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Why is that? We, anterior well, just promote you to host now and then I'll have Teo, uh, leave the best of luck with the teaching. Thank you. And I'm going to have people. It's getting me. I'm not enough to set, you know? A lot of what? Sorry. I'll just make you host. I can't seem Teo take my kind of off, either. Um, try. Oh, yeah. I think you have to be coastal make you coho 70. And then thank you. Okay. Thank you so much. Okay. Um, you guys hear me properly, you know I can. Okay, fine. That's fine. I think maybe it was just my my wife. I was quite bad right now, So, uh so, yeah, try screen sharing. Just so we know that you can put your slides on. Yeah, sure. Do you wanna go first area. Okay. So I mean shooting, and then we can decide basket. So we've got the, like, the power point view. Did you want to put it into, like, the present of you, Or, like, slight. Yeah. I'm not too sure if it's my wife, I That's a big allergy or whether it's someone else's side, but I'm not sure if I'm, um, hearing you guys properly. Mm. Um, I delayed talking to you on your side. Oh, you're okay, I think. Okay, that's fine. That's fine. There we go. Now we can see that size. Great. Yes, a little. Basically, I am sometimes. Okay. Shall I try and share mind? Just quickly. Just a trial and error. Everything. Well, Can you see that? Yeah, that's what Lovely. Do you want me to keep these up now? Hurriyah? Uh huh. I'll keep him up. I think maybe it's for a while. Yeah, possibly. Possibly. You might just be a little bit slow if anything happens. I don't mind taking it over and just kind of going free stuff. Sure. Do you have each other slides? No, I don't. Actually, I'll get her to send them to me, just in case I haven't seen them, but I'm sure, but I'm sure I could give it a go if anything, you know, drastic happens, but hopefully should be okay. So yeah, that would be great. So I'll get great. Get the two feedback links. We've made one for each of you. Thank you. So you'll be able to share those, like, about an hour into the talk. Okay, Maybe I'll leave you guys to it and, uh, contract with you guys. Laser me. Think. Really, Genya, period. You want to send me your slides? Just in case? Because I think I'm not sure if it's my Internet on your Internet, but there's a little bit of, like delay and sometimes your voice on my side sounds of it crackly. I'm not too sure who's wife It is. But just in here, because I've sent you my slides. Do you mind just learning New York? So I just in case something drastic happens. Yeah. Yeah, of course. No, I think that's a good idea. Um, under that, actually, I'll send you my sites, okay? And if my wife I keeps playing up, um, I might give it a my joined with my sister's laptop. Yes. Okay. Hopefully just we should be fine. They think is cost. Yeah, and then I'll just fine now, Sunny. I can hear you now. Yeah, I think he's just just just crazy sometimes. I don't know. Typical food is just the other. He said you let me know when you're ready. I got the feedback clings, so Okay, well, don't drop thumb the chaplain. Okay, great. So is it just always starting, like at six. Or just before? Like, I'm happy for you to lead and whatever just introduced me in on their carrier and I'll stay for the whole thing. That's don't worry. So I'll just manage the traction. The cure names. Lovely. Thank you. Sorry, I got to leave early. By the way, You know, there's a, um, played so high, people worst in joining. So then we could just had everyone. I hope you can all hear us. Uh, just say yes in the chat if you can. Okay. Amazing. So my name is Hoodia, and this is Oh, he, um So thank you so much for attending this session. So today we're going to take you through the common cartilaginous profess stations that would come up in this case, special skis. Um, so this event is the port you buy in collaboration with cutting from Semitic. Send a say it's medical Siris. Um, and yeah, and thank you so much for attending. So So we've got same. Who's going to go first? Everything. Some reason for taking your time. Um, to do the session with this on Don't want. So we started with her three stations that if we don't take over um, so yeah, I'll handle, but easily. Great. Thank you very much. Area s Oh, I hope everyone can hear me. If there's any problems throughout, just pop it in the tract on We'll try and go through about hopefully There won't be any Internet problems today s Oh, my name's oh, he as Korea said, I'm a final year medical card if it the moment. But last year I indicated in emergency and prehospital medicine eso my interest is in kind of acute medicine, but not going to give you any clues yet as to what we're gonna cover in the case of today. So this is just another view off some of the great sessions that a sit on the card if Muslim medics have been covering. And of course, today we're doing cardio and rest eso I'm going to move on to my first case presentation now eso Korea Is there a student who's going to volunteer to take part in the session? Is there anybody who wants to get it? Give it a go. Yeah, I think. Yeah, hopefully, we'll get somebody from the audience volunteer guys. So it's gonna be like we're gonna try and into, like, a little 15 minutes station, so we'll start with the history, if any. If you feel is being brave enough to volunteers can be quite brief on. But, you know, I'm sure. So we will help you to waste it. Wouldn't. Oh, yes, it is recorded. It's life streaming in middle. So yes, you are. It is recorded. Yeah, I saw a hand go up. Um, I don't see any more. Um, two people have raised their hands. Okay. Um, so I had Ali shake come up on my first. I hope I'm pronouncing that right. How are you happy for me to, um, about a Panelist? Is that? Hopefully it was Yeah, right. Panelists. Okay, great. Thank you, Ollie, for for volunteering. Great. Ali, can you Can you hear us? Kidney? Yes. Thank you very much for volunteering, Alley. Hopefully it'll be helpful s. Oh, I just go back. It's not like you're back on my slides. There we go. So this is your case presentation. So this is what you're gonna get on the outside of your skin. Eso your fourth year medical student on your placement in D on. Do you have a 40 year old male presenting with acute chest pain? So you have seven minutes to take a detailed history from the patient on produce a list off differentials. Okay, So you got seven minutes when you're ready. I'll pop it on my time on my side on when you're ready, Just let me know. Okay. Um okay. Goes right to say now. Yeah. Okay. Hi. My name's Holly. I'm a third year medical student. I've been honest to take a history from yourself. Is that okay with you? Yeah, that's fine. Yeah, I can I just confirm your name and your date of birth, please. Yes. So it's Mr Alan Jones on. It's the first off the January and of 40 years old. Okay, Perfect. Thank you so much for that was what's brought you in today. What's going on? Yeah, is really It's really weird. I've got this chest pain. I've never had it before. I'm really worried. Okay. When did it start? Oh, so it started this morning? Yeah, about three hours ago. Okay. Okay. On dumb. Ah ah. Do you feel short of breath at all? Yeah, I do actually feel quite short of breath. Yeah, more than usual. Okay. Any cough or anything like that? No, not no cough? No. Okay. Would you be Would you mind just pinpointing exactly where the pain is? It's just like right in the center of my chest. Like, right here. Okay. And is it a sharp pain or a dull pain? Yeah. It's like someone is stabbing me. Okay, Onda, um Onda. Is it spreading anywhere? No, it's It's just in the center here, like a stabbing sensation. It doesn't go anywhere else. Okay. And have you tried anything to ease the pain? Had anything helped? Well, no, not really. I don't believe in medicines. I don't like taking too many. So I haven't taken anything today. But I will if you think it's a good idea. Okay. Okay. Any of the symptoms, like nausea, vomiting, fever. Well, you mentioned I just feel really under the weather. I feel really achy, like, hot and cold and just just really tired. Yeah, really, really tired. Okay. And And how long have you been feeding me? He fall. Well, I think I had a cold last week, Not cough or anything. Just a sniffily nose last week. And, um, it kind of went got bit better. But today, now it's just a pain in my chest. Okay, okay. And so you've got the sharp stabbing pain with feeling hot and cold, you know, vomited or anything like that. No, no, I'm not vomited. No. No. Okay. And, uh, is there, um, anything that makes the pain worse? So is it just constantly stabbing? Uh, know So it is on and off, but it does get a lot worse when I take a deep breath in. Or if I cough a band also, when I'm trying to like, I've been trying to rest on the sofa before coming into a any and it's been really bad lying down. So I feel like I've got a proper self forward. Okay. Okay. Onda, um, on a scale of 1 to 10, where would you rate the pain when it's stopping? It's about a nine or 10 is really bad on dumb. So you go and have you got any other medical issues or Well, I do. I do have asked him a on also I've been told by the GP that my BP is a little bit high. Um, and I was in hospital a year ago. Just for a day a day? A hernia that was fixed. Okay, so you've had a hernia operation. Any other previous operations? No, no, no. Okay. No. Any regular medication that you're taking? Well, I've got my asthma pump. Just the blue one for my asthma on. And I take a drug for my mental health called. I think it's called Citalopram. Um, Andi, I also take Is it ramipril for? For the BP? Yeah. Yeah. Okay. On dumb. Uh, any allergies to any medicines? No. No allergies. Okay, on, But, uh, just a few other questions. Do you smoke at all? Um, I I am a smoker. Yeah. Yeah. And how much do you smoke? About 20 a day. Okay. Okay. Anyhow, ho in. Take no. Only at Christmas. And birthdays and things just just once in a while, okay? And any drug you saw anything like that. You know nothing right now. And with this pain, have you ever had this pain before? Um, I haven't had the pain before. It's completely new. It's really weird, actually. Okay. On dumb ever had a nice small Thai. This isn't feeling like I've had asthma attacks, but they've never been really that bad. And never anything like this. And I feel short of breath, but it's more my my check. It's like stabbing. I don't. But I don't think asthma would do that, would it? I'm not too sure. It feels different. Okay? And it does your chest feel tight? No, not tight. Just as a stage is painful and just worried I'm having a heart attack. Okay. Okay. On DM in terms off. You mentioned you had someone. You cough. It's painful. Have you coughed up any blood? No, no. This it's It's Ah, not nothing coming up. Really? No. Okay. Um, it's just a dry cough. Yeah, just just a dry cough. But I think I'm a smoker. Smoker. Cough. Really? I've had it for a while. Nothing new. Okay, so I'm just going to summarize what you've said to me. And can you please let me know if I'm missing anything s o you've had Ah, You've been feverish for the for the last week or so. You've had cold like symptoms. Feeling a bit under the weather. You've also got this stabbing pain in the middle there on did it's, um it's off nine out of 10 constantly. They're worth when you're coughing. Um, and you've never had this pain before? Um, I'm I'm missing anything. No, I don't think so. No, I think you've got everything. Okay. Um okay. What I'll do is I'm just gonna take your observations and then just have a quick word with my senior. Um, how does that sound? Yeah, that would be brilliant. Thank you very much. Have you taken any pain relief? Ah, so far. That's the time. No, I have not taken anything. Great. Thank you very much. I really That was great. Thank you so much for volunteering if you just want to, um you you, Mike, I will just go through some teaching bits, and then we've got bits that you can get involved with later. Sensation. So So please summarize your history on provide your top differentials and why. Please. Oh, Ollie again. Okay. So top three differentials possible, uh, heart failure because it's ah, were sweating possible heart failure possible PDD possible. Am I a swell on? Perhaps even uh, perhaps even a day or take her aneurysm. Yeah, really good differentials. Thank you. Some of the important ones to think about. So just maybe even. Uh huh. Yeah. Absolutely, Absolutely. Eso if we just go through the case presentation for everyone. So just is just summarizing what alleys found out from the patient. So this was a 40 year old male presented with presenting complaint of chest pain that started three hours ago in the morning. It's central in in nature and correct. Rooster know all a sharp in nature and severe 10, 9 or 10 in severity. No radiation, a tall. And it's worse when the patient takes deep breaths in or has an increase in thoracic pressures of coughing, sneezing on better when the patients it's forward on as early found, other symptoms in created