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Um, yeah. Can you see that national hold Well, right? Yeah. So Okay, let's crack on them. So, as I said, I think this is the second one in your your oh, Siris on today, we're gonna be talking about neurological examinations. Okay? The students are often bit worried about this one. It seems to go inside a lot of fear, but it's actually probably one of the better examinations just because it's so methodical on. Hopefully, by the end of our or two today, you'll feel much more comfortable let knowing the steps and knowing how you can pick up a relevant signs that might come up in our skis. So the session is gonna run in introduction to the station that you'll see on the door you introduce yourself on. But why Neurological examination done, Then we'll go through an upper limits. I'm in a bit more detail, and there's also some nice pictures on videos of a couple of the signs that we want to pick up. After this, we have a bit of a break on, but there's a feedback forms I can fill in so you could get your certificates as well. Then we'll go into the lower limb and a bit more specific around. Some of the signs will see there, um, however, the relevant investigations, because that's obviously often the next step in your skis. So you're performing examination, your nail that. And then the instructor will say, Okay, what's next? There? We'll go through a bit of what we can answer to that in a couple of helpful Nouman. It's that help me in my finals and then finally, very briefly. We just have a quick look in your, uh, imaging and how we can, um, speak about any images that we see. So here's a general former of stations, you know, you leave it to your history, your examination. You may get given some data or scans and bloods to to a nice you might be asking for my clinical scale. So in mind, I had cannulation. I had urine dip for pregnancy test. Um, and then you might be awesome. Follow up questions so it could be basic management. It could be what further investigations do you want to do? A lot of it's just acting. It is, you know, quite different to really life. Those of you have been on placement will see the you know the history examinations are more runs of a far, far shorter to the ones that you have to do in your your skis. But you know, it's important to learn the full amount so you can understand everything that the doctors are doing when you're in the hospitals. Most important thing is just practice. So get a group of you. I I was lucky enough to live with some fellow medics, so we just sort of practice histories, practice examinations on each other, and it's good, especially in a couple of months leading up to your skis. Just do as many as you can because it's the, you know, the best way of cementing skills. And then probably the best piece of advice I have is that Oh, I had sorry, is that the hardest part is getting to the starting line. So the two months leading up to ask Is there incredibly stressful? You know, they're you're you're big exams of medical school. You sort of worked, you know, maybe 56 years to to get to this point. But once you're in there, it's it's really not as scary as you think you know, it flies by. And by that stage, you have a lot of knowledge. So it's just about being confident, getting to the starting line. Um, and you away from that? So today we're gonna talk about examinations on, and I know in the other session is that a few of these other bits of blobs of being covered. So just before we start, we're gonna get our brains in gear s. So if you can put any answers to these questions in the chart, these ones quite easy. There is, um, some more difficult ones later on throughout the session. If you've got any questions, I'll try and keep an eye on the chart. And I think the rest of us kids eating well, so on. So any questions that we have a well right for this one? Yeah, I'm sure most people will be able to get this. Um, yeah, yeah, yeah. Again. People seem to be getting this one. Um, interesting point. Polycystic kidney disease is what that is, and those with polycystic kidney disease and more likely to get the berry aneurysms in the brain, which, conversely, Vinto leading toe. Um, so the rocks Yeah. Gone. I think people are getting this one. So Yeah, it's pointing a seizure, but any space occupying lesion will present with a postural headache. Um, waking at night is is an important one to ask and then on vomiting and also also can give you an idea that, um, there might be something occupying space in the head. Yeah, Nice guy is important to ask about vision. Um, because you can get, um, a pretty nasty visual field lawsuit or vision loss with with temporal arthritis next one. Yeah, we've got one or two, so yeah, glaucoma. And then the final want to this little section short of mirrors, space occupying lesions. You get a similar constellation of symptoms, but typically young young females. And this is why, when we go through investigations in the bed, it's always useful to say fundoscopy cause it can take a pick up. Pick up, please. Um, okay. Great. Right. Let me want to looking at examination. So this is what you'll come to the door. You'll get your your two minutes to read the station. And this is the kind of thing that you'll see, and it's just working out in your head. How best to tackle the station then and then I'll give you some new Monix That really helped me, because on the day, often your your mind is moving so fast and you don't really have time to think so. The more you can do without thinking just means you're you're relaxing the day and everything we'll see. We'll come a bit. Well, naturally. So for all physical examination's these the important things we got to do it the beginning. I've got a statement that you can say that I said in mind, but it basically covers the so we always want to wash hands. Um, interesting yourself. Check who actually dealing with unexplained way with that. Always examine the patient from from the right side. With the neuro exam, you're gonna have to get them to move a bit, and you'll have to move yourself a bit when you when you test various muscles and stuff. But ideally start from the patient's right side, Um, really make a show. As I said earlier, it's it's about acting on when you're