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Hello. Hello again, everyone. Um, it's now time to begin the sessions for today and for our very first session. Um, we have Emily Lan Lan Castle who's going to be teaching us about respiratory. Um, and Emily is an fy one from Southeast Scotland. So Emily, would you like to begin your presentation? Hi, everyone. Um, so I'm Emily, I'm currently at the Western doing colorectal surgery. Um, and I just graduated from Edinburgh last year. So I know what you guys are going to at the moment. Um, so I'm gonna talk a bit about respiratory today. Um, I'm not able to cover absolutely everything in respiratory just because of the time constraints, but I thought I'd focus on the main things that I think could come up. So, um, we're going to focus on acute and chronic asthma as well as acute and chronic CO PD, um, pneumonia, lung cancer, pe, and pneumothorax. Um, and before we begin, I thought I'd just mention, um, a quick tip for the Emily, uh, for the E LA and sort of, um, prioritizing what to revise. So I found when I did it last year some, um, conditions came up in more than one topic. So, say, for example, for rest, um, pneumonia would come up and rest and then also come up in infection. So if you notice things come up more than one time, I would say, definitely try and make sure you understand those topics just because they could come up, even if they didn't come up and rest, they might come up in another, in another section. Um, and that was something that I didn't really think about until sort of quite last minute. So I thought I'd just mention it then. Um but I'll just get started now. Um So first of all, with an M CK, I'll give you guys a few minutes to a minute or so. Treat you that. Yeah. Mhm. Say, say a few more seconds and I'll move on. OK. So the answer for this one was d which um most of you got. So this is to do with the diagnosis of COPD using spirometry, which we can talk, which we'll talk about in a second. Um And I think we've got another question. Well, so the answer for this one is big. Um And we'll talk about why again in a second. So, COPD is a chronic um progressive airway obstruction. Um Typically it presents with uh shortness of breath productive cough. Um They would have a wheeze and they quite often have re uh recurrent respiratory infections. Um Mostly it's caused by smoking and is seen in an older population, however, it can be seen in nonsmokers and younger patients if they have uh alpha one antitrypsin deficiency. Um and this could be especially true if they've got say, for example, a family history of nonsmokers having a COPD or if they've got liver problems as well. Um in terms of diagnosis, um you would use a clinical presentation of the of and also the um spirometry. So, um they would attend a spirometry clinic and you would tend to see an obstructive pattern, which is where the F EV one and FVC ratio is reduced. And so that uh typically in COPD, you'd expect it to be 0.7 where the normal would be one. Um Gold classification is used to determine the severity of COPD. Um It, the stage doesn't necessarily correlate with symptoms, but it's quite often a it can be an exam question which they ask. So essentially stage one would be the least severe where the FEV one is greater than um 80%. Uh And then as you go down the stages, the FEV one gets um worse and worse. So in stage two, it's between 50 79%. Stage three, it's 30 to 49% and then stage four is less than 30 they would have really quite uh quite bad lung function. Um In terms of management, you might have seen the box um before with the, the sort of four different areas and I quite often find that a little, little bit confusing. So II remembered it more in the three steps of who would get different treatment and why? So essentially when someone has a diagnosis of COPD, everyone would be started on a short acting beta agonist and a short acting antimuscarinic as well. So that would be something like uh salbutamol and ipratropium. Although I think they might not necessarily say the specific um type of medication, they might say more the um drug class just because different trusts might use different um specific types of the medication um as a first line. So that's why they might say more a short acting beta agonist rather than salbutamol. Um Step two is where there's uh the change. So this depends on if they tend to have more of a asthmatic and steroid responsive feature or not. And features that indicate that they might be steroid responsive would be if they have a diagnosis of um asthma or ATP in the past. So that would be things like eczema or hay fever or allergies that could indicate that they might be more responsive to steroid features if they have um variability in their symptom in their peak flow throughout the day, that could also indicate that they, they might be more responsive to steroids. And if you look at the eosinophil count um as well. So I think if I just go back to the last question um here, this patient had eczema. So that's a history of atopy. Um And they also had a raised eosinophil count. So I was trying to get that he was um more s uh sensitive to steroids. And for that reason, the answer would be a long acting beta agonist. Um and uh inhaled corticosteroid. Um And that's uh but then if they don't have any of these features, you would um still start them on a long acting beta agonist. But instead of a steroid, you would tend to start them on a long acting antimuscarinic. Um because if you think they're not responsive to steroids, then it makes sense to try something else. First. If they still aren't, if their symptoms still aren't being controlled, then you would start on triple therapy. So you'd start S laba and Alama um patients would also quite often still have their um short acting inhalers as well just in case they suddenly get uh an increase in their symptoms that can help to relieve it quite quickly. Um At this stage, if their symptoms aren't controlled, that's when you would tend to start referring to specialist because they might need some more specialist medications. Um And then just in general management, um they would also tend to be referred for things like pulmonary rehabilitation, smoking cessation and they would get uh annual flu vaccine as well as the pneumococcal vaccine as well. Um, an acute exacerbation of COPD is when their um, symptoms suddenly get um, much worse and they might present with, um, so a productive cough, much worse, shortness of breath and they might be quite wheezy. Um, this can be, this is quite often in response to some sort of infection, whether it's viral or bacterial and a common, um, organism that might cause this in COPD specifically could be a he, uh, the haemophilus influenzae, uh, which we would tend to treat with amoxicillin. Um, not all COPD, exacerbations are infective though. So that's just something to keep in mind. If someone comes in who you're suspecting might have an acute exacerbation of COPD, you would want to get a set of bloods off them including inflammatory markers. Um You'd want to get some cultures, both of any uh spec and they're coughing up as well as some blood cultures. Um You would want to get an ECG, a chest X ray and then an ABG as well. In terms of the ABG, usually it would show uh respiratory acidosis because people with COPD tend to uh can retain carbon dioxide. So that would make them a bit more acidotic. A chest X ray could indicate a pneumonia. So they might have some consolidation there. Um Bloods, you might see the inflammatory markers are raised and an ECG could potentially show a bit of right heart strain if they have. Um if the, if they have something like a core pulmon core pulmonal as a result of their poor respiratory function in terms of the immediate treatment for acute exacerbation of CO PD, we'd want to start them on some nebulizers. So usually it would be salbutamol and ipratropium, which is the short acting beta Agnes and muscarinic, you would tend to give them steroids. Um So if they're tolerating oral steroids, you can give them that, but you could also just give them some IV hydrocortisone. Um If you think it's an infective exacerbation, you would start them on antibiotics. Usually, at least in the Southeast, we would start something like an amoxicillin. And then in severe cases, you could consider things like um IV medications, noninvasive ventilation and potentially ICU but you would want to be involving a senior at this point. Um quite of sometimes in acute exacerbation of COPD, they would also be requiring some oxygen. So, um just a little note on when and how to use oxygen in COPD because I think that can be sometimes a bit confusing. So the reason that people get concerned about oxygen in COPD is because a lot of these patients are chronically hypoxic. The only thing, at least in patients who retain carbon dioxide that is um driving them to breathe is actually the fact that they are retaining carbon dioxide and it's, they want to um get rid of that. So if you then, so they don't have the hypoxic urge to, to breathe. So then if you start giving them a um oxygen, then it can actually reduce. No, sorry. That's, that's wrong we around. So in people with um who are carbon dioxide retaining, they only have the hypoxic urge to breathe. They don't have the build up of carbon dioxide. So then if you give them oxygen, they then lose the hypoxic urge to breathe and they don't have the urge to breathe off the carbon dioxide. So that's why people can be a bit worried about giving, about giving people with COPD too much oxygen. And why you might see um on placement that people are on scale two, which is slightly lower oxygen saturation. Um But say if someone with CO PD comes in and they're critically ill, you would tend to start them off with a high flow oxygen. Um And then you would after that, um then wean wean the oxygen down and that's just because if someone is critically ill, um you don't know if they're, if they retain carbon dioxide or not, you would want to start them on high flow oxygen because that could potentially cause a lot of harm if you didn't, if they are not critically ill and if they're more stable, you would start them on oxygen versus with a nasal cannula or a ventura mask. And then at 30 