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the okay. However, in the knees, too many more of the effect is coming Walking in Edinburgh on my graduate. Different, I don't know about three years ago, and I wanted my finals. Um, so it's a privilege to be teaching you guys today. It's all the SSS finals day, and I'll be teaching on your respiratory. Um, doesn't quite a whistle stop toe. So if you have any questions Oh, you and interview any time just feel free, even speaking too fast if you can hear me, just that, You know, um, now is stop my video in general, it's lying. Okay, so today I'm just gonna especially a These economic teach causes a few being a broad topics that are running just need snore, few conditions and disease processes. So what's that doing? Excuse on some of the topics, and then we'll explore that further and into is the end of all. Do it of our ski trips this well, because then we also use that coming up soon. So again, any questions, uh, that you and our surgeon he stopped me, or, um and, you know, I might not be able to keep an eye on the check. But if you want osteo, I meet yourself or you can I can always I'll see you guys at the end of the presentation. Okay? So couple of excuse, unfortunately, wouldn't be nice enough to do then on a separate form. But I think the best thing to do at this stage is when you get the questions. Kind of, um, have the answer in your mind. And if you even better if you don't even look at the options and have a v a s a coupon. So in your mind, and then try and test yourself that way, and I'll give you guys a little time. Um, before I reviewed the answer, Okay, so let's start. Okay? So hopefully everything's have time to read you the question and picking on something that's called when the most straightforward questions and if you, all of your lungs is really just maybe we want to know. Yeah, So there is a B, and this question is is very straight for aggression. Just testing a login, the excessive me to the fast. Mind the pipes off that and how it's classified. And it's got a little big and exams. Although it might be maybe slightly there straight forward if they could. It's coming up with the question, but so she just know your constipation's quite well. Um, but the life threatening exacerbation remember that First, you must qualify for having severe small so with your tachycardia and you're taking near, um, and high Cokes yet and then you're considered a little these 10 things about the peak flow of the EKG results and clinical examinations. Really? So how that chest sounds like idea starting pyre out. What's the EKG tracing looking like? And let's see a Bible Science. It's pretty simple. You think about it. Just reminded me the situation from you. So, um e in ability to complete sentences that sparked a severe criteria. See that if I send it, it's not that person. Um, Sinus turkey is again part off, um, severe asthma criteria. Uh, I want to go into things I fasted for the going to other would be nice. Then it becomes life threatening and a baby nice. Except if I had this pretty acceptable. But she's a young person, so yeah, and I wouldn't say that's refractory if we've not given fluids so other things like that So be it will be the best on so all this. Well, next question, uh, face. Guys are saying I'm cool. Yeah, key is skin is a little bit more time starting the question allergy liens and five seconds cool. So this question is testing your knowledge on kind of the diagnosis of the virus already. And sometimes if you get into the details can be a little bit confusing, so avoid increase over 100 50 is actually not announced today. To diagnose asthma definitely should be 200. So it's just numbers they get into your head's be that easy that that ratio is not obstructed, so it should be less than 0.7. And just remember the diurnal variation of Ask My Diagnoses as well. It's worse at night, so don't get confused. Um, and you need to have a people diary that has and the diurnal variation is have been documented more than three times a week for in these two weeks. So this against public shopping, and they can get much more tricky with me. All the numbers staying around, but we'll get the vaccine. Oh, and all the other, all those other criteria, Um, situations of room air on the one or spaces for me. Are you really relevant? So, yeah. Given I would say maybe straight for aggression and bs with that. We just had one question. Yes, that I thought I asked her was worse in the morning. Um, I find out myself, but I appreciate it and right, but double check that. Sorry, guys, that I go, um, if that was his hands would be, but about once a night. Um, yeah. Okay. Next question. Being in a realize and five seconds. So this question is, um, is about the discharge Great era. All right. I think a lot of questions focus on acute management fast, but really, what happens after that? Um and I think I'm always on that. So we're looking at this patient. She was treated accordingly, even, you know, you know things like nebulizers and magnesium oxide in all those things. But she said it's an ongoing oxygen requirement. ABG actually looks not too bad and her feel to her she's not have oxygen to be in Tuesday. Right? But, you know, she can she still been taking me still borderline tachycardia. Um, and basically just got an ongoing oxygen requirement. So in the immediate phase, she probably still needs a bit more nebulizers to help bronchodilator lungs a bit more. And only what happens is that we'll get that for maybe like least 24 hours and see the next day. She is improving. Yeah. Some patients said the turnaround very quickly, then hospital, maybe to these wrecks. So for her, looks like you just need a bit more nebulizers could probably stop it makes the going from back. Um, changing the eventually most probably wouldn't do anything to come as a fine on the rescue is escalating oxygen requirements. We wouldn't start in hell called ago. Steroids for an acute aggressive is to ask that it should be five the course off on insulin. Um, and let us probably aren't really helpful in this context. Wouldn't say they were wrong, but I wouldn't say the best that management for now. So and the other thing is before, if this is the first admission whole still, make sure you include things I asked Medication. Referral to the Asmanex is and they be full of a no PT. If this is an occupation, say things like that would definitely get your body point because you think about the control up for these patients Was just better in line. Great. So just a little bit up last month. Sure, everyone. This took me nearly all these things. Um, that wasn't Benzal. We used chest tightness, breathlessness and the most call them precipitants is of arrival. Illest. Rete? Um Oh, sorry. Oh, yes. It's worse in the early morning. So the question was your idea. Sorry. Days Uh, did I go in a room? So difference also as know if you have a patient in all ski station repeating history, You forget things like the only access is always the COPD lover cancer looking for the reasons. Well, but obviously you pees out things like weight loss and aged and other risk factors in history and talking about the diagnosis of you mentioned earlier, You get your spyrometry. Did the class ability test? Um, he needs some obstructed test on the probably function people there is great, and you don't really need all these, But I know she use most of the time you can get it for the physical examination, and and, um, all these things will help with that as well. Another exactly where it is kind of drug classes of rational medications. So knowing mostly the side effects of each inhalers and potentially the mechanisms, that's all. But they wouldn't believe me that Mickey and ask you that, I think. But I think knowing that I can that doesn't help with the side. Affects. Um, no. The classes of each and why you're prescribing them and side effects, mostly helping me all sensations as well. If you need to call so patients on a syndications on inhalers and then you can explain things like you know you have it might be a bit So I see my feet 11 of this after using doing here this Austin Um and you definitely see that often in some patients will be a tachycardia after they are so beautiful. Um, college or spirits doing all this leader or all their local systemic. The local effects is also stem effects. And then my all skills that he asked for side effects of steroids. No, the last patient, but in a in a different patient. But nothing, I would say at least five off the top of the hip will be really, really helpful for anybody sick. You'll excuse. Mirrors will great. So Income's about acute. Asked location when you see them in a resource Amaryl in whatever way to ask you guys, um, important questions would be. Have you ever been admitted horse pill before? Or have you ever been admitted to a level to a Level three characters? That's really helpful. There's good evidence to show that you've been admitted ones, too. I still hate to you. There's a high chance that you be And they took in, um, and they might look all right at the time of admission, but to keep a close eye on that because they might be period really quickly. Especially young patient. So you need to monitor them. Were quite closely. They're normal people, normal people on the monitor resource. Um, you should get some blood, some baseline bloods, peak flu, and obviously in the evening GI um, and you definitely could locadia oxygen requirements in the peace. You too. Um, making sure they're not hiring out when you're breaking the DVD, um, heart. And if they are, definitely, you should consider night. You, um, review because they might need been many a bit more oxygen support, like Hi, Phil or CPAP or what? I'm religiously might need to be there, but that's really rare. Okay, So just, um I'm sure you guys have got an average went down to the TV. I know, but obviously oxygen get some labs on the doses in an authorization. If you do get this in your research scenario, you will probably be asked to prescribe the nebulizers. Don't worry. Don't need to. My my cycle is just off the top of your head because we always give you be enough. Didn't refer to five. I guess, Um, if you can remember the dose and still be really helpful so hydrocortisone. This is only what we give him that acute setting because their breathing quite hard you're not, you know, immediately taking tablets and usually they get magnesium is well, sometimes to get through your file in, but there's no good evidence with it. But if someone's breathless, if I have, you had to throw them everything you can. And as I said referred and I see anything. Okay, so we went to the next, um six. Use you just 10 months. So this is a question about oxygen there. Any oxygen therapy? Um, from my experience, crucially love asking without the oxygen algorithm from from the beach? Yes. So? And somehow it seems pretty when they first come in. You need to treat that. I poke here first, and I know that's always at the back of your head. You always think I think you're retaining a Are we giving him too much oxygen? He's getting a bit confused. I can see why some of you would choose deep, but with the union ABG for us to prove that because he might be getting confused on the hypoxia you compel. And then the IV is you inform you where they need to decrease the oxygen or not. Oh, that makes sense. Uh, I don't have a picture of the guy and here, but I'm sure you guys know what I'm talking about. Is that PTSA? Excellent guidelines. And just go through that. I know that well, because it's definitely an exam. Favorite fighting group. Next question. Want in the seconds to consult your menses? Okay, so the answer for this is easy and I have you, um So this guy, he's a he he SUPT. He's a longtime ultrasound there and clearly has declined in the past two weeks, and it could be low reasons for that. But the question's not asking that for the moment, basically a vacation in front of you who is hypercapnic and he's starting to routine. He's been a bit confused and clean. His gas is show that he's getting quite as adult e and basically used to go into an IV. Um, yeah, they're they're some reasons, I guess we do need to. That gets us. Some of you might have chosen the other options. We don't need to think about why that has happened. He might have had a pneumonia, and that might have caused, um, this episode old. His lung functions to go off or attention. You're on too much oxygen. And that's why he said, get hyper can take a few things to think about right now. The most important, they give him an idea. Just seemed question. How's your vision? Chronic and acute retention, is it? And that's a good question. And yeah, I would say, Normally we just look at the pH, uh, and the the bicarb UTI and the base excess and if someone has metabolic compensation that we could quiet be that there's a chronic retain a and we wouldn't giving too much oxygen. I know that's what I hear. Well, the bike up here and it's a little bit. It's just a little bit. Also needs a bit of a visible the line question this one. Okay, but I think on the other the other part of it is that he's also just been. Well, it's been confused, Um, and maybe that points to bit more that he's not a coronary repeating her. I would be an IV. And the other forms, of course, is the living and in terms or, um, do you mean in terms of other kind of things, I see it happen things and my intervention of you mean just like a nasal cannula that needs a hammer. So that's a good question. Um, I think for him, this is a guy who, assuming those gases are, were she's getting more acid. Also, um, and he is a retainer. Giving more oxygen via nasal can last. Not the best idea, because he's just going to retain more and get books. And what's a dolphin? So you need to get, um, just need to get ventilation into the different week and there's no leave. I will see if that helped. Any sense. Thank you. Okay, next question you gave me, but 10 was good. Squeeze. This one was a bit more great. Okay, well, then, guys, so these images can be on the computer, the rubber hit around. But for me, that's right. If it's the criteria, um, and you can see that when he gets for me, that's the oxygen hiss. ABG becomes much better. So even a sense for B you can see the forties a sausage in Mason routine, so that's probably too much oxygen for him. And we might want to reduce when the try Juanito to read this first and then repeating the BG. And that's C is definitely out, because if if the patient's most all someone at home smokes is competing on contraindications for the L Tots and Family and B's and C's a little bit more border line, maybe some of you didn't choose it because it's 8.4, and it doesn't fit the criteria of appeal to lessen eat with signs of polio hypertension. But he does have signs of that. We have attention. To be fair, he's got tired pulmonary artery pressure. He's got beautiful Dina. And yes, it was a fit. The criteria. He's probably someone's going to need it family soon, I think. And I guess they are probably other reasons he might have high upon pressure as well that we might need to consider. But that's only if the vendors of those questions I'm going to go into that. So I'm sure you only the Elocon 30 record Well, and, um, again, quite Publix and question. And I probably won't go to Washington because everything seems so. Most of these things have gotten that right. So well, then so about COPD, um, videos on spyrometry. With that extra active picture, begin home. Your function test can be helpful as well, especially if you wanna one of the progress and see if these coins probably don't need to get to go down about things like the the gas trends with transit factors. But that's some of the rationale for why they're reduced. Um, occasionally you can see police pena in COPD patients by. That's probably pretty bad. Pretty chronic simply, um, four minutes trips eating, We give you your brain and you only come to the then under specialists required. I was like this of request and they're young occasions. And also the the non smokers, Um, and maybe a chest X ray, painful or COPD regions Fairly typical. And see hyperinflation slept in by friends and see my changes. And there are just some questions in the chart again, Um, so one of them says for two questions ago, if there's an option to intubate ship me, choose that since the pH is pretty low. Um, good question. So number. You you follow the stepwise management first. So a lot of people can come in ability unwell with acid or acidosis, whether it's from, you know, things like COPD or even DKA and all those kind of things. And you always do the least invasive option for skip them. A trial of an IV. See if that improves the gases. Um, and similarly, in any other kind of disease process, like the K, you get included to get on the protocol and see if that improves. And most, like most young people, came to turn around. And obviously, if that doesn't go well, for the soup. You know, patients that you beat to intubate them. Um, the most of the time. Usually an IV works. What's difficult is that they don't tolerate it. But I have very, very leucine COPD patients getting to be that not so much, because that's not like that is technically the next item. Medical management. But these stations are frail. We've got reduced respiratory compromised. Um, you're interviewing them is but not the best idea. Because then getting them often to be those could be really, really difficult. So most of this eating all care tends to be an IV. Oh, that makes sense. That's just answering the question. They could go go front of you. But that's not gonna be asking exams. It's just kind of that doesn't happen often. And I be works. It's just getting into salary. Essentially, that's what you and yes, you definitely get the reference ranges in exam. Sorry about that. Um, there are you? Definitely. The reference range is Okay. So, super the exacerbations, um, non B patients come in with increased specialist small symptoms. Sometimes you can see, in fact, the symptoms that could be an effective exacerbation. Um, usually triggered by a viral illnesses. Old actual is this, and it's kind of lists quite similar to ask my exacerbations with the monitor. Their situation's get some blood tests in particular. Get her extra call. They look like they've got infected symptoms on TV. GI and a chest X ray is important, particularly for to look for new with your PSA was our exist or just contamination. Really? Okay, let me. I mean, occasionally, quite also. And you won't see your focus of infection on the chest X ray, but off course, rival of things that can also treat excessive a shin street and cultures would be great as well. So management's quite similar in oxygen. Um, you can get the labs, of course, and always give them prednisolone to reduce the inflammation in the lungs. Thie Odean guidelines. So antibiotics is the recycling. You give them 200 stat and in 100 but getting don't worry about that, that will be you always have the venous. Your father too. Um, and I'm sure they won't give you a 15 different types of antibodies. It's picked for this. I'm sick. You know, just if you want one option Um and of course, was always in those ups. Patient and get the two readings of the respiratory upon beauty might ease in positive pressure. And in general, COPD patients always encouraged and to stop smoking. They will probably need to get their vaccinations, cause they are. You're very much prune two for the chest infections Are the life self activity to be kinda like nutrition and boots? Um, stations can acquire a hectic, um, with the chronic COPD of the N C. Student seen in patients. They should be getting the usually payments and should hopefully be using them. And some patients who are so prone to exacerbations who their weekend and we got a hospital, they Sometimes they'll get a long term antibiotic prophylaxis as well. And again and again, people uses insulin license. And for that, just remember that a prosecutor he see So you need a baseline EKG for that. And some patients will also get rehab. Um, yeah, and again, just inhale a class this full COPD, um, salmon llamas. Just basically they're entering anti muscarinic. Thanks. And because of that, I think like drying off isn't a say the extra calories and all that kind of things doing well. We don't get to go down about the different types. So my name's expire in Trimble. Just thinking of the classes and what they do. All right, next question. Okay. He just put five seconds. Three. So yes, well done. Good. I can see the confusion in this question and to be our be used. Also agree. Answer. Um, so this is a lady who essentially she's got a cap and she's the tree. It's just got quite a significant kept. And she said to me, being from that point of view, so high dosage requirement, it sounds like a lung has collapsed further on which is not getting on top off the infection despite IV therapy and quarrel of oxygen or 18 m already, she's in pet one restriction failure. I think this one's a little bit tricky. I feel like the immediate action would definitely be to increase auction livery. Um, most people we just started to 15. Some would do. Is that wise? I don't think these are 30 roll answer and quite a row of argument for this question to build this, but we need this lady. She's in pet one or swish your radio shows significant right side along collects potentially parapneumonic effusions brewing. And she's just not doing well. So actually, she needs a good guy to you. Um, when you consider kind of level to a level three support with