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No, I was gonna say where was it at a higher med at leeds, I thought it was leeds, um So she's now doing medicine. So if any of you have any questions about being in first year or different pathways into medicine, or if you're thinking of applying to Manchester or leeds for any of these things um feel free to put personal questions and she also be keeping an eye on the questions in the chat, so um yeah, okay, So I think we're nearing five past I will make a bit of a start, so I try to make this interactive um but basically the point of this evening is we're gonna we're gonna meet a patient who's come in with a problem and we're gonna ask him lots of questions to find out what's going on and get to the bottom of it and then hopefully work through a few different diagnoses um yeah and find out what's been going on so um This is going to be a bit dry if I have to talk to myself so as much as possible, try and put your suggestions in the chat and we can we can work through it all together. Um So, yeah this is john doe for those of you that don't know johN doe, I think jane doe are the terms that we use for patients in the hospital when we don't know their name, so if someone's come in unidentified and we haven't got any you know wrist bands on them or you know they're driving license or anything like that and we don't know who they are. It's a very old fashioned thing that we call them a johN doe, so that's why I picked this name and he's come in. He's a 65 year old male and he says Doctor I'm really short of breath so um I mean shortness of breath can be caused by lots of different things, so what questions do you want to ask him about his shortness of breath. A peak flow test yeah that's very niche, let's ask him questions specifically, let's not jump to investigations, let's go to let's go to more about finding out you know his symptoms, specifically what you want to ask him trying to see everything has he had Covid recently, yeah how long has he had it for that's really important when did it start, Yeah daisy what more about the history because this part of this part of assessing a patient is called the history, yeah if he smokes also really important, yeah how long are you feeling breathless for this is all really great, okay, so jen, if I summarize what's been in the chat, we're asking him generally a picture of of what his shortness of breath has looked like so has it come on today and he feels really short breath or has it been going on for a little while, is there anything that he thinks could be causing it okay, so and we've also got a little bit about what we call the past medical history, so does he have asthma or does he have a genetic history okay, so we've got a little bit more information about his shortness of breath are there any other symptoms that might come alongside his shortness of breath that you might want to ask about so what if you're short of breath, what are what are the other things that you might be experiencing uh chest pain. Yep, really important coughing. Next one about coughing. If we can characterize the cough, so what different types of cough might you get palpitations and chest pain are all really important dry cough, chesty cough, yeah, okay perfect any other symptoms, so I think we've had dizziness, fatigue, sore throat, cough, um sorry, if I've missed any any final symptoms, palpitations, chest pain, yeah I think there's one in my head tiredness, yeah, okay um There's one I'm thinking of if patient's have asthma, what might their breathing sound like does anyone know, It's musical, wheezy, yes perfect, creaky door, great, okay, so let's move on. These are the things that I thought would be important to ask um So basically when a patient comes into hospital, we have different things to ask in that when we're taking a history from a patient, so the first thing that we write down is presenting complaint, which is usually what the patient has said. They've come in with, so it's not a medical term, it's I'm short of breath so um as doctors we might call that like dyspnea um or I'm trying to think yeah if they had chest pain, you might call it angina or am I myocardial infarction. Those kind of things that presenting complaint is what the patient says it is, so it's not a medical term, so here it's shortness of breath and then after that we're then trying to characterize um a bit more about that specific presenting complaint. So this section is called the history of presenting complaint and that's what all that we've done in the chat. That's what we're doing here is, we're getting the history of it, so like you've all said in the chat how long has it been going on for is it getting any better is it getting any worse or is it about the same. We also like to ask this thing called exercise tolerance, does anyone know what that is or can have a guess. It's something that helps us gauge how short of breath. The patient might be kind of, so it's actually more simple than the lung capacity yeah is it worse, nonwalking that kind of thing, so um my exercise tolerance granted, I'm not a runner, but might be that I can run you know five kilometers for. For mr doe, he might previously have been able to walk you know 10 miles a day and his short of breath has got so bad that now he can only walk up the stairs and then he has to stop so that's a really good way of characterizing how short of breath this patient is so yeah. I used to able to walk five miles and now I can only walk up the stairs like being said in the chat, so that's a really good way of characterizing it and then all the other symptoms that you've said chest pain are they wheezy, are they dizzy, are they getting fevers, so I think that was the only one we might not have we might not have got they got fever. Um All of these questions we ask in our head. We can then be making a list of all the different things that that might be going on given that he's short of breath and we can start to rule out yes or no depending on what he answers to these symptoms, so um let's move on and get a little bit more information okay, so if I summarize what what John has now told you you've asked him all of these questions and this is what he says in response, So this is john doe, He's a 65 year old man and he's his presenting complaint is I'm short of breath, so he tells you that he's been becoming progressively more short of breath for the last six months. He used to be able to walk 10 miles every weekend, but now he can only manage to the shops, which is about a mile away and he has to stop multiple times on the way. He recently collapsed after feeling dizzy and his gp has now referred him to hospital. He feels exhausted all the time and he's got very mild chest pain, particularly when walking. He has had a bit of a cough recently um and it's had green sputum in it, but it's got no blood um um And he's had no weight loss, no wee's and no fevers, so I'm going to give you like 30 seconds to just read