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So I think we have a few people now. Yeah, hi, everyone. Um, just bear with us. I think we'll wait a couple more minutes. Um, wait for a few more numbers and then we can go from there. You're on mute, just letting you know. Sorry, I was sending a voice note to someone in the committee. Fine. So I think we'll start introducing things and then hopefully by the time we start, um, a few more people will join. Hi, everyone. Um, welcome to the start of our final series. So we're part of a society called Metic Teaching which, um, so we've been around, er, a few years now, er, previously called Thursday 15. Er, but that's now the name of this final series. Um, so the plan is that, you know, we'll cover a range of questions around 13 to 15, um, each session. Um, and, well, the aim is to kind of cover most of the core topics um over the course of the, the series, uh and just to greatly introduce ourselves. So my name is Mehmet. I am currently in F one working at the Norfolk and Norwich Hospital and I'm Nandini, I'm an F one working in NHS Lanarkshire. So, at Monklands Hospital and today, as I'm sure you're all aware, uh, the, the topic is respiratory medicine, um, and we'll kind of split up the topic into acute conditions and chronic ones. Um, and in terms of the timeline for the series, er, so this is already on our medal page as well. Um, in the advertisements that we've been sending out, er, just so that you're aware, schedule is also here if you want to take a quick screenshot as well. Er, but we recommend if you are keen, then just subscribe to our medal or follow it. Um And that way you'll get notifications and you'll be more up to date uh with our sessions. All right, without further ado, I think we'll just carry on. Um, hopefully a few more people will join. Um So as I was saying, so we'll go through a series of questions. So we'll give you around a minute per question. We have 14 questions for today and then if you just jot down your answers on a piece of paper or somewhere and then we'll come round to giving you the answers and when we do so as well, um we'll, we'll go through the conditions as well that the question focuses on. All right. So I'll start the timer in a minute and then we can go from there. Ok. So I think we'll get things started now. So around a minute question. Ok. Um So good luck. All right. So hopefully we had a go at all of the questions have well done for that. Um So as we go on to the answers, so the way that we'll do it is, uh, we'll, we'll show you what the answer is first and then we won't really delve into the question at that point. Um I'll touch on the conditions, some of the key aspects of it and then we'll come back to the question after that and we can break it down together. Um And just a th another thing that I forgot to mention at the start. So obviously, the MLA syllabus is quite new now. Um and it focuses not only on the conditions but also on the presentations um and personally, from my own experience as well. And as I've been told by other people as a junior doctor, being able to like recognize signs and thinking about the differentials, I think is so key, especially like a lot of the times you're going to be the one reviewing the patients um when the consultants aren't better. So you need to be able to pick up on these like nuances or these uh these signs have a think about what's going on. Um So we've got a nice structured way er for a bunch of respiratory signs as well to have a think about the differentials. Um So we'll go through the key ones for those presentations as well. All right. So let's have a look at the answer. So, question one. So this is the question of the young boy, um, short of breath, they had a dry cough but otherwise, er, not too unwell, they took a few days off school. Um, so the question asked what the GP would do next in terms of their management. Um, so hopefully you would have picked up that this question is about a condition called acute bronchitis. All right. Um So actually, the management plan here is not to really do all that much. Ok. So I'll have a look at acute acute bronchitis, have a think about it and then we can come back to the question at the end. So, um acute bronchitis thinking, think about the name. So bronchi. Um so this is essentially inflammation of the bronchi. Ok. So it's a type of upper respiratory tract infection. Um And it's usually viral in nature and self limiting as well and it usually lasts for around a few weeks. Um But for some people, the cough can for, for a bit longer than that. Er But nonetheless, uh patients shouldn't be too worried in terms of the risk factors. So it, it, it can kind of affect any anyone. But um some things do make you a bit more prone to smoking. A history of C FCO PD. Uh But as I mentioned in this case, the patient is it, it's an idiopathic case, um in terms of the common organisms, anything viral that affects the upper respiratory tract, like your Rhinovirus, influenza, parainfluenza. I think it's key to distinguish it from pneumonia. So, one of the key defining features is the fact that this is upper respiratory as opposed to lower respiratory like pneumonia. Um So in terms of the presentation, er, the fever is often mild with that said, um sometimes it can be an acute bronchitis, upper respiratory, but the patient might be a bit more unwell and we'll touch on that when we look at the management side of things, the cough, like I said, can usually last up to three weeks, uh but it can persist beyond that. Um and it often it's nonproductive or minimally productive. So again, it's quite important to think about it when distinguishing from pneumonia where the patient might be a bit more, might be producing a lot more ski and phlegm. Um, patients are short of breath, they might have a wheeze as well, especially if they have underlying asthma. All right, in terms of the examination, more more often than not, it will be completely normal. Ok. And again, that's another way to distinguish it from pneumonia. So you won't have any focal chest signs, uh but you might have a wheeze, as I mentioned. Um, so often the systemic features. Uh So general unwellness like a high fever won't be present, uh but they're more likely to be present in pneumonia. It's often a clinical diagnosis which is important. So you don't really need to do much investigation unless you are suspicious. It could be a lower respiratory tract infection. At which point you do the usual test beyond bloods, like your um like like a chest X ray management wise, just rest. All right. So offer analgesia advise, rest. Um Like I mentioned, it's of often self limiting in nature. One thing that is mentioned on the nice guidelines. So the C KS website um is that you can offer antibiotics even if it is um still in acute bronchitis because some patients might uh be a bit more systemically unwell, er, the patients more likely to be on one of those, a bit more elderly, those with preexisting m er, comorbidities. Er, and so something that's mentioned on the C KS website is to really think about, er, the A, the C RP and guide based on that. So, if I remember less than 20 you don't offer antibiotics 20 to 100. You consider it. So that's a gray area. In terms of your exam, they won't give you ACR P in that region. I think that would be quite unfair. Uh, but anything beyond 100 it does say give immediate antibiotic. So that's a number to be, to be, er, wary of um, oh, going back to the question. So some of the key features to think about. So the patient had shortness of breath a dry cough had some nonproductive, they only had a mild fever, un remarkable respiratory exam. So, already you're thinking they're not that unwell, it's probably not a pneumonia and it's more in keeping with an acute bronchitis. Um, and as we discussed with the management advised rest paracetamol for analgesia ensure that they're well hydrated. Ok. So the first presentation, so obviously we mentioned shortness of breath, er, and that's gonna be quite er prevalent as we look at all the other respiratory conditions. Er, but let's have a think about it. So I'm not going to dwell on this too much now. Um You're welcome to take a screenshot. We'll also upload the slides, er, once we're done with the session today, so you'll have this as an available resource, but you can take a