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I'm gonna put another pole again just to make sure. All right. Yeah. So we've got some answers for e for this question which uh I can see where you guys are putting your ideas forward for this. You're technically on the right lines of thinking, but not technically the um correct answer for this one. So the answer that I was looking for would be for small cell carcinoma of the lung. And I've put in a highlight over here that uh we have Si A DH Cushing's Lambert Eaton syndrome which explains approximal muscle weakness and is chemosensitive in treatment. Now, the reason why that uh before I go into the reason why that would be the answer is to explain what uh Cushing's syndrome is, is a collection of conditions causing an excess cor secretion of the hormone cortisol. And it's much more common in females than males. Classically. Uh You have many different causes of Cushing's and conveniently enough which you have to painfully learn. They've come with a different names that attach your Cushing's as well. So the most common cause that we have is that it can be due to excessive Glucocorticoid consumption. Such as uh using too much of a medication for asthma or for immunosuppression, which is uh which we call Cushing's syndrome. So, if so now that we have an idea that this may be caused by a tumor. Unfortunately, Cushing's disease is the term that's only used specifically if there is a tumor in the pituitary gland. And knowingly for this, we can also have tumors in the adrenal gland, which we term adrenal Cushing's. And then for anything else that's outside of these uh hormonal sort of uh glands, we term ectopic cushing's and the classic example that we usually refer to the most as small cell lung cancer. So Cushing's with the excessive, excessive release of cortisol causes someone to gain weight, um have lots of mood swings, acne build up her two, which is a male pattern, baldness and growth of body hair. So you mean it means that women suddenly can grow beards and have baldness. I classically seen in males. It would also affect uh libido in both males and females. And for females specifically, it can cause irregular menstrual cycles as well. So clinical signs can include the dose of cervico fat pack or classically termed as a Buffalo hump before recently. And a plethoric face, which is you can also see in older textbooks called a moon face. They also have a specific pattern of obesity where you mainly get it in the trunk and the upper limb just well a as opposed to um getting it all over the body as well. And a classic thing that I always like to refer is like purple stria, which are these purple, superficial marks, which are a lot of like stretch marks that are dot around the abdomen as well. And if it's specifically Cushing's disease because of a pituitary gland defect, you can get headaches and a visual field defects as well. Generally, uh you, we can do your normal bedside investigations. Your normal blood tests with a VBG, which classically shows a hypokalemic hypochloremic metabolic alkalosis with a hypernatremia as well. Alongside this, you want to measure glu blood glucose for ruling out uh diabetes or ruling in diabetes in this stage as well as uh various special tests. Uh specifically a low dose dexamethasone suppression test, which is basically administering a dose of dexamethasone and to measure the serum cortisol on the following morning to see if there's a response. And if there is a failure to respond to that influx of dexamethasone, you're going to basically confirm a Cushing's syndrome of it. And the treatment usually is divided into managing the hypertension and glycemic control and to stop the underlying cause. So, if it's excessive glucocorticoids, you wanna take off the steroids. If it's a tumor like Cushing's disease or adrenal Cushing's, you might have to remove the tumor. And if it's ectopic adrenals, like we discussed earlier, you have to find the underlying primary cancer such as this where you have to go through some excessive surveillance and imaging to find a lung cancer of any as well as revisiting the history as well. Right. So that is quite a big war for Cushing's. Now we're going to visit another case, which is where we see a 52 year old woman presenting to her GP with a progressive fatigue, weight loss and dizziness and standing. The GP notes the below observations which uh we can read over in the question and on examination, the patient appears quite nauseous, has uh increased pigmentation of the skin, particularly around the palm creases and the cheeks of bal mucosa. And therefore, from all of us, the GP thinks that this could be an Addison's disease, but there are many causes of Addison's disease and out of all these options. Um Which one do you think is the least likely cause of Addison's disease? So I will give you guys a few minutes to think while I set up another pool. All right. So based on the answers I see over here, uh some of us have been going for a and like the other one, it's another bit of a tricky question, but it's something that does appear in exams from time to time. So the answer would be a thymic hyperplasia, which is the 01 not for all of us as uh increase in the size of your thymus is more associated with uh myasthenia gravis, which is a condition where you cause a generalized weakness due to um acetylcholinesterase uh inhibiting. So what we're go, we're gonna go through what Addison's disease is, which is where there is a deficiency in cortisol and aldosterone from the adrenal cortex being released. And there are many different causes of it. And the one and we can split these causes into primary and secondary causes. Uh primary causes uh due to a direct destruction of the adrenal cortex. And that, and the most common cause of that in the UK is an autoimmune cause. Whereas elsewhere worldwide, we have a plethora of other causes including tuberculosis, lymphoma and hemorrhage, which we term as waterhouse friction syndrome. And this is caused by secondary to a meningitis leading to a meningococcal septicemia. Addison's disease can also be caused by secondary cause where we suddenly withdraw a stubborn medication, uh such as when or uh when someone goes into surgery and we do not taper the steroids uh acutely before they go into a theater and being an autoimmune condition. Most commonly in the UK is associated with a lot of autoimmune related conditions such as type one diabetes, celiac disease and sarcoidosis. Uh generally, the symptoms you have are very nonspecific but um your examination findings do point you towards the diagnosis with the hyperpigmentation that we've seen in the history. Uh You can also have vitiligo and the loss of uh pubic hair in the axil