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Production today today, we're going to go to respiratory um part one. So this is the history taking session. And what I've tried to do is I've tried to condense um as many different conditions into two broad um presenting complaints for respiratory. I'll try and talk you through the thinking process which I follow when I'm trying to take a history from the patient's and just really see how, how like how we can tease out more and more information, get to the differential diagnosis and sure the examiners that we're thinking clinically, this is especially relevant for the year fours. But if any year to does it will really um kind of like draw you apart from the rest of the pack kind of. So trying to show them your thinking clinically, you're thinking about the different diagnoses that will be the main point and the main message from the session. So we're gonna cover cough, we're gonna cover shortness of breath and we're going to cover a sample case at the end which is going to be interactive. I have some questions and we'll see how it goes from there. So the first cases cough, let's say a patient presents with the cough immediately in the risky. I think. I'm quite sure most if you've been told to do this before as well, you need to start thinking about questions outside of the station. So you just read the prompt, you read cough in your mind, you should structure out how the conversation is going to flow. For example, when I think of a cough, I first think, okay, I'm gonna introduce myself. I'm going to ask him an open question. Always start with open questions. What's brought you in today? How can I help you today? Let the let the patient give you as much information as they can. And once you have started with the open question, maybe one or two open questions, then start sieving down into asking more specific questions to try and see what the diagnosis is going to be for a cough. The first thing which comes to my mind is I have to ask for him. Octus iss because they're going to be red flag conditions such as lung cancer, cubical osis, which will cause hemoptysis. And if I don't ask it, it might be, I might miss some major life threatening diagnosis. So for me, cough means hemoptysis iss productive or not productive. Do they have a fever? And then another main question is for how long have they had the cough? If a cough has been going on for, let's say two years and they're producing white sputum for the last two years. Then I'm thinking okay. This is more of a chronic condition such as COPD if it was in acute cough started two days ago. Now I have a fever, I'm thinking infection. So just from uh from outside the station, when you have the two or three minutes, just think through some of the main questions to ask and how you can break down the station into the different types of diagnoses. So these are the set of questions, obviously, it's not exhausted. But these are the main questions you should be thinking of asking a patient who's coming with the cough. When did it start? You want to see whether it's chronic or acute? Because the differential list is very different for the two chronic. Once again, like I mentioned COPD, uh would be one, a classic example of a chronic cough. You'd be thinking about potential malignancy is if it's been going on for six months or so. Whereas if it's acute, you thinking about the infection, you're thinking about pulmonary emboli things like that. Has it been there constantly or does it come and go is not a good question to ask? Has it got worse over time? That's a very important question to ask. And I'll explain to you why it's important to ask, let's say, for example, a 55 or 60 year old patient who smoked throughout their life says that, yeah, I've been coughing roughly 4 to 5 times a week every day. For the past two years I've been producing a bit of white sputum. But suddenly for the last five days I've been coughing a lot more dispute. Um, color has changed. Can anyone on the chat? Tell me what, what they think is going on in that patient? So, they've had a cough for two years, produced white Sputum. But for the last five days or so, they're producing yellow sputum and the cough has gotten a lot worse and they generally feel a bit ill. Exactly. Exacerbation of their COPD. Brilliant. Why is it that for? That's why it's very important to say or ask rather. Has it gotten worse over time? Because then you can determine the exacerbations could be an exacerbation of COPD, could be an effective exacerbation of the wrong practices. So many patient's might have a long term cough, but seeing how it's changed in the last week or so, we'll be able to deal innate the diagnosis. And what's important is that in an infective exacerbation, you need to treat that infective exacerbation first stabilize the patient and then go on to treating the long term underlying condition of the patient. So, very important to ask for any symptom, not only for a cough, whether it's gotten worse over time or not. Are you coughing anything up or not productive or nonproductive, essential dry coffee, thinking down different lines, viral infections. Are you thinking about pulmonary fibrosis, productive coffee thinking about COPD bronchiectasis iss pneumonia completely different. And the main question, your twos, your fours both have to remember this. Have you coughed up blood? Because if yes, you're thinking about some sinister diagnoses and always when you're asking about a systems review, my personal opinion, this is not restricted to respiratory, but for any system is just start off by saying, have you noticed anything else associated with the cough? It's an open question you're not going directly down into. Do you have headaches? Do you have chest pain? Do you have palpitations? Instead? It's a nice and open question, giving the patient sufficient liberty to talk about what their main symptoms of what they're feeling at that moment. And often you'll find even in your risky Eroski that the patient gives you a lot of information that you need. If you go straight into asking about, do you have chest pain, do you have palpitations? What might happen is you might ask a certain list of symptoms, but you miss out some other ones and the patient won't have the time to talk about those and that might change your diagnosis and take you onto, onto the wrong course. So my opinion, even when you're starting the systems review, start with an open question. Have you noticed anything else? And if you do not get sufficient information or you don't get the information you require, then go into the specifics. Like, do you have any shortness of breath. Do you have any chest pain, fevers, night sweats or weight loss? Always very, very, very important questions to ask, especially in a cough history. Can anyone tell me why it's very important to ask these three in a cough history? Malignancy is a good shout. There's another very common TV. Absolutely. Very, very important to ask about fever, night sweats in weight loss. What I did for my s keywords, I actually asked this for almost every presenting complaint apart from maybe orthopedic presenting complaints because fevers, night sweats and weight loss, you can get them in a myriad of different conditions and the constitutional symptoms. If you do have these symptoms, it might mean that something serious is going down, going on. So I find it quite useful to ask it for most of my history's any nausea or vomiting. This is a very interesting question and rather an open question once again, something I ask for most patient's. But let's see, a patient comes in with a dry cough and they say that, yeah, occasionally they get this burning sensation. Um, but yeah, they have this dry cough and they're really worried. They don't know what's going on. What would you, what would your top differential be? Then a dry cough, a burning sensation in their chest guard. Absolutely. To never forget about the other system causes of a cough. One of the most common mistakes made in is Keselowski's is that you go in thinking or cough means respiratory nope, it might mean cardiac. If the patient has like for example, leg swelling, it might mean that he has heart failure and heart failure is often associated with the cough, which might even be productive. Occasionally heart failure, patients', especially systolic heart failure, patients' get a frothy pink sputum. So it might be heart failure, pulmonary edema due to heart failure, the patient might have gored. So these are important things to think about infectious diseases. It is TB so always think about the other systems as well in your systems review and rule them out. Many people like going from head to toe. So they ask everything in the system review from headaches, visual changes, cough to chest pain. I think that is still acceptable for your two's. But in my personal opinion, for your force, it needs to be a focus system review based on the history of presenting complaint, based on the presenting complaint. What do you think the main differentials could be? And your systems review questions should be targeted to finding out