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Yeah, well, come, come. Okay, guys, uh, if you guys enjoy the break So we're gonna go over the answers to allow the SVS that you guys just said, Ah, be a chill session. I'll take time going through. You know, you will be just going through SPS, okay? It won't be any sort of specific teaching on any condition will just go break down. All the SBA is go through interruptions. Why particular answer option was correct. Why the other options that were not correct on DA you? You guys will have the opportunity to ask questions throughout on diffuse any. There's any particular question. You want me to go over in a bit of detail. Be happy to do that as well. So let's go through each one. So this was question one. So this was a question about a patient with pruritus for a couple months. Osteoporotic. She was fatigued on day. She was joined. This investigation showed conjugated Billy Rubin increased. A lot of the tests were normal. So this is in keeping with PBC primary biliary cholangitis. Um so why? BBC's of PVC is a condition that needs to destruction off intrahepatic bile ducts and the key Hallmark features off PBC is that it affects middle aged woman on generalized per itis is the hallmark off PBC. So generally writers and millage woman is plastic Foot is a classic story for BBC getting obstruction of bile ducts. So you get a obstructive picture of jaundice. So that's why the conjugated Billy Rubin is increased. And she's also got, uh, scleral icterus is well, and osteo processes, it can be a complication of people. See a swell. Okay, Eso I've got some of our previous revision size as well as his, um revision slide on all the other autoimmune liver diseases and a little side of osteo process for your vision and a little provision light on jaundice. So question, too. So this was a 20 year old man who presented with fever ultimate status. Ah, he had a tick, your rush on his trunk and arms and he had a positive clinic sign. Uh, CSF showed gram negative diplococcus I and then, uh, after better became, he started to deteriorate, became hypertensive, uh, fluids where he wasn't responding to fluids on butter showed a low sodium high potassium on, but he had abdominal tenderness as Well, eso can you put in the chat? What was the diagnosis in this patient? What do you think? It was the diagnosis in this patient? Meningea cockle septicemia. Good. But what's the complication that led from the meningococcal septicemia? The I see. Good. And what happened because of the d S E. What's the cause off the was because of the hyponatremia and the hyper clena. Yeah, good Waterhouse Fredericton syndrome. So basically. So this is scenario describing what? How's free treaters in drum? So this is a patient to presented with bacterial meningitis. So why Bacterial meningitis, fever altered mental status. Post of chronic sign CSF showing drag negative. The cock I was gram negative. Difficult. Okay. What's the organism? Yeah, Nice. Even a minute Neisseria. Very good. So nice. Your meningitis. So classic. It's a story of meningococcus septicemia. Okay, from because of my Syria, she's deteriorated. Start became hypertensive Septic, septic shock on dot So the hyponatremia hyper clean years? Because the patients basically got developed adrenal hemorrhage because of the meningococcal septicemia. Because of that, d i C. As a complication off it on. That's led to adrenal hemorrhage, which leads to a picture off adrenal insufficiency, so that leaves to hyponatremia and hypokalemia. So the questions asking which of the father is likely to be seen and the answer is increased. Brennan. Because if your adrenal glands of feeling uh that means that Renan is gonna increase because it's not able to after is working able to act on the adrenal, so it's gonna build up an increase. So that's why that's the correct answer. So that's that's what That's the story of this SP. It's a story of civilian meningococcus septicemia because of bacterial meningitis leading to Waterhouse, Friedrichs in Syndrome got a tough SBA okay, but tried to cover a little bit of a couple of different aspects of medicine in that one. Eso is a revision slide off Addison's disease on so this. So let's go over the next question. So this is questioned. Three. This is, hopefully a bit of uneasiness. SBA. So we have a 65 year old man who presents with weakness greatest in the morning and in terms of the actual weakness, it's, um, so great in the morning and he can't hold his arm. You can't keep his arms up or his head up, but the weakness improves of as a day on day goes on to his strength increases. And he's also reporting some autonomic features. Dry mouth, constipation and you also got features off a blood streaked cough. And it's a long time smoker s. So what's the cause of the weakness in this patient? What's the like because of the weakness? Lambert Eating syndrome. Very good. Why is the diagnosis not why the diagnosis, lumber eat? And rather than myasthenia based on the just on the weakness, why would you say I say Lamberti tongue? Yeah, very good. So it Lambert eaten the key difference between Lamberti Done syndrome weakness on my senior gravis. Weakness is that with somebody to be generally, the actual strength increases as you do exercise as you use the muscles more and which is a key different from my just different from myasthenia, where the weakness actually worsens throughout the day. Um, so what else is another thing that differentiates it is that with my senior, you don't typically get autonomic symptoms. You don't really get things like dry mouth constipation on that's more autonomic features are more feet off a feature off diamond eat and syndrome Onda. Obviously, if you guys no lumps, most patients with somebody syndrome get it as a complication of small cell lung cancer carcinoma. That's why the crack down to here was small cell lung cancer. Um, so remember small cell lung cancer? Most patients are small. Cell lung cancers are smokers, so smoking's very strongly associated with small cell lung cancer. And it's also suggested by the blood street cough this well, So that's why that was the correct answer. So we have ah, little summary diagram off lung cancer, the different types of lung cancer. Um, also a little summary slide on Lambert Eat and syndrome, which was taken from our neurology for final session. Um, so yes, let's go over the next questions. A question for eso. This is a 40 year old woman who is presented with a history of epigastric pain, urinary frequency, greasy stools, history off, um, stones or kidney stones. On on investigations, he has high gastrin levels on dusky shows. Multiple. Do you get ulcers? S. So what's the diagnosis? Say, what's the overall diagnosis of this patient? This is ah, quite a trick Yesterday. What's the prognosis Xolegel since syndrome Good, but What's the Yes, the couple of you gotta men One. Okay, so multiple endocrine neoplasia type one. Um so the station has features off men one. So men one is encompass by priests. Three sort of end of crime tumors. There's pancreatic tumors. There's 2 to 3 tumors and this parathyroid adenoma. So in terms off the, um, pancreatic of the sort of neuroendocrine gi I pancreatic tumors, this patient has Zoolander Ellison syndrome. So solid else is Allison syndrome is where you get a gastrin and producing tumor. So it's a tumor producing loads of gastrin, which leads to hyper secretion off hydrochloric acid. So that explains why the patient has high gastrin levels and has multiple doing, you know, ulcers. Okay, because of these all in Jellison syndrome and also explains the epigastric pain as well because of the multiple. Dude, you know, ulcers. Uh, why is the patient sorry? In terms of the greasy stools of the greasy stools? That's a sign off steatorrhea. Okay. And that's again. That's a feature off Zoolander else's syndrome. Can you explain? Why do you get steatorrhea if you have withdrawal and Johnson syndrome? What's the reason patients gets the artery a Why? If you have loads of hydrochloric acid, why would that lead to steatorrhea? Why would that lead to greasy stools? Can you explain that? No. So the reason you get steatorrhea if you have loads of acid is because the high levels of acid means that the pancreatic enzymes don't work. So you can't like these enzymes don't work, so you can't absorb fats as well. And that leads to stacked area. Okay, so it's just because of the hyper secretion of hydrochloric acid leading to a the environment not being suitable for enzyme function specifically like based function. So you get steatorrhea. Eso explains the greasy stools. Uh, urinary frequency. So urinary frequency. So why don't Why is this patient got urinary frequency? What's the wise see? Got polyuria. Very good. So high pickup. He's got high calcium hypocalcemia because off hyper parathyroidism. Okay, again. Another feature off men One. Okay, so he's got, um, urinary frequency. Um, so yeah, So the questions asking which of the additional findings would like to be seen. So the correct answer here is amenorrhea a case of be amenorrhea. Ah, why is the answer even area? What's what would lead to a man area with this patient? Yeah, for 23 pituitary tumor. So the 2 to 3 were typically classically Amenorrhea is a classic feature of duty adenoma. Okay, prolactin release is affected. So that's why the correct answer here is a minor E A. Okay, production of music, One of the common, most common functional tumors, the toujeo tumors. That's that's why AMENORRHEA is theca wrecked. Answer here. Okay, Hopefully that made sense in terms of the other option. So arachnodactyly. So that's a feature off Marfan syndrome, which would be seen in men to hypertensive crisis. Sign off the ACR um Cytomel is again seen in men too. Firm Barry nodules have to sign off. Adultery, thyroid cancer again seen in men, too, on skin flushing. That's a sign off carcinoid syndrome, which is not seeming, which is a completely different condition. Okay, so that's why the correct answer here is amenorrhea. Okay, Hopefully, that makes sense again. It's quite there was a quite a trick ESP a. But it's testing a lot of different medical knowledge. Um, so let's go through it. So revision slide on multiple endocrine neoplasia. Okay. All the different men syndromes their stuff I was talking about there Onda little slide on hypoparathyroidism a lot of the features the patient had, Um so yes, again, the patient had a history of renal stones as well. And remember, the renal stones was because of the typical see hypocalcemia because of the hyper parathyroidism. Okay. Ah, have to go to the disease as well. So remember, patient had multiple peptic ulcers because off Zoolander Ellison syndrome onda little t slide on renal stones for your revision as well. So next question. So this is a This is basically a status question. Okay, Bit of medical biostatistics commonly comes up in finals. Okay, It's important that you have some basic knowledge off medical statistics. So, uh, we have the four year old woman who's presented to the breast clinic She's hard a f in a don't, which is said the test