myalgias. So muscle aches and pains generally feeling under the weather fatigue, fever, um, and shortness of breath as well. This is a Z said the past medical history on drug history. For example, one thing that really didn't pick up. But don't worry, I wasn't gonna offer it too much. I'm a bit of a mean patient, but I just don't realize. Remember to take a family history. So this patient's father had an M. I, 52 years old on the patient, was worried about heart attack when taking a bit of a, um, you know, a social history about what you was. Ideas, concerns, and expectations were so always really important to kind of get that in there at the end. So that was the reason why he was worried about the heart attack with the symptoms. Um, that's just this point. Any questions anyone has, Um, you guys are probably all clinical Stevens now, so you'll know how to take a history. And that was really good by alley. But remember any pain that patient has always do through your Socrates s. So you start off with your sight. So where the pain is your onset When it started your character, So what the pain felt like on what it feels like just to describe the pain for the Are your radiation A Is your additional symptoms? I think this is off the top of my head, so you probably get it all right. More than May. Tea is obviously your timing. So when exactly happens is that are, you know, constant. Is it up and down your exacerbating and your leaving factors? What makes it better? What makes it worse? And your severity, which is, you know, out of 10 with 10 being the worst imaginable pain. How bad is it on? That was all covered by alley. Great there. So wonderful. So these are the differentials that I came up with? Uh, many of them were picked up my alley. There s so I like to split up into, like, a surgical save. So thinking about all the different parts of the body or different organ systems together. So in terms of the heart, which is what we really think about first, when we're thinking about a test pain presentation, you always want to rule out really, really important things are going to, you know, kill the patient s Oh, that's things like an M. I will be right on the top of my differentials, even if it's not really something. Even if you think it's something else, it's always really important to tell your examiner. You know, I think this is my top differential. However, really important differentials to exclude would be a myocardial infarction is this. You know it's potentially life threatening Onda. The patient has chest pains. We want to rule this out. So So that's one of them. The big ones. They're myocardial infarction. The other thing that I had on my list with pericarditis just because the patient is presenting with kind of feverish type symptoms a recent illness and also is a kind of phloretic type pain. So patients it's forward, you know, pain on coughing and things like that. Thinking about that pleuritic pain as well. You want to think about your respiratory causes so again, the ones who really want to rule out urgently would be your P E. Again. This comprehend it with very vague symptoms, maybe just even a tachycardia with a little bit of shortness of breath. But generally, what we think about classically is some pain. You know, pleuritic pain worse when you take deep breaths in, for example, so that's a really important one to rule out again you month or it's again a very dangerous one. If it turns into a tension, or if it's prolonged and very large, it can actually decompensate patients if they have other comorbidities. So that's another thing that you'd want to mention, even though we haven't examined the patient yet, so we need more information. As Ali said as well. You want to think about your new pneumonia, your community acquired pneumonia is your caps. Or if the patient is an impatient thank you about your haps, your hospital acquired pneumonia. This is because again the patient has shortness of breath, is generally unwell, has kind of feverish type symptoms on. Then you want to think about your other things that it could be so thinking outside the box. Ali had a great one there that I didn't think of beforehand of aortic dissection. Really important. Think any kind of chest pain? You know, if this is radiating to the back, for example, you want to be thinking about you Triple A's and your dissections. Thea. The ones I bought off or costochondroitin this because of the chest wall pain, you know, would have to ask more questions to elicit this, you know, Is it pain when you touch it? Or is there any certain movements that exacerbate the pain and again would mean we need more investigations and examinations? Finally, dyspepsia is another thing so acid reflux because a lot of patients come in with chest pain, thinking it might be a heart attack. Or am I? Actually, it's just a bit of reflux that's causing irritation of the esophagus in the same kind of retrosternal area. Eso questions that you can do to elicit this in the chest. Pain could be. Do you have any symptoms off kind of a, Zali said. Any vomiting, any regurgitation of food, any abdominal pain on do. Also, you might want to think. Is there any unpleasant taste of the back of your mouth? Because sometimes when patients have Afrin reflux, they can taste the acid at the back of the mouth, and that might be assigned towards that. But no brilliant what we've done so far. So the Ali This is a continuation off the case now, so the you decide to do an examination. So on inspection, the patient is distressed, diaphoretic and sweaty eyes visibly short of breath, and it's Satur clutching his chest. His observations here sets of 98 heart rate of 110 BP systolic 1 50/89 or 38.6 on the temperature and his glucose is 5.6 on the of pre scale. He's speaking to you, so he scores on a for alert on on systems Your view and doing your a B C d e. You notice he has clear chest sounds and a soft nontender abdomen. But when you listen to his heart sounds you feel that you have a 1st and 2nd heart. Sounds a normal. You can hear a pericardial rub. So moving on now, what investigations do you think you'd like to request for this patient? Um uh, Check first. Cast X rays. Second on a full blood count using things uh, a lefty's on D. Uh, troponin, um, CRP on D c crp. And then no put on possibly even a ct pa. Maybe, uh, on D any CT? Yeah. Great. Yeah, absolutely. Some really good investigations there. Thank you. You. Can you tell me wife any of them or anything really important in this case more than of this on D. So chest X ray, um, would help see whether there's any pneumothorax on or cardio make Lee can with troponin. That would help rule. And am I out on day? Same with the CT just received the city changes. Um, on. Do you know CRP and Bloods That would help with, uh, seeing if it's any in underlying infection. Brilliant. That's perfect. Yeah, absolutely. Eso just to kind of go on what we said there again just to go free eggs. Exactly what he said. So how I like to split it out in terms of investigations, there's lots of different ways to do this. So please have ah feel of what works for you. I know a lot of people use the boxes at Crim. Um, and I'd have to google that off the top of my head because I don't use it myself. But when I'm presenting back in a in an Oscar Nesky, why I like to do is I like to think, Okay, I'm with the patient. What can I do at the bedside first? And then I like to think, Okay, what's the next step? I take a step back. What? I'm going, what we're going to do then on then take a step back again. So I think bedside, then bloods. And then let's take those referrals and send them to have some imaging. So at the bedside. Pretty much for every single patient that comes in. He's acutely. Um well, I wanted to take a full history examination if I've got the time. This is usually already taken a Z part of the first part of the station. But I always say I would make sure to do a full history examination for the patient on if they're cute. Um, well, I'd like to do my A B C d. E. Assessment. So that was always what I would start with then I'd like to be thinking. Okay, well, we need some observations on this patient. We need to make sure the hemodynamic consider able. So I'd set up the news chart to get some vital signs. And I've actually transferred his patient to recess so that they can have cardiac monitoring because they've got chest pain. So it's just those little extra bits that will help you stand out in your SQPT. Think about, you know, making sure this patient in the right place where they're having investigations, then Blue Coast Never forget glucose. It's really, really important, you know, Especially if you've got a patient have syncope or something like that. You know, they have a faint or the short of breath or they have confusion. Glucose is always really important, and I say it for every single patient that I'm seeing in a any. I always get glucose reading. It's actually one of the first things that the nurses do when they come into any so glucose, any CG, as we said, hugely important because you want to see if there are any abnormalities going on with the heart. We want to rule out the M I firstly, with that be a stemi and stemi or looking for any changes of any of the pathology on an ABG again. But some of you might consider this is blood's. But this is something I want to do straight away. One with the patient. I want to take that blood. I want to run it quickly, especially if the patient has shortness of breath. If they have shortness of breath they might have, they might have a problem with that acid base balance that might be causing other problems. We want to look at that, and also if this patient is having an M, I lactate to the Forest senior as well, so that's always one of the things I do straight away. ABG is more relevant if the patient has a shortness of breath. If they don't have shortness of breath and you're not too bothered at looking at the oxygen too much, Um, and you just want to look a quick, you know, hemoglobin or some of the electrolytes, and then what I do instead is a VBG. Add your cannulated and taking your other bloods so ABG if you're really worried about the oxygen levels. But if not, then a VBG might be more appropriate because you don't have to do the painful procedure taking out the artery. So in terms of bloods, as Ali said, I always try and give a bit of a reason when you're presenting back your bloods. It's really nice to see, you know, present back and say Why you're thinking about doing these examinations and tests. So FBC, of course, for your effective markers to make sure the patient doesn't have an infection using these electrolyte abnormalities as we know things like hyperkalemia these samples and rhythm years on. This concludes chest pain. If the heart is beating in synchrony, the same with the bone profile that has calcium and calcium can also cause a lot of arrhythmias that could need to chest pain. CRP are, or any Assad probably CRP is more relevant. This's the information. So as we thinking about pericarditis or other kind of conditions like that, we want to see if the patients got an infection or inflammatory process going on your troponin. That is really important with any patient of chest pain. You want to do this in a serial manner. Eso cereal components essentially means taking two troponin. It's at different times to see a change. So even though you have a normal troponin on the first, when you take it again in three hours or four hours, if that increases and that's gonna be sharing you that there's a ongoing ischemic process going on. So I always take the first proponent, a soon as the patient gets into E. D. And then you want to take your 2nd 13 to 4 hours later on, you want to look for any increases or decreases, and that's going to just help you decide whether this patient is having an MRI on not a lefty's. Ms is really helpful. Along with the use any so that the kidney function liver function. You want to give the patient any specific medications, and that's always really helpful. You know, just in case any antibiotics are not tolerated in patients who have a low T e jafar or who have chronic kidney disease on the same with her packed in toxicity as well. Fifties air Gonna help again with the rhythm years eso doing that might show you the patient has hyper para hyperthyroidism. Sorry, um, and that can help you rule that out. The differential blood cultures. The patient does have a fever. His obs are a little bit high. He had been high in use score, so we might want to be thinking is the sepsis. So in that case, you want to do the sex is sex, although that's not where I'm going with this taste again autoimmune screen, a viral screen and a drug screen. The reason I'm thinking about this is if we're thinking about something like pericarditis or an inflammatory process, want to see if there's anything in the lying on my proposing that so we just want to make sure that there's nothing else going on these wouldn't be my first line investigations, but there's something to add on that