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Yeah. Hello everyone. Welcome back to the year four Academy Provision tutorials, which is a week long series that covers all the specialties relevant to the Edinburgh medical school curriculum, recovering rheumatology and a Crime and Renal today. And we're very lucky to be joined by Dan, 1/5 year medical student over to you, Dan. Okay. Hi guys. So today we're gonna be covering these three topics. It's not really going to be like a comprehensive guide through any of them. It's just gonna be a few questions on each topic, hopefully as an adjunct to the learning you've already done. Okay. So let's get started done. So, first of all, in rheumatology, you have a question here just going to try and get the pole up, right? Does that poll come up for everyone? Yes. So I'll just give you about half a minute for each of these so we can just plow through them. So it's more important to kind of talk through the answer than to just sit here for a while. Okay. Uh Okay. So is everyone okay. So, uh okay. So it's split between heliotrope brush hypertension. Uh So kind of going for a heliotrope brush. That's um so the question is kind of two part, the disease you have to identify is rheumatoid arthritis. So symmetrical poly arthritis of the small joints. Um and heliotrope brash is one of the pathognomonic signs for dermatomyositis. Uh all the other kind of things you can get with rheumatoid arthritis. So, keratoconjunctivitis, you know, I information um the cervical cord compressions because the inflammation causes uh weakening of the ligament across the dens. Um So you can get atlanto actual subluxation. Cardiovascular disease is a major kind of thing in all the inflammatory conditions and Felty syndrome. That's like a triad of rheumatoid arthritis, splenomegaly and neutropenia. Uh you know, probably, probably not something you're gonna be asked on, but worth worth knowing anyway. Um Okie Dokie. So a Heliotrope brush. That was that one. Uh And these are just some photos of some of the things you might see in inflammatory conditions. So top left, you can see the heliotrope brush, I think. So, that's kind of reddish, purplish discoloration of the eyelids. Um You can see some pitting of the nails, maybe some monocle isis, so you can get, you know, your nail nail changes. Um It's a, it's a really kind of poly um multi organ um disease, all of these rooms, you know, rheumatological things. Uh knee swelling, top, right, I think is erythema nodosa. Um that's an inflammatory conditions um and some kind of rash in the bottom, right? Um So Yeah, rheumatoid arthritis, inflammatory condition, symmetrical small joints. Uh One of the things you can use is the bass score. So, disease activity school. Um and I think, I think that that's 28 is the one they like to use. Um Basically, it just takes into account a lot of these things you see this table in the bottom, right? So number of joints affected. Yes, our CRP duration of symptoms uh and CCP. So CCP is quite a specific marker for rheumatoid arthritis. Yes. Our CRP are just kind of general inflammatory markers. They're not specific rheumatoid factor. Again, it's not really specific is raised in a lot of things even when you die of the disease. So CCP is quite specific. That's why it's given quite high school um hand deformities. You might not see so often these days because of improvements in treatments. But you know, Britannia, you know, when your finger kind of goes like that uh swan neck the other way like that said thumb and I wanna deviation. I'm sure sure, you know, they are okay. So it's got into the second question. I cannot give you about 30 seconds. That's fine. Okay. So yeah, most people are sort of going for the right answer there. Retinopathy. I suppose this question kind of highlights as well what the side effects of methotrexate actually are. So uh shortness of breath, why is that? Because methotrexate has toxicity in the lungs? Um It can cause lung fibrosis. It can also cause a hypersensitivity, pneumonitis reaction. So that's the kind of acute thing where patient's will present with shortness of breath. And if they've started taking methotrexate and they present with shortness of breath, you need to stop the therapy, we need to, you know, you need to tell them to stop the therapy and seek advice from rheumatologists. Um So that's not something you should continue with. Um methotrexate can also cause gi upset. Um So methotrexate is actually a like a chemotherapy drug in cancer as well. So it targets cells that divide quite a lot. And if you think of that kind of principle, it makes sense, it causes symptoms in the gi system. G eye cells have a high proliferation rate, hair loss as well. Your hair is always dividing. Um So, if you think about it in that way, it's also an immunosuppressant. Um So it's kind of logical that neutropenic sepsis would be something um you know, something it's associated with or it can cause. Um So the answer is the retinopathy. Um and that's a side effect of another dimard hydroxychloroquine um where visual acuity um monitoring required. Um Also another thing because it's a folate and I, I think it, you know, prevents you from making folate. Um You want to be careful or you don't really want to, you don't want to have it. You don't want to be treating someone with methotrexate while they're on trimethoprim or sulfonamides because they also, um, have a similar mechanism of Axion. It will just kind of add up. Right. So let's go into the next one. Um, and if anyone has any questions, feel free to kind of put, put a question in the, in the chat box, which are my best. I'm not an expert on any of these, but right next poll, then, so if the patient experiences shortness of breath, you'd advise him to stop and seek advice. So stop the methotrexate and seek advice from a rheumatologist, I think. Yeah. Um I think in terms of the others mouth ulcers like nutramine except this isn't, is an emergency. So they would need to be seen immediately for that. Um I'm not sure about the others. I would, I would say you probably uh advise them to seek advice from rheumatology, but definitely the shortness of breath one you can except this one. There's a kind of red flags. Okay. So this one, yeah. So everyone's generally gone for the right thing for blood count LFTs using these. Uh So yeah, um it can cause raised liver enzymes. So A L T uh if the LT goes above 100 from what I've read, you need to stop that for two weeks and check, but probably vary depending on the patient and the doctor. So I can raise your liver enzymes basically. So you need to monitor them. Uh and it can also reduce your renal function, which is why you need to monitor your using