Computer generated transcript

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

Ok. All right, good evening everyone. Um Just a little confirmation from any one of you to say that you can hear me and you can see the slides, please. Perfect. Thank you, Ashley. Um So we'll wait for a couple of minutes before we start that. Um We'll probably start um a free pass and then I'll hand um I'll hand it over to Ben who's gonna be doing the teaching. Mhm. And just to remind you guys, um after the teaching, there will be um sort of osk practice in breakout rooms which I highly recommend that you stay for. It's really quite, it's really useful to practice what you learn in the session. Um And you get some really good feedback as well from all of the facilitators. So definitely stay. Yes. OK. Right. Just for the people that I've joined, just a reminder that there's going to be osk teaching at the end or not. Osk teaching. Sorry. Osk practice after the teaching highly recommend that you guys stay really useful. Um And you get to put into practice what you learn in the teaching session. Um I guess it's three past now. So um we can, I guess we'll start with the session. Uh, if anyone has any questions, they can pop it in the chart. I'll be, um, I'll be looking at the chat, um, throughout the session anyway, so I'll hand it over to them. Ok, great. Yeah. And just again, make sure you do the, um, sessions at the end, the stuff we do go over should be quite useful for it. So you'll get a chance to go over it again. So the things that we're gonna go over in this lesson are heart murmurs are just some of the common ones and some of the causes and then importantly how to listen for them. Um Then a few common cardiac conditions that present with shortness of breath. Um then go for drug counseling. I'm not sure if you guys have learned about how to do that sort of as an association yet, but I'll talk through that and give a couple of examples. And then if we've got times I prescribe you at the end, um it's actually will be quite useful for ay so hot MS um where to listen for the different heart valves. Um You can see on this image. So obviously, the aortic is right, second, intercostal space, pulmonic on the left and then um tricuspid lap four things called a space and then at the apex for the mitral valve and you can see those different areas on here. Um And that can be quite helpful in working out where to listen for different heart murmurs. So, we'll go over that in a second just first, just for like the basics of what actually are the different heart sounds. There's two main heart sounds and they're called S one and S two. Um and the sort of gap between them marks systole, which is where the heart's pumping. So, during systole, the ventricles contract and blood rushes up out of the aorta and pulmonary artery. And as that happens, the atrioventricular, so the tricuspid and the mitral valve snaps up and that's what you're hearing is. S one then during daly, sort of the opposite happens. So the ventricles relax and rushes back down in and the A V valves open and then in a working heart, what should happen is the aorta and pulmonary valves should snapshot and that's S two and you'll see at the bottom of it and there's some extra sounds you can sometimes hear and we'll maybe go over S3 a little bit more later. But in a sort of larger heart where there's more blood rushing into the ventricle, you can sometimes hear a third heart sound S3. And that's sort of to do with an increased ventricular filling pressure. Ok. So that'll be relevant to one of the conditions we talked about later. But the main two things to think about is S one is the A V valves snapping shot and S two is the aortic valve snapping shot. So you can get extra heart sounds if there's issues with the valves. So, stenosis, which is narrowing of sort of any lumen, but in this case, narrowing of the valves will create an extra heart sound and regurgitation, which is if one of the valves are sort of incompetent in some way and they're not shutting correctly, then as blood should push against them and shut them and they should stop the blood, some blood is actually rushing back where they shouldn't. So sort of using that knowledge alongside how the heart pumps, you can work out what the systolic and diastolic murmurs are and have a guess as to where you'll hear them. I mean, so you don't actually need to remember everything in loads of detail. So I'm not sure if he wants to do this interactive or not. But does anyone have a guess as to whether aortic stenosis or do they know, will that be systolic or diastolic or where do you think you'll hear it? The loudest? Give you a chance if anyone's feeling brave, if not, I can just rush forward. There we go. No, we've got something in the chart. Um Oh, we have got something in the chart. I can't see the chat. Oh, is there ejection? Systolic? Ok. So if someone's even added an extra word in, that's great. Well done in mirror. It's definitely a systolic murmur. So, yeah, as the ventricles contract, blood should rush up out, um, if they ought to. And so you'll expect it to be a systolic murmur. Right? Cos it's during con contraction of the heart, you'll often hear ejection systolic, like you said, a mirror. Another phrase you'll hear about it is crescendo, decrescendo. So there's often these fancy words which go along with the term, which you can maybe remember but aren't as important. What is important is over the right second intercostal space. you'll