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Finals in Focus Session 7: Respiratory Medicine

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Summary

In this educational session, participants delve into the treatment and management processes for patients presenting with pneumonia. The speaker discusses first-line community treatment, hospital referrals, and the use of intravenous antibiotics, as well as additional supportive care like fluids or oxygen. They also cover the process of bedside investigations, including the utilization of blood, labs, and the significant role of imaging in diagnosis. The session thoroughly dissects typical and atypical pneumonias, and the organisms causing them, along with the varying treatment approaches. The speaker also provides numerous examples, and discusses a typical case of a patient presenting with chest pain. This allows participants to work through the diagnostic and treatment process, from understanding symptoms to following guidelines for pneumothorax management. The session also discusses the importance of patient-centered treatment and touch on post-procedure management and support. Packed with information, this session also examines pleural effusions, addressing the signs, causes, a recommended course of action, and the importance of fluid analysis. Ultimately, this session is a must for medical professionals looking to better understand and improve their approach to lung-related health issues.
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Description

Join us for Session 7 in our medical finals revision series: Respiratory Medicine.

This presentation will be led by final year medical student, Hugo Duncan-Duggal who has a special interest in respiratory medicine.

The session will cover topics relevant to the UKMLA exam, in the structure of multiple choice questions (MCQs) followed by teaching slides. This event will occur online via Zoom.

We will go through the MLA content map to help you identify gaps in revision and strengthen previously learned topics to help you to smash your exams.

Don't miss out- register now!

Learning objectives

1. Understand the first line treatment for pneumonia and the factors influencing hospital admittance for these patients. 2. Learn how to differentiate between typical and atypical pneumonias, and understand the different treatment options for each. 3. Familiarize with the British Thoracic Society guidelines on pneumothorax management, and understand the decision-making process for treatment options based on factors such as symptoms, high-risk characteristics, and patient preferences. 4. Understand the different causes and diagnostic tests for pleural effusions. 5. Ability to interpret patient signs, symptoms, and test results to correctly identify the underlying cause of a pleural effusion.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Kind of in the community with oral kind of antibiotics. So the first line here is five days of a mox. Um And then if you're in GP and a patient's scoring two, you'd be thinking about wanting to refer them into a hospital, maybe getting some IV antibiotics. And also is there any any other supportive care that they might need? So fluids and maybe some oxygen and then if a patient was scoring three, then you'd kind of be quite worried about them and you'd be wanting to talk to itu and considering their escalation of care in the hospital setting for patients coming in with a pneumonia, you'd think about your investigations. So going through bedside bloods and imaging, you can see here you'd wanna do general labs, maybe get a sputum sample to try and work out the causative organisms. Um Do maybe take a urinary sample, get an E CG, take some general bloods and also get a chest X ray to confirm the presence of consolidation and moving on. Just got a table here which is just talking about uh your typical versus atypical pneumonias. So your atypical ones are ones that are caused by organisms that cannot be cultured in the normal way and they can't be really detected using a gram stain and treatment with penicillin is usually ineffective. So they're treated with macrolides. So that's like cycin and your fluoroquinolones, like levofloxacin and also tetracyclines. So like doxycycline, um and then kind of in this column, you can just see some clues that you'd be looking out for in MC Qs and in kind of exams. Um a few of which we talked about already. Um But yeah, this is a good table just to get your head around and definitely remember some of those exam clues some more common than others. Um And yeah, we'll release these slides after. So you can have a longer look at this table moving on to question two. So a 30 year old man presents to the emergency department complaining of chest pain. This started last night and has not improved today. The pain is sharp and worse on inspiration and he's got a past medical history of bronchiectasis and smokes about 20 cigarettes a day on examination. He appears breathless and his observations are as below 100 and 25 heart BPM. Uh BP of 100 and 32/91 respirate 24 and sat 92% on room air on chest X ray. It shows a pneumothorax with a rhythm of three centimeters of air. So, based on this information, what's the most appropriate next step in the management for this patient. A give oxygen and admit for 24 hours monitoring. B insert a chest DC attempt needle aspiration, D reassure and discharge with outpatient review in 2 to 4 weeks and e reassure and discharge with lifestyle advice. So we'll give you again a couple of minutes for this question. Just a little. Now. There we go. Give you