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Uh, no, she don't want the time to, uh, you know, uh just really, really, really nice something. I'm okay. I'm just really nice and I never want enough to say that. It's crazy how old that supported that. Right? It's crazy. Yeah, I was joking. Yeah, we got your Yeah. Yeah. Uh okay. Thanks for thanks. Uh All right, of course. Sorry, I think happy. Uh uh, no, no, I don't know. You know what I'm gonna school enough. I like nature, uh, music. Uh, yeah. Uh give them better. Uh, yeah. Yeah, my friend, you're not the biggest fan but, uh, thank you. Uh Simple start. Okay, thank you. Okay. Yeah, I could sit in your whole second, sat down. You have a good, you know, you can hear me. Hi. Oh, wow. Uh, it's okay. It's okay. I can honestly, I'll do it later then when things start up, I'm gonna marry you man. Literally the salvation. Uh, okay. Let's get started. Is it good to keep things good? See, it's just beers. Crazy nose acts very good. Right. Okay. All right. Let's get started. Um, we've got a lot to cover today, by the way. Oh, also. Hello, everyone. I hope you're well. All done doing your skis. Have you had heard back yet? Next week? I heard a rumor that everyone did really well, actually, like, um, I spoke to Doug coalfields and, uh, she still part med school. Uh, anyway. Um, yeah, we've got a lot to cover, I think we're covering like, two whole cases this week because we can and the first cases quite sure. And we might just chuck them together. Um, you've got your progress test with them extra questions coming up, right? Yeah. Okay. So today what we're going to cover? Oh, by the way, these guys past finals to the doctors now? Okay. Okay. Cool. So, limb problems we've already covered half of this for so just be a quick reminder, progress focus. So progress test is just pure recall. National ID. Super weird. People do really well at this test. So be as weird as you can today and you'll do well, I promise. Okay. Um, there is a sign up form because everything's on meddling that and that's how we're gonna be doing things going into this year and next year. Hopefully. So, none of that disclaimer. We have a great relationship with university really, really intimate and um have to meet myself now. Okay. That's fine. There's no admin. That's good. All that stuff you guys used to be really tired, right? It's been a long year. You got a PAP now, is it? Yeah. So zero motivation study, I'm guessing. Right. Yeah. If you cannot tell your supervisors you've got exams and hopefully that will help a little bit or they'll use it against your Nikki work more. So, we'll see. Okay. Yeah, we're covering a lot of stuff. Station. The first thing I'm gonna cover is peripheral vascular disease. Okay. Uh, does anyone know what that is or another name for it? Would you try to stand up? I just sit behind this thing and it becomes a little day because these guys cannot see me. You don't need to see you just break it off. Okay. I'm going to use. Can you see at the back by the way? Not, not that I'm asking you to move but can you see I was a hint feed to me for dinner. Do you see the custody moving and stuff? Is it? Yeah, you can. Okay. Fine. Cool. Anyone know anything about peripheral arterial peripheral disease? That's another name. Pros one snippet to get started and wound up. Anything is full back to normal. It's good to be back. Yeah. Ok. Just think of it like this. Yeah, I'd like to thank you. I'd like to have this condition to the heart. You make comparisons to the heart and similar disease of the heart will be very easy understanding. Blood vessels are in the heart, coronary arteries, same thing. Every blood vessel in the body is susceptible. So that dumb process atherosclerosis. Remember the whole information, phone cells, macrophages, all that stuff that come in packs fill up. Ok. The same way that can happen in the coronary arteries that can happen in any artery in the body. Specifically here. This case, peripheral artery is fine. Um, also you can get close that they form somewhere else in the body. What's it called? When a clot moves? Confidence, shelter one o'clock, huh? Embolize is that it becomes an embolus. Very good. So when a thrombus, a clot moves, breaks off for whatever reason it embolize is and that can happen, it can embolize and block an artery in the rest of the body. Okay. So many reasons many causes this or biophysics is whatever in the bin. Forget it. All the point is ischemia in fox, same thing in the heart. It causes ischemia and you die their muscles in the body that need blood. Those muscles will die. Same concept. Use it as an analogy. It'll help you a lot. Okay. And it's the same risk factors, old male smoking. Um, that always says cholesterol, uh all that stuff, okay. You don't need to focus on histories now because you've done that stuff until next year. But it's the same thing. Imagine that was a coronary artery. Same kind of picture. Just imagine it in the leg, peripheral arterial disease disease typically affects the descending aorta. The common idea, ax, the split of the eye drops, the femorals, the proper thiel's and down to the lower feet. Okay, you can get it in the arms, but it's a far less common presentation focused as a leg thing. Okay. Think of it as um and in fact of the leg muscles now when you get an in fact, or ischemia in the heart muscle, what symptom does it cause? Okay, I'm Gina. So, is it not a fair extrapolation to draw that to here where you get angina of the leg muscles? That's a fair assumption to make. So that's what this whole disease is. Angina which in Latin means pain but not of the heart of every other muscle that is affected by crappy blood vessels. Understood. Just think of it is like that. Angina, not pectoris, angina, leg leg, Legace, whatever uh what we call Angina Legace, we call it quadication. Never say Angina Legace ever. Okay. Also we've done your skis. Whoever said intermittent cortication. We've no, that's not a disease, right? What is it? You sit up? Mm So intimate quadication is a presentation like and like um chest pain is a presentation. The disease is angina. The disease here is peripheral arterial disease. Okay. I know you don't. Have you done your rescue? So if you've made that mistake, you've made it. But now you're never gonna make it again. Okay. I know fifties that made that mistake. So don't worry about it. Ok. Claudications just means Angina. So all of that text rubbish there is gonna say Angina. Of the leg of the muscles supplied by a crappy artery. That's what it is. Okay. Here's a very niche condition. I want to be that in your own time. It's when the specific atherosclerosis of the common I jacks or abdominal. Yeah. Okay. Fine. They go and it causes a set of symptoms. That's all so, really rare. But if you see bomb pain, erectile dysfunction because erections are a vascular process and decreased pulses. It's a vascular oration. Just remember that if you see that in a male presenting your progress test, think it's vascular because a they're not gonna throw in. Um Yeah, they're not going to throw in the fourth year stuff in you. It's gonna be a vascular problem. Okay. Any questions so far, I've always forgot, always ask questions, days, any questions at any point, anything I've said whatever, correct me everything. No. Okay, fine. This is a way to classify someone symptoms. I've never seen it been used. I've never even seen it in a question. It's just theory. Fontaine classification. I don't know, I've never seen it in you before. I don't think these guys have ever seen a hydra in practice. Okay. I mentioned treatment here. Ignore this bit because I say a lot clearer later on. Much clearer. So don't get confused by this little bit here. I'll tell you something though. The most important part of treatment isn't to throw them under a scalpel and make the blood vessels for them and bypass this broken vessel to know the main point of operating. I'm sorry. The main point of treatment is lifestyle modification, not just with this, but with exercise, they have the ability to do angiogenesis, meaning they can create their own collateral blood supply through exercise. The human body is amazing. Veg f vascular endothelial growth factor. These things huge amounts that are released during exercise and stress. They can develop their own new arteries when that fails. When secondary prevention medication fails, when symptoms persist, then we operate and we put new arteries and news veins and arteries and stuff like that. Any questions so far, I'm gonna repeat this in a few minutes anymore. Okay. Fine. Does everyone? No one A BP I is, you should be able to know what this is and be able to not explain but um interpret data on this as well in an exam. It's in the name and the order of the name is the order of how you calculate him ankle. This thing here, break your BP, index, your heart pumps up blood's insisted at 100 and 20 millimeters millimeters of mercury that that much pressure to solid. There is no reason why that BP should be different in your foot as to your arm because it's the cells in your tone, you the same BP that cells in your brain and your fingertips needs, right. If there is a disparity between that BP problem in claudications and this condition, the ankle, BP will always be lower. So if you have a small number, so a ankle small number, then big number of a ratio brachial. So let's say this is 1 20 up here and 90 down here, it's going to be less than one that ratio by the maths, right. So the smaller the ratio just work at the work, the math out, Look at the name ankle then brachial, the worst the patient's doing okay. Does anyone know what the normal acceptable range of A BP I is? So BP difference between here and your ankle? I said that I did hint at it though. I said there should be no difference if there's no difference, what would the ratio be by maths one? So it should be about one. There is tolerance 1 to 1.2. That's fine. Cool. We investigate and you can't remember this less than 0.9. So if your example, if your BP in your arm is 100 and your ankle, BP is 90 that's a 0.9 A BP. I okay. Anything below that refer them to Baskin. Okay. Cool course. Notes how there is a gap in between 0.9 to 1 and we have some mediums that we're okay with them. Okay? Cool. You can get a D P I S that are quite high like 1.3 that isn't caused by atherosclerosis. It's caused by, remember, I don't know if you guys remember 1st, 2nd year where blood vessels were described as having um like what's it called? Okay, very recoil impulse style. So there's like rebound, like three rebounds and a healthy blood vessel. Then as you get older, it becomes two rebounds and then if you get really crappy vessels, it becomes one rebound, then you can't even hear it at that. Right. If your arteries become very stiff, not filled with atherosclerosis, but stiff and calcified, it can increase the BP in your foot. So the ratio would be gracing one calcification and diabetes cause a greater than 1.2 BP. A PPI okay calcification. Diabetes. Fine. All very confusing, really clean and simple. Okay, same thing. I just said racing 1.2 stiff calcified arteries increased BP in the foot compared to the arm which doesn't make sense normal. 