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Yes, we can hear you. Um, I can hear you probably. Ok, thank you. All right. So let's get started. So, uh, we've got four cases today. Uh, we'll just go through case one. so a 20 year old man is brought into the accident emergency department with abdominal pain, nausea and vomiting, uh, with increasing polyuria, polydipsia and drowsiness since the previous day. He was diagnosed with type one diabetes. Two years previously, he mentions that he ran out of insulin two days ago and these are some of the, um, observations and examination findings. So you find that he's tachycardic heart rate is 100 and 23. His blood pressures are 100 and 6/67 and, uh, he's breathing quite fast as well. So his respiratory rate is 32. Um, on examination, you find that he's extremely drowsy. He's got, um, what's called cosmo breathing and his abdomen is mildly tender and it's quite diffuse tenderness all over. Uh, but he's not got any gardening or signs of peritonism. Um, on the investigations, you find that his blood glucose is 25. Um, on the ABG, you find that the ph is 7.24 B CO2 is 25 bicarb is 12 white cells are 18.5 sodium's 100 and 28 potassium's 5.2. Um And you find that the ketones are markedly raised as well in the blood. So, having seen all of that, what are your initial thoughts so far? Just pop it in the chart and then we can discuss it. Ok. Yeah, exactly. So, in any diabetic patients with these kinds of symptoms, always suspect EK A, unless proven otherwise. Um, you, you get that in the history as well that he's a known type one diabetic, um, in the investigations, you find that he's hyperglycemic as well. Uh, his potassium's quite high but not over the a, uh, normal limits. Uh, he's got a lot of ketones in the blood as well. Um, and his bi bicarb is quite low as well. Does anyone know what causes more breathing is before we carry on? Yeah, exactly. So, it's, um, it's basically when the breathing is quite fast and quite deep as well and it's quite regular and consistent. Um, so it's quite obvious when you see it, um, a different type of breathing is you might see in other types of, um, sort of acutely unwell patients or something like change those breathing, which is a bit more irregular. You might have a bit of deep breathing and then have a period where they stop and then they start again. But it costs more breathing. It's quite regular and it's quite deep as well. So we'll just go through. So, why is the abdomen mildly diffuse uh tenderness? Um, to be honest, I don't know the exact mechanism but abdominal pain is quite a common symptom in DK A. Um, the two, the two factors that are, um, big killers really is the hyperglycemia and acidosis. Um, so tho those are the two of the factors that you need to control in DK A. Um I'm not sure of the exact mechanism how it causes the pain, but it's quite a common symptom. So maybe that's something I can read into and I'll let you guys know. So EK A is quite a common emergency in diabetics. Um It, it, it can either come on in people who already have been diagnosed with diabetes or they might not even know that they have diabetes and it's a new presentation. Um It's often uh triggered by um certain factors such as infection, recent surgery, uh pancreatitis. M I, so anything that makes someone acutely go unwell, it might be a trigger to a DKA episode. Um And the pathology of DKA is basically when, so in any normal, in a normal body um in a patient without uh without diabetes, um people generally use carbohydrates, uh and they metabolize those carbohydrates for energy um in a, in a state where DK A is happening. Um There's hyperglycemia and there's a lack of insulin as well. And because of the lack of insulin, the uh the glucose is not able to be taken into the cells. And because there's more glucose in the blood than the cells, um the body sort of goes into a starvation state. Um When it goes into that state, it uses um other mechanisms to produce energy. Um It's in these states where they metabolize um uh other things and then they turn into things like acetone, which is what causes the acidosis. Um So that's what we're trying to prevent really. Um And in terms of the parameters for diagnosing DK A, these are the three main factors here. Um So most of these, you can get from a VBG or an ABG. Um you need to do a urine dip as well. Um And a simple blood test as well. So, ph if it's less than 7.3 of bicarb is fif less than 15. So either one of those qualifies a blood glucose is greater than 11 and the ketones are greater than three in the blood or uh more than two plus on a urine dipstick. Again, either one of those qualifies, but you need all three of those to qualify um as a diagnosis of DK A any questions so far. All right. And these are the common signs and symptoms to look out for. Um So patients can present uh with altered conscious consciousness, but often it's not a sudden uh onset a loss of consciousness. It tends to be quite slow and progressive. Uh same with HHS. Um again, like we mentioned before, abdominal pain is quite a big symptom. There's uh a lot of vomiting, uh polyuria, polydipsia, uh ketotic breath as well. So this is uh