Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Uh my allergies were to uh describe difference between upper limits and your legion's. And then it was mainly based on the next chapters of um back pain and uh spinal problems and like all the pathology and red flag symptoms and stuff. I'll be covering a few of these and I have a few slides explaining the answers to the SBA S. So the first S P A is um P R reading 32 year old women presents with spastic and rigid muscle tone, absent circulation's and hyperreflexia. What is the cause of this presentation? Mhm You want, you can just say the answer. Yeah. Put it on the phone. Is it big? That's correct? It is big. Um Yeah. So uh upper motor neuron lesion. So rigid muscle tones and hyperreflexia should think upper motor neuron um absent or hyporeflexia would, would mean um lower motor. Uh So the next question, 46 year old man presents with proximal myopathy, hypotonia and hyporeflexia. What is the type of lesion and site? You? Shout out the answers. Yeah. Shout out the answers if you want. Mhm So it's lower. So for this one, it's lower motor neuron legion and the site is um a neuromuscular junction. So this is not specific to this question, but where a lower motor neuron legion would be, for example, would be a neuromuscular junction. So um the stable I just found on Google actually, but it was really good because it showed like it just condensed it also as it was the point in me writing it all when this is basically what I'm trying to say. Um So the site of the lesion is something I feel like we don't fully covered properly or so nicely, forget to learn. But yes, the new muscular junction would be the most important in terms of lower motor neuron lesions. And then really the brain stem and the hemispheres is for the upper motor neuron lesions. And that makes sense because that's mostly upper the neurons in the lower motor neurons at the junction. Um But yeah, in terms of muscle tone, the rigid gypped e and the hyperreflexia is upper madan, lower motor is like you lows Eurohypo reflexe, eah and your hypotonia. I remember it. Um uh And uh what else is there? Uh Yeah, that's the main things. And then the fasciculation, Zinn's um as well. It's just that it's absent for offer and there are fasciculation zones for lower motor neurons. Um I'll just go to the next one. Um This is the question. So a patient presents with the tumor that has spread to the spine, which is the correct fight form of transmission and the task metastatic site. Um in the list below. So, where has it originated from? And how does it travel? And to where um this was from the lecture by the Spine Dragon? I believe so. Um Yeah, if anyone knows it can just shout it out. Uh uh huh. Hmm. Go on U N. I don't know. Is it e that's insane. You don't know. Um I'm guessing is he? Unfortunately, it's a um uh is correct that it, if it's in the prostate, it does travel by the pelvic venous plexus. But um it actually goes to, I believe the thoracic have to see. Oops. Um it goes somewhere else. But yeah, the correct answer is a so long travels by its segmental veins to the thoracic thoracic. Um Well, sebastian venous plexus, anyone knows or if they still be in uh um let's see, it's small veins with no valves. Um So this is a really good form of transmission for loads of like tumor's because it doesn't have any valves and it's a very low pressure. Um it can easily just move around and um I have an image which shows exactly what that means. So that's the bastions plexus. So you can see that within the actual spinal column. It says really, really small veins that have nothing like no valves or anything. So you have something from your lung that can travel by a uh these veins or if they get into these veins that can travel to basically anywhere in the, in the, in the spine. So, the mechanism um of metastases, it can be bloodstream or wait. I mean, you're right. Actually, it is lumber. Um You would, I don't know if you're still here. Um Prostate pelvic, venous plexus is lumber. You're correct. Sorry. Um That's my mistake. I must have put that wrong and the other one is breast travels via the azygos to thoracic and lungs, segmental to thoracic. Um Yeah. Um So then another way is vast and venous plexus which uh which I just went through and then third is like direct spread. So that's obviously if it's directly in touch with the um with the site that it's spreading to. Mhm You see the uh please. Oh, okay. Um So a seven year old child presents with non specific hip pain, belly pain and refusal to wait. There. He has no fever. What is the likely cause of his presentation? No one wants to take, take care. Um uh So the the bit of the lecture that this, this question is um talking about is how a spinal infection, which is the correct answer um presents differently in adults versus in Children, Children. So, in adults, it can be very uh you have the classic symptoms. Um So you have pain fever or sometimes even neurodeficits. Um And if you have all three, that's very highly suggestive of an epidural abscess, which has a significant mortality risk if untreated. Um, thoracic most common. I just add that and never, um, for an epidural abscess. But, yeah. So, a typical presentation would involve pain fever or in your deficit and if it's pain fever and