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Hi, everyone. I hope you all had a good and refreshing lunch um and are ready to crack on with our final three sessions and for the next session we have um Lizzie Drinkwater here with us who's going to be giving our session on neurology. Uh Lizzie is currently an fy one in at the Manchester Royal Infirmary. So over to you Lizzie. Hello. Can you hear me? Ok. I can't hear you at the moment. Mm um mm. It says my microphones on. Oh, perfect. Other people can hear. Oh, that's just a glitch with my computer. Thanks everyone in the chat. Great. That's all set. Lizzy, as that said, I don't have any solutions but let me know. Um Hi, everyone at my name's uh Lizzie. I graduated last year so I might know a few of you. Um I'm also full of a cold so apologies if I sound a bit um throaty. Um I've not used metal before, so also apologies if I glitch with the tech, I'm gonna share my screen to do the slides. Um but it will mean that I won't be able to see the chat box in the polls So I'll rely on Beatrice to feedback. If you want to ask questions as you go, that's fine. Feel free to interrupt. And Beatrice, you can just yell at me and yell the questions out. Um And when we do the polls, I'll ask Beatrice to let me know when most people have answered. Um and then we can um I can have a look and see what you guys put. All right, I will share my screen. Yeah, I can see that now. Lovely. Is that on full screen? Yeah. Ok. Ok. Uh Yeah, as be said, I'm now working down in Manchester. Um So also if anyone has any questions about uh Manchester for fy, feel free to get in touch at the end. Um I would be doing the neurology session today. Hopefully you will have a good lunch break and a feeling recharged ready to hit the lovely joys of neurology. Um or maybe you're all in the post lunch slump either way. Um I felt these days are good for breaking up the long slog of finals revision and doing something a bit different. Um And having someone talk at you for an hour rather than having to motivate yourself to do things. So hopefully the session is useful. Um We are gonna do some uh like based around some or best answer questions. Um I'm not gonna go into oy revision in the session just because we don't have ages. Um I did want to put a little note on to remind you guys to revise cerebellar examination as like a separate exam. There's a good geeky medics um summary on what to cover in that. Um But yeah, just as a little tip. Um and also for a revision things, I found quite useful. So these are the key presenting complaints for Euro. And I think what's quite useful to do is to go through them all and think what questions would I ask if these um presenting complaints came up in a history? Um And what sort of have in your mind? A few differentials for each presentation? Um And I think if you can write those out and have them fresh in your mind, then it's helpful in the in the osk for when you get a weird presentation in the exam and then they ask you for differentials at the end. Um So you have to start with the list, the key ones to go through and then maybe in sometime in your, you can write out what would be my key questions for history, what would be the key differentials? So we'll start with a question. Um 27 year old female Potential Clinic after a first seizure where she fell to the ground with muscle stiffness, began jerking bit tongue and lost control of the bladder e eg demonstrated unequivocal epileptic activity. She has a past medical history of a hysterectomy following postpartum hemorrhage five years ago. How should they be managed? Um, so hopefully there is now a pole available for you to click on. Yeah, that's polling now, I'll let you know when, um, a number of people have replied. Yeah, that's about half the people replied now and it's almost an even split between option one and option two. Okie Dokie, I'll give you guys a little bit a few more seconds if anyone else wants to, um, have a go at the, and then we can go through the answer. Also. I'm not sure how I'm gonna do for timing on this presentation. So I won't go too quickly and hope that we, um, don't run out of time at the end, but I don't want to rush through. Yeah, still and even split the two most popular answers being one and two slight. Option one is slightly winning. Ok. Ok. I'm gonna go on to the answer. Um, so this is a tricky question. Um, and I remembered answering this question last year and also went for option one. but the answer is actually option two and we'll come on to the reason why shortly. Um So epilepsy, I think it's an important topic. It's very common. Um, but the management, the sort of treatment side of things is quite specialist and isn't really something you would be initiating as a junior. Um So I feel like the exam questions on it, don't go into the sort of treatment side too much but I think it's good having a like basic level of the main antiepileptics used. Um And I felt this question is a fairly reasonable question for them to ask. Um So firstly, we were just going to cover the like acute management of seizures, but this is very relevant um when starting work and I feel like it could come up as a sort of a at e scenario. Um So someone was seizing running through in an at E approach. First thing you want to do is start a timer and make sure you protect the patient from any injury. So you don't want to restrain them, but making sure there's like a pillow underneath the head that they're not going to bang into anything. Um Then a thinking about airway adjuncts can be quite hard if they're having a generalized tonic clonic, um probably not gonna tolerate an oropharyngeal, but you can pop a nasopharyngeal airway in. Um otherwise want to make sure they've got a non rere mask on and then if you can get IV access, um or if the nursing staff can help, um Then that's a fact she sent off some blood. Um And then d thinking about causes of why they're seizing, want to rule out hypoglycemia do ABM if the hypoglycemic gives them glucose. Um And then e starting to think about reversible causes. So, are they withdrawing from alcohol? Is there any known electrolyte disturbance that you can correct quickly Um Is there any suspicion of drug use, things like that? Um And then in terms of going on to manage um status epilepticus if the um ongoing seizing after five minutes. Um First thing if you want to use, if they've got IV access, you can give IV LORazepam. If they don't have IV access or you haven't managed to get it whilst they've been seizing, then you can use Buckle Midazolam or Im Midazolam. Um, and wherever you go, we will have quite nice flow sheets of the timings of when you use things. Um, but it's normally you wait, you give the, um, one dose and then you wait another 5 to 10 minutes and then you can give another. Um I think it's just useful knowing the sort of first line steps for the treatment of status. Um, but then if it's ongoing after 15 minutes, that's when you think about escalating to quick care. Um, because they'll need IV antiepileptics. Uh Sometimes those can be started like on the ward. But if they're seizing for that long, you want to get quick care involved. Um, then going on to talk about investigations for seizures. Please let me know if I'm whistling through too fast as well. Um So the first seizure, first thing you want to do is look for reversible causes. So check the electrolytes, check the glucose, as you mentioned. Do they have um, an underlying infection can think about um, blood urine cultures, are you suspicious of a, um C NS infection or an encephalitis sort of picture? Um Do you want to consider a lumbar puncture? And then, um main sort of mode of investigating, I want to refer them to the first foot clinic and they'll organize an E eg in terms of imaging. Um Sometimes they'll think about doing an MRI or a CT scan, um, sort of within six weeks after the seizure. Occasionally, if someone's presenting to A&E they'll do a CT head um as they're admitted, but not always that useful unless you're sort of thinking about. Is there a space occupying lesion? Do they have other sort of symptoms and signs that might point to that? Um And for sort of general idiopathic epilepsy, they only tend to consider imaging if they've been started on an antiepileptic and that's not working. Um And then I just put a little table in here for, in terms of focal seizures and just being aware of the typical features for each um lobe. I feel like they're fairly easy questions to sort of ask in the, the stem, they'll maybe say some of these features and then which lobe is it likely to be stemming from? Um So I'll let you read those in your own time and make sure the slides are sun around afterwards. Um So in terms of treatment, this is coming on to the question that we had. Um So you want to consider antiepileptics after a diagnosis of epilepsy or after first seizure, if there's a neurological deficit, if e eg shows unequivocal epileptic activity. So I think that's um the key point that was in that question is that the patient had had an E EG and it showed um this unequivocal epileptic activity which basically diagnostic of epilepsy. Um If they didn't, if the E eg had been normal or um they hadn't yet had an eeg and they maybe just had the one seizure. Um then that would sort of lead you more towards the, maybe we don't need to start treatment um after just having had one seizure because obviously, a lot of people may have just have one seizure in their life and then never sees again. Um other points for when to start treatment, if patient um considers a risk of further seizures to be unacceptable. Um So maybe they're vulnerable or they have, I don't know a high risk job or things like that or if there's a structural brain abnormality on imaging. Um And then in terms, in terms of what antiepileptics we use for generalized tonic chronic, first line of sodium valproate or Labo or levetiracetam for women of childbearing age because sodium rate is teratogenic. Um in that question, it was a bit sink because she's had a hysterectomy. So that's why um we were able to give that patient sodium valpo. Um But normally women of childbearing age, we want to avoid Um And then for focal seizures, the first line is lamoTRIgine or time. So I feel like it's fairly um strict, like there's not too many anti epileptics to learn for the first line. And I think it'd be quite mean of them to stray from these sort of like first line anti epileptics. Um And then for absent seizures, eis succimide is one in particular that's um first time for that and then just being aware of the D VLA rules good for ay um advice stations. Er can't drive for six months following any seizure. And in epilepsy, you've got to be fit free for 12 months to regain your license. Ok. We're gonna go on to question two. But does anyone have any questions about um that case or epilepsy first? Sorry, it's very weird. Not been able to see the chat box and not been able to see myself as well. There's no questions in the chat at the moment, but I'll let you know if any appear. All right, we will um move on to the next one and then you can always ask questions at the end. Er So question two, your clerking patients in the evening. It's around midday. Your next patient woke up at 9:30 a.m. with left arm and leg weakness. And his husband noticed that he was fluttering his words on examination. There's no visual field defect or facial weakness, right limbs, five out of five power, but two out of five on the left arm and three out of five on the left leg starts at 95%. Blood pressure's 200/1 05. What is your next step? One, Aspirin, 300 mg, two IV, labetalol, three supplemental oxygen, four IVR places of five CTN people are very speedy in asking this one. Currently the overwhelming winner is CT head. Lovely. Um Yeah, fab I will move on to the answer then. So yeah, the answer is CT head. I feel like I've tried to occlude a mixture of harder questions and also slightly easier questions because I think when you're arising, it's hard to remember the stuff you do know and the stuff that um it's fairly straightforward to answer and questions will be a lot of questions will be straightforward. So gives you a bit of a confidence boost. Um But yeah, thinking about, I don't know the other answers sort of trying to sway you towards thinking the sort of A to e approach. Um So airways fine B breathing sats 95%. So we don't need supplemental oxygen. C thinking about BP um could be swayed towards IV labetalol. But actually in um ischemic stroke, we don't want to lower the BP too quickly. Um And clearly the most pressing issue here is um getting the diagnosis of stroke so that we can initiate treatment. So CT head would be first, you won't, obviously don't give aspirin before the CT head because we need to rule out a bleed. Um So going on to stroke definitely probably the biggest topic within neuro. Um So initial investigation of management want to do a A to E and then don't ever forget glucose co hypoglycemia, big mimic of stroke. Um get the CT head and then once hemorrhage has been excluded, you give 300 mg of aspirin stop and that's continued for two weeks. Then thinking about thrombolysis and thrombectomy. Um So certain criteria for both for thrombolysis needs to be within 4.5 hours of symptom onset. And there's a big list of um things that are contraindications that you need to make sure um the patient is not fulfilling um good to have a little read of what the contraindications are for thrombolysis. Um OK. That could be a question or something in an ACY that they might ask. Um and then thrombectomy. Um So has certain criteria as well. It's only done in certain centers. So the patient might have to be transferred. Um CT angio needs to demonstrate occlusion of proximal arterial or posterior circulation um or there has to be chance of salvaging brain tissue on imaging there, certain time frames when it's um only relevant for they need to have a good prestroke functional status. And um it needs to be quite a profound stroke. So they need to be scoring more than five on the um stroke symptoms scale which is then a HSS. So going on to TI A make sure, you know, the definitions know the difference between TA and stroke. So ta S ischemia without infarction symptoms should be resolved within 24 hours. Once I think they're moving the definition to talk more about um sort of on imaging it being like infarction versus ischemia. Um But generally, we still use the sort of less than 24 hour symptom. Um cut off for TI A, you can give 300 mg of aspirin immediately. And then if we're in the GP, thinking about um next steps for referring to hospital, if they're on anticoagulation, um then I'll need to go to ed straight away cause they'll have to have a CT head to exclude hemorrhage. Um If they, um otherwise ti a clinic normally seen within 24 hours. If they had the ti a over a week ago, then they don't necessarily need to be seen within 24 hours. But most of the, I don't think that would really, they'd catch you on an exam question like that. Um In terms of other investigations want to do an E CG to all that af and um carotid imaging to see whether they need any stents in terms of secondary prevention. Um Also we start on clopidogrel, 75 mg, a statin important to know that you don't start a statin immediately in ischemic stroke, you need to wait at least um, 48 hours after stroke and then your general things like BP and diabetes control and addressing modifiable risk factors, smoking weight, all those important things. Uh Just a little note on BP control, sorry if this is a bit blurry. Um, but just sort of knowing the differences between uh BP control and hemorrhagic versus ischemic stroke. So, as I was saying in that question, um for ischemic stroke, don't acutely lower the BP unless there's a hypertensive emergency. So, they've got signs of hypertensive encephalopathy, nephropathy, um ac sciatic dissection. So basically any um sort of emerged situation where you would have to lower the BP um or gonna be throb they need to be around um 185 systolic. Whereas in hemorrhagic stroke, it is more important to um try and control um the BP again, not acutely um lowering it too quickly. Um but just sort of ha having that tighter BP control is more important. Um OK. Question three. Um I'll save questions on stroke till the axis is another uh stroke related question. So, a 70 year old percents to the ed with five hours of left facial paralysis, right limb, torso, sensory loss and reduced hearing. She has a CT which shows a hyperdense area of ischemia, which artery would supply this area. I'll give you a minute or two on this question. So currently the er majority by quite a lot are going for left anterior inferior cerebellar artery stroke. How many people