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okay. Wonderful. Her If there were, we can still see and hear me, but yeah. Today I'm gonna be talking a little bit about neurology. It'll go to sort of movement, just quite important topic. Quite a big topic in terms of the clinical work that you doing. See? Um, so first of all, I'd like to start off talking a little bit about what's the difference between upper motor neuron versus lower motor neuron? Now, you probably know a little bit better than I do, but open motor neuron just essentially means anything to do with the CNS. So, um, I'll show you a picture in a second. But anything to do with a CNS of the brain, the spinal cord, whilst anything to do with the lower motor neurons, which is essentially from the spinal cord all the way to your muscles. There's quite a lot of different names to it. So, for example, the, um en week sometimes called the paramedics tracks and you might see that on textbooks, especially in clinical situations. But they're basically just interchangeable. So here's just a diagram of a promoter verses, lower motor neuron lesions. Now we also want to know What kind of things? Uh, what clinical signs might people present with if they have an upper motor neuron lesion or Lomotil your lesion? Uh, so if anybody can put in the chat, you don't have to. It's completely fine if you don't want to, you could get sent me directly. Ah, personally. Or, um, put it out to everyone. But any ideas on What do you think? Could be, um, Could fill in some of these boxes? Yeah, perfect. So spastic and flaccid paralysis get now. Spastic viruses. Paralysis is for mostly for, uh, promoting urine lesion whilst flaccid process more, more so for a lower motor neuron lesion. The reason why that's the case is because you can think about as theobroma it in your on's being a bit like controlling. So they're controlling and so off, trying to stop things from getting two out of hand. And so once you take away that control, you have this plasticity okay. With the upper motor neuron lesion. The opposite, obviously, with lower motor neuron lesions, we have more flattered tone. Exactly. Perfect. We have hypertension and hypertension, So upper motor neuron lesions. You have hypotonic signs. So, for example, if you try and move somebody's arm. So one of the signs that we do for our practical exams in clinical school is you grab somebody's hand you saw Move it around like this. Move the shoulders, move up and down. Checking each of the different joints. Okay. Making sure if there's any problem with the tone. Okay. On what you should feel Is that that great rigid? Okay, they're quite hard to move. Okay? And that's more hypertrophic kids. Okay? And somebody also sent reflexia perfect. So somebody's reflexes will be slightly different. Okay, so with the upper motor neuron lesions, we'd have hyper flex year. So you have breast reflexes. So that's your obviously your tendon, your tendon reflexes. So your biceps, uh, I forgot the rest of the muscles, but your ankle, your patella reflex is a lot. These are hyper reflexic and, uh, promoting your lesions. What's their hyperreflexic in lower murder on your lesions. So let me just show you a lot. This So that's everything that we've said. Plus the difference is an atrophy. So you will see atrophy in both upper motor neuron lesions and lower motor neuron regions, except in a promotion urine lesions. It's mostly caused by a disuse. Okay, what's in lower murder? Your missions is caused by a wasting. Okay. And often motor neuron lesions. We also have a positive Benty sign. Does anybody know what that is? How we elicit a babinski sign in someone? Yeah, perfect. Good. So if you it's quite painful, actually. But if you get the tip off, tendon hammer usually have quite big tip where you can get something else. That's a little bit shop. You're still running across. The person's the sole of their feet. And what you should do is that they should Curlin. Okay, Now, if you have positive uh, venti sign, you should get a plantar reflects exactly that off extends. Okay, Like this? Yeah. This is normal in ah, very young babies, but it's not normal, Fadel. So if you see that, that's something that should be noted. Secondly, we have testicular A shins doesn't run or for circulation's is if I'm a fasciculation in in any of my muscles. No. So a fasciculation is basically just the cough. How do I describe it? So the tingling of muscles. Okay, Not literal tingling, but you can see sort movements of muscles are little bits of muscle disorder moving. Okay, I don't know for sure that I have a video of it, but you'll see some fasciculation. Okay? And that's a characteristic or lower motor neuron region. Okay. And the reason why it's because with the lower motor neuron lesions, the signal is still traveling. Okay, just a little bit in the muscles. Where will start off? Quick. Little bit. Okay, So without the signal from the neuromuscular junction, muscles are just so fire little bit and so decide to be a bit of radical times. And the last do we have ankle clonus, which essentially, what you do when you saw grab somebody's sort of foot you can solve. Wave it about like this. It looks a bit weird when I'm doing it my hand. But then you push it up like this. And what you should feel is somebody pushing back like this. Okay, that's an ankle clonus on portrayed it pronator drift. Okay, is basically you ask a patient to do this. Okay, so