minutes, you would get uh ABG and with the ABG, you're really looking at the carbon dioxide, um if they retain it or not, and the sign that they would retain it is if the carbon dioxide is high. But then also the um bicarbonate is also high or is, or the bicarbonate is different because if the bicarbonate is changed, that means that they, this is a longer term issue and that they've uh have learned to um compensate for this and not become acidotic, um noninvasive ventilation uh would be indicated if they have a side of greater than 6.5. And if their ph is less than seven point point 35 and those numbers, um, sometimes come up on exam. So just, uh, it might be worth making a note of those. Um, right. I'll move on to next MCQ. Ok. Ok, a few more seconds just to get last few answers in. Ok. So the answer here was e, uh, raised, um, P CO2, next question. Ok. Ok. The answer for this one was a, so refer for reversibility and you testing. So, asthma is a chronic inflammatory airway disease. Um, unlike CO PD, it has, it is reversible. Um, and it is also tends to be seen in a younger population. Um, it's reversible through use of bronchodilators and symptoms tend to worsen as well in response to different um, triggers. So, for example, something like pollen exercise or cold, uh, could increase symptoms and, um, certain medications like nsaids or beta blockers can also worsen symptoms. Uh, people quite often also have a history of ATP. So that would be eczema, hay fever or allergies and that could be a personal or family history and that might put you more towards the diagnosis of asthma. Um, usually, um, as I said, usually it's seen in younger patients when you suspect that someone has asthma, there are several different investigations that you can do. Um, so I'll just talk through them now. So you could refer them for a spirometry. Um, and in this, you would see AF E one to F EC ratio of less than 0.7 as you would in CO PD previously, um you would have received uh reversibility testing. So, reversibility testing is where after you've initially had some spirometry, you would be given a bronchodilator like a salbutamol and then you would have your spirometry tested again. And essentially, if your um if your F EV one gets better by 12% then or greater, then that would indicate a diagnosis of asthma. If it's less than 10% than 12% then it would be, it wouldn't necessarily rule out asthma, but it wouldn't be a supporting um supporting condition, uh supporting evidence for that. Um People might also use a peak flow diary. Uh So that would be where they do a peak flow at least twice a day for several weeks. And if they have a variability um of 20% between the morning and the evening, that could be a positive sign. Um This is because asthma tends to have a diurnal variation where symptoms tend to be worse later in the evening. And, and at nighttime, rather than during the day, um they, you could also have a FENO test which is fractional inhaled nitric oxide. Um and this is where the amount of nitric oxide um in would be measured. So patients would breathe into a machine and that would measure how much uh nitric oxide is within their um airways. And this is a marker of airway inflammation. So, if they have a lot of air airway inflammation and the marker is above 40 that would be a positive result which would support the diagnosis. Um And another investigation which tends not to be used very much anymore would be a direct bronchial challenge test. And this is essentially the opposite of a reversibility test. So, rather than giving them something that would bronchodilate and improve the symptoms, you would give them something that is a bronchoconstriction and would make the symptoms worse. So, things that, so for example, it could, would be uh anti uh histamine, sorry. Um If they breathe that in, that would cause bronchoconstriction and that would um make their spirometry worse. And you'd want to look at the concentration of the um chemical that you're getting them to breathe in. Uh that causes um a twen a 20% um yeah, a 20% reduction in their um spirometry results. So, if they have uh if it's a concentration of eight or less, then that would support the diagnosis if that makes sense. Um, there are, these are quite a few different investigations. But at the moment anyway, nice recommends to initially try reversibility testing and the FENO as your first line. So you do both of those, which is why a was the correct answer in the last question following that you would do a peak flow diary if you, the results were a bit equivocal and after that, then you would try the bronchial challenge test. But that would be sort of um the last test that you would try. Usually, um this is the management of uh adult asthma which is chronic. Um I know that there can be some differences in the um different guidelines for, for chronic asthma. And at least this is the one that we used in our year and last year. Um They told us that even though some steps in different guidelines are different, they would tend to ask questions and have answers that would fit into all of the guidelines. So, um I know a lot of people were worried about which ones specifically to learn and use, but they would tend to fit in with all of the different um guidelines. So after um a asthma diagnosis is identified, they would tend to be started on a salbutamol inhaler as well as a regular preventer. So the salbutamol inhaler, they'd only use when they're symptomatic and the preventer, which is the inhaled corticosteroid um at a low dose they would use every day, even if they weren't getting symptoms. If that's not enough, then you would add on uh initial. So you'd add on another therapy. So that would be an inhaled um laba um as well as the low dose, inhaled corticosteroid. If that again isn't working, then you could either increase the inhaled corticosteroid dose or you could add a leukotriene receptor antagonist. Um And if they weren't responsive to the laba before, then you would just stop that. And then if the symptoms still aren't being controlled, that's when you would want to refer on to a specialist. Um And importantly, if there's so some people's symptoms sort of get better or worse either throughout the year or throughout the different stages of their life. So if it become so they might initially be uh say, for example, only on the, only on the um salbutamol and low dose uh inhaled corticosteroid and then have to step up or people sometimes also step down. So it would be important to regularly check in with patients to make sure that they're um both complying to the therapy and that they still need the therapy. Or if they need anything more, um acute asthma is quite a common presentation and it can be quite um quite a scary presentation in A&E um this is where symptoms um of asthma rapidly deteriorate. And again, that's quite often response to um a trigger they would present with a progressive shortness of breath, they'd be very wheezy. Um, they might be, have quite a high respiratory rate and have quite a lot of increased work of breathing. Um, when you auscultate them, they might sound quite tight in their chest and quite wheezy. Um, and just generally feel very short of breath. Um, in terms of how you would um, diagnose asthma, it's quite important to try and get an idea of how severe the asthma attack is as that can guide management. And when you would try and call, um, call for help and things. Um So in the, I think that's what the first M CQ about asthma was um talking about and things you would look at. Um So I've got this table here which shows the different um severities and things you'd be looking at would be uh reduced, uh reduced peak flow. Um If they start to become tachycardic or if the or um tachypneic um would be a sign of an acute uh severe asthma attack and then life threatening signs, um which would be very worrying would be say if they're altered consciousness level. So for so if they're drowsy, if they're exhausted, um if they are, um if they're starting to become a bit hemodynamically unstable, so their, so their BP drops. Um and then if their peak flow is also really low, um Importantly, if you listen to someone's chest who you think is having an asthma exacerbation and if it's silent. So you might not, so you might not hear a wheeze, but you would also not hear any um breath sounds. That's actually quite a worrying sign because it would more indicate a life threatening asthma. Um And then in terms of uh near fatal asthma, that would be the raised carbon dioxide. So that's why the answer to the first question was the raised carbon dioxide was the most worrying feature because that would be a sign of a near fatal asthma attack rather than a life threatening asthma attack. Um And this is essentially because in the ABG, typically in an asthma exacerbation, you would see um alkalosis and this is because people who would be breathing really quickly would be breathing the oxygen, uh the carbon dioxide out very quickly as well. So that would mean that they would have less um carbon dioxide. And so then they would be alkalotic um when they start to become tired, they wouldn't be able to breathe out as well. And so the carbon dioxide would initially normalize and then if that continues, then it would get, um then it would get increased. And this is a sign that the patient is becoming really tired and really exhausted. And that's really worrying because they might then need um ventilation support and itu so that's just something to keep an eye on. If you do think someone is having an asthma attack, get an ABG and see what's going on with the carbon dioxide in terms of management of the um asthma of the acute asthma attack. You would tend to start sort of start off up at the top and then put and then off at the top of this list and then um move down as you need to. So if someone is hypoxic, then you would start them on oxygen, you would then start salbutamol nebs. And most people also get steroids again. It can either be oral prednisoLONE or an IV hydrocortisone. Sometimes people find it quite difficult to swallow tablets if they're breathing so quickly. Um, if that stop, if that isn't working, then you would consider some, um, nebulized ipratropium. And then after that is when, then you start the IV medications and you'd really want to get a sooner involved before you start the IV medications. Um, but the first one that you'd probably try would be magnesium and then salbutamol following which aminophylline and then after that, you'd release probably be considering the it for ventilation. Um, so, you know, most people who present with acute asthma attack hopefully wouldn't need to get that. But it's important that you recognize that this is a possibility. So if you are worried about this, it's worth just giving it to a critical care a call. Um, so they're kind of ready for this patient if, if they need to be, um, after you sort of get control of the acute asthma attack you also want to. So once their symptoms are controlled, you want to maybe try and have a look at their, um, normal medi uh normal asthma medication and see if you can change that to try and prevent them from having another attack. Um, you would tend, a lot of people tend to go home on a short course of steroids. Um, and if they are getting attacks more than twice a year, say you would want to refer for a specialist, be refer to a specialist because um, it could be that they would need more specialist input to prevent this from happening. Moving on to the next M CQ. No, um, few more seconds to get the last few answers in. Ok. So the answer would be e uh community acquired pneumonia. 