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Just ready to go if everyone can hear me, just give me a yes or something. Ok, cool. Right. So, hello everyone. Um Hope uh II see some familiar names from last week. Uh I've decided to do this little series looking at um assessment as a junior doctor. You're gonna be um in the field and you'll com common commonly be asked to assess a patient. So II just basically want to run through some uh things with you. Um and we're gonna be breaking these up into kind of free areas. Uh So three separate kind of presentations. So continuity is key uh because each one will be getting more detail and they'll, they'll all kind of link together. So the first kind of aspect, the aims of this series will be to know to find out, you know, the changes and how to do an at uh covering, you know, news scale, uh G CS. And we'll run through the at E and talk about, you know, a survey examination for each of the, each of the letters. Um The second point would be to basically to kind of use that to work out the cause. Um or how to use at e to figure out what's going on and what other, you know, other investigations or other examinations you might need to do. And the last is like the action phase where you're able to escalate and manage the deterioration. Uh, so initial treatments for different kind of underlying causes, um, and the kind of under appreciated aspect or the overlooked aspect is, um, how to escalate safely and appropriately and handing over information effectively. That may be between you as an F one and an F two or registrar, er an I MT or CST er or, you know, consultant or even, you know, another department, if you're asking for advice, uh you'll frequently have to contact radiology to vet scans or, you know, cardiology for any weird uh 12 lead EC GS. So how to hand over and talk about a case that's developing effectively. So the aims of this presentation. So you should be able to recount the at um you know, recount, like the news to G CS scoring systems and you know, how to conduct an at survey examination. I've also missed out, but I'll add in there. Uh We, we'll talk briefly about escalation and we'll talk briefly about different aspects that I mentioned in the previous slide. Um So getting started, what, what is the at this is the, like I said earlier, you know, the basis of um all kind of physical examinations in the NHS if you are seeing a patient for the first time um during the middle and something's gone wrong or, you know, at the end after operation, you're always utilizing an A to e approach. Um And you should really be learning this and recording of the heart, uh especially as after we talk about these things, you should be able to kind of study it, practice it and think about it when anyone is asking you for um to what you would do if a patient was deteriorating, uh frequently asked in interviews, you know, an interviewer will ask, give you a case. So what would you do? You know, um like we discussed in the A LS course, it will be very similar in an interview. They want to work out what you, what structured approach you take if you can fulfill like cover all the A to e and take and, and therefore use A to e to figure out and deduce what's going on and how do you properly treat and manage it. It's an interview standard. I just wanna, before we go into it, I actually want to talk about some common pitfalls er when it comes to at, people tend to forget the D the D and E um everyone kind of knows ABC like airway, breathing, circulation, but disability and exposure. Um You know, those two are very important points and you may forget during the heat of the moment and not complete the at and you might miss a sign, um, in DNE, which might escalate things quicker or point you to a completely different cause. Um, as you do an A to e you might, um, you know, focus on something, um, er, rather than moving on, obviously you should focus on any obvious signs and especially if it's life threatening, you should manage that before moving on, but once something's slightly dealt with, you might forget where you go back to and you might have to end up doing another A to e because things might have progressed, you might have left it delayed it a bit longer um for things to be different. Uh So, um yeah, people kind of rush into things, but even in interviews, you've got to say uh and ask the question, like is it safe to approach the patient might be needles, there might be tools on the floor, it might be wet, it might be slippery. Uh It might be a patient requiring PPE you might have just walked into a, into a single room, they might have tuberculosis. So you need to know what is around the patient. If there's any risks when approaching a patient, cos then you might jeopardize o other patients around you. Um and cause a breakout. Um These are all, like I said, important for interviews and the main thing is also, you know, at e has multiple factors and um uh when it comes to serious signs, you need to know when it's requiring escalations sooner it comes with clinical experience, it comes with nuance and understanding what other life threatening uh conditions that we need to look out for. So, if we're talking about airway, you know, like we kind of mentioned in a s like, is the airway patent, is there any kind of direct occlu occlusion? Is there a foreign body? Is there any aspirations, secretions, blood objects, foreign or otherwise that may be in the airway and blocking um air from getting to the lungs? Um Is there any anatomical narrowing such as, you know, an allergic reaction, tracheal narrowing, tumors, uh inflammation, infection, even high BM. I, you know, think of sleep apnea when uh patients with large BMIs lie down, they might have some slight restriction to the airway because of the fat that's around the neck and even like vocal cord paralysis. Um But that's more of a a LS kind of thing. It still can happen. Someone might just suddenly not be able to breathe and might be experiencing some things. Uh You know, you can see them, there's some findings like hard to breathe, shortness of breath. Um Stridor is a big one that you should think about as peripheral cynos, especially more noticeable in elderly um uh or, or CO PD patients. Um And if the respirate is pretty high, um no, like when we talk about the at e the way I like to phrase it is, you know, we're, we're doctors, we're investigators, we're detectives in a way. Right. So, uh, you know, you should always be asking questions, um, as to the status of the patient. So, is the airway patent, you know, that would be the kind of first question we have to, uh, think about, um, you know, aspiration is very common, especially with patients with an NG tube. Um, reasons for why they might have an energy tube is um, well, I worked in general surgery. Most common would be for obstruction. If the, if there's a obstruction or blockage in the intestines, then V CS can't pass through, everything builds back up and goes up through the stomach and out. So by putting an NG in, we're kind of sucking whatever's coming up out of the body. Uh But, you know, if they're in the first instance, if someone has a vomiting episode, um then things can get into the lungs. So that's aspiration. Also, if they're neurologically compromised and a stroke, then their reflexes will be damaged. So anything they, they vomit can just get immediately thrown into the lungs and cause an infection. Um And uh, like when I think back there were two cases, I can think of like, uh we had a stroke patient who, you know, after you have a stroke, you have a dietary restriction and the, the, the, the diet, the dietary therapists are there to kind of build you up uh to a normal diet and that takes time after a, uh, a stroke because there's some neurological damage for the, especially for the esophagus. So, um, there was a patient who was on a specific diet plan but he was non, non compliant, er, didn't want the food we were giving him and his wife, like, snuck him a pack of biscuits which he hid from the nurses