Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi. Hello. Hello. I think we're live. Hope you're all doing well. Um, I'll just give it a couple of minutes just to see if we can get anyone else coming in just as we. So we start. Um, but yeah, just give it a few more minutes. There we go. I'll make a start with. We've got a few now. Um, so, yeah, so I hope you're all doing well. I recognize a few of the names. Um, so, uh, so thank you for coming back for those that are new. Um, yeah, this is just gonna be hopefully about an hour. Um, it's just 20 past med questions. Um, and we'll just run through them, run through, why it's the correct answer and why the other ones aren't correct. Um, it's all gonna be done, Bob Via Polls. Um, so it's all anonymous. Um, no one sees who voted for what, um, if you have any questions. So please, please just put them in the chat. Um, and I'm happy to answer them, but if you don't want any interaction, then that's completely fine. Um, I've been there before, so don't worry. Um, so you can just sit back and enjoy. Um so yeah we'll give it about 60 it says 80 seconds there but I don't wanna take up too much of your evening so we'll start about 60 seconds and see how we get on from there but I can make it longer if we need to. So yeah. All right we'll start with the first question then. Alright. 10 seconds. All right. There we go. Everyone seems to have got this one. So this one should be quite quick. Um So yeah, so well done. So it's right. Sensorineural deafness. Um So hopefully, you know, Weber's and run these tests generally what they are, you might just get confused on, on how to interpret, but that's fine. Um So if we start with Chinese test, so Renee's test is done first. Um any place for anyone that doesn't know you place the turning fork on the mastoid process like the bony prominence behind the air, you ring it and then the patient will hear the noise and then as soon as they can't hear that noise anymore, you lift up in front of their ear and they should still be able to hear, they should be able to hear it again then indicating that air conduction is better than bone conduction and that's a normal test. Um So in this patient here, if we go back, uh we'll go onto Weber's in a second. Um In this patient here, air conduction is better than bone conduction on both sides. Um So we're not worried about a conductive hearing loss. So, sensorineural. So then it's working out, is it left or is it right sided centre in Euro? So if we go back, so Webber's test, you do that afterwards. Now, even if you've picked up a conductive hearing loss, you'd still do Weber's test. But Weber's test, you do the same thing to you. Ring the tune and fork, you place it right in the middle of the head and normally you should be able to hear it equally the same in both ears. But sometimes patients will say they can hear it more and then either the left or the right ear. Now, if they've got a sensorineural hearing loss, they'll be able to hear it more in the normal unaffected air. And that's because obviously, if you've got a sensorineural hearing loss and let's say your left ear, then you just can't hear. There's, there's no, you've got like a neurological issue with that air. So you hear it more in the normal air. If there's a conductive hearing loss though, then it's the other way around. And that's because conductive, let's say they've, they've got conductive issues. So let's say the left ear is full of earwax, then they've got no background noise coming in on that left side. All they can hear is just those vibrations. Whereas on the other air on there right here, they've got all the background noise along with uh the Webbers test. So it sort of clouds it. Um So yeah, so if we go back here, so we can see Weber's test, it's so there's no conductive hearing loss first and then it's lateralized into the left side. Um So that gives us right, sensorineural deafness. So hopefully that makes sense. I can explain it afterwards or explain it again if anyone has any issues with that one. Um But yeah, next question, 10 seconds right. There we go. Uh Let's see how I wanted. It's a bit more of a mixed one. Yes, I can go through the knees and Webbers again. I should. No problem. Are you all right to hang on if I go through that at the end, is that ok? Um Just, I don't wanna take up everyone's time too much. So I'll go through it at the end if that's, if that's OK. Um But yeah, so for question too, um is BPPV. Um So well done to those of you got, I think the majority got it for this one. Um So we go through why? So this is sort of a classic history of BP PVD. So it's recurrent episodes which is classical there episodes and then only lasting 10 to 20 seconds and then once they're over there returning back to normal and they're well in between turning over in bed is like a classical uh Rosky and MCQ description of when these patient's experience there episodes. Um And I'd say last 10 to 20 seconds. Now, the reason that it's turning over in bed that they get these symptoms, um It is because if you don't, if you remember air anatomy, um you've obviously got the three different canals responsible for giving you your orientation of lateral and vertical and rotational and what's happening in B P P V as you get these little stones that get lodged in these canals. So you can imagine if you turn your head over, then these stones are going to go flying down with one of these canals. And that's what's triggering the sensation. But as soon as you just rest there for 10 or 20 seconds, the stone will settle and you'll go back to normal. Um So hopefully, that's ringing, ringing bells in your memory. Um But that's BPPV, think if you, if you put different ones for this, so we'll go through it so many years disease. So that is a cause of vertigo. Um Here though episodes normally last a bit longer. So 2 to 3 hours and it's not related really to head position, not classically the over key feature of many years disease. Something that you should always be look out on the lookout for in a question stem is oral fullness that is like the classical description of many years disease. Not everyone has it. But from an MCQ point of view, if you see that can think of many years disease and they also have hearing loss, some multiple sclerosis. Um So vertical could happen but unlikely in M S. And if it is present, it's unlikely to only last for 10 to 20 seconds, unlikely to be related to head position. And you would be expecting other features in the question stem of M S. Um whether that be an upper motor neuron lesion sign or optic neuritis viral labyrinth fires. So there's a question on this later on. So we will go through it in more detail. Um But generally you'd expect to see that after a viral illness. Um And you'd expect hearing loss as well and it would just be one constant episode of vertigo. So you wouldn't have these 10 to 22nd episodes recurring. Um So yeah, and the final one posterior circulation stroke. So that's just a sudden onset of persistent vertigo. If I'm honest, I'm not the best we've learned in the different types of strokes. But yeah, so I just know it's, it's a sudden episode and it's prolonged, persistent vertigo, which isn't the case here. So, yeah, right next question. 