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Right. Hello everyone. Thank you for joining us this evening. Welcome to our um fifth session of our seven Foundation cases on Call Series. Um We really appreciate you all taking the time to join us this evening. My name is Boris. Um I am on one of the co-lead of the seven foundation cases this year and I will also be teaching some of the session tonight. Um And we've also got um Oscar M who's here with me today. Um We're both foundation year two doctors at the Bristol Royal Infirmary. Um A little bit of housekeeping as we go along, those of you who've been before will know how it all works. Um If you haven't used me all before in the top right hand side of your screen, you can access the chat function. Um Please just use the chat function throughout the talk to ask any questions or to answer any questions as we go along. Um Participation has been really good in the past few sessions. So it would be really helpful if we keep that going. Um One of us will try and keep an eye on the chat. So if you do have any questions we'll try and answer them as we go along. Um, if you have any other comments, like, um, the slides are moving too quickly, um, or you need us to clarify anything. Just give us a shout as well. Um, hopefully we should be done by seven this evening and, and we can let you get back to the rest of your evenings. Um, and yeah, I think that's all. Um, I'll send around a feedback link at the end, which would be great if everyone could complete. Um, and I will hand over to Oscar who will start talking about, um, chest pain and ECG S a little bit. I briefly put the learning outcomes here for the whole session. So we'll talk a little bit about chest pain, how to assess it on call basic sort of ecg interpretation and what you need to know. Um, then a brief approach to shortness of breath and hypoxia and some chest x-ray cases at the end, which hopefully should be useful for you. Great. So that was good cracking. Hi, everyone. Um, thanks very much for coming along this evening. My name is Oscar. I'm one of the F two S working at the BR at the moment. And so my section of the talk tonight is on chest pain and there'll be a bit of kind of ECG S integrated into that. Um, I think it's a good one for anyone just coming into F one because it is a really common bleep. Um, when you're on call to be asked to see a patient who's, um, got chest pain. Um, and it can be challenging when you're first seeing it, um, to work out exactly what or what not to do. Um, so we're going to try and run through it. I've tried to make it mainly sort of case based, um, because I think that is more realistic to kind of the scenario that people are coming into. Um, in terms of, you know, working as an F one and I've tried to make it interactive. I know people can't sort of speak out loud on me all, but people can put messages into the chat. So I'd really appreciate if people can try and humor me and put some messages into the chat as we go along to, um, sort of participate in the cases, um and say what they, what they'd like to ask the patient or what they think the ECG shows, et cetera, et cetera. Um And I think that will mean, um that it's just generally more useful, hopefully as well. Um So just to start off with, I suppose when you ask us to ask the patient with chest pain, I think it's always just useful to, you know, just keep an open mind and, you know, I don't think we need to go through and list every single cause of chest pain. Um, but I think, um you know, there's um always useful to break it down into kind of um whatever you like. But a symptom, a systems based approach is, is useful thinking about what are the, you know, the possibilities? Could it be a cardiac cause? Could it be a psychiatric cause, musculoskeletal cause? Um pulmonary related cause? Um And yeah, just I think keeping an open mind when assessing a patient with chest pain because the the differential is really broad. Um And so with that in mind, then how do you go about, you know, trying to break that down and trying to think about what the likely cause of chest pain might be. Um And I think it's all in the history really. I think um a good history, particularly a good pain history is really important when trying to um you know, break it down and try and identify what you think might be causing the patient to have pain. So going through your Socrates, um in terms of um trying to ask about the pain. So asking about where is the pain? When did it start? What's it like? Does the pain move anywhere else? Um What makes it better? What makes it worse? How bad is it, what symptoms you have alongside it, all of those things are gonna, you know, increase or decrease the likelihood of this being cardiac chest pain or, you know, respiratory chest pain um or something else. Um And then alongside that, I think, even if you're, if you're bleeped over the phone by a nurse and told that the patient has chest pain, there's, you know, some other things that you're gonna, you want to know straight away that again are gonna, you know, make things more or less likely. So, uh why is this patient in hospital? Are they, are they in because they've had, you know, a suspected cardiac event and they're awaiting an angiogram or are they in because of something completely unrelated? And they've no past medical history of any cardiovascular risk factors? Well, then a cardiac cause of chest pain is going to be far less likely in that patient. Um So going through that, when you're asked to see a patient is, is useful and then if you're going to see the patient, um I think obviously, if the patient's acutely unwell, then at that point, you want to go through an A T assessment and um work through that. Um but the majority of patients that you're asked to see both be acutely unwell and in that case, I think a focused exam is usually adequate um focusing on the heart and lungs um and some specific things um can be useful not to miss. So, thinking about pulmonary embolism, make sure to examine the calves, make sure that you're not missing a big DVT. If you're thinking that actually maybe this is musculoskeletal pain, sometimes it can be useful to just palpate the chest wall and see if that, you know, elicits the pain or makes it worse. And even just looking at from the end of the bed and looking well, does this patient look well or do they look terribly unwell and hot and sweaty and clammy? That's gonna tell you a lot. And then in terms of any investigations that you might ask, I always think if you're, if you're be by somebody and asked to come and see a patient with chest pain and over the phone, you know, you can't convince yourself that it's absolutely nothing. And you know, you, you agree that you need to do, go and see this patient, if you're concerned enough that you need to feel like you need to go and see them, then asking for the nurses if possible in your hospital, for them to do an ECG before you get there is really useful. Um, because otherwise, if you think an ECG is indicated, which will, it will be in the majority of patients, you're gonna waste a lot of time once you're there trying to find an ECG machine and then trying to do one. So if that information is already to hand by the time you get there, then that's incredibly useful. And always remember to, to compare any new ECG to, to