THE INITIAL CLINICAL SURVEY AND HOW TO IDENTIFY THE LESION BEFORE EXAMINATION (MODULE TWO) Transcript Integration of Clinical Forms

Transcription

1 THE INITIAL CLINICAL SURVEY AND HOW TO IDENTIFY THE LESION BEFORE EXAMINATION (MODULE TWO) Transcript Integration of Clinical Forms Presentation by Drs. Datis Kharrazian and Brandon Brock Okay, so we re going to Let me tell you what we have for the rest of the day. What we have is, we have this kind of review process. There s so many things that we want to fill in; some of the forms we didn t get a chance to do, so we wanted to fill those in, and kind of talk about the weaknesses and strengths of how these forms can and cannot be used, right? But we also, once we get through this, then we have a where we go into cases. So and myself, I m going to show you we were going to present to you guys cases, going all the way through them, that kind of apply all the principles that we re doing, so it becomes very clinical, and that will take us right into a quick review of everything, and that will take us into questions, and we ll be done for the day. So, usually by this time of day people are really fatigued and tired, and the goal is to really just make sure you understand the concepts that you ve been exposed to. It isn t just to kind of constantly give you new ones and have you fatigue out more and be more depressed and all those things, okay? More depressed, more psychotic So we keep bringing this diagram up, because we really want this thought process to continue to just be pounded into your brains, right? That you have a chief complaint, you localize the region and we ve given you forms now to help you localize the region but you can also localize the region many times by just gait. You can many times localize the region just by doing the initial survey, just what you see in front of them. So those things can all help. And once we localize the region, we ll get into how you rehab it, and the things you do. But it s the first part that everyone has a problem with, with patient outcomes. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 1

2 The reason most patients fail is because they weren t diagnosed properly. And if they weren t diagnosed properly and they were treated for the wrong areas and the wrong things, there s no outcome. So part of The best thing is really, really, really, really improve your skills of picking up on the specific regions and assessment before you go into treatment. Okay? If you know all these little treatments but you re terrible at diagnosis, you re going to be a bad practitioner. Right? But if you re very good at diagnosing it, and you know where the region is, you can always look up finding ways to activate certain areas, right? Because they re pretty straightforward and then you know what to look for, what applications to do. So, our focus to this point has really been on localizing the region, and we ve given you different forms and different things to do, but the initial clinical survey and obviously we ve had to deviate from the survey and talk about exam findings and talk about certain things just to make it make sense but the initial clinical survey starts before the patient encounter, as we went over. We have several forms we gave you: the brain region localization form, the peripheral nerve localization form, and the initial survey, metabolic survey, and then assessment of speech and gait analysis. What we plan to do is, as this course is moving along, and also how advanced everyone is becoming very quickly, we re going to put a lot of we re going to put more videos and more little ancillary videos than before. Because now we have a lot a bigger stronger foundation to work with. So we ll put together some speeches and gaits and things to keep involved. So keep posting on the Facebook page more so than before, because now we can Everyone has this strong enough base where we can really get into more of the clinical stuff. Now, we have We gave you guys these clinical quickie forms. These aren t necessarily exam forms. We don t expect anyone to take a clinical quickie form and use it as an exam form. They re not meant to be exam forms. The clinical quickie forms are meant for you to take some of the information from the presentation and have a clinical thought process of how you would start to look for those things in our exam. Because we also know from a learning perspective, there s a disconnect from just getting a PowerPoint dump, and some information, and then what are your actual steps to do when you look at a patient; applying that information. So, the clinical quickie form is just an exercise form. It s not an exam form you would be expected to do in your office. And the goal is for us, as we teach you any clinical concepts, to give you some clinical quickie forms as an exercise form. But not as an exam form, okay? Now, the brain region localization form, I want to that will be an intake form I use in my office, you know. So that s the kind of that s a different screening form. If someone has a peripheral-related condition, then the peripheral nerve localization form could be a good form to use as well, right? But the quickie forms So if you see the word clinical quickie Andrea made that up. Well that looks great. She goes, Don t you think that s a great name? We re like, I don t know if it s that great of a name, but if you think so But the point of it is just really quickly going through and looking at certain things, okay? So, please don t mistake the clinical quickie forms as being exam forms. They are not. But if you can go through the process of it with some patients, maybe on Monday you re just going to look for one thing, as an exercise. Take you two seconds to do. And then what you should find is, Wow, this form sucks. I should add all these other things I know into it. But it s not meant to be a complete form. It s meant for MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 2

