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Hello. Hi, everyone. I hope you can hear my voice now. Apologies. I thought the micro's on. Um, could everyone please confirm if they FM audible or not in the chat box? If they are able to access it. Great. All right. Uh, everyone I'm know era. I'm working as a clinical teaching fellow at Royal Blackburn Hospital. Uh, I thought we should discuss chest pain today because again, it is one of the really important things that we come across when we're on call and whether whether you're working on the medical wards or or on the surgical wards, uh, you'll be often bleeped to see a patient with chest pain. So it's really important to go through the common causes of chest pain and how you will be able to assess a patient who presents such. So I have two cases here with me, uh, that I saw, and I'll discuss how we approach those patients'. So I'll begin. Um, now, the first cases when you're part of the medical on call team and you're asked to clock a patient who has come in with chest pain. So you're you're you've been actually called by the any team and they've asked you to come in and see this guy who has chest pain. What you know so far about this patient is that he's a 36 year old male he has presented with a central crushing chest pain while sitting in front of his TV, and it radiated up to the neck and left arm. He described it as pressure like, and the numbness lasted for three hours. Uh, he said that it lasted for until he came to the any, which was approximately three hours, and he had a similar episode about a few days ago. It's a classic history, really, at this point, so I suppose everyone will have certain diagnosis in their mind already about what's the possibility. You go and see the patient, and you take a further detailed history of what's been going on. Uh, he tells you that he has a past medical history of, uh, diabetes, and he's on metformin 500 mg twice a day. He's also known to have high cholesterol levels, and he's taking it over statin for that. But there's no previous cardiac history. But when you come to the family history, he does tell you that his dad died of an M. I a 38 years of age, and his mother had cabbage at 47 years, and she passed away in her sixties. So you can see that there is a history of, uh, premature ischemic heart disease in the family as well. I say premature. Because if it's usually if they give a history of M I in one parent, maybe after, uh, the age of 70 or 80 it's not as significant as it would be. Of course, if, uh, someone had an M I A 38 47 Um, in terms of his social history, what you know is that he works as a plasterer. So what you should be able to pick from this is that you know that he has an exertional. Job. So in terms of thinking about the diagnosis, possibly a cardiac cause you would have to need you would need to give him some advice in terms of his job as well, when you were to discharge him. But we'll come to that, Uh, he smokes 15 to 20 secrets per day for the past 15 years, and normally his good, uh, he has a good lifestyle, his mobile. He's active, and he has a good, normal exercise tolerance. Right? So coming onto his obs, everything's pretty normal if you look at it. His BP in both the right and left arms. It's, uh it appears, okay. His heart rate is fine. His saturation is all right at room air as well. Respiratory rate is 12 when temperature is 36.9. At this point, he is well settled. His chest pain has also subsided. Uh, we do the BP in both these arms, because again, you would need to rule out a potential differential, uh, which we will discuss later. But if anyone has any guesses, uh, would you mind putting them in the chat box? What do you think? Why would we need to do BP? Check BP in both the arms. Uh, it is essentially, uh, if we think about biotic dissection, it also comes with a sudden onset of chest pain provided that, uh, this guy, his BP is not really low. And in someone who's presenting with, uh, who has presented with the history somewhat representing biotic dissection, you would expect in the key of hypertension as well. But that is the reason why we checked BP generally in both arms. Because sudden chest pain should also, uh, alert us off a possible dissection. Especially if the history is very much suggestive of it, that the pain is radiating to the back. It's Central. It came on all of a sudden in this guy, although it it it would be a differential, but would be probably probably be further down the list. So this is his e T. G. What do you think of his E. T. G? What do you think is happening there? Anything that you can spot. Would anyone share it in the chat box? What do they think? I'll see if I can create a bowl. Okay. ST Elevation at V two V three tall TV IBS tall TV, IBS, right? All of those are valid points. But, uh, the reason why I really shared this case was because it is actually quite interesting in terms of its e c G. So normally, uh, the criteria for ST Elevation is that you would have, um at least you need to see the changes and two continuous leads So if we're talking about the limb bleeds, there should be a rise of, uh, more than one, uh, small box, uh, compared to compared to the baseline. So, uh, if everyone can see my mouse, I hope my sorry, My, uh my cursor. So, uh, there should be a rise