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Okay. Good morning, everybody. I'm so sorry to have kept you waiting as you know, we're all working doctors here and I had a meeting that I couldn't leave. So I hope you can all hear me at the moment. I'm working for my telephone, which is far from ideal trying to get me set up. I've got a bit of a problem with my laptop, but we're working on it. Um, okay. So were you at the previous lecture is the first question? And, um, I hope you were and I hope you enjoyed it. Um, so some of you who are here will have had, um, a sheet, not one of those, a sheet that looks like a blank, one of those if you haven't got it. Um, certainly at the end of this session, I will put up a suggested completed version for you so that you can look at that. But part of the point of that is that, uh, rather than just making lists of things, you think a little bit about how stuff fits together. So sorry to interrupt doctor, I can put the worksheet from last time in the group chat. Now that would be really helpful if you could. Thank you. I'll do that now and I said email now also. Okay. Let me, let's refresh. It's not picking it up yet. Um, it'll arrive in a few minutes. Okay. We start as usual with a sort of a clinical scenario on this occasion, visiting friends who've got a seven year old who is bright, intelligent and so on. Um, and you're just chit chatting with the family about how he's getting on and family say, oh, well, you know, he's such a day dreamer. Um, he's uh so he's a daydreamer. He doesn't pay attention in school. Um And so he's not doing very well at the moment, you know, he never pays attention to anything. Um We're a bit worried about him. What do you think? So, what are you thinking? Is anybody thinking anything at all? Personally? My cricket risk. Sorry. Can you speak up? The person might be depressed? Might be depressed. One is ocean. There could be many reasons. Okay. It's a seven year old child, Chen. Yeah. So seven year old child, probably not your highest priority to be thinking about depression, but certainly something that you would want to think about. I agree. Okay. Any other ideas? Like would you say this uh like hyper, sorry, I didn't hear that. Like, would you say that this child could be hyperactive? Could be hyperactive? Yes. So we could think about maybe a D H D. You Yeah. Uh, logistic. The child suddenly stop talking or is the, like, the solvents? Yeah. Good. Is this new, is an important question? Yeah. So, is it new? It's been much more noticeable since he's been going to school in school? Yeah. Something from the school. Maybe he's not an active, uh, somebody in the school is not being appropriate. Yeah. So, something might be happening at school. Agree with you there. So, we might first asked if a child has friends in school but he doesn't have friends in school. You might as a teacher. How is in the classes? Well, they reacted and the call is very quiet. Hello? Can you hear me? Now? You can hear me? Okay. I think you're muted. Um, because I can see you're talking. My, my, my mic is on. Yes, my mic is on. Try again. Say something as add anything. Okay. Yes. Now I can hear you. Hurrah. I'm sorry. It's been such a chaotic start to the session today. Okay. I was saying that first we might ask if the child has friends, doesn't have friends. We might start the teacher. How's the child in the class? Talkative. Interactive. Very dull. Oh boy. Yeah. So you want to find out what's happening for this child? Is it anything happening at school? Some of you live in places where there's quite a lot of civil unrest or just plain war. So all of these things might be feeding distress. What other things. Might you think about seven year old, bright, intelligent, lively chap, superficially normal, physically healthy, bit of a daydreamer doesn't pay much attention. What else in terms of medical things might be causing him problems? You can see that child might hiding something, might be hiding something. Yeah. Medical problems. Things that you're going to check out my check childhood as a physical examination, whether something is bothering, like physically pain, which he's not telling me. Yeah, straightforward things that you can check. Can you hear? Okay? Yes, we can't see what we can agree. So you can check his hearing. Maybe he's not paying attention because he just can't hear what's going on. You can check his eyesight. Is he not paying attention? Because he can't actually see what the teachers putting on the board to ask him to do A D H D. You might also think about, think about trauma and you might think about epilepsy. What sort of epilepsy would give a young child this pattern of for no particular identifiable reason. They're a daydreamer. They zone out, they're not paying attention, they're not doing well at school absence intervention to uphill section. Can you lots of interference? Could you say that again? I think you might be right. I think uh like uh absence uh yeah, tends to be early school years when absent seizures start to manifest. So it's certainly something that, that you would want to think about. But you also you know, you have to be practical. Also, things that people might start to notice once a child