looking, make a show of looking at the patient, you know, spend a good few seconds looking around the beds. We'll have a bit of a talking a minute. But what we're looking for but, you know, very obvious walking aids or oxygen supplementation. Or, you know, anything that gives us an early idea of what what we might be looking for further down the line, systematic. And then your exam is a great one because you've got to check off a few a few of the same things in every exam. So it's quite easy to be systematic as long as you've got ways of remembering what the next step is and then finally put on a show. So, um, what you say the exam where you act, it's all gonna be exaggerated. You know, this is it's a bit like you're driving test. You've got to make sure that the Examiner knows that you know what you're doing. So there's a few different tipped into trucks I'll cover in the session. But most of all, it's just about putting on a show and trying to appear confidence in all times. So why do we perform your exams? So we want to have a look, see if we can find where a potential problem is so there's various ways of doing this. But the end. We've got to find out if there's a problem with the patient's motor system or if they've got any sensory loss, because this can then tell us where the problem is, whether it's in the head or the spinal cord. All peripherally. So if you've got a motor problem a most basic level, we need to try and work out whether there's an upper motor neuron lesion or a lower one s. So this is the the brain or spinal cold or the periphery so that the nerve root, the peripheral nerve, the muscle itself or the junction between the muscle in the nerve. This is just quite a help table. So when the slides get it sent out to you, this is worth learning one. But basically for a while, Upper motor neuron Lucian's. Everything goes up, so you get hypotonia. You get hyper reflexia on then, whereas with the lowers, you lose reflexes, you lose muscle tone on. You have to get things like the circulation's, which will see in a minute, and then things like weakness and paralysis could be could be president both. So how do we actually find out this information. So this is probably the most important slide when you actually come to do your examinations. So these are the steps that we have to go through. So we have to inspect. We have to assess their tone. They're power their reflexes and finding that sensation and coordination The way I remember this was is the physician really so cool? So when you're starting outside the door looking at the scenario and you see you've got to do an upper or lower motor neuron apple, our urological exam, this is the thing to remember. Is the position really so cool? And you just go through the steps and everything starts to fool? Quite. Actually, you can feel the time very easily on. Yeah, So this is the one to remember on Go through a bit more detail now what to do in each of these steps? So, first of all, we're gonna look at the upper level and how we examine the neurological function, um, of the arms. So as I mentioned earlier, this is just a good stock phrase that you could use it every examination. Um, it shows the Examiner that you know, What you do is if you can get this slick as well as the concluding statement at the end, it goes a long way to making a good first impression and a good, uh, last impression to the Examiner's. So my name is Harlem, and I'm a final year medical student. Before we start, Please just confirm your name and date of birth, so make sure you got the right patient and then just a brief explanation of what you're gonna be doing, so you don't need to go into any detail. But just having a bit of a look, testing muscles and testing sensation and then just clarify the patient understands and that you've got that consent. The little part of the bottom, I always ask. I guess it just conveys a bit of empathy. So, yeah, just to check any pain on also in your exam, you could ask about any tingling or any weakness. But as a stations, maybe about the examination, it's just important to check their in pain. Um, on def. They're not any pain. Make sure they know you can stop any point if they get uncomfortable. If they do have any issues, it's always important to compare side to side. So if they you know, if they've got left arm weakness and make sure you compare left biceps with right bicep because you'll have an idea of quite how weak they are possible inspection. So is so we look for as 100. And here any signs that might elicit any signs of my indicated problems. So, you know, eczema frames, walking sticks if they've got a tens machine or even anything with their general health. So any medications on the side and the oxygen on a good new monitor? This is swift. So, um, looking pretty scars, so we'll see a couple of the next slide. But, um, you know, various neurological problems may have been operated on in the past, and in our ski, you probably get told information. So it's important to, you know, really expose the above the waist of the patients and make sure we're looking out for any scales. Symmetry is a good one as well, because then that will give you an idea of, you know, if wasted on one side. Then then we know that there's a potential neurological problem. Circulation's, as I mentioned, is a lower Newton, um, lower motor neuro lesion on, then tremors Well, can can be a sign of neurological deficits. So here we've got so a Z look at the screen on the left. We've got a scar from carpal tunnel, which is a problem with the median nerve on definitive treatment is with release of the flexor retinaculum in the wrist there, So that could be a sign that they found median nerve problems in the past. Um, here, the patient's right arm. It's got some muscle wasting, so that's important, too. As I said earlier, compare between side and you can see here that it's smaller, indicating some atrophy it on. Then the final one is the circulation. So it's, you know, uncontrollable muscle contraction that that could indicate lower. Most in your, um, a lesion in the stage is also important to look at tremors. So here are three of the most common ones. So, firstly, central tremor actually quite rare. Um, it's worse if arms up outstretched, it's often bilateral, which you won't