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I know I got it. Okay. Oh Lord. Uh huh. I'm already seeing people can see us now. I think they can. Okay. Let me get the people. Yeah. Hey, guys, can you hear her? Brilliant, amazing, cool. All right, welcome, welcome. Thank you for joining us. Um Are lovely. Um, committee members currently and Lewis are going to take you through this presentation or then approach the shortness of, should we give it five minutes to see if anyone else is coming? Okay. Should we make a stop? Yeah, absolutely. So everyone, hi, everyone and we're going to be talking today about approaches to shortness of breath. Um The idea of this is to be um kind of like a discussion between, between everyone in the group. They've got a few polls going as well. So I would really like you to get involved and it's interactive if that's all okay with you guys. Can you hear me? Ok, sorry. My thing has been a bit. Yeah, we can hear you all Lois. So, yeah, I'm Lois. Hi, I'm I'm Carly. Um and yeah, if anyone, anything we've got wrong or anything you'd like to come on on, please. Just give us a message in the chat because that would be great and yeah, I just feel free to contribute in the chat as well. Mhm. Cool. Um, so I think I'm going first. Is that correct? Lows? Um cool. So hello, welcome everyone. I'm Coralie and I'm in my third year at the moment. So, apologies if anyone's older out there. And so I'm doing a good job. But yeah, as low said, we really wanted to kind of give you an almost in man like scenario where we're going to present kind of presentations based around shortness of breath and then have um I think about differentials and go for it as if we were in that kind of Simon A B C D style um situation. So um yeah, I hope you guys enjoy. So we're gonna start here with our first case. Um So in this case, you are working in the, as an F I two in the emergency department and your patient is a 75 yards lady named Avodart Presidente Mrs Olive Ellie is brought into a and e severely short of breath and I'm well following a collapse um past medical history, she's got, she's had a known myocardial infection two years ago. Um So we're just going to start off with asking if you guys know where to start first. So you've got three options here A B or C and I'm gonna open the whole. So when you see it's open. Yeah. Start boating when you're ready. Can everyone see the poll? Okay. Okay. So we've got eight responses. If anyone else feels like adding some or 12. Perfect. Okay. 13. Wait for one or two more. If you're onshore, don't worry. Perfect. So I'm gonna go ahead now and, and move on because I'm not sure we're going to get any more votes. So the answer is actually that you want to take an ample history first. So don't worry if you guys haven't heard of this before, it's just like a really short Hamonic that can help you take a history really quickly in these kind of emergency situations. Um So ample starts that ali stands for even allergies, medications past medical history, last meal or intake, which is more important in a sort surgical emergency or by an emergency that you think is going to need to be managed by emergency surgery, um and event information. So that's basically what happens. Um So in this patient, Mrs All Adelie, we're going to try to take an ample history. Now. Um So when we approach the patient, we start asking her her allergies and this patient is too short of breath to talk to you at this point. So, um we're thinking now, do you guys know what you want to do next? So you, you can maybe put some responses in the chat if you're feeling brave, Sarah, do you want to move this like uh Yeah, good answer is about, I completely agree. So now we want to get on with our A B C D because at this point, um primarily concerned firstly about the airway and then moving on. Yeah, that as well, um concerned about the airway and then moving on to breathing as well. So we're going to assess the airway first. So when we come to this patient, we have a look um her airways, so she is alert and she can't respond to verbal prompts, but like I said, she's too short of breath um to talk to you. So what you might want to do is just have a look and see if there's anything obstructing the airway. So have a look in her mouth, you can't see anything. Um So we're gonna say that her airway is clear is what do we want to do next? So thinking about breathing, what kind of things in breathing? Um Do you want to do once again if you want to put some answers with that? Yeah, oxygen starts. I like that. Um So if I give you her oxygen sats at 87% on room air, anything else you want to check chest expansion good. So her chest expansion is normal bilaterally. Yeah, respiratory right is 27 breaths. Yep. Same