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Yeah. All right. Can you guys is Can you see that? This side? Yeah. Yep. Great pool. So, yes. So since rants, um, as I said, I'm from, uh um recent follow this year of three. Right? Did medical finals four years ago. Now, um, in carded, I think. I guess this talk is kind of a mind at a bit of make sure you know everything that you need to about near surgery for finals, but also kind of it for the for the non specialist who's gonna become a GP or ah, medic. You know, a physician or, um, e d Doctor, The things that you need to know about your surgical pathology to have to assess and manage these patients, if after best, does, um, just hopefully a little bit interactive reporting. It happens. Happening. Polls. So I'm just gonna be relying on you guys too. Um, cancer, Um, attractive things. Cool. Um, best we get that. So it's it's obviously I can't couple of new surgery and certainly can teach you how to operate by a zoom, but hopefully really high yield based on my memory of finals and covering a few things that are important but I think at least anyway, cool. So case based, I think we've got eight cases. Um, I hope you take us just under an hour to get through them. So we got case. Ones are 37 year old lady. She's been complaining of fatigue, headaches, loss of motivation for last year. GP has been attributing this to her having a stressful job and recently divorced. Um, it was a routine eye test, and she's trying to have a visual field defects. So you could see in the bottom screen. They're the black is where she can't see. So I just got this superior by temporal quadrantanopia. She can't see the upper. I have to part of both of the visual fields in both eyes. Um, question further. And she's had oligomenorrhea for two years, and you gained some weight. So what people have is what people putting the differentials for that. Yeah. Oh, Okay. So we've got lots of pituitary adenoma. One prolactinoma. Yeah. Okay, good. So everyone is in the right area, so recommends. Got some sort of seller. Um, lesion. It's exactly so. Yes, the differential. Based on that, Just that visual field defect that it has to be something pressing on the chiasm. Um, probably from below, because it's a superior. Be going to that little, a little bit more detail. Gemzar differentials is a few things that can be pressing at that region. So this is just the quick vision of the anatomy of the cellar regions. This is imagine your, um you've you've got Coronas section. So you kept Cut the face off base, agree, and you look him right behind the nose. Um, and you can see the pituitary gland in the middle and you got your optic chiasm there, which is what would be pressed on from below. Um, however, there's a few other things around the ear and nose. It is that's the cabinet Sinus, which is covered a juror. So you can have many Germans. That book that could cause this equally you've got your internal carotid artery. There's that on aneurysm. From that could cause is a similar picture. Um, Andi, a cranial for in June, which is a, um a related to a remnant of the of of embryology that can equally and compress the chiasm. Now there's a space for subtlety and how in the visual field defect that you can have from charismatic. Um, compression. Everybody would have seen this style ground before in terms of what your visual field defects hour ones were interested in in this point of the ones around the chiasm. So that is, See, So this bitemple hemiopia, um is this I suppose it although I'm not sure I've never seen it Actress in in clinical practice. But it's in a lot of text books, and it's certainly in the exams where you have ah, differential loss off your superior. Enter an upper quadrants, your bottom one. You know, in theory, ones depends on whether the kinds of being compressed from below or from above on the TV behind that Is that your retina you think of you're at in there. You can see on this screen your retina inverts the image, Really that that was going into into it. So the right side of the the retina sees the effect of the left side of the world. But equally that's true. In the in the opposite plate to the the bottom part of the rash there sees the top past the world. So then those fighters that coming from the Boston part of the retina, covering the carrying the information from the top part of the world, then end up on the bottom of the kinds. And so if you've got a future team of grown up from below, you get, um, you lose those fibers sort of a bottle, very retina, and therefore you lose on the image from the top of the world. The reason you have this by temporal so that out to part of both eyes loss is again because of the cars. And he's wearing these fives, a crossing eso The information from the right side of the world goes to the left side of the brain. So again, the that's the things that cross the things on the opposite side of the world. So you have the outside of the visual field lost again. This is just another stricture of Salomon at me. But just to show you that based cream is a lot of stuff in and around that area, and a very small space. Um, so really things that read after that baked to be causing compression. Um, yeah, that's what you what you end up with, and you can often see this on a MRI scan. It's been occurring with you. Um, you got to see that. The cars and being compressed. So just a bit about pituitary adenoma Is that broadly divided into effectively Two types. They're non functioning or functioning. Um, and also by side is so So what? The functioning that refers to whether they actively secrete um, any sort of hormone. Um, so the non functioning ones are effectively just growing, and they're not doing a lot. Sometimes they excrete FH your LSH. Um, but usually that they're not doing it and they're just growing, and they then get picked up clinically when they become big enough to cause basically the rest of the acute grand to be compressed. And therefore you have deficits of the other pituitary hormones and or you've got visual field stubbins to the non functioning ones typically present when they're large. Um, either Makharadze name was in larger than a centimeter functioning ones. Are you the ones that are have to be secreted? Um, something they tend to present before they're big enough to give you a visual fields disturbance. Because you the patient presents with, you know, they they've got a gun last year or they've got acromegaly or, you know, they're hypothyroid is the TSH screening tumor, So they, before they get chance to get