find in. A couple of other ones will talk about. It's improved by alcohol on day. Often there's a very strong family history um, of off the tremor, so that's important to ask if you suspect it. So it looks like this is quite obvious. Tremor worse, arms outstretched and often bilateral. Next is Parkinsonian, which is the classic pill rolling tremor. It's often you're up. You're not truly Parkinson's. Often start you actually. So, um, things like rigidity. The tremor will start in one side. There's a few other symptoms that you learn about as you go through medical school, so they often lose their sense of smell. They have a characteristic facial features, but the Big three are rigidity. Bradykinesia, which is We'll talk about a little bit in a bit, but it's difficulty initiating movement on then the classic pill rolling tremor. It looks like this, and then the final want to be aware off probably are stages, um, dystonia and the tremor that comes with that. So it's it's jerkier. It's actually more common than a central tremor on. There may be other neurological features in the in the rest of the body as well, whereas with the other two often the tremor is what what is noticed, So that would be jerky. So it's not as know smooth there's a zero of the others, I guess, and then we'll talk about about intention tremor later. When we go through a bit of the cerebellum problems and and test that we can do, two different you that. But that's that's one to be aware of is well, so we've done infection. This is just a quick one. A quick actually getting that, if you remember, is quite good, because it can give you quick snapshot of the beginning of your examination. Whether there's a neurological function on your little deficit that we need to be aware off on. It would indicate a problem with the corticospinal trucked, which is the main voluntary motor tract going down from the brain to your muscles. So this is how we tested. So we ask patients to hold their arms out in front with palms here to the ceiling and close their eyes, and we just wait for a few seconds to say so. So this lady's got a normal response. But if it was abnormal, this is what would happen. So the patient would pronating. There are with drift in indicating a problem in the courts conspiring pathway. Next, we're gonna assess the patient's tone. So this is basically, um it's the hand shakes. So you ask the patient to let their arms go completely flop it. But you take their hand in your arms, support their elbow, and you basically move their arm back and forth on toe assess whether they've got, um, high tone or low tone. And if they're struggling to relax, if the patient can't relax, and you and you, um, you think they're not fully well, actually, you can't elicit that's home. You can get them to try distract them so tough. Many were there. Other hand is quite a good way of going to relax as best they can. So this is just image that will show you how you do it, but so the patient is completely relaxed. You take the hand in yours and you move it around to check all the muscles up the rest jet their arm on height. I would obviously be stiff. Low tone will be overly flocking with high, too. You can separate it into spasticity and rigidity, and this is all to to do due to where in the spinal cord lesion, all the brain were big, so it's persistent. Is velocity dependent so fast you move the limb on the worst, the more tonic, the limb gaps and the stiffer it becomes. So I see, as you do a test for tone, it will become more stiff when you move it on. This isn't typically accompanied by weakness as well, and then rigidity with extrapyramidal lesions. So this is things like Parkinson's disease, but this is with involuntary movement, so this means that it's velocity independent. So with Parkinson's people, they'll be rigid all the time. Um, well, see, when I talk a little bit about gait, later will be up to see some of the rigidity that happens in Parkinson's disease. And there's two main types of it's called well, which is what you get in Parkinson's. So you've got the tremor on top of the the high tone on lead pipe rigidity as well after tone comes power. So here's what we want to compare side with side, so we get an idea of the patient's baseline level on. It's important to check the dominant side first so we know what we're comparing to. We want it greater power to five. So when we come to our concluding statements. At the end, we condemn her objective figure to to our findings. So five would be normal so they can, you know, they can push against resistance. It's normal power that that you are. I would have. And then four is slightly weak, slightly weak, but still relatively normal. Three would be their able to move against gravity, but no against resistance, so they'll be able to lift their arm in the air. But soon as you create any resistance, they're not able to do so. Um, Andi So on. So just learn every scale it is, you know, a good one to bring out the end that shows You know what you're talking about when it comes to power grading and power ranking with the phlegm. These are my terms that need to be tested. Um, so you can stop with shoulder abduction, So get the patient. You know, if it's if it's a child, you could say, you know, like a chicken. Hold your arms there on. You just gotta go through each my toe methodically. So we start with shoulder abduction. Then I'll be affections. This is testing biceps. So ask So hold the patient in this position and ask them to fill it to you on if they could pull against resistance, Obviously, that that would be a five of the scale. Oh, extension turned around around and awesome to push you away thing deflection, squeeze fingers, finger abduction on are some toe stop. You pushing their fingers together? There's a couple of other tests we can do is well, so you can do finger abductions. Like, for example, in this position, you can put a piece of paper between their fingers are some toe hold onto it and stop pulling away. Making a few test, um, action as well. But these these five cover the main myotome, which is important too. Test all of them in the exam. So if you do these five, um, you have a fairly fairly good idea of the foot ocean off. You know, the majority of their upper muscles in the nerve roots. So that that