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Hello, everyone. Thank you for coming in today. Um So it's just me and Jack presenting today, go over some of the data, data inter things for your A CD. So I'll be doing spirometry analysis and joint fluid analysis and then pass it on to Jack to do CSF and P fluid. So that's just the conference we're gonna go through today. So in terms of data interpretation, there are some general point as I'm sure you're aware. So you wanna say what test you're interpreting first. So whether it be urinalysis or ABG whatever it is, say this is an ABG and then move on to on whom. So that would be name, date of birth and patient ID always give all three. Um And then when and what time it was taken as well for the date and time and then do the interpretation aspect which we'll go through in a moment and then always give a diagnosis or a management if they ask in the question in themselves and uh to get some of the high marks, if you suggest some of the further investigations you can do, um that will be good as well. Firstly, we'll go over spirometry. So it is a test done. Um, mostly on respiratory patients. Sometimes you can do it on um, other patients like if they have scoliosis and things like that as well. So it's just checking how well your, um, your lungs are doing in general. Um, in terms of general pointers, they tend to do it three times and then get the best of three and two of them have to be within 5% of each other. You do not need to know this for the is it's more a pt type of type of question. Um So once the barometry is done, you can classify the results into restrictive and obstructive patterns. And there are three major um numbers that you want to look at. So F EV one which is your forced expiratory volume, FBC um F EV one which is your forced expiratory volume in one second and the FBC is the total in over about 15 seconds and then you get a ratio between the two of them. So F VC is you take a full breath in total inspiration and then what you can breathe out forcefully over 15 seconds. F VF EV one would be how much you can force out maximally within the 1st 2nd of breathing out. So in a normal patient, if you try blowing out as much as you can in one second and then continue breathing out, that wouldn't be much left after that 1st 2nd. So in a normal patient, that would be, if you do the ratio, it would be more than 0.7. Um In general, F EF VC looks at the capacity of the lungs. So how much air your lungs can take in? And F EV one looks at um, the airflow itself. So your airways, the bronchus, bronchioles and things like that. So we'll go through obstructive and restrictive separately as far as the obstruction. So anything that restricts airflow um going in and out of the lungs. So things like asthma, CO PD. So both emphysema and chronic bronchitis, bronchiectasis, cystic fibrosis and airway obstructions as well. So anything blocking up the airway would be mucus or just constriction on its own can give you an obstructive um picture. So if we look at this graph here, there's volume on the left and time on the right. The green line here is what a normal person would have. So this parts would be the 1st 2nd of exploration, how much air they've breathed out. So that would be the F EV one of a normal person. And if you keep going, that would be the F VC of a normal patient as well. So as you can see, the F EV one and F VC aren't that far away um from each other in a normal patient. Whereas in an obstructive patient, the amount of air they can push out past those obstructions is not going to be a lot within the 1st 2nd. So it's going to be a gradual expiration over time, which is why the E B1 is reduced. Whereas the total lung capacity remains largely unchanged because the lung isn't affected. It's the airways that are affected. So if the F EV one is reduced and the F VC itself is normal, you get a decrease in the ratio. So that would be below 0.7 in anyone with an obstructive pattern and anyone who has an obstructive pattern, you do a reversibility test. So basically give them some salbutamol and see if there is any improvement in that F EV one area. So if it's over 12% and there is a total volume increase of over 200 mil, then that means that it is reversible um obstruction. So that would be something like asthma. So the most common type of pictures that you see with the obstruction would be asthma and CO PD. So asthma in adults, in every patient, you want to recommend Feno as well on top of the spirometry, regardless of what the results are. And in Children, anyone below 17, anyone above the age of five, you want to um offer the FENO only if the spirometry comes back negative, but you're still suspicious of asthma. Um So feno, if it's over 40 in adults and over 35 in Children, then that is indicative of asthma and moving on to cop DFE V one F EC ratio is going to be below 0.7 as a result of it being an obstructive pattern. And if you look at the predicted values according to the gold criteria for the top MI you can say whether the patient has