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I think we'll do some introductions for now. Uh, so that'll hopefully give us another minute or two and then we can crack on with the questions. So, hi, everyone. Er, thanks again for joining us this evening. So hopefully you've been to some previous sessions with us. Er, but we're part of the, the med teaching series. Um, and we're currently doing a row to final series covering, oh, apologies. Uh, we're covering various specialties leading up to finals. Um, and a lot of the content is still relevant to, you know, exams in earlier years as well. So hopefully there's more than just finally your students here. Um, so today we're doing neurology, um, just a quick introduction. So I'm a, I'm an F one. I'm currently w working at the Norfolk and Norwich and I've personally done, er, a neurology placement as my first one. So I know Bits and Bobs but definitely not as much as, uh, a lot of my seniors did. So, uh, but I have some tips and tricks and hopefully some inside things that will help not only for your finals. Um, but for the job as well going forward. Um, I one my name is has I'm um also an F one based in Stoke. I've not done a neurology placement. It's more just revising around the top place to just teach you a few things about it. Um And yeah, please do message on the group chat. Um We, I'm happy, you know, we're happy to answer questions. Don't feel like you have to ask it at the end. So, yeah, lovely. Um So this is a timeline of what we're covering. Uh So the neuro session today, obviously, and then we have a few more coming up. Um So hopefully some of those will interesting, you'll be joining us for those as well format of the session. So these will be the main topics that we'll cover today. Um We'll go into a bit more depth for the higher yield topics, um less depth for the lower y yield ones. Um And there are some other ones under the neurology list that you'll see on the MLA uh that we've kind of left out here because they're not purely a neurology focus and there's an overlap with other specialties. Um So these are the ones that will mainly get treated by the neurology department. OK. So for each of the questions, you'll get a minute. Um So I'll start the timer when you see the question. Um And then we'll go through the topic itself and then we'll come back to the question and just discuss how you should be thinking about it and some of the key parts to the question. All right. Um, so everyone get your brains into gear. We'll start the question one. No. All right. So that's the minute. Um, so we'll carry on and we'll have a look at the topic. So topic revolves around stroke and ti A. All right. Um, so stroke, as I'm sure you all know is focal neurological deficit and it's presumed vascular origin and it lasts over 24 hours. So that's the key differentiation between ti A and stroke. Um And as I'm sure you all know, the etiology will either be hemorrhagic or ischemic more likely ischemic, much more likely. So, 85% of the time, um there's the, yeah, so just looking at the etiology for the two, just bear in mind that for a hemorrhagic stroke, it's treated by stroke if it's intracerebral. Um So it's within the parenchyma um o but other things like subarachnoid subdural, um epi er extradural, um often the patients will come to the neurology department within the region. Uh but they will then be referred to the neurosurgery department in the wider region or if there is one in that hospital. Um and they will often either say that it is for treatment surgically or it will be treated conservatively within your own neurologic uh neurology department. Um bear in mind that that hemorrhagic strokes are more commonly due to hypertension. Um and other causes of nontraumatic uh he hemorrhagic strokes, you have vascular malformations as well. Um So these are somewhat common and brain tumors vasculitis too, risk factors. I'm sure you all know, but hypertension is a big one. So you after a hemorrhagic stroke, especially, you really need to try and manage that. Um even after an ischemic stroke, because you have areas of ischemia damaged cells, they're at risk of uh all the vessels nearby are at risk of rupturing and leading onto an is um a hemorrhagic stroke after the ischemic one. So, a stroke presentation, we should all know acute and onset. Um You have the facial droop, uh limb weakness is a big one. Um dizziness, not so much, it depends on which er region is affected. Coordination of balance again related to which part, but we'll look at the anatomy shortly. Um All right. So thinking about the vessels. So we have the circle of Willis here. Um And so the anterior ones, they arise from the carotid arteries and then you have the ones in the posterior circulation, those come from your er vertebra basilar arteries. Uh So in the posterior chain, um so you need to be aware of which parts of the brain are affected. So I think slightly ni nicer picture here. So the anterior circulation typically affects this territory, more MCA is more lateral um and then your PCA posterior um right, and you need to know the BD Classic classification and this is particularly important on the walls as well um often. So it, it's, it's more so clinically guided. Um th this Banford classification and it doesn't really change the management all too much um depend look whichever type of stroke it is. Um but it's used to classify ischemic stroke. So the main categories that you need to think about uh unilateral weakness um so that can be the face, arms or the legs, uh homonymous hemianopia. So, visual field loss um on the same side in both eyes um and also higher cerebral dysfunction. So that's various things, but the most common ones will be dysphasia. Um So that's affecting speech dysphagia. So that's affecting swallowing. Um and just a nice way to remember that. So, dysphasia with an ss for speech dysphagia, er g for gagging. So, er er swallowing is affected. Um you can also have visio spatial dysfunction as well. So the anterior circulation. So what you need to think about in terms of the presentation of which part of the brain might be affected is uh the cortical homunculus. Um So the anterior cerebral artery affects the part of the motor cortex that's it's predominantly involved in controlling the legs. Um So it it supplies the frontal, so the later parts of the frontal temporal and parietal lobes um in terms of the associated signs, um it's more so going to be the apart. Oh, sorry, looking at the wrong slide. Um So, yeah, it'll be the low, lower limbs more so than the upper limbs and that's important and you, and you will often get behavioral changes with that as well. Um So your middle cerebral arteries, so this is what affects the frontal temporal parietal lobes. Um In this, in this case, you get the upper limbs affected more than the lower limbs. Um and you can get er aphasia or dysphasia um as well and quadranopia as well. So this, I won't go into much depth now. Uh but I think we'll cover this when we do the ophthalmology session more. So, um thinking about the posterior strokes, the cerebral artery strokes. So this mainly affects the except lobe. Um and with this, you can get contralateral homonymous hemianopia. So when you see these sorts of visual signs, er then you're thinking more so