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Ok. Hi, guys, I'm Bean from one of the F ones working at Grove Hospital. Um, I'm currently on endocrinology and I've done two medical rotations. This is my second one. and I've just done one surgery at the very beginning as well and I've got ma here. Yeah. Hi guys. My name is Matt. I'm the F one at Musgrove as well. Also done two, medical rotations, done a lot of, um, phone call and take shifts. So hopefully he'll be able to help you guys, you know, out with, with, with that as well. So, so, yeah, so today we're just gonna, um, speak briefly about medical, take shifts and on call shifts and what to expect of them and what common conditions you meet and how to treat them. Uh, we're gonna keep an eye on the chat. So, um, we're gonna try to make it as interactive as possible. So please engage with us and there's no wrong answers here. Um, and if they've got, got any questions, please, please let us know as well in the chat. Oh, so just before I begin, can you guys see the slides? Ok. And can you hear me? OK as well. Can you just let me know in the chart? Um but while we do that, I think where they spoke about it, we're just gonna um speak about the take shifts, basic principles of clerking and documentation and basically an approach to diagnosing and managing common acute medical presentation, right? So we're just gonna speak briefly about take shifts. So as an fon working medical uh ward, usually you're gonna be on a day uh shift. So that's your usual 9 to 5. Sometimes you're gonna have in our choice, it's like one per week, once per week, you're gonna have the long day. So that's your 12 hour shift. You're gonna be with the oncall team. So with the oncall team, you are basically the crash team. You're gonna have to get um go grab your sleep at the beginning of the day and you're gonna do your normal day shift from 9 to 5. And after five, you're either gonna be on call on the wards looking after your sick patients or you're gonna be with the take team, either Clar king or post taking patients that are already seen. And then the third shift is gonna be the night shift. That's also as part of the on call, they usually start around half 8 p.m. to half 8 a.m. or nine depends on the trust and that's usually just trying to chase scans like reviewing urgent jobs. So the night is usually just the night usually involves um looking at a really sick patient. And lastly is the tape shift, which is mainly the clerking. So in our choices are the AM UF funds. So those who work in AM U and they basically see um all the new patients that comes from A&E or from GP. So I don't know if you guys have ever been to a handover just um with the on call team. But before starting the F one, I was never um I never attended one of these. So it was a bit of a new experience to me. But basically, we'll start, you'll start um handover from the outgoing uncle team and you will be expected to introduce yourself, take the bleed from the oncall team and make sure that your, to know your seniors who your a are who your friends are and take their contact details. So their phone numbers and bleed cause you're gonna need them quite often. So make sure that you know how to get reach of them and then usually high-risk patients will be discussed in that meeting. So either those are cards or just around the hospital. So just make sure that you're listening in, especially if they are on your ward cause you're gonna probably be bleeped about them quite a lot. Um And also it's like a good opportunity to ask about these patients specifically who are unsure about what to do and want to escalate So that's always a good opportunity. And um the handover to ask about that and as I already told you guys could take, um shoes are mainly clerking and seeing new patients. Um And there is fake where you go around with a consultant, just doing jobs of the patients who work hard by your colleagues. Um And every system is different, but when you're uncle, you're gonna get the jobs either through an app or a bleep. And the most important thing is just trying to stay organized, triaging the course or the jobs that you get. And if you're quite busy, do not hesitate to ask the nurses to do some stuff while you um go review that patient or until you go review that patient. So things like duplex E CG. So ask the nurses to do that while until you go and see that patient while you're finishing, for example, another job. And at the beginning, it's just don't be scared to escalate if unsure, your seniors expect you to escalate quite a lot. Um especially medical registrars, they're always happy to be contacted. So do not hesitate to contact them. And if there is like a proper emergency, like for example, seizure per arrest don't be scared to put out the crash call. So double two, double two because they're always happy to come and have a look at the patient. So just a bit about Clarke, I'm pretty sure you guys know all of that already. But basically when you call patients, they're either gonna be from GP or A&E if they are from GP, just make sure that you are looking at their new score, use or use score because if they're scoring high, you need to go see them ASAP just because GP referrals do not get seen in A&E. So they wouldn't have any bloods, they wouldn't have start any antibiotics, fluids extra. So you need to see them as soon as possible and present a complaint as always Socrates and with every symptom going to detail with past medical history and drug history, just make sure um to have a quick look, even if you're not gonna see this patient, especially if those from GP, just make sure that they haven't got things like some critical meds. So things like Parkinson's medications um that they need to um take as soon as you see them with social history, things that you already know about pets jobs. Um for example, if they work in a bakery that might exacerbate their asthma, it seem uh recent travel. We had a case where there was this patient, he had bilateral pneumonia. And um we only found out that he had a recent travel to China like two days in and obviously it was conditional. So or always ask about travel history and then you ask about rest of symptoms, head to toe and red flag symptoms. And with examination, it's always a good idea to do it and also document it, especially if you're clerking A to e just to make sure that you haven't forgot, forgotten anything and always do a quick neuro examination, especially a quick A MT. Um, that's just to make sure, especially in older patients because a lot of them would be confused or the, the areas and with investigations. So try, especially with the GP referrals, try and order these investigations, add on and get the results uh back before you discuss with your seniors, like discuss the sa case with the seniors, especially if the patient is stable. Um just because it makes it more time efficient that way and with plan, so don't overcomplicate it. Just simple things, everyone would need pain relief, antiemetics. Um they would need an escalation form discussed with them. So make sure to have that discussion. VT prophylaxis and just some initial management like for example, fluids or antibiotics. And just these are common investigations and