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Hi, everyone. Welcome back to the Five Academy Provision tutorials. We'll be covering dermatology, e ent and ophthalmology today and we're very lucky to be joined by Jenny, a final year medical student over to you, Jenny. Great. Hi, buddy. My name is Jenny, like Lucas said. Um I mean, finally, I'm really excited to be doing this tutorial. Um, so be on ophthalmology, ent and dermatology. Um These are perhaps the smaller specialties in year five. However, I think, um it's a really good idea to get a good grasp of the key concepts for these specialties because they're essentially easy points as they're almost, um, you know, will always come up. So we'll start with ophthalmology. I've got some and polls so that this can be a bit more interactive. Um, but essentially for ophthalmology, these are the main symptoms of presentations that you will come across. Um I'll be going over the top three symptoms and then the rest um um likely to come up or you're likely to already be familiar with other specialties like neurology. So we won't spend too much time with that. Okay. So the first symptom is the red. I um, when I see a red, I typically try to think of it um in kind of pattern recognition recognition type of style. So the first thing you want to think about is whether it's both eyes or just the one I, so we'll be focusing on the unilateral red eye. So here's question one and I'll start the polls you can answer. No, I'll do 10 more seconds. Okay. Um The correct answer is D um laser, peripheral iridotomy. Um And that's because this is a presentation of acute angle closure, glaucoma and we'll go on to talk about that. So the term glaucoma is actually um a term that covers, covers a spectrum of diseases that cause damage to the optic nerve. Um So design that's associated with damage to the optic nerve is optic disc upping and which you can see on fundoscopy. So when you look at a slit lamp and look at the back of the eye, um a lot of people think that you always have to have raised intraocular pressure. Um when you have glaucoma, that's not always the case. Um In fact, you can have something called normal tension glaucoma, which is damage to the optic nerve, but the pressure is normal. Conversely, you can have something called ocular hypertension and that's when the eye has raised pressure, but there's no damage. And usually that's just because certain individuals are um less sensitive to changes in pressure in the eye closed angle, glaucoma. Um does indeed presiding with raise intraocular pressure. And that's due to a build up of the acquis fluid in the front of the eye. Um And this build up is because if fluid isn't able to drain out of the front of the eye, because the virus has moved up to block that drainage angle. Similarly, in open angle, glaucoma, the pressure is also raised because of fluid can't drain, but that's not because the angle is blocked and rather it's due to inherit kind of structural changes. So for example, when someone gets older and the trabecular meshwork, which is the drainage angle might change a little bit open angle is more common um than closed angle, glaucoma. These conditions can be acute, chronic or acute on chronic. So for example, someone can have chronic closed angle glaucoma um which in general does not cause them pain, the eye isn't really red but the pressures are high. So they might be treated by an ophthalmologist with drops in the long term. However, if this patient, for example, doesn't kind of adhere to treatment, the better might have an acute episode of angle closure glaucoma where they get a lot of pain and red eye. So acute angle closure, glaucoma is considered an emergency. Um So it's really important that we're familiar with um the signs and symptoms of this condition. So I've listed the risk factors and the features of it are as I've said that I pain, headache, and it's usually really, really severe. So, patient's are often quite nauseated. Um and they often vomit and they report seeing halos in their vision. The main three signs that you must remember for glaucoma, acute angle closure, glaucoma is fixed, mid dilated people, cornea edema. And the pressure is typically above 50. Normally, our eye pressure is around 11 to 21. Um So that's the pictures on the right hand side where you can see all three of these signs in terms of the management, they need to be referred to ophthalmology immediately. Um Otherwise, this can lead to blindness really quickly. So there's several eye drops um that patient's would get often actually to both eyes um to reduce the pressure. And I've listed them on the slide and once the pressure has been reduced, the I calms down a little bit, the patient can then come back in the future for further appointment to get what's called a peripheral iridotomy. And I've inserted a picture of that on the bottom right hand side. So essentially what that is is a punch a hole in the iris. So you can see that little black dot And that allows um an alternative way for the fluid to drain out so that the pressure doesn't build up. So here's a really dramatic picture on the bottom there. So if you see a patient like this, you might not know how to measure an eye pressure. For example, I think most non ophthalmologists um won't know, but red eye looks a bit hazy pupils look unequal, definitely think about acute angle closure, glaucoma. Um And this has come up on my exam both in fifth year and in six year. Okay. Here's the second question. Okay, good. The majority of you got the correct answer, which is D pseudomonas. Um The diagnoses here is keratitis. So, keratitis means inflammation of the cornea. So anytime you see the word kara and ophthalmology, it's referring to the cornea. Um keratitis can be bacterial, virus, fungal. Um So we'll start with back to that stains with flow racine die. And you also get hypopyon which fluid you see at the bottom of the front of the iron, it's essentially a collection. Um sorry to cut in. I think you lost connection for a quick second day. Oh That's okay. Just track back to the start of this slide and explain again. So, yeah, no problem. So, yeah, just let me know if I cut out again. Yeah, that happens. Thanks Lucas. Yes. As I was saying, um keratitis is