its high flu nasal cannula to see that helps Ah, a surgeon a shin or whether she needs to be cute. Um, I think this question is a bit tricky. I think it will be if this something similar comes on exam. Just the attention to kind of the living of the question. Um, immediately, yes. You give her enough oxygen, But really, what she actually needs is to sleep. What she's going to getting and those oxygen is not gonna be enough Freddie soon. So, yeah, I shouldn't be about Cox. I'm sure you're old. It's very straightforward. Um, I'm sure you'll know the code crazy require. Well, remember the blood coaches from the 66 Guinea BG if they're not such a reading, Well, um always get a sputum go see in this and then she'll leave for legionella testing. Um, And you sometimes you feel urine. It's older. Check for pneumococcal nation bodies. Just extra always a least, um, three period. We rarely do people aspirate. It's for patients with a cap. But if they've got a huge effusion, sometimes sometimes we would, Um because obviously, if someone has in someone comes in and pneumonia and as a coach, pre infusion the different show is, is that fluid fusion caused by the pneumonia or that she has underlying bit concede? That's causing all of this So But there were, You know, that would become the parents as the nation goes by. If we're not getting a top of the infusion with diuretics and things, and usually they will consider aspirating and sending away for cytology off. Seen this a couple of risks like this bandwagon. I think whenever a patient comes in with pneumonia, you need to ask yourself why most is the kind that old and feel, and that's medicated, straightforward. But if you have a young patient coming within pneumonia like a baby, you'll, for example, and they're not in use pressed, need to ask why and when you should send off. A typical screens are HIV and things greed. So, um, not gonna do it really quick exercise and those wits I did this in my finals Come down like you're back in 2020 and that that was really good. Um, basically, also, um, just really, really short for is Nece. And in your mind, hopefully diesel in immediate leak. You help you come to mind certain microorganism. So these different things, Um, for example, the IV in you and you might immediately think off PCP There's no right or wrong answers it It's just exercise to help you guys. Kind of strain of the Q mindset, So Oh, any sense I'm trying to I'll give you guys about 20 seconds with. Okay, So the same boat parents, hopefully the box of deaths attaching. Uh, very I didn't know that two years ago in my final section will hum IV the you patients. They come to get stuff aureus in their lungs, all the see if they're really in the compromised PCP so easily. Um, I'm an icy PCP. I mean, it was a cyst. You regret you, which is a common infection in in in in the immunocompromised population. So if you came with every meal, if they fought any other autoimmune condition for which there are even suppressed for happening Treatment. Um, and he microscopic hematuria trigger thoughts of the genitalia. And you send off a urine sample for that. And that's, um, quite a passionate favorite, I think, And trying to be positive. Cool evidence is mycoplasma. That's when I just keep a scent of it. Great. Okay, next question. Okay, So the answer here is be and hopefully ever go to the English is here that he's basically so culinary fibrosis is, um I think I realized the trigger. This question is, Is it is it basically the pipe off? Probably for both is he has. So he's worked in serum aches and poultry. So he's a high risk ulcer, the courses, and that's all trying to get for here. And it's in the closest with common because Arpaio fibrosis or about the middle, We don't put me fibrosis and that side you can see changes in the bones. Sorry, that was the trick in this question, but definitely you guys are particularly know the the shadowing is obviously, um, a key finding on the night pf skin. No idea of PS skin. So very quick. About probably four versus that can be an older adults and It's insidious onset, um, slowly progressive breathlessness, some weight lost, a dry cough. That's quite distressing. Um, should think about what occupation they do, what medications you're on have to go and have a connective tissue diseases that's associated with fibrosis. And, of course, someone who has got bilateral crackles and it's progressively breathless. You should think about things half in you as well. That's probably more common of an E V g. With pretty much sure had toxemia. Um, although they can still be saturating quite well, um, on you man chest X ray, which showed, um, Ritalin out of the changes. But usually it's only disease. Although it's not too bad, you can can look quite all right, um, they will send it, scans the chart. Think he's. I'm sure, you know, and I don't be quite useful to memorize. There was four points there about the ground glass changes or two, and a little shadowing and honey Call me because that's quite the, uh, skin favorite to ask as well on, Of course, the restrictive on Pamelor function testing So this it's impacting it, and I think it's useful in the morning to remember what causes up a little changes. The changes, Um, and it's Yeah, a fortunate just appointed, memorizing them beauty. Um, the most common one that you'll see is idiopathic, and that's always a little low fibrosis. Um, also you sort of bad. And my nephew drugs that would cause of a look purposes because that's also exactly every task. Okay, which isn't a move on four inches of time. Um, and again, as you get again, this is a V a z Q or viable ski kind of question. Um, the management before your fibrosis is the smoking cessation. Don't need a referral to the session. This the night in the oxygen there's some new agents. Middle of evidence is always changing. So doing Bogie's on down about trying to memorize then I wouldn't worry about that long trip was definite is what is usually ready offered in the population that gets here and quite often don't eat. Only people can get one, because the trajectory is, um, it was the end of life, but I never use okay, next question. Okay, so the answer is a and essentially at this station has a pensione with your ex, and we know that because that way. We know that because he's got, um because of the clinical examination have residents and most importantly, is tricky as DVT good to the left. So that indicates tension on the right weight associate that, you know, absent bear sounds and things like that. He's something to be compensated, but I just falling. So he needs that compressed this up. So the best on cell the full here is to decompress it by the cycle of the cost of space critical online. So this is another question. Sorry. It started an hour ago for the picture of me. Okay, so this question is almost thing but a little bit different. Um, this is a second during your blood or X. Very. I just I didn't know what the options are if I sit. Okay. So hopefully you guys own you. That that was a second year in year ago. Right? So, um, 30 on, he's on the of this cycle because of his age. And if I take a COPD, so then he needs a chest ring in Southern. As for the Garance, the other thing is, remember is but the safety triangle, which they might asking me in the AM sick use. So is the borders off this evening triangle for chest reinsertion? And just remember, it's a natural edge of that dose. I actually have a major and the base of the exit and the best place to go is the closest place. And that's just a couple questions. John again, Would you want a chest X ray? Her setting dream and normally no. For a straight forward starting a drain in session. You can You're just going to the safety triangle and their techniques. We didn't the chest reinsertion that will tell you whether you know, right spot. So, for example, is a stress strain bubbling? And that usually tells you the best thing in the in the lung. Um, also the treasury insertion. You're having to get a chest x ray dull to see if you've course another new with are expecting that, uh, and also see if they're doing with the rice is resolved. So yeah, so just x ray after you put the dreaming. Um, and that's the one question about measuring the size. Yeah, you do need to mention science. That's a really good question. Um, sorry. There's no love. Um in your exams. I'm sure they will make it much more detailed. I think I'll cisterna go with that. That was quite a big bill. Like a decent size in the box. Um, but they'll make it much more days. And your exams, it will be like if they don't give you a measurement, that is like to see more three cm. They'll make it so obvious. Like she just got no longer on. And you'll know. So, yeah, I don't really about it. And yeah, so, um, I'm going to the other with them. If he's breathless to get a chance, bring any me. But as I said and exams, they will make it so in big list, it'll be fabulously, I think. Okay, so you're the reason. I mean, just a remember, get a repeat chest X ray after you put the dreaming encouragement to stop smoking. All starts when you can have this because that means you're prone to forming more believe and when does it was burning? But you get in with our eggs, and your office is They cannot fly off the 1 to 2 weeks over a normal chest X ray, and they can not they've ever. Unless they have that surgically fixed with the vets procedure. So important allegations. Okay, great. And just one more last excited about Bublitz. Um, so that's like, this is a oh, could guess. We'll see. I mean, I still see your sites. I can just see, like, a white screen. Um, try it again. Okay. So you have, actually, like, this is a popular final question, I think because of that privation does this like this? So one of these things will come out for me. It was the first one. They're just knowing the consummation of symptoms. So each of us great this condition. I'm just on the Januvia. Sansa. What? The first one is your good passions disease. The second one is, um gp and that that one is easiest for you to pee. Okay, Cool. So we'll just do a quick one for the ski stuff. I know. See? Yes, sir. Flowing just else in the chat on what's the subtle news? Seven. There's a deformity off. Um, your nasal structure reading it was just so I don't have a picture like, just google it. So if you go, um, GP, you probably sing a good picture of it, but it is literally just a nasal deformity off your off your facial structure. Okay, so in the all see how to present your respiratory findings. I'll just do this, um, quickly. But essentially, if you do a breast exam, um, I don't know what they do for you guys to see. And I don't know if you've heard whether you have really patients with examinations or whatever going to tell you the science, but we got a list. This is just give you guys obstruction and ALC is any findings in the especially extent. So this presentation is based on that assumption that you will get some kind of science whether it's told or not. Um, so gonna focus on presentations with bilateral cracks. It's cars and, you know, virtually bell these. So when you when you see when examined someone and it's financial cramps Oh, sorry. Not trying to be sure that Is that looking up? Yep. Okay. But they so what causes bilateral operations? I'd be neat if you're an Aussie situation, and and you're not to know this begins that thinking about different tools already. You need to look at the other signs that you should be looking for and see thick foam thing that big diagnosis by, for example, like clubbing or supplementary oxygen or things by the bedside. My inhaler. You think about the causes of those potential complications and definitely what you want to do next. And they're almost always the same thing, so don't worry about that part. So Benadryl cramps. The most common cause is is usually pulmonary fibrosis. Obviously new. Listen to the nature of those crackles are they find out the cost. But if you if you do hear kind of the ladies standard fine crackles. Not really with some bigger clubbing, you can't even get to think about fibrosis. And then in your presentation itself, it would be greatly had mentioned the cause of that. And you sound really slick and reading the spots. So just that and nine. So this is a really this is an example over. See if some of the shit every single patient but always start by saying what you examined. Um, the patients that go fix and when the king with start always with your bits on inspection, that's, you know, comfortable if you with the stress and in a respiratory station. Definitely always mentioned when he's on oxygen, that's that. Is all this relevant, Uh, think clubbing is relevant is that she wouldn't qualify. Ghost. This and your part about hearing the fine especially crackles. My last, really? And once you've done presenting your examination, the next thing you should do, he's going to see what you think is going on. So these findings are consistent with public fibrosis all, for example, these findings consistent with bilateral pneumonia, if that's what you think is going on all congestive heart failure. Any of those things, um, and then parry a differential in before you think is going on. So this could be the part that progresses during use or connective tissue disease. As long as it makes sense, you will never be wrong. It's almost your Your differentials are consistent with what you found. Don't be afraid to say them, and they'll definitely I'll see what you think is going on. So you may also say in your presentation the next part about what you want to investigate is pretty standard in the breast exam. So you want to get a proper history, didn't get his jobs you should get his baseline bloods. And if you'll if you're thinking of cyber since things like rheumatoid fight the anti CCP is also useful because that's what you're considering. And I could never go over with a BG know this and definitely always get chest x three. And I've included hate our CT here only because your social station has primary fibrosis and you know that's go send it so you can include that as well. But basically in any extended just see, I want to examine the history on all these bloods and think about what imaging you want. And that's about it, really things they might ask you this time while we see the chest X ray. And we went through that earlier and I'm sick use. So the attraction Sorry, the vertical and all the shadowing were receiving HR CT. So the bronchiectasis is the honey coping you see restrictive, probably function tests and maybe go ask you what you do for people of fibrosis. And they didn't go into a great idea. They won't be time to ask you. So many things don't very, but we'll probably ask you to. That's fine. And if they're asking you more questions. That's a good sign. So the worry, Um, I think about your education very young and a bilateral Crips, and it's creating that the side of the table. Then hopefully your differentials will definitely send changing. And you're not thinking so much about pride, bro. Sis. Well, not probably for losis in the older population, but potentially cystic fibrosis. So just remember that if you see an application in the vest station, um would be able to separate places also mold excessive. Um, they examine like a bunkie extra station. They've got other sanctions that Jerry complications. So I I highly, though building you really cystic fibrosis station in the air of cool bit. But I guess what some knowledge is Well, you know, if they got never changes or, um, peripheral, demon and science off kind of gi I and lung issues and you might think about cystic fibrosis Oh, if they for insulin at the table or crew younger self So good questions. Are you? What's Creon? Oh, Korean. Korean is a supplement for it, and drinks of medical patients with basically need pain created problems. So patients in to see if I grosses they become because the pancreas is affected. They can make the enzymes that novel pancreas of me, the Koreans of supplements for that. So they eat it with their meals on. But it contains things like the light cases and things that'll bring on your friends that what normal people can do. So people with cystic fibrosis all sometimes even like chronic pancreatitis. Oh, really? Bad type one diabetes, BBC. The people who don't ever pancreas anymore. They're all on Creon Dizzy. Thanks. Oh, okay. So, managing people with cystic fibrosis, they don't get chest pains. Those they do need long term that developing cirrhosis so prone to infections. They need a pneumococcal vaccinations. Oh, cryonic. And ultimately, transplant. Is it difficult stuff? So maybe the education, it's got hesitations with the natural. Terrible to me. Um, they might ask you, you know, is this a low back to me or pneumonectomy? I'll tell the difference. And why would someone eat anymore? I mean, when I can feel the back to me. Different jobs. If you see someone in the left buttock all from your Scott would be, um Well, the back me you would like to me, Um, like me. And if they really need, I have a Louis surgery on one of my friends. And finally, a definite go asked. All the indications were a sky because kept asking, getting getting again. I've Louis surgery is a surgery full also for your cancer, and they all breathe. There's two stars is a midline the protein in a swells. Electoral pericardium. These guys, just for the way they need to approach cancer. So they need to go through the chance, and then you go to the 10 years ago. So that's one of the things you can keep in mind. Um, how your different shape. That's based on the chemical examination. If you don't get a chest X ray. So the human agonies need to be the entire side of the lungs taken out so there will be no breath sounds. The trachea will dvt towards that side because of boredom loss. Um, and there will be no chest expansion on the inside as well or reduced extension, whereas with a little bit to me, it's about a small subtle because your lung can, depending on which partners which lobe was removed, you can really expand and actually feeling its face. So maybe just a little business breath sounds of the upper lobe. The trachea probably won't be. Um, hum, that's all on day. Indications excuse cancer. Um, rarely. People have projects this confined to a single loop and sometimes that surgically amenable, um, or localized to be a slow again. It's just one example, and it's the same system. Has a full what? You examined how it was patient, How the you look like a rest. Any prayerful signs. Show them what you found me. Just a star. Uh, what he found kind of reduce their sounds of the Duce have extensions, and we'll put it all together and see what you think is going on. So everything is a little low back to me that you mentioned this could have been because of malignancy or localized disease just to be. And then you more to see one investigate further with the chest x three and a full history and olds and thinks ambulance questions they might ask you is what would you see on your sex race? So his name and I could just be completely fell on that side. Um, and you also see the trachea DVD that towards the body blows and and if the old and I saw what you see in public time. So we're going through that so DVD that you Kiana these extension belly discussion and your breath sounds. This is a clamshell book or any scar. It's pretty rare. I'll be surprised if they ask, you know, exam. But it's basically a long transplant scar. They would be with this awful trauma vacations. But could anybody really the focus of empire? This expectation out with the quick out with the cool that era I was Yes, we could just give you peace with the sky. Um, and then you examine that I didn't tell them that you think he said pneumonectomy and why? So, yes, I could, I would say it's definitely you're saying authorization, but that's the kind off. I don't know what they didn't call it, but they're they're getting new patients with real science or whether they will tell you there's a scar and I'll see what you think and tell you the signs as you examined them. But yeah, it could definitely be one station. So if you see a lung transplant, got, um, CF an Alpha one antitrypsin eating. Probably intervention because off for one of the tricks, seamless years. But really, you know, COPD patients get on transplant, but yeah, and think about side effects off transplantations. It's which is universal the old man's locations. But it's a long haul. Your pancreas, your kidneys, rejection infections in your suppression secondary really disease. And and I go a transplantation in my house Keys station, four G. I not full not for lung, and they ask about side effects. And then they asked about side effects off the drugs, and he asked about what I would tell vacation. So, yeah, great and funny if they give you a patient unilateral bell. These, um, could be effusion. Could be collapse. Could be raising the Diphen contact of cancer. Um, don't be kind of doing the face. If you only find one thing this 22 22 the friendship from just the single signing like a single double bass and it's probably been infusion, and then we'll see about transit. This exhibits itself. Okay, that's all. Um, I hope that was okayed. Apologies for the asthma confusion in the beginning as well, right? Yeah. Thank you. So much. I'm just a few back for me in the chart. If everyone could fill that out, there will be one purchaser. And this is just really important for the tutors of also for us. Assess. I'm looking into the future. So if everyone could take a couple minutes just to do that and then I think we should reconvene