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so anyone that's watching the recording. Apologies, guys, we haven't gone through much of the first case. If you go back a slide, a swell there that he said that least the first question is there? Yes, of course. Yes, they're just for anyone who's watching this as a recording. This is the question. First question on Done. Um, yeah, the correct answer. A sweet distracted I in deficiency, the anemia. So you guys have you have any questions? Just got them in the chat to here, and I will answer along the tutorial. So if we just go to the next line now, so just want to talk about some differentials for the gentleman In terms of Upper GI I. Bly's, um, it could be a peptic ulcer disease. In which case, like I said, you want to ask about symptoms off dyspepsia on. But the majority off peptic ulcer disease actually caused by a Spiro shade bacteria. That's cord a few, like a back to pylori Onda. Um, also, you wanna look how for their medication history. So any history off NSAID use or steroid use without a appropriate proton pump inhibitor PPI cover can give you a peptic ulcer disease on also could be variceal bleeds. So this usually a cause, um, at the junction off court or systemic anastomoses. So normally, when you have a soft a jewel, Barris steals eyes, thie dass trick veins and the portal veins, that's yeah, that's causing the bleed on. Then, like I mentioned in when you do the, uh g d, your primary concern would be to rule out a a perjury I malignancy just because sometimes a tumor can also very on, then exposed the underlying exposed the underlying blood vessels and also with tumors. You have a new blood vessel formation called new, and you're genesis on. These blood vessels are quite torturers and are very prone to bleeding on Just, um yeah as, ah, side nose. Um, miscellaneous things such as basket amount formation. So this specifics thing called a deal. If I leave them which normally found in the esophagus or the stomach lining where you see there's a congenital arterial malformation shown in the picture where the vein Sorry, the artery and arterial is quite large and torturers and very close. Teo the surface mucosal, therefore making it very prone to bleeding. Um, and then Because we're talking about iron deficiency anemia. I just want to talk about I'm transport in the blood in the body. So most off the eye and we get from ah, you take. And the iron is absorbed in the proximal part off the Judean. Um, Andi. So not so you can get, um, I'm into a state. Or you can get a ferret crime, which is every two plus. And you can get ferrous I'm, which is every three plus. So the, uh, enzyme in the intestinal wall will trump convert all of their f e three plus into f e two plus on your interest sites lining the duodenum Well, transport these Ferric Ryan's through a transporter. A cord die Vaillant Metal transporter into the cell itself on. But once the iron has reached the entrance side, it can do a couple of things. So either it can be transported to the blood vessel through this again protein This transporter called Fair report in, or if the blood vessel has within the blood string, that's enough. I am president. Then it will cause the iron to be stored in ah is stored in ferret in. So essentially that's Ah, trunk of iron attached to proteins and apple proteins that's stored in the entire aside on. But when, um, your, uh, iron level in the blood is low, it will create a positive feedback loop. I don't cause mortar flux off iron outside of the Intrasite. On there's another protein just worst mentioning court have side in so that cause it gives a negative feedback. Teo this protein where it will inhibit the transport off iron out of the south into the blood vessel. So, essentially, that's how I am. Transport works in the body if we just go onto Case two s. So it's the same gentleman from question one. We already determined that he has I'm deficiency anemia. So now we are going to do a I and study for him and just pick the answer that you think it's correct in terms off. What will his iron study results look like? Good. So just another 10 seconds. Um, there we go. Yes. So the polls are penned. I don't have a look at the questions. So if you hear someone said they missed the ABG lesson but was unable to find it on medal. Has that been up closes the AVS, and yeah, far as I'm aware it is uploaded. I could check here again. Yeah. Um, So is there a risk of rupture? Bring any vessels during Oh, Gee, D, yes. So with any procedure, the risk up you can say is always infection on bleeding, so that's definitely your risk. Um, but the point we are doing, uh, d d is not only does it have a diagnostic value in terms of departure morning, what is the source of bleeding? Sometimes it also has a therapeutic value s So, for example, with varus seals, you can use GED and throw GED. You can inject things or patch it up to stop the bleeding itself. So some is really about weighing risk. Onda benefits, um, in terms off. Wether yeah, that to do the procedure or not. Um, so there's a risk with any