Good afternoon, everyone. Thank you so much for joining us. My name is Charlotte, and I have the pleasure of presenting tonight's webinar, signed, sealed, and delivered, mastering your cases.
I'd like to first, firstly say a big thank you to Vets On Care Network for sponsoring tonight's session and for making this webinar possible. So, a bit about our speaker today. Doctor Richard Joseph is a board certified veterinary neurologist with over 40 years of experience in clinical practise, education, and innovation.
He's trained interns and residents and supported veterinarians through consultations and online forums and lectured around the world. As founder and CEO of Vets On Call Network, Doctor Joseph is the leading, is leading the digital transformation of veterinary medicine. His his work focuses on telemedicine solutions like teleconsulting, with corroborative care, AR enabled telecoaching, telecytology, and AI powered teleradiy, bridging the gap between general practitioners and specialists in real time.
Driven by a world, driven by passion for education and innovation, Doctor Joseph continues to shape the future of the veterinary care worldwide. So I wish to let you all know that today's session will be recorded and available on playback, and you will all receive a certificate for today's attendance also for your CPD. Please use the Q&A box for any questions you may have for Doctor Joseph throughout the presentation, and at the end of the session, we'll see if we can get, we can answer any of these any of these questions you may have.
If we run out of time with the questions submitted, we will email out any responses to you in the next few days. So with no further ado, I'd now like to hand over to Richard to start today's session. Thank you.
Thank you very much for the introduction and to webinar vet for allowing me the opportunity to give this presentation. Tonight I want to, or today I want to talk about side, sealed and delivered for those of you who know Stevie Wonder, this was a song that that obviously he's known for, and I believe that this is a really good framework to help you master your case. And it's something that I use and have used for many years when I approach a neurologic case.
So the objective of this presentation is to have you understand the signed, sealed, and delivered framework, to learn to identify and to interpret neurologic signs, to build effective communication strategies for your clients, and to incorporate digital transformation solutions to enhance quality and efficiency of care. So, but if we start with the framework, the first thing would be the sign. The sign would be recognising the input.
The sealed would be processing the information. And the delivered would be educating and acting. It, it, it, it takes, it just takes commitment to learn to recognise neurologic signs.
And when my mentor A was teaching us neurology. I was always amazed that before an animal, before he even put his hands on the animal, the animal would come out of the cage. We'd watch it, and within a couple of minutes he'd know where the localization was.
And so through observations we can really learn a lot about about the animal even before we put their hands on him. And I hope really to develop this for you as we go through this. It's very difficult in the neurologic presentations to cover everything in an hour about neurology.
So I'm trying to, to hit the highlights and the high points of what I think is the most important thing, as a review for you in the neurology realm. So if we look at Laya here, who is my daughter's dog, she's looking at a sign that says down. And And then you could see that she's looking at another sign and she says sit.
So if Leila can recognise signs, we all certainly can, can do our best to recognise signs. If we, if we look at the difference and we define a sign. Symptoms are when patients communicate to you in the communicate to a physician in a medical practise.
A sign is when the client communicates to us, so, or the sign is recognised by us. So, so that's an important distinction. Sign recognition, if we look at key categories of neurologic cases, we have mentation, gait, posture, reflexes, and pain.
When we look at these categories, we're looking at the as how we evaluate this both from a historical standpoint, from an observational standpoint, and from our hands-on exam. So mentation is alertness. How wakeful they are, and then you have appropriateness or behaviour changes, and I'm going to go through each of these categories.
Gait would be ataxia, paresis, or lameness. We have posture reactions which the most important posture reactions for me is conscious proprioception. Obviously there's other post reactions hopping, hemi walking, but to me this is the most important one is conscious propriception.
Reflexes, we have cranial nerve reflexes, and we have spinal reflexes, and then we have pain. Pain could be obvious or subtle. So if we look at mentation or consciousness.
Mentation is divided into level, which is how alert an animal is. So you have alert, dull, stupor, and coma, and mentation or level of consciousness is orchestrated by both the brain stem, whereas there's the reticular activating system that alerts the cerebral cortex. So if you have an animal who's dull or stupor, it's not very localising because it could either be brain stem.
Or forebrain, forebrain being cerebral and thalamus, brain stem being here. The other part of consciousness is, is the content of consciousness, and that's orchestrated by reverberating circle circuits in the forebrain which is demonstrated by this red and blue arid area of the forebrain. Content is changes in behaviour, intellect, personality, habits, seizures are, are a form of disruption of forebrain function, obviously, so that would indicate forebrain disease.
So this is more localising and whenever we look at signs, it's so important to understand when is a sign localising is not localising as we go through this, you'll see further. Next category is ataxia. There are 3 types of ataxia.
You have proprioceptive, vestibular, and cerebellar. So we look at propriocepted first. What we're looking for in the history is crossing, sliding, dragging, knuckling of the limbs.
On the exam, you would see evidence of delayed or decreased conscious proprioception. It, it should be noted that proprioception deficits are very lateralizing. They're not very localising because if you have CP loss on one side, it could be ipsilateral cervical, ipsilateral brain stem or contralateral cerebral.
So it's very lateralizing but not very localised. So when we check proprioception, you could see that it's a very long pathway. You have the, the peripheral nerve entering the spinal cord and ascending up and crossing to the contralateral cortex.