n two minutes. Time to start Cardiology with. Told me so. Thank you so much, Jimmy. Thanks, guys. Um, good luck, for example. You'll be fine. Do agree. Has about, um, I think, Yeah, it Should we start off? Yeah. I'll just try to share the screen, test it out first. I can't. There goes that working. Yeah. Great. Yeah. Okay, well, ready to start. Okay, Dokey. So I'm Tommy among G F Y. Tuesday. I was in Edinburgh, Grab two years ago. Uh, my talk today would just be an overview of cardiology. Now, from what I understand about your exams, it will be very heavily nice guidelines based. So this is the aim of this presentation. Cardiology has a very strong evidence base. So a lot of it has been published in two very clear guidelines that we follow. So therefore, ah, lot of the presentation today. You'll see a lot of flow charts, so but I'll talk you through them as we go along. Okay, so the first topic we're going to cover is acute coronary syndrome. Now that combines three different things. So that's that's umbrella term for Table and Gina, an end stemi and a stemi. And to approach in acute coronary syndrome, you start with the history and get details about their chest pain or any other similar sounding symptoms. Now, you have to be very careful in terms of, most importantly, getting the timeline of when the symptoms come in because they'll be relevant for treatment, Uh, and also try to find other clues that will point you towards acute coronary syndrome such as kind of pain more worse on exertion. Uh, and you want to find out if this kind of came on quite suddenly or whether they've had similar symptoms before. Une c g is crucial in everyone who presents with chest pain. Um, you want to look most importantly for ST Elevation, the criteria of which I've put down there, um, and also on the CT will be able to kind of guess which territory is being effected. Which territory of the heart which then can point you towards which vessel might be affected. A swell, Um, Now and then you want to do a few Easter? Geez, at a time is well cause some people can have a threat and stem you where the blockage is just almost closing off. And if you do any CT later on, you do suddenly get a stomach so you don't want to miss that. So if they have ST Elevation, then they've got ST Elevation, am I? And if they don't have ST Elevation than you do, you can do serial troponin. It's now proponents. You do them initially at baseline and then at three hours in six hours, I'll show you flow charts to that later on and the different cutoffs. And if you see rises in troponin, then you can put them to the category of an instant me and then risk stratify them and then decide whether you want to treat this conservatively with medication such as anti platelets, or you want to go do a nerve early angiogram and see if you can do an intervention to their coronary arteries to help open that up. Now you have to review those proponents in the context of cardiac sounding chest pain, because even the most high sensitivity one's there are other causes that can raise it, such as a pulmonary embolus, heart failure, myocarditis, a renal failure. Now the different classifications of an M. I, um, type one is your most box standard one. It's your heart attack from a trump. This, um, type two you can see quite often and hospital. Sometimes it's when the heart just isn't The oxygen supply that the heart is getting is just not coping with the demand. So this can either be from the supply partner from the demand bit, um, the coronary artery spasm, which would mean that the supply of the oxygen to the hardness inadequate. A written this. If it's a tachyarrhythmia, your heart can go really fast and not cope with that. Um, and anemia can also just mean that there's less blood supply into the heart, and all of that can cause a type two and my and you get a skin. Yeah, you get troponin rises, and in some cases you could treat them in a similar fashion to a type one of my as well. Now the other stuff, it's it's less important, but it's just there for the sake of completion. A type three AM I is someone who's come in, who's died effectively, but you think it's from a heart attack. But you don't have any evidence of that because you've not been able to take blood samples yet for A is related to PCI for B, it's related to a stent thrombosis. So they've had a PCI, and you know, it's just stuck again in a smaller orifice. And Type five is when it's related to a bypass graft. Now I'll put in the C g up here just so that you guys can have a look and then just have a think of what this could be or what's important to think about. Okay, this would be a present patient that comes in with chest pain, the gate. So this is this is the most important city to really know. Um, so this is ST Elevation. So that's a stemi right there in the anteroapical lateral leads. Well, mostly anterior from V one to be four. Now I'll show you here and any chest low the in approach to, um, my cardio infarction. This is what's used in the emergency department. So you can see here that when someone comes in with suspected a. C. S, they go into one of the three pathways. So ST Elevation, you need to have over two millimeters and two adjacent chest leads. So that's the V one to be six, and or he can get over one millimeter rises into adjacent limbal eats. And now the tricky the to trickier criteria is the new left bundle branch block. So whenever you're looking at a PCG, it's always good to look at any previous CT. Geez, um, and go from there. Now, if they've had previous left bundle branch block, I would always check in with the cardio Reg. If you're suspecting that they could have ST Elevation on top of that and what they would look at is what I've written here before, Which is the scar both criteria. Now I'm not gonna talk about that in detail, but that's basically how one of the ways you can tell if there is ST Elevation on top of a left bundle branch block because the left bundle Branch block. I'll show you later when we talk about arrhythmias. Um, but it looks quite similar. And another criteria is over two millimeters of ST Depression in view one B three and that signifies of posterior. Um, I. So if you can imagine the leads you put in V want to be six? If you extend that further on, you could put a V 70 89 which would basically just show the heart on the different angle. So if you flip that over, it will be an ST elevation and my that's also important. A little careful because that gets commonly missed. If you get a stemi, your treatment is to get in for an emergency. Ah, basically try to organize an emergency PCI, and that involves calling in the cardiologists on, and usually that gets diagnosed on the ambulance when they do a a rapid ECD there and they'll just take them straight to ah, Primary PCI center. Um, and the treatment initially is giving them aspirin and a high dose of Lipitor girl or any other anti platelets that, depending on your trust, it's, um, IV heparin. You can give them some sub Lingle nitrate in analgesia to help with the pain as well. Um, and then they would go for that. Now, if you have any other signs, such as a new horizontal or down sloping ST Depression of over two millimeters or any deep, symmetrical T wave inversion in two adjacent leads, um, then they go into the end. Stemi pathway S, o n and stemi can be diagnosed on the GI or also through proponents, which will be just later on in this pathway here, Uh, and the treatment for that is aspirin, A 300 clopidogrel 300. Or again any other anti platelet, um, and your nitrates analgesia and you can consider things like fund a paradox as well. Um, and then you can do a chest X ray just to look for any other causes of chest thing. Now, if you don't, if you don't have a diagnostic CT, then if you have a really high suspicion that this could be an A C s type picture, you can still just give them the aspirin and then see if they have any response to a sublingual GPN spray, and then you will have a look start doing blood tests for them. So you look at an initial proponent and then you'll get these slights later on anyway. So I'm not just I'm not going to talk about the troponin results and have to interpret them there. But you can have a look at what we use here and how we interpret proponent results. Okay, now, in terms of nice guidelines, it's It's very similar to what's written up there. But why I have put this on this well is it's important to think about the time frames because of them. MCQ setting. They can say, for example, if the symptoms came on 15, 16 hours ago, or if they came on, you know, eight hours ago, then what do you do? So the pathway to look at is if you go down the reproducing option and you are going for a primary PCI, so if you can offer that if they present within 12 hours of symptoms and the PCI center is within 120 minutes so they can be delivered in 120 minutes, um, you can consider it for other, um, other indications as well, such as if they continue to have pain uh, there's continued. There's more evidence of myocardial ischemia, or there's a cardiogenic shock. And then if you just follow the other pathway so if if there is no, uh, PCI center, then you can go under the brain a lysis pathway. And that's another common question where you either are outside of the therapeutic window or you don't you're not in your PC. I center. You're somewhere rural is, for example, um, and you can go down that pathway and then you can read again this in detail again. Um, now that that is for a ST elevation Onley if you go down the end stemi pathway. Um, if you have a confirmed diagnosis of and stemi than what you can do Sorry, just give me one second everything. That's just my, um, plumber coming in care back. Great. Sorry about that. Um, so the idea the research evidence shows that you can use something called a gray scoring system to predict mortality, and then, based on that, you can, um, identify the risk and then offer different guideline based treatments for them now, in in really practice, we don't use it that often, but it's worth knowing just in case they ask about what type of risk calling system can be used. Um, but usually this decision we leave to the cardiologists where you can decide between conservative management and just use medication to try to break the clot, Um, or if they need to go for an angiography within 72 hours, okay, and then. But all pathways go down to thinking about cardiac rehab and secondary prevention, which is all very important to reduce further risk. And the things to, uh, kind of be aware about from that point of view is the usage of a nascent hip bitter on to continue that a swell a zit beat a blocker. Now those to import are important because they prevent cardiac remodeling. So they help the heart retain more most of its usual tissue after an infarct, um, and then statin to lower your cholesterol and then just dwell anti platelet therapy to prevent future term boasts, and also just to treat the current from versus and everyone gets referred to cardiac rehab, um, team as well, and then they'll give all the lifestyle advice and management of stress and health education. From that point of view, and that has its own evidence base for being very beneficial. So is all very important. Uh, and then for patients with kind of heart failure, we'll talk about later on in the presentation when we talk about that topic specifically, but what you do, but the four main states for treatment that you need to know or asymmetry is be the blockers. Dual anti platelets on a statin. Okay, we've just had a question. What? Andy thrombin and fibula. Fibrin elliptic. Would you give the, um, license off the stemi. Who? Um, good question. I'm not quite sure because that's not something done at the Royal. Um, I'm I'm not quite sure. I would have to look that up so I can look that up at the end of that and then get back to you, or you can email me. I've left email at the end there on. Then I can get back to you on that one. Sex, Find out. I know. I know what I know. The different ones they use for stroke, but I've actually never seen one. You specifically for heart attacks? Sorry about that. Is there any other question that's just coming? So Okay, So the different complications to be aware about following a heart attack is, uh, patient could go into a cardiac arrest. Most commonly, that happens as a result of tricky alert fibrilation, which happens most commonly in on, uh, inferior stemi. Yeah, and you can get various arrhythmias if you damage the conduction pathways of the heart. If he can go into shock, you can. The infarct could be so significant that you could rupture. Um, just the side of a ventricle on. But you know, often after that you die. You can get a mitral regurgitation if one the papillary muscles that, you know, pull the mitral valves, get broken in the process and get dressed syndrome, LV aneurysm and heart failure as well. So I've got another question there. So is fund a paradox? First line in an instant, me following the things done during initial 80 now for the parents is an interesting one. Um, of course, you'd go through the initial 80 things. And once you diagnose an end stemi and you're sure about that, then you can give for the parents because you don't want to give that before a patient who might go for a primary PCI, um, fund. The paradox given for and stemi goes for about 10 days or until their discharge. Cardiologists don't seem to fuss about the fund. A paradox, Really. Um, most patients get it as kind of like instead of doubt, a parent because it's proven to be better just for a regular clot prevention and hospital setting for patients after an instant, me So they do give it, um, but it's it's not too important. I think the most important things are the aspirin, clopidogrel and seeing their response. A nitrate from the paradox is another answer. You add on just because of the evidence base. Um, so I'd focus more on the aspirin and Lipitor girl first. That makes sense. Okay, And now I've got another ECD here to look at. Just give you guys some time to have a look at that. Never think. Commit yourself to unanswered. Write that down on a piece of paper just for your own learning. Yeah, great. So someone's written their past year. Am I? That's correct. Um, so you can see the ST Depression that I've talked about earlier and be 1234, and you can see some reciprocity changes around in lead one and a p r a swell. Now, this is commonly misdiagnosed or treated as an end stemi on. It's important to recognize this pattern specifically because you be going down the ST elevation pathway. Okay, Eyes, they're not ST Elevation in 12 and three. Yes, sir. It's so those those are rested properly changes. Uh, basically, which Mean that because, um if you just because of the way the CDs work and bleeds where they go from, the angles that you look at in the Texas Kenyon different waste. So, for example, um, the posterior leads here are feel like they're kind of flipped upside down if you want to look at the back of the heart. Um, I'm just saying, if you questioning, it wasn't introduced them. So I think I think the idea of this is to recognize the posture stemi. Now it's not extremely important whether, um, you know, whether because everyone's heart and that's me, it's different. Everyone's coronary arteries, it's different. You know, sometimes you can get our trees that kind of lie in the side where you know, on the CT, you can see that there's a bit of posture and inferior also kind of where you put the leads on the variation of that between people. Now what's important is just to diagnose the stemi, because no matter of it's an inferior or posterior stemi, they will go down the same pathway and get a PCI, Uh, if that makes sense. But whether it's an inferior or posterior stemi, it's purely academic in this setting. But I think it has a very clear posterior stemi here with very deep kind of ST Depression and those leads. Okay. Oh, I just moved down here. So the next topic we're going to talk about is heart failure. So just to start off, I think commonly a medical school you're taught, um, about the chest X ray signs of pulmonary edema, and those were just listed on the side here. Common ammonic use for deafness to the 80. So for alveolar Dema carly, be lines cardiomegaly divert to pulmonary veins. Pleural effusion. Um, there's good resource is online from the radiologists in terms of looking out for those signs and where you can find them and then labeling on the chest X ray. So I would look at that to see them in detail now. I think the thing important from a clinical practice point of view, um, to look out for is, um, looking at the cost a frantic angles. And then if there's blunting of that, um, it's hard for me to kind of show here, since I don't really have a way to kind of point towards part of the screen. Um, but then it's quite it's quite evidence that there's some pleural effusion. Cardiomegaly. It's difficult because most people who come in with pulmonary edema will get an X ray, a portable X ray or an X ray. That's kind of front to back onto your posterior. So those because of the projection and the heart being closer to the um beam means that you can't accurately say that's cardiomegaly because it will look a lot bigger on 80 film. You can only really say that in a p A film. Um, and it's all about looking at the overall clinical picture, whether they are through an examination in history, whether you feel that they have heart failure rather than just purely based on the trust me. So classifications most common cause of heart failure is due to low output, so the heart, for whatever structural reason, is unable to pump blood out as well as it should. And it's not pumping adequately for the rest of the body, and therefore you get low output failure. High output failure is when your body needs more than the heart congenital eight, and the body often needs more when there's higher metabolic demand in cases like hyperthyroidism, obesity and pregnancy. If the content of the blood they're pushing out is not enough, that's an anemia. So you know the heart's not pumping out enough, even though it's working normally. Another differentiation between the different types of heart failure is left sided and right sided heart failure. So right sided heart failure is you may have heard it called core pulmonary on Do. That's because it's associated with respect recondition like COPD, where there's backlog into the right ventricles because the right ventricles can't pump into the pulmonary arteries as well. Because there's, um, high pressure is there, and the backlog just means that you know, the heart muscles remodel and the right side of the heart can pump as effectively anymore because of the high pressure there. It doesn't need to. So it adapts to that and then cause this right sided heart failure, the symptoms of which are on the screen there that you can have a look at in left sided heart failure. That's more common. And I think it's important to differentiate those two from a symptomatic point of view. So in an MCQ can often get questions where they present. Ah, kind of like a very classical list of symptoms of right sided heart. First, some of those things and right sided heart failure would be, um, you know, things to look out for is a race. JVP ascites, um weight gain on just a demon Just because of the Venus backlog In left sided heart failure, patients often complain of practices. Um, nocturnal dyspnea get woken up from sleep, which is breathlessness, and they just have kind of evidence of pulmonary congestion. You know, their uh basis or crackly when you listen to their chest, Um, when they lie flat there breathless, um, the heart can beat fast to try to compensate as well, because the heart's stroke volume, it's not as strong. So has to compensate for the heart rate to get adequate cardiac output. Okay, So nice guidelines have a very vague kind of like, um, guideline for how did manage heart failure in acute setting, you always start with an 80 assessment and you identify problems there and treat those, um, things to watch out for from, ah, heart failure. Point of view is you want to give him oxygen. A lot of people will decide actuate in acute severe setting. You want to establish IV access for furosemide? Bolus is if you suspect heart failure. You shouldn't be giving them IV fluids. You should be fluid. Restricting them catheterizing them is important because, um, you want to get urine output monitoring, so you want to see how much they take in and how much they took out, some pointing to keep a very kind of clear, fluid balance chart. Now, that might not be practical in every setting, just because of the pressures and the ward's that you're gonna work in. So ah, good kind of way to assess whether there, you know, they're losing foot or they're gaining fluid is just to do daily weight instead on regular using these because you know, you can get an achy I you can develop electrolyte abnormalities on. Also, the treatment you can get for heart failure can cause further dips in your kidney function as well, and can cause electrolyte abnormalities too. So, you know, ideally, you should get a flu balance chart. I think that's mostly if you have got a really good medical admissions unit or if the patients on well enough to go to 80 you then and I'll be documented there. But otherwise daily weights this ah, vital minimum. You want to do an echocardiogram as well? Um, update. If there's no recent over the last year, um, that you look out for the function of the left ventricle and because a lot of the heart failure treatment is based on what the