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Cool. Yeah, hi everyone. Um can Ronan or Jack just tell me if you can see my screen in the presenter view if that's ok. Cool. Ok. Um So hi everyone today we're gonna go through um some blood tests and ABG. So um these are like sort of the content list of like what we're gonna go through um today. So hopefully you have a better idea of like um what to order during a ski and also like in real life as well. Um So in terms of how you want to present your blood results. So I would always suggest you to mention what are the abnormal stuff before your normal stuff. So what is reduce, what are raised and based on these results and the history or the exam that you just did um like combine these two together and then try to come out with a differential of what this could be just so I think what we saw, we'll probably wait just a bit because sometimes you have, you know, people coming in from the couple of minutes and we're still getting people being admitted. So I'll give you five. Yeah, cool. We'll start over in five minutes or so. Just someone put on the chat if he can hear because we just need to know that it's getting through to. Oh, they can. Brilliant. Thank you. Yeah, we'll just start in five minutes. This is a good opportunity. Um, if, uh, anyone has any questions kind of just relating to the series or anything else, I'm here and Jack's here as well and Jocelyn. So if there's anything that's not related to the teaching thing that Jocelyn's going to go through anyway, then we'll happily answer in the chat. So if you have any questions, just drop them in. Ok. Yeah. No. Yeah. Has anyone got any questions you can put in the chat or you can try to answer it now? But um, good luck for your mary nose coming up after a PT, I'm sure you guys will be fine. We just give it a few more minutes then shall we start now? Um It's about 35 past and I don't think a lot of people are coming in. So, yeah, let's go for it. Ok, cool. So, um, yeah, just so today we're doing blood tests and um, ABG, so that's the sort of contents that we're gonna go through. So hopefully you have a better idea of um, these of the, these are quite common in your ee as well. Um So just a reminder of how to um present your blood results. So always mention the abnormal stuff before the normal stuff. So example, like what I raised and what I reduced and then based on the history or exam that you just did this and then come up with a differential and you could um combine these two together and then you'll get the point that you want. Um So we're gonna go through different cases. So I think there are eight in total. So for the first one, this is a three year old girl that came to the GP with one week history of recurrent epistaxis and bruising on her flanks. One reported that the patient has been feeling a bit more shortness of breath while resting as well. So um take a look at the blood results and I'll give you um a few minutes to just to have a think. Um and then I'll um explain what this could mean. So hopefully, um from these results, um firstly, the school will always give you reference ranges. So don't um stress about not remembering them. Um So, from these results, hopefully, you could tell the um hb neutrophil and platelets are all very low, but the um white blood cell count is normal in this case. So, um I hope you guys could all think to rule out um acute lymphoblastic leukemia um based on these sort of recurrent epistaxis bruising and more shortness of breath. This is something that you definitely want to rule out in a three year old kid So um I would always mention the HB neutro fusion platelets are low and then be like based on these with the sort of bleeding and shortness of breath. Um I would like to rule out an acute lymphoblastic leukemia, but um I would like to remind you of other differentials that could be. So for example, um ITP, but for ITP, the um platelets are always low but everything else is normal. So in terms of um full blood counts, um A LL ITP are all very common um to um order if someone had these two conditions. But um just to remind you don't forget about non accidental injury in a Children. Um So clues in the history or exam findings could give you an idea if this could be one. So for example, if you see bruises behind the ears or in some sort of soft tissues area, you always want to um take a more detailed history escalate to senior and social services and you want to do a full body X ray skeletal survey as well. Um So other than sort of A L and ITP, it could be sort of um anemia as well. So I'm not gonna go through what are these types of um anemia, but I'm pretty sure you would know it by now. So um just reme just remember to look at the um HP values and the MCP values because they tell you which type of anemia it is and for purposes, if someone has um microcytic anemia, it's almost always iron deficiency anemia. And you could see it in celiac or um ulcerative colitis. Noy anemia is slightly rare, but you could see an anemia of chronic disease. For example, if someone has sl e um for macrocytic anemia, um b12 folate deficiency or alcoholics are quite common as well. So we're gonna go through the next case. So, um, this is a 28 years old man just came back from a surgery and as part of the routine, some bloods were taken, so have a read again and then see um what you can think of. Look at uh look at these results. So hopefully, you could tell the