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Off today um with cardiovascular emergencies, we're hoping that this is a very interactive uh session. So we are gonna ask questions and we hope that, you know, you use the chat button to really have AAA dialogue going again. There are no wrong answers, guys, we really want to make it interactive so that you know, you you are prepared II in the future. So the first case that we'll be doing is case one, you are the fy one doctor wording front door in Annie, you were asked to see a 60 year old male called Mister Bush. His wife has finally convinced him to come to the hospital regarding his shortness of breath because he does not appear to be his usual self. So what information as the fy the fy one doctor, do you want to know before heading over to assess Mister Bush? So let's just get back to the scenario. You were called to go see a patient who has shortness of breath and he doesn't appear to be his usual self before you go to that patient. You know, before you know soter on over to him, there is something that you would require. The very first thing that you wanna think about before you go over to assess Mister Bush, is you wanna think, is this an urgent situation? Is this a non urgent situation? You're still gonna assess the patient but you know, they're very, they're very different ways that you would, you know, begin to go over the problem if it is non urgent versus urgent. So the very first thing you'd want is his vitals. In this case, his BP is 100 and 60 over a hu over 100 his heart rate is 100 and five BPM. It's regular. His respiratory rate is 24. His SATS is 91 on room air. His temperature is 37 and he's using about a six. So various AE departments have different escalation standards after patients have been triaged by the nurse. Some hospitals have policies that state any patients over in new seven can only be seen by a senior IE uh registrar working in A&E or a consultant. So sometimes you will go see a patient as the F one working in A&E and you, you know, the patient could be in U six and you still see them. Um even though he has a bit of, you know, his vitals are a bit, you know, unstable at this time, his heart rate, he's tachycardic. His stats are about 91. You, they go and see this patient. Some patients, they're more of a senior that would need to see those patients are normally in recess or if you know, if they've been triaged and the nurse says, you know, we need a senior clinician to come. I it would not be you. But in this case, unfortunately, this patient is in U six, you would go and see this patient off the bat. You wanna think along the lines? Ok. He's using a six. This seems as though this patient might, might be a bit unstable. So upon arrival to the clerking area, the patient appears anxious and seems to be breathing very hard. What should you do? Now, we don't have anything in the chart yet, ok. So at this point, you've, you've come to Mr Bush, he seems very anxious and he seems to be breathing very hard. Now, you already know off the bat. This man is tachycardic. Um He's coming with shortness of breath and his saturations are 91% on room air. At this point, the most appropriate thing to do would be to start an A&E an at E assessment. So an at assessment is a very quick way that you'd be able to go over um a patient's clinical uh status very quickly. So with this at e assessment, you find out that Mr Bush, he's, his airway is patent. He's speaking in short sentences. His, his breast rate rate is 24 uh saturation is 91 in room air. He has bi basal crackles heard on auscultation. There's some dullness to percussion at the lung bases, but he has equal air entry for C which is circulation. His heart rate is about 100 and five BPM that we discussed. His capillary refill time is about three seconds. S one and S two is present, possibly some sort of S3 sound. You're not really sure disability. We would say his C which normally covers blood glucose. We say his CBG is six and his temperature is 37 °C. Now, every everywhere else there's three plus pitting edema up to his knees bilaterally, it's cool. He has slightly clammy extremities and he has some JV distension which you would have noted on his circulation exam. So at this point, you need to, you look at him, you couldn't assess him. Um, what you should really do is to take some history. Um, obviously you could put him on oxygen. He's saturating at 91% as well. Um And you could try to get some history o out of him. Um, if he, his, if his airway is patent and he's happening to speak in, in short sentences, just some, a very short history is what you need. Um So history of his presenting illness is that Mr Bush has had shortness of breath for a couple of months. Now, he has increased worsening of shortness of breath over the past three days. He has swelling in both of his legs that has increased tremendously in the past week. His background, he, he is states that his shortness of breath used to worsen when he moved or if he lied flat on his back. But now, even when he just sits, his shortness of breath worsens, he denies chest pain and states he has some chest discomfort past medical history, includes that he has hypertension. It's poorly controlled, uh, his type two diabetes. Uh he had an M I uh once two years ago and he smokes one pack of cigarettes per day for 30 years. His meds include Metformin, which we, which we know he takes for the type two diabetes, Lisinopril, which is probably for the hypertension aspirin. And his wife tells you as, you know, you're taking the history that he does not like taking his medication at all. So what, what would you do with this patient? And what are your differentials? So you've come upon this patient, Mister Bush who's having the shortness of breath. Um, www, what are we thinking? I in, in this scenario, where are we going in regards to diagnosis differentials? What would you, what would you think anyone can put anything in the trash? Ok. So you've got Omar saying post MRI central dysfunction. OK. Post M I central dysfunction. OK. So he's clarified a bit further and he said he's in heart failure with fluid overload? Ok. OK. That's brilliant answer Omar. That's very brilliant. OK. That's a very good diagnosis. Um, so heart failure with fluid overload. Ok. So if that's the case, what investigations are you thinking of? We've got dios suggesting a chest X ray. Ok. Yes, I love that chest X ray. Yes. We did hear some crackles on auscultation. Chest X ray. Brilliant. What else? We've got a suggestion of chest xrays, ecgs and troponins. Yes. Yes. Ok. Perfect. Yes, absolutely. The person who said troponin is very brilliant, even though the patient denies that he has chest pain, we have to remember that he's also type two diabetic, even if he was having um, uh, heart attack, most likely it's called a silent M I that's normally seen in diabetics. We have to make sure that we, we rule out that, you know, this guy is having, uh uh another M I given the fact that he has a history of it. That's brilliant, brilliant, brilliant. I love that answer. Um We've got a few, several suggestions actually. Um, echo serum, R FT and R BG, R FT. Ok. And R BG. Ok. So FB FBC S and UN es Yes. Those are very simple investigations. Um, anti pro B MP. The reason why we want to do an anti pro B MP is that obviously, um, these are just the blood investigations for actual investigations like chest X ray echo E CG Y. We're absolutely doing those as well. Cardiac enzymes like trope this HBA1C. The only reason why I would say to take the HBA1C, the A&E you know, consultant would say just leave it for the medics. But if you're taking blood, you know, just, just add it on there, we know he doesn't take his medication and it's a yellow top and all of these would be placed in a yellow top bottle. Anyway, I just run it for the medics cause this person would most likely be referred to the medics. So I if you could do that for the team, that would be much appreciated. But some consultants are like, oh, you know, they're gonna be seen by the medics. Let the medics run the HBA1C chest X ray A BGL E CG, took you for a second. Sorry. Um The slides are stuck on the um A three E slides. So we're not seeing the investigations at the moment. Oh, you're not OK. Let's see. It's on the three and the history about um, let's see. Can you see my sides now? Still the same slide? I can actually OK, I can actually see Lonnie's active um slide moment. Yeah, I don't know if the audience are seeing the same