heart, uh, the left ventricle is doing, um, and you can escalate to age to you if they need either IV nitrates. Ah, I know tropes because, sir, off their BP or ventilation because their pulmonary edema so bad that you know, if they're starting to be a CD, make their they've got respiratory failure or they're just exhausted from Chechnya. Yeah. Okay, So chronic heart failure, the nice guidelines are mostly based on, um, diagnosis from, uh, primary care kind of setting. So, uh, the blood test that they often use to diagnose it is it's called a natural date. Peptides, the anti Probi MP and the cut offs are there. So this is a common I'm sick. You question a swell, they'll give you a number, and they kind of like put options as to, uh you refer them within two weeks, your further with him. Six weeks. You just observe and reassure. Um, so it's worth kind of going through this chart and just having an idea about the cutoffs now Management who question here. So just in terms of management of coupon oedema, Nice says to don't use nitrates routinely having any most patients who came in the coupon we received IV. Sure, as my IV nitrate, that seems like something to do it. We'll see. Other good one. Yes, so? So that's That's quite a senior decision. From that point of view, I know nice guidelines do say, to not use thumb routinely in the initial setting, and if you do use that, you probably want to go to 80 you to use that, um on. But if you're if you're struggling with IV furosemide, I think, and from a practical point of view, if they've got it really severely, that they need IV nitrates, they usually do end up in the higher dependency setting, whether it's the coronary care unit or just a general age. Do you, um, cpap that there are no clear cut offs again, that's quite a senior decision. I don't think there'll be a decision that expected to make, um, any time soon unless you're a registrar and certainly from a neb CQ point of view, they're not gonna ask about any specific cutoffs where you need to start thinking about CPAP. Um, I think cpap you'd realistically use if they decide trait up to a point where they need that sort of spirit resupport where you know you're putting them on 15 liters oxygen through your nonrebreather, and that's not really working. Um, okay, does that answer your question? Cool. So now there's two different types of heart failure from a management setting that you need to be able to differentiate. So one is if the patient has a preserved ejection fraction and the others, if they have a reduced ejection fraction. So in patients with a preserved ejection fraction, Um, the evidence based for treatment is not very good. Doesn't really show most research papers have shown that, you know, there's not really much of a difference starting them on all the medications that you're going to see for reduced ejection fraction. So the mainstay of treatment remains to manage their co morbidities and just offer lifestyle advice unless her conditions unstable. Um, and what preserved ejection fraction means is, if you do an echocardiogram, he can look at the function of their left ventricle and their cutoffs. You can calculate, um, and the accepted cut off for ah preserved ejection fraction difference from guideline to guideline. But, uh, from thie. Nice point of view. I think it is 40%. And that's in line with in the latest European Society of Cardiology guidelines as well. So if you get a patient would reduce the junction fraction, then you offer them important treatments like a send him pictures and be two blockers Ah, and, uh, MRSA. So memory is like spironolactone or a player numb. Now all of these separately haven't evidence base for reducing the risk of mortality in the risk of, ah, hospitalization. That's all very important that you titrate them one at a time. Um, in low the in anyway. All patients would reduce the junction. Fraction get seen by the heart failure Nurse is the heart failure team in clinic regularly to be able to titrate this medication effectively and monitor for their symptoms and do regular blood tests because each of them can separately cause a variety of issues, mostly renal on do. If the symptoms persist despite off that first line treatment, then you have other options. You can replace an ace inhibitor with something called entresto. That's a sack you bitter, a level certain that's quite a new drug. It's probably been here for 67 years, used more commonly if they have an even lower ejection fraction than your previous cut off, Um, and you replace an ace inhibitor or an ARB with that because part of that drug is valsartan and that's an air be already, and that has really good evidence basis. Well, um, but you know, everything in this box here just becomes a bit more specialist now, but I think the most important mainstays of treatment that you'd be more involved in for many setting is, um, offering them in a centimeter, beat a blocker and, um, are a whom So at any questions from heart failure here. Yeah. So high hyperkalemic is a big risk for sure. Yeah. Um, on. But I think it's also worth I think last when I was in finance, I had a question Where, um, you're in a setting of a primary care and the patient's kidney function. You've checked them in the community to see what it's done after starting of a nascent hitter. And, um, the creatinine has risen by whatever amount. So what do you do? Do you stop it? You continue to reassure. And it's another question. I think I would look in the BNFL for us, but if specific cut offs from there, because I'm sure that's where I got, um, where I looked out up before. So I can't remember the exact cut offs, but I would look it up there because that might be a question. Uh, Niego. So we're looking at that. Okay, so we're just gonna move on to hypertension. I'll be another bread and butter exam question. Uh, Yeah, the slides will be provided later on. So there's quite a lot of material in here, and it's very heavily guideline base and flow chart based. So I'm not gonna talk about every specific detail and all those flow charts and leave that for you to read up on. Sadly, cardiology is a lot about kind of just memorizing those pathways for your exam. I think in real life you can just look at them, which is a bit annoying. But here we are, the flow charts that you will need to memorize provide later on. And those will be the recess council ones on the cute management of various life threatening conditions. So, um, the nice guidelines for hypertension. So, um, I think most people who come in get their BP done in the clinic will fall into the category of either, you know, being under 1 40/90 on between them. Um, so anyone who kind of goes in that middle category there often get bloods taking just to look for any end organ damage. Um, and then they can get there Cardiovascular risk assessed on. Do you can either tell them to get their BP at home Done, which is realistically, what's more commonly done just because of resource is rather than an ambulatory. But if at home in their own setting, um, they're higher than 13, 5/85 then you can consider drug treatment. Um, so the slide here is mostly for cutoffs and what you do based on them the specific treatment I'll go through another slide. Um, and for patients who have 1 80/1 20 or more, then you can start drug treatment immediately. Um, if there's evidence of a target organ damage? If not, then you know white coat syndrome is the real thing. People do get really high blood pressures in the clinical setting. Um, so we can repeat that in seven days if you don't see any evidence of target organ damage. But do you usually get blood taken if you find some concerning symptoms or any evidence of papilledema retinal hemorrhage looking to their eyes, Um, then you can refer them to a any for assessment for that point of view. But patients with high BP don't normally get routinely referred to a any unless you're really, really concerned. Um, how would, you know if target organ damage to kidneys? Yeah. So, from a practical point of view, uh, if a blood test has taken the GP, then often you get it back in a day or two. Um, you know, usually people who are found to have high BP are found that in a routine monitoring kind of setting or if they're coming in for other reasons, people don't often come in for symptoms of high BP. So, actually, you know, it doesn't make that much of a difference. It doesn't have to be treated as emergently that you need things to come back. Um, in in a day or two. You know, if it comes back in a day or two, then it's not. It doesn't make that much of a difference because, you know, that problem could have been there for months. Um, and then in your blood tests as well, there could be evidence of other causes of hypertension that you could investigate, and we'll go through a list of those like trod um, so bobby scissors asked, uh, a good question there in terms of what sort of values. So this is another annoying thing that differs trust, trust and how your labs work From what I understand in Loaded and I think it's the top values, not the ones in the brackets. So over 2000 between 400 to 2000. So I normally go buy them because they're kind of easier to remember. They're more round numbers. So would you wait to start drug after this is confirmed? Onley. Um, so the things that you can find immediately are you know, if you look into their eyes on find hemorrhage or if they have, um, kind of, like, really bad, uh, headache. Or if if they've come in because of a symptom that you can kind of attribute to high BP And they found out 1 80 to 1 20 you can just give him treatment straight away if they've come in for other reasons. And they have a high BP. Um, but at that point, you have no target organ damage, and then you take a blood test, that blood test comes back, and then you find, you know, damage to the kidneys than I think most people can either send them, um, foreign early review of their BP either and then any setting or start medications for them after getting those results back. So um, I know it says immediately there. But, you know, that's that's but flexible just in terms of practicality as to when you get results back. Um, most people would be also advised just to check their blood pressures will be safety net it and advice to take their BP at home as well to see because some people can get white coat syndrome and go up to the two hundred's. And that's that does happen. Okay, Perfect. So we'll just move on here. So those are your cut offs here again, something just to memorize. Unfortunately on, then we'll talk about targets a swell just in the later slide. So here the's a rust very common Execute questions and again, fortunately, cardiology another a flow chart to memorize. So anyone with diabetes it's an ace inhibitors. They don't tolerate that to get an ARB. Um, there's an evidence based to show that, actually, if you're, uh, from a black African or African Caribbean family origin that you just start on Airbnb stead. Um, and that just goes for everyone with diabetes. Now, if you don't have diabetes and you're under 55 then, um, you can go straight and start in, uh, with nation have turn air, be anyone who's 55 or over or of black, African, African, Caribbean family origin can get started on a calcium channel blocker. Like a lot of PT. Um, Step two is often the combination of those two medications, or you can also consider starting. Uh, I I like diuretic like indapamide. Um, so that's quite straightforward. If you're still not meeting your targets with step one of treatment and then once you get to step three, you just have a combination of all three. Um, Now, if the hypertension still not being adequately treated on you have confirmed elevated BP at home for ambulatory BP monitoring, then you want to look for Well, you just want to discuss if they're taking the medication. Um, if they are and you check their BP on standing and it's still that high, then you probably want to start getting some expert advice. You can consider things such a starting of spironolactone, um, or in alpha or beta blocker as well to manage the BP. And that does happen. Okay. And the cutoff. So you've got on the bottom right there. So anyone under the age of 80 ideally, you'd want the clinic BP to be under 1 40/90 on a regular check or at home. Lesson 13 5/85. You encourage people to keep diaries off their readings. Anyone above 80 you can be a bit more liberal because than the benefit of keeping your BP low is not as important if you're of a lower age, because it's more about kind of like managing a long term risk, Um, and you can look at increasing those targets by 10 points and systolic setting. So 1 50/90 in a clinic or at home, or an ambulatory setting 1 45/85. No, in an older patient as well. You also have to think about the risk of developing postural hypertension that, you know I get dizzy, more prone to getting dizzy on standing up and falling. So you want to be a bit more liberal from a BP control point of view, especially if they're frail or multi more. But, um Usually you just use your kind of judgment as to how frail they are and whether controlling the BP is important anymore. Yeah, so now most common cause of hypertension is primary or essential hypertension. It's what you call it idiopathic. Don't really know where it's come from. Um, you know, could be related to a fair variety cause. I think you don't really find anything specific. Um, and most commonly is just due to age or due to diet, Um, now secondary causes. So there is a humongous list, as you can see here, and the list of medications on this presentation slide. It's not all the medication that can cause it. Uh, I may have put in the Linkous to where you can find it, but either way it's a nice so you can find that. So I think it's good to know kind of the headaches of the various secondary causes of hypertension and which would be such a renal vascular and the crying. Um, and a common one that's often forgotten about is actually alcohol misuse. So just chronic alcohol misuse hypertension is often resistant to medication, and actually, if you are abstinent for a week or two than that, hypertension can completely disappear. So that's an interesting phenomenon to just be aware about, um, medications to definitely know that can cause hypertension. A swell is theca binaural, contraceptive pill, cortical steroids, um, leflunomide and cyclosporin and said's Venlafaxine and over the counter decongestants effort, Dream and female propanol. I mean, are things to watch out for. And then there are other conditions. They're listed at the bottom. Um, I wouldn't go too hard on myself to memorize all of these, but were thinking about if they present your patient with hypertension and then you see something on in their blood tests or not medication that they're on that could explain it is Well, okay, it's just haven't idea that there are many causes. So if we move on to the next topic is ineffective and your card itis now. I think this is the most important slight here for that. So diagnosing effective endocarditis is very, very difficult. Um, there's no clear kind of symptoms and no clear findings that will be a definite and even the most invasive imaging, such as a transesophageal echocardiogram or just even a trance. So or like transthoracic cardiogram. Even those kind of imaging with allergies can for definite, um, show that there is under carditis. So it's very difficult. So the best thing we've got is the Dukes criteria. So we use that to diagnosis on D. He kind of and cut offs or the criteria is for definite endocarditis. Since you have, if you have two of the major criteria, um, or one major criteria and two of the minor criteria that you got written here or five of the minor criterias. So, yes, the blood cultures are very important. Everyone with suspected endocarditis gets an echocardiogram. Every report will say that they can't rule it out if they don't see it. And if they see it sometimes it's not sure if it is. Ah, vegetation. Now what you can get caught out on them I know some people have, is if a report comes back and you're in a me setting on, you've got, like, a question mark and calcium. So they just see you kind of shadowing. Um oh, I've gone way over time here. I'm going to speed up. Um, then, um, then you can, uh Then you can you need to discuss it with cardiology. Basically, I've put the slide up here for the different clinical signs. You can have a look at that in your own time just and how common they are. End of carditis point of view. Treatment is MDT focus. Got the list of antibiotics that you start them on here again. Something to know up to four weeks or six weeks if you get endocarditis in your prosthetic valve Arrhythmia. So this year is a big topic, but I'm going to speed through it. Um, so check for a pulse. Check for response. Check for breathing. If they're not cardiac arrest, you go through this algorithm here. Okay, that's most important. Um, thinks didn't be aware about is whether you've got a shock trouble or a non shock. A bill rhythm. It's a shock. A little rhythms include VT. That's monomorphic polymorphic VT there or ventricular fibrillation. This you should never see in a totally DC G. Um, you should just be shocking that straight away, um, on the morphine VT. Uh, put a slide here explaining why that happens. You want to treat that because that can go into V f polymorphic. Bt kind of looks like the Arctic Monkeys logo. Common causes are prolonged. Q TC, um, and causes prolonged QT C can also be from electrolyte disturbances. So you want to treat that Ah, long list of medications again. Another list of medications to be aware about the most commonly antipsychotics. Amiodarone on every three mice and a Claritin or my son. Congenital. A swell. It's worth knowing about, um, you can get by directional VT. A swell where you get one kind of normal, curious complex and one kind of et looking like, and that is usually a sign of very severe two jobs and toxicity. Um, I got a question on MCQ that, um, in the community setting what you would do So 30 chest compressions to to rescue breaths, um, Onda in terms off the algorithms for treating a tachycardia or Braddy cardio from on her gyn kind of like emergency point of view. You've got the guidelines from the Research Council here I go through them in detail for each bit and my next few slides here that you can again look at in your own time. And then I've just put up the new 20 new kind of guidelines from a nice in terms of managing nature fibrilation. I think the point here that's changed is that they used the orbit score instead of the house blood, which you may have taught before success bleeding risk. Uh, and again, I put all the treatments there, whether you're thinking about things like apixaban or warfarin and then great control, rhythm control strategies. And again, if there's any bit in here, that doesn't make sense. Just you can email me and I can answer that, uh, separately about Okay, um, acute management of a f and then managing brandy Cardio, um, different types of heart block here as well. Definitely worth knowing Easy sed question on them. Stick you, um you only start treating of its mobitz type two or worse. Or if it's trifle, stick your block. Um, all the CDs to know. So I think this will be more renal, but it's worth knowing about the hyperkalemic changes, because that can also be an easy question. Now, what's important to realize here is the T wave. You know, you say 10 to ti wave. A lot of people panic when they just see kind of like a high T wave, and that can be normal. So you have to property. See it pointed. Um, And it needs to be higher, at least in the QRS complex. Um, often you can get just high. Great. And then this is a bad sign. This means you're going to die in a few seconds if you don't give them calcium gluconate. Oh, you don't treat the potassium. It's called sine wave ing. That's kind of really bad. Hyper clean. Yeah, um, pericarditis here and then just a few slides and aortic dissection. But I think you're gonna have a talking that in the over a week from the SSS. About that from a vascular. Right. So I'll let them talk about that. Okay. So good luck with your exams. Um, just let me know again. If there's anything that one that you don't clarified in Isabel, distribute the slides for you. Okay. Thank you so much. Told me I've just put a feedback form in the chart. If everyone could get started on doing that, and then we'll start with G I with Oscar in about a minutes time. Yeah. Oh, okay. Thanks, everyone. Oh, Uh huh. It's really given. I didn't really give him a break. Busy Because they've been going for most of the morning. And I would be dying inside a little bit when I did this last year. And I'm happy to wait. I know you're on a tight schedule, but yeah, okay. We can do a 10 minute break. Yes, you fun. Who's that? We reconvene in about 10 past. Um, we'll stop. Okay, for about ready to stop. Um, I have to start recording again. Awesome. Hi, guys. Blames Oscar. I'm a doctor. I know. It's amazing. If you knew me before, I don't really know how I got here, but a It's only talk about GI. I stuff on the abdomen's a big place, so let's go. I'll take questions at the ends. I'm gonna ignore all your questions during, uh, because otherwise we'll just let it get slow down. Uh, saw we'll talk about is maybe a couple of accused of the images. And if we have time, well, there's some osteo and Alexander tips. There's an abdomen. Abdomen is a big place. Lots of stuff happens in it. This is a lot of conditions that you guys should know something about. Some of this stuff will not be covered