the end if you're thinking of US specific pathology and then, as we said, really important. A chest X ray, any chest pain, whatever is always do a chest X ray because even if you think it's one thing that may be a surprise on the chest X ray. So I always do a chest X ray to exclude any other respiratory, cardiac or otherwise any other pathology, it'll that's really important. And then finally, an echocardiogram will be done later down the line. This is to exclude any any problems with the heart function, so that might be causing the problems. For example, effusions which may be related to a pericarditis type picture on. Also, you want to exclude ventricular failure too. Okay, so are we here? Your investigations? What now is your top in friendship? So if you just work your way through three the the investigations on, then I'll give you the answers of what they are and just tell me what they're suggesting for the patient. And don't worry, if you don't know I can open up to the floor is well, um Just give me a sec. Um, yeah. On. And there seems to be some ST elevation and leads who? One and be five. Um uh, I need needs to Yeah, there seems to be ST Elevation, but then Proponent is normal on Do CRP is high. So uh huh. I'm thinking maybe some I'm not sure that's okay. Don't worry. Don't worry. Does anybody I'm having? Look at the chart. I'm sorry. I was ignoring all the message in the chat. These are excellent dancers. Anybody have a clear if you want to put it in the chat. Yeah. Yeah. Fab some of great great answers there. So everybody has seen correctly. So if I go into the next slide So you've all correctly said that we've got a widespread ST elevation, which you did see alley well done on, and you've got a PR depression as well, so I'll point this out. Can you see my mouth? Um, so here we've got all of the ST elevations throughout, and they're called a saddle shaped because they kind of sleep quite quickly in be in the upstroke. There s so it kind of looks like a horse back saddle. If you if you Google that on P R. Depression is also another sign you can see I'm trying to look to see. Yeah, here you can see it. So between the pee on the QRS complex, you can just see that slightly lower than that. Isoelectric mine is not massively obvious, but it's one of the classic signs off pericarditis. As you said in the chat eso also another view of the blood test. As you said, the CRP is high, which is in keeping off pericarditis type picture, and all the other tests are no abnormalities detected. Um, So as we said, the final diagnosis is pericarditis. Ali, do you want to have a go? How you would treat this patient Ask for help if you need it from the audience on, But it is a, uh, drained through. And I'm not sure if it's dreamed for an echo or I'm not entirely show, but I think there's a drainage. I'm not sure off our strength. Yeah, that's great. So that is one of the options that you can do in pericarditis with fusion. Absolutely. Um, does anyone from the audience want to just type in the chat before we reveal the answers? Yeah, absolutely. Well done, guys. So you probably got loads more answers, and I could have thought off, but this is how I would answer this question. So in your osteo, you ST, depending on how you like to hold the most things I was like to split mine up into conservative medical and surgical management on before all of those, the really important things to make sure that you're a safe F one or wherever you're practicing a safe doctor, you want to be ensuring that you're doing your A B c d e. So you're making sure the patient, it seemed American stable. They're not going to decompensate very quickly and they're not going to go into cardiac arrest. That's a really important thing. So every single patient that comes in TD um, while you want to do this on the second thing, call your senior. That's really important. That was one of things. That card of medical school when they run a revision session, Forest said that you would fail if you did not say Senior review. If the patient was very very, um well, because you can't handle this is the first year that you're in. You know, as you're a doctor, you need help from the seniors of a B C D E. On call for your senior if you need help. So breaking it down now into your conservative medical surgical so conservatively you congenitally say roughly the same things for every single condition, especially if they're more chronically managed. Eso patient education is really important. Tell the patient what's going on. You need to tell them you know what what's happening, that they're reassured them that they're not having a my card infarction. They're not having a heart attack and tell them what's going on to you. Want to describe that to your patient? That's really important. You want to make sure that it comfortable because it's going to be really painful? Is the saw a nine out of 10 pain severity, So you want to do fluids you want to rest on? Do you also want to be thinking about giving analgesia, which is coming on into the medical side now lifestyle. So they're always really important. Some of these things can exacerbate a kind of a pericarditis. For example, smoking is not gonna make any easier. It's gonna hit the inflammatory response on the immune system. So, you know, I always recommend the stop smoking diet and exercise really important. And then we come on to the main management off pericarditis, which is, as many of you said in the chat, Well done. You've got your anti inflammatory. So your end cents on you also have your aspirin. So either all usually ends. It is the one that go for on it's 1 to 2 weeks long, including a proton pump inhibitor. Because I wasn't, you know and said can cause irritation of the stomach on that can lead to issues with ulcers and acid reflux, which may exact Subait chest pain again. So you always give a PPI such a net result. Lines up result with that, and that will help to reduce that inflammation of the heart. Then we've got Coltrasine, so Colchicine is another medication. It can also be taken in gout, so it has, um, a function in kind of anti inflammatory, rheumatological type symptoms. I'm not too sure exactly how it works, but it is helping to reduce the inflammation. It's taken 500 micrograms for three months to help reduce the risk of recurrence, and if it's really, really bad, it's not being touched by the ends of the Colchicine. Then you might consider giving steroids again to help reduce that inflammatory process and help to settle the pain. As Ali said correctly, If this is, you know, really, really serious or it's causing a lot of problems, then you can do a pericardiocentesis. This is a operation or procedure where, by you very carefully, place a large needle into the pericardial space on drain out and aspirate that fluid to help with not only cardiac function, helping to feel the heart more quickly and help with diastole, but also they also helping the systolic function as well, cause you're not squashing the heart with all that fluid. And if you have a complete emergency such as a a cardiac tamponade, which is whereby that's fluid build up so much in that small space in the heart, but it stops the heart from beating. Then you could do a clamshell thoracotomy, which is something you'll not be expected to do as an F one or above, so not essential that you mention it in your in your risk. Your ski on Essentially, this is whereby you open up the chest, flip up the chest wall, you access the heart on you, take make a cut, a direct cut manually in the pericardium to let that fluid all out on. You can also do cardio massage and things like that. And that is, if they are in cardiac arrest. Nothing you'll do is an F one. Um, so this is just another view off pericarditis. So we have spoken about this, so I won't go touching a team much. But we've gone through all the symptoms. You have this to look afterwards. Some of the causes we didn't go through, so it can be just a known you can get it from a viral infection, which is why we want to do that viral screen and are infections. You know, our investigations. You want to be looking at the bacterial infections as well. TB is actually the most common worldwide cause off pericar dying tests. So it's something that you always want to think about. If you're in, You know, if you're in a new area that has a high incidence of TV, for example, some areas of London, um alter immune diseases as well. So if the patient has a history off rheumatoid or SLE. So Lupus or back, it's disease, you know, even inflammatory bowel disease. They have it at heightened risk off having inflammatory like diseases. So that's need to think about certain drugs as well. So penicillin and is a nice visit, I hope announced that correctly, but that isn't really common causes. Well, so have a look at the medications as well. That's something you could mention Investigations. I checked to see what other medications are looking a drug chart and then address. Listen, room, which is actually pericarditis following an m. I. So even though this patient had pericarditis, didn't have any changes on his Eastern gee suggestive off a nesky make event. Always think if these patients are looking like they have pericarditis haven't had a previous ischemic event. We've already being for the investigations. And then we've already been through the management as well. So just a really quick overview off a differential that I thought was interesting and important to talk about was, um I So I'm sure lots of you know this until you're blue in the face now, but just to go over it really, really quickly as it's important, and it's very common, so it might come up in your your exams. So as we know, it's a central crushing chest pain that radiates to the left arm and up into the neck, associated with lots of different symptoms. Such a shortness of breath, nausea, vomiting, feeling very sweaty palpitations and that feeling that they're going to die. This impending doom. Just a point. Be very careful about those who might have a silent Am I? So lots of patients may have, you know, be having ischemic events, and they have no idea it's going on. They just feel it. It's a bit not quite right. They might feel very sick under the weather flu like symptoms, but actually they're having a cardiac cardiac ischemic event. So always think about this in your diabetic patients and also middle aged women as well, because they can present differently. This is because of the autonomic nervous system dysfunction in diabetic patients, at least so because they're they're nervous system has been effected by their chronic hypoglycemia. It means that they don't feel paying quite the same on both a present with these am I that just don't have the classic symptoms. So if you have a patient that's very vague, maybe it's worth doing a troponin just to make sure that they're not having one of these events. So again, with the investigation spitting up into bedside bloods and images, so observations and start the news charge, we mentioned the C G. Where will have look at things such as ST Elevation, your Q waves and your T wave inversion, which will go through in a second on also your ABG as well looking for any lactate, as I mentioned on, If they've got shortness of breath, you want to be looking at that oxygen level are the hypoxic? Do we need to get the more option the Bloods again? FBC and CRP very much for the same reasons as pericarditis. Also important thing. Anemia can cause chest pain because if you can imagine, you don't have enough hemoglobin current around your oxygen back in lead to an option deficit. Not meeting the demand of the heart can meet Teo chest pain and tiredness. So something important to think about their using these and bone profiles again for reading years. But cereal troponin I mentioned before, which is diagnostic for at least the stemi and an end stemi and then risk factors might be useful. A swell. So your glucose c, HBO and C and your lipids is these can kind of give us clues as to why the patient might be having an m i or these kind of symptoms. We could help risk gratify as well. And then also LFTs and amylase. You want to be thinking because the pain is central in the chest, you know, could it be a different kind of pain? So, in epigastric pain, could it be a pancreatitis causing this although there should be other symptoms along side Back on again, Your chest X ray for everything with chest pain on your CT angiograms. This will be later down the line, looking specifically up those corny arteries injecting the dye and seeing how blocked up these arteries on that that controls didn't done during a PCI, which is a procedure to help unclog of those clogged vessels. Essentially S o A. C. S here. This is essentially the umbrella term for any kind of estimate event of the heart on many of us on the chat said, Why isn't angina one of the differentials? It definitely could be I Maybe I should put a C s there instead of my card infarction. Specifically. Absolutely. It's untenable. Angina could be a symptom. So how you kind