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Finals Lecture Series 2024/25 - Neurology recording

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Summary

In this teaching session, medical professionals will learn about the intricacies of neurology with a focus on patient cases (or 'paces'), aiming to ease nerves and confusion surrounding neurology patient cases in clinical practice. The session will shed light on the basics of neurology station and how to approach it. It will delve into the understanding of potential cases from previous years, and a brief glance at the history and stations that might turn up in the context of neurology. The significant focus will be around emphasizing two main questions during a neurology exam: where is the lesion, and what is the lesion? Interactivity is greatly encouraged with participants being free to ask questions at any point. By the end of the session, the goal is to equip the attendees with a road map to navigate and interpret complicated neurology cases.

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Learning objectives

  1. Explain and describe the purpose and process of a neurology station in medical examinations - particularly identifying lesions.
  2. Interpret and analyze case studies related to neurology and lesions, determining where and what type of lesion is present.
  3. Differentiate and categorize symptoms and signs between upper and lower motor neuron lesions, including the manifestations of hypertonia and hypotonia.
  4. Understand and apply the definitions related to neurology, such as 'tone', 'spasticity', 'rigidity', 'antagonist', and 'myopathy', in an appropriate medical context.
  5. Enhance the ability to perform a comprehensive neurological test, identifying key components and features that should be included.
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Computer generated transcript

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

Um this time last year and obviously remember it quite well, unfortunately, work out imperial. So I have to see Charing Cross quite a lot and that still brings back the nightmare of paces, but we are hopefully demystified some of it now and hopefully give you a a good bit of interaction, hopefully that you just have a flavor of what pace is going to be like and sort of maybe put your mind at rest about some of the worries to it. Um feel free at any point to ask any questions, um be doing a lot of interaction with it mainly through the chat and, and hopefully through using your um your mic, which will be much easier for us all. Um Today, today we're going to be covering three things. So we're going to be covering the basics of the neurology station um focusing mainly on how you should approach it, how you need to think about it. Then we're going to be going through some paces about what I think is really likely to come up and what has came up in previous years. And then we're going to do a very cursory sort of look at any sort of history and stations which could come up in the, in the setting of neurology. So let's start with the basics. So we're all sort of on the same page in neurology. When you go into your pacer station, you are trying to find out two things. You're trying to find out where is the lesion and what is the lesion? Those are the only two questions you need to answer from your neurology exam, if you are able to answer those questions vaguely accurately. So especially where is the lesion that needs to be sort of accurate? But what is the lesion if you can give some good guesses towards you will do very well at your paces? That is exactly what they are looking for. They are not looking for you to make some sort of spot diagnosis in a lot of, in a lot of ways they are looking for you to, to pull things together and just answer these two questions from your exam. So let's start off with just a case just to get us all thinking. So we've got a 27 year old female who presents to her GP with hypotonia and hyperreflexia in her upper right arm, two months after an episode of intense eye pain, which self resolved? Ok. So where would the lesion be? Ok. So can someone sort of unmute or drop it in the chat? And what is, oh, sorry, not where is where is this lesion? I will see an upper motor neuron. Exactly. Yeah. Thank you. Yes, it's an upper motor neuron lesion. Ok. Perfect. What is the lesion it be like to multiple sclerosis? So, multiple sclerosis would be the diagnosis and that's entirely correct. That is what the diagnosis is. But in your cases, the diagnosis is sort of optional. You don't need to go in there and just do an examination and come with the answer. That is exactly what this is, that is bond or XYZ. It could well be and we're going to cover some of those, but you do not need to get that to pass. So in this case, you're quite right. It's upper motor neurone lesion, but the lesion itself is an autoimmune. Ok? It's a demyelinated condition caused by an autoimmune disorder. It's its body attacking its own myelin sheath of the neurons. So while it is multiple sclerosis, you don't need to necessarily say that to get your answer, it could be autoimmune, it could be due to many different things. We are going to talk about sort of examples that you could give during your pa station, even if you're not really sure of the exact er pinpoint diagnosis. So where is the lesion? So as Asher mentions, so we've got upper motor neuron lesions and the opposite being lower motor neurine lesions. Ok. These are essentially sort of opposites to one another. So in upper motor neuron, like we have a fat lady, we have hypertonia in lower motor neuron lesions. We have hypotonia. Ok. Now, when we say upper motor and lower motor, upper motor is anything relating to the brain and spinal cord and lower motor is relating to anything towards the peripheral nert. Ok. So if you have any condition which causes a problem to the brain and which then would have clinical signs, you're then gonna end up with your hyperreflexia. You're not gonna have fasciculation, you're not gonna have wasting. You are gonna have your arm flexor, your leg extensors affected. Um and you will have clonus as well. Ok? Whereas in lower motor, lower lesion got the opposite, you're gonna have hyporeflexia, fication wasting is going to be localized to an earth and you're not gonna have closeness. Now, in your places station, you may have someone who has had an off motoneuron lesion for a long time and that off motor neuron lesion may affect them being able to use part of their body. So it may have an impact on their arm or their leg. And because of that, you may notice a certain degree of atrophy of the muscles because they just aren't using them as much. And that will be the same if any one of us say we were admitted to sort of it and we weren't using them for a while. Your muscles do start to break down. They are not going to be as dense as they were, don't get that confused when you see that in places. Ok. Wasting is very localized to a specific area of where that nerve is supplying it. Whereas atrophy of an upper motor neuron lesion will be a bit more generalized to a certain limb or a certain way that they would be mobilizing. But generally speaking, we don't have wasting in an upper motor neuron lesion, but we do in a lower motor neuron lesion when looking at the patterns, just sort of looking at pyramidal or extra pyramidal. Don't worry too much about that. That's sort of thinking about the pathways and the tracts that carry the nerves from the brain down through the spinal cord. And essentially the only extra pyramidal pattern that you're going to ever come across in sort of final year is going to be your Parkinson's disease. Now, if you ever see any condition where in final year, any sort of case, anything in your writtens, which has both upper motoneuron and lower motor neuron lesions, that is motoneuron disease. Ok. You can put that answer down. Select that on your spa. You'll get that right. OK. If you've got both, you're going to have motoneuron disease. That's just, that's a very nice question if you get it in your writtens. So definitions with that. So when I said tone, there, tone is defined as the resistance to passive movements. So that is one of the first things you do in your neurological exam. After you've done a good inspection, you're going to be looking at the patient's tone and you're going to be moving their limbs around when you are doing your exam. That isn't just because you want to show the examiner that you know what to do and you know how to investigate her. You need to be a bit more specific than just moving the limbs around and working out. Right. You know, um, hypertonic or hypotonic and the way you do that is you look at the velocity of the tone. So in some of the lower motor neurone lesion, this isn't really applicable because they'll