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So can you see that? Ok. Yeah, I got all good. Perfect. So hi everyone. My name is Megan. I'm the current Ake president this year. Hopefully some of you will recognize me from the session I gave last Thursday, which was the cardiology um station uh for the examination. So I'm really glad to be back today to now be going through a history with you, which is the respiratory station. Just a reminder as Joe said, we got two giveaways today. Um So if you feel it in the feedback form, one person will be selected to receive free access to the amazing gee medics ay station resource. Uh This is something I use for my osk a lot. So it's definitely worth making sure to stay for the feedback form so that you can enter that giveaway. Um The other one is the 6000 follower one as Jo said. So if you take a picture during the session of me teaching, you're watching us from wherever you are in the world. Um Share it to your Instagram stories. Tag us at a easy official and make sure to follow those six accounts. Then um you'll have lots of things that you can win some things you'll win automatically by entering and we'll pick some extra winners. So make sure to take a photo and share it to your story um during the session today. But without further ado, let's get started. So what am I gonna go through today? So I'm going to be going through the three main types of respiratory histories. So, shortness of breath, cough and hemoptysis and we'll be going through uh what components and what questions to ask in a history, the differentials you should be thinking about investigations and management for. I would say the main respiratory conditions that should come up or could come up in an AY or an IY situation. So before we get going into the histories, let's warm everyone up with a bit of spot diagnosis. So for those of you that haven't done it before, uh I'm gonna give you a vignette or a description of a patient and you need to tell me in the chat, what you think, uh what condition you think this represents. So we'll start with our first one if you guys give that a read and then pop in the chat for me. What condition you think? Um, this patient may have? Amazing. Thank you guys for engaging so early as well in the session. Yeah. Awesome. Well done everybody. Yeah, pe pulmonary embolism. So we've got a lady who's short of breath, sharp, chest pain when breathing in. So that's called pleuritic chest pain. She's H RT, which would be a risk factor for pe and breath sounds are normal, which is quite common in patients with pe so well done everybody. Next one. Awesome, awesome, well done guys. I'm very proud that you all didn't fall into the trap that I laid for this one. So you are correct. This is a pneumothorax. So you've got a 22 year old male. So usually a younger male develops sudden onset shortness of breath when playing rugby. So that's classic of a pneumothorax, shortness of breath when doing a sport he's known to have asthma. So I was thinking some of you guys might have put an asthma exacerbation or acute asthma. Why have I popped in that past medical history for someone with a pneumothorax? Yeah. Awesome. Uh Just to remember that. Yes. So definitely this would be a secondary pneumothorax because there is a underlying condition that's caused this pneumothorax to happen. So lots of respiratory diseases put someone at risk of having a pneumothorax. So co PD and asthma are probably some of the common ones, especially asthma in a younger um male patient so well done for not being tricked thinking this as an asthma exacerbation. Um and then on examination, his lower left lung field is hyperresonant on percussion, which is classic. Once again, findings of a pneumothorax. Cool. Next one, I'll let you guys give that one a read. Awesome. Yeah. Good job guys. Yeah, this is quite a hard one, I think. So, this is bronchiectasis. So, you've got an older male who's coming in with recurrent chest infections, producing a sort of green sp, constantly coughing. Um, cystic fibrosis. Why is that relevant? Do we think it's relevant? Why do you think I put that in there? Yeah. So it's sort of to do with the recurrent chest infections just to know that people with cystic fibrosis are more likely to develop bronchiectasis. So similar as before. Yeah, exactly. It's a risk factor to think about for bronchiectasis. Definitely. And then on an examination there is clubbing. So just to remember COPD does not cause clubbing bronchiectasis can. So just uh that will uh we'll go through that more in the examination um station on Thursday this week. But just remember the respiratory causes of clubbing and that CO PD is not one, but bronchiectasis would be cool. Next one, last one. Awesome. Yeah. Well done guys. Yeah. So a lot of you said asthma acute asthma, asthma attack. Perfect. Yes, this is an asthma exacerbation or any of those other times you guys have used. So we've got a younger male struggling to breathe chest tightness. The cold has likely triggered this uh the cold and the exercise has likely triggered his asthma and therefore he's technique. There's a wheeze and he uses a blue inhaler, which is a bit of a clue that he might already have a diagnosis of asthma. Awesome, well done guys. So we're gonna start going through our histories now. Um, so we're gonna start off with a shortness of breath history. This is typically something you would find on the door of your ay stations if you're about to take a history. So a little bit about your role where you are, which is really important to note because as part of your, er, management of the patient, if they're in, say general practice, um, or A&E you might need to admit them into hospital or admit them to a ward. So make sure to take note of the setting. Um, a little bit about the patient, what their name is, maybe how old they are, what they're presenting with and what your task is, which in this case is to take a focused history. So we'll start off with a shortness of breath history. So, um, initially, we would obviously ask for the presenting complaint of the patient. They would probably say something along the lines of I'm feeling really short of breath. I can't catch my breath, that sort of thing. So what questions would you guys then like to ask the patient if someone comes in saying they're short of breath, thinking of the history of presenting complaints. So not thinking necessarily their past medical history or drug history at this stage. But what further questions would you like to ask? Yep. Duration. Yep. Oh, lots of good ones. Guys. Yeah, duration onset. Exactly. When did it start, uh, progression? Has it got worse over time? Definitely. Timing. Really important. Yeah. On exertion or at rest. Definitely. When did it start? Triggers? What were they doing? That's a really good question to us. What were they doing when the shortness of breath came on? Exacerbating, relieving factors? Does it, uh, vary sort of day to night? Di diurnal variation? Do they have any chest pain? Any wheeze chest tightness? Awesome guys. Loads of amazing suggestions. Yeah. Previous similar when it's happened before. Definitely great one. Perfect guys. So this is how I break down my history of presenting complaints. So I start off, um, quite simple is something called Socrates, which you guys will often use for pain histories, particularly chest pain histories that gets taught for. So our sight onset character, radiation timing, exacerbating and alleviating symptoms and severity, obviously, with something like shortness of breath, you can't really ask things like sight, er, er, like where is the shortness of breath? Cos there's only one place it really could be, it's probably gonna, they're probably gonna feel short of breath in the lungs. So it doesn't really make sense. So what, what I do is I work through Socrates, but I work through the sections that I realistically can ask and that makes sense. So, onset, you guys definitely raised really well and you've got all the parts of onset as well. So for onset, I like to break it to four bits. So, when did it start? So, one day ago, a week ago, three years ago, that sort of thing. Did it come on suddenly or gradually? Like if someone's got pneumothorax, it's probably gonna come on in, you know, seconds to minutes. Whereas if someone's got CO PD, it's probably gonna get worse and worse over years and years and sort of have a really insidious onset that they don't maybe initially recognize. Is it intermittent? Is it constant? Is it always there if it's been, especially if it's been there for a long time. Is it always there? Is it not always there? And if it's intermittent, uh, what's the interval? So, like, do they, um, have it for six hours and then they get relief for 30 minutes or do they have it for two minutes and they get relief for six hours? Um, sort of understanding sort of the pattern of, um, the shortness of breath that they're having and then progression, as you guys said, does it, has it got worse over time, better or constant? Then the other ones I think you can do here are timing. Um, I think someone mentioned the diurnal variation that you often get with asthma. So that would be really useful. Is it worse at night? Is it worse in the morning? Is it worse in the day triggers? Is another thing to ask for that as well? So, um, I think someone said, what were you doing when it came on? So that's a really good thing to ask, especially in a in acute history, exacerbating and alleviating very similar to triggers that's really important to know and severity. Do they just feel a little bit short of breath or are they really genuinely struggling to breathe and they feel like they're gonna collapse? The next thing I ask is things that are often related to your presenting complaint. So some people put these in their systems review, but I also sometimes like to put them in the history of presenting complaint if I can remember. So as we'll go through in the presentation today, the main respiratory histories that you get are cough, hemoptysis and shortness of breath. Often conditions will overlap between those presenting complaints. So I think it's really useful in your history of presenting complaint uh for whatever um thing the patients come in for to assess those as well and do a sort of semi detailed history if any of those are present. So is there any chest pain? You could do a Socrates, a quick Socrates with that, if it's present cough. So uh what are they bringing up? What color is it? How much are they bringing up? And the same with if they're coughing up blood as well? So what type, what color blood are they bringing up? How much are they bringing up, et cetera? Cool. Then the next section I like to move on to is where I start to switch my brain on if you like and really think about the differentials that could come up in this situation. Um especially ones that maybe you wouldn't necessarily think of