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Uh Yeah, go ahead. Yeah. OK. Fantastic. So, um as you can probably see this is on ment, so you can join with this code here. Um And you should be able to ask questions throughout using ment. I've also got to open on my ipad so I can see the metal chart, but that might be a little bit slower. So before we kind of move on to the talk, like, you know, who am I? Why am I here? Um My name is Kate Re, I'm one of the year five students. Um And essentially, you know, the reason we're here is because we've done this before. I've sat my, I've done neurological examinations and it's to try and give you that kind of real life feedback and idea of what's gonna come up on your exam and maybe drill back down into the nitty gritty of it. And it's to kind of just give you some tips and I really want to be about what you guys want to do because it simply isn't possible to teach you how to do a neuro exam in one hour and remotely. So you're gonna have to go home practice, you're gonna have to use your OSK tutors all of that. But this is to give you kind of the tips and the exam technique and the kind of intellectual, how to think about how to approach the examination. Um And, you know, I think I've done pretty well in my exams and I'm also part of various societies and I actually really recommend getting involved with I CSM societies. Now you're in clinical years because of like the mocks you'll get offered in the academic t so enough about me. So essentially, like I said, we're going to cover an exam recap how to do it a bit, um How to present your exam, which I think is really important and is really kind of under discussed um and a bit about history taking. And I know that, you know, this is kind of halfway through the lecture series, there are going to be bits you're really familiar with, there are gonna be bits you're really not familiar with it. So for everyone to get the most use out of this time, what I really want to know is what, why are you here? What has made you decide on the last Tuesday of time to come and join this lecture, so I can make sure I hit that today. And if that means going right to the history taking bit at the end or if that means talking straight away about how teams are tuning fork that is completely fine. It's the goal of this to be flexible and to work around you guys. So I'm just gonna give you a few minutes to just have a think and kind of tell me what you want to get out of this. And hopefully, we can make sure that by the end of the hour that learning objective is met. And if you're having any issues using the mentee or anything like that, ok. So you've got upper motor versus slow motion urine sign an absolute classic. We can definitely talk about that. I know that there's hopefully more than one person here. Um I can't actually see how many people there are, but I'll give it another couple, couple of minutes. Ok? And talking about how to do a systems review in your history taking. Yeah, I completely agree with that. I think it's like it's often really badly taught actually. Um and I have a very kind of personal idea about how I, how I like to do my assistance with you. Ok. So from what people are saying, it sounds like this is less, how do I do the exam and more, how do I interpret the exam? And then how do I really polish up my history taking, which is fab um and somebody's asking the chat whether this will be recorded. So I think it is being recorded but um correct me if I'm wrong on that one. Yeah, it's gonna be recorded. Yeah. Is there like way more than two people that I should keep waiting for or not really? Uh there's nine people at the moment. So I think just, yeah, I think I three is pretty good. Ok, so from what you guys are saying, I'm gonna completely skip how to do the exam. The slides are there, we can go back to them. You can always send me an email and I'm gonna really go straight to the findings presenting them and then we'll come round with a history and the systems review at the end and hopefully that's gonna cover everything people want to do. And then the specific bits of just the technicality of how to do the exam, we can come back to that fabulous. So just kind of as a basic thing, you know, I'm sure you know, this 10 minutes, this is the hardest one to do in the time, but you absolutely can. You won't feel like it now, but you can if you practice. Um, and before I get on to the meat of what you guys want to talk about, this is what I want to tell you. Um And it's one of our top tips of please practice on patients, please. Um I know in years three, it feels very easy to think. Practicing patients is difficult and hard and practicing. My friends is easy. But you know, things like upper, lower and upper motor neuroscience that will click in your head when you see patients with the signs and similarly using the medical I MT S using the med regs. They, they've gone through like really high level exams on how to do these examinations and they're often the best people to really polish you up and give you the top tips. I often do have a bit of time to do bedside teaching on the ward. And I think the two questions I really want you to take away from this when you're studying is first like, why am I doing this? And we'll talk about that now thinking about like collections of signs, you know, like to kind of paraphrase the Sherlock Holmes, you want to see and observe, you want to feel you putting everything together into this nice, lovely package of your differential. But also, you know, they're not going to bring a frail stroke patient to your exam. So you can be a bit smart about what's like to come up and have that all kind of prepared. Um And also please buy this book. I