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Hey, can you hear me? Yes, I can hear you. Perfect. Um In terms of sharing the slides. Yes. Um Is this the only way you can share it? Uh This is the best way. Did you do it via share PDF? No. What did you do? Did you share the window or share the entire, share the window? Yeah. Ok. Well, up to you look the another way to do it is if you um export your, your powerpoint as a PDF slide and then you can share PDF and that way you won't, it won't be on your laptop, you know, and it won't be sharing anything change on here. Yeah. Yeah. Yeah. Yeah. Oh, that'd be that ok. I'll give you like whatever you can have as long as you need to do it because perfect. Usually it takes a little while for people to show up anyways and Oh, but it's not gonna get rid of the animation. Yes. Possibly. Uh It doesn't matter. It's only on the fast light. Oh, I'm sorry that you give up your, your animations. Yeah. Uh I mean up to you, whatever is easiest for you. Yeah, because it is quite annoying. Having to go back and forth. Hm. How does that work for you? We, I, they're moving fine for me. I can see them. Yeah, it's just so the idea was that they can see this II would ask. Uh, I see, but I'll have to do or should I, I, I'll just do the, do it this way to begin with and then go back to that. Sure. I mean, I'm pretty sure it's quite easy to change about. So I don't think it should be an issue. Uh Are you good to go? Am I am I OK to? Yeah. Yeah. Ok. So, uh welcome everyone to the called Blue Oy Abdominal distension and Weight gain series. Uh So today we've got, is it Kaim? Ok. We've got Robs today who's gonna be presenting for you guys as per usual 45 minutes of teaching by Reba. And then we will be uh moving into breakout sessions to get more personalized, sort of ay style um practice scenarios which will help you uh Polish off your skills that Raba will teach you in the following session. Um Please be as interactive as possible. I'm sure it will help Raba as much um to hear your guys feedback in the session and to leave the feedback behind at the end of the session so that you can get uh a copy of these slides sent to you. All right. Uh Thank you very much and I'll let you guys take it. Ok, thanks. Hey guys. So yeah, I'm on the and I will be doing a presentation on abdominal distension and weight gain. And so essentially focusing on endocrine conditions and osteo related. So I'm sure you guys have all, if you've been to other events and sessions, you've already had all this. So here's our partners. Um If you're interested in a geeky medics, you can get 10% off and obviously, the slides are made by, by myself, I'm also a student. Um but they have all been checked by a doctor and check if everything's, you know, medically correct. So in terms of the learning objectives for today, it's just to go through some of the um common endocrine conditions and what their symptoms and signs are and then also to um be able to take a thorough endocrine and look at how we might wanna structure a, an explanation, explanation station for us in terms of endocrine conditions. Ok. So as Elaine, as had said, it'd be amazing if you guys can keep interactive. And so as I go through, I'll be asking questions if you can pop it into the chart. I don't know if you can unmute or you can shout out. So for abdominal distension, what are your po potential endocrine causes? If you can just put it in the chart? If anyone has any guess is what good Cushing's hypothyroidism? Yeah. And do we know what the mechanism of why that could be or any other guesses. So yeah, as we've already put, so Cushing's Syndrome, really good Adrian and phaser hyperthyroidism. So, hyperthyroidism can also cause it. And then you've got things like Addison's Addison's disease and then other things like diabetes, Polycystic Ovary syndrome and acromegaly. So in terms of Cushing's syndrome, that the way it caused abdomin is that it doesn't necessarily cause true abdominal distension, it causes weight gain around the midsection. So around the belly, which can come across as abdominal distension. Um and also can with hyperthyroidism, it can lead to constipation which can lead to um abdominal distension. Hyperthyroidism again can cause hyperactive um inte like your intestines, which causes diarrhea and things and bloating, which leads to abdominal distension. And likewise, Anderson's disease can interfere with the function of your intestines and c lead to bloating in things. So how about for weight gain? What are potential endocrine causes any guesses guys? So that's good. There we go. So your again, Cushing's syndrome. So, well, very commonly cause weight gain, hypothyroidism this time again. Yeah. Good. Cushing's um hyperthyroidism will um will this time be the only one since it causes weight gain. Whereas hyperthyroidism usually instead leads to weight loss and then other things like diabetes. Again, polycystic um PC is essentially metabolic syndromes as well, which include things like um hypertension hyperlipidemia and obesity. Ok. So how about your other potential causes any guesses? There's