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Yeah, hi, everyone. Hope you can hear. Just let us know whether you can see the presentation and hear this all. Ok. Can everyone hear is alright and see the presentation? Oh, brilliant. Ok. So we'll get started as we've got quite a bit to cover. So today's session, we're going to be going over kind of differentials like kind of the common presentations that come up and I mean, more so with your acute histories is kind of a quick whistle stop tour one on those kind of stations. Um and then as we go, I'm just going to go over some quick spot diagnoses as such. So certain things that they can sort of chuck in um to, to test you guys. Um and then Jocelyn's is gonna go over the CBD station. Ok. So let's get started. So we're going to, we're going to go straight into it. The first kind of big presentation that you guys should be quite familiar with is your chest pain histories. So obviously, you know how to do your Socrates and take your kind of standard history and structuring, but this is sort of to go over your kind of classic diagnoses. I always used to kind of categorize them into your kind of subsections. So your cardio rasp gi um your musculoskeletal conditions that can cause chest pain and then others. So cardio, I always thought of a CS was like your big one and then kind of you for the categories, pericardium, things like your pericarditis and myocardium being kind of more niche conditions like myocarditis or even your cardiomyopathies, which are rare to come up in acute station, but can be at the forefront once you've ruled out more common things, um your conduction system problems. So any like tachy arrhythmias, you can get um so that can be things like af or any other arrhythmias that patients commonly present with um and then your vessel problems. So I always kind of call them vessel problems like things like your aortic dissection and stuff. Then you have your respiratory conditions. So your big four, mainly your pneumothorax, your pneumonia, pe and asthma with all of these, you get like a your pleuritic sort of chest pain. So the patient breathes in and the pain is worse and then you can kind of differentiate them based on other symptoms that they commonly have. So, um your pneumonia, they'll obviously be coughing up stuff. Normally your pe will be a similar thing, they'll be coughing up stuff, but it might be a bit of hemoptysis rather than like yellow, greenish sputum you get and your pneumonia and then your pneumonia as well. You get your fevers and kind of malaise feeling of general unwellness, other contacts might have similar symptoms, that kind of just and then your asthma exacerbation. Um Normally you have kind of your patient with the background of asthma and if it's their first presentation, you might be able to make it more likely a diagnosis if they have other atopic conditions in the medical history. Um and then kind of your other things that go alongside asthma. So um good things to pick up in the history is things that can classify its severity. It can make you stand out as a candidate. So can the patient complete full sentences? Um is the patient kind of posturing differently to kind of breathe? Those kind of things can make you more aware of how unwell that patient is coming through the door and then your gi conditions reflux your peptic ulcer disease and gastritis. And this kind of chest pain as such does have more of a characteristic description with how they're eating habits of affecting it. So do certain foods bring it on specific times when it causes the pain to be worse. So a duodenal ulcer will be slightly different to a gastric ulcer, gastric ulcer, you get the pain straight away when they're eating and then your duodenal ulcer is a bit more delayed as such. So that would be like peptic ulcer disease and then your MSK that's kind of with your costochondritis that can be sort of a pleuritic chest pain as such. But the way you differentiate that is your physical examination. Um, so all these things you can kind of bring in to your differentials. And then lastly, the things that people don't always think about but can be quite classic presentations of chest pains, a panic attack, um, and anemia. So, with your anemia, you'll have more systemic symptoms as well. So they'll be short of breath, they'll be feeling tired all the time. Um And it'll be more of like a chronic process rather than acute. See you. So, uh when I say the key with chest pain, I uh I also want us to establish it for all the other kind of presentations just because something fits a classic description, doesn't mean you should rule out your other conditions that are good differentials to keep in. So, just because a patient presents with a productive cough and chest pain, yes, kind of your pneumonia would be kind of on the top of my list if it was like greenish yellowish speech and they were bringing up. Um but it doesn't necessarily rule out your other conditions like a pa or even something like a CS, you do have your main diagnosis and that one, you should be kind of hitting an acute history because they try to make it straightforward for you to pick up because you only have four minutes. But the way you can gain is extra marks and look more slick on the day is say your main diagnosis and then throw in a couple of other causes of chest pain. So, as I've just mentioned on the previous slide, all these other causes, if you throw in another couple, it just shows that you're thinking outside the box of what it might be initially presenting as. So I wanted to kind of quickly go over your angina and A CS just because it is quite an important one. And it's good to go over what kind of things you could pick up in your history outside of just this is the presentation, these are the symptoms because these are the kind of things they do like you to pick up in the extra parts of the history. So the one thing I would want to be focusing on in a classic A CS history would be your social history. So picking up important factors like their exercise, tolerance, their diet, contributing factors that could um uh put them at risk of A CS, but also tell you about how severe their acs or Angina is. So if they're getting the symptoms when they're at rest, not on exertion, that tells me that it's more of an unstable picture of a CS rather than Angina where it's on exertion, their symptoms of Aleve when they're at rest and those kind of things. And as I've got on the right, you've got your kind of three features of angina. Um And for it to be typical, you need to have all three of those and then atypical kind of falls outside of hitting all three of those, you only have two of them. So yeah. A CS, you kind of have your three conditions that fit into that. So you have unstable Angina, your nstemi and your stemming. Um I'll go through those later on, but these are kind of your symptoms that they commonly present with. So you have your crushing chest pain, sometimes they say it feels like someone's sitting on their chest and they have specific areas that often radiates to so your arm or your neck and then they have all these other kind of features such as shortness of breath, they can be a bit sweaty, they can sometimes even have that sense of impending doom. Um And occasionally you get the present with nausea and vomiting and palpitations. Um, a very common thing that diabetics can often have going on is they don't actually present with your classic acs history. They can have