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OK. Hi, everybody. Uh today we're doing the final ACMS educate UK MLA lecture series. Um I hope everybody can hear me just pop a message if you can't in the chat. So, um it's presented by me AKC L ACMS President and it created by the K CLA MS Secretary uh Yasmin Yanker. So, the conditions we'll be going through today are acute kidney injury, AK AK I urinary tract infection, uti appendicitis and hypertension. So, uh these are structured as we just kind of do a quick topic recap. Um just kind of the important aspects of the disease and then we do some questions and answers and a little bit of reasoning to practice. Um So, first of all AK I, so AK is acute kidney injury and this is basically caused when there is a reduction in renal function due to sudden damage to the kidney. That's why it's acute, not chronic. Um These are split into prerenal, intrinsic and postrenal. Um And when you get a question, just always try to break down in your head, whether it's prerenal, intrinsic or postrenal as um they can kind of uh change the way you manage. Um AK I. So prerenal causes uh these basically occur in the circulatory system before reaching the actual kidney itself. So, an example could be hypovolemia, meaning sort of low volume either through diarrhea because you know there's fluid loss or vomiting. And it can also be because of renal artery stenosis. So the artery before uh entering the kidneys that supplies the kidneys, uh is sort of narrowed, meaning you get less blood flow. So these are both prerenal causes. Then you have intrinsic causes intrinsic meaning within, so, within the kidney itself. So, intrinsic causes, relates to damage to the uh renal tubules or the interstitium of the kidneys themselves. And there are lots of different reasons. Key ones to not in exams are toxins which can either be drugs or contrast. So that'll be contrast nephropathy, but it can also happen through immune mediated go go nephritis. Uh for example, uh G GG gary nephritis, sorry, acute tubular necrosis, acute interstitial nephritis, rhabdomyolysis or tumor lysis syndrome. So, uh postrenal causes are usually after. So this can be uh related to problems after the kidney, such an obstruction to the urine coming from the kidneys, resulting in things backing up. Uh and this can affect with normal renal function. So, think of system wise, either it's gonna be something like a stone that's in the ureter or the bladder. This might cau cause fluid to sort of backtrack and backtrack into the kidneys uh causing AK it can be uh BPH where an enlarged prostate can sort of cause a constriction um of uh urine outflow, also causing a backup of fluid into the kidneys. And then it can also be based on external compression. So example, could be through to benign but also malignant masses that can compress the ureters or um which can also cause obstruction. So, ak I there are some quite a few risk factors for it. Uh The key one is if you have chronic kidney disease, you're likely to have acute kidney injury due to sort of sudden causes. So somebody with a background of CKD can have AK I on a background of D any other kind of organ failure also makes it quite difficult to uh for the kidneys to kind of work through and process and filter through excess toxins or excess um or organic materials. Um because the organ that should be working correctly fails. Um So this can cause AK I anybody with a previous history of AK I is more likely to have AK I again. And the use of these five common drugs are likely to uh cause nephrotoxicity. So we have nsaids, aminoglycosides, ace inhibitors, angiotensin receptor blockers and diuretics also iodinated contrast agents. So anybody who's gone through, let's say like a CT scan with contrast is likely to have an acute kidney injury if you know their renal function is already quite like suboptimal people age 65 years or older, just because as you get older, your kidney function decreases and then also oligo urea, um if you have decreased urine output, that can also cause AK I so most of the time AK I is asymptomatic, but the key signs probably would be if you're taking a history. And the patient sort of mentioned something like if they haven't passed urine in six hours, um or more, that could be sort of a key sign. Um So that sort of reduced urine output. Another one could be any signs of pulmonary or peripheral edema. So just listening and auscultating the lungs and just having a feel of the extremities to see if you can feel for any edema. Uh arrhythmias could also um be a sign of AK I. So make sure you auscultate the heart and any features of your anemia. So, pericarditis or encephalopathy. So just make sure that you do a good uh neurological examination, nothing to um sort of advance, but just making sure power um is good reflexes are good. They are co cognitively sort of alert and not confused at all. So, investigations, so you want to obviously do bloods. Um the key calls um could be due to sort of deranged um sort of clinical biomarkers, urine analysis is also another one you'd want to do. Um And then uh you'd also want to do, uh if you're kind of worried, you might want to do like a urine um sorry urinary catheterization just to measure urine output. If you're thinking it could maybe be um like an obstructive cause you might want to measure the urine output. And see also, um if you can't identify the course of the deterioration after you've done the clinical history, the examination and these sort of bedside um assessments you wanna consider doing a renal ultrasound within 24 hours. The nice guideline says, um you want to detect AK I, either with the P I four A kin or Ko Kygo definitions. Most people use the Kygo definitions. Um And