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Hi, all I've given, I've been given the go ahead by Phil to start. I'm just gonna check that you guys can hear me. Yeah, we can, we can. Ok, cool, thanks. So, my name is Nilo. I'm one of the IMT ones working at the Royal Brompton Hospital. Um, I've met some of you actually, I don't know, I can't recognize any of the names. Um, well, I haven't looked at all the names anyway. I've met some of you, but I'm the Bron, this girl, I'm on the host defense firm. Um, so, um, you may have met me on the wards, but today I've been asked to prepare a presentation for you on acute care and this is mostly for your cases, uh station on acute care. So these are not, it's not diagnostic dilemmas here. These are very barn door cases. Um, and it's just for a tool. Um, so that when you go into your stations, you'll have a structure, you'll know what you're doing and you'll be able to think, um, a little bit more clearly about the case in front of you. Um, I didn't go to your university. Um, but I did listen to the previous two years, um, of the same presentation. Um, so I have a bit of an idea, um, as to, I think how they lay out. Uh, I would really appreciate it if you guys could, um, I can see a chat. Um, if you guys could, uh, respond to questions on the chat. If you want to raise your hand and unmute yourselves, that's really good. Um, but otherwise it would be good if you could respond to chat because it's because it's for your paces and your paces, you will be doing it, it, this will be best in person. Um But some uh some interaction would be great. All right. So, so this is the brief that I was given um by, um, uh Phil who organized this, uh as to what your acute care station entails. So they want you, they give you three minutes to read uh history and examination from an s then you have to summarize key findings from the history and examination, give a diagnosis and probably some sensible differentials. Um, say what investigations you would do. They give you investigations. I, I can't guess which, what investigations they give you. Um But I've, I've, I've freestyle it and create a management plan and explain the management plan to a relative without using any go. So I, before going into it, I will tell you and this comes up. So for my IMT interview, um, as well, this always uh applies is that all the examiner wants really wants to see is, are you a safe doctor? It's all about being safe and escalating appropriately with all these cases, as long as you're sensible, as long as you escalate to a senior and as long as you say that, um then you should be ok. Um But I never had a station like this uh for my sky. So I think it's quite a good one. I think it will prep you well, for F one F two. So let's start. Um Our first case is breathlessness in a 25 year old. Um And I think you guys know what's coming. Can I just confirm that you guys can see us by saying breathless to a 25 year old? Confirmed? Thanks. Ok. All right. So the first one, the first uh history and examination I um presented a bit differently to what I've gleaned that they presented to you. But here we go, here's the history. I'm just gonna give you some time to read it for yourselves. OK? Is that enough time? And the examination? I think they present it to you a little bit differently. But what I wanted to do with this is to give you a little bit of an idea of what's involved in a um in a, an A to e examination. So I'll summarize this case for you. So we've got a 25 year old with breathlessness. Uh a week ago, she had a sore throat and her, and a runny nose since then, she's finding it more difficult to breathe and she's feeling wheezy, she's coughing but she's not bringing anything up. Um, she's using her salbutamol inhaler and that's giving her some relief, but she's having to use it a little bit more. Um, in the past few days she's feeling tightness in her chest but not pain. Um, as of yet and she got rapidly worse overnight. Um, so she called an ambulance. She's got a background of asthma. She's been hospitalized twice in the past. Um, in terms of drug history, she's only taking her salbutamol and her inhaled corticosteroid inhaler. Uh, she's got a cat allergy for what it's worth. So, therefore she has no pets. She works in an office, she smokes socially, um, doesn't drink, uh, and her partner has a cold. So going to her a t examination, she's completing full sentences. She's not got any stridor. Um, she's, her respirator is a bit high. It at 28 and she's using her accessory muscles as well. You can really see her working hard to breathe. Her sat are 90 her is not deviated chest expanding equally re throughout. And when you listen, you hear a bilateral polyphonic wheeze BP is ok. 100 and 25/82 heart rate is on the high side at 100 and 12, but her peripheries are warm. Well, perfused um with a normal cap refill time, temperature is normal G CS is OK. B blood uh BMS are OK. Pupils are equal, fine calves are soft, nontender, no swelling, nothing else. OK. Summarize key findings from history and examination um in an ideal world, I'd pick on one of you to do this. Um but um I won't, uh what I have done is given you a little bit of a crib sheet on. OK. So this is, but this one is supposed to be a bit more clear that this