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but good. So let's talk about the, um, investigations for polyuria. Okay, so we talked through some of the key differentials. Gonna talk about the investigations in a bit of detail to remember when we're classifying investigations, and I'll see we divide it into bedside investigations, blood tests we want to do on our imaging and special tests. Okay, So can you give me some general investigations that you think would be useful to mention in an Oscar for polyuria you and it's okay. You're going to do a bunch of urine test. Okay, Um dipstick, urinalysis, um, HBO And see so that that's specific for diabetes. Diabetic patients should mention it. Blood glucose. Okay, so but any polyuria you would say you do. A BM became blood glucose measurements. Uh, what about it? Thinking about diabetes, insipidus. Is there anything any general investigation that would be useful Blood tests? Yeah, morality. Okay, Steelman, uh, the the plasma and urine osmolality. Okay, as well as you need. Okay, so, for any polyuria. Okay, these are some of the key things I think would be useful to mention. So basic observations. You announce that's very important. Okay. We'll talk about how to interpret your analysis on the next life. Um, so, you know, this is very important. Mentioned you calculate the urine osmolality and the senior most velocity. Okay, because particular for diabetes. Insipidus you want to catch at the paddles? Morality's to check if there's any descriptive pregnancies, They're okay. I think about diabetes. And stupidest, where the urine becomes very diluted. Okay. So the urine osmolality will be very, very low on Lucas and keep tones. This should be very obvious. Okay. Think about diabetic diabetes. Uh, you And he's What? What's the point of doing you knees. Why do you need to do you need? Yeah, that probably is a good one. Dehydration. That. Another big thing I can think about if there's a creatinine bump hyperkalemic Good. So you know, things like, um, DKA the essential potassium to services. Yeah. Sodium is another big thing you want to check? Okay. Particularly for, um, die views. Insipidus. Where there's there's a problem. In regulation of water, you can get a sodium disturbances with that. So those are some of the tests I would mention for any polyuria. Okay. Doesn't matter what the cause. Uh, what, you think that likely cause is okay. I would mention all of these tests for any polyuria presentation for specific differentials. There's some extra things you can mention you would do. Okay, So type one diabetes mentioned that you do a blood glucose measurement as well. Okay. As well as a type two diabetes CPAP types. Um, a Z Well, in type one type one diabetes as well as anti got antibodies is about a bit more specialists investigations that. But you can offer to mention it. I can type one diabetes because sounds were being destroyed. C peptide will be low again. A lot of time. Type one diabetics will have a positive, um, anti glycemic acid decarboxylase. Um, antibodies. Okay, The type two diabetes. You can also mentioned you do a fasting glucose double. Okay, as well as HBO. And see, we'll talk about differences in his bones. How to use the HBA. One C in fasting, glucose in a bit. Okay. And okay. Tell me, why do you not use fasting glucose in type one diabetes? Okay, right away. I want to see our way. Are we using type and fasting lookers? Yeah. Risk of high person were on the type one diabetics that insulin dependence. Okay, so you don't really want them to be fasting? Desperation, Blood glucose measurements. Okay, so it depends, and it's a risk of hypos potential risk of DKA as well. Okay, um, see it. That's what risk of, um, don't do fasting glucose and type one diabetes. It's usually just a clinical assessment off hypoglycemia with based on clinical speech is okay. Cranial diabetes insipidus. So we'll talk to you. Is these investigations but the keep the investigations you want to mention are your fluid deprivation studies and your DESMOPRESSIN test? Okay, these are your investigations for diabetes insipidus prolactin to remember with renal diabetes insipidus. It's usually due to a problem and your pituitary gland. Okay. And, uh, often it could be due to to to have a normal prolactin is one of the most common is the most common functional pituitary adenomas. That would be a you saw blood tests to mention is Welchol cranial diabetes insipidus at more ahead as well, because the solution in the brain also useful to say, an MRI head. Okay, cool. So let's talk about So we talked through some of the general investigations for Prolia Okay, let's go through urinalysis. So one of the specific investigations we mentioned was to do a urine dipstick. Okay, This is something that a lot of people like to do after you study that. Well, okay, how to actually interpret your analysis, but these are the sort of key different parameters that you can get on a urine dipstick test. Okay, so and it's important to be able to understand the technical significance off each of these different parameters. So for ph. Typically, normal range is between 4.5 and eight. Okay, but it's not that clinically relevant. Okay, But if someone has a high peak age, if the urine is very Alkalaj sick, that sort of indicates that they have lots of protein in the urine. Okay. Sorry. The lack of protein in the urine. Okay, That could be because I have a vegetarian diet. Essentially, ever uti. Okay, low be HC and other things. Such as if they have a high bruits in that. Okay, it's not that expensive. Relevant glucose. So you guys know how I glucose in the urine suggestive of diabetes? Um, that's a major thing that can be other causes off high glucose in your urine as well. Ketosis. Well, you guys know this. If someone's prolong having some prolonged fasting okay, as such as a starvation they could back and close like eat. Owns diabetic ketoacidosis is characterized by high levels or ketone, so they could be positive on a urine dipstick. A specific gravity. Can anyone tell me what specific gravity is? What does it mean? What does the actual term specific gravity of off the year and me? Yes, it's basically the amount of stuff that's in the year. Okay. And as someone said, it's basically corresponding with the osmolality off off the urine. So essentially, if someone has high, you were no small deed. That's the civic. Gravity is going to be high as well. Okay? And someone has low urine osmolality the specific gravity will be low. Okay, So again, it's basically the amount of solu It's desert devolved in the urine. So can you tell me what's the specific gravity off your water off your Stillwater? What's the specific gravity? Yeah, it's one. Okay. So specific gravity of water Okay, is one. So everything is basically a relative to pure water, so they're all normal range off. Uh, urine is typically between one, but not not 2 to 1.3 five. Okay, but if you have someone who's got particularly concentrated urine, okay, such is in dehydration or other causes off very cold hands and fated urine that can increase these seven gravity if someone has very diluted urine. Okay, So low your nose Multi. Such as in diabetes insipidus primary polydipsia that can reduce the specific gravity. Okay, So diabetes insipidus, which we'll talk about a bed, can have a low specific gravity protein. There's many causes of protein urea, which we relevant to other discussions nitrites seen in UTI. So okay, particularly gram negative infections. Like cola looks I s s rays. CNN indicates white 1000 urine. Okay. Could be seen in UTI. So, uh, blood in the urine. Can you guys give me some causes off? He materia What can cause a positive bloods? What can cause positive blood on the urine dipstick? Yeah. Nephric syndromes. Uh, different types of cancer. What? It is not, um he material. What? What else can cause a positive blood on a That's that you have robbed? Um, I rubbed on my OSIs. Okay, that's a big one. Yeah, my globin uric it. Okay, so he thinks so. Hematuria is many causes. Okay, So bread, blood cells in the urine. There's many causes of red blood cells appearing in your urine. Hemoglobin, urea. What can cause hemoglobin to end up in your urine? It doesn't want anyone have any idea. Yeah, someone has severe hemolysis. Okay. Intravascularly mal Asus on that because chemo globin to end up in your urine. Okay, remember, generally, yeah, it would have to be very, very severe hemolysis because typically, when you're ready dot sounds great. You usually have things like haptoglobin, which can bind all the hemoglobin and the blood. Okay, so if someone has hemoglobin in the urine, it indicates that they have very, very severe intravascularly mal assists. Okay? It means that the most this is so severe that have to go in there, not finding up the hemoglobin. My living area working cause my blood been two and a pin your your Yeah, rhabdomyolysis. Okay, so someone's got some situation of skeletal muscle breakdown. Okay, That can cause my glove and to end up in the urine. And that can cause a positive positive blood on a urine, dipstick. Okay, You're a pill in June. Billy Rubin. So we're going to talk about them. Okay, this is is relevant to your biliary obstruction, okay? And yours? It's part of it's important part of assessment for jaundice patients. If you want to learn more about how to interpret your ability gyn and Billy Rubin in the urine, Um, make sure you check out my Jonas for finals weapon out, which is currently available on the metal clasp from Okay, Cool. So we just talked about how to interpret your now since. Okay, Now, let's let's come back to diabetes. So we're gonna talk about the diagnosis for diabetes mellitus and how to diagnose diabetes. She's insipidus is well, so diabetes mellitus. Here are the key numbers. Okay, so you just need to be able to remember these numbers, Okay? The three main ones remember 11, 7 and 48. Okay, So if someone's random glucose or there, world records tolerance test is greater than or equal to 11.1. That's diagnostic off hyperglycemia, okay. Or someone's fasting. Glucose is greater than seven. It also is diagnostic off high glucose levels. Okay, if someone teach, be able to still. So hemoglobin a one C is greater than or equal to 48. Okay, that's also diagnostic off high blood glucose levels. Okay. Remember, the key thing to remember is that for type two diabetics, Um, if they're not symptomatic, you need to separate measurements. Okay. You need to separate measurements off high glucose levels to diagnose type two diabetes. Diabetics. If they're symptomatic, then you only need one. Okay, but if they're asymptomatic, you need to a separate blood tests. Okay, so that's your diet diagnostic. So that's that's how you diagnose diabetes mellitus if they're not quite the level of diabetes mellitus if their glucose level is high, but they're not quite the level of diabetes mellitus. That's basically this spectrum off prediabetes. Okay, prediabetes is the spectrum off where patients are at high risk of developing diabetes mellitus with their glucose isn't as high elevated. Okay on do you can do vied prediabetes into impaired fasting glucose levels and impaired glucose tolerance tests and that glucose tolerance. Um, if someone has impaired fasting glucose, it means that the fasting glucose is abnormal. Okay, but they're oral glucose tolerance test is normal. Okay, So they have an abnormal fasting blood plasma glucose level. If someone, if someone has impaired glucose tolerance test in Paktika Stalin's, it means that there or glucose tolerance test is abnormal. Okay, Doesn't