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okay, I think we'll get started. So if you might have already noticed, I'm if you've already been to some of our electricity in the past. Usually it's me and somebody else. Yeah, and today is just me because I'm providing today's lecture. Uh, today's lecture is going to be on emergency cases. Some of the most common cases that you see in a any just some content warnings. Before we start it, we'll be talking a little bit about overdosing or some mental health. That's also a little bit of a hint on what some of the cases might be up a little bit later. But this could be either a weapon or more interactive style if you're if you're really feeling keen. And hopefully some of you are pleased to type in the chart if I ask some questions. But if not, I'll just give you guys some time to think. And, um, hopefully you could just think about some of the things that come up during today's webinar. So reason why we're talking about emergency cases today is because preclinical, there's no enough so off juicy medical stuff, and emergency is personally my favorite specialty. It's where the juiciness is okay because you're arguably saving people's lives every hour or so every day. And this is where the really medicine is. Personally, anyway, let's get started. So it's gonna be quite a case based discussion. So we're going through. Let's four different cases. Five minutes, maybe five different cases. So just have a little think about some of these cases that I show today. So first things first. Hopefully, you guys can still see my screen, but you should see a case number one. A 67 year old gentleman is coming to you in a any complaining of chest pain. I thought I'd start with something that should ring clot A bell's bring lots of bells and zor sound, lots of alarms. But if you guys are happy to, could you type in the chat? Maybe. What do you think could be happening? Why your diagnoses? That that could be coming up? So let's say you were the only person there that has medical knowledge in a room full of non medics and people that don't know any health care. What are some of things you're thinking off yet? Perfect. So my quarter infarction, perfect angina Yes. So these two we can combine together into something called A C s so acute coronary syndrome. So both of these are something to do with the hearts of cardiac? Yeah. Perfect. Does anybody have any other ideas of what kind of things could be happening? So we were mostly talking about cardiac cause is, but could there be anything else going on? It's up other than cardiac cost. The contractors? Yes. So that's also a possibility. Although, yes, it's kind of kind of unlikely. So pad up with something else later. But yet that's a good point. Good. Yeah, exactly. So hopefully if you come across some of your anatomy in Fab And also maybe it might be also in home that a lot of people who have reflux also have or seem to feel like they have chest pain. And they might actually go into a any for that because they think it's Oh, my gosh, I'm having a heart attack. But really just having reflux. Yeah, Perfect. So we've got some of that causes. We've got some of the musculoskeletal causes. We've got some of gastric courses. Does anybody else think of any other ones? Maybe respiratory prosperity causes. Yes. So I'll take dissection. Yes, I ordered back section is one of them a cell eyes, One of the also cardiovascular causes. Well, and we'll talk about that in a second. Any respiratory causes that anybody can think off. So what else could be going wrong? Well, what can go wrong with the love? Yes. So somebody said blood clot as well. So but what's the blood clots can happen in the lung. And we'll talk about that in a second as well, but yes. So those are some of the causes. Let's look at some what some of the difference was I thought off some of these you might not necessary, no straight away, because obviously, you're doing heavily biochemical sciences in the first three years. But some of these that so should ring a bell acute coronary syndrome. So one of the first answer is that you probably should have thought about is my cardio infarction heart attack or angina? Second one might be a pulmonary embolism. Okay, so that somebody said blood clot, and that's effectively a blood clot inside the pulmonary artery. Okay, so the lungs are getting refused enough. You have dyspepsia. So basically, just GERD or gored, no matter what, you you can go out. But some people get some pain in that area, and they associate it with a cardiac problem, okay? And they might come in of some people also make an anxiety attack. So some people also present uh uh, any with the panic panic attack. And I don't know if anybody has already had a panic attack or knows somebody that's had a panic cycle witness somebody else that has a panic attack. But some people really feel like that dying because they're sort of a big construction all around your chest. Okay. And if you think I mean, you might think, Oh, then it's obvious. What if it's an anxiety attack or a cardiac cause? Because usually, oh, maybe people of this group might usually get an anxiety attack. These people who, um, much older males might get a C s, for example, but, uh, if you is it the hospital? Actually, quite a lot of patients have mental issues as well. Okay. And a lot of mental health problems, and some of them do you get anxiety attacks, okay. And if you have a 60 year old male in this case, 67 year old male that is having chest pain on. Do you didn't ask them already? Oh, is there a lot of stress in your life? You know, maybe they're gone through a divorce or, you know, a member of the family have died? You don't really know. So anxiety attack is should be one of your diagnoses or things that think about as well. James also said costal chondritis. Yep. So we see is just the inflammation of the So this area, that's the chest. Okay. Week. I've sort of pulled up with musculoskeletal pain and the way you might differentiate costal chondritis and musculoskeletal pain compared to