what we call a silent M I. So whenever I have a patient who comes in and they have a bit of shortness of breath or they have a bit of nausea and vomiting, um especially if they have a history of diabetes, I'm much more reserved in investigating for something like a CS compared to someone who doesn't, just because the symptoms can often be masked. Um So doing things like your ecg and a troponin, you wouldn't be wrong and wanting to rule that out in someone with diabetes as such. So as I said, you have your three kind of uh um kind of conditions that fit into a CS, so you're unstable and dry, you're uns you sting unstable angina. The, the main thing to just remember is you send off the troponin and troponin comes back normal. Your troponin is a really good marker of telling you that a patient's got ischemic damage to their heart. It's a marker of damage to the heart. Um So it's telling you that although they're symptomatic, they're showing that they could go off at any point. They don't have the evidence that their heart has actually sustained damage yet from an ischemic event, an end Demi they have got damage, the troponin comes back and it's elevated and your ECG will often or sometimes it can be normal, but sometimes it can show features, but it doesn't have that classic ST elevation which a stemi will show. Um And the other feature that a STEMI can often demonstrate on an ECG is a left bundle branch block and will go through an E CG kind of teaching session on features of what to pick up on an E CG. But your classic kind of description is your William Marrow, which is kind of an abbreviation of how to remember it about. We'll go through that in that next teaching session. So this was what I just kind of wanted to quickly go with you just because it's an important thing to kind of understand your STEMI will present in different stages on an ECG. And it's basically telling you how the heart is being affected. And it's kind of depolarization, repolarization states as the damage becomes more established. But your classic is your ST elevation and that will occur within minutes to hours of the event. Um And then you start developing other features like T wave inversion and kind of developments of what we call a pathological key wave. But that often happens within a couple of hours to even days of the ischemic event. But the ST elevation is what you will pick up in that initial phase. Um So yeah, it's very important to kind of understand the idea of your serial troponins with A CS. So we don't just send off one troponin, just decide if that's good enough. We'll say that they don't have an M I, as I said, the different features present at different times as ischemic processes establish themselves with the heart troponin is no different. And often you have troponin release 6 to 8 hours after the ischemic event. And it's significant enough that it would come back from the labs as being raised if it came back normal, but you're still suspecting they have an M I, then you would do what we call a se or troponin where you would take a level, kind of a couple of hours later. I think the guidelines, at least where I work in Betsi is four hours after your first troponin. Um But each troponin um kind of the guidelines differ between different trusts. There's different trusts use different types of troponin. There's not one such type of troponin level, but they all kind of behave in a similar way. They might just show at different times after the onset of the M I. So I've got, we've gone through a CS which is quite an important one to kind of understand and appreciate kind of your features as well as things that could come up on the day in the station. Shortness of breath is quite similar, but it, I often preferred to remember shortness of breath in a different way of kind of categories of what could cause shortness of breath. So your hypoxemia is things that have caused low oxygen in the blood, ok. And that's um, things that could be limiting blood flow or actually limiting kind of absorption of oxygen into the blood. You then have your hypercapnia, which is where you've got your increased CO2, which is causing the person to kind of push, get out all that CO2 that's in the blood. So your COPD patient, you know, there'll be a CO2 retainer quite often. Um, and even your asthma exacerbation patients, those, those patients can't ventilate. So they have an increase of CO2 and they basically tried to get it out. But asthma is a bit more complicated because there's different stages of asthma exacerbation. I would worry more. So if a patient who has an asthma exacerbation has an ABG that comes back as normal compared to it showing something like a respiratory alkalosis. Because that tells me that they, they're tiring and if they have a raised CO2 on their ABG, that's even more worrying because that tells me that they're um tiring so much, they can't even get out. That CO2 acidemia is kind of your separate entity to your oxygen and CO2 as such. So that's patients who have acidosis of their blood and basically their um body is producing a response where they're trying to offload CO2. But it's to compensate for that those increased hydrogen ions or whatever's causing that increased acidosis in the blood. And then you have kind of your next category, which is your impaired oxygen delivery. Ok. So that's things that way your body is almost shutting down to such an extent that it can't even deliver any oxygen to places in the body. And as such, patients become short of breath because the body almost goes into a state of needing lots of oxygen. It's not getting it. And it's basically telling your body to take in more oxygen, but it's not an issue of it, absorbing oxygen into the bloodstream, it's actually an issue of it just delivering it where it needs to be. Um And then kind of your others which don't fit into any of these is like your anxiety, your pain and your coronary artery disease, which you could argue your coronary artery disease goes into like your hypoxemia or your impaired oxygen delivery if it's like heart failure, but I normally just class it as other. Um So yeah, I wanted to kind of quickly go over asthma exacerbation. Um just because I think it's quite a fair thing for them to kind of throw at you as a station and they can even sort of give it to you as a PED station as it entails of two elements, both pediatrics, but also quite a fair testing on taking a history on shortness of breath and taking a quick acute history. So you have your kind of three categorizations of severity and it does differ for adults, but it is very similar with the features that are picked up to be honest. So things like them having low oxygen saps, we often can kind of check peak expiratory flow rates with the spirometry and you aspirate. I wouldn't really take too much account as to the specific values, but I would more be worried if someone's breathing kind of at a very fast rate and usually it's over 20 then it means they're fairly unwell. Those are your specific values. If you want to know, but what's more kind of important, which you can pick out even when you're taking a history and examining someone, which tells you much more about whether someone's unwell with an asthma exacerbation or not is how are they talking to you? And how do they sound on their chest? That's what I often pick up more so with severity. So, are they using their accessory muscles? Are they actually even able to speak without getting really short of breath? How