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Mhm. Yeah. Mhm. Okay. Let's get started so high again. Everyone. Thanks for joining this. Uh I N G T U K Weapon are that will focus on some important concepts within internal medicine and prepare you for the plan exams as well as UK Clinical Practice. So this series is hosted by the Widening Participation Medics Network. And uh it's also sponsored by the Medical Protection Society, which is a leading medical indemnity provider in the UK. Today we have doctor Fish Oil Galab, who's the foundation program trainee in the east of England and passed his uh lab exams about a year ago and joining him, we have Doctor Olivia Kuo, who's an internal medicine trainee also in the east of England. Before we get started. I'd just like to remind everyone that if you have any questions at any point, then please ask them in the chat and then we'll answer them. And at the end of the session, we'll send out some feedback forms for the teachers today and I would appreciate it if you could please complete these. So I'll hand over now to be sure. Hi everyone. Hopefully everyone can hear me well and So as uh my colleague, Mr Bahadur has already said, um we're going to be talking about uh we're gonna do a bit of the talk about internal medicine today. Um The topics that we plan to cover today is just some management of some common presenting complaints using the uh nice guidelines. Uh and then in preparation for plaid exams and of course UK clinical practice, some important things that you might need to be able to approach these common presenting complaints. So, review of basic history taking and safety netting, review of what might be needed as part of an A T E assessment, uh review of the components of the news score and review of the anti coagulation record A K A um the yellow book and what that kind of looks like. Um some scores that we use to help guide our management like the curb 65 score are well score and our um Pepsi score. And also just the comparison between um the British Thoracic Society and nice guidelines for asthma slash COPD. So we'll start with clinical case number one. So this is a 55 year old mill um presents to A and E with sudden onset of chest pain whilst lifting boxes as he was moving house, the chest pain is described as central and burning and the patient has been having similar episodes for the past six months. So pretty vague history, but we know that's somewhat um cardiac um presenting in general. So I guess the question that I would post to you guys is what should you do first to manage this patient? And I'll give you guys a moment just to put in uh the answer in the pool there that's popped up and how, oh, great. Or getting some uh responses in. Now, I don't know how many people we have. So I don't know when to, with the stop for a break. Let's see. Have a boat. Great. So I think we have pretty much everyone's replied. So, um so we kind of have almost a 50 50 split between option two and option five. So um out of all these options, so we have option number one, no one chose it and correctly. So um called the Cath Lab as the patient is having a stemi. Um We don't have enough information to be able to um confidently say that it is an ST segment television, myocardial infarction. So I'm glad that no one chose that number two, uh further history about the patient's chest pain. Uh That is the correct answer and I'm very glad for the uh the people that were able to get that answer and we'll discuss why that one is the correct answer in a little bit. Number three, send off a troponin and triage to the cardiology registrar. Well, sending off the troponin is, is definitely part of the work up that you would do for this patient I think it's a bit premature to be able to escalate to the cardiology reg at this point. And I think to be honest, if you called them at that point, they would just uh bat it away. Um, uh Number four, diagnosed the patient with panic attacks and consider starting propanolol, no one chose that one either. And to be honest, the presentation doesn't really fit with panic attacks and obtain an E C G. So obtain an E C G is definitely part of the work up. So, uh I kind of agree with that 50 50 split. The answer that we had chosen was number two is the most correct answer further. Um history about the patient's chest pain. And the reason for that is, is there are multiple ways that chest pain can present. So, so far, we know that it's central. Uh And um I believe we said it was non radiating funds. Yeah. So central and burning and we didn't describe any radiation or anything. So here we have some differentials for chest pain that we should be thinking of when someone comes in. So, yes, it could be cardiac in nature. So if it is cardiac in nature, we're looking for, for example, um that radiation to the left arm we're looking for, um you know, um patient's who usually staying, it's, it feels like a heaviness underneath the sternum centrally. Um If it's something along the lines of, you know, lung pain is it, does the patient had a cough recently? Do they have pleurisy? Um, do they have pneumonia? Have they been spiking fevers? Um, have they been bringing up sputum? Um, you can consider, for example, a patient you might have, um, the most common cause of chest pain. Uh, gourd. Right. So, does the patient have a history of, uh, reflux? That's, um, that's been really bad. Um, you can also consider, um, patient's who have um um epigastric pain. So, let's consider for example, patient to have um a gallbladder pain or pancreatitis. So, we have that pain that's central and radiating to the back uh with pancreatitis pain, we have gallbladder pain which uh starts off uh like right upper quadrant can be central in, in nature, happens after meals, radiates to the right shoulder. Um for that referred pain due to um that diaphragm irritation. Um we can consider uh for example, A P E. So, does this patient have hemoptysis? Iss um do they have shortness of breath? Are they hypertensive? So all those things that we can um you know, look for clinically as well as ask for in the history um other things that we can ask about for this patient. So, and other kind of emergency um diagnosis, think about your aortic dissection. Um Does this patient have a history of very high uncontrolled hypertension where uh and we have central chest pain that radiates to the back? So, um these are all just common diagnoses that we need to be thinking of and trying to rule out in our minds before we can continue and say definite, for sure that, you know, we have an acute Coronary syndrome, for example. So what are the components of a good clinical history? And what are the things that you are going to be expected to kind of collect as part of the plaid exam? Um to be able to end obviously for a good clinical practice in whenever you're seeing patient's. So the basic parts are the ones that I've listed here. So one introductions always make sure that you are um you know, saying your role, so your name and your grade and kind of what department that you are um working with, that kind of helps to build rapport with the patient uh and helps them to know kind of uh what to expect going forward with the interaction that you're going to be doing second building report. So figuring out um making sure that the patient is comfortable, making sure um you know, uh that they are happy to have a discussion with you. Um if they are um in need of a chaperone or they need any assistance at that point as well, feel free to bring someone in uh and then our history of presenting illness. So these are the questions that are going to help us narrow down our differentials. So uh making sure that you're asking open ended questions, making sure that you're not asking compound questions. So for example, only ask one thing at a time. Um So as to make sure that you are not confusing the patient and that you're able to gather all the information that you can uh without confusion. Um Something that's also very important is to continue with the past medical history. Um as that helps to narrow down your diagnosis. For example, if the patient has a history of reflux, that would kind of uh make you look down the gastrointestinal um you know, system disorders pathway more. If the patient has history of pain on exertion, for example, more cardiac history, if the patient has a history of, you know, um uh cancers in the past, um you know, you might be thinking, oh, is this uh presentation of metastasis or something like that? Um Then medications because we know medications can, can have side effects um allergies, social history. So does this is this patient for uh an alcoholic uh increasing my differential, for example, for things like pancreatitis? Um and um also drug history which can present with um that central chest pain. So, thinking of things that are sympathomimetic like cocaine, uh patient patients who are using cocaine rather. Um and then obviously, at the end of all, this is really important and these are how you get those extra points on, on the plaid exam is to always explore um ice and those are your ideas, concerns and expectations. So, always try, if you can incorporating in your history. Do you have any idea what this might be? Um, usually patient's have a very good idea of what they, of what they have, they have, uh, they're, they're the ones that know their bodies the most. So, always asking them, you know, what could it be? Um, is there anything that you're concerned about? And are there any expectations that you might have as part of the treatment plan that you would like me to include as part of the plan and by allowing the patient to participate in their care in this way, um, you're not only going to allow for better outcomes for the patient, but you're also going to improve patient satisfaction. Um And obviously another bonus is that you get bonus points on the exam. So it's a win, win, win just to add to that really quickly. Um It's also really important in social history, particularly with chest pain to ask about smoking history. Um So specifically how many cigarettes a day and for how long, um and even if they have stopped a good question to ask, um, in this sort of setting is not just, do you smoke? Because some people say no, but they might have stopped smoking but have a significant previous smoking history. So just have you ever smoked and then just delving more into it and determining what their peculiar history is just, meaning one pack year is 20 cigarettes a day for a whole year. So then just trying to just extrapolate, um, their pack, your history is going to be really, really helpful for stratifying their risk. And the only other big category to think about is family history. So particularly when you've got cardiac standing chest pain, wanting to know whether they've got a history of heart attacks within the family, particularly if they were family members who were first degree relatives, and particularly if they were less than 65 years old. But it's still worth finding out regardless of their age, whether there is a history of coronary artery disease within the family. Yeah. And to add to that, another thing to ask with family medical history is our patient's