result is negative on the questions asking one of the chances that I really don't have breast cancer on. So this question is basically asking, What does that mean? If you ask that question and so the correct answer, his be negative predictive value. Okay, so basically so the question is basically saying I've got a negative test. So what is that? What is the likelihood that I don't have disease? Okay, so it's basically saying if you have a negative test, what is the probability that I do not have the actual disease again? That and that question, that's Ah, Statistically, that's classified as the negative predictive value. Okay, because the next predictive value, the way you caltrate NPV is to calculate the true negatives over the total negatives. Okay, so two negatives a z proportion of don't have disease, and total negative is the total proportion total number of people who don't have disease and this calculation will basically tell you. Well, basically, answer that question. Okay, so that's why the correct answer here was negative predictive value. Little summary table on all those different statistical terminology. Okay, Sensitivity, specificity, positive predictive value, negative predictive value on do all the different formulas. So just remember the remember remember what each of the terms mean? Okay, It's not just enough to be able to know what the calculation is. Just have a sort of conceptual understanding of what the terms mean as well. Um, So there that was Thestrals. Question six. So this was a hypertension question. So this was a 67 year old female, uh, who, uh, is in diagnosed with hypertension. Okay, so, uh, she her first reading was 169 over 102 on the ambulatory BP waas 161 over 99 millimeters for Mercury on by Added in this thing about struggling to tolerate lisinopril Oh, So what do you guys think was the correct answer for this one? What did you What did you guys think was the correct answer? See? Very good. Yeah, very good. So I'm lot of being so I tried to trick you guys at the last one. So, uh, suppression, basically testing your knowledge off the nice guidelines for management off hypertension. Okay, so basically a nice guy, Big questions is testing. What's the first line management off hypertension in patients over the age of 55. And the answer to that is a calcium channel blocker. Okay. Specifically a dihydrote pyridine on calcium channel blocker and out of these options, it's a lot of being have not been the one that's most commonly use. I added in this thing about she's has difficulty tolerating lisinopril just to make you think about putting on putting a and you're tense and Recep um, receptor blocker. But remember, she's over 55 of the most appropriate. It's first line option is to use a calcium channel blocker. Okay, um, I didn't need to say can tolerate lisinopril. Yeah, I just I threw that in just a trip. Put people off. I remember that. Remember the guidelines? Um, so yeah. So? So another quick question. What's the what? Stage of hypertension. What does this patient half you based on the readings? Yeah, Stage two. Okay, So remember, if they have a BP reading off, uh, greater than 1 60 over 100 on the first reading. And the ambulatory is greater than 1 50/95. That's stage two. Okay, Just a little bit of just remember their readings for hypertension, so, yes, sir. The key learning point for this question is that calcium blockers are first line in the over 55. A troop if they're less than 55. Ah, or the Africa. Sorry. If the less than 55 the first line. What's the first line management of the less than 55? Yeah, a celebrity. It's okay. A centimeters or angiotensin receptor blockers if they're not going to tolerate the ace inhibitor. Okay, but yeah, that's why that was the correct answer. So little revisions. Flight on hypertension from our cardiology for final session. Uh, and here's the flow chart for the management off hypertension from again from a cardiology final session. So again, remember, over 55 or if they're Africa Oh, Caribbean, go for the calcium channel blocker. Okay. The dihydrocodein calcium channel blocker. If the less than 55 or if they're diabetic, then you use a A significant okay? Or enough? Yeah. Good. Okay, this is a This is a sneaky question. This is a This is the pneumothorax question. So you're a 34 year old man who was brought to the ambulance brought by ambulance to the emergency department. Uh, has a GCS off eight, and he is unable to brought a history on examination. His breathing is noisy. Tricky is deviated to the left. This hyper residence on percussion off the right side, off. Ah, right side of the chest. And there's reduced chest expansion. On the right side of the chest is sats on 90% on room air rumor. So the question is asking what is the most appropriate next step? Okay, so what did you guys think was the most appropriate next step in this patient? Okay, we got a mix of B and E. Uh, which is the split I was expecting, So Yeah, I think couple of people said most of you have you said B so yeah, be is the correct answer. So away maneuvers. Okay, I'm sure most of you were able to pick up the diagnosis. A Z uh, attention. You moved or X s. So it's clear this a clear picture of tension. Um oh, we got a patient whose human down. I'm free. Stable. They have a deviated trachea. Hyper residence on percussion. Reduce chest X expansion losartan. This is old signs of tension. Pneumothorax. Okay, you should be able to diagnose this just based on the just based on the features you don't. You shouldn't be needing a chest X ray or anything. Uh, but the correct answer is actually be so airway maneuvers. Okay, So even the definitive management for attention the first the most important Sorry. The definitive steps intentional direct is to do emergency needle decompression. Okay. And I in terms of that acute management, but, hey, I've told you that her breathing is noisy. Okay? So in terms of the 80 assessment, the first step is a minute management. So her breathing is noisy, which means that she doesn't have a patient airway. She's not maintaining your own airway patiently. Uh, so that's where the most appropriate step is to do the appropriate early management. Okay, Things like airway maneuvers. Joe, tell Ted had thrust to see if that improves. Your breathing improves airway. Um, because, remember, it's a noisy, noisy breathing doesn't It's not a sign off on a normal airway. Okay, Normal airway means that patients are responding to you Appropriately. Noisy breathing is not a sign off. Completely functioning patient airway. Okay, that's why appropriate answer here was be our maneuvers. Good. So yeah, So our mind you, it comes first in the management off the acutely unwell patient. So is the summary off the newer thorax guidelines? Okay, so this is a This is the BTS skylines for management off a spontaneous pneumothorax. Okay, so this is very important. This comes up on exams all the time I was tempted to put in a question testing guidelines, but a tantrum and I eso yeah, just remember, the difference is between primary and secondary pneumothorax. And remember, there's different management pathways depending on that on the size of the pneumothorax and depending on if they have, if they're breathless at the same time. Okay, this is this is very important guidelines to learn. Ah, and yes, that was questioned. Seven new outdoor expression had. So Okay, this was a hematology question. Let's go. Let's have a look at this on. So we have a 44 year old woman who was receiving a blood transfusion. Uh, she had she's getting a transfusion because you had you try and bleeding, and then I'm deficiency anemia. 30 minutes after the transfusion starts, she starts getting flank pain and chills observation. So temperatures 39.1. So she has a high temperature on? Well, the other observation seem to be normal. Uh, so and then I told you that the transfusion has stopped, but she continues to have symptoms on. Did lead from the catheter site. Um, so what was the answer ever and put down for this one? We'll see you. What do you think? The correct answer here for this one was This is a tricky question. Be, Ah, humility, transfusion reaction. That is the correct answer. Um, why do you put any What's what indicates that this is a cute one indicates that this is a cheap hemolytic reaction. Yeah, there's a There's a lot of it Has a lot of the features off acute tons. Ah, hemolysis eso A key humanistic transfusion reaction. Basically, they've been given the they've been given the wrong blood type. Okay, potentially, due to some clerical error, some form of a reason. They've been given the wrong blood type. And that's let your age accumulated. Confusion, reaction. So typically, there's a humanistic transfusion reactions they developed within an hour off the transfusion. Okay, unlike anaphylaxis, and a flex is typically occurs immediately or within seconds or minutes off starting the transfusion. So, uh, it's not anaphylaxis again. There's no sort of signs of angioedema hypertension, difficulty breathing or anything like that. Okay, so it's not like to be on a flax is okay, Someone's us. Is that the same as a D O incompatibility? So, yeah, this is this is referring to a B A incompatibility. So it's They got an acute humility transfusion reaction because of a B o incompatibility they've got they've been given the wrong blood. Maybe your blood type basically eso features off. Acute humanistic transfusion reaction flank pain, chills, fever, tachycardia all features off the acute cumulative transfusion reaction. What's it? What's this stuff about beginning to bleed from his catheter site? What does that indicate? Yeah, the I see. Very good. Disseminated intravascular coagulation is another sign off. Complicated hemolysis. Okay, um, so yeah, that's why the correct answer here was Ah, kidney malicious, Uh, in terms of febrile nonhemolytic transfusion reaction. So ah, you don't typically get that. It's typically doctors later on. It's quite common, but you don't expect things like flank pain, chills or D I. C with febrile nonhemolytic humility, transfusion, reaction, uh, transfusion associated circulatory overload. So this is basically where you give too much blood. Um, so the patient doesn't have risk factors for fluid overload. He doesn't have any sort of heart failure or anything. Or is, um, there's no features off hypertension or any sort of findings off fluid overload, but they things like hypertension. Um, juggle a venous distention third heart sound, Um, that that sort of thing. It doesn't have any of those features, so it's unlikely to be because of a circulatory overload on delayed hemolytic transfusion reaction. So this is occurred within 30 minutes. Okay, this is an acute hemolytic transfusion reaction. So hopefully that makes sense. Ah, again, testing a bit of hematology knowledge off blood transfusion reaction. So, yeah. So remember, acute hemolytic transfusion reactions typically occurs within one hour, and it starts after, and it's because of a mismatch. Confusion. Okay, because off a B o incompatibility. So here's a revision slide on the blood transfusion