is asthma. So I've given you a bit of a crib sheet on an SB a presentation. So when they ask you to summarize it, you can never really go wrong by doing an SB A and these are the things um that would be important to mention in a patient where you would be um suspecting asthma. So we've got situation which is just a headline of what they've presented with what you think they, what, what they presented with it is supposed to grab their attention. We've got a 40 24 year old female presenting with worsening breathlessness, give the relevant past medical history. So here we have asthma, asthma and eczema. She seems like an atopic individual, someone who's prone to allergy and what treatment are they normally on. Um And this gives an indication of what line of treatment they're on, how severe their asthma is, what the likely trigger is. So, in this case, she's had a cold. So we think that it might be uh a viral upper respiratory tract infection um that has caused this. Um and really importantly, um when you are presenting asthma cases in the hospital, at least, is have they been hospitalized and have they had any itu admissions? Um because that, that gives an idea of how severe the asthma can get for this patient in the assessment. Uh You briefly go through their obs. What are their saturations? Are la these saturations are a little bit low at 90. Um What's the, what's their respiratory? They look like they're in respiratory distress? What do you hear on listening to the chest? Are they hemodynamically stable? What's the blood, blood pressure and heart rate? And are they pyrexic? Um And in recommendation, um you would say, I think I'm worried that the diagnosis is X, I've commenced this treatment. Uh Please come review or advice uh on next steps. And so that's the SB a uh for someone with breathless as someone who you're suspecting uh has asthma. So it suggests the likely cause of this patient's presentation. So I wonder are people on the chat? I wonder if people could provide some differentials on the chat. If possible. I've given you the diagnosis for this one really already, but I wonder if anyone could suggest any possible differentials. Yeah, that's a good one, asthma attack caused by viral illness. But anything else that you'd say as differentials, things that you'd like to exclude for breathlessness in a young patient. Yeah. Pe Yeah. Pneumonia. Correct. Any other things? Yes. Pneumothorax. That's a good one. Breathlessness in a young patient. You want to exclude the new pneumothorax. That's why in my A T examination, I checked uh if the trachea was deviated and I did, I mentioned the uh resonance to percussion. That's enough. Really? OK. So this is what I came up with. Um, most likely. So it's good to start with the most likely. First. I think that this case is most likely asthma, as you said, caused by um a viral upper respiratory tract infection. But other possible differentials, it could well be a pneumothorax. It could well be a pneumonia just because they're not, they're not spiking at the moment. Um It doesn't mean it's not a pneumonia, um pulmonary edema a little bit less likely um in a young patient with no cardiac background. Um and also COPD a little bit less likely, but it is a diagnosis for wheeze, for breathlessness and wheeze. So I think these things are sensible to mention, I mean, differentials as long as they're sensible. Um As long as they're not completely offed, uh then you can get and then as long as you also in your investigations, um say how you would rule each one out or in. So, yes, asthma is the correct diagnosis. But this slide um for the British Thoracic society. Um It's important to know they might well ask you in your Viber as to how to stage asthma. So let's think about our patients. I didn't give you her peak expiratory flow. Um But looking at the other things, she had a respiration, didn't she of, of 28? So that's high. Her heart rate was over 100 and 10. Um But she, and she was struggling to complete sentences in one breath. Um But also her oxygen saturations were less than 92. So any one of that puts her in the um in the life-threatening category, but it's important to know the criteria of what's considered severe and life-threatening. And for the life of me as a medical student, I could never remember all these criteria. It just looked like loads of numbers to me. Um But this is what I used for my IMT interview for some reason. This mnemonic helped uh a chest. So arrhythmia altered consciousness level, cyanosis, normal PCO two hypertension hypoxia and then e for exhaustion s for silent chest uh showing severe bronchoconstriction because if there's less airflow to cause the wheeze in the first place, um and uh threatening peak expiratory flow for some reason. This helped me remember life-threatening asthma. So I put it on here in case it helps one of you guys, what investigations would you perform in the chat, please? Yeah, perfect. Big flow. Yeah. A BG chest x-ray Y you guys are quick on the A BG, well done. Anything else? Uh you guys just want the ABG and the imaging according to the chat. So this is a general structure for investigation. This is what I use for my OSI. And it really helped me um when I'm in the nervousness of the O. So I should say pacs and the nervousness