about a minute for this one. OK. With your Hands Bridge. Oh, so I've ended the poll there. Here you go with uh T between B and C and a couple for a perfect thank you. Um And yeah, so well done for those that put b um quite a tough question, that one. So I can understand why there's a bit of a split and we'll go through that now. So this is based on the New British Thoracic Society guidelines from 2023 where there are a couple of changes. Um And so in our question, the patient is a couple of bits you wanna pick out is that he's symptomatic. He's breathless and he's also got some kind of background um lung disease. So he's got bronchiectasis. So the answer is B for this one. A is incorrect because this is an option for patients who have an asymptomatic pneumothorax, which is secondary. So our patient is sym sym symptomatic, sorry with high risk features making this first option inappropriate. B is correct as the patient is symptomatic and has high risk characteristics, which is in this case, an underlying lung disease c um This approach is taken in patients with no high risk characteristics and where the rim of it is big enough for us to intervene. And usually when the patient has a kind of priority of rapid um rapid relief of symptoms, and then d is indicated in patients who are asymptomatic or patients with no high risk characteristics who have kind of don't really want, they want to avoid a procedure as their priority. Um And we've got a flow chart in the upcoming slides, so it will be a bit clearer. Um And then e so kind of this shouldn't really be an option for any pneumothorax. Um You should always kind of get someone back in for an outpatient review. Um But the lifestyle advice should be given anyway, such as avoiding smoking to reduce the risk of further episodes. So this is the flow chart that I was talking about. I hope it's big enough and readable. Um If not, you'll be able to see it on the slides that we send out later. Um But when managing a patient with a pneumothorax, you must first consider if they're kind of hemodynamically stable or not on it. And then also if they're symptomatic, so if they're not hemodynamically stable, then you move straight to a chest drain. Um But yeah, that's what work through the flow chart for our patient. So the first step, um, from our patient's point of view is decide if they're symptomatic or not, which our patient was. Um, if they weren't, then you can opt for conservative care regardless of kind of the size of pneumothorax. If they don't have any symptoms, then you can, uh manage in the community and kind of bring them back in for a follow up. Um, but our patient was symptomatic. So we move on to whether or not they have high risk characteristics, which our patient did. Um the ones you want to assess for up in this box here at the top. So kind of hemodynamic compromise, significant hypoxia, bilateral pneumothoraces, underlying lung disease or greater than 50 years of age with a significant smoking history. So our patient had an underlying lung disease. So we moved over to this side where you need to then decide if it's safe to intervene or not. And this is usually decided with imaging and I believe it says it's at the bottom, but it's whether or not the rim of air is greater than two centimeters. Um if and also if there's no high risk characteristics, sorry, just going down this leg of the er tree, then it's more patient centered and they can kind of decide. So that's what a few of the answers were about on the question that we've done where the patient had a bit more of a choice. Um Whereas for Oz, he did have high risk characteristics and it was safe to intervene. And so we went for a chest strain and then there's a bit more about their patient journey in each of those boxes and ongoing management. Um So then when inserting a chest drain, you wanna use the triangle safety, which is the fifth intercostal space with the mid axiliary line and the anterior auxiliary line and kind of just, yeah, that's the area that you use and then follow up. Uh All patients will require a 2 to 4 week follow up. This will be kind of used to give advice about stopping smoking. Um kind of things about flying and scuba diving if the patient fancies doing any of that. Um So yeah, I hope that's cleared up a bit more about that question. Also, when inserting a chest drain, you wanna kind of obtain a chest X ray to check the position once you've done that, moving on to question three. So Bill is a 67 year old man recovering on the orthopedic ward after a total hip arthroplasty. He tells you that he has a sharp chest pain when breathing in and has become more short of breath and developed a cough over the last 48 hours. Bill has a 35 pack year smoking history and has a has had a previous myocardial infarction in 2014 on examination. He has reduced breath sounds on the bilaterally and there is a dullness to percussion I should say in the bases of the lungs. Um and a chest X ray demonstrates a moderate bilateral pleural effusion. A pleural tap is conducted which reveals a protein level of 2.5 g per liter. So what is the patient's, what is the most underlying likely underlying cause of this patient's pleural effusion. So, a lung malignancy B, pneumonia, C, pancreatitis, D congestive cardiac failure or E asthma just launched the new pulse, I'll give you another minute. So just showing the results. Now, most of you have answered 80% of you are going for D with a few for B and C Sweet. Thank you very much cyp. Well, on all of those who went for d congestive cardiac failure is the answer in this question. And so there are a few clues in