That's a century limb, and then you have the motor limb coming down. When you check proprioception, you should really stand behind the animal, make sure no one's distracting them. They're standing squarely in front of you and you're slowly turning the paw over and seeing if they pull that paw out of your hand or leave it there, not knowing it's turned over and check right and left sides and compare symmetry to look for a deficit.
The next category of ataxia is vestibular. Vestibular is listing, leaning, veering, falling, rolling, head tilt, or widehead excursions if the animal's affected bilaterally, kind of like Stevie Wonder or Ray Charles playing the piano. On the exam, you may find evidence of nystagmus.
If there's asymmetric, deficits, one side's affected more than the other, that's what causes the nystagmus to be present. If both sides are equally affected, you won't have nystagmus. If, if you are affecting both sides, you may lose vestibular eye movements.
So when we look at, at the signs for vestibular disease, the most common sign would be a head tilt. And the animal would list lean and veer towards the side of the tilt. When we look at the localization of of vestibular signs, it's, it's typically inner ear, 8th nerve, vestibular nuclei, or floccular nodule lobe of the cerebellum.
Those are the areas that would cause leaning, head tilt, veering, nystagmus, that's spontaneous. Next area cerebellar. Cerebellar disease will cause dysmetria of the head, and tension tremor, eyes, pendular nystagmus, no fast or slow phase, limbs, hypermetria, or trunk, a trunkal sway, kind of when they stand, they may sway a little bit.
This, this, these demetris typically mean there's a hemisphere problem, a cerebral hemisphere problem. The, the cerebellum can also cause postural dystonias. You may have heard of the cerebellar rigidity.
That's where you get opistotinous, front limbs are rigid and rear limbs are tucked in. And then finally, you can get vestibular signs, as we mentioned earlier with the cerebellum, which are usually s which can be ipsilateral, but they also can be paradoxical where the head tilt would be opposite the side of the lesion. So here are some obviously cute cats with cerebellar hypoplasia, showing kind of the typical head tremors that you would see.
The next category of gait, we just went over ataxia. The next category is Parisis. Parisis is defined by decreased ability to maintain weight support against gravity, or initiate movement.
When we look at an animal who's weak, we typically assess reflexes and we assess tone, and we make try to make an assessment. Are we upper motor neuron or lower motor neuron. So if we look at this dachshund here who you can see is weak because he has trouble standing.
With spinal disease, you lose proprioception before you lose motor. So, if this doxin has loss of proprioception, loss of motor, if we evaluate his reflexes and their hyper and there's increased tone, then that would help tell us that we are T3, L3. His front limbs are normal and his upper motor on rear.
If this dachin had myasthenia gravis as an as an as a as an alternative and it wasn't a spinal cord problem, he would be weak with normal conscious proprioception. That's more typical of neuromuscular weakness. So with neuromuscular weakness, you have preserved conscious proprioception unless you're so weak that you can't move your limb.
Very important distinction. Reflexes don't always help us determine if your upper and lower motor neuron. In many instances, they do, but they don't always, so I oftentimes we also rely on limb tone.
Lameness is the last category of gait change. It could either be one limb that would be partial and non-weight bearing. If it's neurologic, it's, it, it would be like a pinched nerve or a radiculopathy.
If it's orthopaedic, like a, a cruciate ligament rupture, a fracture, then, then that would be an example of one limb affected. If you're multiple limb affected, it could be neuromuscular. You could have meningitis or it could be like a polyarthritis.
Here's an example of a dog with a radiculopathy. He has other signs of neck pain and vocalising and holding up a limb that's called a nerve root sign. And if we look at kind of why would you get a radiculopathy, you could see on the left the normal disc with the nucleus propulsis, the annulus, and here you can see the disc has ruptured and compressed the nerve, and that would cause similar signs as, you know, orthopaedic lameness, except there's neck pain and helping us determine that it's more neurologic.
We move on to reflexes. We have cranial nerve reflexes, so when you're doing your exam, you start off with observing mentation. I always watch the animal walk.
And then while they're walking mentation and then I look at their gait and I try to characterise is it normal or abnormal and then delve into what type of abnormality I think the gait is and then I go ahead and I do reflexes, cranial nerve reflexes, and when you evaluate your reflexes, the reflexes that are, are going to be affected with forebrain disease are menace, that's cranial nerve 2, and you may Decreased palpebra, which is a partial decrease, not completely lost, and decreased nasal sensation that are contralateral to the deficit. So if you had a left cerebral lesion, you could have decreased menace, nasal sensation, and palpibrile on the right side. With brain stem disease, which would be midbrain, ponds and medulla, you would affect cranial nerves 34, and 6 with with ocular movement.
You can have 5 for TM atrophy, nasal sensation changes, 7 decreased blink, 8 head tilt, and vestibular ataxia, and then 9 through 12 would be voice change, gagging, regurgitation, movement of the tongue. With brain stem disease, typically the lesion, the signs are ipsilateral. When you have sensual involvement, you would start to get changes in consciousness.
The animal would be dull with brain stem disease, with forebrain disease, they could be, would be inappropriate. You would have CP loss that would be ipsilateral to brainte disease and contralateral to forebrain disease, and then upper motor neuron with both of them, either ipsilateral or contralateral, and then vertical nystagmus is typically indicative of a brain stem disease. It's on.
