Respiratory Conditions



Join Roopa, a 4th-year medical student from UCL, as she delves into the fascinating world of respiratory diseases. Focusing on commonly seen conditions like asthma and COPD, this recorded session is crafted to equip you with the practical knowledge essential for your clinical practice. From pathophysiology to risk factors, triggers, signs, symptoms, and management, Roopa provides a comprehensive exploration of every facet of these conditions. Roopa also stresses the vital importance of correct inhaler techniques in patient management and shares light on understanding investigations linked to these diseases. This informative session promises to be a useful learning experience, leaving you better prepared for your clinical years. Queries are welcome during and after the session.
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Learning objectives

1. By the end of this session, learners should have a comprehensive understanding of key respiratory diseases such as asthma and COPD: their pathophysiology, triggers, and common symptoms. 2. Learners should be able to discuss the risk factors for common respiratory diseases and understand how they inform diagnosis. 3. Learners should be able to explain and interpret key investigative tools in respiratory medicine like spirometry and fractional exhaled nitric oxide tests. 4. Gain proficiency in the management of respiratory conditions, including the different medication options and their administration routes. 5. Understand the importance of patient education in managing respiratory diseases, including correct inhaler technique and lifestyle modifications.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everyone. Um, sorry if I to do this uh presentation as a recording last minute, I hope it's still useful to you. And I hope you've enjoyed um, today's talk so far. So we're just gonna finish off by talking about respiratory diseases. So you've probably had a few tools so far and are keen to get back to your weekend. So I'll try and be as quick as possible. Um, it's just a bit about me. Uh My name is Roopa. I'm 1/4 year medical student at UCL. Er, so I did my I BSC last year. We do. I was in our third year. I did mine on cardiovascular Sciences, which I really enjoyed. So if any of you approved clinical U CLI really would recommend it or at least recommend considering it. It was a really fun course, gives you lots of free time as well to explore your own hobbies and sort of have a really relaxing year before your clinical medicine starts. Um And yes, let's get started. So we're gonna cover various respiratory conditions. This probably isn't gonna cover all the ones you need to know. Um, but they cover the key ones, if at any point you have any questions, I'm gonna leave my email on at the end and also ask them to put it in the chat at the end as well or throughout the presentation. Uh If you have any other questions about conditions that aren't on this slide that you wanna know about, feel free to email me as well. I'm more than happy to answer any questions about respiratory um diseases. Um C LS get started. I'm gonna start off by talking about asthma. Um But just before we start actually, so it's really, it's really important that um you'll hear a lot of cliche cliches throughout medical school. One being common stuff comes up commonly. Um But it is true. Once you get to clinical medicine, you realize that a lot of the conditions that you will see are gonna be the common ones like you're not gonna see like Wilson's disease that you might see on house or something, right? So you're gonna see a lot of co PDA, lot of asthma. Um And yeah, so that's, that's just something to keep in mind, especially when learning and trying to like think what do I need to know the most about? Maybe for example, it's different, but at least when it comes to your clinical years, what do you need to know about the most is the common stuff? So we'll get started with asthma. Um and a bit of a pathophysiology, chronic condition uh due to reversible airway obstructions. This can be a cause of bronchial hyperresponsiveness or maybe a little bit of underlying inflammation. Um There are various triggers. They can have occupational triggers. However, more commonly, it's like environmental allergens and pollutants. So like your pollen, stuff like that. Uh A lot of people can have reactions to the temperature. So in the cold or in the winter, they can have a asthma. Um but then in the summer it sort of goes away. It can also be caused by exercise and stress and it's important to have these risk factors and triggers in mind because when you, you come across like clinical vignettes on pass or something, it might be, um, 37 year old male started a new job, er, in a factory and now he's got these symptoms, you're thinking, oh, maybe it's occupational or for a lot of the, um, exercise induced ones, it'll be seven year old boy. Um, JP. Uh, he started, um, feeling short of breath, he's been unable to, um, sort of partake in p sense and you're sort of thinking, oh, maybe it's a bit of exercise induced child induced asthma. Um, and the so sort of typical signs that you see, um, cough with a diurnal variation. So this essentially just means it gets worse at night. So the vignette might be like, um, yeah, the kid, uh, has a cough gets worse at night, it's bothering them, can't sleep and you're thinking maybe it's asthma, a wheeze and decreased exercise tolerance. So, on the right here, we can see that there's 1000 deaths annually in the UK due to asthma. So this is really like a problem because um there'll be a lot of emphasis on inhaler technique. So especially in your clinical medicine at, at UCL, I'm not sure about other ones. One of the sign offs is um educating a patient on how to use their inhaler. And you might think surely everyone knows how to use an inhaler. It's obvious there's still 1000 deaths in the UK. So a lot of this is probably or can be caused by poor inhaler technique. So you really, really wanna know how to use an inhaler properly and be able to uh relay that to a patient and explain to them how you inhale properly, how long you wanna hold your breath for stuff like that. So I believe the proper technique is blow out and you take a deep breath um and hold it in and if you use a space, so that's even better. Cos it means that more of the particles are getting down to your lungs. And there's certain risk factors. For example, if they have a family history of ATP, there's a lot of antenatal risk factors which you might want to elicit when you're asking a patient or clocking a patient, maternal