10 seconds. There we go. So a few of you got this one, a bit more of a mixed picture, a bit more mixed. But have you ever got this one so well done? Um So there we go. So a seven day course of amoxicillin. Um So hopefully you all got that. This is a Titus media going on. Um, yeah, it's a sort of a classical picture, young, young child acute presentation with a fever, tugging and pulling at the ear. That's sort of a classic one in Pedes. Um, um, and then, yeah, and then obviously you've got your ought oscopy findings. Um, so antibiotics. So, the tightest media by itself you don't have to give antibiotics. There's just specific criteria for when you give antibiotics. Um, I think I know what Manchester, you probably have your exams coming up quite soon. I suspect it's the case for a lot of Younis, I never learned these like by heart. But if you do enough past med questions or Quest Med just on it, you will kind of come to see the common ones, but these are the five sort of criteria and that if any of these present, then you give antibiotics. Um if, if any of them aren't present, then you just give them analgesia and you just reassure and safety net and that would be fine. Um So you can see here. So I've highlighted the main features in bold. So if it lasts more than four days, if they're systemically unwell, but they don't need to go to hospital. Obviously, if they're immunocompromised or at risk of complications, if they're younger than two bilateral otitis media, and if it's perforated, there's discharge in the external canal. So if we go back to it, you can see from the history, it's perforated with discharge in the canal and he's also under two. Um and it's bilateral. So there's perforation in one side, but there's the infusion behind the other tympanic membrane. Um And yeah, amoxicillin is the first line antibiotic treatment that you give for a Titus media um seven day course. So in this case, you've got multiple reasons why you give it. So that's hopefully makes sense. Um Discussed with the ent is a valid sort of thing if you're worried. Um The main reason why it's not the correct answer though is because tympanic membrane perforation is quite common with the tightest media and it's not like an alarming feature because it resolved by itself most of the time. So you don't need to speak to ent about every case, reassure advice and give some porn ig Asia. So, like I said before, that's the general advice if they didn't meet any of those criteria. Um But they do in this case. So that's why you don't, you won't pick that one, a seven day course of the antibiotics spray and steroid spray. So you might hopefully you might know that's part of the management for a Titus external. You wouldn't give it for a tights media, especially in this case. Um One because Neomycin is auto toxic and two because there's a perforated eardrum, you don't want to be given any drops or any sprays because it will just go straight through into the middle there. Um Your final option review again in 12 to 16 weeks. Um So most of the time the Tympanic Membrane heels women once two months. Um So it's, it's a good thing to review them, especially if they're a young, young child to make sure it's healed. But in this case, it would just be too late to review them anyway, you'd want to be seeing them earlier on. So yeah, so hopefully that makes sense. If you guys have got any questions about anything, please just put them in the chat. I'm happy to go over anything, but if not, we'll move on to the next one. Okay. Five seconds. If it's not referred at 12 weeks, would that be a referral to ent? Um I believe so let me check during the next question, but I believe that sounds sensible. Um But yeah, I'll check during the next question. Um Right. So well done a lot of you got this one. Um So yeah, so it's one week of olive oil drops and then you would review them. Um So hopefully for those that understood what I was talking about when we went through Weather's and Renee's, you will, you would have seen that there's a conductive hearing loss in the left ear. Um Obviously the next sentence cells you there's compacted earwax, which is the most common cause of conductive hearing loss. Um It's a straight away thinking obviously compacted earwax as the cause. So you've got to treat that. So then it becomes of how do you treat that? And the first line step for ear wax is olive oil drops or drops in general. So you can give olive oil, can give almond oil or you can give sodium bicarbonate drops. Um, olive oil. The ones that I just remember. So if you're not, if you don't know the other two, just remember olive oil and it'll be fine. Um, and it's free to four times a day for a week which I don't think you'll be asked about specifically, but a week of olive oil drops. Um and then you review them for the most part that clears it by itself and it's fine. And as long as the hearing resolves, then that's fine. If it doesn't resolve the wax, it doesn't break it up and dislodge it, then you go to the next stage and that would be irrigation. So it's like water irrigation just to help relieve it and dissolve it, dislodge it. I should say that doesn't, that's not one of the options, but that is the next step and that can be done at a GP providing they have facilities for it if they can't do it or it's contraindicated or they've done it and it doesn't work. Then the next step is referred to Ent for a manual removal. Okay. So it's olive oil drops first, then irrigation and then referral to Ent for manual removal. Um The other two options that they have here that some people put, which is fine is refer for audiometry or for, for hearing aids. So in this case, you've got a clear cause of a likely cause of a conductive hearing loss. So you don't really need to do the audiometry first because you want to get rid of that wax. And then if they're still is hearing loss, then you could consider doing audiometry and the same thing for hearing aids, obviously try treat whatever is going on and then if it's still going on, then you can start thinking about further treatment. Um So, yeah, so hopefully that makes sense. So olive oil drops first, then irrigation then referred to ent for manual removal. Next question. Yeah. OK. Time's up there. Let's see. It's uh most people seem to have got this so well done. Um So cholesteatoma, um we'll go through it if you've not heard of it, don't worry, but we'll go through it. Um So, so cholesteatoma and what it is, it's like a benign growth in the air and it typically occurs in this region of the, of the air and it's on ought oscopy is referred to as the attic crust and it's always sort of in this region and it looks fine there. But the issue is it grows inwards into the air and it can invade structures nearby. So that's why it's worth being aware of. And the general management is obviously referral to ent for considering surgery to remove it. Um, but cholesteatoma so generally affects 10 to 20 year old people, people within that age bracket. Um, like I said before, it's got that attic crust appearance. So it's normally in this sort of region and appears like as, as the name says, crust and hopefully you can see it's sort of crusty. Um, it says here that this recurrent discharge, it doesn't specifically mention anything about the smell of it, but the classic M T Q one is foul smell and persistent discharge. Um So if you're gonna remember anything about cholesteatoma, I just remember attic crust and foul smell and persistent discharge. Those are the two key pieces for it and you can get unilateral hearing loss, okay. And it's a unilateral because obviously it's only affecting that one unless you're unlucky enough to have it in both fares. Um But yeah, go through the other ones. It's a small amount of wax. So it does kind of look like wax. Um But one, it wouldn't really explain the discharge and two, the location of it, it's not on the tympanic membrane. It's not big enough that it's blocking anything. So I wouldn't really affect, it wouldn't explain why they've got hearing loss on that side. Chronic otitis media. So here, the tympanic membrane looks pretty normal, um, external canal opposite other than this region here generally looks okay from what we can see. Um And that is what you'd expect in chronic otitis media. So I think the membranes perforated there, but you can see hopefully along the