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Perfect. Hello. I've forgotten how to do this. I got um for the people that are here. Um Thank you for joining us. Um We're gonna do a session on um emergencies. So we're gonna go through five cases today. Um You guys have the option to turn on your mics and and cameras. Um We'd love it if you guys would interact with us. Um and then obviously we're gonna have sections that that just have questions um and then we're gonna put out a poll for you guys to answer and then we'll go through everything but feel free to to turn on your mics. Um plus minus cameras. Yeah. Let me know if you can see this if you can see my screen. So yeah guys let us know if you can see it. Mhm. Ok, cool. So Paul can see our screen. All right. Mhm. So guys, obviously you can always use the chart as well to to type in anything while we're going through the the slides as well. OK. That all right. Should we should, should we get started and then people can just join in throughout. Mm Yeah, let's start now we start now. Yeah, and you're happy with that. Ok. That's cool. All right guys. So again, welcome to, to this session. My name is M Moon. Um I'm an F two at any age and we've got our other presenter. She, she's also um an F two at any age. Um So today we're just gonna go through five cases of uh emergencies that, that kind of commonly come up in, in exams. Um If you guys have any questions, um, if, uh, you know, but if you'd like to interact a bit more, feel free to turn on Mike's cameras and then obviously you've got the chat as well. Cool. So, we get started. All right. So for the first case, we've got a 5058 year old male who came into the Ed Department, uh, with intermittent central chest pain for the past 12 hours. Um, the pain is squeezing it radiates to the left arm and jaw. It's associated with nausea, dizziness and diaphoresis. Um, he had an episode while going up the stairs and another one while while watching TV. Um, the episode resolved with the GTM. Um, he doesn't have any history of the infection fever or previous coronary interventions. And then on the right side, we've got his past medical history, hypertension, diabetes, hyperlipidemia and medication. Um, he's got a 40 pack year smoking history and he work, works in an office. Um, and then we've got his abs, um, when he first came in and then on examination, his heart sounds are normal. Lungs are clear bilaterally. So we do an E CG and this is what we get. Does anyone, would anyone like to, to volunteer to take us through the E CG? All right. At least tell us what they see. You can type it in the chart as well if you'd like. Yeah. Mhm. Ok. So, on the E CG, um, we've got ST elevation in a VR and then widespread um ST depressions on further investigations, we get a troponin which is 14. Um And then a chest X ray is clear, normal. Um A point of care, ultrasound shows a normal left ventricle function. So for the first scenario, what is the most appropriate next step? And then can we put a poll for the first question? I, I've got two responses so far. I'll try to give you guys a minute to, to answer the question. It might have been more than that for now. Sorry. Yeah. So half of our audience have answered so far. I know. Yeah. OK. So the majority of people want for um E use GPN, we get testing and monitor the patient overnight. Um But then the correct answer in this scenario would be a repeat troponin in three hours. And then why is the the correct answer? Um So a repeat troponin in three hours is the correct answer because a CS cannot be ruled out from a single normal troponin um guidelines recommend um serial troponins. So repeat after three hours um to kind of see the pattern of either increasing troponin levels or decreasing troponin levels. Um And then this will usually be associated with dynamic changes on ECG. Um So um an an you could start off with a normal ECG that then turns into T wave inversions like we saw on the previous one. these T wave inversions could also turn into ST elevation um which would um diagnose a stemi. Um And uh you'd always have to, to kind of repeat the troponins. So, serial troponins and ECG S to, to kind of further guide your treatment options. The next slide please straight. And this is just a quick revision slide about which leads correspond to which territories you can, you can always go through it whenever you would like. Um And then the management for a suspected antemi. So initially, you would, you would get a baseline troponin level with um ECG um you would repeat the troponin levels at three hour intervals. Um And then obviously, if the troponins have been negative, um the pain history is atypical, you'd start considering alternative diagnosis. Um So some, some things you might wanna consider are costochondritis or um um an aortic dissection, for example, um because you could have mild to moderate troponin elevations with, with uh a dissection as well. Um And then risk stratification, you've got the grace score