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My name is Saba. I'm one of the, um, ay leads for mind the bleed. Um, so my camera isn't working at the minute. So, really sorry about that. Um, but hopefully you can all hear me properly. Um, so everyone just want to pop in the chat if you can hear me and then if so we can get started. Yeah, the audio is working. Ok, great, thanks. Um, ok. So, um, today I'm just gonna do um, a bit of a tutorial on um, neuro cases, um, that will hopefully help you for your upcoming Ay. Um, so the style of the session is, um, basically we've got three cases uh that we'll work through. Um, and for each case, um, if we get a volunteer to, um, come and, um, act as if they're the ones um, in the Osk station, um, taking a history and I'll be a pretend patient that you can take the history from. Um, and then whilst, um, that person is taking the history, everyone listening along, if you just sort of jot down your, um, ideas of what you would have maybe, um, how you would have maybe asked questions or what questions do you think you might have wanted to ask? Um, and also if you're listening to the person who's doing the history and you hear anything, um, that they say that you quite like, um, the way that they phrase it or anything like that, then, um, you can keep a note of that as well. Um, and hopefully that will help you when you're going on to do, um, your own cases. Um And then at the end, um, we'll just give a little bit of feedback um to the person who's done the case. Um And um, I'll then go through a few key sort of learning points um from that session, um, that you can take away with for if you ever um, do another case where you've got a similar presentation. Um And then at the end of the session, um, all of the cases that we've used today will be published on the mind the bleep page so that you can access them and practice them with your friends as well. Um, whenever you would like. Um. Ok, great. So, um, can anyone think of sort of what presentations you might get um in a neuro ay station if you could just pop some in the chat? Ok. Yeah, great. Um All good ones. Yeah. So, um, we've got limb weakness here, um which is definitely one, headache again. Yeah. Um, and palsy loss of consciousness, loss of balance, paraestesia. Yeah. All great things that you need to be thinking through. Um, what sort of questions you want to ask for those presentations. Um So this is the list that I've got, um, of, it probably covers the majority of presentations that you might want to prepare yourself for getting. Um, but there might be a few other niche ones in there, um, that I've missed out. Um, so main ones would be something like loss of consciousness, um, or a seizure. Um So if you're getting a seizure presentation, it might just be that the person has lost consciousness and you won't know that it's a seizure because it wasn't witnessed. And so you just want to keep that to function in your mind there. Um So then muscle weakness, um is another one. and again, something like stroke, um, which I think was popped in the chat might present with us a muscle weakness there. Um, headaches. Uh So you want to be sure that, you know, sort of how to differentiate between all the different types of headaches and what questions to ask there. Um, dizziness, which again can be sort of quite a vague one. So, um, dizziness can mean different things to different people. It might be that they just feel sort of a bit out of sorts and not quite themselves or it might literally be that the room is actually spinning around them and they're unable to sort of stand up and balance. Um, it's so very important that you try to differentiate what they mean by a dizziness if you've got that as a presentation. Um So back pain could also be one. So back pain in a neuro um sort of uh case would probably um also present with some other um sort of focal neurology. So some limb weakness or something like that, um They might have a tremor, um they might have sort of issues with sensation um or they might just um be generally confused. Um So we'll move straight on to our first case. Um So this case is focusing on a headache presentation. Um So does anyone want to volunteer to um sort of unmute and um take the history for this case? Um Can anyone, yeah, anyone at all? Would you like to do it? Yeah. Sure. Yeah. Ok, great. Um So um Sam Ween is your name? Yes. Yeah. Hi, Sam. Nice to meet you. Um So for this case. Um So absolutely no pressure at all. Um No. Um worries if you know, you feel like you're struggling or anything or you'd like a bit of help then just let us know. Um and um we can just go through this case. Um and um everyone listening, just think of um anything that you want might want to feedback on things that Sam is doing well during the case. Um And we can go through the feedback afterwards. Um So Samine, um if you just take a history from me. So, um, my name is Janice. I am a 67 year old woman who is coming to see you in the GP surgery because I've been suffering with headaches. Um, so I want you to take a six minute history. Um, and then afterwards I want you to discuss sort of appropriate investigations with me. Ok. Um, don't worry too much about timing. Um, I'll put a timer on but if you go over, um, that's, uh, don't worry about that, just keep going. Ok. Um, ok. Are you ready? Yeah. Yeah. Ok. All right. So, um, I just confirm name and date of birth first. So, um, Janice, could you please let me know what you've come in to see the GP about? Um, so I've come in today because I've just had these, um, really bad headaches for the past three days and they've just sort of gradually been, been getting worse and it's starting to, to get to the point where it's really worrying me about how bad it is. Mhm. Um, where exactly on your head is the headaches? Um, so that just on the right side of my head, um, just sort of just above my eye, um, is where I'm feeling it. I see. Um, and you said it started three days ago? Did it come on suddenly or