Computer generated transcript

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

So um start off with the starting with the uh yellow of relating the national uh anatomical structure of the pelvis male and female to um the function. Uh So if you start off and this is our first FDA. So uh if you one's got the um questions up. Yes. Wonderful. So a 35 year old female sent some GP with a 12 month history of mom numbness pins and needles in her Parini. Um She also notes an increased urinary frequency and pain during sex. Patient is an avid horse rider and has feeling competitively to since childhood. The G P suspects her symptoms are due to the damage of a certain nerve, which nerve does the G P suspect is damaged. So try and give this one a go. Don't worry if you get it wrong because I'll try and explain it afterwards as much as I can. I can give you about. I think you want to check the slide. I think it shows the answer already. Oh my God, I'm so sorry. Uh Whatever that boilers don't look like the answer. I'm so sorry. How embarrassing. Okay. Maybe this is uh okay. Well, funnily enough. You got that right? Because I got the slide mixed up. So yes, this is the dental nerve. I'm sure you guys would have got that right without that. Anyway, I'm absolutely sure. Um Okay. So let me just explain a bit about that. So sorry, I'm like working in like two different screens and it's a little bit slow. So, apologies. Okay. So, oh my God, sorry about the technical difficulties. Let's get back. Yes, the perineum. Oh my goodness. I'm so sorry. The perineum is the tide by the p dental nerve. Um So as you can see here, we've got some diagrams that help um describe what the perineum is and this is just the area um exterior lee um between your legs essentially. So it's got the anterior and uh the inferior all that you can call it the, the anal triangle um as well. And then yes, it's all surprised by the pudendal nerve. You can remember this by saying 234 keeps cool off the floor because it's collectable like the anal sphincter muscles as well. It's all in your pudendal uh a pony um area. Okay. So moving on to second question. Sorry. Okay. Hopefully, I don't know the answer this time. So a female um 18 year old patient presents to the GP with recurrent uti symptoms, including pain on urination and increased urinary frequency. After being prescribed antibiotics. She asked the GP, why is it that many of her female friends get UTIs but not her male friends. Um Let's see to see if I can relaunch this pull like I, okay, I'll give you just a few more seconds. See if you can give it an answer. Okay. All right, I'm gonna end it there. Well done. Everyone who answered. So the correct answer which makes that you've got, um, is, uh, is see, uh, let me just explain that now. So I'm just gonna take screen couple of all your results. So yeah. So you see, and the reason for that is that the male urethra shoulder in the male urethra. So the female urethra is around four centimeters long, whereas the male urethra is 15 to 20 centimeters long, which is because it has the whole penis to go through as well. So the female urethra is more susceptible to infections. Um not to be confused, urethra with the ureters which go up from the bladder to the kidney. Uh OK. Brilliant. So let's go to the next SBA and I will relaunch the pole in a sec. So a 26 year old female patient presents in A and E with a two day history of sharp intermittent right, lower quadrant abdominal pain history, built her last menstrual period for seven weeks ago. Suspecting ectopic pregnancy, trans vaginal ultrasound, ordered in order to determine the location of the pregnancy, where is the most likely location of the ectopic pregnancy. Get this one. Again, if you can. Okay. I just get a few more seconds. Look like a lot of you guys are getting this one so well done. Okay. I'll end it. They're fantastic. So, as most of you correctly identified, um see again the correct answer in this one. So it will be done. So I just think every bit of the anatomy of the fallopian tubes here. So, um as you can see, uh the ampullae a here is the most common site for the ectopic pregnancy. That's probably because it's the most common site of fertilization. Um You can remember the order of the different sections of the Ethiopian tubes with this pneumonic, which is four inches across is the dots because the fallopian tube is around four inches across or 4 to 5 inches across. So that's the embryo infundibulum, ampullae and isthmus. And as you can see, it's quite helpful little infographic here. So most of um ectopic pregnancies to occur in the flipping tube somewhere, uh basically in the, in the ampullae to um but then again, they kind of cut in other places like the from gray and the isthmus and in very rare cases, they can actually uh intraabdominally. So most most commonly this would be in the rector uh in the touch of Douglas which is in between the uterus and the rectum. But again, that's quite rare. So well done. Good job. So let me go on. So this is the next question you guys are doing really well, so well done. Um Let me reorder to pull in a sec. So a 76 year old female presents to her gynecologist with a bulge in her vagina and increased urinary frequency. She was diagnosed with a prolapse uterus. The doctor explains one of the causes of a prolapse. Uterus can be due to a weakening of the uterine ligaments, which ligament connects the uterus to the labia majora, passing through the inguinal canal. So this is a bit of a tricky one. It requires a bit of anatomy. So give it a go and if not, we'll, we'll go through it in a second. OK? Would be just a few more seconds. You guys are doing great. A few, a few mixed answers on this one. So