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Discussion. Um, we'll go through the SBS, take a break histories and then a break and then exams. Um, cool. This is in case anyone missed at the end of the last lecture, um, which is some handy resources um, here and some tips for med school. But we can go through these at the end and they'll be in the recording. Cool. I'll make a start for now and then come back to those. Cool. So first sp a urine G P and you see a 24 year old female who's got, uh unilateral throbbing headaches, which are better when she lies down in the dark room, uh, triggered by stress and foods and she finds they get better with Sumatriptan and aspirin and they prevented using propanolol, given the most likely diagnosis. What's the, which of the following fits best a few minutes just to have a think, feel free to write down your answer or pop it in the trap. Yeah, we're getting uh four as the most common response. Perfect. Okay. Excellent. Well done. Excellent. So, a bit of a two step question which can be common in um, medical school finals. So you kind of one have to work out the diagnosis and then to have to work out what's the associated feature. So quite trick questions are well done. Um So correct, you guys said four. So that's proceeded by zigzag visual disturbances. Um So that's classic for an aura and the headaches classically described a migraine. Um We'll go through the other differentials on the page later. But yeah, number one associated with glaucoma. So that's a large one, unilateral dilated people with a blurry kind of cornea because they're raised intraocular pressure. Um The sharp stabbing pains down the faces, trigeminal neuralgia, so, irritation of the trigeminal nerve. Um So that's not what's going on here. These are more throbbing headaches and they've got other features. Um worse on leaning forward is always a red flag for raised intracranial pressure. So that's what I see B stands for. Um That's uh because the gravity, obviously, when you lean forward or light down gravity is gonna um cause the pain to get worse. And then communist uh an over fifties, that's wrong. So, migraines uh is a red flag to have a new diagnosis of migraines and then over 50 year old um until you look for other causes of headaches. Um two migraines classically start at the younger age. So let's talk a little bit about migraines. So features uh usually very severe debilitating, usually unilateral and usually they stick to that one side. Um So one person will carry that person will characteristically have recurrent left sided headaches if that's their side, but it can be variable. Usually they're throbbing in nature but can be different, different natures and different people describe the pain differently. Um And then a prodrome. So hours or days, even before that migraine attack, people can get a sense of feeling unwell a bit, uh sick and kind of, they'll get a feeling that they know is familiar with their migraines. And the aura describes the nausea and vomiting, the photophobia. So difficulty with light phonophobia, which is sensitivity to sound um and sometimes visual changes. So you can get kind of spots in the vision or zigzags and the vision which are transient and then self resolved. Um They're very specific diagnostic criteria on the nice guidelines. It's quite um quite useful um in terms of how many episodes of migraines they have and the features and if, if there are features of or or not, and just be careful because you can get aura without the headache. And that's so you can get the visual changes without the headache. And so that can be quite tricky diagnosis to make because obviously that's quite similar presentation to something like a stroke which we covered in the last talk. Um but have a look at the diagnostic criteria. You don't need to learn those off by heart for exams. But I think it's useful to have a look at those. Um And migraines are very common. And um in real real life, actually, they're quite um strong family history. So patient's usually will have had a past history of migraines and um it runs in the family as well. Um And they're quite common um treating them you high dose. So trip tans um which are quite helpful specifically for migraines, painkillers like high dose NSAID. So, Ibuprofen naproxen, um our aspirin and then antiemetics such as metoclopramide or prochlorperazine can be used as well because you get a lot of nausea and vomiting with, with migraines and then avoiding the triggers of some people. It's chocolate, some people it's different foods, some people it's stress, uh aware of medical medication, overuse headache, which is when people use a lot of strong analgesia and then I got to get a rebound headache. Um There's some of the preventative medications as well and there's new kind of drugs like Candesartan been trialed for migraine prophylaxis as well. That's if they get really, really frequent severe debilitating, debilitating headaches and it's better to prevent it rather than treat them acutely. Another thing to remember is that the oral contraceptive pill is contraindicated in patients with migraines, especially if they've got aura because there's a risk of thrombosis as well. So that's something important to think about when with a crossover with contraception. Okay. Any questions so far, put them in the chat and we'll move on to the second S P A 29 year old male with severe excruciating headaches around the left eye, fifth episode this week and also associated with tearing in the eye redness and nasal congestion. He's got a, he's a smoker otherwise. Well, what's the best treatment given the likely diagnosis? Um So far we've just got one person who's going for nasal triptan and high flow oxygen. This is a really tricky question as well. It's a bit of a niche one. Um So well done. Yeah, that is correct. So, nasal triptan and high flow oxygen. So this patient that this scenario describes cluster headaches and we'll comment to that in a little minute, in a little minute um in a moment. So that's um the severe excruciating headaches with the kind of sympathetic nervous system still uh stimulation. So, autonomic uh symptoms such as redness in the eye and discharge from the nose and the eye. Um So two pyra mate is one of the potential prophylactic drugs for migraines. So that's not um this isn't describing a migraine. So that's incorrect participle in um April, we'll come onto that in a little bit later. Um Option four would be the treatment for glaucoma, which is uh ophthalmology, ophthalmology condition where you get raised pressure inside the eye. Um And although this seems like it could be a an ophthalmology condition, um it's less kind of visual loss that they're describing it. It's more the headache around the eye and the and the redness in the eye and the and the nasal discharge which points you away from glaucoma. Um and then carbon monoxide poisoning is treated with high flow or hyperbaric oxygen. Um But that's a slightly different presentation in terms of that's more of a generalized headache and exposure to carbon monoxide such as a faulty boiler or a barbecue. Okay. So just talk a bit about cluster headaches. These are classically excruciatingly painful, one of the worst um kind of headaches to have. Um usually it's kind of around the eye or behind the eye, kind of stabbing unilateral pain and named so because they occur in clusters. So patient's might be free of symptoms for a while and then in a space of a few weeks or months, get several episodes clustered together for these headaches that can last for a long time associated, like I said, with nasal and um eye symptoms such as discharge and redness, they can get a bit of a Horner's syndrome. So, constriction of the pupil. Um it's a diagnosis that has to be made by a specialist. So they require onward referral um to exclude other differentials. Um and then acutely like, yeah, somebody correctly pointed out is a nasal trip dance or something like zombie trip down or sumatriptan given into the nose and high flow oxygen classically helps resolve the cluster headaches. Um and there are drugs like verapamil that can be used to prevent them. But again, it's a specialist diagnosis. So you wouldn't necessarily make this diagnosis um in G P and start the patient on treatment. Do you need to refer them onwards? But if there's a pain out of proportion really severe around the eye and also classically in patient's who smoke, hence his um smoking history of 20 a day. Uh That's another respect for cluster headaches. Subcontract tan. I think subplot, triptan might be an option. I'll check and get back to you on that one. Um As far as I'm aware, it's nasal trip turn, but subplot is another route, route of delivery for trip down, so I can check on that one. Okay. Cool. Uh sub arachnoid hemorrhage we covered in the last talk, but I've just got it um in the slides of completion. So feel free to just um look through the recording of the last lecture for subarachnoid hemorrhage because we cover that in traumatic brain injury in Tuesday's talk next SBA. All right. So 60 year two year old man presenting to a and E with the right sided headache worsening over the last few weeks. It's worse when he touches and it causes difficulty in eating. He's today noticed a loss of color vision in his right eye otherwise. Well, but having some aches and pains in the last few months that he's put down to age. What's the most important management acutely for this patient? Have a go. This is another tricky one. So don't worry if you're a bit stuck you've got to people saying one high dose IV steroids and PPS. Excellent. Okay. Give you a few more seconds. Is this okay? So far we're going, is anyone one, we're going a bit too quickly or too slowly or happy with this place, by the way, let me know in the chat if so. And okay. Cool. So, yeah, the correct answer here is one so well done if you've got that. So, um, you might guess this is a vasculitis. This is giant cell arteritis and I'll go through why