and in the night he had eaten a biscuit and he got stuck. Um Yeah, he, he got, he got stuck in his uh esophagus when he tried to swallow and he went into a asphyxiation and died from cardiac arrest because of the simple biscuit. So, you know, it can happen. Um Another patient like we were on HD high dependency unit. It's a unit to where it's not a ward, it's a ward, but it's not a department specifically to yours. It can be having patients from different departments but who are in a bit more of a precarious situation that requires more frequent monitoring or they might have central lines, arterial lines and might need higher management from and and more eyes on them uh so to speak. So we go upstairs in, in this department, in our hospital and a neighboring patient not under our care developed Stridor, which is the sound of, you know, difficult inspiration. It's really like that. But this patient, you can hear it from the end of the corridor. It was so loud, which kind of is an immediate red flag. It, and it shows severe deterioration. Uh Something is blocking the airway. We watched the main team cos this patient was under ent um So I watched the main team come in and uh the registrar was called in on call overnight. Um And so was the consultant, cos they had to look, er, they passed a tracheoscopy down to visualize the vocal cords and it was completely shut. It was amazing to see. Um So the patient was taken to it for intubation. So this is why you know, airway is important. So, yeah, so these two cases and this is the vocal cords and on the left, you see, um it's just closed and it will not open, which is like a neurological failure there. Um So let's move on to breathing. So the question here would be, are they breathing comfortably normally? Um Now you need to know uh the normal ranges um which is gonna be 12 to 20 respiration, um breaths per minute. And um you know, this is something you have to just keep in, keep in your mind, the more you kind of keep the reference ranges in your mind, uh the more efficient you'll be when you're looking at the values on the patient's chart on, on any active monitoring that's going around. Um We also want to know the saturations which is 94 to 98% in healthy um normally healthy patients uh or normal, so to speak, because there's an exception um which is 88 to 92% in COPD. Now, quick question, can anyone tell me why? Uh why do we have a lower range? We, we obviously want patients to get enough oxygen and keep the blood uh blood cells, you know, well oxygenated and that helps the the metabolism of the cells. Um you know, the normal kind of metabolic processes in the in the cells. Has anyone got any idea as why we aim for a lower um po two uh or oxygen oxygen saturation and you want to, but to be fair, I don't blame you because when I started it, it kind of caught me off guard as well. I was thinking, well, you know, everyone needs oxygen. So the main thing with um CO PD is that CO PD chronic Obstructive Pulmonary disease found in heavy smokers, I think smokers, you think there's um more CO2 retention because there's like impaired effective ventilation. These patients have a chronic level of CO2 in the lungs which is causing the lower than normal saturations of oxygen when you assess a COPD patient normally. However, if the oxygen is too high, then that actually, you know, there's a respiratory drive center um in, in, in us where if we get too much oxygen, then it tells us that we are having too much, we need CO2 for a healthy um ph uh because it'll become alkalit So it slows down our breathing to try and reduce the amount of oxygen that we take in. Um And you know, the thing with that is they increase the CO2 in the lungs because then suddenly your ventilation goes CO2 will rise rapidly and it will cause sudden, you know, respiratory acidosis, which can lead to death. So, especially in respiratory units, um there's something called noninvasive ventilation and it's interesting you should look it up where in those cases when COPD patients have been given too much oxygen, they can correct it with these kind of noninvasive means to try and correct things slowly. Right. Looking at the rest, you know, we have to do examination in a thoughtful way, you know, inspection, palpation, auscultation, these are the things that we've touched on in uni but what are you looking for? So at the end of the bed, you know, you can see someone having any shortness of breath or cough. We talk about stridor, there's types of breathing you've mentioned, you know, there's chain Stokes which is cyclical like apnea with different depths of inspiration and the rate of breathing. Um And there's different causes for this. We won't get into that, but that's one, there's Kosel ones as well, which is a deep thigh respiration, uh mainly associated with an acidosis, namely diabetic ketoacidosis. So look up those kinds of breathing for more information. Now, our patient looking at the tracheal position is any deviation. Um Is there equal chest expansion? Uh We can also percuss obviously doing from side to side comparing as we go. Um looking for any hyper resonance, any dullness. Um But you know, in a loud busy environment percussion really is not used as much, obviously in demonstrations, you need to show that, you know what you're doing, but in reality, you may not elect to use it, it might be too loud around you, especially if you're on Ed or A&E or if there's a million people crowding around the deteriorating patients. So just have that in mind. Um And auscultation is the main one. So we need to look at any CRPS or crackles, dullness, bronchial breathing or like wheezes. Uh these are general things we all should know. Um So we look it up as well and obviously any trauma, you know, especially if you're an Ed. If someone's got a knife uh in the in the lungs, there's immediately things we can think about as uh as to what's happening. Um uh chemo pneumothorax, there's blood in the lungs as a result of trauma, uh and a and a pneumothorax at the same time. Um So there's a lot of things here. Now when we're initially kind of trying to manage the patient, I mean, we need to ascertain um the oxygenation status, the ph um and compare that also with uh the metabolic side. We need to look at the bicarbonates. So we need an ABG really. Um And uh you know, we aim for the radial artery um which can be down uh here, there, we are down here, radial, right uh on your thumb and you palpate go in with a heparinized needle and hopefully hit the artery. It's a bit difficult in deteriorating patients, especially in hypervolemic patients because they're in a state of shock. So the arteries become a bit more harder to find. Um So, uh you know, we're looking for oxygenation content, also the carbon oxide because we need to rationalize if there isn't a respiratory or metabolic acidosis or if there's any metabolic compensation going on, if the patient will give us clues as to what's been going on, if this is something that's built up over time and the body has been compensating for it till now and then it's crashed. And we can consider if there's any organ damage or organ failure at play. And if this has been going on longer or is it or not, um you know, if we're talking about the lungs, we need a chest X ray. If we're concerned of any respiratory or lung impact, we need to get a chest X ray, specifically portable bedside x-ray. Uh there's different trusts uh across the country, but generally speaking, uh if in, in bigger hospitals, they have, you know, portable X rays, otherwise it's a standard X ray. Um And you know, the main thing we wanna do is provide oxygen. If it's required, there's a saturation probe that you attach to your finger and it will measure your oxygenation. So a nurse might call, you say there's patients um who's normally fit and well has a saturation of 92%. Ok. Start oxygen, nasal cannula, 15 L. And we need to titrate that down. Never keep out 15. For the same reason we talk about CO PD, we don't wanna impact their res respiratory drive. So you would start on 15 L of oxygen, nasal cannula. That is the standard that is high flow nasal cannula. Basically, if you say high flow to anyone, then it's 15 L of oxygen. And if you, you know, it's a standard thing, high flow nasal cannula, 15 L um and see if the saturations increase. Um if they do titrate it down as appropriate, nurses will know how to manage that. Um They know that they have to titrate oxygen down um to keep it at a safe level. They're aiming for, you know, um like above 96% generally uh or no around maximum 96 I put 98 there. It's 94 to 96 ideally, but 98 is also acceptable, but 96 is probably the best in between. And you know, you think, think logically if someone's lying down and they're struggling finding it hard to breathe, sit them up, try and give them some support, especially if there's any way like like high BM I issues. He wants to just get the weight off so they can manage breathing better, right? Circulation. Um, again, learn the normal ranges. We, we need, we need to know the normal heart rate, which is between 60 like 99 like anything. 