these. Okay. So it's a toxic drug. It's gonna do, you know, it's gonna probably impact some of your other systems. Um And then full blood count because it can cause thrombocytopenia. So, platelets and leukocytes opinion neutropenia again because it targets immune system and uh cells that divide quickly and bone marrow cells divide quickly. So dumb odds. Yeah. Methotrexate, leflunomide, mycophenolate. They're all contraindicated in pregnancy. I think that's because they're teratogenic. So, if you're a woman of childbearing age, you need to be on good contraception while you're taking these. Um or if you're planning a pregnancy, you need to come off these. Um because they're teratogenic methotrexate michael Fennelly, you need to stop three months before getting pregnant. Leflunomide. You need to stop two years before getting pregnant. Um And I think for the other D mods, aside from these generally fine, but though, you know, a risk assessment will be taken with the rheumatological team, um, vaccinations killed vaccine safe because their immune systems dampened. Um live vaccines are contraindicated. So that's, you know, that's quite intuitive, I suppose. Um And then the auto antibodies. So at some point, you probably just kind of have to learn these. Um So as well as we come across CCP for rheumatoid arthritis, uh I'd say also learn anti Rohan laugh or share grins. Um So these are kind of quite easy questions I can ask you in the exam, um, as well. So it doesn't really take that long to Sloan. Um A and A, I don't, I don't think that's actually super specific for S L A. Like a more specific one for lupus is the anti D N A, I think. Um, and then, yeah, the different ones for the limited and diffuse cutaneous systemic sclerosis. So it's just something that can quite easily ask you ones are worth going over. Okay. Next poll. So that was a bit to read there. So give you like 10 more seconds. Okay. Okay. So see there's a bit of a split here between all of them, apart from alcohol. Okay. So the answer is for as mine uh So jobs that can cause gout there's a monarch called fact. So for us, my Aspirin um cytotoxic six and Thiazide diuretics. Wait, which one is least responsible? So that would be Metformin? Um Yeah, so we've got, for his mind, we've got bendroflumethiazide. That's the thiazide alcohol. So the a stands for aspirin slash alcohol. I'm a aspirin. So the answer's Metformin. Cool. Uh So I, I suppose why would that be? Probably because if you're dehydrating them or something to do with the electrolytes. Um I don't really know. Um But yeah, fact F A C K F A C T froze mine Aspirin to have to talk to exercise sides. Um Right next one. So the most appropriate initial management is the same stem, right OK. So most people have gone for cultures seen, some people have gone for diclofenac. Uh So I think usually cultures in and N nsaids are both good options. I think this question is getting at the fact that this man is a past history of peptic ulcer disease um which apparently is um contra indication. So, yeah, I think the answer is diclofenac. Um Oh wait, no, I think it's culture seen. Yeah. So yeah, nsaids, nsaids are contraindicated with peptic ulcer disease. So yeah, cultures seen and it's also low dose cultures in specifically um because it's quite toxic for the gi system can cause like diarrhea and colic. Uh So our piano is, yeah. Um It's a preventer basically, it's not, it's not using the acute management. So then a fill okay. Viagra is used in systemic sclerosis. And four boxes start is another xanthine oxidase, xanthine oxidase inhibitor. So same mechanism of action is that appear in all. Um So you're not used in the initial management. So yeah, and Satan cultures in and say it's contraindicated because of peptic ulcer disease. So cultures in uh long term urate therapy. So I think for boxes uh um it's so it's more expensive than al appear, know, it's more effective than our LaPierre know, but it's um I think it would be kind of a second line thing. It's not recommended in cardiovascular disease. Um Yeah. So I think I think it's just more expensive to be honest. Um If you, if you're not getting, if you're not getting enough control without a Pyrinyl, you might go for it as like a second line preventer. That's what I would say. Um So in terms of gout pseudogout, this is another really easy thing that can ask you on shit. Um So the different, the different ways they look under the microscope, gout needle, like natively birefringent pseudogout rhomboid crystals positively by reference agent. Um And it also really helps you to differentiate them like in a, in a question. Um because obviously they present pretty similar. Uh So that's the main thing just to get those. All right, next question. Uh Okay. So it's pretty split in the poll. Um Kind of everyone going for everything. So I think the answer is cerebral berry aneurysms. Uh And that's because that's seen in polycystic kidneys. Um But the rest of them I think are associated with the diagnosis. So what's the diagnosis? Um and closing spondylitis? So, it's a young man that's generally the demographic. It kind of presents in it's got some pain in the back of his heels. So some achilles and society, this uh gradual onset low back pain, worse at night, morning stiffness. So, inflammatory back disease, young man, probably ankylosing spondylitis. Um So there's kind of six days of things which are associated um Atlanto axial subluxation. So it's similar to rheumatoid arthritis, anterior uveitis. So again, Isis's um app pickle long fibrosis So at the apex of the long top of the lung, aortic regurgitation, amyloidosis uh that can cause nephrotic syndrome, um and autoimmune inflammatory bowel disease. So, yeah, again, a lot of these, a lot of these inflammatory joint disease is um effect a lot of the different systems. So the lungs, particularly the heart, the eyes. Um and as you know, as part of your rheumatological screen, you should probably be asking about a lot, a lot of things, hair loss, mouth, ulcers, general fever, malaise rash is. Um So there's a lot, there's a lot of things for a lot of these. I think the main takeaways, I think that's one of the main takeaways for this question. And cerebral berry aneurysms are polycystic kidney to these. Okay. So next question. Yeah. Okay. So it's going between methotrexate and hip replacement in the poll. So the answer is actually the methotrexate. Um And why is that? Because uh methotrexate doesn't really have an effect on the spine. Um It's only really used if the patient also has um other joints and what like, you know, small joint involvement as well, that's causing them a lot of problems. It doesn't really have much effect on the back. Um So in terms of