at least of one small box in to continuous leads. And when we're talking about the chest leads, there should be a rise of at least two more than two small boxes. So that doesn't really fall into the criteria of ST Elevation. This particular E c G doesn't fall into that criteria. Yes, there are tall T waves, but it would make us think about possible hyperkalemia. But then again, with hyperkalemia with someone present with a classic chest pains, which really kind of you would think classic. You would think about, uh, all tented t waves. But the interesting thing is that this patient's potassium, when you eventually you'll come on to the investigations was normal. So the reason why I shared this case was because of this e c G. Because then we went back to discuss why were these findings there? So this is something um, that is called hyperacute TVs. So the rhythm is fine. It's Sinus rhythm, but these e c G changes. These are, uh these tall TVs are basically called hyperacute TVs. And these are not the hyperkalemic TVs, which would be tall, tented peak TVs. Uh, uh. I'll discuss the morphology in a bit. The reason why these CVSs are significant are because they can represent an early am I. So these may eventually go on and form the classic ST changes as the elevation changes that you would see at a later stage. But if you pick these up and your potassium is normal, do not essentially rule out, huh? Mm. I, uh, I do not think that because this is not hyperkalemia, then this can't be anything else. This does If it does not fall into the criteria of ST Elevation, then this E C G is essentially normal, because that wouldn't be the case. This would be an early indication that, uh, potential big m I is going to happen for this guy. When we did the Bloods, it's full blood count. Um, these were normal again. His potassium is fine. So you know that those changes are not due to the hyperkalemic cases exchanges. These are not those CRP is also Okay, So you're not worried about any, uh, inflammation? At this point, there is really no indication of any infection. And, yes, as expected, His, uh, cardiac enzymes. They're high. His first drop has come back as 1 58. You did a V BGs And his lactate is also high. So that also suggests again, uh, again, I'm not mentioning the diagnosis because I'm going to ask you later or actually immediately after this side. But his lactate is also high. So the lactic acidosis is also pointing towards that same diagnosis. His blood glucose is high, which can be linked to the lactic acidosis in itself. And he is type two diabetic. You know that his d dimer czar essentially normal, and his troponin to which came back six hours later, was also high, and chest X ray was fine. So anyone who comes in with the chest pain potentially sounding like a cardiac cause, You would think about doing the e c g and the drops. But you would also want to do a V BGs. You would want to check the lactate levels. Uh, for this guy, we did the blood glucose because he had a history of type two diabetes. And, uh, d dimer is because you want to think about, uh, pulmonary embolism. So although in pulmonary embolism, the E C G will show generally does show Sinus tachycardia and wouldn't show those changes. But, uh, one of the other changes that you could see is, although it's quite uncommon, is that s one Q three t three changes that you see on the C G. Um, normally, if the D dimer is not high, it potentially rules out a p E. But the D dimer is can be elevated in other conditions as well. So, uh, in pregnant women in someone who's septic in someone who has a history of cancer, you can, or someone who has chronic kidney disease. The do timers can still be high, so we can't rely on them alone. But coming back to our patient, his proponents are high. His e c g l has the hyperacuity babes, and it's just X ray is fine, So the diagnosis is pretty much evident at this point. So again, I can't seem to, uh, put up a poll. But if you guys can mention in the chat box, what do you think about the diagnosis among these? I think we're pretty much it's pretty much straightforward, isn't it? Yes. Yes. So this is acute coronary syndrome, which can be unstable in China. Uh, it can be a nstemi or it can be stemi. So it can be a STI elevation with, uh, yeah, with myocardial infection. It can be both and stemi ostomy So you would have to, uh, because you saw the hyperacuity beds and the crops were high. At this point, you do not have the potential diagnosis of stemi. So you would go ahead with an n stemi at this point. But let's see how that can actually affect the management. So another thing that we need to be aware of it, we typically see as particularly in the elderly, in diabetics and in women. Uh, the classical symptoms may not be there. They may present with Disney a fatigue weakness, and it actually kind of kind of becomes a diagnostic challenge, uh, to, uh, diagnosed this patient's with the C s. But again, it stresses how important the E. C g would be And how important. Uh, our laboratory investigations would be in helping us point, uh, towards what essentially is going on there. Right. So what do you guys think? What should be the management for this guy? What would you give for the acute management of a C s? I'll give you a minute to comment. Yeah, aspirin. Someone