. When we do a neurologic exam, it really, let me just go back a second. It really should only take you 40 seconds to do a neuro exam and I always do a fundic exam first. I think it's really important to, to do that on every patient.
The fundic varies in every animal and by, by can do it in a bright room with the right equipment. You want to see the disc, you want to see the, the, the torpedal area. You want to see the surrounding discs, the vessels, look for any haemorrhage, any changes, you do it enough, you'll get to appreciate things.
So you, that's the first thing I do. Then after I do the funding exam. I go ahead and do a a PLR because I have my light out.
I check the light from the nasal to the temporal retina. Then I do the menace from the lateral visual field. Check palpribrile, which is 5 and 7.
Nasal sensation by covering the eyes, to slightly touch your nose. Go ahead and check the ocular movements, make sure they're having the normal fast and slow phase, and then look for positional stagmus by putting them their head up and checking that they're swallowing their tongues moving OK. So that exam should be built into your general, your ENT and it literally, it takes 40 seconds to do.
And sometimes I get, I get referrals and emergency cases that come in and you see in the, on the, on the soap that they've done at the emergency clinic, you know, complete neuro exam's not done. And I, I understand when you're not a neurologist and you don't, you know, you have cobwebs on a lot of these cranial nerves, etc. But I, I, the, the, if you force yourself and you understand that this is, this is, you know, what it takes to just quickly review it and look for any asymmetry, it'll really serve you well.
Spinal reflexes. If we look at to understand them. When we look at reflexes, we're testing one of two things.
We have segmental reflexes like the patella reflex. So you have a sensory nerve that comes in and then a motor nerve that comes out. How many of you have seen a dachshund where you check the reflex, the do the dachshunds paralysed and the owner is like, Oh, that's wonderful.
Oh look, he has a reflex and you hate to break it to them that the reflex means nothing because the dog has no deep pain. So you, when we do the reflex, it's just assessing the local area. And in the classic reflex that is affected in the segmental fashion, you have hypotonia and decreased reflexes, decreased tone and decreased reflexes.
With the upper motor neuron, you're really now assessing, I like to call it the in, up, down and out reflex. This is the in and out reflex. Is this segmental, the rostra segmental is in, up, down and out because you're calling in to play the brain.
And the brain is gonna modify the reflex and if you have a a a a reflex of, a lesion above the segment, then you will get upper motor neurone reflexes typically which cause hypertonia, spasticity and hyperreflexia. And this idea of segmental and rostral segmental also works in the brain because if you do a palpebra reflex, that doesn't call into play consciousness. So that's a segmental reflex.
If you have an animal under light anaesthesia and they're not conscious, they still will have a palpebral, whereas the metas reflex. Calls into play the cerebrum. You will lose your menace reflex, obviously if you're under anaesthesia.
So that's the distinction between segmental cranial nerve reflexes and rostral segmental. Proprioception is a rostral segmental reflex because it calls into play the thinking portion of the brain. Obviously, so those are are ways that you can think through your, your, what you're testing and try to localise.
So, so sensation is the last category, and I I was always taught with sensation by my mentor was. You want to really find out in the history if you think they're painful, because if we just rely on an exam, we're probably going to overinterpret pain because you could take 10 animals and really press on their back and only and and they all may be normal and half of them may resist or resent you pressing on their back and sometimes even try to bite you and that may be all behavioural. So you really want to get a good history about whether the owner thinks they're in pain and they're showing signs of pain.
So pain may be overt where they're having posture changes like, you know, this dog's clearly in pain, arch back yelping. They may have a lameness when they're when they're uncomfortable. They're they're lame, they're yelping.
It may be covert where they're having these episodes that are very vague. They may be reluctant to go upstairs. They're just standing there going to approach it, but they won't go.
They have other subtle behaviour changes. They may have Sorry about my birds, they're, they're, I hope that they're not disturbing the, the lecture on the parakeets. When the exam is normal, I suspect if, if, if I suspect they're in pain and they're yelping, I mean if they're yelping and we suspect they're in pain naturally, then, and they have no other signs, and I typically think that it could be spinal.
For example, dachshunds, sometimes they have intermittent pain and they have no other signs and, and they're not lame and you know, those would be, you know, obviously classic cases that you would suspect spinal spinal column disease. We, we always want to correlate the history, as I mentioned. Some dogs are very stoic, so they don't tell you when they're painful in exam.
Some animals are wimpy, and no matter where you palpate them, they don't like to be touched. And then some animals are aggressive and you can't even get near them. So only a fraction of animals on your exam are going to really be believable.
So I hope I made the point that not everyone agrees with this, but I find it to be very useful. So now as we move along on the signs, we've talked about all the various neurologic signs and as we evaluate the patient in the history on our exam, we're gonna pull all these signs together and we're gonna have a sign time graph. For how these signs came on and progressed, so we want to do an onset duration and progression for each of the signs and then kind of have an idea, a timeline of how this, this, the clinical course of this presentation is.
I always tell owners when I ask them questions like, I'm trying to move in with you. I'm sorry for all the questions, but I really want to understand what is going on and how things are progressing because that's how you prioritise your differential. Finally, once you, once you are, you, you gather all this information, then you have to localise.