in your deficit, uh you think about your abscess. Um, but in Children they can get hip pain or belly pain. Um, that's very nonspecific and they have to kind of refusal to wait there. But uh the, the, the presence of fever is very um half, half, it's like 50%. Sometimes they're happy, sometimes said it was an adult. Have a. Um, so the next uh this bit is just a pneumonic uh disgrace which I think was also uh spine drug and lecture to um remember, well, most likely to get infections of the spine. So, diabetes diabetics, people who do drugs, um immunosuppressed um immigrants. So, yeah, that was something you mention of the lecture that immigrants are more likely to have um infections of the spine as well. Um, steroid spinal surgery, genital urinary issues like recurrent uti s. Um oh, um rheumatoid is it goes with the immune, er, oh no, it's immune suppressed. But yeah, I mean conditions, um, adolescents, elderly grange. Yeah. Um and then you mentioned also the good disc, bad news, bad, this good news things that if you have a good disk but you have these signs of an infection but your disc is fine it's likely that it's not infection but it may be something more worse like cancer. Um, but if clearly your disc is bad then it's good news that it's just an infection and it can be drinking it. Um, so, yeah, that's the good despite these things. Um, so what does this image show? Um, I'm sorry if it's not clear, um, it at like screenshots. But, um, does anyone know what this one shows? But if anyone wants to have a guess, is it the? Yeah, that's right. So it's spondylolisthesis. Spondylolisthesis feel like I have a list when I say it. Um, yeah, so just a bit about scandalous itty follow about spondylolisthesis STIs. Um, so that's where the vertebrae slips on top of another virgin, right? Um, so bilateral party fact, I think was the one that we learned in the lecture for like adolescent. It's like people, especially adolescents that do like gymnastics or like those kind of things that they can get is it's like acquired because of their doing like those kind of like, um, really like, you know, flexing and extending kind of stuff. Um, you can have, you can damage your, by your past. So your past was, um, the bit that's like in between the, you're like in the Scottie dog thing. It's like the neck isn't anyway. Um, so, um, yeah, so it can, you can get the forward, uh, slip. Um, so it can be high grade or low grade. So, um, I think that's depending on how much of slipping over. But anyway, um, so the presentation so it can be a symptomatic if it's like a low grade slippage. But you can have obviously the typical lower back pain. But if you have, but you can also get like buttock pain, thigh pain and groin pain as well from the slipped disc. Especially, you can get the pain anonymous if the L5 S one like nerve is compressed, which is the most common um urinary and bowel um problems you can sometimes get as well. Um But yeah. Um okay. So what is the management for Korda China surgical decompression? That's right. Yeah. So surgical decompression is the management recorder, Qana um so called a coin A like we've, we've covered quite a few times like every election. I remember that you put a kind of, but it has the classic like saddle anesthesia. You'd asked for um urinary incontinence, fecal incontinence. Um obviously the bilateral sciatica. Um but you can do pr examination find produced anal turn. Um But yeah, Coquina um is like a really common one that they like always ask the red flags for when I was on my GP placement. If anyone has no back pain. The GP was always like like saddle anesthesia, like you can't have any sensation or any like foul or thingy problems. Um Yes, super management. Um You can get an MRI which we can see most clearly with. But, um, yeah, it's, uh, surgically congressional lumbar decompression surgery. Your, um, correct. Um, and then the causes are like any causes that can, you know, with the desks and stuff. So her native desk and eat tumor's, um, trauma infection, all that kind of stuff. Um, so in just, in terms of the nerves of the cord A coin A they supply by exactly what the red flag symptoms were because sensation, bladder rectum, perineum is actually get like the anesthesia and um you have the incontinence motor, you re throw anal sphincters and stuff. So that on the er examination, the reduced anal tone would align with the reduced motor function due to the nerve supply being damaged and parasympathetic bladder and rectum also aligns with the incontinence. So if you have reduced kind of feeling of uh fullness and all that kind of stuff. Mhm. That's it. All right. Brilliant. Thank you so much. Um All right, next stop. Um Jane or Benjamin, feel free to take it away. Whichever one of you wants to go first. Well, Sandra, if you want to go to your rehearsal, feel free to tip out. Sorry, I couldn't stay. Thank you very much guys. See you. Yeah. All right. Okay. So let me shut my screen, right. Ok. Um So, hi, I'm Ben on the third years. Um So my first hello, that I'm covering today is described the structure and function of the back and spine So can anybody uh label number two here? Uh Yeah, that's right. So I guess it's quite important to kind of remember this picture. I think it came out from the progress test. And it's