you might have heard this before but it's the, the fruity kind of breath where they're releasing this extra acetone because of the uh starvation state the body is in. Um and that comes up in the breath though. Uh coma is again a quite a severe uh end of the spectrum. Um They can be quite lethargic on presentation as well. Uh So this slide kind of covers uh some of the things we've already mentioned. So just a few extra ones. Um so blood glucose, so it on the bloods, you're looking for glucose levels and ketones, urine dip, we mentioned ABG we mentioned um the last three. So the cultures E CG and chest X ray, those are ones that are not necessarily going to point towards a DK. Um But what it does is it rules out other causes. Um and in a standard A to e assessment, these are things you need to be ordering anyway, just in case there's other other factors pointing towards another diagnosis. Um And the uh what's mentioned below is the criteria um for diagnosing a severe DKA. Um So if blood G ketones are greater than six, if bicarb is less than five ph is less than seven, um potassiums, less than 3.5 if they're quite hypotensive. So these are the, the factors you're kind of looking out for on the, on the VBG. Um As, so you don't need multiple, um, multiple uh ones of those to be uh qualified as a severe DKA. Just any one of those says that, ok, this patient is going to deteriorate soon. Um At that point, definitely involve a senior member of staff, um speak to your registrar or um what they really need to be doing is get transferred to an ICD or um a high dependency unit. Um So that what usually happens in the ICU. So we've got a question here saying how do we know that DK has resolved? Um So we will go through that in a little bit. There are certain um parameters you should look out for. Um again, uh you need not one but all of those things to be resolved, things like the acidosis, the hyperglycemia, you need that to be resolved. Um We'll go through the exact numbers in a little bit. So, yeah, going back to the ICU transfer. So what usually happens is they get central venous access though. So for example, if the potassium is uh less than 3.5 and they need potassium replacement, usually it needs to be uh replaced at a faster rate. And um you can't really do that on a normal ward Um Because again, you guys might know that replacing potassium too quickly can have other side effects, which is not good for the patient, basically. Um So yeah, the the these things are better managed in an ICU. So yeah, I think sour has mentioned that some of the factors uh you look out for uh when decay resolved. So that's, that's mentioned in the slide here. Um So some of the aims is you, you ideally want blood ketones less than 0.6 you need the Ph to be greater than 7.3. Um And the by cards be greater than 15 as well. Um Some of the er so you need the ketones to be falling by 0.5 millimoles per liter by hour. Um So that's kind of what you're looking out for. Um Again, what you're trying to do in managing DKA is replacing the volume lost and correcting the metabolic defects because of that. Um So you'd mainly do that by using fixed rate insulin infusion. Um The normal rate we use is 0.1 units per kilogram per hour. Um You can find all of this in your um trust guidelines, but again, it's, it's quite a good thing to remember um just to save time. Um But whilst you're using that insulin infusion, you need to be monitoring the blood glucose as well. Um So initially, you find that the BMS is less than 14, but again, still greater than 11, you can halve the I influ insulin infusion rate to a naught point naught five. Um So yeah, just replace it as um according to what blood glucose levels you find. Um So like like any emergency you, you need to do an ATV assessment um replacing the volume is very important. So the the initial thing to look out for is the systolic BP. Is it less than 90 or greater than 90? If it's less than 90 they almost always need uh a fluid bolus over 15 minutes. And then uh what you have to do is monitor their response. If they do respond, then great, then you can move on to 1 L. Yeah, we can make it available to reread the slides. Um We can send the slides out. Um So 11 L over one hour, usually after the fluid bolus and then it's progressively given over two hours, then two hours, then four hours. Um if the initial fluid bolus doesn't really increase the BP, then um give another fluid bolus if the second time doesn't work as well as when you need to be speaking to senior members of staff, seeing whether they need inotropes, other methods to increase the BP. Um potassium is a big factor to manage. So, on the initial VBG, you can measure that as well and you can confirm it on the blood levels. Is it less than 3.53 0.5 to 5.5 or is it greater than 5.5? Um That's the levels you're looking out for. If it's greater than 5.5 there's no need for any extra potassium to be added if it's 3.5 to 5.5. Um you need to add a 40 miller uh potassium to that bag. Um And what it means, I think he's asked a question though. Uh So what, what does a second bag mean when adding potassium? So it's important not to add potassium straight away. Um because