Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everyone. Um, lovely to see you all here. Um, we'll just wait one moment. Those people are just creeping in, and then we'll start within about 30 seconds. All right, so we'll make a start there, so Hi, everyone. Um, today I'll be covering urology. Um, and this is part of our basic teaching series. We've got loads of more specialties to go. We're not even halfway there were covering endocrinology next in three days. Um, so do follow us on Facebook and Instagram to keep up with the entire series. Um, so I'm a final year medical student, and my email is there. If you have any queries at all, don't hesitate to, um, drop me a message, and also, this will be recorded. So if I go too fast, or if you miss anything upon filling the feedback at the end, you can always watch back without a problem. And make sure you stay until the end for the feedback which was sent. Okay, so today we're going to cover a very quick whistle. Stop. Tour of neurology will cover stroke T I. A hemorrhage is epilepsy, Parkinson's s and myasthenia gravis. There's going to be some SBO. So I'm hoping the pole feature works. If not, I'm going to all be active and in the chat and ask any questions as well. Um, so yeah, without further or two, we'll get into it. So here's the first ST A. So Ibrahim, a 72 year old gentleman presents to the stroke assessment unit after experiencing a funny term examination, reveals a left sided facial sensory loss. Three out of five left hip abduction and the extension a left homonymous hemianopia was noted. Reflexes are equal bilaterally. How would this patient be classified according to the Oxford Stroke classification? So I'll watch the pole, so you should all be able to float. Okay, I'll send it there. Okay, so most of you put option a, um yeah, which is the correct answer. Um, there's a slide here. So about the classification, which I'll go into a bit. So what is the stroke itself? So a stroke occurs when there's a disruption of blood flow to the brain leading to tissue damage. Um, and there can be two reasons for why you can have this. Either an ischemic stroke or a hemorrhagic stroke is your consultants favorite question on the neuro ward. Um, so 85% are ischemic. 15% are hemorrhagic, um, as well. Um, so it's really important that you do a CT scan to exclude a hemorrhage, and this is the actual stroke classification. So you've got a total anterior circulation embarked, Um, and for that, you need to fulfill three of the following criteria unilateral hemiparalysis and for heavy sensory loss of the face arm leg, homonymous, hemianopia and higher cognitive dysfunction. And then partial anterior circulation in part. You need two of these three. And that could be any two of those three and a posterior circulation stroke. You need any one of the following. So loss of consciousness isolated homonymous, hemianopia and cerebellar or brings them syndromes and, like, you know, stroke. Um, they tend to not crop up that much in SPNS, but worth knowing any way you present with one of the following unilateral weakness, face and arm, arm or leg or three pure sensory stroke or a toxic hemiparalysis. And here, this is very This is a very common STD. A question, um to present you with some symptoms and then asking you which artery is affected in the brain. So it's definitely worth going through these, um, just to cover it briefly. I think this is definitely a slide. That's worth sort of writing out and memorizing, um, as it is does crop up so much, but I will cover through it. So the anterior cerebral artery, um, that one is occluded causes contralateral hemiparalysis and sensory loss. And the lower extremities are affected more than the upper extremities. So what that means is that your legs are affected more than your arms, um, in the military. But artery have contralateral hemiparesis and sensory loss, and the upper extremities are more affected. So that means your arms are more affected than your legs. Um, in the posterior cerebral artery. How this is really important. You have macular sparing and any SBA that says macular sparing, um, immediately. You think posterior cerebral? Um, posterior inferior cerebral. Also called lateral medullary syndrome. It's contralateral extremities, temperature loss. And on the same side, you have facial pain. Um, temperature loss and Horner's syndrome. Close it that way. Okay. Onto S p A number two. So Daniel is a 67 year old man who presents to the emergency department with some right side. The weakness on examination. He has five out of five. Right wrist extension Alba Flexion and shoulder shoulder abduction. Two out of five. Power in right hip flexion extension and called plantar flexion. Equal reflexes bilaterally. Based on this clinical presentation, which of the following blood vessels is most likely to be affected? Um uh, just launched tone, and I'll answer that. So most of you went for auction number D. Mm. Which is the correct answer. So how do you Which tools do we use to assess for a stroke? So there's two sort of systems. There's the act fast. So this is something that you use in the community, and there's the rosacea score, and this is what you use in the emergency department. Um, so those are the two sort of key assessments we use. If the roses score is more than one, then a stroke is