complications, which was taken from our hematology for final stock. We did a couple of months ago. I'm just highlighting some of the key points of each of the different, uh, complication. So have a read when you get the slides. Yeah, I'm realizing now there was a lot of ah, tricky questions in this one. So this is Ah, this is an endocrinology. Questions. So we have a 35 year old woman who is presented with a history off irregular menstrual periods. Um said she's got irregular periods. She has a history of Milky discharge from the nipples for the past two months as well. Okay, so she has this this nipple discharge, which is what the questions asking about shows has joint pain, muscle pain, history of weight gain. She has a history of hypothyroidism and schizophrenia, which is managed by a liver toxin and Reprisal, respectively. There's no examination findings, but test show a normal morning cortisol mildly elevated prolactin on. Ah, high TSH. Okay, this is this is one of the harder questions I definitely put in. I may have a discussion yesterday, but what did everyone think was the answer for this one? See? Yeah, mostly you got? Let's see. Very good. Mostly got. It's a Yeah, hyperthyroidism. So that is the correct answer. We'll go through. I'll explain the physiology of this one, but this is quite a bit trickier, but correct answer here was See, I both thyroidism eso the questions asking what is the likely cause of our nipple? This judge, um, she has features of hype about them. She has, um, normal cortisol. Okay, so that rules out Cushing's disease. Um, mildly elevated prolactin level. So? So it could Some people might have put prolactinoma remember, But prolactinoma I will be. It will be significantly elevated. This is only mildly elevated on it doesn't. The discharge is explained a bit better by the hypothyroidism. Um, she has features off weight gain. So again, feature of hypothyroidism. Um, I've also mentioned this stuff about a repeat our e p prazole, which is a antipsychotic. So remember, antipsychotics classically can cause high prolactin levels, which can lead to, uh, which can lead to nipple discharge. But remember, I purposely chose ah, repeat Brazil because, ah, this's the one second generation. This is the one antipsychotic that doesn't cause high prolactin levels. This one specifically doesn't cause the nipple discharge. So I try to trick you with that one. So it's not that one. And it's not physiological, too. She has, uh, she has some other pathological features so correct and says hypothyroidism. Now I know a lot of you will be wondering How does hypothyroidism lead to nipple discharge and let's go through the day. Can anyone explain that why this hypothyroidism lead to nipple discharge? Yes. So it's got a high high trh yet did th which stimulates prolactin release increased tho least do increased prolactin, which leads to, uh, which can lead to features off the nipple discharge. Okay, so that's why correct answer is hypothyroidism. I'll go through the physiology now, but yeah, the Rh can stimulate prolactin secretion. And that's something that explains the nipple discharge The best. Okay, so I made I made this diagram from my endocrinology session a couple of months ago. So this is a diagram explaining the physiology off productive production on gonna add a troponin production. Just highlight that th it stimulates the tea I can lead to the carotid tired home on purpose of th stimulates release off S H, which then leads to stimulation off production off T four and t three. But trh also leads to production off prolactin. So it also stimulates the anterior pituitary to make prolactin on that can lead to the nipple discharge. Okay, so remember, if you have hypothyroidism that will back and eventually too high trh which can lead to a high prolactin release, Okay? Hopefully, that makes sense. If you want me to explain that again, and I can, but hopefully that's the physiology of that. That question. Okay, so is there somebody slide on prolactinomas well on his the summary slide on the different causes off hypothyroidism, which we discussed in the endocrinology for final session a couple of months ago. Okay, so question 10, Uh, this was a question about variceal bleeding. Um, So what did? So we got a 64 year old man who's presented who has a history of excess drinking. She has features off chronic liver disease. So umbilical blood vessels, primary thema evidence of shifting Dulles again. So these are all features off chronic liver disease. Um, prominent umbilical blood vessels. That's a sign of compartment. Use I, Palmer erythema. That's sign off. Like of estrogen metabolism and evidence of shifting dollars. So that's a sign off. Ascites. Well, features all peripheral stick matter off chronic liver disease again on. So this is patient is presented with bloody vomits. Okay, so she's presented with variceal bleeding on. I've told you that Fluid's have been given, uh, she's been given blood transfusions on she's being given to be present as well. Okay, on an endoscopy has already been organized. So the question is asking what? Which of the following is the most appropriate next step. Okay, what is? What's the most important next step to do in this patient. So what did you guys put? What did you guys think was the most appropriate? Next step. See? Very good. I see everyone was ready to answer that one. Hopefully, yes. So this was a That was the correct answer. Give intravenous antibiotics. Okay. So basically, as part of that initial initial resuscitation to stabilize patients with variceal hemorrhage, you need to give you fluids, blood transfusions, Tony press in, and you also want want to give antibiotics as well again and the antibiotics it's given for a couple of reasons. And one of the most important reasons is that you want to reduce the risk of the patient getting particular infections, particularly things like spontaneous bacterial peritonitis. So an infection within the ascites so very important to give IV antibiotics as part of that initial resuscitation a swell in terms of the other options. So refer foot refer for tips so tips would be done If endoscopy doesn't work. Okay, then they haven't been able to control the bleeding after endoscopy. That's when you would start. Consider if Earl to for tips propanolol is the propanolol is is not used acutely for management of Paris's you use per panel as secondary prophylaxis. Okay, so to reduce the risk of bleeding on long term after they've had a variceal bleeds, it's not part of the acute management balloon tamponade, so balloon Tambor nod is occasionally used. If you wanna sort of, um, sort of, ah, halfway 0.2, you wanna stabilize the patient, but it's only a temporary measure, and lonely control the beating temporarily. It's used. For example, when you're when a patient's waiting to have a tips procedure and you want to stabilize that bleeding, that's the sort of situation it might be used in. Uh, PPI COPD eyes are given after and oscopy Okay, if you don't typically give PPI So, uh, before endoscopy for variceal bleeds, that's why. Correct Answer. Here, we'll see. Give antibiotics. Um, CM. So a little summary slide on Upper GI I bleeds, which we talked about in our gastroenterology and hepatology for final sessions are a couple of months ago. Uh, here's the summary off the management of variceal bleeds a swell like in terms of the, um, order in which you do things. This is the sort of pathway, and the definitive management for variceal bleeds on. Here is a summary of the management off Upper GI, I believe in general. Okay, so we've done. We've done the, uh, 1st 10 questions of this study. Quite a heavy session or library Forgot. This is Ah, we did a lot. There's a lot of questions, but we'll try and go through the list because I can ah, question 11. So this is a 64 year old woman who is presented with worsening dyspnea upon exist in has a dry cough on auscultation. There's crackles bilaterally on each base on day recently started clear. My center treats non Hodgkin's lymphoma s. So what's the diagnosis in this patient? What's the complication that the patient has got pulmonary fibrosis? Very good. So remember, bleomycin is toxic to the lungs. Okay. Bleomycin is a chemotherapeutic agent used for lymphoma on day. One of the complications is pulmonary fibrosis. So the question is basically asking which of these answer options It fits the spyrometry pattern for pulmonary fibrosis on the correct answer option here is See, um so remember Polly fibrosis, you get a restrictive pattern on spyrometry, so get a reduced F e V one, But you'll also get a reduced FBC so reduce forced, vital capacity on because both values are reduced. You get an increased everyone FV one to F B C ratio. And remember, with fibro's long, the actual lung capacity is reduced. A swell against the lungs can expand, probably. So this decrease total lung capacity. So that's why the correct answer option was See, um, see, uh, so it's a little, um, summary of the causes off pulmonary fibrosis. Onda little cheat Sweet teacher to remember the different causes off, uh, upper lobe fibrosis. Okay, okay. Question 12 s. Oh, this was a bit of a longer question. So this is a 43 year old woman who has history off Lupus. Okay, she has. She's been found unconscious on the pavement. She's lethargic. She's no, she's on. She's not being compliant with the medications as well. On examination, she's confused on. She's only oriented to person. There's evidence off just venous distention bilateral edema. On examination, there's a pericardial rub on. There's widespread ST Elevation. Um, so yes, so questions asking what is the most appropriate next step? Ah, what do you guys think was the correct answer here? Yeah, Very good. Hemodialysis. Human. Alice, this is the most important step. Okay, Um, So what does this patient got? Features off. What's the cause off most of the center. What's the cause off the confusion. What's the cause off the pericardial rob the the CT findings? Yeah. Uremia. So this patient basically dissipation with Lupus? Who's got features off? Uh, you know, renal failure. Okay, so she hasn't been complying with the medications. Likely got renal kidney damage because of the Lupus. Okay. Lupus nephritis, for example. Um, and that's led to features off kidney failure. Okay. Specifically, it's letter features off uremia. Um so uremia. So she's you review high levels of urea is dangerous. Secondly, to you getting careful. A pretty because of it. Okay, so she's lethargic. She's nauseous. You can get pericarditis because of it. So she's got a pericardial rub on Dwight for ST elevations that sign off very coordinated pericarditis as well. Um, on DJ juggle a venous distention bilateral pitting edema. Those are features off fluid overload, which you can get with what you get with renal failure. And he's also got, um, a metabolic. She's got acidosis because of her high levels of your ears. Well, so that's why the correct answer here, Waas. That's That's where the diagnosis was uremia because of the renal failure. So the questions asking what's the most important next step? And the