just be hypotonic. The limb will be very lax, you'll be able to move it around very easily. But in some of an upper motor neurone lesion, you have to really sort of move the limb and sort of really move it out and in quite fast and really add that to your neurological examination, really add moving the limb at the elbow joint at the leg joint. Because what you'll be able to determine that way is whether someone is spastic. So where they have a velocity dependent hypertonic limb, and what we mean by that is it's sort of what they call a clasp knife. So as you're sort of opening the elbow, you'll get a lot of resistance and then it will snap open. Ok. So that's spasticity in rigidity. You might have heard it sort of the buzzword of lead pipe rigidity and that's in Parkinson's. So if you're getting someone where, no matter how quickly you move the limb, it is just rigid, it is not moving, it is just moving at the same speed the whole time. Um Then you've probably got your diagnosis right there. That's Parkinson's and they're probably not going to throw in anything else, which would be extrapyramidal. Like I said, promo spasticity X, which is all your sort of peak sheet for your pas. But really make sure when you're moving the limbs around, you're not just moving them around to assess high or low toad. If you do have high toad, make sure you then start moving it quite fast. Um to see if there's any velocity changes some further definitions for you. So we've already covered what an upper motor neuron lesion is in a lower motor neuron lesion. This is if you are rarely looking for the gold medal, but I would advise you you've got a lot of stuff to cover. If you really like neurology. Absolutely try and do this in your exam, but to be safe, you will still get an excellent mark, which I did and I didn't bother defining it. In this way, if you really want to be specific, you can try and identify where in the lower motor neuron the lesion exactly is. So if you have something which is purely affecting the muscle, that would just be a myopathy, if it's affecting the junction. So it would be myasthenia nerve would be neuropathy, plexus, plex root radiculopathy would be the anterior horn. It would be a myelopathy. Ok. So if you really think you have an idea of what this condition could be, if you are noticing that they are getting more fatigued, the more you try and make them do stuff, or if you think that it's just the muscle, the nerve part of it aren't affected within your examination, you can try and give a bit more specific. But the problem with that is that you also run the risk of maybe being a bit overconfident and getting something wrong and the neurologist noticing that. So my gold standard advice would be keep it simple, say upper motor, say lower motor, you don't really want to give them anything that they can mark wrong. And if you say that you'll still probably get an excellent, excellent mark. When you've got your sort of um what is lesion? Upper motor, lower motor, you then need to work out whether it's purely motor or purely sensory or if there's both. Ok. So obviously when you're going through your exam, you've done reflexes, you know, you've done power, now you're moving on to sensation. So you're doing various parts, you're doing dermatomes, you're doing proprioception, you're doing hot and cold. Really? One major part of it is whether it is purely sensory or motor. Now, you can test this in your exam following it the way you did in third year. So going through all the different dermatomes, but if you really think in your exam that you may have found a sensory lesion, they're going to be really impressed with you. If you then, then take the time to really address that sensory lesion and find out a bit more about it. So you can do that in three different ways. So you can do it from distal to proxil. So if you're thinking someone's feet, they didn't really notice it when I pressed on their toe, but maybe around their calf was ok. Well, is it just their toe that's affected or is it higher up? And so if you wanted to do that and that would be typical in diabetes and you can sort of start the toe and work up and get them to tell you yes. And when they can feel and you begin, when they can begin to feel you and dermatome. So that would be the way you'd normally approach it absolutely fine. For instance, if you, you know, there's two dermatome affected as we've just before and described that would be a radiculopathy, patchy dermatomal involvement. So, if you're thinking you might have L4, then for some reason you've got ll one effect is if you are really testing that, that would be quite high up, probably more if you've got L3 and L5 effected, but missing L4, you might see that it's more of a plexopathy and then finally, does it look at a particular nerve? Um So if you're finding that, for generally speaking, you know, when you're upset in the lower leg, if, um or let's say the arm, for instance, if you're finding that c six to the foot is generally ok. Um But then maybe if you're looking more towards like the ulnar nerve lesions, you know, 678, as you start, it just the, the ulnar nerve is affected, that would be sort of a neuropathy. So if you're looking at the hand, if you can't think of any, um if you're noticing that multiple dermatomes are affected, it might be that it's linked to a that particular level. And so you want to really look at if that's possible to determine. But don't worry if you don't get a particular nerve, you can just say the dermatomes. Um in my exam, I didn't have a sensory lesion. But if you did and you really want to go for the gold marks and you can try and look at it if it does affect a particular nerve. But in general, the most likely one that's going to come up is going to be peripheral neuropathy. So we have sensory lesions. Um modalities. As I've just discussed, you, you've got fine touch pain, temperature, vibration, proprioception. One thing that you're probably all you know, maybe a bit worried about for patients is are you going to have to use the pin prick to test pain on the patient? And your best bet is just to ask the examiner while you're in there. Would you like me to assess a pinprick? And they'll probably say no. Um, unless the patient has a specific lesion that they want you to test in which case they'll probably say yes. Um, or maybe they'll just say, just do a certain area because they don't want the patient to then have to be jabbed in all the areas that we know are gonna be fine when it's just one little area that's affected and temperature, you also won't have to do and you can offer that. You can either offer that during the exam as you're going through it or you can offer it when you're presenting your case back. But generally speaking, you won't have to do temperature during your exam. You will have to do vibration. You will have to do proper reception then. And some people who have already done their cha and cross neurology rotation will know who I'm quoting when I say the main spices. But generally speaking in paces, you're either gonna get motor sensory, maybe a bit of both a cranial nerve lesion um and potentially cerebellar, but that's very rare. I wouldn't really count um on cerebellar coming up. Ok. So we've done sort of um where is the leisure? Now, we've worked out whether we say it's upper motor or lower motor. Now, it's for what is the lesion, which is, as Ashwin said before, in that case, there's multiple sclerosis. But, and that's what I'm thinking is more of a diagnosis when I'm saying what is be lesion, we can use a sort of a surgical sieve for it. So, Vitamin C is sort of rarely useful in neurology and it will just sort of come naturally to you eventually. Once you've been doing plenty of practice and you saw plenty of patients, but generally in any neurological condition or any upper motor or lower motor neuron lesion, you can give one of these potential causes of the lesion as one of your differentials. Ok. So for instance, you've got a person like we just saw with hypertonia and hyperreflexia in the right arm that may well be due to an autoimmune condition like multiple sclerosis. However, that could easily be due to a um vascular cause. So that could have been due to a stroke, ok. It could be due to trauma, ok? To the brain affecting that area that could have had a previous head injury. Ok. It could be very simple. It's a congenital cause. Ok. And they've always been like that, you know, there's plenty of congenital causes which affect neurodevelopment in your exam. Once you've presented, you know, you say, I believe this is an upper motor neurone lesion. This could be due to an autoimmune vascular or traumatic cause to investigate this further. I would like to do XYZ and we'll come on to what we think XYZ should be later. You do not need to pass in your cases to give an exact