And when you localise, you want to first decide what area of the nervous system is affected. Is it brain, spinal cord, neuromuscular or multifocal? And then I always separate the, the, the the categories into dysfunction or disease.
For example, if an animal has signs that are diffuse cerebral, affecting the, the front of the brain. And the animal's dull, that could be dysfunction, and dysfunction means it's either metabolic or toxic, where disease would mean that it could have a prefrontal tumour that's midline and affecting the animal and it's more structural. So dysfunction would often be metabolic toxic.
It could be postdictal signs if you had an epileptic and he's, he's, he's postdictal from all the seizures, that's dysfunction. And obviously his function is frequently reversible, but you can have significant signs with dysfunction. When we localise, we always try to come up with one disease to explain the localization.
Sometimes we have two localizations. Not all cases with two localizations are multifocal disease. Multifocal disease is typically inflammatory or, or metastatic neoplasia.
Sometimes you can have an animal whose seizures which, which would suggest forebrain dysfunction and have a head tilt, which would suggest that he has a brain stem or a middle inner ear disease. And so sometimes you can give them a better diagnosis or a better differential if you consider two diseases instead of one. I hope that's clear.
The final thing I want to say about the sign is sometimes it's extremely frustrating gathering information from clients because they don't always communicate as well as we'd like. So we wanted them to communicate what they see, not what they think. We want them to use simple terminology.
Don't use terms like they're imbalanced because when they say imbalanced, it sometimes means they're sliding out. If they say weakness, it, it may mean that they're just limping. They just have Trouble getting up and sometimes when they communicate things, they communicate things as if it's occurring all the time and really it's, it, it, they're what they're describing sometimes is an episode that's recurring, but the animal's normal in between.
So you really have to take the time to sometimes take control of the history and ask them pointed directions again so that you have a good idea of what you're dealing with. So I saved the medical terminology for my record and I try to keep the descriptions as if they were like a teenager just relating what they're seeing to me. Next thing we want to move on to is sealed.
So sealing, sealing the information is processing it. We want to start really thinking through the information we have. A lot of times this occurs while you're writing up your record, you know, or even while you're thinking through the case.
I've had a, I can remember times where I'm writing up the record and, oh man, I should have asked them this. Oh, you know, and something dawned on me as I'm writing up the record because really your processing part. So you want to ask in your head as you're taking about this, when was the animal last normal?
That's really important to know and establish that and make sure you believe it. Sometimes they tell you a cat started circling and that's when the signs started. When, when you were to find out when you really questioned them, the cat stopped jumping onto the counter a month earlier, and it hasn't been grooming themselves, but they didn't think about telling.
That they just told you about when it started circling. So that's one thing that that is very important when we say take apart the history. I already mentioned strict definition of signs.
The reason why I went through the sign is you want to understand all those signs neurologic signs. What do they mean and use those signs very rigidly because they're your tools to localise. You want to correlate the signalment.
Of the pet and the systemic signs of illness. I always separate it out. I always start with what are the neurologic signs, and then I want to know if they're animals sick because if they're sick and it's preceded neurologic signs, I think about they may have systemic disease.
And then response to medications is obviously very helpful and previous history, will also be, you know, you get hit on the head and maybe that's why now he's an epileptic, all the things that you can gather. The thing also that had always been drilled into my head is observations. As I mentioned in the beginning, I learned from my mentor, I do everything I can to try to localise before I put my hand on the animal, and I use my exam to refine it.
In this case, every animal that I look at, I, I always make sure. Hold on a second. Every animal I look at, I always make sure I watch them walk.
I want to not only watch their gait, I want to watch their mentation. Are they recognising? Are they looking in both directions at this dog so I can tell that he's normal and his gait's normal.
And then videos are hugely helpful. I'm sure a lot of you have read. Recognise that this dog had an episode, the same dog that we just saw walking.
If you didn't have this video, she would be describing what she's seeing, and it would be hard to believe that the animal was actually abnormal when you looked at him walk. So I always encourage people, especially with strange episodes, to either video the episode before they come in to see us, or I always look at the episodes because it can be very helpful. The next part of the the that we want to seal in our head is the is the neuro and physical exam has synergy.
So the neuro exam is to confirm your impressions. As I said, we listen to the history, we observe them. We're already thinking what part of the nervous system is affected brain, spinal cord, neuromuscular and then we then do our exams.
So we're not going into our exam with an empty head or clear head. We're trying to see what kind of deficits we have. Then we want to correlate with the physical exam.
We don't want to skip the fundy, as I mentioned, that should be done on every animal. A good orthopaedic exam, especially if they're lame. And a rectal exam is important in, you know, as animals age, especially dogs, and we always want to palpate the region that we localise.
If I palpate something to vestibular, I want to palpate the bullet area. I've seen animals where we didn't palpate well enough. We do imaging and we're like, wow, we could have felt that maybe.
So we certainly don't want to. To skip over a good thorough evaluation of our patients because we may save people money and we may be able to You know, do better. Next thing that we want to seal is the neuroanaatomic diagnosis.
The accuracy of the neuroatomic diagnosis really does depend on knowing normal. Then recognising the hardest signs, what are the most localising signs? That's what means hardest signs.
