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Everyone. My name is um Sh and I am my current fy one. I am working in the East Kent Deanery and I will be giving you your lecture today on endocrinology and diabetes. So this is basically an outline of what we'll be covering. We won't be covering all of it because we can't do that in an hour timeframe. We'll be covering most of the bits in bold apart from the hyper parathyroid and hypoparathyroid because we don't have time for that. Um But I will add some extra bits to the slide so you guys can have that if needed. But the other things in bold we will cover and then the things that aren't in bold then make sure you read about in your own time. They're sort of relatively straightforward. They're not that high yield topics, but they might come up. There's a good chance they'll come up in your finals, either written or your pieces. OK. So, um about finals paces, essentially, you're going to have simulated patients with um, problems that you will see every day in practice essentially. So you'll have a lot of things like diabetes coming up and thyroid issues et cetera. Um, so you've got four names of, I think, I think we're just getting a bit of your mic feedback. Sorry to interrupt. Oh, that's ok. I can't hear anything now. It's gone now. Yeah, it's gone. Ok. Um, yeah, so essentially they're split into four domains. You've got your focus history, uh, which you take about five minutes to do, summarizing your key findings. I'm reviewing your relevant data. So that'll take about one minute or so you can go over these times a little bit along as long as you're within time for station and then investigations and management, which is probably one of the most important things that you're assessed on and then of course your overall professionalism and how you are in the station. So get familiar with the official Year Six Paces Mark scheme. I think you can find that on blackboard, just be familiar with how it works and apply it to a new practice. Ok. So we're gonna do, I think I've got five cases. Um and they're gonna be a variety of things and then we're gonna discuss conditions and hopefully you guys are gonna be interactive and reply with what you think is going on, et cetera. So we'll see how it goes. So case number one, you are a junior doctor seeing a 60 year old male referred by the GP for Polyuria and Polydipsia in the Endo clinic. Um You need to take a focus history, you need to suggest some key investigations you'd like to perform and discuss the management with your examiner. So, just from polyuria and Polydipsia in an endo clinic, what are some of your differentials that you're thinking? Feel free to shout out or you can put it in the chat. I can't see the chat right now. But if one of the coordinators could let me know what's being said. That would be great. Yeah. In the chat someone's written diabetes, diabetes, insipidus, diabetes type two. Yeah. Yeah. Good. Exactly. So, automatically alarm bells are ringing. You're outside the station, you see this, you're like, this is probably going to be a diabetes history and just go through. I used to essentially quickly revise in that sort of one minute, two minutes I had, um, about how I want to take a focus history and possible investigations and management. I'd want to discuss. Um, ok. So, yeah, as you guys said, you've got type one, diabetes, type two, diabetes, diabetes insipidus and hypercalcemia. So, hypercalcemia can present with polyuria and polydipsia, which is also good to note, um, when it comes to your investigations and how you want to manage this patient. So, moving on to investigations. So split your investigations into your bedside, your bloods and your imaging. If you think it's appropriate, it's just a nicer way to present things to your examiner and it means that they can just follow you a bit better. So, at the bedside you want to do a urinalysis. Um The reason why you wanna do this is because um you wanna look for any signs of infection that can cause um polyuria. Uh You would also want to just have a look at the ketones, et cetera. If it is a complication of type one and they're really unwell, then it's just good to do it at the bedside and it doesn't really take much time and then blood test your usual spiel. So full blood count etls and then of course, blood glucose and HBA one C look at the calcium, look at PTH and do your urine and plasma osmolality for diabetes, insipidus. Um specifically talking about diabetes though. Um Do you guys know what the criteria is like how you define persistent hyperglycemia? What are the specific tests you can do and ranges any ideas? Again, feel free to shout out. Put it in the shot. So in the chat, someone's mentioning glucose tolerance. Yeah. Anything else fasting glucose above 126. So someone's put OK. Anything else? I guess also HB A one C. Yeah, so we're along