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So, yeah, if you want to keep updated with all the opportunities we have to offer and stuff place to subscribe at some point in this session, we'll post a a link to sign up to our mailing list of instant. Would you be able to do that so that people can sign up to the mailing list? And since we're free, free platform, we work on people sharing us on social. So if you really enjoy the session, do feel free to post it on your instagram Facebook or Twitter. But these are our handles. At our ski is the official for both Twitter and Instagram and face will get on skis. Um, without further ado are let moving. Take take the session away. Yes, some wonderful SBS and concept to teach you today will be hematology part one delivered by him, right? Thank you very much. Just share my screen. Go. All right, so Hello, everyone. Thanks for joining us today. Today's as remind mentioned will be one of our finals Easy sessions. And today I'll be your presenter Moving for those who are joining us today for the first time part of our ski see. And today's the first part of the thing the hematology for final Siris finalists electorate where I'll be hoping to cover some higher concepts in about 1 to 1.5 hour a period. Uh, coagulopathy these platelet disorders focusing on trauma site opinions from blood products used and then ending it with blood transition complications. So, without further ado, let's start off with the first question. Someone from the team launch the poor. Now, do you guys about 50 to 60 seconds to answer. So I wanna launch the pool I think it has been launched. Morning. So has it. Okay. Concert steer. Okay. Gave me Stop sharing for a second. Well, there you go. Okay. Some reason I can't see the That's my mind moving. You carry on with your presentation or Aleve. Okay. Can you tell me what the same constant to see the pool. Yeah, that's fine. You can you can see a screening. Yeah. Yeah. So majority of the people have gone for the 51% followed by see 31.7. Okay, so majority have gone for a line. Okay, So most of it before I, um um it is unfortunately, it's not the answer. It's actually IV iron, which I'll come on to talk about now. So this patient is having, uh, symptoms to interpret in barrier fatigue and, um, abdominal pain, which is most likely in line with malabsorption syndromes such as celiac disease. So in celiac disease, you can get iron deficiency anemia because of reduced absorption off iron. And this is why you get the classic spoon shape nails. Can someone tell me on the chat what? That's called the exact term for spoon shape news? Yeah. Yeah. Perfect. Carnican. That's the one. Um, so this is a patient came in with symptoms of celiac disease. And because of that on the, uh, autoimmune diseases such as type one diabetes on graves disease point with it will likely be to be a muscle disease. And as a result, since you have malabsorption, there's there's no, um, using giving or a lion because, um, the I'm not be absorbed through the gut. So therefore, IV and is the best option. Okay, Okay. Next question. You know, just the pool. Can someone on the team stop it around 50 to 60 seconds on? Let me know what the It's common answer is a moving. I respect you bringing the fade out. You know what, man? Yeah. Um, 39% went for a and 38% went for D. And so most is carrier. That studies, which is the correct answer. Well, dinner. Um uh, guys. So this is a patient presenting with signs and symptoms of anemia. Chronic fatigue on DA work up is done, which shows a normal city, um, anemia and past medical history shows that hypertension chronic in using about and chronic kidney disease is actually one of the one of the causes of normocytic anemia. And this is due to reduced PPO synthesis in the kidney due to progressive failure on Because of that, you get reduced bone marrow synthesis off red blood cells. Your iron stores are usually normal, Um, and just have ah reduced red dots of production because it produced PPO, but it is important to always a small of you have gone for is carried on studies. But the second one was giving PPO so you wouldn't just give PPO. You'd want to see if the patient has normal iron iron levels. So you do. I am study check serum iron ferritin and things like that toe. Make sure that the iron levels are normal before giving you peel because there's no point giving you pee or if you have low iron levels. Teo, despite giving you pee, or you won't be able to incorporate if there's not enough iron in the, um I'm starting the body and in the serum. So therefore is doing study. So Okay, next question. So much the poor and yeah, okay. I know it's ah. Name is quite a broad topic, So I've put in a quite a couple of questions before explaining. So please bear with me. I will be doing some explaining is well, so most people pick D is the answer. Yeah, Brilliant. That is the correct answer. So this is a patient coming in with, um, kind of anemia reported to have dark urine and has a significant, uh, surgical history, which includes aortic valve replacement and Coombs. Test is negative. So colds, testes just whether to check with it's autoimmune hemolytic anemia else. If it's not negative, it's less like to be autoimmune cause of humanity. Cantina on Do you have dark urine? Which supports the human human? Assist him a license off a red blood cells, which is why you get increased bilirubin as it is. Well, if you get dark urine and also the Arctic valve replacement, what I'm hitting that there is this's patient probably have a metallic valve replacement, and as a result, that could be a cause of mechanical problem, which cleaves red blood cells, causing them to have this helmet cell kind of appearance which are showing a few slides time. And this is because of the mechanical drawing mind that she is stress causing it. And it's It's one of the causes of, um Intervascular Hemolysis. So because of the metallic, the Arctic love on it's supported by and a humanistic anemia is a type of off normocytic anemia just shown by the normal hemoglobin. And sorry, normal MCV Um, it's a fine and bilirubin traced because of him. Honest, it's but, you know, release. And then we're gonna formed subsequent reactions. And then you get increased ridiculous size, which is the thing you see and humanities as well, because the bone marrow starts producing in metro red blood cells and a faster it to keep up with the, uh, keep up and overcome. The hemolysis is, um, okay for question. Is the poor someone else or just check? I thought, I understand seeing you know, President does my president, you know? So in that question that was actually a normocytic anemia because of goes in chronic kidney disease, you get a normocytic picture and you'd only check. I'm my levels and I do and studies just to sectors. There's enough iron to be incorporated when you give PPO to stimulate the bone marrow. So if there's not enough iron, there's no point giving you peel because even if you give you pee or the bone marrow can produce because that's not enough, I am incorporate into the hemoglobin. Which is why so that was a normocytic anemia. Uh, because of that, yes, I will. I will mention, though, this world. Yeah, especially for the previous question. Okay, if I just