um sodium um is raised the potassium, your creatinine and CRP is all raised as well. So essentially, um these are all parameters if someone's is having a acute kidney injury. So, um for sodium, it's a bit of a special one. It could be hyponatremia or hyponatremia if someone's having AK. But um almost always you will have a high potassium level, high urea levels and high creatinine level. And um AK I is actually really common. Um after someone having surgery because imagine having surgery, you will have a lot of blood loss. So, um, almost always you can see A AK I picture and what you do is just give them fluids. Um just do a fluid challenge. Um Case number three, we're gonna go through some LFT. So, um this is a 45 years old lady who presented with a right upper quadrant pain. It is colicky in nature and these are the blood results and you did examine her and there was no sign of jaundice. Um no sort of inspiratory arrest and she's scoring a new of zero. So I want you to give me sort of a differential of what it could be. Um And based on these results. Ok. All right. So, um with the right upper quadrant pain, um I always think about three differentials. So biliary colic, acute cholest ascitis and ascending cholangitis. So I think from the sort of um exam, um the news is s and there's no inspiratory arrest and no sign of jaundice. I think you can then rule out ascending cholangitis and um acute cholecystitis. So it's almost likely that this person is having um, Bellary Colic because of this sort of colicky, right, upper quadrant pain and she's about 40 she's female. And by looking at the um LFT, um only the AP is slightly raised, other everything else is all normal. So this is um, a little list of what the results could be for these three conditions. So, for bilary colic and acute cholecystitis, you could have a normal LFT, but sometimes they could have a raise AP as well. So the main way to differentiate between bilary colic and acute cholecystitis is the high new score. So bilary colic, your news normally is a zero. But for acute cholecystitis, your news is always high. And for ascending cholangitis, other than the highest knees, you have raised bilirubin, um, and, um, sort of jaundice and they could be confused as well. So this is just to remind me to tell you that, um, if someone's having your right upper quadrant pain, um, always have pancreatitis in your mind as well because, um gallstone um is also going to cause a pancreatitis and just um almost always do a amylase on top of the um LFT that you're doing. And I've been told that if someone's having an abdo pain, if someone is in childbearing age and is a female, then always have thing. Do you want to do a pregnancy testing just to rule out if they're, if they could be pregnant or it could be a topic? But this is just, um for, yeah, just to remind you. All right. Um So we're gonna go into case four. So this is a 75 year old man in M AU with a background history of severe CO PD using Trimble inhaler. And this is the news chart that you're presented with. So the news chart is probably the only thing that you're not given with the reference range. But I think unfortunately, you would know what are some of the normal stuff and what are not normal. So, um, have a read in here and think about what kind of um thing that you want to do based on these um new um score. So I think from um these news results, this person's pretty septic. So he has got a high temperature SAS are quite low on air and then he's tachy cardic techne BP is quite low. Um So the first thing that comes up to my mind is a three approach and sepsis six. So the one thing that I want to remind you is um remember to do blood cultures because I always um forget blood cultures part of sepsis six. But it's actually really important because you want to prove if there's any um um bacteria in your bloods, just an extra thing to add on for everyone. Sorry to interrupt Austone, I was going to say for a sepsis. It's very important to note that patients don't always have a fever. Ok. And they can present with abnormal abs. And in fact, if their temperature is normal, it usually can indicate that their body is producing natural uh features to reduce a pyrexia. So, very commonly have patients who have uri or night sweating or just sweating in general. Those are all mechanisms of the body to reduce the body's temperature. Um So if you still have a normal temperature, but all your other obs are going off or differentials should always be some kind of sepsis. And especially in a clinical context, like a COPD, if someone's coming in with severe COPD and it looks like an exacerbation, infective exacerbation of COPD causing a septic like picture should be on your differentials. So, yeah, thank you. So, going to the next case, we gonna go through a bunch of um ABG. Um So if you want to um have a read of this ABG and then have a think of what this could be. Um I've got um some details on how you should present um an ABG as well. So have a think of what this could be. All right. OK. So um by, so I always start with the PH first. So the PH is slightly raised in here and the CO2 is low. So um this is respiratory alkalosis and the um bicarb is normal. Um So it means there's no sort of metabolic compensation in here. If there's compensation, the um bicarbonate should be quite low. So less than 22. So this is actually quite common in someone having a panic attack because you're basically