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Ok. Go for it. Okie doke guys, I'm Georgia. I'm one of the doctors. Um, I'm gonna pop this presentation on about neurology and I will wait for San to tell me when she can see it. I can see it. Thank you very much and just let me know when you feel like we're adequately fall in the room and go for it. Fabulous. Ok. So we're covering some neurod conditions today. Um, I don't need to go through this, but just so you're aware of what you're getting into. Um, I thought I'd start with some case studies. These aren't intended to be really my cameras and even on you poor people. Hello? Uh, these aren't intended to be really tricky case studies. I'm not trying to catch you out. It's just if you can recognize these, then you can recognize the condition and then we can get into management and initial steps and treatment plans. Um, using the chat is probably your best bet for this. So if we have a look at this case, I've got a 20 week old baby presenting to Ed. Um, you can read the rest but a few things I want to point out that might be helpful for you is this rash that's nonbranching and this bulging Fontanelle. Um If anyone can pop in the chat, what they think their diagnosis is or differentials for their diagnosis uh was starting good that way. Um And one thing I want to point out just while you're popping your, your messages in is this glass test in the top right of the screen. Um Basically, it's a way of telling if a rash is blanching and it's something that you guys should be able to explain to a patient or explain to a parent of a patient, maybe less. So for like CCS stuff and finals, but more just for real life, we've got some very good answers. Absolutely in the chat and some really good differentials. So for this case specifically, sorry, my phone's going a bit dodgy but we're looking at meningitis. Um the key for meningitis is this non brunching rash. Um That's the biggie encephalitis is always gonna be in your differentials with meningitis and vice versa. But meningitis is, is the nonblanching rash is pretty patho neon, especially in exams as well. Uh Thinking about septicemia seems really likely considering how unwell this baby is. Um And again, yes, you can have meningitis and denis at the same time. Um I presume you're aware, but just for a recap for everyone, they're both just inflammation, meningitis, inflammation of the meninges and encephalitis is more inflammation of the brain. Um And just because it didn't quite come up in this case, this is the kind of triad of symptoms you'd expect with meningitis, this headache, fever, neck stiffness. Um Now, the reason I bring it up separately to the case itself is first of all, to point out that, hey, congrats, you guys can recognize it without needing the full triad. But also if you do see this triad, you can always bring up meningitis. That's, that's always gonna be something you need to consider. And even if you only see, you know, half, well, two thirds of the triad, you can bring that up as well. Equally with this altered consciousness just at the top, altered consciousness in this context can present as someone who's drowsy, reduced GTs and also, especially in kids when you've got fever, altered consciousness. Yes, septicemia. That that does mean you're gonna get seizures with it as well. So you could get this kind of presentation alongside a seizure. So initial treatment and investigations, the big thing that I wanna point out here is that it's a neuro emergency. So in this particular circumstance, we're already in hospital so we can start treatment and investigations. But anytime you're not and you're seeing this kind of thing or in a question, your biggest thing is getting someone to hospital and giving the antibiotics straight away. Those can be IV or IM given in the community, but obviously don't delay. So the non branching rash is a sign of meningitis. Men, meningococcal septicemia to so please feel free or I know anyone else to correct me if I'm wrong. But from my understanding, you can get it basically with meningitis, the line between meningitis and men, meningococcal septicemia is quite thin. And in real life when I was speaking to my colleagues about this, um I got the feedback that an Ed Reg had been like, yeah, if you ever see a non branching rash on a baby, they're probably dead before they get to Ed, which I appreciate. Yeah, exactly. If you're gonna have meningitis, you're going to get septicemia with that. Um So this is in real life, you always have to look out for that kind of um nonbranching rash because it's a red flag. And if you ever see a rash, you need to document if it's branching. However, in uh practically in an exam. So they're gonna use that as a thing for men for meningitis because it's such a like paop thing in real life. Things can be a little bit more sketchy, but for exams, non bunching rash, just think meningitis and meningococcal septicemia. Um Another thing here I could consider steroids and that's just because the evidence base is a, is a bit mixed. Um When it comes to steroids, you're mostly looking at avoiding complications of meningitis rather than actually treating the meningitis itself. Although of course, uh we're not, we're reduce the inflammation with the steroids. So the big complication that we can avoid in kids is hearing loss. We'll come on to that in a little bit. Um And the reason that we've also sorry highlighted this history, it'll become clear hopefully in a wee second. So, and that's mostly this. So when we're talking about meningitis, there's quite a few causes. Um, bacterial meningitis is the one