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Yeah. Mhm. We've got some people joining. Ok. Hello everybody. We'll start in, we'll give everyone a couple of minutes because I think we've got a few more people joining and then we'll start but welcome. No, take care. Bye bye. We can probably start with the introduction actually. Should we just start with the introduction and then people who join? Sure. Um Can you see the record button on your end? It says live, whether it's being recorded, I can't see. Have you pressed record? No. Mhm. I'm not entirely sure. Actually, it does say live settings. No, it's not come up. So that's fine. Sorry for the delay. Shall we assume it is being recorded? I think. Let's assume otherwise the slides are going to be available to everyone anyway afterwards. So. All right. Ok. Brilliant. Let, let's just crack on then. So, hi, everyone. Thank you for joining us um, on a Thursday evening. So today's tutorial is hosted by myself and also Milly. Um, maybe you've seen us before when we did our C MB series a long time ago when we were in second year and you were in first year. But anyways, we are currently in fifth year and we're presenting our topic today on abdominal pain and LFT S. So, um, if you're new here, this is part of a teaching series called Teaching Things. Uh We do weekly tutorials um at 6 p.m. every Thursday and we're focusing on core presentations, um and also approaching things with an AK style because we do appreciate how tricky that can be in your first clinical year. Um Our slides are reviewed by doctors for um accuracy and we keep you guys updated on our events through emails, group chats. And you can also subs subscribe to our teaching things um account on medal, uh which he can follow as demonstrated here. So today's um learning objectives, uh we want you to be able to identify physical signs um come up with some investigations and just awareness of management for some range of conditions that present with abdominal pain. Um being able to understand the difference between initial versus gold standard investigation or definitive manage uh sorry, initial versus definitive management. Um And this is very much an a QT specific skill um understanding LFT S. What do they mean? What do the results indicate and also how to present those findings in a CPS A and OS scenario. So these are some sort of conditions we lifted off of the UK MLA content map um that can be relevant to this specific presentation. This is more so for your own revision. Um and maybe coming up with some differentials this can help you with that. So I'm gonna hand over to Millie to get us started on some quick fire questions. Ok? So um hi everybody. Um so what we're gonna do is we are gonna give you a few kind of quick five questions that we want you to have a think about write down your answers. And then what we're gonna do is we're gonna bring these questions back at the end. So if you could have a quick read through, I'll, I'll also read it out loud in a second. The idea is that you write down your answer and then at the end, you see whether maybe you might have changed your answer, maybe you might have some different ideas. So don't worry too much right now, if you're not entirely sure we'll be able to go through all of this at the end. So we've got a 40 year old woman who's come to the GP complaining of pain in her right side. She says that it comes and goes, but it's especially bad just after eating and it's also been going on for a few months. Um And she also mentions that she's gained a lot of weight recently now with a BMI of 34. So now what is the most likely diagnosis and you've got a few there to pick from? So everyone just have a quick have a thought, write down your answer and then what we're gonna do at the end is we're gonna put up a poll so we'll be able to put down your answer. Ok? I think we'll get a few seconds and then we will move on. Ok. So we'll move on to the next question. Uh, so this is the next one. A 65 year old man represents the emergency department complaining of extreme pain, feeling like his insides have been ripped out when asked about the location using Socrates. Um We'll go through that a bit later. He tells them that the pain appears to go through his back. The man is becoming more confused and is sweating profusely and subsequently collapses in the ed. What is the definitive management for this condition? So, just have a think, write down the answer and remember if you don't know this right now. That's ok. The idea is that, um hopefully by the end, you can have a think about it. Um You've got the whole session to have a thing, ok. And let's move on to the third one now. So, um this time, um a 24 year old presents to the emergency department after her partner noticed that she had turned yellow, she is very distressed and she is usually very healthy and has noticed no other issues lately. Um So you send off some function tests, which is going to be the focus of today. And um we had the results of an alt of 40 an ast of 25 ALP of 45 GGT 25 and total protein 6.5 Bilirubin 27 album 4.3. Um, everything else was completely normal. So what is the most likely diagnosis? So, um, have a think and there's the reference ranges that we've put in for you there as well. So, um, just consider what it could be. Um And then we will move on and as I said, don't worry if you're not sure. Right now, we're gonna be um going through these later on and you'll have another opportunity to change your answer if you have any other ideas. OK? I think we can carry on pre um All right. So this first section is just covering some key concepts that we think might be um good to sort of keep in mind for those ay situations. So the first slide here, questions to ask for abdominal pain. So in the chat, would you guys be able to um write out some questions that you might wanna know from your patient? If they come in with Abdo Pain Millie, you're gonna have to very much be my eyes cos I can't see the chat. Uh I can't see any messages yet in the chart, but if anyone else wants to write some things down, it doesn't matter if, if you're wrong. Don't, don't worry at all if you're not sure just anything is great. Someone says, when did the pain start. Someone else has said how long has the pain been present for? And when did it start as well? So, yeah. Good time, sudden or gradual onset. Yeah. Really important. Anything else? What is the nature of the pain? Good. Um And for the person, I think Rohit, you said the nature of the pain. What kind of things are you thinking with nature of pain? Can you name some things? Uh someone else has had location of pain? Any ra radiation? That's great onset. Yeah, postprandial or constant good. Anything helping relieve the pain? I can see some people have a good framework in mind. Yeah. Ok. I think let's um stop there. That, that's some really fantastic answers there. I think we're very much following. Um I loved Mnemonic Socrates. Um If you aren't familiar with Socrates, it's a good way to have a framework when you're asking a patient about pain. It doesn't have to be abd, it could be pain anywhere. Um But it's a good um framework to follow. So it stands for sight onset character, radiation, any associated symptoms, the timing of the pain, any exacerbating symptoms and then severity. So rating the pain out of 10 is always good to tell the patient. 10 being the worst pain you've ever felt and one being um sort of no pain at all. So for abdo pain, specifically, abdo abdominal pain is one of those presentations, which is annoyingly vague because it covers a ton of specialties um under that presenting complaint. But I would say in terms of in an osk situation, if you were to be presented with this situation, I think two of the most important things to identify is onset of the pain. So, is it acute subacute chronic cause that can often tell you um about sort of whether it's an emergency level thing that you need to sort out, for example, like a triple uh AAA um or whether it's something that's more sort of uh ongoing long term like peritonitis or diverticulitis, that's been a long term issue. Um And then looking at the sight of pain. So looking at the nine regions, this is an image from geeky medics, which is really helpful um and useful to sort of um refer to in your history, some other things that can give you an indication of the diagnosis. So looking at the age and gender, so there are certain um diseases that occur in certain age groups. So for example, cystitis, um that's a renal condition that's more common in women. Also gallbladder disease as well is more common in women as well. Um Looking at age, for example, so vascular disease is more common in the elderly, but then mesenteric adenitis is more common in Children. So age and gender could usually point you in the right direction of what the patient might