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um, All right. Sorry, guys. I'm just bumped. Thought hi, everyone. Thank you so much for attending. This is, um, the FT series by a fit medical. Serious times caught it. Plus the med, it's We're gonna be hosting a few different stations. Um, to take you guys through. Hostile about common conditions come up today. So from a common, it's common in a space. That's what we're going to go through and have to manage those conditions. We've got someone from Muslim Cardinal somatic today doing the talks. Thank you so much for them. From coming on to victory of them are follow and give us a follow to keep up to date with everything on. We've previously been running some sessions. Um, a normal revision. SYRIZA's. Well, as you might have attended on, just answer a few questions before we start. You got any talk related questions? I eat like something about the content. Um, knowledge questions actually put them in the human, a section on anything else, but, um, in the tract section on, Yes, the slides on the recording. So we made available on to our metal page. You know, if we used to get access to that. Me truthful in the feet but form that will be posted right the end. So whatever you already asked me Enough. Um, feel free to sneak in a way. Thank you, dear. I just can't seem to turn on my video. I give me one second. Sorry. Sometimes it's, uh yeah, that should work. Everybody see me. Such Is that like a pop back? Thank you so much dot Hi, everybody. My name's just mean. I'm one of the finally a medical students that card if you diversity. Um So like I said, this is the first session that were running. You know, common things are common is key Siris. And so what we've tried to do for the Siris is we've had a look, um, that's common stations that have come up at Cardiff University over the past five and six years, and that's what we've based on these lives on. That's what we base the presentation on. I think there's a really big fear around skis and what can come up on, but it's often try to kind of then everything I must. Of course, it's important to have a awareness of everything on all the different differential diagnosis it is. I hope you guys can find some reassurance and knowing that as long as you guys know the most common and the most serious presentations on conditions, you will you will be fine and you manage those safely. You'll be absolutely fine. And there's nothing to worry about. Okay, so that stopped. Okay, so today we've got seven cases to work through. I just thought we'd start by just briefly recapping some basics that we need to kind of fall back on on during our history and just what to do to stay safe in the station s o. In terms of the examination, I haven't covered that because it just depends on you guys practicing with your friends. So practicing the upper and lower in urological exam and the cranial nerve exam on for quite a few diversity, they've never to my knowledge asked any other neurological exam, for example, a Parkinson's disease focused examination. You you only kind of tend to get either upper know or cranial nerve exam. So in terms of the examination, just do lots of practice. However, with regards to the history, you do need to know certain things I need to specifically ask about in history just to show the Examiner that you are considering seriously differentials for presenting complaint. Even if it's very obviously something not sinister, you still need to show the examine examiner that you've considered the other serious differentials. And so just to start off with for the General Neurological review on Always Ask About Troller always ask about a seizure of fooled dizziness, loss of consciousness on new neurological deficits. So that's weakness. A lot of sensation in terms of back pain. You want to show the Examiner that you're considering quarter quietest and drones, so you need to ask about incontinence, both fecal and urinary. Saddle anesthesia, urological deficits. And then you want to show the Examiner that you're also thinking about cancer and malignancy to ask about weight loss, fevers, night sweats, a person history of cancer on again, any trauma. So four headaches. You want to show the examine your thinking off meningitis always, no matter what age, so you want to ask about fever, stiffness, photophobia and a rash on? Do you also want to do the exam that you've considered a sub arachnoid hemorrhage? Even if the kind of headache is more kind of. It perhaps sounds a bit more chronic, just asking about, you know, sudden onset pain towards the back of the head gets you those extra marks and shows the exam that you have considered a suburb back again, asking about new neurological deficit because it's a massive red flag for headaches. We also want to show the Examiner that we've considered temporal arteritis. So ask about any changes to the vision any joint called claudications and any stop tenderness. Um, also, you need to show that we've considered girl coma. So any visual problems and red eyes and halos on finally just to kind of gauge the, um, severity of the headache. And if the headache disturbs somebody, sleep, it also becomes a don't ever had flags. So asking specifically if the headache wakes them up from sleep is important. And again, we want to ask about to trauma and with headaches again, just for extra marks. If it's a female patient who could be pregnant, you want up who could be pregnant and so may have a clamp. CRP camps. Yeah, you want to ask if she's pregnant essentially on that just shows the Examiner that you're considering pre cum C, which is a bonus marks on, then finally raised ICP symptoms. So I just have a new box of them. So that's headaches are worse in the morning. Had aches that get worse or better, depending on the position. So a red if I would be headaches that are worse on nine flats or were some straining, such as coughing? Any vomiting? Because that's a sign of raised ICP reduced GCS and again any neurological deficit. And finally, for a seizure or a seizure or his off all history off a full. You want to ask a civic me about the cardio respiratory system? And that just shows the Examiner that your thinking beyond two year old new like neurological causes So you're considering, for example, on atrial fibrilation or any other everything is that could have led to that fall. So it does. It's not specifically, um, neurological. Okay, And then I just thought again, just quickly covered differentials. I can see stuff in the chat. I think somebody will be What? Okay, what is? I think we'll Yeah, I was gonna say if you focus on the track and then we can like asking questions, right? The little we're not interrupting your flow normally. Okay? Yeah. So you don't just send hushes along, and then hopefully the under feet will hope you'll have some time. And I work through the question. Rest of my business. Okay, so So this is just your starter pack differentials. So I really like the new, you know, new monitor, Vitamin C D. You guys might have your own room on it, but just in the actual exam before entering the station, Essentially, you're going to see this kind of three lines. Kind of don't really put much information on there at all. I don't, for example, might say just like a headache on what you want to do before entering that station is actually already have the differentials in your head. Because once you have kind of three or four different schools in your head, when you enter the station, your history use you show the Examiner that you've considered those differentials by addressing every single one in your history. So this is just a nice way to think off at least four differentials for any station. So you have something to say. Even if you are a bit thrown off. So for vascular, we've got hemorrhage or infection for infection. There's meningitis in Catholic Tous, Lyme disease, HIV, syphilis, trauma and toxins. And you've always got alcohol and drugs or two. Um, you've got diabetes, multiple sclerosis, um, hyper hyperthyroidism, sarcoidosis and every vasculitis. So most neurological condition presentations can be caused by vasculitis. So that's a good one to just have a backup if you struggle in terms of metabolic on deaf in a puppy or any inherited conditions and the ultra cardiogenic so things that we caused to the patients as doctors, um, steroid, myopathy, radiotherapy and any drugs that we give the patients terms of new plastic and nutritional. You've got Bittermann B 12 deficiency and timing depression deficiency. These two things alone can cause sub acute degeneration of the spinal cord so they can lead to a whole host off kind of odd neurological presentations. So, again, just a good one to have it the back of your head if you struggle on congenital. We have Wilson's syndrome on degenerative. There's a massive list, but at the top of them really don't mean one to notice Parkinson's, but and also much and urine disease. Okay. And finally, this is the investigation started. Pack So another great pneumonic to have in your head and just really in there is a B boxes. So fasting is the bedside, then second beast for bloods. Those for orifice is that's mouth, anise, anything. Any orifice is in the body. X is for X rays and images is the C G on S s for special tests. If you stick to this structure and you just it's it's a great way to make sure nothing. You don't forget anything when you're in the exam under pressure. And so, in terms of bedside, I always say I'd start with a full neurological exam, including cranial nerves. You can also say vital signs at the bedside again that's relevant to almost everything. Um, urine dip relevant to quite a few things just rule out infection on blood glucose that clear cruises actually relevant. Almost everything you do it almost every patient that presents to the hospital, the emergency department. So that's a great one to just always say as well. In terms of blood, I've kind of listed all of thumb here. You'd have to be selective on which one do you say in the exam? Depending on the presenting complaint? Pretty much standard. We've got your baseline bloods that show your full blood count screen for any infection using these. And look for any kind of electrochemical disturbances. Entities your CRP again for infection. Your calcium, which is both linked to malignancy and sarcoidosis. B 12 and folate, which can both affect the spinal cord. Third function Test Thyroid function tests Because on your thyroid, can that have a significant impact on your neurologic, your neurological health and then HIV in line disease can present very and they can. They can present with very kind of, um, um specified kind of odd symptoms. And so it's nice to just have it the back of your head, but it could. It could be an infection, infectious disease, and then