we get really, really nervous about. It's much rarer than viral meningitis, viral meningitis, viral meningitis, especially in adults. The advice is much, uh we care a lot less about it. Bacterial. It can be fatal, especially in kids. Um It's a notifiable disease. You need to look at prophylactic antibiotics or vaccination as is appropriate to the cause as well of the, the meningitis. Um And it's about the close contacts for seven days prior to illness onset. That whole thing about um contact your respiratory secretions is mostly about us as healthcare workers. So practically that would be something you'd discuss with occupational health and ward managers, et cetera. Uh viral meningitis as I can as you can see, again, less severe, more often, more self limiting. It's a virus. Yes, but it's still a virus. It's a neurovirus. It can still be fatal and especially when people are quite young, can be fatal. Um Treatment is mainly supportive, have just popped on that caveat because one of the viral causes could be something like HIV can cause meningitis. And obviously you'd still want to treat the HIV. Um I would not personally recommend and please don't listen to me, listen to your medical school. Um, but trying to memorize every single vaccine for exam purposes, but it's definitely, definitely good to have a broad idea of what they're actually vaccinated against. Now, the vaccines here, it isn't some of them, you know, men, men see might effectively it's against viruses that cause meningitis. So things like pneumococcal can also help with that as well. In terms of follow up, it's especially important for kids that they get reviewed 6 to 8 weeks after discharge and you can pop that in your heads because if you're ever doing the p job, that's going to be your job to write on the discharge summary. Um There's late onset complications. I've described a few of the most common ones there. So I and II appreciate that by describing the most common ones. I've basically described everything because visual motor, cognitive impairment, it's kind of everything. So any sensory loss, it's a neurod condition, you're gonna get neuro impacts. Um There are rarer cases where Children can end up with like amputated limbs because of meningitis. Uh But the main ones that I think you probably need to be aware of are things like hearing loss and seizures. They're the, they're the big ones that you'd have to safety net for meningitis. I've talked about kids a lot because that's when we get nervous, especially because kids can't communicate that they have the neck stiffness and the headache quite as well. But especially in adults, uh you may need DV involvement regarding seizures. Um Obviously, if someone's been hospitalized with it, then that makes your life a little easier because you can wait and gather guidance. But if you're not already, I'd have a look on um the UK GOV website, the DVLA, they literally have an A to Z list of conditions, um, with guidance on each one seizure specifically, if they're having ongoing seizures that aren't explained by something, it's usually neurology will kind of give you advice on that a second case presentation. Um As soon as you've read it and you've got an idea of what's going on, feel free to pop it in the chat. Um, but a 17 year old was a bit unwell with fever headache, then started to become quite confused and was acting quite out of character, had an episode of loss of consciousness and mom described it as kind of, his limbs were jerking at the time as well. Now I say your initial investigations, but he is quite confused and quite out of it. So you're not able to get much off him. But looking at him, you can already and just trying to have a conversation, he's not particularly orientated and he's not, he's got some reduced G CS, he's not fully conscious effectively. He's got reduced consciousness. Any ideas about what, what our differentials could be spoilers. I've, I've not gone outside of the scope of what this presentation's about. Yeah. Yeah. Encephalitis viral. Yeah. These are all really good, really good suggestions. So, the answer, the, the reason I've written this presentation is to be in encephalitis. Any ideas about what your kind of next steps, investigations, treatment of encephalitis is gonna be. And this, yeah. Lumbar puncture. Mhm. Two. Absolutely. We're thinking it's, yeah. A for, I was gonna say, yeah, ZT had all really good suggestions if I show you this, um, encephalitis is more often viral than bacterial. Much more often viral than bacterial can still be dangerous even when it's viral. Um I'll go a little bit into the causes but because of that, we can give some acyclovir. Yes, we want the bloods, the neuroimaging. So ct head. Um and yes, lumbar puncture specifically with encephalitis. We thinking cultures and PCR. Now this is probably the point where I need to stop and say that those two presentations were not that dissimilar between the encephalitis and the meningitis. Even with me trying to pick out things that make them quite different. So with encephalitis, you won't have a non bunching rash, but you can have other rashes because people who are unwell, particularly with fevers can get rashes. So, in real life, there might be some overlap, you might wanna give someone some uh acyclovir and also start them on some antibiotics just to be safe while you're waiting for results and certainly no one would, it is very unlikely that anyone would be, uh, frustrated or? Oh, my goodness, sorry, upset with that decision. There we go. It's my laptop closing. I'm not just cursed. Um, the throat swab and stool sample for Intervirus are