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It's just loading. All right. Hi, everyone. Thank you all so much for joining. Um We'll just wait a couple of minutes. Um, and then we'll get started. We've got a little introduction and then I'll hand over to Greg for the main part of the talk. All right, I've given it a couple of minutes. I think we'll just get started. So, my name's Ramya. Um I am one of the F one co leads for mind the bleep along with Manish and F over here. Um, and we've also got a lovely team of Deanery reps, um, who make up the F one team. So this is the first talk, um, in what we're hoping will be a long and successful series of medical education talks. Um They are aimed at, um F ones. Um We've just started, um, obviously you guys have had a couple of months already. Um And so you might have an idea of things that you want to learn more about at this stage. Um And that's really what these talks designed for. Um, they are centered around, um, on call situations primarily. Um And we're hoping that in each session, our lovely speakers will go through a couple of cases that they've encountered during their time working as an F one or even more senior as an F two or an I MT, for example. Um And they'll take you through the case. Um It'll be really interactive, hoping to use lots of polls in these sessions um and make it really engaging. Um And there'll be plenty of opportunities for you guys to ask questions. Please do just pop questions in the chat throughout. Um And also if you prefer just asking them at the end as well, um That is absolutely fine too. So they'll mostly these talks be on Tuesdays um at this time, so 7 to 8 p.m. and as it says on there, they aimed at F ones. Um So there will be a few talks that are on Mondays or Wednesdays instead. But yeah, primarily on a Tuesday at this time to try and keep things consistent. So we've also got to put a few disclaimers on, so intended just for healthcare professionals. Um We've anonymized all clinical cases, we've asked that our speakers have done that. Um And we do try to ensure that everything is accurate, but of course, it's meds and things do change. Um And so, um that's our little disclaimer there in the blue with that. Um And if you want to find out more, um you can follow that link to the website f any further resources if you guys are interested. Um, hopefully you'll all know about the whatsapp groups, um, for each deanery. Um, there's a little QR code up there to scan, which has a, will take you to a link where you can join the whatsapp group for your relevant deanery. Um, please do follow us on med all. Um, and that'll keep you up to date with any upcoming sessions that we're running. Um, and of course, there's mind the bleak website which has all the articles, um which Yeah. Mm. It's sort of up in your pocket there on which is ready to go. Let's see, f um just a little preview of what's next. So today we've got lovely Greg Mills. Um He's gonna be taking us through some cases in cardiology next week. Um We've got a talk on gastroenterology cases the week after endocrinology, the week after that. I'm hoping it'll be a nice practical session on just data interpretation, things like ECG S or chest X rays. Um And then the final session this month um is going to be on urology. So without further ado I'll hand over to Greg who is an I MT one working in the Northern Deanery. Brilliant. I hope you can see my slides as well. Ramer. That's up to see that. So, yes, good evening everyone. My name is Greg. I'm one of the I MT trainees in the Northern Deanery and we're gonna be focused on chest pain as part of your on calls. Um, probably many of you have done on call shifts now on days, weekends and night shifts, but we'll just work through a few cases and hopefully you can pick up some top tips. Um, so you have to around here for sort of inviting me along, hopefully finish. So we're just gonna quickly run through, um, sort of my approach to on call shift and very briefly cover ABCD but mainly focused on chest pain. I'm sure you're very, very familiar with ABCD anyway, for medical school, but also as a foundation to your assessments on call. And we're gonna run through some case presentations of patients that I've seen with chest pain. We'll try to keep it as interactive as, as possible. Obviously, it's not an in person, um, lecture or seminar, but we have got some polls arranged just to try and keep you thinking um through the cases. So we'll just go through an ABCD E approach that's adapt it for chest pain, recall the key investigations to perform in most patients. And then based off your assessment to come up with a differential diagnosis and then an initial management plan, what it's not gonna be, it's not gonna be an ECG tutorial. It's not gonna be focused exactly on management of this specific condition in the pathophysiology, but just getting you thinking, you get that leak call on your phone, whatever it is in your local hospital and you have to see a patient with chest pain that might fill you with dread. You, you know, it might be an extremely busy day. Chest pain is such a spectrum of, of causes and severity and patients might be extremely well or they might be critically unwell. So it might be that, you know, that bleep when that call fills you with dread. But hopefully we can just make things a bit easier following this talk. So, just a few very, very top tips for sort of your uncles. I've always found very helpful when you've got that call. When you're on call, always have pen and paper handy. You know, it'll be that time when you don't have pen and paper handy, you need to write something down, they get the patient's details, you know, the name or the hospital number, the ward, the bed