the question that you wanna look for. So he's got a previous kind of cardiac history. Um There was a dullness to percussion bilaterally and there was a bilateral pleural effusion. And this is um this the all this information kind of points you towards a congestive cardiac failure and also the protein level will point you towards um the fact that it's transitive and the congestive cardiac failure is the only cause of a trans transudative pleural effusion from the choices here. So yeah, let's go through it. So the patient's got a kind of classic presentation of pleural effusion. He's got pleuritic chest pain and reduced breath sounds and dullness to percussion. But the main clue clue here being the protein content on aspiration, which shows that it's transudative. Um And this means that the answer must be d as this is the only cause of a transudative effusion. And as I mentioned already, um it's bilateral, which is again more classically due to transudates. So, asthma while going through something else is the incorrect asthma does not typically cause a pleural effusion. So we can rule that one out. And then lung malignancy pneumonia and pancreatitis typically cause an exudative effusion in which we would see like a higher protein count. And so that's kind of the rationale for this question. So we'll go through a bit of information about pleural effusions. Now, so this is a collection of fluid in the pleural space. Patients will present typically with um a shortness of breath, dullness of pre percussion over the effusion, reduced breath sounds and in if it's a very large effusion, then they'll have, have some tracheal deviation with anyone presenting with kind of signs and symptoms of a pleur effusion. You wanna do basic obs sputum sample. Um if considering kind of a pneumonia and an E CG, if they're experiencing chest pain, you can then use these um tests and other blood tests to screen for infection and kidney function. So, first line imaging would be chest X ray. So on this, you'd find blunting of the costophrenic angles, fluid and lung fissures in larger effusions, you'll see a meniscus um and in very large effusions as mentioned, there will be tracheal deviation, then you'll also do some pleural fluid analysis. And this requires a sample to be taken by aspiration or chest drone. And these can also be kind of therapeutic and help establish an underlying cause. So this chest X ray shows a bilateral pleural effusion like the one mentioned in the question. And in this case, the left is larger than the right. And so you can see there's more left, lower zone opacification and also some other findings as kind of a they've had a medial median sternotomy from a previous cabbage and have had a left sided pacemaker fitted as well. So there's just a little bit on that X ray to look at. So then working out whether it's transudative or exudative pleural effusion can be I found it pretty tricky to remember which way around was which um but yeah, transudative causes relate to fluid, moving across or shifting into the pleural space. So they kind of trans meaning across and they're almost always associated with an imbalance of fluid or protein. Some of these examples being congestive cardiac failure, hypoalbuminemia, hypothyroidism, and also an uncommon one called meigs syndrome. And then, whereas exudative causes are related to inflammation. And so this inflammation kind of results in protein leaking out of the tissues into the pleural space. So X meaning moving out of um and then so there's kind of two ways to work out whether it's transudative or exudative, you can use the more crude technique of kind of, is it less or more than 30 g per liter? Anything greater is considered an exudate and anything less a transudate? So in our question, I think he was 2.5 g per liter. So that points you to a transudate. However, when it's kind of borderline, it's a bit more difficult and you can use lights criteria for this. And this uses either the serum and pleural fluid protein or serum and pleural fluid LDH levels. Um So the fluid is considered an exudate if any of the following are present. So the ratio of pleural fluid protein to serum protein greater than 0.5 or again, the ratio of pleural fluid LDH to serum LDH greater than 0.6 or the pleural LDH value is greater than two thirds of the upper limit of the normal serum value. So I'd recommend kind of taking a bit of time to familiarize yourself with this as it can definitely come up in a few more of the more tricky finals questions and then thinking about what kind of causes of pleural effusions. So sometimes when you're taking off fluid from a chest drain, um the question will describe the color or content of the aspirate similar to kind of when you get information about L PS in questions. And so this can also give a clue to further diagnoses. Um Yeah. So if there's like low glucose, then you'd maybe think about ra or TB. Um if the food is clear, but the PH is less than 7.2 in patients with a sus suspected pleural infection, then a chest tube should be placed. Um And then, so you can also get something called a chylothorax. And this is where lymph accumulates in the pleural space. This is kind of most often caused by lymphatic obstruction, secondary to malignancy and can also be caused by surgery or trauma to the thoracic duct. And with that, they'll kind of describe a milky looking fluid. Um And yes, that's just a another quick table that might be good to have in your notes to have a look at when you're coming across questions like this. Um If there are no kind of questions so far, we can move on to the next one. So