of the pacers examination. This really helped me. So you go for bedside first and things that are included in the bedside, the OS peak flow ecg sputum urine dip MC NS. Then number two is you go for bloods and you say which bloods you would request all the, the, the the Holy Trinity F BC use an ECRP and also you rarely go wrong requesting LF si think um the important extras such as d-dimer, troponin amylase, other electrolytes, magnesium phosphate. Uh And then if you, if they've got blood loss, remember to send a group and save or if they've got proce, if they got surgery the next day that you think they might lose blood, remember to send a group and save clotting as well if they're gonna have any procedures um and blood cultures if they're pyrexic. So remember those extra bloods and imaging x-ray imaging uh a chest x-ray, abdominal x-ray you can just do um but always say when you would go up. So things like CT and MRI imaging just say that you would do it under the guidance of a senior All right. So, what investigations did I say we could do in this case? So, the full set of observations that we've done and monitor those closely peak flow, like you said in the chat, um, ECG, she was just, just for a baseline and she was tachycardic. Uh, and you could do a viral swab as well. Um, it's, it's a, it's, it's extra, um, but it might give us a cause for her asthma if you want. I don't want, ah, bloods FB CS and E CRP NF. Uh, and we also put a pe as one of our differentials. So you could say to rule out a pe I would do a well score and consider performing a d-dimer on her. That would be reasonable. We definitely want to do a chest x-ray and with senior guidance, um, we'd, uh, you, you can say we might consider, depending on the d-dimer and the well score a CT P to rule out, uh, a pulmonary embolism and yes, under blood. It should say AB BG. It looks like I didn't update it on the slide. So, yeah. Ok. So interpret investigations and explain what they show. Can you see that? Well, could you tell, could anyone say on the chat what they think of this x-ray? This is all patient's x-ray. Yeah. Yeah, there's nothing on this x-ray, well done. Um, so the x-ray helps us to rule out a pneumonia and a pneumothorax and there isn't one on this x-ray uh in asthma, most likely the x-ray is normal, you might have some hyper expansion um as well. So, hyper expansion is uh defined by. So you look at the anterior ribs and you should have 6 to 7. So if you have seven or eight, then that would be hyperextended. Um OK. Very good. Next investigation. Any comments on the chat about this ABG correct. This patient is in respiratory alkalosis and they not the capitals. Yeah, depo respiratory alkalosis. Um So I always remembered um e even now I think about carbon dioxide being acidic um and bicarbonate being alkaline. So they've got low carbon dioxide with a normal um bicarbonate. So they are in an alkalosis. And so someone said borderline a query hypo their, their oxygen level is in the normal range, but it's kind of sitting there at 10. And so why is this patient's CO2 lo why are they in respiratory alkalosis? Yeah, they're hyperventilating. They're breathing out all of their carbon dioxide, which is what you would expect them to be doing for someone so breathless. Then you would, you would expect them to be breathing out the carbon dioxide. Ok. Fine. OK. How would we treat this patient's chat, please? Ok. I'm getting some good suggestions. So good oxygen due to low saturation. So you always want to go back to the A to E approach. Where was it? We always want to go back to the A to e approach. So she's got no stride or she's completing full sentences. So the airway is fine. We can check that off, looking at breathing. Um We've got a respiratory rate of 28. We've got oxygens of 90. So we need to treat that. So with the A TE approach, once you, if you get to a and you see a problem, you need to treat it and only then do you move on to B So we're on b we see a problem. Sats of 90. We need to treat it, we need to put her on some um oxygen. Uh And then once we've done that, then we need to sort out this wheeze. So people on the chat have put nebulizers, which is correct. So we truly sort the wheeze with nebulizers. OK? And then we move on uh to see uh she's more or less hemodynamically stable. She's got a bit of a high heart rate. Um uh but she's, she's, she's well perfused at the moment. She doesn't need any fluid therapy or anything. And then we move on to the, and then we move on to eat. OK. Uh And someone also has mentioned steroids, which is really good. So I have summarized uh the British Thoracic Society guidelines for asthma treatment. Um And hopefully, this will be easy for you to memorize. Um So in your cases, I would say I would uh stabilize the patient using an A to E approach first. And then I would say I would early, early escalation to a senior. Then I would say these things. Meanwhile, we want to maintain their oxygen saturation is above 94. Um We want to give them uh salbutamol nebula. That's A B two agonist. Um B two agonist, uh give them ipratropium bromide if acute, severe or life-threatening or poor response to the salbutamol steroids, well done to the person. The child said steroids, they need 40 to 50 mg for five days. Um The