Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello. Good evening. I hope you will hear me. Mine is for Cuba on Welcome to the beach to Healthcare. Steris. Our session on clinical scenarios. I'd also like to welcome the one for the jobs shoes here too. Man, the chapped this evening while I'm teaching s so pleased to ask questions. And Josh will make the vocal because I can't read the chance. Pretty Cooper. I picked to very embarrassing photos today because why not be teaching like scenarios? I'm 30 a medic at King's College on Do we go for to hear me here again? In a photo of me dressed as a sheep. Just approved. You don't have to be sensible to be a medical student, because why would you? Um, I make a better sheep. I think that I do a doctor, but I'm not a doctor yet, so maybe I'll land area making the most of this session. Please take notes. They are useful for you. They help you learn as things go along. I think the session tonight will be Maurine traction. I think the know Take it. But if this basically wanna write down, there are work writing down. Please ask questions particularly. We're trying to make everything very interactive in the moment and see if we be more fun, so pleased to ask questions. Please do participate. Please do answer questions. We love it. When you do have you draw a bit, please feel free to email or ask and we can give for the resources. Any questions? That's my email address. Please do send them along. We also have an instagram. I'm very bad at running it. But please, do you give it a follow? If you have instagram and we'll have a Facebook, here's where we currently are. So that's like the case this session today, 10 February. We're still waiting for a new date to re book in our nutrition session, but we'll let you know when we have that next session coming up we bone anatomy part one, which I believe is myself again. Don't let that put you off. It should be a concession. So anyway, on with a critical cases, let me just check the check before I get started to make sure I'm not doing anything stupid. Josh, can you quickly confirm you can hear me? Yes, I can hear a fabulous Okay, Good that means that I, um not just talking aimlessly to myself. So clinical cases, uh, the aims for this session where I will present to you three patients, these patients were all sort of made up their well, based on real life patients. But obviously, for the purposes of, you know, basically majority there no actual people, they're all made up their rule images off Google images, etcetera. Um, we'll give it to you in a sort of presentation Similar to how? For some of your medical student these were having These are how they would appear in an exam or enough ski or else keeping sort of practical exam sort of a. You're given a scenario and you go in new treated patient. Um, they're also similar to how you get similar things. Things like nursing school, I think slightly more aimed at med school because I'm a med school. So I know the way my exams appear. Um, And if you want any further information, you have sort of gather it so you can ask in the chat. Can we have this? Can you tell me this about this particular person? Um, And for some questioning and maybe some testing, etcetera. You could try to figure out what is going on. In the end, we want you to try and come up with a diagnosis and a matter of plain. More specifically, we're going to What? What's called a differential diagnosis? Think is my next flight. So a differential diagnosis is working out a Siris of potential answers. So if someone comes to you with chest pain, for example, you might go and say, Well, it could be socially, the heart. It could be their lung. It could be part of a jest of system. It could be the bones it could be the muscles on. Do you work out through a process of exclusion What it is most likely going to be on then, if you can find a particular test or particular thing that nails you with one particular diagnosis? Absolute treat. That particular one. That ever differential, is sort of narrowing down the field from every possible condition. Every possible thing out there in the world of medicine down, too, you know, three or four potential, uh, potential diagnoses, Um, for those night with the Q and A. Please do. Just if you think that there's a diagnosis, you think that it could be or you a couple of diagnoses. Please stick it in the queue and a And if there's any things you've know heard about, like if we mentioned something you don't know about it just lets know. And we can talk about it more and and teach you more on it. Or if there's a particular condition I haven't said or has been said in the chat that you think why hasn't been said like I don't know if I if I give you a foot of an injured foot and we haven't said something about like dislocation. Please just put why no ankle dislocation or ankle dislocation? Question mark in the chat so that we can just talk for it. I have a white it isn't included. Or maybe we've missed it. Sometimes it's just important knowing why some things are excluded and when they're not there. But also there's no such thing, a silly question of silly answer. If you genuinely think this might be something or there's a reason why you think it might be, they're pleased to ask it, Please do suggest it because I'd be more interested to try and explain to you why not? And therefore in the future, you know that, uh, rather than you go away thinking. I wonder why it's not X y z, sudden, we'll start with patient one. I'll read it out to you and then, um, yeah, already out. And this is where I'm hoping just is going to agree with all my clinical points because just is also medical student, and he's slightly further ahead of me. So for this scenario, your student in a GP service, you're reviewing patients before they go in to see the General Practitioner GP. General practitioner in America's on the school family doctor, just for clarity there. Maria is an 18 year old female who has recently left her family home to go to university about six months ago. She's come to see the GP because of increasing fatigue at what she says gets worse throughout the day. So in the morning she's somewhat more energized, and in the afternoon she's really knock it, but consistently, she's overall very tired. She's got no previous medical conditions, and he takes no regular medication. Her only known allergy is cat dander, So Cather, which makes the skin itchy and chemical feel a bit more easy. This is the entire picture of Maria. What were you on last, Moria? So please, in the chat, people put things. And if you don't put things just will put things. And it'll confused the heck out of me to put a few things you'd like to ask Young Maria. And as we discovered the other week, I think it takes about 10 seconds before you can hear me after I say it, and then few minutes for you to think. So we'll give it a 60 seconds or so small cyst begin pumping through. Does she consumed caffeine on a daily basis? Uh, interesting question. Let's go with yesterday. Does. But but not a huge amount since she's been getting tired. She's had a couple of coffees a day. Maybe you know, one or two, but such a really good question 100 thought about caffeine consumption. I move it back to this slight so you can read what we do know about Maria as we go along. But yeah, so maybe she's had This has a bit of caffeine in her diet. Not too much, though, And someone's put uh, any question, Mark any, Okay, we're starting to get something that could be a diagnosis there. Okay, Well, you can't really ask her. Do you have any, But well, we'll come back to that in a minute. Um, how long have you been experiencing this? Increased fatigue. Good question. Again. Here, time length is always important. If anyone comes to have any symptom, you need to sort of know when did it start? And how long's that gone on for Maria? Let's say, you know, she hadn't really noticed it to begin with. We sort of noticed it over the last couple of weeks, but it's probably been building up slowly over the last couple of months. Uh, any changes today? Your routine of than the massive change going to university? Obviously. No, not really. She's living her normal life. You've got someone else suggesting a possible diagnosis. So, some of the anemia? Sure. Another very valid diagnosis suggestion. If someone else wants to do the iron levels. Yeah. I love to be really good one. So a zit for things like a test. So the one thing we can test for his iron in the blood um, I think we're gonna move on to that in a second, but yeah. Yes, I did. Um, Sudan. What else do we know about her daily routine? Uh, she's a student, you know. She gets up lakes. She goes to lectures when she could be bothered. Things out with friends. A lot. Part of badminton society at all, um normal sort of university student. If you recently had a covert or another virus. A very valid question, especially at the moment in time. Now, I don't think it's any illnesses lately. Nothing if she remembers. And what's their diet like on does he didn't. X ice diet is a very, very good question the moment. So we'll come back to diet in a second question, actually, exercise a bit. Badminton, maybe. And you know what? Students do nightclubs. That kind of thing. I'm sure I can't. Is exercise on someone else suggesting low iron? Yeah, you get a very good suggestion will come back to those in a minute that if she's stressed about anything Oh, I love that song has gone mental health. I love that. It's it's such a n'importe. Nothing to always consider, especially with someone who's coming to you with something like tiredness because tired. This could be so they're eat It could be mental tiredness. Could be physical tiredness. It could be a bit of both. Um, let's go with. She's no, actually, not particularly stretches. Quite happy. Go lucky young person. But I love that someone went there is such a really important thing to remember, particularly anything like stress or fatigue. Yeah, brilliant. Love it. I'm her periods normal. Oh, normal for her, this is the easiest way to suggest that that's the answer you always get in any sort of medical test is periods of normal for the person on any. No nutritional deficiencies. Again, Really good. Goes in with the diet one earlier. Get on to that in a minute. So I'll see. You can't just say, Are you deficient in anything? You have to test him for it. Um, is she home sick? Does he have a high workload again? Goes in beautifully with the stress one earlier, but it's a really important question. I'm going. No, she's fairly happy, You know, everything's going quite well for her, but again loving that you guys have gone that way. I think it's I think it's a sign of the times, in a way, I think people who might even in my don't think so much that way. But think more than a couple years ahead of us and so on. Uh, does she have any headaches or any other symptoms? Ah, no. Just just a bit of muscle ache sometimes. Like her body feels a bit heavy. Um, yeah. Game. So what? I found the chat now as well. Get hey, gained or lost weight expectedly know, Uh, maybe lost a little bit of weight, but not a lot. What's your sleep? Like? Sleep has been good. What's that? Personal life like And also, uh, what's the balance between study and