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Everybody. Now we're going on to some of the UK MLA lecture series conditions. Uh The slides are made by um the ACMS S um Amazing Secretary Yasmin NKA. Um and it's presented by me tonight. Sorry, the case L ACMS president. Um So there's three conditions that we thought were quite key um that are possibly quite likely to come up on the EK MLA, which is uh atrial fibrillation from the cardiovascular topics, um pneumonia from the respiratory conditions, topics and the meningitis from the neurological conditions. Uh The structure will just be a topic recap. So just recap of key important aspects of the disease and then part B will be some Q and A s and some reasonings um behind it. So, first off atrial fibrillation, uh so there's three types of atrial fibrillation. So, paroxysmal kind of means it's spontaneous and it's usually on and off and the episodes typically last less than seven days each. Um with each episode lasting less than 24 hours each. Uh the next one would be persistent. So this is a form of arrhythmia that is not self limiting. Um but um lasts, lasts about seven days. Sorry. But can be cardioverted. And then the second, sorry, the last type is permanent. So this is continuous af which can't be cardioverted. So it's typically, you may see it's not amenable to cardioversion, meaning if you try cardioversion, permanent af is usually resistant to it. Uh So the presentation usually you get chest pain. Um So angina normally because think about it, if the atrium is sort of um in af it sort of disrupts the blood flow around the body. So, um the heart muscle itself doesn't get enough blood which carries the oxygen. So you get chest pain due to the ischemia, uh you might get dyspnea similar, you're not getting the oxygen around the body, so that deprivation of oxygen can lead to shortness of breath. And then lastly the palpitations. Um and patients may just sort of describe it as like a fluttering or like a butterfly kind of feeling in their chest, like a tapping, sort of, you know, a, a really funny rhythm in their chest. Um and some signs, um normally it's, I would say if you're doing the cardiovascular examination, the key sign to be aware of, if you're palpating the radial pulse, for example, is feeling that irregularly irregular pulse, make sure if you do feel it rather than sticking to either 15 seconds, times in by four or 30 seconds, times in by two, make sure you're doing it for the full hour um to sort of gauge. Um the rhythm rate character. Um And then on ECG, you'll see a narrow QRS complex tachycardia. There won't be any like sign of all visible P waves that you can see um on the ECG. And then there's also irregularly spaced QR S complexes. So for example, the RR intervals vary with each um peak like R wave peak. Um So here and also just if you look at the baseline, the baseline is very, very irregular. Um So, like I mentioned before, um a normal uh EKG brilliant, you've got your P wave, you've got your QR S within normal limits and then you've got your T and it's usually a like a typical stable uh rate. However, in af the baseline is very regular, no discernible P waves, the RR intervals are mixed match and there's a narrow QR S. So there are some common causes which you can remember with Smith S stands for sepsis, M stands for mitral stenosis or regurgitation. And this is the key one because this typically comes up in exams. Um Another one is ischemic heart disease. This is also another key one. Um Sometimes the way I like to think about it is if there's an ischemia to certain parts of the atrium, that means that there may be different focal points of the um depolarization. So you get that atrial fibrillation because there's like lots of different atrial depolarizations going on and it's not all confluent um in like a single stream, uh thyrotoxicosis can cause af um and also hypertension can cause Af. So Smith, remember, af is also it kind of there's a uh how do you say like a co um link between AF and ischemic heart disease? Because AF is also a key risk factor for ischemic heart disease. Um sorry, ischemic stroke, sorry, not heart disease. Um and this is because if there's af there's sometimes like to be um sort of clots forming and those thoughts can become emboli when they sort of dislodge and go into the circulation, which can cause a stroke, um ischemic stroke in the uh head. Um So some of the lifestyle causes that are known to cause af is alcohol and caffeine. Um but similarly, things like drugs can cause it as well. Uh So simplify management, it's either rate or rhythm control. There's sort of the two ways to think about it and then you'll then have to consider anticoagulation. Um First line is always af for af it's rate control unless four criteria are seen. So either um it's always rate control unless there's a reversible cause for the af that you can reverse yourself. So, you know, if there's a target thyrotoxicosis that you can reverse, you do that rather than the rate control. For example, um there's new onset af so within the last 48 