the right lines. So um nice guidelines have said that persistent hypoglycemic is defined as random plasma glucose of above 11, fasting plasma glucose of above seven and HBA one C of above 48. Um you tend not to use HBA one C as a diagnostic tool for new diabetes. Um So if they've had symptoms for less than two months. Um because it's not that good of an indicator. It's more of a chronic um how someone is controlling their blood sugar levels, more chronically speaking. So you would go with a random plasma glucose in the first instance because it's easy to do, you can do it there and then, and then go from there. Just a note though, at the bottom, if the person is asymptomatic, you don't diagnose diabetes based on one single reading, you need to repeat it. If that is also normal, then arrange for monitoring because you can have prediabetic states. So essentially you want to just keep on, keep on track of that patient in case they develop into full on diabetes. Ok. Um So management, um so this is management which applies to both type one and type two. So most importantly, you want to refer them to a diabetes specialist for their individualized care plan because everyone will have target ranges that are specific to them, et cetera. So that's really important to do ASAP. Um So general things that are just good to say to your examiner and provide like a holistic approach and ensure that you're thinking about the patient in more, just more than just the medical way. Um So things like providing advice and support because it's like a lifelong diagnosis. So it can be a bit stressful. Um provide advice on lifestyle measures, of course. Um because those can, you know, minimize the risk factors and make your prognosis a bit better. Um offer the necessary um immunizations. And of, of course, tell them that they're gonna need to be regularly monitored. So H A one C should be measured 3 to 6 monthly. Um And you need to monitor the anti diabetic treatment and control according to that. Ok. So then type one diabetes is quite, um, in terms of like management, it's essentially insulin therapy most of the time and it's the specialists that organize that. So as junior doctors, you won't, you won't need to do that. You just need to make the necessary referral to like the diabetic specialist nurse or whatever you're doing whatever works in your trust and of course, educational self monitoring of glucose and the optimal targets as well. And then type two diabetes. Um, so does anyone know what drug you tend to give in the first line instance, even like second line, third line options, any general anti diabetic drugs that you know of shot up? Metformin is the first line in the chart. Mhm. Anything else apart from me, Metformin, if that doesn't work or if it's contraindicated sulfonylurea DPP four inhibitors? Yeah. Bonus question. If someone has got cardiovascular disease or heart failure, does anyone know what is a really good drug you can give, um, in context of their diabetes? The SGLT two has been put in the chart. Yeah, exactly. So that is a, that is a relatively new thing. Um But it will likely come up in finals because they love to talk about it these days. So, yeah, so you off the standard release Metformin initially unless it's contraindicated. Um it might be contraindicated if um you've got renal impairment. So a low EGFR it also might just not be tolerated and patients can have G I effects as well side effects. So you might need to move to a different anti diabetic drug. Yes, as you said, SGLT two inhibitors are given if the patient's got cardiovascular disease or HF um, so you add that to the Metformin. Um And if it's not tolerated or contraindicated, then you can consider all the other anti diabetic drugs that I'm sure you guys know about. Ok. So complications of diabetes, there's two main life threatening ones, diabetic ketoacidosis and hyperosmolar hyperglycemic state. They love to ask about this in finals, especially DK A to make sure you're really familiar with the management. Um So I'm sure you guys know this already, but I just did a quick summary about it. So patients will present like acutely unwell, abdominal pain, lethargy, vomiting, nausea, like confusion, even as well. The signs are all there. So they're acutely unwell, they're hypotensive, et cetera investigations. The most important thing to do is your urinalysis and in the urine you'll see two plus ketones and in the blood. I think it's like 1.6 something, but I'd have to check that. Um and then of course, blood glucose as well, blood glucose can be normal in a diabetic ketoacidosis patient. Um So don't let that put you off diagnosing it. It's the ketones that's the most important. And then management you need to admit them. Don't say you send the patient home, uh start with IV fluids first and then IV insulin and potassium replacement accordingly. I would learn just