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hijack. Are you all OK? Hi. How are you? I'm good. I'm good. Thank you. Are you Yeah. Yeah. So I'm going to just probably start around seven or five people in. Yeah, I'll just Yeah, sort of like at 702. I can just do introductions and stuff. So if you that's fine. If you could share your slide, so I'll just ask you to the press next. Let's just pause the recording while I'm talking. Yeah. Hi, guys. Today's reading out by a certain medical series is going to be infectious diseases by our beloved Jack Wellington. If you're from Cardiff, you're if you haven't heard of him, I don't know what you're doing. Jack, could you go to the next slide? Sorry. Perfect. So, um, so far in the series, we've had your cardiology, respiratory, GII, neurology, endo, general surgery as well. So this is infectious disease with hematology. We just need to change that on the poster. It's not been changed. We swapped hematology in pediatric dates because the teacher for pediatrics, because it could only do that on that day. So make sure you join us for the rest of the series as you have been doing something because I know a few of you have started to recognize the bases. Please do fill out the feedback form that we sent around eight o'clock before you leave in terms of housekeeping. Any questions related to the teaching itself? Make sure you ask them in the queue and a section. Any other unrelated question. Just ask them in the chart function, and someone will be manning good chats to let you know if the reply is a bit delayed. But just there, with us also in the queue and a function, if we can't answer something, will redirect it to Jack and just a bit more about Jack. Then Jack is fantastic. He knows a lot about infectious diseases. He's always telling us some fun coolfax and he's done. He's done an embassy from the London Smaller Tropical Hygiene and Medicine, which is such a prestigious university, and he's got lots and lots of research papers. So if you need advice from him as well about anything about applying for MSC or just generally about how to go about brushing, you can message him as well. I'm sure he'll be more than responsive and you can add him on LinkedIn because we all know that from Arlington. So how can I not promote that for him? Um, so, yeah, I'll hand it over to you. Just wonderful. So thank you very much for having me today. I'm going to put the camera, so yeah. Okay, fine. So I've been asked pretty much to give an overview of what infectious diseases is and what will be tested commonly in the progress test. Um, as you can appreciate infectious diseases is quite a wide variety of things. It makes up all your communicable disease. So it's quite difficult to pinpoint exactly what we come up in the exams. But I will go through the high yield stuff which commonly comes. Uh um, so yeah. So, as I said, looking objectives there quite difficult purely because, um, it's such a wide variety of things. My approach is just gonna be the high yield stuff which commonly comes up. So I'm going to do a bit of neuro bit of sexually transmitted diseases, those sorts of things which you might see in general practice and also in secondary care. So, um, as you can imagine, as I said, it's very, very wide, very, very wide, um, topic. And what I'm going to be doing is trying to make it logical. Infectious disease is a medical micro is actually very, very logical. You just need to relate bug or the virus or whatever, which is causing the syndrome to. Then it's management, and most of the time it's going to be you can you can classify. You can go into antibiotics. Anti virals, Anti psychotics These sort of families of antibiotic and antimicrobials can only targeted towards infectious disease, but it's recognizing that infectious disease in the first place, which is the difficult part so often symptoms relate. Pathogen question. So if a pathogen produces a toxin such as Staphylococcus aureus, then think of toxic syndrome. For example, staph aureus causing staphylococcal toxic shock. It's It's quite simple because that bug produces a toxin which causes the syndrome so you can relate. And then infectious diseases is covering your Big five bacteria. Viruses produce humans, parasites and fungus is most of the time the medical school finals. It'll be bacteria and viruses. Sometimes you get a weird fungus, which can, you know in immunocompromised patients who always remember that using Occam's razor. So if it seems like a canary and looks like a canary, then it's probably going to be the most common thing, which is a canary. So think about it. If it's typical presentation, however, with any, um, infectious disease that may be the weird and wonderful. Coated 19 is one example. We did not expect it. And look what happened to your topical and tropical diseases. Think we had a wonderful antibiotics? Make up most management if it's bacterial, but do not get into the habit of treating every suspected prodromal symptoms with antibiotics. This is where a lot of you know in primary care. Um, some people will give a lot of antibiotics for something which is viral, which is not gonna do anything, so just be want and in exams, remember your stains. So gram stain, um, acid, fast bacilli, stain. Even silver stain can come out, which I'll come into later, but those stains will give you the answer. If you know what the bacteria stains as to say, gram positive gram negative et cetera. As I said, it's very it's a very big topic, so it's impossible to cover everything, but always remember infectious diseases makeup about, I'd say a good 40 to 50% of what you're going to be seeing as a doctor. So I always remember your basics. I'm going to go through, so I'll be covering the following chest infections are quite common questions which come up all the time. So I'll give your typical and atypical pneumonias and how you diagnose and manage them. CNS infections, which holds a place in my heart, is meningea encapsulitis etiology does. It does like to come up in exams and how they present and how you manage them. STDs, um are again. It can be common to less common etiologies, but it's good to know HIV complications come up a lot of exams. So if you know the bug associated with HIV, then you should get the answer and then got infections, which I'll think of it as well. So what we're gonna be doing is going to do SBA, and I'm going to learn from them. So if I just, um if I just hide the floating meeting controls, so this is the first question. And if you put your answer in the charts and then someone can relay that to me. If that's okay, a 45 year old male presents to his local GP surgery with new onset fever, cough and lethargy. He's a known smokers 30 cigarettes a day and has a past medical history of chronic bronchitis. The sputum is pure lint and his sats 91%. You sent him to the hospital. Admission. So which of the following is the most likely cause of his symptoms? Is it a strep B haemophilus See Moraxella d klebsiella or e mycobacterium avium intracellular. Have we got an answer at all? Okay, so the answer is Haemophilus influenzae. Now COPD is quite a big problem in the UK, and it comprises of both chronic bronchitis and emphysema. So if you know what the most common bacterial organism is, which causes acute exacerbation of COPD and related pneumonias, then, um and then you can work out what the bug is. And the most common bacterial organism which is associated with acute suspicion. COPD is haemophilus influenzae. Now, don't get this mixed up with Hemophilus influenza type B, which is what causes hepatitis. And that's what we vaccinate against. There are many different See a variance of haemophilus so just remember them. But again, COPD is very common reason for inpatient mission developed world, other causes, uh, streptococcus pneumonia and Moraxella catarrhalis And always remember, with acute exacerbation of COPD, it might not always be a bug. It might be a virus. So rhinoviruses, which, of course, your common colds RSV less commonly and influenza and coated 19 is another very important, of course. So always suspect someone with with any chest infection to test for covert 19 and as it's particularly right at the moment, Okay, The next question. So a chest X ray shows consolidation consistent with the right middle lobe pneumonia. The patient is allergic to food. Clocks are still in what would comprise the management plan for this patient with acute exacerbation series and an associated pneumonia. I'll give you a minute and then maybe if if you don't mind telling me what's on the track is, cancel it. So the correct answer. So this patient is allergic to amoxicillin. That's a family of penicillin, so therefore you can't use amoxicillin, so when you treat pneumonia, you can usually use three antibiotics. Well, it depends on your local micro guidelines, but they usually either a penicillin such as amoxicillin and macrolides. Just clarithromycin or a tetracycline such as doxy. So you have to think. Okay, which ones can this patient have? A knot? And because those patients go on exacerbations CBC, their management in the future is going to need a course of steroids. So what you're going to do is give this person clarithromycin because they're allergic to the glue clocks and, of course, are the course of pride. Now, this is the exact nice guidelines from 2010. What you're going to want to do for an acute exacerbation of COPD and this is comedy tested in his keys and on skis is you're going to increase the Bronco dilator frequency and query warranted and nebulizer. You can administer a five day course of oral steroids, if not contraindicated, and this will usually pride 30 mg a day. Antibiotics only considered if there's clinical signs and symptoms ammonia. So, basically, if this transaction, you know and this also person's bring it up, you're in dispute. And so if the antibiotics are warranted, as I said, you can either use amoxicillin, crystallizing or doxycycline, plus a five day course of steroids and Usually this will clear things up. If it doesn't, then you might want to consider other You know, long term measures for people with COPD some people are put on. Is it from my sin as an immune modulator drug? So even though it's a macrolide, it does have immune modulation effects. So that's that's something people can consider in the future. And this is what the right middle lobe pneumonia will look like. And when you're thinking about if the