3 you to kind of just get your thoughts in process with what we ve been trying to share with you, and then use whatever you want to it. At the end of the day, you ll probably take all the different clinical quickie forms, exam forms, make your own form that s specific to what you re looking for in your background and what you know how to do and what you need to evaluate, right? So these are just meant to be an exercise type of form. So, the first form that we gave you was this clinical quickie neurological assessment before the patient encounter. So this is the one you can maybe, if you haven t already, if you have office staff in your office, communicate with them in saying, These things are important as we evaluate each patient that walks in the door. So one of the things you want to start looking at is just punctuality. Not as a judgment thing, not as an issue related to that, but just, are they late or on time? Now, here s something else I just want to throw out there. What does it mean when a practitioner s always late? Why would a practitioner always be late? Because we you know we re picking on the patient. But let s pick on the practitioner for a second. You guys, a practitioner can be late because their timelining sucks, because their brain is unhealthy, because they can t focus and concentrate. You guys understand? Those are real things. I had a friend of mine he s in Switzerland and he was seeing that his office he found out his office staff was turning his clock throughout the day so we would be on time. So he would go to switch rooms, and they d go in the room before he got there and switched it so he would think he was super late and then finally get out, but he actually started being more on time. So, these things do make a difference. So if you re just some things to think about. You re when you guys, hopefully you guys will fill out the brain region localization form yourself. If you have any of the symptoms on the flow chart we talked about, why someone could be late, they could apply to you, right? So see if you have any left inferior parietal-related issues. See if you have the ability to timeline. Make sure your frontal cortex is okay. Okay? Because those can also make you late. So it s a diagnostic thing both ways. So, when the patient comes in, get in there and just find out what s going on. The biggest clue is that someone drives them, are they super early, are they late, are they, you know. And then you have to make it a fun discussion and just kind of see what s going on. So just that perspective of you and your office to kind of understand things are diagnostic, very helpful. And I can tell you from a psychological perspective with your staff, it makes them more compassionate when they realize some of the things patients do are not personal but just because of their brain function. So whether they re really irritable or really crabby or really complain or really needy, you know, when they kind of start to think that learn that these are sometimes a reflection of their health, and their brain function, it makes things different. It really does. Time to fill out forms is another one, and then looking at their handwriting. For the most part, you guys aren t going to see essential tremors every day. You guys aren t going to see micrographia every day. But you need to know what to look for, because when you see it, it should just scream at you, okay? The most common thing you ll see with handwriting is sloppy, and it s one of the things you want to fall up with is, Has your handwriting changed over time? The key thing with sloppy handwriting is that it s gotten worse over time. That s the only thing about it that s diagnostic. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 3

4 And then, sensitivity to office stimulus: I wrote a whole bunch of things to light, sound, and smell intolerance. I m just going to put those into an ancillary video for you, and then we can go you guys can have access to that information, because I think the information there is actually really good, clinically. So we ll just make that into a video for you guys without taking time from anything else. Anything you want to add about the initial pre-encounter with the patient? My biggest thing on this really is, there s a lot of factors that go into this. You guys know this. I mean, anything from I m not from this state, I don t know where your clinic s at, there s several things that can go on. I will say this. The world is becoming more geographically challenged. Because we have GPS. So I really don t think we develop location as well. Just like memorization of numbers. How many of you, like, don t even know your own freaking phone number? I mean, it s really literally a situation called digital dementia, where we have a whole generation of people growing up and, like, look: My daughter is in the generation right now where all emotions are shown through emoticons. I had to learn how to, like, smile and frown and flip somebody off and all that stuff through emoticons, because it s, like, that s how my kids communicate. I m like, sad face. And I m sitting there going, Why don t I just call her? Because she won t pick up. So it s just this weird sort of Brains develop differently with technology, and I m not saying it s bad, but, like, I don t know my wife s phone number. Sorry. But I know my three best friends from middle school, because I just do this: beep. And let me tell you what else is happening. I have nurse-practitioner students that come through all the time, and they pull out their phones and start looking at drug dosages, and I m like, Put it away. They re like, But somebody s going to die. I m like, Put it away. If you don t know any of the dosages, you need to sit down and start studying. What happens if your battery runs out? They re like, I guess I d plug it in. I m like, There s no charger. Well then, I d go find one. There s no outlet. Well then, I would get a generator. Well, there s no generators. Well then, I would I don t know what I would do. I guess the patient would die. I don t know. What I m trying to tell you is, the world s changing. The one thing I do like up here the most is the handwriting. Because handwriting, along with tremor, along with drawing shapes, and along with getting a light pen and holding it, and it not shaking and jumping around There s a bunch of things that we re going to show you in the physical exam module to diagnose what is the hertz of the tremor, where s the tremor from, and then what can you do to suppress the tremor. Those are important things. So, when you look at something like this, it s like, you really do need to know a little bit about handwriting, because it s going to lay into about five different modules. And by the way, those are important modules. How many patients have Parkinson s disease? Well here s my goal with Parkinson s disease: I want your drugs to work as good as they can; I want you to take the lowest amount of drugs possible, and I want you to be able to get up, walk, start, stop, turn, and do the things that you can do. I m not going to cure Parkinson s disease, but I want you to be functional. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 4