posterior circulation um and you have agnosia as well. So, difficulty in recognizing familiar objects or faces. Um And yeah, it can also affect uh balance um as well. So that's another one that you need to test in patients. Um So here you have your er hemianopia, but again, we won't discuss that in much depth today. Um So with your posterior circulation strokes, just think Danish. Um So you're thinking about your cerebellar signs. Um So the Danish um covers the disc diadokokinesia, er patients will have ataxia, nystagmus intention, tremor, slurred, staccato speech, um and hypotonia. And if you've not done a neurology placement, you'll actually find it's, it's quite a nice one because it, you do often see quite a, a number of these signs. Um So it is quite a textbook. Um So, yeah, as part of the posterior stroke, you have your posterior stroke syndromes as well. Um And the one that we'll focus on a bit more in a bit more depth is Wallenberg um or lateral medullary syndrome. Um And with this, your, so there's a list of things and I haven't really got a memory device to, to memorize it, but um just remember the list for this. Um So you'll of they'll often present with nystagmus. Um They'll have vertigo er Horner syndrome on the same side that's affected um and facial sensory loss on that same side as well. Um But just be aware that you have your stroke mimics as well. So various things that you need to test for. Um So hyperglycemia is a big one. So you need to rule that out. Uh Bell's palsy. So it's ACN seven palsy. Um and often you have the facial droop and stroke, which is also because the CN seven is effective. But just remember upper spares, upper upper motor neuron stroke will spare the forehead to the upper part of the head. Um and then the lower motor neuron. So the bowels will have that affected. So you usually just get the patient to try and raise their eyebrows to try and differentiate that um obviously, uh before you do any investigation, um space occupying lesions, um another type of stroke mimic, especially if there's some sort of compression. Um All right, investigations wise. So this is often done on the front door. So an ed er, but you need to get act scan urgently. So within the hour and make sure it's non contrast. Um and the reason we do that is more so to rule out a hemorrhage. Um so often you won't see any sort of change uh or ischemic changes within the hour. Um But you will often start to see some sort of ischemic changes within 24 hours. Um So look out for the ischemia and yeah, so this will be uh hypodensity. So it will be a bit darker compared to the hemorrhagic stroke, which will be a bit brighter, which signifies blood on the CT. Um the another school that's used. So I think this is important for your exams as well. Is the N I HSS score? Um You don't need to know it in, in too much depth, but just be aware that they do a score for patients when they come in. Um And you then repeat it within 24 hours and then after a few days as well. And it's, it's a good way to kind of uh monitor the patient's progress. Um And hopefully you should see improvement if you've done something about thrombolysis or started aspirin. Um uh just some other investigations that you need to consider as well. Um, so, yeah, so do the glucose to rule, er, to rule out hypoglycemia. Um, using these, you want to rule out any sort of electrolyte imbalances, like low sodium. Um, it's important to do, uh, an E CG as well because AF is a big cause of an ischemic stroke. Um, there we go. And, yeah, that's a really important point there as well. So a normal CT doesn't rule out an ischemic stroke. So e either you would do an MRI uh quite soon after or you can repeat the CTA bit further down the line, both will show areas of ischemia. Um So we've already kind of discussed this uh in terms of the investigations as for the management. So if it's an ischemic stroke within the 1st 4.5 hours, um if you want to thrombose the patient typically with IV ter Place, um after which you then start the patient on aspirin 300 mg for around two weeks or for two weeks. And then after which you would convert to clopidogrel and you would give that for life long. Um And just remember the numbers 375 so 300 aspirin if you're given the high dose, which is usually in the first two weeks. Um and then 75 for clopidogrel, some patients will also get dual antiplatelet therapy. Um And that's just based on the severity of the stroke. But for exam purposes, I wouldn't worry because even in, er, when you're actually on the ward, even that's just kind of up for debate and it just varies. Consultant to consultant. Um. Right. So further investigations and management. So the MDT is particularly important. Um, so you have your swallowing assessment. So, um, but obviously patients might have dysphagia. Um, so aspiration pneumonia is something that you need to look out for. Um make sure that they have VT prophylaxis. But if they're on a DOAC already, you don't really need to give them anything like an epic span on top, er unless they have atrial fibrillation. So if they have atrial fibrillation, then you want to give them a DOAC um at, at which point you wouldn't need to give them any VT prophylaxis like dalteparin. Um Yeah, so you have your various M et members. So you have the list there. Uh but we can give the slides out after for you to look into that in a bit more depth. Um So for you can do act angiogram as well. Um If you're suspicious that there's a larger vessel occlusion. Um And yeah, and this is particularly important for patients who you think will be candidates for a thrombectomy. Um So you'd refer them to interventional radiology for that. Um And yeah, so again, this really depends um on the ward, but some consultants will always do a carotid Doppler. Um And you're looking for a carotid artery stenosis and anything that's greater than 70% they can be referred to the vascular team for an endarterectomy. Um, secondary prevention is important. So, for an A AF patient, um, so this isn't er, strictly correct. Sorry. This, so it should be a doac for prophylaxis, but again, it might vary based on trust. Um, and if the patient isn't on af going forward, um you, so you would start on aspirin initially and then you can switch to switch to clopidogrel after two weeks. Um lifestyle is really important. So, discussing that with patients um and thinking about the hemorrhagic stroke. So um if it's intracerebral hemorrhage, uh so as we discussed, um then it's treated by the stroke department. So in this case, it wouldn't be for neurosurgical evaluation. Um Apologies, this slide is more relevant for when we look at the other cerebral bleeds. Um And so yeah, thinking about Ati A. So this is you have stroke like symptoms, but it resolves within 24 hours. Um And yeah, you can use the ABCD score to estimate the risk of stroke. Er but typically if it's something that resolves within 24 hours, um there is likely to be ati A and in terms of managing it, you still need to give the patients 300 mg of aspirin. Um And you give that stat um if it presents within seven days of the episode, you also need to have a, you need to have a specialist review within 24 hours, anything after seven days, they need a specialist review, but you can delay it slightly. Um, and for secondary prevention, again, with these patients, you just, you still need to put them on clopidogrel. 