uh insulin levels affect potassium uptake into the, into the cells. Um So you should not add it straight away. You should wait a little bit after they have found the fluid bolus. Um So when I mentioned earlier, 1 L of fluid over one hour don't add it to that bag. Uh add it to the bag after that. Um And then it, you need to continually monitor the potassium after that second bag. But that first bag of fluid should always not have potassium is what I'm trying to say. All right. And another thing to import uh to remember once um all the things we mentioned earlier. So once you've realized that the DK is resolved, um it's important to start the sub insulin only once they've started eating and drinking if they're not eating and drinking, discontinue the uh fix rate insulin. Um And once you've started the subcu insulin, um continue the fixer insulin for normally half an hour to an hour after that do um after that you can stop. All right. So quite a lot of information there. Um Any questions on DK? All right, we'll move on to the second case. So a 40 year old woman comes into Ed with palpitations, sweating and very anxious. The history reveals a three month history of unintentional weight loss. She also complains of abdominal pain and has had a few episodes of diarrhea. She is also short of breath and has orthopnea. Uh The observations you find that she's quite tachycardic. Heart rate of 100 and 18 respiratory rate is mildly raised at 22. Um examination findings. You find that she's talking in short sentences, she's a little out of breath and she looks very sweaty and clammy. She's unable to lie flat as well. Um She's got a lot of pitting edema in the lower limbs. Um You, you see that she's got protruding eyeballs and she's got a bit of clubbing and soft tissue, uh swelling of the fingers as well. Um And there's some blood tests in the corner there. So you find that her TSH levels are very low are 0.1 and her free t four levels are raised at 2.6. Um What are your thoughts? All right. Yeah, exactly. I feel like I've made it quite obvious. But yeah, that's absolutely correct. So it's a thyrotoxic stone. Um So the important terms to remember. Thyrotoxicosis is the process of being um in a hyperthyroid state. Thy thyroid storm is uh an extreme version of that when um the patient starts having systemic effects of that high thyroid levels. So, a severe thyrotoxicosis p uh proceeds onto a thyroid storm. Um And yeah, exactly. So graves can be one of the causes of a thyroid stone. Um Again, they may be undiagnosed or they may already have it and the medication they're having may not be enough. Um Can anyone say what the the sign is? That's on the slide though? I think it's already mentioned though, but it's already uh so it's basically exophthalmus. It's uh it's a sign of Graves disease when the eyeballs are quite protruding, it's like almost like the patient's staring at you. Um It's not always obvious when you're looking at the patient uh straight on. Sometimes you have to look at them from the side and the, the eyeballs protruding is a bit more obvious from the side. Um So I think examination skills is quite important though. Um the clubbing and so soft tissue swelling. Does anyone know what that signs called? So that's basically called um thyroid acro fracture. So it, it does present with a combination of clubbing and uh swelling of the fingers, normally, all of the fingers. Um and they can appear quite red as well. So, again, that's uh another sign to look out for when someone is in a hyperthyroid state. So we'll just go through a little bit about the background, background of thyrotoxic storms. Um It, it is an emergency. Uh, normally it, it's brought on by excessive production and secretion of thyroid hormones by an overactive thyroid gland. Um, it's usually caused by certain factors. So things like sepsis, pregnancy, hyperglycemic states, um pe M I trauma, um sometimes thyroid surgery can do that as well when um, a slight bit of trauma to the thyroid gland can accidentally release uh thyroid hormones into the bloodstream. Um And these are the factors you should look out for really. So if someone has a high temperature, um if they have uh a high heart rate or signs of heart failure, um C NS signs. So C NS signs can range from agitation. Um when it progresses, it can go into a bit of a psychosis. Um The more severe end is things like seizures and coma. Um gi effects. So, if someone has diarrhea change in bowel habit, um the more extreme end of that would be unexplained jaundice. Um And number five there, when you have clear precipitant, like the uh the factors mentioned on the left there. So, sepsis PM I. So those things can uh trigger thyrotoxic storm, um it can be quite difficult to differentiate those. So when someone's already had a, an M I, for example, a lot of the symptoms can um overlap with a thyrotoxic storm. So you may not always realize that there's another pathology going on. But what's gonna pull you towards the thyrotoxic storm is some of the signs on examination. So if you see the eyeballs are protruding, you, you see the hand signs. Um if they have an enlarged thyroid gland, for example, if you spot those things, you