commented. Oxygen? Yeah. What else? Guys, don't be shocked if this is not an exam. Yeah, exactly. All right. OK, so there's actually a pneumonic quite popular. Um, Mona. It's called Emmis for morphine, Always for oxygen. And it's the nitrates and is for aspirin. But it's important to remember that he wouldn't have to give all of these in every patient. Like for this patient. His saturation was actually 95% at rumor, so you wouldn't need to give him oxygen. His pain was settled by the point that you went to see him so you wouldn't have to give him off in. So it it kind of depends on what? Uh I mean, you have to think about the management in terms of your patient. It should be tailored to your, uh, particular patient. So you will start off with Codec monitoring, you will attach a cardiac monitor to him. It's highly likely that it will already be done by the time you go to see this patient. But if it isn't, do ask for it. Then you would want to maintain the saturation. Now, this guy, his oxygen saturation was already fine. But if it would if it were not fine, then you would want his oxygen saturation to be about 94%. And if he of course, had COPD, you would want the saturation to be between 88 to 92%. Uh, we generally give aspirin 300 mg and we give a second anti platelet, which is take a grill. Or now this is what, uh, it can sometimes vary from cluster trust. But literature suggests, uh, the use of ticagrelor, uh, in someone who is not at a high high risk of pleading because ticagrelor it does increase the risk. Completing why it is generally recommended is because it does tend to have a higher anti platelet effect. So generally aspirin, anti cockerel or 1 80 mg once daily are given in someone who's on an anticoagulant or anti coagulant and has a higher risk of bleeding. Clopidogrel is generally preferred again. Individual trusts. They have their own guidelines. So it's always important to check what your particular trust suggests. And of course, you would give him G t n and g t n. It can be given, uh, every five minutes if the pain does not settle. But if it is, if it has not settled at least after three times, then we need to start considering the possibility of IV nitroglycerin. There are certain side effects and settled contra indications, of course, to take into consideration. Um, this guy's BP was normal. But if you're patient were hypertensive, then you would be very cautious when thinking about IV nitroglycerin in an elderly patient who has, uh, severe aortic stenosis. Uh, G, T g T n and nitroglycerin would, uh, again, you have to be very, very cautious. And, uh, nitro glycerin would essentially be contraindicated in those patients' because they would become I'm extremely hypertensive than in someone who was, uh, who was at the same time taking sildenafil for some whatever reason for pulmonary hypertension or for erectile dysfunction again, G t n or night night rights would be contraindicated. So whatever you're prescribing, it is important to see if there are any contraindications in my particular patient or not. And then, yes, you would ask for a cardiology review. So these are the things that happened with this guy as well. Uh, this this was the plan that was followed. And after this acute management, he was booked for an echo and for a DSN review, which is that diabetic specialist nurse review. And he had that done because if you remember, his blood glucose was a bit high. It was 9.1. So you would want, uh, the diabetic specialist nurse to give their input in as well. And why do you think this would particularly be im pointed in someone who has, uh, come in with an A C. S? Uh, think about his medications. Would you want to change his medications? Because now he's been diagnosed with this. Yes. So if you remember, his medications are metformin 500 mg twice a day and atorvastatin 10 mg once daily in terms of his new diagnosis of a C s. Now, is there anything that you would like to change here? What do you think? Drop your ideas in the common box chat box. Okay, uh, someone mentioned at over starting 80 mg. Exactly. So that's really important. Now this guy would need, uh, secondary prevention, right? Firstly, he was taking it over statin for hypercholesterolemia. But now he has had a cardiovascular event. So in terms of his, uh, medications, yes. He would want to change it over starting to 80 mg, because that is the standard dose for a second re prevention. But what do you think about his metformin? Okay, someone commented. Metformin is adding to his elevated lactate, which is exactly right. So metformin causes lactic acidosis. He his lactate is already high. And in ACS, uh, Lactaid does tend to go up. So you would want to suspend metformin for now, which again makes the his optimizing. His blood glucose level is really important because you're stopping one of his antidiabetic medications. So you want to monitor his blood glucose levels, and you would want a ds an opinion on that, as well as to how to manage it in a better way. Yep. So I think everyone really, uh, everyone knows about that now. Um, in terms of thinking about when to do, uh, coronary angiography or when to do PCI, which is percutaneous coronary intervention. Um, because that would be the ultimate treatment, basically the gold standard. So if there is a school that we