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And uh someone was asking how many CPD, will it give those uh um 22 hours? So it will be um definitely two CPD S you? Yeah, thank you. Yeah, two points. Yeah. OK. Uh We are just uploading our slide um and we start our presentation shortly. Um Thank you for everyone to join with us. Um I hope it will be a very interesting session. And please uh to our viewers, please, you can always uh ask your questions in the chat box. Someone will respond to you, please. Thank you dosing. In the meantime, you can um discuss about the feedback. How gonna be good? Uh Give the feedback. Uh Do you want me to say it like? Yeah, because we are just uploading your slides. So, in the meantime, OK. Yeah. Uh Thank you um regarding the feedback because it's very, very important that you give us a feedback because uh it's uh after you give the feedback that your certificate will be automatically generated. So we appreciate it for you. Uh If you uh can give us a feedback about how the event went. Uh What we did, well, where we need to improve and something very important. I would like you to add to your feedback because um I think there is no column for, for that. Uh but just want to make to with what we have. So if we appreciate it, we can just add where you are uh attending the conference, the, the your location, um uh especially the one you registered with on me. Uh If registered with India, please at uh um uh attending a conference from India. If you are from Nigeria, you say in the feedback at a conference attended from Nigeria. If you are from um Sudan U UK anywhere in the world, uh please make sure you, you add in um I think the first uh part of the, the first part of the feedback form. So just add um attended uh from uh UK Nigeria us wherever you are attended the conference. Thank you very much. Um um Thank you, Tosin. Um I was trying to um you know, and invite our to our main stay, but I don't know why it is not working. Would you mind to, you know, just um try to do it in the meantime, I think I should start because otherwise we'll be late. I think I should be able to join from our own. Um And uh without being invited, she just needs to um press joint, joint stage on um on the app. So, um ok, so um ok, I think we'll just have a look later on, but in the meantime, I think I should start and then once I finish my presentation and then when you carry on, then I will just work on it um with. Ok. Ok. Ok. Um So thank you everyone uh for joining with us. Uh Good morning, good afternoon. Um I don't know what time uh in, in every country has a different time. So um I'm Doctor Hira, one of the medical register in Luton and Down Stable Hospital. And I have two other wonderful colleagues. We work together in Luton and Dance Hospital. Both of them is uh Doctor Tosin and Doctor Artan. The both of them are working as a um clinical fellow in a for last couple of years. So they have quite good experience and they know how does the system work and everything. So I thought like, OK, we should um you know, let other people know because maybe in future this area will be, you know, um is a good place uh to work in N SS uh for, for the, you know, for any doctor. So um today, our um we are going to present um uh our topic is about the, you know, the overview of uh same, the emergency care service and then common cases we usually see in this um clinic. So I hope after having uh our presentation today, you will understand um how does the emergency, same emergency care pathway works? And um uh you, you will identify the common problems, common medical problems. Basically, we usually see in a tic and also um definitely it will um eventually it will ha enhance your diagnostic and treatment planning skills for common cases encountered in Atic. Um And I also believe that it will definitely increase your confidence in decision making and problem solving abilities within the context of fast paced uh fast paced uh same day, a secure environment. So what is same day emergency care? So every hospital, you know, sometimes they use indifferently, the name is different. So sometimes you can find out that some hospitals says, ok, they, they say it's like ambulatory care. Um some people might say like unscheduled care. And um so basically, so the simply emergency care basically is a kind of setting in which medical treatment is offered for conditions which are not immediately life threatening but could worsen if left untreated. So this is same day and definitely from the name you can understand. So this is the same day. So the patient will come and the patient will stay and then we'll do our assessment and you know, the investigation and everything and management and they will send the patient home. So usually the average um s uh usually the a average length of his stay is 4 to 6 hours, but it could be definitely shorter or longer based on the, you know, the complexity of the patient problem. So and also it is important to know that this is uh this uh same emergency care is a bridge between emergency medicine and also acute medicine. Um And, and this is the place who is works as an alternative to admission. So in this case, if it's anyone needs admission, then um um but patient um you know, we can avoid that admission, to be honest by doing the quick assessment and investigation and management. Um So what are the services? Who usually means how does it work? So, mostly um it's run as an outpatient service from morning to evening. Um Yeah, we usually, you know, that take the patient referral. Uh and we see the patient from morning until nine o'clock in our hospital. Uh but usually it opens 24 7. So um because some patients might need overnight observation and also some patients uh might need uh you know, hospital admission. So in that case, they have to stay until they got the be in the hospital uh ward. So, um so that's why just 24 7 service our own um settings. But uh this is the way that it's um it, it does work um in our um hospital. Um sometimes it's um also allows the other specialist uh especially is um for example, a cardiologist or neurologist, they want to assist the patient or want to see the patient quickly. So sometimes we ask the patient to come to take and then we just um you know, just give them opportunity that they will be assessed by the specialist the same day. And um so now, um now I will, it's a very important to know why, why, why you have this setting to be honest. So um uh ii know it's not medical things, but it's better to know. So you do know the importance of having this te service. So the um the important um benefit of this definitely, as I mentioned earlier that we can avoid unnecessary medical admission and it will be the shortest day. So definitely it will help to prevent the hospital award infection for the patient. And another benefit. Definitely, if you keep the patient for a short time, definitely you can uh save the cost for the our um National Health Services as well. So the the long term plan for this uh service is that uh that we can increase the proportion of acute admissions d just on the day of attendance from 1/5 to third. So now it is for example, if this patient admitted to come to the A&E for example, or any acute settings in a good medical take, whatever. So they we usually have to admit, for example, five patients. Um um So uh in that case, we just plan to do just maybe the just two patient more and then we can just reduce to third me three. So we can admit three patient. So um this is a very like you know, um it's a, it is a very good long term plan that we can achieve if we in um you know, we can increase the services in. So what are the criteria for the ST patients? So uh definitely this is the m means criteria we meet uh is me by the um sa means uh um staff means, you know, the hospital like there is a policy but uh all these criteria should be or should be, you know, reviewed by the primary care setting. So whoever is just referring this patient to sick, they should uh have a look at this criteria and they should take all the boxes. Uh no, and to um when they will assist the patient in order to make sure they are doing the appropriate referral to sick. So who are the patients? So that they usually they refer the patient who is, who are ambulatory. So means they are mobile, they don't need any support for the activities of daily living. And also they um they don't need organ support, for example, they don't need any oxygen, they're quite stable, they don't need any IV fluid um and also um primary definitely will be with the medical problems, not any surgical or you know, the gynecological problem, it should be purely medical problem. So what do usually they do so that we're doing the referral in the primary settings, they usually ask the patient by seeing the all the criteria but definitely as a, as a doctor or um you know, a healthcare professional, you have to make sure that, you know, and it can be changed anytime because for example, patient was presented with maybe something to the primary settings, but it had changed. So when they will come to, you just be open minded, um usually you can explain, ok, maybe this uh problem is related to medical problems but it can be surgical or you know, it could be gynecological problem as well. So you should be open minded rather than just thinking, OK, it should be medical. Um So who who does usually do the referral to sig? So definitely anyone cannot come randomly to sig from the community. Um So we have the referral system. So um or the common people, they can refer uh usually they refer. So that is in the community settings, we have some s some um you know, the services they can refer and in the hospital setting. So in the community settings like uh the urgent, you know GP clinic, they can refer this patient or maybe GP surgeries, they can just review the patient first and they can asses and they can refer the patient to a stick in hospital settings are usually from Ed. So usually any patient comes to Ed and they usually they assist the patient. Um and you know, they um uh then they can um uh review the patients and they can uh they can refer to stick another person that we can sometimes equ medical take. So um they can refer the patient as well from uh sometimes triple one. refer from triple one as well and or some, some, some for medical outpatient clinic, they can refer the patient as well. Um So the interesting point is now um i it definitely whoever is referring. So um how does it means, how do you look uh uh it may mean, what is your expectations? For example, if you go and see uh normal medical, what that will be different one? But here is not a proper clinic as well. So the settings is basically um more is like you will say, mostly mostly there is a chair. So the people can just sit down there and then also you can see some couches that you can, it can help to assess the patient and few of the beds available. So there you can examine the patient. Um um So who are the people is um who are the healthcare professional and you give all the services to te so this is definitely a multi disciplinary team. So we have the resident doctor, uh doctor, you know, the um a consultant register and then junior doctors and also we have physician associate. So um so there's the other medical health care professional they usually see. And also definitely we have the, you know, the specialist um consultant as well as specialist nurse and we have the our um own um you know, the nursing staff and healthcare assistance. So this is the thi this all the people they usually um you know, keep all the services to te So what are the common cases we usually see? So the common cases usually we see that is um um uh like uh ii should say like common um presenting complaint, patient come to at. So when um so the most common um problems, it means presenting complaint will be like chest pain. The question is chest pain with or with just short of breath, but the chest pain with or without shortness of breath, for example, um usually they usually assess the chest pain, usually definitely as as I mentioned earlier at the primary care setting. So definitely this is quite a stable chest pain. Patient does not like they're very sick patient, not like that. OK. So for example, if there is anyone as the patient with the chest pain and very patient is very sick, hemo is stable and then uh sorry, hemodynamic un is stable and patient might have out dissection definitely in the primary from primary care. So no, will refer this patient to AEC. OK. So usually I should get chest pain with the with a stable patient. So in that case, what are the common find common differential diagnosis we usually see in regarding chest pain, usually very common like pe so pneumonia and then cardiac chest pain, like for example, is stable, you know, angina. Um um sometimes we might find that known is elevated ami is, it's very rarely ST elevated M I but definitely it, you might see as