100 and, and above is gonna raise an eyebrow. Um, uh, so is this therefore Brady or is it tachy? If it's below 60 it's Brady. If it's above 99 it's considered tachycardia. But there's nuance, as we've said, we'll go into that. Uh No, the normal BP, which is like 100 and 20/80. And it therefore, you know, is the BP Hypo or hypertensive, um look at the food balance, which is incredibly important and kind of something as an F one you're really taught about a lot fluid is very important. Um especially in a hospitalized patient. If they have impaired diet and impaired like parenteral, um, enteral access, I should say you need to keep their fluids up. They're constantly, constantly losing fluids. And the thing that matters most in, in that regard, organ wise is, is gonna be the heart really because um the heart is managing the blood, the blood contains the fluids which are not in the cells um and will respond in kind if there's a sudden drop. Um And if there's too much, then it relies, uh then the fluid will simply leach out into the lungs. Uh might be edema. So when examining, look for the color pallor, think pale cyanosis, um like peripherally and think of edema, peripheral like at the ankles is a good marker. Um And think of, you know, there's ascites in the abdomen or severe sign, but if there's ascites, think of the abdomen, um palpation, CRT capillary refill time should be less than two seconds, grab the farm, pinch it down and you know, let go, it should come back red, less than two seconds. Um Again, kind of showing a hypovolemic state if it's more, taking more time for it to refill the blood. Um you know, think of temperature, you know, are they cold, are they warm? Um and JVP uh jugulovenous pressure, very important can show, you know, um sudden backup of of fluid and blood. Um If there's a heart failure element to it, you can see it um quite visually on the side of the neck, but there are specific methods to measure it otherwise you look at. So yeah, in this day and age patients will always like especially older patients will always have a heart condition like hypertension. Um and you know, everyone's different. So you need to rely on the patient notes um and the monitoring serial monitoring notes to see what, what's the baseline for the patient, what's normal for the patient. You know, someone who can have a high BP might be physiologically fine, they have hypertension fine. It's not an emergency is it if they've always been 100 and 40 systolic or 100 and 60 systolic and they're fine. It's not a acute issue. It's a long term issue. They'll need hyperten anti hypertensives. Um, or they might need management of it, might need to, might need to talk to cardiology to rationalize the new treatment or for them to see in the, in the field outpatient to get it down to a healthy level, but it's not an emergency. So you need to know the nuances that come with it in terms of fluid balance going back briefly. So, you know, on patient monitoring, they will have usually a track fluid intake output. Uh it's part of the notes. So how many fluids a patient has had orally IV uh or otherwise and you know, urine output, um any vomiting or any bleeding, you know, everything's accounted for. That's the aim. So there's we everyone knows what the status is and you know, this is the kind of the pitfall is poor monitoring. So make sure you're always checking the notes to ensure that the nurses are also monitoring the patient properly, especially if it's a serious patient that you want monitoring for, you have to state and make sure they're doing it. You know, women talking about palpation, just have, you can kind of see if they're flushed and if they're sweating, they're looking like they're having a bad time. So you can kind of see these things at the end of the bed. Auscultation is the main thing here. You see HS one plus two plus zero. So that's a general format for heart sounds. So heart sounds, if you can hear one, that's a one plus two, the second beat plus zero, it should always be zero. If, if there is, then it's plus three, which is a third heart sound uh which can happen, but it's a very serious uh thing we need to look at. So that's how you document that. Also. You can document any murmurs, any pericardial rubbing or any muffled heart sounds for any pericarditis uh that might be going on initial treatment. So we need IV access if they're newer, most patients, if they're depending on the ward will have a cannula in place already for any fluids. If they're hypervolemic, you want to form a set of bloods, you want FBC using these LFTs CRP mainly because you know FBC, you want to assess if there's anemic. If there's blood loss, you can compare it from past values to see if there's any acute blood loss or internal bleeding, any anemia that's in the picture if they're new um that you were, you know, it would be able to tell you and then you can look back in the history and see if they've got an anemia diagnosis, what the type is. E um you know, we want to look at the renal status and especially the electrolytes, electrolytes have a big effect on the heart and heart rate because we need to think about any possible arrhythmias that will be going on. And what's the, you know, what's the calcium, what's, what's the potassium? If we're thinking of circulation, calcium, there might be and, and you might need to add, you might need to add that on as a investigation on the system because it's usually sodium potassium that comes through and chlorine ions, uh potassium, uh sorry, uh calcium magnesium, those are separate investigations. But if we're worried that if a patient has a lot of heart comorbidities, you might want to get the calcium and magnesium uh and make sure that's fine. Also, I didn't mention it here. We talked about it, I think briefly in the ALS but with the heart, you want to know if there's any myocardial infarctions, right? If you need to think about any chest pain as well. So if there's any clinical signs of a heart attack, then you know, you should add on a troponin. Troponin is a protein, you know, released when the heart is damaged, high levels, there is a strong correlation to a heart attack. Obviously, you need to rationalize that with an ECG. So you'd ask for a 12 lead E CG as well. C RP is mainly inflammatory marker. Uh but it will help in the grand scheme of things to, to degrade the scale of inflammation and damage. Yeah, you might be confused with bladder scan, urine culture. But when it comes to fluid balance, we need to, if there's, you know, a reduced urine output and the patient has some pain abdomin, you might have, you might think that it's wise to scan the bladder, there might be an obstruction there that might need the catheter and urine culture, especially if they show any infective signs. Uh You might want to consider potentially like uh endocarditis or something. If, if there's really, you know, no kind of cause as to what's agitating the heart, you might have to rule out any