screenshot now. Um So when you're thinking about shortness of breath, respiratory is a big area, but obviously think about the cardiovascular side of things and another big one is uh psychological, psychological, like anxiety or a panic attack. Um It's a different er, re er, so you have this diagram which is quite nice. Um And I would recommend this when you're thinking about differentials, think about key features that will distinguish one differential from another and that might just be like a symptom, a sign, a key investigation cos when it comes to your exams, it's just gonna be those little points that's gonna distinguish from one, condition to another and that way, um, a lot of the questions are now two steps in that you have to a think about the diagnosis without them telling you. And then you have to think about like an investigation and then a management. Um, so if you can nail the diagnosis side of things and I think this really does help. If you do that tactic, then you're only really thinking about the investigation and management. All right. Question two. So this was the lady that she underwent surgery recently uh following a fracture. Um She suddenly felt breathless pain in the right thoracic region, worse on inspiration. So, pruritic chest pain, uh observations wise, tachycardic, blood pressure's fine. Uh So they're not unstable and we'll come on to that shortly, respiratory rate is raised. SATS have dropped slightly. Uh temperature is normal. Um So how, how should they be managed based on the top differential? I think this is a straight forward one. we're thinking about uh a pulmonary embolism. So the answer for this was c so anticoagulate them. All right. Uh Let's have a quick think about pulmonary embolism. So risk factors. Um I thought this was quite a nice memory device one that I definitely still use now when thinking about and it's quite good one if you want to show off if a reg asks you or something. Er but the memory device is CT SV play. So obviously, because you're gonna be asking for A C TDA. Er, that's why it's the memory device but CT S play. So, CT S VP, er, so think about the CS, the key ones there, someone who's got a malignancy or cancer chemotherapy, er, patients, er, factor C deficiency, er, T so trauma as in this patient. So, er, patients, the, the surgical patients are most at risk of a pe are the orthopedic ones or the ones er, er, following trauma. So that, that was the case in this question that we did as well. Um, patients with l er, recent travel, et cetera. So I can leave this as a resource for you if you want to take a screenshot by thought, it's quite a nice, er, memory device to use presentation side of things. I think this is quite good to think about, especially now clinically, er, now that I've been working as an F one, you get a fair range of patients, um, in terms of how they present with a pe. Um, so it's not always going to be disastrous like a massive pe. Um, so obviously, if they have a massive pe, the patient's gonna be a lot more unwell, they might even crash. Uh, they have really severe pain often, um, and they're very short of breath and desaturating quite substantially. So it might drop to like the seventies eighties. Um, if it's a smaller pe, you will still see shortness of breath. Um, so actually, er, tachypnea, so raised respiratory rate is your most common sign. Uh which is also strange because um uh when we come onto the scoring system, they don't actually take that into account when we do the well score. So, which is strange. But anyway, so you have the raise of respiratory rate. Um you, you often s you might see hemoptysis, I think in around 50 60% of people er p chest pain um and thinking about the E CG. So this is obvious this is quite classic for um your finals sinus tachy is your most common finding? All right. So this whole S one Q three T three know it for exams. You don't really need to know it in real life. Um I was speaking to a respiratory reg the other day who's been working for a, for a while. He's only ever seen a couple of cases where they've seen that and even those are a bit questionable. Um So just be aware of the words, but I don't think you need to be able to read it. Um, and some patients might also have a chronic pee, but that's usually if it affects their microvasculature, well score. So you all know about this. Um So used to estimate the risk of a pe the classic numbering is greater than equal to four, think high risk, do A C TPA, less than four, slightly lower risk D diner. So know this for your exams in real life. It's more just about clinical suspicion, you still do a well score, but even if it doesn't reach the four, then, you know, you're, you're putting yourself at risk if you don't do, if you don't escalate it further. So oo often, especially in my trust, you see, C TPR is a lot, a lot more often than not. Er, but for the patient that we looked at the wells score was a six. So um it's pe number one diagnosis, it's a bit of a cop out that one often you're gonna say yes. So that's already three points. Um They were tachycardic, they had recent surgeries. So that puts them on to six points. Management wise. First thing you think about are they hemodynamically stable? So they spp over 90 if yes, respiratory support, anticoagulate them. Anticoagulation will vary depending on your your hospital trust. But for the purpose of your of your exams, think go out cos that's the nice guideline and my trust, for example, we use a treatment dose of dilta which is a low molecular weight heparin. Er but nice guidelines would say it expand River Roan. So have that in mind. Um one thing to be aware of and this is important for exams as well. Um Think about the eg fr for the patients. If it's too low. So less than 15, then you need to be a bit more cautious with anticoagulation. Um In which case, you would give a low molecular weight. Heparin or unfractionated heparin. Ok. Um, if they're not stable so they are unstable, er, massive pe, so that's the buzzword. Um, in that case you would thromb, um, well, sorry, you would not thromb. Er, you would call a senior who would then think about the thrombolysis procedure. I say that because, er, for my SF E interview I was getting absolutely grill. So they were saying what would you do as an F one? And they repeated that. Um, and I almost didn't stand my ground there. But yeah, just that wouldn't be the F one's job, but for the sake of exams, you do thrombolysis. Um, and beyond that, you do an endy uh presentation wise. So. Oh sorry. Yeah, so sorry. We've got the question here just to break it down again, recent surgery, recent fracture. So those are already risk factors. They were breathless pain in the right thoracic region. So often they will be able to kind of localize it to one side, depending on which um, which of the airways is affected. Sorry, which of the vessels is affected. Um, it's worse on inspiration. So, pleuritic tachycardic, but the blo BP was normal, so less stable. Um And so in this case, you would just support them respiratory wise and then anticoagulate. All right. So another presentation. So we touched on chest pain, more specifically pleuritic chest pain, but I've just included chest pain in general. So we have the respiratory side of things. Again, take a screenshot, cos there's some other key ones like gi cardiovascular musculoskeletal. Um But yeah, so you have the various respiratory presentations um and how you distinguish between them. Again, another diagram you can use as well. This is the one that I actually used. Um And I still kind of remember till now. Um So you have that as well. Pleuritic chest pain, just think about, you know, conditions where it's the pain is going to be worse when the lungs are moving. So what you need to be thinking about there is where do the lungs actually touch? So what is the lung in contact with? So you have contact with the media Styn. So you have the respiratory. So, so the cardio, the cardio cardiac side of things. So you're thinking things like pericarditis um and abdominal as well. But for the sake of this presentation, just think about the respiratory, which I've highlighted there. Um, and some examples there, but I won't dwell on that for too long. You can go through that in your own time after you take a screenshot. Question three. so this is the patient who had a productive