because there's three leads. What state? What type of devices? This on exam. It shows you this just actually, what kind of device would you say? This is I CD. So I see the You'd explain you typically with a chest X ray. You get a thick lead in the ventricles. Okay. With an I C D. Um, yeah. Couple of you got a C A t. Cardiac resynchronization therapy. Okay, so this is a different to the dual chamber. So with CRT, it's also called a biventricular pacemaker pacemaker. So you have leads going to the right ventricle and your left ventricle and your yours have a lead going to. You're right, Atria. So if you look really closely, you can see three leads. Okay, One for the atria, one for the right ventricle and one for the left ventricle. Okay, so that's that's cardiac resynchronization therapy. Um, So my question to you guys is one of the indications for cardiac resynchronization therapy. It be sorry. I I should expect by one of the indications for cardiac resynchronization therapy in the context off acucar of heart failure in a heart failure patient. When do you consider cardiac resynchronization therapy? Yeah, on responsive to therapy is what else? Ejection fraction less than 35%. Good. And there's one more thing that they need to have. Yeah, Wide widened QRS complex is okay. Those are the three big things. So if they're symptomatic despite medical therapy, okay, if they have a left ventricle ejection fraction less than 35%. And if they have very broad curious complexes, these are the indications for CRT in heart failure. Okay, Um, a bit of a random question, but it's, ah, useful topic to know. Okay, so cardiac resynchronization therapy. Good. Okay, sticking with the chest. What is this Chest wall deformity here? Yeah, practice excavatum goods. Okay, so it's excavated. You think about, you know, um, us excrete something. You're digging something up, right? So it looks like something someone's escalated the chest. That's practice excavatum. Uh, what about this one? Yeah, this is practice. Carry needs. Um, Okay. So this is the pigeon is often known as pigeon chest. Okay, this is fact is carrying. It's, um okay, I said these up both types of chest wall deformities that you wanna inspect the chest for, um, and practice X rated is commonly seen in connective tissue disorders like Marfan syndrome. Practice carrying it. Um, it's been the cause is of that unknown. Um, okay, so this is another. This is a video off the, um this is a video of a device that's placed over the sternum, and I want you guys to try and think What? This physical finding us? There's place just over the sternum. What do you guys thinking? This Sinus? Yeah, it's, uh, he Okay, so we're gonna talk about heaves and thrills, okay? But this is trying to show what's known as a right ventricular. He, um So can you tell me what is? The heat indicates what is a right trick trick. Lucky? Yeah. Hypertrophy. Okay, so it's your when you do it, you're facing a hand over the sort of side of just the side of the sternum and you're trying to feel for that, right? Ventricular hypertrophy. Okay. And here we can see that there's right ventricular. There's a heave because this thing is moving up and down. Okay, that's a heat again. So it's a sign of right ventricular hypertrophy. Um, so is this is different? It thrills. Okay. Thrills is is the thing. You said you're basically your palpating from murmur. Okay, So apart Will drill is basically your palpating from a murmur. And so you should pop it for, um, Thrills in a while. Four auscultation areas again. We'll talk about the auscultation points, but you should probably get a thrill in all four areas. I should when you're palpating a drill takes a hand really lightly just so that you can really make sure that it's actually a palpable thrill. Um, yeah, that's a That's what throws us so that different to heaves on you, and then you want to make. Then you want to palpate the a pack. Speed's okay. Can you tell me what? What is the typical location for the a pack speech? Typically, impatiens. Where do you take Aleve? Where's the epic sweet Typically found. Yeah, 15. Because of space midclavicular line. That's the normal location off the apex feet. Okay, so whenever I palpate the patient's eight packs. Pete, I always try and find it. Okay? And then I show to the Examiner I come down the intercostal space, says, um in the midclavicular line to show the Examiner that I've ah, that I've confirmed that it's in. It's normal location. Okay, um, but this is a slide. That's basically how you, um, the clinical significance of apex beats. Okay, then algorithm. So when you're probably the apex beats, you want to know? Firstly, is it a forceful beat or if it's not forceful, if it is forceful, you don't want to think about, is it sustained? Okay, so is it sustained throughout Systole? Is that a forceful apex beat that's happening throughout the duration of Cicely? If it is sustained, that means that the ventricle is pressure