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Hi, everyone. My name is Alex. I'm now an F one in Oxford. I'm doing an academic or a specialized foundation program. So if you guys have any questions about working in Oxford doing an SFP or about final year, feel free to ask me that at the end as well. I'm always happy to help the session today is about acute care. So we are going to be going over essentially a few different cases and I really hope you guys will go along with my plan of trying to make this interactive, not in an annoying way, but hopefully in a helpful way because I've structured this session to follow the exact structure of your paces. So you can interpret this as a combine it as like a revision for your writtens, but also practice for your paces. So hopefully that will be good. So I'm going to start with just a brief structure of the acute care station. Move on to my advice on how to succeed in that station. That was my favorite station in finals and I scored very, very highly. So hopefully, this advice will help, will help you. I then have three cases again in paces style. And if we have time, I actually have 10 bas at the end, going over a range of emergency or conditions in acute care just for some added revision. Stop me at any point for questions or for any technical issues. All right, let's get started. So the acute care station basically works like a case presentation. It's like someone has done the clerking or, you know, in an ideal world, you've done the clerking and you're presenting it to a consultant and then they are going to ask you some questions about how you're going to take care of this patient moving forward. So you're gonna start by reading some documentation that gives you the patient's history and an examination. You're gonna have a max of about three minutes to read that the examiner is then going to ask you to summarize the findings from what you've read on that paper. They are then going to ask you what you think is going on with the patient. In other words, your differential diagnosis, if you want to be really, really good, I wouldn't even wait for them to ask that question once you finish presenting your findings and with your top three differentials. The next question, I guess makes sense. What investigation do you want to perform? And then they are going to hand you those investigations. Hopefully, if you've said the right ones, if you haven't done stress, they will guide you and they will ask you to interpret what you are seeing and following on from that, uh They'll ask you how you treat the patient. Um And that's essentially it, one of, one of the sort of struggles I had in that station was if I've presented three differentials, and they then tell me how are you going to manage this patient? I was always like, well, I've, I've given you like three conditions. Which one am I supposed to talk about? But I think the key thing to remember is that the acute management often follows a similar pattern. And second, if you know they haven't corrected you, it probably means that your t differential is the correct one. So that's what I would go with. And the very last part of the station is once you've sort of said, how are you going to investigate and what your treatment plan is? They'll ask you to explain it to the patient. You don't need to start from zero. You just need to explain the treatment to the patient in simple terms. OK. Hope that makes sense. But again, stop me if any questions. So what are my sort of top tips for the station? The the key thing to understand is that much like any other paces station? To be honest, the key to this is practicing. So when you're there on the day and when you're practicing, start by reading the documentation really carefully. Three minutes is actually quite a long time. So, so you do take your time and be thorough and for any question that you are asked in the station, but also in any part of paces, make sure you are following a structure. It just, you might be saying the same things, but if you have a structure, it just looks so much better compared to not having one. And I'll go through sort of the structures that I use for each of the different sections in a second. Make sure you are practicing out loud. So this is a station that actually if you really wanted to, you could sort of prep, it's always best to prep with others, but you could prep on your own as well. Make sure that when you are practicing you're speaking, I know it's really weird but it makes a huge difference to read in your head or to actually say it out loud and in the actual station, if you are sort of, I don't know, freaking out, you're not sure what the answer is. Just make sure that you are thinking out loud to the examiner because it helps them see that you are not just blanking and not saying or thinking anything. You are just processing your options and trying to think logically. All right. Um in terms of structures. So when I'm summarizing the case for someone, I actually like to use SBAR, like I'm giving a handover because that's effectively sort of what you're what you're doing in that scenario. So it's helpful to start with a bit of a one liner on what the situation is. So who is this patient like age and gender? And also what did they present with a bit of a background? So just key past medical history, some key treatments, key admissions assessment, this is the section where you are going to summarize the key results of that initial examination or if they've given you any investigation results, you say it there. So when you, when you are given that initial paper, you'll have a history, but you will usually already have, it's like the clerking note. So you'll have the full history and you'll have the full examination and you might have a couple investigation results maybe. And in the end, usually when you are giving a hand over, you end with your recommendations. In this case, you are going to end with your top differentials. Ok? Um I'm gonna assume that so far so good cause I don't see any questions. Um But again, interrupt me if there are any questions. Cool. So summary think of sbar investigations and this guy applies to any paces station, not just acute care. So when you my my sort of first line whenever I was answering a question about investigation was, well, I would take a bedside bloods and imaging approach always. What, what would you like to do for this patient? Well, I'd be begin with a bedside bloods, an imaging approach to my investigations practice saying a sentence like that. And I guarantee it'll make a huge difference. I just put on the slide, some sort of key bedside bloods, imaging and special tests that you may or may not do, do not just blabber out all of these for every single patient as you know, that's not very helpful. But I do find that when I'm under pressure, it's helpful to have a list of some common things in the back of my mind. So that if I'm blanking instead of sort of expecting myself to just think of the answer right away, I can sort of go through a checklist in my head. So, you know, bedside ops is that relevant? That's always going to be relevant. ECG do I need it? Do I not ABG, do I need it? Do I not? And so on. So just to guide you if you're feeling a bit stressed. So these are some common ones you might, you might ask for and finally differentials. So when it gets to the differentials, that's quite simple. Not much of a structure, I guess, just start by giving your most likely ones, the one that you think is most likely what's going on. But then try to suggest maybe two others that are possible, but less likely, less likely. And you can even explain why you think they are less likely, don't spend a lot of time on that just a one liner, you know, like this could also be a pneumonia, however less likely because they don't have a fever, something like that. Um, and if you, if relevant and if it makes sense, you could even have one more differential from, say the same organ system and another differential from a different organ system just to really show that you are thinking outside the box. But again, only if it's relevant, you don't want to be giving sort of silly to other differentials as well. Cool. So we've got gone through a structure for how you present your case, how you start your investigations, uh, how to give a differential. And finally, how do you present your management? So the last section is you're going to start by usually telling the examiner how you're going to treat your patients. And the management generally follows two sections, maybe three. So immediately what you're going to do now. So this is the sort of acute care part of the treatment and it usually involves stabilizing your patients or I often call this, stopping someone from dying or any sort of treatments that you need to do right now. So if they've got a clot and they need thrombolysis that would sort of fall under there. And then the long term management are medications that they're going to need to be on, uh, for obviously longer term, possibly continued by the GP. And if you really, really, really want to stand out, maybe put a line there about follow up. So, I don't know, say someone came in and was found to have an arrhythmia, you've treated them, you know, you've given the immediate management, you've suggested what sort of meds they need to go on long term. And then you can say, and I'd recommend review in cardiology clinic in two weeks', time or a month's time or whatever you think is appropriate would sound really good. OK, so that's it for structures. Uh Any question about any of these structures um that I've spoken about so far. Anything you guys wanna clarify because from now on the session is going to be about putting these things into practice. Ok. Fab. Um So I've now got three cases prepped and these are like three full paces stations essentially. Um I was gonna see if we could go through them each in about 20 minutes max. Um And I'm, we can do this in, in, in different ways. We can either get one of you to do like each of you to do one full station or we can actually take turns, which given that there's more than three of you here, it might be nice to take turns just so you're not sort of under pressure for too long. How does that? Does that sound good? Yes, we can take turns fabulous. So, case one. So we've got a 35 year old woman with sudden onset