procedure. Christ. Okay. And then someone said, How would a peptic ulcer disease and variceal bleeds present differently? So, with peptic ulcer disease, um, sometimes, especially if you're the peptic ulcers present on the posterior wall of the stomach road into one off the arteries called a gas would do a dino artery, which is a brunch from the, um, essentially like celiac stem eso. When that perforation on, also right into the, um, artery, it can be very, very painful, whereas with very seal bleed. A lot of times is not that painful. So that's one of the differences on. Also, it would differ in terms of the clinical history. So with peptic ulcer disease. Like I said, if there's been a lot of symptoms of dyspepsia, essentially indigestion and acid reflux, it's so you know, like a metallic taste in the back of the mouth after you've eaten food on. Also, depending on weather is duodenum or gastric ulcer. You can have pain up before after eating food. However, with barest your bleed, it does normally a history off chronic alcohol intake. Um, okay, And then somebody asked, Can I explain a TIBC? So if we go through the answer and I explained them what the components off iron studies mean, so pretty straight results. Yeah, again, 62% of you have voted for a, which is the correct answer. So if we just go through that yet so essentially the things listed on the top are the component that you can get in your arm. Iron studies. So I and obviously measures the level off serum iron in the blood and ferritin is what we mentioned. Essentially ferreting is the same as I'm store in the interest sites on day, transferring saturation. So when I end is transported out of the south into the blood it's attached to transfer in and transfer in just a protein that carries the iron in the blood on total iron. Binding capacity is essentially all of the transfer in your blood on. But what their capacity to bind the yes so the amount of I and that can be bound to the total amount of transference. So that's essentially the definition off total iron binding capacity. So we just go through each one on day. Why each condition corresponds to, um, the iron study picture showing here. So with iron deficiency anemia very obvious from the name that I N would be low on because you're constantly either losing blood or having malabsorption so that you're not absorbing iron. Therefore, the iron store in your cells would also be low on because the iron level in the blood is no a slow. It means there's no enough iron to go around to bind to transferring to the transport protein off iron. So therefore, the saturation of transferring would also be low on because there's no love. I am bound to transfer. And that means that total iron capacity total iron binding capacity increases because there's a lot of because your body also tries to compensate by increasing the amount of transferring it will in order to increase the iron level. But because the problem is in the iron level itself, it means that the total I am by and in capacity increases in iron deficiency anemia on done, um, so if we go on to the next one. So with anemia of chronic disease, so anemia of chronic disease is is essentially a, um I in a transport problem where the eye and cannot be transported out of the cell due to suppression off the protein that does the job on. Usually you get this when there's you have a chronic inflammatory disease that's a long term causing the anemia chronic anemia of chronic disease. So because all of, um yeah, because there's a impairment in I and transport into the blood stream. That means the iron in a C D is low, however, because, um, the store so so. Yet because there isn't any problem with absorption itself, the Iron store in the cells would actually be high on. But in terms of transferring saturation, it is also low because again, when you are in a chronic inflammatory estate, the proteins your body don't create sufficient proteins to bind to the iron in the bloodstream. Therefore, that is low on. Then transfer in saturation total. I am binding. Capacity is always the opposite of each other. So in this case, that's high on with hemochromotosis. Essentially, that's when you have too much iron. And then, um, there's a protein that inhibits that I'm transport from the Intrasite into the blood cell doesn't work. Essentially, you continuously pump iron into the bloodstream. Therefore, all of those things are high on. Then you have a low total iron binding capacity because all of the transferring has been bound. Therefore, there's not many free spaces for iron to be bound to transfer it in the blood and the next one B 12 and folate deficiency. It's not an iron problem, so the iron study would be normal in this taste on done with the labs leaves Sallis see me a major eso is a beater. Globin train. Um, you take a shin. That means that the beetle globin train isn't incised properly and therefore that human global sense of size is impaired. So essentially, it's not a I am problem, but because the beater train is impaired, it means there's not enough good hemoglobin to