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Ok. All right. We'll just wait for a few minutes for, um, um, people to join and we'll start the teaching. Ok. Right. Ok. I think we'll just make a start and hopefully more people die as, um, we go on. Ok. Right. So, hi, you guys, I'm Pat. I'm one of the, um, fy one in, um, Saint James Hospital in Leeds. I'm currently, I'm currently doing my rotation in, um, psych. Um, but I've done my first and the second rotation in gastroenterology and general surgery. So, um, as you guys can see, I'm trying to basically cover, um, common A Eines, um, that I think, uh, you guys would, um, basically encountered when you guys are on F one. So this, uh, um, there are 33 scenarios in general. Um, I hope to, that I could do more but I think because of the time this is only a one hour session. So I can only manage to, um, incur three scs. But these three scenarios are basically based on my experience. Um, I try to, I do make some adjustment just to make, um, the case, um, shorter. But, um, yeah, it's still based on my real um, experience um when I was working in the gastroenterology and general surgery. Um, so I hope that you guys would probably gain a lot of benefit from this um, scenario as well. Ok, if you guys want to let me know where you guys are from, are you guys, uh, f one doctor as well or are you guys uh, medical students? Um, just so that I know, um, um, like if you guys have similar experience or anything like that, um you guys can unmute yourself or type in the group chat that um so that I basically know where you guys are from? Ok. Um Shall we start then do you guys know about a to e um have you guys heard about it before? Um Do you guys know what it is? Ok. So um it is basically if you guys don't know, it's basically, it's like um an, an assessment that we um go through each step of um assessment as we um assisting the patient and then we kind of like um detect or like find out what is wrong with the patient and then manage them accordingly. So, um the first eight is basically ABCD E so A is a, a um basically you check um with the patient a part or obstructed. Um This can be done if you can basically, if you, if the patient is speaking in full sentences, then um the airway is patent. But if the patient is not speaking, you hear abnormal sounds like um stridor or like a gurgling sounds. Then you probably would need to um check the patient airway to see whether that's anything obstructed and then remove it with um suction. Um OK. So B is for breathing. So you can check the pulse oximetry using um um basically use the pulse oximetry to check for any oxygen saturation, check for patient respiratory rate and um check for the chest examination. This include checking for the position of the trachea, um auscultate, um the chest for any abnormal breathing cells and check for the chest expansion. OK. So, um then there's some tests that you can also um done in this step, which is include ABT or ABT. So, ABT is basically a blood gas that you do from the arterial and ABT is the blood gas that you do in from the um venous um vein. So um you can do that if the patient is having low um oxygen saturation or having low um EE CCS. And um you can also order D CSX ray if you think that you, that the patient is having any lung pathology. OK. So c is for circulation as well. You check for the um capi any pulse um and check for a patient, pulse, check for BP and then you auscultate for the chest. If there's any abnormal heart sound like murmur or if you could hear um tachycardia and in here, you can basically um order for ECG as well to check for um patient um heart trace the electric um electrical heart rate. And um you can also put in the L IV Cannula if you think that um patient would need um blood transfusion or um need antibiotics or fluid resuscitation. And you can also insert urinary catheter in at this point to um assess um fluid balance and also um the urine output. So next one D is for disability, it's basically when it's why you check for um G CS, um when a patient is basically having um G CS of 15 or 15 or have you reduced G CS. Um and you can also check, another way you can check is using a V pu system. So I don't know if you guys have heard about this before, but it's basically being used a lot, especially um when a patient is having cardiac arrest, if you need to present, you can use the A VP system. So it is basically alert. So if the patient is alert and speaking to you, that's a if the patient um is responding to your voice that is weak and if the patient responded to pain only. So if you basically press on the supraorbital area, and then patient responded, that is um um pa patient is responding to pain and you is fall unresponsive. So the patient does not respond to respond to anything that is you. Um So patient is being is ha become unresponsive um in disability, you also check for the pupils, um glucose temperature and check patient drug shot as well here, ok? Um And the last one is exposure. So this is why you basically expose the patient um to look for anything that could basically be the cause of um making the patient become acutely unwell. So here you can check for any sign of bleeding and you rashes any injuries. You can also um perform um abdominal examination or other kind of focus examination. If you think that um if you suspect any system to be the cause of the deterioration, then you can do that focus examination here as well. Any questions so far here, you can type in the, in the chart if you have any questions. Ok. Right. So let's move on then let's not um wait, let's move on to the exciting time. So c one this is basically uh you are an fy one in general surgery. You um one morning you arrived at the hospital and then you see on um the ward list that one of the patient is having. News of eight. This lady is um an 87 years old female. She is admitted with acute cholecystitis and she was treated with um cholecystostomy drain and antibiotics. Um She is fine now she's fully treated. She has remained more for quite a few days, but she is just um waiting