big enough to cause a visual field defect they present because of their underground disturbance. The slight unusual thing with these is that in a macroadenoma that's causing pituitary hormone deficit, you can get oversecretion of prolactin because the way the prolactin is productive excretion is is controlled for a negative feedback mechanism from the hopes elements. So if you have compression of maturity stalk, you end up having uncontrolled, productive release s so that can sometimes look like it's pretty productive own, but that actually it's just that you've lost that feedback control on your productive on production. Anybody have any burning questions about that? Uh, cool said next cakes another one that is far too common in exams for how common it is in real life. You got 27 year old man to come enough to be an assault with a knife. He's got stuck wounds all over it, or so um on. But he's, you know, he was on, um, quite stable in in the emergency room. Got weakness in the right upper and lower limbs. Um, with absolutely no power from see eights. Time was, um it's got reduced flying touch and vibration sense on the right, but his left side, his frantic vibration. Okay, and pin pricks sensation. So what's the diagnosis here? Yeah, so evil. Got a good, um, sprints. This is Brians accounts and dream, which is that side is incredibly rare in real life, but it serves Teo demonstrating that having your own ISP works in the cord. So it's not a court. It's the opposite to the brain. Being in the middle of the court is the gray matter. The outside is the white matter, whereas in the brain, you've still got your cortex on the outside of your gray matter on white matter on the inside. And you got a sending trucks which are transferring information from the limbs to the brain. And you got descending tracks which transmitting information from the grave to the limbs. Are you their motor and sensory? Um, now, what's confusing is that they have it as as with all everything, almost you have all of the information for the right side of the body going to the left side the brain so that all of the pathways have to cross over at some place. Um, and this is basically there. The diagram that explains it. So here you can see the two primary sense of sensory pathways on. So this is the dorsal column pathway on the spine for lamictal. Half right. So on the left side of this diagram, you can see what happens when you have, um, for example, proprioception or like to touch kind of being stimulated on. So this is the dorsal common bathroom troubles at the back of the doctor called the dorsal past. The cord wishes well, when in control and and the the anatomy of this is the the primary neuron, which has the touch receptor on it has a ganglion, has to allow the sensory century nose in the dorsal roots that's right next to court and that it sends that accents. It's the same year and sends the axon up to the medulla. On the same side, of course, is, um as you've how's your touch receptors and then synapses in the in the medulla, the medial meniscus on. Then that second one, you're on cross seeds, so it decorates up in the medulla to go up to the to the thalamus on thereafter. Cortex. So if you can imagine if you've dropped the cord in half at that point, you lose the, um, proof reception vibration and, like type sensation from the same side of the body. Converse Safety. Look at the right panel. This is now in the spine is Lamictal. So you've got your pain receptors and your temperature is actors. Um, again, you've got this prime in You're on, which has ganglion. So it's it's a nuclear slides in the dorsal root ganglion that then sign ups is on another neuron right there at Spinal called. So it doesn't that that accent doesn't get some depth. The medulla it's there in called at that level. And then that second one, you're on crosses at that level. Sometimes it's a level above or below, but it's at a similar level in the cord that crosses there, and then and then it goes up to the supplements. So again, if you think that now, cutting through the record on the same side as your um, you say on the right side, as you're looking at it is that, um, that court say both Where where the pain receptors a shown and you're you're not gonna have any effect on pain receptors on the same side of the body. You're going to lose the pain receptors from the opposite side of the body. Do you have this split sensory loss? Um, on the the the motor function follows the same pattern as thie Dorsal column because the courts were spying tracks the tract which covers your motor function. Tm blame muscles again. Process in the medulla. I am at the pyramids. Pyramidal tract equals called spinal taps into change the tens cool. So hopefully everyone's after date with that course. Now we've got a couple of similar cases to each other or least related. Um, we've got First of all, this 43 year old lady presented to the emergency department complain of a drooping left eyelid. Got any pain on the headache? Examine her and she's got you got to sit on the left hand side restriction in a deduction elevation on depression of the left arm. But she's got normal ab ductions. If you look a parent, see there she can maybe doctor left eye it can't be. Can't be a d doctor left eye compound. Any other abnormalities you want to? What people think of is causes for this. Okay, so we've got plenty of people saying a third nerve palsy, Um, and then a couple of people saying talk about cabinets, Sinus diagnosis. We'll come back to that raised ICP. Um, fine. Yeah. So this is a third nerve palsy. Um, see, a third nerve controls all of the, um extraocular muscles as then you, um lateral rectus in your superior a week. So your lateral rectus is what allows you to maybe, Doctor I, um so And he also, um, controls Levitra. Probably something that I like you to open your eye here. I live properly, and so it tends causes. Is this concept of surgical? This is Ah, medical third nerve palsy East, which are classically, there's I think there's actually evidence against this, But for the purpose of this, your surgical third nerve palsy is a something is compressing the nerve. Um, give you pay you and they give you pupillary abnormalities because the parasympathetic nose to the people are kept carried with the where is a medical cause of the nerve palsy. So most commonly, something like mononeuritis multiplex due to diabetes will not give you any capillary abnormality, But we'll give you the mask. Muscular loss, muscular. Um, weakness. So this is just a little bit of the anatomy