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Hi, everyone. I hope you can hear me. Could somebody just pop a comment in the chat if they can hear me? Ok, and let me know if the audio is like too quiet or if I, you can hear me relatively ok as well. That would be good. So today's session is going to be focused around heart failure. Um So we're going to look focusing more on the sort of management. Perfect. Thank you Ryan. So we'll be focusing more on the management and specifically in the NHS, how you go about managing heart failure. Because I think in university, a lot of us tend to learn like what is heart failure? How do you classify? I'm sure we're going to cover those briefly, but the crux of today is going to be more so about how you handle those patients. For example, if they come in A&E and it's their first, the first time you've met them and they've got, for example, maybe a background of heart failure. So it might not be something you're immediately treating, but it's something in the background and it's still something you need to be aware of because it can lead to complications or just when you, when you're dealing with a patient, you're not just dealing with what they're presenting with currently. You're also making sure that all of their background conditions are well controlled because they could be contributing and making them present with that, with that um with that admission into hospital. I hope that makes sense. So um provided everyone can hear me. So um yeah, I think we'll make a start and then hopefully if anybody else wants to join, then they can join. Um So, yeah, my name is so, so I graduated from Bulgaria from the Medical University Vana. Um So I graduated in December 2023. So it's getting on quite a bit now. Um And since then I just did attachments. I did some locum work and really, yeah, like I've, I've enjoyed um locum work so far and I think um I've done most of my shifts down in emergency medicine. I've done so in on and also on a medical outliers unit. So that was quite interesting actually being able to see because a lot of medical outliers was things like flu positive patients or very elderly patients with social reasons why they can't go home. So a lot of the things hopefully that I can at least teach you guys will be from my experience um working mostly with elderly and I think a lot of you guys will not be specifically interested in peds um will also be working mostly with elderly people also down in A&E um It's mostly like geriatric patients as well. So I hope I can give you guys some um useful insight. Um As always, if there's any questions, please feel free to pop during the chat and I will um I will answer them when I can. Um So yeah, hopefully the session shouldn't take too much of you guys' time. If anything isn't clear, just put a question like I said, um and it would be great if you guys can provide us some feedback. At the end, I'll send a little feedback form in the chat. Um So yeah, let's, let's make a start. So in terms of what we'll be covering today, I hope everybody can see the slides changing. OK, let me know if not. So we'll be, we'll start off with a case just to sort of, I want to hear what you guys' opinions are. You can just like write a message. Um And then at the end, we'll revisit the case and hopefully you're more confident or you can give some more points, which maybe you, you initially didn't think of. Then we'll go over what is heart failure? Some of the causes a specific type of classification called the NYHA classification. Then we'll go into the integrity of what is the, how would this patient present? What are the sorts of questions we need to be asking um to know if this is a heart failure patient, the clinical signs, what investigations we'll run very importantly and this comes up a lot, especially in interviews is what are your differentials? That's something that they really want to know is, what are you thinking? Where is your mind going with this? What what tests are you going to order to rule out your other differentials? And we'll go over a cohesive management plan and finally, we'll come back to the case like I said, ok, so for this part, guys, it would really help if you can just put any comments into the chat. Um So this is just a little bit of a case, ok? It's quite vague. It's purposefully that way. So we can get your, your thoughts without giving loads of like clues into exactly what it is. It's more to stimulate you guys and get you your thoughts about it. So we have a 70 year old um male gentleman who's come to A&E so he's presented to the emergency department and he's having shortness of breath and he has a dry cough. So this is all you know, and a lot of the times guys, this will be literally all you know, sorry, that's just my emails going off. I'll put my phone on silent. So a lot of the times you're, you're going to have very little details before you go and actually see the patient. Ok? So they, they, he's already been seen by somebody in the emergency department. Ok. And they wanted to refer to the medical team. So the medical team is you? So now you need to further optimize and manage this patient. Ok. So just, just throw whatever you're thinking, honestly, there's no right or wrong answer. I just want general opinions. Ok. Like imagine this was you, um, and you're the doctor on call or you're the doctor down in A&E what sort of questions would you want to know? Um, and what, what differentials are in your mind? Um, if anybody could just put some comments in the chat that would be really helpful. Yeah, great. Thank you, Chris. So, how long have they been having those symptoms? So, yeah, exactly. So, how long have you had the shortness of breath? How long have you had the cough? Yes, great. So, yeah. So do they have orthopnea? And that's something we're gonna talk about? Um, definitely. Yes. Thank you very much. Yeah. Do they have orthopnea? What else are we gonna wanna know? Let's consider the age, let's consider our differentials. Anybody wanna pop in any differentials we're thinking about? Yeah. Is there a history of asthma? Absolutely. Could this be them presenting with, uh, severity of their asthma? What we call an asthma, exacerbation? Definitely. Is it worse on exertion? Absolutely. Yes. Very important. Is it worse with exercise? Does it improve with rest? Definitely. Do they smoke? Yes, definitely. It's a big risk factor. Um, definitely something to consider good. What other differentials, guys? Shortness of breath. What other differentials? Ok. Mhm. Absolutely. Yeah. Upper respiratory infection. Yep. Yep. So, things like a cap or if they've been in, um, the hospital recently then a ha, so cap is community acquired pneumonia hap. Is hospital acquired pneumonia. Um, yes, absolutely. So, that could, um, that could be an, an indicator of a disease that they have at the moment. Yes. Do they have swelling? Absolutely. Very good, Brian. So, do they have swelling in the legs? Ankles, feet? Yep. Very important. Yes. Medications is a big one. What medications are they on? A lot of the times guys, if you just look at the medications alone, you can get a very good idea of what they have already. So sometimes if you have no information you can go into the GP records online and, um, obviously depending on your hospital system, you can see what meds they're on and already that'll give you such a good idea. Like if they're on, like, um, well, I don't wanna say the drug that I was about to say cos it'll give you clues. Um, yes. Do they have hypertension? Yes. It could be ac O PD, exacerbation, what we call IEC O PD, infective exacerbation. CO PD. Very, very big differential. Good. So, we've mentioned, um, cap, we've mentioned IEC O PD. We've got some symptoms people have mentioned, which are about today's topic as well. Heart failure. So good. Yes. Do they have hypertension? Very important because that could be what's caused them to decompensate and get worse. Yeah, absolutely. Ok. Fine. Um, any other questions guys, before we move on? What about this dry cough? What else do we want to know about the dry cough? Yes, that's very, I was hoping somebody would mention this as well. Yes. Anybody who presents with shortness of breath you need, you need to rule out a pe so it should be high on your differentials list. And the way to rule out, we have something called the Wells score, which I hope you guys are familiar with. So there's a really good app called um MD CALC. So that's MD and then C A LC, let me just write in the chart here, MD CALC. So this app is really good um because you can, you can get a lot of clinical scores very quickly. Um So you can type in like well score and it'll ask you and then it'll ask you the different factors. So things like recent surgery, are they on oral contraceptives? Um Have they had a recent DVT um recent immobilization? So it'll ask you all of these