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Everything you need to know about BLOOD TEST INTERPRETATION + ABGs

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Summary

Join our teaching session entitled "Anemia and ABGS," a weekly tutorial series aimed at enriching the diagnostic abilities of medical professionals. This session, led by fifth-year medical students from UCL, discusses the global prevalence of anemia and its role in reducing the body's ability to carry oxygen to the body's tissues.

We'll delve into a clear exploration of symptoms and signs of anemia, from general fatigue and shortness of breath to specific symptoms based on the types of anemia. The session will include in-depth discussions about the different classifications of anemia i.e., microcytic, normocytic, and macrocytic anemias, exploring their causes and implications.

The session puts special emphasis on Iron Deficiency Anemia, exploring its causes like dietary lack, blood loss, malabsorption, and excessive requirements in cases of pregnancy and rapid childhood growth. We will investigate Full Blood Count, Mean Cell Volume, and platelet rise in cases of anemia. Your questions and active involvement are strongly encouraged.

Join us and stay updated with weekly tutorial sessions, enhance your diagnostic ability, and provide improved care to your patients.

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Description

Struggling to interpret blood test results? Feeling overwhelmed by ABGs and unsure where to start?

Join Teaching ThingsTHIS THURSDAY 6-7 PM ON MEDALL✨ as we cover EVERYTHING YOU NEED TO KNOW ABOUT…BLOOD TEST INTERPRETATION & ABGs! 😍

Join our clinical medics, Akul and Srijan, as they break down critical topics like understanding routine blood tests, recognising key abnormalities, and mastering the art of interpreting arterial blood gases.

🔥This session is essential for your medical training and will equip you with the practical skills to approach real-world scenarios with confidence.🔥

All slides and recordings will be available on our MedAll after the session, and you can also check out our full schedule of upcoming sessions! Remember to sign up for the session on MedAll!

*PLEASE NOTE THIS EVENT IS INTENDED FOR MEDICAL STUDENTS SITTING THE UKMLA/OSCES!

🩺Blood Test Interpretation & ABGs: Everything You Need to Know!

📅 Thursday, October 31st, from 6-7PM.

🔗 https://app.medall.org/event-listings/blood-test-interpretation-abgs

🩸🧪 We can’t wait to see you all there!

