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Okay. It's taken a while for some reason. Okay. Hello everyone. Welcome back to the Five Academy revision tutorials. We'll be covering H O P B and Renal today and we're very lucky to be joined by Louisiana, a final year medical student over to you, Louisiana. Yeah. So thank you very much Lucas reminding me. So, hi, everyone. My name's Luciano Crossover and I'm one of the final year medical students. So today, what we'll be going through is quite a few topics which will be on hematology, oncology, palliative care, breast disease, renal, and urology. So um with that, I mean, that's quite a few topics to go through. So the aim of this won't be to go through absolutely everything, but we try to focus on the key things that you know, may come up and also be relevant and near future careers as well. So just in terms of housekeeping as well, um uh you don't have access to a microphone. Therefore, if you do have questions, please try and put them in the chat as well, um please try and put them in chat and I'll try and answer questions as I go along, just bearing in time with the amount of slides and things that got to go through. We will try and keep the two hours we may or may not go over. So, you know, if you do feel that you can't make, make it stay until eight o'clock, please feel free to leave. This session will be recorded, recorded as well and the slides will be available for you after two. And we'll also have a little link as well with feedback. So, um I hope that's all saying well with you and hello there and that same, I guess we'll go get started. So what we'll start with first is we've got hematology. So what is anemia? So I'm pretty sure you're quite familiar with anemia. So you kind of like lacking healthy rebels cells, kind of like transport oxygen around the body. And you know how these um how is oxygen getting transported? Well, the main ways about using hemoglobin and that's formally part of the red blood cell and these are some of the symptoms that you can experience. So you can have this kind of whiteness to your eyes and and kind of like skin and square. So you've got Palo and then you've got breathlessness and Jeannie kind of like heart is kind of like struggling a bit the cardio my sites people can experience palpitations as well and kind of like with that a sensation of kind of feeling their pulse and beating them years and also latitude. So they'll be feeling like fatigued and like kind of low on energy. So, um you may be aware of kind of like a general structure that we follow when it comes to looking at anemia. So, cells and these red blood cells, they can either be too small in which their turn microcytic, which is on the left hand corner of the screen, they can be normal size, but you just don't have enough of them. So it's normocytic or you can have these really big abnormally large red blood cells, but they're just the hemoglobin content is just not sufficient. And um I think it's important to mention different proteins in the blood as well. So for example, ferritin is a protein that's like a storage molecule and it's found in in the cytoplasm of all cells, but it's especially found in the leather spleen and bone marrow and only a tiny small amount of ferritin is found in the blood. And iron is important because we need it for making these healthy red blood cells essentially. And another um protein that we want to kind of like make sure that we know about is something called transparent. And that's kind of produced by the liver and that's transporting iron from the stores to the red blood making cells. So they have this um the urethra pancreatic cells have receptors on their surface for transferring. So, in terms of like microcytic anemia, we know that there's, you know, in iron deficiency, there's not much iron going in. So there won't be much iron to store. So stores alone and you know, this can also be in the form of you're not getting enough iron in. So in terms of celiac, we have, you know, the reaction to gluten. And also you've got problem with kind of like absorbing iron in that sense. So kind of the ferritin um stores will below the free iron will be low as well and transfer and will be high to try and like get as much iron as possible even though the iron is low. So um you know, your body tries to compensate by making more transferring. So in terms of there's always kind of inverse relationship between ferritin and transferring. So another problem um when it comes to microcytic anemia is it can be to do with the actual globin chains of the hemoglobin. So um this is in terms of kind of like hemoglobinopathy zor thalassemia as well. And then when it comes to kind of like the normocytic anemia's, the iron is essentially kind of like stuck in its stores and the new cells like really hard to make. So even though the stores that can be normal amount, so fairytale will be normal, it's just really difficult to try and get the iron out. So free serum will be quite low and the transferring will be low because of that universe relationship. Remember and then you got bone marrow failure as well. So in bone marrow failure, like to think of it, it's like a weed grown throughout the bone marrow. So it's completely kind of overtaking the bone marrow. So everything will be got anemia when you've got the platelets as well, will be low and the white blood cells will also be low as well. So this can be due to kind of like radiotherapy and also kind of excited toxic drugs as well. And then in kind of micro macro cytosis, you've got these large big red blood cells, they just, you know, they don't have that um kind of oxygen capacity like carrying content as well. So in terms of kind of, if there's a problem with the blueprint of the D N A, in order to make these red blood cells, this can be due to kind of like vitamin B 12 deficiency and also folic deficiency. So they're kind of the two big main ones and B 12 is an animal protein as well. So I like to think of B 12 is like beefy like meat. So um this can be a problem for people who have like a largely plant based diet as well. And then you can also have these big kind of like red blood cells as well if it's um hemolysis. So that's destruction of the red blood cells and and especially 1000. Yes, of course, there's going to be catch it recording um Elizabeth on the, on the slides coming up as well. So, and in case um of also the breakdown, the hemolytic process, you'll also see changes in the reticular site count know from ridiculous. Thank out as well. So the immature red blood cells will be loads of them to try and compensate for the blood process breakdown. So with that in mind, you've got a little question to start off with. So I'm going to start a pole for you all. So just have a read through. Yep. So you can see one person has responded so far if we can get a few more responses as well. So if you think about the history, she's kind of got fatigue, colicky, a hemoglobin, try and think what type of anemia she may have her look at the MCV that will help you judge which type and it's great that most of you are getting it right, so far as well. Seepa. And in questions they will generally try to, you know, kind of like help you as well. So even look like that patient age as well that can guide you to order a certain answer over another. Also who prefer me, like I read out the question as well, just say I know that sometimes I just like to read the question my own time. Okay. So I think we'll stop the poll there so well done most of you um did get it right. So in terms of this person, you can see that they've kind of got uh kind of celiac symptoms. It's a relative young person and it's also kind of like an autoimmune problem. So if you look at the hemoglobin, it's low. So that's telling us there's anemia, uh we've got the MCV is low too. So that's a microcytic. So she either's got an iron kind of deficiency problem or there's a problem with the Globe and chains. And um what is the most likely cause of iron deficiency and film? Is she like losing blood from somewhere or is she not absorbing it? So, in this case, um we're kind of thinking on the level like lines of celiac here. So her immune system is kind of making substances against, you know, gluten, which is finding like as a threat and the body is just, you know, kind of attacking essentially. So it's finding it really difficult. Um the damage that's done to kind of like small bowels, it's disrupting the body's ability to kind of absorb the nutrients. So, um here, it would just be, we'd want to do the TTG antibody screen tested tissue and translate, terminates. You can't think of the other ones as well. But, you know, realistically, we really want to see what's going on. That would be our first line. So I hope that makes sense. So we'll move on. So, next question. So, and then this is um um I just put the pole up as well. So if you try and identify once again the type of anemia she has and then also keep in mind what the patient would like in this instance. Mhm Seeing response is coming through. Yeah, we like it. I just like distress as well. Even getting the answer wrong, it's better to have a go and then no, why you kind of like got it wrong as well because then it kind of prompt you to think so. And this is honestly not a digital environment at all. So I've made plenty of mistakes and it's always a good way to kind of learn. It's a safe space. So rather make them now than in an exam or later on. Perfect. Okay. So we'll kind of stuff about that there. So once again, we just go through a question. So we kind of got a new, new type symptoms and then her hemoglobin is low. And if you look at the MCV, that's also also, again, we've got this kind of like microcytic anemia type picture going on. Her ferritin is low. So that's something she's got low iron stores. So with that in mind, we've again got either an iron deficiency problem or a problem with the globin chains. So in this case, she's not taking enough iron in because in terms of, you know, animal protein and she's being a vegan, we can assume that it's like um microcytic rather microcytic. So that the full B 12 intake are adequate. Therefore, the problem is more to do with the amount of iron going in. So, whilst kind of like red meat would increase her iron, it's not the most appropriate and this would also be going against patient wishes. So we'd also want to go through like most least restrictive option as well. And we need to replenish her stores in the long run. And this week, we've achieved by commencing oral famous fumarate so well done to use for those who got that. Um we'd want to do the treatment for at least and three months because this will allow the stores to be replenished. And if you think about kind of like the life cycle of a rebel cell as well, it's that's 120 days super. So we're gonna move on. So again, it's just like a little recap slide as well. Um In terms of iron deficiency anemia, usually to do with like blood loss or not absorbing enough