chest pain because as soon as you start getting your presenting complaints, I want your mind to immediately start thinking about common causes of chest pain. In this case, in a young woman. Ok. So you open, you come into the station 35 year old woman with sudden onset chest chest pain and your first instruction. The first thing the examiner tells you is read the patient's clerking an examination notes. So I'm going to give those to you now. So the clerking notes read added on the slide. So history of present complaints, sharp stabbing pain over the chest, worsened by inspiration. So we've got some element of pleuritic chest pain. She also experiences some shortness of breath at rest. Doesn't have a cough, doesn't have any wheezing is feeling quite lightheaded and describes some palpitations but has not experienced any syncope. She's never had this before. So she's quite scared. She does have a history of asthma since childhood but never hasn't needed any inhalers in over 10 years recently had quite minor surgery to her knee. She takes the combined oral contraceptive pill and also some Ibuprofen because of the surgery doesn't have any allergies. Her mum had a hip replacement in the past, but that's her only family history and she is not a smoker doesn't drink much. Alcohol works as a marketing executive recently returned from a trip to Shanghai and lives with her partner and two Children. You have a read through her examination findings So her A to E and her airway is patent. She's speaking to you respirate 28 SATS 89 on room air, but you've put in 4 L nasal cannula and those improve to 93. She is using accessory muscles to breathe but how normal breath sounds? Chest expansion is fine. Her heart rate is 112 regular BP, 102 89 cap refill less than two seconds. JVP is fine. No peripheral edema gcs, fine alert orientated pupils are ok. Blood glucose is 5.6. Her temperature is 37.1 and she does feel some tenderness in her left calf. Ok. That was a lot. But now the examiner, let's assume we've had three minutes for this. For this case. The examiner asks you summarize the salient points of this case and they may not say this, but in brackets, they also mean to say and present your differential diagnosis. So, could I please have a volunteer? And I am very happy to go back to each of these slidess if you need while you're presenting, who is happy to volunteer? I'm happy to go first. Fabulous. Sorry, I can't see your name. All right. My name is Ash, Ash Fabulous. Ash. So summarize the point point of this case, please. Uh I had a question though before. Uh, how long would it take? 30 seconds? One minute? How long should a presentation be? That's a good question. I would say 30 seconds to one minute. Definitely not really much more. One minute is fine. I wouldn't go, definitely. Wouldn't go past two minutes. That's way too long. But yeah, if you, if you aim for a minute, that's enough to get, get the important points across and make sure that your examiner doesn't sort of lose patience or focus because they are busy consultants, especially in acute care. Right. They want everything to be very quick. So give it a go, right. Uh Can I go to the history slide first? Yes, of course, you can D RL. Ok. Uh So this is a 35 year old woman with chest pain and breathlessness at rest. And uh she also has a lightheadedness as well as um tender cuff. So, um she some uh relevant factors here, risk factors here are recent surgery three weeks ago. Her being on the combined oral contraceptive pill and a recent uh return from a work trip to Shanghai. And uh her, according to her observations, uh she's tachycardic at 100 plus BPM, tachy at 28 breaths per minute. And um that's a tender left calf, I think. And uh the BP is quite low as well at 100 systolic around 100. So, based on all this, my top differentials would be um pulmonary embolism arising from a DVT, my less likely differential could be uh maybe uh asthma exacerbation given her previous history of asthma, but it's less likely cause she hasn't had it for over 10 years. And um maybe um from a different system could be uh psych like anxiety. Would anxiety be something that you'd um would it really be, would it be a top differential for you in this case? Why or why not? Um It sounds like you are thinking more a panic attack but it is a very low differential down the list. Maybe I could ask you a bit more about a social history. But my top differential is being at this moment wonderful with anxiety. It is absolutely yes. A differential for shortness of breath just be very careful when you're presenting it because it's one of those where you don't want to be missing things like asthma or pee or an because you are calling it a panic attack that doesn't need treatment with medication a lot of or probably does actually, but that's not going to, you know, it suggests there isn't an organic cause which in this case, there is well done. How do you, what do you think about that? Yeah, I mean, uh I think it was all right. Uh I kind of forgot to say the O2 sets as well. Um Yeah, but I think, I don't know, I I'm not sure if I, I'm seeing almost all the information there because it came a lot of it was relevant. So I just said what I told was relevant about it. Ashin. I think you did a wonderful job. So this is how I summarized it guys, by the way, as you've realized now, since you're in your final year of med school people do things slightly differently. So just because I did it this way, doesn't mean it is the only correct way to do it. This is just my preference. Ashin. I loved what you did. I think you, you had a really good introduction statement. You stated this 35 year old woman pleuritic chest. When you said a couple of things you were worried about, you then talked about risk factors. You then moved on to the assessment and highlighted the findings. You could remember that were important and you remembered pretty much the most important ones and then you went straight to differentials that were perfectly reasonable. So I think well done. And so I went with, this is a 35 year old woman with heretic chest pain. Recently, she's had knee surgery and a long haul flight from Shanghai. She also takes the oral contraceptive pill and has a history of mild asthma on assessment. She was tachypneic and there was apparent respiratory distress. Her oxygen saturations were 89% on room air were improved to 93 on nasal cannula and she's got normal breath sounds bilaterally, percussions, re and chest expansion is fine. She's tachycardic and her BP is, has a systolic of 102 there is tenderness in the left calf and there are no other findings of concern. In summary. My most likely diagnosis here is a pulmonary embolism, but I would also like to rule out pericarditis or a myocardial infarction from a cardiac point of view or less likely from a respiratory system and asthma exacerbation. Although she hasn't had any issues in her asthma for almost a decade, which I think is quite similar to what you did. Um Well done. Cool. Anything anyone wants to comment um about this summary or any questions about that? Great. So this is your summary. We're thinking this is a pe hopefully everyone here agrees. But again, if you don't or if you think I've missed a very important differential, let me know. Um but my next question for you in the meantime is what investigations would you like to perform? And again, could I have a volunteer for this? Yeah, that's fine. I could go. Uh Thank you. So first see at the bedside. Well, they've got her observations already. I would also like to do an ECG by the bedside to rule out um an M I um in terms of blood, I'd like to get a full blood count um as well as troponin. So we rule out the M I um A VBG as well ABG. And um in terms of imaging, I would like to get um a chest X ray as well as a CT pulmonary angiogram. To rule out a pulmonary embolism. Fantastic. Thank you so much. A question. Uh The ECG you're only looking for an M I um sorry and also uh pericarditis. Ok. Anything else? Um, what? And the ECG um am I pericarditis? Um and pe sorry? Yeah. No, don't, don't apologize. This is a safe space. Ok. Like I, I'm, I'm asking you questions on purpose. Um So you, you get used to it. Don't worry. You did really well. Um All right. And the trip, another question for you, you said that the troponin was for an M I. What's gonna happen to the Troponin in ap in a, in a big pe um, could it be slightly raised as well? It might also be raised? Probably not as much as it would in an mi but it could also be raised. Yes, absolutely. Well done. So you asked me for an ECG? So, oh, actually hang on before that. So these are the investigations that I said. So I do observations, I would calculate a well score if I'm thinking, could she have had a DVT causing AP ECG? And an A BGI usually put my ABG S at the bedside? II know that they are technically a blood test, but they are just done very quickly. So you can put them in either and it's fine. And I said ABG instead of VBG in this case, which is rare for me because I also mentioned asthma was one of my differentials and we are thinking it could be a respiratory thing maybe in which case, an ABG may be slightly more helpful, but a VBG would be perfectly reasonable here as well. I think it's just that ABG you need it when you care about the oxygen level, basically, which I kind of do in this case. So I went for an ABG anyway, bloods, full blood count using these CRP and LFTs. But even more importantly, ad dimer troponin and I also set a group and saving some clotting. Why, why would I want the clotting? She's not gonna have surgery. I want the group and save and the clotting because, um, if my main suspicion here is a pee and she ends up having a massive peeking needing thrombolysis, then the clotting and the group and save may be relevant in case she just to make sure she can have the thrombolysis for starters. And second, if she bleeds that we have her blood type and imaging. Yes, absolutely. CTPA is your gold standard here. You could also do a chest X ray that's perfectly valid. I also went for a Doppler ultrasound scan of the legs. Um, why not? Ok. So you asked for an ECG. Um and I'm gonna be really cheeky and if it's OK, ask you to have a look at this ECG and tell me what you think. And again, guys, this is safe space. So shall we break it down? So do I see a regular rate? Yes or no. Yep. Yeah, I