inflammation of the cornea. Um and it can be caused by various groups of pathogens, including bacteria and virus and fungal. Although fungal is quite rare in the U K. Um for bacteria, the top three path pathogens are staph aureus, staph epidermis and pseudomonas. Um If the question says the patient wears contact lens, the main pathogen we should think of is pseudomonas Um However, if the patient says they wear contact lens and have been swimming and whilst wearing it, then the most likely pathogen is account amoeba. I think it'll be quite mean. Um It's quite hard to kind of differentiate just from the history um between kind of keratitis caused by staph aureus and staph epidermis. So I think for an exam question that's unlikely to come up. So I think it'll be something kind of obvious um statistically like contact lens where okay. Um So in terms of the clinical features, so red eye, of course, um pain um especially severe if it's acanthamoeba, blurred vision and photophobia on examination, you'd see an opaque patch on the cornea um when you stay in it with flora, see and you also see high Popeye on um which is the white fluid that you see at the bottom of the, the eye in that picture. Um And it's essentially a collection of white cells that have fallen to the bottom. So, keratitis is quite a serious disease. Um it can lead to kind of abrasions and ulcers which can really affect um the patient's vision long term. Therefore, they should be referred to ophthalmology, um who will scrape um the cornea for example, and then give topical antibiotics or in the case of acanthamoeba, it's chlorhexidine E and it's quite long course, often several months. Um you can then also get viral keratitis. Um The most common being herpes simplex type one keratitis. It has a really, really classic presentation of dendritic lesion on flores e staining. So as soon as you see this in the exam question, you know, it's herpes simplex keratitis. Something that's also quite specific to HSV keratitis is reduced corneal sensation. So that's tested by um kind of touching the patient's i with a bit of cotton wall and then they often have no sensation or no reaction to it. And so that's quite specific to herpes for management. Um GPS can initiate this um with topical cycle via, but if they suspect deeper infection, it's best to refer to an ophthalmologist who might try oral acyclovir or topical um steroids, happiest nocera, ophthalmic assess um is another kind of viral infection that can, can affect the cornea. Um is essentially kind of what you might expect to see um in shingles, but it's across the distribution of the uh opthalmic division of the trigeminal nerve. So they get the usual kind of symptoms that you might expect. Um which shingles like, you know, headache, fever, pain, and vesicles. Um, a sign that's very specific and should make you kind of be worried that the virus might be affecting the eye itself is called Hutchinson signs. So that's when the basic a while vesicular rash extends down along the side of the patient's nose into the tip. So that's really um specific to um herpes zoster is affecting the eye. So again, so much tingles, you treat it with um or antibio treatment. Um usually a cycle via um that's five times a day for about 7 to 10 days. Um You should start as soon as possible and they can also be given some topical steroids as well. Um Something I found really confusing and when, when I was studying last year was the difference between Episcopal rightists and square itis. Um So, epi scleritis and scleritis um is um inflammation of the sclera, which is the white part of the eye. Um What I've struggled with was how to differentiate between whether it's epic or whether it's just um scleritis. Um So essentially, um so both of them will present kind of put red eye. Um However, episcleritis is kind of the more superficial layer of this clara. So, pain is often more acute. So it often becomes worse um overcome 12 hours. Um and the pain um and the sorry, the color is often less red. So it's usually kind of pinkish. Um And patient's are usually not in pain or only have mild kind of discomfort because it's superficial. You can often manipulate the the kind of blood vessels, the redness in the eye with a cotton um cotton bud. Um And then those red vessels were blanched if you add um Phenykephrine drops, um Ethics kuraitis um is not dangerous. It usually goes away on its own. On the contrary, if you have scare Itis, um that's a deeper infection of the sclera, um often it comes on over a few days and pain is very, very, very severe. Um, patient's often can't even kind of move there. I and if you look at the color of the eye, it's really, really like red and almost like blue and purple ish. Um this requires an ophthalmology consult because it can um lead to kind of severe vision loss as it's quite deep, it can extend to affect other structures in the eye. U V itis. Um is inflammation of various parts of the evil track. The three, the three main parts being the various the ciliary body. Um and the choroid visage at the back of the eye. So you can get kind of different types of UV ITIS depending on which part is inflamed. Um But by far the most common type of uveitis is anterior uveitis. Um this is also called arthritis. Um Again, it's quite mean. Um it's quite difficult to differentiate between what type of E V itis it is. Um So I think it'll be quite mean for that to be an exam question. So oftentimes kind of with what I've seen on the actual exams and other kind of various practice question. Thanks. Um If you, the ITIS is an option, they won't give you options of anti Vitis and interpret it uveitis. For example, they'll just say you be anti Revi itis and the other options from the E V ITIS. But yeah, in terms of how it presents eyes, of course, red, again, painful. Um and patient has photophobia. Um The key clue in the history that should make you think of uveitis is if the patient also has other conditions associated with the HLA B 27. Um So those conditions are ankylosing spondylitis, scoriatic arthritis, reactive arthritis, IBD. Um uveitis is also associated with M S and sarcoidosis. So, if a patient comes in with one red eye and as a past medical history of these conditions, think uveitis, okay. And specifically