for the discharge planning. So 8 a.m. today when you arrive, she seems to be deteriorated with um tachypnea, tachypnea and um difficulty breathing. So um she, yeah, when you have a look, she's having news of eight saturation oxygen saturation of 87% on um nasal cannula 3 L respiratory rate of 28 heart rate of 122 and temperature of 36.1 BP of 154/96. So um in here, you probably are a bit worried about um her oxygen saturation and high respiratory rate, isn't it? Ok. So then um patient is using of eight, obviously. So you need to go see the patient. So you would run like that in the patients. But I think you guys would probably know if you guys are a doctor in the hospital that this is not the case. You don't always look this nice in the hospital, especially if it's 8 a.m. in the morning. But anyway, you would run to the patient right away. So at the bedside, you found out patient looks very breathless and distressed. Um She is grasping for bread. You can see that that subvital inhaler next to her bed. And um patient told you that I have used it, but there's no benefit. Um The nurse informed you that um patient has um history of right lower lo lung mass. Um And she's be basically being treated with radiotherapy and she also have COPD. So now you start um your assessment right away. Um ok. So do you guys think that this patient airway is obstructed or c patent? Ok. How would you tell whether patient airway is obstructed or patent? Ok. I might try to make a pull actually. Mhm. Sorry. Struggling to make a poll. That's fine. Um So if they are speaking, that's potent. Yeah, thank you. So, so yeah, so the patient was speaking just now, right? She was telling you that I have used this salbutamol and it's not working. So then you would probably be able to um assume that patient I A is patent right away. So you don't need to do any other extra uh maneuver to keep the air to protect the airway at this point unless she start deteriorated. Ok. That's great. Thank you. So now you move on to breathing. So you start with listening to patient um breathing. So, oh sorry, listening to patient additional breathing sound, you can hear that patient is having expiratory wheeze. Um when you stand next to her, it's quite loud, quite clear when you ask the chest. Um you can feel you can listen, you can basically hear the bilateral wheeze throughout and there's some reduced breathing sound at the right lung base. The new pal palpate doing the chest expansion and then that is equal chest expansion. Bilaterally, patients, saturation is still 87% on 3 L, nasal cannula and respiratory rate is 28. So I guess we are quite, it's quite worrying, isn't it? This oxygen saturation? Um 87% is not great. Um So she has a back out of um COPD. So do you guys know the target set for um COPD patient? How, what is the range of the um oxygen set for ACDC O PD patient? So um in CO PD patient, oxygen sat is 88 to 92. So um you would try to give the patient oxygen sat in that range just to make sure that you don't over um oxygenated the patient and then they start retaining um the carbon dioxide and developed type two respiratory failure. Ok. Right. So now you basically found out about the breathing that patient have expiratory weeds, um bilateral um wheeze when you auscultate eco she expansion but does reduce oxygen. So um is there any other thing any test do you think you would do at this point to assess the patient at this step? You can do a chest X ray? Yeah, we be doing chest X ray. Thank you. So she had x-ray and this this is patient. She had, she has x-ray. Um Right. Are you, are you worried? Are you guys worried? Like do you think this is worrying? I think that's a hint that this is actually quite worrying, isn't it? Ok. So, oops, sorry. So um how you could tell um that that is basically you can tell that there's some um hazy white area around the right lung base. How you tell that this is the right lung base is basically um is that patient x-ray is normally in the opposite side to you. So, if this is your left, then that's um that would be the opposite side of you. So this would be patient right lung base. Um And this area of hastiness is basically um is basically um a consolidation. So what is consolidation? What is consolidation? Do you think, what is such as, do you think it's um like an infection in the lung? Fluid in the lungs or lung collapse? We know that that's a right consolidation in the right. Um That's consolidation in the right lung base now. So normally, consolidation can indicate that there's an infection or fluids um in the lungs. So at this, if for this chest X ray, you probably would su suspect that there is an infection in the right lung base. And there might be some component of the um um pleural effusion of fluid in the lung as well. Ok. And um yes, we could also do an E BG or a BD in this patient. So, because the patient is um in this, this patient, she, she has CO PD. So she is basically having high risk of retaining um oxygen, oh sorry, retaining the carbon dioxide in her blood. So, we probably would do a BD at this point because it's allow us to assess whether she is retaining any carbon dioxide. Ok. So what do you think? Um this is her a BD result? She is quite acidotic, right? You can see her ph is 7.2. That's quite worrying. Um her car, I is um ok. Her oxygen is a bit low. Um and you can see that she's having lactate of 4.2. That's not good. She's having quite a lot of lactate. So um what do you think? Is this a type one respiratory respiratory failure, type two respiratory failure by looking from the ABT? Can you can you see the ABT? Oh Am I like, am I stuck on some of the slide? And you can't see the ABT? All right. Uh No, you guys can't see the, do you not, do you not be? You can't see the slide, the ABG slide. Are you on the chest X ray light? Ok. Um That's OK. If you can't see when I move on to the next slide, let me know. And the one before she has x-ray. Oh Wow. OK. That's not great. I'm not sure if this 250, you can see the ABG. Not that great, right. OK. Let's go to um ABG again real quick. So as you can see, Ph