in a respiratory history and you could easily miss off your differentials. I think these questions are also some of the most important because it shows the examiner that you're thinking about what um differentials could be present in this patient. So you could ask about orthopnea, which obviously you wouldn't say to a patient's face. But you would say something about you finding you're sleeping with more pillows at night at the moment, that could suggest heart failure similar with um paroxysmal nocturnal dyspnea. So they do the wake up at night feeling they're severely bre breathless or gasping for air. It shows that those are very specific symptoms that are often related to one, maybe two conditions. But it shows you're really thinking about what the diagnosis could be and you're ruling stuff in and you're ruling stuff out. Leg swelling. Is it bilateral? Have they got like pitting edema which would be heart failure or is it unilateral? Have they got a DVT that's caused a pe, have they got a rash? This is a diagnosis that's often missed on a shortness of breath history. Are they going into anaphylaxis? That's something to think about as well. And a really good one to throw in your differentials if you've got an acute shortness of breath history. Um And once again, they might say, oh, it was triggered by me eating nuts or something. So that's one to think about as well. And syncope, we've got aortic stenosis. So when you guys pop in the chat for me, what's the triad of symptoms that you get in aortic stenosis? Sad. Yeah. Perfect. What does SA stand for syncope? Angina dysnea? Perfect. Yeah. So yeah, syncope, losing consciousness, angina, chest pain or exertion and dysnea for short of breath. Perfect. There's obviously many more that you can ask to do with certain conditions, but I just wanna give you guys a flavor and maybe pick out the ones that you might not initially think of in a respiratory history. Next I move on to the systems review personally, my systems review tends to stay fairly similar between the respiratory presenting complaints. The things I mainly like to ask are the bee symptoms. So uh the four that I pick out are fever, fatigue, night sweats and weight changes. I've put there for cancer but can you guys think of another respiratory condition? Um My clue is it's an infection that can also present with those. Oh yes, you guys are on it. Perfect. Yeah. TB. So I've put notes for cancer but don't forget that people can also present with that. Um er with TB as well. Someone's just asked what is an open ended question? Yes. Sorry, I forgot to mention this. So at the end of your history of presenting a complaint, I'd like to ask a bit of an open ended question, especially in anis where the person that is acting as your patient often has a bit of a script to run on. They know what they need you to ask and they're just waiting for you to say it basically. So I usually end my history of presenting complaint with a bit of a cheat question saying, is there anything else that you feel like I've missed, it's quite an open ended question. And hopefully, if you say that the examiner will say, oh yeah. Well, I've actually also been experiencing this or, you know, I just wanted to let you know about this. It leaves an open ended question. It gives them the ability to um sort of give you more information without you having to direct your brain about specific things and specific diagnoses. Anyway. Sorry about that guys. Moving back to the Assists review. I then, um, after I've done the bee symptoms, I then worked through a couple of um sort of signs or symptoms from each organ system. Um or um yeah, organ system to see if there's more systemic effects of whatever's causing them to present. So, um for cardiac, I tend to do chest pain and palpitations for, if I've forgotten to cover them already in the history of presenting complaint, I'll do cough and hemoptysis. So, obviously, the presenting complaint is shortness of breath, but I cover the other two. and then nausea and vomiting change in bowel bladder habits. That's what I tend to do for sort of digestive or dirty urinary. And then pain cos if they have pain anywhere, that could be M SK that could be loads of different presenting complaints. So just generally asking have they got any pain anywhere is quite good. Next, I move on to ice. I think this is quite controversial. Cos a lot of people put ice at the end of their history. I actually find that after the assistance review is probably my favorite place to put ice just because it's really important to quite early on elicit what your patient's ideas of what um what's going on and what they're concerned about, especially in real life practice where say you're in the GP and you've got 10 minutes with a patient, you don't want them to leave dissatisfied from when you've talked to them. They want to feel like you've got true empathy for what's going on and you understand why they're there and why they want your help. So I think if you get this in, in an, it's really good empathy points, I think to get this in early, but also in real life, it's really important to know why patients are presenting for help. Cos it may be vastly different for the same um condition for different people. So I would ask this early about after the systems review I would say, and remember to get their ideas of what they think is going on, what they're concerned about and what their expectations are for you to do. So, moving on, I'm then gonna go over the past medical history. So once again I tend to ask, er, an open ended question. So, do you have any medical conditions that you see a doctor for? That's how I normally start in an, is they'll sometimes just give you everything after that question. If I'm honest, patients in real life, probably, especially if they, they've got comorbidity. So they've got lots of conditions going on at once. They might forget to tell you something, especially if it's something you need to know and you don't prompt them. So, in an, is if you feel like they're being a bit cagey maybe and they're not telling you everything or just generally in practice, I would tend to ask for any diagnoses more specifically to the system where you're working with. So I would ask you, have you got any diagnoses to do with the lungs at all? Have you got any conditions to do with the lungs? If, for any medical condition they tell you, especially if you think it's very relevant to your complaint that they come in with, ask, when were they diagnosed and how well are they managing with it? So, if, for example, they've got asthma or co PD, how are they getting on with their inhalers? Have they got, do they understand how to use them? Are they having annual reviews, et cetera? You might not have a lot of time to do all of that in an is, but just showing that, um, you understand that it's all well, good saying, oh, I've got this condition but if you have no idea how well it's actually being managed, um, that can make things quite challenging down the line. So I would throw in those questions if you do have time. And the other one, which is a major one is uh especially for respiratory histories, is, have they been recently, um have they recently had any hospitalisations, especially for a prolonged period of time or any surgeries? And as I put there, those can all be risk factors for a pulmonary embolism. Next, I've got the drug history. I'm not gonna go through this in major detail, but the main things to cover are has have the patient got any drug allergies if so what happens to them when they have a reaction? Do they take any medications that are prescribed to them? Do they take anything over the counter? And I also cover, do they take any herbal remedies or alternative therapies? Um Just so you're covering all basis. The only thing with a respiratory history to add in I would say is do they use any inhalers quite often in medical practice? Patients will forget that inhalers are medications. Some will, some will and they will give that to you. If you say you prescribed anything, they'll say inhalers. Yeah. Other questions definitely. Like, do you have any rescue packs? You can explore sort of what their plan is for asthma and COPD, that sort of thing if you have time. But I think if you just want to throw in one extra question to show that you've really got your brain switched on for a respiratory history, I would say do use any inhalers or inhaled medications. And that shows that you're really thinking, yes, this is a respiratory history, especially if they have a past medical history of asthma or COPD. Next is family history. So once again, I'm not gonna go through this in great detail, but I'd start with an open question again. Do you have any medical conditions that are common in your family or you know, run in the family? And once again, if they say yes, don't just stop there. If you have the time, go to, ok, who's affect? What have they got? When did they get diagnosed? How they're getting all that sort of thing? And once again, for that extra question related to a respiratory history. Are there any conditions related to the lungs in the family? And once again, remembering to use patient friendly language finally, is the social history, the new manic I use for this is lost. Um And then I add a few extra things in for a respiratory history. So lost. I ask in every social history. So living situation, occupation, smoking and travel. So living situation, who do they live with at home? Are they getting on? Ok. Have they got family members to support them? It's really good to show that you're thinking, OK, how well is this patient coping at home? Are we going to be able to discharge them, that sort of thing? Occupation. This is really important in a respiratory history. Can you guys pop in the chat? Why would we be so concerned with a um respiratory history and occupation, especially going to previous jobs as well. Why is that important? Yeah. Awesome. Great job guys. Yeah. Asbestos exposure 100% which could cause things like lung fibrosis, chemical exposure. Mesothelioma is a big one. Absolutely. You guys have smashed that. Yeah. So um it was things like asbestos exposure. Um people can get um occupational um compensation if they've had uh if they've developed a mesothelioma or developed other disease because of it. Yeah, you guys have got some really good ones in the chat. Um, damp is uh sort of similar in the, if someone's got damp in the home that can trigger certain diseases like asthma and things. So just generally getting a bit of an idea of if they've got any damp in the house, if they sound like they're presenting with asthma or something like that, that could be a trigger, um, smoking, alcohol and recreational drugs. Um, I know some people put recreational drugs, um, in drug history, I tend to forget if I'm honest. So I tend to put it in social history because it naturally follows through with smoking and