The A-E Approach for an Out of Hours F1 - Part 4



This medical teaching session is designed for physicians to learn more about managing common medical issues in rapid succession. It will cover topics such as diagnosing differentials, thinking about the clinical picture, getting proper information from nurses, anticipatory management (e.g. calling for help versus getting medical advice), and being able to interpret diagnoses and chest x-rays for real case studies. It will be a productive and interactive experience.
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Learning objectives

next section. Learning Objectives 1. Recognize the signs and symptoms associated with potential pneumonia and congestive heart failure. 2. Use clinical guidelines to determine appropriate management for a patient with tachycardia. 3. Identify the essential diagnostic tests and assessments needed to evaluate a patient with tachycardia. 4. Interpret the findings from an ECG, a chest X-ray, and lab results to make a diagnosis. 5. Utilize appropriate treatments and interventions for a patient with tachycardia.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

So you guys, it's quick fix every time. Now it's only take 10 seconds while this goes down. Someone else put something in the chart. Not sure. Goods we've got possible possible pneumonia was to acquire these clover to seven days. Now could you have congestive heart failure? Could you have a P exactly So good. So a lot differentials and some of this information we're going to get for our Italy and some of it Actually we need to do a bit more digging and think about the whole clinical picture. But the point of that something is actually a the moment. Do we need a diagnosis? Know, because we're going for Rytary. We're dealing with our with our problems here. Some of the things that I've gone to a day seven crave it. It might. It's probably just the progression. You could have A P, and we're going to think about is antique around. And maybe once he's off off CPAP and often five, maybe we'll put in for a CT K can't really do a D dimer because he's got Covina against behind anyway. It's not sickly useful. Could he obviously printed bacterial infection goods? Chest X Ray to see if we've got any consultation and maybe we can have a look at the blood. So if we do them later or three days, but again, once we finished our rate away and see if he's got a neutrophilia, um, has he got a new month or it's We've got bilateral chest chest expansion. We've got bilateral chair at the air. Entry is tricky, a central, so we think it's unlikely. But again, we're getting a portable chest X ray so you can have a look. There has got pulmonary edema while assesses C section and also the chest X ray is going to help. Good. So we kind of broadly down with this B. But it's going to need a bit more digging after to find a definitive solution. But the moment we're happy, that is maintaining his saturations. Although he's working hard and we've asked our nursing seen but potentially get CPAP radicals. We think he's going to need it once we've done an ABG for him and he's had a senior of you. For now, we're happy that it's stable, but he has big city. He's unwell when you need to be seen by someone senior. It does anyone have any questions about that section? Birthday was quite a sick patient, but I think we did no cane job with him. And he's safe for now. But needs needs a good looking either. Did I miss anything in the B section as well? We're going to shoot from quiets that we're happy. We don't have any questions. I think we need to get into our C section. Yeah, okay, let's move on. So let's look at Tony's tachycardia. So, Doctor, please, can you review my 65 year old patient, Tony. He's been treated for a pneumonia with intravenous antibiotics. It was well today by just text observations, and it's hard, right? It's 100 and 60 s. So if we're if we forgot our management of tachycardia guidelines, then click there. We'll take a picture of that and have a look at those, but putting the chance if we've got this cool. What information you going to directly asked that nurse now to assess whether you're the appropriate person to see this patient? There are several key questions that come to my mind. I think it's really important that we know about obviously Tony's 1 80 approaches one sixties quite high. Is that any ideas? And if no open at length, and in the meantime, I'm going to print on 10 years. Question for a surgical ward. When should we ask for a red for help versus medical Reg? I'd always are discussing your surgical register, but that's going to be seen by uh, by the medical team. Probably speaks your surgical risk. Start first and see what I see you. We'll see anyone anywhere. Good. So this looks my dear. Yes, just a new one. And we can answer any CG thinking again what we discussed earlier from me. Ask things from from our nurse and stuff before we go and see the patient. Just