am not being advertised um to get this book, but it's great because I think it really explains why we're doing it and what the constellations of signs are. Um And I absolutely swear by essential examination. Um So that would be, you know, if you take one thing away from this talk, why am I doing it? Talk to the med Reg and buy this book? Um or get the library to buy the book. So, based on what everybody wanted to go through, I'm assuming all this stuff about how to do the exam, you are happy if at any point, you can actually, I'm not sure how to do this. That's completely fine. We can come back to it, but I'm gonna go straight to this idea of presenting. And the reason I'm gonna talk about presenting and then the constellations of signs is that the reason we care about all these groups of signs is essentially to give this really nice presentation while you're making it super, super clear to the examiner what it is. So when you're thinking about these signs, think about how when you notice all these upper motor or lower motor neuron signs that gives somebody a story of why it's your differential. So what are the findings on the? And I think this one you guys have, have touched on, you talked about upper motor urine and lower motor urine and those are the two main things you need to be aware of. So I find it really helpful here to just go back to the anatomy. So it's actually upper motor neurons, everything in your brain or spinal cord. So this is kind of just a nice picture of like your brain, spinal cord as a peripheral nerves. I mean, low motion is everything else. And that might seem like a very banal statement to make. But it's important to remember that, that still gives you a lot of wiggle room and leeway and that neurology is quite messy. So I just want us to remember that when we're talking about upper and motor neurone lesion signs, you don't always get them all together, you don't always get them like across your whole body, for example. And the reason for that is about where that lesion is actually located in space. Um And I'm sure some of you have been going through the Oxford Clinical Cases handbook with the red cover um that you will do the which is really good. And that has a really nice kind of a neuro history section where it talks about how with your history, you should actually be able to localize to a specific place in um the neurological system where that lesion is. And essentially, that's all of promotor neuro signs are, there are collections of signs we tend to see depending on where the lesion is. And this is a really nice example of why you should buy the essential examinations textbook. Um because it is gonna give you this kind of nice table of the clinical features. Um Essentially, I hate to say this is something you kind of just have to learn. Um you can think through the pathophysiology, pathophysiology if you want. But I kind of found that that could get you quite bogged down and it's nice. Mnemonic is in an upper motor neurone lesion everything goes. So you have a higher tone, but you have specifically, you have spasticity. So you have velocity dependent increase in tone. And if you don't know if your spasticity and rigidity, please put that in the chart all the questions. Um because that's a really important thing to talk about. Um You're gonna have Brisco reflexes and upgoing planters and upgoing Planar is just like a fancy way of saying you've got your, you know, your toes going up. Um when you stroke them, when you do the Babinski's reflex kind of thing. Um And you have decreased coordination, but if you think about it, that probably makes sense because everything's kind of stiff, everything's stiff and increased. Um So you wouldn't, it would be kind of weird if you had really good coordination when you're struggling to move your limbs. And also the upper, like your brain essentially is what is kind of coordinating all of these fine features. So, essentially, what happens is you've damaged your brain and you're removing the inhibition on your muscle. So your upper motor ner tell your muscles don't contract all the time, basically. Um And then when you want to move them, they remove that inhibition, it says do contract, but you've lost that inhibition. So they're just contracting all the time. Um And you also get clonus, which I don't know if you've seen is that they have, you know, when you're examining the feet and they go back for like several beats. It kind of sucks that my camera isn't working. So I could give you a nice kind of demonstration with my hand. But you can look, look for a video of that and it's normally closed. If it's more than three beats, essentially in an upper motor neurone lesion, everything goes up and then the lower motor neuron lesion, everything goes down. You've got these reduced reflexes, reduced tone. I think why some people get confused is that in both of them, you do have reduced power. But again, I think, you know, you fundamentally you have something wrong with your, you know, nerve. It would be weird if you were then stronger. So you can kind of, you know, the power thing. I think so again, people get confused and can up from your own power is gonna go on. But that's something we've got to kind of common sense, check it. And realistically what you are gonna see on the wards and you should be seeing on the wards is upper motor neurone lesions. Um because that's really common. Um Can anyone name in the chart the condition that causes an upper motor neurone lesion that I'm probably thinking of that. Hope. Hopefully most of you have seen between starting med school. Yes, stroke, right. So you're gonna see loads of stroke patients and if you examine a stroke patient, which can be really difficult