question four, a 62 year old man presents to the respiratory clinic after being referred by his GP for persistent shortness of breath and a dry cough. He has not smoked for 25 years but does have a 20 year pack history from when he was younger systemically. He is well, but symptoms have been getting worse over the last eight months on examination. He has bibasal fine end inspiratory crackles and finger clubbing. A high resolution high resolution CT scan shows a ground glass appearance to the lower zones of the lungs bilaterally, which of the following conditions is most likely to have caused the patient's symptoms and CT findings. So, is it a tuberculosis B coal workers, pneumoconiosis, C idiopathic pulmonary fibrosis d sarcoidosis or e hypersensitivity pneumonitis. So I'll just give you a minute to have a think about that one, not the po so and the that um share the results. So 94% gone with C and a few for D Perfect. Thank you very much. So, you guys have obviously been doing your revision about about respiratory. You're doing very well. So you 94% you got the answer correct, which is idiopathic pulmonary fibrosis. And we'll go through as to why this was um for those of you that didn't get it. So there's a few questions, a few clues in the question again, which I've highlighted um a classic one from exams being like this by basal finer ending spiritual crackles and also ground glass appearance on your high resolution CT scans being two kind of big clues. Um OK. So this is like a, so I PF is a chronic lung condition with progressive fibrosis. And so it's more common in people aged 50 to 70 twice as common in men. And as you can see in this question, it's kind of a man within that age range with some of the classic features including a progressive exertional dyspnea and the those bye basal crackles, a dry cough and finger clubbing. And so diagnosis is always kind of needed need to this high resolution CT scan for your interstitial lung disease. Um And also another clue in questions is whereabouts the um interstitial lung disease has affected the lungs. So many different con conditions can cause lung fibrosis. But um sometimes they preferentially affect the upper or lower zones. So I PF tends to affect the lower zones and that's therefore the most likely answer in this case, as all the rest of these answers will usually affect the upper zones of the lungs. So that's another way that you can determine what the correct answer is. So, interstitial lung disease itself includes many conditions that cause inflammation and fibrosis of the lung. Parenchyma, fibrosis involves the replacement of the elastic and functional to lung tissue with nonfunctional scar tissue. As I mentioned, diagnosis always involves clinical features along with the high resolution CT scan and spirometry. Spirometry is quite a good thing to get your head around. As in quest in finals, some questions may present to you with spirometry results and I expect you to interpret them as a bit more on this. In the next slide management for interstitial lung disease, uh generally kind of, well, it generally has a poor prognosis as the damage is irreversible and therefore, treatment is primarily supportive. You should focus on kind of giving patients pneumococcal vaccinations and and your flu jabs. Um lung transplantation is an option but is very done done as it has kind of very high risks. And on the CT scan, this is kind of what you'd usually see as quite a lot of fibrosis and this kind of ground glass appearance. Um also important management kind of being yes, stopping smoking, physiotherapy and pulmonary rehab. Um And yeah, so the spirometry interpretation. So, spirometry is a method of assessing lung function by measuring the volume of air that a patient is able to expel from their lungs after a maximum inspiration. It's quite a reliable method of differentiating between obstructive area disorders and restrictive disease. So your obstructive ones being CO PD and asthma and your restrictive ones being your fibrotic lung diseases. And so in exams and uh in clinical practice, there are three main results that you'll be given uh these your forced expiratory volume in one second. So your F EV one. Um and so this is the f the volume exhaled in the 1st 2nd after a deep inspiration and force expiration similar to kind of when a patient's doing a peak flow, it's like that that initial one second forced expiration, you also have the forced vital capacity, which is the total volume of air that the patient can force the exhale in one breath. And now have the ratio between the two, which is expressed as a percentage. Um This the values of F EV one and F VC are expressed as a percentage of the predicted normal for a person of the same sex, age and height. And so in obstructive disease, this is when there is damage to the lungs or narrowing of the airways, making it harder for them to exhale ha air as quickly. So they'll get a reduced F EV one and also reduced F VC. But to a lesser extent than the FEV one and a restrictive pattern. On the other hand, has reduced F EV one and a reduced F VC. Um and they're both kind of reduced by about the same amount usually. So the F EV one and F VC ratio is normal and so moving on to causes of pulmonary fibrosis. So this can be split as mentioned in the answers of the questions to kind of upper and lower zone fibrosis and different causes. So it's important to be able to diff differentiate between the causes. Um and it's quite a common exam question. So the most common causes of fibrosis is idiopathic pulmonary fibrosis and drug induced all cause low ozone fibrosis. So I