both important ones to look at as well. Um, and also history for the course, including sexual history. So, just move on and show you. But one of the most common ones uh is basically herpes herpes simplex virus. Um So things like sexual history are more important because we think about viral changes and also exposure to other things to other patients who might have been unwell. Um can be bacterial or fungal fungal especially is very, very rare. Autoimmune causes are a bit more common but caveats, autoimmune is you can have autoimmune encephalitis that was triggered by a diff by a different virus. So something like COVID-19 practically for purposes of doing an exam, recognizing it, knowing that it can be, it's more commonly viral, knowing the steps you've given me things like lumbar puncture and CT head are all really helpful. Um And I've not added a slide going through um lumber puncture readings because I would just be reading a slide to you. But personally, I found the geeky medics summary to be really good and it's something that is worth if you don't already know it uh kind of trying to memorize before exams because it does often come up. Yeah. So we don't do uh uh lumbar punches and signs who have signs of an, of reduced CP. That's true. Um But that's most places if a patient comes into Ed with like reduced GC, you can have them in and out of a CT scanner and you'll be able to have an idea of what's going on. No problem. So we've got another case presentation again. As soon as you think, you know, the answer, feel free to pop it in the chart as well as any differentials as well. A 23 year old female, she's got a left sided, throbbing, throbbing headache with photophobia and just a caveat from clinical practice in uh exams. When someone says they take photophobia, take it as they have photophobia in real life. One good way, especially with kids to investigate it is if you're in like a GP. Um For instance, they've got those big fluorescent lights and that child is looking directly at them, then they're probably not photophobic. Um Yeah. Proceeded by five minutes of a tingling right hand and some weird changes to vision like a Kosco. You'll get that description. A lot of people find it really difficult to explain what's going on in their eyes and to their vision. Now she does report she had a bit of neck stiffness and poor concentration since waking up this morning, but otherwise seems well. And when you do a little bit of a preliminary examination. She's apyrexial BP is normal. She's generally scoring fine on all her ups. She did say she had a similar episode last month and she lay in a dark room for the day and took some of her friend's naproxen and it got better. So again, any idea what could be going on here if you just pop it in the chat? Yeah. Fabulous guys. So migraine, migraine with aura, the aura is really important in women of childbearing age because, um, aura can basically make it so that you, it is contraindicated for you to have the combined oral contraceptive pill. So it's worth having that in your back pocket. Yeah. Treatment. So migraine causing neck stiffness. So there is no reason for a migraine to cause neck stiffness. That's kind of the trick of it. Um, it's not like a, a migraine act like a mechanism of migraine is kind of debated. People think it might be to do with the blood vessels in your brain. Um, the key with this one is that sometimes people will complain of muscle stiffness and neck stiffness and it's nothing to do and headache and it's not meningitis or encephalitis. People get symptoms with it. Yeah. Absolutely. People can get it with the tension. If you speak to people who suffer with migraines, they will give you the strangest symptoms and it is like a nice recognized things that neck stiffness can be among those. Um, but the key going back to that vignette is just that when you take a Rs, they're absolutely normal. So, yes, she, why does she have neck stiffness in this is because I wanted to make that point. So thank you for picking that up. Um, treatment of migraine. I appreciate this is quite a, a block of text to give you. But the gist of it is that you want to start with simple analgesia because if that's controlling it, great, rarely will you find someone who is controlled with that? Um, well, rarely will they come to you with paracetamol and Ibuprofen sorting them out. Uh Your next step is a Triptan. Usually sumatriptan. They have some interesting dose rules because you essentially have one as soon as the migraines starting and by migraine, I mean, the headache, not the aura. Um and you can then have another one if the symptoms return after two hours, but the symptoms have to go in the middle. So there's no point a patient taking it and then it doesn't help and then they just take another one that won't make any difference at all. Um There's also things you can give for nausea that standard nausea, medica, anti nausea medications, it's nothing too complicated. Um The next steps are a nice one as well. So headache, diary avoiding triggers, triggers can involve things like chocolate wine cheese, uh caffeine and sometimes lack of caffeine. Um, migraine is one of those conditions where it's a bit like if you've ever looked into IBS or any sort of bowel disorder where different people have different triggers or like a, a dermatitis. So, it's about figuring out what the triggers are for that patient. The patient ever wants to think about prevention. Uh, propranolol is a good option. Uh, topiramate is another one, but you've got to avoid it in women of childbearing age or make sure they're on a pregnancy, uh, prevention