sputum looks purulence or not, you can use this. So if it's quite you know, clear and watery, think more mucoid. See if it's got a tiny bit of yellow nous, then think you can pull it. And if it's green, yellow and nasty looking, then think pure lint. And even if you're not really sure what what color you know, the sputum is, and the chest actually shows that it's pneumonia. You're gonna treat with antibiotics regardless, so just always use your clinical insight. Okay, a 56 year old female presents to a local and department complaining progressively worsening chest pain, lethargy and fever. She also shows you the most recent sputum sample, which appears red and jam like she has a past medical history of liver cirrhosis and consumes 30 units alcohol. Every two days, chest secretaries completed and you observe a cavity waiting call consolidation in the right upper lobe. So what organism is most likely to be the etiology for this patient? Okay, so this has got some key buzz words in this question. Okay, The big things are plasma history, personal liver services there, and they consume a lot of alcohol. Now, when you think pneumonia and alcohol is should be only one bug you're thinking of, especially if it's capitated. Certain bacteria caused massive capitation within the lungs and like an abscess forming and these can be quite nasty, quite harmful. Bacteria, new new Koike bacteria and the red and jam, like sputum is all red jelly like sputum is classic of one bacteria, and that is collapse. Um, klebsiella pneumonia. So if you have a question which is called alcohol in it with a pneumonia, think klebsiella. Now, this bug is actually very, very dangerous, and it's resistant to a lot of things. A lot of bacteria, and it's a nightmare to treat. Actually, it's got about 30 to 50% mortality approximately 40% on here. But it's about 30 to 50% mortality purely because it causes these cavities and lesions, which antibiotics cannot penetrate sometimes. So that means, You know, some people have had to give a percutaneously drainage, and it's just a mess. It's a horrible, horrible bug, and the reason for this is a gram negative bacillus. If your grandson is going to be negative, if you grow it in a culture, it will literally look like snot. It's horrible mucus forming because it's encapsulated. It produces an endotoxin, and it's a mute point bacteria The transmission hospital acquired. You won't really see this bacteria in the community. It's usually a resistant bug, and the clinical unique features are common in alcoholics, diabetes and bronchiectasis. But remember, the most common bug for for COPD bronchiectasis sort of those sorts of diseases is haemophilus. Still, it may follow aspirations, So if someone's got a problem with, if someone's got like a neuromuscular junction disease, um, or it's got recently had a stroke, they could aspirate, so it could be one of those causes of aspiration pneumonia. Red current jelly sputum is the classic. Don't get this mixed up with, um interception. But red car and jelly sputum is classic of it. It's predominately upper lope, so it's an upper lobe cavities and lesion, and it's abscesses forming. This is where you should be an X ray in a minute. This is where it's quite difficult to penetrate with antibiotics sometimes, and it may also cause UTI. Usually klebsiella is a gut bacteria, so just always think it's a There's other types of infections because and this is what a chest actually will look like. It's as you can see, it's usually upper lobe forming. You've got where the arrows are. You can. You can see this cavity waiting area, and that would be consistent with an abscess. If you had this picture, you might get mixed up with maybe a specialist, which is a fungus or TB, but think it's all about the history. You get 90% of your information and diagnoses from the history, so take a thorough history, and you should you should know what the bacteria or likely bacteria which is causing it. Okay, um, antibiotics wise for klebsiella is really difficult because it's resistant to a lot of things. So usually if someone septic. Then you'll follow. The 76 pathway right next to a 75 year old male presents the local. Any department claim the cough, lethargy and fever. The symptoms followed from a previous flu like illness, and he now complains that his hands get very cold and pale when walking his dog. On examination, he looks unwell and pale with conjunctival palate. You observed target like lesions on his legs with associated bruises on his torso, He explains. These lesions have been there for a while, but thought nothing of it. You order a chest X ray and observe bilateral consolidation, a lot of information. And what investigation would confirm the etiology of this patient's clinical presentation? So it's not asking for the bug is asking for the investigation you would do in this situation to find out what is causing it. So if someone in the track can, um, someone could regulate the track and tell me what answer is the most common? That'd be great. We've got a Okay, so we've got a A Any other answers, we can see someone sits. Anything else? Okay, so we got agencies so a lot of information here, but there's one thing or two things you can pick up on this, which will give you the answer. So the so the first thing in the history would be the very pale cold hands, and and and he's got conjunctival palate. Now this suggests there's a sort of anemia happening, some some sort of human lytic process happening and that can be associated with one bacteria, especially if they have pneumonia. The other thing, which is probably what people will guess upon, is the target like illusions. This is consistent with something called erythema multiple and that is associated with a bacteria called mycoplasma pneumonia. And this is the type of pneumonia, pneumonia causing bug. But the investigation of choice is serology, which is seen your MRI antigen. I'll get onto it a bit later, but serology would give you the diagnosis so a bit about this bug mycoplasma. It's morphology is really complicated. The microplasm family reason why they call Micro is because they sometimes, um, reflect some of the properties a fungus might have. So that's why it's quite difficult to stain a bit like TB, TB, bit of nightmares, state, so use a different type of pain stain, but it's past physiologic. It's it's parasitic, so it lives within yourselves. It lacks a cell wall. Hence my grandson. It would be a nightmare to use and immediates immune responses. This bacteria likes to play havoc to your immune system, and the way it's transmitted is usually by droplet or respiratory aerosols. And it's very unique in it's clinical history, so it causes epidemics. Classically, it's every four years to think, you know, uh, up here every four years there's going to usually an epidemic micro plasma, and it's got increasing resistance. Any bacteria which doesn't have a title like in Cell Wall, usually has some resistance mechanisms to protect itself against not having that cell wall. And it's got a longer duration of these, and you get this blue light prodrome, then a cough on a chest X ray. You'll get bilateral consolidation. That's just classic. It might not happen, really. In practice. It's textbook, and it's immune complications. Immune disease and complications are quite unique. So this whole pale hands when in the weather it could it could stimulate a Reynaud's phenomenon, and this is it is a complication as I GM. So your antibody IgM mediated, called a gluten in autoimmune hemolytic anemia. Now you get cold and warm autoimmune hemolytic anemia as, um, if you're thinking bugs, think cold. If you think in CLL, which is a type chronic lymphocytic leukemia, then think warm. So called a gluten means at at approximately four degrees Celsius humanities pill form. And that's what causes this. You know, clinical features of Raynaud's phenomenon and something called acrocyanosis, which is which is cyanotic features due to poor circulation. Basically, and this can be intervascular and complimented predominant. Now, tests for this complication is a direct Coombs test, which will be positive, and a cold and flu tenation test was positive. But that was not what the question was. Asking questions asking, How would you find an etiology, which the investigation of choices serology and called occlusion autoimmune hemolytic anemia is a type two hypersensitive, according to the girls, the Coombs hypersensitive reaction list. So those those sometimes you know, can be tested in PT to always remember that now the difference between erythema multiform and know dose um is they're both hypersensitivity reactions to type for, which is your T cell mediated, but they're so delayed mediated. Sorry, But multiforme is superficial. Microvascular information. Whilst know dose um, is your supper cut fast inflammation and you can tell there's two different types of multiform, minor or major minor would be non mucosal. So it doesn't really affect classically questions big guns or major, which is mucosal guns. And that is seen with a disease called off, which is fine and cows. But don't worry about that now. Other things mycoplasma pneumonia can cause is CNS disease. So Green Beret syndrome, just like campylobacter, it can cause bone marrow and then the meningitis encephalitis, which is quite rare. Other things which are listed but rare is bullous myringitis or myringitis, which is basically initially of tympanic membrane and then liver dysfunction. It sometimes causes a hepatic or pancreatic picture and then less commonly. But I'm going to tell you anyway, uh, essentially arthritis and humility chronic syndrome. But humanistic remix syndrome also classically associated with an echo like usually, and it can cause the pericarditis or myocarditis. But the big thing to know is I just immediately called the Houston and erythema multiform. If you see that in a question target like lesions, then it's mycoplasma, and this is what erythema multiform looks like. It looks like it. Tiny looks like ringworm, slightly like TV captors, Um, but it's not. So it's these target, like lesions on the on the surroundings. You get this heavier red erythema and then in the middle of this sort of empty area. And then if you look at this blood film, then you can see how it's It's sort of agglutinate together, and this will be at four degrees. So that means, therefore, it's called glue tenation these management. Usually it's a doctor. Cycling