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Uh, okay. So, yeah, let's get into it. So we're going to start off with our first case. So we have a situation. We have our Rosky station here. So our role is we are the foundation year one doctor were in the emergency department. And we've been asked to see Mr Steve Rogers, an 84 year old male who presents with shortness of breath and a cough. And we've been asked to take a focus history and initiate a management plan including pertinent investigations. So here's a slide covering the sort of focus history taking for shortness of breath. Uh I'm not gonna show go through this in too much detail, try and cover the key things. Uh, shortness of breath you can do as somewhat Socrates. Okay. You can cover the stuff that is relevant to shortness of breath, even though it's not a pain history, you can do a makeshift Socrates just on the shortness of breath, key things you want to know if it's an acute presentation or more of a chronic presentation, how, how quickly has a shortness of breath come on and um, other things with the shortness of breath, you want to know, is it pleuritic? Okay. Is there pain with the shortness of breath? And is it worse in the morning or worse than the night? Do they wake up with shortness of breath? Okay. How many pillows do you sleep with that night's important. Think about orthopnea. Um, so that's where the shortness of breath, uh, in terms of the cough, um, things to really think about with the cough. Is it a productive cough or more of a dry cough? How much sputum per day? Ok. I asked the patient to quantify how much sputum they produce per day. And if the sputum has any particular characteristics and really important to ask, have they coughed up any blood? Ok. Have they had any episodes of him? Octus Iss and really try and quantify what type of what the blood appears like? Okay? Is it just streaks? Is it just fresh, fresh, fresh blood or is it more plots? Okay. So that's your sort of focused questions you were thinking about with the history of presenting complaints. Um past medical history. We were thinking about things like uh history of heart failure, history of asthma COPD, just general underlying lung disease. Have they got any risk factors for a pulmonary embolism? Okay, like calf swelling, history of immobility, long haul flights. And do they have any history of potential TB travel immuno suppression? Okay. So think about tuberculosis infection. Okay, always do your systems review. So checking for other symptoms ok, just quickly rule out all of these other symptoms in case they have them. And here's your sort of social family drug history. Okay. General things to be thinking about, um, with inhalers. If they, if they mentioned that they haven't, if they use an inhaler, always quite, uh, clarify what inhaler they're using? Is it just the blue inhaler or they're using, uh, different color inhalers? Okay. Is it the preventer reliever? What specific inhalers are they using? And always with any shortness of breath presentation, trying to figure out if they've had, if the symptoms have had any effects on their functional functional status. Okay. So effects on there activities of daily living and if there's been any psychological impact as well because of their symptoms, okay. So that's just your general history taking for shortness of breath. Ok. I went through that pretty quickly but have a read of the slides and try and mention all of those, all of these different questions. Okay. And in terms of the differentials for shortness of breath, primarily today, we're going to be focusing on the respiratory differentials. Um So I've listed out all of the respiratory differentials, the key respiratory differentials for shortness of breath. Um I'm not going to go through it, but this is hopefully something you're familiar with, but these are all these sort of characteristic features you want to be picking out in their history. Um And that should help sort of help with your differential diagnosis. So these are all your respiratory differentials. I've listed some of the other differentials as well. So we talked about a lot of these cardiovascular stuff last week. Um like A C S dissection Palmer edema. We talked about this stuff last week and I've also mentioned anima, this is definitely not an exhaustive list. Okay. There's, there's way more other differentials of shortness of breath. But today we're going to be talking about uh the mostly the respiratory stuff. So let's get into it uh quickly. So this is something that people always struggle with, tend to struggle with. Okay, presenting a history in a Noski. So let's let's try and practice presenting a history for respiratory differential. So when we're presenting history is this is a sort of structure we like to teach for presenting a history in your Rosky. Okay. So we're always whenever you do anything in your Rosky, okay, whenever you speak in your ski, always start with the patient details. Okay. That's just a general principle. Brosque talking in our skis, always clarified patient details. That's the first thing you always mentioned. Okay. Um So when you're presenting history, start off with the key presenting complaints, okay. The key thing is when you're presenting a history is that you're not just regurgitating the history back to the examiner, okay, you're not just uh listening to the patient and then just regurgitating that back to the examiner, okay, in order to present to present a history effectively. You need to be able to pick out what's the most important most relevant features of the history that a senior of senior professional would need to know about the patient's okay. It's not just about, it's not about just being able to memorize the history. It's about being able to act on the history and pick out the most important stuff. So if we present a history of, let's say a patient with a suspected pulmonary embolism started the patient details. So say today I spoke to Mr Steve Rogers, an 84 year old man who presented with pleuritic chest pain uh with the shortness of breath. And this started two days ago while uh while he's been on the recovery ward after having a total knee replacement two days ago, um history presenting complaint. So you can say um I sort of mentioned that the shortness of breath started in the last hour. His option, saturations have gradually been dropping and I'm worried that this patient has having um pulmonary embolism relevant negatives. So we talked about this last week. What are we thinking about with relevant negatives? What do I mean by relevant negatives ruling out things good? So it's more, it's basically things that help you exclude other differentials. Okay. So with, so it's it could be different symptoms, it could be red flag symptoms that you're thinking about. Okay. It's just anything that's relevant that you've, that you've picked up from the history that helps you exclude other differentials of shortness of breath. Ok. Um So you could say, uh with shortness of breath history, you could say there's no history of heart failure because we're thinking about palm edema or uh there's no history of trauma. Just anything that is relevant to help pick up to help exclude another differential of shortness of breath uh relevant past medical history, surgical history, social history, drug history. So the key word here is relevant, okay, you're not just going to repeat all of this history back to the examiner. You're just picking up picking out what's relevant. Okay. So, but upon re embolism, you want to pick up that this patient has had a recent surgery or this patient has a history of cancer or this patient's are been on the combined oral contraceptive pill. Okay? Or um if it's pommery edema, you want to say this patient has a history of heart failure, okay? You're just picking out the stuff that's relevant, okay. And always clarify what the patient's main concerns are. Okay. That's always something good to present in your history. So always present what the patient's ideas concerns and expectations are. And then you can go on to what your top differential is okay. So you can say my top differential, my top differential would be a pulmonary embolism because of the patient's um risk factors for um a thrombus. Okay, including the recent surgery. My other differentials would include a pneumothorax and, uh, a pneumonia, okay, just quickly straight to the point and giving a reason for why your top differential is your top differential. Okay. But that's how you, that's how I would go about presenting your history. Okay. It's just, it's all about having a good structure. Okay? And picking out the key bits of the history. Okay. So let's move on. So now the examiners gonna probably gonna ask you what are your next investigations? So let's talk through the investigations for shortness of breath. Ok. Acute shortness of breath. So shortness of breath presentations to the hospital. Can you guys tell me how do we classify investigations for shortness of breath? Uh, sorry, investigations in general. What is the way we classify investigations? Yep, bedside blood's imaging, those of you there last week should be, should know bedside blood's imaging and any special tests. Okay. This is the way I always like to think about investigations. Okay. And think about presenting investigations. So with acute shortness of breath for any patient presenting with acute shortness of breath, what investigations would you guys order? Good. I like, uh, Princess, you smashed it. The first thing you should say is a to be assessment. Very good. Okay. That's the first thing you should mention for any, for any acute presentation. What other investigations would you do? Yep. Chest text. Very good. Uh, sputum analysis, sputum analysis. You wouldn't necessarily do that on every single presentation or shortness of breath. OK? You do it for specific presentations. I'm just talking about any presentation peek expires your flow rate. Again, that's for specific presentations. You would do it. Respiratory examination, good check, saturations. Yes, observation is good. Yeah, so you guys are getting a respiratory examination A B G good. Yeah, so let's talk through it. So for any shortness of breath, OK? Doesn't matter what the differential is, what your top differential is for any shortness of breath. These are the different investigations I would mention. Okay. So for any shortness of breath, I'd mention that I would do an A B C D assessment of the patient, I would mention that I would get basic observations including auction saturations on a pulse oximeter. I would mention I would do an E C G okay because we're thinking we want to make sure we're ruling out cardiac causes, okay, acute coronary syndromes particularly I'd mention I would do a respiratory examination, okay, and particularly auscultate because um very important to mention, I definitely mentioned that I would do a COVID swab. Okay? Because um this with, even though you're on skis is a simulated environment, I think it's important to realize that we're living in a world where COVID 19 exists. Okay. So I definitely recommend you guys say you would do a COVID swab. Okay? Don't assume that just because you're in, you're off skis just because you're in a simulated environment. Don't assume that COVID 19 doesn't exist. Okay. It does. So mentioned I would definitely mention doing a COVID swab um in terms of your blood. So generally with blood tests, it doesn't really matter how many blood tests you order. Okay. You don't need to think about, you don't need to worry about ordering too many blood tests. You don't need to think about draining hospital resources. The key thing in our skis is that when you're ordering any type of blood tests, you need to be able to justify that blood test. Okay? Why you do that blood test? So let's let's work through, let's work through each of these blood tests and justify why I would do it for uh shortness of breath. Okay. So a full blood count, what am I going to get from the full blood count for showing us a breath? What, what is the full blood count gonna tell me infection? Good? Okay. So white cell count very important to check uh anemia. Good. So if someone has low hemoglobin that that would tell me that the shortness of breath would likely be due to anemia. Uh what would a high hemoglobin tell me in the context of shortness of breath, polycythemia? Good. Okay. So high hemoglobin would indicate polycythemia. Why would it, why would someone get polycythemia and with shortness of breath? Yeah, it suggests someone the patient's likely would have might have had chronic hypoxia. Okay. For example, in COPD a lot of patient's will have chronic hypoxia which can lead to a secondary