75 lifelong cos they are, they're at increased risk of having an actual stroke down the line. Um, give them statins as well. And again, BP control is important uh preventing the risk of um an er a hemorrhagic stroke. Ok. So looking at the question, um the key is that they have these stroke like symptoms. So speech becomes slurred. Um they drop their books so they have this weakness, facial drooping, er but then it resolves within 20 minutes. So for this patient because it's an, it's, it's ati a er you need to start them on 300 mg of oral aspirin. OK. So we'll do the next question. So again, you have a minute um and then we'll discuss the question after. OK. So that's the minute. So we'll go through and discuss the condition first. So Parkinson's um so the condition, so you have chronic progressive neuro degenerative condition um and that is caused due to um a loss of dopamine dopaminergic neurons in the substantia nigra. So this should hopefully be buzzwords that you're aware of at the moment. Um In terms of the key presentation, it usually starts with this unilateral tremor and then it can progress bilaterally. Um you have chri rigidity and then you have this postural instability, which is because of a postural BP drop. Um thinking about the pathophysiology. So you have your substantia nigra. Um And so the, yeah, so it's important, er so it's in the basal ganglia and this is important because um usually it's involved with er inhibition of muscle tone. Um So when it's affected, you have this increased tone, hence the cog rigidity, um it uh coordinates slow and sustained movements. Um And so you have a lot of coordination with these patients once that's affected as well. Um So moving on to the presentation as we discussed, so you have bradykinesia, so it's slowing down of the movements and it becomes less coordinated. Um So you have this ataxia as well, er resting pill, rolling tremor and this is usually quite classical, you actually see them kind of rolling the pill. Er So it's quite textbook and as we mentioned, you have the coal rigidity as well. Um And with these patients, you'll have this posterior instability, a shuffling gait. Um and you have this mask faces as well. Um So a Parkinsonian mask, so, differentials are very important. Um So parkinsonism is the overarching condition, but if it's idiopathic in origin, er, then it's called Parkinson's disease, um, it can be drug induced as well. Um So several medications can cause that because they all cause um a reduction in dopamine So you have your antipsychotics, some antiemetics, uh lithia methyldopa as well. Um And the other one to be aware of your Parkinson plus syndromes, which we'll look at very briefly now. Uh But it's not the most high yield thing for your exams going forward. Um So the key one to be aware of is dementia with Lewy body. Um So you have this early onset of dementia and you have parkinsonism symptoms as well. Um And it's important that to realize that the dementia usually comes before uh the parkinsonian symptoms. Um And you also have these visual hallucinations which um aren't as classical in Parkinson's disease um and also change in consciousness, fluctuation, cons consciousness. So, er they might become quite delirious as well, er progressive supranuclear palsy. So just think about the names you have supranuclear. Um And then you have this palsy as well. So with these patients, you test their vertical gaze if they're not able to move their eyes er superiorly and they have this palsy, then it's quite a key sign, er multisystem atrophy. So you have really profound autonomic dysfunction. Um so, particularly this posterior hypertension. So a big drop in their BP when they stand up. Um and then those patients are real, like, particularly quite unstable. Um And also they're, they're more likely to be incontinent of urine as well and it's, it's, it's more severe in presentation. So those three are the main ones, but again, we'll send you the slides, you can have a look at uh at the last one which I won't go through for the sake of time. So, in terms of the management of these patients with the M BT is very important. Um and so pharmacy wise, so levodopa is the most effective medication that you can give. Um and it often provides patients good control for the first six years, 6 to 10 years after which um it becomes less effective. Um So it's usually given as Coben or Dopa because um it's given with another medication um and both of them together. Um So the other medication prevents the breakdown um of, of levodopa in, in, in your system. So, um so Cobey Dopa is often given is, is how levodopa is given. Um you can also have dopamine agonists as well. So, ropinirole um is an example. Um but the main one for the sake of exams you'll need to know is just er, your levo dopa or Cobl dopa. Um All right. And so if it becomes very severe and patients are refractory to medication. So once you've tried one type of medication, you can then give another one as an adjunct. Uh but if it becomes really severe and refractory medication, er, there is a, something else you can do more surgically, which is a deep brain stimulation. Um So that's, that's when you place these electrodes on the basal g in, into the basal ganglia Um And it, it's the aim is to kind of resolve things but patients after it typically vary off their baseline. Um and it, it's, it's more so just to prolong life um as opposed to being curative. Um the other thing to that kind of overlaps is the tremor. So because the tremor or the pill rolling tremor is the key sign. It can be confused for an essential tremor, especially in the older population. Um So an essential tremor is very, very common. Um Family history is a key aspect of it. Um And patients will have more so have a bilateral tremor but just be aware that in Parkinson's um bilateral is if it's drug induced parkinsonism. Um So that will always be the case or it can be more severe. Parkinson's that's progressed from unilateral to bilateral. Um So that's not the only sign with an essential tremor to look out for. The main thing to look out for is uh patients on movement will have a worsening tremor. Uh Whereas in Parkinson's, it'll more so be when they're resting. Um So if you distract them with something else in Parkinson's, then the tremor worsens. Whereas in essential tremor, you'll ask them to do the finger nose test, for example. And as they're reaching out the um the, the tremor gets worse as they reach out. Um it improves with alcohol. Uh But what's key is that you don't really get um other neurological deficit with it. Um And in terms of the management propranolol is used first line. Um and that's what your us that will usually settle uh things for most patients. Um You can add another medication primidone as well. Um but it's often given as an adjunct or in, in place of propranolol, but there's not as much evidence for it. So, looking at the question, um so the key points here were that as a 50 year old patient, the tremor is bilateral. Er, so again, not the main way to differentiate between a central tremor. A Parkinson's tremor, er, but nonetheless relevant. Um So it's been for a number of years fine. Um There's a family history which can also be the case