10, the correct answer was a. So going on to pneumonia, um, pneumonia is an infection of the lung tissue and there are a few diff uh main types. So, uh cap which is a community acquired pneumonia would develop in the community cap which is hospital acquired, uh develops uh greater than 48 hours after hospital admission. Um You could also have a ventilator acquired pneumonia, um and also an aspiration pneumonia which would uh happen after you aspirate, um while eating, for example, and just um, a note on the um, aspiration pneumonia that tends to be seen more on the right side. And this is because the right main bronchus is um, the caliber is bigger and then also it's uh straighter. So the, if you do aspirate, it tends to go more to the right side. And I tend to just remember that by thinking bites go to the right, just because it rs and it tends to be more of a, um, it's, and it tends to be a, um, oh, thank you. I'll, I'll come back to that, sorry. Um, in terms of signs and symptoms. So people tend to present with um, shortness of breath, they would have a cough which is typically productive. When you examine them, you would find bronchial breath sounds coarse crackles, which would be um focal to one area and they would also tend to be um, dull to percussion in one area as well. Um When someone comes in with a potential pneumonia, things that you would, uh, in terms of investigations, you would want to get bloods including inflammatory markers, um, cultures of the sputum and the blood and blood as well. And you would want to consider getting a chest X ray, um, and that could indicate a potential consolidation which you can see on this chest X ray here. Um, you would also want to um, consider their curb score, um, and this can indicate the severity of the pneumonia and this can guide then your antibiotic, um, choices. So the curb score um includes confusion. So if they are newly confused, um, and disorientated, that would score a point on their bloods, if their urea is raised greater than seven, if their respiratory rate is really high, greater than 30 they're really short of breath, that counts as a point as well and their BP. So, if their BP is less than 90 systolic or 60 diastolic that counts, um, and this could indicate that they've got quite a severe infection and they're becoming potentially a bit septic. And then as well, if they are over 65 that scores a point as well. When someone has a curb of 0 to 2, they would tend to be treated with amoxicillin. Um, as long as they're not allergic, if they are allergic, it would be more something like a doxycycline. If they are um, curb 3 to 5, then it would be more um, uh, Coamoxiclav and Clarithromycin and this would tend to be IV usually as well. Um, people who are potentially uh curb zero would, could usually be treated in the community. But then as you start to go up to the curb score, they would usually need a hospital admission. Um, just because of the severity of their illness. Um, in terms of microbiology, I think a lot of, um, pneumonia is probably one of the, um, conditions that you would be expected to know a few of the main bugs. Um, usually the three main causes of pneumonia would be a streptococcus pneumonia. Um, haemophilus influenzae and Moraxella catus are also fairly commonly seen. Um And then there's also some atypical um organisms that they like people to know about and they all have different sort of buzzwords or features that can come up in MC Qs that would differentiate them. So, um legionella, uh pneumonia is typically caused by infected water and inhaling it. So that would be um say, for example, if you stay in a hotel and there's air conditioning in the hotel, then you would be potentially more likely to get it if the, if the water is infected. And so the typical MCQ patient would be someone who is presenting with a pneumonia after a holiday in a hotel which has air conditioning. Um, it can also cause um, hyponatremia as well. Um This is because it causes um, si A DH. So if they do have hyponatremia recently, stay in a hotel in an M CQ, at least, could likely be a legionella. Um Legionella. Um Pneumophilia is as um diagnosed with a urine antigen test as well, which would be different to the other types that sometimes can come up as well in an exam. Um, mycoplasma pneumoniae is um, uh, can cause erythema multiforme and that's those ring lesions that, um, are typically a bit paler in the, in the center. And so if someone and the, I think the pneumonia tends to be a bit less severe in this type of pneumonia as well, but if they do have pneumonia and they have those ring lesions in an M CQ tend to tend to point towards the mycoplasma. Um Coxiella burnetti also known as Q fever um is associated with exposure to animals. So, in an M CQ, the typical patient would be say, for example, a farmer or someone who has a lot of exposure to animals. Um chlamydia pistache is exposure to birds um specifically. So that would be someone who owns a bird, for example, who would come up and then um Pneumocystis uh ve which is PCP um tends to be seen in immunocompromised um patients. So for example, someone with um HIV with a very low CD four count could be more susceptible to PCP and this is a fungal pneumonia. It also presents um less uh presents a bit differently to a typical pneumonia. So they would tend to have a dry cough rather than productive. Um I think the chest X ray can quite often be clear. So it wouldn't have that consolidation that you might typically see and they would also um have shortness of breath and reduce saturations on mobilization and they may have night sweats as well. Um PCP tends to be treated with uh cotrimoxazole and often people who are immunocompromised, get a a prophylactic Cotrimoxazole, which they're on long term just to stop them from developing this. Um I've got a Pneumonic to try and remember the different atypical um organisms. So I've got atypically legions for legionella of clams, which makes me think of chlamydia and uh sty mind for mycoplasma. There are PS for PCP and cues for Q fever. So atypically, legions of clams mind their Ps and Qs, which I know is a bit stupid, but I read it once and it really made me remember it. So I just thought I'd mention it here. Um So moving on to the next, um M CQ. Oh. Mhm. Ok. Ok. The correct answer is C which is a chest x-ray within two weeks. So, going on to lung cancer. Um, lung cancer is very common within the UK. Um It's the third most common type actually. Um The vast majority of lung cancers are associated with smoking. Um However, not all of them are the main types of cancer. Um would be a small cell lung cancer which is seen in around 20% of people and a um non, non small lung cancer, which is seen in around 80% of people. Um This is then split into three subtypes which is adenocarcinoma, squamous cell carcinoma and large cell carcinoma. Um, something that I used to remember where the non small lung cancer, non small cell lung cancers would be seen um is LA is on the coast and that's because large cell carcinomas and adenocarcinomas tend to be seen peripherally, uh uh tend to be seen more peripherally on the lungs rather than centrally. And squamous cell carcinoma is, is central. And so that's why I think LA is on the coast because those, um, types are more seen on the peripheries. Um, in terms of presentation, they would, uh, people would typically present with shortness of breath cough. Um, they might have hemoptysis and finger cubbing. They could also have more, uh, generalized constitutional symptoms like weight loss or general malaise. Um, there's also some extra pulmonary features which I'll talk about, uh, shortly and then that can point you towards um specific types of cancer as well. Um In terms of investigation, the first line investigation, if you suspect uh lung cancer is a chest X ray, and you'd want that fairly urgently within two weeks. Um following that you would get a staging ct. Um and then you would get, um, you'd also want a bronchoscopy with a biopsy so that you can see what type of cancer they have specifically as well in terms of referral criteria for diff for chest x rays. Um Essentially, if they are over 40 they have typical features of um lung cancer like clubbing lymph adenopathy, which is the, the raised lymph glands, they've got recurrent or persistent chest infections. And if they've got um raised platelet count and chest signs of lung cancer, they would get a chest X ray within two weeks. Um And then you'd also order uh offer chest to patients over 40 who have unexplained symptoms like cough, fatigue, shortness of breath, um weight loss, appetite loss, that you can't explain, um, through other diagno, through other diagnosis, um, they would tend to be, um, offered to patients who either have two or more of those if they have never smoked or if they have one or more of those, if they have had, if they smoked or if they've had previous