5 So, even if you all you do is, you just start to look for, I know handwriting can be diagnostic. It can get smaller over time, it can get larger. Micro- and macrographia. It could shake from tremor. It can have deviations of angulations to one side or the other, right? If you start to look for that, then you feel the clinical sense, and you start to just be reflexively looking for it. And that s what you want to do. So it doesn t really matter if you see a diagonal skew that you know all the things associated with head tilt and all the mechanisms to treat it, but your first thing is to be able to identify it. So once it goes into your thought process, start looking for it, then the next step becomes easier. Don t wait to know all the different treatments and outcomes before you start having the clinical eye for stuff. The clinical eye is actually the most important thing, right? The clinical eye to catch and see things. Because what happens when you see people get a second opinion by, let s say, someone who s more trained in something is, they have a better clinical eye. They see things that are there all the time, like, Do you see the ptosis? Do you see the lack of arm swing? Do you see that? Do you see that? Yeah, now that I m seeing it with you, right? So you want to have your clinical eye improve as it relates to handwriting, and start looking at what those things could potentially mean. Now, the other thing that we talked about, and we went into at length with this, is the brain region localization form. It s not a perfect form. It will probably change over time. There s some questions that we may need to make different, for patients to understand them. There s some feed back we ll get. So there ll be a different version of this coming out. If you have any suggestions with some of the questions, we can actually change it. So it will be, throughout this program, we ll have different versions of it, but this is a good version to get out to a bunch of practitioners all over the country, get some feedback, fine-tune it, and continue to make it better, okay? But it is definitely going to help you trying to understand the regional involvement of these things. If you guys want to know your neuroanatomy really well, as clinicians we tend to learn it when we know there s a clinical application. So just to sit down and memorize all the gyri and sulci and name it is really hard to do. But if you know that s the function of that area, it s really easy to do, because it immediately has a significance, right? So you have to have significance in order to learn it. So, if you go through and start to learn all those questions really well for each of those regions, it will give you a huge leap into understanding brain function and symptoms that people have. And the fact that there s R and left. I know when we got done we were like, I wish we had this. And we ve been doing this for a long time, and we ve never actually made the form. We finally go, Hey, we want to teach people to be better than us. Let s make a form; they can get there faster. So we finally put it together, and now we re like, Wow, this is great! We re going to use it. And by the way, whenever we talked about making the form, we both were like, I hate you. Like, Let s make a form. Sure. And then all of a sudden we said, Ooh, let s make a form. Ah, that s going to take a lot of time. But, I mean, I just want some feedback. I mean, don t patronize, but how many of you think the forms on an ongoing basis is something that s useable and a good idea? Okay. I don t think there s a lot of people that aren t going to agree with it. And it s not that we re trying to make this to where I really want to say this out of respect for all the people who have become a diplomate, and who have gone through the process, and then know how to do an exam, that have learned this material. Or who are good clinicians. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 5

6 We re not doing this to take the place of being good. We re doing this so that people can learn faster and be better. In fact, I would love for a lot of diplomates the people with the big S on their chest, right? Not always I would love for those people to start using these forms too, so that it can enhance their practice. See, we re trying to make everybody a little bit better, including ourselves. You wouldn t believe how much we learn every module, just putting things together, because we re forced. When you get backed into a corner, and you know you have to put something together, it s amazing what you can end up learning. So, these intake forms are not meant to cheat. They re really meant to enhance. And I want to make that an imperative thing. And they re not meant to diagnose. They re meant to clarify. Diagnosis These are not standardized. In other words, there s like, if you take an Oswestry or something, it went through a standardization process that is researched and clinically used, and all that stuff, and they went through trials. We didn t to that with this. That s not what these are. These are just an extension of your review systems, really. Yeah. The goal is, really, instead of trying to remember each of the functions for each regional lobe is, is just to have it done and save you time. So, processes really make things efficient. So to be completely thorough, you need to have steps and processes, right? So your forms can really speed things up and help you when you actually have to see the patient, so now, if you how much time would you shave off your history by having these questions already accounted for before they saw you during your history? It saves a lot of time. And not only that, but sometimes you don t get to see it until you see them all clustered together. And not only that, sometimes you don t know how important it is until they grade it. Like, This happens almost every day, versus, I have some nausea. Oh, okay. Well, interesting. No, no, it s a four. Oh, you have this almost every day all of the time? Yeah. Well, that s totally different than having some occasional nausea, right? Or a little dizziness. So there s some advantages to using the forms, but not as a replacement And I ll be honest, I don t think a history by itself will sometimes be as efficient as having a form to use with it. Well, not only that; when you use these forms, is it possible to give somebody the form? Because it s scored, remember? Is it possible to give it to them three, four, five weeks later and then have them do it again, and then all of a sudden you look at it, and you re like, Do you realize that everything you re telling me about your frontal lobes has improved significantly? Look at where you changed. In other words, it s a very nice, tangible tool that takes the subjective complaints and by the way, these are all subjective. They re not objective. This is what the person s telling you. But it objectifies it just a tad bit. Most people will not realize every single thing. They won t remember everything they put down. They fill it out again, and you look at it, and you re like, Man, either your frontal lobes are getting better, or you can t perceive what your own problems are any more. And they re like, No, I m perceiving what s going on. I m just Maybe I m better. So it s kind of cool to get the feedback from the patient to just turn around and give to them and say, Look at your differences in what you told me. And it s amazing feedback. It s very healing for some people. Do you know how it is whenever you say, Man, you re doing better, and they re like, Nah, I don t really get it. And they think that you re just saying that maybe because you want them to be better, but then when MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 6