Learning objectives

  1. By the end of the session, participants should be able to define anemia and appreciate its global health implications.
  2. Participants should be able to identify the general and specific symptoms of anemia and recognize the signs of anemia.
  3. Participants should be able to understand the classification of anemia based on the size of red blood cells, and be familiar with examples of microcytic, normocytic and macrocytic anemias.
  4. By the end of the session, participants should be able to understand the causes of iron-deficiency anemia, with a focus on dietary intake, excessive blood loss, poor intestinal absorption, and increased iron requirements in certain life stages.
  5. Participants should be able to interpret blood results relevant to anemia and understand how these contribute to the identification and management of anemia, specifically iron-deficiency anemia.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Why everyone will get started in like a minute or two. Just wait for a few more people to join. We'll start at like five past I think. Thanks for waiting guys. All right guys. Thank you so much for joining our tutorial. Um So yeah, welcome to the Teaching Things series. Um So our tutorial today is run by me and three. So we're both fifth year students at UCL. Um and it's gonna be on anemia and ABG S. Ok. So, um we'll be like monitoring the chat. Uh I think that's like really the only way you can kind of interact. Uh So I'm sorry about that. But um yeah, we'll get started. So teaching things if this is the first time you're joining. So we do weekly tutorials that are open to everyone. Um And uh it's kind of focused on core presentations and kind of teaching diagnostic technique. Um It's by medical students and it's for medical students as well. Um And all of our sides are kind of reviewed by doctors as well to make sure that they're accurate. Uh And we're gonna keep you updated about upcoming events via like group chats and emails as well. Great. Ok, so yeah, my name's Ale. Um we're gonna start with anemia. Um ok, cool. Uh fine. So what is anemia? So, anemia is just a decrease in the number of red blood cells or a decrease in the amount of hemoglobin. Um So that just means that there's a reduced ability to carry oxygen to the body's tissue. So you can see in the, in that picture there, normally we've got lots of red blood cells but in anemia, there's a decreased number, uh, or it could be just like a, a decreased number, uh, amount of hemoglobin. Um, and why is it important for us to know, kind of like as medical students? Well, anemia causes around or it affects around 30% of the global population. And, uh, iron deficiency specifically affects around 1 billion people worldwide. And it's the most common cause of anemia. Can anyone put into the chart? Um, any symptoms of anemia that they know? I'll give it a second. Ok. We'll, we'll, we'll just carry on. Um, so general anemia symptoms. Oh, yeah. Tiredness. Yeah, that's good. That's correct. Um, ok, so general anemia symptoms, these kind of are symptoms that regardless of what type of anemia, you'll probably have some of these, um, so fatigue, um, dyspnea on exertion. So that just means you're getting short of breath when you're exercising or you're walking or doing any kind of activity, um, palpitations specifically tachycardia. So, the reason um, for that is just because, because we have less amount of red blood cells. Um, the heart's kind of working harder to try and pump more blood around the body to try and get oxygen to all of our tissues. Um, and just you, you feel generally a bit cold as well, but there are some specific symptoms for the specific types of anemia. Um, and yeah, this picture kind of just goes over a few more symptoms as well. Ok. Now I've got some signs of anemia, sorry, something a little bit kind of gross. Um, can anyone tell me what the top left one is this one with the, the nails? Just put it in the chat? What do you think it's called? Ok. I'll try, I'll give this one to you. So, ok, this coil in here. So that just means spoon shaped nails and you can kind of see in that picture that the, the nails are a bit indented. Um, they kind of like leather spoon. Um, ok, so the next one, is you can kind of see like the cracks on the mouth around like the edges. Um, so that's called angular stomatitis. Um, that's also quite a common one that you used to be aware of. Um, this tongue is quite kind of, uh, well, it's, yeah, it's called atrophic glossitis. You can kind of see it's kind of smoothed over. It's a bit, a little bit inflamed as well. Um, this next one, it's a bit more of a niche one. But um does anyone know what we're looking at and you know what, what that sign is? So something that you would see and maybe like a endoscopy? Ok. So this one is called um these are post cry post cricoid webs and you kind of see this like web structure here. Um So that's something that you can get specifically with like a certain type of iron deficiency anemia. Um And the last one you probably will know is uh conjunctival pallor. So you can see like kind of like under the eye. It's, it's not as red as it should be. Ok. So now we're gonna kind of go through how we kind of classify anemia. Um So if we start, we start off just kind of classifying all all anemias by the kind of size of the red blood cells. So M CV just stands for mean cell volume. So that just means kind of like the size of the red blood cells. Um So we kind of classified that into kind of less than 8080 to 100 and more than 100. Um So those are the three kind of groups of anemia. Um and they, they have the names microcytic, normocytic and macrocytic. So, microcytic just means that the cells themselves are a little bit smaller than they should be. Normocytic means that the red blood cells are a normal size and macrocystic. So, macro means big cytic means something to do with cells. So they are bigger red blood cells than normal. So, different types of uh anemia. You don't need to know, you kind of need to know like just a few examples of each one. You don't need to know like every single cause. Um but thalassemia, anemia of chronic disease, iron deficiency, lead poisoning, sideroblastic anemia and sickle cell anemia. Um some causes or some examples of normocytic anemia we've got here. So, anemia of chronic disease. Again, blood loss specifically like kind of acute blood loss, uh C KD and hemolytic anemia. And then lastly, macrocystic anemias and for examples, b12 deficiency folate deficiency, we've got a few others there as well. Ok. Um So this kind of is a kind of like a, a decent diagram to kind of show how we kind of classify anemia. And it really helps to kind of know which, which kind of category each one goes under cos it kind of helps them to remember them. Um ok, so we're gonna start off with the microcystic anemias. So if we remember um they kind of they're classified as those that have red blood cells that are less than 80 in terms of their mean cell volume. Um So the examples we have is uh thalassemia anemia of chronic disease, iron deficiency, lead poisoning and sideroblastic anemia. And if you see I've kind of bolded them in green, like