Computer generated transcript
Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.
Hi, everyone. I think that just about is, oh, no, my clock is early. You've got a couple more seconds seconds on until 605. We're back. Um, hi, everyone. My name's Khadija. Er, and this is Joan. You can see in the other corner of your screen. Um, and welcome to teaching things. Uh, so if you're near here, um, teaching things is a sort of group, um, of tutorials set up. They're weekly tutorials, they're focused on key presentations, um, and techniques that you might see that might be helpful more directly to your Aussies and they're all tutorials are all made by medical students for medical students. So we know what we feel like is really important and relevant to our exams, but they're also reviewed by doctors to ensure, um, accuracy. Uh, and we can keep you updated on our up upcoming events via emails and group chats. So, yeah, I'll pass on to, um, job. Yep. So, um, the learning objectives that we'll be going through, um, are identifying the key causes of pneumonia and atypical pneumonias, listing, the investigations indicated and pneumonia and the kind of management. Um, could you do, we'll do a part where she reviews chest radiographs for key respiratory presentations. And then after we'll be looking at some um pleural effusions as well as the presentation of tuberculosis, the risk factors investigations and management. So, starting off with tuberculosis and lung abscesses, I'm going to put a pole through. Um ok, so this is a 64 year old woman who presents to outpatients with a two week history of low grade fevers, weight loss and a productive cough, which is occasionally hemoptysis. Um A chest X ray reveals patchy consolidation in the upper lobe of the right lung. What do you think is the most likely to be seen in the sputum upon Z Nelsen's staining? Ok. Yeah. OK. I Yeah. Yes. Yeah. We'll just get that a few more seconds. OK. Do have a go even if you're not sure I can see the responses but they are all anonymous. So just have a go even if you're not sure. OK. Yeah. Yes. Could you, should you mind the next slide? OK. So the correct answer was B red rod shaped organisms against the blue background. So when a question talks about Nielsen staining, you should always think about tuberculosis because this is the acid fast process of mycobacterium tuberculosis staining because of the waxy coating. They are quite hard to gram stain. So they go through a different staining procedure where it's zero Nelsen and acid phos just means that the basil is stain red against um this kind of blue background and they are quite hard to culture just because they are quite slow growing. So it does take a while. This is a question that they do like to test. It's just something that you should remember. OK. So a bit more about the um how tuberculosis may present. So it can be latent, active or multisystemic latent, meaning that a patient may be infected, but they are asymptomatic and they're not contagious at the moment active also, meaning primary infection, meaning that they are actively infected with the infection. And multisystemic is just um talking about how a presentation may not, may not be pulmonary, but it might present with lymphadenopathy or bone pain or in some patients, they might have um kind of come in with different kind of pleural symptoms that are a bit more systemic and transmission of tuberculosis is via respiratory droplets in the air and talking a bit more about the risk factors of tuberculosis. The most important one that you should remember is immunosuppression, especially those infected with HIV. And the biggest cause of death in those with HIV is actually tuberculosis. So when you think about immunosuppression, you're thinking about patients who um might be taking immunosuppressive medications. So if they have some kind of autoimmune disease and they are taking infliximab or some kind of DMA, um if they're from a high risk country. So this is India Pakistan or Romania's other kind of Eastern European countries, obviously, if they're exposed to close contacts who may be infected, homelessness, just because of crowding and not being able to get health care as well as alcohol and drug use and elderly patients as well as Children are at greater risk as well. Ok. So like we said, presentation can be latent active or multisystemic and this is just showing a kind of process wherein from the droplets entering the alveoli and stimulating the immune response. So, if there is an adequate immune response, you get immediate clearance of the infection. If the immune response is inadequate, it may present with the active or primary disease. And hematogenous dissemination just means spread of the bacteria via the bloodstream. And this causes miliary tuberculosis, which um just means the bacteria has kind of colonized other tissues around the body and it presents on um imaging with this kind of miller seed um image, which is quite characteristic, characteristic. Hence the name latent infection happens when you get formation of this caseating granuloma and the infection is contained and there's a risk of reactivation of a latent infection later on, especially if a patient is immunosuppressed. So once again, it's important to check for patients who are taking biologics such as Infliximab, riTUXimab. Um And if they're undergoing kind of chemotherapy or anything like that, it does. Ok. So just a bit about the pathology of tuberculosis. So we had the initial exposure and patients may be asymptomatic or they might have mild flu like symptoms. So a low fever and potentially a cough and just feeling quite under the weather. In general. Three weeks later, you get a delayed type four hypersensitivity reaction. Yeah, Khadija is that your slides? No worries. And um this is when the T cells have a delayed response where they recognize the mycobacterium tuberculosis antigens and they trigger an immune response which leads to localized inflammation, which is seen as this kind of caseating granuloma called a gon focus. And it's a caseating granuloma because it's got a kind of cheese like structure with holes in it. Once the spread reaches the lymph nodes, you kind of get this gone complex, which is a combination of