for Parkinson's, er, but again, the key difference is when he's outstretches, his arms, the tremor worsens. Um and in terms of the next step in management, starting a propranolol was the correct answer. So we, we know it's an essential tremor from the presentation, but another key area is that it greatly limits the activities of daily living. Um So with some patients, there might be certain things that trigger the essential tremor. Um So it might be psychiatric, for example. So you can, if it's not as severe and it's not really d uh limiting their daily living as much, then you can maybe think about reassurance and trying to resolve those triggers first. But because this is more quite troublesome for the patient, you would just start them on a trial of propranolol, er, which should usually work for most people. Um, differentiating the two, pfizer. We've covered that already. Um, so we'll have a look at the next question now. So, again, you have a minute on the board, um, and then we'll go through the question after. All right. So that's the minute. So we'll have a look at the, the topic now. So this is more so the uh the, the, the types of brain bleeds that aren't in the parachma. So let's start with extradural hematoma. So this er for this, the, the etiology is that you have a rupture of the middle meningeal artery. Um And so you have this er collection of blood in the space between the dura and the skull. Um, and the key etiology for this is a head trauma in terms that e epidemiology obviously can happen to anyone. But um you typically see young patients who've gone through some sort of trauma like a motorbike accident is, is quite a common one that you'll see or a sports injury. Um, and just be aware that with these patients, you'll also see some sort of skull fracture as well um alongside the bleed. So that's, that's something to be aware of um in terms of how it presents. So you'll have this trauma, patients usually have um uh a loss of consciousness and then they have this interval after where they're a bit looser, they're not quite themselves. Um And if it gets particularly severe, if there's any sort of compression, um they can get these and particular swelling, then you can get a raised intracranial pressure. Um for that, it would be more of an emergency um in terms of the investigation. So you need to do an urgent er, non contrast ct head. So any sort of bleed, bleed, whether within the parachma or not, you need to do that as an investigation um in terms of how to remember it. So, extradural starts with an E so I always just think egg shaped. Um So that's how you can differentiate it on a CT scan. Um You might follow up with an MRI after that's if there's any sort of doubt with um with uh what, what, what you think the di differential is. Um And as for management again, you just, for these ones, you just contact the neurosurgical department and they choose whether er, to treat her conservatively um or whether they want to treat her on their end so they can use a craniectomy or er for that. The next one is a subdural uh just be aware that you can have both acute subdural. So that's within a few days, a chronic subdural. Um So it's a blood bleeding that's been present for over three weeks. Subacute, so that's er in the middle. So 33 or four days to 2 to 3 weeks. Um and then you have acute on chronic, so a patient who's had a chronic chronic bleed, um and then that uh bleeds even further or there's recurrent bleeding um that can then cause er more of an acute presentation after. Um. So with this one, you have the bridging veins that are affected and that causes blood to collect between the dura and the arachnoid er layers. Um risk factors again for this and all of them, it can be due to trauma or falls. These patients usually er, are more so they're elderly patients who have slightly weaker veins. Um so more likely to tear the bridging veins. Um alcohol is a big risk factor as well for these patients and for any sort of brain brain bleed, uh prior use of anticoagulation or current use of anticoagulation. Um and just be aware. Yeah, the the trauma may have happened a while back. So that's thinking about more of a chronic subdural hemorrhage. Um So in terms of the presentation, it, this is more of a progressive presentation. Um it's less acute. So you have this gradual continuous headache. Um and with these patients, they might have fluctuating consciousness, er they can be confused, the personality can change. Um and again, if there's sort um er particularly large bleed, then they can get compression, raised sign, uh signs of raised ICP um in terms of the way to remember the imaging. So subdural er is like slide. Um so, y you see this kind of banana or slide shape on the, on the lateral part of the brain. Um Yeah. So again, refer to neurosurgery. Uh, but we've had our surgery talk, I believe. Um, so I won't go through the, the options in much depth here for that. Um, you have your subarachnoid hemorrhage as well. Um And so that's bleeding into the subarachnoid space. Um, key etiology to be aware of is um rupture of er an aneurysm. Um and a key risk factor for that is polycystic kidney disease. Um So it's important to think about the patient's past medical history for that. Um but the main cause of um a subarachnoid hemorrhage is trauma as well. Um And again, that's, that can be in any uh patient age group, the presentation. So we should hopefully notice you have the thunderclaps, very severe headache. Um And often the pain will be in the back of the neck and kind of lead uh back of the head and lead a bit further down the neck. Um And for this, you get signs of meningism as well cos it affects the er meningo layers. So you have photophobia and neck stiffness as well for that investigation. So again, do do an urgent er non contrast ct head um and aim to do it as soon as possible. Er, but you'll only often really see er, findings within the 1st 12 hours. Um and if, if it's been around 24 hours or sorry, if it's, er, beyond 12 hours, then you'll have a bit of doubt. And so if you can't see anything on the CT, then you would refer them or do a lumbar puncture, um, with the neurologist department. Um, and then what you're looking for is to see if there's any blood products in, uh, the CSF and that would cause, um, presence of oxyhemoglobin and also bilirubin. Um, and you'll see this kind of straw color. So you'll be able to see it when you do the lumbar puncture as well. Um So yeah, the the name of the test is you do a xanthochromia managing it. Um So ignore that. So this is the one that you refer to neurosurgery for. Um and yeah, so if it's particularly severe, then they might need to go to ICU. Er but er neurosurgery will often deal with it. Um just be aware from a pharmaceutical perspective. NiMODipine um is given for these patients as well. Um that reduces the risk or delays, er cerebral ischemia complications to be aware of. So patients can have re bleeds, uh spasming, so vaso spasming and this can then lead to a secondary stroke, um Hydrocephalus as well as you as you can with any sort of stroke or brain bleed as well. Um and er si A DH is unique to subarach subarachnoid hemorrhage as well. So you need to be cautious of their sodium levels looking at this one. So this, it's a younger patient, they've had a