1 to 1.2, no 0.9 to 1. Okay. One to the patient yearly doesn't leave them in the NHS view pole of patients that never get seen properly right? Until they get really ill. And then something happens okay. Less than 10.9, that's called peripheral arterial disease. Less than 0.5, it's called severe. And you should know this less than 0.3 for more than two weeks, is known as critical limb ischemia. I'm going to present two times to you. Now, I want you to be prepared to take them. There is critical in ischemia and acute limb ischemia. Both are very different. Okay. Acute is short term, even the critical sounds more sinister. Critical means more long term through two weeks. And it's this thing. Okay. Happy. Any questions. This side is the same as the last side. It's just much clearer. Okay. So see, I, whenever I see I it means contraindicated, I'm gonna, Georgia is going to cover something later and I'm gonna cover something as well. Something called venous insufficiency. We're talking about arteries now, problems if the veins are messed up and you know, you get swelling, their, their legs balloon up really big and stuff, the way you treat it, the first line main treatment is to put stockings and then really tight stockings to force the food back in. Tell me if you're putting really tight pressure and they've got a BP. I have less than 0.4. What you gonna do two or three is by accident, you're gonna compress, those are feedbacks. And so you're gonna worsen, even though you're trying to treat venous problems, you're gonna worsen any arterial problems. So one test is going to come play through again just to prepare you again. One test that will come up whenever you're offering a stocking to someone with a venous insufficiency, you have to do an A DPI to check that their arteries are still intact and holding pressure. I know that was a side track But do you have any questions about that? I can explain it again. No worries. Okay. Cool waste of time this test. They mentioned it. It's in your ski booklet, whatever from back in the day as in a few weeks ago. But yeah, knee pure waste of time. Never done in practice. I wouldn't even be a niche medical student to flex this. I think the vascular surgeon will spit in your face if you need this. Like they'll be so upset that why you're trying to flex. However burgers test is different to Berger's Disease or I don't say burgers disease is that word thromboangiitis obvious around whatever it is. A vasculitis. Do not get it mixed up. How are we gonna recognize this condition? Middle eastern smoking male who gets peripheral arterial disease? Basically, those are the things. So me if I start smoking, okay? Cool. What are some signs and symptoms of peripheral arterial disease? You guys go. It's nice. Wow. She's listening something else. Some of that has got really, really bad. Mhm Brothers had ulcers. Anything else? I'll drop something? Six peas. Save them if you don't. If the arteries are messed up, what can you not feel? You can't feel your there? Posters, posters. What supplies nerves, blood vessels. So what they're gonna feel if their nerves are dying, they're gonna feel nothing or parasthesia and then, then paralysis. Do you think? What, what makes your, your, your foot warm is a the air. Where's the blood? It's the blood. So, what would it feel the foot if there's no blood in it? Harish in the cold. Uh, we're getting okay. So a is very painful. That thing I wrote in brackets, hanging foot off bed at night. What does that mean? They'll have such bad symptoms when they're lying down in bed, they'll have to hang their foot off the bed just to make some blood flow go down. Very MCQ. We kind of thing. Not real life. No patient's actually one slow healing wounds. There's not enough blood houses are both said that discolorations. Well, we're gonna come to six P S in a second. So there's specific discoloration that they get. I think they get paling like atrophy and launched or whatever it's called, they get hair loss as well and skin changes. I'm not sure. Oh, there you go for vacation. Amazing Magnet Cool Bristol channels. I don't know if that's the thing. You guys need to be able to identify the difference between different pulse is what to what are two or three main types of ulcers that we we really see in medicine, arterial and Venus. And there's also a neurogenic as well. Let's focus on those two an arterial ulcer. We've covered this before. But just remember again, there's some key differences to always remember because it can company question and arterial ulcer is always more distal meaning further away from the central body. It is punched out like this, like someone just gone and got a hole punch and it has got clear defined edges. As you can see, I can see the borders are well delineated and it's often on the tubes or on the start, it is a venous ulcer is more proximal close is the body bigger wider um, stuffy edges, meaning unclear edges like uh the difference between the or is, it also is not ulcer is wet, it's not clear and they probably have swelling and stuff like that. Happy. Okay. You should be able to identify that. What's your ulcers punched out? Circular? Oh, wow, amazing, cool. Uh These are skin changes, fine uh protocol. This is treatment for arterial ulcers. Meaning what all that says there's no treatment. Just wanna make sure it's clean and looked after basically. Okay. Fine. Now we're on to something important. This was general peripheral arterial disease. What happens if an embolus all of a sudden moves and cross the whole property. Last week, the whole femoral artery, the whole dorsalis pedis. What a garden club? This clogs it. What do you do then? Okay? Or if the the arthrosclerosis just blocks in one go to uh no more. This is acute limb ischemia. The signs of acute um ischemia. I should have mentioned six P S then I should have mentioned it there. This is the six piece bit, okay. Pulseless because there's no bug going then pain. Okay. Hail that word. Means, I think very, very cold paresthesia and then paralysis, there's generally a timeframe to deal with these patient. Does anyone in the timeframe? Roughly timeframe? It's about this. So the first four hours you can treat that if they're parasthesia is treatable. But once you hit paralysis, which happens about six hours, it's kind of hit and miss and it's this risk of gangrene. Okay. Uh That's literally all that says the same thing. I just, I just blurted out okay. The treatment is if there is a clot there, remove them literally go in. Think about the heart. What happens when they have a heart attack due to a stemi PCI, right? Think of this as a PCI but for but these blood vessels on the heart go in vascular surgeon, retrieve them, get that clot out, restore blood Shane. Any questions acute um ischemia. Okay. This bit is telling you the difference between acute and critical in the scheme, critical. It's a longer term A B B P I of less than 3.3 and they have symptoms. Basically the point is it's not acute, they don't have these symptoms there. That's the key thing. This needs urgent referral. This needs the same day. Get them in the hospital now or they'll lose it in. This needs like a two week wait, almost okay. Happy, fine. Does anyone know the long term treatment of peripheral arterial disease? Not acute limb ischemia? We said, what was it? Go in and remove the clock if someone has a PPI 0.5 point 4.35, whatever. How are you going to treat them long term? Um, no, no, we don't amputate. No. No. Yeah. Come on, give them a chance. You're gonna be one of them said, designer anything. Mhm. Statin. So, secondary prevention. That's the bad thing. Remember the first thing I said was let them create their own blood vessels. You need to have a dedicated supervised exercise program. 150 minutes a week of dedicated exercise. Okay. Very important. Fine. Then you go into your antiplatelets guidelines. Stage Klopp second line. If they can't tolerate clock for any reason. Aspirin and manage their secondary prevention. Generally statins ace inhibitors if they've got BP, smoking anything happy, okay. If there is no improvement with all of these, do a bypass surgery, not a coronary angio bypass, a cabbage. No, a bypass of the blood vessels in the legs. People make this mistake, the legs have blood vessels. You can bypass them with the same vessels that you'd use to bypass the heart saphenous veins. Same thing. There are other ones but the staffing is short and great. These are the main themes. Okay. Uh Angioplasty, all that means go in and pop it open. Okay. Any questions? That's very, very 4th, 5th line. Don't worry about that drug. Okay. Huge side effects. Don't worry about it. Okay. This is I'm gonna skip over this side. This is just for you to memorize the progress. This use up all the secondary prevention for this cardiovascular diseases you need to know. So that stroke, heart attacks and uh peripheral arterial disease. We were looking at the bottom tonight here. Happy. Okay, cool. Um So this is the same thing that we've been discussing before. Remember how I said it can happen to any blood vessel. Why does it happen to their leg? Only? It doesn't problems if it happens to the karate's problem, okay. If it breaks off, they can get stroke, whatever, not good. So we call this carotid stenosis. Um And generally, I think it's more than 70%. If it's still knows, you have to operate. I think if it's more than 50 with symptoms, then you operate as well. Read that one over if you can. Okay, parroted stenosis. The treatment is called an endarectomy, which means I've seen one vascular surgeons. They might be annoying, but so talented, so, so talented, I've seen them remove them like they literally cut open the karate kid, remove the entire entire layer of the that carotid artery and do micro stitches with like 0.2 Prolene. And it's the most intricate thing I've seen. It's just a shame that they're so insufferable as human beings that uh I'm gonna get kicked out. You need to shut up. Oh, yeah, it is insufficiency. Okay. I love ask your service now, with our arteries. Yeah. So we're moving from the arteries don't mix up the tube. We're working with the veins now. Okay. The return venous insufficiency causes a load of symptoms. The main thing being edema and swelling. Remember, arteries, they have to go into capillaries and they release in particular a lot of the things yesterday. Mistake. You kill me. Go on. Yeah. Yeah, I know what you mean. There's some questions, uh, questions about this. Yeah. Yeah. The they say if there are symptoms on one side, so let's say they get a left sided or is it Boris? No, it's um it's really weird but like one of the main symptoms is like you cirrhosis fugax where like they lose eyesight for like a few minutes, right? Because there's a blood vessel clots that, that uh flies away, embolize is from the carotid stenosis. They said if it happens on the left side, you have to investigate the right side just in case something like that. I think that's what the guidelines say. No, I don't understand that. I know what you mean. There's, there was a question about it. I got it wrong. It happened in our progress as well. Yeah. Read that out. There is a question. It might be um you know, the progress questions on one that info, that is the past progress questions. I think it's that you guys should all rinse those by the way, three or four times because they repeat questions, you know, what the questions I'm talking about. One made info. Yeah, we will know them. Right. Ok, cool. I'm sorry, Mohammed. I couldn't get the uh, sorry some honey. I wish I could anyway, back to the veins, venous insufficiency, arteries into capillary beds. If there's an inability to return the blood from the capillaries up back to the central circulation, venous insufficiency. Okay. The main thing is all that tissue fluid is not returning back into the veins, oedem. That is the main thing. They also get skin changes, venous ulcers. We're gonna look at everything like that is going to show you that. Okay. What all these words are? Ok. Full cool. This is explaining what each wide means. I'm just gonna show you pictures because that's easier to understand. Don't really care. Okay. Cool. Be happy to look at all of these and be able to know what they are or no, the words that the words that are being used to describe them. Be able to understand what it's associated with hemosiderin staining. That's because of blood pooling. I think the blood dies and it breaks down into hemosiderin and stains. Um, the skin tissue venous eczema. I think all of the leaky because all that tissue field is leaking out of the skin as well. The skin becomes very irritated and exematous. So they want to itch it off. Not nice. I don't actually know actually blanches but it's no, uh um, we've all seen patient's like this. I know we have, we've every we've seen old people with this kind of like inverse champagne bottle. That's what it's called thin and very fat and wide. This is a venous ulcer. Remember the arterial ulcer was on the toe. Look at how far up this is proximal wide. I can't really tell that. Well, the boundaries. So this is very typical venous ulcer wide, not punched out shallow wet, slopped edge, Okay, fine. The management, all this is going to say by the way, all of that texture say give stockings. What is the stocking, tight compression around the leg? What was the main contraindications to venous stockings? If they have a very low A PPI of Destin 0.4, you cannot give venous stockings because it's going to compress the arteries that are already rubbish anymore even though this is a venous disease. Okay. Fine. Uh Thank you go. Just done. Let's we're going to try and stand up the same, right? Somehow the DVT. No good. Um They don't know the fly out blotting. There are three things that contribute to closing burke