iron as well. And what we really need is the ferritin as well transfer and will also kind of like help. And I mentioned that inverse relationship where one goes up, the other ghost and down. And also in kind of like if you have inflammation around ferritin can be falsely elevated. So you can just need to take into account the clinical picture as well. And then in terms of inefficiency management, we really want to kind of like start with replacing nine stores. So we start with kind of ferris um sulfate and then we kind of still continue to try and build it into their lifestyle and advising you to eat iron rich kind of things like spinach and kale. And then, yeah, of course, if patient's are losing weight and you know, especially in a man, you really want to consider if there's some sort of know lignin see going on and if it's a younger person, then think about seniors screen as well and just mention as well, I in itself, um it can cause quite a bit of tummy upset to a few people. So that's just something to bear in mind. They can have like black stools as well and it's worth you can reduce the dose or move them onto a different form of iron supplementation to. So, uh next question is we've got a 52 year old female. Um, when would I infusion be indicated? Okay. So usually, um there's like a limit. It's kind of um if you've got a hemoglobin below 80 and um say person has like angina symptoms as well. Um They kind of like lost a lot of blood and it's really kind of more in like a acute type situation. I remember I was on a ward and there was a patient had like a really, really low like hemoglobin. I think it must have been about 33 but she was absolutely fine. That was normal for her. She would be chugging along. So it kind of really, really bury and that's why it's, you know, don't be afraid of picking up the phone to, um, you know, hematology and saying hang on, what do we need here? Because there is risk as always with any intervention that we do give. So a very sensible question, Alex. I hope that incident perfect. So I'll just put up the next poll as well. So, so this time we've got an older patient and they've got a two week history of parasthesia. So that's a numbness and tingling for anyone who doesn't know. And then once again, if you focus on the hemoglobin, also the MCV that can direct you. Um luckily they've also given us some other handy information to mhm Keep the response is coming. Well done. It's good. There's a spread as well because that means we can talk about things too. Well, then I think we'll stop around there. So well, then the correct answer was option D so we'd want to start with vitamin B 12 injections then one, no fans. I am every three months. So if we just go back to the question itself, so she's got anaemia. It's a macrocytic type of union. We've got those large big red blood cells. So again, we've either got a problem with the B 12 or FOLATE or we've got some sort of hemolysis going on. And here they given us that it's, you know, we've got a low foley and we've also got a low B 12. So really, we need to replace both. An important thing to remember is that when it comes to B 12 and folate, you always want to check the B 12 before replacing the FOLATE because it can precipitate cord disease. Um So I don't know if you know the before, let me just, you may or may not come across it. But if you just spell out the word before B as in B 12, so always remember to check the B 12 before full late. So um and B 12 also only comes in the form of injections as well. So this wouldn't be an oral suspension. So that's why I hope that makes sense, right? Yeah. So again, this is just a little bit of a reminder. So these are both important in kind of like making healthy red blood cells as well. So we can do blood test to measure the levels of these and we get injections to replace the B 12. They usually occur every three monthly and falling is also replaced, but this is in an oral form as well. And you know, you'll see lots of people in the world they'll tend to have I can folate deficiency and that will be on oral folate. Uh Again, you just want to avoid complications of the um subacute combined a generation. So, so in terms of B 12 and B 12 is um absorbed by the terminal alien and in the stomach, it kind of used to bind to intrinsic factor and then pernicious anemia, which is an autoimmune condition. You've got antibodies is an intrinsic factor. So that can be a step where you got this macrocytic anemia or you have a problem with the term the island. So this will be kind of like an in functional bowel disease. And also you just may not be getting enough and going in of the B 12. And if you remember B 12 beefy. So you know, plant based um kind of people who eat lots of plants, they won't be getting that animal protein. And in terms of foley as folate as well, there's obviously a great demand in pregnancy. So that's why it's important. We give pregnant women folate because it can otherwise you're cause neural core defects as well. And again, malabsorption and even taking it in. So, yeah, so we've got another question now. So I'll just let you have a read of that there and get the next bullet. Yeah, he said responses coming in. That's good. Keep them coming. You can also think about kind of like the chronicity of what you're being presented with. So you've got three months previously. Unwell. Think about the lady, other things this lady has to hypothyroidism. You got some sort of mild, slower icterus. So the yellowing of the eyes again in the same type symptoms. So you've got a bit more respect of answers with us. Good. I can see why certain people, you know, why you'd pick certain answers as well. So, yeah, some people thinking something to do with liver, with jaundice and things. Yeah, that's good. So, I think we'll move on so well done. The majority of you did get the right answer. So in this case, we want to do um acute test. So going back to the question itself and we've got a bit of shortness of breath that she's experiencing and conjunctival kind of like pallor as well. So you've got, and that's pointing towards anemia and you know, that's the lack of the healthy red blood cells in terms of the scleral icterus as well. You've got too much um bilirubin, which is the sudden it's, that's produced when the red blood cells are being broken down. So somewhere along the lines, there are red blood cells being down then in terms of her full blood count as well. Macrocytic. Again, we're thinking either kind of like b 12 folate or, you know, is there a humanistic process going on? So it's important here as well, the mention of hypothyroidism as well. This is um an autoimmune disorder as well. So um it's pointing towards kind of like an autoimmune picture. So particular account site, it would confirm that, you know, humerus is going on because you see the kind of compensate ori mechanism to try and boost your red blood cells. And so that gives you like higher ethics, but it doesn't necessarily tell you the course. And then blood film and it's useful when you're looking for particular cells. For example, in malignancy, if you're suspecting, you know, there's something going on, but we don't have kind of like the night sweats, the weight loss, sweating fevers, like that's not given in the questions then and then again, liver function test that would kind of show they high bilirubin. So because it's uncomplicated in that sense, it's not water soluble. So it's not getting peed out and it just hangs around in the blood stream. So that's why you get this yellow as well. So all in all, I just want to make sure that I don't give away the answer. Yeah. So basically this woman has an autoimmune hemolytic and email, which is where this question was going. And, and typically it causes like a mild micros itis as well. You can get features of jaundice. And so I can see why some people went the liver function tests as well. But again, that wouldn't really give you kind of like because it would just, you know, tell you that there is something going on. So again, you get high reticular sites and also get decreased haptoglobin levels and you get other compensate ori changes that the body kind of tries to um come back and there's loads of different causes um can you can get and you see it's kind of um the enzymes itself, um deficiency and horatio spherocytosis. So, on blood films, you can see different types of shapes too. Um red blood cells as well, malaria and Reese's diseases too. So I'll just keep moving on. We've got a lot to go through, but you're doing really well so far. So again, this is a specific test and that was mentioned that the question is trying to go for this Coombs test. So it's just important one to remember as well. And that's that will essentially give you the diagnosis for autoimmune hemolytic anemia. So yes, but yeah, you'll get all the slides after so you can go through it. So now we'll just go into a few questions about blood transfusions. So I'll just put the pull up. So in terms of the transfusions, which do you think is the correct statement? So people with o negative blood can receive blood of any type in an emergency at the highest risk of pregnancy. In terms of humanistic disease of new gone is a recent positive mother and a recent negative child or a positive individuals can receive blood products from the positive donors. An individual with type papered can receive blood from a AB or O or Amy positive individuals can receive all types of blood and plasma. Which one are we thinking is true out of those options there. Don't worry, I had to think about this one as well. When I first saw this question, there's a really useful side as well that will hopefully come up to that we can go through. So we've got a few responses coming in. Yeah. So well done. The majority, majority of you are getting it right. So ab positive individuals can receive all types of blood and plasma. So we'll just go through the first one. So o negative blood. So these people and they have type of blood, so they don't have any antigens, but they have antibodies to A and B found on the surface of other blood types. So the antibodies on the surface of will attack any A or B type blood. Then in terms of recess disease. So it only really happens when the mother is the one that's Reese's negative and the child she's carrying is Reese's positive and she has to kind of be sensitized about. It needs to be like a first pregnancy as well. And it means that mom with her being recess positive, the mom has the resource antigen and the baby has no antigens. So it's recess negative. So the mom doesn't create any antibodies against the baby as the baby doesn't have any like recess um antigens. In terms of a positive individuals, they have eight antigens um surface. So they'll have antibodies to be. So if um blood um of the eight plus individual comes into contact with be blood, then there'll be attack on the B B blood as well. And then in terms of the next statement as well, so an individual type A blood has