ZAV_202
Identifying atypical signs & symptoms
When to worry about developmental and psychiatric disorders in childhood
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• Welcome
• Timing
• Toilets
• Fire escapes
Welcome, agenda and housekeepingIntroudiction
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• To raise the ability among pychiatrists to spot the red flag signs of progressive disease in children with developmental and psychiatric disorders by…
• Applying the appropriate questioning style in history taking
• Performing an appropriate neurological examination
Learning objectivesIntroduction
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The problemIntroduction
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When you get a case like this –how do you handle it?
The problemIntroduction
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Detection rate:How many do we miss, and does it matter?
The problemIntroduction
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So – how can we ensure that we detect the red flag symptoms?
The problemIntroduction
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Detecting red flag signs and symptoms always begins with a solid history and examination –getting the ”basics” right.
It can go wrong, based on what you have heard and seen.
The problemIntroduction
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In the first part of the session we will focus on knowing what to ask and what to look for :• History taking• Examination• Diagnostic tests:
• Biochemical investigation• Genetic analysis• Neuroimaging • Further, specialised testing…
The problemIntroduction
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Meeting the patient and his/her parents– history taking in practice
History takingStep 2
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Meeting Sally, Jonathan’s mother. Part 1
As you watch the film, note your observations in the workbook.Q1: What strikes you as being of particular importance or interest?Q2: What would you want to clarify further with Sally?
History takingStep 2
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Meeting Sally, Jonathan’s mother. Part 1
As you watch the film, note your observations in the workbook.Q1: What strikes you as being of particular importance or interest?Q2: What would you want to clarify further with Sally?
History takingStep 2
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Meeting Sally, Jonathan’s mother. Part 2
As you watch the film, again note your observations in the workbook.Q1: What strikes you as being of particular importance or interest?Q2: What would you want to clarify further with Sally?
History takingStep 2
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Meeting Sally, Jonathan’s mother. Part 2
As you watch the film, again note your observations in the workbook.Q1: What strikes you as being of particular importance or interest?Q2: What would you want to clarify further with Sally?
History takingStep 2
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Meeting Sally, Jonathan’s mother. Part 3
As you watch the film, again note your observations in the workbook.Q1: What strikes you as being of particular importance or interest?Q2: What is your suspicion for Jonathan? What will be your next step?
History takingStep 2
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Meeting Sally, Jonathan’s mother. Part 3
As you watch the film, again note your observations in the workbook.Q1: What strikes you as being of particular importance or interest?Q2: What is your suspicion for Jonathan? What will be your next step?
History takingStep 2
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What are your tips, as experts, on efficient history taking for this population?
History takingStep 2
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Neurological examination• How do you approach this?• What difficulties do you find?
Performing a neurological examinationStep 3
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Performing a neurological examinationStep 3
As you watch the films, note your observations in the workbook.
A. Introduction & gait B. Dynamic assessment C. Arms & legs
E. Other cranial nervesD. Eyes Play all
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What do you look out for in:1. Introduction & gait
2. Dynamic assessment
3. Arms & legs
4. Eyes
5. Other cranial nerves
Neurological examinationStep 3
Play all
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Play all
Neurological examinationStep 3
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Neurological examinationStep 3
Atypical signs:
Dynamic assessment
Arms & legs
Eyes
Other cranial nerves
Introduction & gait
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Think about where in the brain the symptom indicates there may be a problem
Step 3
Cerebellum
Striatum
Midbrain
Hippocampus, Thalamus
White matter, Subcortical regions
Cause: Changes:Ataxia, Dysarthria
Dystonia
Gaze palsy, Dysphagia, Cataplexy
Memory impairments
Psychosis in young adults
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Summary of the neurological examinations of Jonathan
Q1: What strikes you as being of particular importance or interest?
Q2: What would be your next step in a rational plan of investigation? Note the top three diagnostic tests you would want to conduct.
Neurological examinationStep 3
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Break
Neurological examinationStep 3
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Please begin working through the case description by reading the referral letter.Then continue with the next parts step by step.
A case of teenage depressionStep 4
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History-taking, Victoria, part 1Please summarise your discussion of the interviews with Victoria and her mother.
Q1: What strikes you as being of particular importance or interest?Q2: What would you want to clarify with Victoria or Patricia?
A case of teenage depressionStep 4
Victoria, 15
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History-taking, Victoria, part 2Please summarise your discussion of the interviews with Victoria and her mother.
Q1: What strikes you as being of particular importance or interest?Q2: What is your suspicion? What would be your next step in assessing Victoria?
A case of teenage depressionStep 4
Victoria, 15
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Neurological examination,VictoriaPlease summarise your discussion of the examination results.
Q1: Can you identify 4-5 red flag symptoms in her examination?Q2: What would be your differential diagnosis?Q3: Note the top three diagnostic tests you would want to conduct.
