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Hi there, everyone. Hopefully, you can hear me. Um, we'll just give it sort of another few minutes and let everyone else arrive. So give it to just after seven, and then we'll get started. So maybe we'll just get started night, because it is seven o'clock. And there seems to be quite a few people now in the lessons space. So, firstly, hello and welcome, uh, to your finals revision session. Um, I'm sure a lot of your quite daunted by the prospect of it being in a in a week's time. So your first set forth year exams? Um, I'm sure you'll be fine. Don't worry. So I'll introduce myself, and then I'll let will introduce him. So I said, I'm Charlie, uh, currently in fifth year following interrelation last year. And will and I both did fourth year two years ago. So we were the first year through the new curriculum. Um, that you're all sort of following at the moment. So will you wanna introduce yourself? Uh, so my name's will. I'm academic foundation doctor at the RBI. Um, and like Charlie said, I sat the fourth year exams with him. I guess I would have been two years ago now sitting these exams and I can remember the apprehension, um, and, yeah, just the amount of knowledge that you have to take in in fourth year Seems like a lot. But we want to, um, teach and stress some of the high yield concepts. So these lectures and hopefully improve your scores and help you pass these exams. Um, for this session, I will be monitoring the chat function functions. So if you have any questions throughout, just message and I'll, uh, either relay them to Charlie or answer them myself. So I'll give it back. Yeah. So, guys, please. I know you've all probably been in the library revising all day. Um, I don't envy you at all, but if, as well says, put it in the chat or just shut out, don't mind asking questions, and one of us will answer it. So today, hopefully it won't take the full are. But if it does, it does. For those wanting to watch the football. Uh, hopefully you'll get the second half in, so we're going to go through hepatology and nephrology. So will and I had a long chat about these two topics. and we went sort of through the amount on our exams when we were doing in the fourth year, and there was about 20 questions or so based on hepatology nephrology. So there's something that's quite high yield. So we're gonna start with the case, so hopefully you guys can see this. So kiss one. So we've got 45 year old man attending his G p for his diabetic checkup, and he has a history of non attendance. He has a B M I of 33 an incidental Bloods show, an increased a l T. His past medical history. He's got type two diabetes, and he's got high BP and medication wise. He takes insulin twice daily Don ramipril and he takes metformin bit of social history doesn't smoke, and he drinks six units a week. So before we go on to look at some differentials, does anyone want to hazard a guess as to maybe what has caused this mind? Have an increased a l t bearing in mind. We're talking about hepatology short out or typed in the chart. Yeah, good stuff. Everyone's on the right lines. Clearly, you've all been doing your revision very good. Yeah. So starting to think about nah fault here. So nonalcoholic fatty liver disease. So if we go through, have our differential. So yeah. So, nah, field will probably at the top of my differentials just because of this man's sort of past medical history. Um, so I'd also want to be thinking about things like autoimmune, hepatitis, alcoholic liver disease, liver cirrhosis and maybe later down the line, a pad, a cellular carcinoma. So, apart from the past, medical history, is there anything that would sort of point you away from something like autoimmune hepatitis or away from alcoholic liver disease, liver cirrhosis? So, again, for me, it's just his metabolic risk factors. So looking at the, uh, past medical history so good. So basically, what will and I want to do in these, um, set of lectures is for you guys. When you see a case to think what are my top three or four differentials and then start to work down from that in your questioning and you're thinking so just bear that in mind when we're going through. So in terms of how, uh, awful happens So we've got fatty infiltrates that get into the liver, and it has to be with 5% of the hepatocytes having steatosis iss, and I'm sure you're all more than aware of this. So it's somewhat of a step wise process. Uh, so individuals get hepatic steatosis iss, and as the disease progresses, they go on to get steal hepatitis, which can or cannot have fibrosis and then on to cirrhosis. So when you get to the fibrotic and scerotic stage, that's when you're starting to not be able to have any reversal of the liver. As I'm sure you're all aware, deliver is regenerative to an extent. But as soon as you push it past that point, it's gonna have gone too far. So So any further tests that we're going to undertake So obviously a l t. We've seen it's raised. So typically, Nuffield something that loves to be examined is that it's three times greater than a S t. So if you brought up sort of a blood profile, um, so your liver enzymes. So if the A L T. Is looking to be about three times bigger than the ST, that should really be starting to get your brain thinking that this is nah felt. So you're obviously gonna have a look at an ultrasound scan and show those fatty liver changes if we go back and see here in the diagram that you'll be able to see an ultrasound scan. So I put a point there. That patient's with the high B M. I is obviously going to have a less reliability of your ultrasound scan, and that's just through the mode of the ultrasound. Uh, the more tissue, the more fat the more organs you have to go through, the less you'll be able to see. And that's why MRI is the most sensitive way and the best way of diagnosing now for So that's going to be so you end, um, investigation to confirm your diagnosis. So the way when I was doing your exams, I like to think about Nah, field was in five stages, so the first thing is to suspect baffled. So in the next slide, you'll see the way I think about it. So you're in your management. The first thing you should always do is suspect Nuffield, and that's in someone who's got the metabolic risk factors so overweight older gentleman women