did it come on gradually when it first started? Uh, no. So it has been sort of gradually increasing and how severe it's been. And if you had to describe the pain, is it a sharp pain, a crushing, a burning, a stabbing pain? How would you describe it? Um, so it's more of, uh, like a dull, aching type pain? Um, that sort of, um, I don't know, it feels like there's a bit of pressure or maybe throbbing there. Mm. I see. Um, and does this pain move anywhere so down your face or towards the back of your head or your ears? Um, uh, oh, I have noticed that it does sort of move down towards my mouth, particularly when I'm eating. Actually, I see. Um, so do you think the itching could be a trigger for the headache or is it just something that makes it worse? Uh, no, the headache is there all the time but when I eat, I do notice it's a bit worse and it definitely moves more towards where my mouth is, my teeth, that sort of area, right. Um, and is the pain brought on by touching your face or brushing your hair at all or? Um, yeah, it is actually, um, uh, if I touch sort of that area where it hurts, it definitely does get a bit more painful. I see. Um, have you noticed any sort of aversion to light? Does the, um, does bright light make the headache worse? Uh, no, I've not noticed that. No. Um, have you noticed any loud sounds make it worse. Uh, no, I haven't noticed that either. Um, have you had any neck stiffness? No. No, I think my neck's been fine. No issues there. Luckily. Um, have you had any nausea or vomiting? Uh, no, I haven't noticed that. No. Um, any dizziness or lightheadedness. Uh, no, none of that. Um, do your headaches get worse at any specific time of the day? Uh, no, I mean, they've just been sort of gradually getting worse, sort of persistently. Um, it doesn't seem to be related to the time of day. Um, and you said that eating makes it worse? Is there anything else that makes the headache worse? Uh, yeah, just eating or like, if I was to touch that area, they're the only things as far as I've worked out. Really? Um, does anything make the headache better? Um, originally it was sort of going away if I took some paracetamol. But now, I mean, that's making it a bit better, taking the edge off but it, it's still there. Um, and if you had to describe the severity of the pain with one being very little pain and 10 being the worst pain you've ever felt. How would you rate it? Uh? Oh, it's, it's pretty bad. I'd say it's at least a seven out of 10 at the moment. Yeah. Um, you said the headache was just above your eye? Have you noticed any eye symptoms or any redness? Any watering of your eye, any changes in vision? Um, no. So my eye doesn't look red or watery at all. Um, but the, this morning I have noticed sort of occasionally my, my vision's gotten a little bit blurry. Um, but it, it, at the minute it's ok. I see. Um, and is the vision affecting the side of the face that the headache is on? Yeah. Yeah. It's been my right eye actually. Yeah. Ok. Um, um, just to ask a bit about your past medical history. Now, have you ever experienced this sort of headache before? Uh, no, I don't normally get headaches at all. Mm. Can you think of anything that might have triggered this headache? Um, I'm not really sure. Um, I mean, um, I was wondering if maybe I just developed migraines and that could be what's, what's happened. Mm. Um, do you have any other medical conditions? Um, yeah. So I've got, um, hypertension and, um, I've also got arthritis in my knees. I see. Um, and do you take any medications at the moment? Uh, so I take amLODIPine for my BP. Um, and I also sometimes take, um, paracetamol or I use a little bit of VRE gel when my knees are getting bad. Ok. Um, do you have any allergies to any medications? No, I don't. Um, are you working at the moment? Um, no. So I've recently retired. Ok. Um, do you think these headaches affect your activities of daily living living? So they affect you from doing anything you would do normally day to day. Um, I think they might have started to, um, now just because of how severe they are. Um, I mean, I was able to get here ok, and everything, but it's definitely taking me longer to do things. Can I keep going? Yeah. Yeah. Keep going. Um, just to ask you a bit about your social history. Um, do you drink at all? Um, I have, um, some wine occasionally. Um, how often would that be? Um, maybe one or two glasses a week? Not very often. Ok. Um, do you smoke at all? No. Ok. Um, any recreational drug use? No, never done that. Ok. Um, ask a bit about your family history. Um, does anyone in your family ever experience headaches like this? Um, yeah, so my sister has migraines actually, which is what made me think. Maybe this, this was a migraine. Um, she's had them for quite a long time now. Um, no one else has ever had anything like this when your sister has migraines. Is it a similar pain to what you're experiencing? Um. Oh, gosh, I don't know. Um, uh, II think so. I mean, she normally says it's just that 11 bit of her head tends to hurt and it, it does last a few days sometimes. Ok. Um, I think that's all of my questions. Thank you. Ok, thanks. Um, ok, really well done. Um, so um, Samu, do you now want to, um, discuss sort of how you would go on to investigate Janice? Um, firstly, since we've taken a history already, I would do a full neurological examination. Mhm. For the cranial nerves examination. Um, then I would just do some bedside tests. So, check her heart rate, respirate temperature pulse. Um, I'd also like to do an E CG because she's had some, she struggles with hypertension, um, just to make sure her, nothing's related to her heart. Mhm. Um Maybe refer her for a head ct or um ultrasound of her um arteries cause this could be joints or arteritis. Yeah. Excellent. Ok. Um Anything else you'd like to do or is that everything? Um I'd also like to look into her eyes. Um fundoscopy just to make sure there's no um increased pressure. Yeah. Yeah, but that's all I can think of. Yeah. Excellent. Ok. Well done. Um ok. So um