more information with regards to those differential diagnoses. If you go from head to toe for presenting complaint, which doesn't really, it's not really associated with. For example, visual changes, it might not look as good, especially for your photos for your twos. If you're more comfortable with the head to toe at this stage, that's still all right. But for your fours, definitely try to keep your systems review focused to the presenting complaint and the history of presenting complaint. Past medical history often is set to ask for respiratory diagnoses. Very important. But what I like doing once again is starting off open. Do you have any medical conditions? You see your G P four? Have you been hospitalized recently? Have you had any surgeries? Usually if they do have a major respiratory diagnosis, they will definitely tell you that once you ask the open question, if they don't, then ask it specifically. Have you ever seen a lung consultant or chest consultant for anything? Have you ever been hospitalized for any chest related conditions? You can go more specific, but once again, start open, then go to the specifics, drug history. Once again, very important for a cough history. What medications are you taking currently? Let's say a 55 year old man has high BP has been taking medications for his BP comes in with a dry cough which is irritating him. He's not, he doesn't know what's going on. He doesn't have a fever. What are you thinking about them? Is it a bit is perfect? But I just want to highlight here that the main quitting is you need to ask about the medications. Otherwise you might not know what the diagnosis is, any herbal remedies. Many patient's take herbal remedies and we they may or may not have an effect. They may have an effect on the medications you're going to prescribe to the patient. So very important to ask many of, you know, Saint John's wort is an enzyme inducers. If the patient's taking Saint John's wort need to recalibrate the dosage of the medications. So very important to ask what herbal remedies any over the counter medications. Very useful to ask once again, generic. Any presenting complaint, any history always ask herbal remedies over the counter medications and for both your twos and you force drug allergies are an absolute must. You have to have to have to ask for drug allergies. Family history might be quite important, um, percent respiratory conditions but social history, I really want to focus on the social history here. Do you smoke? Very important to ask as we all know many respiratory conditions are West Center linked to smoking. So you have to have to ask for smoking. Pakalitha is very important. I see someone's asked in Pacquiao. Yes, you will have to calculate Pacquiao as the easiest way to calculate. A peculiar is ask the patient, how many cigarettes do they smoke a day? And for how many days, how many years have they been smoking those many cigarettes? Let's say a patient says I've been smoking 40 cigarettes for the past 10 years. The way to calculate the pack years would be to divide 40. That's the number of cigarettes to having payday by 20 that's two multiplied by 10. So that's 20 pack years. Once again, the formula I'll write it down once again on the chat as well. Is the number of cigarettes the person is smoking, divided by 20 multiplied by the number of years. They have been smoking a quick risky tip for me when I'm nervous when I'm agitated and I'm thinking about different stuff. Math often fails me. So I, I may not be able to do the quick, uh, small, uh, like the number of pack years, um, quickly, but I have a rough estimate that. Okay, let's see, a patient smoking, 60 cigarettes per day, extensive smoking, uh, smoking history, 60 cigarettes a day. And then you can calculate the pack years later on if need be. So if you can't calculate the pack years immediately when you're reporting back to your examiner, don't get startled or don't get worried about it. Just say that you think it's an extensive, uh, smoking history, 6 60 cigarettes per day or 50 cigarettes per day for the last 25 years is sufficient as well. But if you can calculate the back years looks very slick. Where do you work? We'll come back to this. This is very important. And I want you to remember this question because I will come back to it at some point during my presentation and I want you to remember it, but it's a very, very, very important question to ask another generic question which I think everyone should ask in all histories is who's with you at home and is everything all right, at home. Well, come to shortness of breath, but a common concern is when people get very short of breath, they get concerned, they won't be able to carry out their activities of daily living. So you need to know who's there to support them at home or are they caring for someone? In which case, when they've come into hospital, you need to ensure that adequate care in the communities provided to the person they're caring for. So these are the kinds of holistic care approach is if you bring into your risk, is it will show the examiner that you're really thinking about the patient as a whole, rather than just simply a diagnosis, any pets extremely relevant to a respiratory history. Can anyone venture? Why pets might be quite important allergies? Asthma? Absolutely. Absolutely. I remember when we were practicing, excuse for in our escape practice group, one of the station's was uh patient's are developing asthmatic symptoms and they recently bought a new pet. Very important to ask, especially if you can, if you're thinking about something like asthma or um asthma or allergic rhinitis, something down those lines. If there's any change to their home atmosphere, any new pet will be a very good question to ask. You can even ask about um their home condition. Is it damp at home dampness? And most bill that was one of the commonest causes of asthma exacerbations. Absolutely. Silicosis. But fancy, his lungs are all good answers and their possibilities. So, pets, quite important you can ask about whether it's damp or not at home. That's another question you can ask and long haul flights. I'm quite sure everyone's familiar with that. It's, you want to, if you're thinking about an acute cough, hemoptysis, shortness of breath, chest pain, you think the pulmonary embolism, you want to ask whether you want to figure out whether it's provoked or not provoked. So other questions you can think about if we think it's a pulmonary embolism or did the patient have surgery recently, which would come out in their past medical or surgical history or do they have any inherited hypercoagulable condition? Have they had long haul flights, a recent travel for which they were sitting for a long period of time? All of these are good questions to ask if you think the diagnosis is pulmonary embolism for second years. If you just keep it in mind that this is a question you should ask. That's good enough. But for 40 years, definitely tailor the questions according to your presenting complaint and symptoms. So far, ideas, concerns and expectations, extremely important and part you're all medical schools drill this, you need to ask them what they're concerned about the way I like doing it. Is, is there anything you're concerned about in particular? Do you have any idea of what might be going on? And is there anything else that I can help you with. I like to end it that way. I know it can be quite artificial at times, but that's the way I incorporated it into my ski take risky and history taking. So if you find that useful, please do use that or while you're practicing, I'm quite sure you'll come up with a method of your own. So, in my mind, cough histories, productive, dry and productive and thinking pneumonia, TB COPD bronchi actresses, heart failure, dry cough. I'm thinking viral infections very common. Many of us have seen it during COVID during the flu season, many people get a dry cough which might eventually become productive if they get a secondary bacterial infection. But often it starts off with the dry cough, pulmonary fibrosis, classic dry cough causing medication related and gord. So I have clue. I think thinking about these diagnoses, especially for 40 years, but for second years is quite important as well. It's useful for you to know, you don't need to know all the differentials. But as long as you know, some of them that productive has a different list. Dry, has a different list and never forget him. Octus iss key message from a cough history is hemoptysis has to be asked and lung cancer TV. In very severe pulmonary embolisms, you can also get that classic hemoptysis picture. So that's the way I would think about going in the history. So once you start off the history, ask them productive or dry. And once you know that it's whether it's a productive cough or a dry cough, then tailor your questions according to differentials, it could possibly be, always ask about hemoptysis, summarizing a history, summarizing a history, everybody but a person will have their own method of doing. So this is just a generic framework which I have tried to bring out over here