hours, you find the af in your diagnosis, you can do rate uh rhythm control. Uh there's heart failure caused by the AF and there's symptoms despite being effectively controlled by rate control. Um So all of these four ones, either you would try to find the reversible causes and that you reverse it that way as the management or you do rhythm control. Uh So rate control, first line is a beta blocker. Uh Atenolol or Bisoprolol is typically used. Um And then often second line is a calcium channel blocker. Um This type is the non dihydropyridine calcium channel blockers such as dilTIAZem or Rapam. Um But verapamil is not preferred in heart failure. Um Key thing to remember is you can't give both a beta blocker and a calcium channel blocker at the same time or it can cause um the heart rate to go really, really low leading to sort of like heart failure. Um So don't give those two at the same time. Also, if somebody, uh for example, if they have asthma and like a beta blocker is contraindicated, then you can give a calcium channel blocker. First line. Uh Next, if somebody's a bit older, they have a sedentary lifestyle and they have the persistent af um you can give digoxin, but it requires a lot of monitoring and actually has reverse mortality benefits. Um But it does obviously have quite good symptom control. Um So you have to talk to a patient about that and weigh that up. Um But anyway, rate control, the main thing is to bring the heart rate back down to normal, not necessarily to change the rhythm of atrial fibrillation. Um So next, rhythm control, uh rhythm, rhythm control, um like I mentioned before, can be used in these four cases. And the aim of rhythm control is to revert back to normal sinus rhythm. So, there are two types of rhythm control you can think about during either you can do a pharmacological cardioversion or electrical cardioversion. And as of these two, there are also two types, the immediate cardioversion and then the d delayed cardioversion. So, um with the immediate ones, the ones that typically uh happen is electrical. So electrical means that you would give a shock and the shock would shock the rate back into sinus rhythm. And you'd do this via the cardiac defibrillator and you need to make sure that you'd give some form of sedation for this. Uh However, sometimes you can use pharmacological cardioversion and key ones would be for canine and amiodarone. However, if there's a choice between electrical or pharmacological, I think typically electrical is preferred. Um And card immediate cardioversion is usually done. Um If af happens be before 48 hours. Um And that is the only time you would do that and that's the only time you'd use pharmacological. Um you can do a delayed cardioversion, but basically, you have to make sure that there are, there is no signs of possible clot formation. So sometimes you would do an echocardiogram to make sure that there is no clot formation at all because what you don't want to happen is essentially af happens. A clot forms in the atrium and then you cardio that. But then that when it goes back to sinus rhythm, you don't want the um clot to turn to an embolus and dislodge and move around the body causing ischemic stroke. So if it's delayed, you typically want electrical cardioversion and you would give some sort of something to make sure that there is no clot formation in that time. Um Yeah. Uh Also electro electrical cardioversion is also very good in cases where the patient is hemody dynamically unstable. So, when treating af um rate control is good if the patient is hemodynamically stable. So, for example, the BP is above um sort of 90/60. However, if the patient is hemodia directly unstable, you want to do a cardioversion and potentially the main, one of choice would be the electrical cardioversion if it's in the immediate. Um But still also if it's delayed. Um So yeah, like I mentioned before, if you're doing the uh delayed cardioversion, the patient needs to be anticoag coagulated at least three weeks beforehand to prevent that um clot formation. Or you can make sure that you've done an echocardiogram to make sure you've ruled it out, but it's a bit risky. So most of the time patients are anticoagulated. Um So there's some other long term um things that can be used for rhythm control. Um So you have beta blockers. So it's like long term. So if somebody has um a for a long time, you can give beta blockers first line and then you can give uh John Doone a second line to maintain your normal rhythm whilst um sorry, uh you can give John Dra a second line vomiting normal rhythm while patients have had successful cardioversion. Uh So if you all those steps that I've talked about before, if those are successful and you want to make sure the patients don't go back into af then these are the medications you give and then you can also give amiodarone, which is useful in patients with heart failure or left ventricular dysfunction on the anticoagulation. The key thing people use is the chad vas um criteria which you can see on the scoring system here. Um And let's just make