 For all those waiting, I'm going to give it just a couple more minutes for everyone. Feel free to chat in the chat box where you're from. Okay, let's get started everybody. So I'm Anna Esparham I am a physician and I'm triple board certified I'm certified in pediatrics and then I went on to go get more pain training I did. I'm a board certification and integrative medicine, and then I went on to get my board certification in medical acupuncture which yes as a physician you can become a physician acupuncturist. We actually have our own board certifying agency and our own medical organization as well. I am an associate professor at the University of Missouri Kansas City School of Medicine, and I work at children's mercy hospital and I direct a headache treatment center it's a pain center for a lot of kids and young adults and pain so I do a lot of procedures. Mostly all day long. And then I'm here on behalf of advanced e clinical training I'm one of the pre med mentors it's an incredible program for those wanting to go to med school, and they have other certifications which will get into as well and I'm also the founder of health is power is podcast, really focusing on women's health and wellness so we're going to do real DX case 24 1024 on headache fever and radiating neck pain but before we do that. I do want to tell you about advanced e clinical training. It is, like I said a really great program for allied health students also it's really designed for people who want to go into the healthcare field. And its mission is really to provide just really good clinical certification programs, including certified medical assistant certified patient care tech certified pharmacy tech advanced medical terminology. And it's pretty asynchronous and they have a really good physician pre med mentorship program as well which I am one of those so if you want to go to med school hop on in there's also I think by doing this virtual training you get a $100 promo with the password webinar. And so take advantage of that. I'll probably say that at the end to just so you guys, whoever comes on later will know about that little gift as well so welcome. We're going to make this a pretty interactive experience I'd love to hear your thoughts and get you engaged with this case. And it's really just to kind of get you thinking, like you are a medical student yourself. And then a different type of allied health student. Because you really do need to embody your identity if you're going into whatever healthcare, you know field career, you want to embody that person to become that person and so I think this is really going to help you guys get there. So, let's get started. Okay, I'm going to share my screen. Okay. Okay, let me do this. Alright guys. Now I probably will have you use the chat function just to make sure you can hear the sound because I think the last time they did this webinar. The sound wasn't working so I want to make sure you guys can hear it so. Alright, so this is headache. Next stiffness and then subjective fever and it's case 24 in real DX so let's get started but please chat in the chat function when I started make sure you can hear it. Hello, good afternoon. I'm Dr. Moore. Thanks again for taking the time to do this video. You mind just telling us your own words. Okay, great. The chat function is disabled. Okay, great. Pressure is on the spine last night. You had fevers? Yeah. How high do you know? It was 127 was the highest but it went down past 99.5 a low grade fever. I had chills and it was full body ache. But when I woke up this morning I couldn't move my neck at all. You couldn't move your neck? No. Are you able to bend it? Are you able to like touch your chin to your chest right now or is that really bothering you? It's still bothering me. Your neck is kind of stiff even if we try to help. Does that hurt a little? Yeah. Okay. And you take plaque one now, is that correct? Yes, I have a chest disease. The chest? Okay. So you're taking a medicine? Ectema infusion for it. You have an infusion? How often do you get that? Monthly. Monthly? Okay. All right. Well, we're going to do that lumbar puncture that we talked about, okay? Right. All right. Thanks for taking the time. Okay, so I'm going to do a little poll for you guys to answer before we get to the next step. So let's see if this works for the first question. This is often what you're going to get when you first start in med school. Okay, is the appearance of the patient, do you think sick or not sick? And honestly there is real like no right answer to this, but I just want to see what you guys think. Okay. All right. Almost there. Okay. All right, I'm going to share with you guys. Okay. So most people think sick, which yeah, I'd agree sick. It's totally subjective though. And really when you walk into the patient's room, you really want to have that appearance. First thing and foremost is, is this patient super sick? Do I need to act super quickly? Or, you know, is it really going to just take a lot more time and then it's more chronic condition, maybe less sick. So you really just want to know if you need to maybe code a patient or if you can take your time with more diagnostics, history, work up and things like that. And so we'll get more into it and really decide, well, what the real DX decided in just a moment. So let's look at the vitals and then get a little more into her physical. Hold on just a sec. Okay. All right. So, okay, so vitals and demographics. So female 35 years of age. She does not have a fever when they took her temperature her heart rates 56 kind of low for, you know, most adults but maybe she's an athlete. We didn't really get into that respiratory rate 17 she's doing just fine pulse ox is great 100% her