hear it the loudest and it will radiate up to the carotids. So as you move your stethoscope up, you'll hear the sound as well. Um The crescendo, decrescendo is just referring to the fact that as the aortic leaflets open wider, the sound gets louder and as it gets, as they begin to close again, the sound gets c louder er gets quieter, sorry. So systolic, right? So means costal space. Yeah, ejection, systolic, I'll just go through the next of them. Ok. So common causes of aortic stenosis in younger people, it's more likely to be a bicuspid aortic valve and then in the older population, it's more likely to be due to degenerative calcification. Ok. Good stuff. So the next one's mitral regurgitation and the common term you hear about this is pansystolic and that just means throughout systole. So as the ventricles are contracting blood, it's pushing back against the mitral valve and it should usually not be able to go back up. But in this case, there's an issue with the mitral valve and it creates this systolic murmur and that's best heard of the apex and it radiates out to the axilla as well. Ok. So common cause as much regurgitation, just damage to the valve or the heart. So, post M I, so if you've had some kind of damage to the papillary muscle or the cord tendinae, which attached the p the papillary muscle to the valve, then other things like infective endocarditis, rheumatic rheumatic fever. Again, it's just things that have damaged the heart. So that now the mitral uh valve is sort of incompetent, get uh aortic regurgitation. So this is a diastolic murmur. So as the heart is relaxing and the um semilunar valves, so the aortic and the pulmonary valves are closing, they're not working correctly and blood's rushing back down into the ventricles. So it's sometimes referred to as a early diastolic blowing murmur. So this one you don't hear of the aortic sort of region because you can imagine the blood sort of moving the opposite direction and you hear of the left lower sternal border. And importantly, for if you're on the ward or in your Aussies, if you get the patient to sit up and lean forwards, you can hear this um murmur louder. That's a way of sort of accentuating. It common causes the most common cause in outside of the UK would be rheumatic fever. But then it's again, calci calcification is another common cause. And then connective tissue diseases. And then also again, this bicuspid valve, which is a congenital problem with the aortic valve. Um There's some other signs specific to aortic regurgitation that you can look for in the patient. Um And they're to do with the fact that they're getting this wide sort of pulse pressure. So the blood's rushing backwards down the aorta and you can see that pulsating in their nail bed and that's called Quink sign. So as you're um doing your cardiac exam, that's something you might be looking for in the nail beds. And if it's more severe, their head might even bob back and forth cos the change in pressure is more extreme. But yeah, just to recap, it's this diastolic early diastolic murmur of the left low external border mitral stenosis. Um So probably getting the idea by now. So if you're imagining the heart's relaxing and blood's moving from the atria to the ventricles, you can imagine that this is gonna be a diastolic murmur and this is a low pitched murmur. And the reason for that is just cos it's low pressure between the atria and ventricles. So that's in contrast to something like aortic stenosis where it's a much higher, higher pressure. And this is her best at the apex. And you can make, you can accentuate this murmur by getting the patient to l sort of lie on their left side or lean over to their left side, sort of pushes the apex of the heart closer to the chest wall. Um, so that's another way to accentuate it. Now we're racing through and, yeah, the most common cause of mitral stenosis is rheumatic fever. So, rheumatic heart disease. Yeah. Ok. So I was asked to put this in, I'm not sure this will become more relevant when you're in fourth year, I think in doing about, um, and doing pediatrics. But it's quite interesting. Um, So I don't know if you guys know about the ductus arteriosus. I think maybe you're having preclinical stuff done about that. So it's the a small duct that connects the pulmonary artery to the aorta. And the reason that that exists is it's to sort of bypass the circulation from the lungs. Cos obviously, you don't need your lungs when you're in uro after birth, the baby takes a big breath in and fluids clear from the lungs and also prostaglandins are cleared and that stimulates the closure of this small duct. So importantly, in some babies, it can remain open after birth. And that's, that's much more common in premature babies. Um And sort of whether it's severe or not or concerning, depends on um the size of it. So some of it doesn't matter and in some it needs some treatment. Um So a question, if it is stimulated by prostaglandins being reduced or cleared, can anyone guess what common medication might be used to treat an open patent ductus arteriosus if we wanna get rid of, if we wanna reduce prostaglandin synthesis to stimulate this nsaids. Fantastic. Yes. So things like literally like Ibuprofen or another one more common indomethacin used for this. Exactly. Um And again, not necessarily relevant to you, but for pediatrics, sometimes it's even necessary to do the opposite. So to open this duct even further, there's some congenital heart conditions that babies are