is a smoker and has got Type two diabetes. So if we think about the guy from our case, he's 45 in case he's mid. Um, not too old, but he's old enough. He's got B M I of 33 so he's overweight. He's a beast, actually, and he's got type two diabetes. So that's starting to think. I should really be suspecting nah filled in someone like this. So then we've got to go on to diagnose it. So as I mentioned before, MRI is the most sensitive and the best way to diagnose it via imaging. But you also can make a clinical diagnosis with the help of some tests. So I've got have done a load of things there. But the most important point is that a raised a L T on its own is not enough. So you have to have the raised a l t. With evidence of steatosis on your ultrasound scan, uh, evidence of steatosis on the ultrasound scan itself or a raised L t. With the metabolic risk factors that we talked about. So that's going to be that clinical diagnosis, um, that we talked about at the start. You can also go in for a biopsy. Um, obviously its pros and cons to any procedure. With a biopsy, you're introducing foreign body into body. You're also going to have some recovery time from the wound as well. Interestingly, 46% of people with nah fault have a raised I g a. Not that you're going to test for that, but that is something to be aware of, especially for SBA papers. Um, you can also have a raised ferritin with normal transfer in saturation in around a third of people. But as I say, MRI is the most the most accurate and best diagnostic. Um, modality for Nuffield. So we've suspected it. We've diagnosed it. Now we've got to think about staging it. So just before we go on to Does anyone aware of, um, the staging process for Nuffield? Anyone aware of the first thing you're gonna do? It's a type of score. I'm sure you've all learned it. It's fart in the chart if you've got any idea. Yeah, very, very good. Good stuff. Yeah, it's flooding through. So yeah, 54 see someone mentioned elf as well. So yeah, that can be used. So we'll go through the specific way of doing it. So hopefully this kind of makes sense. You start at the top left and move down to the bottom, right? So agreed. So we're gonna do a 54 score on this gentleman, so that's gonna combine. His age is 45 is A S T his A L t. And his platelet count. And the most important number here that it's going to compute for you when you put it into Medco Alcor on the Internet is anything under 1.3 is going to rule out advanced fibrosis. So at this point, if we're ruling it out, we just go on to some conservative management and and it's the same at every stage. If you don't hit the next criteria, go back Conservative management, which will come on to talk about. So yeah, under 1.3, you're not too worried over at 1.3 and less than 65 over to, um, and over 65 we're going to go on to do some transient elastography. So that's your next step in your staging process. Um, so if you're transient, Elastography comes back with a score greater than 8 kg Pascal's, you're going to start to consider liver biopsy. Obviously, we've already mentioned doing a biopsy has its own risks. So you're going to pick and choose your patient's and who you do that on. The benefit of doing a biopsy is you can see the extent to which deliver is damaged. It's fibrotic, and that can allow us to stage it finally. But we've got to go through each of these steps before we can get onto that staging process where we use biopsy and it's stage from F not to F four, so f not f f not too f one is we're not too worried. We're going to reassess that in four years. So the patient is obviously got some liver disease, but we're not too worried. Reassess Do Conservative Management F two and F three Again, we're thinking more conservative management lifestyle. Treat the risk factors, which again we'll come on to talk about and give them some more targeted therapy if we feel it's necessary. So F four is where we start to think this person's got some long term and some long term liver disease, so they need, um, they need some viruses screening because of the liver disease. And they need itchy see monitoring because of the risk of a pad, a cellular carcinoma. So let's have a look at the treatment. So you kind of put all the treatment in here. Uh, you're fine with my slides. I kind of try to squeeze as much information on the one page and try to keep the information as small as possible. So you're learning less material. So in terms of the treatment we talked about conservative, So that's your lifestyle, your weight loss. So I wanted your This is the point that we were taught. Just remember that exercise is good even without weight loss. So you're going to improve someone's met about metabolic profile, um, and reduce information if they exercise. So even if they're not exercising to lose weight, you should always advise patient's to exercise because it's going to improve that metabolic profile in terms of diabetic management. Obviously, there's an array of drugs we can use, but pioglitazone and Lyrica tied have been shown to decrease steatohepatitis, and that, therefore, decrease that fibrotic risk. Obviously, you've got your hypertension management, your ace inhibitors, your RBS, and these again have been shown to be anti fibrotic. We're going to assess an individual's Q risk and if it's hired, give a statin people with Nuffield. I mean, obviously they've got some metabolic risk factors. They're more likely to get sleep apnea. So we need to treat this and ensure that they're sleeping well and losing weight for that as well. Smoking association. As you said, that's going to increase their fifth fourscore. It's not good. So interestingly, we can give specific natural treatment, which is vitamin E, and that can be given for people with this, uh, staging of F three, which can help to reverse Nash. But if the diabetic, we're going to try the pioglitazone or the Lyrica text that does the same the same job. Another said, if they've f four fibrosis or are cirrhotic got to start to monitor for paracellular carcinoma and some viruses. So just to make you all aware, they love to ask about conservative and lifestyle management. And if it all, if it ask, sort of What's the first line management in this? Or if you get asked that in your modular go for conservative, always lifestyle, weight