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different present. So we'll be going through different neurological presentations on how to diagnose them. Investigate them, etcetera. So let's start off. So you've come up to your skin station on You have come up with this case. So you're a foundation. You one doctor, you're in the emergency department. On the patient is Mr Peter Parker, a 17 year old male who presents with a headache. So you need to take focus history, and we want you to start management plan, including pertinent investigations. So you guys that have been to our ski revision sessions already will know that we like to start with spot diagnosis. So I'm going to give you a clinical vignettes. A little description about patient on what you guys to type in the chat as quick as you can. What you think the diagnosis is? So to start off with, we have a 23 year old female she presents with the union actual frogging headache with associated nausea and flashlights in her vision. Any of those phone company in keeping coming? Yeah, really good guys. Yes. So well done. Everyone got that right. Amazing. So, yeah, it's a migraine on Dwell done to Those of us are a couple that have migraine with aura being really specific. So that's really good. And so what in this scenario suggest it's a migraine? Well, we've got this unilateral headache, which is typical of migraine on gets throbbing in. It's kind of character, which is also quite classic on the flashing lights, and her vision is referring to the aura that you guys spoke about. It's quite common for people to get a change in the vision because of a migraine. Does anyone know any triggers of a migraine? Could anyone pop them in the trap for me? What might trigger someone to have a migraine? Chocolate? Yep. Lack of sleep. Stress. Alcohol? 50. Yes, Pretty in Christ. You're already good. So some of you guys might have heard of the acne, Um, chocolate. It helps you to remember the different triggers of a migraine. So you have chocolate. You have hangovers, orgasms, cheese or contraception. Ally in alcohol, travel and exercise. See a really well doing guys. So next thing. Yet so a 19 year old male university student presents with a headache, drowsiness, fever and vomiting. Um, he has had his eyes closed when you've gone to examine him. What do we think the diagnosis is? Yep, builds Bones is coming in. Brilliant. Yeah. So meningitis. Yet So where? It says I'm supposed on examination. That's kind of hinting at Photophobia. So he's got a headache, is bit drowsy. He's got fever that could suggest infection on. He's got that photophobia as a 19 year old male university student. If we're going a bit stereotypical and for our SBA questions that we might get, does anyone know what organism my be most likely to? Of course, the meningitis. Does anyone know? Yeah, brilliant. Well, the guy's yes and no serious meningitis that that would be the most likely because he's a teenager and he's the university student. Great. Good job. What's that? So our next in yet so 36 year old male who presents with, uh, bilateral pressure type headache this time it's not made worse by activities of daily living on it is present for 20 days a month. Any ideas on the diagnosis? Yeah, really good again. Yeah, especially guys. So, yeah, this is a tension time. So can anyone typing the chapped for me. What features suggest that it's a tension, headache. What bits of that scenario suggest It's tension. Hand like pressure bilateral pretty and yeah, you guys have got the right idea. So it's Yeah, it's a bilateral pain. It's like a pressure. A tight band also said it's not made worse by activities of daily living so classically. Your migraines are made worse by activities of daily living, but tension type here. It's not so much on the reason why it's a chronic tension type. Headache here is because it's present for 20 days a month. Eso the difference between an acute and a 10 chronic tension type headache is in a chronic tension type. Headaches. It's there for more than 15 days a month, so 20 days he is definitely over that fresh old next one. So we have a 78 year old male. He presents the headache, which is the worst he's ever experienced. After he had some head trauma is worse and lying down. He's a bit drowsy, and, um, he's had a meeting. His heart rate's 100 50. He's got a regular breathing rate of 22 his BP is 1 50/75. Yep, you guys smashing it. Brilliant. Yep. So this is a summary, actually. Temperate. Well done on. The thing I was trying to get here is Well, is the fact that he's got a raised ICP. So can anyone tell what try out? I'm trying to elude to in this scenario. Yeah, brilliant. Smashed it. But if I see it, cushions tried. So Cushing's try it. We have our, um We have our regular respirations here. Um, we have the high BP, which is the which has also got a wide pulse pressure as well. S 01 50/75. Um, sorry, guys have just noticed it should have been abroad Equality and know tachycardia. Apologies for that on here. So a bradycardia, regular respirations and a high BP would suggest a raised intracranial pressure on. That's basically because, as you as your intracranial pressure rises, this so in this case, it's filling up with blood. Does bleed. There's an extra mass in there. Less blood is able to kind of force itself into the cranial cavity in order to profusion brain. So when your brain is getting less perfused, it's becoming hypoxic on. Do that causes kind of a sympathetic stimulation in your nervous system to say, Hang on. We need to get blood to the brain. So your BP increases and you initially do become sachi card It. However, um, that doesn't last long, because then your parasympathetic system kicks in and goes, Hang on. We're really we've got really high BP on then. It makes you bradycardic instead on the irregular respirations come from the pressure that's being put on your respiratory center center in your brain stem, which is when you're getting that raise pressure in your cranial cavity dates and pushing on that, which is then closing the irregular respirations. Great job. So your next one, a 40 year old female presents with a dull, constant headache. She has a past medical history of migraines. It's already known, and she takes her acute relief medication for her migraines about 12 days a month. Does anyone know diagnosis? Yeah, Pretty in. Yeah, really good guys. Yes. So it's a medication overuse, headache. And so if she's got past medical history of migraine does, they won't know what her acute relief medication that I'm alluding to might be. What class of drug trip tones yeah, fabulous. So, yeah, it could be something like sumatriptan could be combined with, like an NSAID paracetamol, that kind of thing. Um, but the definition of a medication overuse headache is when you're using either something like an opioid or a trip down for more than 10 days per month or something like paracetamol in sets for more than 15 days, eh? So in this case, she is using her trip tons for more than 10 days, so it's likely because she's overusing that that's causing a headache. Pretty, in the next month, we have a 64 year old female she presents with a severe headache, and it's blasted night. She has a red eye with people's that I'm reactive to light. And she has a reduced visual acuity. Any ideas? What that is? Okay. Couple of ounces in the chart. Any other ideas? Okay, so we've had we've had a few. We've had glaucoma, arthritis, temperature rises, that kind of thing. So well done. Those of you that put acute angle closure, glaucoma. I know this isn't something that you usually associate. Maybe with your different was for a headache, but it's an important one to consider. So it can produce like an ocular like an eye type pain, but can also present as a really severe headache is well. And does anyone know why it's worse in dark rooms? Why? Why is this female finding that it's worse when it's dark? Why does that suggest? Yeah, Brilliant, Yes. So basically, um, at night, obviously your there's not a lot of light around, so your pupils delay in order to kind of let in a more light on as they do that that kind of pushes makes the angle that you have in your eyes that lets out fluid. It makes it thinner on when it becomes thinner. That means that Lester it can drain out, and that can raise the pressure in your eye. And that can give you girl coma. Um, brilliant. Yeah, well, like I said, the next one. So we have a 30 year old male presents with a severe dagger like unilateral headache. It's focused around his right eye. He smokes about 40 cigarettes a day, and his eye on examination is red and watery, and he has a runny nose on. When you're trying to talk to him, he's really rest. This Oh, yeah, You guys have got it straight as I looking chap. Brilliant, Yes. So this is a cross. The headache. So, um, the pain typically happens in episodes last about 15 minutes away, up to like about two hours on down. It's the reason one of the reasons it's called cluster Headache is because it comes in clusters, so people will have about 4 to 12 weeks or so where they keep getting this pain lasting for about 15 minutes to two hours, I say, Um, and it's always centered around one eye, so in this case, it's always going to be this patient's right eye. It doesn't tend to switch between the two eyes between the different presentations. Um, and it's a really, really intense pain. It's really hard to deal with on. Patients could be really restless during those attacks and other clues here. Bread, watery eye, runny nose congestion. That's all very typical. Over cost A headache. Um, did they won't know whether smoking history is significant. Yeah, Brilliant. Yeah, well, don't see your smoking is a risk factor. Eso class. The headaches are quite common in both males on those smokers. Well, billion on our last stop diagnosis. We have a 37 year old diver. The presents with a pressure type, facial pain. Um, does anyone know it's worse on bending forward? Any ideas on the diagnosis for this one? They had a couple of ideas. Any any others that people want to put in the chart. Okay, yes, I think most people go with sinusitis, which is the correct answer. So why do people think it's sinusitis? Why? Why is that coming to mind? Yeah, brilliant. Yes, it's it's It's a facial pain. Brilliant. And it's also worse and bending forward, which is really important for this one. Because when you bend forward, it increases the pressure in your Sinuses. Which is what that occurs here on down. Why is it significant? This is a diver. Does anyone know you're Yeah. Pressure changes. Well done. Yes. So, swimming or diving anything like that. Their respect is a swell for sinusitis on smoking as well, which we didn't have in this history. But it's also a respective sinusitis. So brilliant. Well done, guys. You did really well, eh? So when you're taking a headache What? What do you need to ask? What do you need to find out. Obviously, start off with the essentials patients, full name, date, birth age, things like that. And then we'll move on to the history of presenting complaint. So Socrates, you'll probably have heard off as an acronym that used for pain when you're taking a pain history. But this could be used for lots of different histories, and you can work it, work it around, the different from the presenting complaint that you have. Um, so next case, you know, where is the pain? When did it start? Was it's character etcetera, for it's radiation? That could be quite important. So if you get a pain, the headache that radiates to the neck that could suggest meningitis. If you have anything to do with the eye, you might be thinking like glaucoma or cluster headache. Things like that, Um, timing as well. If you think, uh, headaches that worse in the morning. You've just been lying down for the last few hours. How, however long you sleep all on, so that could be a sign that if someone's got a headache worse in the morning when they're lying down, that could be a sign of a cause that's causing a raised intracranial pressure, so that's really important as well. Then we get on some more specific questions for headaches. So is that you need actual bilateral. So you guys have just brilliantly pointed out that your migraines that typically unilateral where is your tension type? Headaches are usually by natural. How quickly did it reach its maximum intensity? So, for example, with the subarachnoid you took it here, it's a thunderclap headache, and it reaches that maximum intensity just within a few seconds. Ready? So that's an important one to ask. Have they had any changes in their senses? So this could be something vision. Associate it with aura. But hearing smell, taste. Also good to ask about, um, nausea and vomiting. What's again could be a sign of a migraine. Or it could be a sign of race. Intracranial pressure, uh, phobia, neck stiffness, rushes. I'm sure you guys all know what that's pointed towards. Things that meningitis, um, sleep disturbance is similar to the timing's a swell. So if they're struggling to sleep, they're obviously hopefully lying down with the sleeping, eh? So if they're having issues with that, then that could suggest they raised intracranial pressure cause and I think that's been put in the chart a few times. Tenderness to the temporal region. What diagnosis is up suggesting? Yeah, GC. A giant, self righteous, all temporal arteritis. Yeah. Brilliant. Um, I pain. We talked about things that cost ahead. Eight glaucoma, that kind of thing on Ben. Just some other neurological signs as well. That already good twice. A loss of sensation, motor weakness, concentration, things like that. Then you go into your past medical history in your surgical history. So have they already got a diagnosis of the type of headache disorder? That's good to know. Um, have they got any malignancies? Which could be suggesting maybe that something's in the test sized and going to the brain, and that might be causing a raised ICP and things like that had BP, any bleeding disorders, previous surgeries. All these things have really, really good things to ask is well, is trauma as well. Then we go through our systems review. So I like to ask for main questions first, So fever, fatigue, unexplained weight, loss of loss of appetite, and night sweats mainly I use these for things like a malignancy. but they're good to ask, around or around as well. And then I try and work through the different system. So chest pain, palpitations, cough, shortness of breath, you and cardiorespiratory nausea, vomiting and sweating on syncope as well. Really important things to ask. And then we go on to our social family on drug history. So is there a family history of any neurological disorders Azul see later on in the presentation? Some disorders do have a family history to themselves, important to elicit the money to get our smoking history. Specifically, are they X Makkah current smoker? How many pack years except her on. That's really important, as we said, because smoking could be a risk factor for some things as well. Like we said, sinusitis and things like that. So it's important to know alcohol. Once again, these are things you need to know, and, as we said, they can trigger migraines, so that could be really important to know. But you can also get headaches that are caused by alcohol withdrawals. That's also important to know how, after they've been taking alcohol before, how often they taking now? Are they trying to withdraw exactly on Ben things like recreational drugs as well. So what are they taking? How often are they taking it? So you can get headaches with a lot of different recollect recreational drugs so you can get it with cocaine, cannabis and vitamins, that kind of thing. Um, obviously know what drugs there on the on any medications for any probably headache