generally use, it is called grace score, and it takes into account your age, your gender, What? Your vitals are at the moment, uh, at the time of your presentation and how unwell you are. And basically, it predicts, uh, the probability of death from admission to six months. So generally, less than one person means that you're low risk. 123% would, uh, put you in in intermediate risk category, and more than 3% puts you on a high risk category and depending on how much of a risk you have, uh, it can actually help determine when to do the angiography. So someone with a high risk would actually remain inpatient, while someone who has a low risk can essentially be discharged as well. So that is also one of the scoring systems that many trusts use to make a decision about when to do. Because if you can't book every patient for coronary angiography, uh, that would take up all the beds, and you can't discharge as as someone who is at a very high risk, because they would present with an A C s again. So you have to make that decision. So this score actually helps us determine it. So for this patient, what happened was that he, uh he had an inpatient angioplasty and stenting. So, uh, again, it really interesting that there was 95% stenosis found on his left anterior descending artery in the mid This, um, level of stenosis actually puts a patient at a very high risk of stemi. So the SEC changes that we found the hyperacuity viv's. They actually represent that he was heading towards stemi. Which again, if someone had picks those e c g changes and is able to, uh, understand the importance of it can actually escalate the PCI to be had to happen at an earlier stage. Because for this patient, his PCI happened after 13 hours from what I remember. So it happened about I think, uh, the next day because he presented sometime in the evening. So with someone who has 95% stenosis, he is a he is at a very high risk. He did not have a previous Codec history, but the e c G in itself. It does suggest that, uh, this is something that needs to be escalated. And he was pretty. He was a fairly young guy, right? He was 39 years old. So, uh, the stresses, the importance of needing to be, uh, being able to, uh, signify the HCG changes and be able to understand what it could lead towards. So it was reduced to zero person in the sky, and he eventually recovered because, uh, yeah, So again, uh, in terms of his, uh, inpatient echo, there was some degree of damage to the myocardium. So his ejection fraction was between 40 to 45% and, uh, there was moderately impaired left ventricular systolic function. So, uh, it is also important to look an echo for these patient's because you would want to establish what their heart function is essentially, and that this also again stresses the importance of secondary prevention medications, which we are going to discuss now. So, in terms of his discharge, what do you think? What should he be discharged on? What medications does he need to have now? We're talking about secondary prevention. Mm. Someone mentioned Statin? Yes. Uh, so he would be He would need to be discharged on atorvastatin. 80 mg. Uh, what else think about, uh, the acute medications that we gave him. So we gave him aspirin and ticagrelor. So we give him 300 of aspirin and 1 80 mg. Uh, ticagrelor at that point, Uh, in the standards, Uh, do you think we need to discharge him on that, or would we need to maybe decrease the rules? Yeah. Someone mentioned aspirin, 75 mg. That's right. And he would also need to be on a second, an anti platelet drug, which would be, uh, like a grill or in this guy. And, uh, we would have the ruse, so we would half the dose and then basically spread it over 12 hours. So we gave him 1 80 mg once, uh, start dose when he first came in. And now we're giving him 90 mg BD for 12 months at least. Um, since we're giving him a sprint, I grill. Or do you think he needs to be on a PPI? Yes, of course. Because that would increase his risk of good are gastritis. So he also needs to be put on a PPI. Now, uh, we need to give him g d and spray on discharge. And he also needs to be on an ACE inhibitor and on a beta blocker, which would improve the mortality long term. So this guy, he was discharged on ramipril 1.25 mg speedy and bisoprolol, 2.5 mg. Uh, so on the smaller stores. Really, uh, follow up was arranged with the cardiac rehab team. Uh, he was advised about smoking cessation, and, uh, a g p follow up was arranged in one week to titrate beta blockers because they were he was only just started on them. He did not have these medications previously. So it is important to mention in the discharge letter that these medications they need to be optimized, uh, depending on how the patient responds in terms of his BP and heart rate, and eventually he would need to be seen in the cardiology clinic, Uh, sometime later, probably after six weeks or so, and he would have need to have a repeat echo at that time as Well, so from a junior doctor's perspective, it is important to understand what medications a patient who presents, who comes in with this year's needs to be discharged on. If this patient, uh, I was on an anti coagulant and he was given clopidogrel, what do you think? Uh, should we should have in mind when discharging him in terms of his PPI s. Do we need to have