smoking, if there was any infection during the pregnancy. Um and there's also something called a hygiene hypothesis which I'm sure you've heard of before. Just a s where people say that the more a young child's exposed to like dirt, um, and, um, stuff that they can infect them, their, it builds up their immune system. Um, I think some people believe it. Some people don't, it's completely up to you but some people say that it's a risk factor for asthma. Um, so the investigations spirometry, I'm sure all of you have seen this heard of this during preclinical medicine, maybe during a levels, they got you to practice it as well. Um So what's affected in asthma is actually fe B1. So that is because there's an obstruct, an obstruction and so the amount that you can blow out in one second is really significantly reduced. However, if you're given enough time because it's just that partial obstruction, you're able to still blow out the same amount. So your F EV one will really decrease. But your F EC which is the amount that you can blow out in total will still still stay the same. So this leads to the ratio decreasing. And this is what we call an obstructive picture. You can also use something called fractional exhaled nitric oxide. So this is because during an inflammatory process, um nitrogen oxide is produced. So this elevated levels is often used as a diagnostic marker. And you also wanna do a chest X ray just to rule out any other pathology that's going on an infection, something that can be causing the patient's symptoms. And so another thing we can also do is actually um a bronchodilator reversibility test. So that this is essentially um giving the patient a bronchodilator and seeing whether this resolves their symptoms uh due to the fact that we said that it is a reversible um pathology. So this, this is why that would work. So we have in the uh management, we have a short acting beta agonists such as salbutamol, which you might give in a bronchodilator reversibility test and patients will often say, oh, I'll take a blue inhaler for asthma, that's what they're talking about. So the blue inhaler, a short acting quicker, short acting to relieve the sort of acute attacks um and relieve their symptoms. Uh And then if that's not working, you can move on to a second line drug. Uh The I CS is the inhaled corticosteroids like clomesone fluticasone. People will often call this the brown inhalers and it's more of a preventer. So it's a long term um inhaler and they take this every day irregardless of whether they've had symptoms or not. And it's really, really important when you're er explaining this again in an inhaler technique. If they're on an I CS, you want them to wash out their mouth and brush their teeth after they use the brown inhaler. This is because that there's a key side effect of oral candidiasis. So they're really prone to these infections uh in their mouth when they're using that inhaler. And then you've got your long acting beta agonists and your leukotriene receptor antagonists as well um to control your burdo. And there's something called A ma which is an inhaler where they have both the maintenance and the reliever medications. So for example, a long acting beta agonist and an I CS, uh this is gonna have various benefits. For example, if the patients get them mixed up, right? You don't want them taking their bra, their blue inhaler, you don't want them taking their salbutamol every day and then their fasone only when they're having the acute attacks cos that's the wrong thing. Um, and so basically having it in one means that they're not gonna mess that up also for patients that I don't wanna be carrying around two inhalers with me every day. Uh, having one is better for them. So sometimes you wanna go for what the patient, you really wanna sort of ascertain what the patient wants as well. Cos at the end of the day, it's them that's gonna be having to take, um, the medication and whatever's easiest for them is often better. Er, cos it means they're also more likely to use it. Um, and that's important cos you don't want them to not be taking it, um, especially if it's like they come back to you. They're like, oh, this inhaler isn't working as is getting worse and you're like, well, are you actually taking the inhaler? And they say no, then that could be a problem. So dance is also a very important thing in um clinical practice. So now we're gonna move on to CO PD. It's like asthma, but it's not reversible. Fortunately, he's quite chronic. Uh yeah, a heavy link cooking also you to that quite early. Um and also exposure to stuff like coal cadmium grain, the signs and symptoms that you might see. Um So just before we talk about that, just a quick note as well. Um So uh I use signs and symptoms quite interchangeably in these presentations. Um If you wanted to be pedantic or like just know the exact differences uh strictly talking, a symptom is something the patient will have. So they'll say um I have pain here. I have a cough, right? Whereas sign is something that you can elicit in a examination. So the difference between pain and tenderness is pain is what the patient will feel and tenderness is what you've elicit on an examination. So if you're cussing on their rib cage and they wince or go out, then you're eliciting that. So it's tenderness. Whereas if they say to you, oh, I have pain in my ribcage, that's pain. Um And so that's the difference between signs and symptoms, but to be fair, you can use them interchangeably. I don't think anyone will call you out on it. Um So here in AC O PD, patient will have a cough like asthma, but it's often productive. They'll again have shortness of breath or wheeze. And if it's severe right, heart failure, which can cause uh a peripheral edema. Um And so again, S OB right, so I've written that as shortness of breath. Um So people often use abbreviations in medicine, but it's really important that you be careful with these as they can lead to confusion. For example, LF TSI do my clinical medicine, but they're now on gastro and like obviously, it's like the liver function tests and more more commonly than if you ask everyone in the hospital, what an LT stands for, they'll say liver function tests, but it's just trying to um make sure that there's no confusion. Um So try and avoid them when you can uh just um yeah, just a quick note. So now we're gonna move on to investigations. Uh So you wanna do against spirometry cop. There's also an obstructive picture on that and the bronchodilator reversibility will fail um quite commonly due to the uh irreversible nature of COPD on a chest X ray, you might see