just, I'm not quite sure. Are you guys fourth year or fifth year? But just a quick tip for us, it's always a good idea to present if you're um, car patient, for example, in that station, it's always a good idea to present the investigation into a group into bedside bloods and imaging and same with management like things like conservative medical and surgical. It just let's talk that be. Um and last thing do not forget to communicate with the nursing staff the plan that you've put in place or the investigations that you ordered. Um Just because for example, you can prescribe antibiotics, but if the nurses do not know it's prescribed, it will never be given. Um And that's quick. So you can have a look at um the side on your own time. But that's basically how we do documentation, write your name at the top time if written in retrospect, not sure to document that as well. And then you um document in the same order that you take the history and usually there is like a performer that you can fill in straight away, right? So we're just gonna have a look at cases. Um So please interact with us and um, I'm just gonna ask you a couple of questions. It's gonna be what common um cases so that should know the answers. So first case is Mister Harvey, 59 year old admitted to Ed with chest pain radiating to the arm and there for a couple of hours crushing and that's his past medical history on examination. He's a bit tacky. BP is fine and respirate. He's a bit kidney as well. But overall he looks stable and you've done some bloods C RP is just 12 other than that, nothing really pops up. What would you like to do right now? Any other investigations you wanna have a look at or ask for? What's the first investigation that pops into your mind? I'm sure you guys know it like an maybe. Yeah, someone said it yes. Right. So you've asked for an E CG? There is your A CG? What do you guys think? And Trump is for right now, can you guys? Um So let's start with simple. What's the rate and rhythm and what is the most obvious thing that you guys can see any thoughts? And if I tell you that the drop initially was four and it went up to 38 and then you did another one in a couple of hours and it's gone up to 400. What do you guys think that is? And what should we do about it? Like as an F one? What would you do? Yeah. Well, then it is a natural. So just going through systematically with EC GS, just make sure you go through it systematically. So the rate is around 84 rhythm that's regular from what I can see, there's no axis deviation. If you look at 123, no axis deviation, yours complex is they're normal within range. ST So you've got ST elevation in leads one A DL and V two to V six. So that's like anterior lateral. So that's an anterolateral M I, you've got the reciprocal acid depression in these three and A DF. So that um give you an idea that this is quite deep as well and it's quite a big uh block. So with that in mind, and with a troponin rise, what do you guys think you should do is an F one. Would you escalate? Would you start any treatments? Would you ask for more investigations? I mean, start simple things, right? Any ideas what we can start or should we escalate at this point? If you guys are not sure that's fine. Um So at this point as Yeah, yeah, I just seen your comment all good. Yeah. Yeah, perfect. So yes as an F one. So you wanna involve your seniors. So always, for example, text your s but do not be scared to start treatment straight away. So you do not need to wait for s or registrars to come around. Yeah, all done. You guys um So you wanna assess them at if not already, but if the patient has any signs of shock, if they've got heart failure, if they've got syncope, that's a red flag. You need to involve the crash team ASAP because this is a peri arrest patient. So you need to involve them straight um as soon as possible. But if not, if the patient is relatively stable, then obviously you guys said, so you wanna, first of all, so we're going a to oxygen first of all. So you wanna check theirs. If that is lower than um 94 as some of you said, then you wanna put them no breath and titrate on. If they're not, then just leave them straight away and if they're saturating ani around 94 if they're conscious, you can set them up, right? Because that also helps with Ergen. Next, you wanna give them a analgesia. So with these patients, you wanna take blood as soon as possible, but also put in a cannula um for painkillers and fluids if needed. So, the best thing to get is IV morphine because it's also got acute, um it's also got um vasodilation or vasodilatory effects of the coronary artery. And then you wanna start the J ju antiplatelets. So you usually give aspirin and clopidogrel, um clopidogrel if they are not, if they are high risk of bleeding and just be aware if this is a surgical patient that just came out of surgery prior to starting antiplatelet therapy, just make sure to discuss it with the um registrar, the surgical registrar because usually they would want to speak to the surgeon prior to starting any of that because in surgical patients, it's gonna be risk versus benefit and it's the surgeon who decides if they are to have treatment or not with the medical team. So as an F one, you wouldn't decide that. But for example, if they had surgery 10 days ago, you can start it, but just let your surgical as um as a Children registrar know prior to that and then GTN spray or nitrate nitrate generally, unless they are hypotensive, then avoid it. Um For the parents, I'll come back to that as well. But at this point, that's your acute management. And at this point, if the patient has an sty, you wanna make sure that the V know because they might be suitable for PCI. So the gold standard is PCI S happen within 1 20 minutes, but they are eligible, especially if the patient, if it's an inpatient, that's why um like usually heart pain or cardiopress. Oh, what is cardio um MRI S are picked up quite quickly in patients. So you can always send them to the PC lab. But if you're clar them, they can still have PCR up to 12 hours from the onset onset of the pain. So you just need to inform the cardiology uh department or the cardiologist on call. Um If you find the sting and with this treatment, you need to make sure to repeat the E CG uh within 90 minutes. If you find that after 90 minutes, there is no, the E CG changes have not resolved, make sure to escalate as soon as possible because they might be eligible for A PC. Um And then after all of that, you can do secondary prevention, which includes them, starting them on the ace inhibitor beta blocker and statins. But obviously, you do not need to do that as soon as possible. And with, from the parax, so that's an anticoagulation that's usually given in N sties. So with NTE, you do the grade score for mortality risk and if they've got high grade score, then you wanna escalate to senior because they are eligible for further investigation. And gold standard is APCR within 72 hours. But obviously that doesn't always happen. And that's a little overview of what um we just spoke about. And so here you're gonna find fibrinolysis. So nowadays I find that less people do fibrinolysis just because it's high risk of bleeding. But obviously, if the patient