this is a rise in serum creatinine of 26 or greater within 48 hours. A 50% or greater rise in serum creatinine known or presumed to have occurred within the past seven days. Um So sometimes very high levels of serum serum creatinine um are high enough just to know that this is, I guess you're presuming that this is a very high level and it's above a 50% rise. Um And then also for a urine output of less um to less than 0.5 mL per kilogram per hour for more than six hours in an adult. So, staging, um so most often uh staging is done via the serum creatinine changes and or the production of urine staging is usually done. Um based on these from 12 and three, as mentioned here. Additionally, um if a patient is deemed as stage three AK I, they are comments on renal replacement therapy, irrespective of creatinine or urine output. So, uh let's have a look at the creatinine um sort of levels that causes each stage. So if it's an increase between 1.5 to 1.9 of the baseline, then that is stage one. So for example, if uh the baseline was something like 100 and it goes to 100 and 50 or 100 and 90 that is stage one. Uh stage two is increase of 222.9 times the baseline. Um And then stage three is an increase of above three or if it's above 354 micromoles per liter. So if at any point in time, it's above 354 that is straight away. A stage three AK I so urine production is done based on the milliliter per kilogram per hour and the time. So if it's uh below 0.5 for more than six consecutive hours, that's stage one. If it's below 0.5 or above 12 consecutive hours, that then moves to stage two. And then if it's less than 0.3 for above 24 hours or the patient hasn't like when you do the um for example, urinary catheterization hasn't produced any urine for 12 hours. That is immediately a stage three. Uh So management management is being supportive, meaning if it's something like a prerenal cause you want to replace that fluid, um, that's been lost. So you might do like an IV fluid bonus and then probably fluid maintenance until they can sort of drink, um, water independently. Um, and you wanna stop any offending medications that they're on. Um, and you just want to monitor things like BP, um, to make sure that it's at a good enough level that there's good perfusion of blood, uh, to the kidneys. Um, so it's mainly supportive in that way. Uh It's quite important to know what kind of medications are safe and not safe to use an AK I. So for example, the safe ones are paracetamol, warfarin statins, aspirin at the cardioprotective dose of 75 mg once daily clopidogrel and beta blockers. Um the ones that should be stopped in AK I as may worsen renal function. So this is important because this is because it worsens renal function. This is why it should be stopped. And I like to think of it as N AAA D. So that's nsaids except from aspirin at the cardio protective dose, amino glycosides, ace inhibitors, angiotensin two receptor antagonists or diuretics. And then some of these other ones are to be stopped, but not because they worsen AK I but it's because you're really worried about the risk of toxicity. That's Metformin lithium and digoxin and lithium is quite a common one. to be aware of cos lithium toxicity is very bad. Ok. Some um SBA S time, sorry, it's a bit blurry. Um I'll make sure that I read out loud. A 74 year old female presents with a three day history of diarrhea and vomiting. She has a background of chronic kidney disease, congestive cardiac failure, and atrial fibrillation and type two diabetes, neuritis. Her blood results were as follows. So bit blurry but sodium is 140 potassium 4.7 bicarbonate, 26 urea 7.1 creatinine 124. But today, that was, that was five weeks ago. But today uh sodium is 145, potassium is 5.9 bicarbonate is 22. Urea is 15.4 and creatinine is 356. Consequently, the admitting doctor reviews her current medications, which of the following would most likely to be considered as safe to be continued. So, is it digoxin furosemide, Metformin Enalapril or Warfarin? Any ideas or medications if you wanna pop it in the chat, that would be great. If not, I can reveal the answer and some explanations. So 54321. So the answer is you'd want to continue using the Warfarin, all the other medications um have the that they in AK I they can either produce toxicity such as digoxin and excess and Metformin or they can cause worsening of AK I itself, which is fur which is a diuretic and Enalapril which is an ace inhibitor which needs to be stopped in AK I. So question number two. Sorry for the the quality is a bit bad. But um a 84 year old woman admitted for the treatment of a lower respiratory tract infection and she becomes anuric on the ward for the last six hours. Blood tests taken show urea is 11 and creatinine is 100 and 56. She had a baseline of 78 previously. According to the acute kidney injury AKI staging. What stage of the AK I is this woman at? So is it a stage zero B? Stage one C, stage two D, stage three or E stage four? Yes. Good job. I haven't seen that. Right. It's stage two. Exactly. Yeah. Yeah, you're correct. Um because uh essentially you, we're looking at the creatinine here, the creatinine has um gone up by two. So times two. So that's stage two based on that definition. Um You could argue that um urine production is only at less than 0.5 over s um at six hours. However, you go at, you go based on the most extreme of the criteria. So if one, if the urine output is stage one, but the creatinine is stage two, they're at stage two AK I if that makes sense. So you go at the most extreme definition. Very good job. Uh question three. You are doctor Larking for the acute uh for acute medical team on a night shift. A 65 year old man presents to the emergency department with a six