also quite important to know that to manage spinal stenosis. It's a laminectomy. This is a fun fact. And then moving on to the second question, which of the following is classified as a cervical vertebra. Well, okay. So the answer is um the the by fit um spinous process with to transform in. Um And so like this is like the list of um the different vertebrae and like um the different things like the presence of stem. If I sit on on each side of a heart shaped vertebral body and that, that would be the thoracic vertebra. Um an inverted triangle would be a sacred um the large kidney shaped vertebral body with no cost all facets is that the number vertebra? Um And then for bifid spinous process with to transfer Foreign Minister cervical vertebra. Um And the coccyx is the terminal part of vertebral column. So I guess just like, you know, get pictures online as well. But yeah, these are like certain keywords that could probably help you in your exams if you have to um identify the vertebra. Um Next question, a five year old presents to a and E with neck stiffness, photophobia and temperature of 38.1 degree Celsius. Um A lumber puncture was performed for suspected meningitis. What's the quite order of lumber, puncture needle costs? Mhm. Right. So the answer is b which is the super Spanish ligament uh into Spanish ligament and then ligamentum flavor epidural space do a matter uh right. No matter. And flaperon backspace. So I feel a picture off to this. So essentially it's um yeah, it's that super spinous ligaments, you know, ligament ligament in favor the epidural space is good matter. Yeah. So I think that's quite high yield to remember for exams as well. Um Question for Michel was using his phone while driving and got into a car accident. Um This gave him hyper extension injury on his spine, which ligament in the spine usually limits this more movement. So either his ligament ligament of flavor in the spinal ligament at the anterior long latino ligament, posterior long interior ligament or super spinous ligament. But anyone notice. Right. Yes. So the answer is um and the chances is anterior longitudinal ligament. Um And if you think about it, it's the most front, that's how I think about it. And hyperextension means um the neck is kind of kind of bending backwards. So this would create tension um for the anti long or longer tenure ligament. But even though it creates attention, it would prevent it from hyper extending, like kind of it will prevent the anterior like longer tail ligament from snapping, but that's the tension still. So it prevents the hyper extension if you think about it. But this picture is quite helpful. I think um question five, what is the main function of the posterior vertebral column? So this question came out for our as to last year. And I think this is very, very high heel and I think quite a few like of my friends and I we were really confused with this question, but it was in the lecture. Does anyone notice tension ban? Right. Yeah. Yeah, it's tension van. Um So it's from the introduction to case for the lecture. Essentially, it's just this slide. So the anterior columns mainly for confession, the posterior column is mainly for tension. Uh And yeah. So if you think about it, everything that is positive to the vertebral bodies usually for tension instead of like compression. Um Yeah, it's just something to remember, I guess for exams. Um Next bit. So the second L0 is outlined the functional anatomy and physiology of the spinal cord and peripheral nerves. So the first question is a patient with M E A trophic lateral sclerosis is actually A A R S presents with muscle atrophy and wasting which final track when damage can contribute to this finding? Does anyone know this? Uh mhm. Uh So the answer is a lateral corticospinal. So essentially among all the options, corticospinal is the only um descending motor pathway compared to the rest the rest of like spinal column mix. But spinothalamic, spinal, cerebral, spinal cerebella So like the name kind of gives you a hint of where it's coming from and where it's going. So, corticospinal essentially coming from the cortex towards the spine and for spinal column is is very good from the spine, the spinal cord wrapped the thalamus. So that's how I remember it. And um the lateral corticospinal tract is the descending motor pathway. Um And so the rest are ascending sensory pathway. So, essentially muscle atrophy and wasting would mainly be a, a part with the descending descending pathways and um specifically in lower motor neuron which which um Sandra probably talked about. Yeah, it causes muscle atrophy. So that's something to remember and you can probably look back at her slides as well. Um And uh the next question, a 25 year old male presents to a and e after being involved in a severe road traffic accident accident, you suspect here spinal shock, which reflects would be best to elicit to a test for this. So you want to know this right? So the answer is a bubble Cavan osis reflex. So I think this is 11 of the lectures I can't remember in case 14, essentially the bubble Cavan osis reflex is the lowest um kind of reflex. Um And it's, it's all mediated by the s to to ask for spinal reflex arc. Um And it's really, it's really um it's really important to see. Um and if you have