each of these options is correct or incorrect. So this is a large vessel vasculitis. So that's an inflammation of the blood vessel. Um and it classically affects the temporal artery, which is the one that kind of goes around the temple. So the side of the head um and splits off to supply the kind of the face. Um the side of the face, it can also affect any large artery. So it can affect the aorta and multiple arteries anywhere in the body. But classically affects the temporal artery, hence the name temporal arthritis. Um So it's associated in about 40 or 50% of patient's with a condition called polymyalgia, rheumatica. Um and this is kind of aching, stiffness and pain in the shoulders and the hips, but they don't actually have weakness. It's just a kind of muscle inflammation causing stiffness and ache um and pain, but no actual weakness in the shoulders and the neck and the hips. Um um So it's classically associated with that. So that's what the patient is getting out with shoulder aches and the stiffness in the last few months. And that's an exam classic as well for these two conditions to be associated. So, patients who have one or more likely to have the other um features of giant cell arteritis. So it's severe pain and it's very tender. The scalp tenderness of the patient will be jumping off the bed when you touch the side of the scalp or the affected area. Um they get jaw claudications because if you think about it, it's a vascular problem. So you're getting narrowing of the artery, it's just like in the legs, you can get vascular claudications when patient's walk a long distance and they get pain in the calves. Um The more you use the jaw and the tongue. Um for example, eating or talking uh because of the vascular narrowing in the inflammation is reduced blood flow, unable to meet the demands, the vascular demands and oxygen demands. Um So after eating, they might get pain in their jaw or even pain in the tongue after eating. And so that's, and that will get better once they stop chewing. So it's a classic symptom in about, I think, third to a half of patient's with G see A. Um And then the other thing you have to ask about in any headache is visual loss and So that's when the ophthalmic artery or nerve to the optic vessel to the optic nerve is involved in G C A that can cause visual loss um and it can be irreversible if not treated. So, any blurring loss of color, vision, loss of vision, um double vision is an emergency. So that's why you have to have a high suspicion for giant sellers writers and it's classically occurs in elderly patient. So above the age of 50 at least, if not, if not older. So it's almost unheard of in under 50 year olds. So you need to treat it with um with urgency on the same day because um it can develop, they can develop visual loss. E S R or CRP is classically raised. Um in most cases of G C A um treatment if you suspect it is high dose steroids, usually oral steroids, prednisoLONE, 40 50 60 mg with something like omeprazole because it can call it that can cause gi upset. And you also have to urgently discuss with ophthalmology and rheumatology. Um but usually you'll treat before the patient gets kind of their outpatient appointment because it's an urgent condition that need to prevent visual loss. The reason this one was intravenous is usually if there's visual loss, they might have IV steroids. So IV methylprednisolone, for example, um if there's all existing visual loss, whereas there, if there's just the headache and no visual loss, then oral steroids would, would be the correct answer. And obviously you're not gonna wait for them to get rheumatology referral because that might be a few days or weeks. And by that time, they might have lost vision, biopsy. And temporal artery ultrasound can be used as a diagnostic tool. But you wouldn't, again, you wouldn't wait for them to have that investigation because that might take some time to arrange. And usually you'll let the specialist rheumatologist arrange that to confirm the diagnosis. And CT head wouldn't break show that's good in this, in this case, the key thing is treating when there's high suspicion and early discussion with ophthalmology and rheumatology. Um and they can, then they'll arrange the ultrasound of the biopsy to confirm the diagnosis. Um And also classically, once the steroids given, you should get a very rapid improvement in the symptoms and the headache and the, and the visual changes if they're reversible. Um if you don't get an improvement, they should start to consider other diagnoses. And because classically Johnson arthritis will get better with the steroids because it's, if you think about it, it's an autumn e uh so that's a classic diagnosis. Over 50 year old with a headache. It's something you have to exactly when you're seeing them in G P or any, you have to be thinking of giant cell arthritis, relatively rare. But because it's life site threatening, important to always consider we'll see you okay. 24 year old female presenting with a few months of a band like headache over affecting the front of the head. No visual changes, no vomiting, a past history of depression. Um easing sertraline for that and paracetamol for the pain every couple of days and has recently been quite stressed. What is the most likely diagnosis given this history? So, we got one person who chose tension headache. Perfect. All right. So very good, excellent. So tension headache is the correct answer. Um We'll go through why. Um why? That is obviously the other ones are important headaches, important causes a headache to exclude such as meningitis and subarachnoid. Uh but let's go through why this is a tension headache. All right. So very very common. One of the commonest causes of primary headaches and primary headaches essentially is a tension headaches, migraines and cluster headaches are the kind of primary headaches where as a secondary headache is, for example, head injury or meningitis where it's something else like trauma or infection or cancer causing the headache. Whereas primary is that there's kind of idiopathic in a sense. So that includes cluster attention and migraine potential tension headache, very, very common, usually stress related and kind of muscle tension related. Um So that's hinted out with a patient being a student going through difficulties in life and stress with exams and home life. So that that leads towards that diagnosis although, and it's a diagnosis of exclusion. So you want to rule out any red flags such as, you know, vomiting, such as visual change, such as focal neurology. Um usually it's around the front of the head and it's like a band like squeezing pain and usually affecting both sides. And again, none of the red flags that we we mentioned. Um and treatment. So main things as stress relief and CVT, things like acupuncture and physiotherapy can actually be quite useful and reassurance if once other causes are excluded. And M O H as I mentioned, report medication overuse headaches. So you want to avoid loads and loads of frequent use of strong pain killers like cocoa to mall or traMADol or Ibuprofen because you can get that kind of rebound headache and the patient can come dependent on those medications and get a medication overuse headache when they use regular analgesia like that. So it's using um counseling the patient on that and using um things like parasites more a bit more sparingly. Um And it's more of a holistic management as well as medications in this case. Um but very very common tension headache associated with stress um and one of the key primary headaches, but make sure you exclude other kind of more life threatening causes like migraines and subarachnoid and meningitis. So, meningitis that would have a fever, that be, have an infective picture, that be vomiting would be more acute. Um subarachnoid hemorrhage again, be very, very acute and would be unlikely in a patient this age. Okay. Next one. I think there's one more sp after this 29 year old male was six days. Have a sore throat, fever, pain in the face on, leaning forwards and a blocked nose. Generally feeling quite a key in lethargic. Um, and roommates been unwell recently. What's the most likely diagnosis? Meningitis, sinusitis, venous thrombosis, brain cancer or giant cell arthritis. Have a, so we've got to sinusitis. Mhm. Perfect. Ok. Excellent. Hold on another, quite a tricky one because it's a bit of a nonspecific history and it's a bit of a bit of a curve ball but very well done. Those of you said sinusitis. So um bit of a trick question might, some you might have been thinking of meningitis, which you're right to think of with somebody with a fever and a headache. Um worth on leaning forward and kind of infective symptoms. So, meningitis is, is something to consider, but there's no features of what you call meningism. So that's headache, photophobia, neck stiffness. Um So this patient has no neck pain, there's not been vomiting. Um They've only got a low grade temperature and the fact that they've been going on for six days, it's unlikely that it's, it's less likely that it's meningitis. They probably have deteriorated and become septic and more unwell with the bacterial meningitis for six days. So this more hints at a kind of upper respiratory infection, something like a flu or uh nasal infection causing sinusitis. So, that's the sore throat, fever, coryza symptoms, uh, and then classic sinus pain, so pain on the cheeks and on the forehead. Um sinus pain blockage worse when you lean forwards, worse on pressing. So, if you pressed firmly over the sinuses, it's um, quite tender and you might have had sinusitis, sort of flu in the past. And, you know, it's really, really painful when you press on the cheeks and the forehead. So that's what this history is getting after that sinusitis. Um venous sinus thrombosis is a blood clot in the vein in the head. So like uh almost like a DVT but in the, in the veins of the brain. Um and that causes the patient to become very unwell quite quickly. They can have vomiting, they'll have neurological signs, cranial nerve palsies, um and they'll be a bit more unwell. Um And they would have a risk factor to have a blood clot such as a clotting disorder. Brain cancer is quite unlikely given that it's only been six days and they're quite young and giant cell arteritis, like I said, is a disease of older people over 50/60 years old. So be very rare to have it in 29 year old. And also they haven't got those kind of classic symptoms of visual loss and dropping. Uh and sinusitis, usually it's viral but can be bacterial and be treated with things like amoxicillin. Um If it's going on for a long time or there's puss coming out of the nose of the sciences. Um, but usually just kind of rest fluids, fluids and hydration and pain relief, like high broken and paracetamol. Um, usually as most viral things that will be self resolving. And the key thing to remember is that tenderness in the face when leaning forward and the viral symptoms as well. All right. This is the final question. 