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Okay. I think we'll get started. So I just want to say hi, everyone. Thanks for joining again. Um This I MG Tuk webinar, we're going to be focusing on some important clinical concept with an internal medicine to help prepare you for the plaid exams and for UK Clinical Practice. This series is hosted by the Widening Participation Medics Network, which is a national charitable organization that aims to make the medical workforce of the UK more representative of the population that we serve. And the series is also sponsored by the Medical Protection Society, which is a leading medical indemnity provider that offers services specifically tailored to international medical graduates. Uh working in the UK. Today, the stock will be hosted by me. My name's Joshua. I am a F one soon to be F two trainee in the east of England with a special interest in internal and renal medicine. Um Before we get started, I just want to remind everyone that if you have any questions at any want at any point, uh Please ask them in the chat and at the end of today's session, we're going to be sending out some feedback forms for the teachers today being myself and would really appreciate if you complete these, please help us um improve future teaching sessions. And at the same time, we get to see where you guys are from and help to deliver content that way. Without further a do I think we shall get started? So the topics that we're going to be covering today, as always, we're going to be discussing some common presenting complaints. Using the nice guidelines will be talking about the components of a volume assessment, the resuscitation Council UK guidelines for Infl Axis Melanoma criteria and the stop AKI guidelines. So we'll start with our case one. It's a 60 year old female. She has a past medical history of osteoarthritis. She's managing pain with Ibuprofen, admitted to the hospital for a community acquired pneumonia. She's been relatively stable. She's responding to IV antibiotic therapy. Her CRP is coming down. White cell count is coming down but two days into the admission you get bleeped as the patient has a low BP of about 88/60 for looking at the news chart, you notice that has been slowly dropping over the past 24 hours and so we'll put up our first pole. So what should you do to first manage this patient? Would you give a 500 ml bullous encourage po intake if the patient is dry and able to have oral fluids perform a volume status exam, medication review or if the obs are stable, ask the nurse to repeat them in an hour. I'll just wait for those answers to slowly trickle in on the pool. What do you guys think? I see the answers are slowly starting to trickle in. Okay. So we have an interesting split actually, for this answer, most people answer to give a 500 ml bolus a fluid stat and the rest of you guys said to perform a volume status exam. Now, I think those two are obviously very reasonable things to do in a patient who has low BP seems to be coming down. But that being said, um when we do decide to give fluid to a patient, one of the most important things that we have to do first is to do our full assessment of them. So, a BCDE first and then um possibly do a volume assessment reason for that being is that we don't even know if, if we do give fluids, whether this patient is going to be fluid responsive. And if we look at the question, we see that she's been receiving fluids for the, for the most part and she hasn't really been responding but still coming down. So, um while giving the fluid bolus might be appropriate, it might not be appropriate in this particular case before having done a volume status exam on this patient where we might meet where we might uncover something that's a bit more alarming. So let's get started. What are the components of a volume status assessment? So um first of all, the thing that we have to remember is the classification. So there's three classes that we should be expecting to see in the patient. It will be either hypovolemic, euvolemic or hyperkalemic. And what we want to see in these patient's is a few things. So if they're hypothalamic, then um we're expecting these people to be quite clinically dry. Um Think of our dementia patient's that are not eating or drinking, think of our patient's who might be in too much pain, so they decide not to eat or drink. Um uh You could also think of are anemic patient's who are not um eating and drinking appropriately. Euvolemic patient's are most of our patients that we see on the day to day and our hyperkalemic patient's being our fluid overload. Patient's. So heart failure patients', um patient's with society's patient's with uh edema up to the level, the sake from all these things, right? So the volume status assessment is quite important to assess what the volume status obviously is of the patient's. Um And that kind of helps the guide our management and see where, what class we need to classify them into and then see what the differentials are for that particular class. So the first thing like with all exams is you're going to start by inspecting the patient. So what are you going to be looking for? So first thing we might look for is for cyanosis, right? And so this can be secondary to inadequate oxygenation and poor circulation. So that's this what we see in this top picture on the left here with the blue fingers. So is the patient having um poor circulation. So, evasive constriction, secondary to hypovolemia. This is an extreme case, but something that we need to look for clinical signs wise to, we might look for pallor in the eye. So look for signs of anemia or poor profusion. If someone is um hyperkalemic, for example, uh it's not going to be reaching areas that are not vital. And so, one of the first places that you want to look for is the mucous membranes. So that's going to be under the eyelid of your eye and underneath the tongue, they're going to be the two places where you're going to be looking for power. Third thing is you might look for mallard flush. So mallory flesh can be a sign of a um can be a sign of heart uh not adequately pumping appropriately. So I believe that can be seen with an aortic regurg and mitral regurg. So that causes metro flush, uh sorry mel our flesh rather, um you're gonna be looking for patient's with shortness of breath. So in this picture, in the bottom right corner here we see this patient has um accessory muscle use, right. So his scaliness coming out his sternocleidomastoid is coming out um, and we see that he's using that to help him breathe. If someone has, uh, you know, fluid overload and they're not, not able to keep up with the huffing and puffing. Right. They're going to start using their accessory muscle and that's going to tell us