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low and good evening. Although we got yet Sorry. Check the patient's stuff. Good evening. And welcome to the age of healthcare. Siris, man. It's pretty, Cooper. I'm gonna be a chat moderator for this evening. Welcome to our wanna say, Third, it might be 4th, 3rd set of clinical cases. We do this every couple of months. It's a session is gonna be hosted by the wonderful doctor. Just Harriet. Alison, explain why he's doctor in just a minute. Um, with every session we have here, open up this slide. Just some bits that you can do to try and make the most things fill for you to take notes. A really great weight, actually. Remember things and learn from things as we can look back on in the future if you want to. It's just the best way to learn really is to is to practically do things around stuff you're being told. Uh, please do ask questions. We love it when you go. The last questions. It makes it so much more interesting. Session. Both the, um for us on. It's really great way for us to know what you're thinking and where we're aiming things. It just makes everything that much more productive for everyone involved on. Finally, it's any better, particularly enjoy. Feel free to email me, um, asked for resources or ask any questions you might have the bit longer. Perhaps, you know, we're more than happy to support you with the learning that also goes like questions about universities. Whatever any questions you got about academic things, please do dramas note any queries. That's my email for your Cooper. Like happy to answer more or less anything. We also on instagram and a Facebook. I am eternally call updating. These do exist and, yeah, please to give them a follow. If interested, I I lucked out of blue Depth the first two sessions we've already done that was our airway breathing and our circulation sessions. Today we're on clinical cases on in two weeks' time, we'll be having our disabilities and exposure to complete our 80 Siris. This one's just in here because the person I want teaching that disability and exposure question is doing finals at the minute. So I didn't want, you know, pressure them s o clock. It's night disabilities and exposure to finish off the 80 in two weeks' time and then on to a couple of other interesting sessions. Uh, that's my technical 50 slide. We don't need that one has just joined. I see Josh. His joint are Share your slides, Josh. Yeah, we'll do of worried for a second. I couldn't hear you, um, moved. And he can explain why he is very much doctor. Is sure. Is that how you introduced me? It's It's you're correct. Title, is it not, Doctor? Um, not human. Has someone else altogether, isn't it? Just Harriet. Sorry. I never use your certain time anyway. Oh, uh, to Yeah. So, everyone, My name is Josh. I am a final year medical student. Imperial Soon to be doctor, hopefully on. But I'm going to talk to you today. About kind of case starts in case studies on. We're going to focus on the investigation part of that and hopefully quite attractive way have on her butt. I'm sure Freddie will tell me. Case one Mr. Jones is a 75 year old male. He turns and he for coughing a fever. What questions do you want to ask, Mr Jones? We work out normally about 32nd delay before everyone just the joy of Microsoft teams takes about 30 seconds from here. You said so give them 60 seconds. Seems reasonable. Doesn't if they get 30 seconds to hear it. And 30 seconds to think. No left? No. I'm gonna end up having to answer lots of questions about Mister Jones. Yes. And if you approve questions, I think I can see them on my phone. Oh, sure. I was okay that you attend E from, I think in what was going to write. Read them out for you, but he goes, like, published these. Can you see them? You got about five That now. Full life. Want me to read them? All right, thumb. Uh, so we've got When did it start? That's good question. Uh, join the mall or do you want Oh, yeah. Oh, yeah. So and then we've got the history next page. But when did it start with? Got what kind of cough? How long has he had these symptoms? How long has he had the cough? Does he bring up blood or sputum? Very nice. That how long has he been presenting with these symptoms? So yeah, a lot of when did it start? How long's that been going on and what's going? Yeah, these are all very good questions about cough, Definitely things. You kind of want to talk about things like coughing up blood. That could be a massive respected for things like cancer. So we definitely to make sure they don't have that. And, yeah, it's now okay? Any lifestyle or recent medical history, Does he have any past medical history such as asthma or COPD? Does he have? How high is his fever and does he smoke? Also, questions have any questions? So look at this great animation, so questions that you might want to ask. So when did the cough and fever start, which I think we've got? How has it changed over times if it started a month ago? Actually, life, I think, a better physical. What's that kind of thing on in terms of the cough? Are you bringing anything up? So I think we got that in terms of the type of cough that's the phlegm is bringing up. So is that blood in it? Which is there, or is it like a clear one? Or is it like green and gunky, which suggested might have an infection going on? Um, any shortness of breath, any chest pain on been any weight loss of appetite, changes that might kind of point you towards a cancer because rather than effective was the feet that you want to know how high it is, so someone I start well. But actually, most patients don't measure their temperature than have a way of measuring the temperature. It's always helpful to ask if they got you measured up. Otherwise, it's just how high do you think it s? Have they been in contact with anyone who's unwell, particularly anyone who has covert, which they probably have? Because this is a pretty classic presentation of Kobe? Potentially any diarrhea, vomiting that might point you towards a different cause of the fever. Any urinary symptoms again. Maybe they got a UTI that's caused the fever. The cough is something else on any cuts, greens, grazes, wounds or ulcers again, suggesting them. I have, like a cellulitis that's caused this fever. I'm skin infection rather than the cough itself, causing the fever any dry gauze that's just going to check in the severity of the fever that like shaky movements that you might get when you're ready on. Well, it's in terms of the history of some people playing the cough from the the started three days ago. I noticed, like off in the morning. Three days ago on the fever came later in the day. I don't have a thermometer at home, but he does feel awful. Bring out lots of gunk with this cuff. It's green, but I don't think I've seen any blood. I feel quite short of breath and I get pain in my left chest. Right? Breathe in. I haven't been around anyone who's on well, and I don't have any problems going to the I don't think I've got the cuts or scrapes of medical history, not taking any medications, not allergic to anything that had COPD in because he smoked locks and got lung cancer and sister and son off the have asthma and smoke 20 day and have smoked for ages 40 years. That load, about 45 years to quite a lot drink 10 points at the weekend. That's what, like quite a lot of alcohol. So what do you think might be going on here? What is the differential diagnosis I get? Get a minute Yeah, give him that. 60 seconds. There was Ah. So you actually wanted to mention because I was with the lung doctor right before this, right? For we did this. And she said there was six questions you always want to clarify because they defined cancers versus infections. And that was fevers, rigors and night sweats, weight loss, fatigue and lethargy. Her, like categorically, like six key since six. Key things to look for. I'll put in the chaps Just if you think about cancer as well, you can go for the floors. Acronym A F L A W switch includes a lot of that to fevers, lethargy, appetite changes, weight loss and night sweats. Like your scary cancer symptoms like this sore spot. Emoji in their answer, honestly feel that I've actually got empathy. Healthcare will ruin that for you. Empathy. Yeah. Anyway, that's what got infected exacerbation of COPD. Sad face. That is a very, very valid A differential. That asthma slash COPD could run in the family community. Acquired pneumonia on COPD or lung cancer in there. One. Yeah. Sounds pretty valid. Yeah, there's some good ones. Um, it's already everyone. Is there a particular thing? You have not seen so far that you're thinking I've got loads of next page is going to say I think the ammonia and other lung infection. I think it's quite big. Probably coughed less at this point. Oh, big blood concerns and lifestyle changes I'm not. That might be at its more questions Go question mark at the end of it, so we're not sure what's. Maybe that's more things to ask him anyway. So in terms of lung problems is, you always want to categorize a basically everything you know. It could be infected exacerbation of COPD. It could be a new moon, you know, it's it's a cap could be a lung cancer, which we also got, and then it also confusing, like a lung abscess or an empyema, which is basically just an infection of the different part of lung or cove. It is also very, very violent. It doesn't have a break off, so that kind of suggest it's maybe not crave. It could be infection of some of the sauce having so it could be like a meningitis or something we never know. And then I was thinking of pericarditis that cause you like about the chest pain. That's inflammation of the sac around the heart. You get a fever, you get chest pain, you get cold symptoms. So it makes sense based on these differentials. What do you want to do next? Ignoring years on the slide. That's, uh, well, so just Yeah, that's the power points. Likes to come up some really weird ideas. Sometimes they're sometimes they're quite funny. So I leave them in. There's one. When I was doing the airway and breathing session on it, it just kept giving me a raft. It was like, Right, fine. We're just gonna go for an aeronautical theme this evening. I know. Just planes. Uh, so we've got do a set of ops? Definitely. Uh, always a beautiful way to do anything. Yeah, yeah. We've got a sputum culture. We've got a thought. Only babies and Children got meningitis. Oh, that's an interesting one. Blood test. Lung function. Testing. Calculate curbs 65. Someone's medical. Get you if not in hospital. Um oh, So just regarding that kind of meningitis thing, actually, anyone to get meningitis, It's just that certain people tend to be more likely to get up, so that tends to be intensity that, like young babies, kind of addressed kind of not a one. And then old people are arrested, but also people who are, um, the immune suppressed