and it's something that you can try and incorporate. But I'll just go through the main principle. The main principle is that you should provide the examiner with sufficient information for them to be able to know what the diagnosis most likely is. What the next steps of investigation should be as well as the next steps of uh management. Summarizing a history is something which I learned in the wards. And I think one of the registrars, the way he explained it to me was the best explanation I've ever gotten. Think about it as if you're explaining or like talking about a patient summarizing a patient basically to your consultant who's going to make the final decision of what the next steps are. You don't want to give a lot of information which is difficult for the person to take in in a short span of time. Instead you want to give the important relevant information which will make them decide that okay. This is what's going on. For example, let's take a random history the way I would present it if it's a cough history would be, I took a history from dash, dash a dash or a 75 year old man who came in with a cough. So I've given the presenting complaint the next thing, the cough started three days ago. So it's an acute cough. It's not a, it's not a chronic cough, important information. It has progressively worsened over the three days. Okay. So, the patient's clinical status is deteriorating. He's coughing up one egg cup a day of yellow, green colored phlegm. I've quantified the amount of sputum he's coughing up. Very important. I've given the color yellow green indicates infection a change in management. It gives us a direction of the differentials. He describes having rigors, rigors a shiv is and has recorded a temperature of 39.9 degrees centigrade. So obviously, the patient scenario, I'm describing, the patient has a good, good, good understanding of what's going on. But many of the patient will say that he has have been shivering a lot more recently for the last day or so, which would mean that they're having Rikers from the history of presenting complaint. It's quite evident that this patient has an infective picture I've given, I've drawn that image in the examiners mind that this patient has an infective condition and infective respiratory condition. There is no weight loss, night sweats, chest pain or shortness of breath, important negatives. These are stuff which could twist the direction. For example, if she had night sweats. I would think about TV. Perhaps very important over here. It will also be very important to say whether or not they have had hemoptysis. Iss just saying that no, there was a patient says there's no hemoptysis would be good enough to mention here past medical history, very important because medications might change. For example, diabetic patient's often they have, uh during infective periods, they have an increase in their blood glucose levels. You may need to titrate medications, especially their insulin dependent. So very important to ask. So just mentioned past medical history is significant for hypertension BP, both of which are well controlled, the medications, the person takes Ramipril Metformin as prescribed by the G P over the counter medications and the drug allergies over here. I've given the back here as well and the fact that he's an ex marine so that there's no occupational cause of this patient's condition and currently lives with his wife at home and is well supported. Very important to add that final statement in because it tells the lead clinician that okay, we don't need to rush into sorting out community support for any of the patient's family members. What is he worried about useful thing to add in? And then you go onto my top differential. I always like ending my summarizing of the history is based on the, based on the findings or based on the history. My top differential is that this patient has a pneumonia. However, other differentials I'd like to rule out would be an effective exacerbation of this patient's perhaps underlying COPD as well as lung cancer. A quick tip. I'll give you here. It's often difficult to think about three relevant good differentials. But one of the methods I was told to, if you can't think of three obvious differentials is think about the one which is most likely is. So you talked differential one which you absolutely don't want to miss out. So a malignancy or something which if you do miss out now is potentially life threatening. And three is a wild one or like a rare one which could be or could not be. So things like psittacosis or boy fancy as long might be in that category. So if you can't think of three obvious differentials go for the top differential, the one that you think it is most likely going to be one which you wouldn't want to miss and one which is quite rare, but is a long shot. Basically, the next step of any ST station would be to ask for your investigations. Always follow a structured approach of bedside blood's imaging and special test. Different universities can lock their risk is differently. But I'm part I can say for certain, for cardiff, if the patient is acutely unwell, don't start by saying it at the bedside, I will start by doing a respiratory examination, an acutely unwell patient, you don't you start off with the A two E approach. It doesn't matter what the examiner has said. Typically, the examiners will work the questions by saying, how would you manage this patient? Because if the patient is acutely unwell, you should straight go into and I would like to stabilize this patient using an A two E approach. And many of your investigations will actually be done during the A two E approach. However, in most cases, when you're asked for the investigations start off simply, I'd like to take a full set of basic observations. I'd like to do a respiratory exam. If you're suspecting asthma, I would like to do a peak flow. And an E C G N E C G pretty much goes for any patient through the door in hospital will have an E C G because pommery embolism, you can get sinus tachycardia pneumonia often can trigger atrial fibrillation. So E C G is something that you can generically safer. Almost all presenting complaints. A full blood count, very important shortness of breath. For example, if a patient comes in with shortness of breath, the full blood count will be to see check whether the patient has anemia or not liver function tests and your urine electrolytes. Once again, very common, quite generic. Um Any medication you're gonna give can potentially affect the kidneys or deliver. So you need to know what their baseline function is like arterial blood gas. Now, I want to stress stress here a bit for, for their rather conflicting opinions regarding this, for your tools, just stick to A B G for your force. If you suspect this patient has severe respiratory distress, definitely go for an A B G if you just want to ensure and just want to double check what their blood gases are like. You can consider A V B G because of E B G is um less painful. But if you want to be safe and A B G is, for example, in a patient who has an exacerbation of their COPD, they're quite hypoxic and severe respiratory distress. You want to do an A B G, never forget an A B G for most patients who have come in complaining of severe shortness of breath or respiratory distress because you want to know what their blood oxygen level is. You can do A D dimer if you suspect a pulmonary embolism, but the world's court is below four and A C reactive protein, very important to assess infection and the C reactive protein actually guides management of pneumonia patient. So once the CRP often has a lag feel that once it starts dropping, it means the infection bed and in the patient is reducing, be the cough, the shortness of breath. A chest X ray will often be the first point of first imaging conducted and most respiratory patient's and then you can go onto the most slightly higher level imaging options such as a ct thorax. If you're thinking about lung cancer, staging high resolution CT for bronchiectasis of the pulmonary fibrosis. A CT PA. If you think the world score is about four in this patient, almost most definitely has a pulmonary embolism for people with a productive cough, being an infection, sputum microscopy culture and sensitivity. Very important to add in because you can tailor your antibiotic management based on the sensitivity results. If you think the patient has TB active TB, that is three early morning student samples of the gold standard. So once again, the the investigations will be more tailored upon what your differentials are. But a common pitfall is that you focus on your top differential and you didn't put any investigations for you. Other two differentials don't do that have it have investigations should not be focused only on your top differential. The special tests can be but at least the basic imaging, for example, a chest X ray will most likely rule out um cancer or so always ensure that you have one or two, any differential of given in. You have an investigation to rule that out or rule that in quickly going over how to structure management. So when you're asking