fall. Um So they've left, hit the left side of their head, they lose consciousness quite soon. Um And then you have this lemon or egg shaped hemorrhage uh in the parietal area. So, the age group you're thinking um the loss of consciousness as well. Um And then the key thing here is that it's egg shaped or lemon shaped. Um So, you know, therefore that it's an extradural hematoma. Um And that the etiology is um the tearing of the middle meningeal artery. All right, let's have a look at the next one. So again, you have a minute on the board and then we'll discuss it after. Yeah. OK. And then we'll have a look at the next question as well. So again, you have a minute for this one. All right. So let's go through the topic. So, meningitis. Um So this is when you have inflammation of the meninges, um it's typically infectious in nature. Um and just be aware that the one of the main causes is bacterial. Um So you need to know the possible organisms based on the different patient age groups. Er, but I won't cover that in much of that. So you can take a screenshot or we'll send the slides after as well. Uh So you can have that for your notes, um viral, you can have viral meningitis as well, but this is often less severe. Um It's self limiting. So you don't really need to manage it other than supportive care. Um You can have fungal infections too. Um And that's more so in the setting of HIV or patients who are immunosuppressed. Um So the main species to be aware of is your cryptococcus Neoformans, um and Candida species. Um And also you do see TB meningitis here and there as well. Um So we'll go through some of the LP findings which will be important for differentiating, differentiating the type of meningitis um in terms of the headache. So you have the classic triad of um headache, neck stiffness, and photophobia, er be aware of the two signs. You don't really see them tested much on the wards. Uh But from an exam standpoint, it's particularly important. Um So you have king signs. So this is inability to fully extend at the knee uh when you hip flex the hip at 90 degrees. Um and it's limited by pain and then you have Brzezinski sign as well. Um So when you flex the patient's neck, you get this spontaneous flexion of the knees and hips and it's all just because of the meninges going down the spinal column are just kind of irritated. Um Patients will often have a fever as well um and feel quite nauseous too the diagnosis. So initially, it it there's a clinical suspicion um and you start patients on an antibiotic. Um And so specifically, that's IV cefTRIAXone on first line. If there's any sort of clinical doubt and you're thinking more so a meningoencephalitis, um then you will also start them on an antiviral, but with the anti virals, because there aren't many side effects in that regard and it's better to be safe than sorry. Often you see a lot of people at the front door just start bother because patients, they, because it's, it is very distressing even if it is just meningitis and that in itself can cause a bit of distress in patients. You might be suspicious that the patient isn't quite at their baseline or behaving as they normally would, er, which would make you more. So think encephalitis, but we'll discuss that in a bit more depth short, shortly, um, definitive. So you want, uh, in terms of the diagnosis, you want to do a lumbar puncture, um, and you usually do act as well. Um, you just want to rule out something like in, er, raised ICP, um, which is important before you do the lumbar puncture as well. Um, the different results to be aware of. So the appearance to start with. Um, so for all of them, you'll see this kind of cloudy turbine appearance. Um, aside from a viral, which is colorless or clear um, protein, er, for a viral one, it, it can be normal or it can be raised, er, but for a bacterial, you will typically see it raised, um, and then the glucose for viral will er often be normal. Whereas for bacterial, you'll more so see it reduced. Um And yeah, the predominant cell types and borders of bacterial is neutrophil. Viral is your lymphocytes. Um And yeah, just be aware. So TB has a very similar presentation uh on the results to a viral. The main thing to be aware of is the cloudier appearance. Um and the glucose is more likely to be reduced but normal and viral. Um So, encephalitis. So this is when you have inflammation of the brain parenchyma as opposed to meningeal. Um and again, it's commonly due to an infection. Um and the infection is often secondary to uh infection from organisms. So local structures. So it might be um like an ear infection for example, or throat infection. Um and it can be non infectious as well. So with, especially in younger patients, you, you often do an autoimmune encephalitis as well screen. So you would send bloods off for that. Um And you can check uh for autoimmune causes as well. Um And yeah, the most common viral organism is HSV to be aware of for that. Um So in terms of the presentation, it's slightly different, you don't really get the signs of meninges of as much, er but it can happen. Um And so the key presentations they have this fever, they can have a headache. Uh but the main thing to be aware of is that they can have behavioral changes um and they can have this sort of confusion as well. Um So differentiating it, the key thing. So doing a lumbar puncture for one helps but from a clinical standpoint, if you're it, yeah, if, if, if there's suspicion of both, then it is deemed a meningoencephalitis um for the diagnosis. So yeah, you, you do an LP for, for patients, but you also do a viral PCR which would then uh pick, pick up a possible virus. Um You do an autoimmune screen so you send off bloods for that. Um So there's various ones that you can send off like Casper two and the NMDA A um imaging for these patients as well if you're thinking another possible cause. Um and it could, you could you do an E eg for some patients with do where there's doubt as well. Um especially if it's an epileptic patient, they might just be postictal causing their confusion in terms of managing them. So you need to treat with IV or Cyclovir um if it's viral in origin, er but if there's other possible causes like paraneoplastic or autoimmune, er then you can start them on steroids. So looking at this question, so this patient that's coming with photophobia, neck stiffness and, and they have quite a high temperature as well. Uh There's a bit you, you're not 100% sure on what's going on because they're, they're quite confused because they're not orientated. Um and they're not quite the normal cells. Um So there's a bit of doubt it could be a meningoencephalitis. But in, in the first instance, um especially if you're on the front door, then you would want to start these patients on IV CF Trione and acyclovir. Um And then the neurology team, thereafter, they can kind of decide which one to continue with once they've done the LP as well. Um A MG. So you'll see that more. So in gastro or gen surge conditions, um IV cefTRIAXone alone, just because of the confusion, you would want to start on Acyclovir especially cos there aren't uh particularly severe side effects from it. Um dexamethasone is an important addition once your confidence or, or you've confirmed um a diagnosis of a bacterial meningitis. So