if everyone listening would like to just pop in the chat, what they think um the diagnosis might have been with Janet here. Yeah, excellent. You all seem to be getting it giant cell arthritis. Um ok. So um going back to the case. So um Sambre you did really well there um uh to ask all the sort of relevant um relevant questions that made it um obvious what the diagnosis was and it was clear that you, you knew what um the most likely diagnosis was because you said about the ultrasound of the arteries. Um, do you want to, um, would you mind just, um, I'm muting again and just see how you feel that went. Um, I think it went. Ok. Uh, I did go over the time limit because I think I was, I really wanted to get all of the presenting complete questions done. Yeah, maybe next time I'd need to keep a better around the clock. Yeah. Yeah. Um, yeah, so I would agree. I think you did a really good job. Um, and you did get, um pretty much everything out of the history there, which was really good. So it was very thorough. Um, and I think in this case, um, although you went over a little bit, it was probably, um, a good thing that you may made sure to stay thorough just because that visual symptoms came out more towards the end, didn't they? Um So you might have missed that otherwise, um, in terms of ways that you could speed up. So, um, there were sort of times when, um, you were given sort of multiple different options when you asked the question. Um, and it probably would have been better just to keep it a bit more open ended. Um, just because then that gives the patient a bit more freedom to say specifically how they would interpret the symptoms rather than opting for one of the words you've chosen. Um And also it will just speed it up a little bit so long as you've got a patient that sort of, um, got a fairly good idea of the symptoms that they've got and they're not sort of struggling to answer your questions. Um, you don't necessarily need to give them all the options because they'll probably be able to say quite confidently, you know, how they would characterize the pain and things like that. Um, so that's just one tip that you can do to try and speed it up a little bit. Um But otherwise I thought you did, um you had a really good use of structure throughout your history. Um You used so well to characterize the pain. Um And it was really good that you made sure to ask about um visual symptoms. Um And you also used signposting quite nicely to, to show that you were moving on within the history, which was great. Um So, um another thing that you asked that um maybe is, was a bit harder for the patient to answer was um when she mentioned her sister had the migraines. Um So generally, they might not have sort of that good of an idea of what sort of symptoms um the cyst I was having. Um So I think that's a really useful question to ask if I had said, oh yes, I have migraine sometimes um to check if it feels similar. Um But if I'm saying someone else in my family has it it might be a little bit harder for the patient to answer that there. Um And then, um when we were going through the investigation, so, um you said pretty much everything that you needed to say. So that was really good. You investigated her really thoroughly. Um And you used that good structure with your investigation. So you built up from um your examination, the bedside tests onto the more sort of complex things. Um So you mentioned CT head. Um and in this case, um so if I'd been in um A&E presenting to you with a headache, um act head would be sort of a much more doable investigation and probably would be up there. And one of the things that you would do, um but just in GP practice, obviously, you don't have the same access to act head. So you want to be thinking about um OK, does this person actually really need one? Because if so I'm going to need to send them over somewhere else to get that organized? Um And then, um again, in terms of specific investigations for um the most likely differential here, which was GC. So you've got the ultrasound of the arteries, which is really good. Um And that most likely in this case would have been abnormal. Um One of the things that you could have mentioned just about that would be um a temporal artery biopsy as well. Um But again, those are both investigations that you'd need to be referring on into secondary care to organize, you couldn't do them in a GP surgery. Um. Ok, great. So, um, so here are just a few key points. Um, that in just a general headache history, you want to be making sure that you're covering. Um, so as with any pain you want to go through Socrates, um, then, uh, you want to be checking if they've ever had any headaches like this before. Um And this is really important in headaches just because um a new headache in someone who's a bit younger, um uh is, you know, it could be any of the normal types of headaches, but if they're a bit older, um so in this case, you're 67 um it kind of changes what your differential would be because it's less likely that she would have suddenly developed migraines at 67. Um And it's more likely that actually it's um a sinister underlying cause to that headache there. Um You also want to be checking um if there's any auras, um and that would help you to rule out things like a migraine. Um So, um Sam Marine did it really well by asking about any visual symptoms. Um But you could also check if she's had any other um auras comes in different ways as well. So, um one nice way to ask it might be, do you ever get any sort of warning symptoms that a headache might be coming on. Um And then they might tell you about something else that they had thought was completely unrelated, but I realized that actually comes for every headache and you get your aura out that way. Um visual disturbance is really important to us because um in cases of GCA, obviously, it can cause visual symptoms, but also other headaches can have um visual related symptoms. So you might have something like um glaucoma um where they've