have responded so far? At 36? Lovely. All right, well done everyone. It is left anterior inferior cerebral artery. Um So I hated these questions because I feel like getting your head around the sort of niche stroke syndromes for some reason, really confused me. Um So I've put this horrible, well, hopefully it's a, a simplified table in um for the artery areas and the features. Um I think obviously in the question, once you work out, OK, you've got left sided facial paras, right sided um limb symptoms. You know that it's not gonna be your standard um anterior middle cerebral artery helps you to think about. Ok. Is this a cerebellar stroke? Um I think what things I found useful for in terms of um so the anterior inferior cerebellar artery and the posterior inferior cerebellar artery. Um one has facial weakness and one has facial sensory loss. Um So that could be a way that you can help to differentiate the Weber syndrome. One has a cranial nerve three palsy, which is um quite a bit like the thing that stands out for that one. Um But yes, it's one of those things that there might be one question on it and it is quite a lot of information to learn for that one question. Um But yeah, I think definitely knowing the anterior middle cerebral um artery in terms of like the upper and lower limb differentiation. Um and also being aware of the like further classification of anterior circulation strokes. So the difference what fulfills the criteria for a total versus partial anterior circulation stroke. Um But it seems like you guys are fairly on it with um a lot of people getting that one, right. So, yeah, don't be disheartened if you've not learned these or you're quite confused, but hopefully this table is something that you can come back to and, and have a look at all. Right. I'm gonna move on. Um, ok, we're gonna move on to a different topic. So, does anyone have any stroke questions? I haven't gone into hemorrhagic stroke too much. Um So obviously make sure, you know, the like CT had findings for subdural extradural that those lovely things. Um Yeah. Any questions on stroke, no questions at the moment. What my wife? Um. Right. We'll go on to the next question then. So the question for you are leading the ward and on the acute receiving unit when you meet Glenis, a 75 year old lady who's come in after a nasty fall. She has a past medical history of Parkinson's disease managed with levodopa. She's more drowsy compared to normal and has been vomiting. What is the most appropriate management of her Parkinson's disease? I've started that poll and we just had a question come through, uh, from Hazel who asked if on a blood thinner and has a tia a would you scan first or give aspirin first scan first. Um, yeah, I don't, I think, I think that's my gut instinct. Um, maybe have to double check on nice guidelines. I guess. I guess if symptoms have fully resolved, um, and therefore you're confident it's a tia a they might give aspirin. Um, but I imagine it would be quite important to get the CT head and you're gonna be referring them to Ed on the day rather than the ti a clinic if they're on anticoagulation. So you can get the CT head quite quickly and then they can give aspirin. Um That's my gut instinct, but maybe double check on them. Nice guidelines if you can find it. Ok. How are we doing with this question? Uh 36 people responded so far and the most popular option is uh option four. Um but people have voted for all five options. So it's a kind of smaller spread across the other option, but option four, I'll give it a couple of minutes in case anyone else wants to answer. Ok. So the answer is number four. So majority wins. Um a bit of a trickier question. Sorry. Um I feel like Parkinson's is a rarer condition but something that's quite important to know about for when you start working on the wards of uncles and things. Um because Parkinson meds, I feel like are one of the big important things that don't really get taught too much about in terms of how you like practically manage them. Um But yeah, the answer for this one is to stop and convert to patch. Um This is because it doesn't sound like she's gonna be able to swallow a med, she's vomiting. Um, but we need to make sure that she's getting. Um, the meds are another route. So you convert to tine patch and there's good like conversion guidelines depending on how much levodopa they on. For what dose of patch you can prescribe. Um The other options I feel like are all fairly good distractors. Um double the dose of levodopa that a lot of um things where like steroids, you double dose don't use um where you could be thinking with that um a stat dose of haloperidol uh hopes that people didn't choose um haloperidol is one of the key things that you have to avoid in Parkinson's disease. Um um Yeah, going on to the complications and the management because that brings in some of the other meds that are listed there. Um So I've not gone into too much about the path of physiology of Parkinson's and the sort of the main um treatments of levodopa, obviously important that you guys have got that somewhere in your vision. But I thought I would um take the time to go through some of the like complications and how you can manage those. Um So daytime sleepiness, thinking about D VLA advice and thinking at how we could address any reversible causes. There's a drug called MODO. I don't think that's something that you need to know of my heart just for your interest. Um The bits maybe to be aware of more um, orthostatic hypertension can be a problem in patients with Parkinson's, especially the form of Parkinson's M SA multiple system atrophy. Um So thinking about whether they're on any meds that could be worsening that and mid mid mir and fludrocortisone, the two meds that can help with uh the hypertension aspect, um psychosis, uh thinking about when we actually need to medicate. Um And when we can use other sort of reorientation calming techniques, um if medication is needed, you can use a low dose of QUEtiapine, like I said before, important to avoid how the paradox with some Parkinson's disease. Um and then some other complications that can happen dementia drooling. Um I think it's a, a disease that can affect multiple aspects of a patient's um life and quality of life. So, managing different symptoms best we can. Um So that is um very brief Parkinson's. Um So does anyone have any questions on that case? We go on to the next, no questions so far, but I'll keep an eye on cha I heard there's not too much to um that you need to know for exams, but just obviously being aware of the pathophysiology, the first um like main line treatments. Um yeah, than just having a bit of awareness about things. So we will go on to question five. No one has any questions. Um So your next patient is a 36 year old pregnant woman who tells you her migraines have become troublesome and affecting her quality of life. She asks you what you can give her as a preventative medicine to reduce the frequency of migraines. Yes, sorry. I hope my cough isn't too loud through all your microphones. So speedy, speedy response for this one. vast majority going for propranolol. But some people saying er option two and some people saying option five as well. Ok. Have. Yep. So the answer in this one is propranolol. Um number five would be an important lifestyle um choice to give her. Um but seeing uh she's asking for a preventative medicine um and the key bits in the stem is that um the migraines have become troublesome or affecting her quality of life. So, um there are some indications for starting to think about extra medications. Um So in terms of migraine management in the acute phase, um analgesia nsaids, paracetamol, triptans uh useful me to start um right, the onset of migraine antiemetics if uh as it is associated with nausea, um an important point to avoid opioids in the management of migraine pain. Um it's been shown to worsen migraine pain rather than help. Um and then for prophylactic treatment, the indications for starting that are if symptoms are significantly affecting quality of life if for some reason, um, they can't take acute treatment. So maybe they're intolerant to nsaids and paracetamol. Um, or if those things have been ineffective, um, or if they're having so many acute flares that, that, um, sort of having to use analgesia so often that they're putting them at risk of medication, overuse headache. That could be another indication for thinking about prophylactic treatment. Um, so the main prophylactic treatments are propranolol, amitriptyline and topiramate. So that was one of the other um answers in the case. But in the case, the lady was pregnant and topiramate is trato IC. So I'd want to avoid that one in this case. That's why propranolol was the answer there. And then for the other anti sumatriptans, obviously, some of them using the acute phase rather than as a preventative medicine. And as I said before, I want to avoid opioids. So not or a off. Um and then otherwise just thinking about lifestyle management, stress management, sleep hygiene, hydration, eating regularly exercise, all those things um useful to think about how you might um counsel someone in and ask you about like lifestyle management and stress management. It's useful to know the things like reducing caffeine intake. Um and how you'd explain things like sleep hygiene to someone that can be an easy ay scenario. Um ok, so going onwards, um I thought I would include um indications for CT head following head injury. Um Maybe because this is something that I always struggle to remember some of the, the key points and the time frames of things. But also because I think it's actually quite useful for when you, um start work. I feel like I've been called to a lot of falls and a lot of people banging their heads. And so it's actually something that's quite useful to remember as you go forward and not just for exams. Um So do you really wanna put in the chat box? What do you think some indications for doing act head would be? And then I will reveal maybe if Beatrice can read out what things are going through. So we've got first one loss of consciousness. Someone else said vomiting more than once. Amnesia. Mhm Yeah. Any of this, there's lots just wait for some more to come through. Mhm. Uh confusion, neurological deficit signs of basal skull fracture. Signs of intracranial hemorrhage, low G CS. Anyone know what, what G CS schools were thinking about? Someone else has said uh G CS less than 13 when assessed irrespective of time, post injury or G CS, less than 15, 2 hours, post injury. When discussed with surgeons, I think, um and someone else said on blood thinners, hospitalization on anticoagulants, skull fracture. Oh yeah, well done. I think we've got a lot of those. So um the things that we get you a CT head in one hour G CS score less than 12 or less on initial assessment, um G CS score of less than 15 at two hours after the injury. Um which is what someone was saying for, if you suspect an open or depressed skull fracture, the signs of basal skull fracture or things like um panda eyes, um hemotympanum, um, or CSF fluid leaking from the ear or nose if they've had a seizure. Um, if they've got a focal neurological deficit, and as someone said, more than one episode of vomiting, then things that can get you a seat head in eight hours. So if they've had loss of consciousness or amnesia following the head injury and one of the followings. Um, so if they're over 65 years of age, if they've got any bleeding or clotting disorders, if they had a dangerous mechanism of injury, um, which I think important to remember what those are. Cos they, they don't always have to sound that, er, dangerous like a, don't fall down five stairs. Um, and especially in the elderly. Um, so just falling from, um, not that high height can actually be uh, like classed as a fairly d dangerous mechanism of injury. Um, and if they've got more than 30 minutes of retrograde amnesia of events before the head injury. Um, and then the key one about anticoagulants. So if they're on anticoagulants or antiplatelet, um, if they're just on aspirin, 75 mg monotherapy, then that's won't, won't cla er, classify, but if they're on dual antiplatelets with clopidogrel. Then those things would get you CT head in eight hours. Um, then I've just got a little quick quiz um, for us to do so. These are quite random questions about, um, quite a few different conditions in your, but I thought it might just be good to do like quick, quick fire um, answers. So maybe if you've got a piece of paper or when to write on your phone, um If you want, I'll give you like a few minutes just to go through and then we can go through the answer of these. I feel like it's useful to go through lots of SBA type questions, but sometimes it is just good to test your knowledge with quick fire, sort of one way to answer questions, I'll read them out. Um So number one, painful cranial nerve, three, palsy, what's the most likely called? Number two, what medication is useful for treating spasticity in MS? Number three, what treatment can be used for essential tremor? Number four, what are the features of normal pressure? Hydrocephalus? Number five, treatment for trigeminal neuralgia and number six features of broner aphasia and which brain region slash arteries is uh supplying that? Um Violet said for question two. Alophen. Yeah. Hold on. Yeah, you can either put them in the, you can answer them in the chat box if you want or just on your phone. Someone else said for question one. S ISA H uh Yes. There's a specific um leading to SA H but for bonus points and someone else said for question three BB. What? Sorry, someone said PP question for BP BBBB beta blocker. Sorry, a bit slow today. It took me a moment to look at the abbreviation as well. Um Oh, there's a few more answers now. So uh question five, someone has said carBAMazepine. Mhm. Uh Question for someone said popular edema and headaches. Mhm And for question one, someone else said posterior communicating artery aneurysm. Perfect. That's what I was after f well done guys. So I will show you the answers and then we can talk through quickly. So yeah, number one, posterior communicating artery aneurysm. Um It's one of those like spot diagnoses sort of things if they say it's a painful um cranial nerve, three palsy. That is the cause. Um BMS Baclofen is the key one. Use gabapentin can also be used um treatment for essential tremor propranolol. Um And make sure you no differences between parkinsonian tremor and essential tremor. Uh Number four features of non pressure, hydrocephalus is something that doesn't really get taught that much. Um But it's a condition that these sort of three things together and a question would point you towards um don't feel like you really need to know much more about it, but just knowing these like three key features. So the um features like gait disturbance, dementia and urinary incontinence. I think there's some sort of like, um there's a way to remember it, that's like wobbly something else and um like wobbly confused and peeing a lot, but it's not that much along those lines. Um And then trigeminal neuralgia treatment called Mazepine, someone got that all done. And then Broca's aphasia. So that's an expressive aphasia. So they can understand what you're saying, but they're not able to um formulate the speech output and the area is in the frontal lobe and it's the inferior frontal garri supplied by the superior middle cerebral artery. Um There's different ways of remembering the Brock and Wen Aass. Um And I think it's useful to know which areas and which arteries they are. So that could be a question that gets asked. Um Again, a bit of a confusing I remember but sorry. Um someone asked if they could just see the previous slide again. Yeah, sorry, I should have. Um I put the answers underneath the questions. I don't really think that went through and someone else has shared a helpful way for remembering wet wobbly and wacky. That's it. I knew there was a uh something along those lines. Um Yeah, wet wobbly wacky. Um It's funny the things you like half remember from revision, um The things that stick with you a year later and the things that don't OK. I think um that's been helpful showing the previous slide and they've got what they needed, I think. Um So just a little list of things that I haven't covered today that are probably, um, important in terms of like the other MLA core content topics. Um, hopefully things are fairly like small topics. I'll try to cover the big things today. Um, is a bit of a minefield in terms of like a lot of niche little bits. Um, and it kind of feel a little bit overwhelming but just try and keep it as straightforward as you can. Um I think getting your head around being able