that comes power we've done is the physician on. We're on to really so cool. Next. So next comes reflexes, and there's three in three places for in the lower limb. We got a cover. So with the, uh, pollen. We've got the biceps reflex. We've got the triceps reflex. We've got super later, Um, with the triceps, you can use the reflex hammer straight onto the patient, but with the other two, it is easily to hit your finger. Um, often with researchers, because patients don't see it coming. They'll you know it'll be. It'll be hard to elicit a reflex. So one way around this is our patient. Teach their teeth, which which helps the muscles to relax. And hopefully you can. You can elicit a reflex with the low end that they're much easier than the upper leg. So the upper limits just about doing to practice. Maybe, maybe, by every reflex hammer or borrow one. I just just trying your friends to see if you can. You can elicit reflex, a sign that the, um, could give you some idea of of pathology. This is one where if you flip the temperature patients fingers as it showed in the video, if another finger or the phone flexes, that's a positive. Hoffman's reflex on again, similar to pronated drift into get injury to the corticospinal pathway. So if you find yourself with time in the Oscar which may not be a case is there's a lot to cover the neuro exam, but this is one that shows you know what you looking for. Um, and can you show you an injury? Show you if there's an injury present sensation? So these are the, um, things we weigh. Want to look up? It's important to get reference point, so ask patient to close their eyes because otherwise they'll just say yes when they see it so and then test monitor and make sure they can feel it. Make sure they know what kind of sensation there feeling for before moving on testing the damn tones. So here are the ones in the upper limit on the image there with the with the smoking adults where you want to test, I'll talk a bit about which sensory modalities we want to use. But here's where we test them on, but it's important to test each of them in each dermatitis separately, and you can also compare on either side. So we want to get a century level. So, for example, of something like diabetes, you often get glove stocking sensory loss so you wanna get a century loss either side where they feel up to, um, using different modalities because it can tell you a little bit more about where the pathology might be in the in the spinal cord. Next is is vibration. So rather than anything, the tuning fork on the patient or on the desk, or even on your knee a good way, just pinch the end because I think especially urologist, get quite fussy about how you initiate the tuning fork. So just pick the end on with this. You don't need to test every dermato. You just test approximately distillate approximately, but it's felt distally you don't need to move up. So this is about testing the bony prominences. So start off while you can see from the image. So start off on the bony prominence of the base of the thumb on. You could just move up if the patient feels that you don't need to go any further, Um, as it would indicate the trucks or untucked. Next is prone. Reception. Uh, so again, how special to close their eyes, we want to hold the joint on the side. So with the uh playing, we test the thumb lowland test, the big toe. So you hold the joint on the side, not on the tip, because they'll feel the pressure when you move it. So you hold on the side on, then show them what is up. What is down? Uh, so So they know what it feels like when it's up. When it's down on, then move it around the bear on, then awesome to tell you if it's apple down on this gives you an idea. If there proprioception isn't tucked, why do we wanna test sensation? So this is a cross section of the spinal cord. But the important ones for this part of the exam of these, though in the dorsal columns it's fine touch vibration and proprioception. So we want a test liberation proprioception in. You know, if they've got a problem with their with the post area of the spinal cord and then the lateral spot inflamx is pain in temperature, Which is why when we use the pin prick, um, we don't our level need to worry about temperature testing because the pain aspect off our sensation testing is covered on if that's intact. We know that they're natural. Spinothalamic tract is intact, but it's important to check one at least one modality from each of the door for columns in the spinal column attract in each dermato. So C five to t one bilaterally. So So we've got idea of, you know, the the level of spinal cord that potentially that could be a problem or is intact there, the whole of both upper limbs, right? The final main point of the your exam. So is the physician really so cool? Coordination? Piano playing. So just get them to play the piano in front of you and given idea of gross coordination. Um, and then picking up a pended or coin can tell you if they've got you know how good that they're fine. Motor skills are, um, finger to nose test again. That can tell you bit of it if they've got intention tremor or or any difficulties with syrup cerebellar function, which I'll go into a little bit in a minute. Um, this big old head just I don't. Coakley's Here is is one that gets bandage around in med school. I remember hearing in 1st 2nd year and thinking, you know, well, I think no idea what it meant. But It's just this option on its way of determining, um, whether patient has in talks about a function if it's not coordinated. So if they struggled to do this. And so the best way to do is demonstrate yourself first, say to patients, You know you want to get behind like this is quickly as possible. It's not most you know, people aren't used for this movement. So, you know, explained to them first that it you know, it is a bit complicated, but it's just a test that we do on. If it's not coordinated, it could be a sign of It's a lateral cerebella pathology. One point here cerebella problems cause it's lateral problem issues with neurological function. Where is with a lot of the brain? Um, it causes contralateral problem. So if you have a stroke, you have to get contralateral hemiplegia on visual field loss, whereas with the cerebellum, it's it'll actually on the same