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Hello, everyone. Uh give us a few minutes just so we'll let people come in. I'll be with you shortly. Hello, welcome everyone. I think we'll, we'll give it a start. Um Welcome to Crash Course finals. Uh This is the, this week sessions on, on SK S TBA S for medical finals. So if you're joining us for the first time, welcome. Um We're group of final medical year students. Um and we sort of just started this series for um students and, you know, studying for the finals just to help um adjunct their studying. Cool. So we'll get to it. So that's who we are and what we do. So we're planning on sort of continuing this series all throughout the year and we'll have different systems delivered by doctors. So typically we get the doctors who have worked in um whatever wards they have or specialties. So they have a bit more of a practic clinical experience. Um You know, so if you're interested in enhancing your portfolio um and going with this, you can use this QR code, fill out a form and, and be, be a master for crash course finals. It's a very low effort job. All you have to do is just kind of share the posts and events that we have. Yeah, that's sort of, that's on Instagram. And yeah, so if you've not been here before this, how we run the sessions that we've got three sections, six easy questions, six medium questions and six hard questions and how we'll do it is that we'll read out the question and the stem a poll will pop up and you have time to answer the poll. Uh It can be quite annoying with the polls cos they kind of go across the screen. But if you click answer later and come back to it, that seems to work quite well. Ok. So just some general house house rules just be respectful. Any questions you guys have put in the chat, we'll we'll answer at the end of each round and I think we should just crack on, go round one. OK. So starting off with the first question. So question number one, a 69 year old man presents at the clinic with complaints of bone pain and fatigue for the last one year. He also has gradually become hard of hearing. Examination reveals bossing of the skull, X ray of the skull shows marked thickening of the vault with mixed lytic and sclerotic lesions. What is the most likely laboratory finding in this patient? Is it raised serum parathyroid, raised serum calcium, raised serum phosphate or isolated APR and we'll just give you around like 30 seconds to answer that. Yeah, today as well, the polls are completely anonymized. So even if you don't really know the answer, just give it a go. Thank you. No. OK. We'll just get a couple more seconds and get a bit more answers in and then we'll go over the answer. Ok. So it looks like quite split on that one from the answer polls. So the most likely laboratory finding in this patient would be an isolated AP rise. So just going over, this is a question testing on Paget's disease. So Paget's disease is increased, uncontrolled bone turnover. So it's when the it's a disorder of the osteoclasts that are working excessively, the classical finding in an exam will normally be an older man who attends with bone pain and he has an isolated Apr. So the the bindings we listed below. So the reason why it's isolated in this case is because the calcium and phosphate are typically normal. He may have hypercalcemia if he's had prolonged immobilization and his parathyr parathyroid hormone will typically be normal as well. In terms of management for this disease, there's certain indications for treatment which we've listed on the slides such as bone pain, deformities, fractures and the management for this disease is typically bisphosphonates and it used to be calcitonin. It's less commonly used now. So it's normally bisphosphonates if you get a question on this in the exam. So moving on to the next question. So, question number two, a 45 year old female presents the emergency department with sudden onset, severe lower back pain, radiating to her buttocks and bilateral lower limbs. She reports urinary retention, pineal numbness and difficulty initiating maturation. On examination. There's decreased sensation in the saddle area. Bilateral, lower extremity, weakness and absent ankle reflexes. What is the most appropriate management? Is it a electrosurgical repair b high dose corticosteroids, c, urgent referral for surgical decompression or D nsaids. So again, we'll give everyone around 30 seconds and we do encourage everyone to answer it's completely anonymous. So have a go and to see. Ok. Ok. We'll just give everyone a couple more seconds. It looks like most people have answers. Ok. So the answer is c which looks like the majority of you got. So this is a case of ca equina syndrome. So this is compression of the lumbo sacral nerve roots that extend below the spinal cord. There's many causes for this. But the most common is a, a central