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um, kind of how to double it and hcg in an Oscar station. Kind of when you're given an E c G. One of the things you look at it, how do you talk through it? I'm in order to kind of gain the maximum mark marks. I think a lot of times the nurse station you can gain a lot of the marks by just kind of going to your thought process and showing the Examiner that you're like thinking of it the right way. And sometimes, even if your answer, your final diagnosis in the end is not really right, that's fine, because you regarding a lot of the marks from just explaining your thought process, which is really important. So let's go over that today, So I'm gonna jump right straight into it. Um, when you first given an e c. G like this when you handed it in Oscar station consumable in the chat, the first two things that you look at the first two things patient details. Great. That's one of the second one patient details on DTaP. A shin perfect. What is calibration mean? Yet when when it was taken, that's also very good Yeah, that's good. Calibration the calibration. I'm looking at paper speeds. Exactly, which is a here over here. Um, just 25 should be 25 millimeters per second. And the voltage of the machine should be set to 10 millimeters per mil a volts. So when you're under occupation, just be like this is John Smith. Easy GI. Date of birth is correct on def. There's like something that says when he said he was taking, like, all these shoes taken today, which is correct on dust. Look at the border. Make it really Obviously look here the calibration be like our calibration is right. It's 25 millimeters with second paper speed and 10 millimeters with minerals old age. And and then you can start with the actually cities. You've already secured at least the mark there, which is great. Perfect. Um, so in terms of interpreting the trace, it can be very tricky because you kind of can get blinded by so much that's happening in there. So many squiggled you like, Where do I start? Well, the a way of looking at it is kind of using the demonic, which kind of rhymes It's R P. W Q S t. And if you can remember this than this kind of gives you a system off, what to go through. And this doesn't come things one. It gives your systems. You kind of have an order. Second, it make sure that you don't miss really important things. Because if you remember the name on it, you're going to go through in your head and you won't forget things because you're stressed on drums and on skis is really about overcoming the nerves. So having a system really helps, especially that becomes like muscle memory. So what it stands for is rate, um so that the heart rate you can calculate the rhythm irregular or regular? Um, the P wave morphology. We should get into the with off the curious complex, broader or narrow. Think UTI interval prolonged or is it short? Was it normal? Theoneste E segment Is it Aysel ect trick? Is it elevated or is a depressed? The T wave is abnormally peaked. Is it inverted things like that. So if you remember our p w qsc for every EKG because through that would make it be easier to talk through on In addition to this You can add on, like axis deviation and stuff. If you have time on, sometimes I sit deviation. Can't even help you with your diagnosis that we'll get to in a second. But these are the bad basics that you would have to do. And I'm sure that would be expected of you department on. So, in terms of rapes calculating, right, How do you do that? So, in an e c g paper, right. You got big squares like these big these big squares, and you got a little squeeze within them. So one small square is 40 milliseconds. Each of these little small twice, and then one big square contains five small squares and therefore one big square is 40 milliseconds times five, which is 200 milliseconds. This is helpful in touch in a ting rate because, um, if you if they refuse, if it looks like the rhythm is regular, then what you could do is you can count the number off big boxes between two are waves on, but then divide that from 300. So, for example, with between these two are ways you have 123, and then half and half your four big boxes between these two are waves, so you divide that from 300 that gives you roughly 75 BPM, which is normal. So a lot of times, and all skis they kind of broke. Amend, I've heard is that they would recommend that you kind of give your answer to rate it as a multiple A Z one of these multiples in 300 or 1 50 or 175 because it shows that you've used you'd use this formula to calculate the rate and that, you know, just blindly guessing the rates to Sometimes it's helpful to kind of, even if you like. If you blacked out and you can't like and you just your brain to start calculating the rate in that moment, Just if you remember these numbers and kind of resting it, what the rate might be from it that that would probably make you sound confident. Um, so how do you calculate the rate? If the rhythm is irregular? Can someone tell me in the chat? Because this is her regular rhythm? What happens if the rather miss irregular someone's ask the Chazal? Yes, Can anyone to that. Yeah, Perfect. Exactly. So what you can do is on the rhythm strip at the bottom over here if you count the number of curious complexes. So let's go back for a second, okay? Out this slide. So if you look at the rhythm strip, which is lead to over here, but this is like regular breathe. Um, but let's do it was irregular. Okay? So 123456789, 10, 11, 12, 13 So, 30 and yours complexes, if you multiply that by 6. 13 times six should give you, like, somewhere about 75 BPM somewhere around there on that, that will be fine as well. The reason you do it times six is because, um, this east 1 cc g strip gives you like a 12th window into someone's heart. Some heart rhythm. And so obviously, if you want to get their BPM, it would be 10 times six. And that's why you multiply it by six. So if the rhythm is regular, then you come off the number off big boxes between our graves and divide up from 300. If it's irregular. just counter of curious complexes and multiplied by six. That's great. Um, yeah, that makes sense. The usual thing, especially in the context of, like, a my card in function would be knowing the Cardec access that the cardiac territories s o n which artery supply each other territories. So just to quickly go over it, your lateral leads would be one A B l be five mg six your inferior leads to three. And ATF Your septal leads are the one and the two, and you can't eerily every three. And before someone once told me a pneumonic to remember, um, this, like in in the exam. So if you look, if you just have a look at the column here So this this first column would be big lie because l I I the next time will be little like because l I so big lie little eye and the third column would be asked, So a s s and the fourth column would be all a l l So if you're, um, a big lie, little I ass all that kind of helps you, um kind of have a visual image off the territories you're headed in the examine you blank out. So just remember being a little I asked. All I personally said helped me. So if I hope so, that's great. Fab. That's have to get to the e g. So for the first one, I'd like you guys to kind of have a look for a second on. Do that. I'm going to go through it like as per the pneumonic we discussed. So just take a few seconds. Don't put anything in a chat with Doctor. It's only, um, just just have a second to look at it yourself. Okay, So the first thing we said it obviously patient details and calibration that start on this easy, G. But you would definitely mention it. And if it's not on the EKG and your ski, definitely say, where are the patient? I can't see them. I can't see the Beijing details. And therefore, I can't confirm this divide patient because sometimes they could they could be, could be a trick, um, to question and definitely say I'm also looking for the calibration, but I can't see it. And therefore I would assume that it's correct or something like that. Okay, then we use our pneumonic are P w Q S t. Right. So let's look good rate, because that's the first thing. So waiting rhythm. Right. So do you guys think the rhythm is regular? What is the rhythm? Rhythm is regular. Yes, I would agree with that. Okay, Onda. Okay. So given that the rhythm is regular, how do you guys want carefully the rate. Can someone tell me how they cut it would calculate the rate of his EKG. Yeah, someone said it perfectly. Three squares between each peek. Yeah, Perfect. You've got about three squares with each peek between each are wave to divide that from few hundreds and you get 100. So estimated rate would be 100 bpm. That's great. Perfect. Next, we're looking at the P waves. So, um, can you guys are we able to see Peewee? It's This is just look at the rhythm strip now. Can you see Peewee is? Yeah, you can On what do you guys make off the PR interval prolonged. Yeah. Why? Why? Why is it prolonged? Yes, Someone's as over 200 milliseconds. Yeah, So a normal PR interval is up to 200 milliseconds, which is up to one big square. Anything over that is considered prolonged. So in this case, if you look at it, if you look at this one, for example, this is a P wave, and this is the beginning of the cures complex. So the PR interval here is way more than five small squares, and that means it's prolonged. Perfect. Okay, what about the with of the curious interval? What do you guys think about the with? Okay, what's the normal Kjaer's interval? Yes, less than less than about 0.12 seconds. Let about 120 milliseconds. Right. That's about three small boxes. So if you look at this over here, it's about three small boxes. So I'd say it's normal. It's not narrow, and it's not. It's not abnormally broad, either. That's great. So that we don't our p w we won't look it. Um, the cure is complex morphology. Is there anything that you can point out? Um, is anything you can see on this? Easy, g curious about your eyes. Complexes away. Progression delayed. Um, much about that, actually. Um, okay. Actually, I'd say it's quite normal. Um, sorry. I don't mean I don't make you overthink this, but it's actually fairly normal of his easy. Um, And what about the ST segments? Yes. Yeah, I would agree that the segments of bit abnormal in V three on before. That's fine. Okay. Fab on. What about, um what about access? Deviation? Normal? Perfect. Yes, I would agree the access is normal. Great. Okay, so in. Okay. Yeah, we should go up. We can go over axis deviation. Is that That's absolutely fine. Um, can So could someone then tell me now, based on what we've just discussed what they think that this easy issuing. Yeah. Yep. Okay. Perfect. So this, actually, I've taken this easy that I've taken is actually a first degree and to rent a killer block 80 g. Given the prolonged PR interval, however, I can see why. You might think this would be, um, anterior stomach, even the ST elevation here. But obviously, I haven't really given you a clinical vignette. And therefore, like, there's no way of really, like saying for show up the east years if you don't know who the patient is on what that presented with, So that's absolutely fine. Um, So again, the characteristics or first degree every block are primarily a regular rhythm on the fact that you have a prolonged PR interval and by prolonged, I mean over 200 milliseconds, which is more than one big box. Okay, um, so in an Oscar station, how would you present this? So, for example, be like, Okay, this is the easy G of John Smith. Correct date of birth taking today are 50 of the time, 12 PM Calibration is 25 millimeters second on day, 10 millimeters per mil. A vote, which is correct. Looking at the rhythm strip of the bottom here, I'm able to know that the rhythm seems regular and therefore calculating the rate. The rate appears to be 100 BPM. Um, which is slightly Daddy. Kartik, I'm looking at looking for peewee waves. I can identify Pew years and they look normal looking the PR interval. I can identify that it's slightly prolonged. The PR interval seems to be longer than 200 milliseconds on their four. I would consider this to be longer than normal. Then you can move on to the cures complex and say, I think your risk morphology looks normal to me and is within 100 20 milliseconds in length. Thie ST segment looks, eyes or electric with no evidence of elevation of depression except for in leads. Um, the three refill on the five where it seems to be slightly elevated. Um however, without a clinical picture, I cannot cannot. I cannot see whether this is relevant. Um, Andi. There's no evidence for any access. Deviation of the access looks normal. So, for example, based on what the patient in your osculation present when you could be like, these findings are consistent with first degree every block on. That's kind of how I would present this easy gene or occupation. I hope that makes sense. Great. Um, well, there's some more details about all these 80 G's on the slides. I did a full STD talk that's like two hours long, and you can find this on our model page. And that's way more detail in this. This is very, very condensed version of that talks to definitely go Watch that if you want some more practice. Um, okay, there's another one. So those two the same thing again really quickly. Can someone tell me, um, the rhythm, what they make of the rhythm and irregular. Yeah, up on what is haven't given up. The rhythm is regular. How you going To calculate the rate count the number of curious complications. Much about my sex. Perfect. So can someone. Actually the right for me. You go. 123456789, 10, 10 times. Six or seven times. 