side as the lesion. So that's that's the absolute exam. There's a few things, as I said, I need to to make a show out of it. So how we're gonna finish up the examination so we want to explain to the patient examination finished cause Well, that day they may have had, you know, 10 exam, so they know it's come to the end. In reality, these patients may have never had a neuro exam before. So, um, you know, we wanna let them get, get closer together, and then relax so they know it's finished. We want to thank patient, um, and, you know, make sure you know that on any pain. You know, if they got me questions and then again we can wash hands and then a really good way of making it seem like you know what you're talking about. Uh, you know, even if you don't pick up any thought, a geez or the patient's completely normal, it's good just to have a a back concluding statement that you can say after every exam on it. And it just shows you you know what you'd be looking for. Onda. It's a good way to seem slept when you finish your examination. So again, when you guys get the slide, you can you can read through this, you put your own name. Ah, so but the patient's name? Um, if you find any findings, then you can include them. But I know in our our skis because of Cove, it they could really use actual patient. So it was, you know, we perform the examinations on other medical student, So, uh, you know, they weren't any findings, but so this is, ah, stock concluding statement we can use that shows You know what you're looking for. You know what you're talking about? Um, on. Yeah, Just just summarize it nicely and put a nice ending point on the examination. Um, always gets, remember, remember, the name and a judge doesn't. Particularly after if you forget, because obviously enough ski. You mind wearing a million miles an hour anyway, but always nice if you come, um, and then just just go through again. Just is the physician really so cool? So inspection tone, power reflexes, sensation, coordination. You know, you can say they were normal if you found any findings. Just say them, um on then a bit later, after we've covered lower limb, we'll talk about what we might say to complete the exam or if we get any questions about what the next steps are. But I got to go through that a little bit once we've covered lower level. But I think first initially, right. Well, have a break now. Or should we have a break after 11? They're human. Um, well, we should really treat crack on with this and have a break after. Yeah, that's fine. Okay, So lonely. So the general four months to say there are specific things you could look for in I actually, for lower limb, there's a It's a baby. Easier to test the big muscle groups bit more easy to elicit reflexes, even tone as well. But the overall, the overarching structure to the examination is exactly the same. And it's really nice because assume is, you know, you know, the six steps is quite easy to just put your mind on autopilot on work your way through it on any signs that might might come up, you know, become apparent as you're going on. But it's also uneasily to summarize at the end, you know, rather than with a cardio or restaurants out. You know, there's there's lots of different body parts to think about, um, the Santyl to jump out of random, whereas with this, they will fit into their their need packages and It's quite a nice way to, um, to think about doing examination. So again, is a physician really cut? So cool? So inspection is exactly the same. We look at the scars, wasted any tremors. And if circulation's or any regular muscle movements, um, as well as you know, just general signs of the patients overall health, you know, they come to me at rest. Um, so it's about she's very similar. It's important to, you know, get the patient exposed as much of the lower limits, you can get them to wear shorts, take the shoes and socks off, set him on the bags. Um, because especially, you know, with your exam inspection is a massive part of it. And you you can pick up a lot of Sinus just by looking toe, so this is assessed slightly differently. So you get them to sit, and then you basically wiggle their leg. So you ask him to relax as best they can. Um, you know, again, you could destructive um, if if they if they not relaxing very well, So get him to you know, um, you tap the other knee with their hand because you want to relax as best they can. So first you shake their leg from side to side and that give you an idea, then quite quickly, So the patient can't anticipate it lift up behind their leg. And if they've got if the hypertonic they're here will come off the bed as well because they're high tone means that you know, their their legs are relaxed. So there, the whole leg lift off the bed, and then a good one of the stages is to test the clonus. Susie conceive in the video, you pull it for intercourse infection on then, as you see in the video a number of beats against your hand so any more than three is indicated pathology. And yet so this is really a not promoting their upper motor neuron lesion. Um, So when you finish assessing tone, um, you know, But obviously check for. You know, we've already checked the pain and things like that beginning, but, um, it's a good way. A good way of assessing other patients got clonus after Tony comes power. And again, it's just about going through the my toes methodically so hip flexion, um, be with different doctors. And they say do it way. You can test the muscles at the same time. So, actually so if you come, you know, you could put a hand on, depending on how tall you are, but you could put a hand on on either 11 do them. Not so much protected action, but with quadriceps function, we can do both at same time. But with it fracture, the way to do it is well, it's the, um it shows. So you you ask them to keep that extra raise against you on again? We could use the MRC scale. So can they left it against resistance. Is it just against gravity? If they got any movements at all, you know, Is that is it just a flicker of muscle contraction, or is it no movement at all? Next is the extension. So with this week, we can do it Well, actually, two compared directly. But ask you to get the patient to to kick out against your hand against resistance ankle dorsiflexion