certain considerations? So what I'm saying is, let's assume he's being discharged on aspirin and clopidogrel. What do you think about his PPI? Any specific thing that you need to keep in mind Does anyone want, I guess, In the comment box? Yeah. Product Mhm. Yeah. So I think someone mentioned that PPI decreases the effect. So that is, uh, actually write that omeprazole in particular PPS. Generally, they do tend to decrease the effect of, uh, clopidogrel. Uh, the, uh essentially the metabolism of clopidogrel is is, uh, is affected by PPI s. But, uh, what again? Literature suggests that omeprazole has a tends to have that affect the most. So generally lansoprazole pantoprazole. These PPI s are advised because this patient does need to have a PPI. Otherwise, he would have cost right? It's or, uh, he would eventually have. Good. So he does need to have a PPI, but it is safer to use lansoprazole compared to members. Also, this is one of the things that we when we are making the discharge letters, we change if we see that a patient is unprofitable, Uh, someone also asked, Can you tell us again why take Advil or and not clopidogrel? So from the studies that have been done so far, the randomized control trials, etcetera they suggest that ticagrelor it does tend to have a better anti platelet effect. So generally, if someone does not have any contraindications, we prefer giving aspirin and ticagrelor. But if someone has, uh, a tendency to bleed if they are running on an anticoagulant, if they are elderly, then we go with clopidogrel. Because ticagrelor Although it does have a better anti platelet effect, it also has an increased bleeding tendency. So that is why, because it actually goes hand in hand. So because it has a better anti platelet defect, it would also increase the risk of bleeding in someone who is already at an increased risk. If that makes sense, So for someone who's already taking an anti CAA gland like a grill or would be way too strong, So we're thinking about clopidogrel now. Okay. Right. OK, so another question for you guys, Uh, if this patient was discharged on clopidogrel, what do you think about that? Over starting. Do you know about any introduction between clopidogrel and it over starting? The answer is actually the same. That it over starting. It is also, uh I mean, statins generally they do tend to decrease the effect of clopidogrel. So studies they do suggest that simvastatin is better in terms of it over starting. So many trusts, they do advise, uh, discharging patient's on simvastatin if they are being discharged on the clopidogrel rather than it over starting again. This is, uh this varies from trusted trucks and guidelines defer. Some consultants prefer something else, but generally from from where I work and ask for my experience, we tend to discharge patient's with simvastatin if you're discharging them on clopidogrel rather than it over. But for this patient and there's no such contraindications, so it always all right. Uh, we would all Yeah. So basically what you need to take away from this slide is that five medications are really important in terms of discharging a patient, so he needs to be on two anti platelets. He needs to be on a PPI. He needs to be on a statin on an ace inhibitor. And on, uh, beta blocker, ACE inhibitor is also really important for this patient because, yes, he's a diabetic as well. So that kind of complete is the, uh, beneficial effect that he's going to have from this. And you need to have some sort of a follow up plan before you send him home. Um, I'll go through this really quickly because I've already discussed the significance of hyperacute t waves. But, uh, what I really wanna again just mentioned really briefly is that these are actually a sign of early coronary Vassallo Korean, so you might not see them in every patient. Some patient's may just have, uh, some patient's. They might not have these changes, but if you do see them, these could indicate and and am I just read and am I waiting to happen? A big am I waiting to happen? So it's in the way somewhere. So you're kind of picking it up at an early stage. So in terms of the morphology, it's not always that these are really tall, but basically the amplitude it varies compared to the QRS complex. So generally, if you see uh, hyperacuity wave. Generally speaking, it should be more in amplitude than though QRs complex. So it's more than half, at least, so there may. There must be some hyperacute TVs who are who are maybe like up to here. So if you see something like that and it's more than half of the amplitude of the QRS, do think about the possibility of hyperacuity waves in terms of, uh, differences from the hyperkalemic TVs. So, yes, if you would want to still have you any s for this patient, so you would still want to correlate your E c g with your U. N D s. But only looking at the SCG. The hyperkalemic are really tall tented, pointing like this so you will not see these sort of peaks in the hyperacuity, which are more blunt again. This is like a rough way to estimate it's not really like a specific guideline, because there is no specific definition of hyperacuity vibes It's only, uh, you could say that it's recently come up as one of the indicators, and it's not yet, uh, major thing, Uh, in terms like a state division. We know