may, you may think, ok, I need to add thyroid levels for the blood tests or um you might already find that they're already diagnosed with uh graves disease in their history. In that case, then it's a bit more obvious to look out for these things. Um Does anyone know why you would get heart failure signs in a thyrotoxic stool? So, normally heart failure signs is a sign that it's been, the problem has been going on for quite a long time. Um It, the way it happens really is because um patients are often tachycardic because of the high thyroid levels, but not too tachycardic where they feel unwell. They say they've been tachycardic for a while because of that, the heart just works a lot harder to pump that fast over that period of time. When the heart does that, it gets weaker and weaker because it's not just not able to keep up with the cardiac demand when that happens, excess fluid gets deposited in the lower limbs. Um So that's why people present feeling breathless, uh with lower limbs, pitting edema. Um So heart failure signs usually is a, is more of a severe sign. So these are the common signs and symptoms, uh the pictures on the left. So the top picture is thyroid Acro Crutcher, like we mentioned before, it's swelling of the fingers, they can appear very red. Um, and with clubbing as well, I think, I don't think the clubbing is that obvious in the picture. Um And the, the bottom picture is called pretibial myxedema. So this is basically, again, the skin looks very red and it presents with skin changes. It's like thick plaques that er appear on the shins. Um This is another sign you can look up for as well. So patients present sweaty, tachycardic, restless, uh with diarrhea, like in this case, abdominal pain, confused, um heart failure and they can present with af as well. So the aims of management, you're do, you're trying to do three things. You, you want to reduce the peripheral effects of T four, you want to inhibit thyroid hormone synthesis and you want to treat the systemic complications and like any emergency, you want to do an ATV assessment. Um IV access is very important because uh this patient might have had diarrhea for a long time. They may present shocked um and quite dehydrated as well. So that fluid bolus might actually save their life at the start. Um If they're vomiting, consider angio tubes. Um on the blood tests, consider T three T four troponins. If you've not already found an M I uh because of a lot of the overlap of symptoms, uh blood cultures, uh glucose levels and an ECG as well. Um And if they present with heart failure signs, um a bedside echo might help and chest X ray might help as well. Um some of the treatments for thyrotoxic stone. Uh So propranolol is quite an important one. What propranolol does, it basically reduces the heart rate and it also um, sort of prevents the peripheral conversion of T three to T four. So it has a double effect though, uh, you can use digoxin for that effect as well. Uh What's actually going to reduce the, uh T four synthesis is carbimazol and Propyl thiouracil as well. Um, often those two medications, uh, only one of them in this case, uh, is given before, uh, blues iodine. Uh, but normally you need both. Um, that's gonna reduce the synthesis. Um, and the IV hydrocortisone, um, is again going to reduce the peripheral effects, um, of the symptoms here. Um, so those are the kinds of treatments you're trying to give though. Um, if the, um, if they are not responding to the treatment, um, I think some, some something you should always consider is, um, emergency thyroid surgery. So, thyroidectomy, um, is done where the, you know, the thyroid levels are quite high. You've given all the treatments. Um, they've had the max dose of carbimazole, but it's not, they're not responding. They're still quite tachycardic. They're having the systemic effects though, then they may need a thyroid thyroidectomy to resolve the symptoms. So that's something you should always have in the back of your mind when you're managing this. But obviously, as an F one, you're not going to be doing all of that. Your job is to do the A two E assessment, um, knowing which, er, investigations to get. So T three T four is important, Um getting things like the chest X ray and E CG is all part of your A three assessment. So, you know, you know what to get and why to get it. Um the treatments you're not necessarily going to be starting all of that yourself. So always discuss with the reg when you're not sure. Um If they're tachycardic, that E CG will help because you will know, are they having uh irregular tachycardia? Are they having irregularly irregular tachycardia? Are they in af so that E CG is important and then you can start giving them the propranolol? Um So don't worry if you don't know what to start straight away, you, you, you've always got the registrar, um, the consultant fees that will help any questions for that one. Ok. We'll move on to case three. So we've got a 36 year old woman who's brought in by ambulance, having been found unconscious by her neighbors. She's maintaining her airways. You find her with a medical alert bracelet around her hands with the words Addison disease, a