loss, exercise and diet, good Okay, so I think that is that kiss. Has anyone got any questions on that kiss? Well, come on to talk about cirrhosis and paracellular carcinoma in more detail, but not filled Pretty straightforward. Know your staging. Know your treatment, Treat the comorbidities. Um, and just yeah, be aware that people with metabolic risk factors probably going to have some form of baffled, so kiss too. So 50 59 year old man with history of alcohol access was brought in by ambulance after he's found in Eldon Square. He's with his wife who gives you a collateral history. And she states he vomited blood prior to collapse. What are people thinking? Oh, so sorry. There is a question there from Amy. So they get screened for viruses every six months if their scerotic or in fibrosis stage four. So yeah, so we can monitor AFP, so that would be part of the HCC um monitoring. So good. Yeah, AFP come on to talk about as well is also going to be raising other cancers. So just be aware of that so it can be raising germ cell tumors. Um, I'm not sure if you guys have covered yet but those sort of tumor's of the specifics of the female and male genitalia we owe have genitalia. So good questions, though. Yeah. So, case to any thoughts, in case to so again thinking kidneys, slash liver, someone alcohol access, and they've vomited blood. Brilliant. Yes. Good work. Tom Johnson and Vinnie. Yeah, Good. Really good guys. Yeah. So we're thinking about viruses here, and that's what you'd want to be thinking every single time. So if someone comes in like this to any, what's your first thing gonna be? That you do? But they bang on about it all the time. What form of assessment? Yes. Good. Good stuff. Yeah, we're gonna do an 80 assessment. I'm sure you're very confident in doing that. Um, although I know fourth year is not the best year for it, but I'm sure you're doing it. Okay, So you do your you do your righty. So you find he's requires intubation because he's bleeding so much, you've had to stabilize his airways for him. His heart rate 130. He's hypertensive. BP 89/63. He's a Parexel Parexel. As we'd expect, auction starts in 90. John disc Clara. He's alert to voice, and he's got some societies and peripheral edema. So what is everyone thinking here? So obviously viruses as the cause of the bleeding. What do you think the underlying pathology of all of this is? He's got John Disc Lera. He's got alcohol access. It's kind of pretty straightforward. Any thoughts? Yeah. Good stuff. I'll call liver disease. Good. Yeah, Pretty straightforward. So let's think you're in your Mosler. You've got an abdominal. Um, monster station. You're gonna start at the hands, go through the examination. What kind of things might you see? Shout out, Put it in the chat. What might you see if someone's got alcoholic liver disease, like longstanding alcoholic liver disease? Always think. Start with fingernails. The hands move up. Up to the neck, up to the face, To the chest, to the abdomen. Okay. Let me see if I can catch up with this portal. Hypertension, juice races, perhaps. Spider Niva. Excellent shifting dullness. Yep. From the sides. Hepatomegaly. Brilliant spider. Levite. Exactly. Do trans contractions. Some clubbing. Good Palmer erythema. Very good. Uh, you can put me do some, uh, Santa Laxima yet. Good paddock flap. Very good. That's the one I forgot about. Especially the equipment is a Asterix is yet brilliant. Yeah, Good nail changes due to I'll be very, very good. So I can never say Look, young Keir looking, I will not be able to say, uh, Luke Connie Kaye. So, yeah, that's the nail changes argument. Um, good. So I think pretty much everything in my list. Palmer erythema finger clubbing, low albumin gastric. This despite an IV. Right? So does anyone know how many spider knee by our pathological? The main question that some consultants like to ask because people can have spot an IV. I very good. Yeah, five plus Exactly. So if you've got more than five reason, there's anyone three of enough to tell me why you might get Pfizer an IV I It's the same reason that an individual with liver disease might get gynecomastia. Yeah, very good. Yeah, it's all about, uh, you have an x estimation. Very, very good. Very good. And as this man's got, he's got some peripheral edema. So at Adina, um, obviously caused by the liver disease as well. And it's all about the reduced albumin, so same thing that causes the fingernails also causes the pressure of anemia. So that reduced argument. Good. Okay, so these are my differentials decompensated alcoholic liver disease. I think we all pretty much gathered the alcoholic hepatitis. I think he's gone past that. You all agree with me so unlikely to be middle igne insee. It's a bit too acute. Unlikely to be obstructing John Bas, um, in the sense that he's throwing up blood. So it kind of takes away from that picture. And it was good to have heart failure on your differentials because of that edema. Um, just keep it there again. He's throwing up. So it's not going to be in this case, but good stuff. Okay, so again, I put some investigations that probably go through. So we're going to do urine deputies, you get the bad side, and I monthly stabilized a bit for often bloods that are relevant to deliver exam allies. LFTs, bone profile, gamma GT and magnesium. Um, in adults find T T abdomen. Is there anything else you want to do in this gentleman? If I go back to his presentation, it's at the bottom there, something that's relevant. So we've done all of our investigations. But what's special testing that we want to do. Okay. Yeah. We will do that on the line for sure. We'll do no good at some point. Flash of sport agreed. Yeah, we're gonna do that. Very good. Exactly. We're gonna do an aesthetic top. Very, very good. So the reason to do in this city cap someone mentioned is the stags to do the tax court yet in the acute were wanting to rule out, um, spontaneous bacterial peritonitis so obvious, even know he's got bleeding. Haristeas. At this point, we've all agreed on that, but we also need to rely possibility infection. Okay, He's a Parexel. But it still could be some, uh, bacterial infection going on. So good. Let's say there was some spontaneous bacterial peritonitis going on. Does anyone know what part of the antibiotics which you use? Local guidelines and