steroids, if they're not responding to the, to the nebs and the steroids then consider giving magnesium sulfate. Um They're advising not, not to give antibiotics unless you're sure that um this is coming from an infected, a bacterial source. And the really important thing with asthma um is early escalation and early icu involvement because these patients tire. Um and they might need ventilatory support very early. Ok. And these are um the guidance. This is the guidance basically for when you refer uh to intensive care. This is just sort of for your information. Uh worsening, peak expiratory flow, worsening, hypoxia hypo, uh carbon dioxide going up, uh getting blood, getting more acidic, getting exhausted, drowsy, confused, re dropping their GCS and of course, uh respiratory arrest. Ok. So say the nurse comes up to you and says this patient is not doing well. Can you reassess and you repeat an ABG and this is it, what are you guys thinking about this repeat. A BG. Yes Manish. Yeah. Correct. Yeah. So your patient, unfortunately guys, she's now in type one respiratory failure. Her carbon dioxide is normal but this is not good because you would expect her to be blowing off the carbon dioxide but her muscles are tiring. Um So she's, she's keep, she, she's not blowing off the carbon dioxide um which is not good and what's happening to her ph it's going down. Ok. So this is not a bad sign. She is deteriorating. You need to be calling, thinking about calling it to review this girl. All right is ok. So I would wonder whether one of you guys would want to volunteer to do this because I think it would be really useful. Um and I think it would be awkward for me to just explain, to explain to you how to explain to someone. So the last part of your case station is assuming that I am the patient, patient's relative with no medical knowledge. How would you summarize the plan to me? Give you guys some time to, to work up the courage if you can. Yes, we've got some unused. Who? Who? Yeah, I I'm all right going. Ok. Go, go. Wait. Can I ask your name? Uh Mish, hi, Mish, go. Oh Hello. Uh My name is I'm one of the uh one of the doctors. Um I'll just come to explain to, to you about what's, what's been happening. So essentially, um, your relative has had an asthma attack. Um, but it's really good that you caught, brought them in. So we've been giving them some treatment hoping that it'll get a bit better and they've responded a bit less than we'd hoped. So, we've actually started just involving some of the senior doctors just to make sure they're, they're ok. Do you understand so far? Yeah. Ok. So, with the asthma attack, um, they've been struggling to get enough oxygen into their, their lungs and we've been giving them some medication to, like, open up their airways and because they've not responded as well as we'd hoped, we've, now, um, we've decided to get involved with, you know, some of the consultants and the, um, the intensive care doctors to think about what we can do going forward. Yeah. Understood. Ok. Um, do you have any questions so far? No, I don't, but I'm sure your patient relative will. Thank you. So, anything else to say Manish? Uh, I mean, no, I guess I'd talk about the medications that we give and stuff. But, yeah. Do you want to go? Yeah. Yeah. So, um, so just at the time being just so that you're aware of, you know, what's going on, um, the things that we can do, we can try and get the airway, you know, as open as possible and we're giving it oxygen and we're trying to do all the right things however there is a, there is a chance that I want to warn you of that, you know, they might have to go to the intensive care unit and, um, be put on a ventilator, which essentially means they might have to be put in a medically induced sleep for just a little bit so that they can handle that. Now, we'll update you as soon as we can and hopefully we can avoid that. But I just want to sign pi that, that is a potential thing that can happen at the moment. OK. All right. Anything else? Uh That's alright. You don't have to say anymore. Thank you for volunteering. Thank you for volunteering. So that was really good. So you told them what was going on? Um You didn't use any jargon. Um You said all the management that needed to happen and would happen. So this is what I've done the structure and maybe, maybe I should have told you the structure at the beginning. You had quite a good structure. You said you told them what was going on, you asked them if they understood midway, which is good. Um And you also asked if they had any questions. So for structure, I would say, what do they know already? What is actually happening? Why do we think it's happening? How are we treating it? And what are the next steps? I think you did go through all of these. Um I've given a little bit of what I would say. Uh in this situation, this is kind of spoon feeding and at the moment you're not going to remember what I've written. Um But just to maybe compare. Um, so we think that whatever the patient's name is, is suffering from a worsening of her asthma. And in my one, I've explained a little bit about what asthma is. Um this is when an irritation or in inflammation causes the airways to narrow and swell, making it difficult to breathe. And then why is it