to localize um where things are coming from is a big part of it. Um So you haven't covered things like cranial nerve palsies don't need to know all of them, but making sure, you know, the like 346 is at the like top top three ones that they had to ask about um and visual field defects, the whole homonomous hemianopia, things like that. Um Not covered things like spinal cord injuries and peripheral opathy. So that also sort of comes under TN oa bit as well. Um Oh yeah, just having a few. Um make sure you think about some of the causes of peripheral neuropathies, especially for um oy being able to list off some differentials. Um F and D Mycena Gravis Classic Edinburgh, um topic, uh, infection haven't covered. Obviously, meningitis is a big topic um or important topic. Um So make sure, you know, um investigations, antibiotics, et cetera and then we covered a little bit on hemorrhagic stroke, but not in that much detail. Um And then M ND and MS, things like that. Um So hopefully feel like you've covered um a decent amount in this hour um and not too much extra to look up. Um Yeah, so that is uh the end of the thing. We've still got 10 minutes or so. I think um you can either do some uh some questions or um you guys can have an extra long break. Um I'm gonna stop sharing my screen. I've also got a feedback form if you guys wouldn't mind. Um filling that in, that'd be really helpful. Um Has the portfolio getting things signed off, never stops. Um So it'd be great to get some feedback. Uh Any MLA specific tips I told you um MLA specific, I think, make sure you've done the previous papers that they give you access to. Um So it does help to see. Um Oh Fab, is that for me or do I send another? Uh You're welcome to share your own as well, Lizzie. Um This is just um for everyone else as well if they have time to share. Um we're doing feedback for each session today. OK. That would, would you be able to forward that on to me? Yeah, absolutely. I'll, I'll just go through that one. It's probably a better form than the one that I've created. Um ma specific tips, I think in general the questions are I don't know. I found in comparison to some of the Edinburgh mock papers, I do think the questions are slightly easier. Um, I don't think they try and catch you out as much. They are quite similar though because, I mean, a lot of them are written by Edinburgh people so I wouldn't get too stressed about it being, I don't know, super different but just make sure you've done the papers that they give you access to because it helps you see the style of questions. Um get used to like reading the, you know, when they're like the best thing to do next and just like the the wording of the question is always really important. Um And often where they can split people up on. Um Yeah, and then just make sure you've looked through the big like MLA core content map um because they shouldn't ask you things that aren't linked to that. We did have a few like picture questions as well, I think. Um So just make sure, you know, what things look like. Here's another random tip, any other questions or either about neuro or just general exam tips or two. I hope it's been useful. Um And I hope you guys are all doing OK, revising. I know it's a very long marathon slog. Um So make sure you're looking after yourselves. Any tips on me for research questions. Um Yeah, I mean, I don't think they, they were always quite, they're quite niche, random things, aren't they? I think there's sometimes things that you just won't have been able to prepare for and they'll ask you a very weird question and you might guess it right. You might not. And I just have to take that on those questions. But I think in general, um, like knowing, knowing the key terms, like knowing what sensitivity specificity, um, having a quick read about different types of research, I think a lot of like Edinburgh gears you up well for like having had done previous research. So hopefully that gives you some background knowledge about different studies and stuff. Um But yeah, I think just familiarizing yourself with like key research definitions um and doing the previous questions to see what style of questions they ask for those, any other questions at all. Yeah. Thank you very much Lizzie. That was a really helpful session on urology and you cover a lot of the great stuff. Um So thank you. Um We've got a couple more questions coming in and maybe a few more minutes. Yeah. Yeah. Um I'm also happy to be emailed. Um I think my email is at the end of the slides but um you guys will get some um but feel free to email any just general questions or about fy stuff. Very happy female. Uh What kind of pitch stuff was it? Gross pathology instruments, et cetera. I think like a couple of instrument things. Um I don't wanna, not to, like, don't start googling every single instrument. Um, but, yeah, I think just if you, like, if you come and pass stuff in your vision and you think, oh, I don't really know what that is. Just have a quick Google as you're revising but don't go out to start, like, stress googling. Um, lots of random things. Um, yeah, I think just having a, like the stuff as you're revising that I think you think? Oh, I don't actually really know what this would be practically. Um Yeah, let's have a quick look. Um I don't think we had many. I can't really remember. I don't think because I felt there was, there's more pathology sort of questions in the Edinburgh style mocks and previous exams. Um I'm not gonna say that there definitely isn't cos I can't fully remember, but I don't think there was many. Yes, there were. Um, but yeah, try not to stress you guys all be fine. Um, like if you've done the marks or you've done the papers, the fact that you're here today is, um, a great sign and be fine. All right, I will, um I'm gonna end my video but I will stay on for the next few minutes in case anyone has any more questions. But thank you all for listening and I hope it was some useful and engaging. Um, and I hope the rest of the day goes. Ok? Thank you very much. Lizzie. Um, so we have just under 10 minutes now as a break until our next session, which is on surgery and anesthetics. So, feel free to go grab a cup of tea or coffee and join us back here at, um, 10 to 2. Hi. Ok. Hi, everyone. I hope you had a good break and are ready to crack on with our next session. Um, so for this session, we are covering anesthetics and surgery and this is going to be delivered by Magdalena who is a current Fy one in the academic program based in Oxford and she is also yes, assesses previous president as well. So over to you Magdalena, thanks Beatrice for that introduction. I hope you can hear me. Yeah, I can hear you. Lovely. Um Hello everyone and thank you for joining us this afternoon. As Beatrice said, my name is Magdalen and I'm an academic fy one in Oxford. I'm an Edinburgh graduate and I was in your position last year just about to sit my finals. I've been asked today to deliver a session on anesthetics and surgery, which I hope that you'll find useful. So, firstly, what to expect from this tutorial, it's impossible to cover all of anesthetics and surgery in one tutorial. So we will go through anesthetics, general surgery and vascular surgery, highlighting the key points to know for finals. Other high yield surgical specialties for finals um are orthopedics, urology, pediatrics and breast for some bizarre reason. We had a lot of breast questions last year. Um, but I'm not going to cover the surgical specialties in this tutorial as I believe that they are covered in other tutorials. There will be MC Qs throughout. So please vote for the correct answer using the pole function which is anonymous as the, and these slides will be made available to you after the tutorial. I have included, um, some additional notes as well as explanations for the MC Qs in the note section of the slides. OK. So um let's start with anesthetics. I think for your finals, there are really two topics that you need to know from anesthetics and these are area management and pain management. There is a lot more that we could talk about within anesthetics, but I think those two topics are the key ones to know. So I will go through both of them very briefly. Let's start with an M CQ which I hope will be nice and easy for you. So a 23 year old female is brought into A&E after being found on her bedroom floor with empty bottles of omph on her bedside table on examination. She does not open her eyes to voice or pain stimuli. She does not obey any motor commands. However, it flex is to withdraw when you squeeze her trapezius muscle, she initially makes some incomprehensible, grows. However, after a few minutes, this stops and she only makes snoring sounds what is the most appropriate next step in the management of this patient? So is it a conservative management only? B give Po naloxone only. C insert an endotracheal tube and give IM or IV naloxone D, insert Nohn goal airway and give Im or IV naloxone or E give im or IV naloxone only? So I'll give you a few minutes to answer that. OK. So we've got um some responses now, it looks like the majority of you have gone for D, which is the correct answer. So this patient has a compromised airway due to a low G CS. If you calculate the G CS, given um the information that you have here, it is GCS seven. So um one for eye response to for voice and for, for movement. So she has a compromised airway that you need to manage. She's had an opioid overdose. So you need to give naloxone, it's not safe to give oral naloxone as her swallow is um unsafe in this case. So you can give naloxone Im I IV or IM. Um any of those would be fine in this situation. Now, an endotracheal tube. So intubation and ventilation is unlikely to be required here. Um sort of managing the airway with just simple airway maneuvers and adjuncts such as an oropharyngeal airway is likely to be sufficient to maintain this patient's airway. Um And I just wanted to say that I had a very, very similar scenario in my a two E AY station. So you might need to manage the airway in your um ay. Ok. So um area maneuvers, I'm sure you all know them head tilt, chin lift, um which this diagram shows nicely how to do the contraindication for. This is a suspected or a confirmed c spine injury. The other maneuver is a jaw thrust. It's more effective than the head tilt and lift and you can use it if you suspect um ac spine injury, it is however very uncomfortable if your patient is awake or semi conscious. And in practice, you use both of these maneuvers simultaneously. As long as the patient's level of consciousness allows you to do so airway adjunct. So urinary airway typically well tolerated. Even if the patient is awake or semiconscious, it's useful if an oropharyngeal airway cannot be inserted, for example, due to oral trauma or jaw trismus size from the tip of the nose to the tragus of the ear. And the contraindications include any facial or nasal trauma, nasal lesions, suspected or confirmed basal skull fractures and any coagulopathies, oropharyngeal airway, which you may hear people referring to as a good deal airway as well. They can produce a gag reflex if the patient's awake or semi conscious and they are quite rigid in structure. So that can cause bleeding. Um if you cause any trauma to the oropharyngeal um structures on insertion and its size from the midpoint of the incisors to the angle of the mandible, supraglottic airway, such as eye gel or laryngeal mask airway. They prevent oral secretions from trickling down the trachea, but they provide incomplete and unreliable protection from aspiration of gastric contents. So, the contraindication therefore, is um any sort of risk of aspiration. For example, a patient with a full stomach or bowel obstruction bag of elf mask ventilation. So that provides high flow oxygen and you can place it over the top of nasopharyngeal and oropharyngeal airways. And you can connect it to slot airways and endotracheal tubes as long as you remove the mask part first, um and endotracheal tubes. So it's a definitive airway as it transverses the glottic opening and resides in the trochlea. There's an inflatable cuff which provides an excellent seal, preventing aspiration of any gastric contents or any blood and finally surgical airways. So, tracheostomy, a definitive airway or cricothyroidotomy. Um It's a common misconception, but this is actually not a definitive airway. It's just a temporary emergency measure that you can use, but your patient is then likely to require a definitive airway afterwards. So, like I said, you may need to manage the airway in your A two E AY station. Make sure you know how to recognize airway compromise, know the signs know the key features of the different airway maneuvers and adjuncts. And most importantly, know the indications and contraindications for each. Remember that airway maneuvers and adjuncts can be used simultaneously and within reason multiple airway adjuncts can be used simultaneously. So for example, you can use a nasopharyngeal and an oropharyngeal airway at the same time. And most importantly, demonstrate confidence, be confident in managing the airway, show that you know how to use the airways, you know how to insert them and you will be all good. Ok. So um in terms of pain management, I think the wh o pain ladder is a useful tool to use. So for mild pain, use paracetamol nsaids and um you can use adjuvants as well. I've listed some adjuvants that you may want to consider here. And then for mild to moderate pain, you can additionally use weak opioids such as codeine or dihydrocodeine and then for moderate to severe pain. On top of the weak opioids, you can use strong opioids such as morphine and oxyCODONE. So that's all that I really want to cover with anesthetics. Does anybody have any questions at this point that they would like to ask or anything that they would like me to go over again? What conversions should we aim to learn is, do you mean conversions in terms of um like converting the different opioids? Oh OK. For syringe drivers, et cetera, I would know the main ones. So, morphine to oxy um to oxyCODONE, um oral morphine to subcutaneous morphine. Um I would know what the different patches contain. Um Yeah. So conversions between codeine, dihydrocodeine and morphine and oxyCODONE essentially. Um And also converting from oral to subcutaneous and yeah, everything that sort of tends to be covered within palliative care. I would, I would know um, they do quite like those questions. I hope that clears things up. Anything else anyone would like to ask? Ok. In that case, I'll move on, um, moving on to general surgery which will form the bulk of this tutorial. So the acute abdomen is a key presentation. There are many potential causes and it's useful to separate them by abdominal region or specialty. So, just a bit of brainstorming to um start with, can you name any potential causes of acute abdomen? Just pop your answers in the chat, appendicitis, s any others cholecystitis, cholangitis. Yes. Can anyone think of any that are not um sort of gi related bowel ischemia? Yes, diverticulitis plus of infection. Yes. Good. Ectopic pregnancy. Very good. A rupture. Good perforation. Good. Ok. So I really like this diagram. It's um rather comprehensive, but it illustrates nicely just how many potential causes of the acute abdomen there are and there for what an important presentation it is and it also shows that the causes um are from many different specialties. Um So another empty Q for you, a 50 year old female presents to A&E with acute abdominal pain. She describes episodes of intermittent pain in the right upper quadrant. These episodes last a few hours and tend to come on mostly after dinner. She's also vomited during some of these episodes. Her observations and blood results are within normal range. She has a raised BMI and has been trying to lose weight for some time now, however, her span is difficult given the most likely diagnosis. What is the most appropriate definitive management of this patient? So, is it a mix them know by mouth and insert an NG tube? Ber CPC, elective laparoscopic cholecystectomy, D laparoscopic cholecystectomy within 24 hours or e discharge with worsening advice. Ok. Most people go in for ac which is the correct answer. So, these are typical features of biliary colic. Um And the definitive management for biliary colic is an elective laparoscopic cholecystectomy. So, bilary colic, it's due to the presence of gallstones in the biliary tree. The typical clinical features are a col of pain in the right upper quadrant that may radiate to the back, the right shoulder or the right scapula, its worse um, postprandial as gallbladder contraction is at its maximal at that stage. Um and it's particularly um bad following fatty