in uh if there is effective marker signs, then you might need to collect cultures from the blood as well as the urine just to see uh if there's any bug in the system. So yeah, what can cause sudden changes in the heart rate? We've already kind of briefly talked about it, but, you know, hyperemia, it's like physiological function reaction to low volume in the blood infection will always drive up the heart rate. Um arrhythmia, irregular heartbeats, you know, think of electrolytes or any other preconditions. If any past Mr S or heart attacks, that the heart might be fibri, there might be changes in the pacemaker locations, there might be compensations, there might be heart blocks. So you have to consider that even pain, you know, something as simple as pain might be causing them a higher heart rate. Uh So there might be a trauma element that they may not know about or might be undisclosed to you as the doctor, they might hide something, especially if they, if it will give them if it, you know, risks a criminal investigation, you know. So let's move on uh to disability. So this is like I said, you know, the underappreciated kind of like overlooked areas. So disability, what does that mean? So does the patient have a reduced loss of consciousness? Sorry, a reduced consciousness, I should say not reduced loss of consciousness, but is, is there loss of consciousness and is there reduced consciousness? So the scales we look at G CS and we look at a CVP U which is like levels of consciousness where alerts, you know, the patient is alert to your voice and they're fully aware of what's going on. If there's any confusion, it's just new or worsened. Very important in dementia patients. Um especially when I, when I was working on stroke, there was baseline confusion which is also kind of mixed into the picture after having a stroke that we have to kind of work around. Um and it could, the stroke could have made things worse as well. So you need to understand what their baseline is verbally is there, are they talking normally, you know, again, stroke, it's kind of relevant here. Er, if there's, if they're not talking normally, if they're slurred speech, you need to call and get a CT head scan immediately because the patient might be having a stroke uh along and do the rest of the assessment for stroke. We'll talk about that brief in brief later in the, in the, in the next presentation. Um And verbally, you know, if they, if they're wincing, if they're struggling to speak, if they're in pain, you know, they're not going to speak normally, are they? Um and speaking of pain, you know, are they responsive to pain? So there's different methods of this. There's something called, I'll bring it back to the slide. I can put a camera in here. So there's something called, um, a sternal rub. Now, this is the thing. They are different. Um, there are different ways of assessing pain. Um, historically, er, one was a, a sternal rub where, you know, if you're exposed to the patient's chest, you pull your hand up in a fist and you're pressing on the sternum and rubbing up and down and it is painful. Um, and should generate a response. However, you know, um, the Research Council have advised that it is not appropriate because it can, it, it's not the best method um, of use. And, um, you know, they would advise a Trapezius, uh, Trapezoid pinch or you get the traps, um, you get the traps and you, you know, pinch deep, you know, if you have, you might have felt that before but it's very painful if you pinch hard enough. So that is more appropriate to use when assessing if patients are responding to pain. Um and you know, are they unresponsive if there's no evidence of any eye voice or motor responses to pain, you know, open the eyes if there's any uh light reflex as well, uh if there's any dilated pupils or pinpoint pupils and then, you know, fixed pinpoint pupils, you know, you need to think about any overdoses or any drugs. Um So this is the G CS, which is a Glasgow coma scale. It's one to it's scored at 1 to 15. And I got an image on the right to kind of demonstrate that. So it measures the levels of responsiveness and orientation. So like I alluded to earlier, so you need to do a pupillary response and you briefly kind of test their urology and you can only probe probe deeper if it's kind of concerning. But you know, if you can see that they are obeying your commands, moving and localizing any pain they are feeling or, you know, they might be eyes closed and not really responding to your commands. But if you do a trapezoid pinch, you might see them like instinctively reflects away from the your pain stimulus. So uh if there's any, the the neurology comes in when we're talking about abnormal flexion and abnormal extension. So, so look up uh your, you know, assessments for a neurological exam. Um the neurology exam for physical assessment is, is important in these situations, especially for example, if you are on stroke or like neurology. Um So like, I alluded to earlier, if there's, you know, pinpoint pupils and they're not or dilation and there's no response. So we need to look back on the drug chart to see if there's any causative agents. Think opioids, think sedatives, think anxiolytics, these can cause um you know, sudden changes in consciousness or sedative kind of effects. Um but also we need to get uh ABM. Now BM is an outdated term for the glucose strips used in the testers. So if you, it's a, it's a quick term like nurses will use uh when they're getting uh a glucose level, uh pinpoint glucose level from a diabetic patient. So, cloacally, if you ask the nurse, can I get ABM of this patient as well? They'll know that you want a glucose level or you can just specify on, you know, a blood glucose. Um The normal range is 4 to 5.8. There's different kind of mill moles and all that, but 4 to 5.8 is fine. Um If abnormal, then you need to check if they're symptomatic and you need to uh check for ketones if there's any uh DK A at play here causing a reduced consciousness. Um So, e for exposure, are there any other hidden cause of deterioration? Um This is when you basically need to expose the patient for any potential triggers, you keep them you know, keep maintain dignity if they're, if they're, you know, a woman or otherwise, you know, you need to cover up their sensitive areas, gentles or their breasts, anything they would care about, you can ask them if they're conscious, you know, and, and talking to you, you can ask, uh, can I cover this? Can I cover that, maintain dignity at all times and keep in mind that you, they're gonna be exposed, they might feel cold. So try and work quickly. So, you know, have a look at the skin. Now, are there any rashes, any bruises, any infections? Um look at any cannula sites. There might be uh uh phlebitis um at play uh infection at the site. Uh because you can see it like uh you can see it tracking up. If there, you have a cannula in your anti in foster, it can track upwards the infection. So there's kind of telltale signs there. Uh do an abdominal exam, you know, if there's any abdominal pain, um look at the uh at that point, you know, we're looking at palpation and percussion auscultation, you know, the basic examination. Uh and you can kind of work out the abdominal causes. Is there acute cholecystitis? Is there obstruction? Is there a hernia? You know, you have to work through that accordingly and therefore might have to call general surgeons uh for their opinion. Uh Is there cyst as well? Um So, you know, calve tenderness, why do calves get tender. You have to think about DVT. Uh it's very, very, very, very painful. So I hear, uh, you have a clot in, um, in the fro, in the, in the veins, uh big veins in your legs that blocks up blood. Uh, you know, uh around the lower limb gets congested and this, and this tissue gets ischemic. So it becomes a big problem real fast. Fluids leach out and you have a lot of edema building up. So, you know, calf tenderness or any swelling is very important. Um, for ruling out DVT. Do they have any surgical