agree. Do I see p waves before my Q RSS? Yep. Yeah, that looks good to me. Do my curss look all right. Are they, you know, I don't know, too large or are they nice and narrow? I'm not, it looks narrow but I'm not sure if there's a, yeah, they are narrow. They look normal. The curia should, should be ideally narrow. So I'm, I'm, I'm happy with that. Do I see any strange ST changes, any massive ST elevations or just ST elevations somewhere? No, I don't. So, but what I do see is that this rate is a little bit raised for what I'd expect from a 35 year old woman. Ok. So my, uh what I'm seeing in short in the CCG is Sinus tachycardia, which is not coincidentally the most common finding you would have on an ECG for someone presenting with a pe. Ok. So, um, if you're stuck with an ECG, it is completely. Ok. Just break it down uh into smaller steps and you will get to the answer. Ok. Um Don't stress. I have a second. ECG Wait, uh I have a question on this E CG though. Uh Would you say that AQ QT is a bit prolonged or not? Really? No, I don't. I, you know what QT you would need to properly calculate it. Um But from eyeballing it, I don't think so. But I need to be sort of counting the squares. And in fact, I don't even know the, the formula for the QT corrected QT interval by heart. I always just put it on MD and it helps me out but just eyeballing it. Not, not really. But you know what if you're worried about it, you can say possibly some QT interval prolongation. But I'd need to calculate that more carefully. Right. And the other question I had was uh I don't know, I just saw like a W shape in V one. So I just thought of left bundle branch block. But do you think it is not, so not in this case, um There is some T wave inversion in lead three and also in V one and two and three if you look carefully. But no, I don't think there is a bundle branch block in this example specifically. OK. All right. Um But speaking of bundle branch block not to, you know, give things away if anyone wants to have a look at this ECG and tell me what they think. So in this CC G, um I guess the easiest way to think about it if we're thinking of, I, I'm gonna give you a clue. There is a bundle branch block in this, in this CCG. OK. If you look at V one, do you see the little M shape? Well, you cannot see my pointer. Give me one second laser pointer. Do you see this? Um Yeah. OK. And then sticking with the M, sticking with the M and then if we come down here, can I, can I maybe convince you maybe there is a W shape here. Yeah. Is it right bundle branch block? Yeah. And the right bundle branch block. Um There's also some quite extreme right axis deviation. Um And the other thing is, what's the guys, what's that really rare sign? But that's a lot of imperial medics will know for pe that very, or I guess, fairly specific but incredibly, or, but pretty rare sign on an ECG. The S one Q three T three. Yes, exactly which apparently is present on the CCG as well. So uh S one leave three Q waves here and T wave inversion in lead three. Do you see it? Yeah. Yeah. Ok. So this ECG is meant to show extreme right axis deviation, right, bottom branch block and S one Q three T three. My goodness, I really don't think you're gonna get this ECG in your station. Um But the point I was trying to make uh is you can get um these findings if you have a really big pee that's causing a lot of right heart strain. Ok. So if you think about it, you the right side of the heart is trying to pump against a huge clot to try and get blood through. So you're gonna start um you know, in really severe cases getting some of these changes. That was just the point I was trying to make. But much more likely you're gonna have something like this. A sinus tachycardia, ok? But it's good to be aware of the harder stuff as well. Just so it doesn't completely throw you off on the day, ok? Moving on, you requested an ECG and you also requested some scans. I'm not gonna give you all the scans you requested because that's just a lot, but I will give you this one here. Um Very quickly. What is this gun C test? It's A C TPA, oops A C TPA. And um and you know what I assume you can see my laser pointer and you know what this thing is that I'm encircling, I'll give you a clue. There's sort of two of them. So you've got this one and it links with this one, the aorta. Yeah, exactly. So to help or orientate you, this is the ascending aorta. This is the descending aorta and this is the pulmonary artery. OK. Right here. Now, my question for you is this is, so this is a CTPA, you've got your lungs here, your lungs here, contrast has been injected. Look at your ribs here on the sides, your spine and so on. Now, what's that? That's weird. Why is there hypodensity there? So the blood clot. Yeah, exactly. And it's a blood clot going through like the pulmonary trunk. Yeah. Whats that called pulmonary embolism. Yeah, it's a pulmonary embolism, but specifically it's a saddle pulmonary embolism. Ok. It's a really big one going through basically the, the pulmonary trunk. Ok. So both sides affecting both sides. Ok. And it's all of this here is clots. This hypodense area is clots. Why? Because your contrast is white, right? And you can see that it's just not going through. The only reason why it's not going through is because something's blocking it. What's blocking it? A clot? Does that make sense? Yeah, great, cool. So we've done our ECG, we saw, we saw really bad, right? Heart strain. We've now looked at the CTPA and we see a really big clot. How are you gonna manage this patient? Is my next question. Anyone wanna take this question? Anyone wanna give it a go I can try this. Beautiful. So, thank you. Yes. Um So, well, I mean, obviously the first thing I'll do in such an unstable patient would be a, a two year approach. Um So looking back, I think her O2 set was still at 91% even with oxygen. So I'll just titrate it up to uh maybe 15 L normal or mask, hopefully get it um as high as possible. And um and then in terms of uh BP, maybe give her some uh IV fluids and then um in terms of actually managing the problem, I would start her on a thrombolysis. Um if she has no drug allergies. I can give her something like alop place maybe. Um, and after that, yeah, I think that is how I would do it, the management of the acute scenario. And in more of the long term scenario, I would give her anticoagulants, I would try to establish this looks like a provoker DVT to me, uh NP to me. So I would say maybe give her an for three months, uh as a long term follow up. And uh also I will also want to check out the leg because that is the cause of it. So I'll arrange the ultrasound leg at the earliest in instance and see what to do that you need to do Ashman. That was, that was beautiful. Well done. Thank you. And the first one as well. Um Yes, I agree with you. So part one immediate management, you wanna stabilize your patient and I actually I didn't write this here but we'll talk through it. So you take your e approach and you solve things in order. So if you think she's um you know, desaturating, desaturating, yeah, 15 L non rebreathe her SATS are actually fine here. Funny enough. They were 93. So I'm less worried. But in any way, in an acute scenario, you're worried about someone desaturating, whack them on 15 L non rebreathe and then you can downscale later in this case that had already been done for you. If you were worried about her being hemodynamically unstable. Yep. Start with 500 L normal saline to bring that BP up. One thing I'm going to highlight about any case like this is you can say like I would call for help. Are you going to do all of this alone? No, you're not. You're going to need all hands on deck, right? Like if you think about it in a resuscitation scenario, this is not quite what this is, but if it was, you'd need like ideally two IV Cannulas in place, a patient comes in with no Cannulas. Sometimes maybe one. What are you gonna do? Put two Cannulas on your own and coordinate the management, you can't do that. So you need to start by calling for help, by pressing the buzzer, get mds to help you. So say nurses or pas or advanced health practitioners can help you with things like Cannulas taking the bloods and so on, prepping the saline and you can go on and do other things like prescribe the relevant medications. So once you've stabilize them from a fluids, oxygen point of view your immediate management for AP if they are stable, you give them a DOAC. If they can't have a DOAC, you give them an IVC filter, but that's most of them will be fine to have a DOAC. So you give them that our patient however, was not really hemodynamically stable and she had a massive p. So that's not what you would do you would give them thrombolysis. Ok. So you start with some unfortunate heparin, which essentially stops the clot from propagating and then you treat it with thrombolysis, which yes, is indeed out of place. There are some people who can't have thrombolysis and I'll go over some examples of why that may happen in the next slide. If that's the case, you give them the heparin again to stop the clot expanding. And a doac if they really can't have thrombolysis and they also can't have anticoagulation, you hope for the best and you go for a surgical embolectomy, hopefully that won't happen. Um But yes, that is another option. But yes, in any case, the key treatment to know in this scenario is, is, is thrombolysis. Ok? And if you want to sound really good, you'd say I'd start with some unfortunate Heparin and then give them some al to place long term management. You are right. So if it's a provoked embolism, which this one sounds like it is. She had a lot going on, didn't she? She had surgery recently? Long haul flights? I think we've got a lot of risk factors just there. Three months of a DOAC should be fine if you didn't have any obvious cause for VT 3 to 6 months, at least if not lifelong. If you find, say some sort of genetic mutation that may be causing risk of continuous or, or repeated uh, risk of having clots and pea. Ok. I hope that makes sense. I mentioned some anticoagulation uh or contraindications to thrombolysis. Sorry. And these are some absolute and relative contraindications to thrombolysis. I am going to share these slides with me. So this is just something that you can look over afterwards. Don't worry about, you know, memorizing all these things, just