7 you give them this back and say, Hey, how do you feel? I feel a little bit better. Well, this is what you just told me compared to last time I saw you. And they re like, Wow, this is really profoundly better. Some people don t remember how sick they were, six or eight weeks later. Have y all realized that? It s very People are very quick to say this: I was sick, and I m very happy now. I don t even want to remember that stuff. And another point here, though, is the way we re progressing the structure of how Because we have long thoughts of how do we get people to learn this model? Because this model s all over the place. It s huge. How do you make the world seem smaller and smaller and smaller? Well, you make people feel comfortable with the material and know where it s all headed and how they can set that aside. So, even if you don t use the form, if you know all the symptoms of those regions, it makes you a better clinician. So the goal for us for the next session, for neurodegeneration, is each of these sections you have in the brain function in this brain region localization form are then going to be exposed for the next step, which is the exam. So if you see a lot of overt frontal, or you see a lot of superior parietal, inferior parietal, here s how you would examine them. So we want you to have that thought process. So, last time we went over the neuroanatomy specific to function. This time we re going to the symptoms related to survey and observation, and then you have those bases, you kind of localize the region, and then next time we go, Here s all the exams for each of the sections of the form. So we have to have people have a linear way to learn it, so it becomes easier. So if they see spinocerebellum versus cerebrocerebellum versus vestibulocerebellum, which are the exam findings for each one of those? Yes. And how do you know the difference between an Alzheimer presentation and a vascular dementia presentation and a frontal temporal you know, demise presentation. All of those will fall into the context of This is how you examine what we ve been talking about for the last two modules. And it s really cool when you say, Man, I ve got these findings here. Are they real or not? And then you examine it, and you re like, They re absolutely real, because here s some exam findings to prove it. So now you can kind of start to look at these intake forms and say, I m not worried about this, I m more worried about that, based upon what I found on the exam. And when you add it all together, this looks like Alzheimer s. Or, This just looks like neurodegeneration, like from cellular fatigue. Or, This is truly frontal temporal demise. So when you leave, you will be a whiz at being able to now finally get to the nitty gritty of and teaching the physical exam in a neurodegenerative model is cool, because the whole cortex is involved. And for most people, when you find on these like on the brain region localization form, that one side s really impaired, and they re, let s say, in their forties or fifties, they probably have degenerative changes in those areas. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 7

8 Yeah, they In combination with probably developmental delays that are now catching up with them as their brain is degenerating. Those things are theirs. So the form will also transcend to each of these things. Now, once But you also will see the way we re structuring how we re teaching this to everyone is, once we have, for example, a person fill out this form, they have all these cerebellar issues, that goes right into a more intensive cerebellar vestibular exam form. So now you can go, What part of the vestibular system is really off? Right? So it s kind of a process. But we know that simply saying it doesn t work; that you have to have it in forms, in a linear format, and then they often build up on each other. Okay? So, really master this form. Really make sure you know all the symptoms. Make sure you You know, the suggestion I had is to really look at this diagram, as you look at the form, and really understand the right and left brain together, so you know all the symptoms associated with the image, and fill this out, and even just tag one area, or test each other, if you guys are clubs. Test put a pen in one area, and what are all the symptoms? And you can just start with the brain region localization form so you know all of them. That makes you really learn the stuff really quickly. Now, the second part of the brain region localization form was this aspect with seizures. So, we went over different types of seizures, right? So there s some general questions in the back related to seizures on page four of it, but a lot of those symptoms are going to show up with people that don t actually have seizure activity. So someone may notice that the muscles may jerk spontaneously at times, but they don t have myoclonic, you know, epilepsy, or things like that. So you still want to quantify. You just go in there and do a general screen. We just want to have a form where we talk about areas of impairment, and all the major seizures on one piece of paper to even if anything as a learning exercise to make sure you re familiar with the questions to ask, or to know how those presentations are. Yeah. And really, how many of you order EEGs on some of your patients? Or you even do EEGs? Okay, large percentage, not. So look, here s the thing. Is there usually medical necessity for the need to do and EEG? There is. Especially if it s being paid for by insurance or whatever. I will tell you right now that intake for seizures is a great form that says this: There s medical necessity for this test. I really like doing EEGs that are halter EEGs, where they re wearing it around all day, and when we do therapy, if we trigger epileptiform activity, it just shows up right there, and then we say, Oops, that s not what we should do. So there s actually some pretty cool stuff you can do with an EEG. And I will tell you this: If we tried to teach you EEG, we would have to get a whole other three hundred-hour program put together. That is not our goal. But our goal is to say this: This is when you should do one. Because there s a lot of epileptologists out there that know how to do these, and I ve got one guy that will actually send me reports back and say, The right brain function doesn t look as good as the left brain function. So I ve actually talked to the guy and said, Listen man, I really don t care if you can tell me if these are tonic-clonic or atonic or all that. I already know that. You can tell me that; that s fine. What I need from you and this is what I suggest you all do with your radiologists and the people that do your diagnostics. I need to know functionally how MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 8

