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Uh huh. Okay. Okay. Do I love with me? Thanks week. Uh people observing. Can you hear me on Zoom? You'll see me on Zoom you've seen on Zoom? A screen has a sweet showing. Okay. Let's get started. We're going to start. We're gonna do diabetes and thyroid today. It's a really, really long pace. There's a lot to teach. It's about 100 slides. I don't know how they put both together. It's very, very shameless behavior. Admin spine. Did you guys manage to get, did you check medal and slides on the anyone who did check? Did you were able to access the slides on medal? So it actually works crazy, crazy, crazy. I put on, I put on like two days ago. Uh maybe I put it on yesterday from, but I did put it on. Uh I hope so. The reason we're moving to Medal is because it'll be better to have everything in one place. I think that's the belt. Okay. Feedbacks, fine content place. We're going to cover a little bit of diabetes. Um physiology type one, type two, the emergencies and complications. I'm going to skip over all the Oscar stuff because I think you've done your skis. Okay. There is a constitutional Zakarian. There you go. Is very important. Adam, when you cut your hair, you're going to be a different man. I promise. Okay. Content. Uh, thyroid as well. So there's a lot to cover. Usually these are two separate cases. I don't know what they were thinking. We will suffer together, diabetes, refresher anyone. What diabetes myelitis is just as in flex everything, anything, you know, Entomology, everything gone peeing. Yeah, honey. Mellitus means honey. Yeah, we'll say sugar a lot actually. Uh we are blessed with greatness today. Ashton. Uh I love that guy. Okay. We'll just move on. Diabetes just means peeing and myelitis mean sugar. There's diabetes insipidus, there's diabetes type one, type two. So just because you see the word diabetes doesn't always mean sugar. Okay. My license means sugar, find honey, whatever. Cook a home. Why is it important? Why is diabetes so bad complications? What, what, what, what, what's these complications? What does it cause? What's the problem with diabetes? The issue is sugar. Glucose is extremely inflammatory in the blood vessels and in the bottle having elevated amounts requires and recruits inflammation, inflammatory markets, interleukins, TNF, all these things all very step on us m which I do not remember at all. Oh, and we're joined by our, you know, uh Mohammed, the guy at the front always answers questions on Zoom. Okay. If you want to share screen and put your video on come join us. Okay. Anyway, um so it causes a lot of end organ damage. And the organ guys don't talk, don't talk, don't talk and talk. We've got a lot to cover. End organ damage always refers to in most conditions, hypertension. Anything things with very sensitive, delicate important nerves and capillaries. So what are these, the kidneys, the eyes, what else? Retinopathy, network, pathy and neuropathy. Really? These places are extremely sensitive, highly vascular, highly susceptible to information and leakage. That's the problem. Okay. Fine. Moving on which we're gonna be just said these things which organs microscope kind of cool. Nice bit of probably cause I wanna do a PAP on that. Probably 8% of the total NHS budget. Okay. Cool. The main types type one, type two, there is type three but we're gonna talk about that type one. All you need to worry about is there is some sort of genetic influence into it is an autoimmune presentation. This whole HLA there's HLA B 27 is HLA this as well. Um Also the destruction of the B cells, beta cells in the islets of Langerhans. All that stuff you covered that in stem for. No. So if you're gonna be teaching it in very soon, you have you ever seen that case? That sound? All right, you're gonna be doing that. Yeah. OK. Type two is known as summer. You guys have still talking, I'm just gonna talk. So type two is referred to as incident resistance. We're very familiar with this metabolic picture very prominent in western diets. That's fine. I have seen that guy on Instagram reels and tiktok. Like, says, if you eat like these cereal bars, you're gonna the carnival guy. That's what his name, he's all over it. Like, if you eat one cereal bar, you've got diabetes for the rest of your life to die, something like that. I thought his name. But anyway, I think it's very funny. There's one, there's another type here gestational, that's here for you'll cover that near four. Um, that's a whole mess in it. So pregnancy. Yes, crazy. Okay. Causes of reduced insulin or insulin resistance isn't just an autoimmune picture of that type of diabetes, by the way, some viruses can induce type one diabetes. That's a little fact. Okay. Things that can cause a reduction in insulin production or insulin sensitivity or whatever pancreatitis. This is a big one. Hemochromotosis is another big one as well. Bronze diabetes, what it's called cause your skin turns bronze, the iron deposits in all sorts of places, your liver, your brain, the liver, nice, your brain, your liver, your pancreas, these things. Okay. Um We're all aware of cushing's having a lot of steroids cost is all, all these things precludes you uh diabetes, acromegaly. One of the acromegaly is increased growth hormone production from the two suicide than usually from a tumor. You've all had acromegaly, right? Causes hypertension. It causes big hands, big feet, face change, change in the pace of the shape. What is one of the diagnostic tests for acromegaly, oral glucose tolerance test? Remember as well as an MRI if they're O G T T comes back elevated. Uh So insulin is extremely important marker of many diseases. Okay. Uh What else? Medications? That's fine. This is year four. I just had some scientific antipsychotics. I think it's respiratory and stuff can cause diabetes, insulin resistance. Uh, I haven't really, how much did they talk about? Talk about Maadi and stuff like that. No, it's really, it's really niche. It doesn't really happen. Um, there's one thing that I didn't put the slides, but I've just remembered when it comes to type one B diabetes, go home and write about this or learn about it. Something called Cpeptide and these things, there's another one as well. Like they're like markers to see where they're not used often. It's consultant endocrinologist. Clinic ship. Basically. Sorry. I'm sorry. But you know, okay, fine. That's hip in bad thing. Actually. Know who that was for a while. That's hitting okay. Type one diabetes. Ready. Let's go fine. When you don't have enough glucose, we have too much glucose. Rather your liver has to use something called fatty acids. Breaking that down, releases acetone. It's a physiological biochemical procedure, whatever. Um, and that's what causes ketosis, elevated ketones, acetone breath. You know, is that something you're aware of Acetone breath. I've never smelled it on the D K patient person. Fine, ketones are released as, uh, a byproduct and it's not good if they build up, it's a really bad thing. So, the first presentation of type one diabetes, you guys tell me what, what things that they present with. It's in, the name is very common and you should know so they can present an emergency. Me being DK. That could be it. But that isn't symptoms because there are symptoms of DKA. What things are looking for? Two basic things? Abdo pain can be one. Yeah, that's D K. Uh but just general type of diabetes, polydipsia polyuria just say that really simple, increased us increased. Um We, we because they're peeing out too much. That's fine, weight loss, failure to thrive all these things. It can be a first presentation of DKA were aware of this hypoxemia. We'll talk about that in a minute. Does anyone know what customer breathing is? Essentially? Your blood is very acidic? How do we, how do we get rid of acid? Breathing out? The CO2, CO2 isn't acidic? But why? How is the acidic kind of carbonic acid when it dissociates into in the plasma? Okay? It releases HPE US islands which are protons, which is acid which is not good. Fine. Here's a video of that obviously doing cosmo breathing. Uh No, no, they're not leaving. Okay. These are causes of costal breathing anything that increases these a few of these are basically acids. Key terms, acidosis, uremia, kind of sepsis, acidosis salicylates. What's an example of a salcylate aspirin poisoning? Assets? Fine method of course is all these things, acids find it. I'm happy with that long term management that you need to be aware of. This is kind of skittish but not really. It's mostly the whole like, you know, Manchester Spiel and we're going to educate, you will do diabetic nurse these things monitoring their BP target is 1 35/85 not in type two and type one, if they show signs of end organ damage, the BP target drops to 1 30 of it. So type one diabetes with albumin area, meaning diabetic nephropathy. So like your um A C are not the modern warfare two gun. The I don't know if you ask to you to your young finance. Very good. Exactly. So if it's more than three, um and definitely it's more than 70 you need to do um, BP