questions and they'll to it all up and they'll give you a score and then you can know um if the well score is above a certain value, then it'll say yes, you, you have enough um enough evidence for you to request for ad dimer. And if not, then you should consider other things and they might be more likely. But if somebody is, I guess with a pe we, we'll obviously will. I'm not sure if it's myself who's doing it, but we're going to be covering pe in one of the later talks anyways. But if somebody is suddenly desaturating. So what do we mean by desaturating sudden drop in their oxygen saturations? Ok. So somebody has shortness of breath. So really sudden desaturations are really, really suddenly they've increased their oxygen requirement, maybe they were on 4 L. Now they're on the full, full around, they're on the full 15 L. OK? If they're having that um and their sinus tachycardic on their E CG. So you've ordered the E CG, it's come back sinus tachy. OK? And then that chest X ray is not really showing much, it seems quite clear. Um And maybe they've had recent surgery or maybe they had a flight recently and they've had some recent immobilization. All of these things should be signaling in your mind. Um A pe so that's when you would um do the well score and then consider getting ad dimer and from there you can start them on the treatment for it. OK? I hope that makes sense. Yes. Past history of M I, absolutely. Yup. Yup. That will be helpful as well. Ok, great. So let me just make a note. Yes, absolutely. Very good. A past history of M I is important because that could be a risk factor or that might be the cause as well. A CS could be, could be causing um their presentation now. Yeah, absolutely. OK, guys, let's move on. So, um yeah, I do ask a lot of questions in this but it's com it's a completely judgment free zone. You can put whatever you think it's more so that we're interacting and we're like, I think the best way is to just like you don't have to put your mic on or anything, but just like putting in little comments of things you're thinking, it helps me to gauge where we're at and what we need to further improve. So anybody can give any suggestions about heart failure. You don't need to give me like a full formal definition just like what do you think it is? Um or like any buzzwords that come to your mind when you hear of the term heart failure like li you can treat it literally like heart failure. What does that? What does that mean? Thank you. I one amazing. Yes. So a reduced or a preserved ejection fraction where the heart doesn't pump properly? Yes, that's a very good definition. Thank you. Yeah, fluid overload. Yeah, absolutely. So some some say it's like a syndrome or you'll have these things or you can just like describe it exactly how I on it. But yeah, basically. So II use the term ejection fraction. So ejection fraction is basically the um the amount of like blood volume, which is getting pumped out of the left ventricle and going to the rest of the body. Um And typically we're looking at a range of so this can vary, but for most places we're looking around um the 5055 mark. So if ejection fraction is severely reduced, so, um some say below 55 some say below 50 but you can always check with your your own trust guidelines which are available. Like if you just log on to your normal computer, the first thing that comes up is the trust website. You can just put in heart failure and check your individual trust guidelines. Um But yeah, most places it will be uh an ejection fraction less than 55 or 50%. Um They will turn that as 11 of the definitions for heart failure. Yeah, increased, preload, increased afterload. Yes, very good. Yeah, the heart cannot keep up with the demand. Yes. Literally the heart is failing. It can't keep up with the body's supply. So thank you guys. Very good. So I think we've pretty much hit, hit the nail on the head. So heart failure is an inability of the heart to produce a cardiac output, which is adequate to meet the metabolic requirements of the body. Basically what we've all just talked about. So your heart's not doing its job to the best of its ability. OK. Fine. So we've already touched on this a little bit. But what do you guys think could be some of the causes for? Why the heart's not keeping up? Why are we getting this sudden heart failure? We have already touched on some of them. So, um, that should give you a clue. But just any, any ideas for that and then we'll, we'll, I'll explain each, like the main ones and then we can move on. Yeah. Yeah. Good. M I valvular disease. Yes. Following an an acute coronary syndrome. Yy, all very good answers. Mhm. Mhm Yeah. For regurgitation. Previous M I. Good. OK. Yes, we've touched on a lot of them. Yeah. Good. I'm happy with that. So. Yes. Um Nikita. Yes. Thank you. Cardiomyopathy as well. Ok. So the most common causes. Yeah. The most common causes are so the first one is ischemic heart disease. So I've tried to explain it a little bit. So you can understand. So ischemic heart disease because if you can imagine the chambers there, the the vessels and the chambers are accumulating this atherosclerotic plaque. Ok. So the blood flow which can go through the coronary arteries is going to be a lot lower. Um and it's not going to meet what it needs to and that by definition is heart failure. So I hope you can see the link there. It's, it's those plaques and it's going to become more stiff. Ok. Next one is valve disease, as many people mentioned. So, obviously, if your valves are not opening or closing properly. So if you've got some sort of stenotic or regurgitation impairment that's going to affect how much blood goes out. And if you have reduced blood going out, you're not meeting the demands again. Heart failure. Ok. The next one being cardiomyopathies. I know this is a topic we all hate as students, but you'll be glad to know. Yes, there is genetics as well. Yeah, absolutely. You'll be glad to know that. What, from what I've seen, unless you're literally in the cardiology ward and it's very specific from what I've come across. Um, we cover it in a very broad sense. So it will be something in the background history, um, something to be aware of, but you don't need to know the intricacies of every single type of mutation and every single, um, like distinction between all of the different ones. It's what when I've come across it, it's been something you have in the background and you just kind of need to know. Ok, the heart might be a bit stiffer or something. So, yeah, I've explained to you. So the heart will be a bit stiffer or larger or thicker and you can get development of scar tissue. So again, for the exact same reasons as before, the blood is not being as effectively pumped, anything which causes reduced cardiac output, reduced blood being um pumped throughout the body, by definition will, will, will fall into this. Yeah, arrhythmias. Yes. Um afib yes. Um also hypertension. So you'll have a raised BP in the body. So the heart is obviously working, having to work harder. Ok? It's got an increased um demand but the supply is not, is not meeting that. Ok. So over time it'll try, it will try. So the left ventricle will thicken, it will enlarge, the blood vessels will get thicker, but they can't keep up with the body's demand. So it's more, it's an imbalance of supply and demand for that one, eventual heart failure. Now, we've just got some other causes which I haven't really seen as much, but it's good to be aware of. So, um again, infiltrative diseases, storage diseases, toxins, infections like Chagas disease and drugs also. So just things to have um to bear in mind in the background as well. But the main ones which you are likely to see in clinical practice are the ones that I've um explained. Like I HD valvular disease, cardiomyopathy, hypertension. And these are usually the guilty suspects in a lot of different cardiac um presentations. So you don't even have to memorize it like they'll go hand in hand sometimes. Um And it's just kind of like going through it logically. Um I hope that makes sense guys. Ok. Has anybody heard of something called the NYHA classification? I'll be very happy if somebody knows it. Um Does anybody know what it stands for or does anybody know what factors it looks at or just like anything to do with it. If not, it's completely fine. We can go on to it. Um, but yeah, it would be great if he says that you just heard of it? Good. I'm glad anybody else have any ideas. Yes. Perfect. Yep. Yep. So, it's a, in the New York Heart Association classification. Now, I know it's, it's from New York. Yeah. But II have seen it um when I've been working, like sometimes I've seen they'll put like uh Niha level 30 yeah, just one thing I want to explain actually. So I'm not sure. So every hospital works differently. OK? But sometimes you might um the consultant might say, yeah, I want