the exact amounts and um what fluid preparations to give as well. Just so you can reel it off and you can just answer it very quickly in the exam and then hyperosmolar hyperglycemic state. Ok. So what's the main difference between these two presentations cause they can present very similarly. No ketones in the chart? Yeah, exactly. So the main thing is that the ketones are going to be normal and not out of range. So that's how you differentiate between the two. They can present very similarly and the management is essentially the same as well. Ok. So, oh, and this is just ad K a treatment summary which I just thought was quite helpful. It's got kind of the like reference ranges and things if the glucose isn't reaching a certain target range, et cetera. So it's um quite good to use, I think. Ok. So case number two. So you're a junior doctor and you're seeing a 30 year old female for fatigue at the GP again, history suggests key investigations and discuss the management. So fatigue is super, super general. But anyone wanna throw out any, um, differentials for fatigue in a relatively young person. We've got hypothyroidism, anemia. Yeah. Good stuff. Anything else? Diabetes? Yeah. Ok. Good. So, when someone's got like a general symptom like that, you want to take a focused history to find out what is going on essentially. So, um, things you want to ask about is the timeline, you know, when did it start? et cetera? How long it's been going on for? Um, you wanna ask about sleep because if someone is sleep deprived, then they're gonna be fatigued, isn't it? Um If they're feeling generally, generally weak, you wanna ask about their mood, um because fatigue can be a sign of depression as well. And of course, you wanna do a flaws history and all of your paces histories do a flaw. Um because you want to rule out like one of the most important things which is malignancy. Um And then of course, ask about systemic things. So that's all kind of there kind of covering whether this could be a thyroid issue, whether it could be a recent illness issue, whether it could be bowel, bowel induced and things like that. So, from this lady, you find out that she tells you she's got some skin changes, some hair loss and she's been craving salt a lot in her diet. Um She uses steroids, um but she is forgetting doses or missing doses uh while she's sick and she's got a family history of autoimmune conditions and you ice her as well, which you should do in every history as well. So, now do your differentials change or is anything sprung to mind? Addison's put in the chart? Yeah. Good. Exactly. So, that's where we're, that's what we're getting at. This is just a bit more to kind of push you towards the Addison's, um, perspective. So they're tired all the time, but sleep is good. Skin looks darker, not had a tan, adding salt, lost some weight, et cetera, et cetera. And she's got a background of anemia when she was a bit younger. So, yeah, so differentials are Addison's is the top one again, hypothyroidism, hypopituitarism, iron deficiency, anemia, bit 12 deficiency and chronic fatigue syndrome. These are all good things. Also in your cases, it's good to have like at least three differentials. You can list off after you've taken the um history from the patient because it shows that you're thinking about more than one thing. Ok. So investigations for Addison's, which I'm sure that you guys are aware about. Um, so at the bedside, you wanna do a thyroid exam to rule out thyroid issues and, and, and an ABDO exam as well, blood tests as listed all there. But the main thing is the act test, um, that you want to do and then you want to have a look at what the Cortis is doing afterwards. So I would learn these um ranges. Um so that in the writtens and if you have to have to interpret results on the day in pieces, you can automatically be like, yeah, this is too high and it's not normal. So or this is too low and it's not normal. So um then I know what my, what my top differential is. OK. So this is a bit of viva um on adrenal insufficiency. Um so feel free to say what you think. But what um on examination findings can you see to help distinguish between primary and secondary adrenal insufficiency? Any ideas? The chat says vitiligo and skin changes? Ok. Anything else? Yeah. OK. Good. So, skin changes is the main thing. Um So in primary adrenal insufficiency, you will see hypopigmentation and the sort of physiology of why that's happening is there? So at the end, you get increased alpha M sh OK. So um how would you distinguish between steroid induced and primary addison's? What's like a symptom you might get in one but not the other. Any ideas? That's OK. So um essentially, and steroid induced, you won't get the hyperpigmentation or the hyper potassium or the salt cravings. Um And actually in steroid induced, they steroid induced, they can appear slightly