walls, it's all red and inflamed all along the tympanic membrane doesn't look healthy. Um So it doesn't really look like that. So it's not a chronic Otitis media, bullous myringitis, time pronouncing it correctly. Um That is, I've only really come across this recently. Um So you don't really need to know about it, but what it is, it's an infection of the tympanic membrane and you get lots of fluid filled blisters on the tympanic membrane. So I've got a photo, so it looks like that. Um So you can see all these different fluid filled blisters on the tympanic membrane and again, it doesn't look like that. So it's not that and then retained grommet. So if there was a retained gromit, obviously, that is what a gram it looks like. Um It's like a little plastic tube that just connects the middle there to the our. Um And as we can see here, you're not seeing any evidence of like plastic, like remaining pieces of plastic there and the location of it, it's outside of the Tympanic member in here, so unlikely to be that. Um Most of the time they do just fall out by themselves. So, yeah, right next question. Uh Let me uh I'll post about the time room. So a gram it is used for if you get chronic otitis media. Um There's a bill obviously types of media, there's build up of like fluid and puss within the middle air. Um, so if you have a gram, it, it's just a tube that connects the middle air to the external. So all that can just drain by itself. And so you want to give it if people have like chronic otitis media. Um, and it just helps to relieve that pressure and stop it perforating. Um, see, all right, five seconds. Oh, sorry, I didn't put the polls on, um, I put the polls on, just put that on that and then I'll give you a second, um, R T tubes the same as Grommets. I've not heard of T tubes. Maybe if so, I'll open it up to the floor if anyone else has heard of T tubes. I suspect so, but I've not heard of the term T tubes. Let me just google it quickly. You think the best chromate? Uh, yeah. So it says Grommets stay in place 6 to 8 months. Occasionally longer. T tubes stay in place long, even longer than that. Around 8, 1.5 years. So they both serve the same purpose. Just T tubes last longer than Grommets. Um, but you learn something new every day. Um, fine, everyone seems to have got this one. Just a few coat over than a few people, but don't worry. Um, so here for this one. So hopefully we'll go through it, but hopefully you've got from this history. It's a titus external that's going on here, but can be if you've not come across, it is difficult just to work that out just from the history. Um So if we just focus on this one, so otitis external, so a titus media is obviously the middle air, a titus external is inflammation of the external there. So the canal, it's canal wall itself. Um So you can see, it says here, ear canal is a rough immitis. So that, that's obviously pointing you in that direction. Tympanic membranes intact. A key feature of a tight extern that is whether they're a swimmer, that's a big, big risk factor and MCQ wise most of the time it comes up along with it. So the tightest external, how do we manage it? So this was one of the options in the question on the tightest media. So it's the spray. So the first line treatment is a spray and it's either an antibiotics spray by itself or a combined antibiotic and steroid spray. So you can see here, they've, they've done both. I believe it's just up to the clinician which one they want to pick. Um But yeah, um IV Terazosin. Um So I don't think anyone put this. Um but that's given for necrotizing titus external. Um It sounds similar but it's different in that it's a lot more aggressive and it invades down into the bone. Um So you have to act a lot quicker with that one. And that's why you give obviously IV antibiotics. Um, the classic feature for necrotizing tights external from MCQ point of view is it's normally in an elderly diabetic person and it's extremely painful. Um, but you can see her 19 year old woman so unlikely, um, oral amongst Acilin. Um, so that's given, as we talked about before, that's given for the tightest media only for certain circumstances. You might remember. There's those five circumstances. Um I don't remember all of them, but for example, under two with bilateral otitis media, etcetera, etcetera, I'll send the slides out at the end. So you'll have it all on there and oral ciprofloxacin. Um um So that's not used for otitis external. Um That can be used as a step down drug if you've got necrotizing tights extern. So you start on IV Terazosin and then you could go down to Ciprofloxacin, um topical hydrocortisone cream. So is technically on the right lines because obviously it's a steroid, it's a topical application of it. Um But you need an antibiotic. So you can give an antibiotic by itself or an antibiotic with a steroid but not a steroid by itself and it needs to be drops or a spray as opposed to a cream because if you can imagine it's difficult to get cream on the inside of your air and it's much easier just to do drops or a spray. Um So yeah, so hopefully that makes sense next question. We're going through these quite quick. Okay. Five seconds. So there's 16 questions, Aisha today. Um, 16 questions. If not, I can put my email on the chat and then I can go through afterwards with you if that's easier. Um, but if you search Weber's and Renee's online, there's loads and loads of videos about it, um, which should be quite helpful and explaining it. Um. Right. Well, go on. Um, so well done to those that got it. Auto sclerosis is what's going on here. Um So let's go through it. So, auto sclerosis, I'm sure some of you will have will know what it is. Some, why not? That's fine. And what it is is obviously you've got your little bones in the middle air which helped to amplify the sound waves coming in. And what happens is each of those free bones starts to fuse with each other. Um So it doesn't work as well and, and that is what's going on there. So it's a conductive hearing loss. Um even though it's middle, there is conductive because it's stopping that conduction of sound. Um It's a genetic condition. Okay. So anytime you hear in an M C Q or Aronofsky of a family history of um hearing loss as particularly in a sort of youngest person, always think of Otto sclerosis, okay, because it's genetic occurs in both is um it's bilateral autism, all dominant. It doesn't mention it here, but it's just been worth aware of the over way that you might see it described in MCQ questions for auto sclerosis is a flamingo tinged tympanic membrane. And I've looked at photos of it and I didn't think it was that convincing. Um But that is the way that it's described on MCQ. So if you see flung go tinge tympanic membrane, a family history of hearing loss, think auto sclerosis. Um So yeah, the over ones to go through acute labyrinth fighters, again, we'll go through it in a moment and, but like I said before, you need is typically seen in someone that's had a recent viral infection. Um There would be here in Los as there is here, but you'd expect it to resolve a lot quicker than it has been here. Cholesteatoma as we just went through that it would be conductive hearing loss because you get the destruction of those bones, but it's unilateral as opposed to bilateral and there's no mention of any discharge as well and particularly foul smelling discharge many years disease. So again, as we went through before, you'd expect unilateral uh hearing loss and it'd be sensory, sensory neural hearing loss as opposed to conductive. Um You'd also expect like we talked about the key feature for MCQ point of view, oral fullness um and the vertigo attacks. Um Neither of these are mentioned. Um And again, it doesn't explain the family history because it's not a genetic condition. Um