Lonnie, you can go and present a mode and I'll um see, um, what about the um attendees? Are you guys able to see Lonnie's side slides? OK, great stuff. So they're, they're seeing OK. That's fine. So, as I was saying, uh chest X ray ABG E CG Echo. So the investigations come back guys. His troponin is about 28. His NT PRO B MP is about 15,000. His HBA1C is 89 and his chest X ray shows bilateral pleural effusions with cardiomegaly. So, Omar said heart failure with fluid overload, that's a really good diagnosis. Um The uh another person also mentioned an echo given this his troponin is about 28 right? So the nurse is gonna come back and say, oh the results are back. Doctor, what are you going to do? Well, his troponin is 28. Um wha what should we do? The normal is 14. It's come back at 28. What, what do we do then? Uh a positive trope is greater than 30 but his is between inter i indeterminate. WW what should we do if we're concerned about that? We don't see anything on the chart um yet. Ok. So because his troponin is a little bit higher. What we can say is that we know that trope is released when you know the heart has a bit of um not only ischemia, but there is some damage, general damage uh to the heart. It could be strain, it could be that, you know, his myocytes are overworking a little bit hard. So it's a little bit higher than you. What you would expect if you are in doubt that this person might be having an M I, what you would tell the nurse is, it's OK. I would go speak to my edge, I would say most likely, I think that we need to run the troponin again, probably in a couple of hours to see what it does. The reg will probably agree with you as well. Well, if you've got his comment, saying oxygen aspirin, furamide and cardiological consultation by Omar. Correct. Correct. So, um Omar. Perfect. Yeah. So basically you, you've, you've, you, you've, you've gotten it um especially with the cardiology uh consultation and that's just something I wanna touch on as well. So before we even get there, I just wanna say that essentially this case scenario is very typical for someone presenting first time with signs of heart failure and those with worsening of uh their preexisting cardiomyopathy. So he's presented with acute heart failure. Now it's a rapid onset of. So the definition of acute heart failure, that's a rapid onset of new or worsening signs and symptoms of HF often a potentially lifethreatening condition requiring hospitalization and emergency treatment. Typically the patients that come in into A&E and especially elderly people, you will sometimes be the first person to make the diagnosis for heart failure, the elderly folks when they come in, they sometimes will wait a very long time before they actually present. So this man, I, you know, he'd been having a hard time sleeping on his back for so long and he finally presents and the first time he presents is because he now has acute heart failure. Um his symptoms has completely decompensated and he's now come to A&E recognizing the signs, you know, the clinical signs is very important for this diagnosis. So, common causes of acute heart failure includes uh coronary artery disease, heart valve disease, arrhythmia, d alcohol and pe diabetes hypertension. This man had so many risk factors. He had a previous M I he was diabetic, he was hypertensive and he was not taking his medication. He smoked cigarettes. Most likely there is uh coronary artery disease, especially since he already had an M I one could definitely ascertain that. So this patient is handed over to the acute medical team. So in A&E how it works is once you've seen the patient A&E kind of decides where is this patient gonna go? Is this patient gonna go to the medics? So you would get, uh you would basically get to refer to acute medicine or is this patient going to surgery? And that's basically, or does this patient needs to be seen by any inhospital team? Is this more of, you know, a, a non urgent situation that can be, you know, dealt with with outpatient by the GP? So that's what A&E does. They basically assess uh sorry, um assess where this patient will go. So they've handed over to the acute medical team now. Um And basically this answer is already said, you said oxygen IV access, sorry. Um So the management for acute heart failure, they would probably come see the patient and they would say what we need to do is start them with oxygen IV access. We need to position him. We need to fluid restrict him because we know that he's in fluid overload. Normally we fluid restrict about 1.5 L to 2 L a day. He needs diuretics, furoside. He needs vasodilators, uh nitroglycerin and BP elevated and no contraindication exists to reduce preload and afterload. Sometimes those vasodilators um we don't typically give them with patients that have, you know, tachycardia, but it depends on how he's presented abruptly. So this would be so uh vasodilator would be something that perhaps the acute medical consultant would be the one to say, OK, we can give him this. Now, if the patient worsens, seniors would consider inotropes and referral to cardiology. Now, I want to stress as the F one doctor, you don't pick up the phone and call cardiology um without having something to give them something to work on. So make sure that you've run your NT PRO B MP, you've done your E CG and your echo and your echo is requested because cardiology is very, very, very busy and majority of the registrars, they're, they're dealing with a uh you know, very heavy caseload. So if you call them and you say, well, I think this patient has acute heart failure and they said, OK, good. Have you, have you done the NT PRO B MP? And you say no. Or have you done your an E CG at least one? And you say no or you know, you, you know, say you haven't requested the echo. Sometimes you, you can basically say, oh, you know, I think he has acute heart failure. Do you think I should get an echo? And they say yes. But if your anti pro B MP isn't done and you don't have an E CG to show cardiology, they might hang up on you and to be fair, you know, uh it's well deserved. We have to make sure that we're handing over properly. Um W why do you think this patient has acute heart failure? And how do, how, how can I prove that? It's not something else. So I've done the E CG and it doesn't show any new ST elevation or anything like that. I've done my NT PRO B MP and it shows that this guy is coming with an, with a, a value of about 15,000. I can say that I, I would clinically diagnose and say, well, I think, you know, this patient is highly suspicious for acute heart failure and we would love if you could, could come and review him, given his vitals and th then they'd probably accept the referral and say yes. Uh we'll come. Um So the treatment for acute heart failure focuses mainly on managing fluid overload and hemodynamic compromise. Um But a as the F one doctor, of course, majority of some of these things, you wouldn't make the decision on like vasodilators or inotropes. But, um, other things like, like the job to get the referral to cardiology, um, that's something that you will have to do. And when you're referring someone, it's very important that we have, uh, a general scope of results that we can really give to the team that they can make a proper decision. Does this patient need to be reviewed first or is it the patient that you know, has that's been having some, you know, stabbing chest pain for about two minutes? Do I need to go see that patient? That's what the cardiology registrar will think, you know. So depending on how you hand over and what results you have, they'll be able to see your patient uh quicker and um basically triage them appropriately. So very well done uh to the to the um to Omar who said uh that it was fluid overload and handled it as such. So, case number two is you are working in a gastroenterology ward, Miss Barbara, 50 year old female was admitted to the medical ward two days ago for abdominal pain. She's now complaining of a headache and the nurse has asked for you to review her. So typically, um if you're on a medical specialty ward, uh if a patient, you know, presents with some new symptom, you know, it's not the consultant that's gonna come and see the patient you would be the first point of contact that the nurses would would go and ask, hey, you know my patients saying this, can you come and see them a as the f doctor f one doctor and you say? Ok, so before you go, sorry one moment, can everyone see my screen? Yeah, we can see the