cushingoid um because of their increased steroid exposure um for a chronic period of time. Um So, yeah, again, these are Viber, so it's just a bit of like bonus knowledge that you may get to with the examiner. So it's not completely, essentially essential and in terms of managing this patient. Um So essentially, if they're in Addisonian crisis, you need to admit them, you need to give them fluids ASAP and you need to replace their cortisol essentially. So you need to give their hydrocortisone stat and then continuous IV for 24 hours and the doses are all there. I would advise learning the doses um just to make it easier in the exam because sometimes they like to test you. So it's not just the drug name, but the doses are quite important as well. And if they're stable, then you don't need to give it IV. You can give them oral hydrocortisone or predniSONE plus fludrocortisone as well. And then general things sick day rules apply. If it's steroid induced, you want them to have a steroid emergency card, a medic alert bracelet and you wanna involve your seniors very early on because they can deteriorate quite quickly. And then if no one's seen a steroid emergency card, this is what it looks like. Um, so you guys can look at that in your, in your own time. Ok. Case three. So you're a junior doctor seeing a, um, 30 year old female for weight counseling at the GP again, take a history, key investigations and discuss the management. So this patient has been having some weight gain. So these are just some bits in the history that you would want to ask about. So you want to ask about the timeline where they're gaining weight? Are they exercising if they're exercising a lot and they're still gaining weight? Then what? Like it could be something, um, something that shouldn't be happening essentially. Um How is it affecting their quality of life if they've got stri or plethora? Um, if they've got thin skin because, you know, steroid use, et cetera could point to a statin diagnosis, um cold intolerance um because that could be hypothyroidism. Um Again, flaws as well. Just do it in every, every history that you take and then ask about systemic things. Do a systems review. This person has been having some vision changes. Um And uh if they're female, ask about their menstrual history because that can affect weight gain and weight loss as well. Ask about steroids, alcohol excess and family history of thyroid things and of course, ice them. So it's a lot, but it kind of all makes sense when you're thinking about multiple differentials. And it's just good to show the examiner that you're thinking about more than one thing. So it's not essential to ask all of these things because obviously you might be nervous and um four minutes or five minutes is not a long time, but make sure you should do the main things if you can. Ok. So this is what she said. So she says that she's gained so much weight around her tummy. She's got these red stretch marks. Um, she isn't able to wear her usual size of clothes. She's got dors cervical fat. Um, she's got bruising and they don't go away for a long time. She used to take, take steroids for her rheumatoid. Um and oh, no changes to vision. Sorry, my mistake. So she hasn't had any changes to vision and she hasn't noticed any hair loss and her periods are regular. So what are your top differentials for this patient? Chance says Cushing. Mhm. Anything else that's different to Cushing's currently? No advances on Cushing? Ok. That's fine. So this history is so typical of Cushing's. So you're right. Um could also be hypothyroidism as well. It's just good to have and sometimes people can have both anyway. Um And of course, Cushing's disease, does anyone, can anyone tell me what the difference between Cushing's Syndrome and Cushing's disease is? So Chat says a disease caused by a pituitary adenoma? Yeah, exactly. So syndrome is basically just explaining the symptoms of having excess cortisol in the body and disease is when they have an act producing pituitary tumor that causes excess cortisol, et cetera. So, yeah. OK. So causes of Cushing's um this table is quite good to learn. Um So you've got a dependent, a independent and then pseudo Cushing's um which is also good to know about too. So, a ct dependent, the most common is pituitary adenoma. So that's where your Cushing's disease comes from. You can also have ectopic a from um, a squamous cell lung carcinoma. And then you've got act independent, which is from like chronic use of steroids, adrenal adenoma adrenal carcinoma. And then pseudo is from alcohol excess and even severe depression, which, um, is not too, the pseudo ones are just good to be aware of, but the focus is on the dependent and independent. Ok. Um, good. So next for investigations, which again, I'm sure you guys are familiar with. So to confirm Cushing syndrome, you want to give them one mg of dexa