that again and then hopefully we can come up with a list of things that you think might be going on with JOHN doe okay daisy, so you are very very right. These are some of the things that we would want to ask, um but we'll we're going to stay on history at the moment and then we'll jump ahead to investigations a little bit later on okay, so we've now taken a big part of the history from JOHN, so we've collected a heart token and the tokens are gonna appear on the left hand side. Once you've done different parts of the, of the quiz, um so a few of you are already posting in the chat, so when we come up with a list of things that we think are going on with the patient a list of medical diagnoses, we call them differential diagnoses, and these are the different you know you might make a list of four that you think of the most likely that's going on with the patient, so we've got chest infection, does anyone else have any ideas. Some of these things. I'll give you a clue are things that might have been discussed this week copd asthma. All of these are on my list. Any other suggestions new Matara. It's a good idea. Yeah yep good hint amelia, if we think about things that can cause shortness of breath in the heart as well, yeah mitral valve regurgitation good. Yeah angina what about I'm not sure if anyone um does anyone know when you get older. Um Often you see it with little old ladies and they've got really swollen ankles. Um It's often a side effect of something going wrong with the heart, does anyone know, I'm thinking of blood clots, yeah good idea, so the fluid retention, it's not lymph, yes, it's called a dema, um and that's usually caused because of heart failure. Yeah that's right because the inability of the heart to kind of pump the blood around the body. It essentially backs up the wrong way and pools in the legs great, so we've got some really good differentials going on here. Let's see what I've written okay, so I've cheated a little bit um and put on a few ones that I know, definitely aren't aren't right, but let's go through them. So you've all said angina, asthma, copd pneumonia, so chest infection. We've said kind of valve problems, so mitral regurgitation or aortic stenosis, so those are your leaky valves. We've said heart failure um a few that we haven't thought about so um We don't know loads about um john doe at the moment, but he has said he's short of breath um and we don't know you know, we don't know if he smokes. We don't know if he's got any other risk factors, but we do need to think about lung cancer in this chap, um pleural effusion, so the thing we were talking about earlier in the week where you can get fluid at the bottom of the lungs is gonna mean the lungs aren't as good as expanding as they would usually and so that can make you short of breath um. And then a couple of other ones, so a pulmonary embolism, which is a clot in the vessels in the lungs can cause shortness of breath. Pneumothorax ending is less likely, but it's important to put that in there. And then anemia, which is a bit of an unusual one, but can anyone can anyone tell me why anemia might make you short of breath, so uh anemia is a short reduction in the hemoglobin in the blood, yeah, so it's to do with the lack of oxygen, so essentially you're short of breath because you don't have enough of the blood cells carrying the oxygen around and that can make you short of breath, but it can also make you really tired um. And mr, doe said that he's been feeling tired, the thing about lung cancer making you cough up blood yes, that is really important and can anyone remember a different symptom in the history that might help us rule out lung cancer go back, which one of those symptoms that he doesn't have would make us think lung cancer is less likely. Two, yeah no blood, so the one i'm thinking of is no weight loss, which is a common symptom that we think about with um with any cancer as people because cancer requires a lot of energy because it's making cells all the time um If patients have weight loss often that's quite a late sign that they might have something nasty going on okay, so we've got this list of differentials, which is actually quite a broad list at the moment and what we need to do now is try and narrow them down by asking more questions to the patient um to try and rule some of these things out so what else would be useful to know, So I think some of these questions have already come in, but this is how we structure the history, so some of the questions that you might want to ask. Based on these categories, does anyone know does he smoke, yeah really important cancer in the family, Yeah, does he have any pets at home, Yeah really important because that could be an allergic picture. How often does he drink yep, yep great, so all of these are you know, really really good questions and things that we ask our patient's all the time, so we follow this structure and essentially we we use the structure we have the presenting complaint and history of presenting complaint to help us find out about the patient's symptoms, but then we use all of these other headings to help us kind of um draw a bit of a bigger picture so past medical history it could be things like asthma, it could be diabetes, it could be high BP or high cholesterol yep, and then in drug history usually they correspond with what's in the past medical history, so what medications is he taking. Based on the the things that he's the other family health issues that he's got and in drug histories, it's always really important to ask allergies and usually um that means drug allergies, but you know in patients with shortness of breath. It might also be important to ask. Um you know allergies to other things, so is he allergic to a cat and his partner's just got a cat and that's why he's short of breath because he's just having an allergic reaction all the time and things like that has he changed his washing detergent. Um Family history is a, is an interesting one, so it becomes less important the older, our patient's get because um the older, our patient's get the more likely they are to just have a have a condition because they're older, whereas in young patient's that might be presenting with cancers or something that's inherited. They're much more likely to have got that got this at a younger age, but but yeah really important and then social history so there's a few things that come under this. Usually, it's like you've all said already, it's smoking um It's how much alcohol they drink, it's who they live with at home, so we get a good idea of like a patient's baseline function, do they live independently at home or are they in a care home and they rely on you know carers for washing and dressing and all these things um do they have any pets at home all of those things so you've asked John these questions um and this is what he tells you, so, he's got asthma, but it's very well controlled. He's never had a he's never had to go to hospital for his asthma and