and also weakly and student 1st 2nd year university students. Yeah, that's quite common, but someone told me some point. Really? This year, more than half of all new meningitis cases are young university students. Yeah, it depends on with that. Have a vaccine or no. So there's the exactly that there was literally a booster vaccine you meant to have before you go off to. You need that help prevent meningitis because it is such a common in that in that age category. Yeah. Um, to the ulcer is babies. The Children can't get it, but then also, But that article big Children, Young adults, Onda, uh, older adults. Yeah, basically anyone? Anyone in between can still get it if they're not, if they're not got a good immune system going or if they are unlucky? No. So I think that's your list you've got there. Just so the things they would like curb 65 glut tests and lung function, sputum and obs. Yeah, Um is a harvesting your sputum in terms of structure. I just kind of wanted to maybe going to a little bit. So there's generally a way that we approach things most of the time. Um, we should always kind of do it in this order to make sure that we don't miss anything. You take a history from the patient, you can examine them. So that would be our next step, actually, So we would examine probably eight we approach, which we'll discuss in a second on day. You'd also, um, examine the chest, listen to the lungs, then going to just sort of obstruction once that, and then a bunch of investigation and switch will break down a little bit later. So in terms of the examination, eight weeks examining to the lungs and we've actually got a three series ongoing. At the moment you can go on to metal, and I have a read of kind of the on have a watch of the different scenarios and stuff we've done, but very briefly. It's a northern of things that's going to kill you. So it's an order of the way you examine them. So is, um, away So all of a breathing Is that how it tightened? You know, Easter's and but breathing, how hard they breathing? Um, is it, uh, what does it look like? Everything really hard. What? That's that's logic. Are they blew That kind of thing and see is the heart rate and BP and kind of what their heart sounds like, whether able to get, like, blood to the tissues diesel about neurology. So whether they have weather kind of a week and a lot, um, whether that peoples are normal with that blood sugars are normal on, Then ease everything else. So expose is what we say kind of uncover the entire patient and have a look like rashes and bruises, and then also feel the abdomen, check the temperature. So that's how we're gonna set him. So we've done a set of observations on a good way to quantify are observations, um, is to country a news to school on. This basically gives them you're kind of idea of roughly how stick this patient might be based on their new scale. Um, there's some things for the national early warning, Scott. And what you do is you pick something like, um, if you get but a laser printer up. Do you think something like your respiration? Let's say this is 24. You go along on respirator, Okay, They've got respirator 24. They make two points, and then you go for your sets, your air, oxygen, BP, pulse, conferences, temperature and then add it all together. And then it will give you a score out of something around 20. Remember exactly what it says on, but basically the higher it is, the more sick they're likely to be on gets used as an escalation scale. So any nurses or any Hexi is who spot a news of kind of three or more. They should ask great toe enough. And then any invite seven to go to a senior doctor because that kind of more risk of things like sepsis. So can you have a girl working out this patient's new school? I'll give you a clear you don't need to use at the SATs scale, too, because that's for patients who are confirmed to retainers or they have confirmed severe. It's confirmed COPD we don't know yet, So we're gonna use scale one, um, to ignore scale teeth and let's see what else we got. Thank you. Have not let this out myself. So let's go say it's mass time for you. Um, there are Okay, I've got school. I think there's anyone got, I think the threat of masses, but everyone off. That's fine. Being fair. These things are are pains sometimes. And also I don't necessarily agree with him. Always like a BP. 1 60 to me is more worrying than scores. You know, I mean, school, zero for 1. 60/90. But that's kind of high. Yeah, but I guess it's it's high for chronic reason. It's not highly for unleaded. He unwell. Situation maybe. You know, I still feel that the US It could be the normal BP I'm like, but it's a BP. 1 60 isn't going to kill you now, but it might in 20 years time. Um so just to speed things up, I was out from that, I think. Which should make it five school teacher Respirator. One for sets. None for being on None. Very normal BP. One for pulse, none level consciousness and then one for temperature. Yeah, I did Great. I make five this Well, Well so terms of other investigations you need to split them. Well, let's let him into a kind of a specific order. So there's things we don't The bedside, um, kind of point of care investigations. So these are things that we can basically get a result for immediately. Do you think about blood tests? We're going to send them off to the lab. It's going to take quite a while for them to come back. But bedside test the ones that we're gonna no answer for, like in the next couple of minutes. We wanted to kind of think about blood and any other any other samples you want to send, and then we think about radiology. So in terms of bedside tests, you consider doing a year in depth to look at the urine. Um, you doing the C G, which looks at the heart, and then a B G, which is the arterial blood gas. So maybe he is essentially, it's a profile of all of it. Gasses in the arteries of the blood in the arteries. So normally we take a blood test. We take it from the veins are actually an ABG retection the artery and that allows us to have a really good idea about kind of the level of oxygen in the body and me. Chris level of acidity is well. The first thing we need to look at is whether the oxygen is low. If it's low. It basically suggested the patient has an element of respiratory failure. You don't want to know the pH. I'm being kind of basically the level of asset. If it's pH is high, it's alkali. If the pH is low, it's more acidic. So if the pH is high, you want to look at the CT on the bike off. So if you think about the 02 that will then dissolve in water or like blood serum Teo form, Carbonica said, which is absent. So if you have loads of two in your blood, you're going to become more acidotic on day. For example, if you if your lungs, for whatever reason, can't dentally and you're not able to kind of get rid of some of that, so two in your blood it's gonna build up. And so we get a respiratory acidosis, and that's basically just, uh, basically low pH. That's because the lungs aren't working so well then. Similarly, if our bike Harvinder is low, that suggests a metabolic acidosis, which is basically just your bicarb is is one of the buffers in the blood. If you have other kind of that's it's going on of ass is being created for global lactic acid or ketone. They're gonna buffer with the bicarb, and then your bicarb is gonna pair lower. Um, just to kind of buffer that, but actually, you've got it's kind of metabolic acidosis. So you've got a your blood is acidotic, um because off a, um, other assets go around, and that's if you pick the PA should be low, by the way, that's wrong. On he hates is high. Um, okay, be hatches high. You don't need to again look at the two of the bike off. So if you are losing see or two from your body, for example, you're blowing out for your breathing really quickly. To get rid of that, you're going to develop a respiratory alkalosis because you're getting rid of all of the acid on if you have loads of bicarb floating around, whatever reason, but you're making more, you're going to develop a metabolic alkalosis just kind of how they work. They can give us a good idea of what the cause of, um, patient's unwell ness might be, um, and not a lot of time. It's all in terms of bloods. These are some that we did so doing F B C, which we'll talk about in a lot of detail later. We don't use the knees, which are your area, and electrolytes. So we'll look at your urine creatinine, which is a way of measuring of dehydration but also kidney function. We've got a lefty's which your liver function tests, which I've got entire case, then lactate. So that's a measure off, whether your tissues that perfusing on our so let's can't get to your tissues, your tissues going to start to switch tto on aerobic respiration because they can't get the oxygen. That, and as a result, you're going to create lactate is one of the byproducts. So you're like table start to build up in your blood, and that's one of the things that can cause this metabolic acidosis. And then you've also got CRP, which is kind of a very non specific inflammatory marker that just suggest that something is wrong somewhere in the body. And then I'll send blood cultures if the patient sick enough for um so you can kind of grow whatever bacteria they might have in their blood and then see what it's sensitive to and then give the right antibiotic for it. In terms of imaging, this is a chest X ray on, but at first it might look a kind of a little bit confusing, but we have a systematic approach, so initially you want to look at the airway. So I think you can kind of appreciate Hey, there's a dark and kind of cheap here and then it splits off into two. So one goes down here longer is down here, and this one splits off a little bit more outlined here. So that looks for you. A truck? Yeah, on this bet, and then your bronch. I just splits into a hair so you can look at your airway and see if there's anything maybe locking up. We'll see if there's a tube in it or see if it's deviated to one side. You don't look up breathing, so you want to look at the lungs. So a good place to look at this is to look at, kind of compare them side to side. So if you look at this left lung, okay, we're kind of the red laser pointer s. It's lovely and clear. It should be this sort of gray, but not black. It's nice and clear. It's great, but And if you look at this right lung, there's it's clear for most of it. But I'm actually down at the bottom that it becomes whiter. It's kind of patchy. And so this is just that maybe something's going on that's making the bottom of this long a bit more dense. That could be a couple of things, for example, like a lung collapse. But actually, given this patchiness offer, this is very much like to be kind of puffs. Building up in this area like a pneumonia is kind of pointed out there. In terms of See, you have need to look at the borders