28 year old female with a history of acne um presents with worsening headaches, they're worse when leaning forward. She also gets formatting in the morning and has noticed blurry vision. Um you notice blurry discs, blurry optic disks on fundoscopy, given the most likely diagnosis. What is the best frequent to go for? This is another slightly niche one. Um So we've got acetaZOLAMIDE, okay. All right. So now another tricky one. So well done. The correct answer is acetaZOLAMIDE in this case is describing idiopathic intracranial hypertension. So, idiopathic, meaning there's no cause that's found intracranial. So, in the brain in the head and hypertension, high pressure. So this is a raised kind of CSF pressure in the brain. Basically. Um let's talk a bit about this one. So, classic case and exams um is younger female child bearing age and you associated with obesity. Uh There's a host of drugs that are associated with it. So things like uh retinoids which are vitamin A and touch cycling's and these are both used in the treatment of acne. Um And so that's what the history of acne severe acne is getting at that. The patient might be on something like tetracycline or retinoids. Uh um And there's a lot of other drugs um that can be associated with this condition. Um The way it presents is usually the headache is the primary factor and it's raised intracranial pressure. So the red flags such as headaches worse when leaning forward with gravity, worse in the morning after they wake up because they've been lying down and the pressure and the CSF collects when you're lying down. Um, vomiting, especially in the mornings and vomiting with the headaches and feeling nauseous and also visual changes. So, tunnel vision or blurry vision because of optic nerve damage. Essentially, it's a disease because to do with kind of failure of the drainage of the CSF in the brain and imbalance. Uh and it causes um higher amount of CSF to collect in the brain and that causes a higher pressure as you can imagine. Um there's a whole host of different tests, a blood test to exclude other causes, uh CT and MRI of the brain. Um And to look at the kind of measure the pressures in the brain. Um and the treatments, the main thing is conservative treatment like weight loss, um and stopping the drugs that are risk factors. That's the key thing um with the most benefit. And also acetaZOLAMIDE has been shown to help also drugs like to hear, um, eight because it's got a dual action and kind of causing think weight loss as well as it's an anti migraine, um, drug as we talked about earlier. And the headaches, um, can kind of have a kind of migraine phenotype to them as well. And so to her mate has been found to be quite useful. Um, and then, like I said, weight loss and then if it's still bad, they can do things like surgery to the optic nerve to, um, shave off parts of the optic nerve so that it's less affected by the pressure. Um, they can put shunts in. So shunting some fluid out of the brain, uh, there's more complex further down the line kind of receivers for idiopathic intracranial hypertension and it used to be called benign intracranial hypertension. But then they changed the name because it's not benign. So you might see that use in some older textbooks, but that's um slightly more rogue one. But important to consider because it's, it does happen, it can be quite debilitating in younger patient's and um, is quite an exam favorite. So look out for those risk factors and uh red flags and again, we covered meningitis in the last talk. So I'll just, I'll just left the slides in here for completion. But if you want to, um, see the talk of meningitis, just go to the Tuesdays lecture. Okay. And this is one of the non blanching purpuric rash on different skin tones. And if that's just remember if you see that with meningitis, that means that there's bacteria dividing the blood. So their septicemia or meningococcal meningococcal septicemia. Um And so that's kind of severe form of meningitis. Just two final word on headaches. Some of the other diagnosis that we didn't discuss but important, important ones to consider. So common things such as dehydration, stress, sleep, um, eyestrain or not having the right glasses for your prescription. Um Those are common kind of causes of headache that you see every day. But obviously, when you're taking a headache history, it's important to rule out the life threatening causes. So sinus thrombosis, like I said, it's a blood clot in the blood vessels of the brain. Um and usually they'll have risk factors such as being on the pill or thrombotic problems. Um severe headache with focal neurology, seizures, etcetera. Um carbon monoxide poisoning. Um important to think about in the winter because people have boil boilers on and if there's a faulty boiler and a leak of carbon monoxide that can cause poisoning in a really bad headache. And the classic exam features cherry red lips. I also think of other drug use like cocaine and things like that can cause headaches. Um hypertensive emergencies and preeclampsia are important to think of space occupying lesions. Obviously, brain cancer, abscesses, that sort of thing and usually they'll present with systemic symptoms and um problem neurological problems as well, medication overuse. We talked about using things like Koko tamal traMADol, too much. It can cause a rebound headache. Uh traumatic head injury obviously can cause bleeding, trigeminal neuralgia. We mentioned earlier is that electric shock like pain and the treatment to know for that is carBAMazepine. Um and you might need to do imaging to rule out things like multiple sclerosis. Um and then also don't forget that e ent and ophthalmology pathology because in the same area can all see uh records referred headaches. And so it might be glaucoma, but the patient comes in with a headache. But really when you look, you see that dilated pupil and the red eye or it's a UV ITIS or uh you know, an E N T infection that's causing the patient to say they've got a headache. But remember, I think it's not, you're not just looking for the cause of the headache, you're also looking in the eyes, the ears, throat for referred sources of pain and then asking about things like visual change, right? Take a couple of minutes has got anyone got any questions, anything about differentials for headaches before we move on to the next section? Okay. So somebody has asked a question about chiari formations. It's a good question. I'm not too sure. The only thing that I know of um chiari malformation is that it um gets to do with the either cerebellum or the brain stem. And it's the kind of malformation that puts them at higher risk patients at high risk of having the kind of herniation of the brain. Um, what's called koning is when the, I think when the brain, uh, stem kind and cerebella tonsils get pushed down into the Foramen magnum, I'm, other than that, I wouldn't, I don't know too much about them and their headaches, but I can have a look and maybe try and add something to the slice, um, afterwards so that they sent out. That's, it's a good thought. Um, something that I have. Um, I'm not too sure about, I don't wanna give you the wrong answer. That that's all I know about those ones. Any other questions? Okay. All right. Let's go to what are reading for time? All right. Perfect. Cool. So, moving on how to take a headache history. So now you start to think about all the kind of differentials common and life threatening for, for headaches. I think it's really useful to have a think about your differentials first. Um, and then once you go into the history station or you're seeing a patient in a, any you, um, ask your questions directed way in order to rule in or rule out the different differentials that you've, you've thought of. Otherwise you can be kind of asking questions and you're not really sure why you're asking them. But if you think about the differentials first before you go and see that patient obviously have to keep an open mind because it could be something that's on your list or higher or lower on your list. But then you're able to focus your questions to ask, you know, do you have tenderness? You have jaw pain, do you have visual loss because you're thinking about particular differentials? So that's why I think it's useful to think about the differentials first and then go and see the patient sometimes and you can help target your questions better. So I think, I think consider with neurology is that the history tells you can help you tell you what kind of pathology you're dealing with or it's a stroke or it's a vascular problem where it's a infection or it's a cancer. Pardon me? The examination helps you localize where the lesion is. So is it in the cerebellum is in the cerebral hemisphere is in the peripheral nerves because obviously, you know your generic history structure. So you start the presenting complaint and then take a history, presenting complaint, find out what's been going on. How long has