9 this brain is symmetric or asymmetric, or if there s a way to tell me if it s suboptimal or not. And the guy that I brought in, he goes, I ve never had anybody ask me that, but I m glad you are. And so, that s what he does for me. And I get a ton of cool feedback. He s like, otherwise he goes, I would never comment on this because nobody knows what it means. Same thing with the radiologist. I tell him, I need you to comment on volume loss. Yeah, that s very, very true. Even a minimal amount, like if cerebellum anterior lobe is not that great, I need to know because that person s going to be ataxic, and it s going to affect their legs, and it s going to have to do with B vitamins, and stomach acid, and possible antibodies to Purkinje systems, and they re probably an alcoholic if they don t have SCA. So, these are the things that we want to teach you. We don t want to teach you to read an MRI, but I need you to say this: Look, Mr. MRI guy, I want this, or else I m not sending you my imaging. Hey Mr. EMG guy, I need this, or you re not doing my electrodiagnostics. Or, Hey Mr. EEG dude, I need to know this on my feedback so that I can take care of my patient from a functional standpoint. I was speaking to a neuroradiologist recently, and I go, Hey, why don t you actually write what s actually happening to the brain on the report? Like, why don t you comment on degenerative changes that are there? He goes, Well, we don t because no one really wants to know about it, and then people just want to know if there s a tumor, or mass, something serious, and that s it. If it s clean or not. Is it clear, clean, ready to go, or not? And I m like, Well, other people care. So he s l like, Well, they should let us know. So again, so you re working with your team to get any imaging and stuff, or special diagnostic studies, that s there. Now, I will also mention one quick thing. With these forms, I have found in my practice, it saves me a lot of time when they bring them in instead of filling them out in the office. However, that leads to another problem, is that if you have a lot of forms, which I like to use a lot of forms to make things go quickly, if they forget to bring them in, it throws off your whole schedule. So I like So the way we do it in my office is, you can t book your appointment until all your paperwork is in. So then they fill it out, they finish, they turn them in, then we can actually put them in the schedule book. So then we actually have the forms. So that s an easy way to do it. That s how I do it. But it s up to you, depending on how you want to do it. A lot of people are like, I don t know where to start with this in my practice. Well, here s what I would say: Don t start booking all of these new, like, functional neuro or metabolic or whatever it is that you re trying to learn, first thing Monday morning. Do your regular practice and what you re good at, and when you start integrating it in, put it at the end of the day, and then make it a whole day, and then make it half of another day. And then put it at the end of the day, because if things go long, and you have to think a little bit longer, it s just your time; it doesn t back up your whole waiting room. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 9

10 So, when people ask me, Where do I start? I m like, start at the end of your Tuesday or something, and say, From three o clock to whenever I get done I m going to see these two patients, and I m going to sit down, draw everything out, learn it, take my time, and not get in a hurry, and really get good at it, and then when I get faster, I m going to do more. And so, I have done that with a lot of students, and they have integrated it that way, and they say that it works tremendously well, versus trying to convert their whole practice right at the beginning and just, Screw it, let s just start doing all this, and they, you know, get hurt. So it s a way to start out. Ah, peripheral nerves. So listen, again, I can t tell you People are like, Okay, so where do I start? Well look: On Monday, just do this: Find out if people have weakness. Just ask: Do you have any weakness anywhere? Oh yeah, you know, I ve got weakness in my legs. Explore why. Yeah, I ve got weakness in my hands. Explore why. You know what? It s hard for me to swallow and I have a hard time breathing and my eyes feel really weak. Explore why. Sensory stuff. I ve got You know, people will come in, I ve got pain. I ve got numbness. When they lose large-diameter afferents, and they ve lost proprioception, they ll explain it as numbness and heaviness. So when somebody comes in and says, I don t feel right, Well, what do you mean you don t feel right? I have pain. Well, what do you mean you have pain? Where Pains in my hand. Where in your hand? Right here in my palm. Why Well, I fell on it. Or, You know what? I m just tingly. Where are you tingly at? I m tingly around my face, and I m tingly all over, and, you know, I m having a really rough time right now. Well, what s going on? Do you have anxiety? Yeah, I m hyperventilating a lot. Or, Hey, you know what? I ve got numbness in my feet. Well, how long have you had that? You know, ten years. Well, tell me a little bit more about your family history. Well, you know, everybody s diabetic. Are you diabetic? Well, I don t know. I m scared to go to the doctor. Well, are you having any other problems? Well yeah, I m having some brain fog, and I m depressed, and you know what? My blood tastes like maple syrup, and I don t know what That s obviously a sign that they have a lot of sugar in it. Just for your that doesn t mean we re actually bless you over there, by the way. So look. Motor stuff, sensory stuff, and then autonomics are the last thing, and autonomics are this: Do you have good blood supply? Are your sweat patterns normal? Are your pupils normal? And then, we want to know this: The patterns that I talked to you about earlier. Is it a nerve root lesion? Is it a plexus lesion? Is it a peripheral nerve lesion, neuromuscular junction, or muscle? So let s just run down. The first thing you would have is the nerve root. The next thing you would have is a plexus. The next thing you would have is one of any peripheral nerves. What s the three major ones in the upper extremities? Radial, median, and ulnar. And each one has how many entrapment sites? Three. So you run through that and you re like, Is this a peripheral entrapment? And if it is, cool. Diagnose it. One thing to add about these forms: These forms all have weaknesses. So if you re having someone fill out the form and you re asking them to interpret what they are saying, it may be difficult to do because the areas of the brain really aren t healthy to do that. And the peripheral nerve, also, we have to look at it. Some patients may not know they have sensory loss in their hand or their feet. So that will come out in the exam. But if you know how the form works, it helps your diagnostic thinking skills too. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 10