maybe some of the key ones, right? So generally, you know, ischemic strokes like major trauma or a head injury, aortic dissection. I guess these things, some of these might be relatively easy to remember others less so, but they also have to be rare. So, yeah. OK. I hope that makes sense. The last question you will be asked in the station is now that you've sort of gone over the case with the consultant. They'll be like, how would you explain to your patients who has no medical background, what is going on? And here you're only gonna have about a minute again to do this. So who wants to give this one a try? Mm I'm happy to, I'll go over this one because I realize I haven't gone through any structure for this. Um Again, guys, everyone does this differently and I think the key part for this section in particular is speaking in a way that makes sense for you, right? Because you want to sound fluid and natural. Um You don't wanna sound awkward and like you're not confident in what you're saying. But if I had to explain what was going on to this patient? I would say something like, so you don't need to go from the very beginning to the very end. You just give a brief summary of what is going on and how you're gonna treat it. So we think you may have a large blood clot in your lungs. We call this a pulmonary embolism to give a little 11 line of what you think is going on. I always like to give them the technical term as well because when they read discharge summaries or whatever, they're gonna see a lot of technical terms. And if you haven't explained them to the patient, they're not gonna know what they are. So large blood clot in the lungs. I then like to ask, have you ever heard of this? You're not gonna have the patient with you in the room. So it's up to you whether you want to ask this or not. I actually probably wouldn't. In this scenario, I would just go straight to explaining it just for the sake of time. So blood clots often form in your legs, which is why your leg was swollen and then they can travel up to your lungs. We can't be sure what caused it. But there are things like long haul flights and taking the contraceptive pill that can increase our risk. Therefore, we started you on some medication to break down the clot. That's the thrombolysis and another medication to stop the clot from getting bigger. That's the heparin. How does that sound so far? Do you have any questions again, if you have an examiner that is sort of engaging and interacting with you, you can ask that if not just go straight to the next section. Moving forward, we're going to talk about your medication to prevent blood clots from forming for a few months and then review the things that can increase your risk of a blood clot, like taking the pill. And that's it. Saying all that probably took about 30 seconds. It doesn't need to be longer than this. So the key thing to say is if it's just you and the examiner and you don't have a lot of time, you may want to skip these questions here for all the other stations where you do have a patient with you. I always like to ask these things. Like, have you ever heard of this before? What do you know about this? And then making sure you ask if they have any questions and to be fair, even the one where it's just you and the examiner, I think giving the patient space to ask any questions is really important. If you're worried that the examiner might not seem like they are engaging very much and you might waste a bit of your time, ask it at the end, uh because they're gonna move you on anyway. Ok. Does that sound, does that make sense. Does that sound reasonable? Yeah. Cool. Amazing. That is the end of case one, you will be relieved to hear. So on to case two. So now we've got a 72 year old male with cough and some shortness of breath. Why do they all have shortness of breath today is what you and I are both thinking. So question one, read the patient's clerking and examination notes. You have three minutes. Let's go over these together. So who is this man? He has a history of presenting complaints. Five days of cough, productive of green sputum. Two days of shortness of breath at rest, no chest pain and more recently fever at 39.8 degrees. He has a past medical history of COPD including two admissions to hospital, both word based care. So no itu he also has a history of hyperlipidemia. His drug history. So he takes Symbicort and atorvastatin no drug allergies. His mom died of an mi at age 45 and he is a smoker. He smokes an average of 10 cigarettes a day for about 40 years. Does anyone know how many pack years? That is 20? Yeah, exactly. 20. So we've got one pack is 20 cigarettes. A pack. Here is how many packs you smoke per day times the number of years. So one pack is 20 cigarettes. He smokes 10, that's half a pack for 40 years. So half of 40 is 20 pack years. I hope that made sense. Um If not, I will add that somewhere on the slides or the notes when I send the slides to you guys. Ok. So his A to e so his examination findings, Airways patent respirate 36 oxygen sats 82 on room air. He is using accessory muscles. He's got to wheeze throughout an auscultation and some coarse creps in the right lower zone as along with some dull percussion notes. His heart rate is 100 and 25 and regular his BP, systolic of 100 cap cap refill time is fine. GBP, not elevated, et cetera. His GCS is OK. He's alert blood glucose 7.2 all good. His temperature right now is 38.9. Um So summarize the salient points of this case and present your differentials who wants to have a go at this. Um I can try. Thank you. Perfect. Go on. Ok. So this is a patient that's come in with a five day history of a cough and a two day history of shortness of breath. Uh patient has productive green sputum and a fever and a history of COPD, uh which he takes Symbicort for and he's uh a smoker as well. Um On examination, the patient is um tachycardic and um starts on room a or 82% low um course palpitations on the right lower zone um as well as down as to precaution in the right lower zone as well. Um, sorry, I just don't think I can remember. Um, yes, he is oriented and his temperature is 38.9. In terms of my differential diagnoses. I would, I'm thinking of, um, pneumonia as well as an infective exacerbation of COPD and, um, possibly, uh, asthma. Any, any other differentials. Um, mm, maybe like, um, what is it called when you have? Sort of, sorry, I can't think when you have fluid in the lungs like a pleural effusion perhaps. Yeah. Could you could have a pleural effusion? Thank you so much. That was very good. Um Again, the key thing about this summary is you've got all these text you don't just want and by the way, in your actual exam, they may very well write even more than what I have. So you're not gonna have time nor does the examiner want you to be reading everything else you need to, you know, highlight the key findings. So what are the positives and what are the relevant negatives? The relevant negatives are there to when you have that those top three differentials from in your head, those negative, those relevant negatives are the ones that are going to push out the two of your top three that are less likely to be the, the true diagnosis and help you justify the one that you think is the top. I'm not sure if that made any sense, but that's how I think about it. So well done. This is how I summarized it to a 72 year old male with cough shortness of breath and fever. I often cut out the duration's personal preference. Some people don't. That's ok. He's got a background of COPD with previous hospital admissions for infective exacerbations, not requiring ICU admission. He at the moment presents in visible respiratory distress. His respiratory rate is 36 that's 82% on room air. He has a wheeze and course crepitations on auscultation. He is currently febrile at 38.9 tachycardic and his um systolic BP is 100. You're probably wondering or maybe you're not, but I would be why Alex do you sometimes say they're tachycardic rather than saying, I don't know, their heart rate is 125 and then you tell me that their BP is 100 instead of saying they're hypotensive or whatever, I have a few answers to that first preference. Um Second, I find it helpful to say the numbers on two very specific occasions. One if I'm really worried about the number. And so it's like when I say he's hypotensive, I'm talking about a BP of, you know, 65. OK. So when the number is so shocking that you're like, it's not enough for me to interpret it and just say it's hypertensive, I'm going to interpret it. But then I'm also going to tell this person the number so that they get as worried as I am right now. The other time where I give a number is when say like when I think it's fairly borderline. Ok? So, and I'm like, and this is maybe a bit of a cheat, but I'm being real with you guys giving you a tip here if I'm like, ok. Yeah, this is technically tachycardic but I'm not super worried about it. So I don't want to take them to, I don't want to distract by saying like, oh my gosh, they're really tachycardic and actually their heart rate is like 95 or whatever like that is tachycardic. But actually I'm more worried about something else. So I say it either when I'm super worried and I want them to know the number or when I'm like, you know what? This is a bit borderline. I'm going to say it and they can interpret it as well so I can see what they think. Yeah. Yeah. Yeah. Just being transparent here. Cool. So I agree with you. The most likely diagnosis is infective exacerbation of COPD with sepsis. I find that the differentials are harder when someone gives you a case that they're trying to make quite obvious because you're like, come on, I'm like, this is obviously COPD like what are you talking about? Um But some other differences you could think of is maybe this guy could have lung cancer or he could have sepsis from another source. My advice for this again is when you are giving these differentials, when your, when your diagnosis to you is quite obvious first, never assume anything because sometimes you might just be forgetting something. It's good to keep an open mind. But in a case like this, you're pretty sure or at least your top differential is definitely going to be COPD. And then as one of your differentials, you said asthma, when you're saying that maybe, maybe highlight to the examiner, like why you're