week history of dysphasia and poor appetite associated with reduced oral intake. His physical observations are within normal ranges. However, blood tests performed at triage show stage three AK I, what is the most important investigation to perform immediately to help you establish the cause of the AK? So um thinking about where they are. So emergency department and thinking about the most important evacuation to do immediately. What, what are we thinking? A anti GBM antibodies? B ECG C Gastroscopy D myeloma screen or e urine dipstick? Ok. 543 21. So the answer would be a urine dipstick. Given the stage AKI. Yeah. Really good. Yeah. Yes. So you do want a urine dipstick. Um Do you think so given the, given up the surgery already? So, you know, it's a stage three AK I based on uh the fact that they haven't been eating or drinking at all. So you, you're assuming that they haven't passed urine? Oh, that's right. You're assuming that they haven't passed urine at all because they haven't been drinking at all. Um But you don't really know what the cause is per se. Um So you want to do a urine dipstick just to kind of see the, the functions, functioning levels of the kidney. So you wanna see protein, blood leucocytes because you are assuming that it's an AK uh but you kind of want to know a bit more about what is going on with the kidneys, are they producing a lot of protein as a result or could it possibly be an AK? But for a different reason, for example, if there's blood, they could have a co urinary tract infection or kidney stones that could be kind of happening at the same time. Um So a good one to do is urine depth. Also, you, there is no indication to do any of the other ones. If you did think that, um, you needed to anti anti GBM antibodies, maybe the clinical picture would have told you that there are maybe, um, signs of protein urea and other signs related to that. They haven't already told you, they haven't told you they have any sort of cardiac features that you're worried of pericardial or anything. They, they did say dysphasia. So maybe a gastroscopy maybe, might be indicated. But the question is for the cause of the AK I itself. Um, not really any other cause. And then myeloma screen, normally you're thinking things like hyper hypercalcemia symptoms which isn't really shown here. Um, it's more like sort of di diarrhea, I think. Picture. Um, so you're in depth. Yes, exactly. Yeah. So the other investigations are not like directly relevant. Yeah, I agree. Yeah. Really good job of sh um, so another question, an 81 year old woman is admitted to hospital with a urinary tract infection and subsequently diagnosed with stage two AK I. Her regular medications include aspirin, 75 mg daily naproxen. Z 250 mg four times a day. Loso 30 mg uh one daily paracetamol, 1 g, four times a day. Metformin 500 mg twice daily, lithium carbonate, 1 g daily and simvastatin 20 mg at night. Some of her recent blood tests are shown below. Um So I'm just gonna the key ones to kind of be aware of would be creatinine is 167. EGFR is 57 which of her medications should be stopped due to a risk of worsening renal function. So you've got a Aspirin B, lithium C, Metformin D naproxen or E simvastatin Aspirin. Probably. So I understand why you would go for aspirin. But remember that you were allowed, I think uh aspirin at cardioprotective doses. So, can you think of any, any other ones here that you wouldn't want along the same lines of what you're thinking of? No. Ok, I'm gonna reveal the answer but I understand your line of thinking. So it's gonna be naproxen. So what I think you thought was aspirin because aspirin is a form of NSAID, but there's an exception to the NSAID rule which is you're allowed aspirin at cardiac doses. So at 75 mg once daily, it doesn't affect the kidneys yet. Its mechanism mechanism of action affects the heart. Um, so the NSAID that you were looking for was naproxen but really good a er guess, yeah, I realized, yeah, you probably were thinking um of an NSAID. So really good attempt there. Um And the other ones, for example, like lithium doesn't cause lasting renal function. It causes um nephrotoxicity in high doses. So does Metformin uh simvastatin. I'm trying to think, I think you can still continue that. Uh So now we're moving on to UTI which is the next topic. Uh This is an infection of your bladder kidneys or ureters, which is the cues that connect the bladder to the kidneys. Um So symptoms, dysuria, meaning pain on urination, increased urinary frequency, urinary, urgency, cloudy or offensive smelling urine, low abdominal pain, low grade fever, malaise or confusion in older adults. Typically in older adults, the only thing that they kind of present with is that confusion. So it's whenever you come with an older adult adult with confusion or like delirium, I guess, always think uti um so investigations kind of similar to what we were talking about with the AK I, you kind of wanted to do a history and examination as yours would and then urine dipstick. Um A uti you have positive nitrates, not nitrates nitrites. And then you might have some leukocytes and some red blood cells, but you might not always get um white blood cells um in UT S because they can be sort of lacking in, in that in the um in the urine. Um You might wanna send a urine culture to identify the bacteria or yeast causing a uti um and urine cultures must be sent under the following conditions. So you should always send a urine culture if there is non visible or visible hematuria. So if you do the urine dip and you see blood on the urine dip, but visually, when you're looking, assessing the urine, it looks like cloudy. It doesn't look like it has blood in it, that is non visible Hema hematuria. So you want to send a