really likely. And you must must do a noncontrast ct head first. Um, so in any SBA where it's like, you know, a guy comes in with weakness. Facial drooping. What's the first line investigation? Always, always, always. On contrast, CT head first. Before you do any other management. Um, this is what it looks like on the image. So on here you have a CT head. It's hyperdense show attenuation, which suggest ischemia, and how do you manage straight? So this is really important for STDs and as well as your risk is, um, you really should learn this live sort of my heart. So you must do a blood glucose. You must exclude hypoglycemia, and you must do, uh, they just did a CT head to exclude a hemorrhagic cause once you've excluded those two things, you must give 300 mg aspirin stat after the CT and continue that for two weeks. If you've got symptoms within 4.5 hours, you can go for thrombolisis. If you've got symptom onset within six hours, you can go for thrombectomy. So how like in the long term, so secondary prevention. So this is people who have had a stroke, and you want to prevent them having another stroke. You can recommend giving clopidogrel 75 mg a lifelong. If it's not tolerated, you can give as aspirin plus dipyridamole. You should also start a statin. Um, if their cholesterol is more than 3.5 And if a patient has more than 70% occlusion in their carotids, you can also consider a procedure called carotid endarterectomy or stenting, and that's more than a 70% occlusion. Also, make sure you're modifying your risk factors, such as diet, hypertension, saturated fat intake, etcetera. Um, you must always check that the patient is safe to swallow when they have a stroke. So if you have a patient that's coming with a stroke, you want to ideally, keep them near by mouth until assault assessment to be done, because the last thing you want is for their stroke to be treated, but then choked to death because their throat muscles are compromised and they get aspiration pneumonia and die. So you must always do a salt assessment to ensure for a safe follow and also refer them to stroke rehab as well. Okay, onto our third SBA. So Ellen is an 85 year old woman who present to the hospital with left sided arm and leg weakness. These symptoms resolved after 55 minutes. She has had a CT scan of the head and has been diagnosed with having a transient ischemic attack for T. I A Which statement is most applicable to this diagnosis? Uh, most the whole. Okay, I'll send it there. Okay, so most of you went for option B walk, so that answer is actually option C. So, um, I believe if I remember correctly, the definite the definition of a Tia has actually slightly changed now. So we don't do it based upon imaging we do it based upon Oh, sorry. We're based upon imaging, um, of the tissue appearance. Now, Um, So what is a t i A So a tia is a new definition, as I mentioned of the tissue based definition, Um, a transient episode of neurological dysfunction caused by local brain, spinal cord or retinal ischemia. Um, and it lasts less than a day. Less than 24 hours is the classification. So how do you manage? So you give aspirin 300 mg immediately. Unless, um, sorry. One second. Unless you've got bleeding disorder. Unless you're already taking low dose aspirin or unless it's contraindicated. Um, and then how do you manage? So you need an urgent assessment. If it's happened in the last seven days, you want an urgent assessment within 24 hours and you can consider antithrombotic therapy, um, similar to that of a stroke as well. And if the carotid, as I mentioned before, if the carotid artery stenosis greater than 70 and you can do that procedure carotids and are directly s be a number four. Uh, So Glenys is a 65 year old woman who complains of the worst headache of her life. While gardening, she felt like she was hit up the back of the head with a baseball bat. Glenys had some parents eat more for the pain, but it hasn't helped. She vomited once other time and complains of some neck stiffness. She's taken to the emergency department by her daughter. What is the most likely cause of her headache? Uh, small stone. So this should be hopefully quite an easy one. Yeah. Those of you are getting it right. So it is indeed a subarachnoid. Want subarachnoid? Yeah. So it's got all the features there. It's got neck stiffness, worse headache of life. Um, those kind of be careful. The differentiation between subarachnoid and meningitis, often subarachnoid, can mimic the sort of meningitis symptoms or photophobia and neck stiffness. So they're usually be one of a couple of things in the SBA that will point towards that diagnosis. Okay, so subarachnoid hemorrhage. So, um, typically, as I said, like, that's the worst headache of your life. Thunderclap. Um, and it's usually occipital. You get as I just mentioned meninges, Um, photophobia neck stiffness and nausea and vomiting. So, in your history, these are all questions you must ask in the setting. Um, what can cause a subarachnoid hemorrhage so it can be spontaneous? Could be due to trauma. And this is they love asking this in SPNS, but sort of the genetic conditions inherited condition that can predispose you to a subarachnoid hemorrhage. And that's PCKD polycystic kidney disease. And, uh, I done lost syndrome as well as the malformation. So what do you need to