pain. Evidence of heart failure. Good. We're starting to think about the compensation, and if he's I haven't gotten another cardiac out the past medical history. It potentially, but we can have a look at that after any surgery done recently, again useful, but actually, it's not going to dictate. The question I'm getting at is whether this patient needs a gradual on. What we need to know is, has he got any chest pain as you got a signs of new heart failure. Is he maintaining cerebral appropriately? So is he conscious? Is he speaking to you, or is he getting a bit drowsy? We've said about chest pain, and there was one more I know. And obviously we need to ask about his BP, cause if he's dropping by pressure, that might be a patient that's heading towards a shock again. Not something for you to spend 10 minutes walking across the hospital to see when really neat people senior by the bedside immediately. But for birthday, all of these, the answer to all of these questions are reassuring. So it's not. No chest pain is about no signs of new heart failure at all. The sudden it up and he's speaking to me and it's BP is one oh, 5/65. So not great, but not often He's No, he's not one himself. A shot yet. Good done. A. We got to see Tony and we've done our to weigh on usefully. We've got some information from that already. So here's some key information. If we remember from the end over, he's being treated for a bacterial pneumonia so that probably explains that his saturations are quite good. Is a respiratory rate's good and he's only on well. He's on a moderate amount of oxygen, but nothing like 30 is not acceptable work of breathing. What are we going to look at in in Tony C section and we've already got one of them again thinking about are subjective, objective, actionable points you guys doing with work for me now? So this is fantastic for ensure Lansdale flare from Scotts up now. Yeah, get so they're We've got some objective stuff from Antonio BP. Completely real full time on pulse is we can think about temperature now if we want. Or if not, we'll put it in the D section. What about are subjective stuff? We got any subject of information we can get from our 80 way have recess so stuff. So what I'm going to do, I would probably have a feel of his peripheries and see if he's cool, because if he said, he might be warm. But if he's kind of help, it's dropped. You might have called peripheries on. We can do that while we're doing this capillary refill time, we'll probably have a quick listen to his chest is, Well, I good. We're looking at these in Sinuses. Will probably come in the beast section. Kind of might be useful with these Got reduced kinda help. But, for example, if he's anemic, but again, not necessarily something we'll do it with now on. We might have a look at his legs as well to see if he's got any office pitting get in terms of objective stuff that we haven't asked for yet what we did earlier. Obviously, this money's an EKG, and hopefully our nursing stuff already done it because we asked him on the actual points. At this point, we need to think about every needs, fluids. While I might be surprised toning well if we're thinking about this fluid chart, particularly if he's got quite a nasty pneumonia and any additional medicine or additional interventions. And this is what we've got for toning. So he's running at 1 60 exactly, so that hasn't changed since the last hand over. We've got an irregularly irregular peripheral pulse that's good volume for free, and that's his E C G. In the bottom of anyone wants their interpret. That for me, is BP is is okay, but no, amazing is urine output usefully is already in chances. Mills kicks per hour. And for anyone that doesn't know that's in keeping with an a k right if it lasts longer, nasty, really poor urine output, his heart sounds one plus two plus zero, but a regular. He's got quite poor crib, particularly refill time peripherally. And he's you know, he's cold and actually because we said earlier, So we're going to cannulas in, and we're gonna take offs and bloods things that you said earlier. So whether we want to use the knees, for example, what we wanna charges FBC every CRP, because he's got a tachycardia will probably think about a bone profile and a magnesium. A swell to see if they need to open up. Got a needle in And Mommy a cannula. Rent is that takes four. So that's quite high. His latest chest X ray. We had a look in the B section, but just for your note is the right lower lobe consultation. No signs of overloaded. That's good that we had a look at that there, but we could have had a look later. The alea s So what we're going to do for anyone that doesn't know that we have a patient in airflow. Fast ventricular response that looks like he's got a poor year in out, But he's cold peripherally and his lactate. It's probably in keeping with, um with, uh, dehydration. What are we gonna do? Think about 18. We've identified a problem, so we probably