S.18/05/2026; Short clinical: 1- Abdomen st.; Transplanted kidney,2- Respiratory st.; Bronchiactasis

Added: 2026-05-24

[00:00:03]Alamikum the short clinical day first scenario Mr. Paul Smith 45 years old gentleman please examine his abdomen very >> hello my name Abdullah alah I'm one of the doctors in the exam um thank you Mr. B Mr. ball. Uh, Smith, right?

[00:00:26]>> Yes, please.

[00:00:27]>> Um, I'm here to um, uh, examine your tummy if that's okay.

[00:00:33]>> Mhm.

[00:00:35]>> Okay. I will start from the end of the bed. I will, uh, look in the uh, surroundings. Uh, and do I have any picture? Um, I will have a look first in the abdomen. I will come the end of the bed. I will ask him to uh uh with a good exposure I will ask him to take deep breaths in and out and uh give a cough for the tummy.

[00:01:04]>> Okay. Patient has coughed.

[00:01:06]>> Okay. And uh I will also um ask him uh okay Mr. Paul um let I will have uh attached to your hand. Can you give me your hands hyperextended hand? I will see if there's any tremor, >> flapping tremor and I will see there any clubbing if there's any lucunia features of chronic liver disease >> and palmer um dubert contractor and I will see exposure of the arms and forearms if there there's any um fistulas I will touch um >> there is fistula >> where >> braifalic fistula on the left >> on the left I will have a look closer closer uh for any needle And uh I will uh touch for any thrill and I will listen also for a thrill.

[00:01:57]>> Okay. No thrill. No need this time.

[00:02:00]>> No needle. But there is a thrill.

[00:02:02]>> No trail please.

[00:02:03]>> No thrill. Okay. And I will look in the eyes for any uh jaundice or bellor.

[00:02:10]>> No jaundice.

[00:02:10]>> I will look in the mouth. open mouth widely um for mouth hygiene and if there is any uh uh ulcers and also I will look for any gum hypertrophy.

[00:02:23]>> Uh okay I will look in the neck for any uh I will look in the neck for any uh raise GVP. Um yeah >> no chip nourished >> is the is the patient uh okay uh now which position >> uh yeah uh I will have a look to the um uh neck scars for any previous uh for for the is there any recent or current uh can uh re um uh diialysis line central line >> no central Okay. Uh okay. I will have a look now to the expose the uh uh the abdomen uh closely. I will ask him I will palpate for uh first first I will look for any scar >> J-shaped scar on the right photo.

[00:03:17]>> Do you have any pictures right? Okay. I will ask okay I will have a look uh for I will uh ask him. Do you have any pain anywhere? Yes, I have pain in the right in the in the where the scar is.

[00:03:32]>> Okay. And I will uh have a uh Okay. Is the tummy distended or not or >> not distended?

[00:03:39]>> Is there any caution feature or not?

[00:03:42]>> No.

[00:03:43]>> Okay. I will have a touch uh away from the nine areas away from the pain area.

[00:03:52]>> Okay. And um yeah uh palpate lightly and then I will go >> tenderness >> mild tenderness >> where on the right lower okay I'm sorry okay I'm sorry I will also uh have a palpation for the area on the right iliac fossa right lower iac fossa uh below the scar uh do I feel a mass do I feel the transplant or >> it will be with difficulty okay Um okay and I will go for is there any other scar in the middle line of the umbilicus or okay and I will go on the feel the liver >> deep the palpation from lower right to lifosa and then going upward.

[00:04:36]>> Okay and uh with deeper inspiration and also I will go for the same for the spleen.

[00:04:42]>> No no pip and I will also um per cause for asitis.

[00:04:49]>> Okay. Okay. Noitis >> for shifting dness. Noitis. Okay. And also I will oscultate.

[00:04:57]>> Okay.

[00:04:58]>> For around the area of the uh transplant and for any venus h and also for the uh I mean brewy and also for intestinal sound. Um okay sounds >> I will have palpation. Okay. I will okay I will uh close on the area of the of the abdomen >> and I will uh I will close on the exposure of the area of the abdomen and I will pulpate for the neck for the lymph nodes >> and also I will go for the lower limbs >> check for ankle edma >> mild ankle edma bilaterally and there is the no DVT right it's calves are lax >> I don't know if sensitivity but mold >> bilateral. Okay. Bilateral.

[00:05:50]>> Yeah. Yeah. I will have a look to the um okay. Um um any atrophic is the body underbelt or um generally temporal wasting?

[00:06:07]>> No. No. No.

[00:06:08]>> No. Uh is there any tremor fine tremor on outstretched hand before?

[00:06:13]>> No. just as a reminder. Okay, I have finished my examination. Thank you.

[00:06:18]>> You're welcome.

[00:06:19]>> Um I would like to complete my examination by uh full uh vitals chart and a urine um dipst stick if available and uh analysis and erectile examination and hernal or examination.

[00:06:38]>> All right.

[00:06:39]Thank you.

[00:06:41]>> Thank you.

[00:06:42]>> Yeah. So, can you present your case, please?

[00:06:44]>> Uh, Mr. I've examined Mr. B. He's 45 year old. Um um he's lying comfortable.

[00:06:53]Uh he has um he has um a a failed uh he had a previous um renal uh transplant.

[00:07:12]Um uh so but uh when I examined him he is um uh he was uic uh he was um not showing any features of toxicity um there was a visible scar J-shaped on the right lower iliac fossa and there was underlying um uh pulpable mass uh uh likely uh kidney transplant which was tender on uh palpation and um I could not appreciate any the patient is eupholic and there is uh no features of uh uh of uh cytotoxin uh uh cytotoxic medication toxicity.

[00:08:02]>> Mhm. And um and there was a um no uh there was a previous uh brachioipalic uh uh fistula uh for previous diialysis which is not really showing any recent needling and it would not be a current mode of uh uh diialysis.