is not suitable for PCI and they're not improving on your dual antiplatelets, then obviously, this is an option. But you can have, we're gonna upload the slides after this. So you can have a look at the slides right next case. So you've got this 79 year old lady who was admitted with a fall, so she fell out, she was trying to get out of bed. Um She felt a bit funny and then collapsed and she tells you that she remembers the details and she couldn't get um up straight away. So she stayed on the ground for quite a while. And she did say that she also um had she's got currently increased urinary frequency and that's her past medical history on examination she's using is zero. And other than that, she's a febrile and clinically stable and, and you do an E CG. So you find an A, you find a patient in af her bloods are fine other than a CK or of 500 and a slightly low potassium. What do you think is happening here? And what else? Or what other investigations would you like to have on the examination? You examined her head and you find that she's got a little laceration on her scalp. Yeah. So, first thing c had definitely what else, any investigations that you would wanna know as well? So quick bedside ones, she had ACR P of 56 increase your frequency. What do you think about all this? Yeah, so you're in the because it could be an infection. So, so in this patient or when you're cracking a fall, generally you wanna ask two main questions, why did the patient fall, especially this patient and that will help you prevent further falls? And secondly, did they, did they sustain any injuries right now? And in the elderly you're gonna see lots and lots of falls and usually they're m multifactorial. Um so do not jump into labeling them as mechanical unless you fully considered other things. And before, I'm pretty sure you guys know that already but go um so break down your full history into before during and after. So was it witnessed any postictal, any um S prodrome, anything like that to help you find the cause? And the E CG is very important in case you find out there is heart blocks and in this patient. So we found out if um that is AF is an a fast af is old, is it new? So, you always wanna ask these questions and in all the most important thing, especially in elderly um is a long in standing BP. You'd be surprised how many patients have got pressure or hypertension and especially patients on um antihypertensives. So they say these on bisoprolol and Ramipril with which both drop the BP. Anyway. Secondly, you wanna rule out is a bleed. So ac uh a head bleed. So you wanna do a CT head straight away, especially if there are blood thinners. Um And here in this lady, she has got urinary frequency. So you wanna rule out a uti but also urinary retention. So you wanna do a quick bladder scan and generally when examining falls in a um like a falls review or you're doing the falls review, an elderly patient, make sure to always palpate every bone starting from head to toe, including shoulder hip just to make sure that you're not missing any broken bone and have very low threshold to x-ray, x-ray any bones. Um if tender in diabetics, make sure that you do a neurology exam including sensations just because they are a high risk of preferred neuropathy. Um and that may be why they're having frequent falls. Um Don't forget about seizures, obviously. So any tongue biting, any waking up. Uh So questions you should ask is um did you wet yourself waking up? Not quite sure what happened, any bruises around the arm that were unexplained. So on and a quick overview of falls you wanna think about, as we spoke, injuries, causes prevention in the setting. With the setting you wanna involve OT and PT straight away just because they, they're really he helpful in these situations. Um They provide equipment but also make sure things like lead to a to make sure that the patient has got the right equipment at home to prevent further falls. And as always, analgesia make sure to give them adequate painkillers, especially if they've got bruises all over. And, uh, with elderly, make sure to be prescribed cause a lot of the medication has anticholinergic effects. And you just wanna make sure that you're not causing these patients to go drowsy by giving them these medications. I think that's it for me. If you guys got any questions just I'll drop it down and chat. But, um, moving on to that if you wanna take over. Ok, guys. Um, so go through the next, next scenario. Uh, so this is scenario three, Mr Singh, he's an 81 year old who was admitted to ed with fever cough and what appears to be a new confusion. Uh So on the history, he's obviously confused, he's unable to give a clear history of his, of his symptoms. Um, however, he has come in with his daughter, uh, luckily, which is helpful for you. So you get a bit of a history. So, uh, she tells you that he's had a five day history of just generally feeling unwell general malaise, um, a cough, um, productive of some yellow brown color, sort of sputum. He's been getting a bit more short of breath than normal recently. And obviously he's got this sort of confusion which is unusual for, for him. He doesn't have any, uh, nausea and vomiting or any, uh, urinary or bowel changes. That's his past medical history there. He's on, obviously a lot of medications being a fairly common 81 year old. Um, and his uh social history, he lives alone with no package of care, um, non smoker and not, not, doesn't really drink. So his examination findings are there. So we've got a high new score of 10. So he's got a high respiratory rate of 30 uh saturations of uh 96% on 2 L of oxygen at the moment. He's got a BP of 92/58 and he's tachycardic at a heart rate of 125. He's also got a temperature of 38.7 as we've got the rest of the examination there, he just generally appears unwell. It's a good, obviously a good um method for, for you guys as F ones, you know, just to sort of look at patients, you know, end of the bed gram, see how, how they generally they look and this guy looks clinically clinically unwell. He's got dry mucous membranes, he's uh quite cool peripherally with a a cat refill time of three seconds. Uh He's got an irregular pulse, um, sorry, regular pulse, er, not irregular um, with a heart rate of above 100 though. So he's quite tacky. Um, he's got also quiet breath sounds when you listen to his chest. Um, he's got basal creps on the right side. Um, but his abdomen is, is soft and non tender and his calves are soft and nontender. Uh, he done an E CG which has shown uh sinus tachycardia only. Uh and you've got his blood results there. Um So going through that, is there anything that jumps out at you or any uh further investigations that you would like to do? Uh for, for this, for this gentleman? Obviously, you've done a full set of bloods there and you've done an E CG um considering what he's come in with and his and his bloods. Is there anything like you say, any, any other investigations that you would do if you were asked to see this, this, this man? Ok. Yeah. So we've got a chest X ray. Yeah, that's great. That's the, that's the main one, obviously, his sputum as well. That's a really good shout considering he's got um that's his chest X ray. Um I'm just having a look at