the beginnings cos a nice acronym that we, a lot of us use to try and remember. This is Tales. Um So that's just kind of a, a nice, easy way to, to remember some causes of microcytic anemia. We're gonna specifically talk about iron deficiency anemia. Cos I think that's the most important one, that we need to know about and we probably need to know the most in depth about. Um Can anyone tell me any causes of iron deficiency anemia? If you feel brave enough, you can press a go on stage and then you know, unmute. But I understand if you don't want to, but you can just type in the chat. Does anyone know any causes diet? Yeah. Good. Ok. Yeah. So if you're not getting enough in, uh, iron in your diet, that's definitely the cause. Yeah, malabsorption as well. Really good. Can anyone else think of anything? Pregnancy? Yeah. Really good. That's a good one. Ok. So we'll go, we'll go through some more. Um, ok, so the first one could be like excessive blood loss. So obviously if you have, if you're losing a lot of blood, you're gonna be losing a lot of iron as well. Um So it's important that in OS specifically. So that's why I've boarded that. If you have a station that's about kind of someone who's kind of got anemia symptoms. It might be like a young girl, for example, it's really important to ask kind of questions about their kind of men cycle just to check if that might be a potential reason uh, for the iron deficiency anemia. Yeah. So, um, like someone said in the chat, so inadequate, inadequate dietary intake, um, that's quite an important one. so vegans and vegetarians are more likely to develop iron deficiency anemia just because there's a lack of meat in their diet. But that doesn't necessarily mean that all vegans and vegetarians are gonna have iron deficiency deficiency anemia just because um you know, there's lots of other sources that um they can get that iron from uh in their diet. Um So yeah, once again, in the oy, remember to ask about diet. If someone has these kind of symptoms, you're thinking about iron deficiency anemia. Ok. Uh Poor intestinal absorption. Um So this one. So yeah, like malabsorption. This one is basically kind of alluding to celiac's disease. So I think we don't really have time to go on CX disease today, but just be aware that Co X disease is definitely a cause of poor absorption. Um and it's also always something to consider when someone has iron deficiency. Um And yeah, the last one is increased iron requirements. So that just means that uh sometimes when people are kind of going through different kind of stages in their life. So for example, pregnancy or if you're a child who's kind of kind of growing, growing a lot, then that might mean that you need more iron and therefore you'll become deficient in it because your requirements are higher than normal. OK. If anyone has any questions at any point, please feel free to just like unmute or put, put, put the questions in the chat and we'll do our best to answer them. Um, OK, the next one, next thing we're gonna talk about is investigations for iron deficiency. So this is kind of like a lot of exam questions specifically like in like a KT S and stuff. Um they really like to ask kind of interpretations of like bloods. So uh that's what we're gonna go through here. So if we start off with a full blood count, there's always gonna be a low hemoglobin or it's gonna be like slightly low or very low depending on how severe the iron deficiency anemia is. It's gonna have a low mean cell volume. That's just once again, just because it's a microcytic cause of anemia. So this is uh this time, so reactive thrombocytosis can be observed. So it looks like quite a big like kind of confusing term. So reactive just means that it's doing it in response to something. Um And thrombocytosis just means that you've got a raise in platelets. Um So that's just something that you might see on a blood, on a like a full blood count with someone with iron deficiency anemia in response to kind of the stress of having that anemia. The platelet, the platelets are gonna go up just a little bit. Um Yeah, in response to low iron, OK. And this last one is quite um it's kind of an important one to be aware of just for your understanding. Um because it also kind of links to what we see on the blood film. So it says elevated red cell distribution width. So that just means it's kind of a fancy way of just saying that the kind of variations in the size of the red blood cells is really high. So that means that we've got lots of different, we've got kind of loads of small red blood cells, some normal ones and also some big ones. So there's in, if there was a low red cell distribution width, it would mean that all of the cells are the exact same size. But in this case, there's like quite a large spread, the size of different red blood cells. Yeah. OK. The next thing, this is probably the most important bit of the the investigations. Um So iron studies and I think it really helps to kind of understand what's going on in order to be able to interpret them and also differentiate iron deficiency anemia with other anemias when you're looking at iron studies. Um So serum iron naturally is gonna be low because we've got because obviously you're gonna be deficient in iron. Um the serum ferritin. So ferritin is an iron storage protein. So that's how our body kind of stores the iron, um, and kind of, you know, saves it for when it needs to be used. Um, so that's gonna be low as well. Just because if we don't have much iron then there's not gonna be enough ferritin as well to kind of store it. Um, the next thing is transferrin levels. Um, so transferrin is a protein that is responsible. It's kind of in the name for kind of transporting iron in the blood. So that's gonna be increased. So the reason it's gonna be increased is because um it's trying to compensate for the lower levels of iron in the body. Um And trying to max maximize transport of whatever iron there is there. OK. The next thing is uh transferring saturation. So this is so usually they don't actually tell you the transferring levels, but I I'd include it just because it, it's useful to understand, they usually just tell you the transferring saturation. Um but they're actually the opposite. So we have high levels of transferrin but the actual saturation. So that's like the percentage of the transferrin molecules that bound to the iron. Um that's actually low because we have, we don't have enough iron to bind to all the transferrin we've got. And the last thing is total iron binding capacity. So that's just kind of a fancy way of saying how, what is the potential that the body has to bind to any iron? So, if, um, I have like all of my iron stores are completely full then and like all of the transferring in my body is bound to iron, then I'm gonna have a low T IBC just because there's not, I can't carry any more iron than I already am doing. Um, but in, if I'm, if I have, for example, iron deficiency anemia, I don't have much iron bound to the transfer, my potential to carry more iron is gonna be really high. So that's why the T IBC is high. Yeah, hopefully that all makes sense. Uh Just let me know once again if you've got