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All right. Is that, is that what you guys and we can chat if it's the same? Is it better? Is it uh can you hear me at all as you can't hear me? Mhm Such as if you guys can hear me or if it's understandable, I might just uh go on an interest of time. Is, is that happy for me to continue or is it, is it too bad? Any objections? Does it sound to be enough? It, is it better if I speak louder? Does that help at all? II might just speak louder and and continue. It's not a lot of content. Yeah, there you go. So it's not a lot of content to cover. I mean, I plan on finishing about 1520 minutes early. So I think we might be on time uh if not still earlier to be very honest. Um So it shouldn't be an issue that your schedule, I'll just try to make an effort to be louder and if I'm not being loud enough, um just drop in the chat. Um and I'm happy to be loud, so I'm gonna share my screen again. That's, it's nice and cool. Actually let's just screen two. Sure, 12 point wonderful. And everyone can see the screen. Is that correct? All right, the screen. OK, perfect. I'm gonna be using this, I'm gonna be using a finger like a point big and II hope can see this as well. I change it very soon. Any issues at all. Obviously just uh I'm, I'm honestly really sorry about the uh delay so far. So moving on. So we're gonna talk about the adrenal axis. Um And really understanding this will interpret all the s that will come for um with all the diagnosis, look uh very shortly. The only reason the kidney is here is to let you know where the urine gland sits, which is on top of the kidneys. So two kidneys, two renal glands and once you know that you can just pretend the kidney uh in diagram, so the is gonna be secreted. So, and as with a lot of things endocrinology, there's an access here to control control the amount of cortisol that is produced and when it is produced as well. So you have positive and negative feedback. So let's start all the way from the top here. That's your hypothalamus, that's your anterior pituitary. That's your adrenal gland health matters. So, whenever you do need to produce cortisol, your hypo, your, your hypothalamus is gonna produce just corticotropin releasing hormone. Once it three, the Rh that's gonna stimulate the anterior pituitary that so they stimulate the produce ACTH, once you have a H that goes and stimulates the adrenal gland to produce cortisol. So, instead of a three way step, um and this is quite important how they are very clear. So, crh ach and then cortisol. So that's the positive feedback. If you have crh, you will get ach, if you have ach, you will get cortisol. All right. So it goes 123, that's the green stuff. Now about the, the stuff here is the negative part of the axis. So if you, if you want to get a, the cortisol is negatively is gonna feed back to both ach and cr see going back here saying there's enough cortisol you can stop now and that's such production in the and production in the hypothalamus and that's pretty much the negative and positive feedback. That's everything you need to know about the adrenal axis. So cr is cortisol. So it's plus and plus. And then cortisol says that's enough to stop something. Just keep in mind is in not sure how important it might be. But this diural variation for cortisol, it's highest in the morning. Usually at least at night before you sleep. That's what it's called the stress hormone. It's also high in infectious and an important point. Uh Keep in mind. So you will need surgery, infection. If there's any all about this, just drop in the chat and I'll, I'll keep running back in the chat. Um, a couple of slides, but drop any questions you have about in the chat. Um, and I'll get back to it, but that's the relax and I really want you to fully understand it whatsoever. Just drop it in the chat. So now we're gonna go for clinical vignettes. I don't want you to answer the vignettes. Just read through it. Have an idea of what the vignette is saying and then we'll stay. So let's go with the first patient that we're seeing is a 38 year old man who's presenting with increased fatigue and difficulty sleeping. Of the last few months, he has noticed significant weight gain in face and he feels they come around on clinical examination. He exhibits suggestive of cushing which is central obesity, a Buffalo pump and thin skin with purple striae, stria is just stretch marks. So in this whole keeping in mind, it's quite chronic. It's quite, quite nonspecific. Most independents are uh it does have a few very noticeable features. It kind of really jump out um straight to you and we leave that there. And the second patient, four year old woman, progressive weakness and severe fatigue over the last six months as well. Chronic, she she her skin is becoming darker, especially the creases of her palm and she also reports of dizzy and lightheadedness particularly when she's standing up quickly, right? So that's your first patients that 1st and 2nd patient orthotic hypertension would be standing up quickly. So let's start studying. So we're gonna start with Kush syndrome. All right. And we've got a, a picture um to kind of really accentuate all these things you're gonna expect to see on a physical examination and Cushing's syndrome. So in Cushing's syndrome have prolonged high levels of cortisol and the prolonged high levels of cortisol bring about all these attacks. Cortisol is the mainstream that the adrenal gland. So it brings all these effects that you're seeing here on the right. The cause can be um pneumonic cape I Pneumonic as well. That can help remember all the features. But they, they are quite patho and what you it's quite easy to remember. So you'll see obesity or weight gain, but that obesity is mainly going to be central and you will be seen in the face and it could be be trapped area where you're gonna help. So you're gonna have really proper hump in the back as you would for Buffalo just where the game come. And you'll see a very clear round face sh like appearance. And this because it's quite rapid and it's a lot of fat that goes rapidly. The um the abdomen. It it cause stretch of the skin physiologically, the stretching of the skin results in stretch marks and these are purple stretch marks. You can really see them as quite, quite thick and it's and and it the skin feels very thin because of how rapidly they gain weight in the abdominal area and that these are already hallmark features that you will see in patients with uh Cushing film. And I, as you mentioned, these other nonspecific symptoms you get in and I depression get limb wheezing, um easy bruising hurts. So in, in women's uh reason and here, let's see the other causes of the cape. So because of Cushing's syndrome, we've got disease. So II think very important thing to keep in mind exam as well. So Cushing's syndrome is the whole syndrome or the associations of signs and symptoms that we're seeing towards the um right. Um of the screen. Cushing's disease is a cause of Cushing's syndrome. It's a pituitary adenoma that releases the excessive ACTH. And if you link that back to the adrenal axis, we just saw the ACTH, the excess ach is gonna act directly on the um adrenal gland and we need to excess production of cortisol.