loads for this, this out. So, essentially non endocrine causes what's gonna cause abnormal distension. So, think about your like gi stuff. What could lead to a distension? Yeah. Very good. So, con con congestive heart failure, liver failure. Um every failing since the sky. Yeah, ascites good. Yeah. So what's aging? So those are things that will generally lead to um fluid retention um which can lead to ascites. Ok. So here's your full list. So um autosomal autosomal polycystic kidney disease. Um obviously, if you, which is where you get lots of different cysts um grow um in the kidneys. So that's gonna enlarge your kidneys and can eventually lead up to abdominal distension due to the space occupying um lesions. So, and then anything gi really irritable bowel syndrome, IBD diverticulitis, celiac disease, they can all lead to abdominal distension and then things like obstruction. So as um it's been put in the child bow bowel cancer, which can lead to obstructions. And, but also the fact that there's a in um later stages, um the fact there's a space occupying lesion in itself can lead up on distension and then um ascites caused by various conditions as well. And then in females also just consider pregnancy as a possibility. Ovarian cysts and endometriosis. Ok. How about for weight gain of non endocrine it causes. So for weight gain, it tends to be things like lifestyle related muscle, um and medication related. So it's always important to take a thorough lifestyle history and see if there's any factors that are affecting, you know, the eating habits, their exercise habits and things which can lead to weight gain. And then, you know, medication history is important as well. So classically steroids, antipsychotics especially can cause weight gain. Um and then other things like antidepressants, insulin and anti elastics as well. And then you can get weight gain due to fluid overload. So things like heart failure, liver failure, um or kidney disease, which can lead to nephrotic syndrome can all lead to fluid overload. Ok. So we'll just go through each one of the endocrine conditions very quickly. Um Cushing's syndrome. So d does anyone wanna put in the chart? What we mean by syndrome? Just give you a minute to do that? Very good. Yeah. So a collection of symptoms. So essentially is any collection of symptoms or signs that are characteristic for a certain disease or condition? So that means that it can have many m many different causes and it's not just one disease on its own. So for Cushing's syndrome, it signs and symptoms that developed after prolonged, abnormal elevation of cortisol. So essentially someone's got Cushing's Syndrome, all you know is that they've got raised cortisol, you don't know what the cause is since there could be lots of different causes for it. Um And then in terms of how it causes weight gain and um abdominal distension, you get increased lipogenesis and fat deposition. So that's the met metabolism of fat um creation essentially. And then you also get increased glucose through insulin resistance, which can all promote fat storage and gain weight. So, in terms of your signs and symptoms that you look out for that would suggest Cushing's syndromes. So usually you get um so increased weight gain essentially around the face and midsection. So you get moon face usually uh it's described as um again weight around the abdomen and also Buffalo hump due to storage of uh at the back. And then you get things like pepper stray, usually more common in the abdomen rather than other parts of the body. Um And then characteristically, you also get um prox, so proximal muscle, um dystrophy. So you get thinner, weaker limbs as well and then you get a bigger center. Um and then in terms of your actual physiological changes, um so you get high BP due to raised cortisol, you're gonna get raised heart rate. Um and you're gonna get raised glucose levels as well. And it can also affect things like your sleep, your general um energy levels, and you feel more fatigued. And then in the long term, you can get complications such as osteoporosis and also um reduced immunity, which can lead to repeat infections. So, it's important to know the general pathophysiology. So, um depending on where in the cycle here things go wrong. So you've got your hypothalamic pituitary adrenal axis, depending on where it goes wrong, you can get either tertiary causes, secondary causes or primary causes. So, Addison's disease tends to be sorry. Cushing's disease tends to be the most common one. So that is a specifically where you've got pituitary ad adenoma releasing excess of ACTH. So where, where in the cycle here it's going wrong is at the pituitary. That therefore is a second thing. So um it's a secondary cause of Cushing's syndrome and it's where you've got raise ACTH due to a tumor in the pituitary gland. So there's other causes. So for example, you can get um exogenous, sorry. So if someone's taking prednisoLONE for something like um rheumatoid arthritis, then it can lead to Cushing's Syndrome as well. Yeah. Ok. So hypothyroidism or hyperthyroidism. So in terms of signs and symptoms, it's