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So to start off with, I'm gonna go through um the structure of the structure and how things are gonna be run. So we're gonna be going through all conditions. Firstly, we're gonna be going through enduring conditions. So diabetes menus, type one, diabetes, menus, type two as well. Then we're gonna be going through a musculoskeletal condition and that's gonna be osteoporosis. And then lastly, we're gonna be going through an infectious disease which will be meningitis. So in terms of the structure, I'm going to go for each precondition and I'm gonna go through it in this order. So I'm gonna start off by going through the pathophysiology. So why the disease occurs? Then I'm only gonna go through the signs and symptoms. So how the disease presents, then we're gonna go through the investigations and how we go about diagnosing it. I'm only gonna go through the management. So how we go about managing the disease as well. So, starting off with diabetes mellitus type one, it is an endocrine dis um disease that is characterized by the autoimmune destruction of pancreatic beta cells, which leads to insulin deficiency, which therefore leads to impaired lupus uptake by cells. Now, there are some risk factors that make patients more likely to have diabetes. Type one compared to other people. Those risk factors are genetic predisposition, Vitamin D exposure and viral infections. So, um genetic predisposition if you have a family member. So a sibling, your mom, your dad or um any other family members who have had type one diabetes, then you are more likely to have it. Exposure to Vitamin D is associated with um diabetes, type one as well and viral infections, for example, entire viruse. So sometimes the signs and symptoms. One thing you'll notice is that type one diabetes and type two diabetes present very similarly. And the main symptoms that patients present with um in a GP setting is polydipsia which is excessive thirst, polya, which is excessive urination and also weight loss. Another symptom that is common in um diabetics as well, which I've touched upon in the next slide in the type two diabetes, um portion of the left child is um fatigue as well. So keep that in mind too. And one thing to also not is that in UK MLA type questions when it comes to diabetic diabetic questions. One telltale sign that the question indicates that a patient has diabetes is polydipsia and polyura. If you see those um two in combination with each other, think diabetes, but keep in mind there will be other stuff in that question that indicates as diabetes mellitus because polydipsia and polyheme of um diabetes insipidus as well. So in terms of investigations, if a patient is symptomatic, keep in mind that patients could present symptomatically and also asymptomatically too. So, if a patient is symptomatic, then alongside their symptoms, one of the following results is sufficient for diagnosis. And these tests are notable when it comes to diagnosing diabetes. So that is a random blood glucose. So that is your blood sugar taken at any random point. And if the patient receives a score of a blood glucose score of 11.1 or above is considered sufficient for diagnosis or if they get a fasting plasma glucose test done. So a patient um fasts for 8 to 12 hours. So no food is consumed or any um caloric drink. Then after that, their blood glucose is taken. If they receive a score of seven and above, then it's sufficient for diagnosis too. They could also take a two hour glucose tolerance test, which is why a patient ingests a glucose solution and their blood glucose is taken two hours after the ingestion period. And if they receive a score of 11.1 and above, then again, it is sufficient for diagnosis. And lastly, we have an HBA1C, which is a type of blood test and her HB A1C is tells you how much glucose is on the patient's hemoglobin in their blood. And if they receive a score of four eights and above, then it is considered sufficient for diagnosis. Another thing that I forgot to add on this slide and also the diabetes tattoo slide is when it comes to managing um their um blood sugar, they need to make sure that they keep their HBA1C at 40 below that is that um that is the level recommended by the nice guidelines. So 40 below is the level that need to keep their blood at. And if it's not at that level or if it's above that, then um other interventions are acquired in order to keep their blood work in check. Now, if a patient is asymptomatic, so they don't come in with symptoms, then two results are required from different days. They could take a random blood glucose or a fasting plasma glucose on two different day. Um they can get those results but they have to be done on two different days. One common combination that they deal with the plasma glucose medicine, a two hour glucose tolerance or a HV A1C. But sometimes they won't add the HBA1C because that's a lot easier to remember. So they probably mentioned the fasting plasma glucose and to our glucose tolerance levels. And one thing to note as well is um you need to remember the levels for what is considered sufficient birth diagnosis of um type one and type two diabetes. So 11.1 for a random blood glucose seven and above for a fasting plasma glucose, 11.1 for a two hour glucose tolerance test. And you also need to