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uh, for example, or I put in a seriousness to the T waves because that's like pointing towards something else. But obviously, that's something to consider when you're given an easy to interpret, um, on the spot, um, then blood, someone correctly said they would do. Troponin is, and I've highlighted again. It would be sort of cereal proponents, um, to see the the change we don't something I've been hearing a lot. Um, at work nowadays actually, literally in the past week, is we don't treat numbers. So an elevated troponin on its own means nothing. A troponin that keeps elevating. Um is something worth investigating? If that makes sense, Um, and you would do you would likely do a full panel since you're taking blood. Um, I would say again here, no one has really done it, obviously, in the chart, But just things to remember when it comes to listing investigations be be a bit mindful about why you're asking investigations. So it's very fair to say that you would like to have sort of a set of your sort of sort of right routine bloods like full blood count using these LFTs n crp as a baseline. That's absolutely fine. You also want to look at calculation because one of your exponential, for example, was aortic dissection. Is this patient bleeding into his thoracic cavity or his abdomen or whatever? Like, are we gonna be needing to intervening that way? Um, and you're and you're you can literally say anything as long as you can justify in a way that makes sense for your clinical practice and what you're trying to achieve. For example, if if someone said a d dimer because they were thinking, um, that this could be like a presentation of P, that would also be, um, fine, if you should can justify the reason why you're why you're doing an investigation. Um, you would most likely get some sort of, um, chest X ray, especially because, um her if you mentioned, for example, like your heart failure, Um, and, uh, And again, whatever you ask, you will be given, um, nine times out of 10. So you asked for e. C. G. Is anyone able to just write in the chat or a mute and serves out what is the most obvious abnormality with the C C G again? No one's asking you to sort of go. This is the C g of patient X y z taken on the whatever. Whatever you have, the in the history that this is this G that you did for the specific patient. And you keep being given that in cute, um, a kid setting to interpret, um, sort of fast. So what does this show? I don't know. Actually, um, can someone also write in the chart? Are the slides showing all right or are they a bit too small Showing? What do you guys think about this? Yeah, um, exactly. It's the elevation, uh, more pronounced. That V one all the way to be four. Um, be five. Doesn't look great either, but, um, you know, but yes, you're right. There is some ST Elevation. Um, and Harris has said in the antral lateral leads as well, So even more sort of, um uh, specific, Which is great. Um, so yeah, So you're given that and then you asked for some bloods. I'm realizing that my the blood results are not showing great. Um, because I always pasted and it didn't faced really well. Uh, so the one before last, I suppose state proponent and so that it showed that it started at 40 went on to 100 and then 250 because you asked for serial proponents, Um, with Bloods as well. You I actually don't remember very little from the whole basis. Um, and I remember even even littler That makes sense for from whether there were normal values or not when we had our bloods, Um, I think there might have been for for something similar to your Britain's. You might be asked to remember, for example, the normal range for sodium, potassium urine pattern mean, Um, but for the others, you might you might be given some sort of normal values. I don't know if the university has confirmed that or not with you. Um, so you have your bloods and you have your chest X ray, and we'll not shout out anything abnormal that they see anything that catches their eye in either one. You can also mention that the increasing troponin, which have also pointed out But, uh, I won't take this as a as a wrong answer and also trying to maybe look at sort of what's important for for this presentation. Um I mean, everything would likely be, um, of interest to you, but the fact that you have a very sort of obvious rising troponin makes you think. Okay, like my main abnormality. And my main worry with sets of blood is the the increasing proponent. Um, chest X ray. Um, I don't know if anyone, um, spotted something. Um, uh, this was intended. Intended to be a normal x ray, because, um, you might not. You want to necessarily have changes. It's not something that unless there was a sort of pre existing, um, condition, uh, you might not really see anything. And that's on the point of the station of this case either. Uh, oops. Anyway, well, I give it away, but, um, anyone want to shout what they would do? Not that we have that this patient has a rising proponents ST elevation on the e c g. Um, and we're thinking that we've confirmed our primary differential, which was, uh, am I or acute coronary syndrome? What's the most important thing this man needs the most important intervention that this man needs. Um PCI, Yeah. Brilliant. Yes. So this so even if you started with that, you're like I have now confirmed that with my confirmed I'm I am really, really strongly suspecting because of this and this and this that this man has, uh, under a under a lateral, um, stemi. And so he needs an urgent um PCI. Yeah. Perfect. Um, some of you have read an aspirin. Um, that's right. And there's a, uh the pneumonic I was using was not monarch basic. It was Mona Bash, which was for morphine, oxygen nitrate, aspirin, uh, beta blockers, anticoagulants, statin and heparin. So here there's a few more things. And I think this might be just a tiny bit more, um, complete maybe than the one I was using. Um, it doesn't necessarily have them in the order that you would do them. It's just a way for you to to have all of the, uh, the steps in your mind. Not everyone will be eligible for an ace inhibitor or, uh, to our blocker, but it's just things that you would want to start a patient on. And then, depending on what the presentation is, you can say I would like to start this, but actually the patient has contraindications for that. For example, um, but yeah. But even if you say the most important thing would be, uh, PCI and then medication wise, you can even play it like that sort of medication. So, um, medical treatment would be this surgery will be that, um you would always mention sort of escalating to a senior, asking for maybe cardiology input because you are in, like, a sort of emergency setting you You're not necessarily the thing that would, um, ultimately be caring for this patient if this was a representation. All right. Very well. Um, does anyone want to have a go? I think this is one of the most, um, important things for you guys to, um to practice. Um, we don't I don't know how how it is for you and I'm hoping is different for you, but I think we don't often get the opportunity as medical students to describe to, uh, the patient or the relatives. Um, what we've done what we think is happening and sort of update them on the management plan. Um, so this is an opportunity for any of you to just sort of try to, um, give me, like, a two minutes, three minutes or summary of what we just discussed and what the next plans would be for this person. As if I wasn't, um, medically trained. Does anyone in a volunteer to try? Shall I go? Shall I try? Of course. That is, if you want. Yeah. So, um, so I might assume you're the patient. I'm the I'm the patient daughter. Okay. So high. Um, are you, um, the patient's okay, so we have done some, um, tests in, So, um, he came in out, and, um, it looked like the easy heart