it's like a major criteria major indicator, but this is something that's being discussed more and more now. I thought it would be interesting fracture. Right. Okay, so we're Yeah, we only have 20 minutes for the next case, so I'll move on. Um, your the medical Sichuan call and your bleeped to, uh, basically come and see a patient who was admitted one day ago to the acute medical ward. And now he's complaining of chest pain. What do you think? In terms of taking the call? What? When you're believed about any such patient who, Uh, the nurses come and they ask you to see that this guy has just been What would you want to know on the phone before you go and see the patient? So I'll mention that, because again, we're short of time. So what you want to know at this point would be, of course, knowing where the patient is. How old is he? Uh, you would want to just take the number of the patient because this I'm just mentioning that because sometimes it's, uh, really easy to miss and, you know, mix and match whatever patient's you're getting. So it's important to keep track. And, you know, you would want to know why this patient came into the hospital in the first place. And what his what is his relevant history? Um, why have they called you now, what went wrong in that particular moment? And what are those observations at the moment? Is he vitally stable? That kind of tells you the time, gives you an idea of how urgent this is, and you can prioritize your jobs and if possible, at this point, you can also, uh, ask the nurses to give oxygen. If they're not already, all the most of them would already have. But you can ask about his saturations, and you can ask them to give him oxygen. And if they've asked because you know you're going to need an e c g. So you can ask them to get an e c g while you sort out your stuff and go and see the patient. So when you're when you breathed about any suspicion. It's important to just mention all of these things. Uh, while while you're taking the call before you eventually go and see him. So when you go and see him, you find out that he's a 65 year old guy who was admitted one day ago with shortness of breath and cough, and he's now, at the moment being treated for an effective exacerbation of COPD. And from what you've read, his background is that he's a type two diabetic. He has COPD. He has a scheme ick heart disease. And he has BPH right now. His vitals are that his BP is 1 45/96. Heart rate is 98. Respiratory rate is has gone up to 30 and sats are 85% at room Eah, Temperature is fine. It's 37. So, looking at this right now, what do you think could be happening with this guy? You will have certain diagnosis in mind at this point. Of course, you will need your investigations to supplement your suspected diagnosis eventually. But at this point, some differentials should be running in your mind. Look at the background and look at his vitals. Does anyone wanna, uh, share in the chat with the Think what is happening with him? A few guesses. Yeah. Hmm. Okay, so someone mentioned PE and yes, that would be an important differential. And you would eventually need to calculate wealth score for this patient. And you would have to Based on your wealth score, you will think about sending a d dimer XYZ. And if those come back high, you will think about doing a CT, pa. And based on your examination, you would, uh, think about yes. Looking for is looking at his calves if they're soft nontender But only looking at this slide at the moment, the two things that do point towards, uh, be a possible pee is a sudden drop in his oxygen saturation. And, uh, secondly, his respiratory, it's gone up. And he is, well, borderline technique. Arctic, You could say so, yes, It is a potential differential. I agree. What else? Acute exacerbation of COPD. Hmm. Right. Uh, so, yes, he is already being treated, but it could. The pain could be because of the infection that is already having. So that is actually a valid, uh, differential as well. So because of the infection that he has, uh, many patient's with infection. They would, uh, of course, have a degree of chest pain. So it could be that his, uh in terms of that, his COPD infection test infection that is coming with that is worsening. So here the just been pain could be a manifestation of that. In terms of his ischemic heart disease. You would also think about a possible cardiac cause, Uh, you would, uh, again it you wouldn't have it at the top of your differentials, but yes, you would want to rule it out because there is a sudden chest. Pain is at it. And again, there is a sudden drop in oxygen saturation which could also be associated with an M I. So you would want to rule it out. And he has a history of ischemic heart disease. So that's important because there's ongoing inflammation. You would also think about pericarditis, but again, that would have a very specific history. And you will have your e c g two. So to help you diagnose it, um, because he has COPD, you can also think about a possible, uh, bully rupture so it could be like, uh, spontaneous pneumothorax or secondary pneumothorax. Really? Because he already has, uh, diagnosis of COPD. So you can have pneumothorax on the top of that. So all these things should be running into your mind at this point, just looking at the slide