diagnosis. I didn't know what my gentlemen have in his exam and I think I scored 100% on that station. You don't need to score. You don't need to give an exam diagnosis. You just need to go in, be slick with your exam and try and suggest some differentials that you'd like to sort of investigate and maybe offer some treatment. The benefit in neurology is that neurologists, as I often know admit is that there isn't many treatments in neurology, they tend to diagnose a lot of conditions rather weird and wonderful conditions. But in terms of treatment, there are very few conditions that you need to learn about that we actually treat if you can come up with at least three of these sort of types of lesion that could occur and you'll absolutely pass your sort of diagnosis and clinical formulation part. Ok. So in pas the patients you're going to get are going to be ones that have to be examinable. There's no point in getting some really sort of niche signs which you can only rarely distinguish at a register or consultant level. They are going to be barn door signs, which you will be able to see if they are hypertonic. It's not going to be sort of Oh, are they hypertonic? It's not going to be with power or is this a four? Is this a five out of five on the MRC scale? If they've got reduced power, they won't be able to lift their leg probably. Or lift their arm. At least, not very much. If they're hyperreflexic, that leg is going to move that arm, that tricep reflex, you're going to get it very easily. Um So they really need to be examinable because of that. And because you need to find it, it sort of limits what Imperial can throw at. You know, someone who has had a stroke would be an excellent patient because they've probably got an aphasia, which is very nice to spot. You know, they can't make a word, they can't understand what you're saying. Although maybe if they couldn't understand you, that wouldn't be very good at examining, but it means that they have to be very stable. So that rules out loads of conditions, you're not going to have a key stroke, you're not going to have Guillain Barre and you are not going to have any sort of brain aet which could make them sort of septic. That doesn't mean you can't suggest that as a differential, but it limits what Imperial can throw at you in neurology. Um It's likely going to be there for a chronic condition, something that these patients have been living with for a while and probably came to terms with it probably happy for you to examine them. Um, and something that is still stable. So people might say motor neuron disease is a very chronic condition. I suppose it is depending on the course, but they're not really going to put them in an examination room with you. Probably because they probably won't be that happy with the diagnosis because it's often diagnosed a bit late. It's probably misdiagnosed, but also because they probably suggest who they're going to have for patients a few months in advance. And in a few months, the person could have gone from having some disability to being in a wheelchair or even being paraplegic. So they are probably not going to throw that at you all you need to do whatever patient comes up is suggest. Um where is the lesion? And what is the lesion? That is the key. If you can answer those two questions in your exam, if you go on to your firms and you clerk a patient and you say that to the neurologist or neurosurgeon who is on the ward and you sort of are on the right lines. That's perfect and you'll absolutely smash your neurology patients out of all of them. This is probably the nicest, it's not like cardiology where you need to exactly attune your ears to what is an ejection, systolic or diastolic murmur. It's not like the abdomen where you can have all those weird and wonderful scars with patients with extensive surgical histories. It's, it's quite a nice one because they'll have to make it very obvious. And there's a very limited patient cohort that they, that they can sort of take from the community. If you really feel confident you can suggest a diagnosis. Um, nothing to stop you. There's plenty of multiple sclerosis patients out there, high likelihood you'll see one. but don't feel like you need to. Absolutely don't need to. Um, I had a good idea of what it was. Um, in my case, I said, I think it's this. Um, but it could also be XYZ that's also perfectly acceptable. So a bit more interaction, I understand. I've talked to you a lot. Um, this is your Pacer station, you've walked into a cranial exam. Um, you have bill, you sat there looking at you like this. Um, this is one of those ones where you probably can and just do a spot diagnosis. It's one of the few, but does anyone want to unmute themselves and sort of tell me what it is and how we know is it Bell's palsy. Yes, it is. Chelsea. How do you know it's Bell's Palsy. Um, so it's either that or a stroke but this is not forehead sparing. Yeah, exactly. So the one that looks worse is, is the lower motor neurone lesion. So it's going to be that. And like I said, I'm not going to give you stroke. Um, so if you said stroke in the exam about that. They'd probably be a bit confused but quite correct. It is Bell's palsy. So, chance, because you have a mu yourself in cases what causes of Bell's palsy are likely to come up and can I have a viral cause viral? Yeah. Give me two others. I don't know. So, there's, um, let's see, um, inflammatory cause, um, of the autoimmune. Yeah, definitely. Perfect. Absolutely. Perfect. So, um, Bell's palsy very common um to come up in terms of um e essentially non uh non viral causes because Bell's palsy often happens for a variety of reasons. We are often taught in exams that it's viral, potentially sort of maybe EVD related and that causes it and you give them steroids for a bit and it comes back. But people get Bell's palsy because essentially it's just a lower motor neuro cranial nerves lesion for a variety of reasons. And a very stable patient population is those people who've had parotid surgery. So those people who might have had parotid gland surgery because of a adenoma, um they will have a scar on the side of their face. Um and that will cause just a permanent Bell's palsy for them. It could be because they've got a viral cause. They will often try and get, um if they have maybe lost somebody from the Pacer station that they were hoping to examine, they may send out a rapid call for the community and you may get someone who is coming in with a viral cause, but often you'll just get people who are post surgical very stable and they'll have a scar over their parotid and that's because they removed an adenoma and the facial nerve has unfortunately been damaged. Um It could also be due to malignancy, pra, pra dad's name aren't. Um, I mean, ii don't know the exact, but I don't think of that. Um, they're not overly urgent is what I mean, like, you know, you can be stable with them, you can book someone in, they do need to be operated on. Um Could they probably attend paces? Probably? Are they likely to maybe? But that means that that is a perfectly sort of valid differential for you to give and that's often the reason that they then end up with the scar and they then end up with coming to paces looking like that. Cool, excellent, well done. Chelsea. Thank you for meeting yourself. So, next, so you're walking into your lower limb. No, and um Doris is there and you see this foot at the end of the bed. Ok. And on the examination, you've expertly noticed that she's got foot drop, she's got wasting of the calf muscles. She's got reduced ankle reflexes and you've done exactly what I've said and you've noticed that there's a sensory problem. So you've started going distally from her toes up. Um And you notice that it's sort of in a stocking distribution maybe stopping just below the knee. Any suggestions on and where is the lesion? And what is the lesion, the lower motor neuron? And that's for the, so maybe I think something mebolic like diabetes would be most likely. So, yes, it could be diabetes. It has got the sensory part, but we've got the sort of foot drop part. So there's a motor component. So can you think of any causes which might give a motor components as well? Um So like some kind of radiculopathy? Yeah, could be like that. Yes. So trauma would be a good one. Yes. So that would be good because that would knock out the nerve causing motor and sensory. Excellent. So you've got some ideas there. You know, it could be metabolic, it could be diabetes, it could be trauma. Um It could be a variety of things. It could be autoimmune in some way, but just affecting the peripheral nerves, but rare and frankly for Obu. Um so this is a um a pacer favorite um in some ways and your, these, these patients often come in, they're often very stable, often very happy to be examined and tend to do it year in