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I'll just click in. O can I? OK. Can you, can it be seen now? Yeah. Um Can someone write in the chart if they can see and hear us properly? Yes. OK. So um hello everyone. My name is Thea and I am the vice president of grad scape. Um So, um firstly, thank you all for joining today's topic on approach to chest pain. So I would like to hand over to doctor Aro who would be presenting this topic. Fine. Thank you for that. Um So just in case you could, I couldn't hear before. Um So my name's Irish. I'm working as an fy two doctor currently at Western Hospital. Um II graduated from Sophia um a couple of years ago. So like most, well, I assume most of you here um are studying abroad. So I II know what it's like to have got studied abroad and come back to work in the UK. Um Basically the, the whole purpose of today's talk. It's not, I'm not gonna make this a lecture and I'm not just gonna sit and talk at you guys for half an hour, 45 minutes cos you're not gonna gain anything from it frankly. Um I want this to be as interactive as possible. Um I'm aware you guys might not be, be able to unmute yourself, but I want you guys to get involved in the chat. Um Just typing answers. It might be a bit easier that you guys don't have to speak. Um But this, at the end of the day, we're going over how to approach chest pain, which is something that you're gonna be dealing with a lot as a doctor. A lot of times it's gonna be quite benign. Sometimes there will be the occasion where, you know, shit, it's a fan and it, it's actually something serious and needs to be acted on um quite soon. So um I wanna try and make this interactive as possible because at the end of the day, it's to help you guys. Um and it's to help you guys as doctors. So I wanna see how you guys would approach this. I don't, I'm not just gonna speak at you for 45 minutes or half an hour because you're not gonna gain anything from it. Um It like i it's not, it's not for me to get anything. It, you guys won't really gain anything from it. Um And I want you guys to have your own way of, of developing things and how you work. So we're gonna just go through a case. Um It's a case basically, I've, I've dealt with on the ward and we're gonna go through how you'd approach it, what you wanna do. Um, and what investigations you wanna do, what differentials you wanna do. Um, and then we'll talk about other differentials to consider with chest pain essentially. Ok. So, oops, um, fine. So you've got a 88 year old gentleman. Um, he came in presented last week, uh, just feeling generally unwell background of type two diabetes, hypertension, high cholesterol and obesity. He was treated for in infection query source. Um He also had AK I two and he had a raised troponin secondary to his AK I. So it wasn't a massive troponin. Um just slightly raised, probably a type two M I and um he was treated for an infection ac has resolved. He's currently um MOF so, MMO FD stands for medically optimized for discharge. So essentially that's when a patient is medically stable and they're just awaiting discharge. So they're awaiting like social issues. So they might need some, some carers at home that the hospital have to arrange. So you're on a ward round. Um So you've gone to see this patient and he's, you know, he, he's fine. Otherwise he's just mentioned of a bit of, you know, central chest pain. Um He said it was a little bit of burning and um a bit of a cough as well. What, what else do you wanna know? So you guys can put it? II don't think you guys are able to unmute yourself if you can. That'd be great. Um, if not, um, you guys just put in the chat, you know, what, what you'd wanna ask him, what you wanna know. Er, and we can go through that. When did it start? Good? Ok. So it started, I'll, I'll just identity the patient then, uh, answering these questions. So it started, um, it started last night, you know, kind of kind of came and went. Um, but, you know, it's, it's just come on again this morning. Um But now, now it's a bit more settled sight onto Socrates. Fine. Ok. So everyone's gone for Socrates straight away, which is good. Um Fine. So in terms of sight, um patient just says it's quite vague. He just points around here, you know, in the middle of his chest. Um, it came on, um, it came on last night, like I said, and um, it kind of just came and went. It was a bit intermittent character. No, the character he said it's, he said it's burning ch chest pain. Um, in terms of radiation for Socrates, it doesn't radiate anywhere. Um You know, it's just, it's just here in this area. Um, for a what, what's a in Socrates stand for and what, what do you want to know about it? Fine. So the a is essentially associated symptoms. So he, you know, like, yeah, Alle F as well. Um So a, a technically is associated symptoms cos you'll need to think about what other symptoms that he might have. Um, so he's mentioned in the stem it's mentioned about he's got a cough. Ok. That's the only associated symptom he's had, um, in terms of tea for timing. Um, that's intermittent. It just said it comes on intermittently. So it came on last night, it was a bit intermittent, you know, it came again this morning and it's just intermittent. Um, e is, um, exacerbating factors or alleviating factors like, um, Ahmed as mentioned here. Um, nothing that makes it worse, you know, and I've not, I've not tried any nitro actually, to be honest, no one's, no one's given it to me. Um, and then for severity. Yes. Um, you know, when, when the pain is there it's about seven out of 10. Otherwise it's, you know, sometimes it's not really there. Ok. So that's your history for the chest pain. You've got this past medical history. What, what other things do you wanna know? Or what, how do you wanna examine him? How, how do you wanna examine him? Mhm. Is it positional or related to inspiration? So, um, no, it just, it just comes and goes. Pain just comes and goes, you know, it's, I can take, I can take a breath in and it's fine. Does anyone have any other questions? Duration of the pain? Like I said, it's just intermittent, just comes and goes, you know, it's been coming since last night and it's just