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Hi, Maria. Can you hear me? No? Yeah, I can hear you. Ok, f and then I can see your screen as well there. Ok. Yeah. Is that ground? Yeah, perfect. Eye. It's the first side there. Ok, great. Thank you, friend as well. No, it's fine. I'll just wait to seven to start. Yeah, perfect there. Sometimes one's join like, you know, a few minutes later. But ok, that's grand. I mean the first bits all just like enter anyway. So it's fine. Well, I got your email as well. So, so I'll send them on to be sent to the portal and then this should be recorded and as well. And if you need anything else, let me know. Ok, thank you. Ok, guys, we'll just crack on and um other people hopefully joint as well. So this is just a chat today on respiratory medicine. Um and I'm just kind of covering um what was probably most likely to come up in your exams. So we wanna go through asthma co PD pneumonia, lung cancer, lung fibrosis and with thorax pleural effusions and then touch a tiny bit in oy as well. So asthma is an obstructive lung condition. So what that means is the F EV one over F EC will be less than 70% on spirometry. Um So like often MC Qs will be asking you like which of these would be the results that you would expect for someone with asthma. So, like that is the take home message from this. Um, the symptoms patients will often come in with will be that they have a cough that's worse at night. They'll be short of breath, they might have a wheeze and experience chest tightness. Um And if they're having these symptoms, like more than three days a week, um, the diagnosis that we would be thinking of is asthma and how to diagnose it would be spirometry with bronchodilator reversibility and it's more than 12% or an increase in 200 mL after taking the bronchodilator. Um And if that is negative, then the second line test would be feno testing and it's positive if it's more than 40 parts per billion. And then there's a few risk factors that would probably often come up in MC QS such as like having eczema or high fever. This is also like if you're having um an OS station with someone with asthma in the past medical history, it's a good thing to ask about as it kind of shows that you're thinking more broadly. So this is the management plan for asthma. Um Really, it's just something you kind of have to learn, there's no real easy way to do it. The most important thing um is knowing the first line, which is that you would give them uh Saba, which is a short acting beta agonist such as salbutamol. And then you would also start them on a low dose um inhaled corticosteroid as a regular preventer. So the regular preventer is something that they have to take daily. It's the brown inhaler and then the salbutamol is the blue inhaler. If people are taking this more than three days a week, um and are needing it often, then that's when you start having to think about increasing um their asthma management and it's really just like following this plan. So yeah, just learn this, to be honest, I don't think we've ever had a question that goes past like the second line of it. Um So it's just good to know the saba and inhaled corticosteroid. So then acute asthma and this is a frequent M CQ. So um it's really just sitting down and learning this again. It kind of makes sense whenever you go through it. So moderate asthma is just whenever they're having increased symptoms, their peak flow is still more than 50 to 75 and they have no features of acute. So acute is peak flow between 33 to 50%. And then the magic numbers are 25 for respiratory rate and a heart rate of 100 and 10. And then just the inability to complete senses in one breath and then life threatening is less than 33%. Your oxygen SATS should be less than 92 if it's life threatening, less than 8% on oxygen sats. And then really, like any, um, change to the BP, like less than 90 systolic being hypotension or if they're exhausted and then the really important one is near fatal. So you always need to do an ABG on anyone who has asthma. And the thing you're really, really worried about is their P CO2. So if someone with asthma has a normal P CO2 or raised P CO2, you'd be really concerned because they should be breathing a lot and their P AC two should be low because they have an increased respiratory rate. Um Whereas if that's been raised, it means that they're breathing less, they're getting very tired and it would be a sign that you need to contact a senior and that they might need to get mechanical ventilation. So how do we manage, um, acute asthma? So you always, if this is an ay station you always start off with, I would take an A to E approach and, um, get senior help involved. The, the first thing you do, um, is make sure the airway is patent and then whenever you move on to breathing, um, how you're going to treat them is giving them oxygen and it would be 15 L non rebreather mask um, especially if they're hypoxic if their sats are less than 92 um, you'd want to start them on nebulized salbutamol and, um, also give them a steroid, oral steroid is usually fine, 40 to 50 mg. Um, and sometimes IV can be used but like the standard is using the oral and then after those two steps, then you're thinking ium bromide and then very severe would be magnesium and aminophylline and then intubation and ventilation. The severe ones, this is all, um, stuff that someone more senior than you will be starting. But it's just, um, to know like what the next steps are. Sometimes that might be in an M CQ question, someone