wounds? Especially for those, if you work in general surgery, there will be wound sites. Is there any, you know, irregularities there, the borders, uh normal, is there redness, is there any purulent discharge or any blood coming out? You know, I think logically are the sites, you know, infected drain sites too, you know, look around the drain sites. So these are the port kind of drain sites that might be on the side of, you know, the abdomen here. If they're going inside, they are just tubes connected to the body. So, you know, they can get infected any internal bleeding. You have to look at the, um, if there are drains, if there are drains there, look at the piping, look at the C bag, the drain bag and see if there's any blood. Um, that might be indicates that some of the surgical closures have opened and there's internal bleeding. Um, yeah, you need to also consider, er, PV or PR bleeds. So, if they're a woman have, they got suddenly had APV, bleed or is there apr bleed per rectum? So, uh you might have to, you know, uh, whilst maintaining dignity as best as you can explain briefly to them that I need to just have a look just to make sure everything's all right. Have a look, see if there's any bleeding or any discharge, then continue on. I mean, if there's any bleeding, obviously, you want to control it. If there's any overt bleeding uh on the body, then you want to control it, especially if they have a cyst that's burst or something like that might need some padding, um some gauze and the like uh some compression uh bandages or something like this. Um But you know, if there's internal, then you need to escalate. This is one of those things where you have to escalate appropriately, right? So, and if they're Hypodermic Hypodermic, you have to manage their temperature um and manage any infections if present. So this is a news two score. So this is a commonly used score. 99% of hospitals in the country. This is something that you should be aware of. Like I said earlier, learn the ranges of the middle score zero, those are like normal ones, the normal references. Um Right, you see the systolic pressure can go up to 219. Obviously, it is still something to consider, especially in a, in acute med or gen med. If they've got hypertension, there is an accepted level of tolerance, but I would say looking at 100 and 80 would be, and if they're not on any, any anti hypertensives, there will be a discussion with the consultant to start a patient on antihypertensives. But in an emergency, you know, if they're having a uh some sudden event, if it's above 220 then it's out of the range of hypertension, normal hypertension. So that's why they put it all the way down there. So I learned what uh you know, is a normal zero score. We don't want any numbers ideally zero on any healthy normal patient. Obviously, like I said, hypertension can score a one can score two otherwise or like heart rate can be elevated, might be the baseline. So there's new ones here requiring your input. So yeah, essentially this is only for like equal or above 16 years old. It doesn't account for ped er like pediatric patients, obviously. Um and this is used, you know, for initial assessment if a patient comes in er for admission, um the the nurses will do that first to get a baseline serial monitoring from then onwards and any assessments if the the the patient's deteriorating. So, you know, from, you know, speaking to nurse and colleagues, if patients are scoring zero and they're stable, they kind of delay their serial measurements. So they're less frequent. So if they're having a deterioration, then they will assess again with this score. So essentially, again, prehospital why it's imposer, it's important to know what a normal reference is when I was on general surgery. Um Sorry, uh when I was in general surgery I held the bleep for GP referrals for general surgery. So I would get a call, a consultant would call me and say hello. I think I have a patient that needs admission to general surgery. And then I ask them, what's the new score? And you know, some of them may not have done it, it might be really acute, but they'll give you a score and you then have to ask, you know, what is the patient's scoring for? Is it their baseline? Is this normal for them or is this out of the ordinary? It kind of builds a case for you as to why the patient should or should not be admitted? And your seniors will ask, you know, if, if they're actually deteriorating or is this their baseline because they have CO PD or otherwise or other things going on heart issues, you need to know what you're getting. Um This is an example um that I found. Um, so, so you can see here um the values that a nurse or for example, has found and you know, on the charts they'll calculate it at the bottom um to add up, add it all up together. Uh So you see the respirator is 21. So it is elevated oxygen saturations are 93. So the lungs are affected here. However, the patients on there at the moment and the BP is stable systolically at 120 with a slightly elevated pulse and a temperature, wait temperature 38.5. So the new score is six. What do we think you know is going on here? What do you think the cause is, can anyone say? Um and we can if anyone's got a clue? 00 yeah, I see a question. So in what situations would the A C BPU scale be better to use on the Glasgow coma scale? It depends on the the hospital really. Some people use A C BPU in a very acute circumstance um to quickly kind of ascertain what's going on. The G CS is there is a scale, it's a scoring method. So one could say that takes a little bit of time to calculate exactly. But uh and people can just use a C BPU alert, confused voice, pain, unconscious to quickly triage things you can use both. Um And in monitoring nurses will do a quick G CS just to make sure things are ok, depending on the trust in the hospital, they might elect to focus on G CS over A CVP U. But G CS is a score that's the main thing. A CVP U isn't a score, it's just a quick assessment. So when a, when a patient acutely de deteriorates, use A C BPU, it saves time for you as a clinician trying to work out what's going wrong. Um And if you have time, you know, look at the, you can rethink and er think back to what happened when you saw the patient and work out a rough G CS, that's fine. Um Also, you know, med CALC is a uh is a site that has loads of calculations that you can use. Um and you know, can plug values in and it will automatically calculate these things um which makes things easier and faster uh to use. So I hope that helps. Um But yeah, going back, can anyone kind of tell me, you know, what can, what's going on here? Right? Told you a lot already. Um We've covered A B and C, we've covered the heart and there's a heart rate, right? We've covered the lungs, there's a raised respiration rate, there's low oxygen saturations and we have um AAA temperature of 38.5. So it is, you know, Pyrexic. Ok. So can someone answer and just say what they think is, is going on here? Think very simply the clue is in the temperature and therefore the lungs. I want an answer. Yeah. Thank you very much sepsis. Very clear, simple picture for sepsis. You have an insult to the lungs because there is saturation decline in 93% in a normal person that is quite significant and an increased rate of respiration. So, there's a increased demand on the body now because the body is feeling uh you know, some hypoxia um or hypoxemia, which is uh decreased oxygen in the blood. And what's causing that increased metabolic demand for oxygen is a, is an infection. It seems. So after I see this, I would ask myself what is the source of infection? And then we start the A to e, right. Er, so going so even like this, you know, a nurse might, you know, sh bring you a chart and you'll have to quickly scan through, work out what the news is or they might have calculated it for you if you've got some very kind nurses, er, it's commonly done, er, they'll calculate the news call you and say, oh, we have a new six. We need you to assess but bear