[00:08:27]Um yeah.

[00:08:30]>> Okay. So what is the diff what are you what is your diagnosis and differentials?

[00:08:35]So I uh so this gentleman given the area of uh the tenderness at the site of the renal transplant but uh he is not showing any features of uh he is he's well and not show and uic and not showing toxicity um urimic uh features uh I would uh I would uh think about um the that the transplant um can be working the transplant is working. Um other features that can be uh is infection uh at the uh uh the area of the of the of the kidney uh such as uh a urinary tract infection, bonfritis or a recent infection of the of the around the area of the surgical scar. uh there should be uh another differential of u um uh yeah yeah yeah that's my thoughts um >> okay so how will you investigate this patient >> um I would like to start as a basic uh blood tests I need to look for the uh blood blood count in for any anemia and uh uh infection markers white blood cell for any current infection ction and the C reactive protein. Uh also looking for the kidney function importantly rule out any uh kidney rejection transplant and also we'll look in the uh liver function tests um which will give an indication about any uh congestive uh hippatopathy or and also we'll look for the cytotoxin levels uh tacrolymus uh levels uh h and uh we'll do ultrasound of the transplant. Uh that's imaging uh tests.

[00:10:41]Uh importantly we need before imaging do um if the patient was on a steroid we need to look for the any hemoglobin A1C and how is the diabetes control. Um I would like to um also have a check for um uh imaging uh to make sure that what is the cause of the abdomen tenderness. Uh I need to detail further about that with history taking.

[00:11:11]Um yeah.

[00:11:15]>> Okay. So thank you. Oh, >> hold on.

[00:11:20]>> Uh, okay.

[00:11:23]>> All right.

[00:11:24]>> But but but uh sorry you I thought you just investigation. You didn't go to the management.

[00:11:29]>> No, we are going there. I just thank you for the I mean for the >> Okay.

[00:11:33]>> for answering the question. So how will you manage this patient?

[00:11:37]>> Okay. Um I will manage as in a multi-disiplinary team um and um involving the um so in involving the uh involving the the internal medicine the nephrology involving the um uh involving the uh the um physio therapy, occupational therapy um and we need to uh also have a look to the patient's um medication chart. Uh okay. So in terms of management that uh depend on the patient diagnosis uh of uh so uh things will tailor uh uh so depending on if there is a need for giving um um so if if the is the patient requiring uh um a preparation for further another uh transplant that depends on the uh kidney function at the moment. If the patient is the is there any uh need for modification of his um uh transplant current management any change in the doses of the of the of the of the of the transplant cytotoxic medications.

[00:13:19]Um and also um we need if the blood pressure to make sure the blood pressure is it under control or we need further optimization um and um diet control um um uh >> thank you thank you doc. So let's say this patient is the >> Yeah.

[00:13:48]>> What you felt on the right fossa is a renal is a renal mass a kidney.

[00:13:55]Do you think what would you think what what are the possible causes of pain in a patient with renal transplants?

[00:14:05]>> What pain in the patient with transplants? First is the kidney transplant rejection but it doesn't fit given the patient is stable and uimic uh which I'm not sure how to correlate these. Did you say the patient is uvelic? Why did you say it's uvelic?

[00:14:25]>> Umic. Uh uh sorry. There is u given the patient is uh comfortable at rest there is there was a slight there was lower limb edema. Yes.

[00:14:40]Uh there could be a questionable kidney function the transplant kidney function.

[00:14:45]In that case, we'll need urgent nephrology review for um to to review what is the cause of the of the of this rejection and things like initially infection um uh surgical site um uh causes such as uh uh is there any local bleeding?

[00:15:10]>> The scar is well healed is a well healed scar >> well healed. Yeah. Okay. if there's any um uh clots inside uh the renal vein or if there's any um uh uh yeah and also we'll need to consider um uh consider uh the the the further history uh is the kidney is the kidney transplant aged and require another kidney transplant uh that that can happen after a long period of time of the transplant and uh um so yeah.

[00:15:59]>> Okay.

[00:16:00]>> Is there any medication induced also in toxicity over the kidney? was which of the which of the tox which of the medications >> uh tacrolyas uh also uh some uh uh antibiotics if especially if there's recurrent infections UTI tract infections um things like uh uh genttoycine um um >> thank you thank you so Well done. Yeah, Dr. P.

[00:16:40]>> You can comment, doctor. I understand.

[00:16:41]>> All right. Yeah. Okay. Thank you. Well done you for the presentation and then I mean the examination everything. Well done. Um well examination well it was it was good >> but I would say that what I could say about it is um >> possibly the the the the um the sequence the sequence yes the sequence is something that of course we're all working towards perfection >> the sequence of the examination needs to be you know >> work more upon so that you won't be going back and forth Um also when you were checking for the that's a couple of things I think that would be would have been helpful if you are checking this patient you might not find anything but of course it's good that you are actively looking out for it the only um sign of toxicity that you checked in this patient after picking that he has a J-shaped scar previous um nonfunctioning a fistula in on on the right arm you should be seeing looking out for any form of other forms of drug toxicity like steroid any question you need to look out for in this patient I did not see you looking out for you have to be looking out for the pop of the fingers for you know uh needle pricks you know for glucose monitoring and things like that um yeah you what you eventually checked the lymph node but it was something like >> afterward you also need to have checked for you know skin for the any form of rashes you know but um skin cancer is quite common in patient with um that with transplant and also an imunosuppressious trans medication so need to be actively looking out for that you didn't check the back of this patient for any scar though this patient does not have a scar but it would have been helpful if you have oh can you sit up for me please check the back any scar and also I mean that would pos what what if this patient have had a nephrectomy previously and you've missed you've missed the scar.

[00:18:53]>> Oh, okay.