monitoring and control. Okay? You give a synopsis by the way. And she also mind if you, if you can remember that. Fine, cool, cool, cool. And obviously in student, we're gonna talk about different incident types. This has been overly complicated my entire medical school life. The first line incident, forget the brand names, forget everything. The only incident a patient should ever be on. If they're a type one diabetic is a basal bolus regimen, meaning a basil amount of instrument throughout the day through a continuous infusion through that they'll pump they have in their pocket. And then bolus is meaning huge spikes of insulin when they have a meal basic. That is it. There is something called biphasic release and stuff like that. That's second line. I wouldn't worry about that. Basal bolus. I don't know why we won't talk this properly, but I blame myself and obviously monitoring very, very mundane slide, very low. You, you get the thing. I'm not just showing skin for no reason here. What is this showing? Very good. So this one of complications of having insulin injections, it can cause lipomas or like fat hardening in that area. So they had to switch sites and stuff. That's fine. Cool. Key thing I want to remember is diabetic specialist nurses deal with these things. They know more than most F one F two. Even some consultants probably okay. Fine reads. There's the F one and any an eight year old boy comes in with severe vomiting and Abdel Feen. He's dehydrated, drowsy and looks like he's going to pass out. He's worried, his, his worried mom tells you he has diaper on diabetes. I'm gonna keep doing the whole session, you know, the on zoom. Like before your year, I think I did fall sessions in an accent once in a while because I was in my room in London just at home. I'm so bored. I do the whole session. Disgusting. Huh? Okay. What are you guys going to do next? Very good shelter. Yes. Anyone who comes in the E D, he don't care what they have. 80 unless it's a resource patient. Fine. And then that's when they have a whole protocol there. Like a T L s and stuff. Okay. Very good. 80. That's not good. Okay. So this is kind of a ski stuff but you don't have 100 50. Um So he's able, he's always patent fine. He's tachycardic. Sorry to keep Nick A B G shows metabolic acidosis. Oh circulation, heart rate is high BP is low E C G normal. You put your too wide ball can Julian glucose is 17 ouch is a bit feverish ouch. Everything else is fine. Apart from a dip that shows ketonuria, what's going on here? Very good. Okay. It's probably an infection that triggered A D K. He's a well known diabetic. So you have to find out that the original cause. It's not. First presentation, something happened. Infection puts the body under an unnecessary stress, increased cortisol information. DKA very common in questions. If you see signs of infection in a diabetic, think compromise and how do you manage them in student fluid stuff like that? Okay. Fun. We said causes of decade nonadherence is a major one and stopping it during illness is another major ones. So nice. Diabecline me. What does that? Mean, does, you know that means they're like a, if they have like a gastroenteritis and they're vomiting up so much bulimia in diabetes, they get dehydrated quickly and then they die. DKA, basically everyone understand what I'm saying. No. No. Okay. Fine. Cool. Sign the symptoms, abdo pains are really, really, really nonspecific common presentation. So, anyone who comes in with ABDO pain has a kid, think diabetes DK is the first presentation, especially in questions, they can slip it in like that. So nonchalantly you, you'd be surprised, drowsiness, reduced G C A G C s, um increased breathing. If I'm happy this, how is it diagnosed? I need some parameters. Not just general blood glucose. Zachariah. No, I want actual parameters with numbers and boundaries. There's three main parameters. I'm looking for that. You need to have memories off by heart beer. Ph Fine. What should it be above or below or what was it? Very good doctor? Very good. Less than 7.3. What else? So Ph is one. So blood acidity is one domain. There's another way to measure blood acidity, by the way. So blood acidity is one. They've got middle one and one over here. So if you leave blood acidity, that's another one. It's in the name kind of has to have this. You can't, you can't, you can't not have this key turns very, very good. Okay. How are we measuring ketones? That's one of them here. Think, think, think think, think, how do you measure Keaton's? That's one way. So, urine dip, how's your addiction? Does it show a number on the stick? It shows classes. How many classes? What classes mean? Yeah. Two or three. You need three. Probably. Okay. Three plus is, how else do you measure ketones? This is the middle one. We, we've done acidity. We're doing ketones. Blood. So, blood serum ketones more than three, I think. Okay. Next, what's the last one? How do you? So we've had ketoacidosis. So we've done the keto, we've done the acidosis about the diabetes. Bird sugar. There has to be some sugar that. Okay. What's the promise of sugar? Hk Once you can't be because that's a long term blood because three months, four months, not fasting it just a random glucose because you don't have time to fast them and then if you fast them more in DKA, you might as well just, I'm being horrible and uh it's random glucose more than 15 at least. Okay. Let's have a look. So, acidosis. There's two ways to measure acidosis. Ph, like in the V V G A P G or their find out their bicarb, bicarb is a measure of alkalinity. If you have low alkaline, you have high acids. Okay. I poked assuming, sorry, more than 11. My bad. That's what I mean. I should, I should teach, okay, fine. Or there should be a known diabetic. So more than 11 if it's a first presentation or that kid, for example, fine ketosis three plus or actual serum ketones. Fine. You have to memorize this for your progress since there are no two ways about it. It's six things. Super easy to remember. Remember it, diabetic keto acidosis. It's in the name. Don't get confused. Okay. What are complications of all of these things? Okay. The main things are probably deaf. This is from dehydration, thromboembolism that blood becomes like honey viscous and pick arrhythmias. We'll talk about that in a second. Um This is a problem as well. Cerebral edema, overcorrection of flewis can cause the brain to swell up. That's the problem as well and an odds as well. We'll talk about that later. ARDS, acute respiratory distress and bring um fine. I did not put these beams in him. I don't. Okay. What will kill a diabetic patient? A D K patient dehydration. Yes. We said potassium balance. Very important in acidosis. Very good. That's fine. So this is like the focus. The things you're gonna do in the A B C D approach skip over it. How do you treat A D K is really simple to treat. Big Picker is too long. I'd say there's three main things to worry about my D K. We'll talk about this, but this is the full thing for you guys to DKA about and go home. Okay. First thing is always fluids, fluids, fluids, make sure they're hydrated. So you're gonna give bonuses and bonuses and bonuses 0.9% saline. Um People get really scared to give apartments. Why do they get scared to departments? But it's got potassium in. Um If you actually look at the amount of potassium inside apartments, either teaching session with an intensive ICU guy and he basically says he only prescribes apartments will only not prescribed apartments if their potassium is more than eight. And he said they'll be dead before they even need the talent. Since the amount of potassium department is very little. So it's actually much, much, much better um fluids. Um Anyway, that's me. 91 incident is the next thing to give you give IV infusion of insulin straight away. The dosage is always 910.1 units per milliliter per kilogram per hour. So if there's 70 kg, you're going to give seven units based of them in one hour. That's so important. And you have to know this off my heart just but it's not hard once give an incident, will the glucose not come down? It will. Now before you send them into a hypo, give them some sugar. So you give, once the glucose is below 14 or 15, then give some IV dextrose IV sugar. It's about controlled and balance of time. Potassium is really, really, really important. Okay, you can get hyperkalemia in DKA. What does insulin do once you've given a lot, given a lot of insulin in DKA. What does it do to potassium, it shoots it down so you can send them into a hypo killeen problem, right. Both problems, both cause cardiac issues. Not good. Monitor the potassium regularly. You can do that on a DVD if you need to find. Okay. Cool. The rest of this is just rubbish. Basically. Um, you can look at that in your own time. Three main things, fluids, insulin, say potassium, glucose, their cut them as one happy. Uh huh. As I said, they always ask these things, what make you work it out can cause hypoglycemia cardiac or it's not good science and how to manage. We'll talk about that and stuff. So the complications of