has APAC O2 that is raised or having an acute asthma attack. They might say they've already been on salbutamol and a steroid and then you'd be thinking, ok, potentially they might need intubated and ventilated. So that's asthma in, uh, whistle, stopped her. So now for CO PD, um, so the standard patient for CO PD would kind of be, um, someone who's over 50 they'd usually be a previous smoker that would be in their, um, past medical history. And, um, the symptoms would normally be like a productive cough. They would get short of breath on exercise usually, um, and a reduced exercise tolerance and they would also present with a wheeze, um, in asthma you're more likely to get triggers that bring on their symptoms. Whereas, um, such as like dust or exercise like in CO PD. Um, the usual thing that brings it on is like having a chest infection or also, um, exercise. Um, or else they can sometimes get the symptoms at rest as well. So, investigation wise, um is spirometry. We got this in our a in fourth year. Um, and it was taking a history from someone with CO PD and one of the main things that we had to ask about really was that they were having like frequent infections. So people with CO PD might have like four or five infections a year. So it's just being aware to like ask that in your history and um see how they were treated with those. So um it's diagnostic of CO PD if they have this like clinical picture and also have their obstructive um spirometry, results of F EV one over F EC less than 70%. And then the severity is just up here in the top box. So um it's indicated by the F EV one. So over 80 is um mild and then stage two is moderate, three severe and those are the things. So just learn that wee table sometimes it comes up in M CS as well. And then your standard chest X ray of someone with COPD would be hyperinflation um with flat he me diaphragm and you always need to do this investigation just to exclude lung cancer in these patients. Um because um the symptoms can be fairly similar and you just always, um, don't know. So you want to be sure. So the stable management for CO PD, the most important thing that anyone with CO PD can do is stop smoking. That is better than any drugs that you can ever give them. Um, and then next line is actually the, if they get their annual influenza jab and then their one off pneumococcal, that is very good, you'd have pulmonary rehab and then use a stepwise management over here. So everyone would either be started on a Saba or Assama and you'd see how that's going. And then if they're still complaining of symptoms, then you need to assess whether they have any asthmatic features or features suggestive of steroid responsiveness. So that's the four bullet points that are in the box. So if they have a history of asthma, if they have raised um is in a full count if they have a lot of variation in their F UV, one or a diurnal variation in peak expiratory flow. So if the answer to that is no, then you would keep them on a Saba and add a Laba and a llama. And then if the answer of that is yes, it would be Saba or Sama as required. And then Laba and I CS and then if on either side of the spectrum, it's not working for them, they're still having symptoms, then you go into triple therapy with your Trelegy, which is Laba Lama and I CS. So, again, that's a really common um M CQ question and it's just kind of getting into your head. Um When do you choose I CS and Laba? Because they'd usually already be on a or SAL and the question would usually be showing that the person's like, not well treated. So, what do you do next? So just follow this, um pass me a diagram and you'll be grand. So what most people with COPD will come in with is um exacerbations. So the first thing you kind of need to work out is is this infective um or non infective. And then after infective would kind of be like they're producing green sputum. They have a fever and um the most common organs is h influenza. So that's a wee common M CQ as well. And um normally their symptoms would be a lot worse than their baseline, like they might be extremely short of breath or rest. Um And they will be needing to use their inhalers a lot more and they will have significant chest tightness. People with um COPD exacerbations can become very, very unwell. So, um it's really important to know the management plan for them. So you need to increase their bronchodilator use. So that's the blue inhaler. You would give them oral prednisoLONE 30 mgs five days and then if they are infective, you'd be treating them with antibiotics. And also for infective and non infective if you're worried about them. Um And you know, you started them on bronchodilator and oral predniSONE and it's not working, then you would consider admission and tailored oxygen therapy. So it's really important anyone with CO PD needs to get an ABG on admission to see if they are a CO2 retainer if they are a CO2 retainer, um their CO2 will be high and that means that their oxygen shots will need to be tailored to 88 to 92%. Whereas if their ABG is normal, then you can just give them the normal oxygen shots of 94 to 98. And then, so that's talking about they're prone to type two respiratory failure. So if someone does have type two respiratory failure, low oxygen and high CO2 and ABG and they also have um acidosis in the ABG, then you might have to consider um noninvasive ventilation such as BPA. Um So that was um CBD. So now to move on to pneumonia. So, um this was actually our third year. Um o we had a chest X ray and then you