is quite low, this patient is acidotic. Um No, don't worry. That's a, that's why don't worry. Um Ph is um 7.28. So patient is quite acidotic. Her carbon dioxide is ok. Her um oxygen is quite low. Um then the lactate is quite high as well. So, do you think this is type one or type two respiratory failure? Right. So uh in this case, um because it seems like patient is basically not retaining carbon dioxide and it's the P the P CO2 is 5.39. So it's actually it's quite normal but the oxygen is quite low. So this patient is still not retaining yet, although that decided that there might be some um compensated here. So I feel like this patient will probably drop into type two respiratory failure um quite soon. But um at this point, she's still not retaining, she was, so she's still in type one. noted the high lactate as well. Um She's probably retaining quite a bit. Ok. So right now you have done the breathing part, move on to the circulation. So, um patient told you that there's no chest pain. The um cap refill is less than three second. The BP is 154 slash 96. Um No risk. JP heart sounds normal and ECG shows sinus tachycardia. Ok. So, um well, I think she's, she might be slightly um dehydrated. Uh see, um cap refuses less than three seconds. But other than that, I think that's not, that's too worrying at this point from here um from this, from the circulation assessment. So you move on to disability. Patient is alert gcs of 15 or 15 pupil is equally reactive to light BM is 5.7. So it's normal and temperature is 36.5. So that's also normal as well. So that's not nothing worrying from the disability assessment. So now you move on to the last one exposure. So expose the patient, you have a fever around the abdomen, so abdomen is soft and nontender. Um So you quite, you can probably be reassured as patient, patient is not deteriorating from the surgical cause, even though she was admitted for the surgical um reason. But um at this point, that's not the cause of her um deterioration. Um you can assess the calf as well as soft and nontender. So there's no sign of DVT. Um at this, there's no sign of DVT or cellulitis. Um no signs of peripheral or sacral edema. So it's probably no signs of heart failure or fluid overload. Ok. So let's summarize our finding a little bit. Um So this patient is basically having acute onset of shortness of shortness of breath and tachycardia. She has b bilateral wheeze and reduced uh in to the right lung base, chest X ray show right pleural effusion um and consolidation. Sorry ABD showed type one respiratory failure with raise lactate. Ok. So what do you think is a differential diagnosis for this? Reminding that she has past medical history of right lower lobe lung mass and also CO PD. So from this point of view, yeah, thank you. Yeah, that could be pneumonia definitely um for pneumothorax because that is um basically that is a co expansion. I think Iotrex would um be would rank quite low in our differential diagnosis at this point as well as lung collapse as well. But um that's bilateral wheeze. So this would suggest that that is basically um something um that is causing the airway narrowing in her lungs, isn't it? So, um she also have a backup COPD as well. So I think this is probably an exacerbation of COPD. Her chest X ray showed that that is um that is um chest consolidation in right lung, sorry, that's consol consolidation and pleural efficient in right lung base. So that's probably pneumonia. So this is the differential diagnosis for this case is most likely infective exacerbation of COPD, which can be life threatening um in this patient because you already see the P the um ABT she's quite acidotic. Um And another one is ho hos hospital acquired pneumonia um because she's been staying in the hospital for quite a long time as I said, she um has been treated and she's m medically fit for discharge, but she's awaiting for discharge planning. So, um hos hospital acquired pneumonia could be um another differential diagnosis. So this is COPD. Basically, I just wanted to show you guys really quickly. I think you guys are probably already know about this So CO PD is basically when there is a narrowing and inflammation of the airway causing the airway to narrow and um excreting a lot of uh excess mucus. So you can see that this is a normal um airway and when that is um CO PD, uh um flare up. So there is a narrowing of the um bronchi, meaning that there's less air passing through um in patient who have COPD as well. The that is the breakdown of the al al alveolar membrane. So um you can see this is the normal alveolar membrane and this in the patient with COPD, um that is basically the membrane is broken down and there is a less um space for the air exchange in the lung. That's why it's causing patient to have low oxygen, low oxygen saturations. So I have a I have a um yeah, I have a comment from here from, so saying from an ay point of view as an fy one, at which point would you say escalate to the senior in this case? So honestly, um in my case, I escalate to the senior um right away after I um see the patient new score. And when I see the patient and how unwell she is, um the point where I really try to escalate to someone is after I see the ABT because she's very acidotic um ph of seven point two is basically could lead, could cause patient um to be to deteriorate and into cardiac arrest. So I would escalate to dysemia as soon as possible. Unfortunately, um In a point of view, you definitely would that escalate right away when you see the patient, um when you see that she's not, well, having really low oxygen saturations, um having grasping for bread and having um shortness of breath is not stoping with the salbutamol just escalate to the C. But um unfortunately, um what you put on a per call in this point, I would say I could have because I did escalate to the C but it was difficult because it was at 8 a.m. in the morning for my, for my, for my experience, um it was very difficult to get the senior to come down because they are busy in the handover. Um So, one thing I have learned is