be presenting with. We talked about pain onset and then characterization. So when we talk about colicky pain, pain comes and goes in ways that's usually indicating some sort of obstruction of a visceral structure. So that could be the ureter, it could be the bile ducts, it could be the intestines. Um, any severe pain on movement, that's usually suggesting either a perforation or a peritonitis. Um, any tearing pain or tearing pain that's suggestive of aortic dissection or rupture. So that's sort of leading you down a more vascular route and in constant dull pain or constant sharp pain. Again, that's inflammation, um infection. So we're thinking appendicitis, diverticulitis or peritonitis and things like that. This next s slide is talking through some key differentials for ABDO pain. Um I've gone more extensively into the gi ones because that's what this presentation is about. Um But we've also got some brief um explorations within renal gyne vascular and also other causes um um of abdo abdominal pain. Uh What I will say is from my Acies, what I learned last year is I think it's quite easy to come to the diagnosis. Usually that's not the sort of um most common problem for a lot of students. It's rather coming up with um sensible differentials with the symptoms that the patients presenting cos often when you've got the diagnosis, you sort of have blinkers on and you can't really think of anything beyond the diagnosis itself. Um So it's a good idea to practice co uh this particular skill of being able to come up with key differentials um for any presenting complaint. But yeah, hopefully this slide should be able to help you out with that. So, coming on to our next question, what are some functions of the liver? Hint there are five. So again, please do put your answers um in the chat. Uh someone says, role in clotting. Yeah, absolutely. Uh We've got conjugating bilirubin, we've got detox. Yeah, these are great. Thank you guys. Keep going. Yes. Got metabolism, clotting factors and protein synthesis. So the synthetic function. Yeah, absolutely. Um Gluconeogenesis as well. Great. I think we've almost gone through all of them. So we've got a detox which is great. Um Maybe there's one more, I think maybe that. Yeah. Say anything. OK. That's OK. Let's um have a reveal of the slides. So most of you got all within all five sort of features of the functions of the liver. Um We've got filtration. So, yes, it removes those toxins, those um byproducts. It has a metabolic role as well of breaking down carbs fats, amino acids and conjugating that bilirubin storage. So, glycogen iron and copper synthetic, that's a very important function. So producing bile producing fat soluble vitamins. So the way I remember those is Drake um but the are are small because it's Vitamin D AK and E um the liver also produces clotting factors. I'll explain the bracket in a bit. Um And then obviously detoxing. So, breaking down ammonia into urea for excretion or other hormones such as insulin. Um So the reason why it's important to know vaguely the functions of the liver, you don't really need to go into the specific details. But when you're looking at management, so for example, a patient suffering from chronic liver disease and then you see on their management, they've been, you know, prescribed um Vitamin D AK and E and you might be thinking why those specific vitamins just having an idea that the liver actually synthesizes vitamins. So if they have a not very functioning liver, it is important to manage them in that respect. Or maybe a patient comes in who, you know, has cirrhosis or severe liver disease and they're also presenting with some clotting problems. So we know that Vitamin K is necessary to produce certain clotting factors. So the the way I remember those ones is 1972. So clotting factors 10, 97 and two. Uh these four rely on Vitamin K in order to be produced. So obviously, if your liver shot, then you're not producing the Vitamin K if you're not um supplementing that within the management, and then if you're not supplying that Vitamin K then that's going to impact on those clotting factors as well. So just thinking about the bigger picture and how those dots connect can be quite useful. Uh if you're on the spot and you're trying to figure out either the cause of something or how you would manage something. Um, coming back to the original sort of, um, physiology can be a useful thing to do. Brilliant. So this is just a brief anatomy of the biliary tree and the gallbladder. I remember in fourth year I was really confused cos every disease to do with the gallbladder started with AC and I couldn't really sort of differentiate between the different ones. So this is why this image is, er, here in the slides. So, uh really briefly, we've got the right and the left hepatic ducts, they come down together to join the common hepatic duct. Uh We've got the cystic duct which branches out from the gallbladder that joins your common hepatic duct to form your common bile duct, which then leads down um into your digestive system. So now if you have a problem at each of these specific bits that then has a different name. So if you've got inflammation of the gallbladder, that's known as cholecystitis, if you've got um, an inflammation within the b biliary tree, then that's known as cholangitis or acute cholangitis. Um, if you've got a stone blocking the opening of the gallbladder, then that's known as biliary colic. So it's just a good idea to be familiar with all the different terminologies. Um, there's a useful Pneumonic to know. So, fair, fat, female, fertile and 40. These are your risk factors. Um, for gallbladder disease, it's not the most polite pneumonic wouldn't recommend seeing it in front of patients, but it's a good and easy way to remember what your risk factors are if you think someone's presenting with the symptoms of gallbladder disease. Um and then really quickly going through understanding the causes of jaundice. So as we know, they can be divided into three different levels, prehepatic, intrahepatic and post hepatic and they all present in slightly different ways. So, your prehepatic um causes um of jaundice can include things like excessive breakdown of red blood cells. So, excessive hemolysis and what's that, that's causing um an overproduction of unconjugated bilirubin. Now, the key thing to remember about unconjugated bilirubin is it's not water soluble. So when you're looking at the patient in front of you and you ask them, have you seen any changes in your stool or urine? They might say actually, no, I haven't. Um It's actually normal in color and that's because your unconjugated uh bilirubin can't actually be excreted within the urine. And obviously, the stool is going to be normal in color because you're not blocking that release of bowel production or excretion um into the digestive system that's intact. So that's why you get those normal stool and urine uh presentation. Uh if we're looking at intrahepatic causes of jaundice. So that's either going to be a problem with the liver itself or it's going to be a problem if we go back uh with something pressing on those right or left hepatic ducts uh and that comes under your intrahepatic causes of jaundice. So, at that point, you've got um, both conjugated and unconjugated bilirubin within the bloodstream. So your stool actually might appear a bit pale or a bit clay colored because if your bowel excretion is impaired, obviously, that's going to affect the coloring of your stool, your urine um will be dark because um, conjugated bilirubin, in fact, is water soluble, unlike unconjugated bilirubin. So that can leak into your bloodstream and get excreted by your kidneys, affecting the color of your urine. Um So that's the sort of picture we're seeing with intrahepatic and there's loads of causes, you've got hepatitis cirrhosis, uh PVC cystic fibrosis, all these can cause um an intrahepatic picture and then finally, post hepatic. So that's any sort of obstruction or problems with the biliary tree itself. So, after the liver, um and that's those uh problems we talked about in the previous slide. So at this point, um we've very much got a problem with uh bilirubin excretion. Um And so that is going to cause that dark urine again because of the conjugated bilirubin being water soluble. And it's gonna cause those pale stools because of that lack of bile pigments actually entering the digestive system. OK. That was a very quick whistle stop tour through some key concepts. I'm gonna hand over to Millie for LFT S. OK? Thank you for that. So, my first question for you guys um is Well, why, why are liver function tests? Like why do we do them, why, why are LFT S done? Can anyone think of any ideas of, you know what indications we might have? Ok. Let me just have a look at the chart. Um We've noticed patients coming in with jaundice post