your trust guidelines? Does anyone know what medication you might use to help with the ascites one B 12? Uh, yeah. That's going to help with him in general. Good. So that's Yeah, it's exactly like for the spironolactone. Well, correct me if I'm wrong but ugly. That's potassium sparing, um, diuretic. So yes, It's a very good thing to remember for your exams. So Spironolactone is going to treat your studies Good. Another thing I know again, we're in the acute scenario. But you also want to rely on other forms of liver disease. So you're probably gonna do a liver screen of some sort. So just what? I'm on the investigations. Um, I'm sure all pretty well versed in this, but I'm not sure you've done Moscow's yet. So a little bit of, you know, advice from will And I would be When you get asked in the Mazda, what investigations would you like to do? Always structure it bedside. So what you do the bedsides of things you can do when you're standing there. So that's your urine dip. E C G peak flow, and it's respiratory. And for the blood. So all the blood and they often ask me why you would do certain blood. They might say, Why would you lefties in this situation? Okay, this come from the liver disease, then you move on to imaging so irrelevant here to do Dom enought. I'll check up the ultrasound or a CT abdomen to have a full look and then the last thing you want to talk about is special test. So try and arrange it in those four. It's easier for you. It's easier for the Examiner to see what your thinking, Um, and and it's a nice little pick box for you to have. So he sent off some bloods, and this is potentially, uh, this is potentially the picture you see when they come back. So Oh, that's his ST ST You've got that increased ratio greater than two for our alcoholic liver disease and less than one nonalcoholic. So And I said it raise g t suggested alcohol abuse. Just don't take that on its own because it could be suggestive of COPD or renal failure. Uh, okay, so we've mentioned impaired albums that's causing our swelling and the lucky Anchia. I'm saying that right? So, again, this is another, um, point that does come up in exams. Thrombocytopenia is typically the most common blood results see in alcoholic liver disease. Do you remember that? It's thrombocytopenia is the most common thing to see if someone's got bought overseas. And as I'm sure all were, uh, again, you might see a macrocytic anemia. If it's a chronic picture, of course. Pharmacies. So what makes someone Deke compare any ideas? You might have other suggestions than I've got. But what makes someone go from a point where they're compensating with liver disease to a point where they've got feeding viruses or they've got other complications? What kind of things pushes that person over the edge? It's public Q infection. Good alcohol intake yet so if they access the alcohol intake, Dehydration, sepsis, species good lift. Yeah, Yeah, be alcohol. Do you have bleeding? Consultation Infection? Good. So constipation is an interesting one. Um, which will come onto going to talk about part of encephalopathy infections. Infections. Good. I think someone mentioned earlier No, I can do all the schools, the all the messages. Did someone mentioned earlier Port affine from Boost this as well? So that is something which also occurs in people with liver disease. So, yeah, be aware of that. But yeah, I agree with all those, uh, suggestions. Pretty much what I have as well, so good. Uh, interestingly, with portal vein thrombosis, you've got 10% mortality. So bear that in mind. When you guys come at Monza, who's and some comes in having the black human could just eat all of the interim bases if they've got liver disease and have a low threshold to look for it. Okay, so, yes, we've got decompensated So race this year. So again, as I said, I like to keep my notes and actually short for you guys, and you will be getting the slides after lecture, so hopefully they'll help. So you got your side is you get that risk as we mentioned the S p B. We're going to treat that with the antibiotics, and we can do a diagnostic parasynthesis and three an inch so we can use our SAG. So someone mentioned SAG. Does anyone know how SAG works? And what score means that it's caused by liver disease? Our makes sense. It's caused by the port. It's the portal. Hypertension, the causes it. But good. Yeah, it's greater than 11. Very, very good. So don't get not mixed up less until greater than 11. Um, means that this side is is huge. Portal. Hypertension to the SAG score is measuring the theorem albumin and the albumin. Yeah, I'll be one of these studies. It's a serum albumin minus albumin. of these studies. I just get over 11. Perfectly good. Yeah, we can use that diagnostic Paris and Texas for that. So paddock Inca Flopsy. Someone mentioned, um, constipation, didn't I? So, people with party gone to, uh, philosophy or liberties when they get constipated? Typically, they can, um, have a deacon considering event like paddock and philosophy. So the reason for that is you get that says in the notes portosystemic shunt, which results in increased gap toxins in the blood. And it's the increase in ammonia that's awful from brains. It's not a pneumonia that causes the paddock and catalog coffee. It says they're most common causes constipation, patient's with liver disease. Quite commonly, you'll see them just on lacked list, uh, the routine medication that they're on all the time. And that's just because as soon as you run the risk of having any consultation, you run the risk of causing worsening of the hepatic into philosophy and increase sort of decompensation events. Malnutrition will mention that about the magnesium. Um, so especially alcohol. If you have a disease. Typically, people have a low B m I. They don't have a great diet, so they need additives they need help that need diet dietitian in but again in your muscles. A good thing to say MDT approach can get dieticians involved and social workers all that kind of thing. That's good. So go on stock. The virus is any moment. So this is just the on the right hand side or the stages of cirrhosis, which can Sure, you're all fairly aware of and and, as I mentioned earlier, you can be compensated and you can be considered with viruses as soon as they start to bleed. Those are sort of those decompensate