or math, right? Right. Next question. A 25 year old male has just arrived back from a holiday in Spain, feeling miserable. Now that is key words. If you see that in the question, you should automatically know or see what the bug is. Most likely, he has developed a new dry cough and flu like symptoms. His vitals. His vitals are 80% on SATs, and his heart rate is bradycardic. He's got a tympanic temperature reading with 39 degrees Celsius and BP. 161 116. You admit this patient and order some blood, which fear a lymphopenia lft derangement and hyponatremia, the patients becoming more confused and well, do you want your chest X ray, which reveals patchy consolidation bilateral pleural effusion. What investigation would confirm the etiology of this patient's clinical presentation? Anything in the chart? Anything at all in Trump? Okay, so this question has a couple of buzz words. I pretty much for me, this question to have every single complication of the Senate regarding this bug. So the Spain so usually a pneumonia which has come from other country, which is not typical to the UK can be class is atypical. So this is an atypical bug which is called pneumonia, and his vitals are weird. He's got a temperature of 39 but his heart rate is quite low now. This is something called relative bradycardia, which means that you'd expect this person to be quite tachycardic if he's got a region temperature. So the only a couple of syndromes cause this and this is one of them and the the the lab results. You know, a lymphopenia LFT arrangement and hyponatremia is quite specific for this bacteria. So if you have a question which is a pneumonia and it gives you blood results and it has a low sodium. Then you should know what bug it cause this syndrome is being caused by okay, and plural fusion is sometimes associated with this bug as well. So this is legionella or legionnairesdisease, and the way he would test that is a urinary antigen. Okay, now Legionella pneumophila, it's one. It's one of my favorite bacterias. I did research on it a while back, but it's a weird it stains. Quite weird. It's got a weird structure. It's a grand negative coccobacillus, so it sometimes can be. Not really differentiate between a caucus ridiculous, and it's intracellular. And it's beta lactamase producing beta lactamase, which basically means penicillin are not great treating this because it destroys the beta lactamase truck. So legionella pneumophila usually has a transmission through water. So it's your water tanks, air conditioning and usually people stay abroad, stay in hotels and classically, this bug was formed and and found and contracted in a conference where the air con and the water tanks are not great. And it was called the Legionnaires Conference. Hence why? This bug is called legionella pneumophila and the disease is called legionnairesdisease. This, uh, this bacteria also causes another sort of less severe form called Pontiac Fever, which sometimes is tested in higher specialty exams. But legionnairesdisease is the full blown pneumonia, and its clinical features are without relative bradycardia. Lymphopenia hyponatremia is the thing, which you will see in progress as questions. Probably 30% of people will have a pleural effusion. So if someone has a pleural effusion, you wanna do a diagnostic aspiration of that perfusion to see what's see what's causing cause. Sometimes it can be caused by could be transmitted, direct stated, and lft arrangement is classically associated with it. It's more of a hepatic picture, not obstructive picture, and this is what it looks like. And, um, it's sort of patchy. But sometimes you get a little plural fusion, which starting to form ever so slightly and costophrenic answer. But the investigation of choice is it produces this anti gyn a bit like streptococcus pneumonia. You can test it with in your urine so you can do a urine dipstick of this or send it to the lab. It's more likely going to have to do a urine culture centre lab, but that's where your testing for and the management is macrolide classically clarithromycin. No pneumonia. Other causes. You can get a pneumococcal pneumonia, which is caused by streptococcus pneumonia. It's morphology is a gram positive, cocky in chains and its clinical features. It is the most common cause of community acquired pneumonia, and it's got a sudden rapid onset, so you're gonna feel rubbish very quickly. High fever. You get horrific chest pain so sometimes it can mimic a P. And it's worse on inspiration and in question. Sometimes it will be associated with herpes virus, which which is basically a cold sore. So streptococcus pneumonia sometimes decreases community and gives body stress. Therefore, herpes, which is can be residents in your in your ganglion, in your in your urine or ganglion, it can be reactivated cause in the cold sore picture. Other classic exam questions would be Staphylococcus aureus. No pneumonia. Staph aureus. Very, very common skin. Flora is a grand positive clock in clusters, and it is common post influenza. So if you have the flu and then getting pneumonia, think Staphylococcus aureus. It's treated usually for the clock too soon. Okay. 21 year old female presents for annual review at a local hospital. Her past medical history is consistent with cystic fibrosis, and she is currently under the pediatric respiratory specialist for management of CF. Recently she has had increasingly more frequent admission to the hospital concerning exacerbations of the Bronchiectasis. She informed you that she has been visiting another patient on the CF Ward, who she has feelings for. What organism or organisms are you most concerned about? Regarding her recent inpatient admissions? You might think this is a niche question that actually is very important. When you're transferring patients on CF who nausea, we've got some deep we've got to see. Okay, that was very quick, which is good. Any others? Lots of these cities. Good. So the is actually the correct answer. So with cystic fibrosis, usually the most common organism, and this is what also predicts prognostic factors for lung transplant is Pseudomonas and pseudomonas is horrible. It's just a horrible resistant bug, which is, really, is Passy. It's disgusting. It smells horrible, and it's It's a nightmare to tree. And if you want to wash and you smell pseudomonas, you'll know it's pseudomonas straightaway. In culture, it actually smells quite floral, and it produces this, um, this pigment called by signing and which gives it a green bluish floral culture appearance. So it's quite classic Pseudomonas vehicle during the patient is another horrible resistant bacteria. And these two bacteria together, um, or the, uh, patient is a complex, by the way, if they're together on you know, a sputum culture, then it's, uh, then it's a concert indication for lung transplant, so it's a very poor prognostic factor. So when you're canceling patients who got CF and say you know someone else because they're in hospital all the time, they meet another patient to see if you you you have to isolate them from each other because they're more likely going to spread it between them. So pneumonia, bronchitis, exacerbation bronchitis is the most common associative. The following organisms chemo for this InfantSEE, Even though I said CF is usually associated with pseudomonas, Bronchiectasis, in general is haemophilus a bit like COPD. He also got club pseudomonas and streptococcus pneumonia. In the context of CF, cross infection with another CF patient needs to be cancelled. It's really important and vehicle patient to patient, complex and pseudomonas are the two common colonized bacteria, and if you have a vehicle, the occupation chronic infection, or pseudomonas, is a contraindication to long transportation, and these are very resistant organisms in hospital. What they usually give is an inhaled tobramycin, but as a junior doctor, you will not be expected. You have to ring micro basically to get a result on what to give. You know, patients. It's very hard to treat. This is way above your pay grade, but it's good to know, for example, purposes because it's textbook and this is what Pseudomonas looks like. It looks horrendous and it's resistant. It can be cavity waiting. You can see this sort of capitation in the, uh in the right below, and it's just horrible, and it's really resistant to a lot of things. Vehicle diarrhea is more upper, but again, it's not very, very nice. Now, a bit of pneumonia assessment. You've probably heard of Curb 65 but in a community or nice guideline suggest is using CRB 65 to get rid of the area because it's quite difficult to measure urea as you can appreciate in primary care. So in the community, CRB 65 spice And that's confusion. So if you use the abbreviated mental test, um, am CS then, um, if they have less than eight, then its class confusion and sometimes an exam. They'll just give you that so they won't say the patient's confused. You have to work that up. Respiratory. It's about 30 BP 90 systolic, 60 diastolic and above 65. Now, if it's zero, they're low risk. They can be managed in the community. If it's 1 to 2. Moderate risk, maybe consider oral antibiotics 3 to 4. You're thinking, you know, I got to get the hospital. Need to be hospitalized and above two is one in the hospital assessment. Nice. Also recommend Point of care. CRP Testing. This is not currently done. If they got a CRP 100 they going to be done. Antibiotics. But as you can appreciate your primary care, sometimes this is not done, and the point of care testing is actually quite uncommon in Hospital. 