do? Um, well, urgently. If you suspect a subarachnoid, do you have to ct? If a CT shows nothing, then you can do a lumbar puncture at 12 hours and look for xanthochromia as well, which can also suggest a separate point. So what? How do you manage and how what can what sort of complications. So what you need to do is you need to immediately refer to neurosurgery. You need to make sure that they're you kind of get in touch with the neurosurgeons, that anesthetist as well, and make sure that they're not going to raise intracranial pressure as well. So bed rest and BP control. Um, a lot of them are treated with calls by interventual neuro radiologist as well. And you can use a 21 day course of an important vaccine to prevent these spasms as well. Um, so what are the complications? So, um, these are some complications, and they do like to crop up in exams as well. Also in sort of a risky settings as well. I remember being asked the potential complications of a subarachnoid hemorrhage, so it's worth knowing. So a rebleed is a complication vasospasm. And that's why we give them a motor. Fine. Um, SIDH, which can cause hyponatremia hydrocephalus. So that sort of build up of CFC S f in your ventricles and unfortunately, death. So neuro imaging. So this is an extra day or hemorrhage. So you've got that characteristic biconvex hyper dense lesion, which is a limited by the suture lines, got some slight midline shift as well. And this is a bit more information about extra door hemorrhages. So you've got this, um, lucid interval. So in the SBA, if it says the patient sort of felt fine for a bit and then really rapidly deteriorate that point towards the diagnosis of an extra dural hemorrhage raised ICP can also cause, um tentorial herniation. So you really want to go in a school setting up your It's sort of describing, um, what you do. So you would say, you know, you discuss with the neurosurgeons for under supervised specialist control to initiate mannitol, uh, the patient upright, discuss with anesthetics for controlled ventillation, etcetera under specialists. As a junior doctor, you wouldn't be doing any of that. But you need to, uh, if you say all these things that yes, Under specialist control, you can consider that would really be showing off. And, yeah, fixed and dilated people you can sometimes get due to compression of the ocular motor nerve. And the definitive management is a craniotomy and evacuation of the hematuria right s be a number five. So a 76 year old woman presents with episodic confusion and headaches for the for three weeks. She has a history of alcohol, excess frequent falls and type two diabetes myelitis. Her daughter reports that she has been having frequent spells of confusion of the past few days. Neurological examination is unremarkable, and her blood sugar is 6.7. A CT head is done, which reveals the below. Um Oh, sorry. I think. Yes. There you go. Yes. So this is her CT scan. Oh, sorry. The answer is, Well, never mind what is the most likely diagnosis? Um so apologies. A lot of that. That's an issue with my animation. But yes, the answer is a chronic subdural hemorrhage. So it's the answer. Is this because, as you can see, it's darker than the previous image of the extra I showed you. That's hypodense. Um, and it's got a crescent terror collection of blood, which is highly suggestive of a chronic subdural hematoma. And it's not restricted by the future lines. Okay, so subdural hematoma. So what are the risk factors you got old age alcoholism. Anticoagulations. So in the in the S p. I just showed, you know, all the risk factors, alcohol access, she's old. All points towards a subdural, um, fluctuating consciousness or what that means is basically, you know, sometimes they're confused. Sometimes they're not. Sometimes they're really alert. Sometimes they're not. There's kind of this fluctuation, which is indicative, Um, how do you manage? So if there's if it's small or no symptoms, you kind of conservatives, that's kind of things like, you know, if they live alone looking at packages of care, looking at the safety safeguarding issue blah, blah, blah all your conservative, otherwise, if it is deemed significant, compromising the safety of the patients. Unfortunately, a lot of them are elderly patients who live alone. Um, you can consider decompression with the holes and evacuation right on to the next SBM. So a 37 year old woman presents with a two month history of marked fatigue. She feels tired all the time. Blood test two weeks ago, which are insignificant alongside this, as she also describes a two week history of parasthesia to her legs bilaterally. She intended today because of worsening right sided I pain on eye movement and some loss of color vision. What is the most likely underlying diagnosis? Um, so I'll just watch it at home. Okay, So most of you said, be my senior gravis. Yeah, Oh, sorry. Multiple sclerosis as well. Uh, yes. So that is the correct answer. Multiple sclerosis. So what is multiple sclerosis? So we use them at once and then called the McDonald's criteria, which is, um, um, where you have two or more relapses, and this is disseminated in time and space. So having one episode of, um, sort of feeling tired all the time does not constitute a diagnosis of M s. It has to be feeling, um, that way. Um, at two, at least two different time intervals. Um, so