that have a family history of a first degree relative with sudden cardiac death. So someone especially when you have a young patient that might present with chest pain, um usually following exertion, that should be one of the red flag diagnosis that's at the forefront of your mind. Um And so this is a very famous monarch that hopefully all of us know. Um and we always use this to stratify pain. It doesn't matter if it's chest pain or anything, but all kinds of pain. And that Socrates. Uh and so that helps us know uh basically the site the onset. So the site of the pain is it central, is it right sided, is it left sided, all of which help us, um you know, narrow down the differential onset. Is this something that's just happened for the first time today? Is it something acute that I'm going to be treating? Or is it something that's been happening over a long period of time? As in this patient, for example, six months time likely to be less acute, um uh less likely requiring immediate intervention in the hospital setting. Character is a, a dull pain. Is it a sharp pain? Um Is it a burning pain? Um All of which to say that each kind of description of the pain kind of helps us figure out what kind of system usually um is, is it radiating anywhere? So we know for example that if it radiates to the left side, more likely to be cardiac pain, if it's um if we have, you know, referred pain to the right shoulder, um we're thinking usually it's something more gastrointestinal gallbladder, pancreatitis. Um We could have some like a perforated uh diverticulitis that's irritating the diaphragm as well. Um associated symptoms. So, uh are we having, for example, hemoptysis, for example, um in this case, thinking of P E or if it's frothy sputum, thinking of heart failure, um uh again, time and duration as well. How long does the pain last for? That's the difference between time and onset, right? So, onset is how or when did it, when did this episode start versus time and duration being. How long have you been having this overall? And how long does the pain last for any eggs exacerbating symptoms? Really? So, uh, does anything make it worse? And also at the same time you want to ask, does anything make it better? Have you taken anything, for example, uh, most commonly patient's have been taking paracetamol here in the UK, making sure that they have taken any, anything for pain management has that helped. Um, and then severity. So you give them the pain scale, telling them one being little to no pain, 10 being the most pain that you've had in your life. What is it on the pain scale? And that kind of helps you realize the severity of the, for lack of a better word, the severity of, of the, of the patient's condition that they've come into hospital. Um, so going back to our case, right? So this patient with the additional history presenting illness has told us that they have a central chest pain. Um, it does not radiate, it settles after about 15 minutes. Um, it's present only after exertion and there's no pain at rest past medical histories that the patient had hypertension, high cholesterol in our social history. We've determined that he uh, smokes about 20 cigarettes per day. Um, really poor diet, know physical activity, vitals are stable for now. Um, and our physical exam isn't really showing anything and our blood tests and our troponin are pending. So now we have to decide as the patient, as you know, the admitting doctor seeing this patient. What are we going to do with this patient? What are the kind of our next steps? And um you guys have correctly identified. Um You know, we have to do an E C G. So uh here is the patient's E C G uh if you can in the comments, kind of just let me know, what do you guys see? Do you see anything that we need to be concerned about or does this look like a normal E C G? We'll give it another 10 seconds or so. And then if not, uh maybe Olivia, I'll get you to, to tell me what you see on the CC Jesus. That sound. All right, cool. Yeah, go ahead. I love you. So I think when you're looking at any cgs, um it's important, it's difficult to see here. Oh, there we go. We've got sinus rhythm and no significant ST or tea segment changes. So, essentially, yeah. So you're looking to see if it is in sinus with them. Obviously, you do all the checks. So who is the patient? What time was it taken? Was it taken when they had chest pain at the time? All these are really relevant factors to when you kind of when you, when you do get an E C G thrust in, in your, in front of you, which often happens in E D and you don't really know much about the patient. But, but these are important questions to ask and then having a look at the paper speed and all the parameters to make sure that um it's set up as, as standard because otherwise it can look like someone's particularly toxic article bradycardic, but it just may be the paper speed that is kind of skewing that. And obviously, in this case, um you are particularly interested in if there are any particular ST or tea segment changes. So T wave changes. So T wave inversion, in particular, you might be looking for Q waves to see if there's an old established infarct. Um And I can see someone here said are the T waves a bit taller than usual. Um Actually, sometimes this is, this is just the appearance of it. I mean, if you're thinking about patient's who have hyperkalemia and you think about tall tented T waves, they are really, you know, much more pronounced than this. So actually, this isn't too far off perhaps. Um there are just physical variants that are normal for people. I have seen T waves that are like this, then they're pretty normal. Um So that is reassuring. But yes, as, as one of our viewers has said, you are particularly looking for any ST elevation um boat in in any of the leads really. But then you're thinking about the distribution of the S T O T wave changes So you're thinking in terms of if it's in an inferior anterior or lateral pattern. Um So you're thinking, you know, 23 aVF particularly for your inferior, um you're thinking one A V L V five E six as well for your lateral pattern. Um and then your chest leads primarily for your anterior and septal changes. And then the other thing to members, if you get um particularly ST depression in V 123, you just want to be mindful that sometimes um you may need to consider doing posterior leads, which means just basically putting the leads, those leads on the back and doing what they call V 78 and nine. And essentially, you're just swapping things around because when you're having a look at the front, you might see ST depression, but actually, that may just reflect um ST elevation, but you're seeing it from the other side. So that is something to consider as well. I don't know whether you want to add anything there Bishnoi. No, I think that's perfect. Um So we've seen R E C G like you guys correctly identified. And as um Olivia said, we see sinus rhythm, no significant ST wave changes. I'm going to tell you that the troponin came back, it's absolutely normal. So hopefully we have the differential in our mind. But again, let's say the troponin hadn't come back yet. We did see some changes in the E C G. What are, what is something that we absolutely need to rule out. And this is our acute coronary syndrome. So let's say this patient came in, he's presenting with chest pain. It's not necessarily um only on exertion, it's also at rest. What are some things that I absolutely need to rule out in order to make sure that this is not an acute coronary syndrome. I do not need to go to cardio. So you've done an E C G. If it showed ST segment elevation, then it's a STEMI I need to be, if I'm in an area that provides primary PCI, then I am doing that referral and it needs to be done hopefully uh in 90 minutes. If not, then I am hopefully in a position where I can provide fibrinolysis or I'm talking to someone that was able to get your analysis. You as an F one R F two probably are not going to be doing that by yourself without some senior advice. Uh But let's say you're on the other side of the algorithm. So we don't have any ST segment elevation. However, we do see some ST segment depression or T wave inversion, then our next go to thing will be to look at the troponin. So if our travel, if our troponin is elevated, then it's a non ST segment elevation. And my, and uh we're going to treat them uh medically basically, for the most part, uh we remember Mona Bash, which is our morphine oxygen nitrates, aspirin, beta blocker ace inhibitor, a statin and heparin. That's mona bash. Um Those are our mainstay treatments for uh an end stemi versus if there's no elevation in our troponin, then we are kind of a bit more at ease. It's unstable uh Angina um for this patient because we did not have any ST segment changes than uh we know that it's normal and most likely it's a stable, uh it's a stable angina because we had after exertion. Um or it's some other differential that we haven't considered and we need to go back to the patient, gather more history or do some other tests in order to be able to narrow down the differential. Um So let's put the pieces together for this patient. So we had a 55 year old male. He came in with pain after uh lifting some boxes E C G showed no ST segment changes, sinus rhythm, troponin was normal. His obs are normal for the most part. So me as the admitting doctor would be quite um you know, calm uh about kind of sending this patient home. So what are some things that I would do? So uh one discharge the patient, if you feel comfortable, you can discharge them to something called the chest pain clinic. So some trust have chest pain clinics G P can refer them or you can refer them yourself uh in order to get follow up on uh specific symptoms that they're having. Um, or you could refer them to the G P. Um, the other thing is you might give them a G T N spray, um, to kind of help do vasal dilation. That kind of helps to relieve their symptoms when they're having those, um, central chest pain symptoms. Um, and then you could start an Aspirin statin beta blocker depending on, you know what they're bloods were showing. Um, And I fixed this before, but I think it hasn't fixed in this one. So F two is technically can discharge. I was talking about this with Olivia before um because you're technically an S H O. Uh and that you, um you know, you have a full license so you're, you are able to discharge, but usually you wouldn't do that at the F two level without, um, you know, discussing at the senior level. Um Anything, any questions, does anyone have any questions about this particular case before we move on to case number two? We'll give it about 10 seconds or so while we're waiting for questions. The other thing that is useful at this point is, you know, obviously this patient's presented with stable angina. Um But we want to start measures sooner than later us to prevent um further deterioration and blockage of the coronary artery. So we're thinking about giving lifestyle advice. So always think when you're giving, when you're managing a patient, think about conservative management first, then medical and, and then surgical if it is warranted, but not really in this case. But if