anterior uveitis also called arthritis. Other um signs that they might mention in exam, prompt two point you towards anterior uveitis are erratic precipitates and posture. It cynic ei and hypopyon again. So these three signs together um strongly indicate anterior uveitis this in terms of treatment. Um you dampen down the inflammation with some topical steroids and in order to prevent um posterior seen Nicki. I so I, all right. Oh, sorry, sorry guys. Okay. So uh Jenny High Lucas. Can you hear me? Okay? Yeah, I can hear you. Sorry. Did I lose connection again? Yeah. Last you for a sec. Oh, that's annoying one sec. Let me try to move. Sure. What a second. Ok. Moved rooms. Um can do you okay now? Oh, it's dropped again. Hello. Hi, Denny high. Sorry about that. Is it better now? Yeah, it's working okay now. Okay. Okay. I've moved closer to the life but that means I am in my flats hallway, but hopefully it'll be okay. It's okay. Now, um, do you want to tell me which slider was on? And I'll go back over it again. Um, so you are on interior UV ITIS. Um, you can just let me do. Was it this one? Ok, great. Ok, good. Sorry about that guys. Hopefully there'll be no more issues going forward. But yeah, as I was saying, until you VHS by far the most common. So other um other clues that might give you in history would be these three signs chaotic precipitates and posterior Synechiae and Hypopyon. And I've attached to corn corresponding pictures on the right hand side there. Um So these are signs you typically see on a slip lab examination. So in terms of treatment, um they dampen the information with some topical steroids in order to prevent or to break up posterior synechiae. Um use my dramatics which are drugs that dilate um the people um in order to pull it off and break up the adhesion. Okay. So this is a summary slide of the most common presentations of red. I um so we went over unilateral red eye. So um the things in the red box are kind of, I guess buzzwords or triggers um that would make you think of those um diagnoses bilateral red I didn't really talk about, but that's because it's usually quite obvious and so conduct active itis and the discharge is really peru lint, that points where it's bacterial if the discharge is a bit more watery or clear and that it's more likely viral, also viral. And we typically see follicles which are little bumps, raised bumps under the lid, bacterial conjunctivitis and viral conjunctivitis can start off in just the one I so cause one red eye. But because it's really contagious, it then often develops in both eyes because people then have, touch your eye and then touch the other eye. Other clues in the history about conjunctivitis could be that the patient might have family members have been ill recently, um or family members who have also had red eyes recently, allergic conjunctivitis. The predominant symptom is by far itchiness and you also get papillae on examination. So these are like follicles but the bumps are bigger and then dry eyes. The predominant symptom is gritty and burning and you wouldn't see discharged. The next key symptom in ophthalmology is sudden vision loss. So I typically think of it as painless or painful. And this would give me clues to the diagnosis will mainly be focusing on painless vision loss in terms of painful vision loss, like giant cell arteritis and optic neuritis. Um You would have come across this in um kind neurology or G P. So we'll focus on painless vision loss, okay. So we'll do another pool. Ok. Potentially quite a tough one and we're quite split. Um The correct answer is retinal vein occlusion. So well done to 29% of you who got that correct. Um I'll come back and explain later. We'll move on to the next question first. Yeah. Very good. So the majority of you seem to have gotten that. Um And it's retinal artery occlusion. Some of you have went for a diabetic retinopathy, which is okay. It's not correct and we'll talk about that and then a little bit. So first cause of sudden pain, less vision loss is retinal vein occlusion. Um So, yeah, patient's would literally come in and say, oh suddenly I've noticed um I can't really see out of one of my eye. Um And when you examine them, using the slip lab and look at the back of the eye, which is what these images are. Um You look at the retina, the classic appearance of a retinal vein occlusion is the blood and thunder appearance on the left hand side. So this appearance indicates that the central retinal vein has been occluded. However, other veins can also be included other than the central vein. So if the vein and that's included is only a branch of the central one, then you can get kind of hemorrhage rather than hemorrhage all over the red. Like in the picture. On the left hand side, you can just get hemorrhage that's distal to the branch that's occluded. So this is a picture you saw him in the question earlier. So that's the first way they would kind of classify retinal vein occlusion. Is is it central retinal vein occlusion or is it branch retinal vein occlusion? Then retinal vein occlusions can also be thought of as non ischemic or ischemic. So, in non ischemic, the main complication that we see with it is macular edema. So the hemorrhage that you see the leaky blood vessels settle in the macular causing adama and causing blurry vision with this. You don't get rapd relative effort, papillary. Um um but you would treat it with um injections into the eye um of a anti veg F drugs in S chemical R V O, you get makayla Dema and S key mia and this ischemia essentially causes hypoxia. So new blood vessels form trying to compensate for this. Um these blood vessels platform are abnormal and they break easily and lee easily. Um So they're not good. So the way you would treat that is you would give the anti E E G F injections to treat the macular edema. And you would also give the patient PRP laser to treat the neovascularization. If the um new blood vessels are left to continue forming, they can extend into the iris. And these new blood vessels can block the drainage angle leading to glaucoma, which is what we discussed earlier. The specific type of glaucoma is called ruby, ah tick glaucoma. Okay. Next, you have that note artery occlusion. Um Similarly, you can have central retinal