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And um I think we're going live now. So my name is Ted, I'm one of the newly qualified uh doctors also graduated from Imperial um not long ago. So I know exactly what you guys are feeling. I was exactly the same, but was you last year at this time? Um I think I just finished my S S J T S at the time. So congrats to all of you who've done it and you've got, you not go along to go. So I'm just gonna be talking about a few tips and tricks on the medical shots for finals. Uh And then there's so this station is gonna be quite a short and sweet station. Okay. Um It's hard to do well in this type of station. Um especially because if you're, if you're hoping to get a distinction, if you're hoping to get a marriage, I would suggest that you put more effort in your Paces stations, especially like this one because this is gonna be topics to do with endocrine, which you've been, you know, honed in about since year one Imperial. Um the four domains like all the other Pacer stations and we'll cover it. So focus history in this session five minutes or less. Keep it short and sweet, but make sure you keep it focused around the presenting complaint. Um summarize the key findings and you're gonna be tested also on other domains that we're all familiar to at this point. Now, such as suggest any relevant key investigations starting from your noninvasive first to your most invasive uh if relevant and your management and what they want to look for is whether you can suggest things in an organized manner. And of course, you've been marked on your professionalism as well. So those are your four main domains. I hope you can see the mark scheme that I've copied. So we got given a copy of it especially I think this will happen sometime after your exams talk. Um, but it's exactly, I know it says 2017, but it's, it's still exactly the same. So what I did with a couple of my friends around exam time is that in your little paces groups, we just went around marking each other, uh, you know, not trying to gas each other up, but just trying to be like, um, quite frank with the markings for it. So I would definitely suggest using it, you know, paces practice. Okay. So I hope we can get some people in the chat, um, answering things because I was hoping the session will be a bit more interactive. Um So case one, let's start with you being a junior doctor. This is what you see on the door before you're going. You're supposed to see a 59 year old lady who's been referred by the G P for bone pain in the end of crying. Click. So please take a focus history, suggest key examinations, etcetera and discuss the management. That's the blob, right? So now that you've seen that blurb in terms of bone pain, can, can you guys put in the chat? What sort of questions you'd like to ask, please? In the history. I'm not sure if I'm seeing the chair. Okay. Past medical history of cancer. There we go. Cool. Yeah. History of any injury. Good. So traumatic. Some symptoms of mm I'm thinking multiple myeloma. Yeah. If it's not a good giveaway guys. Um, yes. Symptoms of hypercalcemia distribution. Yeah. Fine. So I'm sure you guys will do your Socrates. Well, so I'm not gonna go on and on about your Socrates at this point. We all know how to do it and fine. All right. So you get this history. She comes back with telling you that this is a constant lower back pain started about six weeks ago. Seven out of 10 severity. Occasionally she gets around the hip girdle to okay affecting her activities of daily living. So, um, so she's, she's the main care of her husband is what I'm trying to right here. Sorry. It's a bit crowd ID. Um, but she's also reported reported other symptoms along side as well. Like your hypercalcemia symptoms, drinking lots of water going to toilets. Uh, more frequently than usual notice that she's tired all the time initially, your and say gel helped but didn't really relieve the pain to make it go away. Um Of course, I know you guys have done your, you know, your fifth year Gynie history, whatever holding on. But remember you are still, um, trying to, you're still being assessed on um asking questions in holistic manner in your final paces. So make sure you do a quick Gynie, you know, screening questions. So you find out that she's post menopausal um since five years ago, she's got known history of Renal Calculi Socrates. Thank you. Yeah. All right. So that's your history and uh I gave it away already, but those would be the main differentials that should be floating your head, which you guys already got already looking at the chat. Um So your multiple myeloma as well. This is the main. So what sort of symptoms would you want to ask for, for multiple myeloma to try and find out a bit more about the pain? Yeah. Flaws. Thank you. Yep. So you wanna flaws them early? Yeah. Um Fine. So if you guys remember your crab symptoms of multiple myeloma as well. So, hypercalcemia, your, your renal failure, anemia as well as your B being your osteolytic bone lesions that you see on X ray. So, based around that. What sort of investigations would you like to, um, do for this lady in the clinic or maybe refer to do for her? Anyone? Dipstick blood test? Okay. Cool. Yeah. So your normal blood as well as Dipstick, what are you looking for in the Dipstick? Yeah. Good. Excellent. So, urinary Bence Jones protein for, to screen for your multiple myeloma? Perfect. Okay. So this is your, so when we're talking about investigations, I think in paces as well, you know, you don't have to be, you know, suggesting anything revolutionary your mind blowing. I think what they want to see is um an organized thinker in a, you know, everyone knows that you're stressed about exams, but they want to see at least some sort of structure to your answer and you can do exactly that by saying that I would like to investigate this patient from. I like to like, I like to start off like a bit of a spiel. So I want to say that beds, I would like to start from noninvasive testing to as invasive testing as appropriate, starting with bedside tests such as blah, blah, blah blood test, such as blah, blah, blah imaging, such as blah blah, blah, and I'll make it relevant to the case. Um Just try and practice doing that. Um I'm sure you guys already doing that. But yeah, uh anyway, so blood tests wise specifically to rule out the differentials that we suggested previously I think would be relevant. Are your polyuria to rule out your polyuria, polydipsia symptoms? Do your B M your HBA one C do your diabetes insipidus testing such as your pedals, morality's protein electrophoresis as well to cover for your multiple myeloma because sometimes you might not always pick up your urinary best Jones protein. Um looking at imaging, bone density scan is particularly relevant in her case. Remember she's a 59 year old lady. Okay. So she's, and she's post menopause that she's bound to have some d varying degree of osteoporosis anyway, and give that if she has your plasma calcium raised because of potentially hyperparathyroidism, then also it's gonna worsen her osteoporosis. And as you suspect from your Dexa dexa scan, she's got her t score of less than minus 2.5 which suggests that it is osteoporosis. Okay. So her blood test came back with a high P T H and your calcium. You're asked to interpret it. What would um Yes. So that would be what would be the main diagnosis. Now, looking at it, you would have guessed it's hyperparathyroidism. Um So I just wanted to hone in a bit more about the history for hypercalcemia. So now that we know the history, so the main things to think about are your, I'm sure you've heard of this phrase before. Stones, bones