he's only really had it as a child, but he still takes his blue inhaler. He's got high BP, he's got high cholesterol and he's got type two diabetes, So these are all quite common conditions, but help bigger build a bigger picture of johN's overall health and then drug history. He tells you he's on salbutamol and beclomethasone inhalers. Um does anyone know what these drugs what type of drugs these two things are you might not um he's also on ramipril, a statin, and metformin, which are BP medications, wants to help the fat in your bloods and then also um for type two diabetes, the metformin yeah exactly right, so salbutamol is your beta blocker, which helps to open the airways and then the back lomita zone. Generally things that end in own mean steroids, so that's right great, um and then he tells you that his son has eczema and his mother died of a heart attack. I don't know if anyone knows the significance of his son having eczema and the fact that he has asthma. This might be a difficult question, but you're all doing really well a toupee, yes amelia, does anyone know what the third thing is in an atopic person, so it's usually um asthma, eczema, yeah, so it's usually uh asthma, asthma, and hay fever are the three things that often patient's if they have one they might have another or um if you know one of their family members has one of these things they might have another, so the fact that his son has asthma um isn't quite as surprising because we know that as as a family, there potentially quite prone to having allergies, so he's an, and then about his social history. He tells you he's an ex smoker. Um He smoked about one pack a day for 30 years, but he stopped about 20 years ago. Um He lives at home with I think that's supposed to say his wife I'm sorry and he's independent. He keeps pigeons which is a bit random, but he does and he's currently working as a roofer, so probably we've built up a picture that yes okay, John has maybe not got that greater diet because he's got high BP. He's got high cholesterol, but he's still independent. He lives with his wife. He's still working and he's 65 he used to be able to walk 10 miles a day, so he's quite a fit person, really for a 65 year old, so hopefully, in our head, we're building a picture of some of the things that we think are more likely and some of the things we think are less likely. Um I'm sure pigeons do have diseases that isn't why I mentioned it here, but I will come back to it to it at the end um okay, so now what we've done is we've taken a full history from mr doe, we've done his presenting complaint his history of presenting complaint and then built a bigger picture with all the other questions that we've asked, so we've got two tokens okay, so I've got the list of differentials that we had up before. Based on these, things are there any of these things that you want to rule out immediately and say I really don't think that's what he's got has anyone got any suggestions. I'm just going to turn the heater off in my room, I'm sorry, okay, so I agree um what did I rule out immediately. I'm trying to remember pneumothorax. I agree, I think I would rule this out immediately does anyone know why I really don't think it's this. It's okay. If you don't so a pneumothorax because of the way the way it works is um it's essentially build up of outside the lung space and often it happens either because of uh injury or trauma or if the lung has been punctured and so as a result air from inside the lung can get outside and sit in that space and usually when that happens, it happens really quickly and it's sudden onset and the patient's have the potential to become quite unwell very quickly and so with this chat because it's been going on for a series of months. I really don't think it's a pneumothorax because I think he would have come into hospital a lot sooner. Um I can't remember which other things that I pulled out, so let's go to the next slide okay. So let me talk you through my thinking for this, so pneumothorax. Hopefully, I've explained that to you and that's why it's really important to get history of how long this has been going on for, so pneumonia, I thought was less likely, I mean he did have um he did have phlegm, but he's generally been well, and it sounds like these symptoms again have been going on for a little while and he's not had any fevers, so I'm not worried that he's had a really high temperature and he's brewing an infection and then finally asthma, I think it's really important that you will ask these questions, but um it said in his history that it was well controlled and that he hasn't had a flare since he was a child and so I think it's unlikely that his asthma is going to have been making his shortness of breath worse over the last six months or so, it's more likely that something new has happened that's um that's causing his shortness of breath. So all of these other things, we haven't quite ruled out yet because you know he could still have heart failure. He could still have angina. With you know, we know he's got chest pain. We don't know that he's not anemic because we haven't done any blood tests on him yet. Um Unless you know, we don't know that he hasn't got lung cancer and this is one of the things that as doctors we have to do is, we have to make sure that we rule out the worst case scenario so either the things that are going to kill you really quickly, so a pneumothorax for example or like a chest trauma or a sepsis because of the pneumonia um Or you know the worst case scenario In terms of you know a cancer usually um and yes, he hasn't had any blood and he hasn't had any weight loss, but weight loss is usually a very late sign of a cancer and he does what he does what we know about his history. There's one thing that's making me really worried that he's potentially got lung cancer. It's something in his social history, does anyone know what is the biggest yeah smoking, sorry, I think there's a bit of a lag in the, in the chat so yeah, um he's got quite a significant smoking history and it's also been quite a slow onset of the shortness of breath, so I want to make sure that I'm ruling out lung cancer because to me, that's going to be his worst case scenario that he's worried about as well um and all of these other things will work through now. I don't, I noticed there's a question of how do you fit this through in one appointment, so I think it essentially it depends where the patient is presenting, but if they're coming to you in gp quite often, you know the patient anyway and so you've got you've got lots of information about whether they're a smoker or their past medical history you've got their drug history in front of you and you usually read through the notes before the patient comes in, so you've got a bit of a background anyway. If the patient's coming into e. D, you do have to ask all of this information and usually takes a little while, sometimes it can take 10 minutes, but sometimes it can take you know 30 40 minutes