number, whatever, but also have the, the contact details of the person that's ringing you so that you can ring them back if you need to, you know, if you're going to be delayed getting to that patient or, or you need to get a hold of them. For whatever other reason, when you take the course, really, really useful, it might be obvious, but it's really useful to hopefully have some observations done and have a new score that can help you work out. How well is this patient? And hopefully the nurses might be able to give you a brief history or background. I always ask them as well. Are you concerned about this patient? Do I look seriously unwell? Because that often helps you work out how quickly you need to be there too. And then also in the interim, you might be getting across a very large hospital. So there might be jobs that the nurses can get on with as well. So can an E CG be performed whilst we're getting there? Can the nurses get some things ready like previous EC GS? And then can you give some safety netting advice as well? So sorry, I'm just getting over a cold as well. But if you're not getting to that patient straight away and the pain's getting worse or the OBS are getting worse, can you give me a call back? Always useful? And then generally when I arrive on the ward, I'll quickly eyeball the patient when I, when I'm passing their bay, just make sure that, you know, I'm happy that they don't look critically unwell at that moment and give yourself a minute to, to look at the EKG if it's been performed, double check the OBS and if you can quickly flick through the notes to get an idea of exactly what's been going on, why they're in the hospital, what investigations have have happened. So you'd have a bit more information before you go see the patient if that's possible as well. So, like I said, very briefly, I'm gonna touch on ABCD. E just with a bit more focus on, on cardiac sounding chest pain. Hopefully, you're very, very familiar with ABCD E but obviously A is for airway. So either is it patent or added sounds by or use a as an opportunity as well to look at appearances? So when I looked from the end of the bed, does this patient concern me? Did it look unwell? There's a difference between the patient with chest pain who is, you know, sat in bed on their phone, chatting away to the other patients around them as opposed to the patient who reports chest pain is obviously struggling to b breathe is a bit gray and clammy. They're not really interacting with, with anyone around them. So that's probably two ends of the spectrum with B hopefully you've got your observations which include your respiratory rate and oxygen saturations, but it might be that you are doing them instead whilst you're there with the patient. And then obviously really looking at their breathing, are they struggling? Have they got accessory muscle use? Is their breathing regular? Is it something that doesn't look normal when you auscultate as well? Obviously, you're listening for all sorts of sounds, but hopefully a clear chest expansions and percussion might be necessary as well, particularly if there's some reduced air entry or dullness on one side and then often as well, if the chest pain might be quite focal palpate in that area, you know, is it related to a broken rib or something like that, that's quite swollen. You've got your interventions like a blood test or chest X ray, which might be appropriate at that point in time, as well as immediate treatments like oxygen or ventilation as well. Hopefully, this is nothing too new to you. And then when we get to see in circulation again, you should have a heart rate, BP and temperature. When you're feeling for the radial pulse, you're obviously feeling for rate and rhythm. But it's something so useful to do in a patient with chest pain. It's just feel for a radio radial delay, have a feel of both of your pulses at the same time because again, it's just something that's really reassuring. And then depending on the history and how well the patient is getting something done like bilateral blood pressures is another really useful but quick, quick assessment that you can get done fluid status. It's one of those sort of assessments. You will hopefully get more and more confident um as you gain experience on the wards, but that obviously well might include chia refill time assessment of JVP mucous membranes, urine output, peripheral edema, listen to the lung basis, things like that. Um because that can become quite important if you know, if you think about fluids and when managing these sorts of patients. But um getting an idea of of their fluid status is are they euvolemic or are they wet and then obviously listening to the heart sounds as well. And obviously this is related to chest pain. So an ECG might be quite an important investigation to get done, but don't forget bloods, which might include a troponin IV access. If you don't have it already as well as fluids, fluid balance, catheters, those sorts of things that you might want to um look at getting done as well. I think ABCD E, we're normally quite good at doing up to CD. Sometimes not so much that disability obviously encompasses a range of things. BM often more useful in sort of neurological presentations, but it never forget blood glucose A and G CS, hopefully you're familiar with. But if necessary, sort of doing things like examining pupils or doing a grossing assessment might be, might be necessary too. I always use it as an opportunity to look at things like pain control as well as medications in general. So never forget to review the medication chart, see what patients are prescribed, see what they're missing and see what they're actually taking. Cos just cos something's prescribed doesn't mean it's