does their chest sound? If I hear wheeze, I'm thinking ok, they're, you know, fairly bad. If I hear nothing, then I'm very worried because then they're not even ventilating properly. Um, and then if I see anything else where they're becoming, you know, confused or they're very drowsy that makes me feel like this is almost like a life threatening one. And rather than remembering your specific things, the best way to think about asthma is if they look like they're tiring, then that's a worrying sign. And the more tired they are the worse, the asthma exacerbation is because most asthma patients, the severity is almost graded on. How long has it been going on for? And are they getting to the point where will they be able to ventilate and keep their airway open? That that's how the severity works in effect. So that was asthma exacerbation. We've gone through chest pain, your shortness of breath. The other big one that you kind of need to be slick. And on the point with is your ABDO pain. And the best way to think of your ABDO pain is split it into your sections and think what organs are in those places. Ok. So you write out hypochondriac, you really only have your liver sitting there, your gallbladder, your epigastric, you have a couple of organs, it's your stomach, your liver to some degree, your esophagus, your um uh pancreas. um, and sometimes you can even have kind of your chest pain. So like your acute acute coronary syndrome, actually causing pain radiating to that site. So with any abdo pain, II wouldn't necessarily rule out something like a heart attack. And even with your diabetic patients, I'm more kind of, um, reserved in doing something like an ECG and, and, and that, and then you kind of left hypochondriac, you have things like your stomach sitting there to some degree. It's more to the center, but you can have like your gastritis there. Um, and then your spleen, the only time I would actually be worrying about your spleen is if you've had some kind of trauma, your spleen only gets damaged as such if you've had that kind of trauma to back up the history. So that's why it's important if you're taking a history knowing whether they've had anything that's built up or asking them, your ideas concerns expectations, you'd be fairly kind of in a good position if you've asked, do you have any ideas to the patient often than not, if they've had kind of a serious trauma to that place, they'll most likely tell you. And that's where you can pick it up before you even having to ask those questions in your center or your mid region. You've got your umbilicus, which you've got a couple of organs that sits there, but you can have your pancreas, your appendicitis, that's kind of moving over as such. But that's more in kind of your right lower quadrant but appendicitis can be there. Um Your AAA um and kind of your bowel obstruction and colitis and those kind of things. Um And then your right lumbar and left lumbar, you've got your kidneys and you can have a couple of other presentations of things like colitis and bowel obstruction and then in your iliac regions, that's where it's important. And it goes on to my next point, which is on the next slide. Don't just think about abdominal abdominal causes where it's like gi think about other things outside of that. So, with any kind of abdo history, you should also be taking a Gyne history and if it's a female and there's potential for pregnancy or they're pregnant also an obstetric history. So, um and even for a male, you should still be asking kind of your sexual history as well because you can't rule out things like your uh testicular torsion or kind of S TI s and those kind of things. So that's very important in Abdo history. So, as I said, don't just think about your Abdo causes. So, on the left, you've got your obstetric history, especially if it is a pregnant woman and it's confirmed. Absolutely. You need to be asking things like, how far are they into their pregnancy if they had any complications? You know, is the baby, can you feel the fetal movements if it's kind of past the 20 week mark or something? Um Those kind of questions are very important because it's, it's not just about the ABDO complaint, it's about the baby as well. And what, what's going on there? Um, in the center, you've got your gyne history. So females, you know, you'll be asking kind of um about their periods, kind of, are they regularly getting pain on their periods? Are they having pain during intercourse? All of that? And then for males you'll also be asking kind of the same kind of questions. So, pain kind of during sexual intercourse. Are they getting any discharge, those kind of things? And then on your right, you've got your kind of vascular complaints and that specifically is your things like your AAA, which you definitely don't want to rule out. And I would always worry if ever I've got a patient coming in and they say that they've got a, a pain in their tummy and it goes through to their back. Any pain, that kind of radiates through into the back isn't a reassuring sign and the feature that I kind of worry more. So if they describe it as a, a tearing pain, then that worries me even more so that it's something like a AAA one thing which I wanted to go over which, um, is always kind of confused with, um, kind of bowel obstruction. People don't necessarily understand that even as a medical student, I didn't particularly understand it as well. Um, differentiating between your large bowel obstruction, your small bowel obstruction, things that I wanted to kind of specifically state, um, with the features of large bowel and small bowel, small bowel, you'll get things like vomiting, large bowel obstruction, often than not, you won't get vomiting unless they don't, they have a, a I impatent valve because it means that the IOC cecal valve which would normally stop that from happening is allowing stuff to go back. So large bowel obstruction, you'll get that. Whereas persistent vomiting more fits a feature of small bowel obstruction, your x-ray will kind of at least your abdominal X ray will show features which allows you to quickly differentiate and I'll kind of show those features really briefly, but I'm going to do a teaching session more. So going into those features and how to analyze it properly, but you kind of keep it at a location on the abdominal x-ray. Where's the dilated bowels? And then the other feature is, do they have the, what we call the valvulae convenes, which are, um, demarcations on the bowel that go all the way across the bowel or your haustra, which is large bowel, those relate to large bowel where it's like small indentations on the bowel that you can see on the abdominal thing. And I'll show those, um, on the next slide, um, with your bowel perforation, which is how you differentiate it from your obstruction, you have both your examination findings and also your actual um uh history features. So, peritonitic abdomen, a peritonitic abdomen is where they're rigid. When you try and press in. They have gardening and a patient who does have a periton abdomen, you'll know it's not like their gardening. Occasionally it's, they won't allow you to touch their tummy. It's so tender and you can have other features like your rebound tenderness where you take your hand off and the pain goes through the roof. These patients just don't look well, you can tell fairly easily when you see them and then they often have systemic features like your tachycardia and your hypotension. Um