urine culture for that and visible would also be, would be when you see that the urine contains blood and it does contain blood on the urine dipstick. And you'd also want to send a culture for that anyone over 65 as they might grow um sort of um uncommon organisms, pregnant women. Um and males, uh let's see the reason why males is because um males don't tend to get UTIs due to the uh length of their sort of um urethra, which kind of prevents getting a uti. So you sometimes wanna do a culture. So management is kind of split into kind of three different ways to think about it. So if you're a man or a non pregnant woman, uh you can give them either trimethoprim or nitrofurantoin for three days if you're a woman and for men, like I said, it's not as common to get a uti. So you wanna give them a little bit more uh sorry, you wanna give it for a little bit longer. So you wanna give trime trimethoprim or nitrofurantoin for seven days. Next, you have to consider pregnant women separately. So, um whether they are symptomatic or asymptomatic, you just wanna just send a urine culture and then you wanna treat with first line nitrofurantoin and second line, either amoxicillin or cephalexin. And then catheterized patients are kind of put into their own set category and you don't treat any asymptomatic bacteria. So, if they have a UTI but there's no symptoms, there's no fever, no malaise nothing. They just have, I guess a uti and you're in depth, you don't wanna treat them in men and non pregnant woman. Um So if a patient is symptomatic, you typically want to treat for seven days. Um The only case is kind of here with women who are not pregnant, you might want to treat for three days. Um And then you should always avoid trimethoprim in the first trimester during pregnancy um in pregnant woman because it's teratogenic, meaning it can sort of cause um the babies to sort of ha the fetus to have um sort of symptoms uh related to the teratogenic genicity such as, you know, cardiac um malformations um and things like that. Ok. Some in practice, question time. So a 32 year old woman who is 10 weeks pregnant presents for her booking appointment. A an em su a mystery urine sample was collected for a dipstick and culture. The urine dip comes back positive for blood nitrate nitrates and leucocytes. The urine culture comes back for E coli which is really common. E coli is one of the most common um bacterias found in the UTI I. Despite her being asymptomatic, she is treated with a seven day course of nitrofurantoin which she has now finished. She remains asymptomatic after treatment. What is the most appropriate next step in the management of this woman? Um So a no further action required B urine dip C urine culture D seven day course of C Keflin e continue nitrofurantoin for a further seven days. Any ideas? No further action. Anyone have any ideas. That's what I've got one message in the chat, I'll show the answer. So in this one, you want to do a urine culture. Um and the reason why is because she's 10 weeks pregnant and you've done a course of seven days, that is the end of the course. So you need to just make sure you need to check that the um that the uti is actually gone. The reason for this is she may be asymptomatic but still has the uti in culture, meaning it's still growing the bacteria. So if you stop it, there is still bacteria in the urine and it will continue to grow, grow, grow, grow, grow, causing the uti to come back. So you don't want that to happen in pregnant women. So you want to make sure that all of the bacteria is completely gone and that they're asymptomatic before no further action is required. Um So you need a little bit more caution with pregnant women um by doing a urine culture to confirm that they are. They don't. Their uti has completely resolved. Uh Question number two, a 68 year old woman presents to her general practitioner for an annual review of a poorly controlled type one diabetes. She reports feeling well in herself on examination. The patient has a urinary catheter in situ due to recurrent urinary retention, a urine sample sent to the laboratory for an albumin creatinine ratio which is unchanged from her baseline. Uh with no stage four chronic kidney disease. The laboratory report states that the urine sample showed scanty growth of E coli. What is the most appropriate management of this patient's urine analysis results? So a no antibiotics is indicated at this time. B prescribe a three day course of nitro C, prescribe a three day course of trimethoprim D, prescribe a seven day course of nitro erin or E prescribe a seven day course of trimethine. Pop your answers in the chat if you have an idea of what it could be. Ok. So we've got some answers. Either B or CI definitely do think the management for UTI S are quite difficult because they have lots of different rules attached to them. Um So yeah, she is a woman. So that is something. But what else does she have? She also has a urinary catheter in situ and she says that she reports feeling well in herself. So currently we know she's an asymptomatic woman with a urinary catheter. Nothing has changed in any of her samples. And, um, yes, it does show scanty growth of E coli but nothing has changed in terms of her urine results. So, actually you give no antibiotics. The reason for this is because a lot of patients with urinary catheter. Exactly. Yeah. Really good. Uh No antibiotics. A lot of patients with urinary catheters tend to grow bacteria because you are introducing that foreign substance into the urinary tract. So they do tend to grow it. Um She's asymptomatic. She's got a catheter, she's all fine. There's no derangement of her function test like her urinary uh results. So, in this case, no antibiotics is indicated. But