polycythemia. Okay. So that can lead to increase the hemoglobin. And that's what, that's a, that's a reason why a lot of COPD patients will have palmer erythema as well. Okay, because they get uh secondary polycythemia. Uh So yeah, that's the full blood count is also useful to check your sin appalls as well with the full blood count. Thinking about asthma also COPD as well. It helps with the determining the likely management as well. So that's your full blood count you and he's, what am I what, what are the you? And he's going to tell me for showing us a breath, why is it useful to get you? And he's what are the, what are the area and electrolytes? Blood test going to tell me in shortness of breath. Yes, sepsis. So think about renal function if they've developed an acute kidney injury, uh why would it be useful to get the urea insurance Sabra? What could the urea be useful? Yeah, good. Curb 65 scores. So you, you need the urea to calculate the curb 65 score on patient's presenting with pneumonia. Um What can what about electrolytes? What kind of electrolyte disturbances might someone have with shortness of breath? Hypochelemia? Why would someone have hypochelemia with shortness of breath? Yeah, if they have acute metabolic acidosis, potentially someone's using salbutamol salbutamol. If you're gonna give salbutamol, you will be careful because salbutamol can cause um shifts of potassium um sodium abnormalities. You can get sodium disturbances with, with certain types of pneumonia or lung cancers. Okay. So there's a lot you can justify with for the uh um and he's um so yeah, that's the urine electrolytes, okay. Uh A B G I'm sure you guys will be able to justify doing an arterial blood gas for acute for shortness of breath. Ok? You need to do, you need to get an accurate measurement of the uh PA 02 and you need to get an accurate analysis of the acid base balance. Okay. So arterial blood gas is an essential thing to mention. And I would also mention doing a CRP because it's very useful too because that's gonna really help with your differential diagnosis if someone has a raised CRP, okay, particularly with thinking about infection in inflammatory conditions, okay, like pneumonia and you have to mention you would do a chest X ray, okay. You just have to mention you do a chest X ray for any shortness of breath, ok? Cause there's a lot of differentials that can be picked up by doing a simple chest X ray film. Okay. So that's what I would mention for doing any for any shortness of breath. I've mentioned all of these investigations. Okay. Now, for specific conditions, there's specific stuff you can add on. Okay. So for an asthma exacerbation, I would mention that I would do a spirometry okay. And make sure I've mentioned that I would do a spirometry with bronchodilator response. You can also check the fino so fraction of expired nitric oxide and I also mentioned doing a peak expiratory flow rates. Okay. So in an acute asthma exacerbation, the peak flow can help tell me what the severity of the asthma attack is for a COPD exacerbation. So because most COPD exacerbations are infective, I would all would definitely mention that I would do the sepsis six, okay, initiate sepsis six to manage an acute COPD exacerbation. Uh similar to asthma mention spyrometry. Okay mentioned doing sputum cultures for COPD exacerbation because again, most COPD exacerbations are infective. So I wanna do sputum cultures and send it for uh microscopy cultures and sensitivities consider doing a ct thorax. Uh You, you couldn't, can be useful in stupid exacerbations and echocardiogram. Well, why would I do an echocardiogram in COPD? What could the echocardiogram tell me? Why would an echo be useful in COPD? Yeah, Cor Pulmonale. Good. So if someone's if some if a patient developed Cor Pulmonale, so because of their COPD, they've developed pulmonary hypertension and then that's led to right sided heart failure that that can be assessed using echo, doing an echo to check for a right sided heart failure. Okay. So that's those are the investigations for COPD for pulmonary edema. We talked about possibly edema in detail last week. Okay. Mentioned BNP for heart failure, echocardiogram to assess um the ejection fraction, uh pulmonary embolism. So we'll talk about pulmonary embolisms in detail later. But for pulmonary embolisms calculate the world score. Okay. So the well score, if the welsh score is high, that means that I should do a CT P A um immediately. Okay. I should organize the CT PA immediately because if they're well score is high, that means that the patient likely has a pulmonary embolism um if it's low, but I think the patient is still having a pulmonary embolism, then I can check the D dimer levels. And if the D dimer is then raised, I could do the CT PA to check. Okay. So that's the well score. Uh perk score is a scoring system that's increasingly being used in the emergency department. So if a patient has a perk score of zero, that basically rules out a pommery embolism. Okay. So a perk score of zero basically rules out a pulmonary embolism. Okay. So those are the investigations for pulmonary embolism for pneumonias. So I'm sure you all recognize that you need to do Sector six for pneumonia. Okay. So if someone has a acute chest infection, you have to mention you would do the Sector six. We'll talk about the curb 65 score later, okay, how you calculate it? But the findings are the values of the curbs, curbs 65 score is heavily based on certain blood test values. And you should also mention you do sputum analysis, okay microscopy cultures and sensitivities. Okay. Uh Finally, with TB. So tuberculosis infection, active, active TB. Uh the key, the key sort of diagnostic tests is you need to get, you need to get sputum samples. Okay. At least three sputum samples and one of them has to be an early morning sputum sample as well. Um And you should check it, send it again for culture sensitivities and ct thorax is also useful to also important for pulmonary TB. Okay, to assess for changes. Can anyone tell me why would I do LFTs in active TB? What would liver function tests be useful in TB? Why would I, why would LFTs be useful in T F in TV? Yeah. Good. Baseline for basic, yeah. Baseline for before you start treatment. Okay. So we're gonna, we'll talk about TV, treatments briefly later on, but a lot of TV, medication is hepatotoxic. Okay. Um, so it's good to get baseline at a liver function before you start. Um, certain Chibber closest, um, medications. Okay. So that's why I mentioned LFTs for TV. But those are your investigations for shortness of breath? Ok. I hope that I hope this table is really clear and it's going to help with your revision. But that's the sort of approach I would take two learning investigations in general for our skis. Okay. Always learn the investigations for the broad presenting complaint. Okay. And then you can add in specific extra investigations based on what you think the likely diagnosis is okay. Good. So let's move on. So that was basically covered the acute shortness of breath history investigations. Now, we're gonna talk through specific conditions and the way I've structured it is that we'll do a chest X. Well, I'll show you a chest X ray. You guys will tell me the diagnosis and then we'll talk through the management plan and some important type of stations that can come up with that condition. So, we've been asked to see Mr Bruce Lee, a 64 year old male who presents with shortness of breath, please review the chest radiograph and initiate a management plan. So have a look at this chest chest X ray. So we have a chest X ray station coming up in a few weeks, okay? If you're not sure about chest x rays. And um in that, in that session, we'll talk about how to present chest X rays. Um because that, that's very important in our skis. So now can you guys just tell me, what do you guys think about this? Text? Chest X ray? What are you gonna, what's your diagnosis? Yep. So I think a couple of you got it. So, um someone said tension, there's so this is definitely a left sided pneumothorax, okay. So I've draw the sort of pleural line, uh the edge of the pleural line here. Okay. So this is a left sided uh pneumothorax, okay. Um So why So remember on a chest X ray film, uh you're looking for the presence of lung markings, okay. So here there's absent long, long mark lung markings in all of this area and there's a clear pleural line, the edge of the pleura is very visible here as well. Um So this is a left sided pneumothorax. And the key things with the key thing with the pneumothorax is that you want to assess if there's any features of mediastinal deviation, okay, mediastinal shift, okay. And the the key features you want to be thinking about is the trachea. Okay. You want to check if the trachea is deviated. Um So this is not a trick, this trachea is still normal. Okay. That that's not a deviated trachea, that's still midline and there's no sort of um other features of mediastinal shift. Okay. So this is just a spontaneous left sided pneumothorax. Okay. Remember in your our skis, what's the first thing you would mention when you're presenting the chest X ray in your actual loski? I just I went straight to the diagnosis which I shouldn't talk but in your or ski. What's the first thing you should mention when you present the chest X ray? Yeah. So you always start with the patient details. Okay. I'm gonna stress this throughout. Always start with the patient details. When was the chest X ray film taken? What the patient complain of? Okay. Always start with that basic information. Okay. It's very, very important in your are skis. Um And also when you present, what else can you mention when you're presenting chest X rays? What else is it useful to have when you're presenting a chest X ray to the examiner? What else would you off? What else would you like to do with the chest X ray? Yeah. A Prp Azo is important to mention. Okay, clarify what type of film it is. Um Yeah, compare with the previous test sector. Very good. Okay. That's definitely, that's definitely something I would mention. Okay, so I mentioned ideally, I would like to compare this chest secretary to any recently taken chest X ray films or any previous radiographs taken off the patient. Okay, because in in reality, in clinical practice, that's actually super important to help see if there's any changes um that's happened. Okay. So always mentioned, I always offer to the examiner to compared to any previous films and do your basic chest X ray um interpretation. So check if it's rotated, check if the inspiration quality is good check if the patient is positioned adequately. Um Again, we'll talk about all that stuff in the chest X ray station. Okay? For now today, we'll just go straight into the diagnosis. So uh can you show me the pneumothorax without the outline? So I'll take out the outline. So uh if you can see that the there's a clear plural outline there. Okay. So yeah, that was the left side of pneumothorax. I've just got a picture of a pneumothorax. Yeah. Okay. It's a nice little visual representation of a pneumothorax. So can you guys tell me how would you measure the size of a pneumothorax on a chest X ray film? Where, where do you measure the size of the pneumothorax? From what level on the chest X ray do you typically measure from? Yeah, at the level of the hilum? Okay. So I'll show you now. So you measure at the level of the hilum here. Okay. So around here. So you measure from there from the, from the edge of the pneumothorax, okay from the edge from the pleural line and you measure it to the um where the normal position of the pleura should be. Okay. So that you'd measure this distance here. Okay. So that's how you, you would quantify the size of the pneumothorax. Why is it important to measure the size of the pneumothorax? What why is it useful to, why do you need to know the size of the pneumothorax? Yeah, the management changes depending on how big the pneumothorax is good. Okay. So we'll talk about the guidelines now, but it's very important to know the size of the pneumothorax and to know if the patient's symptomatic or if there's any evidence of lung disease as well. So let's talk through the management of pneumothorax. So this is these basic guidelines for management of a pneumothorax. Okay. The BTS 2010 guidelines. Absolutely essential to learn all these guidelines. Okay. It's very clinically relevant. Um I'll go through the key thing. So if someone has evidence of underlying lung disease or if they're over 50 and have a significant smoking history, then you're gonna treat them as having a secondary pneumothorax. Okay. First off with a primary pneumothorax. So if they don't have any of these beach is, um then we want to know how big