in mind there are still cases where news of five and six can be explained quite quickly and easily with any pre er, comorbidities, er, or baseline, if they've got very, if you, if they've got a lot going on, their internals will not be optimized compared to a normal human. So they might have a raised new score but nurses will highlight and kind of might push you to see a patient that is inappropriate for you to see. So you need to know specifically um what the patient is going through and if this is normal for the patient. So before you run off to go and see them, like their life depends on it. Just look into their patient notes, right? Very, very, very important thing you should take with you before you practice. Always look at the patient notes if their new score is ex extremely high and they're decompensating and they're, they're, they're acutely unwell. Then of course, rush, it's an emergency. But if the news 56 and the other, you ask the nurse otherwise stable, uh, at the moment and they might say, yeah, it look unwell, but there's no, he's otherwise talking or he's otherwise uh stable at the moment. Then you have time to look at the patient notes, see what the diagnosis is, see what he's got, comorbidity wise, see what medications he's on and then you're well prepared when you meet the patient and you won't faff around wasting time figuring out what they had in the background while they're actually feeling unwell. Right. Um Thank you very much for answering that. It's, it's a very typical sepsis picture in and we, we, and where's the sepsis? We have a clue. It's in the lungs most likely, uh, because the lungs are affected. So we, it could be a viral infection or, you know, it could be a lung infection. We might need to auscultate, have a listen to the lungs maybe chest chest X ray, get some blood cultures. It may not be directly original source may not be from lungs. It can originate from the urine. We need a urine culture. You know, it gets you thinking as your as your experience grows, you immediately think of these things as you you get experience. So you know, this is just basic recap. So what did we talk about? The kind of elements here is like, look, listen and feel um and do a head to toe examination. At most of the, at we've discussed, you know, inspecting from the airway, you know, we sort of looked at the lungs for ventilation, breathing stars, for example, we talked about trauma, any swelling, any inflammation, infection with, listen, we're auscultating the heart and lungs so we can um assess for normal heart rates. Um um and you know, if there's any uh lung issues, coughing, stridor, shortness of breath, uh or any basic communication that patient could give us, uh which can give us information for, you know, a CVP U or G CS. Um We feel we, we palpate percuss um and you know, feel the calves, you percuss, the lungs, percuss the abdomen. Um But the what, what, what is something I've not mentioned? What aspect of examination have I not mentioned? It's, it's the back, right? Very, very, very important. Oh, sorry, I see that question just now. Er, what news to is called? Require escalation. Yeah, there is the, the, the escalation we'll get to, um, right, the escalation, er, we'll get to, uh, in a second. But, um, you know, an escalation depends on what the patient is experiencing at the moment. So you will have to assess the patient first before you escalate uh further, but we'll discuss that in a second. So the back, the back, always check the back, it can hide a rash, it can hide an infection, purulent cysts that might burst any trauma, any bleeding. But when I was on the A LS, one of the instruction instructors mentioned uh that he missed a trauma wound, er, in the axilla, there was a like a, like a, a knife er, injury in the axilla and the patient was bleeding through that the patient was kind of lying flat, so he didn't see anything so, you know, exposed properly and see um and, and assess properly for any missed spots like the axilla. Um, don't miss out the toes, especially in diabetics who don't want to see a toe going black. That is all it's about a sign um for any sudden ischemia. So yeah, always look at the back, right. Uh Never forget that you'll have to, if you're thinking of an obstructive picture, you'll have to do apr examination. So you will need to rotate the patient onto their back and onto their side at least. So you will be able to get a view. But if you don't think of doing apr examination, still consider the back and make sure there's nothing going on there. Ask nursing colleagues, can we just rotate onto the, onto the back? Can you just lift him forwards? Can I have a listen to the lungs on the back as well? Just to make sure you're covering the back as well to some degree. So we'll talk about briefly about initial management before we get on to escalation, right? Um, so, you know, oh, I see the other question. Um, you know, what's the threshold in terms of response needed? Uh when regarding the news to there is, you know, if you ask nurse and colleagues and if you look it up, you know, nurses are directed after news four or five, well, five, they need to call the doctor team to assess the patient and that inr and then the monitoring of the patient is more frequent and that scales up um with the new score, the threshold in terms of response needed to needed really depends on the situation. So say if you have a normal patient breathing otherwise, well, who's new? Zero? Suddenly a nurse calls you saying they, they, they look really unwell, they've, they've suddenly taken a turn for the worse. Something's happening. I need you to come and assess, then you need to run if they cos they haven't even done any, er, er, er, you know, taken any vitals at that time. They are that worried I would run and just make sure things are all right. If they've taken a new score and it's 45 on admission, then, you know, you can say, you know, if they're otherwise well and not acutely deteriorating, then take another measurement in an hour. So we can or take another serial measurement in a, in like four hours, whichever is more comfortable for you and see if their, if this is their baseline. Um you know, and if it's only news eight from a news five like POSTOP patients, they will have a nasal cannula in situ. So that also I forgot to mention if a patient is on air, that is a zero. If a patient is receiving oxygen in any way, shape or form, that is a new score of two. So, you know, postoperative patients may have a nasal cannula after an operation after coming out of theater, it's a recovery phase, uh especially if they've been intubated, intubated for theater. Um So they already have a new score. Then if you had hypertension, then you, you had, you know, heart rates above like 100 and one, they're already in news five. So if they suddenly go to news six, well, if you already know their baseline is news five and they've just stepped up to news six, it could be something minimal, but you have to rationalize it with the, with the patient. And the case if they suddenly jump to news tw, like, er, news 10, then obviously run it. It really, really depends on the patient and their ba background and their baseline. But when it comes to escalation, we'll discuss next. It's always about the status of the patient and what they need. Er, and if they can't manage with, uh if you can't manage the patient, you, if you expect the patient will need to go back to theater, will the patient need intubation, anesthetic support, er respiratory support? Itu you know that question will kind of help with isolation. So the initial management management, we're not treating all, we're not um treating the underlying cause. We're trying to manage a patient and keep them stable, preventing any further deterioration. So, supplemental oxygen could be with a nasal cannula, uh face mask, non rebreather mask, there's loads of different ways. Um temperature control, positioning of the patient, wound management. Um initial management by taking bloods cultures, that's not