any questions. Yeah. So it's raised as the transferrin has a large potential to bind to iron. OK. So next thing is it is quite important as well is to try to understand what this actually looks like when I, when we look at a blood film. OK. So this is quite a complicated word. But um I find really useful with medicine is that whenever we've got words like this, try and break them down and also try and learn like what the etymology is like what the origin of that word is. Cos it really helps. OK. So anisopoikilocytosis, that's what we're seeing on this blood film. But what does that actually mean? So that time is a combination of aoc psychosis and poikilocytosis. Aiso means unequal sizes, right? And then Poi kilo means variable shapes. A cytosis just means to do itself, right. So we've got on the blood film, you can see that there are lots of different red blood cells with different sizes. There's lots of different red blood cells with variable shapes, right. We've got like these ones that are kind of stretched out and then we've got more round ones. Um, yeah, so there's a lot of variability so that we would just kind of coin that term as a anisoic cytosis. Another thing we see before I kind of I'm gonna like highlight some of them in some of these cells in uh in a second but try and have a look if you can spot any of these before I do. So have a look if you can see any target cells, I think, yeah, there are, there are a few if you can see any pencil po poi killer sites. So this just means like a cell that look kind of looks like a pencil, like kind of a bit longer target cells will just have like a kind of like.in the middle and uh hypochromic microcystic red blood cells. So hypochromic just means there's less color. So they're not as red as they should be micro city again, just means smaller. Um OK. So now we can kind of go through a few of these OK. So target cells, if you look, I think this one in the middle is probably the best example of the target cell. Um You can see like the dot It really just does look like a target, um, heel poikilocytes. These are a few examples. These three in green, they just kind of look stretched out and kind of more like a disc rather than like a kind of circle on the, er, blood film. And these ones are kind of hypochromic. So you can see that they, they don't have, they've got like a lot of white area inside and they've barely got much kind of red. So they're not really like properly formed red blood cells because there's not enough iron to make them. Ok. Good. Ok. We've got the first SBA of the day. Ok. So I want, uh, so everyone just have a read of it after a minute or so. We'll put up a poll and then you can all put in your answers and we'll see how everyone does. Don't worry, it's all completely anonymous. So just give it your best guess. And don't worry if you get it wrong because that's, we're here to learn too and still really early on in the year. So we've got a 72 year old man who comes to the GP with fatigue and dizziness. He has no significant past medical history reports. No weight loss, no fevers, no changes in bowel habit or urinary problems. What is the most appropriate next step in management? Ok. So we've got arrange hospital admission. Yeah, I think the PS gone up as well. Yeah. Arrange hospital admission, prescribe oral iron, iron supplements, routine referral, urgent hematology, referral and urgent two week wait, referral. Give it another like 1015 seconds. We'll see how everyone does. Alright. I think we can close the pole. Ok. So we've got it's quite a spread of answers. Um, no one went for arranged hospital admission. Ok. And II agree with that. Ok, let's let's go, let's go through what, what was the actual correct answer? Um OK, fine. So yeah, the answer, the answer is actually number five. So there's an urgent two week wait, referral on the colorectal cancer pathway. And you can see we've kind of highlighted like the hemoglobin is the only thing that's uh deranged. Um Yeah, that's the only one that's deranged iron is a little bit low as well. Uh And ferritin is low. Um but hemoglobin is low, it's, it's only 100. Um So the reason why and this is kind of touching on quite an important point. Um is that in uh kind of people over 60 with a new onset of iron deficiency anemia, you always need to think about colorectal cancer. Uh and at least try and rule it out as soon as possible, right? So, if someone presents to their GP with a new onset iron deficiency anemia or low hemoglobin, you need to send them for a two week wait. So in the colorectal cancer pathway, that means that uh you need to send them for a colonoscopy, um if they have symptoms of upper gi cancer. So that's like esophageal or er stomach like gastric cancer. Um and they have a low hemoglobin, then you can do a non urgent upper gi endoscopy. That that would be an O GD or it's a fo gastroduodenoscopy. Um but yeah, in this case, if we just go back, um yeah, 72 year old, 72 year old man who's got new ones that are in deficiency anemia. Um, so even though it says he's got no weight loss, no changes in bowel habits, it, it doesn't matter, you need to still rule out colorectal cancer cos this might the earlier you catch it obviously the better for the patient. Um, but yeah, you probably, you would do a fit test as well, uh, at the same time. Ok. So now if we go on to management. Um, so yeah, the main thing. So always try and identify and treat the underlying cause and you're gonna get that from your investigations, but also from your history, right? So like asking you about the diet, asking you about, um, kind of menstrual cycle like your periods as well. Um And then in, in terms of what we can actually do so recommend an iron rich diet. So eating kind of fortified foods that have lots of iron, uh, dark leafy vegetables. So I've put a picture of spinach in there and me as well. Um, and then Yeah. The last, in the last case, we've got oral ferrous sulfate, which is basically just like a an iron tablet. Um And they need to, importantly, I think they need to take it for about three months after the iron deficiency has been corrected. So even if the hemoglobin and the iron's like completely normal patients need, still need to take it for three months. And that's quite an important point just to try and replenish the actual stores of iron. Ok. Uh Just a quick note. So this is another type of microcytic anemia. So it's called sideroblastic anemia. You don't need to know as much about it. So we've just got one slide. Um So in this case, we've got red cells or like red blood cells that fail to completely form heme, um which is made in the mitochondria. So this means that because the hemoglobin's not being made properly, iron actually deposits around the mitochondrion. Um and that forms a ring around the nucleus and that, that's what we'd call a ring sideroblast. Um So that's why it's called sideroblastic anemia. Cos we see these cells um on the blood film, we've got pap and hyer bodies which are these kind of like these little things here that arrow is pointing to and also basophilic sting. And you can kind of see all the little dots dots around. You just need to kind of like at most be able to just