cough. They were short of breath. Sorry, I haven't got, I forgot to write short of breath my bad. Um, they were orientated to time place and person so they're not confused, they're pan allergic um, observations wise that they were febrile. Er, they have a slight oxygen requirement, not too high, only on 2 L. Um And they're tachycardic as well, blood results. So white cells and neutrophils are raised does sound like an infection. So that's expected, hemoglobin is a bit low, but it's not really relevant here. Uh C RP is raised. So again, I'm thinking inflammatory markers. Um and the other one that's key here is urea as I'm sure you will know the, the curb score because this is a pneumonia. So we'll touch on that shortly. But the answer was a for this. Um, so referring to A&E A&E uh for, for treatment with doxycycline and the next question, so we'll cover both of them and then we'll think about pneumonia. So which of these, these are a recognized cause of hospital acquired pneumonia, pseudomonas, Egana. So let's think about pneumonia. Straightforward. One. Obviously, they drill us into you at uni er, so I think two definitions of which are quite important. So we know community acquired pneumonia, you get it in the community, it's an infection. Er, but just the er, the key number to think about of hospital acquired pneumonia is pneumonia after you've been in hospital for at least 48 hours. So if it's still within that 48 hour window, they've probably picked up in the community and just come into hospital. Um, so it'd still be considered a cap another really nice diagram. So I encourage you to use this for revision. Um, so we're thinking about the various organisms. I haven't got a memory device as such for these. You just kind of need to learn them. Um But you have the typical and atypical organisms, your hospital acquired organisms and then your aspiration pneumonia organisms. All right. Um So from the cap side, the community side, let's think about the typical. So you have strep pneumonia uh and this is by far the most common. Um Sorry, I should always mention I should have mentioned, sorry, you always do a Sputum MC NS uh for pneumonia and then you can think about the organism. Sorry, you don't always do it often in practice, you see that, uh, you know, you just put them on um, er, a, a type of antibiotic based on your trust guidelines. Er, but you only do like a blood culture to see what the organism is if they're really unwell, er, or if they're spiking their temperatures. Er, but for the sake of your exams just say that they, you would do a Sputum MC NS and until then you just kind of put them on broad antibiotics. Um, so then thinking about the organisms so I won't dwell on this too much. Like I said, it's just a case of learning a few that I would highlight. So, Staph aureus just think IV drug users and that it can turn into a cavitating lesion or an abscess, er, klebsiella think alcoholics. Ok. Um, from the atypical side, of things. Er, lesion Ella, the buzzword air conditioners. So, ac patients can have hyponatremia, they can have abnormal LFT S. These are all key features for, for the sake of exams. Uh, chlamydia psittaci. So I think birds or if they have pet birds like parrots, um, that's, that's often the classic. Um, he sisters Juve. Er, so that's HIV, so that's AIDS or HIV defining, but just note that is still not the most common organism in HIV patients. So it's still strep, streptococcus pneumonia. Um, and yeah, so hospital acquired pneumonia, uh pseudomonas aosa think about that for cystic fibrosis and bronchi. So that's important as well. Severity wise curve 65 we touched on it. So already just you see the number 65 automatically think age, so that one's easy to remember and then the rest of it. So you have C for confusion, the, the urea respiratory rate and then the, the BP. So for the patient that we looked at, they had a score of uh two and we'll look at what that means now. So a score of one, you can treat them in the GP. Um, or if they're in the hospital, you can kind of give them oral antibiotics and discharge them and then follow them up for a repeat chest X ray in 4 to 6 weeks time score of two. you can admit them to the hospital. So for the sake of exams, I would say admit them to the hospital. But in reality, um, it's still a bit of a gray area but anything three and above, you definitely want to send them to the hospital. And at that point you're probably thinking ICU as well. Uh, but often they won't actually take the patient on unless they're really unwell. So in terms of the antibiotics, again, I won't dwell on this too much for the sake of time, you can take a screenshot. Er but just remember with typical organisms amoxicillin, if it's more severe, something that contains amoxicillin, but caan acid as well. So give them co amoxiclav if they're allergic, give doxycycline. So that's the key to the question that we just looked at um atypical think CCL Erythromycin. Um Yeah, and if the pathogen is unknown, you kind of give both amoxin and Clarithromycin to give good cover hospital acquired. So, staph aureus, so flu clock and you see that and loads of things that any time you see staph, you give uh flu clock M Sra Vancomycin pseudomonas gives tazocin and gentamicin. Um So that's quite a difficult one to tackle. Um So for Pne assist Jove, you give co cotrimoxazole er and for the anaerobes after aspiration pneumonia, you give uh amoxicillin, you can add metroNIDAZOLE as well. So just take a screenshot of that and it's one of those you just have to learn. So I won't do it on that for much longer. Um Thinking about this question. So as I mentioned, this patient had a curb score of two. So the urea was raised. Um and yeah, so the age was over 65. So that's why you would want to send them to the A&E um you you can monitor there and then you start them on Doxycycline and then from there, you can kind of think about whether they're well enough to go home or you keep them admitted. So, yeah. Pseudomonas Aeruginosa, we already mentioned this. So hospital acquired, you're thinking pseudomonas, the rest of them uh are more typical and atypical er community quid demonias. All right. So a differential here we looked at was cough. Um So you can have a chronic cough and a more acute cough. Um Yeah. And so again, I'll just leave that there. Um You can go through that in your own time, but it's a nice structured way to think about things. Question five. So this is the young gentlemen they're taught. Um So they're feeling breathless again, left sided uh pleuritic chest pain. So it's low class to one side, but otherwise they're, well, they haven't got much of a past history. They have reduced breath, sounds unequal chest expansion, but they're only using a one because of saturations being a bit low. Um A chest X ray shows a, the pneumothorax on the left side that's seven millimeters in diameter, but they still short of breath. So the answer here would be needle aspiration and giving them oxygen. Ok. And we'll discuss why. Now, so pneumothorax, um this is when you have an abnormal collection in the pleural spaces of air. Um And just so you're aware. So if it's traumatic, you're typically affe er damaging the parietal pleura cos you're the damage will be outside as opposed to from within. Um So that's one type of pneumothorax and then you have spontaneous pneumothorax as well. And that's more likely than not the, the visceral pleura. So just the, the layer just below. Um cos that's more likely to be um pathology from inside. Um So that's one way of just er categorizing things. You can also think about primary versus secondary, which actually is more important clinically because that determines the management pathway. So, primary, just think tall gangly um or just someone who hasn't got uh past medical history. Um So this is your typically a ma fans patient or just a tall, skinny male, um is what you'll see in the stem of the question, secondary, think preexisting lung disease or pathology. Uh someone a bit older they have, I don't know, asthma co PD one of those conditions. Um and it's more likely to be secondary because of that. So the management, I'm sure you've all seen this table or something along these lines. Um But again, you just need to memorize it. So, just think is it primary or is it secondary? And that's how you um that's how you split the