neighbor tells you she's been unwell with a viral illness for a few weeks. Um When you've brought her in by ambulance into the hospital, you find that her observations are still quite happy hypotensive. So her blood pressure's 85/58 and her heart rate is 100 and 16. So she's very tachycardic. So this patient is in an Addisonian crisis. Um So we'll talk a little bit about that for the next few minutes. Um So again, this might be in a patient who's already diagnosed with Addison's or maybe a new presentation. Um In a, in this case, it's quite obvious because they've got this medical alert bracelet around their hands and a lot of people with Addison's do have that or sometimes they have a, a steroid card with them as well. So these are the clues you're looking out for. Um certain triggers are things like infection, trauma surgery and mis medic medication. Um So often because their adrenal glands are not producing the corticosteroids that the body needs. They're having uh exogenous corticosteroids uh to replace that when someone forgets to take that, that's when they go into an Addisonian crisis. Um Normally they present in a quite a shocked state. Um So in this case, they were hypertensive, low BP and they are quite tachycardic. So the body is trying to compensate. Um So when someone's having low BP and a very tachycardic as well. You know that, ok, it, it's an, it's an emergency because in initially the, the tachycardia is not, doesn't happen straight away when the tachycardia comes on is when the body is in a bit more of a uh a dangerous state and is trying to compensate. So, you know that they're a bit more unwealthy, they can also present with hypoglycemia because of the lack of endogenous corticosteroids. Um And the last box, there shows some of the symptoms you look out for if they haven't been diagnosed with Addison's. So they can. Um so I think in this case, they've presented unconscious. If the patient is conscious, you can get these things from the, from the history. So if they've been very fatigued recently, they've, they feel very weak, you can see skin pigmentation. Um They're hypotensive like we mentioned, they're craving salt. Um They've lost appetite and they've lost weight. Um So, and can people do, do people know when, where the skin pigmentation usually happens and where to look, look out for that pigmentation? Like where on the body would you look for it? Yeah. So back of the neck is quite common. Um The hands are quite common as well. So anywhere in the body where there, there are creases is what you would look out for. So between the hand uh between the fingers, um any parts of the body which is not visible. So like on belt lines, a around collar lines um in the creases of the mouth as well is where some of the pigmentation occurs. So again, your examination skills is very important in looking at the patient and finding out what's going on underneath. Ok. So some of the aims of management, IV hydrocortisone is the mainstay of management here. Um Most patients when you're suspecting Addisonian crisis, most patients need uh IV hydrocortisone start straight away. So 100 mg start and they normally require uh an infusion after that. So 200 mg usually over a day, um you monitor that and then you titrate it according to their response, then you can taper that infusion down um because they're shocked you need to uh resuscitate them with fluids. Usually a 1 L of fluids rapidly infused over 15 minutes and then um 4 to 6 L over that 1st 24 hours. So you can see that here that they need quite a lot of fluids in the 1st 24 hours. So IV hydrocortisone and fluids are both very important. Um Blood glucose levels is also important to monitor. Um So there's a risk of them becoming um hypoglycemic. Um Normally you give that a 5% dextros with normal saline um because they can become hyponatremic as well. Um And these are some of the things you need to advise a patient on. So whenever they have a minor illness, they should double the dose of uh corticosteroids, they take um or if they're having a minor surgery without needing a general anesthetic or without fasting. Um, again, in this case, you would double the dose of corticosteroid if they're a lot more ill, um, if they're unable to swallow or anything like that, then they usually need parenteral, uh, corticosteroids, um, usually need requiring, er, hospital admissions in these cases. Um, but again, these are, if someone has Addison's for quite a long time, they'll become very used to that. It's usually patients who are new into their diagnosis, say in the first year or so. Um That's when they don't always know how to manage it and that's when they get they present to the hospital or if they don't know they have it at all. All right. And these are some of the uh things we mentioned earlier. So medical alert braces normally look like that. Obviously, they can vary. Um and they usually will have some information on them. So what their name is, what their condition is, what treatment they normally take. Um, it doesn't, it's not gonna give you a lot of information but it can point you in the right direction of, ok, maybe this is the cause of why they're, they're suddenly