asbestos exposure. Um, and that's just because smoking is quite strongly associated with, um, with lung cancer. And so if they have smoked before, then you'd only need one or more of those symptoms in terms of extrapulmonary manifestations. This can quite often come up in MC QS. Um I would say small cell lung cancers uh can cause a lot of extrapulmonary manifestations. And this is because um the small cell lung cancer cells have um neuroendocrine Granules in them. And this means that they release neuroendocrine hormones um which then results in these um additional uh extrapulmonary symptoms. So they uh so si A DH would be caused by um ectopic production of ADH by the small cell lung cancer cells. Um They can also produce ectopic ACTH, which would result in Cushing's Syndrome. And then they can also result in um limbic encephalitis and Lambert Eaton Myasthenic Syndrome. And this is because they can also um secrete um antibodies as well. So, for limbic encephalitis, the small cell lung cancer produces an antibody called anti hu anti who um and then that targets the limbic system in the brain resulting in limbic encephalitis and that would typically present with things like hallucination, confusion and seizures. Lambert Eaton Myasthenic syndrome um is where there is an antibody against voltage gated um calcium channels. And I tend to think of this. Um it's fair. It, it presents fairly similarly to my my gravis. Um but it's important to note that it's the calcium channel um rather than the acetylcholine receptors that's targeted and it tends to present with a proximal weakness of their muscles, uh ptosis, and also they might have slurred speech or dysphasia. And this is all due to the uh weakness in their muscles. Um squamous cell carcinoma tends uh can present with a hypercalcemia and this is due to the ectopic release of parathyroid hormone. Um And then there's also um some extrapulmonary manifestations that can be just because of the positioning of the tumor itself. So Hornos Horners syndrome, um which is a triad of ptosis, which is eyelid, drooping meiosis, which is constriction of the people and anhydrosis which is no sweating, um tends to be caused by a pancoast tumor which is um a tumor in the api in the apex of the lung. And I believe is most commonly an adenocarcinoma uh that presses on the sympathetic ganglion and that causes the these symptoms. Um You might also see a superior vena cava obstruction and this is when the tumor presses on the superior vena cava. And this can present um with really enlarged um and distended veins in the neck and the chest. Um And they also have a pemberton sign, which is essentially when they raise their um hands above their head, their face gets really congested and they also get quite cyanotic and this is a medical emergency. So, um you want to get help as soon as you can and is usually treated with a stat of steroids. Um You can also get a few different nerve palsies just depending on where it is. So if the, if it, um if the tumor presses on the phrenic nerve, that um results in weakness in the diaphragm and results in shortness of breath. And if it, if it presses on the recurrent laryngeal nerve, then that results in hardness and hoarseness of your voice. XM CQ. When I say air entry is normal and tachycardic, that's meant to say on room air, sorry, oh ear entry. Ok. And I'll just move on just in the interest of time. Um The correct answer is ap span for three months and this is to do with a pe which is a blood clot in the pulmonary arteries, um which has moved from elsewhere in the body, typically from a DVT in the legs. Um, signs would tend to be shortness of breath, cough, hemoptysis if they have an inspiratory chest pain. Um, quite often patients are tachycardic and they could be hemodynamically unsta um unstable as well. Um when someone um presents with signs and symptoms of a pe, um, you'd want to do a well score. Um, and the well score includes things like heart rate greater than 100 if they've been immobile, if they've had previous DVT or pe um, hemoptysis and malignancy, and then you would calculate that. If the score is greater than four, you would immediately go to a C TPA or a treat and prickly if there's a delay in getting that, if it's less than four, you would first want to do ad dimer. And if that's positive, then you'd go to the CTPA. If it's negative, then you would consider another diagnosis. Um And we don't tend to go. Um Yeah, so that's right. So, well, score cannot be used in pregnancy. Uh ddimer. Oh no. Uh So D dimer are very unspecific as well. So say, for example, um in they could be raised by a lot of different things, a lot of inflammatory conditions. So say after an operation, all patients would probably have a bit of a raised D dimer. So you would tend to not do ad dimer in everyone unless you were really suspecting something like a pe um things that could increase the risk of them having a pe would be if they've been immobile, if they had surgery, um estrogen can increase your risk. So if you are pregnant or if you're on um hormone replacement therapy or oral contraceptives, and if they have previous conditions like m malignancy or clotting disorders and management is typically with, um, so management is with anticoagulation. Um Apixaban Ian is first line and then low molecular weight. Heparin is used second line of the companies for any reason. And in terms of length of treatment, if it's a provoked pe so say if they've had a surgery, like the patient in the M CQ had, that would be a provoked pe because you sort of know that that's why they had the increased risk. And so they would only have it for three months if they, if there were no, um, no reasons that you could identify for them having a pe, you would tend to give it for six months and then you would tend to give it for 3 to 6 months in active cancer because these patients are, um, quite high risk of developing clots if they have a massive pe with hemodia compromise, that's when you would consider a heparin infusion. Well, that's when you do a heparin confusion and, and, uh, consider a thrombolysis. Um, and this has quite a high bleeding risk. So you want to make sure that you monitor the patient carefully and just consider all the potential risks with that as well. Um, next, so last M CQ. Mhm. Ok. I'll move on just because we've only got a few minutes minutes left. Um, so the answer to this one is a, so aspirate with a 16 to 18 gauge cannula. Um, and I'll talk about why in a second. Um so pneumothorax is where there is air within the pleural cavity. Um and there are several different types. So there's a tension pneumothorax, which is the sort of scariest and most emergency one. And then there's uh spontaneous. So that could be a primary second pneumothorax and iatrogenic, which is where we've done something to cause it. Um Typically, it would present with a sudden shortness of breath with um inspiratory chest pain. Typically in an M CQ, the patient would be uh sort of a tall and slim male who's playing sports. The first line investigation would be a chest X ray and the management would depend on if it's a primary or secondary um pneumothorax and the size of the um pneumothorax as well. So essentially, if it's a primary pneumothorax, by which, I mean, they don't have any previous um respiratory conditions and they're a nonsmoker that would count as a primary um a pneumothorax. And also if they're younger and then a secondary pneumothorax is if they have uh underlying disease, respiratory disease, if they're older and if they are a smoker, um so if they've got primary, then if it's um greater than two centimeters, then you would um and if they're breathless, then you would consider um aspirating and if it's not, then you would discharge them and review in a clinic. Um If they are secondary and it's greater than two, then you would insert a chest drain, if it's 1 to 2 centimeters, then you would drain it with a cannula. And if it is, um, if it's less than that, then you would still consider admitting them and just on oxygen and to monitor them and not on chest strain. In terms of placing them, you put them in the triangle of safety. And this is because this is an area of the chest which wouldn't have any structures, which you would want, which um because the, the chest has a lot of structure that you wouldn't want to damage. And if you put it in the triangle of safety, then that's less likely to happen. And so that's made by the fifth intercostal space, the mid axillary line and the anterior axillary line. Um in terms of attention pneumothorax, that's where trauma to the chest wall creates a one way valve. And that basically means that the pressure within the thorax increases a lot and this can eventually lead to cardiorespiratory arrest. So it is very serious um signs you would maybe notice on the airway a deviation of the trachea away from the side of the pneumothorax because of the pressure, you would have reduced air entry, increased resonance. And you would also notice a unilateral chest expansion. Um They could be tachycardic and hypotensive, they might have reduced consciousness and they could also have signs of chest trauma and you wouldn't want to wait for a chest X ray in this patient you would want to immediately insert a large bore cannula um into the second intercostal space in the midclavicular line. After that, um You would want to insert a chest drain once the pressure has been released and that is um everything if you've got any questions. Um Do let me know. That's great. Thank you very much Emily. That was a very helpful overview and well done for compressing so much of respiratory into an hour. Um We're now going to have a five minute break until our next session which will be on Ob Gyne. Um And can I ask if you have time during your break, please do fill in this feedback form for the session that you've just had. But we'll see you again in five minutes at 10 past uh quarter past 11. Can you hear me? Ok. Hi Carrie. Yes, I can. Perfect. Um I can't seem to share my screen but I can share my slide as a PDF. Um But it's messed up all my fancy um slide things. So I'm just trying to edit and some of the powerpoint slides I have to try and redo it. That's no problem. Hopefully it won't take long. Ok. It's