6. 66. Great. Perfect. Six beats a minute. Great. Um, okay. Can you see people Aves? Yes. Uh, how is the PR interval prolonged? Yeah, I was agree. It's increasing. Yeah, Perfect. Someone said increasingly prolong gated. I would agree that because if you look in the rhythm strip, you can see that as you go along the rhythm strip this is between pee in the are waves becomes increasingly longer perfects great before we jump her diagnostic decisions, guys, that just keep going with the with the morning. Right? Um, so you don't pee pee? We have NPR Interval. What about the Q wave Cures complex? How is the cure is complex. It's normal or low altitudes. Um, intimate and drop. Yeah. Okay, fine. For example, Here you can see that Although there's a P wave here, Um that's a beautiful there on Bellevue is there but, for example, that there is no cure. It's complex. After this P wave, which is concerning, um, Andi, start 70. That's something you would take note off. Um, on what's next? Next? You will look at the ST segment. How is the ST segment? Okay, after the ST segment is mostly normal, mostly eyes electric. Uh, but we do have some flat t wave that would agree in some leads. That's fine. Um, okay, great. Um all right, so and then what about your cardiac access Codec access? Anyone yet? Left axis deviation. That's great. Can someone cookie say why I can go through access again? Yes. The cardiac access is basically it's this, like, kind of imaginary, like 3 60 degree access that your heart's it's on and based on how much muscle mass is present and whether there are bundled launches but bundled blocks in your heart. Sometimes electrical impulses travel more towards one side than the other. And this can be a sign of pathology, for example. So so someone has said here in this case that it's left axis deviation because it's positive in one in one and negative and a V f great. So, um, in terms of Codec access, I've got a got a diagram that I'll show you later. But basically, if you think about the easiest way to look at it is if you have, like, a leads one and a V f. Okay, Um, if I also look, it leads 12, and three and 80 s. So you think about if the it's usually always positive in one and two, Okay, because your heart impulse is traveling towards one into, um and then sometimes and then a V f is kind of the other side towards the right. So if your impulses traveling more towards one and two and a way from a V F, which is the other side that that means it's going more towards the left. That's left axis deviation. So it would be positive and one and two and negative and a V F, whereas if the waves are more positive in a V, affects upright in a V F, but very, very light short in one or negative in one thumb. That's right, axis deviation because it's going more towards a V F and away from one. If that makes sense, I've got a diagram in my other E c g talk. That kind of explains it. My spent a long time explaining it. So go back and watch that video, and hopefully that will clear things up. It's hard to explain that I have them a sense. Okay, great. So this is second degree every block. This is type one is called a one key back ab block. And this is because you get, um, progressive prolongation in your PR interval and keeps getting longer and longer until finally a curious complex is dropped. Um, so initially you got every P wave is followed by a cure is complex, and then suddenly you have a P way and there's no cure is complex on dicyclomine gins again. So this is called wacky back ab block. This's a type of second degree, every block, So there are two types of second degree 80 blocks. The first one we talked about was wanke back, which is moments type one where you're progressive prolongation of the PR interval until a cure a stopped. The second type is mobitz type two, which is where there is no progressive for on Gatien. The PR interval remains constant. It's prolonged on. It. Just remains just a prolonged throughout the CT. But you will see some nonconducted p waves. That's how you can tell whether it's type one or type two. That's the main difference. Really? Okay. Okay, here's another one to somebody wanna say what the rhythm is of this easy G irregular is irregular. I could see why is into irregular because there's nothing that I would say. It's fairly regular, actually. Yeah, it's regular. What about the rate? How is the rate? It's bradycardic Fine. What is the rates? 30 beats a minute. Yeah, it's really slow. Yeah. Okay, so we decided it's regular, and it's bad. Kartik, that's perfect. Fine. P waves. How do you feel about the P waves present? Yes, Yes. Um, okay. And then the PR interval. Yeah, PR interval of it. Random eczema. It keeps changing. Like if you look good, PR interval. Here. It's like less than one big box. But the PR interval here it gets longer and longer and, uh, just a bit brand, um and not every every PPI. We have results in a curious complex. So, really, there's no Association here between pee waves and the cure is complex. Can someone say what? That should immediately kind of tell you that it might be type three heart block with that also called? Yeah, complete heart block. Exactly. So complete heart block. You had complete ab dissociation where there's no real relation between the P Wave and the cure rates. Complexes on the PR interval is really variable on. Typically, you get a regular rhythm. That's very ready, Kartik. Very slow. That's kind of the picture that you got here. Yeah, as perfect. Well done, guys. Really good. Um, perfect. Okay, next one. So there's no rhythm strip on this one. Unfortunately, um, so don't worry about calculating rate for this one. Can someone tell me is just start with the P waves. Oh, um, a cure. It's complex is normally about 120 milliseconds, which is three small boxes. If it's below this or above this one that's used because it abnormal, depending on how big it is. So over 100 20 milliseconds is quite broad and look obviously broad. And that's usually ventricular and origen, whereas matures complex. That's less than her dream. A millisecond is called narrow complex I'm on day. Could be supraventricular itchin. Okay, absent p waves. Um, yeah, I see what you mean. Yeah, okay. Broad caressed. Yes, I would agree with that. Um, can someone tell me why they said broad your asses in this example? Yeah. So, you know, it's not very clear here, is it? But, like, critically, if you look at the start of the cure is complex, which is there. It ends over there. And that is definitely more than thought. Three small boxes. That's more than 0.12 seconds in there for that's broadcast complex. Okay, fine. I can someone tell me in terms of the morphology about yours complexes? Um, what do you think? The morphology of curious complexes. Someone says M w something Ours. Our initial Q wave and B six. Okay, um great. Somebody said something called Ours are in the one. Um What? What is what is the air is our pattern a lot of you're pointing indicated right, but a bunch block. Okay, perfect. So basically this easy, gi. If you look at it, you can't really see that many people waves that we can't really comment on the PR interval if you don't move on to the cure is complex, it's brought in nature. And if you look at the morphology off, the cure is complex. In the one especially you getting this weird Double two peaks cures complex morphology here. Whereas in the six kind of getting this very deep s wave over here is Well, um, so as well. If you look at the access deviation, you think kind of see a bit of right axis deviation, it's less positive. And we've on and very it's very deflected towards a V F, as you can see, which is indicative of right axis deviation. So really can the diagnosis of the CCG is right Bundle branch block on be the key identifies looking for in a right bundle branch. But it's easy, as somebody mentioned is firstly abroad QRS complex. So 100 more than 120 minutes seconds and second is the morphology in V one and the two you get the single and ours are yours complex. And this is our it's called our s our because you get to our waves to get one our way than an s way. And then another r wave and therefore you get, um, it's called Ours are on. You get this because in right bundle branch block Your ventricles are delayed when they depolarizing one ventricle depolarizing is after the other than not synchronised. And therefore each of these are waves are symbolic off ventricles kind of depolarizing a synchronously. That's where you get to our waves. That's what these this is, um, at the textbook description of I've been rushed. Book is called Marrow because you get an M shaped wave QRS complex here was kind of looks like a m N V one, and you get a double U shaped. It's complex and b six, but signified by the deep s wave. Said this thing is kind of a double you. So that's kind of what you're looking for on the right bundle. Branch block on. We saw a bit of right axis deviation as well, Which contributes that. Okay, another one. So again, the rhythm strip. Sorry about that. Um, can someone tell me, um what is? Can you can you see Peewee Aves in this? You can see people Aves? Yes. Um okay. Are they? And how is the PR interval? What? Normal? Yes, It's normal. Fine. The cure is complex. Would you guys think of that as it is? Quite normal, actually. Yes. Great. Perfect. What about the ST segment, then? Normal. Yeah. Normal ST segment. What about T waves? Eyes you electric? That's the correct word to use perfect T waves. Yep. Perfect to someone said the inverted there's with T wave inversion here. So if you look at, for example, the to be three weeks before so anterior lead, you can see some amount of t wave inversion on. And then someone tell me how you might interpret that given that your only finding T wave inversion and anterior leads Yeah, it could be a sign of ischemia. That's perfect. Potentially an end stemi Exactly. Yeah. Visit on ST Elevation? Yeah, evidence of myocardial ischemia. That's great, guys effects obviously, with again, without a clinical picture, I can't really diagnose and easy g. But if somebody presented with, like chest pain, typically a C s type type symptoms on getting this easy, gi, there's no ST elevation, so that comes in end stemi. But there's evidence of ischemia due to the TV of inversion in your anterior leads. This is an anterior non ST elevation myocardial infarction. That's fab. Great stuff. Oh, the other thing, I would say about 80 g waas. So if you notice the main team of inversion that's happening in this easy G is envy three and re for if you look at it a day and you also get this thing sometimes is called by basic T waves in agitate leads. So given that the T wave inversion is like most obviously occurring in between before sometimes get by facing we t waves in the leads next steps just be two and be five. And this basically means that your T wave goes up and it goes down. So whereas in this in vitro, for example, it just goes down and you have isolated inverted t wave in V two, for example, this whole this whole give me a second. Oops. This whole complex here is a T wave. It's called by Phasic because it goes up and it goes down so you can comment on that as well. But I imagine asking setting like they're not gonna want you to recognize that could start is important. But I do think it'll make you sound very smart if you look for it. Um yeah. Great. Um, Pap. Here's another one on this one. Let's do this, like from scratch again Because we ever them strip. So from the beginning, we're looking for patient details. Okay. John Smith. Date of birth taken today. I'm looking at the calibration 25 millimeters per second paper speed on by one centimeter of a millivolt voltage. Perfect. I happy with that Now I'm gonna look at the rhythm. Um, what do we think of the rhythm, guys? Irregular. Irregular. Okay, what about the rate? Irregularly irregular. Perfect. Okay, the right tachycardia. Okay. Yeah. Someone says about 100 to be P m. Great. That's fine on. But let's get people with. Can we see people? Aves? No, we can't see Peewee Aves. Okay, fine. Um, if you can't keep your weight is you can come into the PR interval. Don't want to move on to the cure is complex. How is the with the morphology of It's your it's complex. The cures complex. Narrow cure small. Actually, a lot of states is normal. Curious complex. About three small squares. Really fine. And what about the ST segments? Normal? Yeah, I'd say It's normal. Um, T waves looking okay to you? Yes. Okay. Axis deviation. Normal. Yeah, I do agree that fine. So given our find, easy G, we have a irregularly