eight antigens on the surface and it has antibodies to be social tech and donors with blood type B which has the B antigen and type A B blood, which will have both antigens and oh has no antigens. So it's like the universal donor as well. So I hope that makes sense. So we've also got the next question coming up. So just put the next poet for you. Well done. Yeah. So in this case, you've got an elderly lady, she's had a fall, she's got enough neck, the femur fracture and she's kind of on a few medications there. She's anemic. So she's been given a blood transfusion and then you got her observations there. So you have been asked to basically suggest what is the next appropriate step? Mhm. So you've got answers coming three. So again, I just say I have to go. There's, you know, no harm in getting it wrong here. So kind of approaching a good amount of responses now. So we'll stop there. So, um well done. The majority of you got it right again. So we definitely want to give IV furosemide, we need to get fluid off. So this lady she's frail, she's had a long bone fracture. She's probably losing quite a bit of blood as well. And she's already got a problem with heart failure and fluid overload. Um you know, being pumped full of blood is a type of fluid anyway. So that's also important, you know, just even in your own practice, moving forward, when you getting blood transfusions, you know, thinking about their fluid balance, kind of right raised GBP is mentioned, the crackles opportunity and that it's all pointing towards like fluid overload. So in terms of the option available, you know what she's maintaining her own airway. At this point, we don't need to call um anesthetics. So in terms of blood cultures, and there's no really mention of like a fever or acute pain or anything. So we don't really need to be doing that and ensuring a D N A C P R form is in place. Well, we've got a reversible cause here and um you know, we want to give the chance to, you know, recover from that as well. So that is a bit, you know, you want to say this patient, you know, today she's definitely say verbal. So and IV Furosemide is the correct answers here because we want to get that fluid off. So even like sitting her up as well and kind of like giving her oxygen, which they've already started as well. So all kind of like the simple steps. So well, then everyone. So again, this is kind of like the really useful chart. So just when you're thinking about blood types, say a person has type a blood, it's the antigen that's on the surface of the red blood cell that's mentioning and it'll just be the opposite um kind of a type of blood that will have the antibodies against. So, again, typo, you know, universal donor and that's just important thing to kind of like, and it's also, you know, useful to know an anti baby is the universal recipient as well. So we'll move on again. I'll just stress that you'll get these slides after as well. So when it comes to giving transfusions as well, it's not without risk as well. And they can range from kind of like mild and kind of more severe type pictures as well. And this is like a really useful flow diagram as well. So, um Taco is like transfusion associated and uh upload and then transition uh related as long injury as well is like trolley as well. And again, you can just arrange from just giving paracetamol to really needing kind of like severe intensive observation as well. So again, Taco, it can be easily missed. Um but you know, simple things to do, set them up and give him some oxygen, get that and for us might to get the fluid off. And obviously people who are frail, them are more susceptible to it and those with heart really too perfect. We'll just move on in the interest of time as well. But again, we've got transfusion related acute lung injury to. And again, this stress is very rare and it's unlikely that you'll come across it, but it's just um useful to know, keep in the back of your mind. Like sometimes they do like throwing in rare things just in terms of like exam questions as well. So we're going to move on to the next poll. So, um we've got a young patient here and we are asking you what is the most likely diagnosis? So you only been unwell for like the last three weeks and you know, he has some skin changes as well. And I guess the clue here would be to really the blood film probably mention is giving you a pretty big clue. Mhm So again, we've got two options in the lead, which is good. Mhm So I think we'll stop it about there. So I can say that most of you have got it right. So am else acute my load. Um Leukemia just put the post of A L L. So um why it's um so with it being a kid, you would think it would be a lot because the communist type of militancy is um acute lymphoblastic leukemia. It's not the correct answer here. In fact, it is myeloid leukemia and the acute myeloid leukemia is really pointed towards by these our rods in the blood film. And with chronic myeloid leukemia, it's not a very chronic picture and this is really unlikely in the child. And then hodgkin lymphoma. This usually cause young people to and you'd also have kind of like a mention of like Alimta adenopathy because to do with like the proliferation of lymphocytes. So we'll move on to the next question. So this time we've got a 76 year old lady, it's given you a very big hand here. So again, we've got similar options. She's feeling quite fatigued, she's sweaty at night. You see a different type of cell types seen on the blood film. Keep the answers coming. You're doing, you know, you're doing it really well, so fast. So have faith in yourself and just pick an answer. Mhm. So I guess um well, kind of like stop the polling around there. So um the answer here is chronic lymphocytic leukemia. So the big clue here is these smudge cells. So I say when you're thinking about like hematology, like oncological questions, um it's really useful to think about the cell types that they've given you. That will be kind of like the indicator. Um And that will be um kind of really useful to, again, this lady just kind of got the b symptoms going on with the fatigue, the weight last sweatiness at night and it is more like a chronic type picture as well. So kind of that discounts the AML but really um CML is the rats here which most of you got, which is super, what would you see on blood shell on CML? So we'll probably actually come later on in the size as well. So if you hang fire, so if we just go with a lele, so acute lymphoblastic leukemia is the most common one in like young Children and, and it's common in adults as well. And really, you've kind of got the marrow failure picture. So you've got the anemia, you've got your low plates. That's um, it also makes you more prone to bleeding with the kind of like the low white cells as well. And again, you can get like liver adenopathy and gum high church. We might be prominent in adults as well. And in the barrow, bone marrow, more than 20% will be blasts as well. There's kind of like different definitions that go with it too. So you may have come across that in some other lectures. So in chronic mild leukemia. So um Liza just mentioned uh to your answer, the blood smear, you'll see kind of like more grain your sites and monocytes and and you'd want to send a bone marrow for like cytogenetic analysis as well. Um But with chronic lymphocytic leukemia, that's where you see the kind of smudge cells whereas CML and you're just seeing increased numbers of like granulocytes and monocytes. So, Philadelphia chromosome, you probably would have heard of it. I hope so you get this and be siara able to from fusion protein and you get the main presenting features are kind of bone marrow failure and also you get massive spins as well. So if you're feeling and kind of like the left upper quadrant of people, it can be feel like a really quite prominent spin where you feel like the notches, um hepatomegaly as well can can occur. So in the right upper quadrant, and again, imatinib would be the kind of like targeted therapy that you would go for in these patient's. And then in terms of lymphocytic leukemia, it's more of like a leukemia of like older people. So, um here you got, you know, presenting features, it's usually kind of like an insidious onset type thing. And you've got this lymphadenopathy that is painless. So, you know, in other types of um kind of militancy, you can have like tenderness of the lymph nodes. But in this case, it's, you know, this is not harming them, well, it's not hurting them in any way. And again, you've got these be type symptoms and you'll see really quite elevated white cell counts and you see the smudge cells on the blood film tea. And again, there's more information that you can go through in your own time there. So we've got another question. So I'll put on the pole it for you. So you've got a 63 year old and he's going to a GP with about three month history, feeling tired, feeling out of breath. Um He says that, you know, he hasn't weighed himself recently, but he felt that his way size of degree. So that's indicating there's some type of weight loss going in there and then we've got these blood results come back. So I'll just put the pull it for either. So, what do you think is the most useful, um, investigation to do next to understand what's causing your symptoms? Mhm. We've got a few answers starting to come through. That's good. There's just in terms of questions, think about what they're asking you as well. So here there, you know, pointing for the cause. Um other questions can ask, you know, frame it in a different way where they're looking at staging as well. So just think about the wording of the question too is what I'd say. Perfect. So I guess we'll move on and stop the polling now that's well done. So the majority have you got it right is serum protein electro freezes. So kind of like the clinical type picture we've got going on here this pointing towards a medical malignancy and it's kind of like normocytic anemia within the blood results themselves. You've got a high calcium, which is, you know, over a very big clue here. And the creatinine is pointed towards like an issue with kidney filtration as well. It's quite elevated. So here we're thinking um along the lines of kind of like multiple myeloma. So really um serum protein electrophoresis would give us the kind of like a correct diagnosis. Uh I'll just go back a slider as well. Hopefully you still got the pole up. But the ct of the thorax Abdo test, it would show like little commissions. Potentially the classic is kind of like the pot school or kind of like raindrops school appearances on the X ray and the PS PSA the prostate. And it doesn't mention any specific like urinary problems as well. I feel that would be in a question if they were asking for it. And the blood film, the there's like a test for paraproteins as well and it's um serum protein electrophoresis and it's not a blood film. So yeah, the top answer is correct. So, yep, crab is the one, you know, I hope that you