plan. But for the purposes of migraine, you'd go for a few alternatives first, essentially amitriptyline as well. Um, that can amitriptyline and propranolol, both, uh, amitriptyline antidepressant. Um, but also propranolol with physical symptoms of anxiety can have dual purposes in your patients. Um, just because your patients can have, uh, like stresses and such in their life can trigger migraines as well. Um Another thing to be aware of which is a little less examined a little more real life is that people sometimes get migraines when they're unwell specifically. So, taking a really good history of if they've had ever had that pain before and things like that is really important. Uh, medication overuse headache isn't really in the scope of this, but just to throw it in there, um, that essentially a medication overuse headache is quite common and it's really good to interrogate how often a patient is having their medications, something that I think can come up reasonably often and on like multiple choice things as well. Ok. Another case presentation again as soon as you think, you know what's happening, just pop it in the chat. Uh 42 year old, he's got a moderate bilateral headache radiating to the neck. He's a very good historian. Uh Now he walked into the examination room completely normal examination. He did a full neuroexamination with OPS and it was fine, but he's describing it as a band around his head. Now, he's told you he's had headaches for the past six months and he's averaging about five headaches a month, but it is relieved well with a paracetamol and Ibuprofen. Yeah, you guys have proper got it. That band around the head is really kind of like bang on for a tension headache. Um but particularly kind of a bilateral headache radiating to the neck. That's all very, very tensioning. Now, um the classification that I bring to your attention mostly because of the fact that a medication overuse headache, basically a chronic can evolve from a frequent one. But then there's a lot of crossover between a chronic one and a medication overuse headache as well. So just to draw that to your attention, um just because of the, the fact that often it's treated with simple analgesia similar to um a migraine, things like regular amitriptyline can be an option. Usually you'd start with non pharmacological things. So think about triggers life, lifestyle management, tension headaches again, are quite closely related to like life stresses and things like that. So, trying to work out essentially, if there's anything else going on, um, that might require things like CBT. Um anything that might require physiotherapy, it's more of a holistic look at your patient. Um, you can kind of extend to other medications but usually simple analgesia takes care of a tension headache and you do want to be super, super aware of um, medication overuse. And also if there isn't controlling it of looking at alternative diagnoses point is the tension headache, especially completely normal examination as well. Ok. Another case presentation for you, we've got a 13 year old boy, he was brought in by ambulance to Ed with loss of consciousness while he was out with his friends. Um with any loss of consciousness, it's easier to set them as this kind of before during and after personally, during my exams. If I was given like a vignette, I like to, to do that as well. Um And sometimes these are the kind of descriptions that you can get with seizures, which you've all look very nicely identified is this kind of people aren't really sure what's happening. You have to kind of describe to you have to really ask probing questions like were their eyes closed? What, what did their limbs do? Was it all of their limbs? But yeah, I think you're all on it there. So what I'm describing here is a tonic chronic seizure, but in the context of epilepsy. Um The big thing here is that there's this prodrome where he said he felt funny and then came and sat on the floor. So often people with epilepsy will know they're going to have a seizure before they have it and also the biting of the tongue. So biting the side of the tongue specifically is very seizure rather than more of a faint. Um, and particularly in exams because even in, in real life, there might be a bit of overlap in exams. That's something you want to look out for. And also this, this kind of postictal phase while feeling drowsy confused, that can last for quite a while. 20 minutes is a reasonable time. Um And you can understand how somebody could end up being brought in by ambulance, even with a known diagnosis of epilepsy. So just focusing on the next steps here, first seizure clinics are a lifesaver. Um The the idea is that your patient will be seen quickly. Um So within a matter of days rather than weeks, but obviously, it depends where you're referring from. Um hopefully not relevant in this 13 year old, but no driving until the review. Generally, even in the community, if someone identifies, they might have had a tonic chronic seizure and you think they might have epilepsy, you would still say, um even when you do your referral, it's still, you know, no driving till the review, keep a seizure diary. One thing I haven't mentioned here is um getting people to record the seizure is really helpful as well. Um And also if someone is having a seizure record it time, it timing gets particularly important as I hope you're aware, thinking about things like stasis epilepticus. Um And when you want to be thinking about giving treatment, uh but especially for that review. So advising your patient, like we're gonna book you in for your first seizure review with