actually got quite significant visual disturbances because the eye is the main problem. Um But because of that pain there, they're actually presenting as a headache. Um Then you want to check if there's any positional variation um and um any nausea and vomiting as well. Um So these things, um so particularly the nausea and vomiting, it might be ok, but it also actually could be a bit of a more sinister sign. Um So you might get a bit of nausea and vomiting and a migraine or um it might be if they're getting early morning nausea and vomiting. Um and their headaches are actually quite a lot worse at that time as well. You might be a little bit more concerned that actually they might have raised intracranial pressure and there might be something like a space occupying lesion in the brain. So that would um sort of change how urgently you wanted to um manage this patient. Um And then time span is also really important. So, um here, I've had the headache for three days, um, which, um, doesn't really help differentiate too much between headache types because three days is still within sort of how long a migraine could last. But also it could be something a little bit more sinister. But if I was coming in with a headache that had gradually been building up over a longer time period, so, more like, um, six weeks or more, um, then you might be getting really worried that actually there might be, um, a space occupying lesion or raised intracranial pressure or something more sinister going on again. Um, because a headache continuously for that length of time is definitely abnormal. Um And then also, um, always important just to check that they haven't had any injuries beforehand, um, which could have triggered something like a, um, bleed. Um So then next, we've got red flags here. So we've talked about a few of them already. Um But one big red flag would be thunderclap headache. So, um, if I was saying my headache started immediately, very quickly reached its maximum intensity and then stayed the same. Um You'd be really concerned for a subarachnoid hemorrhage. Um So what been lying down in the early morning nausea? We've already discussed them. Um And then if there's any focal neurology again, you might be concerned of something like a stroke or um, a, um, space occupying lesion. Um And um, then the meningitis red flags. So they will be photophobia, fever, neck stiffness and maybe a rash as well. You definitely want to rule those out in all headaches. Um And then if you've got someone who's in their third trimester of pregnancy, um, and they're coming in with a new headache that they've not had before. Um, you would be a little bit more worried that it might be um, a presentation of preeclampsia. So you'd be definitely wanting to make sure you check their BP and do a urine dip in them. Um And then as we had in this case with Janice, um jaw claudication, temporal tenderness and um visual loss are red flag symptoms um because of temporal arthritis. Um So, um other key points that you want to be doing elsewhere in the history. Um So one question that would be really useful to ask in the past medical history that just shows that you're really thinking about um how the past medical history might relate to that presentation of headache. They've got at the minute is if they've had a cancer um before, uh particularly if they've had one recently, um or they've got a current cancer that they're having treatment for. And the reason for that is you, you would be concerned um that it might have metastasized to the brain and that's the cause of the headache. Um Then in the um medications um part of your history, uh it's really important that you check if they are taking any analgesia. Um, because if they are, then that could be an analgesia, overuse headache. Um, so in the case of Janet, she was taking paracetamol. Um, so one thing that you could have done in the history, there would just be quantifying a little bit more how much paracetamol is she actually needing. Um, because if she's using it for more than a couple of weeks within a month that puts her at quite high risk of having an analgesia abuse headache. Um and other analgesias that would do it would be um opioid analgesias. And um if someone was taking Triptans for migraines as well, they can all cause analgesia overuse headaches. So you just wanna um stay aware that that might be the underlying cause, particularly in sort of a general headache and you can't really work out what might be going on. Um It could be because they're over using that analgesia and then within the social history, really important you ask um about stress within their life. So obviously the Janice, it's um a bit less likely because she's retired. Um So you might think that that's sort of lower down your list of differentials. Um But always important to just ask that as its own question just because um it might be that there's sort of so other aspects within her social life that are causing her quite a lot of stress recently. Um And that could be causing her headache. Um ok, So then in terms of management of um temporal arthritis, um so what you want to be doing is um if you're in a GP surgery, you want to be sending them into hospital urgently. Um so that they can have sort of a same day assessment. Um And what they would do in hospital would be um a biopsy, um plus or minus an ultrasound of that artery, um which would help give a bit more diagnostic certainty there. Um If there's a any delay in them being reviewed in hospital, and then as the GP, you would just start them on the steroids immediately um to start treating it. Um And that's because with giant arthritis, um you can treat it as sort of a clinical diagnosis. So the things like the biopsy, they will help um but they're not, they're not needed to make the diagnosis. And if you've got sort of a high clinical suspicion um to avoid any longer lasting complications as a result, you just want to make sure you're going and you're starting them straight on the steroids. Um