COVID vaccine vaccine um suffers with hepatitis. OK. Any, any other ideas? Why else might we check LFT S? Ok. Ok. So one thing that I found is also really important. Yeah, hepatitis is very important whenever you order any investigations to think. Well, why am I ordering this particular investigation as it's something that they could ask you potentially in a nosy or C PSA situation? So, when everyone kind of goes, oh, what investigations would you do? And you kind of go FP CS using these LFT S going through all that? It's really important to think. Well, why am I doing each one of those? Uh, great. We've got some good ones here. So, after giving certain medications. Yeah. Absolutely. So, some medications are hepatotoxic, um, drug metabolism excretion. Yeah. So sometimes before we give medications as well, we want to do it, uh, to do an LFT because if they've got poor liver function then they're going to be metabolizing their drugs differently. Um, looking at what part of the system is damaged. Absolutely. We're gonna be going into this, so, preassessment investigations. Good. Yeah. So sometimes we need to do, uh, kind of just some general, uh, pre pre op assessments. Um, ok, let's have a quick look just because of times. So, um, yeah, we want to investigate patients with suspected liver disease. We want to monitor effects of hepatotoxic medications. So someone said that already, um, monitoring patients who've got confirmed liver disease as well is very important. So, if they've already been diagnosed with cirrhosis, you want to be following them up. Um, and also just as part of baseline screening as well for patients presenting with a wide range of symptoms as well. Um Normally the LFTs are included with that. Um especially given the kind of number of different risk factors, the kind of general population might have for particular liver diseases. So let's carry on. Um So can anyone write down quickly? Do you know what LFT S include? Just kind of any standard, any kind of things that you can think of that you've seen before? Um I know sometimes there might be a bit more or a bit less but anything that you can think of kind of standard ones, um I can give you a clue. A LT is one of them. Ast. Yeah. Bilirubin. Excellent. Yeah, excellent serum protein. Yeah, albumin T Yeah. Um And so sometimes we can go on to the next the next slide if that's all pre. So these are the ones that we've provided today. So sometimes they can also then go into kind of unconjugated and conjugated bilirubin as well and serum protein. But we've just kind of given you the basic ones for today. Um And then we've provided some reference ranges too. Um So uh I don't need to go through all of them, but essentially what we've got is a mixture of uh enzymes, proteins and then bilirubin, which as we mentioned is a breakdown product of uh red blood cells. Um So let's have a little look at the next one. So does anyone know like the kind of if I asked for the location of these? So uh alanine transaminase, aspartate aminotransferase, you know, where, where would these particular enzymes be found if we had to kind of localize them? Um I need a uh G GTA LP and yeah, that's, that's the, the last two I'm gonna start. It's like a tongue twister a little bit. Um Oops, someone said in the child, sorry mitochondria. I'm thinking a bit more kind of just like in a, in a grand sense of things. Um kind of just like which kind of c like cells maybe? Um or which organ maybe? Yeah. OK. So ast we've got liver, um muscle, kidney, alt hepatocytes, alp, bone and bi tree? OK. Good, excellent. So let's go on to the next slide. So um essentially, this is just important to kind of just be aware of because if you can try and figure out and localize where each of these are, then you can start to think about why, why they may be raised. So for example, with ap we often um we can often associate it with certain conditions, you know, whether it could be hepatocellular disease. Um sometimes we may also get kind of it in as well. But because it's also found in the bone, we also need to start to think. Ok. But is there maybe some kind of uh bone disorder, is there some kind of problem there too that we need to be, need to be aware of? Um So it's just important to kind of think about the, the where these are located. So that's why I wanted to give you guys that slide. Um And then Bilirubin, do you guys know we've kind of, we have spoken about it about what it is. Um But do you guys know kind of what it could be a marker of? Um And also do you know what an isolated bilirubin rise without further LFT derangement might suggest? Do you guys have any ideas about those questions? Um I appreciate it's a little bit difficult to see the questions, but if you guys can have a think about those and you don't have to answer them all in one go, you can answer multiple, you can answer one or the other. It doesn't matter too much. Um If you don't want to answer, you know, the first one, you can answer the last one. OK. We've got uh bone pathology pagets. For bilirubin. I don't know whether that was from a previous, from the ap possibly hemolytic conditions. Ok. I think what we might do is just, just for time. So, um I appreciate. Thank you. So it's a breakdown product of hemoglobin release into the blood when, when red blood cells hemolyze, which is uh what pre has mentioned already. Um So we say that it's a marker of like severity of acute cholestatic pathology and also acute hepatocellular liver injuries as well. Um And if we have a an isolated bilirubin rise without further LFT derangements, normally, we're thinking of prehepatic jaundice or we're thinking Gilbert's disease. So, um sometimes with a prehepatic jaundice, it may not have caused further derangement quite yet with um some of the uh liver enzymes. So it might not have reached that point yet. Um But so it could you, it's important to kind of be on your list of differentials, but Gilbert's disease as well. So, um Gilberts syndrome, if you're, if you haven't come across it, um it's basically a congenital disorder that's present in about 5% of the population. Um And it results from a deficiency of um glucosyltransferase which is responsible for the conjugation of bilirubin within kind of liver cells. Um So essentially we can end up with a raised bilirubin and, you know, people will be jaundiced, but they might seem perfectly well. Um And they don't quite understand what's caused it. Um And yeah, so it's just an important thing to be mindful of on your differentials. Um OK. Yeah, so I think some of the chat is coming in a little bit later. So, I'm sorry. Um I've had the isolated uh bili bilirubin increase. Um, so, yeah, thank you. Um, so essentially what we've done is we pop this in just kind of for your reference, you guys will be getting all of the slides, er, anyway, um, but this kind of just shows you how bilirubin is it, you know, where it's broken down, where it is taken, when it's taken to the liver. We have mentioned a few things like conjugated and unconjugated bilirubin today. Um, but we don't like, we didn't wanna go into like every single aspect of it because this would probably take around, you know, 15 to 20 minutes itself, but do be aware of some of this physiology. Um It's all helpful to kind of understand that that's why we did the anatomy as well. If you start to understand the anatomy and physiology of these things, things make a lot more sense when you start to interpret. Um, some of the FTS. So we'll, you'll have all the slides so you can have a little review of this at a later date. Um So next, just albumin. Does anyone know um what it is and what it demonstrates if you can just pop it in the chat? Oh, you got someone, any, any thoughts on albumin osmolarity. Ok. Anything else? Yeah. So it's a protein. Absolutely. And, yeah, it can affect the osmolarity. Maintains osmotic pressure. Good. And why does it relate to? What, why does it relate to the liver? Yeah. So, essentially what it's doing is it demonstrates we can go on to the next slide if that's all right. I appreciate. Um, it, it basically is important for demonstrating the synthetic function of the liver. So, um, what can happen is if we've got something that's damaged uh the liver, the liver cells. So, in he cellular injuries, um we have impairment of the synthetic functions of the liver. And um those squares are supposed to be um arrows, but I'm not sure why they haven't come out, but that's OK. Um And essentially this will result in decreased albumin. Um So we also use coagulation studies as well um because they may also show like prolonged prothrombin time. But in terms of our LFT S, the albumin is what we will see being decreased. Um And also note that even if the at and ast is normal, um the albumin could be impaired. And that's if there's like a very chronic pathology such as cirrhosis, because