finish off this question and I'll go back and do that, Okay? So we and, uh, for their Yeah, sorry. Um, majority, 48%. I've gone for a 44% of gone for C. Okay, moderate. He was a Z. Yeah. Okay. Thank you. Want, uh So most of you wonderful for late on. Um Okay. So what do you guys you guys put on the chat to tell me what? This patient? What condition this patient is having before revealed The answer. Any any thoughts? B 12. Okay, B 12. This This. Okay, um, So, um okay, we got a bass takes have acute or correct? Yes. I mean, someone said it B 12 and folate. So you've got someone with combined B 12 folate deficiency because usually get in in a V. A personal adopter weaken diet can become deficient of B 12 because, um, meat is a good source of 12. So and alcohol abuse can reduce your calorie intake, and as a result, you can get a folate deficiency. So this patient has a combined for lead and B 12 deficiency on. But the starting the, um, starting off possible a neurological involvement as well. So it could be developing sub acute situation new generation of the spinal cord, which is why he has numbness as well on it's conducted palace anemia and your psychiatric symptoms like irritability on intoxicated shoes that he's having a lot of alcohol on common access. And hey has a hyper segmented neutrophils on blood film, which is a sign of megaloblast media and common cause of microblast IQ is B 12 folate deficiency. So in this case, what I was aiming at is you would need to replace both B 12 and folate, but you replace B 12 1st to prevent sub acute, and someone said it as well. So we prevent sub acute degeneration off his spinal cord. Um, because you can get things like parasthesia hemiplegia things like that. So to prevent that you treat the B 12 1st, and then you would go on to do for it. Supplementation. Okay, so before we move on, uh, you should just go back. Uh, eso the I didn't I'll talk about these, um, later on. But for your size, you usually see in autoimmune hemolytic anemia or inherited ones like, um, yeah, headed many as well. Our jolly bodies you usually see in hypersplenism. And it caused, like, sickle cell anemia bodies you would see in G six PD, which is, ah, type of required humanistic anemia and target cells. You usually see, um, one of the causes iron deficient in in an hour come to talk about them a bit later on. Hope that makes sense of schistocytes are usually seeing you to the sheer stress of things like metallic bars could be from by a swell, anything that causes blood just to, uh, become humanized. Okay, so let's go on to talk about anemia. So there are three different types, but generally they're different, uh, different cutoffs in terms of anemia in men and women. So in men, it's less than 1 35 g per liter on in women. If it's greater than 1 15, then you would look at the MCV you confirm the Albany me A. To tired to determine the type of anemia, and then you can try to figure out the cause of the anemia. So microcytic it's less than 80 normocytic 8250 liters on macrocytic is greater than 100 and microcytic. The most common cause is iron deficiency anemia To come in to talk about other things. Like we did see me aside Relast IQ and that poisoning. Um, do you have any anemia of chronic disease? So in 75% of cases, this is a normal cytic anemia. But in 25% of individuals, it can be a microcytic anemia. Okay, To keep that in mind, it's most commonly going to be a normocytic. Anemia can be microcytic is well, and then you have things like CKD hemolytic anemia and a plastic anemia to a plastic anemia, usually a subtype of bone marrow failure. And then macrocytic. As I mentioned that to types megaloblast IQ, which includes for later vitamin B 12 deficiency and then you have non megaloblast IQ, which is other things like hypothyroidism, alcohol, excess on cytotoxic drugs, things like that and for good before letting him, because you are okay. So Microcytic anemia so focused on both the iron deficiency anemia. So in terms of mechanism there, various different types, the most common one of the common presentation is due to blood loss. And this is, uh, usually chronic blood loss. So usually in post menopausal women and generally in men, it's you usually do to gastrointestinal bleeds. Eso. It's important to us patients about their medication history. So if they're taking any and sets that can constipate cost is to form and then you could bleed. Um, and in premenopausal women, if they have heavy periods, um, Energia, that can cause a large amount of blood loss, and as a result, the's kinds of patients can develop a difference. Dina. Another important one, remember, is especially in the older population is colorectal cancer, which is a because of chronic GI I bleeding. Something important. If you see a patient with weight loss, things like that, it's important to keep that in mind. And then, obviously less common cause is like no dietary intake. So, um, patients with the different diets they've removed a red meat, especially rituals of iron and Then there was also a malabsorption syndromes mentioned, which could also cause I'm deficiencies. Well, so celiac is one of the causes, and then you have increased requirements. So in pregnancy you are requiring I and for both the going baby and the mother as well. So as a result, you can get increased demand. And if you don't need that demand, so if your diet friend it is not sufficient, you can develop. I understood in union, and the clinical feet just are assigned medication. You know that shortness of breath on exertion or exertion or disappear for dig conjunctival pallor. Palpitations because your your you usually the body's oxygen demand increases and you can supply because you have reduced your blood cells. Um, and as a result, you can get palpitations because your heart's gonna have to work harder. Things like that colicky a justice putting the funerals and rest a Matitis justice reddish kind of discoloration around the edges of your mouth and a side issue just the enlargement of the tongue. As I mentioned in history. Ask about changing eating habits, have a reduced or stopped eating red meat and strokes cycle. Have they been having increased frequency off mental periods or heavy periods and medications, again said. And then obviously the classic picture would be a high program. Is microcytic anemia in the answer microcytic mean low and CEO Lower volume slash size hyperkalemic is indicating, that is, that's less hemoglobin because there's less. I am performing a global. You get that classic picture using these. So these are This is very me on Important can help in diagnosing a upper GI bleed. You can feel bleeding from the esophagus down words. You can have a raised urea. This is because the blood is digestive use, like a protein year on down. This can kind of produce urea, and as a result, race urea serum urea can indicate that jive leads. You can do things like endoscopy, determine where the root off diabetes and things like that, and then we can do a blood film on it. So boy killer of psychosis. So this is variations in the size and shape of red blood cells because, all right, but those are the same size size of shape because unless I am and impaired production and you also get target cells, which I'll come on