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Hello and good eater. I mean, we'll take stuff that there we go. Hello. Good evening, everyone. Money is pretty Cuba, And welcome to our what's most serious from November. This is clinical scenario. Discussions may. I'm trying to find a different boat of myself every week, every session I do, which is becoming more difficult, I imagine I don't take enough floatiness this May. I'm pretty Cooper. I'm a third year medical student at G. Katie Med School Kids College, London Uh, shows slight again. A share it every time. Basically, most session. Do you take notes to ask questions on Do feel free to email and ask a bit more. If there's anything you want more information on any queries. That's my email address. Also, you can follow Instagram on Facebook. This is where we are on the once much seriousness days case discussion. Our next month will be dying a palliative care with the nutrition in January, So please, do you keep throwing up. These are, hopefully concessions. I'll check your feet back later to see whether it'll that's true. On Thursday, we will serve myself teaching again. This is for gastrointestinal anatomy, with four session in our anatomy, Siris. I have a little bit good. So far, I've actually quite good. Seriously, the anatomy one. So if you haven't been showing up to those, please do they are being very They have been very good so far. Only that being said, let's do some clinical scenarios. So, uh, for those of you in the chat, I've shared any poll of pull everywhere, whatever it's called. Could you please make sure that you open that up because I'm gonna try and use it? Don't hurt. It'll work or not, but we'll give it a go how this evening is gonna work. I've left the see these clinical discussions sessions quite blank for the people presenting them. The one tonight I'm doing because someone else was going to do it and isn't available anymore. My interpretation of it my well, I'm going to go for it is I'm going to present three different scenarios. It's these are three patients. All these patients are completely made up using sort of, ah, a knowledge of previous patients. So they were all completely, you know, identifiable. They're not really people. Um in each scenario, you'll be acting in the role of IRA student or a shadow that's a shadowing or learning. But you can advise off so you can't necessarily do anything on your own. But you can advise those around you on, and it's meant to help stimulate you to think about more about these situations on. We can use them to teach some areas of medicine and health care that I don't well fitting into. Other things were teaching later on. They're all fairly common scenarios that now is the bruise is a bruise. Is people sometimes the first very niche cases their horses in? That's another year on just that. Well, you know, teach interesting. There is a medicine on healthcare on, uh, there weren't always be single. Best answer the polar have is to correlate to the answers that to the questions I will show you. Um, I'll quickly talk about what differential diagnosis Is that something we know we maybe mentioned in previous Syria in previous presentations, but not really talked about. Basically, differential diagnosis is coming up with a list of potential diagnoses diagnoses in that case, the plural of diagnosis. Rather, the diagnosis is diagnoses that fit what's going on. So it's the options about what could be the answer to what you're seeing. Um, normally we list the sort of in terms of most likely to least likely almost dangerous slash life threatening to least dangerous life threatening on. Then you sort of work your way down, ruling out, um, as you go on the wait until you come to the the most. Likely that you know the final diagnosis. Although in some cases you'll never find a single specific diagnosis. Um, an example. I just quickly talk through the same like chest pain. Um, and I'll talk through that and then, uh, the let's think of a few potential diagnosis. You might get some presenting with chest pain. Um, if they say they have a pain right in the middle of their chest, we just don't think about what's going on in the middle of their chest. The anatomy that's there, You got your heart. You have some bones in your ribs and maybe in your spine towards the back. You know, muscles, the intercostal muscles. You have your abdominal muscles off below your chest, but we think it just yet. Maybe it's the diaphragm and intercostals. You got your lungs, you've got your esophagus and your stomach so that connects your mouth to your stomach and in the top of your stomach. Um, so any one of those things could be contributing to this pain. And we have to start ruling out basically ruling out systems and then also sort of ruling out things going wrong with those particular systems to get to the final answer. Um, so if you take a bit of history, you talk to the patient, you get some more information, pain is sharp, is going down there, left arm feels tight, they look really great and and, well, that sounds more likely to be a heart problem, that it has other things. So it's the heart. Heart problems go to the top of your your differential. Also the heart in the situation, probably the most dangerous, most dangerous diagnoses would be to do with the heart. That office, it goes right to the top of your list of things. We want to rule out to make sure that that's not what's going on. Make sure it's not gonna kill the patient before you figure out the answer. Some things like a marketing infarction, some sort of vessel rupture. Tampon art, which is bleeding into the Perricone arguments. It's around the heart. Talked a bit about it in the cardiac anatomy session. If you haven't seen that, please go back and find it on our medal. It was quite good session, you know, December for myself also sort of arrhythmia. So we need to do some tests according to this, and start ruling out some of these options until we come to the final option of what's wrong with the patient that we can fix. Some of the other problems aren't so bad, so you wouldn't immediately go right. We're gonna test for reflux because more gastroesophageal reflux isn't going to kill someone. So no, kill them very quickly. Um, certainly not killed them before, you know, a massive heart attack so we can worry about those maybe bit later, if we run out of ideas on be ruled everything out early on. That's the basic idea of the differential diagnosis. Let me just check the make sure that no one's also you think that no one has. Okay, so hopefully that's clear off. See if that's not. Do you feel free to ask you about that later. Most of narrow. I think all those scenarios I've gone for tonight don't have too much, you know, variety in the differential. This a couple of quite obvious options in them. Um, but all that's doing worth mentioning that people think about all the range of things that might might be going on in these situations. So start with patient one. So, patient one, you are shattering an ambulance crew seal. You're going out with the ambulance and watching what they do. And you called to an 83 year old man who was falling down two steps on your arrival. He is alert. He is breathing normally, but he's a lot of pain. He's lying on his back and his right leg appears to be shorter and