11 So you should have it on the form, because it quickly screens for it, but you shouldn t think that if the form is clear that it s cool. But knowing how the form has a thinking process with the peripheral nerves makes you be a better clinician, because then you know what kind of things you re looking for, whether it s sensory loss to the hands or feet or both or one side. Does that make sense? So, some of the questions on the peripheral nerve localization may be difficult related to some sensory loss, because they may not have tinglingness or numbness or pain, they may just have the loss, and they don t know they have it until you do your exam. So be aware of that when looking at the forms too, that the forms are not a replacement for the exam, and one of the weaknesses with a peripheral nerve questionnaire form, just because of the nature of asking questions is, patients may not have perception of it until you actually examine it, you know. And they may not know what things like sensory loss is, and they may not even know what things mean or weakness are related to. So it can help you if you get some answers, but even if it doesn t, if you know how the thought process of the form is organized, it will make you very efficient as you look at your exam findings. Yeah. It s like somebody coming in and saying, I can t see. What do you mean you can t see? Are you blind? No, I m not blind, I just can t see. Well then, what are you trying to say? You see double? No, I don t see double. I just can t see. Well, after you go through the whole thing, you just find out that they have blurry vision, because they have cataract. Or something like that. So people will describe things the way they perceive it, and I ve got to be honest with you: Some people describe things in a way that has absolutely nothing to do with actually what s going on. And you guys have all seen this. And the peripheral nervous system is no different. Nobody s going to come in and say, You know what? I ve got a herniated C5-C6 disk, and it s causing neuropyramidal narrowing, and I ve got a radiculopathy, and wow, I think it s actively denervating. You should check out the fibrillation potentials on this thing. It s going to be amazing. I had that. You did? No. I was like, wow, really? That s pretty cool. No, but people will come in and say this: My neck hurts and I ve got something shooting down my arm, and the pain s killing me. Or they ll come in and say, You know what? My feet feel like they re on fire. And those are things that you can say, Oh really? Well, let s engage in that a little bit more. Remember to start at the center of what they re really telling you, and work your way out, and get everything you can around that one major issue. And also, don t forget that some people will, if they ve had something for five years or longer, they consider that normal. You have to understand, like migraines. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 11