[00:18:53]>> Yeah, it could have al also been important. Then um reporting wise um there are some things that you were you were say you said over and over again that this patient is ubmic from EV evidence is available says that this patient has an ankle edema which is something that you know finding that is is a common question in ces even if you don't report it they will ask you what is the fluid status of this patient and once you've picked something like that just stay on it. This patient has volume overload with the ankle edma is sufficient evidence to say that there's volume overload in this patient. So you need to emphasize on that. Then um welfare this patient has a tenderness in the right iliac fossa and you still went ahead to do a deep palpation.

[00:19:50]Do you get? Even if you are going to go ahead with a deep palpation, you should be seen being caring for the patient like okay am I all right to go deeply you know things like that now we know that you are conscious of this patient having of course most likely they will not bring a patient with actual pain in exam I don't think anyone will do that but of course simulation they can ask them to simulate and things like that but we just need to be seen making that effort like okay you have pain there okay all right am I all right to do this is it just you know it's just you checking the patient they would know that is what you you know you're supposed to do that but but because of the pain is is a something for welfare another thing that I think you should have also look out for would be guarding though it's extend garden because the patient has had you say J chap cannot have any other thing.

[00:20:52]Appendicitis can and it's on the right.

[00:20:55]Appendicitis could have been there. It could have cost it could have been any other thing, any other infection. And that was why I asked her what are the other causes of what are the causes of pain in a post transplant patient. Okay.

[00:21:10]Which you answer post um um all rejection can occur.

[00:21:17]You said the infection but you were not particular about the infection. It could be because of of the location. It could be appendicitis. It could be a dasculitis that is that is happening there. It could be an obstruction. It could be a ureic block that is happening. It might not be an outrage rejection. It could just be ureic block that is happening there. It also be due to medication toxicity like it can cause abinal abominal pain abominal cramping can can happen with it. Those are the it can be a stenosis ren stenosis. It can be a trombosis that can happen along with the with that I mean along the along that region. Those are the things that are quite that can happen cause pain in such p in such patient and those are the things that should be your differentials.

[00:22:20]We are thinking of alograph transplant because patient have an evidence of fluid overload in a patient that you know that had an old graft. We saw a kidney plant transplant between plant possibly an alligraph rejection appendicitis um things those are the things that can that can also that can come in even if inflammatory bowel disease consider being in this in this patient.

[00:22:51]Okay. So that is that being that being said then >> what disease >> eh >> inflammatory bwell disease because of the right you know Crohn's disease is common and that's though there's no other things that can suggest it I'm just saying that things that can that can that can be differentials in this patient then management wise um you know investigation wise okay the uh I'm not quite sure you spoke about the Um, renoplotrasound for this patient. Quite important. We need to check the renad plot in this patient.

[00:23:28]Just to rule out.

[00:23:29]>> I did. I did.

[00:23:30]>> You did? Okay. Possibly. I knew I knew I had an ultrasound, but I didn't get the the duplic.

[00:23:36]Okay.

[00:23:37]>> Possibly I missed that from my side.

[00:23:38]Okay.

[00:23:40]>> So, um, you you did a urine deep, which is quite good.

[00:23:47]kidney function test which is which is quite good in this patient. You also had say for the for the uh imunosuppressants which is which is very very good. So I think your investigation was good but I think I miss the doppler >> part of this of this you did ultrasound scan. Okay. I believe that once once you mentioned do ultrasound you did your UCR and you um you did your you able to do your abumin ultrasound scan. I believe that clinical judgment should be good.

[00:24:18]That that is what I think. Then MDT MDT including the nephrology. Then you need to talk about urgent mode of renal trans because this patient is not actively going through possibly going through any form of replacement. At the moment if alograph is is holograph is our first differentials.

[00:24:39]There is no EV. This patient does not have any evidence of um imod dial replacement at this time.

[00:24:47]So he needs an urgent imodialysis assess okay in this in in in this patient. So MDT or immodialysis if if indicate of course you want to take an adequate history MDT or immodialysis assess then um look out for possible cause of the of the hograph any any infection do it appropriately control blood pressure control blood blood glucose and u ultimate replacement I mean renal replacement therapy which could be another form of renal transplant as well in this in this um in this patient. Then another thing I think we should also look out for we should also look out for I mean to say is um in a patient with transplant apart from looking out for scalp don transplant scar of previous um um central line also look out for scal parathyroidctomy >> is something that that show up previously in exams. So scar of parade parathyroidctomy >> is is another thing that we need to look out for previous diialysis is another thing I need to look out for. So I think basically that is all but we we did well and that question would have been what are the complication of >> why the patient had nephroctomy >> no no this patient does not have I'm just saying that >> that you have to check but of course there are causes of nefrectomy polycystic ging disease that have indications for nephrectomy that's one of the common things common things in pieces this patient has automatic kidney disease. What are the indications for nephrectomy in this patient? When I say carinoma, you need to do reftomy as well, isn't it? So >> yes, >> those are the possible things to to >> So this patient just a question. Sorry B. So it's this is the patient with likely rejection of his renal transplant.

[00:27:05]>> Yes. and he's not on current mode of diialysis and showing volume overload.

[00:27:11]So what what could be the if there's no recent so he was um he was di dializing with the his transplant basically.

[00:27:20]>> Yes he was having replacement was transplant before but this is showing evidence of rejection at this time.

[00:27:29]>> Okay.

[00:27:30]>> Okay. Yep. All right. So I think basically >> a nice case. Yeah. Thank you.

[00:27:35]>> That is it. So septic full septic work up in this patient is >> review the review the chart looking out for blood pressure looking out for vital signs I mean temperature blood pressure vital signs and things like just to see how what looks like.

[00:27:54]>> So basically that is it. Thank you so much. Well done.

[00:27:57]>> Thank you so much. Nice case. Um you can uh judge me on the marking. I didn't do well. Yeah.