that's usually after you've done the LP, you also want to start on dexamethasone. Um You, so it wouldn't apply in this case because we're not 100% sure whether it's bacterial or not. Um urgency to your head you might do. Uh but the, the key differentials here would be meningitis and encephalitis. Um So there's no need for an urgent scan in that regard. Um Sorry. So, apologies. Let's go back to. Yeah. So for this question, um where is it gone? There we go. Um So you want to start the patients um on oral ciprofloxacin. So that's your er so for family members of patients, um you want to give them prophylactic treatment if you think it's a meningococcal er, er, meningitis. So slightly more severe than pro patients who or family who have been in close contact with the patients. You want to give them prophylax um prophylactic oral ciprofloxacin. Um, so that's a constant question you'll see. All right. So moving on to cord compression, so I'll quickly give you another minute for this. Ok. So we'll have a look at the condition. So, cord compression. Um, so this one you have injury to the spinal cord um and causes of which include trauma. Uh So that's more so in younger patients or if there's an elderly patient, you're thinking a tumor. Er So it might be one that's metastasized from elsewhere like longer breast. Um or hematological key one to think about is your is multiple myeloma. Uh patients might also be osteoporotic um and there's a fracture which might be causing the core compression um in terms of the signs and symptoms. Um so patients will often present with limb weakness. Um They usually have this upper motor symptoms below the level of the lesion. Um and at the level you see this lower motor neuron. Um So I won't go through the path pathophysiology now for the sake of time, uh but they, they can often have sensory symptoms as well um in which includes back pain, which is a key sign um and autonomic ones as well. So, uh urinary retention constipation as well. Um Key investigation to do that's important for a definitive diagnosis is your MRI spine. Uh, often the whole spine is done because it's, it's quite from a clinical standpoint. It might be difficult to kind of, er, focus just on one particular area of the spine. So they often just do a whole spine. Um, you might also do act um and you can do lateral x rays if you're thinking mm uh malalignment. Um If, if it's due to a fracture from a blood standpoint, uh you can do tests for multiple myeloma, which includes electrophoresis. Um If you think it's hematological malignancy, um and benzos proteins to cover that as well. Um so called a equina. Um So this is, this is when you have compression, um and it's usually due to er disc herniation, er a compression in the spinal canal. Um and with these patients, you get symptoms like back pain, um reduced anal tone. So you need to do apr exam, saddle anesthesia, um and positive obi. So they have these upper motor neuron signs. Um Radiculopathy, impingement on the nerve roots, er, past uh past the spine. Um And so, yeah, here you get the lower motor neuron signs, but I won't go through that uh for the sake of time. Er, but we can give you the slides after. So the key investigation for this patient was an MRI whole spine. Um So that's the key for a definitive diagnosis. Um So very quickly we'll do this question as well. And then, so you have a minute for this one as well. OK. So we'll move on. Um So this question is about uh the differentials for a headache. Uh So we'll start with primary headaches. Um So this includes uh tension, headache, cluster headache, migraine trigeminal neuralgia. Um I think for the sake of time just because we are going over quite a bit. Um I'll, I'll just discuss the main condition after that was relevant to the question. Uh But you're welcome to take a screenshot. So I use this as a resource for my finals. I thought it was very helpful. Um and it kind of summarizes all the types of headaches. So here you have your primary headaches, um the secondary ones. Um So thinking more intracranial. Um So that's that. So if you want to take a screenshot, and lastly, you have the secondary extracranial causes as well. Um But for the sake of time, we'll quickly move on, we'll, so the answer to this question. So you're thinking a young patient with a higher BMI I, um and they're female, um idiopathic intracranial hypertension is something you should think, think about er, quite quickly. Um And the fact that they're also on the combined oral contraceptive pill, um and again, it's a very common condition that you do see. Um So that was the answer in this case, right? Ok. Um I'll start my questions now and make sure we'll try and finish on time. Um So I'll give you another minute for this question and then a member time he went to start explaining when the minute is done. So that's the minute left. Cool. OK. So let me just talk about epilepsy treatment. So it's quite clear from the case that it was epilepsy. So this is how you go about um you know, treating it. And actually these guidelines, I think they're fairly new as in, in the last couple of years. So when I was revising for finals, I think these had actually changed when I did neurology in third year. So, um you tend to not give any medications or pharmacological interventions after the first episode. When a patient has their first er seizure episode, they go to the first epilepsy or first seizure clinic that is to, you know, investigate for other causes of epilepsy or causes of the collapse. Um But in certain situations, you may start it after the first incident. So um if there obvious signs of neurological deficit, uh there's brain imaging um associated with that is the neurological cause, an E eg can also be part of it. And then also if there's a strong family history or the family or patient would, is very keen to actually start on medication. So um I don't have any fancy rules to actually remember a lot of these treatments, but we can go through some of the medication. So general tonic clonic seizure. So that is when you get a stiffening and then you get a jerking and that was actually in this case. Um So for men, you give sodium val and women, you give lamoTRIgine or levetiracetam. The reason why is uh sodium val is taraso. Um So therefore, in women, you give lamoTRIgine, especially women who are, who are child bearing age. Um then for focal seizures, those would be your frontal lobes, your temporal lobes or septal lobe seizures. Um It would be lamoTRIgine first line and then second line would be uh carBAMazepine er absent seizures. That is when patients will go blank, they may not be speaking and actually, they don't even necessarily remember that they had an absent seizure. They may describe that they were lost in the room or unable to capture where they were, but that's what they would do. Um So you give oxo suing side and butchering of these pronunciations and then for men, it uh second line. So vs and women is or uh myoclonic seizures um that will be just jerking that er you give sodium valtrates and then levetiracetam and then tonic or Atonic and that's just stiffening in patients who just fall to the floor, uh fall to the floor stiff again. Men, sodium val women love Motrin. So if you go back to the question, um the answer is lamoTRIgine. So it's