breathing, right. Anything else? Yeah. Okay. Yeah, I like all of those. Um So her trachea is central and her chest is moving bilaterally. Um She is probably looking a little bit distressed because she's severely short of breath. So short, fresh, can't breathe. Having a general look at her as well. She's looking quite pale. Um, and quite clammy looking. Mhm. Looking for one more thing, something you might listen for. Yeah, perfect. So, I have to get the chest. So, um, on auscultation, your hearing some by basal crackles, but you do have um, normal air entry on both sides. Um So you guys can write this down on a piece of paper if you want or pop some ideas in the chat. So I'm just gonna have to think about now. Um what differentials you might be thinking of? Mhm. Yeah, she's got normal breath sounds other than crackers. Okay. Let's move on. So I would to a list of differentials we have, I'd steer away from infection um a little bit just because we haven't said that she's presented with a fever, although obviously in the elderly, especially with fools or collapse, you can't be too sure. I really like the suggestion of acute left ventricular heart failure. I think that's fantastic suggestion. Um So maybe if you guys can think more along the kind of cardiac line. Uh huh. Yeah, lovely. Thank you, Sarah. So these are the differentials we have. So once again, crackles can be indicative of um infection, especially sort of inspiratory crackers. However, crackers can also just be fluid in the lungs or that's like um pulmonary edema as, as we've got here in the Chat or Florida Fusion. Um, but so we've got some, the French was here are top being acute heart failure that's mainly based on her history really. Um, but along with the fact that, uh, you can hear these crackers indicative of, you know, fluid on the lungs, um, with P which is a little bit further down the list, especially because p there's sort of nothing in the history that would suggest it, but it can present with shortness of breath and, and that kind of fluid build up once again. Uh similarly atrial fibrillation and body cardio and obviously using top lock can also um or heart block leading to bradycardia can also once again present with shortness of breath and fluid on the lungs. But we're mainly thinking acute heart failure from her history because she's had a past mis were thinking along the lines of this damage already existing um to the heart that's kind of built up over these two years and and has led her to come in with sort of acute crisis of of heart failure. Um So I don't know if you guys have any um thing that you think would be suitable to give in this moment in time remembering maybe her kind of her oxygen saturations. Yeah, perfect. Any thoughts on how we might want to give? Yep. Perfect. Okay, perfect. Um So you go to your um drawer of oxygen masks and you have a look in there. Oh You also might want to do a chest X ray in an A B G at this point. Um Noninvasive ventilation, I think at this point would be a little bit too early. So we can just see if she can, she'll be helped with some versi with just some oxygen. Um So you open up the draw and you're presented with this array of choice of masks to put in your patient. This could feasibly happen. And you're saying man, scenario. Um So do you guys know which one you're looking for? So which one is your 15 lead to non rebreather mask? I'm gonna open all now for you. Lovely. Thank you for puffing the presentation for me there in the chart. There is uh Well, I'm impressed you guys don't really know what, what you're looking for. Um So any I just wait for a couple of more answers don't be shy. I can't see who's put what? So it's worth having address. Okay. So yeah, is see that you're looking for. So sees the one with the bag attached um which is kind of the non rebreather element. Um Perfect. Okay. So you've, you've got your mask on your patient's hopefully her oxygen sats are rising. So now it's time to request that, that chest X ray. So you can go ahead and, and call radiology, requesting your chest sets rate moving on in A B C D E what kind of things might you want to look for and see? Mhm Thinking along? Yeah, BP, perfect. So her BP is 100 and 50 over 100. Could the review for this three seconds? Heart rate's 100 and 10 BPM. Yep, we might request an EC so we definitely will request an HCG in this situation. Yeah, lovely. Thank you, sir. Um I think we had a B G mentioned um earlier or V B G if we're using IV access to that. Um But perfect do some do temperature as well in circulation also saying with chest, we're going to have a listen. So we have a listen as a third heart sound present. Um and we have a look at the patient. You can also see a raised JVP. Um So having to think