the pneumothorax is. If it's a big pneumothorax, so greater than two centimeters or they are breathless. Um So they have symptoms, then you go for a needle aspiration. Okay. So basically a cannula in the area of the pneumothorax. Uh if they haven't got any of these speeches, then you, you should consider discharging them and then reviewing them in a outpatient pneumothorax clinic. Okay. If they have any of these speeches. So they have a secondary pneumothorax. Then again, you want to ask the same questions. Okay. Is it a big pneumothorax or are they and or are they breathless? Okay. Symptomatic. If they are breathless with a secondary pneumothorax, okay, then you're gonna refer them to have a chest X ray chest strain straightaway. Okay. That's the key thing. If they have any evidence of underlying lung disease, then it's a chest strain straightaway. Okay. If it's not, if it's not, if it's less than two centimeters and they're not breathless, then you want to know is it between 1 to 2 centimeters. So if it's between 1 to 2 centimeters, then you can just do a needle aspiration. Okay. If it's less than one centimeter, okay, then you can, you should admit them and start high flow oxygen. Okay. So for anyone with a secondary pneumothorax, you have to at least admit them. Okay. Even if it's a small pneumothorax, you still admit them and you start high flow oxygen. Okay. So that's the, that's the key thing with a secondary pneumothorax. Okay. So those are guidelines, okay. Just try and commit this diagram to memory. Okay. It is clinically relevant for now. Let's have a look at this chest X ray phone. What do you guys think about this chest X ray? What do you think? Mhm Good. What am I? What is all of this and look at the tricky? Look at the tricky as well. Yes, good. So I think there are a lot of your son to get it. So this is a left sided tension pneumothorax. Okay. So this is a tension pneumothorax, okay. Different to the other one. So again, similar to the last one, there was a loss of lot lung markings here. There's a lot more loss of lung markings here compared to the other one. And you can see the pleural edge. It's a lot further to the patient's right side. Okay. It's a lot more, there's a much bigger pneumothorax and there's also evidence of media standard shift. Okay. There's clear tracheal deviation to the right here. Okay. This is a tension pneumothorax, okay, left sided tension pneumothorax. Um So let's think about the management now. So the examiners now asked you please discuss the acute management of this condition. So, can you guys tell me what is the first thing you're going to tell the examiner? When, when the, when the examiner ask you this question was the first thing you would say yes, A B C D assessment. Okay. So let's talk through the A B C D assessment of a tension pneumothorax. Okay. So what are you guys going to do in terms of your airway for attention pneumothorax or any type of acute presentation? What's the things, what's the typical steps we would do in terms of the airway check of the airways patent? Okay. Check. Um uh Just check for a response for the patient. Good. Might you might need to do airway maneuvers uh tricky all positions. A trickier position is I'd say that's, that's more part of the breathing assessment, okay. Uh But airways, so check if they're responding, um check their talking. Okay. So that's your airway assessment, breathing, breathing. There's a bunch of different things you need to do an attention, you will direct. So what do you guys think about breathing? Okay. Before you do a needle decompression, you need to do a lot of things to realize that you need to do a needle decompression. So what do you need to do first assess chest expansion, percussion, very important, okay, respiratory rates, pal patient listen, okay. Very important. Okay. You need to do all of these steps in order to accurately determine if they have, if they have tension. You Martha rights auction. Saturation is good. Yeah, so let's talk through the breathing. So you guys have talked through most of them. Okay. Check sats, okay, check, tracheal deviation good. So check sats check respiratory rate, check for reduced chest expansion, okay, particularly if it's unilateral. That's very concerning for attention, pneumothorax, parkas, okay with the pneumothorax, you're gonna get hyper resonance, okay. And we'll talk about respiratory examination tomorrow. But classically with the pneumothorax, you're gonna get hyper resonance to percussion. Um and if it's unilateral, that's very worrying. Uh oscal take. So if there's reduced air entry, okay. So absent breath sounds that's very concerning check for trade tracheal deviation. So again, we'll talk about how you assess or take your deviation tomorrow. But if there's evidence of tracheal deviation, that's going to give you a big hint towards attention, your thorax. And as some of you said, if there is signs of attention, your thorax, then you need to do an immediate needle decompression. Okay. Um Where do you do the needle decompression guys? What's the location of a of doing a needle decompression? Yeah. Set a second, intercostal space, midclavicular line. Good. Okay. And all other important things to do. Put out a peri arrest court. Okay if they're having signs of tension pneumothorax, okay. If you need to do a emergency needle decompression, it's good. I'd say good to put out a period. Rascal um do an A B G. Okay. Very important in anyone with shortness of breath and always start high flow oxygen for acutely unwell patient's in general. Okay. Uh All as, as how do you check tracheal deviation? We'll talk about that tomorrow. Okay. We'll talk through the respiratory examination in detail tomorrow. Um So make sure to tune in tomorrow in terms of circulation. What kind of things are you, are you going to do for circulation in general? Pulses, cup refill E C G. Yeah, BP. This this is this kind of stuff we talked to last week, okay. Um Fluid balance check heart sounds, get an E C G start fluid resuscitation if it's appropriate. Okay. And given algesia if it's appropriate gain intravenous access as well, disability, so check of poo level, okay. So the level of consciousness um so use of poo uh I wouldn't say G C S and you're on skis, okay. It's always easier to do have poo generally uh check of pupils are equal and reactive to light, check the glucose levels and ketone levels as well. And finally, in terms of e so in a tension pneumothorax, it's always important to inspect for any trauma to the chest. Okay. And if there's any evidence of bleeding, if there is any evidence of bleeding. So this is a trauma patient, then you need to make sure you would mention doing a group and save and cross match, okay? Because they likely need to be taken to theater uh check temperature, get a catheter in uh after you after you've done the decompression, then you can mention you would do a chest X ray okay or do a ct thorax. Um Remember you mentioned that after you've done the needle decompression, okay, you're always managed the tension pneumothorax first before doing a chest X ray. Uh ideally, uh and then you should, I would say discuss with the respiratory physician and because they, you need a chest drain inserted for the patient's okay. Usually chest pains are usually inserted by respiratory physicians, okay? Or interventional radiologists, okay. It's not usually something that's done by sort of foundation level doctors, okay. But that's the sort of a B C D assessment of a pneumothorax, okay. I hope you guys are really clear on all these different steps, okay, of acute management. Uh But let's move on. So I've got a question for you guys. Um So let's say the patient's about to be discharged. What advice is given to pneumothorax, patient's on discharge. What kind of safety netting do you need to give to pneumothorax? Patient's a good return if symptoms get worse. Okay. So offer a follow up appointment. Uh What else? Uh No smoking good. So smoking should generally be avoided and pneumothorax okay because it increases the risk of future pneumothorax. No diving. Very good. Uh One can 11 can patient start diving again for the pneumothorax. No, so they can never dive. Okay unless they've had reconstructive surgery. Okay. Unless they've had surgery to prevent future new authorities, they can never dive. Okay. Uh What about flying? Can they fly? What's the advice on flying? It's a, flying is generally an absolute contraindications until if you've confirmed that it's resolved. Okay. So let's talk through these different uh things you need to advise them on. So key things is make sure you book, you tell them that you're gonna book respiratory follow up appointments, okay and safety net. So if they get any symptoms, if they get any symptoms, similar symptoms to return to hospital offers smoking cessation support, okay, because that increase the risk of future new majorities in terms of diving. So diving is an absolute no, no, ok unless they have uh preventative surgery and in terms of flying, so flying should be completely avoided until there's been complete resolution of the pneumothorax. And in terms in terms of confirming resolution. So you need to do a chest X ray to confirm that the pneumothorax has resolved and then they can start flying one week after the chest X ray has confirmed it. Okay. So these are the important bits of advice to give to pneumothorax. Patient's um when you're discharging them, okay. So we basically, we pretty much covered pneumothorax that okay in terms of the key things, key clinical knowledge related to new pneumothorax. Um We're gonna cover asthma now and then we'll take a short break. We'll go on with the rest of the session. So we've been asked to see Mr Benton, a 23 year old male who has a history of asthma. He has presented with shortness of breath and wheeze, we've been asked to take a focus history and initiate a management plan including pertinent investigations. He's now quickly. So this is a slide all about E B G interpretation. Okay. I'm not going to go through it, but I put this slide in for reference. If you guys want some quick revision of how to interpret A BGS, okay. There's a little guide to how you approach A B G interpretation in general. But personally, I think the best way to practice interpreting A BGS is to just practice actual cases of A B G. So let's go through a B G interpretation and try and go through the common acid based disturbances at the same time. So have a look at this, see A PG and tell me what you think is going on. I want the, I want the acid based disturbance and if you think this is partial or full compensation. Yeah. So this is a respiratory acidosis with partial compensation, partial metabolic compensation. Okay. So we have a low Ph okay. So, respiratory low ph but high P CO2 sats, a respiratory acidosis and bicarbonate is elevated. Okay. So uh that's an appropriate metabolic compensation response. But because the PH is abnormal, that means that it's only a partial compensation. So this is a respiratory acidosis with partial metabolic compensation. In terms of the common causes of a respiratory acidosis. I've listed some common causes here. Things like COPD asthma, things that can affect your ventilation and lead to uh difficulty in carbon dioxide to be exhaled, that can lead to respiratory acidosis. Okay. Have a look at this A B G. What do you think about this A B G here? Yeah, respiratory acidosis with full metabolic compensation. Sorry. No, no metabolic alkalosis with full respiratory compensation. Okay. This is a patient who has a normal P okay. This is, this is why I think I see why the confusions here. Now remember it. So um so the ph is normal here, okay. But the P CO2 is high and the bicarbonate is high. Okay. So it's to determine if someone who has a normal ph if you want to determine the compensation, I it's easiest to basically think about the halfway point. So I like to think about the halfway point of the normal range as 7.4. And because the 7.42 is slightly higher than 7.4, I assume this might be it might have been a metabolic alkalosis Okay. So if I assume this is a metabolic alkalosis iss this was a metabolic alkalosis, then um then we can see that the bicarbonate is high. So that would cause a metabolic alkalosis and the P CO2 is also high. So that's an appropriate respiratory compensation response to a metabolic alkalosis. Okay. So the key thing is because you i with someone who has a normal ph I take the halfway point. So assume that the halfway point is 7.4 and 7.42 is slightly higher. So assume this is a metabolic alkalosis and then you can interpret as accordingly. Okay, because the PH is normal, this is full respiratory compensation. Okay. So common causes of a metabolic