Computer generated transcript

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

Will be taking us through upper and lower limb examination and the recording starts, so go for a color. Whenever you're ready, thanks, so yeah I said I'll be going through the upper and lower limit examination um So that's one of the neuro uh stations that you can get in your c. P. A. So what I'll be covering is. I'll start over by what you actually do in the limb examination. The things that you have to cover then, I'll be looking at some of the pathological findings upon examination. Um. Then we'll go through some mri's some disc herniation because at the end of your station you can be asked there some questions you can be showing some scans, so it's good to have a look at what some mri's and CT scans like look like and then I'll have a few practice questions that you guys can go through as well, So for the limb examinations, there's five things uh there's four things that you need to have a look at, so the first thing is tone. Then you also need to assess the power the reflexes and sensation and all of these um give you a good clue as to what pathologies a patient might have and it's really really important to go through these in order to be able to pick up on anything that the patient might have so. Um as always, you'll be asked to introduce yourself to the patient's This is really important that you go over it and you know really well. Um so always start off with wearing the right PPE and washing hands. You'll be advised if you still need to wear a mask and have to wear gloves we did during hours, but that was a couple of years ago um So they'll advise you on that, but definitely washing hands. Then you want to introduce yourself, so say who you are and um your role, so for example, hi my name's callum, I'm a second year medical student. Um Then you want to check the patient details, so you want to go over their name and their date of birth and make sure that's the full name as well. You also wanna gain consent. So for this, you want to tell them so today, I'm just going to be examining your either your upper limbs or your lower limbs, so I just want to have a look at your arms, so involve me having a look feel and move them um. Is this okay with you and that's really important in order to get concerned. Um Then you should tell the patient that they need to be bare from the shoulders or they need to be wearing shorts so either one so you won't be expected to do both the upper and lower limb and one station. It'll be either or um and the bed should always be positioned to 45 degrees um And then finally it's really good for empathy, marks that you and check that the patient's comfortable and that they're not in any pain before you begin and if at any point they do experience any pain, just let you know um and then you'll stop so the first thing that you assess is toned, so your muscles are constantly in a state of partial contraction um even when you're resting and so this is referred to as tone, So in order to assess this. You wanna passively move the patient so this means that they have to be completely relaxed. You don't want them to be tense and you should take their full weight off their limb and be able to move it um. So throughout the exam, you always want to be comparing both sides, so arm to arm, left arm too left, right arm, right arm too left leg, um so right leg to the left leg, and that constantly let's you know if there's any pathology effects on one side or the other, and you can constantly see if there's any difference that shouldn't be there so in your arms. There's three areas that you need to assess toner, so one is the shoulder, so you want to move around in a big circular motion, um and when you're doing this, you want to stabilize the shoulder so you want to make sure that they're not moving anything and you're just moving their arm in a big circle like this um and that will assess the shoulder then he wants to move on to elbow, so this is flexion and extension, so again just support their arm here and then move their um their forearm forwards and backwards and just assess the tone and the elbow. Then you want to assess the wrist so you want to assess uh flexion and extension, so you want to move forwards and backwards and then pro nation and Super Nation so you want to rotate their wrists as well. Um If there is any increased tone, then we call this hypotonia and the joints will feel stiffer and harder to move. Likewise, if there's decreased tone will call this hypotonia and the joints will move much more freely against very less resistance. Um You'll only be able to tell if there is hypertonia hypotonia, really if you're comparing both sides, but also if you've clots a lot of patience and you've done this surprised as much as you can and then you start to get a good feel for what normal tone should feel like um but don't worry in your actual cpa, that I don't think they'll give you any pathologies. Um They didn't for are you, so I really don't think they will or lower limb. Um Then you need to assess for three other areas, so the first one is the hip, so this is done by the leg