born with. So one is position in one specifically is called transposition of the great arteries. And that's where the pulmonary artery and the aorta are attached on the wrong side of the heart. And that's really bad. Cos it basically means you've got two separate circulations going on. And in that case, which is really a very serious congenital heart condition, you need to keep it open this small duct um just to maintain some sort of connection between these two circulations. Anyway, why are we talking about this? Because it has a murmur. This is always described as a continuous machinery like murmur. Um So I'm not sure exactly sure what machinery means, but you can see what it looks like on here. So it's always there and you can imagine it's below the clavicle and it radiates through to their back as well. Ok, good stuff. So how to assess a heart murmur in practice if you're asked to do it. Very good. Adrian says Inder Meth. So I didn't see that until now. Well done. Um How to assess a heart murmur on the ward if a doctor asks you to do it. So, I think the two most important things, uh, is it systolic or diastolic? And where can we hear it the loudest? So, it's sometimes recommended that a good way of working out if it's systolic is to feel for a pulse as you're listening to the heart and then sort of correlate the sound to if it's, as you feel the pulse, you're hearing this extra sound, it's systolic. And if it's after and it's diastolic, that's good and you should definitely do that. Um, what I do is I just listen for S one and S two, the two heart sounds and if you're hearing the murmur in between them, then it's obviously systolic. And if it's after the second heart sound, it's diastolic. So just have a practice doing that and you'll get the hang of that whenever you get the chance to hear what a heart murmur is, then obviously, where is it the loudest? Um And after you've done those two things, you'll probably have a good idea of what it might be. And then you can think about even accentuating the sound. So can you get the patient to lean forwards or lie on their side, whatever it might be again, then once you've got an idea, so say you're, they have a systolic murmur, you've heard it loudest over the right second intercostal space, um, you think it might be aortic stenosis, you'd be listening up as well to see if it's raining to their neck or et cetera. For the other ones, there's then things in this sort of mnemonic called script for how to er, describe a heart murmur, including like his character and pitch. But that would be, I think that would be quite above and beyond if you were doing that on a ward in the year three. So focus on those things. Always investigate a new heart with an echo is a important thing to know. So there are different grades of heart murmurs. Um instead of remembering all six separately, you can kind of just break it down into different groups. So 12 and three have no thrill and 45 and six do have a thrill. Um Then 12 and three, I mean, it's slightly subjective, I guess, but they're essentially, you can barely hear it, you can hear it pretty well and it's quite loud. So that's quite easy to remember as 12 and three. And, you know, it's got no thrill. And then 45 and six are divided up by this. Um sort of quite funny classification of whether or not you can hear it with the stethoscope on the chest. So if you can lift your stethoscope, sort of like a millimeter of the chest. So it's not even touching and you can still hear it and it's grade six, if you only need it partially on the chest and it's grade five and if it's just a really loud murmur with a thrill, but you need the stethoscope fully on the chest, then it's grade four. So hopefully that's an easier way of remembering it. Ok. So that's all we can do about heart and numbness. Um, just like I've said, systolic murmurs, which is to do with valves. You know, they must be to do with a stenosis in the pulmonary or aortic valves or regurgitation through the tricuspid and mitral and the opposite for diastolic. So obviously, you maybe don't need to remember that if you've got an idea, but there is this little thing here. A S Mra S Mr and D. So A S Mr is aortic stenosis mitral regurgitation and those are the systolic ones and diastolic is aortic regurgitation, mitral stenosis. So you can use that too, have more confidence. But in theory, maybe you'd be able to just work it out now and yeah, investigate murmurs with an echo here. We're racing through cardiac conditions for breathlessness, history taking. So we're just gonna go over some common cardiac conditions um and some of the signs that you'll see in the history and maybe an exam and I think a couple of these will be in your or maybe one or two will be in your practice station later. So you'll know which questions to ask if you have a go at those practice Huskies. So, infective endocarditis what is it? It's infection and inflammation of the inner lining of the heart of the endocardium. And you form these vegetations on the endocardium and they can lead to problems with your bowels. Um And then you can get systemic consequences because little chunks of these vegetations break off and travel around the body to different organs. Um, a sort of classic thing to maybe know for the progress test when you were trying. That is that in IV drug users, staph aureus is the most common organism. Um And that now is the most common cause of infective endocarditis in the UK. And it used to be streptococcus radians