CPCP2 Lectures

Question 1

What is IC24?

Answer 1

• integrated urgent care 24 hours

Question 2

What components make up IC24?

Answer 2

• NHS 111
• clinical assessment service
• face to face services
• home visiting services
• walk in centres
• health and justice prison services

Question 3

Where does IC24 cover?

Answer 3

• kent, Essex, Norfolk and Waveney

Question 4

What does the term cradle to grave refer to?

Answer 4

• having the same doctor from birth to death

Question 5

What does CAS refer to in IC24?

Answer 5

• Clinical Assessment Service

Question 6

What is the NHS telephone triage system?

Answer 6

• a clinical decision support system
• supports remote assessment of callers to urgent and emergancy services

Question 7

What is social prescribing?

Answer 7

• linking patients with providers for their specific needs and wants
• treatment that is non medical to improve health in the community
• accounts for patients wants and what matters to them

Question 8

When did social prescribing become adopted by the NHS?

Answer 8

• 2019
• resourced alongside primary care

Question 9

What can social prescribers help with?

Answer 9

• put in contact with support groups and charities
• focus is on patients health and wellbeing
• practical and emotional support

Question 10

What is a link worker?

Answer 10

• connect people to community groups and help the person to develop skills, friendships and resilience

Question 11

What is the main role why social prescribing link workers are employed?

Answer 11

• to give time

Question 12

How long do social prescribers generally provide support for?

Answer 12

• 3 months

Question 13

What is the Office of National Statistics Wellbeing measure?

Answer 13

• tool recommended by the NHS
• tool to measure outcomes
• 4 questions scored 0-10, so total score is 40 (40 is best)

Question 14

There are 5 main components to the neurological examination, what are they?

Answer 14

• Mental State / Behavioural evaluation / Cognitive / Language
• Cranial Nerves
• Peripheral Nervous system•
• Gait
• Cerebellum (some) & Speech

Question 15

There are 12 crenial nerves. Using the acroynm: Ooh, Ooh, Ooh, to touch and feel very good velvet. Such heaven

What are the 12 nerves?

Answer 15

• Ooh = olfactory
• Ooh = optic
• Ooh = oculomotor (means eye-motor movement)
• To = trochlear (means pulley)
• Touch =trigeminal
• And = abducens
• Feel = facial
• Very = vesicular/acoustic
• Good = glossopharyngeal
• Velvet = vagus
• Such = spinal accessory
• Heaven = hypoglossal

Question 16

What is a snellen chart?

Answer 16

• chart used to assess binocular and monocular visual acuity

Question 17

What is the Ishihara colour chart?

Answer 17

• the most well known colour blindness test

Question 18

The first thing we do in a neurological examination is assess cranial nerve I (1). What is this nerve and how do we assess this?

Answer 18

• CN I = olfactory (smell)
• ASK: have you noticed any change in your smell
• offer a substance under each nostril to check

Question 19

The second thing we do in a neurological examination is assess cranial nerve II (2). What is this nerve and what would we ask?

Answer 19

• CN II (optic)
• Ask: “Can you see out of both eyes equally”

Question 20

Cranial nerve II (2) is the optic nerve and we would start by asking if the patient can see out of both eyes equally. What are we looking for in the patients vision?

Answer 20

• Visual acuity and colour perception
• Visual fields & blind spot (use hat pins when offered)
• Reflex (pupillary reflex & swinging flashlight test)
• Fundoscopy (red ‘reflex’, optic disc, retinal quadrants and macula)

Question 21

What is the fundoscopy?

Answer 21

• exam that uses a magnifying lens and a light to check the fundus of the eye (back of the inside of the eye, including the retina and optic nerve).

Question 22

After cranial nerves I (olfactory) and II (optic) what would we assess next in the neurological examination?

Answer 22

• cranial nerves III (3), IV (4), VI (6) (oculomotor, trochlear, abducens)
• • assess full range of tracking eye movements (reports of diplopia) in a H-shape
• reflex (convergence-accommodation)

Question 23

The fourth area to assess is cranial nerve V (5). Which nerve is this?

Answer 23

• trigeminal

Question 24

The fourth area to assess is cranial nerve V (5) which is the trigeminal nerve. What are the 3 parts of the trigeminal nerve?

Answer 24

1 - opthalmic (V₁)

2 - maxillary (V₂)

3 - mandibular (V₃)

Question 25

The fourth area to assess is cranial nerve V (5) which is the trigeminal nerve. What are we assessing for in the trigeminal nerve?