an absent of the bubble cavernous is reflects, it is quite indicative of spinal shock. So that's something to remember. Um And also, yeah, I I checked in a bit of a quarter equina syndrome, but I think Sandra already probably talked about this as well. Um OK. Moving on question tree. So this is um I think they fine, fine dragon did talk a bit about like the Sunderland like stuff, but I don't think came up for us to last year, but I think it's quite important to try to remember. So Jamie's hand is injured from a heavy weight dropping on his hand. While at the gym, the dimension of has lots of external and endo neural continuity. A few months later, tapping his arm along the side of injury, gives him a tingling sensation three cm this study than he did at the time of injury. What is the most likely diagnosis? Okay. Anyone notice I think to be fair. This is quite a difficult question. So the answer is see Sunderland type three essentially is I got this from one of the lectures from nerve anatomy physiology response to injury that the plenary. So essentially Sunderland type one, um it's violent damage but the conduction is slowed but even though it's damaged, does the continuity is still there? Um And for type two, the external continuity is damaged but the engineer um is still intact. Whereas type three is both the axons and the engineer. Um the continuity is lost. Um And then for type four, it is not just it's also black all three external in general and perineural. Um Yeah, I guess you can look at some pictures online as well for like how the nerves look, but what's important as well is um when they say tapping his arm along the side of injury gives him a tingling sensation three cm just like that he did at the time of injury, That's indicative of um advancing Tinel's and that's mainly type two and type three. So once you see that um you can kind of rule out the rest and then you can just focus on either choosing type two and type three. Okay. My last oh describe the anatomy, anatomy, ical relationship of the spinal cord and peripheral know foods to the vertebral column. So um first question, what vertebral level does the spinal cord terminate in adults? Does anyone know this? Uh 102? Yeah. Okay. So in the adults, the spinal cord ends at the L1 L2 level. Um And so that's why in adults um number puncture is usually done like lower than L1. So she she around L4 um in Children, however, because just the developing the spinal cord ends like much lower around L3 L5. Yeah. So probably the lumber puncture would probably be even lower. Um Yeah. So the second question, a medical student is asked to label the nerve foods on the cervical spine, X ray, which nerve exits at the level marked by the arrow. Does anyone know this? Right? Okay. So the answer is C six. So essentially, um I think it's really important to be able to identify um and that kind of label cervical spine, X rays. Um So the C at C seven level, you can see the vertebral prominence which is like the kind of longest bit. So that's the spinous process, but at C seven is also called vertebra prominence because it looks very obvious. And so that's why that's C seven. And if you remember from PCS, they used to say something like above, see some vertebrae, the nerve food sits above the vertebrae at his name after because above see one, the nerve would the C one nerve who is above the C one vertebra. So the nerve would below C one vertebra. So around here, um So the, so the nerve would here will be see one, he'll be C two, C three, C four, C five, C six. So that's why that's the C six nerve would. Okay. Moving on. The next question is um you're looking at it and am I um of a lumber office? You're looking at a MRI lumbar spine of a 60 year old meal. The nerve exiting the level marked by the arrow is damaged, which nerve has been damaged. All right. So anyone does anyone know this? Mhm Okay. So moving on, it's L tree. Um So essentially what's really important to remember is like, how remember is like that bit where it curves is the S one oh And every anything below the T one the nerve would sits below the vertebra. So for example, um for the L tree, the know if it would be L tree, this, this will be the altreno of food and Alfano through L5 nerve food which is like different that and the one that the ones above um um the ones in the first question, the C seven when you know who is above the vertebra. Yeah, there's something just remember and what's important as well. The S one like being able to identify whether S one is so important. Um I think this is my last question. So a 28 year old male develops low back pain, radiating down right leg. Um Examination shows absent, right ankle, reflex weakness of right, any reflection and plant affection with loss of sensation over right lateral foot and posterior leg and MRI lumber spine is done. What radiculopathy is the patient most likely experiencing? So this is the MRI um of the spine. So little head like I can give you guys a little hand. Um This bit is like kind of a bit weird. Yeah. Does anyone know this answer? Right. So the answer is um S one um essentially. So the diagnosis for this would be um an L5 S one. This prolapse. So as I said, this was the s one from the previous picture from the previous question uh as one, remember the S