recognize the o and anything more in in detail about those? Um OK. And then on the bone marrow, if you take a bone marrow sample, this is when you'll see the, the ring side or a blasts and you can kind of see like the the iron that's kind of around the nucleus. Um and this is kind of, it's called a prussian blue stain. So I don't know if you have like a really like intense exam question that says what kind of stain is being used? It would be Prussian Blue um to check for sideroblastic anemia and then some acquired causes. So there are congenital causes as well, but some acquired causes myelodysplasia, alcohol lead poisoning and anti TB medications like isoniazid. Ok. Cool. All right. It's not a second SBA. So, yeah, we'll put the polyp in like a minute. We'll uh give everyone some time to look at the table. Yeah. So a 53 year old woman presents to her GP with four month history of fatigue. She's got a, a past medical history of rheumatoid arthritis and then her blood tests, her bloods show the following. So just have a read at that table and the direct antiglobulin test was negative. So which of the following most likely explains the patient's findings. So, autoimmune hemolytic anemia, methotrexate, use iron deficiency anemia, anemia of chronic disease and Fter Syndrome. And we'll go through why? It's not each of the the other options when we find out what the actual answer is give it a minute. OK. I think we can, we can close the pole, we'll see how everyone's done. OK. So uh the most popular answer was anemia of chronic disease. So like 57% of people pick that. Ok. So the actual answer is, yeah, it's anemia of chronic disease. Um OK. So the reasons why, OK. So if we start off by looking at the blood test, so the hemoglobin is low, which is kind of showing that there's anemia. That means our volume is 84 which is between the no, between the reference ranges. Um So that means it's a normocytic kind of cause of anemia already just by looking at the first two. Um, so already you can kind of discard the other ones, uh, platelets are high and we'll get to why they are high in a second. Um, the white blood cells are normal. So you can kind of rule out any kind of infection. Um, uh ferritin is high and we'll talk about that as well. T IBC is uh slightly low. Ok. So in terms of autoimmune hemolytic anemia. So we kind of ruled that out because of the er, anti direct a direct anti test, um being negative. So if it was positive, then we probably be, be more inclined to think about that. Um, but yeah, so if you've not heard of it, don't worry. But at least now, you know, the next time that you see that, that test being mentioned, you're gonna need to be thinking about er, autoimmune hemolytic anemias, um methotrexate. So methotrexate might cause anemias. Um but it usually tends to be kind of macrocytic and it's more linked to kind of folate deficiencies, um iron deficiency anemia. So, I mean, we've talked about this a little bit. So ferritin would be low, the T IBC would be high. It would be a microcystic. So that so the MCB would be low as well. You might see a rea so this is what a reactive thrombocytosis would look like it'd be a little bit high. Um But yeah, the other ones uh kind of r rule out iron deficiency and you, you being correct. Um and Felty Syndrome. I don't know if you guys have heard of it. So it's basically just rheumatoid arthritis. Um and uh neutropenia and splenomegaly. So it's a triad of those three things, doesn't really mention the other two just as rheumatoid arthritis. So, anemia disease is the answer. Um So what is so ok. Yeah, so we'll talk a little bit enorm cystic anemias now. So those are the ones that are kind of 80 to 100 in terms of that mean volume. So, anemia of chronic disease is the first one, acute blood loss, chronic kidney disease and uh kind of destruction. So, hemolytic anemias. Um So hemolytic just means that like you, you're breaking down red blood cells. Um and Yeah, you can see that it says ABCD. So it's a nice, easy way to remember that as well. So we've got tails for microcytic and a ABCD for normocytic causes. OK. We'll talk a little bit about anemia, chronic disease. So it typically arises in response to chronic conditions um that are characterized by inflammation or immune activation. So in the, in the question, we just did, the patient had rheumatoid arthritis. So that would be an example um of something that they, that might cause an immune chronic disease. Um So yeah, you can have chronic infections like tuberculosis, um any kind of malignancy, uh chronic kidney disease, autoimmune disorders and chronic liver disease. Ok. On the blood film. So uh I don't know if you, if you guys um remember from the diagram I showed with all the different causes in terms of their size. Er anemic disease was on er microcytic as well as well as normocytic. Er the reason for that is because initially it kind of shows a normochromic. So that means like the the red blood cells have a normal color er and no normocytic picture. But over time, uh as the condition kind of persists, these changes have become hyperchromic and microcystic. Ok. So investigations. So this is why we kind of need to understand iron studies because you need to like try and differentiate uh this from iron deficiency anemia. Ok. So the serum iron is low, which is the same case as uh with iron deficiency anemia, but it's most likely not gonna be as low as it would be uh in iron deficiency um serum ferritin is high. So the reason for this is because it's an acute phase reactant. So that's just, that's just kind of like the technical term, but it just means that when there's kind of like an infection or inflammation or the body's kind of in like an acute scenario, um these kind of molecules will like increase the number. So we've got a raised ferritin because it's an acute phase reactant. Um OK, transferrin. So you remember if this is the protein that's responsible for transferring transporting iron in the blood. So that's low. Um So the levels of transferrin itself will reduce during chron chronic inflammation. Um but the saturation, so the percentage of the transferrin that's actually bound to iron uh is also low. And that's just because there's not enough iron in the blood, the T IBC. So remember that's like the potential for the body to kind of er bind to the iron um is low, which is the opposite of er iron deficiency where we have a lot of potential to bind to iron. Um and that's because once again, the transferrin levels are low. So and then that's, that's kind of what determines the potential to bind to iron. Yeah, hopefully that will make sense. Once again, just put, put a question in the chat. If you've confused about anything. Ok. Third SBA so 60 year old woman presents to the GP feeling tired and cold all the time. She has no red flags of malignancy and her depression screen is negative. Her eyebrows are laterally truncated. She has dry skin and thin hair. So the eyebrows thing that just means that um they're kind of shorter on the sides. Um This is a bit of a harder question. So we see everyone does. Um So if we look at her full blood count, she's got a low hemoglobin. A raised M CV, normal renal function, normal