the key word is at this time. As soon as you realize that it is asymptomatic, sorry, it's gone from asymptomatic to symptomatic, then you would treat. Um So I hope that makes sense. A 70 year old wo woman presents the GP with a seven day history of dysuria and urinary frequent urgency. Sorry. She also needed the toilet eight times to yesterday which caused great distress. She had a uti 12 months ago for which she needed a catheter during treatment. She has a family history of diabetic nephropathy. The GP suspects another urinary tract infection and an MSU sample sent. What aspect of this woman's history necessitates this investigation to be carried out. So basically why do we need to do A MSU which tends to grow like cultures um to be sent? So, is it a because she's aged more than 65 B, the duration of her symptoms? C family history of diabetic nephropathy d history of catheter in situ or e previous urinary tract infection 12 months ago. Yeah. So comment says the only thing I can think of is her age, really good job of shock. So um if you look here, age more than 65 years old is one of the like reasons why you would want to do a culture. Next question. A 45 year old man presents a GP with a four day history of burning pain and passing urine during the day. He finds that he has to pass urine every 30 minutes. He has no past medical history except form an allergy to person and is not sexually active. His temperature is 37.1% degrees Celsius. His heart rate is 75 BPM and his BP is 100 and 26/75. An abdominal examination is unremarkable and there's no renal angle tenderness. A dipstick is positive for leucocytes and nitrites. What is the most appropriate? Next step for the GP to take a prescribe nitrofurantoin for three days. B prescribe nitrofurantoin for three days and send a urine culture. C prescribe nitrophen for seven days. D prescribe nitrofurantoin for seven days and send a urine culture. E refer to ur for further assessment a little bit trickier here because you've got both uh any ideas in the chart. Ok. So he definitely needs a seven day course of antibiotics. I wonder if he needs a urine culture along with it. So let's have a look. You're correct. So seven days of nitro time, he's a male, he needs to be treated. So a right day, right medication. And then also you might want to send a urine culture as well because one of the, I don't know if you remember the page, it was like one of the things that you're pregnant, uh your age is above 65. Um and you're male, those are the reasons why you want to do a culture. Amazing. OK. Next topic, appendicitis. So, appendicitis. So, appendix, you know what that is? Uh ascites means information. So information of the appendix, which is this little thing right here. I don't know if you can see my cursor. So uh symptoms, sudden pain that begins on the right lower side of the abdomen. Actually, sometimes it starts at the um umbilicus and then it travels down to the uh right side of the lower abdomen. Uh So yeah, they set it here. So it's sudden pain that's around the navel and it shifts pain that worsens with coughing, walking or making other jarring movements. So, anything that I guess increases uh intraabdominal pressure or causes friction or rubbing, nausea. And vomiting is really common. Loss of appetite is quite common. Low grade fever is really common. Um And it may arise as the illness worsens, constipation or diarrhea could occur and then you might get some abdominal bloating and gas. So there are key signs here in clinical practice. I don't really see many people doing the sign. Um but it is important for exams because it does come up. But the Robson uh sign does come up in exam and in clinical practice, uh this is when you basically palpate the other side of where the appendix should be. And it, because of you, you've increased the raised, you've raised into abdominal pressure. It actually irritates the contralateral side because the entire abdomen's pressure is increased and it causes that irritation because it's causing the appendix to kind of have that friction. Um And that will cause pain um in the right lower um abdominal area. Um And then the soas sign is like you extend the side um of the leg where the appendix is located. Um and you extend the hip back uh backwards with the leg going backwards. And this is if it's um a retro cecal appendix, appendix tend to have different um positions. So it can either be positioned, moving forward or it can positioned backwards, um which is like a retro cecal position. Um There are other things that may occur on um like an abdominal assessment, you may get generalized peritonitis. It may be really hard for you to do percussion on uh the abdomen as it can cause pain. Um If you're touching the abdomen, it can cause rebound tenderness. When you release your hand off the abdomen, it can cause guarding where the patient doesn't want you to kind of touch the abdomen. So the abdominal muscles tense and it can also uh occur with rigidity. There could also be a boggy sensation upon digital rectal examination. So when you feel and you palpate, it feels boggy. Um and then just classic right sided tenderness um with a pelvic appendicitis. Ok. So, on examination, you've done that now kind of investigation wise, you're gonna do a full blood count and also some of those inflammatory markers, for example, A S RCR P, you'll get raise in function markers. Um And then also kind of with that. You wanna make sure it's compatible with the history and examination findings. If you have that alone, it's good enough for you to diagnose in appendicitis. Typically, it's a neutrophil predominant leukocytosis. So, when the um leukocytes, the white blood cells are like broken down, you get more neutrophils than