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Hi guys, I think that's working now. Um So I'm s I'm one of the final medical students at Manchester and I'm based in Preston. So I'm gonna be doing your teaching on central chest pain, which is just going to be around explaining the cardiology conditions to patients. Um Yeah, trying to keep it short and sweet. So that you're not having to listen you on for 45 minutes do run over. I apologize. Um And the other thing is that some of the slides are a bit wordy, so don't be alarmed. It's just for when you get the slides, you'll have a chance to read through them and have something to refer back to. Right? Can we get the next slide, please? Tony. Uh Next slide. Not sure if that's working for you. Has it changed? Not for me? Does it, does it say learning objective or? No? No, it doesn't. I'm not sure if that's just me or if the students can't see either. Oh, yeah, that's gone now. Yeah, perfect. Thank you. Yeah. So our goals today. Um I know you're from, you must be familiar with abuses now because we've covered them in past sessions. Um and then we'll co cover the following conditions. So, coronary heart disease, angina talking to patients about mis and atrial fibrillation. And then our final thing is how to apply these to counsel patients after they've had a heart attack because that's the station that we've had in the past. Ok. Next slide, please. Johnny. Is it like in behind? I wonder, I don't know if that's just me or if that's the students as well, but I'll just give a second. Let me try and like squeeze air. Sorry, everyone, sorry, technical difficulties. Yeah, let me just stop that and then I'll screen. Share it again. Ok. Is that working? I am, I'm afraid. Ok, there we go. I think it's just lagging behind a bit but that's fine because we can just carry on with this. Um fine. So I know we've covered pieces in the past. So I just thought I'd get you guys to write in the chart, what pieces stands for, but that's fine. Should we do that? Then if everyone wants to write in the chart, what is just as revision for your results? And hopefully I will be able to see the chat. If not, we can cover it again. That's fine, Johnny. Yeah, so abuses um stands for a brief history. Understanding concerns explanation and summarize. So it's the structure that we kind of teach to help you with explanation stations and what it is is that you take a brief history at the start do ice the way that you're used to. And it's really important to delve into what the patient's specific concerns are. And then you go into the explanation and the way to stop to the explanation is to start off by talking about, this is the normal anatomy cardiology. This is what's going wrong, go into what the causes are, go into the complications and the problems that could possibly arise. And it's really important at this point that you safety net as well. So let me know what's the worst case scenario and how to cope with that. Um And then we can get into the management. So the little mnemonic that I used to remember the explanation of the disease is normally we can probably manage and I just have both uses and normally you can probably manage in the back of my head whenever I'm doing an explanation station at the end as well. It's really important to summarize and signpost them to other information sources and offer a leaflet, which is just a nice thing to do to cover all your bases at the end. Ok. Next slide, please. OK. So just a few tips for explanation stations. Um So in third year, the focus of the explanation stations is very much on the explanation. It is still important to take a history but sure that it's relative. So it only needs to be about two or three minutes. So in your first sort of few questions with the sp just giving them a minute or two to speak and get everything they need to say said. And that way you've done your information gathering, you can tick that box in terms of cardiology. It's important as well to take a really good social history. So asking about diet, exercise, smoking, because those are all the of viable risk factors of conditions and it's important that you cover them so that you can address them in the explanation. Ice is really important as well. I know you guys are probably sick to death of hearing about it. But it's important the explanation stations to get an understanding of what they know about their condition, any misconceptions that they have and to find out if there's anything that's particularly worrying. So with ice, it's important that you address it again in the explanation. So that's why it's important in terms of tips for your explanation, part of the station. So this should really be the bulk of your station. So the remaining six minutes, I think it's good to draw diagrams and to use analogies because we're so used to using medical terminology. And it's a bit difficult sometimes for a patient to understand that. So if you can draw diagrams, use metaphors or use a comparison that a patient can understand that's really helpful in terms of management plan, it's good to play part. So the things that the medical team