sometimes those two might return back to normal, but the albumin will still be decreased because the liver is still not able to perform its synthetic functions uh correctly. So, let's go on to the next slide. So I just want you guys just to have a little think. Um, I'll give you like a minute or two just to kind of have a think about whether you think, um, these are gonna be normal, whether they're gonna, uh, increase. If they're gonna increase by a lot, then you could put like two, double arrows or if they're just gonna be like normal or a bit increased in these two different conditions. So, just have a little think about what, uh about what's going to increase and then what we'll do is we'll show you the answers. So, what I used to do is I used to have a white board or a piece of paper and I would just kind of try and map this out and just think, OK, but what is going to be increasing? What, you know, think about what's being damaged, think about um you know what, what enzymes are going to be affected, what proteins, etcetera, just have a little think about those. Um And I'll give you about a minute and then we will, we'll show you the answer. So maybe if you've got a piece of paper, just write it down. Um Unfortunately, we can't do a drawing function which would be quite fun um on this to get everyone to draw all over the screen, probably a little chaotic as well. But um yeah. OK. Mhm. Mhm OK. Should we show the next slide then? Um There we go. So have a check with what you got um essentially acute hepatocellular damage. So maybe an acute hepatitis, for example, will cause a raised alt, a raised ast as well. The AP will be normal or it might be slightly raised, same with the GGT and uh the bilirubin will, so there'll be a bit of a range. Um Whereas when we're thinking about like cholestasis because it's an interruption of, of bile flow, you do end up with um you might have some like increase in the bilirubin levels. Um And also you're gonna have a high AP and a high GGT because that shows that there's dysfunction in the bilary system. So, um, a few causes of cholestasis, we've got kind of, uh, things like intrahepatic or extrahepatic biliary obstruction. We can kind of, uh, just separate out like that. So intrahepatic could be something like hepatitis or cirrhosis. But then you've got your extrahepatic, which is things like gallstones. Um, cholangiocarcinoma, for example. So, um, yeah, we'll move on to the next one. So, very similarly. But this time, what I want you to do, can you focus on thinking about the ratios of the at to AP specifically? Um, this will make a bit more sense in a second, but sometimes this is something that comes up in, um, you know, a KT questions. Um And also when you're just interpreting liver function tests, looking at the ratios between at and ALP is important because, um, it can help you to understand what the pathology is as well and we'll be going into this in a bit more soon. So again, I'll give you about a minute. We might move through a little bit faster just because of time. Ok. OK. On the chart. Yeah. So think of it in terms of like, is it three fold? Is it four fold, two fold? Is it normal? Yeah. So that's all right. I'm pretty sure we can, it's all good. So with hepatocellular disease, the alt will be raised by at least two fold. When you're looking at your alt to ap the ratio will be above five. Cholestatic disease normal alt normally um can sometimes progress into an increased alt though because remember it's all connected. So the cholestatic, the cholestasis can then eventually affect the liver. Um AP will raise at least two fold. Um But then the at AP ratio will be less than two. And then yeah, with your, you can have mixed disease. So as I said, your cholestatic disease can um often, eventually it will like cause damage to the liver itself. So you often get a mixed disease as well. So that's just important to be aware of. So we'll move on now. Um So in terms of interpretation um of liver function tests, I'm pretty sure we can get this up if that's possible. So use your reference ranges really important to use your reference ranges and they should give them to you. Um if you've got, uh, a greater than 10 fold increase in, at and a less than three fold increase in a A LP, then that suggests that it's gonna be a hepatocellular injury. So there's a really, really big increase in, at. Um, and that's because like the, at and ast will enter the circulation when the he, the hepatocytes when they burst and they die. That's why we get that massive increase in alt and you won't get as much of the AP rise. Um But then if you're thinking about like a cholestatic cause, you essentially won't get as big of an alt increase. But instead, you'll have a larger, you'll have an AP increase as well. Um And it takes longer for like the transaminases to uh to increase. Um And then I've spoken about the mixed picture already. We also spoke about the isolated A LP rise. Um If you've got uh bone pathology, so bone cancer, Vitamin D deficiency, uh any recent bone fractures, then you might have a raise in AP. Um But then if you've got a GGT increase, then that can be caused by um like biliary, epithelial damage in the bar flow like obstruction. But you might also get it in cases where people have had alcohol excess or the use of uh fenytoin as well. So, always think about your drug courses. Always think about, you know, uh alcohol consumption. So this is why when you take a history, you want to be thinking about all these things and your history taking can be so important to have alongside the results that you're using. So, always think about the background of the patient, as pre said, think about those risk factors as you are interpreting the results, they give you a lot of help. Um So we can go on to the next slide. Um If you've got um an ast that's greater than alt will, it will suggest it's an alcohol related injury, alt greater than ast, it would be likely to be ischemic, liver, viral hepatitis, drug injury, hepatitis. And if you've got alt that's within the thousands, it's more likely to be acute viral hepatitis ischemia or paracetamol. So like paracetamol overdose. So always just consider these differentials when you're interpreting your um AST and alt S. Um But also remember that things can be mixed. You might have a mixed picture, you might have someone who's kind of had a background of um maybe they've already got like a viral hepatitis, but instead they've now come in with a kind of a drug induced injury on top of that. So, you know, and maybe even like paracetamol overdose, you know, think about all these aspects to the patient. Don't kind of completely rule it out, don't just think, ok, is alt in the thousands. Therefore, there is no way at all that it could be caused by alcohol. Well, there might be an alcohol component there but it might just be more likely that it's an acute viral hepatitis. So just think about those. Um, so now we're just going to go through a few cases. Um, so, you know, you guys have already been amazing at writing down answers in the chat. So keep engaging as much as possible. Imagine you guys are in ac psa oy scenario. I know you said present the results. Unfortunately, I think, I don't know whether you guys can unmute yourselves. Um If you can, then that would be great, but I don't think it, it's possible right now but if you can then feel free to unmute. Um But I want you to present the results of the kind of the LTs throughout the cases. We've got a few prompts and questions we're going to ask you before that. Um And yeah, remember like mistakes are the only way to learn. So please, do you know it's fine to make mistakes, just write down what you think. There's no judgment here at all. Um The more practice, the better. So I'm gonna give you the first case now. Um So you're 1/4 year medical student in general practice who has been asked to see Lily, a 44 year old woman presenting with right sided, aching, abdominal pain. So, um I want you to start off by thinking what questions are you gonna ask her? What kind of things might you ask? Um and just pop them in the chart. You, yeah. Any ideas, what kind of questions might you ask? One can be anything at all? Just any kind of history taking style questions? Ok. Oh, yeah. Got one. Let me have a look. Uh, yeah, Socrates History. Absolutely. Full history using Socrates examine extremities, face eyes, abdo exam. Ok. Yeah, absolutely. So that's good for the examinations as well. Part. Really good. Thanks, Alice. Um, what other thing might we ask maybe to do with her social history? What else might we ask with social history that's kind of related potentially family history of liver disease and alcohol use? Excellent. Yeah, you guys are doing really well. Um ok. And then now just yeah, anyone else got ideas for examinations you might do? Yeah. Ok. Great. Past