house someone. So some eight. Yeah, Vodka's Triad, which has three things which is described by these three sections. So we have homeostasis. So being a mobile um then we have pro thrombotic conditions. So cancer, pregnancy, blood conditions, and we have hemostasis, know endothelial tissue damage and such trauma, hypertension infections. Okay. That's what counts. Um So DVT, there's a clot in the deep veins, which is mainly going to be in the legs. Um, especially as future if one's, um, it's one of those things you don't want to see as long as you want to prevent. Okay. Um, so almost all the patients are going to be in hospital wards, wherever, really important to think about. Prophylaxis. Don't know what medications we use for DVT prophylaxis. I know it is. There's an injection heparin. So yeah, low molecular weight heparin is the most common one and then some medication sports. So uh we had a Ducks. Yeah, got any examples of ducks expand and Rivaroxaban. Perfect. Um So yeah, we always want to think about prophylaxis and put on stockings as well. Um, signs and symptoms far away what symptoms someone gonna have with the DVT. Yeah. So swollen leg. Anything else? Second anyone pain? Yes, red hot swollen calf is the main thing that we start off with. Then you're gonna have pain as well and get a Dema um is it gonna be unilateral or bilateral unilateral? Perfect. Um So he said red hot tender, get fever, get edema. You're just gonna have a difference between the size. So you said it's probably gonna be unilateral. Um And the size difference which is in the scoring criteria as well is one cast can be more than three centimeters. Um Why it converts the other one? Um uh There's a sign called moments. I'll be honest, I didn't even know this before ever. The slides, but I'd say don't ignore it. Uh, risk factors, risk factors are plotting in general. What happened? Uh, me, yeah. Yeah. Fish, pregnant barcos veins is a bit more of a complication because of your pregnancy. So, we've got pregnancy. Mhm. So again, uh, contraceptive, sorry. Yes. Agreed. Um, got trauma as well. Uh, recent surgery because that's the mobility. So let me just again, think about the workhouse triads. There's just a few things in each category. Okay. Um Previous DVT S varicose veins, cancer, obesity from ophelia as well. So that can be loads of conditions that are both robotic and the contraceptive. Any questions so far? Okay. Um That's a nice picture. Um So um what the differentials of DVTs in general? There's 11 main differential trauma. Yes, there's an infectious condition as well, which is really common cellulitis. Okay. Um But again, if it's bilateral, then you can exclude both. The DVT is probably gonna be unlikely until your life is going to be very unlikely as well. We had a Baker cyst. Okay. That's all right. It's more of an M S K thing, but essentially it's a fluid cyst that comes behind the knee. Um But again, you can get a bit of a red hot swollen like um we get a photo there. That's, that's a Baker cyst there. Cellulitis is the first one. Um How do we diagnose the DVT? We have a scoring criteria for DVTs. What's that called? Well, school, perfect. Okay. And do we remember what score if it's above? What score do we think it's probably a DVT or more likely to be a DVT F is for, for listen DVC. So if it's above 22 and above, then we want to investigate that further. Okay. So two main things, if it's above, we want to do an ultrasound um within four hours as well, you might want to do a D dimer as well. Do we know what A D dimer is? Yeah. OK. Degradation products of vibrant um very xanthum, not specific. So if it's positive, that doesn't say much if it's negative, then you can say it's probably not a DVT everyone happy. Uh So yeah, we've got the world's criteria as well. There's no real sick, you know, you don't really have to learn these off my heart. Just remember if it's one or less. It's pretty unlikely. If it's more than that. We want to investigate further. Ultrasound is what we generally want to do. If that's negative, then it's very unlikely to be um A DVT. Um If it's positive that confirms it and that's just a bit of a summary slide. This is probably the best summary slide. That's the last few, few bits. Um So DVT treatment, what did we say? What's the first line treatment to DVTs? Uh huh. We've already, we've, we've mentioned a few things already. I asked this kind of before. I really can't come on a shout out with my passions. Well, I can't hear anything. Yeah. Say it again. Doha. Okay, thanks. Who even said I can't even hear Duac. Oh, thank you. All right. Okay. Uh So agreed. It's a dark, okay. Um And we said the big Salmon river expanded to Maine once. Um If you suspect it, you just go for it, you start it once it's confirmed, then you continue. Okay. Um You can use low molecular weight heparin as well. That's a bit more for prophylaxis. And if ducks are contraindicated, so things are metabolism. So about the disease or renal impairment. Um So if it's a provoked DVT, so it's because of immobility, son's been hospital recently. It's surgery, it's pregnancy, there's something that we can, you know, point towards that you want them to be on medication for three months. Um If we don't know what the cause is, then go for six months, we want to work out what the cause is. So that could be some sort of clotting disorder. Um You know, you will invest investigate further. Um And if there is a clotting disease, then you switch to Warfarin as well and you've got slightly different iron, our targets as well. Everyone happy and that's it for Facebook. Thank you very much. Good evening. Don't go yet. You know, hold Masons. He said I was nice to warm up. I'm gonna do what I needed that to start off stage. Even though we're more qualified to teach. I feel a lot stupider than it was in both joint pain. I don't know. Yeah. You get dumber off the finals weather. All right. This is a chunky case you found. I was talking to my teens. Uh, don't gossip. Uh, it's gonna go shit, gonna straight my head, just straight my brain. Okay. Let's get started. Headaches. Do you guys like before your Oscars finish off the last few cases properly? Did you know them inside out and stuff? I remember mine, I mine were coughed like her but, but they cut off like a few days before. So I didn't do last four cases. I just kind of said shot mine. Yeah, I just want to see if there, if this trend is anyway, this is a really, I know this is T CD four cause that's what used to be. It's 22 whatever you brought them. Okay. Headaches. That's okay. We got all this stuff we're covering a lot today. Okay. Whether in all these headaches, all his secondary causes an epilepsy as well. Okay. Epilepsy is 1/4 year thing. I'm not going to drag on too much about it. Can I ask in your T C D because I'm actually read a lot. How much were epilepsies actually mentioned that cc'd? No, during discussion, I think under present, but you don't have any energy yet. It's this next grouping So they go through like all the different types, focal generalized awareness, impaired awareness. Wow. Okay. We're gonna do it fine. Primary headaches. Okay. There's like forward ways to classify headaches does not matter how you classify it. Just know what they are. The first one I'm going to do and Georgia gonna do is I'm going to tag team this like, like this. Okay. This first bit of the teaching, you should know it. I'm not gonna speak much. I'm gonna, the way I'm going to do these slides and George as well as Socrates so site on Stepmother. Okay. So starting off with tension headache, everyone with me, tension headache site. What site is it roughly? Um okay. Onset, gradual. Yeah. Stuff like that. Very various. Usually during stressful periods of time. Okay. Fine or works okay. Character, key thing is not pulsatile or throbbing. It would just feel that pressure. That makes sense. Ok. Throbbing. Impulse tile is more indicative of what kind of headache? Very good migraine. I'm having one now. It's really nice. Ok. Radiation's is now, now I get out of their associated symptoms. I can't really think maybe neck pain. I don't know. It was a bit of Yeah, head muscle soreness. Fine. Okay. No visual changes. No sinister changes at all. Ok. Um Fine. No aura. No. Yeah, I'm very important. These are all pointing towards probably migraines and stuff. Okay. Causes whatever. Yeah, genuinely. Is these things sleep issues, dehydration and stress. These are really, really common causes okay, time onset, whatever timing, fine. All right. We'll talk about exacerbation. What an overuse headache is. Does anyone briefly no one overuse headache, ear's tell them issue with my case just, uh huh. Okay. So, not necessarily migraines, but a patient doesn't because lots of headaches regularly, whatever they are takes lots of nsaids, takes lots of party eating off, taking those medications can induce headaches themselves and they become dependent and rely on it. And the way you treat an overuse headache is to wean them off it. And that will cause headaches actually for the first half of a month and then they'll get better. Yeah. Anyway, cool. It's not that deep. Okay. Symptoms. Not that severe regional idea. Okay. Management is predominantly insides party smell, stuff like that. Acupuncture maybe helps. I don't know. Uh, sublimating allergies, chronic. I'm a trip to them. Acupuncture. Fine. Okay. Next one, George is going to cover, this is an important one. You have to be able to recognize this. Um, what's the site of a cluster headache? We're on the eye. Yeah. Both eyes. One, I, yeah. Yeah. One. Correct. So, unilateral, uh, onset, I'm pretty sure I do. Yeah. Um, comes in clusters. Um, how do you, how do patient's describe the pain? Normally? Stabbing pain. Yeah. And what is it right here? Oh, my word. Good. Any other symptoms that we get as well? Uh, yeah. Initiative, running, listening, restlessness. Yes. Yeah. Yeah. So yeah, patient's generally with cluster headaches. What relieves them is walking around the room is, it's quite, you know, we will get agitated. It's the opposite of migraines. So you don't want to go to sleep but you want to go around. Um move. Um Sounds horrible. Anyway, so was that red? I, we get discharge as well. Um, runny nose. We said what's my osis? It's got to do with the pupils constructed or unless it's construct it. Um, it might be. Yeah. Um, yeah, so it can last from 15 minutes or three hours. Sometimes a few times a day. And again, quite variable thing can be every three months can be up to two years are really defense. Um, it's quite trigger related. So specific smells, exercise, alcohol. Uh, and you said, and movement generally improves the presentation. Um, yes, time does suicide headache. So, I wouldn't recommend, has anyone had a cluster headache? Good. Good. Uh, so, um, typical patient. Yeah, that's 50 year old old male smoker, right. Um, so how do we manage it during the attacks? There's one main thing. Oxygen. Yes. So we want 15 liters. 