And then you might have other features like their BP drops and, and that kind of stuff and they're pyrexic, but that's obviously related to the perforation causing faul material to leak out into the, into the abdominal cavity. So this is a abdominal X ray showing a large bowel obstruction. The way you can tell is if you can see on the X ray, the, um, there's like little indentations, the white indentations that come from the edge of the bowel into the middle, but they don't go the whole way across. They kind of just briefly kind of stick into the bowel and it's just like little indentations. They're not all the way across. So I can tell this is large bowel based off that. The other feature is the location, if you're seeing that is a dilated bowel and it's on the periphery of the bowel rather than in the center. This one is a bit more deceiving because the transverse colon is actually kind of flipped over into the center. But the sigmoid colon you can see is coming out from the edge. So I know that that's likely the sigmoid colon and the other kind of feature that you can pick out if you see that there's a nice demarcated point where the, um, there's no more large valley. You can, you can see the level of the obstruction and especially if it's things like a cancer, you might actually be able to pick out an increased density, which tells you that that's the cause of the obstruction. So this is your uh dilated small bowel and this is what I was talking about where you have the valvulae contes. Um It's shown quite nicely with those yellow, um, kind of stripes that go the whole way across it on the right side. You've got the lines that go all the way across the bowel. Um, that tells you that small bowel and the other feature is it's in the center of the abdominal X ray, it's not on the periphery on the outskirts. So you know that this is likely small bowel. Um And then they often use your kind of measurements that you should mention. So the law that they call it is your 3691. So small bowel should be less than three centimeters large bowel, excluding the sigmoid colon should be less than six centimeters. And your sigmoid colon and your cecum or more. So your cecum should be less than nine centimeters, but it's all arbitrary. You can tell quite clearly from Adonal x-ray, whether something is a bowel obstruction. And then the last feature is mentioning is figuring out whether it's a large bowel obstruction or a small bowel obstruction. The other way that you can tell is, um, by your history and the features that the patient presents with. So it's taking everything into account really what I wanted to quickly go over your way of differentiating your different kind of types of gall gallbladder problems. So there's only three big ones. You have your bilary colic, you have your cholecystitis and your cholangitis. They've got specific points at which they kind of grade themselves up. So bi colic, you'll have the pain, ok? And it'll kind of come and go. Colic is the bi colic is basically describing the process of, there's a stone that's caused an obstruction. Your gallbladder is recognized that problem and it's basically trying to squeeze it along to get the gallstone out basically. And it will do that for a bit and then it'll stop and it'll relax and then it'll try and do it again. And you have this kind of coming and going pain cholecystitis is where that process has led to the gallbladder becoming inflamed because it's not allowed stuff to, um, basically pass out of the gallbladder. It sat there for a while and that's caused inflammation of the gallbladder and you'll get the kind of constant pain in your right upper quadrant. And they'll also have the feature of being feverish and maybe also tachycardic as well. And then your last stage or kind of your, your last condition is your acute cholangitis. So this is where the obstruction is basically caused, um, er, the inflammatory process of the gallbladder. But then also you've had kind of bacteria that normally would sit in the duodenum. Basically, they've had a, uh, it's allowed enough time for them actually to track up the bilary tract. And this then creates an infective process on top of what you already have and you have what we call the Charcot triad where they have the jaundice, right, upper quadrant pain and fever. So, as you recognized before the bi of colic was the pain, the cholecystitis was the pain and the fever and the maybe tachycardic swell and the acute cholangitis is the pain, the fever. And now the jaundice, another big condition, which I kind of just wanted to emphasize is your a AAA ruptured AAA. You're very unlikely to be speaking to that person with them, still being awake and conscious. So, more so this relates to a patient who's just got A AAA as such, they'll have the back pain um and they'll have that kind of tearing pain that's radiating through to the back. Another very important feature is picking up on the kind of predisposing medical conditions of A AAA. And that's like your high BP, that's your main risk factor for A AAA. Um And then I've kind of mentioned your key features there more. So for a ruptured AAA, which the prognosis is very poor, to be honest, um is you have you reduce G CS and um they'll often be hypotensive. Um and they might also be peritonitic as well. Um And with a ruptured AAA, what is a bit beyond what you guys kind of have to know as such the presentation and how unstable the patient is, will actually depend on how the rupture occurs. So often AAA, they rupture posteriorly and those outcomes are worse because there's, there's more space for the blood to seep out as such and there's less kind of causing the um uh aneurysm to actually be blocked to stop the bleedings as such. Um Whereas there, there's fewer kind of triple that rupture anteriorly, but I'm not going to say the prognosis is really good, but it's better than when they rupture posteriorly as such. And I kind of want to just quickly mention about your acute pancreatitis because it's a really good one for them to throw into your risk because it tests your history beyond just taking a simple abdo pain history with E sos. So asking about surgical history, you'll pick up things like have they had gallstones before? Have they got an autoimmune condition that you need to know about your ethanol being the main cause of acute pancreatitis that comes up in your social history, trauma that will come up in your kind of other things that that kind of could be related. So have you had any trauma to your tummy, um steroid use that covers kind of your drug history? What medications are they taking at that point? All these things kind of come up relating to causes of acute pancreatitis. And so it's a really good one to test your ability to take a good succinct history across the board. Um So it's one which I just wanted to mention about simply because it shows the importance of taking a history across the spectrum and not, not missing out kind of important components of the history. So going quickly on to headaches, the way I often structured kind of take um thinking about causes of headaches was physiological. So things that have a physiological process, um not necessarily physical as such, compared to intracranial where you know that the physical problem is in the brain like a bleed or meningitis, there's an infection causing that problem. That's how I used to like to think about it. And then your extracranial being things that still have a physical cause. But