to get to the bottom and really understand what they um what their symptoms are, can anyone think of a situation where you might not be able to get this information from a patient and that therefore it makes it really tricky, yeah if they're unconscious or confused, yeah those are the two situations, I was thinking of so if the patient's really unwell and they've come in you know with reduced consciousness, they're not going to be able to talk to me, but also, if they're confused, which can be for lots of different reasons, it could be long term confusion in the background. Um They've got dementia or something like that, but it also could be acute confusion. So you know have they taken an illicit substance, which means they can't tell you the information um have they got an infection that's making them confused, have they got low blood sugar, which makes them confused. All of these things does make things a little bit tricky and what might you do in that situation to get some information from the patient or can't speak english. I have an interesting story about this that I can tell you at the end um about language barriers between patient's what might you do to communicate with a patient that's ought to get information about a patient that's confused or unconscious perfect. Yeah, ask, ask their family members ask a relative or a friend and this is something that's you know really common that I have to do in my job as the junior doctor um is to ring family members for patient's that have got dementia or they've been admitted from a nursing home. Is um we call this a collateral history. So um you know you ring the family and say oh you know your grounds acting a little bit strange today, We're not sure that this is quite quite what her usual behavior is like can you tell us what she's like normally um So that's yeah that's really common bit of a tangent um okay, so what I've tried to do is now separate your differentials into heart, heart, lungs and then anemia, which is a bit of a bit of an unusual one in there that doesn't really fit into either category, so let's go through them, so based on the new information that we've got and I've ruled some of them out which of these are less likely, can't remember sorry, okay what would you like to do next, so, we've got our list of differentials. These are the things that I think could be going on. We've got rid of a few already, does anyone have any ideas what we might want to do. Next, once you've gathered all of this information from the patient blood test, yeah what else yeah okay, so all of these things that you're suggesting yeah okay. Finally, so all of these things that you're suggesting we want to do some investigations and that's great but one of the one of the main things that we can do to gather more information is examine the patient, so we can have a listen to their chest. We can you know have a feel of their tummy um see what their heart rate's doing what their pulse doing all of these things, so the next steps that we want to do um like you said is examine the patient and order some investigations okay, so when I were a little bit closer, these are the things that we're gonna do an examination. So On examination, you've listened to their chest and the lung sounds nice and clear. You can't hear any wheeze and you can't hear any crackles, does anyone know what crackles on the long might show, has anyone heard of that term crackles on the lung pneumonia. Yeah, exactly so it can mean a couple of things or a build up of something yes, it can mean a couple of things, so one it can be an infection, So if you imagine when you've got a really runny nose um the thick kind of mucus, sorry for the graphic description can build up. Similarly, if you get a chest infection, can build up in your lungs, and that essentially because it's really sticky and dense, makes it harder for the airways to open up and as a result if you imagine scrunching a paper bag and then letting it unravel that's the kind of noise that you hear on the lungs rather than a whooshing sound and then that's a sign that potentially the airways are sticking together a little bit um and then we use like that's mainly to do with the airways being kind of constricted. If you imagine a flute and you're altering or a flu or um pan pipes. If you're altering, altering the dynamic better of the of the pipes, they're going to sound different when, when errors blowing through them, and so that's essentially what wheezes. Um so we've done that and then you felt his pulse so his pulse is normal, it's regular and it's got a good volume, but when you listen to his heart, so this is the way that we write it, so it's one plus two plus murmur, so essentially one plus two is normal heart sounds, so that's the lub dub and usually what we write is one plus two plus zero, so no other sounds but this guy When you listen to his chest, you hear one plus two plus another heart sound that you're not quite sure what it is um and then you want to take some bloods from the patient, so the question about if someone is confused are you allowed to take take bloods or do a chest x ray. So yes you are if you think that that is in, essentially if that's in the patient's best interest, so obviously the first rule of being a doctor is, do no harm. Um You know potentially if we're ordering unnecessary investigations or taking blood from patient's then that could cause more harm. If they're not indicated, but in a patient that you think is really unwell and needs bloods, and if you weren't going to take the bloods, they might become even worse, then yes, you are allowed to take blood from a confused patient, but we we usually document it and we assess the patient's capacity so in that time they're probably not capacitors to make that decision because they're confused um and so we can act in their best interest so good question. Um So exactly so the murmur is an indication that potentially uh the heart isn't beating the way it should be, so we know that it's beating regularly, but if we think about what the heart sounds actually are, does anyone know what we're hearing when we hear the lub, dub exactly the valves, so if we hear another heart sound, what do we think is going what could be going wrong yeah exactly so that's going to be the blood potentially going abnormally over the valves um fine, So we've got actually quite a lot of information from examining this patient, so we know that there's no crackles and there's no wheeze, so again we've ruled out asthma and we think that a chest infection is less likely um does anyone know what his heart rate might be doing. If he had an infection, yeah exactly his heart rate might be a bit higher. Um This is called tacky cardia, so tacky in medicine usually means fast uh and braddy usually means low. I'm hoping amelia might be able to spell that in the chat for everyone um so yeah and the good volume essentially usually means that the pulse is nice and strong it means that the heart is beating um nice