the other white blood cell counts. Um white blood cell types, and then you also always wanna do a urine analysis such as like a urine dip and also a pregnancy test to rule out pregnancy renal colic and uti. So management. Uh so, appendicectomy is what you do, it's either laparoscopic. So with a keyhole or it's open, very few surgeries nowadays are open them, mostly all laparoscopic. Um, you do want to give prophylactic IV antibiotics. This reduces the wound infection rate. So before you do the um operation, you wanna give the IV antibiotics prophylactically. And if it does become perforated, meaning if the appendix ruptures, you want to give copious abdominal lavage, which is basically giving fluid into the abdomen to like wash out the, I guess the infected matter out of the abdomen because you don't want it to cause um any sort of peritonitis. Some questions. So really quick question, an eight year old boy presents with a classical appendicitis pain that has migrated from the umbilicus to the right iliac fossa within the last 12 hours. When the doctor palpates the left iliac fossa, the boy feels pain in the right iliac fossa. What is the name of this eponymous sign? Eponymous? I think it's an eponymous side. Yeah. So mcburney sign wing sign. So I sign kig sign. Cope sign. No brain evolves in sign. Yeah, a really good job. So evolves in sign really easy. Number two, a six year old boy is brought into the emergency department, complaining of abdominal pain which started in the center of his abdomen and has since migrated to the right lower abdomen. He has vomited once and is feeling continuously, nauseous observations reveal a temperature of 38 °C BP of 127/89 heart rate of 98 examination reveals guarding in the right iliac fossa. These are the blood tests, just make sure you have a look at the white blood cell count, the neutrophils and the lymphocytes. What do you monocytes, eosinophils. Kind of what do you think there given the likely diagnosis, which of the following options is required prior to surgery? This is interesting. So you've got abdominal ct, abdominal x-ray anticoagulation, blood ketone test or intravenous antibiotics. So, the key thing here is prior to surgery and what is the clinical picture telling you? So it's clearly, it's clearly a appendicitis. So, you know, it's appendicitis because all your clinical investigation history and the blood test results. So what prophylactic measure would you need before during the surgery? Any ideas? So I'll reveal it. So you wanna give intravenous antibiotics um would seem to be an option. Um I feel like so s are difficult because in clinical practice, an abdominal ct may be good to kind of visualize the appendix, see what position it is. Um And see if there are any other sort of um inflammation that's spread anywhere or even like peritoneal fluid to see if it's rupture or not. Um which is, which is something you could do. Um But I think the question was telling you what you need to do prior to surgery. So I think in my head, I think the question meant more like they are going to do the surgery before they actually do that surgery. What do they need to make sure they do? Um They need to give the antibiotics. But I get, if it said, what kind of imaging should they do to ro to rule out or to rule in an appendicitis? I think, then you would go more with the Abdo CT way rather than Abdo x-ray. I would rather go with an Abdo CT just because uh x-rays normally to visualize the bones, but a CT is really good at visualizing soft tissue. So, yeah, are we clearing things? No. So um prophylactic means that you're less likely to have um like a wound infection site rate. Um Sometimes in some cases, uh nowadays, in some cases, people are given antibiotics as a way to treat um appendicitis. So it can actually do both. Um But in this case because it's told you that they're doing the surgery um for this case is to prevent the wound um infection. Um And, and after x-ray, probably not an after x-ray um as in, in real life, you would have a clinical dis discussion with your seniors. OK. Is, and you know that they are going to drink the surgery. What do you need to do uh before the surgery for it to happen rather than what imaging do you need to rule out the other um causes basically here, it's telling you to presume that, you know, it's an appendicitis. So you're not gonna do an Abdo CT or an Abdo x-ray. If you presume that, you know what the um the diagnosis is, if that makes sense. Um, it was in a bit of a difficult way. Ok. Another question. A 25 year old man presents to the emergency department with a one day history of abdominal pain, beginning in the umbilical region and then spreading to the right iliac fossa. The pain is worse on movement. He has had some association nausea but no vomiting and he has had no urinary or bowel symptoms. His height is 193 m and his weight is 74 kg. His respiratory rate is 25. His oxygen sats on 97% on room air. His heart rate is 98. His BP is 1 30/75 and his temperature is 38.3 on palpation. His abdomen is grossly tender what is needed in order to confirm the most likely diagnosis. So this is a little bit different where it's like you're suspec suspecting something. What would you wanna do here to confirm what you're suspecting because you think there could be other differentials here possibly and you want to confirm it. So, are we gonna do act abnormal with contrast uh MRI scan of abdomen, uh non contrast CT abdomen, non the clinical diagnosis from this vignette is enough for you to diagnose it and to move straight on to treatment or uh e ultrasound scan of abdomen. This one's a little bit tricky. So I'll say the answer. So here, non, the clinical diagnosis here is enough for you to basically confirm the