blood pressure is normal. So maybe on the lower side for most adults, but she, she's not in shock and she doesn't have hypotension so we're good there. She does report fever at home though so we still have to take that into mind that she is having a fever so there could be some infection going on, or there could be some inflammatory process because she has the chef's disease and the chef's disease is a auto immune disease. Usually they have a lot of ulcers in the mucosal membranes. And she is treated with immunosuppressants. And so I do, I think I do have another poll question on that so let me see. Oh, well hold on stop sharing. Okay. So, all right, answer. What are the red flags in her history, based on what we just talked about. All right, let's see, almost there. Yeah, it looks like, okay I'm going to share the results. Okay. It looks like immunosuppressed is winning yeah that is the biggest red flag in her history. So you guys are right. I know the, this is kind of a trick question but the combination of having a fever headache and neck stiffness is concerning for some kind of infectious intracranial process but that immunosuppression is a huge red flag and so really anyone with immunosuppression. There could be a high risk of infection because their immune system is depressed. Okay, so let's go down. Okay, so actually this is another question about her differential diagnosis and I'm going to have you guys answer that. Oops, there we go. Okay, so what do you think is the differential diagnosis. We'll give another 15 seconds or so. Okay, let me end the poll, share the results. So we've got, obviously this is not an exhaustive list, but autoimmune flare it looks like you guys were super concerned about autoimmune flare meningitis was second then viral illness and then cancer and tumor and so yeah let's let's actually get into their differential diagnosis first. Okay. All right so their differential was viral illness viral meningitis and migraine headache and so oh shoot you're not supposed to see the labs because I have a poll on that hold on. Okay, there we go. All right what labs diagnostics what imaging would you order. I thought you can do multiple choice on this but maybe not. Okay I'll give you guys 10 more seconds. All right. So definitely complete blood cell count that one out and then lumbar puncture and CFS CSF cell count so cerebral spinal fluid cell counts to see if there is an infection and then also CSF culture as well. And then also you guys decided next steps were MRI of the brain and CT head and blood culture and then serum glucose and serum protein and actually most all those are correct. We're going to get into that, and I'll show you why. Okay. Okay, so the patient work up that they did is typically yes you're going to get a complete blood cell count. But most often, especially if you think the patient is septic, they didn't really think the patient was septic so I don't believe they got blood cultures just regular blood cultures. And typically, if you are worried about viral meningitis or any type of infectious process in the brain or in the CSF fluid. You're definitely wanting to get a serum glucose and a serum protein because you want to compare that, which we'll get into to the CSF glucose and protein determine if it's bacterial versus viral meningitis. Typically, most people get before a lumbar puncture. If they're worried about herniation, because you're going to pull out CSF fluid from the spinal cord typically between L4 and L5. If you're pulling out cerebral spinal fluid, there is a risk if someone has a mass in their brain or if someone has cerebellum in their near under their brainstem. For example, going into their spinal cord, there is risk of herniation if you're pulling out more CSF fluid is just going to like pull that brain down. And so that person can herniate that person can code if you do a lumbar puncture on that person. So that's why most people want to get a CT head before they do a lumbar puncture. There are specific rules around that. So not every patient needs to get a CT head, but that is a concern. So, so what do you guys in the Q&A, what do you think the diagnosis really is after I told you all that you can put that I think in the Q&A function. Yeah. Perfect. Yeah, so we've got three people saying meningitis. So the answer is, yeah, meningitis, you guys are right. Here it's viral meningitis. So we're going to look at what they did and we're going to actually look at how a lumbar puncture is done, because definitely if you become a medical student or a physician you are going to have to learn how to do a lumbar puncture. So let's take a look at that. Great. So we'll talk about treatment as well. Obviously, if you are worried about meningitis before the labs come back, you really want to treat it for bacterial meningitis and we'll ask that question in a minute. But let's take a look at that. How they're going to be doing the lumbar puncture. Makeup's in order. Thank you. And thank you for letting us do the video of this procedure here. We're about to start a lumbar puncture. Miro is our star for the procedure here. We're going to get this prepped up. So we got her in a sitting out position, which I do think is better for lining things up if you're able to get the patient to sit up. It's not as good for testing opening pressure. But in this case, we're concerned about infection. So what we've done is we've indented part of her skin right there with the end of a syringe, blunt, sorry, not syringe, well, yeah, syringe, just the blunt part of it to mark it. And then we're going to have her kind of bent over on the table here. We're getting prepped up. We'll prep it with lidocaine, betadine, and then put some lidocaine in for numbing