is in school is that they don't hear very well, they don't see very well. There might be some kind of trauma or abuse going on. So the first thing you want to do is make sure that it's not a simple question of getting them a pair of spectacles getting there is syringed out, seeing if they need hearing aids and things like that. So, and it's the kind of thing, especially for boys that it's just kind of, you know, that kind of behavior is, you know, well, you know, he's a boy, he's a daydreamer, he's not that interested in school. Yeah. And we'll talk a little bit more about why absent seizures, which usually only last 123 seconds, why they're so disruptive and why it's important to try and recognize them. Okay. Good. So not every medical situation is a crisis. Sometimes it's a bit a straightforward common sense. In fact, most of medicine, to be honest is straightforward common sense. Okay. So last time we talked about different things that increase your risk of having a seizure. It talked about the fact that most people who have a seizure have a single seizure and we never find out what caused it. They never have another one. It's all pretty straightforward stuff. We talked about why it's important. We talked about the risks which include death um sudden unexplained death, which often happens at night, but also having a seizure, you might fall against something and hurt yourself. Um It's almost certainly going to be embarrassing to you. Um So lots of kind of social, personal mental health issues associated with having had a seizure, even if you just have that one seizure and never have another one. And we also talked about medical emergencies in seizures and specifically status epilepticus. Okay. So there are stages of a seizure. And if you've got the spider map, you should be able to see that I've suggested that there are three phases. Would anybody who's been shy so far? Like to suggest what those three phases might be called, what they might mean? Even just just one, if you can identify one phase for us, somebody who's not spoken yet today, just like our stage. Hmm. And I think there's uh particle stage two is the recovery period. Yeah, that's right. Well done. So three phases. You got it. Exactly right. Well done. Pre ictal, ictal and postictal. Okay. So the ictal phase is the seizure itself. And when we talk about different sorts of seizures, then um there are differences in there in how people behave and how it affects them pre Actel. If you're lucky, you get what's sometimes called an aura or a program. So prodrome just means before the event. Okay. Everything in medicine is actually really simple. Yeah, some people will have some kind of warning that they're going to have a seizure and that varies enormously from person to person. Some people have a particular smell. Some people have um like a visual hallucination very briefly. Some people just have an uneasy feeling that makes them certain they're about to have a seizure. And this is very useful for them because it means that they can make sure that they're in a safe place so they can sit down so that they don't fall and hit themselves against um a hard object, maybe there are people around them that they can say, I think I'm going to have a seizure. This is what you need to do for me. Yeah. And some people have um pepes that seem to be able to predict a seizure coming on which, which is a very interesting phenomenon. Postictal again, varies enormously from patient to patient. But patient's tend to have the same pattern for themselves. So if it takes them about half an hour to recover, once the seizure has terminated, then it will usually be about half an hour. Whereas for another patient, it might only be about for a few minutes. But this postictal period is why some patient's with a diagnosis of epilepsy are looked after by a psychiatrist or at least unknown to a psychiatrist. Because what other kinds of problems do people have in the postictal period? Again, if somebody's feeling brave, who hasn't been brave before, so varied outcomes that you're almost bound to be right. Whatever you suggest. Oh, silence Azad. Go on. Then some people are very fatigue. Some are, can some have confusion. Yeah. No, she ate it sometime. Yeah. They might not be able to remember what's happened where they are, how they got there. So they might have a little bit of retrograde amnesia. Most seriously. Some unfortunate people, they're postictal period. They become psychotic and they will need inpatient treatment. And again, it can be short lived. It can. Last weeks, I had a lovely lady in one of my jobs. King got catatonia and usually needed about five weeks on a psychiatric unit. Before that catatonia started to resolve the other group of people who tend to at least have psychiatric involvement. Uh If they have a diagnosis of epilepsy is people from the learning disabled community. Um There is an increased risk of seizures if you have mild to moderate learning disabilities. And um so that would be an indication, not everybody who has mild to moderate learning disabilities will necessarily have a psychiatrist. But if they get seizures, then we would certainly be be looking at that and keeping an eye on them and trying to keep their