you can't really say that they're in the brain, they're not intracranial. So like your sinusitis, it's in the sinuses, but it's not actually in the brain as such. Um So kind of your classic presentations, the attention headache that will present as kind of a very kind of a tight band that goes across their head. Um And often they'll get it kind of later in the day and you'll sometimes have predisposing features, but it's often associated with things like stress and such. Um If we're going to go on to the next side, I think I actually go through this. Yeah. Um So your tension headache, you'll have your band like pain and it can be associated with things like stress as such. Um You cluster headache, these are very severe pains. Um they often last for about 30 minutes um to a couple of hours. Um They often get it on one side. Um And often or not, it's usually associated around the eye and that's where it can present with like kind of the crying features of acclimation. And also they might get a bit of flushing. These are very severe headaches. They'll often come in, um, pain nine out of 1010 out of 10. Um, and the reason why these are, they're so horrific as such is, um, um, you often can quite easily look at the data of um, how these patients fare long term once they've had their kind of episode of cluster headache, their first cluster headache because they often occur over a couple of months and they do recur um the suicide rates for patients who have these conditions is very high. Um And so it just shows you the severity of this condition. It's a very nasty nasty diagnosis. Um Eventually they do go away, we can treat them with things like triptans and there's good evidence to show things like verapamil helps with preventing them. Um But again, they're very difficult to treat these kind of conditions. Migraines. Um migraines, you often get at one side, you get like a pulsating pain. Occasionally patients will also get a, sometimes you can actually have uh the migraine is the aura. So they won't have the pain, they might just have the aura presenting and that's usually things like either they get spots or kind of lines in their vision or sometimes they have like the flashing lights and stuff. Occasionally they can have like sensory disturbances is how they all represent. And then your trigeminal neuralgia is like your stabbing pain. They'll get it in that distribution of the trigeminal nerve. So either V one V two, V three, and they'll have like features in their presentation. So like the history where there'll be triggers. So if they're shaving it might trigger it. Um if they're combing their hair, sometimes that can trigger it. And it's very important to differentiate this one to things like your, your giant cell arteritis and stuff. Um As that one can kind of have a similar thing of they'll have scalp tenderness with giant cell arteritis. Um But with that one, it's taking a good history and knowing what is it specifically about that trigger that brings it about. And quite commonly you often have with trigeminal neuralgia, you may have symptoms of an external cause. So it could be a presentation, first presentation of MS or having something like a brain aneurysm for instance. So with this one, this was kind of one of these spot diagnoses that I really wanted to kind of go over and does anyone want to kind of put in the chat? What they think this is? Had she back? What does everyone think? I'll just wait for a couple of people to go down? OK. OK. Good. So I see that someone's put strokes, someone's put hemorrhage, someone's put sa H specifically what type of hemorrhage, intraparenchymal? OK. Good. So this one is kind of your spot diagnoses, which if I go through it really quickly personally said people are over thinking subarachnoid, hemorrhage you're spot on. OK? So the way in which you can tell this is a subarachnoid and it's why I wanted to kind of quickly show you guys what things you want to look for for a subarachnoid. OK? The first kind of places that I would often look for something like a subarachnoid is going right? Is eilan fissure, OK? Which is kind of a almost like a depression that you can see in the CT, OK. And also your basal systems, that's when usually the blood actually accumulates, it's in the basal systems and that's right at the center of the CT head. OK. Um You have your ventricle and then your basal cys basically kind of almost adjacent and it's kind of like an X shape. If you see white accumulating around there, the white shouldn't normally accumulate there. So it tells you that there's fluid that's kind of sitting in that place. Um And there's only a couple of things that that can be and most often than not, it's going to be blood that's accumulating there. Um So if I have a patient who's coming in and they've got like your classic subarachnoid hemorrhage presentation hit in the back of the head with a baseball bat pains, come on all of a sudden really quickly. Nine out of 1010 out of 10 pain, sometimes they present with reduced G CS, sometimes they kind of they're aware, but the headaches all fall, they might have neurological symptoms presenting with it. You're going to do a CT head immediately. And the first place I'm going to be looking is right at the basal systems. So if we can just kind of click, um Yeah, so it's not showing it. So, um if I can, are we able to edit this at all? I think I can. So if you can just demarcate um Joslyn the, the two white kind of splodges on the right and the left side. Sorry guys, this is going to be, there was meant to be an annotation, but the slide is obviously not working. Um Yes. Yeah. So the X the X shape there, you can everyone see that you have like your kind of your black spot right in the center, which is your, your ventricle. OK? And then underneath, sitting, sitting underneath that you have almost like a V that kind of like is holding that that bit. Yeah, right there right there. That's the basal system, OK? And it kind of is like an X shape and the blood basically is sort of basically seeping into that. OK. Um And then your Sylvian fissure is on the outskirts, those few bits. Yeah. So that bit there is one of your Sylvian fissures and then the other side literally just adjacent kind of same spot. That's your Sylvian fissure as well. So that's where your kind of two places are that you want to look for, for subarachnoid. Um So I just wanted to kind of quickly go through that with you guys just so you can make sure to spot it in the, in the, if they give you one. So a venous sinus thrombosis. OK, is a bit more of a niche one, but it's, it's a difficult one in the sense that especially when we're kind of investigating these patients, um especially when we're investigating these patients, you do a CT head, the CT head might come back normal, but they kind of have your features of, they have a severe headache. They might also have neurological symptoms, they had a seizure before loss of consciousness, those kind of things. So the way in which you kind of pick this up, at least in the IE which might help with your differentials and help you guys on the day is what I've starved there, which is your hypercoagulable state. That's really the main thing that they might chuck in for you guys that really helps you pick up on it. So feature or kind of conditions that cause a hypercoagulable state is things like pregnancy. So pregnancy is a really big one. Um other conditions as like hematological conditions that can cause a