slightly rotated compared to the left. So assumption would be there might be something going on with his leg for you guys. I have three questions. And for this, if you had over to the pole evey I can hopefully pull this up. Not really sure how? Polly, these work. Here we go. Yeah. So we head over to the police e. Type some of your some of the answers to the questions they're of was, you know, just think about yourself. You'd rather offer free to put them in the queue and down here. I don't really mind before the policy would be a nice way to sort of correlate anything people have thought about. Um And then I'll go through two and three. No. After effects of balances. Okay, 60 seconds. People to think about their initial concerns for this patient. Uh, you see, if I can share this, my screen might disappear for a second here, but I'm just gonna quit change screen too. This one that go, I realize I've put in a word. Clouds. It's maybe not the neatest format. So we go ahead. We've got distracting. Go break C spine. C spine is a very good one to put on here. For those who don't know that is, that's the top vertebrae in your neck. And they could be very, very dangerous if you injure those. A lot of the nerves that come off with their control. Things like your breathing, making control, things like control. Basically, a lot of the important functions are staying alive. So if you damage that on you several one of those a patient conversion. Sick. Very, very quickly. I think someone tried to put same old bones break easier. Cold cold is always interesting. Older people get colds quite quickly if they're lying down. Exposure. Yeah. Coldness, Pain. Pain is a good one to worry about. Let's move on to the second one. So what you want to do about his pain? Someone mentioned in the last bit. It's good thing I've got Melanie here somewhere is my, uh, no, these were doing watching the chat for me. She's a pharmacist. So we will be judging everyone's knowledge of pain killers for 60 seconds to kill. It was, um it's not the pain. Listen, answers and knocks. Really good one. I'm glad. So we'll put that talk about that a minute. Opiates yet? Perceptible and analgesia. Yeah. Ibuprofen. Perfusion of a good painkiller. Yes. Thank you. Good answer. Just a lot. Um, morphine. Today. Opiates, perceptible analgesia. You are a perfect yet. I mean, that's a fairly good encompassing list of I think pretty much the majority of pain killers will use in certain in the prehospital environment process. It'll person morphine and morphine derivatives and Internet's tend to be the most common for sometimes you get advanced paramedics or pre hospital doctors. They use things like ketamine. Um, can I just jump in on that one? Pretty sure. So with this chap, he's 83. I wouldn't use ibuprofen for him because ibuprofen, you probably hope for you all aware if you take out taken ibuprofen on European, he has to take it with food. And the reason for that is because it's really irritating to the stomach so old and that it can cause ulcers. And it's much higher risk of doing that for a cold person on. It's also bad for kidneys as well for old people. So that's why so I didn't put a profit on my response because for this age of patient, I wouldn't have said it was a good choice. Firstly, I was going to talk about that a minute. Thank you. I'll move on to the last of the three. So what's your plan for this patient? And then I've got slide talking through a basic overview of some of these of these situations. Yeah, did you share emerges? But seeing a session like this once with some parents, students on but people began just sharing emojis that, like the ambulance emoji on that. I think it's quite encompassing of their intended plan. Yeah. Pain killers and hospital, uh, turn a good plan so the wouldn't set this one of the word cloud off really cold. It's a different. A little bit of broke with picking him on what these things presented. What else? Trellises. Guessing? Note. That was one check leg isn't broken. Give pain meds. You know, again, assessing the leg is a good plan. I think everyone seems to be going for the same sort of plan. That pain killers is where we want to go. Here, let me move back to my Power Point weekly. So, uh, skipped. So this is my take on the three, uh, for thoughts. What's going on? Ah, a big worry here would be probably a broken neck of FEMA. Go talk more about what that is in a minute. Um, given the fact that, like it's shortened, it's rotated compared to the other one is important. We rule out any injury to the pelvis. The pelvis injuries in the pelvis complete quite a lot. And there's quite a lot of space there for blood to get into very right quickly so patients can get very, very sick very, very quickly with pelvic injuries. Um is also important to check the patient's previous medical history. It's unlikely that he's going to have normally a shortened rotated leg, But it could have been something he's had before, and it's never been repaired. Or it could have been, you know, a problem he's had since birth. It's unlikely, but it's potential. It's worth ruling out that in terms of the pain ambulances carry into, Knox is something we mentioned a minute ago and looks is very, very effective. It's quite fast acting on it, too. So see, it's patients from the pain they're feeling. So in this case, probably I would say you put the and put them on the Internet. It's It's the gas they breathe in and probably given about 60 to 90 seconds. I would imagine they start being less affected by the pain. It doesn't mean the pain's gone. It just means they're not not noticing as much on then. Once they're sort of a bit more under control. With that, you could start thinking about giving IV medications such as IV perceptible, actually. Really, really good drug. I think Melanie probably would agree there. Hope Melanie would agree that I've parastatals a lot more effective. Uh huh. One of my favorite drugs. Paracetamol. Yes. A lot of people neglect the Aricept. Um, or they think that it's not very effective. They, I think because people take it so much and they often take it for the wrong reasons. People just assume it doesn't work very well. Paracetamol taken for the for the right sorts of pain is a very, very effective drug. Um, but if you take it for the rule thing is just not gonna do anything. Um, the most common one is a lot. People take it for headaches and actually, a lot of time. It is not going to change your headache if your headaches for a reason. If you're dehydrated, for example, if you're having headaches, you're dehydrated parastatals. Not a lot of water. It's not gonna make your headache go away, But actually, I'll make it be a little bit. It's painful on then. IV morphine, like we were saying before, opiates depends on the patient. Know it depends on how much pain he's in something that's quite deceptive. A lot of some older patients is they tend to sort of grit their teeth and bear it so they could be in an awful lot of pain and just not tell you on. Try to mask how much pain there in. So it becomes a bit of a balancing act between trying to persuade to them to let you know how much pain there in and then managing that pain on the plan is. Just get the patient hospital safely. Get them off the ground. You don't really want them standing on a potentially broken