medicine, and then go in with the needle. All right, so before we started, we marked our lane marks. So we're made a little mark right at the level of L4 here at the level of the ASIF, and I put our thumb there. Now we're going to clean her off. We'll start in the middle here. So this is a sterile procedure. We'll do this generally three times. Make sure it's nice and clean. Once we've done that, three times we'll put on the sterile cover to access the site. Get off with that small little wheel or a small amount of lidocaine right in the area where I'm going to inject you. So you're going to feel a big poke? This is 1% lidocaine. This is 2% without lidocaine. We'll just skin the wheel off the top to make it all easier to go in. That's probably fancy how you can go in. I'm trying to follow the same path that you would with this final needle. That's going to be almost horizontal mirror. There you go. Like that. Just go in and kind of spread the lidocaine around there and just be generous. So we get her numbed up just kind of along the track that we need to go in with the lidocaine. There's a couple of attempts here. I think this person is learning. She might be a resident anesthesiologist. Needle we have 22? This I believe is a 20. We do have extra spinal needles in case we need to switch. Holding my needle with my thumb over the bevel. The bevel to the side. I'm going in with the needle now, okay? It's going to be pretty far out. So you can go ahead and push again. You're going to feel like you're through the ligament of land. And then hopefully you're not even close to being far enough. Push farther in. Like a couple more inches on this. How are you feeling? You okay? So what she needs to do is she has to get it in. One of the tissue that actually will get into the CSF fluid. And so you hear this pop. And I don't think she's quite there yet. So she pulls the needle out so she can see the CSF fluid come out. So that CSF, once you're into that cerebral spinal fluid space, the fluid should start just coming out of that spinal needle at that edge of the. Pale pink area. Just remember that when you're doing this, you're below the level of the cartoquana. You're going to hit the vertebral body if you go too far. So people are always worried about going too far. But if you do, you'll hit the bone. So you, I mean, you want to ideally get into the right area. And then you'll feel that pop and you see it come out. But if it feels like it's going in the right area, you can keep, keep advancing till you feel that pop. And sometimes you're going to have to get in pretty far. And then you're going to have to get into the right area. You can keep advancing till you feel that pop. And sometimes you're going to have to get in pretty far. That's okay. What did you feel there? Which leg? The right leg. The right leg? Yeah. Maybe a little bit off midline. You can try a little farther if it feels good. Are you feeling pain? So she might have just hit a little bit of the spinal nerves that actually radiate down to the leg. So when you're redirecting a spinal needle or actually any type of needle, you usually pull it out not all the way out, but you can pull it out up to kind of the edge of the skin. And then be able to redirect it pretty easily. It's, it's really a lot harder to do adults than it is kids. Adults have a lot of degenerative issues and bones and disc disease. And so it is tougher to do adults than it is young babies and kids. All right. So here we'll see the successful attempt. And you'll hopefully they're going to show that CSF fluid. Okay. So you'll see the CSF fluid coming out. That's exactly what it looks like. So also one of the questions too was, um, why was there? Uh, why did he have to do more lidocaine? It was because he actually went up higher. So you're going to have to do more lidocaine. So we're going to go with that. And then we're going to go with the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the, the. The, the, the, the, the, the, the, the, the, actually went up higher than the other woman. And so that part wasn't numb. And so that's why he put more lidocaine. And then another question was, why did he have to pull out the needle? That was my question as well. So great questions, guys. Typically, we don't do that because kind of in sterile procedures, we then that needle is no longer sterile typically. So we just have to watch out for that is just like not pulling that needle all the way out. But he did it. So and she turned out fine. Okay, so I am going to ask, oh, no, actually, this one part, because we're going to look at the final labs. So also you see how clear it is. That is like a perfect CSF fluid tap. And we'll actually probably see that in the lab results. But if it comes back all bloody, then you know, it's not the best tap and and the lab results might not be that good because of the bloody tap. Sometimes we can't really tell. See how clear it is. And one thing some people will get severe headaches after a lumbar puncture. And when that happens, you do have to worry about pretty much low pressure headaches, which means low intracranial pressure headaches, because you pulled all that CSF fluid out. And what is the big risk, you can put it in the Q&A, what is the big risk when you pull out a lot of CSF fluid, and you get a headache, what could happen basically to the brain? And it is life threatening. Does anyone know? It's kind of a tough question. We mentioned it earlier today, but you can put it in the Q&A. Yeah, sinking. So your brain sinks, because the CSF fluid isn't, you know, basically that boy that's holding it up, so herniation. So you can get herniation. Yeah, good job, guys. How long does it take for the body to restore the amount a CSF