previous ones to look for any new changes. Um, it is useful. Um, a troponin is going to be useful if you're at all concerned about a cardiac cause of chest pain. Um, but I think I wouldn't send one out of the blue. Um, definitely if you're concerned about acute coronary syndrome, then, absolutely. But, um, often, you know, patients have a bit of heart failure or something like that anyway. And then they're otherwise unwell with intercurrent illness. Then if you send the troponin, the likelihood is they've probably got like a little bit of myocardial strain in the context of just being otherwise unwell and it's gonna come back very slightly raised and then you're gonna be obliged to do another one. So it's not always useful. But if absolutely, if you're at all suspicious of um a cardiac cause of chest pain, then sending a troponin is gonna be useful. Um And then if you're thinking about pulmonary embolism, your d-dimer and CT P is your um uh next steps. Um I think obviously the we score can be used to risk stratify um patients who you suspect might have pulmonary embolism and patients with a lower well score can send a DDIMER and otherwise get a CT. But I think if, if you're convinced that the patient that the most likely differential diagnosis is A CTK and you're gonna start them on treatment for a CT P for a pulmonary embolism, then I think you're, you should really, you know, the indication for A CT P is quite solid. And I think in, in most cases, your radiology department should be happy to uh crack on and do the definitive diagnostic investigation, which is a CT without sort of skipping that middle step for a d-dimer. But those kind of patients that you're worried about as well. Um Always remember that you can ask your seniors, your medical registrar, what they think is the most appropriate thing to do. So I want to crack on with the cases really. So this is the first case. It's a 62 year old lady who you've been asked to see when you're on call at seven o'clock, she's on the respiratory ward. She's in, with an infective exacerbation of COPD. She's on some antibiotics. She's got COPD, which is, um, fairly moderate to severe. She's come into hospital a few times with exacerbations. She's got a bit of heart failure. She's got type two diabetes. She's got hypertension, she's got CKD three. So she's got some risk factors. Um, and she's got an underactive thyroid. So, if you're asking to go and see this patient, could anyone pop into the chart? What they'd like to, to ask her in terms of a history and I'll try and play the patient and feedback to you as we go. Yeah. Um, so the pain, um, it is, it sort of started sometime this afternoon. I'm not too sure exactly when it started. Um, I've been coughing a lot today and it seems to be a bit worse when I cough. Um, it's kind of more on the left side of my chest. It doesn't really go anywhere else. Um, it's maybe like a five or a six out of 10, I think. Um, and yeah, I had a bit of paracetamol that helped a little bit. Um, I didn't really want to take anything else for it or I always kind of knocks me off a bit. Um, I feel a little bit short of breath still but, um, you know, I think maybe that's getting a bit better. I know, like, I mean, I, I came in with shortness of breath and I've been on some antibiotics so I think that's helping. Um, even though I still feel a bit breathless still, I don't feel nauseous or anything like that. Um, but I've been, I've been coughing quite a lot today. Um, all right, I've never had, um, this type of pain before, I don't think. No. Um, yeah, I've been coughing up a lot. I've been coughing up some sort of greeny phlegm. That's what I've, um, had since for the last few days. Really. Um, it's definitely worse when I cough. I don't really think it's worse when I breathe in the, um, yeah. Ok. Um, kind of localize it. Yeah, it's like, kind of more on the left, I think. Yeah. Um, and then you have asked the nurses to do an ECG and it looks like this. Um, anyone got any comments on that ECG. Does that make them worried not worried. It doesn't really radiate anywhere else. No. Um, yeah, Greeny phlegm. Um, am I using any pillows? Um, I usually sleep with two pillows at night, but that's just been the same. It hasn't really changed. Um, my finding it difficult to address. Um, no, I'm still managing that thankfully. Um, got a few sinus rhythm. Looks sinus. No ischemic change. No ischemic changes. Yup. So I agree. I think that's a normal sinus rhythm. Um So then what would people like to um look for on examination? So that's just the, the history recounted there on the slide. What would people like to look for on examination? Lung? Sounds? Yes. So you have a listen to the lungs. She's got um a few by basal craps. They're a bit worse on the left side. She's got a little bit of mild wheeze as well. Yeah. Central cyanosis. No, she doesn't have that. Um The nurses have kind of done some s for you. So she's just using a two at the moment. Um just for some nasal oxygen. Um But that's actually been weaned today. She was on a venturi mask now she's just on a couple of liters via nasal cannula. Um So other than that, yeah, she's certainly not cytic. Her SATS are fine. Um Heart rate is 85 BP is 12, 7/77. Her resps are 20 she's afebrile um chest movements. So nothing abnormal. Seen Hamsa. Um just doesn't look like there's any sort of particularly increased work of breathing or anything like that. Somebody suggesting an A BG update bloods chest x-ray. Um, yeah, you can see it. So that's how she examines um, other things, her normal heart sounds. Um Definitely you can tell that her pain is, um, elicited a bit when she coughs. Um, and she's a bit tender actually when you palpate her left uh anterior chest wall there where she's saying that it's a bit sore, her calves are soft, um Searching for signs of consolidation. Yes. So she's got some scattered cramps in keeping with her infective exacerbation of COPD, but it doesn't sound like um there's any frank consolidation. She's had an x-ray when she came in 1 to 2 days ago, which shows that she's got um a bit of um consolidation on both sides worse on the left. Um That's the chest x-ray from a couple of days ago when she came in. Um A G, I think it's not wrong to do an AG in this patient, but she's got a reducing oxygen requirement in comparison to previous. She doesn't look distressed at the end of the bed. Um So I'm not convinced that I would personally do an A BG in this patient. If you were worried enough, you could do a venous gas and um you and up. So and then so, yeah, what would people like to do is we've got a few suggestions here. We've got somebody asking for you. We've got quite a few people asking for a chest x-ray, uh, um, what to do or not to do for this patient and what do people think might be happening? So, we've got one suggestion for MS K pain costochondritis worsening, iecopd hop spirometry. We could do. It's certainly possible that her, her pneumonia or, um, infective exacerbation of COPD. I think there's little evidence to support that it's worsening though. Her oxygen requirements reducing. She's not febrile. Um, you know, she doesn't look particularly unwell. Um, but obviously that's where in real life you're gonna look at her, you know, bloods has she had some bloods today? What were they like in person since previous, are inflammatory markers going