hip. In this case, they work in neck femurs. Paul the hip. Um, you want to immobilize the fracture size? Don't make those standard. Think like scoop Stretching will help you get them up. And here's some pictures to go alongside of all that. So we got in the left here. I don't have you seen my mouse. This cylinder in the top left is enter knocks. That's what it looks like. It's the same as an oxygen cylinders, really, with a full nose clip rather than a lot of soft plastic clip to go into it that goes to a mouthpiece. The lady here in ah hospital gown is using the mouthpiece. This is one that you actually put in your mouth and breathe through it. You can also have it with a more of a doxidan mask down the bottom. Here. This lady's got it with a mask preference there that has which one you use. I don't really know which one's more effective. If you have to make more of a seal with the mask to get a good, good, um, draw of the Internet. It's very where is actually with the mouthpiece off the Pop it in your mouth. It's a lot more effective. It's a lot easier to get a good drawer, but if you've injured your mouth, if you've injured your teeth, it's no, it's great. Something else I wanted to highlight here with this drug up top, this sometimes known as a little green whistle. This is good pen through ox. Basically Penn Trucks, missile something. I forgot what the word is. It's written on its own. It methyl flu. Uh, anyway, uh, works a bit like interlocks, another inhaled analgesia, and it could be very, very effective. The only big problem with it is that you can't really use it in enclosed spaces because everyone else will get really high. Um, because you blow out, you breathe in pens, rocks and you blow out pen frocks because you don't absorb all of it every time you breathe. That's why it's got its lovely carbon filter on top. This is to try and take a much pen frocks out of the breath. You're growing out as possible to stop. You know the person trying to relieve your pain getting really high. Uh, next to that is a scoop stretcher, as I mentioned before. This is basically a metal structure that you can break in half so you can put one half either side of the patient and then push the two halves together. So you haven't got to lift the patient off the ground to sort of get the stretcher underneath. Um, and then you could lift that on, put them in a vehicle without them actually moving on, going to keep them as still, it's possible, and lastly, at the bottom here, a couple of examples of local pelvic binders. These are quite good if you have a pelvic injury, because they actually try to keep your pelvis in a source station stable place, so it's not moving around too much. So if you've broken part of your pelvis and this should hopefully stop you from aggravating that, making the fracture of worse as you move thumb. Like I said, you can lose an awful lot of blood into your pelvis very, very quickly. So you really don't want to make a nasty fracture in your pelvis. You want to sort of keep it as as still a possible. And those are all the things you know. Be having an ambulance. Maybe not pen trucks some ambulance is carrying these days. Not all do. It's been sort of coming Maurine to fashion in the UK It's been used in Australia quite a lot in the past, and it's very effective drug. It's also it's just a little effective a little pen that you, you know, pain or little sort of a cylinder so you can keep that core effectively in a first aid kit, for example, and you haven't got to carry around the big cylinder of enter knocks, so it's quite a good drug can, um, in hospital. So for this particular patient, we take the patient to any. The patient has an X ray of the area. Now, I know we haven't really done X rays before. Um, I took this one off Google images, so I see him. It's no identifiable. But either way, I took it from Google images. So Ah, if anyone wants to Has it a guess. What do you think we're looking at with this X ray? This isn't on the Paul. If if anyone's going for the just wants to pop it in the queue and a on teams of was Melanie, it's Well, I'm gonna pick on you, and you're gonna have to tell me what you think of this X ray. Give him a minute, but for anything else? Doesn't think anyone's gonna help me. Doesn't gonna pick on you. What do you think of this X ray? I mean, I have no idea about X rays, but the presenting complaint and everything sounded like enough to may. Right? So I don't know if you happen. Nations left hip was the one that were left. Leg was the one that was shortened. Was it left? Was it right? Was right. A card. Which side? I said it was. Somebody has not unanswered track to help me out right now instead of the pelvic area with a broken femur. So what was it? Yeah, John adds that what you want? I put so much effort into making sure we got the right gender for this X ray. I don't think I put enough effort into figuring out what angle Where is the right leg or no? Um, so if we're looking, basically, we know that this patient probably has something wrong with their leg. We can have a look at this whole situation going on immediately. Generally of X rays. If one side matches the other that we conceive, the particular that's no, it's not exact science. But for the for the purpose of this evening, I think that'll cover most of the thing so we could see the pelvis itself looks pretty symmetrical. It doesn't look to have too much going on one side that it's not got going on on the other. We can look at this this nice femur over here, and it's got nice, smooth, intact shape. But if we look at the one over here by comparison, it's got this sort of group of It's got some of this, uh, well, gap. Basically on that is the fracture in this scenario so that that bit there shouldn't look like that. It should look much more like the other side over here. And that is the in this case of femur fracture on that is the neck of the femur fracture. No, for neck of FEMA refers to this part. I don't know if you can see my mouth's been effects with this part here. So you've got your your main femur shafts here that then becomes the neck and then the head and in the head sits inside the pelvis in a thing called the Acetabulum. Um, we'll talk more brother in another session one day, but yeah, so the That's the neck. That's the head. That's where the head sits. In this case, the neck has a break. I got to make sense, um, repairing of this so the patient would like they're full require some sort of hip replacement. Hip replacements have ever weird, um, a weird term, really, because they don't all involved replacing the hip. They involve replacing the neck and head of the femur. So here are the few different options that are four operations available here. And so it depends on how old the patient is, how badly they have damaged it. Um, so we've got things like internal fixation. This involves just basically putting a few screws through the shaft of the femur into the head of the femur to sort of re join the two Bill it, nailing couple bits of wood together, we've got the hip compression screw effectively. This works by sort of pulling again. You drill through the through the femur and into the head and benefits of pulls the two pieces together on it was them to heal and get it for structural support. That then is bolted further down to the