on and off. Ok. Is there anything else you wanna know? Yeah. Good. Yeah. Fine. So, yeah, perfect at E so mind hit on the head at E, you know, you've, you've, you've probably got as much as you need to get from, um, his history about the chest pain. You know, you've done Socrates, you've, you're covering everything there and you've got everything you need to know essentially. Um, so go on to your at E. So does someone wanna quickly type out what, what they look for in a, in a at E? I mean, I'm sure not a lot of, you know what it is. It's just, you know, I wanna make sure that, that everyone's familiar with it and, um, everyone knows how they're going about it. Um All right. So I'll, I'll just go through the at essentially for him. Um So, so we've gone through Socrates. So for those who don't know what the Socrates the morning standss for, um, this is what it stands for and you use it mainly when you're assessing anyone for chest pain, any, any sort of pain. To be honest, you can use it. It, it Socrates translates to taking history from a lot of different things, chest pain, even headaches. Um Good. So, so Marin's typing out. So I'll let Marin type out while I finish talking about this. Um Yeah, so Socrates, you can use it for a lot of different things. It's not just chest pain. Um, so do utilize it whenever you can, to be honest, if you're, if you're unsure or want a clear history. So, obviously, with Socrates, you're asking about where the pain is. Um, so with this patient, it's quite vague, he's just pointed around here, um, onset, you know, we've said it's, it just came on last night, um, and it comes and goes character. He said it's burning, radiation doesn't radiate anywhere. Um, in terms of associated symptoms, we've just said there's a cough, er, for timing, I've just said it's intermittent as well. Nothing about exacerbating or relieving factors and severity. I've said, um, it's about seven out of 10 when it's present. So I want you to keep, I want you guys to keep those factors in mind and keep that history in mind as we go through this case, cos you're gonna tell me soon what investigations you wanna do. So have a start having a think of that. Um, fine. Yeah. Yeah. So in terms of a, to e, so like my room's kind of typed it out here. Um, a, you're looking at the airways. So if the airways present, er, present, if the airways patent, um, so if they're talking back to you, you can assume the airways patent, um, if obviously there's some signs of airway instruction like snoring or gurgling, you should be a bit more concerned. They might need a airway adjunct, um, or suctioning. If there's Friday, you should be very concerned and probably call for help straight away, to be honest. Um So airway patent breathing. So again, checking their sat and checking their respirate. Um you can do that, you know, when the nurses take the obs or if you're doing the obs, um you can check that then and um checking their listening to their chest. So having a listen to their chest, you can check for chest expansion as well. Precaution, not, not really used that much nowadays. Um But it's good. It's a good practice to actually do that as well, especially depending on what you're suspecting if it's like a a fusion or pneumothorax. Um and just having a look at their chest if there's any scars. So going through the whole inspection, palpation, precaution, auscultation. Um But the main thing we're gonna be doing is auscultating the chest. Um in terms of circulation, again, the main parameters you're looking for in the arms is heart rate and BP. Um Other things you'll look for. So when I'm doing an at E and when I get to circulation, I like to start peripherally and kind of move up the the body essentially of the arm. Um So you're just checking their cap refill time by just pressing on the end of their finger, um you're just feeling the periphery. So seeing if they're warm um bilaterally, um you're having a feel of their pulse as well, um checking their BP and then you check the JVP. Um I'm not gonna go through how to check that. Um And then just have a look at their mucous membranes. So see if they're dehydrated or not simplest way to do that, ask them to stick out their tongue. If it looks quite dry and cracked, they're probably very dehydrated. Um And then listen to their heart sounds as well in an acute setting. Um probably not as necessary. Um, but it's always good just for completion. Um Cos you know, if you find like an abnormal heart sound in the acute setting, you're not gonna do anything about it there and then, but it does help for the diagnosis and everything. Um, and, and like my said, you know, some investigations she's put with at E um for for disability. Yeah, fine. So I'll, I'll so cr someone's asking the child what the CRT in Pearl stand for. So, CRT is your cap refill time. So that's where you're pressing on the end of the finger like this and you hold it for about five seconds and when you let go. So when you press on the end of the finger, if you press on the end of your finger, now it should blanch essentially. So it should go pale when you let go, you should see it go pink within two seconds, um, or three seconds if you're well perfused essentially. So if someone's cap refill time or their CRT is longer than two seconds. They're probably a bit dehydrated or they're not really well perfused to their peripheries. Um pearl basically stands for um pupils equal and reactive to light. So you're just shining a light in their pupils and you wanna see that the pupil sizes are both equal. So there's no asymmetry between the sizes and that they constrict when you shine a light on them. Um So other things you look for in disability, so you check the blood glucose that can just be done as a finger prick test, um, check their temperature and check their G CS, um, or just check their alert. Essentially, you can check their body tone as well. So check the tone in their limbs and then e is for exposure. So that's basically just doing a full head to toe, um looking for any wounds, any rashes, um, any bruising or bleeding, um, do a quick abdo exam. So you don't have to do the full like liver exam, spleen exam, everything, but just have a feel