DKA, we've just, we spoke out about three seconds before just again, just remember chaps, she can cerebral oedema, hyperkalemia, arrhythmias both do too hyper and hypo fine. I finally said all this uh okay, very quickly. Just the high yield, the high yield of all of you guys were going to talk a bit about acidosis and specifically metabolic acidosis like DK, I've taught this before in November last year to some of you guys. Um So just very, very quickly, metabolic acidosis just means I ph not caused by respiratory causes like not infection, sorry, not um pneumonia and these things. Okay. DK is one of the biggest causes. How would you be classified? Metabolic acidosis? Is it's an eye on gaps. Remember this, don't forget it. It really does come up in progress tests I promise you, they will give you all the parameters to work it out without telling you to work it out. And the only way, you know, you have to work it out is the options because four of them will be raised an eye on gap and one of them will be normal, an eye on gaps. And that's the answer. You understand what I'm saying? So if you know how to work out, the eye on, on, on gap, which sounds complicated, it's not, you've solved many questions. Just a bit of a side note, the same thing applies completely different topic to plural effusions and the S A G from a different part of medicine. They love these kinds of questions. If you know you're difference between transmitter and Exodus, they'll make four options an excellent and want to transit it. And that's the answer. Do you know what I'm saying? So please, if you're gonna do a high yield crammed amount before do it on these things. Okay. Fine. That's how there's a lot there. It's so simple. All the an eye on gap is looking at you sneeze, there is acidosis okay. If you calculate the amount of ions that are present, you'll be able to help with any the cause of this acidosis. That's all this is. Look at the use and ease everything that's positive, put them together, everything that's negative, put them together and then subtract them from each other positives minus negatives gives you an iron gap. That's what it is. If there's a raised an island gap, think of Luca, that's all we have to do. Lactic acidosis, shocking sepsis. Your, it's get that ketones. So the D K and the poisons basically try and remember this if you can, okay. This is normal, an eye on gap, don't worry about this. This is a bit too much happened. This, this lives a bit. But if you know these by elimination, you've learnt these if that makes sense because none of these are similar to any of these. If that makes sense, learn these ones learn to raise iron, iron gaps. If you don't recognize the answer, it's going to be done. Okay. Fine, cool. Really important. They always ask about hyperkalemia is relevant to this case. Let's just mention it really quickly. Why do we need to manage it because of hyperkalemia? Okay. There's a very, very nice pick talk that Mario made about me teaching this while a while ago. This one. Uh Yeah, we're not gonna do it now. Just what are the signs on the C G? So tall tins T waves, wide, QRS and flat or absent P waves. Fine. We know this. If it gets really, really bad, what is the name of the E C G sign that you get when it's really bad? Like above eight a sinusoidal wave, it literally looks like a sine wave from maths as I've lost all composure, no dignity left. Okay. Why we need to manage hypokalemia, arrhythmias signs. So signs tend to begin after six minimum. So the normal range is what until 5.5 or something? Something like that, right? Ok. So we always said this fine, all three of these, how do we treat them? Three per um three things. So calcium gluconate to do what to stabilize the resting membrane potential of the heart. So it doesn't hyperpolarize. Okay. Fine. Next incident, what does that do? It drives into cells? So it doesn't deal with with the at already. It just throws it away from the heart and into the cells that hides them after a few hours. Where is it gonna come back into? Okay. So there's a, there's something else I have to do after that. What's another way to drive into this house or help do them a sub use morning? Does anyone know how we actually deal with the testing? Long term? Not long term, but our terms rezoning. Very good gluconate is now Rizzo knee um is later okay. That will actually expel it through the gi system and make them poopie out. And PPL basically. Okay. Fine. Everything I just said is on what we just discussed this here. Fine. That's kind of a wet thing to say stop ace inhibitors. Okay. Fine. Very I hope that whoever this is very proud meaning me. Okay. Courses hypochelemia. Fine. Don't forget Addison's. Please don't forget it's don't little. Okay. We're not doing a quiz. Type two diabetes. Anything blew up. Uh, I don't know. Defi, yeah, you guys don't seem interested. Part two diabetes. So this is the one. So now switch, switch your brain's over no more DK no more. Starting an incident. Straightaway type two diabetes. Metabolic picture diet induced all this rubbish. Fine. Okay, cool. You don't, do you need to know this? I mean, you already know it. You already know this stuff. Obesity, family history, gestational fine. Okay. How does someone other than asymptomatically? Really simple question. How does someone retired? Two diabetes? Will they, how they present? Very simple polyuria, polydipsia, these things, they will get all sorts of extra things such as opportunistic infections like UTIs while they get increasing on the ETS even in men. Sweet pea brings the bees, meaning sweet pea brings infections and bacteria and stuff like that. That p is gonna be sweet. Right? Okay. Sweetie. Okay. Um ulcers and stuff like that. Someone with type two diabetes can present with end organ damage. Someone especially is not looked after themselves. So think about vision and their kidneys and stuff like that and nerves. We've already covered this history a long time ago. So forget this fine. Now all of this is our ski stuff. The next like six Liza Rosky stuff. So you were gonna skip, we're not even look at them. Is that OK? Okay explanation. Right in the bin go. Okay. Kind of cheat a little bit. Okay. Really important. This is such progress. Stuff always hates it. There are two things that we're going to talk about diabetes and prediabetes. Okay. I need you to memorize the boundaries and, uh, you're almost in English and the rangers. Thank you. The ranges you English is my first language. Bothering. There's not much tissue. Okay. Let's memorize the ranges of pre diabetes and type two diabetes and then with the treatment threshold and when to step up one step down treatment, there's lots of numbers. It is pure, pure memorization. I've got no, no monix know nice flashy zacks flipping packer and these like, I don't know these weird things. I can't. Okay. Fine. Help me out. What are some tests we need for diabetes? Type two diabetes? HBA one C. Okay. That's funny. Tell me a bit. Someone to me a little bit more about that. Our friend mentioned it and something about every three or four months. Why red blood cells 120 days, basically. Okay. I don't actually the initial logistics of how it works like something because attaches onto it or something, something like that. But the point is you use it to monitor treatment, adherence and disease progression makes sense. Right? Okay. What's another thing? Fasting? Because there's two. What's another one? Random mucus? That's three. So that's repeat them. HBA one C. Fasting liquor's did someone say that doctor said um fasting glucose was the other one running glucose in the last 10 G T T. Those are the four things she has meant fine to be diagnosed with diabetes. You need to have an HBA. One C, it's not all of these, you need tap, it's all of these and to have all one or the other. Does that make sense? Ok. HBA one C is greater than 48 fine random glucose slash O G T T of more than 11 twice if they have no symptoms or once if they have symptoms of hypoglycemia, polydipsia polyuria, these things. Okay, mama, okay, fasting glucose is more than seven. It should be in a fasting state overnight. The glucose should be loan have not eaten or had any spikes of carbs or anything like that. It should be low. These are, these are the easy events, prediabetes you guys try and help tell me. So HBA one C, what should it be? Stay with your chests. People for someone said 41 to 47. Anyone else have a guess? 40 47. Okay. Um Fasting glucose. What should it be? He was very important where it can't be seven? What's below seven? 