up or are they going down? Um, well, if they help, put that sort of thing into context included here. Um, spirometry. Yeah. Again, if you know, if you're worried about her COPD, um, but I think in the acute setting it's gonna be hard to order spirometry, isn't it? It's seven o'clock on an on call shift. So that's not something that you're going to necessarily be able to do acutely. Um, you could get her to, um, do an FV one, can you? Um, but I'm not too sure, I'm not too sure what that would add. Any other suggestions for anything anyone wants to do. Sputum culture. Sounds reasonable if she's not had one. Ok. So we'll move on to. So es everyone agreed. Um, her ecg was normal sinus rhythm. Um And I think the most likely diagnosis is that she's got musculoskeletal chest pain. She's been coughing a lot. She looks, well, her s haven't changed anything. They've improved. Um, she's got a bit of tenderness when you palpate her chest will just support that. Um And so I think that will support the pain being related to the skeletal. It also could be related to the fact that she's got infection in her lung consolidation as people have suspected. Um all of those things like checking her CRP doing sputum culture are all completely reasonable. Um Yeah, that someone says normal time, normal so is not in distress, probably just monitor. I would agree. Um This is somebody who probably the tro would be a little bit off if you sent it, but it's certainly not wrong to do that. Um And it certainly wouldn't be wrong to send the d-dimer either. But again, the chances of it being slightly falsely elevated would be high enough. Um ok, so I think um all of those were really reasonable suggestions. Um But I think the main, the main takeaways are her obs have been fine, they've not got worse. She looks very well. There's little evidence from her history, support her card or chest pain. So um Alexandra, I think values of troponin vary from hospital to hospital. Um So I think you just need to look at your own hospital in our hospital. I think anything over 14, you can't rule out an A CS. Um So if it's over the normal value, then you want to send a repeat to for dynamic change. So if it's up trending, then that makes you worried. If the second one is less than the first one, then you can be reassured. Um But yeah, often in a, you know, in a big a in and Troponin will be very high. Um Cool. Let's move to, I think, let's skip one scenario just in the interest of time and we'll skip to uh scenario three. So you've got the same patient again. Um And you've been asked to see her again. Um And this time, uh you are going to see and you've asked the nurse to do an ECG and it looks like this. Um Has anyone got any thoughts about this ECG? And we're going to assume that any changes you may or may not see are new changes when you look at the previous one. So we've got some T wave inversions being tested here. V six V five V 41 and two. And I agree with all of that. Yeah, T wave inversion, T wave inversion, T wave inversion. OK. Fine. Um So let's then go back. What would you like to ask me? I'm the patient? Yeah, Socrates again. Exactly. So doing a pain history always gonna be key. So this time my pain started, um, fairly late on this afternoon, like a couple of hours ago at most, maybe kind of the last hour or so. Um, it's quite central. It feels, um, like it feels like quite heavy. Um, it's kind of here in the middle of my chest. It doesn't really go anywhere else. Um, um, yeah, it, it came on fairly suddenly, to be honest. Um, and yeah, as I say, I feel like it's kind of getting worse. Um, I've had some paracetamol but it's not really cutting it. I'd like something a bit stronger. Um, and I don't feel too short of breath but I do feel a bit nauseous, um, associated symptoms. Yeah. Um, and it's, it's not great. I do feel quite sore. Seven out of 10. I haven't lost consciousness or blacked out. No. Um, my heart racing. Yeah, maybe a little bit. Um, yeah. But, yeah, I, I feel, I do feel a bit sweaty actually. Yeah. O case I do, um, palpitations. I feel like maybe my heart's racing a little bit but not really. Um, to previous ecg all of the changes that you can see if you can see any are new. Um, previous eg shows sinus rhythm, um, palpitations a little bit pain. Yeah. I think it's getting worse. Yeah. Ok. And then anything else that you'd like to ask me or what would you like to look for on exam and pain worsens with movement? I haven't really moved that much. To be honest, I'm not too sure. Uh signs of heart failure, nothing really obvious striking you. Um, when you see her initially cardiac history. So, um, yeah, I've got type two diabetes and hypertension and um, I had, I know they said my heart doesn't pump as well as it used to. What would you like to ask me on or look for an examination? Uh, no new swellings in the limbs? No. Nice. So, skin. Yeah. So she does seem like maybe she's peripherally slightly dry. Um, JB P is not, obviously raised. Her heart sounds, sounds a bit tacky. But, um, other than that, um, nothing else, obvious breath sounds, she's just got some scanty cracks but we know she's got COPD. So we're kind of expecting that cough. She's got a bit of cough. Yeah. She's had that few days since she's been in the hospital. No, no blood. No, she's not. She's not bleeding from anywhere. Urine is fine. Yeah. No, there any new symptoms. Mhm. So, she's a bit tic. Her heart rate is 100 and five. Her rests are slightly young. Her BP is low normal. No, R and B. Gracy. That's a good thought and shake that breath. So, on the basis of all of that, yeah, she looks a bit sweaty from the end of the bed. What do we suspect? And what might we want to do? Send a drop suspecting an N sty? Yeah. Cultures. Yeah. She's not had, she's not spiked a fever but, um, it's not an unreasonable suggestion if she's not had any sense before new score is going up, isn't it? So, and try or more for pain. Yeah. Yeah. Repeat the OS. Yeah. So we've got one suggestion of N sty as to what might be going on. Does anybody agree with that or anyone have any other differential diagnoses? Abdomen? Soft. Yeah. So somebody suggesting starting some a CS treatment. So, clopidogrel aspirin, consider fondaparinux. Yeah. All right. Um So we'll move forward, we'll look at her ECG again and as everyone rightly pointed out, so she's got some new T wa in versions, doesn't she? Um and lots of her different leads. So V four, V five, V 612 and A VL. So that's gonna make us if those changes are new, which they are, that's gonna make us concerned about ischemic change. I think you could also say in V four and V five, she's probably got some borderline ST depression, but it is difficult to see it be difficult to confidently say that it's ST depression, but certainly she's got, she's put her T waves in multiple leads, um which is definitely concerning for an ischemic ecg. Um And on that basis, I think whoever suggested sending a troponin would be absolutely right. Um We definitely need to rule out um a cardiac cause of chest pain here because the history is in keeping with that. Isn't it? Heavy? Chest pain, central? She's sweaty, she's nauseous. She's got risk factors and the troponin comes back raised. So, on that basis, I think I'd absolutely agree with whoever suggested starting some A CS management, um, clopidogrel, Aspirin, Fondaparinux. And I think, um