one is here, which is like the weird like COVID bit. So this is an L5 S one, this collapse. And I think this uh this is something that I struggled to get my head around. But essentially, I think this was one of the, one of this was in the case 14 wrap up lecture. So why is it most likely as one vendor neuropathy? So essentially, um for an L5 S one, this collapse. So any of this, this collapse pretty much it is most likely posterolateral. Um and that will affect the travel saying nerve food instead of the exiting nerve food. So the traversing nerve food is enough food that exits below the next vertebra. So for example, so this is totally unrelated, but I couldn't find a picture for an L5 S one this prolapse. But imagine if it's an L4 L5 disk collapsed. Um Even though the, the X, the exiting that would would be L4, L4 nerve food and the traversing nerve would be L5, the L5 nerve food. So in an L4 L5, this prolapse, it would be affecting the L5 nerve food, which is like the nerve food that is like below the next with the bus. So that's how I remember it. So for an L5 S one is collapsed, is most likely posterolateral. Um And hence this affect the travel single food. S one which that's why they give, they have like all the, the symptoms of like loss of like anger be flags, which essentially the s like is mediated by the S one um S one nerve food. And also the one more clue is, I guess a loss of sensation over right lateral foot and push your leg. Which so if you think about the dermatome um that those kind of dermatomal areas are where the s wonderful like um supplies. So yeah, just look out for, I guess clues in question stamps and then yeah. Yeah. All the best. Yeah. Yeah, that's about, that's all the questions I have. Yeah. Mhm OK. Brilliant. I think we'll um Yeah, Jane if you, right. Um Okay. So um yeah, so the first learning outcomes I'm going to cover, it's about outline the physiology of bone health. So first question, what is being pointed out in this image? So, um does anyone want to have a go at this? So the answer is E Fyssas. So if you look at this image, I've tried to put all the labels there. Um So what the arrow is pointing at is, is soft, fine line. Um Right before that, that uh the approximate end of the bone. So that's a female that's the tibia fibula. Um Prices basically means the orifices is also known as the growth plate. So that in adult bone because growth plate is already fused, you can't really see a growth plate, but instead you can see a very finite growth goes across um the ends of long bones. So on the female, you can see as well. There's a uh there's suffices right over there. So anything above um sorry, anything that's more um I should say towards the end of vices is called app if isis any anything before the vice is called meta Fyssas um and defies, this just means the bit of a long bone that's um in the middle. So in the next slide, um again, that's devices of the fema vices off the tibia. So that's um an X ray of uh long bones of an adolescent. And you can see here that the growth plays a lot more obvious because the growth plates haven't used yet can sit on the femur on the TB and also on the fibula. So second question, you're in a G P surgery in reviewing a patient on examination, you notice a horizontal scar across the midline of the neck. What is this patient at risk of developing? Mhm So the answer is muscle spasms or also known as tattoo new. So this is what a midline horizontal scar looks like. Um horizontal right across the neck. Adam midline. And this is usually indicative of a thyroid surgery. Um This common, the common complication of the virus that there is damage to the parathyroids causing hyperparathyroidism. Because as you can see, over here, the parathyroid glands live very closely to the thyroid glands. So any damage to the parathyroids uh will cause a low P T H level and I will in in effect cause a low calcium level in the blood. Local earn basically hippocampus, hypocalcemia um will cause muscle spasms and parities around the mouth and feet. Right. You're on placement under the orthopedic team as you sit through the fracture clinic to consult, to ask you what stage of bone healing takes the longest time. I think this is a question that a similar question that came out in one of the uh s to last year. So the answer is um bone remodeling. So this is sort of like the progression of um secondary bone healing. Um So I'm not going to go into primary bone healing. Primary bone healing is basically when the bone is not displaced. Um and bone and primary bone hitting is basically the same as um normal bone turnover and secondary bone hitting. However, that's four or five stage depends on what source you look at. Um So it starts with hematoma, moves on to inflammation, soft callus formation, high callus formation and then bone remodeling. So for hematoma takes 1 to 5 days, inflammation takes around like 10 days, soft colors formation takes around 2 to 3 weeks and heart colors forming ticks around um 4 to 8 weeks and bone remodeling can take from as little as six months to multiple years. A 65 year old woman attends a G P surgery worried about osteoporosis after neighbors suffered a fall and broke a long bone. You refer the patient for a Dexa scan. What results on Dexa Scan will indicate