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👉 *IMPORTANT 572* 👈 *For history taking* Before asking about monthly periods take permission. May I ask you some personal questions If permission granted by the patient ask her what about your monthly period are the ok regular, if she says yes then no need to probe about blood loss tempons etc Ask about these details if she tells there is some problem with her peroids paceUrMRCP.

👉 *IMPORTANT 571* 👈 *For history taking* Always ask about 3 Ps in history taking of a lady in child bearing age ( more important in this age ) Periods , Pills and Pregnancy paceUrMRCP.

👉 *IMPORTANT 570* 👈 *For history taking* Always be polite in asking about sexual history. Always ask are you in a relationship if patient says yes you may ask permanent or casual if he says permanent polity ask him any chance of casual relationship in the recent past . Never ask straight away do u have any unprotected sexual relationship paceUrMRCP.

👉 *IMPORTANT 569* 👈 *For history taking* Try to avoid asking sexual relationship in exam always use the words lik private or intimate relationship. paceUrMRCP.

👉 *IMPORTANT 568* 👈 *For History taking* Never say do you use illicit drugs...it may seem a bit offensive. Always be polite and say do you use any drug for recreation or do you use any party drugs paceUrMRCP.

👉 *IMPORTANT 567* 👈 In a patient with HHT, Pregnancy is not contraindicated but we must confirm AVM before pregnancy as they may worsen due to hemodynamic stress during pregnancy, For this reason it should be a planned pregnancy and refer the patient to woman health specialist. We will confirm AVM by doing some imaging before she gets pregnant paceUrMRCP.

👉 *IMPORTANT 566* 👈 *Examination in CKD.* Look for • *Periphery*: Peripheral oedema. Signs of peripheral vascular disease or neuropathy. A vasculitic rash. Gouty tophi. Joint disease. Arteriovenous fistula (thrill, bruit, recently needling?). Signs of immunosuppression: bruising from steroids, skin malignancy. Uraemic flap/encephalopathy if GFR<15. • *Face:* Anaemia, xanthelasma, yellow tinge (uraemia), jaundice (hepatorenal),gum hypertrophy (ciclosporin), Cushingoid (steroids), periorbital oedema (nephrotic syndrome), taut skin/telangiectasia (scleroderma), facial lipodystrophy (glomerulonephritis). *•Neck:* JVP for fluid state, tunnelled line (if removed, look for small scar over in ternal jugular, and a larger scar in 'breast pocket' area), scar from parathyroid ectomy, lymphadenopathy. • *Cardiovascular:* BP, sternotomy, cardiomegaly, stigmata of endocarditis. If right-sided heart failure/tricuspid regurgitation, JVP does not reflect fluid state. • *Respiratory:* Pulmonary oedema or effusion. • *Abdomen:* PD catheter or scars from previous catheter (small scars just below umbilicus and to side of midline), signs of previous transplant (scar, palpable graft), ballotable polycystic kidneys± palpable liver. paceUrMRCP.

👉 *IMPORTANT 565* 👈 *Common symptoms of CKD* Symptoms of fluid overload (SOB, peripheral oedema) anorexia nausea vomiting rest less legs fatigue weakness pruritus bone pain amenorrhoea impotence. paceUrMRCP.

👉 *IMPORTANT 564* 👈 *The most common causes of CKD in the UK are* diabetes (24%), Glomerulonephritis (13%) Increased BP/renovascular disease (11%). paceUrMRCP.

👉 *IMPORTANT 563* 👈 *Certain systemic diseases which may cause CKD* Diabetes amyloidosis sarcoidosis Heart failure TTP Alport syndrome Fabry disease paceUrMRCP.

👉 *IMPORTANT 562* 👈 *Possible complications of Renal Replacement Therapy:* Risks of dialysis catheter insertion and maintenance Procedural hypotension Bleeding due to the requirement for anticoagulation Altered nutrition and drug clearance. paceUrMRCP.

👉 *IMPORTANT 561* 👈 *Possible indications for renal replacement therapy:* Fluid overload unresponsive to medical treatment. Severe/prolonged acidosis. Recurrent/persistent hyperkalaemia despite medical treatment. Uraemia eg pericarditis, encephalopathy (more common in CKD). paceUrMRCP.