the thing to say is that every hospital will have their own acs protocol and you should be familiar with where to find that. Um And then it's really just a matter of escalating care. So this is not a patient that you um want to manage alone. This is a patient that you're definitely gonna want to involve the senior medical team. So at least the medical reg probably the cardiology registrar. Um And yeah, you're gonna want to refer to your own hospital protocol. So this is the one that we use in the BR I. Um And on the up on that basis of your troponin, um I think you're gonna, it's over the cut off for starting a CS management. So you're gonna want to start that escalate care and start a CS treatment. Um T wave inversion, old mi I so T wave inversion. Um Yeah, definitely can be seen in the context of an old M I. But if it's a new T wave inversion, which I'm telling you that this is um then that will make you concerned for new ischemia. Um When would you conclude ischemic changes? How many and what leads? So you want to look ideally for two contiguous leads or two leads beside each other for um being suspicious of um, ischemia. So, new changes in two leads beside each other. Um Yeah. Um And if this patient had ST elevation rather than depression, obviously, you'd be thinking about whether she needs PCI, you know, immediately. Um And that, that patient is definitely gonna want to be discussed with cardiology for consideration of that. Would an echo be ordered? Yeah, I think it would be um not acutely acutely. You're gonna want to just manage this with a CS treatment, but in the fullness of time over the next few days, she's probably gonna warrant an echo, I would imagine. OK. Um Got one more case but we are at half past. So I'll just ask Boris, what he thinks in the interest of time is worth doing. Yes. Um Yeah. Should I just do that? All right. So we might just skip a couple of other ecgs to look at cause I know that's uh an area that um is often difficult and you're often asked to look at an ECG um in that last algorithm GTN. Yes, I'd give her GTN um often helpful for cardiac chest pain. The only time you want to be careful with giving GTN is if the BP is quite low because it will vasodilate and it will drop the BP. So, if her BP was in the eighties, systolic, I'd be, I'd be, um, I'd be concerned about giving her GTN, but as long as her BP is stable, um, yes, I would definitely give her a GTN uh diagnosis scenario three. So the scenario we just went through the diagnosis is NSTEMI. Um So I think often the thing that you're concerned about when you're looking at an ECG is is there any evidence of ischemia or infarction? So the criteria for stemi um over two millimeters of ST elevation in two contiguous chest feeds or one millimeter in two contiguous limb leads. Um Or the other one is a new left bundle branch block, um which I think is a bit of a, it's one of those ones that I think is a bit debatable and apparently most patients with a new left bundle don't have a stemi, but you certainly can't exclude a stemi on the base of it. So, again, it's an ECG that you'd be escalating compared to cardiology for an opinion. Um Hyper T waves are an early sign. So sort of big peak T waves, but like your hyperkalemic T waves and an early sign preceding ST changes of cardiac ischemia. So that's somebody, again, you'd want to repeat the ECG um you know, within 15 minutes, half an hour, that kind of thing or keep them on a cardiac monitor. Um ST depression T wave inversion. Um Again, you're looking for 22 contiguous leads. So you're looking um for two leads beside each other and that's indicative of ischemia. Um, if it's more than one millimeter, that's more specific. So we got a couple of ECGS just to look at, has anybody got any thoughts about this? ECG what might be going on here? And again, we're presuming any changes we see are new from an old E CD which shows sinus rhythm. ST elevation. Yeah. Where abouts 23 A VF I'll take that. Yeah. Inferior M I inferior, MRI RC A compromise. Inferior I OK. Yeah, I think I'll, I'll buy that. Um So we can see new ST elevation in the inferior lead. So we'll look at ECG territories in just a second. But yeah, in leads two, lead, three, lead A BF which are all the inferior leads. Um looking at the inferior aspect of the heart. Um We can see ST elevation and then we can see some reciprocal changes um on the lateral leads. So in lead A BL and also in, in lead one, um we've got some ST depression and T wave inversion which um fits with an inferior myocardial infarction. Um So it can be helpful to sort of think about territories that the different leads are looking at. So leads V one to V four, usually looking at the front of the heart um and total. Um and usually that's your um lad left anterior descending coronary artery. Um Then you've got your lateral leads which are a BL and lead one and to a lesser extent five and six. And then your inferior leads, looking at, um, the inferior aspect of the heart, which is usually as somebody said, the right coronary artery is the artery that supplies that aspect of the heart and that leads to lead three leads af um, where we saw the elevation in the last ECG and then we'll just look at one more ECG Can anybody, uh, tell me what this might be demonstrating? Someone suggested a lateral in for it, ST elevation in the lateral leads. Pericarditis. Yeah, anterolateral inward, se somebody else has gone with it as well. I think I'll, I'll take that. But yeah, there are fairly widespread ECG changes here, aren't there. Um But I think the most marked thing is probably if you look at a BL and lead one, that's the most marked ST elevation um that you can see there to a lesser extent, there's a tiny amount of ST elevation V five and V six, but it's really quite difficult to, to pick that out. But I think you could probably say that there's some hyperacute T waves in V five and V four really as well. But I think the most marked thing, there's definite ST elevation in one and A bl. So that's in keeping with the lateral. Um and you'll see the reciprocal changes then in the opposite leads, which is your, your inferior leads. And so you've got the the marked ST depression, you can see that really clearly there in lead three, there's marked ST depression and an A VF as well. Um But there's really widespread changes throughout the ECG. Um OK, so I think in the interest of time we'll probably move on to the shortness of breath aspect. Is there any final questions that anyone's got? I know it's a bit of a whiz through. I think the take home messages are to um you know, put the put chest pain in the context of the patient. So, is this a a patient with cardiovascular risk factors with a cardiac standing history or is this, you know, a patient who's 20 years old come in with something completely unrelated with no past medical history, in which case, a, you know, acute coronary syndrome is extremely unlikely even, you know, before you even set eyes on the patient, um looking at their observations because if something serious is going on, um you know, at least you'd expect at least one or two of their physiological parameters to be abnormal and to be changing. Um And then if you're at all concerned, obviously escalate care, um when you're on call and people are gonna be happy to be called, if you're at all concerned about a serious cause