know about so crab features, you know, bone pain, these lytic lesions that you'll see on kind of like the CT. And then yeah, so lower back pain is probably the most common site, but you can get this rib pain as well and hypercalcemia. So you've got increased osteoclastic activity. So it's being released into the blood. And then this influences the way the kidney's working. You get kind of like trapping these light chains and it's really difficult for kind of blood to be filled to properly. So that's going to cause you renal failure. And again, the multiple myeloma will result in anemia kind of a lowering in the neutrophils as well and also low platelets too. So, and another one to mention is monoclonal gammopathy of um understand significance MG US. I know they all have really long things. Um So it's a paraprotein in the blood, but they're essentially no other symptoms and it's fairly common with increasing age. So, um you'll have a small percentage of people um that have kind of use paraproteins in their blood. So, um there'll be a mild increase in the plasma cells, but it's less than 10%. So again, when it comes to definitions, there are certain kind of like criteria that it feels and there is like a risk of it turning into multiple myeloma as well. So you'd want to check the blood levels annually for this paraprotein blood uh paraprotein levels. Sorry. Okay. So we've got another question coming up. So we've got a 66 year old woman and she's had black Tarry stools. And then this question is what do we do with regards to her anti coagulation? So we're thinking about what do we want to do with this Warfarin? So, do you want to continue it? Um or should we check it and continue if it's within a certain range or do you want to monitor and withhold the iron? Are we will hold the water and sorry or withhold it completely until we determine where this blood is coming from, the loss is coming from? Or do we want to give vitamin K to kind of like reverse or anticoagulants, anti coagulation as well? Don't worry if you don't know, you know, this is, you know why we're here teaching about all this. So it's all good. I'll be like tables later on that will make this a lot clearer as well. And even in practice, you know, we can just open our phones and tables will be there to like help us direct our clinical decisions team. So, okay. I think we'll just move on. So um the answer here is actually option E so we'd want to withhold her Warfarin and administer vitamin vitamin K to reverse the anti coagulation effects. So just in terms of the question itself, um so having a low iron are means that blood is thicker. Whereas if you have a high iron ore, it means that the blood is thinner and kind of like takes longer to clot. Uh Warfarin is a vitamin K antagonist. So it's blocking the enzymes that kind of use vitamin K to produce the clotting factors. And this in turn disrupts the clotting process. So um taking it takes longer for the blood to cut essentially. And if someone's bleeding, we don't want them to bleed out which kind happy. So the body's natural processes to plug the hole is someone's bleeding. And in this case, because she's on Warfarin that's been altered. So what really needs to do is just kind of like reverse the warfarin effects, which is why we give the vitamin K. So for those of you who just a bit confused avr in the question and here it just stands for aortic valve replacement too. So again, um just in terms of like clotting pathways as well. I don't know if you've come across um like different kind of like no Monix and thinking of this. But the and prothrombin time is kind of like prolonged by warfarin. So this can kind of like vitamin K deficiency as well and the businesses and like um D I C as well. And I like to think about who thrombin time as pet. It's part of the extrinsic pathway. So let me type this in the chat, extreme sick and then a P T T. So I like to think of like a pint. You may have already come across this. So I'm sorry if I'm repeating this for you, but it can be just useful to think of. There you go. So we've got pets. So prothrombin time, think of extrinsic and actually two from past in time, it's the intrinsic pathway and then in terms of reversing um warfare itself, um you can find type tables for example, in nice B N F as well, that really useful. So here we've got the different iron, our ranges as well and what you do with regards to either withholding or kind of just testing the ana or giving vitamin K as well. So, so we'll move on. So next one. So we've got a 76 year old man. So he's had a full and, and so, you know, yes and he's had a hip replacement. So he's taken a few different things. We have a subdural hematoma found on CT. So what would we want to give this gentleman? Mhm. A few responses coming in. So I'll just give you some time to get, try and get a few more answers in if you can. Okay. So we'll move on. So in this case, the correct answer is uh vaccinate alpha. So we should have a lovely table here coming up, which is here. So if the gentleman's on Warfarin, we try, we would give vitamin K um and PCC and he was on Apixaban. So the reversal agent for that is um an X A alpha. If he was on Heparin would give protein sulfa. Uh The bigger trend is another kind of um antiquarian agent and um edit prisma um would be um used to kind of like reverse the anti pagination effects. So we'll now go on to Reno as well. We'll have um just a wee breather before we go. So try and get your mind thinking about renal. Okay. So we'll just jump straight in. So we've got a 52 year old man who's come in for just a routine medical. He's got type one diabetes. Um BP, yeah, a little bit high, but you know, roughly okay. And then um everything else um in terms of examination is okay. We've got investigation as well. So what do you make of this? What would we else would we want to do for this gentleman? So, would we think about doing your analysis for him? Would we want to go and do a renal biopsy? Uh Would we want to look at kind of like the urine protein creatinine ratio? Would want to have a look at his kidneys and do an ultrasound or kind of do like a vasculitic screen. Yes. So the answer is we've got so far doing well. Mhm. Got to clear runners in the lead. That's all right. That's good. I like that. You're thinking on the right lines though. So I think we'll stop there. So just in terms of the question, we can see that he's got like a race creatinine and he's got a low EGFR. So clearly there's something going on with his kidney function at the minute. And here we're expecting, you know, this person has kind of like, you know, potentially diabetic nephropathy. So he's got a bit of damage to the filtration system, you know, the memory live the kidney and you know, diabetics should be monitored annually for this. And um really like for the microalbumin anemia and pretty because you know, you've got the damage. So it's letting protein through and really the best test for this is the albumin creatinine ratio. So the closest one here is their protein creatinine ratio, which is alright. Albumin is a protein. So the test will include albumin as well and including light chains and also other glad things as well. The your analysis is not too useful, like he's not complaining of kind of like urinary symptoms or leukocytes. And we're not really expecting any blood either. The renal ultrasound wouldn't really be appropriate. It's quite time consuming more also than like a urine sample as well. Um with like results sounds if they were, for example, to have like small scarred kidneys that could be to do with them being small, do to kind of like renal artery stenosis. And then in terms of like the vasculitis screen as well, he doesn't have any other kind of like vague symptoms that can occur with vasculitis. Um for example, he doesn't have any problems with breathing or nasal crusting and there aren't, doesn't seem to be any other widespread ponds so well done everyone. Yeah. So who got some information about diabetic nephropathy? So again, it's just telling you about the levels of kind of like album in, in the blood, which is a type of protein. So clear, you can grade this into different systems. And again, as I said, you want to test and annually um for this and you'd want to give, you know, inhibit the renal uh angiotensin system of steer energies heads and system. So even, you know, if they don't have a low BP, so you really want to try and manage the other cardiovascular risk factors as well. So in terms of glomerular disease, I'm sure you're familiar with this kind of like slide here. You've got kind of like the protein nephrotic six also kind of like bit more inflammatory nephritic picture. So you can see that for example, minimal change, you'll have lots of protein urea, so loads of protein coming out in the urine, whereas for example, in good pastures, which is also called um anti GBM disease, you'll see kind of like Frank blood in the urine as well. And um in other types of kind of like renal problems too. So our next question. So we've got a young patient and this time he's presenting to his GP with a three day history of hematuria and also oliguria and previously had two days of suffering Kreisel symptoms. So having kind of like a runny nose and a cough and here we've kind of got his observations as well. So what we're trying to ask here is what do you think is going on? So when thinking of this question, I had like there were two ones that came to the forefront and it's deciding which one would be more appropriate out of the options listed, I think, make sure you off a bit or struggle, but that's all right, we can get to it. So really what I'd focus on here in this question is kind of like the your analysis results. So you've got protein one plus and then blood three plus as well. Super. So what I think we'll do is we'll stop the fall. So, um the correct answer is um IGA nephropathy. So the protein in the blood in the urine analysis is pointing towards the more nephritic part of the graph. He's also got a bit of a higher BP as well. 1 46 everyone, 16 and onset is after an illness as well. So you should be thinking really post streptococcal or I G A as well. Post strep tends to occur 1 to 2 weeks after and here it's not been long enough. And so the answer would be um I G A and um you know, it's classic post upper respiratory tract infection as well. So who got just a bit more about IGA nephropathy? So you kind of get these um complexes um the kind of deposit in the Masindi um which makes it kind of like hard to filtrate and also get a bit of information as well. And usually it's in the context of kind of um upper respiratory tract infection, but also gi tract disease can do it as well. And as I mentioned, I G A, you can think of um it also is like I G A like three letters like 2 to 3 days. Whereas post trap you no longer words. So it takes longer. So it comes, you know, 1 to 2 weeks later, something like that and again, just look at the BP as well, that can be useful. And