that if you put on the per risk call, everyone is gonna come. Eventually, we did discuss with the ICU um rush anyway about this patient. Um So, uh there's no harm in putting on the per risk call if you feel like you could not get um senior health quick enough. Um And you would need one, you would basically need somebody to come and see this patient because if this patient is entitled to respiratory failure, uh and if she, she is basically retaining quite a lot of carbon dioxide, you would need to um have a better um respiratory support for the patient. And you could not do that on the ward. The only way you could do that is to send the patient to ICU. So you could, you would definitely, um you could put on the per risk call in this case. OK. All right. Any other questions? If not, we should move on to the management. Ok. So let's say you have escalated to senior while you're waiting for the senior. That's something you could do. Definitely. Um hopefully they have arrived at this point. But if not, um we can, we will learn how to manage them while waiting for the senior right now. So, um yeah, so the first thing you should do is to put the patient into the correct position. So um in the patient who's struggling to breathe regardless of any cause if the patient is grabbing for bread, it's easier for them to breathe if they sit up um and leaning forward. So you would encourage them to sit up that way, put a pillow behind their back, set the bed up, make sure that they can take a deep breath in and out. Um OK. And when after you put the patient in the correct position, then you will start to correct the oxygen if you regards, remember this patient basically have the COPD. So you would use the wintry mask in this case and her oxygen sat is 87. So you would aim oxygen sat to be around 88 to 92. So you can give the 15 L um while winter mask to correct oxygen saturations. After this, you can basically use the nebulizer. So um the main nebulizer we use in um CO PD exacerbation is Sam and Ipra toin. So in this case, you can use SOOL nebulizers, 5 mg back to back. Um how you give it is that you can give it through the VR mask. So the nurse will basically add the 5 mg um serotonin nebulizer to the ventric mask. And the patient would breed that nebulizer in through the ventric mask. You can give it back to back or maybe it's not necessary if the patient is no longer having any wheeze. Oh, so you just have to assist the patient. Um And then uh after giving the AOL, you have to keep IOP bromide 500 mcg stats. Um you will not believe me. But after I give this nebulizer, patient basically settle um down quite, it's quite a fatigue. Basically, patient does settle down after having these um nebulizers and their breathing do improve quite significantly. Ok. Uh The thing that you do is basically start IV antibiotics right away because like you can see that uh this patient might have hospital acquired pneumonia and that's an evident of um consolidation in this case. So just start IV antibiotics um according to your trans protocol. Um and the last one is giving the IV fluids, you can give one hour um 1 L um of IV fluid two hours because this pa this patient is having high lactate. Her lactate is 4.1. So you can give IV fluid to get to get rid of this lactate basically. OK. So let's say you have done all the thing has come and review. Um You said get off discontinuing, continue assessing and then they spoke to the ICU, the U have come to see the patient. Um Thank the patient is well enough and do not need to be um supported um in ICU so she can be remain on the ward, right? So you kind of basically have cured the patient. Um By the afternoon, the patient becomes settled in the bed. Um She no longer having wheeze or breathlessness, no longer required oxygen. You repeat the ABD. Um and her, she's not having any respiratory acidosis. She her oxygen um is still quite, it is still slightly low. But um we can correct that with using the Ry mask and give her a bit more of oxygen, she's not retaining any carbon dioxide and her lactate is 1.8. She's not comp compensating anymore as well. So yes, you have treated the patient. She cured the patient, basically she's well now and she was discharged a few day afterwards. So yeah, you have treated her well and that's basically how it is in the hospital patient do become unwell with the reasons that they are not admitted with. But um with this exerbation of COPD, you, you patient would look quite dis in a lot of distress when you first see them. But you can um if the A BD and everything would look quite scary to you, but you can definitely treat them um quite quickly and get them back to their baseline quite quickly too as well if they are not in like um a really bad conditions. Ok. So let's move on to C two before I move on. Do you have any, do you guys have any questions? Anything you want to ask at this point before we move to C two? Ok. If you do have any questions, just type in, um, just type in into the, um, the group chat and then, um, I'll try my best to answer it. Ok. So I'm sick and so is, again, you are f 11 in general surgery. You have known this patient for quite a while. Um, he is a 57 years old male. She, he is POSTOP day one, elective reversal of ileostomy. So he basically have his ileostomy reversed. So get rid of the ileostomy and connect about together, right? He seems to be recalled well, after the surgery when you see him during the walk out this morning, but suddenly you got a call from the nurse saying that he has complained, um, about having come a about having palpitation and the nurse is quite concerned. Um, she informed me that he has, um, past medical history of having two cardiac angioplasty, um, hypertension and diabetes. And she asked, uh, could you review this patient, please? Ok. So you go and review the patient at the bedside. You can see the patient is sitting out in a chair. He looked well. Um, he said I keep, I was feeling fine after the surgery yesterday, but I started to feel that my heart has been racing for the past 10 minutes. Um I don't have any chest pain