disorders. Are they on any anti coagulation, which might be pointing towards the bleed? Allergies are fire suit in yellow. Don't forget allergies. You don't want a favor station cause you get to ask about allergies and make sure to get that one in. And then a lot other social things as well on get the patients ideas, concerns and expectations. Billion. So four headaches. We have a few red flags, and we have a little handy pneumonic on which can help. Does anyone know the new Monica used for the red flags of a headache? Okay, this is different ones in our like this. Lots of different ones. Okay, The pneumonic that I like to use is called head pains. Do they want want type in the chat? What do you think any of those letters might stand for in head pains. You got a lot to choose from. Any ideas? What could be all red flags of hip pain of headaches system? Yep. Sudden onset. Pretty in. Yeah. I'm getting lots of amazing ideas, guy. So we're done? Yes. So this is the new monitor, but I like to you. So head injury. So has there been any history of trauma? I pain. So we just talked about some of the causes of high pain. I paying like a cluster headaches, things like that abrupt onset. You guys got really, really good. So yet we're thinking something like a subarachnoid are funded cup headaches, Um, drugs. So have they been maybe over using their medication or is a new They've started a new drug, and then the headaches come on. That's important to know. Are they presenting? Atypically so in where, you know, 100% sure what the headache type is? Um, you want to make sure that you read flag people, cause that's important. We find out what's causing it, changes in the pattern of the headache, or it's come on really recently. That's important to know. And if they've got high fever, so systemic symptoms, that's important. what exacerbates the headaches we said about position and things like that. Pregnancy or pay part, um so hope that, um being the period kind of just before and yourself childbirth is if they're having a headache, then that's important to know you guys talked about aged. So our cutoff is generally if they're above 50 years, and that's a bit of a red flag. If they're immunosuppressive as so, they're on any therapies, they have hatred, be anything right back. If they have a current or past medical history of cancer, that's important to know on day swollen optic disks. So that's putting towards Papilledema. So these are our main red flags off our headaches. So what I've done here, guys is I put together a summary table for you guys to make me read in your own time about the differentials of headaches and maybe talk through them in our spot diagnosis, and you guys seem very, very confident on them, which is really good. Um, I've sent him into our emergencies and breads are primary headache disorders in this pinky purple color, some other ones, and I any anti so you guys can get through these in your own time. So you've just taken your history. You're formulating your different to diagnose basis. Mean they need to present that back to our examiner. What's really important is when you do this, you don't as has been said before in the Siris. You don't want just regard to take whatever the patient said to you because and, you know, that's quite an easy still, anyone could potentially do that. You want to show that you process the information you've taken it from the language that the patient might use on your putting it in the language that, like a medical professional would use on gets shows that you've really understood what the patient said, and you're able to kind of put your thoughts together in any way. Um, so this is the structure at risk. Easy that we like to look you. So we start off with the patient's details on what they're presenting. Complaint is so, for example, here it's a headache, the history of presenting complaint. Then we talk through the relevant negatives. They won't know what I mean by relevant negatives were reinforced it a lot the Siris, but it's an important one to not forget. What does it mean by relevant negatives? Yeah, pretty. And yes. So it's it's things that complete you away from another diagnosis. And they're also red flags as well that we'd want to make sure that we include when we're presenting back. Good job, any relevant past medical history as surgical history, social history of drug history. You don't have to talk about all of it, but just pick out the bits that are really, really relevant. Teo Teo relate to your examiner and ice for the patient as well on then your top different, Um, why and then a couple of other differentials as well. So with the vignettes I gave you at the beginning of the presentation, say we have, um, Mr Peter Parker. He is a 17 year old male who is presented with a headache, So I covered the first books. His history presenting, Blake say, is a, um, headache that's been there now for a couple of days, and he's got some photophobia and neck stiffness that say on, but that's the main. But I've got from my short history of relevant negatives that say he doesn't have any eye pain or changes, envisions That's maybe rolling up things like a coma and my grains and things like that. Um, the actual virus, positive history, surgical history, social history and things. Um, so not too much relevant. Maybe he's the university student. As I said on that could be important to know on Go through ice for the patient on top. The French. Um why so with that history, What top differential do you think we're thinking at the moment? Yeah. Brilliant. Brilliant. Yes. Isn't that meningitis on? Then we could unless some other different was that one for a swell, for just to complete our relaying of the history. Good job. So acute headache investigations. So how do we break up our investigations? What different categories do we use if we want to structure are investigations. Yeah. Brilliant. Yes. Starting with bedsides, then bloods, then imaging. Fabulous. Yeah. So bedside bloods and imaging. So for any headache, these are the things that I kind of think you would want to be thinking about. So you want to start If they're coming in acutely a B c d. Always a good way to start any acute station along with some basic observations as well um it will be good to do a full neuro exam. So upper and lower limb can be helpful as well as a cranial nerve exam, just to see if they've got any abnormalities at all. And then we want to do for endoscopy as well. Why do we want to do fundoscopy? Yeah, pretty and papilledema. Yep. Looking for raised ICP? Yep. You guys got it pretty in eso then bloods. I think it's important to do FPC's. Just to look for infection is we'll see in a minute you want to do your LFTs and you're using these. This is a kind of like a baseline measurement, but it's also important to know because, say, if someone has like a change in their BP because of the condition, you want to make sure that's maybe not affecting their livers and kidneys, that could be important. Reason to do. Those on your CRP or your s are just once again to see if there's any information or any infection, which is really important for imaging. Because of the different differentials of headaches. You could have something like primary headache disorder, where often those are quite clinical diagnosis without the need of many invasive investigations. Imaging is important to consider, but it's no always used. So these are other conditions that I'm gonna talk through as to what extra investigations you might want to mention. So for meningitis, can anyone think of any extra investigations you might want to do If you think someone has meningitis number puncture, get anything else? Yeah, CT. Fabulous. Anything else in the blood blood? So the bedside do we think love coaches? Yeah. Pretty and ready. And anything else we can think of You've really got quite a good list. Any others, guy? Yeah. Yeah. Brilliant ideas, guys. Really good. So this is the list I come up with? Apologies. If the middle box is a bit small, um, so I think you should do a calculation screen. That's maybe you would do because if someone has an infection, sometimes they're regulation Congar. Oh, a bit. But we're didn't get quite a lot of these. And so it's important to check that their blood isn't doing anything abnormal. And then you do a whole body PCR as well, eh? So if someone's got meningitis, that could be back here, or it could be viral on diffuse you a PCR then it can help you to find the DNA from like, a bacterial causes a meningococcus all bacteria on that can obviously establish your cost of agent, which is really important to find out. Then you I said, blood cultures. That's really important as well. Another way to establish what your cost of age and maybe it might be, Um, glucose is good to do is well, eh? So if someone has an infection, that glucose might be high or low because we know that say, like, bacteria infections, they use up a lot of your glucose. So it's important to check that as well. And then you might want your blood gas either VBG or an ABG, depending on the patient. If someone has infection, this is kind of really important, because if they was going to sepsis, you want to know what their lactate is to establish. Are they septic? Are they not things like that? So, uh, VBG or navy will be really good today, and then in terms of our imaging, I've put a CT heads and ideally, you should do a CT head first before you do a lumbar puncture. Does anyone know why we do that? Why do we do a, um, city? At best? Yeah. Brilliant. Yes. So we don't want the brain to undergo coding. So if you imagine that you're probably doing the in someone's fine on the drawing out the CSF that's going to kind of pull the CSF, but surrounding the brain down into the spinal cord kind of make up this the CSF, you just run out on that. Sometimes it can bring the brain with it, which isn't very good. We don't want that to happen. So we want to do a CT had first, just to make sure that as you go, I said, there's no communicating cause of the raised intracranial pressure. That's not gonna cause coating of the brain on off. See if we do that. Do you see that? As you can see here, that is a contraindications. We should not be doing a number puncture, um, for a lumbar puncture. Ideally, you want to do those very quickly, ideally within an hour off someone coming into hospital just because you want to start the antibiotic treatment ASAP. But obviously, if number puncture is delayed, you don't want to delay the antibiotics either. So that's important thing to think about. Brilliant. Okay, So, temperature, right, is is our next one. What other investigations do we want to do for that temperature biopsy? Brilliant. Yes. Ah, brilliant. Yeah. Yes, I was a really important one. Yeah, well, the guys. So, Yeah. So what I've put here is obviously we've got the ears on kind of any headache, but you guys totally right. That's really important for temporal arthritis. You need it generally to be a of 50 for it to kind of be diagnostic. So, yeah, even though, yes, ours. Over here. It's very, very important into temporal arteritis that you get that done on. As you guys said, a temporal artery biopsy is really important. So for those of you that haven't come across it, basically, it's kind of a surgical removal of a small piece of the temporal artery from the side, whether I kind of getting the symptoms and then that sent to, um, some a to look to be looked at under the microscope just to see if there's any giant cells that could suggest joint self writing Center has temporal George's. Um Did they won't know what a problem is with temporal artery biopsy. What? What issues might come up? Yeah. You guys are on it? Yeah. Yeah. Skip lesions. Pretty it. Yes. So in this condition, the whole artery might not be affected, so you might accidentally biopsy a bit. That is fine on. Then. It wouldn't necessarily suggest that is temporally right. It's so that's an important thing to think about on down for vascular. Oh, just ultrasonography. I put that in here. Basically, that's an ultrasound of the blood vessels. Either the temporal or as well as the exhilarate artery as well. Because sometimes this condition can go down to effect kind of the vessels of the upper limits. Well, this is basically just no alternative for temporary temporary biopsy on. It's noninvasive. So you might see that you used but temporary biopsy. And he s Are you main things for temperature, right? It's called, um, unfriendly. Some hemorrhage. Any ideas for that one? What extra investigations? Yep. Those CT heads, lows of lumbar punctures. Brilliant. Brilliant closing screen. Amazing. Yeah. Ready goods yet? Because he's up the Crimea. Brilliant. That's really good, guys. Yeah, really. Well done. Um, so for this one for supper, right, Lloyd? It's a bit obscure, but I would also do an EKG just because if someone has a separate would hemorrhage, it can cause some e c t changes s. So I would add in a little ECD as well is really important. As I said before, if someone's, um, go, um, any kind of bleeding or a brain injury be anything like that, it can cause your glucose did go up. Eso it's important to do blood glucose there, you guys a clotting screen Really well done. So get once again coagulation, Congar Oh, they're weird sometimes if you have a subarachnoid hemorrhage, So it's important to treat um, a group and safe and across that she was already really important. Thing is, is generally done kind of for any hemorrhage, any bleed where there's a loss of blood. For example, in the subject with hemorrhage. When you treat it, um, which will go into a bit later. You might also lose blood, then a swells. It's important to have those bags of blood ready to go that are gonna be compatible with patients. But eso they're ready to go. If anything were to happen. You need your blood quickly. Um Yep. You guys must it on CT head and lumbar puncture. Very similar. So on a CT had what would we see in a separate college and a one Describe? Yeah. I'm just Sorry what you see changes would you expect? So you can see kind of arrhythmias. You could see a lot of things you can see Arrhythmias problem too cute e intervals on. Sometimes it can mimic a CSS. Well, yeah. There we go. This is popped in the chart. Thank you. Yes, a spider or star? Yeah. Brilliant. So you see blood in the basal systems on which basically dilations of the separate fluid space. And as you say it, kind of like a spider or a star. That's really good. Um, and the lump bunch of yet once again, as long as you've ruled out there's no communicating cause of the race ICP. That's really important to do that first with the CT. But you can do a lumbar puncture if your CT head is negative. But you still suspect the subject would hemorrhage, so I'll repeat that. So if you get a CT head executive, but you still think it's a suburb annoyed based on the history and things you can then do a lumbar puncture. You want to do this about 12 hours after the onset of symptoms because in the lumbar puncture, if I said you're looking for something called Sent the Premier, which is when the CSF looks a bit yellow and that's due to the breakdown of red blood cells. And you need to kind of give enough time for those red blood cells that are in the bleed to break down and travel down. Your, um, see efforts f that surrounding your spinal cord. So we allow 10 about 12 hours for that, and then finally, CT angiography or an angiogram story. So that's a really important because, well, can you guys tell me what's a common cause of a separate good hemorrhage under underlying what? What happens to causes of a rip roaring hemorrhage? Yeah, brilliant. Yeah, and your is, um's Yeah, good. So if we do a CT angiogram, then it will hopefully show us where the aneurysm is. That's burst or other