can do in terms of, you know, maybe cardiac rehabilitation or the medications that the patients will be offered. And the other part is the things that patient can do. So the changes to lifestyle that they need to make. A, I would say my top tip is just to be really sensitive about how you're having that conversation about lifestyle changes because when you're talking about things like diet exercise, stopping smoking, the touchy topics for patients. So it's important that the language you use around that is gentle and nonjudgmental. But I'm sure you guys know all of that um chunk and Chuck. So what that is is that you say a little piece. So you might talk about say the normal anatomy, but it's important stop frequently and just check in with the patient making sense of them. And that can just be as simple as asking, you know, does that sound OK? Does that make sense? Do you have any questions? I know what people like doing sometimes is that at the end of the station, they just ask the patient to summarize back to them. So to check that their understanding is correct and they haven't, you know, misunderstood something. So that's another way you can do it. And again, just make sure your language is really because it's very easy and I've definitely done it before falling into the trap of you're so used to the medical terminology you start dropping in things like atherosclerotic disease and patients don't necessarily understand what that is. So just listen to yourself as you're speaking and make sure that the language you're using is something that patients can understand. Again, make sure to link back to the patient's specific concerns. So if they're worried about, for example, taking time out of work, this is the point where address their particular worries. Um Yeah. And finally at the end, the little mnemonic I use is SSS. So making sure I've summarized, I've signposted them to relevant information. I offer them a leaflet for example. And then the safety netting is really important as well. So what happens if their symptoms come back or their symptoms are w are are worse? Do they need to go to the emergency department? Do they need to call you just to give them somewhere to go to? So that being OK. Next slide, please. Yeah, next slide. So we're gonna talk about stable angina and I've got a bit of a practice question for you guys. So a 65 year old man presents to his GP complaining of heavy central chest pain, which is triggered by exertion but improved by rest. So he has a past medical history of asthma and anxiety, which medications should the GP start for this patient? Ramipril allopurinol Ril or bisoprolol. So if you just type your answers in the chat a couple of minutes to do that, Johnny, I was just wondering, is there a way to make a poll. If maybe people are a bit shy to answer them, they can just answer on the poll and it should be anonymous if I try that. Barry. Yeah. Would you be able to do that if you just, there are, there are only four options on one and they, I'll do that for you now. Thank you. Ok. So I'll give you guys a few minutes to answer. So it looks like it's between C and D at the moment. I'll just let a few more people answer. Yeah. So it's kind of between C and D at the moment. So why don't we discuss what the answer is? Can we have the next slide on you if that's OK. Yeah. So Verapamil, um and the reason for that is because he's this past medical history of asthma, give her um a beta blocker, he'll go into bronchospasm. So that's why it's contraindicated. Um So when it comes to stable Angina, your first line medication is either a beta blocker which wouldn't work in this patient because he's got asthma as we've discussed. This other option is a calcium channel blocker. So giving accounting channel blocker oil or dilTIAZem. The other thing that I kind of didn't mention in this question was that if you're giving a beta blocker first line and that's not enough to treat them, then you need to add a second line medication. So usually a calcium channel blocker, you would not be able to give the beta blocker plus the verapamil together because that causes complete heart block. So that fatal to the patient I have I just thought I'd mention because it does come up in progress test, beta blocker at first line means that you can't have verapamil. Second line, you need to give amLODIPine because of that risk of complete heart block, stable angina patients. All of them should get a GTN aspirin and a statin as well. Just to just for like long term prevention and management of symptoms. Ok. So that's the best question. Just wanted to give you a flavor of the kind of things that come up in progress test. So can we have the next slide, please? Yeah. So how would you explain sayina to a patient? So it's good to start with the normal anatomy of the normal physiology. And the way I like to talk about it is that the heart works as a pump and its role is to deliver blood around the body to different tissues. And then how many blood is it because it contains, it means that the body needs to do its normal functions. The important thing about the heart is that it's has