the gone focus with hilar lymph nodes and this is not yet visible on radiographs. It only becomes visible later on as a um as a ranking complex when you kind of get this calcification. So calcium deposits as well as fibrosis, which is collagen deposits. And um this demonstrates the kind of a healed lesion of tuberculosis and that is visible on a chest X ray which you can kind of see on the right good. Ok. So this slide is showing some of the symptoms that a patient may present with in an active or primary disease. So the fever is usually quite low grade. You're not going to have a really high 39 degree fever with tuberculosis. Patients may complain of shortness of breath, dyspnea, chest pain, as well as a cough, which is initially dry, but later can become productive. And it might also be tinged with blood. They might present with some kind of worrying symptoms such as night sweats, weight loss, anorexia, and malaise and extra pulmonary. And these are really important because patients may present with lymphadenopathy and that might be the way that doctors identify cases of tuberculosis. So, lymphadenopathy especially um cervical or supraclavicular lymphadenopathy, skeletal pain, especially um spinal spinal tuberculosis, which is Potts disease, um abdominal pain and swelling from kind of ileocecal tuberculosis and ascites from peritoneal tuberculosis as well as urinary symptoms as well. If patients have kind of flank pain and present with hematuria, that also may be extra pulmonary symptoms of tuberculosis. Ok. So moving on to the next SBA. Ok. So this is a 67 year old man who presents to the ed with a five week history of cough, weight loss and malaise. His daughter has recently traveled back from India and also is a bit unwell. And since the tuberculosis diagnosis is clinically suspected, which of the following is the Gold Standard investigation. Ok. It he manu test chest X ray, sputum culture, a sputum smear or a CT chest. What would you think is the Gold Standard investigation? Ok. So we have a mix of results. Um some people have put Mantu test as well as sputum culture or sputum smear or a chest X ray Kesha. Yeah. So this question is asking for the Gold standard. So all of these investigations can be used at some point during the investigation of tuberculosis. But the gold standard is looking for what will consolidate your diagnosis. Mantu test is more so used for screening as you can see on the left here as well as interfering gamma release assays. And these are to screen for kind of latent infection or those kind of close contacts of those infected. So that wouldn't be your gold standard. Um A chest X ray is a kind of imaging that you can do. Um However, the kind of signs that you see on chest X ray might not be indicative of tuberculosis. Um A sputum smear is something that you can do by the bedside and it can be very useful for tuberculosis. However, the gold standard is a sputum culture and at the bottom, we have um tests split into screening bedside bloods and imaging. So at the bedside, you can do a sputum smear and a culture, a urine microscopy and ECG for bloods, you have the normal bloods as well as HIV testing, like we said, because those who are immunosuppressed and those with HIV are at greater risk. And for imaging, we have chest X ray, um spinal joint x-rays CT head if you're suspecting kind of meningeal involvement, um ultrasound of the lymph nodes as well as echocardiogram. OK. And um oh, we have a question why the urine microscopy. So, urine is done for um because of the extra pulmonary symptoms and how um urinary and kind of perineal um tuberculosis can present with flank pain and hematuria. A urine M CMS just is able to rule out uti and um it can kind of lead your diagnosis to help you go towards tuberculosis if that makes sense and moving on quite quickly to the management of tuberculosis. I use. Well, everyone uses the acronym right to remember Rifampicin, Isoniazid, Pyrazinamide and ethambutol. These are the four key um drugs that you use in the treatment of tuberculosis. And so for active infection, we ripe the patients for two months and then they continue on rifampicin and Isoniazid for a further four months. For latent tuberculosis, we only use Rifampicin, Isoniazid and pyrazinamide for three months, followed by just Isoniazid and pyrazinamide for a further six months. So treatment is quite long for tuberculosis. And during this time, patients will be monitored with sputum smears and cultures and these will be attained monthly until two consecutive cultures are negative. And I've asked her why pyridoxine is co prescribed with isona. It does anyone have any idea why? See. Mhm Yeah, you sit OK, we can go over it. Ka if we do the next slide I oh that's fine. We can go over it in a second. It's to do with the kind of side effects that you get with some things in the chart. Saying to prevent neurological symptoms. Oh, lovely. What on guys? Ok. We'll do the poll. Now, we will go over that for those who weren't quite sure. So, this is a 55 year old woman presenting the, presenting to her GP, complaining of some changes to her vision. She has noticed that some colors, red and green appear washed out. She was recently started on a course of antibiotics after presenting to A&E with night sweats, cough and a low grade fever, which drug is the mo is most likely to be responsible for her symptoms. See? Yeah. Ok. It few more seconds. Ok. Ok. And the correct answer was OK. Ethambutol. Ok. So this patient has come to the GP with changes in her vision and colors desaturating especially red and green. And she was recently started on a course of antibiotics with this kind of presentation. And the answers here are hinting towards a diagnosis of tuberculosis. Can anyone tell me what, what kind of, why is she complaining of um eye symptoms? What is this condition that she's complaining about? Yes. Yes. So, and any ideas? Yeah. No. Ok. We can move on SIA. So ethambutol was the correct answer and I remember this because ethambutol can cause optic neuritis, which is what happened with a patient when she had the desaturation of colors. Um after recently having a diagnosis of tuberculosis and the side effect of these drugs do come up quite often in SBS So it is quite