causes that might cause is a bright blood hemorrhage, and that's important as well, really, in so Well, don't we? Don't know investigations an hour on the kind of the data interpretation side of the station on so lumbar punctures. We've kind of said what they are. So the idea is to get CSF from the subject my space surrounding your spinal column. So that involves inserting a needle into your back on getting that CSF out because they won't know what level in an adult. We usually in seven needle. Well, what landmarks we use. Yeah, brilliant lows. The correct answers Coming through a great job, guys see about health four or five. We use truffles line. So it's kind of if you feel for your top of your iliac crest and kind of do a line across that's kind of the line you're aiming for. That's really good. So we go through the skin. The muscle was the ligaments through the jury motto through the Iraqi revolted to get to that subarachnoid space, and they won't know why. Why we do a lumbar puncture. Why? Why would we have a do one? I know we've talked about it a little bit already, but why generally, why would you do along the way? Yeah, just check for CSF. Brilliant. Yeah. In fact, in CSF analysis collecting the fluid. Yeah. Brilliant. So, yeah, so if you want to analyze the CSF, that's been important. So if someone is saying is got meningitis, you want to see what's going on with CSF? Same with supper, right? Good hemorrhages. Well, um, if you might also use it, you might use a lumbar puncture needle to give saying epidural. So during labor for some pain relief, that's important. Indication. Sometimes you give medications for a number bunker a swell on. Also, if someone's got a lot of CSF, which is called hydrocephalus, you might use a lumbar puncture to get rid of some of that sees have to kind of relieve the symptoms. Um, brilliant. So, interpreting this lumbar puncture, what's the first thing we're going to do when we interpret a number bunker? So you get given what I've given you on screen. What's the first thing we're going today? Yeah, pretty. And what's on, guys. So, yeah, um, I've given you the patient's name, which we need to confirm. So we need to confirm the patient name, date, birth on by age. We want to see when it's performed. So it's today on. We want to offer to compare it to any previous number. Punctures. Obviously, a lumbar puncture is not something that's often done like very often. So you might not have a repeat. But it's important to offer to compare it if you can. And then what are we going to do? What would you guys then say? You don't expect the interpretation? Yeah, pretty. And I've had I've had some country to May. Yeah, what? It shows? Yeah, so I was I'd start off by saying What the results are so just kind of working away through. So we've had appearance result and it says it's yellow. Cloudy. We've had polymorphism 10,000. This is high based on the normal range, which is written on the right here. For these, we've got lymphocytes of four within normal range. Your glucose is low, so it's lower than 2.8 on. Your protein is high. It's above normal range. So does anyone want to tell me what type of Yeah, you guys got it? Any other ideas? What? What's the cause? Is it? What kind of agent? By tier? Oh, viral TV, that kind of thing. Yeah. Bacterial. Brilliant guys. Can anyone tell me why it's bacterial? What points to bacterial with this number one glucose is low high pollen, Most I protein. Yeah, Brilliant. Right? Well done. So don't worry. If you didn't get that, we've got a few other ones here. So I popped the normal values at the bottom of the slide. So can you Guys, I haven't given you the patient details, but you guys know that's what we worked through first. So can you tell me what the likely causes for case? One says that. Say, is it bacteria, viral TV? Fungal. I I, um Okay, we'll get you know what? I think we got your mixture. TB and viral made me. Which is understandable if I tell you the answers TBA. So why don't they put that anyone tell me why it's more likely to be TV than viral. What sport? Pointing towards TB. Yeah, the appearance is yellow for a start. Not clear. She's ready. Goods. Um, on Yaz. You guys have said the protein is high, which is really good. Okay. Case, too. What do you think this one is? Is it bacterial TV? Viral? Yeah, I've given away. Haven't I heard? Well, don't go see. Yeah, this one's a viral ones. It's clear. And it's mainly lymphocytes went many polymorphous glucose is in normal range, and so is protein as well. Uh, so it's viral well done on finding case three. What we think this one is bacterial TV viral young guy, Fungal fungal from Oh, yeah, brilliant was on of them guys yet, so that one's a fun guy, so we'll go through. Here's a little table that I have made you can use in your own time for lumber Country interpretations. Um, I had a question in the chat, so I'm just cancer. It problem. Also, many things like neutrophils basic fills us in a bills. Basically, they're generally the things that come up in your in a immune system so that your first response on where is your lymphocyte to let you be lymphocytes new T lymphocytes that are mainly used in your more adaptive response? Um, so the way I like to remember this are bacteria are really messy on. They're not very sneaky. So, um, they use up blue cose so your glucose is low. They they need the proteins to make their own products on. They change the color of the CSF. They're not very sneaky. They let you know that they're there, and they quite easily trigger the pollen. More PSA's. Well, the in a response. So that's why that goes up. Um, whereas I like to think of viruses is more sneaky and less messy, so they don't change color. The CSF on basically a lot of stuff is normal, so they've almost got away with it. But then they raised the lymphocytes quite a lot. So, um, and that's because only really you need the reductive immune system to deal with your virus is eso. That's why that's raised. And then for TB. It's kind of a mixture of bacterial viral, and you get these results on from guys the same. It's also kind of, ah, mixture of bacteria viral. The main difference is in your proteins. Their TB proteins brace for his in front guy. It's not. I was Australia. The most likely cause of agent for Mr Peter Parker, uh, is a shin of meningitis and you guys got it right. A team. It's That's a Roman a meningitis. The way I like to remember this is a bit of a crossing over rule with this table eso Whenever you go down to the next row, if you follow the arrow that becomes the second most common cause becomes the most common cause in the next road. If you look at this in your own time, hopefully the hours will help to make sense. So really good. We don't Our data interpretation so management. So we've got some meningitis. What do we do? So meningitis? A. It's an acute presentation. Usually. So remember, you're 80. That's really important. Then we need to give them some supportive treatment. So things that fluids and allergies or if they're in pain in it I got fever, gamesmanship, Iraq six, um, anti emetics that they're being sick as well. Then we need to do a contract tracing on informing public health Does. They won't know. Why do we need to do that? Why is it important that we contact Trace and that public health know what's going on? Yeah, pretty in. Yeah. So men and meningitis is notifiable disease on. Basically, what that means is that you need to inform public health authorities what's going on and that you've got a case of meningitis and need to find other contacts as well as well, see in a minute why that's important. I've also written here the medical management of meningitis. I'm going to let you guys read through. It made me in your own time, but mainly in the community. Start off with I am pen benzylpenicillin in on day. Even though you are giving that beauty, you need to still send them to hospital. But give that initially, if you're thinking meningitis Germany if you're once you're inhouse. Still you receive IV Kevin tax mean on bats. Before you get the results off, what infective agent is causing it If someone's that the extremes of age So less than three months or greater than 50 years, you give on amoxicillin a Z well and then after the organism as being identified, you can change. It is according to this box here. But let you guys read that in your in time. Okay, sir, my question for you guys when should mean Jacor called meningitis prophylaxis be given for close contacts. So we've said meningitis it. So we need to trace our contacts. We need to find out. He's got it. Does anyone know? When would we give a prophylaxis everything? Well, yes, and when someone's been a close contact. But we need to give them some treatment just because we think they might generate it. Does anyone know it's quite in obscure question. Yeah, you guys getting it really, really good? Yeah, Same household. That's really important. Yeah, brilliant. So there's two. There's two main criteria. So if someone has prolonged household contact with the index case, so the person you're treating doing seven days before they got ill, they need to receive some prophylactic treatment on anyone that's had kind of less time spent with the with the main index case. But as maybe the name really close contact, there's been some droplet or secretion contact around the time of when they were hospitalized. That's another time to give perfect treatment. Um, as he said, bacterial meningitis on meningococcus Meningitis is well, they're notifiable need to required by law. You need to let the government authorities in public health know and that prophylaxis that we just said for those two main groups of the top need to give that a PSA, ideally, within 24 hours after the diagnosis off the main case that you're dealing with on these other things that you need to get. So finally, I know this wasn't related to the case, but I think it's quite important our primary headaches and their management, and so, firstly, migraines. So we usually take a conservative medical surgical approach towards management. Obviously, with a migraine, there isn't much surgical what we could go for our conservative and our medical eso conservative. You might want to tell the patient to keep a headache diary. So get the patient to record when they're having the headache. What they were doing when the headache came on, things like that. It's really important for them to do that toe, identify their triggers of their migraines, as well as to see how effective that treatment is. So you might have started treatment, but they're still getting headaches every day, and that's really important. Obviously wants to identify the trigger. You want to inform them to avoid it. It were possible office. See if it's something like, um, no stress. That's not a quick fix for something to avoid. But you can give them things that lifestyle advice on so things that stress management, good sleep hygiene, keeping hydrated except her to minimize the amount of them kind of episodes of the migraines that they get on. You also want to give the patient information about support. They can get a swell s o. Something in the UK is called the Migraine Trust. This is a charity that educates patients about migraines and also helps them to manage it. So that's really important to tell your patients well. And then, in terms of your acute prophylactic management of migraines, so your acute medications are used. When you're actually kind of having the migraine, you're feeling it coming on. So we've said before, that's a trip down with either and said's or paracetamol as well. On prophylactically. You can give them one of these two drugs. Um, so you can give them a copy roommate. But you shouldn't use this in women of childbearing age. Does anybody know why? Why do we not give to Paramount's in it in childbearing age? Women? Yeah, tractor cardiogenic. Any other reasons? There's a couple to rest. A cardiogenic is one. Does anyone know the other? Yeah, I just I just had a progressive. You the really well, really well done. CIA to rest. A cardiogenic is the main one. It can also reduce the effectiveness off hormonal contraception. And so, if you're taking this, but you're still taking contraception, your hormonal contraception might not work as well. Which kind of see cause cause issues and women of childbearing age that maybe don't want to conceive. So Democrats avoided and women of childbearing age on. But we can also use propranolol as well as prophylaxis but off. So we don't give that in asthma because it's a B two blocker. So for attention are crossed, I purposely left thumb off. Do they won't know the acute management of a tension headache in terms of medical management? Yeah, brilliant. Simplon a Jesu and said's pretty in. And does anyone know the prophylactic management of a tension headache? Yeah, lifestyles, a good one? Anything else that we could give them for a prophylactic? Lots of ideas coming through. Okay, so person is on Wednesday. It's usually all acute management with prophylaxis. They actually generally advise Act upon show, usually about 10 sessions, is quite good for prophylaxis as well, and they give that over 5 to 8 weeks really good. I would cost a headache. Same question. Acute management of Crestor headaches. I think someone already put it on the chart. Yeah, pretty And yeah, 100%. High flow oxygen. Brilliant. Um, prophylactic management. How can we prevent a cluster headache? I think this. So it's already been put on the chart as well? Yeah. Ever after meal. Really? Well done, guys. Yes, our 100% oxygen Because we said cross Alex quite severe. They often do present more acutely. So you want to give them oxygen on? You wanna give them a subcutaneous? Tripped on a swell on prophylactically. Bracknell Calcium channel blocker. Really? In a while. Done, guys. So we got through our first section. Very well done. Let's take a break for But it got so on to our next presentation. So on, Except instructions. So you have your foundation. Year one, doctor, you're in the emergency department again. On you're seeing Mr Making else. Who's an 86 year old male who presented weakness once again? Take a history on initiate a management fun. So once again, our spot diagnosis. So let's let's do this. So you have 40 year old female she presents with motor weakness that's been ascending from her toes up through her legs. She had gastroenteritis one month ago. Any ideas? Um, diagnosis. CVS, CVS, CVS. Really? And well done, guys. So can you tell me in the trap? What parts of this vignettes? Guess it's Gideon Bari syndrome Ascending? Yeah. Ascending weakness. Recent gastroenteritis? Yep. Yeah, brilliant Wasn't going to get The fact is descending classic for Gilliam Bari. It's following an infection. So typically the cider is something like gastroenteritis. Um, or it's a respiratory infection as well. So for those of you that haven't come across getting barring before, this is when there's kind of a demyelinating in of the purple nervous system where when you have one of these infections are the gastrin writers are like, um, respiratory infection your antibodies made against those. But when the enterprise, um, it made against that infective agent, it also matches Those are on your mind and she for your axons in your nerves. So then it finally goes to the antibodies, go on to attack those as well. And that's what causes the demyelinating. That's why it follows on from pretty good. So your next one So it's an 82 year old male presents that insidious weakness that's developed is likes. The weakness improves with muscle use. He's a smoker, and he has lung cancer. Any ideas? Yeah. Any ideas? Keep open them in the chop. Yeah, this is the heart. Guys don't know if you got this one, but I can see some of you got it in