alcohol and just remember, um, to ask sort of if they're smoking or if they're drinking, how much are they doing a day or a week? Whatever you think is relevant. How long have they been doing it for? And if they say they, they don't smoke or they don't drink, just check that they haven't done it in the past cos they might have stopped a year ago, but before that they might have an 80 year pack history or something that you don't necessarily know about if you ask, are you smoking today? So just be aware of that and travel history. Can you guys pop in the chat? Why is travel history important? Especially for respiratory histories? Yeah, perfect. So, yeah. Um, Sonia is right as well. DVT, which can, er, develop on planes. Um, which is why we also ask about long haul flights. Um, so checking for a pe that might have developed after a long haul flight or going on holiday. But you guys have got it. Yeah. Really? Well done. So, thinking about, um, atypical pneumonias or TB, all of these infections that could potentially present as shortness of breath. Um, so it's important to know where patients have been and if they've traveled out of the country, the only other things are, do they have any pets? This could be a trigger for certain diseases. Um, like asthma, for example, especially if they've only just recently got a pet and the other is mobility. So if someone's immobile for a long period of time, that could also cause apa perfect. So awesome. Can you guys throw into the chat for me? A patient's presented with shortness of breath. Um We'll split it into uh acute and chronic causes. Um Can you pop in the chat for me? Some differentials and things that you'd be thinking about? If a patient is presented with shortness of breath, what conditions could they be presenting with? Just throw them on the chop M IC O PDP E pe pneumothorax, asthma, heart failure, co BC O PD. Exacerbation. Perfect. Yeah. Lower respiratory tract infection. Yeah. Me acquired pneumonia, cop DPM. My asthma. Perfect foreign body. Amazing. A CS pneumonia, pulmonary edema, pneumonia. Yeah. Really good guys. Awesome. So you've got your brain switched on. That's really good. So I've grouped them like this. This is in no way, an exhaustive list, but I tend to find uh useful to find at least five diagnoses for um each type of shortness of breath. Um And each presenting complaint you have just so that when you're in anis, you, if you've ruled something out. So say for example, I definitely ruled out that it's not asthma or COPD because they don't have them as a past medical history. Then it makes it a bit harder for me to put them in the differentials. So I tend to have more than three for each one. Obviously, it could be asthma or COPD and they've not been diagnosed, but generally you want three really good differential diagnoses. So, acute ones, I've mainly gone for pneumonia, pe pneumothorax. These are all things you said acute asthma and acute CO PD, chronic asthma co PD in the more chronic form pulmonary fibrosis, pleural effusion, lung cancer and mesothelioma as well. The other thing I encourage people to do when especially with something like shortness of breath, which is highly related to the cardiac system as well. Try and think of other differentials that are not necessarily uh from the respiratory system. So anaphylaxis, that's more immunology, panic attack, that's psychiatric. Um And then I believe the rest are sort of hematological or cardiological conditions. I would say when you're presenting back your differentials to an examiner, try and throw in one non respiratory differential, it just shows that you've sort of switched on to the other systems can cause these presenting complaints. You haven't just hyper fixated on the lungs. So if you can and if you think it's relevant, please do throw in one from another system. Sorry, you guys cool. Speaking of which um after you've done your history, you'll need to often present this back to an examiner. Um I know this is something that people often really struggle with. I definitely did when I was revising cos it's really hard to get all the information in and be really succinct with it. So this was the structure that I tend to recommend people use. So start off with the patient details on what they've come in with. So today from Joan, a 46 year old female who presented with shortness of breath, that's your first sentence and it's gonna be pretty much the same bar those bits and yellow, whatever history you take, then I would just think back to what you've already talked through. So that history of presenting complaint, tell the examiner really sort of briefly um about your history of presenting complaint. What you found, talk through that Socrates, um talk through the relevant parts, don't just say everything, but if something useful has come up in the sort of Socrates that I showed at the beginning, say that there same with the sort of chest pain, cough and hemoptysis mention that as well. The relevant negatives is mainly for that last bit of the history I showed you. So where you've asked questions about other systems also in the systems review as well. Um where you've asked questions that are related to more specific diagnoses and a patient said, no, I don't have that. For example, like, no, I don't have syncope or I don't have leg swelling, that's really important to mention in step number three, which is relevant negatives. Once again, this shows the examiner you're switched on, you're thinking about what diagnoses are possible and you're actively asking questions to rule them out. Um So make sure to present that back to the examiner so that they know that you're thinking about it. Um Then the step four is the relevant past medical history, surgical history, family history, drug history and social history. With this. I would once again try and this is really difficult. I know, but go when someone gives you, when you're going through those bits of a history with a patient, really be thinking, OK, what bits of this are relevant? Um What bits are related to what they're presenting with? Don't just spout off everything they've said to you. I would just be really honest and say there's no relevant past medical surgical family history. They're allergic to this and they're currently taking this medication and socially, um they have an 80 year pry just only focus on the bits that are really important to what you think the top differential is or the top differentials. Then I would do ice. I know I recommended doing this earlier in the history, but for your history presenting back structure, I'd recommend putting this in here. Um Mainly just saying what the patient thinks it is and what they're concerned about. I would say the two to emphasize just so once again, it shows that you're thinking about the patient and what they want. Then my top differential is pulmonary embolism, for example, because of or due to due to sorry. Um and giving evidence from what you've already said as to why you think it's that differential. So my top differential is pul embolism because the patient was on a flight um a week ago and she's also presented with uh unilateral calf pain and calf swelling. Um And yeah, sort of tie in bits of the history of presenting complaint. Maybe she's on H RT, maybe she's on the combined pill. Sort of bring things together and sort of put together your evidence to as to why your top differential is what you think it is. And then finally just round it off with other differentials I would like to rule out include and I would probably list three here. So you sort of want four differentials altogether your top one and then three others and with the other differentials, if you've got time and you feel like you haven't rambled too much, you can also slightly justify those as well. Um, but don't worry if you haven't got time, I'd focus on steps. Um, sort of 1 to 31 to 4 1st. So, investigations, I appreciate. This is an extremely busy slide. This is more for your revision later guys. But what I've done with all of these, er, presenting complaints is I've put together the investigations that I think you should consider under our headings of bedside bloods, imaging and special tests. Um I would start when you're presenting this to an examiner. I would also use those to say at the bedside, I would perform a respiratory exam. I would perform a cardiovascular exam, et cetera. Same with bloods, that sort of thing. Be aware that the examiner may also push you back on certain things. So if you say I'm gonna do ad dimer, they might ask why and you might have to justify which is why on this table, I've put there some of the justifications for why you would do these investigations. So hopefully you guys will find this helpful when you're advising. I'm definitely not gonna go through this whole table now. But just to remember to structure your investigations as what are you gonna do at the bedside, what bloods are you gonna take? What imaging, imaging investigations are you gonna do and what special tests are you gonna organize? Just to explain as well in one station, you definitely do not need to say all of these things. Um, I would once again and you'll see it from the table and the reasonings tailor your investigations to what you think the differentials are. So if it's pe if you think it's pe you're probably going to do a wells score and then see if AD dimer is needed, think about um, a C TPA and potentially a VQ scan. But if you don't think it's a pe um or you've ruled out it's a pe then you're not going to include those. I would tailor these investigations to what your top differential is and what your three other differentials are. Um But this should hopefully give you a comprehensive, a fairly comprehensive list for whatever um differentials you could be faced with. So I'm not gonna go through data interpretation too much in this session today just because we are going to have ses sessions later in the series which cover chest x rays in full detail, um Other data interpretation, other imaging as well. So I don't want to invade into those sessions at all and you guys should definitely check those out, but I'm gonna talk about some of the things that they might just throw you in a station that maybe wouldn't be classed as data interpretation. So if you've got a patient with pneumonia, for example, they could ask you to um they could tell you a bit about the patient state and ask you to calculate a curb 65 score. So can you guys pop in the chat for me? A bit of a reminder, what are the criteria that make up curb 65? Mhm. If you guys know numbers as well. That would be amazing. Yup. Awesome. Yes, great job guys. Really good knowledge. Yeah. Great, cool. Right. Yeah, I think you guys have got the majority of them. I think they've all been said at some point. So these are them here. So confusion, as someone said, a new confusion um is best. So this is um this can also be assessed with the abbreviated