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So, uh I think we'll just make a start. So I just want to introduce the program. I'm Fran. Um I'm one of the surgical trainees um at Musgrave Park Hospital in Taunton. Um and I'm the founder of the Prepared For Practice program. So this program aims to teach you everything that you need to know to start work as an F one, which I think is fairly well accepted as a pretty scary thing um for everyone at some point, um myself included. So hopefully this will take away some of those nerves. All right. And the way that the program is designed is that we will be starting with some of the basic skills that you'll need in any F one rotation. So, prescribing um investigation interpretation and then we'll be moving on to things like clerking patients at the front door. So managing the take shifts then um working on the wards when they're admitted. Um and then reviewing unwell patients when they um are admitted to the wards and you're covering them out of hours or overnight. All right. And then we've also got a little bit at the end about um wellbeing and career planning and then finally we've got our Q and A session. So anything that we've not covered or anything you're still worried about, that's your chance then for us to talk about it. So, welcome to the program. I hope you enjoy it. And I will hand you over to Lucy and Carrie. Mhm. All right. Enjoy. Right. Um, sort f so this session is focusing on, um, some basic investigations, kind of the main ones that you'll be interpreting as an F one. So that's EC GS chest X rays and a tiny bit on MS ES right at the very end. Um, so we'll get started. Um, my name is Carrie. I'm an F one and I've just moved on to PS, um, I'm Lucy, I'm also an F one. I just went on to Jerry's. Yeah. Um Fab. So we're gonna start with, um, just looking at this ECG. Um, so I want you to imagine that you're presented with this ECG. It's 2 a.m. You're one of those class ones on call and you're given this ECG by one of the nurses and if you can just look at it for 10 seconds and just have a think about whether you would feel comfortable interpreting this. Um, and, and what you might, might think is going on. Um, if you want to send some things into the chat, we're gonna try and make it as interactive as possible. Um, so if you send some thoughts about what you might think and what's going on here. It doesn't have to be a diagnosis. It can just be some things that you spot some abnormalities or, or normalities. Wait a few seconds. It's a chat working. Mhm. Mm. Slight time. Mm. Oh, there we go. Thank you. Yes, that is definitely going on. There's some two version going on which leads you will know. So, it's amazing. So, the main reason we've put this ECG in is not because it's meant to be an easy spot diagnosis, but actually because it's just a really horrible ECG to interpret. And me and Lucy both really struggled when we looked at it initially to know what was going on. Um But basically, the point of putting this on was to try and highlight the fact that as an F one, you're not expected to be able to diagnose someone with something off this ECG, your main purpose is to be able to recognize something that's abnormal, escalate it appropriately and be safe with your practice. Um So if you see this ECG and you think this does not look normal, but I have no idea what's going on. Being able to describe it to a senior or your friendly med reg on the phone is the important part, not being able to tell exactly what's going on. Um So it's hopefully just to reassure you that you don't need to know everything else, an F one and you're not expected to. Um and in terms of what's actually going on with this ECG, um it's actually some T wave version like you guys have said, if, if you want to before there's some white axis deviation, which somebody else said um on it, you guys are literally nailing it. Um And yeah, the diagnosis at the end of the day was actually a pe um but obviously we weren't expecting you to get that from that ECG. It's just um to kind of point out that describing the ECG is the important part. Fine. So moving on to what we're trying to get out of today's session. So we're going to be looking at some key investigations that you might encounter on the wards when you start F one ECG S chest, X rays, urinalysis and MS use and how to interpret these and some um in, in particularly in the context of some key pathologies. Um We're not gonna be doing it in a kind of an ay style format, which is what you might have been taught already, but more how you'd approach these investigations like day to day in reality. Um And we're also gonna then apply these at the end to some common clinical scenarios. Um So I'm gonna start by having a look at the, how you GE generally approach uh looking at an E CG. So you'd approach like the, the approach would generally stay the same for every ECG you're given. Um So starting, obviously you want to confirm the patient particularly their name and date of birth. Um don't want to get that wrong and it does happen. Um And obviously checking the details such as the date and time it was taken and then you want to look and see if there's anything, if there are any previous ecgs to compare, compare it to and seniors would always ask this. So it's, it's really, it's something to be like. It looks really good if you've already gone and had a look at look for previous ECG S. Um And it can also help determine whether there is any big change and you're trying to look to see if there's any changes from the previous ECG. Um And then we're gonna go through the, the kind of the review of it step by step in the next few slides. But as