matter about the fasting. Glucose is if someone's oh G T. T is between 7.8 and 11. That indicates it's that they have impaired glucose tolerance. Okay, that's your prediabetes. And that's how that's the basic investigations for diabetes mellitus into diabetes. Insipidus, um, is a major things you need to remember. Okay, so we have three different conditions. Your primary polydipsia where patients are drinking too much. We talked about it. And after a cardiogenic diabetes insipidus and cranial diabetes insipidus. Okay, so there's two different investigations. One is your fluid deprivation studies, and one is your DESMOPRESSIN administration test. Okay, the key goal of your fluid deprivation studies is too. Um, basically either rule in or rule out diabetes insipidus. Okay, so if you think about it, if you don't drink for a couple of days, Okay. What do you expect to happen to your urine? You expected to become very concentrated, right? If you If you just don't drink for a couple of hours a days you start producing very concentrated here. Okay, so you're now smile. She will increase so someone doesn't actually have any pathology. Okay, so they don't have any diabetes, insipidus. Then what's gonna happen is that your your personality will increase. Okay? If they're if they just have primary polydipsia where there's nothing actually wrong with the kidneys or pituitary gland. If the ADH. Is working normally, then after fluid deprivation studies your urine osmolality will increase. Okay, if it doesn't increase that diagnosis diabetes insipidus. Okay, um, so if the urine osmolality remains low after flu deprivation, that diagnose is one of the island after Jack the eye or cranial. Be okay. In order to differentiate between nephrogenic d I or cranial of the eye, you need to do a desmopressin administration test. Okay, so desmopressin is a synthetic form of a D. H. Okay. Uh, doesn't don't know. Why do we use a synthetic form of a T. H desmopressin? Why don't why don't we just use actually 88 to do the investigation? Also problem with using actual 88 on short. It's short, short acting good. So but what's it? What's the other name for ADH the basic pressing. Okay, it's in the name basal pressing. Okay, so 88 is a basic press. Okay, You can have effects on cardiac contract contractility. Okay, if you actually use proper a th, it can affect the cardiac contractility. Okay, that's why you use a synthetic form off 80 eight's. Okay? Desmopressin. It's a lot. It's a lot safer to use than actually V eight, which, um so yeah. So when you give desmopressin, um, what's gonna happen is if someone has cranial diabetes insipidus where there's a lack of 88 and then when you give desperate press in the use of urine, osmolality should increase. Okay, because you're you're just replacing the efficiency, but with nephrogenic diabetes insipidus because the problems in the kidneys, your hospitality won't be it won't change after desmopressin. Okay, so those are your investigations for generally for diabetes mellitus and diabetes insipidus So gonna sort of I have a question for you guys. Can you guys tell me one should be able to be avoided to diagnose diabetes? Reglan C gets so Hey, try and see can be low and pregnancy hemoglobinopathy is good. Any other scenarios? I'm deficiency anemia. Yeah, um, splenectomy is a good one. Okay, so if there's anything that's gonna basically affect the red blood cell life cycle, it's basic. You shouldn't really used to hate to be MNC. Okay, Type one diabetes mellitus. Good. You don't use HBO and see for type one diabetes mellitus. Okay. On in Children in general. So here the key still of different situations in which you should avoid using the HBA one c. Okay. Um, so have a read of them. Um, you you you've mentioned most of them. Okay, cool. I'm not gonna go through this, okay? This is just for your revision, but on technical skills that you could be asked to do is to do a B m. Okay, do a blood glucose measurements. Okay, So if you want some quick clinical skills revision, I've listed some of the key steps to remember when you do a lot glucose measurements. Okay. Remember, always dispose off the shop in a sharps. Been okay? If you don't. If you forget to put the test strip in this in the bin, that's a potential safety. Let's do Okay, but yeah, make sure to revise your clinical skills. Okay, so we just talked about the of GP presentation off polyuria. Okay, we talked about different GP presentations. Now we're gonna talk about an emergency hospital presentation of polyuria. Okay, which is DK common complication off type one diabetes. And I tell me if the Examiner ask you to discuss the management off DKA, what is the first sentence you're going to tell the Examiner? Yes. Good. Okay, way started throughout the series. Okay? But you mentioned that you had taken a B C D s, um, approach okay, on assessment. So I would go through some Ah, go through just to stop. That's relevant. Okay, So general airway assessments, things like checking of the patient is talking. And if the airways patients, okay, and if there, if there's evidence off a compromise, give this evidence that the airways, not Beaton's, do things like our maneuvers and insert a jumps, Okay, Like or a prandial Airways needs a pound. You'll always okay in terms of breathing. Can you guys tell me some things that you do for breathing for DKA patients? What would be relevant? Always. You'd mentioned you do everything, but what's the stuff that's relevant for DKA? Yeah, spiritually. Eight What else? Yes, my left breaths. Okay, that's a good one. What? What do you need to check? What else do you need to check with their breathing in DKA? All right. I spoke to a bunch of water. Yeah, um, but you said hyperventilating cause more reading goods. Okay, maybe G is another important one. Uh, breast sounds cool. So check auction saturations. Hopefully, you guys mentioned that, uh, check respect to wait, cause more breathing. Doing a BG and stop type of oxygen. Okay. It's an acutely unwell patient. As you can tell me. Terms of circulation. What are the stuff? That what's relevant to do not pressure goods. Okay. DKA patients. They could be berry d. I drove it. It's okay. And they have a risk off, uh, gang hypertensive. Very quickly. Cap refill goods. Okay. So, general, looking for features off, um, shock. Okay. Different things to look for a shock. Okay. Hyperkalemic shock. Um, what interventions would you do you like What kind of treatment could you start now? Yeah, it's Ah, ablation. Trevena success. Okay, too big cannulas and both arms fluids. Okay. Uh, so some of that fluid boats of BP less than 90. So you'd give fluids in general. Okay. You're gonna start fluid resuscitation, whatever their BP is. But if it's if the hypertensive you definitely you give it as a stop. This, uh what I typically one lead to normal saline. Yeah. You guys have got most of them. I think it start insulin. There's what? In circulation. So we talked about the T. Things are different things to assess for shock. Okay, start normal ceiling. Okay. Five millimeters. Normal saline typically start if they're hypertensive. Um, and then you write gradually, slow it down. Ah, one step. BP is, um, normal on start the Testim replacement as well. Okay, we'll talk about the testing on the next line, but you can start the task in the basement as well, once you know what their results. But it's okay for the potassium on. You can start the insulin infusion at this point as well. Okay, once you suspected, it's DK. You need to start the incident. Infusion. It's possible. Typically, it's gonna be a fixed rate infusion. No complaint. One units per kilogram per hour. Okay, um, stuff. It's a if it's 80 70 kg, man, you're going to give seven units. Okay. Um, there there was a different things we need to think about with circulation Disability. So general things. Okay, check the after level check. People's are equal and reactive to light. Check. Blue goes. Keep your levels that very, very important. Okay, um, make sure you mention that on. But also, I would say a good thing to mention is that you would establish a monitoring regime. Okay, so remember DK's all about monitoring. Okay. You need to check a bunch of different things at regular intervals particularly. You need to check that glucose levels. Check that ketone. Check that VBG. So Okay, just do the venous blood gas regularly to check electrolytes on very, very important different stuff you need to monitor. And finally, in terms of ee exposure, uh, general things inspect for features of DKA. Okay, they go. Any signs of infection to remember? Infections. A very common trigger for DKA. And he features any injection sites for insulin. Check that BRAF odor. Okay. So you can mention breath order with the breathing, or you can mention it. Here is well, check temperature. Do your analysis as well. Um, m c and exchequer infection again, Make sure you mention you instead of catheter. Okay, very, very important. Okay, Is particularly DKA where you want to monitor their fluid inputs. And, uh, puts, um, very closely. You need to mention that you would instead of catheter just x ray because you're looking for signs of infection on. But you can consider giving trouble for prophylaxis like heparin as well as inserting an n g tube. Gave the having difficulty feeding. Okay, So that your a b c D. Assessment. Okay. These are the different things. I I would definitely mention if the Examiner asked you to discuss the acute management off DKA. Cool. So this isn't that slide. Uh, I made last year to summarize the management of DKA. Remember, in terms of the diagnostic trial for DKA. You looking for three different things. You looking for hyperglycemia? Okay, so that glucose is greater than 11. Check the pH. Okay. Do they have a metabolic acidosis? So the ph lower is Ah. I can't really low as well. Okay. Less than 15. And finally, do they have any feature off key tones in the blood? Okay, So keep Donia. So if the key towns is greater than three. That's also diagnostic. Okay, so you need both to three different things to form the diagnosis of DKA A Okay, in terms of the general management that it's very summarized this like, Okay, I have some right into the three different major aspect. So you want to get fluids, okay? And this is a typical of fluid regime, so he give fluids very aggressively. Uh, the starts again. Gradually slow down the speed at which you give fluids. Uh, give incident. Okay. Given fixed incident infusion rates. Okay, if they typically take a long acting insulin, we'll talk about different types of instant in a bit, but they take a long acting insulin. You can continue that on, but but yet make insulin Very important aspect can use, um, what is the most important reason why you give insulin in DKA? What's the major reason why you give insulin? Do you give it to bring down glucose levels? What's the what was the most important reason why you give insulin potassium? So we'll talk about potassium. So the most important reason to give insulin is to stop producing heat Jones or someone said Okay, That's the most important reason to just switch off ketogenesis. Okay. And reduce the ketoacidosis is okay. Remember, in DKA, the big problem isn't really the high levels of glucose. Okay, That's not what's going to kill the patient first. Okay, It's the ketoacidosis. That's the big, big, big, big problem in DKA. Okay, that's the most important reason to give the incident. Okay, too. Stop the production key tones and reduce the key to acidosis. Okay, Uh, potassium won't see relevance of potassium in DKA. Why do you need to