something like a cardiac cause. Is that a kite? That cause usually is spread out all over the chest. So you probably all heard that it spreads out on the chest, maybe goes up to the jaw, also goes down the left arm. That's something that is typical of, um of a minute off the heart attack, but something with them escape pain. A patient. Usually if you ask them to point exactly where is they'll be able to point and say, Oh, it's here, and if you touch it, it's going to hurt a lot. Okay, so that's how you can differentiate between something that's more musculoskeletal versus something that's a cardiac cause. You might also get some acute lung infections, so obviously you'll get all the symptoms as well. So if you're having pneumonia, you would usually expect things like productive cough. Uh, that would be quite ill. For example. They might have a fever, so usually you would expect some other causes. But if we're thinking just broadly, then you might also think about acute lung infection. Some people didn't. You might also think about some chronic lung condition conditions. So asthma COPD Um, so again, this sort of presents with some tightness in the chest, especially if you have, um, an acute episode of either asthma or COPD. You get this tightness in your chest and it's quite painful, okay? And some people might miss take that again for, uh, an M I. Somebody also said I ought to take section, which is a really important diagnosis to make. If you don't know what I ordered by Section is, it's essentially when if you think of the aorta is just being a tube, basically the inner lining. The endothelium comes off, okay? And essentially, it makes a full Sloman. Okay, so it comes in and it makes turbulent flow. Okay, And we'll talk about the two different types of or the different types of aortic dissection a second. But it's really, really important that it's something we don't miss because the patient really could die. And lastly, we have or have syndrome. I don't know. Does anybody know what Bauhaus syndrome ease, or can anybody give me a guess? You can probably google it right now if you wanted to, but if there's anybody no, no. So assume that nobody does. So both have syndrome is essentially there's a tear in and in the esophagus. Okay. And that can happen for a number of different reasons are usually it's because of chronic remitting. So a group that might be predisposed to it might be, for example, alcoholics. Okay, because if they had quite a lot and excessively in a short period of time, that could cause on a tear in the esophagus. Okay, Presents with salt, a Quincy sound. And I know that sounds a bit weird and gross but you can have a crunchy sound when you put your stethoscope on their chest. They also might be vomiting blood. Okay, so that's some of the, uh, stuff with four halves. But you also might have heard something called a Mallory Weiss tear, which is no particular the same thing. But it might get mistaken as a bull half. So Ball House is an emergency. This person needs to go into theaters pretty much assume it's possible whilst amount. Mallory Weiss Tear is just tear in the esophagus, Which makes you might you might cough up some blood. You might vomit a little bit of blood or have some blood in your vomit. But that's essentially the difference between the two. Okay, so any ideas on what kind of investigations could we do? What kind of investigations? So, uh, just so you're aware when we talk about investigations, that usually means things like blood tests imaging. So that doesn't include taking a history or doing examination. That's separate part but an investigation. What kinds of investigations could we do to rule some of these things in or rule some of them out? So please do just have a guess this. They're all right on system romances, but, uh, but it be great if somebody said some, so yeah, chest after a PCG. Perfect. See, some of these are great investigations that we might do. Yeah. Any other investigations we might do? Yes. So blood tests of bio markers is a great investigation as well. Any other ones? So you've got imaging. Uh, we got imaging. CG blood test for biomarkers. Anything else? So it in clinical medicine, we usually like to split the investigations up into three sort of categories. Per se. One of them is bedside tests of test. You can do pretty much immediately because they're they're on the ward's. Okay, so that's your for example. Compare it. We blood tests. Okay, So, blood glucose, then you might have your blood tests. Okay, so that's when you have to send off to a lab, and then your other ones might also be your imaging. Okay. And then you might also have some special investigations, but that's usually links with the other ones as well. Okay, well, some. So here's some of the stuff that you might do if you were in a any. So somebody said blood test of bio markers and biomarker that was specifically looking for, especially for something in my cardio infarction is proponent. Okay, so you wouldn't know that muscles have troponin. And it's one of the chemical bio markers that we have in a need to decide whether or not, uh, there's bean at ischemic solve episode of the heart. Okay, obviously, this is going to take a little while. Adam books. It takes couple hours. Maybe, uh, our at the minimum. Probably. So you take it, but it wouldn't be given to you for another couple of hours, so you need to make sure that you take it, but don't rely on it because as the aura in the investigation, because it's gonna take a while. Your bedside test of choice, however, would be an E c g. Okay, So if you looked at your home the home stuff and looked at any CG wave and looked at heart wave, uh, that any CD can be done really, really quickly. Okay. And if you ever had any seizure in the hospital, literally, somebody stands there, put some electrodes on you. It prints out the sheet or pretty, and we'll look at any CD in a second lower. You might also consider doing in an angiogram again. This will take a while. And if you already know about any chest, so waiting times and especially