medical history, alcohol intake, drug use. Ok. So you guys, you guys have got it. Um What about examinations? What kind of examinations might you do? Thanks BM I Yeah, good thinking. Yeah. BMI is very important. Um Yeah, and sometimes you might have to ask some kind of um difficult questions for patients as well. Sometimes asking about alcohol consumption. It can also be very sensitive for some people. Um but you, you do have to really like delve in deep sometimes. Um and if you like preface there we go um it with something like, oh and this is something we do have to ask everyone. But um how many units of alcohol do you drink or if they're not sure about units, just say, do you drink alcohol? And if so how much, and then you might have to do the calculation. Some people can be very vague about this kind of answer. So it's very important for you to um make sure you do get the actual number. So Lily herself, she's on 10 units of uh alcohol a week. Um, she has gained some weight recently. Um, any bedside tests that you might do in imaging special tests. And I'll tell you that her BM I is 31 ultrasound of bi tree, ultrasound of abdomen. Yeah. Ok. So for each, every time you do it just think, can you, can you guys give me a kind of reason? Like why would you do that, for example? OK. Of course. And like any, any bloods possibly. Ok. So with this, with the, with this case, we probably want to do certain things like we'll start off with some bloods, I think that's always good to do. Um So we want to screen kind of do a, a full screen. So we'll, we'll of course do our normal examination. Um We'll do an abdominal examination to kind of check for any kind of pathology. See whether the pain is. Um we're going to do our kind of full history as everyone's mentioned with this with Socrates. But we want to be screening for kind of uh liver like liver problems. So hepatitis for example, uh we might do an auto antibody screen. So we might want to see if this could be like an autoimmune cause of hepatitis. Um We could also do things like um kind of, we'll do our normal LFTs as well. We should probably just do our uh fbcs. Um It, it might be important to kind of see whether there's been any kind of hemolysis, which you might have and you can get that from your FBC S as well. So doing kind of each uh blood test is important because you'll be able to rule certain things out when you receive those results and you'll be able to start to come towards a more kind of focused differential. Um So always make sure that you are kind of using your routine blood test to kind of support your diagnosis. Um And you can also do with, especially because she's, she's a woman. We always want to kind of ask about pregnancy. Um because pregnancy can also present um you know, with that, she might just have some discomfort, maybe she doesn't know she's pregnant or maybe she's got an ectopic pregnancy. So all those differentials that pre has mentioned earlier, you want to be thinking in the this case, so maybe a pregnancy test would be useful here. You could also do a urine dip as well. Um All these things are very kind of quite quick and easy to do that. You would be able to do in general practice specifically before referring on for imaging because remember that imaging that's going to take time before you'd be able to get there. Um So yeah, let's have a quick look now um at the, so here are some of the results. Can anyone um tell me what they're thinking now, any ideas of what they might, what of what it could be. Um And also just tell me how you might present it. So in the chat, just write down a couple of things you might mention um or if you can unmute, which I'm not sure if you can, but if someone wants to unmute and they're able to, then please let me know. So I think I can invite someone to the stage potentially. I don't know whether that will work. Does anyone want to be invited to the stage? This classic me priests probably thinking what is Millie doing? But it could be fun. Anyone wants to, they don't have to. Otherwise you can just write down your thoughts on the chart. That's also fine. OK. OK. We've got blood suggest cholestasis. OK. What, what, which part of the blood uh suggesting the cholestasis do you think? I Yeah. OK. Yeah. So remember think back to like where we're kind of localizing things. So think about where AST and A LT are more localized and a LP as well. Um mhm PLT. That's plate platelets. Sorry. My dad. Yeah, it is uh intrahepatic. Involvement alcohol. So she's on 10 units only of alcohol per week. Um, her, her BMI is 31 and uh, as I said, she's 44 years old. So think about all these kinds of things, any kind of differential that you guys have? No. Yeah. Ok. It's quite common. Ok. I think we should probably move on. Ok. So essentially based on these results, we would suggest that this is probably a non alcoholic fatty liver disease. Um And the important thing to note actually about this is that they are replacing the name of nonalcoholic fatty, non alcohol related fatty liver disease. Now, so they're actually changing it to, um, and I'll put it in the chart so that you guys kind of have it for reference. Um They're changing it uh to metabolic dysfunction, associated steatotic steatotic liver disease. Um It's quite a mouthful, popped it in the chat. Um They're making a few changes with the naming of things. We've kept it as NAFLD because this is a, it's a very new kind of replacement. Um II came across it after I'd made the slides already, but just have a look because I think there might be a few other names that might change. So if you start to see things being like named differently, just be aware of that we're going to just move on just because of time. Um So what would you do next? So now that, you know, it's nonalcoholic fatty liver disease. What kind of things are you gonna do? Think about the risk factors and, like, how would you explain it? Just think about these, these three things. Um, any ideas at all is fine. One. So, uh, lifestyle measures. Absolutely. Really important. What kind of lifestyle measures are we thinking? No, alcohol, true drugs. All a stat. Yeah, we can, we probably wouldn't start on or a stat straight away. We'd probably start off by considering kind of, um, you know, asking her, you know, what kind of, what's her diet like right now? Is she exercising very much, um, kind of thinking about which things that could be changed within her current lifestyle before we go immediately to medication. And also when you're explaining the condition you want to talk about, kind of, you want to go into a bit of detail about what it is. You'd always offer a leaflet when you're explaining these kinds of conditions. I would always practice doing this explanation. Um, but essentially what it is, it's where excess fat is building up in the liver. Um, and that's not because of alcohol. It's usually because, um, of being overweight, but there are other risk factors as well such as diabetes as well. Um, and the fat is essentially kind of causing irritation and damage to the liver and then over time, this can kind of cause this dull ache. Um, some people are asymptomatic, some people, it just comes up on routine bloods, um where they have this uh this raised uh like alt um and maybe slightly raised ast usually the liver function tests aren't too deranged. So I think someone's asked kind of like how, you know, you can indicate it as NAFLD. We wouldn't necessarily confirm this as NAFLD right now until we've undergone kind of, we, we, we, we, we do further testing to kind of confirm it, but this is kind of just what I was trying to hint at. So you would make sure that you want to rule out other things as I mentioned. So you do the bloods to make sure that you are ruling out other kind of autoimmune uh conditions. You'd also probably do some noninvasive uh like fibrosis tests. So they have something called a fibroscan, which can be used in order to assess the level of fibrosis. Um you can then do the ultrasound, which can also look at the kind of um the liver as well to see kind of how fatty it is. Um So there would be a few other things that we would also use to support the diagnosis, but it would just be an indication to probably if you had those bloods back, you would as the GP for example, you would probably refer them for these scans. Um And yeah, I think the reason why I wanted to highlight this is that it's quite a subtle presentation. It's not like it's not a super acute presentation, but it is a very common presentation too. A lot of people have, um have NAFLD. Some people don't even know about it, but it's kind of an important thing to consider when you've got someone who doesn't appear to drink that much alcohol, um perhaps is slightly overweight but not like majorly. Um So it's just important to kind of consider um with, with, with this condition