happening? We think that it's caused from a viral chest infection. Um How are we treating it? We're using nebulizer to help widen the airways. I think you said this morning to make it easier to breathe and steroids to reduce the inflammation. Um We hope that she will get better with the treatment that we give her and we'll closely monitor her. Uh We'll see, we'll ask her to be seen by the respiratory team and ask the specialist nurse to how to further manage her condition at the hospital and prevent future attacks. Um I didn't mention here um about ITU and having to put her on a ventilator. Um And because I guess, I guess this was before I added the second AB BG to my slides. So maybe um in terms of escalating to it, you could say we're keeping a very close eye on her and we might need to get um the intensive care doctors involved to see whether she needs to go to a place, um, of more intensive treatment where she can be, where she can receive more support and more observation. Uh, if that's not where you are at at the moment, something like that. So as to inform them, but also, uh, maybe not scare them too much if it's, if you're not there yet and ask if they have any questions which you did, which is great and always offer a patient information leaflet. OK. Moving on from uh blue, which is my rest color to cardio uh to cardio which um to red, which is my cardio color, chest pain in a 56 year old male, we know what is coming. I'm sure. So read the documentation uh from patients uh history and examination. So I think this from the slides that your predecessors did last year. I think this is how they actually present it to you guys. Maybe you guys know more than I do, but I'll give you a little bit more time to read this. OK? All right. Summarize key findings from history and examination. Um So essentially, I have a 56 year old gentleman with crushing chest pain. Uh You wanna tell me the relevant past medical history? What are uh what, what, what are his risk factors basically? Hypertension, hypercholesterolemia. He's a smoker. What's his BMI? What does he do for a living? Um And then though, uh you, you they don't give it to you at the beginning, but in, in the hospital you want to tell them what is their ecg showing, what is their observations, any significant findings, uh, on clinical examination? What is their troponin? What have you commenced? And what do you think it is? So, I won't make you summarize them but practice amongst each other using this, um, as an example. Hi, what is going on here? What's going on with this gentleman in the chat? Yeah. Yeah. Any other differentials? Uh huh. Ok. Fine. Everyone said mi, I mean, it's a but yeah, that's really important. Somebody said dissection. Ok. So this is a barn or case of, uh, acute coronary syndrome, um, myocardial myocardial infarction. But other differentials, you could say stable angina aortic dissection, which is really important to rule out so well done. Uh, pericarditis, pneumonia, pulmonary embolism, gad and, uh, musculoskeletal pain. But if you're, if you're gonna say, uh, things like musculoskeletal pain and anxiety related breathlessness, I would always say once I've ruled out more serious causes or something to that extent, uh, just to make sure that you're being safe. Ok. What investigations would you perform guys? Yeah. Ok. For bedside, I've got, I've got observations, um, and it's important in chest pain to do serial AB uh ECG S, uh, depending. So if your first ECG is normal and they've got chest pain that sounds cardiac. It's important to repeat the ECG uh, in in half an hour or so to look for any dynamic changes. Um uh Because, because things can change, the, the, the ECG S can change. Um I won't go too much into that at the moment. You have a cardio lecture soon. But I would say for this station, I do serial ECG S. Uh the bloods, I would do a full blood count. Use an A CRP LS as always and troponins you correctly said and men serial troponins, um you don't always need to do serial troponins. Um uh but that I would mention that and chest x-ray, you rightly said, um and you might consider an echo if you said things like pericardial effusion and things uh in your differentials. OK. Interpret the investigations. What is this? What is this ECG showing? I feel like this exact ECG came up in my final year MC QS. So, yeah, this is this, this is a, this is a stemming. It's in the inferiorly 23 A VF you've got some reciprocal change here in A VL. Um And bonus points for telling me where this is coming from, which, which coronary artery is it most likely coming from? Yeah, RCA. In 80% of cases, it's coming from the right coronary artery and uh in other cases, it can, it's coming from the left circumflex artery. OK. And this is the troponin. Are we, are we concerned? Are we concerned? But per personally, I'm very concerned? OK. How would you treat this patient in the chat? I'm really enjoying the capitals. Yeah, you guys have got it. You, you have the, you have the right idea. Of course, we must stabilize every patient you where in your cases you should say I'll stabilize the patient using an A T approach. You need to escalate to a senior. You need to move this patient to a cardiac monitored bed. Um because what is a common complication of an mi yeah