because of Cove it and now it's flu season. This is going to take a water. Okay, so you it's not your first line investigation. Your chest X ray is something that's really, really important to do because you don't want to have something as pneumothorax and chest or look at chest infections. And also, you might also see some aortic dissection as well. Does anybody know what new my four X is? I'm sure you probably come across it in. It is a family home neutral, but doesn't even know what pneumothorax is. Yeah, perfect. So it's an air trapped into the chest, and we'll have a look at the next rate on what that looks like in a second fusion culture. So if they've got other identifying sort of factors that suggest that you know they're coughing a lot, they've got a fever. You might want to do a sputum culture, and if they're spitting out a lot of productive mucus, you gonna want to send that off. Unfortunately, this takes anywhere from two days to even up to a week. So this takes forever. Okay, So you would want to treat them even before you find out what microbes air in the sputum. But it's helpful to decide which sort of medications to take in which antibiotics to take. Because some of them might be resistant. Some of them might not be unless they would just do a typical blood works. I don't know if you've ever seen any of these. Off initial is, um slash acronyms, So F B C stands for a full blood count. So that's your hemoglobin that your red blood cells, that's your white blood cells or your neutrophils is enough pills, lymphocytes, cetera. Okay, that's where your full blood count you're using knees or your ears and electrolytes. So that's your sodium potassium creatinine. Your areas, obviously on D calcium. All these ones are using these yes, our and CRP, or both infection markers. So CRP is more of an acute infection marker, so it'll rise whenever you have a new acute infection. And if you test it as soon as you get the infection, it will be high, but he s or is mostly used if they've had a chronic condition. Okay. Does anyone in Connecticut guess when any s or might be high whenever? So what conditions might cause thean you system to be flaring up often. So any guesses? Asthma? Yeah. Asked my Could be one of them. Yeah. Any other ones exam? A Yes. Auto immune? Yes. So pretty much any autoimmune. So rheumatoid arthritis, for example, causes choir high or race? Yes. Are. And if you see high? Yes, Our that indicates to you that there's chronic inflammation and this off, possibly an autoimmune condition. And, um, it could potentially, um, possibly chords because Ah, hi. Yes, are more so that if it wasn't high year, so you wouldn't mostly think it's more to do with, um, an autoimmune condition that supposed to more anemia, But someone e mails can be caused by auto immune? Definitely. Yeah. Perfect. So this is just something that was quite interesting to you Don't need to remember at all with is something called the well score. So if you ever if you know what the pathophysiology of pulmonary embolism is, usually comes from a clot somewhere else. in the body. Okay, but anybody know where that clot might come from or tends to come from? Yeah. So a leg, So a DVT. Okay. So passing with DVT Usually Oh, can get a pee or a pulmonary embolism. Okay. And we use the well school to decide basically their choice of treatment. Okay, unfortunately, I ever made this. I think is a little stupid because one of the options is pulmonary embolism. Is the number one diagnosis or equally likely, which is three points. Okay, you would think that. Why would I need to do the scoring system if if I thought it was already pulmonary embolism? I don't know. It's a contention you can complain about it once you get into medical school is well, but either way, this is the thing that we use, whether or not, uh decides the treatment. And also, besides the investigations that we do, is this some of the treatment again? You don't really have to remember it. Um, but for the changes in treatment, depending on the well school and also whether it's a provoked an unprovoked pulmonary embolism. So the difference between provoked an unprovoked probably Advil is, um is just whether or not they've had a sort of event that could have caused it. Can anybody guess what might be a provoked event for pulmonary embolism? What kinds of things could cause a blood clot in the low or predispose you to a clock in the lung? Yes, So perfect. So being bedbound or stationary. So definitely, uh, if your cough had a surgery or you've broken your any of your legs, for example, you might have, ah, increased chance of developing a blood clot anywhere in your body, but especially in your lungs. Anybody else can think of anything. Medications and medications can definitely cause a perfect pee. You might think about that. If, um, they've started a medication the last couple weeks, two months, something you definitely should consider. The other one. The big one is surgery. So if somebody's had surgery so quiet love people, especially the older generation, might get a hip replacement. And that's also so, um, tied up. Teo being stationary a Z well, So if your bed bound your stationary on, do you just need us? You just had a surgery, which, you know you can't walk in. Then it could definitely cause a P being overweight, I would pass. I would think that it's more of an unprovoked things because it's more of a risk factor that eso the different screen a provoked an unprovoked pee is more so. That is their singles off defining event person if that makes sense compared to something that's more of a risk factor. So definitely being overweight can increase your chances of getting a P and also a DVT. But you can also think about it as indirectly made. Maybe that person is more likely to be stationary or more likely to be bedbound. But definitely being overweight is as a risk factor for for a P hope. So this is one of the initial assessments that we might do a hospitalist well on. This is usually used for things like pneumonia, and particularly in the beginning of the curve, it