roll, so you just want to move the leg just by rolling on top of the thigh and um and uh sorry a top above and below the knee you should see that the foot rolls quite freely. Um Just after it. If there's increased tone, then the foot will be very rigid um and the foot will just roll um yeah as as rigid as it is. There's decreased tone. Then you'll see that the foot flops quite a bit and um used much more freely. Then you want to assess with the tone in the knee so to do this, you want to pull the knee up briskly, um So you want to you make sure that it's nice and loose, then pull up quite briskly, and he'll should remain in contact with the bed the entire time. There's increased tone, then you'll see that he'll will come straight off the bed. Then you want to assess for the tone and the ankle so to do this. You want to stabilize the lower leg make sure again that they're allowing you to take full control of their body weight off their leg weight and you want to put your hand on the bottom of the fur and move it in a circular motion. Um You'll see that there's a greater range of this hypotonia and decreased range of this hypertonia. And then finally you want to assess for ankle clone, so do this right after you've assessed for the ankle, so as you're moving in the circle, then stop suddenly and push it upwards. Um If there's a clonus, then you'll see that the foot will sort of flap against your hand um up and down and that's a uh that shouldn't be there that's a sign of pathology, which we'll just go over. So as I said hypotonia is where there's a lot less resistance, so this is caused by lower motor neuron lesion's. So this is because there's a lot of tension for the lower motor neurons, which is causing the muscles to be a lot more relaxed. Um The opposite of this is hypertonia, which is caused by upper motor neuron lesions, So this is where because the upper motor on upper upper motor neurons have a inhibitory effect on the lower motor neurons, so when there's a lesion to the upper motor neurons, there'll be a loss of this effect and that means that the lower motor neurons um will be a lot more stiffer, This this is hypertonia and then finally we came across the am, pickle clones um in the last slide and this is also caused by an upper motor neuron lesion, so a few questions, so if you want to put your answers in the chat, um um I'll have a look otherwise, we'll just go over in a few seconds but what type of lesion will cause cause a high degree of flexibility in the elbows. I just said just put your answers in the shop and then go over um So you've got one for uppermost you're on, does anyone agree or disagree, go over it now, it's a low most of your lesion, so remember we said that um the oh sorry um mr uh yeah lower motor neuron lesion and then what would cause a clonus to be present, any guesses, yeah and uppermost in your lesion, it's so nice. Uh Then you want to assess for power, so we assess power against the mrc power scale, so it's got a range of scores zero being no contraction, all the work to five, which is the normal power which any of us should have um and there's different stages along the way. Um So again, there shouldn't be any pathologies in your actual exam but is really good to know about this mrc power scale. So this is where you then start to ask to move the patient against some resistance that you'll be providing um And here is even more important stabilize the joints so that you make sure that the patient isn't using any other muscles in order to try and mask uh the loss of muscle um power um And again it's really important to compare both sides. So throughout the exam, you want to be going from one arm to the other one leg to the other, so in the upper limb. Um you wanna test shoulder abduction and adduction together, so the way you do this is you ask the patient to put their arms out like this like a chicken and then do one arm at the time to put your hand on their shoulder and say don't let me push it down and then go across the other side, don't want me to push it down and then shoulder adduction keep your arms out and now push down against me. It's also really important to know which nerves you're assessing in the nerve roots because sometimes they can ask you what you're assessing so for a shoulder abduction of the auxiliary nerve, which is c five for shoulder abduction is c six and c seven. You don't want to assess for elbow flexion and extension. So this is where you ask the patient to put their arms out like this like a boxer and again one on that time you want to stabilize their arm, so you want to put that hand just above the elbow and then ask them to pull me towards you and then push me away from you and again you want to make sure that they're only using their biceps and not the um their biceps and triceps to do this. You want to make sure that they're not moving their entire arm from the shoulder just from the elbow and for l reflection this is c five and c six and for elbow extension, this is c seven and finally you want to assess the wrist flexion and it's just wrist flexion as far as I'm concerned, so you want to ask them to make a fist with