management, there's kind of a similar kind of principle of management as I'm sure you've gathered for a lot of the conditions. So conservative things like exercises, physio, you never not going to do that. That's, that's always gonna be done probably. Um and then stepping up to NSAID. So naproxen, um you know, most of these diseases respond to NSAID, um steroids for flares in uh in some of them dimard. So methotrexate, not, not really in this case, but in a lot of the others um biologics. And then eventually, if things get bad enough, you might consider doing surgery. So if, if this patient was getting a lot of inflammation in his hip, he was getting a lot of erosion of the bone. Um it might be worth going to surgery and getting a hip replacement. Um I guess this can also cause problems further down the line. If they're young, you give them a hip replacement, it's gonna have to be replaced at some point again, revised. Um But yeah, some of the things to consider. So the spondyloarthropathies, what can we say about these? So, yeah, there's ankylosing spondylitis, that's an actual spondylitis. So it affects the back. Um And you can, you know, you might not get any radiographic changes initially in early disease, but eventually you'll get kind of squaring of the vertebrae on the X ray, you get kind of bony connections between the vertebrae. So that kind of leads to really stiff back, whether they, they won't really be able to bend it at all. Uh It's called like a bamboo spine because it's just so straight. Uh um What else do you have? You have enteric arthropathy Um So that's kind of associated with IBD celiac disease, whipple's disease. Uh If you treat the bowel problem, the arthropathy often improves because it's all due to this inflammation, psoriatic arthritis. So that's another kind of important association you should know. So, psoriasis, skin condition where you get these plaques all over your skin. Um and it's often associated with quite bad arthritis and nail changes and uh cardiovascular disease, proactive arthritis. So, yeah, usually in response to a an infection um particularly S T I S in young men, which I think we're gonna come onto in a little bit. Um Right. So let's move on. But yeah, okay. So most people have gone for a oxygen. So that's what you shouldn't really be doing or there's no point in doing it, which is correct. So, um if you've identified this as joint tell arthritis, you'd be right. So, headaches, stiffness. Um Yeah. So um yeah, so this is g see a um this is commonly associated with polymyalgia, rheumatica, which is another inflammatory disease. Um There's a theory that they're kind of a continuum part of the same disorder. Uh So, yeah, what you usually get these headaches uh get scalp tenderness, jaw, claudications. So, pain on cheering. Um you can often get visual disturbance as well. It's called amaurosis. Few gaps. Um kind of a transient, darkening of your vision as well as all the kind of usual systemic room symptoms like fever, malaise weight loss fatigue. Um, so you want to take blood for ESR and CRP just to show that there's some information, um, prednisoLONE. So high dose steroids, that's, that's the kind of the main management of it, high dose steroids. And you're gonna want to continue that for a while. Um, high dose for quite a while and then eventually lowering the dose, tapering it off, tapering it off as you go along. Um, but yeah, starting high dose steroids, important and your e reduced over time. Um So investigations, you know, you can do as well as the ESR and CRP but they're not very specific. Um So you can do temporal temporal artery biopsy. Um But this is also quite tricky because there are skip lesions. So not all of your temporal artery. Um it's going to come back positive so it can kind of go in bits. So and a negative result doesn't rule out basically. Um And if it's clinically suspicious, then you know, you shouldn't really delay steroids. But yeah, that's quite an easy one to identify and it's asked about quite often right. Next poll. Yeah. So this one's I'd say this, this one is fairly easy. So everyone's gone for the right answer. Subclavian still. So all the others were kind of touched on already. So elevated ESR yeah, just information, jaw claudications in polymyalgia, rhuematica, it's associated with that disease, blindness. Um to have mentioned the amorous is few gaps. The temporary vision loss um can actually go into full blindness. So that's why it's quite urgently treat it. Uh So Subclavian is still, that's associated with tacky ass is arthritis. Um So that's kind of the blood, the blood kind of goes the wrong way in your vertebral arteries, I think. So it go, it goes up one way and then it goes retrograde lee, down the other. Um But you probably don't need to know that I didn't know that. Um until recently. Um Right. So kind of touched on this one, one of the previous slides. So if you're listening, hopefully you'll get it. Yeah. Okay. So, yeah, this is reactive arthritis. Um So young man going to mbatha uh wonder what he's done there. Um So yeah. Um was it reacting to an infection? What kind of infection? And ST I um So yeah, we discussed as one of the other ones. Um So chronic chlamydia is actually a really common cause of reactive arthritis. Um So it's sexually acquired reactive arthritis. Um And it's usually seen in men as it's often a chlamydia, a symptomatic in women a lot of the time. So, uh that's why it's common eight young men. Uh There's a thing called Writers Disease, which is a triad of chlamydia. Well, your arthritis, conjunctivitis and rheumatoid arthritis and I think you need to know that it's just a bit of trivia. Um And yeah, it won't, it won't really be like a classical rheumatoid arthritis presentation. So it'll be like an asymmetrical oligo arthritis. Um And yeah, your level, the systemic um features as well. Okay. So next question. Um Okay. So yeah, most people have got it right. It's hydrALAZINE. Uh So the disease here is lupus. So photosensitive, rash, arthralgia, um anti materia because lupus affects the kidneys as well. Uh So there's a pneumonic for drug induced lupus ship. Um I don't know if that's what you guys are using. So s self, one of my h hydrALAZINE, I ison eyes it P Finito in other p procainamide. Um I suppose it's just, yeah, one of those things it's good to learn. Um Yes. So hydrALAZINE is a BP medication as well as most of the others. So, okay, Lupus multi system disorder um as they all are. So, um yeah, the systemic features as I've already talked about for a lot of them, malaise fever, fatigue, you can get weight loss as well. Um might be drug induced could be relapse, remitting. Um And you know, the kind of key features are the photosensitive rash