or e events side. These hepatic encephalopathy virus is this is the three main decompensate, or E uh, complications. So I think of liver disease. Good. So we mentioned this person is acutely managed, so in general, we're gonna interpret them. If they've got painting viruses and give them oxygen, I'd be accessing cross mites because, in theory, don't know how much blood they're losing. Yet. It's coming up this way, but also keep going, gone into the stomach, um, so cross match and get maybe give some loan egg if it's needed again. Blood transfusion. That's why we've done the cross match and antibiotics reduces the risk of re bleed and of infections. So good to have are depressants. Come out. Just statins. Does anyone know about either of these? It's kind of an awful question, actually. So basically smart a satin is non cardioselective. So in some instances, is preferred to Turtle Preston, but not well, and I've ever seen anyone with, uh, bleeding piracies. I I think you might have read consultants and to give Terry Preston unless it's, um contraindicated. But the matter statin, just to make you aware, is non Cardiff selective can be better incidents. This is so if we still haven't stopped bleeding at that stage, we need to think about what we can do surgically so we can attempt to band ligation if that feels a trans jugular. Intrahepatic portosystemic shunt. Does anyone know what a tips does? What is connected to what anyone. What something do you connect to? What are their something? Go on, Can see portal to hepatic Been very good. Yes. You're gonna connect the portal to the product. Been excellent. So if it in for the purposes of time, always through this bit. So this is just through your long term management. So you've stabilized the patient, um, treated the decompensation. Bleeding viruses, child Pugh score. So, child Pugh, greater than it is if someone has that increased risk of virus still bleeding. So this, uh, individual would have had a high, uh, Pugh score for the Preston can. Maybe some mild satin ending on your trust. So the big thing of feeling varsities secondary prevention. We don't want this to happen again. Super panel law is a good option to give someone mentioned a Dogg. Yes. It's following the bleed. We're gonna want to have a look. We're going to get the general. Surgeons have a look without the GI surgeons to have a look. So school gridded and zero, they get near G. D. Um, I remember the last, uh, sport pretty very easy to get score, Dylan Zero. Um, pretty much everyone had bleed is going to get scoped, and then you're gonna have a two yearly o g d. If you've got ours, is so I think. Yeah. So again, just treat vitamin D deficiency and screen for osteoporosis. Is it any malnutrition? Things good? Okay. Sorry for the purposes of time going to fly through this next one. So basically, this is just the path physiologist to race this So the liver cell feels, um, liver cell failure causes over expression of visit the letters, which is it'll explain it circulations through some speculation. So that increases the port of blood flow, causing the portal, hypertension and the portal hypertension and visit relation. The loss of albumin causes their studies. So the vins, the lower third of the esophagus, is, um, drains back into the portal system. So if you've got portal hypertension, that's going to back up into the lower esophagus Vin's And that's why you've got the intrahepatic something and you get the formation of new things, which is the angio genesis on the formation of viruses. So if you don't understand why viruses happens, hopefully when you get the slide, this little slide should give you a stepwise manner. This happens, this happens. This happens and try to think of it like that. So you get that portal hypertension because it drains from the esophagus. It all backs up a bit like in heart failure, where you back up into the lungs causing pulmonary Dhiman. This backs up into the esophagus. Possible piracies So you see here this is just the basis of liver disease. Uh, liver health, where you go from a health deliver to fatty liver or an alcoholic liver. Or you can just go straight fibrosis with chronic hepatitis, viral hepatitis. As soon as you sort of get As you said earlier, too. I brought it with a cirrhotic stage. We're thinking we can't really get back and to a healthy liver, er and then the risk is hepatocellular carcinoma. Uh, talk about, Yeah. So I just feel a few facts about itchy skin. I'm sure you guys read a lot about it, and I know a lot 9% of all over cancers. If you're cirrhotic, your risk is very high. So I mentioned six monthly checks. Six monthly ultra fine. Think someone asked about that earlier? Um, so they do screen someone mentioned FP earlier. They do screen off feeder protein as a management. Do you have to be aware, is sitting for other things. Wow. Um, interestingly, if you've got more, if you've got too many jurors, you're not. You don't get taken to transplant. So if you got widespread liver and catastrophes of widespread paracel, it across the normal deliver. Um, we'll just get conservative management because, uh, likelihood of recovery. It's not less and good. So that's about yes. I've thrown some notes in. I just I like small notes. So I throw in some notes in about some autoimmune liver diseases, and these can cause, um, fibrotic livers. They can cause cirrhotic livers and therefore can cause paracellular crossed anouma. So the way to remember primary biliary cholangitis is emerald. Sure, you guys gone through this a lot. So you got I g m a m a Middle East woman. It's of the ducts. So it's gonna have an increased LP, and you're just gonna give, so they get really itchy. So you're gonna give your so deoxycholic acid or the other one. Interesting question about rhythm person. So does anyone know what Rifamycin does to bodily secretions? I don't know if you know this. Well, anyone know? Yeah, I get it. Does. It turns them orange. Don't know why. I don't know how, but it does. You don't need to know that, But there you go. Some of you know it. Just looking at autoimmune hepatitis. 