1. MND
   1. diagnosed 3 months ago
   2. ongoing SLT for worsening dysarthria
   3. referred by GP for increasingly slurred speech
      1. bulbar MND
   4. lower left facial weakness
      1. weakness in lower BUT NOT UPPER side of face is a contralateral UMN lesion
         1. right UMN lesion
   5. tongue deviation towards the left
      1. tongue muscles receive innervation from CN XII (hypoglossal nerve), which receives unilateral UMN input from the contralateral side
      2. if there is a unilateral UMN lesion, the tongue will deviate away from the lesion
   6. brisk jaw jerk
      1. hyperreflexia is a sign of UMN damage
   7. "croaky" voice
      1. could be due to spasticity in the vocal folds typical of UMN damage
      2. could be due to smoking
      3. could be due to respiratory difficulties
   8. asymmetric gag reflex with uvula deviating towards the left
      1. same when stimulated on either side
         1. when soft palate muscles contract and uvula is raised, the uvula deviates towards the intact muscles (away from the lesion) due to reduced or absent muscle contraction from the affected side (unopposed action of intact muscles on the contralateral side pulls the palate and uvula away from side of lesion)
         2. CN X receives bilateral UMN input, so this asymmetry is a sign of LMN damage (because if it was a unilateral UMN damage, the right-side soft palate muscles would still get UMN input from the other side and be normal; or if it was a bilateral UMN damage, the palate and uvula would be symmetrically weak)
            1. mixed LMN and UMN damage is typical for bulbar MND
   9. reports fizzy drinks makes nose sting
      1. nasal aspiration
         1. unable to close off nasal cavity due to palatal weakness (unable to raise soft palate)
            1. CN X lesion
   10. no abnormal neurological signs in the limbs at first neurological exam
2. Progression
   1. "speech difficulties have worsened rapidly"
      1. bulbar MND survival typically 0.5-3 years after symptom onset
   2. difficulty being understood by strangers
   3. difficulty gripping things with right hand
      1. signs of MND beginning to spread across body
   4. 2 falls at home, unable to get herself up
      1. leg weakness, tripping due to leg dragging
   5. "difficulty managing the stairs"
      1. shortness of breath with everyday exertion typical of MND progression
   6. losing weight
      1. muscle wasting?
3. Comorbidities
   1. ischaemic heart disease
   2. chronic obstructive pulmonary disease (COPD)
      1. respiratory issues typically later in MND progression but exacerbated by her respiratory issues (COPDD + smoking_
   3. multiple chest infections requiring intraveneous antibiotics
      1. not sure if aspiration or something else (aspiration pneumonia can be a terminal event in MND)
   4. osteoarthritis affecting cervical spine and hips (limited mobility)
      1. makes falls quite dangerous
4. Cognition
   1. "difficult to ascertain whether she is following recommendations about managing dysphagia at home"
   2. not always able to locate written guidance for swallowing to show new carers
   3. attendance a SLT clinic has been erratic
5. Social
   1. husband also in poor health "metastatic prostate cancer"
   2. no children or close relatives
   3. unhappy with carer service
   4. refuses to move to care home
   5. difficulty being understood by strangers
   6. carers meant to assist with midday meal, swallowing care plan has been provided
6. Swallowing and ax
   1. fizzy drinks cause nasal aspiration
   2. difficulty chewing certain foods
   3. losing weight
   4. coughing but not sure if COPD or aspiration
      1. instrumental ax
   5. OME
   6. information gathering
      1. find out why she has not been able to give swallowing care plan to new carers
      2. find out if she has been following strategies and why/why not
      3. find out why she has not been attending SLT clinic
7. Intervention
   1. education around importance of SLT and strategies for managing dysphagia and dysarthria
      1. ensure COM-B for strategies
   2. symptom management
      1. muscle weakness
         1. orthotics
            1. improve limb position
            2. optimise residual motor function
      2. muscle cramps and stiffness
         1. physiotherapy
         2. drug treatment e.g. baclofen
      3. drooling
         1. drugs e.g. hyoscine patch, botox injection to salivary glands
      4. communication difficulties
         1. AAC
         2. legacy work
      5. ventilation
         1. non-invasive
            1. face mask or nasal tube
            2. overnight when sleeping
            3. progress to daytime
            4. choice between breathing aid and speech
         2. invasive
            1. tracheostomy
            2. fenestrated tubes preserve laryngeal airflow for speaking
      6. dysphagia
         1. weight loss due to poor nutrition can accelerate MND progression
         2. PEG can be inserted some months before needed (e.g. respiratory failure)
   3. advance directives
      1. location of end stage care
      2. DNR
      3. medication for symptom relief
      4. feeding tube
      5. ventilatory support
      6. organ donation
8. Floating Topic