you can see it, we want to look at the rate rhythm axis, P waves, Q RSST and T waves and QT. And then obviously you want to be considering the clinical scenario. So it is a patient, for instance, with chest pain and how this might affect the interpretation. Um So we're gonna start with some examples. Um So if you can all look at this ECG II, hope you can see it. OK. And the size is OK. Um But we're just gonna go through it symptomatically um systematically with the things that we just mentioned. Um So if you imagine the clinical setting is that this is a 33 year old woman who presents to Ed and she's got some, some shortness of breath. Um So if you guys want to shout out what you think um the rate is or put on the chart. Yeah, sorry, that's what I mean. Um And then we'll go through them all. Amazing. So you all got that. Um The rate is around kind of, we've written down, um, 100 and 30 I think, 132 which is quite specific. Um, so the way that you normally figure out weight is, um, there's two different ways you can do it, so you can do 300 divided by the number of large squares in between each QR S which here was about two and a quarter. Um, but I appreciate it's quite small. So you couldn't quite see that. Um, and then all the other way to do it is the number of QR S complexes in the rhythm strip, which is the bottom one. and in terms of, um, the rhythm, does anyone have any thoughts about what the rhythm is and the axis and things like that as well or what? Just the final diagnosis? Oh, yeah. What you guys think it is? Mhm. Yeah. So the rhythm is regular. That's a really good differential. Yeah, that's definitely what you would think of here. Um, could it be ap, um, and what would you say is the, is the kind of main thing on this ecg, what would you diagnose someone with? Exactly. Yeah. So it's sinus tachy. Um, and definitely pee is something you want to be considering, um, along with lots of other differentials. Um, does anyone have any other ones? Yeah, definitely could be that. And other ones I guess to consider, yeah, would be infection. Infection can definitely make you, um, tacky, um, and things like dehydration as well would often cause you to be a bit tacky if we move on to the next one. Oh, so that's all the, um, the different things, the different aspects. So everything was normal except the rate which was high. Great. So, moving on to the next ECG. Yeah. So, um, this is another ECG you're presented, um, with an 80 to 9 year old woman with shortness of breath and palpitations. So, similarly to before joints just so in this one, we're gonna concentrate on the rhythm. So don't worry too much about the rate. But what do you think? How would you describe the rhythm in this ECG? Yeah, you got it. I got it. Um And what other aspects of his ECG are notable. So you got in a regularly irregular rhythm, which someone has always said, is there anything else that's noteworthy? Yeah. So the, the things that I would be looking at and noting in this ECG is that, um, the, the rhythm is irregular, irregular and there are no P waves and together these things would, would very much suggest af so rhythm can be irre can be regular, whether it is equal space be, or it can be irregular. If the rhythm is irregular, it can be regularly irregular. I regularly irregular where there's a, the beats aren't equally spaced, but there's a pattern to the irregularity or irregularly irregular where there's no pattern and it's kind of sporadic. Um if it's irregularly irregular, generally think of af which is very common. Um And we're gonna go into some courses of af in later slides and then for sinus rhythm, um it is important to think that to remember that every complex must be preceded by AP wave and also that the P wave must be positive in lead to perfect. So the next one, we're just gonna focus on access. Um So this is a 79 year old um who's admitted following a collapse. Um So this is a wee bit of a spot diagnosis. Um Does anyone want to say what this is? So, one of the ones you should definitely, you know, entering into um F one, it's not something you're gonna see very commonly, but one to definitely know about. Hopefully not and we'll go through QR S complexes and things in the next slide. Yeah. So this is BT um in terms of the access here. So, um the way that you interpret access and I always used to forget this, um, or find it confusing is so you concentrate on lead one and need aVF. Um And if they both are positive, then that means it's a normal axis. If they're facing away from each other, um, then that is left axis deviation. Um And if they're facing each other, it's right axis deviation. So, I used to think of that as like if they're facing away from each other, they left each other. So it's left access and if it's right that I used to think of it as like they're right for each other, so they're facing each other. Um And that's how I used to remember it. Yeah. Um And if both are negative, then it's an extreme access. Um And that's kind of the main way to, to think about it. Um Yeah, I don't think there's anything else particularly to. So on this EKG, you can see that um lead one and lead um aVF are um leaving each other. So it's left access deviation I two and three as well. Yeah. Um So yeah, this is BT and so next E CG um this is a 73 year old woman and she's had a full something you'll encounter a lot of in F one. Um So in this one, we're concentrating on more of the P waves and the pr interval in particular. So with this in mind, what are the main abnormalities you can see on this? ECG anyone maybe thinking about the pr interval? Does, does, does it like a nor does, does it look like a normal length? Does it look