of chest pain, like an M or a pe or anything else. And these are patients that your senior team want to know about. Um So if you're at all worried. Um you know, discuss them and ask for a senior year review. That's it. So I just want some cake. All right, great. Um Thank you so much, everyone for participating. It was um lots of comments was really good to, to keep it going. So, thanks a lot. Right. Thanks everyone. Um I will move on swiftly to shortness of breath and chest x-rays. Um I might whizz through the start a little bit and then we can get to the cases at the end, shortness of breath again. Like chest pain is a really, really common bleep on call. The bleeps you get can vary. You know, it might be someone with low saturations that the nurses are calling about. It might be someone with difficulty breathing. Uh It's just a high respiratory rate or they're just bleeping you because they're scoring a three in one parameter and they need to notify someone. All of these scenarios could possibly be a patient with a respiratory issue or something that's causing respiratory distress. So, on the phone, can anyone put in the chat? What more information you might want if the nurse has bleed you about someone with a high respiratory rate? For example, there's a clue in the picture here. Yeah, exactly. So you'd want to know their sats, you'd want to know their obs in general and importantly, you'd probably want to know their OS trend. So not just the most recent obs because actually sometimes you can get caught out with patients who are scoring a five, but actually they've improved from a seven earlier in the day and you probably don't need to review them and certainly not urgently. So you don't want to know exactly how much oxygen are they on? Um, are they known to have airway disease? And you know, are they a patient with COPD? Are they known CO2 retainer? Are they scale two? Um Are we escalating for the wrong SA targets, for example? And what are they in hospital for? Are they in with a pneumonia? Are they on IV antibiotics already or are they in with a completely unrelated non respiratory pathology? In which case, we'd probably be a bit more worried if they suddenly developed a new oxygen requirement or new hypoxia generally as a tip, hypoxia, you know, in your airway and breathing comes quite early on in the algorithm. Um hypoxia is a medical emergency and if you go and see someone and from the end of the bed, you're worried about them, they look sick. Um It's worth escalating early and getting some extra hands on deck. If you think that they're really sick, generally anyone sick, you go and assess while on call, you should use an A two E assessment. I think sometimes, particularly when you're starting off on the wards, you can quickly sort of panic when you see someone sick and forget what to do and where to start the whole point of a three assessments is it's the sort of systems approach that you've learned and practiced a lot in, um you know, in ki in SIM sessions. So, you know, anyone sick, just start with the basics, assess the airway once that's done. Move on if you encounter any issues along the way, um, always try and solve the problem before you move on. So if they've got an airway problem, definitely want to try some airway maneuvers. You probably want to put out a per rest call or ask the nurses to do so so that you can have some extra help because you're not going to be able to support their airway by yourself. And once the crash trolley is there, you can try and put in an airway adjunct and things like that. Obviously, that's quite a lot to be doing as an F one. But I think going back to the basics and just doing your simple A to ease and asking for help is really all you can do and will be really helpful. Importantly, then obviously you want to assess their breathing. Um A few tips, sometimes the SATS probe isn't actually getting a good trace. So if someone's getting low A TS, you just want to make sure that the trace it's picking up is actually adequate. Generally, obviously, simple things to do is sitting a patient up um that can often improve their oxygenation. Um And you'd move on with your assessment then. So you'd inspect the chest, you'd percuss, you'd aust generally speaking, if someone's hypoxic and unwell, giving them 15 liters of high flow oxygen whilst you assess and, or seek help is going to buy you time by oxy. The patient. I wouldn't worry too much in this context about patients with COPD and whether they, you know, whether they're scale two or not as a general rule, hypoxia is going to kill someone before hypercapnia. Obviously, if someone's known a known CO2 retainer and it's documented on the drug chart that they are meant to be scale two, that's something to bear in mind. But certainly in the acute setting, I wouldn't worry too much about that. Obviously, I've not run through a list of all the things that can make someone short of breath, but there's, you know, a lot of causes. So looking for clues both in the notes in the history and in your assessment of the patient in the bedside is really useful to try and determine what's going on. So, you know, has the patient been on IV fluids if they really positive fluid balance over the last few days? So they known to have heart failure with reduced ejection fraction could be palm. Um Is there any evidence of swallowing problems? Have they had a recent stroke? Is there a by mouth sign on the wall? Do they have dementia with a known difficult swallow? They may have had an aspiration. Are they on a cardiac monitor suggesting some sort of a cardiac event? Um and generally NIV patients, if they're deteriorating, you probably want to increase the oxygen via their NIV. And if you're not experienced with it, probably call for help early and um alert your senior reg and ask them for help. Generally with the A T obviously, if they're well and stable, complete your A two assessment, if not always initiate treatment before you move on to the next step. And generally anyone with an airway problem who's hypoxic or tachypneic, um, basic investigations would be an ABG if they've not had one and a chest x-ray. Certainly in newly hypoxic or deteriorating patients, you'd really want quite a good reason not to do those fairly simple investigations. And especially if you're calling your for health, often they would want to know what the ABG showed and that's something that you could in theory do. Um, in your assessment, portable chest xrays can be really useful if you've got a really sick and unstable patient who you don't think would be well enough to go down to the x-ray department. Um, and I've put in there check respect to escalation status. Um, it's worth checking if you're going to see older patients. Um, you know, whether they're end of life or whether they have a respect form that has certain escalation status, for example, you know, not for invasive blood tests or um things like that you can sort of be caught out because obviously, respiratory distress is quite a common presentation, especially end of life. And you've got patients with end-stage COPD, for example, who will undoubtedly be breathless. Obviously, in those patients, you just want to make sure you're not rushing in with invasive blood tests like ABGS that can be distressing and, and unpleasant for the patients if it's sort of clearly documented