screen. Ok, so mm mm. Um are you ok longer? Yeah, I'm ok. So before you head over to this patient that has the headache. Yeah, you're working on a gastro gastro wards are notoriously known for being extremely busy. You will have so many jobs on that ward and a nurse comes over and says, hey I need you to see this patient. The very first thing y that should pop into your mind is OK. How urgent do I need to go see this patient? So you should think every time someone comes and says can you review this person? Um you know, II would really like if you could see somebody, the very first thing that should pop in your mind is OK. What are the vitals? So the vitals for this patient is that his the news is about five, the BP is 220/1 20. The heart rate is 95 BPM. It's regular. The respiratory rate is 20 the saturations are 96 on room air and the temperature is about 37.2. Now any doctor who sees ABP of 220/1 20. The very first thing that would come out of my mouth is, have you checked it again? And the nurse says, yes, doctor, I've checked it three times. I've even checked, I've even used the cuff on myself to see if it's actually working. And so if that's the case, you would head over to this patient. So you go to this patient, the patient's in bed holding her head, given her vitals. Yeah, there are two ways you can go about this. You assess the situation, you can do an at e assessment first or you could take history depending on your clinical assessment of the patient just by looking at them. Now, in this case, the doctor decides I'm gonna take uh history first. She states that the headache started two hours ago and it's in the occipital region. It's 1010 in intensity and it's associated with nausea, pressure behind the eyes, accompanied with blurred vision. On her past medical history. She has hypertension, she is poorly controlled on amLODIPine. Um She's noncompliant. She has type two diabetes. She's a type two diabetic on Metformin and she has CKB social history. You find out she smokes 10 cigarettes per day for 40 days. So on examination, generally the patient's alert but she's in distress due to headache. Um, she has no, you listen to her heart, no murmurs, normal S one and S two, no signs of heart failure. Her rest on listening to her chest, you find out she has equal here entry bilaterally, bilaterally and the chest is clear uh posteriorly. Uh it does not say that there, but it should say that abdomen is not no tenderness. Normal bowel sounds neurological, she has no focal neurological deficits. Pupils are equal and reactive and her cranial nerves are intact. Now, at this point, what are your differentials given this patient has ABP of 220/1 20 she is now having a headache with nausea and pressure behind the eyes. What what are your differentials? We don't have anything yet. Ok. Just give a few more seconds. Ok. Ok. Omar size, urgent, hypertension, urgent. Ok. So urgent. OK. That's, that's of uh malignant hypertension as well. Fair enough. Ok. Yeah, she's not taking her meds. That's fair. I like those answers. But yes, immediately recognizing that his patient is going through uh emergency hypertension and intracranial hypertension have come through. Ok. Fair enough. Perfect. So someone said urgent um hypertension and another person said emergency hypertension. Correct. That's right. Yeah. Yeah. Ok. So it's very important um that we understand that hypertension comes in two forms. You have hypertensive urgency or slash emergency and sorry, you have hypertensive emergency, a such urgency and then you have, you know hypertension, but it's non urgent. There are no clinical signs that this is an absolute emergency, an absolute urgency for this patient. She's had her BP taken three times. We know her BP is about 220 and we know that currently she has nausea and pressure this patient is having and she has blurred vision. We know that this patient is having an emergency or an urgency of hypertension. So the this is very important that you get right on top of this. So, hypertensive emergency, this is a severely elevated BP associated with new or progressive target organ dysfunction. Although the absolute value of BP is not as important as the presence of an organ damage. The systolic BP is usually greater than 100 and 80 the dist BP is greater than 120. Now, if clinical suspicion is high treatment should be, is initiated immediately without waiting for further tests. This is very important because you will see patients that again are very noncompliant with their medication. Even while in hospital, some will decline to even have their, their medicine. Um and some, they, they will just go into this hypertensive emergency uh s clinical situation and it's very important that you treat this as soon as possible because the the complication of this is a stroke and once they start having the clinical signs that they're having an organ damage, you have to get on top of this immediately. So risk factors and etiology, chronic hypertension, normally the patients have chronic hypertension, they are non compliant with their medicine. They have kidney disease. Now with the n organ damage presentation, you can ha have uh neurological deficits. It will normally present with confusion. Sometimes they will, they will start having, you know, signs and symptoms of a stroke or encephalopathy, which is just generalized confusion. Some can have like heart symptoms, which it will, you, you will have heart uh sorry, acute heart failure symptoms. And so they'll start having this this massive swelling. Um J just generalized anasarca, just generalized uh edema throughout their entire body. Um Some can even have an M I kidneys. You can have an acute kidney injury. This patient already has C KB and AK I on C KB would not be the best clinical scenario for, for a patient like this eyes um as well. So she, we know that she's having this blurred vision. Um So most likely she's having some kind of ret retinopathy if this is the case for a patient like this, you know, you have treated her. What tests are you requesting? Because you can't just say, OK, I'm gonna give you some anti antihypertensives. We need to make sure that what we're doing, you know, uh I is clinically accurate. So we've treated her but based on her symptoms of the blurred vision and the nausea, what else, what else? Tests should we, should we um request what w or tests or anybody else we need to speak to? What, what would you do as a doctor? We've not got any answers yet. Oh, so you OK. Come in. Mhm RT R FT sorry and CTR FT CT OK. Fair enough. I can go with that. So F BCU and es urine dip urinalysis, you wanna check for protein, urine hematuria that might suggest a hypertensive nephropathy. We know that she has C KB. Most likely you know, these tests would probably come back already positive because she has KD. So that wouldn't be, that wouldn't be exactly anything new E CG an ophthalmology referral and a fundoscopy. This is very important if someone starts complaining of blurred vision, um uh n new neurological deficits such as blurred vision. And you think that this is a hypertensive emergency. I would absolutely recommend that. Of course, you treat the hypertension but make sure that this patient is seen by ophthalmology if there are any new um clinical findings on the fundoscopy and that will be important for the patient for follow up. So, investigations that you'd like to order for. Well, to consider, I would say for patients, um thyroid function, test, liver function, test cardiac enzymes, anti pro B MP and CT, you would, you would generally consider this um because of course, with this patient, we know the reason behind why she's having this hypertensive emergency, but because she's having this headache, that is 1010 intensity and she's having that nausea, but she has no neurological deficits yet. One could argue, I don't think she has a stroke. She hasn't had a, a hemorrhagic stroke yet. I don't think, you know, there's anything on that would come up on the CT, another doctor might argue and say, how would you know that you haven't actually done the CT? So in any case like that, you would obviously be speaking to a senior to decide whether or not you get the CT. But it is very important that that's in the back of your mind that this could be something that you might need for this specific patient. Such anti pro B MP and cardiac enzymes. Y you can offer this as well. You know, if they are complaining of uh you know, the generalized chest pain, if they're having a hypertensive