liver function and normal B12 and folate. So what is the single most likely cause of higher anemia? So, anemia, chronic disease, iron deficiency, hypothyroidism, alcoholism or hemolytic anemia. So remember with all of these anemia questions, you always the way you know they're anemic is just because the hemoglobin will be low or their red blood cell count count will be low. Uh And then you always need to look at the MTV to try and think is it microcytic normocytic or macrocytic? And then you need to start, you can start like ruling out options. And also there might be some clues in the history as well. Yeah. So if we can put the pole up, give everyone a minute. Mhm Five more seconds. OK. Yeah, we can close the pole. OK. Yeah. So 75% of people put hypothyroidism, which is correct. Um OK. So there are a few clues um for this question as to why it is hypothyroidism. Ok. So, first of all, it's uh a macrocytic cause of anemia. So we already know we can rule out the first two options just because of that by itself. Uh Other clues that it's hyperthyroidism is that, so the eyebrows being laterally truncated. Um So that is uh kind of a, a sign you can be aware of. It's come up in exams before. Um, and I'll have a, I have a slide on it in a second, uh, dry skin, thin hair and also it says that she's feeling cold all the time as well. Um, all of these kind of together with the fact that it's macrocytic point more towards it being hypothyroidism. Um, so, yeah, the eyebrows being kind of shortened on the side. That's something called Q, er, queen enzyme. So you can kind of see it here. Um, his eyebrows are like very thinned on the outside. Um, yeah, so you can have a loss of the outer third. Uh, which is, it's just a good thing to know for exams cos its like a sneaky way for them to try and hint that it's hypothyroidism. Ok. And then the fourth sda, uh, 34 year old woman presents with pallor fatigue and dyspnea. She has a past medical history of type one diabetes and hashimoto's hypothyroidism. She has noticed her tongue is thicker than usual and she gets pins and needles in her feet. Her initial blood tests show a low hemoglobin, low vitamin b12 and the blood films reveal an abnormally large and oval shaped red blood cell. So which of the following confirms the most likely diagnosis. So, a positive shilling test, autoantibodies against vitamin b12, anti tissue transglutaminase antibodies, antibodies against intrinsic factor and low serum folate levels. Yeah, we'll give it another like 1015 seconds. OK. I think we can close the pole. OK. So yeah. So the majority have put uh yeah. Option number four, which is correct. OK. So uh this question is, is kind of about er pernicious anemia, right? And we'll kind of go through each option. OK. So positive sing test you, you probably haven't heard of it. II didn't hear it. I haven't heard about it really before. So it's basically kind of like a historic, it was historically used to diagnose B12 deficiency but it's, it's really not used anymore. Um autoantibodies against vitamin b12. So, pernicious anemia is an autoimmune condition. So there are autoantibodies but they're not against vitamin B12 directly. They're actually against intrinsic factor uh or like the gastric parietal cells and all that in a second. Um anti tissue transglutaminase antibodies or if you hear that word, it means that they're talking about celiac disease. So if, if the it doesn't really, there's no really like any clues about uh it being CDX in the question. So we can kind of rule that one out. Um And then uh autoantibody against intrinsic factors. That yeah, that is correct because it's low vitamin B12, it's macrocytic anemia, which is, and it's, it says that because there's abnormally large red blood cells. Um And then uh yeah, it's not low, low serum folate just, I mean, that is a macrocystic cause of anemia but it doesn't have like the, these signs of like the tongue like or like the pins and needles and her. Um ok, so we're gonna talk a little bit about Maxine. So those are uh oh sorry that that should be above 100 MCD. Um ok. So basically Matic anemias can be divided into two separate groups. One is er megaloblastic and one is um kind of nor, nor blastic. Um So that basically just means if they are me megaloblastic, there are hyper segmented neutrophils. Uh Normoblastic causes don't have those. Um So you can kind of see here the hyper segmented ones. They, they've got loads of different like tiny sections. The normal ones are just like kind of one, one whole piece. Um and there's only a few megaloblastic causes. So it's B12, any kind of B12 deficiency. So, pernicious anemia will come under that because it, it's a cause of B12 deficiency uh and folate deficiency as well. All of these ones. So the, the question kind of like the question before last was hyperthyroidism. So that one wouldn't have hyper cemented neutrophils. And yeah, these are just some other causes you need to be aware of. Ok. So pernicious anemia is an autoimmune disorder. It affects, it affects the gastric mucosa which results in a B12 deficiency. Um So pernicious means it's causing harm but in a kind of gradual and subtle way. Uh and that's kind of like how their symptoms are or like the signs of the this condition. So the way it works is there's antibodies to intrinsic factor or there might be antibodies to gastric parietal cells as well. But what that means is that intrinsic factor is blocked, which blocks kind of like the like it blocks the B12 binding site. Um So people with pernicious anemia aren't kind of able to absorb B12 into their body as easily as other people can, which results in a deficiency. Um if they have the gastric parietal cell antibodies, that means there's a reduced acid production and you can get atropic gastritis, um which is kind of, it's like kind of like inflammation of the stomach, um which also leads to reduced intrinsic factor production. Uh and therefore not as much B12 and now b12 is really important in not only producing uh blood cells but also in my nerves. So that's why you can get kind of neurological symptoms with this condition as well as anemia symptoms. So, yeah, normally it kind of appears or around middle to old age and uh they'll usually kind of hint to it because there'll be other autoimmune conditions uh in the question. So, in the stem, they might say like they've got like hyperthyroidism or they've got Addison's disease or uh Visar or something. So that's always something to kind of be aware of. And yeah, so you have anemia symptoms, but you also have the neurological symptoms. So, yeah, you can have uh something called subacute combined degeneration of the spinal cord. Uh And we'll go into that what that is in a second if you've not heard of that. Um And you might also get some psychiatric problems as well. Ok. So investigations were finished with anemia. So you do a full blood count and when you do that, you'll see there's a high M CV cos it's macrocystic anemia on the blood film because it's a megaloblastic cause it would be hyper segmented neu er polymorph or neutrophils and they'll be low B12 and folate and you might see anti intrinsic factor antibodies. Uh or, and sometimes