65 is is added to your ear. About seven investigations wise um, chest X. During beauty and blood cultures. You can also do pneumonia, pneumococcal legionella and your intestines, which is just a urine sample and CRP monitoring to see how the disease is progressing. Antibiotics. If they're low risk amoxicillin, macrolide or tetracycline. Such a biopsy. If there's, you know, pass for moderate risk or high risk amoxicillin, plus, uh, Macrolides. Or if you need a beta lactamase stable, and products such as flu cloxacillin or Cold Boxing Club, you can add that Okay, a 35 year old male presents to his local GP. With worsening exertion will disappear and persistent dry cough. That should give you an indication. Already, he has also been experiencing night sweats, weight loss and fluctuating fevers. He has an established history of HIV, which is not well controlled with highly highly active antiretroviral therapy. His last CD, four count, was under 200. You send in the hospital. The subsequent, uh, secretary reveals a one centimeter pneumothorax, otherwise normal. You treat accordingly. What is the most likely cause of his symptoms? You put it in the chart that you want lots of sees lots of seeds. Okay, I was very, very quick, and I'm very impressed. Okay, so there's lots of seeds and I'm going to go with C. C. Is the correct answer. And this buzz words with this question. His past medical history of HIV last number one. It's not well controlled anything which has got a two CD four count of 200 below is classically assume is classified sorry as AIDS. So this person is entering AIDS, and you've got is really, you know, pro. It's going to be prone to opportunistic infections. So think alarm bells is either going to be a TB or it's going to be a fungus, okay or something weird and wonderful now worsening exertion or dyspnea. This is classically associated with Pneumocystis Jenna bitchy, which is, um, it also used to be known as Pneumocystis paradigm, but it's a it's about. It's a it's a fungus and the exertional dyspnea, or they'll give you statins, which desaturate after you walked a couple of you know, steps that is classic design question and dry cough. This is what distinguishes between tuberculosis. Tuberculosis is a classic wet cough blood hypothesis, and you know I'll talk about TV in a bit. But TB is also associated with night sweats, weight loss and fluctuating fevers. So that's why I was gonna It can complicate things, but because this person has got AIDS that's also associated with that. So, um, so with this question is the exertional dyspnea and also HIV AIDS, which would give you the answer. The new math authorities, or pneumothorax is also associated with your sisters and otherwise normal chest. X ray is also associated with PCP. Pneumocystis therapy three million. So etiology. This is a lovely, lovely fungus, which is, you know, cellular. And it's yeast like Okay, so assist for me basically, and it's clinical significance. It is the most common opportunistic infections, HIV slash aids and if you hence, if your CD four count is below 200 this could be another exam question. You've got to give co-trimoxazole prophylaxis. Now. The management of this pneumonia is co-trimoxazole, which is a bit weird because it's a fungus, and co-trimoxazole is a mixture between trimethoprim and a sulfur sulfur. Drugs just sulfadiazine so it's, um so it's a bit weird, but it actually works for this fungus, so just, you know, it's just proven now. Clinical presentation Exertional dyspnea is number one. Dry cough is number two. TB is classically associated with a wet cough, but not always. There's not so much tastic martyr. You don't get that much, you know, respiratory signs and you may see. Not common, though that pattern splenomegaly and cord lesions. Choroid Um, correlations been quite rare. And the chest x ray? I mean, most of the time it can be normal. You may see bilateral institutional influence infiltrates and a pneumothorax, but classically, this disease is associated with a normal chest secretary, so some people may miss it. So it's good. 90%. You get from your history to take a thorough history. Sputum cultures futile. It won't do anything, so instead, you need to do a bronchoalveolar lavage. Not everyone does a bronchoalveolar lavage. It is an invasive procedure, but we'll give you the diagnosis and on silver stain, which is the which is the associated staying for this fungus assists. I'll show you what it looks like in a minute. Management is coach muscle. If it's severe, which you're not supposed to know, you can give IV or aerosolized pentamidine, which is, um, it's an anti mycotic but also could be an anti parasitic drug. And this is what it looks like. This is a silver stain, and you can see these lovely button cyst cysts, which are classic with this fungus. But in is how, um, fungus is, uh, replicate. So just remember that. And this is what the chest actually looks like. It doesn't look too bad, actually made some bilateral institutional in infiltrates, but it doesn't look too bad. And that's why it can mess you up. If they give you an exam question and it's the chest actually looks normal. They've got HIV. Think this, uh, this fungus? Sorry, Jack. You asked a question about what's the gold standard investigation for PCP, right? Gold standard. Okay, so gold standard for PCP. Um, sputum culture is futile, so it depends. There's no Usually people will just take it from the history. But once you've done all your bloods, the gold standard would be some form of culture. And as sputum culture is futile, a bronchoalveolar lavage would be the gold sort of standard. It's not commonly done. So, um, you usually get this from you usually get this usually from the history. But the gold standard would be a bronchoalveolar lavage. So right, next four year old boy who presents the Children's assessment. You see a with his parents at the same day referral from his GP this morning, where he received I am Bentyl pen. That should give you a clue. The patient does not look warm and well, perfused and irritable. So in pediatrics, you get If a kid either looks miserable or irritable, then it's a big difference. Miserable, you can manage, but irritable. They're well, they're quite well. That's what a pediatrician for on examination. This boy is pale with, uh, disseminated nonblanching rash and does not cooperate when examining papillary reflexes. You've got a bit of photophobia that you listed a positive turning sign and immediately start empirical and Protestants condition. What's the organism? So we've got mostly seed? Uh huh. Okay, fine. So this is a really important diagnosis. We've vaccinated against this. We also vaccinated against a streptococcus pneumonia. But this is C Neisseria meningococcus. So this is this is meningea. Uh, this is the meningococcal septicemia, okay? And as a doctor, you should if someone if a kid is photophobic and it's got meningism, this should be your first caution. Okay. If you miss this, then it's big. Be death. It could be auto amputation. It can be a lot of things. You need to be very, very careful. The nonblanching rash is classic for meningococcal septicemia. And this is why the glass test is very important. If you're taking a GP, consult over the firm. And if someone's got symptoms like this, tell the Tell the mother or the guardian to do a glass test because this is the difference between life or death sometimes, and it's all about the history. You should know this on the phone. You shouldn't even see the patient. It should be like straight away and the I am Benzel pen that is given in primary care. If you suspect this, it's a it's a it's a stepping stone. It's just preventing. It's not preventing. Was trying to, like, eat like trying to basically delay the time before you get to the hospital? This is nice stream and into Congress now to go back. Sorry about PCP. You can also do PCR but the But the problem is PCR might not be all always, you know, accessible. So you need to get basically microorganism protection. You need to see it under the skin, basically. So the ankles are the Lovaza is probably the cause, right? Meningitis, probably something which I've taught a lot about and is really important. You should know this. That and the clinical features early features can be, you know, can be quite flu like so. Headache leg pains, fever with cold hands and feet. If you have a fever, cold hands and feet, that's a that's a red flag, an abnormal skin color so they could be a modeled color, which is bad news. Bears, basically and late features. Meningism is a triad of nuclear urgency to neck stiffness. Photophobia. Sometimes you get on a phobia and headache. If you have this, then think meningitis or minimum meningeal irritation. Clinic sign. This is this is to do with manages um, and Meningeal Irritation. Clinic sign is quite specific, so sometimes you can't elicit always. But it's classic, classic tested, and it's pain resistance on passively extension with the hip fully flexed. Okay, so sometimes people do a straight leg raise and like sciatica, and that will stretch them in India's and cause the symptoms. And if you do this to a patient who's got suspecting a minute septicemia, they all scream and jump up and pick, so it it's quite specific. Brzezinski signs their testing textbooks and exams, but they're quite rare. You got cheek sign and some physical sign. I wouldn't really rely on this for clinical. You know, it's just something which is tested. Decreased GCS may they may present in a coma. Uh, seizures. About 20%. Local CVS signs about 20% which is like a third nerve palsy and opisthotonos, which I will, um, explain in a minute the particular rush. The nonblanching rush is classic except miniature contraceptive senior, maybe only one or two spots. So if you notice them, you need to test them. And this is done by a glass test. You want applying pressure to rush? It should disappear. If it does not, then it's basically hemolysis. It's capillary. Um um, capillary problems. So I think you know this person's septic, they're leaking, and that is what's causing it. Okay, now this on the left, Does anybody know what you could Probably on the right? I've already talked about it is, you know, a big sign. And Brzezinski, uh, classically Kernig's on the right. But on the left Does anybody know what this is called? Or what condition is related to? Nothing as of yet. So I go, I said, there's no answers yet. Okay. I didn't remember that picture from a lecture but really jogging my memory. Historical painting. It's like it's very it was done for one disease in particular and we use in textbooks. We use it for teaching quite a bit infectious diseases. So this here is something called Opisthotonos, and it's this classically archin of the back, which you get with meningeal irritation. And it's classically associated with tetanus, which is a toxin which is caused by Clostridium Bug custodian Test nine and causes a logical. And you get this. Get this picture okay. It can sometimes be associated with meningeal irritation. Hence, I've shown it diagnosis, right, So this can be a PT question, but also risky and skis. And when you are asked, how did you manage this patient? Always 80 e. You want to treat them straight away before you? You know you don't you don't want to delay treatment. You treat them