socializing? She barely have a studies because she's the first year student on Yes, and not too much work there. Yeah, lots of social life. So, you know, I think that's a really great it's in there, so I think they're really good questions. So here, with the questions I sort of came up with. So the lifestyle changes in lifestyle other than fatigue, any other changes? Um, any other health problems? I think people have mentioned all of these has her mood. I'm really glad some people mentioned things like this. How the periods been really glad that came up and had diet. You know, I think you guys really covered all the ones I wanted to point out there, Josh, Anywhere things you think of that I missed on this leg question list. Uh, so I think the fact that it makes just have to think is probably know or nothing, very obvious. He's gonna know. It's so weird about how your adrenal glands, the one that put on there is weight, which you're starting in a way, and then also things like heath and cold intolerance. Mmm. That's not working. How have you been feeling You cold all the time. But I think, yeah, for the most part. Well done, goes covered everything I can think of there. So some tests. Basic tests, normal observations. S So you're normal observations of things that your heart rate, your breathing rate, your BP, your blood sugar on your oxygen saturations that how much oxygen is in your blood? Because this is an important test to do more or less every patient. Really. Most patients need a set of observations just to see if there's anything out normal with this patient. Like I said, particular temperature is just feverish. Maybe she's got infection. She got the low temperature that could lead to conclusions. If her BP is particularly low, that could make you really tired. So if you're not having enough fluids or for some other reason, is keeping yourself a very low BP on blood sugar could be that she's just not eating enough. And so she's having like very low blood sugar makes you very tired. Or she could have had undiagnosed diabetes and have very high blood sugar for a long time. And that could make you quite tired. After a while in blood tests, I put here the HBA one C test. This is what you This is basically a more long term test of blood sugar. So if you do a blood sugar test that tells me what your sugar is now the HBA one c tells me sort of what your sugars have been doing over the past couple of months basically works on how much sugar is bound to your red blood cells. That's a very basic way of explaining it but it's the way I try to remember. Fire instruction. Josh mentioned fibroid in terms of hot and cold firewood function. If you got hyperthyroidism, you tend to have a lot of energy and burn off quite quickly. But hypo, you can end up very tired. Um, and then a full blood cramp blood count, including what's called hematocrit, which is for anemia. So hematocrit is basically looking at how much iron is in your blood and a full blood count. We'll look at how much blood is in your blood. But if we have any blood, how many red blood cells are in amount of your blood? Um, and this is what you do to test if someone had anemia. So, differential, listen to point where I want you guys to begin telling me all the many wonderful diseases you think is going on. Oh, going on. Sorry. Um, so please far away many, many diseases. I know. We had a couple earlier on, um, suggestions of Emmy. We had suggested to anemia earlier. So what else we got? I noticed the other good questions. They're weight loss, hydration. Um, anything that makes it relieve her symptoms and just see, what about yet all really good questions? Actually, there is. Well, um well, worth asking, but so what do we think might be wrong with our young Maria who follows L A C E v a. Uh, we got diabetes. Diabetes? Yeah. I could go in there hot. Very fire. It is, um, diabetes again. Yeah, we got some nice interpret things. I think people have been listening to music relaxed couple weeks ago. Uh, BP, BP. She could have low BP. She's a young female. That's not unusual. Glandular fever. But that's a very good one. All were like that. Yes. Lunch or fever makes young people particular university very, very tired. It's very clear. Diabetes again. More diabetes. Um, I do like a good diabetes. Um, any more give, you know, like, 20 seconds to see if any more trick trickle through. I should have made a way to, like, record. What's on this differential? That's silly of May. Um, but, you know, I think glands are very interesting one to have on there. I think if we did normal sort of observations and her temperature was quite high, I think Blanche Laffite was a very good potential B 12 deficiency. Okay, again, that's a That's a sort of anemia. Leads to an anemia, so yeah, no. Good. All right, let's go on to my next one. So, uh, this light is going to confuse many people. I've basically picked out a blood. I don't know what else to call it. The print out someone's blood test results on. We're just going to sort of go through this a little bit in this particular case. So let's say, with Maria, we'd send off some blood. We tested for anemia and it comes back with, as is displayed on the sort of left hand side of the screen. So her white blood cells are normal. That's what WBC stands for. White blood cells on the normal. Certainly she's unlikely to have some sort of infection. Also rules. Outset, cats. What doesn't rule out that decreases your risk of cancers? Uh, her red blood cells. There are still a fair few of thumb. She's still got a good amount of red blood cells, but her hemoglobin is low and her hematocrit is low, not hugely low, not like terrifyingly in her boots. But there is a a low amount of thumb, which on then there's MCV, which I think it's mean. It's like mean cellular volume. And that is like the average size of each red blood cell and M. C, H and MCHC. I can't remember what they stand for. Its mean cellular, especially how dispersed they are in a sample car over the exact wording, for it basically means like they're so he's got very small red blood cell, not small red blood cells. Red blood cells are kind of empty. They haven't got much iron, much he in them on. They're quite dispersed because they they're there. Yeah, that little bit smaller. Um, And so in her case, if we look here at a describing up normal blood results in adults, what we're looking at is that she's got a low hemoglobin, which suggests iron deficiency, anemia and a low MCV mean corpuscular volume. So a slow as well below the 80. So that means suggestive that she's got small red blood cells and lack of iron, so she's probably got some sort of iron deficiency anemia on Then this hand here is basically describing how hematic it sort of works is not a very good way. It's the old way of working it out. Um, and it's basically involved taking blood and put again a centrifuge as spitting it because all the really heavy red blood cells fall to the bottom and ALS the plasma sticks to the top. And then all the white blood cells will end up halfway in between because they're not very not very heavy compared to red blood cells on dust. Basically measuring how much of this is read. How much is plasma, which is mainly water and how much is white? And we don't tend to do it this way. So much nowadays in humans, although this is very common. And if you ever go to a vet clinic, you know your your dogs a bit sick on decide they're going to a test for anemia. They will do it this old fashioned way on. Have a centrifuge in another room somewhere to do it unless they're really fancy. So here's a breakdown of the bottom. It's of the anemic blood sample has very low, very, very small portion of red blood in the same volume overall of blood on then Polycythemia. They've got a lots of raise blood on not a lot of water left on the top. So in the case of our young Maria, she's a bit iron deficient. Um, so I don't know what the next one. That's next patient, especially just to conclude what's going on with Maria. So it's not uncommon for particularly fortunate for young females. They're quite good at losing. Losing a bit of there are another blood, but it's It's not uncommon for people who are having a change in lifestyle change in diet to end up being a little bit anemic and, in her case off. So she's come away from home. She's cooking for ourselves, having to subside, you know, provide for her own self on. It's unlikely that she's getting enough nourishment on, particularly things like I and I tend to come from things like leafy green vegetables on red meat. The most common ways to get hold of it off season of like beans and pulse is a swell, and they're they're smaller amounts and other sorts of food, Um, but something that young students, definitely people who haven't really cooked before, are very bad. Eating is green leafy vegetables, red meat, beans, and pulse. Is there things that people tend to just not cook? So, in this case, most likely Berea is diet doesn't really match her need. And she's got to try to just for that And a simple of wait for that for her would either be toe change her diet up, learn to cook a lot, potentially just to have some iron supplementation. Someone suggested B 12. It could also be a potential that she's not going to be 12. B 12 helps of iron absorption of fixation. Substantially some B 12 injections might help routes. Well, order some iron tablets. I think that just, you know, any other clinical investing clinical bit should add from Palm A rule, maybe some folate. Yeah, you do. B 12 folate. Um, do you said take three a one C barrier function liver function, cause why know, um, deep these knees have a look, uh, sodium. Potassium that could make a fire. And also, if she's got, like, a kidney, kidney infection or something. Yeah, but in terms of natural management, give us, um, folate. Give us, um, mine. Give us, um, b 12, maybe. Yeah. Figure out what? She's anemic and generally in young females. It's because of periods. Um, it might not be. Yes. You have a male that presents or older woman. Classically, you just assume they have a d. I bleed on, but immediately send them off for a colonoscopy and they scope to look at the stomach is Well, yeah. Yeah. What's the difference? Treat hemoglobin and hematocrit. So hemoglobin is off. It's the iron rich protein compound you have inside blood. It's where the iron in your blood is inside your red blood cells. It's what binds oxygen. Um, and hematocrit is like the measurement off that somatic written him. A global is a biological compound. Hematocrit is a sort of statistic measurement thing. Um, I don't know what the best work. There's another word for that car. What? It is No statistic. But it's, uh yeah, it's a number. Oh, yeah, that's the main difference There. Any other questions? Yeah. What is it that Yeah, just that one. Do a better answer for what matters. Criticize. Besides that, the percentage off bread read in blood simply what it is, it's the percent of your field blood that is red blood cells. But the way it kind of gives us from hemoglobin is your hematocrit is affected by the other things in your blood. So if you've got an infection going on, you got loads of white cells. Then you're gonna have more a higher percentage of white cells in the blood, so your