And then you want to commit to the localization, primary or secondary, . Sometimes you have one area, you know it's vestibular and sometimes you're not sure it's vestibular because you think he's veering, but he may not. His cranial exam is normal, maybe it's cervical.
That's what I mean by primary secondary. When you arrive at a er anatomic diagnosis, as we said, the hard findings, the most localised, I use the analogy of a toilet in a bathroom is like a head tilt for vestibular disease. Whereas circling is like a sink because a sink could be found in the bathroom or the kitchen where circling can be seen in the with forebrain disease or with vestibular disease.
So it seems may seem like a little crazy analogy, but it really works with the nervous system. There's signs that are very localising and less localising, and I can give you a whole lecture about that, but I wanted to introduce the concept. Next thing we seal is to prioritise the differential.
We want to look at the signal and obviously different ages have different categories of disease. We want to really make sure we understand the sign time graph. Is it insidious and progressive?
Is it acute and getting better? Is it episodic? And what are they like in between, and we want to correlate any systemic signs that precede the neurologic signs.
We want to consider that they could have systemic disease and and really evaluate them closely for systemic disease. I had a dog yesterday that that had a dropped jaw. It was a 7 year old, a small breed dog.
It could not close its mouth. That was First sign it showed the vet had done blood work. It developed facial paralysis, a partial, a smaller pupil meiosis on one side, and he had decreased nasal sensation, vertical nystagmus, so I was like, we need to MRI him.
But then when I looked at the bloods, he had 43,000 platelets, and I'm like, well, maybe this platelet clumping. We went ahead and rechecked the platelets. The manual count was 18,000, so I'm like, I can't MRI this dog.
There's something going on systemically. So when you evaluate your patients again, a good neurologist always, always understands medicine, always considers the whole animal, looks at the character and nature of diseases, and this is what I'm talking about sealing, very, very important. And of course we all know that you have the damage scheme, which really helps keep you honest because you can always go back to it.
If I'm rushing a little bit, I apologise. I want to get through this. Sealed.
When you seal a diagnostic and planned, you want to have a plan A and you want to have a Plan B. Plan A is, is sometimes evidence-based medicine is the best thing. When we want to get an answer, we're, we're concerned about progressive disease and we want to make sure that we're going to customise treatment.
The people want to know prognosis, they want to be informed, knowledge is always powerful. Treating the treatable, sometimes it's reasonable. Like if it's a dachshund, can walk, you think it's IVD, we all do that short anti-inflammatory trial.
If it's, you got everything to support epilepsy. I don't MRI every 23 year old dog that has seizures because they're probably epilepsy. I always make sure I get a minimum database relative to what the presenting signs are, and then we can always change the plan if they're no better or worse.
Now we're moving on to deliver. So deliberty is educating and acting. And one of my really important aspects of being, you know, a veterinarian and, and, and being a specialist, and I always admire veterinarians because I don't have to worry about all disciplines and doing everything, and I'm marvelled by the skills of veterinarians who who really cover all disciplines very well, but I, as a neurologist, obviously take a lot of pride in making sure I'm doing the best I can.
And one of the things I Focus on is always making sure that pet owners really understand and that they, I'd rather educate now than explain away later why we did these tests, because if we don't inform them, let them know pros and cons, why we did what we did, then later on, they're going to have all these questions if things don't go well. If things go well, everyone's happy, but if they don't go well, that's obviously when they're going to ask questions. But if you cover it, you, they, you set the expectations.
They understand, then that's what I mean by communicating like a pro. We always want to let them know when their options Plan A, Plan B. You want to compare them and contrast them.
That's how I also get to know the clients and try to help them make the right decision for them. I do believe that every pet has a right to a fair trial. I really think that telling me or saying that your animal's too old or they're worried about anaesthesia, really unless there's A good reason that they have multiple problems in an old dog, but if they're otherwise healthy before whatever came on came on, we don't look at age.
And if, if the anaesthesia, if their organs are good, their heart rate is good, anaesthesia is generally not considered risky. So those factors, I think, get minimised and I focus on whether they really want to know what's going on. And I try to deliver everything in a really organised fashion.
So if we look at communication, we want to review the salient features of the history. We want to discuss the neuro and physical exam findings. Explain the neuro anatomic diagnosis, outline any history physical lab findings concerning for systemic disease.
Discuss differentials, review Plan A, Plan B, educate regarding pros and cons, and answer questions. So that's a lot in a half an hour, 45 minute consult, especially when you have trouble getting a history or the owner's tough. We want to spend the most time we can with the owner.
That's where I want to just mention Vettrec. For those of you who you're not familiar with these AI scribes, I, I, I'm an advisor, so I wanted to have you have a disclosure. I became an advisor because I was using chat GPT.
I got introduced to the CEO, through a friend. And I gave him a really hard time and once I started to use it, I was like, I'm blown away. You, you can, it does your medical records summary.
It streamlines all your documentation for your soap, for discharges, enhances accuries, reduces errors. They have this diagnostic system, which is an AI thing that can help you with your differentials or looking through referral records, and it integrates with a lot of the apps. If I just briefly show you.
What it looks like on the screen. Basically the way I use it is, my staff will set up my day. They'll put all my records in for the day, and so I know my first appointment would be down here.