and the stimulus one schwannoma. Um There is a unilateral sensor in your uh hearing loss and you might have come across this before, but that's the one that where there's facial nerve palsy is and potentially ataxia as well. Um So don't worry about these too much, but auto sclerosis, the main thing that you need to know for MCQ is a family history of hearing loss, particularly someone that's younger, bilateral is conductive and flamingo tinged tympanic membrane. Those are the key features of auto sclerosis. Um So yeah, question eight. Okay. Okay. Five seconds. It seems to be between B and E for everyone. Um There's a bit of a mix of both, technically correct is which one do you do first? Um Fine. All right. IV antibiotics. Um the world and I think the majority got this one. Um It's a world and for those that have got it. Don't worry if you, if you got, if you got any one thing else though. Um So hopefully you'll picked up from here from the history. The condition that's going on is mastoid itis. Um And we'll go through the different features that you'd expect for that. And so like I said, the patient has mastoiditis. So it says here, um obviously, the ear is displaced anteriorly. So you got your mastoid behind the air. So you can imagine if that's swelling up, it's going to push the air canal forwards or anteriorly. Um It's tender over the mastoid process um which is another key feature of it because it's an infection here is particularly worried because there's a septic picture from the systemic features and they've got a history of the tightest media. So you've got a history of a known infection that's very close to the mastoid that could have easily spread there. So you're high, highly suspicious of it being mastoi itis and, and the main complication, the main thing that you're worried about with mastoiditis is one that is septic that can progress to sepsis. And two, because it's so close to the brain, you're worried about that infection traveling intracranially. Um So that's what you're worried about here. So that's why you give IV antibiotics as opposed to oral antibiotics is because you need to get, you need to get it on top of pretty quickly. Um And I assume it's, yeah, it'll just be acting then obviously if you did it orderly. Um IV antibiotics first line elective crom it insertion. So they have the tightest media with an infusion because they've got suspected mastoiditis. That's got the priority, what you need to treat first, um oral antibiotics. So let's say you've got to prevent an intracranial infection and you've got to get on top of that potential sepsis picture that's going well, likely septic picture that's going on there. Um So you need to give IV antibiotics reassurance and safety net. And for the same thing, um you know, you're not going to give it in someone that's septic to safety net. Um But even if it was just the Otitis media and they weren't septic and there was no mastoiditis picture, it's still be inappropriate because if you remember back to the previous slides, one of the features of when you give oral antibiotics for a title media is if it's lasted more than four days. And another feature is if they're systemically unwell, which they are here, the different here is that the systemically and well probably require hospital admission. Um Yeah, and then urgent surgical drainage. So a few of you put this one so that can be done. But you do that once you started antibiotics and once you're not seeing a response with the antibiotics because then you go in and you start trying to drain it. Um because like I said before, you're worried about that infection traveling into the brain. If, if you start them on the antibiotics and the antibiotics are working fine and they're getting on top of it, then I believe you can just leave it as that. That might be wrong on that one. But the main thing I'd remember for mastoiditis is IV antibiotics first line, just make sure you start that first. Um So yeah, so hopefully that makes sense. I've said before, if you got any questions, please just put them in the chart. I understand if you're, if you just want to bash through it. But if you do have any questions, please. Just let me know. Yeah. Five seconds. Oh, Zoom in, in. Um I don't think I can serve it. Sorry. Lucy. Uh I should have made it bigger for the, I should have made it bigger. Um, fine. I will let me see if I can if I make it bigger on this next slide. Hopefully one second. Right. It's not outdated. Yeah. Okay. Well, well done to those that got it. Sorry, I didn't make it big enough, but basically what's going on here. So normal hearing the main thing for audio grams, I don't think they're going to come up in your M C Q s. But the main thing that I learned for it because I think I may have had it once come up in our exams or maybe I'm just remembering wrong. Um The main thing that you need to know is 20 decibels. If anything is above 20 decibels, then that's considered normal. So like you might not be able to see on the screen to apologies again for that. But the 20 decibels is just is just if you can see my mouse and everything is above that line, so it's considered normal. Okay. Um If there was a conductive hearing loss, then only the air conduction would be impaired and they'll always give you like a key at the bottom of the graph. So you can see the air conduction is the circle and the cross um if it's sensorineural hearing loss, then both air and bone would be below would be impaired. And if it's mixed here in Los, it's the same as sensorineural where both air and bone are impaired. But the difference is air conduction is worse. Oops, sorry, air conduction is worse than bone in mixed picture. Um, you don't have to worry about that too much. Unlikely that they test you that on your exams. I think, Um The main thing I'd remember if this seems new to you is just anything above 20 decibels that's considered normal. Um See you. So hopefully that makes sense. Um All right. Next question for 10 seconds. Last chance to get you guessing. All right. Um So a few of you got this one so well done. I used to struggle with this but I've learned a new monitor or a trick for it. But what's going on here is Labyrinth fighters all viral bronchitis. Um which was a difference with the past couple of questions. So I'm getting around to it. Um So if we go through it, um The main thing I always think of viral labyrinth fires and of a stimulant. Your own itis is a very similar conditions. They're different, but I always feel it in my mind is very similar. Um They both present with vertigo in someone with a recent viral illness. So if we look back here, she's got sudden onset dizziness and it says other than a recent cough and cause your symptoms. So you've got both of those features present. So be thinking about one of those two conditions. Now, the main way to distinguish it is one has hearing loss and one doesn't have hearing loss. So I just remember it as simple as um there's an L in Labyrinth Fighters. It's an L for Los hearing loss and there's an end for neuron itis an end for no hearing loss. That's as simple as I try and make it. Um the other way, the actual reason why this hearing loss here and there isn't hearing loss. There is, it both affects the vestibular Cocula nerve. But for viral labyrinth fighters, it's the vestibular nerve and the labyrinth are involved and because the labyrinth is involved, that's why you get the hearing loss. But for vestibular neurone itis, it's just the vestibular nerve that's involved and the labyrinth is fine. So that's why there's no hearing loss. Um But like I say, I just remember it with L and N and that seems to do the trick for me. So hopefully, hopefully it seems like a lot of you got that one. So you, you probably got your own system. But, but yeah, hopefully that