year out. Um So those people who may have seen that sort of foot before quite. Right. Right. Normally it's a lower motor neuron lesion. If you gave those differentials and ideas, you'd absolutely pass 100%. But this is um shark Murray tooth disease. And so it's not a condition that's ever really occur in any lectures and, but loves bringing these patients to, um, to pas and they bring them pretty much every year and you can absolutely get your diagnosis, upper motor, lower motor, in this case, lower motor without knowing this disease. But it really does help if you've now got a bit of awareness to it because as soon as you see those feet as you walk in, you can relax, you've got this, you know what it's going to be. And so it's an inherited disease affecting the peripheral motor and sensory nerve. So it's lower motor neuron, relatively common. So it affects about one in 2500 people, hence why it also becomes relatively. So um the classic features um so the high force arches that you just saw there, what's called Pez cuss. Um yeah, you, you could quite nicely get a diagnosis from that. Um You can see that there's muscle wasting and that causes the inverted champagne bottle legs and the weakness in the lower legs, particularly loss of the ankle dorsiflexion occurs as well. They also have weakness in the hands. They do have reduced reflexes, muscle tone sensory loss. Um But again, again, it's a classic lo moon lesion, but we have plenty of other differentials. And if you gave them the some of these differentials got peripheral neuropathy and you'd be on the right light and you'd be right in your right to say it. There's a lot of reasons that can cause a peripheral neuropathy. If you can think of something that causes the motor with it, um They'll really appreciate that you've got a full idea of this patient and if you can even get the diagnosis now that you've seen this in this lecture, um they will be very impressed. Um but you don't need to get it to, to pass, you just need to know slow motion or you just need to suggest a few um semi reasonable um diagnoses. Um And they'll pass you quite nicely. Um at the end of the day, that's what we're looking for. Ok. Does anybody have any questions about this so far? I realize I'm going through it quite quickly. Excellent. Ok. Right. So pace is free. So you're now doing an upper limb exam. Um on examination, you're looking, you're doing a very good job. You've walked up, you've saw the bedside, um you've looked around the bedside and you've seen the wheelchair, sometimes it's hidden behind the door as you walk in. So make sure to do a nice, a nice look around. And as you walk in, you see the wheelchair, you go up to the patient, introduce yourself. Um and you start performing your examination, you notice that they've got wasting of the phen eminence of their hand and they've got a real difficulty releasing their grip. So their grip sort of looks like this as it's sort of clenched and then opening it sort of, the hand sort of makes that sort of, sort of motion. And you notice that this weakness is really quite, um, worse distally compared to approximately. So they've got good shoulder strength but maybe their wrist strength and their finger strength is really quite poor by comparison. So, can anyone tell me what they think this lesion is, um, and what could be causing it? Mm. Anyone wanna have a guess you got a 5050 chance of getting the first one? Right? Is that like some kind of rigidity? So maybe you're thinking that there would be an upper motor neurone lesion. So I see what he thinks because you're saying about sort of the hand looking, obviously, you know, it's not sort of extended properly. I can see you and weakness and maybe lower. So, yeah. So, yeah, so I can see what I can see what you mean. I can see how we can use it more. It's more of a lower motor. We've got the, we've got the wasting going in a wheelchair. They've got difficulty, um, releasing their grip and whatever I can understand how that's quite hard to him. But what you really sort of gives it away is that their muscles are wasting here and, and they can still sort of, you know, move it a bit and I can get it. It's kind of hard on a picture to get whether it's like very stiff or not. I completely understand that. Um excellent. Before we go on to sort of what this actually is anyone got any suggestions for differentials, what could the lesion be if you got this in the exam, you just go back to your c OK. So could be again, both for you. OK? It could be congenital, this could be a congenital condition causing it. Ok? It could be due to um, trauma is unlikely, but it could be due to trauma. So you just sort of start suggesting things, ok? You just roll them off, could be metabolic. Ok? They've got a distal problem that's worse than possible. It could be due to something to do with that. Ok. So just try and have a think, just roll some off if you are not sure that's absolutely fine. Ok? If you're not sure that your investigations rarely help then and you sort of start thinking how you would investigate it. And again, we will go for investigation in a little bit, but you are quite right wrong. This is a lower motor neuron lesion and the wasting is what gives it away. If you did more of the exam, you'd probably find out that there's weakness, hypotonia, hyporeflexia, but this is um dystrophia, myotonica. So, myotonic dystrophy, um, obviously you've done peds, you've probably heard of like other ones like Duchenne and Myotonic dystrophy. This is very different. So this is an autosomal dominant genetic condition, which is lower motor neuron. It's classically that they have a problem opening and closing their hands. Ok. So if you get in the start of your examination, if you get them to, when they put their arms out like that, because you're assessing um maybe for tone, you're assessing to have a little look at their hands. If you get them to close it and open it as fast as possible for every patient at the start, that would be really helpful because it will give you a good idea of grip strength. It will give you a good idea of whether they're Brady kinesics if they have sort of like Parkinson's. Um but in this trophy Myotonica, that is very classic that they are very slow at opening and closing their hands. And if they can't do that sort of having a problem with that, um you'll then see that it fits more of the lower motor neuron afterwards as well. So even if you don't get it with that fit in, um if they've got a wheelchair at the bedside is often because they have dystrophia Myotonica, they are often just wheeled in, they are very straightforward patients, very stable again, lots of them in the community and they bring them up time and time again in patients. So they do love them, lower motor neurone lesion. They have the was in particular areas and they will have hypotonia, they'll have the hyporeflexia. But again, just about where the low motor neurone upper motion lesion gives some suggestions. So, again, congenital is a big cause is what I'm trying to really and get across to cool. So we're on to our fourth station now. Um So you got upper limb exam and the patient's hand as soon as you walk in without even ask him to do something, it looks like that. And on examination, you realize that there's some spasticity. So when we say it's spasticity, we mean that that's velocity dependence. So you've tried to move that elbow and you sort of move it and then it pops open, move it and then it pops open, you get their reflexes, they're very hyperreflexic and they can't open um their hand when you ask them to. OK. So anyone wants to give me uh what is the lesion? Uh um Sorry, where is the lesion? And what is the lesion? So in terms of uh what is the lesion? It is? It's an upper motor neurone lesion. Good. Um Given the spasticity you found to be more specific. I could see a pyramidal tract lesion. Yes, it's a pyramidal tract lesion. Definitely good. Any causes by what might, what might be causing it? Mm II do have a few differentials. So example would be like um yeah, good. Maybe like a malignancy like a tumor pressing. Yeah, definitely. And another cause I can think of couldn't be Yeah, definitely. Definitely. Really. And that's exactly it. So upper motion or reason you wanna be more specific. Absolutely. Great pyramidal um tract as being effective. So, it's like the pyramidal tracts. Lovely. Absolutely. The perfect thing you haven't been specific and that will absolutely get you really good marks. Just keep rolling off some of the Vitamin C and then not forgetting the congenital cos. That's a lot of these patients. And quite right, this is sort of congestive cerebral palsy. So it's a highly variable condition. So a lot of people might see the extreme ends, someone who is in a wheelchair, who requires a lot of care and might not be able to look after