had to chat about pneumonia. So it's really common comes up all the time. So it's something to um know about. Well. So the symptoms are cough, sputum, um fever, p like chest pain and shortness of breath. Um The signs would be someone having a low sp O2 being tachycardic and then like on listening to the chest, you would normally hear like hoarse craps. Um The investigations you want to order on everyone who you're concerned about having like significant pneumonia would be a chest X ray, full blood count, uni CRP and then a sputum culture. And then you would also potentially consider sending out for like um legionella as well like urinary antigens. Um So the curb 65 this is something that's really simple, but really, really important. It guides management. So if you um have a patient with new onset confusion, that will score you one, if there's a patient who has a history of dementia, um then you can't really apply this as well. But usually if it's like they have a score less than eight out of 10 on the ATS, then that is whenever you would give them a one, the urea is more than seven respiratory rate is more than 30 BP is less than 90 systolic or less than 60 diastolic and their age is more than 65. So I think in our third year Os, they asked us to what um like the Curb 65 was and you had to say it and then they asked what like applied it to the patient that was in front of you. So, um it's pretty easy to do, but it's just kind of getting into your head. It's really common M CQ question as well. Um And then it kind of just determines the mortality. Um, so if someone has a curb score of one, you'd be more likely to look after them at home, um, and give them antibiotics. Whereas if they have a score of more than two, you'd be thinking they might need IV antibiotics in the hospital. If it's more than three or four, then you might be thinking, God, this person might end up needing to go to I CE or how care. So, um these are just the different types of um organisms that cause um pneumonia. So this is like a bread and butter M CQ question as well. Um So the first one, the top of it has been cut off, but streptococcus pneumonia, um high fever, rapid onset, um you might have a cold sore as well and then h influenza is CO PD patients. Normally. Um Staph aureus is like whenever someone comes in having recently having the flu, um if that's written in the M CQ, you're thinking, ok, I'm gonna click staph aureus. Um mycoplasma, it's like one of the atypicals. So, um atypical pneumonia is actually treated with Clarithromycin, not amoxicillin. Um So it's treated with the macrolides and it's kind of a dry cough. Often it'll say that um like they'll be young, they might have a sore head as well and it can cause they might give you blood results which show an autoimmune hemolytic anemia and sometimes they can have a rash, um, erythema Multiform, which is essentially just like um big circle rashes in the body. So if they have like a chest infection and that, oh, sorry. Um Then you'd be thinking mycoplasma legionella is the one whenever people come home from holiday and have stayed somewhere with bad air conditioning would be the classic. Um, and they'll have the low sodium in the bloods and then pneumonia is like normally in the MC, it will give you a brief with someone um being an alcoholic or have high alcohol history and they will present with red currant jelly sputum. And then the final one is um, Pneumocystis ger and this is seen in patients with HIV and wee dry cough and whenever they exercise, their SATS will decrease a lot. So this is kind of a chest X ray. So this is like very similar to what we got in third year. You just had to use um, the uh X ray approach which I think someone else is gonna give uh um we chat on and um, yeah, you had to go through it kind of state the most obvious abnormality, which is the consolidation in the um, right lower zone. And then, um, yeah, we were asked a series of questions. Um, yeah, it was a chest X ray. Um, they might be like if you say this is pneumonia, then they will follow it up with, oh, how are you going to treat it in a always state that you're gonna check like the patient's drug allergy status and that you would follow local trust microbiology guidelines for treatment. Um It kind of covers you for everything. Um And so like that, that is also what you do in real life. So yeah, this is just management on CB 65. So we chatted about that already. So more than three you're considering ICU and then all patients with it, um, pneumonia will end up getting a chest X ray six weeks after. So this, um, now we'll move on to lung cancer. So, um, the red flag symptoms are hemoptysis and then any of the following for three weeks. So having shoulder pain, shortness of breath for three weeks, hoarseness, weight loss, enlarged lymph nodes or persistent cough. Um So the symptoms in any respiratory history that you want to make sure that you cover would be um shortness of breath, cough hemoptysis and then wheeze and chest pain. And then after that, you need to think, ok, I need to make sure this person doesn't have cancer. That's kind of what she goes through her head and all. Ay, so then you would be thinking, ok, have you had any weight loss, have you had any changes to your energy levels, any night sweats, um, and any change to the appetite and that will cover you if you don't ask those questions and you could miss like a really important diagnosis. And um, if you do ask them and they're all negative, then you can be quite reassured. Um, so on