you're thinking conservative management, then it's really important to, um, you know, think about your, uh, smoking cessation discussion with them, um, that will really, really help prevent further deterioration. And also, um, you've really talked about commencing a statin but also just recommending dietary and exercise advice to them would be really important. Uh, I think we have a question here. It says, how soon would the patient be seen in chest pain clinic? And for how long would we continue the medications for? Uh I think for how long it takes to be seen in chest pain clinic could really depend on, you know, availability. Unfortunately, not everything is um kind of zoom, zoom, zoom in the NHS. But um usually they would be seen, you know, as soon as capacity allows, I would say probably within two weeks or so. Um I think it also depends, trust to trust. So in our trust fish or there's a rapid access chest pain clinic and they're seeing quite soon. But um, I think the reassuring thing is that this patient as long as we start management and start um secretary prevention, um then actually they're stable for the moment, but they obviously need further input and assessment by cardiology to, to optimize their therapy and management kind of long term. So I probably say in terms of the continuing the medications, um I mean, the aspirin is usually we just continue it. Um, anyway, because, and the statin as well, it would basically be preventing, um, further occlusion. So, the anti aspirin being anti platelet therapy to prevent, um, you know, platelets, um, causing obstruction of the coronary arteries. Really. So, these are all secondary prevention therapies and, um, obviously, alongside the conservative management, it's really, um, I mean, long term, unless cardiology feel like that's a case when it's, it's they can discontinue it or if they have any um particular adverse reactions. So if they are taking a statin or a beta blocker and they can't tolerate it for, for whatever reason. I mean, with the statin, there are lots of different statins. So some people might struggle with one and then we can consider switching them to an alternative one as well. But again, that's why we, we would refer to the specialist and we refer to cardiology at this point and then they would take over. Amazing. Um I think there are no further questions. So we'll go to case too. Oh, no, actually there's one more thing that we have to say uh and that is safety netting. So this is really important, you'll do this for all your patient encounters. So let's say the patient, you send them home, you're confident that they have stable in China. And um you know, you send them home. But you know, there's still that, that possibility that even though they're low risk, they could still come back with, you know, worsening symptoms. So something very important to do would be to safety net. The patient that's basically making sure that if there are any red flag symptoms. So for this particular patient, the patient gets further chest pain, they get shortness of breath on exertion or even without it just shortness of breath, chest tightness. If they're getting pain that's referred to the left arm, anything like that, it would be very important to highlight those symptoms to the patient. Let them know that their, um, that this might be a worsening or a, you know, progression of their symptoms and be very important for them to come into, into hospital. So, um, make sure that you talk with them, maybe get them to repeat back what you've told them to make sure that they, you confirm their understanding, see if they have any concerns at that point and then make sure that you document that and whatever you are um documenting about the encounter to make sure that, you know, in case something does happen that you, you've made that advice, uh, to the patient. Um Yeah, I agree. That's really important. I remember when I was an F two in E D, I was actually quite nervous because it was my first job after being an F one and as an F one, because you're not fully, you're not fully registered with the G M C, you can't legally make a decision to discharge someone so naturally having that ability at that point was quite daunting. So, I mean, the main thing is, you know, if you're safety netting someone and highlighting the red flags to them, as long as they seem sensible and are able to, to kind of, or even if they're not that not that receptive themselves, if they have family members that can kind of look out for them and you can make sure that the family are also looking out for these features. It's really a way to in power, patient's to take hold of their own management because we can't be with them every step of the way. And there's always going to be an element of risk, just like if you put, if you prescribed all the medications that we've said, um, the patient may not be compliant. So there's only so much you can really do. Um, so it's really important that you try and do as much in terms of education as, as possible. And this is part of the education side of things. And again, like I said, really documenting everything that you've explained to the patient will actually, um, protect you in some way. So if they come back and they claim that they haven't been educated about all this, at least you have something to, to back you up. Um I think that's hopefully the end of case one. Yes. So I go to K C and I'll leave it in your capable hands. Thanks. So, um, for case to, we have a 55 year old gentleman who his, his only positive history is that he did have an MRI about five years ago. He is now presented with worsening shortness of breath on exertion. Um, and also low limb swelling. There's also a chance that he might have had some shortness of breath at rest as well and you can use the New York Heart Association criteria to stratify this. Um The nurse asked you to see him for a news of six. So news or six will go through in a moment, but it's just basically uh gives you an idea of how unwell the patient is. Um And so we'll go through exactly what news means. Um but to begin with, so how would you initially manage his patient, given the presentation he's coming with? Okay. So I'm not sure if you got any more come in, but that's fine if you wanna keep answering that question looks like it's pretty uniform in the response. So everyone has gone for conducting 80 assessment and I think given how well he is. Um and the fact that he's using a six, which is quite a high number in in the scheme of a new score. Um It is appropriate to start with an 80 assessment for any unwell acutely unwell patient in terms of the other options, obviously freeze my being a diuretic um and giving it intravenously, um may be something we want to do down the line for this patient. Um obtaining a chest radiograph for him just to see what, what is going on within the lungs is also quite useful. Um And again, escalating to a senior, I would say that if you, if you felt out of your depth, um I think it is a good start to do an 80 assist mint be, but at any point, if you feel like this patient is too and well, it's never wrong to ask for senior assistance and that's absolutely fine. It's always better to ask for help sooner rather than later. Um And then in terms of obtaining UCG, um that's also part of your work up. But I think I would agree with you all that if you felt comfortable with doing an 80 assessment at that point, that would be the most appropriate thing to do. So we talked about news. So that refers to the national early warning score and there's not actually a national early warning score to now as you might see that referred to and essentially is a scoring system that was brought in nationally in order to try and help um stratus fi risk of deterioration in in patient's. And it was a way to use the observations um of a patient to direct our health care uh colleagues. So our nurses to know when to escalate to the medical team. So there are six physiological parameters. So mainly there observation. So their respiratory rate, their oxygen saturations, their BP, pulse rate, and then also they added then temperature, but they've also added in level of consciousness as well as new confusion. And that also refers to um end organ um kind of hyperperfusion, for example, that may lead to uh decrease consciousness or confusion. So this is what the charts look like. So on the left is the handwritten charts. Um And on the right is the electronic system, if that's what your trust uses and obviously it varies between trusts. Um and on the back of the score ing system or on your electronic new school system, this is what the nurses will see. So usually have kind of 4 to 6 hourly monitoring is the usual standard minimum of 12 hourly, but the typical is 46 hourly on the wards. Um and then based on the score that they get in each of the categories. So if we just go back, one is quite small, but you might be able to see the different colors on here. Um And that refers to the number of points that they get on their school. So white is zero, yellow is one and then two and then three and then essentially they put in the the parameters and at the bottom they tally it up and then on the next slide, if we go back again, um it will then say, you know, if you get fight wonderful, then you continue doing what you're doing. But obviously, if the nurse is concerned, so even if your score ing wonderful, but the nurse is concerned that there's been a significant change. So for example, if someone is gone from being alert to being confused or only responsive to pain, then even though that doesn't really score very highly, that is quite worrying. So an element of this does rely on the no, on your nursing colleagues um kind of concern. And I think nursing concern is often a really good measure because obviously they see the patient data day to day and throughout the day and they'll be able to highlight any abnormalities, um significant abnormalities that they've noticed in the patient's clinical state. Um But then again, if there's, if they're scoring five or more or if they get in the red category, so 33 and more in one parameter, then the nurse would usually highlight to us juniors on the ward um pretty promptly. And then obviously, if they're total of seven or more, that's when you're really, really starting to worry because there are lots of, there's lots of abnormalities usually in multiple, multiple categories in order to get to this score. So news of five. So this gentleman has a news of five. So when we, when we go through his score ing system, he's score NG um for his respiratory rate, which is elevated his oxygen saturation. So he is saturating within range. So more than 90 for uh usually up to 98% but usually more than 94 is fine. Um And he's on four liters of oxygen and that usually just being on oxygen scores you to anyway, his BP is under and 14/87 which isn't actually the grand scheme of things um too bad in general, but given that he's so he's 55. So that's not too bad. It really depends on what his usual baseline is obviously, if he was 80 and he's got essential hypertension. Um And his usual BP hangs around 100 and 40 then this would be obviously low in, in that context. So it's