correct answer is hemodialysis because anyone with features off uremia, uh, warrants an indication for hemodialysis. Okay, because, um oh, that's the most important. Next step Teo do hemodialysis is to filter out the urea. Okay, um, some of us would you do me what's waiting to set up the Aricept. So would that be pointless? Um, he's all right. So the potassium, So the most important step is the high lows of urea. Okay, there's no point correcting the potassium with the urea is too high a swell. So that's the most important step is to do the hemodialysis. Okay, hopefully that's clear. Yeah. So features of uremia warrant urgent referral for human Valassis. So his D is a nice way to remember the different indications for Bernie. See dialysis. Okay. E i o u. Okay. So if they have a metabolic acidosis, if you have some kind of specific electrolytes imbalance on, not that's not responding to therapy, you can do hemodialysis if they have ingested certain toxins. So aspirin, Effient glycol, methanol, lithium. These old toxins that can warrant a referral for a dial cyst if they're not responding to it. If you're not able to remove fluid so they're fluid overloaded, and they're not responding to therapy is. Then you can dry. Ah, dialysis. And the big one is uremia. Okay, so any feature of uremia that warrants, and, uh, that's an indication for emergency dialysis. Okay, And here's the summary slide on Lupus. Okay, So remember the one of the complication Big complications of Lupus is, uh, kidney disease. Okay, we you know, fairly you can get Lupus. Nephritis, which can be fatal in a lot of patients with Lupus is Well, okay, question 13. So this was a 62 year old woman who, um, presented with a dry cough, severe chest pain. I, uh, had my cardio infarction two months ago. Okay, So big emphasis on the two months ago, and she's got features off, Basically, pericarditis. Okay, so he's got a high pitch scratching sound sound loudest. Urine expiration. When the patient is sitting upright on BCG shows, diffuse ST elevations on troponin is elevated as well. So what do you guys think was the correct answer here? Yeah, be dressed. Listen from very get. So this is, uh this is a bit of a if, you know, you know, what kind of questions are crushing? Asking about the complications off a myocardial infarction on. So patient of features off pericarditis, basically our case. Other questions, basically, remember, with my cardio infarction, one of the complications is pericarditis. And that can either call within a few days if it occurs within a few days after the m I. That's Ah, that's just, um, really infarct associative pericarditis. Okay, that's that's what happens within a few days off the myocardial infarction. But if you get the pericarditis picture a couple of weeks after the M I, that's stressful syndrome. Okay, so that's why the timing is the key thing that makes that dress listened from here. Okay, Constricted pericarditis. So this is something that takes months or you even years to develop. Okay, Uh, cardiac tamponade. So this So this isn't cardiac tamponade, okay? There's no features off that bec Striant that you see What? Cardiac tamponade. Okay on. I just made up the myocardial be in five function thing. So correct answer here is be restless syndrome. Both eso Here's the summary slide on the post myocardial infarction complication. So Okay, so different complications of em. I, which we talked about in the, um, cardiology for final session we did at the start of Siris. So I have a read when you get the slides. Yeah, So next question. Um, so this is ah, longest be again. So this is a 64 year old man who has brought to the emergency department because off high fever and confusion, two day history of a productive cough and green sputum. Okay, I smoked a pack of cigarettes daily for the past 25 years. Be my eyes 30. Hey, has lymphadenopathy as well. On examination, there's ah has patterned ugly and splenomegaly on chest X ray shows evidence off consolidation. So this is all in keeping with a feature with a picture off pneumonia on the full blood count is shown below. So he has, uh, low hemoglobin. He has low platelets as well. On D has a massive lymphocytosis. I've told you that blood cultures and antibiotics and supportive care of already been given So the question is asking what is the most appropriate next step? Uh, what do you What do you guys think was the most appropriate Next step? Yeah. Yep. A This is a tricky question. Again, I appreciate this is ah, very long questions, but I probably should have shortened this question on, but yeah, the correct answer here was a flow cytometry. Um and then we'll explain. What's the wise? Why would you do a flow cytometry? What's the reason? What's the diagnosis this patient has? Yeah, this is cll. Oh, this is a chronic lymphocytic leukemia. Okay, so this is a patient who has pneumonia. Okay, That told you that? A classic story of pneumonias. Yes. High fever, productive cough of green sputum on. Do so. And she has She has consolidation in this right lower lobe. A swell. Okay. But I've also told you that he has a lymphocytosis. Okay, is a massive lymphocyte counts. Okay. His lymphocyte is 10 times the normal range. Okay. And that's diagnostic for cll. Oh, okay. On Dalser. Yes, I other complications off Cialis. Well, if he has a lymphadenopathy, he has hepatomegaly. He has flown omega we as well on D also has a low hemoglobin and low platelets as well, because of the c l o a swell. Okay, that's why the diagnosis of CLL on. I've told you that management for the pneumonia has already been given. So the question is asking what's the most appropriate next step? So, basically, what can be done to diagnose the c l o. And so the correct answer Here's flow cytometry so you can do in. You know, you knew slow cytometry to look for a certain genotypes to diagnose the CLL. Oh, Okay. Um, so in terms of the other options that bronchoscopy so that's not gonna be useful. You don't need the bronchoscopy. You've already You can already pick up that the patient has pneumonia because of the CLL Jack. Two mutations. So that's for polycythemia. Um, that this is CLL, okay? You don't need to do a lymph node biopsy for C l o. Okay, flow cytometry is usually good enough. And this isn't on Epstein Barr virus infection. This is, um, flow cytometry you don't need to do. This is a cll. So it's flow cytometry. Someone's asked. Would you not do a bone marrow biopsy? So remember CLL is is a completely It's an indolent disease. Okay, most patients are asymptomatic. Okay, if you really wanted to, you can do a bone marrow biopsy to confirm disease. But majority of patients with CLL don't get a bone marrow biopsy. Okay? It's cedar. You don't do about biopsy, bone marrow biopsies and cielo in general because they have indolent disease that typically asymptomatic. Okay, But a lot of them will be immunocompromised, which can lead to this, which can lead to infections. For example, of this patient who has got pneumonia. Okay, so there's a quite a lot to break down in the SBA. Okay? And I appreciate it was only 90 seconds, so putting a lot of time to break it down. But that's the sort of story of that sda Okay? Yes. Remember, Cialis cock cries by a dramatic leucocytosis. Okay, so see if you see that massive lymphocyte counts, think about C l o. Okay. And remember, this is an elderly man as well. 64 64 year old man. Classically Cielo is a disease off the older age group as well. So here's the summary off the curb school for pneumonia. Okay, So that's what the patient completed, presented with little summary slide on CLL, which we, which is taken from our hematology for final session as well. Um, so yeah, that's so Okay, we've reached halfway. So this is a question about urinary cost. So this is a question. This is sorry about a 55 year old man who presented to the mostly department with a gunshot wound to the abdomen on. He got shot because the gun fell from the top shelf and unloaded. So he has. He has a gunshot wound. He's he wouldn't empty, unstable. He stuck a cardiac. He's hypotensive, his skin is coming and the school to touch and ears dry mucous membranes on, but it can occur after is inserted, and he has cast in the catheter. So the question is asking what type of costs are likely to be found? S So, what did you guys think was the correct answer, ms What if it the bullets? It is kidney strangers Question. And then if it could be red cell red little costs What if the bullets it is kidney? That's good. That's actually good question, but But I said, I Yeah, I see what you mean. Hopefully no one confused it for that. All right. I'm sorry if you confused for thinking it was that, uh okay, I see it. I see you're not the question that the at the actual answer is a Okay, So I've told you the Yeah, I see. I see what you mean. They might have been. Remember, red Cell casts is more of a feature off glomerular nephritis. You know, people, you get bleeding. If it if you got a shot in the knee in the you get blood in the catheter bag. But I wouldn't expect to see costs because of the if you got a shot in the kidneys. Okay. Regular sarcastic, more of a peach off the Maryland, The fridge, it ease, You know, things that cause more of a nephrotic syndrome. Um, yes. I can see what what you mean. But going on, say is a money bronchoscopy. Oh, why's that money broadcast? What? What? What causes money? Broncos. Yeah, You, too. Blue cross is very good. So this question So this is a hemodynamically unstable patient. This is a patient who's basically has hyperbole. Make shock. She's tachacardic hypertensive has features off dehydration as well. A skin is client Tommy. Cool to touch on Diaz Drive because membranes all features are dehydrated, sort of low fluid in the body. Okay, reduced perfusion to the kidneys. So and he's developed cost. So he's basically got features off a sort of pre renal acute kidney injury. But now he's got cast. So that indicates that the pre renal acute kidney and has led to a intrarenal acute kidney injury. Okay, so the lack of perfusion to the kidney has led to acute trouble in the closest. So damage to the troubles with in the kidney on that's led to costs. Okay, so muddy Brown car says, basically puffing. You monitor for acute trouble in the crosis. Okay, so that's why the correct answer here was a okay on terms of their ups of their options are highly in cast their scene and other things. They're very non specific. There are you often find them in patient to ah, exercised a lot or have some sort of kidney disease. Um, bread sarcastic. That's for grandma and affinities that we talked about, uh what it costs. Can't remember what works. Cast was the thing I might have made it up, but white cell casts on That's more of a sign off. Um, acute pyelonephritis. Okay, as that's why the correct answer here was a money Brown costs. Okay, has decayed. I go. Acute kidney injury classification. Okay. Taken from our Reno nephrology for final session a couple of months ago. On down here is the sort of difference different types of achy I look in your premium. Like I really like I and post renal a chi. And you also