remember the level for the HBA1C which is 48 millimoles. So in terms of management, diabetes, man has both pharmacological management and also lifestyle management too. So starting off the pharmacological management insulin therapy is um the first line. So on the right here, you can see an image of a person with an insulin pump. It shows a nice little diagram that explains the mechanism of it. So there's an infusion set that is usually placed on the stomach, some with subcutaneous um fat. And what happens is the infusion set has a little cannula that pumps out insulin periodically and also measures the blood glucose and releases the insulin in response to that whenever it's too high to kind of bring it down to a normal level. Then that insulin pump is that little mechanism that shows the readings. So patients can check whenever they fail just to make sure um their levels at the right are at the right level. And also it tells them when it's battery needs to be changed, all that stuff that's really handy. And it's really um it's really good. The insulin is really good because patients don't have to inject it manually themselves. They don't have to worry about it. It does it by itself. So another pharmacological um management is BP control. I'll touch upon that later on in the slides. But patients um diabetic patients need to, um, ensure that the BP is at a normal level as it's, as diabetic patients are unfortunately at higher risk of, um, further health complications and a high BP is one of those. So they need to make sure that their BP control is controlled well and there are medications in place for them to do that. Another thing is hyperglycemia management. So, hyperglycemia is low blood sugar as the blood sugar levels of diabetic patients is um cannot be controlled by the body itself. It's very, very easy for it to um either become too high. So hypoglycemic but also become really low hypoglycemic, which both is very dangerous sometimes of hypoglycemic treatment. Um patients will have some patients will have on hand, an IV intravenous glucagon and injection that they can inject into their leg if they're unconscious. So someone will come and inject it into their leg if they're unconscious or they'll have um Gluco gel on hand if they um notice that their blood sugar is quite low and they're feeling drowsy so they can consume that instead. So in terms of lifestyle management, diabetic patients um need to monitor their blood glucose regularly. So they can do this um by using that pump to check their blood glucose levels or also by using glucose strips and a little um kind of monitor that measures that level within a few seconds. I have a picture on the next slide that the next few slides that, um, shows what that looks like. Then we also, they also need to take out regular follow ups. So going to their, um, GP for any appointments to check their, um, HBA1C and make sure it's, uh, at the level 40 or below. And also just to see if there are any other symptoms I'm experiencing because as I mentioned before, unfortunately, diabetics are at more risk of other health complications. Psychosocial support is also offered because diabetes is a lifelong condition and can take its toll and affect their daily life. So, psychosocial support is there to help them manage and also gain as much control over their life as possible. Exercise is highly recommended as well. Keeping a healthy lifestyle, also exercise and a healthy diet. In terms of diet, they don't want, you don't want um, diabetics are not recommended to consume unhealthy foods. They need to keep, have a well, healthy and well balanced um diet potential that their blood cases that are keeping is well controlled alongside the insulin therapy too. That kind of just helps with everything and smoking cessation is highly recommended in diabetic patients who smoke, smoking has an effect on um insulin and and also affects its efficiency. So it's recommended for patients with diabetes to stop smoking. So now I'm going to move on to diabetes. Mellitus type two. Diabetes meus type two is a chronic metabolic condition that's characterized by inadequate insulin production from pancreatic brain cells resulting in insulin resistance. So this is the difference between type two and type one diabetes. Type one diabetes is insulin deficiency. Whereas type two diabetes is insulin resistance. And as a result, this leads to an elevation in blood glucose levels causing hyperglycemia. As I mentioned before with um regular blood glucose monitoring. This here is a glucose strip and a monitor that measures the blood glucose within a few seconds. And what happens is patients get a little needle and prick their finger and they squeeze their finger to get that little drop of blood. Then they'll put it on that little glucose strip there, that white strip and they'll insert it with the machine and within 5 to 6 seconds they'll get a blood glucose reading and that is pretty accurate. The patients will usually do that before or after meals. So, in terms of signs and symptoms, um, one thing to know is individuals with type two diabetes, mellitus are initially asymptomatic and over time their symptoms may develop. And that is due to the fact that these um type two diabetics, they'd have no idea what's going on. So they're not undergoing any treatment for their type two