hyperventilating. So you're blowing off all these CO2. So obviously, CO2 is going to be low in your system. So um just to remind you of the sort of Rome acronym um so respiratory opposite. So looking at your ph and CO2 and metabolic is the same. So looking at your ph and HC 03, I found it's quite helpful. So I think there's actually sort of three ABG that you should sort of remember in, in your head. So, panic attack and then the next one, if someone's having AC O PD, um so have a think about this one again, remember in cop, they always consider about type one and type two respiratory failure as well and maybe it's just test yourself like, what are the main differences between them? All right. So um this patient is having quite a low Ph in here. So a acidosis, um CO2 is quite high sore acidosis, but looking at the um HC 03 level is quite high. So probably someone is um doing, giving some uh metabolic compensation in here. So this is actually quite a common picture in someone having CO PD. Um they will be having sort of acute on chronic respiratory acidosis. Um The reason why it's sort of acute on chronic is because you could tell the um carbonate level is really high. So they've probably been on a very high level of um carbonate level to sort of compensate their um acidosis. So just have a, just remember in CO PD, you could have acute on chronic respiratory acidosis and then for the next one. yeah. So just to remind you of type one, type two respiratory failure, um it's mainly looking at the C two level if it's high or low. OK. And rem like obviously mentioned about the acidosis and what's high, what's low. But in CO PD important to mention if it's in type one or type two respiratory failure as well. So, the next one, I have to think of what this could be. All right. So hopefully you can spot um the person has a high glucose level and high ketones level. And um this is basically someone having a diabetic ketoacidosis. Um So again, looking at the ph um so it's quite low. So, acidosis and then the um carbon level is very low. So, metabolic acidosis and there's no sort of respiratory compensation in this case because the um CO2 is quite lowered here. Um So I think for ABG, it's mainly sort of DK AC O PD and sort of panic attack that I will sort of like learn because they come up all the time. And next thing that I wanna go through is paracetamol overdose treatment graph. I know it's not really bloods, but um I think this is quite a common topic and ki as well. So I'm not sure if everyone knows how to read a paracetamol overdose treatment graph, but um have a read and see um what you think and um let me know if you think they should be treated or she should be treated or she shouldn't be treated. All right. So hopefully you have sort of broken down the question a little bit. Um So first thing I want you to remember is that um if someone is having a staggered overdose, that means they have taken an overdose over an hour and in this case, she has taken overdose in 30 minutes. So this wouldn't count as a staggered overdose. Um timing is really important as well. So she was brought to the ed by three in the afternoon and the blood test results came up at nine. So this is quite important because you want to um plot the graph in here. So that's about 66 hours then. So you would look into six in here and they tell you the um concentration level is at 80. So you'll just go up to 80 in here. So this is um above the treatment line. So you will treat the patient with neck. Um So this graft is only useful if you done the blood test and like after four hours. So it wouldn't work if you do anything between in here. So always um just, it's a, it's always after four hours and anything above the treatment line. So anything in here, you would always treat it and if it is on the line, you would treat it as well. OK? Um So if you're not sure um about the paracetamol overdose treatment or anything, you could always go on to B NF. So if you go on to B NF and then just type poisoning, they should give you quite good um summary treatment and you click on paracetamol overdose, you could click on the treatment graph and then they should give you all the sort of um how to treat paracetamol as well. Just to follow on, there's probably best advice that you can get from talkspace. The BNF is only limited in what it will provide based on paracetamol overdose if you want the best kind of up to date guidelines, especially for the trust you're at. And this is where it's different from going to the BNF to get what antibiotics is best for, you know, infection saying that you would check the BNF. The gold standard in your exam is if you would check micro guide, it's the same with something like an overdose, whatever the overdose is, you'll get some of the marks. If you say the BNF, you check and you'll probably have the gold standard if you say I'm going to check to space and if I need support, I will check with to space because they have doctors there who are specialized in these specific overdoses. Um The other advice is if there's not a time frame as in, you don't know when they had the paracetamol overdose, which we sometimes do have presenting to us in a and a patient who is unconscious and we don't know when they've taken it. You start the NAC regardless and you basically check all of their bloods and make sure that they meet the criteria. That's why top space is much better because they have guidance on that specific scenario