mental test score. Um, as someone said, this will be um less than, or equal to eight urea greater than seven respiratory rate greater than, or equal to 30 BP, less than or equal to 90 systolic or um 60 diastolic and then age greater than, or equal to 65. So, and when you're going through these, er, you can see it's CU RB and then 65 for those of you that haven't seen Curb 65 any, er, before, that's how to remember it. Uh, can you guys tell me if someone was in, er, primary care or general practice? How would this school change and why if you know? Yeah, so Urea is left out so it becomes curb 65 if you like, why do we not do Urea and GP? Yeah, perfect. Yeah, you're not gonna be able to get a Urea when you're in primary care. Um, you can assess confusion, you can get their respiratory rate, their BP and age, but you're not gonna be able to have access to get a Urea test done in primary care. So you leave it out. Cool. Awesome guys. Um, so what I've also done for these stations is I've tried to pick some of the top differentials that probably come up and make you guys sort of management um slide or management posters for a lot of the key conditions. So when you're revising, you know what to mention under each of the headings. So I've sort of given a clue here by the slide. But what are the three headings that we like to break our management into when we're presenting back to uh an examiner? And there's a few ways you can break it down. But yeah, yeah, perfect. Conservative medical and surgical. So conservative being anything that basically isn't medical or surgical, basically, um anything that doesn't require medical intervention, usually something like education, but we'll go through more of that in a second medical as someone said, anything sort of pharmacological um medical invent interventions in that way and then surgical is obviously any surgical treatment. So, um for pneumonia, um oh, sorry, I was gonna say um as well as breaking it up into conservative medical and surgical depending on the type of station you get in your Aussies, you may want to break it down into acute and chronic and in the chronic, you might want to then break the chronic down into conservative me medical or surgical. It does sort of depend on the condition and I've sort of changed these boxes dependent on the condition but just be aware, acute and chronic is also quite a good way to do it. So if you've got someone coming in with attention you with or X, you're gonna do stuff straight away and that might be a mixture of conservative medical and surgical interventions. But then after that, you'll need to do other stuff as well. So it depends on the condition. Have a think about it for each one. But, um, you can break it down acute or chronic or conservative medical surgical. So for pneumonia, um, I've split, split it into conservative medical, there's not really any surgical management for pneumonia. So, um A to e, so starting off with our acute management, you wanna take an A to E approach and in my acute management, I always like to say A to e approach and referral to somebody. So, er, here over an A to E and then referral to respiratory on the medical registrar. Um and to sort of get help with this patient cos it shows that you guys as sort of newly qualified doctors realize that you're not gonna be able to um cope with this patient on your own. Er, then generally the things I always put in conservative are educating the patient about what's going on, letting them know what's happening, giving them leaflets about the condition so that they can read up if they're not acutely unwell or unconscious. That's a common mistake. People say give them leaflets, if they're unconscious, you can give family members leaflets but probably don't give them to a patient if they're unconscious. Um and generally, if it's more of a chronic condition or recurrent, you can direct them to charities as well. So I've tried to include charity on each of these slides, but the British Strong Foundation probably covers most of it if you're in the UK. Um, the other thing to add into conservative is if there's any scores, for example. So pneumonia we've gone through is the curb or the curb 65 score. So you can calculate those for pneumonia. And, um another thing to think about sort of host your management, you'd want to give them a chest X ray, six weeks, post discharge medically. So everyone tends to forget analgesia. If a patient is in pain or they're uncomfortable, give them some pain relief and if they've got a temperature, which may be the case in pneumonia, give them some antipyretics. So, paracetamol, for example, four times daily. Then another thing for pneumonia is this is something that's quite easily, um, quite easily can go septic. So, um consider blood cultures, urine output, you guys know your sepsis six and it's written there. Um, but make sure to get broad spectrum antibiotics at the beginning and then you can narrow it down later after blood cultures are done. So, pneumothorax is the next one. I'm not gonna go through all of it in great detail. Cos it's quite repetitive. Er, the main things to raise for pneumothorax I would say are in the conservative treat or control the cause. So, if it would say due to asthma check that asthma's under control and once again, admit them into hospital. If they're not already there, if you're in GP medical will go through the medical management in a second. But don't forget to get them high flow oxygen. And if they keep having pneumothoraces, consider um a referral to the thoracic surgeon for a vats procedure procedure. So a video assisted thos cop surgery, which can be used to prevent a pneumothorax. Coming back. The other thing with pneumothorax, if you're breaking this into acute and chronic or acute and ongoing, I've labeled it here. Think about um a really good thing to raise wi in your exams is to show that, you know how to counsel the patient after they've had a pneumothorax. So they can't, they need to stop smoking if they're smoking, er advice around air travel. So to wait at least a week um with it confirmed on a chest X ray that there's no air left and ideally wait greater than two weeks and scuba diving, they need to stop forever. Basically because of a risk of a new thorax coming back. So credit is to niche for this diagram, but this is um to explain how to manage a spontaneous pneumothorax medically. So, um basically, you'd start off with an ABCD E um and then assess if it's primary or secondary in cause if it is greater than two centimeters and or they're breathless, then you would aspirate. Um I won't go through this diagram. But basically this shows you when you'd aspirate, when you'd do a chest drain, um, generally give oxygen to these patients depending on their O2 sats as well. Um, but generally aspirate first, especially if it's smaller and then, um, if it's still not working chest drain cool. So then we have acute asthma. So, uh, asthma and COPD, if they're ones to come up, these are usually really nice ones to show off that, you know, the management of these patients. So once again, I'm not going to go through all this in detail, but generally determining the severity of asthma attack is really important. That's going to um tell you a bit more about how to manage the patient. Um I'd say the main thing with asthma is to know it's medical management. So generally, um I know people use certain acronyms if you guys wanna put them in the chat. So they don't catch me on the recording. What acronym do we tend to use for the medical management of acute asthma? Some people do use different ones to be fair. There we go. Yeah, cool. So that is the um acronym that we use for acute asthma. And you can see that down the side there guys, the e is for escalate care, but I would tend to put this in the conservative side with your referral to respiratory or the medical reg once again acute asthma with your sort of chronic management is where you can really show off. And I've tried to put as much detail as I can there, um, about the ongoing management. So when to discharge them, so they need to be stable and discharged medications and their peak flow needs to be greater than 75 their best or predicted one hour after treatment. Um, you need to check their inhaler technique. Do they know how to use an inhaler? Cos potentially having poor inhaler technique could be the reason that they uh could have contributed to their admission in the first place. They need to be given us albuterol inhaler and five days of prednisoLONE orally and then just generally talking a little bit and alluding to chronic asthma management a little bit. So mentioning it's an MDT approach. So you've got asthma liaison, nurses, GPS, respiratory physicians, physiotherapy patients and if their family is smoking, stop them as well, making sure they're getting their annual vaccinations, having an asthma action plan. So what to do if they get an exacerbation, what medications they're on and making sure that they have an annual asthma review as well. So meeting someone, either, someone in the GP, so normally a, er, nurse in the GP to sort of discuss, er, how their asthma's going, how well it's been managing and sort of prompt any new medication changes in case those are needed. Uh, someone's asked what it's a rescue pack. So this is, um, some medication that people with asthma can have at home. So if they feel like they're going into an exacerbation, they can sort of catch it early and start to medicate themselves before potentially getting um admitted into hospital. And then finally, for acute asthma, more generally GP follow up two working days, post discharge is really important once again to check on the patient and start to think about why were they admitted in the first place and starting to rectify that and alter their asthma plan accordingly. CO PD is very similar. So I'm not gonna go through that if that's ok, guys, you can read this in your own time but similar structured before you got the acute stuff here with your at E approach medical emergency call and a referral patient education CO PD Foundation is great and then the medical management is quite similar. But I'll let you guys read that in your own time. Cool. So that is the shortness of breath history. Now, I'm going to be moving on to a cough history. So let's see how well you guys were listening earlier. What would you guys like to ask someone who has got a cough or hemoptysis? These histories are very close and I tend to ask very similar questions. When I was looking through my notes again, they were pretty much identical. So I've grouped them together. But what are we gonna ask if someone has a cough or they're coughing up blood. Yeah. Onset. How long have they had it for? Perfect. Is it dry or productive? Really good question to ask. Do they smoke? Definitely blood volume. Yep. If they're bringing up blood, how much type of cough, whether it's