management off at the start. Um And so the size is centimeters are not millimeters. So it was a bit of a sly one in the que question that I just did. Um, so it's actually less than two centimeters for that patient but be wary. So it's, it's, you're thinking about the size but also whether they're symptomatic. So, in this case, although it was less than two centimeters, the patient was breathless. So in that case, you would go on to um aspirating them, ok. Uh with a cannula. So, um that, that's what the answer was for the question and I won't dwell on the secondary side of things. Um You can take a screenshot again and focus on that in your own time. It's just some rote learning that you have to do. Um So tension pneumothorax and this is the emergency side of things for pneumothorax. Um So in terms of the pathology and what's going on, you have a one way valve. So you have air entering the pleural space, but it's unable to leave. Um And so with this, you get a patient that's a lot more unwell basically and you see them deteriorating quite quickly. So they'll be very short of breath. Um from a clinical examination standpoint, it's crucial that you, you have a feel of the t trachea. If you're feeling any sort of deviation, then it's more than likely going to be a tr um attention to pneumothorax alongside that you have a severely reduced chest expansion. Um and the patient will have a silent chest as well. Uh Long story short, the patient will just be very well in front of you quite classically. So that's when you're thinking tension tha and the management for that, as I'm sure, you know, is slightly different. Um And the other thing worth mentioning as well because you have this mediastinal shift, um you get the pressure on the heart and that can cause it to reduce its uh BP or its output and then you have tachycardia to compensate for that low BP as well. Um And it is an emergency because the hypertension, uh the BP can drop quite rapidly and that's what causes death, the BP dropping um just to have a quick think about um shifts like mediastinal shifts and what's actually going on underneath because here your, you're increasing the amount of air in the thorax. So there's a higher pressure on the side of the tension pneumothorax. And because pressure moves from high to low, the the media ST and and everything will want to shift from the high pressure side. So where the tension pneumothorax is to the low pressure side, hence it shifts away but something like a lung collapse or a large lung collapse that will shift towards because there's less air in that thoracic cavity. So um you have lower pressure. So it goes from the higher pressure on the normal side to the lower pressure on the pathological side. So it'll shift towards it. So that way you don't have to just remember the words. Uh You can actually think about what's going on to, to, to uh to say which way it shifts in terms of managing the tension, pneumothorax, large bull cannula, so often a gray stab it into the second intercostal space, mid clavicular line just so that you're aware, you go just above the third rib as you can see in the picture here. Um And that way you avoid the neurovascular bundle um which is a bit higher up in the, in the second intercostal space. All right. Question five. How are we for time? Ok. We've gone for quite a while. So I'll quickly skim through this. Yeah, we touched on this. So this was a patient. It was less than two minutes centimeters, but they were short of breath. So you do a needle aspiration. So you just need to memorize that er, diagram this question. Patient is coughing. Um They have hemoptysis and a fever. Um They've been experiencing worsening of, of shortness of breath and also unexplained weight loss for some time. Um after visiting India four weeks ago, er which investigation is crucial for making the diagnosis. So here, the answer is chest X ray. Um And so patient here, you're either thinking some sort of tumor er, because of the weight loss, but more so the risk factors are suggestive of tuberculosis and we'll think about the investigation of a chest X ray is crucial here. Um, another T TB questions to think about TB medications, which one is going to cause uh a potentially cause abnormal color vision ethane. But so I'll go for a good memory device for your, er, for the side effects of your tuberculosis drug shortly. And that way you won't, you will always get this question. Um definition is a chronic infection disease. Yes, it's caused by the mycobacterium tuberculosis organism and it can affect multiple er, organs as well. So it is quite a debilitating disease um especially in immunocompromised people. So that's one of the risk factors. So if you become immunocompromised people who've gone to densely crowded living areas, um and certain areas of the world are more prevalent as well like Africa, India, Bangladesh. So you'll also see that in the stem of the question. Um TV, how it presents classically? Yeah, you have a cough which can be productive, shortness of breath, just note that hemoptysis is a bit of a later sign. Um and then just think about your floor symptoms. So you're gonna see lethargy, anorexia, weight loss, night sweats. Um So we'll move on. I won't spend much time on this but just be aware of the life cycle. So once you first get infected by tuberculosis, which is a lot of people. So I think at least 2 million people in the world have had atb infection at some point. Um So the, the, the infection can go away in most people. But then for some people, it can persist, it can become latent, which means it basically, it just hides um in a, in a granuloma or specifically a caseating granuloma in the lungs. Um And f for other people, it can become like primary active, which is uh the more debilitating disease which can spread. Um and the latent um TV can also er eventually evolve into primary active TB again. So there's a chance of recurrence and that chance there is a chance for anyone but that chance increases for certain populations, especially those immunocompromised cos you have a weakened immune system organs that are involved, I'll leave this but just think when it someone has a primary activation. So the first active infection of TB, it's more than likely just going to be pulmonary in nature. So the symptoms, it often if it's reactivated that that's when you see um other organs being involved. I've highlighted some of the key ones. So TB meningitis is important. So II did a knee replacement and I've seen that a few times a couple of times. Um Yeah, erythema to do some clubbing. That's important. You'll see that in stems of questions as well. They'll try and catch you out. Um get to get you to think about like an IBD, for example, but it's still just TB, it can affect other areas. So I'll move on. Uh, but you can have that, um, when you get the slides at the end, um, medication side effects. Oh, sorry. Investigations. Um, so, yeah, thi this was the key to the question. So you need a Sputum MC NS, but you do not do a ground stain. You do it with the Zeal Nielsen stain or the AFB stain, acid f um, not a ground stain because that doesn't actually cross the ground, the, the wall of the, of the organism. Well, and remember you need three samples of those. Um And often you will start treatment if you're suspicious clinically because the results for that can take quite a while uh 6 to 8 weeks. And the other part of the investigations that you must have is a chest X ray. So you kind of need to have those two things to be able to have a, a to confirm the diagnosis. Uh But like I said, you can treat it sooner than having to wait for the, for the MC NS. So that's for active TB. The patients are very symptomatic. They've come in with er, a acute activation of it. Uh But then for the latent test, you can do a Monto test, um which is like a skin prick, you can do an interfering gamma release assay um and just be aware if a patient is coming with active TB, you don't treat close contacts. Sorry, you don't investigate close contacts with the Sputum MC NS and the chest X ray. For those you do the later tests like the Montu and the Interferon gamma assay. Um All right, in terms of the medications, I'm sure you will know this but ripe. Um just be aware that they can all cause hepatotoxicity. So for the sake of exams, that's not gonna be the side effect that