of the abdomen, see if it's soft and nontender. Um, and just have a listen to their bowel sounds as well. Er, and then have a, have a feel of their calves cos you wanna see if their calves are soft and nontender. Um, cos if their co if, if their calves are tense, what, what could that indicate? So if they've got a bit of pain in the cough or um it's a little bit tense. Yeah, perfect DVT. Um And then also just check for if there's any edema as well. So with this patient on the at E, his airway is patent on the breathing, you know, SATS are fine, respirate is fine. Nothing on the chest. You don't hear many, many crackles um when you examine him initially, um in terms of your circulation, heart rate's fine, blood pressure's fine cap refill is a little bit prolonged. Um, his temperature's fine. He's alert, his pupils are reactive and on exposure, there's some slight, um, some slight pitting as well. So, um, that's his at E findings. What? Um, so you've got, you've got his history, you know, you've got a history, history of the chest pain. You've got his at E findings. How are you gonna work this patient up? So, what after you, after you've done your history in um, your history and, and um, examination, you need to think about what investigations you're gonna do and you also need to have some differentials in your head. But obviously that will become clearer once you've got some investigations. So what investigations are you gonna do for this patient? This is your patient. You're on the ward, you're doing the ward round. He's complained of this pain. How are you gonna, um, manage this patient? Good drop levels. FBC. Any other suggestions? D diers? Very good. Yeah. Chest X ray E CG renal function. Good, good. Very good suggestions it to see if anyone has anything more. Yeah. Chest X ray. Yeah, fine. So I think you guys have hit the nail on the head there, to be honest, like any, any person presenting with chest pain, new onset chest pain should get an E CG and get a drop as well. Um So in terms of the way I split my investigations up when I'm dealing with, um, when I'm dealing with a patient is bedside bloods, imaging and any specialist tests that you wanna do good. Someone said B MP as well. Actually, just before I do that. So, um, yeah, so basically that's how I split my investigations up cos it allows you to basically cover all bases and you probably won't miss much, er, doing that. So in terms of your bedside investigations, that stuff you can do li like is in the name just at the bedside. Um, so E CG is obviously the most, um, most crucial one that you need to do essentially and it's a very quick and easy examination. Um, E CG techs will just come do an E CG quickly and that'll give you a good indication of what's going on. Um, blood glucose as well. Um, again, finger prick test can be done on at the bedside in terms of blood, just get your full standard, full blood, aren't you? And C RP as well? Troponin, um, B MP. So what, what might cause a raised BNP. Heart failure. Yeah. Good. Does anyone uh obviously that's half fail is the main one. Does anyone know any other causes that cause A B and B? Heart? Yeah, everyone's saying heart failure, anyone know any other co heart failure's obviously er, correct. Um, anyone know any others. Ok. P Yeah. Yeah. Potentially. Actually. Um I think pe is more um good. Yeah, someone so. Yeah. CO PD perfect um atrial dilatation as well. Yeah. Potentially. I think pe is actually more um troponin can actually be raised in pe. But again, it's, it's good to consider that um for B MP, CO B MP is essentially released from the ventricles. Yeah, perfect. Someone said it. So anything that increases ventricular strain. Um So if you're having left ventricular hypertrophy, any right ventricular hypertrophy overload um To be honest, pe as well could could cause it cos there's gonna be some strain. Um any ischemia and then other conditions like CO PD sepsis can cause it as well. Um even like cirrhosis, but heart failure is obviously the main one that everyone kind of ties it in with. Um do A VBG or an A B VBG is probably less painful for the patient. Um But ABG as well, probably checking their lactate is gonna be an important thing and just checking their ph checking their not um acidotic or um alkalotic chest x-ray as well. So chest X ray you can get, you can just ask um you can get that at the bedside essentially. So if they're quite unwell, you can just get the porters to bring up the chest X ray machine and they'll in UK. Anyway, uh, I'm not sure about if, um, anyone else, um, has seen otherwise in other countries. Um, and then an echo again, that's, um, more of a specialist test. Um, that'll be probably done later on. Ok. So you've got your investigations there. I want you to start thinking about what differentials you're gonna have in mind. You've booked your E CGE C GS come up, done the E CG. This is your E CG. So does someone wanna, because you guys can't turn your mics on, I'm not gonna get someone to talk like type out the whole interpretation of it. They wanna tell me what they, what they can see. Is it a normal E CG? Is it abnormal if it is what's abnormal on it? Sorry, if, yeah, potentially, sorry, I'll zoom in a bit. So irregular, irregular. Yeah. So it's a, it's a difficult one for af because, um, the P waves you can kind of make out the P waves sometimes and then it just kind of goes, but I would say this is, this looks like af um, a V block. I don't, no, I don't. It's not, I wouldn't say it's a V bo really? Um, and it's hard to tell as well cos if it's af he's not gonna have P wave. So it's hard to really indicate if there's any his pr interval um finds af is one. OK. So why evgeny if I'm saying that correctly, why would you say untra seal? Am I key waves? And uh so, so what's, what's Q wave? Yeah. Yeah. Good. So, yeah, T wave inversions. Yeah. So you can see here. So, I mean, T wave inversion can actually be normal in lead V one and a VR. So if you, if you saw just T wave inversion and a VR and V one and then it was completely fine everywhere else, I wouldn't jump to call it in stemi cos T wave inversion is normal in those leads. Um Just because of the way the axis um is. Um but obviously you