overloaded. So with things like aortic stenosis or hypertension, there's a pressure overloaded ventricle, which is leading to a sustained contraction, and therefore I sustained a backseat if it's not sustained, so it's forceful, but it's not lasting the entire entirety off the systole. That means that it's a volume overloaded ventricle. Okay, so situations where the ventricle is just overloaded with blood so that would be situations like a little radio station and mitral regurgitation. Okay, um, so that's for a postal. A pack speed, if it's not possible. Okay, So if it's just feels normal, then you want to think about if you can palpate the first heart some, I'll be honest yet, and I don't know anyone who was able to do this. Okay, Able to actually palpate the first heart sound. But in books, it says, if you can palpate the first heart sound, then that's what's known as a tapping apex beats. And that's a sign off mitral stenosis. Okay, if it's not forceful, to be honest, if it's not forceful and it's not the plate displaced, uh, that's a normal apex beat. Okay, um, that's what we think about with the apex speeds and some causes off a disc. Displaced apex feet would be things like trickle a hypertrophy scar, little abnormalities like, um, scoliosis. There's a bunch of other causes, but yeah, that's the apex beats, um, so let's talk about the chest. So we talked about sort of the inspection and palpation of the chest. So these are the different things you want to be expecting of the chest, and we talked about the different things. You're palpating. So you palpating for Eve's help Pay for thrills and your palpating the a back speed's okay. Okay. This is the last big chunk of the talk today, okay? Talking about auscultation, which is pretty much where the half the better of the examination comes in. Okay, so it's a pretty heavy talk, but let's go through the principles auscultation. So this is a stethoscope. Okay? Some basic principles of the stethoscope. This is the bell of the stethoscope. And this is the diaphragm of the stethoscope. The bell of the stethoscope is best for listening to low pitched sounds die from his best for high pitch stones. On here is the auscultation areas. So I'm not gonna I'm sure most of you will know these different ostentation areas. So remember, with the civil, the best location to hear the aortic valve is in the send the second intercostal space, right? Sternal border pulmonary valve. Second course of space left paracentral border. We tried involved Best heard it in the fourth intercostal space. How's the left? Cymbalta? And the mitral valve is 1/5 intercostal space in the midclavicular line. Okay, If you guys can drop your best acronyms on your Monix to remember that, please leave it in the charts. But that's the auscultation areas on. Now we're going to move on to murmurs so important concept with murmurs to think about is that right side and members are loudest on inspiration and left sided members allowed us on expiration. So what I mean by right sided murmurs is that we're talking about the specific valves theand atomical position off the valves. So you're right. Sided valves are your, um, pulmonary valve and your tricuspid valves. Okay, So murmurs involving those valves will be louder on inspiration and left sided murmurs. So moments involving the mitral valve and moments involving the aortic valve will be loudest on exploration. Okay. And a useful way to remember that. Is this still saying the inspiration and lax for a shin because right side of members allowed us on inspiration less, I remember allowed us on expiration. Okay. And a bit with heart murmurs Will will run through some principles of heart moments, but we have a focus session heart murmurs in a couple of weeks, okay? Where we can spend a bit more time talking through the actual detail of heart murmurs and how to investigate and manage different heart murmurs. But I was just gonna cover some of the basic principles of auscultation today. Eso also when your auscultated you want to auscultate the corrupted for radio for the radiation of aortic stenosis which we talked about on when your auscultated also make sure you also take the exhilarate for the radiation off mitral regurgitation. Okay, these are the different things. You just want to make sure you're doing you're showing to examine it that you just auscultated the carotid and Exelon. Um, also another thing when you're actually auscultated the four different valves, what else should you do at the same time, while you're also taking what else? What should you do with your other hand? Yeah, So feel either feel for the carotid pulse or feel the radio pulse at the same time. Okay, that's a very important thing useful for auscultation because that helps to tell you is especially if they have a movement that helps tell you, uh, if the murmur is insisted the audacity. Okay. Um yeah. Remember to always help. It's one of either the I prefer doing