important to learn. But luckily there are lots of fun and interesting ways to remember them. So for Rifampicin, oh sorry. So for Rifampicin, um you can get discoloration of fluids. So, discoloration of the urine, um turning kind of red orange color. It's also a cyp 450 enzyme inducer. So you kind of need to be careful with the interaction with some drugs such as if a patient might be on a combined oral contraceptive pill, it's also hepatotoxic. So for patients with kind of liver failure, you might need to be a bit more careful for isoniazid. I remember it because I can't feel my peripheries. Um it can cause peripheral neuropathy and um that's kind of you can kind of get kind of tingling or numbness in your peripheries. And that's why we prescribed pyridoxine, which is um an enzyme which is a vitamin, sorry that present prevents um this kind of side effect from isoniazid is also ac YP 450 inhibitor. And it's also hepatotoxic for pyrizinamide. It can cause kind of arthralgia as well as gout due to it kind of leading to hyperuricemia. And obviously, we mentioned Isham buttal and optic neuritis. Sure. OK. And just quickly we'll go over how close contacts of those with tuberculosis are managed. So, in the prevention of tuberculosis, we're going to have to identify, test and treat those at higher risk of infection due to to infected contacts and um contact tracing by the Public Health England have had this aim of reporting 90% of cases to have a minimum of five close contacts identified and screened. And in the screening process, um they will have their bloods taken as well as a Mantu or a chest X ray and or a chest X ray. And for those where the vaccine is indicated, this would be the BCG vaccine. When we talk about close contacts, this can mean um people who share the same bedroom, share the same bathroom. So household contacts as well as um close work, colleagues and partners or health care professionals who might be looking after these kind of vulnerable patients. Yeah. Ok. N SBA we have a 78 year old man admitted due to recurrent episodes of fever, chest pain and a productive cough with foul smelling sputum. His past medical history is significant for a recent a pneumonia infection and the radiograph shows a round lesion in the right lung. And what is the most likely diagnosis? Yeah. Ok. I. Mhm. Ok. Yeah. Mhm. Ok. Very well done to those who identified that it was a lung abscess. So this patient has come in with recurrent fever, chest pain and foul smelling sputum and he's recently recovered for pneumonia infection and he's got this round well demarcated lesion on radiograph. So a lung abscess is a collection of pus in the actual lung parenchyma. It's a little bit different from empyema, which is a collection of pus in the um pleural space. Lung abscess is a collection of pus within the lung tissue itself. And this causes a fluid filled cavity usually due to necrosis and the key risk factors to remember for lung abscesses is aspiration. So, um the commonest cause of these kind of aspiration, lung abscesses are mixed um anaerobic bacteria. So you need to kind of look after patients with poor oral hygiene just because if they do aspirate, they're kind of taking a lot of that bacteria down into their lungs, um any kind of um aspiration. So, if they have a tumor as well, that can be um any kind of obstruction such as a tumor can also be a quite a big risk factor once again, immunosuppression, um necrotizing, necrotizing pneumonia, tuberculosis. This is um infective endocarditis as well as recent trauma or surgery. And the presentation of lung abscesses is kind of recurrent fever and a productive cough with a kind of characteristically foul spelling sputum that also may or may not be hemoptysis. Patients, patients will be short of breath lethargic and they may also have night sweats and weight loss. So it's quite similar to tuberculosis when examining these patients. We notice finger clubbing and dullness on percussion over the lesion as well as reduced air entry over that kind of abscess, pussy space. Ok. So what kind of investigation should we be ordering for? Mr X? I'll try and monitor the chat as they come in. Ok. So if we're suspecting a lung abscess and you're kind of seeing this well, demarcated lesion of pus on his chest, X ray. What kind of investigations should we do? Thinking of investigations that we do at the bedside? Any bloods that we might take and any kind of imaging that we might do show any ideas in the chart? I bye. Ok. Can you sure? Ok. So splitting in these into bedside bloods and imaging. So we would like to take a sample of the sputum at the bedside, both for a smear and for culture just to see what kind of um uh what kind of microbes we're kind of dealing with for the bloods, we'll take a full set of bloods which we'll be um expecting to see raised white blood cells as well as some inflammatory. So CRP also like to do a baseline of his liver function and kidney function. So, Ts and EK just so we can monitor the kind of drug that we're giving him um a blood culture as well as well as well as a clotting. If we anticipate that we might be doing any kind of surgical intervention for imaging. Like the question mentioned though, um we should do a chest X ray which will show this well, demarcated round lesion, which is quite characteristic um a CT chest and possibly a bronchoscopy which can be diagnostic as well as um used in management and a question there. Just which lobe do you think is most likely to be infected in, in lung abscesses? Is it the left or the right lobe? 5050 chance getting a right? Any others I popped a little pole if you didn't want to put it in the child? Lovely. Right. Right lobe. Right is the most common one. Lovely, well done guys. So the right lobe just because like we said before, aspiration is the most common cause of lung abscesses. And if you think about the kind of the anatomy of the right bronchus, and since it has a kind of wider diameter and also the structure of it is a lot more vertical, it's more likely that um any kind of objects or any kind of tumor or anything aspirated will be going down that right bronchus stent into the right lobe. Ok. So the right lobe is most commonly affected and after Mr a stabilized on admission, what