mild, moderate severe or very severe CO PD as well. With those numbers there failing to mention, this aspect is not going to make you fail, but it will give you the high marks. So moving on to the strictest. So this is when the lung itself is affected. So you get three different types. The first one would be the interstitial lung diseases. So things like pulmonary fibrosis or aids, post COVID, um post pneumonia, sarcoidosis or anything that deposits within the lungs itself. Um You've got your allergic pneumonitis as well in occupational um patients. So you've got your Alvear that causes, so going further into the lungs themselves, you've got your pneumonia. So the more acute type of patients who come in with an infection, you would have the picture. Um pulmonary edema. So that would be a bit A R DS as well. Um that causes pulmonary edema. You get lobectomy patients who've had previous surgeries from things like cancer can present with this kind of finding and Panchal tumors as well. Um with tumors be careful. So some tumors, if they're within the airways, then they're gonna cause more obstructive type type picture. Whereas if they're parenchymal, they're gonna cause more restrictive type picture. But that's, that's more pt type knowledge as opposed to your. Um And finally, you've got your extrinsic causes for restrictive um picture. So things like spinal, spinal issues. So kyphosis or scoliosis. So if you imagine trying to contort yourself into a specific position, your breathing is not going to be as effective as it would be. Um otherwise, uh same thing with pneumothorax. But I'd be very surprised if you recommended a spirometry on a patient. You're suspecting pneumothorax on um without any interventions. Um Things like pleural effusions, again, it sort of restricts the lungs from being able to expand. Um and therefore you get that kind of picture. Um you also have your respiratory muscle weakness. Uh So these would be the more neuro conditions. So things like GBS, um A L LS myasthenia gravis that can all cause respiratory muscle weakness. So, in terms of the graft, what happens with restrictive conditions is whatever the normal graft is, it just kind of squishes down. So both the airway and the lung capacity have been re uh decreased, meaning both F EV one and F VC have been decreased. So when you do the ratio, because both of them are decreased, you're gonna end up with an unaffected ratio. So it can come back normal. In other words, greater than 0.7. So in terms of its summary, if you look at a spirometry result, always look at F EV one FBC ratio first. And if it's below 0.7 you know, it's obstructive. If it's above 0.7 it's either normal or restrictive and looking at obstructive first. If it's reversible, either through bronchodilators or feno test positive, then you have asthma and if it's not reversible, then it's CO PD. Sometimes you can get partial reversibility, but that's outside of the scope of issues in general in those patients, it's more likely to be whatever condition like CO PD or whatever with a background of asthma as well, which is why you get partial reversibility of some symptoms but not all of it. So, moving on to restrictive, if both F VC and F EV one are below 80% of predicted, then it is restrictive. But if they are above 80% then that's just a normal patients with a normal spirometry result. Ok. So moving on to urinalysis, this is a lot of words on, on one slide, but really it's only the top few um rows that you want to look at. So Ph it's not really indicative of any conditions. It's, it's more just a background thing you can use to support your diagnosis. So if it's low below 4.5 then think about acidic causes because your urine is acidic. So things like metabolic acidosis DK, a lactate from things like sepsis or shock in general can cause a low Ph in urinalysis. Um Hi, sorry, that's a typo there. Um metabolic alkalosis. So, anything that pushes your bh up um and uti S as well can push your bh up into the alkaline area. Um The main one you wanna look at your analysis, especially in a patient that comes in with infection type picture would be your leucocytes. Um If that is positive, the most likely um differential would be UTI S but remember, it can also be positive in things um in conditions that also give blood positive results. So basically, your your renal area has been damaged enough to allow blood to come through if red blood also can come through. So can leucocytes and as a result, if you have blood positive, you're gonna probably have leukocyte positive as well. Nitrates is quite specific in the sense that it's a byproduct of the breakdown of um bacteria like E coli. So if nitrates are best in, you're only guaranteed, it's a um uti blood, it can be positive in loads of conditions including a uti. Um But keep in the back of your mind that it's both myoglobin and hemoglobin as well because things like rhabdomyolysis and trauma can also push up blood. So direct trauma through things like renal stones or direct trauma to the abdomen, causing problems to the kidney