you might see uh the antigastric parietal cell antibodies as well, but you usually do those kind of second after you check, check for the intrinsic fact antibodies. Um and if you do find the these antibodies are really specific for the condition, so if they're there, you probably do have anemia. Ok. So just a quick thing on subacute combined degeneration of the spinal cord. Um So it's caused by B12 deficiency, not just pernicious anemia specifically. Um So you, it kind of affects like three parts of the nervous system. So the first is dorsal column. So that's kind of involved with proprioception and vibration sense. So that's gonna be impaired and that's why the patient in the stem before had kind of tingling. Um So it's probably related to that. Um the lateral corticospinal tract is also involved. So you get upper motor neuron signs that usually develop in the legs first, like hyperreflexia spasticity. Um And you'll have the uh the reflex as well. The last one is spinocerebellar. Um So in this case, you'll probably get kind of like sensory ataxia. So the gait might be off uh and Romberg sign will be positive as well. So that's like when they can't kind of balance with their eyes closed. Ok? I think this might be my last ss ba OK. So everyone just have a read and look at the table as well. So a 74 year old male presents to his GP with three month history of lethargy. He has noticed painful cracks in the corners of his mouth. He has a background of psoriasis and uh has a healthy balanced diet including meat. So considering the most likely diagnosis, which type of cancer is he at increased risk of developing. So, yeah, just have a look at the numbers in the table. Um So colorectal cancer, gastric cancer, prostate cancer, small cell lung cancer, and thyroid cancer as well. Try and move it on a little bit quicker somewhere. I have to finish a few minutes late. Ok. So we've got about like 10 seconds to answer this. So put your answers in. Ok. Uh, I think we close the pole. Ok. So, yeah, most people who put gastric cancer, which is the right answer. Um. Ok, fine. So this is just you, all you need to just be aware of is that if you've kind of got pernicious anemia, you're more likely to, uh you'll kind of predispose a little bit more to gastric cancer than you would be if you didn't have it. And that's probably because of like the gastric paal cell antibodies that kind of affect the production of the stomach acid and also the lining, which means you're more likely to kind of get the irritation from the acid and get um gastric cancer. Ok. Last thing, just a quick note. So, uh we don't really have time to go into hemolytic anemia cos it's quite like an in depth topic. Um So kind of learn it when you're actually on hematology. Um, but just a little bit to be aware of. So there's quite a few different types of hemolytic anemias, but all of them kind of have this in common where there's kind of a excessive breakdown of red blood cells, cos normally red blood cells kind of get um recycled every like 90 to 100 and 20 days. But um when there's an excessive amount of that breakdown, you'll get anemia symptoms, but you'll also get symptoms specific to hemolytic anemia like jaundice or splenomegaly. Usually they're normocytic. Um And then here are some c here are some causes. Uh You can just kind of go through these in your own time. Um But yeah, ll learn these when you're specifically when you're actually on hematology because they can be a little bit confusing. Ok, so yeah, thank you so much for coming listening to my section. Um I'm gonna pass it over to three JN. So yeah, hi there, my name, I'm one of the other fifth year students and yeah, my section will just be on ABG S. Um Yeah. So starting off with ABG. So essentially the basics, what it is, it's just a blood sample that's taken directly from the artery. So usually it's the radial artery that's used and um is usually used uh in acute settings uh and quite a lot on in the respiratory ward um to assess pulmonary function. Um So to perform it, um you always offer a local anesthetic. Sometimes the patients may not want it, but you should always offer it. Uh You, you get um an ABG needle like set and all you have to do is just remove the sheath and insert the needle at 45 degrees into the radial artery and it fills up by itself. And then um then the housekeeping, applying gauze dressing and getting rid of your shops um, before you analyze your ABG, make sure to invert it as well. Um, why it's preferred over VBG. Um, so VBG doesn't accurately show P two and PP CO2 and ABG is much better for that. Um So, yeah, uh OS tips, always ask about contraindications to it. So, are they on any blood thinning medications? Do they have any allergies? Um, for example, they may have an allergy to the local anesthetic or, uh do they have any clotting disorders? Um Always offer the Allen's test. Uh It's good. It's used to see that the blood supply to the hand can be maintained solely by the ulnar artery. Um always do this and other TIPSS would just be basic osk tips. So always check name, date of birth, uh palpate the radial pulse before uh ensure that you say that you'd wait five minutes for the anesthetic to stop working and dispose of dispose of your shops and invert the sample. So, yeah, um So what's shown on an ABG? So there are quite a few things that are shown on an ABG uh the main things that you should always like look at first. So you at ph uh see whether it's in the normal range or if it's acidotic or um alkalotic. So if it's acidosis or alkalosis, the PC two and the PO two that gives you the indication of. So if it's a respiratory disorder or a metabolic disorder and if it's compensated or uncompensated. And then finally your um your anion, your um your bicarbonate chloride, sodium and potassium. Uh that just helps to calculate the anion gap if it is metabolic acidosis, and then your base excess again, also just shows acidosis and alkalosis. So, the Ph and Bace are the two main things you want to really look at to see if it's acidotic or alkalotic. The normal range for ph 7.35 to 7.45. And then the normal range for the base excess is minus two to plus two and anything outside of it is um your acidosis and alkalosis aa uh your PO two PCO two and your bicarbonate. Um These three values that they needed to calculate if it is metabolic or respiratory. The PO two and the PC two. Um So the CO2 will be high usually uh in respiratory. No, sorry, it'll be normal but it, if it's high, then it's um a type of respiratory failure which I'll come on to later. Uh And then the normal ranges are there on the screen as well. So, yeah, um your four main interpretations um in the top corner, I put the normal ranges for the P CO2. Um it shouldn't be 6.4 it should be six. But um yeah. So your metabolic acidosis is when your bicarbonate is um less than 22 and uh your ph is less than 7.35 and the CO2 is usually normal in that uh metabolic alkalosis is when your bicarbonate is high. So above 30 then in that case, the PH is also gonna be high. Um then you have respiratory acidosis. Uh here, your bicarbonate is usually normal. But um your CO2 is high. And respiratory alkalosis is when your um bicarbon