pandemic. You might. People might have used this because they thought that the person had a pneumonia instead of cove it. But we call this the Curb 65 score, and essentially it's basically deciding whether or not to this person going to hospital and get IV antibiotics, or should we just send them over with for antibiotics, and that's basically all okay. Usually a score of 2 to 3 will suggest that they should stay in north before. Okay, you should consider keeping them in hospital and each one of these points. So urea over seven gives you one point, especially rate over 30 gives you one point. A BP so sisterly of less than 90 or a Diastat or less than 40. We'll give you one point. And anybody over 65 also give you a point. I okay. Does anybody know what this diagram is talking about? What is this time? Aortic aneurysm? Almost. It is related to a or two. Can you is, um, aortic dissection yet? Perfect. So these are different types of aortic dissection, so you can hear the top. Annoyingly, there's two different naming convention xfiles for your aortic dissection is there's a Stanford and the baking. Personally, I prefer the Stanford because that decides or helps you decide on, uh, the treatment. But essentially a difference between type A and type B is that Type A is involving the A. Sending aorta and tighten me is involving the descending aorta. Okay, The treatment for these different. So if it's a type A in the Stanford naming system, essentially, this person needs to go to theater immediately. Uh, because they could die, um, in by and tight. Generally, we have more of a conservative treatment, so usually give them, uh, medications that might reduce that BP, so it just doesn't make it worse. Okay, so that's just the interesting thing about, uh, aortic aneurysms. So let's go back to the case. So upon further questioning, he tells you that he was doing some gardening when suddenly he felt a shop central chest pain. Does that lead to any particular diagnoses? Which diagnoses could be more likely from the list that we had earlier? Do you think he broke something more interconnected? The think so? And then mind so an MRI is definitely much more likely, for it seems like it's possible much more possible than let's say, as most COPD considering you is sudden and quick. Okay, So the important parts here is that it's a sharp central chest pain. Okay on that he was doing something at the time. Okay, usually people with them, I might be doing something with or for example, angina. They might be doing something at a time. Okay, having some exertion. So here's an E c g. I don't know if you've seen one. EKG still terrified me to the snake, so I I don't suppose if any of you can have a look at it. But does anybody have anything that may think that this's a bit weird? Obviously, a lot of you probably haven't really seen an easy do properly in the before, so don't worry if you get it wrong. Yes, so somebody said ST Elevation. Exactly. So there's ST Elevation in V one V to be three before a little bit in the five g six, maybe in one, maybe in some other ones as well, but mostly in the's V ones. You don't really need to know at this stage what, what v one and V to be thrilled. This is, But you just need to notice that there's a big jump. So compared this so big so of humpback thing, from maybe lead to whether it's this is more of a normal. This is what you would expect. Okay, I hope you can see my cursor. Uh, but you can see in lead to that. This is more of a normal elevation, whilst this is massive in Vedic. Okay, so let's talk about the two different types off a C. S. I was gonna ask. This is a question. But then I moved on to the next light, so I won't do that. But we have my cardio infarction, and we have angina. Us. Okay, we combine them together. We have acute coronary syndrome. Um, but an M I usually as a scheme of damage. So with an M, I, um usually getting was not enough oxygen to the blood. And there's two different types which we'll talk about in a second and yourself Angina. Okay, which usually doesn't cause a skin damage, but it still causes pain. Okay, so it's not not particularly nice, but angina can eventually lead to an M I if the conclusion is big enough, But generally these are two sort of separate things. Okay, so here the four different types and this might be kind of interesting to put in. Maybe your home essays or five s is if you're in first year, but here of four different types of, uh a C s or and my slash on China's. So your, um eyes a split into stem ease and and stem is okay, so a stemi is basically stands for ST Elevated, am I? So if we go back, if I can go back here, Okay? If you know your cough way if your sed uh, ECD wave this segment here is your ST segment. Okay, So this isn't it elevated ST segment, okay? And that's what we call in ST Mi. Okay, Because it's ST elevated. Let's treat it. Okay. Okay. Usually a stemi is your worst kind of am I? Because it's indicated off 100. Almost pretty much 100% occlusion of the coronary vessel and end. Stemi, on the other hand, is basically the same thing, except you don't see any elevations. Okay, so it, for example, you might see a look the lead to basically the same on all of them. Okay, so it doesn't really look like there's anything obviously wrong the best. Still getting chest pain. Okay, The difference between the two is that and stemi is more a partial occlusion. So it's less than 100% but still quite a lot. So usually over 90% occlusion, while the stemi is 100% occlusion. In both of these, this leads to escape make injury. You can see that one of them, says Transmitral. That just means the whole so off block of the heart. So the whole thickness of the heart is damaged. Well, some endocardial just means heart for a little bit of the heart. Is is damaged or not the full thickness. And because of that, because there's a ski, McDonald's troponin is raced. A second we'll talk about is angina. We have unstable, unstable angina, and the way we differentiate both of these is literally just can this person does this person get chest pain