diabetes. And over time as the diabetes gets worse, they start developing symptoms of polya. So excessive urination, polydipsia, excessive thirst, unexplained weight loss, blurry vision and fatigue. So, in terms of investigation, it follows the same principle as type one diabetes. So if the patient is symptomatic. Then one of the following results is sufficient for diagnosis. So a random blood glucose. So a score of 11.1 and above is considered sufficient for diagnosis, fasting plasma glucose. If you remember patient fasts for 8 to 12 hours, a score of seven and above is considered sufficient for diagnosis. Two hour glucose tolerance. So, um patient consumes a glucose solution and their glucose, their blood glucose is measured two hours after a score of 11.1 and above is considered sufficient for diagnosis. And like I said, lastly, HBA1C, uh HBA1C S and the glucose score of 40 above is considered sufficient for diagnosis. And if a patient is asymptotic, so they don't, the symptoms which is quite common and two results are acquired from different days in order to support diagnosis. So in terms of um management for type two diabetes, again, it's both pharmacological intervention and lifestyle intervention. Lifestyle. I want to quickly touch on lifestyle intervention, cos I didn't make a slide on it specifically, but it follows the same principle as type one diabetes. So regular clear by monitoring with broke strips like that image, I showed previously also regular follow up and also healthy diet and exercise and smoking cessation. So exactly the same as type one diabetes too. What's different here is the medication type two diabetics don't usually um take get insulin therapy to treat their diabetes. Rather it's different medication types with different mechanisms of actions. And these are the five medications that, um, you could, you potentially see a diabetic person taking. And the reason why there's so many different ones is because some people react, di different diuretics, react differently to different medications in terms of side effects. And also in terms of whether or not it lowers their blood sugar well enough or not. And these medications are as follows. So SQ inhibitors, DPP, four inhibitors, softener, nail, urea, thiazolidinediones and Metformin. And one thing I want you to remember is that these medications are not all taken altogether. Patients will either go through um, something called monotherapy, which is one medication or duo therapy, which is two medications or triple the or triple therapy, which is three medications taken all at once. They don't take all and five. So starting off with a flu inhibitors in terms of how you go about remembering a flu inhibitors and with um, all medications LSU two inhibitor medications end with the word floss. So that's something they can use to kind of help you remember? And when it comes to UK related type questions, especially about diabetes as well, we all know that we have to memorize a lot of different medications and when it comes to diabetic questions, they really want you to know um, their mechanism of action too. So what do U two inhibitors do, how they work? How do GPP four inhibitors work? How do soya work? How do the thiazolidinediones work and how does Metformin work as well. So here's like just like a nice brief kind of explanation of how each of them work. So S glu two inhibitors, as I mentioned end of Bross and how they work is they lower blood glucose by blocking the reabsorption of glucose. It's in the name, it works by um inhibiting the S glu two channels which essentially blocks the reabsorption of glucose, which then follows the blood sugar. And like an example of an SP inhibitor is DPA sin. And you can see there and Zosen next, we have DPP four inhibitors. These are also known as Gliptin. The na medications end in the word gliptin. And again, it's in the name how it works. So it's mechanism of mechanism of action. So what it does is it blocks DPP four which destroys incretin, which is an enzyme that helps produce insulin. So how it goes about um lowering blood sugar is it stops the destruction of incretin, which leads to an increased level of incretin, which is what helps make insulin. Therefore, you didn't do it, increase the level of insulin and insulin therefore, lowers the blood sugar. An example of a DPP four inhibitor is SITagliptin and you can see that it ends in gliptin. Next, we're gonna go on to sulfonyl urea and these usually end in Zs very common for patients to be on this as well. And how the mechanism of action of a sulf of a sulfonyl urea is it stimulates pancreatic beta cells to release insulin. And a common example of a sulfonyl urea is gliclazide. Next, we have thiazol lions and these ending zones. And the mechanism of action of those is it decreases insulin resistance. And a common example of the bioz theion is pioglitazone. Lastly, we have Metformin which works by inhibiting hepatic leukogen andis and also opposes the action of glucagon. So here is a nice little diagram that basically sums up the management. So first line, second line and third line management of type two diabetes. And what's the first line therapy for newly diagnosed patients with type two diabetes is Metformin. So, Metformin is the one that inhibits hepatic Leukine agenesis and opposes the action of Metformin that is