comes up. Um It'll be the more niche ones. So R is rifampicin. So just remember R is for red orange, so red orange secretions just not, it's not just urine uh which is a misconception. Um It can be like tears as well. Uh Like if you have rhinorrhea, like a leaky nose that can be red orange as well. Um Isoniazid is the I iso so ice sounds like ice. Um So just think about when it's winter time, you haven't got your gloves, your hands feel really numb and you have these like this tingling sensation, the paresthesia. So they have peripheral neuropathy. So that's a bit of a long winded way. But once you remember it, you won't forget. Um and just remember to get rid of this peripheral neuropathy or rid of the sensation, use pyridoxine. So that's vitamin P six. And I think that's quite an important. That's quite a nice one to remember because I used to always confuse it with pyrazinamide. Um And this way, I, I've, I don't make that confusion anymore. So, Pyrizinamide is one of the TB medications. Um, so remember the first two, you only take, sorry you take for the six months, the last two you only take for the first two months. Er, yeah, Pyrazinamide. Pyra like pirates. So r um, stupid way of remembering it but it works for me. Um, so r like pain. Er, so they're gonna have pain in the knees and joints because of gout. Ok. So they can cause hyperuricemia. Ethambutol E is for eyes. Ok. So there's two things to think about optic neuritis and reversible red, green color blindness, which was one of the questions that we looked at. Um So quite a few good memory techniques um that I would recommend. Yeah, so we've touched on this already. So do chest X ray and I try to catch you out here by doing the Sputum microscopy but with gram staining as opposed to acids stain uh was Neelsen. So yeah, chest X ray and then you do three sputum samples and then the answer here because we're talking eyes, vision, ebutol, E for eyes. Very good. OK. So for question eight, you've got a mum who's bringing in her infant son into the GP practice short of breath kind of coral symptoms as well. Um and also some apneic episodes and when you're looking at him, you can see he's got subcostal resection. So obviously breathing quite hard. So the answer for this question is b so it's admit to hospital for supportive management and what this child has is bronchiolitis. So, bronchiolitis, it's a very similar pathology to bronchitis, but obviously, it's occurring lower down in your airways. So in your bronchioles, it most commonly occurs in infants, which I think is really key when it comes to a lot of your peed questions where you'll have like uh 100 different um lower respiratory tract infections. Um Just noting that if it's a child under the age of two, it's much more likely to be a bronchiolitis. Um The organisms that typically cause bronchiolitis are R SV. So respiratory syncytial virus and parainfluenza three. And of course, any infant can develop bronchiolitis, but some of the risk factors for developing severe episodes are if your child has a congenital heart defect or if they have Down syndrome. So the way that bronchiolitis presents as you saw in the stem, um the child may have shortness of breath, they might have a dry cough. So, not a productive one, they may have some coral symptoms as well. And if it's a serious infection, of course, they can develop apnea episodes. Um and they might appear to have quite a visible work of breathing. And as with Children just becoming generally unwell, they might go off their food, they might be more fatigued. Um So, signs on examination that you might see are wheeze and bilateral inspiratory crackles. And again, as I said if it's severe, you might see some subcostal recessions. So, for the management of bronchiolitis, it's generally a clinical diagnosis. So for the most part, it's supportive management and safety netting, especially if it's a child who appears relatively well, they're in the community. Um, you just want to make sure they're getting fluids, you're taking care of any, um, temperatures that they may have. Um, and making sure the parents have worsening advice. It's really important though to watch out for some of your red flag symptoms. And I don't think we've got a slide here that shows it, but there's the traffic light system for any of your pediatric conditions. So, if they have some of those symptoms and in the question that we did have, that was the apnea episodes as well as the subcostal recessions, you can admit them to hospital both for your supportive management, giving them humidified oxygen. If they have low oxygen stats, if they have a lot of secretions, which may be affecting their ability to breathe, well, you can suction those and if they're particularly um poorly poor feeding, you can put an NG tube in as well. And so we've just listed some of the kind of red flag symptoms um which are like particularly specific to respiratory conditions. But when Children, especially young Children become unwell, they become so systemically unwell. It's important to look out for these, even if they're not presenting with a bronchiolitis or a respiratory tract infection. So if you see central cyanosis, even if you've not witnessed an apnea episode, if their parent is telling you, oh, look like they stopped breathing, you really wanna admit them to hospital. Um if they appear to be in respiratory distress, if oxygen sat to less than 92% if you see them grunting cos that's a sign of um a really hard like work of breathing. And if they have a respiratory rate of above 70 that's probably quite age specific. But I'm sure when you look up guidelines, you'll be able to figure that out. Um, but it's good to have a number in your head for each age category just so you know how to kind of risk stratify them. So again, just going over the answer, you've got an infant who's short of breath, not a productive cough, it's a dry cough. They've got coral symptoms, they've got two red flags symptoms, one of them hasn't been highlighted, which is my fault. Um So that's why it's not just safety net and sent home for supportive management. It's admit to hospital for supportive management. So for question nine, you've got a 60 year old man. He's got a chronic cough, worsening, shortness of breath fatigue and an episode of hemoptysis. He does have a past history of smoking, not traveled abroad and his user show that he's hyponatremic. So the most likely diagnosis is gonna be small cell lung cancer And I think the trick in this one is kind of differentiating between non small cell and small cell lung cancer, which we'll get into. So, with lung cancer, obviously, it's a malignancy of the lungs. Some of the key risk factors that I'm sure we're all kind of aware of, are smoking, um, any occupational exposure, especially to asbestos, any radon exposure um at previous radiotherapy. And of course, with any malignancy, if there's a family history, you want to be um particularly suspicious. So there are kind of two types of lung cancer or primary lung cancer. You've got non small cell lung cancer and that includes your adenocarcinomas, your squamous cell carcinomas as well as large cell carcinomas. And although these of course, can occur anywhere in the lungs, typically in exam questions, you'll see that adenocarcinomas and large cell carcinomas will appear peripherally in the lungs. Whereas your squamous cell carcinomas are often described as like a central mass. And then you have your small cell lung cancers. Um and these are like often endocrine cells and they cause a lot of like paraneoplastic syndromes. And so that's a little diagram, just kind of detailing types of um non small cell lung cancer. So for the presentation, um you've got your respiratory symptoms. So you've got shortness of breath, chronic cough, they might have a bit of chest pain or bony pain as well, especially if they've got metastases, hemoptysis is obviously gonna be a red flag symptom. And despite the fact that there are multiple different conditions that can cause it because obviously, lung cancer is such a significant condition. You wanna rule it out as soon as you see somebody presenting with hemoptysis, and you've also got your typical symptoms of malignancy. So, loss of appetite, general weight loss, maybe they've developed like anemia of chronic disease on examination, likely that you'll see