well. It's not uh I'll not be surprised if I see a elevated M I but it um but uh any cardiac event can happen and then also very common, this is musculoskeletal pain. Ok. So this is very, very common and definitely my colleague will ex um you know, explain more about um uh how do you assess and you know everything. Um So and then another presenting complaint is leg swelling and with or without pain. Ok. So that is very, very common. Um I don't know if there is uh like uh how many, how many patients you can see in a day, like so many patients with leg pain and uh with or without, you know, sorry, leg swelling with or without pain. So, the common differential diagnosis we usually see that is cellulitis DVT or peripheral vas. And I know d so that's the all the problems, you know, you know, that's um can come with a leg swelling. Um and then another problem presenting could be headache. So, headache, very commonly, we see usually see migraine patients. So they usually come to, for example, they are very bad headache or maybe go went to GP and then they just referred to us. So migraine sometimes hypertension related or sometimes infection related, like generalized by patient has viral infection and now is complaining about the headache. So we'll discuss later on about that as well in details. And another problem you can see the arrhythmia. So incidence and diagnosis by GP this patient has um for example, um some you know, like incidental finding of a or you know, any arrhythmia. So they usually refer to for further assessment and investigation and then very commonly uh abnormal blood test may, for example, patient is um was assessed in medical outpatient clinic or maybe in GP settings or wherever. So they found they did some blood test but that would the then incidental finding of like anemia, you know, abnormal LFT or you know, electrolyte imbalance. So they will send this patient to ec for part you know, diagnosis, you know, management assessment and everything. And then sometimes you might see that is um like for example, simple infection in uti or, you know, simple like viral infection. Um and then um neutropenic sepsis um and gi bleed sometimes as well but died sepsis is I think um this is not the common case um in our um um in, in, in, in settings, but in our hospital, they may be just made this policy. That's why we sometimes see the neutropenic sepsis patients. So they usually keep the bed in the side in a stick. Um So just, you know, so we have to see that patient as well, but all the neutropenic sepsis usually for admission. But um yeah, so now um I think um yeah, so I'm going to now pass to um my colleague to um who has very excellent experience in walking in that. So now he will um uh present uh with uh you will discuss about the chest pain um and all the differential diagnosis and probable management and investigation. Thank you. Yeah, thank you very much. Uh uh She has introduced me. My name is, yeah, so uh I'll be checking chest pain. Um Well, chest pain is one of the um commonest uh uh presentations in eg and it's just because uh i it's, it's, it's uh very of uh conditions present as chest pain from maybe just musculoskeletal something that is simple, not life threating. So sometimes um MRI S uh so it's very, very important that we actually uh know how to really assess for chest pain. So that's so we'll go through the important ones. But first of all, I would like us to know that not all chest pains um are are fit for AE settings. Um uh things like um A CS proper A CS, um uh especially if they are stable, they are not fit for ae although sometimes because diseases evolve, um we still find them in sex. So, aortic dissection, you know, these are acute things that can kill the patient very fast. So, pneumothorax, a syndrome, especially in sickle cell anemia patient. So these are not really uh fit for ec but don't be close minded, you can still have them. So, but they on rare occasions. So the common now, um uh conditions that we see in ec includes pneumonia, muscle, chest pain, uh gastro vagal reflux disease, pulmonary embolism, angina, stable angina. Sometimes we see unstable angina even we see mis including stemi and tey uh like I mentioned, the uh conditions evolves over time. So don't keep a close mind that this is se I'm not expecting this kind of patient to be ne we still have them. So, uh that's very, very important. Uh First, I will, I'll go uh I'm going out to explain um how pneumonia presents and how we go about uh the management uh the assessment. Uh basically uh this next slide, please. Uh pneumonia, basically. Uh as we all know, present with cough, uh that is productive of sputum, sometimes yellowish, sometimes greenish, sometimes it just is whitish, sputum and this patient can be febrile and then chest pain, usually pleuritic chest pain when they cough, they feel the pain in the chest, maybe on the right side or on the left side, even uh depending on where the pneumonia is. So when you examine this kind of patient, it be febrile and uh you may hear some uh gras well cause gravitation, uh maybe on the left, lower lung zone, right, lower lung zone, depending on where the pneumonia is. Uh and then when you pass out it will be dull but it depends on how about the pneumonia is. Uh, so sometimes may not even, uh, uh, uh, hear you do, it may not be due to precaution and then sometimes you can have reduced. Er, so something that is very important here is that you use C 65. Although, uh, when patient is being referred at this ought to have been, uh, put into consideration. Uh a patient with CV 65 or four normally should not be in te. So uh that's very, very important, but just make sure you use go 65 see you RB 65. So determine whether you are going to discharge the patient or you are going to admit the patient to the world or you, the the patient will will be uh taken to the itu for proper management. So when you do blood, um you expect um released inflammatory markers including CCR P white cell count and but white cell counts can be subtle. Absolute white cell count is not enough to, for you to say there is no infection ongoing. Make sure you look at the differentials, especially the neutrophil in a bacterial infection that could be uh risk neutrophil while we are asked the absolute white cell count is normal. So that's very important. Chest X ray can show consolidation and uh uh the treatment. Usually we give antibiotics based on the severity of the pneumonia. Some you just ask for pneumonia, I just give her amoxine, but some will, uh, will require a stronger one like co amoxiclav. And then if a patient is allergic to penicillin, there are options which include Clarithromycin or Doxycycline. But note that some people, uh, may have atypical pneumonia. So the organ that is causing, there may be all this, um, uh, lega mycoplasma, all those sorts. So make sure you, you had Clarithromycin if you have high suspicion for atypical pneumonia, and then uh if the patient is a stable patient, you discharged from mistake. Uh But if the patient is unstable, you have to admit some will require oxygen, some will require itu admission. So that's all about um pneumonia. Uh So we move on to cardiac chest pain. Uh That's a typical presentation of a cardiac chest pain. Uh usually squeezing or feel like a pre feel like a pressure. Some people may say I felt like an elephant. Uh OK, when I was having the, the pain, I felt like an elephant was sitting on my chest. So people may say it's it, it's, it's like a a tightening. So you have to uh be familiar with those terms that people use. So um if, if that happens uh that typical uh cardiac on the chest mean it happens when the patient is exerting himself uh maybe while walking or just walking up the hills, some patient will come to you. They say I was when I was hoovering the house, I felt the chest pain and then I rested it, the pain settled. So if that's the case, that's like a stable in, that's a, a patient that is really fit for te so because they might not need an admission. Uh But if there is a cardiac and chest pain with very minimal exertion, that's and the troponin is negative that fits uh uh that is gonna be best uh, described as an unstable angina. So it's under a CS. So that patient, uh, should not be discharged, it should be put under I CS protocol. So, there are some, uh, con, uh, symptoms that are associated with uh, uh, uh sudden chest pain which include shortness of breath, palpitation, nausea and vomiting, pro produce sweating, especially if we are dealing with M I. So, uh, what you need to do first, uh, you do ecg the two most important, uh, um, investigations for what you are, uh, thinking of M I, uh, are ECG and uh, Troponin. So, uh, Tron or whichever one you do in your, in your hospital. So, um EKG first is usually done at triage by the nurse. So, and most time they take it, take the E CG immediately to any doctor around to have a look and then check if there is any minute action that needs to be taken. So, uh, you see, if you see, uh, if what you see is, uh, ST elevation that is uh something you need to act fast. So that patient don't need to wait for troponin, whether it's positive or negative, if you see the elevation or you say um a new left bundle branch block, uh that is a stemming, uh you need to act immediately, that patient must be the uh uh nearest C lab ASAP. Um So, but if uh is normal or you notice some ischemic changes like two week, two week invasions give aspirin, send off for troponin. And then um if the troponin is positive, uh um yeah, uh that is uh te if it's negative, that is uh uh um uh unstable Angina, whichever one is still treat as A CS. So we just have the A CS protocols. So, but uh for left bundle branch block, if it's in the setting of um uh chest pain, well as it is. But if you have uh uh A, the whole E CG always compare, some people might just come with another thing and you noticed left bone branch block, they might have had left branch block a long time. So, um so that's about the A CS. So other investigation that we can do in um in sorry, in A CS is um dim ACR P who block on you and his just to rule out other possible differentials um like in pulmonary embolism in the D like some people will just have pancreatitis. So, and you with uh A as a epigastric pain. So, uh sorry, one question that uh our audience asked, how do you differentiate stable and unstable angina in tic settings? Ok. So, if a patient comes in with uh a chest pain and is still having ongoing chest pain while sitting down, that is either if it's a cardiac standing chest pain while sitting down quietly, the patient is still having chest pain. That is a CS proven otherwise. So it's either it is uh uh uh an ending of sting or uh unstable angina difference between stable and unstable angina is that for stable angina, the patient have pain only when they are exerting themselves. But for unstable, they are stress or with very, very minimal exertion, they are having the chest pain that will be classified as a unstable angina if troponin is negative. But if troponin is positive and the uh uh the E CG shows uh just ischemic changes of normal, you take it as inte but if it is ast elevation on the left body branch block, that is a stemming, you need to act fast. So, um yeah, so I think I've mentioned that. So if there is, if the, if your diagnosis ends, you start a CS protocol uh and then cardiologic cardiology review. So a CS protocol, usually there used to be an acronym mona. So, but you don't have to do all the mona if the patient is not. If the uh oxygen, if oxygen level, the DPH is not below 94 you don't need to give oxygen. So first of all, you know, the patient with dual antiplatelet like uh aspirin or agre or depending on what your hospital uses. And then um uh some, if the BP is high, you can give, ok, why going to that? So you gi you can give GT spray to also to relieve the pain and then uh establish we need atorvastatin, then we need demanding bisoprolol um Ramipril that this is your inhibitor depending on you have to, there are some criteria for you to start all of that because if the BP is low, you don't want to give Ramipril. Uh So that's not about that. Uh But if there is a sta please, the next uh the nearest cat lab that that patient must be there uh as soon as possible. And if you don't have a cat lab locally in your hospital, you need to blue light the patient to uh the nearest uh cat lab. So uh sometimes people may present with uh just uh ending you started a CS protocol. Despite that, they are still having um uh dynamic E CG changes. Maybe E CG uh the T invasion was in just the inferior lis before. Now, it's now in uh inferior leads and lateral leaves, you need to act very, very fast to the near uh you to be in the near nearest cat ASAP because there is dynamic uh changes. But before if there is a, you know, something that could be logistic delay, so you can start that kind of patient in uh on um a ISOS Dinitrax. Some people call it uh Isoc that's like a trade