irregular rhythm. The rate is started. Hard to get about 100 BPM. We can't see peewee waves. Um, Andi think you're a small fall a Gee, the ST segment of the T wave look normal, and there's no evidence really left that any access deviation. So given these findings, what made these findings be consistent with f Asian population? Perfect. So it wasn't a joke. Flutter. Can someone tell me why this would not be atrial flutter? There was no sort of pattern. Yes, but also there's another really important differentiating factor that's easier than a soft with pattern to identify would be regular, perfect. So the primary difference between atrial flutter and age of relation is that age old flood. You get a regular rhythm. Where is the age of formulation? You get an irregular rhythm. That's like the basic difference. And then after that, you look at morphology is you get this sort of pattern in a in a chair, flatter, and you get like the irregularly irregular lack of waves. Chaotic 1018 Fibrilation. Okay, how'd I can't say the rate? Because it's irregular. Rhythm I Catholic. The rate by counting the number of curious complexes in the rhythm strip and multiply it by six. Okay, Fab Great. Perfect guys smashed. It did. Really? Well, that's great. Um, I feel like you guys. I really hope you kind of getting an idea of getting used to going through the system now in your head, Onda, have a dog if you're an Oscar, because that's the most important part. So that's why I'm making a point. Talk about every single thing in every You see, GI, cause that's what matters. Great. Next one. So this one, I I would like you all. This is something you kind of have to be able to recognize instantly. Can someone's Yeah, great to see some really good words. Someone said polymorphic ventricular tachycardia. Words we love to see Well done. Tore sides deport. Very good. Yes. That's exactly what this is So sad. The prior a k a. Polymorphic ventricular tachycardia is a life threatening arrhythmia. Okay. And basically, what you get here is a prolonged. It's basically the major risk factor for the development of this, like chaotic for them, is a prolonged QT interval on. If you study for finals, you know there's like a range of drugs and arrange your electrolyte abnormalities that can cause for long QT interval. That can predispose to this rhythm so you could see a polymorphic ventricular tachycardia. You know it's particular because fat one, it's Broadcom plex. The cure is complexes are broads. A zoo can see here. Then when I say polymorphic, I mean that they all look different. So no to cure is complexes Look the same release. If you compare this curious back, tourists felt somewhat all of summer shorter. Some have ridges on them like they're just different on. That's called polymorphic on data ptotic. The rate is really fast. This is life threatening. And that's something you need to be able to identify. Like instantaneously and very good. Well done. Okay, this is the last 1.5 you today. So examples of drugs that might cause there's so many go back a second. Um, you have a lot of them, like macrolides. You have like SSRI is It's a teleprompter on here. It makes like solid sotalol. So many drugs. Really? I would look it up and pass med. Or like, Ambos something for a comprehensive list. And I would definitely under the finals. Um cool. This one. Lets work out the last one together. I would appreciate it. No one chucked the diagnosis into the chat so we can all work through it together. Just the last one. Let's start again. I'm looking at the patient details. So John Smith date of birth when it was taken, I'm looking at the, um tell abrasion I'm looking at Is it written here? So I would come into the Examiner that I'm not able to ascertain the calibration of the EKG. But I'm going to assume you presume that it's normal for the sake off this exam. And then you start with P waves that we thought with rhythm and rate. So how do we What do we think of the rhythm guys? Preg yeller Fab. Okay, what about the rates? It's regularly irregular ice water like that. Um tachycardia. Normal rate. 100 ppm. Yeah. I hope all of you kind of understand how to calculate rate to this point if it's irregular or regular. around 100. Okay. So, yeah, I would agree. Status are fine. Um, what do you think of the PR interval? It's been cold looking, isn't it? Um, it's hard to design. Yes, I was in that. It only asking if you're confused. If you feel like it looks really odd, don't just a side and literally just stayed out loud. Say that it's hard to see because sometimes that might just be the case, like they want you. They want to hear you say that it looks odd, and it's hard to comment on because they want to be able to see that you can differentiate between a normal and abnormal EKG. So if it looks odd and you're not sure what it means, just say that it looks odd, and then you can't quite tell what it is, but it doesn't look normal. Um, which one is the P way? Very good question. I actually think that's the P wave. That's the P wave. That's the start of curious complex. In my opinion, however, I could be wrong because it's a bit it's hard to tell. Is it by phasic? I actually think that, um, that's the P wave. That's so the cure us. And that's the T waves. You know, I don't think it's by basic. Um, Fine. Fine. So we kind of call into the PR interval because it's hard to tell. What do we think of the cures? Complexes wide. Yes. Definitely very abroad. Exactly. It's going to stay out of your face. Isn't especially these perfect? I would agree with that. What about, um um ST segments and old ST segment and T waves? What we think Tented. Yeah, p told tented t waves. Yeah, they're bit like tens, aren't they? Look at these ears that he was. This is You're curious complex. And that's 30 with curious complex t wave Perfect that tall and peaked on elevated Broadcom Plex. Perfect on this. Positive psychotic. Amazing. Great. So, uh, any evidence for axis deviation? For the sake of completeness, sake of completion? No. Which of the T waves in the rhythm strip? It's really hard to tell, actually, eh? So if you can I think that I think that is that he waived the second hum, but it's hard to tell, so I just say okay, Fab. So actually, this is hyperkalemic, uh, on is very characteristic because you get these peaks T waves on broad trust complexes on Dwight A P waves step perfect. Well done, guys. Really good as a whistle stopped. Oh, on easy G's um, Andi, I kind of went for just the most high you want. If you want a more detailed explanation like, just go to him at all stage, find my home with me, Although I don't feel as the axis deviation eso Hello? Hello, everyone. I'm sure you know, being by now and Meghan, I'm gonna be going through the next bit of data interpretation today, which is mainly going to be focused on imaging. But before we go to that, I've got a little bit on CSF finances because I think that's also quite high. Yield is well, so to start off with a little bit just in general, information about that won't labor the point too much on. But just remember, in a lumbar puncture, we're trying to go into the several employees, get cerebrospinal fluid, or CSF. This is the course of a lump bunch needle. You might gas this in your finals, but you probably wouldn't be asked it. And in a Noski. Um, in an adult, remember that you want to insert the needle at the level of L4 L5, which is basically to fears line, which is the line between, um, the iliac crest. So that marks the level of L4 L5. And that's basically to make sure that you don't hit the Conus medullaris, which is the tapered bottom end, um, off the spinal cord itself. So very quickly just to get our brain's working. Can anyone pop in the chat for me? Some indications as to when we do a number puncture meningitis. Yeah, CSF analysis yet really good. GBS have less? Yeah, brilliant, really good guys. So I've got the indications into two different parts. So you can first the use it for diagnosis, which is what you've already alluded to, which is really, really good on two things that men and meningitis, a mess of Iraq, things that this that you've already talked about. So we're trying to use the CSF from what's in it to get a diagnosis off something. Um, you could also use it as a therapeutic thing for a lumbar puncture, so you could be delivering medication for epidural for, um, if someone's in labor, some medications have given violent bunk just such a zonal geezer and chemo on. You might use it for fluid removal as well. So if there's a communicating cause of a raised I CPA intracranial pressure and like of listed here like communicating 100 capitalists or an idiopathic intracranial hypertension, something where you're not going to cause Koning when you put the needle in you can use, um, you can use a lumbar puncture to remove some fluid to relieve that high pressure. I've also adjusted to hear some country of vacations remember puncture, which might come up in directly. And Noski. You might be asked what investigations are, what management you want to do next on def. Have any of these don't have a bug, eh? So if I've got a long communicating cause of raised intracranial pressure so they have some sort of space occupying lesion, we don't want to cause koning. So let's not do a lumbar puncture. And if they're only on any anti coagulation, or if they have any other cutting problems, um, you might get a kind of a traumatic tap. We call it when you insert the number going to need a little. So we don't want someone, um, with any of these disorders having a lumbar puncture because we don't want him to bleed excessively well, so I don't want to do it. If there's a spinal abscess because we don't want to push the new through the abscess and then push all those bacteria pathogens into the spinal cord, that wouldn't very be very good at all if there's any risk of herniation. So something would Arnold charry malformation, which is basically, as you can see here, where the cerebellum is herniated down the frame of Magnum. So if we put a number but you need to win, that's going to, uh, compress that part of the brain that wouldn't be very good at all. So we don't want to do it. Then, um, I'll ask, you guys have If someone's got a spinal cord trauma or any congenital spinal problems, why would that country indicate a buncha someone's had some trauma or they've got problems with the spinal cord from birth? Why would we don't want to do a lumbar punch on them. Yeah, you've got the risk of affecting this local, but Why, Yeah, it may be that the spinal cord finishes love the normal. That's on the right lines. Yeah, So, basically, if someone's got something wrong with their yeah, perfect on a topically different. That's why I was looking for. So if someone's had trauma, well, they've got any congenital changes to the spine, like scoliosis. Things that that are tethered cord We probably wouldn't We wouldn't want to do a lumbar puncture book. Insert needle You caught The bony anatomy is isn't the same, and you can't really be sure where that needle is going. So reschedule. You guys said that you could affect the cord, which would be good at all on. Obviously, if there's an infection at where you're going to insert the needle, we don't want introduce that infections. That's contraindicated as well. And then I won't go through this Now. You can read the slides later when you get access to the more medal. But just be aware that there's some complications of a lumbar puncture. The main one that you might. Montana is a low pressure, post lumbar puncture jewel headache. It's quite common itself results within a few days. It's basically when when you in. Certainly doing take out some of that CSF. You obviously lower the pressure inside kind of your ventricles and on the pathway of the CSF, because you're taking out some of the volume of it on because of that that causes traction on some of them in India vessels Some of the kind of cranial nerves as well on bats. What causes this headache? It's worse when you are sitting up and it's better when you're lying lying down. It should resolve in a few days. But if it's constant, that might mean that there's a lot off loss of CSF. So that's something that note Cool. So on to some quick interpretations of lumber punctures results. So if we look over it, case one keep you guys, tell me what you think is the course of organism. If I gave you those numbers puncture results, I've put the normal values up in the top right for you. Any ideas? What the type of cause it Ivorians is, um, off case? One would be you had a few, but bacterial viral TV. Bacterial, fungal. We've had all four of them. Okay, Had quite a mix. Okay, so should we talk for it. So if we talking with dinner, osteopathy would start off with any page details and things that we'd be given in the time at which it was performed on, then we'll we would talk through these. So, looking at the appearance of the CSF, it's yellow in color and the pollen off. So are three, which is within the normal range. The lymphocytes. Ah, hi. Because it's above five. Glucose is no 0.9, and that is low and the protein is