pace your MRCP-PACES

👉 *IMPORTANT 494* 👈 *Few pearls about Diarrhea* Bleeding per rectum+ skull or bone osteoma + skin fibroma + family history +ve = Gardner syndrome Good Luck

👉 *IMPORTANT 493* 👈 *Few pearls about Diarrhea* Bleeding per rectum + perioral pigmentation = peutz Jepgh syndrome Good Luck

✌️✌️ *HEARTIEST CONGRATULATIONS* ✌️✌️ To *Dr. Phoebe* For passing *PACES MRCP ( UK )* from Malaysia. She was with us in our batch of May 22 online courses for PACES. We wish her the best for her future.

👉 *IMPORTANT 492* 👈 *Few pearls about Diarrhea* Bleeding per rectum + loss of weight + history of acromegaly = cancer colon . Good Luck

👉 *IMPORTANT 491* 👈 *Few pearls about Diarrhea* Bleeding per rectum + AF + metabolic acidosis = Ischemic colitis . Good Luck

👉 *IMPORTANT 490* 👈 *Few pearls about Diarrhea* Bleeding per rectum + aortic stenosis = angiodysplasia ( commonly affect right colon). Good Luck

👉 *IMPORTANT 489* 👈 *Few pearls about Diarrhea* Bloody diarrhoea + elderly with left iliac fossa pain and tenderness = diverticulitis . Good Luck

👉 *IMPORTANT 488* 👈 *Few pearls about Diarrhea* Diarrhoea + vit B12 def + oral ulcers = Crohn's disease . Good Luck

👉 *IMPORTANT 487* 👈 *Few pearls about Diarrhea* Diarrhoea+ perianal fistula or skip lesions+ more constitutional symptoms as compared to diarrhea = Crohn's disease . Good Luck

👉 *IMPORTANT 486* 👈 *Few pearls about Diarrhea* Bloody diarrhea + positive P ANCA = Ulcerative Colitis Good Luck

*Brief management summary for Ankylosing Spondylitis by the courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* The following is partly based on the 2010 EULAR guidelines : encourage regular exercise such as swimming NSAIDs are the first-line treatment physiotherapy the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement the 2010 EULAR guidelines suggest: 'Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments' research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease Good Luck

*Few Investigations for Ankylosing Spondylitis by the courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* Inflammatory markers (ESR, CRP) are typically raised although normal levels do not exclude ankylosing spondylitis. HLA-B27 is of little use in making the diagnosis as it is positive in: 90% of patients with ankylosing spondylitis 10% of normal patients Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. Radiographs may be normal early in disease, later changes include: sacroiliitis: subchondral erosions, sclerosis squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) syndesmophytes: due to ossification of outer fibers of annulus fibrosus chest x-ray: apical fibrosis If the x-ray is negative for sacroiliac joint involvement in ankylosing spondylitis but suspicion for AS remains high, the next step in the evaluation should be obtaining an MRI. Signs of early inflammation involving sacroiliac joints (bone marrow oedema) confirm the diagnosis of AS and prompt further treatment. Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints. Good Luck.

✌️✌️ *HEARTIEST CONGRATULATIONS* ✌️✌️ To *Dr. Aimi N Zaidudin* For passing *PACES MRCP ( UK )* from Malaysia. She was with us in our batches of Oct 21, Nov 21, April 22,June 22 & July 22 online courses for PACES. We wish her the best for her future.

*Referral criteria for ankylosong spondylitis by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* NICE advise: all patients with suspected ankylosing spondylitis should be referred to a specialist 'Do not rule out the possibility that a person has spondyloarthritis solely on the presence or absence of any individual sign, symptom or test result.' Good Luck

*Few clinical features of Ankylosing spondylitis by courtesy of Dr Toqeer bhatti. Thanks a lot Dr* *Introduction* Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old. *Clinical features* *Features* typically a young man who presents with lower back pain and stiffness of insidious onset stiffness is usually worse in the morning and improves with exercise the patient may experience pain at night which improves on getting up *Clinical examination* reduced lateral flexion reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible reduced chest expansion Other features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female Good Luck

*Few complications of ITP by courtesy of Dr Toqeer bhatti. Thanks a lot Dr* Complications of treatment are related to side effects of specific drugs used for treatment of ITP. A referral to local haematology department is desirable to weigh up the risks and benefits of choosing a particular modality of treatment against the risks of bleeding. I.e. if platelet counts are stable and above a certain acceptable threshold (depending on hospital guidelines, i.e. >50 and asymptomatic), it may be reasonable to continue monitoring. Patients who received splenectomy require long term prophylactic penicillin V and pneumococcal/meningococcal vaccines. Most patients with ITP do not have severe bleeding. In a review of adult ITP cases in Oklahoma over a 10 year period, 83% patients were managed on an outpatient bases. Indications for inpatient management of ITP include: Large bleeding; Haemodynamic compromise; Intracranial haemorrhage; Platelet count of less than < 30. Inadequate response to conventional therapy agents. Good Luck