have is is there summary off the different sort of cast you get in, urinary when you're doing your your analysis. Okay. Um oh, yes. So what's this guy's? That's for chronic renal failure. Okay, cool. So next question. So this is a hematology question. So this is a 43 year old man who's presented the GP with a two month history off exertion or dyspnea. Easy fatigue. Okay, so these this features off Anemia recently became a vegan. He takes surgery and for depression to manage. It takes a feeling for his depression. It takes isoniazid for TB, and on examination, he has conjunctiva pollen. Hey, as a shiny tongue. And as evidence off hypo Pigmentation on his hands. There's no splenomegaly. So And I've also got some blood test finding. So he has a low hemoglobin, so he's anemic. His mean cell volume is high. Okay, so he has a microcytic. Anemia on his lymphocytes are normal. So what do you guys think was the correct answer here? What do you guys think? No. Well, you come for C car dances A here is he finishes anemia. Tricky. Yeah, it's definitely is a bit of a split between. See, any looks like, uh, the correct answer here was eat pernicious anemia. Um, so let's go through it, Kenyon. Tell me why is it pernicious anemia? What suggest Spanish is an email and this patients? Yeah. Yeah, it'll I go. So hyper pigmentation sign of vitiligo. Yeah. And yes, I would make it a good point. The reason it's not C is because it takes a couple of years for people to get B 12 deficiency because off being vegan. Okay, I know a lot of people talk about vegans not getting enough B 12 in the diet, but it takes good going. You need to be very strict on your diet as a vegan to not take any meat products on it. Even if you did, it takes a couple of years to actually get symptomatic B 12 deficiency. Okay, because and that's what this patient has. So this is 12 deficiency. Why is it B 12 deficiency toe? He hasn't yet. There's a macrocytic anemia. Okay, so that's the desiccating. It's a macrocytosis. B 12 deficiency. Causes a macrocytic anemia and finishes anemia can cause a macrocytic anemia. Okay, um, I said I used it, so I said, I said use can cause an anemia. Okay, but typically, it's not a macrocytic anemia. Um, we talked about, see myelodysplasia and see em out. That doesn't explain. Um, that doesn't It isn't better in keeping with finishes and any of the cause of the anemia on with myelodysplasia. That's I just I think I just around, um, the other the the curtains, his He publishes anemia because there's B 12 deficiencies. And remember, with pernicious anemia, there's damage to the parietal cells, this autoimmune damage of pride ourselves. So the parietal cells cannot produce intrinsic factor. So you can't absorb B 12 properly on. That leads to be 12 deficiency. Okay, I classically it because it's an autoimmune condition. It's classically associated with other autoimmune conditions such as vitiligo. So I told you about the hyperpigmentation. That's why crackdowns a hair waas eat. Finish this anemia. Okay. And the tongue looks Chinese. That Yes, a sign of glossitis. Okay, that's again in keeping with, uh, B 12 deficiency as well. So if you have a question made sense, um, so you have to remember finishes. Anemia is associated with vitiligo on as a complication of finishes, an email you get B 12 deficiency and that causes a macrocytic anemia. So it is a summary slide off the different causes off a macrocytic anemia, which was talked about in our hematology for final session. Okay, so again, see, B 12 deficiency can be caused by pernicious anemia. Um, so yeah, that was question 16. So this is questions. 17. So this is a question asking about the, uh, basically asking about guidelines for managing type two diabetes. So we have a 69 year old man with type two diabetes and also history of heart failure. Okay. Very relevant. He's currently on metformin and ramipril. A time of diagnosis is HBO and C is high on this. HB a one c is now 59. Okay, so and also his His bm eyes high as well. And he hasn't been able to lose weight through his lifestyle measures. So he's not, um is on doing well with sort of conservative management. Um, so it sounds as well. So, what do you think was the correct answer with this one? Yeah, be So it's your add seat. A gliptin. Okay, so, uh, some of you said don't know the dose of metformin. So the key thing here is that his hatred on C is high. Okay, so his hatred on C is still high. Um, it's above the guidelines. Target HBO and see after treatment with, um at Foreman. Eso. The key thing is that usually want it. It's a step up the therapy. Okay, so that's why you still keep the metformin, But you're in a donut therapy. So the most appropriate add on therapy out of these options is seated Lipton. Okay. Um, so it's a it's not pioglitazone because he has a history of heart failure. Okay, so you don't want to give her glasses on Insulin is, uh, insulin is no added right now. Okay, it's a bit you can add a bit later on. I was a third line therapy. So correct. Answer his B add seat of Lipton. Okay, so let's talk about the guidelines. Here's the summary of the, uh treatment algorithm for Type two diabetes adopted from the nice guidelines. So you have a read when you get the slides on. Here's a summary off the anti diabetic drugs, sort of in terms of the key side effects and key contraindications as well. Yeah, that was questions. 17 diabetes. Andi. So let's have a look at 18. So this was a gastroenterology question. So this was a 54 year old man who's presented with a five month history or progressively worsening chest pain. After meals, the pain occurs daily and is worse after eating spicy food. There is no history of weight loss. He has a 35 yes, smoking history. Uh, upper GI endoscopy is performed and shows evidence off erythema off the distal esophagus. And the biopsy is performed, which showed no evidence off metaplasia. Um, so this is a patient who has basically reflux has a history of reflux on. There's no sort of red flag features. There's no history of weight loss on, but there's no evidence of metaplasia as well. Okay, so there's no active evidence off change in the appetite idiom. So can you tell me what was What did you guys put as the right option here? Okay, we got a bit of a mixed couple of you were going forward. Be the Okay. This is ah, split by most people. This is Greg Antares. Be esophageal strictures. Okay, so it's a question of asking about the complications off reflux. What is the different complications? Reflux and so out of these options? Um, basically, A and D are the only ones that are proper complications off reflux. You know, adenocarcinoma. Because patients get Barrett's esophagus on down that leads to have no carcinoma again. Strictures are again a complication off. Um ah. Reflexes again, uh, continuously in. Why's the answer D rather than eight. Good. There's no medication. Okay, so there's no evidence of medication currently, so there's no evidence of a barrett esophagus on. So at this stage, the patient is most at risk for strictures rather than add know carcinoma. Okay, so remember, strictures are one of the most complicated, more common than add a costume, then cancer in general. On go, it's generally more. It's more common. Uh, it's a more common situation to encountered an adenocarcinoma. So statistically it's probably you would have got it more likely to get it right by putting D. Yeah, that's why these. No, there's no current evidence off medication, so it's more likely to be strictures. Okay, squamous cell carcinoma. So this is, um, this isn't associated with the Barrett's esophagus. This is more associated with smoking. Okay, which is the patient does have we also have a smoking history, but again, it's because of the reflux. That's what we're talking about. Hiatal hernia. So that's it's not a complication of reflux. Okay, so that's why they correct answer option. Here is the esophageal strictures. So is the summary slide on reflux. Okay, And here's the summary slide on the complications off gastroesophageal reflux disease to remember, you could get suffered itis you get strictures, and you can also get cancer because off court okay, these are the key complications off reflux on. Here's a summary on the, um different types office softgel cancer in terms of the key points. Okay, so have a read when you get the slides. Question 19. So Okay, this is a again, a very tricky question. I appreciate. I decide to understand that, Wise, these are very quick, tricky questions made these very quickly, but yes, a question 19. So this is a 79 year old man who has has a two week history of worsening shortness of breath. Um, so yes, Breakfast at rest is unable to mobilize on. He has a history off diabetes on heart failure. And now he has all these different features of heart failure. Okay, Decompensated heart failure is JVP is high. Yes, a third heart sound. Okay again. Sign of fluid overload. He has crackles bilaterally. Okay, so sign of pulmonary edema. He has bilateral ankle edema again. Sign of peripheral edema. So in terms of his current medications, he is currently taking ramipril metformin, spironolactone, atorvastatin, foot furosemide and GTM spray. Okay, so it's pretty much exhausted all of these sort of medical therapies. His most recent echocardiogram shows he has a low ejection fraction. Okay, 24% on his EKG shows he has a normal Sinus rhythm and narrow QRS Come complex is on. He has been stabilized in hospital after treatment with IV furosemide. Uh, this is a very tricky question. I'd say this was probably the hardest question I put in personally, but what did you guys think was the correct answer option here? Okay, I see a lot of people couldn't eat. The crackdown stopped in here is actually a I see. Um, see, this is probably the probably take some explaining, but yet they're cans. Here's our option. A implanted cardioverter defibrillator. Okay, so on I see d device. So this is a question basically asking, what can you do for patients who have, uh, refractory, refractory heart failure? They are very severe heart failure on Did not responding to medical therapy. So question asking, what's the different options you can take? Um, so I see the So this is an implanted cardioverter defibrillator. So it's you given to patients to reduce the risk off dangerous arrhythmia. So the key thing I want I want to emphasize with this question is that the highest risk of death in patients with very severe and stage heart failure is from ventricular tachycardia is and ventricular fibrillation. Okay? It's from these life threatening arrhythmias. That's the thing. That's the height that gives the highest risk of death in severe heart failure. Okay, He's very dangerous. Arrhythmia. Except why I c. D. Is very important to consider initially information, but still be a heart failure. Um, and they won't tell me. Why is the option interruption not see cardiac resynchronization therapy started? Seattle doesn't improve mortality. Yeah, but what else? Why? Why is this patient not a candidate for cardiac resynchronization therapy? Yeah. Good. The is curious is normal. Okay, is he has a normal