1:20 oops okay uh hi sir Hi how are you I'm good what about you sir fine thank you and how is that Kerala is having such a such provincial Reign that most a good part of the stage is underwater now to run children till today we didn't have the rain in the past days but today we have a heavy rain so Kerala is experiencing an exceptionally heavy rain torrential rain continuously sure
2:10 our good evening experience we will have the we'll initiate the session uh today we will have some spotless and also some discussions about some basic things so we I need volunteers to answer the questions spotless will be mostly electrocardiogram and hemodynamic data and exit test we will also touch upon some of the basic things like absolute forces and how to define and how to what are the factors which influence the wall stress so we'll go to the
2:57 share the screen best okay can you see my screen is it visible to you yes sir oh so we'll start with the first session first season what do you mean by contractility and how do you measure contractility and how is contractility difference from force of contraction
3:44 any one of you can answer measurement is by DP by DT very good vpdp by D is the measurement of contractility Define contract is G what is your name what is you're from uh Medical College General Hospital okay what do you mean by uh can you define contractility the rate at which the force buildups in The myocardium no no that is
4:33 DT so what is meant by contractility and how is it different from Force to contraction okay anybody who would like to Define contractility that's not a problem because effectively something which uh you must know this is a basic thing and anybody eats
5:32 contractility is defined as the intrinsic property of The myocardium to contract independent of the loading conditions that's the most important thing loading conditions can always influence the course of contraction of the migraines preload if there is an increase in preload according to the starlings law the force of conduction can increase if there is an absolute reduction the uh the marketing can perform better and empty its condensed lecture the contractility is something which is the intrinsic property of The myocardium to contract independent of the loading conditions
6:18 and it is the anatropic agents are the ones which increase the contractility and the contractility is measured by DP or DT what is afternoon this is a much similar question what is absolute [Music] what is meant by optional anybody who would like to address this question what is meant by afterload there must be
7:30 okay what is meant by afterload afterload is a resistance against which The ventricle pumps the blood so every in the electronical it starts with [Music] just a minute foreign
8:29 or flow region so if there is an outflow obstruction that will add to the option node then there is a vascular resistance the the the the the complaints of the blood vessel or the resistance offered by the blood vessels the resistance offered by the the blood the viscosity of the blood all contribute to the absolute so absolute is the resistance against which the left ventricle or the right one the ventricles from the blood and what is the importance what do you mean by afterload mismatch
9:15 any one of you and what is the importance of this afterload mismatch Ranjit would you like to try we need it is seen in iotic stenosis yeah this is not the only condition where you can have this [Music] suppose you should Define what is the afterload mismatch [Music]
10:03 anyone of you would like to try what is the what is meant by an absolute dispatch then there is an increase in afterload what will happen to the left hypertrophy concentrating yes it can hypertrophy one very good there is a common significance when does this what is the relevance of upload mismatch and there is an afternoon mismatch significant upload with Splash there will be fails to pump the adequate
10:48 quantity of blood it can lead to heart failure very important example then becomes more clear for you offload mismatch is the inability of The ventricle functioning at a stable level of enotropic stage to maintain normal slope volume against the alternative flow this is Sudden Change in if there is a sudden change in the afternoon whenever you may find it difficult to pump the blood and it may not be able to form adequate quantity of blood that is what is meant by afterward mismatch after mismatch is the inability of the wonderful functioning at a stable level of inotropic state to maintain normal stroke volume against the alternate absolute best example of an afterward mispatch is
11:35 an acute systolic loading of The ventricle in acute hypertension if there is an acute rise in the blood pressure there can be a afterward mismatch the left ventricle will develop pump failure without myocardial dysfunction most important thing is that all the parameters of magnetic function the conductivity the every parameter of the paragraph function is still maintained but only thing which has changed is actually an absolute foreign state to maintain normal stroke volume against the altered absolute example
12:22 acute systemic loading of The ventricle in acute hypertension can lead to LV from failure without myocardial dysfunction another important situation where can anybody mention another important situation where there can be an afternoon mismatch problems in a patient with the micro legal depression when they undergo micro replacement holding material replacement can be a sudden absolute describes why it is so in one of you in a patient with microorganization after a while replacement the patient can suddenly go inform after all this fight
13:08 in a patient with a micro regurgitation LV was decompressing through the mitral valve once the MBR is done then always unable to decompress via the material value just to pump against the pump through the iotic valve only so there is a sudden increase in the afterload absolutely so in a position with microbrew regurgitation uh when the patient is having deletion the LV is able to pump blood into the electron between elasticium which is a low pressure Zone and uh onto the diode also so the LV was working against a very low after Loop but when the microbial valve is replaced you have the microwave reservation is over and the LDS or the
13:56 whole quantity of blood into the Iota which is a high pressure zone so there will be an acute rise in the afternoon and some of this if there is a the LV is not able to sustain good cardiac output then we call it an absolute respect sometimes patients with the iotic stenosis especially patients with aortic stenosis with a small iotic analysts when they undergo well replacement there can be an afterward miscarriage that is because these patients can have a heterogenic iotic stenosis because of the the the Michael iot guidelines is narrow small hence the the prosthetic valve itself behaves like a stenotic valve and some