So when I come in my, my appointment, I go look, and this is the records recap from 100 pages of medical records, it's recapped. Then when I go in the room, I start recording the history, then I do my exam. And when you record, you'll get this screen.
You know, and I have it on my phone. You could use it on the desktop. You hit record.
I record the whole, the whole history, then I do my exam, I shut it off, and then when I'm ready to speak to them, I record everything I delivered to them and answer their questions. When I'm done, I hit generate and it generates my soap notes. And then when I'm done, I just process them.
I go back to my office. I just modify my soap notes, and then once I modify them, I save them, and then I go to my, my chart and my the the chart area and I generate discharge instructions. And literally every case I'm done within 5 minutes of seeing the case.
I have a plan. I have everything done, modified, they're out, and they're very happy. You got a loads of templates.
That you can work with. They have a library, you can modify templates, you can make your own templates, and they also have a, integrates with a lot of software platforms, especially the ones that are cloud-based. All right, that's vera.
Let me go back to the lecture here. This is another thing about delivered. They like to ask you, what would you do?
And it's easy to tell an owner what I would do, but if they're asking me as a specialist or they're asking me as a pet owner? Are they're asking me because I have a special bond with this pet, or, or, but, but I don't even know what bond they have with their pet. So I always tell them, listen, I could tell you what I would do, but the bottom line is, is you need to wrap your head around everything I'm telling you so that you're educated, and then you could, if you're not sure how to make a decision after I educate you, you'll ask me questions and then I will.
Back and forth, and if you can't decide, I will help you. But again, this is for me is the best thing to do because people have to live with the decisions they made after they made them, and it's just a shortcut asking you what you would do. And sure, if you say that that if we find a meningioma in a cat and I would remove it, of course I would do it.
So it really depends upon the case, but I always feel that this is an important thing to address with an owner. So. When we look at educating a child, a client, when we look at delivering information at the ultimate who is in charge.
Yeah, are you in charge of your hospital? Are you, are you going to refer him to a neurologist? Those are really your two standard ways of dealing with a case.
I would say in my referral population there's some veterinarians who refer and they don't even do bloods, and there's some veterinarians who do everything they possibly could and they only refer like for the MRI. So, . There there's another option these days where, where you can use virtual solution, and that's one of the things that VOCN has brought to the forefront.
We have teleconsulting, teleradiy, and telecoaching. Teleradiy is not really anything new. The only thing we added with the teleradiy is AI, and any virtual platform has to have teleradiy.
But what we brought to the forefront is telecoaching, I'm sorry, teleconsulting with a corroborative app and Teleconsulting with a corroborative app and tele coaching with augmented reality. I'll just run quickly through both of these. This is teleconsulting with our corroborative app.
If you look at the platform, let me just go, we have a web version and an and a mobile version. If we look to the platform, we have a an online submission form, so you, you put in your clinic name and you have to register with us to do this and then you will either do a teleconsult or you could do tele coaching. It may be a recheck.
If we look at each one of these you can select the neuro consult with tele coaching, you'll see the options that are available. As I go through the presentation, if we look at a teleconsulting case, this was a case that came in through one of the hospitals that use us. This was a French bulldog.
You could see we set up the patient channel in their hospital team. It's a 2 year old French bulldog that was a neuro consult within 24 hours done by this neurologist. If we go to the top of the channel.
We set up the consult form gets uploaded into the patient channel. This is the the case as it had developed. So here's the consult submission form.
This is the history. They uploaded the videos of the patient available for the neurologist to review both the the observation, the hands-on exam, all the medical records, and the X-rays, etc. So as a specialist, we're reviewing it as if you sent it to our clinic, our hospital.
And then there's back and forth. She's asking the neurologist to clarify some information and tell them this was a case of narcolepsy that was very, was, was went on for quite a bit of time to try to get the dog stable. When she's done, she, she goes ahead and provides a neuro consult report, and then if there's any questions, we try to make it educational so it's case-based learning.
And then if there's any questions. About the case, there's a back and forth with the specialist so that you're guided. So it isn't like you called someone, you can't get a hold of them again, you're getting guided.
The goal of this, this platform is to try to keep revenue in your hospital, get cases looked at by specialists quicker, help you learn with each case, and, hopefully save owners money because especially hospitals can be very expensive. So things that we can keep in your practise is one of my missions here is to try to democratise veterinary care. So that's a consult.
If we look at the AI, for teleralogy, we have an AI powered solution, but we also have option for radiology read. Obviously, AI is instant and it's pretty reliable. It's, it's not 100%.
It's just an over the shoulder look, and it has a list of, of, of, of disease processes that it picks up. And it's a good screening. It comes back quickly.
It, it integrates easily with your practise, and it's, the cost is, is very, is, is actually the, the lowest on the market. Once your, your X-ray machine is, is the DICO send is set up, it takes about 5. Minutes to upload the AI scan, the platform scans it and then it tells you what the risk is.
If you want to submit it for a full radiology report within an hour as stat, within 12 hours as priority, or within 24 hours it gives you a read and we've gotten really good feedback. So that's the AI teleralogy, and then we have AI telecoaching with augmented reality. This is really excites me because no one else is doing this level of augmented reality that I'm aware of, and I will show you a video next, but this is real-time guidance.