on suspicions that they've gotten into some your meningitis while because these tests can sometimes take a while. So when you're doing when you're presenting how you would manage saying honesty, first thing you want to say is a two week, I would treat this patient accordingly and then do your investigations on top of that. So nice to include the following. You're going to do the whole blood, everything under the sun. FPC's using the LFT CRP inflammatory markers coagulation screen because their septic a bm even there for blood, sugar, blood cultures and whole blood PCR. Now, if you've got meningococcal septicemia, a lumbar puncture is contraindicated because you want to make sure that there's no raised intracranial pressure. And if you've got meningococcemia, everything links. So if you put a big, massive needle into someone, see a subarachnoid space and they're leaking, it can also cause compression, so and they're thinking that space. So what is what is said? Did you do a whole blood PCR for meningococcus? That is the test, until you definitely rule out that it's a an active political septicemia or raised into a depression. And you do blood cultures, obviously, So you're doing the sepsis. Six. Picture A BG BG. You want to see if there's any raise lactate. If they got metabolic acidosis we've raised and engage, which is associated with this sepsis chest X ray. You can do as well take throat swabs, which is quite good because the three big bacteria which live in your throat are Neisseria meningitis, streptococcus pneumonia and haemophilus influenzae. So if you swap them, you can find out, um and consider HIV. TB tests in anyone who comes in with a full blown sepsis and you know it's got any signs of immune compromise. Then do an HIV or TB test. It's stable, and there's no signs of increased ICP. Get a senior health before 11 puncture. Okay, So if this person didn't have any concept of the other meningitis and they've got their quite you know, that's stable enough and they and they've got no signs of, you know, focal neurology raised ICP. Then you consider doing a lumbar puncture with one hour. But if they are unstable, step asemic and signs of increased BP get I see, get I see you help straight away. They may need intubation in airway support A in a two week airway. So always check their airway, and you're gonna treat them. You're going to give you gonna basically smash them with antibiotics. Um, even before you, you know you've treated them even though you've been, uh, diagnosed them. It should be a clinical diagnosis. Usually so talking about contraindications is for your boy. You've just seen It's been started on the empirical antibiotics, but as a weight and blood cultures horrible PCR relevant blood. Your senior ask you to perform a lumbar puncture in the meantime, which is not an absolute indication to perform in a lumbar puncture in this patient. Bit of a harder question. And the only shop we've got all of them d A b. We've got a wide range. Okay, that's fine. Okay, so this is a difficult question. I've made it hard, So think about it. What? So you don't want to introduce the needle in someone's subarachnoid space? Um, to, you know, for risks of a couple of things. Big one is raised intracranial pressure. So if they've got any focal neurology, one being 1/6 nerve palsy, which is a focal neurology. And it's one of the first signs of raised ICP, actually. Then, um then you wouldn't want to do it. Christians triad is obviously for raised intracranial pressure. Christians. Triad is a chance to experience so weird, irregular breathing, bradycardia, hypertension. Um, you wouldn't want to do that. Meningococcal said to see me. I said you wouldn't want to do a lumbar puncture and until you wouldn't want to do it, D I see is when you basically your your your you know, fiber in products and degradation and you just bleeding. It's just everything remains basically your coagulations. Not great, so you wouldn't really want to do it then. Or spit Sign is a is A. It's basically for psoriasis when you when you touch the skin and it moved and it bleeds. Basically, that's what spit sign. So it's nothing to do with the lumbar puncture, so the correct answer would be a spit sign, but you could work it out. If you don't know what spit sign is, you could work it out from the others, so think logically. You don't if someone is leaking, which is sex is basically leaking into all the tissues. You don't want to start introducing more fluid into the canal. It's going to compress input process. So a lumbar puncture a procedure. So the procedure itself you probably don't you don't need to know, but for like, you know, higher higher exams, which is MRCS, then you should know the anatomy and you might and you might be trained in the lumbar puncture may be doing his left one. So always keep in mind from posterior to anterior. When you put the lumbar puncture needle into your into your spine, you want to do it below where the spinal cord finishes, which is around L1 L2. So you're probably going to put it around L3 L4, the space in between. So you go through the skin superficial fascia. All these ligaments, ligaments inflamed. And it's a bit where you feel a tug, you go in and then, you know, you're either the epidural space of the subarachnoid space epidurals where you put the epidural finding for, you know, partial anesthesia for childbearing and then subarachnoid space. This is where you get your CSF, and this is also where they do a spinal tap and spinal anesthesia Complete process and contraindications raised ICP cerebral herniation or mass. So if someone's cone in and they've got signs of raising chickens pressure, you're never going to do this. You could kill someone believed in diocese. That basically means throw thrombocytopenia coagulopathy um, those sort of things. So where someone's bleeding out? Basically, site infections, if they've got a raging infection where you can put the needle. You don't want to introduce infection in two separate space or the the central nervous system. So you're not gonna do it then, and the chewable deformities actually so kyphosis scoliosis because you can actually damaged spinal cord if you don't put in the correct place. Adverse effects. These testing believe in progress test. So the most common is post spinal headache and nausea, and the treatment is prolonged bed rest. Some people find it better if they lay down. Basically, um, and CSF really prepare via something called an epidural blood patch. Analgesia. Caffeine actually is great to get them, get them a cup of coffee or get some IV caffeine. That usually works, but most of the time it's, um, long bed rest and it it can be. It's a very dull headache. After the fracture. Paresthesia like usually resolves epidural hemorrhage, rare and adhesive arachnoiditis. That's very, very rare. Don't worry about it. Um, but epidural hemorrhage you need to think of so an actual hematoma after number point of this is why you wouldn't want to do if someone has a play in diabetes. Okay, 55 year old female presents a any with progressively wisdom headache, fever, neck stiffness. So you probably know what's going to be already. She's recently recovered from a chest infection, has been experiencing vertigo alongside diplopia blurriness. On examination, you listed in abductions, No deficit and science manages, um, the past medical history is consistent of HIV AIDS, which is poorly controlled. If a lumbar puncture was performed, what would be path economic for this clinical presentation? Pathognomic. Meaning they can only be this thing. Anything in the shop. Okay, time's sake. I'm going to speed it up. So a couple of things you should know about this opportunistic infections for HIV. So you think something weird and wonderful, maybe a fungus or TB? So this is classically associated, a produce sensitive deficit. And this vertigo and a recent chest infection is associated with something called cryptococcus and performance, which is a fungus. And if you do a lumbar puncture and stain it with India ink, that's the big buzz word you would see in capsule. At least the answer is deep. Cryptococcal meningitis problems common form of meningitis for HIV complications. So always remember that now a lumbar puncture interpretation could come up. I would just learn this table. It'll take me time to go through it. But the idea is a couple of things we're going to suggest is if it's bacterial, you're gonna get more polymorphous. So your, um in eight immune system. If it's viral, you're gonna get more lymphocytes. If it's TB, it goes from, um Polymorphism two lymphocytes, because it treats the immune system goes attacks the infection as a bacteria. But it does. It gets resistant to that, and then lymphocytes are needed. TB glucose is markedly down. It's a glutton for glucose. They also get rid of all your glucose compared to your serum, glucose levels and fungus is they've got a higher open impression. So those are a couple of things in it. And a fungus. You do a fungal fungal plate, and then, uh, TB, you do it as fast as the line etiology. So if someone is 0 to 3 months, think group B strep, which causes, you know, pupil fever and neonatal sepsis. If later on it goes morning, uh, Syria manages to streptococcus pneumonia, um, and also for the knee and extinguished area, which is another one. If immunocompromised also think, Let's do your monocytogenes. Right. Next question. A two month old infant has just received a diagnosis of bacterial meningitis caused by streptococcus agalactiae, which is group B strep. You want to initiate empirical antibiotic therapy? Which the following should you administer? This comes up quite long in, like past medicine and PT Be mainly be okay, so the correct answer is be so underneath. Under three months old, you add on either amoxicillin or ampicillin quite similar drugs. But for empirical therapy, third generation cephalosporin such as cefotaxime or care triax, sir, and usually keep track so usually But if they're under the three months kept kept track some cataracts in plus that additional so ampicillin, amoxicillin. And this covers the listeria and that's why you're doing it. Okay. Now by two meningitis management, it's quite difficult. As you can see, basically, all I would take out of this is underneath three months. Add on the amoxicillin, amoxicillin, everything pretty much else is just that one cap, a taxi, more cataracts. Um, if they have, um, the serotonin site a