14:42 of these patients can be the stenosis can be the the gradient can be so significant there is something known as absolute mismatch so in patients with diotic stenosis especially with their small iotic analysts when they undergo wire replacement that can result in a softened so these are the few situations where there again be an afterload respect out of it the most frequent situation where we come across an absorbent species acute rise in the systemic blood pressure resulting in acute leftover failure after mismatch occurs when the preload Reserve is unable to compensate what usually happens when there is an increase in the afternoon is that there is an increase in the preload because initially there is a reduced stock volume when there is a reduced stock
15:28 volume that will result in uh increase in the and systolic pressure that can result in this is in the end diastolic so when there is an increase in the industrial equation that will compensate because the increase in the industrial impression that is the preload will increase the force of contraction of The myocardium and that will compensate for the absolute increase so in this now through absolute increase there is increase in the payload and that will result in the increase in the postal contraction mechanism will not be able to function properly or it may not be enough to compensate the acute rise in the afterload and the patient goes in for an
16:13 afternoon dispatch you must definitely know the term one afterward misplaced and what is meant by afterload message we'll go to another important basic uh thing in cardiology that is about the world stress what is monsters what are the factors which can modify monsters anybody what is watch this and what are the factors which can modify voltages these are all in related after lower stress all these are Under related and also you should know what are the factors which uh what is by the wall stress uh cavity and the thickness of the cavity cavity of the chamber diameter of the chamber the radius rather radius
17:00 of the children and thickness of the chamber um and one more point and absolute yes absolutely absolute the radius of the uh LV which is the the [Music] chamber in in involved in Monsters and third is the thickness of the myocardial so and how how does this uh Define monsters what is monsters questions in one of you again you would Define what's this what's this it is the load
17:46 on per unit of myocardium during system it is a reverses you should understand is defined as the load on per unit the migration during system s is modified by afterload LV chamber radius and the heart muscle thickness applying the laplex replies equation what does this equal to the absolute in the radius divided by the thickness so we have to load as well as the radius increases the horses while the thickness which reduces the volts versus
18:32 so the thickening of The myocardium in a patient with an increased substitute is a common symptomatic cancer so in a patient systemic hypertension or a patient with pulmonary iotic stenosis there will be LG hypertrophy which is a common certification it helps to bring down the worst you know anomalies is the monsters if the patient continuous layer wants us graduates The myocardium in pain and they may not be able to perform properly so the hypertrophy is a common symptom again normalizes the horses is the load on per unit of myocardium during system what's this is modified by afterload LV chamber radius and hard muscle thickness
19:18 applying the laptop equation forces is proportional to the absolute and radius and inversely proportional to the thickness of the myocardial okay now we'll go to an electrocardiogram and any volunteers to discuss the electrocardiogram there should be volunteers to discuss electrocardiograms oops anybody can try you
20:16 show sufficient enormous sense to them well this will display the previous what is the axis any abnormality in the QRS complex I'm surprised that the Pioneer DM students are not able to analyze this this is a very simple City very good um
21:12 okay so there's electricity logically the right hypertrophic when this combination comes why did you diagnose leftover enlargement in this patient uh the terminal portion of the P wave is more than one millimeter in depth in V1 okay not one millimeter depth is not enough actually what is the definition of a reptile or left side overload or left side will enlargement in the previous in V1 more than 0.04 millimeter second so 0.003 more than 0.003 Milli volts seconds not millimeter millivolts
22:05 should be more than 0.003 millivolt seconds so if it is equal to one small square then you can take it as you know here it is more than one small square so I agree with you then selected the enlargement or left right in over room okay then what else why did you diagnose are we it uh the amplitude of R waving V1 is 10 millimeter yes there is a QR pattern in V1 with the small q with this Ro pattern there is no S Wave at all that that's okay and R by S is the criteria applied for diagnosing iconic micro trophy yes what is this patient having do you want to
22:51 modify the rvh I would like to say that garbage would strain with the STD changes oh yes it's three so what does that mean suppress systemic arbitration yes super system always with the especially QR patent with the uh with the STD changes suggest you know strain pattern then you have to consider that the patient may be having Supra systemic permanent artificial so what is the condition which you can get this combination of electrical enlargement with the right hypertrophic what is the condition clinical condition
23:37 where this combination is possible that is a very simple question you know you must be seeing plenty of such cases this combination of the title enlargement with right molecular hypertrophy I am surprised foreign
24:34 okay this is slightly more difficult Electro cardigram this is for any volunteers to discuss I will help you this is a monitoring lead for a rhythm strip is showing uh ATL rate of 74 beats per minute okay uh with the ventricular rate of 80 bits per minute uh with uh with the intermittent
25:21 conduction of atrial to ventricular uh conduction okay so so it will really surround 74.75 and when the rate is around 80 81. yes so um what is the problem abnormality in impulse formation or abnormality numbers conduction normality in impulse when the lower rate is more than the uh upper rate the rate of the atrium is less than is less than that of the low vertical rate then you consider it as an abnormal
26:08 in impulse formation if there is more than the ventricular weight there is an abnormality numbers less than the ventricular rate indicating that this is an abnormality formation now what is there is capturing the ventricular activities capturing the multiple activity so what is this Arrangement what is the rate is only around not a very fast rate the rate is only around 882 so a junctional ectopic activity
26:57 rhythm with intermittent but it is a basic Junction rhythm with a sinus capture a junctional rate is 80 82 is it the normal Junction of it or is it a faster rate Junction tachycardia yes but but the rate is only 80 for us to politicize very often we expect the rate to be more than 100 so what what time can you give