you want to kind of in this person, you'd want to kind of start ace inhibitors, um cortical steroids, but only if it's like rapidly progressive acute decline in there kind of kidney function and then 20% do progress to end stage renal failure as well. So that's just another important thing to consider. So we've got another question as well. I hope the places. All right, you're doing really, really good. I just want to make sure that we get through enough because I know that, you know, questions are handy. So, so we've got a 62 year old lady. So she's got fluid overload. She's got kind of like pitting edema and it's developed kind of over the course of weak, but she's otherwise kind of asymptomatic previously. She was kind of a injury news drug user and she's had like a recent diagnosis. A happy and, and she's on methadone as well in terms of investigations we've done for her. So urine sample has been sent um it's foamy and she's got some urine but no other abnormalities. And then I'll just, in terms of they see what we're thinking, what type, what diagnosis is. She essentially saying? What is the most likely diagnosis? I'm sorry, I move appointees. I've got their, I'm sorry, you should be able to see question 14. Mhm. Sorry. So the options and should be post strep um FSGS minimal change in member anus and the neuropathy and also good pastures. There we go. Sorry, I can see them change as well. So. Mhm. Mhm. Okay. So we've got a bit more respect of answers, but that's fine. I know it can be a bit more difficult when you've got a lot of information. So what we'll do is we'll stop there. So this lady just looking at the clinical picture she's coming with like nephrotic syndrome. So she's kind of got the protein urea adom A and then low album in as well. That's given it in the blood results as well. This is protein heavy. So it's more on kind of like the nephropathy side of the graph as well that we previously saw and she's having, you know, she's got lower album in the blood, she's getting rid of it, you know, as protein in the urine. And the correct answer in this is membranous nephropathy, which is what this lady has in terms of minimal change. It's kind of also um nephrotic as well, but this potential caring Children, um FSGS, it can be idiopathic um and it also can occur in HIV and drug abuse. It's um to do with my GM deposition FSGS. Um but membrane is, is the most common cause of nephrotic syndrome. So this is what the question is kind of like going for. So here we also a bit about member anus and the property So it's the most common form of nephrotic syndrome in adults. Um to do with kind of like the auto antibodies against kind of like the potus sites which are like the little foot processes. Um in the kidney. And in terms of management, you'd want to start with a scene. Hih bitters. And you'd look at um considering like cyclophosphamide when you took some bad if it's severe as well. And in terms like prognosis, about a third, get better and about a third, they have this like persistent nephrotic syndrome and the third do go onto progress to end stage renal failure too. So the next question, I'm not sure if you can see but yeah. So in terms of most likely diagnosis, um there should be a pole and about the question 15 with, oh, sorry, sorry. I may have missed up the polls income, but the answer was membranous nephropathy. Yeah. Sorry. I think I clicked on one of the next polls in advance. Sorry. Violet. Yes. And then in terms of um, yeah, question 14. Thanks, Alex. Yeah. So the next question that we're on now is question 15. So if it's popping up in your chat box, go to question 15 for this one. So this lady, she's a primary school teacher, she's feeling a bit unwell. She's kind of having these intermittent fevers and kind of like this rush that's appeared. She's kind of got some autoimmune things going on a bit of hypothyroidism and she's taking medications for this and in her blood we can see kind of, um, Hying sniffles and also correcting of 300 and there's a trace of blood and protein. So, we want to know what is the most like diagnosis here. So, your options should be. Could this be systemic lupus, erythematosus? Is it good pastures? Just a psa nisus? Um, acute interstitial nephritis or F S G S? Uh, yeah. So vocal segment called glomerular nephritis. Oh, sorry, let's see if I can. Mhm. Mm. Hi. Know venous, sorry, I don't think I can open the pole again. What you could do is um put your answers just in the chat box and type A B C D or E. Mhm. That's George. Thanks for that. Mhm. There are other options available as well. So just think we've given that information there. What do you think is the most likely thing going on here? Perfect. So you all seem to be thinking on the same line of thought and yes, you are correct. It's um acute interstitial nephritis. So it's kind of like giving an allergic type picture here. So, and the attic area as well. So also autoimmune has been thrown in there as well and this is usually in secondary to medications happened to and what has she started recently? Well, recently she has started taking and that result um as well because she's had a recent gore diagnosis too. And in um, A I N, you typically have a triad as well. So you have fever eosinophilia. So that's the high levels of eosinophils and you also get a rush as well. So that's what this question is pointing to. So, yes. So you've got this allergic triad. So it's good to know just what medications can cause this because it's something that can be asked as well. So, um, as I said, um, that result was the one that was pointed in the question here, but certain antibiotics to an NSAID and again, it's not necessarily allergic as well. You can have infectious causes infectious courses and also you get the noxious is it's part that I A I N so mushrooms as well. So what I'd like you to do is if we go, there's certain boxes covering. So boxing moron, it's covering a certain words. So if you can type away in the chat box, what you think and, and send it through, I don't have a pool for this. So it's just free text answers. So if you want to do 12 and three, all at the same time, that's more than welcome to. So, um, hint the number one is that it's a disease that causes kind of like a spectrum of changes at the glomerulus. Yeah. So, Alice. Um, okay, you're both, right. So sle well done. Uh, next one. So we're on the nephrotic side of the graph this time. So you've got the high key mature ia's, you've got the lots of burning urine and then you've got low protein. This one tends to be associated with like long hemorrhage as well. That's another hint. Anybody else want to have a stab at what it could be. Number two. Yeah. So, um, auntie do be in is the correct answer. So well done. And then thanks for all. Getting away. Sorry for those of you who didn't see it was from the left side of the screen. So we've got lots of protein, but we've not got a lot of blood in the blood and it counts put in kind of like a nephrotic syndrome in most Children and then about quarter of adults as well. Center number three. What we're thinking. So, all right, you can, if you keep, if you saw the answer, that's fine. Minimal change. Yeah, well done. Super perfect. So we've got another question as well. So this one is kind of like cross specialty a bit. So we're looking at kind of like biochemical changes. So I'll just start the polls. You've got a 67 year old man and he's coming to the emergency department. He's got muscle weakness, nausea, vomiting, and he's kind of got end stage renal failure as well. And then you're presented with this potassium and then which E C G changes would not be in keeping with this man's presentation. Mhm So I can see some of you answered already. That's good. You can keep the answers coming in. That'd be brilliant. Mhm Think we're getting most responses here. That's good. Super. So we'll start the pool there. So yeah, the majority of you are correct. So um would not expect to see large P waves. We would actually have flattening of the P waves instead because I had to read up on this booth just due to the prolonging of action potentials as well. And then all the other E C G changes we would kind of expect to see. So given his E C G changes, what would be try to do? So I'm just gonna put the pole up here. So would you want to start off with calcium? Would want to give him an incident extras infusion. But we start him like on a salbutamol nebulizer will be calling anaesthetics for central access or would we try and get an emergency hemodialysis? What you think is the correct answer here should be a nice and quick answer. Well, then we've got a few responses. That's good. You can get a few more. That'd be brilliant. Okay. So just in the interest of time we'll move on. So in this case, we want to stabilize, it's like cardiac memories. So the first thing we would go for is their calcium gluconate. And this kind of like salbutamol nerves will drive the potassium into the cells and this will lower kind of his extracell your potassium levels. Um But really the what we want to do first to stabilize cardiac memories. The other options will kind of deal with the potassium. The calcium won't affect the extra study potassium by shoving it into the cells. So we first go with the calcium and then choose all the other options which will help to kind of like lower the potassium level. So here we've got the E C G changes as well. So you kind of got the normal pr ways and you kind of got the flattening and then the prolonging of the pr and then you eventually will have um sine wave and kind of like cardiac arrest, which is not good. So in terms of hyperkalemia management, as I said, the first one to start with stabilizing the cardiac membranes, then you want to go with interventions that will actually reduce their potassium levels as well. So we'll move on. So our next patient, we've got a 72 year old lady and then, so she's on the orthopedic board and she's on Ben Dro which is a diuretic. Her BP is 135 or 75. She's got a JVP, that's 2 to 3 centimeters, that's, that's normal for those. Um you don't know, and then she's got no pitting edema and potassium is within normal range as well. And we're asking what type of fluids does she need this lately? So, do you think oral foods would be enough or would we try with holding fluids. Just give us some maintenance or replacing resuscitation. Mhm. Mhm. So, we're getting a few responses. That's good. Okay. So we'll just, um, stop the poll there. So, um, option C which is maintenance foods is correct and she doesn't have any signs of fluid overload. She isn't hypertensive. She, there's no mention of dry mucous membranes and she's currently stable. So, all that she does need is maintenance foods. Really. And then if you think about it's small frail and ladies don't tolerate um large doses of fluid. Well, so it wouldn't be good to overload her. So and in terms of the fluid, how much fluid do you think that we need to give her? So I'll just bring the pole up as well. And