fluid removes? I can't recall exactly how many days. I'll have to look that up for you guys. I'll find that out. And then have them send an email. Did you guys all sign up for an email to get this webinar? I don't know if you did. Okay, yeah, okay, good. So that way, hold on, let me write that down. Great questions, guys. Okay, so let's look at the lab results. All right, so this is the cerebral spinal fluid. They did not get a serum glucose and a serum protein, it looks like. Yeah, I don't think so. But that's fine. They were actually thinking it's probably viral meningitis instead, and maybe they didn't put that down there for you. But if you look here, the appearance is clear, so great. It was a great tap. Xanthochromia, just like basically it's clear. Red cells, there's not that much red cells. It's just 17. When you get a really bloody tap, it is a lot. Lymphocytes is really, really high. So 83, and lymphocytes really is more fighting a viral illness. So people who have an upper respiratory tract infection, that's a viral illness, typically their lymphocytes will be elevated. Monocytes are also an immune cell that helps protect against infection. And yeah, so CSF lymphocytes in the fourth tube was also elevated. And glucose, the CSF glucose and the CSF protein, really, if you can't compare that to the serum glucose and protein, it's pretty hard to interpret, which we'll get into into our PowerPoint. Okay, and so they also did. And so cultures, CSF cultures are for bacteria. And then in order to do look at the viruses, they'll do a PCR, much like how we detect COVID-19, it's by a PCR. So the CSF, when you look at it, you're going to do a PCR of different viruses. And what they found was rhinovirus. Most often in kids, we see more enterovirus. That's kind of more common. And so I'm going to have, oh, wait. Oh, why do we take and analyze multiple tubes if the CSF fluid is from one patient? Because it takes four tubes to actually analyze the CSF fluid. So we actually have to have enough plus, they actually save some if we need to do any more tests on it. So they'll save the tube for seven days. Orthophysicians don't do lumbar taps. It's anesthesiologist, primary care physicians, pediatricians, neurologists, and internal medicine, family medicine. However, that was like back in my day, where we did more of that at the bedside. And nowadays, more and more adults are going to interventional radiology to have their lumbar puncture done because they can use fluoroscopy. And so it's just easier on the patient because they really just do one try. They don't have to do multiple pokes, multiple tries. So interventional radiologist using that fluoroscopy, it just significantly is better patient care, though it takes a lot of our procedures away from us because we're not doing the lumbar punctures as often in the emergency room or in our clinics anymore. So, okay. So now that we know it's viral meningitis, I'm going to do a little poll. Okay. All right. What treatment, what immediate treatment do you recommend? This patient is in the hospital and we need to treat her. What should we do? All right, 10 more seconds. All right. I'm going to end the poll, share the results. Okay. So let's see who won. Oh. Oh, Ivy Fluids won. Okay. And then antibiotics for bacterial meningitis. So, yes. Pretty much, we can do all of these things. Now, Ivy Fluids definitely first and foremost because, you know, it was likely the patient wasn't eating, wasn't drinking as much because she felt so sick. And we definitely absolutely have to start antibiotics even though she doesn't have bacterial meningitis. We didn't know that. And it's probably going to, it probably took maybe several hours to, you know, maybe even overnight to get those labs. And so it is life-threatening if we don't treat her within an hour, at least an hour when she arrives to the emergency room, which maybe the lumbar puncture takes that long, maybe even longer. We do need to start those antibiotics until we get those cultures back. The intracranial hypertension medications, now we are concerned for increased pressure in the brain when there is any infectious process. And so she probably didn't get this because it was just viral meningitis and she probably got an ophthalmologist. They looked at her eyes. You can look at the optic disc to see if there's any increased pressure in the brain. They did a CT head scan and I'm sure that was normal. There was no risk of, you know, there wasn't signs of increased intracranial pressure. And so they didn't need to start that. But if she did, we would probably need to start something like hypertonic saline or mannitol to get that increased pressure down in the brain so that she doesn't herniate and she doesn't code. Supportive care is definitely always a part of any virus. And so because she does have viral meningitis, that is ultimately what she's going to receive. Okay. All right. All right. Let's take a look at, all right. Okay. Yeah. So I think we did all that. Okay. Let's go to our PowerPoint. And then feel free to ask any more questions, guys. I'll keep holding that up. Hold on. Let me see. How would a viral infection cause increased intracranial pressure? So yeah, great question, Brennan. Any, a lot of processes, especially infectious tumors, cancer, anything that blocks the brain from doing its normal functions. So like its own, that has its own lymphatic system, it absorbs the CSF fluid. Anything that really prevents that from occurring like inflammation from an infection can increase that cerebral spinal fluid from being reabsorbed. And so that is the reason why it can potentially cause increased intracranial pressure. And so one of the things that we do in the hospital to make sure is definitely