leading to blood coming out of your urine. Um Remember the Nephritic syndromes highly unlikely that's gonna come up in your in your exams. They're more likely to go down the uti kind of picture and also malignancies with anything that relates to blood um protein. So it would be oppositely nephrotic syndrome. Um in a pregnant patient always think of preeclampsia as well. Um as well as UTI S glucose. Um it is quite self-explanatory really. If you have diabetes, high levels of glucose in your blood is gonna end up in your urine as well. And another thing would be certain drugs can push glucose from your blood into your urine. So things like S DLT two drugs. So things like Lyin dapagliflozin, the way they lower your serum blood glucose is by pushing all of that blood into your urine, then you have your ketones. Um It's a good quick bedside test to check for ketoacidosis. So that's from be starvation. Um SGL T two related or diabetes type one, diabetes itself. It can be positive if your patient is pregnant in their first trimester, vomiting, loads and loads and loads and they're completely dehydrated. And those patients sometimes can get some ketones in their urine as well. You a bi um this is when other systems get involved. So things like your prehepatic and intrahepatic conditions. So, if your red blood cells are breaking down and as a result, you have a lot of bilirubin in your blood that's gonna end up in your urine. So things like prehepatic and intrahepatic course of jaundice will cause high levels of IMIL and then you have your specific gravity. It's practically never really looks at um in clinical practice, but a good way to think about it. Is, is it a basic test that indicates urine osmolality? So how many solutes are within your, your urine? How concentrated it is basically. So if it is low, you've got diluted urine. Um, so things like diabetes inhibitors where you, you pass loads and loads of urine would have um low specific gravity and high specific gravity would be concentrated urine that can be from dehydration. So you're not, you've passed so much urine, you don't have enough blood in you. So you're so dehydrated that your urine of morality goes up. Things like he uh heart failure and sometimes contrast use as well can cause this. So this is just a basic case. It's one of the more complicated ones you're gonna get. So um I'll just go through the case with you. So you have an idea of what kind of things can come up. So 56 year old lady presents with like three day history of increased frequency dysuria, Nouria. So you're going to be thinking along the lines of the uti there, no loin pain and back pain systemically. Well, so that's just pointing towards the idea that this patient doesn't have a pyelonephritis or a systemic um infection going on past medical history. This patient has type two diabetes. So from there already, you can expect some glucose in the urine and rheumatoid arthritis drug history. This patient takes Metformin and proliferin. So that's the SGL T two and Meth methotrexate with um folate as well. Patient is allergic to penicillin. So always in your history, ask whether the patient is allergic or not because if they start bringing you up MC NS reports and you don't know whether they're allergic to one thing or another, then you're a little bit stuck. You can always ask the patient after you finish the history as well, rather than give them a random antibiotic that they might be allergic to her. Eg fr was one week ago um in the normal range. So that's just pointing towards some of the antibiotics we can use as well. So in terms of interpretation, we'd want to go through saying this is a urinalysis done on this patient's date of birth. Patient's ID taken on the sixth of November 1984 or whatever. At whatever time, when you go through the positives, you don't need to mention every single negative. There is either just go through the positives. So it would be this patient has a urinalysis that shows strongly positive for leukocytes, nitrates, bloods and glucose, everything else was normal. So this points towards the diagnosis of a uti the glucose in the urine also can be a result of the patient's type two diabetes mellitis as well as the drug history of lysis. If you move on to the MC NS report, you can mention the fact that the culture grew E coli and it is sensitive to trimethoprim, nitrofurantoin and coamoxiclav. In terms of picking one of the antibiotics, you would not want to go for trimethoprim in a patient is taking methotrexate at the same time. Ideally, you'd wanna go for something else. You've got nitrofurantoin, which you can use since it's sensitive and the patient's renal function is fine. Coamoxiclav you do not want to use. Since the patient has penicillin allergies. The first line for UTI would anyway be nitrofurantoin or trimethoprim depending on where you are working at the moment. But considering this patient has methotrexate in the drug history, you'd wanna go to nitrofurantoin. So finally, from my aspect, we're gonna go through arthrocentesis analysis. So