you to make a referral for this patient to cardiology, for example. OK. Or they might say, yeah, I want you to book an echo for this patient. So hopefully you will be able to um like know the system and know how to book the echo but um the NYHA scale. So I've seen that as something that people have put in when they're requesting an echo um to assess like the extent of somebody's heart failure in. So usually when you book a scan guys or when you book an echo or anything, they'll ask you for clinical details. So in there they want a picture of what's happened. Why are you requesting the echo? How is that going to um benefit your management. What are you going to do about it? And why, why are you like, why are you requesting the echo basically? So if you have a hard grade, that can be something which further, which you can further put to back, back you up as more evidence, um we'll get into other things you can mention as well. But um yeah, like it's quite a useful tool and I have seen people put in their referrals like this patient was a Iha level three or something. Um And that's just like an additional thing. So you can really understand the extent of the heart failure. Um Yes, Iman, yeah, it's based on their symptoms. Exactly. So let's um let's go into it. So this is the New York Heart Association classification. Ok. So basically it, it gets worse as you move down the classes. So in the first class, they have no limits of their physical activity. Ordinary physical activity does not cause undue breathlessness, fatigue or palpitations. So basically they're asymptomatic and ordinary, ordinary activity doesn't affect them. Ok. Then class two is there's a slight limitation, so they're OK at rest, but ordinary activities might give them some level like slight symptoms of some breathlessness, fatigue palpitations. Um and then level three. So there's marked limitations. Again, they're comfortable at rest. So this is important to know like what are the differences. So again, they're fine at rest, but less than ordinary activity will give them those symptoms. Ok. And then in the final class, they can't do any physical activity without facing some sort of discomfort. So, here the symptoms are at rest. So in all of the previous they were fine at rest. So in level four, it's where their symptoms are at rest, any activity will give them discomfort, will give them those symptoms and will cause like an exacerbation of it. So, um, that's just something you don't have to have that like memorized, you can look that up like when you're, when you're trying to um like make a referral or when, if you want to explain it to your consultant or in your management. Um So these are like universally uh I can talk universally accepted classifications. OK. So let's get on to if so imagine you're clock in this patient, they've come in for the first time. Um And they've come in with shortness of breath. So the sorts of questions we want to ask. Um this is a clue, guys, this might come up later again. I'm gonna ask you the same questions again. So in terms of what do we want to know? So, firstly, the duration of the shortness of breath. So how long have they been having that shortness of breath? Somebody asked that earlier, which was very good. Um Also, is it that first time or have they had these episodes before? Is this something that's very sudden? Um or is it something that's been progressive. If it's something sudden you're more likely to, to have alarm bells ringing for a pe whereas if it's progressive and they, they've got like a known background of it, it's more likely to be like heart failure or something more chronic, possibly. Ok. Next thing, how many steps can they walk before they become too breathless and they need to rest. So, kind of like the nyha classification. Um like how, how much activity basically can they do before they're becoming symptomatic or uncomfortable and needing to rest? Also any associated symptoms? So, do they have a cough? Um Could there be some underlying infection, especially if it's a productive cough? Um We'd be thinking of cap, we'd want to be getting like a sputum culture um and getting a CRP and querying infection as well. Do they have hemoptysis again? That could be part of a pe or some infection, et cetera? Um Do they have a fever? Are they pyrexial temperature? Do they have night sweats? Do they have chest pain? Chest pain is a big one again, because you, you know, there's so many differentials a CSP E is this something gastric related that is radiating? There are many different things that it could be as well, but I know some people, some people might think like, why are these relevant? But you absolutely have to ask all of these symptoms. Um There's like a blanket thing so you can do your clerking and then at the end, you could do a blanket um asking of symptoms and you could just be like, do you have chest pain? Do you have calf pain? Do you have this that sometimes you might have missed something and then your, your check at the end might reveal it. So it's absolutely important to ask all of these symptoms. These specifically are more associated because they're presenting with something that's respiratory. Um It's important for us to ask a lot of these questions. Ok. So is the shortness of breath causing them uh causing night waking? So, are they waking up at night gasping for air? So, um this is the same with obstructive sleep apnea as well. So a lot of the times their partners might be the ones noticing it. Um So the term for this is paroxysmal nocturnal dyspnea. As many of you guys may be aware. Um So yeah, that fluid accumulation, obviously, when they're supine, it's, it's going to affect them more and that's why sometimes they'll, they'll feel that and they'll, they'll wake up at night sometimes gasping for it as well. So it's just um a good one to know sort of to, to further distinguish if this is related to heart failure. Also. Do they need to use additional pillows when lying down? Also, guys, all of these that we've written, these are genuinely questions that we ask the patients. It's not like, oh, we could ask that maybe we could like, maybe we don't need to. Absolutely. These are questions you will ask them if nothing is too not, nothing is a silly question. We, we will definitely use these, um, and consultants also use these. So, yeah, do they need to use extra pillows when they're lying down? Sometimes they might say like, oh doctor, I've, I've had to use more pillows. I've been struggling with my sleep, et cetera. Um, so that would be orthopnea as somebody mentioned earlier. So that's this, um, dyspnea, the shortness of breath when they're laying down in the supine position. So that's important to know as well. Have they had any changes or any shifts in their energy levels? Do they feel more tired or um, are they experiencing more fatigue? Cos another symptom of heart failure can be fatigue. It's a simple one, but it can absolutely be there. Um And they might also say that they, they, they feel very swollen and it's affecting their mobility. Maybe they felt reduced mobility. Mobility guys is extremely, extremely important when you are clocking patients in some hospitals. Like they will like in most hospitals to be honest, but they will really prioritize what is because the reason they do that, especially when it's elderly patients is because you need to know how they had a change in their baseline. So what is their baseline? So can this person who does this per person live with? Are they 18? But they live alone. But then they seem, they like you think they, they look like they're struggling. So you might ask them. So, who do you live with? Who does the cooking and the cleaning? Who does the daily activities for you? They might say, I have a son who lives next door. They might say no, I do everything myself. It is a bit difficult, um, ask them how they mobilize. So they might use a walking stick, they might use a Zimmer frame. Um They might have a full hoist, they might be bed bound and have carers four times a day or something. So it's very, very important to know this. Um This is a, this is all part of the social history. I know like abroad, we don't really focus on it as much, but here it's very critical and a lot of the times patients will have delayed discharge purely for social reasons. So you've treated them medically, they're completely fine and they're staying because they're waiting for what we call a package of care. So a package of care might be something like um getting um carers for, for them at home, something like that. So you might just be waiting or maybe you're waiting for funding from a care home or something. So, um it's very important that you have a baseline. Also, a lot of consultants will, it's sometimes it's the first thing when you present a patient to them, it's very important to make clear their baseline. You might