uh emergency, that is having cardiac symptoms, thyroid function tests. Um Depending on the consultant, they might say, you know, once you go to them about this, they might say, OK, just run T FT S just to be just to be safe in a patient like this. They probably wouldn't because they would say the reason why she's having this hypertension is because she's non compliant to her medicine T FT S are usually done in a patient that you know, doesn't have a background history of noncompliance and has been treated for hypertension but not necessarily investigated for any other uh causes such as uh thyroid issues. So how would you manage this, this patient? So I in this case, you would escalate as soon as possible you call the medical registrar, you would start your IV anti hypertensives and you'd aim to reduce the mean arterial pressure by no more than 20 to 25% within the first hour and then gradually over 24 to 48 hours to avoid ischemic complications. So, after you've had that discussion with the medical registrar, they'll tell you to start I vi uh antihypertensives. And of course, the reason why we are not reducing it um very fast is because um you don't want to hyper perf sorry, hypo perfuse uh the, the tissues um and that will cause ischemia. So you don't wanna drop the BP. So suddenly that the there's reduced blood flow which would lead to ischemia. So you want to reduce it gradually that there is a good perfusion i in, in the tissues you give analgesia. This patient is having so much pain that she's holding her head, she's in distress. It's very important that we, we take the patients out of pain that can also be contributing to tachycardia. She says she's nauseous, give her some antiemetics, monitor her urine output and check her neurological status. Um probably you would say one hourly or two hourly until this is brought down. So rapid lowering of BP in these patients offer no benefit. It carries a theoretical risk of relative hypotension and and organ hypoperfusion, especially in individuals who have a longstanding, severely elevated BP. So, for this patient, you're not only treating the most important thing, which is the hypertension, you're also trying to, you know, treat her holistically. You wanna give her pain medicine, she says she feels nauseous. You give her some antiemetics, you monitor her urine output and neurological status checks. The reason why you're monitoring her urine output is because she has B um and she's not having this hypertensive emergency. Um she could develop an AK I on D which you do not want. And if she starts having reduced output, you want to be able to treat this as soon as possible. Um Chen, is this your patient? Yeah, this is my one. I'll take it with. OK. Sense. I uh so thank you guys. Uh the slides a moment rule out IC H Yep, I agree. He's a brilliant, brilliant doctor Omar. He's a really brilliant doctor. OK. That's fine. So case number three is we've got, we're in A&E um again and so we've got a 65 year old man who's come to A&E with this chest pain, chest pain state started around 30 minutes ago. He looks quite pale, quite sweaty, quite um and quite unwell. What are your initial differentials? What are you immediately thinking? And what further questions do you wanna ask him? And what do you wanna find out? So you have a response from DAO who says myocardial infarction off the bat? OK. Nice, nice. OK. So very good sort of thinking, immediate sort of urgencies in terms of immediate um acute things that are causing, causing the chest pain in port a bit of a range of history as well, just trying to further explore what else could be. So Omar says you can ask about the description of the chest pain. Mhm. Yeah. Ok. So if you go a bit further into the history, so essentially he's describing sort of central sort of crushing chest pain and we tried to keep it a bit typical. It's radiating to, to his left jaw and into his arm, his waist dates feels quite nauseous. He's vomiting, becoming quite sweaty, quite short of breath. In terms of kind of further exploring things like his past medical history. You find out that he's got a history of Angina and he's also got a history of high BP as well. He's quite a heavy smoker. Um Well, not too bad, actually two pack here for about 20 years and in terms of medication he's on atorvastatin, um has GTN his Angina R and also amLODIPine as well in terms of family history, which is also quite relevant to explore in these sort of patients as well is that we find that his father died of an M I as well. Ok. What sort of investigations would you wanna do for this patient? No reply yet. That's right. We'll start the ball rolling. So straight off the bat, we're gonna get a, a full set of s see, what is going on with the patient itself? Um E CG, especially on the phone. So uh someone says Troponin, E CG. Mhm. Very good. Very good. Nice. Yeah. No, brilliant. Um Some of the main ones really? Yeah. So we'd run an E CG to, we're gonna explore kind of cardiac things what's going on. We wanna get a full range of blood. Someone says chest X ray. Mhm. No. Very nice. Very good. OK. So with the bloods that we're getting, so um of course you things like troponin, we also get a full general set of bloods as well. Things like people using these, I have to use lipids. Um ddimer. What are your thoughts on ddimer as a blood test for the patient with a central chest pain? What is the Chinese? So someone says ecg troponin serum CKB CBC coagulation profile. Ok. No, very good, very good. Um No response to the query D dimer yet. That's fine. That's OK. So with D dimer, one thing I would say is be quite specific in things like A&E settings and stuff like that. A lot of time you'll find patients getting D dimer um carried out for sort of any sort of chest pain that comes in D DIMER is a great test in the sense that it's good for ruling out things like pulmonary embolisms, but it's very nonspecific. So it will get flagged up and be raised to a lot of, a lot of other pathology and conditions as well as soon as you go down that pathway, you need to then really explore a potential pe. So it is very difficult and it is very much using kind of clinical judgment to see if we should do ad dime right in the first place. Ok. So with the gen is that we want for the patient. So you've got a respirate of 24 heart rate of 91 BP is 1 1585 temperature of 37.1 sats 96. So generally not too, not too horrible. He's a bit bit high respirate and a little bit high of the heart rate but not completely, um, completely unwell. Some, we do his bloods as well. Full blood. Can you, his knees have all come back pretty ok. D down, we've gone ahead and done the D down for this patient and it's come back just under the cusp of 500. Usually the cut off for most. Um, most hospitals depends at the hospital. I, I'm not sure Russells do, but it depends if the hospital do ad dimer if they don't. And the general cut off is 500. If they do, then as you get, I think it's over the age of 60. As you get older, you need to kind of adjust for that. Cos patients will have, will have higher D diers naturally. Um So we do the XR drops, zero chops comes back as 95. So as Coco 14 being kind of the cut off at Russell's that already is ringing alarm bells and it is a very high, very high troponin. But as we spoke about earlier, one of the main important things is marking a trend. We wanna see what's going on with the troponins. So we need to essentially do, we've got zero, we wanna do the one hour and the three hour drops even with a patient of 95 troponins, what else could have caused a troponin to be high if it's not kind of say M I in nature, as we're thinking, what else might cause the troponins to be raised? No response yet. That's fine. So essentially any sort of cardiovascular um pathology can raise troponins. So if a patient comes in and they've got a past history of heart failure, for example, that itself can have a background of raised opon. So someone said trauma. So with trauma or damage to the cardiomyocytes. Yeah. Yeah, you're very good. Yeah, that's very fair. Um Yes. So essentially as it's a cardio um cardiac damage enzyme, essentially um any sort of damage will trigger it. So things like heart failure, things like that. We can also see it in patients with um kidney pathologies as well. So we've got quite bad kidney disease can also cause such to be raised. Um as well. 95 is quite, quite substantial. We can't see someone said as well. Ok. Yeah. Yeah. No, very fair. Patients have very bad sepsis and has taken