that they might be approaching respiratory failure. So it's something that we have to look for. And the last thing we might expect, uh inspect for is edema. So what are we looking for? We're looking for obvious signs of fluid overload that could be in the legs. It can go up to the level of the sacrum. So it's really important to check around, in and around the sacrum. You want to check the abdomen if it is distended. Um Is there a fluid, is the fluid in that is they're shifting dullness in the abdomen continuing on for our volume status assessment? What else are you wanting to look for? Temperature is really important to comment on because if you have patient has warm hands again, this indicates that the patient is adequate perfused versus if they have cold hands were expecting the patient to be cyanotic and will be a sign of poor profusion. Second thing being capillary refill time. So, what you're going to do normally is you take the um your finger and you press up the nail bed and you hold it down for at least six seconds and then you let go and then normally what should happen is is that the color should come back to the nail bed if it comes back in less than two seconds, and then this indicates an appropriate capillary refill time. If it's greater than that tells us that profusion might not be as appropriate as it should be. And it would be really important to assess central capillary refill time. How do we assess that? We usually press right above the sternum and we again, hold it down for six seconds and then we release and we look for that change in color. And hopefully, if you do have that change in color appropriately, less than two seconds, then we know that the capillary refill time is appropriate. Okay. The next thing that we look for is something called skin turgor. So if you have your hand like this, sorry, I know my hand is not appearing the biggest on the screen, but let's say we do this and then you pinch uh the skin right. Normally with, with your skin, as you can see with mine, it comes completely down almost straight away because it's quite hydrate. It's hydrated appropriately and the elastin in the skin would come down appropriately if someone is dehydrated. Um And you might have seen this in yourself sometimes when you don't drink water all day uh in your, in your current practices. But what happens is that when you pinch instead of it going back down is when you hold it, um it would stay there, it would remain there. And that would be uh kind of a sign that the patient is dehydrated. And that's because again, it will take longer to spring back in comparison to our well hydrated skin. Um So the next thing we want to do is assess pulse, right? So people who are um euvolemic. So for, for example, if a patient is bleeding, for example, so they would have a poor volume status. Um and their pulse would be kind of weak and threading versus someone who might have a bounding pulse um or a strong pulse. Uh The next thing of course, we're going to check is our BP. Um Is the patient hyper versus hypertensive, do they have a narrow versus wide pulse pressure to remember, pulse pressure is calculation of taking your systolic minus diastolic. Um And if it is below a certain threshold, er above a certain threshold, then that could tell us that the patient is either evil in a hypovolemic or hypokalemic. Um You want to look at the difference between arms. Why is that important? I hope you're thinking of the aortic dissection. So, um let's see, you have a difference between the left arm and the right arm and the patient is hypertensive. Then you should be thinking, hey, does this patient have an aortic dissection or something else that could be causing this patient to have a difference between arms? That is significant of course, it has to be, I believe at least 20 millimeters of mercury difference between the both in order for it to be considered a significant difference. And the last thing you might check for is someone having a postural drop, right? So, uh when you stand up, uh I mean, sorry. So how to be assessed for a postural drop? We get the patient to lie down, take the BP, get them to sit up, take the BP after a certain amount of time, then we get them to stand up. And then we see is there a difference? And if there's more than a 20 systolic or more than a 10 diastolic, then you should be considering a postural drop. And then finally you want to check for JVP. So you're going to get the patient to turn to the left or turn to the right and you're gonna be looking just here, uh looking to see to what level the jugular venous pressure is elevated. If a patient is in hypervolemia secondary, for example, too, right heart failure, we're going to see that uh JVP rides. Um and you can even see it go to the level of the ear. Um something that's really important is sometimes you might not be able to, to see it right away. And so you could, uh what I like to do is check the right side and by and by doing that, you can press on the liver. And by doing that, you're able to kind of extend the, the jugular vein and see it that way. Um If you can't see it initially, and then if you remove that pressure from the liver and you don't see that it is elevated, then that tells you, then most likely the JVP is not elevated at baseline. Continuing on. The last thing is I want you to make sure that you're checking for where the fluid is hiding. So there are four main areas that you need to check for eyes. First of all are the eyes sunken. So patient's with sunken eyes as seen in this picture would be indicative of a patient in severe hypovolemia. So you need to be considering um you know, causes of that second, you want to check the abdomen. So in this patient, um they, it appears that he has quite a distended abdomen. In this case, in this particular case, he's acidic. So you want to check for shifting dullness, you want to check for edema in the abdomen because fluid can pool there and the patient could still be hypovolemic or in a hyper bulimic state depending on what the patient looks like. Third, I've put in the chest x ray of fluid overload, so definitely don't forget to auscultate the lungs. See is there crackling fine crackles bilaterally that would be indicative of a patient in in heart failure. Um and um fluid overload and you would need to assess them that way. And then finally, a place that we normally do forget to check is yes, you check the legs for edema, but also don't forget to check the sacrum. And that's um uh indicative again, severe hypervolemia, severe fluid overload. Um And you're going to be looking for that pen a good um a at the level of the sacrum. So the last important thing that should be considering as part of your assessment, but also as part of your final plan for a patient