some of your other comments. Yeah. ABG that's that, that would be a good idea in this, in this patient. Definitely. Um You would consider antibiotics especially. Yeah, considering his his CRP and white cells. So that's, yeah, that's his chest X ray, which you've got um it's quite a good um good film. What do you think of, what do you think of that? So, obviously, when you first look at x-rays? Yes. So let's have a look. So we've got uh yeah, there is, there is, that's the main of, of uh abnormality is that consolidation in, in the right sort of mid zone as, as, as you say, um obviously, it's important, you know, when you're looking at chest X rays, just don't, obviously, that's the clear abnormality that um is the case in this, in this patient, he does have an um a pneumonia, but it's important when you're having a chest X rays not to just focus on that have a proper look at the whole X ray, make sure that there's no, you're not missing anything, you're not missing a pneumothorax, you're not missing, you know, anything else, anything else that's relevant, any other masses, any sort of air under the diaphragm. If there's any, you can have a look at the costophrenic angles which appear to be uh OK. In this, in this instance, there's no sort of pleural effusion also having a look just to make sure again, if you have a look at each rib, just make sure that there's no obvious uh fractures there and have a look at the clavicle. Let's see if there's any fractures there. Um And have a look at the heart obviously as well. Is there any obvious cardiomegaly have a look if this is a AP or a PA a film? Because if it's an AP, then the, the heart will look bigger than normal. But you can still see if it's, um large and yeah, just have it, make sure that you're not just focusing on, on one thing. Also forget having a look at the trick here as well, seeing if that's deviated. Um So there are lots of different sort of systematic ways you can go through chest X rays and when it go into the detail of those, but there's loads on sort of the g geeky medics and things like that. But obviously try and find your sort of way of having a look at a chest X ray to make sure that you're not missing anything because that could be, you know, a fairly common mistake as if you see any, the obvious abnormality and don't check for anything else. So make sure you have a look at uh everything really? Ok. So that's the x-ray, any other uh obviously any any other investigations that we would do. Um uh you guys have said pretty much all of them. So this, this patient's coming in with some signs of a chest infection and some signs of infection on his blood markers. Obviously, again, he's got a sign of a chest infection on his X ray, but that doesn't mean that he might have uh infection in the urine or uh any other source. So it's important to do just your basic. So, yeah, do your, do your urine dip? Have a look for um, any infection there also, do your ECG have a look to see if he's got any af that could be sort of um, you know, going on at the same sort of time. So, do, do all the basics of, yeah, we've got urine dip, urine antigens, EC G A BGI think someone did mention would be important in this gentleman just to see um their oxygenation basically just to see if they are in type one or type two respiratory failure. Um I'll just go through that a little bit now. So type one respiratory failure, I'm sure you, you guys are aware is um where you have um poor oxygenation. So you have um low um blood oxygen levels and then type two respiratory failure is when you have poor oxygenation. Uh and also uh raised CO2. So you're not big, not able to blow off the CO2 basically. Um So that's why uh ABG is important because um compared to VBG is because an ABG will be able to tell you the actual oxygen um sort of uh perfusion that this, that this gentleman's getting in terms of the bloods. We've already done the CRP, which was really high uh using these N FT S FBC clotting probably wouldn't be um the first thing that you would do in, in this patient, but it's, it's good to just have a baseline clotting to see if uh for future sort of investigations or future managements. Um I think we mentioned blood cultures as well. So obviously this patient is coming in. He's unwell, he looks unwell from the end of the bed and you've done some bloods which have shown some high inflammatory markers suggesting he might have some infection. So, in any of these patients, the first thing you should be thinking and doing when you go and see the patient is you would do your A three E but also do the sepsis six at the same time. And I know we would have told you about the sepsis six loads and loads and loads of times. But it's just really important not to forget it because um, you know, the, that's, that's, that's, that's why it's there that you don't miss these things because obviously patients can get really unwell really quickly with it. So it's one of the important things as an F one is if you see a, any patients who you think, could this be infection, could this be sepsis? Always ask yourself that question. Even if you know, they've come in with something else that's not, you don't think is really relevant. Always ask yourself that question. Uh Could they be septic? And if the answer is yes or I'm not sure, then do the sepsis six. Um So yeah, II won't go through that in detail. You obviously, you know the sepsis six, but just make sure you do it um other things in the management with this patient. So yeah, just getting, getting oxygen. So that's another thing with the, with the ABG as well. So you need to find out in this patient. Are they um do they have sort of chronic c ot retention? Do they have C OC O PD? If so, they should be on uh scale two on their uh oxygenation? So you should be aiming for um lower sats 88 to 92 in those patients. So if they have a diagnosis of CO PD, then then you can, then you can use that or an ABG would be really helpful um just to see their CO2 and also their BICARB to see if they have shown any evidence of chronic CO2 retention. Um So then you would have a lower sort of target saturations for these patients and it's really important as well that you inform the nurses of um or make sure that the nursing staff are aware of if, if patients are scale one or scale two because I've had lots of instances where we've over oxygenated patients, where potentially the communication between medical team and nursing staff isn't, isn't good enough in terms of what target saturations we're going for. Um We might say in, in your medical plan to try and wean them off oxygen. Um But it's important that you have target saturations for, for the nurses to, to, to sort of aim for because quite often I've had patients who are um you know, nurses are aiming for 98% 99% of uh oxygen saturations when they really shouldn't be. And we've been over oxygen, over oxygenating these patients and obviously, that can be quite dangerous in itself. Um So make sure that that communication and that documentation is, is really good. The other thing with the, with the management obviously is is antibiotics. So do you know anyone of any sort of scoring systems you would use to help you decide what antibiotics to, to give or to help you decide how