to show you what is, um, happening aspect is also this is the captain. You got your third nerve coming out from the mid brain. Um, and he's troubling right next to the circle. Well, it's right next to the peak. Um um, because you're communicating artery many troubles, as someone mentioned through the cabinets Sinus and then through the superior. Bleak, um, starting into the through the superior have a little bit. And basically anything along that course stays abnormal. Compress it. But the most common cause is probably a peek. Our manual is, um um a giant percent of communicating artery aneurysm can cause direct compression of the nerve without actually bursting, but give you this exact situation. Um, find somebody mentioned kind of Sinus diagnosis, which can give you, um, a promotion of palsy. Third nerve palsy, but usually, along with, um, the with some calls you the other nerves that trouble through the couple of Sinus. So those are, um So it's the oximeter of It's the the truck with a nerve forth and divisions one on two of the 50 on the six know. So the objections. So you do You typically have multiple knows if you're involved if you have got a come Santa stenosis rather than just appeal, and you definitely not got any involvement of six now because she can a beat up the eye, too. Super Abdus is, they have until after rectus muscle area intact. Grace. Then that brings me to this case. So this is, ah, similar lady seven year olds life on smoking. She collapsed a cheapy with drinking right stilet this time, and she's complaining of that kind of non specific visual disturbance. Also, in the last couple of weeks, she's notice of dropping things with a right hand. Got it paying kind of in the are in the shoulder, bit non specific slightly. The historian. She also reports and weight loss of the last components. Um, examined her. She's just 15. Got a slight Tosis of the right eye and the pupils constricted. So it's a small people. Um, Scott got normal visual acuity. Um, It's got normal extraocular movements session. Look around. Completely normally unknown. Start. Ms, um you got, uh, slight weakness in the right upper limb. Um, I'm destructive. Spin around minutes where you just you can't Can't quite make it the mission. I got normal muscle. Welcome. Some weapon. So I think we've got a diagnosis for this. Good. Yes. We're getting lots of corners and lots of pain in case. Excellent. Because so, yeah. So this is a pancreas, Children, because the wholeness syndrome. Um, sorry after it. And what investigations joint as well. Somebody said conduction studies and mg chest X ray ct. Yeah, I think that was being mean. CT chest. Yeah, because cool. So, yes, this is a thank you stream is This is the chest X ray. You could see 100 amount for the pee days. Ah, um atypical lung dreamer, um, on the right hand side. So the pathology here is that you've got this tumor compressing the cervical chain in the sorts of uncles sympathetic chain, as well as the break your black cyst. And so you got this Horner's syndrome and you get weakness down the right on site. Horner's syndrome is because of loss of sympathetic that it turned to the face to get his partial process. So it's due to a different muscle to the toast is that you get a third nerve palsy. So in certain apples you have weakness of your liver to palpatory, which the muscle but Allie's you to open your eye. Um, where is the sympathetic tone is provided to this noble, a muscle superior task, a muscle and that's involved in holding the eye open once it is open, so you wear is in a third Merkel's. You have a very significant Tosis in homeless interest. It's much more mild, have constricted people, and you have an hydrolysis to a lack of sweating. It can be quite difficult to appreciate that, clinically, there are a couple of tests that you can do, Um, but it's really you diagnose it based on the My Assistant Texas. So there's multiple causes of a Horner's syndrome in itself. Also, this is a band or one where you got of the symptoms of lung cancer. Um, but the sympathetic and asked me is really quite complex. Um, so starts in the hypothalamus you've got one year on, which gets sent down the spinal cord to the sign ups, which is that somewhere, anywhere between T 11 and CERTAINTY Woman's. Um, I think, too. And then you have another, um, you're on them three nights and going to a ganglion in the sympathetic chain, which runs alongside the aorta. Um, and they have a third or order in your on, which then troubles with the internal carotid artery. And then the insulin for sound can actually go into the eye. It's basically a lesion at any point along that, uh, kind of leaked. It can give you this Horner's syndrome, but it actually starts in the hypothalamus, which is probably less than an inch away from people one, maybe two inches away from the people that you've got this route to take. There's well over a meat along probably by the end of it on, But it could be you could have a Horner's syndrome. Many of that. Um nope. Sorry. So this should have been with the previous ones. This is just showing you a p common your is, um um compressing the third nerve. So where you got this green area on the left arm panel. This in a MRI scum. Where you felt that bad? Um, cold, Basically. That's an aneurysm. You can see the black line going right next to it is your is your certain if just being compressed by the aneurysm. Fine. So next case you've got 45 year old lady problem. Really clear land lady. She need to be hypertensive. Takes ramipril 5 mg one today. Um, she's a lifelong smoker and start back your history. Um, she presents after her husband called the ambulance. After seven onset headache and collapse, she gets to the e d. Um, she's a GCS 15. So he's disorientated, um, as my left upper with apple in weakness. What? You diagnosed him? What? Had you want to investigate this lady? Yeah. Okay. Okay. So you got a few several on time or just with one or two you intracranial hemorrhage. Take me intracerebrally on once you strike. So this, um, say he's got a headache. Seven onset headache. So, typically, if you've got just a skin extreme, you have weakness, but no headache. Um, because the brain itself doesn't have any, um know sectors. Um, equally. If you have an interest, terrible bleed. You won't typically get a headache. You just get weakness. Um, so the headache is caused by men. Inject it. Um, irritation. Basically. Eso several tender age. This this situation several hours, average insulin until proven otherwise. Um, in an in an actual antique you examine