you've got your water and e antibody screen. So if you're suspecting vasculitis such a SLE, you could then request auto antibodies on do anything that may then have a surgical input. You want to be requesting coag group and saving cross much, and in terms of office is your main two options are PR exam for neurology that mostly just comes in with suspected quarter in quietness syndrome and to check the angle turn on. And then you could do swabs. If you're suspecting, for example, meningitis or something, you could perhaps do a throat swab. Um, and then in terms of imaging, there's a whole of imaging that we can do in urology. Chest X ray tends to be pretty, um, pretty standard, kind of for any acute presentation. But then you've got your titi an MRI. Um, depending on the presentation again and then for the c G. It's main function is kind of just routine on to check for any arrhythmias and then special tests. We've got London culture on DMG visual input on visual evoked potentials. Okay, I think this is the final station. This This is the final started back part now, So I keep saying, find one of each step, but I just wanted to say always stick to conservative Medical surgical. You guys have heard it lots, but we can't emphasize enough. It really gives you structure and kind of university in particular. Like if you just skip to like medical, um, or surgical without mentioning the steps before hand. Um, you could get yourself into quite a pickle because it shows it doesn't show kind of a holistic, unstructured approach to managing the patient on, because we are the main purpose of the excuse to check that we are competent foundation doctors and the majority off our input will be at the conservative on medical stage or even early medical stage. So if you skip conservative because you think it's irrelevant, it's actually the easiest part on that. That could actually be kind of a red flag for you. Um, so just a nice thing to have again in your head to say, under Conservative, for everything, say patient education kind of love it because it shows that we're carrying practitioners, of course, on it. So it is an important step. The patient used to know what's happening and then the multi disciplinary team approach. Of course, again, it sounds really basic, but it's critical to the management of every patient and then a thing that I discovered just before my excuse that they love is just under medical, say, for medication review, you just can't go wrong with checking patient's medication that they're compliant with it. That they know how to take it on also kind of screening for any contraindications and any perhaps any way that you could basically better improve the medications that the patient is on. So just say those two things under, um, conservative on medical. Okay, these are just This's just something that's just a quick slide on how to avoid red flags. And one of the biggest things in urology is informing the D. V L. A. So almost every condition, whether it's stroke a T. I a multiple sclerosis is even diabetic neuropathy. You need to inform the patient that they need to inform the D. V L. A. On. But if you don't say that in your in your in your neuro station, you are likely to get a red flag because if you're the patient or the person that the patient has had contact with, if you don't tell the patient they need to contact the DNA and that they can't drive and that patient goes on to have an accident. That's kind of life threating for the patient and others around them. So it really is our responsibility as junior doctors to be telling that to the patient. So just don't forget the D v l A and everything. I would mention it under the conservative section. So kind of where you're doing a patient education, about the condition. Um, the second thing is, Oh, this is what I would do is I would always say when something was a medical surgical emergency on. That's just a great way to show the Examiner that you know that this is serious on Do that on what goes hand and hand is that with this is that you would be less in your senior know what you're managing Eso I would just say, you know, some arachnoid is a is both the medical and surgical emergency. So I would initiate my 80 approach and let my seniors know off my management on ask for any further input from them. So that's just a really great way to cover yourself. Because if you do that in practice, even for example, if you forget a step in the management, you've identified that it's an emergency. You've done you 18 approach and you've asked you a senior to review what your own management plan and for any further input. So you're basically being very, very safe on again. That's a great way, of course, to avoid red flags. Okay, so now we have our first case. We do have one interactive case Where will want a volunteer to? We want someone to learn to, To do the case of front of everybody. And it's just a great way to kind of went through it together. And others watching can benefits as well. But for this one, we're gonna be doing it together. So we do need to use the chat function for this because it's on webinar. So just open the chest. I can see. Is there a shot option? I be I'm not sure why It's not letting me open the chap. Ow! Sorry. Okay, So if we have a read of this together and then I'll be asking you guys, basically, um it's like someone's already beat me to it. Bring it to you already putting in their differentials. So we've got Sarah, 33 old women who presents to the emergency department with left leg heaviness and parasthesia. So pretend outside the station, Tommy. Kind of the full things that are going to be. We want to kind of think are four top differentials four or five top differentials before we enter the sensation that we've already got in our heads. And we're gonna address in our history on a great way to do this. There's loads of stuff coming through, which is fantastic. I have a look at that, a great way just to do it yourself. Well, in the exam is put like your top one or top two and then your others, because you need to have kind of a top one in mind, even if it's not the most likely, perhaps the top one that you need to exclude before then going to perhaps less sinister differential. So for this one, there's great stuff coming through on it all looks pretty much very correct on. But for this one, what other kind of the What's that? Top two things we want to exclude for this patient. Talk to differentials. If we just had to narrow it down to two, I'm seeing a lot of stroke stroke his brilliant, definitely stroke guys. What? Some CS when someone expand that somebody for me that oh quarter client syndrome. Brilliant. Thank you. Okay, so quarter point is brilliant. actually, you guys, that's a great one that can one more on what's perhaps said out. We've excluded up to you. We want to ask you about too seriously. That's called a quieter and stroke. What perhaps do you think is actually most likely for this? Present it to the station to be given the patient's age? Yes, brilliant M s. So we're going to go into the station and we want to exclude stroke Exclude. Quarter a quieter on at the back of our head. We think that it's actually most likely Ennis, that's up. Okay, so, um, these are just a few I've got There's actually honestly, cause there's no wrong, all right, because it's not as you and this may be in this one. The main thing is to exclude stroke on. Actually, guys right about executing quoted quieter because I didn't I've kind of based on the legs, so that does need to be excluded. A zombies. You have another two or three viable differentials. It's all correct. So the one I had was in the top part of my head for this lady because of the age and because and medical schools love to kind of have everything kind of much up so young, female, with some with presenting with some new logical deficit. It was most active, the m s. But we're going to exclude stroke. I also put that I'd want to exclude a space occupying lesion and then other differentials of mine would be B 12 deficiency myelopathy. So anything, um, impinges on an actual spinal court and then get Gambari's syndrome because it's because obviously, it's in her leg. And that's an A sending disorder would have that the majority of fuel differentials old. Very correct. And that will very bad. Okay, well, I'm gonna go back. Hey, can you guys have hit up the chat? Now? How do you want to investigate this patient? CT MRI. Okay. See, history, brilliance. Whoever said his street outside, so just taking an order. We want to take a full history and full exam. So that's our bedside and her vitals. That's our bedside. And then, in terms of bloods, what blood? So you want to be taking from her? Yep. A full neurological examination. Yep. So your baseline bloods for blood count using his LFTs, thyroid's anything else? B 12 and folate. Definitely she just mentioned B 12 and folate and thyroid in all in all, neurological in mostly multiple stations. Bone profile is bringing it because that will give you calcium. And again that you can use that to rule out legacy sarcoidosis. Okay. And what's, um, what imaging would be want to do for this lady MRI? Radiant. Yeah, yeah. Yep. And whoever said CT had you're correct because he still actually haven't taken a history. But say we take your stream. We realize that how onset of symptoms wasn't sudden it presented over a couple of hours or a couple of days. Actually, in that case, we drool out. See? See, We draw out a strict and we do an MRI off the, um, brain and spine. Okay. Okay. So, like we said so for neurological exam, including cranial nerves, just do glucose at that site. You can always do glucose. It's always great to just exclude diabetes. You never know. It could be a proof from uropathy on bloods. We mentioned the majority depending on how scared you off the time it's you. Can you have really go wrong by saying HIV like lyme disease and syphilis screen? Because they can present with some weird and wonderful on neurological symptoms and offices doesn't really apply to this in terms of our X ray. MRI is thief first line for M s on down, and most patients in the queue scenario would get a chest X ray just as routine. So you won't go wrong by saying you can't go by saying your routine chest X ray on. Then again, the CD is pretty much routine. So just a stick to our be boxes. You can just a routine X ray routine routine. ECD on finally the special tests for this. I should have asked you guys first, but the special test full and um s would be to do a number puncture and CSF analysis on we would be looking at oligoclonal bands. They're not present in the serum on increased GI, and then another special track test just for extra marks is visual evoked potentials. They're not really done in clinical practice anyway, but the exact at the a bit still