it been going on for? How severe is it? Then you take the history of the patient's past medical history. So any previous medical problems, any previous operations, has they have had this problem in the past? What drugs are they're on and what allergies have they got? That's drug history, family history. Um So relevant things in this case, have they've got a family history of stroke or multiple sclerosis. Social history is really important cause neurological problems, affect function. So what job do they do? Which hand did they write with? Is it affecting their day to day life? Um Do they smoke, drink, take drugs? Because also that can affect, affect these diagnoses and then a review of systems. So things like weight loss, fever, night sweats, rashes, joint pain, et cetera. And then just remember in the neurological history, you're thinking of the time frame is really important. So is it an episodic problem that's been coming and going? Something like M S? In which case, you need to go back to the beginning and to ask, dig down and when the, when the symptoms started or is it more of an acute problems such as a stroke which would be sudden onset or a seizure which would be sudden onset? Is it think something that's going, going on for matter of days or weeks, which is more an infection or something that's weeks, two months, which is more likely like a cancer or an auto mean problem. So the timeframe in the history is really important because it can help tell you what kind of pathology you're dealing with. All right, before we go into the next few slides. So we'll start with headache history. Just people want to pop in the chat or stay on the microphone. What uh important questions are there? There are two ask in a headache history, have a look at the slide. So feel free to pop in the chair. So if you're seeing a patient, what kind of things do you want to ask about? What, what would you, what would you like to know about the headache that would change your management or inform you? Good. So what time of the day? Good. So for example, in the morning, that's gonna be more concerning of a kind of raising chickens pressure. What are the triggers for the headache? Exactly. Very good. Um Other symptoms, excellent, very important. So things like visual loss, weakness, numbness and neurological symptoms that they've got vomiting. Socrates is really, really useful. We'll come onto that in a bit. So that's if anyone hasn't heard of that, that's the acronym for pain, taking a history of pain and the different features, visual loss really, really important. That's good. Any stresses. Exactly. When did it start? Which part of the head is good? For example, like migraines we said are usually on one side or temporal arteritis is usually on one side or as like a tension headache will be all around Socrates? Excellent. Yeah. Really good. That's another, that's a good point. So is it worse on coughing or straining? And that again points towards raised pressure. Um because you can imagine you kind of do like a valsalva move or when you're coughing, laughing, straining and that increases the pressure in the, in the brain um in the head. And if you've got already. If you already got raised pressure due to a lesion or high, high, high pressure in the brain, then that's going to make it worse. So, coughing, lying down, straining. That's a red flag. What if you want to relieve the pain yet? So, pain that, but it's better with, you know, itself or with paracetamol is a bit, little bit more reassuring to pain that's waking up from sleep. That's worse despite using cocoa to mall and traMADol every day. Um And so that can sometimes give you a hint towards the house where the pain. Excellent. That's really, really good suggestions. Well done. Course associated with aura nausea, vomiting, good. So thinking about things like migraine, um that's, that's really good. Family history is another really important one. Excellent, excellent. So this can be a common kind of, yeah, common thing that you'll see in real life in, you'll see all the time in GP and A and E. Um and a common thing that will come up in, in exams and you might have a history station with, with a headache. It's very, there's, there's a lot of differentials and it's a really, it's all in the history. Um is the diagnosis usually in the history? All right, let's pop back to the slide. Cool. All right. So as you guys said, so somebody said, Socrates, so that's site. So occipital headache, sudden onset might make you think of something like subarachnoid or is it temporal like temporal arteritis, which side is the headache on? Oh is for onset. So did it start suddenly? Like then that makes you think of a vascular problem like a bleed? Or is it more of a gradual onset character? Is it throbbing? Like a migraine? Is thunderclap like being hit on the back of the head? Like um like a subarachnoid hemorrhage radiation is really important if it is going to the neck with neck stiffness, like a meningitis kind of picture. Is it focused around the eyes in the face? Like a sinusitis or trigeminal problem? A associated features will come onto t somebody mentioned worse in the mornings worse when you're coughing, straining, stressed. What, what is the pattern like? Is it like a cluster headache, like loads in, in, in a few weeks or is it a constant headache? Um Again, exacerbating factors we talked about um and severity you can ask how bad is it out of 10? Um And is it impacting their daily life like a headache? Like really bad migraines or cluster headaches might make somebody have to lie in bed for the whole day whereas if it's mild headache, but they're able to get on with their daily activities and it it's a little bit, you're a little bit less worried associated symptoms. So I group them according to differential. So if even next sickness, rash photophobia makes you think of meningitis. Um So sometimes when I'm taking the history I like to, I think it's useful to ask your questions in it, to do your Socrates and ask about the nature of the headache, etcetera like you guys did and then do a kind of run through. So in your head, you're thinking meningitis and ask the meningitis questions and then if there's yes, some of those or no to all of those and it can help put meningitis higher or lower on your list. Visual change, weakness, numbness, confusion, dizziness, those are all neurological problems that might you think of a, you know, um uh space occupying lesion or a stroke or a bleed, sure, claudications, scalp, tenderness, stiff shoulders, visual changes make you think of giant cell arthritis, running block nose like cremation. Uh that can make you think of something like a cluster headache, sore throat, blocked sinuses, sinusitis and night sweats, weight loss, systemic symptoms uh can make you think of like a cancer, an abscess, something like that. And also another thing is changing nature of headaches. So for example, some people, you know, a lot of people will get headaches or tension, headaches or migraines. But if they've come and they said to you that the headache is really different, just asking is the headache different to your usual headaches. That's a red flag in itself. Um And if they tell you, you know, I normally get migraines and they're quite bad, but this is something completely different, much worse. You might start to think there's another pathology going on because it can be easy to get distracted and just think, oh, they have migraines in the past. This has got to be a migraine, but it's not always the case. Geeky medics is a really good website for all history, taking an examination skills. And then like you guys said, past medical history, as you do things like cancer, looking for things like cancer, even a suppression PKD is polycystic kidney disease that carries a risk of berry aneurysms in the brain, which is in itself a risk of uh subarachnoid hemorrhage. PMR is rheumatological condition, polymyalgia, which is associated with the vasculitis. We mentioned about um are they on a lot of drugs that might make you think of a medication overuse headache or have they got risk factors for clots like the pill or HRT um or have their risk factors for bleeds like anticoagulants and then family history of migraines of cancer, of stroke, etcetera. Um And you want to check the simple things like A C B G. So blood sugar cause hypoglycemia can give you a headache. You might consider a CT head if you're thinking about a bleed lump puncture, for example, for meningitis or subarachnoid E S are for giant cell arteritis and the list goes on. So depending on your differential list, some of those tests will be higher or lower. Next one we can discuss if first of all pop in the question pop in the chat if there's any questions about headaches. The next one is, um, loss of consciousness. So, how do you take a history for a loss of consciousness again? Pop your suggestions in the chat? Yeah. Very good. So, that's a good suggestion. So before, during and after, that's a really useful way. It's not only is useful, but you don't miss anything because you're taking the whole timeline and it's quite logical. So it's easy to remember what happened before, what happened during, what happened after any other suggestions. Very good. Postictal think that's a really good, really good point. So, postictal phase, tongue biting controllers, Victor's and those all point towards a seizure. So if they've postictal meaning after the seizure, are they really confused in drowsy, have their bitten your tongue, have they had incontinence? And those are all things that might point towards something like as opposed to another cause of collapse. Excellent. Any other thoughts before we go to the slides? So, uh here's something you can just look at the slides later to do with the red flags from headaches for headaches, which we covered. So things like neurological pain, sudden onset, um older age worse with position changing nature of the headache, neck pain. Um And this is another useful