hypercoagulability. Can anyone in the chat put any conditions that you would think would cause a hypercoagulable state besides pregnancy? That's the main, that's the big one. Malignancy. That's a really good one. Yeah, malignancy. Yeah. Antiphospholipid syndrome. Yeah. Being on the combined pill. Absolutely. Polycythemia. So, any kind of myeloproliferative disorder, um, they can often predispose, I'm not a hematologist, so I'll say that much. So, my scope on that front is quite limited. But if I was taking a history and someone said that they had a condition like myelofibrosis or, um you know, they had a particular type of leukemia. I wouldn't be deterred in thinking that might predispose them to a condition like this. Ok. Good, good. So raised ICP. This is another one which I kind of wanted to go over with you uh with you all really quickly. So you can have different causes of raised ICP. OK. And raised, I raised intracranial pressure. Um The patients will often present with a couple of features in the presentation which would make me warrant thinking. This is more rose ICP compared to something else. So a big one is the, the worse in the morning or when they're bending or they're coughing if I've got a patient who says that that there's any kind of headache. The, the first big one, which is your red flag is a headache that wakes you up in the middle of the night. It wakes you up when you're sleeping. Ok. The other big one is, do you wake up with the headache still there? So it's either waking you up or waking up with the headache. The other one is, is the posture, affecting the headache. So that's the bending, bending down. Ok. And then the last one is, is there anything that kind of, ah, is almost a feature that you're doing that just worsens? It? So, coughing sometimes I would think coughing, making a headache worse. You know, it isn't initially something that would completely want me being worried, but it is something that would make me think this could be a raised ICP picture. And then if you have your other associated um symptoms, so you're vomiting, if you have any visual disturbance that worries me and then kind of neurological symptoms, obviously, if they've got any neurological disturbance, that's something that you know, is a worrying sign. And then you kind of your causes of your, your raised ICP physical causes. So your tumor, you bleed hydrocephalus and then one which is almost like kind of your er outside the remits of physical course, your I IH which is the idiopathic intracranial hypertension. Ok. That's your kind of classic patient who's overweight coming in. They've got the features of raised ICP. You've even got a uh they might give you in the station a picture of the ophthalmoscope, what you see. So the fundoscopy, it shows papilledema and then you do the uh you do a lumbar puncture and it comes back with a raised opening pressure, but everything else is normal. Ok. That's like your one where you are reassured in the sense where you can give your lifestyle advice. You can give medications to help um and treating it in that sense. But obviously ruling out your kind of acute problems um that could be causing the VIP one, which I wanted to quickly go over, which was the cushing's triad. Um It's just really important to kind of remember it and make it stick in your head if you have any patient presenting with these kind of features on an OBS chart and they have kind of your presentation of raised ICP, then that always makes me quite worried because your intracranial pressure is going up so much that they're now developing the systemic symptoms, which could be indicative of them, you know, becoming seriously unwell and even causing brain herniation and things like coning, which, which is disastrous if left GC um or giant cell arteritis. Um you have like your presentation of unilateral throbbing pain. Um often their scalp will be tender. They'll often say, you know, they'll be combing their hair or, you know, um be doing something where they're kind of touching the scalp and that's making it worse and they'll often get like jaw claudication with the presentation. So it will be painful to open them off. They'll say that it's worse when they're like eating or chewing. Um The best way to actually treat these is with high dose corticosteroids and it's actually a really good way of diagnosing these high dose steroids. Uh patients with GCA, they're very responsive, they're very quick to respond and if someone is started on these kind of medications and they don't respond quickly, then, you know, it's unlikely to be GCA, a really important kind of condition that will immediately tell you that it's highly likely they've got GC. Can anyone say what medical condition a patient might have that immediately makes you think this is likely GC or makes the chances significantly go up any thoughts? Yeah, we've got an answer in the chat room that polymyalgia, rheumatica brilliant. So if any patient has that, you know, it makes me think, yeah, it's high, likely they could have GC. OK. So I'll speed it up just because we've not got as much time, I'm dragging on a bit. So your causes of collapse. Um I kind of categorize them into your cardio, your neuro and then other, that's like your main big categories. So your cardio is things like your arrhythmias which cause syncope, um postural drop and then very, very rare ones which wouldn't be at the top of my differentials, right at the start is um your vertebrae basilar insufficiency, your aortic stenosis, chronic hypersensitive, rarer compared to your arrhythmias and your postural drop. To be honest, neurological seizure, tia a or your stroke, your vasovagal and your raised ICP intra of these seizure or taking any collapsed history. Very important when you're taking the history. It's almost the defining feature of finding out what the actual problem is or what has caused it. Um is how well you take the history tells you what it likely is, seizure, you'll have your features where you have the, before the seizure happens. They'll have that feeling of knowing. It's maybe going to come on, especially if they have background to epilepsy. They often have features of telling them they might have one during the seizure. They might have the tonic clonic fits, they might wet themselves, they might have some tongue biting all those kind of things. And then afterwards you have like your postictal phase and that um ti a stroke, the main defining feature differentiating between tia and stroke, tia a the symptoms will resolve within 24 hours. They'll resume normal neurological function to what they had before stroke. They'll have deficits left over um vasovagal. Um you know, your kind of vasovagal response, there's many different causes. They often can be situational, it's dependent on the individual. Um We've already gone through various ICP intracranial beliefs. You'll have like kind of your classic history. Um Other things that can cause you collapse or fall, drug overdoses, your alcohol intoxication and then your mechanical falls and that, and then you can have other external diagnoses causing someone to just be very unwell and have a fall or collapse. And then the last one I wanted to go over, which is kind of a big one. I like to sometimes chuck in as you causes a red eye, it's very exhaustive and, you know, I'll leave you all to kind of go over it in your own time because I could spend a whole session going over it. But just being aware of causes of red eye and how to