in the notes that actually they're end of life and it would be more appropriate to be treating their symptoms with things like morphine if they're breathless or um some of the other anticipatory meds, if they're in respiratory distress, right, moving on to chest xrays, obviously, really common investigation. Um loads of different scenarios where you might want to order a chest x-ray, general rule of thumb. Anyone who comes into hospital at Clark will, you know, get a basic set of investigations, which normally includes a chest X ray and ECG and some routine blood. So any suspicion of acute or chronic lung pathology. Um So cancer infection, edema, effusion, any deteriorating patient on the wards, you'd probably want to get a repeat chest x-ray confirmation of NG tube placement. I'll run through that in a second and post any intervention. So like central lines, chest drains or pacemakers mostly to rule out the pneumothorax in that context. Just I've seen your question, Shirlene, I'm not going to run through interpretation of ABGS at the moment. But obviously, an ABG is really useful in a hypoxic, you know, patient or hypoxic, at least on PSE oximetry because it will give us a lot more information in terms of the blood oxygen saturations. Their CO2 level. If they are CO2 retainer, their CO2 might be up and their bicarb might be up as a sort of metabolic compensation. So that just gives you a lot of useful information that you don't necessarily get purely from their S and SATS. So if you tips, there always interpret a chest x-ray in clinical context. So a chest x-ray in itself isn't that useful. You always sort of need to look at how the patient is, look at their obs as a minimum. Um and interpret things in that context. A change in clinical condition always wants to repeat chest x-ray. I sort of got a little bit caught out at the start of F one when I would be assessing a patient. I'd wonder what's going on and I'd look at their chest x-ray on the system from two days previously and think, hm, you know, the pneumonia is not that bad. It doesn't really explain their clinical presentation. Obviously, loads can change in two days. You know, things can change much quicker than that. So I think repeating a chest x-ray if someone's deteriorated, um or if, for example, is newly hypoxic is always useful. Um and no one's going to get you into any trouble for that. It's not the most invasive test. And I think the doses of radiation are pretty accepted generally. And then handover, I put always ask for more information. So this will happen loads if you're doing evening ward cover shifts. For example, if you're on a night shift, that the day team or the evening team will hand over investigations for you to chase. So for example, they will say, please, can you chase a chest x-ray for this patient? It's really useful to ask for more information at the time of the handover because you want to know for example, how the patient is, why are we doing the investigation? Importantly, does it need to be done out of hours? And that helps you when um you're trying to chase something that then gets canceled by the department and you're not entirely sure how urgent it is. So asking the day team while they're still around and handing over to you is really useful and then just asking about an escalation plan depending on your findings, often it's consultants who would have asked for these investigations to be done. So asking them at the time, you know what they would like you to do depending on the findings. So, you know, if it's a a an effusion, um and they're checking a chest x-ray to ensure the infusion hasn't got worse, you could ask, you know, what would you want me to do if the infusion has got worse or if it's a pneumonia that hasn't cleared up with six days of IV antibiotics, what antibiotic would you like me to escalate to? So, just remember to ask all of those questions and to gather more information. When someone's handing something over to you, you will have to look at a lot of chest xrays while you're, um, on call and working on the wards and you will get more and more used to it. I think having a really systematic approach is really helpful and just make sure that you don't miss important findings, obviously, interpreting things in clinical context is great, but sometimes you can get a little bit focused on what you're looking for. And as a result, miss, you know, an important finding that you weren't looking for because you didn't necessarily um approach the chest x-ray systematically. So I'm not gonna run through all of this. But if you screenshot this, we'll just, I mean, I'm sure you will have a system that you can look at chest x-rays. But generally, you know, checking the airway uh first making sure you've got the right patient and the date of the x-rays, the, you know, today that you're actually looking at um airway. So you want to check that the is central. Um You want to assess the lung fields for the breathing part and divide them into the different lung zones. Um so that you can try and assess where the issue is, um and it's also good to inspect the pleura as well. And then in a pa film, so generally, um you can assess the cardiac um contours, see whether there's any signs of cardiomegaly. Um And then just have a look through the diaphragms, make sure you're not missing anything there and then everything else I've just put in to look at, you know, always have a look at the bones, any tubes or devices or anything like that. Um And just have this systematic approach in your back of your mind. Whenever you're looking at a scan, I've just put this in. This is quite a useful sort of anatomical reminder of what you're actually looking at on the chest x-ray. So you've got the Corinna in the center there. And again, I'd recommend just sort of screens shotting there. So looking at up online, um and you can use that when you need it. I put that always compared to previous imaging available on the system. I think that's really crucial. Often you'll look at a chest x-ray that looks odd. Um Looking at a previous chest x-ray from 6, 12, 14 months ago is really useful. If that slightly odd appearance hasn't changed, that's always quite reassuring. Whereas if there's, you know, new consolidation or um anything like that, a new shadowing anywhere or new cardiomegaly or anything like that, that would always get you thinking a little bit more. So we're gonna run through a few chest x-ray cases. Um, we can sort of use the same patient for all of this. But generally, let's say you're at 5 p.m. handover, you're doing an evening ward cover shift. Um One of the day team asked to hand over a patient called Jane Doe. She's in bed 26 on the general medical ward. She's a 78 year old patient. She was admitted with a Euros SEIS five days ago. She's been clinically improving on IV antibiotics. Switched to s today today. She seemed more short of breath. Please. Can you chase the chest x-ray? It's booked for 6 p.m. today. Can anyone think of any more questions? You'd want to ask me if I was handing this over to you? Feel free to just put them in the chat? Yeah, exactly. So, exactly. Yeah. So you'd want to know a lot more about their clinical condition. You probably want to know a little bit more about their past medical history. Um So that you actually know the context in which we're interpreting it. I'm