Chinese you can add, you can take away the cap cap vaccine, um, refrigeration. It happens more in and put gentamicin instead. But it's usually kept track of national empirical third generation. Okay, now prophylaxis comes up in exams. If someone's close contact, they usually given ciprofloxacin windows or relapsing windows. And nowadays it's ciprofloxacin because it's better tolerated with ampicillin is TB drug, and it's got quite a bad side effect profile. Uh, the use of steroids, uh, to, you know, to decrease post, um, many meningitis, uh, secretly is, um, it's usually used with people who have not gotten an integral septicemia. Sepsis decrease immunity of post operative meningitis because they do decrease your immune system. So if someone's got full blown sepsis, avoid using decks. Okay, if they're allergic to penicillin or cephalosporium, then you can think of chloramphenicol. It crosses the blood brain barrier, but be careful in units because they don't produce. Um, they don't produce a certain, uh, substrate, which chloramphenicol works by. I think it's Blue Corona days or something like that, but they get something called gray baby syndrome. If you give, chloramphenicol can kill them like hepatic failure. So just be wary of that Okay, 35 year old male who has recently been working in sub Saharan Africa presented a me the worst headache and fever. He elicit signs of manages. Um, and there's no indications of raised a CT. You conduct a lumbar puncture, which shows the following. Okay, which of the following is the correct diagnosis? And if you know your stains, you should automatically know what this is. People are saying D right, good tuberculosis. Meningitis. This is TB. TB can end up anywhere in the body. You can go in the chest, it can go in the urinary system. You can go in the spine, it can go in the brain, and it can go in the skin. So this is TB positive on Zetia and things and I'll sustain, which is also known as fast, fast bacilli. This TB is a weird bacteria. It does not stay in while gram stain. So the reason why is because if it's still well, it's got a It's got fungal mycotic properties. So hence why different antibiotics, different stains, different everything, and glucose is a glutton for glucose. Remember, that's very, very low. It's quite a big bacteria, so the protein is going to be high, and the opening pressure is quite big against big, chunky so it's going to be higher, and it usually works by the adaptive immune system, So it's lymphocytic. Usually you might also get a different Web, which is similar to funguses. But that's textbook, so don't worry about it now. TB. It's very complicated. It's resistant to a lot of things, but, for example, purposes, I'll go for the main stuff. It's acid fast, Mr like to only staying on that stain, and it's either latent 90% or active. Most people live with TB and not know about it until you become immune compromised. I've got another infection contact, and then it activates. And then you're in trouble. Signs and symptoms. Pulmonary. This is your classic hypothesis is also known as the white plague because people or or consumption because it literally will consume you it. Will you get the whole cancer symptoms that be the symptoms. It's night, night sweats, weight loss, everything and you cough up blood basically, and this is classic consumption, which is on the TV. Very, very rare. You can get something called a Rasmussen's aneurysm. This is Pathognomic. It's a pulmonary artery aneurysm and a pillow sclerosis. So remember the acronym charts for below, uh, below fibrosis. Basically extrapulmonary meningitis. Pott's disease where it's in the spine. Michael. Back to your cervical lymphadenitis. This is not a scrofula. I'll show you a picture of that. Memory is everywhere, and Urogenital is in your bladder and your kidneys. Generals B B symptoms Think cancer symptoms are associated with the TB diagnosis for latent. You do something called um onto test. It's not accurate, though, because you can get false positives if you have sarcoid or, you know, some other autoimmune of being on steroids. Whatever I g R A. There are other tests you can do. Sputum culture is the gold standard, usually for diagnoses. So you always remember that. Okay, and the management. This is important to months of right, so Rifamycin Eyes denies. It appears in my teeth and beautiful, and it's followed then by just the pharmacy. Denies denies it for four months, but latent. You just use. You can use six months of exercise alone or with three months of itemizing and prevention's by the BCG vaccine. It's not that effective by 7% effective, so you can still catch TB. So this is a chest X ray, and if anybody knows what the sign is, that would be great if they put it in the chat. I'll be very impressed. Okay, so this is a This sign is bilateral hilum lymph nodes and not the theme which is associated with TB and sarcoid. So just remember that, for example, purposes other. There are other conditions, but those are classic two, and this is extra pulmonary. So as you can see in the spine, this is Pott's disease in and this here, which I've already mentioned this is a pulmonary artery aneurysm. There's also Mr Rasmussen's and it's classic associated with TV, and it's horrible liver. Tonight's the Scrofula, and it's also research for TV Ripe. So know the drugs, right? Streptomycin. You don't really need to know that so much because the second line but right is the big thing. So the side effects are tested for medicine. So red orange body secretions, everything goes red orange eyes And is it peripheral neuropathy? Do you treat with vitamin B six, which is pyridoxine to avoid that pyrazinamide you get Gap Gap. Basically, ethambutol optic neuritis also is retrobulbar neuritis. So you're going to want to do a visual acuity visual testing before you go on to this drug. Okay, 27 year old female with a known past medical history of HIV eight presents a handy with increasing confusion. Headache. Most recent CT court CD four count is 250 she is not complying with part. CT Scan Reveals Ring Enhancing Lesions Which of the following is the correct diagnosis? Any takers? And this has come up in PT, so people are saying E good. So this is a toxoplasmosis. So, um, and all these other complications associated with HIV, by the way, right? CNS toxoplasmosis Very quickly. It's caused by a parasite or toxoplasmosis. Cardio Toxoplasma County. It's clear calm presentation. If you're immuno competent, it's mild flu like doesn't need any treatment. But if you've got risk factors just being pregnant, because the congenital defects and immune suppression, then it needs to be treated and it can either be given in gently. So which causes a is one of the torches, um, organisms, which cause congenital defects and causes the hydro catalyst problems with your eyes and interesting calcification. And then, if you're more depressed, it's one of the major causes of death in HIV AIDS and results in Encapsulitis and Toxoplasma that throws abscesses. The introduction of heart has reduced the number of cases, but this is classically transmitted through cat feces. So if you're pregnant or immunocompromised do not go near cat feces. Cats are carriers whilst dogs are toxic R A, which is a bit different and undercooked. Foods. Pork, the class people diagnosis serology, amniotic fluid analysis. If you're pregnant, MRI, CT head and the management. If you're pregnant. Spiramycin. Because you cannot take pyrimethamine subsidizing because it's a folate computer. It works via folate. So spiramycin this is a type of macrolide macrolide or I think I mean, like like I can remember, um, but classically, you'll be pyrimethamine subsidizing the folic acid because it's a piece of furniture. Want to put the blood back into Florida acid? Is that and this is what it looks like on the CT head, the ring enhancing lesions. If you see that when you got HIV, it's toxoplasma. Now, this is how you differentiate between lymphoma because it looks very similar. CNS lymphoma. Does anybody know what the scan is called? If not, this scan is called a spect scan and spect Valium scan. And if you have a toxoplasma, you will get basically, um, not so, um, remember correctly. It's, um not so much increase whilst if you have CNS lymphoma, there is increased, um, homogeneous, basically increased volume. So, um, that's how it works, basically, and it just shows it's a way to differentiate between spectrum much. Okay, 28 years old Female presents a handy with increasing confusion. Headache. Past history is unremarkable. Apart from the recent chest infection three weeks ago for which she's also had a flow of the physical oral rash. MRI shows temporal lobe enhancement. What diagnosis? Any tickets to the focus? The answer. Okay, so this is if you see MRI showing temporal lobe enhancement, it's associated with herpes simplex encapsulitis, and that is one of the most common causes encapsulitis in in adults. And, um, as you can see, this person's got in confusion. Headache. Recent chest infection had a flare of this particular or rash, which is, you know, with herpes basically and in adults is HSV one north HSV two. HSV two is commonly associated with genital sores, but in adults is HSV one. So most common etiology encapsulitis is HSV encapsulitis caused by those, uh, herpes simplex one or two and in the in its its two. Because it's required by a vaginal delivery and older Children. Adults is one, and the signs and symptoms are consistent with aseptic meningitis. In other words, you know, no bacteria basically, however, may additional present with pathetic skin or universal lesions. Diagnosis is via that temporal lobe. It has, um, via MRI, I'm PCR, and management is IV acyclovir. For 21 days, relapse may occur. So if you have any inclination that this person may have any careful itis you add on the encyclopedia on top of antibiotics, and occasionally you may get enteroviruses or VZV, which is chicken pox, CMP or 36 encapsulitis. But they're more associated with immune suppression than AIDS. Rare. You don't have to know this is a virus which is taken for the resident evil series. The virus was associated with this, you know, severe fatal encapsulitis which you get from the market. And this is what it looks like. This is temporal lobe enhancement, As you can see on the left temporal lobe enhancement. On an MRI, this would be diagnostic of HSV encapsulitis an 80 year old male presents a day with joint pain. He