do you think is the most appropriate next step in his management? Would it be to order a bronchoscopy? Start a course of oral antibiotics. Refer for chest physiotherapy, insert a chest strain or start a course of IV antibiotics. What do you think? Ok. Yeah. OK. So the majority of you have gone for IV antibiotics. Um And also we have inserting a chest drain as well. So the correct answer was IV antibiotics. Nobody put bronchoscopy and this is um not routinely used unless the kind of sputums and cultures fail to identify what kind of microbe that it is. Oral antibiotics are usually given just because IV is used for better penetration. Chest physiotherapy is very useful, but this wouldn't be the most appropriate next step in management. Since you would want to manage the patient medically first, a chest drain will be inserted if the patient has a poor response to antibiotics, but it wouldn't be the next step. Ok. So the management of lung abscesses, we give broad spectrum IV antibiotics for over 2 to 3 weeks. And this is usually co amoxiclav, but it may differ depending on local guidelines. And then the patient is switched on to oral antibiotics for another 4 to 8 weeks after that. And we also manage the patient conservatively giving them oxygen if they need as well as analgesia antipyretics. If they have fever, any kind of IV fluids as well as supporting them with chest physiotherapy for mucus clearance, the kind of indications for surgical management. And this would be either percutaneous drainage or a kind of bronchoscopy or a lung resection would be poor response to antibiotics, underlying lung malignancy that you would want to biopsy and manage with a bronchoscopy as well as if they have significant hemoptysis. We'd be quite worried about them. Ok. And we'll pass along to Kia. Wonderful. Thank you so much. Um ok. So I know it's a bit late in the evening, but hopefully stay with me. Uh this next bit's got a lot of like interactions on the chat. So, um I'd always appreciate if you don't need me hanging. Um, this next, it's going to be about your classic pneumonia, your bronchitis and your pleural pleural effusions, super, super high yield for Aussies. Um, and also like something that you will see, especially in the winter season. So let's get going. So like everyone and their nan this winter season, er, patient pneumonia is a 78 year old woman presenting to A&E with a productive cough. So, in the chat, can you guys sort of take a history? So, what information would you like to know? And I'll sort of answer it. Yeah. Any information you'd like to know from this history? Ok. Oh, wonderful. Thank you. Um, so is it productive? Er, yes, it is productive. Um, oh, I love this. Ok. How long for, um, it's been around four days actually. Right. This is me really cosplay more drama. It's been around four days actually. Um, the, the color, the color is green, it's this green Sputum. Um, volume. Volume is a really good question. Um, I haven't really noticed but it's at least like a tablespoon or so. Every time I'm coughing, um, it started a couple of days ago I was out in the cold. There's no, I haven't noticed any blood in the sputum. No. Um, wonderful guys. Any other, any last questions before we move on? Um, any shortness of breath. Uh, yeah, I feel a little bit short of breath but like, I mainly feel a bit weak, like I'm just sort of, I'm not able to, like, get up and going as I normally would. Ok. Beautiful sweat. Sweating is a good one. Well, um, nice. No, I haven't noticed any more. Well, I've been sweating on and off through like the night because I'm feeling really hot and I feel like I've got a fever. I hope that answers your next question. Um, so yeah, I do feel a bit feverish, so I am sweating then. But yeah, uh, I don't have asthma and I don't have CO PD. Beautiful. Ok. So this is the information she gives you. Um, mmmm Monea has a four day history of a productive cough, green sputum. She feels feverish. Um, she does have a headache so that sometimes with other flu symptoms that I'm seeing in the chat, she's tried paracetamol, lemon, honey tea and nothing's helped. She doesn't feel like she has. So remembering in a history also really important as some of you did to cover your important negatives. So she doesn't have any chest pain. She hasn't noticed any blood, um, she hasn't lost consciousness at any point. Um, she hasn't been hospitalized recently and also not forgetting your, um, social history. Er, she drinks two units of alcohol a week and has never smoked. Ok. Wonderful. So that leads me on to our first SBA of, um, you can, you, you guys can all read but what is the most likely infectious organism that caused her symptoms? Ok. You can react to my comment if you're not sure there's no excuse. Beautiful. Ok. Um, so the majority of you put strep pneumonia, which is correct. Um, that is the like most common, er, sort of bug, basically infectious organism that causes your standard, um, er, pneumonias. For those of you put in Klebsiella, we'll talk for the, I think someone who put klebsiella, we'll talk about that in the next bit. Um, this is now sort of more, um, really exam focused. This does not pan out as well as it does in real life, but for your exams for your medical school exams in particular, there are some common SBA stems that sort of try and build a picture of what the organism is or like what the pathology is. Um, so can you pop in the chat if you know the answer to these? Hopefully? Nice and quick. Uh, cos I'm gonna be done as well. So can anyone to put me in the chat? Er, what the most common pneumonia is for someone with, er, et, oh, excess, alcohol, excess, most common organism. If anyone I'll give everyone 15 seconds. No. Ok. Um, what about someone who's returned from a holiday in the sunshine? Oh, sorry, we do have someone in the chart. Oh, amazing. Yes. Exactly. Correct. Klebsiella. Um, sorry. My, my, my, I must not be doing things beautiful. Does know what the most likely organism is for someone who's returned from a lovely holiday in the sunshine with some dodgy air conditioning. Better them than me. Yeah. Ok. Peaceful. Ah. Ah. Yeah. Um, yes. So this one is actually legionella. I always get confused between legionella and Listeria. Um, yeah, me too. The