and challenging because they're not talking to you and they're not, you know, you will notice these signs and it will stick in your brain. So I'd say if you're struggling to remember the difference and it seems kind of tried to examine a stroke patient, you know what a stroke is. It's a blood clot in the brain and they have these upper motor neurone lesion signs, lower motor marrow lesions are a bit kind of fuzzier. You tend to see like individual nerve palsies, for example. Um But again, once you see something with like that muscle wasting and like that floppy, decreased tone, um that is something you will again, probably remember quite well. And it's important to go, you know, when you think decreased tone, again, you can feel that they will feel very floppy and you can kind of test this with your friends like, you know, to cleanse or relax and you'll feel the difference in tone. So hopefully, ii understand that I appreciate that it's a bit rambling, but I would say if you're really struggling with this, examine somebody get this book and just pop this in a flashcard. Um And you'll eventually remember it for, it will just come up so much. Um And I also want to shout out to the clinical combinations of signs that people don't always think about, but which do come up in your exams and may come up in your neurovirus, which are extrapyramidal pathology. So that's classically Parkinson's. Um And it's got you know this kind of resting tremor, bradykinesia um and postural instability. So it's like that ataxic gait lack of balance kind of thing and cerebellar lesions um which I don't know if any of you know, the mnemonic danish for cerebellar signs, which is useful, useful, although I can never remember it now. Um but essentially both of these are worth considering as well. And the main kind of way of differentiating them is that you don't get this loss in power and you also, you don't get changes in reflexes and you do get these other kind of constellations of symptoms, much less likely to come up. But I think something to be aware of that, there's a little bit more to neuro beyond lower motor neurone lesion and upper motoneuron lesion. OK. So hopefully that is kind of percolating and that kind of makes sense. The bad news is that it's not enough in your exams to identify a lower motor neurone versus upper motor neurone lesion. First, you won't see people with these lesions in third year because you don't have real patients. And these are quite hard to f consistently for a whole day. But if you think about it, you know the kind of next question really well, why? And this is why like for, for presenting and for thinking about this more broadly, I really want to approaches, I don't even thinking about systematically. So you're examining systematically, you're noting all these signs and putting it together, which is, is a really difficult skill. It's a skill that I wouldn't say I'm anywhere close to being perfect at. And then you need to think back a step and go what could actually cause this pathology. Um And this is where something like which you might have like using a surgical sie can be really useful to make sure you cover every possible um cause this is just one example, this is the one I like to use. And it's just like, you know, you go through what vascular causes infective causes traumatic causes, et cetera. I mean, it's, it's fairly self explanatory but I think just to put it in action, you know, thinking about opera motion neurone lesions. So use the surgical, you know that a neuro is some kind of problem with the brain or spinal cord that gives rise as conflation of symptoms. You're in an exam, you get off what are some causes of promoting your own lesion rather than panic. You go back to something like a surgical serve and you're gonna try and think of some systematic causes. So with this, it would be really nice to kind of see a little bit of kind of thinking systematically rather than just go with some random causes that you know, cause it, it's also to show that, you know, more than you think you do. It's not memorizing a list of causes. It's also thinking systematically and logically about your examination findings. Mhm. Yeah, I've been kind of gabbing away but hopefully that hasn't put you guys off too much. Ok. So I can see something for stroke, which it's great. I was thinking of, of course, um, and I think, you know, if we go back on it, you guys can still response who stroke would be a vascular cause. So I wonder if anyone could think, you know, go one step down. OK. We've got a vascular cause sorted. What about maybe an infective cause of an upper motor neurone lesion? Yes. So is actually a bit of a, a complicated one that has a very specific pattern of signs. So like, but I really like that you put as an autoimmune cause it could be MS and you're moving through that systematically. Um And I absolutely agree that, you know, MS is essentially attacking um the myelin of the neurons and that could happen in the upper um body, all the crap in the lower body. Just MS is a bit weird and I've kind of left MS out of this to not confuse you guys. But yeah, encephalitis is a really good example of a cause of an upper motor neurone lesion. So I saw a patient on ICU a couple of months ago who had salmonella actually meningitis, but, you know, meningitis, encephalitis kind of picture and he had really florid upper motor neurone symptom signs, he was stiff on one side. He was struggling to lift his arm, um, on, you know, the MRC Power scale, he was kind of, you were kind of getting a flicker in the muscles. He had reduced power. Um, and he had quite pronounced upgoing planters. And, you know, I think I'm really glad somebody thought of that. It's about going