and strong, and the blood is pumping around the body well um great, So we've actually found out a lot on the examination, and then we've ordered some blood tests, so from his blood blood test, his hemoglobin levels are normal, so what differential can we rule out now that we know that anemia exactly so we can now take that away from our differential list. We know that his shortness of breath is not caused because of his hemoglobin in his blood. Okay. Next one, the white cells are also normal, so um does anyone know what the white cells in the blood are usually responsible for so we've got the red cells for carrying oxygen and then the white cells are for something else infection, exactly so if his white cells are normal usually, um it's a cell called a neutrophil is responsible for fighting a bacterial infection, so we're now building a bigger picture that he's got no crackles on his lungs. He's got no signs of infection in his bloods, and then the sputum sample does anyone know what what that's from um so the sputum sample would be what he kind of coughs up because he said he's had green sputum and what we do is, we send that away to the lab and they see what bugs they can grow in it, so if they can't grow any yeah, exactly so if they can't grow any bacteria in it, then it's less likely that there's any bugs in his chest causing him to be unwell okay, so again, we're building a bigger picture. I've probably just given this away, but what would you like to do next. I think you've all said already, so we've examined him. We've done some blood tests, which is what we call bedside tests. There's another bedside test that I've given you a bit of a clue at the top left hand side. It's a bedside test that we do to look at the heart and yet we do an x ray e. C. G. Exactly, so does anyone know this is maybe a bit tricky, but does anyone know the types of things that we would look for on an e. C. G. That might help us kind of rule out the differentials. A. F. Yeah, do you know what that stands for yeah all of these things, hr, fibrillation exactly and st elevation, so what we're looking at what does st elevation what that might show what might that show us heart attack exactly and arrhythmias um sinoatrial blocks. Yet all of these things so attend, essentially the e. C. G. Is where they stick the stickers on the patient and depending on the orientation of where the wires go, they show us what the electoral electrical conductive pathways are doing in the heart and so from that I'm not going to go through it cause it's really complicated than something that I'm still you know getting better at, but we can tell if there's any problems with the pathways of conduction through the heart, so from the e. C. G, we can tell if they're tacky or bradycardic, so is there, heart rate fast or slow. We can tell if there's been a delay in the electrical signal getting from the atria to the ventricles um and that could be caused if the patient's had a heart attack and a little bit of that muscle has died because it's not got any oxygen and as a result, that muscle can't transfer the electrical activity from the top to the bottom and so their heart rate might be a regular. Um I'm trying to think what else and then st elevation is this thing that we look for classically in a patient that's had a heart attack um uh It's a similar thing it's because there's been a bit of damage in the heart muscle. The ability to conduct between the two sections of the heart isn't as good and so you get this change on the c. G. So, I'd want to do that just because lots of patients that come in short of breath. We want to do that and also patient's that have potentially a pulmonary embolism, which is the clot in the lungs on clot in the lungs can they might not have e. C. G. Changes, but they might have a really fast heart rate essentially because the clot in the lung is meaning the heart is having to work harder to push to push the blood to the lungs because there's a big clot in the way um So that can tell us quite a lot of information and then the other thing we want to do is order a chest x ray like you've all said. Um So this is in fact john doe's chest x ray here can anyone tell me some of the things that they can see on the chest x ray. These can be good things that can be bad things it can be really obvious things tell me what you can see ok consolidation potentially maybe infection, so what what are the things on the chest x ray that are making you think this consolidation. What sorry that's maybe a tricky question what would consolidation look like on on the chest x ray, would it look whiter, would it look darker bones that's exactly right yeah all of these things okay, so let's talk through the chest x ray um where do we start. I'm not sure I think you probably can't see my cursor can you. Uh I don't think okay, so this big tube down the middle, so you can see in the middle you can see right in the middle of the chest x ray, you can see bones, essentially lots of little plates of bones lined lined up on top of each other um that is essentially your spine and the thing about the chest x ray is. It's obviously you know it's a two D image so everything is displayed on top of each other and you can't see what's in front or what's behind, so you see everything so there's lots of little plates on top of each other, right in the middle, that's your spine and right at the top of those, you can see that it's a little bit darker and there's a tube down the middle um so that is your trachea. So generally on a chest x ray, things that are less dense. I, air are going to be black and things that are really dense, bones or tissue or muscle, they're going to be white um okay, so we've got the trachea and then we're going down a little bit further what's the thing that looks like a boot right in the middle, does anyone know slightly squished spherical thing. It's the heart exactly sorry I think there is a delay um okay so that's the heart in the middle, so you've got that and then at the bottom underneath the heart, you see the two things that are kind of a slightly uh two slightly curved things on the left and on the right. What do we think they are they sit underneath the heart. The heart's almost resting on it bowel close. I'm talking a little bit higher up, what's it's very what's it's right at the bottom of the lungs that goes, yeah, it's the diaphragm exactly so um the two kind of slightly c shaped things on the left and the right, that's the diaphragm and then underneath that you can see pockets of like bubbles of slightly darker area and that is that is gas in the bowel um yep and then above all of that, obviously you can see that those things are are the ribs and the reason they look a bit funny is because you can see there the back and the front of the ribs at the same time um and then either side of the patient, there's their clavicles right at the top and then they've got parts of their shoulder as well, So I feel like I didn't do that in a very logical