so that as we used to test the clonus, But it's where they pull up into your hand. Big toe extension. Um, so it's sort of like a I'm extension about but seeing their big toe function. Finally, ankle plantarflexion pushing against your hands to assess for the S one nerve root. After power comes reflexes lower live The one probably have a nose, you know, since since they're in second school, that's what I perfect you look like. So most people won't have that much of not much of a reflex. That's a good way of testing. So make sure the patient completely relax, taken, hang their legs off the end of the bed If they struggled moving. You can't support their body weight and do itself. But I find this is the best way to to elicit the knee, knee reflex, Achilles tendon. Pull the pull the front door selection and you're looking for construction in the calf. And it's just striking on the Achilles tendon directly. And finally the plant a reflex, which, you may know, is the babinski reflex. So, um, some neurologist again, they're a bit funny about using the end of the reflex hammer s so you could use the you know what? We use the pin prick testing. Running up the lateral part of the foot it into the across the top into the media on a positive reflex would be the toe splaying backwards. This may happen in in some normal people as well, especially if they're particularly ticklish. So warm the patient before you do it that, you know, that is maybe tickly sensation again. We've got to go through the door terms. We want to check whether the dorsal columns intact whether the spine of filament column is intact. Um, again, you just gotta learn the dermatome so low where each of these different nerve roots supply on. Then we just got a test, the meat in turn. So again, make sure the patients I was closed so they can't just look and tell you when it, um you don't look and see when when you touch them on work your way up methodically after using the sternum or, you know, or the forehead t make sure they know what the sensation is going to feel like on then. Um, and then it's that each of the dermatome individually on the vibration. So again you move distillate approximately. If you if they can feel it distally, you don't need to worry about moving closer. So again, it's on the bone. Prominences So start on there. On the base of Victor. Move up to the medial malleolus on the ankle on, then the tibial tuberosity. If they can't, they can't feel it. Destiny. Finally, coordination A good one with the lower body. If they could sign if they could get off the bed. The long bone test. So this test appropriate options? Well, so, um, it requires the poster of the final called the dorsal columns to be intact. So as you continue in the image, you get him to stand up, are standing patient, close their eyes, make sure they know that you know, you're you're there to protect them if they if they do lose balance. But if they start swaying or if they lose their balance, it's interpreted a suppository. Romberg's test Onda It indicates seven pathology within the door. So, column of the spinal cord, the hell she shouldn't test. This is a bit similar to the flipping hand motion we did with the apple in, but it's just a way of determining if they've got coordination. So as we can see from this patient, they've got pretty normal coordination. Make sure that the patient left foot each time. So from the knee, Um, don't do that for a run the hell along, lift up, come back down and push down again because it's a movement the most people are really used to. It gives us a good idea of whether they're coordinated. And again, it's a sign, Um, you know, either they got lots of motor strength, which we can less it when we tested power. Or if there's a cerebellar lesion there. Coordination will be all over the shot, but they won't be able to do this like the video shows and then with the Lower Live. If we've got time again, it's important to check their gait so we can ask. You know, we could just observation. Took to walk across the room and back on. Do any gait. Abnormalities can become a parent. So with Norgay, we're looking out for a few different things. So we've got a taxi gate. This could be a sign of cerebellum. So at the back of the brain, any problems with that? And it's they need a broad based oh balance themselves. They're very unsteady on their feet. Um, and as I said it, it could indicate seven apology or sensory ataxia. So this is what what that would look like. So it's basically very poorly balanced. They need a wide based her to support themselves on, but they just generally look pretty uncoordinated. PARKINSONIAN gate So this was the bradykinesia I was talking about earlier, so it takes them a while to get started. So it's small stuff. Ling shuffling steps there often stooped over. You may notice a a tremor as well. Particularly, you know what side did in the beginning as I mentioned, um, and as they turned, they require several small steps toe turn around and get get going again. So this is what that was like. So you could see that the tremor and the apple ems and then the small, small shuffling gait and stooped over posture as well. Onda the branded conyza is is they struggled to start initially, um, before picking up, picking up pace, finally high stepping gate. So, um, I don't know if anyone seen anyone with foot drop, but it's often do to release of the common paraneal nerve. Um, and it means that they can't lift their foot in the normal way while they walk. So It's a weakness of ankle dorsiflexion so we can see in this patient's right leg. You could see that they can't lift the toes as they walk. So they have to that high step over their foot to insure they don't trip over. Okay, um, I've talked quite a bit about cerebellum dysfunction throughout the talk. This is a good way of remembering the signs that there might be a problem with the cerebellum. So if they've got any problems with coordination either the Hilton test or the flipping of fans that we saw you for the upper lip, that will be a sign that they've got probably the cerebellum attacks here. So if they call, you know, call in a voluntarily, Um, we've we've already seen this video, but a broad based gay lack of balance, but start most, which is flickering of the eyes. Um, as we can