acronym that you can have a look at later. So, yeah, so loss of consciousness. So first establishing, was it just a fall so that they just trip and fall or was it an actual loss of consciousness? I they blacked out and period where they don't remember things establishing the timeline and a collateral which somebody's mentioned in the chat was really, really useful. So was there somebody who witnessed it or videoed it and can tell you what happened while the blessing blacked out? So then going in order. So before, so did they have any chest pain, any palpitations, any cardiac symptoms? Breathlessness? Do they have any headache, loss of vision, feel nauseous for your clammy and sweaty? Um What were they doing? And were they at rest? Were they exerting themselves? So if they're um so, you know, exerting themselves, for example, classic case of, you know, footballers or sports people who have that sudden collapse and you worry about um cardiac disease. Um because if they're exerting themselves than themselves, than um that's when your heart is put under more stress can uh kind of reveal a cardiac problem or even at rest as well is quite concerning. Um But what were they doing? For example, if they were, you know, really, really stressed or standing for a long time, you might worry, you might think it's more of a simple faint or a vasovagal. Um Are there any triggers such as bright light, triggering a seizure? And has this ever happened before? A lot of the times people say, oh, you know, I've had this many times before and it's seizures and I've got epilepsy or so on so forth during the loss of consciousness? So did they black out? Did they hit and then from a, from a collateral history? So somebody who was there, did they hit their head? Was there any limb jerking? Was any incontinence? And then the key thing for seizures is lateral tongue biting. So did they bite the side of their tongue? Um And did they have a postictal phase of confusion that lasted a few minutes to hours? Um during as well, how long were they out for? Was it a few seconds? And then they fell down and got back up straight away or was it a long time? A few minutes they were on the floor for, do they have any cyanosis or turning blue? And especially in elderly people, do they have a long life? So like being on the floor for a long time is a risk factor for muscle breakdown and rhabdomyolysis, which can cause kidney failure. And then afterwards, after the loss of consciousness basically, did they come around and how quickly? So if it's taking a few seconds that they, you know, felt, you know, a bit groggy and then got back up and felt back to normal, it's more likely to be something reassuring like a vasovagal, for example, whereas, you know, if it's taken 30 minutes an hour or more than that, for them to get back to their feeling normal, then you're more likely think it's something like a seizure because then they get a prolonged postictal phase. I also want to ask if they've got any pain anywhere. So any head injury, if they hurt themselves, classically, people black out. And then for example, cardiac simple thing could be if they're black out and they fall, they're less likely to be able to, obviously, if they're not conscious when they're falling, they won't be able to put their hands out and protect themselves. Uh Whereas a simple, if somebody trips over and falls and is conscious than they'll put their hands out and stop themselves from falling. So the ones who black out are more likely to have severe uh serious injuries, for example, hitting uh broken noses or landing on their face or severe injuries because they're not able to protect themselves. So, you know, bruising over the face or in odd places is also a red flag that should make you think that this person have a loss of consciousness. Do they have any amnesia or loss of consciousness after the uh the black out? And that's another red flag, um, obviously want to ask about relevant things or have they had previous friends that they had epilepsy? Have they got a um cardiac problems like valve valvular disease? Are they on blood thinners because they might fallen and hit their head? Have they got risk factors for clots or bleeds? Um And the under really important thing to ask about, have a anti family history of sudden cardiac death. So things like Hokum, which is hyper obstruct, hypertrophic obstructive cardiomyopathy, um which is a classic case that gets discovered in young athletic sports people who collapse and have cardiac arrest suddenly. Um you know, and that can run in the families. Uh So that's a family history is really important as anyone had any sudden cardiac death differentials, like I said, so the main thing is, is a seizure and that's pointed towards lateral rather in front rather than the tip of the tongue. So lateral tongue biting incontinence, um and long prostate four phases. Vasovagal is a kind of um more reassuring differential and that's uh duty, emotional stress or standing for a long time dehydration and you get vagal activity and then they feel a bit nauseous, they feel a bit clammy, their, their vision kind of closes in and then they collapse. But then they get, they fall flat and then the blood supply goes into their brain because they're lying flat. So essentially the brain, yeah, essentially the body goes flat and then the because of gravity, the blood flow goes back to the brain, they get cerebral profusion again and then they feel fine and they get up after a few seconds, um situational syncope. So you might have heard of some when people get severe um intense emotions or Mick duration or different sorts of um situations can cause some people to have syncope or collapse cardiac syncope is really, really worrying. So you need things like an E C G and an echo. Um So how are they in an arrhythmia? Have they got severe aortic stenosis or hypertrophic cardiomyopathy causing an outflow obstruction. Common thing in elderly people who are lots of BP medication is orthostatic hypertension. So that's why you will ask, are you on, have you, have you got high BP, are they on things like amLODIPine, Ramipril that's going to drop their BP? And so, for example, one of the key activities is, you know, today, where they're sitting down, stood up really quickly and then collapsed. And that might indicate that their BP dropped because they're not able to maintain that BP, one standing up and then they get cerebral hyperperfusion and then collapse. And so that's autho static. So um changing when standing, standing up, postural hypertension and then other things you need to think about. So vascular problems like an aortic dissection can cause uh loss of consciousness. If A P if you get a large pe um and then you don't get enough blood cardiac output that can cause collapse, uh low blood sugar. If it's really, really low, it can cause a collapse. Um But you're trying to differentiate mainly between it is a seizure, is it's a cardiac problem, you know, or is this something life threatening like a dissection? And so blood tests blood sugar scg to look for arrhythmias BP, one sitting and then one standing ct of the head. Um, and then all sorts of more detailed investigations and echocardiograms to look for cardiac causes of loss of consciousness. So that's quite a common history. Black eye history. So just remember the before, during and after and if you remember those, that timeline of events and taking that history and thinking of the red flags, then, then you'll, you'll be fine at the station. Cool. All right. Final one is a history of weakness. So anyone can suggestions um any suggestions of mhm What you'd ask for in patient who presents with weakness in um in A and E or G P, for example, Socrates. Good numbers are tingling good. So you're thinking on the lines of neurological neurological symptoms. So it's a motor um it's a sensory, so the numbness, tingling, recent illness, very, very good. What diagnosis are you thinking of their in particular? Excellent Guillain Barr, right. So we cover that on Tuesday's talk. So that's post infection paper. Patient's can get a peripheral neuropathy. Good. Is it specific muscle groups? Is it one side, both sides travel history again? Good. Something you have an effective picture, that sort of thing. Very good, onset onset is really good because that can, like I said earlier history in the neurological history, the onset we'll give you um the onset will give you the the the diagnosis in many cases. Um So for example, yeah, for example, if it's sudden onset, you're thinking vascular. Um So is it a stroke or bleed? Whereas, you know, is it gradual onset, you're thinking maybe more of an autoimmune problem or cancer or something like that? All right. So let's have a look at some nice well done good suggestions. Okay. Mhm. Hopefully you can see the slides. All right. So um so weakness history like so also clarifying. So some people when they say weakness, they might feel, you know, they might be talking about fatigue or lethargy and just feel I don't have any energy. So clarifying what they mean. So things like dizziness and weakness can be very nonspecific and some people think, you know, dizziness means vertigo. Some people think it just means they feel a bit lightheaded and so you need to clarify what they mean by that. So weakness can be very vague. So it doesn't mean, you know, they couldn't lift their arm and they couldn't lift their leg or does it mean they just felt really tired once you've clarified that? And it's true weakness. I loss of muscle power, you have to localize it like you said. So is it the arm, the face, the leg or all of those? Is it unilateral bilateral? Is it which muscle groups? Is it, you know, is it both feet or is it one arm and, and the, and the side of the face in which case that will change the differential? And have they had that before? For example, the previous strokes, previous T I A S um I think that's really useful question, you know, have they had these symptoms before? Because a