helps. Um I'll just go back. Actually, the over one was um many years disease. Um a few people put. So it could, it sounds like it could potentially be that the main thing that I would say, like I said before is there's no oral fullness in the, in the history. It doesn't mention anything about that. Um, and that's one of the key things that I have and because it says the causal symptoms that would point me more towards this. If it said oral fullness as well, then maybe it start thinking about many years. Yeah. There we go. Question 11, 10 seconds. Right. Well, the most people seem to have got this one. You're all clued a funny anti. Um, so pinch, pinch the nostrils and lean forward for 20 minutes. Um, so, yeah, this is just Epistaxis management for this one. Um, so let's go through it. Um, so pinched nostrils and lean forward. So that's the first line immediate steps for epis Texas. Anyone that comes has epis Texas always just get them doing that straight away. You pinch the nostrils because that's most likely to stop the bleeds. So you just get them to pinch and pinch hard. Um, for 20 minutes is what it says. Um, and then lean forward as well. And the importance of leaning forward is that if there is any bleeding from higher up, then that bleeding, it goes down as opposed to down the back of the throat and then it can go into the stomach or the lungs. Um, so just trying to avoid that. So that's why you pinch the nose and lean forwards. Um, like, say it needs to be done for 20 minutes. However, the the you do that unless they're hemodynamically unstable. In which case, you need to escalate treatment much, much more quicker than this. But you can see from the history here, BP is normal Spirito Ray's normal. So that's a normal heart rate is normal. So fine, yeah, over options. Um anterior packing. So that once they pinch the nostrils leant forward, if they've done it for 20 minutes and it's still not working, then for a posterior bleed, the next posteriors, obviously the back of the nose. Um and then you do anterior packing where you just shove essentially like uh tissues, not quite but essentially just to try and block what the bleeding stop it. Um But like I said, you've not done the first line treatment first and it says here that there's a visible bleeding on the anterior nasal septum. So you wouldn't do it for those two reasons here, quartering. So that is the next step for anterior bleeds. So once you've done pinching the nostrils for 20 minutes, because it's only been five minutes since the bleed, then you could do quarterly. Um I've seen here next Septin. And so, yeah, so it's Chlorhexidine and the mice in and you give that to a patient once the bleeding stopped and you do it to prevent it crusting and scabbing inside the nose. Um So obviously, the bleeding is not stopped here. So you, you're not thinking about that just just now and then the final option is referred to ent for posterior packing. Um So that would be done if it was a posterior bleed and anterior packing still hasn't worked. You could consider packing from behind. Um But um if that still hadn't worked or if there was lots of blood loss and there were becoming hemodynamically unstable, then the next step. And so the final step really is sphenopalatine ligation in theater. Um So just yeah, like the name suggests, you go to fear and it's that specific artery that you're aiming for the sphenopalatine, um that would be the final step. So, in terms of epistaxis, the main things for you to remember is the first thing, the most important thing, pinch the nostrils and it's sort of the bottom of your nostrils like the fleshy part as opposed to the boney part, pinch it and pinch it, get them to pinch it hard for at least 10 minutes. But ideally 20 minutes and lean forward unless hemodynamically unstable, then it depends. Is it an anterior bleed or is it a posterior bleed? If it's anterior bleed, then you use quartering and if it's posterior, then you packet, that's generally all you need to know for epis taxes. But if it still hasn't worked the packing, then just remember, spinal palatine ligation is the sort of what you're gonna have to think of um to do. Say. Yeah. Right. So no Septin is given to all fs taxus patient's over. Yeah, that's all right. Let me, I'll leave it there for those that want to read this question, but I won't put the time on just yet. But, yeah, the septum is given as far as I know for all patients with epis taxus. Um, the exception is, um, I'll check it in a moment is that it can, you don't give it to people with a peanut allergy. Um, so just be careful that if it comes up for an antique, you would be very harsh. But yeah, generally you give it for everyone. Um Other than those with a peanut allergy and anterior and posterior packing. So anterior packing is the first line. So for a posterior bleed, you get them to pinch the nose first, lean forwards for 20 minutes. If that still doesn't work, then once you've known that it's a posterior bleed, you then packet and you initially packet anteriorly. So I believe that just means that you go from, you go obviously from the nose, pushing it backwards. Posterior packing. I haven't really come across since I was making these slides, but it says that that can be done after anterior packing. And if that still doesn't work, then sphenopalatine ligation can be done. Although to be honest, in my head, up until now, all I've had for a posterior bleed is pinch the nose, then anterior packing, then take them to theater. Those are the three steps that I have in my mind anyway, for posterior bleeds. So hopefully that makes sense. Um Let me get this poll onto the that you guys can vote for. I'll just keep here if I give you 30 seconds just for those that were listening, just have a go. But it seems like most of you have got it straight off the bat a bit mixed, a bit mixed, right? Okay. So well done to those have got it. Analgesia is the right answer. So the first thing to work out is what actually is going on here. And so the key parts of the history that worth bearing in mind is so obviously, they've got a headache, fairly new onset facial pain with fevers, history of fevers, but a fever at the moment and they've got other symptoms. But the main one that I think of is the dis discharge, thin yellow discharge, nasal congestions and pressure reproduces the pain. So for those, some of you might know what it is straight away and what it is that's going on here is acute sinus sinusitis. Um So your sinuses um obviously just become inflamed now because the main, the main features for acute sinusitis that you need to think about in an M C Q is headache and facial pain, particularly a headache that's worse bending forwards. So obviously, that's the same as a space occupying lesion. So you've always got to be careful that you're not forgetting about that. But facial pain specifically that's worse, leaning forwards with a discharge from the nose, that's thinking of acute sinusitis. Now, you can either get a viral or bacterial sinusitis most of the time, I believe it's viral. And in this case, they've got like classical causal symptoms of like congestion, fin discharge fevers. So you're thinking more viral here and it's more common. Um So the first line, it's starting the wrong one though. The first line treatment for acute sinusitis, it normally clears by itself and it's viral. So you just give analgesia and that normally does the trick. Um Cephalexin is an antibiotic. So it's not normally used for acute sinusitis, especially because it's viral hair, um intranasal corticosteroids, they can be used once it's gone on for longer than 10 days. Um But generally just remember that analgesia is the main thing that you need to worry about. Um Here it's only gone on for four days. So you're not worried about intranasal