100% oxygen. Okay. And that can be given at home. Any other medications? Trip towns. Yes. How do we give the trip? Dance sub cut and there's one more intranasal. Okay. What do we do in migraines? How do you give reptans or, or correct? Okay. Um, what were the contra contra indications of trip terms. It is uh uh I don't know about psychiatry. I don't think so. Not as far as I'm wet but maybe um contraindications also trip towns can cause a vase, a constriction picture overall. Um So anyone with the schema cart disease, previous M I S U M stroke history, uh potential contraindications. Okay. So. Okay. Uh Yeah, because it's basic constriction. Yeah. Yeah, basal constriction. So, you know, if you have a heavy cardiovascular disease burden or something like that, you know, that would precipitate um embolic events. Um You don't wanna have it more than twice a day. Um How do we, what was prophylaxis for cluster headaches? Uh huh. Uh not propanolol. So verapamil's, that's a calcium channel blocker. Okay. And lithium as well. I've never actually seen that prednisoLONE can remember that. Um So using the beginning. Okay. Any questions so far on cluster headaches? Are we okay with that? Yeah. Um So overuse headaches. Um the main medications that associated with overuse headaches are trip tons and opioids as well, but you can also have paracetamol over the proceeds small. Um What's it called dependence and say dependence as well? Uh So etcetera, tons of Asia constrictors can cause drowsiness as well. Um We talked about the administration. Um So overall with overuse, it's, if they're taking men, it's pretty much daily for more than three months. Um And overall there's a bit of a tolerance aspect to it down regulation of pain receptors which makes it ineffective. Okay. Uh The way you treat it is you just withdraw the treatment itself. Um, and you want to achieve roughly 15 days a month maximum where they're not using the medication any questions. All right, Mr Zack. Okay. Yes. Migraines. What? Mr uh huh. Uh, migraines, um, sites. It's gonna be the heads. Yeah, it's not, I'm not damaging. It's appropriate. Yeah. Probably unilateral initially on occasion. Don't be phased by if it says is that Quest medical d if you work for them. Uh What, who's that comes? Uh uh The Circle Mario. Uh we got to jump in one. We have an emergency meeting on this, please. Uh Sorry, you can talk about a D H D. Huh? Okay. Um It's your natural almost all the time but it don't be phased if this is bilateral. Okay. But most commonly as you said, your natural onset don't even know what that question means anymore. But identifiable triggers we'll talk about triggers. Okay. Just remember chocolate. Okay. Always remember chocolate. But we'll see what chocolate means. Character. What's the, what kind of pain is it? Uh throbbing pulse until you feel it like the blood is just pumping in is you can feel you can have a stroke. It's an awful feeling. I get mine in the back of my neck. Amazing feeling I feel present. Okay. Radiation's you can go around, I think down and whatever. Um very good. Actually, it can be preceded by an aura. Doesn't know what or a means. I think for two years. I don't know what the word meant. Genuinely. I thought it meant sums energy and that the star sign combined together. Like, uh, but, or a, I think you see madness is, right? Like it sounds like, uh, like, uh, does anyone have migraine with aura? Yeah, I'm yet to meet someone who's actually had a migraine with aura. What do they see his housemate? Does she or he? I'm not asking somebody experience well prepared. Uh Right. Yes. She asked me happy. It's not like a new, like it's like for boating or just gonna uh okay. Oh, speaking of uh doctor sites. Okay. So someone does get it. It is real. It is real. Yeah. Okay. Uh Okay. Okay. Fine. So aura, so preceded by with it. I'm not really funny. I don't actually uh ok. Associated symptoms is going to be so they can get nausea and vomiting. What are the headaches can present with? What two types of headaches present with nausea and vomiting? Think odd. Okay. You can ask more questions. Subarachnoid, hemorrhage. Mr Quest Med Nashala brother's got brain on his head at the shirt. Okay. So subarachnoid it's been cause nausea and vomiting. They can. What are the very, very dangerous thing? 10 posters, meningitis shot? I'm sure there's other ones is going okay. Cool, nice. It's gonna computer. Cool. Why not? Or a, we said that's fine. Ok. Time people can have up for the three days I've seen it happen very painful. Um, and they like to be left alone in a dark room. Don't talk to me, don't see me. I need to sleep basically. Okay. Really, really severe, debilitating that. The key thing here that differentiates this from tension, they have to stop what they're doing. If they continue, it'll get worse until they just C six. And then I'll say okay, in terms of uh management, we'll talk about the next side. Triggers. Remember? Chocolates? Okay. A chocolate. So it's in ammonic. These are all triggers for migraines. So periods, chocolate itself then h is gonna be hangovers. You know what that is better with that is either cheese, caffeine. So trees, cheese has that, is it trip down or something like that? Is chemical wine? Has it as well? Uh, influence a headache. So the cop can cause that as well. Sometimes I get migraines when I sleep too much. If that makes sense that when I'm properties and I sleep again, when I don't need to sleep, I wake up with a headache. It's kind of stupid. Anyway, it really it. Mhm. Okay. This is all chocolate. As you can see ch other, we'll stop t travels or whatever, fine and exercise. Okay. Moving. Okay. Um How we manage? Migraine? Let's have a look. Ok. Apparently. Were diagnosing. This is all rubbish management. How do you diagnose manager, migraine. First line is going to be essays and trip times. This is express very, very clearly. You know what these drugs are. We just discussed them a second ago with George. All right. Fine. You can give an anti emetic like metoclopramide. I've never actually seen that been given ever. Okay. Prophylaxis. There are some drugs you can take to reduce the incidence of what's happening. But the main thing is trigger avoidance. That's all okay. Fine. We're happy with that for panel. Aw is um um HalfLytely drug, April fatter drug. What is the country in bettering? Very good Asman. It is a nonselective beta blocker. It can construct the belong think Virginia's those things that give us our bronchioles. Cool to pira mate. We'll talk about that. That's a very strong drug and we'll talk about that later. Girl, girls who are trying to get pregnant, you can't have this as well and I'm a trip to um that's a T C A try sector answer present fine acupuncture. Apparently you can get that whatever that is fine, whatever. OK. Cool. Here's a bit of progress. Content in the corner is really nice and it comes up a lot. Metoclopramide is a dopamine antagonist. I'm pretty sure it blocks dopamine. That's how it works. The issue with that is that remember Parkinson's is all that dopamine. If you mess with the doping symptom, you're going to get parkinsonian symptoms. So this could be drug ensued. Drug induced. Parkinson's, what this basically says is metoclopramide. A patient, a woman takes metoclopramide. She notices that her jaw is locked and she's looking left and can't move. These are signs of drug induced something that's parkinsonism. Probably so. Dystonia in oculogyric crisis which means their eyes locked looking up. Trismus means locked jaw like that and talk to Cody's net locked in a position. It causes neurological symptoms. Metoclopramide eyes just remember that it can come up. It is a progress thing. Hyper niche. You will forget it. We'll be done in the air four. Okay. Cool year four content here. Basically, there's something called the UK Met for guidance, which is what is it that always was. I just said, what does that mean? It just means what is absolutely contraindicated for a woman to take the combined oral contraceptive or any contraceptive pill? One of them is if she has a migraine with aura, she is absolutely contraindicated from taking the trip times. Why? Oh, sorry, sorry from taking the combined oral concept of pill. Because migraine with aura suggests vascular compromise. The combined oral contraceptive pill pill causes vascular compromise as well. Increased risk of stroke. High punish if that went over your head. At least you've been exposed to it when you learn it again, when you have to learn it again next year. Like that weird guy who's not here anymore, said something okay. Cool. Last one. Georgia bit slightly weird headache. Um I don't remember the branches of the trigeminal nerve. Yeah. Yeah, I can see uh okay. Three branches. Yeah. Yeah, perfect well done. Uh good job. Um So yeah, normally on one side, um we talked about you'll see a picture again on the distribution. Sorry. Um What about its onsets, sudden, gradual, correct and many triggers? Okay. So get an M C Q S. That'll be like what we described as like an electric shock kind of pain, chewing, light touch, cold wind spice quite a few things. Okay. But you're very, very sensitive condition. Um We said electric shock radiation associated symptoms. It depends. Well, you have a look in a second. Um can be for seconds, can be hours, okay. Very painful. Um Great painful. It's generally caused, this is not something I need to be honest, generally caused by vascular compression at the root entry ponds of the fifth cranial nerve, which is the trigeminal nerve. Um It's like I'm going to ask you this. What do you mean by typical as CIA doing fine? Mm I'm guessing there's not something for us to it. Uh Six years I know in rental instant called the vascular company. Is it um at the roots of the extra ones? Yeah. Oh, do you? No harm? Remember that book that that guy there is any much every month? Yeah, there was a case of this basically achievement with pressing on earth and it was this and the course of trident murali. And then there's a chapter which I didn't rather but really cool chapter typical necessary. Um OK. Claim to that. Um so 80% as a vascular compression and then 20% is multiple sclerosis as well. So you get demyelination of the nerves and again, I was probably going to be at the entry points. So you get too much everywhere. Other slightly rarer causes sarcoidosis, lyme disease, postherpetic syndrome as well. Um He diagnosed it clinically. Um again, just to Socrates, you do an MRI as well. Um Probably have a look at vascular compression, very spoke space occupying lesion is etcetera. Um Do you not carBAMazepine iss I can see notes but I can't hear anything anti epileptic. Perfect. Thank you. Um You do surgeries are about spring more complex. Um So yeah, we said multiple groceries factor, old age and being females. Um And these are the three branches. Any questions? No, thank you. Okay. We'll take a break. But any questions before the break at all, I see five minutes. Uh Well, let's start with the heavy stuff. Yeah, it tends to get merciful recently. Uh You know, honestly, yeah, it was what do you do with that sort of things? Uh I think without having uh different, it's not Maxamaid, you might open, grab my feet. Uh Good. Uh uh Yeah, I think it will be easy even, I don't know. Wait. Uh okay. It's probably a model. Uh It can be he, you know what I want. Uh, you, yeah. Uh, uh huh. Yeah. Uh, get to, uh huh. Uh, how do you not think? Uh, uh huh. Uh, good. Uh, uh, yeah. Okay. Yeah. Not happy as well. I don't know. Yeah, it's tragic. Uh, you talking about what? It's not wonderful even. Yeah. Yeah. Yeah. Yeah. Uh huh. Uh, it's like that. So, uh, things, uh, uh, yeah. Uh, well, I was already done, Uh, storage is next, you know, I think you can. Yeah. Okay, bye. Yeah. By beating. Excellent. Okay. Ready. How do you pronounce this? You don't know, you'll find out next week. And so, yeah, I mean, what do you, have you been, how are you feeling for progress testing also? You doing questions? No. Yeah. Yeah. Yeah. You too much to answer. Wow, you're, we'll do money again. Can I see privacy? I need to learn because it's one word but I'm not even being arrogant. I'm just saying it. That's the one that you're saying your name? London mixed with a pregnant. That's true. And it's, you know, uh, if I said under, uh, hi, I'm sorry, mama. Yeah, sometimes not. I'm going to put you off. Okay. All right. That's the game. Let's say that as creepy as possible. Um, do you know where your friends are? You think anyone is tired crying? Really sad. Playing the Polish? Awesome. No, I mean, generally for this teaching. Where are they? Uh, yeah. Uh, do you think people, they, they don't, I don't know. What do you think? Thoughts? It's a, it's a bit far from my eyes and I have. That's true. L5 p.m. Treasury. Yeah, I reckon next week would be what our last session, two other victims together at all. Yeah, you can do it twice. It's fine. We'll see. Okay. Let's do this. Ok. So temporal arthritis back into studying, right? You get, they're a lot more than onyx. Okay. Does everyone know anyone know what Temple arthritis is? What classic condition it is? Trust vasculitis. Very good small medium big big big vessel. Yeah, big vessel of the temple lottery. Yeah, I don't worry about it. It's okay. It's okay. Okay. It's a large vascular vasculitis, vasculitis. All that means inflammation of blood vessels. We know this. We've been a, I've taught vasculitis it six times to you guys. So just go over the sides if you get scared or unsure. Okay. The reason it's really, really really, really bad and we have to worry about it is because it is not only site threatening, house site threatening. What does it cause lots of, yeah, risk of both eyes, transient lee, it causes Amoros is two gaps that thingy but can you lead to permanent blinding because of information of the restaurant article, artery and opthalmic whatnot. Um And it's life threatening because it can perpetuate a stroke following it. Okay. So that's why it's a problem you have to deal with it earlier. Okay. Any person who is over 50 and