6.9? Okay. Fine, let's move on. Okay. So 42 to 47 HBA wants to remember that fasting glucose as our friend said 6.1 to 6.9. Which uh what's the last one? The random glucose and O G T T 7.8 to 10.9. Okay. Just no doubt. So, the point is you start treatment here if you can medically, meaning give the first line medications and treatments, which is usually Metformin, usually Metformin. Okay. What would you do here? Lifestyle straightaway diet, exercise, diabetic nurse, these things. Okay. Fine, fine, fine. Let's say they're on treatment. Metformin. When do we, let's say he knows the question. Just hold on for a second. When would we step up if they came up with like a blood glucose there on that form? And is that, is that blood test results that would prompt us to move on to a more treatment, increased treatment if the HBA one C increases above 58 while being on a treatment, whatever it is that is indication to step up to the next line, whatever it is, whatever the guidelines are in that area, I wouldn't learn more than Metformin by the way. Or glitters ice because every trust I've seen has different things. They start with a Gliptin SGLT two inhibitor. They move on, they mess around with things for fun. Okay. Here is just a schematic. I took from pulse notes. It's the same thing as we've just said, it's always about um do the test without symptoms, repeat the test with symptoms, start treatment basically fine. There's guidelines, all these things. Fine. Yeah. Ok. Treatment, first line lifestyle changes, Metformin. We said that that's okay. Notice how I just said, add all of these, you don't add them all, you add one depending and then the G P or diabetic nurse will switch whatever is good for them. The most important thing about these drugs, by the way, is being able to identify the side events. That's what comes up in questions because they're, they're well aware. This is exactly what we just said. More than 58. Keep it moving. Next drug, next drug, next drug. Okay. Fine, cool, cool, cool. Everything we just said here's a really important side a lot going on. I'm gonna break it down for you really high yield important stuff. Thing. The first line drug, I actually know this for a long time, but Metformin's class is a big one. And so remember that the main side effect of Metformin is lactic acidosis that's so darn important to them and it will cause a what kind of lactic acidosis raised are normal? Raised? An eye on gap. Okay. Please do not forget that most of these will cause gi discomfort. Metformin especially causes gi discomfort, diarrhea, and tummy pain. Okay. Don't forget that. Please. Please, please please. A very other common drug is victor sides. Now, the reason this is important is because it causes weight gain. So if they're already big, you want to make a big gun. A really important thing you remember with click decides there are only two drugs, antidiabetic drugs that will cause hypoglycemia. What are they? There are only two there are only two drugs that can send your patient into a hyper, less than 20.4 point 11 of them is great. Besides the other one is, I think with your thinking brain at thingies, insulin understood really important. So if they give you a question, which drug is caused hypoglycemia, you don't read the question, you don't read anything other patient, you just see glipiZIDE. You're like, what can you move on? Okay. Um Thiazole A didn't die. Owns the only way I remember what they do is by looking at the name, I see lid, I remember fluid retention. That's all this one causes fluid retention. That's all. And if someone's got extra fluid on there, gonna gain weight, aren't they? It's a weight gain. As I remember. Fine, moving on uh DPP four I this has P and uh in the name. So it causes pancreatitis. That's what I'm OK. Moving on. Uh SGLT two inhibitors. The way I remember it side effects T UTI. Okay. That's I remember, okay, fine, fine, fine and GLP one. Okay. Cool. I've never actually seen that drug in English because they have any questions on this. Don't go and make flash cards and like every single nitty gritty detail and know the key things that I mentioned. Fine, cool. Let's keep it moving. Here are the different types of insulin. The only thing I need you to remember is basal bolus, forget and over rapid forget, act rapid forget this, this this I don't see it often being asked Atlantis, these are all pharmacological brand names, just basal bolus diabetic emergencies. We've covered DK hyperosmolality, hypoglycemic state. You've all heard of this, right? But very, very, very, very few people. No, actually what it actually is, right? The reason being everyone focused on DK, they never focus on this. Who does it affect more type two diabetics? I've got a really nice table. So when your concentration comes back in a second, it will show the difference between DK and hyperosmolar hyperglycemic states. Read the name hyperosmolar meaning their blood becomes very, very, very full of salutes from hyper altamira. They have lots of sugar in their blood and they're in a stale, they're in a mess, okay, affects type two diabetes people and it takes a long time to kick in. We're gonna look at this in a second. Very nonspecific symptoms, dehydration, weakness, rubbish, rubbish, rubbish causes the same as the K all the same nonadherence medication infections. Finally, there are some diagnostic criteria which I'm gonna ignore here. We're gonna look on the next slide. It has managed the exact same way as DK. Basically, the reason I'm sticking over this is because of this, this is much easier to absorb. Okay, imagine this says HHS and this says DK, is that all right? So this column here, whatever you call it, Colombia is DK. This column here is HHS, the onset between D K and H S D K is quick, HHS is slow. D KFX. Type one diabetics. HHS effects type two diabetics. The diagnostic criteria for type one for DK, we've covered already the diagnostic criteria for HHS, which is really important is having very high glucose more than 13. Their blood is super, not viscous, but super hyper osmo them. So the asthma osmolarity, osmolarity, almost the same thing is more than 3 20 the higher the number, the more crap is in the blood's, the more solid is in the blood. Okay. But they'll have no ketosis or ketoacidosis. You can, you see that and the acid will be fine. Probably the management is the same give glucose, give fluids, give in student. Just these things are the main things to remember. Fine hypoglycemia is really, really simple. The only things that get asked about this in questions you'll be able to recognize symptoms. It's gonna be like shivering, confusion, seizures or non specific class. Basically, what you need to remember is how to management essentially don't forget the drugs that cause hypoglycemia. I know it's a GLP one. That's a question mark because I haven't read convincing things on sulfonylurea is too great. Presiding incident, fine loads, of course is alcohol steroids, anything and everything, fine symptoms, tremor sweating. You know what, when someone's but local because I think people felt it before. Okay. It is defined as less than 44.1 mill emo's of glucose. The normal range is between four and 5.5 or 5.6, whatever. Fine. How do you manage someone in a hypoglycemic state? What's the first question you asked? If someone's got hypoglycemia don't know anything about them? Or do you have to know first before you treat it? Are they conscious or they unconscious, the level of their consciousness? Because if they are unconscious, they've not got a safe swallow and they can't drink glucose or they can't take a glucose gel or they can't, if they're unconscious, you know that you have to give the glucose in their veins. That's the most important thing. That's what you have to ascertain in questions straight away. If they even mentioned a hint of drowsiness, they can't swallow or the most they can do is maybe a bit of buckle glucose gel or something like that, that I wouldn't even do that. I'll go straight. So if conscious you can give rapid acting because things so um leukocyte and these things, whatever. Um And then you give a slow acting, fine toast on. I've never seen a question. If unconscious, there are two types. Of course, you can get it. You can give guys just one second. We're almost done for this topic and we're gonna move on to the thyroid Arthur break. Okay. If they're unconscious, you give IV mucus just remember two and one, you can give 20% of 100 or 10% of 200 papers 22 1, never forget, 10% of 200 or 20% of 100. If you walk out the concentration, the total amount of glucose is the same between the two. But those are the two formulations that are in the BNM. You will can get asked the exact amount of because to give expertise to give IV. So be aware of it. Okay. Gruenigen is a horrible drug to give. I've actually never seen an option to actually give Glucagon questions. Personally, it has those are side effects and it's not nice. Okay. That's fine diabetic complications. So you get straight on from that, I've cried about these already retinopathy, the eyes, the retina retinal vessels, neuropathy nerves are very vascular nephropathy. We've talked about this. The capillaries in the nephron is fine, macular macrovascular. It causes all sorts of rubbish, fine. We know this way. I don't want to talk about any of this because this is all very um Rosky ish like uh speak, please speak to a patient about the diabetes and the clinic. Uh No, no, no. This is fine Osteomyelitis. This is fourth year content. By the way, someone come on, it can come up in the general progress test. But on the 50 extra questions, this is all 40 is done. It's