quite nice number because they're basically the exact opposite of each other. So, in hyperthyroidism, you've got too much thy thyroid hormone as in hypo, you've got too little thyroid hormone. Um And generally in hyperthyroidism, think, think about how the whole body is basically in a increased metabolic rate. Um So you got, you're gonna get weight loss. Um if you've got more metabolism going, going on, you're gonna have more energy. So you're gonna get sleep disturbance and insomnia. Um And with everything being hyperactive, your intestines are gonna be too, so you're gonna get things like diarrhea, excessive sweating and also tremors can be very common. And then on the opposite side, you're gonna get things like weight gain, constipation, feeling cold all the time. Um because your metabolism has gone down. So you're not producing enough energy and heat and then it can affect your mood and general as well causing depression. So, for hyperthyroidism where you've got too much thyroxine, that tends to the most common cause for that is graves disease, which is an autoimmune condition where you get TSH autoantibodies. Um and that tends to be more common in young ladies. Um whereas other causes such as multinodular goiter tends to care at older age. So, although these are your general signs and symptoms for hyperthyroidism, there's a few specific for Graves disease which are important to be aware of. So diffuse goiter. So what that means is that there's no nodules, it's gonna be quite soft to feel and quite obviously enlarged. Um Graves eye disease. So um that includes xus and proptosis. So where your eyes start bulging out and then also you can get l um good luck. So, on examination where you, where you get them, follow your finger or a pen up and down. What you find is that the upper eyelid? Well, like, so normally if you look at anyone's eye, you shouldn't see the upper part of the sclera. So the white bit, but in Graves disease, they get li like what that means is that you can start seeing the white bit at the top and then pretibial myxedema um which is where you get skin changes in the shins, um tends to be like a waxy dry appearance. Um On the other side, for hyperthyroidism, most common cause is hashimoto's disease, which is also autoimmune condition. Ok. So, Addison's disease is um kind of the opposite of Cushing's syndrome where you've got um there's less cortisol and also aldosterone. Um again, the most common cause is an autoimmune cause um called primary adrenal insufficiency where the adrenal glands are attacked by the your own immune system and damage, which leads to um a deficiency in your hormones. So, in terms of the signs and symptoms, you've got them here, you're generally gonna get, um, you know, be more tired, more fatigued. Um And then if you've got low cortisols can be the opposite of cushing. So low BP, low heart rate, um low glucose levels, therefore, increased insulin sensitivity. And then Aldoron again can affect your BP. Um you get soft cravings because of it as well and your gi symptoms. So just be aware of Addisonian crisis. So that's basically at your um like the limit limit of the condition where they've, they've got an extreme deficiency of cortisol, especially. Um So they tend to present very severely and patients will be very, very unwell, so reduced consciousness hyp like severe hypertension, they can be in a hypoglycemic state and have electronic abnormalities if you do a VG for example, and generally just a very very unwell patient and it can potentially be the first presentation of Addison's disease. So people will often not realize they've got it and present with the Addisonian crisis, for example, after an infection. So there's lots of different triggers um far at and the important thing there to remember is that it is a very life threatening condition and you never actually wait for investigations, but just assume and treat immediately. So, autosome, polycystic kidney disease. Um as I mentioned briefly, it's basically where you get like lots of cysts forming in the kidneys. Um And again, so thinking about the function of the kidneys, it can cause um lots of different problems and um not so relevant for osk but for like progress as the second most common um manifestation of polycystic skin disease is liver cysts. Um Yeah, and then acromegaly. So this is slightly more niche um especially for oy. But um it's one of the things that can cause abdominal distension because you get um organomegaly in general. So all your organs in your abdomen was become enlarged and cause um abdominal distension and then PCO s so it's not very relevant for you guys. At this stage. You will learn it in year four, in more depth. It is a common and important condition, but it won't come up in year three for you. So we'll just skip through it. Ok. So we've got a 36 year old female presents with abdominal distension and weight loss. Um, what are we going to ask in the history? So if you can all put something in the chart? Yeah. Very good. So you wanna ask about the libi, libido pregnancy menstruation and then just think about everything else. Skin