we'll hold their hands out, close their eyes, and you should see one arm pronating. Okay. And also falling. Okay, I have a little video about this. So let's see if it hopefully works. So hopefully you can see it's not an instant thing. Okay? That this arm is going down quite slowly as pronating. Slowly. Okay, touch. You can see here. It's falling. Okay. Now, the reason why this happens is because when you have the open most of northern lesion, okay, like we said here before, Okay. Is that the pronated muscles in the arm? Uh, much more stronger than the supinated muscles. Okay, so if you kind of d in a vein boat of the stronger pronator muscles so you can imagine it as if you're holding out your arms, your arms. If you said if I told you to rest your arm on the table, you wouldn't go like that. Yeah, you would put it like that because you're pronated. Muscles are stronger. Okay, But then if you if you denervate your if you denervate your muscles, your arm muscles, then don't go into this off basic position. So let's have a look at some cases. So one year ago, a patient, 24 year old male notice general weakness and cramping in his legs was playing football which led to numerous falls on the field over several games. He spoke with his family doctor after two weeks of frequent falling and cramping. His family doctor referred him to a neurologist. Okay, particularly weird. Strange, just from this soft part. So the left side not looking at the examination yet. But just looking at the history, What kind of things make you little bit intrigued? What kind of things make you think? Oh, this is peculiar, Obviously, the fact that he's falling, what's his playing football is or peculiar thing in itself. But, um, if we're thinking about, uh, motor neuron disease perfect, get a young age. Yeah, so this person is 24. Okay, you would expect, if you would expect this to happen, more so in somebody that's older. Okay, but if he's 24 there's something strange going on. Okay, No. And yes, So also during strenuous activity, yeah, get so there's mild muscle. So if you look at the person and trying to examine him, there's more mild muscle atrophy in the hands and lower extremities in good. In the quarter steps of the cough muscles, there's a physical visible fasciculation of contraception bilaterally and has reduced strengthen a lot for the limb. So if you try to do the strength test with him, it's weird. You strength. Okay, There's also increased tone throughout. The limits is positive in ski sign positive ankle clonus, and there's also hyper reflexia. So what kind of things are you thinking? This does link back to what I was talking about earlier with the upper motor lower and moting your own lesions. So do you think it's on a promoting your lesion? Lower motor neuron lesion? But what could be happening here? Good. Yes, so yes. So it's actually a trick question because this person showing both signs upper on lower motor neuron signs. Okay, so it's, for example, like Fasciculation saying that lower but minty Sinus, an upper ankle clonus is an upper hyper reflexive years and upper. Okay, all of these are a combination of both of these suggests that it's not really an upper motor neuron lesion or just on lower motor neuron leisure. Okay, now there is one disease, the one condition that does have both upper motor in your lower motor. Your lesions are more often motor neuron signs and lower motor neuron signs yet perfect a less or just more just generally, motor neuron disease, like a less is one of the, um, one of the examples of motor neuron disease. It's, I think it's the most common. So the clinical features. As we said earlier, it's a combination of the upper motor on Lomotil. You're on spines. I've movement is usually spared. Unfortunately, I don't know exactly why, but if you do, if you're quite interested in that, um, I put a link into the chat so you can have a look at this article on why the arm muscles seem to function despite the rest of the muscles. So I'm not working well, I'm pulling thing that's also something to know is that sensation is also percent preserved. Okay, so they might have difficulty in walking, but they can still feel things. Okay, so if you do your if you've probably seen it before, like your pin prick examination, testing that sensations or your cotton wool as well Okay, that's what preserved it Still exactly the same. Wonderful. Because we want to second case. Then so patient was admitted, the hospital, presenting with a concussion on a whiplash injury to to an NBA. So if you don't want NVA just a motor vehicle accident. Hey, is 18 days Prozac, Sedin and Day 13 post hospital discharge. He's in the shower and the rest independently, but hasn't trouble with fine motor tasks which was putting on the shirt towards the pick up his trousers. So now if we have a look at it, the examination, the patient has a wide basis support. So he's walking with, like, a very wide gait, okay, and has a reduced gait speed in a short stride length. Okay, is a bit shuffle e Okay. In a sense, um, also patient is increased up a body and truck movements during escape. Patient resented slow I movements and with some comment trait, he had turning movement. So basically, in clinics A you might have seen this before where we the doctor is ask you to look at their finger, and they sort of do a hate shaped like this or a plus shaped like this. Okay. And usually we talked. We tell the patient, Don't