27:44 the rate is more than the standard rate of the junction but at the same time we cannot qualify it as tachycardia what can be the term that you can apply that's accelerated junctional very good actually the junction accelerated Junction Rhythm so it's a intermittent so usually they accelerated uh Junction to them will have a rate of around less than 100 usually between 60 to 100. and this can happen associated with the pathology in the heart where the junction is stimulated and it starts firing at a faster rate it is accelerated Junction rhythm with
28:32 intermittent sinus capture of this kind it's an extremely rare ECG okay this is similar any more ideas look at the electrocardiogram well then once you have got some ID you can start talking sinus rhythm sinusism very good PR of cannot actually call it sinus to them actually because the pr is 240 to 280 milliseconds yeah it is how many
29:18 divisions six seven wow seven or seven or seven in the house so almost uh 300 million uh 150 milliseconds this is okay yes rsr pattern with QRS duration of one foreign [Music]
30:46 few hours duration so out of this uh four conditions that you described what is the cause of the broadening of The Gorgeous complex in this patient bottle transplant right which one right bundle left Monday right so this question is axis there are uh plus 1 20 degrees It's A Plus or is it minus all the limits are almost isoelectrics area also is positive yeah
31:38 area feels possible so for put together I would I have I would start thinking that if the axis more towards the right than or to the left right Axis so that's why the axis deviation axis may be around 120 or 120 150 120 would be more correct your business has got an QRS axis of 120 together what is your diagnosis why the patient is having right Axis deviation left okay it's very good what is your name what is your name
32:26 is a second year very good okay what is this we're going to see from one end to other end what is the selection what is the selection so 2 is to an AV conduction sir what did you say 2 is 20 every conduction because uh if we see at one two three four five five uh fifth Beats from fifth beat
33:11 onwards that at the end of T wave 2p 1p wave was there and again next bit also at the end of table one p and next bit also again at the end of tv1p they are mostly right you can see two periods one is a this is a period and you can see let me see so this is the preview and this here is another preview here is a preview here is another view but this is a preview here is another preview but you are you are a statement that is two is one conduction may not be always correct because what is happening this P this PRN is becoming shorter and
33:57 shorter and it has gone through it yeah yes yes yes so what do you what do you think it is Association you can have only one preview here it is so can this be completely probably sir how many diagonals PP interval should be equal and uh RR interval should be equal very good and uh AV dissociation should be there very good PRN women should go on changing yes
34:44 will be V rate will be less than eight real rates or rather p p will be more than two hours public so you want the criteria satisfied if you look at the uh role that VPN driven and then look at all the so there's some AV dissociation because the PO is marching through the QRS complex and you just it has come out to the TV here you can see the period very well here is here and then what has happened I subsequently sinus conduction yeah there is a conduction it's a conductor beat this becomes a normally conducted bit and what is seen in the electrocardiogram what does it this is a lead tube showing
35:30 SD elevation elevation so what is the diagnosis relate to the inferior wall yes the business function transient companies are blocked with the uh with the the little rate is adequate because here the radius around we look at the rate here one two three four five okay now almost between 50 to 60 would be the heart rate so IDK with the uh for completion block and the patient quickly recommend the patient is having interior or myocardial infarction and when it's recovered even the first degree have block recovered business having a normal so during acute phase they can have a
36:15 different arrhythmias and they can even quickly recover especially inferior migrant function this every block can be even transition and they can do calorically okay what is this what is this electrocuting what does this electrocuting arm show this is a three-month-old baby foreign
37:03 [Music] plus 60 degrees okay um with uh foreign okay whenever you see this type of a large basic Reflections in the coordinates what is that phenomenon known as much to phenomenal what is the criteria for diagnosing bioentricular hypertrophy based on the cat's vegetable phenomenon like electrocardiogram more than 50 millimeter amplitude more than 45 more than 45 more than the weather the RLS
37:50 put together should be equal to or more than 25 here it is just short of that but the broad practical purposes we can take it as a catch faster phenomenon and what is the diagnosis question what is the solution that you are going to diagnose Wi-Fi you find when a cat that's why stress number non-restrictiviously non-restrictive yes usually it is a large VST that is that again you rise to cats are still phenomenon and uh in VST what is the type of environment what type of organic line normal is there a how is the value involved how is will be a
38:36 RV will be normal what will be the LV will be holding overloaded and RV will be whenever when the NV is pumping the blood into the RV and from there it is ejected into the permanent reaction even larger volume of blood is being formed into permacy the patients can develop Progressive permanently acid hypertension and that you understand foreign
39:35 [Music] so if you look at the uh environment of the RV and LVN NFA to a large VST it is the volume overloaded then we will be holding overloaded and Ro will be preserved all right and in large vsd also anonymously moderator in moderate VST also High moderate VST also you can get the same phenomenon when the VST is very small then there may not be any change at all because the volume of the blade cannot
40:22 be enough to produce neither the warning overload not the pressure overload secondary hypertension all right okay what is this uh uh SD going in lead one and uh whenever the system going in lead one but it's other lead you should quickly look for any kovi AVL savior so he will also show some degree I am unable to us yes
41:19 sir with the poor our progression yes not bro yeah poor heart progression there is actually um the event they almost curious and V3 before V5 V3 V3 and before there are Cubase so even practically over practical purposes we too also can be taken as a Qs pattern what else what happened what happens to here segment s we are segment depression yes you can see the clear segment depression suggest you to record ID so therefore the full diagnosis in this position would be a cube