its own blood supply, which are called the coronary arteries. So what angina is or what the disease is is that there's reduced blood flow to the heart. And at this point, it's good to link in the the symptoms that your sp is experiencing to the symptoms of maybe chest pain. Sometimes they get this to make it just a bit more personalized to the patient. I think it's useful as well. To mention that there are different types of angina. So stable angina is when the heart is working harder than usual. So for example, during exercise and the comparison that I like to make is that say you're going for a run and your leg muscles cramp up and that happens because of a lack of oxygen. So a similar mechanism, I know where your heart's not getting enough and then that's causing cramping chest pain. I think it's good to differentiate to the patient that there are two different types of angina. One is stable, which happens on exercise and then there's unstable angina as well and an unstable angina happens during rest. And it's really important to emphasize to them that this is a more serious type of angina. And it's really important that they seek hospital care. They start experiencing symptoms at rest in terms of explaining the cause of angina. I would say don't get too bogged down and you know, it's atherosclerotic disease. It's caused by the collection of cholesterol in your blood vessels. I think just don't get too technical. So the analogy that I like to use is that there's a blockage in the pipes. So the blood vessels are like pipes and they deliver blood around the body and Angina is when you get blockages in the pipes, which is kind of like the plaque buildup that you get in the arteries. And I like to draw them of just a pipe that's got a blockage in them. Just so they've got a visual, a really visual picture of what it looks like in terms of causation. I think it's important at this point to Lincoln why it happens. So things like smoking, family history, diet, exercise, that kind of thing. But again, I think just be sensitive in the way that you're wording it and making sure that it's not coming across as real was mental. At this point, it useful as well to introduce the idea of some things are modifiable risk factors. So things you can't control like your genetics and some things are nonmodifiable. So things like diet and exercise and mention to them that our management is very much focused on the non modifiable risk factors. Ok. Next slide, please. Ok. It's really important again, just to make sure the patient aware of the potential complications and how to, then you talk about what are the, what are the complications of angina. So at its worst, you could get heart attacks, strokes, sudden deaths. But on a more, you know, on a more mundane level, angina can really impact people's quality of life if they're not able to engage in their usual day to day activities. Once you've scared the patient enough, um it's important to get a little bit of reassurance as well because it's, it's scary for people to hear about things like, you know, they could potentially die of a heart attack because they've got this Angina. So it's good to reassure them that if they're compliant with medication, if they make the lifestyle changes that we've recommended to them, more than 50% of will be symptomfree within a year. So, to give your patients some motivation to make the changes that we've discussed, uh we'll get a bit into lifestyle modification in a minute. But the things that you need to remember to cover are smoking, cessation, weight loss, exercise, cardioprotective diet. And what that means is like you're five a day avoiding fatty food, having some oily fish, like, you know, you know what to cover. It's just remembering in a station to cover them because there's so much to go through and remembering again to just be nonjudgmental and to be sensitive in the way that you're discussing it in terms of the more clinical side of things. So every Angina patient, as we mentioned, gets GTN spray for. So you need to do a little bit of counseling with the patient and how to use that. So tell them that when they're experiencing symptoms, you spray this under your tongue and hopefully that should improve the chest pain and the breathlessness when it comes to G TN as well. You need to do some safety counseling because it can drop your BP very suddenly cause lightheadedness, it can cause falls, it can cause syncopal episodes. So you need to counsel them that when you're taking the GTN, make sure that you're definitely not driving stairs and you're sitting down when you're taking it. Another thing to consider is that one of the very common side effects of GTM is that it can cause headaches. So just counsel patients to take painkillers if they're experiencing headaches. Because the last thing you want is for them to stop taking their GTM because they're having a headache and really something that could have been resolved with painkillers and they're having all these chest pains and all these chest pain problems. And again, because they're not familiar with their headaches are potential side effects. So make