imaging, now CT head sometimes is not the most accurate in terms of looking at increased intracranial pressure. So MRI brain imaging is way better. However, MRI brain imaging is not available urgently or emergently like a CT head scan is. So usually it takes the next day to get an MRI of the brain. And were we not worried about decreased pressure because of the spinal tap? Well, we don't know, which they didn't say anything if she had worsening headaches afterward. So that's something to always find out when they're in the hospital, especially upon discharge, you want to make sure they watch out for any of the signs and symptoms of decreased pressure and they hate so low pressure headaches, for example. Okay, so let's hold on, let me open this. Okay, there we go. All right, so appearance ultimately real DX actually said she was non toxic non sick and appearance. Now it's all subjective. She was sick. And we still worry even though she didn't have bacterial meningitis, I think you guys are right, she was sick. And we really need to start those antibiotics right away because viral meningitis really could cause increased intracranial pressure. We have to monitor. We have to make sure her vitals are stable. And she does well after the spinal tap and then we can send her home. The red flags, you got it. Immunosuppression was top notch acute onset headache that is not typical for the patient. So we have to actually have to dive into the history a little bit more is serious, especially if there's no family history of a headache. And this was just like a thunderclap headache all of a sudden started really abnormal for this type of patient. Subjective fever, which she did have even though she didn't have it in the ER, it can wax away. She could have taken Tylenol. She could have taken ibuprofen to stop the fever. So it didn't show up in the emergency room. stiff neck and radiating pain down the back down the back. Now, she did look sick. Now a lot of people with headaches and migraines, they still can have neck stiffness, though typically it's not as bad as she had it. All right. So you guys got a great differential diagnosis. Ultimately, she didn't have bacterial meningitis, but this is the first and foremost thing in our minds. We really want to get those huge things out of the way, especially the life threatening ones. And so a lot of the typical bacterium and microbes that cause bacterial meningitis in most humans are strep, nesaria, hemophilus influenza, group B strep, listeria, endicoli. And like we said, treat with antibiotics, ASAP, you guys got that right, especially after she got a CT head MRI brain, get a lumbar puncture, get the CSF culture, CSF cell count and gram stain as well. So always get those antibiotics on board, even if you suspect bacterial meningitis. But she really had aseptic meningitis. So no bacterial cause, it could be viral, but it also could be fungal, it could be non infectious. So there are concerns of mycobacterium tuberculosis, Borrelia burgdorferi, enteroviruses, like I said, which is in most kids. That's a common one. West Nile virus, lacrosse virus transmitted by mosquitoes, herpes simplex is also life threatening, even though it's a virus, we do have to start acyclovir. So commonly when a kid comes in, especially young babies or young children, we always start antibiotics plus antivirals for kids as well. So those two are always started together for babies and kids. They can also have fungal too. I've actually had a friend of mine who had, I think histoplasmosis and he had severe meningitis and he had histoplasmosis sepsis all over his body. And that was fungal. And then you can also have autoimmune meningitis and neoplasm, medications can cause meningitis. So you can get other types. So people who are more susceptible, immunodeficiency, immunosuppress, someone who doesn't have a spleen that can make you immunosuppress, someone who has HIV, sickle cell anemia also can predispose you. And then someone who has a cochlear implant because they have something implanted near their brain, you have to worry about CSF leak. Some kids or some adults who have hypermobility or connective tissue disease can have a CSF leak just spontaneously. I actually had a patient who had one of those spontaneously, a young teenager. Even just a regular upper respiratory tract infection can seed up into the brain if you have a penetrating head trauma. So after, you know, a severe car accident, and then if a child hasn't been breastfed, their immune system is also down since they don't have the immunoglobulins at birth. Let me just double check to make sure you guys are no question. Okay, good. And then neonates and infants are a little bit different than children and adults. So you have to really watch out for some of these signs and symptoms can be totally different than what you saw presented in this case today, because they can actually have hypothermia. So they can actually be really cold or their temperature is just up and down and it's not necessarily a fever. They can vomit a lot. Kids vomit when they do have increased intracranial pressure. They vomit a lot. So if you have anybody with persistent vomiting in your clinic one day, always be concerned about an intracranial process because anytime there's pressure on the brainstem, people puke. Babies and kids do not like to eat when they're sick at all. So that's a really bad red flag, fussy and consolable, sleepy and lethargic. And then a bulging fontanelle because that's that increased intracranial pressure. And then kids always can get seizures with meningitis. So that is when it's progressed pretty bad. Older children as an adult, like you saw, you get it's kind of insidious, it progresses, you get fever, headache, you're