that you need to assess your volume status for it is still one check your vital signs, vital signs are important. We've already talked about them before but our heart rate or is it thready versus is it bounding BP, hypo versus hyper uh attention looking for our pulse pressures, temperature to assess for our level of perfusion if it's adequate warm versus cold is the patient cyanotic um respiratory rate being a sign of uh fluid overload in some cases if it's extremely high. Um And um so that's what we're going to be looking for. Second thing you want to make sure it's part of your plan is fluid balance. So you want to check your in's and out's for the patient. Is the patient adequately in taking what they need to? And um are they producing urine? Um A patient to, for example, is in severe AKI AKI stage three hasn't produced urine in six hours. Uh that patient will be probably severely dehydrated. Um, and, um, you need to, you know, make sure that the patient is receiving fluids uh, adequately enough for them to be able to produce urine. And then if they're not, then you want to check and see what's up. Right. Um, third thing that you want to check for is daily weights and that's going to be really important for our fluid overload. Patient's so consider patient's uh severe heart failure. Um And you're giving them daily Lasix, something that's going to be really important is to check their daily weights and see the progression of them coming down because obviously fluid weighs and the more that they're peeing it out less their weight is going to be. And then that should be a sign for you to see that your treatment is, in fact working. Um something else that's really important is to do a stool chart. So if a patient is having severe diarrhea, for example, they have clostridium difficile and they're producing a lot of, of diarrhea, these patient's are going to also be severely hydrated. So if, if the patient's clinical presentation presents this way, it'll be really important to do a stool chart and note the frequency and the type of the bowel movements. So if you're having type six and sevens all the time, then this patient's going to be severely hydrated and not only that they're also going to have um some electrolyte imbalances So you're gonna want to um replace those as well. The next thing is to check your medication chart. So for example, is the patient on the calcium channel blocker, we know calcium channel blockers uh cause um edema. So is that the cause for their edema? Is that the cost for their fluid overload? It's a rare cause but something to consider, are they receiving Lasix, for example, furosemide? And um is that causing them to be more dehydrated or, or not? Right? Uh Checking your fluid prescription charges also very, very important because has the patient been receiving um parenteral fluids through the vein or are they receiving adequate oral fluids? And that's something that would be on your fluid balance chart that you would see in the hospitals. And then finally, something that's also really important in surgical documentation is this patient post operatively. So if this patient is a POSTOP patient and you're taking care of them or you're going to see them, is this patient bleeding out? Should be your main concern in a patient with the volume assessment, right? Um So let's go to this patient. So this patient's um volume assessment reveals the following um patient mucous membranes, they're quite pale. Um And the patient overall looks quite pale. She's been having fluids, but this really hasn't been helping her BP to go up and she's quite far from baseline, let's say her baseline was 1 20. It's now gone to 88. So we do see that there's a decline on arrival. You see that she's had two episodes of vomiting. Um, and her vomiting looks like this. So, does anyone know what this presentation is? What I'm seeing? What we're seeing in this picture here? Anyone have any guesses. If you do, please feel free to write it in the chat and I'll just give it a moment while I wait uh, to see if there's any responses. That's all right. It's a tough one. I I honestly haven't seen this in real life until I got into hospital. But this what you're seeing here is an example of coffee ground, eh missus. So um if you see that you should be really um worried about an upper gi bleed and you should be contacting a senior immediately to kind of see what uh is going on after you've completed your assessment and you make sure that the patient is stable, right? So this patient is having an upper gi bleed. So what are the important things that we need to do for this particular patient? First of all, we're doing our initial assessment. So as always A BCDE and as part of the A BCDE, we're going to have to do a um volume assessment. Okay. So we want to check and see are the human dynamically stable and do they have any signs of hematochezia or hemodialysis? So we have coffee ground emphasis. So that's in our example of hematemesis in this case. But we also what would be really important is to do a pure examine this patient who uh might be having blood in the stool as well. Uh Initially, BP can remain normal in these patient's. But if we see that, for example, they're having tachycardia, then that should kind of peak are, are, are kind of alert signs, our radar and say, hey, something's not really right here. Um And so if they're unstable, if there's any airway compromise, if they're really hypoxic or we've seen reduced level of consciousness, then you should be ready to do an S part to the ITU as per the BMJ. And then you have to start the initial resuscitation plan. So what are some things that you need to do? You want to give two large bore IV S you want, even though um you know, she's not responsive to fluid, it would be very important to make sure that she is still quite hydrated. So you'll start those fluid bolus is ASAP, you'll put in a urinary catheter um as well just to make sure that you're measuring their uh fluid balance. And then very important is you might start something called the Hong Kong Protocol. Hong Kong protocol is a continuous infusion of IV omeprazole that usually happens over 72 hours. Um And that's going to be protective for the lining of the stomach and it's really important to help in the in the case of uh upper gi bleed, okay. In parallel to this, we want to make sure that we're obtaining medical history if the patient is conscious and you want to send out a set of blood. So what kind of bloods do you want to send out for? You want to send, of course, a full blood count. You want to check this patient's hemoglobin has it dropped recently and we haven't picked it up or is there a sudden drop? Um I want to check our um coag screen, make sure that uh you know, there's not something going on