hyperinflation and they're also quite useful to rule out cancer. Cos again, it won't be like asthma where it's typically an early presentation, it'll be a late presentation cough and you really want to rule out lung cancer, especially when there's such a heavy link with smokers, you wanna rule out cancers um and a full blood count as well can be quite useful here. You can see a classification of severity of COPD. Uh classifications are really helpful as well in medicine because they sort of like help point you down what to do um as well as also uh what the diagnosis is sometimes. So those are really helpful to always have. Um and then the management of CO PD. So you wanna do the general stuff, um smoking cessation, you can give them nicotine replacement or certain drugs like buPROPion. You wanna, like we said, give them because they're prone to infections. You wanna give them an annual influenza vaccine as well as a one off pneumococcal vaccine at um diagnosis. Um And you also wanna use bronchodilators in them. So we have a flow chart here which sort of goes through the treatment thing. So you wanna start them off again with a saba or a saba. Uh And where you go from there really depends on whether they have what we call asthmatic features. So this is any history of asthma as a child or a, any at P if they have on the F BCA raised eosinophilic count if they have any diurnal variation. Uh which is what we talked about with asthma, it's where it gets worse at night. Um And if they do then great, you can put them on the I CSS as those asthmatic features indicate that they'll respond to a steroid. If they don't, then you just really wanna keep going down the beta agonist um to the long acting beta agonist or the long acting musc Muscarinic antagonist route. Er, and if those all fail, whether they are asthmatic features or not, you wanna put them on down here, this uh sort of uh you wanna include the steroids anyway, even if they have no asthmatic features and there's other medication as well. You can give them oral theophylline prophylactic antibiotics because they are prone to um infections. Either you wanna do an ECG to rule out QT prolongation, especially if you're giving him something like uh ayin as it can cause QT prolongation. You'll also um as you're learning about these conditions realize that a lot of the stuff we do intervention wise, medication wise have side effects. So it's really about uh weighing the risk versus benefits for everything that you do. Um As we talk about CO PD produces a productive cough, so you could give them mucolytics to help break down the mucus. Uh and also PD four inhibitors and oxygen, obviously, if they need it if they're desaturated. Um but you wanna be careful not to over saturate AC O PD patient. Uh This is because if any of you were at the previous talk, um uh it's um basically. So in a patient with a chronic obstructive picture, they will naturally have lower oxygen sets and their brain will get used to this over time. And it will mean that the natural mechanism where for a low oxygen sat, the patient will hyperventilate. You don't want constant hyperventilation. So your brain will reset that level to a lower level. So it will think that um a lower oxygen sat is normal. So then if we go and hyperventilate that patient and give them too much oxygen, then their brain might think, oh, we're now too high and they'll actually stop the patient from breathing. And that can obviously like you don't want that. So that's why if AC O sa targets are normally 88 to 92 rather than the classical 94 to 98 I hope that all makes sense. Uh And if you have any questions so far about anything, as I said, feel free to email me um about anything that you're unsure about. So now we're gonna talk about bronchiectasis. Um This was actually one of the very first conditions I came across in clinical medicine uh in a clinic. Uh It's quite sad actually, cos it's there's no cure and it's a very vicious cycle. So what happens is that a patient is particularly prone to infection and these chronic infections that they have leads to inflammation of the airways causing dilatation. So, as you know, as you're going down the lungs, the trachea, the bronchi, the bronchioles, the airways are meant to be getting narrower. However, because this patient has so many infections, it leads to inflammation and a dilatation. And because there's dilated distal airways, uh it's more easier for mucus to get trapped and therefore the pathogens to get trapped and lead to more infections. So this means that the patient is then after more prone to infections, the more infections cause more dilatation, which leads to more infection. It's just a vicious cycle. There's no cure. It's really sad to see. Um, and there's various causes. As we can see here, infective, there's a heavy link with cystic fibrosis. Um There's something called ABP as allergic bronchopulmonary aspergillosis where the patient has a allergy to aspergillosis and is really prone to those sort of infections. Um And that also can cause bronchitis, ciliary dyskinetic syndrome. So, this is, well, there's problems with your cilia which we know is important to clear the mucus that traps the pathogens. Um And the key investigations, a chest X ray, you'll see these typical tram lines which are basically just the dilated airways. Um They're just caught, you can did oh uh sort signet rings. So I see these sort of just the dilated bronchioles showing up on a CT scan and the management is chest physiotherapy. So, II actually got to sit in and um one of these physio sessions and it's just really interesting. So they basically just use breathing techniques to bring up the mucus. So one of them is you basically get the patient to breathe in as much as they can and then just blow out. So you go and that basically just brings up the mucus and there's other techniques that they can use as well and also postural drainage. So the patients will often describe, oh, I'm literally lying off the edge of my bed. I'm trying to get my head um down to the floor of my body as high up as I can just to get the mucus all out. Um And you wanna give them antibiotics and something called a rescue pack. So what this is is if you're in a clinic with them and you're really worried about them getting infections, you might say to them, here's a rescue pack of antibiotics. I don't want you to take these now. But if you have a uh infection, especially in winter, it hasn't resolved after a week, it's very productive. I want you to just start taking these as soon as possible without having to worry about them not being able to see their