Abdul grown second moans. Um So make sure that you asked specifically about those symptoms to begin with. Um remember that our lady had background of renal stones in the past um as a result of calcium deposits, think about your bone resort option, effects of your parathyroid, etcetera. Um And your abdo pain as well exacerbated by especially a surgical seve, like a quick surgical sieve history of whether she's had any um pancreatitis in the past, whether she's had any hospitalizations for your um perforated peptic ulcers, etcetera. Um So remember that your hypercalcemia is associated with increased risk of your duodenum ulcerations um from 71 ratio compared to your gastric ulcers or if you can just have non specific symptoms of bowel herb, slowing down habits like constipation, et cetera. Um The other things have got some screening questions. Look. So like your usual history, you're going to be asking about your medication history, family history, etcetera, but particularly relevant in this case is asking for your syndromic features in your family history as well as your good medical medication history. Like, are you taking any over the counter supplements of your vitamin D? Are you taking any um supplements of your calcium? Because they can also lead to your hypercalcemia? Okay. Yeah, thank you. All right. So etiology wise, um again, a very common Viber that you might get is your, what different types of hypercalcemia do you know? So I think as long as you mentioned, the ones that I've tried to bold and um put in a bigger font like your primary hyperparathyroidism. And uh the second most prevalence, one is your malignancy related hypercalcemia. As, as long as you mentioned it, I like to split my causes into your P T H dependent causes in your P T H independent causes. So if the P T H is raised, then you're mainly thinking about primary hypoparathyroidism. 85% of the time, this might be due to a, just a solitary uh adenoma because remember your parathyroid, you've got four different parathyroid glands attached to your thyroid, uh two on each side. Uh Most of the time, it's just one gland that is um hyperactive. Um but sometimes you can have all four gland disease. Um And yeah, you can have malignancy related non P T H dependent causes as well. So your SCLC yours going sort of small cell lung cancer, P T H related peptides can be released that can cause your surreptitious hypercalcemia. You can have metus disease from your breast and your lung. You can have multiple myeloma. But if you want to gain the top marks, you sometimes it's worth mentioning all those um a couple of the niche ones of the. Um So I would recommend Ledley's learning one of each other category if possible as well. So definitely remember your vitamin D especially vitamin D overcorrection, vitamin A soy, calcium overcorrection as well in a post menopausal women. Sometimes I can redo hypercalcemia as well. Um There's something else that I mentioned here that some of you might not have come across called milk alkali syndrome. Does anyone know, have heard or what that is? Just for the sake of time? I'll tell you anyway. So, milk alkalize syndrome is, um, something that I've come across. I'm sure you've come across in pathology like last year anyway. But it's when you've got excessive calcium intake, um, sometimes that is contributed to as a result of dyspepsia or excess, um, appropriate inappropriate indigestion of the milk um of, of the calcium even. So then um that just builds up in your diet and that can lead to a massive influx of your calcium in your serum. Fine. Um And of course, don't forget your other important men want men to syndromes that will come across later. Your multiple endocrine, your place here types fine. So uh management again, I would like to split it into especially with your electrolyte abnormalities. Um try and uh split it into your acute initial management um and your long term management. So your initial management, especially if the hypercalcemia is really high, moderate or severe. And you, first of all say that I would like to admit this patient, fluids, fluids, fluids as your main part of the resuscitation. How many liters would you give around 45 liters in about 24 hours of your normal sodium chloride? Um And after correction, if you still, if you, you're a good doctor, so you're gonna say that after correction I would also like to recheck the bone profile to check how far this calcium has dropped. If it sits, I would like to do this next. So that's how I would split my management and former spiel. So I'm not just like um rattling off a list. Does that make sense? So IV bisphosphonate based on senior advice, I would um invo of ice, you support, issue, support, etcetera as necessary, you know, you might discuss it with the med rec, etcetera. Uh So that is in a situation. Um Make sure that sometimes you can mention other second line therapies like loop diuretics, which is relevant in this case, but um loop diuretic. So you want to caution on them and you wouldn't necessarily be as the foundation doctor starting these uh second line therapies. Okay. So um of course, long term management, after you corrected the uh electrolyte abnormality, you want to treat the underlying course. So again, split it into your medical and surgical um management of hypercalcemia. So medical management, if it's a syndromic cause and you try like sarcoidosis, they might think about cortical steroids. If it's a uh potential cancer, then think about your specific anticancer therapies, make sure you're adapting it to the situation. Um Think about surgical. So, parathyroidectomy, the main indications are listed here. So if the malignancy for gland disease, um renal disease, severe severe renal impairment or if they're quite young with a good surgical outcome, then you would definitely think about operation. Um and one of the common visors I think I got asked this um was the complications of uh parathyroidectomy. Um And I think it's just, you know, because you're correcting hyperparathyroidism, right? So when you take away that overactive gland, you might suffer from the opposite hyperparathyroidism, then you get hypocalcemia. Um And then just knowing a bit about your anatomy, recalling that your recurrent laryngeal nerve is in your neck and parathyroid uh is the gland in your neck. So if you can sometimes nick it even in the hands of the most expert um surgeon, the chances of the odds of nicking it is around 1 to 2%. So the patient might present with horse voice if you have a current laryngeal nerve damage. Um just if in case there's anyone interested in surgery in the chat, um just want to say that there is a mini, there's a small tube ical, which is an important landmark to mark the site of your recurrent laryngeal nerve. Um And it's called the tubercle of zoo Candle. Basically, most of the time, if you get that nerve, then if you can like find out where the typical is, then you'll find you can most of the time spare the nerve anyways. So, symptomatic hipaa calc hypocalcaemia as well. So, hypercalcemia after the surgery is is temporary and it will resolve over time. But if it persists after the fourth day of surgery, like So you check your bone profile every single day since the, you've taken out the gland, right? So, thinking about the uh management along the way, it's also important. There's something called Hungry Bone syndrome where you've got symptomatic hypocalcaemia, symptoms, post next surgery. So that's just another complication to be aware of as part of your Viber. But if you can answer any of these questions, you probably do really well. Okay and right, Sorry. Next slide is a guy slide. I should have