tired. A lot of adults and older kids will be very, very light sensitive. So it's kind of confusing because a lot of people with migraines get light sensitivities. Vomiting is when there is severe increased intracranial pressure in the head and brainstem for older kids and adults. And then very severe neck stiffness and pain that radiates. They can also have back pain too. And then seizures are not as often, but they can still be present in older children. And neonates and infants though, you do not get much neck stiffness at all. So I can fold a baby just fine when they have meningitis. And they look very, very sick and they can actually code very quickly with meningitis way more so than adults. So this is like a big 911 for young babies to have meningitis. And older children and adults, they kind of go together. But what's interesting about this is they can have a cranial nerve palsy and that means there's increased intracranial pressure. So there's abducens nerve, which is they, it's part of their eye muscles. And so if they're not, if they can't go a certain way or it's not all the way and you call them ophthalmologist and they do a good eye exam, then you know, there could be, you know, worse intracranial pressure than what the MRI showed two days before. So that's when you have to repeat the MRI of the brain. And sometimes people do a repeat lumbar puncture to get an opening pressure of the CSF fluid and also be its own treatment too. But it's a little bit more dangerous doing another lumbar puncture. So that's why most people treat with intracranial pressure meds like diamox or acetazolamide and mannitol, hypertonic saline. I told you about the optic nerve pressure, which is papillodema. So again, the eye doctor can take a good look. I do a fundoscopic exam every day for my patients in neurology. And then it's a late finding of increased intracranial pressure. But what happens is you get increased high blood pressure, low heart rate, and then respiratory depression. So their breathing can slow down and then stop and become apnick. You guys can look up the algorithm. You already know it by heart now. And you know the biggest reason if there's suspected signs of increased intracranial pressure like an abducens policy or papillodema, for example, get a CT head immediately. Later on, you can get an MRI of the brain just to make sure there's no risk of herniation or mass effect before you drain the CSF because that will make it worse and your patient may herniate on the table. And you guys already know about this, about getting the lumbar puncture to obtain all the cerebral spinal fluid labs. But just you don't want to get it if there's any skin infection over that site. And if they have any like instability like their temperature is going up and down, their respiratory rate is all over the place, their vitals are not stable, then you just want to stabilize the patient first and foremost before doing any procedure. Typically, we do get blood cultures prior to starting antibiotics just to make sure that patient isn't septic because that patient could have been septic, meaning a blood infection in their bloodstream. Before we start antibiotics, we want to make sure we're treating absolutely everything we can that's causing this patient to be so sick. And then some people get a couple other labs like pro-calcitonin, which is indicative of a bacterial infection. This is newer research. And then a C-reactive protein definitely is more indicative of a bacterial infection if someone's high. That also C-reactive protein can be high though when someone's obese and inflamed. And here's what I wanted to tell you guys about, which they didn't do. Oh, yeah, you guys can get these slides. I'll write that down. Slides. Okay. Good question. Okay, so serum CSF to serum glucose ratio. When you compare that to each other, so serum CSF glucose over serum glucose, if it's less than 0.4, it is more indicative of bacterial meningitis. Our patient had a CSF glucose of 55. So we weren't really too concerned about bacterial meningitis. This is more like a clinical diagnosis. It's not an absolute diagnosis. And then if the protein concentration is greater than 200, then it is more indicative of bacterial infection because you're getting all that protein from the bacterial infection. And then white blood cells over 1,000. And then neutrophils, not lymphocytes, are typically involved in a bacterial infection. Okay. Let's see. So treatments. Typically, you always want to have something that is bactericidal, which means it's killing the bacteria instead of bacterostatic, which is just kind of like preventing it from getting even worse. So bactericidus, really killing the bacteria. Some people start a steroid because that is also another increased intracranial pressure med. But when you start a steroid, write this down in the Q&A, what can it do to your immune system? And you can put that in the Q&A. So what do you worry about when starting steroids with someone with an infection? Yeah. It depresses your immune system. So everyone's very cautious about starting steroids, but sometimes the benefit outweighs the risk. Okay. So we typically start a third-generation cephalosporum. For most kids, we definitely start acyclovir. Some people will add vancomycin, especially for this woman because she was immunocompromised because we want to get methicillin-resistant staph aureus, which is common, more common now. Okay. And that's it, guys. Yeah. We've got a few minutes to spare. Okay. So Q&A, ask me anything. I'd be happy to help you, even if it's not related to this case. And meanwhile, while you guys are asking your questions, just a reminder for those who came on a little bit later, I mentioned that