productive, productive, dry, color of the sputum? Definitely. That can give you a good idea if it's infected or not, if it smells. Yep. That's definitely a good one to ask quantity. Definitely. Yeah. Really good guys. So once again, I do a similar structure here. So I try and think of Socrates to start off with and how much I can ask if you guys can see this is very similar to the previous one. So just remember the four parts of onset, when did it start sudden or gradual, intermittent and constant? And what was the interval and progression? Timing and triggers? I've put together as well, then we'll ask about um the cough or the sputum itself. So you guys raised really well? Um Is it productive? Are they bringing stuff up or are they not if it's sputum, how much are they bringing it up? How often are they bringing it up color? And I think someone mentioned, oh, that's a really good one to ask as well. Consistency. So, is it quite thick or is it quite thin? And are they bringing up any blood? So hemoptysis and as someone said it in the chat, how much blood do they bring up? Are they bringing like a cup full up or are they just sort of getting spots of blood in their sputum? And what color is it? So, is it dr sort of darker blood that might suggest that it's been around for a lot longer, or is it fresh blood? Um, and then someone said, I think in the chat as well. Have they ever had this before? Is this a chronic condition that's maybe got worse or they're just seeking treatment for now? And then we've got some more open ended questions with the cough. So, are they also wheezing? Do they have asthma potentially? Are they getting any chest pain, any chest tightness? Once again, that could be a cardiac cause or asthma, you can ask about similar questions to do with heart failure as well, which would be really good to ask about. And once again, end with an open question, is there anything that you feel I've missed or that you're worried about? And once again, that will hopefully prompt your patient actor to say, oh yes, I'm also a bit worried about this or? Oh yeah, II forgot to mention this. So you can get a little bit further with your history of presenting complaint. These ones are very similar once again. So I'm not gonna go through these, but once again, just remember the b symptoms which are fever, fatigue, night sweats and weight changes can be due to cancer or TB. And once again, we're picking out a couple of um 1 to 2 sort of presenting complaints from different systems in the body, then we have past medical history. So once again, same as before, start with that open question, ask a bit more about respiratory diagnoses and ask about recent hospitalizations or surgeries. Um I've put there as a pe would you guys be thinking a pe more if the patient had a cough or with hemoptysis? Yeah. Perfect. Yeah, hemoptysis pe is one of those that it, it could cause a cough but it, it's um it's more likely to be hemoptysis where you wanna ask the questions about pe drug history is exactly the same before allergies prescribed meds over the counter meds, herbal alternative remedies and inhalers family history. The same as before. General question about conditions that run in the family and are there any related to the lungs? And if there are any, you can dig into them a bit more and social history. This is once again, very similar to before. So think of that lost mnemonic living situation, occupation, smoking, travel history. And once again, very similar in terms of thinking about pe and asthma. So let's go through some differentials for a cough. So I think I've split these into productive cough and dry cough. So, can you guys pop in the chat some differentials for a productive or a dry cough? Yeah, covid's a really good one. Yeah, I don't think I included that, but it's definitely a good one to mention cancer TB, infection, pneumonia, COPD, asthma TB. Yeah. CO PD. Um, pulmonary fibrosis, idiopathic pulmonary fibrosis, bronchiectasis Ramipril. Really good. We'll be bringing that up later medication. Yeah. Perfect for dry cough, allergies. Really good. Foreign body. Pulmonary, yeah, you guys are fine that well done. So, I haven't included all of those. These are my main ones that I tend to go for so productive. You're thinking things like pneumonia, TBC O PD, asthma, bronchiectasis, heart failure where they're, especially if it's an acute exacerbation, they might be bringing up like a pink um frothy sort of sputum and lung cancer, lung cancer can go in both categories. Um, and then for dry a viral infection that doesn't tend to produce too much colored mucus, um, pulmonary fibrosis. I think someone said, er, I PF so, yep, medication side effects. Yeah, I put that ace inhibitors really well done. That's one that's really easy to forget and a really good one to throw in, especially if they've got that in their drug history. Obviously, that's one of those where if there, if it's not in their drug history, you can rule it out and you could mention that as a relative negative, relevant, negative when you're summarizing your history. If you say, well, I know it's not an ace inhibitors side effect cos they haven't been on an ace inhibitor. Um Gord as well as potentially want to think about if they've got reflux and as I say, lung cancer, really good job guys. So once again, these are the investigations, uh, this is very similar to this table before, but more related to coughs. The main difference I would say, or the main things that I've added it in are about the urinary legionella and pneumococcal antigen, which is just to do with more atypical types of pneumonia. So, um, just be thinking of that as well as someone's got a cough. Cool. Awesome. So now I'm gonna go a bit over sp aren't you? As I say, I'm not gonna touch too much on data interpretation, but I think this is something you could be presented with in an Ay. So it's good to know. So can you guys think of what are the main parameters that we use in spirometry? And what do they mean if you know any of those? There's three main ones I'm thinking of. Yeah, perfect. So FE CF EV one and the ratio of the two. So can you guys tell me what F VC is? What is someone's forced vital capacity? You guys look like you've got a good, a lot of good knowledge if I say someone's forced vital capacity, what does that actually mean? Yeah, perfect. And what is the F EV one? So I'm making you guys type longer sentences. Yeah, that's sort of more the how much they can get out in one second. Yeah, perfect. So that's more the shorter measurement. And um the forced vital capacity is sort of more about their total amount that they can exhale. Perfect. And then we've got the ratio between the two. So the forced expiratory volume in one second. So the F EV one is the volume exhaled in the 1st, 2nd after deep inspiration and forced expiration. So you take a deep breath in and then you try and blow out as quickly and as much as you can. So it's sort of like a really fast um forced vital capacity is the total volume that can be forcibly exhaled. Um And then the ratio of the two is expressed as a percentage. So when I'm presenting, if you were given spirometry and asked to comment on a graph or something like that in an exam, you might get a graph or figures potentially and then a ratio. So just be aware it can come in different forms. The way I present it is the classic way we start with all the data interpretations. And once again, we have specific data interpretation sessions that will go through this in more detail, but start off by just confirming the patient details. There's nothing worse than doing all this interpretation and then realizing you've got the wrong patient. So whatever is given to you, I would generally just repeat. So you can say these are the spirometry um graph or spirometry values for Julie Smith, a 64 year old female of height, 5 ft three ethnicity, white, caucasian, whatever they give you repeat back. Um Do you guys just quick question about spirometry? Why would height be something good to know for spirometry? Why are we interested in knowing someone's height? Why might that be given to you? Yeah. Different lung capacities. Yeah, perfect. Yeah. So someone that's quite short, like me is gonna have much less lung capacity than someone that's quite tall. Um So it's really good to know a patient's height. You might not be given that in a year, you probably wouldn't, but just good to know why you might actually get that on spirometry. Um readings, then I would assess the quality of the results just making a statement of um the if you're giving something like curves rather than values, just saying that there are smooth curves with no abnormalities. So for example, if someone coughs, it will sort of spike off the curve, same if they take an extra breath in while they're expiring. So they say they expire and then they sort of suck a bit back in that will change the curve. And sometimes you, if you're with the patient, it might become obvious that they're not putting in as much effort as they need to. So just be aware of those. Um just a simple sentence just saying overall that I think the quality of the results is good because there's smooth curves with no abnormality probably in Oy, and then we need to assess the spirometry pattern. So I'm gonna show you guys two graphs. Can you tell me one is obstructive and one is restrictive? Which one is which so left and right as you look at it, which one is obstructive and which one is restrictive? Any is in the chat you guys were coming up with some really good values earlier. Mhm. Yeah. Cos if you can work one out, you can work the other out. Yeah. Well done guys. Yeah. So we've got obstructive on the left and restrictive on the right. I think you all got that right. So, really well done. Can you guys give me some values for those or clues that tell you why one is obstructive and one and why one is restrictive, just eyeballing it from the charts. How do you know it's that way round cos you'll, you'll want to justify it in an exam. Yeah. Cool. Yeah. 0.7 is a really good value. Yeah. Awesome. So I've written the sort of reasoning behind each one here. So you'll notice with an obstructive pattern, the overall you will get to a decent final, er, force vital capacity but it will be reduced. Still, it's, it is less reduced than the F EV one, the F EV one is extremely reduced whereas the F EC can be normal but is often reduced as well. Um, so you can see here you can tell the FE B1 isn't as strong because you're not getting that sort of initial increase in expiration before it plateaus off. This is, there's a much smoother curve. It's, it's a much smoother plateau. So if you looked at one second, the sort of amount it's increased isn't a lot. So you can sort of just suggest that the V one has gone down considerably more than the F VC. So if we think of the F EV one to F VC ratio, if the F EV one has gone down a lot, and the F EC has maybe stayed the