say we have a 70 year old gentleman uh lives independently immobilizers with a walking stick. He came in with this. So already you can see how, how important the social history is and how it plays a factor. Um Cos already the consultants thinking. Ok, this patient is quite independent. Let's see how they are. Now, do we need to think about um getting a respect form DNA CPR form or do we need to consider um a referral to get some more benefits uh to get like to physiotherapy to have some extra support for them at home because it looks like they might need it for example. So it's, it's good to have all of this in mind. Um Yeah, so yeah, they might have noticed that their clothes are not fitting on their lower legs as comfortably as they did before. And then when you examine them, they've got like a lot of fluid retention in their, in their calves. Um And a lot of the times these patients will have a known background of heart failure. So sometimes they'll come in confused and they can't really give you much of a history. But if you check um I think most places you can access the GP records online or you can at least get a decent amount of background history online. And in that you can see if they've got a background of heart failure or some of the cardiac diseases that could be contributing. So it's, I would say before you go to see the patient, it's good to know their past medical history because it's gonna help you with your larking and it'll, it'll help you to have differentials in your mind already. Ok. Let's move on to physical exam. Just one second. Yeah. Ok. So I, so I have written these down some, I've seen more often and more frequently than others, but I will, I will make it clear which ones. So um and if it's right sided heart failure, you might see things like A R JVP. So personally, I maybe on attachment, I saw it, but to be honest, like this is more, I feel like consultants can see this better and it comes with time and practice and experience. Um But definitely, I think you can see it on patients. I personally haven't seen it yet, but um it's very possible to see it and I II don't have as much experience. I'm sure like other doctors will have definitely seen it. Um Hepatomegaly also like they can be, they can have additional um blood backing up in the liver and they can get enlargement of the liver or they can have ascites as well. So these are very commonly seen. Um somebody can look like they're retaining literally from everywhere. Um significant peripheral edema. Yes, this is also seen extremely, extremely often even like to the extent when you've done your history and you want to examine the patient. Usually you'll do, like, you'll do a full, like you'll assess them, you'll see how they are from head to toe and then you'll listen to their chest, you'll listen to their heart, you'll palpate the abdomen and you look at the calves. So the calves is a very important one for peripheral edema. So, I know like, well from when we studied, we just kind of like check. Did they have pitting edema? Yes. No. And that was it. But here you have to report, is this unilateral, is this bilateral? Because um does anybody know why actually, why, why would it be important to distinguish, is this edema or are these changes unilateral or bilateral? Why would that make a difference? Why does it matter if it's one sided or on both sides? Yeah. Yeah. Very good. Thank you guys. Yes. So if it's unilateral, um you could be a DVT that could be something you want to rule out whereas if it's bilateral. Yeah. Yeah. If it's heart, yeah, it's bilateral. It's more likely heart failure and they're systemically um retaining that fluid. Um And if it is bilateral as well, what a any um edema, you need to know the extent of the edema. So you start from the ankles, ok, you palpate from the ankles and just go up and you need to like have a good feel. OK. And don't stop, like just at the lower leg go all the way up like um above the knees and see how much they have. So, does it go to the mid shins or does it go above the knees? Um like, really understand the extent of the retention because that will like, it'll show you like how bad it is. Ok. Um So definitely don't just like assess the bottom, like go all the way and if they look like they're retaining a lot, also check the sacrum. So the lower back, so just ask them to like tilt forwards or um turn on their side check if they have sacral edema. Again, just palpate the lower back. Um Is there fluid there as well? Ok. So those are generally the signs of heart failure that I've seen more on visits exam. Um with the the additional one being when you auscultate, you can hear crackles. So when you auscultate and you can hear a lot of crackles. Um again, that's another sign of fluid overload. Ok? I have written some here, some of these signs of left heart failure. To be honest, I have not really seen these in clinical practice. This is just like something I've written. But um and it's just good to know because maybe like one consultant will mention it and then at least you have it in the back of your mind. Um They can have a displaced apical beat, they can have additional heart sounds. Um But the like in my own personal experience, I found crackles edema, um regia, like the other things just being a lot more prominent for me. Um Yeah, just wanna preface with that. So often we can see signs of both types at the same time, which would just be congestive heart failure or um chronic congestive heart failure. So those were some of the physical exam findings. So this is like when you're examining the gene, usually it's good to make them tilt to the turn to their left, um, and have them at about a 45 degree angle. And the anatomic, the anatomical landmark you're looking is basically between the two sternocleidomastoid. OK. And that angle will be raised in heart failure. Basically, that's the crux of it. Um, again, like, don't beat yourself up if you can't see this, it's, I feel like it varies, like some might have seen it, some might have not. But, um, this is just something to bear in mind basically, uh, and is raised in right sided heart failure. OK. Next question. So, ok. So they've come in with shortness of breath. You're thinking this could be an, uh, um CO PD, this could be heart failure. So what sort of investigations are you going to run? Like, what sort of things are you going to use to rule out the whole point of investigations is to rule out your differentials, right. So, and, and to have like to have a good work up in mind. So, what sort of things? Yes. Pro BMP is a very good one. Yep. So that's a blood test. Yes. Absolutely. An E CG. Yeah. Yeah. Chest X ray E CG Echo. Amazing. Very good. Very good, very good. If they have a productive cough, is there anything else you could possibly send? Yeah. Angiogram, I guess. Like uh if you're thinking, yeah. Chest X ray. Angiogram. Yeah. Like if you're thinking of a pe or something you could do a C TPA. Um Yes, I on Yeah. Sputum sample. That's why I wanted to hear as well. Yeah. Um For microbiology. Yeah. So you can send off a Sputum. You might start them on some antibiotics and then when you get the sensitivities back from microbiology, you can switch them um to something that they're more sensitive to. So, yeah. Absolutely. Sweetened culture. Chest X ray ECG Echo. Yes. All very, very good guys. Well done. Uh Echo is important. Pro pe CG. Yes. Um E tt what is et um Brian? Could you elaborate on, et ti don't know if I just maybe it's something I'm just not familiar with guys. What's one of the first things go back to your aeries? What's one of the first things that you should request in any patient? So it's quite simple but we've missed it. It will give us a really quick idea. Um Yes, blood uh exercise to. OK. OK. Thank you. Yes, that would be a good one. Yep. Um, bloods. Exactly. So, what kind of bloods are we sending? Yeah, we can, we can send so we, we can do a well score if we're thinking pe and if the well score is quite high and it's suggesting that yes, you do a ddimer then absolutely. We could do ad dimer. Yeah, we'll send off FP CS. Yeah. And get an idea of the hemoglobin, hemoglobin white cells. Is there an infection brewing? What else would we send? Yeah, I on G CS is always useful. Usually when we're clocking there's a separate bit just for G CS. So, yeah, that will definitely get done. Bedside test. Yeah. Like the um what kind of bedside test? The visa and what was the blood should we send guys? So we're gonna send off FP CS for blood count. What else? What is quite important in heart failure? We've said B MP W what's another thing that's important in heart failure patients to, to assess any other ideas? Yeah. Eer knees. Yep. So urea electrolytes, thyroid function test. Yep. Absolutely. User knees. Yep. What about to monitor the rate of infection? What can we use to monitor infection? Yep. I'll