clear in this one that it is a tonic clonic seizure because uh fell to the ground, very stiff and then had rapid jerking, rhythmic, rhythmically. Um Now it does technically say that this patient whilst his childbearing age is 26 but is not planning on having um any, er, Children any time soon starting a family, you still look to give lamoTRIgine even though er, it's because it can have some, some fertility effects on you. So that's why you still go for that. And then also if the patient was then to, you know, after five years come back and say now I would like to have Children, it can take time to reestablish a new medication. Um And you know, and then start then to, you know, prepare for a family. So that's why you would just start on lamoTRIgine there and then OK, so hopefully that's explained, please do put questions in the group chat if you have any. So I'll give you another minute for the next question, one minute there. OK. Um So let me start explaining. So uh this case was Mysia gravis. So that is an autoimmune condition where you get a dysfunction in your ach receptors. So, ach receptors are actually all over the body generally cause sympathetic stimulation. Um but in terms of remembering um signs and symptoms, it's fatiguable symptoms, fatiguability. So these would actually be the patient generally would be fine in the day and actually get worse at the end of the day or worsening of it. So common symptoms is extraocular muscle weakness, double vision, proximal weakness in the face, the neck limb girdle and that can present as like stroke type symptoms. So it is something you know, it's one of those stroke mimics. And you may need to think about, you know, not diagnose a stroke, think about this ptosis and also dysphasia, difficulty swallowing. Um So in terms of investigations, there's a number of things you need to do and you know, you need to read the question carefully about what it's asking for for a definitive diagnosis, diagnosis or initial investigation of that question, single fiber electromyography. Um and it has a very high sensitivity, there are other things to investigate for. So, thigh murmurs are very common in patients with mycena gravis. So you need to do a ct thorax of that. And if so maybe surgical intervention to remove, you need to measure creatinine kinase levels. Um just because this can somewhat mimic rhabdomyolysis. But in these patients, it would be normal because you're not getting a breakdown of muscle. Um And then also you can do antibody testing like acetylcholine uh choline receptors in terms of management for these patients. Um We're gonna supposed to long term and then acute problems of my in your crisis. So long term is pyrimine, that's a long acting acylcholine estra uh receptor inhibitor. Um Therefore, it's just to increase the activation uh increase acylcholine in your system. Sorry, everyone. Um I think has may have logged out or lagged out rather. Are you still with us? Hello? Can you hear me? Yeah. Oh, fine. Ok. Um cool, I'll just carry on. So, er, management prostigmine, er, can be used for long acting. It, it's a long acting acetylcholine EDA inhibitor. Um so therefore it just increases, increase the activation of these receptors um in terms of mycetic crisis. So that is where, um because these receptors are all across the body, um it would actually affect um your respiratory muscles and therefore you can get respiratory depression, it's normally triggered by stress or infection or an acute problem. And these are medical emergencies that you need to give plasmapheresis and IV immunoglobulins. So we go back to the question. Um The answer is b so er you could tell that this is my senior gravis um because uh well, it, it says it in there. Um but in terms of, in terms of the management, this appears to be an acute episode and I understand it says respiratory distress, increased work of breathing. Typically it is actually respiratory depression. So difficulty in breathing, but normally in the acute phases, you, you get like an over activation of the body, but then later you get this depression um is triggered by a response, whether that's an infection or stress. He said patient had the flu last week and was generally unwell since then. So that's the trigger for the myia graft is because you get an increase in metabolic activity or requirement of ach. Um So that's why the answer is not e and that's why it is b because this is an acute scenario. OK. So we can do the next question. You can have a minute to have a read and uh we'll go through it together. Starts for a minute now. All right. So we'll go through. It's so, uh in this case, it was multiple sclerosis. That is a demyelination of your central nervous system, the neurons. So um it can affect sensory and motor responses. Um in terms of diapsis, it is two or more relapses, er, differentiated by time, er, place and time, er time and space. Ok. Um and we'll go through that. So uh there's different forms of treatment for MS, you've got acute relapses. Um that is when someone's very unwell and then you give high dose ses for five days, it can be IV or oral. And then in terms of your long term management, you've got disease modifying drugs. They tend to be used in autoimmune conditions. So, a lot of these medications are monoclonal antibodies like natalizumab and A CREO IAB. And then also treating for specific problems are known for a er for um MS uh you got uh a patient complain of fatigue, you give amantadine, also mindfulness and CBT can also be given spasticity is a common question. So you give Baclofen or gabapentin bladder dysfunction, self unique catheterization. You can also give oxybutynin. Um So that would be for that's MS treatment. Um Also, uh actually, I'll explain that when we go through the answer. OK. So in terms of the answers, the answer is a, so technically, all these things you would somewhat do, but let me break it down. Um It is MS the way you tell it is this patients coming with neurological symptoms, 12 hours of history of lower limb paraestesia. But then also it explains that two similar episodes in the last year as well as other incidences as well. So that's MS and there's all, there's almost these unrelated symptoms but unrelated neurological symptoms. You're thinking MS. Ok? Um In terms of the management, there seems to be an acute episode that this patient is going on of this lower limb paras sez and it's spreading. So then we need to treat this immediately. Um We do an urgent neuro referral if it's not the first thing, repeat brain MRI and the spine. Um what it, it, it could take time for that and it's very clear from this that, you know, this patient has got an acute exac or, you know, acute relapse of the MS. So it's not needed right away, but you, we'll do it eventually. And then B and C those are long term management for MS. So that's why the answer is a for this case. OK? I'll give you another minute for this question one minute. OK. Let's go through this case. So um it was raised intracranial pressure, so raised intracranial pressure, that is a medical emergency. There are different reasons why you can get it. It could be any of your intracranial bleeding. It could be a space occupying lesion, abscess formation. Um Yeah, I mean, abscess formation like that can somewhat also be associated with