that's basically taking a sign of your fluid sample and um identifying what's wrong with it basically. So there are specific indications as to why you would wanna do this. It is a painful procedure. You don't want to subject every single patient um to artis. So if you're suspecting septic arthritis and you want to grow a culture, so you can better treat that patient with a more sensitive antibiotic, then you do that gout and pseudogout, you can diagnose these conditions without arthrocentesis. But the way se septic arthritis and gout presents can be very similar. So it's going to be a hot, very hot, swollen knee and gout, it tends to be more big toe. But if you, you can get it in your knee as well. So because you can't differentiate between those two, all that easily, that can also be an indication for arthrocentesis. And sometimes you can do it therapeutically as well. If the effusion is so large and the patient has so much pain, you can do arthritis t just to relieve that pressure. So, in terms of what's normal, the fluid that comes out of your sinus, your fluid, um it looks quite straw, like very clear. It has some white blood cells in it anyway. But it's, it's low. You do not need to know these numbers. They will give you the normal ranges um in the exam or say this is elevated or this is lower than normal. You can gram stain as well. In case you have a a bacteria growing in there, you can lift the crystals and you can culture the thing and lift the glucose as well. So again, the big table, it can look a bit intubating, but I'll go through one at a time. So osteoarthritis is going to be largely completely normal. It's going to look almost identical to a normal patient's sign of your fluid because there is no inflammation, um sort of systemic inflammation that's attacking going on. It's more wear and tear that's causing the issue. Sometimes you can get calcium phosphate crystals, but they're not going to be testing you on that cause it doesn't have the classic byre frigen pattern. So, moving on to inflammatory arthritis. So that would be your rheumatoid arthritis, psoriatic arthritis, sometimes reactive arthritis as well. So if you think of any kind of inflammation is going to give you some fluid, that's a different color to your normal. So a bit thicker, a bit more yellow because you've got more white cells in there. So that already answers white blood cells and neutrophils, they're going to be elevated because there is an inflammatory process going on within that joint space. There won't be any grand thing because you're not growing anything. There is no bacteria in there and there won't be any crystals in terms of culture. Again, you won't grow anything unless it is infected. Glucose can be a little bit low just because your, you've got your white blood cells within that space as well, but it's not that relevant to your inflammatory arthritis. So coming on the inflammatory arthritis, you've got gout and pseudogout as well. In general, they again would resemble your general inflammatory arthritis. In terms of appearance, white blood cells would be high, neutrophils would be high because there is an inflammatory process going on. Um But the thing you want to know specifically for gout would be the needle shaped, negative birefringent um crystals and for pseudo gout, it would be the other one. So positive birefringent um rhomboid shaped crystals moving on to septic arthritis. Just think of a wound outside on your skin. If you have a skin wound, it's going to be oozing sort of opaque, yellow, green phlegm kind of looking pus type of picture. So that's exactly the same inside as well. So inside a sign of your fluid is going to look cloudy, opaque, very yellow and gooey when it comes out white blood cells and neutrophils are going to be very high. So compared to a basic inflammatory response to an inflammatory response as a result of an infection, you're always going to be having higher white cells and higher neutrophils. If your gram stain, you can have positive gram stains for um gonococcal. So that would be your sexually active young patients who would end up with those type of septic arthritis and you can have your negative. So that would be more along the sides of infection uh of a knee replacement and things like that crystals. You won't be growing any crystals and aseptic arthritis and culture in an infection. You obviously want to culture and check for sensitivities. They can better treat that patient glucose is going to be very low because all of the bacteria within that space is trying to eat all of that glucose up. Basically moving on to CSF I will pass over to Jack now, right? OK. So for the principle of an it it'd be very unlikely for you to be given a CSF sample where you have to interpret it unless the case is like meningitis or anything like that. So if someone comes in if you have a station where it's a kid with a rash, always assume meningococcal septicemia. And if they give you a CSF sample, you will have to interpret. I think that'll be the only example probably you're