thinking that and why, you know, it's probably not. So a line like other differentials to consider would be asthma would present in a similar way, however, very unlikely in a 72 year old with no history of asthma, just something like that. So you can be like, hey, I know that asthma could technically be a possibility, which is why I'm saying it to you because I'm sharing off my knowledge. But also I have read the case and I do have clinical judgment and I can tell you now that even though theoretically it's an option in practice, it's just that it's not going to be asthma. And similarly here, so it could also be lung cancer. He's presenting with respiratory distress and he's got long standing COPD and fever can also present in cancer. However, it does sound like he's got an infection that needs to be treated first and in terms of sepsis from another source. Yes, it could always be possible. However, I can't ignore the fact that he has also got some coarse craps on auscultation which suggests that the source is probably pulmonary. Right? Ok. Hopefully that made sense. Next question. What investigations would you like to perform? Any volunteers for this one? Yeah, I'll have a go. Thank you. So, what investigations would you like to perform? So I would take a bedside, that's an imaging approach. And since we've already taken a full set of si would uh take some bloods including FBC username L FTC RP. And then I would also do a chest X ray. Wonderful culture, maybe as well. Yeah, perfect. Fantastic. Thank you. So I love that. Perfect stretch concise. And there are a couple of things I probably would have added in there, but you've got pretty much everything. So at the bedside, abs as you said, guys, even if abs have already been done, there's no harm in saying like observations have already been done. I would also do and then continue just like you did. So I do an ABG and you want to check for lactate. I would do an ECG in this case as well. This patient is unwell. And because I was thinking sepsis, I was also thinking the three and three out. So I said, consider putting in a urinary catheter to monitor output bloods, full blood count needs therapy. You probably don't actually need LFTs here. Blood cultures, you're right. The sputum culture is a really good idea that I did not include. So, thank you and imaging. Definitely a chest X ray. Well done. OK. So you asked for an ABG um hopefully. So I've given you an ABG anyone up for interpreting this ABG what is going on here? And can you hear me? Yeah, I can. Yeah. So um based on the E BGI think it's respiratory uh type two respiratory acidosis because the PH is lowered. Um uh carbon dioxide is elevated and oxygen is low and it also raised by just try to compensate, but it's actually not perfect. Yes. So he's got respiratory acidosis with partial compensation. In other words, this guy is a chronic retainer. OK. So why? So he's got partially respiratory acidosis. So his PH is low, low ph acidosis CO2 is raised CO2 equals acids. Therefore, this is an explanation for the low ph. OK. And so you've got a respiratory acidosis. That's your source. He has also got hypoxia or hypoxemia. So low low oxygen levels. Yeah. Ok. We knew that actually already from the sets. Anyway. Interestingly, he's got a raised HCO three. So bicarbonate, which is a compensatory mechanism for the acidosis. Now your lungs, your breathing can change quite quickly, right? But your kidneys and how quickly they sort of absorb or excrete something is not going to change like this. So, the fact that this guy already has a raised bicarbonate suggests that actually he's had a race too for some time. So it suggests to me that he's probably a chronic retainer. Ok. So, because uh this takes a while to evolve. Does that make sense? Yeah. Right. So, yes, respiratory acidosis is the presentation here if you want to go further with partial compensation, suggesting that actually he may be a chronic retainer, by the way, what else would you look at to, to a bit of a like maybe a niche thing? But um if you did a set of bloods and you looked at the hemoglobin in this patient and they were a chronic retainer, what would their age be, be high, normal, low? Would it be high? Yes. Exactly. Why the secondary polycythemia. Exactly. Exactly. So they have raised, it's almost to, to sort of compensate for the persistent low levels of oxygen. You have um erythropoietin stimulation and then you have an increased production of hemoglobin. So, yeah, in chronic returners, they may have a slightly raised hemoglobin, secondary polycythemia. Amazing. Ok. You also asked for a chest X ray and I'm gonna give you a clue. Now, I'm gonna give you two chest X rays because I was struggling to find what I needed. So, chest X ray one, um what do you see guys? I'm not trying to trick you. Yeah, I hyper expanded lungs. Yeah, exactly. So, hyperinflation and you also see a flattened diaphragm according to radio pia, we can also see some increased bronchovascular markings in a small heart. Yeah, I agree. I guess the hyperinflation of thoughts and diaphragm, which is what you'd expect to see in COPD. Right. Yeah. Cool. I'm now gonna give you a second chest X ray. What do you see in this one? Right? Lower lobe consolidation. Yes, exactly. Except it's not lower lobe, it's middle lobe. Um, it's the, it, that's why I chose this one. So, um, if you're not sure if it's middle or lower lobe, you can say there is some opacification in the right lower zone, which is a bit bigger. Um But generally, when it's the lower lobe to the best of my understanding, you'd see the costophrenic angle a little bit more um covered. And I think there's also something to do with the heart border being visible or or not. II can't quite remember because I actually thought that in the, in the in the middle lobe consolidation, the right heart border would be less obvious, but I think you can actually see it here. So, so you know, fact checked me on that one. But yes, do have a look at some right middle versus right lower lobe uh opacification or consolidation. Uh I like to use the term opacification. It's a little bit slightly bigger and therefore often a little bit more accurate when you're talking about x-rays. Uh But yes, hopefully that makes sense, but exactly there is some consolidation in this case in the right middle lobe, but I think completely reasonable for you to think it was the lower lobe fine. So how would you manage this? Patient management is always the hardest, isn't it? But it's also the most important is, yeah, come on. So uh we can split this, yeah, we can split this into short term and long term uh in the short term management. Um because of the o to being 81% I'll give him oxygen at target sets about 88 to 92% given his uh COPD and um maybe give him some IV fluids as well. And uh for the acute management of the infected exacerbation of COPD, I would first give him um oral steroids if he's uh able to tolerate uh if he can swallow maybe prednisoLONE or 30 to 60 mg a day. And then uh I can give him nebulized medication like Saba and SMA and uh yeah. Uh I mean, I would also call in the senior at this stage if he fails to um improve at this point. And uh I will just keep doing regular observations to check whether he's improving. And then in the long term management, I would review his use of his inhaler and um maybe consider whether he's compliance and uh check whether he's up to date with his uh rescue pack and uh discharge him with a course of uh antibiotics. And um if he's doing all the above, then I can consider stepping up his long term management. Uh I can't remember what he was on originally, but if he was on Laba and Lama, I can, so if he was on LA, I can add in Lama as well. Yeah, honestly. Fantastic. That's I think a pretty perfect answer. So, yeah, so breaking it down, immediate management, long term management, management, just like you did. So for this guy, because I am worried about sepsis the way I sort of broke it down. I said in the immediate management, I'm, I would start my sepsis six protocol and manage him for a COPD exacerbation. So your sepsis six, we'll talk about it in the next slide. But essentially when you're thinking COPD oxygen, yep. And you start by putting patients even if they are chronic retainers on 15 L, non rebreathe because remember, hypoxia kills faster than hypercapnia. And then once you've stabilize the situation, you adjust to vent your mask according to their target sets. OK? You want to even some bronchodilators. So it's, it's a good idea to actually know the doses of the bronchodilators for asthma and COPD uh for acute exacerbations. I mean, because it, it, they may ask you so, salbutamol and ipratropium bromide um steroids. So the evidence suggests that giving oral steroids or IV. So oral pred. So if it's oral steroids, it's gonna be pred, if it's IV, it's gonna be hydrocortisone. OK. The evidence suggests that giving oral or IV works the same way. So you always go for oral first, unless say they are vomiting and they cannot take oral stuff or say they're no by mouth for whatever reason, then you go for IV otherwise oral. And again, a good idea to know the doses for this, especially the oral. So it's 30 mg um in this case and then antibiotics because you are worried about an infection. And if anyone asks which ones, you can say I follow trust guidelines, but often it would be something like Amoxicillin, Doxycycline. And yes, long term. So they will need to be discharged on some oral pred for another 1 to 2 weeks. You would of course, review their inhaler technique and what inhalers they are on. So are they taking them regularly, etcetera, just like you said? And if appropriate, they may need to step up their management, they may also need some chest physio after this episode depending how things go in hospital and they'll need to complete the course of whatever antibiotics they were given. Um just keep in mind for the exacerbation. If they're not responding to the, to the management, you're giving them, you're going to call it to come and help you and they can do things like fancy drugs like IV aminophylline or considering bipap for COPD. Remember COPD? You think bipap for asthma exacerbation, you think intubation? Ok. So this is a measurement for the COPD. Always remember your sepsis six. OK. So if someone asks you Oh, what's the sepsis? Six? I assume you guys