alone, right? So when you go to assess the patient, what you see is from the bedside, he's appearing distressed. Of course he would be. You will do your A B c d. Like you would do for any patient, any annual patient. So he's talking to you. So you know that his airways patent, there's no V's no stridor audible at this point. When you were called, his SATs were 85% at rumor. But now do you ask the nurses to give him oxygen? So they have improved to 91% which is fine for this guy because he has COPD, so his target cells are between 88 to 92. Anyway, Oscal station is limited because it's quite unwell. But from what you can hear, he does have reduced breath sounds on the left side of the chest, and there are no added sounds. No crackles know craps, heart rate has now gone up to 1 28 so he's quite technocratic Now. BP remains more or less the same, called a heart rate has gone up, but his pulse is regular and he has worn very freeze. He's a lot at the moment. Blood glucose is fine and you can't find any, uh, any anything else that is remarkable on the examination, right. So as you assess the patient, you will get a quick history from him. Uh, he tells you that it's a left sided chest pain. And the nurses also tell you that this started happening as he was walking back from the toilet. Uh, I'm sorry. I think it doesn't say when it woke him up, it should be when it won't. He woke up to go to the toilet. And when as he was walking back, he started having the chest pain. So it was sharp, tight, and he has experienced this pain for the first time ever. It's worse on breathing in, so it's pleuritic does not radiate anywhere. And of course, there's an associated shortness of breath. His respiratory rate was high, his oxygen cells were low and he it is quite severe. He's in a lot of pain, So e, um, new meth oryx acs too. Again, all of these differentials are running through your mind has you're seeing this patient. So keeping that in mind the investigations that you would want to do at this point should be you'll get an IV access If he doesn't already have it, you will get some bloods done. So you will do a full blood count you any is. You want to see if there's any increase in his inflammatory markers. So are we seeing a worsening of his, uh, effective exacerbation of COPD? You will want to do any C, G and drops will want to do any BDs as well. You want to see if there's a sudden drop and oxygen because his oxygen saturation dread drops. You want to see if he's in any respiratory acidosis or not? Any metabolic acidosis? Um, e c g a chest X ray. Of course, with any chest pain that comes, you always want to do any T G and chest X ray. So that stands true for the last case as well. So in that guy, the chest X ray was normal, but you would still want to do it. And like one of, uh, I think some of you mentioned pee, so you would want to do well, score a d dimer. This is his ECG. What do you think? Okay. Does anyone want to share? OK, Global test. Curious. Deep as weaves. All right, um, the voltage seems fine to me. Uh, in terms of the deepest waves, they could indicate, uh, left heart strain. But in terms of the rate and the rhythm, that is essentially normal in this guy. And, uh, if he's hypertensive, he could still have, uh, the, uh, deepest waves like you mentioned. So that wouldn't be something that is acute. And again when it comes to E C G s. If you have a previous C C G. It is really important to sometimes, you know, correlate and see if these changes are new or not. Because that tells you a lot. Uh, in this guy. Uh, these deepest waves. They would, uh, most definitely be an old finding. This is his chest X ray. What do you think? Tachycardia. Yes. Someone mentioned tachycardia. Yes, That was evident on the priest. So it was normal Sinus rhythm. But, yes, it was he was taking Codec. New meth Oryx. That's right. What do you think? Right or left? Left lung? Yeah. So if you have a look at this chest X ray, you can see there are. It's quite radiolucent here, and there are no, uh, lung markings in this region. Really? So it kind of indicated this one is actually quite a massive new orthotics. Uh, this patient, the case that I'm saying this chest X ray does not belong to him, but, uh, pneumothorax. The small pneumothorax can be quite difficult to pick. Really? So, uh, this is actually a quite a big new methodic, so it should be fairly easy to recognize. And if you see something like this, you want to escalate it immediately because you want this patient to have a chest ring. So he's already having oxygen therapy. He's got the IV access. Now. You want to manage him for the pain. But the most definitive management for him would be chest strain, because that is what would rain the air out of him is her. And, uh, you know, get that pressure off his lungs. So if you don't know how to do it. You would want your registrar to be involved at this point. And, uh, that would be his accurate management, but in terms of, uh, discharging him when it comes to that point the two things that you want to keep in mind Smoking cessation? Uh, you'd remember. But you also want to let this patient know that he should not be thinking about flying or diving, at least in the next six weeks or so. So that is also something that is important to mention to the new meth Oryx Patient's