arrhythmia? Which one? Yeah. V correct escalate, move to a cardiac monitored bed, aspirin, 300 mg stats. And then this patient needs an urgent PC. You call the PCI center for angiography, an urgent primary PCI if they're presenting within 12 hours of symptom onset, which normally they are, I mean, especially in London. Um and if they can't get a PC I within 100 and 20 minutes, then you would consider fibri fibrinolysis and then dual antiplatelet therapy just say as per guidelines. Um I mean, it used to be this. So when I was a medical student, it was just aspirin and cloy, I feel like. But here is this is this is the actual official guidelines. So you see they're saying you give a loading dose of aspirin as soon as possible. Then if within 12 hours um then you and they're going for PCI, then they get prasugrel. If they're not already on an anticoagulant. If they are on anticoagulant, they get clopidogrel. Um And you think about unfractionated, uh heparin um as well, but that's sort of later. That's, that's after you've arranged the primary PC I. Um and then if you can't get them into a PCI center, then you uh would give them a, a fibri agent. Um, and repeat the ECG. And if you're just going medically offer to account what I'm, what I'm trying to, I don't think you need to know this. But what I'm trying to illustrate is that you, there's different, do all the, the, the second antiplatelet agent is different depending on what you do. So just say for the purpose of your exam, dual anti therapy, platelet therapy as the guidelines. And what if the ECG they show you is this, what's this showing an N sty? Very good. So this is the management for um just a, a very brief summary on the management of NSTEMI and Unstable Angina. As I say, you're gonna have a cardio lecture, we're just gonna go through this properly. But this I think is um is enough for you to pass this PAC station basically stabilize, using the A T approach to move to monitor bed, they get the aspirin as well. Um And you consider uh fondaparinux refer to uh cardiology and then they decide. So based on the grace score, um whether they go for angiography or PCI or whether they go for medical management, uh if they're low risk, but often uh from what I understand is patients will get angiography everywhere anyway, especially if they're young. And this is the nice guidelines for it just for your information. But the initial antiplatelet therapy and antithrombin therapy is key for just stabilizing it. And then you do and then you sort of consider further management based on the gray score. OK. What do you mean by secondary prevention? Um So once the patient is stable, you can say so I'll stabilize the patient by doing XYZ as I said in the previous slides. And then once they're stable, think about secondary prevention, moving forward. How do you prevent them from having another mi uh dual antiplatelet therapy for 12 months, then aspirin indefinitely or copy of the aspirin intolerant, they need to be on an ace inhibitor, a beta blocker and a statin and they need to make some lifestyle changes, dietary exercise all the usuals assuming I am the patient patient's relative with no medical knowledge. How would you summarize the medical management plan? To me? Anyone wanna go? Ok, I will summarize to you as if you are the patient relative. So what do they know already? So before you start anything, you are. So what do you know already do? Just always do this because you will get caught out. Um and I have been caught out by not asking what they know already and dropping bombs. So what do you know already your relative has come in with severe chest pain. Uh When we investigated his pain, the heart trace showed evidence of blockage of one of the arteries supplying the heart indicating that he is having a heart attack. So with, with things like this, it's good to, to, to use language that they don't understand. Essentially he is having a heart attack. So you, you tell them that he's having a heart attack rather than beating around the bush saying, well, there's a, there's a blockage in one of the coronary arteries which we need to treat. It's important that the patient relative knows what knows what is actually happening. We've given him a high dose of aspirin to help thin the blood and improve blood flow to the heart and we've moved him to an area where we can monitor him closely. And here I've uh this is a, I've, I've attempted to explain angiography. So we've called a PCI. Sorry. We've called the center where they can perform imaging to see exactly which arteries are blocked and perform the necessary intervention to treat the blockage. This can sometimes include stents, uh which are metal tube placed at the level of the blockage that keep the artery open so that the blood can flow, he should be transferred there soon. Once he is stable, the cardiology team will uh advise on medication and lifestyle to prevent future attacks. Uh offer a patient information, leaflet and ask if they have any questions. This is what I've done. This is not necessarily the right answer. This is just to give an idea of, of how you could do it and how I would do it and what needs to be, what needs to be explained. You explain what's going on, explain the management, um, and explain what the important