can see T inversion here in V two and V three as well. Um Which given with the chest pain, it's um it's getting a little bit concerning. So you've done your E CG and you've got some differentials in your head now. Um So you, since you've seen these changes, you decide to do AE CG half an hour to an hour later, cos you need to get serial EC GS and you guys are very apt doctors. So this is a repeat E CG. Um This look better, does look worse. Does it look the same? What do you guys, what do you guys think of this? And can anyone tell me the rate as well worse? AF two inversion. So why Kuna, why would you say it's an old M I? And someone said worse. A a um afib which, yeah. Correct. History said previous drop. Yeah. Fine. So on a sec 123456789, 10, 1617, 1819 20. Fine. So someone said rate was 72. Um, it's, it, yeah, it basically is, it's not, it's much faster than 72 cos to count it, basically, the easiest way to count rate is just counting the number of um R waves along the rhythm strip and times it by six. So here 123456789, 1011, 1213, 1415, 1617, 1819, 2021 22. That's about what, 100 and 32. So you just basically count the number of R waves on the rhythm strip and times it by six. That's the easiest way to do it for an irregular rhythm. Obviously, people have other ways of doing it like the RR interval and everything. Um So I'm just gonna go back to, I think from what I said about an old M I history said previously raised trop. That's correct. But the previously raised trop that he had wasn't a previous admission wasn't years ago. It was on this admission and that raised trop, that's one thing kind of to catch you guys out as well, which w raised troponin doesn't always indicate an anteing, um what, what can cause a raised troponin? So why might, um, someone's troponin be raised it? So, so essentially troponin is a, a cardiac enzyme. If you're not getting, if your heart's not basically getting the blood and oxygen it needs. So, if there's blood not going through the infarction, yeah. So if your, if your heart muscle isn't getting enough blood supply and enough oxygen through the coronary arteries, that's gonna cause ischemia and can cause infarction, which can cause a raised troponin. So just because your troponins raised doesn't mean you've had an M I. Um there's, there's basically, you have no, they basically, they distinguish between a type one M I and a type two M II. Didn't actually know this before um starting work because, you know, historically, everyone just goes off ma A CS and says stemi and semi unstable Angina. Um I don't know if they taught it really in UK medical schools, but type one M I is essentially where you have a cardiac cause that's causing ischemia and infarction. OK. So there's infarction or necrosis of the, of the cardiac myocytes and the myocardial tissue. And that's causing a CS type two M I is essentially where you've got reduced perfusion and you'll have like peripheral vasodilation, your, your blood isn't getting perfused or oxygenated enough. So this can happen in conditions that cause like systemic vasodilation or that affects your blood supply back to your heart essentially. And affects your vein for return. So pe can cause a raised um troponin sepsis can cause a raised troponin cos there's a, there's a widespread vasodilation, OK. C KD can cause it as well. Um even heart failure because it's affecting the circulation and because there's ischemia to the heart, but the actual cause isn't a cardiac cause. It's something else. That's what a type two M I is. So just, just because he has a raised trope doesn't indicate he has an old M I because technically it's just a type two M I and to treat type two mis, you treat the underlying cause. Um So say if it was sepsis and he developed a type two M I, you would just treat the sepsis and normally with type two mis, that troponin is probably only gonna be in the 100s. Um It won't be sky high. Um So I wouldn't say it's an old M I. Um sorry, I'm going off topic. I wouldn't say it's an old M I here. Um But one thing that's important to look at which we don't have in this case is his previous EC GS from previous admission. Cos you'll wanna see if this T wave version is new or old, you'll wanna see if his AF is new or old. OK. Cos there's nothing in the history about af so make sure whenever you look at an E CG, you look at previous EC GS as well, cos you need to see essentially if it's, um, if there's a new ischemia or if it's old twa, if it's Old Twain version and he's had af previously, I wouldn't be too concerned about this. Ok. Right. So, back to, back to our case. So you've, um, you've got EC GS, ok? You took your bloods and this, these are your blood results. Um, what I've, I've kind of given away one of, one of them with the urea and creatinine. Um What are you guys thinking now with these bloods? Ak I Yeah, yeah. So AK isa um given that to you guys that's is that the most concerning thing? Mhm M I sec second type Rimsha, you mean type, do you mean type two M I is elevated? Fine good. So people have said it's ak I was a given um I've already put that there for you guys. Um type two. So am I someone said second type M II don't know if they mean type two M I at type two M I your your troponin is gonna be um OK. So type two M I is, is basically your troponin is only gonna be in the 100s. OK. An A CS your troponin is gonna be in the thousands which this this guy has. OK. Um But you know he's also got a raise very high B MP like a extremely high. So also keep that in account, keep that in mind. OK. So keep that in mind by your differentials. Um I said M I is the cause of the renal failure. Yeah. Yeah. So that, that's also um a very strong possibility as well because his, you know, his heart's not, not pumping as much. He's not perfusing his um peripheral organs, um peripheral vessels. So basically he's not getting enough blood to his kidneys and he's probably got a prerenal AK I as well. Um Good, fine. So you've got your bloods, you got your E CG. Your report has come up to do the chest X ray and they've done the chest X ray here. What does, what does this show? I'm just gonna hide down. What does this, what does this show here? Ignore this. This ii