GP, whether they've gone on holiday somewhere. Um Stuff like that, you want to get them on it as soon as possible. You might also give them bronchodilators um to try and help them and also immunizations. So you wanna like CO PD cos they're prone to infections. You wanna get them on their vaccines and immunizations as quickly as they as you can. Here, we have a list as one of the most common organisms So haemophilus, pseudomonas, klebsiella, stuff like that. So we're now gonna move on to odds acute respiratory distress syndrome. So this is a very severe condition. It's got a high mortality rate. You can see that it's 40%. And even if in those that survive, they still have very long term and detrimental health consequences that can arise from this uh syndrome. So it's basically where there's an increased permeability of the alveoli capillaries. Uh This causes a massive flow of fluid into the alveoli uh which prevents obviously, the patient being able to breathe as well to get their oxygen. So there can be various causes infections, a large volume, blood blood transfusion, any trauma to the rib cage or the lungs or the chest, uh acute pancreatitis and the features that you might see it's often acute and severe. They'll have shortness of breath, they'll have increased respiratory rate, decreased oxygen sats and on auscultation, you will um have bilateral lung crackles. Um On the key investigations again, you wanna do a chest X ray, you can see a really congested picture here on this chest x-ray. It's just a really congested lung. Uh All this white is fluid accumulation and an arterial blood gas. Uh Here's some diagnostic criteria, pulmonary edema, acute noncardiogenic. You wanna make sure that it's not been caused by something like bright heart failure. Uh Sorry. Um Yeah, heart failure uh and also ma ratio of PO two of F IO two of less than 40. So it's good to have these sort of diagnostic markers uh to try and help guide your management and your diagnosis. But again, it's not like a fixed thing, right? If the patients was 41 you're not gonna rule out odds just because of that. Right, you have to fit it into the clinical picture, the management for this it, admission, oxygen and ventilation, organ support. You don't want their organs to fail due to the lack of lack of oxygen. So you wanna give them vasopressors, er and if you can identify a cause type of COVID-19 or if there is any trauma, you wanna get on that as quick as possible. And again, certain techniques like prone positioning, muscle relaxation can help pneumothorax. So I hope everything on the previous conditions have been clear, we're now gonna move on to the pneumothorax. Uh So this is where between the two layers of the pleura. So the parietal and the visceral around the lung, there's air that builds up and this can lead to a partial total lung collapse. So it's quite serious. There's also something called a tension pneumothorax which will come across. And so how do you wanna classify them primary pneumothorax without any underlying lung disease? And in the vignette, they might say a tall, thin young male. Um this is because they are very heavily predisposed to having spontaneous primary pneumothorax, probably due to the pressure differences in these individuals um And if they've got that sort of tall, thin um body shape and you might also query Marfan's. Um uh and the secondary type is, it's basically just a patient with lung disease as they're predisposed to these. Um For example, if they have cop DCF cystic fibrosis, cancers, um traumatic uh predis preceding event as well can cause them an iatrogenic. So, hospital course, so something that you've done that caused this, which is unfortunate but it does occur. So th thoracentesis or drainage, central venous catheter, you might use this if for example, an IV drug user, often their peripheral peripheral veins are too damaged to use. So you might want to go through a central route. If the patient's on ventilation, this can cause it if you're trying to do a needle biopsy, something like that, that can also cause it. So we're gonna talk, what about tension, pneumoarthritis via a life threatening condition. So this is because the pneumo thrix is so big that it's causing a pushover of all the medial spinal structures including the heart. So this means that the heart can prevent um it can prevent the uh blood pumping out of the heart which can lead to hemodynamic collapse. And as it's pushing over the structures, the trachea will also get displaced, which you can pick up in a examination. And the mechanism behind this is the valve, uh the air going into the lung is through a one way valve So in a normal pneumothorax, air can move in and out. Whereas in attention pneumothorax, the air can only move in and not escape. So it's just constantly, constantly, constantly building up and pushing over all these structures. And it's really severe. And the features that you might see in a pneumothorax are um it's sudden patients are short of breath and they describe something called a pleuritic chest pain. So either they'll describe this or it's something that you can ask them about. But it's basically w where the pain gets worse on breathing in. So you might say, does the pain when it, when you breathe in, they'll say, oh, I don't know, you, so just take a deep breath for me and see where it gets worse. And if it does that's pleur chest pain. And when you're examining them, you might have hyperresonant lung percussion. That's because, um, a normal finding would be re um due to the air. However, if there's too much air, it would be hyperresonant. And if it's too much fluid, fluid causes dullness, uh, specific stony, dullness, it, we'll come, we'll come to that soon. Um And so how you percuss as well. I often see people um, doing it wrong sometimes. Uh I think it's because like you often just said, I'll just do this, but they don't like show you specifically what to do. So just in, in case you want to practice what you want to do is you want to take your hand, people often use the middle finger. Uh, and you can either like, um, put your finger there and lift up the other fingers or some people just leave all their fingers on. It's up to you. You wanna go in between the D IP and the P IP. You don't wanna be doing it on the joints. You want to be doing it in a space in between and you're sort of just tapping on it with your other. You wanna be using your dominant hand to tap and you're not moving your whole elbow, right. You're just keeping your wrist stable and you're pivoting around your wrist. So you can easily just do that on your desktop or something or on