gonna get in the ey, unless it's a subarachnoid hemorrhage where you do a lumbar puncture. Ok. So I'm gonna run through it pretty quickly um because you don't need to know this in detail, but it's useful for PT. Um Anyway, so CSF is very much an immuno privileged area, meaning that the number of lymphocytes should pretty much be minimal. So normal in the CSF range. So, CSF, if you've ever seen, it literally looks like water, it looks clear, it looks like it looks crystal clear, pretty much. Um polymorph are your er urinate immune system, meaning they are neutrophils, macrophages. They are the ones which pretty much are your first line of defense. So when you have bacteria come in and invade, that is your first point of contact really with the immune system. So, if you have a bacteria, your immune system goes first, meaning that your polymorph are gonna go up. Ok. So, therefore, they're elevated. And by the time all the polymorph have eaten all the bacteria, then it should go back to normal. It shouldn't really have to switch to the adaptive immune system where polymorph, an innate immune system doesn't work as much. OK. Therefore, you have your T cells and your B cells working, which are your lymphocytes. So normal to continue opening pressures between five and 20. Um All you need to know is if it's a high opening pressure, that means a couple of things. It means literally there is too much pressure, meaning there is either some, some big chunky bacteria which is taking up space such as TB. So TB or a fungus is gonna increase the opening pressure. A lot cos it's big and chunky compared to a bacteria or virus. Or it's going to be, for example, an idiopathic intracranial hypertension or there's blood in there such as the serac, too much fluid within the um the spinal cord. Um the sorry, the, the cerebrospinal fluid, meaning therefore there's gonna be fluid wanting to come out. So that would really be pushing up your um CSF and your opening pressure, lymphocytes, as I said, this is your adaptive immune system. So if the innate immune system hasn't worked, therefore, it switches to adaptive. So this is gonna be your viruses and your weird and wonderful bugs such as fungus and TB. Ok. Um Glucose as Sarah has basically said, bacteria are gluttons and eat bacteria um and eat glucose. Therefore, if it's bacterial or TB, it's gonna be low and TB especially it's gonna be very, very, very low. Ok. Protein things which are made out of protein include bacteria and viruses. So it's gonna go up um and cultures. So basically, if you have a bacterial, um A suspected bacterial meningitis, you're gonna culture it, meaning you're gonna have a, um you're gonna stain it first and then you're gonna put it for culture viruses. You'd have to do APCR which is not re it's a bit different. So you're actually um you're actually uh looking at the DNA and the RNA of the, the virus for extra marks. If you know the gram stains a certain bacteria that will actually help you a lot. So for example, if you had a gram negative diplococcal, you should automatically know it's Neera meningitis which causes meningococcal septicemia. If it's a gram positive um say rod, then it could be listeria. These are the sort of things which examiners are looking for. So they may ask you, oh, what culture would you do? Oh, what stain would you do? But that's i it's unlikely. The most likely situation is you're gonna have a, a lumbar puncture for either a meningitis or a subarachnoid hemorrhage. If it's a subarachnoid hemorrhage, you do a lumbar puncture, 12 hours post the onset of the headache, looking for xanthochromia, which is basically bilirubin within the CSF and red blood cell degradation. Ok. So all in all, if you are given this, either think bacterial or subarach, it's not going to be something weird and wonderful. That's for PT and passed. It's not for the is it's gonna be bog standard? Really? Ok. Um Next slide, right? Pleural fluid, I really doubt this is going to come up in an ki it'd be very, very mean if it does because this is, this is when you're doing the paracentesis and you really wanna see what's, you know, what's happening in the e um or in the effusion, et cetera or you're doing um a pa either a paracentesis or you're gonna be doing a um a neuro. So I really don't think this is going to be coming up, but I'll go through it. So, pleural fluids, it's your lubricating fluid between the two pleural um layers. And basically you do this when you suspect a pleural effusion which on a chest X ray shows a meniscus sign. OK. So have a look what it look. A pleural fusion looks like on a chest X ray. There are two types as you may know from pt transudative which crosses a membrane sedative which is out. So, failures and fancies is a good way of l learning it. So anything transudate, the most common is heart failure. OK. That is the most common and all your other failures such as liver renal, et cetera. OK. Exudative. This is where things are added, I think. So, basically, infection, pe malignancy, et cetera. So the most common cause