actually being, being administered. N ne exposure, everything else. So might cover quite a few things there. So particularly in a patient with chest pain, if you're worried about some cardiac or maybe even more respiratory, then calves and edema or something to check. So signs for DVT signs for peripheral edema. Also it part of your exposure, you want to be checking for rashes, sort of ideally everywhere in the patient and then all sorts of sites. So this might be a surgical patient. So you want to be checking their surgical sites, always sort of overlooked as well as sort of cannula sites, things like that, which are very common sources of infection too. So just if you're giving the patient a once over check everywhere really. And then I always put bladder and bowel here as well. Bladder sometimes obviously comes under the um, sea circulation, but it's always useful to check for things like retention, urine output. And then bowel can encompass checking the bowel sounds abdominal tenderness and even a stool chart that might be less necessary in a patient with chest pain. But just, you know, if you work through obesity and you're not finding very much, you know, you can always be thorough by checking all of this as well. So, first of all cases, so the first patient, you get bleeps, can you rule this patient with chest pain? So you have to go see, um, a lady who's in her early seventies on your Oncology day unit and you're currently working in a rural hospital. The nurse will tell you that she's got left sided chest pain and then new scores are one. So that might get some thoughts going through your head as you are on your way to go and see her. Um, it might be that nurses are able to do an ECG whilst you're going in there as well. Um But once you get there, so we've got the lady's observations on the left. So, like I said, she's in her early seventies and a new scores of one and that's because her heart rate is getting a little bit tachycardic there at 96. But all of the other observations are within normal limits. The nurses tell you, um that this lady is receiving two different types of chemotherapy for amyloidosis, but doesn't have any other sort of cardiac history that they know of. So you proceed to do your history and again, it's not gonna be how to take a history or how to do Socrates, but obviously that's a very useful approach to chest pain. So this lady tells you that she's got left sided chest pain. It came on acutely, it actually came on at 4 a.m. in the morning when she was, um, getting up to go to the bathroom. It was excruciating at the time. Um, and it lasted for some time, but it eased off a little bit, but still quite a heavy feeling at the time. It was radiating to her left arm as well and she didn't have any other symptoms like a cough or nausea. Um, but she does feel a bit short of breath. It's a constant pain, but it's not associated with any sort of exertion, but it's still there all the time. So it's quite a bit of information. Um She might have told you so brilliant rammy has brought up the, the poll there. So there's no correct answers here. But just to get you thinking with that history and those observations and what might be your main differential diagnosis. So, we've got a lower respiratory tract infection B angina C pneumothorax, D acute coronary syndrome and E called. So I'll give you a few seconds to so put down what you think the main differential might be and then we can to see, see what the spread of answers is. So I'll give you a few, a few seconds. Uh And then hopefully, Raia can help us with bringing up the responses. OK? But it looks like we've got quite a few responses there with the, with the main one being a CF And like I said, there's, there's no, there's no incorrect answers here necessarily, but I would say probably pneumothorax and ACS might be your, your top differentials here because this is a lady with left sided chest pain with sort of cardiac sounding history there. So acute coronary syndrome is certainly going to be near the top of your list and something important that you want to rule out. I'd say pneumothorax as well is something that can be forgotten, but sort of unilateral pain on one side, struggling with the breathing a bit. It's not something insignificant. Angina. Um It's not precipitated by exertion in this case. But again, thinking about the sort of cardiac sounding thing. Um That's at least you're in sort of the right area there. But I'd say for this type of, um, question, maybe just it's good to see that you're obviously concerned about what I would say are quite important. Things. Brilliant. So you move on to examination because it always works. You go through an ABCD approach. So this lady is always patent, but in terms of her appearance as well, she is holding the left side of her chest and looks a little bit pale and her chest sounds clear with good air entry. Bilaterally, she's got a strong, regular radial pulse is volemic with normal heart sounds, she's alert and there's no protein, neurological deficit and there's no signs of peripheral edema or DVT. So that's your, that's ABCD examination. So what is your first investigation? It's a blood gas B chest X ray C bloods, including troponin D, ECG and E blood glucose. So I'll let you think about some of those responses. You might think this sounds quite straightforward. But sometimes if you're, if you're the busy on call doctor and you're trying to, to work out exactly what to do and you've got lots of, lots of jobs and lots of people around you who worry about this patient as well. And sometimes you just need a bit of clarity in your thinking as well. So let's see what the answers are that you've put the, yeah, the vast majority of you've put ECG, which I think is