coke austerity at the moment. Decongestions, it's a bit. Um I guess it depends who's, who's prescribing it. Really. Um The general advice is it can be used for short courses, but you really want to try avoid it, giving it if you can because there's a dependence on it. So the more you use it, the more you have to use to get the same effect and there's very limited evidence for how effective they actually are. Um So generally avoid it other than I think the advice is other than like very important life events. So if someone is getting married or something like that, then maybe consider it then um but generally try to avoid it. Um and Finn Oxymetholone methyl penicillin. Um So that is used if you suspect a bacterial cause of acute sinusitis. Um And like we said here, because of the causal symptoms because the viral is more likely you're thinking mainly viral symptoms. Um So you're not going to go for that straight away. Um And yet analgesia is the first line management for acute sinusitis. Um So yeah, okay. Any questions just put them in the chat or if there's anything you want me to go over at the end, just keep it in mind and I'm having to stick around. We'll go through Rennes and well versed at the end as well. You got 10 seconds, most of you seem to have got this one right, a few last minute on there. Um So I've just put the feedback form in the chat before I go through this one. I'm aware. It's got to eight o'clock if you have to leave, then thank you very much for coming here. I hope you found it useful. Please. Please, please just fill out the feedback form. If there's anything you think went well or could be improved, please just put it down. There's only 16 questions until also it shouldn't take longer than 10, 10 more minutes or 15, maybe So I'll try to go through the rest as quick as I can. Um, but yeah, so well done to those that got it. So you would give antibiotics in this case and those are the reasons. So a lot of you got this. Um, so we'll go through it. So hopefully a lot of you will have come across the center, the center score or the fever pain score in terms of working out how to work out whether to give antibiotics for a sore throat. So I've got them both here. They're both you can use either or and they both achieve the same thing. So these are the features that you need to work out before deciding whether to give antibiotics. So it's personal preference really? Which one you use? I think fever pain is technically the slightly better one. Um So if, if these are both new to you try remember fever pain score, I know center score though just because I find it easier to remember. Um But it's up to you. I've highlighted in bold that it's all like a is an anagram. I I don't know what the word is. Um But I see like C E N T and the same for fever pain, like fever and then P A I N and so if you try remember even one of those, just have a brief look at them, I'll go through center score. Um And if we go back to the question. Um So there is um you can see no Tunsil oxidate. So that's not score in a point there, but there is tender lymphadenopathy. So that's one point. Um There is a history of a fever and not feverish now, but there was a fever last night. So that's another point. So we're on two and there's an absence of a cough. So that's three points. Um So three points out for. So if we go back and I've highlighted it there, so there's lymphadenopathy, there's no cough and there's a history of a temperature. So that's called free out for the center fever pain. It scores two out of five. Now, there, there isn't really a specific cut off of, if it scores more than this, then give antibiotics. If it doesn't, it doesn't center believe generally it's if it's free or more and give antibiotics. But the main thing, if you go on pass med and search for this, it gives you it as a percentage chance of it being bacterial. So if it's free or more on the center score, then there's a 32% chance or more that it's bacterial, it's a 32% about a third. And if it's two or more on the fever pain score and it's a 34% chance it's bacterial. So again, about a third. So two on the fever pain score or three on the center score, just give antibiotics as the general advice. Um So, yeah, hopefully that makes sense. Just let me know if you got any questions about it though. Um, put the next one in the chat 10 seconds. Wow, this is, I'll give it a couple of seconds. But this is, yeah. Well, then this is a clean sweep. Everyone has voted. Just got this answer so well done. Um, if you were, if you haven't voted, but you were thinking of a different answer. Don't worry. And we'll go through it. But um, yeah, it's referred to ent for a tonsillectomy. Okay. So similar to giving antibiotics and the tightest media, there is specific criteria needed before you can refer them. Um So let's go through it. So they need to meet all four of these points in order to be considered for a referral. So it has to be five or more sore throats a year. The sore throats have to be due to tonsillitis. Obviously. Um, it has to have been going on for at least a year. So you can't have those five or more sore throats within the space of three months. Okay. So five talks, sore throats over a year, all due to tonsilitis and the episodes of a sore throat have to be disabling or prevent normal functioning. Um, so if we go back to it here, um, we can see she's at, this is the seventh episode of tonsilitis in the last year. So that's taking three of the boxes already. Um or two of the boxes already, uh, sore throats more than five times. She's, is disability debilitating. She's missing days at school and it's been going on for at least a year. So she's meeting all of those criteria points. Um, so yeah, she's meeting all the criteria points. So you would just refer for a tonsillectomy. Um, you know, uh yeah, the rest, hopefully your eyes aren't as appropriate as a tonsillectomy. Nothing's going to really stop them coming back as well as a tonsillectomy. Um So yeah, question 15. So I got this one and a final one and then we're done. I'll put the food back for him in the in case anyone needs to dash. Um Do you think you should learn the tonsillectomy? Probably not unlikely to come up. The main thing if you're going to remember anything, just remember, you need more than five episodes. That's all I remember. Just remember the number five. Um If you can remember it great, but there's a lot of things to learn. So it's not huge knowledge. It's not a hugely high yield that one. Um Yeah, just remember five and that should be fine, I think. Yeah. Yeah, that's correct. Um I see you've got to do all four of those oh seven or more in a year. Potentially. I have it down on the guidance as five or more a year, but it could have changed to seven. Um I'll tell you what, let me do these two questions and then I'll check on uh C K S unless if anyone can check on CKs if they're curious. Um uh that could be, that sounds correct. That sounds correct. 