check the test him? And why do you need to consider giving potassium replacement? Yeah, So you guys got it. So I just say now, quick plug. If you guys want to learn more about the potassium disturbances are indicate management in general. I have a YouTube video on my YouTube channel. Taxotere. Really? I would have a whole series of videos on diabetic ketoacidosis. Um, where If you want to learn more detail about see general approach to DK, you can check it out there. So it's tactics oils on YouTube, but yeah, in terms of the potassium, uh, potassium in DKA. As a lot of you said the main problem is the insulin. Okay, remember, in DKA, there's an absolute insulin deficiency. Okay, so when there's a lack of So what insulin normally does is that it will stimulate be, uh, stimulate the potassium to move from the blood into the cells. Okay, so it stimulates the sodium potassium, each pierce palms to move from the blood into the cells. Okay, so it stimulates the shift off the calcium into the cells, so that's gonna lower the serum. Potassium level. Okay, but it's just moving the potassium into the cells. But in DKA, because there's no insulin, the potassium is not going to move into the cells. Okay, It's just going to stay in the blood. Okay, so that's gonna lead to hyperkalemic. Okay, on. So that's what that's a. That's a risk. That's what beak A. Patients are risk of getting hypoglycemia. Okay. One of the reasons for that is they have an absolute insulin deficiency. They can also get an acute kidney injury, which can worsen the hyperglycemia. Okay, there's a there's a couple of other different mechanisms, but the key thing is, there's no insulin. Potassium in the blood is gonna build up and lead to hyperkalemic. They can also get an acute kidney and dream which can worsen the hyper cleaning as well. Okay, so that's why patients are addressed of getting high potassium levels. But when you actually start treatment for DKA. So when you give insulin in DKA management's that's gonna cause potassium to move. Okay, so remember, incident causes potassium to move from the blood into the cells. So when you give insulin in DKA, that's gonna drop the serum potassium level because it's moving from the blood into the cells on. So that's why you need to monitor the potassium level again, because the scene on the testing level is changing. So you need to monitor for the risk off hypokalemia. Okay, you don't want You want to make sure that the potassium doesn't drop too low. So that's why you want to monitor the potassium on down incident giving a potassium replacement. Okay, so that's why, even if their serum potassium level is normal, you want to give potassium replacement because you want to reduce the risk of hypokalemia. Okay. If the potassium levels already high, you don't need to give him a basement. Okay, on. And if that's low that you need to call a senior. Okay, Because they might need to be referred to intensive care to get more aggressive. Potassium replacement Done. Okay, but those are the key sort of aspects of managing decay in general. Okay. Fluids, insulin, potassium replacement. You has. No, I have another question for you guys. What are the metabolic targets for DKA management? What are you trying to achieve? What are you trying to achieve in DKA? Yeah. So you want the big things I'm talking about? What's the general? Sort of early targets? Your cheese. Three Lauren kittens Group goes Yes, so I'll just go through it. So the key things I think about you want the key turns to be dropping by least part, um, Opal eater per hour. Okay. That's a big thing you want. You're monitoring your monitoring key tones, and you want to be monitoring things like bicarb, glucose levels, and you want to make sure the potassium's not changing too much. Okay, remember we talked about we talk about why you monitor potassium closely, Onda. In order to say that the patient's DKA has resolved you checked the key tones and the ph case of the key tones are less than 1.6 and the pH is greater than 7.3. And then you can safely say that the key to the acidosis has result. Okay. Does your metabolic targets okay, so that was our first station. Okay, Basically nail down sort of GP polyuria. Okay. Investigations management for polyuria on. We talked about the management of DKA. Okay, Now we're gonna move on to to talk about diabetes and a bit more detail again. Then we'll take a break. So were in the emergency department. We've been asked to speak to you Nemo, a 14 year old male who has brought to the emergency department and was diagnosed with DKA due to undiagnosed type one diabetes. His father, Mollen, has now arrived at the hospital and seems frustrates it. Okay, if he has to know finding the most one of my favorite movies. So, uh, that's why we got this. And I please speak to Marlin and explain what has happened. Explain the diagnosis and immediate on long term mind plan and address any concerns that you might have. Okay, So basically, uh, way we've been asked to speak to and I'm tearful, Other about his son who has recently presented with DKA again. We need to explain what happened. Explain the diagnosis on D immediate on long term management for his son. Okay, so this is Ah, this is this is about a tricky station, okay? Explaining the diagnosis of diabetes to patients. It can be quite. It is a product tricky station. But, um, we're going to go through the sort of general approach to doing an explaining station for diabetes. So what you doing in explaining station? There's a lot of common stuff that you do in general. Okay, so introduce yourself. Okay, General. General consultation, skills introduction. Do a brief history. Okay. So asked us, apparently what? He already knows about what's happened and explained to him what's happened to his son. Okay, just briefly. Okay. Before you start going into the details of what happened, uh, confirmed that the confirmed the diagnosis. Okay, So confirmed that his son has ah, type one diabetes mellitus and has presented with diabetic ketoacidosis. Okay, again, you just getting this stuff out there initially established what the parent already understands about diabetes in general. Okay, this is most very very important in any explaining station is to establish what the patient already knows, because that's going to guide the rest of your consultation. Okay. You always a match. Whatever you're saying to the patient's level of understanding. Okay? You always try and build on what the patient already knows. Okay? And if the patient already understand stuff that's going to save you time explaining, okay, Because you could just say that. Yeah, that's completely right about the about what you know about diabetes. Okay? It's very important to be really establish what the patient already knows and finally do a quick ice. Okay, Obviously, if you parents just found out his son's got type one diabetes mellitus and is in DKA, they're gonna have a lot of different concerns and expectations from you. Okay, so make sure you elicit that from the parents. Okay? So we're gonna go through the different things you wanna explain. Okay. So first thing when you're explaining diabetes, first talk about the normal anatomy and physiology of how insulin works. Okay, Um, do you think the key thing is you want to make sure that it's not very scientific? Okay, now I'm gonna give you a bit of an example Here. I'm gonna give you an example of how to explain it. I want you guys to you listening and tell me what's really bad about the way I'm explaining the physiology off. Insulin to the parents. Okay, Have a listen and tell me what you think is really bad. So let's see. So, So insulin is it is. Insulin is an anabolic hormone which helps to stimulate the transit. Try the uptake off Lucas from the blood into the little muscles. And it does this by increasing the translocation off before because transporters type form, discreet, and muscles, which helps to you still like the uptake of glucose from the blood into the streets of muscles, which will help to lower the blood glucose levels. And this is how instantly work to reduce the postman. You guys glycemia Okay, So what was really bad about the way I just explained insulin? Yep. Too much way too much jargon. Okay. Very scientific. So I was using, you know, I mean, I'm using terms like a glucose transporters time four skeletal muscles, very, very technical terms. That is no relevant or someone said okay. Not needed to. The patient doesn't need to understand that level of detail. I'm speaking to fast as well. The patient not able to understand that a someone said only medical students or doctors might be able to understand. Okay, the stuff I was talking about, that something that you might would only be able to learn properly in medical school. Okay, so it's about being able to explain the physiology and a and it would be that is relevant. Okay. And easy to understand for the general public. Okay, for a General Lehman. Okay. So when you're a good way to explain the physiology off insulin, I think is to use the analogy off the cause. Okay, So you saw where I think to explain it is to say, is something like, uh, think off the sugar in the body as a car. Think off the cells in our body as a garage. Okay? And think of insulin as the keys to the garage. Okay, So what normally happens? So you're gonna use your keys to open the garage, and then you're gonna park the car in the garage, right? As the same thing in the happens in the body So what happens is that your sugar, the cards, they're gonna move into your cells the garage, Because instant, the key is going to help open the south so that you can move the insulin into the cells. Okay, so you're essentially using an allergy, so you're giving it again. It's use using sugar to represent because you're representing the he as insulin. And you can say that the Karaj is the cells in our body. Okay, So normally, incidents going to help move the sugar into the cells. And what's happening in diabetes is that and type one diabetes is that your cells that normally make the insulin is are being destroyed. Okay, so because there's no insulin, the cells are not able to move. The sugar's not able to move into this house, okay? And so if you think about the garage again, so if your car's not able to move into into the garage, then your car's going to be stuck on the road, Okay? And you can imagine if that happens in more possible different garage is there's gonna be a whole lot of cars on the road, okay, and that's what's happening and diabetes so You're good. You're good. Your sugar's not able to move into the cells. It's getting stuck in the blood. Okay. And so you're getting a lot of sugar being increasing inside the bloodstream. Okay, so if you explain it that way, Okay, if you start to use analogies and things, um, lot limited amount of technical terminology, even most patients should be able to understand that if they even kids will hopefully be able to understand that if you give if you try and actively try and make it easier for patients to understand. Okay. So that's how you can explain the normal anatomy and physiology. Yeah. Then you can talk about the effects of lack of incident of the body. So because there's no insulin, the sugar is getting increasing. Okay. And that's leading to the symptoms of diabetes. Okay. Such as increased urination, weight loss, increased hunger. Okay, um, so that effects of lack of insulin and effects of high glucose consensus of diabetes again the polyuria the polyphagia on your hips? Yeah. Okay, then you could explain about what's happened to the sun. So what happens