in this talk like DKA. Addison's a normal really talked about splenic rupture that much because it's not important stuff that you need to know about basically important sides of the abdomen or the road up for quadrant the right iliac fossa, the left iliac fossa in the middle bit. And that's pretty much it in terms of Gee, this is a lot of stuff that you have to look at when you see a patient for the first time in surgery. They love to be putting a glove on, putting the finger up someone's bump so they can see if there's any pool or any blood on the finger. Uh, why do you do a chest X ray? Because if you miss someone who's perforated, he's got free air under their diaphragm, and that's gonna be a big problem. And then of double X rays are for obstruction. Usually, um, the rest of it, um, Elise would be pancreatitis. We do all these usual routine bloods on any sexual unwell patient or first time of seeing a patient. We'll talk about the other imaging investigations. That's where you go through this talk so This is the first MCQ. So it's a 78 year old man. He's got a day history of left iliac loss, abdominal pain and diarrhea. I want you to fill in this pole and tell me what the diagnosis is. You guys can already turned up in a repeat. You have 30 seconds. You can't. You can't do it. If I sniffed during this talk. I'm sorry. I have a fever. It's a very new bus. Okay, so the answer to the question which you guys have all got right cause you're all gonna be sick is going for ticulitis. Is my thing working yet? Diverticulitis. This is what I would look like if you're standing over on operating table with a surgeon. Look, a bit of a mess. So the articulate is there's three bits today. Particular disease. Diverticular is this is a tough dramatic. That's just out pouching off the large bowel. Diverticular disease is symptoms without informations. We have a pain. Yeah, actually do with the balance, but you don't have normal blood. And articulate is is when it's all inflamed and fasting. Diverticular disease, elderly, both five a day. If you smoke and you get constipated investigation is a colonoscopy. We don't really do CT colonoscopy. Colonography is and all actually say colonography on the treatment for diverticular disease is just expected management. You're just conservatively manager in terms of diverticula to the articulated. They come in with the left iliac fossa plane. They might have some blood there, probably have some diarrhea. And when you look at that blood, their white cell in their CRP will be up. Don't do a CT abdomen, and the radiography radiologist will go Alex Perry and playing vasculitic you like this. So in particular it is. Obviously they can come in and be septic a fuck. So you give them antibiotics, you give them some fluid and you resuscitate them. If they're well but sore and stiff have high blood given more like psoriatics. All of these patients need to be seen by surgery because they might need surgical intervention if you get complications such as the ones listed below and the toes of the medical side of abdominal stuff. A lot of this start talking about overactive surgery, which George is gonna talk about after the surgery in advance. George, the symptoms of celiac celiac guys need to know that it's quite common thing that we lost. You get diarrhea, your failure to try it. If you're young, you have a bit of anemia investigations you do is an anti T TG. That is the first line of investigation. We'll see you next, and then you can do an antiendomysial are in iga deficiency kind of thing on. Then if you want a certainty of diagnosis, you would biopsy on, it would show villus actually and crypt hyperplasia. Those are the two key things you're looking for. There are associated water, new conditions. I got a question and on a life finals that showed me a rash. And I was like, What the hell is this on? Turned out it was dermatitis hepatitis for Ms, which is associated with celiac's disease. If you haven't seen that, go look it up because it came up in my exams. The're treatment of C except Giorgio. Although is gluten free diet and treat deficiency, you can get some complications which are listed that crows disease is something you guys know about. Inflammatory bowel disease is quite common in our skin. Excuse in the sixties and baskets in Crone's they come in with diarrhea. It's usually hot blood. If they have blood, you're more thinking about also good colotis. They come in with pain, weight loss as systemic stuff. You do some blood. Yes, folks come from both ends and see where it is. Nothing about Crone's is that it's patchy. This doesn't inflame the whole thing. It's patchy, and it comes up in different places. And there's this. There's specific points that it comes up with. The treatment of crayons is you treat it with steroids. You can maintain it with some other drugs when you have to stop smoking. Smoking is a big problem for proteins, and you should stop smoking. Alternative collect. Is it literally limited to the colon? The large bowel so it doesn't go to the small bowel. It's the large bowel, so they turn up with bloody diarrhea, abdominal pain, weight loss, feeling a bit rubbish for sorry for themselves and you do some blood and you can do a fecal calprotectin, and that will show you what you see. And then you do a sigmoidoscopy or colonoscopy. The thing with you see is is that you try and induce it with a five s A. That's a five aminosalicylic acid, which is such a mesalamine or sulfasalazine unless it's severe. And if it's severe, then you give him some steroids and then you maintain it with some muscle achy. And that could be or Aleve or rectum. Cure for ulcerative colitis ultimately is a colectomy. You just take the whole large bowel out, and that's the problem. Started the indications for that. Are there You guys been ordered and then full cup you ulcerative colitis. The important shit is that you serve a it cause these people that long cancer when we see them later, Um, this is the pathology that you would see you guys should know about this. Smoking is a risk factor for Kroos, Smoking is protected for also collected. You don't really need to lower about true 11 with severity criteria. I've just print that off on. The important thing is that it's a skip lesions on the lesions are cobblestone. They look like cobblestones when you see them on the colon and you see is continuous. And it told me in the colon and they get crypt abscess is okay, so systemic signs and symptoms with inflammatory bowel disease you can get clubbing. You can get conjunctivitis. Yep. I had them again grows, Um you get everything you know. Does, um and you get some abscess else is okay. What is that? Anyone type in the chow? Well, tell me. Well, I Yeah. No, that's not it. Yeah, you got it. This is by a donut. Gangrenosum. It's not pyogenic granuloma. That's different. That's a different thing. Apartment going to let you get on your finger. Pyoderma gangrenosum Gangrenous. It looks like this. It looks pretty rubbish. And you have it with inflammatory bowel disease and rheumatoid arthritis. You want to type in the chat? What? This is? Yeah. Yes, Upon it is erythema. No, does it? This is associated with infections. You can get this with Covitz. I don't have a guy on the ward with the coverage. Who's got this? Is pretty cool. You get it with sarcoid, you get it with some drugs. Any gait with inflammatory bowel disease? What's this? And most importantly, what? It is not a cause of this. That's troubling. Yes. And what doesn't cause this? Yes, COPD does not cause clubbing. And if you say COPD and your exams, you will fail little J K were actually, um, because of this are cardiovascular respiratory gas, right? And I'll and I'll go. Oh, that's the wrong thing. So this is what could cause clubbing. Clubbing is caused by a lot of things, but not COPD. Uh, malignancy. Lung disease, like one kicks this abscess is there was an acronym made up by one of the main doctors in Concord IUs a B c D. And it's abscess that bronchiectasis is cancer. Definitely not COPD and seem empyema. That's like the main ones that will ask you about you asked about plumbing and causes of clubbing, so you should be able to rattle off for God. But these are four courses of clubbing. Okay, this is the second year. So this is a nurse. Think I read it and who has onset new onset diarrhea? I want you all to vote in this pool that's gonna magically appear because I can't put up some reason. Um, but hopefully they'll be a pull that days, or I didn't have to pull up. So you it's like I have millions around. You can do things. That's great. So you to vote in this poll and tell me what drug is causing this presentation. I'll give you 30 seconds to think about it. They didn't think a day. Okay, on board eso the drug of choice that would cause this is cold lots class. Now you might be thinking, Oh, God, what is called much club? Cause that's one. If someone wants to reveal the pole results and see that most of you got it right up early, you know, first we got it right. That's excellent. Um, so this is called C diff and you get is a very, very common hospital acquired infection. You give patients antibiotics and it kills all that got flora and see if goes on resistant, so good to grow like mad. And then they get c diff on the camera with sex because of these other fire four C's. Your careful is Florence, your ciprofloxacin, your clindamycin and your government clamp these cause C diff easy antibody sticks that you avoid in the elderly a little gusts unless you want to give them c diff or micro go. Yeah, sure. Let's give him the the investigation for this is a stool culture and sensitivity. And most importantly, you're looking for pox in eight and beat Proceed if now the manager did. There is a pathway that sits in the medicines up, which I don't use anymore because I don't work in an excess fluid. But you need to know the pathway for C diff, and you need to know if they have a PSA very back to what you do differently. And you got to stop that PPI is when they go to go to a side room and all that jazz that we do with infections patients. Okay, diarrhea. There's different types of diarrhea. You there is usually less than 14 days, and it's usually caused by a virus or bacteria or antibiotics. And the management that usually given some water in your ear rehydrate them when they feel better and they go the's patients off the cuff, the hospital Did you go? Where the hell you here? And they just give him some IV fluids and they go, they feel better. Uh, important stuff of acute diarrhea is if it got any blood. If you've got any recent hospital admissions, any foreign travel, any infected family members as well to their talking about norovirus, because it's that time of year where norovirus is raises its ugly head in killed all the hospitals. Don't mind the fact that over to rite, But you know, at any rate, chronic causes are greater than 40 days. Are all this stuff I've talked about already on some of this stuff? I haven't talked about the important stuff. When you have chronic diarrhea, is it that you need to look for weight loss anemia? If there's a family history of that and you have me tell a field of their tummy in cases are massive colorectal cancer, you're sitting in it. Uh, cool. So this is the third MCP few, and there's gonna be a pole that magically appears which you guys convert on in a second. Here we go back. So 68 year old, three days of fever and drivers she's tender, no rebound, tenderness or ultrasound shows. This she started on IV antibiotics on what is the most appropriate management of this thing? Get a critical A trap. Yeah, really. And that is the right guidelines. Those are the ones that shit in the app that I should all have. If you're going to do stuff about psoriatics so get that up because it will make you feel much better about yourself. Um, I don't know what's called naive. We call micro Guide, but they changed their Yeah, that's right. Okay, we're going to So the answer to this is magically, it's an ercp, right? I call you allow. So there's a difference between an ercp and an M I C e. And this is always really confusing. And MRCB is an imaging methodology that we used to look at the common bile duct and see if there's any stones in it. And ercp is a technique where you go in and get it all straightened out. Basically she she ever chewed down their throat and you go and get some stones out. Mrcb They sit in an imaging intensifier on you. Look at that topping. Okay, that's how to remember it on. Ercp is intervention and MRC pee is a scam, So call stones very common. There's lots of mainly called form of cholesterol. They're formed by other things as well. I might be talking about fast, so I'm going to try and slow down. Sorry. In advance. The risk factors for gallstones are that you're fat. You're a woman. Sorry that you're over 40 and that you also have a family history of it. You turn up with right upper quadrant pain associated with eating fatty food. Seattle Big hurry the other day when you feel rubbish. Cholecystitis is when you have a right upper quadrant pain and a raised CRP for white cell count thing called colored oak. Oh, Cholelithiasis is when you turn up the right upper quadrant pain and jaundice. That means you're still in this stuff. When you come and buy all that, you know, we have to go and fish it out with the Ercp. Cholangitis is the ones that are really sick. And this is what we talked about when we see a shark. Oh, stride And that shocked I was trying out there. Okay, the complications of gallstones is that you get hepatitis and when you get back your titers for gallstones, you have been pretty sick. If we can get a ghost and I'll is where you start, it just comes into your small bowel and causes an obstruction. So this is the investigations off your stones. If you think someone's got gallstones, you do an ultrasound of the men Verse. That's the answer. Don't our sponsor anything else? It's the answer, and then you do some other stuff later on. If you think so. What they said. What not so I will say, Is there stones in the gallbladder border called bladder wall? Stick indoors, Got some fluid or the common bile duct is dilated. If it shows any of these extra things bother, then student in the gold. Better you do an MRI, C P, and it will show us. If you feel is CBD stones and you go do it ercp and get them out. If there's no semen, the stones, you can just put them on a collective list for a lap colic. Or you can do it that same day. It's up to the consultant they make. That decision management of Golson's is You give them being really because they're going to be. So you give them on two medics because they're going to be sick. And if they go already CRP and a white cell count, you know, once politics and all these patients get referred to the surgeons, could they like to take the gallbladder out and do the CBC? This is the one before the magical poll is going to appear in a second. They did they? Did they? Sorry I was late on Princess. That's fine. Um, so this isn't a coupon before what you guys can already and I want you to answer. Yeah, I'm just aware of time because you guys would go other teaching today on Lives on exam sterilize for Okay, So the answer to the custom he's going to magically appear is college or color with Isis. And the reason for that is because she's got intermittent abdominal pain. She's jaundiced and she still are raised. Billy Rubin, which is associated with jaundice. On When you look at our ultrasound, she's got dilated CBD. If you get something stuck in your CBD, it just back feels back to the full bladder in case of the CBD. Just dial it to try and get it out, but it can't get out. Jaundice is visible when the bilirubin is that on. There are different causes. Jaundice is divided into extrahepatic aquatic and obstructive obstructive is when you have yellow people and the other stuff is fine on. Then you got uncomplicated and conjugated form. I didn't really learn about this properly. So I just learned if it's obstructing, then you do this. And if it's a particle and that's probably this so you have to look in their eyes. Basically, door, this is a bit of a complicated thing that I'm not gonna go into great detail about. Ah, I'm just giving you dance to this. Sorry. So you know. So this is alcoholic hepatitis. The reason for this is because they drink a lot of alcohol. They've basically killed the liver off. The reason you could tell they drink a lot about colors because they've got high MCB and low platelets. That's what we commonly see on the liver. Picture is unhappy to. The lt is high. Valchlor says Hi, Billy Rubin is high. The GGT is high. That's all associated with alcoholic hepatitis. Okay, so alcoholic hepatitis can do to to something called Never failure. So the cause is off. Liver failure are listed here, and I'll talk about liver function. Test to the bottom so you can get a hepatic picture or a collar static picture. The hepatic picture is when the Ulta and a S t. R a race See that construct alcoholic liver disease in apple hepatitis from viruses and paracetamol. Big doses means the liver's unhappy, and it means that it's producing more of these enzymes. Cholestatic picture is when there's something stuck or blocking something, that's when you get a raise. Billy Rubin So gallstone gets stuck in the common bile duct. You get something called PSC and PBC on pancreatic cancer can impinge on the common bile duct and cause blockage so liver failure can be decompensated or compensated. A compensated patients usually do fine, and you want to keep them compensated for a long as possible. They just have weight loss. They feel a bit rubbish and they lose weight. If they're decompensated, they turn up with jaundice, confusion and ascites. And, I think, usually have a little flap. See looking for their arms up to do that? Well, yeah, unusually but itchy. So you do that for blank pounds. Their liver function tests the coagulation, which usually has a prolonged PT and the virus. Neurology is important to do virus ology to his viral hepatitis can cause liver failure, and then you would do an ascetic top, and I don't know what this is. The usual investigations that you do with all the liver pate failure patients. Imagine. Olu feeling is just conservative. You just feed them, usually get better. Then you have to treat the complications, which we'll talk about. The main treatment of a little feeling is you give him a new liver on the little waiting list on There's a little transplant service at the rule, I believe, from Ireland. So the signs of liver failure that she will need to know for your skis. He's whitening of the nails. It's just called gluconate. Yeah, you're clubbing, which we talked about Ready redness of the hand. You got a contracture of this one? Yes, spite. In a bar in the chest. You get fattening under your I lose your, uh you got to come ask you, and you can get a big liver until it gets cirrhotic. And then it starts shrinking. Discourage You get something for cap of the juicer. Okay? And I ask you on the slide before you said about a cytic top as an investigation, what you're looking for that I'll get that second. Okay. No sign. Thank you. Um, liver cirrhosis is basically when your liver is so far gone liver has an amazing potential to regenerating. I probably drink my limited F because I drink alcohol and going to the public. Talk to my friends. But this is when you get a really bad day. But that will not regenerate. And it becomes modular and scarred on the complications of liver cirrhosis on nasty place that they say you can get portal hypertension failure and hepatic cell carcinoma on the portal. Hypertension is because you get a blockage of the portal venous system. So everything backs actually get Barris is you get splenomegaly us eighties, so you get water in places that shouldn't be about it. Failure is when the liver cannot get rid off the toxins that's supposed to be able to get rid of. See the toxins end up in your brain C and couple of the other end of your brothers. You get a cardiomyopathy, their end up screwing with your pancreas so you get hyperglycemia and get something called SBP, which we'll talk about in a second. And you have had a renal syndrome, which is when your kidneys fail because you live. Least liver's failed okay? Important thing was when patients have liver cirrhosis is that they need to be looked after and surveyed every so often with an ultrasound and then f p because with hepatic cellular carcinoma, so can someone type in the chat? What? This is this image here. Medicine? Yes, capital You do, PSA. Thank you. So the signs of all have potential is covered Medusa, splenomegaly, viruses and ascites because everything just gets backed up because your port of your portal hypertension is raised. There's a high blood high pressure in your port will be in the system. It can't get the fluid out. So the fluid back feels into your tummy with the veins in your tummy into your spleen into your esophagus will get. Barris is into your rectum. Where they're also Barris, is if you bleed from yourself getting your bleed from the rectum and then you get fluid on your tongue when you tell me because it can't go anywhere else. So complications ascites Now ascites is when you just have a lot of fluid and liver and you do that little test fluid thrill when you do, you're asking. So you need to look fancy. Only do that exam for ascites the way you treat ascites is with the fluid and sodium restriction, and you avoid some drugs. Such a story. That's the first line treatment of Ascites because you give them spironolactone