And um quite often, um they will have a really good and quick response to those steroids as well. So that'll help um sort of uh with your diagnosis as well. Um And then in terms of if they've got any visual symptoms, uh then you want to make sure that they've got a same day ophthalmology assessment as well. Um And in that case, it's quite likely that ophthalmology are going to start them on even higher dose steroids. Um So either IV um methylprednisolone or sometimes they'll also do oral. Um and that will be um 60 mgs or higher um the dose of um steroids in that case of those visual symptoms. Um And again, that's just to ensure that there is no lasting sort of visual loss and you get on top of the inflammation within the artery as quickly as possible. Ok. So, um now we've got case two, which is case on weakness. Um Is there anyone else who would like to volunteer to do this case? And hello? Oh, hi. How are you with your case? Yeah, sure. Um So uh is your name? Aio? Am I pronouncing that right? Yeah, Amio. Aio. Hi, nice to meet you. Ok. So, um Aio um in this case, um you will be in clinic, so, neurology clinic. Um and you are reviewing James who's 32. Um He has come in because he's been referred by his GP with a one week history of weakness in his leg. Um So um take a history for six minutes. Um and I'll do the same as I did for the time, I'll um set a timer, but if it goes off, um that's more just so that you're aware of what you're like with sticking to your time, but you can keep going and finish the history. Ok? Um And then afterwards. Um, if you spend a couple of minutes discussing the investigations with me, um, and then I want you to spend a few minutes just counseling James on his diagnosis. Ok. Ok. For the diagnosis, am I gonna come up with it or you let me know or it makes sense? So, um, you're gonna come up with it, but if you feel like you're unsure, you don't know, um, then we can discuss that in the investigation section. Um, and I'll, I'll let you know before you go on to cancel. Ok. Ok, thank you. Ok. Are you ready? Yeah, yeah, off you go. All righty. So hello, my name is, I'm just gonna confirm your name and date of birth, please. Uh Yeah, my name is James and I'm 32. Ok, so what's brought you in today? Um, so I've come because um over the past uh week I've noticed that my leg has been feeling really heavy and uh quite weak as well, actually. Ok. Would you like to tell me more about that? Yeah. So, um, so it came on a week ago and it's just sort of gradually been, been getting a bit worse and it's now at the point where I'm really struggling to sort of lift my leg up or anything. Um, and it's, it's just in the whole of the right leg, um, and it's now really affecting my ability to walk and things. Um, and I'm just really worried about it. Ok. So you've been having, like, progressive weakness and heaviness in your right leg over the past week and recently it's just been getting so bad, you're finding it hard to walk or move around and it's quite worrying because of, like, you're not able to, like, go on with your day to day activities. Is that correct? Yes. Yeah, that's right. Yeah. It's, um, in fact, it's really like a faxing my ability to get anywhere now. It was a real struggle to get in here today. And I just, I really, really worried about this because it's just gotten worse. Yeah. And, um, how are you, are you able to, like, drive and things like that? Uh, no, no, I've not been able to drive at all because my leg is just not, it's not doing what I want it to do. Um, and I'm not really able to walk. Um, it's been really affecting me. Oh, that seems a, a lot to be honest. Um, would you like to tell me, ha, has the weakness just been in your right leg or? It's in your left leg as well? No, only in the right leg. The left leg feels normal. Luckily. Ok. And would you say, like, your sense of like, feeling, sensation is fine on your right leg or has that been getting worse or something? No, I've not noticed any change to the, the feeling in the leg that feels ok, or? Ok. The leg does feel sort of quite tight, I guess. Um, but yeah, I can still feel it. Ok. And would you say you've noticed any changes to the color of your leg or anything? Sorry. What was that changes to the color of your leg? Uh, no color of the leg is normal. Ok. Have you seen any, have you felt any pain in your leg at all? Uh, no, no, it's not painful. Ok. So it's just really hard to move your leg and it's been going on for the past week. Is that right? Yeah, that's right. Yeah. And do you have any thoughts on what this could be? Um, I really don't know. Um, I, I've never had anything like this before. I've never heard of anything like this before. II haven't got a clue what it could be really. Ok. And you're worried because it's, um, like getting worse and are you worried about anything else? Um, yeah. So I'm really worried that, you know, if it doesn't get better that II won't be able to walk and things. Um, that is quite a big thing to be worried about. Hopefully we'll be able to find out what's going on and try and help you out today. Thank you. Ok. Um, uh, have you, I'm just gonna ask you about any other symptoms you've been experiencing. Have you noticed any other symptoms? Um, I don't think so. No, I mean, I've been feeling quite tired. Um, for the same sort of time period. Um, you know, but, but nothing is nothing else as far as I've noticed. Have you noticed any changes to your bowel habits? Uh, no, bowels are normal and has the weakness been, like progressing along your leg? Like, do you get what I mean? Oh, yeah, I do. Um, no, it's, it, um, always been the whole leg. It's just the area that's affected has gradually gone weaker. Does that make sense? Ok. Yeah, that's, thank you. Mm. Oh, ok. Um, so I'm just gonna ask you a few more questions about your medical history. All right. Yeah. Uh, do you have any current med, um, medical conditions you're treating? Uh, no, I don't. Uh, do you take any regular medications? Uh, no, nothing. Or have