Answer 25

* Facial sensation (all 3 branches, both sides) * Jaw strength (clench and open) * Jaw jerk * Reflex (corneal)

Question 26

After assessing cranial nerve V (5) we will need to assess cranial nerve VII (7). What is this nerve and what do we assess for?

Answer 26

* facial nerve * facial muscle expression and taste

Question 27

Following the assessment of the facial nerve (CN V) we will assess cranial nerve VIII (8). Which nerve is this and what will we assess?

Answer 27

* vestibulocochlear nerve * hearing * rinne & Weber testing * vestibular assessment

Question 28

After assessing the cranial nerves VII (7) vestibulocochlear and VIII (8), we assess cranial nerve IX (9) and X (10). Which nerve is this and what are we assessing?

Answer 28

* 9 = glossopharyngeal) * 1 = vagus * assess elevation of the uvula, cough and reflex (gag)

Question 29

The second to last nerve we will assess is cranial nerve XI (11). What nerve is this and what are we assessing?

Answer 29

* spinal accessory nerve * rotation of the head * shoulder shrug

Question 30

The final nerve we will assess is cranial nerve XII (12). What nerve is this and what are we assessing?

Answer 30

* hypoglossal * fasciculations at rest (muscle twitch) * Tongue protrusion * Tongue strength (in the cheek) * Speech

Question 31

What is a long term condition?

Answer 31

* a condition that cannot currently be cured * patients are supported to optimise quality of life

Question 32

Approximately what proportion of life is spent in poor health?

Answer 32

* 43% of adults aged \>16 have _\>_1 long standing medical condition * 15% of children aged \<15 have at least one long standing condition

Question 33

What % of the population with long term conditions are in work?

Answer 33

* 59%

Question 34

What % of the population with mental health conditions are in work?

Answer 34

* 35%

Question 35

ISBAR is something that is used when doing a handover to other clinical staff. What does the acronym stand for?

Answer 35

* I = Identify/Introduction * S = Situation (explain why you are calling) * B = Background (of patient) * A = Assessments (this is what I think) * R = Recommendation (request specific advice and interventions)

Question 36

What is the PHQ-9?

Answer 36

* a 9-question instrument * used to screen for the presence and severity of depression

Question 37

What is the mental health examination?

Answer 37

* a structured way of observing and describing a patient’s current state of mind * includes domains of appearance, attitude, behaviour, mood, affect, speech, thought process, thought content, perception, cognition, insight and judgement

Question 38

When we are examining the peripheral nervous system, what 2 systems do we need to divide this into?

Answer 38

* sensory * motor (pyramidal = voluntary and extrapyramidal = involuntary)

Question 39

The pyramidal and extrapyramidal tracts are involved in motor control. Which is voluntary and which in involuntary?

Answer 39

* pyramidal = voluntary * extrapyramidal = involuntary

Question 40

What is the definition of an upper motor neuron?

Answer 40

* a neuron that transmits from the brain to the spinal cord or brain stem

Question 41

What is the definition of a lower motor neuron?

Answer 41

* a neuron that comes from the brain stem or spinal cord to the target tissue (skeletal muscle)

Question 42

Where needs to be damaged to cause an upper motor neuron disease/disorder?

Answer 42

* damage to the brain, such as stroke or infection * damage to the spinal cord, especially the white matter of the spinal cord

Question 43

Where needs to be damaged to cause an lower motor neuron disease/disorder?

Answer 43

* damage to the spinal cord, specifically the grey matter as this is where lower motor neurons begin * damage to the neuron between the spinal cord and target tissue

Question 44

In an upper motor neuron disorder is there muscle wasting, if there the affected area is still being used?

Answer 44

* generally no * other muscles in area can compensate and activate muscle

Question 45

In an upper motor neuron disorder there only muscle wasting, if there the affected area is still being used. This is because the signal from the brain can activate surrounding muscles which can compensate (synaptic plasticity). However, is there the any change in muscle strength?

Answer 45

* yes, weakness * muscle can not be activated as much

Question 46

In a lower motor neuron disorder is there muscle wasting?

Answer 46

* yes * signal from brain does not activate the muscles

Question 47

If there is a lesion brain, brain stem or spinal cord, especially the white matter of the spinal cord, this can cause a upper motor neuron disorder. What effect can this have on muscle tone?

Answer 47

* increased muscle tone * spasticity

Question 48

If there is a lesion brain, brain stem or spinal cord, especially the white matter of the spinal cord, this can cause an upper motor neuron disorder, resulting in increased muscle tone and spasticity. Why does this occur in upper motor neuron damage?