rest of the female, back to the rest of shaft of the femur. Uh, we think the partial hip replacement this is replacing the entire femoral head on part of the neck, and this also gets borrowed into the shaft of the femur on. Then you got the total hip replacement, which is very much the same. Except you can't replace part of the cup that the head of the femur sits in the acetabuloplasty least that's all 3 to 4 different options on which one you go for really does depend on on the patient. It depends on the situation that's happening around the patient. Uh, there's a lot of things your to think in these and honestly, I don't think the best place individual to discuss which one's the best for which patients. Um, but things like the patient's age, what sort of state? Their bones. Aaron, if they're quite old and their bones are quite worn out, whether or not they're going to be able to walk, you know, if he was walking a lot before hand, trying to get back to being able to walk again afterwards. These are all things. So how to consider before you decide which which operation you're going to go for, And you kind of want whichever one you're gonna go for. You sort of want to only really do it the once you don't wanna go, for example, a hip compression screw, and then it doesn't work, and you have to go back you to replace the whole hip because it's a lot of trauma for the poor patient. So you yeah, you sort of want to have a think about which one you're going to go for potentially and this one off the orthopedics. They're surgeons. They do a lot of these, and they are quite good at deciding which one is the best option. Um, so normally get off the orthopedics involved, and they would make a plan. Here's an X rays of some. Repair it hips. So I got the hip compression screw up here on the top left. Uh, he's got a Let me think. Which way? Around? I think these on the right is a partial hip replacement in the middle. We've got one hip that's been completely replaced. Total hip replacement on one that's had a compression screw on another supporting screw put in. So I don't know what happened to this poor chap at the bottom, but I imagine his hips weren't in particularly good order beforehand. This is what you might see on X ray General on X rays, anything that's metal bones tend to show up white, and then anything that's more solid than bone shows up very white. And then obviously the soft or something is getting into gas turns black in for example, the one of the top right here. This guy's got a bit of gas, probably in his intestine here. Um, and that's showing up this sort of black cloud. Um, that's a very short, brief touch or next race. I don't know if we doesn't compass as much as Yeah. Yeah. Okay, Good. So any questions on the X rays feel free to ask, but that's a very brief touch on them and a very brief chat room. Hip replacements, um, give you 20 seconds, maybe to ask any questions. And then I'm going to move on to my second scenario. I'm seeing nothing there. Good. So against patient lost volunteering in a care home, you find dot e a normal, frail but very mentally sharp 88 year old residents. She's appearing confused and distressed in her bed. She's alert, seems unsure of her surroundings and isn't sure who you are, even though you've met before. Nursing assistants tells you she was fine yesterday, but today has been quite confused and agitated, hasn't eaten her breakfast or taken her morning medications. So that is a daughter and we'll move on to three Questions for on are again up these will be on the pole evey for those who want it. Take two alleviates. We're gonna start with what you make of her. New confusion was the key word here, which is new. So what? Which was able to share both the Poly VI and the scenario at the same time. If anyone wants any bits from the scenario back again, please do Just put it in the queue and, you know, and I can read it back out again. Infection, it injury. Another 20 seconds. You seeing anyone else wants to answer. You know so, but we'll go. One more head injury. Okay? Yes, sir. Last one is what you think might be causing. I think people put a bit more of that in the last one. So getting your head injury in the infection with the two people seem to go for last time around. Anyone else? Any other ideas other than a head injury or an infection? Only thing one too long? Because we had a couple answers last time around most of the same question, because I I've submitted something. It's not coming up on your screen, so Oh, I think you said that. And Suddenly things happens. I think I think it's like with black UTI and sepsis urosepsis and get a guess You're the one who put urosepsis, um one Poland. Everyone else is, uh, is coasting off the pharmacist. We've had a head injury a swell up, though. Move onto the next one. That's just a couple of different answers there. So what do you think needs to happen next? So depending on what your sort of thoughts are, the patient hospital hospitals affair Suggestion is also, we said, I think dot e is in some sort of sheltered accommodation, sort of supported living situation, meaning she's probably not able to sort of get by on her own. Or she's in a position where she just needs that extra better support to live, to get, for for her every day. Living needs so somewhere like a hospital might be an idea. Now she's been on, Well, uh, I'll get back to my PowerPoint. Just go through what I put a simple answers here. So, and that was her new confusion. New confusion isn't that uncommon in patients, especially sometimes in the elderly. It's called we Call Delirium, so new onset confusion that isn't necessarily linked to things like a dementia. For example, course is it we don't always know it can be due to things like an injured new issue or injury in the brain called uterine infection, as we've had on that could be due to some injuries. So some patients who have had surgery, for example, like and they get delirious on somehow it's also due to disorientation can also be due to medications that can also be due to all sorts of just all sorts of things. Unfortunately, most of these things happen in hospital, so you get a lot of patients in hospital who are delirious with Dottie. If she's a regular resident, she's regular resident. She's been in this this home for a period of time. It's unlikely, ah, that they will not have noticed some sort of trauma. They don't know if she's had a full Someone hopefully would have noticed that she's back to her head on something such as, um, like to have an injury, which is unlikely to have sort of, ah, back to the head. And she's also been in this home a while, so it's unlikely that she is going to become disoriented and or confused do to the surroundings around her steps. Really, it's basically infection or some sort of new issue in the brain, something like a stroke as the problem we need to check dot e. We need to see what's going on. Um, performing a fast test, which I'll talk for you in a minute to check for a stroke or some sort of head injury is quite good getting a full set of observations as your heart rate, your respiratory rate temperature, all these sorts of things. We'll talk about them in a second. Well, on getting some help, probably the best place to begin, depending on how long Well she is. If you look so okay, you might be able