warned you this is just to show where that typical of Super candle was and where the current labs you're nervous. All right, cool. So hypocalcemia just, just for completion. I wanted to include the symptoms of hypocalcemia as well. It's very, very unlikely that this will come across in your medical short scenario because it's going to be, first of all, it's going to be very mean um because it's most appropriate for an acute case. And yeah, so make sure you're asking about your perioral um tingling or changes in your sensation, especially in your digit. Um any muscle preachers, tetany, any confusions, any uh seizures, etcetera. Uh Yeah. So medication history as well. Those are the main causes uh that could potentiates, hypercalcemia. Think about previous surgeries. It doesn't have to be parathyroidectomy is it could be thyroidectomy or any neck surgery that could lead to hypercalcemia if you nick the grand, right? Um So think about your familiar causes of um hypercalcemia, congenital disease or syndrome. If you remember from Pedes last year, um these are, these will be your exam findings that you could see in as part of your finals as well. It's not just the pace is, this is more of a slide for your sbs that you can come back to later. Okay. So just some pictures of it and I wanted to split it into red flags and to your normal um chronic hypocalcaemia symptoms. That's it. Um the BP cuff on the bottom, right? That picture is just showing too. So sign of carpopedal spasm that can occur a few minutes after uh she inflated all the way up. And yeah, you could you would just clinically start to see twitching. Okay. So in terms of the management, just really quickly bedside blood's imaging bloods are not going to be that different from your previous calcium hyperparathyroidism screen. But the main one that I wanted to highlight it, does anyone know why I've got the magnesium and read? First of all, what's the link? I think if you mention um whenever you're talking about counseling, if you mentioned uh magnesium, you'll probably be doing really, really well in that fiber. Yeah, perfect. Yeah. So magnesium and calcium especially they go exactly. Thank you guys. So magnesium calcium go hand in hand. You guys are spot on, on it and they also functionally compete if I remember correctly somewhere in the thicker. Sending Luca Henley or something. Um But they also uh the justice that magnesium and calcium will interact on a cellular level. And as a result, decreased magnesium would tend to also affect the cellular cellular membranes exposure and permeability to the calcium. So, um if you don't replace you a low magnesium, then you're not gonna get correct your calcium, your calcium won't return to normal. So clinically is really important as well. And this is something that will become much more relevant. And that's why it's also important to mention it in paces because they, they want to, they want you to have your clinical hat on how you practically think as a foundation doctor, right? So yeah, so you want to be correcting the both. That's, that's just a screen for it. Um So that's why I've got it in red there and for X rays as well. I want to be considering we want to be considering fractures, any Osteo Malaysia as well, right? Um Initial management we've highlighted here as soon as you notice someone has hypocalcemia. You want to be um saying things like okay, I would get senior support. I would get the local cardiac unit for telemetry monitoring, um or E C G monitoring, etcetera. So you would do the E C G before an E C G after the correction to see for any relevant changes. So you want to see what dynamic changes. Yeah. Um consider if it's the hipaa calcium is mild then of course, you can do just your oral supplementation, etcetera. And again, second line therapies like your fancy drugs you want to be discussing with the med rec or the undercurrent team? Okay. So I think I've hinted this in the previous slide when I suggest the red flags. Um The main thing is if they complain of any tightness, tightness in their throat, then you want to be worried about lowering your spasm and losing that airway. Think about, yeah, seizures, tetany, etcetera, commerce, surgical procedures. We've already talked about it in the past. Um What is the relevance of the calcium and the MRI findings of a pituitary adenoma? So this is really mean if it's survivor, but I've faced it in a mock, I think it was an M M mark. I'm sorry guys. But that was, yeah, that I couldn't answer at the time because I could remember the specific men uh types. But it's now you guys know it's just a multiple endocrine neoplasia type one. Uh You're thinking about your three ps. Um Most of the time, the most common presentation is going to be parathyroid hyperplasia. And as a result, you're going to present with hypercalcemia as a result. Um And you need to be thinking about a pituitary adenoma or some sort of hyperplasia as well. They can also present with peptic ulcer or gastrinoma problems because of patriotic islet cells. Tumor's okay. Right. So next case, now this time you're at the G P and you're the foundation doctor doing your rotation, the G P you're seeing a 30 year old lady for fatigue. So, can you guys think of any specific questions that you would like to ask? Yeah. Get weight loss, weight gain, hypothyroidism symptoms. Yeah. Cool flaws again. Yeah, I think with all these medical short stations you're never going wrong by doing flaws and you want to be ruling out, showing off by ruling out malignancy much early on. Okay. So not just floors ask about your lumps bumps, any changes in your bowel habits, etcetera, diet? Thank you. Yeah, perfect. Yeah. So you want to, even though you and the examiner both know that this, they're probably going to have some sort of endocrine problem. You want to, uh, demonstrate that you're still thinking, uh, you're thinking really broadly is what you want to talk about. Um, someone asked what flaws was. So flaws is just fever, loss of appetite, weight loss, another sleep. Yeah. It's just like it's just constitutional symptoms and you might come across the term b symptoms as well if we're talking about lymphoma, but they all mean the same day. It's just the questions, the screen questions that you ask to. Let me, let's see. Okay. So I think those would be the other specific questions that I wanna talk about. So, yeah, so this is what I mean by, um, um, trying to think about it in a more wide differential way even though we all know that's going to have some sort of endocrine problem, right? So like mood uh remember your Becks triad from a psychiatry. Think about any recent stress is that could have caused any changes to a mood or um energy levels, etcetera. Yeah. So anergia, anhedonia, etcetera. Think about systemic size. We've already talked about all of these. So you have hypothyroid symptoms. Someone mentioned specifically we wanted to ask about your hot cold temperature difference, like intolerances, any skin changes. Um It would be really good if you can just um ask specifically, have you noticed any changes in the uh in between your creases, hand creases, etcetera. We can ask about your armpit phones as well. Medication history. Why do I want to know about steroids? I think it's oh I already said, yeah. So steroid use. Um the reason that I want to know is so that I can rule out any um steroid induced adrenal um insufficiencies as well. So family history of autoimmune conditions. I I love asking about this in the G P because most of the time they will have some sort of problem um autoimmune wise. Um And it's also worth asking about it for both your, as soon as you suspect that if there's an inkling