name and then Angio Asap. So uh we'll move to the next um next slide, please. So, um so the next slide uh was talking about, we are gonna talk about um um pulmonary embolism. So, uh this is uh very sort of presentation that if you're not really, if you don't have high in of suspicion, you might miss it. So it's very, very important. Your patient is coming with breathlessness, chest pain and am not all, all of them are hemos anyway. Uh and they are coming with leg swelling. I'm telling you that is p staring at you right in your face. So you need to act fast. Uh So now there are some risk risk factor. People don't just have ps there are some risk factor which includes maybe a long haul flight, long haul flight um has been described as a uh maybe a flight. Um that is longer than six hours. So, um another risk factor is unilateral calf pain. That's maybe the uh DVT or patient is on hormonal therapy, recent surgeries, recent immobilization or the patient has had DVT or pee in the past or the patient has thrombophilia. And something that is also very important in the, in a group of people that are transgender, some of them are on hormonal therapy, like estrogen or testosterone that can prepose them to having uh uh a a clot either in the leg or in the lungs or any part of the body. So that you must have high of suspicion in uh kind of patient with on dose um hormonal therapy. So also cancer patients, usually they are on active treatment, uh they are prone to having clots. So that's very important. And pregnancy, you know, pregnancy is a prothrombotic uh condition. So they can have pe too. So uh when you examine this patient, that could be uh tachycardia and tachypnea. And then um I think those are the commonest uh findings, tachycardiac tachypnea and then you can say of DVT, some may not have DVT. So you, you don't just assume that because there's no DVT patient can have pe no uh no, don't assume. So they can have pe without a DVT. So if you went during the observation, if the BP is low, please consider massive and uh or bilateral pe that patient, we need thrombolysis and itu. Um So uh when you do the E CG, uh you notice sinus tachycardia that is the most uh most um uh sorry, the most common finding on ECG why S one Q three T three is the most specific but very uh few patients have um that classical S one Q three T three, maybe around 20 to 30% or so. There are different uh values that people are quoting uh about the S uh one Q three T three. So, uh assessment, well, score is very, um um is a very useful tool to assess for risk of pe or D BT. And then um A D DMR also, you know, it's um uh I if, if it's normal, well, it's unlikely that the patient has a DVT or PE, but we've seen a patient with normal D dimer with a clot. So where does, that's a very, very, very, very rare case anyway. So, uh but you cannot say if the D is negative, you are 100% sure. No, not 100% sure. So if you still have highness of suspicion, if your well score is high, please scan the patient. So uh they go on that uh investigation is CT P uh pulmonary uh CT pulmonary angiography. And then if the patient is contrast allergy, you have to, you need to ascertain this before you put uh uh book Act for a patient. So people who have uh die uh uh allergies. So you don't want to do CT P in those kind of patient, then you can go for DK scan uh for that kind of of patient. Um Also uh patients uh that are pregnant. Uh you want to do ABQ scan in them. So, ventilation scan, that is um advisable to uh to uh do ban of CT PA. But it's not a, it's not a compulsory thing kind of that you must do ABT scan in them. If you need to assess for uh a clot, just tell the patients that if, if you, if you go for a CTP, uh I it predispose the mother, it can, it can not, it does, it can prepose mother to having a breast cancer uh especially uh uh you know, uh you know, there is um uh when there is a uh increase in the um cell division. So at that point, if you expose the breast tissue to uh to radiation, it can lead to can, it can be exposed to cancer. Uh but then VQ scan can increase childhood cancer in the baby. So you can just uh some patient may say, oh I, I prefer to have a CTP. That's good. Just make sure you take the consent document it that the patient opted for CT P instead of BQ scan. So we may say, oh I had this pregnancy through IVF I don't want anything to touch the patient. I would rather go for a C TPA. So you now have to weigh the options and make sure you take consent document everything. Treatment, usually anticoagulation. Uh The, well, the commonest use um anticoagulation uh medication is DUA uh or this uh Apixaban Raban depending on what your hospital use is. Um But in breastfeeding and pregnant women want to use low molecular weight uh heparin uh because of teratogenicity. So what it is um severe kidney dysfunction. Um you want to opt for heparin infusion. Um You don't want to give drug in a patient with mechanicals too and in a patient uh with weight greater than 1 20 kg, you may not see in B NF that you cannot use do a. It's in fact, it's done in B NF as of today. But um probably two studies. So whatever means that the, the real, the most common practice is that if the weight is more than 120 you rather give the patient a low molecular weight, a brain instead of do a. So um uh next slide, please. So um in uh pe you want to be sure whether the uh pe is provoked, provoked is if you notice any risk factor or presenting factor for the pulmonary embolism, um That means that is uh just a temporary condition that can be given anticoagulation for three months. But if you take it, you took history, you examine, you have no non risk factor at all or pre factor that patient uh is uh should be on anticoagulation for at least six months. So, and after starting this uh anticoagulation, uh make sure you refer the patient to anticoagulation clinic to follow up with the patient. But in patient with maybe previous previous DVT or the patient that is already on prophylaxis uh anticoagulation, maybe they are on Apixaban for maybe AF or for whatever reason and they still have a pe you have to seek hematologic opinion. Most of the time they say, OK, well, treat with low molecular, with, with a brain. Uh uh maybe tinzaparin or Clexane depending on what you use in your hospital. And sometimes they may say, oh let's go for a warfarin. So it's very important to AAA with um the hematologist in that case. So uh now we move to pericarditis. So, patient pericarditis of time, they have viral like illness, maybe one week, two weeks prior to developing um uh pruritic chest pain, which is uh most time was on lying, lying down and then uh released by sitting up. So, um so history is very, very important in these patients. So when you examine uh you can hear uh pericardial lobe on examination when you al alter to the chest and then blood might show this inflammatory markers uh cr py cell count because it's like, it's like it's like ongoing inflammation, but you need to know that troponin might be raise, especially if there is um and myocardiac uh involvement or epicardial involvement. So, because um the heart can still release cardiac specific troponin if this uh part of the uh heart are involved. So, despite the patient actually has pericarditis, but to be sure that actually pericarditis, uh there is this um s shaped uh ST elevation in um pericarditis uh that you will see and then it's, it will involve most all, mostly all the leads. So it's more like a global ST elevation maybe in involving the inferior lateral and the anterior leads. So, if you see something like this with history of illness, pericardial lobe and the inflammatory marker, consider pericarditis. So, and then this patient treatment especially, they are stable, uh give nsaids plus or minus colchicine and sometimes it may go for that if there is no improvement to, to give prednisoLONE dependent on the just uh follow your hospital protocol. And then uh the next thing is most chest pain. Uh Well, this is very important. Um Half tab uh ruling out all the uh possible uh red flags. So, uh the chest pain is not exertional and then the there is no ecg changes, bloods are fine, everything is fine and the pain only gets worse when the patients, uh maybe uh take deep breath or when they move their body here and there. So that is very, very important. So usually they have history, a history of lifting heavy object or they engage in unaccustomed exercise like a patient that just start recently started gym, gym, you know, and then uh they do pushups or press pressure up that will put some strengths on the chest, on the rib cage and the hand. So the, those people can have uh musculoskeletal chest pain. So when you examine this kind of patient, uh you will notice you might notice that they, they have some tenderness in the chest wall. Some may not have tenderness when you palpate, it may be, it may just be when you move them uh sideways, maybe through uh bypass uh motion, maybe they move sideways or you move their arm up and down. That is when you will feel the pain is still muscle, chest pain. It is usually normal, uh inflammatory markers, normal troponin, normal. The main treatment for this kind of patient is optimal painkillers and then to um to uh maybe for some time, uh uh this is from every, every exercise that puts too much strain on their chest. And then you tell the patient to avoid lifting a few objects for the meantime. So now moving to uh cases that we don't usually see in eg but like I said, don't keep a close mind. You can see pneumothorax in est E uh because the patient may, may come to ahe with chest pain but it stable, we can just treat the patient to ahe. So that's why it's very important when you do a chest x-ray have a look at it. Is there any area of the lung without lung markings? So that is very, very important so that I don't miss pneumothorax. So um maybe there is, there is history of um trauma uh followed by chest pain or in a patient with CO PD or an athletic guy. Um maybe footballer, young man uh that is tall or thin. Maybe all this Min syndrome, all this uh condition that makes people to be tall and thin suspect pneumo in them if they are coming with chest pain pleuritic and they are short of breath, very important, although they are best fit for here and he not aesthetic, but you can still have them in when you are this kind of patient. Um you will notice reduce e entry. If it is a, there will be reduced i entry at the apex of the lungs and then uh there will be when you per. So chest x-, we we we give it out, you will see it on chest x- unless it's very so or maybe very small pneumothorax. That is why you need uh you need a train he to not a chest X, how to interpret the chest x- as a resident doctor. Uh place is a basic uh uh competence to be able to interpret a chest X ray. Please go go online, look for whatever you can know how to interpret chest X ray. It will be very, very useful for you. In your practice. This patient may need oxygen therapy and then need your aspiration or chest, chest, chest string, depending on the uh how big the um uh the pneumothorax is. So um ut dissection uh we this patient is not fit for that like I mentioned, but uh don't keep a close mind, but it's very, always very typical. Although sometimes it can be subtle t pain between scapula, uh the cuff, uh low BP or high BP, depending uh there will be different difference in the breakout of pulse or pressure, BP. So you need to have um high in of suspicion. Chest x- can show uh wide mediastinum, sometimes X, chest xray can even be normal. So that's why the gold standard is um uh your uh CT ato gram. But things that you can do in the adverse side is um you can do echo by the best side. So you can, it will show a dilatation. So treatment is based on whether it is type A or type B, you are not going to get into this because it's uh beyond the limits of this uh presentation. So, um now I go to the um tips and um tricks during evaluation of chest pain. Uh please, next side, please. So chest pain, like I said, sometimes can be misleading. Um uh especially in, let's say in elderly female and diabetic patient like diabetic patient can have um what we call silent mis. So, uh it is very, very important. They may just say, well, I heard that something is not right. Um And I was short of breath, I just feel like something is not right in me. Uh That might be him. I really, they have um other risk factors too. Uh So it's very, very important um that in this kind of patient, elderly female diabetic patient they may not have a classic representation of cardiac and chest pain. So, um that's not bother. And then don't forget to palpate the patient chest to see if there's any tenderness that will point you to a possible musculoskeletal chest pain. Um So, first thing you need to make sure is, is this pain just been pleuritic, is it cardiac sounding? Then you begin your uh work up. So, uh this way, I'll be um ending my own presentation and now uh I will bring it