quite long or quite short? That's more, yeah, I'd say it looks quite long. Um, personally, I think, does anyone know how long the pr interval should be? It's hard to remember sometimes it's quite confusing. Yeah, exactly. So, between 100 to 200 milliseconds. So that's equivalent of 3 to 5 small squares. Um So you guys are all correct. Um So this interval is basically the time taken for depolarization and the time taken plus the time taken for it to, to conduct through the AV node. Um So if it's longer than this, it's just heart block. If it's shorter than this, it would suggest there's something bypassing the A V node. Um You ha you probably know about the um different type is called, no. Can you all see, still see the slides? It says technical error on. Oh, no. Um So I try it. So we're gonna say hi for issues. You can't have a session without a technical issue. I haven't actually got the slides on my computer. That's been, isn't it? Sorry about this? So I always talk to you about, about the heart blocks in the meantime. Um So you've got first degree heart block, which is just where there's a prolonged pr interval. All right. Sorry. Um So um just Carrie will try and get the slides up while I'm maybe gay. Got it. Yeah. Oh, ok. We're back on. So pr intervals, um, we're talking about heart blocks. Um, so belong to PR interval is first degree secondary two types. There's Mobbs type one, type two mo it's type one. It's where there's a progressive prolongation of the PR interval until eventually there's a drop beat mos type two is where there's intermittent non conduction of P waves. But the pr interval is consistent and then third degree is complete heart block. So there's complete association between the PS and QR S complexes. It's quite complicated, but I'm sure you guys have heard of this before. So um this was first degree heart block. I think a lot of you mentioned that um so well done. Um So the next one is Q Rx um complex QR S complex. Um Do you guys want to just have a look at this ecg see what you think um specifically concentrating on the QR S? They do love to bring it up. You don't see it very often in practice or? I haven't, I don't know if you have Yeah. Yeah. So the QR QR S here is wide. Um And what sort of things are you gonna be thinking about if somebody has a wide QR S? Yeah, bundle branch block, that's the one that's kind of, you need to remember when you see a wide QR S. Um And the other thing that's really helpful to look at. Yeah, you guys have got it. Um is to look at the axis. So what do you guys think is going on with the axis in this one? If you remember to look at lead one and then lead aVF Yeah. So there's left axis deviation. Um Any other changes that you can see on this one except for the left axis deviation in the Y pr s. If you think about all the different elements of this, if you go through them all. So the thing I'm trying to get at is the ST segment. So you can see that there's a bit of ST elevation in lead V one to V four. Hopefully you guys can see that. Um And there's also actually some reciprocal changes. Yeah. Yeah. So you guys have got it. Um And the one thing to remember about Left Bundle branch blog is that if it's new. So you have a previous ECG, which is such a hack when you're on the ward and an ECG looks weird and you literally have no idea what's going on if you look at the previous one and it looks exactly the same. That's slightly reassuring. Um But if it's new, left um left bundle branch block that counts as a semi, it needs the same treatment. And on this one, you actually do have ST elevation and things. So you need to be escalating that um straight away to your seniors. Um So, yeah, that's just the things we've already chatted about and that's the diagnosis. So, and so this is a patient who's splinting with central chest pain. So, immediately you're a little bit worried. Say we're concentrating on the ST segments and T waves. What, what are you worried about? What can you see, how do you describe these changes to your reg on the phone? Yeah, I got it in one. What, what particular changes can you see? How do you describe it? Yeah. In which? Leeds. Oh Maybe, maybe that's true. Yeah. Yeah. So the most, I would describe this as being an ST elevation in these one in a VL in V 2 to 6. And it's also reciprocal ST depression in these three and aVF. Um And so it's important to kind of remember that T wave inversion can be normal and in some leads which are always hard to remember. But um it's V one leads V 13 A VR and a VL. I don't really have a great way of remembering these. Um To be honest, I just Google it every time you see an E and T version again, comparing it to a previous is always useful. Um Just to check whether there's a new TW version and then it's also important to look for reciprocal changes and the corresponding leads. Um One isolated lead elevation is generally not concerning for a sty. It's just if it's just in one lead and that used to, that's caught me out a few times where I've escalated it thinking, oh, my gosh, this is so worrying. Someone's got ST elevation in one lead and then you realize actually it doesn't matter if it's one lead, they've not got reciprocal changes and it's one lead and they've not got chest pain. Then you don't really need to be worrying as much. So, this is the last, um, little bit on ECG S and then we're gonna have cases at the end. So that'll hopefully bring it all together a bit more. Um But this is on QT interval. Um So if you all want to have a wee look at this ecg the clue is kind of in the presentation 24 year old who's come in with a suspected overdose. Yeah, rn's got it. So the QT is prolonged and I always have