between the diaphragm code, the lungs that died from the heart, and this will give you an idea about whether there's any fluid building up under the lungs called a a pleural effusion. And you also want to look at the size of the heart, Um, whether it's too big. So the heart itself should be less than half the diameter of the just, Um, and that's just that's right. So it's roughly like that, um, so it probably is less than half of this point, and you want to look at the diet from itself more specifically where it's flattened, which could suggest that the lungs are on over inflated. So if you die from looks vet more, let's get a different color. If you die from looks a little bit more like That's but green Line, then that's more suggestive that your lungs might be over inflators. And similarly, if you have a bowel problem on your bra, bowels ruptured. You might get a runner. The diet from that, that's a little bit like a black kind of whole hair. That's quite a bad sign, but that's one of the things you really can't spot. But you can't miss. I kind of look a little bit like this. Next we look up Well, I let's call kind of everything else or artifacts on the bones and that kind of thing. So you want to look at your bones for example, you can see here in yellow. These are the collar bones, and these go off into kind of the shoulder complex here. I'm we can just about see you got your ribs that you really want to pay attention to. You've got your spine in just about see in the background. So you've got, for example, a vertebra here and here. You can just let see that. See if you can see the fractures. Um, Then on what did I do? That f means something that is all. Just kind of a way of remembering. I just can't remember what it stands for. I didn't I'm color for it. Um, and GI would be the gastric bubble. Um, so in normal, people have a little bit of air in the stomach, so you can look it kind of this gastric bubble. Um, but you can sort of see here. Um and that's a competing normal finding. So that's kind of a rough overview of what a chest X ray looks like. And how's your port yet? And then us along very bright. You said you want to work out cup 65 school, so the capsule keep on a school concert. Five things. Confusion. Urea, which is, um, kind of a metabolic byproduct, that it's sort of this is that you can kind of measure in times of your kindey function. You don't look at the rest right? The systolic BP. That's the higher number and then the age being over 65. What you did it work out? How many of these the patient house. And it gives you a good idea roughly how sick they're likely to be. A lucky to get from this illness specifically this chest infection. So I patients with want I'll probably find to be left at home. They can just have some at home antibiotics, most likely, um, patient to assault to you. Probably thinking more. Let's admit them. But let's submit them for, like, oral antibiotics. Three. You're thinking more at net. Probably needs eye the for your thinking like admit. Very, quite sick. Definitely needs IV. Might easily like ht you. I'm fine if you're thinking. Actually, this patient is probably very septic. They need IV antibiotics and I t use of all. It's no strict like that. It just gives you a guide and space on everything else. so you can see about roughly house. Like this patient might be on with this patient. Actually, he only had a cup 65 1. So he's probably okay to go home on antibiotics, sending have any questions about that first case. What? Anything come contained within it, and we'll give you a minute or so Quite impressed. See? Managed to get that in pretty much. Exactly a third of your time. Good timing. Very one. Who needs to disappear early. I've shared the feedback for men that shot. We do appreciate your feedback. Always sort of shaped how we're gonna puts Siris goes forward. But obviously, those you wanna hang around those you are keen to listen to the rest of session dot so you don't need to do it until the end. Thank you. Uh, but no queries popping up in the moment, Josh, is that one person did mention that they are a Pedes student nurse, and so they used to pews rather than news. This is true. I said, what's the actual diagnosis up on a chest infection? Probably should have Ah, with our Yeah, but yeah, um, this kind of finding on a chest X Ray is pretty classic on kind of lay there. Pneumonia basically just want to describe how the coloring changed their It's gone, um, or dense than Aricept. And what's more dense than AARP but less dense than solid bone? Probably liquid, some form of fluid. And it's sort of patchy and mixed in with There's something sort of in the lung rather than next to the love. So still a bit of good lung going on around the fluid? Um, yeah, it's probably some sort of fluid over that fluid. It's water. And this is pony is inhaled lot of water, which probably knocks only one side for, uh, you know, fluid released because of infection. Pass blood. You can't necessarily tell, but, uh, it's almost likely going to be us. Yeah, the A can't Technically tough hustle. Some sort of exceed eight. Oh, yeah. Basically, the beauty of somewhat the beauty of X rays have simple. It is. You can't You can see things are happening. You just can't tell exactly what they are. Yeah, I think that's it. The questions you want to move on to number to the person that he abused. Definitely. That's I mean, obviously you know this. But for the favor and benefit pews is the pediatric score that use in kids just because it's have different, like normal obs. So a baby with a heart rate of 60 would be very, very, very worrying. But adult in the heart rate of 60 it's absolutely fine. Just makes him just a different way. Using given range is kids, and you also have it a different one for I'm obstetrics, a swell eso in pregnant women. And there's a different one. What in answer to? I said, Just imagine it for remembering. The adult version should just think they're really big kids because it's a fairly straightforward trajectory in terms of like how you account age into pews. Just told people handle people that actually, sometimes really old people go back towards being more civilised. Children anyway. Yeah, but never say the other way around. If you say pizza, just little adults, you'll get slapped very, very thirdly. And so, case, too. We have a 23 year old female he is attending, Huh GP because she's been feeling really tired over the last three weeks, and it seems to be getting worse. What sort of questions were gonna ask her that will give him again. The, uh Yeah, about a minute. 60 seconds. I didn't say it. One of these. You should have pediatrics case, didn't I? You did, But I forgot you had Has Pepper X six. Could be a quite a common pediatric thing. That's what's going to say. You could have made a, like, 13 or even younger, just just for the fun of it. Um, 23. Uh, I said, so far, your questions. We've got lifestyle changes, period. Angel is trash, even eating and drinking. Okay. Yes, I most are changes that make sense if they've just gone off to university or something. Actually, that can really office that people, um, in terms of, like, routine, uh, they want to be sleeping. And also, if they've if their diet or something has recently changed, that might make them really tired. Periods are really, really good. One is a The periods themselves could be causing this tightness through like anemia. But also, they could be a sign that she has something else going on. Going on. You get periods, changes in, like basically any illness, but classically like fire and stuff is Well, um, if then also got weight gain or weight loss. And you also got mental health. Yeah, so weight gain and weight loss. You're thinking fire, right? But also maybe cancer on on then mental health. Definitely. Things like depression can cause you to be really tired and have no energy, but also things like Emmy and chronic fatigue syndrome of fibromyalgia, a role. We're not necessarily mental health insurance, but it meant to help components to those conditions. I love that you guys went for mental health. This is a thing that we get pushed. A lot of my, you know, is this idea that, like 15 years ago, students and junior doctors would never, never think mental health. And it's becoming so much more like a front. It was like like a primary consideration. So when you think about to begin with, it's It's a beautiful change in the world health care, and it's hopefully make a difference for a lot of people. Also, with mental health, you also have to prove that it isn't the physical things, So there's a there's a pyramid of like mental health diagnoses on Be at the top is like organic conditions, and you basically have to rule out that patient has something that could be causing their mental health symptoms before you go. Actually, this is a mental health thing, and I think having it hanging in your fourth front in the front of your mind when you're when you're seeing someone, it's a great development. We also got lifestyle weight, loss of gain, eating or drinking. Changes increased stressed, increased workload. Recent mood changes, changes in menses with heavy bleeds, stress, recent or history of deficiencies. Any supplement consumption and then any new medication go lots of great stuff they have, and these are the ones I came up with. So when did the tightness stop or your classic questions? You can basically Socrates. When did start? How long is it? Kind of. Yeah, I'm when it start. How is it changing over time? What's their sleep like? So how long are they sleeping for? When did they get to bed? What's their sleep? Hygiene like if they really, really tired, but they're going to bed at two AM I'm waking up for what? About five AM I think I figured out why they're tired. Um, and then, if you're thinking about anemia, the patients might get short of breath when they exercise or short of breath on exertion. They might look pale. They might get their time. This kind of might get worse than they actually do things. If they're hypothyroid or have yeah, basically low thyroid, they will gain weight that they won't have much of an appetite. The hair will change, become all thin, and they'll hate the cold. And they become really cold intolerance and cold all the time. A big one to think about is with diabetes. Maybe not so much in a 23 year olds, but again, if this is like a 13 year old definitely on, say, for example, and diabetes, you can basically you've got loads of sugar in your blood, so your body's going to try and get rid of some of that sugar. Um, as it does that also get rid of a lot of water with that, and so you end up going to to toilet loads Onda. You might suddenly kind of need to go to the loo just because you need the loads on on. You'll also be drinking loads a swell because you're losing those of water depression as a key one. We could