to the stage. The next speaker who is uh Doctor Ana Benning, who also uh ask um you call a friend that I have in same day emergency care. We've been together for some time. So I'll bring our hope to start our presentation. Now. Thank you for your audience. Thank you, Tosin. Um So my name is I'm one of the doctors. I work a lot in te as well. Um So I will be talking mainly about leg swellings. Um So if a patient is presenting with the leg swelling, um first of all, we have to think of is the swelling, bilateral or unilateral. Um If it's a case of bilateral leg swelling, then mainly we have to consider more systemic causes such as liver, kidney or heart failure. Uh and we'll have to manage the patient according to that. For example, if the patient is in heart failure, um the leg swelling, bilateral leg swelling can be due to fluid overload. Patient may also be having pulmonary edema. In this case, we have to look at offloading the patient. Usually with uh diuretics, patient may even need IV um diuretic infusion, for example, IV Frusemide infusion. Uh and we usually get cardiology opinion on these patients because if they do not have a recent echocardiogram, we will need to do an echocardiogram to assess the heart function. Um We may need to optimize the other medications and in some cases, depending on the severity, they may need admission. Um So with bilateral leg swellings, always think of systemic causes, moving on to unilateral leg swellings, uh which can be associated with pain or skin changes like redness, they may be local rise of temperature. Um And the most common presentations are usually due to cellulitis or DVT which stands for deep vein thrombosis. So first, we look at uh deep vein thrombosis if we move to the next slide. So deep vein thrombosis is usually presenting with calf pain. Um And when we examine the patient, we'll find that they'll have, they may have other findings like swelling, redness, local rise of temperature. Um We always make it a practice to measure the mid calf circumference of the affected leg and compare it to the opposite leg because uh we'll find that this is one of the criteria which helps us to calculate the well score. The well score is a scoring system using which we assess the patient's risk of having a DVT. So this, this is all the criteria which comes under the sco. So there are some factors which puts the patient at an increased risk of having a thrombosis, for example, active cancer or recent immobilization. For any reason, whether it be paralysis or uh due to any um you know, cast immobilization for fractures. So any uh or recently bedridden due to recent surgery, um all of these can act as risk factors which increase the possibility that the patient may have a deep vein thrombosis. And the wells score also contains clinical features which are more suggestive of DVT. So if you look at the second one, CF swelling more than three centimeters compared to the asymptomatic asymptomatic cough. Um So this is why it's important to measure the mid calf circumference so that we won't miss it. Um when calculating the well score. Um This MD plus CALC is an app. It's also available as a website. This is what we usually use uh for calculating most of the common scoring systems. So it has the well score for DVT and we can click yes or no and it automatically calculates a score for us. So this is the investigation algorithm. So if you look at the very top, the first thing to do is always to calculate the well score and the cut off is two. So if the well score is more than or equal to two, this means we proceed straight to doing a proximal leg vein ultrasound for the patient. And if it's less than two, then we have to do ad dimer test um to see if the D dimer, if, if and if the D dimer is positive, then we do an ultrasound scan. So with the ultrasound scan, the national guidelines is that we do it within four hours. Um but this is not always possible. So if, if we find that the scan is not going to take place within four hours, which is usually the case, it takes more than four hours to get the scan done. So we then um assume the possibility there may be a clot and we start the patient on treatment dose of the anticoagulation until we can perform the scan and either confirm a DVT or rule out A DVT. Um Yeah. So uh these are the main investigations. So the sco D dimer and the proximal ultrasound and the guidelines for the ultrasound is to perform within four hours. If it's not possible, we start the patient on treatment. So once we confirm a DVT, which is using the ultrasound, we can start the patient on treatment of anticoagulation. So there are two options. Normally, we can start the patient on a DOAC which is a direct oral acting anticoagulant, which is Apixaban or Rivaroxaban. According to the nice guidelines, this is the first line for treatment of a deep vein thrombosis. Um in some cases, we can also use a low molecular weight heparin uh like tensin. Um So usually we opt for tensin in cases where the patient is at an increased risk of bleeding or if the patient is pregnant or if the patient is say on some other therapy like chemotherapy. And we find that Doac has more interactions with their particular chemotherapy regime. In this case, we bridge the patient using heparin, using low molecular weight heparin and then we uh switched the patient to Warfarin after that, uh the duration of treatment, the duration of treatment. Um Here, if we go back to, yeah, the duration of treatment will depend on whether the DVT is provoked or unprovoked. So provoked means like Tosin was explaining before. If there is a specific risk factor which triggered the DVT like recent immobilization or a recent long flight, recent surgery, these are provoked cases. Um So in these cases, the treatment will be for a shorter duration, usually 3 to 6 months and unprovocative will always, most majority of cases will warrant treatment for at least six months. And we always do a referral for these patients to anticoagulation clinic. Uh because these patients will now be on blood thinning medications and they will need follow up to check up on them, which is done by the anticoagulation clinic. Uh moving on to cellulitis, which is the other common cause for a unilateral leg swelling. Although in some cases, it can even be bilateral. Now, one of the differentiating factors is that these patients will have systemic features like fever chills. They may be generally unwell because this is an infectious um cause for the swelling. Um In this case as well, we again measure the mid calf circumference and we also use a skin marker to mark out the the edges of the cellulitis. Now, in this case, it's for a different reason, we do this uh to assess the progression of the cellulitis and to assess the response to treatment. If the cellulitis is improving or getting worse, we'll also do blood tests, especially white cell count. CRP to look at the severity of the cellulitis. The management is with antibiotics and the first line is penicillins like flucloxacillin. If the patient is allergic to penicillin, we can opt for clindamycin, which is the second line or which is the first line if the patient is allergic to penicillin. Um Now, depending on the severity, patient may need IV antibiotics. Um or if the patient is not responding to oral antibiotics, they may need IV antibiotics. So with IV antibiotics, using this Aztec pathway uh ambulatory pathway, we can avoid admission for patients who even need IV antibiotics. This is by getting the patient to come in just for the antibiotics and then they can go back home after getting the IV antibiotics. So we can avoid admission um for IV antibiotics because we have this tic pathway, we can also arrange hospital at home services, which is where the patient can receive the IV antibiotics at home. Um So we either opt for hospital at home services or services. Um even if the patient requires IV antibiotics. So that way we can avoid admission for the patient. And just for that reason, now, the only other thing to keep at the back of your mind, which is very important is to also consider arterial causes, um which can cause leg pain and leg swellings. Um So it's always important to elicit a history of intermittent claudication from the patient, whether their pain or their symptoms are worsening when they exert themselves, whether it relieves with rest. And we can also, when we do the clinical examination, we can make it a practice to always look for peripheral pulses, look for any arterial ulcers in the peripheries. And also d um the leg in this case would be cold as opposed to warm if there's an arterial occlusion. Um And in this case, it's important to get opinion from vascular surgery. And we, in this case, we would be doing an arterial Doppler as opposed to a venous Doppler and doing other investigations like ankle, brachial pressure index, arterial Doppler and getting vascular opinion for these patients. So that was a short summary about how to assess um leg swellings and what to keep in the back of our minds. Um Now we move on to some abnormal blood results which are commonly referred to Aztec. So this includes low HB uh which is anemia, abnormal liver function test and electrolyte imbalance like hypo hypercalcemia, hyponatremia, hypo hyperkalemia. So we'll just look at some of the common ones. So, if hypernatremia is something which we commonly encounter um especially in ec um because a lot of the hyponatremia is asymptomatic. So again with hyponatremia as well, we have to think we have to classify the patients into two. Are they asymptomatic or symptomatic? So, symptomatic and severe hyponatremia, it usually warrants HD or ITU admission because they will need um IV hypertonic saline which can only be done in high dependency settings. Um Most of the cases of hyponatremia, which is referred to an Aztec pathway will be asymptomatic hyponatremia. So, and uh there are different causes for hypernatremia and it's always important to assess the fluid status of these patients which will guide us towards what could be causing the hypernatremia. So, if we look at the three different causes volemic hyponatremia can be due to S IUD h hypothyroidism ACTH deficiency or primary polys hypervolemic is usually due to a dilutional hyponatremia like fluid overload states. Um congestive heart failure, liver cirrhosis nephrotic syndrome, and then hypovolemia is due to salt and water loss from the body. Um for example, vomiting, diarrhea, dehydration or excessive use of diuretics. So, this is our trust protocol for the evaluation of asymptomatic hyponatremia. Um there was actually an audit which was conducted um into the cases of hyponatremia. And we found that majority of the cases of hyponatremia, the fluid status was not assessed. Um All the appropriate investigations were not performed and inappropriate referrals were done to the endocrinologist for cases of hyponatremia. This is how this trust protocol uh or this hyponatremia protocol came into place to improve quality. Um and to make sure that we um adhering to national guidelines. Um so as part of this algorithm, uh what it's advising is that we do all the necessary investigations um to assess hyponatremia such as plasma osmolality, urine, osmolality, urine, sodium, urine, potassium. Um And this is available on our system uh as a one click hyponatremia screening bundle. Um So we just click the hyponatremia screening bundle and all of these tests will automatically get selected under the bundle. So this is uh done. So as not to miss any investigations for hyponatremia. Um And um so this algorithm is pretty self explanatory. Um And we can just follow it. Um And it will lead us to the course of the possible course of the hyponatremia. So it's important to follow this because uh depending on the course the management will change. So for hypervolemic cases of hyponatremia, we have to fluid restrict the patient. Um And for courses like si A DH, again, we have to fluid restrict the patient as opposed to if it's a hypovolemic hyponatremia, we have to give the patient fluids because the hyponatremia is then due to vomiting, diarrhea, due to salt and water loss. So we have to give fluids for some cases. Other cases, we have to fluid restrict the patient. And by doing all the investigations, it also helps us to calculate things like first formula, which tells us how much should be fluid, restrict the patient. And according to this guideline, we should only make an endocrine referral if there is no response after for at least 48 hours, 24 to 48 hours of treatment. This is again part of the trust guidelines for assessment and management of hyponatremia. Moving on. Um something we commonly come across is low HB or anemia and some of the common causes which we encounter is due to blood loss. For example, menorrhagia or gi bleed. Um They can also be due to, it can also be due to dietary deficiencies like iron deficiency folate or B12 deficiency. And there are also some cases of um