actually not sure. I even, I was speaking to one of my um mates about this cos we both dealt with this patient. We actually weren't even sure what this was. Um I don't think it's anything pathological. Um But don't worry about this too much. But what else do you guys see here on this chest X ray? Or if anyone has like a systematic way of going to chest x-rays as well? Pleural effusion, pulmonary edema. Good. Any other suggestions you come in base lungs? Very good. I mean, if you guys are all medical students, you guys are wicked at reading chest x rays. Um I was, I was terrible with this with my LA in my last few years. Um fine. So yeah, pulmonary edema, pleural effusion, fluid accumulate in the base of the lungs. Uh Is there anything else that anyone can see? It's a bit not, they're not very clear but yeah. Yeah. Pleura fusion. Yeah. So let me zoom in a bit on here. So uh the way I approach chest x rays, I'm, I'm sure a lot of you have heard of this as well. There's a at E approach. Um So a is not, it's not at E airway breathing so well, it kind of is, but in chest X rays, A you look at the airway, so you wanna see the trachea central. Um Sometimes it might look a bit off just because of the position of the patient. If it's deviated, literally like into here, then you'd be more concerned. So A you can see as central B is for breathing. Uh and you look at the lung fields. Um So here you can see it's very patchy. OK. So there's a lot of little opacities around here. Opacities here, pastes here. What, what could if, if they've got opacities, what could that represent? OK. We've said pulmonary edema is one anything else? Just so you guys have like other um differentials in your head. Yeah. Interstitial pneumonia. Yeah. So just, yeah, let's just keep it simple. So instead of giving diagnoses, let's let's keep it simple and just say what we see. So one thing we've said with these opacities, it could be consolidation. Ok. That's not a diagnosis. It's just a finding. So it could be consolidation. One cause of which could be interstitial pneumonia. Cos with interstitial pneumonia, you'll see more patchy, um, consolidation kind of spread out. Whereas in lowbar pneumonia, it's just affecting essentially a lobe here. The consolidation is a bit more patchy. So again, yeah, it could be an infec could be something infective going on. Um, so in breathing, you know, you look at the lung fields and you've seen there's these opacities here. You can make out these little, there's like tiny little dots here. I can't, I wish I could draw on this. But, um, if I was technologically able enough, um, there's these little opacities, apparently they're pleural plaques. So that was actually what the radiologist wrote on the report for this, that there's little plural plaques, plural plaques are basically just associated with. Um, you'll see them as like little dots on chest x rays. They're just associated with asbestos exposure. Normally they're quite, quite benign as well. Um, so breathing, we've looked at the lungs and you can see there's w could be consolidation, but there's like basically multiple opacities and, you know, a lot of, um, you see a lot of white in the lung field essentially C ca er, cardio. So you're looking for cardiomegaly, I appreciate if someone said you can't accurately assess the heart size here because it's um, ap not pa which is good, but I think just looking at this heart, you know, that's cardiomegaly, like you can just see it extend right to the border of the Mediastinum. Um So I think it, it does look quite enlarged here, but you'd have to obviously take into account. It's not pa it's ap um But I think with this case, it does look quite enlarged. Um D is. So in your X ray approach, you've done airway, you've done breathing, looking at the lung fields, C is cardio. So you're looking at the heart size D is diaphragm. So we can see here, you can, you can't really see the cost differing angle at all. Um You've got, you've got this almost meniscus here, excuse me, um this meniscus both sides which is indicating pleural effusions and um then e is um everything else. So just looking at the ribs, looking at the clavicle, the humerus again, that's not entirely um clinically relevant here, but it's good to just check it. Um And to make sure there's no basic free air under the diaphragm, no air on the Medstone as well. Someone's mentioned interstitial fibrosis, interstitial fibrosis, it wouldn't look as bad as this. Um So um in interstitial fibrosis, you probably wouldn't have these effusions here as well. Um There's a raised C RP. Yeah, good. So, keep that in mind for your differentials as well. So you guys have got your history, you've got your examination findings, you've got your blood, your E CG your chest X ray, everything's laid out in front of you. You need to start thinking of differentials because you're gonna treat this patient. What is your top differential? You just give me, you can even give me like a top two differentials, the top three differentials, it doesn't have to be uh give me a set diagnosis. MRI, heart failure good. So MRI is very broad. So give me a, give me a more specific MRI. There's many types of MRI cos M I if, if you say M I, you need to decide which, how you treat the M I cos the treatment differs depending on which M I is heart failure, pulmonary edema. OK. Fine. So oh OK. S so uh Ahmed. Why, why is it uh a sty so I want you to, to back your back your decision. Why is it a stemmy? See cause edema like kidney disease, the pulmon edema? Fine. These are all very good suggestions. Um and toil. Yeah. So I think most of you've got some good differentials here. Um Main ones. So for me, the main one, the most concerning one cos the be I think the best way to go about differentials is rule out probably the most concerning and the most relevant first and then have your other ones that could potentially also be involved or could potentially um be a cause as well. Name one here I'd say is um an N semi. OK. So it's all right saying M I, you need to be specific in what your diagnosis is or what your differential is because if you say am I the treatment for an end semi is different to a semi, um which is different to our