probably the, the correct answer here cos it's an, it's an immediate investigation that you can get done sort of relatively easy. Um Because bear in mind, this lady sat in the Oncology Day unit in an outpatient setting, but um we have easy access to, to do an E CG. So they perform an E CG there for you. This is an example of what it showed. Like I said, it's not gonna be an ECG interpretation um lecture, but I'll just give you a few seconds to look over that as well. I'll see if there's anything there that it catches your eye or you're concerned about. It's worth saying in the context of chest pain as well. And we don't always do an EKG just to look for something like a sty because you can get weird and concerning arrhythmias that give you chest pain because of the ischemia. And an EKG is obviously extremely useful for identifying that essentially though this is a normal ECG with no S TT wave changes, no arrhythmia as well. I'll just bring up another slide just to highlight things that you might want to look for that aren't on this ECG. But you may really look for ST elevation ST depression T wave inversion as well as any obvious um arrhythmias that might be precipitating the chest pain and just to highlight as well that you've obviously got the different areas on the ECG which correspond to different coronary arteries and um myocardial territories. And if you've got ST or T wave changes in those areas, that might indicate that there is a coronary um cause on the other hand as well, if you've got global changes across multiple um territories that might um indicate a global um sort of myocardial ischemia, something like a type two M I due to severe anemia. But anyway, the main point with an ECG is, are there any concerning features? But also what is the comparison to any previous ECG? Cos that is really, really useful, it might be that there's T wave inversion in a few leads. But if that is consistent with the previous ECG when they are well without chest pain, that might be less concerning. So yes. So you've seen this normal CG, but this lady still got chest pain in front of you. So what is your first step in management? Would it be A to trial a GTN spray B? Wait for a chest X ray C to send a troponin D to get aspirin or E to inform a senior? Brilliant. We've got the, got the responses up there now. So again, I'll just give you a few seconds to, to think about the case so far, the, the normal EKG that you've got and then work out. What, what do you think you would do in this case? And like I said previously, there's, there's no correct answers. Good. It looks like we're getting a nice spread of results as well. Brilliant. Yeah. So quite a spread of results there. So about a third say, trial GTN, a third say and then AAA slightly smaller mix of chest X ray aspirin and inform as well. Brilliant. So quite clearly, you've all been thinking, what would you do about that? And maybe it's a bit of a bit of a trick question, but I would say all of those steps are appropriate. So G trialing GTN in a patient with cardi and chest pain is not, not an incorrect thing to do. And if it's the first time they've ever had a GTN spray, obviously, it'll drop their BP, potentially quite significantly, make them feel even more unwell just to make them aware of that. Again, chest X ray for the reasons that you said concern about maybe pneumothorax. But also it's just a sort of a routine screen for a patient with a chest X ray is not an incorrect option, but also this patient is sat in a um outpatient setting, which might not be the easiest thing to get arranged troponin. Again, an essential blood test to do in someone with chest pain, it's not gonna give you an immediate answer, but it's, it's definitely worth taking the samples that you can get it sent off to the lab. Aspirin. Potentially, you might want to wait a bit longer until you get some blood tests. But so I'm looking at the one of the questions here, if aspirin didn't benefit, it won't harm but could be lifesaving. Yes, potentially the aspirin could be lifesaving. So I'd say there's, there's no, it's not an incorrect answer. So, Aspirin in a patient concerned about who's having an acute coronary syndrome would be the initial first management. And as I highlighted, it's not an incorrect thing to do and it's unlikely to, to be causing harm and then discussing with a senior colleague. So this is a patient who's unwell, you concerned about acs um informing a senior about that. It's never, it's never the wrong thing to do. So all of those seem like appropriate things to do. There's no right answer. But actually in this circumstance, what we did was we took the blood samples, but we weren't waiting to, to get a chest X ray done or to waiting for the blood test to come back because this lady was in a rural hospital in a day unit in the outpatient setting. So in terms of a safety point of view, we needed to rule out an acute coronary syndrome, which meant sending her to the nearest urgent care setting um to get thoroughly assessed where she could sit in a in a safe environment whilst this blood test would come back. And potentially she might need further investigations like imaging as well, which can't be done in the outpatient day unit setting. So hopefully that first case just got you thinking a little bit and then we're just gonna run through two more cases as well. It's a case too. You have to see another patient with chest pain. But in this, in this circumstance, you're on, you're doing the weekend shift on the care of the elderly ward and you're in the district General Hospital. This is a patient, uh, a lady in her mid-eighties who's got some left sided chest pain. Um and then new scores of three that your hand over from the nurses and you go