really just based on the patient as a whole and what their usual baseline is, his pulse rate is 92. Um He is alert, which is really reassuring and he's a febrile. So this is an A B C D E chart. But if we're going through an A B C D assessment, the reason it's in that order is because a, if you've got a problem with your airway that's going to kill you quicker than if you had a problem with be really, it's just the blunt way of saying it. So a in terms of assessing patency of the airway, um you'd want to listen for any airway noises. So think about stride or any evidence of obstruction um you could then think about positioning someone's head. So that's thinking about your adult life support um pathway um and whether you need to do suction. So using a yank a suction um for any secretions that you can see. Um and also whether you need to use any airway adjunct. So you might think about a nasopharyngeal airway or a good else o'nora for and you'll airway. But again, at that point, you're slightly worried about the patient if they're able to tolerate either of those airway adjuncts. Um You're thinking about airway demons. So if someone's got evidence of anaphylaxis, they may have swelling um in the airway that's causing the obstruction. And then if you go, if that's all clear, then you can go on to be. So then you'd um look, listen and feel, hopefully this gentleman is obviously able to breathe in their airways patent. But then you're thinking about the fact that his respiratory rate is 22. So it's a bit higher. You might see increased work of breathing is what we say where you can see accessory muscle use. So whether they're um you can see um them, you know, you get, they're breathing, working hard, really essentially in using more of their accessory muscles to breathe and then also listening for any added sounds. So think about if you can hear a wheeze from the end of the bed or if you can hear any upper airway secretions, um or we're thinking about subcutaneous emphysema. So that's usually surgical emphysema. So that's if you press on their skin, it kind of sounds and feels like what's the best way to say it? I want to say like bubble wrap. Is that the right way to say it visually? I'm not really sure how it's best. It kind of sounds like the popping of rice Krispies. Exactly. Popping rice Krispies. Exactly. It's really difficult to describe, but once you felt it or heard it, you will remember and you'll recognize it, you're thinking about the symmetry of the chest movement. So obviously, if there's a blockage down 11 of the main bronch, I or if you've got evidence of attention pneumothorax, then you might see a tricky a deviating to one side. So usually away from the area of the pneumothorax. Um but then equally, you know, you'll see less chest movement. Um and the same, if there's an obstruction and with the foreign body in one of the bronch, I, then you'll see the asymmetry. So all these are really, really important clinical things to be looking for. Um in this patient, you might want to a really important thing depending on, if this is, this is on your mind. With regards to the presentation, you might want to have a look at their JVP. So that's the jugular venous pressure. So usually get them at 45 degrees typically and get them to look ever so slightly towards one side. So you can have a look, you're looking, you're usually for the internal jugular vein and that's between the two heads of the sternocleidomastoid muscle here, which you can see on here. Um And you're looking for elevation relative to the sternal notch. Um, again, cyanosis, probably one of the ones you'd be able to see from the end of the bed and you'd really be looking for that. So central, like tinged blue tinged lips or even peripheral cyanosis is really important to look out for. Um If that's all good, which hopefully would be in your patient, then you move on to see. So you're just, you know, feeling for the pulse, feeling for the character, feeling if it's thready or not. Um if it's a regular, regular and then also if it's tachycardic or not, and then you think about the BP, seeing if it's hypertensive. Obviously, most of this will be on the obs chart. Um Thinking about how, how, how well perfused they are. So thinking about capillary refill time either peripherally usually centrally actually is quite useful because some people just have um cool peripheries generally. Um and bear in mind that sometimes for obs patient's can be looked like they're saturating lower than they actually are because usually when we put the ox the pulse oximeter on the fingers, um if they're peripherally shut, shut down, meaning that their, their hands and feet are cold, then maybe the pulse oximeter isn't reading appropriately. So that it's all thinking about when you've got someone who's unwell and scoring high, think about whether your equipment is actually working well. And in that situation, it may just mean that you need to try and ear probe or something that, that's also an alternative. And see you're also looking for an evidence of bleeding from anywhere. Um, and um, diaries is, oh yeah, you're looking at, if you're thinking about cardiac, um basically they're fluid state. You're looking at the peripheries to see if there's any um peripheral edema. So pitting edema when you press on their, on their legs. So yeah, and then um in that you might want to do further investigations. So, you know, you might want to do your E C G or request an extra at this point and then moving on to D so disability really. So you're looking at the have Peace Corps. So whether they're alert or responsive to voice pain or unresponsive is really just the quick way of, of, of a sec missing the conscious level, obviously, the formal way to do that is there G C s and whenever you do a G C s and you communicate that to someone else over the phone, that you've seen it, it's really important to give them the breakdown as well um of how they're scoring a certain level of G C s and then you're looking at the pupils to see if they're equal and reactive bilaterally. Um looking to get A B M because obviously, if someone's hypo glycemic, that can also drop their G C S and then you can do a basic, basic neurological examination on here as well. Um And then e is basically everything else. So usually assessing their temperature. Um and then just, you know, feeling the abdomen because we haven't already done that, making sure that they're not, they haven't got an acute abdomen. Um and then thinking about blood anywhere else. So always look to make sure they haven't got any pr bleeding or any bleeding from down below that you're missing. Um So fortunately, in terms of our assessment, this patient as well, he's airway in terms of airway is patent and he's speaking to us, which is means that his airways protected. Um He's breathing, he's got equal chest expansion as we said, he's to keep Nick. He's got by basal crackles and he's saturating about 97% but he's on four liters via nasal expects. Um He has no evidence prefer. So I notice his capillary refill time is great because it's less than two seconds. His pulse is um 91. It's regular, his BP, we've already mentioned before. He has got an elevated JVP, which suggests he might have an element of fluid overload. Um and he's got increased volume of the second heart sound, but no additional heart sounds or murmurs which is fine. Um He's alert his BM S are fine and he has got peripheral edema, which is pitting up to the mid thigh, which is quite significant. So putting into putting that all together the fact that he's got a raised JVP. Um and he's got by basal crackles and he's got pitting edema up to the mid thigh. Um I'm not sure whether we've got a question on the next slide. But what do we, what do we think this is the diagnosis here is likely heart failure, I think is what we're going for cause he already shown that, but essentially fluid overload. So, um that could be because they've got a background of um ventricular dysfunction. So with heart failure, usually it's a term which is a capsule. But to be specific, you've got left heart failure, meaning that the left ventricle isn't really, really working as well. Um And usually in that you get fluid backing up into the lungs. So it's quite common to get upon your edema. Um And that's what I probably expect to see on their chest X on this gentleman's chest X, right? But then you've also got right heart failure as well, which, which comes with its own own um bag of symptoms. And it's more common to, then obviously, if you think about where the, where the fluid kind of then flows back to, you usually get more peripheral edema. But with this patient, because he's got a raised JVP bilateral crackles by Baizley and he's got significant pitting edema. I think it's really important to also consider that in these patient's, they might have fluid within the abdomen as well. So you might also want to do a test for ascites called shifting dullness, which I think you guys, I'm not really sure in terms of whether that's something that comes up in your exams. But um that, that might be something you want to assess for. And if there is any evidence of fluid in the abdomen, you also want to consider these patient's might have got wall edema, which means that they may, if they're really taking oral diuretics, it may be that they can't really absorb those as well. Um And that's why it's in this setting when they're acutely unwell, it's really important to consider IV diuretics too to make sure that they're getting the full benefit of the diary cyst. So in terms of management, thinking about it's very easy to jump in and go. We need to give diuretics, but actually just thinking about the things that you can do first. So obviously you've done your 80 assessment, you want to sit them up because that's going to help um with the oxygenation, you would give oxygen um depending on whether they were hypoxic point. And then you might consider vase dilators like G T N. You can either use a G T N spray um sublingually initially or if they are requiring a G T infusion and their BP allows for it. Then you can actually give a G T infusion particularly there peripherally shut down. And then you can give IV diuretics. So we usually give IV frusemide. Um and you can give this in many different forms, but you can give this either as Bolus is. So you can give kind of 40 mg bolus is and then you can also give and this is I'm currently on cardiology. So we usually just very casually give um not casually, but it's quite a large amount. It's 240 mg that we can usually give in a continuous infusion. Um And that, that sometimes means that it doesn't drop the BP as significantly as having an IV Bolus does. And some people really do need that to help with the diary sis. Um And then the other things that you might want to add. Yep, I can see someone's written something about dapagliflozin or impact the flows in. Yeah. So obviously, this comes depending on whether they're known to have heart failure or not, you'd also want to then be doing um you want to be doing daily weights daily, use the knees um input and output chart and then you want to think about fluid restricting them. So we usually do a liter, two liter and