full, which is high in summary. We've got a yellow CSF color, normal, polymorphous high lymphocytes, low glucose and high protein. So what we came now has that narrowed it down? Yeah, but I think more of you getting the right. Let's now breads. Yes. Now it's his TV for that one on. I'll go through the interpretation on my next slide, but going to face too. Can you guys talk me through or tell me what you think is the causes of organism of this one? Yeah. Brilliant. Lots of right answers coming in. Fabulous be was in viral, which is really why is it viral? What clues? In that case, that's suggesting to that. It's viral. Fabulous. Yeah. Brilliant. Everything's normal, except for the number sites. Perfect. Once again, if you're talking through it in a Noski, you'd say that the appearance is clear. Problem also at three, which is in the normal range. Um, besides are high, which is about five, uh, post is 3.2, which is a normal range on the protein is no 0.29, which is also normal range Says you guys said basically, everything is normal. Except for that. Um besides, so this would suggest a viral calls pretty in for case three. What do we think is going on in case three fungal fungal. I bring any other Any other ideas? Or we were going fungal. Yeah, I think everyone's got a fun guy. Brilliant. Why do we think it's fun, guy? Because that is the right answer. Yeah. Brilliant. Is yellow high lymphocytes? Yep. What about the glucose in the protein locally, case, but in normal protein. Fabulous. Yeah. So I think TB and fun guy of the probably the hardest to to get that I get confused personally differentiating between the two because they're both yellow pollen. More PSA normal in both the lymphocytes are high in my purse and then the glucose is low in both. It's just the protein that's different. So the way I like to remember this and it's a bit it's a bit weird, but it's six. My head is that fun. Guys don't worry about their protein, so basically the protein will be normal in fun guy, but it will be raised in TB. That's my my way of remembering it, at least and then for case for what do we think is going on in case for yeah, brilliant. You guys have got the right idea. Is the one remaining one left. So yeah, you will be perfect. So this is bacterial. So the reason why it's bacterial is because the appearance is yellow. The polymorphous are 147 which is high lymphocytes cell within normal range. It to the glucose is low and the protein is high. Brilliant. So there's a summary table that you might have seen before at one of my previous talks. Just explaining kind of meningitis lumbar puncture interpretation of just number of country interpretation on Gleevec talked through each of these already on how how we can hopefully remember it. And as a general rule as well. Another way I like to remember it is for bacteria there quite messy on. They're not very sneaky, so they're quite messy because they leave the yellow appearance. They leave lots of protein on. They remove lots of glucose where they use that for the various, so the process is. But I'm They are. So they're messy because they leave that and they're not very sneaky because they don't get past the polymerase, which I like your neutrophils and you're in a tin your system, Um, whereas for viral they're more stinky on they're less messy. So the protein and glucose and the appearance doesn't change. And the pollen more stone notice things. They're quite sneaky, but the lymphocytes is what rays what raises. That's what catches them. Overall, they're a bit more sneaking in the bacteria or and then the TV and the fungal I we talked through. They're kind of in the middle with the yellow appearance. The lacquer of raise promotes I lymphocytes, and then the The difference is the protein where the fun guy, they don't more about that protein. The protein stays normal. Been TB. It's raised. I get asked at some places, all the most likely cause it'd bacterial. Well, the reasons why the different organisms that bacteria that may cause things that meningitis eso, this table might be useful for you and I also have a roll call the crossing overall. So if you look at this table, I tend to just focus on the 1st and 2nd main causes in each generation. On you'll see the aging move down the table the second most cause in one generation becomes the first, most common cause in the next generation. Um, much, hopefully help you remember it, but let you read through that table in your own time. So brilliant. That's what I've got on lumber Bunches. I hope that was helpful. Now we're going to some chest X rays. So if you if my chest X ray talk later on in our scales here is hopefully you will recognize the slide. Things basically talks through how you should present in a chest X ray in a ski examination. Um, so what do we start with when we present our chest? Right. What's the first thing we do? Patient details. Perfect. Perfect. Yes, So we go through our patient details, which I've written up here name, date of birth, anything they give you basically allude to and say it out loud. And then in the talk, talk through how to comment on image quality. So the rotation of a chest X ray if it's adequate inspiration brilliant. You guys a copy in the chart. That's great. The picture area is and I am and the picture type is a PP a on. Is there enough exposure to the image? And then, in summary, we basically talk through a B C D e, which is a raise. A look at that to create the Kia, the Carina, the bronchitis, Hyler, the breathing. So looking at our lung fields, the pleura sing If they're they're normal Festive, eh? Trickle with is a thickening when we look cardiac. So the heart size is that normal for the heart borders well defined. Then we move on to the dye from Is it the right shape? You know, I think under the diagram, like a real simple and not the cost of Frederick Angles present or are they blunted? And then we move on to everything else our bones are soft tissues. Any devices or tubes you might see on. Then check over our review areas, which are like the lung A Percy's Things where you might often miss on. Summarize your findings to the Examiner. So I thought, Let's do a bit of a spot diagnosis as quickly as we can Pick it up on some pathologies. So can anyone pop in The chap What can you see here? What's the pathology going on? Okay, like someone's put patient details. That's very good. Yeah, brilliant. Perfect. I think most people got it. There are a few initial surge COPD is to begin with. I could see why people put that because the dye friends are quite flattened on bit. Looks quite hope expanded. But I think most of you have got it perfect. Yes, the answer is a new math oryx. Why do you guys think it's a pneumothorax? What is giving it away in the image? What would you expect to see on a chest X right? Pleural? I'm brilliant. Well done. The pleural line you can see on this image here, so hopefully you can see my cursor. It's this line here and that basically marks the outer thigh, outer side of the lung. So you've got all the air here thing outside of the lung here. Which is your pleural line? Billion. Anything else for pneumothorax? Don't Don't go into tension quite yet on a simple pneumothorax. What else would we see? Brilliant. Yes. Loss of lung, lung, things you can see here on the right side of this, on the right side of the patient. You see, these lung markings here may extend right out to the peripheries, which is good. We like to see that. Where is here? You can see that the lung markings only extend out to this pleural line on then. After this, it's just this black color with no markings whatsoever. Um, yes. Those are the two main bones using have, um, a little line on you can see the lung markings. Are you up to there? If we had attention pneumothorax, what extra things would we start to see? Trick your deviation, brilliant and perfect. Someone put away as well. That's pretty good. Yes. Anything else in particular you can think of if it's a really, really big tension pneumothorax. For example, mediastinum shift brilliant on diaphragm push down. Perfect. You guys got it. So I guess you take your deviation away from the the pneumothorax. Because if you think about it, you're having a refilled one side of your chest cavity on as it does. It's just gonna push everything into a smallest but space and push it away. Your trachea is naturally going to deviate with kind of that long Brinkema's it moves across, and similarly, you'll get about media. So it'll shift for the same reason to the other side, as you can see from the arrow. And it kind of shows why you guys might have thought this was COPD. So because you're having the air fill this space again, it's gonna cause the Hemi die from stuff latter because that air is kind of pushing down. It's trying to expand because it's a gas. And it's gonna push down on your hemidiaphragm. Flattered. That perfect. Fabulous. Right on next chest X ray. What do we think is going on here? Pathology of you can't Perfect. Yeah, You guys have got it Perfect. Well done. Yes. Is a bilateral pleural effusion. Fabulous. What signs to be seeing a chest X ray. If someone has a floor effusion. Meniscus sign. Brilliant. Can anyone describe in the trap? What is meniscus sign? Okay. Yeah, Fluid level. Brilliant. Yep. Really well done on someone's put plenty of the cost for any hand. Was a swell. Really good. Perfect. Yes. So, yes, you're gonna have custom ring costophrenic angle blunting, which is you can see here your costophrenic angles usually down here, and they're usually nice and sharp. But that's not gonna be the case in a low. Refusing because you're having this fluid work up from the base of your lungs. Upwards energy. I said you'll get this meniscal sign where you have it with any fluid. It kind of sits on. Then the ends off tail up a bit. When it reaches kind of the container it's in, you'll get this meniscus sign that Martin yellow is well, really well done. And you might also see fluid in the lung. Fish is so you can kind of see it here, where my arrow is, basically, Sometimes the fluid can work in in the gaps between the lung lobes and because, remember, in a pleural effusion, the fluid is collecting kind of between the chest wall on. Do, um, it's kind of between the the layers of pleura s o. It's outside of the lung tissue, if that makes sense so it can collect in those fissures between the long robes. Perfect. And if it was a really, really big unilateral fusion, what would we expect to see? It was really I know this was a bilateral. Yeah, it could be. Could be complete wipeout if it was really big. Yeah. You guys have got it. Mediastinal shift. Take your deviation. Perfect test. But again, because you're having another massive he, like, fill up one side of the chest where it's union actual. That will cause tracheal deviation away from that side. And similarly mediastinal shift away from that side as well as basically that fluid collecting, collecting and making, making everything else pushing to us with a space in the other direction. Perfect. Next one, what pathology is going on here? Someone's put cardiomegaly. Yeah, that's pretty good. Is there anything else that looks a bit with it? Uh huh. Yep. Yeah, you guys are getting it pretty and yes. So this this chest X ray is showing signs of heart failure or pulmonary edema. So at when we get heart failure. Obviously, the heart isn't producing enough Cardiac output is it Should be on go fluid, come back into back, back into our lungs and cause fluid to go into the palm tree spaces. And that causes a pulmonary edema. So I know you guys have talked for it a little bit in the chart already, but can you put some of the signs of heart failure Chest X ray findings on the top, But an A B C D. That's what I like to see. Brilliant. So a Yep. Someone's put it alveolus shadowing be. I've seen curly be lines and lots of well done. Cardiomegaly. Brilliant. What do you think he is? Diverted a blood to the uploads? Yep. So the upper lobe vessels become diverted or dilated yet? Brilliant. A effusions. Fabulous. Well done. Yes, we have our A, b, c, d e and ammonic for our chest X ray findings off heart failure on DPA Marie Dema. So we've got the alveolar Dema. So we kind of get this back wing appearance where basically fluid is starting to fill up. The out of your space is usually starts close to the Hyler, Um, and that causes kind of these. A pasties that you can see on did looks a bit like back wings, which is why you might hear a call back winging curly be lines. I'm impressed by any of you that could see it from this chest X ray. It's quite high seas of zoomed in, but it's basically these little lines here on. That's basically where you get fluid in the interstitial when you get the palm redeemer of the fluid back in. It's basically when the fluid goes into these interstitial and you usually see it on the lateral side of the chest. X ray on back couldn't suggest for me. Dema cardiomegaly What cardiothoracic ratio is our cut off? No 0.5, yet 50% perfect? Yep. So if the heart is which is taking up over 50% of the cardio thoracic ratio with a class that's cardiomegaly