42:05 and two normalized associated with I could say associated with it very good foreign
42:57 okay like this when you do a if you do a uh program what will be the battery uh info price and uh there won't be a single there won't be H wave in fraction there won't be a way of tracks oh no when the edge goes with it goes with data a h goes with a it is a inference in price here and if the H goes with V it is a Supremacy so that is how you die you
43:44 will differentiate if when when you look record the bundle of this electrogram if the multiplication goes with the atrial tracing that is inflation completion block and if the H the bundle of is tracing goes with the ventricular tracing then it is a surprise in complete heart block so after uh so here it is obvious because the patient is having a narrow purus complex and you can easily make out that this is a surprise right okay very good look at the electrocardiogram and
44:32 tell me your diagnosis broad complex tachy card yeah very good with AV dissociation are you able to make a previous [Music] population because you are not able to distinctly see peers there's a purpose is irregular and there's a broadcast complex so Krishna is having a racist population of
45:18 pre-existing lvb left foreign yes foreign
46:21 [Music] the religion and some other ways are really cool large ways so indicating that this could be a course foreign
47:11 right yes here it is at the junction because there's an Arabia response so you also found that patient is having a prominent UV what else there is a biphasic t in V3 this could be a partly formula part of it may be uh you will you remember prominent and will you say that UAV is abnormal if it's more than amplitude of T wave no it may not be more than laminated T what is the normal temperature of the what is the relationship of U wave to the T amplitude
47:59 less than one-fourth so less than one for the multiple more precise and correct 5 to 15 result the height of the U wave is equal to 5 to 15 percent the height of the TV abnormal foreign yes
48:45 but what is the condition which you can get the problem in a new way population any any chamber hypertrophy applied muscle hypertrophone in V4 R waves one two three four almost 25 23 Editions and what is the V even estimate
49:35 one two three yeah indicating that the business having yeah voltage criteria so uh what are the things that you can detect this patient is having it coming agent population and the LVH so what are the conclusions that you can conclude restrictive cardiomy restrictive cardiomyopathy okay it can be according type of a picture yes but usually the latest population in
50:22 cardiomyopathy is relational refined one fine because the lab will be damaged yeah usually this is a dilated cardiopathy usually will be a finiteal population what are the situations where you can get positive information Nuance at atrial fibrillation the large extent neurons than uh later on because over a period of time becomes fine but uh both set of formulation is mostly associated with valuations especially mitral regurgitation microsnosis valuations
51:25 what will be your diagnosis patient may be in heart heart failure and each Nissan diuretics so hypokalemia may be drug induced very good drug induced too users but as what may be the reason for this question is do you think that this can be detached toxicity yes yeah because this business population the patient might have been put on digital is and the person might have gone for digitalis substitute so full diagnosis will be most likely the prison is having said uh of course
52:14 and you promise you have what is indicating that prominent U.S indicator hypokalemia and the nbh May indicate station which is relation and accomplishment block is also due to digitalis feature is toxicity design effect so the full diagnosis will be the edges of relationships companies are gone LVS epigenemia probably is the list most likely there is digital is toxicity because we do not know the question is received is jealous but looking at the setup and the criteria you can diagnose Associated digital is toxicity okay very good next one
53:03 machine there are two gaps you should explain why there is again what is the reason for again S6 block yes word block sinus exit clock so it is not 760 no wrong
53:52 you can see two negative ways here one one is here no one is here what do you think that babies is it their previous if it is a topic to you what has happened here compensatory posts yeah there's a pause what has this speed have done block the AV induction hmm that's not block Theory conduction
54:43 they are block created ectopics this blocked this is a block data laptop it's a blockchain what do you mean by that uh there is an eight-elect topic which is quite early see you can see that it's very early this has been very really fine they will notice the fracturing that is not able to penetrate the event not because it is a factory because of the previous uh bit it is already in the stage of uh reflection refractive period and the inverse cannot be conducted through the Avenue so when the inverse is not being conducted through the heavy node then we call it as blocked Airtel ectopics but what can it do it can uh travel
55:29 upwards it can depolarize the atrium and also it can depolarize the sinusoid but otherwise this is resetting the sinus flow it resets the sandstone and that will still deny a widened interval between the amazing doing which employee encloses the blocks as electropics and there is a gap there's a gift and this is my block rate is ectopic traveled upwards when the sinus mode depolarized the sinus node and as the reset the senator and when the next
56:14 sense speed comes it comes with a delay so this is a blocked Edge Electronics to block data electronics are seen that is the result form this will prolonged R1 interval don't uh read it as a heavy block it is actually a block 80 electropic okay next one it's slightly more difficult strip is lower down you can see the two lead electrocardiogram and you can see that the rhythms reports
57:05 anyone in this block of morphology is alternating [Music] um is changing yes uh but it's tight so it's likely to be inference here yes it is now whenever you see a high grade AV block three or more the previous or drop then uh almost always is in don't go for anything else
57:50 why this song why it is so then if it is complete third block what will be the usual rate interesting companies not work right from 30 to 40. yes usually there are 40 20 to 40 what will be the rate in a uh in a surprise in community yeah 40 to 50. yeah the numbers is starting from the junction or admission on the Avenue and usually the rate will be 18 40 to 60. so pass the rate they will pass the rate so uh the AV node is the