and you'll more see that in people with poor dental hygiene or people who've had a dental procedure and that's just cos it's found in the mouth. Ok. So risk factors for infective endocarditis. And this is quite relevant because when you're taking your history, you might, and you're suspecting infective endocarditis, you might be sort of looking out for things like this. So the normal heart is unlikely to get this condition. So there's usually something that predisposes you to it. Um So a big one might be that they've had endocarditis before. Um It might be that they have an issue with their valves, maybe they had rheumatic valve disease. They've got a, they've got sort of a congenital issue with their heart. A prosthetic valve is a big risk factor. And then, like we said, IV drug use and that's not to do with the heart, but just because they're more likely to have, um, bacteria in the circulation. Ok. So it's, that's why that's a risk factor presentation. Uh, in practice, I guess, can be quite nonspecific cos they'll have, they'll just be unwell, they'll have fever, night sweats, weight loss, some of them, not all of them, what the really important sign is is that they'll have a change to an existing murmur or a new heart murmur. Ok. So if someone's unwell with a fever and a new murmur that should be ringing alarm bells for infective endocarditis, and then you'll probably be able to elicit some kind of risk factor from their history. Does anyone know what signs you might see on examination for someone with infective endocarditis? So this is in your cardiac exam when you're looking at different parts of the, well, I won't give you any anymore. Does anyone know some signs and the physical exam? Let's see. One new message finger clubbing. Ok. Very good splinter hemorrhages. Good. Fantastic January lesions in Osler nose as well. You've done great. So I've only put in those bottom three finger clubbing. I didn't know about that, but I'll Google it later and see. But splint hemorrhages, January lesions and Osler. No, it's very good. So I've put in some photos of these Osler's nodes. These are these painful nodules and they're on your fingers. So, Isaac kindly suggested that a good way to remember that is Osler has five letters. You've got five fingers, it's gonna be on your hands. Um, January lesions, these are the sort of macules and papules and these can be in your palms or soles. And then there's a photo of splinter hemorrhages there. Ok. So, when you're doing your cardiac exam, which you'll probably be doing at some point in some kind of Oscar this year at Christmas or whatever. Um And you're doing your cardiac exam, you can say I can't see any o nose, no January lesions, I can't see any splinter hemorrhages in the nails. These are good things to point out rough spots. Someone's just suggested that's a really good one. So that's, I don't have that in the um slides, but these are sort of these white lesions that you see in the retina. Um that wouldn't be part of a normal cardiac exam, but it's a very good sign, well done, a mirror. Um Yeah. And like I said, these are, these are caused from emboli, breaking off from these vegetations in the heart and traveling around the body. Good. Let's move on. We've got more to get through diagnosing, endocarditis is done with a thing called the Dukes criteria. Uh It's pretty long, but the main thing to know is that um it uses evidence from the echocardiogram from blood tests. So the blood cultures and different sort of serological tests for organisms and then the clinical signs and it puts that all together to give sort of a likelihood of the, well a diagnosis of endocarditis. Um, so I guess the main takeaway is that important investigations in endocarditis will be an echocardiogram and a blood cultures managed with antibiotics and we go heart failure. So I guess you probably learned in detail about heart failure and the ra S system and everything. But the long and short of it is that there's some kind of issue with the heart, um maybe high BP, um ischemic heart disease and there's compensatory mess kicking in and trying to retain fluid. But this has the impact of leading to cardiac remodeling, hypertrophy, further deterioration in cardiac function and then it just goes round in a vicious cycle and you get fluid overload. Um So when we think about how this might present, there are largely things to do with fluid overload. Does anyone know any signs of heart failure? That's sort of my next slide when we got. So, signs is yeah, signs or things from the history or whatever? Just uh difficulty breathing? Of course, very good kid, severe edema, fantastic shortness of breath, orthopnea. P ND. Really good. OK. A mirror nose lots. OK. Let's keep having a look then. So you can break up heart failure into left ventricular failure and right ventricular failure. So if your left ventricle isn't pumping correctly, the back log is gonna be into your lungs. And if your right ventricle isn't working, then it's gonna be back backlogged peripherally in practice. Uh because left ventricular failure leads to right ventricular failure. Most of the time you see lots of the, all of these signs together. Really. So, yeah, lots of you said difficulty breathing and that is a really big sign in this. So they're gonna be breathless and a really important thing which a mirror seems to know about is that it's worse when they're lying down flat and the fluids pooling in their lungs. So, really important questions in suspected