hemolysis hemolytic anemia which can be triggered by viral infections in patients who have a background of hemolytic conditions like sickle cell thalassemia or hereditary sperocytosis. So, these are the common causes of anemia which we come across. And again, the the important thing to consider is is the patient symptomatic due to the anemia. For example, do they have uh shortness of breath on exertion? Do they have palpitations? Exercise intolerance, dizziness? Um because if they are symptomatic, it's more likely to be a more severe anemia and may need trans blood transfusion. So, investigations, we do full blood counts. We do all the red cell indices like MC BMC H to work out. Is it microcytic macrocytic? Uh, we have to do iron studies folate B12 to see which nutrient is deficient. We can consider peripheral smear especially for cases like if we're considering hemolytic anemia, um or other causes of pancytopenia, so low HB, um if the patient is asymptomatic and if the HB is not very low, like it's, if it's about 70 to 80 g per gram per liter, then we don't need to transfuse the patient. We can just focus on replacing the course, uh replacing the deficient nutrient and treating the course of the anemia. Um as opposed to this, if the patient is symptomatic, then um and we may need to and if the HB is too low, we may need to transfuse the patient. So the transfusion cut off is 70 to 80 uh for stable adults. Um and we have a higher cut off for patients who are actively bleeding or patients who may have any cardiovascular disease. We aim for a target of 80 in these patients for other patients. It's usually seven between 70 to 80. So this is for the immediate treatment of the anemia. Um but after treating the anemia and after we get the hemoglobin levels to a target level or safe level, it's always important to explore what may be causing the anemia. So we can treat the cause of the anemia. So, if the patient is presenting with menorrhagia, it's important to do ultrasound pelvis, get the gynecologist uh opinion. We can do a referral to them um to explore what may be causing the menorrhagia. So that course can be treated in patients who may be having um a possible upper gi bleed uh and stable, stable patients. We can do a fit test which is a fecal immunohistochemical test to look for any blood in the stools. And we can consider an um endoscopy or colonoscopy to look for the course of the gi bleed. And this is for stable patients for patients who are unstable with an upper gi bleed, they would have an immediate endoscopy but these patients are less likely or they are unfit for an sex setting. Um Celiac disease can be a common cause of unexplained anemia. So we can do a celiac screen especially for young patients with other autoimmune conditions. Um do a hematology referral, get hematology opinion if the patient has a hemolytic condition and if we are suspecting a malignancy, we can do a CT tap, which is a CT thoraco abd pelvis to look for any focus of malignancy, which may be causing the anemia, moving on hypercalcemia is also something we commonly come across. Um The two main causes for hypercalcemia is either malignancy. Um This can be a primary malignancy, for example, a primary lung malignancy like a squamous cell lung carcinoma, which can uh release parathyroid hormone type of uh related peptides, which is the paraneoplastic syndrome. Or it can be due to bony mass from other malignancies, uh which can be causing the hypercalcemia. So, malignancy and then the other main cause is hyperparathyroidism. So we have to investigate the course of the hypercalcemia and it's usually uh one of these two. So we, it's important to send uh to look for levels of parathyroid hormone, do a bone profile and do all the other necessary investigations to look for the course. These patients may be presenting with uh polyuria, polydipsia, um confusion, they may have abdominal pain, constipation. These are the common symptoms of hypercalcemia. Um and we have to investigate appropriately bone profile, parathyroid hormone and the treatment is usually IV fluids. We have to give IV fluids and we usually give 1 L every eight hours. Um And then recheck the calcium levels. Some of the patients may, may need IV bisphosphonates after the IV fluids depending on uh how the calcium levels are looking after giving fluids. And as I said, these patients may need a cancer screen as the hypercalcemia can be due to a lung cancer or due to bony metastasis from other malignancies. Um So as we talked about at the very start of the presentation, neutropenic sepsis is also a common presentation. Um, neutropenic sepsis is something we have to consider for patients who are on anticancer treatments. And we consider it if the neutrophil count is less than or equal to 0.5 into 10 rays to nine per liter. So if there is a neutropenia or if they have fever more than 38 degrees or if they have any other symptoms or signs of sepsis, uh we always are very vigilant about neutropenic sepsis and we have a protocol in place um to send a full septic screen and to start these patients on treatment within one hour of hospital attendance. Um This is to reduce the morbidity and mortality associated with neutropenic sepsis. So, this is always audited and this is always uh monitored. So it, this is a protocol that we have to strictly abide by that. This is done within one hour of hospital attendance. Um to send a full septic screen, that's blood cultures and um urine cultures, stool cultures, depending on what the symptoms are and to treat with IV antibiotics. So, the guidelines differ from different hospitals uh about the IV antibiotics in our hospital. We give Tasos, which is the combination of piperacillin plus tazobactam and we may or may not give gentamicin. Um and gentamicin is for the gram negative coverage. Uh So that's the antibiotic protocol for neutropenic sepsis and we have to initiate it within one hour of the patient attending the hospital. Um So these are some of the common cases. Now, I will hand over back to Hira. She will talk to you about the common arrhythmias and other common conditions that we come across in um the ambulatory setup. Um Thank you, Hanna. Um I um uh sorry, I apologize because my daughter is crying. So I will take like one minute and I'll come back soon. Sorry. Ok, thank you. Well, she's taking the one minute, please. I just want to say kindly uh fill the feedback form after the conference. Uh We send it to you via the email. And then one thing we would like you to do for us in the first space where you are going to fill the feedback form. Just mention the country you are attending from uh like uh if it is India, put India, if it is us, put usu K put UK, whatever you are uh attending from. Um I know some of us are in the UK while we still working in um in India. So I think um you can, you can put in there um because that's where you work. That's what you registered with on the me half. So I think here uh when you are ready, please let me know. Um Yes, I think I'm ready, but if you want to finish then you can finish. Let up. I think I'm done. So I the back to you. Thank you. OK, thank you. Um So thank you everyone for your patience. I know it's a long discussion. Um But I hope you will be worthy. So now I'm going to discuss about the arrhythmia um which usually we see in TIC, we usually see in a stable patient that I mentioned earlier. So the common arrhythmia we usually see in um we, we usually, by the most of the time is GP that they have found out the patient. Um in ECG the patient has the new onc uh most of the time is a new ONC. So they usually refer this patient to, sorry, I think is having an issue with um microphone at the moment. Um So yeah, can you hear me now? Yeah, we can hear you now. Oh Sorry. OK. So now if I say like um uh if we, if you find out any patient that the presenting complaint is that incidental finding of a referred by GP. So how do you approach this patient in? So if it's any patient with the presenting complaint, definitely you have to take the history of the, of the patient. So um so definitely there's two parts of this history that you know the diagnosis now is a, so the part of the history that you have to find out whether if is causing any trouble to the patient, whether the patient is symptomatic for this a and also um another part of the mm thing is that whether is patient um you know, um having any, for example, complication or maybe what are the causes of causing all this trouble. I mean, so why this patient has developed? If so this is the thing you have to keep in mind. So definitely, and you can go through the history, you haven't um do that, you know, if. So the um you can ask like, for example, uh the main important concern is that whether patient have any like patient symptomatic if like fast if or anything, for example, whether patients complain of the breathing problem, chest pain, like palpitation, feeling lightheadedness, dizziness. And then whether this patient is uh has any symptoms related to a related complication, for example, like any heart failure symptoms or patient might have like ti symptoms or stroke, anything, any symptoms. And then you have to find out what is causing all this trouble, uh why his patient has. Af so I will discuss about the common um uh means common causes of af shortly. So the most common causes of a is that heart disease most commonly mo stenosis and then um ischemic heart disease or so, heart is still some problem can cause. Um uh So definitely I will mention is have heart disease or ischemic heart disease or maybe hypertension itself can cause some changes in the um you know, heart and it cause it is causing f and another thing is that uh it just uh very commonly we see in Ed or everywhere you maybe take um as well that infection. So infection is causing um you know, the af and another thing is that, you know, that a thyrotoxicosis can cause af as well. Um And then, um if we don't find out any cause, then definitely idiopathic, another important thing we have to keep in mind in the context of maybe in UK definitely that um alcohol. So, uh so usually causes alcohol related arrhythmia, which is uh we sometimes maybe also known as like holiday heart syndrome, like the the people who are in maybe over the weekend, they just drink a lot and then in that case, they might take out like parasal af So in that case, definitely it is important to know what is the cause. So you can just take that action accordingly. For example, if it's alcohol related, definitely, if you fix that point, you can ask the patient advise that to cut down the, you know, alcohol drinking or you can just um you know, give them like edu education properly. So they will know and then uh it will help to, you know, the cure the air. So the next thing is that um what is why I am worried if patient has the f but mainly worry is that as for example, some patient maybe doesn't have any symptoms, but they have af maybe for a long time. The main worry is if you have persistence like arrhythmia like af and then it will um it cause your um at cardiomyopathy. So um if you have cardiomyopathy. Definitely your heart will not work properly and eventually it will lead to develop heart failure. So that is the main concern that you have to treat. Although this is not fast air, it still is stable air, but you have to treat it because you never know when it will go first. So that's why it's very important to know the complication and the importance of starting the treatment as well. And another complication, another word is definitely a stroke. So um how do you know um you know, if, as I told you the already, we know the referral from the GP, but definitely when patient will come to us, we'll do the ECG. There is no doubt. And usually in a or, or when uh before we start to see the patient, the nurse is no nurse already know what is the presenting complaint when they um you know, see the referral. So they usually do the all the blood test uh observation. And also if it's relevant, they will, they will do eg as well in this case, definitely they will repeat the E CG. So um um A although definitely someone already looked at the E CG in the community and then they, they referred to you, but I'll say definitely you should the look the E CG by yourself. And then you can say, OK, so how do you interpret the E CGI will say um if you don't want to remember how means all the, you know the CE CG criteria for diagnosis? A. So in that case, just at least remember this patient, what is uh what is the E CG rhythm? So if it's irregularly irregular, then this is, this is like one of the differential is patient has the F and also another thing is that PF now, so if you just just remember two things, whether the patient is ECG is irregularly irregular or patient, ha II can see, see any P wave or not. So it will give you see the P wave I, if you cannot see the P wave and rhythm is irregular, then this is definitely the rest of the thing I don't want to