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OK, great. So, um today we're gonna be doing a short presentation on neurology. Can everyone just someone let me know in the chat? They can all see this is working? Ok, great. Thank you. So, some objectives, we're gonna take focus history for a variety of neurological pre presentations, identify relevant symptoms for common neurological conditions. Talk about how we might appro uh approach a sort of counseling station and we're gonna apply the counseling structure that we learn to epilepsy. And then at the end, we'll briefly talk about uh some lumbar puncture results. So first history taking. So the presenting complaint, collapse or a seizure. Does anyone have uh sort of structure how they might approach a question like this? If you could pop it in the chat? That would be great. Yeah, exactly before during and after. That's exactly what I was after. So we wanna sort of find out what happened before the event. What were the circumstances of this event? Were there any identifiable triggers? Like head movements, exercise, prolong standing, maybe sometimes it might be like after a meal. Is there any sort of intercurrent illness have they been? Well, uh it's also sometimes important to find out about posture. Were they standing? Were they sitting, were they lying down before? And were there any sort of prodromal symptoms? So they might have been warm or hot or a bit sweaty and a sort of vasovagal episode. Um, in epilepsy, they might have sort of deja vu and other sort of sensory symptoms, chest pain, palpitations, dizziness or shortness of breath might also just point us towards a more sort of cardiac cause. So during you wanna find out, have they lost consciousness? This is really important. And then how long were they, did they have this episode for? Was there any sort of motor symptoms or any movement? And you wanna clarify, what sort of movement was uh occurring? Was there any tongue biting or loss of bladder or bowel control might point you towards sort of epileptic like uh cause? And did they look blue, did they hit the head? Was there any sort of other injury that occurred during the event afterwards? You wanna ask about confusion? Did they have any sort of postictal like face or were they confused? How long did it last? And maybe it might even still be present? Uh You might wanna find out if there's any sort of postevent tiredness, any focal limb weakness and how long it took them before they were sort of fully recovered? You might also then wanna just ask, are there any new symptoms now? So are there any breathlessness, palpitations, chest discomfort, that sort of thing. And after you've done this, it's just like the same as any other history you wanna find out has this happened before? And then past medical history, medications are quite important here. If they can contribute to a fall or a seizure or a collapse family history, especially sort of sudden cardiac death, you might ask about her and a social history. Ok. So that was collapsing seizures now for headaches, it's a bit more. Well, it's quite simple headaches. It's just like any pain sort of history you were taught about from quite early on in medical school. Uh Socrates is a really good structure to apply before I apply a Socrates structure. I usually try and establish a timeline, try and get that very clear. So, were there any preceding events? When was the onset? How long has it progressed? And has it happened before? And then we can talk about the sort of site and that might point you towards certain uh headaches, the onset, the character associated symptoms is quite important in headaches. Is there any sort of sensory speech or visual symptoms that might sort of make you think of an aura like picture? Is there nausea, vomiting, photophobia that might get like a migraine or is any sort of nasal congestion or like cremation, like you might say in a cluster headache, exacerbating and relieving factors are also quite important headaches or of valsalvas, menstrual cycles. Or medications, sometimes even finding out about people's caffeine intake or any alcohol consumption can be quite useful. Also in a headache history, it's really important to ask about red flags. Now, can anyone list any red flags in the chat function for headaches? What might you want to know in a oy headache, sort of the red flag symptoms, or what they're testing you on a lot of the time? Yeah. I found the headache very good sort of pointing towards a subarachnoid. Maybe vision changes, focal neurodeficit, very important waking from sleep. Yeah, that's very good. Lauren neck stiffness, nicer. Maybe a sort of meningitis like thing, weight loss, night sweats. Yeah. Classic bee symptoms. Very good. Worst ever, very sudden onset. Yeah. So it looks like you, you were alluding to sort of subarachnoid hemorrhage. Very good. So there's a few I've got, there are more but, but vomiting, visual disturbance, neck stiffness, fever, dizziness, rash, weight loss, seizure, seizures, neurological deficits and sudden onset severe very good. Also in headaches, it's important to ask about the rest of the history like we always do. But medications are important. These can cause headaches and