sure you're getting that across as well in terms of sex netting, there's this little memory aid that the NHS website has that I really liked 2525989. And what that means is you tell the patient to take two sprays of GT and wait five minutes. If that's not really the symptoms repeat it. And if the symptoms still haven't stopped, then at that point, they need to call 999 because you're potentially looking at acute coronary symptom which needs clinical intervention. So, yeah, that's GTN spray in terms of long term medications. I use the four A S to remember what medications we give patients. So Aspirin atorvastatin ace inhibitor and they're already on beta blocker kind of, I don't think you need to get too much into what the medications do. You can kind of mention that the statin stops the build up of the plaques, the aspirin thins your blood, that kind of thing. But don't, don't make that the focus of your station because the station is on Angina. It's not necessarily on medication counseling. Um Finally, I think it's worth mentioning to patients that if all that's, if your is relieved, there are some invasive procedures that we can do. So, coronary stents or bypass surgeries and what that is is they go through a blood vessel in your groin, they put a balloon in to inflate the blood vessel that's been blocked and they put in a stent which is a mesh and that stays in there long term just to make sure that the blockage is open and your blood is flowing through nicely. Again, just need to reassure patients because worry of they, they get scared when they hear about surgeries. So just to reassure them that this is the last line, sort of last line um procedure after we tried everything else. Really? Yeah, next slide, please. Yeah, mis ok. So if we move on to the next slide again, I've got a bit of a practice question for you and it's based on a scenario that came out your oy. So a 74 year old man presents the ee with central chest pain diagnosed with M I, he's very reluctant to stay in hospital and wants to leave immediately because he's a carer for his wife. With Alzheimer's. You've established that he has capacity and he understands the risks of leaving the hospital. So how would you approach the situation? Would you detain him under the mental health Act alarm to leave the hospital? Call security or arrange for social admission for his wife? So I'll just give you a few minutes to enter the pool there. Yes, I don't know if that's maybe some people, I really don't mind if you, if you're not sure because I know it is a bit of a tricky scenario. I feel like that's the answers. Look a little bit split here. So why that's lagging again. Sorry. Did you say next slide? Yes, sorry, sorry you were liking. Ok. Yeah, that's moved on. Yeah. So you would allow him to leave the hospital. Um And the reason for that is we've established that he has capacity. We've talked about the risks, the pros and cons and he still wants to leave and you can't stop him um in terms of the other answers. So, I mean, it's unrealistic security observed in 24 7. So that's the way um in terms of the mental capacity Act, you'll get into that a bit more on your psych placement in fourth year. But basically what that is is it's like a legal framework for clinicians to act in a patient's best interests when we've established that they don't have capacity. So that doesn't quite apply case because we've established that he's due. So we can't detain him under the MCA. Um Finally, in terms of arranging a social admission for his wife, we can't do that either because his wife is a completely separate patient. So if we were arranging a social admission, that would be because we've spoken to her, we've examined her and we've decided that based on her background, she needs a social admission. It wouldn't necessarily to what's going on with the husband's health. So the reason I brought this up was because as I said, we had a very similar scenario in our third year CCS where there was a patient who just had an uh I think it was an end I believe, and he just wasn't willing to stay in the hospital because of some work issues that he was having. So I just wanted to go through briefly how you would approach a situation like this. And the main thing is patients with capacity are allowed to make decisions that are medically unwise. And you see this in real life as well. Like when I was in Ed, we had a few patients who were symptomatic with chest pain and shortness of breath, but they just refused to say and because they're adults and they have capacity, they're allowed to make their own decisions, even if it's not the decision that you would recommend to them, your job in A CCA or an AUS is first to establish that the patient has capacity. So if you remember capacity ace, she remember the way can they relay their decision making back? So that's not something, it's not really a formal assessment that you need to research. It's just through talking through the to the sp you kind of get a picture of what the level of understanding is. If that makes sense. Second step is, do they actually know the severity of that condition? Sometimes