that the patient is, er, cachexic. So they've lost a lot of weight. They'll probably also tell you that their clothes are hanging off them. Um, you may have focal dullness on percussion. Um If you're able to actually locate where the tumor is, you may see that they have finger clubbing and you may see that they've got a lymphadenopathy. So a chest X ray is gonna be your initial investigation. Um and often times you will be able to identify some sort of abnormality and then, then afterwards you'll do act often chest abdel just because then you can get kind of a good scan of the body, helps you see the malignancy much better. You can actually get a radiological diagnosis and then you can also check to see, um, are there any metastasis throughout the body afterwards to get a more definitive diagnosis? You can do bronchoscopy and biopsy. Although this does tend to depend on the fitness of the patient because obviously, some of your more comorbid patients aren't going to be able to tolerate that but that would be like your definitive investigation in terms of your MC Qs. And then of course, if you're looking for um the spread of the cancer, you'll do a pet scan, which is very important for staging. Just got a little diagram. Um It's explaining in very basic terms and stages 1 to 4. I don't think you'll have to know in depth how you would treat like at three N two M one, but it's obviously good to have an idea of just how severe this malignancy in the patient is. Um So for the management of lung cancer, it does uh vary depending on whether it's a non small cell lung cancer or a small cell lung cancer. So you can do surgery to physically remove the tumor in a non small cell lung cancer. Um You can also do chemotherapy radiotherapy. You can do those adjuvant or neoadjuvant and you can also give immunotherapies for small cell carcinomas because they're often, um as it says in the title, like much smaller cells, they're smaller neuroendocrine cells. You can't really cut them out in the same way that you could with a non small cell carcinoma, which is why it's more of the medical therapy. So your chemotherapy and radiotherapy. So some of the complications that arise from lung cancer, um particularly with your small cell lung cancers is you're gonna get your paraneoplastic syndromes. So you can get syndrome of inappropriate ADH secretion, which will cause hypernatremia, you can get cushing's. So if somebody's come in with some of the symptoms of lung cancer and they've also, they've got a round face, they notice they've got abdominal obesity, kind of weakening of their muscles. Um You may want to consider if this is small cell lung cancer and Lambert Eaton syndrome as well, you can also get superior vena cava obstruction. Um And you can see that in the man in the top picture there, his face is much puffier, um probably will be a lot more flushed when he raises his arms. Um And obviously, that's if your, if the cancer is pressing on the superior vena cava, which tends to happen in a pancreas tumor. So that's when it's at the apex of the lung. And that's the thing with Horners Syndrome. It's often the pancreas tumors that cause that because they're gonna be pressing on the sympathetic nerve supply and that causes um what's seen in the picture down below of the meiosis. So, er, constriction of the pupil and ptosis and anhydrosis. So, not sweating on that side of the face, you can also get malignant pleural effusions and oftentimes in hospital, that's what the patient will initially present with, especially on a chest X ray, which is why they might do a CT chest, a pelvis to actually investigate, is it a pneumonia that's driving this or could it be actually an underlying malignancy? So, just going back to the question. Um So you've obviously got a lot of your red flag symptoms for cancer there. You've got a risk factor. So he used to smoke. Um, and the differentiation between the non small cell and the small cell lung cancer is the fact that he's hypernatremic. So he's got this paraneoplastic syndrome and here's another little, almost like mind map of hemoptysis. Um, it's quite helpful just to think of all of the different er differentials. And I think it's quite helpful to split it up into like airway versus lung parenchyma. Um just to kind of help separate out some of your um respiratory conditions. So for question 10, you've got a middle aged woman who's presenting with progressive shortness of breath, she's got recurrent chest infections, she's got a productive cough. She's a smoker. You've also got a blood test result which showing she's got high eosinophils and she's already got a salbutamol inhaler. So the long term management for this patient should be c if I'm correct. Um It's, yeah, salbutamol inhaler, long actor, acting, muscarinic antagonist and inhaled corticosteroid. So, co PD an incredibly common condition, even if that's not like the primary presenting complaint in hospital, like 70% of your patients will have it. So it's a group of diseases that cause e blockage and breathing issues. It includes emphysema and bronchitis as well. Um And you've also with your CO PD, you've got various risk factors. The biggest one being smoking also being older, you don't tend to see it in people who are under the age of 35 occupation. If you're exposed to a lot of smoke, a lot of dust, um when you work and as well as genetic factors. So if somebody has alpha one antitrypsin deficiency, which is pretty rare, um then they're at a much higher risk of developing CO PD. So with the presentation of CO PD, you've got chronic productive cough, you can have progressive dyspnea, recurrent chest infections and patients often become quite fatigued with all of that going on. Um And on examination, oftentimes they're wheezy, especially if they are having an exacerbation of their CO PD, they might be tachypneic and if they're a CO2 retainer, you might see asterisk cysts. So getting to test for a flapping tremor is quite important. So some of the investigations that you want to do, especially if you're trying to diagnose somebody with CO PD, you want to do spirometry and um it'll show an obstructive picture. So your F EV one to F EC ratio is gonna be less than 70%. And then there's a little table there that kind of goes from mild to very severe. Um and it's stratified based on your F EV 1%. So not the F EV one versus FBC. That's just for the diagnosis of CO PD, not for actually deter the determining the severity of it. And then of course, if somebody's coming in and you think they've got an exacerbation of CO PD. You want to do a chest X ray? See, is it actually a cap? Could it be an L RTI? You wanna do a sputum culture, especially if they're bringing up kind of purulent sputum. Of course, you wanna do a full panel of bloods um chasing those inflammatory markers. You also wanna do an ABG, especially if it appears that they're particularly breathless cos this can be really helpful for determining, are they in respiratory failure? Is that an acute respiratory failure or chronic? And do we need to be kind of lowering their oxygen saturation targets as well as doing an ECG always important. Um This is a really handy table just for going through the differences and similarities between CO PD and asthma. So you potentially someone can be a smoker and develop asthma, but the majority of CO PD patients were smokers or they are current smokers. And as you can see, um in CO PD, it tends to occur in the older population. Whereas asthma, you often get asthma in Children as well as in adults. It's not common for asthma to have a productive cough whereas it is in CO PD. And I think the biggest thing is the variability in the patients dyspnea. So in asthma, it's very variable. Normally they're fine until they get an asthma attack. Whereas in CO PD, it's very persistent. So it's important to understand what some of the asthmatic features of CO PD are because it does slightly alter the way that you manage these patients in the long term. So if they have at P or a diagnosis of asthma, if they have eosinophilia on their bloods, if they've got kind of a wide variation in their F EV one, so more than 400 mils um or a diurnal variation of more than 20% on their peak flow readings. These are all asthmatic features. And so when it comes to their long term management, obviously, there's, you know, smoking