a huge jump out from the heart as well. You can get that as well. No, very good point. Ok. So with this patient we do the three hour drops and we find that it is escalating substantially now all the way into 245. Ok. So as with other investigations we talked about, we do an E CG for this patient as well. What can we see in this E CG hm? OK. Yeah, it's true. No comment yet. Oh, wait, someone says inferior wall. Am I? Mhm. No, that's very good. So with this says Demi Mhm Yeah. So stemi perfectly correct. So this patient is having a stemi. It's important to use the landmarks and the identifier of the chest X ray. Um E CG sorry to see um where exactly they're having that sty is quite useful. So with this patient, we're looking at the different sort of leads running through. So working our way through, we've got um inferior leads, posterior, inferior leads, anterior leads, lateral leads essentially. So we're going to do kind of V one to V six. We're kind of working our way across the chest itself. Now, the inferior leads being kind of two and three. As one of the patients suggested, we can see there's quite nice ST elevation in these 23 and aVF suggesting inferior inferior stenting. Now, why I chose this at this E CG is, it's quite an interesting one because what we can actually see here is if we look at the anterior leads in leads two and leads three in leads V two and V three, we can actually see some ST depression. Now, ST depression in the anti leads is quite a interesting thing. What do you think that might mean at all? Ok. Uh Someone says, reciprocal changes no perfect spot on. So essentially, what we're seeing is if we're seeing the anterior leads are showing um um showing ST depression, what we're actually thinking about is could there be any recip changes? Could there be a actual posterior stomach going on for this patient as well? So essentially, what we're then going to do is you can touch posterior leads V seven and eight to see if there's any elevation in those those leads at all. So essentially, this is an inferior posterior stem. OK. So moving on to the chest X ray that we also want to request as well. Um Have a look at the chest X ray for a second. Are there any obvious abnormalities that you guys can see? And what are the main things you'd be looking for in chest x-rays with patients with chest pain? Sorry, no answer yet. And that's fine. So essentially, this is quite a normal chest x-ray actually. So there's no obvious sort of findings in the chest X ray that we can see. But if a patient does come in with um, any sort of dental, chest pains, the main initial things we look for is things like any signs of pneumothorax. Really, I've not included pictures in this, in the presentation today. But essentially, we look for, um, the main things we look for for signs of pneumothorax is looking at the lung markings. Essentially, we're working our way down to kind of see. Is there any, can we see all the lung markings running all the way through to the edges of the, of the long wall? If there's any abnormalities in that, that can indicate a potential uh pneumothorax also looking at the trachea as well, looking for any signs of any deviation. If the tr is deviated to any um any side or any abnormalities, that can also suggest a pneumothorax as well. Other things we might look for is things like pneumoperitoneum. For example, if there's any air under the diaphragm itself here, we can see it is nice and concise, then we can see the diaphragm one down to the costa angles, we can see quite clear angles on both corners there. Now, if there was a thin line going here, we could see kind of a bit of a shadowing that was just a pneumoperitoneum. We can also see nice clear troph angles, chest, there's no signs of any effusion in this chest X ray as well. So overall, it's a, it's a pretty normal chest X ray. OK. So what do we think is going on in the diagnosis of the patient? So we had inferior wall M I, we had stemi, someone said stem hyperacute. Yeah. All, all very fair. So essentially we'd say inferior posterior stem is what would be the diagnosis of this patient? The initial management when you see them in A&E uh what would you want to start very initially as soon as you get this patient, um you've got the E CG would probably be the first thing in realistic life. The E CG would probably be the one of the first things that's already done by the time you see the patient, what would you, what would you do? What would the very first management be for this patient? No reply yet. That's fine. We'll get the ball rolling. So essentially, you'd wanna give them some stat aspirin if they're not only on any medication already. Um But 300 mg stat aspirin is what you want to start. Uh They're often in a tremendous amount of pain as well. So you'd want to start them on some morphine um as pain relief. And you'd also wanna get them some GTN as well. If the oxygen are going to drop at all, you might replace their oxygen and put them on um nasal cannula or replace the oxygen as needed. So I will give you all the intense details of the ST management essentially, but essentially the main thing is is after we do the 300 mg of loading dose, we wanna assess whether we can give them um primary PCI or not. Now, the main indicators for that is essentially um go through the aspects. We're also looking at whether they present it within 12 hours. And also we can actually get them to a PCI center in 100 and 20 minutes. Now, I know I could be wrong. Lo I don't think Russell's is a primary PC center, isn't it? Ok. But I think, I believe New Cross. So when I went to New Cross and F one, if we had new patients presented with Demi or we had to be raised, we could potentially call cardiology and get them sent off as soon as possible, trying to get them within an hour to two hour mark. I know with Russell's or with other hospitals, there is a little more. So we do have to get, yeah, we'd often have to blue light them, get them to, to Russell's or to another sort of, um PCI I center so that we can do that. But essentially two hours is quite a tight mark in terms of being able to carry it out. So if we're not able to, for whatever reason, then we go down the fibrillin lysis route instead and we start anti doctors. Now, for whatever reason, they're not eligible for that, then we often go through the medical management instead and give them Trag law after we have essentially managed them, treated them for that day, which again would be via kind of cardiology um aspect, we then go through the secondary preventions. So after they've been treated and we've done and we've hopefully saved them, we then go through what we can do to prevent them from having this. Again. One of the first things is they will stay on lifelong aspirin. Essentially, you give them that treatment dose of the um of the 300 mg and then we set them down to 75 mg. Once daily, you'd have to give them a second antipala as well. Um After the 12 months as management, um they'll often be put on atorvastatin 80 mg as secondary prevention with primary prevention, usually being 20 or 40 mg depending on the patient and their curious scores. But we do 80 mg as their secondary prevention. We'd often also place them on ace inhibitors and we'd also start them on some sort of a beta blocker, usually Bisoprolol as well and then also start them on, on, on our Doster antagonist. If there's any signs of heart failure, which can be secondary to an MRI presenting as well. What are some of the complications that we can have from um an A CS or an MRI heart failure? Mhm. Yeah. No, that's so good. So we'll get continue a little bit. So obviously when the main complications is is death if we're not able to treat them, manage them. A lot of patients do die from A CS. Um we can get rupture and damage of the heart septum and the muscle walls as well depending on the extremity of the damage that they undergo heart failure. As was perfectly said by one of the um students, we can also often develop arrhythmias and aneurysms as well. Arrhythmias can be quite common patients after Mr S can end up developing quite common um arrhythmias following on from that and resulting further complications as well. One thing to keep in mind more often for exams really is things like Dresler syndrome. So that's usually um indicated as a post myocardial infarction syndrome usually occurs a couple of hours to weeks after the M I. And they'll often present um with this sort of immune response or reaction to the inflammation that they've