though and her, his nose is ok. It's to him, he is slightly tachycardia. But um the BP, respiratory rate and oxygen sat is fine. Ok. So then you will start your assessment. Um like we like we talked about in the last um um in funeral, this patient was speaking to us. So his airway is part 10 and he's speaking in full sentences. So we do not need to do anything to protect his airway unless he deteriorate. Ok. So move on to breathing. So you can't hear any additional breathing sound. You start auscultating the chest and the chest is clear. Um That's equal air entry bilaterally. So on palpation, that's equal chest expansion bilaterally as well. Um Oxygen sat is still 97% on air with respiratory rate of 18. So it's not worrying. That's nothing that um I think is concerning at this point from the breathing point of view. Ok. So moving on to circulation. Um Oh, so let me mention because this patient, we are not really worried about the um breathing. I think that we could probably skip the chest X ray at this point. But if you in your oy, maybe you should, you should still mention that you would order the chest X ray x-ray. Um But in re in, in reality, it would take some time for the chest X ray x-ray to come or for the patient to go to the chest X ray. So you probably would not do it if it would um prolong your assessment or it was um basically interrupt the assessment. So at this point, I would just skip to the circulation. Ok. So um cap refill is less than two. Heart rate is normal. There's no murmur, no GP patient is slightly tachycardia and BP is 145/92. So it's slightly high. So, is there any other test you should do at this point? Are you concerned that he, he is slightly tachycardia? Ok. Um tachycardic with um high BP, I think we could do a ECT couldn't we? Um his heart rate is a bit high. Yeah, exactly. He did the ECG um cause his heart rate is a bit high. You don't know and he is having palpitation. It is, it's probably good if you um assess with it as any kind of like af if patient is having any arrhythmia or anything concerning, he also have quite strong cardiac history. So I think it would be a really good idea to do a chest X ray it to do a ECG here actually. Ok. You can also do a blood test as well. Sorry. One second. Ok, let's go to the ECG first. Right. Do we skip ABT and BT in this patient? We probably would not skip um BT and ABT in most of the patient. Um It just depends on whether um you want to do ABT is this necessary to do a BD? Cause A BD is a lot more painful compared to V BT? Um So is the question is whether you would do an A BD or a BD? And I think in OS they would ask you like, would you perform a BD or E BTA? Lot of a lot of time, you would need to think whether it is necessary to do an A BD. So in the, in a patient that you think could have um respiratory compromise, then you would do an A BD. But in this patient, um as his breathing seems fine, his sight is OK. I think we can do an A BD. So yeah, we can do ECG and um E BG here. So let's look at the E ECG first. Do you see anything abnormal here? Is this ECG look a bit concerning to you. Can you see a tall tinted T wave? This is basically at wave QR S complex. And this is the T wave, the T wave here is really high. It's really long compared to um the normal T wave. Basically, the normal T wave should look like something like this. But the T wave in lead 23 A VF um we want me to retrieve it's actually quite high. We fall as well. We fall with 5 B6. Um Do you see the ST elevation? And we want we two and we three. Yeah. So this patient is basically having a classic um classic EC D for uh hyperkalemia, isn't it called in the TF? And that's like um also a risk. Um ST this could be because of the cardiac history that also could show that there are some CT changes in your um in the patient in um in the E BA. Basically, there's some E CT change changes at this point. I think I might also consult cardiology because this patient have quite complex um cardiac history. So I would not want to miss anything. But let's say that we um we are consulting the cardio, the cardiology. So, ok, let's move on to the blood gas. Like um we said we would do a V VT at this point. Um Is there anything you worry about in this blood test? So, patient is quite fine, she's not acidotic or alkalosis. Um There's no um reduce in oxygen in the partial oxygen. She's not retaining any carbon dioxide, her sodium level is fine. Can you see the the potassium level is 6.5 that's quite high, isn't it? Ok. The other um electrolyte and the lactase is fine. So you can basically um one of the differential diagnosis that you can make here is basically hyperkalemia, right? So you have had a look at the ECG um right. So you move on to disability very quickly as patient is alert. TS TDC is 15 or 15, um pupils equally reactive BM of six, temperature of 36.7. Is there anything else would you check here? One thing that's really important in this case, I think in the patient who have um electrolyte imbalance, you definitely need to check for the drug shot. So it's just in case that there's anything that could be the cause. So the patient is taking Metformin because for his diabetes, um Aspirin for his um cardiac um problem clopidogrel as well. Um Rami Pill for his high BP, Amido um amLODIPine as well for high blood pressures. So these two medication was stopped before the surgery, um his elective surgery. So last night, he probably did not have these two medication to prepare for his surgery and then after the surgery, he's doing fine. So we started him on these two medication again. So do you spot any medication that could increase the risk of hyperkalaemia here? So, um Ramipril, I think that's quite weird. Ramipril is um ac inhibitor. So that the main side effect of Ramipril, one of the things that we know is um hyperkalemia. So we kind of spot the culprit here. And in this case, um what we would do, I would definitely consult the pharmacist or consult the senior, inform them that this patient is having potassium 6.5 and he's taking Ramco um aspirin as well actually is one of the nsaids. So