next is people after a five day stay in hospital. No, we know we, we can see who our pathologists are in, in the audience. This is good. They sort of, it's been in the hospital for a while and now they suddenly got a pneumonia. Anyone? Oh, no. Ok. That's fine. We can go over it. Uh, people after an influenza infection. What's the most likely organism? Wonderful. Yeah. Staff a nice um uh in terms of haemophilus influenza, er, this, I think h influenza in terms of SBA land, I'm sure that is quite common, but in SBA land it tends to be sorry to give the answer away, but patients with CO PD, but that isn't very high yield. So I wouldn't really worry about that. And what about, um what, what organism is most likely to cause pneumonia in like your immunocompromised patients or people with cystic fibrosis? And I'll give you a hint. It's more than one. We tend to hear this to people quite unwell or if you see it, it's like super pathogenic of like some immunocompromised business going on. Wonderful. Yeah. Pseudomonas. Fantastic. One other one that you hear, am I pushing my luck? I might be pushing my luck. That's fair enough. Um, ok. Yeah. So, what I would do is if you don't know them right now, that's absolutely fine. Go away, um, in your own time and just sort of like ro learn these, like SBA stents cos, they come up all the time and they're super easy marks greater. Yeah, the C A PT one's a little bit rogue, but I thought I'd throw it in there. Wonderful. So, these are all your most common ones? Oh, in the chat. Yes. Yeah. Wonderful. And your pneumocystic Juve is how I pronounce it, but I'm probably wrong. Ok. I've got this lovely table for you. You can screenshot it, do whatever you like it. Um, hang it up on your wall. Er, it sort of really clearly demarcates the causes the main causes of pneumonia. Your majority of pneumonia, um, is going to be bacterial but you also have viral and your fungal ones as well. And if you're looking at fungal causes of pneumonia, that's when you start thinking. Is there like, um, is this person immunocompromised? Do we have to do further investigations? Now, can anyone, um, tell me or, like, explain why some of those, um, are in white? Like some of the names, the bacterial names are in white. What's different about those? No, not sure why they're not. In white. Wonderful. Yes, they're atypical organisms. And can anyone tell me what atypical organisms are or like, how they're defined? If not? It's ok. All right. Ok. Um, so a quick note before we go on to your atypical pneumonias is aspiration, pneumonia is something that's super important to bear in mind. Here. It's predominantly bacterial. And what happens is because you've got the sort of fluid or like, um, contents going back, sort of crudely back down the other way. Um So it's sort of you have like material in your lungs and it's a perfect breeding ground for bacteria. Uh So that's especially what you need to think about if you've got a stroke patient or someone else with sort of a congenital difficulty. Um Meaning that their swallow isn't like complete. So you've also got this, unfortunately, if your patients with advanced dementia, um key osk point is always, always, always in your management include having an MDT meeting and having speech and language therapy involvement. Um just cos they sort of lap that up and it's also really important. Beautiful, your atypical pneumonia in terms of your definition. I thought it was just like before doing this. I was like, oh, just something that's a little bit weird or like whatever, but actually atypical are those that do not ground stain or are not covered by your normal antibiotics. And so a good way to remember these is your like legions of pistachio MC Qs as medical students. You've got lots of MC Qs all the time. So this should not be too um foreign view and the main ones are your legionella neophyla. Sorry, my, my, my spelling is gonna be a bit off and I've also spelled chlamydia wrong there. Sorry, I will correct that. Um chlamydia setacea, um which is like your birds and like your parrots, um mycoplasma pneumoniae and Coxiella burnetti so that your Q fever, that's where it comes from. Quickly. A brief note on caps versus haps. And you might hear that thrown around in hospital, um, your community acquired pneumonia is any pneumonia that you develop either before you've gone into the hospital or within the 48 hours of you getting into hospital because that, like you might have caught something from outside and brought it in, but that doesn't mean that you've caught it from hospital if that makes sense. And these are important because the level of coverage differs. So if you're someone who regularly goes into hospital, you've got lots of antibiotics pumping your way through you. The pneumonia that you're more likely to get is prob is more likely to be like something like M RSA, something that shows resistance to antibiotics that you would normally, um, be like sort of offer in those cases of pneumonia. All right. Ok. Er, next SBA. So what's the single best criteria that can be used to assess the management of this patient that we have in front of us and if this is super, super easy and you know, all the answers already, um, test yourself at home by answering all the other principle. Nice. Ok. I think I've got 100% agreement that it is. Of course, of course, the infamous C 65 score. Um, all right. Now on the back of that, uh, what investigations would you need to help risk stratify this patient? Um, oh, I'm just going to correct the question. Oh, ok. Sorry, I didn't manage to correct the question, but it's instead of, um, obtained for diagnostic work up, it's to risk stratify. So, if you can see the slides, let me see if I can edit it actually. Oh, I can totally. Ok. Yeah, double checking. This is to clarify the degree of risk and not just the ones that you should obtain. I'll give you five more seconds. Ok. Yeah. Again, I'm really sorry, I didn't manage to edit the, the question on the poll, but on the slides, the answer to that is your user and your A MT S. The reason being before there is outcry, um, is those are your essentials that you need to get for your curb 65 score? The other ones are really important. Of course, you wouldn't think