themselves. But in some cases, it can just affect one arm and these are very stable patients. Um Fortunately, you don't see too many, too much cerebral palsy, a lot of the time, but they are in the community, they are often very well managed for that. They get a lot of support. And because of that, especially people who are very able to come in if they have a good baseline, someone who has just had one arm affected might just be affected at certain parts of their body, they are very able to come in and be examined. So with these patients, the main thing and with any patient, rarely in neurology, just be prepared to alter your exam. So I'm so this was what I gave as my differential for my patient. Um in my exam with cerebral palsy. Um and he couldn't open his arm, um his, his hand at all, it was just stuck as sort of a fist. Um So if you see that and then you're asking them to open their hand and they, they're open, maybe their left and their rights weren't open. Um You know, that, that's sort of, you know, zero out of five in those groups if they can't flex or I should say extend their wrist and, you know, it's zero out of five, you don't need to do it against resistance and you can ask them, you know, can you do this and if they can't and you're not sure, maybe you're caught up in the moment of the exam, you're like, why isn't that all moving? I've asked them, have they not understood me? You can ask them, you know, you can be like, are you able to move that? And if they say no, that's fine, you know, all, all good don't try and sort of test it against power because there's no point, you know, zero out of five. Um So yeah, just be prepared to alter it and the examiner will really appreciate that. They'll understand that you're not just trying to just like many imperial students do. You're not just trying to go through a checklist, just hit boxes. They'll understand that you do see that there's a patient there. Um And that will just score instant empathy points with you, to be honest, especially if II think with my patient and with any patient that I examined, I'd just like, learn their name and I'd use it as I'd go across and that would just make you stand out a bit. You're just understanding them, you know, that they've done this however many times before they've seen you and you're not going to make them do stuff that they obviously can't do and not keep on asking them. So just be able to alter your exam. And another great thing I say great thing. Another great sign to look for obviously, which it didn't happen is cerebral palsy. Patients often have a lot of little scars on them and you might, you might be quite worried or concerned about that depending on where they are. But a lot of these patients, if they can't sort of manage their spasticity with medication, and so they often are given like um things like Baclofen is very good for, it's very good for the spast in their arms and they can have surgery to release the tendons and that might make them a bit less sort of rigid, rigid spastic in terms of their movements. Um and that helps them. So if you notice that they'll just be like, I'm not sure what that is. You mention that there are scars and you can always suggest that they may be due to tendon release therapy, which is they are well known to imperial and they are bringing them in. They may well have because it's another easily examinable sign. Ok. Cool paces. Five. It's a cranial nerve exam. Everything's going well. You're wondering why you're examining them. Um But then you do a visual field test the part everybody uh really enjoys and you're like, have I done this? Right? Have I done it wrong? Because you're noticing that they have really poor uh peripheral, they don't have anything else. OK. No, anyone want to tell me the causes for this. OK. Give me some differentials. It's a bit less. Well, we know what the lesion is but give me some differentials. What could be causing this visual field deficit. Did you think of something like a mass, like a tumor or something pressing on the? Excellent, excellent, good. Anything else uh you can think of like vascular causes? So like a stroke or an AVM or anything else? Not sure if autoimmune could cause something that specific. I mean, the thing is it like if you're suggesting it, it could be to do with that, you're right. It might not be as specific but you're not entirely sure. So if you said it, I'd be like, you know, that's entirely reasonable because you haven't done the rest of the examination. To be honest, have you, you haven't done upper limb low? So there could be other stuff. So, autoimmune, I think you're still in the running. But no, thank you for answering. That's excellent. It's really well done. So, yeah, if you're seeing this, you're doing the cranial nerve exam. Um This is the one visual field deficit that you'll get that you'll get if you get it at all and they do have some patients with it and they do sometimes bring them in, but it's the classic My Temple or hemianopia. It has come up previously, it's a bit rarer. But if you're going to get a visual field defect, it will likely be this. And it's nice because they can sometimes use an actor and if they run out of patients and they're in a real bind because an actor is very hard to fake. Um you know, a bell's palsy but they can fake a visual field problem. So if there is a visual field, it's like this one as one of these very well done is you use Vitamin C, you don't need to be very specific, you don't need to go oh instantly. It's a prolactinoma because you don't know there's plenty of other masses that could cause it plenty of other things. So just try and be nice in general. Use your usual neurological sieve that I gave you and you'll be absolutely fine. Cool. Um pace is six. So you've got a lower limb examination. Now you walk in, you start off by examining their gait. They've got a scissoring gait, they're hypertonic and when you move their foot around, you get clonus OK. And when you start examining their reflex, they're very reflexic. Um and they've got reduced sensation in their right leg over their left leg. Ok. So where is the lesion? And what is the lesion? Ok. Anyone wants to answer that? So, an upper motor neurone lesion? Excellent, good. And um what could be causing it? So, vascular causes like a um neoplastic, maybe a spinal cord compression. Yes. Yeah. Excellent. Um Yeah. Anything else? Sorry, I'm not sure. Not sure. That's fine. Excellent. Very good. A really two excellent causes just one again, one more question for you when I say clonus. Ok. So we've got someone whose foot is flapping. Ok. If you did it that on me, you'd probably get my foot flapping if you did it well enough. How many beats of the foot flapping does it take to be classified as true Clonus? Is it 55? Yeah. Good. Excellent. Just really good to point that out because if you do your neurological examination, well, if you've been really good on f if you practice with your mates, you'll probably get a good two or three out of people. Um If you get more than five in the exam, that's proper quot. Um And then you can say that to the examiner. Um But you know, if you've got someone with another lead, you might, you might only have a sensory problem and you do it. Um It might just be normal, but really well, really good suggestions that absolutely, you've got your diagnosis, you've got your differentials really good clinical sort of that part of the market seem really good. So, in this case, all your suggestions were really good, but this is likely multiple sclerosis. It's probably the bulk of your practice during your neurology rotation. They are really good to practice, aren't very stable and have to spend, you know, an hour or more. Um, getting that sort of, you know, immunological treatment. Um I'm just going to put the light on, it's not very dark. Um So they've got their treatments so you can examine these guys really easily and there's also plenty for them to choose from to bring in. They have really excellent or promotion own signs even in someone who is well controlled and may have not had a relapse for a while. They will still have signs. And so they are very good to bring in. They don't need to be in an acute flare or problem, but they are very good to bring in. Um And it tests your ability not to run through the exam but properly elicit it. So you're looking for, you know, class life spasticity, the clonus, the hyperreflexia, you really need to be good at your clinical examination to pick it out sometimes. Um So again, if you just said you gave those answers, even if you didn't mention autoimmune or multiple sclerosis, you'd pass 100% of the heart or 100% of the time. Um, many things can cause it, but this is what I'm just trying to say, this is a good patient population that they'll bring to your exam and paces. Another one lower limb on