to manage patients with pneumonia in general? There's quite a good scoring system that I'm sure you would have been aware of or told of previously that would be really useful in this case. I'll give you a clue. So he had a lot of the parameters that you look for in this criteria. Um He did have in the history. Yeah, C 65. Yeah, well done older. Um So I think, yeah, this gentleman was confused. He had a urea above seven, I think it was, it was much higher than seven. His Respi rate was 30. So that scored a point as well. His BP was low. So the BP is either below 90 systolic or below 60 diastolic, we'll score you a point there and obviously being over 65 as well. So I think this guy's is scoring on everything on the C A 65. So he's a pretty um unwell, unwell chap in, in, in that sense. So it just helps you to sort of identify patients who particularly who could potentially go home with oral antibiotics. If they're scoring a 0 to 1 or if patients are scoring three or above, for example, then you're more likely to consider IV antibiotics. But as an F one, you know, you can do the scoring system and you can get all the results and talk to your senior and then, then your seniors will help you decide sort of um the management for the patient really. But you can sort of make those plans yourself and then just double check and say, you know, I think this patient should be, you know, treated with IV antibiotics and then that, which this patient should be obviously. Um And then you can just use your local guidelines. So I assume that you guys use micro guide, I assume you're aware of that. It's a, it's a really helpful app. I would um encourage you all to get it before you start and have a look at the different um antibiotic guidelines that your trust will have. Um So yes and make sure you, you, you know, basically what, what, what's, what's recommended in, in your sort of area. So, um, for this patient with a high, a high curb score and, uh, obviously come in with a community quiet pneumonia, there'll be a, a set sort of, um, guidelines to go through and obviously double check again, you know, allergies and things before prescribing any of those things. Um, does anyone have any questions about this case? I mean, it's a pretty simple, um, case of pneumonia at, at, um, obviously people can get really unwell with it. Ok. We'll check this out if you do have any questions, just put them in and we can answer them at the same time. That's not a problem. So, if we move on to the next one now, so it's scenario four. So we've got, um, Miss Williams, she's a 21 year old woman who was admitted to the emergency department with severe wheeze and shortness of breath. Um, so going into the history that you've taken, so she's got a four hour history of severe wheeze and shortness of breath. She doesn't have any fever or any chest pain again. No urinary or bowel changes. Um, obviously, um, importantly, she does have a past medical history of asthma, which she takes, uh, Ventolin inhalers, er, and also P RN steroid inhalers as well. Uh, and she's also on, um, Montelukast as well. Um, syp, um, social history wise. So she just lives in, er, student halls, nonsmoker, uh, minimal, minimal alcohol. Obviously, it's important. I know, we've discussed earlier with the social history and asthma, um, look for specific triggers. Is it work related? Is it pet related? Do you get symptoms when you go to certain places? It's important to ask these sort of things, um, especially in, in the history, just be, be thorough with your histories and get all the information that you could possibly need. It's really informa really useful as well for other people that further down the line if you've got a really good history and when you, when the patient is clamped in, so then, yeah, on examination. So also using quite high, I've been using of a seven. So that's mainly because of the high respiratory rate. Uh Her saturations are 98% but she's on a 15 L um non rebreath mask at the moment. So obviously, she's going for that uh slightly low BP of 111 8/62 and heart uh of 126. So she's quite tacky as well, but she's alert and she's Afebrile. And again, just looking at her at the end of the bed, she just appears unwell. She doesn't look like um she should be at home, she looks like she needs to be in hospital um and er pulse is regular, which is uh good volume, heart rate again. Yeah, over 100 on your examination, but heart sounds are normal. She's warm and well perfused. Um but she's unable to complete sentences when she's talking to you cos she's so out of breath, she's got increased work of breathing and she's got a wheeze polyphonic, wheeze as well. So multiple um, sort of um, auditory uh wheezes throughout the chest and no obvious crepitations at the bases that you can hear. Um But in abdomens again, soft and tender bowel sounds normal, calve, soft and tender again, it's really important to, to not miss those sort of things in your examination of everyone just to make sure, um, you know, you're looking for important things there. So don't sort of, um, forget to look at the legs, for example, in, in all your patients is really important. So we've got some investigations here. So, um, we've done an E CG which shows sinus tachy. Um, and we've got some blood results there which are um, very difficult to read, but we've got uh a normal HB of uh, 125 C RP of seven. Um, his ee knees are normal LFT S are normal and we've done an I NR as well, which is one and the white cells are 9.8. So again, in this case, is there anything investigations wise that is jumping out at you or anything that you would do as an F one in terms of what investigations would you like in, in this patient? So, yeah, thanks. I go. Yeah. So we've got peak flow which is really, really good. Um, obviously a lot of patients with, with asthma will have their own sort of peak flow. Um um they'll, they'll bring their own with them or you might have to get one for them. Yeah. ABG and an X ray. I mean, the, the BT S guidelines actually say that you only, you only really need to do an X ray in people with uh who you think are coming in with an acute asthma attack if they've got sort of focal signs on their uh examination. So any sort of focal consolidation that you're thinking chest X ray uh that you're thinking sort of pneumonia or anything like that. But I think in, you know, as an, as an F one and in, in my position, yeah, you would definitely get a chest X ray for this, for this patient just to look for any other things you don't want to be missing any pneumothorax, for example, which could be, which could present fairly similarly with, with the young patients coming in with shortness of breath. Um So yeah, that's the chest X ray there. Um And we've also got uh some ABG S as well. So if you wanna have a look at this on the left, so we've got an ABG on the left for on arrival and then um shortly after say an hour or two hours later, we've got um a more up to date ABG. So is there anything again either in the x-ray or the ABG that screams out at you. Anything that you're worried about, anything that, or again, any other tests that you would like to, to do? I know it's a bit difficult. We haven't given you the normal ranges here for the, for the ABG, which you'll