and the nephritis. So you can also get kind of emergency, rapidly progressive um nephritis with lupus as well. Um And yeah, alopecia, ray nodes, oral ulcers, mail or rash. So I'd say if you're practicing or skis practice doing like a top to toe screen of all of these symptoms. So, starting from the hair, hair loss, eyes, inflammation in the eyes, um or allows is um and yeah, so treatment of it quite similar to all the others. So dumb odds steroids. So let's go into endocrinology then. Yeah. Okay. So this, this drug, this, this question is pretty tricky. And I can like, so it's basically being split between carbimazole and propranolol. I can understand like, I mean, you know, there is an argument as to why you should go with carbimazole because it's uh an eye dean. Uh Well, it's a treatment for this disease. So, okay. So the disease is hypothyroidism. Um So weight loss, sweat Storia um tachycardia, she's got a history of autoimmune disease. So that predisposes her too, something like hashimoto's or um so yeah, so I think the main thing is kind of control of the symptoms is talking about a tachycardia and the propanolol kind of gets on top of that and the kind of arrhythmia as well. Well, I mean, obviously, eventually Cobham is all by lowering thyroxine is gonna improve your symptoms. Um So yeah, I mean, I'd say both are right, but just in different ways. So propanolol something they used to get on top of that tachycardia and arrhythmia. Um Right next one to go. Mm. Okay. So um poles a bit split right now. So the answer's carbimazole. Um okay. Yeah, most people looking for carbimazole. Um So what she, she's presenting with neutropenia, raise inflammatory markers, temperature fever. Um So it's, it's looking a bit like a neutropenic sepsis So which one of these can cause neutropenic sepsis. That's a side effect of cop in song. So it can cause agranulocytosis iss of the neutrophils. So, you know, when you're, when you're, when you're giving them condoms or you want to kind of uh warm, warm them about the safety net. Um If you have any fevers, if you have any symptoms of infection coming immediately because it's a bit of a bit of an emergency. So you should warn them about stopping it if they notice any of these symptoms uh to come in and get assessed ASAP. So, hypothyroidism. Um So yeah, there are several causes of it. It's graves that autoimmune one toxic multinodular goiter to toxic adenoma that's reactive thyroid itis, so darker veins, thyroid itis. Um and that's when the thyroid I think basically just releases all the thyroxine. Um you know, reacting to like an illness or something. Uh and also just having too much levothyroxine. So it can be a tra genic as well. Um And yeah, so thyroid, thyroxin is basically kind of reflection with, you know, controls your metabolism. So high thyroxine, you metabolism's goes up, levothyroxine, Hugh metabolism goes down. Um I think one of the one of the good things to learn with thyroid things is the subclinical hyper and hypothyroidism. That's something they're quite like to ask you about. Um So when the thyroxine is actually in the normal range, but the TSH um shows that something is a bit up. Uh So that, that's something that's quite useful uh to learn about. Oh, and also the scans, I mean, uh fairly obvious to just look at them, you know, toxic adenoma, one thing, multi nodular multiple modules. Oh, okay. Next poll. Um, yeah, I guess everyone's coming for the right answer. Hashimoto's so, yeah, there's no indication that you had a thyroidectomy. There's no kind of past medical history indicating lithium therapy, uh primary a trophic hypothyroidism. Um um that's not the right answer. So, e I dean deficiency. So she's British and that's, I mean, that's kind of a problem in um other countries, not really in Britain. Um So yeah, Hashimoto's disease is the right answer right next one. And just for the previous question. So you get, you get a goiter in Hashimoto's because there's kind of a pooling of lymphocytes and plasma cells in the thyroid gland. Um And then with the a trophic hypothyroidism, you don't get goiter because it's a trophic. So that kind of makes sense. Um Also just to note hypothyroidism is associated with carpal tunnel syndrome, which is why she had the symptoms in her wrist at night. Okay. So, yeah, everyone's going to paracetamol here. Um Yeah, I think that's right. So, um things like PPI S um iron kind of story. Main Barracks Von. They'll um yeah, interfere with thyroxine absorption. Uh anything that contains magnesium or aluminium as well, calcium carbonate foods like walnuts grapefruit juice as well. But yeah, parasite miles usually fine for everything, isn't it? Uh okay. So this is so a young man coming in with abdominal pain, vomiting and a really high glucose. Uh So it's a pretty band or presentation of type one diabetes. Um And furthermore, suggesting keto acidosis as well. Um So diabetes, diabetic ketoacidosis, diabetes. So glucose, urine dipstick for glucose, you already done A BM. So um ketones. So ketones in the urine dipstick acidosis seen on the A B G. So the urine dipstick and A B G. So the short acting test is for like Addison's. Um And yeah, so A and B you need them together, don't you? So yeah, the answer is a so same stem. These are sick, day, sick day rules referring to stick their rules. Yeah. Okay. Okay. So yeah, most people have got the right answer. Um which is B so you either, so reduce insulin or increase insulin. So you're in your insulin requirements often increased during illness. Um So these are the kinds of things you want to say. Um two patient's for they're sick, their rules and they often get like a leaflet and like a kind of plan for this as well. So high calories um increase insulin does. Uh that'll be kind of carefully worked out. Obviously, you go to the hospital if you're dehydrated and vomiting. Um and you regularly check your glucose uh inject the catering area. So, yeah, insulin requirements increase on sick days. Okay. So, driving rules. Okay. So, yeah, there's a bit of split. This is an awfully specific question on the requirements on driving requirements. Um, so which of the following is not relevant to this patient? So it's actually see. Um, so let's go through that. So a he must inform the D A D V L A. Yes. Any changes to his conditional treatment which might affect his ability to drive should be reported. Yes. Well, see, that's relevant. Um, d so he needs to check his blood glucose before, um, and every two hours. Yeah, his blood glucose is less than four. Then, you know, he's probably at risk of a hypo. Um, so that's kind of logical. We shouldn't drive. So, see, I think it's, it's see, because that's true of like, um, drivers who drive like lorries