their palms so that they're not using the part of their finger strength as well and you want to make sure it's facing upwards and then you want to hold their wrist um and you want to ask to you don't let them push down against, Don't let me push you down so they want to be able to keep their wrist there and upright. Again, this is assessing the medium neb which is c six and c seven, um so the same for power in the lower limb. You want to be assessing across the hip and the knee and the ankle again, so for hip flexion, you want to ask them to keep their legs straight and then push up against you. You wanna put your hand on the other leg to make sure that they're not rotating the whole body, so you want to make sure that your your hand is above their knee and so that you can assess that is just the hip flexion and not from the lower leg as well, and this will be assessing for the L1 and L2 nerve roots the same on the other side for hip extension, so they want to keep their leg up and then you want to put your hand underneath with your hand on that other hip again and you want to ask to push down against me. This is the inferior gluten nerve, which is L5, s one, and s two then for knee flexion. You want to ask them to bend their knees um make sure that you're holding the back of the hamstrings for uh knee flexion to make sure that they're not trying to extend their hip to compensate um and then you want to ask them to kick out against your hand, so really should just be that you're holding the back of their hamstring and you're asking them to kick out against you. This will be the sciatic nerve which is L5 to s to and then you want to ask them to um push that um do the opposite for the extension, so you want to kick out against them and this you want to feel for the quadriceps because the quadriceps are the things that are used for um this move and this is for L2 to L4. Then you want to assess for dorsiflexion and plants infection, so dorsiflexion where you're moving up and plant reflections when you're moving it down, so the deep perineal nerve is L4 and L5 and that's for dorset flexion, so again you want to stabilize this just by putting your hand right above the ankle and you want to make sure that they're not moving the whole leg, so sometimes they'll see the patient moving the whole leg forwards and backwards, that's wrong, it's just at the ankle and that's ankle dorsiflexion um then plantar flexion, you want to put your hand underneath the foot and push into your hand and that's the tibial nerve which is s one and s two, So what authorities can we get in power well. Upper and lower motor neurons will um upper and lower motor neuron lesions will both present with weakness, but there are a little bit different so uppermost in urine lesions will typically have a parameter pattern of weakness, so that essentially means that the extensive is in your arms will be weaker than in flexes, so the triceps power will be weaker than your biceps um power and in the lower limits the opposite, so your flexes will be weaker than your expenses, lower motor neuron lesions, however, we'll just have a focal pattern of weakness, so what we mean by this is if one nerve is affected, then it will just affect that muscle group itself. It's got nothing to do with opposing muscle groups, so for example it's the deep perineal nerve, then I'll just be ankle dorsiflexion, which is affected, so you get a few more practice questions, so what nervous tested. Will you assess for shoulder abduction, again feel free to shout out or compete, answers in the chat, it's the auxiliary c five, no where should you place your hand. When assessing for his reflection, this is in order to stabilize the joint and feel for any contraction yep on the quadriceps and what movie is the test is tested when they assess for ankle dorsiflexion, yep, the deep caramel nerve and also just if you can just remember the nerve ridge as well L4 and L5. Because sometimes they can ask you these in the follow up questions, so then we move on to reflexes, so for this. Again you want to make sure that the patient is completely relaxed, Otherwise, you won't be able to elicit any of the reflexes um and you want to make sure that your um technique for this is really good. Otherwise, it can be very hard to elicit some of these reflexes reflexes, so when you're holding your tendon hammer, hold it right at the end, and you just want to use um gravity to produce the school in this way. I don't have any extra power, It's just not needed um just good technique will help this. Um You can also use the reinforcement maneuver or the Jendrisek technique, which is essentially where you ask the patient to clench their jaw as you're hitting the tendon, and this can help make any reflexes that they do a bit more obvious so in the arms. Um There's three reflexes that you need to do the first one is the bicep reflex, this is c five and c six um So what you want to do is you want to move the patient's arm across their body just as you can see in the picture, um And you want to locate the biceps tendon, so what you can do is you can ask them to tense their biceps. Um You'll be