Sinus rhythm and narrow QRS complex is so he's currently not. It's not. It's not gonna be indicated in this patient on, but that's why it's not see a heart transplant. So, um, is a 17 year old man. He has severe heart failure. It's unlike it's the risk of doing a heart transplant is probably exceeded giving. And I CD at this stage. Okay, uh, permanent peacemakers, a permanent pacemaker is not really considered to their permanent pacemaker is used for bradycardias. Okay, to assist with with a rate. Okay. Can you tell me why is the answer up to not been tricked? Left ventricular assist device. Why would I say, Why would I argue that the correct answer option does not left ventricular assist device doesn't improve mortality. So, yeah, once it right, as I'm talking about right side. The key thing I'm trying to get I still licenses the last line of this sentence. Okay? He's been stabilized in the hospital after treatment with IV furosemide. Okay, So is you could be treated stabilized with IV furosemide south for the greater it's not. That means that the assistant ices it Gonna help that much compared to the i c d. Okay, this questions asking, what's that going to reduce his risk of mortality. The greatest on he's been he's been stabilized with furosemide. So the thing that's gonna the assist device isn't going to help him that much more. Okay. The eye sees the thing that's going to significantly reduce the risk of mortality, because again, highest risk of death in patients with severe heart failure is V tac V fib. Okay, that's the big key learning point to remember. Okay, good. So tricky question. Okay. Heart failure. So summary of heart failure. And here's a summary off the management off heart failure okay and comes up the algorithm. So remember, if they're not responding to therapies a Z, a third line option, you can use icy D. Consider CRT. If they're symptomatic if there if they have a low ejection fraction and if they have broadened curious complexes and also transplantation might be considered as well case that seed algorithm for heart failure management. Uh, yeah, Hopefully that question made sense. Um, some of that's why was he not on a beta blocker? I apologize, but I probably just forgot to add it to their medications list. Yeah, I apologize for, um C s a question 20. So this is a 34 5 year old woman who is presented to the emergency department because off sudden onset vision loss, it is in the right eye, two day history or fatigue. Mild pain around her right eye, which is worse with movement. Two months ago, she had a short episode of being unsteady on her feet, which resolved on its own. After about three days. Visual examination shows her acuity is 2020 in the left eye. On that 20 by 200 in the right eye. There's an adoption deficit in in the right eye and stagnant in the left eye was looking left. Uh, there is also a rapid Afrin papillary defect in the right eye. So the question is asking, what is he likely cause off the rapid Afrin papillary defect? Um, can anyone tell me what they did they think was the correct Answer it. It's important to read the question, the question asking, What's the cause of the r a p D? Yeah. I think most of you got see a lot of East and that's the correct answer. So optic nerve information. So we'll see. What's the underlying diagnosis in this patient? Very good. MSR multiple sclerosis. So why Msowoya over a mass is characterized by lesions disseminated in time and space. So is a patient who is presented with a lot of deficits at one time and then presented with deficits at a later time. So fatigue is very predominant, and m s okay and I symptoms is very predominant with m s. A swell. Okay, so and she's got a lot of eye symptoms. Um, so she's not vision loss in the right eye, and she's also got this stuff. Um, sorry. I had meant about relative afferent pupillary defect, so I don't know why, but Rapid. So this is a relative afferent pupillary defect. Yeah, uh, I should've changed. Apologize for that, but yeah, eh. So this is the visual examination. So she has acuity reduced acuity in her right eye on this induction deficit in the right eye and the Starlix and the left eye was looking left. Uh, So tell me, what is this talking about? The adduction deficit in the right eye on nystagmus in the left eye. What is that describing internuclear ophthalmoplegia. Okay, very good. I another and what is? I know close by. What's the cause of you know? Yeah. Good. So a lesion to the medial longitudinal fasciculus. Okay. And in this patient, where's the where's the lesion? Likely located Which side? Which MLF we left or right? Yeah. Right. Okay, So the patient likely does have be marination off the right medial longitudinal fasciculus. Okay, but does does I know cause reduced cause a r a p d does does internuclear ophthalmoplegia cause i r a v d no, it doesn't okay with I know's you gets you get problems with conjugating movements. Okay, but you don't get you Don't get a problem with R A P D. Okay. R E p d. Is a sign off optic nerve damage. Okay. It indicates that there's damage to the optic nerve on. That's the key reason the patient has optic nerve damage is because of optic nerve information. Because of the multiple sclerosis, the most common I sent him you get is optic neuritis. Okay, so that's why that's the cause of the reduced security and the cause off the r a p d. Okay, so the the patient does have an I know. Okay, But the key thing is that the question is asking, What is the cause off the ppd? Okay. So, yeah, that's just important to read the question and be very clear on what he sort of symptoms of different complications are so correct. Answer here is optic nerve information. Okay, there is a summary off multiple sclerosis. Okay. Taken from our neurology for finals talk we did a couple of months ago on. Here's a diagram. Sort of highlighting the key disturbances with internuclear ophthalmoplegia. Okay, I you know. Okay. So remember, with the I know you get, um it's the lateral loss off. Um uh, election. And on the opposite side, you get a nystagmus. Okay, that's the key thing. You get diplopia on corn to get I've movements. Good. Okay, so we're slowly getting those, Uh, it's got a couple of more 10 more. About 10 more questions. So question 21. So we are a three year old boy who has brought to the GP by his mother, and he has bone pain, difficulty walking for the past month. And on examination, there is a soft school with frontal bossing bumps along the cost of chondral Junction shorts actual and blowing off the legs. X ray shows epithelial widening on. His mother says that the child has been exclusively breast fed s. Oh, can you tell me what's the diagnosis? And this patient Brick it, Rick. It's very good, but what's the cause of what's likely cause of the rickets? Why is it why is this child likely got rickets? Very good. Vitamin D deficiency. Okay? Yeah. Child likely has req It's because the most common cause of Rick it says between D deficiency. Okay. And the key thing I'm trying to get her Is that the child has been exclusively breast fed as well. Breastfeeding breast milk classically doesn't have much of it. Mindy and Mother's of generally advise to give it Mundy supplementation to get swell if they've been exclusively breast fed. I'm saying that's classically. That's probably That's the story of the SBA. This is a child with rickets. So basically, there's loads of different features off, uh, lack of bone mineralization and lack of bone structure. Okay, so this soft skull frontal bossing bumps along the cost of Contra junction. Short stature, off signs of sort of Cooley developed bones blowing off the legs. So you guys, what do you call this boat? Going off the legs? What's the deformity coat? But yeah, it's a very It's a virus deformity. Very good. Okay, so it is. Get the booster for me to you at the knees. Yes. Physically. General area spirit going to the knee. Sort of the about like this. That there's a loss of the sort of medial alignment off the knees. Yeah, that's the SPS. It is. Ricketts. Can you tell me what? What's the correct answer? Which one did people, but to go downstairs, see so low calcium, low phosphates high BTH and High LP. Okay, so you have low calcium low phospho you get high pt age because off, um ah, secondary hyperparathyroidism basically okay. And the high LP, because of increased bone turnover, I guess that's why the correct answer option here is See, so, yeah, remember, severe vitamin D deficiency can cause rickets. There is a summary off, uh, different bone profiles. Okay. Different metabolic bone profiles for different bone diseases. Um, so remember specifically talking about osteomalacia. Okay, remember, rickets is basically osteo Malaysia. Rickets just means you get it's it's occurring in kids. Okay? And classically, you get low calcium, low phosphate high L b and high P T h A z. Well, okay, so that's why do you get low phosphate? So remember, Ah, general thing to remember and physiology is that parathyroid hormone generally gets rid of phosphate. Okay, It's the phosphate trashing hormone. I like to talk. All it sometimes so generally, like eliminates phosphate from the body starts where you get the low phosphate. Okay, good. So question 22. So we have a 32 year old woman who comes to the GP because off back pain for six years she describes pain from my neck to the tailbone. It's worse at night, sometimes even waking her from sleep. The pain improves with exercise. She also mentions having intermittent pain at the elbows, wrist and ankles. On examination, there are restricted movements off the lumber spine reduce chest expansion. And she was tender at the secret electorates. Eso Can anyone tell me what the likely diagnosis is here? Very good. I'm closing spondylitis. Okay, so I know a lot of lot of people say ankylosing spondylitis only effects young males. Okay, but woman can get it to okay. I just want emphasize that so patients with this a lot of features of expanded here. There's a lot of features off seronegative spondyloarthritis here, so there's back pain is worse at night. Okay, on, but improves with exercise. Okay. Classic for on closing spondylitis. Um, she also has restricted movements off the lumber spine. Okay, Barry, the hallmark features off ankylosing spondylitis is reduced. Lumbar flexion on Does also reduced chest expansion as well. Okay, So, um, again, because of the reduced, a flexion and reduced ability to expand the chest. And she's also got evidence off sacroiliitis a swell which is again Hallmark feature off ankylosing spondylitis. Okay, So, questions asking which of these is least likely to be found in this patient. So can you tell me one? What do you guys think is least likely to be found? Even the good. So, yeah, I can say Is he, um, anti ccp Can even what? What condition is anti CCP Usually positive? Yep. Rheumatoid arthritis. Very good. So remember we were talking about sensitivity and specificity in that rheumatology for final sessions are anti CCP is very specific for rheumatoid arthritis. Okay, so, uh, these other options can be seen in ankylosing spondylitis. Okay, You can get raised in