the trap. So the answer to this one is Lambert Eaten syndrome. Why does anyone know why I have pops lung cancer in here? Why? Why is that relevant? Yeah, pretty in. Yeah. Well done, guys. So it's It's apparently a plastic syndrome. Correct? What type of I think some people put it in the chart. What type of lung cancer is it associated with? Yeah, Pretty well done. Yes, a small cell. Lung cancer is typically seen. Remember, eaten syndrome. Um, so in this condition was again. It's kind of involving antibodies again. Um, this time, what happens is you're typically your your lung cancer. Your small cell lung cancer. It produces antibodies against calcium channels that are found in your priest. Sign acting. You're on. So if you think it's an antibody, it's attacking the pre set up and you're on calcium channels. You're not going to get those impulses going across. Do your postsynaptic. You're on. And so you're not going to have to send the signals that on the neurons. And, you know, you're gonna get this weakness. Basically. So next one. So a 55 year old male presents with weakness over the left side of his body on visual field testing his right visual fields in both either lost any ideas on the diagnosis. Yeah. Yeah. Brilliant. Well, some guys. Yes. So this is a stroke. So I've said his right visual fields in both eyes. A loss? Does anyone know what type of visual field defect? That's, um, that's alluding to Yeah, Pretty. And, yeah, I'm on, Um, a semi anopia. That's really good. Yep. So, um, he's losing both the same side in both. Isis is losing his right visual field in both his left on my eye. So it's a homonymous meaning kind of same side, same anopia. Meaning, like, half of your vision. Um, Andi, you I think someone's already put it in the chart as well. Well done. They won't know what type of stroke this is. If I said it was an ischemic one. How we cast If I it like a tax or packs or things like that, they won't know how this would with the weakness and visual field defects. What type? Yep. M C A. That's the alter. It affected Really good. They wanted the classification. Which one? It is. Tax packs. Yeah, brilliant is The PACs will be going through more of that in a second, So that should make sense. So a 21 year old female presents after a knack of femur fracture. There's weakness in pointing her toes to the ceiling. What type of weaknesses she suffering with? Yeah. Pretty in Yeah, Common paraneal Nerve injury. Ready? Good. So yes, So what? My alluding to where I say that she's having problems of point Your toes to the ceiling. Yeah, brilliant. So she's She's struggling to Dorsey fax on their four. She's having a foot drop on the neck of the fibula fracture. That's sometimes a common cause for comparing the owner of lesion because that's kind of following the course of the nerve. Pretty good. So 38 roll female. She presents a proximal muscle weakness, which worsens during the day, just as double vision has a past history of rheumatoid arthritis. Any ideas on this one? Yeah. Brilliant. Yeah. Brilliant. We've had a few lows come in. Pretty good. So Yeah, this is my senior gravis. Um, so this is kind of I kind of think this is opposite to Lambert Eating syndrome. So, Lambert Eating syndrome. We've said that improves with the muscle use, but with my Stina gravis, it doesn't actually gets worse the more you use it. So that's what I'm alluding to with. It worsens during the day, so she's been using her muscles a day. This weakness is just getting worse and worse. Morris, um, with myasthenia gravis in this condition. Once again, it's another condition related to antibodies. This time you get your antibodies against acetyl koning receptors in your neuromuscular junctions or the junction between nerve in your muscles On The reason why it worsens with activity is because the more those receptors are used with activity where you're trying to stimulate them, the more of them are going to become blocked up. So that means that even though you're stimulating them or the weekers just gets worse and worse and worse. Does anyone know why I've took a double vision? Why? Why is she getting double vision? Yeah, brilliant. Yes. Oh, yeah. She's getting weakness in a intraocular muscles as well. The muscles controlling the eye so you can test this in a person. You can see if the eyes muscles are getting weak by getting the patient to kind of repeatedly blink a lot of times on, defined in a patient with my sting myasthenia gravis is as they blink. A lot of times you're using that the superior proper breed muscle a lot on as we said, That makes it. We can we can. We can and you gradually get a worsening, worsening Tosis. So your eyelid droops as that goes on on. The reason why I mentioned rheumatoid arthritis is this condition is often associated with other autoimmune conditions such as rheumatoid arthritis. Brilliant. So next we have a six year old male who presents with proximal muscle weakness, and you notice that when he's trying to get up, he puts his hands on his legs and that helps him stand up so they won't know what this one is. Yeah. Brilliant. Are you guys already beating me to my questions while the, um so yes, this is Duchin. That's muscular dystrophy. So this is a genetic condition typically present to get a younger age is we could see with this case on. It causes a gradual, gradual weakening and wasting of muscles on. You guys already said this this sign where patients kind of use their hands to get up when they stand, it's called Gowers. Sign on. Basically, what patients do is when they sit down. They kind of get into, like a kind of a downward doggy yoga pose on their work, their hands up their legs on That's called Gowers Sign on. But it's basically because their muscles of their pelvis that would normally kind of help us sit up right and help us stand are just really weak with this muscular dystrophy that, after being on eso, they don't have enough muscle strength to get themselves to stand up. They have to use their arms as well ready goods. So then a 60 year old, 62 year old male presents with gradual onset clumsiness. He's dropping. His Margarete on D also has slowed speech on There's a family history of this condition on examination. There is weakness. Hypertension. Oh, on vesiculation is that you find any ideas What? This is? Yeah. Brilliant. Yep. You guys have got it. So it's Motrin urine. Sees any ideas? Why, this is not a neuron disease. What's pointing you towards that diagnosis? Yep. For circulations. Yeah. Brilliant. Well, some guys. Yes. There's both upper motor neuron, lower motor neuron signs. So the particular Asians is that up? Motion? You're on a low motion. You're on lover lover. Brilliant. Um, weakness. You kind of seeing both Hyper Tonia upper or lower. Uh, brilliant. Yeah. Well done. Um, so, yeah, that's really classic of motor neuron disease. You're not getting really any sensory symptoms. You're just getting these muscle symptoms, which obviously lines up with motor neuron disease. Your typical patient is this kind of presentation. So it's a later or middle aged man usually in his sixties, might have a family history, because that's quite common with condition. And there's this kind of insidious, progressive weakness that happens on with different muscles in the body. Typically first noticed with the upper limbs on, they can become a bit clumsy, so they might drop them exit. You're not drop things like that that you might noticed. Um, and they can also get slurred speech as well. But the thing you guys probably need to know it's the most is the have both upper know much your insides. That's very important. So, front of case, 34 year old female presents the fatigue, upper limb muscle weakness, pain on my movements on union actual vision loss, you shine a light in one of our eyes, and it appears that both eyes then appear to dilate. Um, previously she's had an episode off. Lower limb weakness is Well, any ideas what this diagnosis is? Yeah, lots of ones in the chart. Pretty and yep. What's on? See how this is multiple sclerosis? Um, once again, why do you guys think it's this? What? What's pointing towards M s? Different episodes? Fantastic. Helped in your eyes his Brady and Yeah, really good guys. Young female. Yes, really good. So with a mess, there's this kind of chronic demyelinating of the central nervous system, and then you guys appointed out common first presentation of m s is optic neuritis. Um, and that's probably the most common presentation. And you say, um And so that can cause, um this, um, feature here, which is when you shine a light in one eye, both eyes appear to dilate. Does anyone know the name of that sign? R E P t. Fantastic. Yeah. On as you I says, is different episodes. So we've had lower limb weakness before. Um, we fed up a little muscle weakness this time and problems with the eye. So that's really important in a diagnosis of MSU. Need the attacks to be differentiated in time. So any stroke up to 10 times and also in space. So you need two different lesions. Sites for it to be categorizes a mess. Fantastic. You guys finished that pretty. And so what do we need to ask in our weakness history. So I won't go through all of this again because we've been through it. But for our history, presenting complaint was again work through Socrates to the best that you can. You can work it for a weakness history. Then we want to know the pattern and the distribution of the weakness is what it start is ascending is the descending. You guys have talked about how I'm getting bar is to begin a sending weakness, so that's really important to know. Then we want to know the severity of the weakness. Or is it a bit like motion urine disease? You just a bit clumsy? Always. It may be a complete paralysis where it might be caused by saying like a stroke. For example, Um, how quickly does the week is? Come on, Really important is intermittent is always there. That's very important. How long did it last? Well, and does it change with if you're using your muscles that we talked about? So if we use on the muscles, it improves the Lambert eaten, but it worsens in my Stina gravis. That's important to know. Um, how is the weakness doing? Is it getting better? Is it getting worse? Does it have kind of, um, relapsing and remitting kind of fluctuations? That's really important to know. So, for example, M S tends to have a relapsing and remitting course, so that's really important to know on was the only sensory disturbances as well. So, for example, with motor neuron disease, you know that you're not really gonna get any sensory disturbances because it's a motor neuron disease, whereas other conditions. You might also get, um, sensory losses say, for example, a strike. And then for a past medical and surgical history. We've got risk factors for stroke because that's a That's a common cause of weakness. And I've written them here. Typically, your cardiovascular symptoms that are really important to know for something like a stroke where they have had one before Have they had a t i a is low, eh? So you want to kind of know what happened when they lost have the stroke or the t I A what deficits did they have last time what happened in terms of their medical management? What What investigations happened? What treatment did they get on Baskas? Well, what neurological deficits they still have from that first stroke because you might find deficits this time, but it's not been caused by what you now think is a second stroke or a t I A. It was already there. So make sure to ask all of those, um, and ask about any surgeries as well. Um, and head trauma. Do you guys know why it might be important to us about what surgeries they've had? Why would it be important to know about surgery. Yeah. From about Isis. Yes. That's important to know. Have they had any treatment for anything? Anything specific about? Like, um, when we go for surgery, there's something we worry about because patients are moving a lot. Yeah. Brilliant. Yeah. So if someone's having a surgery there immobilized for quite a long time, they might have venous status. So they're, um, Blood flow isn't as quick. And you're more likely for clots, which then could lead to something like, Yeah, could lead to individual E. If someone has a defect in the hole, it could also, uh, lead to a stroke. A Well, so that's really important to know. And then we've already gone through systems on our social family history, so that's fantastic. Once again, I've made you guys a little table just summarizing what we've talked about already in terms of our differentials, the weakness. You read this in your in time. Okay, so then our investigations. So you guys have already said we break this down into bedside bloods on imaging. So for if you want to investigate weakness, give me an idea of some of the bedside and bloods on imaging investigations. You probably do for most, if not all witnesses. Yep, I'm loving how ABCDE confess. Pretty. And that's great. Yep. You guys know your eye exams. Brilliant. Yet upper lower. Um, anything else you do with a B C d. Anything you When you first kind of triage somebody off spray and yet fantastic. Any other investigations? You said like neuro exam glucose. That's pretty good. Would you do any other? He's asked. Pretty good. Yep. Training on our exam. That's why I was thinking Well done. Really, In any bloods. Now, you like to do anything like that. Any bloods or imaging that you think probably should be done Castro yet baseline quitting? Yeah, Okay. But we've had a load of good ideas in there. Guys about done so Yep. Bedside, You basically got all of these. So a B C d e. Classic. First thing you say any acute presentation along with your basic labs and in this case once again for your exams are lower and create enough on fundoscopy, which we said was important if someone's got, say, like, a raised ICP that you might see a strike. We also want to do like a urine dip or glucose? Does anyone know why we want to do that? Especially think about stroke? Why would we want to do not straight person specifically? But if you see someone think you think that they've had a stroke, why do we want to do that? Glucose, Yeah, brilliant. Well done, guys. Yes, it's a strike mimic. So if someone has a deranged glucose that can sometimes be a straight a mimic, sometimes we want to rule that out before we say someone's had a strike. Pretty and and so Blood's I've been a bit on descriptive, you guys is that came up with some really good ideas, things like cholesterol. If you want to check for kind of cardiovascular risk factors, that's really good on go. Once again, I probably do. FBC just a little for kind of things like hemoglobin. If they have leaves and things and infections and things like that. Um, I probably want to do LFTs and use knees, especially if people go for CT scans and things like that. You want to check the kidneys on kind of performing badly before you give them contrast for a CT, things that, um and CRP And here's our we said for any information I think is really good on in terms of imaging, probably a CT head would be good for most forms of weakness just to rule out things like strength. Really good. So we're gonna go through some extra investigations for these conditions. Here is Well, um so strike. You guys have kind of mentioned already. What investigations would you do? Fistric MRI, but in CT yet granted the upper fantastic. Me See, J j Brilliant. Crowded. Yeah. Pretty and cutting. Fabulous. Well done, everyone. So yeah, I kind of included ECD and Basic labs, but I probably should have also put it in this top box as well. So yeah, definitely do an EKG in stroke on. Also do a visual field assessment because we said they could get that homonymous hemianopia. You would kind of do that with your cranial nerves, but make sure it's kind