go around. And therefore you have a nexus iron for the amount off humor globe in for the month off, normal hemoglobin that's going around the body. Therefore, you get this sort of picture so we just go to the next case and out open up the whole again. Uh, just have a look at the question. So someone are you Someone would just want to confirm the, uh, protein name. So I'll go back to that diagram after this case on Done. Uh, yeah, and then I'll explain that transport diagram again. Someone asked, What's the difference between alpha and Beat Salad? Femia. So, essentially your hemoglobin. And so he said, there's different types of human globin. It's the majority in an adult body is humor globin a and you go to a to a hemoglobin A is made up off to Alpha and two beater global's. So, essentially, alpha thalassemia is when the alpha globin is defective on beater Dallas. Thenia is when the Beatles Grogan's are defective. Okay, so gonna end this one? Yes, sir. Yes. We've gone through it before again. Uh, the majority of you are absolutely right. S o is indeed anemia off chronic disease. So the clue will be on was in the history yet says her arthritis is worsening. And on examination, there's a lot of cardinal features and signs off rheumatoid off writers. Eso she is in a product like inflammatory state on. Therefore, this anemia is caused by anemia of chronic disease. Um, so just to address, ah, one of the audiences questions I just explained this again. So yes. So the, uh, iron? Um, yeah. I n goes from the Lumen off the, uh, duodenum into the enter side. And this protein is called a dive. A lint metal transporter. Eso that transports I am from the Lumen off the intestine into the intestinal cells. On this point, seen is called for report in which transports I am from the cell into the bloodstream. On when in the blood stream, the iron is bound to transfer and to be transported around the body. Ah, hope, uh, let me know if that explains the question. Oh, no. Worries eso if we go to Yes. So just a, um, explanation on those because Billy Ruben on the previous one, So bilirubin. Yes. 15. So that's normal. Sort of Ramallah. Sears is very unlikely. B 12 from folate Anemia associated with macrocytic anemia. Where us? On here. Um, B 12. So this let me see. Okay, I actually didn't mention that, um, a CD is normally is normally a normal cytic anemia, but essentially, B 12 and folate are associated with macrocytic anemia. So And also, I haven't given any levels for this question, so you can just assume it's normal. So it's not right on balsa history does not mention any obvious or occult blood loss on The most obvious thing in the history is that she has rheumatoid arthritis, which very commonly, if the disease is active, as in this case, it would give you anemia off chronic disease. So just a brief overview of different types of anemia so you can divide anemia based on the red cell size into three groups. So microcytic normocytic on macrocytic. Um, as the name suggests, uh, it just means, like how small or large the red cells are. So if we put a number to them with microcytic anemia, normally that means cell phone rings under 80 with normocytic anemia. It's between 80 and 100 on over, ah 100 for macrocytic anemia on dive just listed some of the causes conditions off each group below. Um, yet the first row on also have just listed some of the features that you can see in each type of anemia under blood film. Um, so with ah, nieces, cytosis and particular size hostesses, which means unequal size and shape, respectively. So that's a pretty unspecific Stein, because you can basically see that in across the groups. I just want to give up his tickle a mention to macrocytic anemia. So within macrocytic anemia, you can further subdivided into two groups of Magdala plastic anemia and non Magal back plastic anemia. So megaloblast IQ and Nina just means that's the anemia is caused by an impairment. Indiana Vince's on. But it's almost exclusively due to be 12 and folate deficiency. Whereas there are other causes that doesn't cause any impairment off the in a thin thesis, which also gives rise to macrocytic anemia on. In this case, I can be chronic alcohol intake because that has a a lot of alcohol has a direct a suppression on your bone marrow. Therefore, your cell don't mature enough on. Therefore, it gives their parents off a large red cell on with him. Elliptical Neemia, Uh, your body tried to compensate thie him elliptic process by camping out more immature red cells on Gwen, You look at that on the, uh, blood film the Imitrex or red cells would have a nuclear is, and that almost takes up the entire space off the cell on de sensually. That would also give on appearance off large red cells. So those these are just a summary, uh, that you can use in your revision for different types off anemia on. We just move on. So, case number four, um, yet 25 year old woman presents to your clinic with lethargy and tiredness. Her full blood count reveals that she's got low hemoglobin and a MCV off. 135 on there. Some blood test here for you to look at