same or only gone down a little, then that's going to make the ratio. So if you imagine it as a fraction with F EV one on the top and F VC on the bottom, if the F EV one goes down a lot more than the F EC does, that will make your fraction lower. And therefore, in this case, it will make your ratio lower. So the cut of value they tend to use is greater than naught 0.7. And with the restrictive, the pattern of the graft is quite similar compared to normal. So it's so it has that same sort of really quick rise and then a plateau. But just generally because with obstructive, the reason why the F EV one isn't as quick to increase is because you're pushing against something, something's obstructing airway and you're pushing against it and you just can't get as much out to begin with. So it's, it's less a problem with the amount of lung you have or like the amount of air capacity you have and more to do with actually how quickly you can get out because something is obstructing the airway. Whereas in restrictive, the breathing mechanism is fine, but you just haven't got as much lung volume to play around with. That's the way I think of it anyway. So you're able to get a lot of air out quickly at the, you know, the same sort of rate. If you think. So, if you do volume against time, it's still a very similar rate to normal. It's just you haven't got as much to get out because you, your chest wall potentially is restricted or something is causing a restriction. So you can't get a lot of air in and therefore you're not going to be able to get a lot of air out. So the F EV one and the F EC are often reduced almost in proportion to each other. But also it's so the cut off here is the fe ev one to F EC ratio will be greater than naught 0.7 but often it can be greater than one as well. They can be sorry, not greater than one like greater than um say like naught 0.8 naught 0.9. It can be very, very high values um because the F VC is so low. Um and they can get a lot out quickly, but then they haven't, once they've got that, there's not a lot of extra volume left to go so they can get quite high ratios for the F VF VC ratio. Hope that makes sense. Can you guys give me in the chat some examples of obstructive and restrictive diseases? So, if you've gone through this and you've said, OK, this patient's got an obstructive picture and the examiner turns around to you and says, OK, give me some obstructive diagnoses. What diagnosis do you think they got? What are you gonna come up with? So, a lot of people are saying asthma and CO PD is that obstructive? I think people are saying that's for just when you put it in the chart, fibrosis is restrictive. Yep. Yep, fibrosis, Scolio scoliosis is a really good one. Remember something non pulmonary, especially for restrictive. Awesome, great job guys. So this is how I've broken it up. So obstructive co PD asthma, bronchiectasis cystic fibrosis. Um and then restrictive, I've actually split it up into pulmonary and nonpulmonary. So pulmonary, as someone said, pulmonary fibrosis, amazing job. That's a very common restrictive um disease and pulmonary edema as well can cause that as well. But don't forget to think about non pulmonary causes as to why the lungs aren't getting to the volume they need to. So someone mentioned scoliosis, I ca I think it was Christina really well done. Um If someone's, you know, got a musculoskeletal abnormality or a neuromuscular disease, that's gonna prevent them getting those movements of the chest wall to be as big as they are, then they're gonna have a restrictive picture. Same with connective tissue diseases, obesity as well. If you've got um, central obesity and that's pushing up onto your lungs, that's gonna reduce how much they can expand and pregnancy. Similar sort of thinking well done guys, that was really good. So the other thing I'm gonna quickly cover just cos it's more of a clinical skill, but it's sort of related is you might be asked to explain inhaler technique to a patient. So we'll start off with just what you're gonna generally do and then I'll quiz you guys on sort of how you would use an inhaler. So to start off with, if you've been asked to explain um inhaler technique to a patient, do normal things that you would do in uh examination. So wipe. So can you guys pop in the chat for me? What does wipe stand for? Which you will know if you tuned into my session last Thursday? Wash hands? Yeah, perfect. Introduce yourself. Really good. Yep. What's the pain patient details? Yeah. As many. Yeah, three identifier. I'd say 2 to 3. Perfect. Um Yeah, and just expose the patient and explain what's gonna go on. Perfect. Yeah. So you'd say something like hi. My name is Megan. I'm 1/4 year medical student. Can I just confirm your name and age. Perfect. Uh, so today I've been asked to talk to you a little bit about how to use one of your new inhalers. Um, for this, I'll need you to be sort of sitting in a chair, sitting upwards, um, sitting upright. Um, and we'll go through how to talk, um, how to go through an inhaler and then I'll get you to demonstrate that for me. Would that all be OK? That's fine. Moving on. I, then if you've got time, depending on how long you've been given to do this, if they, if they literally just want you to talk about someone and tell them inhale their technique, that's one thing. But if you've got time, get a brief history of the patient, have they just started on a, on an inhaler? Why are they using it? Have they got CO PD? Have they got asthma? Um Are they moving up to a different type of inhaler? Just get a little bit of a history as to what's going on? That's usually quite helpful and also check the patient's understanding. Do they know why they're using an inhaler? Do they think it's for like their heart or their brain or something? Or do they realize that what is actually being used for to open up their airways um and to potentially relieve um symptoms or prevent exacerbations in asthma and COPD? So, just get a bit of a feeling of what the patient understands and why you're there today, then there's a few things that you should get a patient to do. So when you're starting to explain inhaler technique, there are three things that a patient should do before they even start, you know, trying to give themselves a dose of the inhaler. So they should do a device test. So this is basically where they um take the lid off the or the cap off the inhaler, press down on the canister and just check the, a little puff of air comes out. Um This is mainly if it's a new device or if um potentially as well, if it's not been used in a while, if um if it's near the end and you're not sure if there's any doses left, that's usually a good way to um test if there's any doses left, just press down on the canister without it, you know, being near your mouth so that you can check if there's any doses left, you can also check the dose counter. So on the side of the canister, um there's a way to see how many rough doses are left. So just they should be regularly checking that. So they have a good idea about when they're gonna run out of their inhaler and when they need to get it replaced and they should also check the expiry date. This is usually on the side of like the metal cans. If you see this picture here, it's sort of the silver bit inside. There's usually a bit on the side that says when it expires cool. And then we're gonna move on to actually the technique of using inhaler. So can you guys talk me through in the chat? How would you start with someone using an inhaler? What are the steps? How would you explain to a patient how to use an inhaler? Yeah, they're gonna need to shake the canister, They're gonna need to shake it. Sit upright. It's really important. Stand and chin up. Perfect. Yup. Bring the inhaler to the lips. Create a seal. Yup. All looking good guys. Yep. Do that initial exhale. Really big exhale. Take a deep breath in. Yeah. Blow out exhale. Perfect. You guys have got a really good grasp I think on inhaler techni. So I'm gonna just go through the steps. So generally I ask the patient initially to either stand up or sit up. It's just so that when they take the dose from the inhaler, they've got as much of their lungs are gonna be able to access it. If they're all slumped over, then it might not go in as far as it needs to. So get them ST stood up or sat up nice and comfortably. Hold the inhaler upright with the index finger on the top, ready to press the top of the canister. Remove the cap, shake the inhaler, breathe out gently and slowly. So a big deep breath out make a tight seal around the mouthpiece with your lips. Stop breathing in slowly and steadily and press down on the canister once that should give them sort of a quick dose. That honestly shocks me a little bit, is quite helpful and makes you jump. But yeah, push down on it once it doesn't need to be a prolonged push or anything, continue to breathe in slowly until the lungs feel like they're full. or um, at least I think 10 to 20 seconds. Yeah. Remove the mouthpiece and hold their breath for 10 seconds or as long as they're comfortably able to and then breathe out gently and slowly, you don't want them to go and just blow all the medication out. So they need to sort of keep making sure that all their breaths during this procedure are quite slow and gentle. Put the cap back on, wash their mouth out with water. Why I put there if a steroid inhaler is used, do you guys know someone's already put in the chat? You're already ahead of me. Perfect. Yeah, that's preventing or thrash. Perfect. So the Yeah, can, so if, if the steroid stays in the mouth, it can cause thrush. So we want them to wash their mouth out and then if they need a second pa puff, depending on their dosing, they need to wait 30 seconds before they do it again. So that's generally the inhaler technique. After that, I'd ask the patient to either explain it all back to you and you can sort of correct and check that they're right based on this sort of orange section or get them to demonstrate it for you, especially if they need to take a dose right now. And then finally, depending once again on your station, if they've got any questions, ask if they have any questions, answer those best you can. If they've got specific queries about dosing or side effects, safety netting, et cetera, then you can go into those. But that depends on your station. Cool. So back to some more management for a cough. So m moving on to chronic asthma. Um The left box is very similar to the ongoing management. I put in acute asthma just minus the thing discharge and then medical when we start off on a Saba, add on an I CS and then add on a leukotriene receptor antagonist, switch that out for a Laba and then finish it off with maintenance and reliever therapy um which can be used both for their sort of daily maintenance as well as the relief of symptoms. If they're feeling that they're short of breath, then CO PD. This