diagnosis. It's got all the classical features of appendicitis here. The classic examination findings, uh slight low grade fever. So you'd be happy to basically say it's uh appendicitis at this point. Ok. Final topic is hypertension. So, hypertension uh is just a fancy way of saying high BP. Uh The common symptoms are, I guess commonly is actually asymptomatic. So pe lots of people go around these days walking around uh with high BP and don't even know it. Uh There's blurred vision if there is, if there is symptoms at like really, really, really high levels, you know, 160 over 100 and 20 kind of levels and you get blurred vision due to the papilledema, you get nose bleeds, shortness of breath, chest pains is really common. Dizziness and headaches. Headaches is a really common one actually. And people can get like hemorrhagic strokes um from really high blood pressures. So there are three ways to stage it. Uh stage one is if it's in clinic, it's over or at 1 40/90. But if they're doing it um at home, so home BP monitoring um or like ambulatory, then anything above 100 and 35/85. The reason for this is because in clinic people get um something called White Coat syndrome, which is when I guess the the BP is just a pathologically high sometimes in the clinical settings. So doing it at home is more likely to have a kind of accurate representation of the BP. Stage two is any clinic level a hu uh 100 60/100 or any sort of ambulatory or home BP monitoring above or equal to 100 and 50/95. And then the last one is any clinical setting where the systolic is over 100 and 80 or the clinical diastolic is over 100 and 20. So the diagnosis uh basically offer um clinical reading. If the clinical reading in clinic is above 1 40/90 then offer them to do it at home or in like an ambulatory sort of setting. And then you can stratify whether they're not hypertensive, they're hypertensive or um they are like stage one or stage two. And then you basically need to stratify um different things. If it's stage one, you wanna basically make sure that um you're treating if they are below 80 years old and they have any of the following at stage one. So target or target organ damage, established cardiovascular disease. So this is like anything like um uh let's think, for example, diabetes, any heart like uh conditions, you know, any uh let me think heart attacks or anything like that, renal disease, diabetes. And they have a cure risk score of 10% or greater. And that means that you wanna treat, giving a drug. Um, however, if they are below 80 they don't have any of these following and they have stage one AKI, you want to obviously offer um, lifestyle advice and support. However, if it's straight, stage two, all patients with stage two, straight away need to be offered a drug treatment. Um And this is kind of another way to depict it here as well. Um If a patient is above 80 their clinic is above 1 50/90 you kind of wanna offer lifestyle advice and consider drug treatment, but you're kind of worried at 80 about sort of like the risk and benefits profile and polypharmacy. So if above 80 you kind of wanna maybe lean towards more lifestyle advice. Um But like I mentioned below 80 any organ damage, any cardiovascular risk disease, any renal disease, any diabetes cure score of, of 10% you wanna offer lifestyle advice and then discuss uh drug treatment. Uh You only want to start drug treatment, like I said, if you have below 80 then one of those where you think that the uh BP is a stage one or above. So here we go. And so the drug treatment of choice um is called a statin. Uh and you might want to um offer a atorvastatin or simvastatin. That's not for the treatment for hypertension. Sorry, that's for the, um, for the treatment. If they have a high cardiovascular risk score for the hypertension itself, there's a separate page, um, kind of depicting what medications you want to treat the hypertension, but to also treat the cure risks, um, score, which is like a score which tells you the chances of having a cardiovascular disease in the next 10 years, you'd even want to give atorvastatin or simvastatin to treat that side. So, uh for the hypertension itself, there are two columns. So the first one is if you're below 55 or you have type two diabetes, so be really aware in questions where a patient has hypertension and type two diabetes. Um they immediately go in that first column, meaning you want to give an ace inhibitor first as first line. If they can't to correlate an ace inhibitor, then you would give an angiotensin two receptor blocker. However, if they're above 55 no type two diabetes or despite everything, they are um Af African Caribbean or Afro um Caribbean black African ethnicity, you straight away want to give a calcium channel blocker. Then after this, you basically want to either give uh if they're in the first stream. So below 55 or type two diabetes, you wanna give ace inhibitor or a RB plus a calcium channel blocker or plus a thiazide like diuretic or if they already are on the calcium channel blocker, you wanna either give an ace inhibitor or an A B or a Thiazide like diuretic. So basically, step two, whatever that they are on, you wanna have that plus one of the other two medications that they aren't on. I hope that makes sense. And then step three, they need to be on three medications and it's one of AC and D then step four, which is fourth line. So if all those three medications don't work, then you need to consider these next two medications. So I'm sorry, next three medications. So if the potassium is below or equal to 4.5 you want to give low dose spironolactone. If the potassium is above 4.5 you want to give an alpha or a beta blocker at this stage. If you've given four medications and it's not