has just started, you know, and has been recently drinking heavily. He also complains of this area a new recent discharge which he states is offensive and person like. Which of the following is most likely etiology Any takers at all? We've got a D. C. Okay, so we got to make it up, right? Okay, so this is is quite difficult. So it's either going to be a L. C. So chlamydia or chlamydia is probably the most common STD in the UK, But this is, you know, he's got joint pain, which means there could be a dissemination which is associated with going to cock your disease. And I see your gonorrhea and offensive past, like in a male urethral discharge usually associated with gonorrhea. Committees can sometimes just be pale discharge then, so it's it's you get this more green discharge with gonorrhea, The answer on it. So, gonorrhea. It's a gram. Negative diplococcus the same family as many justice and clinical presentation in both males and females to Syria discharge females. They might have a service cyclist in males. They might have a prostatitis and It can also cause proctitis and throat infection, so gonorrhea can inflame your rectum and cause you to bleed. And it could be quite nasty if you're got local infection, and it can also be a threat. Complications. So you're reasonable stricture in men, usually reactive arthritis. This is Get this joint pain and epididymitis salpingitis. So information epididymis information, uh, variant of flipping tubes, diagnostics, swamps and by Cosby culture and sensitivity. And this would be where the site of the discharge would be. Some vaginal, oral, rectal or your regional management. Gonorrhea is on the rise to resistance, so it changes. But currently it's I am calf windows. It's quite painful. Those apparently got an injection. Or, if they don't like needles, which sometimes you might say, in the in the in the exam, P O can fix him, and it's it's amazing. Now this triad of you can get some people to try to disseminate it, going to cause infection. This is inflammation of your tendons, migratory arthritis and a particular maculopapular dermatitis. Just remember, for example, Michael, an 18 year old female presents for local downplay the deterior. She also complains of increasing worse than lower abdominal pain. She denies any vaginal discharge. It feels and well. She also notes that she's worried that she's picked something up as she has multiple sexual partners on the spectrum examination, the vehicle excitation is noted, and pregnancy test is negative. What? See HRT A seems to be popular. Wicked. Okay, yeah, this is chlamydia. Reason being is giving away a couple a couple of things increasing lower abdominal pain. She's not, You know, she's she's worried. She picked something up and committed, obviously, was comin. The UK and it's this speculum examination, cervical exhortations noticed. Now that is. You get cervical exhortation in two different scenarios. Pelvic inflammatory disease and ectopic pregnancy. The pregnancy test is negative. You can rule that out. So it's pelvic inflammatory, which is associated with chlamydia and gonorrhea. But this would be more pointing towards a comedy a picture, because gonorrhea is not even on the list. Chlamydia. It's in the UK It's the most common STD, and it's serovar d two K, which is the, uh, the genital STD related chlamydia Communist. You get a to see which associated with eye disease, and you also get L. G V, which is a different type of chlamydia, which I'll get on to. Morphology is an interstellar. You bacteria. It's parasitic clinical presentations so very similar to gonorrhea. But it's not as offensive past forming. It's just some people can be asymptomatic, especially women, and you get, you know, the other symptoms of STD Diagnostic is via a nuclear application. Tests of gnats and the males. This is a urine culture for females is of old fashioned swamp. And you get two weeks post exposure if applicable, um, to see whether you've been treated or not. Management is Dr Cyclen for seven days or is it from rising Now, Does anybody know what this is? Adhesions? Yes, it is. It's you, Curtis. It is Fits you, Curtis. Very, very good. So chlamydia is associated with Harry Potter, Harry hepatitis, which is basically hepatic adhesions. So this is, you know, you get adhesions between the liver and the abdominal wall, this associate with chlamydia, and sometimes people may get this right. Uh, quadrant pain and hepatic picture, which associated with, um, it's called Fitz. You Curtis, 45 year old female presents with an offensive smelling vaginal discharge, which is very self conscious about the odor is so awful that she's worried that others will judge her whilst catching a local best to work. She's in a long term relationship with her husband and denies being unfaithful. Which of the following is most likely Etiology A. N C. Seems popular. Okay, so this here, um, I think the big thing is the odor is so awful, and she's not been unfaithful. So between a one. C, which is the most plausible. Trichomonas vaginalis is an STD, so it's not likely going to be that this is bacterial vaginosis, so Gardnerella and a mixture of other bugs is the most common. The gardener or a vaginal. This is the answer now BV, usually caused by peptostrep, which was the only other options. But it's not as common. Gardnerella Bacteroides Mobile Lanka's and it's pathology is grandma variable, so the sonogram thing could be anything and clinical presentation. It's not very nice. It's very malodorous, so vaginal discharge fishing is often described as offensive, thin, white, watery discharge. It may be a symptomatic, and it's not distressing. It's usually just embarrassing, and the management is P O metronidazole for seven days or topical clindamycin, and you can use metronidazole when you're pregnant as well. Does anybody know what this is called? People are saying clue so yes, this is a clue so very, very good. So part of the criteria which I'll get onto called hamsters criteria is the diagnostics of BV, usually GP. It's clinical, but you can use this criteria to judge whether or not it's TV or not. And this is where all the bacteria surround the cervical, uh, vaginal cells, basically, and that's what a clue cells called, Um, so the criteria is full of things. You have to have a positive test, which is basically a potassium hydroxide in the discharge makes a fishy odor. Vaginal discharge has to be about 4.5 p. H. Now if you have. If you have a vaginal discharge vaginal pH, which is less than 4.5 that's normal. That is naturally acidic to prevent bacteria. But if it's above 4.5, that means it's more out fine. So far back to your confirm a thin white largest discharge and include 1000 microscopy. Okay, a 24 year old male presents with very painful lesions on his foreskin and scrotum. These are very painful in particular in Asia, you suspect ups to infection and want to initiate management. Which of the following is most likely management plan? This comes up in exams by then. Any takers? I think C and D Okay, so the answer would be See, you don't need to add topical steroids. It actually makes it can make things worse. So your acyclovir, acyclovir, is the drug which I mentioned, which is an anti hepatic Asian, basically, and we use it for a lot of as an antibiotic, a lot so acyclovir with the answer. You don't need to add topical steroids at all STT. So genital herpes etiology is either one or two. The overlap. So it's classically people thought, Oh, it's just called, so it's gonna be one. Genital sores are going to be two, but sometimes they overlap with each other, so don't necessarily think that is. But for example, this is the one called Source, too gentle clinical presentations. Very, very, very, very painful. There particular the blisters. Basically, you get to Syria. It's itchy, tender inguinal lymphadenitis. You get lymphadenopathy around your groin and systemic syndrome. You can feel very unwell whether it's not just the source, and it's painful. Diagnosis is the same as comedians not, and you may have to do serology, but that's usually and management is acyclovir. You may only need this long term because it can reactivate. Once you've had herpes, you'll never get rid of it. It just it just sits in the ganglion and relapse. Speaker. Conservative management is your analgesia. Saline bath in topical local anesthetic. If pregnant, you want to do an elective C section because you don't want your child getting herpes. Okay, 35 year old male presents with a generalized rash across his trunk, arms and soil and soles. Sorry, this began six months. Post the development of a painful lesion. Pain, Sorry, pain, less lesion on his glands of Penis. He also described it ongoing fever and widespread lymphadenopathy. What is the diagnosis be? People are staying good. So this is secretary syphilis. So the big clue is painless. Lesion. You think painless lesion is going to be usually syphilis compared to herpes, which is painful. And because he's had this for six months and you get this rash and secondary, then it's secretary syphilis tissue. Really tertiary. I'll come home in the bed. So Treponema palliative is a spirochete which causes syphilis. It doesn't stay well in the ground stain, so you have to use other different types of stain. I think sometimes you silver something like that, but it doesn't stay very much. Clinical presentation. Primary Syphilis is a canker so painless nontender local lymphadenopathy. Some people don't even notice it. Secondary 6 to 10 weeks Post primary syndrome. Yet this generalized rash and snail track buckle lesions You may get condylomatous a lotta, which is these white white like a cirrhosis looking blacks. And in tertiary. This is after many, many years and lots of famous composers and, like Shuman, had syphilis, which caused sort of insanity back in the day. But people didn't know about that. So you get tablets dorsalis. Where it's neurosyphilis has gone to the the lawful columns, and you get perception of vibration loss are the Robertson pupil, also known as the prostitute pupil. It can either be seen in neuro syphilis or severe diabetes mellitus. Government has lesions, just Google or government. Looks like it's not very nice. General prognosis would be insane. Paralytic dementia basically an ascending aortic aneurysm information you don't need to know all this. Just know many years later, management, it's always been the same. I am better than penicillin. G. Just remember