brilliant, the dilated upload vessels as you've I said. So whether is greater our atrial pressures that causes the vessels to be more dilated in the upper zones and that causes are below diversions. I have finally poor effusions. You might see a cost, a frantic angle blunting. I can try and commit you. There's a tiny one there, but there probably is them. So you might see our chest X rays a bit more obvious that there's costophrenic angle blunting. Perfect. Right Next chest X right. What we're seeing here? Yeah, lots of good answers. Be aware. I've seen some of you guys labeling left some rights. Just be aware of see, um, making sure you know what projection it is, um, and that it sometimes can be reversed. Yeah, but in there's a mixture of answers, which is good because it shows it's challenging. So it's really good. I'm seeing a lot of people, but collapse I was the same consolidation, which is really good. And that's what I'm looking for us. So if you look in the right up his own here, can you see that this bit is a bit more white and say this bit? Hopefully you can see that when, when looking at just X rays and talking about the middle skis, especially when you're doing breathing on the level of fields. And I talked about this in my chest X ray talk, make sure to compare like was like when you're working for the zones to check side by side because they should be symmetrical, really, except obviously the heart in the shape of that. But looking at the lungs owns, they should be symmetrical on. Hopefully you can see here. But this section is a lot more pacified than this section section is a lot more white in this section. So those of you that consideration that is correct. If you're not sure you're not scared, something is consolidation. And then don't say consolidation just in case it's no. What's the reason why this is a consolidation? Is the presence of a broken Brams? I'm saying consolidation. Basically, what is happening is there is some sort of dense a mass than a refunding up the albuterol kind of spaces. But whatever that masses, and I'll talk through that in a second, it spares kind of the bigger airways. So even though this dense a mass is turning kind of your lung fields white, um, it will spare your airways, and they will stay black because they still have air in. And that's what in the air program is. Hopefully you can see it where this read our is It's kind of this black bit in this area of a pacification. Um, yes, I was put in the chart. If we aren't sure if it's consolidation, what do we say? Say it's in a passive pacification. Yeah, usually a safe answer. Definitely. I'm so consolidation is when you have the air programs, which are these kind of black bits, if you're not sure, say especially the pacification, which basically just means it is more white in where the area you're describing. And so on that note, Can anyone think of any different tools off consolidation? So I talked about It's a denser substance filling up. He's alveolus spaces. Radiant. Yeah, lots of you put pneumonia. That's pretty. And so in your Monje, what dense substance is filling those spaces? That sounds weird thing to say. Yeah, posture it in. Yeah. Perfect. Any other different? Just consolidation that anyone can think of Can try and think of some different things that could fill Yeah. Of your life. I would make sense, Eligon. See? Yeah. Really good. Pretty and hemorrhage. Yeah. You guys have got the idea. Brilliant. So main differentials are these five here? So, pneumonia, You got to talk about, and that's when the cells will be filled with, like pass inflammatory cells. Things like that. You have primary edema where it's filled with kind of fluids. But your water, um, a lung cancer, either primary or met, and it will be filled with kind of your malignant cells. Some of you guys, says Pommery hemorrhage. That's pretty good. So that will be filled with blood. Or it could be a foreign body that's causing kind of inflammation infection, and you might see the foreign body like a crayon in a child. But then it will be filled with kind of inflammatory cells again if it's causing, causing infection and inflammation. Brilliant on X chest X ray. Any idea what's going on here? I'll give you guys time to do your A B C D E approach and see when you spot the abnormality. Yeah, one of these got it. I think I think, Yeah, I think you guys that work in the right area, you've realize it's something to do with the diaphragm. And yeah, can anyone tell me what's wrong with the dye from? Yeah, pretty and well done. CS. There is a pneumoperitoneum if you can see here there's a little bit of black hair under the lining of the diaphragm that you can see here. A newer peritoneum is basically free air under one or both of the hemidiaphragm. You have to be careful on this side, but not to miss. Take it with a gastric bubble or you can see here kind of some intestines. Just make sure not to not to make that mistake. Definitely. If you're looking over on this bright side here, obviously that would normally kind of be where the liver is in the liver capsule. So there shouldn't be any air under here on. This is a definite pneumoperitoneum. Um, perfect. I've written on here some of the causes and you heard him that you may have in a ski, so it may have come in with this. And then they give you this chat sector and say, What can you see? So if something's perforated, so a peptic ulcer, bowel, appendix, diverticular, anything like that, once that's perforated, going to get onto the diaphragm, the bowels of scheme it. If there's a necrotizing and colitis IBD Millikan see any trauma as well and some other things that well if someone had a laparoscopic procedure, they'll use AARP. Kind of blow up the absolute They have more room to move around on. Do. Sometimes a little bit there could be left in, um and also the pneumothorax. Very occasionally that can spread down into or pneumomediastinum as well. That can spread down in cavity. Perfect. And then this is our last chest X ray. Can anyone tell me what's going on? A little, Um and I'll give you a clue. It's already been said tonight. Yeah, hyperinflation. Brilliant. Hyperinflation is a sign off. COPD Brilliant yet. Hold on, guys. So this chest X ray is showing COPD. You guys have said hyperinflation. Can you think of anything else on a chest X ray that was suggested COPD flathead me die from a brilliant? Yep. Patient may present with, like, a barrel chest, if you like. High the enlargement. Perfect. Yeah. Every bill a while. Done. Yep. So these are the more interesting three findings that you haven't seen a beast so that they'll be hyper with the lungs on because it's a obstructive disease. You're not going to have to force the air out. They have quite a large volume of air in their lungs anyway, So we hyperinflated on because of that kind of exercise. It needs more space to the hemidiaphragm. So we'll go down and be more flattened and they'll have ballet. Um, from where The kind of alveolar I walls are broken down and you get these big pockets of air. You can't really see it too clearly on this test x ray. But you might see it, um, and you because of that, you'll get decreased lung markings and you also get prominent highlight as well. Perfect. So my last section onto a little bit CT's and MRI's. So we're presenting a CT head. I've written here kind of how we go about doing it. So, as always, we have to start by stating the patient's name, the date of birth, anything you're given it, a little state it, then you'd state the modality in the plan of the imaging. Um, then you state the date and time of the scan that's been done and offered to compare that to any previous scans. Then say what you see on then finally state your different jobs and any justifications based on earlier parts of the station on. Don't forget to use that. If you've been in a station on patient sounds like you've had a stroke from the history or the examination findings that you get. Use that as a clue as to what could be coming when you seemed he had. So everything here, in example, that I won't get no through of how you would kind of say all that out loud on but let you read that through in your in time. So we're gonna do some CT head images, spot diagnosis again. See what you guys can pick up on. So what do you think is going on here? Yeah, it's it's coming. And really good. Perfect yet. So we've got extra jewel epidural hemorrhage. Yeah. Why do we think it's the up on the right side? Yeah. Brilliant. What's giving away that? It's that it's confined within suture lines. Lemon shapes, convex. Perfect. Yet you guys know it. So yep, a lemon shape on the side here is an extra door, and epidural stays within the suture lines because of if you think back to normal and geez, um, the jury is very firmly attached to the skull, especially the suture lines. So no matter how much blood feels that space is going to stay really, really attached on dot spare parts. I was brilliant. It's from What do you think's going on here? Yes. Brilliant. Someone's got it. Yeah. So this is an interesting rebuild bleed. Really good. So once again, we kind of got a cute hypodense region within the parenchyma of the brain. Yes, this is an intercerebral hemorrhage bottom. Um, do you think this is sub general? Brilliant, Acute, Chronic. What do you think? Acute on chronic, Chronic, acute on chronic. Yeah, but don't. There's lead acute on chronic. A job that is correct. So you can see there's both a harpo dense of a dark region and a hyperdense region, which is this white region. So it would be an acute on chronic subdural on That gives us this kind of Moonshot which isn't confined within the situations. Brilliant. Next one on the same line of blends into ventricular for excuses, but in the ventricles. Perfect. And the last one, which is probably gonna work out already. What do you think this is, Subarachnoid Perfect. Yes, This is separate. Or the Bloods within the basal systems. And it gives this unless by the shape. So there's all spider. Perfect. So few more CT head First one on the left Hydro, Careful is brilliant. Why do we think it's that? Lots of fluid in the ventricles in their large perfect brilliant. Ah, one on the bottom. This one here, second one in This was probably a tricky one. Any ideas? What this is or just some features of it, If you're not sure. Sorry, bro. Dema yet raised. I see Pay Dema Yeah, really good. That's a good features to pick out. So this is the hypoxic brain injury. Um, for the reasons why you put so in a in a normal CT, we should be able to see the difference between kind of your gray matter on your white matter on. But if you have a pipe AQSIQ brain injury that can sometimes cause edema, which you guys mentioned, which is why you can't really descend the two and you also get this loss of your dry. Ryan, you're so quiet. Whether it's a raised, I see pe brilliant. So you might notice, has signs of raised ICP when you examine him on next one or middle one at the top. Yeah, Yeah. Brilliant. Abscess. Kids. Tumor. Yeah, you guys got it. So to be safe and lost, probably say, a space occupying lesion to start with, um And you can kind of describe it so you can say it's the ring enhancing lesion with a hyperdense region inside. Ah hyperdense ring on. Sometimes you also get a hypodense region outside where there's a Dema and you guys have mentioned probably the two main differential. So typically, if someone is a younger than IV drug user, you might think it's an abscess. Whereas maybe if it's on older individual with a history of cancer, you would probably think a brain met. Really? Well done. So awesome. One again on the rights. What do we think going on here? Wow, you was a very speedy tonight. Yeah, brilliant. Says a hypodense region in the m. C I. There's a hyperdense fire chi radiant, which is M. C a thrombus which someone's already. But is it like a again anterior circulation type of strikes? Well, don't very, very good that you got this you describe Is hyperdense region here on? That's a thrombus that you might see in the skin. It's strike brilliant on our last image on the right. What do you think's going on here? Yeah, brilliant. Not sexual fracture. Very well done. So sometimes it's quite hard, I think, to tell the difference between fractures and, um, the kind of normal and after me of the skull, where we have, um, the kind of breaks in this. So anyway, where we have the six years and things, the main difference is if you have a fracture, it's more of a jack. It's kind of shape, if you like. I know some of these look of it straight, but they are where, as, um, sexual would be straight on. Also, skull fractures tend not to be symmetrical, whereas if you a center line, that will be symmetrical. Brilliant. So I've also fucked up here. I'm conscious of time. Some see teeth or ex images. So what I'm gonna do is I'm gonna let you guys test yourselves on these in your own time from your skip past. Um, I put in a little cheat sheet about CT's and Emery's on why we use them on then a little bit about presenting an MRI as well im ain't it? For this is known the difference between t