PF is a diagnosis reserved for when no cause for the fibrosis can be found to kind of a diagnosis of exclusion. And you can also have several drugs causing um pulmonary fibrosis in the lower zones. And the ones on the slide, there are the most important ones to be aware of, say amiodarone, methotrexate and nitrofurantoin are quite common drugs that we use. Um asbestos can also cause several bad lung related diseases, which we won't go into today. But asbestosis or pulmonary fibrosis caused by asbestos is one of them. Again, that's the lowest zone um cause. And so you can use an acronym called ratio. And so that is um R for ra A for asbestosis, S for SL E scleroderm and Sjogren's I for idiopathic pulmonary fibrosis and O for, for other things including drugs. Um So also something important to note is that most connective tissue disorder disorders like RA and SL E can cause lower zone fibrosis, apart from ankylosing spondylosis, which causes upper zone and then to remember the upper causes. Um I use the acronym charts and that stands for coworkers, pneumoconiosis hypersensitivity, pneumonitis, ank spondylitis radiation, TB, and sarcoidosis or silicosis. So I'm not really gonna go into kind of full detail today about um all of these causes, but I'd say hypersensitivity, pneumonitis, something to look up in your own time. And this is because in exam questions, there's usually a clue. So they talk about whether someone's owned birds before or works on a farm. Um And yeah, that's kind of an easy clue exam question that could help you pick up the marks, moving on to question five. So a 21 year old woman presents to the emergency department with sudden onset dyspnea. Her symptoms started 1.5 hours ago on examination. She is unable to talk in full sentences and she has widespread bilateral wheeze she has no rash, you carry out some observations and a peak flow reading and an ABG. So peak flow is 240 so her usual best is 600. Her obs her heart rate's 100 and 17 respirate 29 BP, 100 and 25 88/82 and att 36.5 and SAS 94 and ABG uh late results are PH of 7.39 P CO2 of 5.5 and A uh and one of those is meant to P OT. Um And so yeah, sorry, this one's meant to be po two the bottom one. And so which feature from the history examination and investigations indicates that she's having a life threatening asthma exacerbation. So a her inability to talk in full sentences. B her oxygen sats C widespread bilateral wheeze D her peak flow results or E her P CO2 and yeah, P the P CO2 being this middle one here just wants the pole now. Thank you. So to the end of the poll, uh a tie between A&E with a few going for D as well. Perfect. Thank you. And so the answer was, in fact, e um so good m good proportion. Are you guys getting on that one? Right? And so yeah, it was her P CO2 being this middle one, excuse the, the type over the bottom one. And so this question was testing your knowledge on classifying the severity of acute asthma exacerbations. So, asthma usually presents with pretty classic features of kind of a sudden onset of shortness of breath and wheeze and this, yeah, especially in M CQ land. Um whereas in the real world, it might be a bit less, less obvious if it's someone's first asthma presentation. So going through the results, all the answers. So a is incorrect. Um It's a worrying sign that someone can't um complete or talk in full sentences. Um but it qualifies as severe asthma, not life threatening. Um So b again, another worrying sign, her oxygen sats kind of down at 94 you'd maybe want them a bit higher. Um But to classify life threatening asthma, the SATS must be below 92% c the widespread bilateral wheeze does not indicate the severity of asthma. However, something to look out for is a silent chest as that would indicate life threatening asthma cos that kind of shows that they're making poor respiratory effort and that they may be tiring um and d her peak flow result. So this is in fact, 40% of her best or predicted which again class her in the severe asthma. And so this leaves E her P CO2. And so when this is normal alongside features of an acute asthma attack, it shows that the patient again may be tiring and that can no longer blow off their CO2. So as you can see her uh CO2 is within the normal range. Um And this shows that the patient may be tiring and so this is quite worrying. So we've got all of those summarized in a table here. Um This is from the British Thoracic guidelines. Um And so, yeah, this is a bit of an exam classic and I think it's quite good to get your head around acute asthma in general and also how to classify. So I know, yeah, it can be difficult to remember all the numbers in this table. So I think sometimes looking at the um symptoms can be a good, easier way to remember kind of what a moderate person might look like compared to a a life threatening of that silent chest. Um ok, so to classify someone as having a moderate asthma attack or asthma exacerbation, they must have no features of an acute, severe one. So even if they got all of these, but then have kind of one of these that would push them up into severe C section. So it needs to be all moderate to have a, to be classified as a moderate asthma exacerbation for a severe patient. They must have any one of the following as mentioned and um any one of the following. So if a patient then has severe, but one of the life threatening ones and it puts them up into life threatening, um and this will kind of change your management and how worried you are about that patient. So it's quite good to think about your clinical signs. So once you're looking at life threatening, you'll be