have picked up on that. So what's their mood? Like Do the, um, had own years? They basically what that describes not and drying activities that you used to enjoy. And that's one of the three core symptoms of depression. Depression do. The one is a nausea, which is basically what this patient has. Tiredness, lack of energy, then cancer. So we're thinking floors. So fever, lethargy, appetite changes weight loss of 90. Let's and then, yeah, periods really kind of helpful tonight, especially kind of how have it out High Street. I've just been getting more, more tired of all of three weeks. I felt generally unwell. I've been sleeping over 14 hours a day, and when I'm awake, a struggle to do anything. I sleep at maybe eight PM and I sleep through the night and ulcer am on, still have to have a few naps in the day. I'm a little short of breath sometimes, but I only want to try and get out the house. I don't have any medical conditions. Never take any medication on has no allergies. So what might be going on. I have given you some, um, you can either less those are given you, or you can kind of give me any new ones you can think off. So But the history Basically more and more tired over three weeks, sleeping absolutely fine. I'm short of breath. Otherwise, no real changes. So I got pregnant seamlessly quickly off the bat. Someone's Yeah, he's on the brain. Um, think that yeah, actually, pregnancy probably would do it. Although you, Yeah, like a bit more time to think. Also a low blood sugar. Uh, yeah. Maybe stays true. Being a young adult, you know, every know what's going on in there. Sort of day to day living quality changes can occur that age. New jobs, new study, no Children getting many more honest during their back. And, um, it's just the history, just in case we won't have a read of it and then commonly know they're gonna pronounce to it. Did you have a slight about lifestyle factors? No, I don't think so. 200. You're keep us in life. Don't give some lifestyle. Uh huh. What does she do? Tell me about this young lady you're looking time to save your history. Yeah, So she if university but is in final year and has, like, just finished a dissertation and a couple weeks ago and actually, after a dissertation that if you kind of started toe, become unwell, um, and finds right, university. He doesn't smoke. She drinks kind of a regular amount. Um, he doesn't take any drugs. She has a dog be in my I know. Normal. Also the Korean Harry Potter studies. Let's get a Harry Potter studies A lot of it's sort of those hard part of studies university, highlands and islands elaborates with Think of the two places you could do it all burn out a love burn out here And the pressure was said before they go quite nicely together, right? Leukemia? Yeah, Go straight for big guns there looking your cancer. So why people little class file those together just for that that particular individuals interest would be malignancy. So that's just all malignancy Just means that's anything oncology based. Yeah, Any cancers leukemias a while, that sort of big old bracket. And then it also includes, like primary cancers versus metastatic metastatic cancers versus of the ones that going away with that so that cool it as a whole, uh, malignancy. Oh, um, so we can move on? Yeah, go to these. The things that I was thinking off on. So anemia. This kind of fits for anemia. So, um, because she kind of has this tiredness is getting worse on day she's got you got short of breath when she exercises, that that's quite well with anemia, I think just because young female, that's quite responsive for things like autoimmune diseases, Addison's is an autoimmune disease against the kidneys. Hyperthyroidism can be in autoimmune condition against the fibroid. Celiac is an autoimmune condition against, but essentially your body making, um, antibodies against. But what's technically glide in that I'm gluten see your body basically attacks there on that attacks itself on diabetes would be. You can get antibodies against parts of the pancreas that which makes incident thinking is like a hematologic ulna liquidity. So someone said leukemia definitely could be also may be something like a lymphoma, which is like a leukemia, but it happens in the lymph nodes rather than in the, uh, bone marry, also like a G I militancy or inflammatory bowel disease. It's quite rare for people like this to get cancers of the guts, but actually it's not unheard. Office on It is 23 24 to get bowel cancer, and if they've got a kind of humor in there, that's hopefully bleeding away a little bit. Eventually they're going to become tired like this. You got yourself mentally healthy conditions. So depression and me kind of teach syndrome, fibromyalgia, that kind of thing. Well, that's the thing in terms of infection so potentially, like a malaria or lime disease that she's been traveling recently. And also there's a virus called parvovirus B 19, which in some people can affect the bone marrow and stop your bone marrow from working for a little bit on diffuse bone. Marrow isn't laughed, and you might have been making red blood cells, which would make you anemic on other things again. Let Lupus and rheumatoid arthritis more common because she's younger and female, Um, and they can cut, sometimes present. It's just fatigue and anemia. Uh, is that things? Just having the back of your mind? There's a load of different things going on. So what we're gonna do next toe differentiate between them eso someone has also posted serum cortisol level Onda. I think I know who answered who put this answer in here. But let's put t a double T screen bloods. Consideration of infection with CRP Added on to also have shortness of breath checking smoker Any hay fever considered chest X ray if worsening s o b slash s o b o e rest screen if new changed with added eh said, be all of these things very dependent on what they tell you with more of a history, of course, bowel changes or celiac screen Onda This'd individual uh, it's a new egg. I know exactly who that will really help get professional That someone you and I both know quite well. Okay, well, I believe it's that person. If it's not, then then blimey, someone. If it is that particular individual that let me I don't don't think anyone other than someone who works in the GI people Actis Woods and came title the time to take a pill. Today that's your only ever do that in GP. But that's the on. It is a classic thing to come from TV if we got anything for anyone else until, uh, nothing as of yet. Blood tests, urine tests. That is a good answer. No, I mean, you definitely urine dick. You can have a look for glucose in that. A blood test? This a lot, but, uh, just saying blood test itself. That's the right idea. Yeah, they're getting your head around. A little different blood test is there are many, many things. Um, this is what I kind of came up with following the structure before. You want to examine them, take us at Bob's, investigate them, and then start to treat them. So in terms of examinations, think you do an eight to the exam. It's part of that. You do cardio exam and after exam and give my exam in the thyroid as well. Um, you then dio full set of observations. I need to investigation. So that signed You do seem like you get in debt. Um, to look the sugar, you can do blood, for example. FBC. He's and he's a he's so look at the full blood count the kidney function, the liver function, a CRP which might give you an idea about infection. You could consider lactate if they were kind of acutely on well, two iron studies. A bone profile authority function tested. Blood fell, Um, and then you also add on like a c that screen as well. Um, And then, if you're thinking it is depression or anxiety, you can do scale, such as the PHQ nine in the God seven, which are just very short question as, um, that can maybe suggest whether someone does have an element of depression or anxiety. And also how so There is a next used to guide, um, kind of treatment. Well, good kind of how well the treatment's working later. There's loads of things we can do to kind of look at why we think Look at trying figure out what's going on here saying, because his case, it is an infection with effects on the F B C to the F B C. Oh, blood. Count on this is all of the components of it, and it's not incredibly complicated. On there's lots of different acronyms that means lots of different things. But most of them, actually we just ignore so very quickly go through them. You look at if you think about your blood, you can basically have three different types of cells. So you have your red blood cells and your white blood cells and your platelets. So you want to know how many red cells you got. Honey, what's what's going on? How many places that you go in terms off red blood cells. You can want to know a few things about them. It's the MCV is how big they are. Thie. Hemoglobin is how much hemoglobin there is in the blood, and then it's slightly different. Marker of that is the matter crap, which is the proportion of the bloods that's made up of red cells. And that's done basically like spinning the blood. And then you kind of get the red cell part of the blood collects at the bottom of the June. You get so white cells in the middle on the plasma on top, and you could look at the proportion of blood that's made it from red blood cells. You then have the means cell. Hemoglobin, which is the amount of hemoglobin, is in each red blood cells on the mean cell hemoglobin concentration, which is a very similar thing. But it's the, um up the concentration of hemoglobin nature and so So if you imagine that you're red, blood cells are actually tiny and you've got really small red blood cells. Your M C H might be really small because you actually have a very little amount of hemoglobin in each red blood cell. But your MCAT, your mean hemoglobin concentration, might be normal because actually, even though that red blood cell it's small, it's still has a proportional amount of hemoglobin in it. But constantly no one really looks. It lies you then have your red cell distribution width, which is basically looking of variation size of red cells on your particular site, count. Ridiculous lights are essentially one of the Percocet is to red blood cells. So if you have ridiculous sites in your blood, that suggests that your bone marrow is kicking out loads off red red blood cells a little bit early, and then times if your white blood cells you could kind of five different types. Mainly, you got neutrophils lymphocytes, baser fills in his NFL's and monocytes, and you kind of want to know the rough concentration of all of those. Most of the time, it's could be made up off mostly lymphocytes, um, with some neutrophils, and the rest of them will basically be not there. There's a question here about a blood film. Yeah, sure. So George really explained blood film