differentiate them. The best way to differentiate the two is firstly, is it painful red eye? Is it non painful red eye and then kind of your features that are associated with those types of conditions in those categories? Um You can separate it based on what is the structure. So your lids conjunctiva cornea chamber, but I often prefer to go down the route of nonpainful red eye causes and painful red eye causes. Um See you so kind of just a little bit. Yeah. So we're gonna have a quick session on CBD. It's not gonna be that long. So hopefully we'll finish in like 10 minutes. Um So I'm pretty sure after your lo is, you know how the station work. And I just want to reassure you that I think most people pass the station. I have never come across anyone that failed a station and you'll remember that you'll be given your exact CBD that submitted onto learning central. Um So personally, I wouldn't recommend like 100% sort of learning your whole case, but make sure you can sort of discuss it in a very like confident manner because obviously you are great on how confident you are presenting the case and also how um suing you are with sort of, um, talking about the sort of findings, management and investigation plan. Um, the examiners should normally ask you the question listed on Learning Central, which I've got a list on the next slide. But as you know, from, um, experiences from um seniors, like this is not 100% the case, normally they would ask something sidetrack. Um Yeah, and so we're gonna talk through like what kind of question they could ask you later as well. Um, so in terms of how long you speak for, um, so you will have, you'll be given seven minutes to speak. Um, so I'll recommend you to talk for about like 6 to 7 minutes. Um, you don't need to use up the whole seven minutes. You finish at about like 6.5. They will normally start asking you questions and you normally finish the station maybe one minute or two minutes earlier and you'll just sort of rest there like, um, that's a little brick for you. So that happened to me last year. Um, so just a few points of why people struggle in the station normally is because firstly, um, their case is not very complicated and they speak less than six minutes, so they finish it really quickly. So, um, a case that's not very complicated will be someone maybe having osteoarthritis. Um, something like that. Cos I did that for my mock ey, um, I think I didn't present it but then my friend told me. Yeah, your case is quite sim um quite simple. So, um that's not much for you to talk about. Um So another aspect is they have nothing on um, social. Um So just to clarify what sort of social and ethical aspect the school wants to talk about is something that's affecting one's quality of life. Um, to put it in a very like simple terms. So for example, if someone has a um neo feur fracture, um and they live alone, they couldn't really sort of take care of themselves. Um they will have to be sent to a care home. But if the patient doesn't want to be in a care home, that's a bit of um ethical issues. And it's like socially, it's affecting their social life or if someone had a fracture, they can no longer run, they're stressed and there's one way of sort of maintaining their quality of life then um that could have an impact on them as well. So it's all thinking about like how their life is affected, then that sort of like the social area or like if it's affecting their work, that kind of thing. And um you should be prepared for some sort of weird question to come up. So for example, um we're gonna go through that later. Um So it's basically something that they could ask you very unexpectedly. So for example, you didn't expect them to ask you about the complications of your condition. So that's something that you could prepare about. Um So this is taken from the um 2023 CBD template on in Learning Central. So these should be the question that you should be preparing for um when you're preparing for your um ski. So I would suggest actually um making a word document and typing out um all the, all your answers to the following questions because these are the one that you should be 100% preparing about because they're on learning central. So it's mainly about investigation, the risk benefits of the management plan and where sort of like the management is based off from. So um it could be from nice guidelines or from your trust guidelines and how does the management plan actually benefit the patient? So it's kind of similar to the benefits of it, but I guess it's more sort of um tailored towards your patient's case more specifically. Um And then obviously you've got the ethical issues and um how did um the patient made an impact from you? So for example, it could be like how to take care of a patient in a very holistic point of view or um take everyone's um condition into um like you should take care of them personally rather than like everyone should be treated the same, that sort of thing. So in terms of how you should present your CBD, um I would recommend you to start from the sort of history, history of presenting complaint, the sort of past medical history, surgical history, drug history and allergies, family history, social history, and then go into your sort of initial differentiations based on, uh, sorry, initial, um, differentials based on the history. And then you can talk about what kind of investigations were taking place in the results and that could sort of help you to rule out, um, your initial differentials and then you could talk about the final differentials and how the patient was treated. Um, personally, I wouldn't talk about my sort of ethical discussion in my seven minutes because if you talk about the, it in your seven minute history, um, when I asked about the um, ethical issues towards the end, if you felt like you sort of repeating yourself. Um So I was sort of hinted for, for example, I would say like, um, socially, let's say it's a neck fe fracture just because I did it last year. I would say like, um, the patient wasn't able to run and this had a huge impact on the quality of life which I'll talk about later in, in, um, the social question or for or that kind of thing. Um So that sort of gave me an idea of like you're gonna talk about this in a more detail and that's gonna be your social. So they were asked about that. Um So you are sort of hinting it rather than them asking you some sort of random questions. Um So, um I've got a few questions that some people ask me. So do you say everything you write down or do you include info that is in there? So for me, um I personally think everything that's on the, a four sheet of paper is the most important thing and you should only write down the most important thing on that sheet of paper because that allows the examiner to have a quick read of what your case is about. And, um, you could elaborate more when you're speaking and it feels more natural to it as well. And obviously when you're a bit nervous, you're gonna talk a bit quicker. So, um, when you sort of add more stuff into it, um, it allows you to sort of lengthen time a bit more as well. And obviously, if you write everything down on the piece of paper, you're gonna sort of lose your eye onto the paper and you need eye contact in your sort of CBD discussion. Don't forget that because you gave back from it as well because that's part of your, how you present your case sort of confidently. So, um, yeah, II would write the sort of minimal stuff on the