heart failure or just a breathlessness? History is, are you breathless, lying down or the really common one is, do you use lots of pillows to sleep at night? So often patients will have to prop themselves up with three or four pillows just to be able to get some sleep. Ok. So fantastic P ND and an answer already. So, paroxysmal nocturnal dyspnea. Do you wake up feeling short of breath? So, they've lied down, they've gone to sleep, the fluids pooled up and then they wake up breathless. It's not a good symptom cough again, worse at night and they might have pink sputum. So again, this is their pulmonary edema. Um Some signs that you'll see on examination. So the basal crackles again, that's crackles in her lungs just from the edema. Um then from right ventricular failure, the raise JVP. Do you guys know about JVP? Yes, you probably do. So, that's when you're looking at the jugular vein in their neck and you can see the blood pooling up into that, into that vein. Good, good. She knows about uh R JVP peripheral edema is mentioned. So you press on the front of their shins and it causes this indent in the front of their shins which doesn't go away for a few seconds or whatever. Um Hepatomegaly fine. So gallop rhythms here and what that's referring to is this S3 sound I mentioned at the start. So during diastole as blood rushes into the heart, which is big, it's hypertrophied and it's overloaded, you get an extra S3 sound and it causes a gallop rhythm that might be worth listening to on youtube or something if you get the chance, um cool displaced heart, apex beat and heave. Those are both signs from having a large heart. So the displaced apex beat, the heart's sort of hypertrophied and where you'd expect to hear the apex beat has moved and heave is where the front of the chest moves forward a little bit because uh again, the heart's become so big, then important things with the history. So heart failure won't just happen. There needs to be some kind of cause for it. So they might have had some of the causes which we went over like hypertension, uh heart attack, whatever or a lung problem. So if you have some kind of issue like sleep apnea or something, which increases the pressure in your lungs that can back up to your right ventricle and cause heart failure that way. So, key takeaways from this, when you're thinking heart failure, ask about the nature of the breathlessness, is it worse when they lie down? Do they use lots of pillows to sleep at night if it's yes or that you're on, you really thinking heart failure. Ok. Moving onwards, we're doing very well for time atrial fibrillations. So I'm sure you know what AF is, but just uh for the key signs, obviously, it's palpitations, right? They've got this irregular, irregularly, irregular pulse, which I'll talk about in a second. But they can feel these palpitations may be important to note that not everyone can feel af so some people walk around with AF and don't know that they have it. And also it doesn't need to be all the time. So it can be paroxysmal and come and go. And these people will still get treatment for af, if their cardiac output is particularly bad, then they'll feel breathless, lightheaded, have a reduced exercise tolerance or might even have some chest discomfort. Ok. And stroke's written at the bottom then, so I'm sure as you know, af is a really big risk factor for stroke cos blood pools in the atria and is susceptible to clotting. And so everyone who has a stroke will have an E CG to check for AF CO, it's such a big risk factor. So here. I've got a AF on an E CG. Does anyone? So II told you it's af but can anyone point out some things in this E CG which make them think that it might be af let's see what we got. I'm relying on. Uh I'm here right here. No higher heart rate. Really good. Nondiscernible P waves. Perfect. Two good hits already. No P waves. Tachycardia. Yes. Perfect. Um Hi PSA, I'm sorry if I'm saying your name wrong, but that's exactly what I was looking for as well. Ventricle. Fine, perfect. Oh, you guys know exactly what you're doing is the entire zig zag shape standard for af, so I guess what you're talking about is the baseline between the R waves there, I think. Um, so sometimes you'll see a really regular, um, what's called a sore tooth pattern and that's called atrial flutter and that's really similar to af I think just the main thing to look out for this wouldn't be called, er, as I don't think this would be as exact shape. So this is just an irregular baseline that you're looking at here. And yes, that would be quite common in af, but you can also get AF wear but like this one here where it's a somewhat flat um, baseline and you just can't see the P waves. So you've all of you have put in the chat already, the ones I was after, which is really good. So this is fast. Af And we can see that I've calculated that the heart rate's 100 and 32. And the easy way of doing that in AF is just counting all the uh beats on the ba on the lead strip and timing it by six. And that's a much more, a much better way of doing that than what you might be used to, which is using the RR interval. And the obvious reason for that is because the RR interval is irregular. Um I hope that makes sense to everyone. The rhythm is irregularly irregular and that sometimes can confuse people exactly what that means. So obviously, you've got irregular. So there's three main types of rhythm, really. There's irregular rhythm, which is just a normal heartbeat. There's irregularly irregular