seizures under control. So that's in very simple terms, what happens during a seizure and try to remember this is an occasion where your patient is the expert, your patient will be able to tell you what goes on for them. They will be able to tell you about known triggers. And sometimes, you know, people are people if you're a young person and you want to go out with friends and it's somewhere where you can dance and there's music, there's going to be flashing lights, it's going to be hot, it's going to be stuffy, it's going to be noisy. You may have alcohol and so on. You know, if you're a young person with epilepsy, they have to weigh up the risk of them having a seizure against the social impact of not going with their friends to these kinds of things. So medicine is all about people. It's all about human beings. We all know how to behave. We all know what's healthy, what's not healthy mostly doesn't stop us from giving ourselves the occasional unhealthy treat. Yeah. So try not to try, try to bear in mind that sometimes people will make unwise choices. But that's because they're human beings and they need, they need the fund, they need the pleasure, they need the social life. Okay. So what would you like to look at next? Types of seizures, diagnosis or management are the three big things that we've not looked at yet? Anybody on anxiety. What do you fancy? As'ad sorry, bad day diagnosis. Okay. How do we diagnose epilepsy? It's kind of three simple steps. What's always the first step in diagnosing anything? Go on, you know that history, history. Yeah. What's happened? Has somebody seen these seizures because remember, the patient may not remember or may not remember accurately. So, has anybody been with you when you've had a seizure? Can I ask them what it looked like? What have other people told you? It looks like do we diagnose epilepsy on the strength of one seizure? They could but that has to be proper proper record. Like someone might say something. That's yeah, he was acting weird. Some not doing features. You you might if the patient was in hospital and was observed by somebody with suitable experience having the seizure and if you manage to get an E E G on quickly, so that you could see some seizure activity, usually you wouldn't think about epilepsy until a person is reporting that they've had two seizures of similar presentation. Now, if you know that it's an insulin dependent diabetic who is deliberately overdosing themselves on insulin either because they're suicidal or they have a personality disorder or increasingly common in young women because if you slightly overdose on insulin, it helps to keep you thin. Okay. Remember human beings, we make otherwise choices. So in that case, having more than two seizures that are due to fall in glucose, you wouldn't diagnose epilepsy. Yeah, because that's that's a controllable circumstance. So normally you would expect good witness accounts or a good history of two similar seizures that are not initiated by controllable, by controllable factors like glucose, things like that. E E G can be helpful. Notice that weasel word can, what have we got? 12 people here today? I think I saw somewhere on my screen if we all underwent an E E G, how many of us would have um abnormal E E G readings? 12 of us here. How many do you think? I think assuming that none of us have a diagnosis of epilepsy. What's the chance of us having something abnormal on R E U G? Yes. Have a wild guess. Put it in the notes or the chaps or whatever it is. How much, what percent? 20%? No, just two, just 2%. Okay. 2%. Any advance on 2%. 50%. Yeah, 50% is closer. It's E E G S slightly over writing nine. Yeah, slightly over half the population will have something on their E E G that is abnormal. So the E G is not a definitive test. It would have to be in association with a good history. It might be where it becomes most useful is if you deliberately provoke a seizure, if the patient actually has a seizure while they're linked up to an E E G machine that is massively helpful and can help diagnose all sorts of things. Um For example, you can read an E E G and you can identify pretty exactly where someone has a brain tumor. Um You can identify from patterns whether the problem is that they've got an en careful opathy, you can identify certain distinct patterns that are associated with specific types of seizures. So it is useful but it is rarely definitive. The other useful thing. And you're going to have to put your thinking caps on a bit. For this one, I think is that any immediate post tonic clonic period? So part of the postictal pattern is that the patient will have a significantly elevated creatinine kidneys. You don't get that any other seizure types, would anybody? But they're thinking caps on and suggest why you might get that rising CK. It was a certain muscle twitching muscles. Uh who who else? And this is a bit off the wall, who else sometimes needs hospitalization because of elevated CK levels. Patient who suddenly has architect. So Marquardt it introduction. Yeah. Anything. Anything where there's muscle damage, people who run marathons? Not uncommon after a marathon in a local area to have a couple of people on your endocrine ward with elevated