A case of teenage depressionStep 4
Victoria, 15
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Further investigationsStep 5A
Investigating progressive intellectual/neurological degeneration (PIND) What would you do?
Jonathan, 9
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Refer to a specialist – a neurologistWhat would they do?
Further investigationsStep 5A
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30 most commonly reported confirmed diagnoses
Further investigationsStep 5A
Condition No of casesLeigh syndrome 17
NARP (including NARP/MILS) 17
Menkes disease 16
Mucopolysaccharidosis IIA (Hunter disease) 15
Cockayne disease 15
Canavan disease 13
Neuroaxonal dystrophy 12
Vanishing white matter disease 11
Aicardi–Goutieres syndrome 10
Alexander disease 10
Glutaric aciduria type 1 10
Molybdenum cofactor deficiency 10
Ataxia telangiectasia 9
Subacute sclerosing panencephalitis 9
Rasmussen syndrome 8
1114 children out of 2636Verity C et al. Arch Dis Child. 2010; 95:361–364
Condition No of casesNCL late infantile 73
Mucopolysaccharidosis IIIA (San Filippo) 69
Rett syndrome 60
Metachromatic leukodystrophy 59
Adrenoleukodystrophy 56
NCL juvenile 44
GM2 gangliosidosis type 1 (Tay–Sachs) 41
Niemann–Pick Type C 38
Krabbe disease 33
GM2 gangliosidosis type 2 (Sandhoff) 33
GM1 gangliosidosis 23
Huntington disease 22
NCL infantile 22
PKAN/NBIA* 21
Pelizaeus–Merzbacher disease 17
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• Neuronal Ceroid Lipofuscinosis
• Gangliosidoses
• Mucopolysaccharidosis
• Metachromatic leukodystrophy
• Adrenoleukodystrophy
Further investigationsStep 5A
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• Niemann-Pick type C
• Leigh / NARP
• Krabbe disease
• Huntington disease
• N’Deg Brain Iron Accumulation
• Pelizaeus-Merzbacher disease
Further investigationsStep 5A
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First line investigation – key conditions to consider• History
• Huntington, Rett, Menkes, Rasmussen
• Examination • Mitochondrial, Rett, Cockayne, Ataxia Telangiectasia
• Consider the degenerative movement and ataxic disorders without significant intellectual deterioration
• e.g. Friedrich’s Ataxia
Further investigationsStep 5A
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MRI scan
Further investigationsStep 5A
Pelizaeus Merzbacher NBIA
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Biochemistry – White cell enzyme screen• NCL/Batten: infantile/late infantile
• Gangliosidoses
• Many leukodystrophies
Further investigationsStep 5A
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MRI scan• Very long chain fatty acids: adrenoleukodystrophy
Further investigationsStep 5A
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Biochemistry – Organic acidsGlutaric aciduria, n-acetylaspartate and sulphocysteine for molybdenum co-factor deficiencies
Further investigationsStep 5A
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Biochemistry – Organic acidsLater - CSF analysis glucose/lactate matched with plasma- GLUT1 and Mitochondrial, protein and cell count
Further investigationsStep 5A
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Check results• Opthalmology
• Visual and peripheral neurophysiology
• Vacuolated lymphocytes
Further investigationsStep 5A
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Have we missed any conditions?
Further investigationsStep 5A
Condition No of casesLeigh syndrome 17
NARP (including NARP/MILS) 17
Menkes disease 16
Mucopolysaccharidosis IIA (Hunter disease) 15
Cockayne disease 15
Canavan disease 13
Neuroaxonal dystrophy 12
Vanishing white matter disease 11
Aicardi–Goutieres syndrome 10
Alexander disease 10
Glutaric aciduria type 1 10
Molybdenum cofactor deficiency 10
Ataxia telangiectasia 9
Subacute sclerosing panencephalitis 9
Rasmussen syndrome 8
1114 children out of 2636Verity C et al. Arch Dis Child. 2010; 95:361–364
Condition No of casesNCL late infantile 73
Mucopolysaccharidosis IIIA (San Filippo) 69
Rett syndrome 60
Metachromatic leukodystrophy 59
Adrenoleukodystrophy 56
NCL juvenile 44
GM2 gangliosidosis type 1 (Tay–Sachs) 41
Niemann–Pick Type C 38
Krabbe disease 33
GM2 gangliosidosis type 2 (Sandhoff) 33
GM1 gangliosidosis 23
Huntington disease 22
NCL infantile 22
PKAN/NBIA* 21
Pelizaeus–Merzbacher disease 17
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If the neurologist still does not have the answer• Complex case review with colleagues in same centre• Consider discussing with colleagues in other centres,
e.g. Amsterdam
Further investigationsStep 5A
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Seeming to regress – common causes• Non-neurological
• Bullying• Stress• School absence• Autism/dyslexia• Factitious illness• Endocrine/autoimmune
Further investigationsStep 5A
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Seeming to regress – common causes• Neurological
• Medication, e.g. epilepsy therapy• Depression/psychosis• Raised intracranial pressure• Epilepsy• Evolving sensory impairment, e.g. blindness
Further investigationsStep 5A
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Further investigationsStep 5A
Investigating static developmental delayWhat would you do?