though, you can improve it with lifestyle changes. So you would need to explain some of those lifestyle changes and show them that they can make small changes including with their diet in order to make a difference. So, thinking about diet, thinking about exercise, you talk through those as well. And then later on, yes, you could consider the medical management if, if the person was still struggling, if they, you know, but there are also certain criteria you have to consider before starting to prescribe like medications. Crucial thing though is we'd probably monitor this patient. So we'd want her to come back. We'd probably want to check her liver function tests as well. We'd also want to check her fibrosis risk. So, and then the other thing is because of some of the risk factors she has, we're also going to be screening for risks of cardiovascular disease too. So, um those are all things we want to consider. So I'm gonna pass back over to preach. Now he's gonna take you guys through the second case. And if you guys have to leave early, I'm gonna put um the feedback form in the chat. Our names are up here as well. We would be really grateful if you guys could give us some feedback. Um I know it is overrunning a bit. Um You guys will have access to the slides and the recording afterwards. Um There was just a lot to fit fit in today. Um But if you can stay, of course, that would also be um be amazing too. So hopefully the feedback form should be there um for you guys to uh fill it in. But if you can stay, then please feel free to stay. We would love to have you guys stay. Um Been very engaging. Cool. I will start talking now. Thank you, Lili. All right guys. So case two, you're 1/4 year medical student in A&E, he's been asked to see Mr Smith, a 47 year old man. He's been brought in by his wife Mrs Smith. So he's presented with acute onset abdominal pain, please take a focus history and interpret his investigations and then you can present your case to the examiner. So the first um slide is asking what are some questions you might ask in a focused history. Um So this was very much a term that was new to most of my cohort. Unfortunately, on the first day of um our AY slash CP SAS. Um So the key thing that differentiates a focused history versus like a full history is you're not necessarily going to be asking each and every question within each category. Um rather you're looking at the presenting complaints. So in this case, it's abdominal pain and really thinking about your differentials already and asking questions around that. Um it's very much an art uh and a skill to learn, I think, and it's a good thing to practice on the wards if you can um doing a focused history versus a full history. But anyway, uh please put your answers in the chat. What do you think you might be asking? Um Mr Smith, any suggestions at all? You guys have done really well? Um Haven't had anything so far. Um Something that we've mentioned a few times already in relation to, to pain. I think someone has mentioned it already. I did see it. Oh, we've got a new message, Socrates. Yeah. Well done. Yes. Brilliant. Yeah, Socrates. Fantastic. OK. I think that's all that we've got in the chat so far. OK. No worries guys. So, yeah, Socrates is absolutely what we should be starting with. So you asked Mister Smith, where is the pain? Right? Upper con uh quadrant tenderness already trying to think about what this is my left. This is my right. There we go. Uh So thinking about what structures are in that region. His onset. So it started last night after a takeaway, it comes and goes and is a bit of a dull ache. Sometimes it radiates to the back. Um, he's feeling quite nauseous and is presenting with dark urine and pale stools. Um, it's a constant pain and some exacerbating factors. So he tried to have some fries for lunch and it made it worse and his severity at the moment is eight out of 10. Um, some other good questions to ask, Mister Smith is uh screening for his other risk factors. So, has he had any recent, uh surgeries? For example, an E RCP, any recent illnesses or infections? Talking about his drug history? Is he taking, you know, copious amounts of paracetamol, Ibuprofen nsaids. Um, also safety netting Mister Smith because an abdominal pain doesn't necessarily have to be gi related. We can also be, um, thinking about vascular causes, um, or cardiac causes as well. So, asking about chest pain, palpitations and breathlessness. Um, can, does anyone actually have an idea of why, what the exacerbating factor might be indicating? This is a very specific thing that the patient has said. But what might you be thinking of when you hear this statement in particular? We've had a few things. So someone said Bilary colic, someone said cholest cholecystitis, um, and someone has also said, does pale stools mean fattened stools? So would you call that steatorrhea? Not necessarily the pale stools themselves? I think with fatty stools, you're usually thinking they're floating. The patient might say they float, sort of on top of the water. Um, I mean, it could be, I'm not too sure, Millie might need to respond to that on the chat. But with the pale stools, what I was trying to get at here, uh, was thinking of those prehepatic inter and post hepatic causes. If we're thinking dark urine and pale stools, we're probably thinking some sort of post hepatic cause. Um, now with the fries for lunch, this is a fatty meal. Um and it actually made the pain worse. So we're thinking something is trying to work in his digestive system to help break down that fat. Um but isn't able to and actually, that's made the pain worse. So that might be a bit of a hint as to what's been going on with this patient. So other questions that might be key to ask in the gi history. So, I mean, he's already sort of volunteered um uh the sort of bowel habits but asking about any changes and then if he does report any changes again, following sort of a Socrates like framework, uh asking about onset consistency, frequency, et cetera, et cetera. Other things you could ask are dysphasia, um dyspepsia, heartburn, um nausea, vomiting, uh jaundice is more gonna be on examination. Um And then weight loss, always preface weight loss by saying, is it intentional, unintentional weight loss cause sometimes patients are trying to lose weight on purpose. Um um So, yeah, not necessarily a red flag feature um talking about red flags. You might also wanna ask about fevers um and night sweats as well. So always do your cancer screening other relevant things to us might be his alcohol use. Um And it's important that you guys can remember how to calculate units of alcohol if a patient does tell you um the amount and what they are drinking other relevant things to ask in the history. So you could ask family history. If you're thinking, um if he was just presenting with jaundice, then uh like Millie alluded to earlier, like Gilbert syndrome, et cetera. Um I think we al already mentioned your drug history and surgical history. So that's OK. But this is all the information, this slide is all the information that Mister Smith has um volunteered so far in terms of the Socrates. So in terms of your further tests and investigations, what might you order for Mister Smith? Ok. So we've got um bloods uh ultrasound of the abdomen, N FT S FBC S. Um I think that's also ultrasound. Um Someone said, can you please go back to the Socrates slide when possible, we can quickly do that. Of course, let's have a quick look. Yeah, just. Ok. Um Brilliant. Yeah, in the interest of time, I will quickly move on. Um So again, because we've tried to present this as an OSK scenario and this is just for general advice on the wards as well. Um Anytime you're presenting investigations or management, having a structure is so important and it looks way more impressive if you split things into their categories when presenting it to a doctor. So for example, if you are asked, what further investigations might you do? Splitting it into so on examinations, uh what examinations might you do then bedside tests? So at this point, you're thinking your normal stats uh temperature, BP, um pulse, um urine, dipstick, ecg, et cetera. And then moving on to your slightly more um invasive um measures. So things like blood gasses, uh bloods LFT S, et cetera. So phrasing it in that structured form. And also if you go to any more of these tutorials and responding to the questions in that structured format just makes it a bit more habitual. Um And um yeah, just sort of second nature for yourself. So when you examine Mister Smith, you're seeing scratch marks um on his arms, uh scleral icterus, right, upper quadrant quadrant tenderness. Um And also you're finding that the patient's finding it a bit difficult to follow your instructions. So, becoming a bit confused, maybe um on his bedside tests, we've got a high temp