and heavy vehicles. Um, obviously because those are more dangerous. So they would need to monitor them regularly, uh, and store them. Yeah, this is a really specific question. You, you probably won't be asked on this. So, in terms of actually diagnosing diabetes. Um, so, yeah, it's either your symptomatic and you have one blood reading of hypoglycemia or you're a symptomatic and you have to, um, so readings on two occasions. So fasting above seven random blood glucose above 11.1. Um, actually the kind of, one of the best ways to test, um, glucose tolerance. Well, yeah, one of the best ways to actually test insulin. Um, is the oral glucose tolerance test. So you give them a slug of insulin, uh, slug of glucose and see if they can lower it with their insulin. So obviously, if they're deficient in insulin type one diabetes, they're not going to lower the blood glucose. Um, but also, in fact, two diabetes because they have a relative, um, you know, it's, it's a, it's a relative insulin black because their insulin is not working on the tissues because they become resistant. So type one diabetes usually young people. Um but it can be at any age. Um you know, uh what's her name? Prime Minister had it got, it was diagnosed. Um So L A D A that's latent autoimmune diabetes of adults. So that's kind of like a variant of type one diabetes. It's um it's type one diabetes but with a slower progression to insulin dependence. Um So it's, it often presents with features of the metabolic syndrome similar to type two diabetes. But retrospectively they see that they progress to insulin dependence faster than expected. So yeah, so um it looks like type two diabetes but it progresses to insulin dependence faster. Um, you know, anything you need to know much more about that. Um So yeah, it's obviously an autoimmune destruction of the pancreatic bead cells. So they stop producing insulin, you know, an absolute insulin deficiency features. So the water ones, polydipsia, you'll be peeing a lot, no polydipsia, you'll be drinking a lot, polyuria, you'll be peeing a lot. Um and they often also, especially, um especially in the past these to present with really kind of faltering growth um and weight loss. Um Yeah, D K s obviously the emergency you need to know about and then types of treatment they get with the insulin. So the basal bolus regimes, so longer acting, base and shorter acting things like never rapid or act rapid for um you know, kind of after make perform meals. Yeah. Um And this is, this is really kind of individualized for each patient. Um And it's something that really kind of changes the way they live their life. Um So it's all kind of about working out what they're eating, how they're going to balance that with their insulin. You know, there's all these kind of calculations they need to take into account all the time. Um So, yeah, yeah, okay. So, yeah, most people are gone for the right answer here. Glycoside. Um So that's a sulfonylurea. So what do we want to move on to that? So he's not getting adequate glycemic control. His HBA one C is at 56. Um and he's already on Metformin. So the next kind of step up is to have a self Nigeria. Um Of course, self know areas are associated with a higher um with higher hypo rate, aren't they? Um insulin? You kind of want to wait. Um until later on to start that. Um, same with Glitazones. I think you want to wait a bit longer. Um, so often I, so often now you're, is next on the kind of treatment ladder. I've kind of given away the answer with this one. Yeah. Um, so I think a fair few of them are associated with weight gain self in all your ears are associated with weight gain. Um, I'm not 100%. I think insulin is also associated perhaps with weight gain. Uh I think Metformin is actually quite good for weight loss. Um And I'm not 100% sure, but I think the GLP analogs are also pretty good for weight loss as well. But yeah, definitely. So for now you raise the main one I'd say. Um I think, I think it's just because like the next kind of step up on the treatment ladder is like a sulfonylurea. Um And do you want a lot of it will probably depend on the doctor as well. Um And the kind of context of the patient, but I think generally like the general format start with Metformin, move onto sulfonylurea and then consider other things. I mean, it depends on a lot of things as well. Like some of them have contra indications. Um We'll go into that a little bit um in a couple of questions time. So is it after for med, then you add insulin? Um I'm not actually 100% sure. You probably know that better than I do. But insulin is always the kind of, you know, last, last kind of thing. Um. Right. Ok. So everyone, everyone's going for hyperglycemia. Yeah, that's right. Okay. So, yeah, type two diabetes. Um, it's kind of associated with this cluster of symptoms, um, like that, that circulate around insulin resistance. So, the metabolic syndrome, insulin resistance, type two diabetes, cardiac disease and hyper lipidemia. Um, and it's associated with like p course as well. Um And important to note that some ethnicities. So like South Asians are more susceptible to type two diabetes. So when you, when you calculate their B M I, you need to take that into account. Um So I think um yeah, so it kind of happens, it happens at lower BMS in some ethnicities. Um and it's because you're getting, you're getting a lot. So initially you'll get a lot more insulin production to kind of counteract the resistance you're getting. So initially you have high insulin. Um and then eventually what happens is you kind of decompensate. So it no longer, even though you're producing lots of insulin, it won't do the job anymore or you'll start to produce less insulin. Um or it could be a mixed picture of you producing less insulin and it also having resistance. So um yeah, it's quite complicated. Um and it actually can be reversible. So a lot of these patient's are quite overweight or obese if they actually lose weight, they can reverse this. Um, so, you know, you can't, you can't control it with, with these medications. But ultimately, the best way to do is just to lose a lot of weight in a lot of the patient's. And yeah, so we mentioned there's Metformin the soft, now your ears, there's the Glitazones DPP four inhibitors. There's also G L P analog SGLT two inhibitors. So that those work in the kidneys, I think um in the Nephron um derived from apple tree bark. Uh and then at the end of it, you know, insulins, you kind of last, last resort. Um Yeah, and um one of the like the kind of counter part D K S the H H S so hyperosmolar hypoglycemic state. Um And so that, that, that represents without ketosis, I think, but they'll often be very dehydrated. So they'll often be