has a headache needs to be differential. It's meaning you have to ask more questions and check. It's not something serious. This being one of the things that rule out. Okay. Fine. Does anyone know some symptoms of temporal arthritis also known as giant cell arthritis can't brush their hair. The typical on so good job lines. Very proud of you. So hold on a scalp. Penniless is meeting, but typically old lady can't brush your hair in the morning for women session. Yeah, that's your age. Remember the thing we did with peripheral arterial disease, intermittent quadication, cramping and muscle pain in the muscles of the leg. Imagine that in the mass term us als Joeckel location for tongue quadication, they get the same thing. So aching and pain going. Uh We'll talk about that in a second here. Okay. As in he's gonna, you mentioned a nice point we're gonna talk about in a second. I know even shoulder pain associated with it. There's a condition and I'm going to ask you guys in a second. You can't answer it. Well, uh album I can't do that. You, you, you, you can't see nothing, you know. So it's a temporal one sided headache. They might have a visible quickened artery, temple, artery number, super, super temp artery here. I've never seen that and I've never heard of it. They can present with transient what transit means? Temporary blindness in one eye? Oh doc and what does blindness mean? They mean like a curtain or just the eyesight has just gone black completely? Okay. That's not good. All right. Brushing hair. So scalp tenderness, fine, very good jaw or tongue qualification. We just said that second again because all of these are supplied by the same blood vessels, external karate's systemically. Why are you going to ask about generalized neck, shoulder or hip pain? And then we can't answer what is Jamelle affects? I mean, very good. So there is a strong association with G C A to something called polymyalgia, rheumatica, shoulder pain and hip pain and inflammatory um arthropathy. Really? Okay. Fine PMR fine. Very, very good. Remember this is a little guy that little principle to remember from now on inflammatory pain gets better with movements, mechanical pain gets worse with Newton's. You'll ignore this right now. But it will be like, oh yeah, that guy said it and year four when you cover all the pains that I am anyway, that's mine. Stroke and blindness. Okay. This is the vignette. They'll usually using them questions. Elderly female has a headache and notices pain when she brushes. I have G C until proven otherwise. Okay. Now, how do we diagnose it? Think crafty about this going by the uh sure someone's coming today. They said doc I lost eyesight in my, I just come back. My scalp is quite tender. Um I've got this really bad pain in my jaw hurts as well. G C A. Right. Pretty, pretty sure. So, are we going to send them for a biopsy? No, we're not missing them for a biopsy. The diagnose, you're absolutely right. Biopsy is the goal. So when the question says gold standard diagnostic method, them questions is right. But we don't do that. But they say if the question says what is the most appropriate next step? Which happens, they're gonna say biopsies. One of the options to trick you the most appropriate next step is to treat until proven otherwise understood. The principle. A biopsy takes two weeks to get it done. And the biopsy has a high fall straight as well. Meaning why does it have a high false rate? The biopsy, same thing as Chrome's, what's the issue of Chrome's skipped lesions there? Skipped lesions in the temple biopsy. So they have all the symptoms that few centimeters that they picked up in the biopsy will show nothing when in fact, they were just one millimeter away from the actual problem. When they biopsy typical progression. They're not going to say what's on the back. They're not gonna say and old lady brushing hair, they're gonna say a biopsy of the artery in the head shows something. What is, what, what are you looking for? Histology? Giant cells read the name that is what you're looking for. Giant cells is the histological presentation on biopsies today. Literally. No, I said it came up in a question. I was like, what is it? There's someone options with giant cell. I was like, that's probably the answer and it was the answer. That's how I learned, I guess. Anyway, so brothers, right? Temple biopsy. Okay. That's fine. That's the full term multi Nucleation of giant cells. Don't really care. Skip lesions. Don't forget that we just spoke about that. Do uh consider doing a CT and MRI of the aortic arch? The reason is or take it say, oh, arthritis, I think um there's another arthritis that's a arteritis that's associated another vasculitis that's associated with this super niche. Nora fine. I don't really care about any of these things. Okay. So really, really important thing to look for is what blood investigations can you do? Yes, I was the most important one E S R is elevated. Very, very indicative of G C A. That's something that can be done in a few hours. You're still going to treat first, but it be really good to do at the CTS are quickly. Okay. So, um everything that's written here is that whole thing. I just, I just spoke about meaning you've got the patient's presented. What do we do? Do we just treat, do we investigate, treat it straight away? I don't care. The side effects are treatment far outweigh or underway. The risks are not treating it and doing the biopsy and waiting, waiting and they lose their eyes and their brain and they die and then goodbye, G M C license can. Yeah. Wow. Okay. What is the management of G C A? This is that it's very good steroids. What kind of, how much? Uh So you can give, depending the answer is it depends on how they presented. They presented with just purely G C A on its own meaning temporal headache. Nothing else but your short Geesey A you get high dose steroids already, usually 60 mgs of bread. Probably typical. Okay, once they present with symptoms, good thoughts. So our friend said, hydrocortisone, good thought, meaning she's increasing potency and hydrocortisone is given IV. That's the right idea. IV, but it's not hydrate what we give super niche drops, eye drops. No, no, no, he's good. It's good. It's good. It's a good thought. It's a good thought, but that won't get to the blood vessels back of the island stunt. So we're gonna give IV methylprednisolone via pulse therapy. Pulse therapy means extremely high dose in one go then weight and high dose. Meaning you're shocking the cells with a lot of steroid in one go impulses. So just three or 3 60 mgs normal G C A. This will stop any blindness from happening or Australia if they have visible neuro and visual signs 1 g. It I D methylprednisolone by a pool therapy. Okay, boring, boring, boring, boring, very boring, boring. These are all side effects of steroids I don't want to go into that cause it's wasted time and energy for both of us to learn. You all know it by now, we've covered steroids about 60 times. You all know that uh side effects and worries of steroids, cushing's and stuff like that. You don't need to cry about that. Any questions on that last topic? That's all. Anything on GCL. Cool hemorrhages. Oh You know how the brain hemorrhage? It's right. Uh So we're the three main brain hemorrhage is that we know actually just that simple. What are the three layers of the meninges? This one? Come on. We want Excellence Cura something in between. Yeah. Arachnoid. So Juror Arachnoid. Yeah. Yeah. So the first big hemorrhage is an extradural. So it's outside of the jurors. So you've got skull jurors. It can be in between those two. Okay. When you have a hemorrhage in that area, it can't cross the future lines of the brain. Okay. So just compresses the brain. Um I don't remember what Libertarian is. Yeah, perfect. So it's these areas here and what's the significance of Terrian a week? Thank you. And which artery is it not allowed? Yes. So middle meningeal artery. Okay. Um So I feel like classic mcq is like a cricket part that hits the heads. Little meningeal, okay. Um So it's more of an of an arterial bleed. So it's very quick and it's a very strong bleed. Um It also I felt again, in MCQ, it's, they lose consciousness, then they wake up, they're doing okay and then they suddenly start deteriorating again. Okay. Um Severe headache and get hemiplegia. So paralytic on the one side, as I said, G C S can start dropping. Um and you get a lemon sign on T t we've got human, just put it on, okay. Um Just remember that because it can't cross the future lines that compress it. It pushes the brain away essentially. So it's blood pushing into it which gives you the lemon sign. Um Yep. And we're gonna probably going to need surgery for an extra draw. Language. Okay. Any questions on extradural images? Yeah. Next is subdural. Do you know what age group is normally susceptible to subdural hemorrhage is? Yep. So elderly alcoholic patient's as well prone to um subdurals. Is it an arterial bleed or a venous bleed? Okay. Right. Sorry, your silence for the next five minutes. Sorry know, write a five minutes timer to yourself? Okay. So it's bridging veins, okay. Um As we grow brain atrophies of it shrinks those veins are stretched and you're a bit more prone. Uh two bleeds. Okay. Um So any sort of trauma as small as it is, especially for someone elderly on anticoagulants, a small small fall can cause a sub Juul okay. Um And quite a few types as well. You can't have an acute one which can be due to, you know, q trauma, get subacute and get the trauma, but then it's very slowly growing away and then get chronic as well. Um Yeah, high mortality, um as I said, will be caused by quite small trauma. Um We said alcoholism is the factor as well and calculation again. Um And that's why facility heads, especially elderly people with falls. If they're just on one anticoagulant, you know, that's literally you go for the CT head, okay. Um Instead of a lemon sign, we get the banana sign. Um That's because subdurals can cross suture lines. So overall, they have the ability to essentially spread around the brain. So they're not pushing into when the brain into one direction, they can spread all around. Okay. And again, we've got some photos a bit later, um symptoms can fluctuate. So again, it's, you know, as a hematoma slowly um enlarges, you can get a bit rid of, you know, advancement of the symptoms as well. So you can get personality changes, G C S changes, exception. And again, it depends, you normally go for neurosurgery. But again, if they're quite elderly for all of that, then you might go for conservative management or if it's not actively growing in a sentence, come any questions on some germs summer up road will cover an event. Um So again, just keeping this into context of Oscar's, I guess um what's your principles of managing an acutely unwell patient's shouters out a Panky ate, we ate two years. That's not okay. You want to do a G C S as part of the 80 you'll do the CT head, as you said, you want to check the blood, you know, they might be bleeding significantly. They might have plotting abnormality that, you know, they need to fix. Um, a stroke units, um, neurosurgery. Um, and then it gets a bit more complex, you know, you might need I C E care, uh etcetera. It's quite important to regulate BP. Well, um so you don't want hypertension, but you also don't want hypo attention because then you're not getting enough perfusion. Uh So what what hemorrhages? The one on the left? No. So between subdural and X and, and extradural, which one is the one on the left? Uh subdural? Okay. So if you can see on the sides this hand, I don't understand. Well, let's see here. Uh Telling you to Yeah, the way I always forgot. Lemon and banana. Sub has B B for banana, banana as a present subdural on planet. Okay. And the lemons other ones zeros after you can see there's uh uh that's extra, right? Uh The one on the right is extra, you know the big Jerusalem. Yes. Yeah. You see outside of the skull there's loads of information damage and there's damage to the outside of the head. Yeah, there's none of that on the lemon sign. Uh the bananas. Uh um is anything else you can see on the bit of the left bit more. That's not that niche, but you can see a bit of midline shift as well. So you're getting all that build up of blood slowly shifting towards the left. Okay. And same something on which on the right. Um, and then I should just understand the anatomy a bit better, but we're happy with those two. Yeah, you'll cover these a bit more