hemoccult will decrease even though you've got the exact same amount of, if you're quite dehydrated, your hematocrit and come up because the amount of fluid will go down. It's a sort of a ratio game, but in a healthy individual with a bit of anemia, that hematocrit will come down good. Yeah, we have you on that one was Good question. So if we could ask them if not, we can move on to human number two. Uh, I'll read out human number two. If there's any more questions, feel free to just pop them in the shot. So you're a student on a night shift in accident and emergency. It's gotten to about four AM on a Saturday. You're about to go into a chocolate bar keyboard and you tired on Joseph has brought in. Joseph is a 28 year old man, and he's presenting following a full at home is flatmates. Heard him come home about Al before this. So about three. AM and came out to find him after those allowed crash in the kitchen, they find Josef lying on the floor. He was brought into any var ambulance who say they haven't been able to get very many details from the patient. He seems quite confused and isn't very clear in answering questions, and it's easily distracted. This is This is the first image that comes up when you Google drunk, drunk, 20 year old male on Google images. Yes, this is drunk 20 year old Joseph. So what do we want to ask you those if I don't leave it on this slide so you can see we've already put any alcohol consumption. I mean, I did say drunk 20 year old, nailed into yeah. Definitely won't ask you about alcohol consumption. Did you have a concussion? He could have a concussion. Is a very valid suggestion to pencil this crash walls. Uh, any physical sign of any head injury? Yeah, that's a good uh, yeah, I have a look. It's head touch. His head. Ultimately is not really answering questions, though. You're going to struggle to ask him. Does he had her on him for him to give you a right answer as he had any drugs? Drugs is a very good one to rule out, I think. Basically any patient appearing at four AM I think it's definitely worth ruling out. Intoxicants. Alcohol, drugs. Yeah. Has he got any medical conditions? For example, diabetes. Again. Really good. Especially good one. Actually, diabetes hypoglycemia could look a lot like being alcohol intoxicated because simply put you in a similar way. Your brain isn't functioning very well about a lot of sugar, so he's a very good one. Task on. Probably test. Do a blood sugar, see what his blood sugar level is If it's really low, that could be wise. Acting like like he might be intoxicated. Yeah, plastic. We we say as well. You kind of got a B C. The airways bring circulation. And then don't ever forget glucose. If your pft on his spring force of one Yeah, don't ever forget glucose because glucose, it can really bite you. If you do, forget it. You got people asking what he remembers. Kind of kind of the event. And then if, um there's anything quite itself from personal details. Yeah, so he's quite out of it. He's not really giving you much on a seven and a second to use. Have any trust, their answers? That's very good point. If he is making no sense, you can somewhat trusted. If he says it a couple of times and it sounds plausible, you can sort of trust it. But if he's saying, you know, I've got stomped on by an elephant, I'm starting to question things. Um, so you can also read the last for the the ambulance. Clear refs And what have they said? Yeah, and having discretion with, like, flatmates. So that's exactly what I was hoping I was going to see if one of the pop that in there basically this thing called a collateral history. So when we talked to a patient were taking history. What's happened in this incident? What happened with you before you know what happened? Your parents was happening in your life. Everything that everything we can about this person to make a picture. There's also thinking of collateral history, which is basically asking the same questions about that person to a different person. So If someone has a full, for example, in this case, you might ask someone who saw them fall and you try and find out what they know. That see how much it matches and try and fill in. Maybe there might be some gaps. You know, if you've collapsed, for example, that might be areas where you don't remember because you were unconscious, but someone else probably saw it. And comptel you, What happened when you're unconscious? That's called collateral history. So I think with some of this confused, some of this disoriented this unable to really give you good, clear answer. Actually, what the flatmates tell you is probably quite good information. Um, you know, do we know what he was up to tonight? You know? Where has he been? Why was he out this late? Does he normally drink? Does he normally take drugs? Does he? You know what happened when he came home? What's in the kitchen? How did you find him? This kind of stuff is really useful to get a flat maids, because if they say yeah, he's a bit of the lad. He goes out most nights, gets really wasted, takes a lot of ecstasy comes home, has a fight with the kitchen table every night. I think I figured out what he might have done tonight. Um, yeah, and then we got checked. People's check. People's on responses. A temperature? Yeah. Yeah, people's temperature. Brilliant. Uh, can he breathe? Okay, a very good question, I think, given the fact he's being brought in through accident Cincy, you do need to assess in the ABC format Josh described a minute ago. A is a rare Is his airway open? Is he keeping it open? If he's confused and floppy, he might not. You might keep closing it. You might keep it. Sort of slumping his head down. Uh, he might choke on, like, vomit or saliva or any other secretions. So that's important. And then is he breathing? Okay, Is his chest moving? You know, if he's awake and his talking is making noise still worth just double checking to make sure that his chest looks all right and there's actually breathing. But you can sort of rules out fairly quickly if he's, you know, awake and and making a move, making noises and stuff, um, and find a circulation. Is he Is he perfused does he look a human color? Has he gotten definitely pay a little grey or blue, just basically ruling these things out really quickly on a similar note. Contract is oxygen levels. Yeah, in case that low, it's a suggestion that it could be a minor heart attack. Sure, we'll keep that for a differential. In a minute on, someone suggested that we could do an MRI. Oh, okay, We'll talk about that basically now, but in a second, that's what we want to ask Joseph. Here was my main questions. How much alcohol have you had? Have a chokehold you have? Normally, it's because it says I drank a bottle of vodka. That's a bit different if he drinks a bottle of vodka every day, or if he's only drunk it for the first time ever tonight. How much is going to tolerate that alcohol? There is a lot. Have you used any other recreational substances? Drugs, whatever you want to call them you on any medication and have you taken it can be quite important because particularly people had a couple of drinks. Maybe they forgot to take their meds. Similarly, if he's on certain certain medications you might give the anxiety or the depression on Bix that with some alcohol, you could end up basically putting yourself into, like, a medical coma, which you don't really want. Basically, putting yourself end up very quickly. Sedating yourself during what happened this evening doesn't actually have any recollection. Is he going to give you a straight answer? Do you remember what happened when you fell on having head? So mostly things you guys have covered. But like I said, some of these I think you'd end up having to get the information from the fat for Ms Flatmates or his friends, Morgan from him. So good work on the questioning. So, differential, let's have some of your potential diagnoses here. Then what we think happened to it. Yes. And we have things like lower levels before we got someone to just in carbon monoxide poisoning left field. Okay, but in if he was kind of a student, or again slightly. But your student housing is great, especially if it's flat makes with similar symptoms. That would definitely if they're all saying they feel a bit woozy in a bit ill. That's if he's only just come home. I would be but confused because also, really, he's very bit outside, but again, if he's been in a really dodgy car also not that I've been some weird guarantee rave or something. It could be, I guess. Yeah. Yeah. So I suggested that we could do fast fast. So we look for strike. Yeah, definitely. Good. Very good. One to rule out, they might be having some sort of major neurological problem. Like a stroke. Yeah. Um, concussion again. The good thing to rule out some sort of, ah, neurological problem. Think people general going here with the Neurontin. Okay, a good differential. So sorry to give you a goal warning. We examined Joseph and we find these physical signs. So these the only signs at all so that, you know, we listen to his heart is that it's hard to listen to his abdomen. Nothing was barrel. We poke his bowel. Nothing going on there. The's four. Let three. So I'll see you before because one of them's on both knees. You got the damage to one arm on. This is meant with the top of someone's head. I think it is the top someone's head. What? What? What do we think may be going on here? So, you know, there's been a bit of a crash in this, uh, in the kitchen. We've had a couple more things saying kind of stroke. Could have taken alcohol or drugs. You know, I could have a low temperature. Could be hypoglycemic. Yeah. Someone suggesting cerebral Adina. Okay. Sure. This. Yeah. Okay, that I mean, it would it would call someone to be confused and wobbly. I mean, I think I would try and find out why they would have. That's a Dean Deemer is a symptom. If that makes sense that you find they've got fluid on the brain, it's not so much a diagnosis, you know, we figure out what's caused it to be the diagnosis. Yeah, sure. On the concussion Had a full Yeah, so he knows. Have this Full breezing a head injury, uh, fellas and his head on a knife. Yeah, I said that's a suggestion. His head broke his arm. Um, Could have been in a fight. Yeah, um, could have had the head injury, actually, before the fall. Yeah, I think that's a really good test. Actually, someone didn't. Uh yeah. So basically to talk through. We've got here. So the top right we haven't are the arm is showing a bit of bruising on the outside. Only on the one arm, though. But beneath that you've got some scraping and bruising on some knees, both knees. And then you've got this nice cut to the top of the head. Quite a long, white, decent laceration to the top of the head. So there's two sort suggestive that he's had a fall or that's just actually a fight. Could have could have caused these as well. But to me, these is not telling a picture of whatever's happened. What's hit the ground is his head are his knees and his arm there, that it's that sort of hit the ground or hit the other person there, the bits that has to stay in the damage on. To me, they're sort of suggests that he's had a full but actually probably tried to stop himself. He's put out his arm to land