to show in a bit. And then, classically, to confirm you have to do on studies on the classic picture is low serum iron can have low ferritin and race TIBC. Come on experience later. Support. Remember for tin can be raised because it's acute phase reactant. You can have race levels of fighting in chronic inflammation. Or if anyone has a, uh on infection and things like that, that can really so you can't just base it off. You can't say, Oh, this patient doesn't have a wonderful telling me if that ferritin is raised Usually you can just wait to after the recover to do iron studies on things like that where 13 would fall that down pretty low levels. Um, and then the treatment. It's important treat the underlying cause. So I be malabsorption syndrome or the dietary changes. Um, and I didn't find very important job. I bleed things like that, and you give for I am usually, um unless they have things like malabsorption syndromes you mentioned then you could up for IV I, and you can also give blood transfusions, especially if they are in need of once. If they're grouping is less than 70 then there will be an indication on Important remembers. Well, if a patient has acute coronary syndrome event, fresh old is if it's less than 80. So it's less than 80 you give it. If it's between 70 to 80 would give it, uh, but in in other patients, less than 70 would do a transfusion. And then here you have the iron studies. Um, as I mentioned, you have low serum iron, uh, the various causes I mentioned. Your total iron binding capacity is increased. This is the amount of transferring, which is the kind of protein that transports island the blood. And that's increased t o like carry as much iron around the body to place like the bone marrow to increase to match the red dots of production. You get low ferritin. So this is ah, indicator of iron stores. Iron stores are load and then you have presented saturation decreased because presented saturation is thie iron divided by the total iron binding capacity. So there's less saturation of I ended, the less present in the blood. Know if I want to ask you guys, how would um how the perimeters be different in anemia off disease, and someone put down the checked and you don't want to put on the chat whole TIBC low? Yep. So what is a virgin will be normal respondent. Yes, so what happens is, um, anemia of chronic disease, usually due to come and talk about that later, is usually due to chronic inflammation on inflammatory conditions like really bad arthritis. And because of that, you can get a raced Friday because it's a fuse fist. React reactant, Um, and you can get increased levels of helps it in as well, which is in the liver and that is responsible for the absorption off iron. So if if sorry, if that's raised, helps it in. You have reduced iron absorption. So it's when it's since it's a acute phase, reactant in inflammation, because the cytokine release and things like that can get really increased. Um uh, increased absent in. And because of that, you get decreased. I am, um, absorption in the gut, and as a result, your serum I and I'm stores and your saturation will be low. But your favorite in, uh, sorry. Your ferritin will be increased or normal because of it's also an acute phase. Reactant okay off that made sense. I If that didn't, I can repeat that. Um okay. Um, so can someone tell me what this? Ah, first one is showing first picture on the left called any brilliant? Yeah, I won't spend too much time. Um, this is angulus dermatitis. And the last one. What is that? Can you tell me what that blood from sure is it so any any anyone wants to give it a shot? No target cells. Brilliant. Yeah, that is exactly what it says. You got that classic bullseye appearance because you get type, of course, makes you get reduced hemoglobin. As a result, you can get, like, a p o kind of center flash ring on because of that, which is one of the process. Okay, so moving on to the other causes, I don't spend too much time on it. These are the morning, but several plastic anemia could be congenital. Do difference Different, deficient in enzymes which are responsible for him. Um, him synthesis. And you can also get acquired. The most common is, if I remember correctly. Is alcohol excess So? Basically, the problem in this is you get You can't incorporate iron into him, which forms hemoglobin on. As a result. Get this incomplete him synthesis and get this something called ring sideroblast. So basically the iron, since it's not incorporated it stored in the my Kandra on. But with the collection of iron, it can form a ring like structure from the nucleus. That's what it's called a ring, as called a ring sideroblast. On investigations, you would have high serum iron for 10 and, um, maybe see on this is because your your iron levels are fine. It's just you can't you like the ability to incorporate into him to producing with moving, and you just usually give supporting management. In these cases, you're beating calcemia to talk to someone recessive condition, and it's clinical presentations according to the phenotype, this major minor tree and trades, Um, and basically it's due to, um, decreased. Um, human blue been here. And as compensation there's increased HBA to and feet of Grogan on the treatment is just simply giving blood transfusions. And you've given I an Achilles thing agent like desperado. Same thing is basically to reduce the amount of organ damage because when you get ill overloading the blood from repeated transfusions that can damage organs. Prevent that. You would give best for your oxygen as well. And other causes like lead poisoning and anemia off disease I mentioned. Okay, then moving on to normocytic anemia on that also has a lot of causes. But generally you can differentiate according to the regular side count. So if there's a reduced red blood cell production, this is usually you stomp either a problem with something on board in the bone marrow, all things like anemia of chronic disease, where you can't, um, necessarily getting are fine as well. And as a result, um, how would the first from my lifting 10 years? They're still enough iron, But, um, usually due to the chronic inflammation and things like that, that can effect better production. And as a result, you get high ridiculous site count because you're trying to, uh, uh, increase. Uh, sorry. I meant to say you're to get a site account. Um, apologies. I'll fix that. When I send it with slides, you get your articular side count because you have reduced, um, production of blood cells. And Azizullah, you can get, um, um, anemia, the normal city anemia, and I'll come and talk about the different types. So bone marrow failure, chronic condition is chronic disease, and then increase that blood cell this destruction or losses and other the type, and you would get not low apologies again. It will be high ridiculous sites because your bone marrow is functioning well. So you get please production of red blood cells, which will have blood cells to keep up with the condition like a few blood loss on human list, is okay, So anemia, chronic disease? As I mentioned, it's a simple surgery. Information in conditions like bloated arthritis was commonly normocytic can also be microcytic. And it's often and incidental