about assessing a potential pneumonia patient without getting a chest x-ray without looking at their inflammatory markers. But the things that you really need and some things that people often forget are your A MT S and your ene. Um Also remembering nonene of you put urine dip, which is fine, but just a quick point if you're um, at UCL, your urine dip is not very helpful in your patients over 60. So you remembering what to do that? Wonderful. OK. And at this point, you guys should be experts. How are you going to like structure your investigations? Pop it in the chat. Come on guys, you got this super, super lovely business. All right, you've gotta do your bedside blood and imaging, nice structure to your rosy. So it's easy for that examiner to give you all the marks. Um And in terms of your bedside, I like, I always don't think it's very helpful to like try and memorize these tests to try and do it really logically, you've got someone who's coughing loads, they might have a bit of chest pain might be a good idea to get yourself an E CG. You wouldn't have someone in the hospital without, without doing obs. So make sure you do obs and make sure you say that in your os exam. If someone's coughing up something, use it, culture it, that's what you're going to do. And remembering if you think in the back of your head, this seems like a chest infection. It seems like you've got a pneumonia, you're gonna do your A MT S in terms of your bloods. If they're short of breath requiring oxygen. Obviously, you're gonna think about your ABG and for any infectious cause or any infectious um pathology that you're worried about. Best thing to do is to culture it. So you're gonna do your blood culture. And in terms of like your blood tests, you want your inflammatory markers to see what your white cell counts are doing. Uh You're using these to help you look at your urea and help risk stratify. Um Your C RP can be really handy in terms of like um sort of looking at like inflammation and, and what's actually going on and your urinary antigen a little bit rogue. But if you're thinking about more um unusual things like your legionella, that can be really helpful, uh especially if your patient isn't responding. So if you've got all of that work up beforehand and then afterwards they've been on like five days of Comox or whatever, then you realize that they're still not responding. That's when your urinary antigen result that you've taken really like kicks in. It's really helpful and in terms of imaging, standard chest X ray is absolutely fine. I feel like as medical students, we tend to be like wanna one up them but not everyone needs act chest. But that's if you suspect complications like an empyema or a um a lung abscess or something else that would have not had. All right. So your consultant is a little mean, we've all been there and they ask you to justify why you're doing the following investigations. So just to see who's listening, um can you quickly pop in the chat? Why would you do an FBC, a full blood count for your patient? Ok. Anyone remember why you do urinary antigen? Yeah, wonderful. Thank you. Um Your white cell count and your type. That's a really good point. Actually, um looking at the types of white cells is, is, is super and can give you an indication of what you're battling with. Um Why would you do urinary antigen for the sake of time you're gonna be on um any idea what you're doing? ABG uh the, we do a blood culture like, yep, amazing. I'm gonna try and match, match them up in my head if you're suspecting liviella, yeah, you would do a urinary antigen if not responding to antibiotics. Yes, that's why you do a blood culture. Can anyone finally tell me why you would maybe do an ABG? Just because I feel like that's not like intuitive. Yeah, if short of breath or like uh Yes. Yeah. Wonderful. Um Thinking about like your lactate. If you've, if you've begun to develop a more septic picture, ABG is really helpful. But also in general, if someone is like oxygenating below, like your standard sets that you'd like accept, it won't hurt getting an ABG uh it actually might hurt the patient a little bit, but it will be helpful for your diagnostic workup. So. Yes. All right. Wonderful. Ok. Next SS ba calculating the C A score, hopefully nice and speedy. Well, it is high school. Uh if you need um normals for the respirate and heart rate, heart rate is slightly high respirate is high. Oxygen is flittering about normal BP is ok. And the rest you've got, got five seconds left. Ok. All right. Um So the answer is actually three. The reason being is your curb 65 is one of these beautiful pneumonics that says exactly what it is. C for confusion. Her A MT S is nine out of 10. So that suggests not confused. We're, we're all allowed up to eight. I think I'm pretty sure um you her urea, her urea is high. So she scores a point for that. R is your respirate respirate over 20 over tht mm oh, I've drawn a blank. Um but she scores a point for her respirate. Um and her BP, her BP is normal so she won't, won't score anything over that, but she is 78 which is over 65. So that's why she scores three. Ok. Um Wonderful. Now, can you quickly pop into the chat? What framework you'd use to interpret a chest X ray? Ok. So like how would you, how would you go about interpreting a chest X ray? I'm sorry, that is my cat. Anyone. Ok. So something that we really, really ripe then a to E fantastic, thank you. Um We sort of say dot to ABC. So you've got your details cos we, we can't forget that then you've got your ripe so rotation er looking at like the distance from your clavicles, inspiration, making sure you've got seven ribs above diaphragm penetration, looking at your spinal processes and exposure, um looking at like the areas that you want to see, airways, breathing circulation, diaphragm, everything else. So here's a nice little photo. Thanks to University Hospital Leicester um that you can take a screenshot of or just like look up really important when you're like interpreting in an osk setting in particular. Now, we've got the fifth SBA. Um how would you describe this consolidation? I really wanna be if you have to go in advance um For seven, I'm gonna pop in the um feedback form. So please do fill it out before you