thinking about a patient that's got altered consciousness. They're exhausting. They may have arrhythmia, um hypotension, cyanosis, a silent chest, a poor respiratory effort. And then you can also think about your measurements. So your peak flow of less than 33% predicted a SATS of less than 92% and an oxygen of less than eight on an ABG or as we had in our question, a normal P CO2 there at the bottom. And so then if you see a patient with a raised P CO2, this means they're seriously tiring and exhausted and cannot ventilate themselves. So this CO2 is accumulating and they that this kind of patient will require mechanical ventilation and kind of maybe it you as well. So that's someone you you'd be very worried about. And so then just thinking about the treatment of acute asthma, this can also be quite tricky as there's a few different stages. All patients who kind of have any, any feature of life threatening or near fatal asthma attack should be admitted um or kind of, if they're having a severe attack which has persist persisted after an initial treatment, then you should also consider an admitting moderate to severe cases, require a stepwise approach until control is achieved. This kind of useful acronym. Not sure if you've heard it before yet, but it's Oh shit me. Um which hopefully with the use of the acronym, you won't be feeling that when you're on F one and you'll also have kind of senior help and escalate adequately. Um But I found this kind of helps remembering the drugs. Um, but there's a bit of controversy, I guess about what exact order you would try all these things in. Um, it's not kind of an exact science in some cases. So the o being oxygen, the s being salbutamol, the H being hydrocortisone, the I as ipratropium bromide T as theophylline and M mag sulfate and E is escalate. But I think obviously you'd escalate a lot earlier as an F one um when you feel comfortable or when you feel like you're getting out of your comfort zone um kind of. Yeah, and then a senior and few they'll think about these more specialist treatment um treatment options. So if there's any, no questions about that, we can move on to question six. So a 57 year old man attends his GP for a general check gen general checkup. He is a heavy smoker with 55 pack years and drinks about 10 pints most weekends. He reports that he has had a continuous cough for about three months and has begun to cough up some blood. He has also noticed his face has become rounder and he's put on about 10 kg of weight. He mentions noticing purple lines appearing on the skin of his abdomen too. He has no significant past medical history and is not on any regular medications on examination. He struggles to get to stop out the chair. He has a persistent cough but his chest is clear and his heart sounds normal. All other examinations, findings are normal apart from his BP, which is raised, you send him to the hospital for further investigations and his chest X ray shows a right hilar mass suspicious for malignancy. What is the most likely diagnosis? Is it a metastatic deposits? B an adenocarcinoma of the lung, C squamous cell, ca lung cancer, D small cell, lung cancer or E mesothelioma, just launch the puz we'll give you guys another minute and just a reminder to everyone, I've popped the feedback form into the chat. It's really helpful if you can fill that out for us even if you've been to the sessions before. So that we kind of know where everyone's come from and how we can improve the talks in the future if that's all right. Thank you. I'll just end the poll now. So 70% of you have gone for D with a few for B and C. Sweet. Thank you very much. And yeah, so really well done again for getting the right answer, which is D. So this man has a significant smoking history and the chest X ray has revealed a suspicious mass. A does anyone kind of wanna post in the chat about what syndrome this man has developed due to his lung cancer or any ideas about what, what, what he might have got her there. Yeah. Really? Well on everyone there putting Cushing's into the chart. Um So the weight gain mentioned is describing that central adipose um kind of deposition. Then there's also the moon face and peripheral muscle weakness, which is I think what, what we talk about here when he's struggling to get up out of the chair. So they're all features of Cushing's syndrome. And this is one of the paraneoplastic syndromes um that are seen in small cell lung cancer due to the tumor secreting ACTH. So that is why D was your correct answer here, but we can go through the other answers as well. So, a for metastatic deposits is incorrect if these were to like metastases and the chest X ray would show multiple lesions usually rather than a solitary hilar mass B is incorrect. Um due to so, adenocarcinomas of the lung are usually more associated with um gynecomastia as their kind of extra pulmonary manifestation. Whereas in this case, we have more of a Cushing picture. C. Um So same squamous cell lung cancers, they typically secrete parathyroid hormones and this can cause all the parathyroid hormone related peptide which causes hypercalcemia. Um And we'll have a bit more information about this in a minute. And then D was your correct? And then e mesothelioma, which is a cancer of the pleura usually due to asbestos exposure. And so there's nothing kind of in this question suggests that they've had any exposure. Um They'll usually mention the occupation as like a builder or a plumber in a question way or they're wanting to you to think more about asbestos exposure. So, moving on a quick recap on lung cancers and what to look out