and then you could give them for his mind. If it's not working, they my needs someone to drain their seventies away. Okay, spontaneous back to I won't tell you it's bacterial SPP, basically is an infection in your ascites, so you get ascites, and then you get this to get bacteria, and this is why you do the acidic tap because you need to take some fluid off. Send it away for sampling on often. If these patients have something growing in the Donald, if they're in our cities, they die. They just get really sick. Well, I avoid in say, it's because it it's a good question. I don't know off the matter. That and then the treatment of sleepy as you give him some antibiotics and hope that they get better off. Then we see people with SPEP and these people just die. Unfortunately, because you can't really treat it very well, have passed again. Breath a lot with the is when all the toxins end up in your brain, and that's precipitated by constipation because there's a build up and you can't get rid of the toxins that are in your poop. So you get lots of Motrin misleads two cerebral edema. You feel unwell. The treatment of this is to make someone poop, and all the toxins just come out. Basically, when you get better, these patients usually do quite well about Torino syndrome I wouldn't know very much about. It's a very niche question, and it will be just one question in the exam. But that's the stuff there if you want to read about it. The approach to Ascites is that when you take a bit of that fluid off, you look at what proteins in it and you look at the CT. The ascites too serum protein ratio is since I'm off and it's called the lights quite here. It's similar for the stuff in the respiratory. When you take a pleural effusion off December, nothing okay, and the reason you want to know whether it's transitive or exited is because there's different causes for transit. It is chronic liver disease like we've just been talking about, or you can get right heart failure. Volume overload. High problem. You can't. You can't, like. Hold the fluid in your proteins on X. Addictive is when you got infection. It's producing a whole load of protein. Okay, uh, these are some other causes. Both liver failure, which you should know about. And I'll let you just quickly read that. Yeah. Cool. These are some other weird and wonderful causes. These guys, they come up in the exams, these do you come up. So Wilson's and human resources, they do like it. So Wilson is the one with the copper on. You end up with the rings and your eyes still give you a picture of the eyes and go, What's that ring? And you go like fireflies. So therefore they've got Wilson's. So therefore, the treatment is penicillin. Me? Okay. And then in hemochromatosis, that's when you've got high iron, lots and lots of iron. See? Feel rubbish. Get bronzing of your skin. Your pancreas shuts down. You can get diabetes. Investigation of that is you do iron studies on the retreatment. For hemochromatosis. It is. I just kept. The doctor comes along and takes blood off you. You feel better than you know the way you have to keep doing that. That's your life. Uh, you know, he's in a last alpha one antitrypsin deficiency, which often comes along with COPD. Okay, so PBC and PSC, they do quite like the's very good, But they do quite like these. These come up, they get you asked about this, and they're different between different people. If it's an older female patient with a bit of tiredness and the itchy is probably PBC, and if they're a male and they're a bit younger and they got progressively on, this is probably PSC. They turned up in different places. And there's different tests, correct? With a specific one for PBC is a m A. I'm sure you've seen it in a bassinet because they ask you a lot faster on. You need to know the ulcerative colitis associated with PSC, Okay? And the reason PSC is important because you end up with cholangiocarcinoma. Okay, the treatments are listed below. You just want to treat the itching and the complications. Okay, CQ number six. So the pole is gonna hopefully magically appear that this is a 79 year old man with sudden onset left sided back on line. Pain sweating, peripherally shot down. BP looks a bit. Now, relax a bit now. Why? It says bit up. Yeah. Okay, so he looked at it rubbish from the end of the bed. So I want you to think about what else could be on then I need to move on in a second. Cool. So the answer to this question is a ruptured aortic aneurysm. This person is dying in front of your eyes. Basically, his BP is rubbish. His heart rate's up. He's peripherally shut down and he's sweating. This is an image of a triple. If you see this on an imaging, this place is probably as good as dead. This patient, this was taken probably before the patient died. This is a little contrast leaking out into his abdomen because there's a big hole in his aorta. The thing is, with Triple A's, because you can't really do much about them. You screen them for men at 65 to get once off of don't watch it. And if there's something there, then they get more monitoring. Um, this is the monitoring that you do. If it's under a certain size of over a certain size. It is over a certain size. And your surgical candidate, they can do something about it. And that's all very vascular. And they're funky. Um, when they rupture, they just like they start dying in front of, you know, since they come in, they look at me like God Pulsatile a little mask. Right? So And your images now, um, so this is an irritation. I want someone to type in the tap What they think it is. This is actually easier. Yes, this is the duck beak sign. This is when the lower esophageal sphincter fails to relax in response to a swallowing wave. So you get dysplasia two solid on liquids. You get pain and you get weight loss. You often need surgery and often need to scope. And I'll go in and they'll dilate the lower esophageal sphincter. Other common esophageal conditions that are benign. You do you need to know about are found your pouch. We have a smell, a graft, and you have small moments or global. Okay, well, about malignancy in a second. This is imaging number two in someone taping the chat. What they think this is This is taken from an industrial that is Barrett's esophagus. Yeah, so you see how this is slightly different compared to that? This is a lot viruses off. Yes, it says call. It's basically metaplasia off their suffered deal after thelial lining where the squamous epithelium becomes columnar cells and that's mostly happens to you to reflux. It's a histological diagnosis. You need to go in there with a scope and take a biopsy. It looks a bit unhappy. And what you treat this, or did you give high dose PPI the lifestyle of ice? The problem with Barrett's is I often progresses to cancer, so you need to so bathe them for adenocarcinoma. And then if they start getting displays your metaplasia, you need to do something about it. These are the two types off. So for your cancer that you guys need to know about, I don't know. Cost number is the more common one and found lower down. Squamous cell is the one that's round higher up. Okay, smoking is important for it's going to sell, and that cost man so reflux is very common. You probably had reflux before. It feels a bit now. If you get a chest pain. You feel rubbish after you've eaten, and it's worse when you're lying down or bending over. And if you take an untested at home, you probably feel better. The risk for all your diet. Yeah, well, you've got a hiatus Hernia, which is when, like the contents of your abdomen start coming up through your esophageal hiatus in your diet. Friend. The increase of doing intradermal precious. You can't get stuff down. Well, you have a reduced this off your influence, which is myself, a geo dysmotility, which can be caused by some trucks because all positions or reflux is you get some basis like we see with Barris, you could get anemia. You get some strictures because there's so much inflammation in there, so you don't swallow properly, so they need to go down, dilate strictures. We'll get barest the thing when you need to. These are the key ones that you need to investigate. If you get anemia like anorexia, rapid onset, you can. They think they can feel masses in this in when they're swallowing, or they start having problems with swallowing, and that's when you need to go in and scoped them. If they're accumulating well, you need you to refer them for a scope. So if they come in with dyspepsia and they're bleeding and a human tennis is, they need to go on the bleeders nest so we can stop the bleeding. But other than that, you just look at the medication lifestyle. If actually you try and monitor, modify that first and then you give him a trial of a PPI. And if it helps, and you continue that or you can scope them and see if there's something going on. Immediate management is better Pap tackle Gaviscon, which, unless it's love and then the long term management is a PPI. This people Isaiah first line for good. Uh huh. This is dyspepsia. So this is when you need it. So you get new onset dyspepsia. Feel a bit uncomfortable on the age is important for this pepcia. If the US is 60 and is know a lot of features, you can just give him a breath or stool test for H. Pylori. If there's a lot of teachers, you probably need to go and have a look with a scope, so it's first line treatment. Dyspepsia is just the PPI and you can. If that doesn't work, we need to look for a follower, which can cause peptic ulcer disease on. Then you treat any follow if it's there, and if not, then you can try another PPI or a higher dose. If this is his, recall your skin more full, desperate care. If there's any red flags out just talked about. You can consider endoscopy once you got proven peptic ulcer disease, which is when you have, and also in your tummy or in your drooling. You give them a full dose PPI for 4 to 8 weeks, and we must testing for his follower. You guys need to know what hate for your education therapy is. I got a question question in my exam. It's on the back. So look it up Online says you need to stop the NSAID, Uh, and you treated on and after treatment, you need to check that you actually treated HBO or incorrect correctly. See a retest on. If there's gastric ulcer, you need to do a repeat endoscopy to check. That also is healing. If it's unhealed, then you're probably not taking the medication. That's probably the most likely thing on Oh that you might have something special such a zone in Dallas and, well, you might have cancer. It was caught one in back in my day. It was called Marker Guide, but I think it's called something else. Now is the fact that although the antibiotic therapy is on ah, so hey, file or E is a bacteria that goes in your gut and make sure it gives your stomach ulcers and you do a stool talented in test, I believe in low the and still uh, and then you have to leave it for two weeks after you have that. If you have a PPI, you have to stop the PPI for two weeks. Then you test for H. Pylori because otherwise it will confirm confound the test. That's the treatment there for a month. You give them amox and Metro. When you give the minute that Brazil so remember a little to get long term your oximetry, they get seven days. They have to re test for H pylori off the eight weeks Look, finishing packing. Okay, here is number three. This is a bit about not being a rich blood. Can anyone tell me what's wrong with this image. What can you see? Yeah. So this is a low calcium here, this is in the line. Off the pancreas is all pancreatic calcification. There is also scoliosis that's there. You all right, neck? There is a correlation, but that might be a way. This fashion sitting so acute. Pancreatitis. These are the patients that can come in on their sick as dogs. Actually, quite a lot of this and they get they looked rubbish. That causes of this is the acronym issued or no is called Get smashed. The two top causes off pancreatitis is gall stones and alcohol. And then we, as doctors, can also cause this life be giving them in the ercp or getting Synthroid and they turn up with pain that radiates to the back, which feels better when they sit up. The's is some signs that you don't get the really seen patients with pancreatitis. And if they do have the signs, they probably need to go type two you student rather than later. What you do is you look at their families. If the amylase is three times the upper limit of normal, the pancreas, they got pancreatitis. And you do something called the Glasgow score, which you guys don't need to know. But that's they're like severity for pancreatitis that you get asked in your boss keys. You say it's the Glasgow pancreas score on what they get is they get a CT abdomen to show that they've got pancreatitis. After that, they get an abdominal ultrasound to show if they've got gall stones, and you could ignore the X on the CX are because they're probably show if it was perfect on the honor up normal on a CT. The treatment off pancreatitis is they don't necessarily have to be new by well, but they should definitely get some IV fluids, some analgesia and some anti emetics. If they got goals. Does that probably need any ercp to get the goal stones out? And if they've got alcohol induced pancreatitis, you should be giving them gene wars and paper. Next, these patients they get on well, the critically unwell because we give that we can give them too much fluid and overload them or their kidneys start shutting down the lung, shut down the curriculum, a shin shots down, they get septic, and then they get later complications or such a CT assistant program. The abscess I'm currently working in the Pancreatic Center for the West of Scotland on the patients that we see are bonkers like that. How the how they're alive is amazing, but they still are. Calling. Pancreatitis is when you have a long term, longer term damage to your pancreas because this off the alcohol hypoglycemia, hyperglycemia or recurrent episodes of acute pancreatitis, there are some rarer causes. Their they turn it with abdominal pain, weight loss and the pancreas starts to stop working because it's literally bean screwed by inflammation for so long. So you do a CT scan to look for calcification of the pancreas and the treatment off this is they get the same as a cheaper appetite, actually given so analgesia and some fluids, and they get better. But then you need to help their pancreas still work so they can get something called Creon, which is like pancreatic enzymes, which makes them feel better. Complications of chronic pancreatitis is, unfortunately, pancreatic cancer, and once you get pancreatic cancer, you don't do very well. It's very sad, and you do get diabetes from chronic pancreatitis because that controls you, click raising the pancreas is image number four. Can anyone told me what this is? Nick, They have answered your question. This is toxic mega clothes on Emily. Yes. So this is Dr My coat. And this is a large bowel just getting so unhappy. Basically on It's basically when the transverse colon, which is this thing here, is hugely dilated, you lose. All the last remark is that these are hostile markings that you can see on the ascending colon here. And there's none of that on there. So because this is either IBD so like ulcerative colitis or infectious colitis from cedar, this is what you see in six CD of patients on. They have to have a normal X rays every few days to check that they've not. What toxic mega colon is that? They don't talk to make it go along. You probably looking at whipping the large bowel out. They won't tell me what this is. Newer medicine, New apparent tonight. It interesting. It's a pneumoperitoneum for tonight's would be inflammation. So it's a pneumoperitoneum. This is a rundown, Ethan, the diaphragm. And this comes from perforations. All the patients that we see that come in, we're actually unwell with abdominal pain. Get an erection step treatment. And the Donnatal X ray. The erect. Yes, Doctor. It is to look for perforation. It has to be erected. It the air conflict would say underneath the diaphragm. You can also get this after you have a laparoscopic surgery. So I haven't covered some of this stuff for constipation. Hemorroids I bs. We keep these interrogates Kenya appendicitis, you guys, appendicitis is common and George will probably talk about it in this surgery stuff. Gee, I cancer. I'm hoping George. We'll talk about any surgery stuff. The viral hepatitis, are they? They'll be two questions on this at most. You need to know about hate. Hate bit. Have be on hep C. If you want to know about it, you need to go to Pass Med. They have the best explanation for it. But I could That could explain it so much better than I can. And then you should know some basic July asked me as to which, but surprised where the surgeons do quite like when they sit in the house keys and they will ask you questions about the blood supply. If you end up with a surgeon in your osteo. Hopefully win. Um, I want my doing for time. Um, Harbel in George's June. Um, he was do five minutes cable with the running out of this. You don't like a good time? Uh, I can just go do a quick thing about osteoporosis. You have that as well. Um, because em see said skis scenarios. Peggy, I I These are the common all ski scenarios. This one is super common. This one is quite common. This one super common on this one. So sleeping. Okay, they go on a pretty I bleed. You need some help because these patients are really usually acutely sick. You do usually a B c d you get You need to support that BP to keep him alive until you can get them to a scope list in the morning or a scope list over. If they're really dying, there is no Marciel. These are the treatment off. Oh, gee, I bleeds. Uh, quickly. Go back to the conversations. Uh, us from stations. Take a screenshot. That if you want to click. Okay, cool. That's right. So I told her arms. Yeah, bleed. The important thing is you just got support. One with fluid on bloods occasionally give platelets to patients who are actively bleeding, and they got a platelet count of less than 50. This is a lot of blood products that you should know about is, well, blood production important, and they can come up in, um in and CT questions So you should know about you should also know about warfarin and how to reverse It has a very easy description of it on the b n f. Or there's a question on There's a couple of questions on the past past minute which have good answers. Yeah, so that I've talked about industrial the patients that are well again within 24 hours, and if they are basically on stable, we go to a blue. This list scars and stones are very common in our skis, and they're often covered in a surgical lecture. But there's some key scars that you guys need to know about the laparoscopic scars of the ones just above the tummy. I only got like a slight little ones. The liver transplants cars are very common. We're often they feel a lot of the liver transplant patients to come in and talk about what's wrong with them. In my fourth, you're asking I got a kidney transplant in my G I station when we've never learned anything about the kidneys before. It was very and you need to know about midline starting the scar middle. I stenotic me scars for your heart surgery and other things, and then you need to know the difference between an ileostomy and colostomy uh, some good stuff in partners past medicine, about the differences between different stones. Uh, honey is don't often come up in our skis, but you do need to know about how you would, how how the honey is a different and why they're different. So an indirect hernias comes in young men. They're common, and they often go by. This dramatic poured into the Botox on the directing. All the ones are elderly, they a weakness of the muscle that runs along there on they usually pretty benign. The complications of hernias is they can get incarcerated. They can cause obstruction if this bowel gets in there, or they could go strangulation when the bowel gets twisted and can't get good blood supply. Now, the humanities, conservatively by popping them back in, Well, your surgical management by opening it up and putting it back in or whipping up about that's that's dying. Basically, um, these are the causes of a pattern ugly. If you want to take a screenshot. This this is the cap. But this is the time you will get asked about the quarters of her bathroom regularly, and you just need to be able to rattle off the U five. And they should be from different categories of the little. I would have infection congestion, infiltrative ones, cancer and a blood one. And then you could just go blank. I'm buying these other ones on the regimen and, uh goes guess they know what they're talking about. Um, this is the causes your splint and make a This's the ones you need to know about absolutely 100% by you gonna learn about. How about a speculatively pleased about these because they do get asked on. Then you can just go right smile. A fibrosis, malaria and chronic myeloid leukemia. Thank you. Next and then. These are the other causes of not flex, but smaller but still quite big. Family mostly needs to be huge for you to feel it until you probably won't feel it in your feet. So don't say in your skin, or I can feel asleep unless they've got, like, a bunkers like huge spilling. In which case is the patients probably quite unwell and probably shouldn't be in a dusty area. Uh, this is a different between the kidney and a spleen. You probably won't be able to feel the kidney either on your skin unless they've got a little about