all know this by now. But just in case here it is. So three and oxygen fluids, broad spectrum antibiotics. Three out blood cultures, VBG specifically for the lactate. So blood cultures lactate via VBG and um catheter. So you can measure urine output. OK. And just in terms of the um inhaler management, so our man was actually on Symbicort. So Laba and an ics. So this is a guideline for what you would consider next. So you'd consider adding in a LMA and keeping the Laba and the ics just adding in the LMA. But I, you, you know, you would probably not have time to talk about all of that in the station to be completely honest. OK? And then um the other thing to be aware of in COPD is that a little bit further down in the management, there is the option for long term oxygen therapy. So that means they get like oxygen canisters at home. And the guidance says that they are meant to use them at home for at least 15 hours per day. It's you don't look, you don't really need to know all of these things like be able to regurgitate them out loud then and there, but it may very well show up in writtens, I would say especially it could also be a question in cases, but certainly I think in writtens. So just be aware of these, they're here, I will let you read them more in your own time. Another important thing to know is that patients who are smokers, which many patients with COPD unfortunately are, cannot be offered uh long term oxygen therapy because of the risk of fire and burns. Ok. And there is a protocol for when they stop smoking. So it's not like they can stop smoking today and tomorrow they are on long term oxygen therapy, They need to have stopped for a while. I cannot for the life of me. Remember what that a while is right now. But just the point I'm trying to make is um if they're smokers or if very recently they were smoking and they just stopped, they actually aren't eligible because the risk of fire is actually too high. So just be aware of that. Ok. Uh last section for this case, please explain what is happening to your patient who has no medical background. So anyone please want to take uh give this one a go. This is the funnest one guys you get to like explain medical stuff in easy language. OK? I will save you from this misery and I will give you my answer for the next one. I'm gonna ask someone to please do it cause it's good practice. So uh how do you explain infective exacerbation? Well, we think you may have a chest infection which on top of your COPD is making it difficult for you to breathe comfortably. We call this an infective exacerbation of your COPD. So chest infections can happen to anyone but they tend to be worse in people who have an underlying lung condition like COPD because the infection seems to be quite severe. We've treated you with some antibiotics through the vein and fluids to keep you hydrated and your BP strong. We also gave you some oxygen mixed in with some medications to help you breathe similar to your inhalers. Um, so sorry, some medications that you breathe in similar to your inhalers to help your breathing moving forward. We'll need to talk about reviewing your inhalers and trying some physiotherapy to help your breathing further. Does that sound? All right. Do you have any questions? That is sort of how I would explain this? So you can see that sort of the first bit is explaining what the problem is and then I move on to explaining how we've treated it in simple terms. I hope that I hope that helps guys. All right, we have about 15 more minutes and one more case, shall we try to whizz through this one? So third and final case, we have a 55 year old man with black foul smelling stool. Um And hey, it doesn't seem like he's got any shortness of breath. So that's a win. Um Cool. So step one, read the patient's clerking and examination notes. You've got three minutes. So let's get started. His history of presenting complaint, progressive fatigue, lightheadedness for about two days. He denies red blood in his stool, no vomiting, no abdominal pain. He does however have some nausea, no recent weight loss or appetite changes. He has a history of peptic ulcer disease diagnosed five years ago, hypertension and has not had any recent surgeries. He takes aspirin, 75 mg, amLODIPine, 10 mg omeprazole, 20 mg. His mother had hypertension type two diabetes and died of an mi age 52. He smokes five cigarettes a day for 20 years. Drinks 15 units of alcohol per week. Usually beer works as a mechanic and does not use any recreational drugs. So is a assessment airway patent respirate 26 oxygen ss 94 on room air vesicular breath sounds, percussions, resonant chest expansion, equal and symmetrical. All sounds good there. His heart rate is 144 and regular BP. 93/56. I'm gonna say that again. BP is 93/56. His cap refill is six seconds. His gcs is 13 because he is responding to speech. Um but he is confused. His pupils are fine. His blood glucose is fine. His temperature is 36.5. So please summarize the salient points of this case and present your differential diagnosis. Who wants to give this a go? Um I can give it a try. Thank you. So uh it can go up 100% all Right. Thank you. So, this is a 55 year old male. He came in with a, his um he came in because of um me, a history of men now um accompanied by progressive fatigue and um lightheadedness. T how um there are negative symptoms of blood, uh fresh blood in the stool, vomiting and abdominal pain. Um how however, experiences nausea, um nausea and upset of weight loss of appetite on a background of peptic ulcer disease and hypertension for which she is taking medication, omeprazole and amLODIPine. Um in terms of social history, um he does smoke. Um he has a four year history and drinks, uh 15 units of alcohol per week in terms of his uh an examination patient appeared to be um Yeah. So patient on examination, patient has basically breath cell throughout um and chest expansion equal um BP is 93/56 with uh increased capillary time of six seconds. And tachycardic at 144 is um he is only responding to speech with the gcs of 13 and, and in normal ver normal vertices with a normal temperature, um one act of differential would be an upper gi bleed um or it could be colorectal cancer or um blood or small bowel obstruction. Thank you. Well done. Thank you so much for volunteering as well. I thought that was very good. My uh you know, you had a very clear structure. You highlighted the important features, the only thing I would say to make it even better is I think there were a couple of things that you didn't necessarily need to say like the blood glucose. I think in this case, a little bit less, less helpful because it's not really going to change my differential at this stage. Um But very well done. And I think it's hard when you know, you have the, their slides rather than a piece of paper in front of you to help. That was very good. So this is how I structured it. We've got a 55 year old male with Melina. He has a background of peptic ulcer disease and is taking omeprazole. He does report some lightheadedness and shortness of, oh, that's not true. Did I say that had shortness of breath? Anyway, apparently he's got shortness of breath for two days on assessment. He has some tachycardia and is hypotensive with a systolic BP of 93 and his gcs is 13. He is responding to voice and is confused. The most likely diagnosis is an upper gi bleed probably secondary to peptic ulcer disease. He is, he also appears to be in hypovolemic shock, probably secondary to hemorrhage. Other differentials could be sepsis although he doesn't have a fever. But you know, in patients who are neutropenic, for example, they may not have a fever or there could be a different source of bleeding such as a colorectal tumor. Ok. What investigations would you like to perform. Anyone want to have a go at this one? OK. I'll give you this one because I really want you guys to talk me through the management. So at the bedside, we've already got some observations. I would do an ABG or a VBG would be fine here because I want to check the lactate and I would do an ECG or place this patient on a cardiac monitor in terms of bloods, I definitely want a full blood count to use an ECP, I want to group and save an a cross match. And I would also do some blood cultures because sepsis was a differential. I would then call the on call endoscopist because I'm worried about an upper gi bleed. And that is going to be our definitive sort of the investigation that will give us our definitive diagnosis. I have a slide here about blood group. So we want a group and save in a cross match because this patient is bleeding and they are very hypotensive. So I'm worried they are in hemorrhagic shock. OK? So just a quick note, I'm sure you guys all know this by now, but just in case you forgot, remember that if a patient is blood group, A, for example, so the the, the letter on the blood group. So A or B or ANB represents the antigens that our blood cells basically display. OK, which means that in the blood, we will be producing antibodies to the ones that we don't have. Because if someone from blood group A, these antigens are normal to them. If we give them blood group B, these B antigens are not normal to them, they will be like, oh my gosh foreign and start to mount an immune response and we build up an TB. OK. So if your blood group A, you've got NTB, so you can receive group A or group, group zero doesn't really produce any A or B antigens. So think of it like a zero. So yeah, key things to remember A B are the universal recipients. They can get blood from people who are blood type A blood type B, blood type A B or blood type O. They can get anyone. Uh but they can only give to people who are A B. So these are like the selfish kind. Um Blood type O don't make any antigens so they can give to anyone but they can only get blood type O because they'll mount an immune response to any antigen because they don't have them. So these are the very selfless kind. OK? I hope that makes sense. That was just a very quick run through. But hopefully you guys all know that right now. Anyway. So how would you manage this patient? Yeah. Um Sorry, I don't know much but I'll try. So would you do like an A UN approach? And so you would give fluids for the low BP, um, you would make the patient nil by mouth. Um, obviously you've prepped the um the bloods just in case a transfusion