of split these up? I'm sure many of you know this, but how I like to think of it. Unstable angina. These patients will have a negative on all the tests. They'll have the classic chest pain, but it will ease off after a certain amount of time. Once treatment has been initiated on that easy do you will be fine. Um, Metrop own INTs will also be fine. So that is an unstable angina. And they need to be thought about either chronic management in the GP or they may need a treatment of hospitalist. Well, in terms of an end stemi. So this is a non ST elevation, am I? So they're gonna have a positive troponin suggesting that they are going to be having changes of ischemia in the heart. But they have no ST elevation. They might have ST depression or T wave inversion. But that ST elevation you would see is not there and then finally, Stemi has everything. So it has positive proponents over time that cereal that Syria level on. Also, they have a new bundle branch block or in ST Elevation on the GI. Here's the C G. This is an example. So within a end, stemi, as they said, you have the ST Elevation, which is one millimeter or more. That's for it to be significant enough to be classed as this ST elevation on this is above the eyes electric line. Or they can have a new bundle left bundle branch block. Um, with, um with symptomatic with symptomatic change is a swell on. Also, it will be localized to the area of damage. So it's going to be localized, Teo, essentially the to to where it is on the on the heart. So this is an example of what I'm talking about here. So as we can see, the inferior are going to be in this area on as so on in terms off something important reciprocal changes. This is something to think about. So if you have a change in ST Elevation in one of these leads, then essentially what you're going to get is a reciprocal change in in the paired lead if you so I'll kind of explain that it was something I had to think about quite a lot to get my head around. So if you've got an anterior, um, for example, here, if you've got an anterior ST Elevation, you can use this acronym called Pales to figure out where you're going to see that reciprocal change, which essentially is thie opposite off the ST Elevation. So it's gonna be an STD pressure. So, as I say, if we got an anterior stemi, then we go to the next one over here. Then we'll have ST Elevations in these leads, which, as we can see well, V l v free. Sorry, before be 56, and then we're going to have as to depression in these I waves. So this is gonna be this area here to your three and your a b f. So they're gonna be slept over on. I'll show you an example, but in the next one, so we've got a Q waves. Eso These are essentially negative deflections, and they can be normal. But when they are abnormal is when they're one millimeter wide and two millimeters deep, which suggest partial thickness ischemia. So essentially, it's not gone all the way through the wall on. So it's only is only in the That's that small section, and that's what that suggests. And then T waves. Obviously, this is after we've had a prolonged period off in ski me. Um, we have a T wave inversion on that's permanent after 24 to 40 hours. So if you see any CD that has that always track of the C G beforehand, because that might be suggestive of a skinny oh, previous ischemia. So this is an example on Daz. You can see here we have an anterior lateral am I. So this is a huge, almost tombstone being ST Elevation. You can see it and be Want me to be three little bit before and it's starting to go out and be 56. So it's very anterior slightly lateral on. And then if we think about this but the anterior here, we jump to the next one inferior. So we have reciprocal changes, as you can see here in 23 and a B F, which is a very A leads, so that will just help you if you're really unsure what type of them I I is. Look for those reciprocal changes and that can help. Um, and this is just the management. I'm sure you know this very, very well. So I'm not gonna go into it too much detail, but you'll have the slides afterwards. So the acute management, as you well know, is your Mona. So your morphine along with an anti emetic your oxygen if you're If you're below 94 you don't want to give it if the patient actually has fine SATs because oxygen has been shown in the research to be harmful towards patients because it can cause free radicals that attack the body on just don't do any benefits, so only give auction were required. And, as you know, 50 liters per minute, 100% on rebreather mask. Then you've got your nitrates. So this essentially is going to be your duty and spray sublingually. Give two puffs, wait for five minutes on. Then you want to be thinking about further treatment on, then your aspirin. So you want to give 300 mg of this and you want to patient to chew it, because that will increase the surface area on it will be absorbed. Sublingually better through that. Frieda, you could, uh, the mucus in the mouth. Um, so then we want to be thinking, Okay. Is it a stemi, or is it an end stemi? So as we said, Stemi is going to be a positive proponents on. You're going to see ST Elevation, So first we gotta think is okay. Can we get this patient to a percutaneously. Connery intervention center within two hours? This is really important. And if yes, and what we need to do is we need to get them there as quick as possible on We also then want to be thinking about your dual anti platelet therapy. So we've given the first anti platelet straightaway in a any we've given the aspirin or couldn't even be given by the member of a public call The ambulance. We want to give the second one. So that's the passive girl. I'm not very good at pronouncing these drug names, so that's this one here. And then you also want to give additional drugs. These are from the nice guidelines you want to be giving your unfractionated happier in. So that's just an anti coagulant which is gonna help with this PCI because, as you say, it is a perfect a notice. They go through the vessels and so they don't want the blood to clot along the way on also something called a bailout GP I on. I'm going to be very honest with you. I'm not too sure what this is. I'm sure many of you do, if you do know, put it in the chat. But it's something that's given along side. I think these go above and beyond what's required for skis. These are just from the nice guidelines. Then what we have is we have on the no side. Well, we need to get me to break down this clots there in the heart before the patient has a cardiac arrest. So we want to do from the license. So this is giving an agent such a selective players or out of place to break down the clock. The additional things you want to give is your anti thrombin because you're breaking down that court. You want to prevent that coagulation cascade from going further and creating this fibrin meshes. So that's just one of the factors that is involved in breaking down on helping to kind of anticoagulant the body. Then you've got your second anti platelet on this side of the algorithm, which is your take ocular a while. I can't say that either on. Then you consider the PCI for the run Just a way to remember which which antiplatelet to give PC. I always give the one beginning with p the past a girl. But again, this is above and beyond what you're required for your rescue. So then, on your end stemi side, we want to give fund a paradox straight away. And this is a form of heparin on. This is just what differentiates it from the end stemi. Then what we do is we need to calculate the grace score. And essentially, what the grace score is is that calculates the probability off a patient dying from this myocardial infarction, lowest considered three and below. And if this is true, then what we do is just give the do anti platelet and observe them in hospital until they seem stable enough to go home. If it's high, so above three, then we need to think about the PC. I either immediately if they're unstable. So if they're, you know, the hemodynamically unstable, they're shocked. They have that blacking out having syncope is, um, or heart failure Science. Then this is what you need to do straight away. And you can do a PCI. If the patient is having a cardiac arrest, a z well, you could do it at the same time. Is the resuscitated on then, if not to 72 hours after if they're stable and again, you want to give you Abdul anti platelet. And if they are going for PCI, obviously you want to give you unfractionated back urine again. And then this is the chronic eso. It's the four raised that aspirin you want to give a B two blocker so atenolol atorvastatin. 80 mg for secondary prevention and then a synod. Bitter. So those are your four aids, but a century's. Then the aspirin Be two blocker, some sort of statin at a secondary prevention dose and any type of a cent Hypotears. Well, that's that's most relevant for the patient on this GTM straight, just in case it happens again. So I'm going to go on to another case now. I'm going to do one more case just in the interest of time. Because her hair has been great cases. A swell. I think what would be most useful is I'll just skip through this quickly because I'll do the last case. But essentially, this is a patient who has shortness of breath. Um, on essentially, if I skip through so, Secretary yet, um, I was going to say my me. So I want to do anything. They have to take it to the Peterson. I'm just going to say I've sorted of sorted it out. Don't worry. And you do 23 cases. Yeah, assorted. That sorry. Know, works is no worries that side. That's fine. Okay, so I just need to myself, so we won't We won't skip for it then. So, uh, if in the interest of time, we're not going to take any volunteers from my section for this one, but they'll be opportunities Hurriyah, But a century. This is a 33 year old female who presented with acute shortness of breath. You're, ah, 50 medical student shadowing a medical registrar who's on call. Okay. Um So what we find from the history is that the patient is presenting with acute shortness of breath. Um, this has onset. 20 minutes ago, the patient was at rest. It was worse. When the patient is trying to get out of bed on, there's been no improvement at all with anything she's tried. It's very sharp, and it's on the left side of the chest, but it's not radiating to a neck. All are mature all on it. It's a lot worse. We should take a deep breath in about six tens. Quite quite uncomfortable racing heart sensation. There's no cough hemoptysis ists, fever, loss of, um, loss of consciousness, nausea, vomiting at all. Otherwise, she's completely fine. Um, when you ask her, she has. She hasn't surgery. She is in hospital because she's recently had surgery. Eso she's got a bit of pain in her leg from her surgery, but nothing else. And she is immobilized in bed and she got a back slap on a dressing on her legs. You can't see her leg of the moment. Um, as I said, she's, um, had surgery for a fib fracture due to trauma. She fell off a horse horse riding on that was operated on five days ago. She's just not really being very compliant with getting up on the feet and trying to get home. She also suffers from Hey, Fever takes cetirizine for that on She's on a contraceptive. Pills were gathered on, which is a combined pill. Her mom had breast cancer at the age of 60 and otherwise, this is a social history, as you see on the screen on in terms of asking her, Why do you want to be discharged? She's a single mom. She wants to get home for child care issues, but she's in too much pain. So she had. She's had been enjoying being your hospital, essentially, but she wants to get home. So differentials if you want to pop them in the chat. But here is, um, up here. So we've got a fat embolus. That's great area, and that's a really great great suggestion. We've got P. E. Here. That's great. Wonderful. So yeah, absolutely. So again, going through our system to review anemia, it could be shortness of breath. She's lost blood in the surgery. We need to take a HB, see what her bloods were doing. S so that could be an option again. M I was another one on hemorrhage just from what I said. Oops, Sorry. Then we got rest. So p e. Is People have said pneumothorax. Absolutely again, just like the last case. Pneumonia? Possibly less so. Could it be a first presentation of asthma? May be very, very vague. Costochondroitin, uh, it's again chest pain, a DVT maybe on then could it be sepsis? You know, she might have a high new school, but let's find out. So these are what you find on inspection. So inspection she sat up in bed. She appears quite comfortable. She's short of breath, but she's able to complete full sentences. Her observation. Follow sushi's hypothesis it at 93. SATs of sorry, heart rate of 124 slightly low but fine. BP 96/40 and at Pyrex, did you not? Pyrexia will replace is fine, and she's a on the afternoon, completely fine with the chest. She has normal heart sounds soft nontender, but then looking at her legs. So she got a cast on her left leg. It's a back slab. Her leg is