foods. Patients often have nausea and vomiting, but importantly, they are apyrexial and they have normal inflammatory markers as well as normal liver function tests. So, in terms of the investigations, you can uh take some blood from them and you can also do an abdominal ultrasound management. Um, give them some analgesia, some IV fluids if they need it. And the definitive management is the elective laparoscopic cholecystectomy. Ok. So 48 year old female presents to amy with right upper quadrant pain which radiates to the back. She has had a few episodes of vomiting on examination. She is pyrexial with a temperature of 38.9 and has a positive Murphy sign. Her blood results are showing below what is the most likely diagnosis? So, is it a acute hepatitis B, ascending cholangitis, C acute pancreatitis, d acute cholecystitis or e bowel perforation. Lots of people are going for acute cholecystitis, which is the correct answer. So, typical clinical features of acute cholecystitis here, the blood results are also in keeping uh with acute cholecystitis. So you can see raised inflammatory markers. You've got a raised CRP and a raised um white cell count. So, acute acute cholecystitis is inflammation of the gallbladder. Typically, patients have right, upper quadrant pain ducts may again radiate to the back, right shoulder or right scapula. They might feel nauseous and have some vomiting. Um The difference between bilary colic and acute cholecystitis is the inflammatory component in acute cholecystitis. So, patients are pyrexial and they do have raised inflammatory markers on examination. They may have a positive Murphy sign. So that's pain um during deep inspiration, when you simultaneously palpate the right subcostal area. And that's because the inflamed gallbladder comes into contact with your hands. In terms of the investigations, you can again do bloods. So they will show raised inflammatory markers and they might show mildly deranged liver function tests, particularly a raised ALP, you can do an abdominal ultrasound and potentially also MRC P if um, you don't find any gallstones on the abdominal ultrasound management, make them comfortable, give some analgesia and if needed, also give some IV fluids. Definitive management is again a laparoscopic cholecystectomy at this time, um, in a slightly shorter time frame. So, ideally within 48 hours. Ok, another M CQ. So 52 year old female presents to A&E with right upper quadrant pain which radiates to the back. Her heart rate is 100 and 20 BP, 86/62 and temperature 39.2 her sclera appeared to be yellow in color. Her blood results are showing below what is the most appropriate next step in the management of this patient? So is it a analgesia IV fluids and broad spectrum IV antibiotics? B urgent abdominal CT with contrast c explorative laparotomy de RCP or E abdominal ultrasound. Lovely. So, 80% of you go for a which is the correct answer. So you have typical clinical features of ascending cholangitis here, but the patient is septic and hemodynamically unstable. So you must stabilize them as much as possible. In the first instance, you must do your sepsis. Six, give broad spectrum antibiotics, um ID early and only then you can think about doing um ERCP. So ascending cholangitis is a bacterial infection of the biliary tree. Gallstones are the most common predisposing factor. Patients often show Charcot's triad. So, right, upper quadrant pain, pyrexia and jaundice in severe cases, they might show Raynauds pentad. So that's Charcot's triad. Um but additionally, also hypertension and reduced consciousness and, and these patients can become very, very unwell and present um even with severe sepsis. So on blood, they will have a raise, inflammatory, raise, inflammatory markers, raise ap and importantly, a raise bilirubin um giving them the you can do an abdominal ultrasound which will show bile duct dilatation. Um and you can do an ERCP as well. Management. Um analgesia makes them comfortable fluid resuscitation, broad spectrum IV antibiotics, um and ERCP. So ERCP, unlike MCP is both therapeutic and diagnostic. It does carry some uh complications um that may potentially occur and it's important to know them. So you can get bleeding, you can get duodenal perforation, you can get acute pancreatitis, you can get acute cholangitis from ERCP as well. Ok, a 48 year old female presents to A&E with severe epigastric pain and vomiting. She's pyrexial with a temperature of 39.2. She underwent an ERCP procedure seven days ago after which she felt well and was discharged at home. Her blood results are showing below what is the most likely diagnosis. So, is it a acute hepatitis B, ascending cholangitis? C acute pancreatitis, d acute cholecystitis or e bowel perforation? Ok. Amazing 100% of you going for c acute pancreatitis, which is the correct answer. So you have typical clinical features of acute pancreatitis, you have raise inflammatory markers on your blood and an amylase that is more than three times the upper limit of normal. Um And I may have slightly led you on by saying that um acute pancreatitis is a complication of OCP. Um but it's important to know that. And actually, in clinical practice, I've seen it quite a few times now where patients present um really unwell with acute pancreatitis following ercp. So another M CQ um same patient, you've got her blood results showing below which parameter within her blood results would help you to establish um the severity of the most likely diagnosis. So, is it a sodium B amylase? C calcium D magnesium or E lipase? Just give me a few more moments? Ok. So we have the majority of people going for calcium, which is the correct answer, but we do have some of you going for amylase as well. Um And a few of you going for lipase, which I was sort of hoping to see. Um So calcium is part of the Glasgow Emery criteria, which is the severity scoring tool use in acute pancreatitis and am and low levels don't actually correlate with the severity of acute pancreatitis and they are therefore not a part of the Glasgow Emery um criteria and sodium and magnesium are just distractors. They're not relevant in this case. Ok. So acute pancreatitis, very serious condition with significant morbidity and mortality. I don't think I realized how serious it was. Um Until I started working, I currently work in it and I've seen a lot of patients with it. Um A lot of patients very unwell and a lot of patients not having great outcomes. So it's characterized by self perpetuating pancreatic enzyme autodigestion. There are many causes. I'm sure you all know the pneumonic gets smashed. Um And like I said previously, it's an important complication of E RCP. It causes both local complications and systemic complications. So, patients might have pancreatic um peripancreatic fluid collections. You might have pseudocysts, pancreatic necrosis, pancreatic abscesses, et cetera, um and systemic complications such as D IC ARDS, um hypocalcemia, hyperglycemia and different organ failures as well. So, patients typically have severe epigastric pain that may radiate to the back or the flanks. They have nausea and vomiting. They are pyrexial on examination. They might show a positive colon sign. So that's periumbilical discoloration or a positive turn sign which is flak discoloration. In rare cases, they might get something called part retinopathy that can cause temporary or permanent. Um blindness investigations raise inflammatory markers on blood and raised amylase and lipase levels. These are typically significantly raised. So more than three times the upper limit of normal. But like we said, um amylase and lipase don't correlate with severity. In fact, amylas might be completely normal as the levels start to fall after um 24 to 48 hours. Um and it's excreted renally as well. So a lot of these patients have renal failure which will affect the um the levels of amylase lipase tends to fall slightly later than, than the amylase. Um And for imaging, you can do an abdominal ultrasound or a contrast CT. But imaging is actually not required for the diagnosis if the patients have characteristic clinical features. And if they have blood in keeping with acute pancreatitis and raise inflammatory markers based amylase lipase, you can make the diagnosis um just based on that. But um imaging is helpful um especially in establishing the underlying cause which can affect um the management. Um Alistair asked why is calcium affected by pancreatitis? I think there it's complicated. Um I don't know the exact reason but it's just a well recognized systemic um complication of acute pancreatitis. Um and quite important to be aware of for that reason. So management analgesia, aggressive fluid resuscitation. So these patients are very often um significantly fluid deplete, optimize their nutrition. So patients might require parenteral nutrition if enteral nutrition fails or is contraindicated. For example, in patients who are um vomiting lots, a lot of these patients will require ICU um and they are also likely to require surgical management. So that can be an early cholecystectomy for gallstones, an early ercp for obstruction of the biliary tree, deprivement of necrosis if um they are failing to sort of settle and they show worsening organ failure or they might need radiological drainage or surgical necrotomy for infected necrosis as well. So, this is the um Glasgow Emory criteria. Very helpful. You can use the pneumonic pancreas to remember it. I don't think there's any need to memorize it. I would just be aware that amylase and lipase are not actually a part of it and um be aware of the fact that three or more of these um should prompt you to consider um it or HD as it's um indicates severe acute pancreatitis. Ok. Inguinal hernias, I'm sure you all know the clinical features. So, corn lump that's superior and medial to the um, tubercule, it disappears on application of pressure and then the patient lies down. Um, patients have a certain degree of discomfort that's worsened by activity, but it's rare that they are in severe pain. Inguinal hernia might become um incarcerated. So patients will have pain out of proportion, it will be tender and it might be a feat as well. They can become strangulated. So, again, pain out of proportion, firm sort of lump on examination. Um, and also possible discoloration. So sort of blue, purplish and discoloration from um, a lack of blood flow and it can cause bowel obstruction as well. So, um, investigations, it's an entirely clinical diagnosis. You can do an ultrasound if there's any uncertainty and ct if there's incarceration, strangulation or bowel obstruction. This is just a table to illustrate the differences between direct and indirect. So direct Bella enters the inguinal canal for a weakness in the posterior wall, it's medial to the inferior epigastric vessels. It tends to affect older patients and it's due to acquire weakness in the abdominal wall. Indirect inguinal hernia be enters the inguinal canal through the deep inguinal ring, lateral to the inferior pro GST vessels. And it tends to affect younger patients as it's due to incomplete closure of the processes vaginalis. So that's an approaching of the peritoneum for which the testes migrate from the peritoneum during embryological development. Um And another examination, you can diff well, try to differentiate between direct and indirect um by locating the deep inguinal ring, which is the midway point between the aces and the pubic tubercule. You can then manually reduce the hernia by compressing it towards the deep inguinal ring, starting from the inferior aspect. And once the hernia is reduced, you can apply pressure over the deep inguinal ring and ask the patient to cough. If the hernia reappears, then it's more likely to be a direct inguinal hernia. And if it doesn't reappear, then it's more likely to be an indirect inguinal hernia. So it might just be useful to watch sort of a quick you video to remind yourself how to examine inguinal hernias for your acies. And this diagram just shows anatomical differences between direct and indirect inguinal hernias. It's a nice diagram and, and you know, examiners seem to be obsessed about the anatomical differences between the two but actually, this is of no relevance to management. Management is the same for both. So you do a mesh repair. Um typically using an open approach for unilateral hernias and a laparoscopic approach if they are bilateral or recurrent. Ok. So that's hernias. Um And now another M CQ for you, 24 year old male presents to A&E with acute central abdominal pain which radiates to right iliac fossa. He has vomited several times since the pain began. He has a heart rate of 100 and one and a temperature of 38.2 on abdominal palpation. He shows guarding and a positive ring sign and his blood results are shown below. What is the most likely diagnosis? So, is it a medical thyro ulit B, Crohn's disease C renal colic D pyelonephritis or e acute appendicitis? Lovely. So all of you going for e acute appendicitis, which is the correct answer. Um Typical clinical features in this question. It's a young patient, acute appendicitis tends to affect younger patients and you've got raise inflammatory markers in keeping with acute appendicitis on bloods as well. Ok. Um And some patients, what is the most appropriate next step in their management? So, is it a refer to general surgery for surgical intervention? B, abdominal x-ray C CT, abdomen, D IV, fluids and IV antibiotics only or E an abdominal ultrasound? Ok. Someone's going for a which is the correct answer. A few going for D and E as well. So you do need to refer to, to surgery for surgical intervention. Imaging is not required for acute appendicitis. Um What is really required is either an open or a laparoscopic appendicectomy. Um, you will need to give them analgesia and IV fluids and IV um, prophylactic antibiotics. Um, but you should as the most important step refer to general surgery because they will need surgery. Ok. So acute appendicitis tends to affect younger patients. They get abdominal pain, uh which tends to be periumbilical and radiate to the right iliac fossa. It's worsened by coughing or moving. And Children are typically unable to hop on the right leg due to the pain. Patients often have nausea and vomiting. They might um lose their appetite, they might have diarrhea, mild pia on examination, they might show a positive ring sign. So that's um pain in the right iliac fossa when you palpate their left iliac fossa or a positive mcburney sign. So that's tenderness on palpation of mcburney's Point, which is approximately a third of the way between the aces and the umbilicus. You can have rebound tenderness, percussion tenderness, gardening or rigidity if there is generalized peritonism due to perforation or a bit of local um peritonism as well. So you will see a raise inflammatory markers on their bloods. Often they show a neutrophil predominant leukocytosis, you should do urinalysis and that's really just to exclude um other causes. So, exclude ectopic pregnancy, exclude um a uti exclude renal colic, et cetera. And you can do an abdominal ultrasound management, um, make them comfortable with some analgesia, give some IV fluids and give them prophylactic IV antibiotics. The definitive management is open or laparoscopic appendicectomy. And if the acute appendicitis has caused perforation, then they will need copious abdominal lavage and fter. Ok. So 72 year old male presents to A&E with abdominal pain and bloating. He's uh constipated and has not opened his bowels for the past four days. He has had a few episodes of vomiting which were green in color. He's usually a fit and well gentleman. However, he underwent a bowel resection 12 years ago due to a colorectal malignancy, it, abdominal x rays showing on the right. What is the most likely diagnosis? So, is it a a recurrence of colorectal malignancy b small bowel obstruction, C sigmoid volvulus d large bowel obstruction or e bowel perforation? Ok. So we've got an even split between small bowel obstruction and large bowel obstruction. Um, and a few of you thinking it's sigmoid volvulus as well. Give a few moments for others to answer. Ok. So now we've got the majority of you 50 per 3% going for small bowel obstruction, which is the correct answer. So you have typical clinical features of small bowel obstruction, um, adhesions, for example, following previous surgery are the most common cause of small bowel obstruction. And you've been given an abdominal, um, x-ray here So differentiating between the small bowel and the large bowel on abdominal um x-rays need to remember that the valvular confident of the small bowel um extends all the way across the small bowel. Whereas the ho t um extend approximately a third of the