get used to really quickly if, if you're not really that familiar with them. Um, as soon as you, as soon as you look at a few and you sort of, do you spend more time on the ward? And you, you know, you do have a look at lots of ABG S and BBg S that people, you know, hand in your face so that you will get really used to the, to the normal ranges. Um So I think the main thing, so firstly, let's just have a look at the, at the X ray. Um So this is of a, of a young uh young lady who's come in, obviously, the first thing that you're thinking of is you, you go again, go through your systems. But the, the worst thing is that you want to rule out a pneumothorax and you can have a look and you can see that there are, you can see the lung markings throughout the lungs. There's no obvious pneumothorax there. I know it's quite a small picture. So you'd have to look at a little bit in more detail, then you'd look for any sort of focal consolidation, any signs of any um any uh infection anywhere or any fluid in the lungs at all. And then you would have a look at the bases as well at the um costophrenic angles to have a look to see if there's any um sign of any um pleural fusions, which there isn't. So that X ray is, is, is fairly normal um going over to the uh ABG S. So we've got the ABG on arrival, which has a PH, which is slightly alkalotic of um 7.4. It's the range of 7.35 to 45. And then the PH is um become a lot more acidotic uh over time, which you're sort of worried about isn't actually below 7.35 is, is the threshold for um um being acidotic, but it's, you're, you're obviously worried about that and the, the main reason is the CO2 is going up. So this is a, they're developing a respiratory acidosis. Um Also another thing that you're worried about is the uh oxygenation. So obviously, starting at 10 and then going up to 26 this lady's on uh 15 L, non rebreathe. So you, you're worried obviously in the acute setting, giving people 15 L, er non rebreathe is, is sensible in, in, in this case because uh hypoxia will kill you quicker than anything else. It's important that you make sure that they're not hypoxic but always have it always have in the, in the back of your mind. You know, are we over oxygenating this patient, should we be trying to wean down their oxygen again, aiming for sets of um 94 to 98%? Um And make sure you have a good trace either on a finger or, or ear. Um So you have a good sort of reading to, to make sure that the nurses are, are aware of, of what oxygen saturations that you want. Um And obviously, yeah, so we've um the F IO two as well as the fr fraction of inspired oxygen is 21% on arrival, which is just the um obviously normal in air and then uh 60% is through the ventura, which we've, I assume now put onto ventura, not a non rebreathe, but you're still worried about. So we, we have weaned our oxygen down from a 15 L to a vur 60 but we just need to have that in the back of our mind. Don't wanna over option over ate this patient. Um OK. And is there any anything else, any other investigations that you would like for this patient? Anything that um or if any, if you have any suggestions on how you would like to manage this patient, then, then go for it as well. That would be good. So I don't know if you've been told uh or you've, you've heard of the different sort of um severities of acute asthma attack. It's really important that you define how severe this asthma attack is because that will change your management and there's some really good, really easy to follow sort of um guidelines on BT S or on the Resuscitation Council. So BT S is the er British Thoracic Society website. So if you just type in acute asthma BT S guidelines, you have a really good flow diagram of exactly what you need to do. Um So yeah, thank you all. So yeah, you got some, some on 5 mg. Yeah, that's great. Er Nebuli and also Ipratropium 500. So yeah, even though the dose is, which is, which is really good. Um er, definitely, but you know, those, those um, guidelines and those um flow charts are, are there to use and they're really quick and easy to get up. So, you know, if any, if any, any of you are worried or you're not sure what dose to give then just even if you are sure just, just get up the guideline is really easy and really, really simple and you can just basically follow it in um, and you don't have to, you don't have to worry then really. But just so, you know, obviously it's important just to have that, um, idea of what you're doing. So, yeah, investigations again, you know, you, we would do an ECG on this patient because we need to rule out, you know, are they n af are they, um, you know, common things are common? So, just do a, do a baseline ECG is really important. Serial ABG S as we've done spirometry, probably not in the acute setting straight away in the emergency department. But it's important to sort of consider that potentially, you know, once you've treated the acute exacerbation to see um how bad their asthma is and things like that and what sort of outpatient follow up and things that you need to do bloods, uh which we've done, I've done the chest X ray and we've talked about oxygen and thanks. Yeah. Although you've, you've mentioned basically the management is um, II assume you would have heard of the, er, oh Ship Me, uh mnemonic as well. It's a really, really helpful one just so that you guys can just think of that straight away. Um, and just use that to help guide you. And the most important thing is oxygen. You know, if that's, you know, if you do anything as an F one, make sure that the patient is got the, you know, oxygenated and, and not hypoxic cos that will, that's what's gonna kill them. Um And then you can start salbutamol basically and it depends on how, how bad the asthma is, how, er, cos there's different categories which we'll go on to on the next slide. But you would start, yeah, with 5 mg of, of nebulized salbutamol driven by oxygen would be best, there's different ways of giving it so it can be, you can drive it through the nebulizer with just air or you can use oxygen. So it would be best normally in patients with acute asthma attack to, to drive it through oxygen. Um and then you can give that and then you can see basically what the response is and you can see you can repeat the salbutamol uh 5 mg within sort of 20 to 30 minutes if they're not improving. But again, the most important thing is, you know, you can start the initial management as an F one and you can start, you know, you can prescribe this salbutamol and you can prescribe the oxygen and make sure that they're, they get there cos that's the, the, the, the two things that are the most important. But then once you've done that, it's really important to escalate to your seniors because acute asthma attacks in, in young people, you know, can be, can be fatal and it is common quite, quite commonly, it is fatal. So um don't want to scare you guys, but just e even in patients who you think, oh, you know that they look fairly well, they're a 24 year old. They shouldn't be the asthma shouldn't be that s severe, but they, they can, they can get really unwell really quickly even if you don't think that that, that they look that unwell when you look, look at them from the other end of the