rhythm, which is where they um E CG is abnormal, but there's a repeating pattern to it. So that might be something like a heart block or something like that or some certain types of heart block. And then there's this irregularly irregular where there's no pattern to it. It's all over the place. OK. So that's that confused me for a bit, one point N A QR s complex that's already been pointed out by, you pointed that out samia well done and absent P waves good. So this is an issue with the atria. So the QR S complex is normal, let's keep going. So, aortic stenosis we've already talked about briefly. What have I got on here. Uh the signs. So, aortic stenosis, what are the signs that you might see? So you might, they might have had syncope. So they might have collapse, lost consciousness. And that's just because their cardio cult, but it's got um so far reduced that they aren't able to perfuse their brain enough. You guys will do about falls history, I think next year. But what's really important in a falls or syncope history is asking what happened before the fall or the loss of consciousness, what happened during and what happened after? And if, if there's a cardiac cause they'll often be a sign of what happened before. So they got breathless or they had some chest pain or if they had an arrhythmia, maybe they felt palpitations or something along those lines. So some key signs of aortic stenosis is obviously they'll have a murmur and then these two things slow rising pulse, a narrow. Um Why can't they call it irregular then? Yeah, I don't know. He'd like to break it up. Yeah, she had a great answer. Ok. So you're all learning from each other. Um, slow rising pulse and narrow pulse pressure. Again, that's from this low cardiac output. The main thing to think about is, is breathlessness, chest pain. Have they just had a fall? Ok. Let's keep moving. There's a lot on here and to know the sort of ins and outs of er, different management of a dyno, I guess you'll involve the patient as well. But if it's symptomatic, you'll often replace the valve. And then if it's asymptomatic and it doesn't seem to be sort of a big, big issue with left, left ventricular systolic dysfunction, then you'll probably not be replacing the valve. But this would all be determined by a cardiologist, I guess valve replacement is the management for tic stenosis. That's the, the takeaway from that. Ok. So we've gone through a lot of different causes of breathlessness, cardiac causes when you're doing a shortness of breath history. Taking. Always try and use, well, don't always, you might decide to use Socrates to sort of investigate a symptom. So, not all of them are always relevant, but you can think like onset. When did it start? Is there anything that makes it worse? Is there anything that makes it better? How bad is it, uh, is it bad all the time? Uh, you know, if someone's had breathlessness for the last 10 minutes, which isn't that severe? That's quite different from someone who's had a year of breathlessness getting steadily worse. And now they can't walk up the stairs. They're really different causes between those two things. Ok. So, so see what you can use to break down the symptom and when they give you something, just latch onto it and think about how you can find out more about it and then go back to the bigger picture. So, examples of questions for sort of a chest for cardiac causes. Chest pain is an important thing to ask about. Then we've got dizziness, lightheaded and palpitations. Then we've got to wake up at night or wake up at night breathless or need pillows to sleep and then asking about sort of IV drug use, fever, night sweats. So we've gone over those four below. I've just written some things. So swelling in legs or an ankles, especially after they've had sort of recent travel that might make you think about pe is there an infective cause? And then this wheezing and coughing? Have they got asthma or co PD? So just don't forget, obviously, breathlessness is a problem likely to do with your lungs, isn't it? So don't get locked in on one thing, but these four things at the top are quite relevant for cardiac causes. So there's definitely something to think about, right? Have you guys don't own any drug counseling stations or been told about how to do explaining information? Uh I wouldn't, uh Nope, she says, ok, while you're in the right place. Um So for all information sharing stations, there's sort of two me, I mean, I've written up three members to it here. What's really, really important. Um What's really, really important is that you get up to speed with them before you start sharing information. So you need to ask what's brought them in today and just take a short history of them to get an idea. Um, Oh, you, oh, you're not Manche students. Ok. So you, I'm sorry for all this, er, talk, which is reference to the Manchester course. Um, so first thing you need to do is find out things about the patient. So, because we haven't met before, could you tell me what's brought you in today and take a short medical history? Obviously in an information sharing station, you've a large portion of your time will be spent telling them things, but you need to find out about them. And if you don't do it, that's often enough to actually fail you. So you need to know, you need to have done that. Then it's really useful to actually find out what they know about. I think they're gonna tell them cos some people will know quite a bit, some people will know nothing. Some