it's an auto immune cell mediated demyelination of the CS CN s system. And as I mentioned that, the dissemination in time and space um and what basically happens is that, as you can see in this image, the myelin sheath is unfortunately effective, which affects the nerve conduction along the axon. Um, which can cause is, um, some of the symptoms. Um, so the most common type this often comes up on SBE questions is what's the most common subtype of s, and that is relapsing remitting. And that's 85% of cases are this subtype. There's also primary progressive, but that's less common. It's just an image so you can see the demyelination so white matter plaques perpendicular, perpendicular to the corpus callosum. Okay, so how do we investigate and how do we manage? So if you need to do an MRI, um, usually with contrast because you want those sorts of other just showed you want those sort of areas of demyelination to light up. So, MRI, with contrast, you can also do a lumbar puncture, Which shows, um, IDG oligoclonal bands. Um, and you can also do an e g, which shows delayed visual auditory and somatosensory evoked potentials as well. Um, you manage So unfortunately, there's no sort of strict cure for M. S. Um, it is sort of a chronic condition, but there's things we can do to modify the disease, and there's things we can do to manage the symptoms. So for an acute relapse to use all IV methylprednisolone, uh, disease modifying drugs. So these are actually really specialist. Actually, it's an undergraduate level. You wouldn't necessarily need to name these all by name, but I think this has come up in an office setting, at least at Cardiff University. So it's worth knowing at least the name of a few beats interferon being, uh, probably the most easiest one to remember. There's also these fancy monoclonal antibody it as well that you can use for spasticity. You can use baclofen and gabapentin for fatigue. You can use amantadine, amantadine and for bladder dysfunction. Um, you can use, um, self catheterization. And that's quite an extreme, uh, sort of end of things. But you can use, I believe anticholinergics prior to that as well. And I'm sorry, I'm not sure it's actually written here. That sort of conservative measures. So that's the lifestyle modification, you know, preventing smoking, physiotherapy, psychological support, etcetera. All these things, um, that when you present your management, um, would make you look from extra extra well versed right onto epilepsy now. So what is epilepsy? Epilepsy is recurrent abnormal electrical activity in the brain that manifests itself as seizures. So you've got lots of different causes. Um, you can have idiopathic space, fine lesions. Um, a lot of them in certain babies can be congenital sort of conditions. Prematurity, prematurity, um, as well. In adults, alcohol withdrawal can cause seizures. Uh, lots of different types of seizures as well. You have a focal seizures and generalized seizures. So what is a focal seizure? A focal seizure is called a focal seizure because it occurs on a specific side on one side of the brain, not on both sides. Okay, um, focal aware means that your awareness is intact. Um, focal impaired awareness is that the awareness is impaired and postictal symptoms So postictal means after you've had your seizure, uh, you might feel really, really fatigued for, like, two or three hours. So that neurologist say, you know, the postictal symptoms include fatigue or postictal. Symptoms include, um, myalgias weakness, For example, um, focal two bilateral seizure. So it starts in a specific area before it spreads, spreads to a generalized compulsive area and generalized seizures. So these are seizures that occur on both sides of the brain, Um, as well. And you have tonic, clonic, myoclonic and absence SPS love absence for some reason. Uh, so absent seizures. So that's usually the stem is like a child sort of stairs into the distance. For a brief moment, lax attention is falling behind in school. What's going on? And usually it's an absent seizure, and you can use, um, sodium to operate for that for the management of that. Um, so So this again, SBA questions in finals. Love to ask you sort of the brain or the anatomical origination of a seizure. So you have the temporal temporal lobe, parietal lobes, frontal and occipital. So temporal lobe. So you use have lip smacking, plucking or grabbing symptoms. Parietal lobe. You have lots of temperature and or pain Sensation. Tingling frontal. You have postictal weakness Jackson in March. So this is when you shake movements and they travel proximal throughout your body. Occipital. Um, that's when you have flashes and floaters. Um, and as well as the visual field defect. Okay. And how do you manage epilepsy? Um, so this is more for, I guess, and of ski setting what you do. If someone's had a seizure on the ward, what's your work up? So you want, you know, ideally, some imaging want some bloods again? Always. Always have to exclude hypoglycemia. You need to do a blood glucose. I'm sure most of you and we'll cover this more in our whisky teaching. But you must have a system of sort of bedside blood imaging, um, in your bedside and sort of work up you want to do a urine dip? Blood glucose, CCGs, etcetera. So that's really important to do medical management. So we've talked about absence