disc prolapse which typically occurs at L4 and L5 or L5 and L1. There are different causes. You can get such as an infection like a discitis or an abscess trauma or tumors even. But the most common is a disc prolapse. In terms of the presentation for this. It's important to recognize this early as it's an emergency. So the presentation will typically be lower back pain the bilateral sciatica, the reduced sensations in the saddle area and the decreased anal tone and maybe some urinary dysfunction. The investigation for this in an exam would be an urgent MRI would be first line and the management would be surgical decompression. So we're moving on to the next question and just to remind everyone if you have any questions, do pop them in the chat and we'll get round to them at the end of each round. Ok. Next question, question three. So a 50 year old female presents with a six month history of a numbness and tingling in her thumb, index and middle fingers. She reports that symptoms are worse at night and are relieved by shaking her hand on examination. There is a sensory loss in the palmar aspect of the thumb, index and middle fingers. Considering the most likely diagnosis. What's the most appropriate initial treatment? Maybe the pulse just come up. OK. Just a few more seconds for people just to answer. Ok. Right. So most of you, 55% of you picked corticosteroid injection, which is the correct answer. So this question was testing your knowledge on uh being able to correctly identify the symptoms of carpal tunnel syndrome. So, carpal tunnel syndrome is compression of the medial nerve within the carpal tunnel. It's a very common um condition that's seen. Uh typically the exam question that will typically say um sort of middle aged male or female that works as more like secretarial jobs that are typing o on like keyboards, mainly that's the kind of giveaway in, in exams. But the symptoms that you get um is because of the is because of the sort of inflammation of the sheath and that compresses the car, the median nerve. So the symptoms that in that sort of it presents with is pain, pins and needles and, and the normal distribution of the median nerve would, which would be the thumb, index and middle fingers, often they sort of shake their hand to sort of relieve some of those symptoms. And that is also a classic sign that they can say in, in sort of exam style settings. Um Some of the further signs that you can get so anything to do with the medium nerve, uh weakness of thumb, abduction, wasting of the thenar muscles. Tel sign is a, is again, is a very common thing that you should do. Um an exam that you should do during your osc. If you suspect carpal tunnel syndrome, I've got a slide on it coming up just to briefly explain what it is as well as found signs of the, the two tests that you can ascertain carpal tunnel syndrome. Ok. So the different causes of carpal tunnel syndrome, mainly, like I said, it, it can be idiopathic or it could be just mechanical but funnily enough. Pregnant women. Um also present with a high percentage of the carpal tunnel weight as well as heart failure, fractures and rheumatoid arthritis. The management of it is, it always starts conservative. So, corticosteroid injections, nsaids and physiotherapy would be sort of the first line treatments and if that doesn't work and it still persists, that's when you would either, um, decompress it and, yeah, moving on. So that's Tinel test. It just involves sort of tapping on the wrist, um, right over the median flexor rein retinolum um for about 30 seconds to a minute. And yeah, and you get signs of pins and needles and balance test as well. Sort of, I'm sure you've all seen it. OK. Moving on. Question four, a 65 year old female presents to GP practice with chronic knee pain and stiffness, particularly worse after periods of inactivity. She reports crepitus and limited range of motion in her affected knee on examination there, bony enlargement and tenderness over the joint margins. X-ray confirms joint space, narrowing and osteophyte formation. What is the, what is the first line management option for this patient? Cool Paul. So just come up, give you some time to think about that. OK. Just a few more seconds. OK. Right. So, so this is a good, this is a good split of um answers. So it's pretty close between oral nsaids and topical NSAID S. So the correct answer is topical NSAID S. That's the first line management of someone with o with osteo arthritis. So according to nice, all patients should be offered with weight loss if they need it. Um, as well as physiotherapy sort of regime, a regime to work on by themselves at home to strengthen the muscles. First line is always the most conservative. So paracetamol and topical NSAID is always first line. Um, and if that doesn't help with pain, that's when you sort of escalate up the ladder to oral nsaids and cox