gonna do anything for the patient. These are all kind of helpful management tools to kind of help us diagnose and control whatever's causing this deterioration. Utilize the people around you. If you have nurses who are with, you attend whilst you're attending to this patient, rely on them, ask them er you know, for any if, if you're worried, then ask them to go to the doctor's room and call a more senior member of the team. If, if you recognize a life threatening or urgent thing that you're a bit unsure of, never hesitate to ask for help. Even in interviews, they will ask you appropriately when doing an A to e you know, uh would you know, what would you escalate this patient? Uh If you recognize a life threatening thing like a LS, the first thing you need to think of is shall for help. So never hesitate to ask for help. Um You know, however, there is some nuance um it will be up to you to know the urgency. Um, so you might need to leave at some points to come back with any medications or you can ask nurses to get medications and you might have to go get a blood kit to get some bloods. Uh, but you know, if they're showing signss of say anaphylaxis, there's no hesitation, you must run and give some adrenaline right there. It is, you know, dependent on the case. Um, like I said, be be polite to nurses. They are there for to, for you and for the patient and you know, lightness goes a long way. Um, in the wider MDT, they might be tending to another patient. So use proper communication skills when delegating. I think back to what we spoke about in the A LS, right? If they're tending to another patient who's unwell, uh I just ask them when you're free, come by and give me a hand with this patient while I assess him perfectly reasonable thing to ask. Ok, now, escalation. Yeah. So as you kind of guys already know a lot can happen uh with a patient and a lot of things can trigger um you know, escalation to you as an F one from the nurses. So what triggers an escalation to anyone senior? Well, the name of the game is situational awareness, right? You'll only kind of develop this as you continue to work as a doctor, but you should have, you should know the um the life threating um issues that can happen with deterioration. If you are, if you are worried and want an opinion, always ask no one's gonna scold you for escalating something stupid if you, if you're not sure right over time. However, there will be an a, a silent kind of expectation that you can manage it depending on the situation. Obviously, that's appropriate for your level as an fy one. If someone's having a high temperature, if they're showing a septic picture, you should know how to handle it. But you can always chat to your F two and give them a call if you're in another part of the hospital attending to them or go back to the doctor's room after you've had a look at them and assessed them and you've found sepsis. So you can mention, you know, in, in passing, hey, um you know, F two, uh I've just seen that patient um that I just got called for this patient. Uh They got a temperature spike of 38.5 and impaired respiration and sat. So they've got a probable sepsis. I'm gonna do a sepsis. Six and, um, start fluids, start antibiotics. And when it comes to that antibiotics, you know, we'll discuss that later, but each hospital has a kind of protocol for it. Er, but we'll get into that later, you know. So you can always communicate to them. I want to start antibiotics. I want to start fluids. They might chime in and say, ok, give this kind of antibiotic, give this kind of fluid first. Everyone might have their way of doing things so communicate. And if it's not serious, just make people aware of what's going on. At the very least if this is, if, you know, for me, say I'm experienced and I've seen, you know, sepsis pictures, I've seen POSTOP complication, pictures, say if I postoperatively after a patient comes up from the theater, we do a review of the patient, which is what everyone does in a surgical ward. Generally speaking, if you find something seriously wrong POSTOP, if there's, er, suddenly an opening of their wound site or if there's sudden like 1000 L is a liter is coming out of their um drain and then it's all frank blood, then I will call my reg immediately. You know, it's all with nuance. Um, you'll experience this when you start work, but look into it, read around it more. There's different situations, especially if someone's having a stroke, if someone's having an M I or the best is call your F twos. Um, hopefully you'll be working with some lovely F twos. Er, everyone, er, you'll find everyone has a personality, right. You'll get along with people, er, and you figure pe, you'll figure people out but give af two, giving an F two a shout or apa, if they're good pa s, um, around you, if they're not busy. Um, in Scotland, the PA S I've worked with have all been absolutely lovely. Right. Um, they have a different system of their Deb compared to England and they're quite on top of things. Um, and there's not that many in Scotland, they've been really, really kind, um, supporting f ones initially. When you start work, you might feel apprehensive, you know, working with PA S ultimately politics. Isn't your concern? Right? Uh Whether PA S are good or bad, you can say for another day there at the moment if you need a hand and you want an opinion for someone, if AP, especially if APA has been working there longer than you. Always just chat to the pa say I've got this patient. Would you mind giving me a hand or what do you think? Um, they might give you some ideas as well, like I said, always ask if you want an opinion, if you're not sure, no one will look at you and grill, you for not knowing immediately if you're not experienced those that do take it on the chin. Say, yeah, you know what I should know this now, I have experienced it. I know what to look for and I won't waste time or I'll be more efficient and faster. Hospital is a tough place. You need to have thick skin. Uh there's limits to that, but you know, you'll pick up over time. So handing over, handing, over, handing over, like I talked in the beginning, you might need to talk to your registrar, you might need to talk to a consultant, right? Um If there, especially if there is a severe deterioration, a triggering like life threatening, if you know, you're first on the scene, you see a patient having some stridor or, you know, some, anything really. Um, and do you want to escalate to an F two or registrar? Whoever use an SB a right situation, background assessment, recommendation decisions if you're calling someone like radiology, well, not radiology, radiology. Yes, actually. So radiology might want the story as to why you, you, you think this patient needs a scan, even if the reg has asked you to call in a, a, um, er, if, if a reg asks you, can, you order a CT head scan, we want to look at this, this and this, you're the one who's gonna have to book it and put in the information and call the, er, the, er, radio radiology registrar to vet it and make sure it happens, the reg might take that call if they're really, really worried. Right. But usually that job's on your hands and it's a big responsibility, it can delay treatment and management. So, so part. Right. What's the situation? Why are you escalating it or why are you calling, you know, uh, what's the current status of the patient? What's the background, what's the stories of their mission? What were they admitted with? What uh what did they have er in the background? Current assessment is like at, at present they're deteriorating. So what's the at e what things have you found? What's their new score? What's their G CS? Are they responsive, unresponsive, what treatments have been started? Um And therefore, you know, why are you escalating further or what's the reason for the call? And you know, decisions is basically a summary that OK, so we discussed this, this, this, we, we, we expect you to provide us help by doing this or this, right? I've got an example here. So I'm using