alkalosis. So I've listed some common causes here. So, vomiting diuretics. What about this A B G here? Yeah. Metabolic acidosis with partial respiratory compensation. Good. Yeah. So this this is a patient who has a low Ph. Okay. So it's an acidosis, okay. Uh And in terms of the acidosis bicarb is low as well. So this is a metabolic acidosis and then we're thinking about compensation. So the with a metabolic acidosis, you'd expect the PCO to to go down. Okay. And this, the P CO2 is low. So the this is an appropriate respiratory compensation but it's only partial because the PH is still abnormal. Okay. So it's a mess metabolic acidosis with partial respiratory compensation in terms of common causes of a metabolic acidosis. Uh You can divide it into causes of a high anion gap and a causes of a normal annan gap. Okay. And I've listed some of the common ones here and you can use these New Monix here. Uh We can talk about anna and gaps um on a later day. Okay. But these are the common causes of a metabolic acidosis. Uh Last one, you can probably basically do a rule of elimination to see what this has to base disturbances. But what do you guys think about this one? Again, use the same principles as we use for this one. Yes, respiratory and sorry, respiratory uh Yeah, it's a respiratory alkalosis with full metabolic compensation. Okay. So again, because the PH is normal here, but we take the halfway point. So 7.45 is higher than the halfway point. So it's higher than 7.4. So we can assume this is a alkalosis. And then if you think if this is an alkalosis, we can see the P CO2 is low. So we can say this is a respiratory alkalosis iss and then um we think about compensation. So bicarb is low and that's an appropriate compensate ori response for a respiratory alkalosis. And because the PH is normal, that's, that's a normal ph we can say this is full metabolic compensation. Okay. So that's your A B G. So in terms of common causes of a respiratory alkalosis. Uh these I have listed some, some common causes here. Okay. So things basically that can cause hyperventilation. So that's, that's your abgs. Okay. That's quick practice on A BGS. I hope that was useful. Okay. So just generally go through it systematically, always think what is the acid based disturbance? Is it respiratory or metabolic? And is what is the decompensation? Okay. And is it full or partial decompensation? Okay. That's the key principles of A B G interpretation. And I've asked you a question, what indicates if a patient is having a life threatening asthma exacerbation? So we're still, we're talking about an asthma patient. Now, what do you guys think? What indicates if a patient having a like to any asthma exacerbation? Silent chest cyanosis, high CO2? Okay. So if it's CO2, that's increasing, okay. If someone has a high CO2, that's not, that's not just like threatening. Okay. That's near fatal. Okay. Um But yeah, definitely with the, you're worried if the P CO2 is increasing, can't speak. That's a bit important one. Peak flow less than 33. Good. Okay. So I put this table here, okay. I basically summarizes the key principles of managing acute asthma. So in terms of the life threatening features, I like to use the pneumonic A chest. So a for arrhythmia, see for confusion or cyanosis, H for hypertension, E for exhaustion. Okay. That's an important one as for a silent chest and T for tachycardia PCPA, always talk about the P A CO2 if that's increasing. And I've got the observations can also indicate if it's a life threatening asthma attack. And I've also talked about the management of an acute asthma attack in these bullet points here. So you can have a read about it. Key things is that you think about nebulized salbutamol, think about oral prednisoLONE and you have, you're gonna refer them to I see you if they're not responding to any of these uh inhaler therapies. Um Okay. So that's the sort of asthma, acute asthma management quick. We're gonna quickly talk about G P asthma. So we talked about acute asthma there. So hospital presentation of acute asthma present of an acute asthma exacerbation. Now we're gonna talk about sort of the GPS approach to asthma quickly and then we'll take a break. Um So reviewing an asthma patient. So, I mean, I'll go through the station. So we've been asked to see Mr Benton who is a 23 year old male who had an acute asthma attack two months ago. Okay. He's now stable and has presented for his annual review. So he's presented to the G P for his annual asthma review. And basically we've been asked to do the annual asthma checkup. Okay. So let's talk about this consultation. So it's an asthma clinic, asthma patient review. So we're going to talk about the consultation in terms of the content of what you need to talk about with the patient's okay general in general with consultations, it's very personal and how you approach communicating with the patient today. I'm just going to try and cover the sort of content which you need to get out to the patient and actually explain. So I'm gonna have structured it into these different sort of aspects which you need to talk about. So in terms of your introduction, always clarify when they were diagnosed. Okay. Um obviously do your full um introduced, introduced yourself and introduce the patient. But in terms of your initial introduction, find out when they were first diagnosed with asthma. How was it diagnosed? Okay. Was it diagnosed in hospital? Was it diagnosed in the G P? Okay? Did they, was it diagnosed by peak flow measurements? Uh find out any relevant past history and what they're isis okay? So what their ideas concerns expectations are? And then I told you that the patient had a history of asthma attack recently. So in terms of their acute asthma episode, the key things I want to find out from that acute asthma attack is what their onset was. How quickly did that acute asthma attack happen? What their time course was okay. How, how many days did it go on for? And what specific symptoms happen during that asthma attack? Okay. Was it just wheezed? Was it completely shortness of breath? Were they uh confused fatigue? Okay. Clarify what symptoms they were getting? Were there any exacerbating factors? So, was it worse when they were trying to speak or walk around? Okay. Was there any relieving factors? Was it, was it responding to salbutamol? Was it responding to their typical reliever therapy? And how severe the attack was? So, did they need to be admitted to hospital? Okay. So that's what I would get from the acute asthma history and in terms of their general asthma history, the key things I want to be getting at is what is their current symptoms? Okay. How do they, how are they currently managing with their asthma? When, how often do they get symptoms? Uh, what symptoms do they get typically during the attacks? Um, always clarify if they get any morning or night time symptoms, uh, the number of stairs they walk before they get symptoms. That's always an important functional question to get. Has that asthma improved as they got older? Okay. So, uh, that's good to clarify if it's improved as they've gotten older or worsened as they've gotten older. Uh, clarify how many times they've been admitted to hospital with asthma? Always important to ask about effects on daily life? Okay. How has the asthma symptoms affected their activities of daily living? Clarify if there's any history of a to be okay? So, have they got any history of, uh, eczema, history of hay fever? And it's always good to clarify what the patient's triggers are? So a lot of asthma patient's will, will have common triggers. Okay. They'll, they'll know the triggers that the triggers for their symptoms are common. Ones would be things like smoke, cold temperatures, dust, stress, medications. Okay. Clarify if the patient knows what they're typical triggers are. And here I've mentioned the Royal College of Physicians three questions. So there's three questions to ask in, in this type of GP consultation to really clarify how effective asthma control is. So these are the three questions to ask anyone. Okay. And this helps, tells you how, how significantly um impaired someone's asthma control is. Have you had difficulty sleeping because of your asthma symptoms? Okay. Have you had your usual asthma symptoms during the daytime? Okay. So just during the normal day, have they had usual asthma symptoms and has your asthma interfered with your usual activities? Okay. If they say no to all of these questions, that means that they have very poor asthma control, okay. Um So always ask these three questions in terms of medication history. In an asthma review, you want to clarify if they have a personalized asthma plan. So all the asthma patient should get a personalized uh package of care. Um, if they're on inhalers, clarify what their current inhalers are okay. Is it the blue inhaler or are they using the brown inhaler? Ok. So clarify what specific inhaler they're using? Um, clarify how many, how many times a day they use it okay frequency of use. Um and also good to clarify what they typically use on a normal day and how many they would have to use on a bad day? Okay, and offered to check inhaler technique. Okay. In your, in your in an actual GP appointment, you would, you would definitely check inhaler technique, but in your Oscar, you don't have time, you so you should just offer to the patient that you, you will be checking the inhaler technique during that day, you can offer a space spacer device if they're struggling with the inhalers. Um So you can offer a spacer device and, and always clarify any other medications that are on as well. Okay. And finally, in terms of ongoing care and any warning. So this is the sort of summary summarize of what you're going to do next for the patient. So if they, if it's appropriate, you can offer new inhaler therapy or a new dose of an inhaler. Um If they're struggling with organizing the inhalers or they're struggling taking multiple inhalers during the day, you can offer to combine inhalers and this is called um marked therapy. So if they're struggling with multiple inhalers, you can offer to combine certain inhalers, uh lifestyle advice, um social prescribing. So you can offer certain support groups that are available for asthma support. Um check they know what they're red flag symptoms are for asthma attacks, okay. Uh So things like uh if they're not if they're having to take more than 10 puffs of salbutamol or, um, if they're feeling, um, drowsy, um, just generally if short, short of breath, okay. Just general things that they need to call 9994, make sure that they're aware, aware of it. Okay. Um, so, yeah, and check if they know what to do during an asthma attack. Okay. So that's the sort of consultation for reviewing an asthma patient. Okay, in terms of the content, I hope that's really clear for you. Um This is a pretty standard typical Oscar station that you might get in terms of a G P Oscar station. Um So hopefully that was useful. Now, we are going to talk about inhaler technique now and I've got my inhaler for you guys as well to show you how to have good inhaler technique, how to demonstrate it. But the key things I would recommend for you to remember the key things that you need to emphasize the patient, make sure you tell them that they need to check if the inhalers expired. Okay. So you can pull the canister out and check if it's expired. Uh Make sure you tell them to sit up straight or stand okay to check inhaler technique before they use it, make sure they're shaking their inhaler well, okay. And before they're about to take the actual breath of salbutamol or make sure you get them to breathe out completely first. And then as they're breathing in, they need to act. So when they're activating the inhaler, they need to breathe in at the same time. Okay. That's really important for inhaler technique. And when they're actually breathing in, they need to hold their breath. So they need to hold all that salbutamol in their breath for at least 10 seconds, okay? Or as long as they can. Ok? But ideally you want them to hold their breath for about 10 seconds. Um And then they can relax. Okay. So let's talk about the, how you actually explain. So, um ideally you want to demonstrate with a placebo if you can, okay in your rosky, if you have a placebo inhaler, you want to use a placebo. Um We're just going to quickly go through this. So introduce yourself, take a brief history from the patient, establish what the patient already knows about inhalers, okay? And what they already know about their asthma and why they need to use inhalers. So you can explain that uh we need, we need to use inhalers because we need to spray the medication on to your lungs to help open uh the