two inhibitors. Ok. And joint replacement obviously comes at a later stage. It will be indicated um depending on the severity of the OA but, but yeah, the first line management is again top of lenses. Great question five. OK. Cool. Um Question five is a 55 year old female presented with severe shoulder pain and limited range of motion. She reports gradual onset of symptoms over the past few weeks on examination, external rotation is notably restricted compared to internal rotation and abduction. Imaging studies are conclusive. Despite oral medical management, the patient's symptoms persist, which of the following interventions is the most appropriate next step in management. OK. And then the pos just up. So it's on the f hopefully straightforward question. Um try to come up with the diagnosis and then think about the management. OK. Just give it a few more seconds. I see. Yeah. And I think, yeah, we can move on to the next slide. So yeah, the the question clearly stated that um they've tried oral medical management so that clearly excludes um initiation of oral corticosteroids as well as NSAIDS. Um So I think from there you can infer what, what the next um next line of management would be, which will be a trial of intraarticular corticosteroid injections. And if you don't already know um the classical symptoms of the frozen shoulder, there's limited external rotation and limited abduction. So, yeah, in this case, you're most likely thinking of frozen shoulder as a diagnosis and when it comes to the management aspect, um initially, you'd start off with oral corticosteroids and oral nsaids and then you move on to intraarticular corticosteroid injections. And if that doesn't work, then you will consider a referral for like some sort of surgical intervention. But yeah, like try to try to read the question properly in terms of um coming up with the right answer. Um Yeah. So let's move on to the next slide. So the next question is a 70 year old woman with rheumatoid arthritis has been prescribed prednisoLONE 10 mg daily for the past four months to manage her symptoms. She has a history of previous fragility fractures despite her age and fragility fractures, she expresses concerns about starting new medications due to past adverse drug reactions. So what is the most appropriate next step in managing a risk of Glucocorticoid induced osteoporosis on the pool should be up. Yeah. So option A offer a bone density scan B, initiate an of therapy. C start iron therapy or D repeat bone density scan in 1 to 3 years. Yeah. No, let me just give you a few more seconds. OK. Ok. Fine. Let's move on to the next page. So yeah, the majority of you have gone for option C So in her case, she's taking a fairly high dose of steroid. Um And if you're above 70 if you're taking a high dose of steroid or if you have previous fragility fractures, you should be offered bone protection. Um These guidelines are formed by the National Osteoporosis Guideline Group. Um I've put the guideline there on the slide itself. Um So yeah, I think the first thing to do in her case would be to immediately start bisphosphonate treatment, um especially start off with oral medications such as alendronate. And then if she can't tolerate bisphosphonates or if she has some sort of reaction to it, then you'd consider initiating denosumab therapy. Um But in her case, we won't be offering a bone density scan just yet. Um Just because like she fits the criteria in terms of uh managing her with bisphosphates because she could get Glucocorticoid induced osteoporosis. Um Yeah. So cool. Let's move on to, I think this time we'll, I don't know if anyone has any questions, you can just type it in the chart. Um a couple more before we move on to the next round. So yeah, just like Brian said, if anyone has any more questions, feel free to pop them in. But if not, we'll just move on to the next question. Ok. So question one of the second round of medium questions. So a 27 year old male presents with chronic lower back pain and stiffness for the past six months. He reports that the pain improves with activity but worsens at rest, especially during the early morning hours. He also complains of decreased flexibility in his spine and hip joints. There's no history of prior trauma, physical examination rules, lumbar spine, mobility, limited lumbar spine mobility with tenderness over his sacroiliac joints, chest expansions decreased laboratory investigations show elevated inflammatory markers. And HLA B 27 is positive. What is the most appropriate management? Is it infliximab like se unsure how to say that cl antibody nsaids or intraarticular steroid injections. We'll just give everyone a few more seconds and then we'll move on. Ok. Ok. So the answer is see the majority of you did get that. So this is a case of ankylosing Bondi. So the HLA B 27 is a clue for that because the majority of patients