see here, intention tremor. So this is quite good. Walk two tests so as they so they may not have a tremor at rest. But as they move into position as they deliberately do something, they may develop a tremor, um, differences in speech. So a slight says that the cerebellum, perhaps control the tongue coordination on. So they may have a difference in speech. So, you know, pauses or emphasis on strange words. And then the h covers hypotonia a while. He'll shin test as well. So, you know, she's a good one to remember if you're suspecting there's a problem with their cerebellum. And as I said that he had, uh, the problems are often on the ipsilateral side to the same side as the lesion, which is different. Too much of the rest of the brain, right? I think it's probably time for a break. So Well, is that we say five minutes next. And then that's what's the time. Oh, she say so. It eight will come back and we'll we'll talk about investigations. So, yeah, see, a bone age? Is that right? Sounds good. Is you happy for the back home to be sent? Yeah, Yeah, yeah, of course. Yeah, yeah. Cool. Okay, guys. So we've known on your exam. Now, if you haven't, you know, picked up everything as we've gone. We could go through this like, you know, besides, will get sent out and you could go through them afterwards. But you know then your exam now. So what comes next? Cause often the next question is, um, more investigations. Would you like to run? So a good way of thinking about this is he boxes because again, in our skis, you're gonna be stressed. Um, we wanna live in the amount of thinking we actually have to do two only things that are different to what we know. Any signs that we need to pick up on anything about unusual. So the less thinking we could do better on a good way of doing this is just get you monitor your head that we can use that every station of what she walks is really good one to learn. So this is history and examination, so we can always say we do the other. So if we if we done and your exam, we could say, I'd like to take a full history. It's bloods, It's offices. So this this is things like a sputum sample, actually a swab year in debt, um, stool sample. So I'll talk a bit about specific ones to do your exam in a minute. X is X ray. So there's any scans that we need is the C g or with your Oh, it's EEEG. And then s is special test. So this is anything extra. So with our neuro exam again, he boxes, That's what we want, Remember, Makes it very easy just to go through what tests we need. What investigations? So, firstly, history exam. So just say you'd like to do the other one. So if you perform an exam, I'd like to take a full, thorough history from the patient. She's on history. I'd like to examine upper and lower neurological function as well as before my cranium. Nerve examination. So this is, um, with any your presentation, we could do an age we approach. If they're acute, we can always ask for basic observations. We can form a new full neuro exam. Is I mentioned and also crazy, You know, Example particularly endoscopy If there's anything, um, any cranial pathology that we're anticipating philosophy could give us a really good idea because we could see whether they've got papilledema, um, or any other problems with the eyes become apparent on fundoscopy on business, said probably in a Noski, you know, 15 minutes and we're not gonna have time through this. So it's important to say I before the full credit know examination, including the use of fundoscopy. Next is blood. So for pretty much any exam we can say for blood count, LFT is using these on inflammatory markers. So CRP s are. But it's also important to testicle ACOs, especially in acute situations, because loads of cases get forgotten. Low technologies get missed when it's just hyperglycemia. Next office is. So let's get a urine dip and then on to X ray. So imaging. So obviously with neuro, it's a head ct. But if it's if you're just putting a spinal problem that you could get a spinal MRI. So, for example, so when we look at specifics in, you know, when it's time called required, uh, we always want to get an MRI. But head CT, with a lot of the ureteral stations is gonna be the one that we want to ask for. EKG obvious again. Not not not completely, necessarily lot stations, but it's just a good way to, you know, monitor good way to all to remember. And often it's a BCG, um, that we're asking for on that special test level punctures a big one especially if we're considering anything like meningitis. Subarachnoid hemorrhage. Um, you know, I think that we we want to, um the where that confused about what's what's causing the picture, and it gives us a good idea. But with love, the puncture deported to rule out, um, if there's any space occupying lesion, so any tumor or issue in the head because with a lovely puncher if they've got a raise the train your pressure when you stick a needle in the spine t o do the lumbar puncture, you can cause a such a massive, decreasing pressure that that could lead to, uh, cerebral herniation. So it's important, as it says, only if there's no signs of space occupying lesion. So that's they haven't got any papilledema on the endoscopy on there's no signs of a tumor on her head CT. And then we can see. So this is a table that when you go to the sides, is just a quite a good one to remember for special test. So cooler recliner. We always want to get an MRI. That's gold standard, um, Teo to see if it is true. Quarter quite a syndrome, and we also want it before with PR exam because they get satellite just easier. They could get in constant incontinence, so that's important ones. Before EKGs a switch earlier with epilepsy or seizure, we could determine and brain activity of whether it's it's a true theory that we're looking up and also a Z. I said that these could be due to hypoglycemia, so we want to get a glucose on also any drugs or alcohol that can be in the patient systems. Stroke visual fields could give us a good side. So, as I said earlier, So if it's a stroke on the right side of the brain that lost to get a left heavy, um, almost hemianopia, which we can see individual fields and then cutting screen, you know, we want to get an idea if there, uh, of the coagulation. So with strokes, 15% are hemorrhagic. So this is so