people will have wrong ideas and then what they want to know what's important to them. And that's this classic ideas, concerns and expectations. Um And yeah, so there are concerns and then finally, after you've done all that, you can get to tell them about the medication or the condition or whatever it is. So headline is, don't just start with the information to find out about them first and then key things for your drug counsel sensation, which I think you're gonna have a chance to have a go at next. Um Explain how the drug works and how it relates to them. So we've got a couple of examples. I'll go through in a second, then you need to tell them how to take it. Is it gonna be long or short term and necessary monitoring? Um And I've written B NF just Cos in Manchester, you get to use the B NF for that, but I'm not sure about other medical schools. They important is side effects and safety netting. And then uh you just think about other things that they can do. So, are there any lifestyle changes or um things that they need to keep up to speed with which they can, which they can do? Right. So let's do two examples, a quick prescribing and then you'll get a chance to do all this yourself. So Warfarin um used to be a really common oy station, I think because um it interacts with things. So it's, it used to be really good. Obviously, it's not actually used that much now. Um because it's been replaced by these doac or NOAC things like Apixaban river Lan. So it might be a bit less likely to come up with, but it's still a good example. So first thing was explain, uh it can be really easy, especially if you know a little bit about these medications to get bogged down and uh details, you know, suddenly you're explaining how the extrinsic pathway works and all these factors. This is not that helpful to the patient. So you need to know it's an anticoagulant or it's a blood thinner, most people say, and it makes them less likely to form a dangerous clot. And the, and you're more susceptible to this because of xo, whatever reason it is they've got a prosthetic heart valve or they've got af, or whatever it is and you'll know that because you've taken a history of them before you've done it. Maybe a brief thing. So, it's a Vitamin K antagonist and Vitamin K is important in producing substances involved in clot formation. Mhm. Yeah. And that's probably as far as I go with that, then you give them the information. So this is the tablet, they take it at the same time each day and they'll want to know a timeline. I'm not gonna be taking this for a week. I'm gonna be taking this for the rest of my life or for years. Right. So it gives them an idea of what's going on. Obviously Warfarin needs monitoring and they'll need to know about that. So initially this will be every one or two days. But when they're stabilized on the drug that'll be reduced every 12 weeks and they can write these down in an I NR book which they'll be given. So other things they can do and sometimes it's quite good to do side effects first. So I'll go over side effects first. So obviously, the main side effect from Warfarin is the whole job of warfarin is they've got an increased bleeding risk. So that can be something quite inconsequential like a nosebleed or bruising. But it can also be something much more serious like a bleed in, bleed in the brain or in the bowels, ok. So that can be quite disconcerting after you say that. And then you can sweeten the deal at the end by saying, however, you can help and this is what you can do by taking the tablet regularly at the same time each day, coming to the monitoring. And then these other extra things I've written here, obviously things with Vitamin K and might disrupt the effects of warfarin. So big diet changes involving sort of broccoli or kale or spinach or whatever um might interact with their io. And then there's this classic thing about avoiding cranberry juice, which er, I don't know, this is what everyone says. So I guess they avoid cranberry juice and warning doctors and dentists. Yeah. Hopefully the doctors and dentists are looking for this themselves. But what hurt? Ok, let's do one more example, Ramipril. So this is information that you'll be given after you found out all about their history and about what they do know and don't know and what they're worried about. So it's a class of drug called an ace inhibitor. It reduces your BP by relaxing your blood vessels and increasing the excretion of salt and water into urine. Or whe a classic osk situation is that the patient will say Well, that's very good. But I don't mind having this high BP, I feel completely fine. And so that's why it's important that you explain what's wrong with having high BP. So yes, you can't feel it. But the issue is if you have high BP over a long period of time, that can lead to organ damage and once that's happened, it's quite difficult to do anything about it. And so we do this management now to prevent that happening in the first place. OK. So then some more specific things for in information. So for Ramipril, this is a dose that you were given quite a small dose initially and it's titrated upwards. And during that time, you have blood tests to check for your kidney function and also to check the salts in your blood. So I say salts in your blood when I'm talking about things like sodium and potassium or whatever, just because sometimes you can get penalized if you're said to be using jargon as it's called. So just to be on the safe side, you can