so ill, the steroid emergency cards um in that top top box there. Um, so this is what they usually look like. Again, they'll have their name, date of birth NHS number and the reason for why they're taking the steroids um, it's important to educate both the fam uh, family members as well as the patient because sometimes the patient may not be well enough to remember. Um, and in that case, the family can advise them, um, and it's important to tell them the common symptoms to look out for as well just to go back to the, er, before we talk about the management. Does, does anyone know what kind of investigations they would order? Yep, your epinephrine is a, is a good one. blood called C levels is one of them. Um, you can do a short synacthen test as well. Um, if they've not been diagnosed, um, ece is quite an important one because in Addison's disease, um, because they're not, um, sometimes they present with postural hypertension and they can have uh hypokalemia and hyponatremia. So eer knees are quite important to look out for as well. Um, if they're hyperkalemic, then you would follow the guidelines for that and sort of treat that. So, a short syn actin test is when, um, uh, normally, uh, so if you see their response and see whether they're able to produce the cortisol, um, if they're not able to produce that cortisol, then you're, you can, you can say that the insufficient, the adrenal glands are insufficiently. Uh, uh, so they're not releasing the, the relevant um, corticosteroids. Um, so you normally see the, the response to that. All right. And the last case we're gonna talk about is hyponatremia. Um This is quite a difficult topic. Um Something me myself ii have to go through it quite regularly to um to remember some of the things and it, it can be quite uh confusing on how to categorize certain causes of hyponatremia. But this is uh quite a useful way. I find anticipating it into the different parts. Um So I think if someone comes in with low sodium, I think it's very important to find out their fluid status. So are they hypovolemic, euvolemic or hypervolemic? Um So hypovolemic. So things like uh have they been vo vomiting, diarrhea? Do they look quite dehydrated? Um Are, are the peripheries quite cold? Are they tachycardic? So these are the kind of things you're looking out for? Um Again, your, we'll go on to talk about it in the next slide. But some of the investigations you have to do in this in this presentation is urine sodium, the urine osmolality and sweet serum osmolality. So these three things are quite important tests to order when someone's hyponatremic, if the sodium's greater than 20 um you're thinking about things like diuretics. Do they have Addison's disease or if they're less than 20 in the urine, vomiting, diarrhea, pancreatitis, euvolemic patients when they're not overloaded and they don't look dehydrated. So you're trying to compare the urine osmolality and the serum osmolality in this case. Um If the urine osmolality before we carry on, does anyone know what osmolality is like what is the definition of osmolality? So, osmolality basically means the concentration of the solutes in whatever fluid it is. So in this case, if we are talking about sodium, uh if I say urine, osmolality is greater than serum osmolality. Thus, that means the urine is more concentrated than the serum. So that's basically what it means. In this case, it would be things like si A DH um pneumonia, uh Meningo Anky colitis, uh infection states can com commonly cause that the other way around when the serum is more concentrated than urine. So, these are can be caused by things like psychogenic polydipsia. When patients come in thinking they have to drink quite a lot um top irrigation fluid. So after prostate surgery, um sometimes after prostate surgery, they use uh hypotonic fluids and sometimes that can make uh patients hyponatremic. Um And the last one, we can categorize it as, as hypervolemic. So you're looking out for peripheral edema. Do they have pulmonary edema? Are they breathless? Um Do they have a background of heart failure? Um So your, your sodium is important in this case. Um So if it's less than 20 in the urine, this is when you're thinking about all the failures. So, heart failure, um kidney failure, liver cirrhosis hypoalbuminemia. Um So these, these are the kind of things that point towards uh a hypervolemic hyponatremia. And when it's greater than twenties, things like steroids, renal failure, hyd So these are some of the symptoms to look out for. Um, when someone comes in hypernatremic, it might be at that point. You don't have much information. Um, it's important to look out for what symptoms they have. Sometimes they might come in hyponatremic and that's normal for them. Um, so they may just be chronically hyponatremic and they may be asymptomatic. Um, so asymptomatic hyponatremia, normally when it's greater than 100 and 25 um when it's less than 100 and 25 they can be a bit lethargic, they can have muscle weakness, they can have ataxia, they can be a vomiting as well. Um When it's less than 100 and 15, um that's when it's very, very low, they'll have more severe symptoms like confusion, headache, convulsions, coma. Um