Marcus, 9
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Genetic analysis• Karyotype
• Fragile X
• Comparative Genomic Hybridisation (CGH)
Further investigationsStep 5A
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Biochemistry• Electrolytes/renal function• Liver function• Thyroid function• Lactate• Ammonia• Plasma amino acids• Creatine Kinase• Urine amino/organic acids• CSF studies
Further investigationsStep 5A
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Biochemistry• Note neonatal thyroid and phenylalanine levels, make
sure these are actually seen • Doing more has a very, very low yield unless indicated
on history/examination• e.g. encephalopathy, consanguinity, ethnic group,
dysmorphic features• Although you may find abnormalities, there is not a
rational system in particular, plasma amino acids will not yield
Further investigationsStep 5A
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MRI head• Consider the yield… 1-60% in a
series of investigations• With static mild to moderate
developmental delay, and nothing else in the history and examination the yield is likely to be <5%, probably <2% of useful information
Further investigationsStep 5A
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UK Eastern region multidisciplinary review 2003-5www.phgfoundation.org/file/2366
Further investigationsStep 5A
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A teenager with psychiatric and neurological symptomsWhich conditions should you consider?
Further investigationsStep 5A
Victoria, 15
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• Epilepsy• Particularly temporal lobe
• Brain tumours• Frontal, temporal
• Nutritional deficiency• e.g. B12
• Endocrine disease• e.g. Addison, Cushing
Further investigationsStep 5A
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• Infectious disease • e.g. encephalitis
• Neuroinflammation• e.g. multiple sclerosis, SLE, sarcoid
• Chromosomal abnormalities
Further investigationsStep 5A
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Main treatable IEM associated with schizophrenia
Further investigationsStep 5A
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Clinical signs• Tremor, dystonia, dysarthriaEye exam• Kayser Fleischer ringsBiological markers• Caeruloplasmin
Disorder?• Wilson
Further investigationsStep 5A
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Clinical signs• Confusion, abdominal pain, nausea, vomitingContext• Protein diet, post surgery, drugs (valproate/corticoids)Biological markers• Ammonaemia
Disorder?• Urea cycle
Further investigationsStep 5A
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Clinical signs• Thromboembolism, scoliosis, marfan-like, cerebellar
signsContext• Protein diet, post surgeryEye exam• Severe myopia, ectopic lensBiological markers• Homocysteiniemia, methioninemia
Disorder?•Homocysteiniemia (CbS)
Further investigationsStep 5A
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Clinical signs• Black or red urine, constipation, confusion, abdominal pain,
nausea/vomitingContext• PeriodicBiological markers• Porphobilinogens (URINE)
Disorder?• Porphyria
Further investigationsStep 5A
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Disorder:• Cerebrotendinous xanthomatosis
Clinical signs• Chronic diarrhea, spastic paralysis Eye exam• Juvenile cataractBiological markers• Cholesteanoemia
Further investigationsStep 5A
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Practical approach to the investigation of psychiatric cases where there is concern about organic conditionsThorough history, consider:
• Positive family history• Consanguinity• Encephalopathy
Careful examination, look for:• Dysmorphic features• Chromosomal abnormalities• Signs of endocrine disturbance• Evidence of autoimmune disease • Neurological signs
Consider epilepsy and non-convulsive static epilepticus
Further investigationsStep 5A
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Should you do an EEG?• Only to investigate non-convulsive static epilepticus• Not to ask if child has epilepsy
Further investigationsStep 5A
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If still suspicious• Simple metabolic investigations to identify the main
treatable IEM e.g. Caeruloplasmin
• Discuss and refer to a neurologist
• Consider MRI scan and/or EEG, whilst awaiting neurological opinion
Further investigationsStep 5A
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What were the final diagnoses, and how are the patients managing now?
Conclusions for casesStep 5B
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Findings from further tests:• Standard investigations for a
PIND disorder normal• MRI scan showed subtle white
matter changes and reduction in cerebellar volume
Diagnosis?• More testing required• What would you do?