examination, they might have a fixed wheeze and then always make sure in the rasp exam that you examine their neck for supraclavicular lymphadenopathy and then lung cancer is also a cause of finger clubbing. So, um, investigations for lung cancer, um, everyone will get a chest X ray, although it only picks up about 10% of people who actually have um, lung cancer. So if there's clinical suspicion, they will end up getting a CT chest. If that um, is positive. Um, or they have any findings, then they will do a bronchoscopy. And in this, they will take samples of the cells to find out um, like what type of cancer it is and then they will do pet scanning and then, um whenever you're doing um investigations for lung cancer bloods might show raised platelets. And then after that management is really specialized. So I don't think you need to know it in detail. Like they do have stuff on pasmed and SMED. But I think, um, you don't really need to know it. To be honest, the bit that you do need to know will be um these symptoms over here. So like what correlates with a small cell carcinoma? They love to ask questions like this. So, um it's just important to kind of sit down and learn it all um and find your own wee way to learn it really. So, like adenocarcinoma, they'll probably have gynecomastia and then they might have HP OA in the squamous cell, they will have like problems um with hypercalcemia, they might have finger clubbing, but they have that in all of them. H pa or hyperthyroidism and then small cell kind of causes um all the weird and wonderful ones. So, um they might have like inappropriate ADH secretion and they might secrete too much ACTH um and cause like a cushing oid response. And then um Lambert Eden syndrome, which is essentially like um a neurological problem that can be presented. So I move on to um idiopathic pulmonary fibrosis. So it's um normally seen in patients that are 50 to 70. Um Whenever I think I was your stage, I never really thought like the age and the MC Qs or anything mattered, but they kind of um will be able to help you like rule out some questions and things, some answers as if someone is like 20 I PF is coming up as an option. It is really unlikely that they have it. But if they're in their fifties, then you're thinking OK. Yeah, that could be possible. So, features include like progressive exertional shortness of breath. Um And that is how they will write it in your M CQ by basal fine and inspiratory gravitation essentially like completely means it is I PF um if that is there and then they will also have a dry cough and finger clubbing usually. So this is actually a spirometry picture of a restrictive picture. So that means that the F EV one will be normal or decreased and then the F VC is decreased and the F EV one over F EC is increased. So it'll be more than 80 um kind of the pathophysiology behind it is that there's impaired gas exchange and um reduced um TLC O and um if you were to chest X ray, someone with um I PF it will show bilateral ground glass calcification. Um They never usually really show you a chest X ray of someone with it, but that might be like what is in the stem and then underneath it will be what is your answer? And then um if you really wanna find out if you're worried that someone has I PF the best investigations to do is CT and this will end up having like a honeycomb appearance through it. So how do you manage someone with I PS? So, pulmonary rehab is really important. Again, stopping smoking. A lot of these patients will have long term oxygen therapy. And then if suitable, there's like a range of um things criteria that can decide whether they could get a lung transplant. Um But this, that's not really that high yield stuff. So if you just learn the things at the top of the slide, it should be grand. Um They love asking a question about um differentiating that causes upper zone and lower zone fibrosis. So, um I think this is like a good way mnemonic to use um to help you remember which ones which um or you could just learn what causes basil and then, you know, if it's not one of those, it'll be an ethical one. Um So yeah, you probably see more of people with um basal fibrosis because like rheumatoid arthritis, really common disease, um asbestosis. Um It's idiopathic one as well and then drug. So if someone has um you know, a history of having rheumatoid arthritis and they are on methotrexate for years, then um this would be fairly common um to happen to those patients as it's just a side effect. Unfortunately. So if you just learn that wee slide, so now we'll go on to pneumothorax is so step one. So people with respiratory conditions, they kind of all will present with very similar um symptoms. Um you know, they'll be short of breath, they might have some chest pain. So it's kind of like you'll need um a chest X ray usually and some bloods to then be able to decide what is going on with the patient. Um And also having an actual clinical examination of respiratory patients is really useful. Um You know, someone with the pneumothorax will have reduced breath sounds, um wherever their lung is reduced and they will have hyper percussion as well. So, um so if someone has a pneumothorax, um this has recently changed guidelines in 2023. So, um this is the new thing for you guys to learn. So, step one is like is the patient symptomatic. Um And if they have a pneumothorax, but they aren't, don't have any symptoms, they're not short of breath, they're not having any chest pain. Then you just do conservative care and review them