a little bit swollen inside, but it might be due to surgery. She's not in any pain, but there's a bit of readiness and swelling in comparison to the other side. So in the chat, what other test would you like to do now to calculate what's going on? Yeah. Okay. I think Abdullah's gone it. So you want to do a well school? Yeah. Great. Thank you, Rachel. Perfect. So you want to do your well score? So your well score is essentially a school. It's done. There's one for DVT. Um, off of Pius. Well, on its tells us how likely the patient has is tow have a p e and how we need to investigate it. So this is the criteria I will go through into much detail because we have a really short of time. But the patient score is nine at this point. Eso what investigations would be like to do if the patient's well score is nine in the chat, the patient has a well score of nine. Yeah, great everyone. So we want to go to a CT, pa. So, thinking of the world school, we break it up into over four or under four. So if we look at four and under, a p E is not very likely. So what we do first is a d dimer. So D dimer is a blood test that looks at how the body is clotting system is clotting, um, to see whether, well, whether there is a clot being formed in the body very simply on essentially, this could be raised by a number of different things. A p yes, DVTs, but also pregnancy trauma, recent surgical history. So there's lots of things that can increase this, so it's not very specific test, but if it's negative, it could rule out a PT. So as we've seen here, negative, we can consider alternative diagnosis. But if it's positive, then what we need to do is we need to admit them comment on the anti coagulation and then probably do a CT pa as well. Um, if a P E is likely on the scores above four, then we do a CT pa. If it's negative, we can do an ultrasound, for example, off the leg that we're concerned about. But if it is ah, positive, then obviously we need to admit on to comments the anti coagulation, other things that we need to do before the CT pa obviously the bedside, which is the same as the previous case Again, a lot of these were the same from the previous case on the imaging. As I said, Really important. Always get a check. Specs array. The radiologist decline to do a CT pa if you've not done a chest X ray first to exclude of the pathology on an echo is well, just to see if there's any bright heart strain from a p e. You know, starting of the heart failure or if there's any other abnormalities that might be causing the patient pain. So here the investigations. So what is the top differential now? So here what we have is we have a A BG for this patient. Um, so the pH, as we can see, is slightly high. We've got a 02, which is low. Are you 02 is also low on. We also have a normal but low on the normal side. Bicarb on our basics. Ass is normal. So essentially, because this is high, you know it's an alkalosis because this is low. We know it's the patient is hypoxic. They're not getting enough oxygen in, um, it's low ast Well, so because we've got a low. So to the patient's hyperventilating, blowing out all this year to you, too, is acid it when it's converted in the body with a hassle back in question. So we know that this oh two is gonna go out of the body on then a bicarb normal. So there's not been any compensation. A tall, but it's slightly low. So it's starting to make its way lower, suggesting this might be have been going on for a while. On then, the base success is normal. So this is a risperidone alkalosis this. Okay, Onda, here's the CT scan that you get on. This is contrast CT. So this is the heart down here we have here the pulmonary arteries popping out of the top here on what we can see. So the blood should all be white here because we've put in a die. But there's something blocking in this in this area here. So this is a CT pa that demonstrates a saddle p E. That's extensive, the segmental subsegmental branches of both pulmonary artery branches. So all you need to know there's a huge clot, but in both off these and it's a saddle cause it's going over both there. So your final diagnosis is a P. How do you treat it? Um, does anybody want to give a quick post in the in the chat? How would how would you like to treat this patient with a P? Yeah, What's in advances? Anti coagulation? Yeah, absolutely. Doac Brilliant oxygen? Yes, lovely. That's great, guys. Well done. So, as we say, as always, ABCDE call your senior. You know Pe's are dangerous. They can cause cardiac arrests, and patients conduct so it's it's you need to get your seniors in there. You need to pull that emergency buzzer if the patient is in stable. But I always get your senior in to review what you've done. So conservative as we said, patient on maybe family education, you want to admit them the hospital and you want to give them the supportive things your oxygen to get their SATs up really important. That would come apart your A B C D e. Your fluids, your analgesia because the patient of pain on antiemetics alongside that and you want to make sure they're in recess, that they've got a P E. And as I said they can go into cardiac arrest, get them in recess, put them on a cardiac monitor on, have 1 to 1. Nursing, if you can. Then you want to do your medical. So as many of you said by the 2020 nice guidelines, we've had a change recently. So yes, the first line is a dose pack for P e apixaban a rivaroxaban, for example. Well, and this is for three months. If it's a back to cancer or if it's unprovoked, I'm not too sure what the cause is. Then six months is is more appropriate just to keep the man to coagulate it for longer. Second line is your warfarin. So this used to be first line before doac. So this is warfarin for three months. But in the meantime, you want to give you a low molecular heparin. So, for example, clacks saying or an occipital, um, until either the ionized above 2.5 to the blood thin enough on also, if they've been on been on the warfarin for five days, you can then stop it after that. And then if there are unstable, you want to give them from below. Isis, just like in just like the, um from a license in stem ease or and stemi is you want to give this in this because this will help to break down the clock. And this is only done if they've got a really, really big P E on imaging or if they're unstable. Um, and you can also give this during a cardiac arrest a swell. And if they do get given out of places or from a license while they're having a cardiac arrest, you need to do compressions but 90 minutes to ensure that the drug is the time to use. And only after then can you decide to terminate. If you think it's appropriate on in surgically, you could do it from back to me. Although not very common on def is a recurrent problem with DVDs and PTT button ivc filter into. That's an inferior vena cava filter, which is a radio interventional radiology Kel test where you put in a coil and it's like it looks a little bit like a virus, you know, I mean by that with the legs and a century, it prevents clots going up to the lungs and the heart. If they're pregnant? Uh, just a few different differences. Checks a chest X ray. Always first to exclude. Even though you're giving radiation, it's still really important. CTP a well or V leaky scan. This is something that's debated, and lots of medical students get confused. I still get confused, but essentially you need a way up the rest of the benefits of both the child and the mother. So a CT pa is worse for the mother because it increases the risk of breast cancer over time. But the VQ scan increases the risk of the childhood cancer as well. So even though you may hear beacuse gone more so in pregnancy, I just have a think about you know who, who, what you'd like to do and what resource is your department has between giving both of these and then the differences in medical a war. Avoid warfarin and doac do not give them. They are teratogen IQ, and they're not. They're not indicated are licensed at all in pregnancy. Use a low molecular weight happier and fall out three months or six months, period. And that's just a Nexium sample of what we've been over today and as many of, you know, hear some of the risk factors, which is the only thing I don't think we've covered yet. So, as you know, inability. That's what the patients had a recent surgery. They've been a long haul flight towards the pregnant. They have cancer. If they're on hormonal therapy, just like this patient was she was on regathered on, which is a combined pill. Um, and also things that she's having too many red blood cells can help clot the blood more making more viscous. And also from a failure on SLE as well. So that was a quick overview. I'm going to you go over the last case. If that's okay with Hurriyah. Unless you want to take over. Do we have time? Thank you. So that's all right. So I'll carry on. Um, thank you guys are sticking with me. Um, sorry. I do. Awful s. So now we've got our third case. So your fourth year medical students on place of the ambulance service, this time you're bringing a patient in the hospital. So it's a 79 year old female who presents with acute shortness of breath. So you take a history on do here they are. So she's a 79 year old female again, cute shortness of breath. It started last night on It's gotten gradually, worse over the morning. She's got really, really very sure of breast. It was initially when she was walking around, you know, going to toilet at night. She felt like she really proper self up when she was asleep last night. Um, you know, really struggling for a bath. But now it's even when she's at rest. She she really, really worried. She's very weak, She's dizzy and she's really panicked. She's mentioned. She also has a cough, which is very bubbly of Fluffy. She mentioned a little bit pink in nature because had know discolored green sputum, no blood in her sputum, no pain. And she's not lost consciousness. You just feels really short of breath with this new cough. Um, she has a F in her past medical history, and she's had an MRI in the past, but otherwise she thinks the heart's doing quite well. She has her hypertension COPD hyperlipidemia, and she has diabetes. Type two on. She takes these drugs for her. Her symptoms. Her mother died of an M. I at 55 her father at 89 off a stroke of CV A. She has an ex smoker on, but she lives with her husband home. He's really worried about her on She stared that she has lung cancer with this new shortness of breath. So Differentials s 01 of the spitting up again. We might be thinking about heart failure in this patient. She's got a cardiac history. Specifically, she's had an MRI in the past that increases your risk of having failure. Ventricular failure significantly. After those, she may be having a Q am. I remember she's a female. She has diabetes. Could this be a silent? Am I just presenting a little bit differently again? We want to exclude the ped. You know, we haven't asked about her mobility, but if she's 89 to maybe less mobile, you know she may be taking. Maybe taking hormonal therapies may be a little old, but she she might be need to take her there. A history of pneumothorax. Also something to think about. As we said, exact patients, COPD and things have not put on there, which I'm sure you can also think about again. You wanna be thinking about your pneumonias and things like that in this older population who are more at risk. So we're now moving on to a case presentation your exam. So she sat in the chair. When you go see with the ambulance, she's gasping. She's using her accessory muscles, and she's got a very wet cough. But when you look at it, it's It's pink and frosty, and she's unable to complete sentences very well. She's very breathless, A SATs, although are quite fine. At 95 heart rate is fine. At 85 she is a little bit hypertensive, but she has hypertension and 5150 systolic on she is. She's not pyrexia. Well, her glucose is a little bit high, but she does have diabetes on, but she's alert when you listen to her chest hurt you here. Fine. Inspiratory crackles on lots of just noisy airways on. Then, when you listen to our heart, she has this kind of 3rd and 4th heart sounds in. In addition to her 1st and 2nd, when you look at her carbs, they're just a dematerialized pitting edema on. She's had this for a while. She tells you So what investigations would you like to do? Can you put them in the trash? Yeah. Great. Since some people saying bmp lovely. Anything else you'd like to do? You're taking her in with the with the ambulance. She's in any What would you like to do? A chest x ray. Great. Got to be across to you. Was great. Anything else yet? 80 g e c g a blood glucose. Excellent. Yeah. Lovely. Great guys. You You don't really well there. So again you want to do? Although he's bedside examinations really important sputum culture. Even though it looks pink and for free. You want to send off that sputum culture on you might want to do a urine dip. A swell if she's an elderly lady and she's decompensating. But she's alert. She's not