to Google this as well to remember how long the QT is meant to be because I can never remember and it's different in males and females. Um But yeah, TCA um tricyclics can increase your QT. Um Lots of drugs can do it. Antiarrhythmics, antipsychotics, antidepressants, antihistamines. Um But if somebody's got an overdose, it's kind of, that's kind of the classics them in a an exam question and then clinical practice where you might get um QT prolongation. Um Some electrolyte disturbances can also give you QT prolongation, stuff like things like hypocalcemia, hypokalemia, hypomagnesemia and people can have it genetically as well. Um So, yeah, this is prolonged QT. Um So we're now gonna go on to have a look at chest X rays. Um We're gonna run through it in the same way that we kind of did with ECG S and then we're going to tie them all together with the um some cases at the end. Um So I just wanted to first go through um the systematic approach of looking at chest X ray and this is a little bit less confusing than an ECG I find to interpret. Um But the main things you want to first concentrate on um is again, make sure you've got the right patient up. You're looking at the right one, it's the most recent one that you've looked at. Um there's things that like in an exam setting, you look at like rotation, inspiration penetration and things like that, that's important. Um And can impact your ability to properly look at any um a chest X ray, but I don't know about you, but you don't really, it can be unless dela obvious unless you're like missing half the chest um is generally it's just, just, just accepted. Yeah. Um And then the way you, you should go through it systematically is to concentrate on the airway first. So you look at the tria, make sure it's central, then look at the Bronchia coming off as well. Um And then go, I go through each lung zone individually to start with the two top ones, then the middle ones and compare one to the other side to make sure they both look kind of the same density and there's no kind of obvious kind of haziness or anything. Um, you then wanna look at the heart, it should be less than 50%. Um, and if it's more than 50% that suggests cardiomegaly, um, and you also want to look at the borders to where the heart meets, um kind of the diaphragm and the diaphragm meets the, the side of the chest. Um You want to make sure that there's no kind of um haziness or menisci which might suggest effusions. Um The last one is to look at everything else. So that's things like bones, make sure you don't miss any um rib fractures if someone's got chest pain, um and look at the soft tissues as well and make sure there's no kind of surgical. It's called emphysema. That's the one. And then I always finish off as well. There's bits of the chest X ray that I always forget to look at. So I just make a note to myself to remember to look at them right at the end. Um And particularly that's the lung ap so right at the very top, um you can have things like as an F one, you're not going to be diagnosing someone with a mesothelioma or something like that, but that's like things not to miss it like bits right at the top where there might be some thickening or something like that. Um, the highlight as well and making sure there's no like pneumonia hiding behind the highlight or behind the heart. Um, and also always look below the diaphragm. Um, because if there's any air underneath it, you that's very concerning of kind of perforation unless it's just a gas bubble in the stomach, which I have gassing. Yeah, or POSTOP very early POSTOP patients if they p of gas or there is a weird term where the bowel sits really high and that like along the diaphragm. Anyway, moving on. So the first thing we're gonna look at is the airway. So this patient has a slight airway problem. Can you, um, shout outs any anything, any problems that you see with this chest X ray? This one is sort of a spot diagnosis? Got help. Yeah. Well, that's exactly right. So this man's been admitted with worsening cough and shortness of breath, um, and his airway. So starting from the top, we can definitely see his trachea is deviated to the right. And then looking through the other um, aspects of the chest X ray, looking at breathing, we can definitely see a large left sided pacification. Um So in area of increased whiteness and then, which would be um in keeping with a, with a, with a um increased pressure in the, in the thorax. Yeah, circulation, um there obscured left sided heart borders and diaphragm looks normal, but then the left on the right, then the left is definitely obscured. So, yeah, conclusion this will be fit with the diagnosis of a large left pleural diffusion. So the main area problem generally seen on chest x rays in clinical practice is tracheal deviation. So whenever there's something that pushes the trachea away, this would suggest that there's increased pressure in a hemithorax such as potential pneumothorax or pleural infusion, a hemothorax or a large mass. And then if the trachea is pulled towards it towards the side of the problem, this would suggest that there's that this is caused by a decrease of pressure in the hemithorax like the lung clamps. So that they are the main things to think about. And it's not always as obvious, it's obviously a huge pure eus. But if there's even just a little bit of blunting at the bottom, that can suggest a little one. So just have a look at to make sure the borders are all clear. Um So next going on to um a breathing problem. So again, these are a little bit more spot diagnoses, but if you can tell us what's going on with this chest X ray, it's a 67 year old man who's come in with a