about those, I'm wondering if you guys think you're differentials have changed at all or what your top have, if you have a thought about what your top differential might be okay. I reckon this is pretty indicative of one of the differentials on the list of earlier. Yeah, heart failure. Um mostly from that third heart sound. We can rule out Bradycardia now because she's tacky card ick. Um Yeah, perfect heart failures, evil. All mainly got that. Um So we're moving on to other investigations and we've already spoken about getting IV access. So do you know what we would use to do that type of instrument or device you might use to get IV access in this patient. Perfect. Yeah, Cannula. Fantastic. So you open your drawer, Cannulas. Uh this is a slightly harder one. Um So you're in, you're in Man station and you open your Cannula drawer in in the trolley and uh you're presented with this choice. So another poll, see if you guys um I have an idea about this one. This one is a bit meaner if you only a second year. Yeah. Fantastic. Guys, I'm really impressed again. It is your green one. Um, because green is for giving fluids and medications. Uh, bluish your smallest and it's for Children. Um, and gray is, is there for your biggest. So it's for very, very quick resuscitation using fluids. Um, and pink is for medications only. Fantastic. So I think on the next slide, we just have, um, uh, table explaining kind of the flow rates of, of Cannulas and the kind of gauge size. So how big they are basically. Um, and they're recommended uses. So you guys will get slides afterwards. You can have a look through these, um, if you want. So moving on. So, investigations why she, you've ordered an E C G, you've also ordered some bloods. I don't know if you guys see my have really briefly seen, um, or C now know the kind of blood you're looking for. So you've got a full blood count here, LFTs using these BMP. So, this is your kind of classic heart failure marker. So for stretch of the ventricle, um troponin particularly, um if we are thinking along the lines of she's had a previous MRI, so she could be having another ACS event or A P as well. Clotting profile D dimer is also obviously a big investigation. P and then calcium magnesium and phosphate eights. These are kind of like we're looking for electrolyte disturbances. We're thinking about arrhythmias is is more with our kind of h of fibrillation. Um and other arrhythmia kind of differentials. So fantastic. So your E C G also comes back and the signs shown on your E C G R left access deviation. Um We've left hypertrophy. So this should really give you one differential in mind. Now, we've already talked about it is heart failure. Um because obviously you have kind of bigger left ventricle. Um You also get your A B G results back. This is a bit of a cheeky question, but I'm wondering if anyone can tell me if this essentially does this information, tell you anything new? I'm wise to feel free to. Um But your answers in the chart, don't worry if, if you don't know it's a bit of a mean question. Um and maybe not worded very well, but essentially, I'm going to move on just some conscious time. Essentially, it doesn't. So a lot of these, a lot of these differentials will present with type one refugee failure, particularly acute heart failure and um A P. So at this point, you're pretty sure of your diagnosis. So it's not telling you much more. Um And at this point, your chest actually also comes back. So I don't know if anyone's brave enough to, maybe people have done rest, comment on some of the signs that they can see on this chest X ray assuming this is a chest that's very over acute heart failure patient. Uh Okay, no worries. Uh I have a bit of a cold guys, talk you through some of the signs on this chest X ray. So essentially down at the bottom, you've got, yep, perfect Hurley be lines. So those are seen quite laterally in the lung fields and they're kind of those thick horizontal white lines there wouldn't be seen um in the in the normal lung field at the bottom as well. You've got slight blunting of the costophrenic angles which indicates pleural effusion um at the top. In the hilar regions, the great vessels are quite large. Um It's quite fluffy and then they're branching out across your your X ray, which has a fancy name, it's called capitalization of essential vessels. Um And to be honest, I don't think this is most enlarged heart you could ever have for an acute heart failure X ray. Um but you have a slight increased cardiothoracic ratio, meaning that the heart um is bigger than normal. So, moving on to your last bit of D any, what kind of things are you looking for in your D N A assessment? Anyone, if they're feeling brave can pop stuff in the chat? Yeah. Fantastic. So, on