confused. So maybe not be relevant, but something to think about in this age group. ABG again? She's short of breath. She has COPD really important. Do that ABG and you might need to repeat it several times on. A lot of these are very similar to the others. As we said so fbc looking for that inflammation markers. You want to do your electrolytes, looking at that renal function, looking at any abnormalities, causing problems with the heart again with the bone profile as well. CRP as again proponents BMP really, really important. As you said So BMP is it is a marker for heart failure. It's not really useful as a one off. Generally, it's done in GP over a longer period of time. It could be used to help with kind of surveillance maintenance of the time. But essentially, it could be really important to help think about referring to cardiologists into heart failure. Specialist on Did something really important be done? It is a sign of heart failure. Liver function tests. So this patient got a Dema. Could it be hard liver failure? Could it be ascites Or, you know, peripheral edema Do two liver problems? Um, again, TFT is a really important for that cardiac chest pain, but cultures because the patient, you know, might have ah, news chart. And if you're thinking about sepsis, something to think about, maybe less relevant. This patient is in. Her observations were better, and she was a Pyrex deal on. Then your cardiac risk factors as well. And again, as he said, chest X ray on really important here echo, because that's going to show you what the heart's doing. So here, your investigations. What are your, uh you know what? Your findings. What would What do you think it is? Differentials. So can anybody tell me anything that's wrong with this? So you got a B C D e. Okay, okay. I'll expand on that in a second. Consolidation cardiomegaly. Okay, we think maybe some pulmonary fibrosis called you my going infiltrations Battling sign pulmonary edema. A great great, um, suggestions, guys. So this, yes is essentially what we're going to find. So as someone said in the chart, your A b c d e off heart failure. So this is a really good new monitor to look for the signs of heart failure on a chest X ray and essentially is gonna be alveolar a Deemer. So when you have heart failure and they're so congested, there's lots of fluid in the lungs. These alveolar going to get really swollen and large. You're curly. Be lines Are these little lines here that are shown very vaguely at the sides. And this, again is a sign of that pulmonary edema of this loads of fluid on the lungs because the heart isn't efficiently pumping that blood on. So all of the all of the fluid stays in the lungs. Cardiomegaly is you said so that's when the heart is greater than 50% off the chest wall, which we can see here the trust capacity. And then we have the dilated upper vessels, which you can see around here is S O. They looks a little bit like Broncho Grams, but they're not quite there. Just a larger second, because it's lots of fluid around them and then effusion. So that's when you'd be looking at this. Cost a friend a Kangol at the bottom, so we can't really see much of it here, So that might be a sign, but it's not generally a very clear effusion, but something to look out for a swell. Okay, so your final diagnosis is acute exacerbation of heart failure. Thank you to everyone that put that in the chat. Well done, eh? So how would you treat this? So first thing you're on the a B c d. E. And get your senior as he said and then I like to think of it as a B C D. Again. So all of the different treatments, I think I can relate into the ABCDE protocol. So with a you wanna optimize the patient's airway the short of breath gasping for air, they're coughing. So you want to sit that patient that private, let them cough everything out on their Optimize that airway By keeping it open, you'll be is your breathing so you want your oxygen so even if they are COPD, if it's acute and they're very very, um, well, you want to give them that 15 liters anyway, later on, you want to think about more closely about the COPD, but give him oxygen 50 liters through a non B breathe mask, which is here you see as your circulation. So you want to be thinking about your blood vessels, and at the moment they're really overloaded. There's loads of fluid in the body, So according to the nice guidelines, the first line is to give IV for reason mind. So this is essentially, as we know, a diuretic to help the patient off load unload of that fluid on then second line is a G t n infusion to this essentially works again. Teo kind of get rid of all that fluid, So GT and as we know it's in my treat on. But it can be given, although it is second line, and then you got to think about daily weights and fluid balance. You don't want to give the patient those fluids, and also you want to make sure that they are dropping that their weight by losing all that water. So you want to be looking at that, then, d I think of drugs so you want to give your morphine and your antiemetics so morphine is. And actually for the pain in this scenario is actually for it's actually just a part of the algorithm. I'm not too sure, actually, why it's given on what the mechanism is. But if anyone does know, that would be great if you could pop it in the trash. But it's a part of that really important steps by step process of treating this patient acutely. We got everything else. Treat the underlying infection. So if there's anything that is exacerbating or causing the heart to go into acute decompensation than treat that, uh, antibiotics, for example, and then consider noninvasive ventilation. This is by pap. So you give this to patients if they are very, very acidic, so they're not getting their see a two out. Very well. So they have a heist you to so above six Killer Pascal's. You want to give them this an IV so bipap to help push auction in for his get it out as well. And this could help patients, um, and then treatment. So, um, chronically I'm not gonna go through this too much about the view slides. Conservative education referred to a specialist nurse. Check the BMP and make sure to surveillance the patient with regular follow ups. Give them their vaccines every year and again. Lifestyle changes to make them to improve that overall health. Then we have three drugs that improve prognosis in heart failure. A sin Hib. It'd be two blockers on potassium sparing diuretic. So just pyrinyl acting. These are the three drugs that proved prognosis on. Then you can also think about things to help about up floating. So fur is, um I'd like a loop diuretic, and then you've got your surgical causes, so treat any causes of heart failure so it might be valve replacement. So if they have a, you might want to oblate the f the atrium. You might want to do a cardiac resynchronization therapy, which is like a pacemaker to help heartbeat more efficiently. And you can think about transplanting patients a swell if there that's still there. And you can also use something called the National L Bad, which is a bridging therapy as well, which is essentially a assist device that helps to bypass that failing ventricle. And that's an overview. I won't go through it again as I know we're very, very short time. I'm so sorry. Area. Um but thank you very much for listening. I hope that was helpful on. But I'll give you my email in the chat and you can email me if you have any questions. Thank you. Yeah. Thank you so much is only for that. That was amazing. Um, yes, we super useful. And again, the cases those every courage are all the common things that would be more likely to to come up in the s case. So I feel like if you guys cover that these cases, you will you know you would cover most of the common things. So, yeah, I think it's every for that. Yes, I came. Say sorry. Went over. No, no, Total. Yes. Sorry. I just completely fine. You know, I think with these with this six cases, usually it just takes some time. I think I just, uh, underestimated the time I fall. I'm sorry. No, no, not the told. Honestly, thank you so much for coming. And, um yeah, everybody's really appreciates. The teaching was amazing. Um, yeah, we will post the feedback link, so you you get 2 ft like planks. I'm gone for a zillion for me. So that we can have two different people legs and then you and then I'll send you the feedback. Yeah. Okay. So, see, are you going to stay for the next car? Told you one, Teo, I'll stay for a little bit, and then I might have t go. That's fine. But you have course, it's my overall. I'm already late for for what I'm doing. But, uh, my, um I'll stay for a little bit. That's okay. Area. Thank you very much for helping me ruin his email. Me if you have any questions that so sorry around over time Yes, you will get the feedback guys will cause the feedback in the next stent stent. 20 minutes. Okay. With post feedback for half seven. Okay. So that everybody could shoot off if they need to. Um okay, so if I can So you don't mind? Um um unsure ing. Thank you. No worries. Yeah. Okay. Okay. So what I'm going to do with my case is is we just got to get Teo. Um, yeah, we're just going to get through them as a team. Um, so I won't be doing them individually. Someone be a picking up on anyone. I mean, you guys, I'm sure you guys know you know about the history of stay good histories, but it's just gonna be going to the case going through the differentials and that and, um, coming up with you. Okay, So first cases here in emergency department, and this is a formula history. Um, Andi? Yes. It's a 24 year old female that has come to us. She's coming with feeling, having a bit of a chest pain and feeling short of rest. Okay, if I just give you a little bit more about, um, about the history so she when you ask the questions, she's very It's really short of breath. And she tells you that he's never have something like this before. It started off yesterday. So she had a little bit of flu like symptoms, and she taught nothing off it. But as the day went and she started, you know, feeling worse and worse, the shortness of breath, but worse, the pain got worse on, But, you know, she's got feverish, and she seemed, and she's being very sugary. She has, right girls. Um, Andi, she's just really worried about what this could be. Um, so yeah, so we will post the feedback at a a half seven. Okay, so right before so feedback in the charts at about half seven. Okay, guys. Um okay. So, um, so far, any kind of ideas off what this thing could miss if I asked. And then if you ask her about her past medical history and she says you're already fitted Well, she hasn't got any other issues on. Do you asked about social history is she says that she smoke socially on drinks over the weekend on. Did you ask her about any kind of drug use over the counter or recorrect Radiational. And she says that a few months ago she just tried injecting heroin because her friends encouraged her to you. And, uh, that was the first of his evidence. And she's never done it before, and she hasn't done it since it was just one occasion. She's done it, um, and then and your issues that you should just a second year student unique on. Yeah, she's away for it to go up. Yeah, get accident. So, yeah, from the as you know, from the history, we can straightaway say that it's infection. The card itis as if you move on. Um, okay, So this is these of the examination findings, okay? Mm. So she's having a path started. Remember? She's tachycardia. She had a high temperature on her SATs. She's needing oxygen. Say, what is the cause of the past? Historically. Remember anyone in the church? Yeah, is it might really good. Which one is more common in people? Who do you see time you took used to get tricuspid six. And this is the meant to be a persistent can be. Um I should be good. Just well goes. I'm only saying this because the classic some question with tricuspid ***. Usually, I mean, trick use. Um, so Yeah. Good. So she's got a plan. Systolic murmur. Any new murmurs and somebody come into it with the fever and a new mama you always think off and fracture of the Congress is I should always be one of your top differentials. Okay on, then, You guys give me any other differentials that you had. So in the exam, when you go to for itself in this case, you would be expected to give some more difference just distant of that, that you are thinking of other things. Good. Mike, I noticed that's a kid to differential. Good success. Yes, it is. Abscessed. Get second to do any fool with infection. Okay, so with everything, they stuck you to be some coming somewhere from the chest to either the heart or the lung skit. So pneumonia, TB curve it. Um my appetite is that somebody said, you know, so any kind of infection is coming on everything that, like, sauce, is either the lungs or the heart. Okay, it So how would you like to investigate this patient's to let me know charge. It's gonna be very interactive, guys. Okay, so I think that's how we learn best. It's so we start with bedside bloods imaging on a special test. So, yes, so