osteoporosis in this patient? Anyone wants to answer this? Mhm So the answer is B U M. So T score more than 2.5 uh standard deviation below the mean. So what it means is basically look at this graph, you can see that there's something called A T score and something called A Z score. And for those who, those of you who don't know Dexa scan is the type of X ray that measures the bone density usually done at the vertebrae or hip. So Z score means um it's adjusted to age, sex and ethnicity T score is not adjusted to age, but instead it's compared to a healthy to deal adult, adjusted to the same sex and ethnicity. So the definition of osteoporosis in post menopausal woman and men over the age of 50 is a T score of more than 2.5 uh standard deviation below the mean. Um And if you're in, in younger adults, which is rare but it can happen. Um osteo processes diagnosed using the Z score. So I've also included a bit about um if your T score doesn't reach the threshold of diagnosing essay, osteoporosis. It's known as a pre osteoporosis or osteopenia. Face. Fifth question, what do you expect to see in a broom profile blood test for a patient with osteo Malaysia? Anyone to have a go at this. So and says, see and I'll uh I'll walk through this. So in a broom profile test, bone profile blood test, there's basically four things or at least four things that comes out of the exams, calcium phosphate, alkaline phosphate and parathyroid hormone. So in also Malaysia, you can see that the qassam level is low phosphate level is low. Uh alkaline phosphate can be normal or high parathyroid hormone levels can be normal, high. Um It's just a you this is just a usual useful table that I took from one of the electra slides of four case 14, right? So what is the following statements describing osteoclast overactivity, compensate Torrey Osteoblasts activity and disordered woven mosaic bone pageants, correct. It's Paget's disease. So, Paget's disease is basically a it's basically what statements are talking about just now. Um osteo class of activity um with which leads to compensate ori uh osteoblasts activity. And also because there's such a quick bone turnover, there's not, there's no sufficient bone remodeling for it to become um strong uh heart bones. So if you look at this bone scan, this is what um they used to investigate Paget's disease. You can see that um because this is done with a radioisotope, not radioisotope radio labeled biphosphonate. Um So when you, when you take the dye and then you go for um an X ray bone scan, sorry. Um The bones with overactivity would light up. We'll, we'll come up as stalker. So over here you can see that the right femur um has a lot of activity going on. And so, so is the left elbow and this bit over here is just a bladder where all the dire sort of um gets excretes out. So this, this bit is normal. Uh This bit is not, this bit is not um right. So the following images are actually pelvis of a male patient. What is the most likely primary malignancy? This is slightly of a tricky question. Um But it's quite useful to know any takers. So it's the prostate. Um And I'll explain why. So this is the image that I've showed. Um just now it's a X ray of the normal, not normal sorry X ray of a pelvis. So if you, if you look at it, when you look at the X ray, the first thing you should do is probably to compare symmetric um or just compare the left to the right. So if you look at the right side of the pelvis, um this bit is sort of normal. But if you look at the left side of the pelvis, this bit shows up as brighter. So over here, there's a normal acetabulum, but over here there's um more bone accumulation, should I say? And that's what we call a sclerotic Mattis metastases. So, for bone metastasis, um there's roughly three kind of categories that you can differentiate them into just lytic metastases. Uh mixed. Uh Yeah. So I've mixed um mastocytosis and also plastic or sclerotic motasisis. So, prostate cancer is solve the only cancer that has plastic are sclerotic motasisis. What it means is it builds bone. Um So that's why it shows up as more dense hyperdense on the X ray here. Um And the common ones for the way I think about it is um prostate cancer is sclerotic and Tyrod melanoma and kidney cancer is lytic and whatever. That's um not what I've mentioned just now, you probably don't need to know that, right. So moving on the next learning outcomes I'm going to cover is describe the epidemiology of back pain and sickness related absence from work. So I think it's sort of social kind of ellos that no one really needs to know. But every now and then there'll be one or two questions um that comes up in s to a PT and it's not very difficult to study this. So if you go through all the questions, you'll probably easily get the point, get the question right. So what are the main risk factors contributing to back pain? Um Just give it a bit of time for you to read through the options. Saran says, see occupational factors, physical in activity and stressful life events. Um So yeah, so the risk factors of developed risk factors for the development of non specific lower back pain includes obesity, physical in activity, occupational factors such as heavy lifting, bending or twisting. So the question stem will usually say something like um this