[00:28:06]>> Yeah. I I will comment on this. Uh regarding the infection, you have also to put in your plan screening for virus PCR.

[00:28:16]>> Okay. Because you suspect the infection to the graft. So I must do the screening for cytogaro and hepatitis or say HIV or other viral could be affecting the imunosuppressent or immuno compromised patient. Okay, >> this is regarding uh the last point which is uh I think this is uh this one belong to the clinical judgment. The next point I want to comment on the multi team. I don't know you think a lot of seconds to to know what team you can call and you didn't mention the uh transplant team which is the most or the the most important team to be involved right >> should I mention people or better just say multi-disiplinary if I don't remember >> no no multi-isiplinary is the best approach but what the team should be in for >> should I pay them.

[00:29:18]>> Yeah, of course.

[00:29:19]>> Okay.

[00:29:20]>> And what makes sense? You have to call them first. Again, as I said in every session, whenever you have transplanted patient, you have to call the transplant team. Why? Because this patient on immun imunosuppressent for his precious organ.

[00:29:37]>> Okay.

[00:29:38]In order to save his organ, I have to either I have to to do a balance between the immunosuppressent not to be rejected and the antibiotics if there is suspicion of infection.

[00:29:57]Okay. So either I will increase the dose if I suspect rejection or I will decrease the dose and I will add some antibiotics in case if I suspect infection. So who will help me in this judgment? The team, the transplant team.

[00:30:14]Okay. So it's a must to call them in the first teams you will call. Then the nefologist of course in the the hospital nefologist in every hospital but transplant team supposed not to be in the same hospital the patient is following sometime they are from a higher center or very far center.

[00:30:35]Uh anyway you will know the the name of the doctors even sometime the patient himself has the contact number of the team or of the of the consultant or the team who did the transplant. Okay. So this is the first thing you have to mention. This is the first point I want to comment on clinical judgment.

[00:30:56]Whenever you mention multi and you have transplanted organ call the transplant team. This is regarding the first uh comment or the clinical judgment. So it's good you mention all the investigation but again don't forget the viral PCR or PCR for viral screening. This is for the infection as a complication here. I think you can maintain the mark no markdown in the clinical journment for the differential diagnosis.

[00:31:31]Uh what are the differential of abdominal pain and transplanted patients?

[00:31:41]>> Yeah.

[00:31:43]What's the fee you mentioned?

[00:31:46]>> Infections of the transplant.

[00:31:48]>> Okay.

[00:31:49]>> Um other is surgical cause which is uh urine stones uriteric blockage um arterial uh narrow stenosis renal artery stenosis or thrombus venus thrombus.

[00:32:07]>> Okay. Uh there is which is renal vein occlusion and other which is less common but more common is uh the obstruction um uh renal anesmotic blockage. Yeah, >> this what I want you to categorize. I would like to divide it to to renal causes or extraal. Marina I mean for the transplanted one because I have a lot of differential for the kidney itself the transplanted kidney itself as we usually mention the infection the rejection okay or reconas of original disease in the top of the differential make sure it might have discomfort or tenderness renal vroposes as you mentioned infection uh to the urinary tract all of them are differential for the transplanted kidney Now I will go to the anatomical related organs might present with abdominal pain. If the right side as Dr. Ayola said haveis or colon TB colitis or diverticulitis whatever the area the patient had the transplant in this is regarding uh the differential.

[00:33:26]So don't give just titles give differential or give the answer as systematic one. What I should think about either related to the real itself and this is in the top of your differential because the patient is present with volume overload. So means this patient has uh dysfunction or malfunction of the transplanted kidney. So I have to put some causes related to these uh transplanted kidney. This is regarding the differential.

[00:33:57]Okay. So it might be borderline because you didn't mention uh the infection the rejection. And you mentioned the rejection right and infection recurrence I said okay >> recurrence I didn't say >> okay sometimes it happens >> okay >> okay >> uh then the next will be for the physical examination I think you cover all the steps well and fluent this time I I can see the difference between now and before >> thank you >> uh they identify also the signs and the skill also perfect apart from the back it's very important to examine the back. Most of the candidate forget the back for the nephropim scar as long as well as the basil cracker. Whenever you escalate or check for the sacral edema or the basil crackers, check for the scar. Okay.

[00:34:50]>> Okay.

[00:34:54]>> The welfare I think also was maintained thanking the patient covering him. uh these are the I think uh good mark you can deserve in this scenario maybe two marks only down in brute differential diagnosis and identify the sign whenever you didn't mention the physical ex the by basal cranks or the back okay >> okay >> okay any question or comments >> uh no thank you >> okay you can post your scenario for Dr. Uh you please >> can you post the scenario Dr. Ayola please?

[00:35:44]>> Yeah yeah yeah >> sorry Dr. Abdullah I will post for Dr. Please any comment or question? Sorry I didn't ask. Anyone want to comment or ask question?

[00:35:57]>> The viral the viral BCR is it in the blood like like a septic uh >> yes like the same informatic markers.

[00:36:07]>> Okay. Okay. And the liver function uh only for the medication toxicity it will be useful.

[00:36:14]it will not be useful for um it's it's difficult to uh uh say why you want a liver function test in most cases liver function test is not that >> okay what if you mention it to the examiner and he will ask you what the rale of doing the liver function test in this scenario what do you think >> I should be prepared to know but in this scenario um be mindful only for the uh if it's there is the hibato toxicity due to the medication such as the transplant medications which can also affect the liver also >> this is one of the answer so some medication can affect the liver cause hib toxicity or even chistatic feature >> yeah and also it will guide for antibiotic uh as a bas baseline um level.

[00:37:18]>> What else?

[00:37:20]um if there is if I don't know >> even the infection itself this this patient or those type of patient are immuno compromised so they might acquire or having infection >> from because of the imunosuppression HIV hepatitis you can consider it one of even cytogallo virus it.