how is it impacting their life, correct history, taking for weakness or altered sensation again, a Socrates uh structure here can just keep you on the right track. Uh Like I said, I prefer to sort of establish a timeline first and ask about previous episodes and then go into uh the details of Socrates. So, what is the distribution of the weakness? Is it your classic unilateral that you might see in sort of a stroke or is it a glove and stocking or is it bilateral onset, sudden gradual? You wanna characterize what the sensory phenomenon is? Is it parathesia? Uh, has it moved, is it radiating anywhere? Is it developing? Is it getting worse associated symptoms? Yeah. So, respiratory symptoms are really important to ask about in a lot of weakness, histories, like in GBS and myasthenia gravis, which we'll talk about in a bit. It's just really important to ask about how their breathing is. Um, bowel and urinary issues might point you as well, maybe more towards like a cord equina or a sort of spinal cord compression. You nice. Has it progressed anything that's making it worse? And what is the severity? How weak are they? And just as we've said, you complete the rest of your history using a normal structure, doing your systems review past medical history, medication history, family history and social history. Ok. So now we're just gonna talk about a few uh common osk sort of conditions that come up under urology. So, quina, this is compression of the nerve roots of the corner cord, quina supply sort of sensation to lower limbs, your bladder, your rectum and your perineum. It also has motor innervation to like lower limbs, anal and urethral sphincter. And it also provides some paras parasympathetic innervation of the bladder and rectum. So if you have compression here, you can get symptoms which will affect um what we just discussed. But the cause is most commonly, it's a herniated disc. You can also get uh metastatic can cancer and spondylolisthesis, which can also cause it. So the spinal cord, does anyone know what level the spinal cord terminates? Because a cord equina is actually produces low motor neuron signs it's not a upper motor neuron. So I don't know. 01 O2, great, you will know this. Ok. So called a recliner, the features and red flags. When you do any sort of back pain history, it's quite important you go into this. So you ask about sub anesthesia. Is there a loss of sensation around the genital? Sometimes people ask if there's a change in sensation when wiping um bilateral sciatica, it doesn't actually have to be bilateral, but uh it's a concerning sign, bilateral sort of weakness in legs. Um and then signs of urinary retention which can eventually lead to sort of overflow incontinence. And also you get can get fecal incontinence um on ad re as well. Some people uh may present with sort of reduced anal tone. However, this examination is sort of um a bit contentious about whether it's uh not necessary. Ok. So what do we do if we're suspecting cor requirements? So they need an MRI as soon as possible. Um And they will require neurosurgical input because they need decompression to protect those varies. So actually, before I do this, does anyone, can anyone just briefly tell me what the difference in signs are between upper motor neurone and low motor neuron signs? This is sort of classic husky staff. Yeah. Very good upper neuron signs. Spasticity, hyper reflex here, increased reflexes. Yeah. OK. So this next slide is demonstrating the difference between corna and a metastatic spinal cord compression. Um chord quina as we discussed uh is below the level of the spinal cord. So it produces lower motor neuron signs. Whereas metastatic spinal cord compression will obviously cause upper motoneuron signs. So, like you guys have said in the chat, low motor neuron signs include sort of flaccid tone, bilateral weakness, reduced or absent reflexes, absent plantars. Whereas upper motor neuron will produce increased tone, brisk reflexes. You might see upgoing uh planters fasciculations. That's a good one that's also been added on by Emelia. Ok. So Guillain Barre syndrome, this is an immune mediated demyelination of the peripheral nervous system. So, B cells create antibodies against antigens on trigger pathogens. These antibodies then attack our sort of peripheral neurons and it causes like an acute symmetrical ascending weakness and there can be some sort of sensory involvement. Often there's a preceding illness caused by the trigger pathogen. Commonly, this is Campylobacter Jejuni which is produces like gastroenteritis symptoms, but there might also be symptoms of like a flu like illness. So GBS symptoms typically begin within four weeks of infection and back or leg pain is often the first symptom you see, and it's progressive, so it's get worse and it's symmetrical weakness of all limbs usually beginning in the feet and it progresses upwards. Um It produces low motor neuron signs like we talked about the absent or reduced reflexes, flaccid paralysis and the symptoms peak at around 2 to 4 weeks. Um, the respiratory muscle weakness is the really sort of concerning feature in GVS. So it's really important that this is monitored and in an AUS, if uh you have to discuss