as a blood film is instead of a lump retreat us. It's a microscopic test, so you would basically take part of the blood preparer and then smear it on a glass slide, look it under the microscope, and then you can do very some of things. You can count the number of red blood cells on the number of white blood cells and platelets and that kind of thing on reticulocytes. But also you can get a good idea off the what the red blood cells look like. Sometimes they'll have different patterns in different diseases. So, for example, they can, if you think of as, like, doughnut with the middle filled, filled in slightly. Um, that's what they should look like but then becomes more spirit in spirits. That hostess, they can look like pencils. They can look like I have drops. They can have fragments kind of taken out of them. They like tear drops. They can be kind of varying sizes. There's lots of different things that you can look up that gives you a better idea off. What's, um yeah, a better idea of kind of what condition the patient might have. And it's usually looked at by kind of by hematologists more than anything. Okay, kind of every five g of what's actually going on spaces like a very old fashioned, the precursor to the full, like blood. Count the formal very sci fi thing. Yeah, it's all want you to imagine someone did. Probably not the 18 hundreds to look at what your blood looked like. And yet it's still so useful. Yeah, but there's a question here about what is the ethnicity of the patient. And consider hemoglobinopathy if low MCV but is a very good point, actually. So if this patient was kind of white Caucasian, quite unlikely. If they were, for example of like a half African origin, you might be thinking things like sickle cell disease, where your red blood cells a shape right sickles that could definitely cause anemia or tightness. If they were potentially Mediterranean origin, they might have something called followed Sr. Which is ah, defect in some of the components of the hemoglobin. Um, I'm not until you where they are from. Have not figured out yet. But you have as a important consideration, um, Teo include, And it's not that just those people can get those conditions. It's just more common in those age groups and those after this is ethnicities. Sorry. Yeah, that's a good point. But let's let's say kind of just cause it white British, I'm going onto red cells. So you if we're looking at kind of the number of thumb, if we have very fear, that suggests that maybe a bone marrow might not be working because, like we, the MRI makes red blood cells, it doesn't work. You're eventually going dot off. You know, we have to replace them. I'm until you might kind of have just as some form of anemia of another course because you've lost them somewhere else, or any failure as well. So you're struggling to make them cause the kidneys involved in kind of making, um, hormones that help you make red blood cells. So if you can use, don't want, you don't make the whole nine and then you can't make the red blood cells that you got too many. This could be a couple of things that might be normal. So if you live in a really high environment, um, say, for example, like in the Himalayas, this very little oxygen and you'll end up kind of having more red blood cells. See, you can transport more oxygen cuff in a better way. Then there's a condition called part of polycythemia rubra there, which is essentially a cancer of the bone marrow. But it's a cancer of the bone marrow that's making basically makes your bone marrow and make loads of red blood cells. Um, on D a secondary polycythemia. So again, if you're a smoker, if you got COPD, you might struggled to auction at your blood, so your body is going to make more red blood cells. Teo Conference A. For the fact that you can't get in as much oxygen. This's kind of why a lot of people with COPD might look soft, bright red in the face, and they constantly like flushed because they got loads of red blood cells going on. If the hemoglobin is life that suggested the patient is anemic of some cause on, do you want to figure out why? One of the best ways maybe other than a blood film is with the MTV eso that me M C, which is the means cell volume, which is also the basically the size of the red blood cells. So in small red blood cells, the's would be things like an iron deficiency anemia. So they're not gonna. I on iron on board. There might be celiac. It could just be dietary. Or it could be periods or anything like that. It's on a senior, which is again, a condition, which is basically that defect in some of the I'm the structure of your hemoglobin. You. Then, if you have a normal MCV, you might be basically loosing loads of bladder into somewhere. Um, acutely. You might also have anemia, chronic disease so often patients with but long term disease is will be anemic just because of that disease process. You might also have other kind of hemoglobin issues, or you might have a hemolytic anemia, which is essentially, there's something destroying your red blood cells. Um, then if you have a high MCV that's pretty classic. The things like alcoholism but also B 12 and folate deficiency. It's also seen in pregnancy as well. It's like if you're good, a rough rough you want might be going on. Well, at least we cut it down a little bit based on the MCV on day, as I said, Kind of live it for before. Ridiculous sites are red. Cell precursors is on. You shouldn't really have many of the in the blood because the red blood cells supposed to kind of form and generally in the bone marrow and then be kicked out to be circulating blood cells. But if you for some reason have fewer red blood cells but your bone marrow is working really well, it's gonna kick out some of the these ridiculous sites into the blood because they'll still be able to kind of work a little bit like a red blood cell, even though they were acidic. Efficient on basically suggests that your bone marrow is working so in some conditions. For example, a plastic anemia, which is a condition where your bone marriage stops working. Not gonna have these ridiculous sites in your blood because your bone marrow isn't working even though you're anemic and then in terms of your white cells. So if there's no that could be for a couple of reasons. So it might be that your bone Marius failed for whatever reason and convenient, you have a leukemia. What happens in leukemia is that one form of cell one for blood cell, for example. Your neutrophils might go off from one on. Suddenly you'll make hundreds and hundreds of them. But actually that means that you're getting all of your energy into making this leukemia neutrophil onion. You know, got any, um, basically energy left to make the rest of your white blood cells. And you might see, for example, a low lymphocyte count If someone has, um, acute Mylar set it on my other plastic leukemia where they're making lows and neutrophils. But actually, as a result, they can't make me my lymphocytes. Then other things could be, For example, I actually Janick, so doctor is causing it. If we give someone chemotherapy, um, that might kind of affect the bone marrow, and it can bring down all of that white cell counts as well. And it's one big thing we need to be worried about and counsel patients on chemo. Is this neutropenic? Sepsis to neutrophils are one of your white blood cells that help fight infection. Classically, they're really good at fighting bacterial infections. And so if you don't have as many neutrophils in your blood, I'm or it's really no, you're not gonna be up to mount a response to these infections, so you're gonna get a lot of infections very quickly, and they're gonna be quite serious. It's intense of high white blood cells. If it's just one type that's high, that's really suggestive of leukemia, especially if it's very high. So it's very kind of a normal white blood cell count would be something like 4 to 11 for total white blood cells. Yes, it's up in like 60 70 even the hundreds. There is basically nothing that's going to cause that other than a leukemia, Um, because you can get a high neutrophil count in the highlights. I can't infections because you need to create more white blood cells to fight that infection, but you're never gonna have fucked many around. It'll just kind of raise a little bit and your plate that one of the sons kind of involved in clotting. If it's low, um, it could be due to these kind of immune conditions, so I t P is basically just a condition where you don't have as many platelets again. It could be due to the fact that you, um your bone marrow has failed because your bone marrow awesome explain. That's on likewise for leukemias. If you're putting all of your energy and to making one type of white blood cell, actually, you're not going to make us many platelets. And if they're high, this can be reactive. So if you have some sort of like just any form of inflammation going on in the body, your platelets would increase just because it's kind of a reactive change. Um, and then you can also get condition called It's sense essential thrombocythemia. We should just you have high platelets because you have high platelets, so we don't really know why. Misses her. FBC I appreciate it, not put any answer for one number. That's fine. I will show you what's going on here because there's a lot to look at. So her red blood cells are low. Um, let's get a panic easily. The red blood cells are low. A hemoglobin is 44. It should be between 115 175. That's really, really no No. One. She stayed in his tires. Her MCV had the size of the red blood cells is 80. It's It's on the lower side of Normal, but it's not abnormal. Ridiculous, like Count has not been given, for whatever reason, but her white cell count is 104 So it's supposed to be 4 to 11, and it's it's almost let 10 times the upper range. That's really, really high and looking at the rest of thumb. Rest of the white blood cells her neutrophils are no 0.8, but actually they should be between two and 7.5. So that then no on lymphocytes, however, our 102. So she's got really, really, really high white cells on most of them. If not basically all of them are lymphocytes on again. She has some basal cells, and some is NFL's and some monocytes that they're not kind of not really contributing much towards this massive white cell count. And again, her platelets are supposed to be between 154 50 56 and that's again very low. Um, so what we think is going on here Based on what I've told you, it's basically only one thing that can cause the white blood white cell count. That is this high sample. Sure. That's what I tried the other day. She's, like, somewhat coarse is a person to have more blood than they're better too. I was like, Well, they drag it. It's true. You got to much blood in your body. How did it get a baby? You drink it. They work. Set. Is that all about Meant? Your