58:38 second pacemaker that we have and whenever the sinus node is not able to control the ventricular weight and when the event spots below 60 The Junction May escape and you can capture them correct with the the activity of the heart so in a patient with a high grade block when the rage points below 40 maybe this is super recent type of companies are blocked the The Junction should escape and that you can result in a normal complex so uh Whenever there is a high grade level block which is quite prolonged and the rate is very slow then most likely it is a in price and type of a computer is envelope of course here it is not
59:26 difficulty because you can see that the QRS is Broad the refers in V1 indicate the right one is branch log so obviously you can easily diagnose that it is a inflation type of way I agree with high grade AV Pro what is the real how we explain this change in the morphology of the curse problems but for this vr's Commerce is going on changing I will give an explanation and what what is what how can there be a variation in the morphology of the QRS combination the limits ventricular escape from different workers
1:00:11 so it is not available so it is I will explain this but in the limb blade you are seeing a variation
1:01:00 well now there is a situation where the the chest leads indicate either I write one by block or a left one branch block or it shows a normal background but the morphology of the QRS complex is going on changing in Limitless you should see a thing of the possibility of alternating and your physical and positive physical block you know you see that the morphology of the QRS complex is going on changing in the limits but not changing in a on the chest list then you should think of the possibility of a particular block and here it is going on changing so you can think of the possibility of alternating left antibiscal block and left positive when this is going to
1:01:45 block that will be right a text deviation and when there's electricity remember posterior posterior Hemi block which will give rise to write the experience so here you can see that this patient is having right button Matchbox deviation indicating right posterior physical block sorry left positive signal block and the patient is having a high gradation what will be the management temperature unlikely because this question is a foreign
1:02:39 very good okay we go to the exercise accuracy exercise [Music] adequate exposure uh very good properly positioned yes yes around 65 to 70 percent day yes on visual assessment you don't have to say 65 70 notice yes if you want you you can use the word mild moderate figure what do you think is a radical language is it the mild enlargement for severe a large argument
1:03:25 moderate moderate so my mild to moderate at the most maybe the what is the celebration may be around 60 near about 60 not a huge enlargement but uh definitely there is and every type of effects what is the salary type because the uh sorry because are we missed it should be lifted up and elements it should go below the diaphragm it should be it should be bending down both are not there so I may not make a comment that I may not commit to any particular form of the LV whether Envy is forming the effects or they are responding approx yes
1:04:11 the straightening of uh left heart border can you describe it what was the studies about onwards on the left part of the heart I have technical yeah very good sometimes in between just below the electric left sometimes a part of the army or flow can be seen sometimes especially in a in patients with a one condition where you can consequently see what are the conditions which you can get from an army also in our outro partitions rvms Remo
1:04:59 any other condition s and also you can get sometimes in AST also when there is very huge especially which is associated with mitral stenosis into the through the ASD into the right one between right it will be significantly over or only overloaded and that can result in 39. not only the body with r will be dilated but the output also can be dilated so sometimes you can get good position so the early outflow in the patient with AST and the army of four positions are felt in the third left in the whole space and it's in the exercise just it can be seen just below the area of the drive of the uh electrical
1:05:46 appendage here what is this so structure that you see are one is what is the structure this is the Iota and what is the structure what are the conditions in which you can get prominent permanent segment ation hypertension purpose yes
1:06:47 [Music] or is it a combination it can be a combination R is also enlarged so R is also enlarged our enlargeable indicates that patient may be having an Associated vegetation or a large volume of blood coming so difficulties can result in right here you can give us what I didn't know you can give us
1:07:33 so two reasons for writing enlargement are one flow of blood coming the radiation and two the blood regurgitating from the right one okay yes and this is enlargement [Music] straightening of left hand border Carina cannot be visualized properly you should not describe you should describe whether it was a performance on the the outing nothing promises
1:08:19 don't describe a staining and or that's not correct let's say there's only a we should impression but that is not communicate with example so whether you know the importance of the left border of the heart after the heart the structures okay so here the problematic segment is prominent and how will you make out whether what is the cause of this problem and proper segment so when you make it whether there's an increase in the formula blood flow I will make out whether this evidence of diabetes peripheral pruning yeah
1:09:12 very large but as you go to periphery there is a seven cut off that's a suggestive formula material images anything else which can help you today is hypertension dilated uh Branch pulmonary arteries will be dilated [Music] foreign
1:10:29 ah very prevalented also showing a lot of broncovaska markings yes if the vessels are actually can be easily tracked to the periphery of the uh of the lung field uh that usually indicates in this in the permanently yes five or more endone vessels yes put together that goes into Europe foreign
1:11:34 [Music] then Central missile here so if this mission is having enough and not muscles or what do you mean by Enron muscles what is an unknown vessel vessels and face the projection of a vessel in Phase yes the the vessels are directed towards the as you take the X-ray the results are directly towards the X-ray beam or away from the equilibrium that will qualifies for unborn business and when they're in Android message it will be seen as grounded uh more prominent Shadows compared to the surrounding structures such as table and non vessels this business here
1:12:33 coffee edema around the bronchus yes there can be reading around [Music] um the Bronco arterial ratio increasing yeah okay so that ratio is altered you can think of organic plethora so the permanent plethora is diagnosed by one tenderness is more than five both