had of their pericardium. They'll often present with this sort of pleuritic sharp sort of chest pain, often fever and pericardial diffusion which we don't really see through, through echo scans. Rarely for these patients, they ought to come back. We do an EC GG on them and not show global ST elevation, maybe some tr inversion as well. The main initial management is things n steroids to get that inflammation down and then peri pericardiocentesis depending on the extent of the effusion itself. Now, although we talked a bit about sty, it's gonna talk about the end sty and um um unstable angina as well. So, although we've got a ST with sta because with the history changes, it is quite common. So a lot of the time you won't actually see sties in A&E. So working in A&E um as an F one, you, a lot of the patients who come with chest pain because they get the EC GS done straight off the bat as most patients then sort of chest pain will as they should. If there's any elevation in that, they'll often be sent straight to cardiology. They often called cardiology D um R A&E um registrar will often have a look at the E CG, send them straight to cardiology and they'll get accepted and hopefully have P CIA lot of the patients. So the majority of the patients that you'll see on A&E as Juniors will be and Sty instead the EC GS will be pretty fine, very small, small sort of changes, maybe things like bits of ST depression, little bits of ST um tier of inversion, very sort of minimal, small changes compared to their previous E CG but nothing substantial, but they've still got the central chest pain. So a lot of the patients that you'll see will, will come back as Anstey. The main thing to keep an eye on for them is the essentially doing the zero hour one. when we start off on a zero hour and three hour, I think they now introduce the one hour CHS as well um as guidelines so we can continue monitoring and managing for the patients to see essentially to see the trend of what's going on. Um in general, a and I've had a couple of patients who have had fairly raised troponins which actually want to do three hour drops has come back stable and it's actually long standing um abnormality. We've still probably referred them to cardiology and outpatient review, but nothing urgent needing to be done. So it's important to see to see if it is an acute injury that's going on for the patient. The third thing and this one's probably one of the harder ones to diagnose ra in truthful aspect of A&E is unstable angina. A lot of time patients that come in and have come in with kind of no really g changes and they've come in with normal troponins. It can be quite difficult to diagnose this patient essentially because if their chops will come back normal, a lot of the time we dismiss them saying, oh, ok, cool. That's probably um not cardiac in nature, but it is important. That's where a clinical judgment comes into mind because you've still got to think the symptoms and the history they presented with everything else tied the pictures together. Is this still a cardiac image or could this be something else that's going these patients uh patients who come in with, with some sort of chest pain? So what is causing this chest pain. It could be cardiac in nature, it could be something else. It makes you step back for a second, I think. But you still still be considering some bit unstable angina. It's probably a condition that often is missed in a and a unfortunately with unstable angina, the main things is risk assessment and endosy. Sorry. So if we want to do diagnose endosy again, so we're thinking about things an therapy and also starting a second year Tobin. But the main thing for them is assessing their risk, going to their grade school and looking at the six month production of their mortality. If they're quite high risk, then we offer them angio um angio angiography and try to get the PC as soon as possible, essentially, if they're quite low risk, then we go through the Conservative Management as we talked about with um with the semi. Mhm. Ok. So we go through our fourth case which is a fairly short case. So this patient, your working nights are very common. Your working nights on the spiritual board, you're bleed by the nurse at 2 a.m. Doctor will need to to review your patient ASAP. What do you need to know? What do you wanna find out? Cos doctors and nurses will often bleep you and they will say you need to come down patients unwell. They won't often give you a clear sbar handover. What do you want to know from that patient? What do you want to know? I I've been saying this um from the beginning of the presentation guys when you start working as doctors and if you are working as doctors immediately, if someone says we need you to see a patient, what do you need to know from that person? Because she's like, truthfully as when you're, when you're on call, when you're on nights, you'll get so many leads and you've got her essentially you've got your own self triaging. Someone says vital, her father, someone says vital. Yeah, which is bad. Sometimes a new school is, is reasonable. It's important to kind of need to know those finals. It's bad for her, for sure. Sure. Definitely vitals. Yeah. Yeah. But it's true. And I think the things at the new school itself, it's a, it's a good gauge of how unwell the patient is and that's what nurses use as well. Really? I think you see, I think it might be different in, um, our Russell's cos we've got the whole Met team system, don't we? Where, um, if a patient uses high enough, they essentially bring the whole Met team down. That varies massively depending on exactly. Someone says, uh, someone says they would like to know what are they concerned about. Yeah. No. Perfect spot on. Yeah. And I said so, um, yeah, so let's have a look. So essentially means that you want to know is you wanna, who this patient is. What's going on and you wanna know their new sport essentially because, like I said, because depending on the hospitals you're working in, you can, um, because I was working at New Cross last year, you can get called, even as the f one first day in, you can get a call for patients using like a Exactly. Can you come very unwell. So you're, you're, you're, you're working there, you, you should already have like a working diagnosis of what's going on, what you want to do as soon as you get there. Um And you should be ready to call them really if you're going to what the patients going for before you even. So for Russells, ours is seven to be seen by a registrar and yours is 12, I would be mortified if I had to see a patient. Our, our, our, our wasn't even 12. It was literally just um whatever the patient with the news was scoring, they would call the F one first if for some reason the F one didn't come. Um But you'd get a Bollock if you didn't go, you will be getting for that 12. Um then they'd go straight to things that are read. Um But no, it, it'll be the F one who attempt. But the main thing is if you do get called from any un more patient that you're concerned about, get a quick, quick little handover from them, quick little bar, what's going on, who is that patient? Why are they unwell? Why are they concerned? What they're scoring for their news as well is really important? Um Exactly what's triggering, what's unwell. A change is also very useful. So a handful of times I've had patients where they've uh believe me, patients scoring like a nine or a 10. Um What were they, what were they previously scoring an 11 before nine and 10 before they're kind of stable on management again, you should be going and reviewing the patient, but it makes you realize, ok, there's plans already in place. If they've been scoring that high all day, what's going on? Important to know things like our respect forms in place and stuff like that for the patient as well before you even go in. Once you get a bit of an idea of what's going on with the patient, you can over the phone, start asking for certain things to be done. For example, any things like chest pain, things like that going on. You can always start saying, can we get EC GS, can we get these bloods? Can we get these things done before I even get there? If the oxygen starts to low, we can start them on auction over the phone before we even go in because we can start immediate management depending on how far away you are. And depending on the hospital, you can be quite far away, depending on which wards you're looking after as Well, so getting a very brief background from this