um NSAID can also cause um hyperkalemia. So I would come consult pharmacist and also um my to see if it's appropriate to stop this medication. It is it the risk of um hyper pressure outweigh the risks of hyperkalemia. So in this case, I think that I would stop these two medications. Ok? And then you just finished the rest of your examination. So exposure, his patient calve is soft, nontender, no peripheral or psyched, no signs of bleeding, bleeding. Ok. So to sum the sum summary of your finding. So basically, patient is post on day one, reversal of angiostomy. He has past medical history of two cardiac angioplasty hypertension and diabetes. He suddenly complained of acute onset of palpitations. His blood basically show risk potassium and there's some ec ecg changes as well. He's taking Ramipril which can cause his hyperkalemia. Ok. So you now know that the differential diagnosis here is hyperkalaemia. So then you start treating hyperkalaemia right away. I was trying to get the lead um guideline for hyperkalaemia treatment, but I can't access it if I'm not in the hospital. So that's really annoying. But anyway, this is the guideline that I used when I was in medical school. So this guideline would tell you when you need to um treat for hyperkalaemia. How do you classify hyperkalemia? So it's classified as moderate, mild with K of less than um six moderate. It K is between 6 to 6.4 and then CV FK is more than or equal to 6.5. So in this case, this patient um potassium is 6.5. So it's actually borderline severe. So we would start um we would look at the ECG that's the ECG changes here as well for this patient. So we would start treating the patient right away. So basically, the first thing we need to worry about in patients who have hyperkalaemia is um arrhythmia, isn't it hyperkalaemia can cause arrhythmia? So we need to protect the heart, as mentioned in the um guideline. This can be done by giving the IV calcium gluconate. OK. After that, then you, after you protect the heart, then you need to consider how you would reduce the hyperkalemia, like reduce potassium level from the blood. So this is done by giving um rapid acting insulin such as a Atro with in, with um with glucose. So that when the insulin start taking glucose out back into the cell, it would bring the potassium um back into the cell as well. So I suppose that potassium is brought back from blood into the cell, it's lower down your potassium level. Um, you can also give Sam as well, although that's not really, um I can't, I don't really see that being done in the hospital, but you can also give Sams to lower the potassium level and you can give um calcium resonium, which is um, a medication that you can give. And then patient is basically cause the patient to pass out the potassium into the stools. So that's reduce the potassium level in the blood. But um this you can see the effect quite slow. So um the IV um glucose with insulin is the quickest way to bring down the potassium level in bloods. So basically this summarize what I have just spoken. So um stabilize the heart with 30 meals of 10% calcium gluconate, then move on to absorb um potassium back into the cell by using pi the fast acting insulin of 10 units with 50 meal or 50% extra. Um You can add sotol 10 mg nebulizer to help absorb the poem back into cells. And then consider using calcium rason resonium to pass um mm potassium out into the stools. And then you should repeat level, OK, potassium level and ecg afterwards to make sure that patient is not no longer um having hyperkalemia and the ECG is basically coming back to normal. OK. Any question from this signal, you can type in the group chat or if not, I'm a bit conscious of the time. So I will move on to funeral three. But the last one is, um, quite simple. And, uh, I have seen this cer quite a few times when I'm in Gastro. So if you have any question at any point, just pop into the group chat. Ok. Right. So you're an fy one this time in gastroenterology, you got a bleed from a nurse asking you to see a 67 years old, um, male who had just passed around 500 m of dark stools. Ok. That's quite a lot of dark stools to be passing. Ok? And the nurse informed you that the patient was admitted with endstage liver cirrhosis and had an acetic drain inserted today. Ok. So he does have, as I did, he, he does have liver cirrhosis, ok. So, um you can see the new score, sorry, I didn't put in the new score here, but you can see that his respiratory rate is 22. It's a bit um, high heart rate is 121. That's, he's very tachycardic. BP is 87/59. So he's hypotensive oxygen start is 94% on air. So slightly hypoxic and temperature is normal. Ok. So in this case, you would definitely run to see this patient quite quickly. Um If he is passing, um, that large amount of dark stools. So at the bedside, you can see that patient is in a lot of pain. Um, he's twisting in bed with pain, but he's conscious and responsive to you. He looked pale and clammy. Um, you had a look at the stool and you confirmed that it is Melina. Again, at this point, I would definitely, um, get the senior help. I will ask the nurse to get the re gastro register or any, any senior you can get. Basically, even if you have another fy one on the ward, I would recommend you to grab them to help you because that's a lot going on. At, at this point, you probably need to um stabilize the patient quite quickly. Ok? So let's move on to the assessment airway. Um So patient is still responsive, still speaking in short sentences. So the airway is patent. So we don't need to do anything at this point regarding the airway. So move on to the breathing. Um All right. So you don't see any sign of sinuses at the moment. Um You oculate the chest, um chest sounds clear echo and preparatory. Um chest expansion is equal, both sides and oxygen size is slightly low. It's 94% on uh but it is, I think it is not too low that you need to start off with pace mark. I'm pretty sure you can basically just give the nasal cannula to increase oxygen sat mainly to like 97%. That should, that should be doable. So you