person works in a supermarket and uh in a supermarket warehouse or something like that. Um And also or can also be uh this person works as a white collar that assistant office doesn't move around much. Um and stressful life events or depression can also cause non specific lower back pain. So next question, how to best describe the prevalent prevail ins of lower back pain? Um I put a remark there because uh it's because in terms of prevail ins data can change year to year. Um This is what I can find currently um on nice guidelines. So um the answer is b it is more common in women than men. Um So in terms of prevalence of lower back pain, it is more common in over 45 year olds, more common and female. Most of the lower back pain does not arise from trauma. Majority of lower back pain is self limiting, which means it can be managed conservatively and low back pain was reported by one in four people aged over 50 year old, sorry, not 58 year old. Um I won't worry too much about the last uh the last statement over there because they're not really gonna ask you that. How long can you issue a sick note for the patient following a new recent diagnosis of chronic illness? Uh This is some of the very likely to tell come out of this question during PT. So it's either A B C D E R E E, right? So it is E six months. So, right, in terms of um the first seven calendar days, you don't necessary have to issue a signal to for a patient. They can often self certify for this period. Um But every now and then you can, it's just that you don't need to um in the first six months of a patient's condition, a fit of a recent diagnosis, I mean, um a fit note can cover a maximum of three sorry um in the first six months of a patient's condition. A fit note can cover a maximum of six months, sorry. In the first six months of a patient's condition. A fit note can cover a maximum of three months. What am I saying? Um If a condition lasts longer than six months, a fit note can be for any clinical appropriate period up to bracket in opening for the brackets, uh an indefinite period and it's taken from golf dot UK this year. Um that's published last year, right? You're an effort on the wards and a patient that is admitted with disabling lower back pain, asked you to write up a signal for him. He claims that his back pain started two days before he was thin before he was seen and admitted to hospital. And he is now on day to being in the hospital. You think he needs two more days to recover before safely returning to work? What should you put for the start date and duration of sick leave? Um This is uh this is very similar to one of the questions that came up in our pt. So answer e from the date from the day symptoms started for six days. So you don't really need to know this, but this is how a sick note looks like. Um There's two bits to it. First is you have to write, when did you assess the patient? Um And second bit is what time frame is a sick note valid for? So if, if you're issuing a signal based on an assessment, the conductor at earlier date, you should enter the date of this earlier assessment in the date of assessment field, which is over here. If your patient's condition has affected their function for some time without a previous signal being issued, you can or not, can you must enter estimated date that they're function was affected in this bit here. So let's say, and in the question earlier, it was about patient coming in and said he had to do a history of lower back pain, right? So let's say you um so you were issued a signal for the day that the symptoms started for six days because it's two days of symptoms, then he presented then two more days in the hospital and then two more days to be fully recovered. So that's six days in total. Um The main thing about the main, I think that this question is asking about is whether you can backdate a signal and the answer is yes. Um The only bit is you have to, you have to fill in when you assess the patient, but you can backdate the signal. So let's say if you're, you assess the patient today, but you can um fill in the signal for two days before that if they had two day history of back pain. Right? So next eldo apply knowledge about the social aspects of chronic illness to understanding patient's experience of back pain and two clinical practices of information support and referral. A patient comes to see you in G P surgery, complaining of two weeks intermittent history of lower back pain on history and examination, you did not find any red flag symptoms. What is the most appropriate management? Anyone would like to answer this? So that says deep offer advice on accepts programs such as swimming. So I'll go through all the options. So the answer is offer advice on exercise program um as put nice guidelines, first option of arranged spinal specialist referral. So we if the patient comes to G P surgery or, or anywhere in general, um, with low back pain, you would give them advice about conservative management. Then if that doesn't work and a patient comes back in three or four weeks with, with persisting symptoms, then only you consider referring them to a spinal specialist. Um in terms of drug management, opioids, benzodiazepines, gabapentin's antiepileptics, antidepressants and paracetamol are not recommended. Um