on. But what's the most likely cause off her anemia? Uh, okay. Just launched a pole again. Yeah, it's so much. Yeah. Yes. So this should be a relatively straightforward one. Um, so just another 12th and move on. Oh, all right. So yeah. So almost all of you have chosen, um, B 12 deficiency. Anemia's pretty obvious with the results shown here and with the range that I've given s Oh, yeah. Like I said, in this case, when you do a blood film, you most likely to see macrocytic anemia on yes or a large, uh, B C and a, um, large red cell on blood film. Um, so next question, you'd like to find out the cause off patients B 12 deficiency from the case that we've just seen. And you find out that she does not have any special diet requirement Onda on examination. This is a picture off her hands on. The rest of the findings are listed. So with this information, what is the most likely course off? Um, her B 12 deficiency. Okay. Okay. Just another five seconds. Oh, we ended that. Okay, so, uh, most off you or more than half of gone for see, some have gone pretty. So in this case, the most likely course that in the questions that Ms that's most likely cause, even though C and D are possible, however, the most likely cause off her B 12 deficiency is parietal cells antibodies. Just because just in terms of epidemiology, that that is the most likely are antibody present. That will cause malabsorption off be 12. I'm not really sure about the reason why she here, if you know you can in license us. Um, I'll have to read that again, But he hasn't the question. Yeah, so, no, no, I don't know. Just in case. So anyway, if we just go through there. So, um, in terms of the picture that was shown on the bottom right hands, I called, but I was a pretty telling sign. So the patient has a little I go, which means the patient already has that auto immune. Um, disease on gum s so that just gives you an idea that the B 12 deficiency is probably a concurrent or two immune process going on that's causing the malabsorption off b 12. So reason why it's not a just because, ah, in the questions tamest state of the patient does not have any dietary special dietary requirements on dairy is no mention off any, Um, uh uh um changes in bowel habit and the abdominal pain to suggest that the patient could have IV d on bike, I said both intrinsic factor antibodies and parietal cells, and for these can cause malabsorption of B 12, just a matter off epidemiology in terms of which one is more prevalent. And in this case, it's parietal cells on gum. Just, um, some bit more information in terms of investigation on, um, management. So nowadays, if you suspect that the patient have one of these antibodies present, you can just do a blood test to see if they're positive or not. However, in the old days, something called a shellings test is, um, used to be done. But now is very rarely done on. But I don't know how in depth your curriculum will go into is I just mentioned it briefly, so essentially, the test has two parts. The first part you drink some radio labeled B 12 solutions on if your bowel is absorbing. Um, B 12 B 12, normally absorbed at the terminal Ileum if that's working, okay, and it absorbs a B 12. Okay, your end up passing that into the blood stream. Then when the blood goes into a kidney, your past the beach off into your urine on do you collect urine for 24 hours on a quantified the amount off Brady A label B 12 that's present in the urine on if you're in contains enough radio label B 12, that means that you're, uh yeah, that means, like, essentially, you don't have a problem with absorption off. Be 12. But if it contains a low quantity or no be 12, it means that you do have 12 malabsorption given rise to pernicious anemia on about How about you still don't know the cause off it because it could be a, um, auto immune process, as it is the case in this case where you have antibodies attacking the cells. Or it could also be things like IBD that's causing inflammation on the malabsorption off be 12. So what you do is that in the second stage, um, you give the radio label B 12 solution again for patient to drink as well as additional intrinsic factor in the solution. So if, uh, this time that you find that the urine contains enough radio label B 12, it means that there is a problem with the lack off intrinsic factors on that's why it's causing be 12 deficiency in the body. Um, so that's the main just off on do just for completion off information. So parietal cells are cells lining funders of your stomach on day secrete no, only hydrochloric acid, but also intrinsic anti hurts or intrinsic factors. Um, which helps, um, your B 12 to be which about but binds to of b 12 and helps that to be absorbed through the terminal ileum. Uh, okay, so we're halfway through out you toria. We'll just a 30 seconds break. You have any questions? Just please post on the chart. I'm really happy to answer them. You got anything to actually year? Uh, no. Nothing. Nothing to add here. Um, I'm just going to point out that you because here. So I'm gonna hand over, I have to take off. So, uh, thank you guys are popping again for some other electricity. You is very medically minded. Be the best person to answer a lot of your questions. Um, so I think that would be great if anyone else wants to get in touch about anything that I mentioned earlier. I have my contact details up here. Feel free to get in touch. I'll leave him here again. And, uh, yeah, that's it. Thank you, guys. Okay, so you guys really see Yes, you should hear. Thanks. Make sure, but all right, you like, if you have a minute, can just post the feedback. Yeah, post a blank right now. All right. I haven't seen any questions. Ah, we're gonna move ahead. So Hey, 6. 