finding. Wondering 18 blood tests in patients with chronic conditions, and you also have a cube blood loss. I'm usually, uh, on the lost causes read that says to be reduced, but the remaining once having a normal MCV. Because I levels are usually normal, a supposed to chronic blood loss, you would be losing blood for a long period of time, and eventually your iron stores are depleted, especially if you're not replacing it enough on as it is going to get a microcytic anemia. So chronic remember chronic blood loss. You get microcytic anemia, a cube blood loss. You get a normocytic anemia. Okay. And if I am and then on to the next one Chronic kidney disease because of Decreased PP Oh, production as a result, off progressive renal failure. And the treatment is the price is stimulating agents like a protein or double voiding, as I mentioned before, important to check iron levels before starting a few extra the enough iron, um, stores on in the serum. So that enough can be important incorporated in the bone marrow when PPO is given, okay. And then you have a plastic anemia. Um, which is basically a pancytopenia. Yes. You get reduced red blood cells, white blood cells and platelets again to subtype off bone marrow failure. And because of movement, feel you get low ridiculous sites, okay. And, um, some of the causes. So if you look at the, um, bone marrow um um, biopsy here, you can see that there's a high possibility realities of the less cells over area. And there's increased amounts of that space is to replace that volume. Thing is a classic hypersal in a bone marrow picture. You see, in a plastic anemia. And you? The most common cause is idiopathic, so there's no because on drugs using chemotherapy on depart, it's like or, um, finical and epileptics like our message peons in a doing, viruses like parathyroids be 19. Um, radiation and congenital abnormality is like fanconi anemia usually seen. And I think if you're less than 15 or 16 years of age and you can get, like, different physical deformities in that and then hemolysis is which I'll come on to talk about now. Okay, so they're different types and, uh, get someone told me on the chat why you would get a raised. Most likely why would you get a raised uncontradicted bilirubin, then a conjugated bilirubin in hemolysis skin? Someone told me that on the chat, please. Any any one read about it in jaundice. Okay, okay. Yeah. I mean, it is a pre, um, So the thing is just generally the cause of your small assist. You, um you get increased break breakdown? Um, yes. I think someone said it. Yes. So, um, it's complicated. Usually valuable to break down. So you get increased amount to congregating enzymes. The liver are fine. Exactly right of destruction. higher than excretion. So your your liver. So you know, the breakdown is so high that the liver is unable to keep up with removing for the body by conjugating it. So as a result, you get a raised on conjugated bilirubin to get traced conjugated as well, because there's more on conjugated bilirubin. But generally you would see a raised uncontradicted be ruling. Brilliant. Uh, then I would, uh, is that he's sleeping. Sleeping late December Lord. No, that's my thing. Yeah, it's going from your stomach. You already was happening. Okay, that's fine. Let me continue self hemolytic anemia. I won't spend too much time on this. It's a busy slide, but I would advise you guys to read this on your own time. So you have two types acquired, inherited, um, quiet, um, and can be differentiated by doing a comes test. If there's on antibodies against red blood cells, which caused them to be hemolyzed, it would be a positive comes test on do of the court. Come. Causes are warm and court, depending on the temperature at which the hemolysis occurs on. There's a variation in the type of immunoglobulins as well, so in warm be a high time for like 36 7 degrees on the I. I G. Is the mean antibody something, you know, go been. And this is a community. An extra extra vascular mal assists, such as in spleenomegaly. Um, and some of the common causes are cll in for my city and the drugs called lower temperature 3 to 4 degrees Celsius gm on. But it's interesting to stubborn intravascular monasteries, um, occurring blood vessels on comedy, singing like atypical pneumonias like mycoplasma it. And then, if you're negative, Coombs um, that's that shows that it's not immune, and it's more likely to be something like the can call from a a Z. I mentioned metallic heart valves on microangiopathic hemolytic anemia You get from by forming the small vessels, um, mainly, and that causes cleaving off the red blood cells. And if you can see this, this is Mr Sides just like a helmet ship because of that clear red blood cell on Deacon. Get it? Things like hyper screen is, um, and in tropical countries malaria. You can also get you wanted to get in here, uh, then inherited conditions. There's so many metabolic syndrome effects like six g six pd member and effects like her to restore cytosis on. Then you also have sickle cell and see me. So geez, expedient headaches. You know, psychosis. Um, it's usually get you need Oh, John, this really the drive and Goldstone's exact that. But what differentiates that, too, is that you're more likely to get spinning megaly in here to restrict psychosis on the different types of diagnosis of G six PD activity is measured in the deficiency. It is extremely deficiency. And here to decides, cytosis you look at, um, a binding and there are various different demographic a groups affected and different inheritance happens are just leave you guys to read that on your own time in the interest of time. And then finally, macrocytic anemia, as I mentioned to types make a lasting are microblast to fix so non megaloblast IQ things like alcohol, hypothyroidism, liver disease, um, pregnancy, regular side doses and etcetera and make a plastic to defer to mean types. B 12 folate S. O. N. B 12 deficiency. One of the causes pernicious anemia where you get antibodies against the intrinsic factor that is produced in the gastric. Prado's an interesting intrinsic factor is important for B 12 absorption in the terminal. Eylea eso When you when you have these antibodies that attack the intrinsic factor, there's less interesting factor for the meter to buy, and as a result, you get in tired between absorption. You also get through this disease because it mostly affects the terminal ileum, and as a result, you get impaired. B 12 deficiency. As I mentioned, we can diet so the decreased, um Indyk because they have cut out meat in the diet. The result. You can get B 12 and the classic signs are for the classic. Clinical features are large tongue off of ascites neurology, so you can get, uh, except Subacute, um, the generation off the spinal cord. As a result, you can get the different parasthesia. And we played yet things like that and also your psychiatric symptoms. As I mentioned, that patient in the question had, you know, was irritable. Other things that could experience is depression, things like that, which is which is an important consideration to make on to investigate for that by, you know, looking a serum B 12 and blood feel very important. You would only get hyper segmental neutrophils in, um, microgestin anemia. And