but he see GI would be about side Good. Other things that you could do in that side is, but is for cardiovascular examination of process of observations. Um, and then let's see little bit coaches. That's key. So any guesses How many but coach is you have to do to make it quit. You know, there's three but cultures. Yeah, good. So they usually has to be. Now we're apart. Um, Andi, each other important with senators, Somebody's mentioned ABG. If we sing using the CRP, that'll kind of brought the blood cultures, you know, And then in the genes since, like chest X ray, um, you know, just exercise quite to the most common one on then with special tests like echo. Okay, echoes gold, standard investigation. Anybody they suspect within effective and the card itis we need to have an echo done either a TTE or a T o. T. Okay. Mm. So, um, it will oppose the feedback, like in five minutes, guys. Okay, so data interpretation. So, um, so these are the blood tests to anybody? Um, So let me take me through to the to the blood skies. What can you see on up? It's one of the main abnormalities. It's a raised inflammatory Marcus, including white sitcoms neutrophil since crp. Excellent. But it did, um, kids excess of that kind of points towards the sample of infection. Okay, which again, um, you know, confirms the diagnosis of in fact you indacarditis. Yeah, it, um And then we have some blood cultures and the blood cultures have grown grand positive. Okay, so guess what? The organism is here, guys. What's the organism that is causing it this infection stuff? Aureus accident. Okay, so most common cause off. In fact, um, Interchronitus, especially in people will use this IV drug is start for us and against, uh, four years is a very, very, very aggressive infection. Okay, so I have seen young people in their in their twenties die from stuff or es infection on in front of you and doctor Carditis. Okay. Very aggressive. Really. Um, you know, you really it can kill young people. Okay. So, um yes, this young lady has gram positive cocoa. Just, uh, for us on that we've got some antibiotics that I resistance slash sensitive to it. So in terms of what I was trying to get from here was when you get blood culture or results, and then when you get sensitivities from the labs off the microbiology lab, the things to always think about is first of all, is a patient allergic to any of these. Okay. For example, if my mission is allergic to amoxicillin, I'll try and avoid amoxicillin and to tested. Okay? Another thing you need to remember is always start with. I'm always go for the lower spectrum. Okay, The tablets, that is a broad spectrum antibiotic. So even though it for my patients, sensitive to it, I will not use started several use a more natural spectrum. Like, for example, that, you know, from the center of your bank of myself something. Okay, so you're always comes in that respect. Um, and the reason that is to reduce the antibiotic resistance. Okay, so I think that is the kind of the main thing. I wanted to get out of this deputation. And yeah, and now people a chest X Ray. Now, this is an interesting just x ray. What do you think? Yeah, don't try drugs. Way to remember. Yeah, that's a really gauge and weight, remember? Thank you. A shiny Thank you. That shiny. That was a really good way to remember, Um, about the tricuspid regurge. Okay, um so look at the lifting of a chest X ray. And what do you guys want to do? You think that's what this lady is? Also presented the shortness of breath and this is quite interesting. I actually saw this in one of my one of my patients has this secondary to the in fact, in the car writers, except a gamble a wild on kera. Excellent. Yes, septic embolize. So when you have infection interchronitus that percent risk of having accepted embolize. So that sets this of those that kind of vegetation that you have any of our roles. But was this letter embolisms to kind of fire away everywhere? So sometimes you can get that in your joints. So that's why people can come in the joint pains. You can get that in your fingers, except some people get less splinter hemorrhages on and sometimes making the Asian Getting in your lungs and that causes September 11 was the shortness of breath. So this winter, these kind of little ambulance can just fire away and go everywhere. I can't even go to your brain and cause a little strokes in your brain. So again, really important thing to kind of remember. Uh, okay, so you're excellent. Very good. And there's somebody that said primary team again. That's a really good point. Because if if, in fact it was under carditis can cause acute heart failure on that can give you pen redeem. Uh, so again, a very good differential. That okay. And so yeah. Thank you. There's really good answers, guys, if you're doing really well, okay. A lead liquid school part. So this is just a little bit about, in fact, of the competitors, and she can usually get a native vials infection or a prosthetic of infection or 11. Jack, appease. Okay, so this late 80 had an IV drug abuse interchronitus. Okay, um, and then we just talked about the signs and symptoms. Okay. So people can send with kind of vague symptoms of, like, flu like symptoms on, and you can get joint pains. Okay, Um, headaches, fevers on. And this is just a little bit of you know how common they are. So which one do you think is the most common cause? Off off, In fact, um, endocarditis. So which bacteria? Cause this is the most common in, which is the second, which is a third common. Any guesses? Yeah. Good. Yep. So this is a yes traveler days, Usually most common in the native kind of infection, Um, and stuff for this most common And do people with drug abuse, substance abuse. Okay, all people with prosthetic valves. Okay. And then if the third one comment is integral Christ, of these three on the slice at the top, most common books that was infected and accreditors. Okay, so, yeah, I've got a little bit of kind of differentials here. List of the French is, but you guys gave a really good missus. Well, so I'm Yeah, and this is a little bit about investigations, and we've already discussed it. Somebody in the chat measured about the do correct. Yes, the well done for. That's to do correct, right? It is really important, you know, in order to diagnose somebody with infected and accreditors. You need to use the do criteria. So usually to measure criteria for one major and three month Proteus or 500 proteinemia will confirm the diagnosis off effective. And the writers. Okay. Ah, okay. And this is a little bit about the management. So before we go, any guesses in the chart of how you would manage this patient? Acutely. If they come to you in 80 with sepsis, exit A to leave any acute stations. Always 80 on sepsis sticks. Excellent. Had a very good on. Also. Very good. Um, Rachel a shiny for for the 80. Assessment. Very good. Um, yes. So that is your go to 80 assessment of substance. Six on, then with this abscess sticks comes giving them antibiotics. Um, before you get the medical to results come back, you can give them the broad spectrum and pickle treatment. Um, usually have you guys heard of micro guide is really good after that. You can use to to find out which antibiotics are used to you locally in your kind of trust. Um, so, yeah, Antibiotics is key on more water. Often than not, these antibiotics were given long term, so patients usually need things like a central line of pick line to kind of make sure that they get the antibiotics. Um, and then finally, surgical is not as it's not kind of for your immediate management. But if if the patient's getting sick and sick and you're you're struggling to control the infection and that you can use surgical management. Okay. Uh, okay. Excellent. Okay. Next case. Okay, So this is a 56 year old gentleman. Let's come in with, um, progressive filters of breath and cough. So, um, if I give you just a little bit of history of our 10 to, this is something that's been going on for, like, 6 to 8 months. Um, and you know, he is kind of feeding. He did. He doesn't think that it's infection because he has these look good. No symptoms of infection. Um, and it's really affecting his day to day life. You know, he's struggling with exercise, um, on, but, uh, and is if you when you ask him if you wore questions, Um, usually the shortness of breath comes on exertion. Um, another course of the cough is nonproductive. A dry cough. Um, and he has, um if you want to ask about the social history, he says that he's been smoking all his life, has been a heavy smoker all his life. Um, and he has a family history off of lung cancer and other lung problems in the family. So what would be you? Talk to your talk differentials in a dry cough and, uh, progressive shortness of breath. What? What do you got? A What do you guys thinking off here? Lancaster again really do. Especially the fact that it's going on for such a long time. And the fact that's going on for six months. Um, so very good on deaf COPD. Okay. But it gives the fact that he's had a very kind of kind of, um, history off like, um, smoking, heavy smoking history. So very kids. Uh, lung cancer again? Um, card, but bronchitis. Very excellent, Serena. Very good. Lung cancer. Yeah, it's taken us from the history of the patient Is weight loss. So when you ask it, he says yes. He does have a close eye on your age. You're perfect. Perfect fibrosis carrier. Very good. That would be one. If you talk to friends. Is a swell because the patient, the dry cough and and the progressive shortness of breath Esposto says yes. So any kind of interstitial lung disease is there? I can see. Excellent. So, yeah, that will be my truck to French is a swell, um, basis when you Okay, so when you examine the chest, you you hear some fine inspiratory and it's pretty crackles. Okay, So So any kind of Does that kind of confirm any diagnosis for you guys when you hear those crackles? Is Frank crackles in the chest? Yeah. Very good fun. Refer Grosses Exit. Oh, could be long, Cool video games. You can ask them if they've had any recent infection. Um, Cupid infection. Okay, so it could be a coast for bit complication. Okay. Because with probably fibrosis that are different horses affects a drug skin cause every fibrosis surgeon Can you name me a drug? That who's this memory Fibrosis? Yeah. I mean, you're doing very good. Good. Um, your drone billion, my sin. Methotrexate. Minor. Very good care. Uh, not your friend too. And accident. So it could be It could be due to drugs. It can be due to kind of feel the occupation. So this gentleman, if you asked him He said that as a young man he used to work in a factory on he waited for What's the factor for, like, more than 30 years off his life? So again, occupational history is really important. Um, and medication is just get really important. Okay, so, uh, let me move. Sorry. Okay. See working. What does this last? This spirometry. What can you guys see from that? What kind of picture is that? Spirometry. So So my question here is is it a restrictive or obstructive extensive, restrictive picture? The X and so permanent fibrosis causes the restrictive her restrictive lung picture. Okay, um, and then they got a chest X ray here as well. So what? What are these? The chest X. It one of the classic chest X ray findings weaponry, Fact doses. Classic exam question. Yeah. So it's Yeah. Yeah. You tell me. Come here. Good that you see that All ct? Um, yeah, it's 30. So you're kind of the most kind of the best investigation of choice of the gold standard is a high resolution CT. But the diagnosis Valerie fibrosis, um, on on the Chest X is usually ridiculous. Noodle a shot a week. So as you can see this little mark, it's it's called reticularis dealer should do eggs for classic, Just extra findings. Okay. And on then you've also got the ABG there. Which shows what type of respiratory failure is that? Your disciple. A structure failure on because of the low oxygen in the normal carbondioxide. Okay, Good. Um, so, yeah, these are some of the investigations that you can if you could request for this gentleman. Um, okay, the in terms of management, then how would you manage somebody? So this just was coming to GP. So I'm not worried as much about the cure to management, isn't it? They're not a steak. Acutely, but so how would you kind of manage them in the kind of war of her chronic setting rather than acute setting? Yes. Well, uh, how do you divide the management in any skin station stations? How do you conservative Medical Surgical? Very good. Rachel's so conservative would be. And it's just smoking cessation. Pulmonary rehab against your library. Get pulmonary rehab. Excellent. Um, yeah. So surgical billing process remission. Very good. Um, yeah. You could further into respiratory accents. If you're in a GP setting, you could if you need to refer them to more specialists. Okay, Um, and usually in Cardiff, we have something called a decision, like dizzy services. So that's, um, a team multidisciplinary team off kind of doctors and nurses and other healthcare