in DKA is it's basically an exaggeration off the common symptoms So what's happening is that your son east is the route of a severe presentation of diabetes. Okay, you can explain again. It's very severe urination. You become very dehydrated on. But again, this is all because of the lack of insulin in his body. Prognosis. So you can discuss briefly about the prognosis of DKA and diabetes so you can explain decay a song. He receives the adequate treatment. He should be fine. Okay. About whether you, um he might need to be referred to intensive care to receive some certain treatments. Okay, on, then you can talk about prognosis of diabetes in general. Okay, So, diabetes, it's a life. Lung condition on patients need to be treated for the rest of their life. Okay, But as long as he keeps blue coast levels at a normal range, that should reduce the midst of complications. Okay. Oh, also, um, make sure that we talk about complications of diabetes. Um, you know, things like problems off. Why? It's very important to maintain normal glucose levels in the blood. Okay, Because if there because the others is too high for accessory long periods of time, it can lead to complications that can damage different organs in the body. Like the part, the feet, the eyes, the brain. Okay. Not trying to scare the pits. Scare them too much. Okay. But just emphasized the importance off. Maintaining normal, maintaining the sugar levels as as normal as possible. Okay, you talk about the management of DKA, which we just talked about the explain that in Ah ah, in a good way to patients that they'll understand. Then you can put about the ongoing careful patients with diabetes. So long depicting that parent parents will be concerned about is the fact that they will need to be on insulin for the rest of their lives. Okay, Um, so you to explain that that his son will need to be receiving lifelong injections of insulin on. Do you explain how to take insulin as well? Just tell me if the if the dad asks you why Why? Why do I need to inject the insulin? Why can't I just take it as a tablet? How would you respond to that? If they don't ask you what? Why can't I just take tablets of incident? Yeah, so you can explain that it has to be injected okay? Because insulin is a protein again. As you said, Um, because it's a protein. You'll get digested by your stomach. Okay, Um, so it's not going. It's not gonna work properly if you take it as a tablet. So that's why we need between jet it into your into your tummy. Okay, Yeah, that's that's the sort of keep considerations to be thinking about with, um, insulin therapy. Uh, then about monitoring. So monitoring a lot of type one. Diabetics don't hear a lot of monitoring. Okay. They'll need to be checking that blood blisters regularly. Um ah, you need to be managed to be a a discussion with endocrinologist or pediatrician. The regular GP follow up. Okay. There's a lot of monitoring to talk about driving, So this isn't that relevant here. Okay, If you're talking to a patient, it's important to talk to about the driving regulations and diabetes. Okay. Important aspect to think about with the consultation on. Then make sure the offer follow up okay to things like offering makes offer, things like leaflets. Okay to explain. Diabetes offered. Ah, follow up appointments with the GP. Okay. Tell them that we will arrange follow up with the GP on. Very, very important thing to you. Think about as well. So that's your consultation. Okay, That's your generals. Sort of content. You want to get out with the consultation? Okay. Again, remember, it's about being a dressing patients concerns throat. Okay. For example, if they ask about the, uh why did why I need to be injected. Just address it. Okay, Um, junk in check. So when I give you that really bad example, I wasn't checking if the patient was understanding anything. Okay. I was just overloading the patient with loads of different information on gets very important to just always check how much the patient understands Awesome to repeat back information that you've given them very important, important communication. Stop. And, as mentioned often, leaflets and checkups throughout. Okay, too. So, um, another important thing to advise patients on are the sick tables. Okay. Especially if they're gonna be on insulin therapy. So can you tell me some sick? They were also for the type one diabetic patient becomes sick. What do they need to do? Increase increased glucose monitoring Very gets. What else? What if they're on insulin? Do you tell them to stop taking incident. Good. You don't Don't stop insulin. Very, very, very, very bit of it Important in type one diabetics. Okay, you tell them, Teo, make sure that it that it that they don't stop instant. Okay? Because, you know, that could significantly increase the risk of them going into DKA. Stay hydrated. Yeah, they might need to let The GP know ago that specialist nurse know, um, what if they're not eating or drinking? What else? What What? What? What might they need to have if they're not able to eat a drink, Monitor ketone If they're not, if they're not eating or drinking and their own incident there, people What? What might they need to have in terms of the insulin? Yeah. They need to be started on my sliding scale. Insulin. Okay. Just just to manage. That goes levels if they're not able to eat or drink. So a useful pneumonic to remember is the new Monix sick. Okay, so that's for sugar. I for insulin. See, for carbohydrates, K for key tones. Um, so, in terms of sugar, as people mentioned increased glucose monitoring, I make sure Teo never saw the insulin. Okay, um, I need to change that dose of insulin carbohydrates, maintain hydration and carbohydrates. Okay, um, if they're not able to eat or drink, okay, seek urgent medical attention. Okay, There's a risk of DKA. Um, and make sure Jackie times regularly as well. Okay, these are major things. There's a There's a bunch of other different advice to give. Okay, But I think these these are the most important rules to remember. Ongoing. Yes. Tell me, in terms of be targets for blue goes, do you guys know one of the actual treatment targets? What blue Coast level will do patients need to maintain sort of after meals before meals with junior is no. The actual numbers 47. Is that which one? Okay, I'll go through it. So the different ones are. It's 5 to 7 when they wake up. Okay. So that fasting glucose when they wake up should be 5 to 7. And in terms of the mealtimes, so before meals, it should be 47. Okay, But after meals. So when he tested glucose after 90 minutes after a meal, it should be between 5 to 9. Okay, Those are the typical treatment targets and type one diabetes. Okay, so we talked about basically talks through a lot of these sort of clinical peaches, the approach to investigating and explain the diagnosis of type one diabetes. Now, we're gonna move on to management on. Obviously, the big thing with managing type one diabetes is to give insulin, and it's important to be very familiar with the different types of insulin. So I'm going to show some different types of insulin, And I want you guys to tell me, is it a short acting fast acting, long acting or a rapid acting insulin? So, what do you think about this one? Is that rapid acting? Short acting, intermediate acting? Yeah. This is a rapid acting insulin. Okay, this is, um, a structural acting against something after I put it in the name, Uh, what do you think about this one? Human Cumin and I Yep. This is an intermediate acting incident. I already I just think about this one. Sure that things are the same as rapid acting. Okay, It's slightly slower onset. Overactive is a type of rapid acting insulin. Last one Levemir when he has things. Yeah, it's a long acting insulin. Okay, so make sure remember when you're learning insulin therapy, So okay, you learn the brand name, okay? You don't need to know what the chemical name is. You might hear things like death. Tamir for Levemir. Okay, You need to just remember the brand names, but yet is a little summary terrible on the different types of insulin. Okay. And the onset keep duration examples. And if there's a different insulin regime, So the top classic one that patients will be have it have is the basic is the bolus regime. Okay, so, um, typically, this is where you're giving short acting insulin during mealtimes, and you're giving a basal insulins are long acting insulin. Um, bet times are extra throughout the day. Okay. Eso the basal insulin is providing a So the long, long acting insulin is giving the basal cover throughout the day. And you're giving Bullis incident of either a rapid acting or short acting insulin around mealtimes. Okay, the bailiff baseball, this regime is the first line. Okay? And typically for the long actings to use Levemir. Okay. It's very good because it allows flax for meals, meal ones. Okay, we're gonna quickly cover this. So this is a going to talk about how to adjust a basal bolus regime. Uh, we're gonna take a break. Surely after in two minutes, I will talk to you this quickly. So in terms of adjusting insulin, insulin, this is something people struggle with, but it's actually not that hard. Okay, um, in order to adjust on insulin insulin, the principle is if someone's glucose level is too low, okay, before a meal or after before a meal. Oh, if I because I was too high after a meal, it means that the previous dose of insulin was too high. Okay, it means that you haven't given enough insulin. Okay, if there is a level is too low, is too low. At some point, it could be It probably means that there those of incident that they're taking previously is too high. Okay, so if we think about the breakfast glucose, if someone's glucose level before breakfast is too low or if that breakfast of their glucose level after breakfast is too high, um, then we need to think about how to adjust the insulin. Okay, so the way we can do it is if their breakfast glucose level is low. Okay, So if their glucose before breakfast is too low, that probably means that the insulin level that they're taking a bedtime. That basal insulin was too high. Okay, so we can just reduce the basal insulin. Okay, so basically, color coded it. Okay, so it's a low breakfast glucose. We reduced the basal insulin. Similarly, if it's a high breakfast glucose, it probably means that they're basal insulin at bedtime was too low, so we can increase the dose of the basal insulin. Okay, so it is actually common sense. Okay? It's just it's quite logical. Okay, that glucose is too low. Lower the dose. It is too high. Increase the dose. Okay. So we can apply the same principle for the rest of them. So if that lunchtime insulin is like this, or if it's too low before lunch or too high after lunch, we can change the bolus insulin. Okay. In the same way as the bedtime. Same thing for dinner. We can adjust the lunchtime bolus insulin on the same thing for the time glucose. Okay, we can adjust the dinner bolus insulin. Okay. It's just remembering. It's just having some common sense of you. Okay. About how insulin is going to affect the blood glucose levels. But hopefully that makes sense. Okay, so we're gonna wrap it up. So this does some other incident regimes. The other. The main ones are your mixed insulin, and they're continuous infusion of insulin. Okay, um, we're gonna finish off with before we take a break With this last question you get sent me one of the advantages and disadvantages. Often insulin pump compared to delay injections If someone's given an insulin pump instead of having to do daily injections of insulin. One of the advantages