[00:37:50]So you can mention it as infection because of the imunosuppression or cancer spread of of the cancer because of also again the imuno compromise condition. Okay. So our baseline for the patient just to follow up the liver function if he has baseline or if he doesn't have we put it as baseline and suppose those patient they will have full panel of the all organs liver kidney thyroid parathyroid eco even okay if you think about invasive test or investigation you want to do for this patient what could be this test in term transplant related what you could do >> something could be related to the transplants what could be the invasive test or investigation you can do >> oh yeah biopsy biopsy exactly yes so don't forget it >> sometimes I have the recurrence of the original disease or antibodies or whatever the stage of the kidney itself I should do the renal bopsy to be definite diagnosis okay great >> okay Dr. Aula scenario. Yes. In the chat box. Examine.

[00:39:18]>> So, examine chest of uh Julia Smith's 45 year old complain of cough.

[00:39:26]>> Okay.

[00:39:27]>> Okay.

[00:39:33]>> All right. Hello.

[00:39:35]>> Hello.

[00:39:36]>> My name is Dr. Ayola. I'm one of the doctors here today. Can I confirm you are Miss Julia Smith, 45 years old? Yes, I am.

[00:39:44]>> All right. Yeah, today Yeah, today I will be exam I will be examining your chest. Thank you for allowing me to examine your chest. I'm looking at your hand, your legs, and your eyes. Would that be okay?

[00:39:54]>> Yes.

[00:39:55]>> Okay. I can see you're already exposed, which is quiteful. Thank you. So, I sanitize my hand and um I look around the patient's bed. Any um any oxygen cylinder, any P flow meter, neilizer, any >> there is one nebulizer.

[00:40:14]>> Okay.

[00:40:15]>> There is one inhaler also.

[00:40:18]>> Okay. So I go to the foot of the bed to the foot of the bed. I look at the patient only the chest um appearance.

[00:40:26]Then I ask patient to to cough.

[00:40:29]There is one thing you didn't mention on the surrounding.

[00:40:34]>> Okay. Oh, okay. I I I can't think of anything. Let's continue. Then you will correct me at the end.

[00:40:38]>> Okay, that's fine. You can continue.

[00:40:39]Yeah. Uh if I want to uh Dr. B, if I want to uh I have a I don't know if the voice will be to to I have a voice. I want to um >> to play. Okay.

[00:40:52]>> So, you'll ask for a cuff, right? Yeah.

[00:40:55]>> Yes.

[00:41:01]I don't know if you can anyone hear it.

[00:41:04]>> Not yet. Just a second.

[00:41:05]>> Okay. Wait.

[00:41:06]>> Oh, sorry.

[00:41:15]The compos uh Um, sorry.

[00:41:50]>> Yeah. Now, okay.

[00:41:54]>> Is the voice uh clear? No, >> I can hear you speak. Not really.

[00:41:59]>> I can hear what?

[00:42:00]>> I will repeat. I will repeat. Okay.

[00:42:14]>> No, it's not clear. Dr. Abdullah, you can share it to the WhatsApp group later on. It's >> Mhm.

[00:42:20]>> Okay. It's productive for >> productive. Okay. All right. Thank you for that. So, I come closer to the patient. Can I have a look at your hands, please? Can you can you bring out your hands out for me? I'm looking now for tain tin fingers. Any clubbing?

[00:42:35]>> There is clubbing. No tar staining.

[00:42:37]>> No t staining. There's clubbing. Okay.

[00:42:40]So I want to any any noodles in the hand. Any deformity? Any thickening of the skin of the hand?

[00:42:46]>> No.

[00:42:47]>> No. So I check the pulse of this patient. What's the p like? Is it bounding?

[00:42:53]>> The bul is not bound is normal volume.

[00:42:56]>> It's normal. Okay. All right. Can you cop your wrist for me? Any asteris?

[00:43:00]There is yeah >> there is a sterosis. All right. Thank you for that. So I I I would love to know the blood pressure of this patient.

[00:43:07]All right. Um >> uh yeah is uh normal 130 over 80.

[00:43:13]>> All right. Thank you. So can you turn your head to the left for me please? Is the JBP elevated?

[00:43:19]>> It is.

[00:43:20]>> Okay. Oh any pain in your tummy?

[00:43:24]>> No.

[00:43:25]>> No. Okay. So I press gently be It grows right or >> uh it's yes it can react it can go up hypathogular reflux. Yeah.

[00:43:38]>> Hello.

[00:43:42]Hello.

[00:43:46]Hello. Any Paulo?

[00:43:49]>> Ah no.

[00:43:50]>> Okay. All right. Are you open your mouth for me? Any any cyanosis in the mouth?

[00:43:57]Okay. So are you are you able to sit up please and put your hand okay and put your hand in a Kimbo?

[00:44:03]>> Yes. So she's trying to sit up and she's Yeah. Looks slightly tired and she's sitting up. Yeah, >> she's sitting up. Okay. So I look at the back. Any scar at the back?

[00:44:14]>> No scars.

[00:44:15]>> No scars. Okay. So I want to put my hand on your chest now. So I want you to breathe in and out for me. I'll do that on the six locations. Any What's the expansion like? You feel slightly diminished bilaterally, symmetrically.

[00:44:29]>> Symmetrically. Okay. So, I put my hand um um I put my hand on your chest on say 99 tactile perimeters on the six.

[00:44:38]>> Uh yes, it looks normal.

[00:44:42]>> Normal. Okay. So, precaution note on the sixth location.

[00:44:47]Yeah, there is some uh dullness um more upper uh upper parts upper zones. Yeah.

[00:44:56]>> All right. So on your chest now I want you to say 99. Okay. When it comes when it touches you say 99 >> on the >> Yeah. Is that from resonance >> perant?