a book to practice doing that. And um the more practice you get the better you'll be at. And with a pneumothorax, you're getting hyperresonance and an auscultation with your stethoscope, you'll be hearing reduced breath sounds. Um And when you're assessing for lung extension, which you do by basically wrapping your hands around the patient's, um, just under their ribcage and then take a deep breath in and out and you'll see reduced expansion. And uh when you sure. And so the management to be fair, if it's asymptomatic, you just wanna give them conservative care. You don't need to intervene if it's picked up incidentally on chest X ray or something like that. Um You don't necessarily need to give them, any intervention, uh, you might wanna follow them up though just to make sure it's not getting bigger. Um, and if they're symptomatic, you wanna go through to it, you want to check whether there's high risk signs. So, if there's any signs of hemodynamic compromise, if they're hypoxic, if the pneumothorax are, whether they have bilateral ones, um, if they're over 50 with smoking history, they're already at risk for lung pathology. So you, you might want to intervene. Uh And if they have blood in the lungs, if they're not high risk, you might just wanna give them conservative management again. Um Give them advice, reassure them, follow them up. Uh You can also use something called an ambulatory device. I'd actually never heard of this until I'd made this presentation, but there's something called a rocket plural vent. I've never seen it. I don't know how much it's actually used in practice. Uh needle aspiration is normally quite first line if you did want to intervene uh or chest strain, if it's a large enough pneumothorax. And um if you, there's another way of deciding whether you want to intervene or not. So, there's something called the remo so on the X ray, which I'll show you a few pictures of soon, um you can measure the size of the pneumothorax using the removal and I believe it's, if it's above two centimeters, you wanna aspirate or intervene. Uh And if it's a recurrent pneumothorax, you can do something called a vats procedure, a video assisted thorascopic surgery where they essentially deflate the lung. Um, and they apply something called, they do something called chemical or mechanical pleurodesis. So the chemical ones just applying a chemical to the lung and then reinflating it. So that when it reinflates, it gets stuck, um, to the ribs so that it prevents there being a gap, um, for the air to build up. Um, I've never seen it but it sounds very interesting. I've seen pictures of it. It looks quite cool and the lungs were deflated and stuff. Um So if any of you get a chance to have a, see why not encourage it, um You'd also wanna avoid, tell them to avoid flying for a week. Um You wanna make sure they're not like, um by having these sort of guidelines that helps you cos if a patient gets annoyed, you'd be like, oh, I've got a fly in three days. I can't miss it. I can't miss it. I won't get a refund and be like, look, this is what our guidelines say, this is what we need to tell you. We have, we have, we advise you to avoid flying cos of the risks and after that, it's out of your hands. And so here this is from the BT S guidelines. Um There's also nice guidelines which I'm sure you've heard about many times. Um But just pick what you want. Um Or like your certain hospital that you work at might prefer one and say, always use the nice guidelines. Always use the BT S guidelines. However, uh especially with medication as well for antibiotics, you also wanna get them to avoid diving or scuba diving permanently unless they've undergone that surgical procedure due to the risks of the pressure changes as you dive. Um And yeah, that's very important. Uh And so on the pneumothorax x-rays you have um I hope you can see it here. There's that sort of difference where my cursor is moving. And so here you can see there's a normal long long pill, there's a white here, it's just a complete blackout. That's the air in, in real practice. This is quite a moderate case. Uh You, you might not see this much air, it might be very, very faint and it's quite hard to actually see. So you really wanna be looking around the whole long outlines when you're assessing a chest X ray. And here you can see quite a severe case. So here on the right, we have a tension in my thorax. So you can see here all of the structures are being pushed to the right, the heart here is all the way on the right. And also here this is at the trachea on the left. It's still quite central, right here, this tube here that is the trachea there. So it's been all the way pushed to the right and that you will be able to feel that on an examination or it should be able to feel it. So we're now gonna move on to fusions. Um So you wanna classify this, whether it's transitive or exit. So this is whether it's a transitive, lower than 30 g per liter of protein causes heart failure. The cause it can be heart failure, low albumin. For example, if there's liver disease as the liver produces albumin nephrotic syndrome, uh hypothyroidism me, which has the trial of benign ovarian tumor ascites infusion. Uh an exudative is where there's higher protein and this can be caused by infection malignancies, that sort of thing. And if it's borderline, it can be quite hard to decide what it is. So we use something called lights criteria. So here on the right, you can see that if the protein's a bit borderline, you, you can tell that it's exudative if the, the protein in the fluid which you'd get from a, um you'd, you'd get some of the food out to do this. Obviously, it's um to assess it for the fluid protein to serum protein ratio is more than 0.5. If the LDH of the fluid is um more than 0.6 times the serum LDH or if the LDH is more than two thirds of the upper limit of normal. So the normal limit is probably around 140 to 280. So uh if it's above four fiftyish um, you'd wanna sort of consider it being exudative and so the classic signs or symptoms that you might see shortness of breath, nonproductive cough, chest pain. Um, and we talked about the stony dullness. Right. So, stony dullness is, can only ever be a pleuro diffusion. Hi there. Sorry. I think my wi fi crashed for a second. Hopefully they will record and save though, uh, previous. Um, so, um, what were we talking about? Oh, yeah, the stony darkness. So, um on percussion and auscultation, you'll always hear different noises even through like heart stuff, right? Go to youtube, listen to normal heart sounds, normal lung sounds, normal percussion findings, abnormal