when they're at rest? So if they're sitting down and they think chest pain, then that is one stable angina. Okay, staying on drying on your hand is when you get enjoying the usually when you're walking, you're doing the gardening, you know, doing exertion or doing activities. Okay, well, for these, there's no ischemic injury, But again, if this is probably an indication toe, perhaps go on a better diet, maybe we should lower the BP. Maybe council medications. Maybe some exercise, because eventually. If this keeps building up, it could lead to an instant your stemi on the whole. So this is the three different types of three features of typical angina. So if somebody's having angina for in front of you, you can figure out if they've got typical angina. I would recommend that, but you should probably help them. But in your head, this is what the three features of different genera, so location. So it's usually substernally. So this is your sternum, so it just means it's in the middle underneath. Central chest pain, okay, has gone normal character and duration. Okay, so usually it lasts for know, You know, it doesn't last for a few seconds and then goes away. It last for a decent amount of time. Okay? And this all stabbing or maybe even crushing. Just pain. Provocation. So typical angina typically gets provoked on exertion or emotion, so sometimes you can get quite significant chest pain. If you know, you've just found out your, uh, partners just passed away, for example, people can get angina from that and also the relief. So isn't relief relieved by rest? And is it relieved by nitroglycerin? Okay, does anybody know how nitroglycerin might work in a situation like this? Why might we give nitroglycerin to a patient with angina? Or am I Yeah, perfect. So it's a vasodilator. So it's one of the first things that we tend to give because we want to make sure that even though it's occluded or partially cleared, we want to visit dilate the coronary blood vessels. So we wanna give them some nitroglycerin. Usually we give it under the tongue, so billing will. So we just give them a sort of a pellet door tablet, and it's all melts in your mouth at the bottom. Um, and hopefully that should give just a little bit of leeway for us to sort of figure out what's going on. Okay, Perfect. Here's some of the management. You know, I really don't know what you need to know much of the management, but here is some of that we use in chemical school. We use the acronym Mona Bash is that is a negative on ammonic Mona bash. So Mona stands for morphine, oxygen, nitroglycerin, aspirin bash stands for beta blockers, ace inhibitors, statins and heparin. Okay, this is a combination of both helping the patient immediately. Now. So nitroglycerin, for example, is helping the patient. Now, heparin is also helping are not heparin. Sorry, but nitroglycerin is helping the patient right now. Oxygen is helping the patient right now. But some of these are also, um or of, ah, long term thing. Okay, so for example, heparin, statins. Okay, these all help reduce the risk of you having another MRI in the next, you know, week or so. So fun. Fact, all from information. You don't need to read these things until you're in clinical school. But this is the we use nice a lot. And this is the A C s pathway. So deciding on whether or not, uh this does this person need to go to a pap forth, for example, for some reperfusion therapy, or can they just be managed medically? What do we need to do? Okay, this is just a knees, ear version of the same thing. Uh, feel free to have a little look at it. It's quite interesting. Um, and if you ever get to go go to Papworth for any reason and watch a PCI, it's really quite interested. Okay, so, basically, that first case person. This old man had an MRI. That's basically the diagnosis. So let's move on to the next case. So 23 year old woman is brought in by ambulance unconscious. Her boyfriend is with her and tells you that he found her lying on the floor of the bedroom, unable to be working. She smells strongly of alcohol. When you call that her name, she doesn't know. Wake, What kinds of things are you thinking? It delivered and it's okay to think off things that might not be PC, I guess in this situation, Um, because it's something that you need Think about, yeah, severe alcohol intoxication. So if he smells quite strongly about called, that's something you definitely don't think about if he's passed out And she called me working up, Uh, and she smiles of alcohol. That's something you really don't think about. Okay, what kinds of investigations might be due? What kinds of things might be due? Actually, this person can't really be working up. She's got pulse and she's breathing. I'll tell you that. So she's not, you know, she's on her deathbed. She's she's still breathing. She's got pulls colors, Okay, but she just can't be working up. What kinds of things might you do, toe? So we'll figure out what's going on. Yeah. So blood tests, So definitely we might want to check alcohol levels and potentially any drugs. Yeah, exactly. So we don't. It seems like she's taken alcohol, but she could have also taken some other things as well That we don't know off. Okay. Luckily, her boyfriend's there. So the first thing in the first thing that you will end up doing as both a PSA clinical student and as a junior doctor and as a consultant, you will take a history, okay? And considering her boyfriend's there, the boyfriend will probably know kind of what's been going on. Okay, So what happened? Did you see her fall? Did you see a collapse? Uh, how long is she being out for? These questions are really important to decide. Okay. What could be happening? Walk a viewing. Some of you might head of the Glasgow Coma School. And essentially, it's basically just to decide whether or not, um how basically awake there are they are, or how conscious they are. Okay. It also helps us decide whether or not this person will need mental a shin or we should prepare ventilation or whether or not they're kind of okay. You also might do an EKG because