sure you sort of weigh up with the has blood or orbit score. So which is the score for risk of bleeding. So just make sure that you're kind of using both to see if the effects and benefits of anticoagulation is better. Um And so if it's a score of zero, no treatment, if a score of one in males, you could consider anticoagulation. Um If it's one in a female, there's no treatment and that's because being a female um typically scores one point anyway, but if it's two or more for both uh genders regardless you should offer anticoagulation. Um Which ones are we sort of leaning towards, we're leaning towards Doac. So uh direct acting or anticoagulants such as Apixaban, dabigatran, Edoxaban or Rivaroxaban. Um and also a second line, you can use Warfarin um in cases where a Doac is contraindicated and um make sure that when you're using Drax, you are closely monitoring the iron ir the target I nr is 2 to 3. So 2.5 would be the perfect spot. Ok. So some SBA questions courtesy of uh Smed and passed. So uh a 62 year old man presents to the emergency department with a three day history of shortness of breath on exertion and dizziness. He has no cough or chest pain but has noticed palpitations for the last three days. The patient takes one pill for hypertension and a GTN spray for his angina. He has no other medical history on examination. He is alert and oriented. Observation shows heart rate 100 30 beats, a minute, respiratory rate, 25 breaths a minute and BP under 30/22 an ECG shows a complex narrow, irregular tachycardia without P waves. What is the most important next step in management? So I'm just gonna give the answer here. Stop Pazol. The reason for this is um key signs, symptoms E CG shows that this is clearly atrial fibrillation and then you sort of think of the the time frame. So this is above 48 hours. So you're thinking more long term rate control. So you're thinking uh something like Bisoprolol, which is a beta blocker. Um If this person had a history of something like asthma where it's contraindicated, then you can give something like a calcium channel blocker. Um But yeah, so just key things to remember is for control, acute onset of af this is offered if it's for 48 hours or if you're un uncertain of the onset, you would give something like bisoprolol. Uh Next, um a 67 year old woman presents to the ed with a two day history of dyspnea, chest pain fever. It's worse on exertion. She has a past medical history of diabetes on examination, lung crackles are audible on the left side of the chest. Her pulse is irregularly irregular and atrial fibrillation is found on the ecg her heart rate is 92 BPM. BP is 100 and 30/83 respiratory rate is 22 breaths per minute and temperature is 38.2. After being prescribed antibiotics, she improves and her rhythm converts to sinus. What is the best next step in her management? Um So these are the options I forgot to say about in the last one, but you got discharge, the patient prescribe Pix, prescribe for the prescribe Warfarin, refer the patient for an echocardiogram. So in this case, you want to prescribe ap span, which is a DAC. This is because, um, you've already, she's already improved, so she's been given antibiotics. So there was obviously, um, sort of something like a pneumonia that caused the af and then you've found the reversible cause and you treated that. So that's ok. You don't really need to do anything in terms of the rate or rhythm control. But then you need to think about the anticoagulation. So you need to do the child pass scoring and she scores 31 for her age 67 1 for her being a female and one because she had diabetes. So that's three in total. So she has to be offered one. And in this case, you would give Apixaban. That's because she doesn't seem to have a sedentary lifestyle from what we see. Um So it seems like Apixaban is the best direct to give. Um Next, an 88 year old man presents with heart palpitations. He has a past medical history of a myocardial infarction and heart failure. His daughter advises you that he has recurrent falls. He takes regular Aspirin, ramipril, spironolactone, bisoprolol and atorvastatin observation are as follows heart rate, 95 BPM and BP, 100 and 55/85 a little bit high. An ECG and echocardiogram are performed. ECG shows heart rate 95 beat per minute, irregularly irregular rhythm, absence of P waves. Echocardiogram shows no artery dysfunction. Left ventricular ejection fraction is 62% what long treatment, what to long term treatment is required. So you have 12 Doan, three, low molecular weight heparin four, no treatment is indicated or five Warfarin. So, here's Edoxaban. Um So it's a, it's a tough one. There's, there are you could have gone with the DOXY and you could have also possibly thought about going for Warfarin. Um So if you do the va scoring, he scores five. So um one for uh congestive heart failure, one for hypertension two because his age is over 75 and then one for vascular disease. Um So he has to be offered an anticoagulant. So uh comparable is an antiplatelet. So he wouldn't be given that and he wouldn't be given