that I'm missing on the as part of the coagulation panel. Uh I might do a group and save just in case that this patient needs to get an urgent um blood transfusion and um you might as well send off uh some syrupy and using these as well. And you want to do a VBG or an A BG to check the patient's lack dates because lactate can be a very important sign for an upper gi bleed carry on. So you've done that initial management, right? So now we have to use something called the Glasgow Blatchford scale to be able to um risk stratify these patient's. So um you'll fall into uh you want to check for these four categories, essentially, first of all systolic BP, secondary there urea. So basically anything above um above eight, gives you a score of three. you want to check for the hemoglobin, uh hemoglobin of less than 100 is going to give you full 0.6. And then you also want to check for pulse and then um whether they have co morbidities that are associated with um upper gi bleeding. And so uh you'll get a total score based on this. So I think the maximum total score you can get is um 99 and 15, 15, 16, 17. I think you get a score of 23 according to this, but I might be wrong. Uh And so basically, if there's 0 to 1, there are low risk of, of um death and these patient's can be measured in the outpatient setting. Don't need to keep them in the hospital. Uh And you can continue treatment as normal to um if they're five or over, then they have an increased risk of of 30 day mortality. And if they have the risk uh score of seven or over, then these patient's need to be referred to for an OGD. So as we said before, 0 to 1 early discharge, uh and I should mention that this um Glasgow Blatchford scale is actually uh usually more important on initial presentation than when a patient is in hospital. When a patient is already in hospital. Sometimes the people report that there's kind of um you know, blurred lines when it comes to these cases. So this is really important for when a patient is actually initially presenting rather than when they're already in hospital. Uh and then based on their hemodynamic status, we might decide uh you know, whether or not they, they should go for an OGD and get embolized, for example, or whether they need a surgery if they're not able to hemo uh to have successful homeostasis. Okay. So that was our case one. So important to remember the components of our volume assessment. You want to check for inspection, you want to check your vital signs and you need to consider where are the areas that fluid can hide? And also um the components of the plan being, our fluid charts are in's and outs are daily. Weights are urinary catheter, things like that as part of the plan from um monitoring the patient's fluid status depending on what the presenting complaint is okay. Uh We are now on case to. So now we have a 70 to a 70 year old meal. He's been admitted following three days of a short of shortness of breath. He has a productive cough, respiratory rate 24 with a saturation of 92% on room air. Um The target sats are 94 to 98. The chest X ray shows a left lower lobe of classification. Urea is 9.1 and the BP is 96/58. So I'm gonna put up a poll now. So. Oh, sorry, wrong Paul. Give me a moment. So based on this patient's presentation. What is the most appropriate therapy? Okay. And I will put up the uh question while you guys answer that. OK, remember we've done this, uh I know it's been a few weeks, but I want you guys to remember the criteria that we use and then go from there. OK? The criteria that we use for um, a patient who is coming in with what appears to be and pneumonia. So based on the patient's Timoney, a what do you think would be the most appropriate antibiotic regimen? I see the answers are slowly trickling in. Okay, let's go to our guidelines. So remember the thing that guides our management for patient's who have um a community acquired pneumonia or any pneumonia is that we need to do a curb 65 square Hope you guys remember that from my previous talk. So the things that we're going to be looking for our confusion, this this patient does not have confusion because we didn't mention it. Uh mention it. We want to look for a urea of more than seven which this patient did. It was nine. So that gives him a score of one. Um We want to look for a respirator of more than 30. Really? This patient's respirator was 20 for so doesn't score there. We're going to look for um a BP of less than 90 systolic or less than 60 diastolic and this patient's does. So again, that's a point there and we get a point for if the patient is above 65. So this particular patient um has a curb score of three. Okay. So for Syria, for his BP and for being over the age of 65. And so because of this, this puts him the high severity um and the high severity uh category. And so he needs to be treated in hospital. And usually this involves the use of IV antibiotics as opposed to just oral antibiotics. So for this particular answer, the answer would have been IV colon marks. And the reason why we also use oral clarithromycin is we use it to cover our atypical um antigens. Okay. And so just to review hospital guidelines, uh the hospital guidelines will have a um antibiotic regimen microbiology regimen that they use based on uh local um resistance patterns. So that will be the thing that ultimately guides your treatment. But if that is not available, then the thing that you should be looking for is these guidelines here. So 0 to 1, low severity, 0 to 1 on the curb score. Um If they're otherwise fine, then you would tell, tell them to go home and give them some oral Comox. Even in the hospital, you might give them oral Comox, but then just measure uh what's called, uh make sure you're looking at uh their jobs and, and they're stable in that way or you might keep them for observation for 24 hours if for example, there um having poor respiratory or oxygenation, um uh like poor respiration or oxygenation. So you could have a score of two, which would be moderate severity. Again, you do amoxicillin and clarity, usually this would be oral and then you would order some microbiology testing. So that would be um a respiratory things like a respiratory PCR, it would be uh speed of culture if the patient is productive, sputum, uh you might look for atypical. So you might send off a urine legionella and pneumococcus. Um And of course, in, in our day and age now, we're definitely sending a COVID test to make sure that they're not flu uh COVID positive, right? Um So now we know what's going on with this patient. So the patient's been admitted, you've started your IV Comex, they're feeling all great, nice and well. And what happens is the patient starts wheezing and itching. You notice that the respiratory rate has gone up to 30 the SATS