well, thinking logically there is something wrong with his upper motor neurone system and that's gonna prompt you on this guy who comes into A&E you know, otherwise unconscious, not able to tell you anything, his flatmates kind of dumped him in A&E which fair enough, I guess. Um So you have to think quite rationally back from your examination findings to trigger doing an MRI brain which reveals the encephalitis and also all your blood tests and stuff, obviously. Um So I put Guillain Barre um which again is kind of a little bit complicated. Um But Guillain Barre tends to cause more of like um a flaccid paralysis kind of paralysis kind of syndrome as far as I remember. So that might be more of a kind of lower motor urine picture. But again, please correct me if, if I'm misremembering that. Um but Guillain Barre has done an interesting one and it's one to be aware of more I would say probably for your exams. Um and that could, but that's kind of more of like a peripheral neuropathy picture where you might get like this motor peripheral neuropathy. So that's really more like lower motor neuron because it's not affecting your brain or your spinal cord, it's affecting your, your lower motor neurone, sorry, your lower motor neurone essentially. Um And yeah, because of that, you get that quite like flaccid picture. Whereas if we go back to, you know, our list of upper motor neuron signs, that's more of that like rigidity rather than being like relaxed. Ok. So final point, whether anyone can suggest a traumatic cause of an upper motor neurone lesion, which I guess would just be to highlight again, the structures we've talked about that are involved in a motor neuron lesion. Yeah. So they in the chat is called head trauma, which you know, is perfect, right? So it's like your brain is in your head. If you hit your head and you know, obviously, then you won't be having a bleed into your brain um or contusions on your brain. And that's gonna cause upper motor neurone lesions, damage to motor cortex. I mean, like, yes, you're right. That's in the brain, I guess damage via trauma was a traumatic cause. Obviously, you know, going back to a surgical safe, well, hemorrhagic stroke is vascular damage. Um you know, encephalitis is infective damage um or like atb meningioma, like atb abscess would be infective damage. A cancer would be neoplastic damage. So like, I think that just highlights maybe the importance of life being a little bit more specific. But absolutely, like if, if your motor cortex is injured that will give you enough in your vision. OK. So that is the upper and lower motor neurone lesion section. Hopefully, you know, explained it in a way that helps it make a little bit more sense for some of you. Um obviously, for other people, you know, you always keep looking to when you find a way that clicks for you. But hopefully that makes a bit more sense of those kind of classical patterns of science. And please do put any questions that you have in the chat or anything else. If you're still not clear on why that is, I can really try and reexplain it for you. Um I think just to kind of tie that back in. So I know don't talk about presenting this is why I'm talking about how when you're presenting, you wanna package that up really nicely for the examiner. So if I'm trying to present to them, somebody who's had a stroke, what I'm kind of doing is making my case for why I think they've had a stroke. Um And something's after the chat, what endocrine issues would cause upper motor neurone lesions. That's a good question. Um Of the top of my head. I um I mean, like something like central pontine myelitis, I guess like if you have an endocrine cause of low or high sodium and then you correct it too quickly and you start kind of frying your brain, um which is probably in Mirren's lectures. So, you know, some of these will be more or less helpful. Like, I think in this case, you know, if IE something like lead poisoning might be a more kind of interesting thing to think about, but often if you wrap your brain a little bit, most of these will be applicable for most things and even if you get to endocrine, oh, I really can't think of any endocrine causes. You've still got kind of 10 things that you could now go ahead and investigate. Um If you're really struggling, the answer is always H I VTB syphilis or cancer because those will cause anything. Um But I think your examiners will realize you're taking the piss if your answer to every Viber question is H I VTB and cancer could cause this. So maybe not the best um strategy but definitely useful in a pinch. Um But yes, like I was saying, so with the presentation, it's really about trying to package it. So if I was presenting a stroke patient, you know, if I say to you, oh, this is Mister Smith and he's 65. I did a neurological examination. So I had to look around the bed. Um and I saw he had a cane and I had a look at him and he looked ok, he had a bit of maybe drooping of his face. Um And then I examined his power and it was reduced on the left hand. So it's like you kind of get to the point. And I think this is often where I kind of see year three students go a little bit wrong. They feel that the purpose of their presentation is to tell the examiner what they just did. But I in the exam and the way you show the examiner that you know how to do a neuro exam is to do the neuro exam and then your presentation is about selling them on what you saw. So if II always start my presentation with my different, I'm sure. So I would say today, I saw Mr Smith, a 65 year old gentleman um and completed an upper limb neurological exam with findings um su suggestive of an upper motor neurone lesion caused by um an ischemic stroke. Um Mr Smith