move your head. Just move your eyes. Okay? But this patient seems to be moving slightly. Okay? Little something. Stagnants noted. There's no changes. Sensation, reflexes. A noble princess. Kind on the clonus or negative. So what could be going on here? What kind of things do you think? Oh, what's contributed to this? I think that's for you. An obvious answer here. But what What could have contributed to this? Yeah, perfect. Good. So this person's in a has been in a motor vehicle accident on D. Obviously, if they've got what forward and then whip back, they're going to get quite five brain injury, okay? And this person seems to her have had some sort of brain injury. Okay, Now, which part of the brain do you think this could be affected If you consider as well that it's unlikely. But actually, it could be the case that you could be Jack this way and that way. But if you're being choked foreign back with, that's that's more likely. But yeah. Good. Yes. So it's the cerebellum. Yeah. So it's the cerebellum, and all these are related, especially with the fine motor tasks. Okay, so if you remember your n h b, which I don't remember too much, very calm myself, but, uh, the cerebellum is, uh, very well placed her toe work with the the fine motor tasks on do If this person could do most things by himself, the gross motor tasks. So bring the shower dress independently. But if he can't really do a his buttons was a Publix trousers. Then something suggests that it could be a cerebella problem. Okay, Now you could, in the other ways that you actually put they see you guys. But what were the ways instead of just a motor vehicle accident? Could somebody damage the cerebellum? Always in this case, it's why obvious? That is just a concussion. He's just being jacked backwards, and the cerebellum is hit the back of his head. But, um what? What else Might somebody, um, have this? Yeah, perfect or stroke is a very common one. Okay, um, and head trauma Potentially, yes. So just any sort of trauma that causes this sort of genetic back and forth can cause that as well, but also a tumor. Okay. And you learn about about this a little bit more if you when you go to clinical school. But there's a difference between central cerebella tumors. There's also lateral cerebella tumors, and you can sort of see which is which. Based on the set of the signs and symptoms that person presents with. But here's a quick way to remember what that's off. Broad symptoms off a cerebella syndrome. The demonic here is Danish. Okay, DEA and I Shh. Okay. This is diet or kinesis. I don't know if anybody's heard of that here, but it's something that you remember quite well in in clinical school. But essentially, yeah, One of the things we ask the patients to do in, um, a neurology exam on it's coordination. Okay, So what we do is we ask a patient. You can do this with me right now is stick out your hand like this. Your the hand put it flat like this. Okay, then lift it, ton other way, and then keep flipping it like this. Okay. Didn't do it as fast as you can, Okay? And essentially, somebody with Sarah Ballads syndrome will get kind of get frustrated because they can't really do it very quickly. Okay. Important here is asking them to do quickly, doing it quickly. If they if they can, they can still do it. But just not very quickly. Okay. A taxi. Uh, as your difficulty in movement. The stagnates We already mentioned it was in the case, your intention, tremor, some of your sledge speech and also your hypotonia. So this is the way that we can remember is Danish. Okay, It's a look at case number three, so history. So this five year old boy had a neck obsessed three weeks ago. It was pretty with drainage and antibiotics. Now he presents with lower extremity weakness. So when we look at the examination, there's absent deep tendon reflexes. That just means your reflexes. So your biceps, for example, your knee reflexes. Um, in both of his lower extremities, his reflexes are diminished both of his arms. And if you look at the spinal tap, there's labetalol protein. Basically, no, what? Instead of looking at the exact cause, what do you think could be the type? Of course. So could it be a vascular cause? Could it be on and inflammatory cools? Could it be, uh, trauma related? What is the general cause? You think given the history they could potentially be? I intragenic Yeah, attention if you consider that this is actually an unusual presentation for this, but, um, this person had a neck abscess three weeks ago. So there is increased protein levels, which could be meningitis. But, hey, doesn't seem to let you know that he doesn't present with any photophobia next stiffness, etcetera. It's just they had a neck obsessed a couple weeks ago. And yet, but yes. So abscess. It could be an infection related on. But I can tell you, this is for infection related. Okay, but not meningitis. Birth. Say so. This is a special syndrome. We call Gillian Bar a syndrome. Okay, now, this is a specific type off Moten. Ah, disease. Okay, that's caused by what we call up or it's caused by usually campylobacter, Junie. Okay, so usually somebody has gastro enteritis. Okay? All possibly even are spiritually. Conditions of this boy had a neck abscess cool weeks ago. That's a bit abnormal. Okay. So usually would expect them to have, um, gastroenteritis. That's using Mr Commerce Communist. So presentation. But what's unique about this is that it's a sending. Okay, So