processing, it's just taking a while. So great. Thank you. We'll give it a couple more minutes and then we can get started. Ok. Mhm. Can you see that? Ok. Yes, I can. Perfect. Um So I hope you all had a refreshing break. And our next session is on Hobson Gynae. Um and this is delivered by Carrie o'rourke who's currently an NF one in the seventh dry. So over to you, Carrie. Thank you. Um Yeah, my name is Carrie. Um, nice to meet you all. Um I'm an F one in Musgrave Park in Taunton which is in the 17 way. Um And yeah, I'm gonna be doing the talk on and um it's crazy how quickly you forget everything after finals. So you might have to bear with me for some questions on and gin, um I will try my best to answer them. Um, but I might have to do some researching at the same time, so bear with me. Um Some of the questions I've put in this talk um are a little bit harder than others. Um And that's not meant to like dishearten you or anything. I just think when I was doing vision sessions, I used to find it more helpful if they were on the harder side and I was getting them wrong. I seem to remember them more. So don't get disheartened if there's any questions like that, but hopefully it will be helpful. Um So this is some of the things that I'm gonna be covering. Um OB Gy is obviously huge, so it's quite hard to cover it in um, an hour, but it's also quite niche. Um Most places don't have an F one job in OB Gy and finals are testing whether you can be in F one. So I wouldn't get too stressed about g but yeah. Um, so I thought we'd just do it with questions and then we'll go over, um, the topic. So this is the first question. Um, I don't know whether we can get, get a pa, I might leave it like 30 seconds and then, um, move from there. Ok. So most people have said placenta previa. Um So that is um the correct answer. Annoyingly sorry, my slides are not properly working. Um So I've just revealed the answer. Um But on examination, in this particular case, you would expect the uterus to be soft. Um This is the next question. We'll go over to Previa in a sec. Um Just answer these questions first. OK. So this one's a bit more of a split. Um There's 26% of you that think urgent C TG and then the rest mostly um IV fluids. Um So the correct answer in this situation is IV fluids and cross match. Um I think one of the most important things with obs and Gynae is that they always want you to prioritize the mom over the baby. Um If the mom is unstable, you're going to want to resuscitate her first. So her BP is low, it's 80/48. Um and her pulse is high. Um So that's quite concerning um that she's kind of in hypervolemic shock. Um So you'd want to cross match her first. Um One of the things with this question as well is that the severe constant abdominal pain and small amount of vagina bleeding obviously is the main things. Um Does anyone want to put in the chart? What they think is going on? Ok. I can see the ch Yeah. Um So it's placental abruption. Um So the reason that I've said small amount of vaginal bleeding is to kind of accentuate the point that um with um abruption, sometimes the shock is quite disproportionate to the amount of bleeding you're you're seeing. Um And that's because if the um placentas come loose at the top of the uterus, the bleeding might be kind of not exposed. So you can't really see um see all the bleeding. Um cos it's happening at the top of the uterus. Um I have some diagrams. So hopefully it'll be helpful to explain that better. But um yeah, like you guys said, it's a placental abruption and first you want to resuscitate the lump. Um So these are just summary sides on previa and abruption. Um So placenta, previa is where the placenta is on the bottom part of the uterus. So it's covering the cervical loss. Um Some of the risk factors for this is that um you've had lots of um babies in the past. Um So you've got twins or more um babies or you've had a previous C section. Um And that's the kind of big one to remember, I'd say because they might put that in the stem and that's highlighting that for you. Um The way it presents is importantly that it's painless. Um And the uterus will be soft, um, and won't really be tender. Um, the shock is also going to be in proportion because um, the is on the spi so all the bleeding will come out. Um, so you can see it. Um Normally it's picked up routinely on the 20 week abdominal ultrasound. Um And then they'll go on to do a transvaginal ultrasound to confirm it. Um So it's usually known about. So that means normally there's kind of a set way to manage it with um rescanning every two weeks from um 34 weeks and doing an elective C section. Um But if they start bleeding before the selective C section, then obviously, you would want to resuscitate the mom, make sure she's ok. Um And then do an emergency C section if the, the baby is unstable um abruption. On the other hand. Um So the way you differentiate them is really that this is really painful. Um And also they're more likely to have a really tense uterus. Um So often it's referred to as Woody uterus. I think that might just be a past my questions. But um that phrase often is kind of means abruption. Um Some of the risk factors are preeclampsia, um Antiphospholipid syndrome, smoking, cocaine use and trauma. Um And it's a, a clinical diagnosis. Um You manage it by resuscitating and stabilizing the mom again. Um You want to check on the baby after you've stabilized the mu that's with CTG um because they're bleeding. Um You want to make sure it's not a previa first by doing an ultrasound. Um And then you'd manage it with ac section to get the baby out if they're unstable. Um Or if they're stable, you might do an induction. Um The other thing with previa, that's important to know is that you would not do a bimanual exam. Um because kind of for obvious reasons you could um cause her to bleed um and become unstable um because the placenta is on the, so these are just the, the diagrams. Um So you can see that the placenta is low lying in the previous one. And in the abruption one, this is what I was referring to earlier. So if it's become loose attached at the top, you wouldn't necessarily see all the bleeding. Um So the shock could be disproportionate um to the amount of bleeding you're seeing. I hope that makes sense. Um So this is just uh a slide summarizing some of the, the placental emergencies, we've already covered previa and abruption. Um Vasa Praevia is where the umbilical vessels um run across the, the os rather than kind of elsewhere in the uterus. Um And that means they're not protected, then they're not running in the umbilical cord. Um So they're not protected by that lining. And that means that they're really prone to rupture. So if, when someone goes into labor and they have rupture of membranes, they might also get rupture of the vessels. Um and that obviously is um can cause kind of devastating hemorrhage. Um And this is a, a big emergency, but it's, it's a lot rarer than the others. Um So that also presents with painless PV, bleeding. Um And also the, the fetus will um, often be unstable. So it might have bradycardia or something on the CTG. Um Sometimes it's picked up antenatally before the bleeding starts or before um, any problems really arise yet. Um And that's usually on a um, vaginal exam, people will see pulsating vessels. Um The risk factors are low lying placenta. IVF multiple pregnancy. Um And you treat that again with active C section or if they're bleeding an emergency C section. Um Aquita is the only one out of all of these four that would present with postpartum, bleeding, bleeding rather than antepartum bleeding. Um And that's where the placenta is like deeply ingrained into the uterus. Um Some of the risk factors for that is previous C section, previous previa or uterine surgery. Um And normally the way they'd manage that is with an elective C section. Um And then they'd have to take the uterus out as well. Um And that's because they, I think it's too risky often to try and, um, kind of dissect the placenta away from the uterus. That's so kind of, um, deeply ingrained. Um, there's different gradings of it as well, but that's probably beyond what the, you need to know for finals. Um, but increta means it's into the muscle and percreta means it's through the wall. Um, so sorry, this bit is a bit heavy on the, um, material. We'll go on to another question in a sec. Um So antepartum bleeding is when it's after 24 weeks of gestation and the main two causes, I'd say you need to know about those is previa and abruption. I would forget about the rest. Um Anything that's before 24 weeks. Um There's other causes which are probably important to know about. So that's things like um ectopics or miscarriage. Um, postpartum hemorrhage is obviously after the baby's been born. Um If it's a vaginal delivery, it's classified as more than 500 mils of bleeding. If it's ac section, it's defined as more than 1000 mils. And that's primary if it's within the 1st 24 hours of um the birth, um secondary would be if it's between 24 hours and 12 weeks after the birth. So the main causes of primary postpartum hemorrhage are gonna be the forties. So that's tones, uh trauma tissue and thrombin. So tone is where the uterus just doesn't kind of tense back up after the baby's been born. Um, and that's often if they've got twins or polyhydramnios that stretched the uterus or they're, um, a bit older or they've had lots of babies in the past, the uterus just doesn't work as well as a muscle anymore. Um, and trauma is normally kind of perineal tears. Rarely, something like uterine rupture tissue is then when, um, the placenta, um, is retained and doesn't, doesn't come out and that you'll just continue to bleed because also your uterus won't tense back up and then thrombin is just bleeding disorders. Um Often that's preexisting ones like Von Willebrand disease, which will be known about. So they can prepare for those um in advance by giving them um factor eight or whatever it is um before labor, um or during labor, the others might be acquired. So something like D IC if they're in sepsis or something like that, the secondary, um normally the, the two courses you really need to know about are retained products of conception or infection. Um So you'd investigate it by doing