exposure, she does have bilateral pitting edema to the knees and sacral edema as well. Her glucose is six minimal per liter and her temperature we discussed earlier, I believe was 36. Yeah. So, yeah, 36.9. So not, not a fever. Um Yeah, perfect. And the other thing you might want to do is up, who's a quick assessment of how alert your patient is? So alert to be response to voice or verbal, be response to pain and you is is unresponsive. Um So our patient's fairly alert um and pupils that you will understand a bit more maybe when you come into neurology, but it's just also kind of an assessment of damage to your such a nervous system and and how alert the patient is. Um Perfect. So yeah, uh final diagnosis is acute heart failure. I don't know if anyone knows the management for acute heart failure in this kind of situation. What's going if you're feeling brave, pop it in the chat. Furosemide? Perfect. Anyone know this dose. You want a Cassina. Yep. Perfect senior involvement. Any kind of um basically dilatory things we might want to give her. Yeah. Love that. Set her up, give her oxygen. Definitely some nitrates. Yeah. At this point, I wouldn't flu. I wouldn't fluid recess her just because her BP um is quite high and also she's already suffering. Um You're sort of fluid imbalance. So you need to be very careful if you wanted to fluid recess her. Um Yeah. Good, good. Fantastic. So the only other thing that I have guys is is morphine. So morphine is both a pain killer and also has a kind of faizo dilatory effect. Um We definitely want to give her oxygen. I think we mentioned that further up uh to bring her sats up Heparin. That's a kind of a trick one. You're likely going to admit this patient. So she needs from both prophylaxis for the time she's in hospital um to stop clots forming. Um A urinary catheter is, is maybe months going a little bit of a third year thing. But that's because because she's in a state of fluid imbalance, we wanna be monitoring very closely the fluids that she takes on board and therefore also the fluid that comes out in the urine. And if you really are worried about um her breathing, then you can put her on to see that. Okay. So really quickly and I have just to spot diagnoses based on the CGs based on other differentials we had during the station. So really quickly fire in the chat with this one is perfect af So the thing that end indicates A F here is there's no key waves is the big giveaway. Um But it's also tacky Cardiac and the QR QRS complex, it's very thin. Um So and the second E C G maybe a little bit meaner. So help a tip might be to look at the P waves again. Um And their relation to QRS complex is not quite although these are all good suggestions guys. Um So this mask in the Pi Rho is kind of a giveaway. This E C G is indicative of heart blocks. This would be third degree heart block because there's no association between the P waves and the QRS complex is. So they're just coming at random times that completely um not connected to each other anymore. Um So you have fantastic, we're done. Move on to the second case. Now this one's a bit shorter. So once again, you're back in the emergency department working as an F I one. Um And Mr Ali, a 57 year old gentleman coming and complaining once again, shortness of breath, anxiety, fatigue and what feels like to him, a fast heartbeat. He says he's currently not in any pain, but he has a previous history of lung cancer and is unable to give you any further information. You begin your 80 assessment in a the patient's um airway is clear and he's alert and responsive. So we're going to move straight on to be I'm going to tell you this time. Um Everything straight away because we've gone through kind of the process of thinking about it be. So he's pale and clammy once again. Um Lots of very similar signs actually. So he's got normal, bilateral chest expansion and percussion is normal. Um He also has um crackers in his lower lung zones in the respiratory rate of 27 oxygen starts at 85 on room air. So once again, we do similar things, his oxygen stats are low. So we're gonna pop him on five flow oxygen um through a non rebreather mask and you're going to order a chest X ray and an A B G. So once again, you can even write them down and put them in the chat. You guys have any differentials for this case bearing in mind that the presentation is quite similar at this point, there's some differentials are definitely gonna overlap. Yeah, definitely P or gets a bit say me in a restaurant Guardia, I'm afraid. Yeah, I haven't put a C S on there, but I think that's, that's probably fair. Okay if we move on. Um The only thing I would say with A C S is offering, you are looking for that kind of characteristic chest pain. Um