discuss. You can say like na QR is complex and so many other things you can you II believe all you know that uh what are other findings, but that's the two things I would like you to remember. So now how gonna you manage? So this is um a stable patient but we have to take the action. So um and definitely in the management option, the first thing is that um you have to take the history, you already done it and then you have to find out the cause and then based on the patient history and then your, you know the um your um findings, clinical examination findings, then you have to do the investigation. So the most of the common investigation, we usually do that is blood test. So, blood test usually um definitely the purpose of doing the blood test to find out that whether it is underlying cause. So for example, whether the patient has any infection, whether patient has any electrolyte imbalance, whether the patient has any um you know, thyroid function test abnormality, which will give you some clue about the underlying cause. And then the next thing is that of doing the another decision that is 24 hour tape. The purpose of doing is 24 hour tape to see whether patient is uh definitely um um uh to see whether the patient has any paroxysmal E or parsin F. So, um for example, GP already uh GP referred to you, but at that time, maybe patient has the E but when we did, we assessed the patient, we did the ECG and ST might not uh have in that ECG because patient in that case, definitely, maybe the patient has a para para. So in order to confirm the diagnosis that you have to do the 24 hour T, so 24 is a monitoring, you know, the whole term monitoring, you know, maybe uh we use like um in some country, maybe holter monitoring or 24 hour, we usually say it's 24 hour tape. So um the purpose of doing another thing is that whether patient has, you know, have any like fast af during that time. And in that time, whether the patient was symptomatic as well because this is important to know whether the patient was symptomatic with this fast af um and then if it's symptomatic, then you have to take the action, you know, immediately. So this is the purpose of doing 24 hour. And then also, definitely we'll do the A AO that is very, very important again to find out the underlying heart valve problem, especially and also to see any um um is atrial dilatation usually in af you is if you see this patient has um uh very commonly, you find out in echo that it will show you the left atrial enlargement, which is an important, you know, mm um you know, uh cause which is leading this air. So that is important to know. So the cardiology will cardiologist will take, you know, the action based on the echo finding. Um and also the CT coronary angiogram. So the um so cytic coronary angiogram definitely to find out ischemic heart disease, whether patient is having coronary artery disease, which can lead to an f. So um uh so they just for letting you know that um um you can do blood test by yourself, you can do request, you can request maybe 24 as well. But um yeah, you can do echo. But for CT Coronary angiogram, you need cardiologist opinion because if they are not accurate, they don't think so. They, they will assist the patient. They will not do it. So usually not just request. Um you know, randomly we cannot do it. I agree with the plan, but 24 hour T and echo we can do invariably it's not a problem. So what would be the treatment now? So treatment, um uh so once you confirm the diagnosis, you establish the diagnosis, the treatment will be non pharmacological treatment and also pharmacological treatment. So non pharmac treatment is the that um you have to educate the patient about the alcohol especially because definitely it is it it can, it can cause a fast um or it's alcohol itself, you know, can cause a holiday heart syndrome. So you have to educate the patients. Now, pharmaceutical treatment. Um uh I, as I'd mentioned, it doesn't matter how, how uh what is the heart rate or you have to start the treatment, but usually the heart rate, if it's stable patients, sometimes it would be like, you know, 60 to 90 for example. So you have to start a treatment. Sometimes you can start the the first line treatment is bisoprolol. So you you're gonna start with 1.25 or sometimes 2.5 mg. And then if it's still the heart rate is a bit high, it's like it's still more than 70 then you can increase the 5 mg uh to bisoprolol. Um And again, that's important of um giving the bicep to control the heart. This is very, very important in order to prevent the tachycardiomyopathy. This is the main aim now. So that's why you shouldn't be too much worried uh that OK, whether I will give this bic or not, because this is important, all the patient has that stable heart rate now. And then um another thing is that if you in your examination findings and if you equal suggestive of heart failure and then also, and now af then in that case, you might consider to give maintenance to digoxin if patient is stable, if patient is stable quite fast, if in that case, you might consider to give digoxin loading test. And another second line of treatment, we can consider that is amiodarone or flecainide. Um But definitely we need um especially if your patient has the left ventricular failure with air. The cardio is they sometimes considered to give um amiodarone because a amiodarone control your rhythm. So it will control, it's not only um so it's a rhythm control medication. So sometimes if it's like live ventricular failure, then in that case, sometimes they consider to give the amiodarone. Now, um another option is definitely uh that uh based on the, you know, you have to calculate the S versus score and based on then definitely you, you have to start the anticoagulant to prevent a stroke. Um uh But I should say for the junior level, it doesn't matter whether the patient is stable, it doesn't matter. We diagnosed, it doesn't matter any new onset of, you should advise you should ask the cardiologist to see this patient because this patient needs long term drug plan. So uh if you do, if you send this patient and you ask the GP you can put this patient, the cardiologist, believe me, it will take ages uh to do them. And so that's why it's very important that because patient is the hospital and we have done all the things and definitely we want uh like, you know, the E especially CT NG and everything. So in that case, um it definitely we need all the patients needs to be seen by the cardiologist. Um So, um so some uh so sometimes the with the cardiologist, sometimes they might consider uh like why I'm saying this long term plan. Um uh because we um if patient, for example, tachycardiomyopathy or maybe a heart failure, um you know, with the AFC, in that case, sometimes they might consider to give the electrocardioversion or ablation. So they have that different clinic, so we have to involve them so they can refer the patient accordingly. So I'm now moving to discuss about the headache. Um This is very interesting topic, uh topic, to be honest. Um although I'm at the working at the register, but it still, I'm afraid of uh dealing with this headache patient. Um It's because there's so many, um you know, there's so many puzzles area in this um symptoms. Um So, uh you have to be a little bit careful because if you, if you miss um you know, if you, if you miss the diagnosis, um especially in a headache related differential diagnosis is very, quite in a difficult one. So it will cause like life threatening condition. Patient might die as well if you miss the diagnosis, especially if you saw arachnoid hemorrhage or meningo encephalitis. So that was like most of the people, they are just a bit, you know, worried definitely about the mm headache. Um So if it's any patient uh presented with headache, um that definitely can I if you as the patient, it can be a real headache for you as well. So how do you evaluate? So definitely you understand this patient come with a headache. So I will say taking the proper history will make your life easier. And also you, it will give you some rationale that you are making this diagnosis. It will um um you know, if it's anything happen, for example, in future, um uh a patient with unwell anything can happen anytime to anyone. So you should have your, you know that uh proper documentation. So no one will blame you that. Ok. You didn't take, you didn't ask this patient properly. So that's what I should say. Please please take the history properly and please document each and every point. Uh So don't ignore anything. Ok. So the first thing is that for any headache patient, I'll say you can go to definitely soccer, you know, that that is style, but I will say few points. I want to mention that you should um just don't miss it, ok? You shouldn't miss that point. First is time of onset. So that is very, very important to time of onset will tell you the differential diagnosis, it will help you to determine the investigation plan as well. So how, how uh how does it work? For example, if you know the time of onset uh like, you know, like couple of days or weeks. Ok. So this is chronic headache. But if it's like rapid onset, like, you know, this, it just, it started uh maybe it's like six hours before or maybe um so 24 hours, for example, so if you know, then it will help you. For example, if it's any, any uh subarachnoid hemorrhage and patient is started to and and the patient is complaining the headache that it sounds like subarachnoid hemorrhage. And then patient come like after six hour, maybe within six hour or within 24 hours. For example, after onset of the headache, in that case, it it can, you can do the CT head and it you can confidently say, ok, the CT head normal. So it's very unlikely patient will have the subarach hemorrhage. So that's why it is very, very important to know the onset. Another thing is that for example, you know, this patient has like headache for like you know, weeks, months, please. I for example, if you think, OK, patient may be indicated, indicate there is indication for LP. OK. You think maybe patient have money or patient, you think patient have the subarach hemorrhage? So patient presented after 12 hours. So you wanted to do the LP, please don't do it any, any chronic headache if you start uh start in a like a couple of weeks or days or so, in that case, don't do LP. Because in that case, there is a possibility that patient might have raised intestinal pressure. Um And then I if you do the LP, then um I it's uh you know that it, it will harm, it will be harmful for the patient. OK. So just be careful about taking the history and please document clearly when is the time of the onset and then now location. So where is the headache actually? So it is important to know is it unilateral, bilateral or is occipital reason or temporal? It will help you to differentiate the diagnosis. I'm not saying that all the patient will present the ty with these typical symptoms. But most of the cases like it will be more typical. For example, if it's anyone say this patient has unilateral headache, I it can just be confident, OK. It could be migraine. OK? But if it's, it's like bilateral all over the head and if it's like a tenderness or something, then you can say, oh, maybe it could be tension headache. And then if it's occipital, you know, that it could be if it's thunder clamp headache and it, the patient is very onwards and he can say, ok, maybe it's thy night and if it's temporal, just make sure that we exclude the G CG arteritis. Um one of the clinic, you know, the common presentation in EC as well. So, so if it's any headaches, just think about that one as well because sometimes we just forget about this um X arteritis. So that's why it's knowing the location is very, very important now, progression. So that is another point. Please ask all the patient. OK. So you should ask when it started and it said like, OK, can you uh you should ask the patient, can you tell me when you feel more like, you know, more like the highest pain? OK. When, when you feel that feel that since you started having the pain. So patient will say, OK, so my pa uh I saw one patient in tic. So the patient was I, the patient was saying like my pain started one o'clock in the middle of the night and it was highest three o'clock and I couldn't bear that pain. I, so that's why I called the ambulance and came to the hospital. So it means the patient pain started at one o'clock and after two hours, patients have no severe headache. Ok. So this is, this is I'm 100% sure. This is not, not hemorrhage because if it's subarachnoid hemorrhage, then patient will say you OK? My pain just started within minutes or second or within maximum five minutes. Ok? So you patient will say, ok, within five minutes. For example, my pain was so severe that I couldn't tolerate. And um I never ever had an any bad pain like this before. Ok. So this is subarine hemorrhage. So subarach hemorrhage is like your um you have