as an outpatient in two or four days. So you don't touch it. Whereas um if they are symptomatic, then you need to decide, do they have any high risk characteristics? So that would include um tension pneumothorax, which will come on to um if they are very hypoxic. So like less than 92 if they have um bilateral pneumothorax, and then if they have any underlying lung disease, which would include COPD asthma, um I pf like any of those, then you would be thinking, ok. Um We are going input this as a high risk and then if they're more than 50 have a significant smoking history or if you're concerned that it's a hemo pneumothorax. Um So if the answer is yes to high risk characteristics, then um safe to intervene, safe to intervene. Essentially means um is it more than two centimeters laterally on the chest X ray or any size? And CT which they can access with radiological support? And if the answer to that is yes, then you're inserting a chest strain. Um And then that's all you need to know for high risk. Um if they are low risk, um and it's safe to intervene, then it's all about now patients priority. If they don't want a procedure, then it will be conservative care if they want rapid symptom relief, um then they will get an ambulatory device inserted. And then if they want um like short term drainage, then you will do the needle aspiration and um if that doesn't help it, then you would do a chest drain. Um So discharge advice for these patients is stop smoking and um that really significantly reduces their risk of having pneumothorax. The standard like patient that gets the pneumothorax is like a tall young male who smokes. Um And if you're like in any cardiothoracic clinics or anything like those will be the young people that are coming in. Um And that will be how they're describing in M CQ as well. So you can fly um one week post a chest X ray and they can never ever scuba dive again. Um And then you need to just review some chest x rays on pneumothorax. Um If you look up them on radio pedia or whatever that will like help you recognize it, just make sure whenever you're looking at a chest X ray that you always like look out to the edge, actually see if there's lung markings. If there's not, then you should think. Oh, is this a pneumothorax? So then tension pneumothorax, this is like life threatening. Um So if someone comes in with a tension pneumothorax, they're gonna be really, really short of breath, they're gonna be in a lot of pain. And um the clinical exam is so important. So, if you are checking, um whether the tria is central and it isn't, then you need to have a listen to the chest and um insert the cannula into the second intercostal space in the mid clavicular line in the effective side. And then the chest drain will be placed after someone with attention to my thorax should never ever get to the stage where they're actually getting a chest X ray. Um because this causes like significant um compromise on their heart and um you need to like relieve the pressure as soon as possible. So, if there's any clinical suspicion of attention pneumothorax, then that is the management that you would do um the signs on examination or hyper resonance on percussion, diminished breath sounds on the effective side. Tracheal deviation, um which is normally away from the side of the pneumothorax. And then um in like really, really severe cases, um you'd be worried about hypotension and tachycardia as well. Um And normally like these symptoms will come on really quickly, um and their chest pain will be more whenever they're breathing in as well. Um So this is also something that like you should always have um senior people helping you with um as well. So now going on to pleural effusions. Um So this is a chest X ray of someone with a pleural effusion. So, um this is a not very subtle pleural effusion sometimes. Um they can be actually really hard to spot and it's kind of just that there is blunting um of the costophrenic angle. Um So that's why it's always important in your chest X ray diaphragm part that you look at the costophrenic and the cardiophrenic angles to see if there's any evidence of like a meniscus line, which is this line here, which just shows that there is like fluid present. So like what features would someone with the pleural effusion come in with? Again, the standard responses, shortness of breath, nonproductive cough, they might have some chest pain. Whenever you examine them, there will be dullness to percussion. You won't really be able to hear any breath sounds over the pleural effusion and there will also be reduced chest extension um on the side of the pleural effusion. So this comes up a lot as um an M CQ. And mainly the main thing is you want to work out whether it's a transudate or an exo cause. So I've always thought of it as transits um or the failures. So the three hs so heart failure, hypoalbuminemia, which is liver disease, nephrotic syndrome or malabsorption or else hypothyroidism. Oh And also normally, if it's a like transit, it will be a bilateral pleural effusion, but it's not always and then um exudates will I use the pneumonic pints to remember it? So, pulmonary embolism, um infection. So, pneumonia is the most common cause of like an exudative pleural effusion neoplasia such as like cancer. Um, so you are concerned if someone comes in um and has a big um pleural effusion on one side and you know, um they don't have any infective symptoms or anything. Then you need to think, oh, this is cancer TB can also cause it as can um S la in rheumatoid