autoimmune. Public assistance is easily so the kidney gets huge. Basically, you should be able to fill the kidney. Um, make sense. This is when this is when you could get hepatosplenomegaly. So both of them at the same time and knees, Uh, that causes, um, you should probably know. You should know some of these. You should be able to just rattled them off off the knees. A common between. There are often ones that can cause her past medical on its own as well, and make yourself all both together. So if you can rattle them off and you're doing pretty well, ah so Billary infiltration slash inflection and cancers last congestion. So it's just a quick acting than it is difficult to remember. Sorry, I tried to be smart, but it's not very small. So sorry. That's the end of my slicer. Isn't any questions about anything? Um, if not, please fill out my feet back. Thank you for listening. You guys will be great. So, B I c was a trial doctor, and I tried to his biliary in a billion bloods infiltration and infection and cancer and congestion. Sorry. You probably won't remember it very well. And I was just trying to remember in in your own way. Um, please fill out my feedback. Thank you. Because I need it for my like portfolio. Thank you. I've just put the feedback form and child serious. Everyone could do that. And then, um, if we start in about minutes, time for renal with Kroger. See you guys for hatred. Be tomorrow. It's gonna be great. Bye. Oh, all right, we'll start. You see, with sharing and screen that Oh, sorry. I'll let you go. So dragged and teach people about important things go this year. Nice PTO Get up. Kiss that. I don't know. Right. Let's see my sharing that. No. Yep. Oh, just get one a minute. Maybe just since you just finished, okay? Uh huh. I was tender. Cameron's worse before. She starts with a lot of talk to the old called his memory awful. Okay, I saw my my main drag. Um, I was a driver you need And what know 11 of the ones that darn hospital north wing gland debate was thinking of applying to the north of England. It's really good. I heard good things about you castles. Well, but I'm bias toward storm. So this is just gonna be a presentation on renal medicine. I think, you know, makes it is actually very, very simple. I think it could be easily were complicated, but basically it's just acute kidney injury and chronic kidney injury with a few little extra bits. So with that in Maine's, I'll just see what we're going to discuss. So the things we're just we're going to talk about is very, very briefly just ki kidney functions. They were going to talk him a detail but acute kidney injury and chronic kidney disease, basically, because there is the most common things you'll get in your MCQ is and the exams or form the bulk of the questions on also is the things I really used for freezing by one. The things that won't be talking about, um, protected you could get one or two questions about in the example Bill that mean would be a kidney transplants on. Maybe dialysis potentially can the cancer as well, and they're smaller topics on. They're very quick to look over, so I just recommend giving him a quick look. And, like with everything there are really good today and start some reason past made for all those things. But he's into the core things we'll talk about so firstly just very quickly. Sort of four kidney does. I'm sure, for one's also have a very good idea. That's already but the most important things that it does you can reach. Remember it by that preserve away bed. So basically, acid base balance. What's it? Begin the filters and it reabsorbs all your electrolytes, your water so it with that in mind that controls your water violence and also helps remove toxins that the blood stream as I would go to the rast system. But it was also very important in controlling your BP and two things that people, some things do you forget about it, though, is that it secretes appeal. And so that, and that's one of the chemicals that helps for him. You're right blood cells, and it also helps activated vitamin D. So if you do have chronic kidney disease and your kidney function is very poor, you can become a little bit deficient and also develop anemia. So the first thing we talk about is a kidney injury. It's probably the most common things we see in hospital, especially next one, and it's basically defines just a rapid reduction and kidney function, a man that can be quite rocket over hours or days, or even a bit longer than that on. But it's it's when your kidneys start functioning and they feel to maintain your fluids and electrolyte balance in the body. And you can also accumulates, um, with products. And there are two ways of categorizing that you can use the rightful criteria. But I just like to use the EKG. I stage 123 things that I think it's a bit simpler and a stage one, and basically is a 1.5 to 2 times increasing your based quick serum graft in on, Then take a stage 22 to 3 a k speech. Three more than three. There's really good tables you can fight and just Google images like Best thing that just clarifies that you can also use your I just like looking at the craft name. Quite useful. One thing I'd see to be weary off, though, is that you can sometimes get false readings, especially in England. Know that using all the Elektronik systems that flag these things up for you and the someone's quite mild nourish. They kind of quit a little creatinine level. If it dips up a little bit to normal levels, you can be getting a works. They have any kind I but this is a false reading. So, like I said, a Kaiser, really. Coleman happens to about one in five patients in the hospital on it, significantly worse ever in each to you, right to you. And it's associated with many days, especially in elderly people, on a lot of the more preventable of the cool air, really on. The most important thing to do is notice that early, stop any harmful drugs and give him fluids as appropriate. So first off, what we'll do is I'll just ask, and I'll just ask everybody. And what causes achy I know they're sort of three reflects both up into three million groups. Does anybody know what those are? Three main groups of Achy I R. Yeah, everyone's got it right away. That's good. That's what makes this assembly you pick up 33 cats, a greasy at prerenal and drain. Oh, poor stream. No and quite itself expired. Jackass. Always the prerenal causes are you Before you reach the kidney Bull Street know in the ureters in the bladder. So the first one with then we'll talk about it is pretty know, and it's probably the most common, and things like dehydration caused the patients not eating or drinking very much or they got diarrhea and vomiting, say abscess, infection, systemic shock and diarrhetics and other drugs that reduce your renal profusion can also mimic systemic dehydration. When you see someone, they may not have any examination findings, to be honest, and but you probably know is a first off the blood that is early stages, but you could you have deep bring off the you know if it's on. You can know it's on there Using east for previously leaky. I tend to have a quite high creatinine. Quite I urea. So you suggested that they're actually dehydrated intravascularly as opposed to other types of Ikea. I you tend to see a much lower area. And if you do your analysis that someone has an EKG and use of urinalysis is premeal. You're probably not going to get anything on the management for previously leaky eyes. That is basically just fluids. And but you also need to remember you're sick. The rules. Does Anyone has ever heard of sick deals before? You're gonna know what that means. It's not something. I came a cold until I started. Okay, keep a look bad to me this June clearly and yes, Oh, yeah, that place. So it started medications on this 44 main medications. I think that will be mentioned by everybody's thoughts for the goods. And yeah, that's good. I can't remember it. Diarrhetics east inhibitors metoformin and insides. If someone comes in and go on a k, I just stop. Stop The reason hitters, everyone metaform and it could be could afford to be off that for a few days. Anything. My proof in crocks and things that I just stopped that. And then you give us a fluids on. I think it's important to remember that fluids are sort of amazing, the drugs well, So we need to think about what's your fluids were giving. People know. I know it's different in different trusts, but generally speaking, if someone's going achy, I I like to try and give them some maintenance fluids. But you can also think about giving them. I think it's plasma up in Edinburgh or Hartmann's. That's usually pretty good. You need to be weary that they're like white levels. Does anyone have any other questions about finishes back there? Don't have any questions that won't Previnaire know achy. I will come in. We'll do some questions on the list as well. It's okay. So I guess we thought that previous we'll talk with your street on X, cause they're the two simpler ones and course we know 80. I mean, it's so much of obstructive. It's just what's causing the obstruction. Most common is probably stones. EPH. You can also get strictures in June Wrists and I Jenkins res. Very rear its possible. And you can also get some really retention secondary to drugs and four post Reno or post renal achy eyes. And if you could do that, more of an exam is important to the abdominal exam. C. Compartment the quarter. See the rheumatoid patient name. It's also, especially in Maine. It's quite useful to PR exam to devalue the size of the prostate. A new analysis in this sense mate reveal that we have blood, especially that got stolen or maybe some active cancer, especially by the cancer, and it can be useful to get outside of the renal tract as well. And if you're if you're seeing your late so you can communicate a CT, scan him again. Well, it'd be simple management, because you just treat the cause. If they have have a stone on, you're concerned about it. You're probably going to get in touch with urology on See they want to do anything about that. And if they have another sort of malignancy, or you'll get in touch with the oncology team for that on day and any other causes, you didn't used to it because I think even intrinsic renal causes of a car, Probably the one that caused people would bother on the like to have these questions and exams, especially just difference between 80 and then here. And so I'll try and break it down briefly for you. I think I have a question, actually, yes, I got practice question, so I'll let you read it. And then, if anyone has any thoughts, it contribute in the chart. So if you want to do any further tests or important thing, the diagnosis might be need to give people a minute. Just read it first. Uh huh. Looks like everybody's been smashing through classmates. And yeah, I think, yeah, exactly. Right. So I mean, it's same. Is injury no, on against the give away for good pastors or onto gpm disease? I think they're leading towards calling anti TB and disease know rather than good Pastor smoked. Sure why? And if that serves as long involvement and on something, you can get him offices and you also get the surf you can get from quick. Frankie Materia. Yeah, that's it's your anti G B antibodies for that. Contrast it so you're a little on the prices and basically is just inflammation of the glomerular I. I can't be acute can be chronic, and this is where we get our nephritic in the fraud six syndromes. So in the fraud, six engines are sort of typically described by triads. You get a lot of peripheral edema. You get protein urea, so quite market putting level in the urine on you. Also get a little blood albumin levels, which are the codes for the first two. The symptoms. Your first. A computer that can get quite a high look. Lipid content in the blood. This does compare quite start the two nephrotic syndrome, which typically presents with hypertension, blood in the urine or he material on also reduced to urinate boots. Annoyingly, the family quite a lot of cross over with be internal diseases, and it's not often so clear cut. But in the exams they are usually quite good at making. All of it is not frantic or in a protic. You can also break it down. It's primary and secondary, based on whether it's just affecting the kidneys or if it's affecting other parts of the bodies. Example. I would be like this for, but the image called to give us the classic. A classic image here. And so in a lifetime, say you've got yourself in the protic syndromes. So the first what first one There is minimal change from the pharmacy. Does that mean you know what sort of age group? You typically see that quick? Yeah, yeah, tends to be Children. Young adults, usually Children, adolescents and on. Then, as you get a bit older, you're more likely to get what you call member Knysna. For opathy, however, that doesn't mean you can't get either or any age and towards the other side. You can see you can see the anti GP and disease in there again and other types of vasculitis A something that definitely confused me. Waas The difference is the IGA Nephropathy and post straight, glimmering the brightest. Does anybody know the death frighten sort of message in the child? A difference in it, too? Yeah, it's all about the timing off it, really. It's got quite similar mechanism and for the disease, but it would hurt the timing of it, So I g in the front. But he tends to happen. It can actually open up the steam. Taymor a few days after a bale of being a sort of a court for an upper respiratory tract infection was poor. Strep tends to happen weeks later, so we sort of talked with this already. But that's your nephrotic syndrome on the on the left hand side, and minimal change is cheaper stick. Treat you with steroids. Remember, this is well, you can treat with steroids, and you can also check that with them Eastern editors and diarrhetics. And you can use immunosuppression from the protic syndromes. But that's no. I was common, and the first six engines, on the other hand, change. But she didn't know aggressively because the diseases themselves more aggressive and and you could you often see and a lot of immune suppression being used in quite severe cases and with cyclophosphamide, anything that that's they all take the more systemic since then, didn't get quickly muscle aches, fatigue. You could get rash and that was it. Hemoptysis. So keep keep you learn a crucis, and this is a variety of causes. This sort of just describe sort of acute death of kidney tribulus, and it could be a skin nick, and that's if you had a poor profusion. Teo to the kidney and the good. We did decide for this from prerenal E guys that doesn't respond to fluid resuscitation. So if you're giving someone lots of fluid and they're not getting any better, you need to be suspicious that it could be 80 and and they're also gonna have quite high urinary sodium. And it's quite important, you suspect that's that you get the recording of the renewal team involved pretty quickly. You can also get this secondary to reaction to certain drugs like gentamicin and look in and sometimes also called in traffic from CT scans. The other one where this isn't actually go on. The MCP question is my explain the exam. But if someone had a full, a little line and the risk the rhabdomyolysis, that can also be a precursor. Ta and my lung was great small print. But yeah, because that an acute interstitial nephritis is more of an allergic reaction within the kidneys. And that's typically do two drugs, usually antibiotics. But there are other ones, but they say, is there that that can cause them and you tend to get quite high. Recenter fills in the blood on. Do you see white, white cell casts on lots of leukocytes as opposed to 80 and where your see sort of sort of a raid sale or mother tasks. For instance, in the fried tests, you just basically stopped the drug that you're concerned is causing it and get us and supportive treatment fluids if you use it. Stopping the drug. Assume it's possible the most important infections again. They can cause it, too, but it's not very common, but imagine that it would come up. That's our That's our any typical renal street. There's a company in there. I finally, and I've never seen this, but I just have. This is occurring. You give you get vascular related kidney injury, and that's also another intravenous calls and most commonly, the large vessels or stenosis of the renal arteries. But you have to exclude quite a lot of it for 90% or more. Didn't really see any effects. And if you think this is the piece, you're gonna ask for an ultrasound dr of the rear arteries and give them a knees and temperature challenge. But ultimately we're not getting any better. You may need to consider doing an angioplasty, so obviously that they're gonna have to be relatively well tolerated. Uh, procedure. So overall, that has talked about a year Eisenbarth thing with anything is your CT and resuscitate them. So I am going to manage life threatening complications that will come on the hyper clean medicine and just monitor them. Make sure everything is on a fluid balance. And the hospital Make sure you know how much fluids coming out now, which is going in. If they're, you know it is dropping off that society in that kidneys are altering three leads. Might need some more fluids and try stopping nephrotoxic drugs as soon as possible. We'll talk with secretarial Zereoue. It's so important and often doesn't happen and just continue to monitor them. Ultimately, if someone's kidney function continues to deteriorate and you're starting to make me dialysis, the first person to speak is the main ridge on, and they thought it was appropriate to get in touch with the renal team. You wouldn't be expected to mention decisions are not good people on dialysis yourself. So this is a second case. You'll let you have a reacher vest and and you can wait me. Let me know what you think may be going on and what you might do to treat this, you know, it is definitely very severe. Clean mail. Yeah, I think everyone saying all the right things there. Yes, so I mean, get it off. It's very severe. Hyperckemia, it's same, just disappeared off corner. I think it was 7.2 wasn't 7.8. And so I mean, your normal range is really between 3.5 to 5, and you can see a lot of the C G changes here. Yeah, something we've told you is God's Air told Tented TV's Road. Curious is you could argue that P waves are a little bit flattened as well on potentially. Maybe some guess and saying leaves. So it's quite advanced hyperckemia. And obviously, if you saw that yourself was a doctor, you'd be getting shown to the Med Ridge. But NBA that management there. So the most important thing for her hyper clean years to give them calcium gluconate it's in. It's possible that's gonna protect the heart, and that gives you a little bit of time on. Then I think it will be May June, but stop eating more names, insulin, dextrose and that sort of helps show on the potassium into the sales and of the blood system. It's yeah, and you want to start you on something, something long term. So you maintain counseling. Result. Um casting. Resorting. Um, it's still used to put a lot of it's actually used it. There's a new drug is a new drug they're starting to use called termer, and it doesn't seem things that just more it's more effective. And it's a lot less nasty side effects and but But you basically want to give them a look. A long term potassium binder. But I just take the time to kick in, so to keep and I monitor them. So really talked about that last the hyperckemia. Like I said, Yeah, if you're worried refractive, hyper Climara northern. Proving I clearly is another a consideration for renewal replacement therapy so that, you know, discussion Utah with the med rage or renal on coal. If you're concerned that they might require dial of some dialysis, and if they're all have their acidotic, you can also give them some sodium bicarbonate. I just help us bring their peach day. That brother, Let's adjust. Um, you find the Internet. Most hospitals. It's just sort of your Your protocol for hyperkalemia is quite useful. It's only only the very long, so it off going to chronic kidney disease and chronic any diseases. But if it's one of two things, but really, it's just impaired renal function for a long time, usually over three months on if you don't necessarily have to have a cause. If you're a J, far is under six day on if and you don't need to, uh, because that still disease and you can sort of see them. It's sort of staged from 1 to 5, and and to see you over 90 is normal 60 to 90 miles, and it go down there. By the time you get two free 15 around you're in, you're in stage. You're really thinking that dialysis or not. So that's all that with the should tolerate it enough and mean chronic kidney disease versus FBI. So and I'm getting the full of different thought may, and for it can exist. Diversity I and all right conferences. You typically see more more imaging soul. You treat protection, see very small, a large kidneys, depending on if there's any underlying genetic causes and the kids have anemia or are hyper parathyroidism second retaining victim. Indeed, deficiencies in the long run. But I mean, really the mean that differential between the two is timing. If something's happening to keeping clippers to be naked eye, it's really in today until Coleman finding and people who are older and you're over six 75 got a lot of one and two chance of having chronic kidney disease. I don't know so many symptoms. You can find a kidney disease by any. They usually is the symptomatic for