attack. Have you heard about that before? Yes, I have. Okay. Um, do you know what it is and what's what's happening? Um, I don't know exactly. I know that, um, some of my friends' parents had it, but it has to do something with the heart, not receiving enough blood. Yeah, exactly. So, um, your dad's heart, um, is not able to receive enough blood to keep his body. So that's why he's getting this chest pain, because the heart is trying really hard to pump blood around the body to get it to, um, the organs. So, um, we have given him some painkillers, so he should be comfortable. But what we need to do now is, um we need to open up the blood vessels that are blocked that are not allowing the hard to get enough blood. And that will allow, um, the blood to return to the heart and and allow it to beat more effectively. Um, and then we, um does that make sense up to now? Do you have any questions, You guys? Yeah. Okay. And we also need to think about ways to prevent this happening in the future. But that's something that I can discuss with you. Um, after we, um, manage your dad and his condition, Um, so that we can make him feel better as soon as possible. Is that okay with you? Yeah, that's great. Thank you very much for update tea. No weight. Right. So exactly. That's all you need. You should have, um, give sort of, um, small bites of information to the patient or the patient's relatives assuming, know medical knowledge. So I really like how hard is I asked me. You know, we think he has a heart attack. Do you know what that is? Um, do you understand what it is uh, And you I feel like you were checking in at various stages. So you were giving a bit of information and you were checking in, like, are you, You know, Do you understand? Is that okay? You're moving on. Um, are you okay with this information and so on and so forth? Um, and that's exactly what we want you guys to be doing in this station and what I I guess what you're gonna sort of have to be doing is an f one. Um, because you will be asked to update. Families will be asked to speak with patient's. You'll be asked to, um uh to discuss with, um, a few maybe non medically trained, um, people and update them on the plan. Um And so, um, things like so assuming know medical knowledge and avoiding jargon is really important for that station. And this is what they're trying to get you to do. Um uh, you you can start the the conversation with asking the relative or the patient, um, what they've been told so far established. If you're the first person that's speaking to them after whatever's happened, or if they know already, some, like maybe the diagnosis or they know already that, um the results have showed something, Um, obviously remaining empathetic you. I don't suppose this will necessarily happen in your finals, Um, and not in the maybe in the acute station, but you might get some reaction. Um, maybe in the other stations, for example, I remember one of my other stations. I had to tell a patient that they needed some sort of treatment. And I got loads of backlash, for example, um, so be prepared to, you know, remain empathetic, if if needed. Especially if it's, um, breaking bad news. Um, because of something. But again, I don't really think they would necessarily ask you to do that in a short, acute care station. Um, allow them to ask questions throughout and or something else about, and Yeah, and it was really nice how at the end, you said, you know, after that, we would need to plan for reducing his risk of it happening again. But that's for a later conversation. Sort of allowing, uh, space and time for these conversations to happen. Any questions at all for these? I don't see any. Uh huh. Yes. I can hear you. Are you trying to ask something? Or am I? Yes. Can you hear me? Sorry. I think it's the mind. Um, yeah. I was trying to ask, How much information do you give them about the biology of what's going on? Because I I sometimes struggle to know where to stop and how much information to give us to what's actually going on in the body. Like, is it enough to just say, Oh, the heart is trying really hard to beat, um, or to come blood and not go into the arteries and the vessels and No, no, you can You can You can So, uh, for the station, I think I'll try to get it with, like, how long do you have left? So is it something that's, uh, you know, worth your time going into or would you rather sort of say, you know, in a maybe not as precise way, but something that explains the situation and then try to get through the other parts of the information that you need to get through like what's happened and because you won't be just assessed on how you explain the, uh, the disease. You will also be assessed on how you communicate the plan and the next steps. So saying, if you had, um, unlimited time, I wouldn't hesitate. Like the fact that someone's not medical train doesn't mean that you cannot go, uh, into a bit more detail. You can say so. The heart, um, as with other muscles in the body, is a muscle. And it's, um, function is to pump blood around the body. And that's how we get all of our our other organs. Perfused obviously, because it's a muscle. The the heart itself needs to get some oxygen through the blood. And it also has some, um, vessels, tubes carrying, uh, the blood, uh, to supply the musculature of the heart. And when that fails, because there's a bit of a blockage in one of those vessels leading to to the heart muscle, the heart muscle cannot pumps effectively, and then you have trouble getting blood into the rest of the body. So you still go into the fact that there's, like, you know, tube supplying blood to the heart muscle. Um, but you're not gonna say, uh, there's four of them. One goes in the front, one goes in the back one goes around. Your dad has had the one that's in the front and they'll in the side. And we you know, So there is a level, Um, but it's not. But the way he said it is is fine. It's very understandable at the claims and the situation. And so you can You can basically gauge the level of detail you want to go into. Um, if you're worried, you're gonna go over time and you're gonna go into too much detail. Um, I would suggest for this light comes at the very end. But for the main emergencies you want to be preparing for have, like a Google Online to see if there's any patient information, leaflets or any forums or anything like that where nonmedical people have tried to describe this, um, in the way that they understand it, or or or it's written by professionals for people who are not medically trained, and that can give you an idea of, you know, what's like a good, concise way, Uh, To do this, you can even make them up yourselves and try them with, you know, family or people who friends who are not necessarily doing medicine and see how understandable they are. But as as long as you have something in mind about how you would explain something to someone who's not medically trained, you should be fine. Um, don't Don't worry too much about the level of detail. Um, is that okay? I hope it is. Let me know. If not, we can come back to that. And we're gonna do loads of those. Um uh, explanations. Hopefully, um, so there's a second case. I can't remember which one is my second case, because it comes to my next slide. Um, but it's a fairly similar similar to the first one. Oh. Okay, fine. This is one that we did to some medical students, Uh, at King's. Um, so it's it has a bit less information, uh, in terms of summarizing the history. So if anyone wants to, um, try this one. Um, I'm gonna show the history Anyone that was to go like someone tried to a mute. Anyone like looking up names like Chad or Chris? Uh, well, someone wrote in the chat. Remember things, Marty, I'm not gonna chop before. Oh, it's okay, Chris. Fine. Um, okay. I'm going to show the case. Maybe that will get a few more people sort of more relaxed