Heparin either and he definitely needs treatment. So it's between a doxy and Warfarin. Um It's a tough one because he has heart failure. Um So you can wait it out between the Warfarin and do the doxy, but a DOAC might be quite useful uh to see how it works here. Um Also, you don't quite know if he has a sedentary lifestyle and you don't know kind of how the the mortality affects the negative mortality effects of Warfarin may affect him at 32. Your female presents to emergency department after suffering from palpitations and excessive, excessive sweating for the past 2.5 days. One question, she has no other symptoms but admits to consuming a large quantity of alcohol and coffee four days previously, she has a past medical history of Wolf Parkson White syndrome which was diagnosed 13 years ago. Observations show the patient is a febrile with a respiratory rate of 22 breaths a minute pulse rate of 73 BP of 100 and 28/83 and oxygen sats of 95% on room air. A 12 read ECG is performed which shows a fibrillation cardio is contraindicated in this patient. For what reason is that her oxygen saturations her past medical history, her recent consumption of large quantities of alcohol, her recent consumption of vast quantities of caffeine or the duration of her symptoms. So it's a duration of her symptoms. If you look at the stem, it says that this was four days previously. Um But she had the uh this thing, the um alcohol and the coffee, but actually she had the symptoms for 2.5 days. So it was just above 48 hours. Um So if it's above 48 hours, you can't give um cardioversion, so you can't give the rhythm control. So that's why. Ok. So on to pneumonia. So, pneumonia recap. So pne pneumonia is essentially an infection that inflam the aac in one or both of the lungs. And there's various different types of le pneumonias due to um for example, like the lobes of the lungs that um are affected, key symptoms, cough, sputum, typically green, but sometimes in different uh microbiological causes can be different colors, dyspnea, chest pain, which can sometimes be pruritic and fever. The signs. Uh If you're doing an examination, you might get high fever, tachycardia, reduce oxygen, saturations, reduce breast sounds, especially over the area of consolidation and you'll get bronchial breathing. So, uh this isn't a microbiology less but these are the key organisms that can cause pneumonia. Um And there's also specific reasons why they may be more prevalent. So I'll just quickly sort of go through some of the key ones. So, streptococcus pneumonia. So, strep strep pneumonia accounts for 80% of the cases. So in 80% of the cases, it's gonna be caused by stroke, pneumonia. Uh This is particularly associated with the high fever and a rapid onset, um and herpes labialis. Um and there is a vaccine to pneumococcus that is available. Next one that sometimes comes up in exams is hemo virus influenza. So that hip that is quite common in patients with CO PD. Uh So if you have pneumonia CO PD, it's probably uh Hemophilus influenza, you have staph aureus. Um, so that often occurs in patients following influenza. You have mycoplasma pneumonia, which is one of the atypical ones that often presents with a dry cough and atypical chest like x-ray signs and features, um, and autoimmune hemolytic anemia and erythema multiforma for may may be present, legionella. Um is another one and that's another atypical one and that presents with hypo hyponatremia. So, you have pneumonia and hyponatremia and lymphopenia on the blood results. You're thinking legionella, um, and this is classically secondary to infected air conditioning units. So, if somebody's like in an old hotel or something and they get like a pneumonia and they have the hyponatremia and the lymphopenia, it's giving atypical symptoms, you're thinking need, you know, uh, KSA, pneumonia, er, typical in alcoholics. So, if was an alcoholic and if there's any history, they said that they were like coughing up sputum, that was like a red currant jelly kind of sputum. That's more likely to heps. And the last one is Pneumocystis gibberic. So that's sometimes called PCP. That's common in patients with HIV. Um and that presents with the C uh dry cough exercise, induced desaturations and the absence of chest exercise. So it's quite hard to pick up. Uh but it's quite common or pretty much typically presents P patients with HIV. Uh So we kind of talked about this for investigation is chest X ray, think consolidation FBC, you're thinking neutrophilia, you and you want to check for dehydration. So there might be like signs of dehydration and also there might be things like hyponatremia for certain microbiological causes. Um C RP is a sign for infection. So the C RP would be most, most likely raise a pneumonia, uh chest X ray, it is a normal chest X ray. Uh So you go from A to EP and then you sort of see that there is like a low bar consolidation here and sort of just widespread sort of shadowing along, um, and some sort of perihilar lymphadenopathy. Um, so you're probably thinking pneumonia. Uh, so pneumonia, the management is