usually given first to patients. And if you remember in terms of the lifestyle management of diabetes, the regular follow ups with their GP is very important to make sure that that medication is working and also for them to present any questions they have or any of the symptoms or side effects they're experiencing. So with Metformin, one thing to know a common side effect is um lactic acidosis, very rare, but it is common and we could bring up a question like it. So I could mention that patient is a type two diabetic and um they bring in um kind of blood results. So their lactate um levels and if their lactate levels are higher than usual, consider lactic acidosis, especially if it mentions that the medication is Metformin too. So if a patient is taking Metformin, they go through a period of taking that medication, then they'll come in for their regular follow up if it's a case of an unfortunate case of the patient not responding well to their Metformin. So the HBA1C levels above 48 then they'll go on to second line therapy, which is well, they'll take Metformin alongside another medication. So, a DPP four inhibitor. So your SITagliptin or a pioglitazone, your thiazone, Naion, the soy urea, which is Eliz or an S B2 inhibitor, um which is your Dilazin. But with SU two inhibitors, in order for them to be able to take that the M criteria has to be met, which I didn't um input what the MS criteria is. But I'm pretty sure it has to do with the renal function as well as also um any other health complications that the patient has. So again and again, patient will go for a period of take second. Um So dual therapy. So taking two medications. So Metformin and another one of those. And if it's a case of um the um their body not responding well to the jaw therapy, so their HBA1C is still above 48 then we go on to triple therapy. So alongside Metformin and another and let's say a DPP four inhibitor, they'll take another drug listed, but So a pioglitazone, a sulfonylurea or an S B2 inhibitor or they will be considered for an insulin based treatment. Again, the patient will go through with the trip therapy. And if it's a case of their body not responding well to that, then they'll go on to F therapy, which is um where they'll consider switching one of the drugs for G RP. One mimetic GOP. One mimetic is something I forgot to add. So I apologize for that on the previous slide. But G LP one mimetic mimics um GOP one which I believe is a channel that is another channel or enzyme that works to lower blood sugar. And it's usually given to patients with um a high BM I, because one of the um side effects which could be considered a good side effect is weight loss. So it helps um as long as they're bringing down the BM I, which is one of the risk factors of diabetes helps lower the blood sugar as well and or they'll be giving it in too. The one thing to know is G RP mimetics can also be taken with insulin. However, if they, a patient is going to be taking that it needs to be done under specialist care. And one thing I'd like to know is if you look at the um orange box above at the top medication choice depends on an individual's clinical circumstance. So, comorbidities, contraindications and weight and the patient preference too So patient might not want to go on cr third line therapy where it says you add another drug. So three, drugs they're taken, patient might not feel comfortable taking all that medication or it's giving them like a lot of side effects. But on the flip side, it could be a case of, um, so they'll be taking, they'll be given the insulin treatment based treatment instead. But on the flip side, it could be a case of a patient not wanting to inject themselves with insulin. They're like afraid of needles. So they'll prefer to be on those three medications instead. So as I mentioned previously in the type one diabetic diabetic portion decides BP is something that diabetic patients need to keep under control. And this is because patients with diabetes are at much higher risk of microvascular complications. And the nice hypertension guidance sets at the same sets the same BP targets as those who do not have diabetes. And that level is 140/90. So diabetic needs to try and keep their BP below that. Uh about diabetes, diabetes and hypertension do um come to come together as a presentation in a lot of patients. So if it's a case of that, then ace inhibitors are usually first line because they're renoprotective, they're not harmful to the kidneys or um an antiintestinal receptor blocker if a patient has Black African or African Caribbean family origin. So in terms of the complications, I want to kind of highlight further what those complications are. So, in terms of mao vascular compli complications, um I'm talking about congestive heart failure. It's really common for patients with diabetes to present with congestive heart failure too. So that's something um that is a complication of diabetes to keep in mind and also diabetic um cardiomyopathy, which is essentially changes to the myocardium due to diabetes, peripheral artery disease is also another macrovascular complication for diabetics. And that is essentially um damage to the peripheral arteries and that leads to symptoms of like tingling numbness, pain in the feet. And also um one common symptom is having like 1 ft colder than the other. And