the treatment would be hydroxocobalamin. Okay. And folate deficiency. Um, usually low diet, low dietary for late absorption like celiac disease, alcohol, excessive alcohol intake, Pregnancy with this increased, um, usually turn over and drugs like trimethoprim and important to remember, Um um, it can cause in newborns on your A tube defects like, um, spina bifida. Um, which is why it's important not to give trimethoprim in the late stages of pregnancy. And you also have investigations accident Florida serum for late and hyper signature neutrophils on blood filled on the treatment. As I mentioned. Important. Always treat B 12 deficiency with hydroxocobalamin and then supplement for late to prevent the development or the progression off sub acute uh uh, dictation on this spinal cord. Okay. And, um, I won't ask you guys with this is I'm sure most of you know this This is a high percent mentally you feel with multiple for 45 loads or more. Uh, which is what you see in my club last week and any okay, on to the next question Can someone wants to pull? Huh? You Can someone stop it at 52 60 seconds moment, someone asked, Is it common to get jaundice with him? A homologous Sorry is in common to get jaundice. Yeah, yes. So if it's if it's severe enough, you can get jaundice, which is what that patient had the yellowing of the slower, and if it's severe enough, you might get there long of the skin as well. The first one who usually happens is the yellowing of the scare. Uh, because you get increased levels of bilirubin, least from red blood cell breakdown. Yeah, it goes with humility. Need is not as common compared to, you know, your hepatic and posthepatic causes to cause clinically to close patients. We clinically doing this, but it can have physiologically increased bilirubin and causes jaundice. Well, that's something else going on medically. Blasting me in the middle of asking means they're very, very large. That's what it basically means because you get impaired. Um, I'll be in a synthesis flatbread blood cells, which causing the kind of but go read it on your own time. A condom exact that the pathology, but it's larger than the normal, um, your blood So which is why you get any very raised MCV you have That isn't when you are a and straining it percent who are. See? Okay. So most of you have said A which is, in fact, the correct answer. Yes. So, um, can you guys tell me what this man is presenting with on the chest? Uh, what condition? Possibly. And what is The mattress is Okay. Brilliant. Can you name the condition which the patient might have? Yeah. Brilliant. Yes. More likely to be him. Failure? A. It is important to remember, Um, and if I would have just kind of trust the question around and say if the patient, um if, um if you forget the question And if I say if a patient has prolonged PT, um, and prolonged a PTT as well, what would what would that possibly indicate? Yeah, yeah. One bill. A band? Yes, exactly. That's what you get. Um, second. Yeah. So since this is hemophilia that affects the intrinsic part way, the PT will be prolonged. Important. Remember on, then. I'll just be if you go to Costco glove cardiomyopathies. Basically, you have You know, your coagulation factors liver and anything that activates them, such as impotence, damage causes the step by step after it's a part with the calculation cascade, which end of it fiber being the end product. It forms the measure of that traps real answers and other things. And for me, a clock, um, Trombetta, that's our clock on. This reduces blood loss in your In fact, you also get a place like activation as well. And cardiomyopathy is basically when you have and most likely and impaired fiber in synthesis in case you're more likely to bleed because you're less likely due for a clot. And the two types of testing, uh, you can test it two parts to the intrinsic and extrinsic part on intensive. Usually PTT extended would be PT or IRAs well, especially if a patient is on something like warfarin important to do and are safe. And I are excreted than one. They are less likely to clot, more likely to bleed. So basically means that you take longer to, uh, clot. And this is capital, using the patient's protamin time over a control for Trump In time. I don't spend too much time. I don't really go through this. I recommend you guys go through it on your own time. Uh, it's important to know, um, about the steps, um, and then focusing on the first case of fact, the question had a feeling after excellent recessive, mostly effects mail. Which is why I put a million divisional in the question Stomach well and female carriers are usually isn't dramatic. Okay, most common type is thing. Fear A. That's the one that's most because you truces on. That's the fact that a deficiency in Philippi is due to factor nine deficiency. Okay, and what you would see is prolonged QT because it's affecting the physical part of a normal PT and no more platelet count. Your platelet counts are affected because the there's no abnormality with the platelets on. Then he'd see eating like a deep tissue bleeding, especially in the joint space, is causing him out process. Um, you can also get subcutaneous and to shoot my promises work because of bleeding. The D I bleeding are very, very unlikely or less likely in hemophilia diagnosis. Usually measuring factor eight and nine levels and treat Mondays usually replace those factors, um, particularly peut bleeding, and you can also give desmopressin int, which kind of increases the release off factor. Factor eight and one willebrand factor on this is a picture off Humatrope, sis. Okay, so this is swollen, swollen, knee drop. Okay, um, we are a part of these guys. What I was going for before was my mistake is, Well, I was going for you to be taking care deficiency where you get prolonged PT and PTT as well, because it has factors affecting the boat. The intrinsic and extrinsic partner. Okay, in one milliband disease, Apologies for the for the mystic on my part. It's, um, belong to a PTT only because it's affecting the intrinsic part way. Um, So this one will burn diseases after someone dominant one where you get either deficiency and absolute or mild deficiency in the 1 mg factor. Or you can get a non functional one. Broadband factors were you get mucosa bleeding like, um, nosebleeds. This taxes or things like heavy periods is well, you can also get a superficial bruising, uh, important. Just just roughly know they could manage measure w fallen. Really band fact the levels and the activity as well play their count is normal. And you can give, um, desperate president to kind of increase the release off one Billy brand factor from the end of the lien. And then your vitamin deficiency, which has so many causes offering on the body, takes care first. Warren's like after Aczone malabsorption, city fibrosis, pancreatic insufficiency and what you get is a deficiency of vitamin K dependent factors like, um and 9 72. How I like to remember it is just another day. It's 1972. So you get one. It's 10 fact, the 10, 9 and seven and two and you get increased bleeding as a result. And important, um, in the pediatric setting is well, is the one of the most common cause is off humor. Adjective disease off the new moon is because of