patient. So she's a 72 year old woman. She came to the hospital a day ago, they diagnosed her having a required pneumonia. She's on IV Comox. So she's on the right medication for what's going on and she has a fair few comorbidities. She's got heart failure CK D3. She's got osteoarthritis and type two diabetes. Now, looking at the diabetes is also very important as well when you're talking to them over the phone, because you wanna know what things you need to think about osteoarthritis patients being unwell isn't really gonna bother you. That's not gonna cause a massive, massive impact. Things that are type two diabetes that can do. There's not lots of interactions that need to take into consideration. There's lots of, uh, diabetes associated, um, um, acute things that might be going on CK D3. Heart failure also very important to consider as well. Are they well managed? Are they well medicated? Is any of that going to affect your management plan going forward? So, we get the ops from this patient. So, respirator of 21 heart rate, 100 and three BP, 81/56 temperature, 38.2 oxygen salts, 96 on room air. So essentially they using seven. Mhm. So essentially from the, er, information that we've been given for the patient, you've got to kind of assess which of these, we're worried about respirate of 21 isn't often a massive worry. Again, it's important to know what was it before, if their res were, they were always scoring to 12 or 13. And now it's 21 you're concerned. But if they've been on 1618, 20 now they're 21 again, I'm not too, too worried. It's quite a crude measurement. Essentially. Heart rate's important to figure, important to think about. I think often over the over 90 gets flagged on the new school. So again, it depends how we draw. It depends what their baseline is. Again, if their baselines around sort of 6065 shot up to 100 and three, you're worried what's going on. But if their baselines around sort of 8590 they're responding, they're reacting to something, but you're not tremendously concerned. BP as well is also a very important one. This is one that you will get called for a lot of the time and we got called for a lot on patients a lot of baseline nights as well. Uh especially upon on the wards and things like that or what's going on with BP. Very important to think about. Again, what was the uh previous BP? If again, cos sometimes we get patients and even depending on how, how, how hypotensive they are, how unstable they are, you manage it accordingly. Essentially, if this has dropped down from say 100 and 20 is their baseline systolic you're worried, you need to respond as fast as you can. If their baseline is around 90 again, you're not too concerned. I've had a patient who I thinks baseline was around 75 for um for so she was a very unwell lady but she was 175 around a week or two. Again, nurses will bleep you for that and say this patient's scoring, scoring very highly. We need to respond, we need to treat them ASAP. But having known the background and knowing what their blood pressure's been like over the last week, you know, you're not gonna start throwing, throwing anything at them because you don't want to be counterproductive temperatures also quite high as well. So we can see the temperatures quite high. We know they have recently been started on, on medication for their pneumonia, they're on IV pros. So, an important thing to consider with temperature being high is, are we on the correct medication? Have we had enough time for the medication to work? Two very important questions to ask when you get a patient who's spiking a temperature essentially, which again will be a very common common thing to get called for. Um especially again, depending on the ward you're working on. Um I was working on this one of the wards which is a um Oncology Ward. Everyone's really neutropenic. So everyone's very unwell spiking very high temperatures. So it's important to think what are they already on? And what's going on hasn't been changes been made and have we given it long enough for the change to work? One day of IV Comox, it should be having its impact. But again, one day a couple of doses isn't enough to really completely treat the infection. So she could still be on the right medication. But she's still responding because the bacteria is still present and we still haven't killed, killed her already. So, what do we think is going on? What's the biggest concern that we have for this patient? Mhm Sepsis. Very fair point. Yeah, the sepsis is a very important thing to thing to consider through all of this. Um So essentially, if you are thinking sepsis again, perfect, you'd want to start essentially the sepsis six pathway, um which a number of them would have already been completed already. Ideally, if the patients coming in with something like you to a required pneumonia, um from the observations themselves, the most acutely worrying thing that I'd be concerned about again, depending on what their baselines is, is the BP. So this patient's main, main thing we're concerned about is that they're hypertensive and it's thinking, why are they hypertensive? And what do we do to manage the hypertension? What would your initial managements be as an F one? Your patients come in their BP baseline was 100 and 20. Everything else is pretty similar to their baseline, but their blood pressures dropped down what would be the first thing you do to manage this patient fluids. Someone says, fluids, perfect. How much fluids, what fluids, what are we doing? That's a good question. Someone says 0.9 Saline 500 mL bullous normal Saline 500 mL bulla over, over 15 minutes. Yeah. Yeah. And I think the actual guidance is less than 15 minutes is what they say, but most of the time in most things you'll be able to write stat and get it given as soon as possible. Um But yeah, so normal Saline, either Saline or Hartmans are the main things we give for any sort of fluid bonus. Um Something that's completely not gonna be any sort of skewed in terms of electrolytes, the quantity of bolus quantity of the bolus is the important thing. So this patient we know has a history of heart failure and CK D3. So we wanna essentially see how much we can give her without overloading. And now she's a 72 year old woman so she could be quite frail. So we'd wanna be quite conscious and quite cautious of what we're giving and how much we're giving and how unwell she is. So you'd want us us a thank you to have a look at her and see how she is. If she's very unwell, we'd ideally want to give her a larger fluid bonus. But if she's quite a frail fluid, a frail old lady oftentimes I'd err on the side of caution, we give her smaller bolus, see if she is fluid responsive. See if the fluid's actually bringing up her BP. If there's something else going on that's causing it, we don't want the BP to be tanking, but also for her to be already flowed, overloaded or something else to be going on and what to making the situation worse. So it'd often start with a 250 mil bolus of fluid um for the patient, a few other things we wanna do and we mentioned this earlier is antibiotics as soon as we treat the acute. So as Lani was saying earlier, we'd wanna do a full a two assessment for the patient with kind of the ops coinciding and supporting his lab. We can see that it's the BP that see acute urgent worry for this patient. Once we treat the urgent um aspect, we get them stable, it gives us a bit more time and space to think through logically of what else we can do to treat and manage this patient. Now, the patient's already on antibiotics, but we need to consider is this the correct antibiotics? And how can we check a lot of time? Hopefully, a lot of these aspects will and should already be done. But we need to, we need to think um has things that speech and culture been done, has things that blood cultures been done um with at the moment. Now, I was um with, at the moment now with kind of winter pressure and stuff like that flus come back massively on the rise. So I've seen a few patients coming in who have become incredibly and well, we test them and they've come back as flu positive over the last few days. Um So that's also something to consider as well. Cos it can be a very viral cause as well, which when you do your bloods bloods will come back very normal, the white cells will be pretty ok. The neutrals are pretty ok. Lymphocytes maybe might be reacting to the viral infection. But a lot of the time I've seen a couple of patients now who have been completely fine