just a bone infection and you use an MRI to diagnose them. That's all MRI for Osteomyelitis. It's fine. I know it's an X ray but MRI diagnostic pulse is the only type of ulcer. A diabetic should be getting is none really. But if they do get ulcer, it's going to be from neuropathy, inability to feel a damaged like a stone in there sheet. For example, that will keep robbing and rubbing and rubbing and rubbing and will cause a blister that will go deeper and deeper, deeper. That's how they get osteomyelitis. That's how they get a bone infection who's been on vascular surgery and seen like that feet and stuff, a diabetic foot. It's like mad, right? Have you seen it? I've seen consultants put their hands in the ulcers and they feel into the bone. The smell on that would is braising. It's like fermented wine, like cemented grapes because like all like the tissues dissolving the stuff. Nice finding. Yes, sir. Uh Great question. There's a brilliant table on that like that. Uh a neurogenic ulcer. Well, typically be on parts of like as it says that where erosion is likely to return where they're in their shoes and their foot. So stones don't happen on the top of it. They will be underneath things like this. I said arterial ulcers very distal punched out stuff like that. Um And Venus horses, we cover them, lost them. These two are the most common by that common questions. This one not really. Um And this one doesn't happen. Okay? Cool. I'm not gonna do these questions. You need me to make yourself No, no ski stations. No. Okay. Let's take a break. Uh let's say come back at seven please. Ready to start. No bickering, know chatting please. You can do it now but not when not at seven. Okay. Thyroid's next. Okay. Okay. Mhm. Uh huh. Mm. Okay. Okay, thank you. Thank you. Uh huh. Uh huh. Mhm. He finished. Uh huh. Uh for me sometimes amazing, it looks good. I'm going to go and come. Uh okay. Okay. Uh All right. Uh directly uh has been called in. Uh you can uh you don't know. Um Are they thinking possums? There was uh uh huh. Okay. These are. Yeah, good. Uh huh. Do you people up on the zoom questions? Mhm. Then take some placing this breakage next uh uh brother of you can sit down and about a couple of weeks. Does that a lot? Thank you. Thank you. Hello? I am so sorry for giving me. Sorry. Okay. You ready? Let's go. So luck. A thyroid. Interesting case. Interesting case. I do three D like this case. Um Usually we have a whole session that again to it. I'm gonna try and bust this out in like half an hour if I can and I just wanna go home. Okay. Oh yeah, that's the thyroid, by the way, we will have one somewhere. You're not. Oh, I was so keen when I really messed up now. Okay. This is a really important concept that we're gonna come come across in a second. This is more examination stuff. If that makes sense. I remember the whole swallow water, tongue out stuff like that. Remember that from your skis. That's to help differentiate thyroglossal cysts from thyroid nodules and stuff like that. Okay. This is such a waste of time. Okay. Now, what is it going to? Very important? It's just any swelling of the thyroid's. This is gonna be really, really dry this first bit. But when we actually get into disease shot last week, it'll be fun. Thyroid modules. Fine. Okay. There are three main reasons why someone steroids can be big. Okay. I either have four main reasons and I had one. Okay. It could be a nodule and I put a splash to cancer because that can cause this small growth and that's, that's fine when someone is iodine deficient. So in the third world, it's very common to have iodine deficiency. You'll see enlarged steroids. I don't know if you've seen, I'm not steroids having like an African pictures and stuff. Some people with big big steroid glands. It's because of usually I put iodine deficiency, then it can be from inflammation. Basically be an autoimmune inflammation which these both are even though they cause opposites, hashimoto's and grapes. That's fine. A thyroglossal sister's always assist anywhere from the midline here up to here, always in the middle, never deviated. There's a cyst to do with improper closure of the frame and seek and whatever it was some m biological acquires basically that we don't care about. Just know if ever a question which I don't think it will, will come up saying, um, the patient, the lump moves on, swallowing and tongue pointing. It's thyroiditis cysts. If it does both, it's the cyst. If it does one, it's not you or thyroid issues directly. Okay. Fine. I do recommend this at least one going to in order to medical school, try and feel one not your own. Someone else is okay unless you do have one. Okay. So I would physiology. It's very interesting if you remember it from some, for, I actually really enjoyed that case person. It's the thyroid. Many, many functions. It does calcitonin, it does thyroxin, it does T four, T three, it has thyroid globulin know it doesn't have any problems in the blood. It has, um, thyroid peroxidase or something like that. Thyroid peroxidase. They even, it's a very, very important book that's, um, we already know that someone talk to me about T three and T four. What's the most important things about T three and T four? Go give me the full name because it's like long, long ass names for each one. What is, what's the whole spiel about? What's the issue? Something like that. Go for it. Screen and sharp another one out. He's gone. Anyone. T three and people 66.6. Absolutely. Yeah, exactly. So, T three is like three times more potent and effective than T ball. It is the active version of thyroid woman's okay. It is produced in a ratio of 20% to 80% T four. Meaning 80% of the production of the thyroid is T four T four is less effective, less active. It's like inactive. It's like a pro hormone if that makes sense. So there's bare T four and very little T three T four. However, is a better market because it circulates peripherally when you can take a blood test and then it is metabolized peripherally into T three into the active form. That's the whole field. T three is better. How does thyroid hormone, these things, how do they travel in the blood? Is it just, there's two ways either free or bound, bound to what thyroid copy in what we measure when we measure blood test, steroids, tshs fine. But what kind of thyroid thyroxin are you measuring free T four? That's very important because if it's bound, you can't use it, it can't be convergent. The free T four is an indication of thyroid activity. Okay. That's fine. What other women did I say is made. It's true with calcium regulation when there's too much calcium calcitonin, which is produced by which cells I think it is it the parafollicular sense C cells which are, which are both very good. Okay, fine, very, very good. There's a lot of physiology, physiology had, that's fine calcitonin and I wouldn't worry about it. Okay. This access is very important. We've covered about 76 times for different things. HPI A don't worry about this. Donnie here. Just focus on these guys. Okay. And to interior pituitary TSH, post the feedback thyroid, TSH. We're going to talk about him a lot. Thyroid T four T three effect. There is negative feedback both ways. T three, T four stops. TSH, and it stops. The, what is it gonna be? Thyroid? Thyroid releasing moment thyroid. Okay. Fine. We know this. I'm not gonna, don't need any of that. It's the same thing. Okay. Just a quick thing on the pituitary which I like to make sure all the medical students' new know what drugs, what hormones come from the anterior pituitary. Say it both of you. So FSH give us one at HPV. Someone. Hey A C T H T TSH, peg p breast milk, prolactin. E I'm really happy and dolphins. Uh gee I want to get big growth hormones. So now we know TSH. So just know if there is a tumor in the pituitary you get, you can get spike in all of these things are fine. What are the posterior pituitary this too? I'm giving birth Oxytocin. Uh I need to, I'm peeing. Okay. Black peg. Always remember. Okay. Happy, happy, okay, good ACTH hormone cortisol. That's the one OK. At H FSH, ovaries, pregnancy, testosterone, all these things, TSH, thyroid H th cortisol product in breast milk and orphans, happy growth hormone muscles and face being big and stuff like that. And because okay, fine TFTs, you should all be able to interpret these without even thinking and looking, you've done the cases, you've done your skis experts. You're gonna teach me okay. We've said everything Aczone have already said T four is a better marker. There is more T four than T three, T three is more active than T four. T four gets metabolized peripherally into T three. Active forms. T four has a half life of around the week. What does that mean to have a half flight? I mean, it only loses half its amount after a week. Basically, that's important in terms of. But TSH, uh how uh long time? No, see. Okay. So just a quick thing, by the way, I thought it's really bad. What we measure in thyroid function tests, forget antibodies. We measure TSH and T four and T three. If someone has low T four, T three, what will they have? High of TSH has