on. He's put out his needs to land on. He's not just fallen straight flat on his face. Kitchens could be quite busy. Areas. They could be lots of chairs. There could be lots of countertops, etcetera. It's quite easy to have try and stop yourself falling and still give yourself a good whack. Um, so in this particular case, I do like the idea of the fight. And I do also like the idea that potentially it could have happened before he had the fall. But we do know this crash. We've had the history. There is a crash when he got into the into the kitchen, so I would be thinking these bruises particularly. They're quite fresh. They're just coming up when he comes to any I think would be suggested there. Probably sustained as he did the fall, you know, maybe is whacked his arm on the surface, trying to catch himself back his knees on the ground on bobbley cut his head open, although again actually would be really interesting to take their Yeah, it would be interesting if if they say, there's loads of blood on the floor in the kitchen. Particular, like maybe a sharp surface like the edge of a countertop or a table. I think that would be more suggestive. This injury happened in the kitchen, but if there's that yet, there's no blood anywhere Maybe it did happen before we got there. That's a really interesting point I never really fought about. So yeah, it's nicely bruised up. Joseph. He's had this fall and he's got this nice cut to his head, Um, in the history, Let's they say that the flatmates say it's gone now he's going out for a friend's birthday and the night we know he's had a bit to drink. You can talk to him and you can smell the alcohol is breath. So he's definitely had some intoxication from alcohol on. He's come home he's had this fall. We could see this sort of damage going on this, this laceration also, we don't know when it happened, but we do know it has happened. I don't so this particular instance a lot of the signs you can get from something like a concussion or another sort of head injury and injury to the to the brain. We'll make someone appears though they are intoxicated, which makes it very difficult to know what is the alcohol and what is the injury to the head. What is causing what So this particular incident someone said MRI MRI was so close, you got the right idea. Wrong scanner. Um, in this particular instance, it is probably best practice to stick them in a C T scanner on. Have a look at what's going on with their brain just to try and make sure there's no actual sort of bleeds underneath the scout underneath the skull or anything. That's probably going off there. So here asked, Um, MRI heads on. I'm just going quickly. Talk through these. Are there any questions at the moment? Josh. No questions. Excellent. So let's look at some nice CT heads. These with probably what I think These are probably the majority of ones I've ever had to worry about, certainly in terms of of units of this stage. So the top left here. We've got a normal CT head on for the purpose of the night. Would say, This is what Josephs one looks like he come. You have a sticker on the CT scan to get him out, and you can see here the skulls mostly intact. It's a nice white skull. CT's tend to come out this way with nice white bones because they basically that they block more of the X ray material on then a rich you can see right at the top of it, like all around it actually causes a roll around his head, obviously. But also there's like Blobel at the top here in the middle of the bone is actually part of his nose. Probably one of the Sinuses in his in his face. Um on that's Eircom sound nice and black on. Then bone and metal would come out nice and white really, really white as anything in between will come out sort of shades of grey so dark agree would be mawr be less dense and closer to white will be more dense So you can see here this, like nice pattern and his case his head looks this day it's not good on optically shot these two white hot spots on this one. They are very, very white. I'm wondering if it's just a a level where we're starting to see some bone beneath the brain. But just from your drawers, there better. It's probably calcification within a start vessel. All right? Sure, sure. So we got vascular disease in this one, then, um, yeah, fair enough. So we'll move across first with sub arachnoid bleed itself. So you've got the bones again, and then we're seeing lots of this sort of white infiltrate all throughout the brain on blood is full of metal. We talked about it earlier around. It's full of iron and heme. So actually, blood shows up quite a lot more glowy in the soft tissues around it. So this particular individual is having a lot of bleeding, which looks like it's inside the brain. But actually it's probably in the Iraq noid layer. So the Iraq noid layer is an area that looks like spider webs. We're going to talk a little about meninges in a minute. Yes, you're getting the subject with bleeding, which was seeing infiltrate the brain, that I'll explain why, in a little bit below that we had a subdural bleed and what you need to look for here. I think if you could see in my mouth, you can see it is this sort of pale a patch here. So basically, this is bleeding that is pushing the jurors matter away from the skull. Ah, on impacting on the brain, says Person could have a hell of a headache and be quite confused. Now we have an epidural bleed. So a bleed around the juror, which causes this what's called a lemon shape on this is basically because the juror is very, very tough. It doesn't like to peel away from the skull on. So in this particular instance, where it's, ah, bleeding and causing it to come away, it becomes a lemon shape because it's it's very much fixed at the top on the bottom. And so the blood is pushing. It's far away that can to fill more space with blood. And it sort of holding on for dear life. I rent says epidural that surrounds the juror subdural below the jurors. So this is bleeding between the juror and the PM matter and then the Iraq noid. This is below the Iraq. No matter. Um, so here are the layers off our meningitis, basically. So this is basically what you'd get if you started slicing through the top of someone's head on your very delicate to look up all the different layers. So you have scalp like it ain't all the skin that is the hair follicles. That's the bit you can see below that we have skull. Below that we have the jury Martha or least the layer of your, um, art to that is next to the skull. Normally, that is very much fixed to the skull is very difficult to get off. It's very thin and shiny and very hard to peel. So takes a lot of pressure and a lot of bleeding to get that off. You then have the meningioma, your, um, art of the other jurors. Marta. They have a layer of it. They're normally very much stuck together, so they don't like to come away. Below that, we have the Iraq, not a martyr, which is called so because it's a bit spider e. So it it creates this sort of spidery filament e fiber area beneath it here between it and the PR Marta. This is called the summer. Ignore it space. This is normally got fluid in it. It's full of cerebral spinal fluid, and it's basically but a bit like a way of holding your brain in place. The PMR toe sticks to the brain on is effectively the outer layer of the brain protects it on basically that between that and subdirectories space, it gives you a bit of space, so your brain can have a little bit of expansion. Not a lot, but a little bit. And it's not. Shake your head around a lot. It's a hold your brain in the middle and doesn't allow it. Sort of go wobbly. Um, and I explained that beautifully there, Josh. But if you've got a better explanation for them, but go for it No, it's not all right enough. So if we take that back here, so what? We're seeing the suburb acknowledge bleeding, Actually, although it goes all around the brain, the Iraq, no matter also can go a little bit into what's called the fish is which are basically between the hemispheres. So we're seeing a little bit this bleeding in between the two hemispheres. Here I was seeing a bit on the edge here, which is actually just probably because the Iraqi matter goes all over the brain and not just on, So it's like on top of the brain as well as in the brain. The subdural bleed, if you see where our juror matter is a subdural bleed, is probably been. It was beneath the jury martyr on. It's basically trying to peel this away and the epidural bleed is around the jury, Mattis. And normally I believe in the middle layers between these two and spectrin appeal these two very tough layers away from one another in scraping this lemon shape here. This person has a weird bump on the side that had here from swelling external to the skull. So they probably did a nasty head injury. Uh, purposes of this evening are lovely. Joseph. He's had a lot of alcohol. He's had a whack on the head, but his brain is in beautiful working condition. Now that he's got some calcifications, he's got some sort of vascular disease, but that's no problem. For now. If we're working in 80 that's the problem. Some other doctor some other time. So the last thing I want to talk about with Joseph and that is the types of wound. So what we saw with him, he has this nice sort of straight line laceration. Style wounds is quite straight, but the edges are perfect there bit rough. This not been. It's clearly not been done deliberately, sort of professionally, you know, maybe with scalpel or something. So it's good roughage. That's a laceration. And so if we could see here. This goes through the epidemics, the outer layer of the skin and into the dumbest, the deeper layer of the skin, obviously, and get incisions and lacerations that go full thickness and go through the derm it into the underlying tissues. That's not quite deep, but in this case yet, so that's what I laceration probably would look like. Is this middle one In the case of Josephs one. If we look here particularly, it doesn't look great, is quite parted. I think probably he would warrant a little bit of glue that's We could put in some some wound glue into this and then hold it together on the left jaw. Should come up with anything alternative. I think the rule is basically never stick your head. Yeah, we'll be working up. Yeah, I think it looks like a nice glue job. You can't really stereo. Your main options are stitches, soup, sugars, staples, which are basically stables like you put paper together with glue, which basically forms an artificial clock and helps it bind together quite well. And as it dries, it pulls it together better, Um, or Steri strips, which are basically like little plasters that will pull it tight. But promise I'll see when's is really hairy. We're gonna have you ever shave the loss of his head. Just put Steri strips on. I think blue, probably with the best bet for him to get that nice and fixed on, then some sort of dressing over the top to hold it in place. Go for a couple of ones. Incisions that tends to be more deliberate off, so you can make an incision type wound. If you like. You cut yourself or knife. Paper cuts could be incisions. They're really uncomfortable. But this is sort of very straight, very clean edged, often quite deep. Wound lacerations. The ages