in year four, but not that much. To be honest, you get two weeks in urology as well. So I feel like if you actually get this into your head from now, it's probably a good idea, really cool surgery if you actually get to see some um, subarachnoid. Uh So he said it's under direct would layer. What's the classic presentation? What symptoms are we expecting? Thunderclap headache? Okay. So very sudden onset, thunderclap headache, worth headache in their life, neck stiffness. We said while the patient's can get neck stiffness, meningitis. All right. Um, and photophobia as well, I think can also be recognized as a symptom of subarachnoid. Okay. Um, they can become a toast reduced gcs. If they're really poorly, they can get seizures, um, traumatic or spontaneous causes. What percentage do we think are traumatic? So, I guess so, actually traumatic or almost, I think it's 80 to 90% of subarachnoid are caused by trauma. Okay. So it's only 10% which actually by aneurysms. Okay. Um Any, especially if you want to see t them okay. Um And then the guidance has changed recently. Um So yeah, so you want to see, see if you have any suspicion of subarachnoid, it was done within six hours and that's normal. Then you don't go on to do a lumbar puncture. Um Actually, let me just explain why you do a lumbar puncture first. So it's a this kind is normal. You didn't the lumber puncture. Um we're looking for, for blood in the CSF, right? Because CSF is essentially is in the subarachnoid space, okay. Um But obviously, when you're doing a lumbar puncture, you can cause trauma, you can cause blood in the, in the CSF itself. Um So you look for sand, the chromium. Do we know what that is? Did someone say something? No? All right. Uh It's a breakdown essentially. So it is a sign that red blood cells are breaking down in CSF. So that's, you know, a marker that there's a bit more of a chronic bleed there rather than just because of the trauma that's been done to keep you um yellow color. Um What else? The management? So you want to use a calcium channel blocker to stop vasospasm, vasospasm. One of the cute things you wanna avoid. So that's gonna cause strokes essentially. Um I can't remember what it's called, but the most common one is the niMODipine. Um In the neurosurgery, you can also do interventional radiology is the most common one. Um risk factors hypertension uh more ctds. Um, Polycystic kidney disease. Uh Zack humor bought CTD stands. Ok. Connective tissue disorders. Yeah. Sorry. Um Okay. Are we happy with Barack Mom's? Yeah. Any questions so far? Yeah. Correct. Um So what you can see on the right? Yeah, bright, bright white essentially indicates fresh blood. Okay, because it subarachnoid, it's can essentially spread, spread within the brain a bit more. So that's why you can see it within the brain, okay, rather than in them and do layers. This is the classic sign that you can see here. Um And that's xanthochromia. We're happy. All right, a slightly more weird headache. Um It's called cerebral venous sinus thrombosis. Uh So that's a clot that's in the cerebral Neurosciences. Do you remember your cerebral dural sinuses? Great. Me neither. Uh the most common one is Sagittal sinus. I don't know where that one is. Um somewhere. Yeah, it's in the back somewhere. Um It doesn't normally affect the cabinet sinus, which is the biggest sinus. Autumn cat is like, I've googled this three times today. I can't remember the uh not, not relevant. Yeah, sorry. Um can be caused by sinusitis. And do you know what gemesis is? It's like a blistering of the eyebrow exophthalmos, very obviously swelling as well. Um It's quite difficult presentation. I think it's one of those things that's probably actually missed quite often. So, headache, nausea bonded saying change in G C S visual changes as well. Um You can get some credit, nerve causes papilledema diagnosis is uh it's a CT venogram. I actually think it's M R I M R venogram. I'll double check that if it is uh in the email, I'll say it's M R okay. Um And it's, you look for the enter delta sign, okay, which I'll show you in a bit, you treat with anti calculation, okay. Um So risk factors, anything that promotes clotting really? So hormones, um pro thrombotic conditions or a contraceptive pill being septic, having active cancer being dehydrated. Um So that's the empty, empty delta sign there at the back. Uh It's just a bit more imaging and so that's essentially CT or MRI being at them. Any questions on this. And so it is a bit more niche. Uh but something's always have in mind. Okay. Any questions? This is that? Oh my goodness gracious. Wow. Really rinse. And that's, it will be three. By the way, this is like a 60 prevention. It's okay. We're just trying to run through all the contents of the bus. Um space impregnation, branching. Any ideas how these headaches present any ideas? I feel like I have one now. Chronic dull headaches basically is those cases that you see on the news on my GP ignored my headache and died. I sued for 3 million lbs, something like that was those kind of headaches. Okay. Yeah. By the, the thing is the brain is really good at accommodating. Um I know it's a closed box space and whatnot. Uh the moment pressure builds up its peak, but tumors grow slowly, slowly, slowly slowly and then they compress, they compress unfortunately, before focal neural presents. So what is focal your immune paralysis? See, that's not focal paralysis, tingling in one side loss of sensation, summer focal signs issues with the IRS, stuff like that before that presents, there's a lot growing that happens especially slow growing like meningiomas and stuff. Very, very sad. Um Cool. Um The typical presentation is raised ICP, raised intracranial pressure. This is the main symptom. These kind of headaches are chronic, dull headaches that get worse when you increase arterial pressure in the head ways you do that uh by doing valsalva maneuvers basically. So straining on the toilet, straining, doing weights or whatever, um bending over, leaning over these things, anything that increases the body always remember the cerebral doesn't formula the cerebral perfusion pressure. So CPP is a 22 steps for me, then it is the mean is the mean arterial pressure minus the intracranial pressure. So if you English, the arterial pressure, you're going to increase the perfusion pressures. The brain boring masks. The point is anything that causes an increase in I C P. Okay space occupying lesion doesn't just mean brain tumor. It can mean a blood clot like a hemorrhage. Um it could tumor, it could be um and aneurysm these things things that is built up and take up space. Okay. And abscess, any of these things. This stands for idiopathic intracranial hypertension. Talk about that in a second. Cool. How does it present? We said headache, chronic, doll, focal neuro takes time but typically nausea, vomiting is, it's fine and headache in the morning as well. Very good gestures. That's true. Too true. Seizures present lates. What is the seizure? Oh my God. We're procedures as well. Mhm. Okay. Yeah. Papilledema. the main sign of raised ICP is popular edema. So that's when the optic disc at the back of the eye gets blown out. Basically. Okay. I don't care, don't care, don't care. Read this in your own time. Fine. This is a normal fungus. This is A I C P raised fungus. Popular dina. Okay. Fine. All fourth year stuff. Don't worry about it. Just no popular edema is bad. Okay. Don't care types of pain. She not one like a waste of time. Be aware of this one and maths, this is the fastest growing one in the worst prognosis. Like 90% death rate. Something that these caused by BTH. Doesn't, it's not a bit, it's sensible bitemporal hemianopia. They, they bump into things. No patient's going to say I cannot see past it and they're gonna say I bump into things left and right. If that makes sense, that's how they present in the questions. Okay. Um You should be aware of this, this and this. These three acromegaly hyper may not hyper productive union. That's fine. Cushing's you should be aware of Cushing's. Cushing's, what's the name of the condition where there's a pituitary tumor that causes cushions? What's that called? Cushing's disease? Not syndrome, anything can cause Cushing syndrome. Cushing's disease is when there's a pituitary adenoma. Okay. Fine management is three things, chemo radiation or surgery. That's what it is. Okay. Cool. Don't care. Do not get, this is important. This is a very specific type of headache typically in overweight women, uh, pregnant ladies as well and it's a diagnosis exclusion, meaning it's not the first thing you point to. It's the last thing you point to wants to rule that absolutely everything else. It's a headache, popular edema, signs of raised ICP that we spent the last three slides rushing through the main treatment is losing weight. Basically, that's the main thing. I don't know what causes them to have raised ICP. But that's it. Idiopathic intracranial hypertension. Um, a larger female, basically. Okay. That's remember encephalitis, the one thing you remember from this puppies. Personality change. Those are the two passwords for the slides most commonly caused by heart things that can be caused by, um, varicella zoster, which is a hepatic virus can be caused by CNV, can be caused by EBV, can be caused by, um, there's all the viruses that I, I don't know at the moment. Um, it is an infection, not of the many allergies. I said inflammation of the brain tissue itself. So whatever the cause whatever virus it will present with a change in personality. Not like in dementia like or is it getting slower or whatever acting? What? For no reason? Mad behavior, um disinhibited. That makes sense. Okay. Altered mental status. That's the main thing. There's gonna be a lot of text in the slide. Ignore it. HSV one and HSV two. This is the non ST I one, this is the S T I one generally speaking. Oh I said all the virus is fine. Cool. Uh There are some weird courses. Don't worry about it. This is so niche, don't worry about it. The only thing I felt I said exactly the wrong I think because I'm smart. Um The thing that you need to remember altered mental status and herpes, okay. That's the main thing you need to look for. You treat it, you give antibiotic cover in case the bacteria is causing it. But you have to give Acyclovir that is an antiviral use for herpes. Okay. Fine. Really? Genuinely. Nothing to look for him. Okay. Any questions on that side? I know there's a lot review in your own time. Uh Okay, meningitis. I think we can speed on this thing because you guys know meningitis. You must know it by now. Why is the meninges? That's what I like to sing. Pointed to his head. Okay. This was a war zone reference that I thought was funny to put that three years ago and I kept it in. Those are good days on the and then the lockdown. These are some good things. Okay. Meningitis, it doesn't just mean infection, it means inflammation of the meninges. There are many causes. So as we're going to focus on are infective causes that cause an inflammation of the outer layer of the brain. Okay. The main causes are many in terms of bacterial embarrasses, threat, Neisseria, meningitidis. Him awfulest last Erion they affect different patient populations. We need to be aware of them all. Okay. There are virals as well. A million others can cause them. Don't worry about it. Um Definitely parasitic. Just remember anyone who's seen train spotting, you've seen the film train spotting, you know the donee, remember the guy who got HIV and then his cat food on him and then his brain died or something true story in the film. He got toxoplasmosis. Like he was even a compromise, the cyst formed in his brain cause meningitis and he died a big splash hacks and like right, a really good film transport. The two years of that it wasn't like, yeah, I don't like it either. Everyone back from one. Okay. Tuberculosis as well, you know, right. For tuberculosis, this is just quick recall, you know this, right, right. Be aware of it, right? But other drugs used to treat tuberculosis, just be aware of that. Those of those of course is to move on this. You need to know. This is a bit afternoon. These are the age ranges and the different bacteria that cause meningitis in terms of most likely. So when you are in urinate, you're just born is things like hysteria and groups, group B strep. So this is the one that caused scarlet fever. But on the brain now, listeria, the risk factor is their mom ate some fancy French cheese because there and the bacteria