a reaction. If someone has high TSH as a reaction, they will automatically have hi T four and T three. If everything's working fine, usually if everything is working fine, if they have loads, TSH, it can either mean that they've got too much T four T three negative feedback or it just means everything is overactive and they get high T four and high T three. These, what I just said is the basis of hyper and hypothyroidism. Okay. The half life of T four is about a week. This is instantly if you just, just think of it as instant. So if something is wrong, look at TSH, it's gonna make more sense in a minute. Do you think of a simple way to explain this? But let's see if someone is hypothyroid, their thyroid is not producing enough thyroid. Common, common. The TSH will be high or low. It should be high. How do we, what do we give to someone who's hypothyroid? You give them artificial thyroxin, basic levothyroxine. Okay. Finally. So realistically there on the meds, they're TSH should come down eventually, right to normal. Okay. Well, it's not maybe a bit low but it should be titrated to normal and the thyroid hormone should be normal if they're non adherent to their medication, their thyroid hormone, the week after the thyroid function test, the week after will be normal, will show that their thyroid levels are cool for the TSH will be high because the fierce age is reacting to an artificially and overall low amount of thyroid hormone if that makes sense is reacting to not, not adherence. Does that make any sense at all? Any confusion? I see a scratching heads. Would you have to explain it again or do you have a question in particular? You're too smart. Very good man. She actually raises a very good point. I'm not sure as in logically, it makes sense. Shouldn't the TSH react to what is happening right now is what you're trying to say. Hmm. Fair point. I just know that the T four has a longer half life. So it takes time to react. That's what I'm so the gist of what I'm trying to say is, and this is a point that comes up in exams. If the TSH, if the TSH is high and they're hypothyroid on medication, it suggests that they're not taking their pills basically. Does that make sense? Ok. The TSH should be a marker of what is normal and what isn't running a surrogate marker? A secondary marker, indirect markers. Okay. Fine. Other things that I mentioned, I'm sorry, I didn't really answer your question. You caught me a deer in headlights. Very, very good. You've done that before as well. Thank you. Anyway, um, other things that need to be monitored are antibodies. I've mentioned basically, all of you, you're predominantly taught TSH are, which is found in graves. We'll talk about that in a minute. There's also anti thyroid, thyroid peroxides, antibody, anti TPO. There's also anti thyroid globulin. We're going to talk about all these things. These are three antibodies you should be familiar with. Fine. There's a lot going on here. Uh, let's just take a break and take it easy. No, I'm not real break, but let's just take it easy. Okay. I'll break this damage. TSH at the top of the axis fine. If that's high, that could be two things that's going on. Either the pituitary is just going crazy on its own. Meaning there's like a little tumor inside a little adenoma that's going to have a very positive feedback influence on the thyroid. Would that cause secondary hypothyroidism or primary hypothyroidism? Do we think if the thyroid is working normally in listening, normally it's completely obedient, it would cause secondary hypothyroidism. Don't, don't worry about secondary or not, it will cause hypothyroidism. Fine. If the thyroid itself is damaged through a parad itis, hashimoto's things like that. The high TSH is a reaction two, no T form because the thyroid is not working. Is everyone with me on that one or we're just heading down a rabbit hole of confusion. Inspire them in tap. Thank you know what, I'm actually gonna cover this another side. So just worry, don't worry about it. Let's break it up. So there's three things, hyperthyroidism and hypothyroidism and then sick. New thyroid is um if you've ever heard of that. Ok. Hypothyroidism is his name is also myxedema. Very confusing term. Don't worry about it. There's pretibial myxedema, these things just liquid, this uh symptoms that you need to look for of hypothyroidism in progress. Questions. They're so non specific how they put the symptoms on that. They will not say very obvious things. The things I want you to remember definitely is the non specific stuff, tiredness, low mood, things like that but you need to know the heavy periods and menorrhagia. Very important, weight gain, feeling cold, dressed too warm for the weather. That makes sense. Very important. This tiredness and low moods, all other differentials can put these together. Shelter, depression. Why not another one? Pecos. Yeah, that's fine. I'll take that anemia. Yeah. Really good. PS PSEO psa isn't that common as a general medical presentation, but you're absolutely right. It does. This is known as tired all the time. Basically, it could be things like our Addison's we've covered already. Diabetes. We just cover that as a few minutes ago. Anemia, depression, fine, just be aware of these things. Moving on. This is what you need to answer me now. So answer these questions. Hypo thyroid is whatever the cause there is a low amount of thyroxin in the body. They're running slow. What's the most common cause of hypothyroidism in the world? Very good. What is the most common auto immune can cause probably ashy motives. Very good. Fine. Which drugs can cause hypothyroidism. Uh huh. Hypo hyper you use that to treat they can cause hyperthyroid is very good. Send me some drugs, carbon result. So any okay, I'm gonna class that as one drug. Carbimazole, propylthiouracil. Any anti thyroid drug that you would use in hyperthyroidism obviously can cause hypothyroidism. Put that to the side. That was a good shot. Anything else I'm ordering, which is used to treat broad complex tachycardia. So everything is very good. Another one used in um bipolar disease, lithium. Very good. Okay. So, amiodarone is the main one. Amiodarone causes a toxicity, fibrosis, lung fibrosis as well. So just run that awful drug. What is subacute thyroiditis? Does anyone know parotitis? Fine or subacute about it? Shot divorce. Yeah. So its before t three and T four about to go bad, the TSH will react first instantly. So you have A I TSH typically due to infections cases, secondary courses are, if we said these are all issues with the thyroid itself, if it's happening more superior in the brain, it's hyperpituitarism, an adenoma by the way would cause hyperpituitarism. So I purposely tourism, very rare. Don't worry about it. How my pregnancy have been involved. Has everyone heard of sheehans? It comes up. We need to be aware of it. It's very important, very rare but very important. There's also postpartum parasite is very important as well. Okay. Any questions? Fine, fine, fine. It's just telling us why we're through with these tests for um, your urine because it causes thyroid, liver and lung fibrosis responses problem. Okay. Moving on. This is all extra stuck of it. She Hunt syndrome. There's like three syndromes that will sound the same, but they're all different. There's Nelson's she hands and Asherman syndrome. Ashmans is therefore she has this this year. She hands is a woman who has given birth has gone through an immense amount of postpartum hemorrhaging bleeding, which is very common. She's lost a lot of blood. She's been transfused and she's in the theater, she's fine. But that loss of blood will negatively affect hypervascular, intensely perfused areas of the body, the brain, she's not gonna stroke out, but she gets a low amount of blood flow to the pituitary gland. So it is essentially a, it is not a stroke nor is a mini stroke. I'm calling it this for the sake of explanation, a tiny baby stroke of the little pituitary gland. So they get atrophy in the scheme of the pituitary pituitary gland causing like hypopituitarism. Does that make any sense? Very rare but very pick it up in progress. Has straightaway, see it postpartum and she has hypothyroidism. It could either be this or put and it mentions you had a hemorrhage like a difficult gestation Carlos. Is this find post partum hemorrhage, pituitary receives less blood necrosis in pharmacy. We just said all of these things baby, mini, mini, mini, mini stroke, pituitary gland, the patient will have hyperpituitarism blood, the blood supply to the pituitary gun doesn't selectively choose the um thyroid trips that release that or the thyroid stimulating hormone. That's all of it will go that make sense. So flat peg we just discussed, we'll get all of these things. A lack of breastfeeding, low product in uh Asian FSH, their period won't return after like six weeks after post partum bleeding. Um you know, post nasal bleeding that period. Um They'll get in all of these things. Does that make sense? The flat peg will go. That's what I'm trying to sing. She Hanson. Dream, happy or not happy questions. Cool. Hashimoto's