will have that. And the fact he's a young male in his twenties, he's gradually developed symptoms. He has no history of trauma is also key to the question and his pain and stiffness in his lower back. That's worse with mo improves with movement and worse with breast is also a key point. The investigations we put up that you do for this. So you would have the inflammatory markers raised it. HLA B 27 genetic testing. The classical thing in the exam might mention on an X ray is a bamboo spine. The Mr you can also do an MRI of the spine which can show bone marrow edema early in the disease. And the management for this first line is always nsaids. Second line, you can move on to the anti TNF medications. Then third line, you can move on to that monoclonal antibodies. And you could also consider interarticular steroids for the specific joints. But the main thing is that the first line is always nsaids in this, moving on to the second question. So a 45 year old male presents to the emergency department with sudden onset severe pain and inability to wear, bear on his right foot while playing tennis. His past medical history includes a recent urinary tract infection which was treated with ciprofloxacin. Considering the most likely diagnosis. What is the most appropriate investigation? Is it A X ray of the ankle B, ultrasound, ankle C MRI ankle or D, no best indication required. It's a clinical diagnosis. So again, we'll give everyone a few seconds to answer that. So it looks like majority of answers. So this one was quite split this question, but most did get b so it is B ultrasound of the ankle. So this is in a case of achilles tendon rupture and the key that gives it away in this question is normally, it will say that they hear a pop in the ankle or a sudden onset pain. It's normally when they're playing sports as well. And in this question, another key point is that Cipro skin is a risk factor for achilles tendon rupture or any achilles tendon disorder. And when you're investigating this, it's important to use. So the Thompson test is included or the semon test, it can be called both the se triad. So it's palpation of the tendon, examine the angle of decline and the calf squeeze test, which was shown a picture here and what a positive test is indicated when there's no plantar flexion of the foot. So the imaging of choice for a tendon rupture is always ultrasound of the ankle. The management of this is always that you refer to orthopedics. On the same day, the non surgical management is that you can immobilize the ankle through a boot is commonly used. And the surgical management is it will surgically reattach the achilles tendon and then immobilize it normally with a boot after. So this actually came up in our exam last year when we sat the Emmi. So I think it's quite a common question and we request on management and things. So I think knowing this is quite key. So moving on to the next one. OK. So next question, 34. No, sorry, a 14 year old male pa patient presents to the ed after falling off his bicycle complaints of severe pain and swelling in his left wrist. On examination. There is a, there is swelling, overlying the ulnar aspect of the hand x-rays carried out and it's shown below. So, what is the most likely diagnosis? So this is quite a tricky question question. Take your time to sort of look where the fracture is and, and what kind of fracture you think is? Um, give you guys a little bit longer for this question just because it's harder. The That's OK. See. Right. A little bit. OK. Hopefully that helps. I'm sorry, that was a mistake. OK. Cool. Right. And so the answer, this is a difficult question. Um is a type three Salter Harris fracture. Um just to bring it back, sorry with to the X ray, it's on a distal f there you go. And it's quite a difficult one to, I don't think, I don't think this is that high yield for exams, but we have seen it been asked before. So just a rough guide Salta Harris a way to sort of remember it is s for straight across a for above the fracture site. L for lower te through everything and R for rush. Ok. Right. Question. 4, 50 year old male presents to the emergency department for sudden onset severe pain and swelling in his left big toe. He reports a history of occasional similar episodes over the past few years on examination. The affected joint is erythemic warm to the touch and extremely tender. The lab investigations reveal an elevated serum uric acid levels and he has a past medical history of hypertension and peptic ulcer disease. Given the most likely diagnosis. What is the most appropriate initial management? Ok. We'll just give you guys a few more seconds. So it is it a NSAID B Allopurinol C corticosteroid injection or D called G? Ok. Well done. So most of you picked D colchicin. Um So this question again was testing um you guys about the being able to recognize gout and an