say it's a You can mention that in the exam. Okay, so our MRI comes back, please. Can you guys interpret that for me? Guys, Anyone? Anyone went to kick Stop. Radiant. Okay, well, and periventricular White matter. Lesions divine. A shin. That's correct. Paraventricular clacks hype. Intentionally using's yet itchy, all correct ways of saying the same thing. Meghan Hearts that brilliant. Yes. Oh, check patient's name, date of birth and scan first. I should have put that on. Never. That's fantastic. Well done. Some erected hemorrhage. No, not quite. Because you'd expect, um, kind of the ventricles. And you'd expect kind of the star the star sign where kind of all the areas where the blood was to be felt to be hyper intense. Because of that, the bleeding within, within the brain. Okay, so first, we're going to check for the correct patient details, date and time on. Then a way to describe this would be this is a T one weighted Exhale MRI scan of the head showing periventricular lesions indicative off multiple multiple sclerosis is that's just a great way to summarize. And it's also great to just have the structure where you just say what you're looking out because I advise you sometime. It doesn't take too long. They're just saying kind of the plane off the the piece of the image, all the radio kind of. But what what's, um, I've lost the word. But just for example, if it's a a chest X ray for the hand, you say hs sorry if it's an X ray behind you, say this is an X ray of the heart because an MRI scan of the brain just say what it is. If you say the waiting, that's again kind of bonus points to show that you know the difference. Do you know what the difference between T one and 22 is? Periventricular by paraventricular mean? But it surrounds the ventricles. Can you? If you guys can see my mouse, there's two kind of opposite C's are the ventricles on? Then you have these hyper intense lesions surrounding the ventricles on both sides. That's why we call it Periventricular on Brilliant. Yes, so T two waiting. So if you remember World War two and water is whites in t two, um, so water like blood. So if you think about it, all of this black is kind of is the blood. When it's teach, you waited. All of this appears is whites. When it's t one weighted all the pieces back So this is a T one. Waited on the plane of the MRI is and exits and eggs your pain. Oh, yes. Please. Please do use the question. A question on some function Just because the questions that we answer later on, we'll get lost in the chap. Okay, so how would we manage this patients? And if we stop by using stop by writing the conceptive months. And so we take our conservative medical and surgical approach always rather than skipping any stages. Yeah. Conservative. Educate her about her condition. Multidisciplinary team approach specialist, Nurse Physio. Creation of therapy. The whole bunch. Brilliant. So what's our medical approach if she has just presented acutely? Yeah. We thought pregnancy brilliant. Yep. And you can, depending on how severe it is you can give the patient. Plasmapheresis is, though definitely on dust a thing again to say in this keys. Is that again senior input? We would never be initiating plasmapheresis. Ask junior doctors So say you know, the mainstay of months management for you know, an acute relapse off multiple sclerosis would be methylprednisolone. Um, however, um, we could consider plasmapheresis under specialist input on. Do you understand? Simple. Okay, And then what's the long term medical management of multiple sclerosis interfere and be okay? Not at least not using that. The up depends on symptoms here. So start with symptoms. Because before we go into, like are disease modifying therapy and biological therapy, the mainstay of treatment is symptomatic control. So, um, do you guys know if you have the symptoms yet? Baclofen. So what's baclofen for spasticity? Yep. Amantadine, your continence. Okay, So let me open up for me. And so he said, we're gonna refer to urology specialist entity approach. We didn't say in from the day today, so we all just got potentially a red flag, a small red flag there and just say informed the d l a, um, under conservative always. Because if she's currently if she looks, she is currently a whole leg is kind of. And she has had the violation. It's affecting her leg, and it feels heavy week. How is she going to be driving? It's our responsibility to tell her that she shouldn't be driving okay on Ben. Don't forget, like psychosocial is Well, it's a great thing You could say that almost every condition as well. So support groups exercise smoking cessation and then in terms off the medical treatment. It is mostly symptomatic so, he said, spasticity. We give back within a neuropathic pain. It's amitriptyline or gabapentin. There is kind of like a neuropathic pain bladder as well, which is worthwhile. Checking out for depression is SSRI eyes on, then for urge incontinence, and you can give oxybutynin or if that depending you to kind of do and urodynamics studies on back. Then it takes what kind of management how we manage her. Your incontinence need that by oxybutynin or by self catheterization on Now for fatigue. The Humane medical management is amantadine. So you said we're going to give me thought pride because it's an acute relapse on on then depending disease modifying drugs. We we start according to certain guidelines, and that depends on the amount of relapses she has within two years. You for card. If I don't need to know any more information than that, you would be surprised how much of the excuse. It's very much kind of just kind of the 1st and 2nd line. You really don't need to go into too much detail much by the detail into kind of the guidelines, because again, they just want to show that you're safe on then the guidelines for exactly when we start kind of disease modifying drugs and biologic for therapy. Always there for us to the cup later on down the line. Okay, so this is our second case. Um, for this case, I'm wondering I'm worried about time that 6. 30 and we should be done by eight. And so for this case, we wanted to volunteer. So we should be done by 7. 30 guys in one hour. So the whole thing will be under an hour and a half for this case. We wanted to volunteer to practice taking a history of stroke history so we can either. Don't know what We can leave the case to the end, depending on how much time you have. Yeah. Okay, guys, we have a volunteer for who would like to practice taking a history from a patient presenting with right sided weakness. Okay, Um, is love admitted. Can we make I think someone just messaged, but in tearing. Yeah, I can see um, for him. He's just volunteered One movement. Yeah. If you want to do maybe that he could do the next case afterwards until we can figure out how to make him a host. Just second, um, let me skip the station. Because this is the one I wrote out in the fall. Went to another kind of a student. Direct. You just stop sharing fast with this and we'll come back to it. Okay. Okay. So, case three, we've got fat in that 42 year old who presents to the emergency department with the worst headache ever. So we stood outside our station. Can we think off kind of for differentials that we're going to address in the station. Pay several. Remember to get that stuff in your top one. Trigeminal neuralgia. That could be one. Meningitis? Definitely. Yes. Migraine definitely cost a headache. Aneurysm. Brilliant. Space occupying lesion. Brilliant. An acute angle closure. Glaucoma. Fantastic. Okay, so again. So we said, remember the side of the beginning? The starter pack kind of pick things too. Not forgetting history. So, for a headache, we need to show the Examiner that we're considering a suburb haploid a space occupying lesion, meningitis and temporal arteritis on. Then we've got our less sense sinister differentials. That are still very common, so we should kind of mention them at the end. Well, kind of at the beginning. Even when we presenting the case back to the Examiner, we can say that we think X y that is unlikely because we've addressed it on. Perhaps the most likely difference is actually a migraine. And so I always have my green in the back of my head, Not back at the front of our heads. Cluster headache, trauma, me to ask about trauma. And then another kind of friendly differential would have would be sinusitis. Okay, so if you didn't get to see too much of that So how do you want to investigate the PE? A patient who has come in with the worst headache ever? It was sudden onset on. She just feels awful. She still feels awful at the movements CC head. Yeah, history. Fantastic. Okay, so at the bedside have done a history at an exam. Any bloods in particular for her? Just so you can stick to our be boxes. Es are brilliant. Yeah, So that so. That excuse that addresses which differential that we need to show a considering. So that addresses the temple. Arthritis? Fantastic. Yeah. Brilliant. And then just our typical kind of baseline. So fpc's LFTs these knees crp sa. Okay, blood culture. You know what? You honestly could have her vital signs. I haven't given you much information, but if this patient vital signs were showing that she has a fever on and then we definitely take blood cultures fantastic. Okay. And then in terms of offices, I can't think of anything for offices unless we Perhaps we're suspecting meningitis or something. And we we could take, like, a throat swab, perhaps. And then in terms of imaging, people already said it. So the first time would be a CT scan on in terms of special tests. What special tests can we do for this patient? Lumber country. Fantastic on what we're looking for in a lump. Puncture something criminal. Oh, okay. Well, sorry. So we forgot to mention on a group and save and cross match for bloods. Why? Because some erection is a surgical emergency. Remember? I said to see if something is a surgical emergency is well, we want to be doing Alcoa Group and save and cross much on just a great thing to know about blood is that you can't really go wrong. If you say something as long as you can justify why you onda why you have requested it? It's absolutely fine. For example, if you press it cast on the on the exam, it's like, Why did you press calcium? You say, you know, perhaps it it could be sarcoidosis or or this that would that would be fine and even. But just tell them that you know it's not a common, Not likely, but you're just testing for anyway. So why would we get ST Elevation? And sometimes you just gotta see elevations with a subarachnoid. My knowledge that's I had in my notes, uh, peyronie's that can that can be seen with this other appetite's hemorrhage. Okay, um, and then in terms are special tests. We've said number puncture. That always has to be 12 hours post headache because the Santa