70% are women. Um, and it needs a biopsy. So I mentioned there Lifelong immunity, depression fit. So steroids, civilian, your level Steroids, uh, is a dye apprint. Then you can go onto, like, micro Finally, um, more fit, uh, all the sort of specialized drugs that will be done in the tertiary center. Just be aware if a patient is on, uh, thiamine, they do have an increased risk of B, C, C. S s ccs and lymphoma. Keep that in the back of your mind. If you see in the stem of the question that someone's on is a different keep on the Bactrim and the last one we've got PSC. Um, so it's of the interim extra like that's its meaning then and it's associated with IBD. So they need monitoring. So if you diagnose someone the PSC, you've got to make sure that you for checking them for they're, um, the risk of IBD s. But giving them a colonoscopy. So yeah, and also the things in purple. So that's what they look like under the microscope. I don't think we get asked about it, but we were taught it. So it's a difference between t b C and PSC's ones. Granulate to come with granulomatous ones don't need screening. Just be aware of it. And then really good. So and again, As with any longstanding liver disease, all through these increase your risk of palace eluate carcinoma, the primary sclerosing cholangitis. You're at more risk of cholangio carcinoma. Um, so that's the difference there as well. Uh, so good. Okay. So viral hap ABC. Sure, you're all aware I let you to throw this in. So you guys have this table. I don't have time to go through it and all it, but you'll get strides. Basically, the H B s, a G is the hep e surface antigen. Anti HBC is the core antibody, and anti HBs is the surface antibody. As you can see, if you're vaccinated, you've got surface antibody, nothing else, and you've got active infection. You're gonna have the surface antigen and the core body again. That's sort of for you guys to go through in your own time. I've never really got my head or unhappy. I'm not sure if we'll has. Um, it's one of those things I just provide before the exam, so hopefully that will help you guys with that. So again, This is just the management, um, of your viral hepatitis is typically the stem of the question is that I'm sure you guys have seen it on possible whatever. 14 medical student, because often their elective, they got a tattoo, they come back, What have they got? And they've got symptoms of hepatitis. So I know you're all looking forward to your elective at the end of the year. That will my saddling is that on? But just be aware of the risk. Mhm. Yeah, well is correct is usually one question, but worth knowing. It's an easy question. So basically from your core conditions, we kind of covered hepatitis, liver failure, cities, cirrhosis and alcoholic hepatitis. You have got the genetic causes like Wilson's and not a permanent hostess. Even. Yeah, that one. You can have a look over those makes you know them. It's quite easy to examine on, and it's been time to go through today. So kiss three. It's a post surgery 50 year old women hope everyone's okay and everyone got good questions at the moment, and this isn't too fast. But I'm just aware of time. So we've got a woman who's post surgery and she started an hyper oppression. So that was a week ago. She was discharged the day after operation. She's presented any today with Oliguria driving us and feeling sick. It's a positive history of hypertension at once in her family. Come back to that question. Okay, Was already on it. So she lives at home with her husband and God, only three cats never smokes. Enjoys glass of wine on the weekend. So what do you think is going on here? Any spot diagnosis is for this or woman who had a knee replacement last week. Oh, no. Everyone is standing up. Any thoughts? Excellent. So, can anyone tell me why they think it's make it back? Very good for spotting. Okay? I always find it very difficult. Just got to think of what it could be. They're asymptomatic. Oh, your Yeah, new and sides. And you'll hear it Exactly. I couldn't say it better myself, So yeah, someone started on an sides and they've got a past medical history of hypertension. And then I got all the career you've got to really start to be thinking. Is this and AKI So you guys can be very nonspecific, but in some cases can be life threatening to. You're just gonna keep that new differentials. So again, this this is mainly just for your guys' note. Um, there's some symptoms non specific Polidori A one starts, and then you've got the risk factors. Uh, here. So this person has already got high BP in the risk factor somewhere. You haven't been on, um, and some nephrotoxic medications, so because they going to science as well speaking this right. So this is just for your understanding of the capital physiology of when you someone is on an ace inhibitor. So this woman, um, and actually has this question. She's 50. She's got high BP. Most likely she's on an ace to go by the guidelines. So if you add an NSAID an ace inhibitor, you run the risk of some three Reno phase of constriction. So that's from the inside. It blocked cox two enzyme the NSAID causes is a constriction of Afrin arterial. Oh, and it's inhibitor visit dilates the different. So basically what happens is you would just become very little pressure when you decrease the g f r, which can push people into AKI. So I think from memory question, we got someone's having an AKI. What medications You stop. So always stop the national toxic medications in that case, So in this case, you'd probably stop the ace inhibitor and the answered. Um, in general, if they ask that and they're just on an ace inhibitor, always stop the ace inhibitor. An attack. So is your stitches. Um, three Ray chaos. So stage one, stage two. Stage three, you got three different causes. Prerenal Post re not an intrinsic. I'm not going to delve into this today. Um, I have left this question work because I was going to get you guys all to answer. But the things you want to think about is what's causing the AKI. Choose one of these three or narrow it down to one of these three, and then you can explore what's involved with this for intrinsic. You're thinking about things like your regular nephritis. Acute tubular necrosis, post renal. You're thinking of things like prostate cancer and hydrogen for assistance for swelling and kidneys, kidney stones and have a pre we know things like cardiogenic shock. So volume depletion and and medications premium as well, always get followed up 123 investigations was, but the diagnosis is