body? How? How else did you get blood? Excessive blood into your body. Well, so what? My supported that. A needle? Yeah. Someone's put one transfusion, please. Plus fit Test full examination into the query, bleed a for the underlying auto immune. And then then to the thought of see a But you don't have to put that cancer off the calcium. No. Yeah, So they think so. Six. That bleeding. So all right. Doesn't. Might be. It could be bleeding because leading gonna cause that white cell count. It's from when bleeding is all your blood goes out. It's not just the bit. It's not just the rate of it. All of it goes. Yeah, actually, if you're losing blood, Um, acutely. Your blood cell counts actually won't change because all of these are basically concentrations. Andi, Even though you've got less blood in your body, you it's still everything. Still kind of the same concentration as everything else. Anytime. So, ratio pump milliliter, isn't it? Uh, it depends on the one, but not like all of these are relative to the volume, so actually it might have less volume, but in that volume, they should still have the same ratio of blood. Yeah, so got cancer and leukemia as other answers. So which see, My pretty sensible ounces, They all since months is say in terms, the next steps. So there's a couple things you could do here If you had a patient like this, they need to go to a me. That play that count is not safe. That hemoglobin is not safe. They have very, very little blood. Actually, if they get a bleed, they're at risk of losing a whole lot. But they got very low hemoglobin. But if they have a bleed there a massive risk off just continuing to bleed. Onda. Yeah, basically, because of that white cell count being so high. The only thing this could be is an acute leukemia. It's most likely gonna be an acute leukemia, and it's most likely gonna be a lymph acidic or lymphoblastic leukemia. So this is most likely a. L. L or acute lymphoblastic anemia. What you could do if they want so sick is refer them to the hematology oncology. Rapid Ox is comics where they'll see them with a couple of days on, be seen by a hematologist within a few days and hopefully start treatment pretty soon after that. So any questions about case too little give them their compulsory 60 seconds. It's almost just said leukemia. I guess that's an answer to earlier. But it's certainly just popped through, say the also. The previous case was leukemia. It was indeed I'm seeing them questions. You want to continue it? If they are skinny, we come back in the end. Yeah, that's good. So I thought my notes on the slide as well. Excellent. So you got a 55 year old male attends any with jaundice and abdomen pain. What questions do you want to ask him? You're thinking of that. Let me just People can cheat slightly the dose for the screen that I was there on the screen. Rhoda fixed up. What questions you want. Ask this gentleman with you understand? Abdominal pain. I fixed it. Even your slides. Good. Oh, I'm going to reset this. This is because I went out of, uh, think you met a guy. Thank you. So I said, How much does he drink? I think they noticed you put the liver function test up. And how long has it been going on? Sure. Coolness is. That's one question. I go explain. Jaundiced just for the sake of anyone who doesn't know to drop. This is yellowing of the skin. Um and you can also get it to rest, which is yellowing of the eyes. They're both caused by basically a raise in a thing called bilirubin. We should talk about later, but you know, you have the skin. We have any liver history. Alcohol history, smoker. Where is the pain? How old's have been four history of Gilberts skilled, but so I put pee pee. Oh, p Q r t s off pain. I'm assuming that's the other version of Socrates. Yeah, and any colistat IQ Joel disc causing medication or the what is covered. Similar. How long fall? Where is the pain Liver? Excellent. Yeah. Couple questions are good ones. So these ones I came up with, um, very briefly on the bus. So when did it start? Always a good one. Has that ever happened before? And then turns the update Pain You can do Socrates. That's sight onset character. Um, rate radiation. So what is the pain spread to associated symptoms Like what else? They get the same time at timing. So has it got better or worse over time? Is it just a certain times? Or is that a what time exacerbating and relieving factors. What makes it better on what's on then? Severity is the house of areas and then other things like vomiting and nausea, any heartburn, any bowel changes and any blood or mucus from the rectum, as well as this thinking about things that might affect the liver. So it's things like IV drug use, which is this kind of how we document IV drug use IVDA that can introduce kind of viruses and stuff into the blood that might affect your liver. I'm classic like that have to try to see you see or B Likewise, Things like tattoos kind of swell. Um, alcohol use. Very important for a liver history. Um, recent travel and food again. You might get kind of a viral thing or parasitic or bacteria or whatever on got a sexual history as well. Excess some conditions that kind of affect the liver that, um, it can be transmitted sexually as well. I thought the rest of history. So I've been feeling on well for a few days. Then I got this horrific pain in the top of my stomach on the right, and it won't seem to go away. I tried taking paracetamol, but that hasn't helped on dysmorphic. My husband noticed my eyes were a bit yellow. He said I should go to any. The pain's mostly on the right upper tummy. It doesn't spread anywhere else. It started gradually over the last four days, and it's slowly gotten worse. It's they're a little time, I say. It's probably getting out of 10. I also feel really unwell, and I think I'm a fever, but I don't want to monitor. I haven't had any changes in my bowels and definitely no be bleeding from the back passage. The rest of history. I've also had some pain for last few years. Mostly when I eat a fatty meal, it's over the same roughly the same area. I cut down on these fatty meals and actually they stopped with pain stopped. I don't drink alcohol. I've never used any drugs. I haven't traveled, and I haven't gotten tattoos. So what do you think could be going on here? Just a point or tattoos? If you're traveling around, you know Thailand, South Asia area. Maybe don't accept tattoo someone offers to do on you for free. Just a general bit life like, for example, a diver or any CG. Or so how this maybe not the best thing to get tattooed for free. Just just life advice for everyone somewhat committed a crying smiley face, which I believe probably means they got a free tattoo in Thailand. But it's, I think, confirms my theory is to who's but also these questions, but nothing else about what could be going on us again due to go back to the actual history so you can read it. It's good might be easier for them to like see what the information is while they think about it. So it's coming really bad. Acid reflux it. Zero idea. Yeah. A Z mutual suffers of acid reflux. Just, um, I can probably both simple eyes greatly with this, uh, suggestion. I'm not quite sure that's what's happening. Cholesterol issues. Nice idea. A fatty liver. Maybe I'm not seeing much else here. There, Josh, you know, maybe have a chat about it. Uh, there's a couple things going on this history, actually, um, so we've got this kind of constant pain in this right upper part of the tummy on, but if we think about the organs, there's a couple of things. So we've got the liver. That's a big one there. The, um, gold brother on it's associated like biliary ducts and stuff. You've got a progress is kind of there about the stomach. And the duodenum is the you've got making that the colon is also in the area. A sweat is this. You've also got your maybe kidneys could also kind of roughly be around there on the bottom of your lungs. Um, kind of just gonna set just above your liver. I don't see your heart. It's sort of may be roughly over that area. A defense where they're actually describing There's loads of different things that could be going on and basically feeling unwell. So we're thinking and actually they've got fevers. They were thinking, Have they gotten infection going on? So there's no changes in the bowel out of no bleeding from back passage, so it's probably not colon thing. Um, well, there's no mention of any kind of breathing issues, but I don't have any breathing issues, so actually, it's probably no on the coughs. It's really not a pneumonia, so I think it maybe it's like liver or biliary tree of that kind of thing. Um, actually, the fact that they've got yellow eyes have suggest that as well. Um, and this history is pretty classic for Goldstein's. So they had some pain for the last few years. If you eat fatty meal, vial is really good at kind of breaking down. But fuck e stuff. So when you have a really fighting meal, but when you have any ill, your gallbladder will contract and squeeze out later vial to help break down your meal. If you have a fucking meal, it'll do that more So if you have cold stones, you're basically squeezing your whole bladder against one of these stones that's trying to get out what can. So you're gonna get this pain when you go about it? Contracts on If you go brother contracts more when you have a fatty meal, Um, then it makes sense that the pain's going to be more when you have this fucking meal and I'll go eventually. That's just make it. Is a cold blooded problem going on. I'm going to have a stone. These are some things I thought off their know organized in anyway. Apologies. But in terms of kind of gold bladder on big bile tree stuff you got sending cholangitis. So that is basically infection on off the biliary tree in itis basically meaning inflammation. That infection, you get inflammation and the colon just kind of part is the, um, bit every tree you got colecystitis, which again is inflammation This time, The coding is kind of referring to the bile system, meaning Basically, it's something that can hold things. Um, so I kind of similar to bladder. So this is a inflammation of the gold bladder and some Aleve or swickle stones on themselves, not causing any problems. Just stop that. Um, it's a differential. Potentially. You think so? Pancreatic cancer is an important cause, so pancreatic cancer can compress structures kind of in your biliary tree, which can then cause this build up a bile and eventually you'll get care of this drawn just going on. However, the think he has pain here, Um, everything's I'm actually depends. So the fact he has pain is actually quite unlikely for pancreatic cancer because there's a law that says, But it's not low, but it's someone came that the rule that sort of fits on the basically says that a palpable, painless go bladder in the context of Joan deaths is unlikely to