what will help you with? This question is her weight as well. So I hope you should just be a simple calculation fee. So how much would you give this lady in 24 hours? And he weighs 50 kg? So we'll stop there. So um this lady, so the standard amount of for maintenance fluid is 30 mils per kilograms per 24 hours. So this lady is 50 kg. So 30 mils times 50 kg will give us 1500 mils in a 24 hour period. So that's what we give this lady for maintenance as well. Okay. So next question, I'm glad that those of you are still here as well. That's good. I like the interviews Alison and then in terms of maintenance fluid, what type of maintenance fluid would we give her? So we decided that we want to give a 1500 mils as well. Hi Violet. Yeah. So 25 to 30. Yeah. So, you know, there's variation but from where I see like on guidelines and things, um, 10 you usually tend to go for the 30 mil value. So, yeah, try and, you know, go for the 30. It's more standard and I think morning but yeah, I know it can be a bit tricky but yeah, I hope that makes sense. Yep. So in terms of maintenance, fluids, what we want to do. So this lady so sorry you don't have like the reference value for potassium. So that may be why she's throwing you. Yes, there will be a feedback link for today's teaching session as well. Um They'll also be like a recording. You'll be able to get the slides too. Yeah. So um the potassium range is within normal. So we don't really need to add potassium at this point, but I can see why people will put it in. So the normal standard um good maintenance would be not 0.1 point 8% sodium chloride and 4% Blucas. So the correct option is option c so maintenance food, we want it to be normal as close as normal to like physiological um blood composition. So 9.9% saline, it's not very physiological. So it's got high chloride contents that can lead to acidosis and um plasmalyte. One for it also contains like a lot of uh sodium as well and it's a replacement fluid. Whereas in this instance, we just want maintenance. So um yeah. So option C is the correct answer in this case. Perfect. Okay. So we've got another question come up too. So you've got a 50 year old man. I just got three weeks of arthralgias, myalgias. So kind of like joint pain and also muscle pain. It's been passing dark urine, got a bit of shortness of breath and then if you look at his BP, it's a bit high as well. And then we've also got some your analysis um results there as well. So potassium can be added two bags as well. Um So yeah, I know, I think depending where you work as well, there will be um different bags of things and usually the nurses are the most kind of knowledgeable about these things that can help too. So super. Mhm. So you've got a few responses going. So we're thinking it's pre renal renal or post renal, any Christian dri or um hemolytic uremic syndrome as well. That's H U S. They've actually got a few good responses there. So the majority have got it right. So this is a renal AKI there's no mention of crush or like a diarrheal illness. So H S usually because after infection with E coli, especially like, oh 157. So that would, you know, they usually say he's had diarrhea or something to kind of point towards that prerenal. There's, you know, there's no mention in that he's kind of like got any dehydration or hemorrhage going on hypervolemia too. So, um, no clots, nurses. And then if you think about post renal, you're thinking what's obstructing kind of like um, urine outflow as well, kind of tumor's clots. He doesn't mention kind of any um post void dribbling or frequency or hasn't since he difficult extreme. So renal AKI and direct damage, the kidney is the most appropriate answer in this case. So, um next question, which of the following is the most likely underlying diagnosis. So I'll just put the whole if you, so I think it's TTP uh A I N should we sell previously? Um rapidly progressive glomerulonephritis, um acute to be in the process or keep piling nephritis? Mhm. Uh Answers coming through. That's really good. Super. So, um with the regional AKI we're expecting like direct damage to the kidney. So give us like a hammering a nephrotic type picture. So 80 N is the most common, but the question is then is kind of leading to like a vasculitis type picture. So it would be more likely to be kind of like rapidly progressive glomerular nephritis. And as you mentioned before, um A I N acute interstitial nephritis, that's the allergic type picture. But here we don't have like that classic allergic triad. So the answer is rapidly progressive glamorous nephritis. This one. So, um do I think they're recording will be sent out at the end of the session? So we've got another question coming up. So here it's just kind of a recall answer. So if you know it, you know it, you can hedge your bets as well. So here this patient has got CKD. Stage four and what type of EGFR measurement are you most likely to see? Mhm So you've got questions uh answers coming through. That's good. Your problems are super and the majority have you got, you have got it right is 16 mil um perm in. So there are five kind of like stages of CKD and you can kind of split like stage one, stage two and stage three in kind of like thirties and then stage three um split into A and B. So stage one is 19 above for E G F R. Stage two, there'll be between 60 and 90 and stage three is split still um between 30. So it'll be between uh kind of like 60 and 30. But because it's between stage three A and stage three B, it's like 15. So stage three A will be like 45 to 60 and then stage be will be like 30 to 45. So that means stage four will be between 15 and 29. So here their answer is um 16 mil. So we've got another question as well. So which of the following? I'm not involved in the management of CKD. So you've got a few medications and interventions we can give. Which one would we not use? So in this question, try and think about like the functions of the kidney that can like help you like what's the kidney responsible for? Like what, where is it involved in what processes? Yeah, super. And the majority of you getting raised. Well, that's really good. Super. So if you think about like function of the kidney um through the protein is made by the kidney, so we obviously want to kind of like replace that and um BP is important and in kidney function as well. So that ace inhibitor would help alpha calcidol is type of vitamin D and vitamin D kind of like needs activating by like um the kidney kind of enzymes. But in this case, in renal failure, the kid, we can't do that. So we're already giving like activated form of vitamin D. And then in chronic kidney disease, patient's tend to retain phosphorus. So you want to give like a phosphate binder and that's what the calcium carbonate is for. And as I mentioned, the chronic kidney disease patient have a prospect city to kind of retain phosphate. So we don't want to give them any more for phosphate. So we definitely do not want to give the last option. So brilliant, well done. So we're moving onto now, oncology and breast. So, another topic I hope you're still with us. So, we've got a 78 year old man. He's got some inability, some abdo pain, bilateral leg weakness. He's also got a history of angina and bronchial carcinoma and dre is normal. So, what investigation would we like to do? So, just put the cold look. So you've got PS PSA, do you want to do a CT spine? Do you want to do ct chest, abdomen, pelvis? Would we like to do an MRI spine or intravenous irritated from? Perfect. So this should hopefully be like a fashion. You've got it just. Mhm So in the interest of time, I'll move on. So well then the uh lots of you, you know, got it right. It is MRI spine that we want. So this man, he's kind of presenting with the quarter require nurse syndrome. So he's got where the nerves are being compressed in his lower back, which usually kind of like supply the lower body and also and the functions. So what we want to do an MRI is good at picking up soft tissues and particularly nerves things. So that's why I want to get the MRI done straight away and it needs to be done as soon as possible because this is an emergency. So next question. So you do imaging and then this confirms that you've got um spinal cord compression. So what is the most appropriate immediate management for this patient? Do you want to surgically intervene? Therefore, go through the consent process with them. Do you want to give him cocoon? Um all fluids analgesia. Do you want to give radiotherapy or we're going to give Dex dex methadone? Mhm. So you've got answers coming through. That's great. Keep on coming. Perfect. So those of you are going for the right answer. So um the correct answer here is loading dose of dexamethasone. So dexamethasone is like a very potent anti inflammatory. So we want to target the inflammation that is, you know, involved with the bony mets compressing the cause. So that's what we'd go for surgical intervention. We might not associate early do because that's kind of like a surgical. So we need a senior review with that and ideologies, urine fluids that can kind of like wait till earlier on what, what this person really needs is the dexamethasone. So in terms of spinal cord compression, we obviously want to look out for symptoms of it. So this gentleman had a normal dre but in terms of the bilateral leg weakness and that's what he did have and then I think he had some retention as well. So really what you want to do is MRI spine first, then you can go on and look for kind of do um cancer and look at the CT um you know, um cup and again, dexamethasone is really what I want to highlight this. So we've got another question. So you've got a 24 year old gentleman. So he woke up in a cold sweat and feels quite shivery. He's had hodgkin's lymphoma and he had his um last round of chemotherapy about second, three days ago. So he's a bit fibril. His heart rate is 85 as the pressure wanted to have sent you one. Um otherwise his abdomen is soft. So in terms of management and what would you like to do for this patient? So, just thinking about his obs as well, that might discount some answers over others. Yeah, I can see that most of you going for the right answer as well. So that's great. So really what we want to do is commence IV Pipracil in terms of act. Um So this person, they've got like a type of um neutral clean except is going on. So you really, really need um to give like a broad spectrum antibiotics um ASAP. So um that's why we want to, you know, give it IV as well. His, he's getting chemo, his immuno suppressed. We really need to kind of get on top of this as fast as we can. So, and here we also had temperature as well and if we did a neutrophil count, it would probably be less than 9.5 as well. We'd want to go away straight in with sepsis six and um not delay giving the antibiotics. Obviously, we want to try and take bloods off and then give the antibiotics straight away. And then if there is no response after kind of like the later stages, then