in you that this could be a potential thyroid problem or if it's a adrenal problem. Um You should always ask about autoimmune because their both links to autoimmune causes, right. So, don't forget to, um, ice the patient. Okay. Fine. All right. So the lady tells you that she's tired all the time, but her sleep is good. She's noticed that her skin looks darker but she hasn't had a tunnel on a holiday recently. Her partner noticed that she's adding salt to everything in her diet. Uh, she's had a few kilos of unexpected weight loss as well. And she's also mentioned when you specifically asked um that she has noticed some hair loss, especially down below etcetera. Okay. Um And also she does have an autoimmune condition um in her mid twenties, she suffered from pernicious anemia, but right now, it's all right. It's not causing any worries. Uh Perfect. Thank you. Alright. Thanks for, thanks for answering. So I think then the chat they just posted about um exogenous steroid use that can lead to adrenal insufficiency, spotter. Fine. So, differentials at this point like you guys mentioned, um really thoughtfully, it's your Addison's hypothyroidism, you know, hyperpituitarism. But also you want to demonstrate to the examiner, you're thinking about your other, other medical causes or your nonfunctional causes like um I'm deficient anemia or any sort of dietary related deficiency B 12 folate etcetera, right? Um Chronic fatigue syndrome is a bit more specific. Um So it's more of a diagnosis of exclusion as you, you would have come across, but it's normally usually diagnosed after at least four months long of disabling fatigue, affecting your mental and physical function. Right. More than 50% of the entire time in the past four months in the absence of any other disease markers. So, hers is a bit more like, you know, especially with her other uh symptoms, it's less likely to be chronic fatigue syndrome at this point. So that's why I should lower down my differential. Right. So, investigations, um, thinking about specifically to, uh, investigate your adrenal problems. Uh The main definitive test is your short Cenac contest. But remember you're in a GP practice, right? Sometimes they might not even have easy access to your Xanax. Then um in that case, bottom right is uh an option which is still marked as first line. So if you've mentioned one thing over another, don't be scared that you've done it wrong in the exam or something because it's still relevant and it's still um the case in a lot of the, a lot of the other parts of the country. So you can do a nine AM cortisol and you can check the levels um afterwards for Addison's or not. Um But if between, if the level is between 100 and 500 then it's known as an equivocal test. So you have to do as an actor, you have to source you as an acting test somehow, right? So imaging what we want to know about any imaging, if there's any lung pathology that could be linked to a secondary uh sort of picture, right. Okay. So the main causes of Addison's. So I like to split it into primary causes and secondary causes. Secondary causes are quite simple because they're all going to be to do with your pituitary problems. Tumor could be a radiation or it could be infiltrated causes to the pituitary. If it's a primary cause, then in this country um or two immune Addison, which is no called Addison's is the leading cause of primary adrenal insufficiency. But in developing countries, tuberculosis is still the main leading cause of primary adrenal insufficiency. But most of the time, there's also the growing population of glucocorticoid induced adrenal insufficiency, which I which I've abbreviated here as G C A I as another main cause as a result of G C A I would occur as a result of, you know, your hypothalamus, oh pituitary adrenal access and after suppressing it secondary to prolonged exposure to your glucocorticoids, etcetera. These are the niche ones you can mention just for the river. Um and also for your sbs as well. I'm sure you guys remember your waterhouse Friedrichs and syndrome. That's your meningococcal septicemia. You can have your anti phospholipids syndrome that you test your antibodies for with your venous from both sees our current fetal losses, etcetera. That's more for obstetrics. So, yeah. Anyway, and so in terms of iver, I thought these would be really relevant, but also it would be fair game for Imperial to ask things like this and exam findings that can distinguish it's an old examiner favorite is the first top question. Um So, well, how can you distinguish between primary and secondary, do you know insufficiency? So your primary insufficiency would have your hyperpigmentation. If you guys remember your palm see hormone breaking down into your ACTH and your alpha MSH, then alpha, um M S H is the one that causes your hyperpigmentation. Whereas in secondary adrenal insufficiency, um you still have the ACTH working. So you're not triggering that hypothalamus pituitary, so that your hypothalamus and pituitary axis part is still working. Does that make sense or overworking? Even um in steroid induced versus primary addison's as well? So that would be another common question that you can get. Um So the gist is in steroid induced, right? You still have your mineralocorticoid activity. In other words, you still have your aldosterone functioning. You just get paradoxically, you just get a lot of um steroid exogenously, right. Um So you're not intrinsically triggering that pathway and overstimulating it. So you don't get hyperkalemia. Does that make sense? Because you still have aldosterone, which can do its thing. So that will be the main difference. Um right. So, primary and secondary. So just to hone in on that primary and secondary adrenal insufficiency would be a clinical finding that is, you know, apparent. Whereas for your steroid induced versus your primary addis ins, it will be a biochemical finding that is apparent as a difference. Um mainly so, right. So how would you manage this patient? Um Just wanted to hone in on the additional points that would help you guys differentiate from other candidates. Uh to mention things like your uh steroid emergency card medic alert, bracelets, involvement, seniors, ICU early sick day rules. If they're on already on steroids, then you can ask them things like in the previous slide about the history, have they double, have they doubled up the dose if they're sick because they should be um or have they just missed the dose recently? Etcetera? Yeah, cool. It's our emergency card. This is what it looks like. If your patient's don't have one, you can print it out for them, right? OK. So I just wanted to test you guys really quickly. If you have a look at the A B G of that previous patient, it's still the same case. What do you think is going on? Yep, metabolic acidosis? Yep, I would agree. Perfect. Um Someone asked me to repeat the hyperkalemia thing that I said, right. I think I was on about aldosterone, right. So aldosterone would help retain the sodium, re absorb the sodium and um lose the potassium, right? But deficiency of the aldosterone would then cause the opposite. So you cause wasting of your sodium with retaining your potassium. Yeah, not least your hyperkalemia. So like in this case, this would be um primary, wasn't it? So uh let me, let me just turn off the chat. Huh? There you go. So, in this case, um your potassium is really high 5.6 here. Um No aldosterone, meaning that you're retaining it, you get the hyperkalemia um and your nana Niall gap, metabolic acidosis. So, if you want to go a step further, you can, you know, take it by saying whether it's a raised anion gap or non race anion gap and it's