30 year, 35 year old male patient who's a strict weekend Comes to see you in clinic. You complaints off tingling off his hands and feet for the past four months, and this has been worsening on the blood tests have shown there, Um on what treatment would you start him on? Um, let me just stop the pole again. Well, and I another 12th guys, 40% of few of answered. Let's just try to get that to 50%. Okay, I'm gonna end the Yes. So 2000. You have gone for the right answer on. I'm just going to go through, uh, Why that is so yes. So the correct answer is indeed 100. So cobalamin, which essentially another name for B 12 B 12 injection first followed by or a folic acid. So, um yeah, essentially. Ah. From the blood results. Both of his B 12 am so late are low on this is most likely. You're due to dietary restriction on gum. And he complains off tinglings and to Paris peasy off his extremities. Onda, um, on examination, he has a, um Hammond in terms of soft touch pinprick. And also, it's Romberg sign positive. So just going to go through that. So essentially all of the signs points on with the ah concurrent B 12 and folate deficiency points towards the diagnosis off sub acute combined a generational, the spinal cord on on day. Essentially, if we go to the next line of just got a diagram here. So the blue, uh, nerve that you see on the left hand side. So that's the dorsal column that's responsible for soft heart vibration. Preceptor in on day, uh, red. The red bits on the right is the lateral corticospinal tract that's responsible for the motor functions off the lens. So essentially, B 12 and folate are needed for DNA. Things is, is. And when you were in severe deficiency, your neurons, the myelin a breakdown and you can have patchy demyelination off thes in your in your tracks on by the door. So column and the lateral spinal sorry lateral corticospinal tracks are the main tracks that B 12 and folate deficiency would. Ah, effective is a longstanding problem on, but just the building. You're over vision. So, like I said, your PSA column is responsible for sensations off soft heart regulation proprioception. That's why he's, um, had reduced soft touch sensations on Do a pro perception, essentially the joint space in relation to one another. It's also impaired. That's why pay from was wrong box. I'm positive on day in terms of laterals. Corticospinal tracks eso the upper motor neuron tend to be more severely affected than the lower motor neuron with, uh, 12 deficiency. So with that, you can get hyper reflexia of spasticity up, blow up going plant. I been ski Stein Positive. So, yes. So that's men symptoms you would get in a sub acute combined to generation off the court. Um, okay. And I just listed some off the other B 12 deficiency manifestations on the right hand side for you. Uh, we Yet So next case, 74 year old gentleman presents toe and be with PR. Bleeding started three days ago on past 4 to 5 episode of Frank Blood on. But he tells you that he went for a colonoscopy for a walk three days ago on warfarin. Wasn't stopped. So, um, this is actually someone die crops during a day show. So, yes, I've opened the polls. Now, um, on it in meantime, just a notch. So just 10 more seconds for more you to put your boat in. Okay. What? Yes. So again, uh, majority of you have, um, yet throws in the right option. I see that some of you have gone from mechanical hemolytic anemia. Understand why you've done that? Because, um, he does have a mechanical heart valves. However, uh, from the questions that, um, the bleeding is quite an acute problem, and he kind of like given you a reason for that. He went for a colonoscopy, but warfarin was mistakenly know stopped on down. So the problems has is for is quite an acute timeline on Does not mentioned that he has any bloody stores or anything more release er, in this case, the most likely answer is indeed acute loss off blood on been terms off management. So who we did was obviously stop warfarin for the patient. And because the patients are human, Globin was in the sixties. So normally, if the hemoglobin is under 70 or in the presence off any more cardio infarction A C s, um and so you would transfuse at 80 it is in the presence of a C s. But normally the transfusion threshold would be force below 70. Then you would transfuse. So in this case, we did transfuse him with two units off red cells on gum because he normally takes warfarin. It's obviously very