of a formal assessment When you suspect a stroke a Z guys alluded to I would do things like a lipid profile. The things like a stroke on HBO. One c um, the kind of cardiovascular risk factors on also a crossing three as you said, If it's maybe a hammer Oh, object stroke. We want, um and they are potentially losing blood and things. You want to see what the croutons like then, in terms of imaging? Yeah, I've talked about, like, an MRI here. That would be really, really good to do. Um, if your CT head wasn't yielding any results A carotid Doppler. Really good. If you had, like, an ischemic stroke that you thinks come from like a carotid lesion, some problem in the carotid artery, then Yet the carotid Doppler on maybe a 24 hour EKG as well. And so you could do like a simple 12 e d. C g. That would be really good to do is part of your basic ups. But maybe if you think someone has a F on that's caused them to throw a clot, you might want to do a 24 hour EKG just to check that as well. Bringing Gideon bar A Any ideas on any and the investigations we do for getting blurry? These are quite hard. I think weakness is probably one of the hardest your atopic, so don't know if you're not sure. Lumbar puncture, fabulous nerve conduction. So he's really good nerve conduction. Ever notion. Brilliant. Yet you guys have come up with great ideas, blood on. So in terms of blood. What I would add is these antibodies here, which are called anti ganglioside antibody. So typically the ones you see in Gillian borrow as you guys said, nerve conduction studies really important. So you're going to see that you can have decreased nerve conduction because of that demyelinating that we get. Indeed, Gillian Barret's That's really important. Um, Spirometry. Why do we do sperm tree and getting blurry to say one, though, But in any other ideas in the shop? Yes, pretty well done. CIA in respiratory in really severe disease, you can get respect your muscle weakness. So we want to see Are they struggling to breathe? That's a really important thing to do on. As you said as well, we want to do a lumbar puncture and Gideon Bari. So in getting Bari does, they won't know what we'd see. Lumbar puncture. It's quite a hard question, but does anyone know what we would say? Yeah, brilliant. Yes, we get a raised protein in getting blurry, and that's because where you're getting this demyelinating in your nerves of coming quite inflamed. And there's, like, widened widespread information around you like nerve roots and things. And that kind of releases your protein. But because there's not really any infection or anything like that, your white blood cells and your glucose and things are normal. But you just get this kind of raised protein ready goods, my senior gravis. Any ideas on this one? Yeah. Brilliant anti. Um, acetylcholine receptor antibody is happiness. Any other ideas? Maybe Any imaging? We've used one of them. CT. So rocks. Brilliant. Pretty N c t thorax. Brilliant. Yeah, I think you guys got the main ones that you're gonna need to know. So acetyl carnitine antibodies on your musk antibodies? A small So you're anti muscle specific Tyrosine kinase is anybody's that typical ones that you see in my senior gravis? That's very important. Um, your single, my single fiber electromyographic. This is an investigation that you can use to measure the electrical signal kind of across one motor conjunction on. That's really important to do, because it could help you too. See that myasthenia gravis is going on because we know that that kind of effects are, um, your muscular junctions. That's really important. Um, spirometry similar reason We want to make sure that they're not getting any respiratory muscle weakness is struggling to breathe. Um, this test here is a bit is a bit, um, obscure that you guys might hear about it. It's basically, um, a test to see how acetyl carnitine kind of reacts in the neuromuscular junction. So basically, you give, um, a dose of joke called neostigmine on DNA. Normally, if you think of your neuromuscular junction, you have your acetylcholine going across to your postsynaptic receptors on. Then when it's done its job, it's broken down by an enzyme coal called choline esterase. And then that brings the acetylcholine back and resets the cycle basically, on this drug that you give me a stick mean it blocks those enzymes that break down acetyl carnitine. Um and so what happens is you get less. Is he talking? Breakdown on. So the levels of a seat up hurting in the near muscular junction go up. Um, and that relieves the muscle weakness because a zoo, remember, the more you use the muscle on the more receptors there are, the more the week first gets first because your acetylcholine is being used up eso If you increase your acetyl carnitine, then you're gonna relieve the weakness. And that's diagnostic on DC teeth or X. A lot of you guys put it in the tractor. Really? Really Well done. Why are we doing a CT for X? Why is that really important in my Stina gravis? Yeah. Brilliant. Pretty. And yep. Fine. MoMA. So you there's a quite strong link between Thymomas on day, which is basically a tumor of the fine miss gone on and most and gravis, both people that have my senior gravis can develop for moments on both people that have farmers can develop. Myskina grabs. It goes both ways. It is quite important thing to check. Really? Well done. M s and I did for M s number function pretty and and MRI Fantastic. Yep. Those in the main two ones I've got here. MRI? Yeah, really good. So we use a t two MRI with contrast, and we use this contrast. Basically, this is kind of a special type of contrast that helps us to identify a demyelinating in. That's why we use it in a mess on a lumbar puncture. Is Ayman low? Yes. I was written in the chart. Really? Well done. You can get these oligoclonal bands that you see an M s on. That's basically due to the breakdown of the mining myelin sheath at different times. So you get this kind of banding pattern on that shows that you're getting demyelinating in at two different times. Which is important, as I said in the diagnosis of MSN needs to be different place in a different times. That helps with that diagnosis. Really in I'm finally muscular dystrophy. Bit of a hard one to end on. Does anyone know any? Only one. A couple? Yep. Muscle biopsy. Ck Brilliant. That was one of the ones I was going for. Genetic screening. Fabulous. So yet greeting kind of these typically raised in muscular just distribute because the muscle wrapped free. Someone said muscle biopsy that is correct is sometimes these muscular dystrophy. How have genetic testing is now has now replaced muscle biopsy is like a diagnostic test. But if he said my muscle biopsy, that has been done before. So really well done. That was a tough side. You guys flushed it. We're done so we don't Our investigations now on two a day to interpretation. So if we were presenting a CT head have written on the right hand side here what we kind of should be doing. So I'm sure you guys know state the patient's name, the date birth, costal number, anything you're given like that, cetera. Then you want to state the modality. So is it a CT? Is a Remeron, etcetera on the plane of the imaging. So can anyone tell me for this image on the left? What? Plano we in? Because, um Satchel? Yeah. Brilliant axial transversus. What was looking for? A brilliant weird, um, uh, then state date and time off to compare to previous scans. Once again, ct. Xanthan day today for patients is something they probably get done very often. So compare if it's available, then I would say kind of what you see in the image on state your differentials. Morning. Justify it, um, And your justifications come with kind of how somebody's presented kind of earlier in the station from the history and examine. You got things like that that should match kind of the CD that they're showing you. Hopefully eso Does anyone wanna start the presentation of this? This one on the left? Here. So what you gonna start by doing what? We're gonna start giving you the image and the techs on the left. What do we want to do? You first. What you gonna tell me? Yeah. Patient details. Radiant. Yeah. Totally missed any start early. And when it was formed, except for things like that. So you guys already said it's actually would have said day in the time. Competitive to previous scans. So let's skip to what you see. What do you think you see in the original left? What is our abnormality feel like? Can you see any abnormality? What do you think's going on? Many? It is. Yeah, buddy. And if you don't think there's an abnormality, do you say, Yeah, it is No, it's normal. CT. So this is quite nice. Normal CT. In this case, you say no abnormalities that I can see. I believe it's normal. Normal CD. Brilliant on. Then you could stay. Your different was that there was a pathology. Brilliant. So I'm gonna do a bit of spot diagnosis, but for CT heads. So when he's nice and quick in the chart. So first one, what's that showing brilliant, great speed guys yet? So either an extra urine epidural. So this is typically a biconvex or I like Think of it is like a lemon shape on it doesn't cross any suture lines. That's pretty important to remember. But in next month, what type of, um, ct You can't hear space occupying. Lesion of kind of. See that? Yes. If I was to say, this is a type of hemorrhage. What type of hemorrhage we thinking is? Yeah. Brilliant. So, yeah. Uninterested interest. A report. So this is kind of any bleeds into the brain parenchyma that we've got here. Bring it in next one. What about this one? Was getting kind of kind of going on the lines of beats. Subdural, subdural chronic. Yeah, Brilliant. So I recall this one is a bit sneaky. I would cause kind of an acute on chronic subdural on Wasn't a little view that put midline shift is Well, there's definitely some midline shifters we can see for the ventricles. So you can kind of see there's a dark, a bit of blood, which is kind of our older blood. If you like, but I would also trying to commit to you. There's a little bit of light of blood here. So because of that, I would put an acute on chronic subdural. Yeah, you guys got it right? Subdural one. That's cause it's present shape and it crosses the suture lines. Brilliant. Next one. Any ideas of missile? Kind of going on the lines of lead still? Yeah, but in Intraventricular already gets we can see this. Acute garden vegetables. Fabulous. On last one on this light Seborrheic. Yeah. You guys got it about Spider. East are shapes. It's white hypodense. You guys got it? Well done. Next, I lost three one on the left. What do we think that is? 100 effortless. Pretty and well done. Middle one. This one's quite non specific. Yeah. Brilliant. Yeah. Space occupying lesion. So it could be It could be something like a tumor. It could be something like that. It's a bit hard to say without the kind of history, but yeah, and that so really important. One to know. Don't know what time. So we've had a CT does. They won't know what type of imaging is in the middle is it. Is it a CT? What? You think of something different? Yeah, I'm alright. Brilliant. Well, um, and our last one. What type of imaging is it? And then also, um, what's the pathology with? I think this one's a bit snaky. I think this is quite sneaky. Yeah, some of you guys got it yet. Sadly, there is. There is a brain, I'm afraid, um, someone's messaged. It's a skull fracture. It's very, very hard to see, but Well, don't you guys got it? Um, diseases. Girlfriend here. Um, as a little tip. When you're looking between suitors and skull fractures, look for symmetry on both sides. So if you have a suit, your typically they're symmetrical. Whereas with school fracture, it won't be on. You can also see here I can convince you. There's a bit of, like, soft tissue swelling here that might be just soft tissue swelling. Or it could be things like a hematoma. So look for those as well. Um, and typically a fracture. Sites tend to be quite back straight. Where is your teacher? Signs tend to be of It's exactly so. That's have differentiate the two really well done. So let's say Now we've got a traumatic brain injury and you need to acutely manage them. Um, what's the first thing we should do in an acute management of any condition? Brilliant, Watson. Guys, I'm very happy. Everybody put up really bad. Um, yeah. So a b c d e. So we're gonna talk through the AB CD more specifically of a traumatic brain injury. Eso for a You check in the patient's talking, um, on back gives you a good idea that they ever ways painting performs my way movies if you need to. But there signs of basil. Skull fracture. First of all, does anyone know any signs of basal skull fracture? What would suggest someone's fractured front of the basic disco hand eyes recognize yet pretty and yeah, brilliant. Those are the classic ones. You can also get like CSF leaking from the ears or the nose. You can also get battles. Sinus Well, which is where you kind of you get bruising by the mastoid process just behind your ear. Andi, don't insert nasal pharyngeal area, but we have a basis. Girlfriend. Um does anyone know why we don't? It might seem obvious, but why do we know insert a nasopharyngeal worry. Yeah, Brilliant. We don't want it to go anywhere near the brain or the cranium or anything like that. Really, Really wasn't pretty. It's then be so oxygen saturations using your pulse oximeter. Check the respect to wait. As we said before we check the pattern of breathing, so is it. Deep is irregular, which could suggest you got raised intracranial pressure. And then you wanna if they're low on oxygen, starting on high flow normally. Breathe those initial air on auscultated chest. Check for trick your deviation or things like that. Really important. Sorry. Then see, we want Teo. Think about our circulation, so check the pulse, but pressure. I'll see if they're fluid overloaded the hypertensive, things like that. And check the heart sounds. The blood's going at this point. So FB sees things like that. Get your E c g. That's really important. Um, you want to aim in a traumatic brain injury aimed for a kind of mean arterial pressure about above kind of 90 to checking the BP is really important because you want to, um, kind of see if you can work out because of the bleeding. Um, so if someone's hypotensive, that might just got hemorrhage things like that. So use the BP to your vantage. Um, if they're cool and clammy, that comes, yes, they're kind of briefly shut down, so that's important. Also note here is Well, um, as he said before group and saving cross match. Really important. Ready for any bleeds on dyspepsia? Let's say they're gonna have any surgery. That craniotomy is craniectomy is really important that you get that sorted toxicology screen really important if you think they've had a drug overdose on lactate. Well, as you said, if there's inadequate order organ profusion and you think they're having sepsis really important to check that as well, Brilliant and d so you want to check their Jesus A GC s level, so here we don't really want to use after you. That's not really good enough for a traumatic brain injury. It's a quicker screening system, great for most stations in your skis or skis. But here we want to use GCS. Um, generally, if someone's got like a mild headache injury that Jesus will be about like 14 out of 15 moderate, a bit lower like 9 to 13. But anything less today is quite severe. And then we want to check their people that eat. Quit. He called me active tonight. Does anyone know why we do that? Why is that important? Why do you check people's? Because I yeah, yeah, so you can check for things like an R e p d really good. Yeah, herniation is really important. So if someone's got really blown pupils that really big on there not