order, but hopefully I've orientated you slightly um and this is a bit of a trick question because essentially this is a normal chest x ray and one of the things you're taught in medical school is that the hardest thing to identify is a normal chest x ray because you're so fine tuned to looking at something and and thinking it's going to be abnormal, but this is normal. I'm telling you things that you might see if they had a lung cancer, so lung cancers generally would look very well defined and they're usually like a small circle, for example, in a particular lobe on the lung, so they would look maybe slightly like a coin, and they would look much whiter on the lung field because they're much denser than an airfield. Salvio lie, so I can tell you from this chest x right. I can't see any signs of a lung cancer um and then the other thing is that I don't think there's any consolidation on the on the chest x ray, so consolidation is a fancy word for gunk or sputum or mark on the lungs, and that again usually looks slightly more white on a chest x ray because it's denser than areas, and so if you see an area that's not very well defined, so spread out that's slightly darker than every sorry, darker meaning whiter on the chest x ray, you might be worried that they've got a bit of a chest infection okay, so you've done all of those things and they're both normal, so we can now rule out a few more things based on that, so we've ruled out anemia now because we know that hemoglobin is normal. We've ruled out a lung cancer because I can't see anything obvious on their chest x ray and we've also ruled out pleural effusion, which um for those of you that have been here throughout the week. Pleural effusion is something that it's fluid essentially that sits outside of the lung space and if you look back on the chest x ray, we can't see what happens with fluid is because of gravity. It sits right at the bottom, so um if they had a pleural effusion, they might have fluid sitting right at the bottom of the lungs, and because fluid has a meniscus on the top. So if you imagine when you're pouring water into a glass, If you keep pouring it to the very top, it won't actually fall out the glass, even it will have a bit of a disc on the top because water forms a meniscus, so water would sit at the bottom and it would have a very straight level and you'd be able to see that, so I can tell you on the chest x ray, there's no pleural effusion okay, so we're now narrowing down the differentials. Even more you've collected another token, so does anyone know what things we could do. What additional tests we could do to rule out either a pulmonary embolism, which is that clot on the lungs or that the patient has copd, does anyone know, It's a bit tricky exactly yeah, a. C. T. P. A, COPD is a tricky one, a ct scan, exactly essentially what I was getting out here is that a chest x ray is very good at showing us an image that's two d, but if we have something that's to do with the tissue inside the lungs, we need something that's gonna give us a much better image and that's going to be something like a ct scan or an mRI usually a cT mainly because mRI s are really expensive and they're much harder to get organized, so a ct scan essentially what it does is takes slices through the body usually from top to bottom, but you get images from uh front to back as well um and you can look through those slices all the way down and see if you can see any clots in the blood vessels or areas of um consolidation or infection on the lungs that you couldn't see before and essentially it just gives us a much better image of what the lungs are looking like and also the individual vessels, so um those are the things that I would do to rule out these other things, but things that you've also suggested so the lung capacity tests and a blood gas would help you know blood gas would help you know about the oxygenation of the blood um lung function test would also be really important to kind of build a bigger picture of what he's um of how well he is so uh like you said a ct scan and a ct mpa, for uh what would imaging look like of copd. This isn't an image here of copd. This is just a generic ct scan um but things copd essentially would look like you get really dilated airways, so you would see I'm not sure if you can see the kind of, to the left of the heart, you've got a white area and then a track running off it, that's hollow in the middle, so the airways look much more dilated um and the lungs also look hyper expanded on COPd, but this is a bit niche, so I'm not going to go into explaining it too much, but essentially a ct allows for better imaging of um the lungs and any aspect of the body okay, so now what we've done is, we've ruled out anemia. We've ruled out lung cancer, which if you were worried that you couldn't see a lung cancer on a chest x ray, you might get a ct to get a better detailed image copd. We've ruled out because we've done a ct as well pulmonary emma, pulmonary embolism. We've ruled out because we've done a ct pa, which stands for pulmonary angiogram, So angio generally means blood vessel and graham generally means image. Um We've ruled out a pleural effusion because we've had a chest x ray, so initially our patient's come in with shortness of breath and I think probably the first thing he jumped to is shortness of breath. They've got something wrong with their lungs, but what this can show you is that actually there's lots of different things that we could be contributing. And actually in this patient, we've worked through lots of different things. We've ordered some tests. We've asked him his history and it's much more likely in this patient given the things that he's told us to be related to his heart, so we're nearly there, we've got another token okay, so what final investigations might you want to order to help confirm your diagnosis, so how would you confirm angina. For example, does anyone know, does everyone know what angina is, sorry, I'm if I'm jumping ahead so um angina, for those that don't know essentially is um chest pain that's usually brought on by exercise, so quite often it's not it doesn't happen when the patient's at rest. Patient's find that if they go for a walk and they exercise their heart and there's doing something that's putting strain on them. They'll get chest pain because the heart's beating faster and there's potentially a narrowing in their coronary arteries, which means that the heart muscle doesn't get the oxygen that it needs to pump and so if you've been at the gym or you've been running really fast and you get a buildup of lactic acid that's because your muscles aren't getting enough oxygen. So at the same happens in angina, so if your heart doesn't get enough oxygen, essentially, it starts to um respire am aerobically and they get and it it that's what causes the pain um okay. Next things, so, echo electrocardiogram um that's your e. C. G. Um I think the other things you're thinking of potentially, I'm trying to