methasone in the night. So at 11 pm and you then want to measure the cortisol in the urine 24 hourly. Um and essentially it should suppress the cortisol, right? So if in the morning at 8 a.m. you see a cortisol spike, then it's Cushing Syndrome because that shouldn't be happening. Um And then the table in the middle is kind of just telling you what the likely pathology is according to the cortisol levels and the act levels after the dexamethasone expression test. So that's just worth memorizing. Um And in terms of investigation. So, imaging that you'd like to do is a pituitary MRI because you wanna look for the adeno, you wanna look for a malignancy and IPSS, which is something relatively new um inferior petrosal sinus sampling. You don't need to know the details of this procedure, but it is there kind of for you in a summary and if you wanted to look further into it, then you could, but it's just good to have an idea that you do MRI plus IP SS as well. Ok. Um, I think we'll move on. Yeah. So management, um, is relatively straightforward. So for Cushing's disease, you wanna get rid of the tumor. So you wanna do a trans adenomectomy. Um, and then second line is medications controlled and then ectopic a, you could do a surgical resection or ablation and then if it's a independent, then you can remove, um you can do an adrenalectomy. Um if it's an adrenal tumor causing it. Um And then, yeah, wean steroids if they're exogenous. Ok. So that's basically Cushing's again, main thing that they're probably gonna test you is the most common cause of Cushing's, which is your pituitary adenoma. So be most familiar with that line of management. Ok. Um Case four. So you're a junior doctor seeing a 23 year old female medical student at the GP for diarrhea, take a focus history, suggest the investigations and discuss the management like normal. So she's got diarrhea. Um these, this is a kind of the questions that you want to ask for a diarrhea history. So again, timeline is very important for any symptom uh frequency. How many times are they going in the day? Um Does when did it start? Um does anything trigger it to certain foods trigger it obviously ask if there's like blood in the, in the like fecal matter and all of that kind of stuff. Um, and ask about recent travel because it could be a bug that they picked up elsewhere. Ask about nausea and vomiting as well. Um, what they've been eating, whether they've lost weight, um, and tremor heat, intolerance, sleep palpitations because that's all kind of pointing towards high pa hyperthyroidism. Um, ask about systemic symptoms as well as below and past medical history and what medications they're on too. Um, if they've got diarrhea and they're on laxatives, then that is completely manageable and you just need to stop the laxatives. Um, and that happens quite commonly in practice. Ok. Um, so this is what she says to us. So it started, um, about three months ago before she had normal bowel bowel movements, um, denies any blood or nausea and vomiting, no changes to the diet. Um, she finds that she lies awake, um, and tossing and turning and she feels quite anxious. She goes to the gym twice a week. Um, haven't had as many gains recently and she takes the oral contraceptive pills. So she hasn't really had proper periods and she smokes socially generally. Ok. So with this in mind, oh, bear with one second. Ok. So I think, I think one of my slides has gotten a bit, um, mixed up there, but essentially this is meant to be the differential side. So, what differentials are you thinking from this? And I'll just go back to what she said in the chart. We have hypothyroidism. Yeah. Good. Anything else? Anything else that might be quite common? Um, in a young patient diarrhea for three months? You've got, I, I BS maybe. Yeah. Anything else, if you had to say one, like a third one? So you've said two and you've got one more to say, what would you throw out? Then we've got IBD. Yeah. Exactly. So, because of the time frame of Sandy and she hasn't had any changes to her diet, et cetera and it kind of comes on spontaneously or it came on spontaneously rather. Then IBD is worth considering because it's a relatively young patient, et cetera. But this history is very typical of hyperthyroidism. Ok. So then moving on to that, moving on to um our investigations for this patient. So remember bedside, blood test and imaging. So at the bedside do like a general exam um to look for like um widespread symptoms, widespread systemic symptoms and focus on the thyroid as well. Um Do an ECG you wanna assess heart function, you know, look for any af or um things like that and do a stool culture and a parasitic screen just in case they have picked up a bug, you could also add a um fecal carro protectant to this as well if you are thinking IBD that would be totally valid to do as well. Um And then bloods aim towards your diagnosis