also another microvascular complication is micro um is cerebrovascular disease. So, in terms of microvascular um complications, we have diabetic retinopathy, which is complication in the eyes due to diabetes, diabetic neuropathy, which is nerve damage that occurs due to diabetes. So, that's um the reason why patients would experience that tingling numbness in their feet and stuff like that mobility issues too, gastrointestinal complications. So, GERD gastroesophageal reflux disease, gastroparesis, which is um kind of where your gut motility stops. Um N AFL D which is nonalcoholic heart and liver disease and enteropathy and also for complications. So, gout is really common in people with diabetes. Um essentially gout is caused by raised uric acid levels and diabetics um are known to have higher uric acid levels than usual due to the fact that the insulin is not working properly. And therefore, that's the kidneys function to um get rid of the uric acid and then lastly sexual dysfunction. So now I'm going to move on to osteoporosis, which is a musculoskeletal condition. An osteoporosis is a um disease that's characterized by the loss of bone density and microarchitectural deterioration, which leads to an increased bone fragility and a consequent increase in fracture risk. And down below here, underneath the um definition is a really, really nice diagram that kind of shows the differences between normal bone and osteoporotic bone. And if you look to the left at the normal bone here, you can see that it's a lot more dense. So we have like just a closer image of the femur. Here, you can see that there's a lot more dense compared to your support bone on the right, which is a lot less dense and looks sort of see through in a sense that represents just the loss of bone density. And essentially. So in terms of signs and symptoms, patients will usually present with back pain, loss of height over time, a suture, pro posture and bone fractures. So the back pain um can be caused by a fracture or collapsed vertebra due to the um decreased bone density. And with the the fracture um occurs a lot more easily than expected in patients with osteoporosis. And one thing you could um find out through a patient history is that they have a lot, patient history and past medical history is that they have had a lot of brain fractures in the past. So that's uh another to sign of osteoporosis. And in the corner here is just a picture of a street poster cos I didn't, when I was um doing my research, I didn't actually know what street posture looked like. So there's a nice little picture for anyone else you can do them. And in terms of the um investigations for um osteoporosis, the Gold Standard investigation is a Dexa scan and the Dexa scan is a dual energy X ray, absorb, absorb geometry. And this picture on the right where you see the woman lying down on this machine, this is a Dexa scan um machine and this is what the procedure looks like. It's completely painless and takes only a couple of minutes. Patient lies down flat quite comfortably with the legs up. And then they have a little, they have these two a beams with different energy levels that are aimed at the patient's bones and essentially soft tissue absorption is subtracted out. And then we can determine the bone mineral density from the absorption of each beam by bent. And what you get from that is at score and at score is measured in standard deviations, hence the negative scores and the positive scores. So what it is is a statistical measure that reflects the difference between your bone density and the average bone density for healthy adults of your sex. So ast score from minus one to plus 2% deviations above the mean is considered normal bone density. Then a score from minus 1 to 2 point minus 2.5 is considered osteopenic, which should not be conceived as confused with osteoporosis. Even though they both are characterized by low bone density. Osteopenia is low bone density but not to the extent and severity of osteoporosis. Then osteoporosis is at score. So sound de minus 2.5 to minus four points away from the mean. So that's quite, it's quite low. So there are other um investigations that are used to investigate osteoporosis but not for diagnosis specifically. So you need to remember that a dexa scan is used specifically to diagnose osteoporosis. These other investigations are used mainly for fractures and also to exclude other diseases and also assess levels of iron, um certain compounds that are relevant to bone density mass. So an X ray could be done for suspected fractures, an MRI of the spine to assess um vaginal fractures, blood tests to exclude metabolic brain diseases and also assess the levels of Vitamin D calcium and also hormone levels which or um are related to bone density. So last thing, last thing I wanna talk about when it comes to investigations is the frax score. So the frax score is the fracture risk assessment to which is used to estimate the 10 year probability of a major osteoporotic fracture. And then it mainly focuses on normal bone density, osteopenia, low bone density and osteoporosis, which is really low bone density. So, a person with normal bone density, the 10 year probability of them experiencing a major osteoporotic fracture is less than 10%. Patient with osteopenia, low bone density has a 10 year probability