1:13:19 sides together two uh one one side only more than three three the endonosis can be traced the vessels can be traced to be free and four there is a enlargement of the main pulmonary arteries left and the right one we have certainly enlarged so these are the features of you diagnose the volume of muscles and don't know this is not the characteristic feature of increasing the pulmonary plethora so is this patient has problems yes yes it is a left direction or the atrial level or whether it is
1:14:12 but which level so it is ASD VST PDF how will you differentiate between astbhd and PDA in ASD what is the chamber which can be dilated which will not be dilated in VST and PDF all right all right but it will not be allowed in bsco PDF what will be the structure which can be enlarged in PDA but not involved in other positions foreign [Applause]
1:15:13 somebody else can try access will be kept in the examination you should be you should be able to diagnose of any difficulty is there a classical exercise so you should not have any problems in one of you just text Behavior will expose an adequately Center centralized okay I will accept there it is properly
1:16:00 exposed yes card exercise appears normal yes what is this is normal the right ATM is not enlarged yeah normal the left main pulmonary artery is foreign foreign
1:16:56 uh our reason why did you say sorry it's more like LV sir yeah you look at the ankle here you look at the angle between the cutting scissors and the uh the the diaphragm in a patient with uh of course left everything cannot come here sometimes you can come here in a business is actually enlargeable it is a diagonal between the heart and the secretary the the I'm going to be doing the uh the heart and the diaphragm you look at the angle and the angle will be obtuse angle in a
1:17:43 patient uh where the electron and if there's a bacterial knowledgement you can see the the angle between the vector frame and the the diaphragm will be an acute angle similarly on this side if the angle between the uh the cutic select and the the diaphragm is circuit angle that will be more in favor of a right ventricle and if the angle is brought is obtuse angle or angle is around 90 degrees that will be more in favor of a left ventricular configuration and another is if the Apex is dipping down then you can be pretty certain that it is a electronic reflex and if the Apex is lifted up really lifted up that's definitely the right type of electrics
1:18:28 so these are the points by which you can say right on different type electronical type and right there is the array is not dilated foreign the width should if it's more than one third of the Hemi thorax if you measure from the from the mid uh from the midline onto the onto the emitter X if the the right one of the heart extends beyond the one third of the hematology there is very good yes if the height occupies more than three ribs and more than two intervals the space yes
1:19:14 or more than two and a half in the cost pieces that also goes into Arrow okay yes cannot be commented because right okay large but maybe slightly unless not very easy roster but what do you find this what is this which are prominent
1:20:18 is turned up okay so that indicates formative inside what are the features of pulmonary venous hypertension indexist is very good facial efficient no that is sometimes you can get this mostly it is a picture of a right heart failure what are the X-ray evidences of pulmonary venous congestion just said two for example versus prominent to clearly be like three
1:21:11 three four seconds sometimes there can be some Industries in edema it can give us the ground glass appearance of the landscape and finally Frank foreign can you see some lines here yes sir there are some curly be lines yes very good and you can see a very bronchial coughing how did I get a spiritual coffee there will be a dark sunrise
1:22:02 white shadow so here you can see very well scene here can you see here yes sir there's an area of pretty bronchial cupping there is an area coming here there is a small area here it's small that's not good so one two four three areas where there is you can make out the very wrong is perfect so very wrong in cupping also suggests hypertension so the extra evidence is hypertension are one a couple of acids are prominent especially permanently waves two the curly B lines are not so important but it is [Music]
1:22:49 so in this patient Apollo versus this area is definitely much more uh opaque compared to the lower area so there can be some degree of phenomous appearance in the midsole foreign
1:23:42 [Music] stenosis what is this yeah in one of you
1:24:30 foreign type of Apex and uh with normal uh iotic knuckle and left iotic Arts what is your criteria when will you say that what is the criteria
1:25:25 you should look at the transverse forces of the so here this is the transistors here you can see the transformation somewhere here so yeah it definitely is beyond the transition of the vertebra so this can be considered as The prominent yeah okay what else what about the permanent segment uh MPA looks dilated yes MB is dilated very good
1:26:15 is very good and with tlv type of capex and uh CT ratio is uh approximately uh 0.5 yeah it is by visual assessment is about 0.5 very good and right side uh uh Branch pair uh looks absent um right there is you can see the large permanent segment here so okay that is creation rights is some main formula formulative branch on the right side is hugely diligent but there is a variable control here but when you try to attract terribly everything is cut off
1:27:01 but I agree with you that there is some relative or reduced value let's flow onto the yes you have the large vessel here what does it indicate Branch PhD analysis okay you can consider that this is why why do you want to say Branch knows you can say that this is a this indicates a huge permanent pulmonary artery anything else what is this what is this classification
1:27:48 where is the calcification no it's not the main problem we can see two parallel specifications foreign so what is a full diagnosis Patron ductus arteriosis business
1:28:35 developed severe permanently hypertension and calcified so you can see calcified duct is here prominent Pharma Iota you can see large pulmonary here and if you think consider that there is no or you cannot see permanent in the left Omega artery anything else which crosses your mind if there's a peripheral stenosis of the variable obstruction or peripheral Branch stenosis of the left side vessels um then syndromes Global are very good actually globalism
1:29:22 when you are thinking of the business having a PDA and on top of that there is a uh right uh peripheral permanently stenosis then you can put two together and think of the possibility of a rubella syndrome of course this patient is not a rubella syndrome but I think you should always concern that possibility especially when you think that there is some reason to believe that permanent artery on the left side is not prominent and this can be one synonym so it's a case of PDA calcified PDA and you can see that as evidence of permanent repetition this Mission had actually born in for uh Asian manga syndrome that is