professionals. That kind of look after these stations, long term. Um, we are very good accessing thinking off. Kind of long term management and accident. If the cause is the medication, you need to stop the medication. Ready? Good. Rachel. Um, so the feedback link? Um oh, uh, I think much of a natural family still here, but I'll put the feedback link in in five minutes. Okay. And accident. Very good. You know, you need to think about it. Vaccinations. Very good to Charlotte. So in your conservative management, you thinking off things like making sure that patient gets the vaccinations. Such a pneumococcal flu, and that could be it. Okay, so yeah, excellent matter of a lot else. Tortoise. Something that you can think about for these patients. I mean, usually the primary fibrosis is like a progressive condition is that gets progressively worse and worse so I think as the patient gets towards the end stage of their life's, we would probably need some long term oximeter kids. Well, it's a very good man of this, really little. So, yeah, Except guys, as you know, really things. Medicals, thinking of antifibrosis medications, but yeah, everything that have is you guys cover it. So yeah, very good. Or a final case, then. So this is a 70 80 year old gentleman does come in with severe abdominal pain, and that's radiating to the back on. And, you see, he's kind of coming in out of consciousness. Okay, So he's got brought in by his wife who was really concerned about him on. Um, yeah, very good. Regina, you went straight for it. Yeah, to triple A. Okay, So coming I/O of consciousness, Central of Dublin, Pain reading to the back class, actually very get other differences on things like a C s. Yeah. Aortic dissection. Triple A rupture. Excellent, Rachel. So any other differences, guys? Pancreatitis. Very good dot Um, so you know, Central abdominal pain or epigastric pain relating to the back? That is pancreatitis. Very good. Panel fractures? Yes. Very good. Renal. colic. Excellent. You go. All the all the things that have in my mind perforated else. That again, A very good defensive there, you know? And that's the other thing. Things you can ask from the history to a certain if it's if it's related Ulcer. What other things can you ask in the history? Good, Melena, or any kind of, you know, any kind of, um, vomiting, you know, little PR bleed or hematemesis. And thanks. Good. Yes. And any kind of use of any kind of medications that could call's, you know, cause ulcers such as s. It's okay. Yeah. Good. Okay, Castle. It could be a cancer. It could be, you know, come his presentation off the late stage cancer. Okay. Ah, so, yeah, you can ask about factors of pancreatitis. Very good. That was up in any recent gold by Goldstone's. Okay, Any recent procedure such as ercp. So I at the moment I'm on the patch ability surgery on, uh, I have a few patients that come in with post. Yes, it be pancreatitis. So you know, it is common to get pancreatitis and especially after yesterday, very good. Something that you need to kind of ask accent guys spend it. Did you? Well, doing amazing. Um Okay, good. So his blood results have anything that explains up to you police, but is it's excellent. Always take it in yet. Yeah, so it could. Could be a JP perforated. Also order Joseph or July bleed. Excellent. That is definitely one of my top defensive. Yeah. Okay. Yeah. CRP is slightly raised. Still could slightly raised that huge for Yeah, it is raised. Okay. And we've got the high particular site count in the high lactate. Anything? Yeah. What? What does that show Cure it. What is that show? Excellent. Bleeding. Okay, kid. Okay. Yeah, it's excellent. Very good. It's, um 4 15 yet because of the high lactate. Okay. Very good to again. That could come in is a dominant paper. Okay, very good. So, yeah. So this person is in some form of ischemia. They're having some form of bleeding. We don't know where they could be a triple eight up to a week, or it could be a perforated also, but we know they're having some from bleeding. Okay, so we already consider about the spaceship. So are you concerned? Oh, not too concerned was getting 1 to 10. How concerned are you? 100. Okay, ready. Get care. Yes. I'll be very concerned about this. Okay, So you'll be calling for help s a p. So this is an observation chart on I think the main thing I want to get out of his that the patient isn't some form of shock. Okay. Um, so, yeah, Very concerned. Very good on Dean. Just for the interest of time, I was going to ask you guys to do an SVR hand over to to your senior college because you're very concerned about this. Um, so just for the interest of time, I'm just gonna skip that, Okay? Now. And if I tell you that this patient has to triple a rupture, can you tell me, how would you manage this patient acutely and locked him eight of assessment. Daniel Weldon. You know, you go to again any huge patients where if you're really worried about patient, always go for your CT assessment. Okay? So really well done. 80 assessment. Escalate your seniors. Excellent. As soon as possible, you stabilize the patient and then surgery, so make sure that you don't take them straight to surgery because, especially if they are hemodynamically on stable, more cake, there's again. There's a risk that patient could die. Okay, But again, you know, with the situation is really difficult. So these patients, there's a very high mortality for these fishing. Unfortunately on for yeah, recanted. Tina? Yeah. Good. So many investigations that you need to do, um, the know, if I actually had put Okay, so they made investigation. That you need to do is to make sure that you do with fbc. You is, um, these group in saving cross match. Okay, So anybody that you think is leading internally or externally always do move in saving cross match. And anybody that you think would be to go to theater. Yes. Very good. Yeah. If it's a G, I believe, then you can think about things like antibiotic to see new review entirely. Press it. Okay. Very good, guys. Very good. Um so, guys, any questions, please feel free to ask. So I know I'm away. I'm going really fast. M S o. You know, these free feel free to ask any questions and And if there's any kind of anything that you guys have missed anything that You want me to cut off? Go through again, Okay. Yeah. I'm sorry. I am away. I'm going really fast because I just don't want to go keep you in for too long. Okay? Um but yeah. So these are your let your imaging on these special tests. Ah. So ultrasound. Yeah, you could do abdominal. I mean, after a sound. You can usually, I mean, when they present acutely, it's not going to be much helps. Much of help. So usually CT angio would be more helpful in acute setting. But, you know, if you about treatment of long term, But if if the patient's stable of honest that they you know they have aneurysm, it's not ruptured. Then after a sample, because you have to look at the size of the aneurysm. Okay, um, but your fasting is against something they can do in the emergency setting. Okay. And okay, Yes. So, ideally, is the CT angiogram before you go to surgery. Because on do so you know where it is and how much the bleeding is, how bad it is. So that just to get an idea what your ideal you see him and you before you go to the, um theater. Okay, um, everyone else are you. Do you have any questions for me? I know I went to three weeks, so and it's a week. So far, we've covered. My first case was, in fact, in the Codey is any questions? You can send it anonymously on Q and A. Or you can put it on the charts more than happy to answer on by second case waas an opponent. Fibrosis. Okay, on the 30 cases, a triple A rupture. Okay, so, yeah, very good. And then just of management we talked about It's the 80. Assessment is you go extended. Um, and then you, um, stabilize the patient and you activate the major hemorrhage particle. Okay, that's the really important thing. You mentioning your exams. Okay. And 80 assessment. Major hemorrhage. Quarter fallen urgency to repair on your own. Going would be things like a surveillance regular surveillance if it hasn't ruptured. Um, maybe a medical things that controlling the BP again. That's the biggest culprit on if they have other conditions, like diabetes or perform. Ask her disease to try and control those and make sure that you know, you put them into control on the surgical could be a surgery, elective surgery. So obviously, if they presented acutely, you would do in urging a gyn surgical repair. But if they have presented, you know, But But if if there's certain criteria, if if they should be stuck right here, you can do it kind of in urgent. There's electric surgical repair. Okay, so yet so that is all the cases I've covered so far. So the no able to complete the medal form. Okay, uh, for effective, would you be marked down? If you say three loss of blood cultures, you would not be No. I mean, it's quite a specific thing to know is on this. You know where it is. Intervention that cultures. That's important. OK, so if somebody comes in with high temperature and you suspect accepts is or this mention about coaches, I think that should be okay. So your antibiotics usually give 4 to 6 weeks. It's just a long usually it's a it's a long course of antibiotics. They usually give you okay or infective contactus because it takes a long time to kind of improve and okay, yeah. No, not a stupid questions that also group in seven. Cross match? Yes. So you can do both. So it would save is if you need to Blood for the future. You don't need it immediately. But crew with course much. You can get that straight away. So I would do both Okay. And most of the times, in my clinical kind of experience, I tried. I do both. Okay, Um, we do a copay savings course much, especially if if the patients come acutely, I definitely a cross match. Okay, Whereas a group and save you could do it, for example, if it's not, you know, as worried or information is going for a surgery tomorrow. You could just do a group in safe, if you need better. Bit more quicker so you could do a cross match. Yeah, but you can't aggressive. All's Yes, you can. Yeah. Okay. Excellent question that that there's a really good question. Okay. Any other questions? Guys, please. Free to ask. No. So I am a What? I went to a to a quick, quick computer is just beginning. Yes, the ct angio. Ideally, you need to do a CT angiogram before you go to surgery. Just so you find out where exactly the the blood is coming from a where the aneurysm. Is that how big it is? Okay. As why don't we give carpeted or three minute 100 mg in a C. S? Um, I'm sure you do. Give clopidogrel. It is part of your atheists management. Um, but it just depends on your trust. Some trust if I give a different, um, got kind of agitated. What you do is a YouTube anti platelets and one anticoagulant. And that's how the management is for a C s. Okay, Uh, feedback clean. He's not working. Okay, I'm not sure why that is. Apologies, guys. Just try to complete as much as there's two people clings. And so if you can't do one was on the second, You the other. I should be okay. If What if that works in the other day? Isn't just used the one that does work. Yes, A soon as you fill up the feedback formula to my ticket, get the access to the slides and medal. Okay. Yeah. Uh, let's see. Anything really matter if he does. Okay, So this is the rescue teaching sessions. Okay, So the other sessions, if you've messages on Facebook, and if we'll send you the feedback Fords on a soon as you could be the feedback for me, you will automatically get in invitation. Teo access to this lives and the recordings. Okay, Okay. If you go any other questions? He's in a few. Free to ask, if not. Thank you so much for coming on there for, you know, being attention. I know. I rushed through. My case is, you know, I was hoping to take more time. I just don't want to keep you in for too long because I am aware that you've been here for almost two hours now. Um, and I know you've got other things to get on with, so I just wanted to make it quick. You have no problem. It'll guys. And, um, if there's anything specific you like to ask us basically free two messages on our Facebook page A said if there's any specific kind of if you want to know anything specific about specific guidelines saw there's anything specific that doesn't make sense. These messages on the first book a memory practically. You okay on, uh, RTL A Yeah. I'm sorry if the feedback clean doesn't work. There is an option. What? You can send us your email to have a Facebook message, and we'll email you the slides. That's another option. Okay? And you can email dislikes. Okay. Okay. So if you don't have any more questions, and if you're okay, uh, we'll finish this meeting. Yeah. Thank you very much, everyone and hope you have a lovely evening. Yeah, thank you very much. Everyone for coming. Really? Appreciate your time on, uh, for your patients will wait for for waiting for two hours and see. Yeah. Thank you, guys. And we'll hopefully see you again, you know, next session, okay?