of the 10 year probability of them experiencing major osteoporotic fracture is between 10 and 20% in the last year. With patients with osteoporosis. The 10 year probability of them experiencing a major osteoporotic fracture is above 20%. So that's a lot higher compared to normal bone density and osteopenia. Hence why people with osteoporosis usually have or have or have had experience um a lot more bear pas than a normal person. Sometimes the management of osteoporosis. It involves both um lifestyle management modifications and also pharmacological treatment. So I'm gonna start off with lifestyle management. So the management of osteoporosis, lot of modifications involves reducing risk factors. So, smoking cessation and also diabetic control. And as I mentioned before, um we want to make when assessing for in the investigations, we were looking at the Vitamin D calcium um levels. We also want to make sure that patients are adequate intake of Vitamin D calcium and protein because these are all associated with um bone density and low levels of these can therefore lead to a decrease in bone density and we don't want a bone density, the bone density of an osteoporotic patient to be any lower than it already is. And also regular weight bearing exercise and also use of hip protectors in nursing home patients. In terms of pharmacological management. The first line um treatment for osteoporosis is bisphosphonates and it's for individuals with a fra fragility fracture and at score of minus 2.5 or lower or if a patient has at score between one and 2.5 with a 10 year probability of a major osteoporotic fracture of 20% or higher, 20% or higher or hip fracture, probability of 3% or higher based on the factor score. So one thing to know um liqui drugs bisphosphonates has some side effects which are really common. And one thing they like to bring up in questions is they'll bring a patient explain that they will, they have osteoporosis. Um After such, after um you've learned about it and you've gotten all this information, you will know that, ok, if they have osteoporosis, they're probably on bisphosphonates and then that patient will probably come in complaining about um specific side effects. And the question will probably ask you, OK. So what drug that the patient is currently taking is causing these side effects? And you should think, OK, bisphosphonates because it causes this and this um side basically highlights the main side effects of bisphosphonates. So, gastrointestinal symptoms. So, dyspepsia esophagitis, um Dyspepsia is essentially upper abdominal pain caused by acid reflux and just pain in the upper abdomen region and discomfort. Esophagitis is um inflammation of esophagus. Also musculoskeletal pain and osteo osteonecrosis, which is loss of blood supply to the bone, leading to death of that bone tissue of the jaw and atypical femoral fractures. However, this is a really, really rare symptom that doesn't usually occur. So, lastly, I'd like to talk about meningitis, which is an infectious disease and meningitis is inflammation of the meninges. And I've got a little picture here that basically helps you visualize the layers of the meninges. So we have the dura mater, which is the outermost layer, then the arachnoid mater, which is the spider webby looking layer and then we have the pia mater, which is the one that's closest to the brain. So, in terms of signs and symptoms of meningitis, the main symptoms are headache, um fever, neck stiffness, photophobia, which is sensitivity to light nausea and vomiting f neurology, seizures and reduced consciousness level and a non blanching tissue rash. The part that's in red is represented by the pictures on the right. And it's I've got two pictures here. So you can see what it looks like in lighter skin and also on darker skin. And if you look closer, you can see that in the top image. Um someone is pressing a glass against the um patient's rash. That's one thing to note with me, the meningitis rash that's quite noticeable. Um If you press a glass against the rash, the rash won't disappear, which is a common um title sign that this patient could have meningitis. And that rash is also a sign of um overwhelming sepsis chill and is indicated when implanting disseminated intravascular coagulation. So, in terms of presentation, the main symptoms that let's say you come across a question and it's talking, if it is talking about meningitis, the main symptoms that they'll probably bring up is neck stiffness, photophobia, photophobia. Um Those are the main two and possibly a non branching tissue rash too. So keep this in mind when it comes to questions because that um should kinda raise bags on your head and suggest me, I just don't. So when it comes to investigations meningitis, um there are tests done to combine diagnosis on. There are some tests that healthcare professionals can do to test for men injury, irritation. So when it comes to testing for meningo irritation, there are two signs that are common in patients with meningitis and that is Koenig sign on the left here and then BRZ sign on the right. So, chronic sign is used to test and evaluate the presence of meningeal mutation and also stiffness in the hamstrings in the lower back. And how the test is performed is the healthcare professional, tell the patient to lie on the back, their hip and