anything about GBS, always talk a bit about the respiratory function. Um Cranial nerve involvement. Yeah, that might also sort of produce double vision or facial nerve weakness. Ok. So what do we do with these guys? You need bloods to exclude sort of secondary causes of weakness. Microbiology might be useful. Uh You can sort of maybe find out your causative organism. So like Campylobacter serology could be useful lumbar punctures. So, does anyone know? Oh, I've written it here, here we go. So does anyone know what albuminocytological dissociation is on a lumbar puncture? When we do this lumbar function, we're sort of ruling out other sort of uh GBS mimics. Yeah, that's exactly right. Amelia, all it means is there's just an isolated rise in protein, quite a nice easy one to spot. Maybe in a ay only the proteins raised, you know, it might be GBS So, nerve conduction studies, neurophysiology, um if you perform that, it will reveal like reduced signaling. However, it's actually not normally abnormal until about two weeks into the illness. So you're usually diagnosing and treating before you have nerve conduction studies to confirm and management. So, VT prophylaxis is really important because pe is actually the leading cause of death in GBS patients and they can't move, they're more likely to get clots. Um IV IG plasmapheresis, I'll need swallow assessments by speech and language. And like we talked about monitoring, respiratory function is really important in sort of severe cases that go into respiratory failure. They'll require sort of intensive care input and probably ventilation and that's multiple sclerosis. So this is a chronic and progressive autoimmune condition involving demyelination in the central nervous system. So the immune system attacks the myelin sheath of the neurons. It's very common in common in young adults. More common in women. It is classically described as disseminated in time and space causes genetics. E BV. There's an association with low vitamin DD levels. So it's more common in northern hemisphere and smoking and obesity. The symptoms of MS optic neuritis is the most common presentation and that's just uh demyelination of the optic nerve. How long does the space and time separation need to be? That's a good question, Paul. So I'm not sure of the exact answer, but I think it needs to be demonstrated on uh two different MRI scans at different times. I don't know how long the interval needs to be though. That's worth, uh, having a look. And you can, uh, let me know, um, what we talk about optic neuritis. Yeah. So you get reduced vision, sort of pain with eye movement and impaired color vision. And on examination, you might see like a relative, afferent pupillary defect, sensory symptoms are also quite common in multiple sclerosis. Uh, and that can present like a trigeminal neuralgia, sort of paresthesia, maybe a sensation of being wet or a burning sensation. And you might also see Lait sign uh which is, that sounds like a French name. So forgive me for my pronunciation, but it's when you flex the neck and it produces electric shock like uh pain down the arms. The symptoms of MS largely depend on where the lesions are. But on the side here, we've got a list of quite common symptoms. So, foot dragging, leg cramps, tiredness, increased urinary frequency, bowel dysfunction, increased tone, increased reflexes and uh sort of unsteadiness, imbalance in coordination. OK. These guys, they need MRI of the brain and spinal cord and in the lumbar puncture, we're gonna see oligoclonal bands in the CSF. So the management, first of all, the nonmedical management, um these guys need some exercise regimes and physiotherapy. They might also need some D VLA advice and to be given a nurse, uh hotline like an MS specialist nurse hotline. And then the medical treatment can be divided into three parts. It's acute preventative and symptomatic. So the acute treatment is sort of high dose steroids, IV methylpred. Whenever you're thinking about giving someone a high dose steroids, you need to think about PPI cover and sort of steroid counseling, steroid side effects. The preventative treatment is using disease, modifying therapies and this is sort of managed by a neurologist. So I wouldn't get too bogged down in the details of that. But symptomatic treatment is the sort of thing that you might um tell a patient about an annoy, which is quite good uh to have up your sleeve. So, SSRI S are used for sort of fatigue and depression that's seen in MS amitriptyline is used for sort of neuropathic pain, urge incontinence. You give oxybutynin and for spasticity, you give baclofen. Mhm. So myasthenia, this is the last one. So it's an autoimmune condition that affects the neuromuscular junction causes weakness that progressively worsens with activity and improves with rest. Unlike GBS, there's no sensory involvement in myasthenia. It affects women under 40 men over 60. And there's a strong association with Thymomas and myasthenia might actually be presenting as a paraneoplastic syndrome of the Bino. So what's going on? The acetylcholine receptor? Antibodies bind to postsynaptic acetylcholine receptors, it blocks them and it prevents stimulation of the muscle by