a half. Um And then the daily weights are really helpful to see how much we're offloading. Really. Um We'd want to monitor using these because obviously, the frusemide and diuretics can really, really affect, affect those and can send some of our patient's into AKI. Um It's really important to use our allied health professionals. So getting our heart failure specialist nurses in early is really important and getting a formal echocardiogram to determine what the ventricular ejection fraction is, is really important. Um I can, with regards to what what's been said in the chat, there are four pillars of um of heart failure medications. So in time, obviously, um BP allowing and using these, allowing you be thinking about getting them onto spironolactone, you think about getting on them onto dapagliflozin as long as they're not a type one diabetic because that can increase your risk of getting A D K. Um You'd be thinking about your ace inhibitors. Um And sometimes you, some people decide to start on Ramipril, but really, you're thinking about your interest dose, you're scuba tral, Valsartan. Um And then, you know, your beta blockers as well. So all those four should be in time um started for their management long term. Um And then I think that's mainly, I think that's mainly what's on this slide, but really referring to your heart failure, nurse specialists means that they can have long term follow up even in the community. And I think that's really helpful and they're really good at giving the advice with regards to um other management of BP of monitoring the BP, monitoring their weight in the community. And also um certain advice you have to give with regards to dapagliflozin because in itself because it helps with fluid offload by um by excreting sugars, you've got an increased chance of developing a uti and also developing skin infections in the groin area. So things like that are really important in terms of education when you start a patient on this management. Amazing. Thank you, Olivia. Um We'll go, I think you've already explained this, but this is basically the heart failure service and I'm serving in the community. Um And usually we continue that in order to continue with their follow up and they don't have and if they don't require hospital level care, then um we'll, we'll leave them and they're very capable hands. Um I'm going to skip over to case three because time is quickly dwindling away. Um So, um our case three. So we got a 68 year old female. She's presented to a and E with palpitations. Um She's been getting them on and off for the past two weeks, but today it started two hours ago. She's feeling a bit lightheaded. She has no chest pain, she has a stable BP. So, um we have this as the E C G once we've admitted her. Um And so I'll keep it up there for about five more seconds. Okay. So we have a pool now. So how would you guys like to manage this patient. I know a lot of words up there. So make sure you read them carefully. Yeah. Mm They're slowly dwindling in looks like we have a split between option one and option four. Uh So far. So essentially based on these option choice is that the thing that really is guiding our management is is the hemodynamic status of of this patient. Um And so to carry on um if the patient is hemodynamically unstable, so they fit into one of these four categories. So if they have myocardial ischemia, if they have syncope eight, if they have heart failure or they're in shock, um If we use R A L S algorithm, then this means that they need to have an A B C D E assessment followed by synchronized DC cardioversion. Um Given that our patient was not um not uh hemodynamically unstable, we can go into the no side of this algorithm. So we have to define symptom onset. So uh the onset for this patient was in less than 48 hours ago. So we would provide rate control or rhythm control. Um So our rate control would be our beta blockers or calcium channel blockers. Um Rhythm control, you can consider thing, things like uh and you know, drone um you can consider flecainide. So those are our different classes of um you know, uh cardiac meds that we can use for rhythm control. Uh If it's been more than 48 hours, then, um, you might also consider starting an anti coagulant as well because with atrial fibrillation, we know uh that, that's basically the atria kind of flipping and flopping about and that causes um stasis of the blood and that can result in an increase in clot formation. And so, if that happens, then uh we are at increased risk for producing uh CV A or a stroke, right. So, um anti coagulation will be very, very important in these patient's. And so the things that we're going to consider for these patient's uh if whether or not we're going to start them on anti coagulation, we have to do something called a chads fast score. And um this is all based on. So basically whether the patient has chf if they're hypertensive, if they are, um if they have an age greater than or equal to 75 diabetics strokes, um and their sex as well as vascular disease. And the reason for that is these are the things which are the highest risk factors for having a stroke. So that in combination with um this presentation, um we can use this uh these criteria to basically guide our therapy. So if we use chest recommendations from 2018, a male, as long as they have at least one point, then we, then we have to coagulate them for females. It's too uh if we compare that to the American Heart Association or um anything like that, then it's more than two for males and more than three for females. Um uh And usually, usually we give a Duac. So um consider things like Rivaroxaban doc's been uh depending on the patient's um usually kidney function. Uh And uh also um you could consider starting warfarin. Um many patient's are on warfarin at the moment. However, this is less and less being used in clinical practice at the moment. Uh And I would say reason for that being is just the continuous monitoring that is needed with Warfarin uh needing to um uh needing continuous iron our checks. Uh and uh Warfarin nurse follow up. Um I'll go on to the next slide. So for, for this station, if you were to get a similar station like this in um the lab exam, uh most likely this would be a communication station, meaning um you'd be asked to kind of explain the diagnosis to the patient. So, explaining that atrial fibrillation is an abnormal heart rhythm uh that occurs, occurs when heart rates are quite high and that the atria or the, the basically chamber of the at the top of the heart are beating at a rate that is different to the chambers at the bottom of the heart. And the signals are not really um um every atrial be to just not line up with every ventricular beats. Basically. Um And uh you might explain going forward all the things that we've mentioned before. So things like starting a beta blocker for rate control in order to decrease that really sped up heart rhythm, you explain starting anti coagulation to decrease your risk of stroke, but also explaining that you would have an increased risk of bleeding because it's a blood thinning medication. And so you would want to again safety net them for things like um to make sure that if they have falls. Um and if they get bruised, that they are aware that, you know, they're at increased risk of bleeding. Um And if you start the patient on Warfarin, then you would explain something, then you can give them something called the yellow book and, and it looks like this. So um it's a book basically saying um if you look at the top right picture here, it'll say we record the date the I N R of the patient. So um what their specific clotting was that day, um what the doses that we're giving. So um if it's Warfarin, for example, today, it might be Monday, Wednesday, Friday, 3 mg, um Tuesday, Thursday 2 mg and then come back to the clinic after a week to reassess the I N R to see if we need to adjust the dose. Um And um you also might mention it also says the indication for the treatment. So whether that's atrial fibrillation or they have a history of um uh deep vein thrombosis or whatever that might be. And also tells the duration of treatment if it's something that's only temporary, like six months, this is the first unprovoked PE or DVT or, or something, or if this is something that's going to be long term. Um, is there anything that you want to add Olivia to what I've, I've been sent so far. Um, not really. Um, I know that, um, the current guidance in terms of the other side. So obviously there's a risk of uh in terms of managing the clots using the child's vast school. But if you're worried about determining their risk of bleeding, um for a F there's a score ing system called the orbit score. Now, which is actually um is you being used more so than the has bled school. So that's probably the only most recent update that I would just add to what you said. Okay, cool. Um Okay. So I think we'll go on to case number four just given the time. So now we have a 75 year old male, they're attending A and E uh they have shortness of breath in a productive cough for the past seven days there. Spirit Torrey rate is 28. They're saturating 96% on four liters. They're a bit hypertensive, 96/64 heart rate is 88. They have a temperature and they're producing green sputum. Okay. Um This is the chest X ray that they have and these are the labs. So CRPF to white cell count of 9.8 H B of 1 20 neutrophil, 7.8 in the area 4.3. So I'll keep that chest X ray up there for about five more seconds and we'll go on to the next one. So what do you guys think is the most likely diagnosis if given this patient's presentation, the chest X ray in the labs? Yeah. And then it responses are trickling in slowly should go back to the chest X ray. Um Because I think people have the polls in front of them. So I'll keep the chest X ray up there for a couple more seconds. It seems to be a split between option two and three. Yeah. So, so for option. So I actually would agree with people that um gave option to as the answers if we look at this chest X ray, right? We have hyper um expanded lung fields. We don't see any specific consolidation anywhere in the chest X ray. The labs are quite normal. So even though the patient does present with um you know, fever and um production of green sputum, it's quite hard to say that the patient has a pneumonia without actually seeing any definite consolidation. Um So it could be, I would say um acute bronchitis uh but it could also be um exacerbation of COPD uh in this particular case uh for those reasons. So I'll ask you guys to scrap that previous X ray and we'll go to the actual X ray for this patient. So again, same thing. So we have a 55 year old meal, shortness of breath on exertion, cough, productive, sputum has a fever. This is the chest X ray in this case. Now, we have a CRP of 1 87. The white count is 13. We have neutrophils of 16 and we have a urea of 8.3. And so let's go back to the question. So again, we have another, what is the most likely diagnosis question? Um So in this particular case, same options. Again, what do you guys think is the most likely diagnosis? And I'll ask you guys to just reach out on the previous um on the previous poll and I'll