have to use trop if you're thinking a CS. Yep. Yes. Thank you. Yeah. Yeah. Yeah. So CRP is the main one that I wanted. Yeah. Yeah, white cells. Absolutely. So usually when you have um, a panel of blood you'll look at um, no, that's fine. You don't have to say sorry. Yeah, fine. So you'll look at um So first you'll see um is the CRP elevated? OK. If the CRP is elevated, OK. Are the white cells elevated? Could this be a bacterial infection? So if the white cells are high, also check the neutrophils. So this is literally the step by step we follow. Um Well, what I follow a lot of the time. So I look at C RPI, look at white cells, I look at neutrophils are these three elevated, then it's definitely suggestive of infection. OK. And um so that's more like likely bacterial. And then if the lymphocytes are low, um they'll always have references there by the way. So you don't have to like look at it and just know off the bat, this is low. Um If the lymphocytes are low, then that could be a viral infection. So if they have lymphopenia in your mind, think this could be viral and make sure you send off viral swabs. So you can literally just print out a form um which just like throat swabs, viral swabs. And it tests for um pathogens like viral pathogens and you can just ask one of the nurses to do that for you. Um And it's a really good thing because sometimes you'll do it and you won't think much of it. It's just like a um a tick box that you've done it and then they'll come back flu positive like that's happened so many times in the past. Um, and, and obviously you can treat them for their flu. Um, usually we treat it with something called oseltamivir. But, um, yeah, that's been extremely common in, um, this winter period. We've had a lot of patients with that. Um, especially when I was on medical outliers, like literally everyone was flu positive. It was crazy. Um, but yeah, like a lot of the times their bloods could even show what they had before I went to see them. Like I could have an idea. Um And then obviously you look at a chest X ray and other things. But yeah, thank you guys, a lot of good investigations that I think we've covered the main ones. So we would get the relevant blood. So FBC sec RP LFT, ST FT S VBG. Yeah, you can do. So VBG is good because it's a lot, it's faster than bloods. Um You can get a quick idea of the hemoglobin, the lactate. So, yeah, you could, you could absolutely do it. Sometimes the consultants will want it. Um Usually I just send off bloods. Um usually like if, if the patient is somebody, for example, with um CO PD and they're like, um, you, you, if they have CO PD, ok, and you want to know, are they retaining CO2? You might do an ABG. So you can know are they retaining, and then if they're quite sick and they're retaining a lot of CO2. The consultant might ask you, can you do go do another ABG? So that, that's what I've had to do often. I haven't had to do many VBG S in my clinical practice, but I do know that, um, they can be requested a lot. Um, so yeah, you can absolutely do it as well. The, the, the main difference between bloods and a blood gas is the blood gas results will come back a lot faster. Um So they, they're very quick, they give you a quick idea. What's the hemoglobin? How's the lactate doing, et cetera? So it can be a very useful test as well? Yeah. Um OK. So blood wise, yeah. So FP UCR P LFT S liver function, thyroid function, lipids and glucose. So, um does anybody have any ideas? This is a bit of a like um a tricky question? So I'll be very impressed. Um Or you can just throw any ideas out basically. So why? So remember we're thinking like this presentation is focusing more on heart failure, right? So think about like the pathology behind heart failure, what is going to be particularly of importance in the user knees and why? Like what, what marker is important for us to look at? Like, is it high low? Is there anything that you guys think we should check more like keep an eye more on and why? Or you can just have a guess? Yeah. Yes. Yes. Yes, yes. Sodium, it's the sodium also the potassium. Yes, but um sodium was the answer I wanted. Yeah. Um So the the um yeah, so to do the potassium is very sure. So the reason that we particularly look at sodium in heart failure patients is because a lot of remember I said a lot of these patients will already have a background of heart failure, right? So they're probably already on medications. So um I know I'm going forwards a bit. But one medication that's often used in heart failure is furosemide. So it's a loop diuretic, right? Um Usually oral, they can take you in community. OK. So um if they're on furosemide, it's a loop diuretic that can affect your sodium, that can affect an elderly patients sodium and it might give them chronic hyponatremia. They might have, they might always have hyponatremia on their bloods, low sodium. So, if they do have lower sodium on their bloods, this can affect their prognosis as well. So that's why it's very important to get a full set of bloods in any patients. Uh obviously in every patient, but especially keep an eye out on the sodium um because it can affect their, it, it can give you an idea of prognosis. Obviously, you won't say that to the patient, but you can have that in your mind. Um Yeah, so um I hope that makes sense guys. Um Yes, potassium, we will be checking all the using these obviously are important, but I especially wanted to make a mention of sodium for that reason um to do with the prognosis. And because if they're on diuretics that can affect the blood sodium levels as well. Next, as somebody mentioned the B MP, so it's brain natriuretic um peptide. So it's released um anytime you have myocardial stretching, and again, this is another good prognostic indicator. So if they've got ABM P, which is like in the thousands, you will need to do a specialist referral. OK? If they've got um over 400 you'll do the referral and you'll do an echo within two weeks. So basically, this really varies like between every trust. So you should check your own trust guidelines and how they look at the B MP. Like I've seen some consultants if there's like an extremely high B MP and the patient has known heart failure. Um and they're quite sick in the emergency department, they'll say, yeah, let's just get an inpatient echo. Um So that's like um they'll go for the echo like whilst they're in hospital and other times like if the patient is quite well and this is just something in the background, then they'll say, yeah, we can just get this as an outpatient. Um It shouldn't delay the discharge basically. So anytime they say, let's get an echo, always ask, is it inpatient or outpatient? Because you will be asked those questions when you're doing the booking and it just saves you having to go back to them. Um Yeah, so if somebody's BNP positive, then that, that's like showing me like, oh, it could be, they could have heart failure or they could not. But if BNP is negative, then it's like it's highly indicative that you need to look at other causes. So B MP is sensitive in that case. OK? Um Somebody mentioned chest X ray, we will definitely get a chest X ray and we will look for um some signs uh that, that's the acronym, but I'll show you guys um So basically signs of fluid overload. Um We can book an echo obviously um as the consultant, like, do you want this inpatient or outpatient? Um So that's up to their discretion. So they might say like um do it inpatient, they're quite sick, they might say just book it outpatient. I'm not particularly worried about them. Um And an echo is very good. It's like um we just say it's like a scan of the heart to patients. Um And it'll give a really good idea of any structural functional motion abnormalities and ventricular function. And as somebody mentioned earlier, we can get an idea of the ejection fraction as well. So it can be very, very helpful. Um It's a very helpful sensitive test. Um Again, ecg because we want to know underlying causes and we want to have a baseline. So if the patient does deteriorate, you have a recent ECG that you can um make like valid comparisons to as opposed to one from X amount of time. Um It won't be as helpful. Um Yes, perfect. Yes, that's some of the ABCD E Yes, you'll look for um Kelly B lines battling ification. Yes. All of these um It might sound like jogging to you guys, but these are like signs of the overload as well. Um Thank you. So, yes. Um This line will be that clear. Maybe um we'll, I'll make sure the powerpoint is available to you afterwards and you can zoom in more or you can just Google if you want chest X ray, heart failure findings. So this is like a nice way to remember them. So you'll have what we call the batwing ORAC. Um So you'll have alveolar edema, you can have Kelly B lines of interstitial. So, interstitial edema, you can have cardiomegaly. So um normally the heart shouldn't