tend to be a bit rougher, used to be more accidental these years of accidental cuts. Um, abrasion is effectively a serious of small lacerations, but they don't go through the epidemics. You could get some deep abrasions that maybe do go a little bit into the dermis, but they tend to be more superficial, more mawr more shallow than a laceration. You have a puncture wound that's basically just something so thin and point he has gone in a penetration wound means it's gone all the way through the skin into the tissue below. So that could be into a muscle or into depending What part of the body you're at. It could be into the muscle. It could be into a bone if it's in the hand. For example, Not very nice. You have a contusion. A contusion is basically sort of a minor bruising going on normally in the uppermost layers, sort of in the epidemics a little bit into the dermis versus the hemotomas. This is a much bigger set of bruising. A much bigger believes. Lots of blood trapped between the epidemics and into the dermis. So basically, you've got sort of with all of them a little bit. You got a contusion is a minor bruise. Human Toma. Massive bruise Puncture wound is a little bit. It's going so thin and shot that's stuck in a little bit. Penetration is stuck in a whole lot. Incision is a good clean cut laceration, a less clean cut on abrasion of a kind of superficial, not very deep Siris of sort of cuts. Basically craze syriza, grazes maybe, Um, definitely that quite well, Josh or any of them you say custody better after yet, but works a decision. Is hot ically a surgical thing as well, so you must have pulled something. But you can also do a kitchen knife. You know, if you're if you're you slip off your cutting something. That's a nice, sharp edge that could make like a good incision wound. Where do you call the incisional? Laceration, I think, is up to the individual. But I would say if it's got nice, clean edges and it's very easy to close, I think I'd call it last on incision. Still, rather than laceration beer that's lots of different types of wound thinking about that and then taking it back to our chapter. Joseph, I would say it's the laceration. I'd say it's a decent sort of depth laceration, and he probably needs a bit of glued to close it, Um, in terms of these ones, in terms of closure, an incision is a very good candidate for surgical staples. It's got nice, smooth edges. You can push it together and staple it. They can also be if it's not very deep. It can also be quite good. One of Steri strips just hold it together. Laceration is a bit more complicated than normal. Bit more torture. It's a bit more tangling again. A nice clean, so it's fairly straight line. One could have staples used, more likely will need suture ing could be glued is another good one Or again. Could be Steristripped abrasions thing to be not so deep, so they don't tend to need a much closure, but again, a bit blue. But because of the really rough edges, you're unlikely to get a staple in there, so you're more likely to need the suture. If it is a very deep bit of abrasion puncture wounds, you take it out, see what the whole is like attention. You might put a suit urine, but actually the initial point of entry is quite thin. So doesn't always need external closure. But some of these you sometimes need to make the incision wider in order to get deeper to repair the deep tissues. So what's beneath the skin? What what's in the Dervis before you can close the top? Because I was, you end up just leaving a lot of damage underneath the skin and just covering it up and then contusion hematoma, and you wait to be re absorbed unless they have really severe. If you have really severe hemotomas, sometimes you might puncture it with a needle or something and let out in the blood. Um, it is causing pressure, causing the problems further down stream. That's all clear. We got any questions on any of those. It's this little question on Emery's on, which was, Why wouldn't you do an MRI first brought the sun. CT is quicker. CT is less terrifying is a big one. The machines shaped like a donut, not like a massive tunnel. Patients tend to prefer to sit in them or a CT to memory. MRI's take a lot longer. They tend to be a lot more expensive in emergency. Situation of CT tends to be a lot more effective in that sense, and actually what you're looking at, uh, a CT gives you as much detail. If no, yeah, it gives you more than enough detail. MRI's. If you're looking for very finite small amounts of soft tissue damage of brilliant, you can MRI the whole brain and scroll through it, looking for small like tumors or lesions or little bleeds really, really effective. Really beautiful. If you're just looking to see right? Is it damaged? Is the whole structure of the brain smashed up? Is there like a big load of pressure on it? Is the bone broken? This kind of thing? A CT is brilliant and it's so much quicker and it just it's so much easier to read an MRI. You probably need to go and get a fairly professional someone who does a lot of imaging. So, radiologist, to have a look for an MRI and talk about it and figure out what's going on the CT. I think most any doctors would probably have to look a CT and go yet looks good. I know I've got no problems with that. When we go, um, is there any other bits you think of Josh? That would differentiate them? I think also. Then you've got the time the patient actually has to stay still for so if they're kind of agitated, um, they're not going to stay still for the 2025 minutes that an MRI brain takes. I may have to be that dead still. Otherwise, you just capillary image where the CT they just passed through the doughnut once on. But that's gone. They're getting to be still for, like, five times. Seconds. Yeah, much quicker. And also just the waiting. Like if you're gonna wait if you're gonna in emergency MRI? No, A lot of places keeping memory warm. They have to leave it on. It takes a while to warm up. So you could be waiting a couple of hours just for the MRI machine to get ready CT scan that you can only turn on. It's about 2025 minutes before you can stick home for it. Uh, you know, also, then you've got the availability as well, because I'm all right. Take a just. That's quite a weight for an MRI where CT is really, really quick to get on. You could bump people that, uh, think you but the certain conditions like, uh, cord recliner, which is essentially spinal cord compression, don't get an MRI within 24 hours, because a CT is not very helpful. Um, and they just get down to the top of the key, but still top of the killer's within 24 hours. There's still quite a delay. Yeah, So we're not saying that CT is always better than MRI. But we're saying that for this particular incidence in this particular setting circumstances, CT is at least as effective, if not a little bit better. But it is so much quicker is so much easier to get hold off and it's so much easier to understand and report on and feed back to your patient. CT can be brilliant Why City still exists like it's an older tool. MRI's more modern, but actually CT is just It has so many benefits that we're never gonna get rid of them. We're gonna keep both, um, just before we move on to case number three in case anyone needs disappear. I've just shared the feedback form in the checks. If anyone wants to give feedback, please do it. Take a hold of certificate for attendance of you on that. But we do really appreciate the feedback. It's how we sort of try to improve. It's a serious is how we improve. His teachers on it just really, really do appreciate it. Obviously, you can fill out the end of the session, but if you need to run off early, it's there for you. Uh, so we're gonna put in the chat? Um I'm also gonna put in a trap the guidelines that we used to decide whether to give someone a CT head or not in a head injury. I don't have anyone is interested. Please do have a look. To be honest, I probably need to remember the more than I do. Mine is normally go for Are they like, immediately ill? And do I want to see what's going on in their brain? But the April is far more finite, formal fiddly than that bump See, being a student, I just got to go. I would like to do this and ask the doctor if they say yes. Then I went so very into case number three on the cell phone in case for the evening. So I think we're running quite well on time, actually doing about half of our case. Not that so you're a student with an at home care team, so going into people's homes to give them medical care and investing. Sandra, this is Sondra. That surgery is a 68 year old woman. She lives alone in assisted comment, assisted accommodation because of her severe COPD. We're going talk about COPD in a minute Normally she's able to get around the house without any oxygen, but she takes it with her when she's sleeping and she just takes it. She's going out. Sandra's says that she's been particularly breathless over the last few days. She struggled to do her daily activities, such as cooking and cleaning. You arrive. She looks quite disheveled, so she's sort of messy. Her hair's a mess of clothes. Don't look very tired. You're clean on. She smells that she hasn't had a proper wash for a couple of days. It's not in a great way, just also assistant. Accommodation normally means a sort of housing where that is normally all on one floor, so there's not normally stairs, and normally there's like a warden. So if someone who comes in checks on you each day, or if you've got if you have a fall or some of that, there's a button you compress for them to come and check up on you. So sort of know, quite a care home is in. There's not people that have like taking active care of you, but there are people there keeping an eye on you. This is describing COPD, just floating out aware of it, and it's effectively the disease caused predominantly by smoking, so it causes chronic bronchitis. So this means that the airways become really inflamed. So the actual point the actual area through which aired transfers becomes much more narrowed. There's a lot of mucus here, and it becomes very difficult to get a through them alongside emphysema, which means that the alveoli the the, uh, the little bundles of sacs that absorb oxygen and release carbon but exchange oxygen and carbon between the blood on the air that come to graded. They've come rough. They become less permeable, they become worse than their job, and they're also less able to fully close. So they're not. They're not pushing all of the air out there, sort of pushing a bit out, basically virus efficient at their job on a low. This together makes basically, really poor quality. Lungs gives people always. It can cause weight loss because you're putting a lot more effort into breathing and you're not getting enough oxygen Course. It's always sort of short of breath. Chronic dyspenea means always a bit short of breath, or having problems with breathing can cause the bring up sputum because of this excess mucus in the bronchi on it cause you to feel quite tight chested because your breathing is pretty poor. That's chronic obstructive pulmonary disease in Know? In a nutshell. COPD for short. So that's what she's got previously. That's why she's living in this flat on her own. What we want to ask Sandra