people hear a heart attack, I don't quite understand how serious it is. So it's important for you to fill in any gaps in their knowledge. So my mistake when I was doing that station in third year was I really shied away from explaining the complications of a heart attack. So I was quite scared to tell him that, you know, if he goes home, he could die, I just didn't want to say that because I was scared of worrying the patient. It's important for you to tell potential complications. So the patient can make an informed decision. I'm seeing a question here. Should I consent the patient before leaving the hospital? So in terms of consent, I'm assuming you mean do you sort of mean like consenting them for procedures or consenting them elaborating on the question of the left? That's ok. And then I can answer that for you. In the meantime, I'll just um carry on with the slide. Yeah. So you wanna fill in any gaps in their knowledge, you want to figure out why they're exactly reluctant to engage with treatment. So is there anything you can do? So with this patient, for example, whose wife had potentially emergency social care services? So that there is some um next thing you want to do is explain what are the we want you in hospital, the pros of and then what are the of refusing treatment? So at that point, again, don't be scared to discuss serious complications, but at the end, just ask them, you know, what are you thinking so far? How do you feel? And if at that point, they still want to leave hospital, you can't force them because again, they're adults who can make their own choices and your daughter is a junior doctor is to make sure you've discussed everything with a senior and you've documented everything and that's more of a medical legal thing. So covering your own butt to make sure that you know, you, if it comes back to bite you point, you've covered all your bases, you've done them. Ok. And shall we move on to the next slide? So, I mean, it's very angina go into too much detail. Again. What M I is is there is a blockage in the blood vessels and the difference this time is also are ir irreversibly damaged. And what that means is that can get long term comp patients. I think it's good patients that there are two different types of heart attacks, which is I sort of explained it as a more serious heart attack. So there's a long interruption of the blood supply that causes changes on the heart trace. And that's something that needs urgent admission to hospital, an urgent treatment in terms of unsteady, don't undermine it because it is still serious. So e explain to them that it still needs urgent treatment as it can progress to an which is more serious. And again, explain to the patient that it kind of depends on the type of the M I. But the options are you can get primary PCI and the PCI is a procedure where they go in through a blood vessel in your groin and they can give you a stent or they can give you some medication to break down the clots and to get that blood vessel open and to get the blood flowing again. Um in terms of long term management or long term prevention after you had an M I, it's good to come into talking about what cardiac rehab. So they do location about diet and exercise, they can give psychological support as well because it's not uncommon to experience depression or mental health issues after you've had an M I. So just sign post patients to that service secondary prevention medications. So the pneumonic that I use is sa which stands for statin aspirin ace inhibitor beta blockers. Again, don't need to go too much into it mechanism of how they work. But in some patients why they're taking them, which is to prevent another heart attack in the future. And to explain that compliance is really important to stop them, experiencing symptoms or experiencing another heart attack in terms of last time, meat ification, um we'll go into this in a bit more detail, but it's the same things of diet exercise, quitting, smoking, that kind of thing. Again, it's important not to shy away from the serious things because the patient needs to have a full picture of what could potentially happen to them. So it's OK to talk about things like death. And also mention that they could develop arrhythmias, they could develop heart rupture, heart failure, cardiogenic shock, which is a more serious form of heart failure that could result in them being hospitalized in the ICU. Ok. Next slide, please. Ok, hypertension. Next slide, please. I've got another practice question. So a 50 year old woman with no previous past medical history presents for her NHS health check. She's found to have a BP of 1 45/90. So what's the next step in your management? Would you stop prosol refer to cardiology? Start amLODIPine, arrange for ambulatory BP monitoring or book another appointment to recheck BP. And again, this is based on that we've had in the past. So that's why I wanted to discuss it with you guys. Sure. This is another one that's maybe stumped people, but you can have a go and I really don't mind if people are a bit confused because we'll discuss it anyways in a minute. Um Just going back