put the chest X ray up. Excellent. So I am seeing basically a unanimous, unanimous so far that this is pneumonia. So, like we said before, so in this particular case, we have some right sided uh consolidation obscuring um you know, the right heart border and um the uh the plural, not the pleural space one, I think uh the uh edge of the lung with the diaphragm there in the right base uh like the costal margin, all the costa, costa margin. Yes, I can't remember the word. Sorry. Yes, the the the costal margin exactly. So we know we know that this is most likely a pneumonia and especially given this patient's labs. Um We can you know, confidently say that this is the pneumonia. And so what kind of guides our management with? What do we do with this patient? Uh, and that's using something called the curb 65 score. And so, um, what are, what this entails basically is looking at, um, five parameters. Uh, them being one confusion is there, um, you know, uh disorientation to person, place or time. Um Does this patient? Oh, we got to pop up at the pool again. Um um Does the, is the patient aware of, you know, where he is, what he's being treated for things like that to Urania? Um So for us, we're looking for a blood urea of more than seven millimoles per leader. Um A respiratory rate greater than 30 a BP that is less than 90 or less than 60 systolic and having an age greater than 65. And the combination of these factors basically help us to determine a patient's mortality. So if a patient has a square between 0 to 1, uh they have a low risk for mortality and so they can be considered for oral antibiotics and can most likely be sent home if they have a score of two, then they're in the intermediate risk group. And so usually, um this patient could still be treated with oral antibiotics, but it's more, it would be better for them to stay in hospital at least for 24 hours. See if we start antibiotic therapy, start fluids. Would that be appropriate for us to, you know, help bring down their numbers and then also help the patient improve clinically, then see if that we would be able to send them home and then if you have a square of three or more, then they're in the high risk group. And so we want to consider giving them IV antibiotics, um IV fluids, if really bad, we could consider an admission to I T U. But again, uh that would have to be, you know, it all depends on the clinical status of the patient. Um So given this, what do you guys think um the curb 65 score is for this patient that we have been discussing so far. Can you put up the carb 65 scoring for people to like I think should I go back to the case again? So, um so he's 75 shortness of breath, productive cough, respiratory rate is 28. Um No mention of confusion. So I'll say that he's probably not confused. Um has a fever. Uh BP is 96/64 and his urea is 8.3. So given those things, what do you guys think uh his crib square would be? Yeah. Yeah. So I can't see the pool for some reason but is the answer? I can't see the results of the pool. Um But in this particular patient that no, they're it's coming up. So I think it was 50 50 between uh there's a 50 50 between uh two and three and uh they're changing. But yes, the answer would be too because the patient is your remick. We have a urea of 8.3 and we have the age greater than, or equal to 65. The respiratory rate is less than 30 are uh the patient is not confused. And um what was the last thing? The last thing being the BP, the BP was not below 90/60. So we're able to confidently say that this is to this patient could probably be treated with oral antibiotics. But what are the things that are going to be guiding our management? So, um what kind of antibiotics are we going to give this patient? So, the first thing to do is that in any given trust, uh there are obviously there are guidelines for what we do to give to treat patients with community acquired pneumonia versus hospital acquired pneumonia. Assuming that this is a community, a community acquired pneumonia. Um The way that we treat this patient to Steve's antimicrobial guidelines that are based from the trust reason for that being is that usually the microbiologists have already determined the local resistance patterns for our uh particular areas. And that helps to determine um what kind of antibiotics usually work in that particular region. Uh And so that should be your first um you know, point of reference. And then after that, you can use kind of, um you know, uh the guidelines that we have to treat community acquired pneumonia versus hospital acquired pneumonia, second, oral versus IV antibiotic use. Um Yes, we can use the curb 65 square. But ultimately, you're going to be looking at the patient clinically to determine whether or not that this patient needs oral versus IV antibiotics. The patient is more, you know, poorly. Um He has a high fever, they're quite ticket nick. Um There immuno compromised, uh you know, all those things are gonna make me more likely to use an IV antibiotics versus an oral antibiotic versus someone who looks clinically quite well. Uh And the third thing is depending on the patient's history. You always want to do uh do two things. You want to do a respiratory swab to check if this is a viral exacerbation of, of a viral pneumonia essentially versus a bacterial one. And the second thing is to do a speed. Um because if the patient, for example, has a history of bronchiectases COPD and they, and they have been producing, you know, sputum in the past. Um they, and they have um organisms that are resistant to particular um antibiotics, even those present and antimicrobial guidelines at your trust, then you're going to be using that to guide your management with what antibiotics you want to give the patient essentially. Um I think that's it for this case. So just to quickly add to that, you could also consider doing a screen for atypical organisms like lead to another and stuff like that. Obviously, that would, it would also be guided by your history in terms of whether they, the typical MCQ is just, it's a business man who's just been away in a hotel, then he's become unwell. And just because legionnaires isn't the water droplets within a reckoned ish inning units. That's the, that's the typical MCQ. But um, just think about the fact that you can do urine culture for the specific antigens for legionnaire's as well and other atypical organisms. And also that um, the criteria for a hap is that a patient has to have been in hospital for 48 to 72 hours, usually more than 48 hours before you classify as a hap in order to guide your decision for whether you go for the guidance for hap organisms versus a capsule or a community acquired pneumonia. Exactly. Exactly. Um We shall go onto case number five. So now we have a 42 year old female. She presents to the G P this time she's had a dry cough for the past year. She's occasionally uh coughing up blood as well. It's associated with weight loss, fatigue, decreased appetite, history of frequent traveling abroad and significant smoking history. Um You know, what are some differential diagnoses that you might have for this particular patient if you were to see him. Uh, if you were to see him in, in, you know, the outpatient setting, what do you guys think? Oh, and there's no pool for this one. It's just kind of like a free, free type in the chat because honestly the, the differentials are kind of a bit endless. Lung cancer is great, lung malignancy, great. So two responses so far I can go back to the case. That way people can take a look and see if there's anything else they'd like to add. TB is an excellent one. Yes, of course, given this patient's, you know, frequent traveling abroad, um we don't know where she's been traveling. So that's definitely a very good differential and also she's coughing up blood and she has a dry cough. So all of those really fit in with the diagnosis. I think we'll keep going for the sake of time. But you guys got like basically the very big too. Um So some things that you should be considering in this patient. So, um of course, the big one that you don't want to miss is our lung cancer, right? So this patient has a smoking history, uh significant, um you know, weight loss, fatigue, um and a dry cough with hemoptysis. Uh these are all red flag symptoms and telltale signs that there might be a malignancy going on. Uh So definitely important to make sure that you do that with the travel history. Um TB is definitely something that you should be considering is this patient from also a TB endemic country, for example, uh that's something to note or, versus recent travel history, how they travel to a place that's recent, that's TB endemic. Um, uh, it could be COPD, hemoptysis is not really quite common with COPD, but this patient who has cough, this patient who has weight loss, um, you know, um, we don't know essentially so it could be COPD. Um HIV also presents this way, right? So, if you have someone who has weight loss fatigue, quite young, um, an IV drug user or, um, is, you know, sexually promiscuous, promiscuous, all those things, right? Can, can be, um, you know, telltale signs that this patient might have HIV. And it might be important to have that discussion with the patient and um consent them to having an HIV test viral load. All those things. And another very important differential is Wagner's granulomatosis also known as granulomatosis with polyangiitis. Uh, it's not no longer, uh, referred to as Wagner's because of his affiliation with Nazis. Um So, um some things that you might be looking for in this patient. So, um, are they having a piece taxus? Um, are they presenting with hemoptysis? Do we have um conjunctivitis? So, I symptoms you're looking for, um, uh, you know, uh blood in the urine. So you might do a urine dip as a sign of glomerulonephritis. Um, you can get nodules and purpura on the skin. So making sure that you're doing a full uh exam of the skin. Um and those are just some of the things that you might see for, for one of those patients'. And obviously there's way more differentials than this is just like a few that we could see with this patient. And so now that you've kind of gotten the history from this patient saying that, you know, lethargy, weight loss, uh fatigue, hemoptysis iss uh what do you want to do? What are some things that you would like to send this patient for uh to kind of help narrow down the diagnosis for this patient? What's the first thing that you want to do? I should say, and then what are some other things that you might also want to do? Chest X ray? Definitely chest X ray is uh probably the first thing that I would do for this patient. I'll give it a couple more seconds. Okay. So we've gotten the chest X ray for this patient and we see this. So the chest X ray here, we have, you know, a pretty dense uh consolidation or not consolidation but a dense some sort of um you know, lesion on the left hand side. Um that is quite suspicious for, for a malignancy. Uh And you know, if you spoke to any radiologist, I'm sure that they would kind of tell you to do an H R C T A high resolution CT of the lungs to kind of see and process like. Is this um is this something that you know, needs to be investigated