karate, boss, but help pay the crowded pulse and auscultate at the same time on. Or remember to auscultate the croutons and auscultate the axilla. And remember, with auscultation, you also want to do the specific maneuvers. Okay? These dynamic maneuvers to help essentially it certain movements. So one of the maneuvers is to get them to lean forward during held and exploration. So get them to lean forward and then listen to the aortic valve. Uh, can you tell me which murmur gets louder with this maneuver? Yeah, a particular station. Goods on The other dynamic maneuver you want to do with the cardio examination is to get the patient to lie down in the left lateral position and then auscultate in the mitral area on Do what? Murmur gets louder with this maneuver, Michael stenosis. Good. Okay. And also which do you listen to this with the bell or the diaphragm? Well, what is it better to listen with? You should do both. For which one does it get? Do typically best. It's typically best heard with the bell. Okay. Might be murmur off, Michael stenosis. Okay, because it's typically it's a low pitched sound. So this is the maneuver. So for aortic regurgitation auscultate the aortic area, but with the patient leaning forward on with the mitral stenosis auscultated mitral area with the patient and left lateral position on. Do it with the bell. Okay. Make you condone it with both. Okay, but make sure you do. It would be bell off the diet with the the stop, the scope for my cluster. No cyst on. Okay, so we're gonna talk about some murmurs in a bit more detail. So this is the grading scale for murmurs. If you hear a murmur and your osteo, this is how you grow it them. Okay, um highlight the key thing. If you hear if there's no thrill If there's no palpable thrilled, that means that it's less than grateful. If there is a palpable thrilled, that means that it's either a great for or above. Okay, most members that you're gonna here in Austin is will be either great three or great for okay. Um, but yeah, this is the grading scale. And when you're describing murmurs in your osteo is, um this is the site type of different things. You should be talking about. Okay, So you want to talk about if heart sounds born into our presence? Okay, So S one s two you want to talk about? If there are any additional heart sounds on, I'll be honest. You're You're not going to really hear any additional heart. Sounds be honest. Okay, This is very difficult to auscultate. Generally, uh, you want to know the timing off the murmur. So is it a systolic murmur or a diastolic murmur? You want to know the great off the member? Okay, so we talked about that table in the last night. So what grade is the murmur? You know, tell the Examiner where the murmur was heard. Loudest. So which, which valve? The murmur was heard loudest in. You want to tell the Examiner if there was any evidence of radiation? Okay. Was there evidence of radiation to the corrupted? Was the evidence of radiation to the Exelon. And you want to tell the Examiner if the if the murmur got louder with a particular type of maneuver, Okay. Was it louder? Leaning forward? Was that louder in the left lateral position? And finally, when you're presenting the murmur, give the final diagnosis off the murmur and how you would investigate that particular murmur. Okay, again, we'll talk about this and a lot more detail during our heart murmur session. Okay? I'm just giving you the basic stuff. Okay? Now we're going to run through some different murmurs again. You guys are gonna listen to the sound and tell me what the likely diagnosis is. So try and hopefully you guys can hear the moments. Probably start it now. Uh huh. What do you guys think? Hopefully, hopefully you're able to hear that. Um, what do you think of that? What do you think of those heart sounds? I play together in case you weren't able to get Probably. Okay. Okay. This is this is that was a trip. That was a trick question. Okay, there was no moment. Okay, those are normal heart sounds. There's a normal s one s two, and that I was Ah, there's a normal heart. Sounds. Okay, um, we'll talk to you some other stuff, but that was a normal s one s two. Okay, so I recommend just listening to asthma. Normal heart. Sounds as you can. Okay. Know what the normal loved up sons are for s one s two. Um, but yet they do. Those are just no heart sounds. Okay. No pathology there. Okay, Next one. So I'm sure you that the stethoscope is placed over the aortic valve and there is some radiation too crowded, and the patient's BP is 1 30 by 1. 