you had any surgeries in the past? Uh, no. Ok. Do you have any allergies? Um, I don't know. Ok, that's fine. I'll be asking you more questions about your general life and everything. Um, do you smoke by any chance? Uh, I do. Yeah. And how much would you say you smoke in a day? Um, so I have about, uh, five cigarettes a day and I've been doing that for a few years now. All right. Um, how many years would you say? Like, from what age or some, uh, so about 10 years, I think? Ok. All righty. And do you drink, um, I don't know. Ok. Do you take any recreational drugs. No. Ok. And, uh, you said that it's been impairing your day to day activities. Do you work? Part? Um, I do. Yeah. Um, luckily I work from home so it's not really affecting my working. Um, I'm still able to do that because I'm just, um, I work from a computer so it's ok there. Ok. But how are you getting on at home with, like, everything? Um, yeah. So I'm really struggling to sort of move around at home and things and going out is, has been a bit of a nightmare and it's, it's really hard without any help from anyone else. Oh. And do you have anyone living with you at the moment? No, I live alone. Ok. And, um, oh, what about, would you say exercise? And how is that for you? Um, so, yeah, I normally am really active. I normally, um, go running multiple times a week, but obviously since this has happened, I've not been able to run at all. Um, which has been, uh, really annoying me. Ok. And when the weakness started, was there anything you were doing at that particular time? Uh, no, not as far as I can remember. Um, I think, um, I just woke up one day and it just felt a little bit weaker. Hm. And, um, you said it's been progressive ever since, like, for the past week and it's gotten so bad you're not able to walk properly and you were really active before then. Mhm. Yeah. Ok. Ok. Thank you for your time. I think that's all the questions I have so far. Ok, thank you. So. Ok. Then, um, ala, um, so how would you like to investigate James? Uh, maybe I'll start from the bedside investigations. Get a Doppler. Mhm. Uh, do a neurological examination. Complete, complete neurological examination. Yeah. Um, then maybe, uh, I don't know, I generally don't know what's going on, but, well, so far that's all I'll do. First we do some blood tests as well. Yeah. Do you know which blood you want to be doing a DD dimer to rule out a DVT or something? It's not likely. Mhm. I don't know. Um ok. Anything else that you want to do? No. Ok. That's fine. Um Yeah, this was a really hard one. So don't, don't worry too much about um if you're not sure what's going on at the minute. So I'll just tell you um what the investigation results would be. Um So when you do your neuro exam, um you notice upper motion neuros, your enzymes to the right leg. Um So that will be hyperreflexia and spasticity. Um increased muscle tone, um weakness and upgoing plantar responses to the right leg. Um Rest of the body neuro exam is completely normal. Um So then in your blood test, um so um you might want to do things like uh full blood count, crp esr thyroid function B12. Um and they'd all, they all come back as normal. Um and then, um in terms of specialist tests that you can do. Um So in this case, um what you'd want to be doing would be a Gainia enhanced MRI brain and spinal cord and on that you would see demyelinating lesions. Um So from what I've told you just there, do you have an idea about what the diagnosis might be in? I Yeah. Yeah, well done. Yeah. Um ok. So um do you wanna now counsel James on the diagnosis and management? 00. I could try but I generally don't have a very good understanding of MS. Ok. That's fine, don't worry. Um ok. Instead do people just wanna pop in the chat? Maybe um how they might phrase the diagnosis of MS to James or if anyone wants to unmute and say um maybe just say it's a condition that affects the brain and spinal cord which um relapses throughout the patient's lifetime. There's not a specific cure for it, but there are medications that could slow it down. Yeah, but it's just figuring out how to slow it down so the patient can live as normal lifetime. Yeah. Great, great. Thank you. That's a really good way to describe it. Um So um yeah, so MS um it's probably quite a significant diagnosis to be giving a patient. Um So you just want to be aware when you, when you're explaining that to them um that obviously this is probably going to have quite a big impact on them and, um, it might be quite hard for them to sort of process and understand that diagnosis. So you want to make sure you're giving them as much time as they need and things and they'll probably have quite a few questions. Um, and, um, you want to explain it as, um, so it's an immune mediated condition. Um, and what happens is the immune system will mistakenly attack the protective layer around your nerves. And that can affect how the nerves with the brain and spinal cord can interact with the body. Um, and then that can cause sort of sudden, um, symptoms of, um, vision changes or um, weakness or numbness or issues with sensation throughout the body. Um And, um, as you said, it's sort of a lapsing and remitting condition. So it's sometimes there sometimes not, um, and might sort of progress and worsen. Um, ok. So, um, and how do you feel like your history went with that case? Um I don't know, honestly, I thought I was barely, ok, barely made it past the mark. I II wouldn't say barely. Ok. I would say it definitely was ok. And it was a very hard case to do. Um And I think really there was one key question that you, you didn't ask that might have given you, um, a bit more of an idea about what was going on and that was just, um, have you ever had any sort of episodes of this, um, similar symptoms like this in the past or, you know, any episodes of, um, sort of, uh sensory changes in the past or, um, visual loss in the past? Um, and just asking that, um, you would have gotten a lot more of an idea about the fact that, um, actually James