cessation, vaccinations, et cetera. But I think the key thing, for example, is gonna be understanding inhaler therapy. So initially, you'll start them on like salbutamol or a short acting muscarinic antagonist if that's not working and they have asthmatic features. So any of the features that were mentioned before only needs to be one, you would start them on a laba and an inhaled corticosteroid. Whereas if they don't, you'd start them on laber and a Lama and then you'd kind of step it up and start, you would just do salbutamol, obviously stays there like their reliever therapy when they're having exacerbations, but then you would step it up to a Laba Alama and an I CS. And normally you start off with like a low dosed inhaled corticosteroid and then slowly build it up. You can also give patients long term oxygen therapy. Um They do have to meet specific criteria for this though. So, obviously having low oxygen saturations and they can have secondary polycythemia. Um if they have peripheral edema, pulmonary hypertension or nocturnal hypoxia. So for the management of acute exacerbations, um especially if they're infected, you want to give antibiotics, you want to give prednisoLONE to try and dampen down all of that in inflammation. Um If they're in hospital, you can give nebulized salbutamol and ipratropium bromide. Um If you think they're fine to stay at home, you just tell them to increase their inhaler use as needed. And of course, you'll supplement oxygen if they're in hospital and they require that if the patient has respiratory failure and they're failing on high flow oxygen, then you may want to consider an IV. So some of the complications of CO PD are recurrent chest infections, especially like if they've got a lot of mucus, that's just kind of sitting there. It's a perfect breeding ground for that. Um Cor Pulmonale, which is right heart failure secondary to CO PD, specifically pulmonary hypertension polycythemia as well as it's a risk factor for developing a pneumothorax. So for just going over, question 10 again. So the reason that you go for um answer c is that we know that she already has a salbutamol inhaler for her presumed CO PD. So you wanna step up her management a bit, you can see that she does have asthmatic features with the eosinophilia. And so that's why you go for the Saber, the llama and the I CS as opposed to option B. So for question 11, you've got a woman who's come in with an acute exacerbation of her asthma. She seems very unwell, um, for determining the severity of her asthma. Um, you wanna look at all all the factors listed. So her observations as well as her ABG and in this case, she has life threatening asthma. So the investigations that you would want to do for this, um especially for diagnosing chronic asthma would be, you could do a peak flow chart. Um looking for that kind of increased variation throughout the day. Spirometry. Again, it's gonna show an obstructive picture. But if you do spirometry after bronchodilator, so after giving them like this salbutol inhaler, you'll see that their um readings are gonna be much more improved, which is something that you won't see in CO PD in the same way. And um for all patients who are adult getting tested for asthma, um or any Children where their spirometry is normal. Everybody does a feno test which essentially your, it's like a fractional exhaled nitrous oxide. So you get them to breathe out into a tube and it's just measuring the level of nitrous oxide because when there's a lot of inflammation in the lungs, more nitrous oxide is gonna be produced. So ra reading of above 40 parts per billion is positive for adults and above 35 is positive for Children. So for the management of asthma in terms of the chronic management, first, try them on a salbutamol inhaler, if not, um salbutamol plus a low dose I CS and then keep kind of stepping it up. And I think it's important to understand like the risk stratification for an acute asthma attack. And this is quite a handy diagram, just kind of going through it. And it's also important to mention that if they have o like mostly the symptoms of moderate acute asthma and maybe one of the features of severe acute asthma, they immediately kind of get stepped up and they're in that severe category. So for the management of acute asthma, you want to give them high flow oxygen through a non rebreathe mask, you wanna give them nebulized salbutamol and potentially nebulized ipratropium bromide. Um If none of that is working, you can also give them oral prednisoLONE, IV hydrocortisone just depending on if they're able to intake anything orally. If none of that is working, obviously escalate to a senior, but you can give them IV magnesium sulfate. And occasionally people do give aminophylline, it's not as common or popular anymore. And that's something that's definitely gonna be a senior decision, but it's good to just know. So just going back to the answer again. So most of her um observations would put her in the severe category. So, you know, tachypneic, uh tachycardic, not being able to speak in full sentences. But the fact that she has a normal P CO2 on her ABG is really worrying. So most of the time, if it's a moderate to severe asthma exacerbation, people are gonna be breathing really hard as you can see. She is, she's still tachypneic, but that means they're gonna be blowing off a lot of their CO2. If their CO2 is becoming normal, then that means that they're fatiguing. So we're getting to the point where we really need to, II don't know, be reassessing. Like are any of our interventions working? Do they need to be escalated up to HD U or ICU? Because then um clearly she's fatiguing, she's not being able to cope anymore. And so this is again, just like a handy diagram, like take a picture or we'll send you the slides afterwards just to kind of get in your head, the different um causes of acute wheeze as well as uh chronic wheezing. So for question 12, you've got a middle aged man, a background of CO PD who's presenting with what is a presumed exacerbation of his CO PD and it's about ABG interpretation. So the correct diagnosis based on this ABG is acute on chronic type two respiratory failure with respiratory acidosis. So I think this is a really handy kind of flow chart just for determining like how am I gonna interpret all of these like random numbers that have been thrown at me? So carbon dioxide and PH H are gonna move in the opposite direction. So if, if it's a respiratory issue, so if your CO2 is a raised, that's gonna drive your PH down. Whereas bicarb and PH kind of work um move in the same direction if it's gonna be a metabolic issue. And in this particular case, um I think the patient having CO PD is a clue that you might want to wonder, like could this person be a chronic CO2 retainer in a chronic type two respiratory failure? You're gonna see that their PH will be normal, but their bicarb is gonna be raised to try and normalize their ph. The fact that this is acute on chronic is shown by the fact that their PH is now low. So they're kind of decompensating and this is just another quick list of different causes of cyanosis. And we've tied this into um the ABG question and the type two respiratory failure just because oftentimes if somebody is in respiratory failure, you might see that they've either got peripheral cyanosis or uh central cyanosis. So for question, the 13, you've got yet again, another middle aged person presenting to their GP. Um You've got, she's got a chronic cough, she's got yellow sputum who's not a smoker and she also has clubbed fingers and inspiratory crackles that are audible. So the most likely diagnosis in this case is gonna be bronchiectasis. Um And so for bronchiectasis, it's caused often by repeated infections and insults to the lungs you get the pathological dilatation of your bronchi and you get a lot of excess mucus build up. Um, so it can also be seen in cystic fibrosis and some of the symptoms are chronic productive cough. And because like, similarly to CO PD, if you've got a lot of mucus there, you've got a lot of inflammation again, like it's a perfect kind of, er, breeding ground for bacteria. Um, on examination, you'll see clubbing, which is a pretty key differentiating factor between bronchiectasis and CO PD. Um You won't see clubbing typically in CO PD unless they've got another comorbidity that's