10. So already they might give you some hand. Hinted as to what? The diagnosis. This, But have a listen in. Yeah. Yeah, I get. Okay. So hopefully able to appreciate it, So that was so can you describe that moment to me? What? What? Were you listening to that? Yeah. So that was an ejection. Systolic murmur. Okay, so if I played again, you can hear there was just after the first house and does that. Okay, um ejection systolic. Most was it was a crescendo. Decrescendo murmur as well. Okay. I mean, okay. And yeah, like people said, that was a a tick stenosis. Okay. And classical with the aortic stenosis. You get radiation to across it, and also you get this what's called a narrow post pressure. So with aortic regurgitation, you get a big difference in your systolic and diastolic BP. with a lot extensive. Classically, there's you don't get much difference, Okay? Typically, it's a small difference in your systolic and diastolic BP on. But yet that was a case off aortic stenosis. Next one. So the stethoscope is placed over the tricuspid area. So, um, sorry. I should let's say that I should have paid. I think I misplaced the stethoscope. Let's say it's placed a bit higher. You got a displaced, a pack speed. There's evidence of a collapsing coast. The murmur is best heard sitting board. Okay, so already some clues there. I have a listen in. Get so you guys hopefully up late again, in case you need it. Okay. Get that. Yeah, I think. Mostly gonna say that was a member off a little bit. Vegetation. Okay. Can you describe that member to me? What, were you guys listening to that? Yeah. So that was a Yeah, that was a diastolic murmur. Okay, that that dystonic members are very difficult to listen to you. Okay, So the key thing I want to play it again. But the key thing with diastolic members I recommend, particularly for aortic regurgitation, is that you're listening for the absence off silence. Okay, so with everything regurgitation, it's an early diastolic murmur, but your list. So the way I tend to think about it is I'm listening for the absence off silence after the second heart sounds. Okay, so I played again and listen, you'll hear that The second heart sounds seems to be really long, but there's actually a murmur straight after the second heart sound. Okay, so have a listen again. And hopefully you can appreciate that. So the way to be so hopefully you can see they're like, after these second heart sound That was just usually with normal heart sounds. Silence. Okay, after a second heart sound normally it's just a crisp loved up. Okay, but with the head there was a love Dutch. Okay. And again, that's a sign of a headache Regurgitation on X one. So I have a listen. So the stethoscope is placed in the mitral area. We have the patient has a irregularly irregular posts, and there's also radiation to the Exelon. Okay, So, typically your skis, you're gonna listen to the murmur first and then pick up a deviation. Okay. I'm giving you are making it easier for you. guys, but I have a listen in. Yeah. Do you think? Yes. Ah, that was a murmur off mitral regurgitation I get. Hopefully that was a lot easier than the last one. Systolic murmur is in general are a lot easier to listen to you. But that was a member classic member for mitral regurgitation. Okay, it was a pansystolic member. Okay, You could hear that during the entire duration off systole. Okay, between the first heart sound and the second outside. So I was a pansystolic murmur, and we were listening to it That was her best in the mitral area. And there's evidence of radiation to the Exelon, and it's an irregularly irregular pulse. Okay. Suggesting atrial fibulation because classically a f can occur because off mitral regurgitation, So update again quickly on time. So you guys appreciate that. So it's a lovely you guys appreciate. That was a pan systolic murmur. Okay, It's pretty. It was quite harsh standing moment. Okay, but it's pansystolic entire duration of a systole. Okay. And that was mitral regurgitation. Uh, okay. Still on the mitral valve. Okay. And there's evidence off mail our faces. Okay. So, again, hopefully that's pointing towards the diagnosis for Have a listen. Yeah, it again. Yeah. Get that to us it If I didn't tell you the malar pieces and mitral and the mitral valve. That's probably quite a difficult murmur to listen to you. Okay, again. Diastolic murmur is in general are very difficult to auscultate. Okay, but that was a murmur off mitral stenosis. Can you tell me what's the what was that murmur describing if you could describe that moment to me. Oh, yeah, I was a mid diastolic murmur. Okay. Star played again quickly. But you can hear it with the other moments you could clearly here. There was a murmur between the 1st and 2nd heart sons. Right? But here it's in the bit of disorganized. Okay, you could hear the second heart some, but then there was, like, a book. Okay, there's, like, a murmur straight straight after the just after the second outside against trying. Listen closely. Yeah. Yeah. So that that was Ah, mid diastolic murmur. Yeah. Okay. Next one, um, have a listen. So this is a murmur that gets quieter after spotting again. It's placed in the pulmonary valve area, So have a listen in that again. Yeah, I think physical contact is quite important. So this is in the pulmonary area, and the moments get it actually gets quieter