[00:45:12]No. Uh 99 which is normal.

[00:45:15]>> It's normal. Okay. All right. So bright breath can you breathe and out for me please?

[00:45:21]>> Yeah. Okay. Uh where are you listening?

[00:45:25]>> So abar uh area you'll find uh uh can you hold just Dr. Basim again? Sorry. Um um I will I don't know this if nothing clear I will repeat.

[00:45:54]I can hear Dr. >> Okay. Nothing. Okay. So, uh you will hear uh co crackles.

[00:46:08]>> Co crackles. Where is the cock?

[00:46:09]>> Mainly mainly only in the upper and middle uh parts.

[00:46:14]>> Bilaterally or >> bilaterally?

[00:46:17]>> Bilaterally. Okay. Are you able to cough for me please?

[00:46:21]>> Yes. Cough. Does it does it reduce and does it change?

[00:46:24]>> It does change. It does change.

[00:46:26]>> It does change. Okay. All right. So before before you lie down, check for for your glands in your neck. I quickly check for enlargement. All right. So thank you.

[00:46:34]>> 1 minute left.

[00:46:35]>> So you lie down. So I want to check for the tracker centrality. Is the tracker central?

[00:46:40]>> Central. Yeah.

[00:46:41]>> All right. You might be a bit uncomfortable. Please bear with me. Put your hand in aimbo in the front. I check for this car in the front again.

[00:46:48]Anything in the front? Any scar?

[00:46:51]Uh no scars.

[00:46:53]>> Okay. I check for the expansion tapters as well in the front and then precaution note and and then um oscultation anything.

[00:47:03]>> Okay.

[00:47:04]>> Is it the same?

[00:47:07]>> No, you only hear on upper bar upper zone al upper part. Yeah.

[00:47:11]>> Bilaterally crackle. Yeah. Yeah.

[00:47:13]>> Bilaterally. Yeah. Yeah. What also you were listening for?

[00:47:17]>> You said what? Yeah. Any whis?

[00:47:20]>> No. No whis.

[00:47:21]>> No whis. Okay. All right. Thank you. Do you have any pain in your leg, please?

[00:47:25]>> Uh, no pain. No, there's no edema.

[00:47:29]>> No edema. So, I quickly also listen for a loud P2. Any loud P2 in those patients?

[00:47:34]>> Yes, there is.

[00:47:36]>> There's a loud P2. Okay. Anya.

[00:47:39]>> Uh, yes.

[00:47:40]>> Okay. All right. Thank you for allowing me to examine you.

[00:47:44]I sanitize my hand and you can wear your clothes.

[00:47:47]>> Yeah.

[00:47:48]Okay.

[00:47:50]>> So, uh pres present your findings.

[00:47:54]>> Okay. I just examine this um 45 year old um lady who um has a wet cough on examination. Uh perily he has a finger clubbing and the significant finding on the chest examination is that of a reduced chest expansion um on the upper and middle. Patient also has a coas crackles on the upper and middle lungs bilaterally which improves with um which improve with uh I mean which improve with coughing which which which clears with coughing.

[00:48:28]>> Yes.

[00:48:28]>> Um there's also evidence of left prostana eve and um and loud P2 as well as umma important this patient has no scar on the on the on the chest. So putting all of this together a possible differential in this patient would be one thinking of a possibility of a um broketis with a c with a with a cunally >> mhm >> in this patient I also want to consider possibility of inter intersticial lung disease >> in this in this patient other things I consider will also be um respiratory tract infection like lower tract infection like a pneumonia though I wouldn't expect a call pneumonia >> then >> okay great >> then I also want to conso want to put in background um um lung lung cancer as well >> okay uh great how you will um how you how you will um uh investigate >> for investigation of this patient first I want to do um would be um first do the bedside um check The patient physician will be forced to do um uh what to what want to do a chest X-ray to confirm the diagnosis. Arteral blood gases as well to look out for any evidence of of acidosis in this in this patient. Um blood um blood test will include food blood count with inflammatory markers and liver function test rule out sepsis in this patient spot culture sensitivity >> great >> will also be important in this in this young in this this patient. Other things want to do will include possibility of high resolution CT scan can also be considered um in this patient. Spyometry also will will also be will also be helpful.

[00:50:32]What you will what you will what could be the possibility in of the spyometry in this patient >> because is my first differential possibility of having an obstructive pattern and it could also also also be be normal but obstructive pattern will be high in this patient.

[00:50:53]>> Okay, great. Okay. Um Okay. And why do you want high resolution CT chest? I just suggest in this patient would help to look out for um number one want to see the the degree of severity of the bronetis in this patient and also if it's also al also rule out any form of um lung lung cancer as well.

[00:51:19]>> Great. How do you manage >> manage of this patient for stability is important? You want to want to check for um if there's need for oxygen therapy you want to give using ABCD of of resuscitation >> then um >> ABCD of resuscitation then you want also want to involve the um the the MDT involvement adequate appropriate history and and an examination review the patient up chart then other Others you want to include will be commence the patient on on appropriate antibiotics according to to the trust policy and change to the to the to the um sensitivity once you have the result of your MCS. Then other things you want to do >> in this patient will include you can also consider chest physotherapy rehabilitation if patient smoke want to cancel and stop smoking. Annual annual vaccination would also be important.

[00:52:21]Continuous follow up in clinic. Then in some in some cases um um lung transplant can also be considered if if the indication um are met.

[00:52:31]>> Great great well done. Okay. Uh what last question? Uh what um uh what are the causes of proactis? You know >> cause of brises could be um first it can be it can be due to um previous it can be due to um lung previous um no it can be due to inflammatory disease like rheumatoid arthritis, inflammatory bowel disease. It can also be due to post post um obstruction and that can be can also be due to childhood um childhood infection like tuberculosis.