10 seconds. So, uh did I put the uh yes. Uh So a lot of you got this one uh so urgent referral to ent for this one? Okay. Um So if we go through it, so the criteria are nice is you should refer anyone for suspected laryngeal cancer if they're over 45 they have Eva or unexplained horse voice as there is here or an unexplained neck lump and you can see that over 45 they've got unexplained horse voice and for five weeks and you can see it's unexplained because no trauma or any other reason. So really just nailing down that point there. Plus they've got 40 pack your smoking history. So it's a red flag obviously for a cancer. Um So obviously anyone with those symptoms just need an urgent referral and needs to be to ent specifically, we'll go through the other options just quickly. So order in a CT chest. So it sounds when I refer to read, it sounds daft, but you can do it because it can exclude a long tumor. That's compressing the laryngeal nerve, which could explain the horse voice, but that would be ordered by ENT. So the GP isn't going to order a CT chest for this at this stage routine referral because you're thinking it's cancer, potentially cancer. You're not going to do a routine referral for it, sending them straight to A and E or the emergency department. They're not acutely unwell. So it would be an inappropriate referral to them and they just get assessed to and a and they put on a two week wait there. So you just messing them around. So not the best one for that and then urgent referral to a respiratory clinic. So, because it's a horse voice, it's more likely to be an E N T head and neck cancer as opposed to a lung cancer. Um So that's why you're, you're going to refer to E N T first, like I say, it could be a long tumor compressing the laryngeal nerve, but referred to ent first for a horse voice. So the main thing, anyone over 45 with unexplained horse voice or an unexplained neck lump, just put them on a two week. Wait for laryngeal cancer. Fine. Final question. Any questions, please? Just let me know. Uh huh. Five seconds. All right. So yeah, everyone seems to have got this. Just a few people open, but don't worry. Um So I'd antibiotics and surgical drainage. So hopefully you will have heard of Quincy's um as a condition and that is what's going on here. Okay. So we'll go through that and then we'll come back to the treatment. So Quincy's is this image here, this taken from zero to finals. Sorry. And what Quincy is, is a parry Tunsil er, abscess. So, perry Tunsil er around the tonsils and abscess is an abscess like a collection of pus. And so you can see on the patient's left hand side, that's the sort of Tunsil there. And here is the tonsils inflamed but all the tissue around the tonsils are inflamed as well. Um, and, and start abscess there. Now, one of the key features um of Quincy from an MCQ point of view is it presents with extreme pain, which comes as a sore throat or extremely painful, sore, throa, difficulty swallowing, and generally difficulty moving the neck in general just because any movement is stretching that tissue and inflaming it even further. The key piece of knowledge for an MCQ for you ever. Quincy is the UVULA, which is, I don't know if you can see my mouth, but you see this little piece in the middle of the throat in the back of the throw. So the key thing with Quincy is that that uvula is deviated and it deviates away from the side of the abscess. So if you look at a photo here, so this is Quincy, it's quite a bad case, but you can see that uvula there and it's deviating away from the side with, with the abscess. Um But yeah, so hopefully you can appreciate that. That is what it can look like at its worst really. Um So the main thing for Quincy is what you need to know is the uvula deviates away from the side of it. It presents extremely painful, sore throa with the uvula that's deviated. And if we go back to this question, the management for it is IV antibiotics and surgical drainage. That's, that's just the management for it. Um So yeah, so that pretty much brings us to the end. And so go on to the final slide from another session that shouldn't be put that. But yeah, that's the final side. So thank you very much for attending. I'll just put the feedback form in once more. Um Yeah, hopefully, hopefully you found that useful. Um, apologies. It wasn't 20 questions. I was just conscious of it when I overrun too much, but hopefully the questions were quite useful for you. You all seem to do really well. It's a good luck for your exams. Um The only thing that says, yeah, please fill out the feedback form. If there's anything you think could be done better, please just let us know. Um, we've got another session. We're coming to the end of our series now. So we've got a session on trauma and orthopedics on Thursday and a session on vascular surgery on Tuesday. Um And those are the final sessions. So it'll just be the same if you found this useful, um, at the same time. Um Yeah, I'll go through Weber's and Renee's if you wanted again, just pop it in the chat. It was Aisha, just pop it in the chat if you want to go through it. Um, and anything else, please just let me know and I'm happy to go through that. Um, so, yeah, thank you very much. Enjoy the rest of your evenings. So, if you, if you're still here, I should just let me know in the chat if you want me to go through it. So, Faisel, so I'll upload the slides after this and I believe it should be e mailed out to you at the end of the session at the sort of, I'll upload it now. So maybe in a couple of hours that you might get it emailed. Um, so, yeah. Yes, no problem. No problem. Right. I'll go all the way, I'll go back. And so let's go back. Don't worry about Weber's and Renee's test. It's very difficult to get your head around it sometimes for the first time or if you've not, not thought about it in a while, but once it clicks in your mind, it stays for a while. Hopefully. Um, don't worry about it. Um, it's just one of those ones, you just sometimes have to just sit there with a piece of paper and write it out and it clicks. So let's go back. Uh, we'll go back to this one here. So, the first thing that you want to do is, um, Renee's test. So, ignore Weber's test for now. Just focus on Renee's test and actually it'll probably be helpful. Do you know how to do Weber's and Renee's test Aisha or is this, like, new, new knowledge? Do you don't worry? Either way. Um, have you seen it being done or have you heard how to do it? Yeah. Yeah. Perfect. Yeah, Jerica. You got it as well. Exactly. See, so, you both know how, how it works. So, that's fine. Um okay, so let me get my notes and I can make sure I'm giving you the right thing. So Renee's you do first? Okay? And what Renee's is doing is you're just looking for, is there a conductive hearing loss? Okay. That's what really is, that's the purpose of Renee's is looking for a conductive hearing loss and in the event that there is a conductive hearing loss and you would hit, you would expect the findings that you can see on the screen there. Um, if there is a conductive hearing loss, they would be able to hear it longer when it's on the bone, then they can in the air. Okay. So they'll be able to hear it on the bone. Here it, here it, here it, then it stops ringing and you bring it to the front of the air and they won't be able to hear it all. Whereas normally you put it on the mastoid process, you ring it, they can hear it, they can hear it, they can hear it, then it stops because it stops ringing and it's ringing slightly. You bring it back up to the air and they can still hear through the air. Those slight vibrations. So normally air is better than bone, but in a conductive hearing loss, bone is better than air. So that's what really is, is doing. That's the first step you're doing is just looking for. Is there a conductive hearing loss going on? So that's Renee's test. So you've done Renee's test. Um Now let's say, let's go, let's go forward. Actually, you can see it, you can see it there, you can see both. So now let's say um there was a conductive hearing loss that's going on. Okay. So on the, let's say on the left side, on the left air bone conduction is greater than air conduction. So you're worried there's some sort of conductive hearing what's going on, okay? You still do Weber's, you'd still do Weber's then. So you ring it place in the middle of the forehead and you would hear that noise hit. The patient said I hear that vibration more in my left ear. The one with the issue than the right ear. Now, the reason for that is because so they've got a conductive hearing loss. Let's just say it's earwax, the ear is