when the patient squats, so have a listening again. So pulmonary stenosis. So it could be primary stenosis, But because if you can you describe that moment to me, What were you hearing that great again? So, uh, this moment is actually a That's actually an ejection. Systolic murmur. Okay, that was actually I think the the sounds might not be playing that well of resume, but attaching an ejection systolic murmur. So can you tell me what the likely diagnosis would be if your hearing and ejection systolic murmur and the pulmonary area and it gets quieter when the patient's squats? Because, know, what would you think the diagnosis was? Yeah, someone's gonna hypertrophic obstructive cardiomyopathy. Okay, that's what I That's what I would be thinking about, like a hawk. Um, okay. If you have, I'm hearing an injection system. Remember? That gets quiet when they spot. Okay, That's classic ball. I hawk a murmur. Um, and typically it's best heard in the pulmonary area, where, as the aortic stenosis typically best it into the aortic area. So they both cause ejection. Systolic murmur is this is This is when you get obstructive cardiomyopathy where you have outflow tract obstruction. That's classic for a hawk, remember? Okay, um, but the classic example. Westchester. Okay, you're not going to see this in your osteo bi annual exams. That murmur off a Hakem typically gets quiet there when they squat. Okay, again, there's a lot of complicated physiology that okay, but the murmur gets quite when they squat. Let's have a look at this one. So this is a place that the tricuspid valve area. And I've told you there's no evidence off really a shin. So have a listen in. Yeah. Okay. Okay. Yeah. What do you take? So this again? Think about this's moment Best heard. Harassed only four quint across the space. And there's no evidence of radiation. Okay, What do you think? What, do you describe the moment to me? Yeah, it's a pan systolic murmur. Okay. Bested. So, yes, I got it. Ventricular septal defect. Okay. Pansystolic murmur persistently high tricuspid regurgitation. Similar. Okay, but the thing is, there's no evidence of radiation. Okay. Uh, ventricular septal defect Would tricuspid regurgitation good sounds similar, except cause it's in the tricuspid area and it's a pansystolic murmur, but and figures out of the effect is more common. Okay, so that's why I accept both on system. Um, but yeah, it's going to the next one. Eso this is the stethoscope is placed in the aortic. Both on both have a listen, but I think played again and someone's got it does sound mechanical, isn't it? Okay, that which it sounds mechanical. What? What do you think about the diagnosis? There. There, there, there. There was a click Sunday. Okay, you're looking really listen really closely. There was a click sound there. Prosthetic valve. Which valve is as a prosthetic valve in it? What type of about basement is this? Yeah, Here's the bottle. Basement gets like a So you play best tasting it on the table. I'll be hearing the click during the second heart. Sounds Okay. So remember, think about your physiology when your s one corresponds to your mitral valve. Closing us to sound corresponds to your aortic valve closing. So you you're hearing the click during s two. Okay, The second heart sound. So that means that your aortic valve is the one that's metallic. Okay, so this is a biologic. Available basements. Okay, um, have a listen to this one. So you still talking about bladder patient? So you know the diagnosis. So this is something mitral valve, but have a listen. What do you think again? That was a mechanical sound again, Uh, so if you update again, I'm sorry. You're not able to hear. Probably I might be rights bit challenging of zoom, but, um, yeah, that was a prosthetic mitral valves. Okay, so in that case, the click was actually heard best with s one. Okay. Was corresponding with s one. And also, there was like, there was a bit of a murmur straight after that. Do you know why is it why is it was the murmur straight after the click. It was a very soft murmur. What kind of how did what kind of movements? That Yeah, it's a flow murmur. Okay. So, classically with the barber basin, you get a flow murmur. Okay? It's a very soft sound. Okay, but the key thing is that there was a collect straight am that corresponded s one. Okay. Okay. I'm gonna I rushed through the rest of this exam is asking What are the complications of my metallic valve replacement? So some of the GI complications to be thinking about with metallic valve replacements can be remembered with the new monitor hated. So age for hemolysis A for anti coagulation side effects, See for thromboembolism. Okay, because prosthetic balls can clot quite easily. Um, be for endocarditis. Okay, so you get infected and carditis off your prosthetic bulbs on D for dysfunction off the boat. Okay, See, above failure and start you start getting regurgitation from the prosthetic ball. So that's the