further? Uh And if you were to see this in the G P setting, uh most likely at that point, then we would go down um what's called um the 14 day wait um pathway. But before I talk about that, let's just review spike. So let's say you see this chest X ray, you need to talk to this patient kind of tell them that they have lung cancer. So the way that we um deliver bad news is using something called spikes, it's a spikes framework. And so essentially what the stands for is starting off by setting up and starting. So um if you're doing this in person, making sure that you're in a quiet area, uh making sure that, you know, the patient is in a mental capacity, kind of to be able to speak with you, they're not really worrying about something else. Um If it's over the phone, making sure that, you know, they're in a, an area where they're able to talk freely and that they have time for because usually these phone calls take a bit of time, obviously, because you want to ensure patient understanding that you might go to p for perception. So, um it's always quite helpful to tell the patient what do you understand about what's been happening to you so far or what do you think it might be or, um, what's happened so far to kind of just do a review of all of her symptoms and all the investigations and everything that's happened so far to kind of just bring that patient up to speed. So that when you do, um, you know, break the bad news to them, they're kind of, they've had that summary and you've also had that summary as well as the clinician talking to them, then, um, you do an invitation. So ask them what they would like to know at this point is quite important to give something called a warning shot. So telling them something like, unfortunately, it's not the best news or, um, we did find something that was a bit worrying or I'm worried that we found something that's a bit worrying on, on the investigations that you've had. And by doing that you're preparing the patient that, uh, to know that, you know, something bad is coming and you're not kind of just telling them you have cancer type thing, which would not be appropriate at all. Um So that's kind of the invitation phase and then knowledge. So giving them, uh, the diagnosis and kind of the work up for their diagnosis in small, easy to understand pieces, uh, leaving room for them to be able to ask questions throughout the process. Um, and, um, basically giving them all the information that they basically would like to know than e being emotion, making sure that you're being uh that your empathizing with the patient at all times, making sure that you're giving them room to be able to kind of grieve if they, if they are grieving, uh same thing with a family member, if you're informing a family member, uh and then ask strategy and summary. So basically laying out what kind of the next steps might be for this patient. Uh and also asking them what, what they would like to see as part of the treatment plan. Are they wanting to go, for example, down the palliative route right away? If that's, if they don't have, you know, treatment options or are they someone who wants to go, you know, uh full throttle, uh you know, take everything that's available to them. So there's two basically pathways that you have to be aware of with someone has cancer. The first one being the 14 day pathway. Uh So sorry, we have a question breaking bad news is after obtaining the results of the biopsy or priming them prior to the histo pathological confirmation. So that honestly depends. So I would say, like, let's say you are suspicious that the patient might have cancer because the patient's come back to you with the chest X ray, you might, you know, give them a warning from them that, you know, it could be something like that. And that's why we're sending you to have these additional tests, right? Um Versus you know, if you do, do a biopsy down the line, uh and you, and do a histopathological confirmation, that would be you really confirming the diagnosis. But you're going to be having these conversations when you have, when right before you're sending them off for these investigations because the patient's gonna be wondering why are you sending me to do a CT scan? Right? Um So the 14 day pathway basically refers to, uh from the time the G P picks up the fact that you might have cancer too, you actually getting investigations then should take about 14 days. Usually that's a scan. So um and that's the urgent pathway that most people will do. Um And then from there, usually by day 28 any um labs you've done or any um scans you've done should be discussed with the patient by day 28 as per you know, the NHS pathway. We also have another one which is the 62 day wait target, which is basically saying from day one of G P referral to the time you receive treatment. If you have a confirmed diagnosis of cancer, it should be 61 days or 62 days rather. Um And so again, from day one to day 14, they should have their scan and if they're confirmed by day 14 to have this, uh uh and if they have their scan of day 14 and then from day 14 to day 28 confirmed to have cancer. Then by day 62 we want to hope that they have started their treatment if they're eligible for treatment. And um their case has already been discussed by the uh multidisciplinary team. I think we have two more cases. Um I'm going to try and speed through them because I know we're a bit over time. Um So 35 year old female presented to ambulatory care, referred from GP, she has unilateral lower limb, swelling up to the knee, uh reddening and tenderness of the cat. She's taking an oral contraceptive pill and the mother has a history of pe So what do you guys think is the most likely diagnosis in this particular case? Excellent. Okay. So we have a unanimous DVT. I think it was quite clear for the diagnosis and the history and sorry from the history and the and the risk factors. So, continuing on from this patient. So what can help us actually assess the risk of a patient actually having a DVT or a P? Oh yeah. So I'm seeing again a unanimous uh pull for wealth score. So just going through all these other ones. So well, score is in fact the correct answer. So the other ones are we have the T I M I score, which is thrombolysis and myocardial ischemia risk score, which is basically um the risk of mortality for patient's that have unstable angina or end stemi. So we can use the T I M I square, we have the pet Z score, which is uh pulmonary embolism severity index. So that basically tells us our mortality from patient's. You might have a P E. Uh Well, score that we've talked about before. Basically, uh what's the chance of them actually having a DVT or PE? And then our chad's last score, which we have discussed before, which is what we used to figure out whether or not we need to start a patient on anti coagulation. So um are well score. So the welsh score consists of basically making sure that the patient has clinical signs and symptoms of DVT. So in this particular patient, they had calf tenderness, um usually you might see one calf that is larger than the other. So you actually go and you measure around to see if there's, I think it's greater than three centimeter difference, correct me if I'm wrong. Uh Olivia between both calves. Um Also, um you're going to be looking for uh uh you know, if there's a pe to have shortness of breath, are they hypertensive, um Other things are gonna be looking for tachycardia. So greater than 100 BPM. Have they had a period of immobilization recently? Are they, do they have active malignancy? And are they being treated or have they been treated for it within the past six months? Do they have hemoptysis? Uh And do they have a history of prior DVT or pe So all those things uh basically pointing towards the diagnosis of a wealth score. And essentially the way to look at it is is that if you have more than four points greater than equal to four, usually uh pe is likely in this case. And um you, you could put this on the, on the request for the scans and usually radiologists are more likely to prioritize those scans versus uh those that have a lower wealth score. Uh And having your score also determines, you know, what kind of risk the patient is that. So if the patient has a greater and six, based on the welsh score, then that tells us that, you know, they're quite high risk. Um You know, if they have a DVT for it to move or for pe for them to deteriorate versus if they're less than six. The other thing that we can talk about is the pulmonary embolism severity index. And so you can, first of all, only use this for patient's greater than, or equal to 65 years of age. Um But essentially, it looks for um you know, looking at the BP, looking at the heart rate, looking at the patient's mental status. And also um if they have any history of heart failure or lung disease, and the combination of those things allows us to be able to predict the patient's mortality. So, um what we would do is let's say the patient is 70 years old. So they get 70 points for age and then you add these additional um criteria that we've mentioned before and that will give you a total score. And based on that, they get graded into a Pepsi class. So um anywhere between zero and 65 there, that low risk of mortality and then if and then obviously it goes progressively higher. So to usually being a class two, which is what I mean for the most part, I'm mostly some patient's at two or three, but you obviously can have higher. Usually, the mortality for those patients are between like 1.5 to like 3.5 ish percent. So nothing too crazy. But then as you go up higher, obviously, the mortality goes up much higher. And this allows us to predict the mortality within 30 days I should mention. Um And then we also have, so what is the pathway that we want to go through if we suspect that a patient has a DVT? So um if the patient has a well score of greater than or equal to two, then we need to for sure, do a proximal leg ultrasound. Um This one nice says that we should do it within four hours. Um If you can do that, that's great. But usually, um given the demand in the hospital is quite difficult to do. The other thing that you can do is do a D dimer, which can be a good um uh way to support your diagnosis, but it shouldn't be the main thing that guides your treatment. So if the patient is positive on their um lower leg ultrasound, then um you can diagnose with DVT and then start um considering anti coagulation. But if it's negative, uh then you and DVT is unlikely, then you want to stop giving them treatment dose delta parent, for example, uh and then things start to keep other diagnosis. So for example, uh like we showed in, in that first slide, it could be cellulitis, for example, um it could be a swelling due to um you know, uh poor valves, poor venous valves resulting in, you know, um phlebitis causing swelling of that leg. Um Those are basically the only ones that I can think of at the moment, but I'm sure there are more. Um and let's go to the next slide. So the other thing is the well score. So we use that for um pe right. So less than for uh it's unlikely to do the D dimer if D dimer is positive, like um then you can admit and commence