are now 90% on two leaders. He's hypertensive, 74/40 heart rate, 55 and the temperature is 36.5. So after having been given this medication and this happened, what is the thing that you're going to be thinking of immediately? Does anyone have any ideas feel free to read it in the chat? We'll wait a few more seconds for going to the next slide and revealing the answer yeah, shocked any idea. What kind of shock are we talking about? Journal? That's excellent answer. So this patient's just received antibiotics, uh IV antibiotics and now it's gone into shock. So, what should you be thinking of? So, yeah, septic shock is definitely a very good answer. So the two things that you want to be looking for is septic shock or. So now you look at this patient's on exam, the patient has a wheeze. You notice him, tongue and lip swelling, he has some increased work of breathing and he has some hives on his trunk. So now hopefully that kind of gears your thought process into something else. What else do you think it could be anaphylaxis? Excellent, excellent Selena. Yes. So this the, I hope the first thing that you're thinking of is anaphylaxis and good job general as well. So this patient now, so let's look at the criteria. This is um from pretty sure the American. Yes, this is the American Academy of allergy asthma and immunology um just using their schematic, but it's the same thing for looking at the uh the criteria for being diagnosed with anaphylaxis. So, um you need to have at least one of the following three criteria. So you need to have a sudden onset of an illness. It could be minutes to several hours with involvement of the skin mucosal tissue or both. So generalized hives, itching or flushing, swollen lips, uh hunger uvula, which we already do see in this patient, sudden respiratory symptoms. So, a sudden shortness of breath stride or being very important because it indicates to us that there's narrowing of the airways and we need to be calling an anesthetist immediately to make sure that um we can secure this patient's airway. Uh And then um if the patient has a sudden reduction in the BP, um or collapse, right? So, could appear as hypotonia, for example. Uh and this could be symptoms of end organ dysfunction. The second thing we might look for is you want to look for two or more of the following happening after the exposure of a likely allergen. So we've this guy has just been exposed to IV Comox. So did this patient have sudden skin or mucosil symptoms? Yes. Did they have sudden respiratory symptoms and signs? Yes, sudden reduction of BP? Yes. The other thing that you might look for and some people also usually forget about anaphylaxis is that sometimes you can have sudden gastrointestinal symptoms. So these patients usually present with really crampy abdominal pain that might present with vomiting and some patient even present with diarrhea. That's not saying that patient's to all patients who get uh antibiotics IV that get diarrhea have anaphylaxis, but it is one of the signs that you should be looking out for. And the third thing you want to look for is a reduction in blood pressure after a known allergen. So, for infants and Children. That's a low systolic BP of greater than 30% from their initial systolic BP. And uh in adults, it's a BP of less than 90 or again, a drop of more than 30% decrease from the patient's baseline. Okay. So what things that should uh guide, what are the things that should guide our treatment? And so the thing that would guide our treatment is uh usually we have something called the Recess Council. So this would be part of your advanced life support training. And so in any patient with anaphylaxis or that you're suspecting to have anaphylaxis like with all um like with all patient's the thing that you want to start off with is to do an A BCDE assessment. Okay. So what are the things that you're looking for in a air way? You want to check that the patient's airway is patent? Are they able to talk to you or is they're strider? You know, if that's the case again, I'm calling the in statist right away, right? Be breathing. Do they have a sudden onset of increased shortness of breath? Um Oh, I've lost, you know, you guys are back. Yeah. So do they have a sudden onset of shortness of breath? Uh increased respiratory rate, increased work of breathing again? I'm calling the anesthetist, see, for circulation. Are they the heart rate going down? Uh BP, is it going down? Uh D disability usually, I don't think there's really that much that you can look for in a patient who has, um, um, anaphylaxis. But something that you might be looking for in this thing is that, are there any lines running? And if so, what are the things that are running? Right. So, if I see that there's some IV Comex running and the patient is having this, I'm hopefully removing that, that drip right away. Right. Um And then e exposure, I'm looking for hives, I'm looking for other me coastal's signs that we've already mentioned. Uh that could, that could be associated with the patient's anaphylaxis. Okay. Definitely going to call for help. And then the only thing that you should be thinking of is adrenaline, adrenaline, adrenaline. You want to get that adrenaline I am in stat. Um And obviously that's going to be dose dependent depending on um, how old the patient is. And I'm going to be giving this patient oxygen. Uh, if the, if adrenaline is not available immediately, but there is a drug chart available, then I might be giving some chlorpheniramine in the interim until I can get that adrenaline from the crash trolley. Um It might also be important to get this patient on continuous wandering. So check the patient's um, sats check the patient's BP. Uh And of course, doing an ECG and of course putting oxygen on the patient if I haven't mentioned that already. So, uh there are some life threatening things that you should be looking for. Strider being of course the most important um looking for if the O2 saturations are less than 92 is there a change in gcs? Is the patient starting to become cool clammy signs of shock? Then of course, I'm administering that adrenaline which will be 500 micrograms. I am in a patient to uh and most adult patient's and then obviously less, the doses are a bit less depending on what the agent. So actually even 12 to 17, you're giving that same dose, but if it's less than that, then you give the pediatric doses. And the other thing is you want to make sure you this patient is in shock. This patient has a little BP, you are replacing that fluid, right? And usually you want to give a crystalloid solution. So you're Hartman's or normal saline, you're not giving something from a colloid in nature, okay. Uh So that is really our anaphylaxis assessment. So things are going to be looking out for