fever, cough and shortness of breath. And yeah, that's correct. Can you be more specific at all? Yeah. Yeah. Mhm. So in this um, chest X ray, you can see that there's, um, there's some, let me just get the right one out um, on the, the right middle lobe, you can see that there's some pacification. Um Otherwise everything kind of looks normal in this um, chest X ray. There's no um problems with the, um, the airways of the central. Um, the heart looks kind of normal size. Um, the diaphragm as well is fine. You can see that gas, um, gas bubble that we were talking about right underneath the left diaphragm, which is normal. Um, so this is a right middle lobe pneumonia and you can tell it's not a lower lobe pneumonia because you can still see the of the hemithorax of the diaphragm. Sorry. Ok, perfect. Um And some things to know as well with just pneumonias is if it's in the upper lobe. Um, one of the consultants that worked with me and Lucy on our first job. Love to tell us this fact lives in the upper lobe. You really, really need to remember to do the six week chest X ray because upper lobe pneumonia are often associated with malignancy. So, doing that repeat. Chest X ray six weeks later, make sure that once the pneumonia is resolved, there's nothing else underneath. I've never seen it in reality, but I'm sure he's seen one case. And now anyway, so this is another chest X ray. Um, this is an 86 year old female who's presenting with shortness of breath and edema. So, puffy legs. What can you see thinking about, um, circulation? So, the heart give a thumbs up. Ok. Yeah. Yeah, exactly. So, you guys have got a lot of, a lot of the key aspects of that. I just got them all. Yeah. There we go. So, we are converting on circulation but we'll just go through it. So the airway looks pretty fine. Um, Trachea is central, the breathing, looking at the lungs, there's definitely patchy pacification bilaterally. Um some people like call this bat swing edema. There's to see there's cardiomegaly. So there's an increased heart size. Importantly, you can only observe the heart size in a pa film, non AP film. Um And cardio is defined as when there is when the heart takes up 50% of the cardiothoracic um border. So the cardio cardiothoracic ratio is greater than 50%. Um looking at d there's blunting of the cost angles, adjusting pleural effusions and then everything else pretty fine. So yeah, diagnosis would be pulmonary edema, probably heart failure. Um This is, yeah, exactly. R is exactly right. There are all the aspects that you'd want to be thinking about when, when um thinking about heart failure, it's a very common thing to see in, in practice. Mhm fab. So last oh no one but last one on chest x rays. Uh So this is an 87 year old who's come in with um an acute deterioration in his cognition and behavior. Um And he also has a background of dementia. Um What do you guys see on this chest X ray classic? It's like every amount of my jerry food. Yeah, Chloe's got it. I feel like it's really hard to like it's quite easy to miss because you're so occupied with looking at the airfields and things that often you just forget to look at the, the diaphragm. But it, yeah, but it's so the the diagnosis here is a pneumoperitoneum. Um So you can see that there's gas underneath the right side of the diaphragm. Um And that's the main abnormality. So, um does anyone know the differentials for that? What kind of things will you be wanting to go and do if you spot someone with the chest X ray like this? Yeah. So the main thing I was going for with that, you need to examine his abdomen, you need to make sure that he's not gentic. Um And the main differential, like you guys have said is perforation. So that could be like peptic ulcer disease um secondary to that or um bowel um perforation um had a burst appendix, something like that. So you really need to go and examine his abdomen and escalate this. You probably need to go to theater. Um And the last one on chest X rays. Um So this is everything else that you might be missed in a chest X ray So this is 32 year old, uh, in Ed following a road traffic accident. What can you see put in the chart? Yeah, exactly. We've got, it's got it. Um, so there's quite a large sided, right sided pneumothorax. Um, you can definitely see the, like there's absent lung markings along the whole of the right lung. Um, and the right side of the heart border is obscured as well. So we definitely want to be thinking about a pneumothorax, but then we also don't want to miss maybe the underlying cause of this. So looking at everything else, we can definitely see um some quite obvious rib fractures on the right side as well. So that's very likely the cause of the new D I mean, it definitely is. Um so things that you want to check for when looking at everything else would be things problems with the bones. So, so, so fractures sort of sclerotic or, or osteolytic lesions as well. Um Looking at the soft tissues like Harry said earlier, looking for any surgical emphysema, particularly when there's a trauma case. Um and also looking for any breast shadows, these might, these can sometimes obscure um like pneumothorax or just look, look, look a bit odd on the chest X ray. Um And also looking for any foreign bodies, like it's always good to know if there's a pacemaker, a piercing like a tube down like an NG tube. ECG leads. Um and then always also like how it earlier, it's always really good practice to double check that you haven't missed anything in the very top or the very bottom of the lungs and the hilum of the apices. Cool. Um, so one thing I guess to just touch on before we just move on from chest x-rays, um, is one of the common