a neurologist. If you've got someone who's seen you have that seizure, bring them with you, uh, antiepileptics, they're long term medications. Um, most of these preventative medications are, you will not be starting these as F one doctors. It's more a neurologist thing to, to kind of do and manage and GPS will like, continue in primary care. Um, now there's a whole host of antiepileptics. The reason I personally picked out these ones is because these are the ones that I all went. Oh, yeah, I prescribed those. Um, and that's because patients come in already on antiepileptic medications and you'll have to continue them. So, being able to recognize them and know that these are, the important ones is important, is good for, you know, your day to day, uh, management of patients, I suppose. Um, but also helpful for exams that you can pick out for a medication list. Um, big one is pre pregnancy prevention plans. Um, essentially if something can affect pregnancy, even if your patient with childbearing, potential swears up and down, they don't care about getting pregnant or they, they don't have a partner. You've still got to think about pregnancy prevention and from like an ethicolegal point of view, it's a whole rigmarole but just being aware that valproate and Tate are two that come up in that as well. Uh This is really blurry, sorry gang. Um But essentially this is just an image I've taken for uh status epileptic as um uh management. I'm not just gonna read through this but, and I don't think there's much of a benefit of me trying to read through this. Um But just to let you guys know that these exist and that it's really good for you to know at least the first couple of lines and how to recognize the status epilepticus. Um And again, the importance of the timing as well. Usually an epileptic seizure is gonna last and self resolve between one and three minutes. So it can be really difficult to elicit that from the history because if that's your friend or your child in front of you having a seizure, then you're not going to think that it was two minutes, you're going to think it took forever. But those kind of questions are important to ask. I know I keep saying childhood epilepsy as often comes on in childhood does have another kind of peak in older age as well. So just something to be aware of that just because someone's never had epilepsy before, doesn't mean this couldn't be their first presentation of it. A, there is a loss of consciousness case presentation for you. About a 27 year old lady, she had a witness loss of consciousness. Uh She felt a bit hot and sweaty before was on the floor for less than 30 seconds. Apparently, her left arm had a bit of a jerk while she was, while she was down. Um, when she woke up, she had a bit of confusion but it resolved within a minute or so. Um, and she didn't notice that she bit the tip of the tongue when you got to ask her a bit more. She said this has happened three times before in the past. Um, and that kind of history about three times in the whole life is, is pretty common. It can be good to be like, are you sure this never happened before? Not even when you were a kid? Um, but yeah, I got some good suggestions. Vasovagal syncope is exactly what we're going for here. Um, just because I there's a lot of investigations that you can do for vasovagal syncope and I think that rarely will people get all of them mostly because most, well, a lot of people won't even go to the doctor about it just because they're up and about after and it's quite well known. But anyone wanna put any suggestions in the chart of things you might want to check. So, any routine things, anything weird and wonderful. Any investigations you'd like to do? Yeah. ECG. Absolutely lying. Standing BP and just a regular BP are both good tilt test. Potentially. It's not even what I've really brought up just from going through nice guidance. But it is, I guess a potential cause of the symptoms that you could elicit, um, line standing BP especially can be helpful, uh, particularly in older patients. We always love to do a line standing BP and always know that if you can't do a line standing, so if they can't lie down, you can always do a sitting to standing as well. Yeah, for dehydration or precipitating infection is a big one. Um And again, this very much depends where this person presents if they present at GP saying, hey, I've had a few of these uh fainting episodes and I'm just wondering if there's anything wrong with me, then maybe, you know, your options and stuff aren't going to be as particularly helpful, but they will be good for you to ask about things like what had you drunk before? Had you eaten before? Had you eaten before being a really big hint for something else. You should check if someone walks through Ed having just fainted. Um and yeah, precipitation infection is a, is a big one as well. Yeah, sugars. So um she's a little bit old for it but you know, this could be a first presentation of like a diabetes or something. Um, but also it could be someone who hasn't really eaten properly. It's relatively common to have that. Um, and the other thing I just wanted to point out in here is you've got the bit the tip of the tongue because it's the physical force when they fall rather than the bite in the side from the kind of tonic chronic episode. And the fact that they have more, they're not down enough and clench in their jaw. Um And also with the face of eagle, you don't tend to get incontinence, not impossible because people just can be incontinent, but it's much, much more pointing towards the kind of an epileptic seizure. So some of the