knee flexed at 90 degree, which you can see this image and then what the p um healthcare professional was gonna try and do is they're gonna try to attempt to extend that patient's knee. And if the patient experiences pain and resistant to knee flection, then this is considered a positive chronic sign and therefore, is indicative of an irritation or inflammation of the meninges. Then on the right here, we have the Brezinski sign, which is another maneuver which is used to assess a meningeal irritation. And what happens here is the examiner will gently fix the patient's neck forward towards the chest with the patient lying in their back. And if the patient involuntary repair fixes their hips and knees in response to neck infection, it is considered a positive ency sign and therefore indicative of irritation of the meninges too. Now, when it comes to diagnostic investigations for suspected meningitis, these investigations include blood tests. So your full blood count, your urine, electrolytes, clotting screen and glucose profiles and arterial a class and blood cultures and imaging. So, c of the head and the information of the head and obviously, and fluid analysis. And this picture below shows what a part looks like. It's not a very nice procedure and it's actually quite painful. So, um you have um exam, the person who is conducting this procedure will have the patient lie down in the future position and then the um examiner will locate the um lumbar spine and will insert my needle into the spinal canal into um get extract supraspinal fluid and depending on the type of meningitis that it is, the eyes will be different um different presentations within the um kind of analysis. So with bacterial meningitis, one thing to note with the analysis, rubrospinal fluid is that will be um the fluid to be kind of t or it could be clear. Um when investigating it, there will be um low levels of glucose due to the bacteria using it for imaging. Um there'll be high protein levels too. So in terms of management of meningitis, 2 g of IV. So grams of which is an antibiotic is given twice daily to ensure um CNS penetration IV amoxin, which is an antibiotic is also given and it's added in patients that age extreme. So really young or really old listeria coverage and listeria and what there is is a bacteria a and and if it's consumed, it can also cause meningitis. And it's actually quite a common cause of meningitis in babies and in the elderly. So adding imoxin helps um cover for that just in case that is the cause of the meningitis here. And as I mentioned previously, if there is a case of suspected bi encephalitis, which is brain inflammation. IV atico gram should also be um administered too. And Ive Amoxidin obviously contains penicillin and if patients are allergic to penicillin, um then Chlo chloramphenicol is administered instead um as opposed to Amoxil and to prevent um allergic reactions. So that brings us to the end of this presentation. Thank you so much for listening. I hope you find it really informative and helpful when it comes to revision, revision. And um I hope to see you at the next. Uh OK. Yes. OK. Um I'm back. Can anybody hear me? Right? OK. OK. Uh Can somebody put in the chat if they can hear me so I can um answer questions and do some experience? Thank you. No. Yeah, so you, you can hear me. Is that I hope so. OK. So, um, on some of the questions, obviously, this is targeted at sort of medical students level. Um So we're talking first to fifth year. So it's very basic. So the questions are a advance um for the majority of audience, but I have a few answers to the first two diabetes. One, the last one is quite complex. So the last question, I think just doing some thorough reading independently as I definitely think that's a consultant level decision whether or not you'd be using um denosumab instead of a bisphosphonate for somebody with D and who is, you know, has BMI 15 postmenopausal anemic Saric with osteoarthritis. So there's a of different factors involved. I'm sure that'll be somebody who'd be referred to an MDT meeting. Um And extensive discussions would be had, I don't unfortunately have your answers for the, um, osteoporosis um, question, but for question one, uh in insulin-dependent type one, diabetic fluid overloaded patients with systolic heart failure, with reduced left ventricular in fraction of less than 35% with SG uh S GT inhibitors uh be contraindicated due to euglycemic ketoacidotic risk. And would the hyperglycemic effects of cco butter or valsartan help in such a patient? Um So I think it depends because obviously um in insulin dependent type one diabetic patients with fluid load and systolic heart failure. UK guidelines generally caution against using an SGLT two inhibitor due to the potential risk of lym ketoacidosis. So generally, that's told with the guidelines, don't really say yes to it. However, if you're considering the individual patients risk factors and you're taking other considerations into it, um it could possibly be used but pretty much probably not. Um Additionally, regarding serol and valsartan, um its primary role is in heart failure with reduced ejection fraction. Um But however, it doesn't necessarily have a direct glycemic control effect like that's not its intended purpose. Um And because it's not, it's intended purpose to address um