able to feel the tendon place you from across it and then again make sure that they're completely relaxed. Otherwise, you're gonna be able to observe the reflex. Then with the tendon hammer, you want to be hitting your thumb and you should just feel the arm move up is that c five and c six for the biceps. Then on the other side, you want to do the triceps, which is c seven and c eight. So the easiest way to do this is to hold the patient's arm out by the side and make sure that they're very floppy. Then you want to fill in the back of the elbow and you should be able to feel the tendon, the triceps tendon, and just tap it with the tendon hammer, and you'll be able to see that their arm will swing out slightly, and again this is c seven and c eight and then in the upper limb. The last one is the supinator, which is the c six, so you want to locate the brachioradialis tendon, which will just be on the side of the forearm, so just below the thumb, you'll be able to see it. You want to place two fingers over this um and want to sort of wrap your fingers around it and then tap with the tendon hammer and you'll be able to see the contraction. You'll be able to feel a lot better, then you'll be able to see it, but you still sometimes can see that the wrist movement, so the easiest way to remember the nerve roots for the reflexes is L1 L2, so L2 L4 kick the door L5, l, c five, c six, pick up six that's your biceps, see 78 keep them straight, which is your triceps so um as I said, l 22 L4 is kicking the door, so that's for the lower limps that's for the knee, which is the patella reflex. So I want to ask the patient sit at the end of the bed and the legs should dangle freely, then you want to locate the patella tendon so this is just below the knee and you'll be able to feel it. Um If you just rub gently and then you just want to tap on this tendon and you'll be able to see that their legs legs kick out. Um Then you want to do the achilles reflex as well, which is s one and s two. So. With the patient's sitting on the bed, you want to make sure that the knees at a right angle, so you want to make sure that they bend their leg at a right angle and then slowly drop it out to the side, and then you want to straighten the foot by putting your hand on the bottom of the foot straighten out the achilles tendon, and then you just want to tap it gently. You'll see that when this is hit that the sole of the foot will just push down into your hand um and this is plantar flexion and that's the achilles reflex, so I'll just say the rhyme again because quite good, so s one s two buckle my shoe that's the achilles L2 L4 kick the door, so that's your patella c five c six, pick up six, that's the biceps reflex. See 78 keep them straight so that's the triceps and then just remember that the break of radio sec six as well, so what can happen with reflexes where you can get hyper reflexive or areflexia, So this is where you can't elicit any of the reflexes or if you can they're really weak. So this is caused by lower motor neuron lesion, and this is because in the reflex arc you have lower motor neurons, so if anything happens to these then you'll lose that arc and then you won't get as good reflex. Alternatively, you can get hyper reflex here, so and this is caused by upper motor neuron lesions. So normally you have the upper motor neurons which have in inhibitory signals, which um sort of stopped the reflexes from being listed as much so when you have a loss of these from upper motor neuron lesions and you'll see really exaggerated reflex is so which tendon do you tap when I listen eight eliciting the supinator reflex, you're going to feel free to shout out and put it into the chair, So supinator reflexes also the breaker radial iss, If that helps um which nerve roots are a success. When you elicit the patella reflex, you can remember the rhyme yep, l, t two, L4 uh and then what lesion would cause. More exaggerated reflex is yeah up the most in your lesions, so then finally you also need to assess the sensation so for your by assessing sensation, you can assess the different dermatome is and then you can also see if any nerve roots have been affected and the way that your assess for sensation is using cotton wool, so the first thing that you want to do is you want to show them what normal sensation is like so using the sternum. You just want to pause on their share make sure you get consent before doing this, ask them to close their eyes and with custom, we'll just touch them on stand and then make sure that they know what it feels like so when you're assessing the derm tones on their limbs. They also they know what it should feel like so in the arms. There's six different places that you need to assess and these are c 52, t two, so see fives just here on the upper aspects of their arm. Um c six is the forearm or the thumb, so I always go for the thumb. because that's really easy to remember, then the middle finger is c seven and see eight is a little finger, so it's the thumb, the middle finger, and the little finger um and then t ones the medial aspect of the forearm, but it's more towards the elbow um so further