really reacted to like that could suggest that there's a raised ICP on Do That there might be brain herniation is quite a late, late sign. But if you see it's it's a big emergency, you need to get it started. And that's because it's getting so bad that it's compressing the ocular motor nerve. That's obviously supplying your eye on your iris and things that's really important. Whereas if someone has, like pinpoint pupils, you might think they have no period toxicity or something like that. Uh, then I'll see formula. Logical examination that's been important. Onda, check your glucose is, he said, because of the being a stroke mimic on at this point. Also obtain a CT head and then finally he check your temperature check for other sites of breeding. Do your kind of secondary survey another things like that. So that's your acute management of a trauma brain injury. And obviously, as you go, keep reassessing your A B C D E and get it early in your neurosurgical involvements. Always call for senior especially like traumatic brain injury would never be doing this by yourself. A surgeon. Yeah, so make sure to get that help really, really quick. So this is kind of the kind of problem physiology, if you like the under underlying bit of stroke I'm gonna wister is because we want to get through to the last station. But stroke two types. Ischemic, which is your clocks on hemorrhagic, Which can you bleeds. You really need a non quote contrast CT scan two different between two so conservative management of stroke. So when we talk about all management's be a said but into conservative medical on do Surgical, start off with the conservative management of a stroke. So as you guys, um, she'll know stroke has a lot of people that look after patients have had strokes. It's a really MDT approach. Most Dysmenorrhea team is really important when people are discharged from hostile with a stroke. They need a really comprehensive plan as to what they're doing in terms of their health, their social current things, Um, and when they leave, they need to really be followed up by the stroke rehabilitation team, which is really important. And so they get for the therapy involved with movement, occupational therapy, looking at their house and things that are speech and language therapy, especially there they have slurred speech is a symptom. Dietitians need to get involved because their nutrition say they're struggling to swallow things that that on sometimes people with strokes can become incontinent. So you want to get the community constant services involved. You then also need to, um, think about getting certain assessments down and also speak to the patient and inform about certain charities. So you need to get swallow assessment, done, check their oral health. That's really important, um, a neuro psychological assessment. So not only do you need to see how the deficits change over time, but also a lot of people with strikes have the suffer with things like depression afterwards. Obviously, it's quite a big event happen in someone's life, So we need to keep keep a track with the mental health thing. That's really important. Um, as you go, I said in the investigations, a carotid artery assessment is pretty important. Just look for a cause. Ongoing times that could be like chronic pain. So keep looking for, um, doing a pain assessment for these patients. And then there's a lot of charities in the UK that are associated with patients have had strokes. So Stroke Association UK is Big One, a national straight association as well. On these really offer support both patients and their families after somebody's had a stroke, because it's a It's a big major life event, So we talked about this before. This is the time to start with a ski mixed Roque. The Oxford Classic Asian of ischemic strokes is really important for you guys. Know if your finals but also may be important, your skis as well. So can you guys tell me I've written here The three criteria for the anterior circulation strikes? How many of those you need for a total anterior circulation strike? Three out of three. Fabulous on How many do you need for a partial? Two out of three. Brilliant. Yeah, So with with attacks or a total anterior circulation stroke, that's when you get a blockage of both your anterior on your middle cerebral artery. So put the circle of Willis here for you, is your middle is here and your anterior is here, so it's kind of blocking both of these same time, whereas in your partial it's usually when we one of these is is blocked or the later block branches of one of these is blocked, it's less of it, but you only get 12 of these three criteria. Then, in a look in a straight, you get one of the following, which is basically when you get one type of last six, uh, usually weakness or sensory or hemiparesis. Things like that. It's usually only one symptom, and that's because it's caused by kind of a smaller area. Lacuna vessels are a smaller vessels and then are posterior circulation syndrome or Pecos. You need one of the following criteria so you might get brain stem or cerebella signs, a loss of consciousness or isolated homonymous hem. You know, Pia, and then this is also your medical management of a scheme extract So if you haven't anterior circulation stroke, first of all, what you need to do for any stroke, as we said before a CT head, because we need to check. Is it a scheme? It is it hemorrhagic, then for an anterior stroke. If it's less than four a half hours, you need to Dom, you should do from Bill Isis. So using something like structure kind Azor to plays things like that. And that's given IV. Um, if it's kind of between 4.5 to 6 hours, you want to Dom from back to me. And if it's gone longer than six hours, but there's still the potential that you could salvage some brain tissue, then you also then want to do it from back to me. If you have a posterior circulation street ever so slightly different, not much so it's the same once again. So if it's greater than 4.5 hours on this potential to say brain tissue, then you want to do it from back to me and from Bill Isis. Um, they have these kind of bit longer than that. Over 4.5 hours, then you just kind of really thinking from back to May and then for stroke is also really important to know your secondary prevention s so obviously this is to prevent a stroke happening again. So aspirin you give this kind of straight after the stroke has been identified to give it immediately, and you continue it for 22 weeks. Nice guidelines in the UK recommends 300 mg on, but that's an antiplatelet. So once again, if you have any ischemic stroke, is going to stop you forming clots, which is really important. Then, after those two weeks reup you switch to clopidogrel usually give about 75 mg, and you keep that going forever. Some once again, that's like come another, and to play that on skin stops with forming clots and things. If you're better grow. Oh, aspirin isn't tolerated. So sacred medical reason tolerated. You'd give aspirin on dipyridamole middle. And if the aspirin also is an, um, indicated or not tolerated or someone was having like a reaction to it, and you just give modified, really start her middle as well. Then you just give a statin for someone's cholesterol you want to give them usually atorvastatin, 80 mg. It's quite a high dose, irrespective of whether their cholesterol levels are high or not on that's kind of started kind of two days, often stroke on you. Continue that for the rest of their life and that reduces their cardiovascular risk factors. They're less likely to have it again. Yeah, Then we have a hemorrhagic stroke. So we talked through these in the see the CT scan quiz. So extra epidural subdural suburb annoyed intraventricular, which is within the ventricular system on the interest Riebel or into a parent time off or within the brain tissue itself. She's really good. So I'm not gonna go through all of this slide, but mainly one of focus on the imaging in the management. So a Z, you know, an extra drawn epidural hemorrhage is kind of within three. Estrogen or epidural space is, um, as you said before, we get that lemon shape liberty of my suits lines commonly in the temporal region. Because typically this is due to rupture of the middle men Joe Artery, which is at the battalion, which is the joining between the bones on your kind of temporal side of your head on defense. Acute is gonna be a white hyperdense collection of blood. If someone has no neurological deficits, then you can kind of observe them. I keep a close eye on them, but the definitive management is craniotomy, a neb actuation of that hematoma. That collection of blood, you know, your me. You kind of peel back skull. You remove that bit of the skull to release the pressure and get rid of all the blood, as I said. But then you put the skull bone back afterwards, and you basically attach in face with some clips and things to make sure it stays there and and then you close up the scalp again. That is in contrast to subdural, So going back to a CT present straight across the suture lines, you can get that mass effect especially. It's really large, and it can be acute or chronic in a subdural once again. If it was kind of incidental, so you can get it with kind of elderly people that might have kind of small subdural is if it's incidental when there's no effects or mass effect. Once again, you can observe them or given, um, conservative management. But the definitive management this time is a surgical decompressive craniectomy, and this is for an acute presentation on the difference between a craniectomy is you peel back to school, you take the skull bladder and you take out the blood. But this time you don't put the bone back. Afterwards, you typically put it kind of in abdomen, where it's bit more. There's less risk of infection on, but the reason why you do that is typically a subdural hemorrhage is due to this tearing of bridging veins that are found between the layers of the meninges on Guerra's in a extra urine epidural. You've kind of got the middle man and meningitis today. It's a fairly big artery. You can sort out, it's bleed, you can stop it bleeding, and then you put the bone back on. No problem. But if you've got bridging veins, there's loads of these, and you won't be able to kind of stop all of them from bleeding. So if you put the bone back afterwards, then one of those might re bleed again very soon. You might not stop that bleeding, and so then you're just gonna have the subject or hemorrhage happen again. So you put it kind of in the abdomen so that if you want to put the bone back later, you can, um but typically, um, they don't do that. They just leave the bone off. Brilliant. And then funny. A suburb Ackroyd. So once again, CT had spider shape, usually white because it's acute. On. As I said, if you don't see any blood visible on the CT, you go for a lumbar puncture 12 hours so that you've got enough time for the red blood cell breakdown to produce. This sent the chromium, so hopefully you can see in this image here the CSF, compared to the normal on the right, is a lot more yellow. And that's because off the breakdown of red blood cells, if this was right, that isn't really that the Crimea. That's more that you've had, like a traumatic tap, which basically means that you do the lumbar puncture. You probably some blood vessels on the way, and so the fluid that comes out is red. And that's not because you have me a summary would hemorrhage. That's more because you just hit somebody vessels in the way, and so it will kind of be this yellow color intestine management. Um, after you confirmed the diagnosis urgently refer to neurosurgery as, say, escalate your seniors, Seniors. You need to do the CT intracranial angiogram that we talked about to make sure you know where the aneurysm is, which is the common cause. And then you can either do something called coiling, which is where you kind of put coil in the aneurysm to stop it. Stop it bleeding again and make sure it doesn't burst or anything like that. All you can do clipping where you kind of clip off the neck of the aneurysm. Um on that stops it from bleeding again. Especially. It's busted. Stop losing blood. That way you can also given a model pain, which prevents any basis. 1000 might also cause exacerbate the subarachnoid hemorrhage as well. Um, and that could be given three weeks. Brilliant. That was a really big section. Glad you did really well. So let's take another break. Awesome. So our last osculation if you like. So you're a foundation. Your one doctor emergency department again, on this time you're seeing Mr Buzz Lightyear is a 22 year old male presents with a transient loss of consciousness. So let's get into our differential diagnosis us about diagnosis. So we have an 83 or female. She describes the room spinning and almost losing consciousness. When she gets up in the morning. Her drug history includes atorvastatin. I'm not peeing Candice. I'll turn bendroflumethiazide on doxazosin. Any ideas on that? The different to diagnosis? Yeah, pretty and well done, guys. I'm seeing a lot of orthostatic hypertension. That's also knows postural hypertension. Say yeah, really Well done. S o Typically, if someone has a postural hypertension that described maybe a dizziness loss of consciousness Onda, that's typically. And what I'm referring to do in this scenario is when someone goes from lying or sitting down to standing. So she gets it when she gets up in the morning. So she's going from a lying position where she's sleeping and she's getting up. That's what's causing her low BP. Her drug history. Why do you guys think a drug history that I've written here is relevant And you're from Mecca side? Yeah, generally, Yeah, lots of anti hypertensives, isn't it? Lots of anti hypertensives. So a common cause of postural hypertension and one I actually quite see a lot in my placement is over medication of hypertensions that causes the BP to get too low. If you're really limiting their BP and keeping control of it, sometimes it could just dip too low when they quickly stand up. Um, other causes are if they recently changed the hypertensive medication as well. That's a common risk factor. And if they've recently started it for the first time, they're on the first helped. It's a drug that's a common cause is well, so on next ones we have a 26 year old female. She has an abrupt loss of consciousness. Her limbs became stiff and then they began to joke. She has blood in her mouth, and her trials is a wet. She felt drowsy and confused about 15 minutes after the event on reports my algebra and you know just what this is. Yes, pretty and well done. Everyone smashed it. So, yeah, this is a tonic clonic seizure. I'm really God, that no one in the chat, I don't think No, I don't think anyone did Brilliant. Nobody for for epilepsy is that makes him very, very happy. So we can't diagnose this female with epilepsy. Just on that scenario, this is a seizure on. I'll be going over epilepsy and seizure in a second, um, so characteristic abrupt loss of consciousness. The stiff and the jerking is kind of suggesting are tonic, correct features blood in the mouth. What's that suggesting? Tongue biting, brilliant and trousers being wet? What does that stress incontinency are brilliant guys that yet those are really common signs of a seizure as well. It's best, especially in kind of medical school, kind of stereotypical exams and or skis and things on here, where she reports drowsiness and feeling confused on. That's because after a seizure, you might get postictal period, which is basically what it says here. It's what you kind of feel confused about 15 minutes afterwards, Um, the my algebra. So that's kind of like a muscle pain where she's been jerking around or see. She's no on purpose, but her