when they ask you, how would you manage this patient, if the patient is acutely unwell, except ick is shivering, the BP is low. Once again, a two E approach sepsis, six are your life savers? That's what's going to get you the marks. That's what's going to make you pass that station any acutely and well, I can't stress this enough. A two E approach. Even if you think this patient has a septicemia secondary to pneumonia before you start talking about curb 65 go get the sepsis. Six done. If it's more of a community acquired pneumonia with the curb 65 score of one or not, then you can start thinking about counseling. The patient. Look, it is most likely is a pneumonia. You can tell them that you can prescribe them oral antibiotics for five days and ask them to, to ask for help if they have any flaring or any worsening of their symptoms. And always ensure, especially for those who are hospitalized. A chest X ray at six weeks to ensure that the consolidation has gone. But one of the common scenarios you might get in your risk is, is actually a patient who has a pneumonia was severely unwell was in hospital and you want to outline the management of that patient. So here you want to show of how much you know about pneumonia. So once you've talked about the 80 approach, the sepsis six IV antibiotics and everything and you've settled the patient down, you want to talk about the ongoing management, the ongoing management of that acutely unwell patient would be canceling the patient on the diagnosis, giving them some information leaflets, perhaps about what pneumonia is telling them that the fatigue and cough might last well beyond their discharge, pneumonia, coughs can last for all the way up to six months. So you need to let them know that they're going to feel fatigue. They're going to have that cough even after being discharged and always alert patient's for any condition for any history. What the red flag symptoms are, for example, for angina patient's, if you get chest pain at rest, call 999, same thing. Tell the pneumonia patient. If you ever get very sick again, high fever, you're shivering, seek medical assistance. Very important to safety net. The patient's, does anyone know why you need to do a chest secretary? Six months down the line. Absolutely ruling out cancer. One thing which will come to shortly is when you look at a chest X ray and you see that there is an pacification or a consolidation, it's a consolidation. It does not mean pneumonias to consolidation can be caused by cancer or by pneumonia. The clinical picture with the fever, the cough might indicate this patient most likely has a pneumonia and that's why we treat them for it. But it's very important to remember that we need to go back and ensure that the consolidation has gone to ensure that the consolidation wasn't masking an underlying cancer. Very important. The sixth week postdischarge chest X tree. That's something which can take you over the next line and get you some extra brownie points with your examiners, lung cancer. Another thing I want to stress here, many people feel very stressed. They need to start talking about the different types of chemotherapeutic agents used to treat the different types of lung cancers. For example, platinum based chemotherapy for small cell lung cancer. That might be useful for your final knowledge based SBA exams, but not for your escape. This is something which I realized during practice as well as after doing my skis, they're looking for a safe practitioner who knows what would actually happen in real life. In real life. A junior doctor would never be prescribing chemotherapeutic agents. So stick to the normal structure. Cancel the patient on the diagnosis. Cancer is a big diagnosis. They need time to settle down, they need information about it. They need to know about the right places. Cancer UK would be a good website to, to show them that maybe if you want more information, Cancer UK somewhere, you can find more information if you have information leaflets. Absolutely. They might need some psychosocial risks the board because a cancer diagnosis is a life changing diagnosis, smoking cessation support. Once again, something which can be said for almost all respiratory conditions if their family members around during the scenario and one of the family is doing well and that they have enough support that they need the patient may, it requires a respiratory physio and rehabilitation especially because if they have severe shortness of breath. So some physio might do them some good medications wise. Always mentioning that the multidisciplinary approach will be taken to managing this patient. So it shows that you know what's going to happen in real life and then you convention so that the patient may require chemotherapy or may be deemed fit for radio therapy. So you know what the potential management options for cancer are? Well, you're not getting into the nitty gritty surgical options. Once again, if the MDT deem surgery is possible, the patient might have a lobectomy where one lobe of the lungs is removed or a complete pneumonectomy, which one they have depends on the various variety of different factors and will typically be a thoracic surgeon guided decision. So if you just say that it shows, you know what's going to happen to the patient immediately, you know, the initial steps and you know, the likely trajectory the patient's going to follow. So it shows in examining your safe, you know what's going to happen and that is sufficient to score quite a high mark in your risk ease bronchiectases. Once again, a common cause of a productive cough, often these patients will come in similar to COPD with an infective exacerbation where the symptoms have gotten worse and they require treatment. But if it is just the chronic bronchiectasis management, the main thing is counseling them on what bronchiectases is on the fact that they will often have coughing and loads of sputum production and look off up loads of sputum, perhaps 2 to 3 air cups a day, encourage smoking cessation which can help reduce their symptoms, ensure they have at least annual follow up and respiratory physiotherapy and rehabilitation is very important for these patient's. They need to be known, they need to be trained on how they can help clear sputum from their airways and physiotherapists can train them to do so. So this is something which they should be offered. Medications are simple things there, you can off some inhalers, there is some anecdotal evidence that inhalers might help their symptoms. But the main things are annual flu vaccine trying to prevent that acute exacerbation, pneumococcal vaccine trying to prevent them from having pneumonia because they're at a higher risk of pneumonia. So things like these wrote set you apart, you can cancel them on the potential symptoms of an acute exacerbation by simply telling them that if ever you feel very feverish and your cough sputum changes color you. It is yellow green and you're coughing a lot more. Do seek medical assistance. A simple statement like that shows the examiner that you're thinking of what could happen in the future when the patient might need to take um support from medical professionals in order to prevent a severe deterioration in health. So always keep these things in mind when you're talking about the management of certain conditions. So now an all important part of this key would be or a ski would be data interpretation. Can anyone tell me what this chest X ray is showing any ideas on the chat? What this chest X ray is showing? I've got one direct message with the correct answer. Normal extra. Absolutely. The best way to do this, trust me is actually just googling a normal X ray maybe once or twice a week looking at a normal X ray up and down And then comparing it with pneumonia X ray or a pleural effusion X ray, the more you see normal x rays, the more your eyes will be adapted to it. And the more you'll be able to just say it off the mark that this is a long normal X tree. The long walking's are in that increase in this. This is actually a completely normal X ray. So like I said, this is just about day in day out, just looking at normal x rays and you'll be able to click as soon as you see one that okay. This is normal, how to read a normal X ray. I'm quite sure all of you have seen the ABCDE approach, but I'll go through it especially for the year two is on the cold. This is something which might be quite useful for you. Airway is the airway central or not. When I say airway, I mean the trick here and if you can see my cursor, this is what I'm looking at. If the trachea is deviated. It means something is going on in the lungs. If there's an absence of lung markings, and the trachea has deviated away from that side. And we're very worried because that patient has a tension pneumothorax. So always look to check where the airway is. You can look at the aortic knob, which is this, this knob over here useful to see. And in some conditions such as certain dissections, you might be able to see a very large aortic knob. But I would say don't, don't be too critical of yourself. You can't see their