what happens is this person will have weakness in both of their limbs, but it starts all the way in the bottom, so distally at their feet, okay. And slowly it rises. Okay, get loss of reflexes. And you also might get some prayerful sensation loss. So I have put up on the screen why this happens. It's because of molecular mimicry. So the campylobacter additions look similar to the nerve cell antigens. And so your B cells are going to fight anything that looks similar. So you're campylobacter. End up your can. Campylobacter specific antibodies. End of damaging your nerve cells. Okay, this isn't permanent. It you, But it does. Can take a while. So usually how this happens is somebody gets gastroenteritis there. Color form after a couple weeks. Then they start getting symptoms like this where they have symmetrical weakness, loss of reflexes on do have some sensation loss as well on Ben eventually start to recover. But it might take weeks, months, or even possibly years so it can read us. Take a while. Some of the investigations you might do so clinically, you can sort of get an idea already, but we could also do some nerve conduction studies on like this case already did. You can also do a lumbar puncture, which you should see an increased protein. Eso somebody asked wise They're raised protein. This yes, F As far as I'm aware, I think that's because the damage to the nerve cells is causing protein to be released. I think that's the case. But do you check that? I think that's the reason why. Okay, but something that's a little bit more different is Mel Officious syndrome, which is actually just a variant of Gullian Barre syndrome. Now the reason why it's it's actually it's caused by the same stuff. It's caused by campylobacter. Um, but that's the The presenting symptoms are only difference in terms of most of it the same. But instead you also have descending instead of going upwards. So from your um, your feet up words usually affects your eyes first. Okay, that's why you get something called Film of Plegia. Okay, so, essentially, your eyes will not really move the way that they should do. Make yourself example. This picture here, you can see that this this size not really doing very well. Okay, it's a military. She's syndrome is just a variant of green bar A. It's more, much more rather than green Bari. But if you see something like a families and descending weakness on both limbs, starting with the eyes. Then you could suggest that perhaps it could be more efficient syndrome, especially if they've had until nous particularly respected tree or GI illness in the last couple weeks. Okay, it's like a case full. So 59 year old man three months ago had acute onset of neurological symptoms. He developed generalized hypokinesia masked faces. Fascia is tremors and dysmetria. Initially, a short term memory functions becomes really compromised. Uh, reports rapidly progressive tax here. Speech abnormalities. Diplopia. He's lived in Germany for 20 years, is an enlisted spouse. I don't actually know what that means, but, uh, no prior history off urologic disease or early to mention there in her family, he has three adult Children who are all healthy and living states. When you look at her examination, she's always wanted to person place time, meaning that turkey cognition is generally okay. She knows where she is, knows who this person is usually if you wanted. If you want to know how we might test that, that's usually when we ask, Do you know where you are? At the moment, the answer should be probably in a clinic or a hospital. Uh, you know what day it is, What day of the week it is. What, uh, what's the date of the moment? And then also, what job do I do? Okay, this person's also able recall is able to recall three items immediately, but this diminished. So the registration okay, off these three items is intact, but her memory isn't very good, because after 20 minutes, you forgot. Okay, She's only able to follow two step commands. How? Language is fluid, but phrase length is also diminished. There's no protein adrift, pronator drift. And there's also hyper reflexing. Anybody has any ideas? Or perhaps in the investigations, we might do anything we might looking to so dysmetria could indicate, uh, cerebellar lesion. But yes, you're right. That a cerebral lesion wouldn't really have, um, memory issues, right? Yeah. We could investigate with a CT or MRI toe. Unless a for tumor. That's correct. Yeah, and could be a dopamine issue. You're correct in that in sense, that people, for example, and I'll talk about it later, actually, um, but even with Parkinson's can also depend. Develop dementia. Um, but I can tell you that this isn't necessarily Parkinson's, and it's also This man is quite young for Parkinson's. I know he's almost 60 but that's still relatively young before with Parkinson's. Um, but something what would want to do is ah, CT scan. Oh, and MRI. So, first of all, let me just show you a video. It's not the same person, by the way, but this is just another case of the if the same disease. But if we have a look at this video, so I won't play the sound because this presence of the answer But I can tell you that this person at this point Dr Collapse Okay, let's see if he see you again. No fever. So hopefully you can salt. So see something before and after he collapse. Okay. Look at what this person is doing. Okay? Now, this person could be nervous, but he's not. I can before we tell you