really easy to calculate it. I just wanted to remind you guys of um the more the common causes of raising our job. Um But a non normal animal got metabolic acidosis. It's just uh plus ing and minus ing your positive and you're negatively charged ions. Okay? Cool. All right. Let's do another case. We're halfway through ish. So you're a junior doctor this time seeing a 30 year old lady for weight counseling at the G P. Um Right. So yes, as the first question for, in terms of weight counseling, she tells you that she's gained some weight. So what sort of specific questions would you like to ask? Yeah. Yeah, good. I like that. I like, I like what you're thinking about distributional weights. Yeah, perfect. So yeah, being really curious about the nature of the weight gain, the character, the site, the distribution of it. Um whether you know, exercises involved um impact on quality of that. I'm, I'm sure you guys always ice your patient's. Um Yeah. So the other associated symptoms, like any skin changes, any easy bruising, um any like stri or, or like a plethora, facial plethora, facial plethora just means that if you've got like a, I think the best way is the best way to I've come across in clinic asking is if you had any um increase in your, like the puffiness of your face face or something like that. I think that's how I would best phrase it. I've come across that before. Yeah, flaws ing them vision changes are important. Why do you think vision changes are important here? Anyone? 40 so vision changes would. So that's I think another symptom market that would also help highlight differentiate between a good candidate and an excellent candidate as well. Yeah, perfect. Okay. Yeah. Sorry, sorry guys. I take I'll take it down a notch. You guys are already excellent and yes, so those will be the main ones that I we would want to know about. Again, exogenous star intake, etcetera, alcohol excess. Why alcohol excess be important in this case specifically related to weight that could also lead to weight gain, isn't it? Yeah, pseudo cushions someone's on it. Yeah. So those would be the main things that I would think about. So this is what she explains. I've gained so much weight around my tummy, but I'm also struggling to wear my usual size of clothes. There's more weight on my back on my neck too. Um If you are specifically. Yeah. So, um she also tells you that she bruises from the tiniest injuries that she doesn't really recall getting to begin with. Um, she does take steroids, but when she was first diagnosed for her rheumatoid but not no longer on her, help me on for the past 10 years. Haven't really noticed any hair loss or no, any changes to my vision. Regular periods. Remember in a lady I think that make you if you take away anything from my session is to please please take a mood history and your guide me like screening questions, then I think that would help you out a lot, right? So differentials, it's pretty obvious here, isn't it? Um Cushion syndrome as the main one could be cushions disease could be hypothyroidism. So you're gonna be a good uh junior doctor. And do you think about these following different causes? So I like to. So I think someone's already mentioned about pseudo Christians. So yeah, alcohol, let's start with that because um finding out the social history, how much alcohol they drink um is a good way of finding out the alcohol excess of it. And you can, I just wanted to highlight here, how would you test for it is by doing your LFTs and also your full blood count, you will see your high MCV, etcetera, okay blood film. Um So ACTH causes and your ACTH independent causes of it as, as the main key. Um leading causes of Cushing's syndrome. So, Christians diseases to do with your pituitary adenoma um but also ectopic ACTH as well from for example, your S C L C, you can come back to the slide later, okay, trying to move on. All right. Um So investigation wise, the key definitive testing to confirm cushions is doing a first of all, you want to. So there's two parts to cushion syndrome testing, right? So the first part is to confirm that they have cushions syndrome to begin with. And that is by doing a 11 pm. So that's like known as an overnight Dexa or like an overnight low dose Dexa test. Um And that has now superseded your 24 hour urinary quarters or testing, especially also because of the logistics of doing that test sort of testing to begin with, but it's also much more sensitive as shown by the new recent studies. So eight AM quarters or spike would, would show that somebody has Christian syndrome because you should have normally suppressed it. And then the next part of the testing, then once you've confirmed that they've got cushions is to do a localization study. So localization study is uh is a high dose Dexa at this time. And now you're trying to measure the code. So alongside the ACTH, so if the CT ACTH is suppressed and your, if your cortisol suppressed, then that suggests there is a pituitary uh problem to it because you've got your access, your HBA access. Um If there is a topic, ACTH, then you've got an intact hp access, but you're still, it's still not working with your adrenal adenomas. However, um you will have your cortisol which is released from your adrenals that are not suppressed. That makes sense. You can do a pituitary MRI as well. After localization studies, sometimes you might get mixed results or results that don't make sense. So, and this is more for your S P A S. I think it's a bit mean to make you guys interpreter as part of your paces. I have seen it in marks though, let me just say um for and you can also suggest other specialist testings in specialist endocrine centers. So as soon as you have a cushion syndrome, you probably want to be making a referral to the endo cry center. Anyway, if you find anything, it's weird and wonderful, exciting on your pituitary MRI because then you can do something called IPSS, which is your inferior petrosal sinus testing. So it's a testing by measuring your cortisol levels through your jugular vein, comparing your central ACTH to your peripheral ACTH. And if it's raised versus not raised to try and localized, um if it's a Twitter resource or an ectopic source, um so management just to, just to complete, I think in terms of the management, it would depend on, of course, the cause as well. So if it's Cushing's disease and you've got your pituitary adenoma. Um So the first line would be surgery to resect the tumor. So it would be via transfer annoyed or spin. I'd bone approach. Um, second line is your medical therapies that you can give. Uh, but if it's a ectopic ACTH release problem, then you would want to do um surgical resection depending on the location of it if possible. Um Right. So a CT independent causes, however, you can treat depending on the course. So if it's an adrenal adenoma that you can think about resection surgery, um and you can think about weaning steroids if it's exogenous. Has anyone heard of um Nelson syndrome? If anyone knows what that is? Nope, yes, alcohol can cause super cushions, but we do have a pleasure. I don't know what you mean by the last bit. Was that a question? Pituitary hyperplasia, post bilateral renal removal. I'll wait for you to come back. Okay. Yeah. Yeah. Perfect. Yeah. So Nelson, I think. Okay. Yeah, I think I get what you guys are saying now about Nelson's syndrome. Um it's after removing both adrenals, you can get pituitary enlargement secondary because of the compressing stock and you get, you get massive uncontrolled ACTH. Um That one Nelson's, you can also get hyperpigmentation because you're interestingly making more ACTH. Right. So you're also stimulating that