technology every time. It's not as important. The main thing is the trickier the breathing feels, then look at the breathing fields. I like looking from the right first and then the left. How do the breathing fields look like? Can I see any loss of lung markings? Can I see any consolidation? Can I see any fluid in the costophrenic angles? Are some of the questions I ask myself when I'm looking at the lungs, cardiac? Remember only if it's a P A chest X ray, only pee can uss cardiac size. If the cardiac or the heart size is more than 50% of the thoracic ratio, it means that it is cardiomegaly. So basically, if the heart is more taking up more than 50% of the space between end to end, you're thinking cardiomegaly and they're numerous causes, but typically heart failure due to dilation of the ventricles can cause cardiomegaly. And then you look at the diaphragms, flattened diaphragm. Does anyone know what condition causes? Flattened diaphragm? COPD? Absolutely. A person's our CF attention pneumothorax. The trachea is deviated away from the side because if you imagine a lot of areas coming in through the pleura and it's gonna push your airway to the other side. But yes COPD, it does cause a flat and pneumothorax. And then you look at everything else. You look at our their chest drains. Are there any tubings? Look at the bones, sclerotic lesion of the thoracic vertebrae, maybe seeing certain malignancies. If you can see any obvious bony fracture. Can you see any air tracking the soft tissues which you can often see in things like boreholes disease? So please, a two E approach is essential. Please refrain from drawing on the slides. Thank you. Please refrain from drawing on this slide. Thank you very much. So, moving on A two E, you've seen everything you've look at what's going on. You then move on, move on to the next slide for some reason. Sorry about this. I don't know what's going on. Let me try and share my slides again. Can you guys see my slides? Yeah, perfect. So let's have a look at some chest X rays. Can anyone tell me what this chest X ray is showing ap chest X ray for um a year to is very rare. You won't see an A P uh chest X ray. I've got loads of correct answers right ahead of pleural effusion. Absolutely. As you can see, this is the meniscus sign. So it's like if you imagine you pour water onto a glass, you can find that you can, you can often see the sign. I'm really sorry. Can you, can you please shut down all annotations somehow? Um Moving on Rohan. Do you just mind checking out the person who's drawing the on the test? I'm just in a minute now. I'm so sorry about this guy's um it's something which is uh something we should be under control. I'm so sorry for the disruptions to moving on then from here, what is this extra issue? And please be as specific as you possibly can be any ideas of what this chest X ray is showing guys. It's a difficult one. I appreciate. It's quite a difficult one. Good, good answers. Cardiomegaly could be, could be heart failure. There's loads of increased markings, lunk left the right. Um No. So what I do is in this X ray, let's focus on the right lung. Well, let's focus on what's happening on the right lung and this is a right upper lobe consolidation. Oh gosh, this is the right upper lobe consolidation. I'm really sorry for the disruption guys, but I'll try to be as specific as I can be. Um I'm trying to close the annotations, but I can't see how they, they're closed and he was, I'll just go on with the session. So why is this not right middle lobe, it's not right middle lobe consolidation because as you can see, this is the horizontal Fischer, the horizontal fisher divides the right upper lobe and the right lower lobe. So if you see that there's a consolidation and you can clearly see almost this border kind of thing. It's like there's no consolidation dropping down beyond this point. This is a right middle lobe consolidation. I'm really sorry. Uh Okay. I'll try and shut down the uh annotations. Thanks for the instructions. I did. Yep, I have disabled annotations for everyone. I'm really sorry for this guy's, I'll just explain this again. So this is the right middle lobe consolidation because you can see the horizontal fissure and you can see the consolidation is above this if you're ever presenting this in an risky or an Noski ensure you say this is a consolidation and don't say this is the right upper lobe pneumonia because you can't tell whether this is a pneumonia or not. Without the clinical picture. It could be a severe cancer. But the best method would be to say that it's the right upper lobe consolidation. So how I would present these findings would be, but I can see on this patient. So the name date of birth when this was taken, this is an AP chest X ray. If you can see the subtle clues, this is an ap so you can't assess cardiac size and cardiac cardiomegaly. I can see a consolidation in the right upper lobe, given the patient's clinical findings or given the patient's history, I think this is most in keeping with the right upper lobe pneumonia. That's the best way to present this. Why would it not be a middle of consolidation? Very good question. The best way I can answer this is it's very complicated. Middle, the middle, the right middle lobe is slightly posterior and it's difficult to see on a chest X ray. Anything above the horizontal fisher is going to be the upper lope for right middle lobe consolidations. If you just Google the images, you will find that it's not as defined as with this boundary here. And because if you imagine the anatomy, the right middle lobe sits somewhere over here in a three D plane. It's more difficult to see on a chest X ray. Remember that's why you percuss the axilla for the right middle lobe. So this finding if you see the horizontal fisher is classic of the right upper lobe consolidation, you can see this patient has some middle zone could be said yes. But if if I was, if you're being pedantic, I think right upper lobe is the best way to go about this X ray because that is what it is. You can see the horizontal fissure and this is the right upper lobe consolidation perfect moving on. What is this. Sure, very good answers. Very, very good answers. Could someone tell me how they would um present this to an examiner? Very highly math. Very good. How would you present this to an examiner? So mass around the right Hyler Lymph node is one of the answer. Very highly mass. All of these are very good. But in my opinion, once again, this is the most correct way would be that this is a chest secretary of this person, this person, it's a pa film, I can see a no pacification in the left, left peri hilar region or left hilar region region most in keeping with the left sided left lung mass. So you're talking about the U pacification of the chest X ray finding first and then saying it's a mass. So I like to stick to the descriptive words first for pacification consolidation and then go on to say that this is going to be most in keeping with a mass or this or that. Absolutely. Um There is a bit of air below the left diaphragm, but that's nothing to be worried about. That is the gastric bubble. It looks a bit odd in this film, but it's just the gastric bubble. Um You have to take my word for it kind of, but the more extras you see, you'll find out that this is can be there. But I I completely understand I would be confused as well whether this is a new, more peritoneum or not. But once again, very good point when you're looking at the diaphragm, ensure you look under the diaphragm as well. Because if you have a bowel perforation, you could get a new, more peritoneum. So this, this is a left mid zone consolidation in most in keeping with a left mid zone mass. Perfect, moving on. So now this one just what's the first thing which comes to your mind? You see this patient, what what do you think pneumothorax is a good answer? Any other answers coming through tension, you were thorax. Absolutely. So once you're doing the 80 approach, if you see the tricky is deviated, you probably wouldn't even have an uh chest X ray. But if you do this is what tension pneumothorax will look like loss of lung markings. And you can imagine the air is pushing the whole mediastinum away. The first thing you should do. A two e needle decompression typically in the second intercostal space. Always remember tension pneumothorax, trachea deviated away from the side which is affected. So moving on to one of the sex or the second most common perhaps presenting complaint, which is shortness of breath. Once again, you want to ask some simple questions. When did it start but start off with open questions? Like how can I help you today or um is there anything specific I can help you with today? And then move on to? When did it start? You want to know when the shortness of breath started once again because of that acute versus chronic thing, an acute shortness of breath. You're thinking about pneumothorax, you're thinking about pulmonary embolism, a chronic shortness of breath you're thinking about, ok, could be COPD, patient could have aortic stenosis. So, acute versus chronic, very important. Has it