normally determined by either the carb 65 score in secondary care or the C RB 65 score in primary care. That's because you can't typically get the ure done in the primary care. And first thing is confusion. Um So MT S score less than or equals to eight, the urea I think is something like it should be less. Is it above seven respiratory rate uh above or equal to 30 BP. So either the systolic is less than or equal to 90 or the or the diastolic is less than and or equal to 60. So, if that makes, so the systolic is most important, but you can have both um for the BP and then age above 65 management. Uh So antibiotics like amoxicillin or Erythromycin is typically used. Uh It just depends if they're allergic to pin or not erythema. Erythromycin can be used in Children when you suspect micro plasma or you suspect something like a chlamydia trachomatis infection, uh supportive care. So, if they're desaturated, give oxygen therapy, if they're hypertensive, give IV fluids and also you need to think about the location of where to treat the patient. So if the C 65 score is zero or one, they could be treated in the community or at home. If it's a to or above, they need to go into the hospital. Ok. So question time, a 56 year old man presents to the accident and emergency department with shortness of breath associated with a productive cough of thick gelatinous and bright red, bloody sputum and fever. The symptoms have worsened over the last few days. He drinks 30 units of alcohol per week and occasionally smokes cannabis on examination, coarse crackles are heard at the apex of the lungs on inspiration, normal heart sounds. Chest X ray shows upper lobe consolidation, suggestive of pneumonia. The sputum ascent for culture and sensitivity. I forgot that in the investigations. Yeah, you will probably want to do a sputum culture uh and sensitivity. Uh What is the most likely organism called? So you are either Hemophilus influenza psia pneumoniae pseudomonas origin, nosa staphylococcus aureus or streptococcus pneumoniae. So csia pneumonia because I mentioned before common narcotics and it's commonly associated with that bright red currant jelly sputum. Uh Next one, a 62 year old woman attends with a one week history of shortness of breath. She drinks 100 and 20 units of alcohol per week. Observations are as follows heart rate, 24 B BPM. BP, 100 and 10/65 temperature, 38.8 resp rate, 26 and oxygen sats 90 on air. These are, these are her blood results Um So just having a look at things, platelets are low white, red blood cell count is high. A little bit hyponatremic, a little bit hypokalemic normal urea uh creatinine is a little bit low but probably because of dehydration or something. And C RP is very, very, very high. Chest X ray shows a right sided lobe pneumonia. What is the most likely um cause clampsia, uh oxytosis, clampsia, pneumoniae, mycoplasma, pneumoniae, staphylococcus aureus or streptococcus pneumonia. Yes. Again, club pneumonia. Think that because she's alcoholic. Um, next, a 42 year old man presented with a three day history of a dry cough, shortness of breath and on off diarrhea, he reports these symptoms were preceded by nearly two weeks of flu like symptoms and that he has experienced general fatigue and nausea on examination. He has increased worth of breathing with mild crackles high throughout the lungs. Bilateral consolidation is seen on a chest X ray and peripheral blood smear shows red blood cells agglutination. What is the most likely cause of this patient's infection? Uh One poxy Bruneti, two sil bar virus, three lesion, Emma pneumonia, four mycoplasma pneumonia or five streptococcus pneumonia. So, this one was a mycoplasma pneumonia. Um and this was a hard one because I mentioned it very quickly, but it's associated with a hemolytic anemia. And in the peripheral blood smear, there shows some red blood cell hallucination. So when you sort of see signs like that, you're thinking a hemolytic anemia. A three year old girl presents to the emergency department with lethargy cough and breathlessness for the last two weeks. The mother tells you that the cough has been getting worse but it is not productive for sputum. Her observations show fever, tachycardia and tachy based on her age and the worsening of the cough. You suspect that the infecting organism is mycoplasma pneumonia. Chest x-ray shows right lower zone consolidation. What is the most appropriate or therapy? So, it's Erythromycin I mentioned before. Erythromycin is really to like typically prescribed in Children when mycoplasma is present. And if she's did have um signs of chlamydia trachomatis, for example, you can also give um Erythromycin uh lost a bit on meningitis. Meningitis is simply the inflammation of the meninges. Um So one of the layers, um jaw, right layers. So two really key complications of meningitis. Uh So one of them is hearing loss, which is really, really common and it's often a sensory neural hearing loss. And the second one is encephalitis, which is also very common. So that should be really remembered and screened for in patients with