if she collapsed because of an arrhythmia, that also happened. But obviously we just do some blood tests. FEC is using these lefties, so LFT stands for liver function test, so you might just check that as well. But the death thing they didn't include was check alcohol levels and potentially any drugs, because talk about that in a second. So you take a cholesterol history from the partner and let you know that she's been previously haven't been having a low mood. She's currently seeing a therapist, and he does not think it's been working. He thinks he saw several open packs of paracetamol on the bed. Does that change your idea of what could be happening now or what could be happening now? Yeah, So, unfortunately, this is a rather common situation, not necessarily a 20 year old woman, but it happens with I've seen a choir lot with, um, a lot of different age groups, a lot of different people and different backgrounds. But this happens and it can happen quite commonly um so a Paris perceptible overdose is essentially what I've seen hinting out here. Okay, so this is something that's on. I believe it's on the government website that you can see, but essentially, we would want to measure how much paracetamol is in this person's blood. Okay, especially if we if the person either the person the patient is unconscious or the patient's relative or somebody that's with them doesn't know how much they taken. Okay, so you want to take how much power sensible they have. And basically, with this treatment line here, we just compared to how much power settles in that blood and then also compared to how much time it's bean. Okay, So, for example, if it's been 10 hours and there's still level at 70 what you might if it's over the treatment line, that's when you would treat them. And below that, you would probably just watch and wait. Okay, But speaking of treatments, what kind of treatments could we do for this person? Now let's say she's already woken up. Now she's awake, but what kinds of treatments should we give her? What kinds of things could give her So any guesses is fine. Please don't worry. So, antidotes. Yes. Some antidotes said I'll talk about a specific antidote. So we do use an antidote for that. Yeah. Strictly come into a decontamination. Yeah. Oh, Grastrinal Abosch. Yeah. So we'll talk about that in a second. Well, any other ones as a transfer seen? Yes. So that is the antidote? Yes. So that is that, uh, that that we do use for paracetamol overdose. We tried to give the I see it's possible, but there is another one that you might consider giving within the hour if they've come in pretty much straight away after they've taken it. Does anybody know what that is? No, that's okay. So Oh, yes, exactly. Activated carbon. So activated charcoal. Yeah. So yeah. Perfect. Rachel guys. So activated charcoal. So if the patient presents within one hour, they may benefit from you giving them some charcoal because it's still it might still be in their stomach. Okay. Obviously, if it's later than that, it's already gone past their stomach. There's no help. There's no point giving them trouble. It's not the most comfortable thing. And and usually you wouldn't see a patient comment immediately within the hour. I personally find that rather or common, but if they do come in in the hour, this definitely could help. Okay, somebody's already said in the past, and that's Little Sistine earlier. Sorry, uh, this is the main treatment. Okay for parasites. Um, all over those, somebody also said, Gosh, it become it decontamination in the past, that is definitely something that we used. Right now, it's not usually something or it's not in the guy that guide, like the cadence that we use for perceptible overdose, particularly because it's not a pleasant procedure on defense battery in distress, you don't really want to make more distressed. It's definitely something that you could consider on, but I consulted could possibly do. But it's not our first night thing to do or the snow anymore. And then I also put down what kinds of things you might need to think about when we talk about some of the things we need to think about. If, uh, this person that's taken so much Paris at the mold that their liver is cirrhosis in that point, okay, moving steadfast on, let's move on to case three. So a 19 year old lady presents to you with abdominal pain on the right side. Hopefully one diagnosis is coming to your head already. Can anybody think of some diagnoses that you might make? Yes. Appendicitis. Appendicitis is definitely one of the the conditions you would be thinking. Right side abdomen. Yes. Appendicitis. Okay. And the other ones that we can think off topic pregnancy? Yeah, or even just pregnancy in general. Yeah, exactly. So I was really hoping somebody would say that that pregnancy is definitely possible in this lady. Okay, so let's talk a little more about the history. So she says that she's the pain is a sharp stabbing pain and points towards the right lower contract quadrant. Okay, So if they you remember from your fab, we can eat a split the abdomen into nine sections or we can split into surgery. We usually just talk about it in four sections or four quadrants. So it's in the right lower quadrant. She says the pain seems to it seems like it's going towards the umbilical region. She was not doing anything particular at the time. The pain suddenly came on and it came quite suddenly. So at the moment, it could still be either appendicitis or atopic pregnancy. What kinds of investigations? What we would we want to do to rule some stuff in rules, stuff out. What kinds of things do you want to do? Ultrasound. Yeah, exactly. So Appendicitis one. It's not the definitive measure, but it's We use ultrasound to be able to confirm just before we go in. Does this person actually have appendicitis? Yeah, Perfect. What about any other thing for the investigations we want to do as well, But particularly with ectopic pregnancy, Yeah, pregnancy test? Exactly. So you could use another sound to figure out if this topic pregnancy as well. But