that, but he's probably not nervous. So what can you see? That's a bit abnormal. Two things. It could be a bit strange. So attention was a muscle extension, perhaps, um, problems with balance. Yeah, Um, this person could have a little bit of promises. Balance. Yeah. Um, anything else you see is that reaction normal to somebody clapping or somebody having a loud noise? Is that normal? So know that this this off reaction that this person had to a loud noise in a sudden loud noise, by the way, this person was told before hand when he was going to when the doctor was going to collapse. So don't worry. But this reaction is severely abnormal. And I'm sure if any of you even the most scared of you if somebody clap next to you, you would not really have this reaction. Okay? Similarly, you can hope for the see some sort of movement of the muscles. Okay? He's moving his muscles, but he's not really trying to. He's 12 trying to keep himself still, but his muscles keep moving to say we know what that is. Tremor Maybe. Uh huh became easier. Kind off. You're on the right lines. Okay. We'll talk about what? This is in a second. But if we look now at a CT scan, is anything strange you see here? Don't worry, Door, Um just have a guess on what you think So and normal basically just looks similar to that's basically but there is a couple of things that aren't aren't koning eso koning is the movement of the stems off downwards. Okay, That's usually because of the high pressure or low pressure, high pressure in the brain or a low pressure in the spinal cord that causes Koning making basically cause. Eventually get there right side. It's more to the left. Just look like it a little bit, Yeah, but that might just be because of the slice of the CT. So the base, this part here. So no, it doesn't. So any ideas on what this could be looking like? If you could see that this seems to be quite a low, I can tell you that brain shouldn't really look this small. So it's not blood. It's just the CSF around. Yes, and there's increased it Could be. I wouldn't say there's any increased pressure that just seems to be much more space in between the brain and, um, side hydrocarbon. It's perhaps also looking at the brain itself. You could suggest that it could be a little bit of atrophy. Okay, so you see these in what types of conditions? Brain atrophy? Yes. So Alzheimer's degenerative conditions? Yeah, perfect. Now, if I point out there's something a bit odd in this area. Can anybody see it now? Oh, actually, you can't see it. Sorry that you can see about that. This sort of area. Therefore, you can see my mouth. Good. Perfect. The slightly white A patch is okay. That's not normal. You shouldn't see that. Okay, um, if you've seen brain size before, they should be, uh, least this part of the brain should be generally quite monochromatic. Okay, Obviously, when you go down more so in the middle of the brain than you would be able to see some white matter gray matter difference. But you should not see spots like this. Okay, Now let's try and piece everything together. So what have we seen? So this is a 59 year old man. Acute onset of neurologic symptoms, meaning that this hasn't happened for years. It has happened quite quickly either in months. Actually, I says months here, but it can also happen in a couple weeks. This person seems to have ah problems with, uh, memory. So dementia like symptoms. But he also has motor like symptoms. Somebody pointed out earlier. But it could be something like a dopamine problem like dementia. I can say that it's not because this is quite an acute onset. You shouldn't really see that Should see something like that. Um, in something like Parkinson's, it's quite a gradual progression. So what do you think could be happening here? Well, rather not necessarily exactly what's happening. Ah, also what? It could be the cause, General. Course. Perfect. Good prion disease doesn't even know exactly what prime disease this is. It's a very specific prior disease. Um, And if you, uh, don't remember when it was eating meat from, like, 1980 till something else. Um perfect. Good goods. Crisfield Jakob Disease. Great. So this isn't thankfully, this isn't super common. Okay, there's a couple of different types of CJD. Um, one of the MS Sporadic meaning that it just happens, but also due to an effective cause. Um, but this is principal Jacob disease that are fighting symptoms are dementia. And my Oh, clonus. Okay, so this person earlier, we'll talk about that in a second. What? He said that, But if you see here, he's jerking his muscles. That's my Oh, clonus. Okay. That's not normal. This person should be so off, moving around. Okay, that much. Okay. Some of the common symptoms you might see or ataxia behavior change changes. And also hyper hyper a clip. I don't have to say this very well, but basically this word here, the bottom just means that what this bus and reacted to. So if you clamp will have a loud noise, this person reacts quite kind of violently. So he starts jacking about quite a lot. So it's, uh, a strong reaction to loud noises. Basically what This is Okay, So if you see something with dementia and my clonus, you could think about that. You should be thinking about a degenerative disorder. So reasonable, Like like people have said already before, like, uh, Parkinson's. But also something like critical Jacobs issued. Also be something that you should keep in the back of your mind, Although it's