Conclusions for casesStep 5B
Jonathan, 9
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Findings from further tests:• In view of VSGP, a skin biopsy
was performed. Filipin staining abnormal
• Genotyping showed a homozygous deletion of NPC1
Diagnosis?• Niemann-Pick type C
Conclusions for casesStep 5B
Jonathan, 9
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Niemann-Pick type C (NPC)• Autosomal, recessive, neurovisceral storage disorder• 30% of patients adolescents/adults
Conclusions for casesStep 5B
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Niemann-Pick type C (NPC)• In children, presents with key signs:
• Prolonged neonatal jaundice (Jonathan)• Hepatosplenomegaly• Learning disability/school failure• Seizures• Gelastic cataplexy• Ataxia• Vertical gaze palsy• Dystonia
Conclusions for casesStep 5B
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Niemann-Pick type C (NPC)• In adults, presents with key signs:
• Ataxia• Vertical gaze palsy• Dystonia• Dementia and/or psychosis• Gelastic cataplexy
Conclusions for casesStep 5B
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Niemann-Pick type C (NPC)• Disorder of intracellular sterol trafficking• Not a classical enzyme-deficiency disorder• Abnormal build-up of cholesterol and production of toxic
levels of gangliosides• Disrupts white matter in widespread fashion• Affects particular grey matter regions: hippocampus,
thalamus, striatum, cerebellum and midbrain
Conclusions for casesStep 5B
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Conclusions for casesStep 5B
Niemann-Pick type C (NPC)
Cerebellum
Striatum
Midbrain
Hippocampus, Thalamus
White matter, Subcortical regions
Changes in: Cause:Ataxia, Dysarthria
Dystonia
Gaze palsy, Dysphagia, Cataplexy
Memory impairments
May together be psychotogenic in young adults
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Disease modification• Referral to specialist centre for
lysosomal storage diseases• Started on miglustat
Supportive • Speech-, occupational and
physiotherapy• Anti-epileptic drug treatment• Specialist educational unit
Conclusions for casesStep 5B
Jonathan, 9
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Findings from further tests:• Kayser-Fleischer rings• Caeruloplasmin levels well below
normal range• Genetic analysis
Diagnosis:• Wilson disease
Conclusions for casesStep 5B
Victoria, 15
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Conclusions for casesStep 5B
Kayser-Fleischer rings Victoria, 15
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Wilson disease• Autosomal, recessive genetic disorder of copper
metabolism; copper accumulation in brain (chorea), liver, eyes
• Mapped on to chromosome 13• May not be as common as originally thought• Detected by neurological examination, slitlamp
examination, MRI, serum caeruloplasmin • Can have a normal caeruloplasmin, and therefore with
high index of suspicion metabolic advice on further investigation essential
Conclusions for casesStep 5B
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Treatment / Interventions:• Penicillamine chelation
• Anti-depressants continued
• Support from community psychiatric nurse
Conclusions for casesStep 5B
Victoria, 15
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Modifying treatments for degenerative diseases• Dietary, for example PKU• Chelation therapy, e.g. penicillamine for Wilson• Substrate reduction therapy, e.g. miglustat for NPC and
Gaucher disease type 1• Chaperone therapy, e.g. pyrimethamine in GM2
gangliosidosis• Enzyme replacements therapy, e.g. Fabry and Gaucher
disease• Bone marrow transplant, e.g. ALD• Gene therapy? GM2 gangliosidosis
SummaryStep 6
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Questions?
SummaryStep 6
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Key learning points• Diagnosing these conditions as early as possible, is likely
to improve outcome• A thorough history is critical in informing further
assessment/investigation• A competent clinical examination is essential in all cases,
although some clinicians have found this challenging, we hope that you now have a system, and of course… practice makes perfect
• Onward referral, for expert advice, is critical
SummaryStep 6
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Subject matter expert• Dr Alasdair Parker, Lead for Paediatric Neurology, Addenbrooke's
Hospital, and Associate Lecturer, Cambridge University
Videos of patients with symptoms• Lysosomal Diseases Unit, Addenbrooke's Hospital, Cambridge
University Hospitals NHS Foundation Trust • Biochemical Genetics Unit, St. Mary’s Hospital, Central Manchester
University Hospitals NHS Foundation Trust
Sponsor• Actelion Pharmaceuticals Ltd
Learning design and production• Symbal Communications
Thank youStep 6
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A. Introduction & gait
Performing a neurological examinationStep 3
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B. Dynamic assessment
Performing a neurological examinationStep 3
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C. Arms & legs
Performing a neurological examinationStep 3
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D. Eyes
Performing a neurological examinationStep 3
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E. Other cranial nerves
Performing a neurological examinationStep 3
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Play all
Performing a neurological examinationStep 3
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1. Introduction & gait
Neurological examinationStep 3
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2. Dynamic assessment
Neurological examinationStep 3
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3. Arms & legs
Neurological examinationStep 3
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4. Eyes
Neurological examinationStep 3
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5. Other cranial nerves
Neurological examinationStep 3
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