Although he is complaining maybe although he's not saying he's in pain, anxiety can be kind of indicative that patient is feeling pain. So I don't think that's the craziest suggestion the world. But yeah, the differentials I have are quite similar to last time. So he like I've already said um valvular disease. Once again, af once again, he's got feeling like he's got a rapid heart rate, short breath. Um it could even be acute heart fail earlier again. So once again, the differentials are very similar, the if the presentation similar than differential is gonna be similar, there's one other um in this one that's cardiac tamponade that's mainly coming from his history of, of cancer and also a kind of fast heartbeat and anxiety presentation as well. Um Perfect. So now you're going to move on to see. And so that's again, I'll just tell you what's in, see. So you do an examination and you see that he has a raised JVP, he's pale and clammy peripherally SIA gnosis. Um apex beat is not displaced. So you don't appear to have a big left ventricle. Um but he does have a delayed cap refill time or four seconds on auscultation. You hear muffled heart sounds and a pericardial friction rub heart rate's 128 BPM. BP is low hypertensive, 84, 64 a temperature of rest 6.9 as well. So you obtain IV access and also order an E C G. So um your differentials might have changed in order at this point. So one might be more prominent than the other. I don't know if you guys um wanna suggest which one that's fine, might help if we say the SCG has come back. So at this point, New York SCG has come back. Oh, perfect. Think someone's got the diagnosis spot on the and told me characteristic findings as well. Okay. So having a look at the C C G, um we've already got the diagnosis but could someone tell me the characteristic sign on the C C G that gives you the diagnosis? Sorry guys, it has like a mother's silly fancy names. Mhm So it's a name for the difference in size between the QRS complex is so particularly, yeah, perfect. If you look at lead to um at the bottom, nice long lead to have a look at the fact that the QRS is basically very big and very small um in height. So aptitude and we call this electrical alternans um and along with tachycardia as well as shown on the C C D um last year they loved cardiac tamponade. I think it came up about five times in the written anyway. So definitely want to be aware of. Um cool. So at this point, this is pretty addictive of your final diagnosis. You're gonna run through the rest of um disability and exposure. So d any there's not much to note here. Um apu your patient's still alert also got a 6.0 minimums per lead to a glucose score. Uh He's people to equal and reactive to light and on exposure. Unite nothing. Um So someone's already mentioned backs triad. I don't know if you could tell me what the three things in backs triad are. Sobek's triad is kind of like a constellation of symptoms that tell us that something's definitely cardiac tamponade. Anyone's feeling brave? Okay. Okay. Okay. Okay. So back triad is basically three things. It's having a raised JVP hypertension and muffle heart sound. So we've, we found all of those. Yeah. Perfect. Uh Mister Ali. Okay. Um And does anyone know the management? So really? Um well, I guess simple is the wrong word but one definitive management in an emergency situation. Um Yeah, perfect pericarditis and pieces. Um So this is done between the city sternum and left costal margin. I don't think you guys actually need to know that, but it's quite fun fact. Um and there's one other thing you might want to do and that's to call your seniors, let the lady got a tampon ad um and asked if it would be okay to give them some inotrope. So these basically drives that increased contractivity of the heart. So obviously in tamponade, the heart's compressed. So it's really struggling to contract think and get enough blood art so these drugs might help. Um So I hope I have a board. You guys too much. I'm going to hand over to Lowes now for us to other cases. But yeah, thank you guys very much. It seems to be doing really, really well. Thank you, Coralie. Um Yes, that was really good. So it's gonna be the kind of thing again, but it's going to be a slightly different kind of, um, like module that we're gonna focusing on. So you're an F Y one working in the emergency department. Mrs dot E A 83 year old female comes in complaining of severe shortness of breath for the past few hours. She's evidently really struggling for breath and currently adopting the tripod position, she has a previous history of COPD and smells like cigarette smoke, but it's unable to give you any further information. You begin your 80 assessment in a patient's airway is clear. She is alert and