not very common. Okay, let's have a look. Taste of the five. So 74 year old man, it's experiencing difficulties with his regular tax around the house because he was experienced shaky. He noticed I had a lot of his movements, were much slower and difficult to get going. His son suggested that he sees doctor after witnessing him have difficulty entering the door was home. He was frozen and any of the guys to step in price of the symptoms. The patient recalls losing his sense of smell intermittently and noticed his handwriting because it's smaller but dismissed the part of getting old. Well, what are some other things here that point you one way or the other? Yeah, kids. So Parkinson's is is your main concern here. And if you saw this person, um, probably definitely think that this probably Parkinson's, especially with his shaking. Okay, now does anybody know? Is this something related to the Parkinson's? So his son suggested I see a doctor after witnessing have difficulty entering the front door of his home. He was frozen and needed guidance to step in. Is that part of the Parkinson's, or is that something different? Yes, it is. Has difficulty initiating movements, so usually it's for a doorway, Okay, but it can even happen. Somebody just walking past you. Okay, on D if we want to sort of help people, we don't really have a drug to help them with that. Instead, we give them advice on what they could do and it works. Different things work for different people. So what? What we might say is them saying, Okay, I'm gonna move my right foot now. Left foot Now, right foot Now. Left foot. Now Or they might have the special sort of laser thing in front of them that shows them where they need to stand. Okay, so it's difficulty initiating the movement. Get we'll write this part here. His handwriting is becoming smaller. Was that just getting old? It could be or it's 100 could be getting a bit better. Potentially, yes, More than movements. Does anyone know what it's cold? Yeah, Yes. So specifically, it's called micrographia. Okay, so you might ask a patient in clinic to write something down, and what you'll see is if you compare it to previous times of four. But you're not just see it on the piece of paper that their handwriting is kind of Okay. Now let's look at the next part of the history, which I don't definitely don't want me to see, because this definitely gives away. But breasting trauma, which is a pill rolling tremor, okay called were rigidity. So if you get somebody's arm where you'll do is you'll feel it or move a little bit. But then get stock, move and get stuck again. Okay. And also bradykinesia movement dysmetria mild Montri difficulty with rapid the alternating room. And, like we said before doing that is really difficult for so somebody already said it earlier. But the typical Parkinson's triad is tremor rigidity. Bradykinesia. Hey, you can really remember that that we could number trap doesn't really matter. But I remember tremor right rigidity and break Pretty kind, either. That's the most common things that a person like experience does anybody know what other symptoms personally Parkinson disease might also experience? Not necessarily. Motor symptoms. Have something else. What were the symptoms? Could somebody with Parkinson's disease How? Yeah, so memory. Somebody with policies can house pocket's disease dementia later. Yeah, you have somebody with promises, definitely have structuring gate and every seeing what the morning around, especially the hospital that have issue from gait any other ah signs or symptoms that they have that all relates to Parkinson's but aren't related to motor symptoms. Yes, so there could be a possibility or loss of smell anything else, So Parkinson's disease is a loss of dopamine. So what else do you think could happen? Good. So these people tend to have no have psychiatric problems as well. Like a like depression, anxiety, things like that. Okay. So, psychiatric since the quite common it's nothing that's also can be quite seen is, uh will be cause off describable. So waking, waking up in the middle of the night or not? Not No, actually, waking up, but screaming. Okay, so that's REM. Sleep upstairs, but it's okay. So in the REM sleep, most people have are inhibited in that movement. So even if you're dreaming, you shouldn't be running. If you're running in your dreams, you wouldn't be running in real life. Or if you're shouting for some reason, then you shouldn't be shutting in real life for them that in a vision is gone. Okay, so even though they're asleep, they'll start acting up bad dreams. Okay, so they might start screaming okay for no real reason. Okay? They might start getting up and moving there. Might jerk about. They might hit, you know, their partner on their bed. Okay, so these are some of the other reasons as well for some of the other symptoms. You might see you Well. Something that's also important to note is symmetrical versus asymmetrical tremor. Now, if there's an asymmetrical tremor, so if you start pill rolling on one side, we Do you consider that idiopathic? Okay, but if you have symmetrical, um, you have symmetrical sort of symptoms and tremor, then we think that might be drug induced. Okay, you can anybody guess what drugs might induce Parkinson's? Also, Then it's parkinsonian is, um, concerning, Um, isn't that a Carolyn? I've never I'm not really Hardly. So this is This is quite need to me. Um, um that might be the