meningitis. Um So loads of signs and symptoms, headache, fever, neck stiffness, photophobia, nausea and vomiting or focal neurology, seizures, reduced conscious level. So all these mixtures of I guess neurological signs, neck thickness, um and photophobia. You're kind of thinking this could be meningitis have a low threshold of suspicion. Last thing to be really aware of is meningococcal septicemia. Um So this is shown by these rashes which are non blanching, particular rashes. So it's a bit harder to see in darker skin tone. It's a little bit more purply bluey and darker skin tones and they don't blanch when you apply pressure on them. So it means that they don't go away when you apply pressure and that is very, very, very, very alarming. Um, so in patients with meningitis, think of the sep sepsis six protocol and make sure you're screening for sepsis as well. Um So investigations, uh you do blood tests F PC, your clotting glucose, you do an ABG, you do blood cultures, obviously to um a culture sensitivity to get the specific organism involved. You do imaging such as a CT head and then you would also do a lumbar puncture of the CSF to do analysis. Um And the analysis will kind of give you a clue whether it's like a bacterial viral cause a fungal cause or like ATB cause. And this is contraindicated in high intracranial pressure. So, if there's any signs of high intracranial pressure, such as like really big headaches, especially when they move forward, uh like a focal head neurology. Um just things like that, like maybe if you do um an ophthalmoscope, um examination of the eye, you might see papilledema or something, you can't do a lumbar puncture because it risks um coning occurring which isn't very good. Um So this is quite um extensive and this isn't a microbiological lesson again, but just key things to be aware of usually exam, you're normally asked undergraduate level to distinguish between bacterial and viral. You very rarely get TB or fungal causes. Um But you can kind of look back at this if you're um really interested in that. So for bacterial, it's usually cloudy, it has low glucose because think about it, if it's a bacteria, they're kind of taking in the glucose. So think about bacterial cause as having low glucose as a differential for viral and then it will have high protein. And last thing of all, it has polymorph. So if it says what sort of white cells it has and it mentions polymorph in the exams or stem, then that is bacterial. Viral is typically clear. Sometimes it could be a little cloudy. Um It has quite a high amount of glucose still in the CSF. So 60 to 80%. Um it's normal or raised protein. Sometimes it's normal, sometimes it's slightly raised, but it's not particularly high. So it's not above 1 g per per deciliter and it's predominantly lymphocytes. Um So if you remember those two, it's quite easy to distinguish whether it's a bacterial or viral cause. Uh So men meningitis, so management is 2 g of IV cef or cefotaxime. Um This is twice daily to ensure cns penetration. Um And also sometimes you can add IV amoxicillin um which is kind of like a penicillin based um medication and this is good for patients like either side of like um the demographic. So really young Children or really elderly patients because this will cover for listeria. Um Listeria is a bacteria that is also a common cause of meningitis in neonates and the elderly. And that's why you sometimes add IV amoxicillin if you're also suspecting viral encephalitis, um um sort of together cause I mentioned sometimes meningitis causes encephalitis, then you wanna give IV Aclovir um as well. Uh And in patients who are allergic to penicillin, you can give uh chlorophenol. So any person who has been in contact with a patient diagnosed with meningitis should receive ciprofloxacin as prophylaxis. So it's not treatment, it's prophylaxis, which is 5 mg or daily. Um And this is why it's quite important to do sort of contact tracing of pa patients who have meningitis so that people who have been in contact with them can have that prophylaxis. And obviously, if they are, if they end up having meningitis, you treat um as such SBA time, a 31 year old woman presents with the ed with a severe headache, general malaise and high temperatures persisting for two days. She reports stiffness when trying to bend her neck and describes the headache as the worst she has ever experienced. Predominantly located in the osteopal region. On examination. She is pierced distress with a heart rate of 100 and 55 per minute BP of 100 and 1/71 respirate of 20 a temperature of 39.1. A new extensive rash is noted on her back that was not present during triage. She also seems confused what is the most appropriate next step in her management. So, basically, you already know it's, um, we don't know, but you are highly, highly, highly suspecting, um, meningitis. Um, it's just the, the symptoms are clearly, um, leading to meningitis. So I wouldn't delay treatment by doing these two investigations just yet. Um, I would probably administer IV Cef Cefotax or if there was IV