examination. All you've got is the sensory loss like that. Nothing else. Where is the lesion? What is the lesion? Anyone give me a few suggestions? Is it lower motor neuron? Yeah, exactly. Because it's affecting the peripheral nerves, isn't it? So what could be causing it? Um, metabolic cause? Um, like diabetes? Excellent. Um, maybe an autoimmune cause um, or infectious cause. Yeah, definitely, definitely, really good, really good, excellent differentials. Yeah. So peripheral neuropathy, solely sensory. It's likely diabetes. Ok. Um, plenty of very stable patients. Um, you wouldn't believe how like awful their blood sugar control is for a variety of reasons. Um, have this, um, you know, we see them on the board all the time. They are often very stable. They are often very much able to come in. Um, there plenty of patients. So they are really good to examine and you can really sort of do really well for this sort of case by talking good holistic management, you know, you could say, oh, improve diabetes control. But if you really went further and you were like, you know, we need a really biopsychosocial approach sort of back to your psyche and you were like, he's not to improve the diabetic medication will think of their diet and thinking what's causing them to miss out on exercise or that. So, maybe speak to the dietician, maybe speak to the life coach, maybe they're having problems with alcohol, which is affecting their blood sugar. Maybe they need to speak to the alcohol liaison team. It's a really nice one for just, um, adding in a load of extra stuff, um, which a lot of people might miss. So it's a really nice one for that. And I think this is the final one and for the Pacers sort of stations, hopefully, um, already got an idea. It's a lower limb exam. You try and examine them very slow, shuffling gait, a lot of rigidity. They've got an ok amount of power. Um, and as we try and move their toes at the end, they, they're very, they're very slow. Ok. So where is the lesion? What is the lesion? Did an upper me urine? Excellent. Great extra permital because of the rigidity. Perfect. Yeah. Um, so maybe something like Parkinson's. Yes, it definitely would be Parkinson's. Absolutely. So, yeah. So again, so that would be one of your neurodegenerative causes. We could easily just say, you know, it could be lead to other reasons. It could be auto, could be vascular just so you can just give those other reasons. But absolutely, this is Parkinson's. Um, they can be somewhat well controlled on medications, but even people who do take it, they can have residual signs. So they are quite good for people to bring in because they will have it. Um, the examination will unfortunately feel like it's taking a while. Er, you'll be wanting to get for you. We wanting to move to the next part, asking them to do stuff. Um, remember if you're thinking it's taking a while before you get to the tow taps, which is right at the very end. And remember, you know, this could be Parkinson's, that could be why they moving rarely, rarely slowly, really good part of the management of this one. Just as a little point is a medicines review that will really show that you've been on the wards and you know what you're talking about. If you ever see anyone with Parkinson's or dementia, any sort of neuro condition, a medicines review can really, really help the patient because there's a lot of cholinergic burdens of drugs. We give even one that you wouldn't suspect and that can really impact people's, um, Parkinson's disease. You can have Parkinsons dementia as well. So just say medicines review in your management sometimes really, really helpful. So once you've taken your exam, you then present it, take a moment to correct yourself. Don't speak too fast. You've got this essentially upper, lower um upper limb for lower limb presentations, you're going to start off with giving you an inspection. Um Swift is a nice little um acronym. So, um scars wasting, um fasciculations and tremor. What was eye again? Um, I'll get back to you on eye. Um, um, anything around the bedside? Ok. And come on, sorry, long day, anything around the bedside, that's what you wanna give them, then you're gonna expect their gate. You're gonna also do trendelenberg with it. Um, if it's lower, lower, lower them and offer them, obviously don't even smack their gate. Um, tone you're gonna do next and you're gonna report it all in this way. Power. The MRC scale is what they'd ideally like you to use. So you can just say reduce power, nothing wrong with that. Um If it's against gravity, so say if someone can lift their arm up like that, it's automatically three out of five minimum, they can resist you pressing down, it's five out of five. Um If they can't resist as much as four. But essentially, if you could say it's either three out of 55 out of five or in some cases zero, They're absolutely happy with that. Um Reflexes, the map sensation, all the different types and family coordination, the cranial nerves, it's a bit simpler. I would do it in this way. I would just say which nerve was the problem. So, cranial nerve two was the problem. They lacked their peripheral fields or they have bitemporal hemianopia or cranial nerve seven was the problem. They had a facial droop which was non forehead sparing. OK. Then you can say what was the problem. Um What you think was the problem. So you might say biting for having due to this and then just say all of the cranial nerves were intact. That's absolutely fine to say that you don't need to say cranial nerve one, they were able to smell cranial nerve free, they were able to a up their eye. You don't need to say all that. You say all the other ones are intact, that's absolutely fine. Once you've given your presentation, you say this is in keeping with an upper motor or lower motor lesion, which could be due to, then give your surgical sie then to investigate this further. I would like to do a full history examine whether you haven't examined. So if you've got an upper limb, I one of the lower limb and cranial nerves and then you want to go, I want like to go through bedside bloods, imaging and special tests. And that's what you need to say in any station. Essentially. That last part don't just say I would want to do obs I'd want to examine, I want a full blood count. That's not what they're looking for. They need you to be structured. So I want to do bedside goods, imaging and special tests. OK? Every single station you need to say that even if you are taking, you're just about to hit the time and you say that and you give no other indication you've shown that you are a safe structured doctor. That's all they are looking for. That's all you need to be in your investigations when you're organizing it. This is sort of what you're gonna put for neurology. So at the bedside, you're gonna want a full set of ops, you're going to want an ECG. Don't forget that in neurology, there's plenty of conditions which can affect the heart and plenty of medications which can as well, which they might be on. You're in depth as well can also be really important. You know, not only because um it sort of gives a completeness and often needed on admission, but also it could be underlying infection causing level of delirium bloods. You want your routine bloods also consider your peripheral neuropathy b12 folate, diabetes controlled, they'll all love that prolactin. If you think it's something in the head imaging, the most likely imaging that you're going to ask for is an MRI with contrast. If you think it's upper motor and very others have varying sensitivities and accuracy, it's unlikely you're going to be asking for a CT, it's not an acute problem that you're probably going to be seeing. So, MRI is probably what you're going to be asking if you want any imaging at all. You can ask for a lumbar puncture. Sometimes it's very useful in multiple sclerosis. And if you are really wanting to blow them up the park, you can ask for neurophysiology. So nerve conduction studies in people with weakness, you can test with bad emg eeg potentially all of this is sort of very niche stuff. But it's just sort of nice if you want, I would consider neurophysiology studies in my exam in any of the stations. I did. I would explain why I'm doing it. Ok. So if I'm thinking about multiple sclerosis and diabetes, I want a full set of obs, I want to look at the BP to see if there's any autonomic dysfunction. I want an ecg because I want to check if there's any arrhythmia. Ok. Routine. I want a full blood count to check for any anemia, use renal dysfunction. And you can just say it like that. You don't need to give an exact reason for it in terms of the context of your patient unless you think that there is a context, but you need to explain why you want everything. Um This will essentially be the same for every single patient that you see. Ok, you