Crimea won't appear on the lump number puncture until 12 hours afterwards, and then the kind of actual the actual gold standard for a separate thyroid is his investigation because digital subtraction, catheter angiography. Um, I didn't have to say that in my exams, actually, so I just stuck with the CT scan, but it is on the guidelines, and it's gold standard you taking. I want to show you the next side. You guys, just cause it said the answer, it's I just want to move the answer so you guys can have a good at interpreting it yourselves. Okay, so your CT scan comes back. He's Can you guys interpret this patient? Do you tell us yet? Separate from hemorrhage. Yes, but how would you say it? Blood in the ventricles? Yep. I'm blood in a way. So systems fantastic and hypertension of the circle of Willis. And it's a new takes your plane. Fantastic. So I know someone's asking about the feedback form. Um, I'm not sure if one of the others could send it to you, and, well, maybe they can put it on nine. Opted. So he opted IV. Good for it. Blood in ventricles and all basal assistance. Fantastic. So this is the star saying that I mentioned earlier, So if you see kind of that hyper intense and start sign, it's kind of your whole mark subarachnoid hemorrhage. So this is a non contrast XL CT scan of the head showing hypodensity well in all basal systems. The bilateral Sylvian fissure is on into hemispheric. Fisher, this is consistent with a subdirectory 10 rich. Okay, okay. And your love, a puncture comes back. So, um, with a subarachnoid hemorrhage, the opening pressure can either be normal or increased. So for our patient, it's increased. Which points towards a subarachnoid. Yeah, supports our working diagnosis of a suburb back. The appearance is yellow. So normally CSF fluid is clear. It shouldn't be. And again back supports our working diagnosis of a suburb. Back bread, Blood cells of present. That shouldn't be any in the CSF on there in south a cream. Yeah, So we could be very sure that this patient has had a separate currently hemorrhage. So how we manage this patient? Yeah. So if that's a B c d. Fantastic. Okay, So this is a medical and surgical emergency. So you had taken a t e approach and then add in your surgical referral. Fantastic. Stop. Invest any onto coagulation. That's great medication of you. Fantastic control. BP, address that. Okay, I'll geez. Yeah, that's great. Actually, didn't write that down, but definitely allergies here on the model peen. Brilliant. to present prevent basis, $1000. So So you would say this is a medical I'm such for emergency. So I would take an 80 approach and for my seniors and ask for their review and input and also ask for on also actually refer to this patient in your surgery. So if I have the first thing you say on that's you're being safe, it's not you being like I'm gonna give This is if you, for example, jump straight to normal Dippin. It shows that there's no kind of structure and thinking If that patient were to walk through the doors and Annie and you're the doctor there and your first the first thing you want to start in, what a pain that would be dangerous. So that's why they take it very seriously Exam. If you kind of miss that first step off saying 80 Approach senior. Urgent referral. Okay, on day. Once we've done that, we can then start our conservative medical surgical. So bed rest of the pressure control which you guys said I've missed a final jeezy. Um, it definitely analgesia so supportive care. See regular monitoring of five vital signs on you can't think off the tee Eastern before phylaxis. That's not giving the medications on. Well, it's, for example, it could just include Ted stockings. Um, so nothing that's gonna thing there, but further. But can we can help them a slow us there in hospital and then, in terms of the medical management, we'd want to be starting this patient on nimodipine again. This is all under senior review on We continue that for 21 days after their after the Supper, because that's when their most likely to develop faces basal spasm. And then finally, um, we, we can consider wouldn't consider this. The surgical management would be coiling, and that's done by the interventional radiologists or a craniotomy clipping, which is done by the neurosurgeons on. Then you can also say, for bonus part marks. If the patient developed side capitalists on you, you can consider the team to consider in setting an external ventricular dream and then a really great thing. To add on to conservative medical surgical for acute presentations is kind of the long term management, because I think most students won't think of that. They'll just think of like the station is here in hospital this is hanging a manage it. But if you don't go on to mention long term that then you know you take a step back, you will then find expensive patient. What's happened? Give them lifestyle advice. You're gonna address any comorbidity. So we know that having high BP is a massive risk factor for supper actually hemorrhaged. They were just going to say that you're gonna address any kind of abilities the patient has. We can do a proper medication review. You guys already said medication of you, which is fantastic on. And then, of course, a multidisciplinary team approach moving forward because they may be left with physical impairment. I'm so on, which needs addressing. We'll just check the job. Um, so something else is saying it's 80 approach good enough or do you take, say each part? So, um, I would say I would say for I would take it is enough is enough to say 80 80 approach. It's That's when there's so much else the E to be saying in that station because sometimes you only kind of got three minutes at the end to talk through the management of a really complex case if you start talking through, kind of. I would check the airway that I move on and oscal take the lungs. It takes a lot of time. And so I would say, Just just say I would take in a tree approach and move on to the rest of me Wants the rest of the management on. But that's what I've done. And that's what my colleagues did on. But having said that in some stations, you can really smoothly slide in your management within the 80 approach, which is, I think almost the next levels are kind of estimate. For example, you can really kind of every step, step, step off the management of asthma. You can integrate it within 80 approach. So in that case, I would talk through the whole thing. So I think it really depends on the case. That's that that you're presented with. Oh, a brilliant suitcase Full. Yes. Oh, if it if it became, is ready to do the case to weaken, allow them to talk now. Okay. So let me stop sharing. I'll be back to case too. Okay. Is it being ready? Uh huh. Yeah. Community. Yeah. Okay. Eight. You just thinking What? You want to hop on the video? So, um, just speaking. That's all right. That's okay. No worries. Okay. All right. So, um, I think the time Pepsis a brand you go to college Union or another university, I got started. Fantastic. Okay, so we'll treat. This is like an acute history. Just for time. Pepsis Rather than having seven minutes. You'll have no minutes. Mystery. Okay, Okay. Okay. Let me just some type of time. All right? So before I start the forest out the timer So you've got early. Who's a 54? He's 54 years old, and he presents to the emergency department with right sided weakness. Um, he's taking an acute history so before. Sorry. Can I presume the consent, which I get through all of that as well. Janet, don't tear a lot. Um, no. You always check mation identity. Always recreation identity. So once you're ready, you can take a minute. Once you're ready to say start and we'll start the station. Yeah, that's there. You sure? Brilliant. Okay. Different. Hi. My name is a vitamin. One of the fourth year medical student. So let us check your name. Your date of birth, please. Yeah, My name is Ali, and I'm 54. Fairly nice to meet you. So I understand you've come in today because you've experienced something a little bit unusual. Could ask you smoke questions about that close. Yeah. Yeah. So just tell me what you're currently So I was just I was just I just woke up this morning. I was having breakfast, and suddenly Oh, I just wasn't able to hold my coffee cup anymore. It's just I have my hand just got really heavy on on day. I said, you know what was going on? I tried to walk over to my wife and and same thing happened on was going on with my legs as well. Okay, that must have been really distressing for you. So you first noticed that when you woke up when you were actually having breakfast? No. When I when I was having breakfast. Just Doctor, I wake up, okay. And did you notice that it was affecting one particular side? Yeah. It's all on my one of my left side's. Okay. Okay. Um, did you fall over when you went over to try and speak to your wife? Yeah, I did. I did. Yeah. I wasn't able to start. Okay, Um and did you have any, like, injuries to your head or anything like that? No, no, it wasn't too bad. Okay, okay, I'm on. So your wife was with you to get this? All of this. Did she notice that your, um your your speech went a bit funny when this happened? No. My speech has been fine. Okay, Um, did she notice that you're on your faiths That started to droop on one particular side? Um, maybe I think it might be just a tad droopy at the movement. Okay. And you still be right now in this moment in time. Yeah. Yeah, it is still there. Hasn't gotten any better. Okay, um, have you noticed any, like, tingling down your left side is all. Big list. Yeah, well, feels a bit funny. Okay. Okay. And did you have any change in your vision? Did you Did your vision go blurry or did things black after you? It'll No, no. Okay. AST far as you're aware, you didn't use any one. You didn't lose your consciousness, did you? Oh, no. I'm remember the whole thing. Okay. Does anything like this ever happened before. You know, when something like this happened that it came from, like, a matter of seconds and it got better. Have never had nice. Been like it's been a while now and nothing's not in. Nothing's getting better this time by Yeah, on gum. When that When it's open. In the past, had you been to see anybody about it? No. No, because it just got back to It was just kind of a 30 seconds. Okay. Conditions to be about. So I think the line, but was signals and great. I missed the last sentence. I'm It's really just wanted to know if you go to the doctors for anything. Yeah, yeah, I've got I've got high BP and he said My cholesterol's a bit elevated as well. Okay, I'm What medications do you want for that? Um, I want some statin on dumb ramipril, I think. Okay. Okay. Um, and just depression. About your family history. Anybody in the family ever had a stroke or any problems to do with the heart? Yeah, I think we've got