is very similar. I think the main thing to emphasize here that I put in blue, please emphasize to these patients or in your management plans, put that they need to stop smoking. This is a major cause of CO PD and their household should also stop smoking. If they're, if they're getting passive smoke from family members, please make sure to emphasize to them that household smoking cessation is also important. Don't forget their vaccines. So they are allowed a one off pneumococcal vaccine and then annual flu vaccine and COVID-19 vaccines, pulmonary rehab will be useful for some patients lifestyle changes. And also screening for depression, I think is a really nice one to throw in because patients with COPD, I've met some patients that are extremely breathless and this condition does take over their lives and a lot of them do feel quite guilty because um because of smoking being such a high risk factor for it. If they've been quite chronic, heavy smokers for a lot of their life, they may feel really sad and feel like they've inflicted this on themselves. So screening for depression can be really important in COPD and a nice one to throw in just to show that you're thinking about the patient more holistically. So more as a whole person rather than just the condition. Then for the medical measurement, you can start off with a short acting bronchodilator, either a saba or a s, then you would assess for if they are a type of patient that responds to asthma, asthmatic, sorry, responds to steroids or has asthmatic features. If they don't respond to steroids, then you're not gonna use a steroid to have a saber, a laba and a LMA. But if they do respond to steroids, then you are gonna use a steroid. So you have a Saba or a, a Laba and an ics if you um aren't sure on what these terms are. Um I would go back to our final was easy series where we go into er, this a lot more in detail. And then finally, as the main cause, er, sorry, as the final management, you would basically just chuck everything at the patient and hope that they respond to that surgically. Um So CO PD patients can form little air pockets called bully, so they can have those removed. So a bullectomy lung volume reduction surgery can help and also a lung transplant as a very last resort for these patients under surgical management, bronchiectasis very similar to start off with education leaflets, charities, MDT approach in smoking, chest physio and pulmonary rehab are really important postural drainage. So, teaching a patient how they can get rid of the mucus and they should be doing this um 2 to 3 times a day. They also have an action plan a bit similar to asthma and CO PD. And remember their vaccines as well. The main medications they need are antibiotics, especially if they have recurrent chest infections, bronchodilators, steroids and carbocysteine, which is really useful for um making the mucus less thick and more liquid surgical management can, if it's just one area of disease, then that can be surgically excised or if not a lung transplant. And pulmonary fibrosis. I think this is my last one for this uh presenting a bla once again, similar approach with the beginning. Just remember that if it's due to work related causes, they can get occupational compensation, medical, you're gonna be thinking of anti fibro fibrotic therapies and I've written a couple there and potentially supplemental oxygen as well. And you can also consider a lung transplant. Cool. So how are we doing for time? I'm gonna plow on guys cos this section isn't very long and I'm hoping to get you all done by half past eight if I can. So, moving on to hemoptysis now. So as I said before, the cough and hemoptysis history are very similar to me or I found they were very similar. So it's not worth me just repeating that again. So we'll skip straight onto differentials. Can you guys pop in the chat? Your main differentials is someone is coughing up blood. What will you be thinking? P etb. Yup, heart failure, cancer. Yeah, lung cancer, malignancy. There's a lot of different ones you guys have come up with more than me. I've mainly gone for these um these ones. So pulmonary embolism, lung cancer, TB bronchi, and um certain types of pneumonia you guys are right in that you should also think about esophageal causes as well because it might be more the things from the esophagus. So I think people have mentioned varices of Mallory Vice test. There are definitely things to think about and things you can definitely throw in your differentials to show that you're thinking more widely beyond just the respiratory system. Awesome job. I'm not gonna repeat this here again, but this is the investigations table for you guys to read in your own time. I don't think there's anything drastically new, just the bronchoscopy and lung biopsy for lung cancer and then our management. So I'll quickly just go over the conservative management for the lung cancer. It will be the same for mesothelioma or any cancer. But the things I often tended to put in my all histories, um, history managements that ended me to a cancer diagnosis. I would say the usual things about counseling, the patient on the diagnosis, leaflets, charities, et cetera, cancer research. UK is always a classic one that you can throw in for any cancer. But the other ones I would put in are offering psychosocial support. Cancer is often a devastating diagnosis to receive and a lot of patients are really fearful when they hear cancer. So offering that psychosocial support for the patient MDT approach classic for this, ensuring the family is well supported because it might be a shock for them as much as it is with the patient. Um So that's that top half. So from council patient to ensure family is well supported, obviously, bar changing the charity up to a non lung cancer charity, I would use that. Um, I would use that sort of, um, list for any cancer diagnosis or esophageal cancer. If you've got someone with, um, vomiting up blood, if you've got them with pelvic pain, with ovarian cancer, that sort of starting section I would honestly use for every cancer patient, um, for lung cancer, more specifically smoking cessation if they smoked, getting them to stop physiotherapy and rehab. And once again, if they've got something like mesothelioma, thinking about industrial compensation, medical radiotherapy, chemotherapy, immunotherapy. I know for my oy, they weren't expecting us to know in depth oncological management because oncology management is often very patient specific, very complicated guidelines aren't as clear. Um So I would just generally show that you have a good understanding that actually you wouldn't be making those decisions. But generally these are the things that could be at the disclosure of the oncologist. So, radiotherapy chemo and immuno and then surgical. If it's a lung cancer, you're thinking a lobectomy. So taking a lobe out or a complete pneumonectomy and a mesothelioma, you're thinking more about the pleura. So you're gonna take out the pleura. So it'll be a pleurectomy pe. So once again, I split this initially into acute and chronic. So for my acute a to e emergency call, make a referral. Um and then for my other conservatives education leaflets and charities always gonna come in and admit to hospital, as I say, if they're not already in that hospital setting, depending on the setting, written on your um station, you can calculate the PC score. Does anyone know what pe stands for pe RC? Well, I know most people know what the world score is but um does anyone know what park stands for? Yeah, basically it's pe rule out criteria basically. So, um it's a list of things and basically, if the patient's got one, you can't rule out anyone, you can't rule out a pe basically. Um, so you can calculate those scores and show that, you know, those scores are related to pe um, smoking cessation is really important, treating the underlying cause if it's due to medications, if like the combined pill or H RT or anything like that, treat that underlying cause change those medications, for example, and you can also show that you know a bit about discharge scoring as well. So the ps uh P ESI score can also be used medically, oxygen analgesia are really important, especially if they've got chest pain. And then if their hemodynamics stable thrombolysis, then you can throw in the name of one streptokinase. But if they're stable, generally they go and you can, you can, if you know the criteria of when not to use a doac and when to use other stuff, you can throw that in. And if that's relevant to the patient, say they have kidney problems, for example, you can show that you already know that you're not gonna be able to give them a doac. But um, mainly you'll give them a doac if there's a reason for their pe ie it's provoked. You continue it for three months. If it's unprovoked, suggesting you don't know what causes it. You're a bit more cautious. Sorry. And you continue it for six months surgically. If they're hemodynamically unstable and thrombolysis fails to get rid of the problem, then you basically can go in and take the embolus out. Um, and if they keep having peas, you can put a filter um in the, um IVC to the vena cava, um inferior vena cava. So that clots can't come up from the legs or the liver, um that may uh then go on to develop a pa fab TB. Then I think this is one of my last ones. So once again, a approach referral, um The other one that everyone forgets in TB and certain types of pneumonia as well is to inform public health. I know this was something that caught a lot of people out in the OS before mine. Um, you needed to mention that you get public health involved. So just think if it's something that um public health might want to know about, maybe something quite rare, quite dangerous. Um There is um, documents online about when public health needs to be informed. So I'd recommend looking those up before your osk and just taking note of the ones that are more likely to come up, things like TB or atypical pneumonia um, um, and adding those in leaflets, education, as you said before and patient isolation as well with TB, you don't want that passed around. So keep them very isolated. The other thing you can throw into conservative if you want to is, um, the baseline investigations that you need to start before certain medications, I won't go through them there. But it's basically to combat or monitor the side effects of your main medications which are rifampicin isoniazide. I'm probably gonna butcher this Pyrazinamide and ethambutol. Um, I've written there when you would use them for active and latent TB. Um, I'd recommend you guys committing that to memory and someone's just put in the chat. Yeah, not viable diseases. Look those up. Those are really important and ongoing throws to the phone about TB if you can remember. So remember TB. Um, is an, an age defining illness. Um, so offer HIV testing doing regular using these and LFT