in kind of older people will be peeing a lot. Um So they have pyorrhea, polydipsia of really high glucose. Um they'll be really dehydrated. But I think one of the important things in management is you don't reverse it too quickly. You need to be careful and slowly reverse the dehydration and the hypoglycemia and type two diabetes is seen quite a lot in younger people now because obesity that's good. So, yeah, so I think you, you obviously don't really need to remember this like this, but it just goes to show that there's lots of different kind of indications for treatments. So uh like if they have heart disease, um all kind of kidney disease that kind of rules out some if cost is a major issue. Um if weight loss you need weight loss. So GLP ones are pretty good for weight loss. Um So basically that, that, you know, there's a lot of ways of doing it. Um and it kind of depends on the patient, right? So next case. Okay. Yeah. So everyone's, everyone's going for the right answer here. So this is Addison's disease. So patient has lost weight. He's got fatigue, episodes of dizziness, low BP, hyper pigmentation. Um So, one of the key things here is to look at the bloods. So he's got high potassium, low sodium. Uh and that's, that's like a pattern you should kind of recognize on the bloods. So why is that because Addison's disease, autoimmune attack of the adrenals, the adrenals produced out of stare own out of steroid. If you don't have aldosterone, you're gonna get low sodium and high potassium. Uh also um the postural hypertension. Um I think that's because of Glucocorticoid deficiency. I'm not 100% sure though. Um Also the pigmentation on the skin. That's because because of the negative feedback, you're getting increased ACTH production um from the pituitary and that has an effect on milana sites. So you get increased pigmentation, which is why sometimes patient's can appear like orange. Um So yeah, the, the answer is the shorts and action test. And this is because that tests whether the adrenals are actually working. So what Xanax then is, is synthetic H th so you're giving them a C T H to see if the adrenals react. Um So if you get a positive test showing that the adrenals work, um wait, I don't know if that's positive or like, so basically, if they don't, if they don't respond to the ACTH, you know, it's a problem with the adrenals, not a problem with the pituitary. Um So the answer is d shorter acting test. Um What are the other ones? Yeah, the other ones are all right. Okay. So next, same stem. Yeah. Yeah. What's the cause of the hypoglycemia? So uh the hypercalcemia and the high area? Um Why is that? I'm not actually sure why, why the calcium is high. Um But I'd say that's like the most, the most important thing really is to know the sodium and potassium like cause and also that makes the most sense if you think about how to steer own. Um It's a good question. I'm not, I'm not 100% sure about the calcium. Um The arena is not really that high. I don't know, it might have just been the inauguration. He's a bit hypertensive, so, hypertension maybe cause a slight rise in your ear. Kidneys. Ongole refused. Um Right. OK. So yeah, everyone's gone for the right answer here. So, autoimmune attack of the adrenals, you know, producing um you know, producing the hormones. So you want to replace them, you want to replace it with flu, your cortisone uh in place of the aldosterone hydrocortisone, in place of the cortisol. Okay. So that, that kind of makes sense. Um So Addison's disease have already kind of touched on primary adrenal insufficiency. That's what you're testing for with this inaction test. 80% autoimmune. Um not really. Oh, so other causes. So actually TB is the most common cause of medicines in the world worldwide, I think. Um just because it's so widespread in other countries, uh can also be caused by HIV um metastases from cancers to the adrenal glands. Um So sometimes you forget vitiligo in autumn mean Addison's that can be another kind of sign to look out for. Uh Yeah, as we've mentioned the kind of bronze, bronze skin because of the stimulation of the Milana sites by A C T H. Um And you know, if you're, if you're lacking steroids gonna be tired, um like really tired, um you're gonna get these, you know, the dizziness from the hypertension um and a lot of mood problems as well. So, yeah, treatment you, you just want to replace them, replace the steroids for you. Okay. So we're moving on to the renal section now. Um kind of put this picture here. The Edson's person looks like and old battered Freddie Mercury, okay. Um So I put this picture here because um when you're thinking about renal is really helpful to think about the principles of the kidney and it's rolls. Um So I think these kind of five things are generally what you need to learn. So obviously, it regulates your kind of BP uh with the rash system, um influences the blood ph. So, with metabolic ankylosis and acidosis, um so what produces like the bicarbonate? Doesn't it, uh it regulates red cell production because it produces E P O. Um obviously excretion of waste products and water. Um And if that's not working, you can get build up of toxic substances. Uh and also regulation of bones because it metabolizes vitamin D. Um So the second part of vitamin D metabolism after the liver, no buttered Freddie mercury, I'm not sure. I see it. Uh Maybe it's, he's got a mustache. Yeah. Okay. So this is hypochelemia, isn't it? Um E C G changes in hypochelemia. So, yeah, I think everyone's which of the following E C G changes would not be in keeping with this presentation. So, uh the answer is b you wouldn't get large P waves. So what you initially get is the tall tenting of the T waves. So that is something you would see. Um sorry for these negative questions. But um so you would initially get the kind of tenting of the T waves that get taller. And then I kind of think of it as if the E C G is like a string. As the potassium gets higher, you're kind of pulling the string outwards from either side. So you get, you get smaller P waves, they get smaller and then also you get wider QRS complex and then eventually it becomes like a sine wave. So it just becomes kind of unraveled a bit. Um That's why I would kind of think of it. So yeah, you would see too all tinted T waves and the questions are negative, which would you not be seeing? Yeah, so sorry about that. The C G reveals tool tented T waves. Which of the following is your immediate immediate management priority? Wait. Uh oh Popo Popo. No. Yeah. Yeah. So everyone's kind of got that straight away. It's the calcium because it stabilizes the conduction in the heart. Um So that's the kind of most immediate threat the heart conduction getting a fatal