meningitis as well that we talked about previously cyst formation. So there's a number of causes for raised IP uh in terms of how does it headache, vomiting, reducing level of consciousness and also uh swelling of the optic disc, you also get this classical cushing's triad. So that it's a common question that they like to ask in finals. So you get a widening pulse, pressure, bradycardia and irregular breathing and those are like form, this is raised ICP in terms of investigations, you would do an urgent er head, then later you would do an AM C head. You can look for like, you know, gross or major pathology. Um And in terms of management, um and this is about reading the question carefully about what to do immediately and then what to do later. So, um immediate or er things is head elevation of um then medications IV Mannitol is there to reduce the cerebral edema or osmotic diuretic er diuresis that's going on. And then you've got something called controlled hyperventilation of my, actually seen this before. Uh you, because you're sating, you're blowing out CO2 that causes vasoconstrictions of your cerebral arteries. And as a result that reduces your ICP, you can also, then once you got there, you look for underlying treat the underlying causes. Um repeated lumbar punches can also be done. We can talk about that when we go through answers. So if we look at the answer, uh the answer is D IV monitor, acetaZOLAMIDE is uh tend to be given for idiopathic intracranial hypertension. You're obese female with all the similar symptoms but probably less acute. Um IV dexamethasone can be given in, in like some more replacement for Mannitol. It, it can reduce uh edema but Mannitol, it tends to be the first line urgent lumbar puncture that can be done, but it just depends on what the cause is at the end of the day. Um Also it can be contraindicated, you know, patients got like these headaches. Um Yeah, then urgent p would be contraindicated. Also, it can take time for that to actually be done. Whereas IV mantle is a quicker thing. That is so yeah, hopefully I've explained that. Ok, we can go for the next question. I think this is the last question of our session. So I'll give you another minute, one minute time. OK. So let's talk about mononeuropathies. I don't really have a great way to remember this. I kinda like learning about this because I've, you know, I've, I've an interest hand surgery or plastics. So the way it is I think about, um I don't know if you guys have done your osk, but I think that when I'm doing my osk examination, all the things I'm look looking for why I'm actually doing rather than just random, you know, hand and arm movements. So let's just try and break it down and it's just pat, it's just pat pattern recognition at the end of the day. So radial nerve you get, um is a if a patient presents with a fracture at the shaft of the humerus, if you look at your anatomy, your radial nerve kinda goes across there. That could be associated with that um, wrist drop as well is associated with radial nerve or extension. So wrist drop is kinda a part of that. You get, you know, a problem with that or they're not able to extend their fingers. So that's why I remember radial nerve, common perineal nerve. II think of it as the extensor hallucis longus, which is your big toe. So you get problems with your big toe. So dorsi flexion aversion. Also your big toe plays a part of that. Your anterior tibial and perineal nerves, they run on the dorsum surface of your foot. So, ok, ulnar nerve, you get the claw hand. So ulnar nerve tends to um you know, supply mostly your 4th and 5th fingers. You get that claw finger shape. Um you get um it to affect your hypothenar muscles. The hypothenar muscle hand is the smaller muscles that are on the base or underneath your 4th and 5th finger. And then your Thile muscles is the big chunky one that's at the base of your thumb. Um And then you get radial deviation as well. Ok. Median nerve, I feel that's easy to remember. That's carpal tunnel syndrome is compression of the median nerve. So that would be wasting of your thenar muscles. The big muscle underneath the base of your thumb, pronation of your hand, your ulnar deviation is opposite to ulnar nerve, positive falls and Tinel's test, um, and thumb, thumb opposition as well. So that's a bit easier to remember. Axillary nerve. Um That's part of your brachial plexus. It supplies, er, classically, um, essentially lost in the patch of your deltoid muscle. Also, if you get a fracture at the head of your humerus, I can't think of auxiliary because it's near the armpits, you get armpit ish near symptoms. Um, and then other ones, I've seen these on past meds traction injury. So, hanging off roof with hands. So these are, you know, let's say handy men who are, you know, up on ladders and then they've accidentally caught themselves and fell off the ladder. They would get these traction injuries in the C eight and T one region. Herbs, palsy is common in, um, um, macrosomia or when you have, you know, larger babies being born by normal birth, they can then one, their, you know, when they are birth, they get these arm hanging loose and problems with pronation and their arms are immediately rotated and then the last one intercostal brachial artery. So that is a problem. Uh that is very much associated with breast surgery and breast reconstructive surgery where you get loss of sensation in your armpit. Ok. So there is no great way to remember at the end of the day. Um it's just a passing recognition. So in this case, the reason why it's ulnar nerve is wasting of the hypothenar muscles that we said it's underneath your 4th and 5th finger finger abduction is also associated with it. So that's why it's nerve. When they give these questions, they don't write down all the things. So let's say you've remembered claw hand for ulnar nerve, obviously, they may not write that. Um So do try and remember. I, I've tried to explain verbally the main points to remember the different mononeuropathies. Perfect. So that rounds things up. So, again, thank you so much to everyone for taking the time out this evening, er, to attend this session. Really appreciate it if you could just give us some feedback. So I think I've posted it in the chat. Um, in return, you'll get a certificate for attendance as well. Er, so it'll help us tremendously for our applications going forwards. Um So thank you so much again. Um Again, we have several, er, several different sessions left for the series. So please do come to those as well. So they're usually on Thursdays at seven, but we might do an additional one on the Tuesday. Um, if it's relevant that week, uh, to, to the talk that we're doing. Um, all right. So I think we'll leave it there for this evening. So, thank you again, everyone. Er, if we could just complete the feedback forms, that would be amazing. So the slides will be uploaded onto the medal, er, with a video, I believe. Um, you're very welcome blessing. Um, so thank you for attending. So the slides, yeah, we'll, we'll upload with the medal if there's any sort of technical issue or it doesn't come through, uh, just message us on medal. Um, and then we can send it to you directly as well. All right, perfect. Enjoy the rest of your evenings. Thank you, everyone. Cheers. Thank you.