from three markers with I'm closing spondylitis. Okay. Even though it's usually very mild, Okay, Usually it's not very gonna be very high. Um, it's a trial. I just We talked about Very. It's a hallmark of and closing spondylitis on most patients where you'll see are hey, tell a B 27 positive. Okay. Most patients with these seronegative spondyloarthropathies off properties will be HLA b 27. Positive. So that's why the correct answer here was be a sorry. He, um anti ccp postive. Okay, Hopefully that makes sense. Um, so, yes. Remember, ankylosing spondylitis is typically seronegative okay, you don't get any of these specific antibodies being positive, and I'm closing spondylitis. Okay, so that's one of the key things that define is the disease. Okay, so, yeah, there's a summary off seronegative spondyloarthropathy. So Okay, so it's referring to a group of four different conditions which have a lot of common features. So have a read when you get the slice on his a summary off ankylosing spondylitis, which we talked about in our rheumatology for final session a couple of weeks ago. And here's a cheat sheet on all the different antibody associations which we talk again. Talk about in that rheumatology for final session a couple of weeks ago. Uh, rapid up, um, So, um, so I'm slowly getting I'm sorry. It's a lot of questions to get through. Trying to finish up quickly. Um, question 23. So this is a 33 year old woman who was brought in because off tonic clonic seizures. She has a history of schizophrenia, and she stopped taking her medications on. You have a bunch of different blood test values, so it's got low sodium. Um different had osmolality values and her urine osmolality has increased after fluid deprivation studies. I can't even tell me what the likely diagnosis is here. So, Greg answer is a primary polydipsia. Okay, uh, I'm not gonna go into to do too much d. So I think eating is that this patient has, uh, low serum osmolality. Okay, so I am, um, the key thing I want to get. I got the urine. Osmolality is increased after fluid deprivation studies. Okay, so it had a low sodium. Okay, so she's fluid overloaded, but then after she's deprived of fluid, So she's gone through fluid deprivation studies. Urine osmolality is increased. Okay, So initially, she's had very dilute urine. Okay, She's got very low your nose. Multi. But then they after doing fluid deprivation, the urine osmolality has increased. And, uh, that's that's a note. That sign of normal physiology. Okay, so if you think about it, if you don't drink a lot of water for a while, you should expect your urine to concentrate again for the urine osmolality to increase on. That's that's normal physiology. Okay, So that indicates that there's no sort of pathology here on, but it's likely that this is just primary polydipsia. So primary polydipsia basically means that the patients is drank a lot of fluid on that's again. That could be because of the schizophrenia. So she's stopped taking a medication. So because of the schizophrenia might have caused that to just drink a lot of fluid, drink a lot of water, but because the OSMOLALITY has increased after fluid deprivation, Uh, that indicates this's just primary politics. You okay? So here is a general approach to polyuria. Okay, In terms of the different main causes of polyuria so prime it probably dip. See a nephrogenic diabetes insipidus central diabetes insipidus Okay, on dialysis. Can you explain why you would expect with the other option? So you can basically just have a read of this table and basically explains where you'd expect in terms of the different values? Okay, if you'd expect it to increase. The key thing is, if that if the urine osmolality increases after doing fluid deprivation studies that basically rule out diabetes insipidus okay, probably means that it's just primary polydipsia. Okay, sometimes this is also known as a psychogenic polyps years. Well, I guess some people might might call it that as well. And here's a summary Off the pathophysiology off diabetes insipidus. Um, so you have a read and his summary off SIDH as well. Okay, Question 24. So this is a 45 year old woman with a history of asthma is presented to the emergency department with palpitations that started an hour ago. The palpitations are triggered after drinking and energy drink. Uh, there's no sort of There's no general red flag feet just said there's no edema. There's no JVP distention human dynamically stable. Okay, but pressure's normal stock car get tachycardic okay on, but the symptoms do not improve after vagal maneuver us. Okay. Uh, there's no chest pain. Nothing to be a CT shows a regular rhythm with narrow cure your s complexes with no discernible P waves. Can you tell me what the EKG is describing? Yeah, SPT So super ventricular tachycardia. Okay, is a classic STD appearance. I, I would have should put in an STD, but I didn't voxpops form didn't allow actually pictures to be shown, so I just described it. So EKG showed a regular rhythm with narrow QRS complex is and no discernible P waves. Okay, That's a classic Um, sed um off SPT like a super ventricular tachycardia. So questions asking, what is the management of SPT So I've told you that the patients had vagal maneuvers done on the symptoms Haven't improved vagal maneuvers. Things like, um valsalva maneuver. Um, So what do you think was the correct answer? Hi. So I see some of you could be the correct answer here was actually a So I sneaked this another start just to trick you guys. But I told you, that's not the patient has a history of acid. Okay, so there's no history of asthma. The correct answer here would be be okay, administer a dentist. I see it's gonna act on the 80 note and, uh, treat the SED. Okay, but because of the asthma, the adenosine is contraindicated here. Okay, that's a very important learning point to remember. And then isn't contraindicated in asthma? Okay, risk off bronchoconstriction so small, suitable alternative would be to give IV verapamil. Okay, so that's why that was the correct answer. That that's why that secret dance here on terms of the other options so synchronized DC cardioversion would be considered if he had any features off hemodynamic instability. Okay, Capital ablation would be done too. And if they had to supervise ample f And you want to remove specific fibro's areas, start. It's you and bisoprolol. Uh, that's a form of rate controlled used for, um, atrial fibrilation. Okay, this is this is an STD. This is super ventricular tachycardia. That's why the correct answer option here is eight. So it is a summary of the management off SPT. Okay. So basically the sort of order and what you do things to remember normally after vacant, a nervous fails, you go for a denizen. But in this patient's because of the asthma, adenosine was contraindicated. So the correct answer option waas um around? No. Okay. Okay. 25 year, five questions will slowly getting best. So this is, uh, neurology question. So this is a 50 year old cook was presented with weakness. Okay, See, there's no history of travel. There's no history of recent illness. Hey, takes. Yes, He feels his legs are weaker than they should be. He has a history off type two diabetes mellitus complicated by retinopathy and protein urea. Okay. On examination, there's weakness in both lower limbs on day eight. It's asymmetric weakness. So there's weakness. Great. And his right leg compared to his left leg, There's diminished lower limb reflexes. Okay, Diminished lower limb reflexes. But there's increased biceps reflex on. There's weakness in both his hands as well. He also has a loss of vibration, sense and pinpricks. It sensation from the toes to the knees. Bilaterally. Uh, can anyone tell me what the correct answer for this one of us? So but see, uh, yeah, a couple of you put a Yeah, the pregnancy here was a, um your traffic lateral sclerosis. Um, so can anyone explain why? Why is the answer here? L s type of motor neuron disease. What? What suggested? Patient has a less in this in this case. Yeah, very good. So this this'll patient has mixed up a motor and lower motor neuron science again. That's the hallmark features off motor neuron disease in general. Okay, They have mixed up a motor neuron and lower motor neuron signs on. So someone is rightly asked, why does this patient have sensory symptoms? So that's the key thing I tried to tricky with. So this patient has sensory symptoms because of the type two diabetes mellitus. So Okay, so they have this, uh, governs stocking distribution off sensory loss. That is loss of vibration sense, loss of pinpricks, sensation from the toes to the knees. Bilaterally. Okay, But that's not because of, um that's because of the type two diabetes. Okay? And I've I've told you that there's already evidence off microvascular complications. So there's evidence off right in opathy this evidence off nephropathy. Okay, so the patient is likely to have evidence off neuropathy as well. And that's because of the loss of vibration, sense and pinprick sensation from the toes to the knees. Bilaterally. Okay, so it's because of the diabetic neuropathy that they have sensory symptoms. Okay, but the key because of the weakness is because off, I mean, terrific lateral sclerosis. Because the patient has upper motor neuron sign. So he has, um, increased by biceps reflex bilaterally. Um, sign off, up motor neuron lesion, hyper reflexia. But he also has a decreased reflexes in the lower limbs. Okay, so he has makes motor science. It's not my senior gravis. Okay, We talked about it. You wouldn't expect decreased reflexes with myasthenia um uh syringomyelia. So you'd expect with syringomyelia. They talk about this cape like loss of sensation. Sorry mainly is basically where they get an obstructed spinal canals and not been fitting with this patient. GM very syndrome. So remember, even though there's a stocking loss of stocking of loss of sensation, it's because of the diabetes. Okay, not because of Gambari syndrome. And I've also told you that there's no history of travel or recent illnesses. Well, um, and remember Gamber. It's typically symmetric weakness. Okay, with this patient, it's more a bit more asymmetric. That's more in keeping with motor neuron disease and, um, very syndrome. A swell. That's correct. Answer here was a a less okay, again, tricky question. But it's sort of testing your knowledge off doing a neurological examination as well. And the key principles off, Um, motor neuron disease is so remember motoneuron disease that you have both upper motor neuron signs on lower motor neuron sites. Okay, so it's a summary slide off the different types of motor neuron disease is taken from our neurology for final session. On Here's the different types of M and D. So ls progressive Boba palsy, primary lateral sclerosis and progressive muscular atrophy. as well. Um, okay, this question off, it will go through this very quickly. What did people say for this question? So it's the hepatitis B serology question. Be very good. Vaccination against hepatitis B infection. So, uh, quickly. So hepatitis B serology. So this patient of stiffness and you're