leave. Er if you can stay with us though, do because we shouldn't be too long. Ok. Wonderful. Ok. Um You guys are experts. It's exactly right. You didn't fall for my trick. Um It is right up zone consolidation. The reason it's not right. Upper lobe consolidation is because one of the pet peeves that you say loves to test, you can't tell distinguish a lobe from simple AP chest X ray, pa or pa chest X ray. Um you can, you can do with like act chest or maybe a lateral view as potentially a lateral view as well if you're um experienced. But if you think about the way that the lungs like layer over each other, this is like in this being like you and your eyes looking through it, you simply don't have enough information, which is why you split it up into zones that are approximately like a third of the, each hunk of the lung. Um, ok. All right. So this is now sort of like slightly going away from chest infections, but I think a really helpful cheat sheet. Um, and I'll sort of on the slides, I'll take away the boxes. Can anyone spot diagnosis? Can anyone tell me what the first box is suggests? I'll give a, 00, no, sorry. Um, I've given it away. It's right off the zone patchy. Your P pa you can see here that the, um, sorry, I'm pointing, that's not very helpful, is it, um, you can see here, uh, the area of consolidation isn't like as heterogenous. Um, and it's in this sort of zone, whereas can anyone tell me what's going on here? On the second one? I might just get through this just for the sake of time. But in this one, you can see, um, like if you look at like the lung markings, um, you can see you're sort of, they almost seem like kind of cloudy, like, not really clear like this sort of section is. And for those, that's when you're thinking about your interstitial lung disease. Um For this one, you can see this is quite obviously like not, not right. Really is it. And that's where um the key characteristic sign is really like your meniscus. So here, um you've got a massive, massive like layer of white and white is, is white as water, I suppose. Um It shows like some density. So this in particular, especially with your lack of meniscus um suggests a right sided, um, pleural effusion. Oh, yeah. So th this wouldn't be, um, like parapneumonic. This wouldn't be because of a pneumonia. This is probably due to like some sort of malignant process underlying it, but we'll talk about that in a little bit. Um, I would screenshot this or do whatever because it's really helpful. It's like almost like a little cheat sheet. And in terms of these, um, you've got your like pneumoperitoneum, it's almost like any other chest X ray that you might be asked to do at medical school. So here you've got your pneumoperitoneum, like super easy. You see the way that your diaphragm is, you got a little bit of air underneath it. Um If I can convince you pneumothorax, pneumothoraces can sometimes be a little bit difficult to distinguish. But if I can convince you around here, um, this part of the lung seems really clear and you almost see like you've got a line here. Um, that's sort of your pneumothorax and in terms of like your like sort of this one, if you look at where the trachea follows, um and see sort of like this, like blank space. It's very, very classic of like a lung collapse. And in both of those, um your tr tr your trea will also be quite helpful for you to distinguish those. Wonderful. Ok. Um S B6, what can you see on this chest X ray? Got like three more left. So I've given you a no clue, option too. So actually no excuse anyone else, I'll give you seven more seconds. Ok. Um If someone's feeling brave, can they let me know why they thought it was bronchitis so that I can help, try and explain it, but that's a lot to ask. So that's fine, if not. Um The answer is ba pleural effusion. The reason being is as I was talking about, if you're looking for this, like classic meniscus, if I go back to the other chest chest X rays, this one's quite, quite a good one. This should almost be like what the edge of your lung markings look like, almost like a little point facing downwards. So at the point where you've got these rounded features, that's really sort of really suggestive of a, of a um pleural effusion. Um Now, how would you manage that bronchitis, by the way, normally wouldn't like, would look fine on a chest X ray. Um We will talk about bronchitis shortly. There are multiple answers. Correct. On this one. So. Ok, so the answers are both, um, C and D dl, some of you put, um, in terms of like treating the pneumonia and let it settle if essentially treating the pneumonia will, like, help the situation of like, obviously that's not going to hurt, but because there's already this liquid that's like, almost like killing, um, you need to sort of get rid of that or like, do something about that, er, in the first place. Um, chest drains within 24 hours shortly, but it's not like, especially with that chest x, if that chest X ray here, the pleural effusion isn't like massive, like you might see in some like malignant, um, malignant pleural effusions that will need, like, that's super symptomatic and you want to sort of drain it straight away. What is super important though is that you get like some aspirate and can anyone tell me, like, why you might want to get an ultrasound and a pleural aspirate or why they might work hand in hand? Ok. Ok. So essentially, um, if you're able to as ultrasound like the lungs and see where that fluid is, you're able to get a better aspirate of it so quickly chatting about pleural effusions for a little bit. I think this comic is brilliant and tells you pretty much most things that you need to know critically. Your pleural effusions are split up in your head to exit and transudative. Yeah, exactly. Brilliant. That is exactly right. You're using your ultrasound to guide the needle in um to remove your aspirate. So, pleural effusions, you split them up into exudative and transitive, you're exudative. I like to use the thing like X, it's like X life cos like your exit is the one where like your cells are dying. You got inflammation or cancer or something like that. It's not perfect but like it's OK. Um And then you've got your transitive, which is more of an issue of like