can start patient on the um nasal cannula um and start giving uh oxygen right away. Ok. Moving on to circulation. So you start accessing the cap refill time. It's five seconds. He's still tachycardia. No rest. JP. He has very cold periphery. Um BP is very low 87 on over 59 and heart sounds normal. So at this point, are you concerned? does he look hemodynamically stable to you? Do you think he's tachycardic and also um hypotensive? Oh So I think he is hemody hemodynamically unstable, isn't it? Right? Ok. So we better in my, ideally, we will start treating the patient right away. But I just want you guys to go through all the assessment first and then we'll talk about the management. Ok. So now you would do blood gas anything you could get the quickest. Um Just do it because sometime patient patient is having high is basically quite hypertensive. It might be difficult to do um V BD if you could get an A BD, do it. Uh If you can't, if you can't get the V BD, just do it, whichever way you can get to broad gas. Um at this point is the best. OK. So this is the broad gas, let's say is, is the V VG. So um can you see that patient hemoglobin is 67? That's quite low, isn't it? That's actually very low. He's passing quite a lot of bloods, you already confirmed that he's passing 500 M of Malia and he is hemodynamically unstable and he is having HB drop as well. OK. Right. So you move on to the rest of your assessment quite really quickly. So disability, she says it's 14 or 15, his um pupils equally reactive to light. His bum is normal. His temperature is 36.8. So I don't think that's anything that's too worrying in this se in this assessment. Ok. So, on the exposure, so you can see you exposed the patient, you can see that he is basically having Melina on the bedsheet and between his legs, um abdominal examination, you found that he has generalized tenderness in his abdomen. Um No signs of peripheral edema, no sign of DVT. OK. So what do you guys think is the differential diagnosis? Ok. All right, we already summarized the findings just now. So, um because he passed 500 m of Melina, he is hemodynamically unstable, reduced oxygen, sat, um reduced um hb drop to 67 and has generalized abdominal tenderness. I think he is probably having upper gi bleed, isn't he? He's probably having upper ti bleed from um liver. So his reversal is causing um well causing um ok. So uh he's probably having livers r rils which probably causing um portal hypertension and he probably is bleeding from that and because it's because it is Melina, it's not a fresh blood. So, Melina is um the indication for upper gi bleed rather than lower gi bleed. So, um in this case, the patient is basically passing fresh blood from um back passage. Then I would suggest that he has lower ti bleed. Um He could have a bleeding from peptic ulcer and have perforation. Yes. But um at this point because he has the liver disease. Um past medical history of liver disease, it's likely to be bleeding from that. Um Yeah. So diff differential diagnosis is upper tear bleed. Ok. So you would need to manage this patient quite quickly. Um Presuming that the nurses or you have already called for help, you can put out a re call as well cause patient is quite unstable while waiting for the help to arrive. You can start doing all this assessment, uh this management. So you can correct the oxygen saturation using nasal cannula 2 L. Um you can um stabilize the patient. Basically, you need to stabilize the patient quite quickly doing using fluid resuscitation. So um 500 meal of sodium chloride over 15 minutes. Um and then just continue to me measure the BP and the pulse rate. Hopefully you manage to bring the patient up the BP up and reduce the heart rate and the patient is no longer hemodynamically unstable. But you can basically repeat this 500 m of um sodium chloride quite a few times to get the um BP up to the normal level. So then you start inserting 2 L ball cannula. So the reasons why you need two lash ball cannula is because you need, you probably need one to do to give the blood transfusion. Another one you can keep the IV fluids or anything else that need to be given through the IV. So you probably need to lash ball cannula here, ok? Um Then you would activate major hemorrhage protocol. So for those of you who have not done this before, you can just call the double two, double two and call them that you want to activate the major hemorrhage protocol. This will basically um basically is to get all the seniors to come down to see the patient and the blood bank will start preparing four units of red blood cell for you so that you can basically get the ca can get the blood um the black um get a blood transfusion ready for the patient as quickly uh as quickly as possible and then start giving the four units of red blood cell to the patient. And then you would escalate to the C or gastroenterologist. Well, anyway, you would have probably done this quite quickly when you first see the patient and then you should keep this patient nearby mouth and prepare for the urgent O GD. So O GD is a camera test that you basically insert it down to um your mouth to have a look for um a the cause of bleeding. So you can have a look through the camera and then you can do an intervention to stop the bleeding as well. Ok. So if you guys want to know more about the upper tear bleed, I actually did another session um a while ago about upper tea bleed that I go through the details of how um the cause of um upper tear bleed. How do you manage them? What is the major hemorrhage protocol? And what are the procedure you can do to um to stop the appetite bleed? So if you it's still in met all, so you can actually, if you are interested in appetite bleed, you can actually go on and listen to that um lecture. So I just wanted to show you really quickly um the about the meta hemorrhage protocol. So this is basically, it's kept different, a little bit different in different task. But how it is is that you basically call double two, double two. You get through the blood bank, tell them, tell them that you are. Um