to do all these things on beginning managing it yourself or with the GP. Um, if she's a bit sicker, you might need to call for immediate medical advice. Reward one or she's quite sick. You might need to call 999 for an ambulance, but it also depends on how you find out and what's going on. I couldn't talk for the fast test. This is something everyone in healthcare needs to know just needs, um you're fast test is your assessment for a patient having a stroke? It can also be used for for sudden head injuries. Um, on basically you're looking at the face is their face, as you'd expect it to be yours. It's fallen to one side, drooping similar with the arms. If they close their eyes and hold both arms out in front of them to they both stay in the same place that was one of them begin to drop. Can they even raise both arms? It's It's useful to get shut the rise because actually the patient sees there are dropping. They can put Mawr effort into trying to keep one of them up, and it becomes so fair Test speech. Are they able to give clear cut here and speak? Or is it becoming mumbled? Is it they're struggling to get their words out to the worst? Not make sense. These could be signs of going ahead then, Then time. Time to get the hospital and you want to get into hospital nice and fast if any of these signs are present, If anything sounds are present and new, I'm going to go with their as well, cause I'll see if the patient's already had problems with their arm and it's already weak. You know that. You don't necessarily to send into hospital every time you see them. If it's something that had for, like six years. Oh, observations. So here's some observations for Dottie. She's a lot but confused. So she's, you know, looking around the room. She's interacting with her surroundings, but it's just not very sure of thumb her pulse. The heart rate is 114. Her respiratory rate is 20 breathing rate. She is a temperature of 39.4 Celsius 103 F. For anyone who still uses Fahrenheit, get with the program. Celsius is better. Saturation is 96% on room air. Her blood pressure's 102 over 60 and her CBG is 4.5. CBG is capillary blood glucose as your your blood sugar measurement. Um, what made it Paul if slide for this one. But if anyone's got any interesting thoughts on these police to share them otherwise, I think about it for a minute, and we'll talk about them in just a second. No, that's good. Um, the's are fairly standard set of observations. You're how alert the patient Is there heart rate, their respiratory rate in the temperature, the oxygen saturations, their BP and their blood sugar. This is your fourth or fairly standard set of observations. Um, so get kind of used to sort of what a normal range is with these. Watson. What's abnormal? Um, quickly talk about the news chart. So the news scoring system is something used predominate in hospital, but it's also used in care homes. I think it's also used in GP is also sometimes used in ambulance services, not so much in ambulance services. That doesn't really work particularly well in the acute setting, but it's basically a way of understanding how unwell someone is from their observational. That doesn't mean that it replaces common sense. If you look at someone or you're worried about someone, um, that sort of goes above and beyond the news chart on get Help as appropriate. But this is basically a way of fitting someone's observations onto a chart toe work out how sick they potentially are if we go back and look at doctor's observations here. So her heart rate is 114. So if we go down to Pulse, which is down here 114 will give her a score of two for that. So theory. Remember the two? Her respiratory rate is 20 so she's a zero that her saturations and 96 so another zero over him. And the BP is 102 over 60. So systolic That means the top number for the BP of 102 schools have one, so she's now on three. Consciousness alert on her temperature is over 39. So that school to another two. So she's scoring a five. What does that mean? I don't know if I've put the thing in here, but I just got new score. Five on the roughly way Score on. That depends how immediately you need Teo Get met. A review from someone of it. Sr Ah, we'll talk about what's going on with her, and then I'll show you what the new schools correlates to. Given a fever, it's likely that dot he has some sort of infection going on. You don't tend to get a fever with a head injury you can with certain ones, but but more likely it's it's due to an infection. Fever is part of your body's your your body's natural way of trying to fight off infection, because I don't know entirely how it I don't entirely get the logic behind it, but I guess I don't fevers. Don't I guess the body fights better when it's a bit warm. Um, a new school Being a five is quite high to definitely needs to see a doctor, and she definitely see that doctor today, depending on what you have available, is the results that could potentially be the GP so the local GP may come out and visit her. Sometimes they have emergency slots where they can go out and see patients like DOT E or it might be in hospital. She might need transferring to an any, uh, the GP would probably want to deal with your analysis. This is dip sticking your and I'll talk more about that in a minute as well. On this looks for signs of infection, because actually, one of the most common if not the most common site of infection, particularly older people, is three urine urinal tract infections on because you're in the already tracked it could affect the kidneys. The kidneys affect how you filter things out of blood. You can cause confusion for just dehydration, because the confusion through having the wrong levels of various different salts in the blood you're in a tract. Infections convey make people quite confused. Um, does the GP needs know exactly where the infection is to begin treatment? The answer really is no, but it is better. If you know it's in a urine tract infection. You can pick what you're going to do to treat this patient based on that. Also, knowing what the infection is is quite good. So in this case, you might take urine. Once you realize that infection that you might send it for culture to find out what is in the urine on do you can pick antibiotics according to what, What you're fighting In the modern age of antibiotic resistance, this is a much better way of doing things. Just generally, feeling people up the antibiotics is a really good way to breed super bugs. You kind of want to know what you're fighting and what is going to fight it effectively. What treatment should be given it for a lot of people with UTI, the vast majority of people UTI, so I probably wouldn't recommend giving them antibiotics. DOT is 88. Dottie is confused. Daughter lives in a in a shot accommodation. I said earlier. In this scenario, she's frail. I think DOT is a good candidate for having some antibiotics to help her fight off this year in a tract infection. Um, and help her get better. Quicker? If, if not, it was 19 and coming, saying that she's got, you know, pain when urinating. I probably wouldn't go to the antibiotics that probably no fight it off herself but also being a bit older. Probably not as able to do that. What treatment should be given. There's a couple different antibiotics. They're quite good for your new