way across the large bowel, which is also um greater in diameter. But actually, I think that's slightly difficult to appreciate sometimes on abdominal x rays. So, um the most reliable thing is just to look at whether you've got the valve continente, extending all the way across or whether you've got the ho um extending only about a third of the distance across. So, uh we've got a question. Large bowel, usually more constipation. Vomiting is usually small bowel. So they can have vomiting and constipation in both small and large bowel. Um I didn't want you to focus too much on the symptoms in this question. It was more about interpreting the abdominal X ray that makes sense. Um But we can look at the clinical features of both just now. So, um small bowel obstruction, adhesions, for example, following previous surgery are the most common cause. Hernias are also a common cause. So patients usually have abdominal pain which is diffuse and central. They can have nausea and vomiting and that can often be vomiting. They can have constipation and lack of fluc flatulence and incomplete obstruction. And on examination, they can have a distended abdomen and tingling. Bowel sounds in terms of investigations. You can do an abdominal X ray which will show you distended small bowel loops or you can do a CT, which is the definitive investigation of choice. Ok. So, um, I just wanted to show you, um, a comparison of what the small bowel versus the large bowel looks like on abdominal X ray. So I hope you can appreciate the differences that we mentioned earlier in the management of bowel obstruction. So make the patient know by my, give them IV fluids put in a naso gastro tube and give them analgesia. They will require urgent surgical management. If there's complete obstruction, peritonitis, um or strangulated hernia and you can do conservative management. Um, if there's incomplete obstruction, large bowel. Um, so colorectal malignancy is the most common cause. Volvulus and diverticular disease are also um rather common causes. So patients can actually show symptoms um of their underlying cause. So they can show symptoms of a colorectal malignancy. They will have abdominal pain. Um, they can have nausea and vomiting, but that's actually quite a late sign in large bowel obstruction. Again, uh constipation and lack of fluctuance, abdominal distension and tingling, bowel sounds. In terms of investigations, you can do an abdominal X ray which shows distended, large bowel loops or you can do a CT, which is the definitive investigation and it's useful in um identifying the underlying cause as well management. So, again, no, by mouth IV fluids, angiotribe and analgesia, urgent surgical management. If there's peritonitis or perforation, you can trial conservative management for up to 72 hours if urgent surgical management is not indicated. But the reality is that most of these patients will require surgical management anyway. Ok. So an 86 year old male presents to A&E with abdominal pain and bloating. He is constipated and has not opened his bowels for the past four days. He often suffers with constipation despite taking regular laxatives, he feels nauseated and has had a few episodes of vomiting. His abdominal X ray is showing on the right. What is the most likely diagnosis? So, a small bowel obstruction, B sigmoid volvulus, C cco volvulus, D large bowel obstruction or e toxic me colon. I'll give you a bit more time to get some more responses in. It looks like people are finding this question a little trickier. There's um a greater split between the answers. Ok. So majority 50% going for BM sigmoid volvulus, which is the correct answer. So I hope you can appreciate the large bowel obstruction on the abdominal X ray. And I hope that you can also see the coffee bean sign, um which are typical features of sigmoid volvulus on abdominal x rays. Sigmoid volvulus tends to be um associated with older patients and chronic constipation which we have in this question. And the clinical features described in this question are also in keeping with sigmoid volvulus. So, ulus is torsion of the colon around the mesenteric axis resulting in compromised blood flow as well as closed loop obstruction. So, the majority of cases are sigmoid. So that's large bowel obstruction caused by the sigmoid colon twisting on the sigmoid me mesocolon. And that's associated with older age, chronic constipation and also neurological and psychiatric conditions. The minority are cecal. So normally the cecum is retroperitoneal and therefore, there's no risk of any twisting. But in the minority of people, there is that risk of twisting because of developmental failure of peritoneal fixation of the proximal bowel. So, cecal volvulus um is associated with all ages. Um It's also associated with adhesions and pregnancy. Clinical features of volvulus, abdominal pain, nausea and vomiting, constipation and abdominal distension. In terms of investigations, you can do an abdominal X ray. So sigmoid volvulus will give you large bowel obstruction and a coffee bean sign and cecal volvulus. And you might see signs of small bowel obstruction on the abdominal X ray in terms of the management. So, sigmoid volvulus, uh usually requires a rigid sigmoidoscopy and a rectal tube insertion. Whereas a cecal volvulus usually requires a right hemicolectomy. Ok. And that's general surgery. So that's um quite a lot that we covered there. Does anyone have any questions at this point before we move on to vascular? I'm going to take the silence as a no. Um. Ok. So another MC key for you, 65 year old male attends screening and is found to. Oh George, sorry, what was the answer to that question? So the last question, this one, the answer was sigmoid volvulus. Ok. So a 65 year old male at attempts screening and is found to have an abdominal aortic aneurysm which is four centimeters in diameter. He has a repeat abdominal ultrasound a year later which finds that the aneurysm has increased in diameter to 4.7 centimeters. He is asymptomatic with no other comorbidities. What is the most appropriate next step in the management of this patient? So, is it a repeat abdominal ultrasound in three months? B repeat abdominal ultrasound in 12 months. C repeat abdominal ultrasound only when the patient develops symptoms. Do you refer to vascular surgery within two weeks for surgical repair or e admit to hospital urgently good? So, must have you going for a repeat abdominal ultrasound in three months? Um So if the AAA is between 4.5 to 5.4 centimeters, you repeat the abdominal ultrasound in three months. So, um AAA risk factors include being male smoking hypertension, most importantly, syphilis, um and certain connective tissue diseases such as Danlos type one and morphin as well. So most patients are actually asymptomatic and the AAA is found incidentally through the screening program, they might have abdominal back or loin pain, they might show the ischemia from embolization on examination. You might be able to feel an abdominal mass that is pulsatile in nature. And if the AAA is leaking or has ruptured, then the patient um may present with collapse, hypokalemic shock and severe pain. So um investigations, abdominal ultrasound, normal aorta is approximately two centimeters in diameter and anything over uh three centimeters in diameter is a AAA. And you can do a contrast CT angiogram as well in terms of the management. So uh surveillance if it's 5.5 or less, um and many AAA actually enlarge very slowly or may stay um completely static. So surveillance is the most common management, you can um do medical management. So that would be your BP control, statin and antiplatelets and surgical management. If the patient is symptomatic, if the AAA is 5.5 centimeters or more in diameter, or it's increasing at more than one centimeter per year, and the surgical management is either an open or endovascular repair. The choice of which depends on the stability of the patient and also the morphology of the AAA. So if your patient is unstable with a ruptured AAA, then they are most likely to have an open repair. But if they're more stable, um they can have an endovascular repair. However, that's only still suitable for certain morphologies. Um So it all sort of depends on the patient, how stable they are. And um the morphology seen on imaging. The screening program is a single abdominal ultrasound for males over the age of 65 less than free. No further action required 3.3 between three and 4.4 we scan every 12 months, 4.5 to 5.4 we scan every three months. If it's 5.5 or larger, then they have a high risk of rupture. And you need to urgently refer them to um vascular surgery for probable surgical management. And if they are rapidly enlarging at more than one centimeter per year, there's also a high risk of rupture. So again, you want to refer them to vascular surgery. Ok. And I believe this is the last M CQ for you. So 54 year old male, female, sorry presents to A&E with central chest pain. It's staring in nature. Her heart rate is 100 and 12 BP is 100 and 76/98 and respirate is 21. Her observations are within normal range. Um Otherwise, and she has a history of poorly controlled hypertension. She undergoes a contrast CT angiogram which is showing what is the most likely diagnosis. So, is it a a pulmonary embolism? B AAA C A mediastinal tumor D aortic dissection or E is this a completely normal CT scan? Lovely. So 100% of you going for the aortic dissection, which is the correct answer. You've got those typical clinical features um of an aortic dissection. And if you look at the CT scan, you can see um a false limen within the aorta, which is the key sign of aortic dissection. Um, now George asked a question about AAA. So if it were increasing at more than 0.5 centimeters in six months, are you on track to go more than one centimeter per year, would you operate? Um, I think that really depends. So, if they are symptomatic, absolutely, they would need surgical management. Um, but if not, then I think that would sort of come down to the surgeon's choice. Um, And whether they felt it was appropriate, I imagine that most wouldn't unless they met the criteria of one centimeter per year, which they might do further down the line. So I think it would just be a case of closely monitoring the patient. Ok. So aortic dissection, um it's when you get a tear in the tunica intima of the wall of the aorta. So the blood can flow between the tunica intima and the tunica media. Um which sort of further progresses. The dissection, risk factors include hypertension. Most importantly, um any trauma, having a bicuspid aortic valve, being pregnant, um Turner syndrome, Noonan syndrome, and again, connective tissue diseases such as Ehler da type one and Marfan Syndrome, typically there's severe um sort of sharp or tearing chest or back pain on examination. You might see that the patient has a pulse deficit, they might have aortic regurgitation may have hypertension and they might show involvement of specific arteries. So, for example, coronary arteries causing uh symptoms of angina spinal arteries causing paraplegia or involvement of the distal aorta causing um limb ischemia. So contrast ct angiogram is an investigation of choice. It's suitable for patients that are stable and it's useful for surgical planning. And the false lumen is the key diagnostic finding on a chest X ray. You can see a widened mediastinum and you may do a transesophageal echo um for patients that are unstable and the risk of placing them in a CT scanner is just far too great. OK. So um this diagram sort of nicely summarizes the classification of aortic dissections. As you will know, you have the standard um classification and the Dabi classification, the Stanford classification I would say is the most important to know because it um affects the management. So if you have a type a aortic dissection, you require surgical management. You need to control the BP to a target systolic of 100 to 100 and 20 whilst you're waiting for the surgical management. And for type aortic dissections, it's conservative management only. So your patient should be put on bed rest, you should keep their BP low with IV labetalol to prevent um further progression of the aortic dissection. So that's everything that I've had prepared for you. I hope that was useful. I just wanted to finish off with some general pieces of advice. First of all, you know, much more than you think you do and you've all made it to this stage of medical school for a reason, I would say focus on knowing the main clinical features, investigations and management steps for the main conditions of each specialty and know what would be expected of a generalist medical school seems to be taking on this new approach of training us to be generalists. And it's all about pattern recognition. And I think passed Oxford handbook of clinical medicine and clinical specialties are essentially all that you need for your um revision. So, thank you so much for joining. I'm very happy to answer any questions um that you may have. I've also put my email in here in case you want to ask any questions after the tutorial. Um But thank you so much and good luck to all of you. I'm sure you all do very, very well. Thank you very much Magdalena. That was a really helpful and comprehensive session. Um I'm just going to put a feedback form in the chat now, um for all our participants, if you wouldn't mind filling that in, it'll give Magdalena some really helpful feedback that I'll send through to her. Um And also if you do have any questions, please pop them in the chat. We've got a five minute break just now and we'll be uh commencing our final session of today at 5 to 3. But thank you again, Magdalena. Thanks Beatrice. I will hang around for a few minutes. So if you do have any questions, please pop them into the chat um Before the next session starts. You're very, very welcome RK. Um Yes, I'm very happy to provide access to my slides. I have sent a copy to Beatrice. So I think Beatrice um will share them on Medal after the session. And like I said, there are just a few additional um, notes and explanations for the MC QS included in the notes sections of the slides. If there's anything that's unclear, do please um email me and I'm very happy to, to chat and explain anything. Hi, everyone. Um Just let me know if you can hear me and see me cause my wifi is not working very well. So I'm having to hotspot. So just let me know if it's not working. Hi, Isabelle. We can see and hear you. Well, let me share my screen. Mhm. Oh, ok. Right. Can everyone see that it might just be taking a second to load? Ok. Let me know when you come. Maybe let me try again. Ok. Right. Is that better? Can you see that? Not just yet? Oh, interesting. Sorry. Let me any problems. Um So it seems to be blocking up. All right, let me try it one more time. Can you see that? Are you still seeing yourself? Still seems speakers at the moment? Oh, no, ok. Thanks for bearing with us. Everyone will get it sorted in just a moment. Let me try and yeah, I'll send you my slides. Um What's going on Paris? Is it better if I save them as a PDF? Yeah, that'd be perfect. Thank you. Ok. Have you got them? They come through up the likes of email. It's just loading. Yeah, perfect. They've come through I'll just upload those now. Thank you. Great. Just uploading which will take a moment and then we'll be ready to go. Ok, perfect. I'm counting that. Uh Thank you for bearing with us everyone and for Isabella as well. Um Soldier, non despite connection issues. Um But yes, thank you uh to all our attendees for um lasting what has been quite a long day so far. Um And for our last session, we're covering dermatology, ent and ophthalmology and we're currently joined by Isabel. So who's currently in Fy One in North and Central London and she's also been on the E SSS committee in the past as well as our senior vice president. So. Oh, good to you, Izzy, thank you. Um So yeah, I appreciate you've all had a really long day and this is the last one. I'm gonna try and zip through it as quickly as I can because it's quite a lot to cover. Um Also I have my email address throughout this. So if you have any questions about any of the content or anything about Fy one, London, anything like that just um feel free to contact me. So if you could move on, can I can I control it. OK. Um So we'll try and spend 25 minutes on der 25 minutes on um ent and then we'll just do a little bit on ophthalmology. I think with ophthalmology, the main thing is just to learn like, you know, the pictures that we do. Um I think the from what I remember a final year, the actual tutorials that they give are pretty useful and they tend to use what I the photos that we use were very, very similar to what um they showed of the