artery occlusion or branch retinal artery occlusion. If it's in the central artery, you then get the classic appearance of a pale retina with a cherry red spot. Over time. This cherry red spot can actually disappear. So some patient's if they present a few days later, for example, might just come in with a pale looking vet inna, but the cherry red spot has already disappeared. If only a branch of the retinal vein is occluded. Um Only part of the retina will be um pale. The way to treat this is they need to be urgently referred to ophthalmology. Um Unfortunately, the vision actually cannot believe it's just worth referring anyways, just to make sure the diagnosis is confirmed in case, you know, some consultant might have some genius idea about how to things to try. But in general, there's no specific treatment for this. The vision is gone, it's beyond saving. However, they also need to urgently be referred to T I A clinic because once you have a retinal artery occlusion, this means you're a much that indicates you're, you've got kind of risk factors, you're at high risk of developing other candy, oh vascular events like strokes. And so uh they should be reviewed to manage those risk factors and there's no driving until they're seen in T I A clinic. Okay. The 3rd 3rd cause of sudden onset vision loss has plain list is vitreous hemorrhage. So the Victrelis or the vitreous jelly is kind of this material that's located in the back of the eye, which you can see in the picture there on the left hand side. Um and Beatrice hemorrhage essentially bleeding into to that jelly material. This jelly material normally needs to be clear in order for light to enter through our eye and hit the back of our retinas, we can see. Um So when there's bleeding in that jelly, um you lose vision, so this bleeding can come from, can be due to abnormal blood vessels or it can be due to rupture of normal blood vessels. So first, I'll explain kind of the two causes associated with rupture of normal blood vessels. So, we've got posterior vitreous detachment and retinal tear. Um I think of these diseases as kind of progression of the same thing. So typically, um the first thing that kind of patient's develop is vitreous floater. So everyone as you age, um a vitreous jelly kind of changes consistency. So, rather than being evenly consistent, um certain parts of the vitreous can form clumps and that make it a bit more opaque. And this opacity when light comes through the eye and hits the capacity, it casts a shadow onto the retina and it causes patient's to see in their vision things they might describe as floaters or cobwebs. This is a normal part of the aging process and therefore, no treatment is required. However, over time, the bitterest gel can further kind of compress and collapse into itself and separating from the back of the retina, this can cause symptoms of sudden flashing light. And if, when that bitterest gel separates from the back of the retina like in the diagram and it pulls the retina along with it, then we call that retinal detachment. And this is what causes the sudden painless vision loss. And if there is a retinal detachment or retinal tear, and this is an emergency and requires urgent operation because if the restaurant is pulled off, then the nerve fibers are damaged and it just needs to be quickly repaired. So we don't lose um the function of the retina. So, vitreous hemorrhage on examination, the main signs and specific to it is that the not specific to it, but that strongly suggests hemorrhage is absent red reflex. And actually, when you try to look into the back of the eye with the ophthalmoscope or slip, that you can't even see anything, you can't see the back because it's just blood covering um the view. So in order to better visualize the back of the eye, you would need to do something called an ultrasound be scan. This is done by an ophthalmologist. Um and the main purpose of this is to be able to look beyond the blood that's covering the view, to look at the back of the eye, the retina to see if there's any um tear or detachment. So if there is retinal tear or detachment, this needs emergency surgery and the operation for it is called vitrectomy. And if there's no, no tear or detachment, um, the management is to just watch and wait. Most cases will resolve. So the hemorrhage will settle, the blood will settle down and the patient's vision will clear and come back to normal. Um, usually over the course of kind of one or two months. Um but it can, where I um and once the blood can resolve, they can get PRP laser another cause um or another kind of major risk factor of developing vitreous hemorrhage is diabetic retinopathy e and the reason for that is because diabetes, as you may know, causes your blood vessels to become really abnormal. They'd come weekly leaky, they're more like to include just really unhealthy. Um So this can increase um the chances of it kind of rupturing and leaking. But also these blood vessels can lead to a retina hypoxia. And Restinal hypoxia can then lead to um macular edema. Um and neovascularization. This is how diabetic retinopathy is classified. So you can get non proliferative or peripheral acttive. Um the er um so particularly you start off with the non proliferative kind. So these are um the list of science that you see on a slip lamic sam starting from my own nonproliferative, moderate severe, and then the most severe form is proliferative where you see new blood vessel growth. And I have pictures of those signs here. So this is probably just worth kind of looking in your own time and it's a familial eyes yourself with them. Okay. So here is um the summary side for sudden vision loss. So again and painless, think of blood vessels, abnormal athlete with blood vessels and think of bleeding um below other diseases or the processes that can contribute to victories, hemorrhage. And again in the red boxes, um designs or the buzzwords to look out for, for painful vision loss. Um you get giant cell arthritis. So as you might have learned already or might, you know already um that's classically a headache on the side of your head, raised esr CRP. It might be associated with polymyalgia, rheumatic, er um this needs referred to ophthalmologist and a long course of steroids