to do with D F R. And proteins were going to check for that. So we're going to check the garden, the proteins, your analysis. We're gonna check glucose and look aside some nitrites in traction. As I said, creatinine is going to give us our score for TFR. So does anyone know when you should maybe take crap mean the true, um, two sets of individuals that you should take crackling with a pinch of salt? Anyone new? Who? They may be good. Yeah. Good. Supportability. Yeah. There's a high mass amputees. Yeah. Good. Also, I was thinking people with, um, like, muscle wasting conditions going to break them down. Muscle. Yeah. And also, the people of mon non occasion, um, descent typically have higher levels of crap. Means that something just to be aware of as well. Yeah. Perfect. So you also might want to do an ox fund. Um, if it's obstructive, see what the destruction is. So then for yours if investigations, you can't go look at the weird and wonderful stuff. So I wasn't really going to go through, but that's looking at for things like sle looking for myeloma, Um, electrophoresis and blood films. Looking at your different sort of bankers and anti community based proteins for vasculitis is yeah, loads of things. You guys, I think you need to know about that. I'm trying to keep it. Sort of Ma's were e um dominant. Yeah. So we've done investigations, So we're gonna look at our management's. We're going to obviously stabilize the patient 1st, 80 assessment, some fluid rehydration. And as I mentioned, stop the estimate where we can stop the NSAID as well. But always stop pacing. Be clear. If it was post green up, we'll be thinking about trying to relieve the obstruction so we can put a catheter in and do that. So we didn't I don't think we've ever asked about it. We could talk about it. Be aware everything called post obstructive diary, sis. It's quite common on the boards where someone who's got post renal AKI the s each other. The F one comes along, put a catheter in. Next thing you know, if all this fluid's come out so great, you stop the AKI. You've stopped the urinary retention whatever, but they've gone into postobstructive diary system. So that's where you lose more than 2000 mills of fluid over 24 hours or 200 mils in two consecutive hours. And these individuals are at risk of dehydration and just be aware of that. Be aware of these questions. So in terms of AKI complications, you also want to look out for so hypochelemia always always, always have a question on hypoxemia and so better than 6.5. You're really starting to worry what sort of cardiac everything is. So we're going to give councils looking at a castle rezone Ian Quickest Ventolin salbutamol in your labs Really, really important? Um, Metabolic asked. This has been drived on with sodium bicarbonate. So uremia. Yes, it doesn't look that worrying. It's just like that. But we remitted leads to Carrick, arthritis and encapsulitis. Okay, you're remaking kept allopathy. So that needs to be treated sort of quite urgently. It's high, and so they'll need dialysis for that. So this is just again for your notes. This is when you should be considering, um, dialysis for your patient's. So if someone's got his acidotic to that extent, if they've got that persistent HIPAA, Caymus you've tried the resume. The, um you've tried to try this w on the labs. They're not working. Intoxication is there's the four drugs that can really push the AKI. And that's something you'd be thinking, right? Maybe I need to get on the phone to someone about dialysis. So overload You got the palm of your edema, and you can't get rid of it. Um, start to think about dialysis, and as I said, uremia so it can lead to park a callous or any catalog prophy. So for the last 8 10 minutes, we're going to go back to case one, uh, Pirmin, Diabetic man. Send cgp routine checkup stuff in blue. We already know about him, but he's not gonna diagnosis Nuffield as well. So, having picked up snaffled, the G P decides they should do some routine bloods have a general health screening of this gentleman. So what? What? Poor man. He's having quite a tough time. So we're kind of talking about Reno conditions at the moment. So what do you think this man might not have given his high BP, diabetes, thinking about long term conditions? Yeah. Good. So CKD is what I was thinking as well. Diabetic properly, of course. Yes. And he probably does. To be honest, yes. Thinking about CKD in this instance. Very, very good. So all the risk factors, um, which will see so g p decided to do some bloods. We got a Z Z f r back 47 albumin creatinine ratio is 4 mg really more. Does anyone know what stage of kidney disease he has? Probably might have written up as well. So you have all the diabetic complications you want to scream for. Very good. Yeah, he's got G three a. And what about his A score? So remember, with CKD you get a G score, which is for the E D F r, and you get a score for the albumin. Good. And it's a two, so we'll see that in the next slide again. This is for your notes. Just your stages. You get your t score and you get your ace score and good. So I can't remember you. I think you lose one g f r. Per year of life. He started, like, 100 and 20 or something. So people do typically have a lower e d f 1 90. It's not really that much to worry about more when it gets to be three a and below or D three a envelope start to worry and you're okay. So again, because is this person has got diabetes. They've got hypertension. So they've got the most common cause on the third most common cause. Uh, Maryland Fridays has mentioned earlier that can cause it as well. Policies and communities and things are actually in solution with bipolar patient's are risk. That's the only increased monitoring. Just so. This is probably the most important slide in terms of CKD. Obviously, hate itself isn't the end of the world. It's the complications that come with it. So typically patient's get hypothermia because you can't excrete the potassium. So we've already talked about how you treat that. That got too high. So there is only in the cooking it net, uh, endocrine metabolic acidosis. So again, you're not able to treat things. So you're gonna have an accumulation of these acids. Hypertension? Is that chicken or the egg? And it is with CKD with hypertension. Which one does come