is needed. Um And then after the endoscopy patient might ha I don't know if the patient might have to have surgery. I'm not sure. And in terms of long term management, um investigating like peptic ulcers, the cause of that. So like advice against like food um H pylori test maybe and maybe like more like control with like PPI S. OK. Well done. See. And you, and you were saying you didn't know what to do and actually there's maybe one thing that you didn't say, but otherwise you pretty much got it. Darren, right? Yes. Amazing. OK. So you're right. What's happening with this person? Let's break it down. They're bleeding inside. So if someone's bleeding, you try to stop the bleeding. Can you stop the bleeding in someone's gut? Not with your hair, not with your hands as far as I know. So you're going to have to stabilize them in another way. So you start with five. OK. Step one, you activate what we call the major hemorrhage protocol. Someone's bleeding, you activate major hemorrhage protocol. That's all I need to say. Uh By the way, this is helpful information for if one do you know who comes when you activate a major hemorrhage protocol. When I first heard major hemorrhage protocol. That sounds quite serious. I was picturing like the whole shebang. You know, like the on call, Endoscopist. I like my med read. No, it brings a porter who's really important but it, it only brings a porter. Um, because they are the ones who will then get the blood that you need from the blood bank. So the message I'm trying to say here is that if you're ever in a situation where someone's hemorrhaging and you need help, you need to put out a crash call to call your team to come and help you and then you'll get the whole shebang your c your edge, whatever. But you also need to put out a major hemorrhage protocol to bring in that porter who will help you get the blood. Ok? So you basically need to make two calls and they're both done through 2222. OK? Anyway, major hemorrhage protocol, you're going to start with some 500 MS of Saline and you're going to prep two units of red blood cells. And then if you look through the major hemorrhage protocol, there is a series of other meds that you can give before you start giving red blood cells and, but keeping it to basics, you're going to start with some fluids, activate major hemorrhage protocols, start prepping two units of red blood cells and you're going to call the on call endoscopist. Strictly speaking, you should only start a PPI infusion after you are sure of the source and the source is a peptic ulcer. So usually it's done after or during the endoscopy. A lot of people um especially at Charing Cross, if I'm not mistaken, actually just start the PPI infusion right away. OK. So that's IV 80 mg of omeprazole. You can also say that you would do a risk assessment. So there are two scores you can use when you are suspecting, suspecting an upper gi bleed. You've got the Glasgow blotch Ford score, which is the one that you usually do. So that's pre endoscopy or you've got the rocal score that you can do post endoscopy. So knowing these, you don't need to know every single part of these scores. But knowing at least their names and whether they are pre and post endoscopy can be very helpful. Ok? So that's what you're going to do, try to control the bleeding or the BP rather. And then you're going to call the endoscopist. They are probably going to tell you. Ok. Can you start a PPI infusion, please? And I will be there and do an endoscopy in the longer term after the endoscopy, they will need PPIs which they technically were already on. So that's going to need some investigation and a referral for gastroenterology for some follow up. You also asked if they need any surgery, not quite, they need an endoscopy. So the beautiful thing about an endoscopy is that you can find the source of the bleeding and you can stop it at the same time. So you send this guy to do the endoscopy out of hours and then you get the endoscopy report and this is what it shows. So they had a look, these es esophagus, normal mucosa, no evidence of varices or esophagitis, nice stomach presence of presence of large amounts of altered blood and clots in the stomach. Not so nice active bleeding from a visible vessel in the posterior wall of the antrum, consistent with a peptic ulcer forest two way. That's just a scoring system, don't worry. No master gastric varices observed. So, and then the duodenum normal mucosa, no evidence of bleeding, interpretation intervention, sorry, the endoscopic therapy applied adrenaline injection and two clips, successful hemostasis, no active bleeding. So impression active upper gi bleed secondary to peptic ulcer, first two a in the Antrim. So your conclusion is you are right. They did have a bleed in the stomach. So, peptic ulcer disease, you sent them for an endoscopy. The endoscopist were amazing and managed to stop the bleeding with some clips. Um And that's it. OK. So uh yeah, that's just the relevant bits. Cool. Hopefully, that makes sense and just to finish off anyone wants to have a go at explaining to the patient what just happened and what are you gonna do from here? I believe in you guys. Uh I can give it a try. Thank you. Um So explain, I explained to her that the patient had. Um, yes, I explained firstly that the patient had um, a bleeding in the stomach. Uh, basically because the peptic ulcer that they been diagnosed for a while with them higher risk of having these, uh, what we did so far is we replaced, we replaced the amount of blood that they lost approximately. Um, we put some clips in the stomach to stop the bleeding from happening. Um And was, that's what we've done so far right now, um to prevent this sort of this from happening, uh the patient will have to be on long term PPI so the medication that they have been taking for a long time and they also need to be referred later for gastro follow up um in the clinic for them to see whether um they are at further risk of this happening again. And then also if you have any questions and if you understand anything perfect. Thank you so much. The only thing I would change if this was in the real exam and II didn't wanna stop because you're doing really well was don't say it as in like how you would say it if the patient was there, think about, think of it as now the examiner will has swapped and they are pretending to be a patient and you were talking to the patient directly. So just like when they ask you this question, just almost, I guess get into acting mode, you've got your patient in front of you and talk to the patient rather than saying hypothetically, I would explain this and say that, but well done. That's pretty much exactly. I think what I've got here. So I would say we found that you had a bleed, coming from the ulcer in your stomach. We call this a bleeding peptic ulcer. There are lots of things that can cause ulcers to develop, including certain medications, a bacterium or lifestyle factors like alcohol and smoking. There are medications to prevent this and stop it from worsening, which you were already taking. It is really important to take these regularly. The gastroenterologist did a scope and found the bleed and stopped it. They have recommended some medications to continue taking to prevent the bleeding moving forward. We've booked you an appointment to see a gastroenterologist. They can help check that the medication you are taking is actually helping and what else we can help with that may have contributed to this bleed. Do you have any questions? Does that sound? All right. And yeah, uh I had a quick question. So for, for this part, would you do it like counseling in base station? Basically, it is pretty much a counseling but it's quicker. So, in an actual counseling for the other stations, I always ask these questions. So I give a little intro sentence and then I go, have you ever heard of this? And I'll let them answer and then I explain further what it is and what's going on and then I asked you, do you have any other questions? And then I'd conclude. So it's sort of the same thing. But in my experience, at least in all the mos I did and in the real one, it was a lot faster and the examiner was more like, yeah, talk to me like I was the patient but they don't want any of this. Like, have you ever heard of this before? Because a lot of them just aren't gonna engage, you know, so you're gonna be talking to them and they may be looking at you, they may be looking to the side. So that sort of thing works less well. So yes, it is like the counseling sections. It's just a little bit shorter in my experience and that is why I often and in fact, we had a session with prof firs and he was like, you don't need to ask these things. Have you ever heard of this before? Just go straight to explaining the management. Yeah, II would still ask this. Do you have any questions just in case you have an examiner who is looking out for that? But maybe just put it at the end at the very end so that if they don't want any of that, you haven't really annoyed them because you've finished anyway. Does that answer your question? Yeah, thanks. Of course. No problem. Great. So guys, those were all my cases. Um If I could please ask you to give me some feedback because I now have a portfolio called Horis. It is the new Bane of my life. Um And so this is very helpful for me because I'll be able to show my educational supervisor that I actually was doing some teaching today and they like that. So I'd be very grateful. I am very conscious conscious that this was meant to finish eight minutes ago. I do have some s spas that we can go through. So it's up to you. Now, the SPS are on the slides with explanations so you can have the slides and go through them in your own time or we can whizz through them. Now, I'll give you say 30 seconds per SB and we do them all in 5, 10 minutes. Um What do you think? How do you, how are you guys feeling? Um I'm ok to do them now, if everyone else is or I don't mind having a read of them later. I mean, for me, it's enough to have one person who wants to do them, to be honest. And if anyone wants to wants to leave, I will not be offended. I just ask you that you please give me some feedback. Um And yeah, I'm happy, let's let's go through them and then if people want to leave, no offense taken. Um Also, I hope this was helpful if, if you do want to tell