medications do. All right. Last, uh, last what last case? Cause I think and they were getting stressed with time. We've got a 20 year old with abdominal pain and vomiting. Um You might not know what's coming this time and it's green which is neither a rest, uh or a cardio color. So, let's see. Read the documentation uh from the patient's history examination. Give you some time to read. I wonder if in the chat you could just tell me some, some key things that are jumping out you. OK. What? OK. Fine. Ok. So summarize the key findings from the history and examination. Um, there's a 2020 year old gentleman who's unwell with abdominal pain and vomiting. He's a university, university student with a background of type one diabetes and he hasn't been using his, um psy for the past two days. Uh So we've got this situation in a one sentence ca catch their attention. You've got their relevant background, um and assessment, rapid shadow breaths, talk about their, talk about their hemodynamic status. He's hypotensive and tachycardic. Um, but he's not pyrexic. We've stabilized him at our commencing investigations. Ok. So just the likely cause of this patient's presentation. We've got one in the chart. Any, any other things that it could be, any other differentials that you would give in this case? Yeah. Yeah. Anything else? We've got gastroenteritis? We've got UT, we've got DK A, we've got HHS. Really good pancreatitis. That is a good one. Yeah. Really good. That's all I have most likely to be DK A. Ok. They're, they're type one diabetic with shallow breathing ABDO pain and polyuria. It's most likely to be A DK could be gastroenteritis. That's sensible. HHS uh is sensible um pancreatitis and sepsis because they are, they're hemodynamically unstable. So it uh with ABDO pain so it could be an abdominal infection. Ok. Investigations guys, we love an A BG. Yes. EG instead. Yeah. Yeah. Ok. Yes. All really good things. So these, this is what the British society of diabetes suggests that you do uh observations, cap and capillary, sorry. And lab glucose. Uh ketones, ecg and MS U. Um normally in A&E we do vbgs basically because because why do we do BGS? So man, you said the BBg instead, maybe what made you, what made you, what made you say that when you initially said AG, well, an ABG kind of is like, like the only advantage of it I guess is like you can look at the respiratory status, right? So then you can still look at electrolytes and Ph Yeah. And what do we need to do with DK A patients, uh, stabilize them. Yeah, and monitor them. Right. Yeah. So, yeah, exactly. Someone said monitor, we need to monitor them so we're gonna be bleeding them loads. Um, so you can't just keep A, a BG in someone. It is a really useful test. Um, but you're right to think maybe BBBG instead, unless you're worried about their, their chest. Uh, VBG, my favorite blood panel. Uh, amylase. Yes, it is painful. I don't know if anyone's had one, I've actually not had an A BG myself, but here at the Royal Broden, we actually, for the first time in our life, we use local anesthetic to do AGS. So that must be really painful. Anyway, uh my favorite blood panel uh amylase, it's good to say alas why? Because one of our differentials was pancreatitis. So if you're gonna give an a differential in your investigation, you need to say how you're gonna rule it out. Um Blood cultures. Yes, because normally we do blood cultures when someone is pyrexic. Um but it's not unreasonable if they're hemodynamically unstable and they look like they're um they've got the other signs of sepsis. It's not unreasonable to do a blood culture in this case. Um chest x-ray because they, you know, they, they've got the deep, shallow breathing, I guess. Um And then if you said sepsis, you might say with senior input, I'd consider doing some abdominal imaging such as a CT or an ultrasound. Oopsy. Ok. Let's interpret some investigations. I think I've just put bloods for this one. any thoughts on the chat? What, what is jumping out at you? Yeah. Yeah, we've got metabolic acidosis. The people have seen, we've seen the metabolic acidosis. What are we seeing? What are we seeing on the, uh, on the blood panel? We're seeing hyponatremia and hyperkalemia. And what are we seeing on the bottom? On the bottom too? We, yeah, we're seeing an insanely high glucose and high ketones. Um Why is the sodium low guys out of interest as in like does anyone know I went through this my registrar today actually? Yeah. Go rob it. It's a, it's a pseudo hy. Yeah, it's a pseudo hyponatremia. So it's because the glucose is so high um dilutes out the sodium. Correct? Very good. How would you treat this patient in the chats? Go. Yes. Yes. Yes. Yes. Yeah. Mm Yeah. OK. So we know. OK. So, but here I've, I've, I've included a slide on the DK diagnostic criteria. Um So we've identified clearly from the chart that this is, this is DK AD K A. You need your blood glucose to be above 11, um your ketones to be above three. and your Ph to be less than 7.3 or your bicarb less than 15, you don't need to know the values. You just need to understand the triad of DK. A high glucose, high ketones, low ph low bicarb. OK. So we stabilize them using the A T approach. Obviously, we escalate to senior in A&E these patients just go straight to recess