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Hello, everyone. Uh My name is Petra. I am currently a Fy two doctor at Imperial College of NHS Trust. Um I'm doing a specialized foundation program and I'm, I also went to Imperial. So um Paces weren't that long ago for me. So good luck. And I hope this helps. I've also got a mental code here. So there's a QR code or you can just put in the code. Um OK, so just in terms of today, um I've got a disclaimer, we will not cover everything. Um I'm gonna give you some tips about Paces and then we'll do some BS which I hope will help with the revision as well. And um in terms of paces tips. So I think when I wrote these, I thought about what might be useful for your exams, but also what would be very useful in terms of fy one. And I think a key thing to remember and to focus on is to learn what is normal before learning what is abnormal pathology. I think it's so, so, so important and I did not realize this um because you can't really understand what abnormal pathology is before you do learn normal uh normal. And um I think it's really important also to practice in real life patients, the more the the sicker you become and um the more you'll be able to just focus on positive and negative findings. And um yeah, we will just cover some differentials for common signs and symptoms in this lecture. So this is just a table summarizing kind of key finding, key things to um include in terms of your history taking. So, um specifically for rest. So I would focus so your main history of course, but definitely include pets and animal exposure, uh work and occupation, um Smoking, both active and passive and uh asking about whether they have smoked in the past um travel. Um where did they go? Where did they stay? What did they do? Um whether if say they present with um kind of like an infected picture, whether anyone else who they don't live with um is ill as well and what effects it has on the activities of daily living. If the key presentation is shortness of breath, always ask about exer exercise, tolerance of apnea, leg swelling and any triggers. Um Similarly for wheeze um day night variations, um is it seasonal history of ap and any triggers in terms of um cough? Is it productive, not productive um quantity color pattern, any blood in it, any triggers and then um chest pain doing your Socrates and also doing your systems review. Um As it could be cardiac as well and other things in terms of your examination, focus on your relevant and significant positive negative findings. Um When I did my pas I kind of as I was going through the examinations and I found something um to remember it, I kind of kept on saying it in my head. Um So that when I was presenting it, um I wouldn't forget it. And I think that was quite important and just kind of using a systematic approach. So your inspection palpation, percussion auscultation, and I've kind of like highlighted here. Um The main things to look out for in terms of hands, arms heads and then chest legs and then for completion purposes and again, for completion purposes, dividing it into bedside blots, imaging and special tests. Um It's just helps you think and organize um your thoughts and it also, it just looks better as well. Um Then in terms of coming to your differentials um for patients think about dividing it either into your vitamin CD or just by local s organs. So you um or local systems, so your rest system, cardio cardio neuro, um whatever works best for you. Um And then in terms of your investigations, again, belos imaging and special tests, um it just again, looks better and helps you think um through it more carefully. And then in terms of your management, it's unlikely for you to get an unwell patient. I think at least it was in my cases. But um with any unwell patient, when you, it comes to fy one, um just think about your at assessment and then in terms of your stable management, think about your conservative medical and surgical. And then I think these are the key things be safe, see your support early. So um this goes both for your paces as well as for your fy one. Yeah. Uh and then just remember red flag exclusions in all your history taking. And then um I'm not gonna go through these in detail, but I thought it might be useful to just have some common um differentials for hemoptysis as well as for pulmonary causes of clubbing. And then um the scars for patients are quite important. So, um again, I won't go through them in detail, but I just look at uh like if you, if you haven't seen them in practice, but maybe just googling them and um also learning about what surgeries um um they were for. Um Yeah, and we are coming on to the first SBA. Um So if you guys, um I put demento here already. Um And the question goes, a 67 year old gentleman presents the hospital with worsening shortness of breath and productive cough for a week when he's asked about his symptoms before. He's admits that he's had a chronic cough and he gets breathless when walking to local shops. He is a smoker and has smoked 25 cigarettes a day for the last 40 years. And this is his ABG. So, um, I'll let you read that for yourselves. And then the question is, what is your most likely