acute flare. So there's a few people that pick nsaids al and Allopurinol mainly. Um And, and why you guys would pick Calpol purinol and NSAID S as well. And allopurinol and Nsaids do have their own sort of um role in the management of gout. But the first line treatment for an acute flare is colchicine and nudes. Um So it's important because um to co prescribe PPIs for those taking an NSAID S and I think I mentioned in the stem is that he's got a history of peptic ulcer disease. That's why NSAID S would not be indicated for this patient. Um So allopurinol has its own role, but it tends to be more of a chronic management of gout and we'll come on to that as well. OK. So just over on the left side. So, allopurinol works by, by inhibit inhibiting the enzyme xanthine oxidase which prevents the breakdown um of sort of DNA um and preventing the formation of uric acid which, which is in what causes gout. Um So, and another sort of good point to mention for exams is that the crystals that form, it's a common question that they get asked. So gout versus pseudo gout. So it's always important to know that gout crystals are needle shaped and um negatively bent under um light microscopy and pseudo gout has sort of rhomboid shaped crystals under a microscope. OK. Right. OK. Um Moving on to the next question. A 65 year old man presents with chronic low lower back pain and bilateral leg pain that worsens with standing and walking. He describes relief of symptoms when sitting or walking uphill on physical examination. He demonstrates limited lumbar spine extension and exhibits signs of neurogenic claudication. MRI imaging reveals significant narrowing of the lumbar spinal canal. Um So it says conservative measures including physical therapy and ICS have been attempted without significant improvement. So, what is the most appropriate next step in managing this patient's condition and then start off with the point. So this is option A, initiate nsaids, option B, start gabapentin, option C give some s epidural steroid injections and option B refer for laminectomy. OK. No, OK. We'll just give everyone a few more seconds. Yeah, we can just move on to the club. So, yeah, this is a case of lumbar spinal stenosis which uh pretty much is characterized by the narrowing of the spinal canal. Um So initially for this condition, you start off with conservative management. Um for example, nsaids and um and just, yeah, ask them to rest. Um just to, you know, just, just to focus on the conservative treatment. Then afterwards, uh you can move on to more serious stuff like surgery, which in this case is laminectomy. Um The other options uh could potentially temporarily relieve the pain, but it's not the final mainstay treatment for this condition. So yeah, and and the know is just, I've just put a screen off the nice guy about lumber miles to know it was just um where it says the mainstay treatment is primarily laminectomy or ligament ectomy. Um And at times spinal fusion surgery can form as well. Um Yeah, so let's move on to the next slide. So to year old professional football player for to the emergency department with acute wrist pain following a fall during a game on examination, there is tenderness over the inatal stuff box and pain is elicited upon telescoping of the thumb initial and subsequently on radiographs of the rest show no obvious fracture. So which of the following imaging modalities is definitive for further evaluation of suspected factor in this patient. So, yeah, the P is just up. So try to think of of what fractured he's experiencing and then um and try to think of what investigations you could use to to come up with a definitive diagnosis OK, just give everyone a few more seconds. OK. Yeah, let's move on to the next slide. So yeah, this is a case of um escape fracture. Just one of the main reasons being is complaining of tenderness over the anatomy of staff box. Um So in terms of definitive investigation or definitive imaging, MRI S is the mainstay of um investigations like I know CT scans are more convenient in terms of um how quick you can get the results. But um in terms of, I think sensitivity and specificity specificity, um MRI scans are more accurate um ultrasound, you can't really see much um in terms of fractures and dexa scans mainly uh focused on bone density. So that doesn't give an accurate, accurate picture of, of um fractures. So yeah, MRI is, is, is the best answer for this case. And yeah, the resource you here is from teaching me surgery. If anyone wants to refer back to it later on, that's why I want your leg slide. So yeah, we'll just give everyone a few more minutes. Um If they want to type any questions in the chat and then we can move on to the last and final round. It doesn't look like there's any questions so far. So we'll try and get on to the next round. So moving on to the hard round question one, a 62 year old