be Goldstone's. I'm pretty sure that's very since what s or something. It's around that. So basically what that saying is, if you have John deaths and you've got maps and you're right kind of the right upper part of your tummy on, but it's painless, it's probably not Goldstone's. And actually what remains, as it might be pancreatic cancer so that you think off. Then there's also um, kind of inflammatory conditions of the biliary tree. So primary biliary cirrhosis, primary sclerosing cholangitis just through those in there for completeness that they're basically inflammatory conditions off your very kind of ducks and stuff. You then potentially have, like intestinal ischemia. So part of blood supply getting blocked to the intestine. Um, which kind of causes it to die? And then you get a lot of pain again. No bowel changes, no blood PR. So maybe unlikely. But it's a suggestion. Georgina on gastric ulcer. So we kind of mentioned reflux, actually. So in this car, Varia is something you could go, especially if you get pain after eating. That's quite classic for gastric. Also, this stomach, other sort of abdominal cancers of some form for compressing things. You always need to rule out an M I or a heart attack in this case because I guess four days later is a bit trick is probably unlikely. But touch me, they could feel the pain from the heart back roughly in the upper stomach on. Do we need to proved that it isn't really? And then also pneumonia again if it's on the right hand side and it's kind of love it, but could be presenting is like abdicating rather than chest pain. So what we're gonna do next thinking of those differentials? But while people of thinking about that there was a question here about difference between Goldstone's and kidney stones, typed out, announced to read it. But in short, similar problem. Different organ. So your goal bladder is separate from it is different for your kidneys. That's the same idea. They see both of them. Uh, not solid material in them builds up to form a math. A lump, which then has to pass through a squishy, fleshy tube to be able to leave on, gets stuck. That points and stops fluid upload past it, making it painful. And both of them are solved in the same way, which is. Either you push the stone through on get rid of it, or it has to be broken up or removed. Um, hum. And there's no one about it in the situs. A suggestion for what's wrong with this chap. That's it. Actually, appendicitis. It's a nice idea, but it's ah, it's, like, different. It's, um, that's quite specific points in the body where you to expect Penders itis. So it normally starts really very much in the middle of the abdomen. But then the pain will eventually move out towards Playschool McBurney's point, which is roughly half way between your navel and you're hit the bony prominence you hit Onda. Uh, although fight another abdomen if you're being not fancy if you're not trying to be. But I'm not trying to be a surgeon. It'll if you don't try to say it the way that surgeons want you to tell them it. And then the vehicle rebounds tenderness that's quite specific with the pen decided, because when you press it, the pain is less. When you release, it gets far worse. Um, um, Reliant on this is more of a sign of oscal peritonitis, which is kind of inflammation and infection off. Kind of the low salt, the lining of the bowel. In a way, it's called the Yeah. Pardon me. Um, um, it is basically when that gets inflamed a swell eyes when you get up. Um, one of the causes fat is kind of like a, um anything in shop? Not so far. What are you going to do next? I want to know what this creepy wouldn't figure. Yeah, it's what was all too smuggles, isn't it? You make it less that I would have a face on it. Maybe let's not do red eyes that I'll be creepy, but I realize, and then, um, okay, to believe has blue hair. Yeah. Smile. Okay. Nice bolting heads individual. And I've got plan for that is why does he look like a human holiday? It's going to top pounds. Are you? Definitely. Definitely. He would tell me just now, much left threatening. They read anything while I'm having fun. But no, I think you're gonna have Teo. If this one you're in, it's I, um always good to start with your examination's after your history. So we're gonna get a two week because we think these guys probably quite a long, um, I'm like, definitely gonna examine its tummy as well. And then in terms of bedside tests that we get a urine dip just cause he got fever, much like a year end up. Um, look for looks like the nitrites, um, which are markers of kind of infection and inflammation in the year. And, um, probably will come back positive, but actually not mean anything, But we'll do it anyway. And the CD you want to have an idea of whether this is at my card in function or not, or outside UM, and then a DVD, which is similar to an ABG. But it's taken from the vein, which will give you an idea of things like lactate. So a marker of kind of your tissue profusion on. But I also give you of refined have kind of the electrolytes in the body on Got kind of thing. So blood tests. So you do. FBC is definitely on with your full blood counts we talked up about before. You use any? Is that your kidney function? Your liver function tests? Definitely. We'll talk about those in a second. You're believe Ruben VBG. You talk about blood cultures, a viral hepatitis screen so you can look at all of the different types of hepatitis on. Do have a good idea of whether patient's currently have them or have had them in the past. We'll have a chronic infection. That kind of thing, um, allies, is a good marker for, um, pancreatitis. And if you're thinking pancreatic cancer as well, you can also do a C A 19 9, which is basically a cancer marker for the pancreas. You've been also got CRP. So that's your kind of non specific inflammatory marker do A cholesterol test is well, because it might be fatty liver. Might be like cholesterol contribute towards stones as well. And then you'd also out of troponin, which is kind of basically, uh, part of your heart muscle that if you get, um, I or damage to your heart muscle your heart basically released proponent into the blood give you an idea of whether they're having hot cycle up. It's radiology. You consider doing kind of an ultrasound or a CT of the abdomen on Be probably move on to do something more specific on such as, um um, MRC piece. That's, ah, basically magnetic resonance cholangiopancreatography, which is an MRV. Basically, it's an MRI off the biliary tree. To try and figure out where the stone is. Is causing issues on to talk a little bit about liver function tests. We talked about it a lot on D. A lot of people don't really have a huge idea of what they mean. Sorry, the first test, and there's also leads about condoms as well, because they're all huge names that you're looking up. The first test we want to look at when we're doing a liver function test is the lt in the ST So the stones for alanine from salmon A Z. I think on then, like a spotting transaminases something like that, but a little and ST and these are Marcus. Off the practice, I see the liver cells being damaged. So if these are raised, that suggests that for whatever reason, your liver itself is done ish in a way on. But you can also look at a pattern. So in some alcoholic disease, your ST will be higher than your Ailton. Usually, however, in like other chronic liver disease is, you'd expect your a little teeth be raised more. And you can use that pattern to figure out whether this patient might have kind of an alcoholic problem or chronic liver disease or another. I'm kind of liver. If things going on is LP, which is alkaline phosphatase, which is, if it's raised, it could be suggestive off a problem with your biliary tree or actually alcohol. But it's not always on. It's raised in other things as well. So if your liver function is normal, mostly so if all of these are normal on the right inside. But actually your LP is high. There's a couple of other things that can cause that for example, a cancer of the virus, Um, a deficiency in vitamin D and any recent fractures of the virus. But and also pregnancy is welcome, Grazer. So a good thing to do is to look at, I think, with the Gamma GT, which is just another enzyme which is also seen in the biliary tree or a Nalco. All damage more so in alcohol are colic kind of liver disease than anything else. Um, so if the out a LPs high and the GGT is high, it's probably gonna be kinda biliary if you But if the LP is high but the GGT is normal, it's probably gonna be something else. Have been everything which is isn't she is a breakdown product of your red blood cells. Your red blood cells only left for about 100 20 days or so, and then they're broken down and recycled on do this and then it re been, is initially in a form that's called uncomplicated, which I don't know enough pharmacology to actually know what that means, but I know it's uncomplicated stuff can't be gone. Rid off that easily. So it's gonna be complicated on be the best way to do this is in the liver. Um, so the only congregated Ruben goes to the liver, it gets congregated, and then it gets excreted into the bile. Um, this bile. Then we'll get drained into the small intestine on D in this morning testing some of the bacteria converted to basically just a different type of bilirubin. And some of that different type could be reabsorbed back into the body. Onda. Then the stuff that remains in the stool gets excreted as stucco been, uh, which is the thing that basically makes your poop brown on the on rest of it. That kind of gets reabsorbed into the blood, gets excreted as your villain by the kidneys so you can look at the pattern off the amount off. Um, uncomplicated versus conjugated Billy Ruben to give you a good idea of up where this high better. If it is coming from on, this patient would have had a high Billy Rubin because they're gone desk better. Even it's the thing that kind of turns your skin yellow. If you think you've got loads of if you have loads of uncontradicted but everything, it's quite you in the blood that's good. Try to get to the liver and deliverable have a certain number of enzymes to confiscate it. But actually, if it's got so much uncomplicated that it can't keep up than a lot of your pretty much all of your bilirubin is very uncomplicated. So if it's all on conjugated, that suggests that actually, your problem is before your liver or prehepatic. If you've got a normal amount off kind of uncontradicted bilirubin and that goes to the liver. But actually your liver is not working very well, and then you've got to congregate some of that, but not all of that. So you're going to get some conjugated on some uncontradicted. And however, if you have a problem after your liver to say that the bile duct that's blocks you're gonna get, um, well, all of your own congregate ear's is