muscles are jerking a lot, and that can cause quite a lot of pain afterwards, especially is well, if they're having a tonic clonic seizure, they might accidentally hit something, and things like that back on cause pain as well. Really good. So next one and 83 or female. She describes feeling a bit funny on, then having a thumping heartbeat before a loss of consciousness. A past medical history includes high BP and inferior. Am I on high cholesterol? Hello. CCG shows a complete a dissociation between pee waves and curious complexes. Any idea what's going on here? Yes, you guys, you guys know your SED is amazing. Yes, I've kept a quick board of said arrhythmia. Be a lot of you guys have put in the chat. So, um, you said it's a complete help boat, which is really, really good. What I know I've said about the easy to train is. But if I didn't give you the CD changes, what? Who kind of points towards a complete heart block? Maybe in her past medical history? What's pointing towards that in her history that say, Well, she could have Yes, pretty an inferior am I? So if someone has an inferior Emily, you will know from your sed territories that can cause of right coronary artery occlusion and your right coronary artery supplies. But if you're s a n N e A V and nodes in your heart and So if you get a V N no, that's not being supplied by blood that can infarct stop working, and that can give you a complete heart block. So that's really important. So here she's kind of feeling a bit dizzy. This is kind of cardio causes a syncope because you get this kind of funny term of people feel a bit funny and things beforehand that's quite classic of a cardio cause of sympathy on day. She's kind of fear something B, which is I was trying to allude to like a palpitation that crediting Well, you well done is the next one. We got 90 year, one year old man. He has a stooped posture, slow movements in a pill, romick rope in pill, rolling tremor. Sorry, and he's lost consciousness consciousness upon standing. What do you think this is? Purposes? Disease? Fabulous, Well done yet So this is Parkinson's disease, so quite similar to the first one. Parkinson's disease causes like an orthostatic, or postural hypertension, on where he's kind of stooped over people with Parkinson's, A quite kind of postural e unstable anyway, so they might lose consciousness and fall over quite easily, but they typically get like a postural hypertension as well. But in and then 62 year old male, they become breathless on DCA laps while climbing a hill. You find it abnormal sound that's heard of the carotid arteries. What's going on? Yeah, brilliant. Yeah, you guys have got it. So aortic stenosis is pretty in, So aortic stenosis commonly is exacerbated by people becoming breathless and collapsing on exertion. So here he's climbing a hill. Onda. Um, why are we hearing a sound of the carotid arteries? What's what's going on? Cartilage. Aries. Why we're getting a sound. Yeah, brilliant. That's where the murmur radiates to Ready and, well, don't I see next one? So I've got 64 year old male. He comes. He's having an acute exacerbation of his COPD, and he loses consciousness after coughing up sputum is quite difficult. One. Does anyone know why? What's going on? What would be causing him to lose consciousness when he's coughing? Yeah, you guys are kind of got the right idea. Well done. So, yeah, it's it's related to him coughing. So this is something called situation of syncope. Yes, I must put in the chart. Fabulous. So this is something that's kind of it's quite rare, but it is a type of thinking that you might find you might find in your skis or your exams on. That's basically where you do anything that might kind of increase your pressure inside. Your thoracic cavity on that can cause you to lose consciousness. Sometimes the here he's coughing. It can also be caused by sneezing, defecating passing urine is, well, exercise sometimes and sometimes eating as well. It's quite rare. You might not get enough sleep, but for completeness, I put it in and finally we have a 62 year old female. She's about to give a speech on stage, and she's beautiful. But normal is years. It's ready, and then she loses consciousness for about two minutes. Um, and I just what's going on? Yeah, you guys have got it really well done yet. Vasovagal brilliant. So these little typically occurs because of a stimulus, usually like fear, excitement, anything like that Here she's probably really scared. She's breaking it before she goes on stage on said she's still a bit nauseous. That's quite common as well. It might go bit Pale was who suggested here before they collapse on day might also get like visual field changes, so sometimes they could describe it as a closing of the vision just before they lose consciousness. And it typically only lost a couple of minutes. Really well done, guys. So I put in here and I'll leave it for you guys to kind of read in your own time, really. But these are the main different types of syncope that we've talked about. So we've got a reflex or vasovagal that we just talked about that kind of like fainting that usually have situational, which was kind of like the coughing sneezing one in the previous on carotid Sinus. Hypersensitivity is another one I just put in for completeness that's usually caused by if you turn your head really quickly or typically, if you're wearing like college shirt. Or if you're shaving things that that it can stimulate the barrel receptors in your crowded artery on do. Sometimes if they're big hype sense to have that can cause you to lose consciousness, orthostatic or postural. That's when you use it when you stand up right on. Cardiac is basically when there's any kind of cardiac thing going on like everything he is structure, abnormality, that kind of thing. Brilliant. So then lost consciousness, focused questions What we're gonna ask. So the main thing we lost consciousness issue is that which what happened before they lost consciousness? What happened during? Typically from a witness. This is typically a collateral history in your skis. On also what happened afterwards. So, um, before you are say that you kind of want to ask how they have this before how often that they had it Has it been very similar, except, uh, then you kind of want to find out what's triggered it. So, like, vasovagal was, like, emotional thing. Well, they're coughing. Where they going to stand? That kind of thing. Did they get any warning? So did they have any lightheadedness sweating thing that that that we might see with, like, a vasovagal attack? Um, what were they doing right before? That can give you a lot of clothes as to why they've lost consciousness. So they say, Well, they just standing. And then they went to stand, and then they lost consciousness. So you think you are a postural thing? Maybe, Um, were there any other symptoms as well? That might give you a close to what's going on then, during as I say, this is usually that collateral history type of thing. How long did it last time? So typically a vasovagal where it's due to about emotion that's typically quite short. So, like maximum like kind of two minutes. You're thinking maybe seconds, easement, even whereas if someone has, like seed yeah, that could typically last. And sometimes it lasts for different duration, maybe a bit longer. Especially. They go into something like status epilepticus. Um, and also you want to know, um, if they're the movements. I think it's important to emphasize. Here is well, that just because someone that kind of moves or jerks when they lose consciousness, there's no automatically mean there's a seizure in terms of Oscar land and finals, and it often does. But in real life, if someone jerks that, it doesn't necessarily mean they have a seizure. A lot of people in the initially lose consciousness do have a little bit of jerking, but in terms of, uh, skis that could point was a seizure on incontinence, and I'm writing, as he said, kind of classic stereotype, a seizure as well And then afterwards what happened afterwards? Did I remember it's We talked about the posts. It'll period afterwards. Do they remember the events where they confused for about 15 minutes or so? Uh, relieving factors? So if they had a postural kind of presentation, did sitting down or lying flat things like that. Help or not, Really, Um, did they have any muscle pain? So I talked about, like the seizure movements causing my algia. And did they have any injuries or head trauma that's really important to know for your management as well, and then past medical history really important to know if they've had it before is to say, Do you have a a diagnosis of epilepsy or any sudden, definite family that could point towards that? That's really important today. Cardiovascular risk factors and say partners, his disease, Diabetes is another reason that you can get like a postural droppers. Well, that's important. Um, head trauma pacemaker. So pacemaker might be pointing towards, like, cardiovascular course as well, going for our systems reviewed before what I'd like to just flag in this is they're driving status and as well see a bit later on. Driving status is really important when someone's lost consciousness in terms of when they can then go on to drive a bit later. Brilliant. So I've done another table for you guys to read later as to the different tools for a loss of consciousness. So little quiz on. Geez, yes. Because this could come up like calculating a GCS school. So can anyone tell me what the minimum number of points our energies? Yes. Three fabulous. Maximum number of points. 15. Amazing. You guys are on it. And what are the three sections of kind of giving you a better clue even am brilliant. Yes. So let's start off with ice. So it's four points and they won't know the 44 points for eyes. If you'll just drop down one more. Like what? Hero One too. Well sorry. What? 123 and four mean? Yep. Spontaneous open alert Voice. Yeah. Brilliant. So you get 11 point if opens maintain easily. Two of them is your voice. Three opens pain and four if you get no response whatsoever. Voice. I'll just put these on here. So I went eight is a doing okay. Are they confused? Are they speaking words they're not really appropriate to the situation that would be inappropriate. Or are they just giving you sounds, just making noises? Or they have in their response to on. Then finally, motor, do they a bake months, localized pain, withdrawal from pain? Do they kind of make a weird flexion because of the pains? They're not flexing towards the pain, but they their muscles kind of flex. You could see here that's called it corticate posture. Or are they extending from pain, which is called a decerebrate posture? So that was cool, you five. And obviously if you get no response is, well, that gets you that well, brilliant. So I'm going to try my best to explain epilepsy, which I think is a really difficult topic. Um, but I just want to start off with some basic definitions best so as we've already talked about, a seizure is kind of a transient set of science and symptoms that occurs because you get excessive synchronous your activity in the brain. So basically your brains like policy of signals between it is really abnormal, and that can cause a seizure. Epilepsy is kind of a neurological disorder in which person person gets the currency but recurring seizures. So it keeps happening. It's not one off the vent because there are causes of seizures that aren't epilepsy. Eso Can anyone tell me in the chopped? Um, why you would get a seizure, But, um know have epilepsy alcohol withdrawal. Fabulous. Yeah, Yeah. Brilliant. Already good guys. And yes, sorry. On the other side, the points for the bone around. I would change that when the size guys and out. Thank you. I notice that is our thank you. Yes, alcohol withdraw is one. Yep. On our high temperature and a young child is typically one is well, see and get like febrile convulsions. They're called that, um causes seizure, but it's not necessarily epilepsy, so that's really important. Just to differentiate the two and status epilepticus is when you get a prolonged seizure that lasts longer than five minutes or you get recurrent seizures where there's not really a gap in the middle. You don't look that have a seizure, recover and then have another seizure. There's no recovery in between. But you have kind of set it. You still I would have separate seizures, but there's just no real recovery in between good. There's different types of epileptic seizures so you can have focal, and that starts in one side of the brain, specifically in one hemisphere. Only on that makes up the majority of seizures. You can lose consciousness with a focal seizure, but you might, you might know, a swell. You might just have, like an impaired awareness of what's going on. Allergies for the spelling mistake that that should say awareness. Um, the symptoms that you get with a focal seizure depend on where in the brain, but it's more focal. It's more localized. Depends on where in the brain you're having those so in the frontal lobe because you've got your motor cortex. That's where you're gonna get some motor symptoms if you have your seizures in that part of the brain, whereas in your temporal lobe you get these symptoms, which are batteries by the acronym head so you can get some hallucinations. Emotions automatisms on. Basically automatisms are basically I'll show you on the next side, but they're basically sensations or movements that spread from one area. Um, and then kind of, um sorry. No, they're no automatisms are things like lip smacking. You might get some that smacks the lips, or they might start to grab things. It's kind of autonomic movements that they're not controlling on. They might also get a job. You a swell, then with the prior to low. But you can get like sensory symptoms because we could also my sensory cortexes. There on in the occipital lobe, you can kind of get some visual symptoms. If you have your focal seizure there and then then you have generalized seizures on that involves networks that on both hemispheres it's time it's kind of spreading across the whole brain and that you can get a focal seizure turn into a generalized. So it goes from one area that it spreads that is not a generalized seizure. It's a focal. Going into a generalized generalized is when you get both hemispheres with impaired, attractive itty from the onset. The seizure, Um, and there's always a loss of consciousness with this one, and it's pretty media. There is another type of seizure, which is called alone. That's basically what says on the tin, where the origin of the seizure isn't known. So but mainly focusing your focal generalized Um, and as I said you can get a variety of symptoms on. We're going to go through through these on the next light. But basically, these are mainly spit into motor and normal. Um, so I'm gonna go through the definitions, but use this slide later to see what the motor symptoms are on. What the normal ones are a swell. So I've popped some of them here and what they mean eso tonic is that kind of muscle rigidity that includes tone was your chronic is the kind of jerking movements that you might get. Um, I won't go through all of these cause you guys can read these later. Just be aware. The hyper kind etiquette the ultimate is, um's only really happened in focal seizures. And then these are some definitions that you might want to know if you know, motor season know motor symptoms as well. Um, on typically the behavior arrest only happens in focus seizures, whereas the bottom to happen in generalized and that was was on the previous life you to refer back to you later. So status epilepticus. What's our keep? Management was the first thing we're going to do. Acute management. If someone