an ultrasound to make sure there's nothing still in the uterus after the baby's been born like some placenta left over or something like that. Um And you would want to do vaginal swabs um to make sure there's not an infection and you'd treat it either by doing a surgical evacuation if there's retained products or antibiotics, if it's an infection. Um I hope that makes sense. I'll just check the chart. Um Yeah. So I think um placenta Previa, the question is just about, is the placenta two centimeters or less from the internal in Placenta Previa. So in Placenta Previa, there's two types. So there's low lying or there's true. Placenta Previa, low lying would be if it's like close to the, the cervical or so, if it's two centimeters away, um then it would be a low lying placenta and that would kind of be managed in the same way in terms of antenatally screening to make sure it's, it doesn't move because the reason that they, they keep scanning every two weeks is to make sure it doesn't actually just, just move and then they haven't got a previ anymore and they don't need to have ac section. Um True percent app previa would be if it's actually covering the OS. I hope that makes sense. Um So management of maternal hemorrhage, um I've just put this quick slide in here. Um So it's obviously an emergency. Um So you'd want to put out a 222 and say a major obstetric hemorrhage wherever you are, um do an a to e resuscitate the mom, um give her fluids while you're waiting for blood to be um to arrive and then resuscitate her with blood products. Um I've just put some differentiating factors for antepartum and postpartum. Um The most important one is probably postpartum to know about. I think that's more likely to be tested than finals. Um And there's just kind of a step wise approach to the things you would do. You probably remember this from Robson last year. Um But the first thing you'd want to do is you try massage. Um So that's putting one hand um by doing a vaginal exam um through the vagina up the uterus and then one hand on top, um and massaging that way. Um Then you'd want to give them Oxytocin as well. Um I think that's quite routine to give Oxytocin. But in this setting, if it's a postpartum hemorrhage, you would give more, um, you, you might give extra doses. Um And ergometrin is another similar one that helps the uterus tend. Um, some people would give oxamic acid. Um, but I think usually the next set um, step if CTO doesn't work is to transfer them to theater and there you would get, um, something like an intrauterine balloon tamponade. I've put a picture up there so you can see it. Um, and it looks a bit like a catheter, um, that they inflate and that um, kind of tampons the bleeding. Um The next step if that doesn't work is you tie off the uterine arteries, then you might try and do the suture. Um And then if that still doesn't work, then you would go on to do a hysterectomy. Um I'll move on just because I'm worried of time, but that's what you would do for an antepartum hemorrhage. Um I think it's less likely to be tested, but just for revision purposes, if it's helpful. Um ok, sorry, that was really heavy. So, next question, I don't think there's as many revision slides, post questions coming up after this. Ok. Um So most of you have said transvaginal ultrasound. Um some have had abdominal ultrasound and some have said urinary pregnancy test. Um So this one's a little bit trickier maybe. Um But the correct answer is transvaginal ultrasound. Um So the reason for that is that you want to, to check whether there's an intrauterine pregnancy. Um Obviously, they've got a positive pregnancy test. Um So you're thinking because of the right iliac fossa pain, does anyone want to say quickly what their, their top differential? Right at this moment is. Yeah, topic. Um So you want to check whether there's an intrauterine pregnancy. So you want a transvaginal ultrasound, which is just more accurate than an abdominal ultrasound, which is why that's the first line um rather than an abdominal ultrasound, urinary pregnancy test. A serum pregnancy test is more accurate than a urinary pregnancy test. Um And you've already got that confirmation. So you don't need a urinary pregnancy test. You've already confirmed that. Um So a transvaginal ultrasound as well. Um You can see um the, the ovaries and the adnexa sometimes. Um and one of the diagnostic factors is seeing um a tubal ring sign on a transvaginal ultrasound for an ectopic. Um, sometimes you can't see that. Um, but something to not, um, you can also sometimes see if it free fluid or not. Um, and that would indicate whether there's been a ruptured topic or not. Um, so another quick question, um, for the person that said, would it depend on what the topic is? It? Definitely. Yes, it would. Um, the reason I said that is because mostly I think it's in, um the ampulla in the, in the fallopian tube. Um But it, it can be anyway. So, yeah. Um and if, if you have an inconclusive ultrasound, um then you would, and you're concerned clinically about an ectopic, then you would always go and do a laparoscopy to uh like a diagnostic plan. Um If that unstable. And so, yes, most people have said a salpingectomy. Um And then second is methotrexate. Um So the actual answer is methotrexate. Um And annoyingly again, my slides have said to this, but I think we all need that. Um So for this question, um the reason it's methotrexate is because so her symptoms are quite mild. Um It says slight discomfort um as opposed to pain. Um Her HCG is less than 1500 but is more than 1000. Um And that's when you would do medical management rather than surgical management. Um I've got a slide with um the diagnostic, like which one you choose in a little bit. Um And that's kind of more just kind of trying to um remember that um rather than anything complicated, but um it is annoying to try and remember it all um ectopic pregnancies. So that's when um, you have the first fertilized ovum that's implanted outside the uterus. Um, the way you diagnose it is that you have to have a positive pregnancy test. Um And often if you do serial HCG S, um you will see that the HCG does still rise um because you, you've still got AAA pregnancy, it's just not viable. Um So the HCG will rise um but it'll rise less than 63%. Um I don't know if you guys have heard of that before, but for some reason I remember that from and G um teaching that it rises less than 63%. If it's more than 63% it's likely to be a viable pregnancy um if it's less than 63%. Um but it's still rising. Um That's suspicious of an ectopic if it, if it's falling, that's suspicious of a miscarriage. Um Another diagnostic factor is that you see an empty uterus um on ultrasound scan, um or you see this tubal ring sign, which is the bottom picture. Um And the way to ultimately diagnose it is by doing a diagnostic laparoscopy. So, the most common site of an ectopic is the fallopian tube in the upper section. So that's in, in the second diagram down. Um And the way it presents is. Um So they'll have a missed period. Um You'll have pain in the right elect foss or, or left ect fossa and often shoulder tip pain because you'll um you've got referred pain from um irritating the diaphragm as well. Um Often it presents with vagina, bleeding, some lower abdominal tenderness and cervical motion tenderness, um which is pain when you're moving the cervix on a bimanual exam. Um I put the risk factors there. Sometimes they're really useful with S and gi find that a lot of the thing, a lot of the questions, um, you get taught all these risk factors and I think the reason they actually helpful is just for, um, the, the stem often they'll put them in. Um, so it just helps you differentiate something. So sometimes it can be helpful to memorize them. Um, so there's just the list there. Um, and the top picture is, um, a picture from a diagnostic lap of an ectopic and the arrow is pointing out, um, where that is. So this is the table, um, about how to manage an ectopic pregnancy. Um, so the most important point, um, is probably if someone's unstable, it's ruptured, they've got lots of pain. Um, then you're gonna do surgery. Um, the other things that you just have to kind of remember is that if the HCG is above 5000, um, then you're definitely doing surgery or if it's above 35 millimeters in size um between just monitoring and medical. Um The main features are um whether they may have a little bit of discomfort. Um And then the HCG level. So if it's between 1000 and 1000 500 then you would more likely do medical. Um, the thing to so the medical management would be methotrexate. Um Other things to know about methotrexate. Methotrexate is that you can't drink alcohol with it, you can't take folate. Um And you wouldn't be able to conceive for the next three weeks. Um So that's just about some kind of counseling for the mums taking methotrexate. Um You also obviously can't have any contraindications to methotrexate and that's things like um being um having, having really low platelets, um having really low white cell count and things like that as well, but that's more for the nitty gritty things. Um You also have to be able to, to attend for serial hcgs for both medical and expectant management. Um So if there's something in the stem about not being able to do any follow up, then they would have surgical management. Oh, that's really annoying. Um Sorry, my slides have messed up. Um I'm gonna go back and I'm gonna just read, try and find my powerpoint so I can read the stem. Um And then hopefully you guys can shout out what you do next. Um Two seconds. So the stem is um a 32 year old um comes into the diabetic antenatal clinic, um, at 32 weeks pregnant, her BP is 100 and 49/98 and she's got a past medical history of hay fever and asthma. Um, what would you do next? Um, so this is in the hospital in a clinic. And, um, that's the next poll. So it's not that poll yet if we hold on. Um, if people just want to message in the chat, what you would want to do next if her BP is 100 and 49/98 and we're in a Antenatal clinic. That's OK. So people have said Nifedipine, if labetalol is contraindicated, um do the P I GF blood test um move to ob triage. And um so that's all really good suggestions. Um The, the thing I've said to do next is to