Yes, you would def definitely need to do group and safe um to get the blood time fusion. Unless the patient already have blood time fusion done before. In this admission, they would have the group and safe, ready. Um Yeah, so you would, in this case, you would probably take group and safe as well while you're taking all the blood and they will d um and then, yeah, send the group and safe to Broad Bank. They will process that um that blood and then start preparing for the blood transfusion. They will, they will prepare you for four units of red and four unit of F FP. And then um then um some of these seniors like in hematology, hematologist, um the gas storage, um everyone would probably come to the bed and then try to um help you with this patient. So yeah, this, this is basically hemo major hemorrhage protocol. It's probably worth having a look at your hospital made a hemorrhage protocol as well. OK. So that's the end of the um scot tree. So basically what you do is um for resuscitation, the patient give the um sorry IV fluids um to resus the patient give the um blood transfusion, four units of red blood cell escalate to CIA really quickly keep the patient near by mouth and prepare for urgent OTD. OK. Right. So that is coming to the end of the sessions, right. So I just wanted to summarize the key point. Um So the key part that for me is really that you can use at e assessment in any situation, it doesn't have to be that the patient is acutely unwell. If you get call when you're an F one, if you get, get called to see a patient who is um you think that is not well or having any issues, you can use at assessment to look for the cost of um deterioration of the cost that make the patient unwell. Um, make sure you go to each step thoroughly. You don't need to complete um every single um test if you think it is not relevant or it's gonna delay your assessment and management. But um a lot of time all these tests can give you a hint of what's going on and what is the cause of the deterioration? Ok. And the last thing is that you should continue to reassess the patients to help arrive or until further intervention can be done. So in os exam, if um you should basically end your assessment with reassessing the patients. So performing at e again after um after you have done your management to make sure that the patient is um responding to all the treatment you have given and to make sure that you basically go through each step and you're not not missing out on anything. Ok. Right. Do you guys have any questions? I hope this session is useful if you guys have any questions, basically, um you could tap into the group chat on with yourself now, but if not, thank you very much. Um I really appreciate that you are being very inactive and um asking questions. Um So yeah, complete a feedback form as well. Um so that you can get the certificate and you can use it in your portfolio, the feed the feedback form is basically if you see, um it's basically on the, the, the area where you put in the chart is on the the end. I'm sorry, just wondering generally after which letter would you call? 2222? Sorry, what do you mean by that? After which letter? So do you mean like when we get call double two, double two? Um in this case, in this case, um if you have a patient who is passing 500 m of Molina, I would escalate to the senior doctors right away. There's no, there's no wrong to escalate to the senior. Basically. Um the earlier you do it um the easier it would be for you because sometimes it do take time for them to come um or they probably know the patient better and probably have more, a lot more experience. So um escalate to them as soon as you can, you can do it as you see the patient. Like once you get to the bedside, you know what's going on, you can just um start escalating to the senior or consultant right away. Ok. So saying an sy like would you say it before starting a two E or during? Yeah, I would, I would, I would start even before doing at E assessment in OS exam, I do remember saying well, so after I see the patient and um understand what's going on, so you would stand at the bedside and probably you have to comment on how you see the patient. So you could say this, I can see that this patient has um past 500 m of Melina. Um look quite sharp. Well, look, look quite pale and cy he's in a lot of pain. Um I would escalate to the senior um doctors at this point. And meanwhile, while waiting for him to arrive, I would start all this assessment and then you go on from A to E Yeah, but um if you forgot to mention that you would escalate to the c um at the beginning before the assessment, you can do it at a at any point during A to E as well during my oy, I think that might be some time that I forgot to mention it right away and I jump into the assessment. But as I'm doing, let's say breathing uh as I'm assessing the patient breathing, II can definitely say that, oh, I'm actually worried um because this patient that is quite low and he is in short of breath, I would escalate to the senior. Yeah. So as long as you escalate um the quicker the better, but as long as you escalate, that should not be an issue in the OSC exam. Ok. Right. If you have any other questions just pop into the chart, but if not, thank you very much, don't forget to um complete the feedback form. Um I would really appreciate the feedback as well. And um you would get a certificate with your name on it on that and you can put it on your portfolio. Ok. Right. Anything else is there anything else I could help with? Ok. If there's nothing else, then thank you very much. I really appreciate your time in joining these sessions. Um I hope you guys get um uh I hope this decision is useful when you manage to get um things out of it. If there's anything that you are worried about or concerned about later on, that's why you can just pop into the, this me all and then pop in type in the question into the chat and I think one of our team would definitely have noticed it and then we will answer it. Ok. Right. Thank you very much then hope you have a good evening. Bye.