palm see pathway, making more alpha MSH as well. Okay. All right. I think that one was pretty straightforward. Um case for your, you're seeing a medical student, a very conscientious medical student at the G P who's coming with diarrhea. So what sort of specific questions would you like to ask this med student? Give me two seconds. I'm gonna find a charger. Ok. Back. Right. Weight loss, hypothyroidism. Good. You guys already know I want to hear and fine, perfect. So I think also be really curious about the diarrhea. I know it. You know, I know we all know it's an endocrine session. But also please please do your normal bowel history as well, right? So your nausea, vomiting, any recent foreign history travel, any recent trigger? Did you eat a dodgy? Take away, you know, all of those classic stereotypical exam, examine what exam is like to hear pr bleeding appetite and then you can ask your hormone related questions like heat intolerance, tremor, sleep, restlessness, palpitations, etcetera, etcetera. Okay. Fine. Um, and also, um, think about the medications that could potentially trigger, um, the cause that I'm alluding to here. Plus your laxatives. Okay. So, um, this was the history that they then give you started about three months ago before normal bowel movements. No changes to the diet didn't eat anything dodgy recently. No foreign history travel. But at night she, uh, they're finding themselves that they lie awake for ages, tossing entirely, feeling anxious, not being able to fall asleep. Um, they're still on it with the gym, but I haven't had many grains recently. Uh they take C O C P haven't really had proper periods of hard to tell. They also smoke and when you ice them, this is what they want you to do because remember there a bed students. So they're a bit like, okay, can you also take a M C N s, do a fecal calprotectin study, blah, blah, blah. Um They already come in exactly asking for what they think is going on. However, um you are a holistic doctor, so you're going to take an approach, examine them. So, yeah, so the other thing that I like to say um as highlighted in this case is that part of my bedside sometimes. Um I want to go above and beyond by making my bedside examination specific. If I think there's a particular examination that is definitely relevant, then I want to mention it instead of just saying I would like to examine this patient. Plus, do these examinations. Does that make sense? So you're just trying to differentiate yourself from? Um Yeah, anyway, um so E C G still M C N s fine, you might do a parasitic screen if you think it's relevant to it. But the key fine uh the key specific ones from to the diagnosis that I'm alluding to here would be your thyroid um TSH receptor antibody testing as well, your thyroid function testing. Um And the examiner might ask because I think this happened, my examiner was quite rude. Okay. So they interrupted me and they would like, immediately went on to ask about the other auto antibodies at the time. Um which like, yeah, just threw me off my whole like rhythm anyway. But so they asked me about other auto antibodies um such as, you know, like the ones that I listed here. So you're anti TPO and your antiviral globulins. But you can say that they're, however, these are non specifics, they can be raised in both hyper and hypothyroidism, which is why the specific ones that you want to be talking about, especially for hyperthyroid cases is your TSH receptor, your traps. Okay. So, imaging testing, you can uh suggest a isotope scan technician, um scan, etcetera. So um these are the differentials top of my list would be grave's could be a toxic multinodular goiter which used to be known as Plumbers disease. Um It could be some sort of viral thyroiditis such as your dark caverns like thyroiditis. So, in the acute phase, you've got your hypothyroid and then leads to your high both. All right. Okay. So similarly with your hashimoto's as well, um you can also get a pituitary adenoma that is producing TSH quite rudely. Okay. So there could be other things that you can mention the estrogenic causes if they're taking medications that are relevant like your amiodarone that can cause your hypothyroidism as well. Okay. So just wanted to show you guys this scintigraphy. So I'm sure you will come across it just, just a different, sometimes it's difficult to make out whether something is diffused or whether if it's patchy. So I would recommend just having a look at some of these images just before um like a couple of days before your paces is just to re familiarize yourself. Okay. Fine. So management of your hypothyroid again, it depends on if it's an acute um thyrotoxicosis situation or if they're stable. Okay. So if they're stable, then you can do your medical, your radiological, your surgical management, if they're unstable and then you're thinking, taking a more acute approach. A B C D E S U H D, you uh you can also mention it in this case as well, just so that you're thinking widely enough, you don't just have to leave it out and not say it okay. Um So you're high dose anti direct drugs, that's all 80 D stands for. Um you're also going to be thinking of cortical steroids just to help give some support. Um and, and, and also beta blockers um for symptomatic relief as well. But of course, if, for example, if they had a past medical history of asthma or some weird heart block, then you don't want to be giving beta blockers in those populations. Yeah, if they're stable, um especially I think this one, I think my case, I made it so that this person smokes. So she smokes socially. So you want to counsel them on smoking because the reason I wanted to highlight the smoking bit is because it's a modifiable risk factor that has been shown in studies um uh for thyroid eye disease, it actually makes a huge difference whether they smoke or not. Like after smoking, that deride eye disease can actually um undergo like less proptose is like less um less like complications from eye disease. Basically, like um less of metaplasia, basically a symptomatic relief. So I'm trying to say um if they're stable. Yeah, so the main therapy is your carbon muscle. So carbon muscle regimen as higher highlighted here, you can either start often really quite high dose and then taper the dose and then continue until they're you thyroid that depending on your TSH findings or you can do an alternative block and replace regimen as well. And the main side effect of carbon carbimazole that you want to counsel them on is agranulocytosis fine. Um You can say that I can, I also appreciate the benefits of other therapies such as your radioactive iodine treatment. However, I appreciate that this is um take some time to work. So I need to give some other medical anti thorough treatment and symptomatic treatment, your beta blockers propranolol. Okay. So surgical treatment would be uh to do a subtotal thyroidectomy. Uh Yeah, but first of all, you need to make sure that the patient is you thyroid before you operate on it because thyroid is a very hyper vascular gland. You don't want to, you want to minimize blood loss as much as possible intra operatively and afterwards. Okay. So again, another common examiner favor break a favorite is how to differentiate between graves and other forms of hyperthyroid. So I like to split it into I signs dermopathy and your nail changes which are all specific to graze as seen in this table here. So graves your proptose iss except dermo's abdomal pleasure, all to do with how your TSH receptor antibodies react with your eyes and cause more college in the position, your glycosaminoglycans. Yeah, all that dumb opathy similarly profitably a mixed Dema is