in a patient with anaphylaxis, you're going to look for those bicoastal science. You're going to be looking for signs of shock, you're looking for life threatening issues. So is there swelling? Is there hoarseness? Is they're strider, is there a sudden increase in shortness of breath? Is there a sudden d saturation? Is there a drop in GCS score? Is the patient looking like they're being shut down perfectly? Are they pale, cool clammy. Are they having a little BP? All these things should raise alarm bells in your mind that this patient is an anaphylaxis. I need to give some, I am adrenaline and go from there. Uh Let's go to case three now. So we have a 55 year old female. Uh, she lived in Egypt during her childhood. She calls your outpatient clinic because there's a mole on her back that her husband feels has gotten a bit bigger recently and she denies any discomfort or associated changes. Um And so I'm gonna put up the pool. Now. What is the most appropriate step in the management of this patient now? Okay. Is it one you agree with her that since she's asymptomatic, no further management needs to be done for this patient to ask her to send a picture of it through secure encrypted email. Uh If this is available at the practice three, ask her to come into the office as soon as possible and to perform a biopsy, four, refer to dermatology and five referred to a private practice to get it sorted. So what are the, what do you think is the most appropriate management for this patient? I know there's a lot of writing here. So I'll give you some time to read the question now. So remember, um you're not in the hospital for this particular um question, but you're actually in an outpatient setting. I don't know if that will change your answer for this. So we have quite a split on this question. It's looking like so far. So it seems to be a split between 23 and four. So to answer this question, I think two and three are actually quite appropriate. So if the patient, so if the practice does in fact have a um secure encrypted email, it might be actually quite beneficial for you to ask the patient to send the images through um that encrypted email or whatever the practice has, they might have their own secure, you know, web mail that you can send images too. Uh And if they do, then they can send you the pictures and you can actually just reassure them over the phone, but it will definitely be very important to bring that patient in and see whether or not the patient needs a biopsy. Um And um it's as part of the plaid exam is that almost never, would you refer uh something that you can start at least start management line? So obviously referring to dermatology might be something that you might need to do down the line. But you as a as enough to should still be able to diagnose Melanoma and get started with the initial uh management plan before referring and refer to private practice will not be an answer on the uh will not be an answer on uh the uh lab exam or any other exam. You should be able to manage it within the NHS. So you get an encrypted image and it looks like this. So this is the mole that is in question and it looks like it is um getting larger as per the patient's husband. Okay. So I want you to keep this image in your mind. So I hope by looking at that you're, you're really suspecting that this patient has Melanoma. And so you're going to be going through the A bcdes of Melanoma. So you're gonna be looking for a, is it asymmetrical is one half similar? Unlike the other be, does it have a distinct border or their areas that are poorly defined? See you're gonna looking for color? Is there an uneven distribution? Is it different colors that you're noticing uh d being diameter more than six millimeters if it's wider than uh the width of a pencil erasure as per uh you know, Melanoma UK. And then finally, evolution has there been a change in size shape or color? So let's go back to this image and go through our A bcdes. So a asymmetrical. Is this a symmetrical lesion? No, it's not, right. So we're just looking at it and we see that, you know, right side looks different to the left side, the house don't look the same be we're looking for borders, there's no really distinct border that we can see here like an actual mole, right? We see that um and it looks like it's still spreading, see color, we see that there's different kinds of colors. In some cases, you might see areas that are a bit green somewhere is a bit darker, a bit lighter. Um You can look for those pearly things and patient's who have, you know, scream a cell, um skin cancer as well. So all those things should be at the back of your mind di diameter. So for this one, it definitely looks like it's wider than six millimeters, right? Uh And e is for, excuse me, uh basically everything else has it evolved. So we know that there's been a change in size um and a change in the shape of this, of this mole. And so all these things should kind of again raise the alarm bells for Melanoma. So what are we going to do? So if the practice is equipped with this, then you're gonna be doing something called dramatic scope. So dramatic scope basically means it's basically highly specialized magnifying glass that are now available at most GPS. And of course, at all dermatologists and it can magnify the lesion's up to 10 times and they look through these dramatic scopes and you're gonna be looking for what the lesion's look like. And so these are examples of what you might see under the dramatic scope. It's not uh you know, you're not looking at them at a microscopic level, you would be looking at the macroscopically, but this is to help you assess again, borders a symmetry color, uh things that you might not be able to easily appreciate um you know, just at the regular with your regular vision. So after you do this, and you suspect that the patient has what you think is a Melanoma, I hope that you are thinking of doing a biopsy. And so the thing that we, that we check for is something called breast low thickness. And based on the patient's Breslow thickness, then we're able to decide basically whether and should these, should the biopsy be positive? We're able to figure out what their survival rates are. So you're going to be doing a full thickness biopsy, it looks like a tiny ring, but it's quite sharp, it goes through the skin like. So wherever the melanoma might be, and you're gonna be going all the way to the level of the subcutaneous fat when you go to do the biopsy and based on the thickness. So, is it limited to the epidermis, dermis or subcutaneous fat? Based on this, you will decide your wider excision margin? So how far out you're going to be um uh removing this lesion? And you can also decide how long a patient uh is likely to survive afterwards. So