up here and then t twos um towards the medial aspect of the upper arm. So just below the elbow, it's also really important to remember which nerve reached your assessment because in the exam if you're assessing sensation, they usually ask you to mention which nerve roots your assessing, so just remember the slide and keep going around can c five and c six, c seven, c eight, t one here at the elbow and t to just below the armpit. Again, sensation, it's a little bit harder to remember which nerve roots in the lower limb, but they still sort of follow pattern, so L2 is on the lateral aspect of the thigh um so just towards the top, then l threes on the opposite side and the medial aspect um more towards the knee, then L4 is all the, with the middle aspects of the leg and but do it at the big toe um L5 is the middle toe and s one is the little toe, so like we assess the thumb, the middle finger, and the little finger from just the big toe, the middle toe, and the little toe, that's an easy way to remember and then s two is the back of the upper leg and thigh. Again, you want to make sure that you're going from one leg to the other and seeing if they can um see any difference in sensation between the two sides and it's also make sure that their eyes are closed so that you can make sure that you're assessing just sensation and they're not just seeing you tap their legs with the customer. Um So again, this just covers all the different and um summer regions, but we went over that already, so whatever is assess when he touched the lateral aspect of the forum unleashed them. It's t six uh where do you touch to assess the s two nerve root yep, it's the back of the upper leg or thigh um and which neighbor is assessed when he touched the hallux or the big toe, it's our fault so we'll just go over the different types, So I've mentioned a lot about upper and lower motor neuron lesions, but what actually are these so uppermost neuron lesions are under than um that would be affecting unsteady upper motor neurons, so entering the cNS and the spinal cord so stuff like strokes um m. S, um any brain or spinal injury, um cerebral palsy, a. L. S, and low most neurons um can be stuff like motor neuron disease, peripheral neuropathy, so stuff like diabetes, um polio and nerve root compressions. So all of these makeup below motor neuron lesion's um It's also really important because if um the examiner ask you um what sort of signs we deceive for some with multiple sclerosis. For example, you need to know that that's an upper most in urine lesion and so there, for example gonna get stuff like hyperreflexia, so this is a quick summary slide. We have gone through all of these, but I'll just go over again, so upper motor neuron reasons you won't see any articulations or wasting, but you will in lower motor neurons. Um In terms of tone, you'll see increased tone in uppermost in your a lesion's, but reduced in lower most neural lesion's, power will both be reduced, but remember we said there's parameter passing off weakness for up most neural lesion's. This is where the upper limb extensors are weaker and the lower limb flexes are weaker in lower motor neuron lesion's, is um focal muscle weakness um reflexes you'll see hyperreflexia and hyper reflexing, lower motor neuron lesions, and upper motor neuron lesions. Will also see babinski Science This is where you do that. Um If you get a stick and hit the bottom of their foot, you see that their toes curl upwards and low most in urine lesion's you can see pronator drift so that's where the arm sort sort of rotate in words, so now we're just going to have a look at some of the scans because as it has said at the end of fury station, they might show you a scan and you need to be able to interpret it so if you want to put your answers into the chat or again shout out. If you want to is this a ct or mRI some says mri, anyone else wants to join in do, we agree yeah it is an mRI, so how can you tell the difference between a ct and an mRI well. The bone appears darker on an mRI as you can see. Um The fluid also appears lighter on an mRI, so it's much hard to see the fluid and the ct scan, but here you can see that the fluid is much more brighter so you can see in the spinal cord, just on the side of it, you can see the csf and that's that really bright white liquid that and the mRI is also much more detailed, so that's the easiest way you can see um so here you can see the intervertebral discs you can see all of that. Um you can see the spinal cord, the csf, all the muscles, whereas the ct scan is much more block. It's much more basic, you'll only really see the major instructions on the bones so how do we read an mRI well. There's a quick trick, which is a two d um is for alignment, beers for bone, uh sees record and decipher discs. So for alignment, you want to look at any of the ligament injury um spondylolisthesis or spondylopathy, isIS um and look at the edges of the central canal, so he can see that there's um it's nice and smooth edges. There's no nothing bulging out uh bees for bone, so you want to look at the vertebral body, so here itself you can see that the vertebral