airways, okay? Because because your asthma is needing to your airways getting narrower. So just basic, basically explain why they need to start using inhalers. Um then do a quick ice, okay. What are they concerned about with using inhalers? Uh and then also checking allergies as well. Very important with, with any medication that you're gonna give uh outline what you're gonna do. So just say so today we're gonna talk through how to have good inhaler technique. And so that's just your introduction bit. Ensure patient is standing or sitting up, okay. You can't, you can't check inhaler technique. You can't do use your inhaler while you're lying down, okay? You need to be standing or sat up uh check the date of expiration, like I said, shake vigorously, okay. So important to shake all the medication in the canister, remove the cap, okay. Uh hold the finger, hold up right with index finger above. Breathe out completely. Okay. So maybe get them to do a full exploration before they about to use it, okay. Uh create a good seal between the lips and then press firmly on the Kansas canister. So they need to with the index finger, press firmly on the canister. And at the same time, this is very important while they are pressing on the canister, they need to breathe in slowly and deeply. Okay. So while they are pressing in, they need to have a good seal on the canister and they need to be breathing in as quick as deeply as possible and as slowly as possible, okay? And they need to hold that for at least 10 seconds or as long as possible. Um And then after that, they can breathe out as slowly as possible. Okay? So if you guys just wanna have a look at my face camera screen, I'll just, I'll show you how to do it now. So um again, check date of expiration and then remove cap, okay? And then I'm gonna breathe out completely. So okay, breathe out completely. Uh I'll do it again and then I'll press at the same time inhale while I'm pressing that kind of stuff. I'm inhaling and then I'm going to hold for 10 seconds and then I'll breathe out. Okay. So, okay. That's the inhaler technique. Okay. Sorry, I messed up my fingers there. But again, hold it for 10 seconds. That's the sort of inhaler technique. Okay. Um So that's how you demonstrate it in terms of after you've done that, then you want to move on to just tell them to wash their mouth out afterwards. Okay, especially if they're using a steroid inhaler. Uh Can you guys tell me what do you need to use a steroid? Why do you, why do they need to wash their mouth out completely after steroid? Yeah. Thrush. Okay. There particularly steroid inhalers. So the brown inhalers, um there's a risk of candidacies. So it's very important that they rinse your mouth out afterwards. Okay. So if I was using the brown one, I'd go and rinse my mouth out. Now, um repeat the steps, okay. So ask the patient to repeat these steps, um and ask the patient to demonstrate it. Ok. So explain all all of these steps and ask the patient to demonstrate it very important in your skis and just make sure you correct any mistakes that they do explain the dosage of the medication. So, um, it's salbutamol is two puffs a day. Um, any side effects. So it's salbutamol. You can get things like tachycardia, um, tremors, headaches with steroid, thinking about candidiasis ease. Okay. And, um, you might need to give them a steroid card as well if they're taking very high doses. Um always tell them when they need to seek medical attention. So if they're needing to take more than 10 puffs a day, okay, or um any of those symptoms we described earlier. Okay. So, um they get feeling fatigued. Um symptoms are just not respond, they're not able to get control of their symptoms, just call 999. Um and then arrange address any concerns throughout and arrange any follow up appointments. Okay. So that's how I would approach the inhaler technique station. Uh other things. So if you're asked to about spacer devices, I've just listed some key things here. Okay. So with spacer devices, they spacer devices help with inhalers because um you don't need to coordinate. Okay. Remote with this one, I had to press on the canister and inhale at the same time. Um A lot of patient's might struggle with that. So it's important to that they get spacer devices. Um Also with a spacer device is very important that uh they need to be washed with water. Okay. Or soap solution. And the key thing is that with a spacer device, you shouldn't wipe it completely dry. Uh Can you guys tell me why shouldn't, why don't you wipe spacer devices dry? Why shouldn't you just completely leave it? Use a towel to wipe down the space advice. What's the problem with that? Yeah, you can get static, static good. Okay. So if they, if they, if you wipe it completely dry, there's a risk of static electricity and uh that can affect the actual delivery of medication. So um avoid just leave it to dry by normal condensation. Okay. And ideally you wanna replace it every 6 to 12 months for spacer devices. Okay. Um So that's your inhaler technique. Okay. I've also got stuff on peak flow. I'm just, I'm going to just skip over this. I hope I've just listed out the key steps for peak flow um explanation. Okay. I'll, we'll take a break now. But I guess with peak flow, the key things you want to be thinking about is that you wanna, I like to explain peak flow therapy as you're just trying to blow out all the candles. Okay. It's about blowing out as quickly as possible. Um And you get, you're taking three measurements. Can you guys tell me if someone has a peak flow of 606 126 140? Which value are you going to record on peak flow? Yeah. Good, you take the highest value. Okay. So in that one, in that case, it will be 640. Okay, remember you don't take the average, okay. With peak flow, you're trying to take the highest measurement, okay, you record the highest measurement. Um And so that's the key thing when with peak flow you're taking it, do you do get three times? And I've listed the sort of key steps with explaining peak flow to patient's. Um And remember you always wanna think about the diurnal variation with peak flow um because with diurnal variation, so if the symptoms are varying from morning today, so if the peak flow is varying significantly from morning today, that's very suggestive of um asthma. Okay? But that's your peak flow. I've listened to the A's, I've discussed the chronic management of asthma here. Okay. So remember with asthma, were thinking about the conservative management and the medical management, okay. And I've talked through the sort of key steps that you want to be thinking about in your presentation of management. Uh These are the BTS guidelines, okay? For asthma management, the nice guidelines are a bit different. Um But these are the BTS guidelines. Um So have a read of these management steps. I hope this is clear slide for you. Uh But we'll take a break for uh let's take a break for five minutes. We'll come back, cut 8 27. Uh This session might run over slightly uh sorry about that, but uh respiratory is a huge station, so there's a lot to cover. Um I hope you guys are enjoying um take a break. Thank you, Nish. Um I was just going to add as well. Um If you guys in the break wouldn't mind filling out that survey for attain, I've just popped it again in the chat. If you could fill that out, that would be really good. It just takes a few minutes. So you'll have ample time in your break, um, to do it. That would be really, really useful and numbness. Did you want us to send out the feedback forms? Yeah, we'll send those out now. Yeah. 10 puffs inhaler. Is that per week or per day? So, the 10 puffs, if, if someone's having an acute asthma attack, okay. And they've taken 10 puffs of salbutamol and theirs and their symptoms haven't improved, then they need to call 999. Okay. So that's, that's not a per week or per daily thing. That's if someone's having an acute attack and they haven't responded to 10 puffs of, of the reliever. Okay. The salbutamol, then they need to call 999. Uh huh. Yeah. How can I tell those specifically attention? Because those, uh the main thing, those tracheal deviation to the right lung for that chest X ray. Uh We, we've got a chest X ray station coming up which uh Megan will be delivering. Um, so if you struggling with sort of picking out tracheal deviation, just general principles of chest X ray interpretation. Um We'll go through it in that session. Uh Megan, you sent the feed back home. Yeah, I have. I will just send it again in two seconds. Yes. What we have coming up next. So we'll talk through uh acute COPD uh COPD exacerbations, talk through pleural effusion, approaching plural effusions. We'll go through some data interpretation. Okay, for spyrometry. So um obstructive restrictive lung disease is um flow volume loops. Okay. A lot of people struggle with interpreting flow volume loops. We'll go through that. Uh and pulmonary embolism will do a espa handover on a pulmonary and and a suspected pulmonary embolism as well. Uh Make sure to tune in tomorrow as well. We have, I'll be going through the respiratory examination tomorrow. Um So if you guys tuned into the Thursday session on the cardiovascular lamination, I went through the uh sort of all the sort of physical findings associated with the examination. We went through loads of uh uh videos and pictures and I showed a bunch of tables and stuff with all the relevant clinical knowledge. Okay. And we'll do a similar thing tomorrow with the respiratory examination. Um So make sure to shit in tomorrow. Okay. Let's let's get going then, sorry, sorry, the brakes a bit short. It's just we have a lot of stuff to get to cover with. These are ski sessions So we're trying to cover as much as we can that might show up in your house keys. Um So let's get started. Okay. So the next station, uh we got a, we got Mr Wolverine who has, it was a 44 year old male who has a 80 Pacquiao smoking history. Okay. So a huge history of smoking. So I'm I'm sure you guys uh pretty much thinking about what the likely diagnosis is already, but we've been asked to review his chest X ray and initiate a management plan. So let's have a look at this checks X ray. And what do you guys think? What do you guys think? So, someone's got it right? So this is hyperinflation, okay. Uh So yeah, it's just like hyperinflation due to COPD. Okay. So classically with COPD, you're gonna get hyperinflated lungs, okay? Because you have obstructive lung disease, you get air trapping. So you get hyperinflation. So this chest X ray um classic normal chest X ray, you should be able to see sort of 5 to 6 anterior ribs. Uh but this is, you can see more here. Okay. So this is a hyperinflated lungs. Um Someone said blunted left costophrenic angle. No, this is uh yeah, that's a normal costophrenic angle. But what, what are all of these? Okay. What's these contours here? What's these contents I'm following here. Yeah, that's that, that those the patient's breasts, okay. So it's, it's not cost, they're not costophrenic angles. These are the patient's um breast okay. But that is hyperinflation due to COPD. Uh But let's say a similar patient presents with this chest X ray. Well, what do you guys think about this one? So yeah, the this again, there's still a high, this still has hyperinflation. Okay. So remember that even though even though you might just assume it has, it's a COPD patient is always important to comment on it on a chest X ray. So there's still hyperinflation of the lungs here. But the key abnormality you have to pick up on is that this bunch of uh airspace pacification here. Okay. So we see there's airspace pacification in the left lower lobe, okay. Suggestive of a consolidation here. Okay. And in the context of COPD. So this is indicating this is an infective exacerbation of COPD. Okay. So again, we have hyperinflation as well as consolidation in the left lower lobe, lower lobe. Okay. So let's talk about the, how you would manage an effective exacerbation of COPD. And I like to use the Pneumonic uh the Senna. Uh So if you guys know Abyssinia who's a famous uh Islamic um philosopher, okay. So he's contributed a lot to the world in terms of historical text. He's also contributed today because his name has given us a very nice Pneumonic to remember the management of acute COPD. So let's go through each one and I'll, we'll try and I'm going to test you guys to see if you know what each letter is going to stand for and I bet every single one of you is going to tell me what the day is gonna be standing for here. What's the A is going to be standing for away? Just generally? What do you think about a B C D assessment? Okay. So is for a B C D assessment? Okay, as well as initiate sepsis six. Okay? Because with COPD would