male smoker presents with a history of progressive bilateral claudication in his buttocks and thighs worsening, erectile dysfunction and absent femoral pulses. Physical examination reveals decreased and femoral and absent distal pulses bilaterally with normal BP in the upper extremities. He's atrophy of the leg muscles. What is the most likely diagnosis is that the A Popliteal artery entrapment syndrome? B, Berger's disease C Le syndrome or D aortic iliac occlusive disease. So we'll just give everyone a few more seconds to answer that type one. Ok. So we'll just move on to the next round, next side. So this is a, this is a hard one. So this did come up in our pass for studying probably not as much as some of the other things like A s, but it did come up a bit and there was a triad that was good to get to know with it. So this is the syndrome which is an atheromatous disease involving the iliac vessels. So it leads to occlusion of the aorta and or the both iliac arteries, which means your blood flow to the pelvic vessel is compromised. So it typically presents with a triad. That's good to know for exams. It is one claudication of the buttocks and thighs. The second part is atrophy of the leg muscles and three is impotence, which is why he had the erectile dysfunction. And it's not the other one because firstly, the popal artery entrapment syndrome usually does present with calf calf claudication, but it primarily affects younger people who are active less likely in someone older that's got the bilateral claudication and absent pulses. It's not be the Buerger's disease because that primarily affects smaller arteries and is strongly associated with smoking. For exam questions. It can present with claudication but it usually presents with ischemia and d they, it's not the or iliac occlusive disease because it is closely related. But usually the triad is more commonly the recent exams. The investigation for this is usually angiography and it's usually also treated with endovascular angiography and stent insertion. But I think the main point for this would probably be the presentation to get to know moving on to the next question. So two, a 72 year old female presents with a new onset headache, scalp tenderness and jaw claudication. She reports fatigue and unintentional weight loss. Over the past three weeks. On examination, there is swelling and tenderness over the temporal arteries with absent temporal pulses. She reports some visual loss and fundoscopy reveals a swollen pale disc and blurred margins. What's the most appropriate initial step for this patient? Is it giving IV prednisoLONE high dose pred IV methylprednisone, sorry, high dose prednisoLONE or doing a temporary biopsy or giving bisphosphates. Again, we'll give around 30 seconds to answer this question. It so give a few more seconds and yeah, try and answer as many as you can. It's completely ominous anon. So we'll give you a few more seconds. Yeah. So we'll move on to the answer. Sites. So from the chat, it looks like most people said b with a lot also saying A as well. So this one can be one that catches you out. So this is temporal arthritis or called giant cell arthritis. And it's a vasculitis that affects, it's not got a known cause and it affects medium and large size vessel archies. It's usually in questions, occurs in fifties but it peaks in the seventies. The presentation is normally someone that presents with a rapid onset headache, jaw claudication, a ta tender, palpable tender art temporal artery and there's also a huge overlap with polymyalgia, rheumatica in question. So it's good to know that. So they'll also maybe present with aching, morning stiffness in their proximal limb muscles, et cetera. So, investigation wise, you would normally have raised inflammatory markers. The main day of investigation for this is a temporal artery biopsy. It can show skipped lesions though. So sometimes a temporal artery biopsy can be clear because it's just not taken a biopsy. The specific area that's affected your creatinine kinase and E MG are normal, which is also key to differentiate between other conditions and your vision testing is really important. So, in terms of the management for this, the initial step wouldn't be to do the temporary biopsy because you always give the steroids before the biopsy. If you suspect this and the urgent, you normally do if there's no visual loss, give the high dose prednisoLONE. However, it did say that this patient's experiencing visual loss. So you'd give IV methylprednisolone before you start the high dose prednisoLONE, you also need to do an urgent ophthalmology review due to the risk of uh any permanent visual loss. And a key. Also in this question, it used to note for exams is that you should reconsider this diagnosis if there's not a dramatic response when you give the steroids. OK. Hope that makes sense. So, moving on