be taking more than 50% of the total ratio. Um So if the cardiothoracic ratio is more than 50% that's cardiomegaly. So it's very obviously visible in this case, um you can have dilated prominent upper lobe vessels and you can have pleural effusions. So, if it was me, I would just look, am I seeing some interstitial changes? Um Is there any of that like alveolar edema? Is there cardiomegaly? Is there effusion? So, effusion, you'll know because you'll have blunting. So, for example, here, we have blunting um of the left side especially. Um So you can see um blunting of the costophrenic angles. So the angles where the um diaphragm and the ribs meet. So those little corners, if you have blunting of those or like fluid accumulation there, that's another clear indicator that you've got um an effusion or you've got some fluid overload as well. Um And so obviously, if you hear crackles, if you're hearing crackles, you're seeing them with loads of peripheral edema and then you get a chest X ray like this, you can already have heart failure in your mind. OK. So we've already touched on this. So I feel like we can maybe we can just briefly say it. Um But what, what, what were our differentials? So, um obviously we've been talking about heart failure a lot. So that is there if we can just like rapidly go through the other ones, um then we'll move on. We've reach, I think we've said like all of them. Um I just wanna cover them quickly, then we can move on. So shortness of breath, what are, what were our differentials? I should have probably put this slight earlier. Sorry about that guys. OK. Uh OK, good. So we're thinking of um chest infection or a cup. Um PE D VTM IP ND. Yep. All very good. Um Yeah. Yeah. Yeah. Pneumonia. Yes. What else did we say? Um For example, if they're a smoker, if they're a smoker. What could they possibly be coming in with if they've got the shortness of breath? What's a big one? Yeah. Worst case is cancer. Yeah. Yeah. Cardiomyopathies. Pericardial. Yeah. CO PD. Yes. So, it could be coming in with an IEC O PD. Yep. Um, and what's the other one? So, the CO PD, and there's another exacerbation as well. What was the other one? Yeah. So it could be a COPD, exacerbation could be an asthma exacerbation. Yeah. Absolutely good. I think we've covered most of them. Yeah, I'm happy with that. Thank you guys. So, our main differentials. So we have infective exacerbation of CO PD IEC O PD. Um, community acquired pneumonia cap, asthma, exacerbation, pulmonary embolism. These are the main ones that I would have in my mind. Oh, I have a heart failure but heart failure should absolutely also be there. Sorry about that. Um, yes. Um, pulmonary edema. Yes, absolutely. So like the way II like to keep it simple in my mind so that I don't forget like the most obvious things. So usually if I've got this, I will go for the most obvious things because the management and the investigations in so many of them are the same whether you're thinking of something as broad as a pe er, sorry, like a cap or if you're thinking of a pe or something in all of them, like you're gonna get an E CG, you're gonna get a chest x-ray anyways. So normally I tend to go for the more like common, um, mostly seen tests and diseases and then if those come back negative, then you can go to thinking of the more like, weird and wonderful and the, the other stuff, but always start off with broad because if you're in A&E, I can guarantee you 90% of those who are coming in with shortness of breath. They're, they're having AC O PD episode or an asthma exacerbation or a cap like 90% and recently flu as well. But um you should just kind of like it will become bread and butter. So I just want you guys to sort of understand that you don't have to go to all of these different differentials, like sometimes or a lot of the times it's gonna be an upper respiratory infection, it's going to be an elderly person who's a bit immunocompromised and just caught a viral or um respiratory infection. And a lot of the times that being said that doesn't mean that you don't take it seriously. You should still as doctors like rule out your differentials. And if you're particularly worried, always escalate and like voice your concerns to your consultant or to um your or your senior. Um Yeah, these are just what I would personally do. OK. Now, in terms of management of heart failure. So there's like, there's a lot that we can say. Um and I've, I've written together like a bit of a plan. Um, Anisa helped me a lot with that actually. Um, she's amazing. Um, she helped me out with that. So there is a lot in terms of heart failure. So, can you guys just any ideas? Um, so this can be anything? So any medications you think they should be started on or you should check? Are they on these medications? Um, yeah, like what, what do you guys think? What other management do we have for heart failure? Yep. Yep. Yep. So beta blockers, Arbs Ace inhibitors eo two inhibitors, like the Flosin et cetera. Very good. Yeah. So that's like um Sol Valsartan. Yeah. Good one. I don't think I've written that in here, but absolutely. Yeah, that's a good one. So this is kind of what I expected in terms of. Yes, diuretics. Absolutely. As I mentioned, like usually Furosemide um is first line. So this is the thing like I feel like for med school, they will always tell us heart failure, you treat them with these medications, but then they won't, they won't show us like, what else do you do? How do you get this patient back to their baseline? What other things? What additional things are you going to do? So, um, I feel like that's like the beauty of the se this series is that you'll get a work to plan, which actually will fully function in the UK. Um And like we'll, we'll give you good brownie points. And your, it'll give you it, you'll have, how do I word this? You will have everything in mind. Um And you'll be a better clinician as a result because you're not just thinking of this patient, medically managing them. You're looking at physiotherapy, you're looking at getting them back to their baseline. You're looking, what referrals do I need to make? What scans do I need to do? Et cetera? Um So that's like the best thing about this area I think. Um Yes, so let's go into medical first. So uh oh sorry, first of all, lifestyle changes, of course. So if this patient is a smoker encourage smoking, cessation, encourage fluid restriction because obviously heart failure, the definition they're going to be overloaded. So I don't know if you guys have seen, you know, there's like small hospital jugs that they have, they're only allowed two of those like in the whole day. Each of them is about 750 mil. So they can have two hospital jugs. Um And that's including, so that's water and teas and everything else. They shouldn't be going over 1.5 L, fluid restriction, um salt restriction as well up to 3 g a day, they should limit the alcohol, improve their diet and physically exercise, obviously within restraints within what they can do. Um Yes. So um pacemaker. So that would be like in more severe cases, I haven't seen it as much, but definitely in more severe cases um these patients will already um be started on that or maybe the consultant will make that decision, but yes, good to bear in mind. Uh Pacemaker or an ICD. Ok. So first line medications is things like loop diuretics like furosemide. So this one, it won't affect their mortality. It won't improve that, but it will, it will relieve the symptoms of fluid overload and it can act quite quickly to do that. So with heart failure, it's usually good to introduce medication slowly and make sure that the patient is stable before you um further manage the patient. Um So slowly introducing, making sure that they're um coping their bloods are doing ok. And then you can move on. Um but yeah, furosemide will be textbook in a lot of heart failure patients. Um They will have it and it can act very quickly as well, which is a good thing about that drug. So as um you mentioned, so we have ace inhibitors so they can improve morbidity mortality, they can improve ventricle function and if they're not tolerating, so if they've got a dry cough or they're not tolerating it, you can switch to an ARB instead. Then we also have beta blockers which are like the Holy grail. For a lot of medics, you use them in a lot of conditions, they can improve your morbidity and mortality. Also, um one that wasn't mentioned actually. So this is um mineralocorticoid receptor antagonist. Mr S. So things like spironolactone, eplerenone, they can also improve mortality and they can help with fluid retention. So we often use those in patients post mis. So I think somebody did say um post M I is a cause. So yes, absolutely. We would use um this drug more in those cases and in patients who are not. So refractory means they're not responding um to your like the interventions you've