about what the cases about, um And see if, um, if anyone will volunteer after seeing the case, Anyone you've seen the case wants to try. Mm. If not, I'll tell you how I might. Something like that. Um, I'm gonna cheat because I pass my exams, so I can actually, um, look at the look at the history. Um, but I would say something like, uh, this is an 18, 18 year old male who has presented with an acute onset breathlessness on the background of an altercation on the road nearby. Uh, there's some, uh, left sided pain. Um, but the patient does not disclose much information, which, actually, I'm not realize it was not on the previous slide, so I might have just updated one of them. Um, he has a background of type one diabetes, um, treated with insulin and has a high, um, alcohol intake. Um, he's on a high oxygen requirement and technique and still desaturating, um, his hypertensive and tachycardic. Uh, and there's a visible stab wound on the left lateral chest. His trachea is central, and there's a dullness to percussion on the left lower lobe with diminished breath sounds, um, and reduced expansion. Um, and that's it. Literally everything. I'm, uh just the things I've highlighted. You don't need to go, obviously, about the into the family history of the mom. You, um you could mention the the smoking of sort of, um, illicit substances, but in this case, it probably wouldn't add much the story. Um, so I put this in because it's it's one of those histories that you don't have much to go by in terms of what you're given on the on the history side. And and actually, with a presentation like this, you might be focusing more on your observations and examination findings. Um, and there isn't also why I put this in was because it gives us an opportunity, um, to discuss, um, sort of trauma, which, at least from me last year It's not really something that we were expected to, um Or maybe so we were sort of expected to know how to, um, how to discuss, but didn't really seem it was, um it's coming up. Um, so I feel like that's it way in my head. We weren't really, um, expected to know. Now, obviously, you're expected to know everything. You know what I mean? Um, anyone wants to suggest any causes to this presentation. Um, I could try. Yeah, but I'll give you the I don't know if that helps, but, uh, sure, so because of, like, the trauma kind of situation, I'd want to rule out like a hemothorax. Great. Um, and also in that line, also a spontaneous pneumothorax as well. Um, and also again, in that line, uh, cardiac tamponade. Yeah. Great. Uh, yeah, that's great. Actually, that's better than my my third. Um, differential. I put pneumonia just because in, in all my in, like, I couldn't really think of anything else. Um, but it doesn't matter necessarily. Um, but yeah, I think you're differentials were great again. Don't worry. Like I just put mind for reference. They don't mean anything. Um, but you're very right in thinking, um, Hemothorax. I put him on pneumothorax because we're sort of a traumatic, um, sort of stabbing injury like that. You would expect some sort of air flow as well, uh, through the lungs. But again, don't get bogged down into the details of whether it's gonna be hemothorax, uh, human pneumothorax or, uh or or anything else. Um, but very good. Yeah. Um, happy with the differentials. And, um, you want to keep going with what investigations you would do and how you would might be managing this patient. Um, I'm sure So, like a I mean, obviously, I'd like to do an a two e and call for help, but, uh, yeah, I'd also do like a, um from bedside bloods and imaging. Um, do you g do a full cardio rest exam? Um, blood glucose and things. Um, and imaging. I think Chest X ray would be kind of helping in that way in terms. Almost diagnostic. Yeah. Yeah. Amazing. Exactly. So here I I just wrote down like, a bit of the 80. Um, I didn't feel like it was necessarily worth going through the a tweet. And I'm thinking about it. Maybe I should have I don't know if you guys want I can include, like, a full sort of eight. We what you would be looking at each domain, but I just feel like, um, we we get told those a lot. Uh, it would It would just be a bit more beneficial to, like, just practice. They're more like, sort of see what information you will be putting in each domain and not necessarily just go through the whole, um what is a What is b and all that, and sort of see it more in, like, a case, uh, specific, Uh, like, um, but I can definitely add a slide at the end. Um, so you you do your eight to a you in my in my station? I was not asked to talk through it. I sort of said I would be, You know, approaching this in an eight to a eight, we manner the examine was like, Yeah, okay. And investigations. What would you like to do? So it depends on on what the scenarios I feel like in this one. The reason why I put a two is because it, um, patient was a tiny bit more and, well, not that you wouldn't be doing that for the other patients' as well. But I thought it was, uh, sort of a bit more. Um, it will show better in this in this example, Um, and so you're looking at the airway. You're looking at the, uh, breathing, um, your sort of cardiac circulation bait. Um, you're very well, sort of mentioned is one of the best sides of glucose, uh, and examinations and all that. I think that would sort of be covered by your 80 I think. But, um, again, you might not be asked to elevate on on that, um, something that when? So So this case was written by, um, a teaching fellow at Kings. And she, uh, put have importance on sort of where you would be looking for further stab wounds as well. It might be because King's is a major trauma center. Um, but, um, just in the exposure, I feel like in the exposure, we sort of always get stuck. And you know what? What would you be looking for? And this is a case where there's something to be actively looking for, not necessarily just exposing to to check for generic things. Um, but you'll be looking for other things. Really? Like rushes or, um, bleeding or whatever else you want to put in E. Um, again. Then you mentioned your bedside bloods and emerging perfect. That's that's how you want to be doing it. um and, um, Bedside. So you mentioned the c g in this case, You you can argue that, you know, they actually can go under imaging. Um, it's it's very appropriate to say that because the patient's really unwell and you want to have, uh because it is diagnostic of whatever is happening there. You can very well. I'm sorry. You can very well ask for a portable chest X ray. It doesn't really change the image you're gonna be given in the scenario. Um, but it's sort of I think it shows, uh, sort of a nice way of, you know, you you understand where, like, portable X rays would be appropriate. Um, the the urgency of the situation again Not to say that saying Jess trick under imaging is wrong by any by any means. Um, but you can present it. Either way, you can say a portable chest X ray or um under imaging. Um, to say that you did an X ray. Um, And again, I'll show you the X ray. Now, uh, you want to be looking at the most obvious abnormality? Uh, the bloods more or less the same. Because this patient you think they might be bleeding. Um, it would be worth doing, like a group and screen or a cross match If you're If you're suspecting some heavy, heavy bleeding that you would need to correct instantly, um, and imaging the only reason why I put sort of, um uh, any form of cities. Because in in trauma, we tend to when people come in and more and more encouragement, I think, than something like this. But you would be considering doing like a city chest, abdomen, pelvis, uh, to check for any other injuries and depending on the mechanism, um, get, like a sort of, uh, closer view of, um of internal organs and stuff like that. Um, and the CT pa, I don't actually remember what I put in. Um, uh, I think was