and disadvantages in general to remember your people Patients might be prescribed an insulin pump if they're experiencing a poor quality of life with daily injections. Okay, they're not able to get good to be able to be controlled with daily injections. They're getting very significant hypoglycemia. They might be given an insulin pump, but one of the advantages of disadvantages of it. So there's less, less patient, depending monitoring. Okay, good. So you don't need to check glucose levels as much less hypos gets to you generally get better glycemia control. Okay. They could send straight to the doctor. Okay, that it's very very, very convenient. Generally for patients. Okay, so this table basically summarizes the different vantage is and disadvantages. Okay, things there's less injections needed with an insulin pump. Okay, on it allows more flexibility with meals because it's injecting insulin directly. You don't need to actually inject yourself. It's It's a convenient access. Access points less risk of hypos. Okay, because of the same reasons and generally because it's more flexible. Last risk of hypos. Patients generally achieve better glycemia control. Okay, but some of the big disadvantage is it's expensive. Okay, He constantly touch to it on because the risk of infections and if the pump fails. Okay. This suddenly stopped. Give inject the insulin. Okay. Patients are at high risk of going into beak. It. Okay, um, so those are your advantages and disadvantages? Uh, and here's the summary off the management of type one diabetes. Okay, was we talked through the only different incident therapies. We talked to a lot of monitoring. Okay. And remember, there's a lot of conservative aspects to think about. Okay? So you can have a read of them in your own time. Um, we're gonna take a break now before we talk about type two diabetes and a bit more detail. Um, if whoever's recording, if you want opposed to a quote. Yeah. Okay, so we're gonna talk about type two diabetes quickly. Again. The way of structured it is that we're gonna basically talk to another consultation. Okay, we're gonna talk through Ah, a GP consultation where we've been asked to see Mr Joker, a 45 year old male who has presented for his annual review. Okay. And we've been asked to basically do an annual diabetic review. Okay. Very, very common GP consultation. Okay. And this is very pretend. Definitely a potential Oscar station. I could come up, so we also reviewed diabetic patients with another. I'm just gonna cover this sort of content. You want to get out in the consultation, Onda? Good way to summarize the different content is the also better approach. Okay, so a for we'll go through it one by one. So it seems your introduction. Make sure you clarify what type of diabetes they have. Okay. What if they have any relevant history? What their current treatment is? Okay? If they're taking specifically if their insulin dependent, that's very important. Trusted, but clarify how often they self monitor on, as always with any consultation. Find out what their ideas, concerns and expectations are then, in terms of a so advice. Um, so there's a lot of different advice you need to give two diabetic patients, so summarize the main ones here. Okay, so you need to give advice with regards to diet, exercise, weight smoking, risk of hypoglycemia. Risk of abusing alcohol. Give the driving advice. Okay, Uh, make sure that they're up to date with vaccinations. Um, if they're not planning on pregnancy, Okay, make sure they're using effective contraception, and you can advise on the risk of erectile dysfunction in men. Okay, so these are different bits of advice you can give. B is for BP. Okay. You know the problems with BP you can get with that diabetes. So advise them that they need to have that BP regularly tapped. Okay. In terms of diet, make sure that they not eating too much salt. You can consider referring to a dietician. And if they have, if they have known diabetes, you can make sure you can clarify that you're going to start them on things like ramipril okay. And here's your target. BP is well, terms of cease to see is for cholesterol or chronic kidney disease. So advise them that the if you have excessive excessively high cholesterol that can increase the risk of heart disease and stroke so you can consider prescribing a statin. And you could make sure that that they're having their kidneys checked for you. Okay, so that they're having their deer park and the CR checked every, actually. And you can advise them that it's very important to make sure that their sugar levels are not going to high. Because if I should go to goes too high, there's a risk of kidney disease. Okay, that see, in terms of D studies for diabetic control. Okay, so you want to ask about how well they're controlling that diabetes in general, So you can ask about how about their blue close monitoring habits? Ask about their previous HB A one c readings. And, uh, if they were high or low, ask about how frequently they get any episodes of hypos, okay, especially if they're on insulin therapy. If they've had any recent episode of DKA or HS, so hated justice for hypoglycemic hyperosmolar states. Okay, we're not going to talk about it. But it's another emergency that patients might have that they've had any side effects of medications. And you can review of any changes need to be made in that current monitoring regime. Okay, uh, is for ice, Okay, we'll talk about eyes, inhibits, uh, so you can advise them that if their sugar levels go too high, that can risk damage to the ISIS. Okay, Try not to scare the patient and saying things like, If you're sugar's going, if you sugar stoop high, you're going to go blind. Okay? Just tell them that there's a risk of damage to the eyes and to make sure that they're getting the eyes checked annually and always do safety. Nothing. If there's any change in vision, seek urgent medical advice. Okay, on the final F is 4 ft. Okay, So, uh, off the you're aware that diabetic form diabetic patients can get problems with feet. Okay. Um, so you can advise them. That's diabetes or high sugar levels that increases the risk of pulse is okay for us is, um try not to scare the patient, saying things like, uh, you're going to get amputated if you have diabetes. Okay, not just try. Just don't say that, okay? Don't scare the patient. Tell them is a risk of ulcers. Make sure that they're examine their feet regularly and getting their foot checked on. Always make sure when you're doing a foot, check that you're examining the neurovascular ST status and their sensation as well. Okay, we'll talk about the diabetic feet. Briefly. Two of the end. So that was our diabetic review. Okay. In terms of the content of the consultation on, now we're gonna talk about specific management steps in type two diabetes. So, uh, obviously a bunch of different diabetes medications, which I have listed here. Okay. A lot of different treatments that are available, too. Treat patients with type two diabetes mellitus. Um, so I'm gonna run. This has a bit of a spot diagnosis where you guys need to choose the specific medication to prescribe the patients. So let's start with the first ones. We have a type two diabetic patients. She's a sense to your woman. Hate to be a one. C is 80. Hasn't managed with any lifestyle changes. Okay, so she hasn't improved with lifestyle changes. No other significant medical history. Okay? And she can tolerate oral medications. Which medication are you going to prescribe? You gonna prescribe metformin modified police? You didn't specify which one? Which metformin? Yeah, Standard release. Okay, so, um, this is a classic first line therapy. You can remember that metformin is your first line therapy. So this is the patient's hasn't got glycemia control with lifestyle changes. Okay. And the first line or old diabetic medication to prescribe. It's metformin. Okay. And this patient can tolerate all of medications as well. Next one, we have a type two diabetic, 33 year old male HPLC of 61 currently on metformin. A history of heart failure. Okay, So low ejection fraction as well. And EFR is 62. What do you say? Which medication are you gonna prescribe them? Yeah. SGLT two inhibitor. Okay, Anyone Tell me why. Why you prescribing an SGLT two inhibitor? Yes. So they They're very good if someone has, um, heart failure, okay. Particularly heart failure. So we will talk about it. We'll we'll talk to. So in terms of add on therapies after metformin, there's a couple of different options. Suffocate things like SGLT two inhibitors, you can add in so often all your areas Or, um, I was a little lady owns. Okay? Not commonly used. Okay, but there's a different There's different. I don't therapies available, but in this patient particularly, um, they haven't achieved the HBA. One c is still high despite being on metformin eso because they have heart failure. History on that Egypt far is is still high enough to be taking actually two inhibitor. It's best to prescribe this one here, okay? Because it's gonna have positive effects on that diabetes, and it's gonna have positive effects on their heart failure as well. Okay, it's going to protect the heart. I'm very good, Okay? And she had a stent in it Is that they're very in the cardiology field. A lot of people are buzz about them, Okay, Because of their positive effects in heart failure. Next one, type two, diabetic 40 viral woman. Hatred on C is high. Ah, significant gi I upset on metformin and not currently on any other anti diabetic medications. Uh, what do you think? Yeah, um, mostly gonna So this patient before adding on any therapies, I would try a trial off metformin modified release. Okay, so you've given describe metformin. Okay. What? She's experienced significant GI. I upset on it. Okay. So because metformin is the generally really effective at two. Diabetic agent, you want to try it? Still try metformin, but you can try it as a modified release. Okay, so it's used one patient have experienced significant gastro symptoms on standard release, you can try a modified release. Okay, a lot. Last one here. So we got again. Type two, diabetic, six year old woman, high heat beyond see, currently on metformin and glipizide. A history of heart failure. History of pancreatitis. Be a miser high as well. What you gonna prescribe to him? So you can't. So you specifically cause you shouldn't describe the lp one here, Okay, because there's a history of pancreatitis. What do you think? SGLT two. Um, Okay, so I understand. So this instead of hot Radiohead, let's say you want to add on the therapy. Okay, Let's say they don't want to take any more medications that they're starting with medications to get control. Insulin. Okay. You're definitely insulin would be a good option. Okay, So insulin, so you can say that patients become insulin dependence. Okay, Um, so here's your pancreatitis means that they can't take the other medications like GOP one medic. Okay, you might try, uh, um SGLT two inhibitors because of heart failure again. But if they're not getting good guy secret control for the past 10 years, Okay, it might be time to strike, try start things like insulin. Okay. To try and bring down the HBO and see so that that's your different medications. Okay, in terms of putting some clinical contacts, city medications, Let's move on. So this is a summary off the different antidiabetic drugs, Okay, in terms of be side effects and contraindications. Okay, um, everybody get it when you get the slides. Okay? This stuff you can read about on this is a useful thing. Someone told me the other day the to to to