Those are the sort of main complications off ah of prosthetic valves. Okay, on here's the summary. Off comin murmur. Does that come up in osteo? Okay, again, we'll talk about all of these murmurs and much more detail with ah ah, heart murmur session. Okay, I will spend a bit more time talking about the pathology of these different murmurs, but this is a little summary table describing the features off the common minister on bless. Finish job with the auscultation bit. So with the chest auscultation, you also take all four areas and palpate the carotid arteries while you're doing it and you make sure you perform development maneuver. Okay, let's finish off with the back and legs. Okay, quickly. This is very quick. Um, you're gonna auscultate the lung bases Check for sick Dema. Okay, so also, day long basis checking percent will be more and also check for ankle Adina. Okay, These are all features, um, off sort of fluid overload. Okay. Classically with heart failure with thinking about it. And you're gonna thank the patient after that and then restored clothing. Okay. So quickly. This is this site slide covering the pathology of heart failure. So what have really upon your Dema listen to the lung basis and listen for those coast crackles. Uh, so, yeah, this is the just the pathology. Okay, So listening for course crackles for pulmonary edema because off a systolic heart failure. And remember to check for sake, really? Dema and ankle edema again. Similar pathology looking for, um, because of back pressure from heart failure. You want to check the cycle of chemo and ankle edema as well? Um, remember, with ankle edema, you won't press for a couple of seconds and look check to see if the edema is pitting. Okay? That's a key thing with them that you want to check with ankle edema as well. Okay. And if it does pit, uh, deep check for pitting edema bit higher. Okay, try and work out how high the level of pitting edema goes, because that's quite important. Okay, to work out the level of pitting edema, but you have, make sure you always check for sacred Dema and ankle edema on. Always check the legs for the sadness vein graft that we talk about. Okay, Don't forget, even if you leave that to the end, just make sure you just check the legs for any being a scrap graft scar us. Okay, that's important to check for in the legs. Um, yes. Oh, God. Just repeat that. So yeah. So that's the cardiovascular examination. Um, So this is how this light is hopefully gonna be useful. Template revision for the party of asking exam. Um, but I think that's it for today. This is how I would go about presenting the cardiovascular examination a couple of sentences for a normal cardiovascular exam. So I haven't really got to get the slights. Just a couple of sentences that you can use for your presentation in a future session. Hopefully, we can talk about presenting different cases that can come up in a cardiovascular station. But, um, that's your normal cardiovascular exam. Yeah, that's it for the day. Thank you, guys. Um, that was again. It was a pretty heavy session. We covered a huge amount of cardiology again. I'm not gonna like this week. We've done a lot of cardiology, but we pretty much covered Ah, lot of the important stuff. Pretty much most of the important physical findings with a cardiovascular examination. Okay. And on Tuesday, we covered a lot of the clinical stuff you need to know with your cardiovascular station. So hopefully at the end of this week, you guys are feeling pretty confident with your cardiology station. Uh, next week, I'll take you guys through respectfully. Okay. On monday, we have, um, at one, which will be a similar structure to our Tuesday lecture. Okay, going through, uh, focus history, taking data interpretation, just x rays. ABG s, um, explaining peak flow explaining inhaler technique. Ask me. Review stations, spyrometry interpretation, flow volume, loop interpretation. Um, ABC, The assessments off tension, your authority Pneumothorax. We got a whole bunch of different stations coming up on on on Tuesday, we'll talk to the respiratory examination. Similar session, too, today on. But hopefully you guys will enjoy that as well. And then we got gastroenterology the following week. We got a lot of stuff coming up with the Oscar series. Hope you guys are enjoying it. Um, um, please make sure you're pulling socials to stay up to date with our events. Make sure you fill in the feet back home for today's session. Let us know what you guys thought of the session. Anything we think we can improve on. I know a lot of people not funds off the long run running time. I appreciate the session is very, very long time. Okay, Two hours is a long time, but I when I teach, I always prefer making sure I'm quite thorough when I teaching. Okay, I'm not a fan of just not covering certain things, so I prefer just taking that extra time to make sure I cover everything. Um, but yeah, I hope you guys enjoy the session.