fundoscopy. So just try and learn them and um pay attention to like diabetic hypertensive retinopathy, macular degeneration. Um pass med is really, really good for that. Um But we touch on that. So I want to start my timer. So let's go. OK. So first things first, um the main question type that you'll get in dermatology is gonna be the spot diagnoses. Um So you'll get a picture. It's usually like the first one on Google. Um Make sure you learn the appearance of the pathology on all the skin because I feel like Edinburgh doesn't teach that very well. They teach mainly white skin um which when you start working will probably trip you up and also in exam questions, we'll trip you up. Um The best sort of resources that I found um would probably be done at NZ I'm sure you've all heard of it and then mind the gap as well. Um and learn your treatment matters. So, learn your atopic eczema, your acne, your psoriasis and what to do if you've had one round of treatment of one type. Um and how you sort of go from there. So let's go on. So this is the first question I'm gonna try and give you about 20 seconds for each one. So if we have a pole with a um and just have a read of that and also whenever, OK, if we could, how about finished? OK. So the answer is emelent, which most you got. So you're gonna start with Emme, especially in young Children, you're not gonna jump straight to corticosteroids. Um So it's atopic eczema. So let's go to the next slide. Um So with this, you wanna be looking for the sort of key features, it's very, very itchy um in babies, it will start on the trunk and face and then it will come to the extensor surfaces and then through childhood it will tend to go on to your flexor surfaces. Um So don't be put off if you've got a very young child and it's not in the flexor. Um The dermatology guidelines say the management should be ABC. So that's avoid triggers, use bland moisturizers for emmolient therapy and then see it's control inflammation with steroids. Um So in terms of triggers, you want to avoid anything harsh, anything that las um or like bath additives, you want to advise parents to stop smoking. Um and to avoid wool and irritant clothing. Um and then emollients as much as you can really rehydrate the skin. Obviously, it's a, it's a skin barrier issue. Um So you want to prevent the breakdown of the skin barrier and in young Children as well, you can use wet wrapping. So, um you've got emollients and then bandages, um and that also stops some scratching. Um So if we could go to next. So in terms of the steroid treatment, um how you do the treatment is you have a short term of treatment, steroids and then you have maintenance dose. Um So for remembering the sort of steps up for steroids, you want to go help everybody and dermatologists. So, h hydrocortisone EO B denote and then Dermovate and that's how you step up. Um So you'll do once daily or twice daily um for 1 to 6 weeks and then you don't want to do any further than that because it can cause skin thinning, it can cause loss of pigmentation. Um So from then on, you used twice weekly for maintenance. Some people use it just over the weekend and then during the weekday. Um and I remember to leave half an hour between a million uses and corticosteroid use. Stepping up from that. Um You can use topical calcineurin inhibitors. This is especially useful for areas of thin skin, so on the face and um on the neck. Um and you want to use that for up to bail. Um, you can also use antihistamines. So if someone's not sleeping at night, you want to give them a sedating, antihistamine, like chlor chlorphenamine, um, you can give them also, um, non sedating if it doesn't really interrupt their sleep. Um, but it's not like licensed use. Um, it's just sometimes also used, um, and then UVA for therapy is better than UVB, which is in, uh, using psoriasis. Um And then if all of that's not working, then you wanna go for your systemic medications. Um with methotrexate, I'd say the main thing to learn is all the rules around like fertility, um how you take it and everything because also that can come up in acies um for counseling someone with methotrexate use. Um whether that's for um eczema or if it's for something else. So make sure you learn that OK, next side. So moving on to the other types of eczema. Um The sach eczema is the one that you find. It's because of um we have um this Malassezia furfur thing. Um Everyone pretty much has it on their skin, it colonizes the skin, but um some people get an inflammatory reaction to it and that's separate der dermatitis. Um So you'll see that in the scalp, you'll see that sort of in the folds um around the ears and that's associated with Parkinson's and HIV. Um So if, if you see Parkinson's as a word in it think seic. Um and also you see it in Children like babies as well. When they're first born in babies, you kind of just reassure in adults you want to give the ketoconazole 2% shampoo. Um and you can give steroids as well. Um And then discoid, um you can get the multiple round plaques, um sometimes very weepy, they're very itchy. It's also called nummular eczema. So don't get uh tripped up by that. Um, quite often misdiagnosed. But what you want to do is take the scrapings and send a micro just in case. And then it's the same regime, emollients and topical steroids and then you've got contact allergic and contact irritant. So contact allergic is where you get this sort of weepy, very acute um eczema. So you'll get one sort of sensitization where you don't have symptoms. And then the second time you're exposed to it, then you'll have symptoms. So it can be like with this ear, you, you can get a nickel allergy. Um It could be where someone's belt is. So it's like very focal points. Um So that one always link to patch test, um and to avoid the trigger and then if you're getting contact irritant, um that's different. That's where someone, for example, the typical scenario get is someone's at work, they're starting work as a cleaner, they're finding that the hands are becoming very chapped. It's not so like acute, it's more just irritation. And again, with that one that you'd use like preventative, um, things like gloves for protection and you try to avoid triggers if possible. So let's go on to the next slide. So let's do a spot diagnosis. Um What do you think this is, um, thinking about what we've just covered as well? Ok, perfect. Let's, and not. So all of you got that right. Pretty much. Um, ec eczema herpeticum. Um So what you're looking for if you just go back to the side, sorry. Um So you're looking for these like punched out lesions. Um They're sort of monomorphic and they're quite angry looking. So now if we go forward, so it's um it's um normally caused by herpes virus HSV one HSV two. it's very, very painful. Um And in Children, if you've got the option of like, how do you manage this? It's always admit same day to pediatrics because quite often they need I VA cycler. Um Otherwise if you get an infection, a bacterial infection of the eczema, it's usually staph aureus. In which case you'd give flu clock, uh four times daily for 5 to 7 days. Um And then in a severe flare of eczema, you'll give oral oral corticosteroids instead of topical. Ok. Let's move on. Ok. Question two. Let's do Paul. OK. So most of you have got that right. So it's d um so this is a squamous cell carcinoma. Um It looks very regular, it's crossing. Um He's got a smoking history. Um So it's the reason that we go with D in this case is normally for a squamous cell carcinoma, you'd want to surgically excise it with margins. So if it's more than 20 millimeters, you want six millimeter margins. If it's less than 20 millimeters, you want four millimeter margins. But if it's in a cosmetically important area or if it's on the face, um you tend to go for mos instead. Same me one. So yeah, um for spot diagnoses, um again, these can come up a lot in exams. Um for the, the way I tend to remember it for the squamous and the um basal cell, basal cells are a lot more pretty. Um They're pearly, you quite often can see the sort of red vessel going over it and they're a lot slower growing. The squamous cell carcinoma is usually very regular. Um It's usually quite painless. Uh You get crusting, think of a, a cauliflower basically. Um And the way that you deal with them is completely different. So, surgical excision with a two week wait for squamous cell because it's a lot more aggressive. Um Basal cell is slow growing. So there's sort of a range of treatment options. Um You can have cryotherapy, you can surgically asci um and then you can have the topical um sort of cytotoxics as well. Um You also want to know about the precancerous. So that's burns disease and actinic keratosis. Um really, the treatment is kind of the same for both um think for uracil or cryotherapy. Um but usually sun exposed areas for bones disease, like that kind of big, irregular, a flat um lesion that you get a 10 keratosis. You can have quite a few. Um They're kind of the hardened, they're kind of crusty, scaly lesions, usually on the backs of the hands, on the backs and then on the scalp as well, most old people have them. So if we move on now, finally, Melanoma, um I remember that, I think this came up in either my fifth year or my sixth year exams. Um It wasn't too much on the treatment because that is just to take it out. Um But it was more on what it could be and spot diagnosing it. So there are four main types. Um The main one is the superficial spreading which we can see here um seen in younger people and you're looking for the sort of asymmetrical um change in border um with new colors in it all that sort of ABCD um sort of features that you get with Melanoma. Um And then if we move on, that's also pretty much seen in the L the Lentic Noma Ligna. Um and that's tends to be in older people. Um but it's much less common. So if you're getting a, what is it most likely to be and something that looks like this, um It's probably superficial spreading. Now, if we move on. So this is your nodular type, it's the big like crusty red or black lump which bleeds and oozes. Um And then moving on, you've got your atrial antigen. Um So if it's on the palms or the feet or the soles of the feet, it's probably going to be this in the question. Um And then also if you've got the sub angle, um that sort of below the nail, that is also probably going to be the acral one. The Hutchinson sign is just involvement of the nail bed. And um just to note that in black people, 90% have this sort of um subungual pigmentation. Um So don't be re uh worried if you see it on the wards, it's probably not going to be a Melanoma, but um it's quite often used in exam questions. So if we move on, so now we're going to do something else. Uh If we could start Paul, please. Ok, let's stop that. So all of you got that right? Pretty much. Um So yeah, we're going to refer to dermatology and the reason for that is because she's got a lot of scarring going on that alone is enough to refer to dermatology. So, if we move on, this is one of the most important things. Um Oh yeah, so if you've got scarring, if you've got nodular cystic acne, um which is this one below, if you've got mild to moderate acne, it hasn't responded to two courses or moderate severe acne that hasn't responded to a course with an oral antibiotic. Um, or if it's causing psychological distress, the patient and then this on the right is something called acne fulminans that you need a same day dermatology referral. And it's usually treated with high dose steroids. It's where you get this sudden eruption of acne. You also have malaise fever, joint ache causes severe scarring and it can also apparently cause an enlarged liver or spleen. But if that comes up in your exam questions, just know same day uh referral. So, moving on. So learn the acne sort of stepwise approach. Um So for mild, you, you've not got really papules or pustules, you'll have a, a couple of comedones. Um for moderate, you'll have the papules, pustules and then for severe, you'll have scarring, um widespread inflammation and you might have nodule nodules and cysts. So for the mild to moderate, um you're mainly talking topical. So that's the Adapalene benzoyl peroxide. So, Adapalene is just um a weaker retinoid. Um topical tretinoin is also a retinoid and then Clindamycin is an antibiotic. Um So you, you choose A B or C um if it's not working after 12 weeks, try another option. Um So if a moderator is severe, um you're going to, again, you'll have the same as A and B as the mild to moderate. Um If they're not working, you can try oral, an oral antibiotic, either Lymecycline or Doxycycline. And you can also consider the oral contraceptive pill in females. Um, if A and B in this case doesn't work, try an option with an oral antibiotic. And if that's not working, like I said, you want to then refer to dermatology, um, if your patient's pregnant as well, just to note that you'd probably use a RCIN instead. Um, but that's just something you're going to have to learn. Um, if you have a moment now take a screenshot, um, or get the nice guidelines up on your phone. Um, and just make sure you know that like stepwise approach, um, if you referred to dermatology, it will be for ISOtretinoin, um which again, learn the counseling, um, learn the side effects. Ah, thanks Beris, um, learn the side effects because that can also come up a lot in the exams. So, moving on. So, just to know on Acne Rosacea, um, if you get a patient and they've got te on the face, um, oh, yeah, the slides will be sent out after. Um, ok, so with acne Rosacea, you'll get the flushing of the nose, the cheeks and the forehead, you'll get the, the blood vessels, the telangiectasia. Um, and then you can also get, um, the sort of flushing exacerbated by sunlight. So, if you're treating that, um, give high factor sunscreen if it's persistent erythema, um, give the brimonidine gel. Um, so just remember that B for blushing primo uh ni if you've got mild to moderate papules with it, then it's ivermectin. Um And then if it's moderator, severe ivermectin plus oral doxy. Um So again, l step wise approach, you know, OK. So if we can do the pole for this, yes. OK. You know, has anyone answered? So we've actually got quite um a big mix here. So it's actually c um so this is psoriasis. Um This is one that we had in one of our fifth year exams and a lot of people got it wrong um because we'd only been taught it on white skin. Um So make sure you learn what it looks like. Some notes uh to be aware of, you can see on the extensor surfaces, it's um affected. So that's a psoriasis and then silvery plaque lesions. If you see that anywhere, it's probably psoriasis. Um So you're going to treat that with a potent corticosteroid and then Vitamin D as well. Um So moving on. So, uh this is what it looks like. Um silvery or white uh plaques in the extensor regions. You've also got papules, very strong genetic uh link and then also risk factor of smoking, um learning the drugs that are exactly. I really tried hard to come up with a Pneumonic for you guys, but II couldn't. Um So the ones that I tended to remember was the nsaids, the ace inhibitors and the beta blockers and then you've also got the lithium antimalarials and infliximab. Um But I think the ones that mainly come up with the beta blockers and the nsaids. Um So if you're gonna remember any, just remember those. So how you treat this uh potent corticosteroid for up to four weeks with the Vitamin D but not Vitamin D in pregnancy. Um You're also going to give um UVB therapy as opposed to UVA and eczema and that's 2 to 3 times a week. Um And then you can move on to the sort of biologics. Um You can also try culture. So, yeah, the methotrexate, um you might give um more quickly if you have a high pass score. So that's the sort of um extent of the psoriasis. So how much of the body it's covering and um how severe it is and it's a score, I think it's at 12. Um So if you get a chance to look that up, if you've got some extra time, so, moving on. Um whilst we're here, let's talk a bit about guttate psoriasis. So that's what you see on the right there. So that's normally the typical patient is someone who has had an upper respiratory tract infection with tonsillitis. And then they've got this eruption of teardrop scaly papules. Um So here you can see um got psoriasis and it's just reassurance that you give them. It looks very similar to pityriasis, rosea, which is on the left hip, the way you tell them apart is even though pityriasis can follow a viral infection, um they tend not really to mention that in exam questions. And the main thing that they talk about is a Herald patch. So that's normally on the chest or the abdomen. Um And then it's followed a few weeks later by small