of transudative um pleural fusion is going to be heart failure, the most common cause of exudative of infection. So specific things which you can see on a pleural aspirate is gonna be pus. So if you see pus, then it's empyema. So the things you wanna test in the past is LDH glucose and you're gonna stain it and send it off for culture. OK? Anchovy sauce. This again, this is gonna be PT land, but this is a sign of amoebic abscess. So, um amoebiasis which is caused by entamoeba. Um oh, what's um entamoeba? Entamoeba or something? I've forgotten what it was called but it's, it's caused by that Um which is a type of dis er amoebic liver disease. Um And then Milky is gonna be chylothorax. So you've got a histolytica. Thank you. Um Milky is going to be a chylothorax and then food esophageal rupture. If you have oesophageal rupture, then you're gonna get, um you're gonna get crepitus. So you're gonna get diaphragmatic crepitus and you're gonna get subcutaneous emphysema. Ok. So pleural fluid. Thank you. You can use something called light criteria. So again, it's learning the numbers. If you have a transitive, the pleural protein or serum protein is gonna be low, it's gonna be less than 0.5 or equal to it. Um If it's, again, if it's exudative, it's gonna be above pretty self explanatory really um exudative, you're gonna really see cultures, you're gonna see cytology. So malignancy and the glucose is an sedative. It's all gonna be pretty much n ad OK. Light criteria. I doubt this is gonna come up in Iski. If it did, I'd be very, very surprised. But other than that. I would really just learn CSF uh urinalysis septic. So, an arthrocentesis and bloods if, if anything, um sometimes they can give you microscopy report. So knowing how to like what's in sensitivity and all that. But o other than that, I wouldn't really too much on pleural fluid. Um Is that the last slide? Yeah, that's the last time. So, thank you from us. Um Do we have any burning questions apart from me getting histolytica? And yes, meningitis does come up a lot. Ok. In a sub like no hemorrhage, what additional features would prompt investigation for Polycystic kidneys, right? So, polycystic kidneys is either autosomal dominant or recessive, meaning that the most common being dominant if you have someone which is suspected for a very aneurysm in posterior circulation circle Willis number one, they're gonna have, if they're skinny enough, they're gonna have really bulky er kidneys. They're gonna have Hepatomegaly cos the the most uh common extra renal manifestation of A um ADP KD is liver cysts. They're also going to have a genetic marker. So you need to send them off for on family testing as well. Other than that, it's very much going to be liver kidneys and perhaps maybe an aneurysm which you wouldn't really know until someone's got neurological sequelae of said aneurysm. Does that answer the question? Oh, and they'd have obviously renal dysfunction? Oh, thank you very much. Hm. Very kind. Any other burning questions? I know you got Anky tomorrow or anything of anything. And just a shout out about meningococcal septicemia, lumbar puncture is actually contraindicated according to nice guidelines. It shouldn't be the first thing you do. The reason being is um when you have meningococcal septicemia, you leak, meaning that you could leak all blood and t uh tissue fluid into the spinal cord which causes paralysis. So that's the last thing you want to do. So, and it actually delays getting a culture or a sample. So, what you do actually is you take a serum PCR and test it for meningococcus. That's the first thing you do. And then he treats empirically and then you go for lumbar puncture for later. OK? Any other questions at all? I know you have like an ST tomorrow as well. So if it's OK, can you explain why you don't do lunch immediately again? OK. Reason being. So there is a couple of contraindications to doing a lumbar puncture straight away. And that's anything to do with bleeding diatheses. Meaning if you've got coagulation issues, then if you stick a big needle into your back, which is most likely gonna bleed into it, then you could cause a um paralysis because all that blood will seep into such a fine canal. And when you have meningococcal septicemia, septicemia means blood poisoning and your whole body leaks. So your mem, so your um your blood vessels go through something called ation, which means um a lot of TNF alpha gets released, it completely po makes it porous and therefore everything leaks. Um And that's why you get edematous and you go into shock. Um So if you do that, then you could cause paralysis because you're having all that fluid leak into you. Ok. So, and it actually delays, management. Management really is going to be empirical antibiotics such as Cef, that's the first thing you need to be thinking is cefTRIAXone plus or minus ampicillin or amoxicillin. So if you have men, meningococcal septicemia in an iski, the first thing you should say is again, sepsis six. And then put, if you wanna be really clever, you do a blood PCR