tract infections. Obviously, if you confirmed it's your own a tract infection, you might go for these. If you haven't confirmed it's one of them. You might have something bit more general bit more broad spectrum than looking amoxicillin. If you know it's a urine tract infection market saying like nitrofuran Oh, in. Um, there's a lot of different antibiotics out there and picking the best one. Yeah, is bit of the game, not a game was better challenge. Sorry, this is a dipstick in urine. So effectively you get a nice black part here full of sticks, that look a bit of this and on the side, or all the different markets of what's going on. You dip the stick into a sample of urine in a pot. The patient gives you that. You give them the parts you tell them to go away on, produce the sample you want midstream, urine. So it means they begin urinating. Wait a couple of seconds and then collect urine because you don't want that initial bit. That initial be it could be full of all sorts of nonsense in the the sort of the at the end of the urinary tract that you just got to flush out. That doesn't mean it's in the urine. It doesn't mean it's further up. You will. You're in this from from the bladder rather than urine's clean. You all, um, you dip stick in there, make sure it's entirely emerged. Normally, it takes about 60 seconds in the urine you taken out and put it down. You 18/60 seconds for these to develop on, then you compare it to the the color markers on the side of the pot. Um, and this will tell you all sorts of things about what's going on inside. The the patient's specific gravity is that is a sign of dehydration. The pH or C. The acidity leukocytes are a type of white blood cell blood. You shouldn't have blood in your urine. This is a way of picking up small amounts of blood. You might not have sin nitrates, nitrites, nothing that you're kind of not wanting in your urine ketones We talked about in the diabetes session before. If you didn't attend diabetes session, go back and have a look. Um, on all the others. It just fits that you'd have in your urine, particularly. You got an infection or you've got some sort of injury. Kidney injury. The one thing that off one of these don't test pregnancy. That's something I've had. A patient asked me in the past that if I dipped their urine, will it tell them if they're pregnant? The answer is no. A pregnancy test is a different test. You can do it with the same sample of urine. Um, months. The's won't tell you you're pregnant. Sometime Important to reassure the patient that it won't tell them that because they're expecting it might, or they're worried it might. Um, yeah. Doesn't tell pregnancy colors. Urine colors are important. I think if you were here for Thursday session with hopes you mentioned this a bit, Um, basically the light of your urine, the more likely is that you've got a lot of water on board. Actually, a very light urine isn't necessarily good. It could be. You got to much water on board with your releasing too much water on your loot, but likewise, a very dark urine. Very concentrated urine isn't great either, because that means you're not drinking enough. And I can cause problems to your kidneys. Um, color wise, it's very clear your heart dehydrated if it's cloudy. This could be that you've got your own attract infection where you might a stone This there's something in your urine. Urine should be sort of, um, transparent. It should be. You should be able to see through it if they're sort of sediment in. It was missed in it. That could be a bad sign. Um, it was going brown. This could be something like you. Go proteins or bilirubins are basic things. You don't want things that shouldn't be in your urine and should probably more likely in your stool. Let's go into urine. That's not a great sign on read. Read his blood or be true but blood. Um, and this could be a bad thing for things like a UTI. You can bleed sometimes into your kidneys if you got UTI or kid the injury. Um, you can also get it from, uh, trauma further down, like a bladder trauma or a bleed into the blood of these kinds of things. Um, other colors, uh, purple. You should never really have purple urine. It just doesn't It shouldn't exist. If it does write it. Write a research paper about it because you'll make you make history. Um, blue and green. They're all some things that could make it go blue and green. Some dyes. If you're eating certain food, dyes could do it that, um, really blue and green, quite rare as well. Normally, it's some variation on yellow, with the obvious exceptions that red and brown red, his blood brown is is stuff that you normally have in your feces action have in your urine on, then foaming and fizzing means. Normally there's proof if it if it gets bubbly and it stays bubbly. That can mean this protein in your urine, and you shouldn't have protein in your urine. And also he's got some sort sedimentation. It's sort of cloudy that that is also not a great site used. Don't think, did I? Silly of me. I had a thing of a minute. Go basically news normally alongside of news chart, you'll have a a tape of system telling you that if they score between this and this, this is what you have to do. Normally, it's sort of if their scoring between one and sort of four. You need Teo. Have them see a doctor within a day. Normally think is the rule. If it's between four and seven, I think they have to see a doctor within the next 12 hours. Might be less than that in my B 12 hours of their scoring up to a four, and then it's like six hours, and then if you're scoring more than a seven, it's, you know, get a doctor immediately. Don't see that doesn't necessarily work if you know you are the doctor who's been called to see them. But this is basically sort of a way of safeguarding that. Patients who are getting a bit sicker get flagged up and someone comes and notices thumb so we don't have very sick people just lying in hospital beds not being looked at. Does that make sense? Um, very questions this point? Nothing at the moment. Okay, Like I said before there, any questions do please share them? We'll move on to the final scenario now. So patient three. You're a student observing. In 80 a woman has brought in her 19 year old son, saying he's very sleepy. He was found in his room with a belt around his upper arm and a needle in his forearm. Around him was a collection of different drugs and paraphernalia. Paraphernalia in this situation means sort of the equipment one equipment one might use to administer, said drugs. That's that could be needles. That could be he's used the belt in this scenario, but it could be things like talking a case toe big veins bit larger so you can get drugs into them. eccentric. The patient is flopping, is unable to walk for himself and has to be carried by his mother and her friend. Did ever weighed one. Here. I see that mothers brought him in rather than calling an ambulance. But that plays into the next visit scenario. Bit better. So to, uh, the lovely polyps. What's your initial concerns? What do you think might be going on? And what are your priorities for this patient? So? Well, there's It's the second click. There we go. What your initial concerns got There we go. T hate, fussed, tested, drug taken. I'm going to seem taken. Drug tested drug. Uh, some combination of words said, I