along to see her as well. So the reason she's scoring a three is because the saturation is a little bit low on room air 94% and her BP is a little bit low as well with a BP of 92/64. So this lady had a fall and then was treated with IV antibiotics for a hospital, acquired pneumonia after getting a cough and oxygen requirement and some consolidation on a chest X ray. She been clinically improving over the last few days. Um In both, in terms of observations, blood tests and symptoms and she, she was set down onto oral antibiotics a few days prior. In terms of her background, the nurse will tell you she's an ex smoker, she's got atrial fibrillation and she's anticoagulated. Um but she's frail and she doesn't use any inhalers. So you see this lady And again, she gives you a nice, um, history after you've used your sort of Socrates approach. And again, she's got some left sided chest pain and she's not too sure when it started, but it's just a bit of an achy pain. It can be sharp at times it's localized to a particular area on the left side of her chest wall and it sounds like it's pleuritic in nature, um, worse with breathing and she's got this ongoing cough, um, which she's been improving with the pneumonia and she doesn't feel breathless, but she says the pain is probably about a two out of 10. So following that history, um, you start thinking what might be your main differential diagnosis. So again, I'll give you a few seconds to put some answers here, but we've got pneumonia, musculoskeletal, pneumothorax, pulmonary embolism and exacerbation of COPD. So we'll see what, what the, what the responses are here. Sorry. So, yeah, we've got quite a, quite a spread of answers. Again, it's quite nice to see. There's a spread across quite a few things, but it's good to see as well that people are, have got pa up there as well, um, which is obviously an important diagnosis in itself, but also quite a nice spread of pneumonia, musculoskeletal, yes, pneumothorax should never be forgotten as well. Um And then I'd see why someone would put exacerbation of COPD as well in this lady who's, who's a smoker. So you go on to take your history as well as your, your ABCD assessment. Now and again, her airway is patent, you're happy with it, but she does look tired and a little bit frail, she's got crackles in that left lower zone. She has no increase in her work of breathing. The chest expansions are equal. And when you palpate that area that she says the pain is specifically and you can't find any chest wall tenderness or any sort of abnormality there. Her pulse is irregular, irregular, um, she's a little bit dry and her BP is normally in its nineties. Um So that looks consistent with her usual BP in terms of D she is alert and on the medication, she is taking the DOAC that um she's prescribed for AF and then there's no signs of DVT in her legs. There's no breast mass as well and she's producing good um, volumes of urine. So you've, you've done that assessment now and you might be thinking what investigations you need to do for, for this chest pain. So we've got a, a blood gas ba repeat chest X ray C bloods, including ad dimer DNE CG and a, a sputum culture. So again, we'll see what, what some of the responses are here. I'd say this might be less clear cut and there's no, there's no, there's no right answer. There's no wrong answer. But um it's just useful to see what, what you might be doing is your first line investigation for this lady who is on the, on the care of the elderly ward. Let's give you a few more seconds. Good. So we've got, yeah, I would say a nice spread of the first four as well. So we've got a blood gas, a repeat chest X ray bloods including AD dimer and an ECG. So, um, obviously this is about chest pain. So an ECG is not gonna be the an incorrect answer to do um bloods including AD dimer. So we'll come back to D dimer shortly. Um repeat chest X ray. It's again, it's a quick investigation that you can get done potentially on the ward as well, which might just give you um some, some answers as well. And then we've got a blood test too. Um I would potentially not be doing a blood gas straight away this lady because um she doesn't appear to be acutely deteriorating. She's not struggling with her breathing and oxygen saturation. So, relatively, ok. And 94% we normally aim for 95 no, for an our trust. Um And then sputum culture hopefully might have been sent to anyway when she had um started with the pneumonia. But again, it's, it's not an incorrect answer. So maybe not straight away in the acute setting. So you get a chest X ray done just because it's uh an easy investigation to do and her EKG was normal in this case, this is a chest X ray and just like some of the other investigations. Um, we, we're not gonna go through interpretation of the chest X ray. Um But hopefully, you can see here there's some left sided um, changes most likely in keeping with the consolidation, um that she was treated for with her hospital acquired pneumonia. Um And actually, when you compare this to the previous chest X ray, it's relatively similar. Um With those left sided consolidation, it is worth remembering as well. That consolidation doesn't necessarily improve straight away on a chest X ray, but also doesn't appear straight away as well. Um So can lag, so you've got that chest X ray, what would be your first step in management bearing in mind? Um, the normal EKG as well? And this lady's got chest pains two out of 10 to a relatively localized area on the left side of her chest consistent with where that pneumonia is. So you've got IV antibiotics, Peptac C TPA nebulizer C B1 and steroids monitor symptoms in s So we'll see and the reason I put this question in just again, get you, get you thinking quite a