advanced eclinical training, I think, has a little special for you. Let me just double-check. Hold on. I've got to make sure. Oh, chat is disabled. Yeah. Okay. All right. So coupon code for all attendees today, get $200 off any services at advanced eclinical training. And so, again, we've got mentorship programs for pre-health students. I'm one of the pre-med mentors, so helping pre-health students get into medical school, get their application really robust. But they have a ton of clinical certifications as well. So is there a certain age to start this program? I imagine 18 years old. If that's not the right answer, we'll let you know. Thanks, Candice. Yes. They should be sending a certificate. You get one hour of virtual shadowing, I believe. Oh, hold on. Okay. Oh, who can we contact about our name being wrong on the last webinar? Oh, yeah. That would be important. I think the email is, hold on. Let me get it in. Oops. Okay. It's info at AD as in dog, V as in victorclinical.org. I'll write it. Let me see if I can write it. Yeah, that's it. David, thanks. Yeah, info at ADVclinical.org. Mentoring. So Diana asked, what sort of mentoring do I give? I do the pre-med mentorship. They have all kinds of mentorship. So pre-med and then they also have a lot of, I think they do nursing mentorship as well. And then they also have a lot of clinical programs for anybody starting physician's assistant school, pharmacy, medical school, and nursing school. So physician's assistant, medical school, pharmacy, and nursing. Yes, I will. Candice. Oh, nice. So you are a high school senior. Okay, cool. And you're actually in the PCT program. Oh, nice. So you just have to have an estimated graduation date. Okay, I'll check on that. Well, let's see. Any other questions? I'll wait a few more minutes. Yeah, the website, let me see. It's advanced. Hold on. I wonder how I can type in, I don't know why the chat is disabled. Let me see. Okay, so go to, I don't know if this shows everyone, but it's ADVclinical.org. Hold on. Send ADVclinical.org. So A, D as in dog, V as in Victor, and then clinical.org. Yes, I probably will be doing more shadowing opportunities. The mentorship program we do, so the pre-med mentorship program, typically when you sign up, you will answer a questionnaire and it's very personalized to you. So then we meet for 15 minutes via Zoom session. So I just can understand how to personalize your mentorship program to you. And then after I meet with you, I go back for a couple of weeks and I do some work on your own mentorship program and then we meet for 30 minutes via Zoom to go over what you should be focusing on, whether it be your clinical experience, your personal statements, shadowing opportunities, clinical opportunities, research opportunities, and things like that. And maybe even if you're getting ready to prep for an interview, I definitely help. I used to do a lot of medical student interviews, so I have a little bit of insight. And so, and then we will meet again after several weeks for 30 minutes as well. So we have a few Zoom sessions together. And then you actually have a whole basically student portal that we have a lot of resources that you really have to go through and it will take some time because in order to make your application pretty robust, you do have to stand out amongst the competition, but also being the authentic you that you can be. And so it's a lot of resources that we've compiled for you guys. And I will be doing hopefully some more virtual shadowing. If the patient were to get diagnosed with IAH, how would the course of treatment differ? So great question. We would typically start increase intracranial pressure lowering drugs. And so that would be like mannitol. And this is in the hospital typically. So if someone has, which it's actually it's not idiopathic, intracranial hypertension is just intracranial hypertension due to meningitis. Since we know it's meningitis and not idiopathic now that I think about it. So increased pressure in the brain super serious. We have to keep them in the hospital, especially if they have meningitis. We will give mannitol. We will give or we will give hypertonic saline. Typically then once they're stabilized, they're doing well. They can eat on their own. Vitals are stable. Everything looks good on labs. Then we'll send them home and we'll typically give them diamox, which is acetazolamide. So that's the mountain altitude sickness drug that a lot of people know about before they go up to the mountain or high altitudes. They'll take acetazolamide. And so that actually helps decrease the CSF pressure as well. I do research. Yes, I do a ton of like headache research. And we though we didn't get our grant this last round from NIH, I do a lot of research on acupuncture and headaches. But yes, there's always research opportunities typically. What would you suggest to someone who is pre-med but does not want to take physics? Oh my gosh, yeah, I had a great physics teacher and even though I hated physics. But yeah, you're going to have to do physics. I would always meet with your teaching assistants, and that's what I did. I also had a great teacher, so I don't have to meet with them that often. But use your resources, use their office time, and make sure you just get help through physics. It's just going to be one year of physics, and then you'll get over it. Same with organic chemistry. Ultimately, it's not that bad. You'll never use it after that. So what made you choose to get involved with mentorship through Advanced E-Clinical? You know, it's a funny story. I actually do a lot of coaching. So I actually do a lot of chronic pain group coaching for women with chronic pain and fibromyalgia and things like that. And I do a lot with