type two M I. So I'd say the main differential here is in stemming. Um second differential you can have is acute heart failure. Um as well. I think someone mentioned about kidney failure as well. Um Kidney disease. Yeah. So someone also said pneumonia, I think pneumonia is a very good differential to have here just given the changes on X ray. Um because, but the problem is with um if you look at his white cells, let's go back up. If you look at the white cells and the C RP, nothing too. You know, if anything, the white cells are coming down and the C RP is 90 which I get it's raised, but C RP isn't raised just for infection. You know, it can be raised for other conditions and 90 is not a tremendous C RP where I'd jump out my seat and start treating it as a hap as uh as, as a hospital. Acquired pneumonia. Uh Why enemy? So we don't have multiple widespread, multiple lead ST depression. Ok. So if you think about an s what an tey is an TEY, you've got an enemy, you've got tr rise and you've got T wave inversion or ST depression. Ok. You don't need both. You don't need to have both ST depression and T wave inversion. OK. Stemi, you need s as, as I'm, you know, I'm, I'm sure everyone knows this but stemi, you need to have ST elevation or a new left on the branch block for um, Nstemi. You have race Troponin. OK? And you have ST depression or um T wave inversion. Ok? I know it's not widespread but at the end of the day, it's not gonna be widespread unless it's affecting every single part of your heart. The T waving version that he had, it was just in leads, 1 to 3, which is essentially your um anterior or antireceptor leads. Um So it's, that's why it's basically entei. OK? Um It's not a type two M I because his trop is, you wouldn't get that raised drop with a type two M I. Um He has had a type two M I initially, if you, if we go back to the initial, he said he had types raised drops secondary to AK I. So essentially um his raised, his raised trop was only about 202 15. Whereas this time it was, what was it? Uh 5500 a day. Um So I'd say ends stem is your main differential. Some people have said heart failure as well. Good, acute heart failure. I wouldn't s cos heart failure. You also need to keep in mind you can have left ventricular, right ventricular, you can have a chronic or congestive heart failure and acute heart failure. He could be having acute heart failure. Um But I think that could be brought on more by his ente so I think the ends sty has triggered everything here. Um And then ak I is another thing that we've, we've got in our, in our diagnostic list. OK? Um So this is basically just, this is, this isn't all his differentials. This is basically a way to separate out differentials for chest pain. Ok. So the way I think about um separating out your d if you've got someone with chest pain, the way I separate out my differentials for chest pain is based on systems. Ok? So cardiovascular system, respiratory gastrointestinal and then miscellaneous essentially. So if you think about cardiovascular causes for chest pain, A CS has gotta be number one there. Um which is obviously very serious, but probably more common than the rest of these aortic dissection. I think the patient would be quite unstable. Um I don't as an F one or as a, as a foundation doctor, I don't think you'd be dealing with aortic dissection much and if you do, you'd be having senior help straight away for this. You wouldn't be having to deal with this on your own. Um Sorry, I'm just gonna turn the light on, this is a bit off. Um pericarditis. So that's another differential to have. So basically, any all the um layers of the heart affected. So the pericardium affected is a myocardium affected or is it endocardium affected where the valves are? Um So pericarditis, the his, his pre presentation of chest pain doesn't really fit with it too much and um the E CG changes don't fit with it too much. What? Just out of curiosity, what E CG changes is specific to pericarditis? Does anyone know if you, if you had pericarditis, what would you see on E CG? That's specific to it? Yeah, perfect pr segment, depression, ST elevation. So SST elevation you see as well, but the one, the one that's specific is pr depression. Um Yeah, myocarditis as well. That's always something to keep in mind cos that can actually cause race troponin as well. Um and can sometimes cause E CG changes. Um then respiratory causes for chest pain. Pe is another big one. pneumothorax, pleurisy is essentially pleuritis. So just inflammation of your pleura um and pneumonia as well is a, is a big one to consider. So if you had some fevers, if you had raise inflammatory markers and if you had chest pain, start thinking about, um and some dyspnea start thinking about pneumonia. Um gastrointestinal causes cos obviously, you know, especially in elderly patients, sometimes they confuse chest pain for abdominal pain, er, or they're quite vague with their chest pain, especially for him. He was pointing around here, wasn't he? So it could just be he could have reflux. Um Initially, I think when the way he described it, I was with this case, I was actually with my consultant and he, my consultant initially said, oh, you know, I think it's just reflux. Um but we said we should obviously get an E CG and do everything just to make sure. And it's a good thing we did cos on this um you could have uh board syndrome. So that's basically where if someone has very like heavy continuous vomiting, it can cause rupture of your esophagus and that can cause very severe chest pain. But the patient again, this is very uncommon and the patient will be very hemodynamically unstable. Um And the PAG ulcers and pancreatitis cos sometimes it could be confused as chest pain when it's really epigastric pain. Um M SK pain as well, panic attacks and rib fractures can also cause some chest pain. So this is basically just um not an extensive list, but it's just a list of differentials you can have in your head. Um I'll see if I can send this out or if, if grad scape can send this presentation out. Actually, if you guys do find it useful um just to keep some differentials in mind. Um So this is basically just outlining kind of red flag signs