changes, heat and cold intolerance. Good. Anything else guys? And just think about all the different aspects of the history taking. Yeah. Very good. So any changes in your bowel habits, if they're feeling lightheaded vomiting? Ok. So as with any history, so obviously, start with a nice open question and then go into the history of presenting complaints. So always you wanna always mention, um ask specifically about onset and duration. So when did um the abdominal distension and the weight loss um started for them. So that that was supposed to be weight gain. But anyway, um and then if the, if the symptoms have gotten worse or better and how they progress over time. So just from the presenting complaint, abdominal distension and weight loss, you wanna think what systems are gonna be relevant? So for abdominal distension, your gi system is definitely gonna be very relevant. And then for your weight loss or weight gain, that's gonna be generally you lead towards endocrine. So for gi always asked about bowel movements and um when asking about bowel movements, don't just ask, you know, um are your bowel movements normal because patients might not know what normal is. Um, always specify how regular and when the, when the last time they went was and specifically ask if there was any mucus or any blood in their stools, um always ask about abdominal pain and if they do say, yep, they've got abdominal pain go through Socrates with them. Um As I already mentioned in the chart. So nausea and vomiting again, part of your um gi system review, always ask and then any dietary changes that could have potentially triggered um for your endocrine um fatigue, any menstrual changes which we put in the chart, um Any hair loss, which can suggest things like hypothyroidism, any skin changes. So in Cushing's, you can get the purple tray in Addison's, um you can get hyperpigmentation. Um and, and then you've got hypo and hypothyroidism where you can get skin changes. So, hypothyroidism, it gets dry scaly skin and then hypothyroidism. If graves disease, you can get the myedema, um heat and cold sensitivity and then fasting urination, thinking about other things and how that affects our electrolytes. So, always ask your general systems um systematic sys s systemic sorry um symptoms or fever, any weight changes. Ok. And whenever you're asking these questions, it's important to know why you're asking them. So, obviously, different symptoms will suggest different conditions just for the interest of time, we won't go through everything. Um And then always ask specifically for autoimmune conditions. So if, if it's something that runs in the family as well, um just cause a lot of the things we've already mentioned in terms of endocrine conditions tend to be autoimmune. Um And then for, if you're thinking it could be Cushing's Syndrome to ask specifically about steroids, which should be covered as one of the causes of Cushing's syndrome and then lifestyle. Um we mentioned that can have a huge impact on like weight gain and things. So I always ask about their diet, their exercise and what are they doing for work? You know, if they're a bus driver, they're gonna be sedentary for most of their time. Um And then always end with a summary and a plan. Ok. So examination, further investigation. So whenever you ask about and you know what further examinations or investigations you would do in your oscopy. So in any exam, always split them up into your bedside and then your laboratory testing, imaging and special test. So um what examination investigations would we do for this patient? So 36 year old female who presented with abdominal distension and weight loss? Ok. Very good. So your thyroid function does. So if you go back and try and do best side first, so what would we do at the bedside? So that can include things like your physical examinations but also things like BP, heart rate. So do a general um and then you're in depth if relevant. So and then for labor testing good, you can do F BCU LFT S and fasting glucose. Very good 12 lead. ECG. So that's for best side. And that's quite relevant for hyperthyroidism and hypo but more so hyperthyroidism which can lead to um things like atrial fibrillation and all the arrhythmias. Ok. What's up? Um in terms of your bedside? So you one do your vital signs of blood, pre BP, heart rate temperature. Um and then you also wanna do your specific examinations, um system examinations. So, abdominal examination, um thyroid examination and skin and nails. So for thyroid, um there's a few that, that are specific for graves disease. So just remember what those are. So and for example, auscultating for a bruit using your stethoscope and checking for proptosis or thalmus lead luck which we mentioned. And my and then you can also do things like u um urine dip, capillary blood glucose, ecg pregnancy, death and BMI. So for your lab testing as we've mentioned, so your T FT is obviously to check for hypo and hyperthyroidism. Um Cortisone A ACTH to check for Addison's and Cushing's. Um and then blood glucose very relevant to check for diabetes in itself, but it's also gonna