for. So any kind of patient presenting with these symptoms will qualify for a two week. Great screening your chest X ray is your first line investigation and findings suggesting lung cancer are kind of things like higher enlargement, peripheral opacities, pleural effusions, and these are usually unilateral in cancers. And also you can see lung collapse, CT scan is then used for staging and screening for Mets. And we've just got a bonus little chest X ray here. Any kind of idea what this X ray shows anyone in the chat. So again, another classic one you could see in exams. Yeah. What I been there. Yeah. Oh, she got that as well. So, yeah, this is cannibal metastases commonly from renal cell um from renal cell carcinomas. So well done. So then moving on a bit more about the um different types of lung cancer and some of their extrapulmonary manifestations and their associated paraneoplastic syndromes. So in the question that we just had our patient had a small cell lung cancer and his tumor was secreting ectopic ACTH and this was causing Cushing's syndrome. So this is quite a helpful diagram and you can just file that down. So here's a small cell lung cancer and these are the different perineoplastic syndromes that you can get. Your most common lung cancer is your non small cell. And so you can have the squamous cell. And that's where there's that parathyroid hormone production that causes the hypercalcemia. And then you get adenocarcinomas and large cell. And with each of these, there's usually different clues that you'll see in the questions to point you in those directions. And then we've also got some extra pulmonary manifestations that you can see. So you can get a recurrent laryngeal nerve palsy, which presents with kind of a hoarse voice. And this is just when there's a tumor pressing on or affecting the recurrent laryngeal nerve as it passes through the mediastinum, you can get phrenic nerve palsy and this kind of causes diaphragm weakness and shortness of breath again due to nerve compression. And then you could also get superior vena cava obstruction. And so this is a complication of lung cancer caused directly by a tumor compressing on the your S vs. And this causes facial swelling, difficulty breathing and distended, kind of neck and upper chest veins. And there's a sign that you can see with this called pemberton sign. And this is where raising the hands over the head causes this facial congestion and spinosus. And this is a medical emergency. So you would really wanna watch out for this one. And then also another classic is Horner's Syndrome. So that's a triad of partial ptosis. So, drooping of an upper eyelid and hidrosis, which is inability to sweat and meiosis. So small constricting of the pupils and this is caused by pancoast tumor or a tumor in the pulmonary apex and this is pressing on the sympathetic ganglion. Um Also in this diagram, you can see other important neoplastic syndromes to be aware of. Um a few of which we've talked about. Um So yeah, you can get a SA DH caused by ectopic A DH production from your small cell lung cancer. Another bit more rare one is your Lambert Eaton syndrome. And this one to be aware of for exams as it's described as a weakness of the proximal muscles leading to diplopia. So double vision ptosis again. So that drooping of the eyelid slurred speech and dysphagia. And this is due to the release of autoantibodies from a small cell of lung cancer. Another key one that comes up in in exams is that hypercalcemia that I mentioned caused by squamous cell carcinomas. And this is due to that ectopic hormone production and this produces the classic hypercalcemia symptoms you might see in questions. Um the mnemonic being or the little rhyme being stones, bones, groans, Thrones, and psychiatric moans. And so this is referring to renal calculi. So, renal stones, bone pain, abdominal pain, polyuria, and signs of an altered mental status. Um So that's yeah, again, another one to have a look at that, I'd reckon recommend moving on to question seven. And so a 75 year old man is recovering from a hip fracture surgery. Four days ago, you were called to go and assess him and as the nurse, as the nurse reports that he has become acutely short of breath, he also describes some chest pain since this morning that is sharp and worse on inspiration. You note in his notes that he has a history of CKD stage five and type two diabetes on examination. His chest is clear and his observations are as follows heart rate, 100 and 20 BPM, respirate, 23 temperature, 37.5 and BP, 100 and 10/85. Given the likely diagnosis. What is the most appropriate diagnostic investigation to perform? Is it a AC TPA B, an echocardiogram C A VQ perfusion scan D ad dimer or EA chest X ray if you wanna stick your answers in the poll for us. Oh, so another couple of seconds, um we'll end it there with about 60% going for a and the rest between C and D. Sweet. Thank you very much. And so this one was in fact, C with the VQ perfusion scan. So let's talk through why. So I think most of you correctly identified this patient's presenting with a pe or a pulmonary embolism. And so the clues towards this diagnosis that they're an older patient recovering from surgery. And so this is a likely provoked pe from a period of immobility and there are symptoms of shortness of breath, pruritic chest pain alongside a tachycardia and tachypnea kind of altogether is a pretty classic presentation. So, um yeah, his well score is a six and so according to the nice guidelines, C TPA is first line. However, this would use contrast and through a vein, this can affect his kidney