for chest pain. So if, if it's very sudden onset and it's like crushing chest pain or tearing chest pain, which is more associated with dissection, um or it's lasting more than 15 minutes, then that's, that's something very concerning. Um if they've got syncope um as well. So if they've collapsed and they've got chest pain that that would be, can be very concerning or if there's hemoptysis as well, um acute heart failure. So, in this case, this, this gentleman did have some acute heart failure. If there's a new murmur or radio radial delay, again, that would be concerning and I would probably get a senior input as well. Um Again, I'm not gonna go through each one too much, but I'll uh I'll just keep this up here just if you guys want um as a helpful guide to kind of remember some red flag signs. Um Again, so I made this little table, this is basically just showing the kind of the emergencies of chest pain. Uh Again, I'm not gonna go through all of it. Um I'm sure you guys have revised us whatever, but I'll see if guys can, can send this out or if anyone wants to take a picture. Now of it, be my guest. Um It's basically just they're not common causes of the chest pain, but it's probably the ones that you should be most concerned about um if dealing with it. So obviously, a CS, um you know, we, we go through about how to manage that. Initially. P ei think A CS and Pe are two ones that are much more common than people think that you're gonna be dealing with on the wards a lot. Um Tension pneumothorax, you probably, if you're on a working on a ward, you probably won't deal with that as much. Um If you're on a respiratory ward, you might, and the patients need urgent care for that, but that's probably more down in A&E same with tampon. I think I've only seen tampon once on a patient and um they unfortunately passed away actually. So, um it, that's very hard to manage and manage quickly as well. Um And aortic dissection, again, that's you're not gonna be seeing that much and same with esophageal rupture, but this is just kind of the most serious ones to have in your mind just in case it ever gets to this. And at least you know how to kind of work the patient up and start management. Um Again, this is basically just kind of going through your differentials of semi and semi unstable angina. So I think someone asked, why is it Antemi? Um like we've said here, your trop is elevated and you can have t wave inversion or ST depression. It doesn't have to just be ST depression, it doesn't have to be widespread. It can be limited to just kind of a set um cardiac territory essentially. And with NSTEMI, you're, you're having a subendocardial infarct. So it's not going through the whole wall. Um It's of your myocardium, it's just going through a little bit. Whereas transmural, it's basically killing off your whole wall essentially. Um OK. So with, so we've said endosy is probably the one here that's causing it acute heart failure as well. How would you manage Endosy initially? So say you've, you've done everything for this patient, you've done the history exam, you've done the work up, the diagnostic work up. You need to start and I'm hoping you're calling your senior for this cos you shouldn't be dealing with this on your own. Um You need to start managing this patient initially. Ok. How are you gonna manage this patient initially? If I'm say you're my F one I'm sho if you called me telling me about this patient, telling me all the examination findings and what you've done to diagnose him. I think that's very great. What would kind of put you a bit further is if you had started treatment for them rather than calling me and saying, oh, I've got a patient who's got n semi, what do I do? So if you had to start a treatment that would make it perfect. Er morphine, ox morphine, oxygen nitrates. Yeah, mona. Um Yeah, so Mona or Mona P is more for sties. Um mona. So morphine. Yeah. So if they're in pain, you can give morphine, I'd probably give GTN first and you can give also some prescribe some oram um the liquid morphine that works quite well. Um Oxygen, he wasn't hypoxic so probably wouldn't need oxygen in this case. Um Aspirin. How much aspirin? 300? Perfect. Does anyone know how much you get for a sty? So what's the dose of aspirin if it was a stemmy? Not an uns semi? No, no, no, it's um no, it's uh no, it's so N se is 300 mg, stemi is 600 mg of loading um for aspirin but your hospital should have um guidelines for this antiplatelet effect is, is 300. Anyway. Um but for, for Nstemi, you give 300 mg aspirin for a stemi, it's 600 mg, aspirin. OK? And you just give that a stat. So II think someone actually mentioned which is good low electro heparin. Um Yeah. Good cos that's one thing that's actually actually often missed out. So this is just a little mnemonic mona Cash B. Um The main things you'd be expected to do as a junior doctor on F one. If you're dealing with this on a ward before you escalate to your senior, give them oxygen if they need, give them nitrates or GTN spray, load them on aspirin and give morphine. OK? Um Then you can call your senior and say I've, I've got this patient with NSTEMI blah, blah, blah, I've done this for them. Is there anything else you'd like me to do or could you come review them um copy as well? So, antiplatelets differ B based on trusts. Um I know cops obviously like the textbook one. There's also Agre and Praag. Um I think if they're, if they're taking any anticoagulants that kind of affects it a little bit. Um But it's, I think if they're um cos agre and prazole have some contraindications, so you have to be a bit careful using them. I think clopi is, clopi is generally used if they're taking anticoagulants um as it's got a lower bleeding risk. Um So clopidogrel, um 300 mg start, you also need to start them on an ace inhibitor. Um cos that's essentially cardioprotective. Um and it helps kind of reduce mortality and morbidity, um statins as well and um low molecular heparin. So most trusts use Fonda parox, which is 2.5 mg subcut um and then bop as well if their heart rate is above 60. Um and just to make sure they're not got CO PD or asthma. Um But again, the main things you'd probably start as a junior doctor