often give you the word thunderclap, but it could also not give you the winter in the crap You need to write two separate times. So several people said investigation CT had to noncontrast ct had to look for keep blood. Basically. So got this scam. So I'm just talking a little bit of this. Um, ask your questions. So we have seen this is the this lady scan. It's a Paxil. Noncontrast CT had, um, taking the correct time. Could anybody I'll give you two minutes. Look at that scan. Tell me. Just write in the chart. What you think that is? What is that showing come into it. Okay, cool. Cool. Yes. We got 20 people saying it's several hemorrhage. Good comes and on. We got one person pumping for em. See a aneurysm. Um, which I agree with you. So? So what I do is if you're in hospice situation, you get You got this I would approach. This is saying Okay, so I've got that says PT had non contrast. Um, on dialysis Mean that it's the correct patient said that correct time. You don't not say yes. You know, um, I'd say so. This is an actual slice through. It's quite low within the cerebrum, so you can see cerebellum. So you got a partly super tend to and starts quietly infratentorial cap on. You can see there's a starship hypodensity indicating keep blood throughout the basal systems. Um, you can see on the right term side, there's a, um the blood is pooling on the right hand side within the Sylvian fissure, Um, and possibly indicating that's the source of the most likely an M. C. A younger person. So you got you can probably get away points for saying that you can see it separates around a hemorrhage. But if you know it, you know, it's so you've got a separate and tremorish on the right hand side, consistent with the right. And then today, on your, um, um you could also say I could see it. This cooling of blood in the fourth ventricle. If you look back there that That's the fourth ventricle. There's also some signs of early heart Catholics. So on the left hand side, you can see that the temporal horn, um of the left lateral ventricle is actually quite prominent. So you can see that there's, uh so that's kind of unusual, given that you can see that the rest of the brain is quite tight. You could have gotten any so kind of arrange the for example of frontal poll. It's unusual to have an expanded, uh, temporal horn that suggested that Probably heard deathless. You had a higher cut. Yeah. So there's several new hemorrhage. Definitely. Next question. Do you want a lumbar puncture? And if so, when? Okay, yeah, we've got a few a few people. Yeah. So we got people correct. 12 hours to get something. Crimea. Others saying only if you don't have blood on the scan on be someone put making very, very valid pump that you got evidence of raised ICP. So would it be safe? Yes. The answer is no. You don't need one. Um, you don't need an hour pee because you only need to get an LP in the context off. Suspected supper after a 10% drop. Motel marriage. If you can't see the blood on the scan, um, you do it 12 hours after your scan. That's right after your, um, onset of the headache. Um, um, you don't as with an l p. You you shouldn't do it if you think there's rays and intracranial pressure unless you There's a few other things that that can, uh, stop you do an LP. But, um, yeah, basically, with that scan, I wouldn't be doing a lumbar puncture. Um, with that consulting, use it for registration. Little bit. Um, but yes, there's certainly no need for a lumbar puncture just for, um, the purpose is off time. Excess. Does this battle over everything Time soon, Like culprit we've mentioned. So it's like you're right. MTA aneurysm. So, um, you just think back to you and after me, you got your cycle with this, um, send it off Is three main arteries three pad on trees. You got your interior cerebral arteries. They come for words on. Then they bend upwards and backwards to go basically between the frontal lobes and serve the medial part of the, um that's he then got your posterior cerebral coming from the splitting of the basilar artery, which go kind of along the tentorium to to say the bottom of the the occipital lobe and the medial part of the practice lobe and then your middle cerebral arteries, which come from your internal carotid. It's which goes straight to the sodium Fisher to supply the lateral parts of the brain. If you got blood like loads of blood in your Sylvian fissure, it's most likely coming from your MCL. Fine. So how? What is your next step in investigating this person? You got a noncontrast CT where you think Yeah, it's probably coming from the right MTA. What's next Know? Some was just asked on the chat had, you know, it's known from trust, so I'll just do that first. So it's not that obvious that it's non contrast on this, but you would expect. See, um, it would be have a different window. So this is very much on a breaking window so that you can see the grandkids of the brain, and you've got this very obvious, very bright white blood. If you've got contrast there, you'd be able to see you early in the front of the problems. You see it and spotted contrast, which is the buzzer artery. And you probably have to see the Sylvian fissure start to be. Mmm. Siheyuan along Sylvian Fissure. And but it's more obvious on some of the CT spit. Yeah, that's the reason why that's not a contest, cook. So what? What's your next step in investigating this lady? Okay, we got one TSA my God on a B C D and secured. Yeah, way. What treats in the raised ICP, someone referred was near surgery. Fine. So yeah. So this is the next step. Once you've got this can is definitely referred to us every but in terms of investigations. Need to find out. Definitely that she's got an aneurysm to need. Some sort of vascular in imaging to an angiogram of some sort. If you're in a d d outside when you swell, if you're in a needy will stop. Probably gonna get a CT angiogram. And and this is where you come. Trust comes in too. So this what CT angiogram looks like on so again, the burning is still very bright, but it's adjusted so that the brain is no dark and you've got contrast and it's time to The contrast is in the arterial phase of the part that happens. And you could see Then we got this very obvious. Very large, right. MTA aneurysm. Right in the same location is where we saw the blood on the previous scan plan. So management shot. Some of you have started to talk about it. I'd be careful about that particular well, enough skin scenario if someone asked you how you gonna investigate and you start talking about referring them to your surgery