acetylcholine, the more receptors are used during muscle activity, the more they become blocked, less stimulation of the muscle with sort of increased activity with re with rest as well. These receptors are cleared and the symptoms start to improve. So the symptoms here, it worsens with you as we've talked about and improves with rest best in the morning and sort of worse in the evening. There's also it affects the proximal muscles of the limbs and the small muscles of the head and neck. So you get issues climbing stairs, standing from sitting, lifting your arms above your head. You also you get double vision, eyelid, weakness, sotos and weakness in facial movements. So sort of swallowing and speech and they're at risk of aspirating. Um as I've talked about several times now as well, asking about how they're getting on breathing, it's really important. So I've got a red flag shortness of breath up here. OK. So the investigations at management, as well as the acetylcholine receptor antibodies that you can measure. There's also two other antibodies that are important is the uh muscle specific kinase antibody and the low density lipoprotein related protein. Four. Yeah, I think so. Yeah. And um these proteins are just important in creating the acetylcholine receptors. So the antibodies destroy these proteins and it leads to a non functioning acetylcholine receptor. So they can all be measured. Um A CT MRI that's of the thymus, you're looking for thymoma nerve conduction studies. So, repetitive nerve stimulation leads to a detrimental response. And this is referred to as like an objective demonstration of fatiguability. The treatments include acetylcholinesterase inhibitors, just boosting that transmission in the neuromuscular junction, immunosuppression sort of steroids, azaTHIOprine uh mycophenolate is used and IV IG and riTUXimab at the bottom here as well. It says that thymex may, may be required even if the thyme is absent. So there's some studies that suggest even if you remove uh the thymus without a thyro member, the symptoms improve. Ok. So a myasthenic crisis, this is a medical emergency and it's an acute worsening of symptoms. Often it's triggered by another illness like an infection. And the worry is that these patients might not be able to adequately ventilate themselves and might end up requiring sort of bipap or maybe even invasive mechanical ventilation. Um So watch out for that counseling. Ok. So we're gonna talk about the structure of counseling and how you might approach it and then you guys can have a go at doing that in the OS session after. So boosters is the sort of one they've code blue have asked me to tell you about that's brief medical history, understanding concerns, explain and summarize. Um That's really good, but you can incorporate boosters into this three part structure that I like. And one of my friends Ben wrote, um first you're asking about them, so you're getting up to speed. Um before you go into the explanation often, what people say is we haven't met before. Could you tell me what's brought you in? And you find out and expand a bit from that. Secondly, you're asking, what do they already know? What do they, what constitutes a brief medical history? So it depends what university you're at. Um And how long you should spend on that. But now at Manchester, we have eight minute stations and they suggest that you spend about two minutes taking a history. Um and then spending the next six minutes of explaining. I don't know how that sounds to you, Paul. But yeah, the second point. So you're asking uh what they already know and what they would like to find out and here you're sort of including your eyes. Um Thanks. OK, great, cool. And thirdly, you're telling them the relevant info. So build on their understanding, explain all the necessary information and summarize um in the OSC if you use this structure, it shows that you're really listening and you're delivering the information that's sort of tailored to the patient. Uh And that shows you're not just sort of memorizing loads of scripts. So, epilepsy counseling, uh this is quite a simplified version of it, how you would go about explaining epilepsy. But I've got here. Epilepsy is a long term condition that affects the brain causing a person to have seizures. Then you might explain what a seizure is, uncoordinated signaling throughout the brain resulting in symptoms that they've come and described to you. This is assuming you've already taken your uh medical history and you're going into the explanation. Now, you then uh got to talk about what might cause the S disease. So here, epilepsy, it's again dependent on the patient in front of you. So it might be there is no specific cause. However, epilepsy is also caused by head injuries, resection, tumor and stroke. So it's quite important, there's not really much point of explaining all the other causes of epilepsy to someone if they don't, if it, that's not what's caused by epilepsy. So it's just about tailoring your explanation to the patient. Some things that you might talk about in an epilepsy counseling station. So he needs to talk about what it means for them to have epilepsy. So what are the impacts on their life? You warn about