lot of the time patients say, oh, you know, yeah, they have. And it's been investigated and it was X Y Z helps you out a lot. So, a variation of Socrates for non pain presenting complaints is just the O A T E S. So onset, was it sudden stroke, gradual, more of a degenerative problem is again worse? Is it constant association? So somebody mentioned numbness and tingling. So is there sensory loss? Um is there other kind of neurological symptoms? So, vertigo, so you're thinking of middle ear all kind of particular problems, is that visual changes? Again, that could be a stroke. Um is that ataxia? So loss of coordination, loss of speech, is there a headache? You might be thinking of a bleed or something like that? Seizures again, loss of consciousness. Um Is there tremor for circulation's which is kind of muscle twitching? They had weight loss. So you're thinking of more of a systemic thing such as maybe like a brain cancer that's pressing on the motor cortex. So the associated symptoms kind of tell you what you're dealing with timing again, like you said, is it constant, is it coming and going? Is that post infectious? Someone mentioned? So Guillain Barr, what makes it better or worse or heat, cold So things that for example M S is made work, the symptoms are worse in the heat. Whereas myasthenia gravis, which is a problem with the Astelin clothing receptors in the in the neuromuscular junction that I think, sorry that gets uh I believe that gets better with the, with cold. Um So you think you can put an ice pack on the patient's uh muscle and then usually that helps them regenerate their strength a little bit. Um stress, etcetera exertion. So you get the idea and severity, what is it stopping them from doing? Is it, you know, classic history of a stroke is someone who's holding a cup of tea or something in their hand and they drop it and they couldn't lift their hands. So that's really severe or is it kind of a mild weakness that this will retain some function? Um And then again, you want to take the stroke, risk factors for previous stroke, diabetes, cholesterol, all those things. Um have they had previous M S and infection? Any recent travel, like you guys mentioned, uh any medication side effects, some, some drugs can cause uh peripheral neuropathy. So some chemotherapy drugs and antibiotics, are they on the pills? Is that respect for a stroke or a venous thrombosis? Um any similar thing for the family history and there's a wide, wide differential, it really depends on the history. But the main thing you worry about is it a stroke or a T I a sudden onset unilateral weakness or neurological symptoms. Todd's palsy. If anyone knows what that is, that's a bit niche. Put that in the chat, hemiplegic migraine is um kind of a newer kind of subset of migraines where you can actually get unilateral weakness or muscle weakness associated with a migraine. But that's very difficult specialist diagnosis to me because obviously it mimics a stroke space occupying lesion. Um again, so that would be more of a gradual onset. Um Guillain Barr A and M S. So demyelination, peripheral neuropathy. So for example, weakness, numbness, tingling in the legs or the arms motor neuron disease, that's classically an elderly people and they might have hand muscle weakness. Herman for circulation's my senior gravis we mentioned is uh neuromuscular problem and that's usually gets worse with, with exertion. So they're fatigue to, they start going up stairs and the by the time they get the top to the top, they're really, really weak because they've run out of the kind of ask alcohol ian the receptors. Um and conversion disorder is usually to do with kind of psychiatric problems and patient's who kind of have what's called like things like functional problems where they um physically, if you tested that if you did like nerve conduction studies, the nerve conduction would be normal, but they described kind of neurological syndrome of symptoms, um investigations you do imaging. So, CT head MRI for strokes, nerve conduction studies from neuropathy, uh E E G is a N careful A gram. So that's looking for things like seizures, for example, the lumber puncture, etcetera. If you're looking for things like M S or Guillain Barr A, any one, any thoughts on what towards palsy is procedure? Very good, excellent, excellent. So, post seizure, you can get a kind of uh paralysis of part of the body and that's called a Todd's Palsy. So palsy meaning a weakness essentially. Um And so that's so that is another mimic for a stroke. So somebody's had a seizure and then they have that weakness that points towards, towards palsy if they had a migraine and then the weakness that can point towards a hemiplegic migraine. But obviously you'd be worried about something like have they had a bleed because the symptoms of headache and weakness are a bit more concerning. But once you've ruled that out or if they've got typical migraine symptoms, then it's more, it might be likely to have a hemiplegic migraine. So those are the important things to consider with weakness. And remember your red flags, sudden onset associated with the neurological symptoms, having vascular risk factors. Or, uh can worry you towards a stroke or T I A if it's crazy. Cool. That's it. For history's any questions before we move on to the last part and examinations? All right. That's fine. Uh That's right. Yeah. And if, if you have to leave early, no problem, just fill out the feedback if you're able to. Thank you very much will be very useful to know how to improve. Um The last bit, we'll try and wrap up by hopefully around eight, we'll run through some examinations. So cranial nerves, so this is just a quick reminder. You can have a look at the kind of the functions of each cranial love through 1 12. Let's run through. So um quick pop in the chat, how you um anyone in any order just run through the cranial cranial nerve. Example steps of the cranial nerve examination, whether it's doesn't matter, it doesn't have to start from the first cranial nerve. But any any steps that you guys remember from examining cranial cranial nerves? Very good. So that's a sense of smell. So that's olfactory enough. Um So asking about any change in smell and um there are certain kind of smelling substances that you can use with classic strong smells like lemon or coffee that would test the patient's, but it can smell very good. So cranial love to sort of looking at their vision. So testing um visual acuity, that sort of thing. Very good God, very good. So cranial nerves 334 and six. So those are all the eye movements. Very good, excellent fish. All right. All right. So here's just a list um thing with examinations. It's the best way to learn them is by practicing. But we'll, we'll run through quickly how, how to go through cranial nerves. So best if you know the each cranial nerve and what it does, then it's quite um logical how you test it. So number one, we said smell to usually the acronym. Um so that's optic nerve afro so acuity. So using a snelling chart, which is the one that you see at the optometrist with the letters getting progressively smaller and how far, how many lines can they read? Depending on how far they are they are. Uh And also testing for color vision visual fields is um that when you cover one of their eyes and you cover your opposite eye and then move your finger in the peripheral vision. And can they see using the peripheral vision um the outer visual field as you move your finger reflexes. So things like the light reflex and accommodation reflex, consensual reflex. So you need a pen torch. Um and that's looking at the pupils, are they constricting appropriately and then fundoscopy or ophthalmoscopy looking at the back of the eye to see the retina and the macular and the optic disc oculomotor. Um And that goes again in hand, hand in hand with cranial A four and six suggesting the eye movements. So the best one is the H test. So get them to keep the head still and follow your finger um as you move it in that kind of big hate shape, so move it to the side and then up and down looking at the oblique muscles and then back to the middle, up and down, and then back to the opposite side, up and down in a kind of double H shape in front of them. And you looked asking them before, before you do that, ask them for any, have you got any double vision or pain while they do that? And if it's horizontal, double vision or vertical, double vision, that can help tell you which which muscles are affected. Um And also remember during every examination, between each step, observation and inspection are really, really important. So um inspecting for any rash on the face, is there any asymmetry? Is there any tosis of drooping of the eyelids that might make you think that there's some sort of syndrome going on? Um Again, quenelle of four and six already done. Trigeminal nerve is mo mainly sensory. So sensation in the face. So the same way you just sensation anywhere else if they close their eyes and then using uh things like a cotton bud text sensation and then pain and temperature and appropriate um in, in, in the face. So both sides, left and right, forehead, left and right cheek and left and right jaw. Those are the three divisions of the trigeminal nerve. If anyone knows the three names of the divisions, then pop that in the chat. Um and then the motor function of the trigeminal nerve is temporary list and masters. So those are the muscles of chewing. So you um, ask them to clench their jaw and feel the sides of the head and you should feel a bulge and the size of the draw and you should feel a bulge and then the um, power in their jaw. So they open their draw from side to side and downwards. That's the power and you can offer to do corneal reflex. So, touching the cornea and they should blink and the Georgia reflex, but usually the examiner won't ask you to do those facial nerve is the motor nerve in the face. So that look for symmetry and will come into that in a moment and then just them test