quite a high temperature, 39.1. Um His BP is 90/60 pulse is 137 but his oxygens are 99%. And then you might also do a urine dipstick and an ECG. But for simplicity, we've not included those results and then moving on to slightly more invasive tests, you might do blood gasses. Um His full blood count shows a raised white cell count. Her CRP is raised and then we've got LFT S on the next slide. Actually, the slide after this. Um But like I said before, just having an idea of differentials in your head is so important and not having that sort of blink vision. Um So if the examiner was to ask you, yeah, what else are you considering? Besides, you know, the m more obvious diagnosis, these are some things you can sort of say hepatitis pancreatitis that supports that uh distress he's experiencing after a fatty meal as well. You could say peptic ulcer disease, um a hepatic abscess, et cetera. So these are the LFT S uh for Mister Smith and I, yeah, anyway, have a look at the results and tell me what do you think your diagnosis is um alongside His Socrates um results as well on history? Yeah. Someone said Charcot's triad fever, jaundice and right upper quadrant pain cholangitis. Brilliant. Yes. One thing that I would also recommend sometimes for these kinds of questions is you want to go through everything in a systematic fashion if you're given something like this. So always, I mean, I know we can't quite do it here but you, you'd go through each one and then you can just say, oh, you know, the bilirubin is raised, you know, then just go through each one that also gives you time to have a little process in your head and for each one just consider, well, what does that mean? What does it mean if the bilirubin is raised? What does it mean if the alt is raised? So go through it in a systematic fashion and explain your thought process as you do. So, and of course, if you were given this in an ST or CPSA scenario, you'd obviously start off by reading out patient details, making sure that, you know, you say this is the name, this is the date of birth of this patient. You'd want to check it against, you know, they'll give you a little thing which says you need to interpret this. You've got to make sure you're interpreting the correct the correct details there as well. And then you can go through it systematically. And I would also, you know, you can give multiple differentials, they want you to be giving differentials with this kind of thing. And then you can give your top differential. That's also another useful useful tip. Yeah, absolutely. Um OK. So I think someone uh did connect the dots there and yeah, diagnose Mister Smith with acute cholangitis. And that is indeed um the patient's um condition. So just a reminder of what the patient was presenting with. Um he had that right upper quadrant tenderness. Um the bilirubin was raised on our LFT. So we can see bilirubin is 100 and your upper limit is at 17. So he will have jaundice. Um And he also had that really high temperature of that 39.1. Um We've, there's also an extra part of acute cholangitis called Raynaud's pentad, which is Charcot's triad. In addition, with confusion and hypertension, honestly, if your patient is getting to Raynaud's pentad, um we would be extremely worried um but I don't wanna give too much, too much away. I mean, actually no giving it away in this slide. But another thing we want to consider is this patient septic. Um because we were finding that the patient was finding it difficult to follow instructions. When we were doing the examination, the patient is hypertensive, they are tachycardic as well and they are very febrile. Um often what we kind of struggled with in fourth year was understanding what is um uh I forgot what do you call it. But um what's the threshold for suspecting sepsis? Essentially, this is a very dramatic scenario. And I think if you were looking at these observations in any patient, you would be quite worried about them, but there are some instances where it's slightly borderline. Um And you might be worried, you know, do I do I do the management for sepsis or do I just carry on with what I was originally going to do? And I would say have a very low threshold for, for sepsis, like no one's going to tell you off. Um If you start the management for sepsis and it turns out to not be sepsis because you're not doing any harm uh with the management for sepsis. So, um going on to the next slide, what would you treat first? I think I have given it away. Would you treat sepsis or would you treat the acute cholangitis? And then if, if it is one over the other, can you tell me what the management might be for this patient? Ok. Um We haven't heard anything yet. I was just writing in the chart. I said, absolutely. I agree with you always be safe. You wanna say sepsis as well? Like it's important to actually say it out loud and that sounds really silly, but a lot of us will just say what the diagnosis is and what we believe the patient has. But no, the patient has sepsis secondary to a particular condition. It's important. You actually mention that um I did a station once, I think it was just a practice station and I actually was carrying out the correct treatment. I don't want to give too much away and um I actually forgot to even say what, what the patient had. So it happens to all of us. So someone said sepsis. Yeah, you've got IV, antibiotics, fluids, oxygen if indicated antibiotics. Uh fluid O2. Yeah. Good. Uh Take lactate urine and cultures. Beautiful. Yeah, absolutely. Smashed it. Yeah. So you would start your sepsis, sepsis six. So remember you take three things. So you take those three observations as mentioned and you give three things. So you would give oxygen. Um you would just, just whack on the oxygen anyway, I wouldn't say if indicated, just do it. Um IV fluids and the broad spectrum uh IV antibiotics. One thing I would say it always sounds really professional and really slick. If a patient is presenting quite acutely looking, quite troubled, distressed, always say to the examiner, you're gonna manage this patient using an at E approach because your OS C PSA S they're assessing to see how safe you are. Um And the way they do that is seeing whether you have a low threshold for sepsis, um be seeing whether you can recognize sepsis in a patient. But also are you able to prioritize things in the right order? And by just saying, you'd manage a patient using an A to E approach in an A&E scenario in an acute situation, just gives that examiner a bit of um reassurance that you would then go on to be a safe doctor, right? Because the A and Eat E algorithm has prioritized those five things in the order that they should be assessed in. So airways breathing circulation and then disability exposure. So just saying that before you even mention any management, I think is always a good idea. Um And that was a tip we got from a anesthetist Um, anyway. Yeah. So you do your sepsis six. And then for the acute cholangitis you might do an E RCP. And then I think usually Milly correct me if I'm wrong, but if patients present with a gallstone problem, um, I think usually the surgeons will just do a laparoscopic cholecystectomy and take the gallbladder out. Um, just to prevent any future reoccurrence, which I think can be common once you've had it. Uh, so just to be on the safe side, they just do a cdec cystectomy in that patient anyways, right. All right. So returning to those, uh, quick fire questions, um, Millie, do you wanna take over? Sure. I'm gonna just see if I can launch the polls, um, if it works. Ok. So can everyone please put that answer down the thing that they think could be the answer? It's the most likely diagnosis cause bear in mind these could all be your possible differentials. Um, it's the most likely diagnosis. Um And you just have to think in the context of SBA land, I suppose. But once you've done a lot of SBA S, you slowly start to kind of build up an idea of what the key words they use when they are like asking questions and they're kind of hoping that you'll give a perfect answer. Unfortunately, when that applies to kind of real practice, it's not always the case. And after all, every patient is very different, but it's so important to consider the risk factors. So. Ok, great. We've got two responses so far. If we can get any more. That would be amazing. We've got three any more. Ok. Four. Mhm. Ok. So I think maybe we can close this now if I can, I don't know whether I can close it. Ok. So we've got, uh, 75% of people have biliary colic and then we had 25%. 