anti coagulation. Uh In comparison, if pe is likely on the well score, then you want to go directly to CT P A. Uh And if that's positive, obviously commence anti coagulation. And if negative, uh the guidelines actually say to repeat an ultrasound in 6 to 8 days, another consideration you should have is let's say the patient is pregnant, for example, then you would not go for a CT PA and then you want to go for a VQ scan instead. Um And then with all of this, let's say you do diagnose the patient with the DVT or PE obviously, you're going to be starting them on anti coagulation. So you need to be thinking about the absolute and the relative contraindications to add a coagulation. So, uh if the patient has active bleeding, hemorrhagic stroke, um if they have, you know, gastric bleeding with peptic ulcers or self angel viruses, um if they've had recent surgery or trauma, then all these things might be contraindications to studying therapy and then you should actually um discuss with the senior, what kind of the next steps would be uh in this particular case? And we have our final case, which is we got an 18 year old female, she's been brought in by ambulance worsening, shortness of breath. She has louise, she's struggling to talk in full sentences past medical history of having asthma since childhood. Um she's been using her blue inhaler, but she doesn't feel like she's um feeling any better. Okay. So let's say you do an 80 assessment, which of the following features would make you concerned about life threatening features. So what of these four options? What, what things would make you the most concerned um in this particular case for this patient and make you want to run to call I T U. I see the answers are trickling in. We'll wait a few more, a few more seconds. So it seems to be, there's quite a bit of division on this, on this question. Um So okay, so we have a split between answer one, answer, three and four. So answer one. So inability to complete sentences in a single breath. That's definitely a sign of um severe asthma, but technically not one of the criteria for life threatening features. But it is something that one would consider. Um obviously as someone, you know, clinically being very unwell. Um when you're, when you're trying to diagnose the patient with life threatening asthma, a respiratory rate of 20 for it doesn't quite meet the criteria. It needs to be 25. I'm being quite cheeky with that, but it is with this um P A 02 of 8.5. So that's actually normal oxygen uh range. So I wouldn't actually be to quite too concerned with someone with a P 02 of of 8.5. And then finally, a P A C oh two of 5.2. So that's definitely something that's concerning because that would be a sign of fatigue. So essentially with someone who has as when they initially present, they're going to be hyperventilating. And so they're going to be pushing out that carbon dioxide. So we should expect them to have a low CO2. But if a patient comes in now and we do an A B G and we see that the CO2 is actually 5.2, then that tells me that they're actually starting to retain. So that would make me worry that the patient is starting to fatigue. Um And so that's when I would, you know, run to coli to you and see if they would be willing to come in. And so this is a lovely schematic provided by University Hospital Sussex uh about how to treat someone with life threatening asthma. So, first of course, do your A B C D E assessment. Uh And then what are the things you want to be looking forward to see if this is life threatening? So if it's like threatening, you're looking for exhaustion. So usually that's um exhibited by someone who um has, you know, x accessory muscle use in addition to that and you know, their, their, their respiratory rate is starting to drop before was quite high, but now it's starting to drop slowly. Um The P A CO2, as we mentioned would be normal. Uh We're looking for normal our oxygenation because we're having um less work of breathing uh or not less were competing. But because our respiratory rate is slowly starting to drop, we're seeing our oxygenation decrease as well. Our oxygen sats also dropping. Uh and our peak expiratory flow being less than 33 of our best or what was predicted. Um So what is going to be our management for these patient's? So, first of all, you want to make sure that most likely you're putting the patient as soon as they come on in 15 liters of oxygen, non rebreather mask. And then from there, we non lean the oxygen as the patient is able to tolerate. Uh you would start that patient on salbutamol. Usually you can start with if, if in the emergency setting, I would do 5 mg, uh nebulize salbutamol, but usually, if not an emergent setting, um you can get 2.5 and then increase it slowly because you're worried about, you know, patient's being tachycardic. Uh and, and that can result in, in uh other complications. Uh You can start ipratropium, so 500 micrograms as well. So you can alternate nebs between that and the salbutamol. And if the patient's really severe, um you can give them steroids, so you can give them um 100 mg of IV hydrocortisone or 40 mg of po steroids. But most likely they're not gonna be able to even uh take anything orally because they're too worried about breathing. So you're gonna be given um the IV hydrocortisone if they're not improving, uh you could consider giving them magnesium sulfate. Um You might consider giving them aminophyllin or theophylline. Uh And so you're going to be uh and if that's the case again, you're gonna be making sure that you're talking to your spirit your registrar, you're gonna be making sure that you're talking to I, to, you see what their management plan is and you're going to be, um, um, you know, handing over to them using what's called an SVR approach. You're also going to, um, order a portable chest X, right? Um, and have all that ready so that when you go to talk to the I T U, um, you know, red or consultant or whatever, you're, you're ready to tell them. So you're gonna tell them using the esper approaching and say my name is Bash. Oy, I am an F one. I'm calling to you about a patient that I've just seen in recess who is a known asthmatic came in with an oxygen saturation of um you know, 76% on room air. Now, on 15 liters, non reprieve, respiratory rate of um you know, let's say 40 um uh respiratory rate of 40 saturating. Um let's say now, 87% on um on 15 liters on reprieve. Here are the results of the A B G. Um I think the patient is having an acute exacerbation of asthma. Um I don't think it's going to be sustainable for us to keep them on the non rebreather mask. Would you be willing to reassess and consider the patient, for example, for I T U uh admission or for optic flow in the H D U setting or whatever would be and then see what they're plan would be uh and if there's anything additional that, oh and you also tell them about your treatment plans, for example, I've given this patient back to back nebs um and start giving them hydrocortisone. And I'm considering starting, for example, and magnesium infusion. Um Is there anything else that you'd like me to add or anything you'd like me to start or anything you'd like me to prepare before you come in? Um And I think, let's see. Oh, so that is in the emergent setting. So let's say we don't see this patient in the emergent setting. You just had a patient with chronic asthma, they've come into you in the G P, what is going to be your, your treatment? So um there are two basically main thing or two main guidelines. We have the British Thoracic Society and we have the um nice guidelines. Um There are basically the same tree, basically the same ladder. The only difference being is that with um nice guidelines, they introduced the liquid try and receptor antagonists or like our Montelukast. So those are introduced before we start a long acting Beta agonist, like our full metro. Um And comparison to um are British Thoracic Society which starts a long acting beta agonist first before starting or leukotriene receptor antagonist. And just because this one is clearer, I'll use the nice guidelines. One. So first you're gonna start with a short acting beta agonist. So our salbutamol are blue inhalers, then you might start with an inhaled corticosteroid in addition to our cell beautiful, inherited a step to the things that are going to be guiding our management are nighttime awakenings. How frequently are we using those cell? Beautiful inhalers. How often are you having attacks? Is that only with eggs, for example, is only with um exercise or does it happen at rest? Um Is it um around, for example, allergy season? are there specific triggers or is there something else and all these things or what guide our management and what are going to allow us to basically increase step by step up the um uh up the ladder for chronic asthma uh management. So these are my references. Um And I think that's it actually. Um Are there any questions, first of all, are there any questions about the case or any of the cases that we've had so far? Um If so, please feel free to put them in the chat? And number two, uh I do, I would like to advertise our talk for next week. So we're going to be continuing with more internal medicine cases um that hopefully will be next Saturday at 2 p.m. and vacations here. So I'll leave the floor with him. So if you enjoyed that and if you thought you benefited from that, then please sign up for our next talk next week at the same time and, and for the case for the sake of our presenters today. If you wouldn't mind, please complete a feedback form which would be helpful for them. And I'll just send that out into the polls. Now, if you have any more questions at this point, uh, feel free to pop them into the chat. And lastly, thank you very much Fish Oy and Olivia for doing that teaching today. And so there was one question about the timing of breaking bad news. I'm not sure if you saw that one. So the question was, I can't see him much just yet. But when exactly would you break bad news, would it be before you got his top of uh pathological confirmation of the diagnosis or would it be uh after this? Uh So I think I answered, but essentially the way that would work is that you would um as soon as you suspect it as the clinician, it might be quite beneficial to let the patient know why you're sending them for the tests and all these things. So that would be the point most likely where you would break the bad news. If you do get confirmation, then you can absolutely tell the patient that you have lung cancer, etcetera and then, you know, go down the pathway that way. Um But the most important thing is to make sure that the patient is included in every step of the way. Um If it's not, obviously, if after you do the scans and the histopathology shows that you don't have it, then you're giving good news and you don't have to worry about it. But then if, if the histopathology does, in fact, confirm it, then you'll be having another one of those spikes conversations. So it's not something that you have only one time throughout this process, but something that you're going to be doing multiple times. Okay. And I can't see any further questions. So I think we can call it that.