not going to go into too many details about this. It's mainly about recognizing the chest x-ray findings for the next few. So the chest x-ray comes back and this is what you find. Does anyone want to suggest any findings in the chat or diagnosis? And then we can talk about what you might do if this is the scan that you'd be looking at and how you might go and assess the patient or what management you might consider. Yeah, heart failure, possibly any findings in particular that make you think of heart failure. Yeah, blunting of cost running angle, left, bilateral basal consolidation. So the central, that's quite good to note. Um Yeah, I've not put on whether it's an A P or P A film, but certainly there is a suggestion that there's quite a large heart there. So, yeah, that's not unreasonable bit of cardiomegaly and there is definitely something going on with shadowing here, isn't there. Um And I see what you mean. It's definitely bilateral. I describe it generally as fluffy. Um You know, you've got sort of, I wouldn't call it consolidation necessarily, but you've got definitely sort of fluffy appearance in both lungs. Um not just in the basis, like you say, a little bit of a blunting in the left nic ale. And yeah, that would be quite in keeping with palm edema um in the context of heart failure and fluid overload. So I think, you know, obviously, like I said, you'd want to assess the patient, make sure, you know, they are stable. How breathless are they? Um Do they have known heart failure in terms of management of this patient? You probably want to as long as their kidney function is. All right. Trial them on some IV diuretic 20 to 40 mg is usually a sort of reasonable starting dose. Um And what you want to do then is just assess their response to that and see whether it makes them any less breathless. If you're assessing someone in the acute setting who's really short of breath and you think they might have pulmonary edema, um because their fluid balance is positive and they've got a bit of heart failure, it's not unreasonable to try some IV furosemide before you even have a chest x-ray and assess their response to it. Clinically given that it can sometimes be a few hours of wait before you actually manage to get a chest x-ray. Great. We'll move on to the next case. So if someone's asked you to chase the same patient, another chest x-ray, you check the, check the images on, on packs and this is what you find. Does anyone want to suggest what the abnormality in this chest x-ray is and what you might do and again, just approach it systematically. So look at the Yeah, great. So you've all picked up on that. There's um there's a pneumothorax on the left. You can see that the lung markings, there's no lung markings on the side there. So this person's got quite a large pneumothorax, the trachea seems to be central. So at least from the x-ray, there's no sign that they're intention pneumothorax. Um And I think, yeah, if you look closely there, I think there's actually a chest drain already in, in this person. So in this, I mean, this is sort of an x-ray you'd hope not to see. But, um, you'd certainly want to very urgently assess this patient. Um, you'd probably want to alert a senior, um, because they're likely to need a chest drain. Obviously, this patient's got a chest drain already. Pneumothorax is the one thing that if you're checking a routine chest x-ray out of hours is sort of the one thing you want to make sure you're not missing because it is something that we probably need something doing about urgently. You know, if someone's got a pneumonia and they're on antibiotics doesn't necessarily need escalating overnight, but certainly a pneumothorax, um, would warrant a patient assessment and a discussion with a senior. Great, same patient again. And this is the chest x-ray that you find. Yeah, exactly. So tracheal like central again, the sort of left lung doesn't look too bad, does it? And if you're looking for symmetry here, certainly the right lower zone looks like there's some consolidation there. Exactly. Great. You will pick that really well. So, yeah, I think I'd suggest obviously, you know, without I'm not giving you too much clinical context here, but this looks certainly in keeping with findings of the right lower zone pneumonia. Um, in this case, we want to assess the patient, you know, check that they've had inflammatory markers, et cetera sent, ensure they're on appropriate antibiotics. Um, if they are, there's probably not very much to be done overnight. Um, and patients like this is worth remembering if you're discharging them. Um Any sort of consolidation like that usually warrants a follow up chest x-ray in about 6 to 8 weeks to ensure that that opacification is resolved and that it was in fact infect changes. So, opacification consolidation are essentially interchangeable. Consolidation obviously suggests that there's some sort of, you know, fluid or infection in the lung that's consolidating it, pacification is more, you know, a term for the appearance on the black and white image if that makes sense. So I think, I mean, you can pretty much use them interchangeably, you know, if you suggested a more infective process and I think consolidation is we need to be used if you want to just be purely um descriptive of what you're seeing on the x-ray cause you're not entirely sure what's going on. And I think then the pacification is to say what to use. Great. This is your next next chest x-ray. So same patient again, it's a little bit hazy this one, but you just want to approach it systematically and write any abnormalities. Yeah. Ham S AC B 65 approach with anyone with um a pneumonia is reasonable to guide your sort of further management. Yeah. Great Shirley. So you can see there the right hemidiaphragm is raised with some free air under it. Um Exactly which suggests some sort of an abdominal perforation. And that's just to suggest, you know, even if someone's got some sort of respiratory disease and that's why they had a chest x-ray. Always make sure you're checking for other things as well. Because if you'd seen this chest x-ray and missed it, for example, that would obviously not be great. Given that there's quite an obvious sign there for um some sort of underlying pathology. So, yeah, pneumoperitoneum, they probably, they've got free air in their abdomen. So again, you'd want to assess the patient check for any signs of perforation or peronism. Discuss with surgeons. They're likely to need a CT to investigate what's going on. Um, they're probably going to need an NG tube and IV antibiotics for intra-abdominal sepsis. Right? And then quickly this is the last case I think for the chest xrays. What can you see here? Yeah, exactly. So there's a fluid line on the left middle zone. Yeah. Yeah. So that's suggestive of an MP emo or pleural effusion or something. Yeah. So again, you'd want to assess the patient important with this would be whether it's a new change. So, looking at a previous chest x-ray, whether that's developed suddenly, um and again, this is a case you probably want to discuss with the senior um because they're likely to need a chest drain or something and it's just worth seeing how unwell they are for how urgently you'd want to do that. Great well done. And finally, I'm just going to quickly run through G tube placement and confirmation on chest