percussion findings. Um and it will help you sort of differentiate, but as I said, stony dullness can only refer to pleural diffusion. So if you ever see that, um have that as your like uh first and highest thing on your differential diagnosis, it's probably a pleural effusion. Or if a doctor asks you, what would you find in a pleural effusion? Say stony dinosaur percussion. Um You'd also find reduced breath sounds and reduced chest expansion. Uh The key investigations you'd wanna do um are a, is a pa a chest X ray. You'd maybe wanna do an ultrasound scan. We see the fluid and the um and also if it is, we talk about malignancy being a cause you can see this on an X ray. Um Contrast CT can be quite useful and as we talked about how you're assessing this protein level or these lights criteria is a something called, we call a diagnostic tap where you're removing fluid to uh use for diagnostic reasons. So this is ultrasound, guided to make sure you're not hitting any irregular structures to make sure you're doing it safe. You wanna use a 21 gauge needle and a 50 mil syringe and then you send it for all these things, PH protein LDH, stuff like that. The management is similar to a pneumothorax. You'd want to aspirate or chest drain. You can also do the pleurodesis. We talked about the vats procedure if you're worried about it recurring. Um and you can also give them opioids to alleviate symptoms. So a lot of the time if the patient is hypoxic because they're hyperventilating, this is actually due to the pain. So when patients are in pain, they don't breathe as much. So by giving them analgesia adequate analgesia, this can often uh restore their um respiratory rate if it's too low if you need to. Um And here again, we have some X rays of the pleural effusion. I'm sure a lot of you must have done chemistry for your A levels or GCS E and you remember that um the meniscus right of the fluid. So you can often see that in the severe pleural effusions. Here, we can see there's sort of a rounded bottom, you lose this sort of costophrenic angle here. Uh This is the typical angle that you wanna see in a lung or where my cursor is and you lose that. You just see this meniscus level. You might not always see that pure meniscus level. So I've given you another example here where it's not perfect meniscus, but again, you're losing that ankle right? And that's how you can assess a very faint one. Cos there might just be one just here. Yeah, you can only see that if you've lost the angle right into space. So I hope that all makes sense. Um So far, um, now we're gonna talk about pneumonia, a very, very common thing that comes up in exams and on the wards. So it technically describes any inflammatory condition of the alveoli, but it's most likely used in the context of an infection. So the cause is it can be anything bacterial, viral fungal. Um There's something also called idiopathic interstitial pneumonia. An example is cryptogenic organizing pneumonia where it is uh essentially a pneumonia caused by rheumatoid arthritis or amiodarone therapy. There are various organisms that cause it, you can see it here on this nice little chart. Um So streptococcus pneumonia is the most common. Um, however, in your vignette, they might say they might just introduce something like S uh patients CO PD and then ask you what's the most common organism? And this would then be haemophilus influenza. Um If it's an alcoholic, uh klebsiella pneumonia, um stuff like that. And again here HIV, Pneumocystis DCI. So, um, yeah, so different causes, um, can also be seen in different sort of groups of patients. So, again, you don't wanna just be seeing, uh, pneumonia and then guessing streptococcus pneumonia, check the whole V, see whether they've mentioned any of this stuff for H IVC O PD alcoholic. Um, unfortunately a lot of the times, um, the questions might sort of say homeless and you've sort of gotta make a link assuming they're a drug user or an alcoholic, which isn't always the best thing, but they do do that in questions quite a lot. Unfortunately. Um, so there's different types of pneumonia, uh C AP HIV. So community acquired as well, obviously just got it in the community hospital acquired pneumonia is used to describe a pneumonia that has got, um that is a patient gets 48 hours or more after being admitted. And the reason there's that it's important to differentiate this is because it can be caused by different things most often. And thus the antibiotics you have to use the most are sometimes different. A little note about the antibiotics. So as I said, there's guidelines, right? So you don't ne so maybe memorize one or two key antibiotics for pneumonia, but in an exam or an OS or CP sa sorry if you're ever stuck, you can, you can literally just say, um I'd like to treat by going off my local trust guidelines for antibiotic therapy. And I mean, they might not give you four marks if they wanted a specific um, antibiotic, but it sounds good. It shows that you know what you're doing and often they do different, differ from trust to trust. So it's also good to keep that in mind. Um, some classical features with pneumonia, productive cough, shortness of breath, chest pain, that could be pruritic and fever. So that fever differentiates from a lot of the stuff that we've talked about before with cough, shortness of breath, chest pain, sorry, fever's on there twice, sorry about that. Um But p will also be tachycardic, uh reduced, uh oxygen sets, um, reduced breath signs and bronchial breathing again, youtube, search out bronchial breathing. You'll be able to see an example of that. Um And yeah, again, with the O2 sets, um, be careful about the patient being, having COPD and over saturating them. We don't wanna do that. Um But again, to be fair, if you, if they, if you get them to the target sets of 92 uh there is a way to check whether you can keep going. It's essentially looking at their CO2 levels, I believe because, um, if they were to stop breathing due to over ventilation, like we talked about, they'd be holding on to CO 02. So you can check their CO 02 levels on an ABG and if their CO2 is low or normal, you might be like, oh, let's get them up a few more percent just to make sure they're healthy as possible. That's more like when you come to clinical medicine, that will be important. So, key investigations again, lungs, chest x rays always or mostly first line s mm So here on the second one, that's sort of middle um of the lung bloods, you might see neutrophilia e very important, you can check for dehydration and urea and ees is also very important for a scoring system we'll talk