12 Time and time again, somebody comes in, they ve got problems, and I m like, Well, do you have anything else? Well yeah, I do have migraines, but that s just normal. I m like, Really? What does that mean? How often do you have migraines? Well, it s once every day. I mean, I ve got them at least three times a week. You know. But it s really not a big deal, because I m used to it. Wow, really? Do you want to go over the gait? I don t think you covered that. The gait portion of it. Yeah, I went over this. But we can go over it again. You guys, listen. I really want to make sure you understand a couple things. Number one: This is The gait intake form is one hundred percent going to say, Is this something central or peripheral? It really is. Okay? Because if you see somebody spastic, you already know this is not a peripheral-based lesion. Okay? If they re cortically fisted and they re circumducting. If they re ataxic, how would I determine if there s a sensory ataxia versus a cerebellar ataxia? By how far they bring their leg up. Because with a sensory ataxia, where they don t fulfill limbs well, they will pull their leg up and sort of scan the environment, then step down. With a cerebellar ataxia, they know where their legs are. It s just a coordination of motor function, so it becomes just sort of, you know, jagged, so to speak, or staggering. The one thing that I see the most up here, by far, is people who just have low cognitive function. They don t have arm swing, they shuffle, and their step the distance that they go, like this starts to shorten, so now they re just like this. And they walk in, and this is exactly their arm swing, and they re like this. We did a vet study just recently where we did research on a hundred and twenty-eight vets, published the findings, and we watched them walk. We could almost and this is, just hear me out on this. This is an observation, not a proven thing. I could almost determine the severity of their PTSD by the way they walked in the door. Tell me this. Ready? They re like this [demonstrates]. I m here for therapy. And you re like, Wow. Versus this: They have a hood on, and they re like [demonstrates]. And the first thing I say is, Hey, how you doing? Everything okay? I mean, these you know, this is a situation where the person s very flat; they ve suffered a lot of trauma. They ve got a really bad right orbital frontal system. Their cortex is starting to shut down. Their emotional trauma can even bring into effect neural inflammation. Every one of those people that we saw that had PTSD very severely also had traumatic brain injury. So it was like this emotional mixture with trauma, and it was all these things, and no arm swing, shorter gait, mask-like face. The person was turned off from reality. You could see it in the way they presented, and you will see it in patients. They re sick. They re mentally not functioning correctly. And it s not that they re staggering all over the place, or that they re slapping their gate, or that they re massively ataxic; it s that they re not shuffling, but they come in very slow, and they don t have that arm swing, and they re very flat. And they re not Parkinsonian; they don t have a tremor. Their frontal lobes are just saying this: I ve kind of had it. And that is called presentation, which is a little bit different than gait. Does everybody understand how a patient presents? Now, when you start looking at people, and you start talking to people, and you start hanging out with people, and you re like, The person has no facial expression. They have no arm swing. They don t want to stand up. When they do, they re stooped over, and I ve noticed that when they look up they do this kind MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 12

13 of thing, and they don t have the ability to sit up straight and lift their head back. And you re like, This person s getting Parkinson s disease. I wonder if they even know it yet. When you look at the questions for gait, it s actually when, again, you look at weaknesses of the form, most people that have a gait imbalance have no idea they have it. Most people don t know if they have a wide stance, or a scissor gait, or lack of arm swing. So again, when you look at some of these questions, some of it you just have to think of it It s also for you to go through as a clinical thought process, right? So just be aware of those. And you don t have to write And I suggest this: When you write on these forms do it in a different color ink. Okay? The Why? Well, because whenever you do that, like if it s been filled out in black, or if it s been digitally put in there, I would write it in a different color ink so that everybody knows the difference between patient and doctor. So if it ever gets looked at, it s like, Yeah, these are my notes, and maybe this is what the patient wrote or colored in. And you may even go back on some of these and say, Yeah, the patient has a spastic thing, and you circle it, and then initial it. Does everybody understand that? Because if not, then it becomes an issue of, Did the patient put this or not? And you have to say, No, the patient didn t put this, because they re so brain-injured they don t even know, so I filled it out for them while I was watching them, and I initialed it. And this is what happened. So that s sort of a medical-legal issue, where if it s an intake form, and you are altering an intake form, make sure you initial that and make it done you do it in a way to where there s a clear difference between patient and practitioner. Otherwise, make your forms where it says For Doctor Use Only in one section. Okay? It s just helpful advice, I promise you, you won t regret it. Okay. So then we went into the clinical quickie metabolic initial survey. So remember, this is not an exam yet. This is just, the minute you see someone, what are the red flags that impact glucose, oxygen, and inflammatory mechanisms for the brain? Because that s what you need to produce neuron ATP. So again, this is not an exam form, but this is something just to have in your mind as you go through it, and really check to see if you see signs of anemia, or if you look at the body composition, suspect if they have more insulin resistance or hypoglycemia. Just their overall health, looking at hair, skin, nails. We all have an initial survey when we look at someone, right? So those just all have to be part of the clinical process. And then let s go on to this one. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 13