appeared comfortable at rest um with a walking aid on examination. I noticed he had um reduced power two out of five on the left hand side, five out of five. On the right hand side, he had um spasticity on the left hand side, but again, not present on the right hand side. Um He had, and he had um hyperreflexia, not on the left hand side. Otherwise, no abnormalities of sensation coordination were noted to conclude this is an abnormal neurological exam with findings suggestive of a rightsided upper motor neurone lesion. My primary differential here would be an ischemic stroke, but I would also want to consider um a neoplastic cause such as a metastatic cancer or um an infective cause. Although that would be, you know, so you kind of see how that's packaging it all up. I tell the examiner what I think it, I tell them why. I think that ideally probably more succinctly than I just did that I could have been way more succinct and then I give them three differentials without them even having even having to ask. And that's how by knowing the patterns and being able to apply that in your exam, you can look potentially really quite slick because you're not going there and noticing the findings but not knowing what they mean, you can put that picture together if this is an upper motor neurone lesion picture, which means there's a problem in the brain or the spinal cord and then stratify that. So I want to think about vascular causes. I want to think about infective causes. I want to think neoplastic causes. I wanna think about all of these potential causes because also if you think about it, even if he has had a stroke, if you saw him in A&E, he would want to potentially rule out some of these other things and some of them might be more or less likely for certain reasons. So for instance, a meningitis, what we call bilateral upper motor neurine symptoms and that comes back to this kind of um image that we looked at about where the lesion actually is within the brain. Um So if, if you see, if you've got a kind of problem in the spinal cord, you might get symptoms just in your legs, but your arms are spared or no symptoms above the neck. Whereas if you have something in the motor cord has like a stroke, you're more likely to get this kind of classic hemiplegic picture. And obviously, infection tends to affect, you know, a large part of the brain. So you get kind of quite a bilateral picture, but that doesn't mean it's not possible. Um But then the question, so thoughts of promoting your own nation, any questions, please put them in the chat and we can go back through. But hopefully that's clarified up the differences for you. So that's a tip for I think you asked for and that has talked about why that is very useful for putting it together in a presentation. So we've covered that as well. So before we move on to talking about um systems review, which that was another thing that people asked for. I just wanna flag what, you know, we've talked about this, this is obviously very important. This is something that comes up over life. However, they are not bringing anyone with a stroke into your exam. So the question you need to ask yourself before going to your neuro of is what can an actor reasonably fake? And the answer to that is a peripheral neuropathy. So when you touch them with the cotton wool, they can say I can't feel it. And when you ask them to move that arm, they can kind of say no, I can't move my arm realistically not sensory. It's gonna be a peripheral sensory neuropathy. But that is what they do in the neuro exams because any other con collection of neuroscience is just not fable consistently for three days. So I think about what do I prepare for my exam, prepare your peripheral neuropathy presentation in a really slick way. Now I'm not saying don't prepare the other, you know, like be prepared. This is about going to be a good doctor as well as for a good exam. But this is what will be in your exam if they decide to have pathology. Um And the reason I talk about this is a really good piece of advice I got given by one of my consultants in year three was that when you go into your exams, you should know from basically looking at the patient, what it could be and be prepared. So a really good example of that is, and you know, you guys can put in the chat with the parliament. If you went into a a room as we've just talked about and you saw an elderly patient with their arm, it's quite stiff, they're holding it up against their chair, their um chest and they've got a walking stick and they've got a drooped mouth. What signs will you be looking for when you examine that person? Obviously keeping your mind open? But what are you expecting to find? Give you a little bit of time. We have, we have just talked about this. So hopefully it's not the world's most difficult question. Yeah. So they put reflexes of spasticity, upper motor neurone signs essentially. So, because they look, you know, they look like they've got rigid arms, they look like they've had enough motion. So when you're going in to your neuro upper limb or lower limb exam, if you get it rather cranial nerves, it's either a peripheral neuropathy or nothing. And you can kind of have that in your mind as you're examining. So, building what we've been doing before, can anybody give me three causes of a peripheral neuropathy? And remember by that, I mean, one of the peripheral nerve, so the nerve that not in your brain or spinal cord is not working, what could cause some of the nerves in your body that is not your brain or spinal cord to not work essentially. Ok. So you've got one response in the chat. I know you've had a couple of people. So let's um give it a couple of minutes, see if you can get two or