vitamin decreased vitamin K because breast milk, especially for baby express bed breast milk, that has less return in king on. Also, if if for Mom is on anti epileptics, that can also review c'mon with me in case well, so this is important condition. You born with something like if they haven't hemorrhage or um yeah, intracerebral hemorrhage things like that. You consider bit, um, in case supplementation and then also give Proton been complex concentrate and FFP been city oblique. Okay, next question can ask my watch. The poor. I thought you were really good, But remember, play table tennis. Okay? No. Shall we the pool there in the interest of time, Um, 50% have gone for a with second being 18% from, uh, 1 30 foodie. Okay. Brilliant. Um, so, yeah, this is actually Timoptic Thomas. Like a peanut popular for this, Um, that I've seen are teaches you posted. This is the classical Penta you get. Um, so you get a fever. Okay, so, yeah, the acronym is fact are in. So f four fever for anemia. Um, he for trump aside opinions a low platelets, platelets level of 70 um, and are for renal impairment. So I didn't really put a renal impairment in this case because you can get real Intamin, both hemolytic uremic syndrome and thrombotic thrombocytopenic purpura. But it's most commonly seen in het us. Our humanity, your neck syndrome, then in TB, and then finally got a neurology is once you get things like, headaches can get seizures, stroke. Um, and, uh, because basically, you get it's a, um uh from about IQ micro and drop it be basically where you get increased levels off. Um, a small trump I formed from platelet consumption is your platelet levels decrease because of so many, like a small clots form, especially in a small vessels. And as a result, you get number cytopenia resulting in bleeding for this is taxes and you get red purple spots on the surface of the skin. Can someone tell me what that is? On the checked? Yes, I will explain the difference. Yet petition A brilliant it is finished it it's on. What you get is a normal PT and PTT because the Kremlin factors aren't affected. It's just play the levels that affected. And, um, that's how you kind of different from everyone else and immune thrombocytopenia. You'd usually get an isolated trump. A cytopenia were at the rest of the parameters were normal, and you would get you wouldn't get things under a lot of GI fever or things like that. Um, and I'll and I'll come on to explain why. So this patient, also another risk factor is the female sex as well. So you get into TV. You definitely get, um, CNN symptoms like headaches. Um, stroke seizures. Um and fever. Okay, so starting off it platelet disorders the drama side opinion is defined as a deficiency in the level of platelets in the serum, and the pain level off less than 1 50. is is indicative of that. Okay, so I t p it's also called idiopathic thrombocytopenic the side of phoenix. So appear, uh um, and it's usually an opting and cause. Causes could be any cause that causes, um, inflammation like SLE. It could be triggered by viral infections like CNN, V h i B varicella sauce, a zoster virus. And what you get is these antibodies and buy into these receptors theanti gp to be three A. And therefore, what happens is these make it more likely for this planet macrophage is to come and consume them so that I kind of like markets, so they're more likely to be consumed. And, um, um, used up a zit results. The lifespan is decreased. Okay, that's why you get, um, Trump Dapena. And that's that's why I get isolated from beside opinion and as they get bleeding, um, eso the platelets. I do stop because if this autoimmune process okay and your classic features could be skin and because of bleeding or nose bleeding, that petition a A and prop your AST well, physical lesson off the small, pretty she ate. Perform a larger kind of bruise, basically, and it can also be an asymptomatic star incidental finding on someone who's 18 tests a Z. I mentioned it. I still ate the pravastatin. Yeah, with all without bleeding. So in a symptomatic individuals, they might just have just the depending on the level off platelets. Well s if it's not not very low, they might not even have any symptoms like bleeding and the other perimeters of FBC on almost the white cell count. Well, that's a count are normal, and it's usually a diagnosis of exclusion. Once you ruled out other causes of thrombocytopenia like TTP, um, human, you remix syndrome and things like that, you would then consider this to be the most common cause. And then it's different between Children and adults. It's It's Children. It's usually self limiting. It's usually due to that infectious process, such as there's a lot softer virus that causes this, and they usually get better in adults. Sense to be chronic. Just why first line instance you would give moral corticosteroids mainly prednisolone, to try to increase it levels off platelets because it stimulates plated production. And then a second you can give intravenous immunoglobulin pulled normal greenness. A globulin on this is indicated because in cases of severe bleeding, way are particularly low platelet levels or if you're going for a surgical procedure, because this will increase platelet levels faster, them cortical steroid. To give it in that case and also can straighten up to me, is not very common use nowadays. But if a patient has a factory time besides the Penis or homicide opinion that isn't respond to the previous Step two treatments like the steroids or the Immunoglobulins, then you would get go for us for an actor. Me. And as a result, without the spleen, you can't. You don't have that platelet consume consumption. Your platelet lifespan increases is really okay. Then you have a GP. Okay, so it's a traumatic angiopathy, which basically means in small, um, small blood vessels like Hillary's and Arterials and things like that brothers, you know, it's quite narrow. There's increased sheer stress, and there's more likely to be a mechanical problem and things like that your blood is more likely to be, um, not necessarily static, but more, uh, more likely to clot. Um, can cause, um, small small platelets to come together to form clots. And as a result, your platelets are you stop. This is because, off, ah deficiency or decreased activity of this ongoing called adult Yes, 13, which is basically sorry. It's a metal Oh, protease. That's usually supposed to, uh, decrease the level, decrease the amount of things like one bottle brand factor, which is bound to the end Italian when there's less. Adam the ts 13 there's more one Gillibrand factor in the and luteum, and that makes it more likely the platelets to clump together because that's one of the mechanisms by which a platelet kind of comes together and forms a clot. And as a result, you get these increased confirmation and your platelets are you stop. Okay, so you get the time. Besides opinion. As a result of that on this overlaps with humanity really mixed in drug because you get Muha. My granddaughter had accumulated anemia to get hemolysis red blood cells. Because of these clots can have that mechanical force to cleave dot So So Okay, which is why you get sister sites on the blood film so similar to mechanical valve and things like that. You