just check her booking BP. The reason I've said to do that first is you want to just double check whether she normally has hypertension. So, what you're thinking here is, is this likely to be preexisting hypertension? Is this a presentation of uh preeclampsia or is this gestational hypertension? Um So, if her book, if I tell you that her booking BP was um not high, so 100 and 8/76 um then that kind of gets rid of the differential of preexisting hypertension. Um So then a lot of you have s have said um kind of do a urine dip, um which is really good. Um So the next thing I'd want to do is to ask her about um kind of preeclampsia symptoms. Um So, does anyone want to list any of the symptoms that they know? Yeah, headaches, visual disturbance, um nausea, vomiting, epigastric pain, um edema. Um Also sometimes they have reduced urine output. Um brisk reflexes as well is quite a bad sign. Um And then you'd want to do the urine dip that you guys mentioned. Um And what would you be looking for on the urine dip? Yeah, protein. Um And you'd also want to do a blood test. Um And that's looking for um whether they have high creatinine, so they have any renal impairment. Um often um your rate is high um in preeclampsia. Um and they might have a high alt. Um What would I be worried about if they had low platelets? And for Daniel who's asked about differentiating preeclampsia and non proteinura, very good question. I think it would be just a clinical picture if they had high BP and they had lots of proteinuria. So it would be the amount of proteinura and just the clinical picture of it. Um If that makes sense. Yeah, those people have said help, that's really good. Um So you'd want to check platelets as well and the person who said, Nifedipine well spotted, she's got asthma. So labetalol is contraindicated. And the next thing you'd want to do is to start her on Nifedipine. Um So if I go back to the slides, hopefully. So that's all summarized there. Um, like we said, um, and annoyingly it's done the same thing. So the next bit um of the scenario is that when you're waiting for her blood test, so you don't know her blood test yet. Um She suddenly becomes unresponsive and um moves her limbs in a jerking fashion. Um What would you do next in this situation? Um And this is the poll for the next question. So ignore that poll again for a second. Apologies. One sec, I'll get the right one up in just a second. Yeah, don't worry. It's actually the next one isn't a poll. It's just a, don't worry, it's um you would do all of them. So, um does anyone want to just mention in the chat? What you would want to do next if she started having jerking movements in your Antenatal clinic and became unresponsive? Sorry. So she um she becomes unresponsive in the, in the Antenatal clinic. She starts moving her limbs in a jerking fashion. What would you do next? Yeah. So the person that said 2 to 22 is what I would do if I was in that situation, I would want more people that ate up. Um So I do 2 to 22. You would want to put out kind of maternal collapse um on the phone and you'd want to do your A to E um and the person that said recovery position, yes, you would want to put her in recovery position. Um, any particular things to note for pregnant people with recovery position. Um So the thing I was thinking of is to put them on the left side. Um, and that's because you never want to, yeah, someone's put it Vena cava compression. If you put them, um, on their, on their right side, then you can press on the Vena cava um and limit blood supply back to the heart and that can cause cat. So, um that's really important. Um And the person that said magnesium sulfate, um that's correct. You'd want to give them IV magnesium sulfate next. Um And you'd also want to get their BP down. So you would give them I Vine Nifedipine and you're gonna want to get your seniors in early. Um because they're probably gonna want to deliver the baby um or give steroids if um they're under 34 weeks as well. Um while they're stabilizing the mom. So that's what the next slide says. Um f So this is uh the next question if um we can have the pole now, if possible. So there's quite a lot of reading in this question. Sorry. Um But I think most of you are getting um to the point that I was hoping to make. Um So most of you have said administer antihypertensives. Um And deliver the baby by emergency C section once the BP is controlled. And that is the right answer. Um So the reason that that's the right answer is again, going back to the point of you always want to stabilize the mom first. So the CTG being abnormal is obviously really, really concerning. Um and you would want to do an emergency C section as soon as you can. Um But at the moment, um you want to stabilize the mom. Um So that would be giving her antihypertensives um first to get her BP down. Um because going straight without doing that would be um very risky to, to um for the mom. Yeah, I think you said. Um So that is the correct answer there. Um So the last few questions have been about preeclampsia. So this is just some of the, the definitions. Um So if they've got preexisting hypertension, so that's essential hypertension. That would be if they've got diagnosed hypertension before 20 weeks, pregnant pregnancy. Um If it's pregnancy induced hypertension, it would be after 20 weeks. Um But the diff the way you differentiate that between preeclampsia is that they've not got any end organ damage. So that's proteinuria or rasal t or high, high creatinine things like that. Um And then the triad of preeclampsia is that they have high BP, proteinuria and edema. Um That's just often the three things that we mentioned in um the exam stem, it's not um diagnostic um thing. Um So eclampsia is when you start having seizures um because of your uncontrolled hypertension and this is an obstetric emergency. I've put some of the, the risk factors here. Um And that's just uh in terms of antenatal risk reduction, um you would give aspirin to people that have one high risk risk factor from 12 weeks until they give birth. Um And that's to limit the, the risk of preeclampsia. And you would give um also give aspirin to people that have more than one moderate risk factor. Um The high risk factors are sort of self explanatory. They have preexisting hypertension, they have had preeclampsia in the past. Um They've got an autoimmune condition like a lupus diabetes or chronic kidney disease. Um And some of the complications are hellp syndrome like we already chatted about um D IC and placental abruption. Next question. So we're now going on to the gynae section. Yeah, you guys are straight on it. So, um the, the answer in this setting is transam acid. Um That's the only one out of all of those. Um That would allow that woman to also continue to try to get pregnant. Um The other ones are either contraindicated like endometrial ablation or the um contraceptive methods. Next question. Great. Um So you're getting the right um the right answer. So it's transvaginal ultrasound, um scan. Um This is a little bit of a mean question. Um The, the reason the answer is transvaginal ultrasound scan in this setting um is because of the palpable pelvic mass. Um So in the nice guidelines, if somebody has a pelvic mass, um in this context, then the first line is always gonna be a transvaginal ultrasound scan. Um All women over 45 would have endometrial sampling. Um So this lady isn't, doesn't quite meet that um criteria. Um Does anyone want to put in the chart? What they think the most likely diagnosis is? Um Obviously there's a lot of differentials to this. Um So any differentials you can put in the chart. And yeah. Um So the thing I was, I was thinking of was fibroids um when I was writing this question, but um kind of uh a malignancy or an abscess or a cyst um or even like things like endometriosis if you had a chocolate cyst or something could be some of the differentials in this setting. Um So this is just a quite a busy slide about having menstrual bleeding. Um One of the, the things they taught us in Edinburgh is about this palm coin different um way to think of the differentials. Um The ones that are in blue um often they present more with this menorrhea. Um But the main ones I would say to know about are polyp fibroids, malignancy and endometriosis. And anyone with postmenopausal bleeding, I would just be thinking of malignancy. Um First off and that should be the first thing you're thinking about, um, to try and exclude, um, and then I've put investigations here. Um, so that you want to do a blood test to make sure they're not anemic. Um, hyperthyroidism can also cause, um, heavy menstrual bleeding. So you want to do T FT S and coag screen to make sure they've not gone for brand disease or any other coagulation problems. Um, you would want to do a chlamydia test if they're under 25 with intermenstrual bleeding. Um And then I've put the, the nice guidelines on when you would want to do an ultrasound, endometrial sampling uh or a hysteroscopy. Um just there. So I'll let you guys read that um in your own time if you like um just become aware of time. Um And this is some of the management of heavy menstrual bleeding. Um So the first line is gonna be your Mirena Coil. Um And that's if there's, this is for if there's no underlying pathology. Um And then some of the other things you can do is give mefenamic acid, especially if they've got dysmenorrhea. Um And transam acid is also another thing you can give um for confirmed fibroids. If it's above three centimeters, you would, you would do as you would for um Mirena Coil and things like that. Um Not Mirena coil, sorry, transam acid and nsaids. Um But the surgical things would be different. So you'd need to do, you'd, there's three options, you can do, you can do a hysteroscopic resection, you can do a myomectomy. And that's why you um kind of you incise into the uterine enucleate, the, the fibroid and then you stitch it back up. Um If someone gets pregnant after they've had that procedure, they then need to have C sections because the, there's a risk of uterine rupture. Um if they then get pregnant after having that um uterine artery embolization, that works because um so the, the health, the healthy tissue will be kind of vasal with collaterals after you've