go up through them. All sorry, exercise tolerance is important yep, so angina is there chest pain getting worse to the point that they have chest pain at rest now heart failure. I gave you a little bit of a clue earlier what kind of signs might you see in a patient with heart failure. Does anyone know yeah shortness of breath like we said and swollen ankles, yeah all of these things um. And then finally the valve abnormalities I think someone has already said would get an echocardiogram trying to work through all of these things. So angina, yeah, so chest pain what we'd want to do. Um I think someone's described is basically yeah. We want to put some dye in their blood vessels um give us an image to see if the arteries in the heart on narrowed and then that might be the reason for the angina heart failure. We want to do an echocardiogram which is essentially like a jelly scan of the heart. So when you're you know in pregnant ladies, we do a sonogram and you get uh an ultrasound scan with the jelly it's the same thing but on your heart and it allows us to see the way the heart is beating and how much blood is coming out with each pump um and then that will also show us the echocardiogram will also show us the valvular abnormalities, so is the blood flowing in the right direction through the valves or is it falling back down again and causing the heart to strain because it's going under more pressure, so yeah you're all right okay, so bonus points, I I think I mentioned these earlier, does anyone know why I said JohN works as a roofer. I think someone might have already mentioned this exactly asbestosis, so what we now know that we didn't know in the past is that asbestos, which is often used in uh roofs um can be a cause of lung cancer and what's really nasty about. It is that it only takes one exposure and the symptoms often take years and years and years to display themselves, so someone what's really important to ask in patients that come in short of breath, not to make stereotypes but particularly men that potentially when they were younger years ago, when we didn't know that asbestos could be so damaging used to work in kind of the docks, or these two workers, roofers or you know construction workers, it's really important to ask what things they might have been exposed to at work because um it's really sad but asbestosis or mesothelioma that we call it is a is a type of lung cancer that's really fast growing and progressive and is likely to to kill people and as a result, although it's no consolation to the person that suffered from it, the family are entitled to compensation from the government um so it's important to have it in our head because um you know we want to get to the bottom of what's happening with the patient, but you know the family potentially later down the line would be entitled to make a claim against the government because they've had this exposure. Um Next one, what's the importance of the fact that he keeps pigeons, This is a very niche reference and yeah pigeon fanciers, lung, which I haven't made up that is a real thing. It's also called bird fancy as lung. Um There's lots of random things in medicine that you just have to learn and you don't really know why, um but essentially, I think this is caused by small mites that sit on the pigeons um and essentially causes an inflammatory reaction in the lungs that can cause scarring in the long term, um So that's a very niche thing that some of you might have known, but don't worry if you don't, it's it's a random thing you learn in medical school but well done to seth for knowing that and I like the Emoji, okay, we're nearly there so bird fancies, long, or pigeon fanciers, lung, um watch out for your neighbours, keeping pigeons, It's not everyone um okay, so you've ordered him an angiogram and an echocardiogram. This is what the angiogram shows you, so essentially like you said before, we insert dye into the patient usually through one of their arteries in their, in their wrist, um and the dye goes all the way up through to the coronary arteries and lights them up so that when we then scan them, we can see what they look like and what the blood flow is doing so. Hopefully you can see here. I know, there's an error on the image already, but that's essentially narrowing of the artery and if a patient has that that that is likely to be angina and at some point what we what do we worry about with the patient has angina or narrowing of the coronary arteries. What might that turn into later down the line. Not quite a stroke, a heart attack. Exactly so um angina. We think oh you know what's the problem with the patient having chest pain. You know they're exercising surely, everyone gets a bit short of breath or get some chest pain when they're exercising, but actually that's a warning sign that potentially there's narrowing in those arteries and if that's to get worse, then um that might eventually close off completely and cause the patient to have a heart attack, so we like to know about this, sooner, so that we can do something about it does anyone know some of the things that we might do for a narrowing in the coronary arteries. We have discussed some of it this week so one of the interventions I will give you a clue We have discussed this week stent yeah exactly so the point of a stent is you again thread it through the artery and all the way back up to the heart and then you inflate it when it's inside inside the artery and it pushes the plaque that's narrowing the artery to either side and therefore allows the blood throw flow through the middle, so a stent is one of them, and then the other one yeah is a graft, so that's what essentially what coronary artery bypass grafting is, so you get a vessel from somewhere else in the body usually from the leg and you stitch it either side of that narrowing and allow the blood blood throw to um uh take take the overtaking lane essentially, if you picture um a motorway with a traffic jam, if you can't get through that way, you then create an extra lane and the, and the traffic can go the other way. So that's what coronary artery bypass is great, so that's what you would do for his angina symptoms um and then the next thing we do is we order him an echocardiogram and what this shows is that um he has thickening of the aortic valve and an ejection fraction of 38% so thickening of the aortic valve. This is a tricky one but I have given you it throughout the night, does anyone know what that's called and he said yeah exactly aortic stenosis, so stenosis generally just means a stiffer valve um So if you get build up of plaque for example or calcium usually is on the valves and they become really stiff. It can make it much harder for the blood to flow through them each time, so when the heart's pumping. If these don't open, then the pressure underneath that's trying to overcome is going to make the heart muscle become really have to work much harder and as a result, later down the line that can lead to heart