to the question in the chat about whether should, should I consent the patient before leaving the hospital? Um I'm taking sort of informed consent as in telling them that the pros and cons of staying in hospital. Um in terms of like what's as if they choose to self discharge. So again, you need to make sure there's informed consent. So they know why you want them to stay in hospital. They're aware of the risks if they choose to still go. Um And then from a medical legal point of view, there's a specific form you need to fill out to make sure the patient is aware that at this point they've taken on the responsibility of discharge for themselves. So anything that happens to them at that point, you know, we've done what we can and it's up to the patient to sort of do and they know what to do, start experiencing symptoms again. So make sure you've safety net it and tell them that if you start experiencing chest pain again, you call the ambulance and you get straight back into hospital. So yeah, from a point of view, making sure the paperwork is making sure they've spoken to a senior as well and saved enough in them. So they know that again, they need to come back to hospital. So we want to the next slide, I think maybe this one's confused people a little bit. So yeah, I be like to blood, blood pressure monitoring. Um And the reason for that is so it's based on the practice scenario we had in third year, which is that a patient had a one off reading of I think it was 60 ish systolic enough reading of high BP. And the scenario was how would you manage this patient and you have to discuss it with him. So when you've had a one off high reading in clinic, that's not actually diagnostic of hypertension because patients in clinic are a little bit stressed anyway, which is gonna throw that BP high. So what needs to at that point is arrange ambulatory BP monitoring, which is with the BP, BP monitor, sorry, over 24 hours and you would counsel them not to do any, you know, heavy exercise that can throw their BP off or not to take any showers that could damage the machine. So just getting a more reading on what their blood pressures like at home feel high, then at that point, you would initiate treatment and not before. So you're not gonna start amLODIPine or Bisoprolol just based on the one of high BP reading that you're taking. Yeah. Ok. So counseling on hypertension in terms of neurology, again, just needs to be very basic that BP is the force that the heart uses to pump blood around the body. And this force is generated by the resistance in the blood vessels. So the thing that kind of goes wrong in hypertension is that the blockage in the pipes and the buildup of causes increased resistance and it causes high BP. So I think the thing that's a bit different about hypertension, just say stable angina or, and and is that patients aren't necessarily symptomatic and they sometimes might not understand why they take all these medications, especially if they're experiencing side effects from medication, but they're not really feeling any benefits from taking the meds as such. Is that gonna make sense? So your job really in that station is to get across why you need to be taking these medications, which is to prevent complications in the future. So in terms of causes of high BP, similar to any other cardiology conditions increase in age ethnicity because unfortunately, being South Asian or being from a certain background means that you're more risk, more at risk of high BP. Um and you can go to lifestyle factors again. So diet, smoking, sedentary, lifestyle and weight. Ok. Next slide, here's one where you really need to discuss the complications because if their BP is not controlled. And there's someone who goes years and years and years with high blood, they are such strokes and heart attacks and you need to explain to them what that means. So a stroke can be really debilitating for people. They can end up with paralysis, they can end up with long term visual and speech problems. And you need to emphasize that that can really affect your personal life. Heart attack can be fatal, but they can also come a little complic. So like all the chronic issues we've talked about and the reason that I want you to really emphasize the complications of hypertension is again because they're not really symptomatic at the moment and you want them to be compliant with medications. So they're avoiding complications in the future issues with hypertension is you can get um kidney problems. So KD and you can get issues with the eyes. And again, the aim of treatment is to reduce these risks in terms of management. We've work, discuss that um full investigation of high BP. You need to arrange for them to have home BP monitoring over 24 hours. Um I'm not gonna get too much into medications at the minute because that on profile and their personal medical history, but just explain to them that we will prescribe you tablets that are on your age, your medical histories and then we do regular checks of your BP to see if that's being managed with a tablet that you're on, if not at that point uh to either increase the