*Some treatment options for ITP by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* ITP at first presentation should be referred to and managed by haematologists. The requirement for treatment varies between patient to patient; as such, clinical status is a key determinant for these considerations - i.e. asymptomatic, bleeding or planned surgical/dental procedures. Treatment is only given to those patients that absolutely require it, hence decreasing the risks of adverse effects such as infection as a result of immunosuppression. Below are the recommendations as according to British society of haematology. First line treatment for ITP is oral prednisone at 1mg/kg daily with proton pump inhibitors . This is given over a period of 2 - 4 weeks and weaned off a few weeks after. Most patients respond to this treatment within a week of commencing steroids. Pooled normal human immunoglobulin (IVIG) is also listed as first line treatment. Intravenous immunoglobulin is administered at 1g/kg. The mechanism of action is unknown but it was thought that one way is by blocking the Fc receptor of macrophages. Splenectomy had been used for many years, long before steroids were used. It is now second line for ITP in steroid refractory cases. It works by avoiding platelet destruction by removing the spleen. Other immunomodulatory drugs such as rituximab, cyclophosphamide and dapsone have also been used to treat ITP. Romiplostim works by activating the thrombopoietin receptor and stimulating JAK2, thus it stimulates platelet production. It has been approved by NICE as an option for ITP. Indications for usage include: ITP is refractory to standard active treatments and rescue therapies or Patients have severe disease and a high risk of bleeding that needs frequent courses of rescue therapies. Additionally it is important to avoid drugs which make bleeding worse. It is important to avoid antiplatelet drugs such as aspirin and clopidogrel. In cases of severe bleeding, it is important to treat promptly with transfusion of platelets, IVIG, tranexamic acids and initiate major haemorrhage protocol. Although transfusion of platelets may not improve platelet count, it has been shown to be effective at relieving the symptoms in acutely severe bleeding. Good Luck

*Some investigations for ITP by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* There are a number of investigations to be considered in patients presenting with bleeding and in those with incidental findings of thrombocytopenia. There is no single blood marker for ITP. Rather it is a diagnosis of exclusion. Minimum investigations to be done if thrombocytopenia is found include: Firstly, full blood count and blood film need to be requested. This would demonstrate isolated decrease in platelet counts, with normal counts in all other cell lineages. Additionally, there should be no evidence of fragments on the film. Secondly, a virology screen including HIV, EBV, hepatitis screen. Further investigations to be considered, as guided by history and examination findings: Clotting screen including PT and APTT, especially in those with severe bleeding. Thyroid function tests Malarial screen Myeloma screen. Immunological tests including ANA is considered especially if coexisting rheumatological features are present. Imaging including CT may be useful if there is a high index of suspicion for cancer. Bone marrow biopsy is no longer a standard investigation for ITP. If there are blood count abnormalities such as anaemia, leucopenia or other unexplained haematological findings, a bone marrow biopsy is warranted. In cases where ITP is not responsive to treatment and there is a high clinical suspicion for MDS, bone marrow biopsy should be carried out. Good Luck

*Few differential diagnosis for ITP by courtesy of Dr Toqeer Bhatti. Thanks a lot Dr* ITP is a diagnosis of exclusion. Thrombocytopenia can be caused by increased destruction of platelets, and/or reduced production of platelets. Important differential diagnoses to consider include: Non-immunological causes of increased destruction of platelets include disseminated intravascular coagulation (DIC) i.e. in the setting of sepsis or malignancy. Pregnancy and its complications such as HELLP syndrome can also cause thrombocytopenia. Chronic liver disease and hypersplenism is associated with thrombocytopenia. Thrombotic thrombocytopenic purpura (TTP) is life-threatening disease which presents with thrombocytopenia but can result in multi-organ failure, cardiac complications, strokes and other thrombotic events. The hallmark for DIC and TTP is the presence of fragments on the blood film. Additionally, drugs such as heparin may result in thrombocytopenia, known as heparin-induced thrombocytopenia or HIT. Immunomodulatory drugs such as gold, alemtuzumab and more recently immunotherapy agents such as nivolumab and pembrolizumab have been associated with ITP. Thrombocytopenia may be the first sign in well patients with underlying viral infections such as HIV or hepatitis. Many haematological malignancies can result in thrombocytopenia such as leukaemia, lymphoma, myelofibrosis, myelodysplasia and myeloma. Therefore it is important to take a careful history, as patients with these diseases often present with constitutional symptoms. Finally, rheumatological diseases such as SLE and rheumatoid arthritis can present with thrombocytopenia. Good Luck

Here is the recording of today's session. Please try to listen the recording in 1 day as Zoom provides limited space and it automatically deletes the old recordings to keep space for new ones ..so the recording will not be available after 1 day☝️☝️☝️