just full of wax, okay? Because they've got full of earwax. They're not getting any vibrations or very little vibrations coming in from sound in the air. Okay. It's just hitting the wax, nothing's going. There's no vibrations traveling through that wax. But when you put the tune and fork on the forehead, it can stick. And here that and there's no background noise that's going to dampen down those vibrations. Whereas on the right hand side, the normal side, you've got those background noises, which is sort of dampened down how much you can hear that vibration on the right side. So hopefully that makes sense. So if you've got a conductive hearing loss, it's gonna lateralized or you can hear it loudest on the side, that's got the conductive issue because it's not picking up anything else in the background. So it's got nothing else to focus on but those vibrations. So hopefully that makes sense. Um So when Renee's is abnormal then is that really is negative. So, yes. Yeah. Yeah. Renee's let me just double check, but Renee's positive uh uh yeah, brain is positive is just normal. So really is negative is when they'd be a conductive hearing loss. So hopefully that makes sense when we focus on just on conductive hearing loss, then when you go back to weather's test, okay. But let's do Weber's test in the sense that there's a sensorineural hearing loss. Okay. So you do Renee's test this first one here. You're not going to pick up any conduction, hearing loss. So in sensorineural, more than most likely air will be better than bone so it will appear like it's normal, okay. But then you do Weber's test. Okay. So again, ping it in the pit in the middle of the forehead. And they say, um let's say, let's say it's still the left ear that's got an issue, but it's a sensorineural issue. Um let's say many years disease. Um So it's many years disease affecting the left ear because there's no sensor. There's an issue with that sensorineural pathway that the ear is not neurologically functioning well, it's not sending those signals off. So the vibrations might be going through the middle air, but those signals aren't being sent onto the brain there not being passed on anywhere. So that left air is not picking up any vibrations whatsoever. Whereas the right air that's still here in those vibrations fine. Um It might be a bit dampened down the normal, but it's still picking up those vibrations. So that's why in a sensorineural hearing loss, you can hear it better. You can hear Weber's test lateral eyes is to the normal air because the left, the the abnormal air just isn't able to pass that message on. Um Does that kind of makes sense? I understand it's unlikely that just from my explanation, it's all clicked in your mind. But does that go some way in helping? I can explain it again if you want me to explain it again or I can explain part of it if you want me to explain part of it. Um Yeah, that's fine. That's fine. So followed until Weber's sensory neuro, that's fine, we'll go through that. So you understand Renee's and Webber's for conductive hearing loss. So that's good. So we're getting somewhere that's good. Um, unfortunately, Jerica, I don't have like an easy pneumonic kind of thing. I think the best case it is worth knowing because you might get questions on Weber's and Renee's like this question, exactly this specific question. But a lot of questions as you probably seen it will give you the Rennie's and Webber's test. If you have time, I'd just watch, just keep watching videos and keep doing pass med questions on, on them and you will eventually pick it up. And I think once it clicks in your mind as to what it's testing for if you understand it and once it's clicked, it'll be a lot easier to remember. Um But it's not crucial that, you know, if you, if you really can't remember it, don't worry, you'll, you'll still do fine, it'll be fine. Um fine. I'll go through Weber's sense renewal though again. And hopefully that that helps. So let's, let's start with Rennie's test on sensorineural hearing loss. Okay. So, um if we look for Renee's test, sensorineural, it says nothing okay. Like we said before, Renee's test, the purpose of Renee's test is looking for a conductive hearing issue. So there's no in sensorineural is not conductive hearing loss. So that test isn't going to show us anything. Okay. So for sensorineural hearing loss, conduction, you're not expecting to find anything really. And likely it's just gonna be show a normal result, but it could be, it could show an abnormal result but likely just a normal result. So the main thing we're focused on is Weber's test. For sensorineural hearing loss, you focus on Weber's test. So if we go through the same example, again, I don't want to confuse you further, but the left ear is suffering with many years disease, which is a sensor in Europe causes sensorineural hearing loss. Okay. So let's ignore Weber's tests specifically, but let's just think of how that sound travels. So sound generally travels from the air. You've got the waves vibrates, vibrates the tympanic membrane, then you've got the obstacles, the bones in the middle there that amplify that sound and then it gets travel, that vibration gets traveling fluid into the middle there, okay. And then you've got all those have to get all the processes, but it works all their, it sends off the signals and then it sends off those signals of what sound, the hearing via the nerves, the nervous system into the brain. Okay. And a sense renew, oral here, initiate hearing loss is affecting that pathway of sending those signals that is what's been disrupted here. Okay. So in this case, those signals aren't being sent anymore. So you, you've got no hearing whatsoever in that air or very little hearing, even nothing or very little or just a range. So if you put, were to pring that tune in fork in the middle of the head, it would travel to the left ear. Those vibrations, those vibrations make caused obstacles to move. It might cause that fluid to move around in the air. But when it's cause those fluids to move around, but that signal isn't going to travel from the air to the brain. Okay. There's just no signal going. So that's why if you have a sensorineural hearing loss on the left side, you're going to hear those vibrations in your right ear because the left ear, the sensory neural pathway just isn't working. So you're not going to hear anything out of that left ear. Um We're gonna have very little so you're gonna hear it more out of the normal air whereas a normal sensory neural pathway, does that make sense? Hopefully, my fingers are crossed but no worries. If not just no, if you, if you're not understanding it, don't worry, it's not that perfect. That's working for you. That's good for you, Jerica. If it's not working for you, Aisha, don't worry. It's not that you're like bad at understanding it. It's just that I'm not able to explain it well enough to you. Hopefully it makes sense. You say it makes sense. That's good. The best thing I'd say is just watch a video on it. If it doesn't work and do the past med questions on Weber's and Renee's just, just repetition. That's all it is. It's just practice. Um, and it should hopefully click. Um, but hopefully that's made sense. Um, good. Is there anything else you want me to go through or did everything else? Make sense today? Perfect. Perfect. I'll just put the feedback form and, um, but I'm glad I'm glad we got there. Um, I'm sure you'll do well in your exams, but good luck for them. Perfect. Perfect. Right. Well, I will let you enjoy the rest of your evenings. Thank you for sticking around. Um, and yeah, I'll see you hopefully on Thursday and next Tuesday if you're interested in TNO, the vascular surgery, well interested or need to know more for your exams. But, yeah, have a nice evening.