in order to save the vision optic neuritis, um signs of that is reduced television R A P D and often painful eye movements as well. Um And you typically kind of see it in, you typically see other features of multiple sclerosis is or be in the typical M S patient, like young female in their twenties, for example. Okay. Um And the last symptom we can cover is gradual vision loss. So if it's the central vision, think of A M D, if it's a peripheral vision glaucoma, and then we've got cataracts and diabetic retinopathy again. So here's your next question. Ok. Really good. The correct answer for the that is um age related macular degeneration. Or A M D for short. And the picture shows um juice sense, which they look like a little yellow patches and they appear on top of the macula and that's classic sign of A M D. So further to the previous question now that we're suspecting A M D, but further investigation, should that patient get good? Um The majority if you got that correct? And that's oh CT or optical coherence tomography. And we've also got responses for uh um oscopy and visual field test. So, in terms of uh hm oscopy, we've already done that. So that's how we got this picture of the back of the patient's I um visual field tests. Hmm You can do, but that's not the most valuable thing at this point. Um And um so we'll go on to that and in a little bit about why we want to do the O C T at the stage. Tinnam A tree uh is measuring the eyes pressure. Um So that's typically used for glaucoma when you suspect there's raised intraocular pressure, an ultrasound be scan, like I said um scan, the I um there's no indication for that in the A M D at the moment. Okay. So, am D is the most common cause of irreversible vision loss in the UK? Okay. And it's idiopathic um M D as the name suggests, affects the macula and this is the part of the retina that is responsible for our central vision So in patient's with A M D, they'll complain of central vision loss. Often they notice it when they're kind of reading because you can't see kind of the words in the book in front of them. But the peripheral vision is actually normal. The classic sign um for M D R juice ends and these are lipid deposits and you see them um as kind of yellow patches on top of the macula. Uh you can also get geographic atrophy of the retina. The reason we do it, oh CT scan is because we want to know if this is dry or wet A M D. So in dry MD, there's drew sense um only but in wet, there's Jerusalem's and there's also hemorrhage and leakage of blood into the restaurant into the macula. Um The reason we want to differentiate it is because there's no treatment for dry mg so often it's just lifestyle advice like stop smoking, eat lots of fruit and veg they can maybe try some um supplements like vitamins and things like that if they want to. But for wet, um A M D, we can treat um the leakage of blood vessel into the macula um with um anti B E G F injections into the eye. But again, okay. So this is again to remind you what juices look like. This is the image that was on a multiple choice question, on the top left hand side there and on the bottom kind of that black and white picture that looks like layers in sand and that's what oh CT scan looks like. So in dry AM D, you can see how did reasons look like on the CT scan where the arrows are pointing and what ab you can see there's drew since, but you can also see some fluid um in the layers of the retina. Yeah. So oh CT scan that allows us to kind of visualize the layers of the retina to see if there's any fluid bleeding, things like that within the layers, okay. Um And that's kind of all I wanted to cover an ophthalmology, but here are other conditions that are worth kind of um familiarizing yourself within your own time. So symptoms, things that cause diplopia and then things that cause transit visual symptoms and some other diagnoses here as well. Okay. Next, we'll go over E N T. Oh Is there any questions so far and just put it in the, the, the shot and I'll answer them as we go along. Okay. The ent so first and common sentiment E N T is you're discharged and these are the top um differentials you should think of. So acute otitis media, chronic otitis media or cholesteatoma, otitis, external ear wax in trauma. So this is how one of the GPS on my placement taught me is and this was just memorize this list for your discharge. Okay. We'll see you. Our next question. Lucas is my um wife. I still. Okay my patches. Oh, good thanks. Okay. The correct answer is otitis external. Um Okay. So yeah, the options are the the top five differential diagnosis for ear discharge, um acute otitis media, the classic symptom for that, the classic sign for that is bulging tympanic membrane. We can't really see the tympanic membrane um in the in the image there, but it doesn't really matter because actually what we can see um is what's typical of otitis external, um which is kind of debris built up in that external ear canal. Um And the main symptom is often itchiness. Um and you're discharged for cholesteatoma or chronic otitis extra is sometimes used interchangeably. Um The history is often more chronic and, and the ear discharge is often really smelly and there's usually associated hearing loss, otitis media with diffusion, also known as glue ears that's fluid in the middle ear without infection. Um The tympanic membrane would look dull. Um and this is typically um something you mainly see in younger Children. So it wouldn't, it wouldn't be as common in someone who's perhaps 29 years old um earwax. Um It is possible um but kind of with earwax, you wouldn't expect kind of discharged, you would expect to kind of come out of the ear. Um, like it does with uh otitis external. Uh um and it kind of certainly wouldn't look like that. This looks quite fluffy and soft and earwax as often um kind of harder, it looks harder. Okay. So pictures of the sign. So acute otitis X, acute otitis media and the top left with the bulging tympanic membrane, dull tympanic membrane, n otitis media with effusion and then cholesteatoma in the bottom picture. Um and O M E and cholesteatoma is often associated with you station tube dysfunction. So patient's may say, you know, as a child, um they really struggled with kind of whenever they have