scaly red patches all over the back and chest and again, that's self limited. So moving on. So let's do another pole. OK. Most people look like they've got that right. So this is linked to ulcerative colitis. Um This is pyoderma gangrenosum. Um So the main thing you're looking for in the, in the question is it started as a small scratch and then developed into a painful ulcer. Um and it's got violaceous edges. Um And these people are systemically well, if you're worried about something like necrotizing fasciitis, your patient is not gonna be well. Um And we'll move on to the other sorts of ulcers anyway. So, moving on. So this is linked to IBD and rheumatoid arthritis, mainly it's kind of the inflammatory stuff because it's an autoinflammatory disorder of neutrophil dysfunction. Um So again, it starts as a small scratch or a bump or a pustule and then it develops into a very, very painful ulcer with purple edges. Um You might want to swab and culture it um because if it's infected, uh you might want to give flu clocks, but mainly the thing because it's autoinflammatory, you're going to give steroids as first line, you know. So then you've got your other ulcers, so your venous ulcers, um they're very, very superficial um due to chronic venous insufficiency. So you can get lipodermatosclerosis like here. Um you can get venous eczema edema. So you want to do an a Doppler ultrasound. Um you want to exclude arterial disease and then you'll treat that with compression banding. Um And then arterial ulcers are a lot neater. Um They tend to be more distal, uh they're very cold, um cold limbs, no palpable pu pulses and then you'll have a low arterial um uh ABP uh the index. Um and then you want to refer them to vascular straight away um for diabetics, um that tends to also be on the feet. Um And that is just because they've lost sensation in their feet. Um And they don't um notice when a blister forms and then it develops into an ulcer. Um So that is treated by basically wound care, seeing the GP um practice nurse um to get that treated. Um If there's any surrounding infection, you'd treat that. So you're moving on. So these were other conditions that I found quite confusing when I was doing my finals. Um So you've got pemphigoid and pemphigus, they're both blistering disorders. Um They're autoimmune. So the first one is the bullous pemphigoid. So I think b for body. Um So that's not including mucosal involvement. So they're very tense itchy blisters. Um, you see them in our elderly patients, they look not very nice and they're treated with, uh, corticosteroids. Then you've got the pemphigus vulgaris, which is basically this, but with, um, mucosal involvement, um these are not as tense, the bus are much eas more easily ruptured, but basically if they're talking about these cause. But I think these two, disorders and again, you treat that with oral steroids. moving on. Ok, Paul. Ok. Yeah. It looks like most of you have got that right as well. Oh, no, actually, I don't think you have. I think it's e is the answer we can move on. Yeah. So it's e um so this patient has a derma, a dermatophyte infection of the nail. Um It doesn't need treatment if you're asymptomatic, but um the patient is bothered by the appearance that you treat. Um So it's positive for Candida. So whether it's um positive for Candida or not is dependent on how you treat it. So if we can go next, so if it's very superficial or distal, um you ca so basically, if it's only used like infecting half the nail, for example, um you can just treat it topically. Um So for fingers, it's six months, for toenails, it's 9 to 12 months. Um And then if you sent scrapings, if it's dermatophyte, um that is positive for you treat with t terbinafine um orally once daily. So for fingernails, it's six weeks for toenails, it's 12 to 24 weeks if it's Candida oral itraconazole. Um So fingernails, you'll give bail for one week and then you have a 21 day break and then you repeat it once for toenails, you just repeat it twice. Um Again, I'm really sorry, I don't have a way that you can remember this other than I would if you're thinking about Gyne and or candida infection. Um And then what you'd give, you'll give him like fluconazole, cotrimoxazole, like the azoles. So I think Candida azole and then Dermat is terbinafine. Um And then the way, just remember that toenails require a bit longer than the fingernails infection. So if you're given two options and it's a toenail infection, it's probably gonna be a longer um course if you don't. OK. So we've got another pole. OK. Has everyone seen up? OK. Most people have got that right again. So that the answer to that is d um So this is Vertigo. Um The main thing in the question that is gonna point you to that is it's a golden crust. Um And it's mildly itchy. So he's systemically, well, it is not particularly widespread. So you're going to treat it with topical hydrogen peroxide. Um I think this is a fairly new guideline. I think it used to be fusidic acid and then in the interest of like antibiotic resistance or trying to prevent it, um They moved it to topical hydrogen peroxide. So, if we just move on, so you'll have thinwalled vesicles, which rupture quickly. Um, you probably, if the, once the child is presented, they're probably not vesicles anymore, they're probably the sort of golden crust. Um, you don't need to send off MC NS for it. It's a clinical diagnosis. Usually a bit itchy, usually on the face. So if it's, um, if there's no, um, bully, um, or it's quite localized then you're giving hydrogen peroxide. Uh Second line is fusidic acid if it's a bit more widespread, but it's still non bullous. You can give fusidic acid or you can give flu clock. Um And then if some, someone's systemically unwell, you get flu clock. So it's 500 megs Q DS. Oh, just go back. Um And then, yeah, say keep the child off school until lesions are healed and dry and crossed over. Or you've started antibiotics 48 hours ago, middle um some other common infections which are good to know. Um So you've got your ringworm um the tinea. So if it's on the scalp, look out for alopecia um on the question route. Um If they're in an urban area, you treat with terbinafine. So if you think t for town um and then Microsporum, um that's the one that is given by animals like cats and dogs. Um So if you think like greasy, like Griseo, that's how I remembered it. Um And you can also co prescribe ketoconazole if it's on the body. You're looking for like asymmetrical annular lesions, they're quite scaly. Um And they have a raised edge. Um If it's not extensive, you can give terbinafine cream. Um If it is extensive then you'd give it orally. Um I think it can be itchy but it's not, it's not like a main feature that you're going to look for, for scabies, however, it's very, very itchy. Um and it's a worse at night itch um to look for that in the question route. Um, when you're looking, um, if you look at the hand there, you can kind of see it's a very pretty, it's a pretty symmetrical shape and then to the right there, you can see you've got a burrow. Um, it usually affects the hands and the wrist. Um, the neck and above is spared. It's a clinical diagnosis and you'll give permethrin cream. If you really want to confirm, you can do an ink bar test. So that's putting a dot of it um like a, a pen on the middle of the pap peel and then you wipe it off and it will go down the burrow. Um And you'll see like a line down the barrow. Um So that confirms it. So you give two doses of that permethrin cream once weekly. I think they have to leave it on for like, I think it's maybe eight hours um sort of overnight and then wash it off and then head lice. Um, I think that came up in our fifth year exams. Um, they just showed us a photo and you could see the sort of eggs and the name of the neck was, um, had little dots. So you're looking for these red brown spots on the skin. Um, you're looking at the name of the neck and the skin behind the ears and then, um, you can see the grains on the hair shaft as well and that causes scalp itch and irritation. Um treatment. You'd use wet combing, especially if a child's got sensitive skin or eczema. Um You'd use that. So you use that every two weeks and you have to do it. I think it's like four times over the two weeks. Um or you can use a spray which basically like suffocates the head ice. Um And you do two doses seven days apart and that just covers the like life cycle. So if you move on, um So other things to be aware of are the rashes. I found it difficult to get um into my head. So you've got the bulls eye and then the target rash. Um So the erythema migrans is the bulls eye rash, which you see with Lyme disease. So it starts with a tiny red papule which gradually expands. Um I forgot to actually mention as well. Make sure you learn before your exams. What's a papule? What's a macule? What is like purpura? Um Because it makes it a lot easier when you're learning. Um Anyway, so this papule then gradually expands, you've then got the central spot, clear skin and then a ringed rash and it's usually, I think, um quite flat. Um It's a clinical diagnosis. You just give doxycycline for 21 days. Um If it's not, then you might use an an is a test, I think um for Lyme disease, but you're probably not gonna be asked for that. Just no doxy for 21 days. The erythema Multiforme, that's your target rash. So, um you get this sort of this ring of edema, um which is how you tell it apart. And then also you've got them kind of all over your body. Um It's usually immune mediated to um an HSV one infection. Um But it can be caused by lots of different things. Um You'll see it all over the body central, um symmetrically um over the extensor as well. It's very itchy, it's very swollen, it's very painful. Whereas with the bull's eye, it's not very painful. Um and um make sure you know about um erythema multiforma major, which then involves a sort of mucosa as well. The last one is pityriasis, versicolor. It's a yeast infection. Um It's not contagious. It's something I think we will have sort of everyone has it, but then it, it colonizes um in, in some people and it can cause basically uh differences in pigmentation. Quite a few people. Will notice it when they go on holiday and they try and tan um and then they have these like spots. Um It can be quite confusable with vitiligo. Um So um in the question room look for any signs of autoimmune disease um cause then that point you towards vitiligo, this tends to cover the back and the shoulders. Um And the treatment for that is ketoconazole. Ok. So let's do a palm. Ok. OK. I can't see what people have. That's it. Ok, perfect. Yeah. D that's right. So few. Yeah. So um in chicken pox um with pregnancy, um if they're exposed, you want to test for the immunoglobulin antigen if they already have the antibodies, um then you don't need to give anything. Um if it's negative, then you might need to give um acyclovir or you give the varicella immunoglobulin. If for example, you've got someone who's pregnant and you arrange antibody testing. Um and it's not going to come back for another week or something, then you just want to give the cyclovir straight away. Um But yeah, the first step would be to arrange antibody testing. You don't. Um OK. So I used to get mixed up between uh chicken pox and uh shingles. So I'm just gonna go through it quickly. Um chickenpox. Um You have your small macules which then uh progress to visors very, very itchy, mostly affect Children, very infectious 24 hours after your rash. So you want to wait until the lesions are crossed over to send them back to school symptomatic treatment. Um If it's in an adult, um you will give us a cyclovir um for seven days. Um And in pregnant women, you also want to give acyclovir, you want to get specialist advice and you want to admit if there's any other symptoms or symptoms of severe disease with herpes zoster that shingles. Um So it's an infection of herpes zoster, but then that reactivates the varicella zoster. So you can only have it if you've had chicken pox before, um it started with a burning and stabbing pain and then you'll get this rash, the fic rash in the dermatomal distribution. So it would be unilateral. Um quite often it's on the chest and you'll just get a strip of it. Uh It's quite painful, it's quite itchy. You want to admit if the tip or the side of the nose is affected because then that can affect the aci nerve. Um if you're getting any visual symptoms or if someone's immunocompromised. So, if it's within 72 hours of the rash, you want to give a cyclovir um or if someone um is over the age of 50 when would IV IG be indicated for pregnant women? Um So I think it, it can be uh indicated you tend to go with a, a cyclovir first. Um I think varicella zoster virus, um immunoglobulin is used but not as much. So, I think it is indicated, but you tend to go with a, a cyclo first if that answers your question. Ok. Um, and then, sorry, I was talking about the shingles. Um, so, yeah, if someone's in severe pain, um, and over 50 years, you'd also think about giving a Cyclovir. Um, and for the first two weeks you can, you can give corticosteroids as well if, um, they have a lot of severe pain. Um If someone's a lot older, they're at higher risk of getting the post herpeticum um neuralgia. Um So that's why you'd want to treat with acyclovir more quickly um to prevent that coming on. So, moving on. So this, if you could use a chat function, we're just gonna go very quickly through some dermatological signs which are associated with other conditions. Um Tell me whats it is or what it's associated with and we can just go through it very quickly. So bits if you can go. So this is a 45 year old lady with proximal mu muscle weakness and myalgia and she's got these sort of lesions on her hands. Come on guys. Quick quiet. Yeah, dermatomyositis. Yeah, I got trans papules. So, moving on. So you want these are the purple plaques on the small joints of the hands um associated with dermatomyositis. So think of the heliotrope rash, uh the sh sign and then the Gottron signs on the knees. Um So yeah, next, can you tell me what this is or what it's associated with. Yep. So, maybe not erythema nodosum. So it's linked to a lot of things. Um I think the main things that come up are sarcoid and IBD um can also be um linked to Beckett's um lots of drugs. So I think amoxicillin um combined pill nsaids and then TB as well. Um So it's tender bilateral. Um and you'll get sort of subcutaneous, no nodules. Um and you can get fever and joint pain with it, you know. Yeah, perfect. That's right. So, moving on. So this is dermatitis, hepatis. Um So it's meant to do celiac disease. So I think head shoulders, knees and bum. So it affects the scalp, shoulders, buttocks, elbows and knees, very, very itchy. It's fascicular uh with symmetrical distribution, you know what sign is this? Yeah, perfect. So this is acanthosis nigricans. Um It's linked to insulin resistance. So, metabolic syndrome type two diabetes and PCOS. Um and also if you're um if someone's you had long term steroid use, you can also get it with that. Um But linked to insulin resistance. Maybe not. Yes. It was also linked to gastric adenocarcinoma. Good spot. OK. Any answers for this one particularly looking at this, this uh face. Yeah, it's so, so again, this is that violaceous. It's like the butterfly rash. And then yeah, you've got the photosensitive rash as well. Um So you've got your butterfly rash. It's linked to uh uh ESL E you can get a lot of different um manifestations of this. Um So you can also get your hair loss. Um You can get bullous S LA. Um So you're gonna look out for other symptoms like nonspecific fatigue, malaise, um fever, chronic pain, and then all the renal involvement, seizures, pericarditis, anything else that sl involves basically. Um and then you're gonna look at your antibodies. So, moving on. So things that I didn't cover because we're running very low on time. Um Think about Steven Johnson's. So that's your drug reaction uh where it causes basically peeling everywhere mucosal involvement and it's uh an emergency. Uh Milos contagiosum came up, I think in exams. So remember if you see Children with um lots of spots with dimpling in the middle, that's me contagiosum pom. Uh Felix eczema. I think it's like blistering eczema. Um It didn't come up in my exams. I don't think I paid much attention to it, but it's something just to be aware if something comes up with that. Uh Lichen Planus. And then also uh urticaria, urticaria tends to be um treated with um like antihistamines unless um you also get an anaphylaxis syndrome, right? Let's do some ent OK. So question one. OK. Yep. So far everyone's got this right. OK. So this is age related hearing loss. Um So what you're looking