important to monitor the iron are, um and it's iron eyes. Particularly high. You could be the reverse it with this pain came in Gestion or programming complex on. You would restart that. Um, either warfarin, once the ANA has come back down again, eso next case s 09 year old boy presents to a, uh, any with fear and painful fingers. He recently moved to the UK on, but there's no medical records for him on the computer as hemoglobin 67. What's the most likely cause off the human believe in? No. Okay, over half of you have answered, so I'm gonna end up. Hold that. Uh, yes. Ah, again, majority of you have gone for the correct answer which was sick or south seas. Um on. We'll just goes through that. So, yes. So it's actually a reason why is no any off the other causes of anemia is because the patient has features off sickle cell crisis there. In this case, the swelling fingers to the sickle cell has essentially occluded the arterials in the fingers. Given rights to doctor miters on. Also on general examination. There some evidence off a spinal megaly on, but could possibly indicates the next sequestration. Yeah, essentially, with patients like this very important, uh, hydrate them with IV fluid, strong pain killers. Um, yeah, because it's very painful. And, um, I'm a pro from paracetamol. Just won't cover it on, but normally the cause off these sickle cell basal occlusive crisis. Usually dehydration or any infections is quite important to find a source of infection. And if patient is septic start steps, it's six. Bundle on, then, obviously, to treat them symptomatically, you would want to give any ah, red cell transfusion on. Also, consider any exchange transfusion. Teo, essentially get the sickle cells out of the body on there. Quite prone to having clots A Z well service, uh, good to consider. BT prophylaxes on d. Just a quick information about why, um, sickle cell patients become anemic. So normally, the red cells lifespan on a normal biconcave healthy cells about 120 days. But with sickle cells, it becomes tend to 20 days because, uh, the spleen, uh, endothelial reticulum system would remove it once day detected like two abnormalities off the cell itself. On down. That's, uh, one of the biggest reason why, on the other two are basal cruise of crisis are seen in this's patient. So with basil cruise of prices, you can. It's a spectrum off diseases. You can get acute chest syndrome. Normally, that's a sickling off cells in the pulmonary vasculature on that gives are rice with chest pain and shortness of breath and such and such. And then you get that license are so swollen fingers in this case on also one of the most catastrophic complication is splenic sequestration, So essentially the blood would pull in the red socks off your spleen on that would cause the spleen to enlarge on may cause spread it rupture once it gets to a certain size on usually spurt splenic sequestration happens in sickle cell patient that that are normally younger. Just because they're spleens on blood vessels hasn't damaged as much. But once you've had several, essentially Sechrest rations off the spleen itself, it becomes Fibro's. So if they survived to a certain point when they become older, desperate enough actually become a lot smaller because it's been replaced by fibrous tissues on then. Another thing to mention is just a plastic crisis where parvovirus B 19 can cause bone marrow suppression on D. Like we mentioned that that early and decide that sometimes are cute. Loss of blood can give you, ah, high reticulocyte counts of ridiculous I just immature red cells or red cell precursors. But in a plastic crisis, you would get a low particular site count because the bone marrow, which normally produces the red cells, are being suppressed. So you don't get any prints passes in this case. So just last two questions. So you want to do a blood film for patient in case eight. So just please write down what you think the blood film will show. So in this for this one, you can just write in the chat. Okay, so I've got one response. Ah, sickle shaped red blood cell. Someone said yes. The two people said Reticulocyte Oh, says, um So I just give you another 10 seconds to write down any thoughts, and then we can go through that. Okay, so we go through that. So, yes, you absolutely right that you would get sick laying off the red cells. So on the left hand side picture, you could tell you could see in the red circles that those are or sickle shaped red cells. Ondas, I was saying earlier, So any society Tosis and particular cytosis which are on equal size and shape off red cells, are pretty like non specific signs off, um, blood films. Oh, off course that you would get that with sickling off the red cell itself on. Another thing we mentioned is that, um, the patient probably is having spending sequestration so that so, when the red cells are going through, the spleen is being broken into red cell fragments by the spin itself. So you might actually be able to see some of the front mints Astro own in the picture on the right hand side. So with us. So if we just do