be affected in conditions like Addison's and Cushing's. Um So in other sense, your blood glucose is gonna be low and Cushing's is gonna be um a lot higher and then inflammatory markers. So in terms of your specific tests, you can do like autoimmune conditions as well and um dexamethasone suppression test for Cushing's syndrome short test for add. Um So I think you guys are having another conditions going through the, in the sorry, another session this week on the 12th and where you go through investigations. So we won't go through that. Ok. So we'll quickly try and go through explanation sessions. Ok. So, um you guys have all probably come across this. So this is your general structure on how to kind of get um structure your answers. So I start with a brief history, check the patients understanding and if they have any particular concerns and then go through explaining the disease, OK. So in terms of your brief history, um so a lot of people think that it wastes a lot of time and might skip sections. So it's very important that you don't actually skip any of these subsections of the history and that you do ask, you do go through the um common symptoms quickly, their past medical history, medication history and their social history. Um Just because all of this is gonna be relevant later down the line where for example, if you've listed that they're smo they're a smoker and they drink alco alcohol, you can then counsel them on, you know, to, to stop the smoking and to stop the alcohol and make it more personalized to them rather than something you just memorize. Um And again, the past medical history that could be relevant um for the disease. So for understanding, just ask one direct question very quickly. Um For example, what do you know already about Cushing, Cushing's disease and then consents. So whenever you ask for consents and, and then they answer with a consent, don't just ignore it. Um Either you will need to address the concern there and then, or what most people will do is just let them know that they will come back to it um later down the line um and it will be addressed and then lastly outline the plan. So instead of just going straight into it, let them know that you're gonna explain what the normal function um of the hormone. For example, is um what Cushing's disease is and what causes it. Um your complications management, et cetera. Ok. So we have one example of Addison's hair. Um So just explain you what the normal anatomy and physiology is quickly. The fact that you've got two adrenal glands that sit above each kidneys um on either side of the abdomen and they produce um different hormones including cortisol and aldosterone. And then just give a brief explanation of what they actually do. Um So for cortisol, you know, that's your normal stress hormone. Um it's what's using your um fight and flight system. Um it's gonna raise your BP, it's, it helps regulate your blood glucose levels and et cetera. So, and then explain what the disease is. So, depending on what that causes is gonna be a different explanation, but just make sure you personalize it to them and link to the patient's symptoms. For example, if they've said that, um, they've got a lot of fatigue. So you wanna specifically say, so you in adder's, your adrenal glands aren't producing enough cortisol. Therefore, that leads to a reduced level of, um, glucose, which is your main for, um, like form of energy. Therefore, you're gonna feel more fatigued, which you are doing, um, just explaining what the causes are. And, and if you've got a list of investigations I've had tell them what exactly the, the cause is in their case. So in terms of complications for Addison's and the main one you'd wanna mention is a crisis and make it very obviously, that's a, it's a medical emergency and what the tell let them know what the signs and symptoms are. And if, if they ever do get anything like it that they must seek immediate emergency care. And so for other, since your management is hormone replacement, using hydrocortisone and fludrocortisone, um and the key there is that whenever the patient does get a illness that they need to double the dose of the hydrocortisone, and if you don't mention that you'll get mo um marked down quite a lot. So I think this was, this came up in the Sy Anderson's disease two years ago for us and always just if you've got spare time, finish with a summary and more importantly, a plan. So what will happen next. OK. Um So similarly, again, for Cushing's syndrome, you wanna follow the same sort of structure. Um let them know what the normal function of the cortisol is and what it does in the body. So the fact that it's a, it usually handles stress and controls your blood sugar and energy levels and helps you keep your BP stable and involved in fighting infections and reducing inflammation. Um And then what Cushing's syndrome is? So that again, personalize it, the specific cause if you already know and let them know the common, common symptoms they can get. So you don't have to go through every single one of these. But if you've elicited what they have um in their brief