you'd look for for the fungal disease as well. So, amphotericin B and further imaging too. So we've got another question. So we've got, uh, you're an F Y two and you're seeing an 89 year old man with metastatic prostate cancer and he's got um an uncorrected calcium of 2.9 and on his birds, he has an albumin of of 28. So that's low. And what is the most appropriate initial course of Axion? But it's fine. Mhm It's good. We've got a few answers coming in. Perfect. So the majority have got it right. So, um you would want to give saline rehydrate and then you want to recheck the calcium. So we're given the uncorrected calcium which is 2.9. And then we're told that this person also has a low album in as well. So um there is interaction between kind of like calcium and album in as well. So in this case, we could actually be underestimating um and his calcium could be lower than what we actually think it is, which is why we corrected the calcium. So it could underestimate the health hypercalcemia in the sense. So even though it's 2.9, his corrected calcium might be kind of towards the 3.8 level as well, which is so that's why we'd want to start giving him fluids and then rechecking his calcium too. Iv's Alendronate. We can always go on to as well. But first, you want to rehydrate this man. And then, as um is mentioned in the answer will be three liters, which is quite a lot of fluid over 24 hours. And then again, if it persists, then we'd consider something like say alendronic acid too. And then I'll let you read that in your own time as well. Don't worry, the slide's will come out. So you have access and then we've got some breast cancer questions coming up now. So in terms of breast cancer drugs, I know there can be a bit, you know, all over the place, but it's good to just have a few of like the main ones in your mind as well. So, um tamoxifen let result and Herceptin. So it's important to know which ones work for like kind of the E er positive breast cancers. So um that's E R is epidermal growth factor and then sorry. Yeah, eastern receptor then H E R two. So human epidermal um growth factor. So, first question. So you've got a 67 year old retired nous and she's got a large lump and no systemic symptoms and then she's shown to have grade three invasive ductal carcinoma and it's er positive and H E R negative. So, in terms of medications. What would be the most useful for this lady? Mhm. So we've kind of got two that are in the lead so far. That's good. So um the majority have got you right is lecture results. So in this lady, her issues and receptor is positive and the human epidermal receptor growth factor is negative. So, Herceptin, it's an antibody that targets H E R two receptors that the expressed on the surface of cancer cells. And it works by interrupting like ligand binding. I need to get like no cell proliferation but her, her is her H E R is negative. So we wouldn't use Herceptin in terms of Elektra's all. Um it's an aromatase inhibitor. So it's reducing the circulating levels of plasma estrogen. And we're told that her breast cancer is estrogen receptor positive. So this is something that we would want. Tamoxifen is also affecting um kind of like that. It's an estrogen receptor modulator. It has like agonist ick and antagonistic um effect depending on what tissue is targeting. Um However, for this lady, she is post menopause or electrical would be the most appropriate answer in terms of Gaza rela it's a hormonal therapy that affects um the GNRH. It kind of like lowers um your LH and FSH and it's more used in kind of like prostate cancer because it reduces the amount of testosterone that kind of the cancer cells feed off of. So just move on to the next question. So, so this lady, so she's HDR T positive and she's started on trust as an AB which is Herceptin. Uh sorry, she's about to start it. And before this, um we've been asked to kind of like counselor about what would be done. So what will she need and what will she need throughout the treatment as well whilst taking this medication? Mhm. So that's a spread of answer. So that's good though. So we've got kind of like liver function testing need and then also echocardiogram and then someone is also going for like nerve conduction studies as well. So in this case, the correct answer is you'd want an echocardiogram. So his septum is generally kind of like well tolerated, but there is a risk of cardiotoxicity. Um and and it's due to kind of like the reduced um H E R signaling in the heart and then it decreases the function of cardiomyocyte. So with this lady, you definitely want to do an echo and check a rejection fraction as well. And if it makes it easier, Herceptin hate for heart as well. So if you think about Herceptin, think about heart, think about doing an echo. So sometimes these little things help. So we use them all. Don't worry. And if you've got your own, that's great as well. So we're going to move on to urology as well. So this is our last topic. So we've got 20 minutes to go. I think. So we're doing well. Um, if you do need to leave, please leave, this session is recorded as well. But otherwise, um, we'll just continue on and just, um, if you are leaving, just to remember to fill out the feedback form as well, it's just popped through in the chat as well. So, we'll be really grateful. So you'll get your certificate as well. Perfect. So, um, on to urology. So we've got a 38 year old man and he's come in with a three month history of scrotal swelling and on examination and you've got a unilateral swelling in the left scrotum and this is transiting relating brilliantly. The swelling is soft, it's nontender and basically due to the presence of fluid, you can't really kind of palpate the structures and the test is full this fully. So what do you think is the most likely diagnosis? Do you think this is a sebaceous cyst? Do you think it's a hydrocele? Do you think it's a Varicocele? Do you think it could be cancer as well or a spermatocele? Perfect. So, I think this is quite an easy one for you. Pretty much all got it right so far. So yes, it's a hydrocele. So the main giveaway here is the trans illuminating brilliantly as well and the kind of like the fluid as well and not being able to pal palpate the chord structures as well. That is classic of a hydrocele as well? Varicocele. And let's see if it's on the next one, we'll just go back. But varicocele basically feel like a bag of worms and then testicular cancer is usually adherent to the testes itself. It won't be separate. So that's why it's not the other answers. So I don't have a pulse specifically for uh these ones. So if you just want to type in the chat box, what you think A B and C are, have a go there's, you know, it's good to have a bash and even if you get the answer wrong, it's good. Perfect. Well done Alex for mentioning your answer. That's good. Try and have a look at what could be going on. Mhm Super. Yeah. So the first one was a little difficult I must um imagine as well. But the first one is idiopathic scrotal edema. Uh This can be quite market as well, just abdomen generally. So um it's a condition, it's benign because in like young boys and not adults, um the scrotum in this case, it's red but it's not painful. So, you know, they shouldn't be screaming out when you go touching them, but as you rightly pointed out B is torsion. So this will be, you know, you'll get the sudden kind of onset of pain and they'll be vomiting and this is an emergency situation need to kind of like go in there do scrotal exploration and kind of re perfuse the tarted um testicle there. Um Barrack Seal Yeah, well done. We'll see. So it's a little bit difficult, but you can kind of see, it looks a bit like a bag of worms. It looks a bit more veiny and also it's occurring on the left side as well here. So that kind of gives you a clue if you think about the anatomy which will come onto. So, um, just in terms of what we've been seeing as well, so as I mentioned, hydroseal and it trans illuminates brightly and the ultrasound will confirm this and it's not painful to touch varicose seals and they'll kind of have like the bag of worms appearance and not, it's not painful as such but can cause like a discomfort like a dragon sensation and then epidural smith cysts, they usually occur like on the top and it's also known as like a spermatocele as well. So, epididymal cyst spermatocele, the is good to know different kind of definitions. So, yeah. So next question, we've got a 20 year old man. So he's got a hard swelling in his last Gautam. Um The GP can't separate it from the testes. So in terms of blood tests, um what should we be ordering for this young person? Sure. So if you think about the age range of this patient and you're thinking about it can't be separated from the testers. Are we thinking, you know, it's a growth from occurring within the testes or the structures around it? Mhm. Yep. So we've got a few people going for Beta HCG. Also see a 125 and see 99. Wonderful. And like most of you have got it right as well is Beater A C D. And here we're thinking this is kind of some sort of testicular cancer. So see a 125, that's um a tumor marker for ovarian cancer. See, a 99 is a tumor marker for pancreatic cancer. If you think about the number nine and see a 99 if you turn it sideways, it looks a bit like a pancreas. So I guess you can imagine you've got like the head of pancreas with the head of the nine and then um beats two microgram boon. It's a tumor marker. Um that's found in multiple myeloma and then serum haptoglobin. It's a protein that binds kind of like free red blood cells. So it's more so like a test for humility, humility, anemia. But yes. So the correct answer here is the beta HCG. Yeah. So just a little bit about testicular cancers. The age ranges typically between 20 and 40. Um And again, as we stated in our question, it's attached to the testes itself. So you can't separate it and it doesn't trans illuminate, there's no fluid around it to say you want to do a scrotal ultrasound as well. And, and you can also include alpha feta protein and LDH as well. And you also want to um stage cancer as well. And yeah, so we'll move on to the next question. So we've got a 32 year old man and he's presenting with severe left acute loin pain and he's got nausea and vomiting, but he doesn't have a temperature. And the CT scans shows that he's got a 25 millimeter and stone in his left kidney. So, in terms of management, what would we think would be the best option for this patient? So would we go for PCN L? Would we give this guy some decline finnic? Um hoping that he'll just pass the stone naturally. Would we try and kind of give him some shockwave birth, lithotripsy as well or would we just give him some tamsulosin or a calcium channel blocker? Would we try and put in a tube to kind of like relieve any puss that may have built up by doing a percutaneous nephrostomy? So here what will help you is kind of like the size of the stone? Mhm. So it's a bit of a close run between