three responses. This is a really key bit of knowledge for your neuro oy, for the exact reason I've said that this is one of the things that could come up. I can see a few. I know um some of you guys were using ment before. So if you're struggling with using it, just let me know. But you've had a kind of response. So one person said chemotherapy, which maybe um I've never heard of oxaliplatin. So I trust you maybe. Um and also diabetes now completely. So diabetes is really, really common cause of sensory neuropathy, the high high levels of of sugar down your nerves over time as I put Charcoal Married tooth syndrome, which is a very clever choice. Um And yes, that is a cause of a mixed peripheral neuropathy to get with sensory and motor causes. It's one of those weird congenital diso disorders that like you read about Wikipedia and then forget about basically yes and B12 deficiency. Lovely. And I'm really glad we've got three because in an exam, the golden rule is three differentials. So if you get a page an actor, OK, you have a peripheral neath or three differentials. That's great. And again, this is from the essential examinations text which is a great textbook and they divide it into sensory motor and mixed causes. Um I would say you're probably you're likely to get a sensory neuropathy with diabetes, renal failure. And plus B12, I think in my exam though you said diabetes B12 and HIV because I want it to be special. Um But I think this is a really good summary of, you know, if you remember three of these, um, your neuro oy will go really well. And then the next couple of things, I've got, I've got two nice tables of, um, peripheral nerve palsies, which may again come up in your neuro exam. I'm not gonna go through those because it's boring and you just have to learn it. I want you to put those in when you're going back over the slides. That's something that is worth looking at it is worth having your flash cards. It can come in year three. So these are, these are like the big scary tables that maybe still a bit familiar from from year one and year two and they can come back up. And then the other thing is just being clear that there are these kind of four neurod conditions that have very specific patterns of signs. So, motor neuro disease, subacute generation of the Chord Syringomyelia, which is actually very rare and causes is weird like cape like distribution of sensory loss um and multiple sclerosis and that's not probably gonna be on your oy, but worth being aware of if you see a question or something you're like, this doesn't look upper motion urine, this doesn't look low motion urine. I'm a bit confused. The culprit is probably one of these quite specific conditions. Ok. So we've gone through upper motion urination and signs and then the final thing that people want to talk about was systems review, which I think is a really good one. And then hopefully we'll have a bit of time for questions at the end if you guys have any questions or we can finish a little bit early and you can get your um Tuesday afternoon back. So, and this is just with, thanks to Dr Javed Akhtar who's uh an F two now. Um I'm an eximer student because a lot of this is from his teaching to me on history taking, it was really good. Um I basically essentially kind of stressed that taking a history for your ACY is a little bit different from having attack somebody. It needs to be very structured. So if we're talking about systems with you today, I'm gonna kind of skip to that, but there should be a lot of in here that give you an idea about how to structure and how to make sure you're covering everything. And this is just like how I personally like to structure a history and you may like this, you may not, obviously, there's lots of different ways of doing it. I found this really effective. Um And if we start with two open questions, an offer that will get you most of the diagnosis, I then do a history of D complaint. And um the great takeaway from Dr Jz A is to my mind, Grossa, which is just Socrates rearranged. So it's in an order that makes sense. Um because I always found Socrates really difficult because I would kind of start with sight, but then go to onset and then come back to power. It just felt like you were kind of going in this order. That didn't really make sense. Whereas if you reformulate it as scrote, so you've got cr which all kind of about pain and then you've got two questions about time and then you kind of go into like the more kind of other things at the end. So I really prefer this and you've got it here in case this is helpful for you too. Um And then it's systems review. So where I think people often go wrong in the systems review is you get taught to do top to toe, you get told, just ask random questions about any bodily system. The problem with doing that is you're not getting useful information and you're showing the examiner that you have no idea what you're doing. You're just throwing shots in the dark. The goal of your systems review should really be to look at that specific system. So for ne if you think about what are specific review, like neuro related questions to review your neurological system, you know, you can ask about headaches, you can ask about, you know, all this stuff, I'm not going to read it out. And for me when I'm going top to toe, rather than just going top to toe and asking like €1 question. One gastro question, you're trying to keep it all relevant. So for instance, let's say you have a neuro patient who has a headache, you actually do want to screen them for all these other neuro related things. Um And then similarly, if through your history, you think, I really think this headache is um you know, migraine like you might wanna