[00:53:09]Um measles can also be a possibility. Um other other things that can cause bronchasis will include um uh uh sorry umary um um sorry >> sorryary disease primary primary um disania syndrome then hyperamagmia can also be can also be a cause HIV infection then other other things that can cause that can cause bronchis. Okay.

[00:53:44]Uh I talk about obstruction, right?

[00:53:47]Those are the things I can I can think about now. Thank you.

[00:53:50]>> Very good. Very good. Well done. Okay.

[00:53:57]>> Yes, you can comment now. Dr. Abdullah, please.

[00:54:00]>> Uh yeah. Um yeah. Um so on the bit side actually so a bronchitis case because of the there is a clubbing there is a uh the causes of clubbing will be common question and there is the the patient is underbelt actually uh so um there is a sputum pot on the bit side you didn't mention which is okay but there is um also expected to be polyite themic rather than anemic. Uh on the examination there is um uh the patient in mild distress. There is other findings are as you mentioned.

[00:54:45]So the differential of uh coarse crackles that improve with coughing and there is the corpal manal features. Um and uh you did very well in the discussion. Um okay so causes of bronchiactis can be yes post infections as you said obstructive but uh and also the syndromic which is cartener mucosel disynesia and there is immuno deficiency can be um oh I'm sorry the cystic fibrosis also very important to mention immuno deficiency acqu hypogamaglobial anemia uh and um um uh other auto so autoimmune disorders such as rheumatological conditions um uh you mentioned uh well I'm sorry idiopathic should be also mentioned also and pulmonary fibrosis traction bronchitis uh complications uh hemoptis um it can lead to emolic septic embolism uh so it's lung can lead to lung absis with cptic embolism inema another pneumonia can lead to lung collapse pneumthorox can lead to uh respiratory failure of course bulmonary hypertension amoidosis better not I don't know if better to mention or not uh so the you mentioned the same tests and uh you've very you mentioned the management um and so in terms of marking. Uh Dr. Basim, you can start and then I will collect look I know what I I don't know if there's anything that uh she did very well. I don't see any marks that uh >> Okay, let's let's be more judgmental.

[00:56:49]Okay. Okay.

[00:56:50]>> Okay. Yeah, of course.

[00:56:51]>> Because she is uh she's having exam next month. Okay.

[00:56:56]>> Great. being having Dr. Aula patient complaining of cuff and you don't observe the cuff container or sputum container or the tissue from the start you can know the case >> sometime the tissue itself for the wet cuff or productive cuff as well as for the container sometimes blood in this in the tissue as well so please take care of this part don't just exam for oxygen cylinder, mobilizer, bronco dilator or whatever. Okay, so be careful. You have to examine or to observe this thing tissue or sputum container. Sometimes also they have the sputum inside for this mark or for this part of examination. I will mark you down because it's very important step just to remind you in every chest examination to take care about this point.

[00:57:57]>> Yeah.

[00:57:58]>> Okay. Otherwise the all exam steps went smooth fluent.

[00:58:04]I think you didn't miss apart from the lymph node. Did you examine for lymph node?

[00:58:09]>> She did. She did.

[00:58:10]>> Okay. Perfect. So otherwise it was it was good. They identify the signs as well was proper. We didn't miss any.

[00:58:22]Then the different theial diagnosis in term of bronctis or coarse crackles either he will ask you what the causes of pronactises or what are the causes of course crackles. I think you mentioned the of course crackles, bronchasis and pneumonia right and overload or bulinary edema.

[00:58:50]>> I didn't mention pulmonary edema because it was more of your upper loop thing.

[00:58:53]>> Yeah. So remember that.

[00:58:55]>> Okay. Yeah. In term of pronis you give all the cause possible cause of pronexis always start as divide it into either congenital or inherited conditions and acquired one inherited as you said the syndromes cartagar cystic fibrosis caryynesia syndrome okay you can mention it it in as congenital the acquire or even the congenital immuno globmia for the acquired Any cause you can put edic post infection either a childhood like MS measles TB or even post obstruction lung cancer okay traction even can cause all these manifestation of cactuses.

[00:59:49]So don't forget to mention it as congenital and acquired. This the first word to mention although you mention all of them but better to mention in this way.

[00:59:59]Then let's go to the next would be for the uh clinical judgment. You mentioned the bedside test good arterial blood gas spyometry or expuls oxymmetry. Don't forget them in any chest scenario.

[01:00:16]Then the general CBC looking for infatty markers, lucytosis, anemia of chic disease or hemopotis can lead to anemia all of them can be helpful. The specific here will be sputum culture, sputum gram stain and the imaging will be chest x-ray starting with it then high resolution CT chest. If you have chemotis you can consider city with contrast.

[01:00:43]For the invasive you can say I would I would like to do the bronoscopy and bron lage just to get a culture deep culture of tracheal spirit >> don't forget it spometry as you mentioned obstructive >> uh then uh the oxygen okay the management plan the term ofity education up to date vaccination as you mentioned stop smoking oxygen supplements and one one very important step you didn't mention and the examin might wait for it if you don't mention it he might minus you what do you think the most important management step in any bronchasis patient what is it >> um prophylactic antibiotics >> no this is no no this is for the long term I mean for >> the attacks Yeah, exactly. Ber drainage.

[01:01:50]>> Yeah, I think you didn't mention right.

[01:01:51]So, >> chesty.

[01:01:56]>> No, you're not always physically here.

[01:01:58]You have to mention moisture drainage.

[01:02:01]>> Okay, this patient is full of secretion and he's suffocating in his secretion.

[01:02:06]>> So, needs to be in in this way to drain the secretion drainage. Okay.

[01:02:12]>> Yeah.

[01:02:13]>> Antibetics you can and the line of the definite line of management in any politics as you said could be transplant. Okay. Transplant.