the diabetes, um there'll be s you know, and it's not there to um to um help a child from the keto otosis. I don't think um you would be giving uh serol Vassar specifically for glycemic control in these patients. Um Next question. So, what could be the therapeutic antiinflammatory effects of Glucagon like peptide one receptor agonists on COVID-19 induced pulmonary arterial hypertension, including non diver patients. So, I don't think there's a wealth of literature currently on that topic. Um So, while there are some potential mechanisms suggesting a therapeutic role for GLP One ra S, it's important to know that research on the specific effects in the context of COVID-19 induced pulmonary arterial hypertension is evolving and there's no clear guidelines um supporting its use yet. Um However, there's a wealth of evidence to support its antiinflammatory effects from the inhibition of inflammatory pathways to vasodilatory effects to endothelial function improvement, reduce reduction of oxidative stress and modulation of immune response. Um However, um I don't think there's sufficient evidence for that yet. Um ok, I forgot another question. Sorry if it doesn't. Um I'm just gonna present the last um section which is some S pa S um on the topic. So I'm just gonna share a tab. Ok, SBA time. Ok. So um a 55 year old patient presents to the clinic with excessive thirst, frequent urination and unexplained weight loss. On examination, the patient has a body mass index of 30 kg per meter squared. Random blood glucose levels are measured revealing 23 millimoles per liter. Considering the symptoms and investigations, what is the most likely diagnosis? Ok. Actually, I will look in the chart. So is it type one diabetes or se reation diabetes, bladder type two diabetes or MODY like a pulse? Can I do a pulse? Maybe not? Ok. So reveal the answer. Uh type two diabetes. The reason for this is, you're thinking type two because of the age you're presenting at 55 years old. Um, that wouldn't be, um, type one diabetes cause usually they, um, present a bit earlier. Um, it's not gestational diabetes because it has no link. There's no information here that it's, uh, um, somebody who's going through pregnancy. Um, it probably wouldn't be maturity onset diabetes young because also the age is 55 years old. Um, but it could be a ladder, but there's no other history of any autoimmune conditions in the stem. So you're thinking more type two diabetes. Um And then obviously, the random blood glucose levels is 23 which is really high. Um And they have, they're symptomatic as well, excessive thirst, frequent urination and unexplained weight loss. Um, something for ay, um, that comes up commonly is the stam won't give you all these symptoms. It will just usually be and fatigue or tired all the time and that's all they'll come in with. And then you have to think of type two diabetes as a possible differential and obviously the patient factor so they may look fit and healthy, but they might have some other um, predisposing factors um that you need to ask in the history, for example, what their BMI you know, factors like that. What's their diet like exercise like? Um So on next, a 65 year old female patient sent to her general practitioner with a history of gradual height loss back pain and a recent wrist fracture. After a minor fall, she reports no significant trauma but mentions a family history of fractures in her parents. On examination, there is a notable loss of height and a rounded chop posture. Considering the clinical presentation which of the following investigations is most diagnostic. So either serum calcium and phosphorus levels, magnesium, re so, MRI of the spine dexa scan, CBC um um bone scan with technetium 99 M, you can put it in the chat or I can review the answer. OK. Nothing in the charts are just revealed because of time. Uh you probably do a Dexa scan. Uh Dexa scans are first line um in patients who present with a clear osteoporotic picture. Um as she does here and last question, a 24 year old patient presents to the emergency department in the UK with the sudden onset severe headache, photophobia and neck stiffness on examination. There is a positive Brodsky S sign and chronic sign. The patient appears acutely ill with a fetal 39.5 °C. Which of the following investigations is the most like diagnostic for the system condition. Chest X ray echo LP with um CSF analysis, ABDO ultrasound or blood culture. Um So this one is specifically for the most diagnostic for this condition. So the answer is um LP with the CSF analysis. The reason is we're suspecting it could be meningitis, it could be encephalitis but probably meningitis. Um and to rule that out just to rule in different types of meningitis caused by different like organisms and you would most likely do a lump puncture and then analyze the CSF. Um But even if you, as soon as you suspect that you probably then want to um kind of think about management with um IV cefTRIAXone. Um If you're expecting it to be meningitis, uh thank you very much. So, the presentation was by Yasmin Mana and the um SBA section was by me. I hope I answer all your questions are quite difficult questions. Um Here's a QR code to our, um, the ACMS sort of where you can kind of follow us and see what we're doing. Uh Thank you very much and that's the end of the presentation. OK?