as well. Um So yeah, that's just a follow on from that brilliant. Thank you. So, yeah, so micro guide to space and B NF would be helpful. So the next case, um yeah. Um So this might looks a bit weird but have to think of like what this could be. Um So this is a 28 years old man presented to a GP with chronic diarrhea and ap no pain with some weight loss and these are the bloods being taken. All right. So hopefully you can um have a think and then um the um, have a look at this and then you'll probably see the M CV and HB is being quite low. So maybe iron deficiency anemia, the Vitamin D level and the vitamin B12 level are both quite low as well. So, um possibly a deficiency in both and the folate level is quite low as well. So, basically, this, this person having sort of chronic diarrhea, a pain, a bit of weight loss, a bit of unexplained, um vitamin deficiency and some mineral deficiency as well. So, in my head, I'll be thinking, ok. Could this be um celiac or um if this is sort of IBD picture? So, um if you want to do some follow up tests, hopefully you would have to think about doing the IG att G total ig A level, maybe um fecal calprotectin. And if the total IGA level is low, you would do total I GG and don't forget about any sort of endoscopy that you would do. So, this person um in my head is having sort of celiac disease. So I just want to remind you if you look at the blood results and it looks a bit weird. Everything is sort of um low and a bit of deficiency. Having some of the gi symptoms always have IBD and celiac in your head. Don't just think celiac, but it could be IBD as well. All right, for example, like you see, you could get um iron deficiency anemia because of the bloody diarrhea. So this is your last case in here. So this is a 35 years old female presented with two weeks history of diarrhea, feeling very anxious and sweaty. Her period cycle has been quite erratic and unpredictable as well. And um on examination, you can see it sort of like a lump on her neck as well and these are her um thyroid results. So hopefully, you can tell the T three t four levels are raised and T TSH level is reduced. So this person is probably having a primary hyperthyroid. So, um differential. So, grave disease quite common. And if there's any sort of additional um tests that you want to do, probably it will be testing if they've got the anti TSH antibodies. Um, just to remind you as well, don't forget your thyroid exam because it could come up in your se and is a very common exam as well. Ok. So after these cases. Um, I just want to remind you of something, um, when you go into surgery. So what's the difference between group and safe and cross match? So, based on my understanding group and safe is basically just determining someone's, um, blood group and if there's, if they have got sort of recist antibodies, so you're not necessarily sort of finding a match in the blood bank, but it's just sort of recording what their blood type are and for cross match, you're essentially sort of matching with the sort of donor and the patient's plasma and for potential um blood transfusion. So for example, if someone's having a um someone's having postpartum, sorry, um someone having a AAA and it's ruptured, they are very, very, very likely to have, they will need um at least two units of blood transfusion. And that's when you would say I would do a grip and safe and cross match. But if someone's having, um for example, just say appendicectomy, I don't think I'll ne necessarily say cross match, I would just say grip and safe, but I don't think you'll be sort of wrong to say grip and safe and crossmatch. This is just me um giving you some ideas of what you do in like real life really. But um yeah, correct me if I'm wrong. Um Jack and Roland. Um and then the next thing is um some sort of test results, not test result, but like test that we definitely want to order if someone's having shortness of breath or chest pain. So essentially your ECG and your sero troponin level would be the most important thing. Um, don't forget your ABG if someone is acutely unwell because you can look at the LAC two results and um D dimer or C TPA. If you're thinking of someone's having a PE or DVT, if someone's having a tummy pain, don't forget about your amylase and your ABG because of your lactate, they could be having acute mesenteric ischemia, lactase is very, very, is a very important indicator. All right. Um, so I've got two quizzes in here. Um, I think you could do it, um, on your own time because, um, um, I know the time is sort of running out. Um, but I've got the answers that are back as well. It's just reminding you of what sort of blood results that you should be aware of and what you should order. Um, so these are some ways to sort of learn your blood test. I don't know if it's helpful. Um, maybe you could sort of write down what, what type of tests and, um, what they will be useful for, for, for example, if someone, um, it's feeling shortness of breath, um, you might be thinking about FBC. If someone's think, uh, someone's having ati there'll be use any, um, chest pain, epigastric pain amylase, um, sort of racing, slowing heart rate. Think about T ft um and this is what I did for my escape, but I don't think it's useful for everyone because it could be quite a scary table. Um So what I did was I just put down what other features, what a acute pancreatitis, what kind of investigation that I would like to do? Um