diagnosis? I put more than five, but I just thought I would make it a bit more interesting. I'll give you a bit of time. I'll just go back to the question. I, ok, I think that's what we're gonna get. Um And yeah, all you guys got it right. Very good. So this is an acute exacerbation of COPD and the patient is in type two respiratory and we can see that because the PA O2 is low and the PA C two is high. So you all got that right? Which is very good. Um So COPD um is a chronic slow progressive disease um characterized by alpha obstruction. Key features are that they are ordered in 35 years. Um And they have risk factors. So are a smoker, they have an occupational exposure to or have an occupational exposure to chemicals and dust. Um Your pulmonary function tests are really important here. So, um post bronchodilatory spirometry testing should give you an FEV one of FEV FVC of less than 0.7 and FEV one is used um uh to indicate severity. So greater than 80% is mild and then less than 30% is a very severe. And then there's of course, infective exacerbation of COPD, which is triggered by bacteria and viral um infections. In terms of your differentials, I've kind of split it uh by your local systems. So cardiac uh differentials would be heart failure, resp differentials would be lung cancer, asthma, interstitial disease, lung disease, and bronchiectasis or you could also guided by your vitamin CDF. Um, it's really up to you. Um, and then in terms of um, your presentation, I think the question highlighted that already quite well, but it's your worsening, breathlessness, worsening, cough, with sputum production, wheeze fever, tachycardia and severe cases, cyanosis and your investigations. I've split those into bedside bloods, imaging and further tests. So your bedside would be your basic obs. I would just do your basic obs in any kind of case, any kind of question. And um your ECG here um mainly because of the possible differential of a cardiac problem. Um Your bloods would be your full blood count using the CRP LFTs and importantly, your um blood cultures, but also sputum cultures and an ABG and an imaging wise, you've got your chest X ray ct thorax and then special test would be your pulmonary function test. And then in terms of management. So if you've got infective exacerbation of COPD, then key points would be targeted oxygen therapy, um, salbutamol and opia corticosteroids, antibiotics. Um depending on your local guidelines, usually is Doxycycline. And then if the patient meets criteria as in in patient, you'd consider an IV and ventilation. Um and then in terms of your management for COPD, you've got your conservative. So, and prevention here, which would be your vaccination, smoking cessation. So, making sure to offer that at every visit, um, rescue packs if they have frequent exacerbations, um, and um, regular, uh, training and proper use of inhalers, that's really important and chest physio as well. And then in terms of, um, your inhaler, um, therapies. So, I it's, I think it's a bit complicated and I think it's something you just have to learn unfortunately. Um but um this is from like the nice guidelines. So it's, it's kind of split it between. So after you offer your sabam and um patients um still have symptoms and exacerbations, then it goes down kind of like two pathways. One is there are no asthmatic features suggesting steroid responsiveness and then the other is asthmatic features and I think it does just something that you have to learn in your spare time, unfortunately. Um Yeah. And then in terms of your surgical um consideration in very severe cases, if it meets the criteria, you would think about lung volume reduction surgery, ectomy, and transplantation and complications include um infective exacerbation of COPD respiratory failure, pulmonary hypertension and car pulmonale coming to you the second question. So a 71 year old gentleman presents to the hospital with shortness of breath, cough and fever, a chest X ray uh shows a right sided pleural effusion, a pleuritic tap. Um shows the following. So 40 g for these of protein. Um What is the most likely cause of the pleural effusion? I'll go back so that you can see the question again. OK. So we've got malignancy and then we've got infective cause. So the correct answer here is in fact, four. And let's go through why? That is. So what is a pleural effusion? It is basically excess fluids in your pleural space. And I think the key um things here are your transitive and then your exit. Um pleural effusions, your transitive is defined by a fluid protein of less than 20 25 versus your exit is defined as your pleural fluid uh protein greater than 35. Now, your transitive um tends to be all your failures. Um and then some other things. Um but it's your cardiac failure, ral failure, liver cirrhosis nephrotic syndrome, heart vol anemia, pe in some cases, but less so than for ex and then Mike Syndrome as well. These usually are bilateral. Um and you would focus on kind of treating the underlying cause. Um And you might consider therapeutic aspiration. Um If a patient has a bilateral uh pleural effusion and it is strongly suggested that it's transitive, you wouldn't necessarily aspirate it. If