if it's in the early stages, it's just limited to the epidermis, then you have up to a 90 to 95% survival, which is quite good. Um Versus someone who has a full thickness. Um Brussel thickness, it's more than four millimeters. It goes to the level of the subcutaneous fat where actually it decreases your survival rate to 45 to 65%. So, it's really important to get these numbers early to, to detect early, ask questions, to be checking very consistently and going from there, right. So what is the management for these patient's? What are you going to be counseling these patient's? So, first of all, you're gonna tell them that you're going to do a biopsy and you're gonna be checking for the thickness and based on that, you're gonna be able to know how far wide we need to do it. So the management of Melanoma is quite simple, you see it, you cut it out so wide, local excision is the way that we do that and how far out we do it is based on the stage. So, um if they are staged as stage zero, you'll do at least half a centimeter um out from where the lesion is versus if they're stage two, you need to go a bit wider, you go two centimeters. Um if the patient has a breast, low thickness of more than 0.8 millimeters, so let's go back. So usually that means if it is beyond the level of the epidermis, so if it goes to the level of the dermis, uh then you are for sure doing something called a sentinel lymph node biopsy. Okay. As well as doing the wide local incision. And if that is positive, then that patient might need to have additional surgery as well. And that can include lymph node dissection or complete lymph uh completion lymphadenopathy. Okay. Um, if the patient has an unresectable cancer, so in the low cases where we don't, we're not going to be able to do a wide local excision for whatever reason. Then there are a few things that we can do. Usually, you could do chemotherapy for advanced Melanoma is that are not responsive to treatment, but you can also do immunotherapies as well. And that would be guided by specialists. You would be responsible for that at the level of enough to, you would have referred by then and then usually dermatologists or oncologists, they will be the ones that are going to be responsible for these things. Okay. Um I think that's the end of case three. So review of Melanoma, look for your A BCDE. Uh make sure that you do a full thickness biopsy based on the full thickness biopsy. You'll be able to diagnose the Breslow thickness and that will guide your management for how wide you should excise it. Surgical treatment, surgical management is the end all be all and main management for this. But if it's a non receptible, then this is treated with chemo and this is exactly actually what you would say. Let's say you have a counseling station um on your Plavix Sam and the patient comes in, they've had the biopsy already and you have to uh kind of discuss and counsel the patient. So again, you're gonna be using our spikes demonic that we've discussed in the previous um talk uh to go through the bad news. If you haven't already revealed the bad news, then from there would be really important to kind of explain what the next process is, would be, which be to explain what wide local excision might be to explain that you might need to take a lymph node biopsy and that if these don't work or the or it's considered to be an unresectable, then we might need to go down the chemotherapy wrote and that would be your full encounter uh and just making sure that you're empathetic during that. And that would basically be what a Melanoma station might kind of look like. Uh And this is the final case here. And uh I'm cognizant of time, we have about nine minutes left. I think we should be able to manage to get these through. Um And so case for so we have an 88 year old male. Let me just prep the pole I can. Um So it's an 88 year old male admitted in hospital for a neck of femur fracture. Uh You've taken over the patient's care post operatively and you're presented with the following blood results. Okay. So I'm going to start the pool now. So sodium looks to be okay. Potassium looks to be okay. You'll see a sudden jump in the area and creatinine and you see a tanking of the GFR. So what do you guys think? What do you guys think we're seeing on this patient's? Um but and let me put up the question now, so it's probably a K I was to say case stage 12 or three oh and let me put up the values again. So that way you guys can calculate if you like, I'll give it a few more seconds before I close the pool. Okay. So let's talk about what AKI is. So AKI is a rise in serum creatinine of 26 micromoles per leader or greater within 2048 hours. Okay. It could also be at least a 50% or greater increase in the serum creatinine within the past seven days or measuring urine. If you have a fallen urine output to less than half a mil per kilogram per hour in more than six hours, then you're going to be having a K I. So what are the kind of stages we're looking for? So this is a table from the pharmaceutical Journal of the Royal Pharmaceutical Society. So again, stages 12 and three. So if you have a sudden increase in uh creatinine of 26 micromoles per leader within 48 hours or you have an increase in your serum creatinine, that is 1.5 to 2 times baseline that or a drop in urine of more than of less than half an ML per kilogram for more than six hours. This is our stage one, um stage 2222.9 and stage three, more than three. So the way I remember it is stage 11.5 to 1.9. Stage 22 to 3, stage three, greater than three. So if you have those three, then you know that uh this patient has an A K I, the other thing, the other side that you kind of want to look for is um urine. So if they have a drop in their urine output, so no, your urine output for more than 12 hours, they're automatically a stage three, okay. Uh And then there are some other ones, so less than half an ML per kilogram uh per hour uh for more than six hours or more than 12 hours, then they're stage one or two respectively. So, for this particular patient, um if you have an A K I above 3 50 for or, or triple the baseline creatinine, which is what we see here, both of them would qualify uh to being AKI stage three. And so this patient is in a chi stage three s some of you guys correctly identified. Um So whenever you see an AKI, the things that I want you to again remember is there are three classifications of AKI, this is going to be your pre renal renal and post renal, okay. Um based on the patient's history and things that have happened in two happened to them in hospital, you should be able to figure out what the cause is and treat appropriately. Uh The thing that you don't want to do in the hospital, that is the most common thing that we see is that a patient