responsive. Okay. So what would you like to do next if you could just comment in the chat for me, please? And I'll tell you the answers as we go along. I know we've gone through this a little bit already. So if we can just like quick fire some, some things we're looking for. Yep. G very good. So we've sent off for one of those. Very good. Yeah, you can't answer from my early my next questions, but that's great. So you eventually mask. We're going to that in a bit more detail in a second. But what would you need before I give you a venturi mask? What do you need to look at? Yeah, that's the chest. Yeah. Very good. Yeah, perfect. Oxygen saturations. So if you could go on to the next slide, Sarah, please. Perfect. So yeah. So we've got oxygen saturations of 74% on room air. Her respiratory rate is 28 sorry, 28 her chest is equally bilateral and percussion is normal. She's also got a ways with scattered crepitations. Um So yeah, you're gonna go and send off for an A B G and you're gonna look for an oxygen mask as well. Um Does anyone know the normal auction range for your average COPD patient? Perfect. Yep, that's perfect. It's about fantastic. Okay. So what differentials are possible now? So this is going to be quite different from the last case. We're thinking less cardio, not rolling it out but thinking less of that. Yep. COPD exacerbation. I like that. Very good and ineffective exacerbation of COPD. Very good. Brilliant. Any other differentials that you've got pneumonia is always a good one, especially in an older person. Pleural effusion? That's a good one. Yeah. P Yeah, we've always got to consider A P they can present a bit weirdly sometimes. Okay. And then if we just move on. Thank you. So what oxygen mask should you give in this scenario? So I would just get the pole up. We've kind of spoken about this a little bit already. Um But hopefully you'll know what it looks like as well. I'll just give a few more seconds for other people to respond. Good question someone's put. So Ben's, but are they a known C O T retainer? And that is important to kind of work out, but we haven't been given a B G back yet. So at this current point in time, we don't know. So the best bet is what most of you have put, which is to go for B which is a venturi mask. Very good. And then this is just a quick summary about venturi masks and you probably already know about this already, but it can give an accurate concentration of option to a patient regardless of their ot flow rate. Um And it has the ot flow rate on each one. Um And it's particularly suited to those at risk of C O T retention, for example, COPD. So that's very good. Okay, if you just want to go on to the next slide, so R A D G has now come back. Would anyone be happy to interpret this for me? I don't, it's a bit bit scary because I got everyone here. But if you just want to write it down in the chat, that'd be brilliant. If not, we can go through it together. I'm essentially looking for an overall diagnosis and I want you to tell me whether it's acidotic or Alka logic. And if there's any compensation, is anyone feeling brave have ago cases, someone's put metabolic alkalosis with the respiratory conversation. Okay. I see where you're coming from with that because of the H C 03 rates um and the base excess, but we've got to try and think about the fact that it's likely to be a respiratory cause because the oxygen has been affected quite severely. Um But I can see where you're coming from with that. So you type two respiratory failure. Fantastic. That's what I was looking for. Um someone else has put respiratory our closest um I disagree because the, the carbon dioxide is high and we've got high lactate as well, which would suggest more the other way. So, more an acidosis. Um So AB GS are tricky and even I get them wrong quite a lot of the time. So I've gone for a respiratory acidosis with metabolic compensation. So the reason I've gone for that is because we've got a low oxygen saturation, a high, high CO2 and we've got the base excess and the H C 03 compensating for the respiratory results, which is why the ph is normal. If the, if the metabolic wasn't compensating, then we would expect the ph to be acidotic. Does that make sense? Because I know it's a bit tricky. Let me know if anyone has any questions about that and we can try and go through a bit more. I think essentially what you're looking at. If the ph is normal, they didn't see either a normal A B G or you've got some sort of compensation going on. Just text chat. I've been doing too much A B G ninja. I like it. That's what we like. There's no such thing as too much. Okay. Um So if we can just move on to the next one. Yeah. Brilliant. Sorry. Okay. So there's not much the in circulation. It's all