aneurysm and then it just ruptured and you ha you are having this hemorrhage pain. Ok. So it will be like within five minutes. So that is important to know when you have the um you know, the severe pain, no severity, severity, like you definitely should ask like how bad your pain is out of 10. So definitely one is the lowest 10 is the highest. So the, so if it's like if these patients say it's 10 or maybe nine, then definitely this is significant. So definitely this is not, we should, we should, we should be concerned like w why this so much bad headache, um migraine subarachnoid hemorrhage, encephalitis um can cause this like 9 to 10 pain. Ok. But if it's like, for example, any other problem like hypertension related or maybe you know, the viral infection related. So it it can be like 67 like this maybe or maybe five or something. So it will be tolerable. And so this, if you. So that's why if you know the severe it is very severe pain, then you have to be a little bit careful about that. And also please uh sorry. And also please ask that it exhibiting a reliving factor. Ok. So it's very, very important. It it it will help you to differentiate the diagnosis. So the important thing is that can you ask the patient like whether you have, you feel like if you sleep in a dark room and in dark and quiet room, do you feel your headache much better? And the patient will say yes, then definitely this is very likely this is migraine. Ok. So the patient will say this is very common presentation for the migraine patients. So because they know how they, how um how they do feel or when they have migraine attacks. So some sometimes they usually do that that and they, they will tell you, I feel that a bit better. And then again, if it's for light sensitive or noise sensitive, definitely is also goes to the migraine more. But it can be like uh photophobia, you know, if you especially photophobia is very specific to migraine, but photophobia can be, you know, vague as well, like it can be presented with uh um cach hemorrhage, meningo encephalitis with migraine as well. So and then definitely associated symptom is very, very important, especially as all the neurological symptoms, you know, they're relevant to the neuro system. For example, weakness or any visual problems, speech problem um uh with the patient has a bit confused with the patient was like had any seizure or anything. So you have to ask all the relevant question, especially if it's like patients like from some fever flu like symptoms recently and patient has maybe some trouble and patient now is complaining about that, that patient was a bit confused. Patient has the headache. So patient might consider or something. So the then it will give you some idea like maybe this could be meningitis or um you know, if it's some not. He. So II saw I know one patient he was saying like when I had this pain, I was very confused and that family member was saying me that I was very, very confused. So, so it's better to uh ask the this confusion history as well. Is it is very important. So now I'll say um as we know that you said um that is a stable patient. So I would say for Atic just um you definitely you have to open mind it but make one of the differential diagnosis you should consider um um this first to keep you in your mind that it is migraine and tension headache. Uh Also you can say some uh some as well. Also this could be like hypertension. So patient has a polia is not 200 something and then patient complain of the headache. So it's it's it's very common. And then in encephalitis, if patient has a fever or as I already explained about that, all the associated symptoms relevant to meningoencephalitis. And also another um differential diagnosis for headache is idiopathic intracanal hypertension. So this kind of patient they to take from sometimes from the eye clinic, for example, eye clinic, they, they were assisting the patient, you know, eyes and they found out the patient has a papilloma and the features of raised intracranial pressure. And then they just um referred to us to just for further assessment, whether the patient has have any idiopathic intracranial hypertension. So, in that case, um um so it's again the history and you know, for IOP in that important, the patient or the patient has, it does take any oc or any or any medication which sometimes can cause uh um you know, um uh especially is sometimes uh the people they take for acne and it can cause this um intracranial hypertension. So it's is important to take and also if patients sometimes can come with a headache, if you think patient is pregnant, um you know, it, it does take op and then now it's headache, just think about if it's progressive chronic headache like a couple of days or maybe, you know, uh weeks or something, just think about whether that could be ce venous thrombosis as well. And then very simple things can cause headache that is viral infection. So I have, I have pain everywhere in my body. Ok. So you have like flu and fever, uh you know, fever, flu, like symptoms and on top of this headache. So, so just think about this simple viral infection as well. So now how do you investigate? So definitely investigation depends on your um you know, your differential diagnosis depends on your um the way you took the history and then what you have found out and based on that you have to make that decision. Definitely not for, you know, the headache, not uh will not do CT scan for every headache patient. Ok. So that's why we are doctor, we have to take the decision based on our history based on our clinical examination and assessment. So um um so just think about that, what when you need it, then it doesn't mean that you don't have to do you, you don't have to do a CT head, you have to do it if it's definitely if it's relevant. So the most commonly the uh we usually do the CT head if patient, there's a clinical suspicion of sar not hemorrhage or maybe patient has many encephalitis or maybe patient has mm any chronic headache with a specification and his, I mean, you know, any suggestive of vilation and raised Intal pressure or whatever, you can just quickly examine the eye as well if you see PPI edema. So in that case, we do the um CT scan, also migraine patient, if it's hemilasia, migraine, um I would explain a little bit later about. So in that case, you have to do the CT head. And now I already mentioned about the suberectin hemorrhages. So, because I would like to mention so uh to just to know that what you can do, like um a patient is suspect of sub hemorrhages. Uh uh uh you know, definitely it's important for the onset. So if this patient presented within the six hours, then you can just do the CT scan. You can confidently say there is uh if it's, if it's just OK, there's no possibility because so sensitive. But if the headache, um he sounds like this within 24 hours. So it will be like 92%. Hello? Hi. Sorry. Can you step a little back? Can you step a little back? We didn't hear the last uh bit of statement that you say uh uh uh when you were explaining about hemorrhage, you, you, you lost your audio function, please. Can you explain that just for a few seconds? OK. OK. No problem. So I saying if patient has the subarachnoid hemorrhage from your judgment, you think this patient has like a pain started and uh when the pain, patient pain initially started within five minutes, patient feels like very bad, severe pain and it's like, you know, the thunder clamping, it's like very severe and within like five minutes. Ok. So that's the highest pain. If your patient says to you in that case. Um uh This is very, this is very um typical scenario that you should consider this is not hemorrhage. And then, so that uh I'm I was just talking about the investigation plan like e patients suspicion of subarachnoid hemorrhage. And patient presented within six hours of onset of headache, then you can do the CT scan which is 100% sensitive to rule out subarachnoid hemorrhage. And if um if your patient presented within 24 hours, then nine ct scan can rule out hemorrhages. But that time it will be like tw um you know, 92% sensitivity in that case. So what is a a patient um um presented within, you know, six hours. And if you do the CT scan, if it's normal, then you can just send, send this patient home. And you can consider about the other differential diagnosis that the subarine hemorrhages. But if patients presented with 24 hours and if it's very typical sub he hemorrhages, uh you know symptoms then in and can, in that case, you should consider the lumbar puncture uh because patient to patient with 24 hours, but lumbar puncture, usually we do easily positive in subarine hemorrhages after 12 hours of onset of pain. So if you be before 12 hours of onset of um pain, if you do the lumbar puncture, uh it will be negative. I hope I, yeah, I hope I clear that um problem. But uh if you just have any issues, if any questions, just let me know. So now I will discuss about the little bit about the helas migraine because it has been quite uh sensitive things to that because the patient usually come is they're very young and then patient might complain to you like, OK, I have had, I had that migraine for a long time. I was OK. But this time that I started to have the migraine pain, I was OK. But uh and the patient, so maybe I thought like this is normal migraine. But suddenly I noticed that I have some speech problem. I couldn't find out the exact word and I have some like visual problem that is not like typical, you know, the aura, not like that. So, so and maybe some patients there might some weakness, even some, some people say like dense hemiparesis as well. OK. So, you know, you know, not a dense hemiparesis and and, but usually if a hemi plastic migraine, they will say, OK, it was there for maybe a couple of minutes or seconds or something and then just I was fine. So this is hemiplegic migraine and this patient needs urgent attention by the neurologist team. So in that case, I would say this patient, we will do the CT scan to make sure there is no any, you know, any infarct or anything. And then after that, you have to give the migraine treatment or also you have to refer this patient to neurologist. Ok. So for the further assessment and this kind of patient need um um especially preventive medication as well. Definitely. Um so I will discuss about the migraine treatment, to be honest in headache point of view. I know so many other thing, other differential diagnosis I already discussed. But um but in te you just commonly see um he um a migraine patient. So how do we treat migraine? So the migraine treatment definitely I can differentiate in two parts, non pharmacological and pharmacological. And then if you, if you, you know pharmacological ee maybe I know everyone maybe definitely know about that, that you have to ask the patient to have some medication. I know that they have to have like proper sleep because sleep deprivation, prolonged fasting, everything can you know that cause the migraine and also you know, some food like chocolates, um more caffeine and it can cause um a mi migraine attack as well. So you have to give some life advice. And then now the thing is that mentioned. So if patient come to us, definitely this is um so the patient come to the hospital for this is a heart attack. So we have to treat that one. So how do we treat? Please make sure you prescribe combination of medication don't give on. Um don't give only one. Ok. So the purpose of giving the combination of treatment is that the pathy is of the how, how the migraine affect the body so that you have to treat uh with the combination medication. So combination of medication is that I'll say three, at least like simple analgesia the first. And then another combination is uh you have to add antiemetic um and you have to keep Triptan. So um so simple analgesia, in that case, you can just give the patient paracetamol. And so not only paracetamol and you have to give either you can keep aspirin 900 mg. So you have to give nites basically as well. So paracetamol and high dose ans it's not like normal dose. So it it should be high dose any side. So you can give so aspirin plus you can give either aspirin 900 mg, although it sounds very weird. But um uh the neurologist I II know some of the patient, they advise the 900 mg. Uh They don't mind means uh so you can keep 900 mg. But if you think, oh my dear, this is too much dose. If you're very scared, I would say you can keep different uh you know, other, other medication, other side. So it's not a problem. So it will be like equally effective. So you can give Ibuprofen 800 mg or Naproxen, 500 miram or diclofenac 5 50 mg. So a a as you know, if you give any, any sites you should consider to give some PP as well and then another thing is that you have to give antiemetic, please. All the migraine patient please prescribe antiemetic. It is very, very important because the path of physalus in migraine is that there's some, is