of meningococcus and then you g which doesn't del delay treatment, give him antibiotics. And then if there's no signs of intra raised intracranial pressure, then you go for a lumbar puncture. Um And that would be that would suffice. Can I add one thing as well? That actually came up my ey first of all, well, then Sara and Jack, that was class as always. Um One thing that um is kind of important to realize it was hammered into me when I was doing peds. Um And maybe you guys can answer in the chat. So do you know how to tell the difference between uh septicemia? Um Sorry, meningococcal septicemia and meningococcal meningitis. So, like clinically, um how you could tell the difference. Um If you, if no one writes it in the group chat. I'll just elaborate cos this is something that's quite, um, class. This is what came up in my skis. Um, and I will tell you what it is cos no one's writing unless they're writing very quickly. So, basically the rash. So the non blanching rash is what tells you that it's, um, that you've got a septicemia that's in your blood. If it's just in the, um, so just meningitis, then you obviously, then you can do the, um, the LM puncture but non branching rash and fever in. Yeah, that's it fairly good. Um So yeah, it's the rash that, that tells difference. So some people think, oh my God, they've got a rash. They've got meningitis. Actually, the rash means they've got septicemia, um, which could lead to meningitis or whatever. So, um, yeah, that's just one distinction to be aware of. So if they've got a rash, that would be kind of a relative contraindication for doing the LP. Cool. Just wanted to add that. But yeah, everything class guys as always. And that's really, really important if you do not know that that is a red flag, by the way, that is a fail because it's one of those important conditions that if you miss it, that's it done like they will die. So you need to know it and it's drilled into you like you don't really see it as much, believe it or not because everyone's vaccinated, but there's still unvaccinated populations out there. You need to know it because if you do not know that that kid will end up with autoamputation, neurologic seal death. So you need to, you need to do it. So, any child, sorry, I'm trying to scare you all. But that is the truth. No. Yeah. No, absolutely. Um, but yeah, and also if they're, if they're newborn or very elderly, they're more likely to have atypical, um, pathogens as well. So you've got a cover for that like listeria, which is really important. So, any child that's like, you know, uh 567, whatever days old. And then you're thinking, and they've got a temperature and they're just generally not very well, always have that as differential. It might not be the, the diagnosis but always have as differential because then you'll never get caught out and also it looks really good um, to the examiner. Um But yeah, if, if you did have that, I had that in my ski. Um and it was, the patient was like 14 or 15, I think, but still they had a headache and they gave you the LT result, the CSF results. Um So yeah, it is, it is important one. It could definitely come up as well. Definitely come up to, to be aware of that. Any other questions. Good luck everyone for tomorrow. The is I'm sure we'll be absolutely fine. You guys are here. So obviously you care about doing Well, so that's, that's a good sign. Cool. I think that's it. Fabulous. Thank you very much. Everyone. Um, please fill up the feedback. Have you got the feedback form? Uh, I don't have access to it. Maybe we can email the guys with it. We'll, yeah, we'll do that. Sorry. Someone's asked a question. So, when you do the LP later, what is the reason for that? Oh. Oh, interesting. So, the reason for that number one is that you've got a full work up, meaning that if there's anything else cultured, you'd know. Um Two, it would basically confirm the diagnosis cos all you're doing is pretty much treating with antibiotics. And PCR in there could be XYZ amount of different organisms and uh complications within that CSF sample. So you still need to do a lumbar puncture. That's the gold standard. But you would PCR because it's safer to do at that time if it's meningococcus. So you, you acupuncture regardless. Cool. Well, as other guys just you can always email the email address if you have any more questions. Um Will the recording be made available with it? Uh So I don't think we have access to the feedback form, do we? Um So we might have to email that over to you guys. We'll do that swiftly for you. Um And yeah, the recorder we made available, I think is if, if they do the feedback form, is it, is that when they get the fee, the um recording, the recording goes at the meal. So if you're following the page, so it should be there. But please still do the feedback form cos it really helps us. Um It's kind of like a, a log that we've, we've done this for you guys. That's the as, as a, as a one. Thank you for us. That would be great if you could do that. Cool. Thank you. Thank you. Thank you, everyone.