history, then just go through those, ok, in terms of complications. So, um obviously, if you've got too much cortisol, you're gonna get raised BP that can lead to problems it can cause over exertion of your heart that can lead to heart disease and increases the risk of stroke, et cetera. You can mention osteoporosis quite common. So that's a good one to mention. And then um over time, you can get reduced immunity which can expose you to and put you at higher risk of infections. So for Cushing's disease, um in terms of management, um all, so you wanna mention what they can do themselves. So in order to reduce the risk um of, you know, their raised blood sugar and raised BP. There are things they can do including exercising and dieting. So mention um, everything that they can do first and then things that we can do for them. So for Cushing's Syndrome, often your first line of surgery, if there's an obvious cause for example, if it's caused by a pituitary adenoma, um, what you do, you usually go through the nose and try and remove it. Um, but if, if surgical management is not appropriate or it's not an option, then medications can be used such as um ketoconazole, which inhibits the production of cortisol. Obviously. Um try and avoid using like medical words and things if you're explaining it to a patient. I OK. So I think that's the end of my time. It's a few months wise on medication counseling. I'll just go through very quickly, but I think you guys get SLS afterwards anyway. Um Yeah, again, always, always take a brief history and cover all the different aspects, um as well. And it's important to always ask about what they already know about the medications and if they've got any particular concerns that they want to be addressed and always outline a plan on what you'll cover. So for hydrocortisone, um so in terms of your osk, I think you can get a station where you have to effect, where you have to explain how to use like steroids and hydrocortisone or prednisoLONE. I think it's unlikely to be in um in the context of a, it's probably gonna be something more simple whether they're taking prednisoLONE for, for something like rheumatoid arthritis or asthma exacerbation or CO PD exacerbation. But general principle really. Um So first you wanna ex explain what it actually is and sometimes it can be useful to explain very quickly and very briefly what their condition means and how the medication helps that condition. So in terms of uh adds the way we take hydrocortisone is that you take it, you take two or 2 to 3 doses daily. And because in um so usually naturally, um you release the most amount of cortisol in the mornings where you need it most and over the day, it kind of plat plateaus down and at night time where you're sleeping, you don't really need any of the cortisol or you need very little in your body. So you want to kind of mimic the same thing. So what you, what they do is take the highest dose early in the morning and take a small dose in the afternoon. Um So usually two doses is enough, but sometimes there might be a third dose in the evening added. So with prednisoLONE, it can irritate the stomach lining and peptic ulcers can be a complication. So it can be useful to take it with food or straight after. Um always let them know that they cannot stop, they shouldn't stop all of a sudden. Um And if they do miss a dose, try and take it as soon as you remember, but I think um gone over a day then do not double dose. So your tests and monitoring. So um obviously you wanna avoid giving them too much penicillin or hydrocortisone, sorry. Uh it's gonna lead to Cushing's syndrome. So you're gonna and look for signs of that. So blood if, if they've got normal BP and normal body weight, BMI um and then they are blood glucose levels as well and electrolytes let them know they won't need regular monitoring to avoid any come to kinda avoid any complications, identify early to so we can manage it and then just be aware of the common side effects and always in all safety net. So especially for any more, any of the more severe complications. So in Addison, you can, the Addisonian crisis can occur. So just let them know if they ever become unusually tired, sleepy or confused, then they can see they must seek medical attention. Um Again, they, they are increased risk, increased risk of infections. So if they've ever got a temperature, uh chill, sore, sore throat, the then they need to see a GP I call 111 and that's it. So, thank you very much guys. Um We really appreciate if you can feed. Thank you very much. S um I will send the feedback form through now as well. It should appear in everyone's charts. If you could please fill that out and we will now have a uh osteopro stations in the breakout rooms. If everybody who wants to join those can go now and Revaz Yeah. Thank you. Once again. Um It was fantastic. Are free to go. Yeah. Yes. Yeah. Yeah, you, you should be good to go. Well, good. Thank you very much. Thank you. Everyone else wants to join any breakout session that they can. Uh hopefully the volunteers will start filling into these sessions as well as we go along.