try a new medication. Um and again, explain to the patient that that role is very much lifestyle modification. Ok. Next slide, please, I will try to speed up because I'm conscious of the fact that reaching the end. So, so it fibrillation, again, you can go to the function of the heart. So it acts as a pump, it delivers oxygen and nutrients around the body. So, atrial fibrillation is that the heart's upper chambers are beating, not in sync with the lower chamber. And what that means is that the heartbeat is irregular. So my GP tutor, when he was explaining atrial fibrillation to the patient, he kind of use his hand to DS, it's like normally your heart's beating, but in atrial fibrillation, your heart's kind of chaotic and doing its own thing. And because the heart's not beating as efficiently, that's what's causing the symptoms of shortness of breath, lightheadedness, dizziness, and it's really good. Again, just as explanation station is generally going back to the symptoms that your patients mentioned in terms of causes of atrial fibrillation, not completely understood. It can kind of happen after heart attacks or serious infections. And the risk factors include things like drinking a lot of alcohol, your age being your age and milide, please, complications of atrial fibrillation. Um So it's important to explain to patients that your heart beating irregularly can create a clot and that clot can go anywhere in your body if it goes into your brain. So, having af doesn't mean you have a high risk of stroke and it's a brought to patients. Um It can also throw clots into the legs to cau which causes limb ischemia and then acute ischemia. Um and a nice way to explain that if there's a clot that's blocking the blood vessels in your legs, that can cause the tissues to die off. And that's also a serious medical emergency. Um in terms of other complications, get heart failure as a consequence of inflation. And again, explain that to them, function of the heart isn't working anymore. Um Management wise, I wouldn't get too bogged down in the detail, but explain the options are either rhythm control. So that's the pill in your pocket, which is fide. So when your symptoms of ha if you have a heartbeat, you just take the tablet and that should get your heart rate back into a normal rhythm. Um The other option is rate control and it's going to get across to patients that this isn't going to fix your irregular heart rate as such. It's just going to reduce your heart down so that you're not really as symptomatic. Um in terms of stroke prevention, I think it's a clinician use it before. And the way you would explain that is that you take into account, they are individual risk factors. So their history of things like hypertension, diabetes, their age, their gender and depending on their personal background, you decide whether long-term blood thinners, that's the risk of stroke and preventing stroke. But we said that a few times, why don't we move on to the next slide? Yeah. So I don't think Code Blue has really done any medication or pharmacy teaching with you yet, but I'm going to touch on this briefly because in third year, we had a station which was a bit of a hybrid. So we had to explain atrial fibrillation. And then we had to explain a medication which was Rivaroxaban. So we had the BNF in front of us and we had to talk through explain Raban to patient. Um and then the mon that we use is athletics which stands for action as in how does the medication work? What time of day do you take it? How to use it? If there are any special instructions, the length of time that the patient needs to be on treatment for the effects, which is sort of why you want the patient to take the medication, any special test that you need to do to monitor the medication and then you go into side effects and contraindications. So when Code Blue does a proper teaching session with you on medications, you'll cover this again. But this is just a brief introduction to what athletic is. Yeah. So next slide please. Yeah. So in my sy or in my CC for third year, I was asked to counsel patients on Rivaroxaban. And the way medication counseling stations work is that you've got to be in front of you, but you still need to be talking to the patient. So I think just as a rule of thumb as you're going through TCD S this year, pick out the important medications and then just have some understanding of how they work and the kind of things you would say in ACC. So you're not sitting there in the station like frantically trying to find all this information while you're trying to talk to the patient at the same time if that makes sense. So I just thought I'd run through athletics and how you'd apply that to Rivaroxaban or a dog. So, the way that it works is that it thins the blood and it prevents blood clots by acting on a protein involving clot formation. And you don't need to get too technical because the patients won't. This is not the important part for them. Timing wise, there's no, it's just once or twice daily. There are no special instructions on how to take it. So you just take it with a glass of water and make sure it's