CK because of the muscle damage. Yeah. So especially um in the tonic clonic because it involves the entire musculature and certainly in status, you will get muscle damage and part of that will be oxidative damage, lack of oxygen, too much oxygen. Part of it will be muscle damage simply from the constant tensing and flexing. Okay. So that's always something to check. So there you are sitting harmlessly in your office in hospital and a nurse rushes into the room and says come quick doc um Someone says having a seizure. So it's not status yet. Okay. Just a seizure. Go and see the patient. What you gonna do patient is seizing now. So some things you're always going to do for a patient who is seizing if you can anybody remember what they are, check the um consciousness. Um uh yeah, oxygen, oxygen, oxygen slap that oxygen on. You're not going to leave the patient till the seizure is terminated. So you put the oxygen on, you turn it up max, you do not worry about what they're saturations are okay. Remember you're buying time for the brain or hyper oxygenating the patient. Okay. Simple test is always the BM because falling glucose, especially poorly people, they might not feel like eating and so on and it's really fixable. Yeah. So you want to find out what's causing it, which is a nice optimistic thing to say how many people we've said this quite a few times how many people have a seizure and we never know what's caused it. 60%. Remember the chances of you, I digging why this patient has had a seizure is pretty low. But if you can, then that's very informative for, for helping them in future to avoid other seizures. Remember highest risk factor for a seizure is having had a seizure. Okay. So if you can identify a cause you're gonna reverse it. Yeah. How long are you going to keep? So the patient's in hospital. They're, they're in hospital for some random, fairly routine thing. How long are you going to keep monitoring them? About a week, about a week. Yeah, you need to give them a, give them a good six hours very occasionally, but particularly where it's, it's space occupying lesions that cause alterations in I C P. You'll get what's called a sentinel seizure. So you'll have like a little seizure that will usually be self terminating. But if it's somebody who has no known history um of seizures of epilepsy and so on, it just might be that there's something happening in the brain and that was just a little warning. So if they have a second seizure, you're going to want to get at the very least a head ct urgently if there's no other relevant history. Yeah, most brain tumours are kind of, they're what, what in the West we sometimes called incidentaloma. Is there a chance finding when we're thinking about something else? They're rare. They're very, very rare. But for obvious reasons, the sooner you can catch any kind of cancer, the the sooner you can help the patient and you improve their survival chances. Okay. So we've got quarter of an hour left. So let's talk about different kinds of seizures. So there's three broad groups. Yeah, there's the partial seizures, the generalized seizures and the non epileptic form seizures. Okay. So two types of partial seizures or are they uh simple? And complex. Well done. Yeah. And since you're, you're here and online. Halima, um, what's the difference between simple and complex? Oh, she switched her, uh, I'm here. The frog. Okay. I've got t on the screen. Taiwo, sorry if I'm mispronouncing your names. I, I do right. Flying back and for simple it's, it's, um, there's presence of consciousness, I think. Yeah. Complex. There is no consciousness. Yeah. Yeah. So, it's a fairly arbitrary division. Um Can a focal seizure become a generalized seizure or are they completely separate phenomenons? Yeah, they can, they can actually. Yeah. And when that happens, what's what's happening to the electrical activity in the brain? All right. Um It's continuous transmission of the Him pulse like been uh it's been um trying to bath around the brain since the it's not, it's not abated. So it's just getting transferred. I don't know how to explain it. I know you've, you've done a very good job. So a focal seizure or a partial seizure, it starts off just with one small area of the brain. It may terminate spontaneously or that disturbance in the electrical impulses may spread across the brain and become a generalized seizure. Ok. Partial seizures are very interesting, particularly complex seizures are associated with hallucinations which do not occur for the patient when they're not having a seizure and interestingly are particularly associated with what the patient believes to be a religious experience. So, the patient may believe that God or angels or something like that is talking to them, giving them messages and, and it may be the origin of um uh people who have visions of God. Um And uh it's up to your personal belief system. If you see that as God interacting with human beings that, that, that breaks down the wall between God and man a little bit or whether you're a pure physicist and say no, this is just the brain being a bit out of control. But it is very interesting that the amongst people who have complex partial seizures, a lot of them have experiences