pressure. So it might be like heart failure or like um sort of like your organ based um failures. So like um nephrotic syndrome, cirrhosis, et cetera, et cetera. To do that. You look at like three main parameters. You either look at the, you either look at your pleural from your pleural aspirate. You look at the protein and compare that to the levels of protein like serum protein. If that's, if that ratio is more than naught 0.5 then it's excessive. Um Likewise, if your pleural LDH divided by your serum LDH is over naught 0.6 then that's considered exit or if you take your pleural LDH. So your lactate dehydrogenase and you find the levels at two thirds, the upper limit of what you'd normally expect. Um That's super, super worthy, but in essence, just think about pleural effusions, excessive transitive. How do I figure out lights what it lights naught 0.5 naught 0.62 3rd, protein LDH, two thirds of normal, I always, always, always confuse pleural effusions with your like serum ascites album ingredient. Um Hopefully, now I've said it, it doesn't mean that you guys confuse it, but I just wanted to be very aware that you're not confusing those two up lights criteria is a lot more complex in that. There are three main branches and quickly, I'm just gonna go through them because um of time basically, but you've got a little note on bronchitis, bronchitis isn't very high yield. It's not really that big in SBA S from what I've come across. But um who knows, definitely worth knowing about in terms of your causes. This is like, generally tends to be all like viral like your R SV or like rhinovirus. You've got a similar um in like neonates and young Children. You've got like bronchiolitis, um which is a lot, a lot more of a problem actually for, for young people. But in terms of adults, bronchitis isn't, your history might be productive. You might have a sore throat, you might have a bit of a runny nose, uh a fever that you're not really worried about, but maybe a bit of a wheeze. So, you know, these are all things that like, yeah, you're unwell but you're not, probably not, probably not that unwell and your prior dominant management is your supportive. Um You can have ACR P and some A&E services will have like a finger prick C RP and you can give um doxycycline if your C RP is above 100 or systemically unwell. Um and you can do a delayed script if your C RP is less than 100. But if you feel worse in a couple of days, you can always go um go back in and, and collect your prescription. Ok. These last two S pa S these are the last two, they won't last very long. They are a bit hard, but I just want to sort of give it a go and see how it goes. So, what is the single most likely diagnosis? A 41 year old man, he's felt unwell for five days. Um, he has a productive cough of green sputum, occasionally, a reddish tinge feeling hot and cold has pain on the right side of his chest smoked 10 cigarettes a day and his obs are as follows. What are we thinking? Just give it a whack if you're not sure you're not sure that's ok. Wonderful. Ok. So, um, most of you did get it right. It's community acquired pneumonia. Um, the main key reasons are even though you're looking at like, you know, quite a significant, um, smoking history. Uh, your early forties is a little bit on the younger side to develop a malignancy, like a lung cancer in particular. Um, it sort of feels very acute. So, like you've got your five day history, um, and like with a more malignant process. You might be thinking of like more of a, at least an SBA lunge. You'll have more of a build up to it. So it might be a couple of months of like weight loss or whatever it is. Fantastic. And the last and final one, you guys were almost there. Um Oh, hang on. How do I? Ok. Beautiful. A 31 year old woman increasingly short of breath. She sweats at night. She has a nonproductive cough, um has lost 5 kg. She's got a temperature of 37.6 degrees heart rate of 95 BP of 100/60. Um and the saturating on 92% on there, but this decreases to 86% on exertion. She is cachectic. So she looks like she lost, she lost of muscle um and has thick white patches on her tongue. Her chest X ray is as follows, which is the single most likely diagnosis. Um I've got one response already. I'll give you 15 more seconds. Wonderful. Ok. Super impressive with you guys. Um It is indeed Pneumocystis pneumonia. The reason being it's really quite complicated and looking at this, you know, we were looking at it and it, it was a little bit hard. Um But essentially you're completely correct with lymphoma that actually your weight loss and your night sweats in someone who's quite young, you should 100% have hematological malignancies in your radar. Um but it's quite like her symptoms are very re based. Pardon me? And um normally in SBA land, if you were to come across a lymphoma, you might find like a non tender node that would be more indicative of that. Um And in terms of like sarcoid, um breathlessness isn't normally like the predominant feature of sarcoidosis. Uh It normally is something that you come across later. And on the X ray, you are more likely to see like almost like granulomas, almost like ring shaped diseases that Joanne to um spoke to you about uh in terms of TB. Um So that is what you're like, most likely to see the reason that this is um your name, sisters, pneumonia is because she is um there does seem to be like uh an underlying immunocompromisation, basically. Um the white patches on the tongue. I don't know if anyone can tell that that's actually can probably Candida er, which is an opportunistic infection that you get. It's very fungal. So you, you know, you've got a fungal infection in your, your mouth and on your tongue and you know, you're more likely to have one in your lungs as well. Um And with this history of like weight loss and, and night sweats, et cetera, you are thinking about um some sort of immunosuppression, this stem was linking more towards HIV um and a yeah, and also critically like, I think the um you're 92% on air but decreased to 86% on the exertion. It's super typical at this time for the money. All right. So that is us. Um Thank you so much. You guys uh do fill out the feedback form that we will send out again. Um And yeah, thank you so much.