don't think not. Extend her in my head. Rule administered taken drug effects. Whether I don't like work clouds in futures could get rid of all worlds glands. I've learned something this evening. Um, drug has taken effect. Espirit in. Yeah. Heroic in elicit. Yeah. Lots of good words in here. So you moved on to them. What do you think might be going on? These there are concerns. What? We think he's actually what we think's actually happened. Administered drugs, possibly legal ones. Yeah. Oh, dosed on the truck. Yeah. Yeah. Pretty good answer. Is heroin overdose? Hypoglycemia, hyperglycemia? Or like a good one? There's a joke from a think of The Simpsons episode where someone took a needle out homes arm because they thought I was taking heroin and turned out to be insulin. He was just diabetic. Um, what's your priorities for this patient? What? What are we really worried about? They're way breathing and toxicity. Yeah, Good couple seconds. Okay, leave it that Well, get back up to my PowerPoint. So I think people covered it pretty well here. Patients floppy and, um, well has been brought in by ambulance. And no one has started any intervention before he arrived. And we don't actually know what was going on when he was found with. We've heard what the mom has said about where he was found. They're not always the most reliable source, you know that? They said this is what was going on around him. I don't think the mom probably knows. Well, she might do, but the likelihood of her knowing what what stuff is involved in taking drugs is rare is minimal. So it's sort of an unreliable witness someone is not really assess what's going on, but no one's started any sort of care for this patient. Between there and here, Um, it's unlikely the patient is. It is likely the patient is experiencing some sort of drug overdose. But things do You need to still be considered. There's still a risk that if he's put a needle into his arm, he could have caused the blood clot or in embolus, he could have injected a bubble, which could now be somewhere in his brain, causing problems. It could be in a lung causing problems. Um, it could also be Dirty Needle. He could if he's done this regular, he could have some sort of happened hepatitis style problem going on, and it could be related to that. Or it could be something completely unrelated. You know, he could happen to have, uh, you know, had a massive stroke whilst you was injecting drugs. He might have how to fight over the drugs and been whacked on the head. You know, there's a lot that could also have gone on. It could have been that his mom caught him taking drugs, and she's whacked him. There's a lot that could be going on here that we don't necessarily know. But it is a fairly good assumption that the needle in his arm is related to his current status. Um, we assess the patient. We need to find out what is going on we need to do instead of observations as we talked about before, we need to assess his breathing. We also need to open and maintain his airway because actually, his floppy is probably not good. Very good. Muscle tone is probably not keeping his head up. So if he's sitting, sat in the back of a car you could really flopped over, he could have shut his airway. And I've had very poor air entry, even if he is breathing. So it's important to get his airway open. Get that supported. Keep that open. Uh, so he's getting some air in on. Then we can worry about things like make sure it's breathing, and then we start worrying about what actually caused this, um, patients unable to support their own airway. They have a respirator of nine, have a heart rate of 120. They have a lack of muscle tone but otherwise appear well now and his pupils are pinpoint and unreactive toe like so, this is the importance part of the history here. So if they're both pinpoint if you've got a head injury, you can end up with your pupils being different sizes to one another. They should always normally be the same size. Pinpoint is a very specific situation. So this is some different drugs that might cause your pupils to be different sizes, right? A supposed to. You could also get red eyes that are infected. This means more sort of blood shock on dilated eyes, constricted pupils. Which is what this chap has very small pupils. Uh, pretty much everything. In that list, there is an opiate. Opiates and GHB tend to cause the pinpoint pupils. I can't think, Melanie. I'm sure we have to tell me other drugs that cause pinpoint pupils. I can't think of anything other than those knocked off my head. So that's that. There you go. It shows you have rare. Anything else that causes that is so it's most likely an opiate or maybe a GHB. Some sort of tablet in medication. No medication tablets, a drug bread. I've sort of physical a shins. Some of the more common street drugs since, like the marijuana weed, that's what stuff Alcohol. Cocaine's kind of dilated pupils, which means really big pupils. Looks like the amphetamines. Things like hallucinogens. The LSD is mushrooms. That kind of stuff. Um, I don't know why they put opiates in that category. That's really stupid. Opiates, heroin calls, tiny pupils. So this thing's wrong in that sense. But otherwise here on vitamins, the sort of drugs that make you feel really, really high tentacles quite large people's things. Tentacles, uh, hallucinogens tend to cause quite large people's Yeah, uh, here's some more people stuff because that people's a quite useful thing to learn about in situation number one. Over here on the left, he's got very pinpoint pupils and on the right has got normal people, so you can just see the difference in size here. The bottom here, the bottom left. We've got a pupil charts. This is sort of an indicator of what's the size you're looking at when all the describe peoples in terms of millimeters, so how dilated they are four millimeters across to be a form formula meters from one end to the other end of the pupil means four millimeter dilation. Um, you get them quite large nine millimeters. You start to get close to a centimeter wide people, which is quite a big people. It's very big people. Um, whereas one millimeter, you're getting very, very tiny. This is sort of pinpoint is sort of 12 millimeter area on on the right down here. I've put a basic overview of of how we assess you have any more assessed people's when it's dark. Your people should be really big, faster, sort of allow more light in when there's not a lot of light around. When there's a lot of light, they should be really, really small. This is to try and prevent too much like getting in and damaging the eyes, and they should always be even So, what that means is that if your left pupil has a lot of light shining into it, you're right. People react the same, and they were both constrict. That's not to say that if you put a little darkness over the right eye, they were both widen up is more. They react to light when they were after dark and they react to a lack of light to become big. Um, so if you shine a light in someone's I, you would expect both peoples to constrict at the same time. If they've got problems, that's the head injury. Maybe only one pupil will react and the other one will stay the same. Um, if they do weird things other than that than be bit concerned, but they should both react together. Um, signs of an