one of the differentials of hyper was, like, likely, like, maybe p or something. Don't worry about that. Um, literally. Just go with what you have said in the moment. So if you were saying cardiac Tampa not maybe you would like to do something like an echo, Um, and so say that in your in your imaging, and you can justify, based on whatever differentials you've given before. Um, you do your c g not going to make you look super hard on it. I appreciate it's not, and I don't think it's the nicest to visit GS, but it's meant to be showing some Sinus tachycardia with no other abnormalities. Um, these are your the blood that you did and the chest X ray. Don't worry about the blood is too much. I think they're grossly and change from the previous patient if I'm honest. Um, but the chest X ray Anyone wants to write in the chat? What is happening? Sort of a bit more specifics outside, um, finding. And maybe also how you would think about managing based on this, uh, x ray or if you want a nude chatter and Newt whatever you want. What anyone? Yeah, brilliant. So, yeah, it's a left side of capacity in yeah, mid to lower zones with fluid level. So considering them, yeah, great. It's important to mention there's no tracheal deviation. I think it's a bit rotated this one, but, um, not necessarily deviated. And so in the in the context of the stabbing and the hypertension and the fluid level in the lung um, I think your colleague so I didn't catch your name. Divinci. Am I Did I butcher that? No, no, it was great. It was great. That's right. But you're very, very correctly said, sort of, that this could be a hemothorax. Um, so Yeah. Great. Um, and any idea how you would be How would you be thinking to manage this, um, fluid in the lungs? Yeah, exactly. It's a chest train. Um, I think there's some I don't know if I include them here or at the end of when you would be thinking to do a chest, chest train. Um, but for this one, same as everything else you would so much. But your senior, um, you would be thinking about doing a chest rain. Uh, fairly quickly. I I don't think you would be doing it necessarily as an f one yourself, but you you would be escalating it quickly enough for someone trained to do it. Um, and I was sort of we're supposed to know that, uh, the safe safety triangles and where you would be, um, putting a strain in an emergency situation. Um, I think maybe a d g h here in D A n E might be asked to do one. Um, but I think usually they're They're in my experience. And I've only been an F one for a couple of months, so don't take my word for it, but, um, you know, um, not necessarily something that you would be doing in your first month of F one. Um, but that's the management. So you need to say it, um, and things like pain relief and sort of, um, uh, sort of correcting the volume depletion, uh, would be things to keep in mind. Um, you could say stuff like get a surgical opinion or a like a, uh uh, breast opinion or anything like that. That would be absolutely fine to do. Um, and you you can Sprinkle a bit of like I would We would decide to admit this patient because you're in, like, an emergency. Uh, the the um setting. Um, But, see, it's not you. You could split it into, like, some medical and surgical by saying I would treat this. Um, I would treat sort of the symptoms of it, but with the pain, relief and the oxygen and that sort of supportive management and explore surgical options or anything like that. Um, but you can also just sort of, um, explore the other aspects of your management that are not necessarily interventions and are more the discussion's that you have the escalation you would do, um, more sort of procedure rather than than medical, if that makes sense. Um, great. And, um, does anyone want to describe to me the patient not And I'm the patient, Um, What you've found out and what your management plan ace for me. And if anyone wants to unmin ute, then give this one a try. Like maybe this is, um I don't know if if, um, if it's a weird one, because there's the stop being involved, and you feel like you can't really get into the sort of details of that. Um, so if that's the case, you can sort of leave it. Um um, otherwise, it would be sort of the same principle as I don't think I've actually got a patient like, but it would be the same principle as before. Um, you tried to establish what the patient already knows, and with patient's, you know, you can sort of start the conversation with, Like, um, so you've had your X ray. Now you've had your whatever. Did anyone come and discuss with you the results of your X ray? Um, because he, you know, his Jesus, for example, was normal. You can assume that, uh, likely they have an understanding of, uh, what's happening to them. So do you. Has anyone talked to you about your results of, uh, what do you remember having done? You've had some blood you've had. Whatever. Whatever. Okay, so with your presentation and with the chest x ray that we that we did, uh, we think that there's a collection of fluid in your lungs and that's causing your discomfort in breathing. Um, because of your presentation because of your your, uh, the mode of your injury like, method of injury. Uh, we think that this, uh, collection is likely blood. Um, So what we need to do is put a strain through your ribs, um, to train the fluid out and help you breathe a bit better, and someone will come and consent you. Um, for this in a in a bit, and explain you more about the process. I realize I've said, for example, uh, like a couple of things that I haven't stopped to check with the patient. So which which can happen to you Take a step back when you're like, um, anything that I've said so far that doesn't make sense Or any questions that you have for me. Um, and you address whatever they might say, and and then you can continue with your your next steps. And so, apart from the chest rain, we will be prescribing some pain relief. We'll be giving you some oxygen, Um, and sort of try to manage your your symptoms. Um, and we will need to do that in the hospital. So we will admit you, um, for that and get the senior surgical thing to come and see if they think any any further intervention is needed. For example, um, and hopefully that's have explained all of the, uh, information that you've gathered the through your investigations, the management that you've created, Um, and your next steps, um, we have come up to case three. We can take a tiny bit of a break. I think the other two cases are are, uh, sort of smaller because there's not a guy sort of Skip that step Stop. Sort of putting blood results and stuff like that that you might be given if you ask them. But I figure we can focus on the actual relevant investigations. Um, but people want to take, like, a seven year break, and we can reconvene that sort of 20 past seven and and go through the rest of the slides that suit everyone. You can just give me a thumbs up or anything like that. Yeah. Thank you, Jen. Yeah. Okay, So, um, I'll stick around. I'm just gonna turn off my camera and my mic. Um, but if there's any questions, let me know, and I'm going to be here, and I'm just gonna too open them again at 20 past ignore questions. Okay? So let me have some water. Right. So we have two more cases, um, which I think are a tiny bit shorter. Um, but if people just want to go through and take one of them, um and you want to leave the other one to sort of go throughout your own time, and that's also perfectly fine. We can also see how we're doing the time. Um, for this case, but yeah, And let's see, we can We can do the third one, and then at the end of it, we can see if you guys want to, um, stop or do the last one as well. So this is actually the case that I had with not exactly the same, but the diagnosis that I was given for my disease. Um, again, different history. Um, but I don't know if anyone's on F one fan