lots of heart problems in the family. Um not sure what what? Which is quite a few people have got something wrong with the chest. Okay. Okay. And, um, some standard questions that we ask everybody to you and Smith little while. Yeah, I do. Yeah. How much would you say that she sees? No. Around 20 a day. Okay. And how long? How long have you been taking that for? Um, around 20 years, I guess. Okay. Um, you already think Cut it. Are you Are you allergic to anything? No, I'm not. No. There. Um, Andi, do you have any eye disease? What could be going on right now? Well, I'm just I'm one. I'm gonna die, Doc or NC A shin and station only ends and history part moving on. So what's your differentials at this point? Everything. I'm sorry. I know that the lining keeps on dropping, so you could still hear me. I'm so given given issue that I took by, um, differential would be a stroke. A Nexium, it stroke. Uh, this could also be a transient ischemic attack that hasn't resolved yet given patients past experience of the t I A on this could be a hemorrhagic stroke is well, I'm finally a space occupying lesion on my differential. Okay. Thank you. Okay. So just work together. So, like you said, stroke, Um, like you said, it could be a Tia that hasn't resolved, I guess on. But it could be a space up occupying lesion. Another one to keep in mind. It starts policy. So after someone has a seizure, they can get this kind of paralysis for up to 15 hours after the seizure. And and then once you can't go wrong with saying or sepsis and hepatitis, they can read lead to kind of all different types of presentations. And my cream actually is Well, so that was the history. So say, on examination, you come to examine the station on D has both upper and lower left sided weakness on the power is three out of five globally on the left, but five out of five on the right. Forget the sensations intact. Say that he has reduced sensation on the left side as well. So how would you like to investigate the station at this point for him? So I want to get you set up by two signs on the patient. Um and then I want her gently order a noncontrast had city. Um, and once that's in the process, I would want get IV access, start taking some bloods. Um, for for blood count a, um, CRP on do experience some of the world effective causes of expectation on most of it's to using. These are lefties, uh, potentially group in saving a press match. And, um, I want to get any surgeon of this patient as a rhythm. You native? Uh, it was like a spinning strip. Um, on. Then I don't want to actually, with a lipid profile in the patient's see how that controls his recently on. Uh, yeah. Leave it that way. Thank you. Okay. So, um, it doesn't say here, but it should say just 80 approach first. So this is a straight your query stroke. It's a medical and surgical emergency. So it takes a you taken 80 approach on that. I believe that you mentioned actually everything, but I think you could do is just sticking to the structure. So I think you had did cover all the investigations. They're sticking through to the structure being like at the bedside in terms of bloods imaging, ECD, a special tests. It just make We'll make you sound a tad more slick, but I think you did a great job job. I think you mentioned a majority on go at the bedside. You'd want to do a full neurological exam. And I did say that he'd been examined, so that was fine. And you want to take the blood sugars anyway, so that's just to get a better idea. Perhaps he could be diabetic as well, which puts him at and even increased risk of stroke, which is our top working diagnosis on you could. Also, just to be really, really sick, you can mention the strict severity scales. So the end and I hate S s or the rosy a scale on that slip just to look fantastic essentially because. And they only have You recognize that this is a strict, but you're also gonna do a part to see how severe this trick is. And then in terms off Bloods, you mentioned the majority great that you mentioned cholesterol like livid profile. You mentioned coag group and save and cross match just in case that he needs surgical inputs. Andi said anergic ct side of the head, which is, of course, the main thing that we would be doing is doing a doctor's just to see whether it is and it's clinic or a hemorrhagic stroke on that would been, um, kind of influence our management down the line. Did you say a CT Assad dream? Did you say a CD? So it's important to say a C g. I think you did. But the main reason we want to say a CD Fistric is Teo is actually to find out if the patient has atrial fibrilation. So if the patient does have atrial fibrilation, that could be the cause of the clot in sheet and then traveled up up to the brain and cause that infarct so really, really important to say that you would take any CT to check for any arrhythmias if a patient, if you want If you're worried that the patient has presented with a strict okay, so, please, can you interpret the CT scan you request, it comes back, We see and separate this every Yes, sir. I'm just checking the patient demographics there. Correct. Um, we're looking for a actually, see if he had, um, a level of the bench boost and and, uh, course abnormality that I can see it is on the last on sides has a large hyperdense region which, um, is in May, um, oven in fucked, affecting a temporal of perhaps on Can you take it? Guests say I was a state isn't just the temple that this is also the part of the frontal that the last the posterior part of the frontal lobe and the parietal lobe is well, is that it's a small part of the temporal lobe. What? Can you take a guess at what's cerebral artery we think has been created? Um, is it the middle cerebral artery? I'm Castaic. Yeah. Yep. So all you're really be required to say or, you know, even required, Is it? If you do say, it looks fantastic and it's very easy to remember whether it's the anterior middle of August serious cerebral artery that has been a coded on. So this one is very consistent with a M. C. A. A question. And also guys, I've just read that this is on the left side to this whole patient would be presenting with right sided symptoms. Of course, it would be on the contractor ulcer. I'd of the body That's my bad have. Okay, so this is an exhale noncontrast CT scan of the head showing hypodensity in the left frontal, parietal and temporal lobe on there is, um, right. We're right. Word. Um, in midline shift on cell call it basement over here. So this is indicated, or they left NCAA infarct. So how would you like to manage the stations? And Brahim? So I'm like to take a a B C D. Approach to, um, patient initially and cried about any interventions. That baby to stabilize is them. I don't want to inform my seniors about what's going on on, but, um, through take in history from the picture, I guess trying to figure out when the symptom onset was on, um lasting symptom a shin on because it will, uh, decide what? What kind of treatment is given me touch on an amendment, But, um, so I would yeah, establish live the actions for the patient, Um, on day, give them 300 mg of aspirin start. Um, Andi, I would then want to, uh Did you ever find the patient on two? I believe this interventional radiologist for either from polycysts would come back to me or both. Um, I don't really want to keep the patient know by mouth. Is there going to undergo this procedure And then, in terms of ongoing management for this patient, who would want to explain explain what's happening to them on provide them with, um, education about about strokes and what they can do to kind of try some of that life start risk factors to the importance of quitting smoking and avoiding free to start treating facts? Um, paying close attention to the BP. I'm getting adequate exercise weekly on, but the patients was like going to require some rehabilitation, so I don't want to get it from the MDT. Mainly from visit a potentially speech and language education does develop a aphasia. Just, um Okay, so, um, but he said a B, C, D and senior repute and imaging within one hour. So you need the CT. We've already done the CT scans, guys. Sorry. So just already done it. So I'm just putting it here for completion, so it's not missed out. So we were We already have established that this is a, um in a in fact, not a hemorrhagic strick. Um, and like he said. Aspirin. 300 mg. So someone's asked what to start mean Start just needs instantly. Sorry. So see if someone presents with and a query No a stroke and you've ruled out a hemorrhage. You can then give aspirin 300 mg that in there on glycated between said. So he needed to have established when the strictest place, because that influences the management. So if someone presents in within the 4.55 hour window, we can go ahead and give the patient from below license. That's that's the clot busting medication exam, but that would be out of place. However, the patient presents, um, kind of within the 4.5 to 24 hour period. It gets a bit more tricky on the management depends on whether whether the senior neurologists and your oh surgeons think that there is salvageable played a salvageable brain tissue on D Onda. If there is salvageable brain tissue, they can go ahead and have a like a broom, said a clot retrieval. And that's done by the interventional radiologists. If there isn't, we just go ahead and give, um, we just give them with the aspirin like you already said that all the patients would get aspirin on then finally, in the long term, like it. But he said we give love salad by smoking cessation. That would be an empty T approach on bend. Just add one. I'm not sure. Did you mention the medical management? So, um, old patient that had a stroke would be on clopidogrel for life or aspirin, and I pyramidal on. They would also be started on the high dose off the statin. So does anyone know what dose off statin would be started on once they've already had a CD? Eight 80. Fantastic yet. Great. So that's thesis and prophylaxis. It's not be Yes. The secondary dosage is not the primary prophylaxis lotus because they've already had a cerebral vascular accident. Now on then finally, um, later down the line at the patient could have a carotid endarterectomy, endarterectomy or stenting, depending on the degree of stenosis on, but guidelines your hospital follows. Oh, okay. Okay. So what if this patient symptoms had resolved? What would he have been been presenting with? I just want to take this on the and cookies. We've covered it slow. T a Fantastic. So I'm ta. The definition before was that it would have to resolve within a particular time periods. But now there is no time period. So any neurological deficit that then resolves becomes a T. I. It doesn't have to be. It doesn't have to resolve within a set amount of time. So just really quickly the motion of tea. A 