bit about why you're doing tests and why you're, you're choosing management options. Probably getting quite a few answers now as well. Brilliant. Ok. So a bit, a bit of a spread as well, but about 40% going for IV antibiotics, right? So, like I said, there's, there's no, there's no right and wrong answers. But you can maybe and try to read through all of them as well. So this lady is actually not clinically deteriorating. You don't have any blood tests to, to show that her inflammatory markers is getting worse and she hasn't got a temperature. So maybe you don't need to escalate the IV antibiotics. I would probably stick away from the PEP attack as well. There's nothing telling you that this is gi in nature at this time, in terms of nebulized altol and steroids, that would be the, the treatment we're going down the COPD exacerbation route. But you haven't heard any wheeze. Um although she's an exsmoker, she hasn't got any diagnosis of COPD and doesn't use any inhalers. So given the lack of wheeze as well, I, I'd be probably staying away from that at, at this time and then see slightly, maybe considering a CTPA, but I can see quite a few people have said monitor symptoms and observations as well. So in this case, what we did with this lady was we just monitored her, her symptoms. So the reasons for doing that were that her observations were stable. She had been improving clinically and this was quite a localized low severity pain that she was describing. Yes, it's a little bit pleuritic in nature, but maybe the point to remember here is not all pleuritic pain is pe although you should never discount pe as a as, as important differential diagnosis. So we thought this was in King with, with her pneumonia, some inflammation of the pleural linings causing a bit of irritation. You might not be incorrect to, to ask for a CTPA. But remember this lady has got an explanation for the chest X ray findings and some of her symptoms. If you calculated a well score, I think that would be a zero. And also she's on Apixaban AAA doac and she'd be very unlucky to develop her pa. Um, although it's not impossible, but given the sort of the clinical symptoms or history, um, no signs of DVT either. And you can be a bit more reassured that it might not be that. But again, so what we did was gave us an analgesia, it actually settled by itself, um, a bit of time later. But, um, we did mention it in, in handover to the, the, the following team just to be aware of if there's any deterioration or any recurrent symptoms and potentially do something like ad Dyer or just going straight to a CTPA, it might be, might be warranted. That's that case again, not clear cut, but there's a few things in there like the severity of the pain as well as the, the history, which might make you a bit uncomfortable, but hopefully can be a bit more confident in, in investigations that you wanted to do and, um, the management that you wanted to follow as well. So we've got one more case to go through now. So you again, you have to see another patient with chest pain because you're becoming an expert in it by now and you're working the night shift and you're covering the Coronary care unit in a, in a large teaching hospital. And he asked us to see a man who's in his mid ff and the nurses say he appears to be having chest pain and his knee scores are five. Now, the nurses say he appears to be having chest pain because actually, unfortunately, there's some language barriers and um his patient speaks a different language and, and they're not able to communicate completely clearly with him, but he's obviously in some pain and with his chest. So he's scoring a five on his new score again because the saturations are 95%. His BP is a little bit low at 99/56 and his heart rate is raised at 100 and 16. His temperature is also 37.5 which I wouldn't count as a fever or a temperature, but it's just creeping up a little bit uh maybe towards one. So the, the history on his, on his note says that this gentleman's got decompensated heart failure and he's got quite a cardiac history of previous Mr and stents severe LVSD with reduced ejection fraction. He's got hypertension diabetes, obesity, high cholesterol. And he's also got chronic kidney disease. You tried to get a bit of a history from him directly and also through the translator service. And he says he's got central chest pain. It came on gradually. And he thinks it's quite a severe pain and feels tight around his chest. It's constant. He thinks his breathing is ok. And he seems to be describing some radiation to his back and also his upper abdomen. And he just said it's generally all over as well and he denies any palpitations, cough, fever, nausea, and vomiting. So it's quite, quite a bit uh maybe nothing immediate jumping out. But again, you start thinking about your differentials with that history. So we've got a pneumonia ba CSC gourd D arrhythmia and e aortic dissection. I I'll just see if we've got a few responses there. Well, so yes, nearly three quarters saying an aortic dissection, I wonder if that's related to the potential, the pain going through to his back. Um I'd say that's really good because again, aortic dissection is not something that you commonly faced with um when you're reviewing patient with chest pain, but in this case, he said there's some pain in his back as well. So it's really, really important to think about, especially in a patient with a quite um cardiac history. So yes, there's no right or wrong answer, but it's really good to be thinking about those important things based off the history that you're taking. So that's really good. So move on to your assessment and again, his airway is patient. And when you look at him, he's an overweight man, but he's obviously