been there throughout or does it come and go if it comes and goes? Does it come on when you're doing something specifically? Many people will tell you that? Oh, I get short of breath when I climb 10 flights of stairs. Well, even I'm going to get short of breath when I climb 10 flights of stairs. So it's important to ask her to the shortness of breath comes on when you're doing something. I think the one key thing for your twos and you're four is if you can establish this in your shortness of breath history, you'll get a very good mark. Is establishing baseline function. How much could you walk before until you got short of breath? And how much can you walk? Now, that will give you an estimate of how much this is affecting the patient potentially? How seriously unlined pathology is so very important to ask, how much were you, could you walk or exert yourself before and how much can you exert yourself? Now, how many pillows do you sleep on a very good question? For what diagnosis do you ask this question? Absolutely. Heart failure. Because you're thinking about pulmonary edema then and tied to that. Have you ever woken up in the middle of the night? Gasping for breath, paroxysmal nocturnal dyspnea? Two questions to rule in or rule out heart failure. And then once again, systems review, start off open. You want to ask specific questions. Do you have a cough with the chest or shortness of breath? Do you have any chest pain associated with it? So let's say a patient comes in saying that I've been feeling quite lightheaded. Um when I walk around, I have a chest, I have some chest pain where it goes down when I sit down and I've been quite short of breath. So basically, the patient has syncope, angina and shortness of breath. Can anyone tell me what I'm thinking about aired Yxta nurses? Absolutely. And that's the classic triad. So what I'm trying to highlight here is your questionings once again, should not be focused on just respiratory, try and rule out everything, any blood in your bowel movements or you're in a very important differential diagnosis, which I often used to forget what you're in practice sessions. Can anyone tell me why you need to know about whether this patient is having blood loss or not? A question? You can anemia. Absolutely. Another question you can ask for anemia is that, do you ever feel dizzy or lightheaded when you're moving around a lot? Often they feel that that because of the low oh hemoglobin. They feel a bit lightheaded and dizzy. Do you feel more fatigued than usual? And always any fevers, night sweats, weight loss, any swelling in your legs? If they have a swelling in their left leg, it's quite painful at the moment. It's quite swollen. Why do you think I'm asking about that? DVT and PE Absolutely. So, if you think about the differentials, you can think about the questions to ask and this should just be a framework for the questions past medical history, once again, start open and then go down to being focused and drug history was just the same as the cough. And so for family history, social history, once again, I can't reiterate this enough, shortness, shortness of breath is heavily intertwined with lung cancer, with pulmonary embolisms, with copds. You need to ask about smoking and where do you work? Occupational history? Once again, very important because many occupations, for example, if you're a coal mine worker, you can get cold workers', pneumoconiosis, which can eventually lead to pommery fibrosis. Very important to document that. And once again, bet who's with you at home? And any long haul flights followed by ice. So dividing it into differentials, a chronic shortness of breath picture which has been going on, let's say, for example, patient's might tell you that I can't quite remember when it started. That means it started quite long ago and it started quite insidiously, meaning it's slowly built up the pulmonary fibrosis, COPD, lung cancer, mesothelioma, plural effusions, secondary to perhaps mesothelioma can all be causes of chronic shortness of breath. The acute shortness of breath would be the pulmonary embolisms, the new majorities, the pneumonias and through the questioning and through the systems review, you can seve down into what you think the most likely diagnoses is or are never ever, ever forget the noncardiac for shortness of breath, heart failures. You have to ask about orthopnea, parks, Oxman, nocturnal dyspnea, asking about questions like, have you ever had a heart attack in the in the past in your history? Will show you examiner that you're thinking about the non cardiac diagnoses, asking about the anemic symptoms such as do you feel lightheaded? Do you feel fatigued to try and rule out anemia? Do you have any, have you noticed any melena, have you noticed any black tarry sticky stools which are quite smelly, very, very, very important. So I can't stress that enough. Think about the noncardiac differentials as well and very rarely atypical angina patient's can often complain that I'm having a bit of shortness of breath, but that's once again, lower down mine. Um Lourdes on my list. I'm so sorry. I didn't mean noncardiac. I mean non non respiratory. Pardon me? Anxiety, very good differential. Absolutely. I'll change the lobby. I meant non uh non respiratory diagnosis. I think about anemia, heart failure, aortic stenosis, angina anxiety is a very good things that can cause an acute shortness of breath, uh, secondary to perhaps a panic attack. So very good differential. Absolutely. And once again, summarizing. So you just want to give the relevant presenting complaint. So I took a 35 I took a, from a 35 year old with shortness of breath. It started three weeks ago, has progressively worsened. It's associated the pink frothy sputum, uh with the coffee to bring 40 sputum. And then this is an interesting um summary. She's noticed her ankles a bit more swollen than usual. Her joints in the hands are swollen, red and painful. She denies any fevers, weight loss, her night sweats, she has no chest pain and is not pregnant. Very important. I'm just trying to highlight how you're questioning my change slightly. So when you ask the question, have you noticed anything else? And the patient starts saying, oh, have swollen red and quite painful joints in my hands, your thinking, okay. This could be a rheumatological condition given that she has pink frothy sputum, uh shortness of breath, she might have pulmonary edema secondary to a nephrotic syndrome caused by systemic lupus erythematosus. So I just want to show you this is a very complicated case and it's most likely not going to be in, in a rescue or on skis. But I wanted to drum this point home for the consultant to get sufficient information from your history. You need to give the patient's age, the sex of the patient and then how the symptoms, when it started, how it's progressed, additional important symptoms. So, pain in the joints are very important. Even if, if you think it's a respiratory diagnosis, it might completely be flipped around with the additional features which the patient has. If she's pregnant or not, often patient can get nephrotic uh nephrotic syndrome that can do to preeclampsia when they're pregnant. So that might change your thinking and your differential list. So if you see a patient child bearing age and she's coming in with these symptoms, asking her, are you pregnant? Currently might be a good question to ask. So you can change your questioning based on what you think is going on past medicals and social history, drug history as usual, very, very, very important what she's concerned about and you want to think about what the diagnosis is. I've given the top deferential here would probably be a pleural effusion secondary nephrotic syndrome secondary to sle other differentials could be heart failure, liver failure. But whatever the main point I wanna talk about is once again, when you're summarizing your history, give the details, which will make it very important and will be differential diagnosis, changing the differential diagnosis, altering very important shortness of breath. Once again, there's a whole host of different um investigations if the patient is acutely and well, I can't stress this enough A two E approach. But apart from that is quite similar to the last set of differentials. But additions could be BMP. If you think the patient has heart failure, uh a plausible, a plausible um different differentials, heart failure, then you want to rule it out using a BNP, you could do an echocardiogram as well to rule out heart failure. But once again, chest X ray will pretty much be bog standard. Most patients with shortness of breath to come into hospital will have the uh the chest X ray and then you can move on. If you think the diagnosis is most likely COPD, then spyrometry just clinched the diagnosis. If you think it's asthma, you can do the phen oh testing or spyrometry once again and sputum microscopy culture and sensitivity very, very important to remember if they have a productive cough. So quickly going through some of the management, you need to just know off your head acute asthma attack. If the patient