is the most common cause of hypothyroidism in the western world because we have iodine in our salt. We have iodine in our bread. It's supplemented in our western diets. Okay, autoimmune conditions. So look for also other ultimate conditions, type of diabetes, vitiligo these things. Okay. Um, one thing I want to say, what is the typical, um, sexually the patient course of hashimoto's. What usually happens. How does it present over time? A little bit? Yeah, let's see. On top of your time. No. Yeah. Yeah. Sorry, go ahead. Exactly. Yeah. So what happens in Hashimoto's is found? Um, um, and Hashimoto's, it's, um, it's just a bit of confusion. You start off with hyper and then it goes hypo. Why does that happen? Does anyone know we'll talk about a second? Don't sell it is acute license of cells that releases all the content of therapy of the physical er, cells that have thyroxine and stuff. So you get a brief uh, thyrotoxicosis that goes down because the cells are dead into thinking. Okay, typically affects middle aged women. Fine. What are we looking for on blood tests? So it's going to show what the TSH show. Hi, what the T four T three be long term. What other things were looking for? Anti TPO, would that be raised or raised? And another one, maybe anti thyroglobulin? Very good. Everything we just said is right there happy you worked it out yourselves. They're all very, very good. What's the son called Hampton sign? What causes it? An obstruction to the head and neck veins? Basically, in this case, we're gonna be referring to what would be causing that. A big retrosternal going to that's pressing on the thoracic outlet in that whatever you call them, right? And I'm gonna do the hands up. It compresses even more. So clavicles and first rib come together, let me do this, right? So it compresses with the guy to all the veins and stuff and then you get a nice red face, okay? Okay. Um This is all a ski stuff thing is it's kind of important because they can describe the presentation of a patient in a progress question. They can say the patient as puffy eyes and loss of the outer third of their eyebrows. What, what condition do they have? Okay. I'm going to ask you to read this in your own time. What are these signs? What's the sign here? This is called a nickel Isis. Everyone has anyone heard of that? Okay. It's like uh it's not coming this, it's um it's a detachment and then I don't actually know how to describe it. It's like the nail bed, like detaches and messes up or something. Splitting of the nail bed. Or even this is called queen and sign. Is it just like being Yeah, basically her eyebrows were super thin. So like they said, this poor woman just getting, she's getting roasted in her grave man's. Um but it is the after 30 eyebrows. Anyway, I will join us. This, it's called peach and cream complexion. This space, I've never seen anyone in this place. I can ask you if everyone scars. Move on, quick question. Move on. Now. Then, then what did you in the clinic? Something? Examination. No way. Nope. Nope, no. Thank you. Buy it. Buy it. Buy it is hyperthyroid isn't a big deal. So what if they have low thyroid? Then what's the problem in pregnancy? If they have left? Both are at home and they're going to die? It causes hyperlipidemia. So it's a problem in itself and there's something called myxedema coma. That's why it's called Myxedema itself. If you're gas, if you've driven a car on low fuel, by the way, you see every single system in the car slowly. If you know when I say low, feel I'm just looking the red light past the red light like the little beat and like you're running on fumes. Imagine your body is running on fumes in terms of its metabolic rain. You notice that the battery starts to go, the starter motor that alternator everything just going slowly, slowly slowly. So you become hypothermic. Your brain function messes up. You get psychotic and then you fall into a coma and then eventually die. If you don't have enough petrol in your engine, you're screwed. If you don't have enough thyroid hormone in your body for a long period of time, long day, or short days to you. Rather. Okay. How do we treat hypothyroidism? You help me? I think that's actually a, that's fine. Yeah. Ok. Just with, just so, you know, they can ask this. I've seen what happens definitely in my ones always you start off with a standard dose of whatever the B N F S. So between 50 and 100 or whatever, okay, you increase dosage is by 25 micrograms every time or you decreased by 25 micrograms every time. Never more. You start, if someone who becomes pregnant, you increase the dosage by 25 the moment they become pregnant they've conceived then basically they're, they're on the gestation list. Fine. Um That's okay. Okay. There's nothing that's to do with that wanting treatment. Another whole thing. I was crying about the TSH and that subclinical um nonadherence that I got exposed about. That's what this side is. So read that okay, other side of the queen, I'm her thyroid is um this is the second last thing we talk about. Okay, hypothyroidism, overproduction of therapy in and buy the caravan thyrotoxic osis. So can you see how high priorities can cause thyrotoxicosis? Happy? Fine. What would you expect to find in terms of symptoms and presentation of something with hyperthyroidism, agitation operations. Yes. It again. Yeah. Weight loss, fine. Someone said I is something bulging eyes that could be one fast metabolism, weight loss. Okay. Fine. What about their periods? Light or gone periods completely? Okay. Anything else? Diarrheas are very good. So, oligomenorrhea, that's what amenorrhea, similar thing I problems. We'll talk about that gritty eyes. What, what type of hypothyroidism courses? That good irritability, overactive psychosis, female. Fine. Okay. And appropriate. Okay. This is just differentials. This is all. Ask you, do you see how Rosky focus this was? We should have done some uh what's the most common cause um of hypothyroidism in the UK good or some other causes of hypothyroidism can affect older people probably or young people. So toxic, multinodular goiter thinking another one, if there's multi, there's also solitary, solitary nodule and post partum, I think. Yeah, toxic, toxic. Other name is what modules and thyroid isis, whatever is okay. Um Who is normally affected to see the elderly toxic modules complications. So you can get something called high output cardiac failure, fine. What drugs can cause hypothyroidism, Neevo. And yep. And I'm, you're drin amiodarone can cause hypo and hyper yes, great drug. Great drug is thyroid nodules. Okay. This this whole thing about hot. So what you do is if someone has a thyroid nodule, feeler, you send them for a radionuclide scan which shows how if it's really active, it will take up loads and loads of, like, um, the radionuclide, it's radioactive iodine. I stood like, I don't know what the number is. I, is 66 or something like that for them. If it's hot issues, something, if it's warmer. Sure. Something it's cold is showing something. I don't want to get into it. But essentially what you'll see, do I have a thing on it? No, I even read the side because it just doesn't come up. You'll see that it'll be really patchy distribution. That's toxic. If you see one hot nodule on its own, that's probably, that's the one nodule on. So that's probably um a solitary. Uh I don't know or something like that and if it's cold, whatever that means, that probably leads to like it means like a bad cancer or something like that. I don't know. We're just really not taught this very well. So I'm not helping. Let's talk about grapes because we all love grapes and everyone knows about it. So, um it's an autoimmune condition where something affects something great explanation what antibodies are found in this commission. TSH are anti thyroid stimulating hormone receptor antibodies. There's TSH released from the pituitary, it goes down and it hits the TSH receptor on the thyroid gland that stimulates the whole producing thyroxine. If you have an, an antibody hitting that receptor, that isn't TSH though, you're gonna have really high amounts of thyroxine produces, that's all it is. So you get high TSH are and you get low anti TPO, what thyroid function tests were you expressed with A T F or the TSH? Be in this? You know what the T four T three then expect it? Okay. Simple. It can also cause eye symptoms in prolonged disease. What is the single biggest risk factor other than having graves' by having graves, eye disease, say it, smoking, puffing them, them sticks of joy. Certain. Okay. So what signs would you say on the examination? Nope zero, none of that when I looked in there. So these, these, these labs in Asia. So you get on a crisis again. Is that clubbing acrobatically? Okay. New. So clubbing refers to this but only acropachy refers to Casey. The knuckles have become very big and developed fine. This is Graves eye disease. So it's called exophthalmia proptosis. These things a little lag. You get gritty eyes, it's very painful by the way. And you, this is, I don't know, this is called pretibial