and, you know, controlling the ICP? Is it different things? And you got some examiners that we'll just pick you up on that and it it's You don't want that, um, equally if you get if you asked if you're asked to invest, how you gonna investigate something and you see you're going to examine their cranial nerves? That's not an investigation. You just be careful about what you say you're gonna do with specific questions. Um, So how you gonna manage them to re talk to, right? You got a TV exactly security way treating the race ICP. So this lady has got Currently she's just confused, too. And she's got a bit of a weakness, which is certainly from the blood on her med strip. On day, um, was mentioned hypertension. It's any other points about managing in several a temperature. Patients get some segment know being corneal. Quit the aneurysm. Yeah, one more thing. Just really important that sorry you had to. So Chantix regulation is really important. But there's 11 more thing. Vitamin 12, every one of these patients. Well, the Z a Fair enough? Yeah. So fluids. And so be in massive problem in these separate look up having average patients so they need to be in in your science center that's given they need their BP control. That caveat with these people that have just had a bleed into the brain, even if they are hypertensive, that's almost certainly reactive to the fact that they've got blood in the head too aggressively. Trying to control the BP is probably not that good. A good night here they so there's two different things things that these people have said is in terms of fluid and sodium. So this SIADH they secrete too much 88 which is probably like a hypotonic irritation thing, so they get. They become hypo know dreaming because they retaining too much water on down this cerebral salt wasting, which is really rare but is fatal, potentially fatal where they actually secrete, um, sodium into their urine basically on. So you be careful about assessing these people basically many, plenty of fluid, and they need their sodium checked probably twice a day for the first couple of days. Um, they're very, very, very susceptible to drop in the sodium. And basically, you shouldn't give dextrose IV teo a separate, not have much patient. That should just get so you mean don't worry about Hartmann's. Just give them normal saving. I'm not keep your multiple on, but that's a calcium channel blocker, the only calcium channel blocker. In fact, it's one of the treatments that's got good evidence in your surgery will stop. Um, the, um about backing from a trial like late nineties 21 days of 60 mg, six times a day of the morphine reduces mortality. Know what? What it What it does is it stops you developing this thing called vasospasm. So the idea is that you got blood, you know, space that it shouldn't be, um, and that causes the after Easter become kind of irritated going to spasm. And that could give you basically stroke like features because you're getting a ski. Me a, um, on this, this is where the BP control comes in again. Because if you drop your BP too much, then that kind of predispose you to having a basis. Dozen managed mentioned on yours and management. Someone was talking about the dimensions on the location of the aneurysm. The other important thing is this lady's got massive hematuria quite large. Him a treatment, um, in a Soviet fisher. So she might want me to clean you out to be purely to get that eight, um, way In which case, you might opt to clip the aneurysm while you doing that. Um, rather than doing a coil, that's, you know, you don't need to worry about any of that tender finals or even unless you're going to become an intervention, your radiologist or a neurosurgeon. So we'll believe that. Um, leave that there. Fine. So now I would imagine you are on half one working your surgery. Um oh, morning. Anybody working your surgery, But you're the point being that your non specialist working your surgery on the woods. This same lady, she's got to do three of admission, Just other. And he was in Korea called in stable. Until now, a confusion is a bit better. She kind of knows Referee, what's going on, but doesn't really know what time it is. That kind of situation. Um nothing stops. She was found on the water and Smalling nurses come up to you in the afternoon and say they're not really happy like this Lady should bit drowsy Spit, you know, not quite sure what this morning do you go and examine her on a GC acids? She's open your eyes pain. She's saying inappropriate words, but he's localizing people's equal on you. So, um no new actualizing urology. So her weakness is exactly the same. Haven't changed. So, first of all, what number do you get for that? GCS. What's the great day? Yeah, you got nine and 87. They want to give me a break down. So give me a GI VM school. Yeah, so? So you got any to be three and five? Fine. So I agree. It's 10. It's 235. So your eyes to pain that that show up for digesting the second. But your eyes open into pain just to go in appropriate words, which is three on your localizing pain, which is by IV um Thank. So what's going on? What? Ah, what you think is happening to this lady to cause her to be minus are Really? Yeah. Dema Okay. Not going to dreamy at you 22 things that I think more likely than any of those that you said so far. And we mentioned about that already Basis doesn't. Yeah, so that's one even more like of them out different ruptured aneurysm. Yeah. Okay. Okay. So this our tractors there again, you know? Good heart, Cath. Listen, is one getting so this lady is has got flood in her head. She's hot air and using coiled. So that's although theoretically could really need it. Unlikely. I shouldn't stable for three days. And she's just got this generalized worsening. Hasn't she's not got Do you have lateralizing urology? She got new weekers to suggest that she got raises. 