realize that I have with you guys, the different diabetic drugs don't have effects on weight. Okay, so you can use that to to to rule. So there's two main drugs that can cause weight gain. So glipizide and pioglitazone, um, there's two drugs that can cause that don't really affect the weights. Okay. Metformin Onda linagliptin okay. I want the DPP four inhibitors and there's two drugs that causes weight loss. Okay, these really very, very important to remember these ones. So dapagliflozin on exenatide eso SGLT two inhibitor and the GLP one agonist. Okay, these both can cause weight loss. Okay, which can be very beneficial in a type two diabetic patient. Okay. His these summary of the nice guidelines for type two diabetes. Okay, taken. I made this slide last year. This is the current nice guidelines for how you step up. Therapy is also have a read when you get the slides, and hopefully you can make sense of it. And I'm not gonna go through this, So Okay, I just for the sake of time, But, um, in terms of metformin, a common station you can get is to counsel patients on how to take metformin. Um, and he used to when you Mike I found to remember the way to do do drug counseling is to use the athletics. You mark. Okay, so, 84 advice. A So action T four time line Hates for how to take the drug. Okay. Powerful. The length of treatments off the drug be for any effects of medications. Okay, d for any testing that needs to be done when they're on the medication. I for any important side effects. See, force it. Any contraindications to that medication? And as for any supplementary advice, Okay, so this is this is a different content to get in a When you when you also do any medication constant. I would make sure you can. You advise them on all of these different aspects, so I'm just gonna fill it in from metformin. So these are the different things, too. Think about with metformin. Okay. When you're asked to do a medication car, I'm saying for metformin, I'm not going to go through this city if you want to. I could go through at the end, okay. But, you know, hopefully this slide will be useful for your revision. And here's a summary off the management of type two diabetes. Okay. Very similar to attack one. Okay. Obviously, the big difference is the medical therapy. Okay, You're gonna use anti diabetic drugs generally before insulin, but everything else is pretty similar. Okay. And, uh, again, I'm not going to go through this for the sake of time. okay, but if someone asked you about how to manage diabetic patients peri operatively. So when they're due to have surgery, uh, have some rise it on this light here. Okay, So you need to think about it if they're on any medications, like or or hypoglycemic. Drugs like SULFONYLUREA is okay. There's key things you need to be doing. Okay? Or if they managed on insulin and there's different steps to take. Okay, I'm I'm not going to read them out, So I'll let you guys have a read of the different considerations to do before or diabetic patients and surgery. But we're gonna move on to talk about hypoglycemia now. So we've been asked to see Mr Pool, but 56 year old male, who has a history of poorly controlled diabetes and has reduced consciousness. So we're gonna talk about hypoglycemia. Can you guys tell me some symptoms off hypoglycemia? What? He has think about what? One of the speeches off hypoglycemia, tremors, sweating, anxiety, reduced consciousness, confusion, hunger. Yeah, s I found a new monitor so you can use the new monitor. Tired? My case. A T for tachycardia. I thought irritability off for restlessness for excessive hunger. A Z Guys said and D for diaphoresis. Okay, so sweating. So here's some important signs. Different. Look out for it to see if that patient is experiencing the hypo. Okay, some an x episode of hypoglycemia. So we're gonna do another spot diagnosis. Okay. Similar thing. But we're going to talk about some causes of hypoglycemia, so I haven't Haven't think so. We have. Ah, patient has hypoglycemia have a history of type one diabetes. His your weight gain. They have high insulin levels, but normal c peptide levels. Uh, what I think is the cause of the hypoglycemia in this patient incident access you ever. What's the likely course off the insulin access based on the C peptide? Eso exogenous would be if if they have low c peptide levels, it would be exogenous. Okay, so if it's normal or high, it would be and are Okay. Someone said it's an insulin oma. Okay, so we'll we'll talk about it a bit. Okay? But C peptide is the main way to to help you to help tell you where the insulin is coming from. So if the C peptide is normal or high, that means that they have endogenous insulin production. Okay, if the C peptide is low, that means that the insulin is coming and your exogenously Okay, so outs from outside of the body. Common cause off endogenous insulin production is if someone has a cancer, which is causing too much influence to be produced. Okay, Uh, so come remember that concept, So I would think about this scenario we have. Ah, patient was hypoglycemia. No significant medical history recently missed the court dates, high insulin levels and a low C peptide. This time someone says sulfonylurea So remember, if it's taking sulfonylurea is that would cause more incentive be produced by the body. Okay, so I would cause c peptide to be either normal or high. Okay, but this patient has a low c peptide. Uh, someone's got your self administering instant. Yeah, that's right. Okay, so surreptitious incident. Use eso inject, basically inject, injecting too much insulin. Okay. Uh, so if you inject too much insulin, so exogenously taking insulin, that's gonna cause high insulin levels, which will cause the hypoglycemia, but it could cause Cpeptide to be low. Okay, because they're taking exogenously. So that's gonna inhibit their production, inhibit the beater cells, which will reduce the C peptide. Okay, stop. Because a low C peptide. Um, what's the relevance off the recently missed court dates? No significant medical history. What could that indicate? Ah, possible drug use. Yeah. Yeah. So I probably haven't been I was trying to get out that this patient might be taking, um, incident too much to explain why they missed the court date. It's okay to explain to the court why they missed the court dates. Okay, It's and I didn't give you enough information there. Uh, the last one, uh, patient has hyperglycemia history of type two diabetes. Currently on oral anti diabetic books. Hasn't hate upcoming HBA one C test coming up soon. They have high incident levels and a high c peptide level. What do you think about because of the hypoglycemia here? So they have a high cpap that level. Okay. If they if they were taking exogenous insulin doubt if they were fasting, they would have a low C peptide. Right? So they don't send out the initiative excess salt finally really use. Okay, Someone's thinking sulfonylurea is excessively on. That would cause them to produce too much insulin. Okay, It's a double because high insulin levels also cause hypoglycemia, but it also cause high C peptide levels. Okay, because it's causing the C peptide. Hi. C peptide means that the body is producing and darkness. Insulin. Okay, esos that confused one c peptide. So I'll just explain it again. So if someone has high insulin levels and that's causing the hypoglycemia, then you measure the c peptide. Okay, If the C peptide is low, that means that they're taking incident. Exogenously. Okay, so if the injecting insulin off that have a lack of cover hundreds of the doctor, um, double that would present with a low C peptide. Okay, if someone has a high C peptide or inappropriately normal CPAP tight. Now, that means that the insulin is being produced normally from the body. Okay? Excessively, I should say from the body. So that can happen. If they have an incident, Norma or they're taking something. Algeria's okay, because something i'll you is induce insulin production from the beach cells. Okay, I hope that's clear. Okay. It's a tricky concept to understand the c peptide and hypoglycemia. Um, but we will move on. Uh, So can you tell me How do you manage severe hypoglycemia? What do you need to do? It's only having a hypo. Good. Yes. Again you got I'm gonna turn this thing as the first thing you should tell me is you're doing a B C D assessment again for any acute presentation. Yeah, and I'll just go through it. So a question that my guy also is if someone's having a severe hypoglycemia, it means that they need to have assistance from another person. Okay, that's the definition of severe hypoglycemia. And in terms of the actual management's, have some right there in this flow chart here. Okay, again doing ABC assessment You need to think about, if they're conscious, are unconscious, okay? And specifically if they're able to swallow, because that dictated the actual different management steps. Okay, so you have a read of the specific management, But again, keep things 80 assessment. Are they able to swallow? Okay, cause if they can swallow, you can give them different glucose loads. If they're not, they need to give you get intravenous access, or you need to give, um, Luca gone. Okay. Okay. We much covered the sort of history aspect. So came clinical type of stations were now gonna finish off by talking through the examination of the diabetic patient and talk through different examination findings. Um, so this is gonna be a bit of a quick fire spot diagnosis, and you guys are going to tell me what you guys see. So what do you think about this? Sign here, but this is on insulin syringe. Okay, that's classically it's an orange. New York. Okay. And that's what the insulin syringe will look like in the hospital. Well, technically, uh, what about this device here? Anything this is Ah, not this isn't the insulin pen. If you look at that, actually says liver clips Idea. Um, this is a GOP one I gonna spend. Okay, this is what I GOP one agonist can look like. Okay, so I'm a GLP agonists. They they inject it. Okay? It's another tablets D o P. A one agonist. You actually inject it. Okay, on. So this is what they can look like next one. What do you think about this device the patient is wearing? Yeah, this is an insulin pump. Okay. We talked about the different advantages and disadvantages of a pump. Okay, so remember, Remember, insulin. You injected into the abdomen. Okay. And you can see the pump is connected. The actual infusion is going through the abdomen in the same place. Okay, but this is what this is what they were. They typically where it's, um, next one here. Well, what is this patient wearing? Yeah, it's a freestyle libre. Okay, this is S o. There's a lot of cool diabetes technology coming out. Okay on. So this is a device to help patients monitor that blood glucose levels without having to constantly prick their fingers s So this is what a freestyle libre? It looks like. Okay, um, so there's a sensor that's gonna connect to your phone, and it's gonna help you tell you what that blood glucose levels are okay. Throughout the daytime. Um, next one, one of these. One of these little things here that you might see that the bedside? Yeah. These are lancets. Okay, if you guys have ever done any clinical skills you'll see use the lancets to prick the skin, and similarly, I'll go to this is a blood glucose testing kits. Okay, you've got You see this all the time, Okay. Something you hopefully very familiar with last one. What do you think about this picture here? What is this picture? What? I'm trying to get out with this picture. Yeah, Manic. A little bracelet. Okay. Medical