say salts in the blood. Um and then the monitoring's reduced once you're stable. So every three or six months, other things you can do is the classic stuff. So if it's for hypertension, it's gonna be things like start exercising, stop smoking, don't drink as much reduce stress, uh lose weight. There's quite a common, I don't know if it is that common but one of the main sort of talks about side effects with Ramipril is that some people get this dry cough. And that's a common reason that the medication's actually changed to something similar. Um, there's this rare but quite dangerous side effect angioedema where you get swelling the tongue, I think. Yeah. And your airway closes so the dry cough they can speak to their GP about and the GP will change it if they're having difficulty breathing, that's obviously straight to A&E and then just an awareness that it might interact with some other medications. But again, if they're given medications by a doctor, they should be checking that. Really? Ok. So we've got a prescribing test to do. We're on 745. If people wanna have a go at this and put what they get in the chat, we can do that. And if, and then I think you can have a go at using what we've talked about to, uh, do some practice scenarios. So you can use the B NF A 53 year old white man has repeated BP readings of 100 and 64. Over 90 the GP decides to start on medication to manage his hypertension. What like an appropriate hypertensive be and at what dose we'll see if anyone can come up with an answer. Does anyone know the, uh, step up treatment for hypertension? So, I guess it takes actually quite a while if you need to go on the B NF and find it. So that's fair enough. But also if people want me to just skip forwards and we can get you into breakout rooms to have a go, that's also fine. This is at the end now, 5%. What do my co moderators think? Yeah. Yes. The ace inhibitor. Ok. We've got an answer initially. Ramipril 1.25 to 2.5 up to 10 mg. Fantastic. Ami rescues us again. Very good. So that's what I've got here. So usually in a prescribing task, you, you have to give the medication, the dose, the frequency and the route are the main things. So if you're, if you're doing an initial prescribing task, yeah, exactly. You'll pick a dose between those two and your uh titrate it up. Good work. Does anyone have any ideas what you add on after Ramipril don't necessarily need to uh go online to find this if you know it and then we'll split up. That's the treatment. 75% doesn't even list any of the meds. OK. So you're looking on the B NF for the treatment? Summaries? Well, that's good. Um Definitely a good technique you've got there, but unfortunately, it won't always work, I think for some of the ones like the main things, it might be worth just memorizing. So, Amira says calcium channel blocker. Yeah, that's definitely a good option. OK, let's get through this. So you can have a go at your stations. Yep. So we have this calcium channel blocker. Exactly. Um, but there's other options. Let's have a look. This is the classic pathway. So it's the ace inhibitor called the calcium channel blocker. And that's dependent on their age where they've got type two diabetes and also whether and also their race, then you add the two together and then you can also consider thiazide diuretics. So you get some choice in step two and then step three is all three of them together and puffed up. You need to see someone who knows more about hypertension. OK. Good work. I think that's it. So now you can split up. I think uh I think I tell you how to split up. I'm sorry, I've never done this before. So I will maybe wait for sio to tell me hello. Yeah, hi, thanks Ben. Um So yeah, so please everyone fill in the feedback form and please do stay for the Os. So at the moment we have, so you see the breakout rooms um in the breakout sessions, bit of, of the event. So currently Isaac and Zona and Sarah are in the meeting. So if you wanna head to those, um and if you want these slides, once you fill in the feedback form, um you'll then be sent the slides or you'll be given access to the slide, the slide. So please to fill in the feedback um at the, at the moment currently Fez's not here um for the breakout rooms and I thought I saw I can't see her anymore. So only Isaac Sarah and Zona at the moment. Um If the other people turn up then um I'll switch you guys around. Thanks. Good luck with the ask you, sir. Cool. So you guys, I think, do you need telling? Should I tell you which breaks to go in that might make it more easy? Um OK. Hang on. All right, let's just do this. Who have we got as the moderators? Uh Shivani? Do I tell them? Um So yeah, you can either tell them or it does get quite confusing cos then people leave and then new people join. Um So what we could do is once everyone leaves the main um session, we can just have a check of the breakout room, see if there's equal numbers and then we can just move people around. Ok? So just go on your own, whatever name you like to look of, go and join and then we'll mix it up. Ok? Cool. Well, thank you very much guys for contributing and I'm I'm done now. Cool. Thanks. Bye, thanks. So yeah, so if the rest of you um want to join the breakout rooms, um just join any of them for now, I'll then be um sort of in and out to make sure that does the there's a right amount of people in each room and not too many of you guys, you guys, are you still waiting to join the room? I don't know if you, I'm quite new to this. Ok. Ok. Ok.