arthritis. So trans essentially means that it's less than 30 g per liter of protein, an accident. It just means that there's more than 30 g, a liter of protein. Um and the investigations that you want to do. So someone comes in and you want to get a chest X ray. The most important one to do is a pleural aspiration. And there's um these five, these, yeah, these five things that you need to send the fluid for. So you want to send it for ph um and if that is like really low, then you might be thinking like this might be a lung abscess instead and it might be drained um protein levels to work out whether it's um exudate or transudate LDH cytology for the cancer and microbiology then um as well for infection. So lights criteria. This is more of an M CQ thing, but it also is actually what they use in clinical practice. As well. Um But if the protein level is between 25 to 35 then you apply these three rules. So essentially, if the accident, it's actually if the pleural fluid protein divided by the serum protein is more than naught 0.5 and the LDH um is more than naught 0.6. And then if the pleural fluid LDH is more than two thirds the upper limit. So essentially how I remember it is just if you work out that the protein is really high, it's an next day. If you work out that the LDH is like more than naught 0.6 it's also than an exudate. And then um if whenever you're like doing your fluid aspiration and it's perent, um which means like it's like yellow or looks like it should be clear. If it looks odd, then a chest drain will need to be inserted. Um And the same with the PH is less than 7.2. Often patients with pleural effusions um might end up needing to get a chest X ray to clear the fluid. But if it's um because of like a failure problem, such as heart failure or liver failure, then, you know, you need to sort out the actual cause of it, there's not going to be much point in inserting a chest because you haven't actually solved the, the cause of it. So um that I don't really think will come up, but lights criteria will and what they need to send off the pearl aspirate and then um to be able to work out if it's or transit. And then if you just make sure you learn their three Hs and pints as well, um And they could give you this chest x-ray potentially as you ay this year and you might have to interpret it and then they might be asking you some questions. So those would be dancers. So um, now I will go through pulmonary embolism. So the symptoms like someone with a pa could come in with would be again, shortness of breath. Um, a common symptom would be like chest pain whenever you're actually like breathing in. Um these patients uh might have some risk factors in their history such as having um cancer or um if they are on a female, on the combined oral contraceptive pill, um, and then recent surgery. So this is kind of the criteria to rule out um a pulmonary embolism. So, if all of these are absent, then it's really unlikely that they have a pe. Um, but these are all sort of the questions that you want to be hitting in your history if you're concerned about someone having a pe. So obviously, you can't ask about like heart rate and oxygen sats like that, that's a clinical thing. But you can ask previous DVT or pe recent surgery, are you coughing up any blood? Do they have unilateral leg swelling? And then any, er, in use. So, after you do the, um, PE RC, then, um, say if they have one of these positive then that's whenever you go on and do the well score. So, um, these are the things that get you points for the well score. I don't think you need to learn it off by heart or anything. I just think you need to apply kind of, um, like smart thinking to it. So, you know, if they've had a previous DVT, you'll be thinking, ok? Yeah, they're likely if they've had surgery, essentially, if they have two risk factors, you're thinking ok, they have probably scored two or three risk factors. They've probably scored more than um two. So you'll be treating them as a pe um and then any clinical signs always gets you points and then alternative diagnosis. So like most people with a few risk factors, then they are going to be scoring highly in the wells. So after you calculate the two levels, p well score, you essentially go down these two routes. So if your well score is more than four, which is like there's no alternative diagnosis that you think it is and they literally have like one risk factor, then you're giving them more than four. So you want to give them, get them an immediate CTPA. Um If they have, if it says in the um M CQ, we block thing that they have um really bad renal failure, then you might not be, do a CTP because the kidney function might not be able to hack that. So instead they would um get something else. I can't remember it now, but it's on past med. Um And then if the C TPA is going to be delayed, then you start them on intermittent anticoagulation, which is, um now do for everyone except people with severe renal impairment, which um only counts if it's less than 15 mils per minute. And then you would give them no molecular weight heparin, but essentially most people can be treated with do. And if they give you that renal impairment below, then um treat them with the low molecular. So C TPA positive, then their P is diagnosed TPA negative, then you would get an ultrasound of their um leg and then, well score less than four, you would get them ad dimer result. Um And then if D dimer is positive, then that would give you reason to do A C TPA. If D dimer is negative, then