their power with if they scrunch their eyes up like they've got, I find it useful to say, scrunch your eyes up like you've got soap in your eyes. And that tests orbicularis oculi and you try and open their eyes and they keep them shut as tightly possible, raise their eyebrows like they're really surprised. And that tests um the muscles in the forehead, puff your cheeks out, grin and show your teeth and pursed lips together. And that's all the different um five branches of the facial nerve and also the facial nerve supplies taste as well. Remember that? So asking for any change in taste, cranial of eight is hearing and balance. So you can do gross hearing. So where you whisper a number and see if they can repeat it while you're putting a noise in the other ear and there's Weber's and Renee's test, um, which can get quite confusing, but that's using a tubing fork to see. And you, if you use both of those tests in, in, together with each other, then you can tell if it's a conductive or a sensorineural hearing loss. Um And sometimes you can test for balance, but that's not a common part of the cranial nerve exam, but that would test for cranial of eight. The last few ones come together. So nine and 10, glossopharyngeal and vagus nerve. Um glossopharyngeal is mainly sensory and Vegas is a bit of both but mainly kind of motor function. Um So things like opening their mouth looking for deviation of the uvula to to one side or is there, do they have uh present gag reflex? Can they, is their speech, their cough there, swallow intact. Um in the sensory components of the glossopharyngeal and the motor components of those are usually the vagal vagus nerve accessory nerve. You test the power in the trapezius. So shrug their shoulders against resistance and turn their head against resistance, which is sternocleidomastoid. And finally, hypoglossal is power to the tongue. So stick the tongue out. Is there any deviation um towards the side? Is there um stick the tongue to the inside of your cheek and testing the power is any weakness, any wasting any fasciculation on the tongue. Um So that's hypoglossal nerve, things like geeky medics and simple Loski are really, really good free websites that are really, really helpful for examination before. So, and then all right, here we go. So here's a quick clinical sign spot diagnosis. So, what, what's the lesion here and is upper or lower motor neuron? And what's your differential again? Her pop it in the chat? Very good. Excellent and yep, very good. So, ophthalmic maxillary and mandibular, the divisions of the try general enough. Very good, excellent, good, which cranial nerve is affected in this, in this picture, I got 11 12 chance if you have a guess seven, excellent. So this is cranial of seven palsy. Is it left, left or right side? It is the patient's left or right? Cause I always actually find it really tricky to tell which is the pathological side. This patient is trying to smile that that might help you out. So is it left or right? That's affected facial know very good, right side. Exactly. So if they're trying to smile, then you can tell there's weakness across the whole of the right side of the face. And this is an exam classic um and is relatively common. So, spot diagnosis. So it's this is right sided, facial nerve, palsy. So cranial nerve seven, the way you can tell that it's a lower motor neuron is because it involves the forehead. So you can see there's a, there's no wrinkles on the right side of his forehead. Um whereas if it um spares the forehead I E there's there's still got power and the and the right side of his forehead, then it would be an upper motor neuron lesion. Um We can go through that at the end if anyone wants to understand why. But basically, remember, I remember as upper, spared upper. So if it's an upper motor neuron lesion, it spares the upper part of the forehead and a lower motor neuron lesion um involves the forehead essentially. So this is a lower motor neuron lesion differentials for that people mentioned bells. So in order to diagnose bells, you have to exclude other causes first. So you have to look inside the ear and see for is there a chicken pox kind of rash such as Ramsay hunt disease causing uh infection of the cranial nerve? Um Have they got Lyme disease? Have they got a tumor such as a Schwannoma on the vestibular nerve? Have they got a parotid tumor? And then once you've excluded other causes, then you've got idiopathic cranial nerve palsy of cranial of seven, which is Bell's Palsy if that makes sense. So it's a diagnosis of exclusion. So any cause of the neuropathy um can cause um cranial of seven palsy. Um weird and wonderful things. I saw one patient with necrotizing otitis external, which is really, really severe, basically ear infection that you get in diabetics. Um And it's essentially the infection that out of here that gets so bad that it goes into the bone and starts kind of eating its way through the cranial facial nerve and they can get a facial nerve palsy because of the kind of malignant infection, essentially uh any cause of a neuropathy. And then if it's an upper motor neuron lesion, obviously, you worry about stroke. Um So if there was forehead involvement or information has risk factors, you'd worry about strokes, you'd be doing the CT head um to look for you natural facial side weakness. Um A space occupying lesion or something like M S as well could cause this picture. And here's something quite useful is a cranial of three palsy. This is a spot diagnosis causes tosis um and the kind of down and out people. So the top picture you can see there's drooping of the right eyelid and the pupil are slightly sorry. The yeah, the is slightly deviated to the outer side and down. So that's down and out because the truck clear and abductions know over taking over because the oculomotor nerve is is weak. And then when you lift the toe, you correct for the tosis. And for example, asking them to move to the look to the left, the patient's left the right, I can't um can't adapt because of the oculomotor palsy. So that's a classic cranial nerve, three palsy. And remember if there's a blown people so dilated people. Like in this case, you worry about surgical course, such as an aneurysm or a cancer or something pressing on the on the third nerve. All right, we'll run through upper limb examination. Any other things in the chat? Excellent, cool. So upper limb examination. So um like always you start with wiper. So there's an acronym that I learned is. So, wash your hands, introduce yourself to the patient peas for permission um to consider, carry on with the examination and get the consent e for his exposure. So in this case, you want to expose uh the torso and the upper arm and the arms and then off repositioned. So have the patient lying down or sitting uh depending on the exam, you doing two questions. So that's what number two sounds for is um are you in any pain? And have you got any discomfort um to make sure the patient's okay and then every exam start with inspection. So you might see a tremor, you might see wasting of some of the muscles in the arm, you might see particular ation. So pitching of the muscles and so inspection is really, really powerful looking around the bed. Is the patient got any medications with them? Have they got a walking stick? Um uh Are they, do they look really well or unwell? Um are they looking, do they look like they're in pain and then kind of the five domains of neurological examination? So, tone power, coordination, reflex, and sensation. Um I used to struggle to remember it. So they, it was taught an acronym. So, you know, I'm an demonic which is top cars, top cars go. So then without the vowels, that's T T PCRs, it's a bit of a stretch, but just remember tone. So that's um you, you kind of approach the patient as if you're shaking their hand and you move all the upper limb joints. So their risk the elbow, the shoulder and you ask them to go really, really floppy, relax their arm. And you look for tones, the tone is a kind of increased muscle, muscle, kind of uh resting strength essentially. So if there's resistance to those movements, then that's an increase in tone. Um And that would mean that they got rigidity or spasticity. Um And you do that on both sides and compare power is quite simply how strong their muscles. So you ask them to do all sorts of movement. So you go from starting from the shoulders all the way down to the fingers and the thumb's testing the muscle power in each group. So you start with power in the, in the shoulders. So getting them to put their arms up in the air, um, um, kind of as if they've got wings but, um, sticking their arms up outside and get them to push up and then push down. Um, and then getting them to put their arms in front of them, you can tell them like a boxer so you can imagine their fists in front of their face. Um And then you're testing their elbow strength. So can they push away from you and pull you towards? It might be easier to show you it's all straight, easier to see this one. So this is, for example, shoulder power, if you achieve my arm pushing up and then adoption, pull, pulling down and then elbow powers are pushing away and pulling towards and then you ask them to do put their arms, um their fist straight out like they're holding a handlebar and then push their wrist up and down and then you do the same with the fingers. So finger extension, finger, flexion and thumb, flexion and extension against power. And you can also test for power grip. So put your hand, put your finger in their palm and get them to squeeze and that's good growth kind of test of power. And then you remember you're comparing side to side. So you want to compare the left to the right because you want to see is there, you know, left shoulder week as compared to their right, right side. Um And there's an M R C grades a grading system which tells you kind of between one and five, how, how good their power is out of five. Um So remember compare side