It connects vets with specialists for live augmented reality assisted. Seizures, it reduces referral costs by keeping stuff into your practise. It's hands-free learning, enhances skills and confidence, real-time coaching, and it is versatile for the emergency room, for neuro exams, for imaging like ultrasound learning, advanced procedures, and even telescytology, as you'll see in this video.
So, I'm just gonna talk through this. It's arrived in clinical practise. You do need some equipment and the equipment is decided based on what you want to do.
The, this first thing is a neuro exam, as you can see. This vet is wearing the glasses. There's a camera in the glasses.
There's a battery pack that powers it. There's a light that you can actually record a funding exam that the specialist could could see it. You could, the specialist controls zooming in, zooming out, can control the light in the OR.
So it's extremely helpful. The vet is hands-free, speaking to them as as if they're right there and guiding them through it, like I'm telling them how to menace. And you could see the other end.
In a moment, this is me coaching that veterinarian through an exam. I'm on my laptop. I'm telling him how I wanted to menace so that I'm seeing the response.
I can pause, I can pause the screen. I can draw on it and annotate it and explain to him what he's checking, and then he sees that in his monitor when I send it to him. So there's a lot of really immersive hands-on.
We can train with ultrasound. By having a PTZ camera mounted, you can see this is a camera mounted on on a station where there's a Windows iPad. The Windows iPad is connected to the ultrasound machine and is connected to the camera.
So the left view is the probe, the right view is the ultrasound, and this image is what's projected to the specialist who can control, the, the instruction. So the, the So the left side is the, the, the the the, the probe from the camera. So the, the, the specialist is now coaching.
And actually showing them what they're seeing on the ultrasound, telling, wait, hold there and explaining that, you know. What they need to know to write up the report. And then we, we have had cases.
We've done a C-section. A new grad needed help with the C-section. The senior clinician wasn't there, walked him through the C-section, and, and everything went fine, like a charm.
They were thrilled. This is a resident who needed some help with the type 2 disc, was able to be coached through this type 2 disc for certain procedure, dissecting it from the cord. And we can control the contrast, etc.
And then we have telleytology, where the cytologist is on the other end and you're just driving, and they, they can instruct you, they can see the cells really well and then make a diagnosis and give you clinical advice about the case because it's really immersive training. And as, as we mentioned, this is all tied into our corroborative care app where we, where we create a hospital team for your team so that you are really plugged into these specialty services. OK.
If I just continue now with the talk, let me see how we are with time. So the benefits of mastering digital transformation solutions are efficiencies, case-based learning, affordability, revenue generating, peace of mind, you know, we talk about burnout. Am I doing the right thing, that people don't have money, you know, work life balance so with AI, I, I finished my paperwork now.
It's a breeze. I can't believe what that rec has done. So let me just give you a couple of examples and then we'll be able to wrap this up so I can try to drive home how each case works.
This is just kind of a, a little stupid funny thing. You could see that this dog is circling on a bed. So what is the sign?
Left circling? It's episodic, it's only on that bed. We're sealing it.
It's only on the dog bed. He has a normal exam intero. Is it forebrain circling?
Is it vestibular circulating? No, it's behavioural because he only does it on the bed and that's how he gets comfortable. So no diagnostic or treatment warranted.
That's, so we explained to the owner, why is it behavioural and why not pathologic and not to worry. Then we take another dog. Who has a gay change, and this is all you have to start.
He has a gay change. What is his gay change? He's listening, leaning, veering to the left.
Oh well. So, now we, we have to look at the sign. One week progressive imbalance with right tilt listing and leaning and falling to the left.
So right tilt falling to the left, the neuro right head tilt with positional sustained vertical downbeat nystagmus leaning left downbeat right head tilt leaning left. Neuro anatomic diagnosis, wait a minute. He's leaning left.
It's vestibular. He has a right head tilt that doesn't fit peripherally. His vertical stagmus, it's central, so it's paradoxical left central vestibule.
With a right head tilt, it's progressive, so it's either encephalitis, an ear infection going to the brain, or neoplasia would be the most common. So we deliver. Plan A would be CBCEM thyroid, MRI CSF.
Plan B would be CBM chem thyroid, titers for infectious disease, clitamycin and doxy to cover year and. And maybe an anti-inflammatory steroid taper and they went ahead with the MRI. We could see this patchy bilateral cerebellar lesions.
CSF was done performed due to concern for increased intracranial pressure, so we did do the titers which were all negative, and we started treating him with long-term steroids as an immune dog, saw the dog back. It's kind of always a nice case. Did well 3 weeks later, Ria.
Next case. This is a 2 year old lab. Unlike the one yesterday, only had a cranial nerve deficit, otherwise normal.
What is the cranial nerve deficit? He, he just ate a meatball. He can, he can chew in the back of his throat.
He can't close the jaw all the way. He can swallow. So we got a really good history for what he can or can't do.
Several days of thyism and he'll be able to close mouth. It's his only sign bilateral cranial nerve 5 mandibular branch. That's how I seal it.
Hypothyroidism occasionally will cause a peripheral neuropathy, rarely cra 5, but I'm a big thyroid checker because I want to make sure it's normal. Idiopathic is most likely versus immune crypto. We've seen rare cases of crypto neoplasia like lymphoma or myelomonocytic leukaemia.