think about infective exacerbation. So initiate the ABC assessment and sepsis six. What do you think the V stands for the ventilation? What what specific auction? How are you gonna manage? Auction therapy? Typically not in COPD patient's venturi mask. Good. Okay. So typically for COPD patient, you're going to use a venturi mask to give control the auction therapy because with COPD patient's, you need to be very careful about giving auction therapy particularly if they're CO2 retainers. Okay. So if you do an A B G and they find out that they're a CO2 retainer, uh then you want to give control the auction therapy because you don't want their auction saturations to go too high. So you can use a venturi face mask because that's going to give you a controlled amount of oxygen. And we'll talk about what venturi face masks look like tomorrow. But ideally with COPD patient, you want to maintain SATS between 88% and 22%. Uh what do you think the I stands for inhaler is good? So you give inhaled therapies or nebulized Bronchodilators. See, we're going to go through this quite quickly. Cortico steroids. Good. Okay. So see for cortico steroids, uh E is for eradicate infection with antibiotics. Okay. It's just to make the pneumonic. So with infective exacerbation, you want to be giving antibiotics typically, okay. Uh And for normal saline, okay, we're just trying to make them um okay. So you need to get fluid resuscitation if it's appropriate, the next end is for noninvasive ventilation. Okay. So if COPD patient's, if there hypoxia is not improving, then you need to consider non invasive ventilation, especially bypass, okay, particularly useful in type two respiratory failure, but which you can get with COPD and the last A is just aminophylline. Okay. Not really that use that much for COPD exacerbations. Typically for intravenous therapies, we might consider theophylline, okay. But we're just trying to make the Pneumonic, but that's the sort of key principles of managing an acute exacerbation of COPD. And I've got, let's say we've taken some blood test from the patient and we've got some blood test findings and some observations. And then the examiner has now asked you to calculate the patient's curb 65 score. So, can you guys calculate this patient's curb 65 score for me? Yeah. Yeah. So this patient's curb 65 score is three. Remember in your or ski, I've presented you with a bunch of data. So in your actual Loski, you'd say this, this is a a series of investigations of blood test values and observations taken off, uh whatever the patient's name is and details are. Okay, always start with patient details. But yeah, the curb 65 score here is three. So let's talk about the curb 65 score. So the curb 65 score is basically what we're gonna use to determine the severity of pneumonia. So sees for confusion, the you is gonna be urea greater than seven. Okay. So in this patient, the urea was high R is for respiratory rate greater or equal to 30. So again, the respiratory rate was high here, okay. So that's two points B is for the BP. So if they have less than 90 systolic or less than 60 diastolic, that would give a point as well. Um So BP is normal here, okay? As in it's not gonna give you score a point on the curb score. And the final thing is if the age is uh 65 or above, okay? Um So this patient is 65 okay? So he's literally on the border. So he would score a point. So he would score three points on the age on the respiratory rate and on the high urea, okay. Uh where where would you manage this patient? Are you going to manage this patient in the community or in the hospital hospitals? Good. Okay. So they have listed here. So key things if they have a curve 65 score, 01 is community. If it's two or three more, then um it's in the hospital. Okay, especially if it's three or more particularly that you're gonna be admitted them for a long period of time in intensive care setting typically. Okay. But that's the key principles of the curb 65 score. Uh So next question for you guys, what are the indications for long term auction therapy in COPD? This is a classic examiner question. Okay. You need to know these indications. What do you think must not smoke? Good. That's an absolute crucial thing. Okay. You can't be giving auction therapy typically if patient's are actively smoking, okay, because you know um explosion risk, what else? What are the specific things we're looking at? Saturation is less than 92. So we're not, we're not looking at saturations were looking at partial pressure of auction, right? So, Polycythemia, so what specific value would we be thinking about polycythemia? Uh low hemoglobin. What what what specific piece pa oh two. Yeah, less than 7.3. Good. Okay. So let's talk about the specific indication. So the key thing is they have to be a non smoker. Ok. They can't be smoking typically for to be considered for um long term auction therapy. And if they have a P A 02 of less than 7.3, killer Pascal's on two separate occasions. So it has to be sort of at least three weeks apart. Then that's an indication for long term auction therapy if they have a P 02 of between 7.3 and eight killer Pascal's and they have one of these features. So one of either secondary polycythemia, peripheral edema or pulmonary hypertension. Um those would all be uh that would also be another indication to give a long term auction therapy. Okay. And COPD. So there's another summary slide on the management of COPD. Okay. I'm not going to go through it. But remember again, with COPD management with presenting any management, always think about the conservative aspects, the medical aspects and the surgical aspects, okay. Um So these are the main things to be thinking about in your presentation of the answer. Um And these are the guidelines for the step up therapy and COPD um quickly in terms of the therapy. So initially you start with fiber and Sama, but if you need to step up, you want to assess their steroid responsiveness. Do you guys know what, what are we thinking about with steroid responsiveness? How do you assess if they're going to respond to steroids? He's gonna feel you as a good one to check what else spyrometry goods. Uh So if they have significant reversibility on spyrometry, what what else in the history might make you think that they'll be responsive to steroids? Yeah, they have a history of asthma, they have asthmatic features of the significant diurnal variation. Those are all features that would indicate that they be, they would respond to an inhaled corticosteroid. Okay, if they have a history of a to be as well, good. Um So those are the key things we're thinking about their. Um So you have a read of the rest of it to really understand the key aspects of managing COPD. But now let's go on to another station. So we're in the G P setting now and we've been asked to see Mrs in credible a 44 year old woman who develops shortness of breath. And we've been asked to review a chest X ray and discuss the investigations. So have a look at this chest X ray. What do you think is going on here? Plural fusion good but be as specific as possible. It's not just the pleural effusion, is it? Yeah, it's a bilateral pleural effusion, okay? Or whenever in on skis, it's all about being specific. Okay. It's not, it's not just about giving the by final diagnosis, it's about going through it systematically presenting that always starting with patient details and in your final diagnosis be as specific as possible. So this is likely bilateral. Um this is bilateral pleural effusions. So my question to you guys is, so I'll tell you there's no history of fever, weight loss or malignancy. Does this patient need to have a plural aspiration? What are you guys gonna, what do you guys think? Would you do a plural aspiration on this patient? Someone asked, you answered yes. But why would, why would it, why would you say yes? Why would you, what, what, what with if you say that this is likely bilateral pleural effusions? What's the most likely cause of the Bible of bilateral transit? Eight diffusions. Yeah. Heart failure. Okay. So I would argue in this with this test extrate initially, you don't actually need to do a chest X ray, do do a plural aspiration for this patient. Okay. Because the bilateral transit infusions in this case likely here is likely going to be due to decompensated heart failure. Okay. So you don't actually need to necessarily do a plural aspiration immediately. What what you would do is treat them for having bilateral infusions and then if they're not improving, then you could do the plural aspiration. Okay, because you don't want to necessarily do plural aspirations on people. So that with this test secretary, I'd initially treat them okay. Treat them as you would for decompensated heart failure. And if they don't improve, then think about doing a plural aspiration. Okay. That's just sort of uh general clinical awareness. Okay. So you see bilateral translate infusions, think about heart failure, but then I've got this chest X ray for you. What do you think about this chest X ray? There's a couple of things going on ahead. What do you think okay, someone said unilateral, this uh this is still bilateral pleural effusions, okay. There's still plural fusion on both sides, but someone's described it accurately, it's asymmetrical bilateral infusion. So the right side of fusion is much, much, much worse compared to the left side of the fusion. Okay. So in this chest X ray, we can't assume that these are both transitive infusions, okay, because one is massive, okay. The other one's a bit smaller. Okay. So, on this patient, what would you do? A plural aspiration? Yes, I would definitely do a chest uh your aspiration on this patient. Okay. Uh What do you think about the trachea? What is happening with the trachea? Yeah, the trachea is deviated, right? So the trachea is deviated to the right. Okay. Uh And that this is interesting. OK. So if you know anything about chest X rays, you'll know that typically if there's an increase in volume on one side of the chest, typically that should cause the trachea to be deviated to the other side. Okay. So, for example, if someone had a tension pneumothorax on this side, you'd expect the the trachea to be deviated to the left, right? And similarly, if someone has a massive pleural effusion like this patient, you'd also expect the trachea to be deviated to the left. But in this patient, the trachea is deviated to the right. Can anyone explain that? Why? What, what does that indicate if the tricky is still deviating to the right here. Yeah. Yeah, very good. So it indicates that there's likely a collapse. Okay. So that indicates because it clears deviate, still deviating to the right. It indicates that there's some kind of loss of volume on that side. Okay. So um there's likely some kind of collapse, okay, some kind of atelectasis. Um So what would you be worried about if there's a logo collapse in the context of a massive unilateral effusion? What would you, what would you be worried about this patient having? Yeah, cancer? Okay. You definitely definitely be worried about cancer. Okay. That's the big thing. That's a big reason why we need to do a plural aspiration. Okay, because worried about cancer. Uh Someone else can I show the curricula deviation? So this is the trick here is deviated here, okay. Um So yeah, we definitely be worried about malignancy here. Um So your last patient performed on this patient? Um So can you guys tell me what investigations should you send the pleural fluid for? What general investigation should you send the pleural fluid for especially in this patient? What do you need to send the pleural fluid for? What type of analysis do you need to be done? You definitely need cytology. What routine investigations do you do for pleural fluid in general? What routine investigation generally? Uh So light criteria, that's not a that's not an investigation. Okay. That's the type, that's something you used to analyze the blood test levels. But what specific, what do you need to send it off for LDH? Good protein PH is useful as well to send it off for uh good. Um So yeah, I said these are the sort of routine investigations for pleural fluid. So ph protein count L D H M C N S. So, microscopy cultures, sensitivities and cytology. Okay. So these are all the routine investigations but make sure you mention cytology, okay, especially in this patient who are worried about having cancer. Okay. So let's quickly talk through pleural fluid analysis. So remember with the infusions were thinking about is there either a transit eight or an exit it? Okay. But transit dates, the main causes are your heart failure, okay? Or your liver failure, nephrotic syndrome and your executive causes, okay. Um So