1000. Um, she's just drying. See, so that is here. Isn't doesn't give you anything to work on is a very generalized so yes, you could have. Now I've got UTI and be delirious, but she's a subarachnoid hemorrhage patient. And the most likely thing is that you've got hard to get this And you saw on the original scan that you had a bit of time to get this There was awfully cope with it for now. So what you gonna do? You gonna get a fresh CT to have a look? And that's what that looks like. So that's found or heart, Cath Lis, Um, you got basically no so cardio and see around the outside. But you got the big ventricles in the middle, and you could see the blood pooling in ventricles on both in the occipital homes of the lateral ventricles. And then the third ventricle there at middle. Fine. So what you gonna do? I'm gonna manage that. Hopefully, if you Enough one, you're gonna call your register and ask them tablets. Scan in, decide what state base of people. But, uh, VP shunt in, ppd. Yeah, right. So Okay. So this this is where you got slightly tricky. I haven't got a good scan to show you here. This lady is probably safe to have an LP. Okay, She's got signs of razor, has he? It's because she got raised it to be because you've got too much CSF in the ventricles about TSF will stop. You can probably all be in the way you work. That is look at a sagittal captive a CT, and look how much spaces around for a month. So you you can probably just drain off 20 mils of CSF from this lady. But yet the other option is to do put median. So I don't know how much experience you got on your surgery, obviously, but you got shunts, which showed your CSF from we're supposed to be in your head to another body compartment most common to the Paris knee. In you got evds external ventricular drains, which remove the CSF directly from your ventricle and put it into a bag next to your head. It's in this case this lady is extending it very much. Be a key Plays with several of hemorrhage put in a shunt in is fraught with problems. The block, they get infected. They just stopped working for no apparent reason. So if you can avoid put in a shunt in someone then you do any VDs first thing to do. Just a little. That's a secretary. Give it a few days to let everything settle down and see if you can eventually get away with no having me. V d. Um, so that's kind of the plan for her. If she had's new limb weakness that I would immediately my top differential would be basis does, um, on no capitalist because this is, you know, by definition of generalized thing. Um, so if he's got a new line weakness essentially stroke right features than that's that's vasospasm. And I do think you're right. Trying to increase of BP, potentially using, um, a troops Um todos, um, maternal. Something just to bring your BP up on dust. Give a bit bit of breath. Better cerebral perfusion pressure. Cool. So that's that generally So we just took a GCS briefly because it's off the everybody names. I'd say it, but it's no amazingly well understood. So this thing about eating up the numbers is a big false um, so if you think, write it, you DCs of 10 can mean very different things. So if you got any to be three and Valium. 10. Which is what this lady Waas She's still localizing. So she's got reasonable brain function to be able to look clients. It's just she's unit rise. Latest there is if you got your eyes open. But, yeah, um, your abnormally flexing that suggests that you got basically no cortical function. That's a very, very different situation. So what I'm saying to you is, basically, try not to at the map. Well, I think there are some example Westchester been where they do open up, which is just nonsense. Um, so you know the numbers. But the important thing is the motor response a sickly This is just a bit. Why so foot in your normal processing what you're doing right now to be able to, um, Bacon. And you need to be able to have you need to have your ears working. Need to have your auditory processing function working. Need to have a plan in motor response related to that. And then send that information from your primary motive cortex dame to you to your gimpy um, your muscles. Yeah, so that emphasize where your localizing I somebody squeezes you on the shoulder and you bring up a hand to push me away. Just a little quite effective cortical processing. So you need a nexus actor, which speaks to your primary sensory cortex that passes information raised to where it came from specifically to your motor planning areas on the new coordinated movement from a different possibility to get to that part of the body and for your withdrawing is much less complex. You're just pulling yourself away as best you can. Um, so you know where it is, but you can't have gotten moved. No significant motor planning to have to coordinate a response. You're flexing you just basically, you've got there's some you know you could. You recognize there's no deception, you know, pay you and you're just doing something to try and get rid of it. But you've not got any your cortex and function. To be able to locate that properly on an extensive posturing is essentially a worst version of that where that doesn't give us the medulla rather than the problems. So you've again you've got no, you got even less spring voting on and one off. Steve not got any great infection. It'll being brought of. The GCS is in research. Um, as in with the numbers out of that is in research. And this shows you that was from a recent trial in traumatic brain injury, where your odds of deaths as in how likely you are to die based on your GTs added up at admission, is essentially linear on or locally. So the lower your docs, the worse you are, I think wrote down. Just wants to say something. At this point, we don't have much left. Price. Thank you. Off. Um, sorry. Sorry to interrupt. Just a very quick announcement. I'm just gonna post a Google form on the chat. This's just to get some feedback on the session on the Syrian, the collaboration itself. So we will really, really appreciate it. If you fill this out, will really help us improve our future sessions and pull the upcoming things that we have planned. Thank you very much. Back to Europe. Just shares Coke. And so next case. So you got such drive. Your gentleman. He's a builder. Um, quiet. Little about being on it for a few years. Just put it down to this job, but he's otherwise well and doesn't doesn't take any regular medication, UM, presents with acute, worsening back pain and bilateral leg pain and some difficulty passing urine. So the sleep, you know, says he's going to the bathroom. Feels like he needs to go. Struggling to start triples. Event comes back and then had me scared to lose again 10 minutes later, she's able to pass urine, but it's kind of tricky, she say. Examine him. Got normally no tone. He's got several parasthesia. Yeah, you still do. Tries to urinate, comes back. You do a post void bladder scan. About 250 mills in his bladder. So what's the diet? It's What's the red flag diagnosis here? Yeah, cool. You know, that's very cool. Apartment yet. Good. She needs MMR. We've got one person saying whole spine MRI. Specifically, we've got another person saying am a member cycle spine. My question here is Come trust