if he's particularly short of breath recently, like Josh to tell me if anyone said anything. It's a water class, right? Is dying. You got three people that said, mental health and stress, I suppose. Yeah, cause, um, if you're getting that panic, maybe she might be a bit shorter of breath. But ultimately issues they sort of the Chevelles not really able to do her normal daily activities. I don't think there's more something physical stopping her. Generally particularly older people will stop it. Nothing to do their know to stay independent and do the things they need to do. Um, so I would probably an hour away from it, but yeah, I could see where you're coming from. Any change to the carrots routine? Oh, beautifully. Interesting question there. Uh, no, I don't think so. I think the parents are the same. They're still checking on her once a day. It's not checked on her in the morning, which which you got up here on the evening nature, which is going to bed, all right. They don't really care so much as you know. They might be a bit of tiding. A bit of cleaning might help her do a shopping, but they don't really like come in and take active care off her. There's always a good thing to think about safeguarding off that, Yeah, what what is happening is really good question. You know, what is that That goes along side? That is also who's at home. So, you know, are they living with issue dealing with husband or wife or some of some form partner for her Children? Does she live with friends that who who's at home with her issue on my own and who is helping her do with her daily activities? You know, normally, you know if she isn't able to wash regularly anyway. But now her son's moved away. Maybe it's even harder, so, yeah, I think there's a really, really useful points in there. We've got a King is in her diet or activity and along the same lines. Has she eaten something that could have caused some of her symptoms? A good question Again. Change in diet or activity. I mean, the last couple days since she's been feeling rough, he hasn't really eaten. Uh, doesn't really done anything. But before she began feeling rough? No, nothing particularly weird. Like, 45 days ago. She was still going the shops. She was still, uh, going down the pub. Checked your mates? Yeah. Could she also be asthmatic? So a lot of people with COPD will have asthma sort of symptoms. Um, I think some of them even get asked more taxed on the job. Know? Essentially, Yeah. You can get a bit of a combined thing. Yeah. So she probably is a bit asthmatic. Yeah, probably a bit. Um, but she's not having an acute asthma attack. She's She's taken the medication. She's only given she's got, like, a couple of inhalers and things like that that she's normally got for the sort of combined effect of the COPD with the asthma. Um, that's just taking them. They haven't changed anything. Um, has she been using her? Oxygen is normal. what her sounds like. Are they normal for her? Really Good question. Well, come on to that in a minute. But yeah, she has been using your oxygen as normal, but we'll talk a bit more about saturations in a second on a stimulant. Know what's what's the BP like again? We'll come onto in a second. And also does she have a temperature? What's that? Used to school a lot. Brilliant. Yes. Well, come on to these in a minute. Yes, Loving it. Has. He stopped smoking if Law. So how long ago did she stop? That's a great question. Yeah, the house smoke. Does she still smoke? What goes on with the smoking? Yeah. What does she smoke is another. Good question, actually. Does she smoke tobacco? Does she smoke cannabis? Yeah. Any allergies on medication? Uh, lots of COPD meds is on the nebulizer. She's on a couple of things. Help thin her mucus, secretions, that kind of stuff. Um, no allergies that we know off know if she knows of that. Least she normally able to wash itself Is she eating, drinking, hydrating and sleeping properly. Really? In questions, but in questions? Yes. The rest assume she can watch yourself. Normally, she's fairly able to deal with the normal daily activities. She's just a bit short of breath when she does a bit too much. But if he also what she done in the last few days, sit on the sofa with that since she's been ill, also has really done it. Sit on the sofa. She hasn't had to get to bed. She's basically been living on the sofa. Just about able to go the bathroom like you. Just about get the energy to get to the bathroom and back. But no, really, no, really, up to much. And then does she have a carbon monoxide? My house? I love to come, but oxide or it? Yes, let's go the other way. She hasn't got gas. He's only got nitric going electric immersion, heater know gas in the house at all Electric hub. All of its electric is all very, very important because this assisted a combination. Um, good question. I don't think you know about that the box. But if you hear anything normally any pain or any increased frequency love it, love it. Yeah, you're in attractive urinary tract symptoms, particularly older women 68 isn't particularly old. Obviously, she's a bit she seems a bit older than she is because of this COPD. The smoking problems. But, you know, really, really good urine attractive infections can cause it can really, really wipe out, uh, particular frailer people. So younger Children, older, younger Children and older people not see, she's got previous history things that COPD Yeah, you're only trace infection is doing really useful to mention what you know, the rule out. So you have really good question that, um here are the questions I came up with for her. How's she been bringing up any sputum? Normally is people with COPD might bring up a little bit pale, clear sputum. Um, so she has been bringing it up. What color is it? What does it look like? How is she other than the breathlessness like that, I think Yeah. Does she have any urinary symptoms? Spot on what? The question was came up there. A change in bowel habit. Has she suddenly have diarrhea? Has she been very constipated? Because again, this consult of tie in ti make her more tired than usual. Um, does she smoke how she smoked How often does she smoke? Um, with COPD? Probability is that she has smoked. Probability is she smoked quite a bit and tends to be people who got COPD still smoke. It's very hard to give up when you get to the point. We've damage yourself that much. If you start to have a little bit damaged, you didn't give up. It's unlikely you'll give up, you know later, um, were saying that you can have you know, COPD style symptoms from other things. You can get things like dust inhalation. You can get things like asbestos inhalation that can cause not necessarily the same but similar presenting conditions. So it could be that she never smoked. Could be. She's got some other problem I've met Load had COPD. You never smoked before because actually inhaled some toxic fumes. They were working and they got exposed to some nasty, nasty. A karma is that he wants some nasty gas. Is that the the lining of the lungs and cause them to develop COPD so you can get people who have never smoked? But it is is rare, Um, and in this case, you know, she's saying she's still smoking. She's still smoking 20 a day. Down from one point was that 80 a day? Like she, she was a very heavy smoker. Now, much less but still lots. This thing called pack years. It's basically working out how much someone has smoked in Total. It's basically taking the assumption of how many packets of cigarettes they smoke per day supply by the number of years they've smoked. Um, so if they smoke 20 cigarettes a day, well, that's a pack of 20 a day. I think this practice 20 isn't it? In my Paxil 10. Josh 10 or 20? I think it's 20 especially how many cigarettes they smoke a day. If they say 10, well, that's half the half a pack year for every year they smoked. If they say 20 a day, that's one pack year. Every year they smoked on. But they say I smoked for 20 years. For example, is the 20 cigarettes a day for 20 years? They have 20 pack years, and you could sort of work out this the severity of damage they probably have done based on that. If they have three or four pack years, that's a lot less than 130 pack years. We worked out the other day that one of the actresses off extenders who thinks now retired, I think she had something like 100 80 pack years behind her. So she smoked awful lots, and she was quite young. I did not badly. Um, I think under 80 is the most I've ever come across. Now. That was the standards actress that we were working out for a scenario. Um, I don't know. Just you come across someone, not the late hundreds. Ah, seen 210. Yikes. That's a look, because that was that. That works out. Children. 10. Would I would be the smoked a packet a day for 100 years or they smoked, you know, getting over, like, 10 packets a day for 10 years. You know, that's that's not great. Yeah, it's about 3 to 4 packets a day for about 60 years. Middle ground that awful on. Imagine their levels were not base about up when they're not lungs. The yeah, no great Germany chest pain, really a port to ask because actually, she's having something like heart failure that can cause that have fluid buildup on the lungs and the very breathless all the other side You're having acute heart problem and we have a great car like failure associated with that. But they went to she last see her doctor when she last. He has COPD team or COPD nurse. Um, normally, if you diagnose is that if you're having oxygen at home, you're under someone who will be managing that. So that's over a team managing a COPD or it might be a GP. So when did you last see them? How they monitored? Have they checked how her COPD is progressing? Is it getting worse? Are these last couple of days a sign that has COPD has just been progressing? Two appointments. It's more severe. Ticket. She doesn't give it up. Smoking it can. It can just get worse. Well, it's worth considering how she got any family nearby. Other people checking in on her looking after. Has she got any pets? Is there anything in the house that she might be tripping over allergic to anything like this? What? What is the house like? As I said, if it's if it's assisted accommodation, it's normally gonna be a single story. So one floor, no stairs and then normally come by and check to make sure it's all semi tight and ovary cluttered. But if she's living on her own, it could be that she's in the whole family home. She's got, you know, Stairs, bedrooms are upstairs, the place, an absolute mess or she's a you know, kept a lot of nonsense. Um, so it can. It's worth, figure out what she's living in. How is she going to get food? Does she cook for ourselves to do her and shopping? Does someone do that for her? Does she have any support at home to someone come in to help her wash and clean? Does they do come and have a cook? Um on how does she get to the bathroom? And is she doing it safe? If you're just getting up and walking, which is not very easy on the feet, she could have a fall and do herself some damage all the other side around if you can't get to the bathroom and no one's coming to check on her for the majority of the day. If he was to have an accident right after the warden checks in other in the morning is any We're gonna