um it is exit, then they would need further investigation. And then importantly, you've got lights criteria. Um that's when your protein is 25 to 35 and fusions are considered ex if um they meet these criteria. Um And unfortunately, again, that's just something that you have to learn, um, in terms of your presentation. So it may be asymptomatic, um, have increased shortness of breath, chest pain, um, cough or associated feature of the underlying condition. Signs include tracheal deviation, decreased chest expansion on affected side, uh, stony, dullness and percussion and decreased vocal resonance. Then in terms of your investigations. So again, bedside bloods, imaging and special tests. So bedside, just your basic ops, ecg bloods. Um again, these are just your basics and then clotting as well. Um And then imaging chest X ray ultrasound might consider CTCA. Um and then other things to consider Aspin mcs if you're thinking this might be infective or a diagno. And, and in, in terms of the diagnostic P, as you would specifically want to see the ph, the LDH and total protein mcs in cytology and you want to serum for those things that's important to remember to be able to calculate that's criteria. Then in terms of your di differentials, um I mean, I think pleural effusions already include quite a few differentials. But um just I guess in terms of respiratory, you could think about your pleural tumor management really depends on the underlying cause. So if you have congestive cardiac failure, then you think about diuretics, physio, they need an echocardiogram. If they're symptomatic, you might consider a therapeutic for, for echoes and giving them oxygen. Um If it's infective, you'd give them antibiotics. And again, you could consider therapeutic for it. And he says if it's empyema, then you would need a chest strain. And then if it's malignant, um, again, I think it's quite complicated. But I think if it's basically a poor prognosis, you would think about a therapeutic. And then if it's a good prognosis, you'd think about pleurodesis or pleural catheter drainage and your complications include your empyema. Uh So that's basically pus um in the pleural space, um pneumothorax after drainage and there's something called reexpansion, pulmonary edema. Um and that's to prevent that basically drain um quite slowly. And so you don't have more than 1.5 L at once. Ok. Coming on to our third question. So a 65 year old retired lady presents to hospital with daily chronic production of phlegm occasionally restricts blood shortness of breath. Wheeze on exertion, malaise and fatigue. Her past medical history includes rheumatoid arthritis, Sjogren's syndrome, and ulcerative colitis. Bless her on examination. She appears cachectic and has basal cramps and clubbing in her fingers. What is the most likely diagnosis? I think you may have to change the slide on ment. Ok. Sorry. Yeah. Does it work now? Yeah, it's working? Thanks. Ok. So, yeah, the majority. You got that right. Um So bronchiectasis. So basically, this is an abnormal dilatation of your bronchi due to destruction of the elastic and muscular components of the bronchial wall causes the most common one is having had previous low bridge tract infections such as pneumonia, puss, and pulmonary TB idiopathic and 40%. Um, and associated with IBD and RA and cystic fibrosis as well as primary ciliary, dyskinesia and allergic bronchopulmonary aspergillosis, which can be shortened to ABPA. Um, symptoms include your chronic sputum production and episodes of hemoptysis, exertional dyspnea and wheeze, there's malaise and fatigue and symptoms of chronic sinusitis may also occur in terms of your signs. You get basal cramps, wheeze finger, clubbing and cachexia and investigations. I'll just kind of highlight the the key things here apart from your usual things to order. So also doing an alpha one antitrypsin as well as an A ana anca and rheumatoid factor. And then the high resolution CT is quite important and in terms of your special tests, um doing an Sputum mcs also sending for fungal culture, uh pulmonary function test, um ABPA screening and genetic testing for cystic fibrosis um for differentials, um thinking about your respiratory causes. So, uh COPD asthma pneumonia and chronic sinusitis management wise, splitting it into conservative medical and surgical. So your conservative would be airway clearance techniques. So, chest physio uh nebulized hypertonic saline and humidification as well as your vaccinations. Um um so you would treat acute exacerbations uh with antibiotics and then you can give mucolytic agents and a subset of patients as well. And surgical, one surgical management includes lung transplantation in eligible cases. Complications include infective exacerbations um hemoptysis, pneumothorax, uh chest strain as well as respiratory failure. Coming on to our fourth question. A 35 year old lady presents to A&E or shortness of breath, productive cough and fever. She has normally fit and well and has no past medical history on examination. Her respirate is 26 and her BP is 100 and 10. Over 82. She's alert and orientated with an abbreviated mental test score of nine out of 10 and her urea seven chest X ray