these are causes that basically you having stuff leaking out into the pleural fluid. So stuff like malignancy infection, okay, pneumonia. Um There's other causes, well, there's a bunch of other causes but that we really want, that's the main thing you want to do with the initial analysis, you want to determine is it a translated fluid or an executive fluid? And then if you're struggling, okay, then you can use what's called light criteria. So if someone has a total protein which is very close to 30 okay, and you're not able to accurately distinguish if it's a transitive effusion or an executive infusion, then you can use what's called light criteria to help you differentiate. So, the key thing with lights criteria is that the, it's the pleural fluid that comes first. Okay. So you assessing the pleural fluid and dividing that over the serum serum level. So if someone has a pleural fluid divided by the serum protein level, uh greater than 9.5, that's indicated of an executive infusion. Okay. So generally if you're having stuff leaking into the plural fusion, that's a executive infusion. Okay. That's an exit it. Okay. So someone's got very high plural protein levels, that's suggestive of exit it. Similarly, if the LDH in the pleural fluid is super, super high, that's suggestive of exit it. Okay. And then uh the value we use is no 0.6. Um And if someone has an LDH, more than two thirds of the upper limit of the serum LDH, that's also part of the criteria for an exit it. Okay. The key thing is that you only need one measurement, okay. That's to um to rule in an exodus, okay. You only need one of these to be true too, too uh to stay that this is an accident. Okay. So if they have any one of these elevated, that means it's an accident, okay. In order to be a transit date, you have to all of these need to be satisfied, okay. In order to be a transit native pleural effusion. So that's, so that's the light criteria. Um There's also a bunch of other things that you can do, okay, which I'm not gonna talk to about. These are some other stuff you might get asked about. But the key thing with the pleural fluid analysis is that you need to know the lights um criteria. Okay. So I've given you a practice pleural fluid um scenario. So uh got some investigation. So the appearance of the pleural fluid is bloodstained protein content is 40 g per liter. OK. There's negative gram stain negative cultures. There's abnormal cytology and there's low glucose. Uh What do you guys think about this pleural fluid? Um What do you, what do you think about the patient? Cancer? Good. Okay. So this is a malignant infusion. Okay. This is very suggestive of a malignant infusion. Okay. Bloodstained high protein. Okay. So it's an exhibit abnormal cytology. Okay. That's characterised, that's indicating malignant cells and low glucose as well. Is uh is also it can also be caused by malignancy. So these are all features of a malignant infusion. So my question is what other investigations should be performed on that patient. So, we've confirmed that this patient has a malignant pleural effusion. Can you guys tell me what other investigations would you do for suspected lung cancer? Yeah, ct chest, abdomen pelvis. Okay, to stage bronchoscopies, pet scan goods. Uh Any blood tests you think about, would you guys do any blood tests for blood cancer? Yeah, calcium is always good to measure and with cancer in general. Okay. We're thinking about hypercalcemia good. So I've just listed some basic uh investigations. Okay. Um, in terms of your blood, so full blood count, thinking about worried about any sort of bone marrow infiltration, bone profile to get the calcium level. Uh LFTs. Why is LFTs useful? Why would you need your LFTs? Yeah. Mets. Okay. So if anyone has, uh if they have evidence of liver metastases, you want to check the LFTs units as well. Very, very important. Okay. Check renal function. Um again, like you said ct thorax. Okay. And ideally you want to extend that up to the neck and the upper abdomen to do um accurate staging uh pet scan as well as useful to help stage the cancer. Uh bronchoscopy super super important. Okay. So sticking a tube down and characterize the cancer and you can also take biopsies using the bronchoscopy as well uh spyrometry. So this is very interesting. Why do you need to do spirometry in lung cancer? Why is it important? Why do you need to do lung function tests in patients with suspected lung cancer? Uh as a pre operative assessment. What do you need spyrometry for? Yeah. So based function. So essentially you you can only if you're gonna remove a lung, they need to have some some level of reserve function. Okay. And that's that's why you need to do the spirometry to check their FTB one FEC to check that they're able to have an operation. OK. A major operation like a lobectomy or a pneumonectomy. Um So that's why we need to do spirometry to check if they have residual, if they'll have residual lung function to, to be able to cope with having a major operation like that. Um So that's lung cancer. Uh Still we're still on. Uh So I've got this slide on lung cancer for your revision. Okay. This is taken from our finals easy series if you want some revision on different types of lung cancer. Um So I've given you another question. So a plural aspiration is performed on another patient. A zeal Nelson stain is performed and microscopy has shown. So here's the image here. Can you guys tell me what is the findings of this total if you do this microscopy? So I've, I've asked you to describe the findings. Okay. I haven't asked you to give me the diagnosis. I see a lot of you giving me the diagnosis. What describe what you see on the image? Yeah. Get acid fast bacilli. Okay. That that's what they say. So if you guys know your micro micro biology. So these are bacilli. Okay. We know have you used the Zeal Nelson stain? Okay. So we got this alli which and the character City. Uh It's an acid fast Bacilli. And like most of you said this is uh indicative of tuberculosis infection. Okay. So this is a tuberculosis pleural effusion. Um can you guys tell me? So if I ask you, how would you manage active TB, what would you be talking about? What are the different things you would be mentioning? Right. Good. So that's the sort of standard uh anti, anti TB medication regime. So let's talk about, quickly talk about anti TB drugs. So there's four main anti TB drugs you guys need to know about ice in eyes, it from person present amide and myambutol. Okay. These are the four standard TV drugs and it's very, very important to learn the side effects of these medications. Ok. It's very, um, topical and exams. Okay. But these are the main TV medications and in terms of the standard TV regime, um, it's typically two months of all four therapy. So two months of all four and then four months of H R s of four months of ison ISAT and four months of resumption. Okay. Um, so that's the pretty standard regime for active TV. Okay. We've got another station. So, um, I'm not gonna lie eyes. We'll probably finish around, uh, 10 past nine quarter past nine. Sorry. We, this is quite a long session but I promise future sessions will be shorter. Um, so we've got a, we're, we're a foundation one year, one doctor. Uh, we're in the orthopedic ward and we've been asked to see Mr Ethan Hunt a 54 year old male. Um, the task is that the nurse from the orthopedic ward has bleeped you about this patient who has a new auction requirement and he underwent an elective total hip replacement yesterday. So, can you guys tell me what, what the, what diagnosis would you be thinking about? Straightaway? Even before you've entered the station? Yeah, so even before you've entered the station, you pretty much know the diagnosis. So it's likely a pulmonary embolism. So, and we've been asked to do an esper handover on a patient with a suspected pulmonary embolism. Um This is the basic template for doing an ESP are okay. Um I'm not going to go through this because we went through this last week in the cardiology one, I'm just going to go straight into giving you a example template of how I would go about doing an esper handover for patient with a suspected pulmonary embolism. So again, with the introduction, clarify patient details and clarify who you're calling. So I'll say something like hello, I mosque easy. The F I one doctor on call in the orthopedic ward. Is this the medical registrar? Okay situation. So situation is where you're giving the breaking news of the patient. So giving the reason for why you're calling that person. So I'll say something like I'm calling because I would like you to urgently review a patient on the ward who has now developed dyspnea and an increased auction requirement. The patient is called Ethan Hunt, a 44 year old man and I'm concerned that he has developed a pulmonary embolism background. So background is where we're giving objective information that we know about the patient. Okay. So any investigations that we've done, any history that we know about the patient, so I could say something like his Disney started half an hour ago, including theoretic chest pain, E C G was performed and showed sinus tachycardia chest X ray was normal. He had a total hip replacement two days ago due to osteoarthritis and has been bedbound since. Okay. So I'm giving objective history. Okay. I'm giving what is definitely known about the patient assessment is what your examination findings are okay and what the patient's news news score is. So I would say the patient currently has a new score of 11 due to being tachycardic at 100 and eight speech per minute. BP is 89 by 64 respiratory is 26 saturations are 92% on 100 100% auction via a 15 liter non rebreather mask. So remember when you, whenever you talk about auction therapy always clarify be as specific as possible. So how much oxygen, how are they taking the oxygen? Uh say he is alert and a federal he has been on enoxaparin for venous thromboembolism prophylaxis. Okay. So that's your assessment and finally your recommendation. So this is what you want the person to do. So, I'll say something like I am worried this patient has a pulmonary embolism, the patient's well score is high. And I've organized, organized a CT P A, I've given one dose of low molecular weight heparin. I would like to ask if there's anything else that you would like me to do for the patient? Gave very, very important statement to mention. Uh Would you also be able to come and review him as soon as possible and assess if he needs thrombolysis and needs to be moved to I T you, please. Thank you. Okay. So remember the big thing you worry about in primary embolism that you need to call a senior for is if they need to have urgent thrombolysis. Okay, if that, particularly if they're hemodynamically stable. Um So that's the big thing you might be asked to do a ESPA handover on. Um but that's the sort of approach template approach I I could use in an office key. Okay. It's just an example. But just again, follow those principles of each stage and here's the summary of the management of pulmonary embolisms. Okay. So the key thing, if they're hemodynamically unstable, then you can, you can try trumbull icis, okay. But typically this is a senior decision if they're stable and then you try anti coagulation. But there's different indications for specific anticoagulations depending on if they have renal impairment or they have a history of active cancer. It's anti coagulation is contraindicated. Then you can try using an inferior being a cave of filter. Okay. And this is all based on the nice 2020 guidelines. Okay. We got our last station now we're gonna quickly talk to his spyrometry and data and then we will be, we will be done. So we're in the G P and we've been asked to see Mr Darth Vader, a 74 year old male who has a 30 pack year smoking history and he's just performed a spirometry test for you. And you've been asked to describe the spyrometry findings to the examiner. Um So I've made this little slide to basically, if you, if you, you might get asked this in your rosky to basically label a spyrometry graph. So you might be asked to label the different volumes on a spirometry or be asked to calculate a specific capacity. Okay. So I'll just put this slide in for reference in case you actually get asked about it, but it's, it's useful to know this uh spyrometry interpretation knowledge. Uh Before we go into actual spirometry interpretation, it's important to understand the principles of lung disease. So, with lung disease in general, we're thinking about is it either an obstructive lung disease or a restrictive lung disease? So, with obstructive lung disease, the main causes are things like COPD asthma, bronchi excess and cystic fibrosis with restrictive