myself as the example. Um So, you know, after assessing a deteriorating patient, you are calling for help. Um you know, say to your F two. So you say, you know, hello, my name is this, you know, I'm on this unit. Uh Well, if they're your F two, you don't need to say what unit you're on. It's bad that you say what ward you're calling from especially if you're in a big hospital, you might be caught covering different wards from my hospital for general surgery. We had three inpatient wards, one admission, we had HD U to cover, we had, you know, new, a new pa inpatient ward, uh to cover. So localize where you are, explain which patient you're calling f er for, you might specify a bed if you don't know the name. Um, I'm calling about patient aid on ward like 105 bed two, right? So I believe this patient has like a pneumonia cos he's septic, he sat on 8% despite despite high flow oxygen, nasal cannula, for example, if it's a when handing over and escalating, you need to know why. So already there, I've said his saturation is 90%. Ok, fine, stick him on some oxygen. Wait, despite oxygen, it's still 90% that changes things, doesn't it cos you're already trying to manage it with oxygen and it's not improving and really signals an underlying issue that needs to be urgently looked at, right. Um So, you know, I wanted your opinion for further management and you know, background, you know, he's 50 fit and well had a fever and cough for a few days. He's only just admitted an hour ago for some abdominal pain. Uh Initially, he thought to be acute cholecystitis. He's not had an abdominal ultrasound yet, but we've ordered it. Uh but on assessment, he is well, well, and kind of tiring. So uh in his airway, he airway is patent, but he can only say a few words, his breathing, he's got like a high ba respiratory rate of 24 and he's got bronchial breathing on the left side. Um You know, his SATS are 9% on 15 L of oxygen. We are trying to get an ABG and a bedside chest X ray. If you're talking to an F two, you might just ask them, can you help? I need you to help me get an ABG and, or you can or can you order me a chest X ray? But in this circumstance, say if we escalating it to a registrar, you can say, you know, try to get an ABG uh and order a bedside chest X ray. Heart rate is 100 and 10 and BP is at 1 10/60. Um disability is drowsy saying a few words. Um And there's no rashes or any other things, see no signs of bleeding, uh no edema, no DVT, you know, palpations. There's other things you can say that I've just simplified it. Um So your reg might say in response. Yeah, that's fine. Um Yeah, that sounds a bit worrying actually, especially if he's got acute cholecystitis. It might be it the, you know, gall there might be a gallbladder perforation, right? If there's cholecystitis due to gallstones, maybe there's no diagnosis of it. But if there's gallstones, then if it's worsening. There might be, uh, a gallbladder perforation, right. A severe complication of cholelithiasis and therefore cholecystitis and inflammation. If the gallbladder swells puffs, it's a mess, uh, internally and there's blood, uh, loss and it's a, it's an emergency for, from a surgical perspective, then I might have to open him up. So, you know, reg might say, ok. Yeah, sounds good. I'll come by and have a look at him. Um, um, you know, uh you can also state, you know, I'm getting antibiotics ready. We've started fluids but you know, despite the oxygen therapy is not improving, can you see them? They might say, yeah. OK. Yeah, they might ask you to do some things or secure the ABG um you know, order the chest X ray portable and continue the measurements. You know, that's a simple handover thing but that you can see and appreciate. There's a lot of elements there that uh is demanded of you. So being organized, right? Getting the information promptly making notes of an at if you get a piece of paper, just write down ABCD. E just make some notes while you assess, write down the new score, write down the heart rate, respirate. Um you know, BP saturations. Um you know, all the values that you require for the new score, it can really help and make a note of their baseline, what they previously were. So emphasis is placed on the new signs and that's basically it guys, you know, we've talked about, you know, kind of scanning, uh scanning the patient, having a look over what, how to do an a to e what things we need to consider the, the depth of which we will cover in the next presentation, right? If I go all the way back, um the next kind of presentation, I want to look at the initial kind of investigations to kind of find out what might be going wrong based on the at right that we've discussed. And any further examinations, like we mentioned, abdominal exam, uh we can talk about that. We can talk a bit more about auscultation, we can talk a bit more about, you know, heart sounds, lung sounds, we need to talk about uh you know, EC GSI want to talk about ECG S 12 lead how to read an E CG cos God knows when you're on the floor and a million things are going on around you. You should be robust in uh reading an ECG and it's not, you know, expected F ones can read your E CG immediately. Um Without some support, you can always show an ECG to a senior, but you know, we need to talk about these things in more depth I feel or we'll be here forever and it's already quarter past seven. So I don't want to take up too much more of your time. We'll cover this next week. Hopefully, if not, I'll give a shout. And the last stage, we will cover the specific treatments to manage the underlying causes and more about escalating anything that's more severe or life threatening that touches, you know, our als kind of principles. Um But we can talk briefly about it. The last presentation after the initial treatments, we'll talk about cases, I'll, you know, bring up some cases and I expect some uh you know, a question answer response from you guys just to test yourself. Um After my presentation today, I want you to review the at ei want you to learn the, the reference si want you to learn um and focus on the examinations that we do read around for next, next week, read around for. What's that? Like simple underlying causes? I'm not asking you to look at like, you know, anything life threatening immediately, but think about the common things. Why, you know, why would you be called to a deteriorating patients? What are the common causes for deteriorations? Um Right. And what examinations would you do? Revise that for next week? And we can go through it and that way if you have any specific questions, I can answer them like I've been doing so far, right? So, so that was my presentation today. Um Any more questions we have before I let you guys go. It's been a long, long presentation. Uh But if there's any other points you want me to cover in the future one, you can let me know if there's um, anything I've missed or let me know, um, or anything from my at e uh, you can always let me know. Right. Obviously, don't, don't, you can always reach out to me. Uh If there's anything you want me to explain further, I'm always free, you know, if I'm busy, I'll let you know. But, um, I'm always down if you have a question otherwise. Yeah. Um I hope this has helped. Um, and I hope by the end of the session, you know, you guys will have an idea of how to assess a patient before you graduate. You'll impress everyone by saying, you know, if you've come from Bulgaria, not in the UK, but you can do a good at, you can operate a good ay station, you know, the common cause of deterioration, you know, the common, the things we all need to consider management investigations, you know, how to escalate appropriately and hand over appropriately to a senior. You impress anyone if you, if you're doing these things on your first week. So, yeah, any more questions? Well, hopefully I make things clear. Um, thank you all for coming. Um, hopefully, same time next week. Um, and we'll look at what I've already said. Ok, thank careful. I hope you enjoy the rest of your day.