myxedema. Maybe see it's to wear this condition because myxedema refers to hypothyroidism. So I don't know what they were doing. If someone's an endocrinologist in the audience, please tell us. Um, okay. Graves eye disease is a lot of text. They're all it says is painful. How do you manage it? Stop smoking and surgery where they go into the back of your eye and they removed the other retrobulbar fat pads, they d bulk them to give your eye more room to move around. Really, really nice, isn't it? You know? Okay, quick quiz that we're not going to do. How do you manage it? Guys? Help me out. How do you manage hypothyroid ast? So give me principles. Let it start throwing words at fine. And once you've done that, just gonna leave them to die, you have to do something that you're gonna block something you have to. Yes. Replace if the block and replace, you can't just block their thyroid. There are some regiments out there that say you can just block it ever so slightly and then tighter it titrate it. I don't actually see that in questions. What I see mostly is you block and replacing title if that makes sense. So the three main treatment options are, we'll talk about this pharmacological radiotherapy and surgery, fine, fine, fine drugs, radiation and then cutting out. But the pharmacological treatment, it's like this palm culturally, you have symptomatic management for Panalog, reduce the heart rate, keep them calm, stuff like that. Or you can actually tackle the, you can hit the thyroid itself. There are two drugs that I used. Carbimazole and prep carriers. So we don't use proper appropriate carriers in the UK. I'm pretty sure just call them as well as you become aware. That's technically just blocking and you could try and titrate it. It's like if we give this much carbon result will block the thyroid by this much. And then the thyroid will be able to produce, will only produce a certain amount. I think what's more common is block and replace where you block the thyroid and then you replace it. Think about it, if you block the entire thyroid, they're going to go into hypothyroidism, aren't they? So we have to replace it with levothyroxine. Fine. So just because someone is on levothyroxine does not mean they're hypothyroid. They could be hyperthyroid. Fine, welcome, replace um fine, fine, fine major side effects. So if someone on carbimazole has a sore throat, what we're worried about? Thank you a says it right that Boston a granular cytosis. So one of the main side effects is that it stops making white cells and stuff, which isn't great. So um the first thing you need to tell the patient this is counseling. But if they come in in a question, you know what to say, they need to be administrated way given antibiotics and monitors, okay. Fine. Radioiodine does not happen in this country at all. I don't see it ever. Maybe like super hyper niche patient's get it in the endocrinology, but it's not common. Essentially you, it radiates with radioactive iodine to destroy the thyroid. Um and then you give like levothyroxine for life really weird treatment. And there's a lot of extra guidelines. Like if you, if you p or pure in the toilet, you have to flush your toilet twice because of the radio activeness. You can't hug your Children. Three weeks different bed, different room, wash your clothes in a different watch to them. Uh, really as a really convenient. The last thing is you can either cut out the thyroid, half of it or all of it basically. And that is guaranteed to cause hypothyroidism. Right. So you have to replace for the rest of their lives. That's the problem. What's the, what's this is super niche E N T knowledge? What is a huge problem or complication of this surgery when you do thyroid actings? No, really good. I was even to say that. So, nerve issues which will cause um, falseness of the voice, recurrent laryngeal nerve. Fine. Another one I know. Well, I said that I came as well raised. I'm like, you know, it's a boy. So just the voice. Yeah. Very good. Exactly. There are four glands behind the thyroid called the parathyroid glands, right? They are always left behind, but sometimes it's hard to differentiate and some surgeons they have issues removing it alone. So you can accidentally cause hypo calcium, which is not good. So, the first blood test, the patient who's had a thyroidectomy guess is a calcium blood test. A bone profile basically to find out are they hypocalcemic or not? Fine? I think that's what? Yeah. Yeah. Fine. Fine. Oh, yeah. Shoot, this is really bad, by the way, a thyroid hematoma, it's an ent emergency. Um, basically they stop breathing and they die because of like a build up of like a blood clot inside. The thing. The thing is, I always used to think that the hematoma would compress the trachea. The tricky is hard and tough, right where it actually does, it compresses the veins around the neck and then it causes um, back pressure on the heart and then they go into heart failure. And I'm um, so you need to either some f ones that had to do this before, cut open the thyroid scar after surgery to reduce the pressure. Does that make sense? Postop to release some, there's some great Matthew rubbish place in. There's some bad stuff you learn optimal next year. Some iphone's, I've, I've been told that if two is whatever people who have like really bad eye infections, they've had to cut their, I open to the side to reduce pressure. There's a name for that little procedure. But if they don't do it now that they'll lose their or some, some of them. So when you're selecting F one post, don't take ophthalmology. And basically, uh so these are some progress test, honorable mentions what to do if someone has a thyroid storm, a thyroid storm is thyrotoxicosis, basically, ridiculously high thyroid moment. Too long. You need to calm them down. Basically, these are all of the causes, these are all of the symptoms. They'll be fever attacking, they'll be very unwell, basically, very agitated. Um Car engine again, you know, when, uh when the bald guy in Fasting Series of Indies or whatever, right? You know, he does that night respond like, like throughout the whole film, just Nitrous engine goes crazy for like three seconds. Imagine that's the whole of your day there. It's nitrous the whole not good, right? And then they'll die. Your heart will pop, your bedroom, pop, everything will pop. This is how you manage it. You get, you get, you don't get a whole base blocker. You, I did this blocker. You calm the whole system down. Um You also give steroids and these things. This is really hyper niche. I learned it from my finals, but I don't actually remember learning anywhere else. I've never seen the question either. Subclinical disease basically. Is our friend mentioned it normal thyroxin but abnormal TSH if that. But then on medication. So it's a subacute subclinical condition. Very rare. It's usually through an inter current illness or before they're about to become pretty ill with thyroid problems. Hypothyroidism, hypothyroidism. Just three. It's rings normal T four t three low TSH. OK. Pregnancy and thyroid disease. Nope, moving on thyroid medicine, pregnancy. I don't think this is going to come up. So I'm going to leave on tired cancel, this does come up. Okay. There's one thing you need to learn about this, the prevalence and incidents of thyroid cancer. That's the only thing I mentioned. Please find my auntie Lauren pillories by, for the most common type of thyroid cancer. Okay. Um, and all the cancers like arthur testicular, it's the best cancer to have or something. If you're gonna have a cancer, if that makes sense in terms of prognosis and survival, survivability. Um, those of you that remember men as in multiple endocrine neoplasia, the thyroid stuff is always this one medullary. Okay. Anaplastic has the worst prognosis. It's so aggressive. It's really bad. Anyone, anyone who remembers my Hodgkinson firm a lecture as a new ball should remember because that's the one we got kicked out. Okay. I just got onto the bit where I was saying if you have a thyroid lymphoma, it is associated with non hodgkin's and hashimoto's thyroiditis. Sorry. That lecture. I mentioned this lymphoma. Basically. Hashimoto's thyroiditis is associated with thyroid lymphoma but it's less than 1% population. Please find my Aunt Lauren really important that you know, the thing they always ask. What's the nice comment? Bad cancer in a patient with who also got pheochromocytoma and parathyroid. Uh What's it called? I don't know that they've got like three cancers together. Thinking men and the medullary thyroid. Oh, okay. That's what the options does everyone and I was just talking about it. The whole men stuff. Okay. Cool, cool. Nope. Uh men. Nope. We just talked about that. Nope. Nope on your face. Do you think that's it? Dunk? It's a callus next week is the last ever session. Bring your friends, bring your family, bring your parents will do a little graduation. What I'm gonna do? Um Yeah, that's already any questions last night. I'm not take care fight. Yeah, that's fine. Yeah. Advising deputy questions. Nope. Thank you. See He Wang. Yeah.