1. 4 patients falling over

2. Mrs April Aged 62 Complains of tripping up when she walks on uneven surfaces Falls over and comes to hospital PMH COPD Vegan Breast cancer 15 years ago

3. Well nourished Normal cranial nerves Normal upper limbs Lower limbs Bilateral increased tone Normal musculature Clonus Brisk reflexes

4. Questions What does this examination suggest is happening? Why was she tripping up? At what level could her neurological problem be? What might be relevant in the past?

5. Spastic paraparesis

6. Sites of upper motor neurone lesions

7. Upper Motor neurone lesions

8. Features Hemiparesis Quadraparesis Paraparesis

11. Mr June Aged 29 History of falling over for last three weeks Also complains of pins and needles in the tips of fingers right hand and left foot PMH Asthma Episode of visual loss 4 years ago which resolved

12. Examination Pupils regular but sluggish to light Optic disc pale on left Other cranial nerves normal Arms normal Left leg increased tone and clonus Up going plantars Brisk knee and ankle jerk

13. Questions What is the clinical finding in the patients left leg? What are the possible causes? What is the most likely cause in this man? What might be relevant in the past? How might you proceed?

14. Optic atrophy

15. Brisk reflexes and Clonus

18. Mr September Several episodes of unexplained falls over the past 2-3 years Tendency to lean backwards Noted to have slowed down and start falling more

19. Examination Slightly dishevelled Slow and quiet speech Increased tone more marked on the right Increased tone is not smooth Normal reflexes No sensory signs

20. Questions What might this story suggest What are the possible causes of this problem? Why might this patient be falling over? This patient is also constipated why might this be? What is the pathological process?

21. Parkinsons Tremor Rigidity Bradykinesia

24. Mr November Has been falling at home for the past 3 months Reports some problems with swallowing past 2 weeks Recurrent chesty cough

25. Examination Cranial nerves Tongue wasted on right and protrudes to left Speech nasal Arms Wasting small muscles of hands and fasiculation Legs Increased tone bilaterally and brisk reflexes

26. Questions What do the signs in the cranial nerves suggest? What is this called? What do the signs on the hands suggest? What is the picture in the legs? Can you suggest what might be going on?

27. Bulbar and Pseudobulbar palsy Bulbar (LMN) Wasting tongue Tongue protrudes to weak side Dysarthria and sometime dysphagia Pseudobulbar (UMN) No wasting Nasal speech

28. Lower motor neurone signs Wasting Fasiculation Hyporeflexia

29. Upper motor neurone signs No wasting Increased tone Hypereflexia Up going plantars

30. Amyotrophic lateral sclerosis (ALS). This is the 'classical' MND and the most common type. About 8 in 10 people with MND have this type. Symptoms tend to start in the hands and feet. The muscles tend to become stiff as well as weak at first. Progressive bulbar palsy (PBP). About 2 in 10 people with MND have this type. The muscles first affected are those used for talking, chewing and swallowing (the bulbar muscles). Progressive muscular atrophy (PMA). This is an uncommon form of MND. The small muscles of the hands and feet are usually first affected, but the muscles are not stiff. Primary lateral sclerosis (PLS). This is a rare type of MND. It mainly causes weakness in the leg muscles. Some people with this type may also develop clumsiness in the hands or develop speech problems.

31. Questions