there some it affects the uh there's some uh signal from the brain is abnormal. That's why you are having migraine, you. That's why you are having he a headache. So that signal is causing some trouble in the gut as well. So in that case, the gut absorption power is also less. So you have to give antiemetic to have the be um you know, the absorption um uh uh uh a about the I know the medication you are giving now and also it will help your um in the nerve and II don't know, I mean, how do it does work exactly 100% but it, it, it does work. So you have to give anti um that also the patient, usually migraine patient will also usually have that uh you know, vomiting as well. So for that, you have to give for symptomatic reason. Also, you, you have to give for uh migraine problem as well because it affects the gut. So that is anti, you can give either me or do and also then you have to give third medication that is Triptan. So Triptan or you can give rapid acting Sumatriptan or ZOLMitriptan. We have a long acting as well, but we usually give um you know, the short acting. Um so, and then BNF, usually, you know, you, you, you can check in the BNF. Uh you can see the dose um um maybe sumatriptan usually start 50 mg stat and then you can have some maximum dose as well. Um But there is some guideline in the BNF. Now, if this patient has the has the migraine, so you have given all three medication, you can send this patient home uh from the EC. And then um if you are very worried and headache and then definitely you can ask for the telephone consultant appointment later on as well, but you can discharge this patient with this all three medication that dose and then prn as well. Now, um n now just for migraine patient, just be just consider whether this patient when patient come to, you just consider this patient need any preventive medication. So how will I decide whether this patient need preventive medication or not? The decision will be definitely based on the patient's symptoms or patient's number of the attack. So if patient has like, you know, this, uh some people will say, ok, maybe I have like 10 days of uh you know, the migraine attack and once it started, it didn't resolve like when the patient is having this migraine headache is like maybe 10 days. So like long time and it's definitely affecting their daily activities. So in that case, you have to consider, ok, we have to consider to give um um preventive medication. Also sometimes might say, ok, this is not, maybe migraine attack was not, didn't last for long time, but it was like it comes once in every week. So this is a uh definitely, I it affects a lot um of the patient's daily activities. So in that case, you have to consider preventive medication. So the first line is um beta blocker that is propranolol or atenolol. And then if patient has contraindicated, for example, young patient, they want to be pregnant, then it can, in that case, you have to give like in the second line, second line is amitriptyline. Um and um you can give some opia or sodium help ba based on the patient um situation and uh contraindication. And then now I would say if he's any headache, don't be panic. Um And definitely um if he is junior doctors, you have someone on top of you. So you shouldn't be worried, especially in you have always registered. So you shouldn't be worried at all. So I will say the main trick is definitely you can take a very good history, don't forget about the um asking about all the 11 symptoms and time of consent um A as well. And then sometimes what you can do some people, especially young people, I'm not blaming them, but it just maybe they have having all this trouble for a long time. So sometimes they will, it's rarely but sometimes they might exert the symptoms as well. So in that case, um, you, you can just overlook, you know, you can just, um, um, see at a glance before patient notice that. Ok, so for example, if they're sitting around, they, they already managed to put their makeup in their face. So it's, it's a bit unlikely that to be honest, that they will have like very bad, you know, headache. So just, you know, just for like um just ii just deep spec you can have a look and then, but if it's for example, if anyone has subarach not hemorrhage or when you encephalitis, believe me, they will be miserable. So they will be not like sitting around, they will be not comfortable at all. So ju just for you know, the um it's just experience, you will, you will learn so many things from your experience and then um and other things that, that definitely um if you are very worried, another thing you can do. Um for example, you have already given the treatment for migraine and you are confident with that, but you are still worried because you don't know if, whether there is any bleeding or anything. So I will say in that case, just book an appointment next day for telephone consultation. So most of the time, believe me. So if you just uh because especially migrant patients, you give the first initial treatment, if patient has a good sleep, patient is 80 yeah, fine, fine. And the next day the symptoms. So and then if patient is feeling ok, then you can just document quickly and you can discharge from a stick. So uh that will relieve your body as well. And another thing is that definitely, if you're still concerned, you don't know what is going on. It. It if you think this headache doesn't meet uh fit with any other um you know your differential diagnosis. So in that case, definitely you have to switch your senior, your register. And yeah, so you can have like entity I should say. And sometimes if I'm a bit uh confused, then I usually ask my consultant as well even on call like w whether or not because I don't want to think this is the main thing. So this is a safety for you and safety for your patients. So just don't hesitate to ask people for help. OK. So this is the way the National Health Services work. Um I really, I like these uh things that so um no one will say you may uh no one will be um saying you to be honest, anything if you ask like a stupid question. So no question means every question is important. So um so that I would say you should ask um you know, for help and give some uh you know, headache to your senior as well. OK. Now, in conclusion, we're just uh maybe we're just about to end our presentation. So I will say um as I believe you do understand that Aztec is a, is an emergency outpatient center service. So definitely from aeg the priority, main priority is that you have to send this patient home. This is the main priority, to be honest because um this is same day service. I want to evaluate everything. I want to assess the patient in the station and everything and then I can um we can send the patient um home but it has to be safe. So you have to see like whether this is, so you have to decide, OK, whether it is safe to patient to go home or not. If it's not safe, then you need admission, you need uh you know, further evaluation, further management. So in that case, this patient has to be in the hospital. So I would say if you decide for hospital um admission, then just make sure you, you know your rational why you are admitting this patient. So usually we admit the patient if patient needs any IV fluid IV antibiotic, um uh you know, for an I and IV antibiotic. Um I can already mentioned, you know, uh exclusion criteria that patient doesn't need admission, but most of the cases, patient might need admission. Um If it's usually if this patient is septic, patient, hemodal is stable patient is looks to be dehydrated, you know, maybe old patient. So in that case, maybe or if patients requiring oxygen. So in that case, we have to admit this patient, OK, for glucose monitoring. And then if you want to dest, so how when you digest? So if you want to dest, you have to think OK, what I have done so far? Uh Yeah, so then OK, so for example, if it's DVT, for example, any patient, so you have done your part, OK? You have done, you confirm the diagnosis, You have you started the treatment, everything done. So what else I can do? So whether this patient need any specialist referral that you have to think about for every patient. So uh because this is because you are sending home, so you have to make sure we are continuing that care. OK? So in that case, you have to make sure that you are doing the relevant specialist referral. And also um I will say um to make a septic chest pain. So you have to think about the stool part, whether II can do everything I can sort it out and I can confidently send home. Um And then, and then the next part is definitely whether patient, this patient, every patient, you should think about whether patient need any specialist referral. So I will say eventually all patients in TIC, if you see, then you have to make SE D plan and then you have to give patients advice, please. You have to do it. If you work in the medical ward to be honest, I don't bother about telling patients like the se advice. But if you send this patient home, you have to give certain advice and then any specialist referral or maybe telephone consultation appointment, you can book as well. Um And so it's like in order to avoid, you know, patient come to the hospital, for example, that's how you mentioned, you know, headache, uh you can just give them a quick call to evaluate the symptoms. Sometimes, for example, we did some blood test but result result will take time to come back. So in that case, we can send the patient home with the relevant treatment and we can call them quickly and you can say, ok, this is your blood test result or this is the administration result. And then based on the result or maybe based on the patients symptoms, you can ask the patient, can you come back to us or maybe you can just do this and that. Ok, so this is the way that um um you can make it like in a proper plan. Um You can, you know they send patient home safely. Ok? I think um that's all um for today, I just want to add something uh very important. Uh you under to it earlier, please don't forget that you always have seniors around you in, in the emergency care, you have registrars, you have consultants, please always speak to your seniors. If there are any doubts always speak to them. Don't send any patient to uh by your own volition alone, please always speak to your seniors. Thank you. Yeah, thank you. Um Thank you everyone for attending. Um I think we um uh to already repeated the same thing that please feel free to fee. Um you know, fill that feedback form. So this is the new platform we are using. We are happy to share our experience with all the doctors, especially in the international Medi medical graduate doctor and also the foundation doctors who just started to work in um you know, the hospital settings. So it will encourage us to do more. Se hi everyone. I just wanna say thank you from my side as well. And um we'll con we'll be conducting more of these sessions like here I mentioned, um especially for international doctors and foundation doctor um to help them with their journey in the NHS. And good luck to everyone who is on the way. Um uh to come to the UK for a job in the NHS. We hope we find these questions is useful. Thank you. Um Thank you everyone. So I think we should end this session maybe uh we'll um see you next time. But one thing I would like to mention as well, like if anyone from our audience, they're interested to participate and they want to present an interesting case or an interesting topic, topic, please contact with us. So I think um I have already, you know, we have the major, all we have the community that is A and D general internal medicine community. So you can join and then definitely you can email directly to us. So I think I put my email address there so we can organize the teaching session for you. OK. So we'll be the moderator and then you can teach that. Um If you are interested, please free to contact with us as well. Thank you. Hello. Uh She said we sh we should kindly review the investigation for arrhythmias. I think that would be a big thing. Uh II don't know we have time for that. I don't know if it, well, it's up to you, but I think that's an algorithm uh for arrhythmia that is uh very common peculiar to the UK that can really help with um arrhythmia generally because we only talked about af here. But if you want a full um uh assessment of arrhythmia, I think that algorithm will also do a good job. Um uh uh um Basically in that um I II do understand, we can definitely add maybe next time we can keep it in mind that we can uh do more like, you know, more present about both the T and R arrhythmia. And then we can show them the algorithm that we usually we follow in advanced life support course. So um I think maybe next time um sorry, I didn't put because I thought it will be the long discussion because we already running out the timing maybe next time in one day. Thank you. Thank you. Ok, thank you, everyone. See you next time. Bye.