the most um likely presenting complaint in terms of your thyroid uh dermopathy, nail changes is your thorough acropachy. So this is thought to be the same as clubbing, but I will can I highlight that this is not the same as clubbing. It's more to do with the soft tissue swelling and a bone turnover formation that happens in the area which might resemble clubbing, but it's an entirely different condition. So another another question that they might ask you is your complications of uh thorough hypothyroidism. Um So again, you can split it into your acute and long term just to show that you're organized in your thinking process, af acute uh site threatening. If you get optic nerve damage, then you can get um within the first year of diagnosis, you can actually get, you can lose your eyesight with graves' if you don't treat it okay. Um Long term things think about your chronic uh conditions like bone loss, heart failure, et cetera. So Elephant Aces is, again, it's like swelling of the legs and that's very debilitating. It's not seen commonly in this country, but it's still prevalent enough to cause problems with graves. Cool. Ok. Sorry, I'm just catching up on the chat looks like there, there aren't any questions at this point. So I'm going to move on. So the opposite side of things is you're hypothyroid uh studies. So again, bedside blood imaging, as you're all used to it by now, you're hypothyroid is the previous antibodies that I mentioned. So you're anti thyroid peroxidase and your anti thyroid globulins. Um There's something called Schmidt's syndrome. Um It's something that you would have come across in pathology um is to do with it. So it's your autoimmune conditions, right? So your autoimmune diabetes, hypothyroidism and your medicines altogether. So you, so the, the way that I would like to phrases is by um saying that I would also like to consider a Schmidt syndrome screen if um there's relevant autoimmune history. So by doing the B M's your shortness, Anakin test for Addison's and your cortisol testing, etcetera, things like that just to demonstrate again that you are a smashing candidate. Um Management wise, the goal is to normalize the TSH. Um And if you're elderly, then you'll start off on a lower dose. Um under fifties, you can start on 50 micrograms. So 50 50 it's easy to remember, elderly, reduced dose to half. Yeah, repeat your thyroid function test about 8 to 12 weeks after you change your dose. And if you're pregnant, then you want to up the dose as well. And you want to counsel the patient of the thyroxine side effects specifically on the impact on the bone over time. And if we, so you want to counsel them by saying that um we might not always get the dose correct to begin with. So, um whilst we're tweaking and checking the blood tests regularly to make sure that we're not over correcting you um etcetera. Yeah. So um things like that E C G also appropriate for your af for your angina or might trigger it. Um in terms of the Viber skin manifestations of hypothyroid, you can, I could argue that you can probably do a, a similar uh table for your skin manifestations of hyperthyroidism as well. But these are the main ones to be bearing in mind. You can also adapt your history to ask about some of these skin changes as well. Okay. We're almost there, right. So your junior doctor is seeing this time, uh 42 year old male for daytime drowsiness. Is there any specific questions that you'd like to ask? Yeah. Obstructive sleep Apne apnea screen. Yep, I agree. Cook. Yeah. So weight changes. Good. Mhm. Meds. Snoring. Perfect. Spot on hypothyroidism. Yeah, I agree. All of the above. So sleep hygiene, asking a bit more, more about triggers. Again, you want to demonstrate that yes, you are thinking to be outside the box. Recent stress, etcetera, caffeine intake, your lifestyle diet, right. Um, snoring, I agree. Any reduced concentration, any accidents while driving, etcetera, um uh falling asleep at work. Um systemic problems, headaches, someone mentioned, I agree. Then now we're getting into a bit more specific questions like your increasing changes in your shoe side, close rings, um any numbness, tingling, etcetera. Why do I care about uh things like tingling of the hands. What's that? Look anyone? Okay. Yeah. Yeah. Sorry. Game. Yeah. Carpal tunnel. I agree. Um They could also have if they're, for example, if they're confused that they're drowsy, fatigue, nonspecific symptoms. Yeah, I agree. It could be hypocalcaemia as well. We never know unless we do investigate. Yeah. Okay. So here because uh did I not have a slide on the history? Yeah. So let's say if they had any tingling or hands, then you want to adapt your bedside examinations to involve the hand, right? So you want to examine the carpal tunnel if they are your Tinel's or your Fallon's positive. All of that visual field testing for endoscopy testing. What am I hinting at potentially any visual field changes because of the diagnosis? What they can of uh which could be related to acromegaly. Yeah. Um You can also adapt it so that you are, you would also as part of your bedside, you can do a sleep questioner like you're up with for your extra sleep apnea. Um You can do an ear, nose and throat example your O S A as well. So if we're mainly thinking about acromegaly, then you want to do your I G F one testing because this is more, this is now more sensitive. It's now replaced as the gold standard testing. Um better than your G A O G or glucose tolerance testing. So, uh just a bit of physiology, growth hormone has a very short half life and it's secreted in your postal fashion, right? And growth hormone will cause increased secretion of this IDF one. So IDF one still correlates with the growth hormone secretion enough in the last 24 hours. Um and it could still be used as a static measurement and you can also use it to monitor progression of the disease as well. All right. So images wise, pituitary MRI will be the main one to think of. Um sleep studies you can do for us. A uh you can do your colonoscopy for colon cancer because acromegaly has an associate increased risk of association. Oh, I've written it on the bottom here of colon cancer. There you go. So, yeah. Um Management wise, first line would be your transsphenoidal approach of the surgery of acromegaly. Um Second line is your medical approach. S S A s just means you're somatostatin analogues because they are the ones like octreotide, they would directly inhibit the release of your growth hormone. Um They're affected in about 50 to 70% of the cases. If it doesn't work, you can move on to something called peg this amount. Uh this is your growth hormone receptor antagonist. So it prevents the demonization of your growth hormone receptor and that then helps um work. It's effective at about 90% of the cases. You could also give something like your dopamine agonist like broken pretty. Um It was initially the bromocriptine when I started Medical Imperial. Um it was actually the first line effective medical treatment for acromegaly, but now it's been so superseded by your octreotide. Um Yeah, as it it was found to be less effective. So you can also counsel them just to show off again. You thinking holistically, counsel them on your studies, sleep apnea advice if you're driving, uh you want to inform the D B L A until disease symptoms are treated and gone away. Um Weight loss Council don't sleep soup. I might make it worse. You can think about other second line uh think therapies like your CPAP machines or your intraoral device is as well. Okay, fine. Last case. Okay. So you're a junior doctor seeing a 35 year old man this time for review of bloods carpal tunnel, immediate