given, they've not responded to them. Um So we, we this is a drug we could introduce in that case. Also, guys, these drugs are not things like a lot of when the patient comes in, you'll clerk them, you can have these ideas in your mind and you can even put them in the plan. But the consultant will come and make like the calls like about starting drugs about adjusting doses, like a lot of the times they will make those calls. So do not worry like if you're looking at this and you're thinking, I'm not comfortable doing this like starting them on XYZ drugs or like messing about with drugs like I know like prescribing and that stuff like um Bulgaria for me. Anyways, it didn't prepare me well for that at all. Um We don't even have to do a PSA or anything. So it can be very daunting but do not worry like you have the BNF, you have your colleagues and your consult. You should always clarify with your consultant and you can check trust guidelines. But because if you check the B NF and you check trust guidelines, let's, let's say they want you to prescribe amoxicillin. OK. So check the BNF. What does it say if for a cap or for CO PD, whatever, how much, how many milligrams over how long, for how many days it might say? Um I don't know 100 mg for five days if you do that and they ask you why and you say you check the guidelines, you literally, they can't, they can't call you out on that. So always like cover yourself. That's why people always say follow like the guidelines, follow the trust. And that way you can't really go wrong if you don't feel confident, that's what I would do. And, and you can always, always, you will always, usually, um hopefully, as long as you're well supported, you'll always have somebody senior that you can ask. So don't worry about this. This is just like I'm saying them. So you have them in the back of your mind, but you're not going to be expected to start the patient on an entire algorithm of heart failure, medications like independently. Um At least from what I've experienced. Uh Anyways. Um OK, so we also have ivabradine. So, um I haven't seen this much. Uh I think I've seen it like once or twice. Um So it improves mortality. It can help to slow down the heart rate. Um So the the clues in the name. So br ad like Brady, um so it slows the heart rate down. So, again, is used for um refractory. So in cases where symptoms don't improve following that triple therapy with beta blockers, ace inhibitors and the antagonist or if beta blockers are contraindicated in the patient. So for example, things like asthma, they're contraindicated because of the vasoconstriction. So um in those cases, for example, possibly and then we've also got hydrALAZINE and nitrate. So this is more for afro Carribean patients, but again, something to bear in mind. Ok. This slide is very important guys. So this is part of your plan for heart failure patients. So if there's anything you want to take away from this whole presentation, um this would be one of the most important. Ok. So what plan, what could be part of your plan or your work up for heart failure patients? So one thing, um if they're, if they've come to you, they're quite sick, they're retaining a lot of fluid, they've got a new oxygen requirement, they're quite breathless. Switch them to IV instead of oral for the furosemide. OK? Um, you can also review their other medications. Um, have them on daily weights again because you want to monitor that fluid retention. So have them on daily weights. That's um, a, a lot of these things. You're not, you don't have to do anything. You just need to tell the nurses, um, and put it in your plan, a lot of them, the nurses will do anyways. So just make sure you've put it in your plan. So um you cover yourself and it's clear also you want to do fluid input output monitoring. So this is very important. So whenever you go to a patient's bedside, they'll have, you'll have like the doctor's notes, then you'll have the nursing notes and in the nursing notes, they'll have like um the patient's fluid out input output, they'll have a stool chart and they might have the drugs, the other one as well. So these are important um indicators also. So the nurses need to be doing like strict fluid monitoring on these patients and we need something called a positive balance. So basically, they need to be re get removing more than what they're putting in. So we need more out than in if that makes sense. Um And logically with heart failure, that makes sense, we wanna get rid, we want to diurese, we want to remove. Ok. Also, um we want to be doing daily eine daily urea electrolytes to see if the drugs that you've got. Are they affecting the blood, uh the blood profile, especially sodium? Um So yeah, like I said, um if you are giving diuretics, sometimes it can push patients into the hyponatremia, sometimes you might even push a patient into an AK depending on how many drugs they've got. So it's very important to send them for daily bloods. So, what you'll do is you'll just print off the blood form and put it in the folder for tomorrow. Um, so make sure it's done all it depends. Like sometimes the nurses want you to do that. Sometimes you put it on the trolley, sometimes you put it at the beginning of the, um, patients folder and they'll get picked up that way. So, just ask like, if I want blood, like what's the best way? Um I know when I was on gastro, like the fleb used to come at 10 in the morning and there was like a frantic chase to make sure you had all those blood forms printed for the Fleb to come. Um because you have a lot of jobs and obviously bloods is the last thing you wanna be doing on top. So yeah, make sure you're printing out your using these forms or whatever forms daily bloods on time. Um In the plan, you should always put to aim to wean off oxygen if they previously had an oxygen requirement. So if your patient is on oxygen, the aim is always to get them off. So you should always put aim to wean off oxygen. Um as we mentioned, inpatient or outpatient echo, make sure you clarify which one they want cos when you're when you're trying to book it, they will ask, do you want an inpatient outpatient? And it's so annoying when you have to go back and um find the consultant, it just doesn't look good for you and it's annoying for them to remember the patient blah, blah. So yeah, always just clarify these things, do a med review. So um the consultant can um look through the medications or you can have um a cardiology review or there's something there's specialists called the heart failure nursing team. So this is a, this is a specialized um sort of designated team. It's a team of nurses. Um They can see the patient in the hospital and they can see the patient in community as well. So after they're discharged, they can still see them and they are very, very helpful in terms of optimizing management, um and optimizing medications and seeing if there's any tweaking we need to do with the medications to help um manage the, the patient's symptoms. So they can be very helpful for that. So, um you can absolutely do a med review. Um Sometimes they might ask you to do it like you can have a look. Um But again, like, I think personally when it comes to changing medications, et cetera, I will always double check it with a senior. Um I wouldn't really like do much myself. Um I would ask and then go like, follow what they've said basically. Um or you can just put a referral to the heart failure nurses and they're usually very good and you can ask them specifically when you cos usually in the referral, they'll ask, what question do you want answered? And you can say, can you just help us to optimize the medical management? And that's quite clear what you want basically. Um, so, yeah, when you're making referrals, make it very clear what you want. Um, yeah. Ok. Um, another thing that we touched on earlier, the patients might have a new, a new baseline so they might have come in before, completely independent and now they might need a stick or they might be using a wheelchair. So you should get um PTO TS physiotherapy occupational therapy input if they have a new baseline and they're going to be needing some more support at home, you think, and also an important thing to bear in mind is you should consider a DNA R because heart failure is irreversible and it's progressive, it's a progressive condition. So it's going to, it will naturally worsen most of the times over time, it's seen more like in, as I said, in geriatric patients. So um definitely considered. So DNA R is a do not attempt resuscitation form. Um Now they're also rolling out a lot of these respect forms. So in essence, it's basically respecting the patient's wishes um at a time that they still can give consent and have capacity and it will be a discussion um usually like um a more senior discussion. So from what I've never had to personally do this