can also get sister sides in, um uh, tp and left me. See, she would show low platelets and in terms of other features off Mom, how you would see race bilirubin and respectful asides to have to keep up with the amount of red blood cell breakdown. And, um, you can also do, uh, the testing for that little a Proteus on if it's less than 10% that is when likely to be TTP and PT and PTT is normal because the correlation factors aren't effective and important. Remember, as I mentioned, neurological symptoms like stroke stages or, um, headaches can occur, and fever is quite common as well. You can get the cause of the consequences of Thomas have to be like bleeding, but the shape of your, uh, treatment on the treatment. Early intervention is key. Do you get do plasma exchange or pattern freezes? I can also give steroids wanted a platelet count, and you wouldn't give platelet transfusions because you already have a deficiency of this model. A Proteus, which means you're by giving it less. You're just encouraging more and more constant form. So that wouldn't really correct the platelet levels for too long on, usually in teaching you a very low bleeding risk. So you don't really have to worry about the patient and bleeding to death or things like that. Okay, And then finally, the last two causes off Tom side opinion. You get humiliated. Your email syndrome overlaps with TTP on commonly in Children that they have, ah, gesterone intestinal illness or infection, particularly the specific kind of equal i e. Coli 157. It's seven, which where this Yet this production off this sugar toxin and that triggers are small platelets to come together and from small clots, which is why it is also a trump trump Arctic. My grand Japanese happens. It's what blood vessels mainly, and you get this cleaving off red blood cells again and therefore you get schistocytes. Other causes include a new pneumococcal Oh, and HIV. On the trial usually see is, um, acute kidney injury. My grandma had the cumulative and the man from was a pina, so you're more likely to get an acute kidney injury from that us than TDP, but they can both have kidney injury. So it's important to do using these and check for any race Urea credit. Okay, so which is why you do fbc Check for the levels. You use any use to check for urine creatinine stool culture so you can see if there's, um, uh, levels off the sugar Toxic. Okay. And treatment would be supportive care. Give fluids, blood transfusions. Um, and you'll get him a dialysis if they have severe renal failure, and they finally have be I see this a minute. Intervascular regulation. I'm sure most of your hair of this owns going to much time on it, but you get this. Um, it's quite spread. Um, usually second reduce abscess and all get side kinds released because information can also get endotoxin is from, um, bacteria. And that kind of activates the cascade. And that uses forming small, small small time by but lately and and fibrilla. Okay, you get both platelets and five in from by. And because of that, you get, um, um increased pt a PTT. Um, because it decreases the coagulation factors present in the blood. So defects put intrinsic. Sorry, effects Both bs extrinsic an intrinsic part three At the same time, platelets from by also formed As a result, you get low. Platelets is also get from beside a pina belong PT and PTT. So it's important to remember that because that is one way to differentiate from the other types of trump aside. Okay, You also get a low five religion because you get 500 gyn is like a precursor before fiber is formed. Says more five minutes for more fiber. No gyn is used up and therefore you have low fiber in your gyn and rested. I'm what on the other cause, including malignancy obstructive emergency such as like an annual fluid embolism or help syndrome. So how you know, if you guys remember what stands for hemolysis which just monasteries year year for elevated liver enzymes and LP for low platelets? Okay, on the treatment would be to just treat the underlying cause of sexually six. In the case of sepsis, um, supportive care, um, fluids, blood and platelet transfusions. Because you need to replace um, the levels of platelets and you would give the 50 to replace the coagulation factors that are used up okay. So I won't ask you guys what this is This is just a tiny pinpoint red spots, red purple spots which are petition and a cool lessens off the petition, the collection of difficult and form Corporal, which is a bigger kind of bruising. And this is basically a summary of the four types. Okay, so I keep e in all all cases, you get low platelets, um, as I mentioned, but in IDP, you just get a nice, elated low platelets, so there would be no signs of small hole like a respiratory been or is ridiculous sites. Um, and there's no it doesn't affect the coagulation. Um, cascade. So therefore, they don't change the PT or GT, and then you have TTP and humidity remix syndrome because both are causes off Muha on What's important, remember, is TTP energy as sport caused this platelet microthrombus I, um, to form in these smaller vessels different mechanisms but they bought have the same consequence. But the symptoms are the main way to separate them in ti Uh, tp you get central nervous system symptoms like headache, and you also get fever. But in him, you the grieving syndrome you it's usually jail nous like equal. I, uh, the spirit of the specific training strain of equalize. And it's usually in Children. Okay. And then the d I see you get but platelet and fiber and Tom by so which, which effects the PT and PTT. So it increases that on, um, And you also can get my heart because you have you have the fiber in mesh work as well. That can also cause the leaving off and break down of red blood cells in addition to the platelets microphone by that are formed, which also cleaved. So you get, um, hemolysis there as well. Okay, okay. On to the seven question. We're almost there. Guys get someone wants the pool. But when someone else, which organism causes each us humanistic, your mix syndrome. So it's mostly the, um, most likely to be the equal I stream, um, Or 457. yeah, yeah, it is a sequelae one. Certainly. Hemorrhagic stream be color. And you can also get from pneumococcal and HIV less common. But what remembering is what? I guess. So he ended there. Yeah, I think. Um, see, um, 40% men for ee and the D 1% went of all. Okay, right. I think you guys are thinking on the right lines, which is so the answer is he okay? But, um, you know, come on to talk about why. So this patient has, um past medical history of F. And they've been in a road traffic collision, which could indicate in a possible bleed significantly on, um, on here, signs of increased ICP, which is, you know, remitting multiple times and has a producing, uh, DCs. And he's also on warfarin, which is what makes it more likely to bleed as well on the city had, in fact, confirms and intracranial bleed and his iron level is raised. So this is a, uh, severe bleed, and it's a head injury as well. That therefore to for the emergency reverse a reversal of anti coagulation like warfarin. You would give a proton being complex century because it contains the factors. 