failure. If you let it go on to too far because the hearts constantly trying to put push against something that's too stiff to try and get the same amount of blood flow around the body and the ejection fraction is the way we describe that so ejection meaning to push out fraction is you know the percentage it is of the total amount, so um objection fraction is what we measure. It's how much blood is being pushed out per pump each time and if that's reduced, it's a sign that the heart potentially isn't pumping as well as as we would want it to and again if you're not getting blood around the body and it's not going around as fast as you want it to and it's not getting to the lungs and it's not getting oxygenated as much as your muscles need it too then um that's going to cause you to be short of breath as well. So as a result you've narrowed down all of these things you've done your echocardiogram and the mitral valve looks completely normal, but you have found out that their aortic valve is too thick. You found out they've got a narrowing in their coronary artery and they've also got a bit of a heart a bit of heart failure because, because their valve is so thick. Um So I think approaching the end. Congratulations, you've all got the diagnosis you've all even given me some treatment options as well. Um So hopefully that shows you that when a patient comes in short of breath, it's not initially what you might think it is and it's really important to work through all of these questions and rule out the things as you're going along. Um I think the final thing I was going to ask so we've managed his angina. We've talked about stents. We've talked about cabbage um does anyone know what we might do for aortic stenosis, does anyone know. I don't know if I think it's a lag in the chat because all of them come through really quickly. I'll give you a clue, it's something that we've talked about this week. Um mr uh johnny was talking about it last night what you might do if you've got a valve problem replacement exactly, so sometimes um sometimes you can repair the valve. Um If it's leaky, for example, which is what we call regurgitation, so you can sit up the valve and remodel it a little bit so that it doesn't leak so much anymore um or we can do an aortic valve replacement and uh mr uh johnny went through all of the different valve valve replacements last night, so you can get metal ones, but generally speaking, we don't like those quite so much because the patient needs to be on warfarin or blood thinners for the rest of their life or we can get tissue valves made out of. Potentially you know bovine pericardium, which is um cows and then they then make some make valves out of the tissue from the outside of the heart and they replace that valve um so yeah and then the heart failure, which is obviously a side effect potentially of the, of the aortic stenosis. Generally speaking, it's going to be a case of reversing the things that were causing it in the first place, but quite often we can give medications alongside to give the heart a bit of a helping hand with its pumping and then I think there was a question earlier up that I spotted it was really good so um about would the would the stenosis be justifying the heart murmur, so yeah exactly so aortic stenosis produces something we call an injection systolic murmur so systole meaning when the heart's contracting so the main pumping action of the heart an ejection meaning um this happens right at the start of sisterly, so just as the heart is pumping blood through through the valve, that's when we hear the noise and essentially you get the extra noise because um the blood flow is washing through the valves and so you get an additional sound. It's not just a really clean lub dub as the valves are shutting, you get a whooshing sound. Hopefully, I think that has answered everyone's questions. Um I think that's everything so you managed to collect all the points along the way you all pretty much had you know all of the things that I would have asked the patient john doe will survive. I'm not sure which one of you is volunteering to do his um cabbage and which one wants to replace his heart valve um. We will be taking applications in the next 10 years um So you have to become a heart surgeon to to be able to do this. A gP would have to diagnose in less than five minutes, so it's tricky a gp um what's really difficult about g. P. Is that they're expected to know so much about lots of different things, but the main priority I guess is ruling out the the most um risky thing at the start like we said and so you know if that gp was worried that the patient had a pneumothorax or pulmonary embolism. Their main priority is going to be getting that patient in the hospital where they can get treatment in a hospital and not in the community. Um heart failure is something really commonly diagnosed at g. P, um but that's one of the great things about working in a specialty in in medicine is that you can always refer to um different specialists to get more advice and quite often the GPS can get advice over the phone from professionals um specifically when that specialty, but again this is something it's not just exclusive to gPS. This is something we do in the hospital all the time because patients come in with one thing and then they got a complication with another and we're constantly having to ring other people and get their advice and that's where all the teamwork comes in is that everyone's going to have a different skills in different areas, so um I'm not gonna rabble on for too much longer. I know it's 10 past eight on a friday night um The post scheme questionnaire is here um I hope you all found that really helpful and useful and interesting um that is fairly similar to what you would do um at Medical school. You work through you ask questions you work in a group um and you all came up with some really good suggestions tonight and, and the most important thing I guess is that you don't always get to the bottom of it um Quite often, you have to ask um more questions or ask for more advice and do more tests later down the line, it's not always clear cut um yeah, so thank you so much all for attending this week. I hope you all enjoyed it. It's been really nice to chat with you all and you've all been so engaged in asking questions in the chat, It makes it so much easier and less daunting to um to talk to you all when you're all engaging. So thank you so much, I hope it's been helpful and hopefully we can do more lectures like this in the future, um but it would be great to hear your suggestions of things that you'd like to hear, um yeah and if anyone sorry I know a few people, thank you all for your thank you. If anyone's got any specific questions or concerns or want to ask questions about the reflection competition, please feel free to email us the email is at the bottom of the slide at the moment, um so you can drop us an email and I'll try and get back to you, and I can mhm, thanks everyone.