had a couple of episodes like this, however, they sort of resolved a bit quicker. Um And um, one episode that he's had, um was um an episode of sort of painful vision loss, um which would suggest he'd had optic neuritis, which again would make that suspicion of MS quite a bit higher. Um Otherwise though, I think, yeah, you did really well to keep a really broad differential throughout. Um I could tell that you were considering things like, um any vascular issues that could cause it, um or um something like, um something that was maybe affecting um elsewhere in the body or um affecting sensory changes as well. Um And you also asked about if that weakness was ascending. So, in like a Guillain Barre type thing. Um So you did a really good job there. Um You just missed that one key question, which I think would have really helped you um, in terms of working out what was going on. Um I also really liked how you made sure to um sort of summarize the, the symptoms that he was describing. Um, and that helped you to sort of really stay on track of sort of what you knew, what you didn't know. And that was a really good um way to check in, in the middle there. Um And um one other thing that you could have asked that probably would have um been really impressive to the examiner in this case. Um Although not to worry too much that he didn't, was just asking a little bit more about the social impact that this is having on James. So just finding out things like, um, are there any stairs in his house? Um, or is he sort of able to get dressed by himself? Is he able to cook himself those sort of things? Um Because that might make a really big difference in terms of um what you do next with, does he need carers to come in and help him straight away? Um Or is he actually ok, and he might just need, um, you know, some crutches or something to help with his mobility, things like that. So you just wanna consider those things um at the same time in your history. Um And um, otherwise though, I think you did a really, really good and thorough history. So I think you should be pleased with yourself there. Um ok, so I think so. No worries. Ok, so in a limb weakness, history. Um So here are some sort of key key questions that you might want to try and find out about. Um So you want to find out has it come on suddenly or has it sort of been gradually building? Um So a sudden onset weakness might make you worried about something like a stroke. Um Whereas a gradual building of the weakness, um and particularly if there's sort of a pattern to it, um might make you a bit more worried about um something like Guillain Barre or um some sort of peripheral neuropathy or motor neurone disease, something like that. Um Then you wanna ask, um have they had any issues with their speech? Again, that's um something that you would um help you differentiate if maybe it might be a stroke that's caused their weakness, um less likely to have issues with speech and other causes of limb weakness. But again, it is still, it still possible depending on the cause um and sensory disturbance as well. Um So, um any patterns of numbness um or tingling or pain as well throughout the body might give you a bit of a clue of. Um actually, could this be a stroke or could it be something else going on? Um Then um you wanna check visual disturbances as well. Um Again, um any loss in vision, um if it's occurring at the same time as the limb weakness, you might be thinking of stroke if they've said. Um actually, I had um issues with my vision in the past, but now it's fine. Um, you might want to consider optic neuritis, um, which we had in this case here, which again, would point you towards a diagnosis of MS. Um, so in optic neuritis, they'll get sort of a painful, um, eye with some blurring of the vision and they also will lose the ability to sort of distinguish colors and things. Um, and optic neuritis. Um, if someone's had optic neuritis, it doesn't always mean that they've got m but they are incredibly likely to then develop MS as a result. So it's, it's quite a key, a key diagnosis to be aware of in their history if you're considering MS. Um and then also asking about headaches. Um So, um if they've got, if they've had sort of headaches for weeks and weeks, it might be that they've had um something like a space occupying lesion which is now causing compression on the motor senses, centers of the brain and that's what's caused their weakness as a result. Um uh Or again, you could get a headache and a stroke. Um So that would just sort of depend on the timing and how long you'd have the symptoms to differentiate between those two there. Um You also um might wanna ask about if they've had any seizures. Uh in this case, um I don't think he necessarily needs to ask that because there wasn't, it wasn't really giving any, any symptoms. Um That would make you concerned about seizures. Um But again, just have that in the back of your mind when you've got some with the weakness coming in. Um, back pain is a key question to ask here because you could have something like um called a quina or metastatic spinal cord compression, um which has then caused them to get that limb weakness, um, as a result. Um And again, if they did have back pain, you'd be wanting to rule out all of the red flag symptoms for chus. So, have they got any saddle paresthesia? Have they had any issues with their bowels? Um, any urinary retention or urinary incontinence? Um, and do they have any pain or numbness in their lower limbs? Um, and then again, you also wanna be asking about trauma. So it might be that they've had sort of a spinal injury that preceded this. Um, and actually there might be a bit of a fracture going on which has caused the limb weakness. Um, or it could have been, um, sort of a more peripheral, um, nerve injury as a result of a trauma. Um, ok. So then in the, um, past medical history, um, really key in this case, just asking about if they've ever had any previous episodes of neurological symptoms, um, because MS you're