discussion, I've watched it, but I've never had to do it myself as an F one. Um, usually like maybe a reg or a senior will do it. But I know, like in some places the juniors will do it as well. So it really depends, um, on staffing and it, there's so many factors it depends on, but ii do believe everyone should be able to have that conversation. Um, and I think Anisa covered it really well in the first talk. So if anybody wants to go back and review that they can feel free to do that. Um But yeah, if you have somebody who's very elderly, they're presenting with so much fluid retention, you think their heart failure is really getting bad and they don't have a DNA R in place. You definitely should be thinking that and your consultant will definitely be wanting that done. Um So again, something to put in the plan um to bear in mind as well. OK. So this is kind of the last thing that we're gonna touch on. I know it's been like about an hour or so. I'm sorry if it's dragging you a bit, I promise we're finishing soon. So there is one caveat to all of this. So um one situation where we need to be careful. So imagine guys that a patient has all of the clinical signs of fluid overload. Sorry, there's a type of that there all the signs of overload that we talked about. They've got the fluid edema, they've got the crackles that chest x- screams retention. Ok. Um So on examination, on investigation, they've got all of the signs, but they are also presenting with a low BP, let's say it's like 90 or 85 systolic. Ok. And the bloods are showing an AK I, so why is this an issue? Because on the one hand, we have the overload, so we need to remove the fluid. We need diuretics, we need to get rid of the fluid, right? But on the other hand, they're hypotensive, they need fluids and they have AK I on their bloods ak I, by definition, we need to treat that with fluids. Um in, in my trust um that I've worked at, we have what they have like an AK I bomb that they gave and they just like throw loads of fluids on the patient. So it's, it's absolutely, it's, it's so difficult. Um in that case, how you manage the patient because like I said, so we're taught hypertension ak I you manage them with fluid boluses, right? Um But our patient already has too much fluid and they might be very frail and they might not be able to cope if you further push loads of fluids into them. So the tip would be, don't touch the patient without speaking to a senior first. Um because these patients, their, their medication, like it's a very sensitive matter if they've got overload, but they're also hypo or they've also got an AK I, you, you cannot, you could work slowly. But again, this is not a junior's decision to make. It's better to speak to your consultant or speak to a senior or maybe the cardiology team can advise because they're, they're usually a lot better when it comes to, um, managing medications and, and knowing what they've got a lot more experience in that, um, it's not a call you want to make and then you massively overload them and it really like cause a severe exacerbation and ultimately lead to like um a severe complication or death or something that's not something you want to deal with. So, um, if you've got that kind of case coming up, just speak to someone is um, the best advice for that. So that kind of rounds off um, the presentation on heart failure. If anybody's got any questions, you can, um, feel free to pop them in the chat. Um Yes, you can speak to Renal as well. Nephro Yep. Yep. You can, yeah, if they've got the AK I absolutely, you could. Um, so it depends on the hospital's policy. So you can do an e referral or if you think it's quite urgent, which I think in this case it would be, you can just um, bleep the sho or bleep the consultant, whatever or if your consultant is gonna handle it, sometimes they'll go, they'll, the consultant will bleep the Nephro consultant and just get general advice, especially if you're quite worried about them. But yeah, Brian. Absolutely. Um Good point. Ok. So, um knowing all of what we've done now, um could we have another go at the same case? This is very helpful for us guys because it kind of helps us to get an idea of how much the um talk has helped and how it's improved our management. Um and it's really beneficial for us. So I would appreciate if everyone can um just give a brief comment before we conclude. So again, let's try the same case. So we, I have a 70 year old gentleman. They've come in, they're having shortness of breath, dry cough again, like I mentioned. So you're the medics, you need to manage this patient. So now knowing everything that we do, what questions are we going to ask? Um and what are our differentials? How will we distinguish them? Um If you could just put something? I know this is a bit repetitive, but I promise this is the last thing and then we're done. Um Yeah. Uh So from history, what sort of things do we wanna know from the history? If you guys can think back to those things that we were talking about? Mhm mhm Absolutely. Yeah. Fatigue is the shortness of breath. Sudden progressive. Yep. So are they waking up gasping for air? Um Yep. What else guys? Very good onset duration. Absolutely. So we've got the shortness of breath and then we've got the dry cough as well. So, yeah. Are they a smoker for the, for the cough? What else are we gonna wanna know? Yes. Edema. How many steps? Very good. Um, how many steps before you have discomfort? How much activity before you're symptomatic? Very good. Very good. Let's touch a bit more on the edema. What specifically could we ask? Cos we can't say to them? Do you have edema? So, what, what are we gonna ask them? Yeah. Is, is this um what I do the symptoms get worse on exertion? Um Yep. Yep. Good. I, man. Yeah. If the um if the clothes are not fitting as well. Yes. Very good. Um Yeah, very good. What about um well, I can't say that without giving what I wanna hear. Yeah. Family history is good. Um So we're thinking respiratory, right? What other questions do we wanna know if we're thinking? Respiratory? Mhm. Peripheral edema. Yeah. If we're thinking this is a respiratory infection, what's something else we should um be asking? Yeah. Selee. Yeah. Yeah. Sputum. Yes. So I, is it a productive cough? If so what color is this an onset? Yeah. Fine. Very good. Just leaning forward. Help them breathe. Yep. Good. Um Do they have a fever? Yes, exactly. So I wanted to touch on that. Yeah. So don't forget the importance of associated symptoms as well. So, fever, chest pain. Um all the other good stuff that we talked about. Yes, because remember guys, when you're doing the history, you're also thinking of differentials. So do they have cough tenderness, swelling? You're gonna look at all of these things. Is it unilateral? Is it bilateral? Um Yeah, very good. I'm happy with that. Ok. Um And then just to finish off with, I know we've done this a times, I promise you all experts by now. Um Yes, no experts. Thank you. So, finally, what are our differentials if you want? Just put it in one comment if you want. Um What are the shortness of breath differentials now? Um Like what, what do you think are the top ones that we want to rule out based off of everything we've talked about everything I've said. Um Yeah, what is the top top things we want to rule out? Amazing. Yeah. Very good. Very good. Thank you. And thank you. So we're thinking P EC O PD asthma, heart failure. Um Yeah, P ECC O PD asthma, exacerbations, heart failure. Yes. Amazing. Well done guys. So I hope, I hope that all um made sense and everyone feels a bit more comfortable about the topic. Any questions let me know. Um I'm going to send a link for the feedback form, just bear with me. Yeah, I hope everybody can see that. Um So if you could just put some feedback in there, it's really helpful for us because we can know how we're doing what we can improve. Um Obviously, we want this to be the best for you guys. Um Oh, thank you for the highest levels of praise. Thank you. Um Yeah. Any questions, anything you didn't understand? Um feel free to drop a comment. Otherwise I think we will conclude that. You're welcome guys. You're welcome. Um Please please fill in the feedback. Um It really helps us. Um Yeah, no problem, no problem. Also um A big um shout out to Anissa as well. Doctor Anisa. She helped me loads with this. Um So definitely credits to her as well. Um Yeah, thank you. I think I don't know if Anisa is here. Let me check. No, that's fine. Um Yeah, I'll just tell, tell my m I should probably say what I'm gonna do. I'll just put on mic off. Anybody wants to put anything. I'll, I'll loiter for a few minutes but yeah, you guys are free to go. Um It would be great if you can do the feedback and we'll do the next session next week. I'm not sure um the date but we'll let you know in the group chat. Yeah. Thank you all for coming. Hope it was helped.