because what do they need? They need like an insane level of monitoring. Um which I go over later, they need fluids first as a priority. They need uh fluid resuscitation. So just give them sodium chloride first and then you mentioned insulin, but you do insulin at a fixed rate. Um And remember, and this sometimes gets missed actually in the hospital um to prescribe if they're on long acting insulin, you keep this going and then you do hour leak of delivery blood glucose and ketones BBg at one hour, two hours, then two hourly. Um And as you go on, you look at the guidelines and someone rightfully said potassium if required, you see if they need potassium basically. Um And uh if the glucose falls below uh 14 millimoles, then you might need to add glucose and ensure referral to diabetes and endocrinology made. So they need to be seen. So to summarize this, stabilize them, move them to a higher monitoring area, give them fluids start their fixed rate insulin um and just continue to monitor their markers. You don't have to say in your cases, how often you do it would you say very regular to mo regular monitoring of the cap blood glucose, the ketones and A BBg to look at their acid base status. Um and their potassium and you might need to replace that potassium and if the glucose goes low, then you might need to add glucose. See, does anyone want to explain? I feel like this might be fun to explain DK. I think it's quite tricky. Maybe it's not in my head. It's quite tricky to explain DK. So, does anyone want to give it a go and impress me sci? Ok. I guess that I am explaining it. Ok. So what has happened? So what do they know already remember? Don't get caught out by not asking what they know already. Um And what is happening, Mr came in with symptoms of tummy, pain and sickness and we found him to be quite unwell. Um So when they come in in DK A that they are unwell. So it's good to reiterate that the same way that we told the MRI patient that their relative is having a heart attack. Uh It's good to let people know that they are unwell and the same way that um me told the asthma relative that, that their patient is that their relative is unwell. It, it, it's good to say that it's, it's good to set the expectations of where we're at and be honest with the me family members. Um What do we think is happening? We think. So this is how I, I've explained it. I wonder what you think? We think that he has a condition called diabetic ketoacidosis this is a serious complication of diabetes, whether it's a severe lack of incident in the body because of this, your body cannot use sugar for energy and uses fat. Instead using fat for energy releases, chemicals called ketones into the blood. These chemicals can build up and cause your blood to become acidic which can be dangerous. You might think that this is a bit O TT, but I feel like DK A, people tend to know what asthma is. People tend to know what a heart attack, but people don't tend to know what DK is. So it might be good to give people like an explanation of what exactly is happening. Um How are we treating him? We uh will rehydrate with fluids through the vein and treat him with controlled amounts of insulin. We will carefully monitor his blood markers are improving by doing regular tests. We've moved him into a place where we can carefully monitor him. We ensure that he gets seen by the diabetes specialist team. We probably can say make sure that his markers are improving and adjust our management accordingly. Do you have any questions? Can I offer you a patient leaflet? I think that's all guys, by the way, that's all I have. Thank you all for listening. I hope that you found this. Um I I ho I hope that maybe this is shown you that, you know a lot and I think that this um station, they're not asking you to diagnose. They're not asking you to, the diagnose is gonna be clear, but you just need to have a structure and you need to have the confidence and you need to make sure that you are safe. Please make sure that you're safe. Always say that you're gonna escalate, always stabilize the patient using a to approach. Uh And if you can please uh I made this QR code by myself to provide me some feedback. And if I've ever signed you off for any procedures in the hospital, then you have a moral obligation to give me feedback. So I could put it in my portfolio. They're all gone and it happened. How was that? That was really good. We really enjoyed it over here. And can you also? So I'm, I've only done three. You told me to do four. But if, if people actually want it, then I can do another three to do the, the other cases that you said that, see what people say. If, if people want me to do more, then I, then I can do another presentation with another three. Yeah, of course. And if anybody is filling out the feedback and if you want more, just let me know know also in the feedback. Otherwise you can message me dad. Um Thanks very much, Nele. Cool. What talk do they have next? There's, there's, I think it's Robin's Talk actually Cardio next week. You have got some things coming guys. You've got some excellent info coming from the cardio talk from an absolute world renowned expert. Um Yeah, we're all looking forward to it. All right. Thank you all 24 hour tape. Goodbye. Bye bye. Yeah.