a long period of time, and so I wouldn't get too worried about it. But it is obviously chronic ongoing, and your IGA far is dropping. You may start to get a piece of symptoms. There's three mean causes of chronic kidney disease in the UTI. Does anybody know when a message in the child they think they might be? Yeah, hypertension, diabetes? Definitely. Definitely. Time was coming. So is actually it's partly and pulling. Pulling cystic kidney disease. Yeah, there we go and hypertension, diabetes and both of kidney disease effects one and 400 to those nodules. So it's it's not common, but it's a little work on that It waas am slower ago, you said. Diabetes is by far the most common and full by hypertension than polycystic kidney disease. There's a lot of other long term causes which one were mentioned, that people renal artery stenosis going Friday tests chronic drug use of certain tapes. And but the top three there and we'll talk a little bit. A little bit of voices and kidney disease, diabetes and hypertension is our Corporates with their own raped on. Do the treatment for chronic kidney disease induced by their of those is to manage the core condition itself and what I would just see for a diabetic to chronic kidney disease you to be quite careful with metaformin and monitoring the region far. This's, Ah, polycystic kidney. So let's go back. That's a polycystic kidney, and it's the most common inherited. Can you diseases off the global dominant? You get multiple cysts, you can speak and start forming quite young age, and you conserves great secret, markedly reduced hypertension, and you get a lot of times these questions and exams. They love to ask the extra, you know, causes of pulling points of the kidney disease. Very aneurysms in the circles will list, which could lead to some rock bottom bridge, and you also get pancreatic and impact exists and weirdly also might revolve pull ups. And the management for polycystic kidney disease is a little is a low sodium diet on also easy inhibitors. Okay, if you're if they're in a function, is dropping this pain management and despite treatment, you can then think about dialysis and pretend to on the fact. Um, and transplant, and often a lot of idle for a lot of bottles does result in that your medications for chronic kidney disease so urinalysis is always useful. I am. You can send off a urine culture and make up across could be a swell under your set of Bloods. Immunology panels could be quite helpful. So your ankle your a any your rheumatoid factor ending on my little must mean if you're suspicious, that that could be underlying cause. Am imaging can also be helpful and a chest X ray to see everything associated lung involvement. You may see that good pastors and renal ultrasounds as well, and you can do you know biopsies then usually know I've done commonly But if someone has unexplained chronic kidney disease, there quite young and there's no really cause identified, you make serving a renal biopsy on. There's lots of complications long term, and the main ones mean just just from the five and 40 kidneys. It mess. It messes up your BP, even even hypertension cause chronic kidney disease was then worsened. Your hypertension is with a vicious circle, and you can get pulmonary Demark, chronic anemia due to the lack of keep you with secretion. You can also get a lot of electrolyte disturbances in careful apathy. And I'm not sweating. People are screened in reviewing clinics quite frequently, trying the base to get my head run. This s so renal osteodystrophy and that just caused by the lack off your activity. Little indeed, that's one of the rules that the kidney performs that results in in lower calcium levels which sort of on a lens in with higher PT and higher false feet on That's called secondary hyperparathyroidism. This is really chronic, and it's been ongoing for a very long time. You get a tertiary where bit which basically ends up with hot and where everything is high on this could be quick. Dangerous because hypercalcemia is a medical emergency on. But I should have asked you about yet with the treatment for Hypercalcemia is, there is well, it's basically I have the fluids and this phosphinates name than that. That's the only reason people are monitored. So course you have chronic kidney disease, especially in stage, and really thought about this already. Am. If you're young on D, it's progressing quickly. You're going to want to get him in. Earlier, earlier Fairland two specialists You want to treat any reversible cold as you can and get them Lifestyle advice. Smoking, drinking. Manage The cardiovascular risk is generally good idea to get to give somebody low dose aspirin and also statin of their lipids Aries in terms of BP. And they're like toxic veggies exams as well. You want to even for under 100 40/90. But if they have any sort of calm abilities like diabetes, oh, are high albumin you want to even for under 130 and and yeah, we really talked about this already, But if they're anemic, he went out, You want to try and replace what's called in them to be anemic. If they're in, they're having a demon second to the chronic kidney disease, you want to think about giving them a fluid restriction and detain to look. Diarrhetics would just be weary of the kidney function, and they do have a signs of renal offered it all straight dystrophy. Then you're going to want to replace the supplements, replace the vitamin D and the calcium on doll. So think of using force feed binders and guess about three to the bar. Thyroid gland is an option as well. But again, that's you know that's going basically floating away on just a sort of know generally and also when you're describing, especially if I would just be very weird people with chronic kidney disease because your your your doses for all your anticoagulants and your opioids often changes. So just have a look at the beginning. But were you doing that? So in summary, start from the diet and the CKD point of things with our talk to them about prerenal. Most common cause is on the poetry. No, and we'll sort of a couple of sort of covered these bits, and I think I think the most important thing to remember is that if oh, I think it's it's quite simple just to break it down into categories on no over complicated. There are several years and wonderful causes of a key thing chronic kidney disease. But the common conditions are common on they're the ones that come up in the summer, and it is, well, a typical man said so and so I've just got our visit equations. At the moment. I'm happy to answer them and and then I've got I've got four multiple choice questions and it is half past. I've got four more questions I got really case that happened to me on my first. We could, you know, doctor, and on your welcome to stay for that. I'll just wait a minute for any questions first. So what? What you've been saying So hypercalcemia What hypercalcemia is, um, and medical emergency again. It depends on the threshold Severe. I can't official for severe hypocalcemia. Like what the? I think it might 2.7 all the cop but a major medical emergency because it can cause a, um, cardiac arrhythmias. Oh, someone's met. Someone already answered. Haven't yet. There's a risk of the redness. Cardiac arrest off really stations. Well, so I didn't get my year five all skis. But, um I mean, it's quite a bit every quite difficult to say, A renal station, purely a sort of a physical osteo, probably more a history because your renal exam is really part of your abdominal exam and really just involves but lost in the kidneys and off school taking the renal arteries. And I think if you were to have a station about someone, then with kidney disease, it would probably either be that someone with polycystic kidneys that you could probably, and you could feel them quite obviously. Or it's going to be someone where you're talking about managing lifestyle with diabetes or hypertension, and I think it's quite hard to get achy. I take question and ski, and so I think that that really wasn't very helpful, and I've never had a renal or ski station, but I would imagine it would be much more history based rather than examination based. It could potentially ask you to maybe explain dialysis to patients or in yeah, last point actually had fluid status. Yes, so and welcome. Very difficult to do a what was never one is well, And when you're saying someone's fluid spaces, I guess that comes for you know, you're basically looking at the whole picture. You're gonna be aimed. You're gonna have have a few of the pulse, have, like a computer capillary full time. See the feel warm. Well, perfused look for purple demon. The hand in the legs. How? Listen to the heart and the chest during essential a central crackles in the chest. Have a look at the DVD on Asked them to stick your tongue out. Ah, yes, I will. Look, a missions membranes easily dry. You're basically trying to stay as further dry. Usually make overload it on. Then if you think the dry off really going to get the some fluid And you may also do I have that there Gold isn't any debt. Second, say injury. I thought I just Yes, I think I think also, Dystrophy describes the process off developed being hyper parathyroidism. I'm a double check for you. Not separately. No impairment. Okay, that's helpful. Yeah. You know, I was just looking up. What said about the hyper heart is No, It's just something goes to just be sort of screams the process that leads Thio and hyperthyroidism. Second intercessory. Okay, so four Quick North twice places that case scenario to run through that anyone wants to head off. I understand. That's that's grand. That's the first question. I'll just let you read it and then you can do within two pools for these to be here. Maybe on it. There we go. Yeah, so they each names that people waiting for a and which in here is the right answer. So this is a young a young boy who's coming with symptoms off a Dema. He's good, He's got frosty urine. So you're gonna guess he's got protein urea as well. And so we sort of got 23 already there the hallmarks of sort of in the front nephrotic syndrome on the best way to assess that in your urine dipstick to look for high protein levels, the other using knees when other one's always be that useful or much for the donor is their second question. There goes the 84% people going to eat and 13% D on there. Yeah, they're they're the two. Two questions you'd expect move to go for So again, this is the difference I think we talked about earlier. So I g n a frothy and pull straight glomerulonephritis sort of a very similar mechanisms. But four straight tames to happen weeks after on the way I just try to remember that in my head easily is like it. It's poor Strap is deleted. Happens later on last IGA nephropathy take can happen at the same time with these After on, it's tensing more in the nephrotic since it's a two things to go. Okay, so 13% free stage four c total t again the the majority of going for C there. So, uh, and see if see is the right answer in this case. So, for most people call it chronic kidney disease. We like to, even for BP under 1 40/90. And but because this person is a diabetic and they also have evidence of micro albumin here abdomen area in there, your analysis and we want to aim for 130 over 80 just cause of their go higher risk factors for surveillance stage damage and and that's it's too the first line on the appetite's of this lisinopril. It's used for most renal on questions is usually in a sense episode Is the the junk you're giving for hypertension, mister? Last question. Okay. Okay. So Okay, so 91% going for B for all course in Germany that this is on the quite a past medication, but it's a start. The question I can see them putting in the exam is well, so as soon as you hear sort of kidney disease runs in the family on because they're hearing difficulty doing the states and you really hearing loss, then you're instantly gonna be thinking all ports. And I said this last, but we the last, which is just fine. 5, 10 minutes. And it's just business it through your case from the first week on the ward's I am. So I was on the wards and I was I heard about this 50 year old man who's admitted he was Jamie Lee feeling away with temperature. He's he's actually he stepped in a carpet talk home on this late of his injury has been worsening. And worst thing he'd been self managing it with Detrol weight, which is actually quite a clever thing to do apparently. And in order to mind the pee in the temperature, you've been taking some ibuprofen and power setting more. At the time he came in to, um, you he was stable. His past medical history there is got hypertension, asthma, take for the probe on multiple eating. And he's gone inhalers as well. No, no allergies doesn't smoke, doesn't drink. No recreational drug abuse is not too worried. You just think he's got an infection. It's not going away so well or you're you can you can either speak up it in the chart boxes. What? Your initial thoughts and what would you like to do next to this point? Not last year. Yes. I mean, the first thing you're going to do is you're gonna do a team is user stable, But I am doing any TV on him. Yeah, that's for the goods. Whenever you see someone coming in and got an area of cellulitis or infection, draw around with with skin marker and so you can see it infection spreading or shrinking, and we'll be starting there. Yeah, it is will be stopping. The recent habits are for sure 60 rolls. Also stopping your eye proof in and they prediabetes. That's interesting. Yes. So it's quite unusual that he's developed such a bad infection from such a simple and talking dream, which is actually wanted the red just the right, the registrar and also thought that they have diabetes. So got feel work up, got blood. Cultures got a full set of bloods, including an HB one C for checking for diabetes aimed on. But they were worried that it look quick, deep, So they asked Same for the plastics team to get involved. As you they be interested in Debray doing removing some of the excess tissue. He he said he'd been feeling hot. He had not. You don't have any actual temperature spikes when he came and he just said he'd been feeling hot. That's the classic. So he was transferred over to the orthopedic Lord. He had two unsuccessful do brain mints, so it means that they removed all the test really quick. But then infection continued beyond. Not and these were these were this is my first met him in person named these were his blood results is used at the time of matin. No. Yeah. So I'm looking at having with these know? Did you? What? What you're thinking about at the moment? Yes, that's that's pretty low calorie. Yeah, I definitely agree. It's it looks. It looks like he's his white cells are off. The CRP is up. He's got infection. He's speaking the temperature to make fat shit. So yeah, here's the sepsis. Definitely what I was worried about sepsis. So we don't have steps or sex, which I wouldn't ask you to tell me, because you'll be paid off. But we gave him. We are already taking blood cultures, done bloods and lactate and everything, but we need to. We made sure he was on antibiotics and fluids. A catheter in so we could monitor is your note, but didn't need any oxygen. So and that's what we're already a success, and he's got a pretty really key eye developing. Probably is your ears quite high? There is a far is dropping and potassium in starting relocating moment. So at this point I was we were thinking, Well, Teaneck fast. To be fair, it's a possibility, and that we it push IV fluids, use antibiotics. Yeah, speak to my crew. That's definitely very sensible. Peek into my group consultants is terrifying but useful, and they don't tell you. And yes, So we did all these things. I think the big the end of it was really that he's not getting better. So we spoke with the orthopedic team and they decided that he was going to have his foot amputated, and so they actually ended up doing a bologna amputation. But we also did a lot. These things, fluids, antibiotics me to read on the steps of six. So this is two days after his amputation. He started to feel a bit on. Well, no, these are new. Your blood results. No, I mean, it's great. I mean, it's clear that has infections looking a bit worse than we know function looking worse. But is there anything else you would sing in? His bloods Know that you're also worried about his sodium is high. Yeah. Uh huh. Yeah. The old building suggestions. Yeah. So, yeah, his renal function is continuing to drop 23 now. That was why I was wondering about was Well, was 18 with Dallas. Says each to you. I tiu his hemoglobin is low is well, he's two days post a big operation, so my I was thinking that he's probably lost blood from his operation. So he's probably maybe the blood transfusion as well. No, because top of being dehydrated and having an infection is not go, He's know am anemic, which is just going to make his kidneys worse. It's sodium is probably high because he's dehydrated, know, always the cause. That's really why sodium's higher on his potassium is probably going up to this candida feeling. I spoke with the and we have actually an 80 I nurse in the hospital, and I spoke with them and I spoke with the on call the whole doctor. They decided that this patient wouldn't be for hemodialysis. I don't know why, but he didn't meet the criteria, and apparently he was two and well, so they didn't want to do it. And then they had a child each to unite, Usually said they wouldn't take him, that he was reward level based here despite doing 55. But I did. I did argument, but my side of things I am so that's what we did there. I won't talk about Hyperckemia and stuff again, but we treat him for Hyperkalemic didn't see GI and everything on, and this is the last part, so he actually continue to get a little worse. Sadly, he was seen by the renal doctor who recommended general mean panel screening to see those. Any internal cold is going on, but he said it was very likely. And previously, his you score shortstop, he would became acidotic. So we started you on some bicarbonate. This is a recent set of bloods here again, his just his real funky Jaafari's know. Seven. His potassium was 7.2. So I'm with refractory to treatment. So the bottom waiting for this patient was is that he needed dialysis. And on, if you wasn't gonna get it, then he's probably not looking good. So we re smoked number that. What else would you do at this point? Do you think this was your patient? Yeah, yeah, ligation. That's a good idea. I didn't panic. Actually, some acid. If it Yeah, I think that's really important that you said, Yeah, he's EKG. Definitely. It's important we still he still for active medical treatment, So we should we should be treating it. When we were giving him old management for hyper cleaning and everything and I think it's also important to know what, just that, because it zj far as to loop. But when your kidney functions, period to just all your antibiotic doses, so we just we just those antibiotics and discussion that mg t here, that's the control. And I think the most important thing here really is on this sling is quite difficult to do is to recognize that those patients know well and he was probably dying, and the best thing to do is to speak to family and to speak to the family, speak to the patient, ask them what they want to do on speak to the palliative care team and to make sure that we had some medicines up from. So if he he was comfortable on. Unfortunately, this patient did pass away. However, he he was comfortable, thankfully, because we got a team in bold early enough. It's just it's not not a side story. 10 going. I think the moral of the story was just There was just teammates sure that you're trying to recognize when someone's not well on to get the family listed as possible on to get out of it. Team involved in this. In this case, I happen to be a renal patient. I think it's so important. And no, they didn't. I looked at's immune screen later on, when the process that I needed a new castle here, he had no, no underlying, like internal cause on Do you have a note to So initially they said just Newport, you know, call. So they think basically he just had worse. Really, really bad Previnaire Oh, achy I multiple cool cofactors And so it's that anticipate remains is absolutely yeah. Does anyone know what? And analgesia You might give this guy because it was really bad kidney function. Yeah, often. So, yeah, you're gonna go think your friend. So for this person, actually, I don't see the family was incredibly was a wonderful family. They're very grateful that we didn't meet him comfortable and looked after the basic. It's so and well, thank you for having me to talk to, but I wasn't made to be a Saturday evening woman important message and on because any more questions than happy to stay on the next few minutes or so. But I'm good luck with finals and everything. And if you need to give me a second here. You're gonna You're gonna You're in the past. I wouldn't worry about that. I pass some walk, so thank you so much quicker. I've just put the feedback form again in the chart. So if ever in here could fill that out, that's or four tutorials for the rest of the day. Will be back tomorrow at 10 o'clock in the morning. Well, we'll be going into surgery neuro senses and HPB on. Then we also have a Q and A the end of the day. Um, I think we'll kick off pretty much at 10 o'clock. So if you could be prompt, that would be great. But thank you again to recur. Um, HPV is hematology oncology. A politician breast. Thank you. Thanks. Bye. Good luck.