shows a lower zone consolidation. How would you manage this patient? Yeah, I'll just go back because there's a lot of information. Ok, great. So, um I think, yeah, majority of you've got that right. So this is your P 65. Um So you come for each, you get one point. So you've got your confusion greater than seven respirate goes in the 30 your systolic BP less than 90 your diastolic BP less than 60 being greater than uh other than 65. Um If your curve is 0 to 1, you're kind of considered mild and most of the time you can be treated in an outpatient setting. Um and given amoxicillin five days pee orally and if you're allergic um macrolide, um I think just, just to say, I think it's always important to kind of keep the clinical picture in mind and consider things like is the patient pregnant? Um Are they very frail. Um, what are the comorbidities? So, I think C 65 is um, important to use, but I think it's, it's not the only thing to consider, um, then going to your cab two. So that's your moderate. And here you would give Amoxicillin and Clarifoam po for 5 to 7 days and you would kind of consider admission and then your C 3 to 5, you would give seven days of co and Clarifoam IV and admit and um mm consider it depending on other factors and then kind of in terms of your management. If you're thinking atypical organisms, that's when you use your macrolide. So one example would be your Clari and then if you have a hospital acquired pneumonia, um most of the time that's Vancomycin or tazocin, but you would consider uh uh you would look at your hospice guidelines for that. Um And again, just to go over that. So you have your community acquired pneumonia and your hospital acquired pneumonia. Hospital acquired pneumonia means you symptoms presenting after 48 hours of being inpatient. These are your s aureus, CPSA pseudomonas. And then you can also um look at pneumonia in terms of typical versus atypical so typical. Um Is your classic symptoms, classic chest X ray changes, they respond to uh penicillin, antibiotics if they're not resistant. And um these include your strep pneumo the eye and your atypical organisms present with atypical symptoms. Um The chest X ray might not be in keeping uh with what we consider a typical pneumonia and they don't respond to penicillin, antibiotics and may have extra pulmonary features. So your classic example, here is your legionella which can be found in water units uh with rising LFT S and a low sodium as well. Again, presentation depends on the pathogen severity, age and comorbidity of the patient. But some common things are fever, shortness of breath, cough, pain, and wheeze. And then in terms of your investigations, splitting it into blood imaging and special tests. Um here important things to highlight, I think would be your culture. So blood cultures Putin ABG um if they're desaturating and um doing an atypical screen as well. And then in terms of um your management here. So if you're acutely unwell, um doing your a oxygen of desaturating and senior support, um and then management for, if they're more stable would be your conservative. Medical and surgical. Conservative include rest hydration, simple analgesia, offering smoking cessation. If they're a smoker, in terms of your medical, this would be antibiotics and that would depend on whether it's a cap, a cap, an atypical organism and whether the patient is allergic to any of the antibiotics, complications would include. Um So, abscesses, these are more typical in your staph aureus and CPSA. Um and then um effusions as we've learned about. Um So these can be sterile, complicated, that means infected or an empyema. So the pus and um or it's always important um to think about VT prophylaxis, especially for these patients. Uh If there's no contraindications. Good. Next question is a 65 year old gentleman with a 20 pack year history of smoking, presents with weight loss, chronic cough and occasional hemoptysis. Chest X ray reveals a large mass at the left eye and suggestive of a bronchial carcinoma, erased, calcium is noted in. But what is the most likely diagnosis? Just go back to the question for you guys. There's also a question in the chart. OK. Um Maybe I'll answer them at the end or. Sure. Yeah, maybe. Yeah, I just do not. Ok. So we've got a variety of answers here. Um So this one is your small cell carcinoma, uh squamous cell carcinoma. Sorry. So I think in terms of lung cancer. So the important thing to remember is that if there is a cancer in the lungs, the most likely cause are metastases um from a different location. Um in terms of primary cancers, it bro, it's broken down to a small cell and then nonsmall cell cancers, your small cell cancers um are typically the most aggressive they may produce Ac So Cushing's Syndrome, um and uh Lambert Eaton syndrome, um as a feature, we'll talk a bit about that. Um Later in terms of your non small uh small cell cancers, you've got your adenocarcinoma, squamous cell carcinoma and large cell carcinoma. So your adenocarcinoma is typically a nonsmoker and, um, you might see hypertrophic osteoarthropathy and then your squamous cell carcinoma disease. I remember the disease. So central cava cigarettes, hypercalcemia uh produces