consider alternative diagnosis and stop anticoagulation. So kind of for these um how I always thought about it, this comes up all the time. Um It more than four get their C TPA any delay and it's more than four, you're starting them on A do A. Um And then on the other side of it, if it's less than four D dimmer positive, then you want to get them A C TPA, again, if it's delayed, think do and, um, if the D dimmer is going to take more than four hours then, and you start them on a DOAC because you can't really do much harm by starting on a DOAC whenever you can just stop it. Um, and then, but you might do more harm if you don't start them. So, and then if the D is negative, that's fine, you know, it's really unlikely to be a pe and then another diagnosis will be considered. So another question will always be like, how long will I be on this blood thinner for? So if you can find a factor why they're on it, such as like they've recently had surgery, they've had a recent COVID infection, they have cancer. Um then it'll be three months if provoked, six months. If unprovoked, you can't find any reason. I also think it's six months if you have cancer as well. Um As they go more lean on the safe side with those patients. So now like what type of rasp things can come up in your Aussies? So interpret chest X rays is the number one, I think it has literally come up every year um for like the last 10 years. So previous patients are pneumonia and chest X ray management. And then last year they got pulmonary function tests and a chest X ray as well. And then the second most common conversation would be a respiratory history um sorry exam. So for this one, just be really careful like a fully read the instructions outside if it says an to your chest, they are not expecting you um to do the posterior and they are just expecting you to do the anterior test and nothing else the same with the posterior. And then if it's like respiratory exam with systems, then they'll say respiratory exam and you will need to do be looking at the hands and um everything else as well. If it is posterior exam only, you need to make sure that you still check the tea on the front, the apex beat and um for any heaves as well. Um As that's all part of the exam, even if it says posterior, that's part of it. So what rasp history could come up co PD? Um So like you need to ask about your smoking and your previous infections, um asthma, make sure you ask about triggers and like the atopy that we were talking about. So hay fever and asthma, then lung cancer could come up. And it would be the red flag features. We actually got in our finals this year uh TB history and they love to kind of like repeat final year sessions as third year sessions. So our ay feedback has just went up, I think or we will be going up soon. So have a wee read of that. It'll obviously be like a lot more condensed for you guys because you have less time. Um But yeah, for like TB, if someone's presenting with like night sweats, they have a travel history, they've ever had any contact with TB before. You're kind of asking your questions and like, it's not any of the common ones that, that you'd normally think, you know, like loads of shortness of breath or anything, then it could be TB because they did a lot on us and then explanation of asthma is co PDI think is really unlikely. It's more of 1/4 year slash final year topic. Um But they could be mean potentially. And then my top tip for Aussies is the social history for respiratory is so important. Um You kind of, everyone always kind of thinks like social history. Oh, but like you only in a, I don't know if you've seen the mark seems but like you only get like 10 marks for actually like the presenting complaint or whatever. And then all your other marks are in your um like past medical history, family history, drug history and social history. Social history is what you're going to end with. So it's what the simulated patient last remembers you talking about. So um you want to make sure that you're coming across as a really caring doctor. Um You definitely always want to ask about smoking and respiratory history. Um It's so silly, but you do get Mar in it for Queens for Travel history and if they have any pets, specifically birds. Um, and then always, always ask about like, how are these symptoms impacting on your life? How do you manage at home if they're old? Um, like if they have people at home with them and then, like, ideas concerns expectations as well. So these are just a few questions now that we're gonna go through. So, um, I'll give you, like, um, 30 seconds to read through that and then um you can just have a wee think of what you think the answer is and then I'll go through it. OK. So this question. So 65. So I highlighted the 65 you know, it's not gonna be asthma um if they're 65. Um and it's a new thing. So two year history of progressively worsening, shortness of breath on exertion and a dry cough. So, within that there, you should kind of already be thinking to yourself. Is it? I pf um he has no hemoptysis. So you're thinking, ok, lung cancer less likely does not smoke or drink again. Lung cancer less likely worked in an office for the last 30 years. So probably doesn't have any occupational cause of a lung disease. Pulse is fine, respiratory rate is fine. He has no temperature on auscultation, fine crackles are heard over both bases and he has finger clubbing. So based on these, what is the most likely? So it's not asbestosis. He has literally no history of that he works in