our last case, 18 year old woman presents to you with a six month history of lethargy and weight loss, she reports know PR bleeding, no history of menorrhagia. She eats a variety of diets, but has been complaining off low appetite's. Um yeah. And then have a look at the examination findings on D. I'm just gonna re launch the hole right now. Thanks. Just another 10 seconds. So some more if you can put in the boat. Yeah. Okay. So more than half of your voters I'm gonna end it right there. I'm just trying to results. Okay, So got quite a ninty sting. Spread off results. I'm just going to go through it I think is a tricky one because it's not quite obvious what's going on. Um, but so but just before I give it away compete, we'll just right in the chat. What do you think the patient has? Um, so I could just gauge um, So if you guys have reached a conclusion off that what the bag nose is actually is So Mariane has said, Is it celiac? Um, yeah. So that's absolutely right. So essentially, um, just with celiac disease symptoms are very non specific eso things like left like you weight loss, low appetite, the's a Larry, very non specific things. The only thing that kind off has given this away is that on exposure. So on examination of the abdomen patient, it's slightly blow said. And also there is visit color rash on the extensive surface off the elbows. So in celiac disease known as, um, dermatitis, a pattern for Ms yes dermatitis a pet for Ms Essentially is, um, a autoimmune phenomenon has, like, the name has happy is in there. But the reason why it's called us, it's got nothing to do with happiest person A but because the, uh, appearance off the rash resembles that off herpes. Therefore, it derived its name from that on in terms off the actual correct answer, it's actually normal cytic anemia. The reason being was celiac disease. You can get a combination off. I'm deficiency anemia on beetle from Foley. Uh, and the, uh, yet deep be tarred folate deficiency. Anemia. So mean salve All, um, a Z we mentioned earlier. So essentially, that's a, um That only gives you an average cell size off the red cell samples that you've analyzed. So with iron deficiency anemia, you get a microcytic anemia. Where's B 12 and folate? You get a macrocytic anemia. However, when that's mixed in with the, uh when all that all of that sells a mixed in on the sample on the blood film, it gives you the kind of average out. And that should give you a normocytic anemia on gum. Essentially, um, yeah, celiac disease, a auto immune response to the gluten in our food on. Then there are some blood tests that you can do the anti t t um, G antibodies. So that's the most sensitive. However, because, um, tissue transglutaminase antibody is a i g a antibody where somebody they can have a congenital IGA deficiency So if you measure that antibodies were important to also measure, um, the level off i g a the person has because it can only be in temperate is if the person does not have IGA deficiency on, uh, the antiendomisio antibodies. Essentially, that is, um ah, component off the intestinal cell war Lining on you can develop antibodies to that Teo develop a malabsorption on degrading antibodies. Essentially, gliding is a component off through it in itself. So you could also develop antibodies to that onda the most. Yet the gold standard test in this case would be to do a ODT and do a biopsy off the duodenum on normally within a healthy, um, duodenum, you'll see pictures on the left where there's very tourbillon, whereas in celiac, uh, you can see a villous atrophy due to the antibodies attacking the intestinal surface on because that's going out throughout the small bowel. Therefore, you can have malabsorption to various nutrients in yet in the food. So that's why uh, you know, in this case is a normocytic anemia. So I think that is the end of our tutorial. Uh, we'll put the feedback link on the on the chat again on day. Happy to answer any questions. Bit sad that I missed this. No, you had him. You had lives the same. Well, when you say you're sorry Hot, there's a hypertensive urgency, Some wood BP. 242. It's like check the BP or for 50 just before about to leave. And then it was 200 fate. And it's like I can't even now. No, it's too urgent. Hand over the little thing. I could be like you guys take off. Uh, I'm still said that I missed it, but it sounds like it was really good teaching of when you come to the end of it. That's why you joined halfway through your getting lots of thanks. Oh, yeah. Thank you guys any any anything? Nice chance. I don't know what the uh, sorry. I'll drug a bit of a blank. I bend a little bit. Knock it. Um, I'm trying to think of any jumps I can think of. Um uh, no, not the minute. Sorry. I'm drawing a blank essay, but, uh, i'll have I'll be teaching tomorrow. Anyways. I'm going to be covering crossing abnormalities anyway. So doesn't sort of be some overlap with some of the stuff that there'll be some overlap with. Some of the stuff is probably talk today in regards to anemia as well, so we'll definitely safer stuff for them. But