sitting up, right. Um The important thing to emphasize is that this treatment is gonna be lifelong. So you're always going to be on blood thinners because once you're in af you're always going to be in af so you're always at risk of stroke. And that's why you need to be on these blood thinners long term in terms of effects. So why we want them to take the medication? The goal is to prevent blood clots that otherwise would have gone on to cause strokes. Um There are no special monitoring tests that you need to do for anticoagulation. So for example, for Warfarin, you would need to be regularly measuring the inr and the advantage of Dox or Warfarin is that you don't need to do that. So that's something you can mention to the patients to make them feel a bit better about having to take to um in terms of important side effects, it's important you do submit safety net in here. So if patients are having bleeding, they really need to seek medical advice. So for example, a nose bleed that won't stop black stools, severe, sorry, severe bruising on their body. If they've had a head injury as well, it's really important. They come to Ed and get a CT scan because they're more at risk of having hemorrhages in the brain contraindications is more for you as a clinician, but for do active things that are relevant are active bleeding and a low G fr OK. Next slide, I think we're approaching the end guys, secondary prevention after a CS. So, Missus Smith is a 63 year old woman who presents the GP surgery after a semi with a past medical history of hypertension. She currently smokes half a pack a day and admits her diet is not the best as she is Ak Baker who has a sweet tooth. What lifestyle changes do you need to discuss? Missus Smith? I'm not really gonna ask you to answer in the chat cos we're approaching the end of the session. So let's move on to the next slide if that's ok, Johnny. Mhm. Yeah. Again, it's the things that we mostly sort of discussed already that you want to have a balanced diet. So avoiding foods that contain a lot of saturated fats, reducing sugar intake, eating five a day, increasing fiber intake, you can refer them to a smoking cessation clinic and advise them that you're more likely to quit if you're getting medical support rather than going cold turkey because that might incentivize them to take up the support that you're offering. Again, regular exercise. The NHS recommendation is at least 1 50 minutes of moderate exercise a week. It's just not to drop that number in an exam just so the examiner knows that you're aware of the guidelines. Um Some other things you can generally mention are that you want to control your co morbidity. So things like diabetes and hypertension that make you more at risk of develop or experiencing a heart attack. Um, and a final top tip is that it's important to keep the patient involved so ask them what the things they are, what things they think they could do to improve their health and to prevent their risk of having problems in the future. Because if they suggested things to you, they're more likely to stick with changes this way if that makes sense. Ok. Next slide, please. That's pretty much the end of our session. If there's anything I've not covered or any questions that you'd like to ask, then feel free to pop anything in the chart. Um And if you can fill out the feedback for me, I'd really appreciate that. Just so we know what to change or to do for me in the future. Ok. But that's pretty much it for me unless there are any questions in the chart. No, I don't think there's anything. Yeah, Johnny, I don't know if you want to split them up into breakout rooms. Yep. Thank you very much for giving out the presentation. Um I will split you guys up into the breakout rooms, please. Could you maybe put a Y for Yes, if you are staying for the breakout rooms. So I know which breakout room to allocate you in. So that's Y for Yes. Yes. Ok. Thank you very much everyone. So we have, I believe two volunteers um today Mustafa and Zona. Um So I'll split everyone into breakout rooms now. So if you can see on the side, on the left hand side, there is a breakout room sessions or breakout sessions? If Adrian Janella Sami could join breakout Room two. And if Mohammed Abdullah and Kevin could join breakout room three, please. Um I just joined. Now, do I just go straight to the breakout room? Yes, please. All right. Perfect. Cheers. Wait. And just actually before I go in, um in terms of the OSK circuits, is it all five of them or is it five circuits that they're on? I think. So, I won't be able to, I'll have to leave a bit earlier. So, um, do I do all five or can I just split? Like, can I just pick two and then I think there's three in my station isn't there? Yeah, you can just pick two. That's fine. All right, perfect. So, uh, so I've sent you an invite to join the stage, maybe try that and then click the break up room to, I'm ok to leave in that case if there are enough volunteers and stuff. Ok. Thank you. Thanks so much for your help and for sharing the slides as well. It's all right. Thank you for doing this. Thanks. Bye Samir. Is it working or not.