not really gonna, um, work out if that is the cause of these symptoms. If you don't have that history there, of them having previous episodes have been similar and then as we discussed before in the social history, um, if someone's got new weakness, really important to work out what they're able to do for themselves, um, what they normally can do for themselves. So, how much have they changed from the baseline? Um, and how much is that affecting their situation at home and their living situation? So, if they've someone who they live in a house and it has stairs, you want to be asking if they've got to go up the stairs to go to the toilet because that can be really key or are they able to just convert to downstairs living? Because again, that will make a really big impact on whether they're actually able to go home and be safe at home. Um, ok, so then in this case, um, as I mentioned before, um, so you do want to be aware that the diagnosis you're giving here is quite a significant one because it's one they're gonna have for the rest of their life. Um, and there are sort of varying severities of MS. It could be that it's quite a severe impact it has on their life. So you want to be really clear and sign post and make it clear that you are, um, just to give that sort of warning blow that there is some sort of really severe news that's coming. Um, so you might want to say something along the lines of, um, ok, So I've got some quite significant news for you, um, here. Um, and then you just want to check, you know, if you've got any, um, relatives or any friends, um, who might be around later on, who might want to come with you while you're, you hear this diagnosis. Um, in this case, in clinic, um, it's probably less easy to facilitate but if you're in a ward situation, um, it might be a bit easier to just wait an hour or so for their relative to come in and then go back and have that conversation with them. Now, while they've got that social support. Um And then whilst you're explaining the diagnosis, um you want to be aware of the fact that it's a lot of information to take in. Um and it's probably quite complicated and you might need to sort of repeat key areas um and check their understanding of everything as you go multiple times. Um And as you go in, you also to just address that emotional impact that it's having on that patient. Um So I know, I think you did this really well. Actually, while you were taking the history, you acknowledged the fact that um this was obviously having a big impact on me. And that is a really nice, nice way to just show that you're giving that bit of empathy as well to that patient in your exams. Um And then also, once you've, once you've finished explaining everything. Um Don't be scared to just leave some silence there in that consultation. Um Because what that silence is doing is just giving that patient that time that they need to process all of the information that you've told them before they can then start asking questions if they need to. So don't try and just fill all of the silence we're talking because that might not be the right thing to do in this situation. Um And then at the end, you want to make sure that you're offering them further support. Um So you can um the key diagnoses like MS and things just have in your mind, the names of some societies um that they can go to for um some further support. Um And um you could also just say um oh and I'll give you a leaflet um as you go home as well with some more information as well um on that condition. Um ok. Um Before we go on to the next case as well, actually, we just talk a bit more about management of MS. Um So um does anyone know how you would treat it? Is it mainly symptomatic like, so you might give steroids during the relapse. Um And then symptomatic as in like pain relief as needed and because there's no cure just treating um the problem as it arises so that there's some level of comfort. Yeah, that's perfect. Yeah. Um So um you're right, the main treatment would be symptomatic. Um, so things like making sure they've got adequate painkillers, you can give, um, medications like, um, Baclofen, which would help with any spasticity that they've got. Um, and, um, whenever they get an acute relapse, you want to give them, um, oral, high dose, um, steroids, um, sorry, not oral. Um, you want to give methylprednisolone. Um, so that would normally be IV, actually, um, and, uh, that would be just to treat any acute relapses. What that does is it doesn't actually um change the um how severe or sort of um permanent, the uh new symptoms that they've got in that relapse will be, but it does sort of speed up the recovery. So it reduces the amount of time that they've got those symptoms for, but it doesn't give any long term benefit to them. Um And then, um in the long term, um you can use um some immunomodulators to help prevent any relapses. Um So there's a lot of different immunomodulators which will have some funny names. Um But if you just try and remember one or two names. Um So the one that I remember is Natali Natalizumab. Um So you can just have that there in case they ask and if I have a question, um what, what drug might you give to prevent relapses? And you can say um Natalizumab would help prevent relapses. Um But again, there is, there's no cure. Um And there's no drugs that sort of prevent anything from happening. Um fully. Um ok, so um oh, I've just seen your message Rahul. Um Yeah, this is being recorded. Um and it will be posted um on the mind the bleep page at the end of the session so you can watch it back later. Um I think the slides will also be made available as well. Um ok, so moving on to our last case. Um So this is a case on confusion. Um Would anyone like to volunteer to do the history in this case? Oh Bianca. Um If you don't wanna be recorded, that's fine. I'm happy to turn the recording off. Um And then I can turn it back on again when we're discussing the key points in the case. Um Let me just work out how I do that. Um.