So it's, it's much more of an emergency at that stage. Um Again, neurological symptoms are quite rare when it's chronic. So, some of the symptoms you've mentioned above, they normally only happen when they become acutely hyp hyponatremic. So it's a, it's more of a sign that ok, the they need sodium replacement relatively quickly. Um So on examination that you're mainly assessing their volume status, are they um edes, do they have signs of heart failure? So you're thinking of hypovolemic, are they bleeding or do they have any dehydration or fluid loss? Do you think of hypovolemic, hyponatremia? Um underlying course. So you need to look out for signs of malignancy as well. So taking a history, um, common things like lung malignancy, um can cause things like SI A DH, which we'll go on to talk about. Um, so it's important to get that history and a neurological exam as well. Um, so you're, you're trying to look for these symptoms that match with the sodium levels. So, if you find any signs on a neurological exam, you can say that. Ok, it, this is a, a more of an acute hyponatremia. The Yeah. So these are some of the investigations you need to be ordering. Um So you need to do routine bloods. Um and we talked about serum osmolality before urinary sodium and urine osmolality as well. Um E CG chest X ray. Again, you're not particularly looking out for certain things. You're trying to find clues about their volume status. Um ec you need to look up whether they're an af or a normal tachycardia as well. Um And these are some of the diagnostic criteria for SI A DH. Um So it basically stands for syndrome of inappropriate um antidiuretic hormone release. Um in order to diagnose that a patient doesn't, must not be on diuretic therapy. So that's one of the conditions. Um and these are the three things you're looking out for. So, most hy hyponatremic patients will have low serum osmolality. So typically if it's less than 275 they have a low serum hospitality normal levels is normally 275 to 295. Um If the urine osmolality is raised above 100 that's when you can say it's raised. Um and urine sodium levels, if it's greater than 30 that means it's abnormal as well. So normally you need all three of those to diagnose da DH. So mourn again, depends on which category you find yourselves in. Um If it is chronic, normally it does not need um a sodium correction straight away. Um, if you found out that it's, it's chronic and they've had it for quite a long time, what you can do is you can still order those investigations, but you need to order extra investigations to find out why they are having the low sodium levels. Um, so then you can do, you can order other uh, outpatient investigations. Um, but they don't need to be an inpatient if it's more acute and especially if they, they have symptoms is when you need to admit them and correct the sodium as well. Um, the mainstay of treatment is hypertonic saline. So this is, uh, what you'll see as when you order it is 3% normal sale, 3% saline. Um, that's hypertonic and that's the normal treatment. Uh, we give ideally, um, you need to be given that quite slowly. Um, you shouldn't give it too fast because overcorrection of the sodium, uh can cause something called osmotic demyelination syndrome. Uh, which is something you do not want to be happening at all. Um which is why sodium levels need to be replaced quite slowly and you need to be monitoring um the response to that as well. Does anyone know what osmotic demyelination syndrome is? Yeah, exactly. So, well, permanent brain damage is uh is an effect of what the, the pathology that happens. Uh Basically the myelin sheaths around nerves, er get damaged by the, the sodium that's replaced. Um when this gets damaged, basically, you're damaging parts of the brain and other parts of the spinal cord as well. Um So yeah, they'll, they'll end up with permanent paralysis and these are things you should not be doing. Uh achieving. Um So yeah, the num the sort of numbers you need to be replacing it by is five millimoles per liter of fluid replaced. Um If you keep it to that, normally it's fine. Um After you've corrected the initial sodium, um not exceeding eight miles per liter in the first day. Um is another thing you can look up as well. Um Si DH, as we mentioned before, the treatment for that is normally fluid restriction. Um So if you restrict that fluid to 7 50 m er mils per day, um the sodium should then start to uh normalize. But again, uh S IH is caused by many things. Malignancy is one of them. Um So they may even though you correct that sodium when they're in hospital, if they have an underlying malignancy, then they may present again with hyponatremia. So, until that underlying cause is uh cured or prevented, um, they're gonna continue uh presenting basically. So you can correct the hypernatremia but always look about the underlying cause. So, yeah, that's the end of the presentation. Um Does anyone have any questions? Um and please uh try and com complete the, the feedback forms as well. The link is there in the chart. Um uh So if you could do that now, er, that would be brilliant. Uh And the slides are available to see again on metal.