or no contrast? Yeah, Non contrast. Got a couple of non compress. Good. So yeah, non contrast. MRI. Let me take a spine unless they have. So you only need to scan the lumbosacral spine unless they have apple in features off, so you can have apple in features from a number um, spine problem on always. They got a promoting your onfi Justin Allex. I got up going planters or no increased tone or brisk reflexes that would suggest that it's a problem that's higher up than the lumber spine. Or come back to that. But yes, he only really discuss. Scan the lumbosacral spine. This is what it looks like. So the left panel It's just to show you the quarter Greiner. So you've got your cord ending as the Conus l 12 and adults and coming off from that Ah, the, um, nerve root. So the peripheral nerves iii, they have low amount in your arms. In them, you should get a flaccid, um, weakness with reduced, um, reflexes on down on the right. There you can see an axe, your cut of a noncontrast teacher way through the mask on and the good thing about t two weighted them are in this situation is that the water is bright To see that one too, right in the middle of the canal looks spinal canal is your CSF. On the black dots are the nerve roots. They have been cutting half, you know, by the standard, um, going down, so you can see that's a nice happy on court requiring, basically compared to this one. So on the left here, you got a similar cat, probably a bit higher up. But you see that the white CSF signal in the middle is much smaller. You can't quite work out from that cut. Actually, what the problem is, if you look a sagittal on the right hand side, Is this a midline sagittal? Remember, you've got someone right down the middle is a this basically you can't see any CSF at that level where the where there's there's a disc book act. So that's what's the l 34? Because see the nice TSF above and below. Um, with on the nerve roots you can see as well, so do that. You kind of or my memory of being talked about called a quieter in med school was it's kind of you think of it as an all or nothing thing. So we got, you know, people that have back pain and his people that have, um your attention, no anal tone bound or cord. A gyne on really is this spectrum, and some people do go straight from okay of its act Care, no problem about bladder, about straight to your attention. But most of them go through this kind of in between stage. It's the people in the in between states that you can really do something about that You can make better with an operation. Um, so it's kind of these four stages of the the impending people don't have any bladder or bowel issues are in complete on Got a quite a way they have bladder or bowel features. Um, so, you know, make you the sample parasthesia here or there, not, you know, that they're, um he hasn't hesitancy, but the post void bladder scan is normal. Um, I, less than 100 50 miles, is usually what's quoted as a normal amount of urine in your bladder after you immediately after going to the toilet. They progress to the with retention people, which the same with the abnormal post void bladder scan. And they make my have sensation or not about stage people that become complete, where they've got at least 48 hours of no sensation of having urinary retention on got no anal tone that's basically reversible. It basically irreversible. So probably get an operation anyway, bent that there's no major urgency to do that because all of those now is gonna be dead. So these people in the red box of people that need to be decompressed, you know, overnight to block the morning, put them in a in an ambulance. If they even have the West to get cut it just a note on examining people's limbs for sensation. I would stick by the Asian chart. If you've not seen this before, just such a just final injury, you'll find it. It's in the public domain, and it tells you everything you need to know about how the dermatomes and my tens work in particular germ a time. So you have realized, I know that each textbook has a different, slightly different version of where the damn Italians cross. If you look at and they said, you've got these little dots, that's a key century points on them. Um, so these are places that are as as far as convenient, guaranteed to be correct for that dermatitis. So in terms of examine the apple in you got lateral malleolus for C five, C six, middle finger, C seven. Um, see ages. The little finger on T one is the medium I Liotta's no point touching anywhere out some hands to do to get your damn times. Um, you know, the only thing that you do you think is it you need into a different triptan carpal tunnel on a C six. Ridiculous e. Then you need to think about the ring finger where you should if you got median nerve palsy, your ring finger should be have spring in the lateral half. Um, vin, you should be. And loss of sensation of me you have won't. But outside of that, don't Don't be trying to touch half again for, um it could be C five C six, for example, on the same the lex. So just use this to work out the places that you're gonna touch people. Teo, examine the dermatomes sign. Next case It was two left, but that quick. So we got 78. Your Lady Scott Early stage Alzheimer's disease. So she's, you know, a little bit confused of the best times when she's living at home with her husband. There is falling. We're currently she takes aspirin. Some programs 75 mg. Once a day. Um, because she had an MRI a few years ago. Family, Bring it to the GP. Um, because they've noticed it to be Keep be more confused the last four or five days. Today she's bit drowsy. Examine her. You can't see any evidence of injury on ahead door or anywhere else. Um, she's not per axial. She's not. She's got normal urine dip chest sounds. Okay, so you don't think she in fact, it, um, DCF's eyes to voice confused days. So be three. Be 5, 10, 6 or 13. Um, yeah. Examiners got mild left Epling weekers um and you got pronated drift on the left. So you are such a pretty it performs. I close your eyes on a, um left hand driftin words. So what? What people thinking intend to differentials? What diagnosis is case? We got straight use of girls and yet a chronic subdural. So yeah, so that corn it's a goal is exactly what I would be thinking. However, if your GP and I have done a GP job, I think you'd still be thinking the most like because of ah, um, increased confusion in someone with Alzheimer's disease is probably delirium secretary to infection. That with the history of falls and taking aspirin as a matter platelet, you got to