14 Well, this is interesting, because it s got a lot of stuff on it. Let me jump to the far left and talk about mental function. Some of this things you re observing; some of these look like exam like an exam form. I just want you to think through all these. So, the person comes in and they re not oriented to person, place, and time. Forty-eight-year-old female, just went through menopause. She, within four weeks, became completely disoriented to person, place, and time, doesn t really know where she s at, and she s now suffering from significant neurodegeneration. I want you to learn to observe that. It matters. So the old adage of, Hey oriented to person, place, and time it really doesn t matter because I don t see these kind of patients You re going to see these kind of patients. I had a buddy that came and visited, and I don t know again, if I repeat myself on stories, you ll have to observe it s my own lesion, right? Buddy of mine comes and visits, and I had this lady in there, and I m like, Just watch this just watch. I m not going to tell you anything about this. Fifty-one-year-old lady. And I walk in, I say, Hey, how you doing, Susie-Q? She s like, I m doing okay. I go, Where are you at today? And she goes, I don t know. She s fifty-one. That s the average age of the onset of dementia in my facility, patient-wise. Early fifties, late forties. It is scaring me to death. So, when you look at this this, and I m like, Okay, are you oriented? Now, are you hallucinating? So I have another girl that comes in the other day, and she s having these issues, and I m like, Hey, are you, like, hearing any voices or anything? She goes, Yeah. I go, Are you hearing my voice? She goes, Yeah. I go, Somebody else s voice? She goes, Yes. Now, about that time a window washer comes flying across my window. I thought I was actually hallucinating myself. I m like, That s real. I had to tell her, That s real. And she, I think, didn t like that too much. But she all of a sudden just came clean, like, I m hearing things. People are saying things to me. Now, does that go back to anything that we ve studied? Could there be some auditory components? Could there be some temporal lobe components? She was diagnosed as schizoaffective. I tried to draw blood on her; she ran out of the building, like ran out of my office, and went to the tenth floor and hid. It took us five hours to find her. I was like It was like finding Nemo, man. I mean, we I didn t know where to go. It was crazy. But the verbal fluency repetition and comprehension is going to go really well with degeneration of the cortex. Now, some people may be so demented, or they may have so much dementia, that it s really not easy to detect a verbal issue with them. Because comprehension is like, hey, you ask them a question, they have so much dementia that they can t it seems as if they can t comprehend. Well, there s a reason for that. I mean, the posterior part of their brain is now going, the anterior part of their brain is absolutely going, and so some of the actual standardized testing for aphasia doesn t work that well whenever somebody s in a global state of neurodegeneration. So I like to know that. Now, I would say that about fifty percent of my patients are probably suffering from some sort of, like, massive cognitive decline, where they, like, have MMSE scores, and it scores from zero to thirty we ll show you what these are the average score in my clinic is about a fifteen to sixteen, which on that Alzheimer rating scale, that goes from, you know, all the way up to seven from zero, they re hovering in at about three to four. Once you start getting five, six, and seven, six and seven we don t treat. Five and six, or four and five, you re on the brink. We ve actually found that if you re really far gone with Alzheimer s disease, and we activate your brain, it just goes faster. So at that point in time, it s a super duper metabolic stabilization MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 14

15 game. And I ve had people come in and they re eight-five years old, and they have Alzheimer s, and I m like, What are you bringing your family member in for? And it s like, We just want her to be able to say she needs to use the bathroom. I m like, That s it? They re like, That s it. If you can do that, it s worth every nickel. I m like, Cool. Come on in. And when we achieve that, the family s like, You don t know what you did to save her dignity and our dignity. So, you go through this a little big more, and now we have memory. Short-term memory, procedural memory, declarative memory. You know, Where am I going? How am I getting there? What about facts and figures? What about numbers? What about faces? So really, what I plan on doing is giving you more of a memory examination that s more expanded, so you can say, Wow, this is, you know, a problem with facts and figures. This is a problem with facial features. This is a problem with names. This is a problem with getting from one place to another. This is a problem with remembering how to do certain things. And then I ll go through the treatments that we use for each. And we do a lot of visualization with vestibular activation at the same time, to solidify those pathways if they re still intact. And it has really done some pretty cool stuff. You go a little bit further, and we ve got all this stuff for names, recall of fact, naming of figures, all that stuff we just talked about. You know, we have to be able to say, Okay, I ve got visual dysfunction. Eventually what does that mean? I have auditory dysfunction; what does that mean? Does that mean that I ve got a rock stuck in my ear, or I have sensory neural hearing loss? Does it mean I have otosclerosis, or I have Meniere s disease? Does it mean that I have cortical deafness, or not? So we will hit those things. But these are just little checkmarks that are, like, I need to start getting ready for this, or I need to start looking into this, or We ve already learned about this, and I need to start asking questions about this, and this is going to be a bigger thing, and we are going to learn to examine this. But for the most part, when you look at the clinical quickies, again, they re not exam forms; they re just things for you to think of as exercises. But at the end of the day, when someone comes in, their mental function and their ability to give you a history is completely diagnostic to you. So if they pause between words, or what was I saying? If they do stuff like that, where you can t actually get words out of them, and they pause, and they do things like that, that are related to not finding words, you immediately have a diagnostic perspective He can t break character. So, these are things that should be useful to you; that you can check their motivation, you can check their drive, you can check their tone. They re monotone, you know that the right brain s down. So these are things you want to do. What most practitioners do is, they don t become practitioners when they do history, they try to be personable, and they re trying to be social, and they re trying to hurry things up. You can still do that, but you can t lose your clinical window. Does that make sense? The patients have a fantasy that if they just say they try to associate their mental function with their personality. I ve always been bad with memory. Okay, that means your memory areas never developed, and now they re degenerating. MODULE two TRANSCRIPT: INTEGRATION CLINICAL FORMS Copyright 2016 FUNCTIONAL NEUROLOGY SEMINARS LP Page 15