We'd find that out on bloods. So CBC. T4 MRI CSF.
Do we really need to do the MRI CSF in a dog that may have trigeminal neuritis? We have that type of conversation with the owner or Plan B, which would be just through the bloods, no specific therapy. If it's idiopathic, he won't develop other signs that it'll get better.
And so they decided to just do CBC and T4, which were normal, and the dog improved within 8 weeks just with supportive care. The final case is a seven year old lab. That you can see has trouble walking, and this is what I was talking about earlier.
He's weak, he has trouble standing, he fatigues, and he has normal conscious proprioception. So 6 days, sudden weakness, no voice change or regurgitation. He has decreased palpibrils, cranial nerve 7, short strident fatigue, collapse, real limbs, no CP loss, 2 + reflexes.
Here's an example of lower motor neuron or neuromuscular with normal reflexes. No muscle atrophy. So because he's weak, he's spinal, rear limbs, and he's cranial nerve 7 with his decreased length, so myasthenia would be by far the most likely differential hypothyroidism, immune toxo paraineoplastic, delayed organophosphate, which he doesn't have a history.
So we deliver that to them, we give them options of testing, but, or what would you do? Would you do the same in-house or would you refer or do a teleconsole? If you had this and you did a teleconsole, we could tell you what to do.
This way back in the past we had Mesanon. So what they opted for was a mestin, blood CBCC T4. We did a tenalon trial, sorry, I said mestinon.
We don't have tensalon anymore, but we gave the dog Tensalon. Now we have to give oral mestinon. OK These cases obviously were great.
It almost was like it was a religious experience, you know, they would come into your exam room, they can't walk. You give them the drug and then they're walking, so. So it was always very nice, but now we don't have 10s, so we have to start them on methanon.
Thoracic radiographs were normal. We eventually got the acetylcholine antibody titis. It was high and some cases you don't have to use steroids.
They can be self-limiting. I wanted to finish 4 minutes ago. I hope I was able to be effective, that you enjoyed the ride, and I really appreciate your attention.
I'm happy to entertain any questions in the, in the few minutes that we have left. Thank you, Richard, for presenting today's webinar. What a great informative session.
We have had, some questions submitted. I think we've actually just got the one at the moment, but obviously, anyone that wants to send anything through, please send them through now. So our first question we have is, for those of us starting from scratch with neuro exams in general, what resources would you suggest we use?
That's a really great question, . In terms of resources, textbooks are generally tend to be extremely, Intensive where they really fulfil you with a lot of information. When you learn neurologically in a in vet school setting, it's, it really is, is very in depth.
What I try to cover is very practical approach to neurology. I have a lecture that I actually recorded that I'm happy to share or that goes over, you know, the neurologic exam, the localization. And some of the things for me, I've taught for 40 years and I've learned from my mentors, so I've tried to do the basic, you know, clinically relevant neuroanatomy and neuro exam techniques.
So I, that's what I was rely on when you're, when you do it all the time, you're relying on teaching those who learn from you. So, I don't, otherwise, otherwise you'd have to look online and see if you can find some, some, You know, some lectures or some things, but anyone can reach out to me. My at [email protected] if they wanted some information or any lecture material, etc.
Oh, lovely, thank you. And yeah, we've just had some message saying that, you know, they'd love to see, see that if possible. So, yeah, if, if, you are able to share that, that would be great.
If, yeah, we've just had someone else saying if we can, get your lecture by email, that would be really useful. It may be a little, it may be a little large email, but we could try to get it, get it to them. Fabulous.
Let's just have a look. What have we got here? Got great talk regarding, I'm gonna pronounce this wrong, I'm pretty sure, is it Mayaina, yeah, Gravis, what proportion are acquired versus congenital and which breeds are for the congenital?
Yeah, congenital, I think is extremely rare. The majority of cases are, are acquired. And the only time you would consider congenital is if it's a very young, you know, young animal that has the onset because it's congenital, they have a deficiency in receptors.
Where the acquired form, they would be normal. It's kind of like saying, you know, how many cerebellar hypoplasias are acquired. I mean, they're not acquired, they were born with an abnormal cerebellum.
So if you're born with a low number of receptors, you're going to be affected from, you, you're going to be affected from the beginning. So I, I, I, I really don't know that it's so rare. So the acquired is by far more common.
Lovely. No, perfect. Well, I think that pretty much wraps us up for today, but like you said, you know, obviously, if anyone wants to get in touch with you, with you, your, website is just showing up now, so BOCN.org.
But thank you again so much, Richard, and thank you also for Vets On Core Network, for sponsoring today's webinar. Yeah, I'm happy to share my email. It's also R Joseph, Joseph, J O S E P H at VOn.org.
If anybody, you know, as you can see, I'm passionate for neurology. If anyone has, you know, information that we could be helpful, we'd love to see what we can do to help. Lovely.
And, and yeah, we'll, we'll get that all, sorted for you. So it's on the, chat now for you, if anyone wants that email address as well. But yeah, thank you, again, and, we hope that everyone all enjoyed today's webinar.
Thank you for joining us at the webinar vet, and we hope to see you all again soon. Thank you for watching. Thank you.