but very unwell but have been flu positive. Instead, we also have to consider, is there anything else that's causing this infection? As one of the um guests said earlier for thinking and the Eps, we're thinking what infection is going on. Is there anything else that we need to be treating? We need to be examining the patient. We need to checking through them thoroughly to see things that the urine output is any sort of abdominal pain, any distention, anything else that might be going on and treating accordingly for that, we can also do a urine culture as well to see if there's anything else that could cause the infection because the patient might have presented with a chest infection might have picked to something else, might have not even been the chest infection in the first place. It might have been something else that's caused them to become so unwell with that fever as well. We wanna make sure that they're on simple things like paracetamol to bring it down. One thing finds a lot of the patients, uh, when they do become septic, be going well, unless they've had fever in the past, they won't have things that paracetamol prescribed. So it's important to kind of make sure that it is available even as a minimus P RN. If they're constantly spiking things, they're putting as QD so that they can be constantly manage the fever and keep them, keep them Abey and then sepsis six as um as someone described perfect failure. So once we've given them the fluid bolus and we've stabilized them and reassessed them, we then have to get a repeat set of box. We need to see what impact have we had, has the impact that we've had been able to support, manage and, and manage the acute cos that's the main things uh especially on like a night shift on a night shift. Very rarely are you um going to be creating new diagnosis, things like that, you're often managing the acute situation and trying to figure out what's going on with the patient and managing the acute concerns. So you wanna bring the patient back to being stable. So looking at the respiratory we brought that down to 88 heart rate's also settling a little bit as well. Their blood pressure's improving from 81 systolic to 89 systolic temperatures settled with the paracetamol and the oxygen salts are perfectly fine using a bit lower now, but that BP is still quite low. Now, their baseline, what we said was 100 and 10, 100 and 20 systolic, right. That blood pressure's still quite low. What do we wanna do next for this patient? Mhm. Waiting. That's fine. So essentially what we know about the patient is we know that they, their BP has improved, having given them a small dose of 250 mL. So we know is their BP is improving. They are fluid responsive, um hypertensive. So we can essentially give them another bolus of fluids again, if they're small and they're f and they're um and the elderly with comorbidities, I wouldn't whack them with 500 mils. I'd often give them another 250 mils and then see how they're responding. If they're younger and they can take the founding more bonus, then you can give the founder bonus as well. But it very much depends on clinical judgment and how well that patient is doing in that situation. But one thing we need to do is we need to keep a close eye on that fluid stages. Now, we know that the patient has heart failure. We know that they're KD. So we know that if we pump the fluids, they might not be able to get rid of that fluids. We know that if they pump the fluids, they can very easily become overloaded. So depending on the extremity of the patient, we need to be very careful with patients like that. We need to be assessing them to make sure they're not kind of peripherally overloaded, list their lungs to make sure they're not. Um no so load in their lungs, make sure oxy stas aren't dropping and also keep an eye on their urine output, urine up, going to be a bit of a less acute thing. Unless they're catheterized, we can keep a close eye on it. A lot of time, urine output won't be assessed in status in an acute urgent situation. So, further management. So if, if we, if after we give sort of 2 to 3 boluses of fluid um fluid as an F one, I would say 100% you want to um to escalate to your senior after this. After you give a couple of boluses. If we're still not able to get their BP up to baseline, uh or even close to baseline, you wanna be escalating it if you're concerned earlier, especially as a new rough one you can discuss with your tier two. Yes or your reg and wanna buy them as well to get a better idea after Tuesday bulls, we need to be very careful. Now, if they do become fluid overloaded, we need to be very conscious of what we do in that situation. Again, as an F one, you, ideally, you shouldn't manage that on your own. You'd have a reg involved as well. But things we've done in the past is where we can give them a little bit of fu as well to get uh rid us with the fluid. Whilst we also stabilize the heart and get their um get their heart BP up as well. But if you give them a couple of bolus and they're still not still not sustaining, we may need inotropic support, we may need further input and this will often be kind of eye to you and much more special l than what you guys would do. But it's important to keep an eye on that and be kind of knowing of that as well so that you know, when to escalate and when to, when to manage a lot of that, you'll develop over your time as an F one because when you first go in patients BP drops, you'll know what to do theoretically, but it will always kind of um get you a bit nervous because you know what do I do in this situation after you do a handful of times, you will become more confident and more certain of how much you can do, how much you can push things and how well you can manage things and when to seek senior support. And once you've done a couple of things with the seniors a few times, you'll get an idea of what you need to do, um, in those situations as well, but it's always best to escalate early when you are concerned. Um, no one should tell you off for that. Um, much better to escalate early than to try and manage things on your own when you feel out of your depth, which is very easy to feel as a new F one. OK. So some of the main topics that we've covered uh today during our session is things like acute heart failure, hypertensive emergency, A CS and the hypertensive patient, all very common things that you will see throughout um via your F one experience. So if anybody has any questions and answers, you can um put it in the chat as well. We've sent week. Um Of course, you can tell your friends about us. We are just starting small now. So hopefully, you know, we'll, we'll build on this. Um But we'd really love if you could fill out the feedback form. Um and you know, we'd be able to improve. Um And of course, tell a friend to tell a friend. Um You can also follow us on Instagram as well. We have an Instagram page where we post little um tidbits on uh things that you should know. Um or you know, just remind you of really uh important information that, that you need to know on just your day to day um clinical work. Um But thank you so much for coming. Um It was a really good session, um very interactive. It was, it was quite good, a lot of answers um that were quite brilliant. If I got sick, I would trust you to take care of me. But um so thank you so much for coming. Of course, if there's anything you'd like to ask us, um We'll be staying on um to see if we can answer any of your questions. Ok. Oh, someone said, thank you. Thank you for attending. All right, let me just check. Uh Oh, thank you. Um You can also follow our uh aspire med account as well. Um And then you will be able to see our posts. Um So we normally have it on Tuesdays or Mondays. Um And you'll be able to join then to register for more sessions. Ok. All right. Uh Thank you. Ok. All righty. So I think everyone has completed the feedback form now. Um All righty. So um we'll see you next week. Um We have two other presenters which will be um Doctor Nasim Nasim and also uh Doctor Kaelan um for gastroenterology emergencies. So we hope to see everybody there. Thank you for the lovely session. Thank you for being interactive. Of course there again, I'd like to say there are no answers. No wrong answers. Um Everyone was thinking along the same lines and I'm, I'm really happy for that. We, our aim is just to get you prepared um for the foundation program. So thank you so much for uh interacting with us. We'll hope to see you next week.