1:30:13 calcification [Music] maybe notice a small area why should they have such extensive classification yes what did you say [Music] so how is the effects in this patients upwards actually you can see that the
1:31:00 from the affection fluid so it is the diaphragm at an acute angle suggest you exercise yes so this is a foreign [Applause]
1:32:16 that's not to go with the okay uh daughter announcements kpbc no wrong so whenever the conditions substance thank you yeah what I think a few one month less than a month and uh usually there will be a diaphragm as well be here and time has disappears by the age of
1:33:11 usually indicates a very serious uh Indian heart disease and the Commerce condition where there can be a nanoparticle and also the absent diagnosis translation yes this person is having when done vessels you can see and don't message you can think of the possible deal foreign
1:34:22 and this type of classification and electron decline happen in patients with aneurysm posting functions so this is a case of the patient that and then another classified and also the left so this is a classification involving the death issue and that this is not functional okay yes okay analyze the calc data anyone in this to analyze the calculation foreign
1:35:11 [Music] seven five five minutes [Music]
1:35:58 different is it single sample or multiple sample single single sample no it's multiple sample 75 Pi is multiple sample single sample is 10 to 11 9 6 11 and 7.5 or more seven or more and uh it's by itself so the step up again we can say in the form whether it is single sample uh how much sir I will repeat again uh single sample uh level 10 level seven level five
1:36:44 repeat if the uh if the Step Up is more than 10 on the atrial side more than seven in the medical side and more than five in the article level single sample single when this multiple samples it can be seven or eight Realm Pi ventricular 5 God so it is 755 multiple samples ten seven by four single sample okay so clear okay thank you sir yes you know operation data somebody should analyze but somebody had started normally the pressure is high
1:37:29 um where is the sun is there a sand here not sure oh what is the mixing options can uh shanties at the level of uh high right atrium to Mid right atrium yeah that's actually what is the mixed human assemble in this mission so whether we should take the highest PC or low SPC for mixed Venus and now you take it Midway within you take it 67. okay
1:38:22 four into 360. so difference is four four six divided by 60 is one one so you add one to the uh to the SVC so six seven plus one eight so take it is 68 68 would be the mixed mean of salt in saturation from there what happened to a mid right atrium then foreign
1:39:29 seriously actually the person due to the some reason it was not recorded because the the reluctable oxygen saturation is there okay I guess professional data you tell me the official data right right when the cross historic pressure is elevated the acceleration is normal very good uh both systolic and diastolic pressures uh slightly high no the 30 can be taken as separately to normal yes
1:40:18 is it a gradient across the um what does that mean maybe infundibular stenosis or pulmonary stenosis okay well you're gonna be you will be better between the Diplomatic whether there is a gradient across the Army outflow whether the gradient 15 gradient is it enough for you to diagnose obstruction No it should be more than 25 yeah usually the the gradient should be equal to or more than 20 20 you can take it as abnormal some people have found that in patients with the convention uh left to right hand sometimes the gradient across
1:41:04 the formula are three permanently is 30 to 40 millimeters and still there may not be any obstructions so next to the very good for multiple plus no a gradient of about 15 millimeters May indicate that it is because of the increase in the formula flow and by itself may not indicate a separate pulmonary or Army of obstruction okay go ahead oh 2p by q s is three two people because you tell me the formula Iota minus mixed minus divided by uh L A minus okay so mysterious is 68 or 67 68
1:41:50 or 68 and uh 98 so it's 40. so 30. 9 you know more than three main formula is 90 second and nine okay so 91 and 95 so it will be around almost more than three all right more than three okay very good excellent you did very well what is your name to change it oh I think you are very good I think you are answering most of the questions I think you have been trained event good excellent thank you somebody else can try this
1:42:39 male baby [Music] somebody else can play in his pulmonary artery saturation is less than uh Iota saturation so it's not a transposition then you're going in there okay like this yes then uh as we see IVC is 70 uh mid RS 71 uh lower ra 70 there is no step up or step down are we 71 72 70 so
1:43:26 no Step Up step uh that level pulmonary artery is 76. step up six so it's a elevated sermon it's Step Up is there very good yes then uh La is 94 lb 94 permanent uh aorta 94. so there is no the step up or step down there so there is a normal is a desaturation
1:44:11 what's the difference stepdad is because of a uh this saturated blood reaching a chamber where the oxygen saturation from the previous chamber to the present chamber is down for example if there is right left hand in a two from the left right one equal to the left this is and if the oxygen saturation is 98 or 99 and then the oxygen saturation in the right the left one level is 92 when we know that there's definitely that they say yes so here it is 94 94 94 there is no
1:44:56 step down whatever we can make out but the options address is definitely on the Lower Side Lower Side okay I guess so what is your diagnosis and pressure okay uh r a a is eight v is nine minus 7.5 okay uh pressure so there is uh
1:45:43 then PA is same uh systolic is same 60 60 in pH is 25 okay minus 40 it is uh so RV Pas are elevated okay yes uh L A is eating uh and 23 elevated okay Lu is 85 okay so there is again step LV is 85 service tally that's only 18. so this is a significant elevation of LV
1:46:28 pressure systems you can only up to go up to 10 or 11 11 10 hours it is going to 18 yes okay ah aorta is 90 by 50. so uh this is so you have to explain two things uh one I can pick up uh ventricular
1:47:17 okay what did you say you know did you say value perceptual effect yes did you say left 200 defect yes sorry sir yeah so how can it be when there's a wonderful there can be a box what are the conditions significant symptoms and there is oxygen desaturation the lectures GM based so I think you should consider possibility of
1:48:03 okay yes what is the reason that she's having this desaturation pulmonary edema yes the vision is failures the industrial column is a lot everything is elevated and so that may be the reason the patient may be having interstitial edema and that may be the reason that the patient is having a deoxygenated blood in the left atrium uh and most likely this is a small child and the patient is presented with the features of the severe significant heart