think about it's chronic subdural. Thank. So this is what scan looks like. Um, so I'll just talk to us. This is an actual noncontrast CT scan. Um, seems to correct patient is he on the right side, there's a large extraaxial hypodensity causing compression on the on the left panel. You can see this, um, basement of the right after ventricle on on the right to panel you could see was actually midline shift. Um, by. So, can anyone tell me why this is just the chronicity jokingly tell me why this is a subdural collection rather than extradural collection. Give me a description on why you see that. Yeah. Good. So we've got someone saying conclave on day, Someone saying that extra goal is bound by the siege is exactly so the, you know, see what extra we would look like. And obviously, in this situation in the, um, history is completely wrong for it to be an extra that typically with the actual you have to see a step in the bones or, uh um, skull fracture and Yes, the juror is tank is obviously attached to the school all way around, but particularly at the suitors is really tightly attack. So is you got this crescent shaped where the, um the blood is restricted inside the Julia by the by the spell it to drives. Um, fine. Not basically always say about that. The the other thing to say is that there's this kind of perception around your surgery. Your surgeons, they don't take anybody, there isn't him impeccably fit. Um, you know, to be able to have it happen operation, And that is true about lots of things. But for the chronic six year old people, it's not true. You could take really quite frail people. Um, because you could do the operation, which is just to bear holes, the one at the front of the back wash wash all that done cat, and you do the operation under local anesthetic, if you need to. So, you know, if you did that in this situation, they would wake up less abused without weakest to, um so the chronic subdural patients can. You know, this is all you can be too frail for it, but there's a lot more of patients that could be taken them for other things. Um, let's see anything without finally last but not least you please. Here. We've got the last case. 72 year old man who is going to be hypertensive has skin it heart disease on atrial fibrilation. Um, he comes to the e d with two hours off the type, which should be right. Decided weakness. Um, I see great to in all of his epilepsy. Um, Andi, Great four is a level in, is stronger and is low. It is like when he's in his arm. Facial droop. But he's got a phase here. Differentials. Got one person saying stroke, and you wouldn't want to be more specific. Got taxi. Fine. Younger anatomical area close. We've got a couple of Asians have an anterior. Several arteries on two MCPs. Three mg. Yeah. So, uh so So to me, that's a M c a, um, kind of sitting dream. So they've got It's worse in the arms than the let's. Someone did mention central court syndrome. He's got you remember, he's got facial drooping. A phase? Yes. So is that this stuff is coming from the brain rather than the spinal cord. Um, yeah. So, as I said, this is you should say right so we can see you got a trace. Easier. So that locates you immediately to the lateral part of the brain of the on the dominant hemisphere, which is the lack side in 95% people. So yet so I would say is the less can see a stroke took, Um, again, this is just showing you the So we'll we'll especially seeing already on. But that's what it looks like on the scan. So do you want to briefly chops? You know, saying the chat, What we're seeing on the scanner? Yeah, yeah, yeah. Okay. So yes. So people saying about midline shift? Absolutely. Um, someone said it's hemorrhagic, which I disagree with. Obviously you have chronic subdural was in the last place. You got this thing that's called a hematoma, which is dark, but it's only dark because that blood is really quick. Hide? Is it worth it? So acute blood is always bright on CT. Um, on. But he's had this for so say two hours. Yeah, two hours. That's not long enough for you. Blood to go dark on CT scan. So this is this This, um this is a scheming, basically, um So no sense of someone said ischemia on background increments of general suits and know so he doesn't have a cramp schedule. It all this is just a ski me a So this is the whole territory of the M c A. So if you just and put, uh um clock that cross off the whole of your left on ta, your brain will look like this with the midline shift that you say you speak because you've got assumes. You call those cells dying, they start lysing. And then you got loans of edema into there, you got a little fluid going into the brain that's dying. Um, Andi, as a result, that swells. And it's such a large area because the MTA serve such a large forth to be breaking that that then in itself, causes like shit starts behaving like a tumor or something in June or something. But it's literally just stevia. Yeah, and so this is No, no, this isn't just a stroke. This is something noticed. Malignant. See, a, um, syndrome. So, as I said, this is essentially behaving like a tumor or are expanding hematoma. And so this becomes a new surgical problem rather than just, you know, stumble, eyes thumb and tend to stroke unit because they've got rate. If this guy's got raised ICP two today for the for these people babied something called a heavy cream yet to me decompressive hemicraniectomy I take all of the bone off, um, on that side of the of the head and I going to swell rather than being in this close box on. But I'm sure you won't know about the mineral Kelly doctrine is, you know, having too many things in your head make you die. Basically. So So that's just something to be aware off off is malignant MCAT Andrew. Um um, basically, people that have a stroke and then drop these? Yes, some to think like, um, whether they've got raised a CPA and they need your surgery on now is everything. Um, so hopefully that was useful. Um, I think the things that I would, um, be trying be aware off files brand Scott's and going super coverage, um, quarterfinal in particular your third nerve, cause he's on your whole nursing room on as a non specialist who is then working in E D. Or may you be aware of highschool manage a separate like average patient in the first hour. So particularly fluid Sodium channels easier? Um, yeah, for that use for guys, that was That was really it's when the case run through was a bit of a switch around with, um, what we usually do. So it was really, really nice to see um, just a quick one. Guys, if you could just fill in, uh