bed. So just always escalate to, to seniors and make sure you're doing the right things. Um And yeah, so yeah, we talked about steroids so you can either use oral steroids, prednisoLONE or hydrocortisone IV. There's, I don't believe there's actually that much difference in terms of a fixity or evidence between the two. Obviously, if they are vomiting, for example, or not able to take tablets down, um then that would, would be an indication to go IV, but you can, you can use prednisoLONE quite well and it does the same sort of job. Um So yeah, and we, we talked about if you go on to, on to the next slide. Um OK. Does anyone have any questions about that at the moment? So, yeah, the, yeah, there's no questions. OK. So yeah, the, the main, the main thing that you need to do with the National Attack is to have a look at the severity. So again, on the BT S guidelines, there's a really good flow diagram. This is taken from the BT S guidelines which just um outlines the severity. So you can do this mainly on the peak flow of their um best is, is the best is best. So if you do know their peak flow or ask them their peak flow, what's normal for them, it's really, really useful because it, it's important to sort of know what's, you know, what's relative to them basically and it can help um it can help you in, in their management a lot. Uh, and there's lots of other things that you can have a look at, the main things to look at for life threatening asthma is if their, um, oxygen sats are, are lower than 92. For example, if they're, um, partial pressure of oxygen is below eight. If they're altered conscious level, if they're starting to show signs of exhausted, but always got a bit of, uh, exhaustion. Sorry. Um, also if they've got any arrhythmias, hypertension sinos and also if you listen to their chest, er, li listen to their chest and it's, it appears silent. That's a, a really bad sign. So you, you need to sort of escalate this to your seniors and if anyone with any signs of life threatening asthma escalate to your seniors, but also don't be afraid to get ICU um, or yeah, itu or, um, med reg in, in involvement in, in these patients. For example, if you, if you're unable to contact your sho for some reason if they're out in surgery or something or either they're difficult to contact, then really don't be afraid to call itu um, and get someone seeing you to have a look at this patient because they, like I said, they can deteriorate really quickly. Um, so, yeah, this is, this is the, um, resuscitation guidelines, er, from the Resuscitation Council. You can, can use this, I mean, I would probably use the BT S guidelines myself but this basically has exactly the same information. It's just slightly slightly differently organized. So we've gone through everything. Yeah. So, um, basically the most important things from an F one is to start oxygen and, and salbutamol, um, and then get senior review and then if that's, if your treatment isn't working, then that's when you need to start repeating salbutamol nebulizers, give steroids and have a low threshold for getting, uh itu staff involved. Ok. So we'll just go through the last scenario quickly. I know, sorry. Um, almost eight o'clock, but we'll just go through this one nice and quickly to let you guys go and um, or do whatever you like to do. So this is um Mr Johnson, he's a 19 year old man who's admitted to the Ed with er, confusion and shortness of breath. Um So he's again, unable to give a very clear history because he's uh that confused, but collateral history reveals that he's had a four day history of worsening nausea and vomiting and generalized abdominal pain. Generally, generally not feeling very well. Um and also a further two month history of just again feeling unwell, lethargy and weight loss. Um, he's had no fever, cough, chest pain or any bowel changes. He's normally feeling well. He has no um, no normal medications and he just lives with it. He lives with his mum as a, as a 19 year old again, he's using fairly high at six. So that's, of course with a raised respiratory rate at 28. He's got uh low staats on air of 94%. He's also got a low BP and he's tachycardic. He's obviously confused and he's um got a temperature of 37.5 as well. So not, not too high. Um He, he plays, he appears clinically sort of unwell again from the end of the bed. Um and he's got increased work of breathing your examination. His chest is clear and he's got a good, good air entry and his abdomen is soft again and calves are soft and nontender. So we've got a few um investigations there. So we've done an E CG usually shows uh sinus tachycardia and we've got some initial bloods there as well. Um Just having a look through. So you've got ACR P of four. So just normal um sodium is uh 137, potassium is low at 3.2 but his LFT S are normal and his white cells, white cells are 9.2 and his uh HP is normal as well. So again, is there anything that's jumping out at you, um, investigations wise or management even? I know we don't have a huge amount of time. But is there anything that you guys, what do you think is going on basically, or is there any other further test that you would like to do just to, just to find out, give you a little bit of time Yeah, but Lyco is really important. It was a great shout. Anything else you would do with that related to the glucose? Yeah. Yeah. Thanks Lauren ketones. That's the, that's the main thing. So what we're thinking in this patient, obviously, with a two month history of lethargy and weight loss, we're thinking, could this be an early presentation or the first presentation of uh diabetes? And, and obviously, in this case with this patient, we need to think, could this patient be in, in DKA? Which is why we're doing the ketones. Um So again, there's um we'll have a look at. Yeah, so this is this patient is, is in D DK A. So we don't have a a ketones example for you, but anything above three is, is abnormal. So again, yeah. So in, in the investigations we wanna do in this patient. Yeah, the main two things are BM and ketones also do just do the basics as well. We'll do a urine, do, do an E CG um probably a chest X ray. Yeah. So we we'll do a chest x-ray as well and just do normal bloods. And again your hospital make sure you guys are aware of your hospitals like sort of local guidelines or your sort of um protocol and guidelines where you get that from, whether that's on the internet or um because there will be somewhere a guideline for DKA, which will be again, a really good performer of exactly what you need to do, what timings and everything. So when you get to your, when you get to your hospitals, just familiarize yourself with the local policies and the guidelines and where you would find those because, um, you know, sp specifically for ours in, in Somerset, you know, our system was, was pretty horrendous. So it just basically didn't work to find any of the, um, it's, it's better now but it used to be really, really bad. Um So it was just really difficult just to find any of these guidelines, but it's important that you're able to know how to, how to get them because in that situation where you've got a patient who you think could be in DK and you're worried about them, just get the guideline up as quick as you