S because of what I've written in the Conservative Management Box and a chest X ray as well at the completion of treatment and they shouldn't travel by air until the R is negative twice. Fab The last thing I was just gonna go through is SARS because I know a lot of UNIS do them. And I think if you're happy with SBAR S and you're happy with your structure, they can be actually a quite nice thing to have relatively for an exam. Um, so can you guys tell me in the chat, what does SBAR actually stand for? If you're asked to perform an sbar? What does that actually mean? And what is it used for if you've come across them before? Yep. Situation background assessment recommendation. Perfect. What is an sbar used for? When would we used to it? Why would we, why are we being taught how to do it? Yeah. Perfect for handovers. It's a communication tool. Yeah, perfect. It's a quick way to hand hand a patient over to someone else to often to escalate their care. Um So as junior more junior or newly qualified doctors, it's important for us to be able to escalate the care quickly and efficiently. So you guys got it smack bam, right? It's situation background assessment and recommendation. So these are straight out of my revision notes. So this is how I revised for an sbar and my structure that I used every single time. Um and I tended to find when I used this, it was quite slick. So I hope this can help. Um So I'd start off with situation who you are and where you are and confirm who you're speaking to and those are really important so that you know, if they do come to find you, they know who to report to and where you are and you also know who they are because you might just ask for say the medical reg but you might wanna know their name as well. And then start to talk about the patient to mention the patient by name and reason why you're calling to say that you want to chat to them about Mr Timothy John, who um you're concerned that he has, I think I've done a pneumothorax case. So yeah, you're concerned he has a pneumothorax and I was taught in an sbar in situation. Basically, you think of the biggest red flags, not, not necessarily red flags and how we use it in medicine. But the biggest worrying signs that the patient has and get these in situation, you don't need loads, but just something that's gonna like catch the ear of the person you're talking to. If you just say I want you to see this patient with a pneumonia that's not gonna particularly potentially concern the person you're talking to, especially if they're busy. Whereas if you say I've got a person who's got a tension pneumothorax with a deviated and they've got like a hypotension of 70 something over, you know, 40 something. They're gonna be like, they're gonna sit up and listen and they're gonna wanna listen to you. So I would put at least one or two really worrying things straight away into situation at the beginning background. So this is basically covering your history in a succinct manner. So why has the patient come in? When did they come in? What is currently happening? So the history of presenting complaint and any relevant past medical history. They have. So what's been going on now, what's been going on before? If they've had this before, if it's related to a condition like asthma. So they've got this asthma attack that they've come in with, but they've had asthma for x many years and it's not been well controlled, that sort of thing. So you talk about what's happening now and then what has happened in the past, that's relevant assessment for this. I would just put in everything that you can fit in to do with any observations. So their oxygen saturation, their respiratory rate, heart rate, that sort of thing, and a new score. So if a new score it has been calculated for you or you can calculate it if you're given a news chart, um I would put that in as well. Uh If you've been doing an A two E which you hopefully should have been doing in an acute scenario, mention any findings there that you might have found any examination findings that you might have found as well and any blood results that will come back and then find recommendation. I would start off by saying what you think is going on, what your diagnosis is at the moment, especially if it's one that you're particularly worried about. What do you want the person on the end of the phone to do? When do you want them to do it? Like how urgent is this and what's really good, I think is to ask, what should you do moving forward while you're waiting and is there anything you've missed? So I'm gonna talk through an sbar, but I've attention pneumothorax. So I started off with, hello, my name is Megan and I, I'm an F one doctor in the emergency department. So straight away, I've said my name, what my role is and where I am, please, can I confirm I'm speaking to the respiratory registrar and you could ask what's your name? Fab? So you, you've, you confirmed that you're speaking to the right person, please? Can I speak to you about Mr Jamie Johnson who has a BP of 87/45 a deviated trachea and absent breath sounds a a absent breath sounds across his left lung. I'm very concerned. He has attention, pneumothorax. Straight away. There are two things that are go, you're gonna sit up and you're gonna go, gosh, this patient is incredibly unwell. Hopefully, at this point, the person who you're doing the sbar with whoever your examiner is will go. Oh yeah, continue, tell me about this patient. So for background, I've tried to keep it as succinct as I can. So Mr Jamie Johnson is a 25 year old male who presented with severe acute shortness of breath to A&E at 10 a.m. this morning, his shortness of breath began at 10 a.m. when playing tennis. He reports pleuritic chest pain and you can say a bit about his past medical history. So he has asthma and he's smoked. That's important for a pneumothorax assessment. The patient has a new score. So I've mentioned the score by name and I've included the parts of the score that give it the score that it does. So this patient has a new score of seven because of a BP of 87/45 a heart rate of 100 and 22 and oxygen saturations of 92. So you show where those points have come from. Uh The patient is conscious on examination, the trachea is deviated to the right. There are absent breath sounds throughout the left lung field and asymmetrical reduced chest expansion on the left side. So you've included there the observations, um the new score and the examination slash A to e findings. Um But this you could also throw in bloods here as well, but this is less relevant for this example and then finish it off with recommendation. I'm very concerned. This patient has a left sided tension, pneumothorax. I would be grateful if you could come to review this patient and insert er sorry, I was meant to say chest drain urgently in the next 10 minutes. So you've said, what do you think the diagnosis is? What you want the pa the person on the end of the phone to do? So you want them to review the patient and insert chest drain and you said when you want them to do it. So you're sort of stressing the urgency like you need to be here in the next 10 minutes. You can then say what you have already done, depending on the station that you're in or what you're going to do. Um It depends what sort of other questions you've been taught through throughout your station. So I've said here, I have inserted a large ball cannon into the second intercostal space in the midclavicular line. I've also um given him 15 L of high flow oxygen. Is there anything else you would like me to do in the meantime? But if they say, yeah, I'm gonna come, I'm gonna come down, you can say, what else do you want me to do? Cos it shows you're thinking I'm not just gonna sit here while I wait for you. You can, you're showing that you're ready and you're happy to start things ahead of time. Um And then thank the person at the end because they are helping you a lot. And um generally in is you might get or osk, you might get a little bit of pushback, especially at the beginning when you say please go speak to her about a patient and you'll tend to get something along the lines of, oh, but I'm really busy. I'm doing this blah, blah, blah. I would just come up with a line that you tend to use in these situations in an ay that basically suggests you, you need them to come now. But in the politest way you can mainly something along the lines of um um I'm very concerned about this patient and I'm worried they are very acutely unwell. So I would appreciate if you could come down in the next 10 minutes, just something to reinforce your point. You don't need to go overboard, but just something to show that you're politely emphasizing that this is an urgent situation. Cool. Hopefully, that's been helpful. I'm gonna just go through some last spot diagnoses with you all and then that's the end. So I'll let you read this one and if you guys can tell me what diagnosis is. Awesome. Perfect pneumonia. Next one, you guys will be pros after this session. Hopefully, what do we think this one is? Yeah. Perfect COPD exacerbation. Next one. Perfect. Great. And someone's put, I was gonna ask why is the radiotherapy important? Radiation is a risk factor for upper zone pulmonary fibrosis? A great job. And our last one of the night guys. Yeah. Perfect. Awesome. Great job of those. Yeah, lung cancer. So really worried there about the bee symptoms, shortness of breath and lung cough and the smoking history fab. Thank you so much for joining the session guys today. I hope it's been super, super helpful. Just a couple of things to say. So I know Joe's been really good at putting the feedback form in. Please fill this in so you can get the slides, the recording and also enter the geeky medics giveaway for the chance to win that ACY stations. This is a super helpful resource. I can't emphasize enough how useful it was for me last year. Um Also, what else was I gonna say? Yes, Jo has been putting in a link to respiratory stations. So if you guys haven't been aware or haven't joined our previous sessions, we're making circuits for every week. So you should get eight stations, four histories and four examinations for each um week for you guys to practice outside of these sessions in your own time with friends. Um that we've made ourselves that you can use, they're completely free. You do need to sign up for a Gy medics account, but that's completely free as well. You don't have to buy anything. Um So yeah, that's a really good resource and we hope you guys will benefit from that just, just being a star and putting those back in the chat. So, um yeah, I um hope today has been helpful. Thank you so much for the, thank you in the chat and please join in on Thursday for the respiratory examination session. We've got the lovely Becky doing that and that's gonna be amazing and keep tuning into our series, keep sharing it with all your friends. Um And we really hope