it. And if your penicillin allergic, you use doxy for any spirochete infection, such as Lyme disease or anything like that, they're all the same. Family Doctor cycle is usually the one you used to be warned of. Something called the Irish Hard Time a reaction. So some people, when they have the penicillin, which breaks down spirochete, it releases an inflammatory response, basically, and that causes the Irish halftime reaction. It's it's mild. You just have to use paracetamol. It's not an allergic reaction, and this is a bit some. I've seen it on Pass Med. I wouldn't really worry about it, but these are different testing you can do VDRL rapid, um, antigen test in T P, H. A and FDA. Just learn this table. If you're interested, I don't think you'll come up other things. Trichomoniasis. So this is a flash related protozoan, and it's again associated with pH above 4.5 like Gardnerella. But it's not going well. It's not an STD. While this is it's green offensive discharge, you get your arthritis involving the vaginitis, and it's classically associated with strawberry cervix, which is this pinpoint strawberry looking service on on the cervix. Diagnosis. Because it's a protozoan, it's total. You can use something called a wet track, which basically get some liquid put on. Put on a slide and you put it under a microscope and you can see it moving. And you're looking for the motile trophozoite, which basically is these protimes management specializing ldv. So I remember I was talking about chlamydia C F R L1 to 3 calls, something called Lymphogranuloma for gonorrhea, and this is associated with HIV confection and men who have sex with men. It's it's more prone in that population. Tropical countries may see increased occurrence, and clinically, it's a painless postural ulcer. Visualize in BUE bows and then proctocolitis. So if you have someone who's got HIV and has got prostatitis and he's got you know, um, and it's got this painless pastoral or ulcer think LDV treatments with Dr Cycling. This is what LGBT looks like on the left, and this is what Trichomoniasis looks like on the right. A 40 year old male has returned from vacation in Vietnam with ongoing crampy abdominal pain with associated water. Watery, non bloody diarrhea has been effective birth life, and he's opened his about 5 to 7 times a day for the last three months. What is the most likely diagnosis be, people are saying, and also e good. So it's be so. This if any of you think anybody come back on holiday, they still got this crampy non bloody diarrhea is ongoing for a while, I think giardia now people like giardia is a bladder protruded a bit like a bit like, uh, trichomoniasis, and this is what it looks like. This mobile thymocytes and the transmission speaker oral usually get off of water and food. Um, clinical presentation, chronic non bloody diarrhea or dizzy, increased, flattering and bloating. It causes malabsorption, lactose intolerance, which means you can get steatorrhea, which is fatty floating stools. And this is why it's been crampy a bit uncomfortable and the diagnostics you want to do stool sampling. So just stool culture and you're looking for trophies sites. But back in the day, people used to swallow string and then have, and that would then get their duodenal aspirate and then test in the microscope. We don't do that nowadays. We just give metronidazole is the treatment. 23 year old females returned from vacation in Egypt with crampy, abdominal pain and nausea and associated water. Not not bloody diarrhea. She's had more than three loose stools in the last 24 hours. What's the diagnosis? You've got someone saying, See? Okay, Anything else be okay, So we got a mixture. Okay, so this again, wherever I said, no can raise a Common things are common if someone's gone abroad. Those common cause of traveler's diarrhea is excellent, so this is excellent. So, um, the other. So with salmon and typhi would be titled fever, they'd be a lot more unwell. There'll be other signs and to me, about his political. That's bloody diarrhea. That's dysentery based. It's a type of district traveler's diarrhea, so most common is estrogen choline gram negative bacillus transmission from the oral is always clinical presentations. Nonbloody, watery diarrhea, cramping, abdominal pain, nausea, vomiting may be seen and the most common cause of traveler's diarrhea lots of people picked up in traveler's diarrhea is associated, and to find is about three watery stools and 24 hours plus or minus association management conservative. And you just have to offer or replacement therapy. Stitches like Imodium or diarrhea, like basically 35 year old male returned from traveling around Southeast Asia with abdominal pain, nausea and constipation. He's also complained of a new onset rash covering his pulse. Um, basic option of fever and 39 the heart rate of 55 was the diagnosis. See good. This is typhoid fever. Big thing with this. If you have a gastroenteritis with a relative bradycardia, which is a decision degrees and heart rate low then and a rash think typhoid. So typhoid paratyphoid fever. Salmonella type of parasite is a gram negative bacillus. It looks like this is very hairy. It's got a lot of It's got a lot, a lot of phlegm yellow basically and Syria. So again, fecal oral water. It's clinical presentation is bloody diarrhea, but it's constipatory is one of the only gastroenteritis is enteritidis, which causes constipation. You get abdominal pain, distention relative bradycardia, and that rash is known as red spots, and it's more common in paradise for complications you need to treat. You usually need to treat this, but sometimes, um, sometimes people don't use to treat this complications. Perforation hemorrhage in in people who've got sickle cell, uh, salmonella species such as enter richness cause an osteomyelitis, so that comes up in exam. Sometimes chronic carrier. You can get also chronic carrier to salmonella, and some sometimes goes to the brain. We have enough management. It's not increasing resistance. But classically, you choose ciprofloxacin. Um, if, uh in this, uh, situation who poisoning, it's really important to know the organism because, according to incubation, if it's got a very short incubation and vomiting straight away, either staph aureus bacillus bacillus is usually associated with rice 12 to 48 hours. Think salmon estuary PSA longer. You're thinking more jihadia and stuff like that. Okay, bit different. But a 47 year old male who has a known I've e d u uh IV, do you has presented specific assessment units with suspected cellulitis. However, on examination, you noticed wrestle hemorrhage with a white pill, center of endoscopy and a murmur. What is the most likely etiology for the diagnoses? See good. This is ineffective endocarditis, most common in people who, uh, inject drugs or have had, like, dental work or anything like that. But this retinal hemorrhages, the white pill center on endoscopy that's known as a rough spot, which is pathognomic for effective endocarditis, usually and then a fever. A new onset murmur. Think effective endocarditis until proven otherwise. The most common cause is definitely serious, but there are other, you know, things that you can consider etiology staff. Always usually. But you can also get staph epidermidis, which is another type of stuff, and that's the most common following prosthetic bowel surgery. So if they are less than two months after prosthetic bowel surgery, think epidemic. This shot record is bogus. Is the surgery colorectal cancer? I would really learn that irritant is dental plaque, poor oral hygiene to move from your mouth to your heart and then, hey, stick. It's just part of the Duke criteria, the modified do criteria, which we use to diagnose effective endocarditis. And funny enough, this comes in on skis. So be prepared clinical presentation if you have any of the peripheral stigma too effective. Endocarditis also knows Janeway lesions of SportsCenter, hemorrhages and a new a new murmur and fever. Then think effective endocarditis, and this is the modified do criteria. Wouldn't learn it in detail. But for example, let's just say you use the modified two criteria. Three blood cultures when temperature spikes usually, and you'd have to treat this empirically so. Initial therapy. Native valve amoxicillin. If it's penicillin, allergic vancomycin is usually used and then you know prosthetic five. You add guaifenesin these This table, um, can be quite important. But basically, if you got staph through cloxacillin, you've got strep benzel pen. And if it's anything complicated as on gentamicin or rifampin or vancomycin. But initially it's amoxicillin. Last question I promised the 76 year old female to be admitted to em are admitted to the MRSA positive cellulitis. You administer antibiotics who believe shortly after this patient's been turning progressively red was the diagnosis and what has caused it. I think we have a, uh, see as well. Good. This is seen. So this is vancomycin is also known as red man syndrome. So if you can Vancomycin IV, you get this massive inflammatory response full of histamine release, which causes which vancomycin is vancomycin mediates, causing the red man syndrome. So this is a classical antibiotic side effect, and these are some of the ones you should know. Amoxicillin. You can get a rash if you have BV. So a glass of fever. Um, and the other one I take out of this is a recognized in a macrolide. You get cut the interval prolongation metronidazole disulfiram effect. If you take alcohol, you're going to feel like a hangover effect If you're on metronidazole Doctor Cycling, black hairy tongue. Photosensitivity trimethoprim think hematopoiesis depression. But with all of these always think allergies number one. And that is me. So thank you very much for listening hope. Sorry. Overrun and open for any questions. Thank you so much junk. That was extremely thorough. I'm just going to drop the feedback form into the link into the chance again. And our next session is hematology, which is this Thursday. Thank you for coming. Uh, someone's asking story. What was the answer to the last SBA again? My medicine. Brilliant. And yeah. So we'll just wait for people to leave. Hmm. No. Thanks for giving up your evening, Jack. We'll forward you the feedback for me once everyone's got it out. Are we still recording? Oh, yeah. I think it's on your laptop. So if you wanna confused with weight, I can do actually recording. Stop