10 9, 72 which is important to ah, reverse that. To reduce the amount of intracranial bleed, you will not give or overdoing care, you born rapid actions. You usually give, um, IV vitamin K okay. And the other ones aren't really necessarily given platelets Not usually given fsb, uh, routinely. But you'd focus on is put on the complex 100 or also known as very plaques with the brand name on. So in in catastrophic beads or severe head injury, you would want to give a PC. Okay, so I would spend too much time on the blood products. I'll let you guys read this on your own time. But if you'd important things, remember black blood cells. Remember compatibility in terms of your recess with the other types like Daffy. But but importance of packing them is to reduce the volume given to the patient to reduce things like, um, body moving. Good. Because you remove the plasma FFP on this after the removal of the blood cells. Such a strong blood cells, white blood cells, platelets on. That's usually to replace fibrinogen. So if levels are less than 1.5 g, we're leader. That's an indication to give it. I'll infusing conditions like the I see liver failure, where there's a loss off reduction in the clotting factors because they're used up on. But, uh, no, that s OAB. Oh, compatibility is also important because it contains antibodies from the donor. Okay, so you can go and attack the glasses and cause Kamala sis conference. It did. This is done by a process processing ffb more. And it contains many factors and bone blip, in fact as well. But, I mean, I remember it also contains fiber, no gyn, and it's similar to a 50 you can give it to replace five religion on, um, forgetting indications are like d I see little Philly and massive bleeding. And then finally, proton been complex on centric, which contains the vitamin K defendant factors 10 972 on it's used in emergency reversal of anticoagulant like warfarin in the case of severe bleeding or intercranial hemorrhage. Okay, on, um, it's has a lower risk off address. It bends compared to a 50 as it doesn't contain any don't antibodies. Which is why it's preferred were, um, Roberts, like FFP to replace um, cooking factors. And then you finally have bled. Let's He's also expressed some some form of a some amount off a video and actually antigens as well. It's important. Member Avio. Mismatched platelets can also be transfused because you're less likely to get a reaction Transfusion associated reactions we'll talk about later from red blood cells. And also it's important. Remember that you increased your a bit of an increased risk of developing infection as well. Because the platelets are not stood at as as lower temperatures of the Temperatures store that is slightly higher. Four degrees Celsius is wrong. Um um and that therefore you get that an increased risk of infection. Okay? And then your different types of modifications look a depletion their sister reduce the transmission off cytomegalovirus because it's usually found in new sites. And it also lowers the transfusion related complications like for Brown on humility, transition reaction and also to prevent transfusion associative grass versus host disease in patients with things I greet on transplants, any radiation, the kind of inactivate Steve lymphocytes, um, in the in the part of the products. And it prevents graft versus host disease in transplant patients. And it's common in it's completely indicated in immune compromised patients. Okay, on to the last question, should we launch the pool? So cryoprecipitates more of like a for the process. For most fft, it's it's a small in body. Okay, so we ended there Anyone, anyone there, so from the team doing in the poor There? Yes, of course. Uh, C C is the highest, with 42% followed D and 24 25 34. Perfect. Yes. Perfect. It is, in fact, for is, um I had an oxygen because this patient is experiencing something called Transfusion associated circulatory overload, also known as taco. So on the risk factors is his age, which is sure that he's quite elderly possibility, possibly friel. Another indication that could possibly included is heart failure. Okay, so they can really help with excessive values because of reduce cardiac function. Um, you get signs off redeem are like shortness of breath tachypnea increased respiratory on and low oxygen. SATs on. Yeah. Okay. And this is quite a MRI similar to another. Um, another complication off blood transfusion, which is truly transfer. Transition. Uh, uh, related acute long injury, which is basically a beautiful get this neutrophil activation. Uh, when the drop attacks, I introduced, um, and you get, um, similar, similar kind of symptoms. But the difference is how differential between the two would be the BP. So, in in taco, which is this one, you get hypertension in, um, Charlie, which is the transfusion related. A key, Uh, acute lung injury. He would get hypotension is you have a low BP. Okay, that's how we differentiate. And, um, because of this volume overload, they get a partner Dema on. Because of the water overnight, you get increased cardiac output, and as a result, you get hypertension. Okay. And the best way is give IV first mind to try to, um, remove as much of that water by the kidneys, and you'd give oxygen as well, because they, uh, low on, um, the options. That's a low. Okay, so, um, I won't get too much time on this. Um, please do read it on your time, but what I would focus on is the other types of of the transfusion complications. Um, do you get, um, a n'importe one, remember, is due to allergic reaction because it's incompatibility. If you have antibiotic bodies that go and attack the red blood cells causing implies on you'd get features like fever, abdomen pain and local pressure. Okay, The important thing to do that is stop the transfusion. Do not restart it. Check. Check for error. If there's ah, blood group A mismatch. The Coombs test to check it does and opening component and then repeat typing and cross matching. And you'd give IV fluids because of the hypertension so they might go into shock. So you want to give fluids to prevent that. And then you also have nine humidity for by reaction. Usually you get fever, chills, and it's usually more likely in play. Let's dinner blood cells. What you do is stop the transfusion, or you can stop it and slow it down or restarted slowly and monitor them while giving precedent. Want to bring the temperature down and the other two you get is allergic reaction, which is, uh, which is, um, get, um, mild. Um, Brutus, um, dick area. What you do is stop stopping, trying temporarily give and histamines and then monitor. Okay, on flax is more more life threatening, going go into shock as well. Because of hypertension, you can get, um, um, breast retreat kind of bronchoconstriction. And as it is, I can get me using shortness of breath, um, Strider as well. And that's CVS hiring of the airway. And you want to get angioedema. Okay, what important thing to do is Stop the transfusion. Do not restart it. Give IV again. I am adrenaline and I refloated free t hypertension on oxygen because the oxygen saturation will probably be low because of the blockage of the airway. Okay, on Yep, That is it for me. Thank you for listening, guys. If you would please, um, to fill in the feedback phone, that would be very much appreciated.