of hyperthyroidism. So for blood count, e allert TFTs TSH receptor antibodies and then imaging, you want to um do a bunch of isotope scans and things like that. Um And then in terms of other autoantibodies you want to do, you can do anti TPO and ant TG. Um you can see both of them in grades and hashimoto's. So you want to just do like a full, full profile kind of thing. So you can um you can be completely safe in figuring out what management to give this patient. Ok. So, um oh, I guess my differential slide is over here then. Ok. Yeah. So um just going backtracking a little bit. So we've got Graves disease. So, hypothyroidism, other causes of hyperthyroidism, you've got toxic nodular goiter, you can have an acute phase of de quer veins, acute phase of hashimoto's. Um you can have a pituitary adenoma um producing TSH and it can be iatrogenic as well. So some medications can cause hyperthyroidism as a side effect as well. Ok. So looking at scintigraphy, um essentially this is worth knowing um in case this does come up in your cases. So if you've got, if it's diffuse differentiation, then it's likely to be gray and if it's patchy, then it's likely to be toxic, multinodular goiter, then that's good to be aware of as well. And sometimes it can come up in written as well. And then in terms of management for someone who's got too much thyroid hormone. So, if they're in thyroid storm, they're going to be acutely unwell. They need to be admitted and they need to go to ICU ASAP. You need to start them on antithyroid drugs. You need to start them on steroids, beta blockers. If they're in, if they've got a fast heart rate and they're tacky, then you wanna bring that down, um, iodine solution and cooling. Um, but remember your contraindications for beta blocker, which are there, if they're stable and they're not acutely unwell, then counsel them on things like smoking like a modifiable risk factor for thyroid eye disease. Um Let them know about their diagnosis, explain it, et cetera, offer support all of that spiel and then of course, your medical management. So carbimazole and beta blockers, if they're symptomatic, um in terms of the dose of car carbimazole, it's 40 mg and then you taper until they, your thyroid and you continue for 12 to 18 months. Um You can also treat them with radioactive iodine if they've got toxic multinodular goiter, this just takes longer to work. Um And then of course, you've got your surgical options too. So you could do a thyroidectomy. Um, as well. That's something to consider. But first line management is medical for hypothyroidism. Ok. So another Viber question, um, how do you differentiate Graves versus other causes of thyrotoxicosis? So you've got exophthalmos, Graves, eye disease. Yeah. So the main thing is that you're gonna see eye pathology and eye disease in graves and not in other cases. So you'll see proptosis, exophthalmos, and Opto ophthalmia as well. Um And you might get some dam signs as well, but the eye signs seem to be the most common that will differentiate it for you and then some complications of hypothyroidism, which is worth knowing about. Um So a really common one that you, that I tend to see in practice is a um and then that can lead to a bunch of problems as well. Um You can get ca um congestive cardiac failure as well, bone loss, um graves with orbi tip and duy as well. And that's why you need to give beta blockers to um control their heart rate. Ok. So then hypothyroidism switch it around and they've got too little thyroid hormone. Um So again, similar bedside is the same bloods are also very similar. Um But you can look for something um known as the Schmidt syndrome. So this is when you have Addison's autoimmune hypothyroidism and type one diabetes mellitus. This is just a very random bit of like extra knowledge um which you can learn about if you want to. Um so to test for that, you would do blood glucose, um act test and cortisol. And then of course, all of your autoimmune antibodies and all your auto antibodies as well. Um in the context of hypothyroidism. Um in terms of imaging, you would want to do chest x-ray and look for maybe some pleural effusions because the um respiratory muscles will be weakened generally um from having a lack of thyroid hormone. So you might um see some effusions there, but that's a, maybe we don't always get that. And then essentially the goal for treatment is to normalize their TSH levels. Um So we've got some um doses over there for you. So in the elderly, you give a lower dose, um under fifties, you give a higher dose. Um and you wanna repeat them, repeat the thyroid function test um 8 to 12 weeks after their dose because you don't want to give them too much thyroid replacement so that they become hyperthyroid because they can get really sick. So you need to be quite careful with your hypothyroid management. Um If they're pregnant, which