can and just follow it and, and involve, again, involve your seniors. Um So the main sort of main points of management uh are obviously just um doing your ABCD again, making sure that you've, you're not missing anything, getting uh fluids in really quickly for this patient. And they, they need, obviously, um people in DK could be quite often really fluid uh deleter, they could, they could be like five or 6 L sort of uh in fluid sort of deficit. So you really need to aggressively fluid resuscitate them and again, just follow the, follow the guidelines, follow the protocol. It is really helpful. Um Obviously, this patient did have, um, was, did have a slightly low BP as well. So again, if, if the, if the BP is low, then you would likely give the first bag of fluids much more quickly, for example. Um, so you would quite often give, you know, a liter over, over the first hour. Um, can be. So, yeah, this is, um, this is basically the protocol that we have in the or in peninsula. So they, they'll, they'll all be very similar and they'll all, you know, sometimes they'll be on paper forms, sometimes they'll be on online, but it's just really important that you, you know, where to find yours so that you just can follow it and not be worried about it and just say, OK, you know, you're, you're confident in managing in this patient because you've got a protocol to follow. Um the other thing with TK A the most important thing is obviously you give them fluids and you give a fixed rate insulin infusion again. You don't really need to worry too much about that because it's, it's all on the proform. You can prescribe it quite, quite easily. Um Just to familiarize yourself with the performer. Um and nurses will be able to um give the, the insulin as per the, as per the performer, it's basically done on the patient's weight. Um And then you can start doing that. Is there any anything else that I've missed? Do you think in, in the management of, of DK A S, we've said fluids, we've said insulin. Is there anything else that we need to be wary of or need to watch out for in, in patients with DKA? Sorry, I know, I'll, I'll, this is the last question I'll let you guys go in a minute. Ok. It's, it's potassium guys. So you really need to be careful of, um, both actually hyper and hypokalemia in, in these patients. So, quite often they're presenting with DKA, they can have hyperkalemia when they first come in. Um So you need to be wary of that and then um and manage that accordingly. But obviously, when you, as soon as you start prescribing insulin that causes potassium to um go from the extracellular space into the intracellular space. So it can rapidly reduce your um serum uh potassium. So you need to be sort of really careful of that as well. So, um again, it goes through it in the performer as well. So you don't really need to worry about it too much, but you just need to be able to check the potassium levels um regularly. Either that with um PBG S would be the easiest way to do that. Um And just again, just make sure that you're not um because that can cause obviously arrhythmias and cardiac issues if you're getting severe hypokalemia. So, um again, just basically regular monitoring and, and make sure that you're aware of these things so that you don't. So, you know, you know, where to find it again on, it's, it's all on the performer. So it talks about the insulin and talks about the fluids, it talks about potassium. So, um quite often you'll give potassium replacement in the fluids as you go down. Um And you would just titrate it to the potassium level, obviously, of, of the patient. Do you guys have any questions about DK A at all? Um Anything you're unsure about any worries? Um Always, you know, we'll be here for a, for a while. If you, if you have any questions, you can message us or you can, you can chat. So just while you guys are putting it in the chart, just a quick summary, always stick to the your system and make sure to call patient in a systematic way. Um And we, they dig it into us through medical school. So don't forget it as an fy we know that you're quite pressurized, but um do not forget your system and just as Matt said, take a really thorough history and make sure you come up with at least three differentials, uh do your initial investigation bedside and that's the least you can do and then do imaging. Most patients who come into hospital have got a chest X ray. So it's not a bad idea to get that. Um And just make sure it's clear as many patients as possible while being like final years because that gives you a lot of experience going to F one and it really does help. Yeah. And the best way to learn guys is to, you know, it's like we say is to clap patients yourselves and get into that mindset of, you know, problem solving yourself and trying to come out, come out with a differential diagnosis and a management plan because if you get it, you know, terribly wrong, you know, or something, then, then that's the best way to learn. You know, you, you, you learn the best way from, from your mistakes or from the things that you didn't think about. And then, you know, when you actually have that patient in real life, you'll remember those situations where you've, you know, forgotten something really important. You know, you might have forgotten to check the ketones for the DK A, for example, you, if you make that mistake once you'll never, you'll never never make it again. So it's best to try and make these mistakes as, as medical students, I guess. And then obviously, um obviously learn from them. But um the main thing to avoid those mistakes again is making sure you get a thorough history. And if you're unsure at all, you know, if there's any, any seed of doubt in your, in your mind, if you think, oh, should I should I do this? Should I prescribe this? I'm not sure. Then just, just talk to your seniors because generally they'll all be so nice and they'll, they'll be able to help you. And if, if you, you know, there's no, like, again, just, just running, running stuff by them, even if you think, oh, you know, this is, this is obvious, just run it by them and say, is there anything else I should be doing? Um, and they'll be really happy to help. So, yeah, if, if you're, yeah, just, basically I talk to your seniors. If you're at all worried, don't, don't make decisions that you'd feel uncomfortable with. That's the main thing really. Don't, don't sort of think that you're on your own because because you're not even if you know you're struggling maybe to contact your sho then go to, then go to your next, next level up or even talk to people in different teams or just if you're unsure, just, just talk to someone, someone will be there to help you. Yeah, if you, if you guys do have any questions about um medical take shifts or anything that you're sort of, you're not sure what it's gonna be like or um any, any worries then yeah, just drop us, drop us a message or, or just um let us know. Um I don't think I see any questions in the chart. Um If that's the case, then thank you guys for coming in and please fill in the feedback form because it does help us improve the upcoming sessions Um And yeah, we've got several upcoming sessions so please join us for these as well. Thank you.