80 taking 80 approach again again for and again for those high marks, say that you would do the A B c D to school for T I. A. And you'd want senior of you on if they have presented within under seven days off having the t I. A. They need Sergent Senior Assessment within 24 hours. If they presented after seven days, then they just need specialist assessment again. But within seven days, it doesn't need to be within the urgent 24 hour window on as a junior doctor, you against, say, under Conservative that you would be providing them with supportive care and regular monitoring off their vital signs of their admitted in the hospital. Um, then the medical managements. You'd always give 300 mg of aspirin unless it's contraindicated on Ben again, like we said before we start starting 80 mg because they have had a cerebral vascular events on you. Would anticoagulated patient if they have atrial fibrilation. Okay, And then finally, again, you could consider a carotid end up endarterectomy or stenting if there's greater than 70% stenosis. So I believe 70% is the European guidelines on That's what we follow but the American guidelines of 50%. And then again, long term, they would need to be on Clocky lifelong. That's the first line. So they're just a few questions are answered. The full moving on which needs Saturday was simvastatin that we named someone asked what circle effacement is So the the brain has kind of those kind of get back to the, uh, the CT, that kind of the cell chi Over here, you can see that they've just been a face they're no longer present on. That's because I kind of this kind of think that this there's slight the slides. Midline shift has led to the face mint off the silk. I So that's what cell called Cell called a basement is Did he doesn't even questions that so you've done Case three. Skip possible this. Brilliant. So now we have Case full will be answering this one altogether. Again. Now, guys. So use the chart. Function s so we've got hurry. Who's 61 years old? And he presents the GP with loss of sensation in his hands and feet. What's out? What's our our top differentials first when you're up in the pap. Diabetic neuropathy. Excellent. GBS. Great lineup. Didn't speak since the feet I mentioned. We know. That's kind of a sending weakness. We have deficiency. Fantastic. Okay. Okay, So my doctor French rolls were diabetic. Neuropathy, alcoholism, drugs. So amiodarone I saw on you. Is it Nitrofurantoine in? Can always add to that presentation. Be tough, stashed. I mean, deficiency on vasculitis. But the others mentioned on the chat a little correct is over because just one thing for DBS because you said sensory, we can STDs is not censor weakness. It's a motor weakness of that one, I think. Is there anyone that's not correct? It just slides will be available. Ousted everyone that's asking. Okay, so, um, how would we like to investigate this patient? So, just like before was taking a lot of B boxes, approached the bedside at the bedside. We're going to do a full peripheral vascular examination, Uncle, break your pressure index. Because if if they have, um, a medication tells you that they have altered sensation kind of and in the lower legs, we need to be checking the A PPI to check that they're not at risk off or they're not undergoing critical ischemia on that glucose. So that would a doubt that would eight hour working differential of diabetic neuropathy be on that? In terms of blood, we do a baseline bloods on down urological screens, every 12 folate, thyroid function tests, hour or two antibody screen for any vasculitis on again. Our cholesterol on our offices, X ray a CT. I didn't have anything down on them for special tests. I did put down that we could consider doing nerve conduction studies that something that you will just saying your exams. But it's not, to my knowledge, very popular in clinical practice. Okay. So focused history of feels that this patient has type two diabetes. Um, and his head's be only one c is 52 minimal. How we manage this patient. Can you guys use the chat? So what we're gonna do conservatively, medically on surgically patient education and counseling. Fantastic metformin. Correct that later. Down the nine optimize medication. Great. It's mechanization. Diet exercise. Great, Great. So that's full conservative. And for medical, we need to do a medication of you. Is he even on any any diabetes medications on then? I don't be that there is surgical for this one. Could you do a urinalysis? So that's that's fantastic. Over. Just said to Could you do a urinalysis figure occurs? We really could. I should have put that down. That's great. So under our office is we could have done a urine dip to test picnickers. Fundoscopy is excellent, um, under a kind of when we be examining the patient to check for any diabetic retinopathy. So that's just why hot down, I haven't written down debate a year, so I've fallen into That's also a DVD as well. Under I'll edit that before I send the slides out the end. So you need to say we need to mention me to tell the patient that they need to inform the debate off their condition. We're not telling the patient they can't drive on the DVS a then handles the rest of that Once the patient kind of tells thumb there stages. I'm not sure what the person says exactly, but our job is just to tell them that if they have diabetic neuropathy that, um, they need to tell the TV any and then under medical, we're going to do, review the medications on starts, any drugs asked at the guidelines. And then the main thing that we missed out is symptom control. So for diabetic neuropathy, a swell a magic, the diabetes, the mainstay of treatment, is symptom control. So it's very similar to our symptom control for multiple sclerosis. So for the pain. And we're going to give the neuropathic, uh, Europe affect pain medications, the amitriptyline, gabapentin, duloxetine. It can also experience ultimate dysfunction. So we'll give metoclopramide for any gastroparesis. Keep the eyes the guards on if they are depressed to give SSRI eyes. Okay, so moving onto Case five. Um, we've got Katie, who's a 15 year old girl, and she's brought into the emergency department by her mother after having an odd for what I did. Wrenches, seizure syncope. There's a vehicle simple to me. It could be Apidra hematoma hypoglycemia. Great cardio. Everything a great posture. Hypertension, fantastic. Chocolate married tooth. I'm not sure about that one. Narcolepsy. Okay, Anemia. Great. So just common things. Uh and, um, but I just You can't go wrong with that electrolyte abnormalities. That's great. So? So that did. These are the five I had again. Um, the majority of those were fantastic. So again, sometimes you just have I would say this one. You would need to have seizure up there. Definitely. You would need to have it really up there because seizure. See, it's most likely a seizure. If it's kind of a funny, it's almost like you. But seizure is very common and following if following that presenting complaint, especially in the skin. Well, everything is because it's serious, Andres. A bagel syncope because it's very common. And then what other? Whatever other two you decide to fill in kind of your top five differentials as long as you come back it up. And you know why you're saying it? That they would be corrected stuff. I just included drugs because it could be due to an overdose or toxicity on mechanical Fall is very common. Okay, so I just saw it quickly. Um, just talk through the falls History together on D. Yeah. So the key thing with force history is that you take her systematic approach and really understand what has happened from before the fall, how the patient was feeding two after the four on. But it's great to say for a full history that you would like a collateral histories. Well, because the patient that had the fall might think they remember. But they might not. So everything might be a bit fuzzy and their head. So it's great that if someone witness the fall, you take a collectible history. So before we want to ask when the patient fell, where what they were doing, any warning signs that with vasovagal syncope, the patient can kind of feel themselves going. They get tunnel vision and whether they're having dizziness, chest pain, palpitations. So that could perhaps suggest since is it everything you, during the fall weed establish whether there was lots of consciousness and then we need to go into kind of the seizure, the seizure stuff. So was there any incontinence, tongue biting on bend safety? Was there any other any injuries which body hit the floor first and how long they were out for on afterwards, me to ask whether the patient remembers the full. Are they still confused? Are they still tired? Or how long did the tightness or confusion last fall afterwards on Ben, Any new neurological deficits and again that concerned her on neurology review. We always need to look out for any new neurological deficit and then ask you take them to the hospital, and that just kind of helps you establish who quit them and who you can take the connector a history from and then later on in your history. So this is just the history of present presenting complaint section later on, and you want to do a full medication review because we know that this patient is quite young. She's only 15. If this was like an elderly gentleman or lady who were 80 they could be on a whole bunch of medications that are unlikely on, in which case and need review using the stock start criteria for the elderly. And so he picked up by taking a proper medication history. Okay, so back to this patient, she's 15 minutes 15 and she lost consciousness during this funny fall on, she had two minutes of jerking movements, and she's still tired now and spend three hours. She denies any drug and alcohol use, and it's the first time she's ever experienced an event like this. Her only relevant drug history was that she's on the oral contraceptive pill. So this points towards a seizure, doesn't it? Because she's, you know, she's lost consciousness. She had jacking movements. She has the postictal phase. So I just thought I quickly real weak help. The cause is off seizures, so it could just be, um, kind of a fast presentation of epilepsy. Many people with epilepsy they don't haven't identified course for it. They just have epilepsy. But it could be a pill actually to something else and which we should have kind of established in history. Mother, she'd had any trauma. Um, it could be a pill exceed you to stroke and old and elderly, more elderly people, or due to a space occupying lesion. And it could be, um, due to alcohol or drug withdrawal, for example on benzodiazepine uh um in particular. What if patients were taking them and they stopped taking them? Even patients of that. Someone has an addiction to them and they