about soon and C ACR P is also an infection marker. Um So the management again, antibiotics, according to local trust guidelines, you wanna give them supportive care. So oxygen IV fluids, if they're dehydrated, and we can also use this scoring system, curbs 65 to classify pneumonia and also decide how we're gonna treat them. So I'm just uh it, it goes through here on the right. And so the C stands for compu patient is the patient confused. Uh And a way to classify those va 10, you classify that a liter respiratory rate over 30 per minute BP of systolic lower than 90 or a diastolic, lower than 60. So if they're hypertensive and if they're aged over 65 years old, so that's obviously out of 51 for each um criteria. Uh If you're in a GP setting, you get rid of you, right? So you just do the C RB 65 and it's out of four. it's because it's, um, just how you do it, er, and the reason the scoring system is so important is because if you've got a score of four, you're approaching 30% mortality at 30 days. So a lot of people will die if they have that sort of score. Um, and what you sort of do is if it's zero or one, you sort of go, I could probably, um manage them at home. Um, if it's maybe 1 to 2, you wanna consider admitting two or more admit for sure. Um If it's more than three, you wanna at least consider itu referral. So if you're really worried about them, just refer them to itu if you're in the hospital, if you're um, if you're unsure, you can always ask for um the it regs helps you just leave them be like, look, I've got a patient on this ward, they've got pneumonia, their club scores, this, I'm really worried about them. Er, could you come and have a look at them, er, or at least warn them. I have a patient with pneumonia. This is their club score. Um, if they do deteriorate, um I just wanna let you know that they might come to itu and again, these scoring systems are amazing for helping you, but they're not set in stone, right? If the patient's mental test scores nine, if their urea is 6.9 if their respiratory rate's 29. If their sys systolic BP is 95 and they're 64 years old, you're not gonna be like, and you're worried about them. You're not gonna be like, oh, there is, the score is zero. I'm gonna send them home with antibiotics if they live alone, if they're vulnerable. If they're like, if you're really worried about them, you wanna still be admitting them even though they're club school. Yeah. Right. So you, you can use these school systems, but it's also very important that you use your own judgment. Um And that's that sort of stuff's important with this. Um And again, based on their score, you'd give them all antibiotics. IV, antibiotics, stuff like that. So now we're gonna move on to TB. So mycobacterium tuberculosis, it's an airborne disease c but respiratory droplets. Um and it all sessions a bra TB renal or gi effect. Uh So the risk factors which might be hinted at in a clinical vignette is that the patients from Asia India, typically they do mention a lot Latin America, Eastern European African or that they've been exposed to a person or a relative with TB, the patient's HIV positive, they're 20 to 30 times more at risk. So they might also include this in the vignette. Um And if someone's immunocompromised, so classically, they're diabetic patients as well. Classical symptoms that you might see is night sweats, a fever which gets worse at night causing the night sweats, weight loss and a cough and the weight loss is more of a, if a patient ever says to you, oh, I've lost a lot of weight. You wanna say, what is it intentional? Uh, if they say no, then you're thinking, oh, it's probably something more sinister. Um, or if they've had a lot of diarrhea, whether they've been eating properly, you wanna be asking them these sort of questions about weight loss investigations for active TB. You want to do a chest X X ray in which you'll see classically upper lobe cavitation. Um So there's an acronym for that charts, but you can look it up and see what the causes charts for upper lobe consolidation. You'll also see bilateral hilar lymphadenopathy. I'll show you that on the X ray as well. Uh Next slide er and ac caseating granuloma. Um Gold standard is a sputum culture. However, this can take weeks. Um a benefit of it as well is that you can also ascertain drug sensitivity. So if from that Sputum culture, you can see which drugs will work, which drugs that that's shown as resistant to. So this prevent, this helps you give them the best management as possible. Um Other options, sputum, it's quicker and cheaper, but you need three and an N A at test which is OK. And then the smear and if you suspect a patient of having latent TB, then you can do something called a man two test where you give them 0.1 mil or one in 1000 purified protein derivative of TB and you inject this intradermally. And then after a few days you come back and you read um uh whether there's a bump at the site of that you've injected. So if it's above 15, it's a very strong suspect that they have an A ATB infection and if it's less than six, it's sort of negative. Um And yeah, so the management you wanna go through will go through soon. I'll just show you these x-rays quick. So this is a normal chest X ray here. Here, we can see hilar enlargement. So what the hi are, it's basically an opening from the lungs and it's where all the blood vessels and stuff travels through. So in stuff like TB sarcoidosis, you typically see this thing called bilateral hilar lymphadenopathy, which is where in these hilar structures, you basically just get lymph lymph nodes being enlarged due to the pathology. And here you can see this typical upper lobe consolidation of TB. Um and the management so active TB use an acronym called Right Ramp and Isoniazide P Samide ethambutol. You get all of them for the first two months and then after the first two months, you continue only rifampicin and is IZ for another four months. So that's six months in total for the 1st 22 months in total for the bottom two. And there's a lot of side effects with these drugs, hepatitis, neuropathy, myalgia, arthralgia, optic neuritis. So you want to keep an eye on these, take baseline LFT S, baseline liver function tests and also take them at intervals to see whether it's being effective. And you want a red um safety net them for the red flag. So again, safety netting is just something when you're discharging a patient for any condition, whether you're seeing them in a clinic or in A&E you wanna discharge them, say this is what you wanna look out for. These are the red flags. If you see these come back to us, go to A&E stuff