investigations I've talked about, you guys have already brought up um neuroexamination, I hope goes without saying even if that patient presents and they had a, a Visa Eagle, you know, weeks ago, you'd probably still want to be like you haven't even awful limbs immobilizing independently. So you'd still ask those questions. ECG is one that it's kind of indefensible not to do even in primary care. Um You could still arrange to have an ECG, it's just how urgent it is. Um, bloods could be something you could consider thinking about. So when I say deficiencies, I don't just mean anything. I mean, specifically like vitamins, uh anemia is another big one that could cause a vasovagal and three BP is mostly if it's relevant. Same with an echo, especially if someone has a history of any heart problems and contacting the D VLA um is a bit of a tricky one. If you've checked the guidance, it depends on if they're likely to have an unprovoked syncope. But at that point, you're thinking less a vasovagal syncope, a more underlying condition. Most people who just have a vasovagal are fine to, to drive, but you would be well within your remit to advise someone to discuss it with ad va or for you to discuss it with one of your seniors. Ok? I didn't have a case for this one because I think it's a really hard one to do a case about. Um it is essential tremor. It's a bit of a finicky one because it can coexist with Parkinson's and if a patient comes in to see me with a tremor, my first thought is, do you have Parkinson's? Um big things about it, bilateral symmetrical. Often I've said upper limbs, upper limbs, but also kind of head, neck. Even the voice can have a tremor but more upper body rather than lower though it can exist in the, the lower as well. When you examine neurologically for tone, there shouldn't be any rigidity, shouldn't be any cerebellar signs and cerebellar signs. If you, you should know how to examine for them. But if you've forgotten, it's all the weird bits of the examination. Like when you start getting people to do all this and heel toe walks and your patients start looking at you like you're trying to make fun of them. Um, family history is a big one because it can be something that runs in the family. Um, and the fact that it's relieved by rest alcohol and be blockers is a little bit unique as well. And so patients might pick up on as well, like, oh, or when I'm at the pub and I'm drinking, I don't really notice it. Um Equally the things that it's worsened by. So essential tremor is one that's important to recognize it's usually quite a fine tremor. Um investigate. Oh my goodness. I'm sorry, investigating possible causes here. Um We want to get a full set of ups including temperature, uh particularly because obviously if you've got a tremor, you're thinking, are they hypothermic? One would hope you'd recognize that especially in T FT S are a biggie because it can be a symptom of thyroid dysfunction. I does, isn't it the big one? Did we do this? Um And then also uh sorry and also about stresses because it can be a physical symptom of anxiety. Um A medical management is quite similar to just physical symptoms of anxiety. So we're thinking about stuff like propranolol. Um Same as we'd be thinking for everything. Propranolol is a bit of a miracle drug when it comes to newer conditions. That kind of, aren't that serious Um And yes, you would be thinking about doing a neuro referral and the signs and symptoms would basically, and the results of your investigations would basically help, you know, how urgent it is. Ok? And that is my last slide. So I hope you will either learn something or being reminded of something that you need to go and revise or hopefully just been reassured that, you know, absolutely everything and have nothing to learn. Um If anyone's got any more questions, feel free to pop them in the chat and I will try and answer them to the best of my ability or make s do it. Oh, migraines and neck stiffness. Uh The short answer is there isn't really a cause for it. Um It's a really common phenomena that people can have neck stiffness with migraine. Not everyone will. The reason I threw that in there is just to tell you that not every neck stiffness is going to be a meningitis or encephalitis either. So when it comes to a migraine, if they do say they've got neck stiffness, then yeah, definitely be thinking of that triad of meningitis symptoms. But the big thing is checking for fever thinking about, do they have altered consciousness? Do they have any sort of rash? Is that rash? No blanching? Um So that's kind of why I've thrown it in there. Um But yeah, neck stiffness can occur with migraine. It's, it's a recognized phenomena. So I don't automatically think that every single neck stiffness with a headache is going to be something really severe. Obviously, treat it as severe until you've got enough history to say it isn't anything else anything anyone missed. No, no problem. Thank you, Albert. Fabulous. Thanks so much guys. It's great. II feel like I was reminded of things to be fair. Uh So was I Yeah. Oh God. God forbid we get be, oh, do you remember? There was like, is there like, there's like a guideline of like what you're supposed to do? You're supposed to give like Ben Pen at the GP or something like that, aren't you for like the emergency staff? Oh, my girl, Ben Pen. And you must give it Im or IV. And then you send them to hospital, however it shouldn't delay going to hospital. So call the ambulance first and if you have it then great and if you don't then everything else. Oh, yeah, go ahead. I phone and ask that. Ok. Um, you know, like normally.