during the seizure which which which are religious experiences. So I just toss that in as a bit of random knowledge. So generalized seizures, I gave you kind of the common names. Um I think on, on your spider diagram, generalized seizures, three basic types. Petit Mal. What's the more formal technical name for a petit mal seizure? So it was a question mom. What's, what's the formal name, the name that you're more likely to find in textbooks for a pretty mall seizure? Cesia. What sort do you mean to Nick clonic seizures? Um tonic clonic would be a grand mal uh okay absence seizure. That's right. Absent seizure, which we've already talked a little bit about tends to manifest in childhood. It's probably been there all along. But when Children start school is when people start to notice the impact. And that's because although the seizure itself is only a matter of a few seconds. Usually one to not more than three seconds, there may also be an additional period of a second or two of amnesia. And so it's like for that individual, it's like listening to a really badly tuned radio that the sound if you like comes I/O, that there'll be gaps of a few seconds here and there. And that's how a very intelligent person can nonetheless really struggle at school because they're only receiving fragments of the information. And that's why it's important to identify it if you can and to get them to a specialist to see if something can be done to reduce the frequency of the seizures. Ok. Tonic clonic is the grand mal seizure and that's the one that we talked about when we were talking about status epilepticus. That's, that's what's happening there. It is. Remember it has two phases. Yeah, neurologists have no imagination. There is the tonic phase and there is the clonic phase. It is possible to have seizures that are just tonic or just clonic or unusual, but they exist. Okay. Sorry. One of my colleagues has just entered the room um lecturing at the moment. It will be 10 more minutes. Okay. And then drop seizures. What happens if you have a drop seizure? I know when you fall down, fall down. Yeah, like I said, neurologists, no imagination. That's what it called. That's what happens. So that would be a sudden loss of tone, often just in the more limbs but not invariably sudden loss in turn, which means the patient falls to the floor. And that again would normally only be a small number of seconds. It may progress to a generalized tonic clonic seizure. But usually it's a, it's a kind of an isolated event. They might be the usual kind of postictal. Remember that varies enormously from patient to patient. And of course, it carries with it all the risks of a seizure. If you suddenly you're, you're standing up, you're walking along the street, you're walking through your office, um and you suddenly fall to the floor. It comes with all of the risks of injury that we've talked about before with the long term risk to mental health, social and personal effects and so on. So, although it sounds quite harmless and it would be rare for a tonic or drop seizures to directly cause death. Nonetheless, it is dangerous and it is very distressing for the patient and carries with it all of the mental health potential issues. Okay, nearly there. You're working very hard. I do congratulate your non epileptic form activity disorder syndrome needs sometimes for a big fancy name. Anybody know what that used to be called. You might even find it called this in older textbooks. No, this is often associated with people who have personality disorder. There is no disordered, um, electrical impulses in the brain when you look at someone having a seizure, it progresses in a very ordered way. If you know your brain activity, it's particularly obvious when somebody has um uh when somebody has, has a partial seizure that then progresses to a generalized seizure because you can see how it spreads across the brain. Okay. So if somebody is presenting with seizure like activity, but it doesn't fit with what you know about how the brain works. So they start off with bit of heavy breathing, bit of rolling their head backwards and forwards on the pillow and then start banging with one of their heels on the mattress that doesn't fit with what we know about the anatomy of the brain and which fits the brain controls. Okay. So that person is not having an electrical seizure used to be called a pseudo seizure. We got uncomfortable with that term because of a suggestion that it's not really which patient's found offensive to the patient. This is a very real experience. They may have personality disorder, they may be desperately seeking help and attention. It is perfectly possible to have both needs and to have epilepsy to have the two running alongside. So some seizures will be genuine for one of a better term, epileptic seizures and others, maybe non epileptic form. And as your last little thinking point, we talked about something a bit earlier that might help us to distinguish what's going on for the patient. Is this is a grand mal seizure. Is it a non epileptic form seizure? Anybody work out what that is? Presentation of the, since the rest of them, what was that presentation about the behaved by seizure? Yeah. So, so you're kind of suspecting