again, that might take a while, and you need to be trained to be able to know how to use the ultrasound. But the pregnancy test is pretty much instant. Okay, just take a urine from the person. Check if they're pregnant. Um, that's it, basically. So here's some of the investigation of the I put down so a pregnancy test. So it's place pretty much we if there's abdominal pain in a lady that's anywhere from the between the ages of 13 or 50 uh, slightly more or less, depending on the person. But, um, anyone around that age range we want to be thinking, Could this be pregnancy? Okay, Even if the patient thinks that they probably aren't pregnant or they don't think they're pregnant, that still could be a chance. Because, you know, even if you use protection or they might have the false beliefs that if they're taking well that, um, doing some sort of things that protected and they definitely won't get pregnant, it's still worth considering doing a pregnancy test. Obviously, you should consider the patient beforehand to make sure. Oh, it is okay if we just do a pregnancy test anyway, just check if this is urine dip eso in that region as well. If you think about the anatomy of that region, your appendix is there also, your So if your readers that there as well, okay. And sometimes the UTI can either present is pain just over the bladder, or it might go up into the kidneys and recall that pyelonephritis okay, and so you might want to do a urine dip develop to check if there's any sort of infection markers there. As people rightly said, ultrasound is something that we definitely use. We could use it to check for this appendicitis. We might have to check for a very interesting in. So ovarian torsion is in a medical emergency. You don't if you want to be losing an ovary. So if it's tortoise, I think that's the word that you would use but taunted that essentially, Ah, the ovary is going to die soon. So that's also a possibility. With the right side of pain chest X rays, something that we also might do in this lady, I personally wouldn't. But it's something that you might consider. Uh, so somebody said, honey, uh uh, possibly could be a cause of the pain? Definitely. So if it's strangulated hernia on, especially if you can feel the mass if in that region. And if you press it and they go, Oh Oh, or they were even that you touch it. It's a strangling to turn year. Or, you know it's an incarcerated hernia, okay, and definitely hold. It could be a possibility as well. Just X ray. The reason why you might want to do that is because we want might want to look at a render the diaphragm. Okay, so usually you shouldn't see any air under the diaphragm. But in some situations. Does anybody know when a situation where you might have some air in the diaphragm? What my checking for if I want to do a chest X ray. Oh, what the indication for this chest X ray peptic ulcer. Possibly so peptic ulcer could be a possibility. So generally that pain would be slightly higher up. So what could be causing pain? Lower down. And also a runner. The diaphragm perforation. Exactly. Good. So if there's a perforation, obviously your gut is basically your outside. Okay. I like to think about is you're sort of outside to be in okay as going to be coming in. And why is that gonna go Okay? Yeah, it's probably gonna go under the diaphragm. I don't have I don't think I have a picture of it, but, um, it's usually quite obvious, and you can see that solves like a line of soft clear underneath that especially the right side underneath, above the liver liver. Sorry. And also, you might just do some blood. Fbc is using knees and CRP. So here's some of the differential diagnoses that I fall off. We've already talked about some of these. Some of two we haven't talked about is I. D. And I. B s. Um Does anyone know what the difference is? IBD I bs. I certainly didn't know what the difference was until idea. What's the difference between the IBD and I did? Yes, but which one are you more concerned about? Yeah, perfect. So IBD exactly is a Z games had Crone's and all sorts of colitis are IBD and usually worse, and I ds. It can be diet related. It's also related to anxiety and stress, but the treatments are busy, quite different. IBSS is usually something that we'd have lifestyle modifications for it and consider it gets a radio daily lifestyle waas IBD Inflammatory bowel disease is quite bad. You might get blood in your stool, for example. It's not a particularly nice thing to have. You also might have them in obstruction. It's unlikely in this person if they stay. They said they've had constipation for a long time now and never in the comments hospital now, but it's only a possibility that we can think off. So here's just a little picture of what ovarian torsion looks like So essentially, if you can remember from your anatomy that there's ligaments there and it's sort of twists around himself. Okay. Somewhat, uh, testicular torsion. Be very interruption. And to see it or shins are medical emergencies. Okay. And so somebody needs to call the surgeon now, and they need to go to a theater now. Okay? Somebody rightly said ectopic pregnancy was one of the possible causes. And it's definitely something that you need to rule in or out. Rule out Sorry s O and the topic. Pregnancy is not for, uh, fetuses not viable inside the fallopian tubes. And if you leave it for too long, that fellow pain shoot burst on. Do this person could get septic and also some bad things. Okay, so ectopic pregnancy is something that we need to consider, especially in the lady of this age. Okay, on. Lastly, this is the sort of sign that could that could suggest, uh, appendicitis doesn't even know what this Sinus called. I'm not sure if somebody in Fab might have told you, but so this is called relapsing sign. So essentially, what happens is if you press on the left side, you get pain on the right. Okay. They should press on the left will get pain on the right. Okay. Obviously, that shouldn't happen normally if you because you press down on the right, you'll still get paid. You press on the left, you'll get pain, but also in the right side. Okay, that's all over. Um, gives you quite good idea. It might be appendicitis or least inflammation of the part of the, um underneath. Okay, Alaska Balm in. It's just quickly go through Case force. Their case for is a total boy that brought on by ambience after his mother, right. 