has a ki I get fluids, But the thing is just because the patient has AKI does not mean that the reason for their acute kidney injury is dehydration. There are other causes. Let's go through a few now. So prerenal, so do does this patient have an absolute volume reduction? So, prerenal causes are basically things that would result in decreased profusion of blood to the kidney. So an absolute volume reduction as a patient is bleeding or they've been depleted volume depletion, for example, a decrease in physiological reserve. Again, think for example, our patient's with um dementia that are not eating or drinking really well or our POSTOP patient as in this particular case, right. Second, they have a relative volume reduction. So for example, heart failure, so they do have their their fluid overloaded, but the fluid is not in the blood essentially, right. So as in heart failure or cirrhosis, the fluid are escaping to other places. Um Third spacing uh and then we have hyper perfusion and that could be secondary to shocker drugs uh then we have our renal causes. So our renal causes of AKI are going to be things that actually affect the kidney itself. So things that I want you guys to be thinking about our acute interstitial nephritis. So patients that are on nsaids, for example, acute tubular necrosis, maybe secondary to um you know, contrast is really important. For example, the patient's just come from getting a CT scan with contrast and then they develop this the next day, you should be thinking of a TN if they have something wrong with the actual infrastructure of their kidney. So, glomerulonephritis. So, thinking about things like um diabetic glomerular nephritis, thinking about lupus. Um and of course, our vascular disease as well that can cause it. Um and then finally, we have our post renal causes. So, post renal causes are going to be after the kidney. So that's going to be our obstruction. So, thinking about things that are happened after the kidney. So you produce urine. Uh and let's say there's a kidney stone, for example, let's say there is a cancer that is in the ureter or in the bladder, uh or there is an obstruction, uh patient is not able to p or we and so they have a build up of urine in their bladder and that kind of has uh that urine backtracks and that causes can be injury. So those are the three things that you should or three classes that you should be thinking of when a patient has AKI and from there you're able to, to treat it appropriately. So, based on this patient now, who is, um, POSTOP and, um, just had a neck of femur surgery, what do you guys think would be the cause of this patient's, um, AKI just based on the history alone, obviously could be other things. But what do you guys think it could be? I'll give you guys a few seconds to answer that question. Yeah, I see the answers are slowly trickling in. Give it a few more seconds. Yeah. So basically, as you guys correctly identified prerenal would be the cause of this patient's AKI. So um this patient just had a neck of femur fracture, likely there's been some blood loss and he's probably not really been adequately hydrated after the surgery as he should have been. And so likely it's a prerenal cause um for this particular patient. So the way that we manage AKI in the UK is we use in Amman, it called stop AKI. Uh not only does this help us kind of figure out what the cause of the AK I might be, but it also helps us think about what um management we would need to do. So stop, stands for sepsis, toxins, optimizing volume status and BP and preventing harm. So, s sepsis of the patient is having septic shock that is resulting in their AKI. Then you're going to be implementing your substance. Six. Remember, take three gift three depending on what your local care bundle might be. And then you want to do this within one hour if an infection is suspected. Ok, tea is gonna be your toxins. So you want to identify and stop or avoid exposure to nephrotoxic and nephrotoxin. So is the patient on an ace inhibitor? I hope you're suspending that. Uh is the patient on uh aspirin or NSAID? I hope you're suspending that, right. Um So make sure that you do a full check of the patient's medications. Has this patient recently received contrast? Were they adequately hydrated afterwards? That's also another thing to consider um oh being optimizing volume status and BP. So this patient, for example, who's had an echo femur fracture, that's likely had significant blood loss or maybe not depending on how the procedure was. Um, you want to check, do a volume status exam as we mentioned before and check their BP. And if appropriate, we're gonna give fluids uh and hold medications are going to be dropping the AKI and BP. So for example, if the patient is a heart failure patient that's now had a procedure for this femur fracture, you've restarted the um furosemide postoperatively or the bumetanide postoperatively, you might consider holding that for a little bit as this patient recovers from the AKI and then you uh control uh and you give them some fluids while uh I know, it's a balancing act, but that's something that you might consider and then p preventing harm. So, is there any reversible causes that you're able to treat? Um So, one of the most important reversible causes that you can treat is urinary retention, which causes a lot of cases of AKI, especially in our older adults. And so the way that you can treat it, and then not only do you relieve their symptoms, but you also relieve, uh, prevent them from developing further AKI spreading in a urinary catheter if a patient has outlet obstruction, uh, somehow, uh, putting in that urinary catheter could literally be the, um, uh, thing that saves their life. Um, and there are a lot of patient that you'll see that will go to AKI stage 12 and three and will be because patient's haven't had a bladder scan, for example, checked and, uh, or it hasn't been noticed that the patient has been passing urine in a really long time. So don't forget to put in that urinary catheter. Um, and I believe that's actually it for my talk today and we're pleasantly on time. Um, I am going to see if anyone has any questions. Please feel free to put them in the chat. Now, from today's talk, I'm also going to send a feedback form. Uh, if you guys fill out that feedback form, not only do you get a certificate of attendance, but it really helps us out as well. Um, to kind of figure out again where you guys are from, if hopefully the topic was helpful and what we can do to improve as well, uh, in our future talk. So if you can do, please, um, take some time to fill out the feedback form and, uh, I'll wait a couple more minutes with questions. Um, and if there are any more questions, then we will, um, we'll, we'll go from there.