normal again, but your CO2 is low, um M is compensated or uncompensated. So this is uh essentially when you have a form of acidosis, you have for example, metabolic acidosis, but your respiratory system is compensating for that. So, if you have metabolic acidosis, your, your PCO two should be decreased to um bring the PH back in the normal range and same vice versa. For metabolic alkalosis, your CO2 will be increased to try to bring the Ph in the normal range, but your bicarbonate will still be too high or too low. And then for respiratory, uh your bicarbonate is what changes in a reaction to the phage being too high or too low. Yeah. OK. And then the anion gap. So within metabolic acidosis, you can get two forms of it. Uh you can either get a raised anion gap or a normal anion gap. Um The anion gap essentially just measures the electrolytes so negatively and positively charged electrolytes in, in your blood. So it's just uh checking the acid base balance in the blood. Um On the next slide, I think, II have a little a picture should make it make more sense, but how to calculate. So it's just your sodium and potassium uh take away or minus your chlorine and bicarbonate. So, yeah, so this um essentially in normal plasma you're positively charged. So your sodium is roughly equal to your um negatively charged uh bicarbonate and chlorine. And again, as you can see the normal anion gap, metabolic acidosis, uh this is, they're basically the same again, by just showing that the chlorine is there is increased negatively charged chlorine to um compensate. But when there is um a high anion gap, the chlorine doesn't um doesn't increase. And so you have more positively charged than negatively charged. So um then onto your respiratory. So you have two types of uh respiratory failure which you can also see from an ABG. So you have type one, which is hypoxia where your um po two is low, but your uh PCO two is in the normal range and that's type one, respiratory failure. And then you have your type two where again, your po two is low, but at this time, your um CO2 is high. Uh So hypoxia with hypercapnia. So some causes of respiratory acidosis, you have um so hypoventilation, sorry, that should be, I think that should be hyperventilation. But um you have asthma, uh pulmonary edema. You've got a couple of neurological causes. So, stroke, intracranial bleed and um some drugs such as benzodiazepines and opioids. Yeah. And then you have respiratory alkalosis. So again, here, this is, you know, I was right. Um So this is hyperventilation, uh a panic attack and um like peas or pneumonias and causes of metabolic acidosis. So you have raised anion gap. So some of these can be um uh I think I've wrote some of these down. Yeah. So, Metformin um Uremia DK prop propylene iron and lactic acidosis, ethylene, glycol and salicyate. And then you have normal iron gap. It's just the loss of bicarbonate through um different systems. So it can either be diarrhea. Um You can have a uterus sigmoidostomy. So a part of your bowel since she's been removed, uh you have so some kidney causes renal tubal acidosis and some medication as well. Um There's quite a good pneumonic for raised anion gap. Uh So mud piles. This is really, this is really useful just to keep in mind and use. So, yeah. Uh and then some causes of metabolic alkalosis. Uh I've just listed honestly. So loss of H plus ions here. So, vomiting heart failure, Con syndrome and loop. Uh and thiazide diuretics, the top two are probably the most useful ones and the good ones to remember. Ok. Um Just some questions now. So uh the first SBA er if you just wanna have a read, so I'll um put the part up as well. Uh You, you'll fall to see a 54 year old lady on the ward. She's three days post cholest and has been complaining of shortness of breath and her ABG is as follows. I'll just let you read that. Um OK. And if you just answer the poll. Yup. Um So yeah, just go through. Yeah, so it is um uh could, yeah. So it is respiratory alkalosis. Um Can anyone also just tell me, so what type of uh respiratory failure? This is um if you wanna put in shop? Ok. So um yeah. Um that is, so that one was um ah so type one respiratory failure because the PO two is normal. Oh no, sorry. The PO two is low but the P CO2 is normal and some of the differential diagnoses for that can be like a pe pneumonia uh or a pneumothorax as well. Uh So if we do the next question. So yeah, uh 75 year old gentleman living in the community is being assessed for home oxygen. His ABG is as follows and these are the results. OK. OK. So yeah, this uh this is um respiratory acidosis um but it's uh it's been compensated. So the PH is in the normal range uh because there's increased bicarbonate. But again, the PO two is low and the P CO2 is high. So again, it is uh type two respiratory failure. Um OK. So again, so a 64 year old gentleman who has a history of CO PD presents with worsening shortness of breath and increased sputum production and again. Ok. Yep. Um Yeah. So this is um respiratory acidosis again and uh again, a type two respiratory failure with compensation, but it's the compensation is not enough. So the PH is still quite low. Um Yeah. Uh let's do the next one as well. So, yeah, so yeah, a 21 year old woman presents with uh feeling acutely lightheaded and short of breath. She has a final university exam next week. Um And again, her ABG so yeah, this uh this is respiratory alkalosis. Um some of so some of the um differential diagnosis, it can be pulmonary disease, uh hyper metabolic today or pain. So the reason it's alkalosis is uh a respiratory alkalosis again. So the P CO2 is low um and your bicarbonate is on the low end but your um it's still within the normal range and your PH is high. So what, what would be the most likely differential diagnosis here if someone wants to type? And sh um so um here uh based on the stem which is quite small, but based on the stem, it'd be um uh so anxiety or, and hyperventilation which caused her to breathe off more P CO2 um putting her in a alkalotic state. So I think I got one more ba at the end. Um So, yeah, a 32 year old man presents in the emergency department having been found collapsed by his girlfriend. These are the normal values. So, yeah, OK. So Yeah, this is, this is metabolic acidosis. Um As you can see, you can see the PH is acidotic, the CO2 is low and the bicarbon is really low. Uh So being metabolic acidosis uh just can someone also, if someone wants to tell me if it's uh a raised or a normal anion gap, just uh put in chat as well if no worries. Yeah. So this, this is a, so here the an iron gap is um so 28 28.5 and so that's well outside the range. Uh So it would be a uh raised an iron gap. So the normal range being 7 to 16, I put that somewhere. But yeah, so this would be a ra raised an iron gap. And so again, some of the causes for that would be um so you can use the mud pulse pneumonic. OK. Uh I think that was my last SBA. So thank you. Thank you all for er for staying. Um We finished just about on time. Um Yeah, please provide feedback and yeah, if you have any questions. Yeah, thank yeah, thanks everyone for um joining. 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