from presentation. People with non epileptic form seizures rarely injure themselves. Okay. They rarely bang into furniture, they rarely empty their bladder. Okay. Um The other thing is, remember we talked about, we've got one test which gives us information about whether somebody is having a tonic clonic seizure, which is not an eeg, well, somebody having a non epileptic form, seizure have raised CK. Uh No. So one of the things that you can do if you're not quite sure is you can do some bloods, which you're probably going to do anyway because you are going to want to check glucose and, and so on. And so try to get those bloods done quite quickly if you suspect non a non epileptic form. Because if CK comes back normal or only very mildly elevated, chances are this was non epileptic form and management is completely different. Would you give anti epileptic medication to somebody who's seizures were nonepileptic? All? No, no, because he's not gonna make any difference your screen with the brain. There are going to be unwanted effects. Yeah. And so best practice is always least medication, smallest effective dose. Yeah. So it is important to be able to distinguish between the different types of seizures because, um, because also we, we're not going to talk about it today. Uh, different anti epileptics are more or less effective in different kinds of, of presentations of seizures. Okay. So that's, that's a very complex area. And I think, I can't promise. I think that we do have a specialist pharmacist who at some point is going to do some, some, uh, presentation specifically about the kinds of medications that, that we use. Certainly in psychiatry there, a specialist um, pharmacist, well done everybody. Thank you for coming. And I hope that you found it interesting. I hope that having a bit of a think rather than just um just reading somebody's power point has been a nice change of pace for you. Do give feedback, do particularly give feedback about the mind maps. The spider diagrams. If you're finding it helpful, I will um provide them for, for future sessions. I do have, I'm sorry, I'm completely useless with these and my laptop, as you will have realized he's playing up, I do have a almost completed copy of the spider diagram. I haven't written down the details of different types of seizures. It's easy to look those up and I will make sure that those are made available to you in in short order. Thank you very much for coming. I hope that you managed to have a good day. Thank you doctor. Thank you. My pleasure, uh person in charge who actually knows what they're doing. Um Yeah. Can we make sure um I did send um a copy on of the company to diagram a couple of days ago to the add mons. Can we make sure that that's made available team or who came today? Sure. I can't send it afterwards. I can send it now though. Would it be possible for you? Would it again quickly? Okay. Where, where is it on the screen where I can actually upload a file? Could you do it? Did you do it on whatsapp previously? Yeah. Could you send it again on whatsapp? And then I'll save it and I'll put it on the chat quickly. Absolutely. We'll do that now because thankfully we've got, I mean, there's pros and cons, but we're running late for the next one. So. Yep. Black baby. Just do that in the meantime, everyone. Um, again, please do the feedback and the certificate for this lecture is already on the chat so you can download it there and if you can't download it, make a note of that and we'll address it. Hopefully. Do course. Okay. Thank you. Don't, I'll work out how to get it to people. Um, do feel free to send me a DM. Um, if you want to talk about anything. Um, doctor, do you remember what day it was that you sent her? No, our internet is going I/O. Now, I'm about to have my own nervous breakdown. It's not, it's not the initial one that you sent them. It's a, no, there should be another one. I will, I will sort it out. Let me just have a look. Did I have the brains to send it to my personal email? Okay. No. Uh huh. In the meantime, if anyone has any, um, admin related questions or anything, feel free to ask me now. So we've got a few minutes. Do we have any new lectures regarding uh Doctor David Young when you have, uh do we have any lectures in this town with Doctor Kim Young? I don't think we have any booked yet, but hopefully we'll have some at some point. Yeah. Okay, I have it now. So I'll quickly figure out that might just be the skeleton. That's not the completed one. No, I see. Um I think the best thing to do um If I'm not mistaken, most people here on the whatsapp group. Um Anyone who's not on the whatsapp group, I'll put the link for the whatsapp group in the chat quickly. Um And then once I get the complete uh worksheet, I'll put it on the whatsapp group for everyone. So even the people who didn't come to the lecture can see it. But yeah, yeah, I mean, I think it's a useful basis for revision notes. So yeah, I'll just quickly put the whatsapp link on. Um Here we go. Right. So that link is in the chat now and I will I think we'll end it here and move on to the next lecture. Thank you very much, Doctor. Thank you. Sorry. It was a bit incompetent today. Oh, not at all. Thank you. My pleasure.