mentoring students ever since because I'm in academics. And so it just kind of made sense to continue. And I love working with students and helping them in their career. Because I think you guys need it, and I didn't have that. And I just felt like I fumbled through the whole thing. So you really need to know early on what you're getting into, and you really need to know early on a lot of the experiences that you need before you apply to different schools. So yeah, I wish I had this. What is... Oh, I just lost one. Oh, do they apply to the courses on site? Oh, yeah. So the coupon... You know what? I'm going to have them send you guys info about that coupon because I don't know if they apply to all the courses on site. I will write that down. How long do we apply to all courses? Okay. Okay. So I'll get that back to you. What is the criteria for getting into a nursing for your program? You know what? I'll send all the criteria... We'll send all the criteria to nursing program. Okay. Oh, yeah. Harine, this is a great question. The person experiences severe dizziness and vomiting but is clear from any stroke or tumors. And this happens whenever they move their head. What would you consider to helping them? Yeah, this is great. So you want to do a couple tests and make sure they don't have vertigo or vestibular dysfunction. And that is very common when they move their head. So it could be benign, proxysmal vertigo. Or it could be vestibular migraines or it could just be vestibular dysfunction, vestibular neuritis. And so there's a couple ways to treat that. Typically they come to us in neurology or they go to an ENT doc, make sure their ears are all right. And then neurologists typically run a few tests. And sometimes vestibular physical therapists will run a couple tests as well. We can do some different treatments, different maneuvers to if they have like a little crystal in their ear canals that's causing the vertigo. But typically that only works if they do have a tiny crystal that shouldn't be in their canal, in their semicircular canals in their ear. The vestibular migraine, you treat it just like a migraine. The vestibular dysfunction, if it is vestibular dysfunction with dizziness and vomiting, typically they don't have a lot of vomiting with vestibular dysfunction. Typically they have a lot of dizziness though. So sometimes they do get motion sick, but it's not super persistent. And so they'll go to a physical therapist that is specialized in physical therapy. Oh yeah. Oh yeah. Yeah, great. Sometimes with IIH people can actually have, so diamox, some people can actually do topomax instead. It's an anti-seizure men and it has similar properties as diamox. Do I have remote research opportunities for students outside of the US? I'd have to think about that one. I don't think I have anything current at the moment. Remote research opportunities. Okay. Okay. So is there a process that we can follow to be some kind of mentee under any of the doctors if we're interested in being a lab assistant? You know, I don't think we at Advanced Eclinical Training have a specific process or outreach for those. Now, if you're in college, typically what a lot of students have done with us at UMKC or Children's Mercy is they'll reach out to one of the liaisons at the hospital and ask about any opportunities in research. And if you can specify what you're interested in, especially if you're interested in neurologic disease or if you're interested in pulmonary or cardiology or things like that, then they can kind of help reach out to specific professors in the hospital and school of medicine. But honestly, the easiest way, especially what I did as a college student, I just reached out to the professors that were in biology, for example, that I was interested in their research and just emailed them and asked if there was an opportunity to be in their lab. And it was easy. They're just like, okay, we'll get you in, we'll teach you, and you'll go. Yes, Candice, just email info at ADVclinical.org and you can ask more questions. David. Oh, they applied to all courses. Oh, great. Perfect. Okay, guys. So advanced clinical training said it is the webinar code. So webinar is the coupon code. It's $200 off, and that applies to all the courses. The shadowing certificate is going to be emailed to you guys. So, yeah, watch out for that. And then we'll see if we can find some of those answers too that we still have to figure out. Like remote research opportunities. I have to figure that out. The criteria for the nursing program, maybe Shab knows if she's on. Oh, yeah, emailed in the next hour, guys, your certificate. Shab, since you're on, is there a specific criteria to get into the nursing program, the mentorship program at Advanced E-Clinical? The nursing pre-health that Leah does. I thought she did nursing. Oh, you don't. Only pre-PA and pre-med at this time. Okay. And then Shab, they had another question. How long does it take to get through each mentorship program? Is there a specific timeframe for each of the mentorship programs outside of just the pre-med? 12-month program, no timeframe. Okay, good. My Zoom account uses a different email than the one I used to register for the shadowing session. Does that still indicate that I have attended the Zoom? Shab, another, yes. Okay. Kenny, you're a go or reach out to info at ADVclinical.org and they'll send you the certificate if you don't get one. Okay. I think we answered. Oh, Shab, since you're on, how old do you have to be to get into Advanced E-Clinical? 16 years old. Awesome. Okay. Yeah, good. All right, guys. Well, have a wonderful evening. Thanks for attending. If any remote research opportunities come up, I'll let you all know. Okay. See you guys. Bye.