comes in with an acute asthma attack, it's severe. You want to start them off on oxygen. If they're saturations are below 94% you don't want to start them off on nebulize salbutamol. If it's an adult, it's typically 5 mg. If it's a child below five, it's 2.5 mg. But don't worry too much. The twos don't worry about the dosages at all. Your photos might be worth knowing if you want to score some extra brownie points. Just remember five for salbutamol adults and nebulizer. A potro p um 2.5 for Children below five and 2 50 micrograms for adults. Once again, don't bother too much. We can't remember the dosage is, they're not as important, but just the fact that nebula salbutamol nebulous epa Tropea. Um and then you go onto, if the patient is conscious and can swallow, you can give them some prednisoLONE or you could give them IV hydrocortisone and then you move on to the more specialist driven management was giving them IV magnesium sulfate aminophyllin. Or if they're just not responding intubation and ventilation, a key is key tip and that's why I've put it in red is any acute management. You're not going to be the only one managing it. You want to show the examiners, you know what's going to happen in real life. You're going to tell them you're going to put on an 80 approach. Call your scenes as soon as possible. One thing we should really push you over the mark would be if you consider or asking one of the nurses to put out a medical emergency call by calling to, to, to, to that will show that you really know what goes on in the actual wards. And you know the practical application of the knowledge that you have learned so far, very important, the chronic asthma management equally important and you can score loads of marks because you can cancel the patient on the diagnosis. Give them information, leaflets, ask the parents to stop smoking or if they're smokers themselves, ask them to quit smoking inhaler technique, I can't stress this enough. You have to double check the inhaler technique before you discharge the patient to ensure that the inhalers you've prescribed are actually doing the job they're meant to do if, if there's severe shortness of breath. So always safety net them, if they have severe shortness of breath, it's not subsiding despite the use of inhalers to seek medical attention, I'm not going to go through the guidance and quite your most of your quite familiar with it. But typically you start off with a blue inhaler, which is simply the salbutamol inhalers, then you move to salbutamol uh hell cortical steroids and then you can add in leukotriene receptor antagonist, but that is available on our final section series if you see the slides for those. And the main thing is for adults double check that there's no medication which could be exacerbating their asthma beta blockers could be a common contra indication and the patient might be put on beta blockers and that's what's causing their asthma to flare up. That could be an s key scenario to ensure you double check what their medications or you say that I'm going to double check their medications to ensure that if they have any medications which could potentially worsen their asthma, I will look for alternatives based on senior or appropriate advice, acute exacerbation of COPD. Once again, you can follow the pneumonic or shit. If they're hypoxic, you can give them oxygen. Once again, nebulize salbutamol, nebulized ipratropium. You can give them the IV hydrocortisone and the steroids. And then you go into the specialist IV aminophyllin, IV, theo fill in. But the key difference between acute man asthma attacks, an acute exacerbations of COPD is that an acute exacerbation of COPD? Typically you consider non invasive ventilation. Another key point I want to stress here, don't say that I am going to administer noninvasive ventilation when you're answering anis key question instead, put it this way that potentially the Ennis assists could consider noninvasive ventilation because in real life, you're not going to be the one who's going to be giving non invasive ventilation. So if you just say noninvasive ventilation and if you want to score an extra mark by, by uh by level positive airway pressure, which is bi pap, that's the one which is given for COPD. Patient's. You could say that but not very essential chronic COPD management. Once again, quite similar to the asthma management. Smoking cessation is key respiratory physio and rehabilitation. And then you can go on to giving flu vaccines annually and one of pneumococcal vaccines safety at them on the signs and symptoms of an infective exacerbation. And I'm quite sure the medication, the treatment schedule is here for you guys to have a look in your free time spontaneously with thorax management. Once again, the main thing is whether they're whether they're symptomatic or they're not symptomatic and that's what defines how you're going to treat them and whether they have any underlying lung condition or they don't have any underlying lung condition. If they do have an underlying lung condition, that it's a secondary. If it's not, then it's a primary but knishes made this wonderful flow diagram and you're gonna have it with the slides. So you can look through it then pulmonary embolism. Once again, if the patient is hemodynamically unstable, very unwell 80 approach and thrombolysis. If a patient with a suspected pulmonary embolism is hemodynamically unstable, they should have thrombolysis typically with IV strep to canes or IV alter place. But once again, call, my seniors may put out a medical emergency call will be very good points, quarters for any acute scenario like that. Conservative. Once again, the classics counsel the patient information, leaflets, smoking cessation and you have the treatment scheduled for you on the slides IBC filters might be an interesting edition. If you consider that the patient has recurrent pommery embolisms, I could consider IBC filters. But the main thing for the risk is is sticking to the simple and stating it quite clearly when you're answering the questions. Now, this is especially for the year too, but also for the fo is a very useful recap how ABGS are interpreted very, very important. Look at the ph first, this is the method I use. I look at the ph first if it's below 7.35, I know it's acidotic. If it's above 7.45, I know it's alkyl optic. The next thing I want to look at is the P CO2 levels. If the P CO2 levels are low, it's a respiratory alkalosis iss. If the P CO2 levels are high, it's a respiratory acidosis. I then look at the oxygen levels to see whether this patient is in respiratory failure or not. If it's less than 10, this patient is in respiratory failure. Can anyone tell me what type one respiratory failure A B G would look like? Absolutely low, low P 02 and type two respiratory failure. Absolutely perfect. Yeah, that sounds good. Ventilation failure. Type two respiratory failure is when you have high carbon dioxide and low oxygen. So you, you basically can't do the funk. The function of if you think about the type two respiratory failure is where the lungs are failing, they can't take in enough oxygen and they can't blow off enough carbon dioxide. And then I look at the metabolic level. What's the bicarbonate doing? If the bicarbonate is low? It's a metabolic acidosis. If the bicarbonate is high, it's a metabolic alkalosis the best way in a quick tip. And I know many people don't use this, but I find it very useful is to look at the base access. The basic cess tells you what's going on at a respiratory level at a metabolic level. So minus two or more than minus two. So let's say the basics S is minus 10. It means there's a metabolic acidosis. So minus means get rid of acid at a metabolic level. So minus 10 base XS means that at a metabolic level, there is a metabolic acidosis and the reverse is true. If it's over two, let's walk through some examples. I think the best way to learn A B G is examples. You've confirmed the patient's name diagnosis when it was done. What does this A B G show respiratory acidosis? Absolutely. It is type two respiratory failure. But can anyone be a bit more specific? There's something very subtle in this partial compensation is a good answer. How? Absolutely. So this is this is a patient who classically find a COPD patient. This patient has had an acute exacerbation has gone into type two respiratory failure as evidenced by the low P CO2, which is below eight and the low as a low P O to below eight. Pardon me? And the PCO two, which is above six. So he's retaining carbon dioxide. But interestingly, his bicarbonate is slightly high. If this was an acute respiratory acidosis, the metabolic or the kidneys basically would not have had sufficient time to correct it or try to compensate the fact that they're trying to compensate, indicated that there has been an underlying acidosis going on for for a duration. So this is absolutely an acute respiratory acidosis with partial metabolic compensation. And this is type two respiratory failure. But the main thing is that, that, that H C 03, if this patient doesn't have, for example, any past medical history, which