a cold, they feel like the ear is like really like waxy, that sort of thing. Next question. Okay. The correct response is paracetamol. I didn't say ibuprofen earlier, but yeah, ibuprofen and or paracetamol um is okay. Um So 55% of you said that um 33% of you say amoxicillin, which is not wrong for treatment of acute otitis media. Um But I'll explain that in a little bit. So which of the following is not an indication for immediate antibiotics in acute otitis media. So, not an indication. Okay. The correct answer is any child under when you're old. Um All the other answer options listed um are indications um to start um antibiotics, oral antibiotics. Um As soon as the patient first presents um with acute otitis media, um so Osoria or ear discharge, the reason we should start that is because it could suggest preparation uh retinas behind the ear, suggest mastoiditis. Um And then systemically unwell. Hopefully, that's quite obvious. No one like that option. Okay. So treatment for acute otitis media, um very common in, in babies in young Children. Um, you know, they often have some sort of recent history of upper respiratory tract infection and then they come in mom's saying they're tugging at their, their ear and they're unsettled. Um So the first thing you give them is just analgesia and safety netting advice like me, paracetamol and, or Ibuprofen. Um and try that first if after about two days, um it hasn't improved or it's gotten worse. Um then oral antibiotics can be started. Uh And the first line is oral amoxicillin and again, listed are the indications for immediate antibiotics. So don't send them were just proceed more and you can start antibiotics right away. The picture on the right um is showing a baby with mastoiditis. So the ear, the back of their ear will look red and it often looks kind of protruded and then down it like sticks out and down. So, um mastoiditis is a very serious infection of the mastoid bone um and requires kind of quite aggressive treatment. Okay. So a slide on otitis media. So there's many types acute um chronic and otitis media with effusion. So as I said, Q otitis media presents with pain, our theme a fever uh uh and then the classic sign on the sim panic membrane, uh these are usually due to respiratory viruses, viruses. And but if they last for more than two days. Like I said, it's more likely to be um bacterial. So that's why you would start antibiotics at that point. Um chronic otitis media can be two different types. New Kozel or squamous. So in mucosa, the tympanic membrane is perforated in presence of recurrent or persistent infection. So often kind of infections that lasts a more than two or three months, um lead to a perforated um tympanic membrane. Um in squamous chronic otitis media, the tympanic membrane is actually retracted and you'd see the co uh a cholesterol to toma. Um in gluey, a there's a collection of fluid in the middle ear without signs of acute um inflammation and there's no preparation of tympanic membrane. Here's our next question. Well, I've accidentally revealed the answer. Oh, never mind. Okay. Um So we have patient examine um in the Webbers test, sound lateralized is to the left ear rennes tests. Um air conduction is louder than bone conduction, both ears and correct well done to the 11 of you who got the correct answer, which is right sensor read, neuro hearing loss. So I thought I'd just cover um Weber and renal renal. I don't even know, pronounce that. Uh It was maybe something that I struggled to kind of remember long term when I was studying for it last year. Um So Weber Weber and think of w so you placed the tubing for in the middle of their heads. There's you know, w just looks like in the middle. Um and in the in conductive hearing loss, sound would be louder in the effective fear. In other words, it lateral eyes is towards the effective fear. Uh On the contrary, in sensory neuro hearing loss, sound, lateral rises away from the effect of year. And so the way I remember that for myself is um I think, you know, in member, if you sense something is wrong, you run away from it. So sensory neuro hearing loss is away from the effective year. Um re in tests. So normal air is lower than bone as you expect. Um conductive hearing loss, bone rather than air. Um sensory neuro air is lower than bone. So really if you want to kind of decide what type of hearing loss and someone has, you really have to do both of these tests and interpret them together. Okay. So I'll try that. Yeah. Okay. And the correct answer is um left conductive hearing loss. So, so if you look first at Rene's test, bone conduction is louder than air in the left ear, we already know that's an abnormal air should be louder. Um So let me go back to here Born Loudon air. That's a conductive hearing loss. Okay. And the Webbers test confirmed that confirms that because um in conductive hearing loss, sound lateral eyes is towards the ear, that's abnormal. Okay. Next question, bleeding from the nose really common. I'm sure we've all had it at least once there's no e option. Sorry, change your answer if you say e okay, good. So the correct answer is cost free and that's with silver nitrate. Um And we'll go over the the guidelines there for nose bleed or eh pissed assist. So yeah, if a patient comes in actively bleeding, you know, obviously you want to first try um conservative management, first eight management, which this patient has done. So pinch um the nose lean forward, um and try for about 15 minutes and we can also suck on ice cubes. Um And that will kind of help um, constrict the vessels. Um You'd be quite surprised at how many people kind of in there today. You might see who get nose bleeds and they'll pinch your nose and then tilt their head back and this is something you should not do because you end up kind of swallowing um the blood from your nose and really irritating your stomach. It can make you quite nauseated actually. Um, if after that bleeding hasn't stopped yet, um you can then do silver nitrate, um Cautery. Um Well, before that, you'd examine the nose and if you can find a specific blood vessel that's bleeding within the nose, you can do cautery on it. And this can actually be done by fy ones who are on E N T. Um However, if, when you examine inside