causing the clubbing. They also get coarse crackles and wheeze. So investigations for bronchiectasis, you can do a chest X ray and you'll see a tramline sign. So essentially that's just seeing um this dilatation of the bronchi, you can do a CT scan and you'll see signet cells on that and on spirometry, it'll show an obstructive picture. So the key management of bronchiectasis is gonna be airway clearance physiotherapy, which is really useful to actually bringing up a lot of that mucus and um giving the patient mucolytics to actually break it down. And of course, if they've got any kind of chest infection, making sure to treat that adequately. So, question 14, you have a 57 year old woman, she's got progressive shortness of breath, she's got a dry cough this time. She has clubbing and inspiratory crackles and she's also got tender nodules on her shins. So, um on her chest X ray, she's got upper zone fibrosis. So, the most appropriate management plan for this patient is long term prednisoLONE. And the reason for that is that the underlying condition is sarcoidosis. So, um just a quick run through interstitial lung disease. So, it's a spectrum of different conditions that lead the lungs to become fibrotic. Um because you've got inflammation repeatedly of the lung interstitial often occurs because you've got repeated injury to the lungs, whether that's infections or exposure to toxins. Some of the risk factors for this are being male. If somebody's smoking, obviously, you're inhaling um a lot of pretty harmful chemicals that way, occupational exposure as well. For example, you can get asbestosis, which leads to interstitial lung disease. Um and your rheumatological conditions, any autoimmune condition can lead not any autoimmune condition, but a lot of them can lead to interstitial lung disease. And that was a nice little diagram. If you wanted to take a picture of just like the different um etiologies. So the presentation often times patients will have progressive dyspnea, um and a reduced exercise tolerance, they'll have a dry cough as opposed to the productive cough that's often seen in your um like obstructive lung diseases, like your co PD bronchiectasis. Again, they're often very fatigued. And if it's an underlying like autoimmune condition, then they may have arthralgia or other symptoms of connective tissue diseases. For example, like Raynaud's and on examination, you might see finger clubbing, they may ha might have fine inspiratory crackles as opposed to course. Um, and they can have swollen joints and they may have erythema nodosum as the woman in the stem of the question did. And that's a clue that it could be sarcoidosis, especially on exams. So, for your investigations, obviously, you want to do a full panel of bloods. And if somebody's presenting with symptoms that are suggestive of interstitial lung disease, you may want to test for autoantibodies and looking at that E sr as well on spirometry, you'll see that um they have a restrictive picture so that F EV one to F EC ratio will be above 80%. So it will appear normal, but the individual values for their F EV one and their FBC are gonna be reduced on a chest X ray, you'll often see fibrosis and kind of your definitive diagnose diagnostic investigation is a high res CT in which you can see honey combing or traction bronchiectasis. And there's a handy chart that kind of splits up the causes of upper zone fibrosis and lower zone fibrosis. And you probably don't have to memorize it. But it is quite helpful for multiple choice questions just to have some idea of which um causes will lead to lower zone versus upper zone fibrosis. So for the management, obviously, you've got smoking cessation, pulmonary rehab, making sure they're getting vaccinated for treating the condition itself. If they've got idiopathic pulmonary fibrosis, they can be started on antifibrotic medications. They may end up needing long term oxygen therapy and they may in the end be referred for a transplant. Um If they've got sarcoidosis, you'd want to give them steroids. So making sure to dampen down that inflammation as with any of the other connective tissue diseases. Some of the complications again are pulmonary hypertension and respiratory failure. So just going over it again. So she's got the symptoms of an I LD. She's also got some signs that are more specific to sarcoidosis. So upper zone fibrosis, as well as erythema nodosum. Perfect. So that wraps things up so well done to everyone for making it this far, apologies that we've gone a bit over. Uh But we wanted to make sure that we were as thorough as we could be with it all. Um So let's just quickly have a look at what was actually covered today just for your sake. Um So from an acute side of things, the only thing not covered was influenza, not the most high yield. So we, we thought we'd leave it out uh from the chronic side of things. Just allergies, uh cystic fibrosis, we'll look at that in our peed session. Um Obstructive sleep apnea, relatively straightforward and again, not particularly high yield and pulmonary hypertension as well. Um And then just a few presentations which again, aren't, you're not a not gonna see it much on the wards when you're actually working and b from an exam standpoint, uh, it's not as important. Obviously, cardio respiratory arrest is important, but you'll see that from the emergency side of things. Um, and when you do your A LS, er, but the thing that you need to remember is just the four Hs forties. All right. Um, so that brings us to a close, if you could all do us a massive favor, we put a bit of time into this. So we'd really appreciate some feedback er, for the sake of our portfolios going forward as well. Um I think we have someone else on committee. Harry. I don't know if you can. Perfect. I'll hand over to you just two minutes before you guys go. I, I'm also part of the me committee and I'm going to find out why Valley Trust. So something that we're also trying to do, especially with the UK MLA being the sort of new thing which you guys are being forced to do, um is to get some research looking at what you guys are, finding your students think of the UK MLA, how you've been preparing, how your universities have prepared you and generally how you think that this could be improved going forward. And of course, I wouldn't be asking for you guys just to do research for us. So what I'm actually hoping to do is offer you guys the ability to actually get involved with some research through collaborative authorship. Um And I know that at least for surgical training, things like collaborative ships are actually worth points now. Um So what's going to come up on the screen is a short QR code and there's a link as well. It's literally three questions, your name, email and uni if you are interested in getting involved with some research and what this actually will involve is you just sharing a survey via a Google form to any final years that you're in uni you mainly through group chats and things like that. Um And we'd only be looking at something like 20 to 25 responses if you can get something like that, the final number hasn't sort of been decided. And if you're able to get those sorts of numbers, then we'd be able to get clubs for off shift. And if any of you need more convincing, I did a similar thing last year again with final year students, something along the lines of 10 to 15 days collectors. We managed to get 300 plus responses and we were able to actually publish a paper looking at wound healing. So it doesn't require a lot of effort from you guys, but definitely, and the ability to get a lot out of it. So if you are interested, um the links above. Um Yeah, I agree. Thanks, Harry would send that link in the chat so people can. Thank you. I've got it. There you go. Lovely, perfect. All right. Thank you so much, everyone for coming. Uh like I said, follow our medal, you'll, you'll be up to date with everything there, but we'll still be, you know, doing our marketing push. Um So I'm sure you'll get a message in your group chats for our upcoming sessions as well, but every Thursday for, for the next few months, um we'll, we'll hopefully see you here. All right. Thank you so much. Yeah, fine. So I think we'll just, we'll end the call cos I think there's some people just staying behind. Alright. Thanks everyone. Have a good evening. Thank you.