try. And with drawings with these try and cut down, they can end up with seizures as well. It could be a psychogenic, non epileptic seizure. It could be pretty constant. If this patient was pregnant on day. It could be due to a metabolic disturbance. Is what kind of seizures? Okay, how would be investigated Station EEEG. Yeah, but we skip the lots of stages. That EEG is correct. Definitely. So we can get elected for motility at the bedside. Fantastic. So we need to do glucose, just in case that she's having hypoglycemic on diffuse hypoglycemic. It really could kind of present very similarly if she's hypoglycemic. That perhaps seems to eat to be's a vagal syncope. When patients have basic vehicle syncope, they can twitch for a couple of seconds so it can mimic kind of a seizure, actually, but it would never kind of last for two minutes, so we are still leaning towards epilepsy. But it's important to your toe to check glucose, and then we just do a baseline bloods. Exactly. So you want to do a full blood count using these out of teas. Um, but glucose pregnancy test well done. So ever said pregnancy test? It's fantastic. Any person of child bearing age, we need to do pregnancy tests for and standing lying, lying, BP. That's great. So that can see we can. That can help us understand whether she has postural hypertension, which could have led to the full. And then we can consider a CT down the line. Depending on kind of what our history Knicks are examples towards on. We might need to, um, to do a CT, add any CD. Great. Yep. For arrhythmias. It's okay. Um, the thing that we missed on blood was productive. And Catelyn kind these. Do you guys know why we need to do a productive and crescent kindness when it's query A seizure so productive and crescent cut. Brilliant. Fantastic. Yep. So productive and caressing kind of ease, Help, differentiate. Help us to friendship, whether this was a real seizure or whether it was absurd a seizure. So that's kind of a key. A key investigation on when you put on the, um it just looks fantastic. It it shows that you know the difference, and you're looking out for the difference is well in in your exam. Okay? I we didn't have anything for orifice. Is, um I guess the pregnancy test could be an orifice with you you're in dipped the patient, and you'd want a chest X ray. That's just routine actually on. But you could consider a CT heads depending on on your history exam so far at this stage because we're very much leaning towards epilepsy. I'm not sure whether I'm not sure. I don't think the CT head would be, Um I'm not sure the CT head would be actually be indicated. Aspect. Guidelines. I need to double check. Actually on BCG. Definitely to check about arrhythmias and then special test. Someone already said it so EEEG on. But that looks for elective form activity. So that would definitely be done as well. Clothes station. Okay, so we think that this patient has, like, he had a generalized tonic clonic seizure. So in terms of the conservative management of radiation, you guys will talk through it. But for this conservative management, we need to refund a station to the first seizure. Click. So that's the first thing we would be doing as it's kind of junior doctors on D. Well, maybe if you, enough to in this patient comes to the GP and tells you about what's happened to her, she needs a referral to the first seizure clinic. You need to educate the patient about what you think is going on on. If this patient was driving, you need to tell her to inform the D bili and not drive. So here is a big difference to what we've been doing before. Where we've just been telling the patients to inform the D bili for epilepsy. We need to tell them too excessively, not drive, because depending on whether this was a provoked or unprovoked seizure, if it was a provoked, this patient is not allowed to drive for six months, and it was unprovoked. This patient isn't it out to drive for a whole year. And so we need to tell her that to stop driving. If she is driving currently And two, I'm why are we giving the station lamotrigine for under medical? Do you know what's normally the first line for generalized tonic clonic seizures, Child bearing age Brilliant. Yet so first line is normally sodium valproate. Why we're not giving carbamazepine. Can anyone remember? So this patient is on a particular medication? She's 15 combined or a contraceptive pill. Fantastic. Exactly. So this patient was on the combined or contraceptive pill. So first thing we've excluded. So she involved create because any person of child bearing age on that with female genitalia cannot cannot be given sort of operate on. Then Carbamazepine is contraindicated brilliant. Someone already beat me to it. Because what does it do to the See why I keep for 50 is in and do so and and the Hib it induces fantastic. Exactly. So we're not going to give common as a piece. So the only suitable option is the mantra gene, which is second line for, um generalized 26 seizures and then finally, under surgical management, we can say if a structural abnormality was identified so that kind of links into whether the team decide to do a CT CT scan. If the structure abnormality was identified, then they could then be surgical intervention to do address that structure abnormality on. I've just put a summary off the management for the three main different types of seizures that I think could come up in your skis. Anything beyond that, I think, would be really unlikely, because I know there's other other seizures as well. But I think I would either be generalized tonic clonic a focal seizure and absence seizures. So I would say, Just know the 1st and 2nd line treatments for those three. So much just asked. My carbamazepine is contraindicated on, we said, because carbamazepine induces the enzyme. See why Keefe or 50 on that's an enzyme that breaks down the combined or a contraceptive pill, which this patient is on. So if we were going to give her cup, if we give the carbamazepine that can deem her contraceptive ineffective, so that would obviously be a very big error on other half stop. So case six. We've only got two more cases to go, guys, so I hope you will be done soon. So we've got Henry, who is a 72 year old man, and he presents the GP with the tremor, stiffness and difficulty walking. What's our differential? So hungry? Parkinson's fantastic. So lots of Parkinson's. We know they left Parkinson's in the exam, but we need to say it. We do have other stuff to say as Ah, differential. Start me for the Examiner. Parkinson's cast fab so that we've got to alcohol. Drug was rolled. Definitely hyperthyroidism. That's fantastic. So technically the trauma could be hyperthyroidism. It could be a cerebellar infarct leading to his instability on it Could be essential tremor Stop drug side effects of antipsychotics. Definitely yet. Okay, so I just had these again. Everything that was service correct. Thank you. Things to say, Parkinson's disease could be Parkinson's dementia. It could be Parkinson's plus syndrome on, I said, drug induced parkinsonism swell on. But today what? My talk that they were before I mentioned, as long as you have kind of Parkinson's and Parkinson's. Plus I think it be imported to say drugs as well, to be honest for the exam. But every kind of you. The other stuff You mentioned your differential list. It doesn't matter. As always. You have a couple on there, correct? It's fine. Okay, well, let me get a quick e. So how do we want to investigate this patients? So we've not even touch them so far, we just we have Let's you just heard that this patient has stiffness, a trauma and difficulty walking. Yeah, and the reason the reason this conclude of much with the exam is that you're likely talking carded eighties. You like talking to the examination and we'll have this on the door and it will say, Perform, for example, in upper limb neurological examination. So we'll do an exam in and act and after will be absolutely fine. And then the patient, then then the examinal say, Imagine that he had stiffness, rigidity and on trauma. What? Talking through a differential. So it would be very much kind of a talking exercise with the Examiner, not something that you would have elicited in be exam itself. It's that she was covered at the moment where they're not getting really patients. Um, so for brilliant. So at the bedside, we're going to examine. Are there any any any bloods that we do? So we want our baseline. That's still, wouldn't we? And, um, if you know, if the station, if the station essentially can have deleted, like dilute, the station may have delirium, and it would be good to kind of check their full blood count for that Good function tests yet collateral history? Yep. So that's back in the bedside. urine dip. Yeah, again. That's just kind of the infection. If they're confused, anything like that, it could kind of be a mix between It could be Parkinson's only or could let you just be The patient has delirium. What were cute on acute presentation of to do do? Um, is it acute? But did it anymore? First presentation of kind of dementia. If it was vascular, for example, where they suddenly get these, um, they suddenly drop quite significantly in their cognitive function and toxicology report. Fantastic. So we'd want to, um, check for blood. Check for drugs long. Okay, so this is what I had. So I had a full neurological exam. Lying standing BP, urine dip for blood count using his LFTs. TFT is you could do drugs as well, depending on what they're on. So someone said, for example, if they're already on antipsychotics for another condition, you can check. You can check, I believe for, um, kind of the levels of that within the blood or just do a medication review from their carrier and see how much they've been taking. I didn't I didn't have anything else. Or if this is in terms of the X ray. Um, it says the imaging, um, Parkinson's disease is actually just a clinical diagnosis, So you'd want that triad off stiffness, rigidity, trauma, rigidity and bradykinesia on golf course. A specialist would be making that diagnosis. But if there was diagnostic uncertainty, for example, someone mentioned earlier essential tremor. Sometimes the way patients present, the team might not be sure that it's essential tremor or whether it's Parkinson's, because both present with, um, a symmetrical with asymmetrical symptoms. And in that case, they would do a single photon emission computed tomography scan. And so that's kind of what's gold standard when there's diagnostic uncertainty. And then you see GI would do that routinely because, of course, these patients, if we're thinking about Parkinson's, they have a significant risk off falls. So any C D is important as well. It's just exclude. Everything is as well, Okay, whoever said that's kinda scan is correct as