embolized the artery. Uh but the fibroid won't. So the fibroid will die but you're healthy. You trying, you were. Um So this is just um a spot diagnosis slide. Um Do people want to put in the chart? What they think these um spot diagnoses are? Yeah. First one is chlamydia, second BV. And the third one. So it's actually gonorrhea. Um But I can see why you said um trichomonas in terms of how you manage those that people want to put in the chart. What the, the management is. Um Just the name of the, the drug for those three ST is. Yeah. So it's Doxy Metro and CF Yeah. There we go. Stop it. Um So this is another question about the contraceptive pill. Um Again, quite a lot to read, sorry about that. Um For the previous slide, I'll just skip back quickly. Um OK. Um I'll send out the slides at the end as well if um that's helpful. Ok. Um Fine. So most of you have got the correct answer. Um And that's to the bottom one. So to take the missed pill, um and the next pill that's due as scheduled to use emergency contraception um and to use a barrier method um or another form of contraception for the next seven consecutive pill days. Um with contraceptive pill questions, I think just practicing them and kind of learning the principles is, is obviously the the the way to go. Um It's, they're really annoying questions and I used to always get them all. Um But here are some of the kind of principles of, of what you would do. So, so if they've just missed one pill, then you just take the missed pill and nothing else needs to be done. Um If they've missed more than one pill, then you, then there's more to it and you need to calculate which week um of the contraceptive pill the patient is on. Um So there's 21 pills in a pack. Um And then they take a seven day break. Um Some of the things that's just important to like remember in the back of your mind when you're reading the questions are that that hormone free interval. So the seven day break starts on day 22 of the pill pack. Um and your first day of the pill pack will be on day eight of your withdrawal bleed. Um, if somebody's in week one, after their hormone free interval, that starts on your day 22 of the pill pack, then you're gonna need emergency contraception because you've not had that seven days of loading period before you've missed those two pills. Um, you're gonna want to take the missed pill and the remaining pills are scheduled and you're gonna want to use that additional contraception for seven days because you've not had a seven day loading period of the pill. If that makes sense, if you're in week two, after your hormone free interval when you miss these pills, um, you don't need emergency contraception. You again, take the missed pill and the remaining pills are scheduled. Um and you're gonna need more a seven day um kind of period of, of using barrier contraception because you haven't had that seven day period, um seven days before. Um If you're in week three, you also don't need emergency contraception, you take the meals pills, um and remaining pills are scheduled again. Um And you're gonna need additional contraception for the next seven days again. Um But importantly, you're gonna omit the hormone free intervals. So you're gonna go straight to your next pack of pills. Um rather than having that seven day break. Hopefully, that makes sense. Um So if we go back to the question, um So she um she calls her GP on Monday and she went to her boyfriend's on Friday. So she's missed two pills. So we know that we're gonna have to work out what week she's in. Um, and so the way we do that is that it tells us that a withdrawal bleed was 11 days ago. Um, so she's, so that means if you, if you go back to day one of the pill pack is day eight of the menstrual cycle. Um, and the withdrawal boo starts on day 22. You can figure out that she's probably in her week one of post the hormone free interval and that means um she's gonna need emergency contraception. Um She's gonna have to take her pills and the next pills are scheduled and she's gonna need via contraception for the next seven days. I hope if that makes sense and I haven't confused myself while I've been trying to figure that out. Yeah. So for Violet, I think she's in week one. Um I still get really confused about this. Um And yeah, so I hope I've explained that. Ok. Um So in terms of emergency contraception, um the most effective one, if that's the question is the copper IUD. Um And you can use that um even after somebody's um ovulated, um and it's, it's fine for five days um since they've had their um unprotected sex. Um, if somebody doesn't want their copper a, a copper IUD or it's not appropriate in that setting, then there's two drugs they can have, they can have levanil or LA one, which is oli Prestol one is the least effective one and you have 72 hours post unprotected sex to take it. Um, and it won't be effective and neither of these drugs will be effective if they've already ovulated. Um, and it, it works by delaying your ovulation by five days. Um, one is, um, a little bit more effective than le leel and you can take up 100 and 20 hours after you've had unprotected sex. Um The reason it's a little bit more effective is it's because it's effective even if you're at your LH surge. So that's when ovulation happens. Um While ail Leel isn't, um you can't have 1 L1 if you've got asthma as well, which is important to know. Um Or if you're breastfeeding, you shouldn't breastfeed for one week afterwards. Um So next question. So most of you have got it right. Um The answer is the A 125. And again, the answer, the reason that's the answer is um because of the referral guidelines on nice. Um Does anyone want to say what the most likely differential is for this woman? Yeah. Ovarian cancer. Um So these are referral guidelines for ovarian cancer. Um If somebody has an abdominal pelvic mass or ascites, which in this question, she says she doesn't have any of those, you would want to do a straight straight away do a two week wait, referral. Um If they've got any symptoms, um that are kind of vague of ovarian cancer, um, then you would want to do a ca 125 in your GP practice. Um And if the ca 125 is high, then you would go on to do a transvaginal ultrasound. And if that's suggestive of malignancy, then you would do an urgent two week wait, this is just a summary slides on some Gyne cancers. Um I'm not gonna go through them because I'm running out of time a little bit. Um but these are just the, the salient points. So um another spot diagnosis and then I think this is the last bit. Yeah. Top one is trichomonas. How would you treat the? Top one? Yeah, Alex has got them. All right. Um And how would you treat those metroNIDAZOLE for trichomonas? So you treat Candida with antifungals. So that's um fluconazole or if someone's pregnant, you would use clotrimazole cream. Um You'd use I am um or Benzathine penicillin for syphilis. Um You'd use Acyclovir for HSV and you would use Podophyllin cream or water con cream um for genital warts and let's just on the next slide. Cool. So that's um the end of the talk. Um I've just put on some oy tips and tricks. Um So these are probably ones you've heard all before. Um But the main things that they're looking at that you're safe as an F one. So they're not expecting you to really diagnose you. You don't do any diagnosing really an F one. So you just have to be honest, if you don't know the answer to anything, say you would ask a senior and that's a really valid cop out to every single situation. You don't know what's going on in um be empathetic. They're just looking to see whether you can communicate with someone. Um So if there's a really horrible Os station, that's just everything is really uncomfortable and something's gone wrong and you're meant to fix it. They're not expecting you to fix it. They're just expecting you to, to, to be empathetic and say sorry and be able to communicate in a good way. Um I try and remember the red flags for things. Um, so that they, you don't have to like really dig deep to find them on a day. Um Try to just focus on the, the first line management for things. They're not gonna expect you to know really niche things. And if you get one, I think it would even be a lucky to get an Ob Gyne station in finals, um, in your Aussies. Um, because they're just gonna focus on the really, really, so this is more general stuff. Um, but they, they're just gonna, um test you on really common things. Um, and maybe a few rogue ones, but I wouldn't worry about those because you're never gonna predict them anyway. Um try and have a systematic structure to what you're doing. I used to use Mosk for um G histories um because there's so many different components to it. I always forgot and I still forgot um one element of it. Um So Mosque for like menstrual history and then obstetric history, sexual history, contraception and screening. Um and then just practice, practice with your friends all the time and that is really the only way to get better. Um I use the MLA content to decide what to cover. Um These are the things I didn't cover. Um And the ones in purple I've um made like summary slides for them at the end of my talk for vision. I hope that's helpful. The ones that are in black II didn't get a chance to do. Um But yeah, I would just really concentrate on the common things because I don't think um S and G is gonna be massively prioritized in, in the final questions and you just need to know the common things. Um This is a QR code for a feedback form. I'd be really grateful if you're able to fill it out. Um And there's a space on that to um enter your email address and I'll send you the slides. Um And this is my email address if you have any questions about seven F one gu I probably won't be able to answer um or anything. Just email me. That's great. Thank you very much, Carrie. You've been very, very helpful. Um As Carrie said, she's got a feedback form there and we've also got a feedback form for you to fill in over lunch as well. If, um, if you have the time, we greatly appreciate that. Um Now we have a lunch break for the next half an hour. Um, so go away, take a break from a screen and come back refreshed. We'll be restarting at 1245 for our neurology session. Thank you very much and thanks again, Carrie.