to the next question. OK. So a 34 year old male patient presents with a recur with recurrent oral ulcers and painful erythema. No, do some light lesions on his lower extremities. He also reports experiencing genital ulcers and episodes of blurred vision and pain in his left eye. The patients symptoms have been reoccurring over the past two years. What is the most likely diagnosis? Is it asl eb Bet syndrome, C Crohn's disease or D rheumatoid arthritis? So support should be up. Um take your time to answer and think about what this question might be asking and eliminate sort of um answers that you might think isn't right. OK. So we'll just give you a few more seconds to answer and then move on. OK. Just gonna move on. So good. So most of you pick Bett Syndrome, which is the correct answer. So Bett Syndrome, if you don't know before, it's a multisystemic inflammatory disorder, it's quite rare and causes blood vessel inflammation throughout the body So there is a triad for exam purposes that's quite important to remember. So it would be oral ulcers, genital ulcers and anterior uveitis. So the the trick for this question that, ok, so the, so the patient reports blurred vision and pain in the left eye, that's, that's something that you have to recognize is likely to be anterior uveitis. The rest of them are, the rest of the signs are pretty self-explanatory. Um sl E yes, some, some of the, some of the symptoms do overlap, but it's more of the trial that we're going for here. The trying to agree that. Ok. Right. Question. 4, 71 year old female presents to the emergency department following a fall at home. She presents with left hip pain and a limp x-ray reveals a subtrochanteric fracture of the left hip. What is the most important management? What is the most appropriate management? Is it a intramedullary device? B dynamic Hip screw C Hemiarthroplasty or D Total Arthroplasty? OK. Just a few more seconds for people to answer. Give it a go. And if you don't know, just guess. Yeah. Good. Right. Cool. Let's move on to the answer. OK. So correct answer is a, so most of you picked a which is the correct answer. So this patient has a subtrochanteric fracture and there's a picture over here. OK. So if you have a look here on this slide, um sub subtrochanteric fractures are fractures of the femur that don't include the neck of the femur. So the most common questions you get or um but yes or the most common questions you'd see in past me is the sort of intracapsular or extracapsular hip fractures. But we're looking at sort of the shaft of the fe femur. So sub and that's, there's the rough area there and it's fractures in, in this region that patients with um these kind of fractures don't qualify for um hemiarthroplasties or arthroplasties. Um But a bit about sort of hip fractures, like I said, the most common hip fractures are intracapsular or extracapsular. And depending on, depending on the patients how well they are, preinjury determines what their uh management is. So for patients that are fit and well and um quite active if they fall, break their hip, your go to would be the total um arthroplasty just because they, they'll be able to go back to that sort of level of activeness. Whereas patients that are a bit more premorbid, have more past medical history and immobilized on a Zimmer, they will qualify for a hemiarthroplasty. And I just wanted to bring um this point up on sort of fractures that are a reverse oblique. Um because II si saw in past med when I was a, when I was in fourth year and did my finals and I never really understood why the management of reverse oblique fractures are different to any of the other ones. So if you look at it, reverse oblique fractures, don't follow the common sort of fracture lines that we see. So because of that the mechanism of injury, um they need to be stabilized differently and how that works is that there's what we call a nail, intramedullary, intramedullary nail that stabilizes the fracture this way. Hope that clears it up because that's a topic that I was quite unsure of when I was in fourth year. Ok. Question five, almost there. OK. Um So yeah, question five, a 42 year old man presents to the emergency department after sustaining an ankle injury while playing basketball, he describes twisting his ankle using a jump and immediately experiencing significant pain and swelling. On examination. There is tenderness over the lateral malleolus and he is unable to bear weight on the affected ankle. So based on the X ray findings, who is the most likely type of Weber ankle fracture in this patient. So there's option a Weber, sorry, option, a Weber, a option B Weber B, option C Weber C, an option D ma nerve fracture. Um be the pools just up. OK. So we'll give everyone a few more seconds. This is completely anonymous. OK. 29 responses so far. Just a few more seconds. Ok. Let's move on to the next