And then what kind of management sort of the acute and the ongoing management in here? So for the ongoing management, I think it's, it's the same for a lot of conditions. For example, quit smoking, hydration, reduce weight loss, um stop drinking alcohol, um Good BP control, avoid any sort of triggering medications. Um I think that's the same for a lot of conditions. So I would suggest maybe making a table for your sort of chronic um management or like long term management that would be quite helpful. And this is a slide to remind you that don't when you're doing management or investigations. Um, don't forget about your electrolytes imbalance as well because I think that has came up in a ski before or in the past, um where they could potentially test you on what, how to manage hyponatremia, how to manage hypokalemia, hyperkalemia, and hypocalcemia as well. I think hypercalm is quite common. So just re just remember it's always fluids first and then you could do bisphosphonates or calcitonin. All right. So that's the end of my presentation. If you got any questions you could put in the chat. Thank you. Mhm. That was a good whistle stop poor Jocelyn. Um Thank you for that. Um So if anyone has any questions about any of the stuff just went over, please put it in the chat um, tips, which I kind of mentioned. So I put it in the chat as well. But you know, I will never, if I'm an examiner as well, I would never kind of dock someone for saying UF BCU and El FTC RP. Everyone gets that as soon as they come through the door, always mention ABG and ABG if it's an acute case because the knowledge that you get just from a lactate alone is what I'm most concerned about when I'm seeing someone unwell on a ward because that tells me, what am I actually dealing with in the acute setting? Is this person showing signs of shock because lactating effect is just your accumulation from their body, not getting enough blood kind of going around and that can be from anything, but it tells me how far they are into whatever disease is causing them to kind of go downhill. Um And then you get all your other facts from, you know, the oxygen and it'll tell you different electrolytes as well and that will give you quicker, kind of quicker values compared to your s and stuff. So, yeah. Um Ella has made a good question. When do you do a G versus an ABG? It's very simple ABG, if they're requiring oxygen or it's anything respiratory related, you go for your ABG VBG is just for anything that doesn't fit that. Um You'll never be wrong in going for the ABG because technically it does give you more results, but it's not as nice to do on patients and A BG is usually quicker to do. So as long as it's not some kind of oxygenation problem, then you can go for a BG. Um So yeah, another thing is ABG. So even on WUS this is for, I guess your own knowledge guys, we can get BGS from patients ears, for instance, like air lobes. So if I'm really struggling to get a patient's pulse, which in resource patients can be the case and I more just need to know what their lactate is and what's going on there than, and if I've been subjecting them to multiple ABG S which can damage your arterial access anyway. Um I'll often lean towards doing the um er, the VBG or the, the kind of test on the air lobe and that'll give me the same um same level of understanding from those bloods say. Yeah. Um Any other questions? I know you stunned them in the silence. I think Jocelyn has done a very good job. All the stations that she kind of went through with you guys are very um relevant and could come up on the day. So I think they're very fair. Um Kind of blood tests and, um, or blood kind of like tests to give you to interpret. Um, and it's, it's more just kind of going through it methodically. Um, and if I'm an examiner, how I normally would go through blood results is I would first have a look myself in my own time and then I would kind of go through it with the examiner saying these are the abnormal test results. This is what I think it is indicating and go from there. Anything else at all before we refinish? Nope, I think, I think that's pretty much it. Um Please fill out the feedback form. We definitely need that before you go. But it was a really, really good presentation while done and we've changed up the teaching for this one which is more case based and that's why the feedback is quite important for you guys because we need to know, you know, it was it helpful you found, did you find it to be different? What would you prefer it to be a mix or how would you guys like it to be structured and we can tailor it accordingly? Yeah, or like, um let us know if there's any specific copies that you want us to go through. We could certainly have to think about it as well. You could send us like emails or em through ingram, whatever is easiest. But yeah, good luck for your PT and the lo is coming up I'm sure you guys will be fine. Yeah, good luck guys. You'll be fine. Well, in everyone, thanks for coming. Ok, we'll just give it a couple more minutes and then we'll, we'll, we'll head off. So if anyone has any burning questions then they can put it in the chart, uh, next week. If any, if you want to know, I believe Jack is doing the teaching session and Jack, you know, the topic better than I do. So you can just quickly give an intro to it if you want. I think it should be a bit of a surprise, but we'll let you, we'll email you in advance and then you can all know.