things that you get called about on, on calls is to confirm ng tube placement. Um And to be honest, I don't think I've ever said yes to, to one of them, um I double check. One thing to know is, don't, don't confirm N GT placement unless you're confident and you know that it's in the right place. Um It's one of the never events that you confirm, it's not in the right place and it's not. Um And someone gets fed. Um There's kind of things to look out for with NG two placement and often your like foundation trust will give you like ele on it. Um But it can often be really difficult to tell. Um And even like I've had to escalate to the me, the me doesn't know before and you need to ask radiologists and things. So don't feel like as an F one, you need to be pressurized into saying yes or no to an NG tube placement at our trust. We're actually, we're actually told that F ones can't confirm NG tube placements. A lot of people do when on, when under pressure. Um but it is good practice just to get it confirmed by a senior if possible. Um So we're just gonna quickly go through urinalysis because it's um it's pretty self explanatory. Um But then we're gonna go through some cases um to finish. So, um with urinalysis again, same thing, confirm patient identity, um check um kind of um the urinalysis details, make sure it's in date and things like that. Um Have a look at the urine. Um I've had it before someone's had like such a horrible looking urine they've brought over from to show us you because it's so disgusting and that is a big clue. Um And then with the actual urinalysis, um leucocytes and nitrites um can indicate whether there's an infection or not or send it for an MSU afterwards. Um especially trying to do that before antibiotics. If you think there's like urosepsis or something going on, protein is really helpful to look at things like renal disease. Um And often people will ask for it if you're asking for a renal review, for example, a KS and things like that. Um blood um is really helpful in uh obviously it can be there for infection and things like that. Um or if there's kind of hematuria um kind of microscopic which needs urology review. But um one thing that's really helpful is when you think there might be renal stones. Um So if you're worried about kidney stones, um getting a urine dip and seeing if there's blood on it is really, really helpful. If there's no blood on it, it's not gonna be renal stones. Um, the other thing is ketones. Um, never forget ketones. If you've got somebody who's diabetic and they're on a deli flosin just do ketones if they've been unwell, even if the, um, the MS aren't high because you can get that euglycemic DKA. Um, and ketones can also be high in like starvation ketosis if someone hasn't eaten for a while. Um, glucose also high DK A. Um And um if there's kidney problems, you also have glucose in your urine and H CG always do a pregnancy test in a woman of childbearing age. Um But God bless him and then, yeah, send your MSU. Um They're really helpful in the septic screen, send it before you start antibiotics if you can. Um And with a dip, you won't, you don't dip people who are over 65. I'm pretty sure it is you just send an MSU. Um So that's just an important thing to know. Um And having a positive MSU doesn't always mean infection either. Often it comes back with like mixed heavy growth and that can mean kind of contamination, especially if it's from a catheter. Um So always go by clinical picture as well and kind of if someone's asymptomatic, particularly in old people, um they can have asymptomatic bacterial urea and you don't need to necessarily treat any. So now, the most interesting part, hopefully fun part. So, right, we have Missus Christie here. She is 87 years old and she's come in with a fall again following a neck of femur fracture, um fine and she underwent a hemi arthro arthroplasty two days ago. So you've been asked to see her on call because she has central chest pain and shortness of breath at rest. So you go to examine her and she's got a news of six. So obviously the alarm bells are ringing slightly at this point. Um Her increased, she got increased work of breathing. Her respiratory rate is 22. Um Her sats are 95% on 2 L. So not awful. Um But it's also important to think about, is this a new oxygen requirement or is this what she's been on since admission? Um Her BP is a bit low. It's 100 and 6/87 and the heart rate is a bit high. It's 100 100 and 11, but she is alert and her temperature is 37.7. Um Looking at her, you, you think she looks quite unwell and you're a bit worried. Um So you examine her a bit more and she, she's, you, you, you, you check her um, perfusion and she is warm, she's well perfused and her pulse is regular and it's good volume. You can tell that her heart rate is elevated she's tachycardic but her heart sounds are normal and there are no added sounds, her chest sounds clear and it's good air and air entry for out, uh, examining her legs, her calves are soft and nontender. Um, they're slightly puffy. So she's got mild bilateral edema. Um, but there's no redness. Say, um, put in the chat, what are some differentials that you'd be wanting to think about and rule out at this point for this lady thinking about her examination and her history. Yeah. So you got P pneumonia, pneumothorax, all the peas A CS, these are some really, really good um, differentials and all of them are all correct. Um You definitely want to be ruling out all of these. So in light of this, what would investigations would you be wanting to do? These are really good guys are thinking outside the box? Yeah. So you've got VBG ABG E CG. Yeah, we definitely want to