function. And if you remember in the question, our patient had C KD stage five. And so therefore, you'd opt for a VQ scan in this patient. Um Nice, also recommends using the cock D grafting gt formula to calculate the creatin creatinine clearance, which obviously you couldn't do in this um scenario because I didn't give you any blood results. Um But just as a bit of background knowledge, if it's less than 30 mils per minute, then you should opt for the VQ scan instead instead. And in our pa in our question, the patient is kind of highly likely to be less than 30 due to this severe renal failure. Um And so yeah, that's what I see. I'll just talk for a bit about the other answers. So an echocardiogram would not be useful in this presentation as used. This is used for diagnosis of any valvular or myocardial wall abnormalities in the conde in the context of cardiac pathologies like heart failure. And so that would present quite differently. A DDIMER again, correct thinking about the pe. Um however, with this, you've gotta think about their Wales score. And the guideline suggests that in a patient with a Wales score of greater than four, you should move straight to imaging for diagnosis. So the DDA M is kind of useful when the Wales scores suggesting that pe is unlikely. So then you can use this to rule it out as the test is highly sensitive. So you won't miss any ps but it's not very specific to a pulmonary emboli and can be raised for a few other reasons. Chest X ray is also incorrect. Um It's a good investigation. It's kind of ruled out other chest pathology and the patient might receive this if they present uh ed or they probably would receive a chest X ray if they present Ed with kind of some symptoms of a pe because those are the things you want to rule out. However, our patient are presented with kind of classic symptoms. He's already an inpatient who is immobilized. And so there's kind of a a provoking reason there. So it's therefore sensible to arrange the investigation, but most likely to diagnose as the pe and so a bit of information. So there are kind of your risk factors, what you wanna watch out for when you're reading your MC Qs and your exam questions. Um some of them usually snuck in there so that can help point you towards the diagnosis. Um, pulmonary emb bladder can be asymptomatic and discovered incidentally or present with kind of small subtle signs and symptoms or even cause subtle death. So there's quite a low threshold for suspecting a pe and these are kind of your presenting features which um I hope most people are pretty familiar with your leg swelling as well. One thinking about kind of dvts that maybe have done um embolized. So, diagnosis is, is a chest X ray again, as I was just talking about all that other pathology, um an E CG you'd wanna do. So, tachycardia is your most likely finding um and kind of textbooks and classical people call, er, talk about this S one Q three and T three changes, but in reality, that's only seen in 20% of presentations. So you're more likely to see tachycardia and then you'd also want to do a wells score. And so the outcome of this decides the next step. And so if it's likely so greater than four, then you'd perform a C TPA or the alternative imaging. And then if it's unlikely, then you'd go for ad dimer and then if that D dimer was positive, then you'd go for a C TPA or, or the alternative imaging. Um I this I think is a good one to have in your head in exams, whether you do well learning all the numbers specifically or kind of what qualifies for your more worrying signs and what your middle kind of criteria and then what your lower ones are. I think it's a good idea to, yeah, have a general understanding of this and be able to kind of recall it in the exams that will help you with your management. Um, other reasons for kind of a raised D dimer that'd be looking at things like pneumonia, malignancy, heart failure, surgery, and pregnancy. So as mentioned, yeah, it's not the most um specific but it is sensitive. So it will be raised, it will most likely be raised if there is a pe. Um And yeah, as I mentioned, I think it's a good idea to have a closer look at that well scoring system as you may need to try and calculate one or at least have a good idea of what's included during the exam. And kind of lastly, there's just quite a helpful flow chart here. I found um to work for your kind of query pe patients and mainly what we've already discoed discussed and a bit of information about your treatment. So first line treatment is your doac drugs, the length of treatment is decided whether it's provoked unprovoked or due to cancer. Um And if a patient is presenting with hemodynamic instability, then you'd go straight for a thrombolysis uh before moving on to any investigations, sy these are the things that we cover today and there are a few more kind of topics that I'd recommend you having a look at that are quite commonly, quite common to come up in exams and would be quite high yield for you guys to go over. Um, and there are also certain bits of this that maybe would need a little bit more looking over. Um, but yeah, I hope that's been really useful and that you've all managed to kind of at least take away something. I know some of those questions were bit bit more tricky than others. But yeah, thank you very much for coming and cheers for filling out the feedback form. If you could all do that, that'd be really helpful. Yeah, thank you very much for coming along guys. Um Please fill out the feedback form before you go. Um And then we can send the slides to you uh via that. Um Next week we've got a talk.