case. I'm not sure. Uh oh, yeah. Okay. You guys know more than me then in that case, but yes. So, uh, what I was thinking was mostly dopamine antagonised. So, for example, your anti psychotics, uh, to be on this list of pocket civilian is, um does anybody know what Lewy body dementia is? Louie bodies mention Well, everybody disease. So hopefully you might know that Lewy bodies are basically just yourself. Camping's up inside of cells. Okay. I think it's the type of protein, but Lewy body dementia and Parkinson's disease is basically the same thing. Okay, The difference is the onset of symptoms. So in pockets and disease, you'll have motor symptoms followed by dementia symptoms where they might not even get the Ventura symptoms over a year after the onset of the motor symptoms. Okay, so you'll have your motor symptoms heart shuffling, for example. And then at least a year or later, they'll get better mention symptoms. Lewy body disease on the other. Hands on your hand will have your motor symptoms and rice either at the same time. So concurrently or within a year off the dementia symptoms. So you might actually get the intervention symptoms first. Okay? And then developed your motor symptoms. Okay, That's just the difference between the two. Welcome to disease. I'm sure you guys know what the first line treatment is. Leave a dope. Oh, that's just giving them dopamine. Um, and usually we give it if motor symptoms are affecting their life. Well, we also might give them is Zatulin, which is a now B inhibitor and also ropinirole, which is a dopamine agonist. Does anybody know what the biggest source side effective things like ropinirole Any dopamine agonist is that's going to show a very careful because I believe in the past they used to give it out quite a lot and that cause a lot of problems were because constricted, I atropic maybe I'm thinking something a little bit different. Dopamine agonists. So basically no hallucinations, but, uh, this inhibition okay, so these people basically end up gambling a lot. Gambling problem is a quite a big one. Okay, um, maybe have sexual disinhibition as well. So they might do something where they might keep wanting to have sex, for example, or they might, um, be quite disinhibited instead of saying the things that they shouldn't really be say, Okay, that's the most common thing with dopamine agonists. Which is why we need to be careful and giving it. And we need to monitor that sort of psychological health and make sure that if there's any signs of, for example, gambling addiction, we need to be able to put them plan intervention in place to make sure or change the medication entirely to make sure they don't, you know, and the big something that we will get it later. Okay. No, I don't have a case for this one, but we'll talk about multiple sclerosis. So the clinical features of multiple sclerosis are generally spastic weakness, optic neuritis and lethargy. Hopefully, you know a little bit about multiple sclerosis already, but it's basically that's the degeneration off degeneration. But they're the autoimmune attack off the mind and sheaths. So looking at it like this, Okay, there's a couple of different types of multiple sclerosis that you might may well be aware of. Okay. Is four of them? The most? Common is what we call relapsing remitting. Okay, so basically, people get a few flare, then they're okay for world. Then they get acute flare. That makes a little bit worse. So about that baseline goes a little bit worse. Okay? And again and again. Okay, then. You also have these two, which is primary, progressive and secondary progressive. So primary progressive is just as time goes on, you just get worse. You don't really have the sort of flareups. You just get worse. A report secondary progressive is basically you do have these flare ups initially and eventually over time, you'll start off being like a bit like the primary progressive. You just get worse over time. And progressive relapsing is basically just the worst version of relapsing remitting. Okay, is that instead of coming back to normal? Okay, well, going back. Oh, reducing your disability again after the flare. Your disability is kind of kept lingering afterwards. Does it? The treatment? Just the recruit. If you have an acute relapse, so somebody comes into a any will give them methylprednisolone. Okay, which is a steroid. And in terms of relapsing remitting cases, we might get some immunity modulators like I enough. Thank you. Okay, so on. Let's see if I can acquire a lot of slights. Well, I'll jump past this one, but let's have a look at some acute combined degeneration of the court, which you may have made nose hold off. Okay, Now, this is caused by B 12 deficiency, and hopefully you can see we went to him about you in a second, actually, but it's caused by B 12 deficiency. Some of the symptoms you might get are some proprioception and vibration sense loss. Okay, you'll get basically upper motor neuron symptoms. So weakness, hyper effects you had with menses going positive. And the typical typical triad that you get is but been sees positive risk any jacks absent ankle drugs. Okay, now, looking at the thing on the left, which actually just gives you the answer. But why? If somebody has been 12 deficiency on for a late efficiency at the same time, why should we definitely not give them Foley first? Why should we give them B 12 1st? Why should I give somebody folate? Why should I check somebody's b 12 before I even give them money? Yes, very. If I stayed my husband B 12 deficiency, so hopefully you can see on the left that folate. Okay, it we the phone, like the B 12 is used in. So returning the foley back to TETRAHYDROFOLATE. Okay, so if we give folate to somebody who has a B 12 deficiency, okay, I'll just make it worse, Okay? We don't want to do that. So we must give b 12 1st before folate. Okay, if they have a combined B 12 and folate deficiency, okay. Oh, yeah. So I'll explain this again. So, basically, if you can see here, the folate, okay? And fully has to be, is when you take it. When you get given folic acid, you take it. Inactivity. Okay. So basically it will get converted to die Hydrophor late, then tetrahydrofolate nothing tight. 