goes into status epilepticus those long, long seizures enzymes that are important yet. But what's the first management? Brilliant ABCDE fabulous. So ABCDE. Let's talk for it. So, airway, we've talked through how to deal with their way compromised before, But just be aware this is really high risk in status epilepticus. It's really high risk that someone might have a way obstruction because if they have secretions or they're vomiting or things like that with the seizure that probably cause, like an aspiration down into the respiratory systems, it's really important that we make sure that a raise pay patient in status epilepticus and we have a base. These are our usual things oxygen SATs except sure that we've, um we've gone through before and just be aware that when we do talk through the management and you do potentially give benzodiazepine and that can cause a low respect, you rate. So if someone does have like a lower respiratory rate, you might be because you've given them a benzo, um, on be aware of well, if someone aspirated something, A Z said it's quite her risk that can also cause that oxygen saturations to go down because it might block the airways, or you might just imperil extra nation in the lungs. So that's an important thing to wear to be aware off. And so you do an ABG to make sure you know how extricated patient is. Um, brilliant. Then see. So it was game fluid. Balance polls, all things like that. I'm electrolyte abnormalities. It's really important may cause a seizure. So it's really important to do things that using these on bone profile and magnesium to see if there's any electrolytes that might, of course, the seizure. Um, we then also wants do things that lactate. Someone's going into tonic clonic seizures on that can go into like an anaerobic metabolism for the muscles. And so that will be important to know toxicology, as we said before recreational drugs, things that that might trigger a seizure. So toxicology screen is really important on check the levels of anti convulsant drugs as well, because you want to see if they're therapy they're having. Is that an adequate level? Because if it's not, then you might need to alter it so they don't then later have a seizure as well. Them for D, check out who check their pupils things like that. Check the judge drug chart as well. On go. As I said before, there are certain drugs as well that contribute seizures. So make sure that they're not on any drugs that contribute seizures and if they all take him off of it, things that energy eat certain energy. Six and certain anti anxiety medications, certain sedatives, things like that consent off seizures, so review that that's really important on once again, check the blood glucose cause low or high glucose was also trigger a seizure and request a CT head as well. Um, it's machine. If the tonic point, um, they might have injuries and things. And then, once again, everything else, make sure to inspect the patient as well, for the reason why the trigger might have happened. And also check the second you torment. As I say. If someone's having a tonic, clonic seizure and their muscles and everything is moving a lot, they might injure themselves, and you've got to also treat that as well. So that's really important. And once again, keep reassessing a B. C. D. You don't just do it and take it off. Go back, check the airway. Still paid in etcetera. Brilliant. So this is the management of an acute seizure specifically going into status. Epilepticus. I'm not gonna go through this too much because of time, But basically, if they as he said, if it hasn't terminated in 5 to 10 minutes, that's the process. Status epilepticus you give your benzodiazepine by the in the community give pr diazepam or back. Oh, it doesn't, um, any hostile you give IV lorazepam. If the symptoms keep insisting you could give a second dose if they keep persisting, given IV infused infusion or something like a, you know, tone. So that's a sodium channel blocker. So that's going to stop your action potentials in your arms. Or hopefully it'll shut off the seizure or these other options here as well. Options as well. If there's no response within 45 minutes, then you really want to think about getting I to use a port on getting them for general anesthesia. That's usually a really good way to kind of shut off the seizure more definitively, but it is a really last result thing because they have to have general anesthesia for 12 to 24 hours. But I'll let you guys were, uh, this in detail, and then it and you're in time. So our last couple things, we're gonna do an SVR already? Quickly. So do you guys know what s P R stands for situation background yet? Assessment recommendations. Brilliant. Yes. So we're going to go through and, Spock, start off with your intro. So you say your name kind of who you are currently the careful you're talking to on. Then you want to go into your situation. So why are you calling them? Who is the patient? Except for where are you? What's going on? Uh, then you talk through the background, which is basically like your history that you've taken that's relevant to the person you're passing on twos and not everything but all this stuff. It's relevant. Then you go through your assessments of what we found on examination, what's been done so far in terms of investigations and the management as well. And overall, kind of what's going on? What? Where do you think you're up with everything. And then finally your recommendation. So you're calling them because you want them to do something or you want them to tell you something So what's going on? What do they want you to do on Dc'ing? They come and help you most likely as well. So I have made an example. Espada for a patient specific, the one that was earlier in the station. So I'm going to talk through a bit of a estar situation. So I'd start off by saying hello. I'm on skis. E on the F one doctor on call in the emergency department. Is this the any success? I clarified how I'm talking to? I'm calling because I want you to Argentina of your patient who is presented to acute. Um well, patient is called Buzz Lightyear is a 22 year old man, and I'm concerned that he has developed status epilepticus. His seizures started about 45 minutes ago in the community where this is, say, lost consciousness immediately. But his count became incontinent of urine and had a tonic clonic movements. He has a past medical history of epilepsy, of specifically tonic, clonic seizures and finally, history of epilepsy. His epilepsy is usually well controlled, using sodium about great and diazepam as rescue medication. So I've talked about the history. What's going on? Um, Andi kind of the background of the situation here. Then I've talked about the patient. County has a new score of 11 because he's tachycardia, cares of respiratory rate of 27 his oxygen saturation of 97. He has been intubated, Um, but he's on unresponsive in a febrile eso. Then that's kind of old. You examination what's going on. I've given a second dose of diet of benzodiazepine after the one in the community, which was IV lorazepam shortly after his arrival in a knee. This didn't terminate seizure, so we have ministered phenotype in 30 minutes after the onset of the seizure. So you've got him up today, or her up to date the anesthetist up to date with what's going on in terms of investigations, management and then, finally, this patient's unstable suffering with status epilepticus. He really needs anergic assessment and should be transferred to the I See You for General anesthesia determination seizure. I would like to ask if there's anything else you would like me to do for the patient on. Would you also be able to come on review emergency, please? Thank you. So you've kind of said your impression. You said kind of what you think diagnosis is. He needs assessment, which is what you're asking for. And you're saying, like, what? Would you like me to go on? Do you please come Urgent? A give do give like a timeframe at the end. Something like urgently control you, the person, how severe it is. And that's quite nice. But always be polite and with thank you. So epilepsy management s O in terms of anti epileptics they usually give him following the second epileptic seizure that somebody has. Does anyone know what conditions we'd give it after the first seizure is quite a whole question, but I want to see if anybody knows that. Have normal eeg EBR it in. That's probably the main one. Well done. Yeah, I'm getting a few other one story brilliant. So, yeah, if someone's got neurological deficit, that's quite important. We don't want them having another seizure. If there's any structural abnormalities Or as you said, any GI that shows anything that suggests is epilepsy, then we really want to give them some anti epileptics. And if they're the patient or family or carrots, consider the risk of a seizure to be intolerable and they don't want it. And then then you would also give it after a procedure as well. I've written the medical management here for you to review in your own time what I would just like up his sodium valproate, which is generally used. First time for generalized seizures can cause problems, your developmental delays and Children. So we don't give it in women of child bearing age or who are pregnant, then, uh, open. Ultimately, I want to go through epilepsy. Counseling is this is something that you might be asked to do in your skis. So I'm gonna just quick through these and conceivable that and then talk through what we should do. So I have a couple of remarks to help you remember this. So what I want you to remember is beause is on this jumbled vessels here. Hopefully, the colors will help you see. But basically, this first mark of abuses is a way of remembering how to share information with patient. Just generally, for any counseling you do So you want to give them a You want to introduce yourself so say you are so raise a while you're there checking patient's details except for things like that, then you want to give a kind of understand a brief history. So why is the patient come in? What are their symptoms? What? I don't want to know what's going on, etcetera. Then you want to understand the patient's understanding of that condition. So what did they understand about epilepsy? Do they have a family history of it? And they know the condition really well, Or is this the second seizure? They've hard and nobody else has it. They don't really know what's going on, so that's really important. Then we may want to concern so specifically ice. You want to establish what the concerns are for the patient. So are they worried about the symptoms? What they concerned about? What do they want to understand? Better to relate, to get rid of those concerns. And then what you want to do is get onto your explanation. So you want to talk to the patient about what you're gonna talk through with them in terms of what happened is he is and things like that. And then we were going to explain it in a second. And then finally, at the end of the comfort consultation in black, K. U summarized the key points, and you arranged to follow them up a later date. Um, and you also probably give them some leaflets as well to help with their knowledge of the condition that they can read because often when you're explaining to them for the first time, it could be quite overwhelming on, but they don't take it or when. So good leaflet does go a long way and then, specifically within the explanation, it's broken down into the second you monitor of color coded here on that can be remembered with NW CPM. So basically, the main thing for explanation if you want to do well in your skin, is avoid medical jargon. Don't don't make this complicated for the patient. Imagine that you know nothing about science. Nothing about medicine on break it really easy for them to understand, so you want to start off by explaining normal brain physiology. So how about briefly explain how the brain works? You don't need to get everything but kind of we pick up sensations more of a Roman, and they transferred to our brain, and our brain can also give us instructions about how to use our muscles things that, um And then you need to go on to explain what that condition is. So what is epilepsy? So epilepsy is a condition where the normal brain signals can go wrong and they can fire abnormally on it can cause you to have a weird sensations. And with movements, Um, Andi, that's when they have a seizure. Epilepsy is when that happens, multiple times. So you want to explain their condition to them in simple language. Then you want to tell him what the cause is of epilepsy. Ask that you understand that, and then you need to understand the complications. Get them to understand the complications on this is really important for epilepsy because there are a lot of complications that they can have so the impact on their life so they can't go swimming on their own, They can't have things that baths because they can increase the risk of seizures. And also the problem with driving, which we're going to in a sec on the complication of status epilepticus to explain to them that this is when they have, like, a long seizure, and it can cause permanent brain damage. If it's not recognized. So getting them toe understand the kind of early symptoms of a seizure and if it's going too long getting them on their families to understand what to do, Um then sued up. So this stands for, um, sudden, unexplained death in epilepsy s. So this is basically kind of when people with epilepsy sadly, dye is quite rare, but it often happens in their sleep. Eso just warning them that that is something that can rarely happen. Um, but if they keep control of their collapsing through their medication, then that can help reduce the risk of that. I'm. Finally, some of side effects of medications are taking is well, that's really important on then, finally talking through the management, off the conditions out, the pharmacological, non pharmacological management I've talked through and also the education of friends and family says, They say if they're going to have her having a seizure, need to educate the family about what to do in that situation. On day wasn't guys, you got the final side well done. So final question for you tonight water already have. I should be given to some weapon etc. Maybe after when they first had a seizure. What should they dio don't drive? Fabulous. Brilliant. Yep. Deviate, I brilliant. Yet you guys gonna amazing. So I'm gonna talk through these different sections of driving advice because I think it's really important. So when someone has that kind of after a seizure for whatever cause it might not be epilepsy, they need to stop driving kind of straight away, and they need to inform the deer D V l. A. That a seizure happened. If it's there, if it's an isolated seizure, it's the first one. It's a vote. Then they need to know be driving, since for six months. If there are no kind of structure, imaging, abnormalities or abnormalities on any GI. If there are no magic, family can't drive for 12 months. If someone has established epilepsy or they have multiple unprovoked seizures, they can drive Is there was a seizure free for 12 months on. If they're seizure free for five years, they can get something called a till 70. License is it, which is basically a license, which is valid until 70. You don't need to constantly have it being reviewed. I'm finally someone withdraws there. Let's see medication is really important that they don't drive during that withdrawal because if they would draw than they might have a seizure on day, I can't drive until six months after their last dose of their collapsing medication. So well done, everybody. You got to the end of the session. Thank you. So so much for staying on.