an office, hypersensitivity, pneumonitis again, works in an office. Um Like usually it will be triggered by more things. Um like not by exertion. CO PD does not cause finger tubbing. Um So, you know, it's not that and then they haven't had any weight loss. This has been going on for two years. It's not non small cell lung cancer. So by thinking like that you can rule out for the answers. And then I PF is the one left and it's also the one that is most likely anyway, if you were reading the question. So this is question two. So again, highlight um their age. So 55 history of hoarseness. So this is one of our red flag features, which is lasting more than two months. Again, if it's more than three weeks, we start having no alarm bells going on. Um He's been feeling more tired. So again, something you'd be asking about in your history thinking long time cancer and has lost some weight at the same time again. So really worrying he is a previous smoker, but he has a chest X ray that was clear. Um So this question is asking which investigation is likely to be diagnostic. So it's not asking for the first line investigations. So sometimes, you know, questions can really throw you if you read it quickly. Um So it would be like really easy to have put down chest X ray. Um or potentially like ultrasound neck if you're worried about the hoarseness, um that neither of those would be diagnostic. Um The thing that you're most likely thinking is ct chest. So the hoarseness um in lung cancer is because it um sometimes you get tumors that press on your recurrent laryngeal nerve. Um So those are called panco tumors. Um And that's why it can cause hoarseness. So you might be thinking, oh, is this like an ent thing like with the MRI head and neck and like the throat exam? Um But with that history of smoking, two months tired, lost some weight, like lung cancer is more likely. Um it's a more common cancer, it's more likely. So you're thinking ct chest. So this is the next question. Ok. So a 55 year old gentleman has had some pulmonary function tests carried out after presenting to the rest clinic with breathlessness, his results are as follows. So 60% predicted 65% predicted post salbutamol F EC is 95%. His fev one over F EC is showing an obstructive picture was the most likely diagnosis. So with his age, his symptoms, the obstructive, um you're thinking asthma or CO BD and then because of his age, then you're thinking, ok, he's 55. It's breathlessness, there's no triggers. Um He doesn't have any like chest tightness. Um It's more likely to be COPD. Um Pulmonary fibrosis shows a restrictive picture. So that's why it's ruled out and um sarcoidosis doesn't present like that. Um and neither does pulmonary edema. It would be more um and wouldn't give you that spirometry picture. So two questions left. So this is just the we carb question I was could come up. Ok. So I kind of highlighted just um like each one that gets him a point. Um So 67 more than 65 there you go. There's going to be one. heart rate is 100 and six. It's not included in the curb score. Respiratory rate is 34 more than 30. There's another point and then his BP um this always used to catch me out like just look at the systolic and diastolic because I'll just try and be sneaky. Um So it's three because three is less than seven. And then um he's not like there's nothing he's alert and orientated. So you're not concerned about any confusion. So, final question. So um in this, it's a young patient 34. So complaining of um shortness of breath um mostly at work um and occupational asthma is what they are suspecting. So which one of the following is the most appropriate diagnostic investigation? So chest X ray doesn't tell you anything to do with asthma. Um A feno is more diagnostic for like asthma that's there all the time occupational asthma, the way you want to be able to diagnose that is to be able to show that the peak flow measurements at work are significantly worse than they are at home. And that there's a difference there and variation then. So that's what shows he does occupational asthma. So he had just read that and had read asthma, then he might be more likely to put feno um specific iga and skin prick tests aren't um diagnostic. So the one here is serial peak flow measurement. So today haven't been able to cover um interpreting pulmonary function tests or ABG S. Um would recommend you guys to kind of get into your head like type one respiratory failure, which is like low um SP O2 and normal CO2 on an I BG and then type two respiratory failure is low po two and high CO2. Um And that's kind of like the most important thing to know about ABG S. Um And then like there's different causes for type one and type two respiratory failure. So just something else to look up in your own time and then like chest x rays, like you guys are going to get one. We've got three, we got one every single year of our A. So um and like when it's kind of just like repetition, the more you do them like the better you guys will get. Um So good luck everyone. Um If you have any questions at all, you can unmute or else just ask in the chat. That's grand. Um That's great. Thank you. So, much. Um I'm just gonna send in a wee feedback form into the chat there. If you could fill that out, that would be great. Just so we know, you know what you find useful and stuff. Um And then also, then a couple of things that haven't been covered, we'll hopefully get them covered in the lecture as well. Um Yes, thank you very much and thank you for joining no problems.