1:48:50 failure so I have to consider possibility of AP window with a torrential flow rather than PDA PD of course large media can have such a situation but I would prefer you to make a statement that in view of the early symptoms early per monthly congestion and any evidence of electrical failure with a significant elevation of the algae diagonal system they are more likely possibilities AP window rather than with inductance okay how will you calculate permanently permanent blood flow system with blood flow and permanent muscle resistance it would be like this
1:49:37 what is formula of the resistance how do you calculate what is formula QP into uh body surfacing one second once again once again okay yes go ahead resistance pressure by flow yeah which is Special by flow not pressure by flow pressure drop by flow okay so what is the formula for permanent Hospital Systems whatever what is the pressure drop pulmonary artery pressure mean permanently artery pressure minus minus pressure so here what is 40 minus 20 20. so it's 45 minus 10 this
1:50:24 is 20 millimeters [Music] foreign consumption divided by oxygen content into um arteriovenous oxygen difference yes so here tell me the formulas so VO2 upon hemoglobin into 0.6 foreign
1:51:40 consumption difference that will give you the permanent so here now what is the oxygen consumption 85 and what is arteries of significance you have to calculate but we are getting oximetry so approximately you have to convert energy oxygen content and oxygen utilizations how will you convert this into four oxygen content foreign into 1.34 carrying capacity 1.3 actually this one point three six three six one point
1:52:26 three four will give you exactly what is the oxygen getting capacity of the hemoglobin but uh some oxen is dissolved in the plasma also so you want to include that if you multiply it with 1.36 okay so that is here also of oxygen saturation in the uh the artery replaced minus or minus early reviews but here it is 94 and the formula at least 76 76 so you can calculate the uh okay we'll go to the next one good so you know it
1:53:12 is where uh PA saturation is less than aortic saturation so no transposition why do you want to go like that stay like that see what other conditions in which way PA saturation can be more than iot exaggeration what else is yes foreign
1:54:24 yes oh because like this is stomach blood pressures are one zero five by seventy five it means 85 normal all right um age 10 B is eight slightly elevated uh [Music] and are we uh Pages by six that is a RV systolic pressures are elevated and pulmonary artery fortified two millimeters that may not be two
1:55:11 millimeter or if you look at the area there's a gradient this is the gradient up to one is can be passed off without any any comment but if it's two or more it is you know what is the gradient level which will tell you about the uh the the significant obstruction main ingredient molecular any gradient any gradient is significant no no option two can be taken away might as well mean too but triggers with one main one or if it's more than one is abnormal informally in multiple more than two is
1:55:57 abnormal and the gradient across the permanently well fifteen fifteen on the iotic valve and problem 20. six to eight so it is uh on the system exchange after 15 is always on the permanent side less than that when you open it is only about less than 10. okay right so there is a gradient across the RH to are we gradient of around four millimeters of mercury okay yes sir and uh PA pressures are 45 systolic uh no uh
1:56:47 with main of 30 so main pressures are elevated okay there is no RV to PA gradient very good and uh pressure is uh uh 16 millimeters of mercury okay uh normal sir okay so is it normal or slide what is the normal 10 to 12 yeah 10 or 11 11 11 is you can go up to 12. 3 is 10 to 11 and when you think of the permanent expression it can be one millimeter extra so 16 is
1:57:32 18 weighs 14 14 so there is a main process for 80 and 16. yes at least 10 okay 10 yes right yes and iotic pressures are uh uh 105 by 75 the elevator Iota gradient of around 25 millimeters of mercury research okay significance
1:58:17 what is the significance up to 15 can be taken off as past office what is your diagnosis strong complex but it is what should be your diagnosis magical disease so again this business but evidence of turmeric uh mitral stenosis tricuspid stenosis
1:59:13 data nothing is possible okay I think that is enough now I think ordinary nine five or will you just take this one's the last one anyone in this let us discuss the last one uh IBC 64. [Music]
1:59:58 there is a step up of around eight percent and um why did you use the word around yeah don't use the unnecessary don't use unnecessary words uh saturation uh 99 normal and uh LV saturation is 86 percent there is significant step down of uh uh 13 percent very good and Iota saturation 85 uh decreased so
2:00:44 our V2 PA step up okay and uh pa2 LV step Downs very good yeah I mean yes okay you have to look at the present item before we draw any conclusions yes yes okay uh uh a equal to Acer and RV prices are uh uh inflow pressures are 120 uh over
2:01:31 eight sir okay uh there is no Rea to RB gradient but there is a significant increased uh RV inflow gradient okay there is a there is a gradient two millimeters of input outflow gradient yes there's a great significant gradient between the output and inflow okay very good and uh PA prices are uh 40 systolic uh uh mean of 25 sir uh elevated and also there's a gradient across the 18 millimeters of mercury okay very good
2:02:20 okay and LV pressures are 120 or eight okay and uh RV price inflow pressures are equal to LV uh prices okay which are the processes which are region so RV LV set and whatever [Music] no no
2:03:06 what is the condition in the RV LV PA and Iota the same VST when they are gone so much PS physiology um foreign
2:04:12 overriding of your time is yeah in this case that day I see uh it is impossible to differentiate because uh it's a 12 year old female too early for the patient to developed VST resulting in technology like technology of analytics situation I would consider more likely than this technology fellow but if you want you
2:04:58 can discuss that possibly also that this patient might have had a large Trend or a moderate system uh on top of that yes there is presenting similar to technology happens organization so what is your diagnosis usually normal elevated what is the reasons
2:05:50 foreign pressure
2:06:38 so this is a case of Technology resistance secondly to large investigation man-made friend most likely a sunroof whether a water circulation or it could be a possible okay I think that's enough [Music] about seven o'clock if I am available I will be taking a class but if I am not available then tomorrow next week there won't be any clubs and then the next discussion will be a case discussion we
2:07:24 will have a case discussion either next week on India we comes next okay okay thank you thank you sir thank you thank you sir so from here now I'm ending this meeting good night sir good night