sorry to have any gyms in a minute. I ended up running back because there's no bus sixes, so I have absolutely tired. Um, flying. Let me push the feedback link up more, more time. Um, bump, bump, bump. Oh, thanks. Good. That's that's quite high. It's quite high, Ray, you're getting that. Really, uh, there was really enjoyed that. Brilliant. Yeah, content will post it up on the medal pages as usual. So please join these makes you make a model account because that's where you get all your certificate stored. We post all of our videos and all of our catch up content is what it's called on metal. So make sure that when you complete the feedback, you request catch up content. Because the moment that all the feedback is completed is when we post up the slides as well as the video on, then that allows you to access the content that we have, essentially. So please make sure to do that. So, yesterday, content from the abdominal X ray stuff will be posted up today on, uh, tomorrow. Where? How? Post up a lot of lily stuff that she's done in terms of the anemia and the video as well. I hope that make sense, guys. I get some rest. I say I will. I will. I promise. Level, Brennan. Um, any last minute questions for really? Oh, okay. Probably don't be. And also the question so lately? No, I think, Yeah, There's not many questions today, so yeah, I'm just gonna ask you might explain. I think you have. I think you have. Um actually, I guess there's one thing that I can think about. War lost. Just one quick. Maybe jumping like a drop. Um uh was going to say, uh, just I think the one thing that I can drop, I guess, treatment from Look, I get a going to, uh it's not too much, but you can't. You call it in the pencil. What? It gets a bit complicated depends on what the complications of it and what's caused it. How quickly you drop the BP. There's only certain situations. We really quickly when I drop the BP like an aortic, their section Or, you know, say, if someone's got a skin nick on a scheme extract, you have to quite quickly dropped the BP and you typically use, you know, the skin extraction typically use things like ice a cap, which is like intravenous nitrate too quickly. Drop the BP to roughly about 1 50 or something like that. But it depends on the course, and this person just had hypertension. But they didn't have any end organ damage yet on didn't have any particular course of his A C s or anything else that I can think of. So you want to lower the BP within 10 to 15 10 to 20% in the first hour and then about another 5 to 10 to 5% C, lowering a very slowly and you continue the start with a low for a P, things like amlodipine or other sort of or BP agents. And if that doesn't work, you can think of intravenous stuff, so I'll leave that at that, but it can get quite complex. We need to make sure is no end organ damage. I, you know, have they got, you know, hypertensive retinopathy? Have they got a particular kidneys? Have they got protein urea on, You know, increased risk of strokes and heart attacks because of how high the BP is and anything above 1 80 should particularly where you anything above 200. So you're ready? Raise your eyebrows on. Depends on what the underlying cause of it is. And, you know, make sure that they don't have secondary causes of hypertension, if that's what's raised that. So you know, things like renal artery stenosis is most common. I progesterone is, um, you know, feel crisscross Saitama and young people, Generally speaking, stuff like that, I'll leave it at that. Um, yeah, that that's pretty. It only brother. Just remember that limber city axis associated with lymphoma. You can get a type of lymphoma with a T cell lymphoma. Let's do anything I'm going to say about it, and that's it. I think we'll send it there. Thanks a lot. Really. Uh, please complete the feedback because, like I said, the feedbacks, How you know how, you know, sort of. It's kind of it's kind of the way that we get paid. Our feedback is how is how you know we look at how we improve our stuff and allows us to, you know, look at what we can do better on, uh, boost off our portfolios That sent you some feedback of you much appreciate guys, make sure to fill out feedback for Linea much as you can. A mixture of her Watch the video down on the content. Please join our Instagram's Facebook on Twitter Page is please tell your friends about us any you know, the first year spread the word, the more people will get watching videos. Like I said, we keep in the content free, but we need a sponsorship for the and the more people we get, the more sponsorship we can get. Simple as that, uh, francs a lot, guys. And hope to see tomorrow six PM Anything from usually? No, it goes. You covered it all very quickly. Talk fast as usual. All right, We'll leave it at that. As of said, we're posted abdominal x ray content today in terms of the slides and the video and the content for today stuff will be posted up tomorrow on please request Catch up content on medication on the feet back page that you can seen when we post things up. Just guys. Thanks a lady by