high risk activities, they should avoid, you know, having long baths with the door locked in case they have a fit or swimming alone. And here skiing again, just a high risk activity, driving restrictions is really important in epilepsy or seizures in osk. You must always ask about this in urology generally because um there are strict D VLA rules that's important uh to let your patient know about. Um it's also important to tell them about what might happen if they go into status epilepticus. So how you identify it and what to do. So these are prolonged seizures without a recovery. So it's over five minutes and you need to tell them how they manage that. So they need to carry emergency medication and the family and friends and people they live with need to know about how they deal. Um Sorry. Um and sewed up, ok, suddenly explained death and epilepsy. So this is also controversial about whether you need to tell patients about it, but I've included it anyway, GKI medics include it. Um but you can talk about how you can mitigate the risks of SUD A through medication adherence and seizure control medication side effects. These are really important, especially in women, there's lots of anti epileptic drugs that are highly teratogenic. So if it is a young woman, you need to talk about effective contraception. And if they were to, if they want to become pregnant, then they need to discuss with the doctor and manage their medications properly and then you can just tell them about the common side effects they might experience. But that's based on the medication uh initiated by a neurologist which brings me on to the next section. So the pharmacological management, as we just said, the antiepileptic drugs are tailored to the patient and this is done by a neurologist. So in an osteo, you wouldn't be expected to start um anti seizure medications that likely you'll be told to uh explain that about um the broader sense of management and what it means to have the diagnosis. Um They're also given emergency medications like we said, in case of stas epilepticus. And then you talk about the non pharmacological uh steps they can do so, avoiding triggers, um adequate sleep, avoiding alcohol drugs and managing stress. It is also quite important about uh well, it just sort of relates to about how it's important to take a medical history first because you can then find out uh if there are any triggers, are they staying up very late? Are they out drinking a lot? Um And we can manage that as well. Uh Recognizing warning signs. Yeah. So um maybe sort of sensations like the aura, they need to let someone know as soon as possible. And family and friends education. So you're teaching seizures, sort of first aid advice here and what to expect. So, this is actually my last slide, this uh short presentation, but my last one lumbar puncture. So, before we do this, can you guys just remind me of what we'd find on a lumbar puncture in GBS? And in MS. Does anyone remember? Yeah, exactly. GBS is the isolated raise protein oligoclonal bands in M That's very good. So here, I've just been asked to uh include a slide about the difference between viral and bacterial meningitis. I'm sure you've all done this plenty of times and aware of what the difference is. But just to put it in for one more time, bacteria, you see this rise in neutrophils, the protein raised and the glucose is usually very low viral. You see an increase in lymphocytes, really, the protein is also raised but the glucose can be normal or slightly low. Right. Do, does anyone have any questions? That is the presentation? If anyone's staying behind for Huskies, can they, uh, drop a yes into the chat? So we can sort it out. I would recommend doing it. It's really good practice. Right? Ok. Let's see if the facilitators are here. Yeah, I think they usually come around 740. So for the people who want to, it might be a five minute break then, yeah, just a double break. And then when, when they're all here, we'll split up everyone into the breakout rooms. But yeah, Paul in. Are you able to put feedback to the child? Unfortunately, I've got an empty QR code just said I'll do that now. Yeah, I'll do it again as well after the OY II. Don't know if there's two different feedback forms, but yeah, there's one in the chart now. Ok, great. Thanks for your help. Thank you for that. You're really good. Take care. Bye. So, yeah, everyone will probably about a be about a five minute break. And then for those of you who want to do the OSK practice, um, when you, when everyone's back around 740 we'll split you up into groups and you can do some ox osk practice. So just hi guys. So, um for the people who are here and still want to do OSK practice, um, we've got two breakout rooms today. So um if you just listen, I'll um send each of you, I'll just tell you which room to join. So if Deborah Janella and Lisa or Liza, sorry if I'm saying it wrong, join Ali's room and then everyone else. So Mohammed Puja and Thomas join um Wars Room. So Deborah Ade, er Deborah Liza and somebody else who's joined. Yeah. So everyone's great. That's great. Thomas, if you're there, if you didn't hear me the first time, um, you're more than welcome to join War's breakout room Warra.