for with that is um dropping off of the audiogram towards the um sort of higher frequencies. So, moving on. So this is a normal one. you're looking for above 20 s in all frequencies. So think about the um air bone gap. So if you've got conducting hear conductive hearing loss, your um air bone gap is is normal, there's no air bone gap because both your sense, you um your like bone conduction and your air conduction should sorry as in your yeah, your air conduction, your bone conduction will both be um no, sorry. I've just said that all wrong. So since you neuro uh since a neural hearing loss, you get no air bone gap, so both of those will be reduced if you've got conductive hearing loss. So the bone conduction is reduced, you'll get um sorry, no conductive hearing loss is sorry. Let me start that again, right? Normal above 20 all frequencies, sensoneural hearing loss um will infect affect the air conduction and the bone conduction um because it's in an area that is affected. So both of those will be reduced. Um And you won't have the sort of gap between the air and the bone conductive hearing loss, which is where you've got the air conductive in. Uh so air conduction will be impaired. So you'll have an air bone gap. So the bone conduction is normal cause the inner ear is intact with the air conduction, you'll have hearing loss. So you'll have a gap between them and then with mixed it, it's not very um uniform basically, it's um you'll get little dips in um in, in both. Um but both should be decreased and you should get air bone gaps. Sorry, I hope that makes sense. So, moving on. So, yeah, with your sensing um sensing, neural hearing loss, you'll get the sort of drop off here. So that can be by age related, it could be something like um an acoustic neuroma um ototoxicity and then many es as well, but many es tends to not look like this. It tends to be sort of a, a low to high um because you get low frequency hearing loss rather than high frequency hearing loss. Whereas um age related, you get the high frequency hearing, hearing loss, moving on noise induced, um you tend to get a dip um rather than sort of tailing off towards the end. So between, I think it's 3000 to 6000 Hertz, you'll get a dip in that hearing loss, you know, and then this is the, the conductive hearing loss. So this is where your air conduction is not working as well, but your bone conduction should be fine. Um So that can be if you've perforated your tympanic membrane, if you've got a TTI media or um any sort of discharge in the air, if you've got ear wax or your oscal are disrupted, you know, and then like I said, the sort of it's not very uniform, the air bone gap is not the same throughout. So that's seen in otosclerosis. Ok? I'll give you a little bit more time on this so you can read it all. Ok? Have we got some answers? Yeah, so everyone got that right. Pretty much. Um So with this one, your his right ear hearing is reduced and the ear canal is blocked. So that's gonna be a conductive hearing loss. So in conductive hearing loss, um the bone conduction is gonna be louder than the air conduction on the side, that's effective. So that's on the right side. So, on the RS, um the bone conduction will be greater than the air conduction. Um air conduction should always be greater than bone conduction in normal ears. Um And then in Webers, um the sound will localize to the affected in conductive. So if we move on. So yeah, um if you're trying to remember which one we is is if you think of a double, it has like a middle bit in it. So I think that is like the midline one for localization. So in sensor neural uh sensorineural hearing loss, it will go to your, it will um localize to the normal ear in conductive hearing loss, it'll go towards the affected ear, the affected ear because if you think of it, the bone conduction is still intact. Um And that's what uh Webers is testing for. Um And then you've not got the sort of the distraction of any sound coming through. Uh the conductive pathway. Um So that's why bone conduction is, is louder in conductive he in um conductive hearing loss and that's why it localized defective. So, next one, yes. Yep, everyone's right. So it's reassuring safety net. Um I threw in allergy to penicillin to throw some of you off. Um So remember if someone's allergic to penicillin do not give them amoxicillin. So this is a titus media. Um you tend to give, uh it's often following an upper respiratory tract infection um which then allows bacterial colonization in the middle ear. Um You'll see this bulging tympanic membrane. So you'll lose the light reflex. So if we just go to the next slide, so yeah, you'll lose this like nice kind of light. Um You tell them to go away and then if it's not resolved, then you can give um amoxicillin otherwise give amoxicillin. If someone's systemically unwell, immunocompromised, bilateral otitis media or their, they perforated the eardrum. You don't. Ok. OK. Um Yeah. So I see you got that right as well. So this one is a same day referral. So if you're getting sudden onset hearing loss and it's not explained by examination because this otoscopy is unremarkable, then you want the same day referral. Um If they've also got focal neurological symptoms, uh then you want to do a stroke referral. Um But you want to rule out acoustic neuroma here. So you're going to visualize um where the vestibular nerve is, which is at the cerebellopontine angle. Um quite often you'll give high dose corticosteroids, but that would be prescribed by ENT. So you wouldn't tend to give that in GP, you know. So let's go through all the different types of hearing losses. Um maybe a screenshot or you'll get these slides after. So hopefully it'll be useful. So we've kind of gone over um age related. So it's sensor, um, neural hearing loss is bilateral affects older age and you'd give hearing aids, otosclerosis um is sort of a mixed hearing loss, um mainly conductive though. Um And so you'll get a mixed air conduction and bone conduction, um reduced. Um It would be bilateral. Um mostly in the question, it'll be a family history onset, it will be at 20 to 40 years and they might get tinnitus as well. Um And you can have surgery or hearing aids will u usually um help out with that men disease. Um I'm sure, you know, it's the sort of triad of vertigo tinnitus and hearing loss, sensory neural um hearing loss is, you know, no, so u unilateral, it might be lateral um but it comes and goes. Um So you're looking for an ISMs that feeling of ear fullness and you tend to give betahistine with that. Um If they're having an acute attack of vertigo, you can give uh pro uh chlorperazine as well for acoustic neuroma, you can get sudden onset um or it can be gradual as well. Um quite often it's unilateral but um I remember something coming up about in one of our exams about it being bilateral um in your um fibromatosis type two. So just remember that as like a pocket of information, um you can get vertigo tinnitus with it. And then in addition, uh you'll also get an absent corneal reflex um because of the, the nerve origin um of the fifth nerve. Um So you'll do urgent ent referral. Um And then it's treated with surgery, radiotherapy or observation. Um think of your ototoxic drugs as well, learn your ototoxic drugs. Um So you'll need to stop using those drugs. Um And that's irreversible. So your gentamicins, your diuretics, nsaids cytotoxic. Um And in addition to hearing loss, you can get tinnitus and vertigo. And then we've also, we've already gone over the noise damage, um hearing loss. So, moving on. OK. That should be an easy one. OK. Moving on. So the answer to this is B which most of you got, um I can see that some of you mixed up A and B. Um So remember with BPPV D is for diagnosis. So dial pike and then e makes everything better. So, e is the treatment. So, moving on. So let's go with some causes of um vertigo. Um So let's start with BPPV at the bottom. So you'll get recurrent episodes lasting 10 to 20 seconds. Um You don't get hearing loss with it and it's usually when someone's turning over in bed and they'll, the room will spin and they're very nauseous. And then when you do the dick's whole pike, you'll get rotary nystagmus. Um, so you'll want to teach the patient the app. So you'll do the app, uh, maneuver and then teach the patient exercises to try and, uh, reset and it normally resolves. Um Then the top two here, you've got labyrinth, labyrinth, sorry, labyrinthitis. And then you've got vestibular neuronitis. The difference between them is in that in vestibular neuronitis, it's only affecting the vestibular nerve. So you're not gonna get hearing loss with it. Uh Both sudden onset, both with vertigo, nausea, vomiting, um and a recent viral infection, um and horizontal nystagmus. And then you're just gonna look out for the hearing loss. Um, for both of them, you'll give prochlorperazine. Um And then Meniere's disease, we've already gone over that. So, moving on. Ok. Sorry, I know you're probably all going crazy, but let's try and get this done as soon as we come. Ok. Um What do people put? Yeah, everyone's got that right. Ok. So this is called a tumor. Um So the main thing you're looking for here, oh, just go back, um, crossed upper tympanic membrane. So you've got that attic crust. Um And that is treated by surgery. It's actually, it is noncancerous, but it is invasive. Um So you need to treat it by surgery and it's, I think it's got quite a poor prognosis. Um And one of the risk factors for it is recurrent episodes of otitis medium. So just to be aware of moving on, what's the central school? OK. Is everyone counted up? What do people put should move on? Yeah, everyone's got that right. It's four. So we've got one for tender, enlarged cervical lymph nodes, one for temperature above 38 1 for tonsil uh tonsillar exudate and then one for absence of a cough. So, learn your fever pain and learn your center scores moving on. Um So the center score is basically to determine whether you think it's a bacterial infection, um bacterial pharyngitis and how you treat this is with Peni. Um So you'll give um for 5 to 10 days. Um OK, we can all remember Clarithromycin or Erythromycin in pen allergy and in pregnant women give Erythromycin um just to be aware. Um It's what bacterial uh pharyngitis looks like middle is viral. But then on the right there, you've got your E BV. So that's viral, but it causes a lot of um pus. So if it looks like that, if it's got a load of pus much more than you see on the left, then it actually is probably EBV, you know, which of these is not a sign of periton of abscess. I probably should say the card, not cardinal sign. OK. She move on. What was everyone put? Yeah, I see. Um So yeah, the throat pain tends to be unilateral. You'll get uvular deviation, you'll get Trismus, which is inability to open the mouth and then you'll get the hot pot voice as well where people, like, sound like they've got something holding in their throat. Um, and the treatment for that if we just move on is usually incision and drainage. Um, plus IV antibiotics. Um, just remember your n, uh, tonsillectomy criteria as well. So seven episodes per year for one year, five, per year, for two years and three per year for three years for um tonsillitis and referring someone for tonsillectomy. Moving on. I'm gonna briefly touch on neck clumps. So your thyroglossal and your bronchial, they're the main ones that come up in exams. So your thyroglossal is a midline and it moves up with tongue pertu um because it's connected to the tongue. Um Your bronchial cysts are ones that um are embryological remnants, um sort of anterior and lateral to your, um steno a mastoid. Um You might need a, a needle aspiration to exclude malignancy and then normally surgically excised. Um Normally in exams it's unilateral, smooth and fluctuant and they might have had a recent infection where they notice it's enlarged, you know, the other thing, um I have to touch on is epistaxis management. Um And so you've got your anterior epistaxis if it's in little's area and then your posterior, if it's a bit further back. Um If someone's hemodynamically stable, you want to sit them forward with the mouth open and pinch soft tissue. Um, and then if that works, you can give some naseptin to just, um, moisturize, but don't give that in nut allergies because it contains peanut oil and that comes up and exams quite a lot. If it's not successful and you can see the bleeding point, then you can cauterize. If you can't see the, um, the bleeding point, then you're not gonna cauterize anything. So you're gonna pack it. Um, if it's still not, um, if it's still bleeding or you're not very stable, then you might need to ligate in theater, you know. Ok. Um, we're almost there. Um, so the other topics I've not covered that, I think you should cover, just go a bit more over otitis externa and how you treat it. So that's your topical antibiotics and steroids. Um, how you treat wax build up. So you can give bicarbonate drops or olive oil. Uh, a pe drum. Oh, someone said there's a new Aspin which doesn't contain peanut oil. I guess you can use that then, um, cover surface air, cover your red flag symptoms for head and neck cancer. Um, allergic rhinitis. Um, so that's your antihistamine steroid spray, septal hematomas. Um, someone's had, uh, an injury to their nose to exclude that. Um, as it requires any drainage because you can perforate. Um, and then, um, epiglottitis and croup, which I hope that the pediatrics person covered maybe, you know, so the last thing um I'm really not going to touch much on this. I really think you just need to use your tutorials. Um So we'll just go through some spot diagnoses if you could type what you think it is. Mhm. Yeah. So this glaucoma, so you're looking for the thin sort of um border of the optic disc. So if we can move on and this one more specifically. yeah. So it's acute angle closure. Um So think of the mid fixed dilated people and I actually think they used maybe this photo in my exam. Um So just know and then you'd give, I think it's IV acetyl the same. Um And you might need to um open up the iris moving down um blood and thunder. Yep. So you've got retinal vein occlusion. I just remember this is, I thought it was really pretty. It's kind of like ti um same move on. Um So to tell between the non ischemic causes and the ischemic causes. Um you'll look at the RI PD and the visual acuity. Um But honestly, I don't think they went into that much detail in the exams. I think it was literally like, what is this? And it was occlusion of the vein. Maybe not. Yep. So it's um Yep, retinal artery occlusion. So that's your cherry red spot. And again, I think this was like a what is this? And we just answered it, we didn't have to go into what you might do. OK. I'm not gonna go into any more ophthalmology. I appreciate that was very short. But what I would say to revise is your macular degeneration, your uh retinopathies, your retinal detachment optic neuritis. Um And then any of the sort of vascular stuff. So the hypertensive retinopathy, diabetic retinopathy and the treatment pathway. So how when you do laser um and when you use like anti vegf um and then um what else you think about your conjunctivitis as well? And when you'd refer, so if someone's a contact lens, wear wearer, remember to refer. Um otherwise you can treat with chloramphenicol. Um I appreciate that's not very useful. Um in terms of we didn't do much ophthalmology, but I wanted to refocus on dermatology and ent because I think that comes up more in your exams. I hope that was OK. Um Thank you very much if anyone has any questions. Uh Let me know. Thank you as well. That was really helpful and well done for bringing such an enormous topic into a condensed format and well done everyone listening as well for concentrating. Um I've just put a feedback form in the chat specific to this session. It'd be great if you can fill that in. And once you've done that I'll send this feedback through to Isabel as well. Um And um more generally um if you have lasted this long, um Thank you very much for coming. Uh It's been a great summary of um five or so specialties so far. Um If you would like to get a certificate of attendance, um, we'd really appreciate if you can fill in the feedback form that's just gone in the chat. Now, this helps us year on year, improve the finals weekend and to target it towards what you want as you're preparing for finals. And the last thing to mention is this is part one, part two will be happening next Saturday the 20th, um same time frame. So 10 a.m. to 4 p.m. and we'll be covering pediatrics, renal and neurology, cardiology, gastroenterology, and then hot boo as well. Thank you again for attending and I hope you enjoy the rest of your weekend.