seizures, so they evaporate Generalized tonic clonic you can use. So you evaporate as well. Um, and lamotrigine, um, focal seizures. You can use carbamazepine as well. And something really important about surgery operate is always try and avoid it in women of childbearing age must ensure that they're on a reliable contraceptive if you are giving it to them. And if women who are on any anti epileptic who are trying to conceive they need more than the average dose of folic acid. So the average dose is 400 micrograms. Um, and, uh, women on anti epileptic mals, uh, 500 micrograms or five mg and also something just for SBA knowledge. Usually, anti epileptics are fine to use during breastfeeding as well. Something else as well. That s pas and progress Test questions. Love to ask is D B l. A rules. This is so, so important. And again in an office setting, you must mention is that you must inform the d d l A, um or you must ask the patient to inform the DBS A. If they've had one seizure, they must be six months seizure free before they drive. If they've had the current seizures more more than one, um, they must be 12 months seizure free before they drive. Okay, status. Epilepticus. So what is status? Epilepticus. So it's a single seizure that lasts more than five minutes or more than two seizures within a five minute period. It's a medical emergency, and it can lead to irreversible brain damage. So this again, um, crops up quite a lot in ST A settings. Um, what you need to know is the sort of management algorithm. So which medications you use? Well, so first you do your all your you know, a B C D E. Start off with diazepam. So if you're in the community, you can use rectal it in the hospital. You can use IV, um, and then you can do a second dose as well. So, um, IV lorazepam. Two doses is the maximum you can do if you're in the hospital, and then after you do Afinitor and infusion, and then if after that they're still not seizing to have a seizure, you must call. I see you. You must call the anesthetist for specialist. Help the intubation. Right? Um not too far from the end. Now a couple more to go. So it's a it's a 72 year old man is brought into your GP clinic by his wife who was concerned about his mobility and behavior. Over the nine months, his wife has noticed that his eye movements have been much slower. He walks with the shuffling gait and has a few recent falls. On examination, you notice that it has a tremor. And when assessing Oh, no, that I put the answer. Never mind. I'll breathe through anyway when assessing Tony not cog wheel rigidity. Given the most likely diagnosis, which answer best describes the tremor you're most likely to see. So since I accidentally revealed the answer, I want you to type in the chat box. Um, what you think what condition you think's ahead. The 72 year old has to just type in the chart. What, you walk the Yeah, Yeah, perfect. Parkinson's absolutely so Parkinson's. Um uh usually, uh, yes, partners. So you've got this triad of symptoms, so unilateral tremor rigidity and bradykinesia bradycardia means the slowness of movements, and they're usually worse on one side. And if they're symmetrical, you want to think about other causes. So there's so many different differential. Diagnosis of Parkinson's is quite fast, so you could have idiopathic Parkinson's. Vascular Parkinson's. Uh, Parkinson plus, um, Multisystem atrophy. Drug induced, um, etcetera. So there's there's quite a few, I think, for the purpose of finals, Um, I think focus on, um uh, I guess idiopathic for the time being. But it's worth having to read into those as well. So what What features do you have? Masked faces. And that trial that we just discussed Micrographia the micrographia, um is when somebody draws a circle and their movements are limited. So right now we can all of us, I hope when we draw a big circle on the piece of paper and we draw a spiral, we have full range of movement and rotation of our wrists, which can make us, you know, have that fluidity and are drawing. Um, actually, let me try and, uh, draw. So yes, so when Well, when all of us draw, we can all draw a nice circle. Someone with Parkinson's. You won't be able to do that. They do something like this due to that sort of cogwheel rigidity. So you can see that difference. Obviously, that's not that accurate. But I'm sure you see the point I'm trying to illustrate. Right. Um, there's also, unfortunately, some psychiatric links with Parkinson's. So a lot of patients have depression and dementia autonomic system function as well. So that could be incontinence. That could be falls as well. Um, yeah. So how do we How do we manage Parkinson's? So you've got, um, sorry. You've got some pharmacological management, and you've got, uh, conservative management as well. Um, so, uh, conservative management. So that's, you know, you must have an entity support. And it's also important to know that a GP can't diagnose Parkinson's. They can suspect it and refer you. But it has to be a specialist, a neurologist that makes the diagnosis for you. And you need all this entity. So you need a physiotherapist. You need occupational therapist. You need adjustments at home. You might need a psychologist for any psychiatric support medical management. So levodopa is probably the one you've all heard of. Um, its efficacy reducing the