kind of pretty expected. We've got IV access, we've got any C G requested and blood requested as well. So why are you going to be doing an E C G in this case? Can anyone tell me? I don't think too hard about it. It's kind of a general answer. So, why do you do an investigation in anything? Okay. I'll help you out this one because, um, it's a bit weirdly worded. So you do an investigation for anything. So I roll it in or rule it out. So, in this case we're rolling out, um, and my ventricle diabetary and arrhythmias, any sort of cardiac problems that could be causing this, it would be a bit of a strange presentation, but because they're short of breath, we would like to be rolling these things out as well. Okay. We'll move on. So, again, we've done lots of disability and exposure. It's all the same sort of stuff. Again, we've got nothing of note. Does anyone? She's got their first does anyone know? It's all right. It's all right. I think we kind of knew that it was a COPD exacerbation right from the beginning. So, that's great. So, yeah, it is a COPD exacerbation and we can tell that from the A B G and the history. Um, does anyone know the management of COPD exacerbation? I've got a big slide on it for the next page. So, don't worry if you don't, because that's quite a lot to it. Can anyone tell me any of the management options? Yes. I petroleum bromide. I like it for the road ones. That's good nebulizers. Perfect salbutamol yet. So it'll be nebulized. Albuterol is perfect. Isabel is on the road. I'm very impressed. Yeah, magnesium sulfate as well. Yeah. Have we got any other answers? Anyone's but sorry, just for the magnesium sulfate. That's more for your asthma management. I'm not sure if it's in COPD or not. Um But yeah, I think that's more for an asthma side of things, but you could have both to be there. Yes. So the the oh shit me is for the asthma management, but I like your thinking option is very good as well. Ok, brilliant. So if we just want to move slides for me, okay. So I'm not gonna go through all of this because there's quite a lot, quite a lot on the slide. Sorry, just go back to the management, please. Thank you. So, yeah, we spoke about oxygen. Um and we also spoke about the echo to retention side of things. Um N I V. So that's noninvasive ventilation. So this is if the patient's getting really severe and we might want to consider using this. These are two agonist that's yourself be tomorrow, which was spoken about. Um I portrayed PVT usually used a bit after that. If it's getting a bit worse, you always want to be using steroids in this scenario because they could be really effective for allowing the patient to breathe a bit easier. Um Theophylline is a bit of a weird one as well. So this is again in a case of like non response. So you wouldn't be thinking this first line. So there are some, we mentioned that the starting infective exacerbation of COPD. Um in that's the next situation, use, use antibiotics, but that's only in ones that are associated with specific symptoms that we actually didn't have. In this case, it was an important one to kind of look at. And then of course, if the patient's unstable, then you want to be doing fluids as well. Thank you. And then yeah, we'll move on to the last case. So you're an F Y one working in the emergency department. MS Everdeen, a 14 year old female comes in complaining of severe shortness of breath. She is really struggling for breath and is clutching her chest. She has tried to use her blue inhaler, but it's not working. She's got a past medical history of asthma and she can't answer any of your questions at the moment. So you begin your 80 assessment in a the patient's airway is clear. She is alert and responsive. So what we'll do is we'll go straight onto breathing next and I'll just give you the, the answers that we've got. So she's really short of breath at the moment and he's crying as well. Her chest expansion because is normal, but she's got audible, wheeze her oxygen stats are slightly reduced. You're gonna give her 15% oxygen through a non rebreather mask. What are our differentials? I'd imagine you guys probably know that we've got a couple that it could be as well. So Pete put them in the chat if you can. Yes. Asthma is number one at the moment. Does anyone have any other ones? Okay. Mean with all right, that's a good one because she's young. Um, she hasn't got all of the risk factors for it, but that's a good one to be thinking about any other ones that you could be thinking about specifically to do with a young person, um, who's crying particularly as well. Yeah. Anaphylax is perfect. There is one more that I've got on here. That's a bit of a rogue one. Can anyone think of it? Yes. Anxiety. Brilliant. So, yeah, a panic