first? Sometimes, and a lot of the time. No one really knows but they both make it to the worse, um, so important to control the individuals hypertension, medication, lifestyle terms of anemia. So, uh, kidney is going to release the EPO, which creates our blood cells. If you're not, if your kidney cells are dying, uh, you're not releasing as much EPO. You're using red blood cells and some fluid overload. And CKD bone mineral disease is probably one of the most important people seek a DEA increased basically osteoporosis. And basically, I've tried to simple act simplify as much possible there. So you don't have drugs that you vitamin D can build your calcium so your body speaks to your pituitary to increase our thyroid hormone, which podcasting from the bone so also pose phosph it from the bones. You end up with a hypocalcemic hyperphosphatemia and because although you're pulling calcium from the bone, you're not getting enough. But you're pulling enough off it. You got increased off it. It's still decreased. The calcium. So poor man, he's come back again. Four years later, there's no I progressed. See a G 483 only 22 or three sides to go, guys nearly there basically what we need to start thinking about here. Um, uh, yeah. You need to start to think about renal replacement therapy and dialysis. Exactly. Do the same thing. Good. So he's probably going to N C H d k b. So these are the scientist symptoms of complications we've already talked about. We're not going through those began. And so this on the right hand side again, really important bits of information. Those are the management. It's a management we need to do for those complications. We want to control someone's hypertense to control the diabetes. It's inhibitor for the hypertension. Also for the protein decrease Aspirin, Staten to CVS. Um, if someone's not for letting their vitamin D, we're going to get an activated 50 costing binders recording. Enter the bicarb. And yet you're all right, renal replacement. And, um, maybe some transplants. Also, just be aware people with CKD get cramps and restless legs so you can give putting salt fit for that. And and again, if you get something in the Moscow is that, uh, it's sort of like a d n a C p. R. Or you're only going to provide active, supportive care in the sense that you're not going to do dialysis on someone who's G f R is less than 10. You need to go about it in a way that's saying it's not that we're going to stop treating your father or your mother or your grandmother. We're just going to not do this part of treatment. Gonna focus on making that person as comfortable as possible. We're not going to stop treating them. I just don't feel the right form of treatment for them, making it really, really clarifying it to the family that you're not stopping treatment. That's why it's called active, supportive care. In this instance. Yes, women replacement, uh, therapy. They start at the top there. A. I own you. So those are your indications to start to think about it. And it's when the e. D F first typically lesson and got some notes very briefly. Hemodialysis and Kathleen analysis. Um, both have the benefits. Um, the weaknesses. Hemodialysis were in hospital three times a week. It takes a lot of time. Partly analysis. There's a lot of burden on the patient to do the changings. And so yeah, so you guys can read into the pros and cons of that Uh, right. So he's had RT for the past few years, but it's not starting not to work. However, his friend has offered him the kidney, so just be aware. Kidney transplants. I'm sure you guys have heard something prepared to exchange, So that's where it's to say, Well, I had a kid offered me as kidney, but we didn't have. We weren't sort of compatible, weren't much. So we would find another pair who weren't much, and I'd take that person. Some other person take wheels, which is a nice way of going about. Can we try to come? Yeah, this is just a little bit in transplantation of your notes. It's gold standard. It's gonna what's gonna stop CKD? It does increase life expectancy. Risks E D. V, which cause cancers at a mega virus. And they love to do a question and doing the specific antibodies. So be aware of them can cause acute rejection. Uh huh. Even if someone is perfectly and they're not specifically matched and that everything's matched h l a. Matching all that you still need to, um, give immunity presents. And there's some examples on the right hand side, so things didn't really cover with diabetics and prop seen products and, um, syndrome, also the American of Fridays. And so you're interested intrinsic causes of AKI. But hopefully I know it was a world like, very quick through two sets of C. D. M's or topics, but we were aware that you guys have got your exams next week who wanted to get through as many of the with high yields information as quickly as possible. So, firstly, thank you everyone for showing up. Hopefully, it's helped, hopefully feel a little bit more confident, even if it was just to see what we knew against what we were teaching. And and if you felt as though you knew most of it, you're probably in a really good position. So it's excellent. I'll just interrupt you there, Charlie as well. So yeah, really appreciated that session. Uh, refresh from my memory as well. Really Good. Um, I just wanted to let you guys know that I'm also running a session tomorrow night from 7 to 8 o'clock on, um, cardiology and respiratory medicine. Um, we'll send out the link to that event, um, through various chats and groups that you guys, um in. So so my sessions? Probably a bit more s p a a bit of Muslim. Her focus as well. Um, but it should be sort of the high yield. Um, content. Um, we won't be able to go through everything, but, um, a lot of the things that are commonly asked on exams will be covered in that presentation. So, um, feel free to come along to that and then provide feedback on the link we've put in the chat as well. And then we can send out the link to the feedback as well. Um, it's really important for us to improve future sessions. Um, but thank you so much for coming along. Please give some, like, detailed feedback of what you guys want. So we're going to run honest feedback. Yeah. Yeah. And then after Christmas, we want to run like a set of 10 sessions before your exams. So we really want it to be