ID bracelet. So, um, very, very important to look look at bracelets in general. Okay. The medical ID bracelet. Still, patients were aware from various different competitions. Okay. Important to just recognize if someone's wearing it in a Noski too. So they'll wear it to help anyone to alert anyone to what condition they have it done. If they're not able to vocalize that they have a condition for whatever reason, then if they have this bracelet that's gonna help easily identify that they have a medical conditions such as type one diabetes. Okay, so that was some bedside investigations. Bedside examination, findings. Let's talk about stuff you can see on a patient. So, what do you think about this sign? Yeah, is on the last. Uh, okay. So I remember. I, uh abnormal lipid profiles strongly associated with type two diabetes. Next one. Yeah. Obesity. Okay. Important to think about habitus with a diabetic patients. Central obesity particularly very strongly associated with type two diabetes uh, what do you think about this patient's hum? Uh, finger? Yep. But so these are bricks. Pinpricks. Okay. Lancet bricks. So indicates finger prick glucose marks. Okay, if someone been repeatedly testing on the same finger, this is what the fingers can look like. Have a look at this video and tell me what you think of that breathing. How would you describe that breathing? Yes, it was rapid and deep breathing. And if you think about a diabetic patient, what could that indicate? Yeah. So this way you describe it as cause more reading. Okay, So this is that what customer breathing looks like? Okay. Deep, labored breathing. Okay, that's what cause more breathing is, uh What, all this one here? Yeah. Good. Um, so this is a features off, eh? So you can see, like, where the abnormal skin marks I Okay, this is typically locations where people inject the insulin. Okay, in the abdomen. About this is evidence off lipodystrophy. Okay, So, lipid, this recent, uh, it's what happens. What happens if patients don't change their locations where they inject insulin? Okay, they can get a complication of lipid lipodystrophy where they're fat, basically redistributes in the abdomen. Okay. That's why it's very important to advise patients that they need to continuously rotates the areas where they inject. What do you think about this one? Because that you might have seen the picture already. Yeah, they can't. This is not cancer. It's okay. So, um, darkened bell, but patch like distribution, Okay. Classically in the exhilarate. Okay, that's a can Tosis. Nigra counts. Okay. Important feature off insulin resistance. Okay, so it's very strongly associative with type two diabetes mellitus. Uh, but I think about what this patient has on in this arm. We talked. We talked about this during the abdominal station a couple of weeks ago. Yeah, 80 fistula. Okay, so we talked about this the other week, Okay? It's opaque. Diabetic patients. They might have a navy pistola. Um, as an access points for hemodialysis. Okay, So remember, diabetic patients that aren't really a scar off nephropathy and risk off and stage kidney disease, so they might need to have him analysis. And so a lot of diabetic patients might have this 80 Fischler created to have to, um, to be able to have a hemodialysis last one? Uh, yeah, I think so. they fixed it. This is the patient's legs. That's what I'm showing here. This their patients likes one of these brown things here. He has no very common examination finding for diabetic patients. Not quite erythema nodosa. Okay, I mean, it doesn't do you get raised sort of red lesions. Uh, so this is just trying to get a diabetic democracy. Okay. Classic. Often they're known as shin spots. Okay, Very common examination. Dermatologic. A teacher. Diabetes. Okay, you get these brown brownish patches over their legs. Okay. Commonly known as shin spots. Uh, skin feature of diabetes. Okay, uh, again. So over the spot diagnosis. What do you think about this patient's I, but it's patient. Have you? Yeah. You guys got it? Okay, that counteracts. Okay, So, diabetic patients in general, they're at a higher risk of getting cataracts. Okay on. But there's a couple of different reasons why I gave the diabetic patients. They're at risk of getting cataracts and lot higher percentage. There are much higher risk compared to the general population. Okay, You see the cataracts here, the pacification off the lens. Okay. We're gonna move on to talk about diabetic retinopathy. Okay? I'm gonna talk about the different features to look out for. For retinopathy on fundoscopy. Um, and I've got a basically, and I've got an animated diagram. I'm gonna, uh, a cartoon image, basically to help illustrate it. So this is a normal rep. Okay, so this is a sort of a a culture in image of a normal retina. Okay, this is what a normal retina looks like. Okay, we have the macular here, have the optic disc here, and we have blood vessels here, and we're gonna shoot an image off, uh, diabetic retinopathy. Okay, So I'm don't get side by side so that you guys can help picture some of the key differences. So this is an image of a normal retina. This is an image highlighting the key differences we've seen diabetic retinopathy on this is gonna help because we're basically going to do a bit of ah, game of spot, the difference. Okay. Eh, So you guys are going to tell me what the different abnormalities I'm pointing to. Uh, what do you think about this abnormality? What do you, um, pointing out here with all these blood Best. I'm trying to get the blood vessels. Okay, Yeah, so? Well, come on, Teo. The hemorrhage and bit. So I'm going to get the neovascularization. So you see, there's very few blood vessels in this area here. You can see there's a whole bunch of other blood vessels forming here. Okay, So neovascularization arguably the most important feature to look out for an endoscopy. Okay. To look for new mask organization. And so the indicative off proliferative diabetic retinopathy. Okay, if they have neovascularization indicates I have very severe retinopathy. Okay, um, it happens because because of the skin damage you get there, you start getting production off growth factors like bad Jeff again that induces blood vessels to be formed in the retina. Okay. Very, very important feature to look out for, uh, what about this? So this is the thing. Are you A lot of you are talking about. What do you think about that? Yeah, Hemorrhage. Okay, so, um, retinal hemorrhages. Okay? They're often they known as dot and blocked hemorrhages. Okay, but dot is they call it a doctor hemorrhage. If you can see the border off the camera chart Aero or a blocked if you can't see the border. Okay. It's pretty hard to differentiate it. So I just said a retinal hemorrhages. Okay. Very, very important feature to work up for endoscopy. Uh, what about these, um uh, whiteish patches here? Yeah, cotton wool spots. I forgot animated. Yeah, but these are cotton wool spots. Okay. Yeah, I think I messed up the animation. So these are cotton wool spots again. Another important feature. So they have been different to these other ones. See that? These are look a lot more fluffy. Okay, indicators, sort of. Optic swelling. Okay, uh, there was evidence of micro aneurysm there because I showed the show you the answer. Um, what about these yellow things here around the macular? What do you think these are? Yeah, hard exit. It's very good. Okay, so these are hard accidents. Okay. Is these yellow yellow spots here? Um, these are hard exhibits will look like Okay, there are a lot smaller. Okay. They don't look. They look different to your cotton wool spots. Okay. Caramel spots. They look much more paler. The lot more fluffy and lose a lot bigger is a hard exit. It's again, as you said, that their lipid deposits on the retina as well. Uh, the last one. Um, what do you think? So if you have a look at the difference here, what do you think about the look at the macular here and look at the marker here. Yeah, macular edema. Okay, so if you look, if you ever be close, like the macular just looks very differently. Maculate Okay, maculopathy or macular edema. Another important feature off diabetic retinopathy. Okay, so these are the different features to look out for retinopathy. Okay. The diabetic patients. Um, so hopefully this cotton image makes it really clear in terms of how we grade the severity of retinopathy. This is how we stage it. Okay, So you can have a background retinopathy. You have pre proliferative retinopathy. Then you got a proliferative retinopathy. What's the main difference between proliferative retinopathy and pre proliferative retinopathy? What? What? When does the patient have a proliferative retinopathy? Yeah, So if they have, if they have new vascular situations that they have these new blood vessels being formed that make that makes it proliferative retinopathy. Okay. And then you have advanced retinol where they start getting complications. Okay, so that was just a cartoon image. I just I've shown you this actually fundoscopic image to actually put those findings into practice. Okay, um, I have sort of highlights of the difference here. So you can see this red arrow Red Arrow here pointing towards the basically the new blood vessels being formed. Um, then we have a sort of the White House point in your blood vessel. Be informed we have this, uh, this Aramark pointing towards be on cotton wool spots. Okay, uh, then we have the hash here, which is pointing towards the heart exit. It's okay. And then we have these, um, this area here pointing towards basically the hemorrhage is in the retina. Okay, so that's how you can put those lovely. You're clear about the findings from the previous light, and you can apply it to an actual fundoscopic image. Okay. Eso in terms of how we grade the severity of diabetic retinopathy, this is the actual grading system. Okay, So you can I do great as an odd one. Are too are three or an m one. Okay, if they have any evidence of proliferative retinopathy. So if they have neovascularization that automatically makes it on our three. And if you have evidence of Maculopathy. Um, that makes it and I'm one. Okay, Venus beating venous, beating it. You don't see. It's it's pretty hard signed to Texas where you see the bulges in the veins like it looks like a beats in actual events. I didn't have an image of that previously, but if you can recognize the ones I've already shown you that should be more than enough for your skis in terms of how you treat diabetic retinopathy, if you get asked about it in your skin is I've listed that sort of main aspects off treatment for retinopathy. Okay, So make sure you mention to optimize that glycemia control optimized BP and lipid profile because that can worsen the retinopathy. The definitive option is to do photocoagulation again. This is what and I will look like after photocoagulation. Okay, you can see this is one. And I looks like after photocoagulation Okay, they could see all these sort of different burn marks. Uh, you can try things like anti by Jeff injections. Okay, Particularly if they have proliferative retinopathy, because it's gonna reduce the new vascular ization. And if they've developed complications like, um retinal detachments or Victrelis hemorrhage. Then you can try that. Retract me. Okay, so you remove the victories. Humor. Okay, We're gonna talk about neuropathy quickly. Okay. Ah, I'm gonna described a couple of different findings, and you need to describe how you would describe the sense how you would describe the deficit in your house key. So if someone has deficits in this distribution, how