100 for weight, and then methyl tetrahydrofolate or folate. Okay, But in order for it to sort of release this methyl group, okay? And turn back to tetrahydrofolate. Okay, because this these two are in combined sort of these to work in conjunction with homocystine Messiah. And okay, that if you saw, want to turn this back into touch high to folate, the B 12 okay. Needs to be converted to methyl B 12. Okay, this metal group goes to here, okay? And then this metal group of entry goes to my client. Okay, So I believe this is part of your crab cycle. I don't actually remember. Unfortunately, sorry about that. But I think this is for your whole cup cycle. Um, but essentially, this is really important, Okay, that if you give folate and then all of a sudden you don't have any b 12 to carry it, okay? Or you have very little B 12 left. It's all just gonna get turn into methyl B 12. Okay? Was just precipitate even mawr B 12 deficiency, so I don't feel that makes sense. Okay? Okay. right? Yeah. Wonderful. Get okay. Good. Leslie will just finish off with one last case. Ah, we won't talk about it too much, but we'll just leave a Z. But let's have a look at X ray. Okay? What do you see? That's a bit strange. I know you guys might have not seen too many X rays, but what better time to start them now? Perfect. Good. A pass it on the left, particularly this side here. Okay. How do I had a look at the X ray report on? It's basically a pass. It e in the left lingula. Okay. By the way, if you want to find some cases that you're quite keen on, uh, this placement picks. This is where it got some of my cases, so just just have been trusted. But basically, this is a small cell. Lung cancer doesn't really know any motor conditions that might be related to small cell lung cancer. No worries if north. So a common motor condition is Lambert eaten syndrome. Okay, now, llama teaching syndrome and myasthenia gravis, which is you've probably something that you've heard off already are quite similar to each other. And actually for you guys will go to the PATHOPHYSIOLOGY. First one is for more helpful for you guys, but Lambie eaten is basically antibodies against the voltage gated. I on time calcium channels on the synapse lost my CEO of nervous. Hopefully, you already know that it's antibodies against the outside as as a taco. The receptors on the neuromuscular junction. Okay. And so you'll get slightly different. They have similar sort of symptoms, so they get sort of muscle weakness. Okay, But what you'll see here is that one of the biggest thing that's different is that in Lamictal eaten syndrome, the strength actually of proves as you exercise. Okay, so if you know my senior gravis that if you get up, you exercise, you get weaker as you saw. Keep walking, for example. But somebody would limit eat and syndrome. Okay, that strength actually improves. Okay, Now you can probably see that The reason why is because my senior gravis is ah, um, antibodies against the Astelin choline receptors themselves. Okay, but the antibody is against this calcium voltages vault equated calcium channel. So over time you keeps or firing this there might be some other calcium child's that aren't blocked. Okay. And eventually, it'll lead to actual movement. Okay, given that. Does anybody can be guess what the treatments could be for either of these. Yeah, Profit. Good. So I see your gravis. We just do not stock cholinesterase inhibitor. Okay, get on the Bluhm. But Eaton's have been more complicated, but for my scene gravis, we usually is part of the stick. Me, which is just an accident. Cholinesterase inhibitor enlargement Eat, um, is actually a little bit different. We'd actually just treat the small cell lung cancer, because if that's the cause, you just want to get rid of it, obviously. Okay. But we also have on feet of my concept, but this drug here, okay, and essentially even looking looking it up afterwards. But basically, I believe it works by just, um, blocking the potassium channels. So basically, the the charge inside of the outsiders sort of changed. Because of that, it makes it easier for for smaller amounts of calcium because, uh, a release of the neurotransmitter already. That's why I think Okay. Wonderful. So that was your sort of blitz tour off everything. Um, hopefully if you have any questions for if we drop them in the chat. Um, if you could give some feedback, that would be great for me. And also in terms of the Precose electricity Aires a zar whole. Please do give some feedback. But if you do have any questions, feel free to put him on the track. But otherwise hope you guys enjoyed it. Looked a lot on. Uh, yeah. Haven't enjoyable rest of your evening.