Answer 48

* imbalance between excitatory and inhibitory alpha motor neurons * excitatory = corticospinal tract * inhibitory = descending tracts (reticulospinal and ponto-reticularspoinal tracts)

Question 49

If there is a lesion brain, brain stem or spinal cord, especially the white matter of the spinal cord, this can cause an upper motor neuron disorder, resulting in increased muscle tone and spasticity. This occurs due to an imbalance between excitatory and inhibitory alpha motor neurons. The alpha motor neurons are responsible for causing voluntary contraction and relaxation of skeletal muscle. How can upper motor neuron lesions affect reflexes?

Answer 49

* increases the reflex response

Question 50

If there is a lesion brain, brain stem or spinal cord, especially the white matter of the spinal cord, this can cause an upper motor neuron disorder, resulting in increased muscle tone and spasticity. This occurs due to an imbalance between excitatory and inhibitory alpha motor neurons. The alpha motor neurons are responsible for causing voluntary contraction and relaxation of skeletal muscle. In addition to increased muscle tone/spasticity, there is increases in reflex briskness. Why does this occur?

Answer 50

* imbalance between excitatory and inhibitory gamma motor neurons of muscle spindles * excitatory = corticospinal tract * inhibitory = fibres from corticospinal tract that bifurcate into medulla reticular nuclei

Question 51

If there is a lesion brain, brain stem or spinal cord, especially the white matter of the spinal cord, this can cause an upper motor neuron disorder, resulting in increased muscle tone (alpha motor neurons) and reflex (gamma motor neurons) response. Combined this causes a specific type of paralysis characterised by significant muscle tone, what is this called?

Answer 51

* spasticity

Question 52

If there is a lesion in the grey matter of the spinal cord or the neurons from the spinal cord to the skeletal muscle, this can cause a lower motor neuron disorder. What affect does this have on muscle mass?

Answer 52

* significant muscle atrophy * alpha motor neurons are not activated so muscle is not innervated

Question 53

If there is a lesion in the grey matter of the spinal cord or the neurons from the spinal cord to the skeletal muscle, this can cause a lower motor neuron disorder which can cause significant muscle atrophy. What can a lower motor neuron lesion do to the reflex of patients?

Answer 53

* gamma motor neurpns do not innervate muscle spindles * alpha 1 and 2 afferent (sensory) neurons do not fire and reflex is slow or non existent

Question 54

During a peripheral nervous exam where are we going to examine?

Answer 54

* arms and legs

Question 55

During a peripheral nervous exam, what position will the patient be in when we examine the legs and arms?

Answer 55

* arms = sat on the edge of the bed faving you * legs = lying flat on the bed

Question 56

Following the general overview of the patients surroundings and any clear observations about the patient, what are the 6 tests we need to do?

Answer 56

1. Tone 2. Power 3. Reflexes 4. Sensation 5. Coordination 6. Gait

Question 57

When observing the patient, what main thing are we looking for in the limbs?

Answer 57

* asymmetry in limbs

Question 58

When observing the patient, we may see some movement in patients muscles, what can these be?

Answer 58

* fasciculation's (spontaneous muscle twitch) * tremors

Question 59

When observing the patient, we can ask them to hold their arms out in front of them. What 3 things might we see?

Answer 59

1 - do arms stay where they should 2 - is there a drift (arms dropping down) 3 - is there an action tremor REPEAT ALL WITH PATIENT CLOSING THEIR EYES

Question 60

When we are assessing tone in the upper limbs, how do we assess tone in a patients arms?

Answer 60

* hold patients hand with dominant arm * non-dominant hand should be on patients elbow * then randomly move the patients arm to assess tone

Question 61

When we are assessing tone in the lower limbs, how do we assess tone in a patients legs?

Answer 61

* hands on thighs and roll patients leg from side to side * watch the foot

Question 62

What is the difference between spasticity and rigidity?

Answer 62

**_Spasticity_** - damage to corticospinal tract (pyramidal) - common in UMN disorders - spasticity is dependent on velocity **_Rigidity_** - damage to extrapyramidal disorders - common in UMN disorders - present throughout range of movement

Question 63

What scoring method is used to assess power in a peripheral nervous examination?

Answer 63

* medical research council grading * 0 = no movement * 5 = full strength

Question 64

How would we assess shoulder abduction?

Answer 64

* testing deltoid muscle supplied by axillary nerve, C5 * place hands close to elbow and ask patient to push agains you

Question 65

How would we assess elbow flexion?

Answer 65

* Biceps assessed and supplied by musculocutaneous nerve, C5/C6 * Hold elbow and wrist with palm up and ask patient to bend the arm