paper, but that doesn't mean like writing very, very little. It means it's just just enough for you to sort of maintain eye contact, but also remind you of the important stuff. Um So in terms of topics of what you should go through in your um CBD. Um I know a lot of you have done Narcof Feur Fracture. Um But I've got some ideas in here as well, so it's a bit of um acute and chronic history as well. Um So I think um Peds op and Ghana are very, very um useful um blocks for taking history because that's actually quite a lot that you could um use it from. So I know some of you haven't done your op and Ghana block. So maybe um when you're doing your placement, have a look at your um patient and see if there's anyone having um preeclampsia um abruption. Um when you're doing your gyne block, then your endometrial cancer, endometriosis or menorrhagia. These are very um classic um CBD history as well. Um If you're doing a neuro block, um if someone's having a stroke, MST I A or just headache, these will be very useful as well. Parkinson's is a very, very good example as well. So feel free to take a syringe off this table and just save it on your phone and then just to have a look if anyone's having these conditions. Um but you'll be given the slides later after you fill a feedback form as well. And um top tip will always be running through your cases with the doctor and going through the questions as well. So, um what I did was I basically sort of prepared my answers and um went to F two and then just go through my questions with her and she also gave me some sort of feedback on um where I could get my information from. So I find it really helpful. Um So in terms of like guidelines, um I'll suggest the nice guidelines would be your sort of top top tier sort of resources that you should use, you should be using it from, but any sort of Royal Colleges will be very useful as well. For example, for your um op Gynae your Green top guidelines. Um So don't forget about your trust guidelines as well because every trust have different guidelines. For example, if you're doing um C diff um some people use Vancomycin, some people use um feed do so um just go through your trust trust guidelines and you could always ask F one to get it from micro as um we said in previous case only um in Wales. Um so you can use it to check your antibiotics as well. And um you could always, if you're not sure about um the micro guide, you could always say um based on the trust microbiology um recommendations um because normally like F one F two will make phone calls to micro and you could say that as well. And um if you look up into any sort of research papers, you could use that to support your um findings as well. So, um what kind of work you should be doing before your EK. So I'll say, um make sure you know the condition um inside out because as we said, um they could ask you unexpected questions. So if you're so um familiar with the condition, you could sort of um talk about it um without getting very, very nervous. So that includes your, your investigation and management and when you practice, your friends ask them to test you on the questions that you don't think is gonna come up. So for example, when I did my neck or femur fracture, um obviously, in my head, I'll be like the doctor is going to ask me about why is a hip X ray taken place? Because that's the most obvious investigation that someone should be having if someone is suspected to have a neck of femur fracture. But actually, in my real ey, they asked me why a FBC was taking place. So I, because I did all the, I asked my friends to ask me all the questions, so I know how to answer that, but um just be prepared um that they don't normally ask you the sort of normal questions and for my management plan instead of asking me, um um like they asked me sort of like, why is the nerve block taking place? So you sort of have to be prepared why like nerve blocks are used rather than like morphine. So the answer is because morphine is more of like a systemic one. So it wouldn't target um the sort of hip areas. But if you use a nerve block, um it could, it will go to your body much more quicker and it will be a sort of instant relief of pain as well. But obviously, a danger will be like hitting um because you have to nerve block for so long that you could have some nerve damage as well. But the risk is very minimal. And it's um I remember someone doing like preeclampsia and they asked about like fibronectin as well. So you can sort of present what they're gonna ask if, if the investigation is very, very specific but always be prepared for them to ask and like very weird questions as well. Um So these are these sort of example questions that they could ask you that is not a learning central. So for example, what were the complications of the condition? Do you disagree or agree with the management plan? And um what aspect would you have changed? And are there areas of management plan that could be improved or they could just have a chat with you on the case rather than sort of asking you questions? Because one of my friends had um something on asylum seeker and rather than sort of asking her the questions on, on the central, the examiner just had a chat with her and it's a very nice chat, but Um So obviously that depends on who the examiners were. So, um the one that normally stick to learning center or the one that's like a more academic fellows, I'll say, um but the one that are sort of out of the blue question will be um doctors or like consultants really. So my top will be always practice the doctor and ask them to sort, sort of check your answers because in that way, you're making sure that you're sort of um talking in the um right line, but also um they're gonna give you extra information and that could sort of make you like looks really as well. Um So that's the end of my presentation, Ronan. So if you have any questions, um just put it down to chat and we'll try to answer them and thank you. Brilliant. Thank you, Jo Hope you all enjoyed that. If you can all fill out the feedback, that would be really appreciated it. We've already been kind of looking at the feedback which you guys have been given over the last couple of sessions and we're going to kind of meet as a team to kind of go over the feedback to kind of tailor the teaching sessions to basically suit you all best. So definitely please fill it out because we really do and appreciate it and it helps us tailor the service for you guys. Ok? If you anyone has any questions, then please put it in the chat. But if, if not, then you will enjoy the session, you're free to go enjoy your evenings and your, your weeks we have a session next week. Is it k, are you doing it or is it? I think next week is the Pharmacology Station? I believe I might be wrong. Like Jack and Sarah, I think. Yeah. Yeah. Brilliant. Well, I don't think there's any questions. So, thank you all for attending. And, um, if there's any questions that's been to mind then, um, oh, that's ok. I gave you that's fine for anyone who attends the sessions. We're more than happy for certificates. You'll be watching the session afterwards on the recording that we'll upload. That's the same for everyone, ah, will be uploading the learning resources for you all to kind of watch at your own leisure later on. So, um, yeah, we'll sort that out and hopefully you all can watch things and recap stuff if you wish. But thank you very much for attending in and enjoy the rest of your weeks.