opioid overdose, so long as you put over your over those This is that's what this patient is. It was meant to be that, uh so you pinpoint pupils. As I said, people get very, very tiny. They lose consciousness. They get this sort of slow, shallow breathing because it's a respiratory depressant. You get very pale skin blue lips linked to not having enough oxygen because of the fact you're not breathing very well and you lose muscle tone's to your airway starts to shut. Your tongue might low back. You don't clear saliva from your airway, so you get snoring raspy, noisy, breathing things you don't really want management. Um, in this case, this patient has severe has respiratory depression. Is respirators quite slow? he's not breathing enough to support himself. The priority is to try and get more oxygen in the patient. So that would be giving high flow oxygen. Or think with a bag of mask that gives the basic means. You can start supporting their breathing, making each breath a bit bigger. We're giving them extra breast if they're not trying to breathe a drug called naloxone, which I'm glad I'm Melanie again because she can explain this better than I have probably can, Which is a Neuroxin is sometimes called Narcan. Narcan is a brand off naloxone is basically reversal. Agent for opiates. It's Ah, competitive antagonised, I believe. Is that right, Melanie? Yeah. Yes. And there was something about drug. Sorry Doesn't work for very long day. Yes, So it wears off more quickly than the opioids they've taken. So depending on what they've taken some opioid, it's kind of very, very long half life. So how long it takes them to be partially excreted? So the effects of the drugs can last a while. But actually no Laaksonen, quite quickly excreted so you can give them loads in a lock so they can perk right up again. Start breathing properly. Wake up, you know, be be back to normal. And then in 15 minutes time that Aloxi is worn off. But the opiate they took hasn't and they go straight back to being comatose. It's It's important to keep monitoring this patient even if they look better. They need to be kept in for a fair few hours, maybe overnight, to be to be watched if it doesn't work, so locks on should take that quite quickly. It works quite quickly. It wears off quite quickly. Quite a good fact in most drugs. In this case, maybe it wanted to last a bit longer, but it's not a good thing. Um, there's a few reasons for this. One of them might be have not given enough naloxone if it taken awful lot of whatever drug they've taken. They might need more than your initially expecting us in patients required to three times the normal dose. So what they've had, um, if they're not taking on opioid not saying only works on opioids, and it works on GHB. Otherwise, it's not going to do what you want it for. So if they've taken a ketamine overdose, for example, and they put themselves into a comatose state because of too much ketamine. You're you're not gonna reverse it with naloxone that patients not going to suddenly recover because of what you've given them, It won't work on other causes that they've had a stroke, for example, in the lock. So it's not gonna do anything. They're saying that it doesn't hurt, have given them the locks. I'm just to rule out that it is an opiate cause. And if it's not a drug, So if the patient state is due to something else low blood sugar, for example in the hypoglycemia so mentioned head injury, all these various things, although just to sleep if they're very deep sleep or they won't notice you're sticking needles in there. I hope that notice you stick a needle in there are even if they're very deep sleeper. Yeah, it won't really do anything to them. In that case, it's time to start trying to figure out what else it might be. So that would be things like a toxicity panel of blood. Zip might be time for some imaging head imaging, the brain imaging, the chest things that is to try and rule out other causes. Um, a word of caution. And this is a very useful word of caution because everyone should take note of this one. The locks on could be very, very effective. It can wake patients up very quickly. Someone said to me once that it wakes up the dead fast, then you believe and I've seen it work. It does do that. Patients, You think, er in a coma? Rel. You know, looking like they're gonna be dead suddenly. Wake up. The patient doesn't necessarily know they were unwell. They've taken a lot of a drug. Let's make him feel normally quite good. I'm not going to condone taking. I'm not going to support the taking these drugs. But these patients take them for a reason to take them. And we have a high or they a warm feeling. Whatever it is they get, they have not noticed. They're very, very sick. They've just felt very, very high. Uh, and you've just ended that you've given them a drug and this high that had is gone. All that money they spent a lot of a drug they've had is now wasted. They wake up. They've also probably not had very much oxygen in the time they've been that time since they've taken that drug. So they're probably quite disoriented and probably bit confused. And all this adds up to make a very angry person. Um, so a good tip when the locks on is to not be the person standing nearest the patient when it's given, because they could get quite punchy. Or you give naloxone quite slowly, so you give a bit of the locks in enough to sort of recover their breathing rate a bit on. Then you give it to them a little bit at a time just to slowly bring them back up to It's a human. Bring them back to normal on giving them a chance to have a bit of the breathe. While that's going on, get some oxygen going round, recover, come back to being a little bit more conscious before they're fully conscious and sort of get an idea of what's going on rather than just give them loads in the lock so they wake straight back up on. But they get really angry. That's yeah, be careful with it. Could be quite effective. And that is the end of my presentation. Are that any questions? I will also find the metal form. Anyone has feedback. Please do your feedback. It's also Hey, hold off the certificate. Um, we do appreciate your feedback. We use it. Try and make our sessions better. So please do give feedback if you have any feedback things you like things you don't like particular things you don't like. We always It's very common to get positive feedback. People always see the positive side. Actually, the negative sides tend to be the best one for us to then learn from and make things better. But thank you for everyone who came along tonight. Thank you, Melanie, for helping out. Um I'm going to leave you with this pain with why Penguin penguins have fema's. That was That was my entire logic. About what? I'm going to end on a penguin. Um, yeah, Penguins have FEMA's nothing was look weirdly human. Um, like, weirdly human. So yeah, of what's any questions? And if not, we'll call it a night. Give another 30 seconds for for animals to you. Any feedback? If not, this session will be available for anyone. Was torture on recording and also be uploaded on to meddle. Um, assumes it's done. I'm seeing their questions. I'll call it there. Thank you, everyone. Have you have a lovely evening and the lovely rest of the week and I should see, Hopefully see Well on Thursday. Thank you.