you know of it will start making you think that okay, this patient most likely has an underlying COPD. So if we can give you loads of information about the patient, what about this one? How do you know it's partial compensation? If the PH is not within the normal limits, that means it can only partially compensate, it hasn't been successful in compensating. And that's, that's why it's partial if it's within the normal, that means it's a complete compensation. Brilliant. Absolutely. Respiratory alkalosis, perhaps from hyperventilation, respiratory alkalosis, perhaps from hyperventilation at some place and had absolutely no metabolic compensation. Very good. Yes, there is no metabolic compensation which tells you this is acute to something which has happened immediately and most likely it is hyperventilation. So this patient may have had a panic attack or an anxiety issue. And that's why they're hyperventilating, they're blowing off the carbon dioxide. And this is what you classically find on there. A B G one final one. Any ideas what this ABG is showing absolutely metabolic acidosis, what would be the most complete and correct way to say it or answer it with partial respiratory compensation? Absolutely. So we can see the carbon dioxide levels are below 4.7. That means there is, the lungs are trying to blow off excess carbon dioxide to bring the ph back to 7.35 to 7.45, but have been unable to do so. So it's a partial compensation. So now comes to a bit of a fun element. Please do engage with it. So I've tried to formulate a new case and let's see how that goes. So this is how an actual is key case would go. You're outside the station. The setting is acute medical unit. Jon Snow is a 55 year old man who's come in complaining of shortness of breath. You've been asked to take a focused history from this patient and then present a differential diagnosis once again, once you're outside in your mind, okay, shortness of breath. I need to ask about whether when it started, has it gotten worse? Is there a cough? Is there no cough? I need to rule out the heart failure symptoms for sure. So I need to ask about practicing on nocturnal dyspnea, need to ask about orthopnea. So basically formulating in your mind, the main questions you have to ask and then going in with the flow. So when you ask, how can I help you today? He says I've been feeling more short of breath recently so that I can only walk about 100 m until I have to stop. This is quite a big change as I used to walk a mile a day. So definitely something has gone progressively worse and some things worsening of the pathology is worsening or progressing. I can't quite remember when it started. That means the shortness of breath probably started quite a while ago, but it's progressively race and, and it's been getting worse. I have noticed anything else. No, not really. So, there's no cough, there's no pain anywhere. He's checked his temperature and there's no temperature, but he is feeling a bit more tired than usual. What do you think the most likely cause of the creation symptoms is at this point out of the list over here and we have a pool for this. I'm so sorry guys, we might run maximum 10 minutes over. So this is coming towards the ending of it. So please bear with me. Yeah, I think I'll stop the pool there. So most of you have gone for the answer. Be B is COPD. But the correct answer, unfortunately, here, in my opinion would be pleural effusion white. The two main reasons, one, there's no cough. So the patient said that I'm not coughing COPD with only shortness of breath and no cough. Very unlikely. Very, very, very unlikely you need the cough to diagnose COPD. Secondly, it's been going on for a long period. He said he was short of breath for two months or so and it's been getting worse pneumonia for two months. No, can't be pneumothorax once again, more immediate won't be like that. And Paul Murray embolism, once again, more acute, acute causes of shortness of breath, the only cause which can be progressively developing and progressively getting worse would actually be a pleural effusion. So that in my opinion is why it is the most likely cause of his condition at the moment. And we will combine two, well, we will come to the underlying pathology soon. Well pointed that that's why the question was stated as what the most likely cause of this patient symptom is, it's probably a pleural effusion. But now we need to get to the root of why that pleural effusion is there transitions, reviews has no palpitations, no lightheadedness. So okay. No, Molina, he's not losing blood, not lightheaded. So, anemia seems less and less likely. No heart failure symptoms. But wolf, that's interesting. He's lost a lot of weight without trying. And that that gets us thinking about okay. Is there something sinister going on? What, what, what is going on here? He has only BP and type two diabetes. His medications seemed fine. He has no drug allergies and no significant family history. So what if now given the scenario you have now and the patient said that, oh, I have severe night sweats. What will your top differential be then out of the list over here? Okay. I'll end the pool. Now most of you have gone for the answers. See, and I completely see why night sweats, good indicate TV. But once again, we have to remember the patient didn't have a cough, he didn't have a fever. It's unlikely that he's going to be an active TB if he didn't have a cough or a fever. This is actually another slightly trick question. A patient who's 55 he's lost a lot of weight. Might have chronic lymphocytic leukemia just trying to broaden your think he has night sweats. Okay. Does he have any HumaLOG tickle malignancy going on underneath. So it's not about the the diagnosis is not important. He's just about thinking broad that okay night sweats, shortness of breath can often be caused by some hematological malignancies. That's very important to think about. Very, very important to think about. And we see he has a 40 back year history, drinks a glass of wine. He had a significant smoking history. Interestingly, he's a retired shipyard worker. So remember I told you guys to think about his occupation. Quite important. He lives alone in his countryside. So once again, now if I was doing the ski, he lives alone in his countryside home. Okay. How short of breath is? He can only walk 100 m. Can he walk to the shops? Can he ensure that he can has food on the table? Can he ensure he does activities of daily living? And if you start talking about this during your management, that I want to provide occupational therapy support for example, these will really show that you're thinking holistically and give you more marks in your, um in your final Lyski. So he's had to quit and he's wondering that who's gonna be able to do his daily chores? So he is quite worried about it. Given the history. What do you think the next imaging would be for this patient? You're seeing him in the acute medical unit? He's short of breath. What do you think you go for? Okay. I'll stop the poll there. Most of you've gone for C and that absolutely is the correct answer. Simple first, chest X ray. Just see what's going on underneath. What is it that is going on and we can move from there and this is his chest X ray. So I'll leave it here for a bit. Think about what you think it might be. Think about the whole scenario. Now try to piece everything together, his symptoms, his occupation, everything, think about everything. Look, have a look at the chest X ray. And then we moved to the question given everything, the occupational history, the chest X ray findings. What do you think this patient's diagnosis is? Hey, I'll stop the pool a bit early just because of time. So get you lost answers in sorry for rushing through some of the questions just because of timing. Perfect Mr Thelium. A Absolutely. I'm quite sure the occupational history gave it away, but shipyard workers are increased risk of asbestos exposure. And the thing about mesothelioma is that you could have a very long lag phase. So let's say someone worked in the shipyard in the 19 forties, 60 70 80 years down the line, they may develop mesothelioma because of that previous exposure. So it could have very long lag period briefly going over what we do for mesothelioma. Patient's much of the same really. But the main thing I want to highlight here is industrial compensation. If the patient does have mesothelioma and they wouldn't work in an environment which expose them to asbestos, they are eligible to compensation, their families are eligible to compensation. And if you mention that in a mesothelioma case, it'll score you loads of arc's that brings us to the end of today's session. I just want to quickly recap one of the key principles of Whiskies stick simple. You don't need to talk about very complicated management strategies, but what would actually happen on the words and for the forties especially try to tailor your questions based on the differentials you think are likely but never forget to ask for red flags. I hope that was useful and I'm sorry for the disruptions in the middle, but thank you very much.