here. Um, and, uh, that's not a requirement to summarize this case external really wants to. I can. I can do this one as well, but if Oh, yes. Uh, amazing. Yeah. Go ahead. Uh, change the slide, so we see how you do. Okay, Uh, this was a 25 rolled with back pain predominant in his left flank, which is intermittent sharp and radiates to his groin. Um, he, uh, has no past medical history. Is taking calcium supplements, Um, in terms of, uh, he has recently returned from, uh, Dobby. And, um uh, there was he, uh he was in a Formula one race and, uh, sweat a lot during that time. Uh, in terms of his systems, he feels feverish. uh, there's no diarrhea and his urine is dark. Uh, he is to keep Nick. He's not. He's not desaturating. I think he was taking Codec, and I can't remember his BP. His GSS was normal, and pupils were equal and reactive to light. Uh, I can't remember. I can't remember anything else. Hmm. There's one tiny bit of information in the in the observations. Um, uh, can we go back to the slider? Don't worry. I'll actually go to them to the next one. So you, um uh I'm sorry. Your presentation was, um, the you. So you said the salient points with the, uh the age, the sort of pain that patient's presenting with, Um, you didn't dwell too much. So you you should have said that the patient is a driver, and so he sweat a lot during the race. Um, which, you know you can, you can argue. Is this, um, like, important enough? Am I taking enough time? But actually, it's sort of giving, like a context for for why he's so dehydrated. It's not because he's, um, you know, neglecting himself. Or, um uh, because he's sort of having profuse diarrhea or anything like that. So? So there's, um You can decide how you want to present it. And for some people, this will be too much information to say that there is a Formula One driver. Um, For others, it won't as long as the information is there. And you're not dragging on saying more about his background with regards to that. And you you're only mentioning it to tide with the dehydration and why this is a significant amount of dehydration. It's not someone. It's not me that round five kilometers and came back home and I was really sweaty like it's, uh um, I put it there because the Grand Prix was recent, but also to show that it's like, uh, an occasion, for example. Okay, it's not really realistic because Formula One drivers drink loads, but someone with that amount of sort of physical stress and amount of losses would be significantly significantly dehydrated. And you would want to sort of, um, flag down. Um, um, you mentioned the systems review and the only other thing yeah, in your observations would be the the temperature, which you again. That's why I said, Don't, um, don't feel to pressure to remember the numbers because you might not remember them, But if in your head you have labels. So you look at the numbers, you know, that psychic are you? Look at the BP. You're like, This is very borderline, To be fair, I didn't I wasn't really helping with with these numbers. But if you knew that you were, like, this is very borderline, um, normal, Normal. Too low. Um, and his temperature is high. You you would have just given the labels, which would have been enough for the context of, um, what we're asking for. I'm not sure if you mentioned them. We know angle, tenderness. I feel like you might have. Uh, actually, I think reading. So these are the maybe the two things that are they're quite important. Just because they will help you sort of differentiate no differential. Uh, just give some extra relevant information, because if he maybe wasn't, um, uh, feverish or he didn't have the renal and it'll tenderness. He would be thinking that he's a bit less unwell, um, than than what he's presenting with now. So leading on from this, um, very, uh, nice and concise. And, um, we'll present. Presented summary. Anyone wants to give, uh, the differentials ago, Judge, you can You can keep going if you want it. It's not. It doesn't have to be something else. But if anyone wants to give it a go, I mean, yeah, I can go if no one else wants to jump. Um, so the top my top differential is probably something like renal colic. Uh, common. Um, well, common. I imagine renal colic is quite common, but it's something else. Uh, something you want to rule out his pylon arthritis, considering his his his pyrexia and tenderness, Um, it could Could be a simple UTI. Could be something else. Exactly. Yeah. Yeah. So I think that's perfectly fine. You said, um, exactly the the the differential that you would would be expecting. Or you you would want someone to to mention. So you you could even swap the You could sort of reverse the order and say, You know, the most important thing I would like to exclude with this presentation would be a parliament Fridays, um, secondary to whatever you can say that, like, I think in my slides actually put that it's pylon for the secondary renal calculus. Um, then don't worry about the common common stuff. Like, because he the the guy didn't have, um um, diarrhea. But, you know, he had some pain radiating to the front. Whatever. It it really doesn't matter. Um, what you say? And then, um, I put testicular torsion because sometimes, um, especially with mail, which there's pain radiated growing. Um, I feel like I feel like people were making a bit fast about mentioning that, even if it's even if it doesn't sound like it, because it's one of the things that you would like to exclude in in men. Um, but again, you, um you said really sort of relevant differential. So these are just for, um for like, a, uh, an example. They're not what? You what you should be saying necessarily. Um, and that brings us on to how you would be investigating his condition and managing him. I No one wants to volunteer. It's basically more or less the same thing you would be doing for for anyone else, you would have your your bedside investigations, your blood, your imaging. And, um now we're just getting to the sort of, uh, more um, I guess I would like a condition specific. Um, differentiations of the the bedside blood and imaging. Um, slide. So I've kept the same stuff, um, across the slide. So for bedside, I've I've always kept, for example, e c g, um, and the the Bloods. And then we sort of keep you See how we keep just changing maybe the imaging or adding some bedside investigations, Adding a few bloods, um, to the to the mix, and that's what you're gonna be basically asked to do. And that's why these frameworks things so you can just edit, like, do very minor editing. Um and, uh, sort of in this insurance that you've covered all of your bases. So, um, bedside, especially with, um arino, sort of. If you think about Reno stones, you can do an ultrasound. Um, that won't necessarily say confidently if there's something there or not. If it does say that there's something there, then, um, you, um can be pretty confident that there is, But if it doesn't, it doesn't exclude anything. But it's a really it's actually a really useful bedside investigation to be using. It's really fast, um, to get access to anything that happens at the bedside is worth investigating if you can use or not. Um, and and that's why I sort of I think in this in in a case like this, you would be expected to mentioning at at least sort of understanding its pros and cons. Um, but mention it for sure, and then a urine dip, Um, likely with some cultures, especially because you you know, you're mentioning pile on Fridays. You're mentioning, um, UTIs so you can test the urine, um, at the bedside, Um, like, very simply. And then with blood's, um, again, it's more or less the same baseline bloods we've talked about before. But this time you can you can argue that you could some cultures because the patient is, um, edging on the on the set of sepsis with hypertension hyper, uh, sort of tachycardia and, uh, hyperthermia. And