xrays. Again, this is something that comes up quite commonly, I think while you're on call and isn't something that you're necessarily explicitly taught about at medical school. So I found it really useful to go through it with you. Obviously, normally we would check NG tube placements by getting an aspirate and checking the ph, it's worth checking what your local protocol is in your hospitals for who can check chest xrays to confirm NG tube placements. Some hospitals, it has to be radiology, um who checks them um at the br for example, it doesn't necessarily have to be radiology. So often it'll be used. The F one who gets us to check that an NG tube is safe to use um in by reviewing an x-ray. So there's a few criteria that it needs to meet for it to be safe to use. So first of all, the chest x-ray needs to be an adequate view. So it needs to include the upper esophagus and it needs to extend to below the diaphragm. The NG tube should remain in the midline down to the level of the diaphragm. The NG tube should bicep the carina, the tip of the NG tube must be clearly visible and needs to be below the hemidiaphragm and the tip of the NG tube should be approximately 10 centimeters beyond the gastroesophageal junction. So it should be within the stomach if you forget these. Gee medics has a really good thing online. So if you want to just look them up on call, it's really useful and just go through the quick criteria. If any of those criteria aren't met, then the G tube isn't safe to use. And you'd have to discuss it with the senior radiology or get a repeat chest x-ray to make sure that we're confident that the NG tube is in the right position to be used. You obviously don't want to be starting feeds and um potentially putting the feed into the lung or somewhere else if you're not sure where the NG tube is actually going. So this is a chest x-ray of a directly sighted NG tube. So you can see that it's an adequate view. You can see the upper esophagus and you can see well below the diaphragm. Um the NG tube remains in the midline to below the diaphragm. It bisects the carina. Um the tip is clearly visible and the tip is clearly projected within the stomach 10 centimeters beyond the gastroesophageal junction, which is approximately at the entrance to the stomach there near the spine. So that's a correctly sighted NG tube that would be safe to use. So you would have to clearly document that in the notes. What about this one does want to write any suggestions in the chat, slightly faint there, but you can see an NG tube. This unfor this is a really common scenario that you encounter when checking chest xrays So is it an adequate view? First of all? Yes, it is great. Does the G tube stay in the midline until below the diaphragm? And does it bisect the carina? It does and exactly Victoria spot on, you can't see the tip. So it looks like it probably is in the right place, but you just can't see the tip. So you can't safely say that it's safe to use. This is a little bit of annoying chest x-ray because um in theory, the radiographer should make sure that the tip is visible. Um And this patient is going to need probably a repeat chest x-ray um to make sure that you can see the tip before you declare it safe to use. What I found useful is when you're putting in chest x-ray request on the system, um It's worth just clarifying and being extra clear that the tip has to be clearly visible. So as you're requesting a chest x-ray, it's worth just clarifying that please, you know, please image the upper ab abdomen if required to visualize to adequately. That'll just save you from wasting loads of time by having to order repeat chest xrays um and delaying obviously patient care by not being able to declare it safe to use. Great. Any questions about that one? Moving on then to this one? What does everyone think about this one? Great Kate. Yeah, she Yeah, absolutely. Spot on. So um it's an adequate view. It doesn't remain in the midline until below the diaphragm. It's sort of coiled back on itself and is sitting somewhere in the bronchial tree there. So that would certainly not be safe to use. This NG tube should definitely be removed and would have to be recited before using. All right. And then finally, this one, what does everyone think about this one? So it's an adequate view. Um The NG tube is clearly visible here. It stays in the midline until just below the diaphragm. Yeah, it bisects the carina, the tip is projected of the stomach, but like you've all identified correctly, it's probably not inserted far enough. Um So that's definitely not 10 centimeters beyond the GOJ junction. So before starting feed, you probably want to insert it further by another eight centimeters or so recheck the ph if they can't get an aspira, you might need to re chest x-ray it, but certainly as it is there, it probably isn't safe to use yet. Great, excellent. So just in summary, then um really well done everyone with identifying those abnormalities. Um but when you're looking at chest x-rays or being handed over chest xrays, always check the patient details. Always compare it to previous imaging. If it's available, always place it in the clinical context of your patient. Um Remember to gather more information when being handed over investigations to chase from the day teams. And obviously, if in doubt about any of this, likewise with your ECG S just ask for help. Um There's no point in wondering whether you've missed something or not. Just ask for help, you know, call your sh call your medical, call, your radiology can be really helpful to call and just say, listen, I'm looking at this chest x-ray looks a bit funny to me. I'm not sure what's going on and they can give you an opinion. Um And it's worth checking your local protocol for confirmation of NG tube placement. But it certainly, if you are being asked to confirm NG tube placement, then using this approach, we've just run through in those criteria is really helpful. Brilliant. So we run a little bit late there, everyone. Um Hopefully that was useful for you. Um We will stick around to answer any questions if you have them. I've just posted the link to the feedback. Um If you could all complete that, um you will all be issued a certificate of attendance on completion of the feedback, um which you can upload on to your Horus. Um And log it as an hour of call teaching those of you some of the names I recognize from other sessions. Um Great stuff, obviously, getting the hours in early in the year is really useful um because you do need 60 hours of teaching by the end of the year. Um So it's really good to get them in early so that you're not scrambling towards a SCP at the end of the year. Great. So if you answer feedback, I think we have our final on call session is this Thursday, which is on more surgical presentations again. Um If you go to our page on med, all you can register for the event on there, the events also on Facebook for those of you who are there. Um It'd be great to see many of you there again too. Thanks everyone. You've been great in the chat function. Um I'm sure you will be great on the wards. Obviously, ECG S and chest xrays and all that can be slightly overwhelming at the start and you'll get used to it very quickly and just remember to ask for help if you're at all lost or end, doubt about anything, no one will hold it against you.