like that that covers your basis. Um And also it means that the patient can keep an eye out for stuff that is worrying if it's latent and you identify the TB, you just wanna give him isoniazide and Perdox for a period of three months. So the last condition that we're gonna talk about is lung cancer. Um So the classic signs that you'll see are a persistent cough. Are doctors have a cough. It's not going away. It's been there for months and months, it's not going away. Then you'd say another question. You wanna ask any time that a patient mentions that they've got a cough. Is there blood in the cough? They say yes. So that's hemoptysis, shortness of breath, chest pain. Again, weight loss is always a sinister sign. So you wanna be thinking you're on cancer or TB um mainly, uh and they might have such weight loss that they're anorexic. Um They can also have hoarseness. So, uh I'm sure you know about the pancreas tumors. So the lung, uh it's the tumor at the apex of the lungs. Um It can cause Horners Syndrome, um which I'm sure you've heard of or if you haven't, it's basically just um a syndrome which causes ptosis, that sort of stuff. Um And the pancreas tumor can press on the recurrent laryngeal nerve and cause hoarseness of the voice cause S VC syndrome where the tumor is pushing against the S VC. Um uh you can also have a fixed monophonic wheeze supraclavicular lymphadenopathy. Um So that's above your clavicles, uh clo of the fingers, but that's very nons P is, you know, a lot of lung conditions. Um It's quite certain conditions. So here you can see the different types of cancers and the sort of the paraneoplastic problems that they can have. So with small cell cancers, you have Lamber Eaton syndrome. So that's sort of like myasthenia gravis. But the cancer is producing um antibodies that block the presynaptic C calcium channel receptors. So, in the neuromuscular junction, myasthenia gravis prevents the post synaptic acetylcodone receptors in a Eaton, you're preventing the presynaptic calcium channel. So uh slight differences, the similar presentations, I believe. Um And yeah, so these are sort of p plastics in guns and also have like sort of um tumors themselves can secrete these things. So a DH ACTH er, parathyroid hormone. So, when you're investigating someone with a high ACTH, you might wanna consider there being a malignancy if you can't find a source for it. Um And so last slide almost done guys. Uh, so lung cancer, um can, it's normally classified histologically as either small cell or non small cell and if it's small cell, this is less of the cases. Uh, so only 50% of the cases. However, it's got a worse prognosis. Unfortunately, um, by the time of diagnosis, it's probably metastasized for. But if you are lucky enough to ca catch it in an early stage surgery is often what is done and most patients will receive a chemo combined course of chemo and radiotherapy. Uh, however, if it is an extensive disease, by the time you've caught it, you might just have to give them palliative therapy. For example, chemotherapy to sort of just relieve the symptoms as much as you can give them as best quality of life as you can analgesia as well. Obviously. Um, and if it's a non small cell, uh there's different types adenocarcinoma, which is the most common, often seen in nonsmokers. So that's another difference. Um So in small cells, typically, I believe smokers, whereas if it's adenocarcinoma, it's like nonsmokers, uh, squamous cell ca uh squamous cell cancer, non small cell cancer, large cell alveolar cell carcinoma, and bronchial adenomas. And you can stage them by either doing their grade or you can do something called TNM staging. Well, this is, helps classify you. Um how bad the cancer is. So, the T stands for tumor size. Uh How big the cancer is lymph node status? So, um how far the lymph, uh how many lymph nodes and how distal lymph nodes um are affected and metastases? So, um have there been any metastases of the cancer? Has it spread anywhere else? Has it spread to the spine? The bones, stuff like that? The neck. Um And so that's the end of our talk, I'll just put this last slide up. So that's my email. Um If anyone has any questions at all, feel free to email me. Let me know. Um if there's any other conditions you wanna know about um feel free resource wise. Um Geeky medics is amazing. Um All of the CP SAS that you've learnt, they'll have thorough guides, checklists for you to practice with your friends, get someone to be the examiner, someone to be the patient. And just sort of you can practice the checklist and again, you really need to be practicing them cos sort of reading through the checklist is good. If you do it enough, you'll pick it up. But if you're practicing, it just helps you remember it so much more. It, it will almost sort of become muscle memory and the examiners, they're having to do so, so many examinations in one day. If you walk in confident, they'll sort of almost maybe switch off or like, they'll be like, oh, this person knows what they're doing. So, if you miss one step, they might, like, not even realize, or they'll sort of just like in your CP sa you'll get marks for all the checklist. But at the end they'll also be like, how good was the person? Were they, uh, empathetic with the patient? Were they confident? Did they know what they were doing? Did they seem competent stuff like that? So, doing the practice and actually acting it out um with your friends, um will really help with that. It will help your confidence um And it will just get into your muscle memory uh so that you don't even really have to think that much while you're doing it. So that's great. It's geeky medics, youtube again, if you're ever confused about what words mean, for example, the sounds hyperresonance, stuff like that. Heart sounds as well or what does this murmur sound like? What does that murmur sound like again, youtube will be amazing for that and yeah, pass me as well. Um A lot of people like um and all that stuff will be great. So, um I think we'll wrap up there. Um But hopefully everyone's enjoyed today. Thank you again for coming on. Sure. Be really appreciative. I'm sure they'll also have a feedback form for you to fill out. I know it's annoying. You've probably just had like four hours of lectures. Um I'm sure you just wanna get back to your weekend and not fill out another form. But if you can uh save it or do it at a later time, please do or just try bang it out now or like whatever you wanna do. But it really does help with these and help f how we organize future stuff. So, thank you very much for that guys. I'll leave it there.