you could well argue that you would sort of try to do like a septic screen for him and then imaging, especially when it comes to things like, um, imaging original tracked. What you would do would be a CT kidney. Your urine bladder. Um, the trauma underneath was not supposed to be there there was something else supposed to be there. Um, but maybe you didn't read it properly, but basically, that's how you would visualize the renal tract and see if there's any stones if you're thinking about stones. And so actually, I think you only have, uh, Yeah, for example. I remember in my station I said that I would like to do a c d k u B to exclude stones. And I was given something similar to this. Um, I don't know if anyone's to write in the chat. Any sort of obvious abnormalities that they see. There's, I think to that should be highlighted here. If you're given a city like this. Any ideas from anyone? Yeah. Um, yeah, great. Both of you Really Well done. So there's a very visible sort of opaque, um, mass. Or you can even say that this is a stone. Um, at this point, um, in the left ureter and you've correctly identified that there's also some swelling of the, um uh the proximal ureter and actually of the whole kidney. Like the whole, uh, cortex is, uh, dilating. Um and so that's it. That's all you need to mention and from that point onwards, they're going to ask you what is the management for this patient? And, um, I don't know if anyone want to hazard a guess. Maybe in the chat about how you would be managing a patient like this. Yeah, Yeah, you're right. It does depend on them on the size, but yeah, that's where I was trying to. I think that's where they were trying to Two point towards with this case when I did the exam is that, um, the It's not just that it's a stone, which you're very corrected in that you would. It would sort of depend on the stone on the size of the stone. Also, sometimes the location of the stone. If it's, uh, sort of proximal mint or the stone, you're there or within the kidney. Um, but in this case, yeah, because you have hydronephrosis. You first need to sort of alleviate that, um, pressure from the kidney. Uh, and so the way that you do this, if it cannot go down, it's gonna go out another way. So you make basically make, uh nephrostomy, which is comes from the Greek stomach, which is mouth similar to the power stoma that you make. You just make an extra point of exit for the fluid that's in there. And so when you relieve the pressure, then you can start deciding whether this would be a patient who would benefit from just medical management with some, um, uh, medication and conservative symptomatic treatment or someone that needs some sort of lithotripsy or shockwave Um, a breakdown of this the stone. I'm realizing that this is now very, very small, but don't worry about it too much. I just put it there for reference that there's just a few like, um, steps in the diagnosis and management. Um, I can't remember where I've taken this from, but I put the link in the notes, so you should be able to follow the guidance as well and, um, see where they're coming from. Um, but for example, in this case, it wouldn't be incorrect to say that depending on the size of the stone, you would be choosing your your management. You would be involving, uh, urology, especially because of the hydronephrosis. And likely not just hydronephrosis, but likely at this point in pylon and Fridays, Um, for the nephrostomy. For closer. Follow up, and they would likely to be the ones to take over the patient as well. Um, and again you can. Apart from the management of the condition, you can talk about management of things around it. So the admission process the, um, stuff, like the deeper relaxes pain relief. Um, if they were complaining of nausea and the sickness and all the sort of supportive measures you would be doing alongside, um and, uh, actual management for the for the specific complaint. Um, okay. And, um, I don't know if anyone wants to a new I think at this point, um, I don't think I'm gonna have any more volunteers to a new it necessarily. But, uh, you all have the slides at the end of this. And so if you wanted to, you know, um, try it with your colleagues and take turns, Not necessarily with the specific cases, but, um, just that sort of. Based on this question, try to and examine each other and assess each other and how you will be breaking bad news. Um, again, I think similar to what I said before. If it's with your colleagues, because it's someone that's medically trained you might not be, um, you might miss them. Sort of fine. Maybe, like, fine details of, like, uh, jargon that we don't really think of it as jargon. But maybe someone who's not medical trained would not necessarily? No, uh, of the term. So try with your colleagues. Try with your, um, family. Try with your non medical trained, um, surrounding people to see how you would be describing stuff like that. Um, Deborah, Last case again. I think it's very quick. I don't know if you guys wanted to finish here because I appreciate it's late on Tuesday or if you want us to just quickly waste the case for, um, up to you, anyone that rise in the chart the first oh, how you feel. I think it's worth going through the final. Yeah, I'm I'm more than happy to do that. See, it's a really short one for a reason. Um, I don't know if anyone wants to give it a try. The question works are there for a reason so that I I forgot to put stuff, but maybe I should have said, um, that is because of the of the drowsiness that you cannot establish any of the family history in the social history. And you you only know the history medical plane and the past medical history in the drug history. Because of what? The nurse who called you to review this patient? Uh, yeah, because of what she told you, Basically, just anyone. I'm not trying to summarize this or has any ideas of anything that stands out in the history that they would be trying to involve in their summary. So for this one similar to all of them, the previous ones you'd be focusing on establishing presenting complaint early on. Um, and then, uh, the the history is actually quite short itself. So you would be saying something along the lines of, uh, 58 year old female, um, presenting with the I could answer, uh, drowsiness, uh, and confusion on the background of, uh, uh, ski me A treated with anti coagulation and analgesia. Um, she's a type one diabetic with history of vasculitis treated with, uh, type one. That history with insulin and vasculitis and further history could not be elicited because of the vacations. Confusion on examination. Um, she is, uh, she does not have any, uh increased oxygen requirements. She's slightly tachycardic and borderline hypertensive, but remains appear. Actually, uh, the most significant examination finding is a g CSF of three. Uh, and you leave it a thought. Um, which is more or less what I've given you anyway for for your presentation for, like, your your prompt. But you just wouldn't be necessarily being too interested in how much omeprazole she's having or what the exact, um, heart rate or the exact temperatures anyone wants to. Happier to guess on the on the chart. Maybe. About what? What? This patient What? What? This could be based on this very, very brief. Uh, could it be hyperglycemia because that one insulin and they'd probably be nil by mouth after the presentation? Or, um, potentially, uh, we don't know analogies if they're on. But could it be overdose if it's like opioids or something? Three. One more. I'll put the history back home just to I I don't think it's It's not like the most obvious one. They put the safe for a reason, but I like where you're going with your differentials. Um, could it be like a brain bleed? Maybe? Yeah, definitely. Exactly. So I put this, um, history. And because it's just so vague. And this doesn't really you