do all of these bloods chest X ray. It's true. Yeah. Controversial. Um Yeah, exactly. So definitely want to be doing bloods, get an E PG, get an APG with, with a new oxygen requirement. You generally want an ABG. Um, but then thinking about the investigations that we've been talking through today, we're gonna mostly concentrate on them. So we definitely want an ECG and a chest X ray. And in reality, you get an ECG and a chest X ray for pretty much any like every patient in medicine. Um, fine. So this is our ECG, this is our chest X ray. Fancy thing about the, the ECG. Um, what do you see anything, anything strike you as abnormal? Um, what are your thoughts about it? Want to pop, pop anything in the chart? It's quite a hard one. I wouldn't have known this and I've never seen it on the wards but it is classic, kind of more in, more oy style. Mhm. Friends got it. Yeah. So it's, yeah, you've all got it impressive. So, um S one Q three T three. That thing you see when you get a pe um and then there's also sinus tachy and right bundle branch block as well. Um So always good to know everything you see in an E CG, not just the most obvious abnormality. Um Anything anyone sees in the chest X ray, does it look normal or abnormal? Wow. What are signs? Oh, maybe, maybe you're right. We'll have to look it up. Yeah, we've got that. It's a normal chest X ray. So if you felt that there was nothing there, then also don't worry cause that's what we thought. Yeah. Um So, so in light of these, um we'd probably want to be calculating well, score something I'm sure you're all familiar with. And then further investigations following this would be to either do a ddimer or depending on what the score is to jump straight to a CTP. Probably at this point. You would be jumping straight to a C TPA. Um if a patient was using a six and there's this funny ECG change. Um And so we'd also want to be starting um thinking about starting treatment dose, Clexane or enoxaparin depending on what your trial's guidelines say. Um if the CTPA is not going to happen within four hours, um In reality, most patients do just get started on a treatment dose unless there's a contraindication um immediately when there's a high chance of a pa. Um Yeah, and also important to think about whether it's clinically appropriate for the patient to be um being anticoagulated. Mhm. Also with the E CG often if someone's got a pe, they will probably just have a sinus tachy and a normal chest X ray. So, um yeah, just to be aware of. So this is the, the next scenario. Um So Missus Davaa is a 62 year old woman who was admitted to e following collapse at home. Um She was seen by her GP four days earlier with a fever cough and shortness of breath. Um We've popped the history and exam down. So she's very drowsy and confused when you're examining her. She's using of 11. Um her respirate is really high. It's 30 her stats are 96% on 15 L, which is very concerning her blood pressure's low, 96/62 she's tacky at 100 and five. She's confused and her temperature is 38.3. Um, she looks unwell. Um, she's got a thready heart rate. Uh, she's got normal heart sounds and she's got some kind of cracks when you listen on the right side of the chest. Um, her calves are soft. Um, she's got kind of mild bilateral edema. Um, no redness and you've all got it correct. So, yeah. Um that screams like a septic person if you've got a high blood um a low BP, sorry. A tachycardia and a fever, you're thinking sepsis. So what are you gonna do next? That's a six. Yeah. Um and in terms of other investigations, um what else would you want to be doing? Yeah. A to e you want to, we've sort of popped down a mini A to E there. Um But as part of your at E you're also wanting some investigations into those. Um So yeah, you want blood cultures? Yeah, that's perfect. All good answers. Yeah. The wide consensus that we definitely want a chest X ray. Yes. This is what you have. What do you think? CP? Mhm Yeah. Fine. So um R is right. Um What do you think? What, how do you describe this? Ecg What do you see on it? You someone's mentioned some sinus tachy, maybe some flutter um as anything else going through a systematic approach. What other things are a bit weird on my A CG? Yeah, you've got 10 T waves. So your T waves are pretty huge. And so what that is suggestive of are is um hyperkalaemia um with ECG changes, which is really worrying. Um So what kind of things would you guys now be thinking is your priority in this patient? Yeah, so Chloe's right. Um you want to be getting calcium gluconate into them. Um uh hyperkalemia with ECG changes is really concerning. Um and you want to get calcium gluconate in them straight away to try and stabilize the myocardium. Um And then you want to start thinking of bringing it down as well. So that's with your, with your insulin dextrose infusion. And before I've had where we couldn't get access on somebody to give them um dextro. So the metro suggested giving salbutamol meds that can also move the, the potassium and intracellularly. Um So, yeah, those are very important things to think about. Um And not forgetting your, your underlying cause as well. So, um I can't remember who said it. It was when mentioned the AK I. Um So that's probably why this lady's gone into hyperkalemia. Um And often it can present in kind of young people who, who come in septic um and have this huge like potassium of like seven and it's because of a severe AKI from dehydration. Um So if you've got a severe AK I and you're asked to review a severe AK I don't forget to do a VBG to check their ph and things like that and their potassium. Um and yeah, on the chest X ray, what was the main abnormality? Yeah, so