999. Has he had trouble breathing? When you speak to him, he's already on oxygen, but it's still struggling to breathe. What kinds of things are you thinking off? Yeah, what kinds of things you're thinking off? This 12 year old boy is struggling, breathing even though he's already on oxygen. Asthma? Perfect. So asthma is definitely something that you could really do. Think off when you told your boy at this age analogy yet perfect. It's our And I felt anaphylaxis is definitely something that we also need to think about. Yeah. Anything else choking? Yeah, definitely. Hopefully they would have dislodge something at this point if they're already in a any but choking, definitely. If it's if it if they come in straight away a P could be. It's unlikely. In a 12 year old, usually a P might come in or you, uh, pulmonary embolism usually is in older patient with somebody that might have had been stationery for a long time, but it's something you could consider, but it's not my primary diagnoses. So someone look at the stuff that I wrote. So we have a few assassination wrestling, which is definitely something that should be on the top of your list. Uh, chest infection Could possibly something that you can think about, especially with the younger kids, because they're, uh, Billy the military. The respiratory tree isn't fully couple adopted yet out for access is definitely something we need to think about it. You could also think about some anxiety attacks this could present, especially if you have a parent that's quite concerned about their child. You might have a child that has anxiety attack, and their parents are so worried they bring him into any. And unless the new muscle wrecks doesn't even know why I put pneumothorax there, especially in a 12 year old. Know So one of the people, one of the groups of people that get pneumothorax is COPD patients. This patient probably doesn't have COPD because it's 12 weeks. I really hope he doesn't. But the other ones are, ah, young males going through puberty. So, um, generally, boys, when the property, they might have quite a big growth spurt. Okay? And as they grow quite tall, their lungs can catch up so quickly. So I'll just show you in this X ray here. Hopefully, you can see in the top left section of the lung that this is normal lung. Here. This is normal lung here. Okay, but at the very top this off a little bit more transparent. You can't see the lung markings as much. Okay, that suggest to you there's pneumothorax. Okay, because this is just a okay, and this can happen in patients who go quite quickly, but they lost can catch up. Okay, some of you guys might have had ah, pneumothorax. Uh, but it's usually nothing to worry about unless it's quite big. Like this is a little bit quite big. Okay, Let's just go back to the case. So Mom says that they were at a friend's birthday party when the patient came to her and played a short of breath. Patient had previous history of asthma nose or you have more than 10 puffs was blue inhaler. This helps somewhat, but still had the same. True with your breasts. What about I know says, do you think Could this be now? What does it lead to you too? Some particular diagnoses competitiveness. So this still could be an acute exacerbation of asthma. Usually, if they've had 10 puffs already suggest that the mass mailing? No, not working. And you should consider changing it after you stabilize the patient, but also because I didn't actually mention it here. But this patient could have obviously taken something, uh, that they were allergic to. Okay, this is the treatment that you would give if person waas having enough was enough relaxes so you would give intramuscular adrenaline. That's just your EpiPen. So hopefully if you have analogy, you're carrying an EpiPen with you. One of my friends don't I don't know why he risks his life for it, but, you know, um, basically carry an epi pen sticking in. But in the hospital, we don't have EpiPens, but I say we just inject it. Okay, so, uh, in two most common journal in don't get it confused with this cardiac arrest, which we also give adrenaline for, but we give double the amount. Okay, so we give a milligram supposed to microgram 500 micrograms. Okay. You can also use it in tryptase afterwards to identify if the person didn't have anaphylaxis so soon. Tryptase would be increased in Ah, in anaphylaxis. Benign conditions. Okay. Ah, here's just some of the treatments that you might use for asthma. Particularly oxygen samba court or steroids or petroleum bromide of magnesium sulfate. This is more for acute asthma rather than Cornick asthma. Uh, this is just some of the treatments that you might use that on disses the treatments that we have. This is the sort of pathway that we use when we talk about and your with your ex. Okay, So I so divided from primary of the secondary, and then whether or not how much of the rim or how much How thick. So if we look at this picture, how big this gap is and then also whether or not they have shortness of breath. Okay, that was a lot. I hope that wasn't too much for you guys. Um, but hopefully you guys enjoyed it. Uh, please do fill in some feedback. It's really, really helpful for us. Um, there won't be electron next week, but there should be a lecture of the week after. I should be pretty interesting, but please do the some feedback. Hopefully, you've got a little bit of sweet and your taste of clinical medicine and makes you want to work hard in part one and part to toe to get to clinical school where the meat really is. But hopefully you enjoyed it. Um, please fill in the feedback on D. If you have any questions, feel free to stick around. I'll be here for another five or so minutes. Um but otherwise you're free to go