going to go into the liver. Liver's working ups that you find is gonna conjugated all it's The conjugated is going to collect up so you can look at your ratios of whether you've got uncomplicated versus conjugated deliver even on to have an idea about what where your problem is. So if it's mostly uncomplicated, this is before the liver on. It's just that, classically, it's just the red blood cells are being broken down too quickly on this. Is that Xenical? He mal ASUs. There's most different causes that, but basically the red blood cells are probably being broken down too quickly. It's a mixed pattern that suggests that had Patrick jaundice or it's a problem of the liver. So, for example, in cirrhosis or alcoholic liver disease or hepatitis, if it's mostly conjugated, then it's a post hepatic. So it's probably that the vials duct is blocked and or the patient actually has a pancreatic cancer, which is also gonna block the bile ducts. However, most of these things they don't actually, even though they're called liver function tests, they measure the health of the liver more than the actual function of the liver, which is helpful. The best way to determine the function of the liver and how it's working is by two tests that aren't actually part your liver function tests helpfully, so you have your you see, a liver makes things will clotting factors which help you clot. And they have really short half life so that if your liver stops working, your clotting factors will reduce, and it will take ages for your blood to clot. We could measure this in terms of what's what a PT on a P T T test. Um, So if those are prolonged and we're taking ages to bleed, we think they just clot. Sorry, that suggest that actually, your liver maybe isn't working that well, And then over time we can measure cynical albumin, which is a protein that's made by the liver, that basically transports everything around the blood. So all of your hormones and that kind of thing, most of them are transported by albumin. Um, so your liver over time will kind of make this If your albumin is no or if your liver hasn't been working for ages, then your albumin, it's gonna be low on. It'll stay low. That's one thing we can look up in terms of pathology on. This is just a very quick summary side, but it suggests all the changes. So if you got acute liver problem. Your a lot in your honesty. There you're, um could have liver markers. We're gonna go up. You might get off. It's like a high l p R G. But actually, it's gonna be a liver problem. Liver things are gonna go up, and your bilirubin is going up a swell on. It will be a mixed that be partially under contract. Uncomplicated and partially conjugated. If you've got a chronic, um, alcohol problem with your liver, your l t is gonna be up, But actually, your ST is gonna be up. Father, you're gonna have a high l p. Most likely Haidt. Um, your bilirubin may or may not be normal. If you've got a non hepatic a non alcoholic liver problem, then this chronic than your l t might be will be up. And your esteem will also be up. But you're able to you'll be more. Many other things may or may not be normal if you've got a bile. That problem your l tenure ST may be fine. They may be slightly raised, but if you're a a pa in your GGT, they're gonna be higher. And if you got liver cancer, then you're able to, you know, ST are gonna be like in the thousands Samos for leukemia with the white blood cells basically in the hundreds. Three Only thing that can cause that is leukemia with liver enzymes when they get into like thousands. Generally, the only thing that can cause that is a liver cancer. Sometimes a viral hepatitis will cause that, but classically is a cancer. So actually, we literally conducted Moses patient based on the history, pretty much on disses. A classic try out a fever, jaundice and right upper quadrant abdominal pain that's called the Charcot Try Out. I'm named after a shocker on, but it's basically a shock. Yeah, that's like named everything after himself. Yeah, basically, it's an infection off the biliary tree. Um, and there's other things you can think of. Kind of biliary tree problems could have related to stones in three different categories. You got the presence of stones themselves, which would just call call stones or cholelithiasis for it's fancy name on. Do you would get right upper quadrant pain there, but you wouldn't expect a fever drawn desk because you're goal. Blood is just gonna be kinda squeezing on these, but it's not irritated in anyway. It's just sort of going to cause your pain. Then the next step up is colecystitis, which is inflammation of the gold bladder, and you are going to get kind of a constant pain here because you have gall stones in your gall brother. But actually, also, it's got a little bit inflamed, so you probably developed a fever as well. The next step up from map is ascending colon ritis, which is what this patient has, where you'll get right up according pain, because you cook basically a massive infection going on in your biliary tree. You're gonna get fever again because you got a massive infection going on your biliary tree on when, um, you're when you get infection somewhere, you get information and that will swell. That's gonna block your bile ducts so you're gonna get jaundiced as well, because that bilirubin can't be excreted. This is kind of the way you can differentiate between three step wise conditions. Does anyone have any questions at all really nicely done? There's one that someone asked. I thought it's safe to the end. That that was an interesting one is ah, what would jaundice look like on someone with they put it brown or black skin. So it's your just look on people who are sort of text book person. Actually, it's a lot harder because that's kind of to be expected. What I can do is just get your photo actually unsure my screen for a second say in the eyes. The eyes are kind of one of the first place is actually to notice that because they're so white and everyone has kind of the whites of their eyes and you will notice yellowing of the whites of their eyes. Um, but it might just be that the skin color looks ever so slightly different. Um, but that is a very good point. Uh huh, You find so I would say just a description. Obviously, photos will help. Um, so generally, the yellowing of sushi as Josh that show in the eyes, it can show sometimes on paler parts of the body. And actually, the Paley of skin is the more likely you are to see the yellowing change intent. Um, been off, obviously, like different parts of the body of paler than others. Sometimes like palms of the hands and place, like this, Uh, but the other one is also that generally, jaundice causes skin to go more. Matt. So by that I mean, it becomes sort of less sort of healthy, shiny looking. If you look at anybody you know, if your skin's nice and healthy, it's got a nice sort of, uh, I don't see the word moistness cause skin should be completely moist. But if it's got a nice sort of, it's got fluid in it, and it it's, you know, healthy skin. There's a sort of shine to it and sort of healthy texture. And Energen really any skin? Uh, it is better jaundice in it tends to not look quite a healthy. Um, how you doing? A picture. I think I've got one. You will be. You're about to be stared up by guy. Okay, just just the prep you for it. They go on, say, Oh, you're joking. Well, last time I came in from giggle, but you can tell him his knees are really yellow in the whites around his eyes. That's one very good way to tell. Kind of. As Freddie said, if the skin looks less Come on, Matt, potentially is kind of lighter than usual. Um, e que to it, but it is more difficult to tell on the best thing to do is kind of ask a patient or a patient relative like Does that skin look normal for them on because they don't know the difference? I think this image is quite hard cause the shining a torch right in his eyes. You can see it's right, so they're they're much more. There's much more reflection here than normal. You can still see as just think. It's like yellowing tone around, not in the square about actually in the skin around the eye. Um and yeah, that's that's probably your best bet, really. They have one quite a lot of things like that. Like cyanosis to have one with skin starts, school bit blue and again. The most effective way to compare it in people of dark skin is that loss of sort of the healthy, shiny glow that the healthy skin has on dot So the mucous membranes, so that the pink of the mouth on the pink below the eyes again tend to go a bit bluer on a bit less pink and healthy. Um, I don't know if that entirely else is the question. But that's just it is harder. It's like it's that something natural health of it. In a way, it just looks less healthy on something that, depending on where you train if you're doing, you know, medicine or nursing, or anything like this, depending on where you train sort of effects, how likely you are to come across it and become sort of used to seeing the the same clinical science and people of different skin tones. It's like an Imagine if you trained in somewhere. That's quite, uh, I won't say monochrome, because that means singular color. But I don't know what the correct, the properly correct term it's, but some of where there's very little diversity. Actually, you're probably very rarely, if ever, going to come across, uh, people of color and even then even rarer when they're showing particular clinical science. Where's Josh and I both trained in London, so we were quite blessed in terms of sort of diversity. And however I did do my dermatology placement and Kelsey a little bit little bit whitewashed. Yeah, so you know these things dairy, I think, in terms of how much exposure you get like a new artist. What is normal? Uh, what is normal for certain individual anyway, if it all has any questions will call it there for the evening. I've shared the feedback like a couple times in the chat. Pleased to go to feedback. We love your feedback. It's really useful for us on actually, a massive Frank is everyone who attended this evening. You guys have been pretty intense. Some sessions, we don't get that much interaction. And, you know, it's quite disheartening for us a lot of the time because we have no idea if you guys are engaged with, not if we're doing a good job. We have noticed that you guys were even like if you guys even kept so actually having this much interaction, it's brilliant. We love it. It makes the session so much more interesting and several fun for us. So so, really massive. Thank you. Everyone on the bubble of see a massive thank you to Josh. Such a brilliant session. Thank you so much made. But I'm seeing no questions, so I will call it in there. It says thank everyone. Have a good evening on and see well in two weeks time for the final part of a T E Siris. Thank you, everybody