look at her and tell the warden comes back in the evening. That can cause problems and infections and other horrible things besides just being not very nice for the full woman. Some tests. So some basic tests, Obviously the basic observations. I can't stress these enough should be doing that. Almost everyone, um her pulse blood Her saturations, I think really important for her. With COPD people, saturations will be less like their baseline saturations. So a normal individual, it'll be sort of 94 95 or above eso with COPD, we sometimes that target 88 to 92 so it's probably notably lower. But actually, if people have long standing COPD and they've been tested, they might know their oxygen saturations are even lower than that. I don't expect them hopefully to have a bit of paper with that on it or a card or something. But I mean, I said someone who said that the rocks from saturations were somewhere between 78 80 as standard, and that's because of the COPD, so they can get really quite low, the the point where you'd be really worried about it in anyone else, but they're so used to it and so chronic and set in that this is just they're normal blood, sugar, respirator. How much is she breathing? Very good Monitor for how? How sick someone is peak flow. Peak flow. People might say it. It's like a little tube that you blow into as hard as you can, and it sort of measures how quickly you can expel a recipe. You got really good set of lungs. You can blow it really quickly and get a lot of air out really quickly. You get a really high school. If somebody's got some in my asthma or COPD we use. This is a monitor how their lungs are working. It's not having an asthma attack. Their their peak flow will be much lower than it is usually on. Then you give them their medication. It should go back up again. So it's a really good monitor. Your hospital. What if we take this person hospital? I think we probably should given if she's been in this little unkempt. We need to probably get it looked at in any in hospital they might do. Think you not hear a blood gas. This is similar to the blood test, we told you earlier, except it's from an artery rather than a vein and involves basically taking a little sharp needle. Attach the syringe and stabbing them normally in the radio after the one on your wrist. Although I have seen break your artery, the one you're on the inside your elbow and I have seen one on the back of the Theanine. Kel, stab it in, get blood straight from an artery. This gives you some of what is going on in the blood that's being pushed around the freshest of the blood, and we check that and see what's going on there that will tell you sort of how they're oxygen's been behaving and how they're compensating for it, what they're doing to balance it out. The chest X ray look through the chest. You can see if there's any damage to the lining of the lungs, for example, or you can actually see cloudiness, perhaps on the X ray, to see what's going on there on sputum cultures that she's bringing up sputum. She's bringing up mucus, get a part of it, send it to a lab see what might be growing in it to see if there's any infection in there. Um, differential. What we think might be wrong with her any any ideas? What what's making her less breath more breathless this time around? One suggestion, which is that he could have, like a chest infection or pneumonia on top of that COPD. Yeah, that's the good, very, very good suggestion. Yeah, it could be an infection. Patients with COPD because they're long support. They are really susceptible to like getting stuff in them so they can get infections really easily. They're just not pushing out the air. They're not pushing out the gunk on there really good. They're really good at picking up just infections. That's a really good suggestion. Um, I just looked on the chat test. Her memory? Yeah. I mean, ultimately, 68 would be think. It's just quite young to be getting a memory trouble, but you're right. I think if he was in hospital, it might be worth just having a chat with her. See what she's like memory wise. And if you're a bit worried, you could do a thing called a marker. This is like a basic test re to paper. Seeing how well people's column it'd function have good people come to function is it's your ability to, like, remember certain words. Remember what certain animals are. Draw certain shapes. And it's a really effective tool for just screening people for things that dementia or early onset dementia. I wouldn't necessarily say that this woman warrants it. She seems to be just having problems with her breathing. Um, but, you know, if you were worried, if you're having a chat with her and she doesn't seem to remember where she lives, she sucks. Get confused. Yeah. Nice idea. Got suggestion that could be Koven or a bad cold. I always writes in the hose and forget over it exists. Yeah. No, it could become It could be a bad cold. Could be just a viral chest infection that obviously with bad lungs that could get worse, could be covered, covered. At the moment you're covered. Okay. It's coming down a little bit in the UK, but previously really common course of people have really nasty lung chest problems, so yeah, no. Definitely could be coated to do a covert test. Definitely worth doing. Every patient in a day is getting them in our moment anyway to make sure they're not spreading it. So, yeah, um, if there's no more suggestions Oh, show you out. Let's let's get to. So this is her check. Now. I don't expect anyone here to really know much about chest X rays, but if you have a look at that, any thoughts initially, just having a look at that it's where someone's gonna be really, really above and beyond. And something nailed the differential ascites. Okay, so ascites you wouldn't describe ascites in a chest in a lung like this. Ascites is basically build up of fluid, normal, tense happen around the midriff on It's basically just extra outside of tissue fluid on that's normally caused by something like liver failure. Because by heart failure, um, and it basically is like dullness if you begin to percuss it. So you know, ascites is a good word. But in this particular instance, not quite so he has got some cloudy against you could make a cloudy is a really good way to describe it, particularly if you look sort of at the bottom here on the bottom. Right there. Stephanie, if you look up here at the top left. There's sort of a nice, big sort of quite dark space is little bit up here is well and then down here at the bottom, sort of on the right hand side. It's kind of foggy and a little bit in the middle. And then a little bit in the bottom of the left. Yeah, was instant. It's also worth remembering right and left. So this is the patient is facing you with an X ray. So what's this might be the left hand side of the X ray. This is their right lung, and this is their left lung. So what suggested New York's so new before X would be Aaron's space between the lung and the pleura? The pleura tends to be in this nights off white space here. Ellipse. That's what I'm quick CNN that there's no new before X here. You noticed that from having over it's sort of a line between sort of lung and then just or potentially between that and then fluid here. If it's like a human for access, got blood in it, um or ah empyema, which is puss basically notice the difference between like the edge of where the chest is and the edge of where the lungs up here. That's an interesting point. Now, I think we should probably have some new before actually stuff in a later session later. Braised, um, someone said, Looks more sure hold in smaller than normal. Um, I wouldn't say necessarily. Does, um, I always looked like a pair of okay lungs. I wouldn't say These are the lungs, Some with COPD. I think you would expect them to be a bit sort of shrunken and shriveled up. It's always COPD. You're not really in this particular individual on, but we'll get the opposite. You can get it, but they don't look right. Do they look at massive and tripled? Really, rather than small tripled. Um, yeah. Um, So I'm talking about this chest x ray, though. Say bits. You're looking forward. A chest x ray. Obviously you're looking the best way to approach it. I've always been told it's a B C D. E, the same as we would for anything else. A airway. So you can just about see here this sort of dark shadow at the top, This is the trachea, and this comes down to this bifurcate. So splits into to go to each lung on Is that straight? Is it in the middle? Yeah. Looks good. That's a good sign that the airway is okay. Be breathing. We look at the lungs. So we're looking at the lung fields. Does it sort of expand all the way to the top and all the way to the bottom? Can we see clearly to the edge? Yeah, Just about. See clearly to the edge here, though. It does give it cloudy. We can't really see a middle edge. And it has got some fogginess in. It's there is something going on with these lungs. That c is circulation or cardiac. So that's looking at the heart. We can see the shadow of the heart here. The heart shouldn't be like two. Big issue and cover too much of this chest. Yeah, the heart looks in all right shape. We can see around the heart. It looks okay. The diaphragm. So the diaphragm is this bit of the bottom Here on. We could just see it. You can see the nice shape of it all the way across. Not too bad over here. Maybe a little bit foggy in the corner, but mostly the the diaphragm and e is everything else? Anything else? You seem weird on this x ray. So all the bones look okay. I can't see anything particularly abnormal on them. We're just seeing that sort of fuzziness really In this chest. This is what's weird. That's two. What is said to be a healthier chest X ray. Now, they're not perfect diet. They're not perfect comparisons. Um, on account of the fact that the level of exposure is a bit different, Meaning you're getting sort of a different level of refraction. But we look on this one on the left. I mean, you could see this beautiful die from here. Actually, both sides bit wonderful. But here we got a little bit of fogginess in the hilum. That's just basically, there's a lot of blood in that particular part of the lung, so you can see you can see it a bit more like this. And actually, this branching here is probably mostly the blood vessels going throughout the lung. But you could see lots of nice black space. That's where the air is. It's not making too much of a problem. I didn't realize this guy had something weird going on up here. I'm not sure what's going on there because that's definitely got cables, anyway. Um, but that's a nice set of lungs. And then you look on the other side here, and we've got farm or fogginess coming in the top and right down here in the bottom here, sort of cloudy, bit more hard to distinguish some of the features. And so that probably means there's some fluid going on in the lungs, which is normally a sign of some sort of infection. So this case, she probably has a chest infection and that suggested earlier, probably chest infection on top of her COPD people with COPD of really good at picking up chest infections. They're really good at getting sick with them, So in this case, she's probably got that it This is not very severe. In this X ray, I