because of all their relative side effects and sets such as Ibuprofen are preferred for the shortest possible time and if possible give them um gastro protective uh Ibuprofen um for the option of encourage bed rest and review again in one week who long bed rest or in activity is associated with worse outcomes. So, if someone comes in with back pain, instead of telling them, or you should rest, tell them that you should move around more or try, try to move around more um referred for radio frequency Denna vacation. So this is what we know we call as tense. Um So um it's basically where they put something, uh put some electrodes on the back and then they stimulated with um some very low current. Um and that in theory, um it stops the back pain. So we will only refer someone for radio frequency D innovation if, if a person has chronic lower back pain and non invasive treatments are ineffective, such as um conservative management such as moving around or pharmacological treatment has proven to not to not be working for them. Yeah. Next question, you recently diagnosed a patient with sciatica. This patient usually drives a car for personal use. What is your professional responsibility as a doctor in regards to the patient driving with a medical, with this specific medical medical condition? Sansa's deep and note that this is specific to the question which is asking about sciatic. Um So scheatica is, is not a health condition that warrants the patient to declare D V L A some health conditions that can impact the patient's judgment or trigger certain drastic changes to the stability of patient requires the patient to report this to the D V L A. And if there are just a normal license holder for a car, for example, for personal use, they are still able to drive if the doctor agreed to do so. So say if they have been um on long term treatment has been stable, um then it's perfectly fine for them to drive. It's just that they have to report it to the D P L A. So what I mean by some health conditions that can impact judgment or trigger certain drastic changes, um it would be things such as um um epilepsies. Um And so say, if you suddenly have a epileptic attack, then that might impair your judgment as a driver or because you will certainly immobilize you being making you not fit to drive. But say if someone has no history of epilepsies, but is hmm managed with uh medication for a long term, then they're fit to drive for bus Loreal coach license holder. The rules are more strict and requires the license holder to report to D V L immediately and stop driving until approved by D V L A. Um Again, there's um, there's a separate list of conditions that warrants the patient to declare to develop a. So if they, if you as a doctor know that they drive a bus lorry or coach or H or H D V s, um you have to tell them to report to declare to develop it. And if they refuse to do so, um then comes of the um S J T kind of question where, what do you do? Um And the best thing to do is to, to tell them, explain to them that they must do it. Um And if they don't, then you would have to report to devalue on their behalf. Next question, a patient with back pain. Now, Trita is worried about going back to work. He has been symptom free and medical fit since treatment and works in a supermarket. He has been off work with sick note and wants to rest for two more weeks before starting his job again. What is your most appropriate actions as a doctor chances be reassure the patient that work is good for rehabilitation, rehabilitation rehab billet ation. Uh um Right. So, so it says um according to uh nice guidelines work as therapeutic and essential part of recovery. Patient's usually should be encouraged and supported to return to work as early as possible. Even with his, with some symptoms, signals can only be issued on the basis of health conditions distressed due to bereavement is acceptable if the patient is stressed, resulting in ill health. So if we look at the question stem again, he says that he is symptom free and medically fit. So um the first option of discussing with the patient to take some time off until you're ready to do so, it's inappropriate because um as per nice nice guidelines um start working is therapeutic. Um in terms of see, refer the patient for occupational health assessment, um this is only appropriate if they are not symptom free, but they are keen to go back to work. Um So maybe for with occupational health assessments, the um their employer can make certain changes to their duties or to make certain changes in their health environment in their work environment, option of the right to fit note sitting, the patient maybe fit for work if on modified duties, it is this is the correct answer if the patient still has symptoms. But in this question where we say that he's been symptom free and medically fit, this is not appropriate option. He write a signal two more weeks for the patient patient feels not ready, doesn't mean he is medically not ready. So you although he doesn't feel, uh although psychologically, he doesn't feel ready, you still can't write a signal for this patient. So that's an inappropriate. So in this case, the answer will be, be reassure and reassure the patient. Basically, that's the end of my presentation. Thank you.