in those cheese that those cheeses went into the baby and it caused meningitis, asterion. Okay. Very wrong. The ones that you need to remember very heavily. This is more of a Pedes thing. These two here, the most common causes are strep. So yes, that one that causes pneumonia in the lungs. Streptococcus, pneumoniae, I can cause meningitis in adults. And then the one in the name Neisseria Meningitidis. This is the famous one. Why is this one famous? What does it cause? Typically the non blanching rush? Remember that rush that the cup test all that rubbish. It's my cereal meningitis that causes this meninges cities that causes this one. That's the one. Ok. Presentation and symptoms. Okay. I've given it here but we know a bynum, neck stiffness, photophobia, headache, fever, nausea, vomiting. We know this by now. Any questions on that. Okay. These are very close symptoms and one associated with meningococcus also known as necessary um Energy cities. We just said it a second ago. Specific sign the non blanching ranch very important. Okay. The name of it is a petition, your rash, whatever. Okay. Fine. There's two specific test called Kernig's and Brzezinski's. Use them kids. You, like, you try and induce the neck stiffness in the neck called bob forward and their, their legs will feel type something like that. Never done in practice. It's one of those Instagram medical things that you see, you know. Yeah, like uh okay. Cool, cool. I don't care about any of that. Yeah, this is Koenig's and that's Brzezinski's okay. Pete's. Ignore it. Everyone has besides the symptoms of meningitis. Okay. Fine, cool. Okay. How you gonna investigate it? Find blood's. Why do I write within one hour from A B G and BBg? Why think brains power squeeze them grew? Give yourself a migraine. Why don't we do an A B G or a BBg within the hour? Why do I want to like say yeah, you do. What's, what's happening is you got an infection, right? What happens the infections in the spreading around the body? Sepsis. Six. There we go. Meningitis is a very high risk factor of becoming septic, especially my cereal, um energy cities. So you need to make sure you do a sepsis. Six staff within the hour actually. But you do an A B G BBg. You're gonna do blood cultures as well. Uh Sepsis six is all coming back to us now. Oh, excuse for like a month ago. Come on Sam E U S B one lumber puncture. Um Do you guys know how to interpret CSF? You should have practiced it for your Oscars. You have not interpreted CSF. You must have not actually got on the bottle and looked at it. I'm saying like, like, you know what I mean? Like the protein white cells, that stuff, you know what I mean? Glucose, you have to be able, not only should you be able to interpret it just in awe ski in a progress that you should be able to identify like that TB fungal bacteria viral has caused this meningitis. Do you understand what I'm saying? I think all of this is just things that you look for in CSF. These are all the parameters that come up when you analyze someone's lumber function. Okay. A lot, a lot, a lot, a lot, whatever you need. This is all this is just telling you how to do the lumbar puncture xanthochromia in case for subarachnoid hemorrhages, as George mentioned, ignore all of this. Okay. You need to memorize this off by heart. If I say that there are 90% neutrophils in the CSF is only one answer. Bacteria because neutrophils good bacteria, they don't deal with viruses. Okay. If I say it has a fiber in web on its appearance, tuberculosis don't even talk to me. Okay. I don't know who you are. If I say that the glucose is normal, it is viral because viruses don't eat glucose they are dead. Only living bacteria consume glucose. If something has been consumed, the CSF will have lower, there will be less glucose in the CSF. Does that make sense? Or am I losing people one by one? We just disintegrating brother at the back of your face looks like you're, you've seen a ghost. All right. You sure any questions from anyone and speed running this thing? Because I have plans and um I could have seen sepsis. We said this. These are complications of meningitis. Basically D I C um that's a huge problem. You know that nonblanching rush, what it is is bleeding under the skin when you bleed to use your clotting factors up. If you use all those clotting factors up in one go, you get D I C I have taught this before in that clotting case. Messy case. 11. But anyway, move on. Uh management. There is a whole regiment of management of antibiotics. Okay. Very important. There's either penicillin, allergic or non penicillin, allergic. I've never actually learned this property. I just always go with a third generation couple sporin like vaccine or for um what's a taxi? That's the one here or kept traction. I just always picked out on because I don't have time or energy to learn these things. One thing to add the dexamethasone helps reduce information if you can remember that. I know there's a lot going on this side and I have explained it in the most horrible way. Just go and look at this one to use for me. Okay. You did two months. That right. Okay. This is the history stuff. But you've done are scarce so we can move on. Uh, Sink be George. Be great. Yes. Um, three broad categories. Is there one ever? Faint kids? Oh, come on. Yeah, they're good. Happy days. Right. So, 33 categories. We have reflex cardiogenic orthostatic, okay. Um, reflex in copitos. You know, it can be your vasovagal has certain trigger. There's somebody when you're upright, cardiogenic is when there's a cut event course. So it could be an arrhythmia that can be a slow heart rate, a high heart rates, arrest anything like that. And orthostatic is normally when your volume depleted. So you don't have enough fluid in you. You're not using a very enough and you can face. So he said based very good reflex um a specific trigger normally withstanding um situation as well. You can get nutrition, nutrition, syncope as well. Um You're going to code this a bit more in, in fourth and when you take force history where it's very much what was happening before, what's happened during what happens after. Okay. Um Cardiogenic, as you said. So bradyarrhythmias, that's a slow heart rate. Um Again, you're just not getting brain fusion tacky arrhythmia. So, ventricular tachycardia um and then you can get mechanical issues. So, one of the most common things of aortic stenosis is is really severe when you suddenly have syncope. Um and then all the static, we said volume depletion gets a side effect from medications. Again, you know, you have other blockers that's causing. So dilation um and breast electrical ticks and then other conditions that we can probably cover a bit more next year. But things with autonomic dysfunction. So Parkinson's is a big one, multiple system atrophy, a bit more complex, but all of them overall cause a bit of a sympathetic parasympathetic activation which results in sync. Any questions, it's, it's quite broad slide is a bit more of an introduction. Any questions on that, right? Um As I said, with syncope, you kind of want to approach it with what's happened before? What were you doing? Then I'm during, did you lose consciousness? Um Did you have any tonic clonic movements? Anything like that? Any tongue biting? And then what happened after? Okay, I'd say look at this in your insight. Um And as we decided the visa vehicle, it's three main things. Um So they're going to be upright, there's gonna be a specific trigger. So it could be emotional shock, it could be you're in theater, there's seen blood, you're dehydrated. Um So be a pain. Uh and then programs that's what happening after. So, no, sorry what's happened just before. Um So I don't know about you guys, but whenever I've got close, the painting, you get a bit dizzy, get a bit ringing of the ears, blood vision, things like that. Are we happy with that? There's a bit of a brief overview. Something else, Mr that come through that was it was your break over? Uh mhm uh So are you sure this comes up like in your T CT? What were they thinking? Okay. What is a seizure and epilepsy? We're gonna define everything and make it so simple. I don't think I actually just did this until after fourth year. Like I just always thought a seizure was just on the floor and I didn't know what the difference with epilepsy was. I don't know the cause is I didn't know the meaning. It's just so badly talk um or maybe I didn't pay attention very simply put, we will know the whole gamma good job nmda and uh the whole gather excitatory inhibitory balance in the brain when there's an imbalance of inhibitory and excitatory electrical signals in the brain. Very simply per but many causes many causes. I'm telling so many hyperglycemia, alcohol is roll, trauma, space occupying lesion, all these things from causing the balancing these excitation and inhibition, inhibition and then imbalance you get a free for all of electoral electoral activity. There is a season, okay. Very simply part epilepsy is that it is too greater than one basic. So one nerd, let's do some maxing two or more. That's the one I was sick for two or more unprovoked seizures, meaning didn't get hit on the head with a cricket bat seizures greater than a day apart. Meaning there's a trend to their seizures. So if one seizure is not epilepsy, epilepsy, or there's another caveat within and they might have to greater than two seizures because they're an alcoholic is withdrawing fine. They don't have epilepsy. So the third bit either's without an um unprovoked is what it means. Okay. That's what I'm trying to say without other identifiable cause focal book. So, you know, I said there's three causes like I mentioned three. That's like a full list of causes genetics, everything, mass effects, meaning a tumor, drugs, trauma, everything, sleep, why not throwing huge one hypoglycemia in very important a blood because of less than two exponentially increases your risk of having a seizure and die. The normal is about 4.1 by then. This is a reference. Okay. Cool, fine. I don't think there's any questions to ask that here is a snapshot because I couldn't always edited myself and I was very tired. What's the difference between epilepsy and syncope? Because in a question, it's not going to be that obvious. They're gonna mention you have to be able to identify extract information from a vignette and say, yeah, that's epilepsy. Yeah, that's syncope, epilepsy. The key things to look for are things like incontinence. If you've lost control of your brain, why have you got control of your sphincter's? You know what I'm saying? You shouldn't have that. I feel like I wanted that. Really? Uh, I think I've never had that. So, is that coin? Oh, okay. I'm going to miss this anyway. Still. Why should you have control of your fingers? You know what I'm saying? If your brain is losing it, why have your, it doesn't make sense. So they will end up peeing themselves or back ending themselves. They might bite their tongue, they will feel extremely drowsy and tiring. They've wasted all neuro transmitters in their brain. Basically one big shop. So they're going to be groggy, sleepy, tired, fatigued and barely awake after the season. Usually syncopal episodes. You're up and about, if you fainted, you're up about within five minutes, you're up and back and walking as if nothing happened, you tell people to leave me alone, right? Okay. Fine. So this thing we call that tiredness after a seizure is called the post ictal state. What it'll mean just means event in Greek, I think. So, post event state, okay. Be able to identify the epilepsy from syncope. There's actual keywords into loan. What is, what is clonic? What is uh myoclonic jerking? What it actually is. This is really for the stuff I'm not gonna go into it now is specific jerking motions because if you've seen someone have someone who stood up too quickly and then they fall down like a mean person, right? A single episode or they faint, they do jump on the floor a little bit. I don't know if you've ever seen people get knocked out as well and they, they do jump on the floor. They have like that's not a seizure, but it could be very easily described as one in the progress question. So you have to use these other distinguishing factors. Okay. Classifying epilepsy. Disgusting topic. 