is. And, uh, he had probably had new methodic because, uh, of the underlying COPD again in the case that we made that we discussed, uh, this is quite a big new mathematics for that case, but this chest X ray was basically meant to show you what it looks like. Um, a small pneumothorax can be quite difficult to, uh, to recognize. But if you're if you're suspecting something like that, it is helpful to ask for an exploration film when requesting a chest X ray because it becomes quite prominent on expiration because what you're doing is you're essentially asking the patient to, uh, there is a decreased air in the lungs. So it's it's more easy to pick up that new of authorites, that extra air, uh, side of the lung. And, you know, there's, like, a small white line, uh, that, uh, that shows that represents the pleura. So an exploration film when you're suspecting pneumothorax is really helpful. It shows the smallest of pneumothorax, uh, Tauruses as well, right? So they've discussed the basics and in terms of the causes of chest pain, because the two means that we just mean causes that we discussed today were A C S. And the second one was new orthotics. But when you're evaluating any patient assessing any patient with chest pain, the some of the common things that you need to be aware of our let's go through them. Yeah, of course. So if essentially everything comes back as normal, you would think about a musculoskeletal cause. Also, the history if it's suggestive of it, if the patient does not have, like the sudden chest pain, sharp central stabbing associated with sweating clamminess. You absolutely have to rule out a C s at that point. If so, the patient has chest pain. That's, um, somewhat related to posture. He's quite tender on palpations. Uh, you start thinking about a musculoskeletal, especially if they had, like, a strenuous activity right before they did it and something popped. These kind of terms should, uh, point you into the direction of a musculoskeletal cause as well. Anxiety. So they would have palpitations. They would have tachycardia that could come with chest pain. And generally these patient's. They tend to have, like a background of anxiety or panic attacks as well, so that's helpful to know. So they already know what's going on with them. But then again, you would go be ahead with an E C G anyway. Yes, arrhythmias, gastritis, good arrhythmias again you'll be able to pick, uh, them on E C G. It's sometimes in patient's. They have something called paroxysmal af, so it might not always be visible on E. C. G. At the point that you've taken it. So for these patient's after we've ruled out the red flags, what we can do is that we can request for a 24 hour E c, G or assembly to our E C G. So they get that monitor attached to them. And then, uh, we can, uh, review those e c g traces outpatient. And if we do find out some changes there, then you can always ask the patient to come back in the clinic to sort that out. Gastritis. Good. Uh, these patient's generally tend to have, like, a central subst, uh, sternal pain. That's kind of like a burning. Uh, they describe it as like a burning pain, Really? And, uh, it can mimic an M I. So again, it is important. If it's if the clinical his history that they're giving you is making you think in the direction of an M. I you do have to again rule out ACS. But, uh, it's important to remember that this could also be a differential, and especially if someone has, like a history of rheumatoid arthritis or anything, any thing that's ready, causing them to be on. You know, a lot of steroids or aspirin and sets clopidogrel. So you would start thinking about gastritis or girl as a cost. I don't think that section we discussed this earlier sudden, sharp chest pain, uh, generally radiating to the back. There's a difference of BP more than 10 10 millimeters, uh, 10 millimeters of mercury. Uh, difference in both the arms that's indicated of it. And in this situation, you will go with a C t N g o. But, uh, and on a chest x ray, you might see a widened mediastinum. But if you're suspected, do you have a high clinical suspicion? You go for a CT mg right away. Um, and these patient's generally tend to be hypertensive as well. Pericarditis the pain. Uh, as you know, it's more or less. It's related to the posture. You will have a global ST elevation in on the E C G as well, and you'll create it with an sets. Nameth oryx like we discussed in this second page pneumonia. Consolidation on the chest X ray would be evident. There would be fever cough. The classic symptoms can be productive as well. And you will see inflammatory markers going up on the bloods MP. I think that we also discussed that. So yeah, that's it for today, guys. And, uh, if you guys can If you have guys have any questions, please feel free to, uh, put them in the common box. I'll drop my email as well. If you guys have any questions that come up later in your mind, feel free to drop me an email. I'll be happy to answer those any questions at all. Let me know. And after that, we can end the session for today. You go again. All right, guys, Thank you so much for attending. Uh, suppose if everyone's provided the feedback, we can end the session for today. And we will see you next Wednesday with another topic and another presenter. Thank you. Bye bye now.