slide. So yeah. Um the most likely diagnosis in this case is um a type B Weber fracture. Um So here the way that the classification system of Weber fractures work is based on um where the fracture is on the fibula and the level of the syndesmosis. Um So if you look at the image on the bottom, left hand side, um you can see the yellow thing over there. So that's the syndesmosis or the fibrous joint. And you can see in Weber A it below the level of syndesmosis. So that's type A and if you look at Weber B, it's on the same level of the syndesmosis. Um And then if you look at Weber C, it's above the level of the syndesmosis. Um So amazing of fracture, interestingly is um a type of Weber C fractures. So pretty much if, if this ever, if this option ever comes up in your exams, um Just think of it as a Weber type C fracture. So, yeah, nice. Um Most of you guys mo um the majority of you guys got whatever be right, which is good. Um Also, it's worth noting that um you, you might want to look up the management of options for, for these type of Weber fractures just in case because I feel like sometimes the MLA questions are, are kind of rogue. So just, just to be aware of, I couldn't find a good resource for, for the management fractures, for these type of um fractures. So it's just maybe even in your own times, you have the time to do some extra reading, just, just just look into it. A little bit. Um Let's move on to the next slide. Ok. So a 50 year old woman presents to her rheumatologist with complaints of symmetrical proximal muscle weakness. She reports experiencing difficulty swallowing and a dry scaly rash in her hands on examination. She has a rash in her in the periorbital region, papules over the extensor surface of her fingers and nail full capillary dilatation. So, laboratory investigations reveal a positive anti antibody antibody test. Um So what is the most likely diagnosis for this patient's presentation? I'll just put the pole up. Um Yeah, if anyone's brave enough in the chart, I don't know if you can type the, the names of these rashes. Um If you know what the periorbital rash is called and if what the extensor surfaces of the rash on the extensive of, of the fingers are cold. Um It's a fairly common thing in the ma exams to test antibodies. Um So yeah, just be aware of such facts. Yeah, excellent. Um I think someone's typed in the chart but he is so rash and got on the nice good one. OK. Just give me a few more seconds, almost done. I'll, I'll put the feedback um and do a chat as well if anyone wants to head off early. Um Yes, you, you will get access to the slides if you provide feedback. Um So yeah, let's move on to the next slide and the answer is dermatomyositis. Um So I've put a nice table out there um for you guys to look at in terms of what antibodies are associated with which um condition. So if you look at the image below that, that's a classical presentation of dermatomyositis. Um So you can see the heal rash as well as the guts papules on the image. Um It's worth to look into the images of these conditions as well just because sometimes I feel like the ea exams, they will just show you the image without showing much in, in the questions then and they'll ask you to maybe probably guess the antibody or or what the diagnosis is. So yeah, I think I won't go over the table. Um I, you guys can see it over there. Um But yeah, just to rule of thumb, try to remember the antibodies involved and try to look at the images um of of the conditions involved as well. That's pretty important. But yeah, well done everyone for, for making it through for a complete hour on teaching. OK. So thank you so much again for coming. And we just wanted to pop a quick QR for this is for survey. It's for mainly like 4th and 5th year patients in Scotland to complete. It's a audit. We're running on rural placements versus tertiary hospital placement. So it will only take five minutes. It would be really useful if you could complete that. And then moving on again, if you've got any questions just pop in the chat. We'll stay around for another five minutes or so and answer anything. And this is just where to find us again on Instagram. That's her email address, that's her QR code that can scan all the social media just to stay updated with when the next sessions are and talking about next session. So the next one is on GI S it's a GI SBA session on Tuesday, the 23rd of April. So a week from today and it's 7 to 8 p.m. again and that's just the QR code for it. So again, thank you so much for coming along and let us know if you have any questions and we've also popped in the chat, the link for the feedback. And for those who fill out the feedback form, you will have access to the slides after as well and also the video of this session. So please do fill out the feedback form. It takes a minute to complete it. So thank you again for coming.