won't use these a, even if you don't think there's a problem with the liver or kidneys because you're probably going to give some medication and that medication could affect the liver or kidneys. That's why you want it every single time. Ok. So that's what you need to be saying in this station, in other stations to rare score. Those truly excellent marks which I know you can all do your management in any station. You're going to do it this way. I would like you to manage this with a conservative medical and surgical approach, depending on the etiology. That's because you need to investigate it to work out how you want to manage it. Unless you've got the diagnosis already or you've got it in one of your history stations. Even. Then you need to say you would structure it this way, but you may not offer surgical management, conservative. So for a lot of patients ot and PT rarely useful diet and lifestyle, very useful, supportive, you know, Bell's palsy. If it's viral, it'll go away, you know. So you need to give them eye drops. In the meantime, you need to give them some tape so that they can close their eye while they sleep. Maybe. Um it's get supportive. It's conservative management, medical always worth saying a medication review, immunotherapy symptomatic treatments. There's very little treatments in neurology. Unfortunately, you're not going to be given an acute stroke. So you can't talk about thrombolysis or thrombectomy. And yeah, if you have got multiple sclerosis and you might consider immunotherapy is what you'd say. You don't need to learn the exact monoclonal antibodies in neurology. Unfortunately, they often they diagnose a lot of conditions with terrible prognoses that they can't do much about. So there's not a lot of treatment that you need to learn, but there's just something that you can say, ok, and depending on what it is, it might be very helpful. Finally, symptomatic and surgical treatment. So you've got your cerebral palsy tendon release surgery and potentially neurosurgical. So, if you're thinking it might be a herniated disc, you know, they might need to be referred to neurosurgery, potentially unlikely pacer stations, stroke, even if they've had a stroke in the past, very unlikely they'll come up. They have excellent rehab these days while there may be some residual things. It's often a very subtle. They don't tend to bring stroke patients in GBS. It's way too acute meningitis, encephalitis, brain abscess, for obvious reasons. You won't be seeing those patients epilepsy, lack of signs. Ok? Unless they're having a fit for each and every one of you, they're probably not gonna bring an epileptic in and even then that probably wouldn't be that good for them. Myasthenia is well managed a lot of the time difficult to assess though. Um finding the signs for it would take a bit too long for the station. So that's probably not gonna come up for Imperial multiple sclerosis, CMT diabetic neuropathy, all of these ones that we've just went through, they are highly likely to come up, but you can always pass without a diagnosis. So even if you're there and you're thinking, God, I remember Jackie went through this. It could be cerebral palsy. They've got a patient with a hand that sort of won't open, looks like that, but I'm just not sure, but I'm confident it's upper motor say it's a promoter, say it could be due to whatever reason, congenital, neurodegenerative autoimmune, you will absolutely pass. Probably just the same as somebody who gets the exact diagnosis and at least then you are not risking potentially being incorrect. Hi, Jack. Yeah. Um, before you move on, you answered this a bit. But, um, I'm wondering how much can their symptoms be masked by their medications? Hm. So in, is this for, um, which, which condition or, or for just all of them? Um, you mentioned the Parkinson's symptoms being slightly masked. So I'm wondering, are there signs that we will have difficulty eliciting because they're on medication? Yeah. So I think with Parkinson's, it's generally that they have obviously the disease and they get the medication and they do feel better and, but often it can be that they've reached a certain dose and it's not working or they've reached a very high dose and there are still residual symptoms or maybe that they are happy about the dose that they are on or maybe they don't want to increase the side effects or whatever. And so because of that, they still have a degree of symptoms, they are still a bit slow. Their gait isn't quite what it used to be and maybe they are still a bit rigid. So I'm still saying that there are symptoms but they are a lot better than if they weren't taking any medication, but they are still probably examinable enough so that you can definitely gain an idea that compared to me or you, their arm is a lot more rigid. That's what I sort of mean. Thank you. Yeah. No worries. Cool. So, top tips, any station, especially neurology, just be systematic. We would go through it organized, examine pretty much every day of neurology rotation. I know they like pros, they'll often say every day you should be examining, it's probably unreasonable because you've got other stuff to do. The written exams are very big and not every placement will be that useful for it. But in neurology, you should try, you should really try and do it almost every day because a lot of it is a lot of skill in terms of getting the reflex being able to assess tone properly and really do get people to watch it. It might be that people are very busy, but you're a final year, you're paying a lot of money to be there. You're going to be a doctor very soon and you don't have longer your neurology rotation and there will absolutely be plenty of people who would be interested in helping you because you're taking the initiative to say I want to see a patient. I want to examine them. Do you mind watching me? I'm not that good at getting the triceps reflex. Do you have any tips? It will really help you? It really will share. So II really would recommend it. Relax when you're doing it come across smooth as, you know, you may have just had a horrible station previously. I know I had one that nearly reduced me to tears on the day and then had to go into another station and you just have to leave that one behind. You know, it's like you've just done that. What's happened in that room has happened? Move on, ok, you can fail some stations. It happens to all of us and you can still pass really well because it will be based on that day. So if you fail them, probably other people have failed them as well. Um So don't worry too much. Ok? Whatever happens, go into that room thinking I'm gonna try and do the best at this station and then move on. I know it's easier said than done, but I've been there. Ok? I've done terribly in some of them. I've moved on, smashed the next one. Ok? Just don't let it get to you any questions about the pacer examination part before we do a quick rundown of the history section for Neurology. A very quick rundown. I know you're all probably eager to go have dinner or just relax and do anything else other than think about neurology, any questions so far. Ok? If there's any, just let me know I have questions at the end as well. So in neurology, there's two main histories that you're gonna be given. It's either gonna be headache or it's gonna be a collapse slash blackout, er, very rare. You're gonna have confusion or limb weakness. The not gonna histories, headache and collapse is probably gonna be your best bet. So, uh, not gonna ask you that much, but essentially we've got Lena's come to a, and a, she's complaining of a severe headache doesn't seem to go away even with medications. And you've been asked to take a, take a history of this lady. Ok. Anyone got any differentials quickly for me? Just for this headache. Maybe a migraine, migraine. Good. Anything else? The subchronic hemorrhage? Definitely. Yeah. Anything else or more? Mm. Faster or tt, yeah. Could get exactly good, good, faster or? Yeah. No, a all accent suggestions. Cool. So, yeah, plenty of things that, that could be your job to sort of differential and sometimes they'll give you, I mean, it depends, sometimes they might give you a bit more information outside. Sometimes they might not. Um, either way you're gonna go in, you're gonna start taking history, you hear its headache. Those are the sort, you know, see the thinking of those differentials because that's gonna tailor what you're gonna say. So, Socrates, we are all very familiar with this and you'll get all these slides. So you want to know where it is when it started, when it started, it is useful for any history. When will really tell you how worried you need to be ok if it started instantly. And, you know, a lot more worried than something they've had a headache. You know, I mean, I suppose worried is wrong. So if