arrhythmia with hypochelemia. So, first of all, you want to stabilize the heart with the calcium, then you can move on to other things. Um Right. So hypokalemia um you know, so this kind of just summarizes what I've said. Um you get mild, moderate severe. So I think from what, from what I've kind of heard with physicians that they usually say they don't really like, you know, you can, you can let it go quite high before you're actually getting, you start getting quite worried about it. So, um yeah, so first of all the calcium, that's what you need to prioritize. So, yeah, as you can see on the E C G, you get the, you get the tool tented T waves first and the P waves start to flatten and then the string starts to get kind of pulled a part of it. So you get wide curious complexes and sine waves, right? So what are some of the things you can do for it? So immediately, yep, the calcium put that in money to repeat, it doesn't actually lower the potassium in the body, but it just stabilizes the heart, which is your main priority. And then what else can you do or you can use insulin um with dextrose because that insulin moves potassium into the cells. Um I think there's some link there with hypochelemia and type one diabetes. So yeah, insulin moves potassium into the soles and you also want to give it with dextrose. But this is something they always tell you to be really careful about because there's been a lot of cases where people are given too much insulin or miscalculated. So it's really effective but you need to be careful. Uh Albuterol is also helpful and moving potassium intracellular e um and then if you actually want to get rid of the potassium in um like one good way to do is like diuretics except you know, diuretics to get rid of the potassium in the urine. Oh, and he may dialysis if it's really bad. So, um so in kind of cases where you want to consider dialysis, you kinda wanna think back to the functions of the kidney. So when, when would you need dialysis? Well, if you have? Um so there's a a I owe you kind of thing. So, a um what comment, what is e electrolytes? So, hyper hypochelemia, i intoxication um oh adama to like refractory pulmonary edema. Um and then you uremia um uh acidosis. So if it's like really bad acidosis, but yeah, hemodialysis is like kind of for when things get really serious and you can't fix it okay. All right. Just waiting for a few more responses. Yeah. So uh I think what this kind of question is getting at is, yeah, she's had a fracture but um in terms of looking at her kind of observations, it's all kind of within normal range. It's a heart rate, BP, there's no need to resuscitate her, her electrolytes look okay. Her using these look okay. So I'm also looking at the stem, she's nailed by mouth. So you're not going to give her oral fluids. Um So just maintenance fluids. I think the answer to that. Um So yeah, so same stem um How much fluid does she need over 24 hour period. Uh So I think there's some kind of formula for the eyes in there. So she's 50 kg, right? So, yeah, most people have kind of got the right answer 1500. Um So maintenance is um so usually you want, what is it? 25 to 30 mils per kilo per day? So, if we just take the upper, so 30 30 mils per kilo per day, 30 times 50 1500. Um so, yeah, I think it's just that simple calculation. Um Right. So this is kind of, this is like the big algorithm um which we're not going to go through all of it right now, obviously, but uh obviously patient's dehydrated, uh you know, hypertensive, they need some fluids going to go for the fluid resuscitation. 500 meals start nothing wrong. Nothing's wrong. Like in that lady, um you can either give her oral fluids or she's not by mouth maintenance fluids. And then also you want to be taking into account a bunch of other things where they can also lose excess fluids. Um So yeah, that, that's just something you probably need to go over in your own time. Um If you're not ready. So I think it's the same patient here. Um Just what type of food? Okay. Uh huh. Um Okay. So it's a little bit split. Um So I think the answer is actually the middle 19.80%. Um is that all the maintenance concentration? So, you know, you give, you give the 9.9% for the resuscitation fluids. Um I think it's the 0.18% and the glucose for the maintenance fluids. So you wanna give glucose obviously to prevent the fasting ketos is um and so the only difference between A N C is the potassium chloride. But if you look at the potassium is 5.6, that's a little bit over. Um it's in the normal, up to five. So there's no point in giving her the extra potassium, it's already quite high. So therefore the answer is c um yeah, I think that's how you go about working that out. Okay. So New Stem. Yep. Nearly that. How do you know she needs glucose? Well, um so you give, you give glucose generally in the maintenance fluids um to stop, to stop the ketosis, that's just like part and parcel of maintenance fluids. Does that make sense? Right? Ok. So yeah, everyone's gonna be either prerenal or renal AKI. Um a couple of gone with H U S. So I think the answer here that I've got is be um So yeah, it's definitely an AKI, isn't it really high? Creatinine, high area hypoglycemia? Um So I'm uh I'm not actually sure why it's renal. Um um yeah, I, I didn't write these questions but um panics a renal AKI. Um Perhaps it, it's probably because of the blood, isn't it? So I don't think you'd expect to see the protein urea and the hematuria if it was a prerenal, right? Um So what, what kind of things cause protein in New Year? And what kind of things cause blood year and nephrotic nephrotic syndrome. So, if it was just like a prerenal due to like hypertension or renal stenosis, I don't think you'd expect to find um protein urea or hematuria. So that's why it's a renal AKI, not a pre renal AKI. And if it was a, it was H US, there would always be in the stem uh infection with E coli 0157. Like that's, that's kind of like a, you know, they love that. E Coli 0157. Him, a hemolytic uremic syndrome. Okay. So, same as them. What is the underlying disease? Okay. So many people have gone for A T N. Um So from my understanding, uh ATM is usually caused by kind of things like drugs, drug reactions, um like antibiotics. Um and, and there's, there's none of that in kind of the history of the stem. So the answer I've got his rapidly progressive glomerular nephritis. Um and I think one of the reasons, so why would it be that? Because it's kind of presented quite acutely or sub acutely with the three week history. It's also got the, the nephritis. So, glomerular nephritis is an arthritis. So you'll get blood um in your urine. Um It's characterized by rapid loss of renal function over days, two weeks. Um