negative, but he's surface antigen positive, which indicates that he's cured. But because he doesn't have the antibodies against the core antigen, this indicates that this is is cured because of vaccination. If he was positive, he had a positive core antibody. Then you can see it's because he was cured because of a previous infection. Okay, because if he had a previous infection, he would have produced antibodies against the quarantine body. But because this is negative, this indicates that the vaccine is what's giving him immunity. Because remember, the hepatitis B vaccine only contains the surface antigen. Okay, It doesn't contain the corn. Okay, so it's a summary of hep B serology on the different markers on his a summary off the different cereal article patterns for hepatitis B infections. Uh, question 27. So this is a question about status epilepticus. So you have a 50 year old woman who's, uh, presented with convulsions 30 minutes ago, paramedics found us seizing. Patient's been given wonders off buckle midazolam. So one dose of 10 mg back in the desert island. Prehospital okay on gum. The key thing here have told us that she hasn't regained consciousness. Um, on Then before they've banished examine her, she accepted. He gets another seizure. Eso remember what status? Epileptic Bill Opticus. There's two definitions. One definition is that they have seizures for over five minutes. The other definition is that the have a seizure, but they don't regain consciousness again. Then they get another another seizure. So that's that's still status epilepticus because they haven't regained consciousness. So this is a patient in status epilepticus on in terms of the ABG. This is just showing. Uh, it's just showing lactic acidosis. Okay. Again because of the status epilepticus. So the question is asking what is the most appropriate next step? What's the Protonix appropriate initial therapy. So what do you guys think? Yeah, okay. Triggered IV lorazepam. Okay, so next step. So this patient has been given one dose off benzodiazepine, but you can you can get you give two doses a benzodiazepine is in ST status. Okay, so you can repeat the dose of, uh, benzodiazepine so you can give IV lorazepam in the hospital, and that would be the most. That would be the next pharmacological step. If they didn't respond, then you can move on to things like I have any towing or certain valproic. It's it's not responding to penicillin. Then you move on to intubate and rapid sequence intubation again. Call the anesthetist. So, yeah, the key thing is to doses of benzos should be given in stages that left against. That's why I correct Answer it. Waas IV lorazepam. So here's a summary of the management off status epilepticus. Okay, So do you remember you get two doses of Benzo's Ondra member. The prehospital doses counts for benzodiazepines. Okay. They give if they've been given a dose and a number, for example, that still counts. If they don't respond, then you can move on to infection. Okay. Such as phenytoin off. You know, barbital defendant. This varies depending on the hospital guidelines. On def. There's no responding to the infusion. Then you move on to I to you on Did things like rapid sequence intubation. Okay, question 28. So this was a question about this in endocrine endocrine question. So this is a newborn whose bone overweight, uh, has significant lateral significant lateral. Next election was needed during delivery on at rest. His right shoulder's addicted internally rotated, and the baby cries with passive movement off the arm s o And the baby's blue coast levels are low, a swell. So come on, someone tell me, what's the, uh, cause what's the eastern of deformity? The baby has it yet, abs 40. Um, So why sports the so with herbs Palsy. You basically get this way to step sign with their shoulders. Adducted internally rotated and the wrist is sort of the can't mm blocks the wrist. Okay, so that they get this weight is so they can't extend the rest of the get this week to step posture on. It's because they get damage off the C five to see six nerve roots which leads to this herb school. See, um, so I can get someone Tell me what's the likely call? What's the answer? Option they went with? Yeah, very good. Gestation. Aled. Diabetes. Okay, so basically sporty. So I've told you that significant lateral next election was needed. So this indicates that the patient during labor their patient had the baby had, uh, shoulder dystocia. Okay, so shoulder was stuck during labor on DA. One of the key risk factors for that is if the baby's too big. Okay, so macrosomia on the key respect of a macrosomia is if the mother had diabetes. Okay, so gestational diabetes can lead to Ito macrosomia. So, Peter, the features being overweight and that can lead to, um, Children dystocia, which can have complications such as herbs palsy. Okay, which is what this baby has here. So it's 40. It's a type of a break up Lexus of a break of faxes. Injury? Yeah. Remember, gestational diabetes can lead to fetal microsomia and hypoglycemia as well. Okay, so I told you that glucose levels are low. A swell. Okay, good. So this is summary of gestational diabetes taken from our diabetes for final session a couple of weeks of months ago on, so Okay, two more questions. This is quite a straightforward passion. I hope so. What did? So this is a 60 year old woman who has a two week issue of heartburn pain most often appears when she lies down to sleep burning throat burning feeling in our fruits and epigastric area unpleasant taste in her mouth. She has difficulty swallowing in addition to our usual symptoms past medical history of hypothyroidism. So the diet basic, basically a patient has reflux. Good. Um, says question, you're asking what is the most appropriate next step? So what do people think is the most appropriate next step in this patient? Yeah. What do people think is the most appropriate next step? Be very good. So great. Dante's be endoscopy. Can anyone tell me why? Why is my does this patient needed? And oscopy very good dysplasia, dysplasia and these dystasia over 55 on. That's a red flag feature. Okay, so endoscopy did. That's ah indication for agent endoscopy to rule out eso sinister pathology such as cancer. Okay, to remember, the speech is of red flags symptom in the context of dyspepsia in a woman over the age of 55. Okay, so here's a summary off the red like symptoms or for dyspepsia. Okay. And I like to use the pneumonic alarms on. Remember, this is it's over 55 they have these symptoms. That's the red flag symptoms. Okay, And here's a summary off the different procedures in gastroenterology again, I talk about endoscopy is here so you can have a read when you get the slides again. This is taken from, ah, gastroenterology for final session a couple months ago. Okay, Lost question. Uh, this is a question about Cushing's syndrome investigation. So it's the patient was Cushing's syndrome. Three month history of reduced libido press it is, um, okay. And there's evidence off central obesity, acne stray and easily bruisable skin. Okay, these are all features off high cortisol. Okay, So features of Cushing's syndrome. Okay, hopefully you're able to get that skin fullness at the dorsum of the neck. So it starts. Um, buffalo hump they talk about took it. That's again. Feature off, uh, Cushing's syndrome. And so the questions asking about the investigation. So Cushing's syndrome. So this I've told you that the 24 hour you know it really court urinary cortisol is elevated on din ATM. ACTH is high. Okay? And I've told you that cortisone levels are suppressed after a high dose dexamethasone suppression test. So what do people think was the correct answer here. This is a question testing you about the principals off investigating Cushing's syndrome, which is can be quite tricky for a lot of people. What do we hope that people think yet be Emory? Pituitary can't. Very good. So, uh, can anyone tell me why? Why are they gonna MRI the Pacific? And what's the cause of Cushing's there? Yeah. Yeah. So the toujeo out of normal. So it's it's Cushing's disease. Okay, so remember, pituitary adenoma. Is that cause Cushing's syndrome, that's they call that pushing disease, okay, confusingly, but yes. So why is this a pituitary problem? So this basically the investigations tell us that this is an e C T h dependent cause of Cushing. So you've already confirmed that the patient has high cortisol levels because you've done the urinary cortisol, which is high, and the cortisol levels are not suppressed after high dose dexamethasone suppression test. So this tells you you've confirmed high levels of cortisol in the blood. But because the morning ACTH is high, that tells us that this is because the pituitary gland is producing too much ACTH. Okay, so the morning s C H is high indicates that this is a a C T H dependent coast. Okay, so in terms of a C t h in terms of, um hey, Steve dependent causes. This is pituitary adenoma on the most appropriate step to investigate a pituitary adenomas to do a MRI pituitary gland. Okay, uh, inferior patrol Savina sampling. So you would do this if the MRI pituitary gland doesn't pick up anything. So you think that they you you think that they have a lesion in the pituitary gland, but the MRI doesn't pick it up. Then you can do inferior patrol. So vein sampling because the petrosal veins basically drain from the pituitary gland. And you can do sampling to measure ACTH produced from the pituitary gland to see if that's high. Okay, but you'd first want to do the MRI before you do petrosal vein being assembling CT, thorax and chest X ray. So remember, small cell lung cancers can cause, um, high can cause Cushing's as well, but because, um, this is this is a picture tickles of Cushing's on CT adrenal. So you'd expect, uh, Lois teach, because that would be in a stage dependent cause of Cushing's. If it was an adrenal lesion. Okay, so, yeah. So his summary off Cushing's syndrome. So this is ah, summary of the causes of Cushing's syndrome to remember, you have ACTH independent causes an ACTH dependent causes. There's a different cloak of features off Cushing's syndrome. And here's a summary off the investigations for Cushing's syndrome. Okay, Um, so, yeah, I remember differentiate between pituitary disease and the small cell lung cancer. I told you that the cortisol was suppressed after a high dose dexamethasone suppression test. So that tells us that it was more likely to be a pituitary problem compared to a small cell lung cancer. Okay, so that's why the correct answer wasn't chest X ray or CT thorax. Okay, good. Uh, we are done. Thank you guys. Uh, thank you, guys. Petunias to get you guys said this is a very heavy session. Probably one of that. Have your sessions I've ever done. But thank you guys for tuning in. This took a lot of work on my for myself. Thank you guys. So much for your support. We really appreciate it. We appreciate you guys to me and and sticking with us. A lot of use stuck in with us from the start. I hope you guys enjoyed it. Um, hopefully find the markings. Um, you saw these feedback where you want us to improve on.