bodies are fine. There's no breaks. There's no fractures or anything. Uh You also wanna you can't really see them too well, but you want to look at the pedicles and deposits in particular various um also the transverse processes and the spinal processes. Again, you can't always see them on on the scans, but if you can always have a look for them first, then you want to have a look at the cord so here you can see that the spine caused nice, has not been affected, It's nice and smooth on either side and it's going all the way down. Um It's really important to look for stuff like edema or any signs of compression um. And then finally want to look for the disk, so here we can see the intervertebral discs and there's no sign of herniation, so it's sort of with the alignment, it's nice and smooth, but you also want to make sure that these discs are in place. There's no bulging, so what pathology is shown here, so someone's asked can you not see the spinal cord on a ct scan, so you can't usually see the spinal cord on the ct scan. Um There are a lot more um there are newer ones where they have a lot more detail, but in standard ct scans, you won't always be able to see the spinal cord so that's a really big tail. Again, the mri, will have a lot more detail so again what pathology is shown here remember to go through a third day so look at the alignment bone, the cord, and then the discs any guesses you got seven spinal cord so that's a good guess um It does look like it's going down here, but it's actually because there's a disc herniation, so if you look at the alignment, we can see that it starts off nice and smooth and down here is, but here we can see that it's starting to impact. Um The bones themselves seem fine. There's no major fractures or anything, um but here we can see that the cord is starting to be um squashed, So I understand why you might have gone severed spinal cord, but it's actually cause of a disc herniation. This is quite a big clue here, so you can see that it's gone completely out of alignment. It's moved from in between the vertebral bodies and it's really um herniated onto the desk so anyone can guess where is the legion so which with the bodies are we looking at not sure question is just in terms of counting the physical bodies see 46 yeah I would agree with you so see six to c seven um So here we've got um c one, c two, c three, c four, c five, and then here's c six and c seven, so here's where the disc is herniated out. Um I I agree with you, it does look like the c four involved there, but um here's where the disc herniation actually is, so will this patient have upper or lower most in urine symptoms of a guess, one or the other, so it's actually a bit for trick questions, so they have both, so they have low most of your lesions in the upper limbs and they'll have uppermost neuron lesions in the lower limbs, So remember because the spinal cord on where the nerve roots are um this haley ation wall um cause low most of your um lesion because they've started to come out in the upper limp and because it's still part of the spinal cord, you'll have uppermost in urine lesions in the lower limp, so actually causes a disconnect when what the types of disc ernie ation, there's three types, so first is the prolapse, so in the middle, here we've got the nucleus pulposus and this begins to bulge um and the bit around it is called the annual is fibrosis, so we can see that it remains intact, but we can actually see this bit in the middle, started to bulge. You can sort of see there's some sort of cracking here, but this is um just a start and then that really prolapses, So this is the first bit where we can see it start to bulge and but it's remained intact as soon as it breaks through that we call this extrusion and this um it's broken through the ambulance fibrosis, um but again it's remained within the disc itself as soon as it starts to come out of the disc, we call the sequestration um and that's completely separate from the disc and can enter the spine of canal. So this is what we saw before on the previous slide so what can cause the disc herniation well. There's three types, so the first is degenerative. There's normal wear and tear, so throughout your life obviously will be doing a lot of exercise and stuff and this will cause the analyst fibrosis to weaken um and obviously, if this weakens as you can see here, then it makes this much easier to come through. Um Equally you can have an injury, so this is where you have a sudden strain, so if you're in a car crash or you're lifting something really heavy then um there's a lot of strain on your back and this can literally just cause the analyst. Fibrosis to break through. The nucleus pulposus can come out or you can have both, so you can have a bit of degeneration, so over time, obviously all weekend and then all it needs is for very little strains something even like a sneeze and the nucleus pulposus will come all the way through, so now we just can finish with some practice questions, so what muscles are tested when you assess for elbow flexure. There's three that I'm looking for any guesses, so yeah you've got the biceps