lung disease. With the main sort of causes would think about is interstitial lung diseases like pulmonary fibrosis, obesity. If they have any deformities like scoliosis or any chest wall deformities and if they have any kind of respiratory muscle weakness. Um for example, if they have Guillain Barre syndrome or my senior Gravis or Phrenic nerve policy, okay. Those can all cause restrictive lung disease. So, the key thing with obstructive lung disease, there's difficulty getting out of the lungs. Okay. But with restrictive lung disease, uh the lungs lose their compliance, okay. So the lungs can expand properly. So that's why it's restrictive lung disease, okay, the lungs can expand properly. Those are the sort of key concepts were thinking about. So spyrometry. So this is a basic sort of graph of spyrometry which you might get in your Rosky. So we got volume on one access time on another access. So this is a typical loop for spyrometry, okay for in a normal patient. And let's label this. So this volume here. So the maximum volume that the graph reaches, that's your forced vital capacity, okay, or your FV. See. And if we have, so we have time on one on this axis. So at one second, if we take the volume at one second, that is your FPB one. Okay. So you're forced expiratory volume in one second. Okay. So very important to you understand this basic sort of labeling. So let's talk about obstructive and restrictive lung disease and what they look like on spyrometry. Um If you see this in your Rosky, what would you think this graph is representing? Is that obstructive or restrict restrictive lung disease. You see this, what, what is this line representing? Yeah, this is obstructive lung disease. Okay. So with obstructive lung disease, there's difficulty getting air out of the lungs. So the key things with obstructive lung disease is that your FPB one is very much reduced. Okay. Your FEC might be normal. Okay. But it will be slightly reduced. But here we can see that the line is still increasing. Okay. So the FEC is likely higher than what this graph suggests. But the key thing is with obstructive lung disease, the FVB one will be significantly reduced much more compared to the F B C. So the ratio of FPV one to F E C will be less than 70%. And also if you give bronchodilators and if the FTB one improves, um that indicates asthma okay, that indicates reversibility. Um So if someone has obstructive lung disease, but if, if the F E B one improves with Broncho dilators, that indicates uh reversibility which indicates asthma. Uh if there's no reversibility, then you're thinking about other causes, particularly COPD. And so we talked about obstructive lung disease there in terms of restrictive lung disease. So this is a graph which is much more typical for restrictive lung disease. So here we can see that the F E Y V one is reduced but not, not that much reduced. Okay, not that much compared to a normal patient. But the key thing is that the F B C is much more reduced. Okay. So that's the key thing where there's a restrictive pattern on spyrometry, the FEC is will be reduced. So with restrictive lung disease, uh the key principles are is that both the F E B one and the F B C will be reduced. Okay. And because they're both being reduced because they're both being significantly reduced in terms of the ratio of both of them, it will either be normal or even high okay or even above 80%. Okay. So that's the key things with restrictive lung disease. Um So I hope that's clear, that's the sort of basic principles of diagnosing obstructive lung disease and restrictive lung disease. So we just talked about spyrometry, then let's now move on to talk about flow volume loops which a lot of people sort of struggle on getting their heads around. Um So let's talk through flow volume loops. The key principles is that with the flow volume loops, the access above the volume is your expiratory phase. Okay. So everything above the volume axis is representing the expiatory face and everything below the volume axis is representing the inspire a tree face. Okay. So above his exploration bolos inspiration. So this is a typical graph for the flow volume loop okay of a normal patient. Okay. So this is representing the expiration and this is representing inspiration. Okay. Um But the key thing is this is representing how the speed at which someone uh expires are inspires. Okay. So you can see here if you think about expiration, if you blow out into a spirometer, it's gonna increase quickly at the start, right? You're, you have a high flow initially. Um but slowly as you breathe out, more and more, it's going to slow down. OK. The speed at which you actually breathe out is going to slow down. So actual flow is going to decrease here. Okay. So that's this, that's why you get this sort of shape with the expired your face again. Similarly, with inspiration, when you breathe in, you're gonna breathe in very quickly at the start. Okay. So your flow will increase at the start. But then as you breathe in for longer longer, it will slowly slow down. OK. So your flow will decrease over time. Okay. And that's your sort of loop, okay. That's your flow volume loop. And that's for a normal patient. Uh Let's you might be asked to sort of label some key points on this type of graph. So the highest point on the flow volume loop that is representing your peak expiratory flow rate, okay. Your peak flow, that's the highest point on the graph. And there's some other, in terms of there might be some other volumes you might be asked to label so the point from the highest volume, okay. So in this case, it's six liters to the end of the axis that is your total lung capacity. Okay. So that's your entire capacity. That is your lung can handle. Okay. Um Can anyone tell me what this volume is here? What do you guys think from this volume? I'm representing here is representing the volume that's in the lungs after expiration. Yeah. So that's your, yeah, this is your residual volume good. Okay. So this is the volume that's left in the lungs after a maximal expiration. Okay. So that's your residual volume. And so if this is your residual volume, what do you guys think this volume is here? Oh What's the capacity? What is there? What is this bottoming representing here? So the the it's a capacity. Yeah, you're right. So it's the vital capacity. Yeah. Okay. So your vital capacity is basically the difference between your total lung capacity and your residual volume. Okay. That's your vital capacity. Okay. So that's the sort of key labels on a um flow volume loop. So let's talk about some pathology. So if the flow volume loop is of your patient is here, what does that indicate? Yeah, it's obstructive lung disease. Okay. So they with an obstructive pattern of lung disease, you have difficulty getting air out. Okay. So your flow is going to decrease. Okay. You see your peak expiratory flow is much lower. And also you can see that the actual graph has shifted to the left. So what does that suggest about that means that the residual volume is much higher. Okay. So you can see that the residual volume is higher because with obstructive lung diseases like COPD, your residual volume is going to increase because there's aired trapping. Okay. So the actual volume in the lungs after expiration will actually be higher. Okay. So that's for obstructive lung disease. Um So yeah, so your residual volume is increasing as well as your total lung capacity. But in terms of the other type of lung disease, a restrictive lung disease, this is what the loophole look like. Okay. So the loop has shifted to the right. Okay. And I like to if you want to remember, you can remember restrictive for right. OK. So with restrictive lung disease, the flow volume loop shifts to the right. Okay. And you can see that the expiatory flow rate is lower, okay. The peak expiratory flow rate is lower and the residual volume is lower as well. Okay. And the actual total lung capacity is a lot lower as well. Okay, because your lungs are not expanding properly. So with the restrictive lung disease, your your residual volume will reduce as well as your total lung capacity. Okay. Okay. This is the we got, this proves the last slide, okay. This is basically a practice spyrometry interpretation. So if you get shown this in your Rosky, this is the kind of way I think you guys should approach in presenting spyrometry. So when you're describing spyrometry, the examiner always start with the patient age details. Okay name age say that this um this is a data representing spyrometry results of a patient. Okay. Talk about the quality of the spyrometry. Okay. Is that adequate spyrometry? Um talk about the number of breaths taken. Okay. So the number of loops for example and then you can talk about the specific data so mentioned the FTB one of central predicted. So in this patient, the percentage predicted is 60.6% then mention what the percentage predicted of FEC was. So this is 97.5, then mention what the ratio is. So the ratio here is 67.9. So that's a low ratio. So it's less than 70%. Uh Then you want to mention is there any bronchodilator response? So I haven't mentioned anything about broncodilator says. So you can mention there's no results of bronchodilator therapy and then talk about the actual grafts. Okay. So the shape of the curves. So if you go through each one, so uh if you look at the actual spyrometry here, so we got the normal one here and we can see the patient's here and we can see the flow volume loops. You got the normal flow flow volume loop here and the patient's here. So what were the, what do you guys think is the pattern on the graphs here? And both graphs? Yeah. So it's an obstructive pattern, right? So here we have this crap is representing that the patient has a low FVB one but a slightly decreased FBC, okay. And this patient, this flow volume loop is indicating uh so the the flow volume loop has shifted to the left, okay. And there's a decrease, there's an increased residual volume, increased total lung capacity. So that's indicating uh that also indicates an obstructive pattern on the spirometry. And also this sort of scooped out appearance here, that's also pretty significant of um things like emphysema. Okay, classically with emphysema, you get this sort of scoop appearance here as well during the exploratory phase for some reason. So that's suggestive of again, it's, it's all indicative of obstructive lung disease. Um and then, and then you can give your final diagnosis. Okay. So in this, in this station, the patient had a strong history of smoking, okay that we were talking about Darth Vader who had a history of smoking. So with a history of smoking in the context of an obstructive pattern on spyrometry, I would say that the likely diagnosis is COPD. Okay. So that's how I would go about presenting spyrometry to your examiner. Okay. Again, with data, it's all about going through it systematically, okay. It's not just giving the final diagnosis, it's just talking through the data and explaining what your thought processes. Okay. So that's how I would break down the data. Um Okay, this is the last slide. OK? I promise this is the last slide. So if you guys get asked about transfer factor. I've just put this slide in for reference. OK. The key thing with transfer factor is that it helps you differentiate the causes of interstitial lung disease. Um So if the, if the restrictive lung disease is caused by interstitial lung disease, your transfer factor will decrease. OK? If the restrictive lung disease is caused by other, other things like respiratory muscle weakness or thoracic cage deformities, then you'll have a normal transfer factor. Okay. So again, it helps you differentiate the causes of restrictive lung disease. If you're, if you have reduced factor, reduced transfer factor with a restrictive pattern on spirometry, that indicates interstitial lung disease. If it, if your transfer factor is normal for high, that means that it's unlikely to be interstitial lung disease is more likely to be one of these causes. Okay. And you can have a read about some of the other disturbances that you can get with transfer factor. Okay. But that's clinically, that's the main thing it's being used for these days. Okay? Oh, that was it. That was a long one guys. Thank you for turning in. Uh respiratory respiratory itself is a huge Oscar station. Okay. There's a lot of content. Hope you guys found it useful. I'm sorry if it was a really long session, but I hope you guys can understand that I had a lot of content to get through. But thank you for staying, staying with us. You guys a lot of you stayed around till the end. Um, uh, yeah, I went to another event and I came back and you're still doing the lecture.