in some distress with, with some pain, you listen to his chest and he's got some fine bibasal crackles, which is in keeping with his decompensated heart failure. And obviously you've never seen him before. So you don't know if that's new or worse than normal. But when you move on to see he's got a strong regular radio of pulse, um which is tachycardic, but you specifically feel a radio radial delay because of the back pain and he's got no delay. His heart sounds are normal. It compared to refill times two seconds, his JVP is raised and his BP is normally and it's nine. So that's sort of where things are probably due to his LVSD. Again, there's no gross neurology. He's alert, there's specifically no spinal tenderness in that area of his back and he's also recently had some analgesia, but he still has the pain. And then in terms of everything else, he does have peripheral edema, there's no signs of DVT, no rashes and you've been quite thorough as well because you, there's quite a bit going on there and he's got no urinary retention, but he does have some tenderness in the upper abdomen as well. So you've, you've done that quite thorough assessment. He's still sort of in pain and you might not be too sure what's going on. But it's evident he's in pain. So you want to do your investigations? So we've got a blood gas B, chest x-ray c, urgent bloods, D and ECG E uh, blood glucose and ketones. It's quite a range to, to look at there. All right. Let's see what the responses have been then. Ok. Brilliant. Quite a few things there. Yes. In terms of your first investigation, whilst you get a few things sorted. It, I think always easy to ask for an ECG to get that done. It's quite a quick investigation to do. It's there on the ward and it gives you time to sort of bring your thoughts together. At least you can review something there and then once you get everything else arranged as well. But I would say also the other investigations are quite appropriate in this gentleman too. They might not be the immediate ones you do. You get the ECG done, but it's certainly worth doing. So, a blood gas in someone with severe pain, you're not too sure what's going on, um, venous or arterial, um, maybe just venous in this case because there's no drop in the saturations, um, would be very useful. It would give you an idea of it. Um, state of acidosis also give you a lactate too as well as some other immediate, um, electrolytes. The urgent bloods. Again, if he hasn't had any recent ones and there's been a change in his, in his clinical condition, you can send off a troponin all sorts of other bloods as well. And then BM and ketones as part of maybe ABCD E as well, um, would not be incorrect. It, and it might be the first line thing, but again, it wouldn't be incorrect to do. So you get all these investigations done. Now, his ECG, that's, that's the one from previous, but it's, it's a normal ECG. You got his chest X ray done on the ward. And actually there's some features there of pulmonary edema, but it looks uh quite a bit improved compared to his previous um chest X ray that he's had his blood glucose and his ketones are actually within normal limits there and your, your blood tests and the gas are back there too. So you can see on the gas side of things, he's got a, he's got a normal lactate there, not too concerning and his gasses are within normal limits. Uh And then on his bloods, he's actually got some raised troponins, but there's no dynamic changes there. His inflammatory markers aren't too exciting, but also he's got a normal amylase, some slight derangement in his LFT S and his kidney function is relatively static. Her background is D there. So there might not be anything really jumping out at you. I mean, when I look at that you've got the normal EKG, nothing too obvious on the bloods or the chest X ray, but he's still still in pain in front of you and you haven't quite nailed things down. Um, so we don't need a poll for this. But what is the next step in management? II would say if you've got someone who's clearly unwell in front of you, nothing really obvious on the, on the investigations and, and he's had analgesia recently. It's been quite strong and it's still not really, really taking the edge off them. I would certainly be discussing it with a, with a senior colleague. So in this case, what we actually did with this gentleman is I had concerns about aortic dissection of the back pain. Um My senior had concerns as well about things that caused his titi with a slight derangement in his TS although not too exciting and the upper abdominal pain that you've mentioned. So we got him a CT scan to try and assess for all of those things. Oh, the answer in this case is you don't really always get clear, clear um diagnoses or answers because the CT scan came back to normal, but you worked through everything um appropriately here. You'd worked out that he had a reassuring troponin and ECG, he didn't have an aortic dissection on his CT scan is um abdomen, didn't have any signs of the cause in his abdomen either. So, you know, you, you worked your ABCD and E there as well. And actually after a little bit of time, just by the morning handover, the pain had seemed to settle and actually, it meant that your, your registrar was still quite aware of this patient could then discuss it with the consultant and work out what to do if anything. Um, so the main learning point from this, this case would probably be if you're not sure ABCD E always works, always helps you with what investigations to do. And if you get to the end of it, either go back to the beginning or ask a senior and it might be that they're also a bit stumped. But yes, just because chest pain in a cardiac patient don't forget about other