ask, then the specific question about visual disturbance because that's related to migraine. Are they getting any or are they getting anything like that? But in general, what I find really helpful and I have this, if you guys want, want me to share it with you is having for each system, a list of all these screening questions that are that specific system. So in your system review, we're not kind of going wild um and asking random things, but you're tailoring that system and you're showing the examiner, I know what this is and I'm asking relevant questions and that can be important as well because let's say you have AAA blackout a falls history. That could be, that could be anything that could be neuro that could be cardio, you know, that could like somehow be gastro like they've been having loads of diarrhea and they're really dehydrated or something. So if you're getting that full history, you're thinking this really sounds like an epileptic fit actually asking neurosystem review questions rather than a bunch of cardiology questions shows the examiner that you're going down the right kind of pathway in terms of what you're thinking about. So for my system review, ideally, you could ask like all of these, but I would say if you're worried about time or if in doubt, try and kind of pick three and you can still go top to toe, that is useful to help you think through those questions and like trigger them. So if it's for you doing my toe, ok. Head, so headache, um put your brain up there, memory problems, visual problems, hearing problems, swallowing problems, falls, going down the body, ok? Like your limbs like muscle weakness, your arms are you driving, you know, coming down to your bowels, all of that. So the top to toe practice would be useful to structure that. But try and think about it in terms of the actual system that you're looking at and then I personally so is a semon that you can use um for some of these circumstantial questions which I tend to throw in systems review just because they kind of like fit there. But you can obviously it's not really a systems review, it's more of a like life review you could call it um ok. This might not be relevant for everything but you know, it's a good trigger, anything effective ask about travel, you know, you again, have they actually have you hit your head that could really change what you're thinking about? Um and diet exercise and rest, you can maybe leave depending on how relevant you think it is. But it again, it is useful more broadly to take a broad history. And I would then include you surely you will know flaws. I hope um I would include that in my system for you because these are kind of systematic questions about like we talk about constitutional symptoms, they affect your whole body. So that's kind of my take on how you would systems review and then like to chuck in ice before we pass by 50 drug history, family history and sexual history, which should often be quite open and sharp. The I think I will often give you a hint about how much of that you need to go through. Ok. So just building on that idea of going through it systematically, um maybe give an example of a kind of system review question that you asked for a headache history. So making sure to go through all the other neuro kind of things that could be happening and then to a bonus point why that might be relevant to a headache history. Yeah. So one person I mentioned vomiting because of encephalitis. Um so vomiting isn't, wouldn't necessarily really be associated with encephalitis. So encephalitis to be more of a kind of seizure or personality changes, loss of consciousness kind of picture. Um But definitely like vomiting, you know, I like the the fact that you're linking it together. I think thinking about vomiting. So that could be relevant to like raising the cranial pressure, which obviously is a cause of headache. Um But you know, that makes it a really relevant question to ask when it comes to headache. Um, you know, relatedly I think in a headache history asking about, you know, in all neuro his history asking about bladder and bowels and that might seem a bit random. But that's because you're saying like PDO are basically could, could there be some kind of cord compression going on? Whereas if you just ask about, say tummy pain, that's maybe not really relevant to Europe. And the exam is gonna be a bit confused whereas you want to be able to justify back every question and the same should go for your systems review rather than taking this like quite scattered gun approach to it. OK. So we have a few minutes left. This is just again, what they can put in your osk, what you could prepare for the osk, everyone thinks of headache, but it's worth remembering that you can get falls, you can get limb weakness in my osk. We got tremor and it was hyperthyroidism. You can, they can try and pull some things out of the bag. And this is just an overview of like taking a falls history because it's a little bit different with the before during and after structure. And it's probably the only kind of history in your OSC where you have to take a, a history structure differently for the rest of your exam. So I'm just gonna be really cheeky and show you the feedback form before I go to the final questions. So hopefully you all get a chance to fill that in and then you can ask questions on Monday um or in the chat if you have any following questions, I think hopefully that's covered the things you guys wanted to cover. We haven't reinvented the wheel and I hope that's made it a lot clearer for you around upper motor neurone lesions, lower motor neurone lesions. Why you're presenting and how to do the systems reviewing your neuro history. So, fingers crossed.