PTHRP. Um, and then your large cell is typically your smoking occurs peripherally and poor prognosis. Um, presentation remember your flaws. Uh, but also persistent cough, hemoptysis, increased shortness of breath, hoarseness of voice, bone pain, smoking, history, family history, um, investigations again, broken down into bedside blood imaging and other other. And then I think important things to highlight here would be your CT chest pet scan, um as well as pulmonary function tests, bronchoscopy, EBUS and CT guided biopsy. Um differentials wise thinking in terms of your rest, um probably to be uh infected exacerbation of COPD bronchitis pneumonia. And then could also think about sarcoidosis or lymphoma. And then in terms of your management, the treatment really depends on the type of cancer TNM, staging their performance status and lung function tests. So, um I've just kind of highlighted the main um therapies, the surgical resection, chemotherapy, radiotherapy, immunotherapy, palliative care. I think this is something that you could also definitely say in cases um that would be fine. Uh And then in terms of complications, I remember a sphere of complications. So you've got your superior vena cava obstruction, pancreas tumor, but that's kind of included that we already know. So then your Horners Syndrome, your endocrine. So your paraneoplastic um syndromes, you can get your recurrent VNG nerve compression and then your effusions and then I've just made this um really for your vision. So you've got the differentiation between Myasthenia gravis and Lambert Eaton syndrome, which I'd like to ask about. And then you've got your severe vena cava obstruction um highlighted here. Um And this is our Horners Syndrome sotos mysis and anhydrosis both side and then last but not least. Um So a 65 year old gentleman presents to A&E with an eight month history of shortness of breath on exertion and a cough. Um, there's no wheeze on examination, there's clubbing and CRPS. I heard at lung bases, lung function tests show fe one F ec ratio greater than 0.7. What is the most like diagnosis? I think you have to open the question again, right? Ok. And yeah, all of you got that right. Very good. So idiopathic pulmonary fibrosis, this is like chronic progressive and ultimately fatal fibrosing interstitial uh pneumonia of unknown cause. Basically, it usually affects people between the ages of 50 to 70. And it's important to rule out other disease processes when considering this diagnosis. Um, in terms of presentation, you usually get shortness of breath and exertion, cough, fatigue, cyanosis, finger club, that's an important one, fine inspiratory crackles as well. And I think in terms of your investigations, important ones to highlight would be your autoimmune screen, high resolution CT and then your spirometry as well. Um And in terms of your differentials again, breaking it down into respiratory. Um that would be your acute interstitial pneumonia, connective tissue diseases, ra, or progressive systemic sclerosis or drug related pulmonary fibrosis. Uh for instance, caused by methotrexate in terms of your management. So that's your conservative medical and surgical. The conservative would be your primary rehabilitation. And unfortunately, medically, there's no conclusive evidence that um any drugs increase survival. Uh But I think there's antifibrotic drugs. So P pine and NTED up um may slow scarring. And then in terms of surgical options, it would be your lung transplantation. Um If there's no contraindications and medical management fails and the complications include, include your pulmonary hypertension and your respiratory failure. And that's it. Thank you so much for listening to me. And uh um yeah, if you've got any questions, then I'm happy to answer them as well. And this is the feedback form. If you don't mind filling it out for me, please. Amazing. Thank you so much. So, we have a question in the chart that says, what's parapneumonic effusion? Is it the same as pleural effusion? Yeah. It's like so basically, para next to pneumonia. So like, yeah, basically, yeah. So para means just next to the pneumonia. So yeah, it's the same as that. Yeah. Any other questions, any questions about Paces, anything else I can help with? You can also send me an email. I'm happy to answer any questions about that or if you've got any questions about Fy one or anything like that. And we have a question that says, what sort of patients would we see for signs and cases? So, I think that would mainly be. So, at least for my year it was quite like stable chronic patients. So you don't. So, at least I don't, I don't think they've changed it anyways, but, um, it wouldn't be somebody who's kind of like, acutely unwell. Um, I think that was the main takeaway from our year. Um, so I think, think about kind of your stable patients. So it could be your COPD patient, um who's not got an infective exacerbation. Um could also be your bronchiectasis patient. Could be um idiopathic pulmonary fibrosis. So I think more like stable conditions. I think that's, that's what I would, I would focus on. Yeah. Ok. I think that might be all then. Ok. Thank you so much guys. Thank you and good luck with.