[01:02:26]>> Clear.

[01:02:27]>> Yeah.

[01:02:27]>> Again the most if you don't mention it in both cases maybe the examiner will you remember it take care about that.

[01:02:37]>> Mhm. uh the the welfare all over was maintained since you sanitize the hand thank the patient cover him take care of the tender or tenderness whenever he has any tenderness you have any question Dr. Huh?

[01:02:53]>> No.

[01:02:55]>> Okay. I mentioned for you some specific points. You have to remember it >> specific or bedside test image in cystic fibrosis.

[01:03:06]>> The cystic sorry of bronctis and the type of bronctis. It will depend on the age of the patient either and acquired.

[01:03:16]Start with this >> then you will impress the examiner.

[01:03:21]>> Okay. Yeah. booster nutrition of course cystic fibrosis need to be uh replaced by high caloric diets >> diet yes >> so you can add it also dietitionian as one of the MDT okay clear >> yes thank you >> anything missed no >> okay anyone want to add any comments organisms of the perctis and the hemoptis management.

[01:03:59]>> Yeah, hemoptis if the patient presented acute states you can say it in ABCD approach. Some patient might have massive and diffused bleeding up to hypoxia because of this aspiration or the blockage of the main airways. ABCD approach might need intubation sometimes double lumin intubation to secure the the healthy lung because you want to inflate the healthy lung and the other one you can uh block it the blood >> so after ABCD approach stabilizing the patient either patient stable or unstable stable he can go for CT and you even imilization if unstable you can shift him to the surgery sometimes might need even lumctomy or lubctomy according to the the vessel itself.

[01:04:52]>> Okay. For the organism it depends on the type of infection is is it uh on top of acute on top of chronic or for the chronic management and also it depends on the disease itself. Cystic fibrosis would be different from other conditions.

[01:05:11]All right. Yeah, >> but the most common organism always remember the same order of any infection.

[01:05:21]>> Yeah.

[01:05:22]influenza and also sedona but I think sudonus would be for the cystic fibrosis >> it's pathogonic right >> but the other infection would be >> inflatoralis normal infection that causes normal thing that causes infection in pneumonia >> but but pneumonia is more for the um cystic fibrosis >> yeah soas I think it's better for sister. What do you want to say to Dr. >> No, is itonmonic? It's very it's like it's very common in in in bronchitis is so is it pathogenic?

[01:06:09]>> This what I remember for the long term and whenever you have the patient is chronic the most common will be.

[01:06:17]Anyone can share another opinion.

[01:06:20]>> Okay. Yeah, I mean being common but not pagnommonic.

[01:06:24]>> Pathogonic as resistant one and the one for >> difficult to transplant >> maybe you mean balder for the resistant. Yes.

[01:06:36]>> And this is contra indication to transplant.

[01:06:39]>> Yeah.

[01:06:40]>> Foria species but for what I remember also for the chronic acidus and the cystic fibrosis.

[01:06:50]Okay.

[01:06:52]>> And we have what other uh uh morell hemophil pneumonia right?

[01:07:02]>> Yeah.

[01:07:03]>> Okay. Okay. Okay.

[01:07:06]>> Okay. Any other question or comments?

[01:07:09]>> Oh, thank you.

[01:07:10]>> Okay.

[01:07:13]Uh Dr. of am investigation for PhD. In this patient he has features of PhD. What is the PHT?

[01:07:24]>> Perhapia.

[01:07:26]Okay. Yes, of course you have to mention it. It's one of the mandatory finding.

[01:07:31]You have to talk about it in the chest station. Whenever you have chest station, you have to talk about the heart failure signs or pulary hypertential signs. Okay. Yes. Of course you have to put a plan regarding the permal hypertention. Even the exam might ask you how to treat the hyper hypertention in this condition.

[01:07:50]But the main uh idea of the management will be for the butcher drainage culture of disputum and antibi according to the culture and sensitivity.

[01:08:03]Stop smoking of course it's very important step you have to mention it.

[01:08:07]oxygen if the patient has end stage lung disease.

[01:08:16]Okay.

[01:08:20]By the way, treat the cause. It's not as edi heart sorry lung disease. This is type three, right?

[01:08:36]And the management maybe if the patients have coral I might use some di sorry some diuretics such patient with leg edema and truth exactly what do you think amidosis heart failure Dr. No the cystic fibrosis itself can cause any lung disease can lead to hyper hypertension right this is type three.

[01:09:07]>> Yes.

[01:09:09]>> And of course with the time it can lead to the core permab and the management as we know the heart failure management diuretics vid dilator okay and oxygen. So sometimes if the patient have been hypoxy and in the term of LT long-term oxy okay any has anyone has question sorry LTO for the COD right l for cood uh proactises And the end stage lung disease will be oxygen continuously.

[01:09:58]Long-term oxygen therapy for COPD patient arthritis features.

[01:10:17]Sorry. Yeah, I mean looked for that.

[01:10:22]Yeah, pulmonary fibrosis as well also LTO. Okay. Uh pulmonary fibrosis I think it's oxygen all through.

[01:10:33]>> Uh no doctor first of all fibrosis as well. It's similar uh criteria for uh LTO NCOD and bulary fibrosis. And my friend he just passed the exam. I think the last date they asked him about what is the indication of LTO in bulinary fibrosis. So he just uh like stop for a few second and he told me that I just throw it as COPD.

[01:11:06]After that we search about it. It's similar.

[01:11:09]>> Really? Okay. Yes.

[01:11:11]>> Okay. Thank you. Good to know. Thank you.

[01:11:15]Thank you. Anyone has another question or comments.

[01:11:30]Play for all chest and abdomen station in both scenarios.

[01:11:41]Okay. So this is the time to end the session and thank you Dr. Dr. See you tomorrow.

[01:11:49]Good luck and good night.