I'm sure you guys have learned from your five, then you need to up the dose um and counsel them on the thyroxine side effects. So, af angina low bone density and um the fact that they can become hyperthy hyperthyroid from trying to over correct the hypothyroidism. Um Yeah, I think that's everything on hypothyroidism management. Ok. So I think this is kind of the last case, but it's split into two and then we should have time for questions and general things. Um So you're a junior doctor seeing a 35 year old male for a review of his blood. So again, history investigations, discuss management So in the findings, essentially, all the bloods are normal, apart from the potassium is 2.6. So the patient says, oh, I've been on all sorts of pills and things and BP tablets. But the other day at home, I still had a really high reading and it was 11 80/1 10 approx that and he gets occasional headaches. So with this, any differentials in mind. So in the chat, we have Conn's Syndrome and Fao. Yeah. Anything else Cushing has also been put in the chart? Ok. Yeah, good. So you could have a bunch of things going on causing the low potassium here. So you could have hyperaldosteronism. You could have A O you could have just renal disease, generally CKD potentially Cushing's and poor medications compliance as well. Poor medications compliance is really um popular as in it's really, you see it all the time on the wards and in the hospital. So keep that in your mind too that it may just be that it's like something as, as simple as this causing um uh electrolyte imbalance. Ok. So, um investigations for this man would be, you'd want to do a plasma aldosterone and renin ratio. Um you would want to do a CT ABDO as well. If the ct abdomen doesn't say anything, then you could do adrenal vein sampling. Um and essentially your management depends on what is causing the diagnosis. So if it's an adrenal adenoma causing it, then you would do a laparoscopic adrenalectomy. If it's bilateral hyperplasia, then you would want to give an aldosterone antagonist such as spironolactone. Um, ok. So what if it was a bit different? The potassium was normal within range? Um, but they had hypertension and sweating, then what would be your top differential? No, we have Fao in the chat. Yeah, exactly. So, that's what I'm getting at here. Essentially. Um, Imperial love to ask about this even though it's not that common in practice, but it always tends to come up in exams and in finals, um, probably not in pieces, but definitely in written. So that's why I kind of included a slide on it here. So again, be familiar with how you are going to diagnose a chroma. Um, you want to look at their 24 hour meris over the Casca means because it's more sensitive looking at the metanephrines. Um, in terms of management, then surgery is the only definitive management for a pheochromocytoma and you wanna pre prep them before surgery. So A before B is a good acronym is a good way to remember it. So you wanna do alpha block first, um, preoperatively for a few weeks and then, um, give them beta blockers um to avoid them becoming, um, you want to avoid them, becoming hypotensive and things. So you need to prep them before their surgery. Um, and I think that is essentially it bit about the etiology is kind of there as well in terms of like the 10 10 10%. Um it's good to be aware about, but it's not super important to um sort of like it's good if you can memorize it, but it's kind of a bit in depth about it. And the main thing is how you're going to diagnose it and how you're going to treat it and how it presents. Um And I think that might be my last one. Yeah. So we finished a bit early. Um apologies for that. Um But if you guys have any questions, then do feel free to ask and I will try to ask them as best as I can. Um There's also a feedback form there, so we greatly appreciate it if you could fill that out um when you can as well. And if you have any questions about like finals or work as a doctor or anything like that, feel free to, to ask. That's great. Thanks very much Giovanni. I mean, obviously guys, if you have any questions, feel free to put it in the chat. Um As Giovanni said, if you could fill out the feedback form, once we get enough feedback, we can also release the slides and the recording. Um Otherwise, if there's no other questions, um Thanks very much Yvonne again for giving a lecture. We can wait a little bit longer, otherwise, feel free to head off. Ok? Yeah. So I'll just wait like a couple of minutes. I think someone asked if I can put the feedback form on the chat. Yeah, I've, I've just put it there. Can you see that? Oh, yeah, I can see. Cool. Ok. Yeah, it doesn't look like there's, uh, there's any questions, so I think I will um, head off now. Sure. No worries. Thanks. Thanks very much. Once again. Have a nice evening. No worries. Thanks for having me. Bye bye bye.