attack. It could be. So it's really important to think about that because you never know. Obviously, obviously you'd rule out the other things first, but it could be a panic attack. Okay. So if we'll move on circulation, so her heart rate is a little high. But I mean, you'd expect that, um, in all of those differentials. Um, so we haven't really got anything different to kind of see on this. So if we just want to move on. Yeah, again, nothing too interesting on the disability and exposure. So, with our diagnosis, so we've already gone through it. So we've got an acute asthma attack here. Does anyone know the management? I know we had a few suggestions earlier. Can anyone tell me what the pneumonic actually means? So, so this is a classic year to management options? I know we've mentioned it earlier. But if anyone could go through it with me, that would be really helpful. So if we start, okay. Yeah. Yeah, perfect. So oxygen and we want to be sitting them upright if possible. What does s stand for and if you know the doses that's even better? Yeah, perfect. So yeah. Oxygen salbutamol hydrocor soon as entrepreneurs alone, hypertropia, um do we know what were the T M and eee sample theophylline? Brilliant. And then the end we mentioned a bit earlier, I think Isabelle mentioned it yet magnesium sulfate and then the e is just for escalating care because um asthma attacks in the acute phase can be really severe sometimes and are often overlooked. So it's really important to and the cysts around if you will need that information. So that's very good if you just want to move on to the next slide for me. Oh no, your patient has lost consciousness. So now we want you to involve a senior does anyone know what S bar stands for? It is, I will be honest with you, this is an old year thing but if you know it in second year, it can be really helpful because you'll show off in person man scenarios. It's very good. Yes, situations. Do you want to be explaining what happens? Does anyone know what the B stands for background? Brilliant and then assessment and they all recommendation brilliant. So yeah, we'll just move on to the next slide. So this you just got a quick summary of all of that will give you the slides afterwards. So you don't need to worry about learning it right now. Yeah, that's brilliant. OK. So then we'll just move on. So the reason I put this on here just to remind you guys that a panic attack is still quite good differential for shortness of breath. Um It wouldn't be made like high up on your list, but it's definitely something to consider, especially if they've got chest pain too and that's, that's everything. Thank you so much for listening. Um If you on our next side, we've got the QR code for the feedback form, I think we can also do it on this system, I think. Yeah. Uh Yeah, we can, I'll thank you guys. Thank you very much. Thank you, Coralie. Um It's been awesome having you guys um talk too short of breath. Um Yes, I'll send for it the floor. Um I'll ask you guys, I thought I've been back for me. I'll send all of you to slide and then you'll also get like an author. Testicle um you attended today. Um Yeah, thank you very much. Okay. Well, I just wanted to, to add as well with asthma. I'm sure you guys have probably been, might already have had because it is quite scarring. Um But in our end of year of ski last year, So at the end of the year, t we did have an or ski same man station come up and they asked us to set up a nebulizer as part of the ocean. It me management and many of us hadn't been shown how to set stop the nebulizer before. So they literally had the like parts there but not together. And they were like, how do you put them together? Um Saying the comments have just added a youtube link to a video that shows you how to set up nebulizer. I feel like they probably wouldn't make you real if that trauma, but just in case they do and you want to cover your backs, uh check out the color video as well. Yeah. Thank you so much guys. Yes, but I wanted to add on top of that Coralie. Thank you so much for mentioning that. Yeah, I heard about your years um situation um in a bit and a video of blackboard of um what's her name? Helen thought that going through how to set the nebulizer. Um but I will put the like um when I email you guys. Uh Yeah, that's, that's all she's such a good point. So the all of the videos that they put in the like clinical skills air of your blackboard, they kind of expect you've watched them by time you get to the Yassky. So even if the skill hasn't been mentioned on placement, but there is a video for blackboard, make sure you've watched as they'd consider that, like, fair game, which is very mean. Um, yeah, you have a watch of all of them, uh, separate. Yeah.