can't really use this year because you have very limited information. So you could be using something like your surgical sieve to say, um, that cause could be sort of vascular effective. Whatever. You know, the, uh, I feel like every person has, like, a slightly different version of their surgical, um, sive, But, um, it's much more uncertain than the previous histories, and I'm not suggesting that the, uh, the university will necessarily give you a history like this, but it was just sort of I an opportunity to try see other ways of presenting your differentials, Not necessarily in order of importance or likelihood, but in, uh, I think your summary likes the surgical since, um, so it was sort of investigating that, and everything you said was absolutely spot on. She she could be hypoglycemic. She's on, she's insulin dependent. And, yeah, she's had some interventions. Has she been fed since? Well, she be given those before, um, for she actually managed to have, um, some sort of food. Um, is this a sort of an opioid induced, uh, drowsiness and confusion she's on pain relief, and her restaurant is not low enough. It's 12, which is, like sort of borderline but would be thinking, Oh gosh, what? What's happening? To cause the restaurant to go down and I think, sort of a brain bleed. It's just one of the things that you wouldn't really want to be missing, especially because she's, uh, being anticoagulated, Um, but otherwise, pick and choose. Honestly, um, at this point, with the information that you have, I think you made a great, um, selection of possible causes for the presentation. Um, and so how would you be managing this space? This patient specifically any, Any ideas? Anything, uh, also from you Her If if you want to, To continue the case. I mean so taking like an 80 approach. And until you definitely want to get their b m as soon as possible to rule out to rule out, um, hypoglycemia. And then I guess, because it's so such a very presentation. So like a full septic screen confusion screen, including a CT head. Great, Great. These are all very nice buzzword. So septic screen confusion screen that's that's actually more or less all. You will be doing, especially if you have a job in things like geriatrics or just any sort of medical ward. Also, any sort of surgical, you'll just be doing confusion screens. People seem to get confused in hospitals, Um, and very quickly said that you would really need to be checking their their glucose and whether you need to be correcting it. Um, starting from the top. I think this is a really, really nice place because it really also highlights, um, the clinical prioritization. So with the Jesus of three, you would really, really be thinking about protecting their airway. So they there's sort of this cut off, which is not necessary, people, people quoted. But um And then it's fine if you do. I'm not saying it's wrong. It's, uh it's part of like a set of guidelines. Um, but you you might see that in reality, um, it's more of like a clinical judgment as well. But they say that if the G. C s 08 and below, you'd really be thinking about, um whether the patient is able to protect their area and her G. C s is three. So you really wanna get in there consider simple airway maneuvers like your jaw thrust that, uh, chin lift till chin lift. Like, that's all very difficult words for me to pronounce, uh, and consider involving anaesthetics or ent Early on, um, you will be trained in F one with some agent, so you can even, uh, mention them that will be trying to insert maybe a good l. Uh, and do some railway, um, maneuver certification tolerated it, which, with the Jesus of three, it's unlikely that they would that they would, um, you do your your b your see these where you would be focusing on for your glucose, and the G C remains three out of 15 and the peoples are now sluggish. Um, and your E would be important because you have very little information about the patient. So if you saw, for example, uh, an injection site, you'll be thinking this patient had their insulin, um, mhm very, very close to the time of review. Um, if they're bleeding from somewhere, um, if they're Russia's, you'd be thinking about your sort of infectious causes of, um, presentation like this. I can give colitis or meningitis. So, um, these are these are one of the, um, at least the way that I experienced it. Some of the cases are are important to have an 80 approach, but you might not be necessarily as elaborate on them because they they have sort of investigation findings beyond the A two e. Um, whereas, for example, in cases like this where you would need to be showing your interventions early on in the 80 you might be as to elaborate a bit more. So, um, just good, too. Um, how these cases in mind? Um and so you mentioned, um, sort of bms at the bedside and aesthetic screen, which will be with you during the day or M c N s, uh, taking cultures full set of bloods that the confusion screen involves many more, many more bloods. And, um, kick emetics has a really nice page on, uh, what sort of blood you would be looking to request. I'm very proud to admit that on my first confusion screen, I turned to geeky medics, and I pulled up this page while I was ordering all the investigations. Um, and I'm I'm not ashamed. Geeky medics will be your friend next year. And and Imogene Yes, City had very, very important. You really wanna with with any sort of low G C s, you would be wanting some sort of brain imaging. Um, the reason why city, uh, more often than not goes above MRI is because it will. It will show you some of the acute pathologies. It's also very quick to get, um, much faster than MRI. Um, and even if it doesn't show something, you might be able to sort of exclude some conditions will show you bleeds. Um, it will show if there's some sort of swelling, and then if a more detailed look into the structures is warranted, you can get that, um, with an MRI sort of a bit later down the line after you've maybe started some some further interventions. Um, so you do all of this. And then that's the city head that you get someone gonna briefly describe it either by a new thing or in the chat? Yeah, That's, uh that's good explanation. So it's There's a large tent capacity on the right side with midline shift because it's a city. Um uh, it's Oh, no, no, I'm doubting myself. Um, I don't want to say something that's wrong. But the the fact that it's a sort of the that there's a possibility there makes you think that there's some sort of a bleed. Um, in that space, I'm pretty sure I should know this. Um, but you don't like you have, like this this doubt at the back of your mind. Um, but yeah, basically, that's a That's a that's a hemorrhage into the plane, the brain. And as you correctly pointed out, there's also some midland shift. Um, so you want to be acting on it fairly quickly? Um, and, uh, if something like that pops up, no one really expects you to know how you would be surgically managing this. But what they would be expecting to say is that you would be, uh, escalating this sort of, um, early to to your registrar, you'd be initiated. Discussion's within your surgical team. You'd be managing, uh, sort of supportively areas of the patient like their BP. Uh, you'd be continually monitoring us and assessing, um, you might want to consider depending on what anti calculation they've had. If you can reverse any of the and, um, it's very, um it's not. It's not just common. It's It's what you would do. You would You would initiate the conversations and sort of ask from both of both your registrar, but also sort of, uh, the neurosurgical registrar or whichever specialties that you're asking help, um, from to give you some sort of advice on what to do initially until they come and review and take over, um, control of the patient. And so that's the level of management you might be asked to to