one t 2 72 with the fat on the fluid a bright because there's two things that are bright And that's why it's a t two. I've got some memory image is for you to look at in your time. So for time, I'm gonna pass over 10 ish on that him for hi guys. Eh? So we're gonna finish off today's session by going over some blood tests and special special test that can come up in office. So we started off with some STDs. We did some imaging with Magan. Okay, Both very important for osteo. Okay, STD's and different imaging modalities. Something you have definitely be tested in your auspices. Well, in terms of blood test in special tests, it's a bit different between unions. Okay, Obviously you could become predict what type of blood test or special test they're gonna ask you to interpret, Okay, because there's so many different types and I'm not gonna be able to cover every single type in the course of this portion of the session. We've tried to cover as much of them as possible throughout the duration off the series, but with blood tests and special test, it's it's all about trying to gain principal principal understanding of how and how to interpret them and and hope in your office easier gonna be able to plan that knowledge to interpret what ever dated they have they're gonna present you with. So gonna do a bunch of different cases. Okay, this is the second. Shouldn't take too long ago. I haven't tried to make it to comprehensive, but I just want to get you guys in the thought process of how to interpret blood tests and how how to present blood tests and special testing your osteo. So, first case, we're in the most of our member. Enough one. We've been asked to see Mr Pie, a 42 year old male who has presented with the hydration lost in temperature data in a systematic manner. So we're gonna start off with some renal function tests. Oh, are you in these common cold in the UK? So you got some you knees here. We got different parameters of information here, so I want you guys to just take a moment to just absorb this blood test. Okay? Absorb the data and take a minute to think through how you're going to process the stage in your ski on. What are you gonna present to the Examiner? So exam is just present 100. You a sheet with this blood test on it? What are you gonna talk about? What's the once the first steps were going to say get Okay. The process is still the same, even for STDs. For imaging. Okay. The process still applies for blood tests and special tests as well. Okay. Always saw with your patient details. Okay. Before you even look at the think about presenting the data, okay? Any of the numbers and you're the values. Okay. Before you try and think through what the clinical significance off the data is, start with the basics. Okay. Patient demographic details. What is the blood test representing when it's a blood test taken? Okay, that's you're gonna get marks. Just was saying that a norske is It's not really about is not too much about demonstrating knowledge. It's just showing you're competent, showing that you have, you're able to think through things in a systematic, logical manner. That's the one that maybe trying to get out with the Aussies. Okay, So this blood test before when I'm going to present that say, this is a real function test taken from Mr Pie two hours ago. Who presented an issue with dehydration that we have values for being the sodium, viable potassium level. Your your level creatinine level, Lucas level back to a level and ferritin. And we have values taken in the same on. We have a blood test values. Six hours later, it'll okay started opening sentence for presenting data, and then we can go into our positive findings. Okay, So what? What? Just based on this data, what kind of stuff with you guys think is relevance to comment on terms of constipation, things hyponatremia had to clean? It gets okay before you before it before we jump into your bus. Specific electrolyte disturbances. Can you generally about what's happening here? What happened? What's happening six hours later? Yeah. Okay. I okay. This patient is developed an acute kidney injury. Okay, so first question is that examined my our shoes. Just explain the changes after six hours. Okay, so we have a blood test. Values are in any way. Okay. And then your blood test I was taking six hours later. So a couple you said have said achy I So acute kidney injury can never tell me. Why do you think this patient's developed an acute kidney injury? Yeah. Increasing creatine and but why? Why? Why does that constitute little achy? You can see that the creatinine is still normal. It's still in the normal range. And any and six hours later, wise, why is this still an achy I How do we How do we define any acute kidney injury? Rise of over 2026. Good. Okay, right. Train six point by, um, that's the, um, definition of an F in a guy. Okay, so in terms off between and it's increase. Okay. Bye bye. The definition of a neat guy. Okay, it's increased by 35. Okay, so that's that's defined anemia. Even though it's still in the normal range. And 80 and six hours later, this is still in a year. Okay? And so then you've defined. You've confirmed it's an ache, I Then you can further qualify it by explaining some of the other findings. So this patient has developed an EKG six hours later on this is further evidence by the increase in urea six hours later on, Do a reduction in sodium and increase in potassium All indicative off reduce renal function. Okay. So first, like defining that the patient has an acute kidney injury. You can further qualify that by explained by using some of the other findings to get further evidence to why you think the patient has reduced renal function. Okay, so another question examine my ass is what is the significance of the raised glucose Burton Andi Black dates. If we think this is acutely on, well, patients, why why is the glucose range wise? Lactate raised? Why? It's very raised. Yeah, Good. I keep face. Yeah, that's a potential you think about sepsis and things. So we started ferritin ferritin is an acute phase Reactant. Okay, so when you see for it in race, okay, Don't Very good. It's not always associated with you know, I in studies and things, okay, but it can be raised a z a cute phase reactant so acutely on. Well, patients. Okay, potentially septic. Britain can go high leukosis again. Similar thing to acute phase reactant. Okay, if some of the qd on well Actually, septic body's going to mobilize energy stores like leuko. So because I was going up, um, finally about lactate. How do you What is the clinical significance of a raised lactate? Boxy esquina? It's, You know, it's generally this is a very worrying sign. Okay, if someone has a lactate above four, Okay, in a clinical practice, if you if you ever see a patient has a lot of above for okay, it's a very, very worrying poor prognostic signs. Okay, sign of skinny. A proxy, a widespread tissue injury. Big work. Big warning sign. Okay, so that's the kind of things you want to be talking about. Okay? And trying to structure answer again. Salad. Patient details solid. What, You think the general problem is okay. And trying to use some of the other findings to help explain what the y the what? The general pathology is so king. Injuries. So this is these are the cage I go Guidelines for defining a guy's Okay. So you said you have a rising PSA captain greater than 26.5 micromoles within 48 hours. That's the definition. Okay? And if he if you were really elite, okay? you can further to say this patient like it has a stage 1 80. I again is It's because it's within 48 hours. And this that's what the numbers were telling us. It's a stage one, a k. I hear some of the other definition we can use. Make sure you remember this. 26.5. Okay. Very clinically relevant. Cool. So we did a quick EKG blood test. Now we're doing going another renal function test. But this time we have a patient, has a history of, uh, polycystic kidney disease and has presented for renal function tests. So again, similar blood tests now, but again, take some time. Teo, give you guys a minute. You just read through and process the information that last you guys are a bunch of different questions about the blood test. Eso again started patient details. Okay. What is this blood test? Okay, so we have blood tests which had values for all these different parameters. We got some pull back on measurements here. You know, Google white cells. We have mean cell volume measurements, spirit and measurements. Transfer in saturation was well as the iron studies. Maybe measurement Here. You have different electrolyte measurements Here is well, you have a value for the e g f R values for calcium pasta and parathyroid hormone is all. Oh, sorry. I had the inside hemoglobin. That rain should be I. This is This is a PhD in, so it's, uh, hemoglobin. Let's say should be. Let's Let's just say the hemoglobin is low, okay? We'll say the hemoglobin slow. Sorry about that. I forgot to, um, edit. This is a patronage. What do you think? Yeah, well, it will say it said 13.5 to a normal range is stating about 5 to 600.5 g per deciliter. CKD Yeah, I had the parathyroid is, um I'm deficiency anemia. What else do you think that things going on? Okay. Yeah, You're going a lot of good suggestions here again. So we're gonna I'm gonna structure this break breaking down this blood test by asking you guys a bunch of bunch of relevant questions. So first question, what stage of really failure do you think is a patient this great for? Okay, we'll go through how to classify stages of renal failure. Okay, but first we're looking at the EFR Okay on, then we look at the staging. The CKD. Okay, but good, we'll go. We'll go through how to say CKD. Next question. What is the type and cause of his anemia? So we can see We'll say the hemoglobin's low. Okay. Based on the other stuff. What do you think about the anemia? Lack of a referral, too. So it's it could be. But what? What if it's a lack of every for protein? You more like to get normal city continue. This patient has what type of anemia stations means that volume is low. Right? So this is a microcytic anemia. Okay. And transfer in saturation is low as well. So this is likely on anemia due to I'm deficiency anemia. Okay, Although again you can call qualify that and your osteo bi saying patient likely does heart's would like to have anemia contributed by lack of the referral through eating as well. Okay, but based on the information here, which has low ferritin low transit saturations low MTB with the low hemoglobin. Okay, that's I'm deficiency anemia. Okay. Last session can explain his low calcium, high prostate and high carb diet home. So those patients, if you look at the final threes. Calcium is low. Prostate is high. PH is high as well. What is the cause of these different descendants is Yeah, secondary hyperparathyroidism. Okay, so if patients CKD, they can get secondary hyperparathyroidism. Okay, so, um, Ph will go up if Ph goes up. And you have that that parathyroidism your prostate goes up because your kidneys are not getting rid of foster not getting rid of prostate. Okay, They're not responding to P. T. H. So your prostate going up and custom goes up, cousin goes down because you're not be absorbing calcium. Phosphate is binding up all the calcium in the blood on also, because you have low vitamin D, you're not be absorbing much. Calcium from the colon is well, okay, so that's so because the second you have a parathyroid is, um you get all of these different blood test findings. And finally, the patient also has a high potassium. So can you tell me some causes off clean And these are just different questions And examine my ask you based on the blood test. So you're trying to probably break down the blood test. What do you think? What the cause of hyperkalemia. So you're off bit it. Okay, Don't just list those, because it's okay. Try and come up with a way to structure your answer. So can you tell me some good ways to structure your answer? If someone asked you one of the causes of hyper clean and your house key, how would you How would you? What would be a good way to structure the different causes? Uh, reduced expression gets reduce. Secretion would be a good way into, um, chefs of potassium. That's another one you could talk about. Increased intake is another one on There's a a pseudo hyper cleaners was another central course as well. Okay, so if we go through the different things, we just talked about that. So first thing we're talking about, it's staging CKD. So these are the different stages of CKD based on the patient's e. Jafar. Okay. Estimated the mile a filtration rates. Okay, now I don't I'm not really a fine. I'm trying to remember these different numbers. Okay, But a useful way to try and remember it is the used the Egypt Far truck. So the e f a clock is this way of trying to remember it. So if you go around, we can see 12 o'clock. Nine o'clock. Six o'clock. Three o'clock. Okay, so if you go around, we can say G one is between it's over 90. Okay, so between $1920 G one okay for stage one between 1960 stage two. Okay, So G 2 62 89 that stage