and it's also associated with hypertension and edema. So it's got hypertension, they're high BP and the DM of pitting edema to the knees. So I think these kind of clinical signs and the time frame point towards that because I think, um, well, I would guess acute tubular necrosis would come on a bit quicker. Um, but I'm not 100% sure. Um, also, yeah, again, all the blood or the protein, um and so rapidly progressive glomerulonephritis isn't really a kind of disease in itself. It's more something you observe which is caused by other diseases. So, um it can be caused by things like anti GM disease. Um idea nephropathy, uh Lupus nephritis, these can all cause like a rapidly progressive glomerular nephritis is, it's like a descriptive term. So you're getting a lot of inflammation in the glamorous and the nephron causing blood and protein associated with high BP and edema. Okay. And there's no history of like drug reaction. So you've probably seen this, but this is kind of like the spectrum of nephrotic and nephritic. So, nephrotic things like minimal change FSGS member, nous amyloid, the nephritic end of the spectrum, you know, that kind of really kind of bad stuff and anti GBM disease post strep that presents with the material. Uh And then, yeah, I idea as well. Um So I'm sure you've seen that, that that's just a pretty good way to conceptualize uh nephrotic versus nephritic, right? Nearly there a couple more questions. Um Okay. So just a simple ckd staging, easy of our measurements. Oh, okay. So, yeah, most people got it. Right. So, um, stage five, I think so. Yeah, it's, it's 16 because stage four is between 15 and 30 isn't it? Um, stage five would be below 15. Stage threes, 30 to 60. Um, stage 2, 62 90 normal, over 90. Okay. That's just a bit of road learning. Right. Uh Last question, which of the following are not involved in the management of CKD. So this is kind of thinking back to that first picture. I show D on the renal all the functions of the kidney. Yeah. Right. Um Okay. So it's a bit split. Um So the answer is the last one, phosphate supplementation. So why is that? Because I suppose one of the problems might be excreting foss fake. Um So you don't really want to give too much of it. Um So what is the kidney, the kidneys, you might, you might need to supplement with calcium and ALF calcidol, right? Because vitamin D metabolism takes place in the kidney. Um Is it the, it's either the one or the 25 hydroxylation? So you might need extra vitamin D and calcium if that makes sense because your kidney is not doing that properly metabolizing vitamin D. Um you might need a inhibitors because one of the jobs of the kidneys to regulate BP, if it's diseased, it's not going to regulate BP, you're gonna get hypertension. So you need a inhibitors. Um And then you might need some E P O as well. Um to kind of counteract um anemia you're getting from E P O deficiency because the kidneys also produced E P O. Um So yeah, the answers, phosphate supplementation. No, no. Uh this is this is um talking about chronic kidney disease. So you're right, you want to withhold ace inhibitors and nsaids as well in AKI. So yeah, that's a, that's a good point. If they're on a inhibitors in an AKI, you want to stop that temporarily for this questions about CKD. Um Right. So yeah, has anyone got any other questions? Yeah. Uh Thank you very much, Dan um for the presentation. Uh Once again, it'll be great if you could feel that to feedback form in the chat and click on the Facebook event linked to sign up for our last two sessions. Um Otherwise, thank you very much for joining and have a great evening. Um I'm sure Dan will be sticking around for a bit if you guys have any questions. So feel free to type in the chat. Thanks for coming everyone. Um It's kind of difficult to say, so kind of difficult to say how hard the questions and the exam will be. So I'll tell you some of them are quite similar. Um But yeah, I mean, I guess so. Um they, they always like to ask kind of what you're what you're not expecting. So, I mean, let learn, learn all the obvious stuff. So I'll bank you a bunch of marks. But yeah, I'd say, yeah, roughly, maybe, maybe not. Uh Yeah, I, I think I would say learn about some of the nephrotic nephritic um subtypes because things like minimal change disease. Um uh that, that, that, that's something that's quite, quite useful to be able to recognize it. And the nephritic diseases like the they can be quite serious, quite urgent. So like G B M learn G B M um learning post streptococcal um nephritic kind of hematuria versus I G A. Yeah, I think it's good to kind of dive into them a bit more and we have today. Uh So it depends on whether it's fluid resuscitation or fluid maintenance and maintenance, I think is 25 to 30 mils per kilo per day. And then you also want to add glucose of 4% glucose and depending on their electorates, you also maybe want to add some potassium. Um because I think you need one minimal per kilo per day of that, but in that case, she had high potassium. So adjust for potassium depending on the patient and then also adjust for any fluid losses they have as well. Ace inhibitors, ARB is a bad in AKI. Yeah. So the main point in CKD was that because the kidneys are, you know, kind of malfunctioning that, that, you know, you're getting damaged to the kidney, it's not working as well. Um It's, you know, the BP the wrath system is going to get a bit dysregulated. So you're gonna get high BP. So that's what the ace inhibitors are for the BP from the CKD. But in a K I, you know, because they act on the, um, like the renal vessels can't remember which way around. Either the Afrin or the different, um, they can worsen. AKI. Yeah. And I think nsaids and nsaids and Ace inhibitors are bad. Would we, would we tend to use the upper limit? Um, all right. Okay. Um, well, I mean, it's, it's not, it's not really black and white, is it? So, I guess if, even if, if you've been told slightly lower kind of rates for elderly with comorbidities, I mean, look, because you're going to end up with a number and they're going to give you a number. So it's about kind of matching your calculation with. There's, you know what I mean? So if, if you come up with a number, uh, and you find like the answer is a bit lower, maybe you will try that one out. If they're an elderly with comorbidities, you try out a lower kind of maintenance fluid and see if you get. So it's about kind of matching it with the answer, you know, in the multiple choice as well, let's say. So, for that one, you know, it was, it was quite an easy 30 times 50. That's what matches up. So, if you're getting a wrong answer which isn't one of the choices you probably need to change the formula you're using. Okay.