that's why we do a head CT. So a noncontrast head CT in the first place to rule out hemorrhagic stroke. But we're going to get clotting screen as well. Bloods. Oh, yeah, Aside mentioned. So a CT scan is the first line investigation to rule out and Roger causes on. Then we go the management of ischemic stroke, which is 85% off strokes. Um, and then you're up. These we want to get 12 glucose. It be able to say, because you know, diabetes is is probably the main. The main cause of peripheral neuropathy on the nerve conduction studies is is it always is always a good one to say in any neuro station, just quickly have CSF analysis. So this is for meningitis in the different causes of meningitis. The tables quite, you know, quite a busy one. So the way I like to think of it, these two are important. So you think of it as if the glucose is low. It's because the bacteria they eat it eat and all the glucose, so it's so it's low, and then the other one took to keep an eye on that, then confirmed differentiate between bacteria virus, which, which is what is that off to get often exams is it will be high polymorphous, it's it's bacteria as the neutrophils and high lymphocytes. If it's a virus on, it is just a couple more specific figures for when you guys get the slides, then just just very briefly interpreting imaging so less about one actually shows. But just how we present if were given some neuro imaging. So, as with us with all of them, we want, uh, wash your hands. We want check the name, check the patient. Sorry. Checkout date, birth. Basically identify that their scan was saying is that is the same patient as the one um, we've examined along with taking history from We want to stay the modality to a CT scan or an MRI, and we'll step the plate of images to this is three different ones. So we've got the such to play, which right front to back the same as the sagittal Sinus in the head. We've got the actual plane which splits the body horizontally on. Then we've got the crowed or played, um, which splits but vertically perpendicular to the substrate plane. And here we can see with, um, head scans the three different plane of imaging. Um, on. Yes. So? So that's just important. Something to mention time limit was taken. And if it's the latest one, um and then we can say, you know, have they had previous scans and and it's always important to compare with. Previous comes just a You're observation. So it's two. What do you see? So what looks different in the picture, you know, is there area of hypodensity So is the dark blood. Is it so, for example, damaged on the left? That would be an acute subdural hematoma because it's it comes up like I'm so so just say what you see. Then you can relate it, um, to the previous part of the station. So if this patient, you know, falling over and hit their heads if they were having headaches, if they lost consciousness. So try and relate your differentials and what you think might be going on with what you've already covered in the station, because it's, you know, it's probably going to be related to that. Um, So again, it's just about knowing different steps that need to be spoken about as you go through the exam aside, go through interpreting the image. Um, you are stage is medical students, you know, expected to know everything. But just to try and look at normal scan to be able to pick up what's different on potentially what your differentials are based on on what you actually see, I think, is what we're looking for. Really? When it comes to my skis, so get so hopefully we've picked up how to examine a bit more today. One of the last things we just will go through a couple more spot diagnosis is just to see if we're still on the ball. So here's the first one. Oh, I've already given it away. Yes. Again, you just put put the hands in the chart. Um, I'm we'll see if we get if you get so so as I mentioned so with, um, acute subdural hematoma. So So this is, um, within the meninges of the brakes beneath the juror on above the Iraq. No matter if it's an acute bleed, it will light on a CT scan, whereas if it's chronic, it'll turn dark over time. Uh, so if the CT scans So it was a dark, um really, that follows the capacity of the brain so it can cross suture lines so as opposed to an extra during the time of that looks sort of 11 shaped these world. So as we can see here. So it follows around the edge of the brain. Um, that indicates it's it's subdural. The next one. Well, this this was quite hard. It's just one of the one of these things that gets examined about often. If you see, is stabbing. This is what their hinting out. Yeah. Yeah, I think people are people are getting it. Um, great. Looks Well, yeah. Nice guys. I think I think people are getting it, so yeah, I will ask. This is the most common form of motor neuron disease. But if if you guys that you, uh, remember the ice bucket challenge from a couple of years ago. But that was yeah, for a last, Which is which is a form of of M and D, But your disease, nice one closes so often. Young women relapsing remitting pattern. So their report, you know, neurological problems that the study in older that improved relatively quickly on. Then there are, you know, six months where nothing goes wrong. Um, before you know, different problem on lots of vision, with pain on my movements, they can also get ready saturation where they lose the ability to differentiate to kind of read quite so well, they could get things like central scotoma is. So where they get a little loss of vision in the in the in the middle of the visual field. So this is optic neuritis. So this is swelling of the optic nerve, which is can be caused by the things, but it's pretty indicative of multiple sclerosis. So in any example, Westchester, because that kind of thing comes up in your, uh, skis, they're often hinting at multiple sclerosis, RMS, especially in younger women. This one's tricky, huh? Yeah, I'm not sure I didn't know this. So this is shock in my tooth? Yeah. Tricky. Well, um, maybe just something to look out for, um, if it comes up. So, yeah, I think I said I think we filled out the feedback forms. I don't know if you've got anything or more to art. No, Their feedback for me has been sent. Does that send it again this year? New taxes? Because you stopped recording