affect. Yeah, perfect. Thank you guys. Okay. So now we're moving on to reviewing blood. So sometimes I just want to, again demonstrate that sometimes don't want to scare you guys. But, um, sometimes it can just be a really vague blood and that doesn't give away anything on the door. Um, but don't be put off by it. So blood's will show that they're all normal except for a very, very, uh, low. Yeah. So I think someone already started talking about, um, any symptoms. Yeah. So you still want to take when you, when we're, when we're so I think the technique to approach in this set station is um the patient will already expect you to as soon as you go in and you introduce is out there. Like, right, I've got some results, right? Like tell me my results. So then just um pause them and say that you would tackle the results bit in a bit, but that you would like to find out a bit more generically how they're doing etcetera. So exactly what Daniel suggested like, what are you will be going on any symptoms? Any family history? Yeah. So you can still do your generic screen, right? Any allergies, social history, etcetera. You can still find out loads of details and that doesn't take you very long. Um Right. So they're now moving on to the blood sped, they're showing that everything's unremarkable except for low potassium of 2.6. And the patient explains that I've been on all sorts of meds, like all the PriLOSEC, all the other BP tablets. But the other day at home I had a very high reading still. It was around 100 78. They have, the patient has a marvelous memory. Right. So, he tells you exactly what the reading was, which is here. And he also says that he's suffering from occasional headaches that he doesn't, he just doesn't seem that bothered about. Okay. So, I think you guys have already started talking about. Yeah. Yeah. So con syndrome bilateral do not have a picture. Perfect. All those things that you're mentioning already. Good stuff. Yeah. So the other thing that it could be is maybe pheochromocytoma, it doesn't fit as well in the history now. But um it's all relevant. Could they could have some sort of uh renal disease that was under diagnosed at the time as well. Okay, fine. Um or they could just be um they might be on a lot of BP tablets but you might, they might, you might find that they're not actually taking them, right? So investigations um the main thing is your plasma aldosterone rina ratio. You will show it will show high levels of a dust Arone if it's uh cons and a low read it because of the negative feedback because of the sodium retention from your aldosterone. Yeah. Um and you're, you do a CT ABDO just to see if there could be um any other relevant pathology alongside here. Um And if the CT is normal, then you can do adrenal vein sampling and that will be able to differentiate whether it's a unilateral cause or bilateral cause. So, in adrenal adenoma, you have excess, um so excessive aldosterone and only one adrenal vein, but bilaterally will be raised symmetrically management. Um doing adenoma, you're thinking about surgery, bilateral, you don't want to remove both glands. Um So you can do what we give spironolactone. But if we were to spin the scenario, if we forget the potassium level, if the potassium was normal, and if they just presented with hypertension and sweating, what would be your main um differential at this point? So the main differential being your failed Chromos it toma as I highlighted here and, and I think you get a lot of the sweating as a side effect because of the high category a means level causing sympathetic activation. So your favorite conversation, Toma main investigations and your management um again, wanted to highlight that. It's now the 24 hour urinary metanephrine as, as the, as the more sensitive testing. And it's now replace your urinary category means testing. Um the sensitivity, the exact numbers, I can't recall that it's something between like 98 like 87% something like that. Um The main rule about your fair Chromos a tumor that you want to show off in your virus is your 10, 10, 10 rule. So 10% bilateral, 10% malignant, 10% extra adrenal, um extra adrenal being in this organ called organ of Souca Candle. That's different too. You're thorough tropical of Super Zuker Candle that I mentioned earlier, by the way, um as a landmark where you're current allergy, a nerve, this is completely different, but it's like the same guy if anyone cares. And so yeah, 10% also familial as well. So you want to be talking about your potential syndromes like multiple endocrine neoplasia at this time is your two A and two B types. Um You neurofibromatosis, you can have Von Hippel lindo as well. Um Surgery would be the definitive management for pheochromocytoma. But in order to plan for surgery, you need to get them fit enough to be able to operate. So you need to give medical management before. Um It's just a memory aid here that I've tried to come up with myself, which is really bad because um a before be that helped me remember that you need to offer block first before beta-blocking. Um or if you remember Sofina phenoxybenzamine um is an apple blocker. So with a pheochromocytoma, you have to give phenoxybenzamine first before beta blockers anyway, whichever helps, sorry if it doesn't help and it just makes you more confused. But so yeah, the give the the takeaway here is that the alpha blocking is the first thing that you care about. You want to alpha blocker for weeks um and be to block because if you don't um alpha block and if you only just be to block, then they can have unopposed alpha adrenoceptor overstimulation of it. Um that can lead to arrest and your hypertensive emergencies at the inter operative table, which we want to avoid as much as possible. Okay. So other blocking help to normalize your BP and your heart rate and things and to replace your contracted blood volume, right? I think that's my final slide guys. So, thank you so much for listening. I hope it was useful. Um I'm going to look at the chat. Okay. Cool. Yeah. So, symptoms of malignant hypertension, I completely agree. So, malignant hypertension is something that um, you don't really come across so much as a medical student, but I kid you not, you will come across a lot as a uh budding a phone. That will be the bane of your existence. But yeah, so it's pretty important as well all days. I hope you found it useful. Um, and best of luck for the exams. I don't know if anyone has been following the recent um, escalations with the B M A and the junior doctor pay situations. I just wanted to say, I, I know it might have an impact on your medical student as uh morale as you guys are coming up to exams. You might think what's the point and all that. But there are plenty of other options. The UK is not the answer guys. So yeah, but keep going at it. Um It might feel like you might not end up where you want in terms of jobs. Um But there's still, you don't know until you start working and you'll, you'll find that, you know, you're a lot more skilled than you actually think. Sorry, good luck. Thank you so much. Um Just to answer the last question, do we have to remember ranges and doses? Not really. I wouldn't suggest remembering doses, but I think for things like your sin acting testing, if you can remember it then yeah, I think that's it shows that you care. Um I would suggest remembering your electrolyte ranges though, like your calcium, your sodium, your potassium. Um Yeah, those would be the main ones on the top of my head. Magnesium. Okay. I'll stick around for like another minute or two if there's any other questions. Yes, absolutely. I will send you the slides, please. Please. Please do my feedback.