two CKD between 60 and 30. We get we're going to divide it up. Okay. So G three a day is between 45 to 59. G three b is between 30 to 44. G four is between 50 to 15 to 29. Okay, so that was about the patient. Hard, in our case on finally, if it's less than 15, that's defies. Okay, so this is the e g f five o'clock. I guess if you make a clock from 12 o'clock and go around the circle, you can easily determine what stage of CKD someone is. It's just a little memory. It you guys didn't have to remember. The different values off the Jeff are two stage CKD. Here's the summary off iron studies. Okay, so we said patients transferred level was low. Okay, that's an iron deficiency. Anemia. You guys get rid of this in your own time. Onda his thesis. Um, are you off different bone profiles again? You guys have a read of this in your own time? Okay, We've gone through this and other sessions. Um, and his summary off the different causes off hyperglycemia. I have a read of this in your own time. Okay. Remember to try to structure answer into different, different methods off hyper clena. So I did you to impact impact excretion. Use extra shifts. Did you increase intake or due to suit? I purkinje okay. Always try to structure your answers and all ski. Okay. It's not just about listing different things. Okay, you can do that. But I think you look, it looks even more impressive if you can find an effective way off some off structure in your answer. Okay, cool. The next case, we're in the GP. We've been asked to see Mr Nobody, a 42 year old male who is presented with an acute asthma exacerbation. Um, so again, interpret the data in a systematic manner. You have a new shot here, okay? And I've circled the different abnormal values which, which, which the patient has as it can Yes, work through the new start for me. Tell me what you think. How would you? What would you comment on in your asking? What? What? What would be relevant to you talk about in your ski news? New starts, Uh, very commonly tested and osteo get you need to go to fill out a new stop that they usually there are. They'll ask you to actually get the information yourself. Okay? They'll ask you to, you know, do the measurement yourself on the patient and ask you to fill out the new shot. Okay, But when you present the findings of the new shot, what are you going to be talking about? New scoring is nine. Good. Okay, so needs attention. So, before you, before you say what the final new score is, what would you be talking about? You're gonna work, work through this individually again. You're asking before you get to the final. What? The new score It's went through each individually and against our patient details that someone said Best fit patient details. So you say this is a new start taking from Mr Miyagi to one hour ago on. Go on, then work through each individual bit. So because if you go through each one, so patient is taking me it at risk you to rate greater than 25 minutes. Patient is, uh, patients Oxygen saturations. It's between 90 40 95% on patient is currently hypotensive with a systolic BP less than 19 millimeters mercury patient's currently alert on, but it does not have a temperature. Okay, just we're just general way of just work through it individually and then calculate the score. So if someone said new score here is nine Okay, the other added up. And so in this case, we would specifically that talking about a patient who is presented with an acute asked my time. You never tell me. Why is that? What? What else can you comment on? Based on the based on the fact that we know this patient is presented with an acute asthma attack, what else would be relevance? What else would do? What else would it be impressive to talk about in your skin? Yeah. Peak for people on. Just I'm talking about just based on these new start readings. What else could you say? Based on the fact that that the patient presented the acute asthma exacerbation? Yes, Severity goods. Okay, so you can talk about the severity of the aspirin, like, based on the new shot findings. Okay, So what? Based on this new start, what indicates a patient? It could indicate severity of an asthma attack. You yet? Respiratory rate's gave his future greater than 25 s. Indicative of severe asthma. Hypotensive. Okay, Patient is hypertensive, so that's indicative of a life threatening asthma attack. Okay, so it's it's well, it's good to just comment on the individual findings. Company knew Scott. Okay, but if you can take to another level and apply it to other patients resented with Okay, that looks really impressive. Okay, so try try. Always apply your knowledge as much. You come. So here we have somebody off the how we how we classify severity of asthma attacks. Okay. Severity in terms of severe life threatening and near fatal to remember, based on the new shot we could tell a patient was hypertensive was static articles. Well, I had a higher response rate. All features off severe or life threatening asthma attack. Okay, We'll see if you have. If you have measurements of peak flow is well, you can comment on that. Says well, but again, Always apply your knowledge is much she can. Okay, Next fits. We are doing some ABG interpretation s. So we're still on acute asthma attack boat. We're gonna refresh our energy knowledge. Make sure you guys are properly on it with a B and deputation. So first one, we got some ABG. See, guys, interpret What do you think about this DVD here? Yeah. Yes, the Risperdal acidosis with partial metabolic compensation. Okay, remember when you present an ABG to examine a Okay, always comment on it. If it's a acidosis or alkalosis off, it's normal comment on if it's a metabolic acidosis, alkalosis or respiratory acidosis. Alkalosis. Then talk about if it's a part, if it if it's a partial or complete compensation. Okay, so in this case, it's a respiratory acidosis or versus an acidosis. Okay, Peaches low. That respect acidosis because 02 is high. So it's a respiratory acidosis. Then we're looking at compensation, so patients bicarbonate is elevated, so that's an appropriate compensate. The response. So there is metabolic compensation. And finally, we need to know if it's partial or complete compensation. So Ph is still abnormal. Okay, so that's only a partial compensation. Okay, Next one. What do you think about this ABG? Then try. Try and be as complete as possible when you're presenting the answers. Yeah. You guys got it? So this is a it's pretty Accidents s o mat matter, but yeah, this is the tricky a senator metabolic alkalosis with full respect. Recompensation. Okay, there's these ones are a bit trickier, but it's always it's hard to. It's always about harder to interpret a BGs when the pH is normal on. So we've gone through this in the respiratory station, okay, but we'll go through it again quickly. So when the pH is normal, the way to do it is to take the halfway point off the normal range. So half a point of normal range is 7.4. So because the patient body of some 0.42 we we interpret the ABG relative to the halfway point. Okay, So, well, a tip to the halfway point. This patient has a alkalosis. Okay, so if you're seeing the patient has had an alkalosis. Then we can interpret the HCG easily. Okay, so if you say this isn't alkalosis, bicarb is up. Okay, so that's a metabolic alkalosis. Then we look at the PCR to so pc two PCO two is high. That's an appropriate compensate. The response on go. There's an appropriate response to compensate. The response on gets a full. It's a full compensation response because the pH is normal. Okay, so that's a metabolic alkalosis, but full respiratory compensation. That's one good. Let's keep going through. And don't don't just leave off the acid base system and says, Tell it, Tell me in detail what's happening for me, okay? And you're asking, You need to be as you get more March by being a specific and as detail as possible. Okay, so metabolic acidosis with partial respected compensation is the right answer here? Definitely. So again, we can work well with their quickly. It's, um, acidosis. Bicarbonate is lows as a metabolic acidosis. PCO to is low, so that's an appropriate respectfully compensate response. And it's a partial compensated response because ph is still abnormal. Okay, last one. Okay, you can basically do it by process of elimination. But when you have things happening yet it is Yes, they say so again. It's a similar work. It work it through in a similar way to you did. For this ABG against this is a risk. Your ejaculate This with full metabolic compensation. Okay, so why Let's go through again? Peaches normal here, But again, we interpret it relative to the halfway point off 7.4. So some 0.45 is higher than sample in 43 cm. This is an alkalosis, and then we interpret the mg. So if you say this and alkalosis go to is low, so that's a spiritual OSIs. Bicarb is low, so that's an appropriate metabolic. Compensate a response on. It's a complete full conversation response because the pH is normal. Okay, so that's a respiratory alkalosis with full metabolic compensation. Okay, that's a biggie interpretation. Okay, Just down principles of 80 interpretation on that. This is some of the common causes of each type of disturbances as well. For your revision again, it's always about being a specific as possible and trying to be as detailed, responsible when you're presenting the answer to be examined and is the summary of interpreting a bee. Jesus. Both your revision. Okay, Now, let's do some peak flows. Okay, so we have some peak flow diary sort of measurement from a patient I gave you. This is Ah, probably quite a quick date. Interpretation of activity you might get. What do you think about this? Peak flow. Diarrhea? What's the main finding to comment on? Yeah, diurnal variability gets. Okay. So when I whenever you get a peak flow activity in your ski, Okay, the main thing that probably gonna ask you about is diurnal variation. Okay? Especially we're talking about and asthmatic patient on so you can see Diana variation. Okay. Morning and night. The measurements changing significantly. Okay, so that's diurnal variation. Uh, next one was still on some restricted dates. Interpretation. What do you think about this spyrometry profile here? They have a read of the's firearm injury information. It's and then have read of the graph. And what you guys think it's happening? It actually have a good read of the information before before you commit to answer. Yeah. Get so much more people. Yeah, you get, you get it. So it's a It's a restrictive pattern off spiral. Okay, so that's What? Let's go through it. Okay, let's go through the information first. So you took 10 things for our tree information. Okay. You want to know? The main thing is looking at the meeting. Overall thing you're trying to assess is is that obstructive pattern of lung disease are restrictive pattern of lung disease. So we go to the information be one is 60% of predicted. Okay, so that's less than 70 sets. It's reduced. FDC is reduced well, and 57% of predicted. That's low, so but they're both equally reduced. Okay, They're both reduce the significant extent, so the ratio is actually increased. Okay. The F E book, the one fbc ratio is actually above no 10.8. Okay, so that's for the evidence for restrictive pattern inspiring. See, they can just add in this line no improvement after administration of beat it agonist. Okay. It's not that relevance to restrictive pattern of lung disease. Okay, on, But again, they might just add that into trying trip, throw you off on reduced transfer a factor. Uh, if we say this is a restrictive pattern of lung disease and the patient has reduce transfer fact that what does that suggest as the likely cause? Yeah. Omit indecision. Lung disease. Okay. Or most likely, pony fibrosis. Okay, so if someone has reduced transfer back there in the context of a restrictive pattern is foreign treat. That's likely interstitial lung disease. Again, if you get if you ever look at this for 100 grass, Okay, we can. As you can see, it's basically showing this information here. Okay, FBC is reduced again. F E b rawness reduced. A swell keeping is the ratio. Okay, The high increased racial. That's the thing that's pointing towards restrictive pattern. Get when you describing some arbitrary. Okay, go through in this process. Okay? I've gone through this in my respiratory station. I just go follow this process on as mentioned. This is likely interstitial lung disease is a summary of first, um, spyrometry lung volumes and capacities. You can have a read in your own time. Some of lung disease. Obstructive restrictive summary of the interpreting spirometry again. We've gone through this in respiratory station flow volume loops, which I've gone through in the respiratory station on somebody of transit factor again. I've gone through in the respect. Your station. Okay, there's the last section up. Okay. We're gonna fly through some lube. It's a little different blood tests and special tests, and it's gonna be a bit fast paced. I just want you guys to give me what you think as quickly as possible. So we got some pleural food, and