cefTRIAXone, you can get that as well. Um, but you probably would want to make sure you get blood cultures before giving that. Um, but out of all of these, the most important thing would be immediately administering IV, uh, Cefta Iine. And if you'd want to do the other ones, you could. But, um, it's quite clear what the diagnosis is also. You wouldn't give amoxicillin because they're not on either ends of the demographic. So they're not very young or very old. Um, a 28 year old man from Zimbabwe presents to the emergency department with a two week history of fever, cough, headache, vomiting, and neck stiffness. He is known to be HIV positive and is on treatment. His most recent CD four count was 450 cells, uh, per millimeter cube on examination. He has no focal neurological signs, but it appears drow and confused. He suspect meningitis and perform a lumbar puncture. So these are the results. Uh So if you just have a look, it's key things are, it's cloudy white cells are lymphocyte predominant. So, have a think about that. There's high protein above one and there was pretty high glucose. So what is the most likely diagnosis either? It's meningococcal meningitis, TB meningitis, cryptococcal meningitis, partially treated bacterial meningitis or heart this simplex meningitis. Um So we didn't go through this one quite quickly, but essentially, it can't be any of the other bacterial causes. So it can't be basically the other three, it could be hyper simplex meningitis. But with TB, think about TB and HIV, coinfection are very, very, very common, especially in Sub Saharan Africa, which is where Zimbabwe is. So you should always consider it in, in a patient. Um So HIV and TB always consider that together and then also patients from Sub Saharan Africa. I know it's quite typical and it's not very cultural competent, culturally competent to say it, but it is just having awareness that this could be something that happens. Um Where TB meningitis is a little bit more common in patients from um Sub Saharan Africa. A 44 year old man was admitted to the medical unit with vomiting drowsiness and headache on examination. He is febrile squinting to bright lights and has severe pain when extended his neck, sorry, his knee when his hip was lifted off the bed. So, chronic sign, he was treated on IV cefotaxime and IV dexamethasone and underwent a lumbar puncture. What is the most common long term complication of this condition? So I mentioned this before. So it's out of these two, but one of them is a little bit more common. So the answer is sensorineural hearing loss um because that's more common than encephalitis and it happens to a lot of patients with meningitis. Um Also just in this time, I think they were also given uh dexamethasone. Sometimes patients are given that when they have um like vomiting and headache because it's a sign that they might have some sort of raised intracranial pressure. So they might be given IV dexamethasone to like offset um those signs and symptoms. Um, a 21 year old lady who has just started her second year at medical school, presented to the emergency department with a temperature of 38 °C, severe headache and aversion to bright light upon the examination. The junior doctor on call notices that the lady has difficulty bending her neck forward and also notices a non blanching rash on the lady's arm. The junior doctor is worried about the lady's condition and after finding a raised white cell count on an initial blood test, he decides to start the lady on some treatment without a delay, which of these is the recommended treatment to start the lady on. So either you got IV Catone, IV, Cefuroximine, IV Piperacillin, IV Aciclovir or Im Benzylpenicillin, like I mentioned before, IV cefTRIAXone. Thank you very much. I know this is a nice whistle stop tour through those three conditions, but I think those are just really good ones to know for the UK MLA as they're very likely to come up. Um And I hope the questions and the content was really useful. Um Thank you. And do you have any questions? Uh That was me presenting? My name is a, sorry, I'm the KT Acms president. Um These wonderful slides um were done by um my secretary Yasmin Nanker. Thank you very much. Can you please clarify what you said about iatrogenic bradycardia risks with be J blocker and CCB CO? No. Um apologies. I see. Yes. So you can give um bisoprolol and Felodipine because Felodipine belongs to a different type of um class of calcium channel blocker. So, Felodipine is a non rate limiting cardio channel blocker. Um But you can't give things like uh amiodarone. Um So you can't give a bisoprolol with a nondihydropyridine or they're sometimes known as a rates limiting calcium channel blocker because if you use both of them, they're both going to decrease the heart rate significantly and then that can cause isogenic bradycardia. I hope that makes sense. You're welcome. Thank you so much. Uh Thank you, everybody for attending. Um That was the end of this lecture and I think there might, there'll be one more for the series, um, have a nice evening. Bye bye.