give. Basically, um, again, with, uh, again explained to the patient, I'm gonna let you sort of do that on your own unless someone wants to stay behind. And, um, we can work together. Or as I said earlier, sort of. You can email me at any point with any, um, anything you might need advice wise. Um, but that brings us to the end of case four as well. Which, um, I think was much shorter than than the others. Um, I honestly cannot really remember the acute care station just because the whole place is went by so quickly. Um, I mean, I sort of I do remember it, but it's, um it's not something that will define your, um, left as a doctor later on. It's not gonna, um, change, um, necessarily the outcome of the of the exam. And it's it's a station that, uh, that you can be really well prepared for, uh, without stressing, um, the tips that I would give you is to practice summaries. Um, go to your consultant or your red or whoever you're closest to your friends, Uh, and just take sort of a bunch of notes or make imaginary patient's and see how you would be, um, really sort of picking out the most salient points. Um, the reason why I mentioned Consultancy is because they normally have very little interest in hearing anything that's not remotely close to what is important for the history, and they will show it. So even though maybe it feels very awkward being, you know, um, having a consultant in front of you sort of losing interest in what you're saying, that sort of gives an indication that Okay, maybe this is not very necessarily, very interesting. Um, for the for the patient. Uh, don't don't be. Don't be scared to try that. Um, we've all been there and the the more you practice, the more like the better you will become, uh, presenting the salient points. Um, but also in general, presenting patient's, uh too, uh, for for any for any occasion. Really? Um, to practice those with whatever you feel comfortable doing practice, you're really know you're a two e and what you'd be looking which appreciate it didn't really do in this session. I just feel like something that gets repeated a lot. But as I said, I'll add a slide at the end with all the extra stuff for you to just, um, be able to review in your own time. And, uh, you can you can feel free to make your own table from whatever I put there or use that as your sort of guidance. Um, and really try to practice that sort of bedside bloods, uh, imaging way of structuring your, um your your initial management. That's why I put these two together. So in eight we and like the investigations that you would be doing, um, make sure you mention escalating early again because the whole purpose of this exam is to show that as an F one, you'd be safe to manage people by yourself, but you would never really be expected to to sort of, um, manage from beginning to add a patient by yourself so you would need to escalate to your reg or other specialties. Um, and it's always appropriate to say that you would be checking local guidelines. Um, even though there's a nice guidelines for, for example, thermal prophylaxis or whatever it is Payment's. Some hospitals will have their specific medication that they use either because of, um, um, the availability that they have in the specific area, the stuff that they have, Um, for for whatever reason, the hospital decides to to be using one medication over another. So, um, I mentioned throughout this relaxes. But that could be the same for stuff like antibiotics, in which you will be checking local guidelines for, uh, common organisms. Or you'll be checking with microbiology for sensitivities and, um, sort of in combination with local guidelines. Um, and really think about your common conditions with this, It's It's not meant to be a station that will throw you off. It's meant to be a station that again, check that if those common emergency conditions come through the door, you will be able to initiate some sort of assessment. Um, and and management, Um, even if on the day there's something that you feel, it's not very common. Um, you haven't 100% revised because it wasn't in the, you know, top list or or in the past, papers or whatever. Don't panic. Just breathe. Um, go back to your basics. Go back to your 80. We go back to your investigations, take it one step at a time. Um, and it might just mean that you have to mention escalating early and asking for help a bit earlier. Um, and that's absolutely fine when it comes to the acute care station. Um, these are my tapes. I'm pretty sure I also have a list of, like, your common emergencies, which I have taken from again one of the previous years. Um, slides. But, um, that's what you would want to be really preparing for. For the station. Um, and my plan was to sort of have a few slides again with the the main and management conditions, not for management of these conditions, but not for us to go through. At this point. I I want a decision to be more about you getting the chance of practice and see what a station would, um, unwrap itself. Like, if that makes sense. Um, but I put this there for a reference for you to have a, like, a starting point. Uh, and from now on, it's just my major stuff. So that's it? I'm gonna let all the extra slides be reviewed by your your own time. Finding clues, stuff like the s bar. Um, some nice stemi guidelines. Um, the e c G results. So everything we might have discussed in the previous, um, cases. What's it? And I finished sometime. Look at that. Thank you so much. Thank you for making interactive and pull the cases. You guys, are there any questions at all? Um, anyone. How often do they make you go through the 80 like, is it is it more common if they will or less. So when I spoke to my to my colleagues, I I don't think any of us really, uh, managed to go through, like, a proper eight weeks. Um, I would sort of try to go back on the sort of paces passed papers as much as possible, and see how many of these cases where? Um eight. We heavy or not, But, um, the it even though it is important, it's not like a a t. L s station where you have to keep reviewing and reviewing like they will likely not make you focus too much on explaining your 80. And and also because it's a 10 minute station. Um, they appreciate that you're gonna say a two e. And they want to get you through more investigations and show you the results get you to interpret them, um, and find a diagnosis to them speaking with the management. So, um, even though 80 is really important to book down and have it at the ready in case you're being your your your ass state, uh, don't be surprised if that if it doesn't necessarily come up, Does that make sense? Yeah. Thank you. Is that the e c g? You want to? I don't know. Or which one. I'm gonna leave this one here, right? If you want another one, I'm gonna I'm gonna change, so Oh, I see. If you provide feedback, you get a certificate that makes makes a bit of sense of how this how this works? Um, because I was wondering how I'm gonna show, like, a feedback form or anything like that. But that that makes sense. Yeah, I think we're all getting used to this platform. Yeah, it's not. It does make a bit more sense than teams, to be honest, um, there was loads of issues with things, but it seems like a nice welcome to be hosting such events. So I'm happy you're you switched to the, uh It's also like with recordings. It gets uploaded, like automatically, as opposed to having to go through the process with the everything, you know. Yeah, that's that's actually great. Well done. Yeah, I'm I can I'm happy for you to to share my my email with with the guys. Um, I also actually write it in the chat. I'll write my entry signals, and apparently that's the one I check out. Most likely swine, Which is quite sad. Um, right. But if anyone has any questions about anything, feel free to reach out. Yeah. Thank you guys for coming. All right. Thank you so much. Take care