time. So, um It's generally started late or when the quality of life is quite badly affected. You've got dopamine agonist, such as the general. Um, and this again, SBA seem to love this. Um, like, so it's important to control disorder, so an SBA might have a stem saying, Oh, you know, so and so 70 year, two year old man has developed an awful habit of gambling. What medication is he likely started? The answer is usually the epidural because dopamine agonist, uh, cause high input control disorder. So that's gambling. Um, uh, promiscuity, lots of sexual partners, etcetera is unfortunate side effect of this medication, um, COMT inhibitors. So this is the enzyme involved in the breakdown of dopamine and can use an adjunct with levodopa monoamine oxidase be inhibitors. This inhibits the breakdown of dopamine as well. And this is so, so important. You can't ever stop levodopa. Carbidopa is a really important medication that you shot. Can't mix or shortness as well. Um, and if they're unable to take it orally, you can use the patch as well. So this is what I alluded to earlier, which is Parkinson's past symptoms. So multi system, uh, sort of start getting progressive supranuclear palsy. So this is symmetrical onset early postural instability, trunk rigidity and a little tremor. Multiple system atrophy. So this is early automatic feature. So, um, postural hypertension, erectile dysfunction and incontinence like I mentioned before Lewy body dementia. So this is, um, an SBA that usually be, um that the the elderly person can see things that aren't there. They're having visual hallucinations, and they also have some impairment. That's what comes and goes. So that points to Lewy body dementia and corticobasal degeneration. And that's, um, a kinetic rigidity involving one in Paktia, Right? I think we're nearly in now, So my senior grab. So my senior gravis is an auto immune antibody mediated destruction of the acetylcholine receptors and postsynaptic terminals of the Neuromuscular junction. Um, so this is quite important. Thymomas are linked to my senior gravis. So in an S, be a, uh, they might say patient is diagnosed with myasthenia gravis. What further imaging is required and they are. And if there's an option that says imaging of the thymus gland, that's most likely the answer. Because Thymomas are linked. And all patients should be, um, should sort of, uh, consider imaging for my members to exclude it. So what are the clinical features that you get in my theme? Grab. So you get progressive relapsing muscle tiredness That's worse on exertion to worse after exercise, Um, is suggestive of myasthenia gravis eyes. You have diplopia Tosis extraocular muscle weakness and dysphasia. So that's difficulty swallowing. And how do you investigate? So as I said, sweetie, thanks for my moments. Um, single fiber e g and anti us to tell killing their stories and the antibodies as well. How do you manage so in a crisis, Um, you do have email globulins plus plasmapheresis, plus mentally support long term. Um, if you've got a thymoma, you want to do a gimmick to me, um, to provide symptom, symptomatic relief. You have to you or you should use period, period. Elastic. Mean. Sorry. All these drugs are for to run out. And, um, for immunosuppression, you can get presents alone to treat relapses. What other things can that can exacerbate myasthenia gravis? So infection metabolic imbalance is drugs as well. Lithium penicillamine beta blockers as well. So Lambert eaten is in many ways or the opposite of myasthenia gravis. So that's a malignancy associated with small cell lung cancer, Um, and that it's the opposite to myasthenia gravis. And that myasthenia gravis is worse after exercise, whereas Lambert eaten is better after exercise. Um, and the legs are often worse, effective, effective. So that actually brings us towards the end. And what we've done is we've made sort of cheat sheets for you before your exams. You can have a quick look at all the conditions that we've gone through and for your skis as well. Look at the investigations for each and also, um, sort of very quick summary. So even when you look back at the recording and when you look back at the slides on metal, you can go through all the sort of key features of all the conditions. So we will thank you all so much for listening. We'll drop the feedback, think in the chat. And if you could kindly fill that out, um, right, let me know. I hope the link works and I'll stay on for about two more minutes, just in case any of you have any questions. All right, there's no questions. Um, so, um, so if you're happy, I'll send it there. And you can end the recording as well. Yeah, uh, thank you all so much, everyone. And stay tuned for the 23rd of October where we'll be covering, um, endocrinology. Any other questions? This messages on Facebook? Yeah, If you a lot. We get quite a lot of messages on Facebook. So do bear with us. If we don't get back to you, give us. And if we're really not responding, please do give us a reminder as well. Cool. I'll end up there. Thank you so much, Abdullah, for sticking around this evening. I appreciate you're really, really busy, but yeah, good luck with the rest of that one. And for those of you who are still here, good luck for your exams. And hopefully you can all A's, the neurology SPS now a couple of evening bye.