well. Um, I the guys I read just said that that was the the single photon emission one was preferable. But, um, in other notes also said that scan So that's correct. Is that, um so I just thought we quickly recap theme motor and normal to symptoms, so that so. It's just a question, because Parkinson's you're unlikely to actually see a Parkinson's patient. It gives the The Examiner has kind of more time to ask you questions. And so he could ask you kind of what are the motor symptoms and what the non motor symptoms. So we all kind of know the classic triad of tremor rigidity bradykinesia on. But be patient got shuffling gait, the mask like face and the kind of small handwriting micrographia that said that that should be in a and microphone. Yeah, but the non motor symptoms I think we might be less first familiar with. So they gotten your psychiatric problems, which include depression, anxiety, a pathy, hallucinations and impulse control. On they get quite significant autonomic dysfunction as well. So dysphasia, constipation, urgency, incontinence, orthostatic, hypertension and sexual dysfunction. They also get sleep disorders and sensory disorders so they can get pain in Paris. The's yeah, on day. Finally, this is thematics mint off Parkinson's disease. So we first we would be referring to a Parkinson's disease specialist. They're not gonna just the marriage and primary care. They're they have to be diagnosed by by a specialist and then the specialist will start. The treatment is so on. Then we'll say that you know that the team will take a multi disciplinary, but a multidisciplinary team approach will be taken on. Do you educate the patient again? You'd inform you. Tell the patient that they need to inform the deviated again. And it may be the case that the patient chondroit for a while before they need to stop. Stop driving on, then medically on. So the medical managements actually depends on the patient's symptoms, so it's not kind. Know every Parkinson's disease patient. We will be starting levodopa for every Parkinson's disease. Patient very much depends on how much the disease is impacting their quality of life. But this is the summary off the the guidelines for when the disease is having a significant enough impact that we need to start medication and it says on science. But do you understand why we give the paci a Don't put your car boxes inhibits or with liver deeper? Can someone extinct? Why we give a do pretty carboxylase inhibitor with levodopa prevent peripheral conversion? Yeah, I see. You said that from the site. But why? So we don't We don't once levodopa in the peripheral system. We just want it to act only in the central nervous system. Yeah, for the side effects. Exactly. So we give Leave it open with this inhibitor. So it only kind of effects thesis ns and not the rest of the body. Okay. And the size will be available So you guys can just read those guys in your own time. Finding that is an option for surgical management. Technically, for Parkinson's disease again very, very rare. But it is in our textbooks so he can say it for me. Skis on. And that's deep brain stimulation for fracturing symptoms. Okay, guys that were done. Now we're done with all the stations, and this final bit is just to talk through. I think just about five minutes left. And that's just when if you come to examine a patient and they actually do end up having some sort of symptoms. So sensory and motor symptoms. I just wanted to explain how you can approach that really simply and not kind of worry about not not kind of worry about what you're going to say to the examiner to say you just didn't exam. And the patient huts, for example, um else its sensations and left, um, and weakness elsewhere. How how we're going to approach. It s so firstly thinking back to our exam. And you know, there is this physician really so cool. We check for we expect the patient. We check the tone, we check for weakness that we check for sensation to check for everything. So first you want to just as examine the patient. We used to just start deciding whether we think this is an upper motor neuron usual or a lower motor neuron mutilation. Because even if we have nothing else to say just taking us just finishing your examination and saying to the Examiner. But I think that this these patients, the station presented with, for example, hyper reflexia and increased own. So this is indicative of an upper motor neuron Asian. Just saying that in itself as a junior doctor is safe, like you wouldn't need to actually make any more further diagnoses beyond that as a junior doctor, because your seniors will be there. So even just making it to finishing the kind of the first step off saying Whether it's upper or lower motor neuron, it's fantastic. So we will know that up. Imagine you're on. You've got increased own versus city hyper reflexia and weakness on for lower motor neuron. It's the opposite, But you've also got weakness on instead of spasticity you've got wasting and fasciculation Z okay, And then if you can push that a step further and you you then used to think about whether, um, the patient, the patient we just examined has bilateral symptoms or whether they're unilateral on that can that help you? Um, that can help you with your with starting to say some differentials for your examine. It's, you know, only told him whether you think it's upper or lower motor neuron, but you've got that you've given some some sort of names if you've named some conditions. So in terms of upper motor neuron and presentations that are but let me to imagine your and diseases that lead to bilateral manifestations, a great one is multiple sclerosis. You can't go wrong with that myelopathy. So myelopathy is just anything that's impinges on the Scots spinal cord load of things. Can you to myelopathy, but you just just saying myelopathy on motor neuron disease so that again needs to bilateral upper motor neuron symptoms on then in terms of the union natural, uh, promoting urine symptoms again, you can say MSN on if you think about it just in terms of the anatomy. If you start with the Inter Inter creamy Um, what we can have in there that can lead to unilateral symptoms so he can have, um, multiple sclerosis. Those lesions. When it demyelination has a cut, you can have a stroke or infarct so and in fact, a hemorrhagic strick, and you can have a space occupying lesion in the brain stem again. You can't. You have a in fact, in the brain stem again or multiple sclerosis and then in the spinal cord. Same thing. You also have an abscess or infection or you can have trauma to the spinal cord is well, so that's kind of how to. But there's some differentials full and upper motor neuron bilateral and, you know, actually symptoms and then moving on to lower Moten urine. It gets a tiny bit more complicated and a great way. A great thing is to consider whether the sensation is altered or the sensation is intact. Eso if we start whether it would if the sensation is intact. If the sensation is intact in the patient, just has weakness. We've already mentioned it before, but you can borrow syndrome so you're lucky and borrow Lambert eaten and lead poisoning so they're kind of your three. For if the patient just has this odd weakness and you think it's low, um, hello and merchant, your own presentation said, like the three that you convention. If the sensation is altered and then you've got anything, you've got your whole kind of and all the differential that we mentioned earlier that can lead to a neurological problems. So that's diabetes B 12 and finding deficiency, any infection. So we said before the meal, it would always want to do like a screen for HIV. You know, I'm disease or syphilis toxins on so actually mentioned this before, but it could be something inherited so the most. The only one I think you'd be expected to be able to list is another name is chocolate Marry tooth and syndrome. Okay, and then, if it's unilateral, lower motor neuron weakness on, but then start thinking off Radiculopathy plexopathy and a nerve palsy. So a ridiculous puffy is when you have an impingement or some sort of problem at the nerve roots, and plexopathy is affecting the whole plexus, so it will present similarly. But you'll get larger. You get a larger scale off sensory loss because you think you because several nerves are affected, not just one on. Then you've got your nerve palsy, which will lead Teo Sensory deficit for that for the area supplied by that particular nerve. So in particular kind of just know your radial ulnar on medial nerves that are most likely to come up on. But we finished now, but it is worthwhile, noting that, um, this is very unlikely. This is very unlikely to come up in in the exam. I think most cases it tends to be it tends to be the other cases that we've covered because it is quite mean to just have a patient present with specific symptoms and then get you guys to guess without having any without any real investigations. Because a lot of these and all of these do I diagnose. A lot of these conditions are diagnosed after six a significant amount off investigations and teamwork. So it's not very fair on them to kind of give it to us to the risk is, but it's worthwhile Just having any in the back of your mind, just in case it really nasty state and station comes up. We're done now, guys, Um, I have more of my sides, but I think I'll just email them because it's just more kind of reading that you can do on your own time about cranial nerve palsies and things like that, which I've just summarized. So you stopped the show. Thanks, everyone. I've posted the feedback link. If everyone just fills that out on, you'll get the slides soon. I'm thanks. This mean that that was great. Have you have even answering E And he questions? Yes, we have about a total of 31 questions answered, but brilliant. Okay. And that other eat after answer will be hockey. Um, there's one. What about subdural and extra hemorrhage? Are these, um, hemorrhagic stroke? PSAs? Well, you see that? Oh, okay. I can't see a touchy. Where do I got the question from, um, more moment? My message that for you. Oh, thank you. Well, I must not sure about that. Whether they cast if I as, um I was, like a stroke or just in intracranial bleeds, the correct terminology and maybe a little, um, I'll set that up, and maybe I don't rest at the end of the the slides that we send for whoever asked that question. Okay, well, thank you very much for advancing questions. Thank you, everybody for coming. I hope that was useful. And if you fill up with you but formed like Norman said, you'll get certificates and you'll get the slides itself. Well, just hang about here. Just, um, until everyone cares. Oh, yeah. Okay. I think that's pretty much everyone show you and then Yeah. Thank you. Want maybe that's great. Thank you.