11 I want to focus on as this generalized and focal, generalized means is both hemispheres of the brain things messed up or is it just one hemisphere? Focal? Okay. That's generally what I want to remember. There was much more to distinguish here. But let's just keep it as that generalized and focal. The next thing I'll need to answer and have to think about. Is there impaired awareness or are they aware? So in focal seizures there either aware they're having a seizure or they are not aware, they lose consciousness if that makes sense. That's the way we describe them. It used to be described as primary secondary generalize that all these things right there still so generous. Okay. So just to summarize again, both hemispheres, one hemisphere focal, it's one hemisphere. If a focal gets on for too long and becomes big enough, it can become a focal, too generalized seizure. That's what was previously called a secondary generalized seizure. In a lot of big words here, a lot of confusion. I think I've summarized that really well in the next slide when it comes to focal seizures focal, as I said refers to a specific hemisphere and part of the brain, there are four lobes are going to be four types of focal seizures. You need to be able to identify all of these huge is every single one temporal frontal prior to activity. What does all of these mean? Read them in your own time? Atypical temple seizure will have an automatism and uh who's read the book Hugo Cabaret, that book? Nope. And Automaton is a, is a machine you designed to move on its own basically. So they'll have uncontrolled movement of their lips for example, but be able to continue what they're doing. They'll do that like that. This, that would be whacking their lips a little. So that's called an automatism. They'll have maybe Deja Vu or whatever for John gave you meaning never seen before. Fine. And then because the temple lobe has the olfactory and gustatory centers in it, they'll have, they'll be smelling things they haven't smelled in a long time ago. Like can you smell that? And it's onions? But they're sitting somewhere else gustatory, they'll have the feeling of taste when they nothing is them be aware of this frontal lobe. Typically a Jacksonian and these things top Todd's palsy. I can explain all of these Jacksonian March is like a twitching that goes up the arm to the head. Um Todd's palsy is opposes, they lose the ability to control some part of their body. This is all very, very annoying. I can't like. Anyway, let's just move on how they present. There are a few types of presentations. The main thing to you to be aware of is a rhythmic jerking of the arms. So, like this, like a, something like that, like should be up and down, up and down, up, down consistently and regularly. Okay. Um, there's things like where, I don't know if you've seen the episode on house where the woman has a myoclonic, the bus driver has a myoclonic jerk. Your numbers. No. Okay. Anyway, there's actually sick episode. Anyway, it's just one big jerk that so you just called a myoclonic jerk. One big factor like a shock, like an electric shock. Cool uh motor nonmotor genuinely read this up in your own time though. This one is a really important one. Absent seizure typically happens in kids and they get, because they get blamed in the question as being un attentive or sorry, inattentive and like disruptive because they're not paying attention. They lose focus for like 20 seconds every few minutes. They're having an absence seizure. It's not just that they're daydream, they will not reply those uh for like 20 seconds. Think of absence seizure. Fine. No, not reading any of that. That's just telling you the typical story of an epileptic uh vision. This is the most important part, postictal state. Okay. Read that in your own time diagnosis. A lot of words here. What did I say focus on criteria 12 or more unprovoked seizures more than a day apart? That is Eckel etc. No, there's this whole thing about how do we investigate it, right, or whatever? Ok. They've had a seizure how the investigator need to rule out other causes. So, are they using these grossly deranged? Are they so hyponatremic, they've got no action potentials left, are they so hypoglycemic? Uh I thought that something, uh uh what's that mean? Um hypercalcemia, all these things, hypercalcemia, all course, Asians, fine. You need to find a course if a child has a fever and then presents with a seizure. Are we going to call this epilepsy? What can we call it? Uh feeble convulsion. There is a phenomenon phenomenon where kids get seizures during fevers. They are at minimal risk of developing actual epilepsy. And it is not a real epileptic seizure. If they're more than two or three, the risk increases significantly. But that's the point you see, you need to find that. Is there an other explanation? If they genuinely have no idea what's going on, you can consider E E G monitoring your brain pads and stuff that looks done and then you can do Mri's to look for specific things. Did this camp in your case? Museum. Temple sclerosis because if it's a long day, no, I didn't. OK. Fourth cover that punishment. The general parts of management are three things. Um anti epileptic drugs or anti convulsants, drug yet, lifestyle and drive. These are the three things you have to know. So give them drugs, tell them, don't take baths, don't become a pilot. Um, don't bathe with kids and stuff with your own Children. Quote, it is not, not, I said don't, don't, okay. Cool. And driving as well as important. So there's two classes of cars, not really, you know, I mean, driving this country licenses, there's personal driving and commercial driving like HDB, taxi, stuff like that. Um The rulings on package, you have one seizure while driving a group, one vehicle. So like your own personal car is a lot more lenient compared to someone who's driving an HPV. Commercially. Be able to be aware, be a one of these really important, really important. Okay, fine. Must stop driving and inform the D D L F have to. You have said that this is probably the most important slide. If a person has one seizure and come to the G P, don't give anything, you don't know what's caused it. You need to query what's going on and this is not a GPS job. There is something called the First Fit Clinic. It's a neurology clinic that is what you send them to. And the neurologist will determine what has caused this season. They'll do a full panel bloods that we discussed a second ago. Glucoses and all that stuff using these everything. Okay. Fine. And they will be the ones that decide do we need to imaging and E G S? Please don't be that person in progress. Text that says E G is first line for investigating a seizure in straight. Also remark for MRI first and procedure in okay, have fun. Don't do that. Here are the list of all the common anti, absent of drugs. There are so many, the main one that is used and guidelines have just recently changed. Are these two lamoTRIgine and Levetiracetam? It used to be sodium valproate. You've heard of this one before? Really common drug problem is it causes this forms Children your tubes details, right? And there's even evidence to show that men who take it can cost, they can, their cells will be damaged and pass it on to if they're going to try and see with a woman, right? Especially women then. Okay. So guidelines have shifted so far. This used to be the first line for almost all the types of seizures. But now it's these two lamoTRIgine and never Tristan and the other ones can mess around. Let's have a look again. I was lazy. So I just copied from my notes. I'm not gonna walk you through this. You guys are very good proficient English mash on la Eilts everything. So you know how to meet. Okay. So please go through this in your own time. The one thing though is for focal and absent seizures. So absence and where's focal here the way I remember it is it's reverse memory if that makes sense. So in focal, see before L so that tells me it's Levitra certain or LaMotte regime. Then carBAMazepine same rule reverse for absence seizures. It's e sorry, it's s before e so you do the first then s reverse that make sense. So ethosuximide, yeah and the sodium valproate just read the name focal. Now, every time you see about focal seizure, look at the l first taken our lamoTRIgine Levitra stan. See Karma's absence s first then the ease. Okay. That means because that said it ethosuximide and then s so they evaporate happy. Cool, fine. There is one major two major complications, 345 major complications of seizures. Okay. The ones that we're gonna talk about our two status epilepticus Ts I'm Sudip, I'm not gonna talk about soda, but she's also on that one. So that just means they suddenly die. That's the main problem. Okay. So the worst I've ever seen you see it sudden unexpected death, neck collapse and student it does drop by a nice little fun. So imagine right now your death certificate sooner. Good way to go. Okay. What is status status? Just means you're, you're in that state. Uh George corrected and this actually the size of one before is any seizure that's longer than five minutes or more than two seizures within five minutes that do not completely resolve. What does complete resolution mean return of consciousness. So it's a very dangerous state to be in that. If the brain is continuously having those electrical mishaps and going crazy, you will get permanent brain damage, permanent brain damage will mean you'll use basil function, synthetic function person. You lose your heart brain and breathing function, you'll die, you're going to, you're comatose in your diet. So you have to turn off the brain, you have to calm down the brain the way we do this is like this. We give benzodiazepines you overflow them with, gather inhibit everything, even if they have too much gap. If you inhibit everything, nothing's gonna create. So you start off and you need to know these drugs, you have to know them. You have to know the right setting, you have to know what to give. So in prehospital you have got no IV access. So the best one is to give P R from behind dies upon if not in the mouth buccal right here. Medicine. Okay. M mouth buccal makes sense to me. Okay. And do you diarrhea if you wanted to just mention right now? Okay. When you're in hospital, first line is always the rise upon always IV LORazepam. Okay. You repeat it once or twice. I've seen two different guidelines on it. She can explain the dairy addict. We've been up there after I'll make a tiktok calling the question. Okay. The key drug. Now that's so we've given some LORazepam. Now we're gonna have some big boy drugs. Benny tone is a really important drug. This is a big boy drug that you give if someone's in status after 25 minutes, 40 minutes after, as it has been rinsed. The key thing is you have to do E C G monitoring with it because it can mess up the heart and stuff. Okay. I don't know if you remember that. Let's say they're still season you send them to. I see you now they've been transferred to start to. I see they've left resource. The I see you have to do RSI. You can tell my R S I s very good almost. He said rocket sleep induction. It's rocket sequence sequence induction. You anesthetized them in seconds, use ton of their brain completely. You give them a paralytic like rock, a neuro neuro knee. Um that one, if you have not seen that one, rocuronium, I see that means it definitely you paralyze them and then you give them a propofol or something like that or whatever or ketamine. Not this one. The also know that the one IV infusion. Okay. Basically you put them to sleep completely, you turn off the brain for them. Um okay. And then you consider doing other causes um pregnancy like a big spot. I was thing about that. Okay. Anyway, cool, fine. That's all of epilepsy and see just done. Wow. Any questions? That was a difficult second, two cases, the respect. Any questions at all. Anything was clarifying or Jorge Mario. Uh, it's MRV, the ground for three billion sites and most, some people that were really with. That's right. Oh, good. Okay, same time next week. Thank you. Just wait, wait. Yeah, if you want to get slides medal now. Okay. We're doing. What metal now do you have to scan or something here? Yeah. Which side is it on this one there? Yeah. The same day though. I'm sure you can same place if you're at the same place, same time here for an hour. Oh, wait. Uh So other funny uh uh session was, yeah. Do the feedback. Otherwise you're not gonna get slides. Uh I can't get it cleaned out of it. Uh huh. Big fucking ask your friends to come next time if you want to talk to you and the zoom people as well. You can't, you can't come in person, by the way. He, uh, something I have trouble. Uh uh okay. It's