the nostril and you can't see an obvious blood vessel that's responsible for the bleeding, then nasal packing can be done instead. And the reason the for this question, the answer is cost tree by the nasal packing is because as you can see circled, um there's a really obvious and kind of blood vessel that appears to be responsible for the bleeding to try caught reaching specifically target uh that blood vessel first. Um If after that, there's still issues and this is kind of time to um kind of consider um discussing uh with a senior uh kind of a bit of an asked me just to be aware of most nosebleeds occur. Um in little area also known as kids. A box plexus. This is an area where about fortified arteries. Well, anastomosis a really prone to bleeding and the most common artery that and ask the most there and it's responsible for the majority of nose bleeds is the sphenopalatine archery. Um And this came up on my exam last year. The exception if, if the nose bleed follows some sort of trauma and the artery that's most likely to be indicated in that instance is the anterior ethmoidal artery and just remember all traumatic nose injuries. Um We'll need to be examined with rhinoscopy in order to rule out a septal hematoma. So blood collection in the septum because if that happens, um it requires urgent drainage because when the blood collects come months, septum, it can separate septum and lead to current necrosis his Kenya, that sort of thing. Um uh The next um condition or group of conditions can talk about is rhinitis and rhino sinusitis. Um I think this was the bane of my existence last year. Um I just really cannot get my head around it and how they differ. And so hopefully, I have been able to simplify it here. Um So rhinitis um means inflammation of the lining of the nose or the mucous membrane. Um whereas rhino sinusitis is inflammation of the lining of the nose and the paranasal sciences. So, in both of these rhinitis and rhino sinusitis, you'd get symptoms like congestion, sneezing, itching, nasal discharge just can be from the front or from the back, which is term nasal drip, posterior, nasal drip. However, um symptoms that would indicate that this is rhino sinusitis rather than just rhinitis um would be facial pain or reduced sense of smell. If these symptoms have lasted for less than 12 weeks, we turn this acute rhino sinusitis and if it's more than 12 weeks, it's chronic, so we'll start with right night is. So treatment for it is to just avoid trigger. So often it can be um an alert due to an allergic reaction to say pollin um or kind of certain, you know, other trick common triggers. Um and you do nasal juices with some normal saline. Um again, if it's allergic, say, um if it's always linked to a certain season, for example, patient's can regulate, take oral antihistamines when the, um, when they're about to be exposed to, to the, to the allergen, um, you can also try nasal steroids and the best type our mometasone and 50 fluticasone. And that's because, um, they don't get absorbed systemically. So you avoid those side effects associated with steroids. Um I'm kind of almost the last resort, um, would be decongestants and oral steroids. I mean, you really only want to use these for short term, oral steroids, short term in order to avoid side effects and decongestants, short term because they can become almost addictive in that. And once you start using them, you get quite a lot of improvement. But once you stop, it then comes back and perhaps it comes back even worse. The patient's can end up never being able to get off of decongestants. So only for short term use to say for a week for rhino sinusitis. A management depends on whether um how long it lasts for. So for acute sinusitis and which last for um which has lasted for less than 12 weeks, less than 10, 10 days is most like to be viral, quite benign. And so they can just go home with simple energy Asia and again, um kind of nasal saline irrigation. If it's more than 10 days, we can consider adding um international steroids and if they have at least three of the following symptoms or signs. So, discolored discharge severe and local pains of pain on there. Face fever, raised esr crp, double sickening, meaning they were improving, then they got worse. Then this could be a bacterial cost. You could add oral antibiotics for chronic rhino sinusitis. You're starting to think is there some sort of underlying problem that's causing this person to keep getting rhino sinusitis or that prevents them from healing from this? So you refer them to ent for endoscopy to look for nasal polyps. If it turns out there's no polyps um that continue with saline nasal steroids, um maybe can consider long term antibiotic. Um and as a last resort, um surgery could be considered. But again, because there's no kind of nasal polyps, there are no real structural cost for this. Um surgery might always work. However, if an endoscopy polyps are visible, uh patient's can uh you know, continue on nasal steroids and then come back for, for surgery if there's no improvement after about six or so weeks. Here's our next question. Okay. So we've got a bit of a split here between option B and option E. The correct answer is option B or amoxicillin and we'll go back to the explanation for why. So, Scott four week history of nasal obstruction, discolored discharge and facial pain. So we're thinking rhino sinusitis because of the facial pain and it's a four week history which means we would still class this as acute rhino sinusitis rather than chronic. Um She has already trialed, um, nasal steroids for the past two weeks. Um, they helped but now her symptoms are back to where they were before. Um, so this is double kind, sickening, better, worse. Again. Um, examination reviews prevent nasal discharge and tenderness over the left axillary bone. So, if we go back to the management for Reynosa, so he's so cute. Rhinosinusitis. Yes, that's our patient and she's tried intranasal steroids um, after it's lasted for more than 10 days and now she's presenting with three of the following signs. So she's got discolored discharge. She's got pain and there's some double sickening there. So the correct answer in this case would be a trial of oral antibiotics and amoxicillin is often in