causes as well. Don't forget about abdominal causes of, of, um, deterioration. So those are three cases that hopefully have got you thinking. So hopefully we've gone through a brief ABCD approach for chest pain, mainly with the radio radial delay, bilateral blood pressures, developing an assessment of fluid status as you as you progress. And don't forget about DNA. Hopefully it's not new to you, but just recap the key investigations. Um, and maybe just to think about tests like Troponin D Diamond, why you're doing them and what management is that going to affect. And then with regards to the cases, we've, we've gone through mainly, um, patient safety point with a patient with potential mi I in an outpatient setting, um, some chest pain that's less severe, um, in the patients who already anticoagulated, but with reassuring investigations and then quite a full thorough ABCD E um examination in a, in a patient where you've assessed everything that's quite serious and you still haven't got to the bottom of things, but your, a senior colleague is there and it is happy with the work that you've done. Hopefully. So, just very briefly before I finish as well, just to touch on some top tips. Hopefully, just as your work is a, is a new F one maybe just during the day. But also when you're on call, some things for chest pain, always, always compare ecgs because that's, that's what you're looking for, looking for changes in ECG S. But also an ECG in relation to chest pain is useful for things like arrhythmia. You know, you don't want to miss someone who's got a ventricular tachycardia. And the reason why they've got chest pain is because of the ischemia from that um treat the patient, not the numbers if you, you know, if you've got a well patient in front of you and a and a small rise in AP, but they're being treated for an infection, but they're clinically better, you know. Um just take that into account when you're reviewing patients, look at for the regular lives and serious diagnosis. So this patient's got chest pain, you know, musculoskeletal, of course, shouldn't be your primary primary um concern. It should be things like acute coronary syndrome, pneumothorax, aortic dissection. And if you take that safety approach first, you're gonna be a much safer, safer doctor. Again, along that line, if you've got a patient with upper abdominal pain, don't say it's gi related because upper abdominal pain can be a missed. Um M I likely it can also be um diabetic ketoacidosis as well. So that's why BMS are so important. First principles, all work is useful if you don't know what's going on ABCD E or an SBAR, that, that sort of structured approach will always help you out. And like I said, if you don't know, then ask someone the worst thing you can do if you don't know is just keep quiet because it doesn't solve the problem. If you ask, you know, you'll get some help and you might learn something as well. And then just a bit more generally safety netting advice. If you've got a patient with chest pain that you've reviewed, giving advice to either the nurses and the patient, it's extremely useful because then everyone's aware of things that eventually go wrong signs to look out for documenting thoroughly as well. Really, really important. I always use the ABCD approach as well, but then also quite efficiently go through meds VT antibiotics, all of that. So just cover everything when you're documenting treatment, escalation plans. And DNA CPR is really useful to, to have a think about that whenever you're seeing patients just because otherwise you'll be on a night shift by yourself. Um And a patient hasn't had clear escalation discussions and it just, if those discussions have been had previously when, when they need to, if someone's unwell during the day, it really helps your colleagues out overnight and also just being organized and efficient when you're on call because it's, it's a busy time. So I always go and introduce myself to the, to the nurses on the wards that I'm covering. Just, it makes things easier if you've introduced yourself and you sort of know, know who your colleagues are. But also if you're, if you're present on the wards at various times, you know, go in and if you're having a quieter night, go and check on how things are because you might pick up on things before, before they get worse. It's always useful as well to have the contact details of the, the whole on call team. So, you know, you've got the number of the registrar when you need to ring them. Um or you've got the number for a, for a colleague who can help you with it with the can that you're struggling to get. But also I find works particularly at weekends as if the nurses on the wards can make a list of non urgent jobs. So that once you're finished reviewing your patients and um some more of the urgent tasks that you've got, then you can go and see um what jobs they've got, you know, to prescribe I VT paracetamol, um things like that. So it means you're not getting calls every five minutes whilst you're trying to get on with your urgent jobs. And then finally as well, you recognize that the job will be difficult. Sometimes you might have already experienced that as well. But the good, the good times are really rewarding and satisfying, but just look after yourselves, you know, seek help, seek support, talk to your colleagues. Um And to be honest, when you're on call, make sure you drink enough water, get regular snacks because they're, they're long days and you need to look after yourselves as well. So I think there'll be a bit of time for AQ and A as well. Hopefully I'll be able to answer some of those questions as well. But um yeah, thank you for listening and also thank you to ram and for inviting me as well. Thanks.