someone has had a headache for several months, obviously it could be a tumor. But in terms of how immediate you need to act and whether you think that there is an immediate right now threat to life, your character obviously makes sure that they describe it. Does it radiate anywhere? So he mentions subarachnoid. So think about it getting down the neck, it starts at the back of the head. Um migraine typically just affects one side of the head. Doesn't cross sort of the midline thinking about meningitis. It might be all over the head, it might go down the neck as well, might be also be pain sort of in the eyes associated symptoms. So you really want to be thinking about your differential. So if it's a space occupying lesion, is there nausea and vomiting? Ok. Is there visual changes to that? Have they got any other signs? Ok. Timing already sort of discussed and anything that makes it feel better specifics um differentials migraine already mentioned, unilateral photophobia. Is there an order anything else? Meningitis, neck stiffness, photophobia, rash, fever, see there is a bit of overlap. So you can include that in your differentials. But what will rarely distinguish you is how you investigate these, it's trauma. Where did it happen? When did it happen? Um Lucid interval, stuff like that temporal arthritis. So make sure you asking about the jaw and if it's slowly progressing, it's just always been cancer. It's never a problem asking of flaws in any history. And it really shows that you're thinking of some red flags, empathy points, you're gonna need these in every station basically. Uh But this is your ice. What could it be that you worry about what you're hoping to get out of today? Finally, your assistants review. Um, he was keeping it general. Ok, very general. You don't have much time in your histories in final year. I think you've got, I think six minutes history before you then have to go through investigations, management and vi um so really keep it specific and you will have to get your past medical history and all that, but really try and, you know, tailor in on what you're really sort of um thinking a lot of the time cool sinus, the cause of the headache. If some people like mnemonics, we've got one here for you vivid. Um, so vascular causes infection, vision, threatening intracranial pressure. So you've got your spial occupying lesion, cph, malignant hypertension and then one that you might sort of miss sometimes might be your dissection as well. Red flag symptoms if they've got any decreased consciousness. If it's sudden onset, focal deficits, reduced vision, progressive headache. Um If it's persistent or worse when lying down, you're going to be thinking you're raised intracranial pressure and finally, uh, obviously you're flawed, non sinister causes. I'll leave you to go through this on your own time. The very good ones that come up in your GP STATION, you can think about the amount of people that would come in with sinusitis or maybe a tension headache and you might have to talk them through that. It's quite a nice one in that regard. Your investigations are exactly the same as the Peer station. These will always be your investigations and they print be very similar to your other stations as well. Um These are your investigations and final sort of case, final sort of part five minutes away from the end. Does anyone want to give me any differentials for this man? 46 year olds came to the GP after collapsing, he's worried it might be something serious. What are your differentials be a face of eagle? Good. Yeah, excellent. Anything else? Mhm. Seizure, seizure, good. Excellent, good. Differential. One more cardiovascular arrhythmias. Good. Excellent. That's really one we don't want to miss. So is neurology you think about other things that are affecting the brain? Got to be very holistic, so really well done. So essentially you can divide them into syncopal causes and non syncal. So syncopal, anything affecting blood supply to the brain. So you're thinking of reflex cause you're vasovagal, anything like that situation or some kind of a bit emotional shock. Cardiac causes excellent arrhythmias. Really good. Orthostatic causes dehydration drugs potentially and cerebrovascular. So if you've got dissection, you've got poor blood flows in the brain. It's another sync course, non sync, someone could have been toxic constipated, they could have taken many drugs. Um very, very common um head trauma, metabolic, you know, think about your hypoglycemia. ABCD, don't ever glucose, epilepsy or non epileptic seizure. It could also be narcolepsy but very unlikely to be your history. Your history of presenting complaints is this structure. If you do this structure, you'll pass no problem. You wanna find out what happened before it during it and after it don't be afraid of asking, did anyone see this before it? You want to know if there's triggers? So if there's reflexion, was there any emotional distress, situational or sexy? All bit less likely to come up, but they're there for your sort of reading. Always ask about head trauma or injuries. Not only things that could have precipitated it, but also may have happened during it. So I know I'm saying this before, but if they fell, did they hit their head? I'm much more worried about the epileptic who fell and banged their head. And I am the one about who felt that they knew it was coming on and therefore they lied down and then had their fit. That's much more safe than the performer a program. Any warning, you know that they smell burnt toast or fla out during it. How long were they unconscious? For few seconds, probably cardiac a few minutes. You're thinking more seizure. Did they bite their tongue, move their limbs? Um, were they incontinence of urine or feces? Just make sure to ask that. Yeah. You can always sign folks that it's a bit personal. Don't worry about it that you, you know that you lose continence if S is caused, it must become flatter but you can get seizures following it. So some people might have a vasovagal might have a bit of a fit. Probably not, it's not true epilepsy, but they'll feel fine after it, but they may have a bit of a bit of a seizure. In the meantime, tonic stiffening again, they will describe it quite accurately if there's tongue biting, that's probably your epilepsy cue um to go down that route and twitching and incontinence. Um epilepsy but can also be very, very rarely is vagal in the context of your cases after it, the recovery period. How long did it take? Um you know, it might be very quick. It is vagal, it might be longer if it's epilepsy or if it's sort of seizure. Um slow recovery and confusion. I can't remember. Um It's epileptic seizure, you know, postictal period can be quite long. Um Anything that help bring you around. Ok. So they lie down, it's orthostatic um ice be your assistants view anything else. You know, it's very similar to what we just discussed and the anticoagulation can be very important for her just because if you're thinking about bleeding risk on the brain investigation is very similar. But as we've already discussed, ecg is gonna be really one of your main ones that you want to suggest. Um, but prolactin is very useful because prolactin will often rise transiently 12 hours after a, a true epileptic seizure. Er, and remember, epilepsy can only be diagnosed if they've had two seizures. So make sure you ask previously if they've had one, if they've had two unprovoked, all that sort of good stuff. Um It's epilepsy probably. Um or you can suggest it as a differential, but prolactin allows you to basically tell a bit better if it's epilepsy because that will be produced during an epileptic seizure. It will also produce during delirium tins and all that. But if you, if you're thinking epilepsy and they obviously haven't got a clear alcohol history or they are alcohol negative, you can be a bit more confident that it's epilepsy using the prolactin level top tips. Relax. You've got this. You've been taking loads of histories, you've done Socrates to death. Yeah, be structured tail of questions. Always ask the red flags and you'll be absolutely fine. Ok. Thank you all for joining. I know I went through that last part very quick. Um I'm pretty confident your smash histories. It's more the pas that I wanted to really drill into you guys tonight and please fill out the feedback form. Um You, you know, it's a lot of, a lot of work. Finally, even if it's very short, don't worry too much about it. Think about what can come up, you know, and use that for anything, you know, think about what can come up for abdominal respiratory cardiac neurology is, is the nicer one in what you can predict. Um And all that you need to answer is where is the lesion? What is the lesion? If you can answer those two questions, you're 80% of the way to passing. OK. Any final questions?