PCML and also um shockwave lithotripsy. So if we look at the question stem itself, um it's telling us 25 millimeters. So any stone over 10 millimeters basically unlikely to expel naturally. So we're really going to have to intervene. Um E S W well, tends to be used for stones that are less than 1.5 centimeters, so less than um kind of 15 millimeters. So that's why this gentleman probably wouldn't have E W S L E S W L, sorry. So we would go for the percutaneous nephrolithotomy. So this is tend to be reserved for stones that are over um two centimeters and you go in via the skin. So, percutaneous and it's usually using a guidewire and a nephroscope is inserted and you go in basically to have a look into the kidney and then also able to remove the stone. This can either be like pulled out or it can also be broken up into pieces to and using the laser. So in this case, we go for the methodology, lithotomy for this person. And then we have our next question. So which of the following is not an indication for urgent intervention of nephrolithiasis. So a kidney stone. Mhm. So I can see you've got a few responses coming through already. Mhm Yes. So there's a bit more spread of answers as well. That's fine. No, that means we can like talk to it as well. Okay. So can ask me you want to put your answers in. Oh, it's close. There's a lot of similar responses going on here. Okay. So um the first response. So fever flank pain hypertension, that's kind of giving us a picture of like you're oh sepsis. Um is definitely something you'd want to do an intervention for. So that would not be the correct answer. This question. Also refractory pain as well is something you know, if you find that your first way of, for example, just giving diclofenac or tamsulosin is not working and they're still in pain, you need to do something about it because there may be um something that may have not been picked up. So you don't want to go and do an urgent intervention in terms of obstruction in solitary kidney whilst um understand, you know, that you want to really want to relieve the obstruction. Um They do have another um kidney that can compensate. So that's why and then a Frankie mature eah. Um in this case is actually the correct answer. So this can occur for a number of reasons. So you can have Frank hematuria because you've had kind of like a traumatic catheter. It can also be post um kind of bladder procedures as well. You can get Frankie materia. So you wouldn't go and try to intervene for, you know, a kidney stone because there's other options there. So, in this question, the correct answer is Frankie mature. Eah. So we've got our next question. So we've got a 53 year old man. He's got recurrent kidney stones and um he's got a few co morbidities. They're, and he's also been taking vitamin D. So which of his medications is least likely to be causative of the recurrent kidney stones. So, you've got some diuretics is in there. You've got some treatments for gout's. Um and I said to Zolamide. Mhm I actually got a few responses starting to trickle through. That's good. Yeah, it is a bit difficult because some of them are quite similar. So. Mhm. Okay. So we'll like stop Nicole roughly there. So, um, the correct answer is actually the thiazide diuretic. So this is because it reduces the amount of calcium that gets released into the urine and information of kidney stones if you have lots of calcium in your urine that makes you more prone to getting kidney stones. So by the fire died, thiazide, reducing the amount of calcium that gets released into your in your reducing the kind of likelihood of kidney stone information. So it would not be contributing to his picture. Um And the uh acetaZOLAMIDE, it's a carbonic anhydrase inhibitor. So this can increase kidney stones. Um it basically interferes with like calcium phosphate metabolism. So that's its mechanism of Axion. Um vitamin D. Um it increases um urinary kind of like calcium excretion. So again, it's making um the urine have more of a calcium content leading to um more prone for formation of kidney stones and then thorosimide, it's the diuretic as well. So it interferes with the metabolic um um way of the kind of formation of the stone itself. So in this case, thiazide is the correct answer. So in terms of like kidney stones, um as I said, um size is really important. In this case, you want to look at how big it is in terms of millimeters, generally for stones, less than five, you can like watch and wait in a sense and you can give some pain relief as well. If they're less than one centimeter, we can try tamsulosin and also calcium channel blocks as well. If it's more than a centimeter or you've got the other indications were talking about for interventions, we'd really want to, you know, intervene, um either consider the shockwave lithotripsy um or kind of, you know, other interventions even proceeding to kind of like PCML or even taking the kidney out in some cases. So, effects. So we've got um a six year old man and he's referred to their urologist and he's got lower urinary tract symptoms and he's got basically in a large irregular prostate and it raised BSA um after performing your transrectal ultrasound and biopsy, we've got a Gleason score of four plus four and he's also got spiny mats, but he didn't have any symptoms of this. So with that information of mind, what would be the most suitable treatment for this gentleman? Should we just take out his prostate altogether or should we just take his prostate out with some kind of spaniel radiotherapy? Or should we give him inserts and radioactive kind of like, um, seeds and give him some spinal radiotherapy, all that post hormone therapy? Mhm. Okay. Well, see, for those of you who don't know like the Gleason score, um, basically, it's kind of like a graded system when it comes to prostate cancer. So it's maybe just an idea of refreshing what that entails as well. So with this question, this gentleman does have spiny mats. So this cancer is spread, it's not local to his prostate anymore, but he doesn't have any symptoms from this. So, um really the prostate cancer is relying on testosterone to grow as well and in the assistance and the combined goserelin and dust axle therapy is the kind of like the correct answer. So, um Cotterell in is um stops LH release and then that influences the testosterone by lowering the testosterone. So you're hoping that the cancer doesn't grow more and the DOCEtaxel is a chemotherapy agent and this interferes with the growth of cancer cells again. So you're trying to, you know, stop the cancer proliferating in and the prostate in terms of the spinal radiotherapy, we can, I can understand why given the spinal nets, but at this point, he's not experiencing any symptoms. So we wouldn't go down the radio therapy route for him. And um as I mentioned, the brachytherapy is radiotherapy is radiation. So these are little seeds that are inserted in the process and is the prostate, sorry. And it's more for like local cancer. Whereas um in this gentleman, his country has already spread. So it really wouldn't be useful for him. Perfect. So I think we're almost there guys. I think we're coming to the end, almost there well done. So we've got a 72 year old man and he has a CT because they're thinking it could be suspected diverticulitis or we've got a little nodule on the left kidney. Uh, this is trying to be renal cell carcinoma. So, which of the following is not a recognized feature of renal cell carcinoma. So I'll just give you a hint, this can be to do like the anatomy as well and just remember to read like the kind of laterality of things in the uh I don't know if you can hear me, but I've had a problem come up on my chap on my connection. Um That may be to do with timing, but thank you very much for hanging on everybody. There is only one final question and the answer to the final question, if you wanted to note it down was VHL just Von Hippel Lindau. It's a bit of a spirits rare thing that's connected with the question stamp, but that's just for your and that was the only question that was left there. So we just about managed to keep in time. So I hope that wasn't too fast. We've covered quite a lot of different topics there. It was a big two hours every time. There's a lot I know, especially coming up to exam season, but as I mentioned, you'll have this recording later on and to look back to you. So please fill out. So the last question okay. No problem. Yeah. So it was basically asking, let me see, hang on if I can bring it up. So um basically the question stem, it was a person who had um being treated for renal cell cancer. And he also had like resection of cataracts, but he was discovered to have on his retina, a renal retinal hemangioblastoma. And the question was asking what condition is likely to be causing this. And the options were hereditary hemorrhagic telangiectasia Von Hippel Lindau syndrome leave from any syndrome, a bracket mutation. And in this case, the answer would have been VHL. It's a really weird one where you can have like different tumor's arising in different organs. So it's just want to be aware of, but I hopefully you'll see that at the end of the slides. But thank you ever so much for, you know, staying on till the end, you've done brilliantly. I really appreciate your participation as well. It makes it so much for engaging. And as I mentioned, um there should be a feedback link as well and we've got the Facebook event link. Um We can look at the further events. I think the next one will be on pediatrics as well. So make sure to attend that. And um I hope you have a good rest of the evening. I'll hang around for a bit if you've got any questions as well. So don't hesitate to drop me a message. Um I'll also put my email in the chat box as well. Thank you very much, Louisianna and apologies for the connectivity issues, not sure what happened there. Um But as Louisiana said, we'd appreciate if you can fill out the feedback form um as well as click going on our Facebook event link because we've got three more sessions coming up. Um But yeah, otherwise thank you very much for coming and I hope you have a great evening. Oh, so 39 the answer was there right sided Far Castle. So that was because you should be expecting a left side of advocacy or for that one. 2 39. Thanks everyone. Yeah, please remember to fill out the feedback link as well. It's just popping up in the chat as well intermittently. So, and as I said, the next session that I think is on pediatrics as well. So you've got an awful lot of good content coming your way. Hang on for another two minutes. If every new ones got any, like last minute questions as well. If you don't have any at this time, you can always like message me, um, send me an email. I put my email in the chat further up. So, yeah. All right. Well, if there are no more questions, um I think I'll sign off, but, um, good luck with everything. I'm sure you'll do absolutely fine. So, yeah, you have fun. Enjoy the rest of the evening by everyone.