is Mona and then I'd probably just confirm we've just seen you before starting them, but they're probably the most critical ones to start first. Ace inhibitor beta blocker aren't as critical to start, but they will need them. Um Also book an echo for your patient. And just, you know, if you're not already on a cardiology ward, refer to cardiology and you can um basically calculate something called a crusade score and either a grace or a heart score. Um because that will determine if they need um angiography and PCI. Um if it, if they had the stemi they'd be getting a PCI. Um if it's within two hours, does anyone know what, what the crusade score or the grace score or the heart score is? So what are these scores looking at or what, what are they used for? So, the crusade score is basically looking at the bleeding risk um from an end semi your it they either use the grace score or the heart score. The gr er the heart score on the left hand side here is basically looking at these factors and is looking at your six week risk of a major cardiac adverse event. Um so they use it in EDA lot or in A&E to um yeah, perfect. Someone said it as well. Mortality risk six month. Yeah, good. Um so the heart score they're kind of transitioning to now a bit more. Um in UK they use it down in A&E cos they can basically, it helps them triage if these patients need to be admitted to cardiology, if they can be discharged and it helps them to triage the severity of the chest pain essentially. Um but obviously, you know, someone's gonna score if their tone is a little bit high and if it's more of a type two M I, they're gonna have a high, high score anyway. So depending on it doesn't appear to be too specific. Great score. Like someone said, a six month post discharge mortality. And that can basically help guide if, if um PCI is needed and also helps de determine their mortality as well. Um This is, this is just from um my trust guidelines. Essentially, it's not, again, it's not too crucial. This is basically just if you have someone say this patient already had af and they were already on anticoagulants, you would basically need to consider what to do with the anticoagulant. Cos normally in a normal situation, you just start off on the paradox. In this case, if they were already on like a Doac or Warfarin, it basically tells you how to adjust that. I'm not gonna go through that. That's very, that's a bit more specialist to kind of help the scope of this um out of the scope of this talk. Um So this is just a quick summary of what we've we've gone through. I don't wanna make this just, you know, going through each single diag each single differential of chest pain and talking about how to manage it, cos you're not gonna gain anything from that. I wanted to just basically go through how to approach a patient with chest pain, go through the at e go through the history and think about what investigations you're gonna do, splitting up your investigations into bedside bloods, imaging and um specialists. And then thinking about what differentials to have in mind. Obviously, cos N was the main differential. We, we kept that in, in um we kept that in mind here. Um So again, like I said, using Socrates will help a lot with the differential. Um And it helps you exclude or include a lot of differentials. Um always consider red flag signs as well depending on how stable or unstable they are. Even if the patient seemed like this patient was just sitting there not complaining at all. So even if they just seem stable, you need to look at the biochemical parameters and the findings rule out life threatening or most concerning differentials first and then start to proceed down to less concerned differentials. So say we ruled out an Nstemi, then you can start to work towards less different, less sinister ones. Um And yeah, motor has b is a good pneumonic to use for Nstemi. Um Is any any question? I think there's one here. Can you explain why the patient had af did the ischemia to the heart trigger it? Yeah. So a lot of times. So af it's, it's not p you can have af it can be paroxysmal um persistent or permanent. OK. So paroxysmal is just where it lasts about less than 24 hours. Um persistent, I think is like seven days and permanent is more than seven days even. So, even for example, you know, say someone has a night of drinking, goes out on a bender and drinks a lot of alcohol. They could actually, the next day, they could be in af they could be complaining of palpitations. They had to get an E CG done. They could have AF cos alcohol can cause AF essentially. Um So this patient could have had af due to ischemia and due to his um ischemic heart event. Um and it could have been paroxysmal, it might resolve after he was, he was treated. Um But yeah, the, I think the ischemic card, the ischemic cardiac event would have triggered his um would have triggered his af and it's probably more likely paroxysmal. Um But you'd obviously have to check his E CG uh over the next few days and see if his pulse is regular or irregular. Um Is there any any questions um just before I finish and hand it back to d um dia if anyone has any other questions not regarding chest pains, regarding working or anything, feel free to ask? Ok. Um So regarding the certificate, uh I think um I send the feedback link into the chat if someone can confirm if they can see the feedback form. So um if you guys can see the feedback or I'll, I'll just send it again. II can see it in the OK. That Yeah. OK. So if you guys can complete the feedback form and once it's completed, the certificate will be sent to your e-mail so we can give you a few minutes to complete the feedback form. No. Yeah. Um Also guys, um our next CPD approved talk is on the 29th of September, which is by Doctor Kraj and it's on um applying for jobs and CV techniques. So uh post regarding that will be made in the upcoming days. So, so that's our next talk and um is, is everyone finished with the feedback form uh if someone can send a message into the chat? Ok. So um thank you all for joining today's talk and a big thank you to Doctor Arou for um presenting this talk today. Um So have a good night. See you uh all for the next talk then. Bye-bye.