controlled, you need to then go to a specialist review. That's quite complicated. But in questions when you have practice, it's a little bit easier to remember. Um, just some key bits of pharmacology, how I remember the medications, ace inhibitors and in the word Pril, Ramipril and Alapril A or BS. And in a such as Losartan Candesartan CCPS end in P such as amLODIPine or Nifedipine, also they can end. So the words can also be rap mil and diltia, but that's usually only used in cardiology. You don't really use Rapam and dilTIAZem to treat hypertension. It's normally uh used to treat like arrhyth arrhythmias. Um So you don't wanna use those to treat hypertension. And then uh these are examples of thiazide like diuretics. They don't have a nice way to end them. So it's just Indopine is a common one prescribed and then the other ones are metOLazone, metOLazone, sorry and chlorthalidone. So you've got metOLazone and chlorthalidone but commonly is indopine indapamide. Sorry, indapamide, sorry. Uh management. So lifestyle would be low, low salt diet, balanced diet, reduced caffeine intake, stopping smoking, less alcohol, more exercise, m more weight loss. So practice, question time. A 70 year old man presents to his general practitioner with recurrent headaches. He has bought his ambulatory BP readings which show an average of 100 and 50/98. His regular medications are, he's already on Ramipril, amLODIPine and indapamide fundoscopy shows no retinopathy and his CT had it done a few days ago shows no acute bleeds or infarcts. Blood results are as follows. So just having a look here, we're kind of more interested in the potassium which is at 4.3. So what is the next best management step? A aMILoride B, bendrofumethiazide C Bisoprolol dizan E spironolactone. Exactly. Yeah. Really good. So low dose spironolactone because the patient is already on AC and D. So they're already on, on an ace inhibitor, Ramipril, they're already on a calcium channel blocker, amLODIPine. And then they're already on that thiazide diuretic and damide. So you wanna give spironolactone. Um And if you look at this, it's also because they have a potassium below 4.5. If it was above 4.5 you consider giving bisoprolol, which is a beta blocker or any form of alpha blocker. So um we is running a little bit uh over time, so I should make this really quickly. Uh So a 57 year old man has undergone ambulatory BP monitoring after it was found that he has raised BP during a routine GP check. His average BP is 100 and 64/100 and eight. His GP calculates his Q risk at 12%. Really important. The patient has no past medical history. He takes ibuprofen regularly for his lower back pain, given the patient's investigation findings. What is the most appropriate next step in his management? So lifestyle plus any of these other options. Which one is the most likely one? So A is the lifestyle CCB. It's stage two hypertension. Yeah, it's stage two. Is it stage two? Let me think so. Yes, it is. What else does he have? He also has a cure risk that's quite high. So he's 57. He has hypertension which is a, a high enough level that you need to treat and then he also has a cure risk score of 12%. So you need to give him a statin to um kind of treat that then to treat the Yeah. So then you need to give him a cast in China Booker because he's 57. So anybody above 55 should be given a cast in China Booker. So should anyone from like an African or Afro Carribean or Caribbean descent? And also always give lifestyle advice? Ok. So a 59 year old man attends his GP for review of his BP. He has a background of hypothyroidism, asthma hypercholesterolemia. He remains asymptomatic and his Q risk score is 12%. His current meds are levothyroxine atorvastatin. No, can diamine. I've never heard of that before, but I'm sure that's P is like a CCB me but Chlorethazine, which is a steroid and salbutamol. He has no known allergies. BP is measured at 100 and 48/94 as an average of three readings, which of the following is the most appropriate action. So I have a thing called what medications he's on at CCB? Ok. So that's one option in the chart. Let's have a look. So in this case, they're saying to add Losartan. So let's think about it. So he's on a statin already. So the statin is treating the cure risk and he's in I diamine, I'm not sure if I'm saying that right. Um P um and things like the end and P or calcium channel bookers already. Exactly. So he's on a calcium channel booker already. So then you think of the next step you can either give him an ace inhibitor or an A B or a, um, a Thiazide diuretic spirolactone is a loop. Di, no, it's a potassium sparing. Diuretic. My apologies. So, you're not giving that, you can't give an alpha beta blocker yet because you're not at that stage yet. You're not gonna not change his medications cos he still has a high BP. So it's not managed, it's poorly managed. So, you need to add Losartan, which is an A RB. Yes, exactly. It could be Candesartan or the Zartan. Yeah. Really good. Ok, I'm gonna finish it here, but just something to be aware of. Is any patient that has type two diabetes immediately with hypertension, you need to immediately give them Ramipril. So you need to give them an ace inhibitor unless that's contraindicated and then you give them an A B. Thank you for listening. That was me uh President of the African Caribbean Medical Society and the slides were made by um our lovely lovely secretary Yasmin Janka. Um That's the end for the UK MLA section. Uh Thank you very much uh for the lovely comments if you could fill out the feedback form. Um and we'll be back at 715 for the second portion which is on uh classic rashes to know um such as, you know, rubella measles, Scarlett fever. Um So back here at 715. Thank you.