can find a more severe looking one, at least not very nice, more severe looking one. But yes, I think she needs probably some antibiotics and probably a bit of monitoring. If you're particularly sick, maybe a bit of monitoring hospital, if not probably going out going home with the antibiotics. But just maybe, with a review of what sort of care is in place for at home? Is someone coming in to actually sought out her house or just coming in to check that you're still alive? I think maybe it might be a time to step up that care. Maybe sounds coming in and tidying for a and maybe just make sure it's all right for a few days. Um, but, yes, the antibiotics actually clear up these lungs Thoughts there, Josh. Yeah, you think steroids? It's just a Make it feel a bit better. Um, yeah, someone's ask. What's the difference between a chest infection on pneumonia? There is no difference. Yeah, pneumonia is a type of chest infection. Basically, effectively think about the chest. The thing about it, in terms of, um, if you tend of Tim's airway session, your airway is divided into a few different parts of your your pharynx and your larynx. So the bit behind your nose to get behind your mouth and then the bit in the back of the throat, going down the throat. Esophagus. Uh, yes, sorry. Know this stuff A good weight what would wear around by here. Suffolk asses for food, truck ears there. Let me get that right. I was thinking, suffered. Just sounds like gas. So I assume it's the lungs. Stupid of me. You kept, um, So if you have an infection of any of these, that sort of your upper airway severe, like a throat infection or infection in the trachea. That's upper airway infections. Upper respiratory tract infections. They're not pneumonia. They're they're a different sort of chest infection that can come down. You can have bronchitis so the bronchi can get infected or inflamed, and you can even having called bronchiolitis so the bronchioles could get infected and inflamed. And I would still say they're not pneumonia. They are a chest infection, and they could be quite nasty, but they're still not pneumonia. Pneumonia is when it's getting into the lungs, is getting into the tissues of the actual lungs themselves rather than just the airways, and that that's when you tend to differentiate. So a chest infection versus and pneumonia pneumonia is in the actual lung chest infection, also with the rest of the respiratory tract that it would be in. Um, I don't see, actually, chest infection. Technically, other bits of the chest that our lung so you could have, like a heart infection or pericarditis Or that sort of a nasty infection that met Mediastinum or other bits of the chest that that wouldn't be love. Yeah, pneumonia in the lungs. You know, the rest of the airway could be also chest infection that if you differentiate them or Josh no. But classically chest infection is just a thing people use instead of the ammonia. Really? Yes. Is another catchall really anything in the rest of entry? Um, if there's no more questions, that is the end of our session. Thank you. Run for a tendon. Pleased to fill out the feedback for more. Share it again. Now on. Please ask any questions you might have. I'm happy to get back over various bits. Person again. It's There's the feedback for him in the chat. Pleased to fill out if you're, um, happy to and otherwise, Um, yeah, Any questions? Thank you. We'll finish with the sheep that's otherwise come for a chief, but it looks really cute, so we'll finish your sheep. Big fan of finishing every session with a cute fluffy animal purely because it gives a bit different. And it brings a run back to reality and away from heretic medicine. Sometimes very book what was actually wrong with patients? Oh, patient too. Okay. Sa in patient whose case? He was intoxicated, and he'd fallen over, Simply put, had been brought in because it was very drunk. But we also had to rule out the fact that he might have something wrong with the brain because of the injury. And actually, being intoxicated might mask symptoms of this. So in his case, I just need his head stitched up. You need to sober up needing to go home. Um, nothing particular bad with him. Uh, yeah. Are you gonna watch the TV adaptation off? This is gonna, um, right. I probably will. Actually, I read the book. The book was brilliant. That was a big fan of the book. Um, Adam K. Is an individual. Mixed feelings on. I think a lot is I've watched sort of his comedy on some television shows, and he does like to sort of basically read You may have read extract from his own book, but then, you know, I read this is gonna her? I read the night shift before Christmas. Both were very, very good. Both were very from my own experiences. At least they seemed very accurate. Teo Life in hospital. Obviously, he's He's taken out a lot of something more boring stuff. The mundane. There's any using the very sort of the the cream of his experience, the best bits. Um, so, yeah, I think if we could show, I've heard a lot of good things. Um, heard people say that the television that they've done a very true to life, they brought the images very truly to life. So I think you'll be good. Look, yeah, I think Syria's to should just be him. Sit in front of a computer waiting for it to load 6% off inside or him sat there in front of him, Sat there waiting for an x ray. So it's patient. Go home for him there, waiting on hold for I t services because it can't log into one of the systems. Yeah. Uh huh. Yeah. No, I think I think I think certainly from his books. On the way he talks about working as a doctor. You know, he did. He did it. He was a doctor. You worked in some pretty good, actually. What's in the same hospital I worked in for a bit. Josh has worked in the hospitals he's worked in. You know, he he does bring very, very good. It brings to life very relaxed. Erian's Is that a lot of us of experience? Not This is the same. That's similar, Um, bucks. I think he brings life the best bits. Uh, so in terms of what it it's not a perfectly true experience, but it is definitely part of it. That is really funny guy in terms of how he remembers them in terms of how he puts in a cross is very good orator. He's very good speaker over a good storyteller. So it is worth watching is where it is interesting. But just don't expect if you decide to go into medicine and particular into like obsessive gynie, which is where he waas don't expect your experience to be exactly what his wants, because he's telling the best bits or the most interesting bits of missing out the Monday that, uh, straightforward. How often do you get unusual diagnoses? That's what you mean by unusual. There's always something that we're going on. I saw a woman earlier today who was pregnant and had broken her foot because she fell over while pregnant on they were like, Well, we don't know whether she might be having something that's causing her some of the epilepsy well, pregnant. You know, there are unusual diagnoses. There's also a lot of the time you just don't know the answer. Um, and you're seeing people off with some general management plan going well, it's something in this bull hockey area. This will fix it a list might fix, and if it doesn't fix it, will think it's something else. So you get a lot of unusual if you think of unusual as I'm not exactly sure what's going on here. But you think of unusual is like I want really Gucci really exciting, a bit less. I think it depends on where you are as well, because if you're in a tiny little hospital in the middle of nowhere, you just go see the sort of routine, mundane stuff but that if you're in a big, fancy central London hospital, you've got the absolute expert on that condition. You're going to see lots of weird and wonderful things. Yeah, the only they racy for the same time in in the really fancy fancy hospital you're never going to see, like, man versus tractor kind of injuries. Or, you know, I've been head butted by a sheep and now my testicles ruptured, you know, sometimes, like, really weird, like in terms of running niche, finite conditions, you'll get a lot of them in the really fancy hospitals because they actually like this is really weird. I told her what's happening here. You get a lot of that. But the middle of nowhere, like deepest, darkest Cornwall kind of places. Yeah, everywhere has. It's interesting bits. Know was boring. Kind of the beauty of health care. There was a pencil department urine. You know, if you go to rheumatology, we're going to see a lot of rheumatology. If you go to respiratory, you're gonna see a little respiratory. I would be a bit unusual for you. Could be that if you're in respiratory on your patient has something wrong with their kidneys. That's a bit unusual because it's not love. Uh, yeah, way had electrified I who was like the world expert expert, and I think we'll pour for IUs, which is essentially a disorder of how you great down right blood cells. I think, um, on do this that's so rare to the point off. It's kind of one in a million is probably roughly the amount of people that have a puff Korea on this, like 20 different types. One million is like the most common one. And he was the world expert and I'd only ever seen four of the 20 types. So you can get some really need spits and healthcare. Really? Really. Um, yeah, There's some old old things out, but this is it, like it's 90% of the time. You'll see the same couple of things in whatever time and you work in. You know, if you work in lungs, you'll see a lot COPD. You'll see a lot of asthma. You will see a lot of chest infections. You will not see a lot off niche flesh eating bacteria or niche cancers and stuff There. We part your specialty, but you want to see it very often. If you go on working cardiology, you'll see a lot off. You know my card infarctions arrhythmias basic like in general heart problems like the same couple of things you will not see. Very many patients come in with their heart born outside of the rib cage. Or they're born with dextrocardia in their hearts, the wrong plumbed in the wrong way around. It's rare, but it is still put your specialty, but it's unusual. So you have that. It depends what you end up doing that that's what you want to do if you want the really wacky weird. And now this world's going to say, like tropical medicine, because you'll get weird, wacky and out of this world. Um, yeah, if anyone is no more questions, we'll end there. Thank you, everyone for your attendance. Uh, obviously, if you any more questions the between sessions. Pleased to drop me an email. Our next session, I believe, will be things the 24th, um, 20? Yes. Next will be both anatomy, part one on the 24th that we're myself on. Then again, bone. It has to be part to be on the 10th off march. So exactly monthly. Thank you for attending. Thank you all for wonderful feedback. Please do give feedback. You're allowed to be harsh if you want to give, like, really catty nasty feedback go right on the head. I don't mind any feedback is good feedback if it helps us improve on do better teacher. So otherwise. Thank you very much. Mass effect to Josh Chameleons. Evening and manning the chapped Being really useful with copays. Enter Thank you very much and wants everyone has love the evening Take everyone by