0, we've had someone else say cholecystitis as well. Ok. Should we go on to the next? Sorry to be. Ok. Brilliant. I couldn't actually see it. I was too busy. So the reason why this is bilary colic is because it does present with a few risk factors. Um, ones that have been kind of briefly mentioned before. So, can anyone remember what the kind of common, I suppose? Although the there's a pneumonic that we mentioned earlier, that kind of gives it a nice indication that it's the reason why it's blurry colic. Can anyone remember it? Pop it in the chart if you can? It, it's a bit of a mean question because yeah, absolutely. The uh, yeah, the 4123455 s actually. Oh, no. Yes. Five S yeah. Fat, fat 40. Ok. So we've got, so it's fair female, fat, fertile and 40. Um, and in this case, in this scenario, we've obviously got quite a few of those. So, um, we can make the assumption based off of the BM. I, um, we can see that she's female, she's also, she's also 40. Um, I kind of gave that one away a little bit. Um, but equally, it could be. The thing is these are all differentials. So if you're in an oy CPSA, you could give all of these as differentials as long as you can back up with the reasons why you're thinking of these. Um, and they're all things that you would want to have in your mind anyway. So you'd want to make sure that you're ruling out all of these. Um, because of course, if you've got a peptic ulcer, for example, you don't want to have some kind of emergency where the, you know, the patient ends up starting to bleed. Um, whereas bilary colic might be, um, slightly less of a, of an acute emergency. So they are all things that you can consider, right? We'll move on to the next one now. Um, ok. Uh, let me just try and get the pole back up. Um, hopefully I'm doing this correct. There we go. Hopefully that's worked. I thanks. Ok, we've got one response so far. That's great. Oh, so, um, someone's actually asked, what do we mean by fair. So it basically means it's more prevalent in a kind of Caucasian population usually. So in a white population, um, fat is obesity over like around 30 BM. I, you want to be concerned fertile. Um, so usually they've had like a child um 40 aged 40 or above. Um And yeah, OK. So remember guys, what is the definitive management? Definitive? So when we're thinking about definitive, so you've got your initial management, which is usually the thing that you do to start off with. So that's usually the thing that you'll do to stabilize a patient who is, you know, as, as pre said, you're going to do your a management. That is the first thing you do initially with any patient, especially when they're coming in with an acute emergency. Um, what we'll, we'll, we'll carry on now if that's what I appreciate. Um So in this scenario, when we're thinking about a definitive, does anyone have any ideas of what, um, of like what we were alluding to here? Um, anyone got any ideas? What were we, what kind of condition were we thinking of here? Oh, have I got two people there? Yes. Yeah. And what specifically might have happened? So, you've got a, what do you think's happened to cause this ripping? Yeah, exactly. So it could be a, yeah, a rupture. Um, and what are we going to? So the immediate thing that we're going to do is we want to get this person person into, into, into surgery, right? That's really, really important. Um, because if you said something like, ok, we'll give them all ibuprofen. Although, yes, we want a man like we want to do pain management for this this um patient, we realistically actually need to get them into surgery straight away in order to fix the what we need to fix the problem and that's gonna be the definitive management. So that's what we mean by that. Ok. Um Lovely. Thanks guys for, for answering and then we will have our final one now and thanks for staying as well. We really appreciate it. Um There was a lot to get through today. So I've just started one more poll if you guys want to put in your answers. OK. So I've had, oh, I actually can't see the answers. Wait, let me see if I can see the answers. OK. We've got one pancreatic cancer. One Gilbert. Yeah. No. Pancreatic. Oh, sorry. Yeah. So um OK. Final responses guys. Let's get them in. If you're not sure, just give it a go and yeah, remember it's most likely diagnosis. It could possibly be something that we've mentioned. OK. OK. All right. We can go on to the answer. OK. So um here I, oh, there we go. Lovely. So here I was alluding to Gilbert's syndrome, which I kind of, I explained before. Um Can anyone tell me why I'm thinking it's Gilbert's, why might it be Gilbert's in this, in this scenario? Isolated Bilirubin rice? Yeah. And we've got a pa person who is quite young. She's, you know, she's very healthy, hasn't really ever had any other. Like there's no real past medical history. Um and this happens to people like it can just happen. Um So it is just important to have on your list of differentials. Um So yeah, and it's, it's an inherited condition. I think I've got a good, if you have a look at, as I said earlier, the nice uh C KS is um really, really good for nicely summarizing um a lot of the different uh conditions. So I've seen like GP S use this before. Um And it's a really nice way of summarizing everything. Oh I don't even know whether that worked. Give me a second. Um I hope that did work, did that work. Um Yeah, so I've sent through that probably twice now. So have a little read through of that of Gilbert syndrome if you, if you're not sure about it. Um There are certain things that can precipitate um the kind of episodes of jaundice that people get and that could be things like psychological or physical stress. Um maybe like alcohol ingestion, like just a bit like could just suddenly bring it on um an illness. So if they've had a recent infection, maybe you could consider that even like lack of sleep, heavy physical exertion, all these things can all um kind of precipitate uh this episode of jaundice. Um And lots of, lots of cases are undiagnosed because it's, it's very asymptomatic. They just have this jaundice and a lot of people might not develop symptoms. So just always have it as a kind of on your list of differentials. But obviously, all of these are also kind of potentials that you would want to consider, but they're probably less likely given the results from the, from the tests. Um But of course, if you did a full history, um and uh perhaps you realize that she might have had exposure to something like hepatitis C, although it's very unlikely you'd always want to make sure that you're listening to the patient, you're hearing out what their um kind of main concerns are because often the patient has an idea of what could have happened to them. I mean, in this case, she has said that, you know, they're not, they're not social. So, um but always, always listen out. That's why ice is so important. If you ice the patient ideas, concerns expectations early on, especially in the consultation, it will really help you to kind of start to have a, think they might give you a nice hint equally. Don't always completely rely on what they've said if they say. Oh, I think that I've got this, you still need to screen for everything else. It's very important to look for other things. Um So yeah, I think that's the end. So thank you guys so much for coming and apologies again for er running over a little bit. I hope you guys have a wonderful evening. Um and I hope that it was useful as Well, what we're gonna do is I'll put the feedback form again, please, if you could send any feedback, um, we really appreciate it and will help us with our next tutorial. Um, so I think teaching things is amazing. I personally found it very useful. Last year I went, um, I tried to watch as many as I could and this year I've been to pretty much all of the ones for, for my, for our year. Um But it's, I think it's a, it's a great initiative and it covers a lot of the very high yield topics as well and this is definitely very high yield. So do go back, you can review the slides, you can have a think about some of the conditions we've mentioned um and try and see how you can um you know, practice, practice interpreting FTS, you know, if, if a doctor comes back and you're just on the ward and they come back with um some blood results, say, can I interpret it and present it to you, you know, try and see if you can do that kind of thing. Otherwise, you know, the more practice the better with these things and you start to notice patterns but focus especially on, you know, localizing. So think about where the pathology could be based off of, you know, the ALP ast um et cetera. So thanks so much for coming again and we hope you guys have a lovely uh evening. Oh, thanks for the messages. Appreciate it. If anyone has any other questions, by the way, we're happy to stick around for a couple more minutes and answer those. Ok. Oh, my camera just came off. Ok. Yeah. Ok. Yeah, I ok. Yes. Thank you for coming guys. Mhm. Um I don't know how, how many more people we've still got here, we've still got quite a few people to be fair. Ok. Mhm. Ok. Let's leave it. Should we finish that? Absolutely. Cool. Yeah.