I was just here on. We got different parameters of information. What do you think is happening here? Good. Okay. Remember, always start with patient details. Okay? We'll keep emphasizing it. But as you guys saying, this is likely and exit dated cruel effusion on, some people are saying possibly malignancy as well. Get what you're saying. This is exhibited. What indicates an exaggerated in, um, effusion here. They, um yeah, the proteins. That big big one To look at this. Okay, So patient has high protein content. Um, on some people talk about, like, criteria. Good. So they would like the the thing with you. The main thing we used to differentiate between an exa dated and translated infusion is to use lights criteria. Okay, on. That's basically looking at these three different things. Okay, Protein contents greater than 30 35. Then looking at the ratio of fluid to see you in protein on. That's greater than no 0.5. Okay, so that suggests Executive Similarly ldh more than two thirds off the serum ldh. Okay, that's also indicative off an exit eight of the effusion. Okay on that. Some people are further saying possibly malignancy, so you can see abnormal cytology, low glucose that possibly there definitely indicative off malignant effusions. Okay, that's how we would interpret that data. So it's a summary off Cruella food and now says that I've gone through in the risperidone station. Next one, we have some hepatitis B serology. What do you think? We should hopefully be finished in the next 10 minutes or so. We have got to much to do. Yeah, okay. Hepatitis B serologies. I was always Ah, it's always a med student. Uh, a bit of ah, panic station for med students. So, yeah, we got a mix of answers. It I think most people saying past infection result get Guess that's the main thing. We're finding that it's likely the patient was hardly resolved. Hepatitis B infection again. So for hepatitis B serology. Okay. You need to be very clear on what each antigen and what antibodies representing. So the first thing to always look at with hepatitis B serology is the surface antigen. Okay, if the surface antigen is negative, okay. And you want to look at the six Antibodies law. The surface antigen is negative. Seven antibody is positive. Okay. Means the patient is immune. Okay, That cured from hepatitis B infection. Okay. And patients can either be cured from chronic hepatitis C infection either from out of by fighting the infection themselves and resolving it. Okay, Like, in this case, Or they can receive the hepatitis B vaccination. Okay, So the key thing why this is not a vaccination is because, uh, the hepatitis B vaccine only contains the surface antigen. Okay, so if someone was vaccinated against hepatitis B, they would only have surface antibodies. Okay, this patient also has antibodies against the core antigen because I mean it. It can't be vaccinated. Okay. The station has actually been exposed to have that is the vice. They've developed antibodies against the core antigen, and that's why that's positive. Okay, so that's why we know this is a patient who has been previously exposed to have that virus. And that's the profile we see there. So somebody hepatitis B serology, different civil. Logical profiles for different stages of infection. Next one, we got some liver function tests. Okay, So you want some different liver enzymes? You can see a picture of patients face. You have a urine sample. Here is Well, uh what what state I might have seen left. Okay, get so we're getting a little mix. Okay, so this is likely an obstructive jaundice picture. Okay, so from this picture together, this patient is doing us on. We have some left to UCS a liver function test. So the key thing why this is an obstructive picture Is that the be in a sec off? They're merely located in the biliary system. Okay, So elevation and a lady and ST, they're very specific for cholestasis. Okay, so this patient has significant elevations in a low B on sorry s. So I just realized that this just a DDT apologize for that. This is a digital sorry for that. It would make your sense that this that they're TT um Let's assume this is DDT. Onda. Uh, so if you see in the city city, this is an obstructive pattern of jaundice Onda 18 HDL also mildly elevated as well. But because of the significant elevation in a Libya and DDT at this wise, like the obstructive part of jaundice and billions elevated as well. So that's because because of the jaundice. Okay, what do you think about this urine sample? Looks like, uh, type of coke. Yes. And document. Okay. So, doctor, and again, I make sure to check out my drawers for finals webinar again when we go through the actual pathophysiology of it. Okay, but patient has dark urine beach off a gated Billy Rubin and the up in your urine, which is a feature of obstruction in the biliary tree again, as someone like, as someone rightly said, patient would likely have pale colored stools as well. Okay, I didn't really want to show appeal colored still, so just, uh, be a viewership. So we have some, uh, lefty summary here. Okay, So, uh, I'm sure you've seen this diagram before. If you tune into our finals Easy, Siris. And that's that. That's the approach to liver function test. And it is a summary off Jonas, taking from my Jonas for finals up on us again. Have a read when you get the slides. Okay. We have some TFCC. No. What do you think about this thyroid function test? It's there is a bit trickier, but yeah. What do you think? So it's not It's not primary hypothyroidism is not quite primary hypothyroidism. Yeah, this is subclinical hypothyroidism. Okay, so this is subclinical hypothyroidism. So it's not quite primary, so DSH is elevated, okay? And so that could be either primary or something. Got hyperthyroidism. Okay, The reason why it's subclinical is because the T four and T three are both in the normal range. Okay, so that makes a subclinical. What's the significance of anti TPO antibodies? Positive. What? It was this clinical significance. Yeah, actually, notice. Okay. Also known as autoimmune cornucopia immune thyroiditis. Okay, so this patient is likely going to develop. I put significant hypothyroidism soon. Okay. They're have autoimmune and viral disease. Have subclinical hypothyroidism. Okay, but remember, don't call this primary hepatitis. Um, okay, because that 43 are still normal. There's a summary off different diet function test profiles, taking from my endocrinology for final session. Endocrinology osteo session on day taking. This is a summary off antibodies, entire disease again taken from my endocrinology sessions. Okay, so now we're going to do some joint fluid. Okay. If you turn into my escape sessions, I'm sure you'll be very familiar with these images. So got an image here off joint fluid. My cross be analyzed underplaying polarized lights. What do you think about this image before you give it before you give me a diagnosis? Crime? Describe what you see. Get negatively by refrigerants. Needle shaped crystals get. Okay, that's that's the full details. Accurate description of what you see there. Okay, so this is indicative of got a cast. People saying Okay, we have a needle shaped negatively by referencing crystals. Okay, that's the classic hallmark. Um, my cost free feature for diagnosing guts. Okay. The main thing you want to look at see is the needles, okay? And they are negatively fire if engines under plainclothes lights. Okay, on, if that was gout on, if those are negatively by infringing needle shape vessels, what do you guys think about these crystals here? How would you describe these ones? Yeah, so these are different. Okay? These are positively by a friend into rhomboid shape crystals. Okay. And these indicative off pseudo gots. So they're wrong, Boy. Chipped. Okay. Also known as polygonal shapes. And they're poorly, positively by rough engines under paper. Polaroids. Lights. Okay. Weekly positively by refrigerant. Okay, that's that's, um, joint fluid analysis questions you might get. Okay, here's the summary off. If you get past about different specific parameters of joint fluid, okay, is a summary table about interpret them. Okay, this is the last one. Okay, that this is the last day to interpretation activity. And this I've made this extremely hot. Okay, just for the sake of fun and just to end on a high yield, I say how you all this is Very, very, very hard. I was trying to come up with a very hard question for you guys. So I'll give you guys a much time as you want to try and work through it and tell me where you guys think is going on. But this is very hard to get. I'll be honest. You won't get that something like this in your ski. What do you think is going on? So we have some urinalysis data here. We have some blood smear data here, and I've told you the patient is complaining off. Polyuria has a family history off sickle cell disease and early onset stroke. Okay, this is this is very challenging. Okay, but I'll be very impressive. Anyone is able to work out what's going on here. Yeah. So let's let's work through the urinalysis. But what's the main finding from your analysis? Ah, no, it's not. It's not diabetes insipidus. Okay, it is not It's not quite diabetes. Insipidus. The patient has polyuria again low specific gravity. But it's not quite even just because it's I Just because patient has dilute urine doesn't mean you can diagnose him and having diabetes. Insipidus so patient. The patient does have a low specific gravity. Okay, that's the main finding from your analysis. Okay, on what about this blood smear? What do you think is happening in this much here? So this lets me is actually normal. Okay, this is a normal blood smear. Okay, so if I tell you now, this is a normal blood spear. So if I say this is a normal blood smear patient has a low specific gravity, complaining of polyuria family history of sickle cell, and early off that stroke and anyone work out what's going on. Why would the patient have these wiser patient presenting with polyuria? What is the cause of all the urea? Get anyone work it out. It's not drinking a lot of water. Why? Why? Why would a sickle cell patient gets, um, urea? What happens in sickles? Up. Yeah, Someone's got that. Someone's got it. So it's private message may. So sickle cell crisis. Okay, so this is what happened here. Sickle cell traits. Okay, So what's happening with sickle cell? If someone has sickle cell trait, they could get basically sit crisis. So patient. This patient is a family history of sickle cell disease. Early onset stroke. Okay, So if his family history found huge of yolks that stroke so they can get basically crisis affecting the cerebral vascular tender get strokes. Okay, that's hinting at the patient having history of, like, having some evidence of sickling on, but this has a normal blood smear. Okay, so this isn't normal. This isn't full blown sickle cell disease. Is it? Just sickle cell traits on patient has a low specific gravity. Why? Why would a patient with sickle cell trait gets a low specific gravity? Get off work at work. That up? This is This is extremely hard. Okay, I'll be honest. I probably should have to do this, but what do you think again? Well, I made this little physiology. It start to go through the physiology of this question, but if you have a kidney nephron Okay, so we're trying to describe sickle cell in front of me here. So this location, this blood vessel here is the basic rector. Okay, we're taking it back to fill on physiology. This is the basic rector supplying the loop a family off the net from so in the visit, after what's happening in terms of the conditions in the base or actively have low oxygen low pH and increase more similarity. So all of these factors, they lead to sickling. Okay, These are all factors which contributes to sickling in a patient with six or disease or sickle cell trait. Okay, contribute to sickling. So they get sickling affecting the base. Erector. Okay. That means that the blood flow in this area is affected. Okay, that it's going to basically disrupt this entire physiology. So that's going to delay free water reabsorption. Okay. And the counter current exchange rate mechanism. Okay, So remember, base Rector is constantly shunting stuff away from the loop of friendly to maintain it counter current system. So if you have sickling affecting this area in this area gets blocked. Okay, this whole mechanism is disrupted. You can't absorb free water properly. Your counts current exchange is gone. So that's going to lead Teo High post in urea. Okay. Or low specific gravity. Okay. That's basically what this means. Low specific gravity. Because you're not able to re absorb free water, you're not able to concentrate your urine. Okay, so that's my patient presents with polyuria. Okay. Very, very challenging bit of physiology, I thought would be an interesting no to finish up. But that's it's, uh this is a summary off your analysis interpretation. We've gone through this and diabetes no diabetes Oscar station. But that's it's, uh we ended on a very difficult oats fun notes. But I hope you guys enjoy the session. I will stop the recording