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Announcement for Online Session No 118 *19 May 2024 *DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE: Today we will have an online session on Zoom discussing 1 Clinical Consultation Station regarding our preparation for MRCP PACES ( UK ) and MRCPI ( Ireland ) WE WILL NOT RECORD THIS SESSION The Candidate for today,s session has been selected. TIMINGS : Saudia Arabia: 4 00 pm Pakistan : 6 00 pm Bangladesh : 7 00 pm India : 6 30 pm Singapore : 9 00 pm Hong Kong : 9 00 pm Malaysia : 9 00 pm Egypt : 3 00 pm Libya : 3 00 pm Bahrain : 4 00 pm Burma ( Myanmar ) :7 30 pm Sudan : 3 00 pm UAE : 5 00 pm UK : 2 00 pm Ireland ( Dublin ) : 2 00 pm Afghanistan : 5 30 pm Kenya : 4 00 pm Germany ( Berlin ) : 3 00 pm Nigeria : 2 00 pm Japan ( Tokyo ) : 10 00 pm Denmark : 3 00 pm Qatar : 4 00 pm Oman : 5 00 pm Italy : 3 00 pm Indonesia : 8 00 pm Mauritius : 5 00 pm Iraq : 4 00 pm Texas Usa : 8 00 am Kuwait : 4 00 pm Sri Lanka : 6 30 pm Somalia : 4 00 pm Zimbabwe : 3 00 pm China ( Beijing ) : 9 00 pm Australia ( Sydney) : 11 00 pm Burundi : 3 00 pm Rwanda : 3 00 pm Morocco : 1 00 pm French Guiana : 10 00 am ( Please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. GOOD LUCK.

Announcement for Online Session No 118 19 May 2024 DEAR DOCTORS : MAY I HAVE YOUR ATTENTION PLEASE: Tomorrow we will have an online session on Zoom discussing 1 Clinical Consultation Station regarding our preparation for MRCP PACES ( UK ) and MRCPI ( Ireland ) WE WILL NOT RECORD THIS SESSION The Candidate for tomorrow’s session has been selected. TIMINGS : Saudia Arabia: 4 00 pm Pakistan : 6 00 pm Bangladesh : 7 00 pm India : 6 30 pm Singapore : 9 00 pm Hong Kong : 9 00 pm Malaysia : 9 00 pm Egypt : 3 00 pm Libya : 3 00 pm Bahrain : 4 00 pm Burma ( Myanmar ) :7 30 pm Sudan : 3 00 pm UAE : 5 00 pm UK : 2 00 pm Ireland ( Dublin ) : 2 00 pm Afghanistan : 5 30 pm Kenya : 4 00 pm Germany ( Berlin ) : 3 00 pm Nigeria : 2 00 pm Japan ( Tokyo ) : 10 00 pm Denmark : 3 00 pm Qatar : 4 00 pm Oman : 5 00 pm Italy : 3 00 pm Indonesia : 8 00 pm Mauritius : 5 00 pm Iraq : 4 00 pm Texas Usa : 8 00 am Kuwait : 4 00 pm Sri Lanka : 6 30 pm Somalia : 4 00 pm Zimbabwe : 3 00 pm China ( Beijing ) : 9 00 pm Australia ( Sydney) : 11 00 pm Burundi : 3 00 pm Rwanda : 3 00 pm Morocco : 1 00 pm French Guiana : 10 00 am ( Please Google for your local time zones to avoid any inconvenience ) Zoom meeting link will be shared 5 minutes before start time. GOOD LUCK.

👉 *IMPORTANT 560* 👈 *Few important points about treatment of hyperkalemia* Treat K>6.5mmol/L or any with ECG changes 1.10mL of 10% calcium chloride (or 30mL of 10% calcium gluconate) IV via a big vein over 5-10min, repeated if necessary and if ECG changes persist. This is cardioprotective (for 30-60min) but does not treat K level. 2. Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125mL of 20% glucose). Insulin stimulates intracellular uptake of K, lowering serum K by 0.65-10mmol/L over 30-60min. Monitor hourly for hypoglycaemia which may be delayed in renal impairment (up to 6 hours after infusion). 3. Salbutamol also causes an intracellular K shift but high doses are required (10-20mg via nebulizer) and tachycardia can limit use (10mg dose in IHD, avoid in tachyarrhythmias). 4. Definitive treatment requires K' removal. If the underlying pathology cannot be corrected renal replacement may be indicated. paceUrMRCP.

👉 *IMPORTANT 559* 👈 *ECG changes on hyperkalemia* In order: tall 'tented' T waves increased PR interval small or absent P wave widened QRS complex sine wave' pattern asystole. There is considerable inter-individual susceptibility. paceUrMRCP.

👉 *IMPORTANT 558* 👈 *Commonly used criteria for Acidosis* Mild = pH 7.30-7.36 (~bicarbonate >20mmol/L). Moderate pH 7.20-7.29 (~bicarbonate 10-19mmol/L). Severe = pH <7.2 (~bicarbonate <10mmol/L) paceUrMRCP.