the first line choice request. CT sinuses. That was the other popular answer choice. Um That could be something we consider once um this has been going on for more than 12 weeks. And if on endoscopy, you see nasal polyps because in order to request, you'd be requesting CT sinuses to plan for surgery to remove those nasal polyps. Okay. Next question. Okay. So clues for those who are still thinking the picture looks like a child. They've got a bump in the front and middle part of their um throat and when they stick out their tongue, the bump moves upwards. Good. The correct answer is I recall. So cyst. So, like I said, characteristically, it moves upwards and with the trunk, tongue protrusion, um brain kill sis. Um So it's typically not located in the center like that. So it's often on the side of the net. So I've listed kind of the classic anatomical location of that cyst and we typically seen it start seeing it in about 10 30 year olds. Um um for NGO pouch, um you actually usually don't see a bump with, this is all this at all. Um It simply um seeing an elderly patient and they come in complaining of dysphasia because there's a pouch, you know, food is really going down properly. So they regurgitate their food or the food can then sit in the pouch and kind of rot or go bad and that causes halitosis or smelly breath, um dermoid cyst and sebaceous. It's not really relevant in this case. So, neoplasms of the salivary gland, really common presentation um especially if anyone's kind of done a day in the neck love clinic. There's, you know, a specific clinic for it. Um So it can be benign or malignant. The most, the top two most common benign neoplasm of the library glands um are benign pleomorphic adenoma and worsens tumor. And by far the most most common is benign pleomorphic adenoma. Okay. And the majority of that will rise from their parasitic glan um it's painless. Um it slowly enlarges um and treatment, you know, these patient's often get referred to the neck lump and, and then the recommendation is surgical excision because it is possible, it can transform into militancy although, you know, 10% and potential Waltons tumor again, maybe bilateral, classically, also the parity it affected, um, as mainly seen in the elderly, um, in smokers. Um, and those are kind of symptoms, you'd also treat it with, um, circle excision or conservative management. Um, depends on the patient. Um, things that would make you think a nickel up might be malignant. So if it's really hard, if it's growing really quickly, if it's sore, um if there's overlying skin changes, like ulcerations, wounds, things like that or if it's causing facial weakness. So I've attached pick of a pleomorphic adenoma and that's quite a dramatic one. Um I think most patient's wouldn't leave it that long before seeing a doctor and the ones I've seen in clinic, um they are quite visible um but smaller than that and then just quickly indications for tonsillectomy. Um So seven episodes in a year, five episodes per year for two years, three episodes per year for three years. Um The way I remember this is um odd numbers. So 357. So, you know, from down to, I like write it out on the papers, I write the odd number 357 and then I write 123 and then fill in the gaps with that um indications um obstructive sleep apnea and Quincy are also indications as well. Okay. Um Next, we'll cover dermatology. So we lots of um polls and lots of spot diagnoses. Um We're starting off at quite a tricky one or I think it's tricky. You guys might not. Oh, sorry. Before we continue, I was also going to mention a really great resource for E N T is the handbook that you can find on learn um is on the year five learn page and it's about 200 page summary of all the common conditions seen E N T. Um Well, I wish I can remember what the um the handbook is for, but it's just called like handbook summary. Uh something like that. It's just attached to your Learn year five page. Um That was a lifesaver for me last year when I was studying for my exams. Okay. Yep. Most of you got this correct. This is in fact, um a basal cell carcinoma um and the classic appearance of a basal cell carcinoma is that the base has kind of a uh pearly kind of sheen to it. Uh I don't think you can see my pointer. If you look kind of around um the edge of the lesion, you can see kind that flurry reflect, reflective um kind of shine to it, which is classic of basal cell carcinoma. Um Some people have gone for Melanoma, which is understandable because sometimes you see kind of that black bit and you think one looks a bit irregular, looks bit were Melanoma. Um But yeah, this is classically A B C C Okay for sure. So what do we think this is correct? Andhra is grandma. So, um, carcinoma and this is just what it looks like. It looks kind of a little sticks out a little bit, not very slightly. I'm gonna have kind of black pigmentation. Next one. Oops. Okay. There we go. So, arrow pointing to what lesion? Yep. Good. So, this is actinic keratosis. So kind of classic appearances often kind of a bit flat. It just looks a bit flaky. Um like a lot of kind of middle aged people have it and don't think anything about it because I think it's just dry skin. Um but it's actually actinic keratosis, which is a pretty disposer to um kind of squamous cell carcinoma. And the other one that looks like actinic keratosis is Bowen's disease. They pretty much look the same, but Bowen's um is often a bit larger. So just worth kind of having um a look at lots of pictures and I find that kind of at least last year, the Dermatology model was really good with giving us those in those pictures to, to look. So we can familiar, familiar realize ourselves with what and they look like uh seborrhea keratosis. Some people have gone for that. Um No problem and not correct. Um And I think I will have a picture of what seborrhea, seborrheic keratosis looks like in one of the later slides as well. So we'll see that in a bit Okay. What's this? Always floating? The suspense. Okay, Lucas. Do you know what I should do at this stage? I just wait for it to loan. Okay. Sorry, I think I dropped off there just a little bit but I'm back now and hopefully you can hear me. Um, Jenny. I think you've cut off again. Okay. It might just be my computer actually.