that's one of them what are the other two yeah fantastic. We've got all through there, so the biceps breaky, the coracobrachialis, and the brachialis, so all of these makeup elbow flexion and that's what you'll be a testing for um when you assess with power, so can you state to positive signs that you might see if you did an upper limb examination on a patient as parkinson's disease, so first of all um what sort of diseases it is an upper or lower motor neuron lesion and then think about what positive signs you'll see so that by positive, we mean any additional signs compared to normal you've got to start a community. Um It's not actually on my slide, but these are the ones that might be able to see much more easily just cause we don't actually test for in the CPA, exam, but you'll see tremor at rest, so if you ask the patient to put their hands out, you'll see a tremor. You'll also see increased tone and rigidity when you're moving that up, limps because see hyperreflective because remember, there's an upper motor neurone lesion and then they'll also have a weakness yeah this side can easiest good answer, um but you won't be assessing that in the cpr, so state, three possible causes of a ankle clone. It so again think about is the upper or lower most in your lesion that will cause an ankle colonist and then three possible cause of that yep, strokes for on them. So you know, it's an optimist in your um lesion. Any other guesses what could cause it. M. S, yeah and cerebral palsy. There's multiple other up, most of your lesions, but these are a few that you might say, so here we've got another scan um does you that of revising you're a recently uh what do you think your diagnosis is and again what would be the associated symptoms if you to do a upper or lower motor neuron upper or lower limit examination. Any guesses yes, so someone's put an extra do extradural hemorrhage, does anyone agree or disagree, yeah it is an extradural hemorrhage um So what be the associated symptoms, so if a patient was to come in what sort of things would you see um if you have to do a upper or lower limp exam on them, so you can see that this is an extradural hemorrhage because um this is a classic lemon sign, So remember subdural will be more like a banana shape, whereas extradural is more of a lemon shape and this because this is arterial, which means that the pressure builds up much more quickly whereas subdural is like a banana because it's much more slower because of venus, so what did the associated symptoms with that. Um So some people put hyperreflexia. We can upper limb extensive is is hypertonia, yeah all of those are right, so you'll have left side of weakness, so um um you'll always get weakness. Remember this is on the right side, So um when you're looking at a ct scan off the head, it's always like you're looking up from the feet to the top of the head, so this is their right hand side and so because on the right side they'll get left side of weakness, also get hypertonia and hyperreflexia, so it's up most neuron lesions remember everything goes up except for power, so hypertonia and hyper reflexive to um and we'll go on to the final question, um but before we do that, can you please uh on the feedback form, just cause that really helps us out and then um I'll go back to the last question so you can scan the qr code that would be fantastic. Hopefully, you didn't see the answers, but which of the following signs would be seen in a patient with this mri, thanks and yeah the feedback form is just in the chap, so, whilst you're answering that if you could fill in the feedback form that would be fantastic, so would you get hypertonia in arms is where the limbs are and the arms would be a lot more rigid. Do you get hyper reflective, so you wouldn't be able to see any of the reflexes in the legs. Um Would you get muscle weakness in the arms to get circulations in the legs or hyporeflexia in the arms. Some said a. B. N. C. Any advances on that, so we'd get muscle weakness in the arms and hypo reflects here on the arms, so we wouldn't get hypertonia because remember in the arms, they come out around the cervical and nerve root levels so that would be low motor neurons and so we wouldn't get hypertonia. We'd get hypotonia in the arms, we again wouldn't get hyper reflexive in the legs because this would be an up motor neuron lesion for the legs, so we'd get hyper reflexive in the legs, we'll definitely get muscle weakness in the legs because both upper and lower motor neuron lesion's cause muscle weakness, we wouldn't get fasciculation on the legs because remember that's caused by lower motor neuron lesions, so this is um get that and hyper reflective in the arms we would get because this is a lower motor neuron lesion for the arms, so that's why we'd get hypo reflects it, so thank you very much for coming. Um As I said, please fill in the feedback form that's really helpful, really useful throw for us and if you've got any questions, then my email address is at the top, otherwise feel free to put them in the chat. Thank you very much yeah. Thank you so much cal, um I'm just going to stop recording here um.