she's got a pneumonia. Perfect. So the last scenario, Mr Jones, an 81 year old man with a background of hypertension and a previous M I has come in with recurrent falls and a uti so you go to review him and he's got an intermittent cough and shortness of breath at rest. He's using a four for a respiratory rate of 22. He's saturating 96% on 1 L. His BP is pretty good. 100 and 24/89 heart rate's quite high. 100 and 32. Um, but he is alert and his temperature is 37.2. So Afebrile looking at him, he appears on, well, he's warm and well perfused. He's got an irregular pulse and it feels a bit thready. His heart rate feels tacky. His heart sounds are normal. Listening to his chest. You can hear, um, coarse crps or crackles throughout his whole chest. His calves are soft and nontender, but he's got, um, bilateral pissing edema up to his mid shins. Um, but there's no erythema say, what are you thinking? What do you want to rule out heart failure? Yeah. Yeah, great. So what investigations? Well, it's pretty much the same as we've already talked about, to be honest. So I'm gonna skip to the, what, what skip to the EKG and chest X ray, which is one we'll definitely want to get. Um and can someone describe what they see in the E CG to begin with? We've got it. So the rhythm is definitely irregularly irregular as we talked about before. And likely diagnosis is af and then what can we see in the chest X ray? Yeah, that's right. So it was quite um those of you kind of, yeah, said what you think's going on and you're bang on. Yeah. So you've got heart failure. Really? Oh, got pulmonary edema and heart failure and then just tying it all together. Um We'd have wanted, we'd probably call this fast flash pulmonary fast af given that the rate is 100 and 32 and flash pulmonary edema. Um So does anyone know how we manage this condition? Yes, if so. Yeah, stat 40 IV Exactly. Um Also just very basic thing to sit them up, give them some high flow oxygen and then give them some IVF Freezy. Um And anyone know any causes sweetheart earlier but any causes of af things that are common and that you might, that you want to rule out. Yeah, exactly. Infection is a really big one. Sepsis, hyperthyroid is important. Yeah, all these are really, really good and importantly, often sometimes we will um consider rate control with a beta blocker or digoxin. Um depending on what their BP is doing. If, if there's low BP, then we'd want to give digoxin instead of a beta blocker. Um Often though the most important management is actually treating the underlying cause of the AF. Um so working out what's driving it and then if you treat that, then often the AF will resolve as a result of that treatment. Um But you should always be consulting this with probably the med reg want to get involved if it's, if it's a new af new fast AF will be med reg involvement. Yeah, like she says, like um underlying cause it's the important part with the way with af um it's not about just like, oh, let's get the rate down. It's why is this person suddenly gone into af as well? Oh dear. Um Hopefully you can still hear us. Oh, we're back um fab. So if we just summarize um some of the key things that we wanted to get across today and hopefully, um that was an OK session. Um Is that essentially as a, as an F one? Um Your role is to go and assess people initially when they get sick. Um And recognize if something's abnormal and escalating it um being able to just stick to A to e is super helpful in stressful situations. Um And always remembering that doing the really basic things like ordering that chest X ray getting that ECG is really helpful um so that you can just hand it all over to a senior. Um Even if things are still pending and you want someone to come straight away saying that you've organized those things is really helpful. Um And not to feel intimidated if you don't know what's going on. Um But just being able to describe things is really helpful. Um We've got some resources um on there which we found helpful. Um And kind of as you go along through F one, the more EC GS, the more chest x rays you look at the more confident you are. Um And I'm sure that will continue to happen into F two and things are definitely not the most confident yet. Um But yeah, always look to your system and you can't really go wrong. You just need to go through everything methodically. Um And then hopefully you don't miss anything. Um Does anybody have any questions about anything we've focused on? Um or any thoughts or comments, all the slides will also be available um to look at that's good. Um After you've completed the feedback form, um which we'd be really appreciated of so that we know what's worked and what hasn't worked apart from the technology error. That wasn't actually our problem, that wasn't actually our fault, but we're gonna apologize. That's always technical. Um Yeah, so if you have any um thing that any other sessions that you want us to focus on, we have got a list of sessions for the future. Um But if there's anything else that you'd like some help with we'd be very willing to do an extra session. Yeah, just pop in the link in the chat and if you want to, um, like our page, that would be amazing. So, prepare for practice on Facebook. We'll be advertising all of them on there. They're gonna be sessions every Tuesday at 7 p.m. Your friends bring people along. Yeah, hopefully they'll be useful. Um, this was kind of a start on the investigations one, but the ones with that are coming up on things like how to call useful hopefully. Um, and yeah, thank you. Mhm. Great. Well, thank you all for coming and we'll, um, make the recording available as well as the slides f see you next.