to side because you want to be able to tell, you know, is the left side compared right, weaker compared to the right, etcetera. Then after tone and power comes coordination. So that's, there's two main tests for that. So one is the finger nose test you might've seen. So that's touching, they take their finger there, touch it to their nose and then they touch it to your finger and you want them to stretch out. Um, so they're having to reach and then you keep moving your finger like a moving target. And so they go back forth, back, forth, back forth. Um And things you might see there is an intention tremor. So as they're trying to reach to you, they start to tremor like that and that's a cerebella signs. So that's in tension tremor. And the other thing is past pointing. So if they've got poor kind of depth perception, they might be missing your finger and going too far because they've got some sort of depth problem. Um And you might have heard of dysdiadochokinesia, which is where you get them to do this alternating clapping movement, but they flipped their hand. So, dysdiadochokinesia is a test for rapidly alternating repetitive movements and that's a sign of cerebellar disease. And so if they're not able to do this rapid alternating movements, just flipping their hand up and down on their other palm, then that's a sign of dysdiadochokinesia being positive, you can do things like cerebella rebound and pronator drift as well, but we won't go into that too much. Um And basic reflexes. So the um supinator reflex on the mid forearm, on the kind of distal forearm with the tendon hammer and the triceps reflex again, tapping over the triceps, tendon just above the elbow. Again, you're comparing left to right. Remember um and you want to see if the reflexes hyper reflexic or hyperreflexic. Um and then finally, sensation. Um So does anyone know the five different types of sensation? You've got, what are the five modalities? So you got things like um kind of fine touch, there's pain, there's temperature, there's appropriate reception and vibration. So use different. Yeah, so you use different um so parasthesia is more like a sensory disfunction. So numb essentially pins and needles or tingling, which is um kind of a dysfunction. Um But yeah, the five types of senses. So pain, um normal pain, pressure, temperature vibration, appropriate option, appropriate option is joint position sense. Um And so you test each of those using either a tune ing fork or a hot and cold test tube depending on what modality of testing and you test in each of the year. Um dermatomes in the upper arm. So around the shoulder, mid arm, forearm, around the hand, etcetera. And you're comparing side to side for loss of sensation on one side or the other cool. So that is upper limb. Uh huh Now, let's see if this works. I've got a quick video for some signs. Techs what? And if you guys hopefully you can see the video, I'm not sure of it, embedded property. So if you want to pop in the chat, what sign you think you can see in this patient? Same here. Very good. Excellent. So yeah, pill rolling tremor, which is consistent with Parkinson's or arrest and a resting tremor. Exactly. Um, so yeah, it's a resting tremor. I, they're not doing anything with the hands and at rest. Um, they've got shaking and then pill rolling, it looks like essentially they're rolling a pill between the farm and the first finger. Uh All right. There we go. So resting tremor. So the differentials for a tremor. So parkinsonism, which is that triad of slow movement, red tremor and rigidity. Um And that is the cause of that Parkinson's disease or Wilson's disease, etcetera, uh benign tremor, which is worse on posture. So when they move their hands to put them, for the example, put their hands out in front of them, then they get more of a tremor and that's very common. Alcohol withdrawal control, the tremor, drugs control cause tremor. And also remember if it's an intention tremor. So, so the tremor's not there when they're resting, but when they go to make a movement, then the tremor becomes accentuated, that's consistent with cerebella disease. Um And in this case, like you said, pill rolling and resting tremor, which in these cases of both due to Parkinson's disease in these compared videos and then finally, just quickly cover in your uh lower exam, lower limb exam again, start with the wiper and the Q Q. So, washing your hands, introduction, asking permission, exposed the lower limbs and reposition the patient on to a bed check. If there's pain or discomfort. Inspect again for a tremor for a fasciculation, infor deformity for asymmetry of the lower legs and then same as with the upper limb except you've got gate as well. So you check their tone. So when they're lying down on the bed, you ask them to relax their legs and you kind of roll them and their foot should flop from side to side. And you're comparing left to right. And then you can also get them to lie down flat on the bed and then lift their knee, you get them to relax and lift their knee and then drop it onto the bed and it should just flopped back onto the bed if they've got normal tone, uh, you shouldn't be stiff and stay, stay in a bent position. Power is, is much the same as upper limb. So, isolating each side left, comparing left to right first, get them to flex and extend their hips, then check the left side and the right side and then to bend and extend their knees on each side. And then two point their toes down and point their toes up at some point the foot down and the, and the foot up and then point they're big toe down and pick the big toe up and then comparing side to side as you go. Um So you're checking the power for each group in the leg coordination is a bit tricky to test and legs. Um Some people do the heel shin test, which is a bit complicated, but essentially taking the foot from, for example, the left leg touching it to the right knee, running it down the shin and then kicking up in the air. So it's kind of a complex coordinated movement or you can do the foot tap test which is tapping the foot down um repeatedly reflexes. So, um Babinski's reflex or the plants are reflex is really important. So running something kind of sharp like thumbnail underneath there around the arch of their foot and the plantar should be downgoing if they're normal, but it goes up if there's a upper motor neuron lesion. So that's the plantar reflex. And then other things like the patella and the ankle reflex with the tendon hammer uh sensation also again, like I said, testing the different modalities of sensation in the duoderm in terms of the leg comparing left to right and then watching them walk. Um So looking for things like Parkinson's gate, so shuffling gait or cerebellar gate, um and then doing, you can watch uh kind of uh symmetrical. Um how's the speed of walking? Are they able to turn around and then they'll be able to stand still with their eyes closed, which is Romberg's test for um joint position. And ataxia, sometimes you can also get them to walk heel to toe or on their tiptoes if you're looking for kind of extra signs, um and then you present all your positive findings um once you finish the examination, so the other thing to check for lower limb is clonus as well. So that's another upper motor neuron sign where you get them to relax their ankle and then wiggle there kind of joints around, wiggle the ankle around and then snap the angle back. Um kind of into Dorsey flexion. And then if they get kind of a flapping of the foot that's positive close, it's the last sign. So let's see, this is what somebody who's gate in the this lower limb exam and if you want to pop in the chat, what you think is going on. Mhm So this is an ataxic gait. So that classically it looks like a drunken kind of gate where they're broad based. So their feet are quite wide apart there, unsteady. They look like they're going to fall over their lack of balance. So that's ataxia. Um classically that's caused by cerebella disease and the causes of cerebella disease are things like alcohol intake, stroke and multiple sclerosis. There are some rare diseases but don't explain about those two those. And then finally, for cerebella disease, remember the acronym Danish. So, dysdiadochokinesia unable to form, perform fast, rapid repetitive movements a taxi a so lack of coordination with walking nystagmus. So that's the flickering of eye movements that you're looking for in the cranial nerve exam. Um when they get to extremes, you know, horizontally or vertically, intentional tremor. So, shivering and shaking when they're reaching out, slurred speech and then lack of tone or lack of reflexes. So those are all signs of cerebella disease and cerebella diseases, stroke, alcohol or M S until proven otherwise. And then this one final picture, just this hemiplegic picture or a parameter weakness where you've got weakness and the extensors of the upper limb. So you can see their arm is flexed and weakness in the flexes of the lower limb. So the opposite. So there are their legs extended. You can see the hip is extended, the knees is, is extended and the foot is extended. And so that's classically in someone who's had a stroke. You might see stroke, patient's with the arm and the leg like that or somebody who's had cerebral palsy or M S, for example, that's just a picture to have in your head of a hemiplegic patient that I think is everything. Thank you so much for listening for staying till the end. I know it. Sorry, we ran over a little bit. Um It's gone the code or click the link in the in the chat for the feedback and just be really, really honest and say what can improve what can be better what you find used to love to talk. Um And any questions, pop them in the chat, somebody put the heart, they wanna fascinate just one moment. I'll and meet them. Just want. Sure. Thanks. Uh You can now speak if you wish to speak by the way and sorry, I can't pronounce your name, I think. And somebody asked, why does Korea happen? Why does Korea?