me something that you, that I could change for next time. Hopefully, you can do that through the form, but also feel free to just pop a message in the chat or email or message me whatever. Um I do generally care about my teaching. So if I can make this better in any way, please do let me know. Ok, so these bs, hopefully they won't be very hard. This is meant to be a fun way to end the session. So 24 year old male with urticaria difficulty breathing, swelling of the lips. BP is very, very low. 8545 you are worried his BP is 120 no past medical history. What is your next immediate step in management? Anyone please shout out or just put it in the chat, whatever you are most comfortable with. I am adrenaline. Yes, exactly. Because this guy has anaphylaxis and by the way, the dose is 0.5 mg of one in 1000. You need to remember that one. It's one of the few things for, you know, for a lot of these emergency conditions, you do need to know the doses of these first line meds. It'll be really helpful when you're an F one when you're on call. OK. Cool. Yes. So I am adrenaline. Well done. That was anaphylaxis. Next case you have a 58 year old man crushing chest pain for the last two hours presents to the ed. His ECG shows ST elevation in the anterior leads. What is the first step in management again? Shout out or chat, whatever you want. The first step in management is the aspirin. Yes, that is what I put. So um you start by giving them aspirin but of course, remember that your gold standard would be PCI. Yeah. So that's what you're aiming for. But in the meantime, we're gonna start them on some aspirin. Cool Spa three, a 65 year old woman presents with chest pain at rest and a normal troponin. Her ecg shows ST depression. What is the best initial management? Is it Aspirin and Chla? Yes, exactly. And what's the condition here? Is it unstable Angina? Yes, exactly. So she's got unstable angina. Um And uh yeah, sorry, I don't know what I was gonna say there. I lost my train of thought. So, yes, you, you, you start with aspirin and some clopidogrel. OK. Spa 452 year old man presented with sudden onset, sudden onset right sided weakness and dysarthria. Of course, I can't speak ct scan. No evidence of hemorrhage symptoms started two hours ago. He was previously well with no past medical history. What is the best immediate treatment? A throm bact thrombolysis is what I put. Why did you think thrombectomy? So I mix them up sometimes. I know there's one that like if this within a certain amount of hours then you can do it. Exactly. So, so both of them is technically within a certain amount of hours, I guess. But usually, so thrombolysis would be your preferred option. But, um, it needs to be started within 4.5 hours. Thrombectomy you can do, um, and you, I think so, the cut off, at least on paper I think is six hours. Some centers manage to do it a little bit later. It is indicated to the best of my knowledge. And when you have quite a large clot affecting quite a big part or say, like, I don't know, big clots affecting like a big section of the frontal lobe. For instance, then thrombectomy may be helpful because you are physically removing the clot. But that procedure of course, comes with risks, right? Like bleeding being a major one, whereas thrombolysis also very risky, right? Because you can also cause bleeding. Um But maybe, ii suppose I must say that would be really interesting to see what, why this is the preferred option. I'm not sure if it's a balance of risks and or thrombolysis might be more effective if the clot isn't giant. And also if you think about it, if the clot is rather small and in an area that's very difficult to reach the thrombectomy procedure would be a little bit or would be very difficult rather if that makes sense. That is, that is how I understand this. I hope that makes sense. Yes. Yes, thank you. No worries. So S ba 528 year old man, previously healthy, sudden onset shortness of breath and pleuritic chest pain. I feel like we've heard this before. Examination reveals absent breath sounds on the right side and tracheal deviation to the left. No, we have not. What is the best next step in management? He sounds like he's dying guys. We need to do something. Lets see. Sorry, please. Yes. Yes, see. Exactly. So this is a tension pneumothorax. So it's a medical emergency. You need needle decompression. Usually in the second intercostal space, midclavicular line. I know that some books still talk about the safety triangle, the safety triangle. Um Yes, but you know what, I think you wouldn't be wrong for saying either of those. But um the second Intercostal space mi CCL line is what I've learned is the way to go for immediate decompression in a scenario like this cool safety triangle being for things like putting in chest strains, for example. OK. Does that make sense? Yeah. Cool sp six. So 35 year old asthmatic with severe dyspnea, respiratory rate of 32 peak flow is 40% of normal. This guy is not doing very well. He is speaking in single words. What is the next best step in management? I'm not trying to trick you. Would it be b Yeah, exactly. So severe asthma exacerbation. Listen, asthma exacerbation. First thing you're gonna do is wax and nebulized. Salbutamol, right? He may very well need things like, I don't know, magnesium sulfate if this is a really severe case, but we're just not there yet. Ok. Well, then SBA 745 year old man known epilepsy comes to Ed with continuous generalized seizures for over 10 minutes. What are you gonna give them? Is it a yes. Um Now things like rectal diazePAM would not be wrong if they didn't have IV access. I said in this SB that they are in Ed. So I think it'd be fairly safe for you to assume that even if he doesn't have IV access, that we will manage to give him IV access. But if they were in the community, for example, or any suggestion on the question that they didn't have IV access, then diazePAM would be fine. IV Midazolam, I guess you could. Um But that's not really the way the algorithm works. And if anything, it's usually Rectal diazePAM or Bal Midazolam that you'd give if you don't have IV available. OK. Spa 863 year old man with a history of prostate cancer comes in with acute onset back pain and leg weakness. What is the most appropriate initial management? And while we're at it, what do you think is going on? Would it be um the DEX? Yes. Exactly. Why, what's going on with this guy? Um He's got the like a spinal cord, like compression. Exactly. And what do the steroids do do you know? Mm Sure what they do exactly. Well, steroids you give in inflammatory conditions a lot of the time, right? So like eczema, for example, um even in things like asthma, so it literally does that it, it sort of reduces edema by reducing inflammation, kind of buys you time. So, yes, this guy has acute spinal cord compression. So you start by giving dexamethasone, um they will maybe need some radiotherapy and surgery, but immediately you're going to give the DEX to help um reduce that edema. And then you're gonna think, well, not you, you're gonna call the friendly oncologist who will tell you what will need to be done um slash neurosurgery. Maybe both anyway. Ok. Spa nine, a 55 year old woman presented with confusion, hypertension, hyperpigmentation. She is known to have Addison's disease. What is the most appropriate immediate treatment? And yes, I made all these questions about management because it's important. Is it a Exactly. So add crisis, you need immediate IV steroids. And we already said before the IV steroid is hydrocortisone. So that's what you're gonna do. Fabulous. Um You are going to need some IV fluids. Of course, this person um, is hypotensive, but that's not really going to solve the, the underlying problem here, which is why it wasn't the best answer. Ok. Spa 1023 year old woman with type one diabetes. Oh, sorry. They give me one second. If this s spa would say like this is tricky. Actually, maybe I should have given more details. Say that in this s spa you had someone who was severely hypertensive and they were in shock, like if you are resuscitating someone, then you're gonna give them IV fluids immediately. Um But the other problem with this question is that the IV fluids I'm suggesting here is, is dextrose which is not a, is really not a good recess fluid. Um So ideally you'd want your, your um gosh, words, your saline or maybe even your um plasma light, for example, but you wouldn't give dextrose in a rhesus scenario. But anyway, the, that's another reason why the best answer here was IV Hydrocortisone. Hope that makes sense. Ok. Last 1, 23 year old woman type one diabetes comes in with vomiting, abdominal pain and labored breathing. And you know that labored breathing is called technical term. It is the small breathing. Yes, exactly. That's exactly what this is getting at. And the blood test show glucose level of 28 ketones are raised. What is the most appropriate? Next step? Is it e you know what? So thi this was just a mean question. So uh yes, you would give fluids before you give insulin but you're not going to give Yeah, but you wouldn't give oral fluids. You'd give IV fluids. So this is just not a very good question. You would not have something like this in finals I II do apologize. Um but yeah, so the answer I was looking for here is IV insulin. But by the way, if you look at the DK protocol, you do start giving um IV fluids before you start giving the insulin. Ok. So caveat there in this case, that was not the answer because it said oral uh and do remember this, the rate of insulin infusion is 0.05 to 0.1 units per kilo per hour. If in doubt 0.1 units per kilo per hour for simplicity. OK. So do remember that as well. All right guys, that is now actually it for me. So if you could leave me some feedback, I'd be super grateful. I sound like I'm selling something, you know, like when those people are trying to sell a product on TV or whatever, that's me with the feedback. So yes, if you have any questions, that's my NHS email. Uh I do still very much use my Imperial email um and I'll have it for a few more years. So just um that's my short code. So you can speak to me through there as well. I really, really hope this was helpful. Um But if it wasn't let me know how I can make it more helpful and yes. Any questions about anything f one final year. Yeah, SF PS whatever. II am very happy to help.