would you describe it in your state? No. Yep. Start pulling neuropathy. Okay. But it's specifically passively polyneuropathy. Describe it as a dog and stocking distribution of sensory loss. Very good. Um, what about this one here? How do you describe this? This steps it. If it's a it's a it's in a distribution of a dermatomes. How would you How would you classify the actual neuropathy if it's a dermatomal pattern off deficit? How do you already describe it? There's a nerve root problem. Ridiculous. Pretty. Okay, So it's a problem of the nerve roots causing said it. Pattern of pattern off deficit in a particular dermatomes. Okay. It's a ridiculous opathy. Okay, uh, next one, do you think about this one? So a specific deficits in the left eye here. Okay. Everything. Guess particular lives in the eye. Like, if you say it's a period of how would we describe? I've the deficits Is that a polyneuropathy is in a ridiculous pretty Yeah, it's a mononeuropathy. Okay. Specifically, it's a cranial mononeuropathy. Okay, on likewise, if we think about the same thing, if we have a similar deficit by unilateral in the leg, Okay. Different unilateral. Um, we can call that peripheral neuropathy. Okay, so you see a deficit and the lower leg lower like here. So it's not any particular dermatome pattern, so that's a peripheral in your model neuropathy. Uh, last one. If someone has a different money, and you're a pretty easy at the same time. Do you guys know how you describe that? It's not as a so even if palsy at the same time is having a a common 15. Pull, pull. See? How would you describe that? Yeah, that's a modern. You're right. It's multiplex. Okay, so and money, right. So multiplex. Basically, if someone has modern uropathy, he's at different locations, but at the same time, that's what modern. You write this multi blocks. Okay, Cool. So go talk to your neuropathy findings now, and I want you guys have a watch of the video and let me know what you guys think the findings are. But the Tell me what you think the diagnosis is cool. So this patient is a third new policy again? Where this video's highlighting some of the key deficits. Okay, so we saw the patient had a ptosis on the left eye. Um, patient had, um a week ago, I was down and out, okay? There was a pupils. Parents. It's classic for I don't know, because it caused by a diabetes. And the patient at the somebody has some problems with my movements is Well, okay, um, if you have a look. So again, some of the death says this patient and down and outside. Okay, pupils sparing on. We'll talk about about the polls in a bed difference between people staring and people if it affects the people. Uh, you see that? I left. I had limited adduction okay, compared to the right side. So patient was asked to look to the right left eye. Wasn't adducted. Okay, So problem with I've movements passing with dinner because it innovates so many extra ocular muscles which are involved in I've movements. Um normal abduction. Okay, so abduct normal abduction because, uh, which muscle conduct controls abduction in the eye. Which extraocular muscle. We have a laugh or Actis. Okay. And the lateral actors is no invaded by the third nerve. It's animated by the 16. Okay, the abductions minutes. Okay, so this patient has normal abduction. Okay, Uh, keep moving on. Um, patient had limited elevation. Okay? Because again, problem with my movements. That can be certain of innovative many muscles which are involved with elevating the island. I can't similarly, with depressing the eye lady, um, they live is responsible for certain muscles that depressed the eye as well. So that's why those are some of the key deficits. Think about again as mentioned. That big thing is the Tosis. Okay. You see, the physician is constantly having to hold the patient's eyelid up. Okay, Because of the Tosis start some keep deficits. You said you get with a certain if palsy caused by diabetes. Okay, Okay. Yes. Tell me something. What? One of the other causes of the nerve. Because even examine. Ask you that. And you're asking other than diabetes, what else would you be worried about? Yeah, Trauma malignancy. Okay, So, surgical, cause as you said, okay, post your community getting artery on here isn't. That's a big, big, big cause you want to rule out. Okay, cool. So it comes up the nerve palsy. I'm not going to talk through it. Okay, But I basically made this light to help summarize the difference. Pathophysiology of a live palsy. Okay, so we have the different disturbances you can get with I've movements. Okay, Andre. So here's the summary of the different. I've movements controlled by different muscles on you need to be able to differentiate between a medical treatment for C and a surgical 40. Okay, So if someone has a medical third nerve palsy such as in diabetes, because it affects the center off the optic nerve particularly, you get primarily a motor deficit. Okay. But it doesn't affect the parasympathetic component. Okay, because the parasympathetic component is on the outside of the new. So because diabetes, it affects the center of the nerves. Typically, you don't get it doesn't affect the parasympathetic input to the people. So that's why the pupils are typically spared with diabetes. Okay, that's what that's what's called a medical building. New pool. See? But if someone has a surgical menopause e, for example, if they have a peak and your is, um so posterior communicating artery aneurysm that can compress it Didn't if because it's compressing from the outside, it can compress the parasympathetic fibers. And that will affect the past him today, up, up in part to the people. And that can cause people dilation. Okay, because your damage, not you're damaging those particular fighters. Okay, so that's the difference between that's why they call a third nipple. Is he due to diabetes? They call it a call it people sparing. Okay, because typically the pupils are not affected. Okay, And here's the summary off the different symptoms off. Medical and surgical didn't see. Okay, we are Slowly. We got two more slides, and then we'll be done. I promised sick they were gonna talk through the autonomic neuropathy quickly. I'm We're going to do this as a sport diagnosis again. I'm going to show you some signs. And you guys were gonna tell me which type of autonomic neuropathy it corresponds with eso. We got a picture off some Viagra. What type of autonomic neuropathy does it correspond with Yes. Erectile dysfunction. Okay, So diabetic patients. Okay, the risk of, uh, damage to many autonomic nervous autonomic nerves. Okay, we're gonna back difference autonomic functions. Okay. Such as, um, sexual activity. So patient. Diabetic patients are a risk of erectile dysfunction. Okay. And Viagra. Very common drug used to enhance increase blood flow to help with erectile dysfunction. Okay, it's specifically sildenafil. Uh, next one. What do you think about this? When I might What is that similar here? Yeah. So it's ah specific type of form which is asking about that fluid's asking about the urination habits, you know? What is it? One of the what type of document this is? Yes, I was There is a black blood. It This is a bladder diary. Okay, this is what a bladder diary might look like again where patients are still in their daily fluid status. Flu? How after they they have urinated throughout the day. Okay. On important in diabetics because they can get bladder dysfunction. Okay. They can get a neuropathic bladder. It should be a problem. Uh, what about this one? Is this patient wearing And what type of autonomic neuropathy is it corresponding with? Yeah, So these are compression socks. Good. What? What can I help treat? What condition can help too? Yeah, venous disease. What us? If you think about autonomic neuropathy. Yeah. So when I was postural Hypertension. Okay. Our office static hypotension. Our patients might be anywhere from them. Okay, But as you guys said, they are used for very stiff achiness disease as well. Next one. So the patients we got a picture of some medical Promide sublets work type of autonomic neuropathy is that my might be treated with them. Yep. Gastroparesis goods. Last one. We got links. Antiperspirant spray. Okay, I've used this sometime in my life. Work that we use for Yes, diaphoresis do. Okay, so don't diabetic patient. They had problems with sweat glands. Okay, They sweats excessively. Okay, because of the autonomic neuropathy. Okay, so you might have a lot of diabetic patients using them. Antiperspirant spray. Cool. We're gonna finish off the diabetic foot. Okay. I lost like I promised eso again. Spot diagnosis. You guys tell maybe findings off the different diabetic foot. What do you think about the these shoes? He has no also says yes. So these are special. These are both optics? Yes. A Z guys. Especially special diabetic shoes. Okay, that help with protecting diabetic patients from features of diabetic foot. Okay, um, so as authentic. So they they're designed in such a way to prevent the certain complications of diabetic shoes. Okay, I'm not gonna pretend like I understand how the different shoes are designed to help the diabetes. Okay, but this is what diabetics use. Like, uh, do you think this picture is going on here? Yep. It's and also Okay, So a someone said this is what type of also, is this likely? Because it's on the sole of the foot. The pressure also. So that's probably a neuropathy cancer. Okay. Typically, neuropathic ulcers are located on the bottom of the foot. Okay, because patients don't realize that they have. And also the vessel, they just keep walking on it, Okay? They don't actually experience any pain from it. So this is one of your particle, so might be distributed. Ah, Laura, This extra here on the foot? Yeah. This is a Charcot joints. Okay, This was a shocker joint. My look like, Okay, we're not going to talk about it at all, but soccer joint is basically progressive this destruction off a weight bearing joints. Okay, Due to neuropathy, can you can see the extra articular destruction here? Okay. And you see their collapse of the mid foot. Um, that's what a Charcot joint might look like. Okay, It's a very complex topic of a shock or joints on next one. Here. What do you think about this Patient speeds. Not the most pleasant thing to look up. Tinea pedia. It's also known as athletes. Foot case is a fungal infection. So that many patients, their risk off infections. Okay, Particularly fungal infections against the athletes sports, but particularly common in diabetic patients. Last one. What do you think about this patient speeds? I want you guys to come to the company. Number of those. I need some time each leg. Yeah, it's Ah, yeah. So this patient has amputations. Okay, so this patient has specifically 33 amputations. Okay? Patient has a till missing on the right foot and two toes missing on the left foot. Okay, So diabetic patients Dabiq thought an important thing to look out for in diabetic feet is amputations. Okay? Never miss an amputation in your skin. Okay? Always count the number of toes patients have. We'll talk about this stuff more during the basket station. Okay? The amputations, Obviously. One of the major complications are, um, peripheral arterial disease in diabetic feet. Okay. Okay. Uh, so this is somebody off the examination findings that we talked about? Okay. A lot of them that we talked about. Just some very slight for you guys being a revision. But that's it. Thank you guys for coming in. I'm sorry it dragged down a bit again towards the end, but I hope you guys enjoy, uh, okay, if you want to stop the recording.