I'm going to end the pole. Um Just a sec. Oops, sweet. Okay. So, yeah, again, it was a bit of a mixed bunch on this one. Um So I'll explain the answer now. That's absolutely fine. I don't think I would have got this answer to be honest, like when I was in the year on uh at all. So the correct answer is the round ligament. Um And this is just sort of one of these things that you have to remember because all of these ligaments have, you know, different things that you need. Remember. So, yeah, the round ligament is the one that goes from the uterus uh into the groin, into the labia majora. And they really can remember this is that women in pregnancy often get pain in their groin because of compression upon the round ligament. So if you remember it goes from the uterus into the labia majora, um the broad ligament is this really, really big one, as you can see, it is broad um suspensory ligament, suspend the ovaries um in position and there's a long like uterosacral ligament and carbon ligaments. The carbonyl ligament is the one that contains the uterine artery and vein. So that's worth having a little look at um if you have the time. So well, then guys, there's no answers there. Sorry. Right. So look. Okay. So off I think final one for this particular L0. Okay. So that's uh I said a six year old man presents with frequent inability to maintain an erection for intercourse. He has a history of hypertension and type two diabetes. Myelitis. The G P explains that erectile dysfunction can occur when there's poor blood flow to a rectal tissues in the penis, which erectile tissue forms the majority of the penis. Uh Let me just re launch the pole. Okay. I'll give you just a few seconds to answer this one. Okay. Well, do I think most you have answered now? So I will close the pole in just a second. Okay. Well done. So, yeah, most of you got this one right? And the answer is the Corpus Cavan. Uh Sorry, not most of you, but some of you got this right. The answer is the corpus Cavan osis. Um Let me just explain why. So yeah, it was basically between A and B. You guys knew that these are the two rectal tissues. The way I remember that Corpus cousin, because this is the one that makes up this. Um the majority of the penis is because a cavern is big, you can imagine. Um So yeah, you got two of these corpus cavernous. Um and they come together and then you got the corpus spongiosum which again, at the end forms the glans penis. Um And then the other two, the other answers were the muscles that sort of squeeze the blood up into the penis to these, the ischiocavernosus and the bulbocavernosus muscle exist at the bottom of the penis. And when an erection um occurs, these muscles contract and squeeze the blood into the erectile tissues. So it's important not to get those mixed up but well done because none of you did so fantastic. So I've got to stop sharing that as the results. So um we'll move on. Uh Hello in just a minute. Okay, great. Okay. So the next L0 is distinguishing the different tissues percent present in the gentle urinary organs of the male and female. So this is all about histology, which I know is your favorite topic. So our first question is a histology. Gist is examining a section of uterus taken on day seven of a patient's menstrual cycle and notes that a layer is missing that would be present on day 28 which histological layer is lost at this point in the cycle. So, try and have a think about what is occurring at day seven. Give it your best shot. Okay. Just give you a few more seconds. Okay. Fantastic. All right, I'll end it there so well done to majority of you who got that right. The correct answer is the stress and functional list. Um And let me explain a bit more. If you did say endometrium, I don't blame you because the starting functional list is part of the endometrium. But it is not, not the whole endometrium is lost during menstruation. So you can imagine the endometrium being split into these two sections, the stress and Vassilis and Stratton functionality and the statin function Alice contains all of these blood vessels capillaries. Um And they, this is the lead that's lost during menstruation and that's what causes bleeding during menstruation. Okay. Wonderful. So we'll move on to the next s be a So I'm sorry, each other results. Okay. So the next one is a 27 year old female patient is waiting surgery to remove. An ovarian cyst surgeon knows ovarian cysts commonly development follicles in which histological section of the ovaries do focals develop. So give this one your best shot again. Don't worry if you get it wrong cause I'll explain at all. Okay. I'll give you a few more seconds, bit slower on the answers of the time. It's okay. Okay. Just a few more seconds. Got a bit of a variety of answers this time. That's okay. All right. So I'll send it there so well done to the majority of you who did get that right. Uh The answer is the cortex of the ovary. So let me just explain that. So here is the histology of the ovary. So as you can see the cortex of this um this part um sort of around the outside and this is where the ovary follicles developed. And then you got the medulla inside and that campaigns the nerves and the vessels. Uh and then the tuna al Virginia is the connective tissue that's, that's not shown on this, but it's the connective tissue that surrounds the ovaries so well done to everyone who said cortex. Okay. So that's the results there. OK. Great. So let's go for the next one. So a 25 year old woman attends clinic for a routine cervical smear test, the clinician that explains the cervix of the high risk of cancer due to a transition between cell types. Um in the echo cervix and the endocervix, which cell type makes up the ecto cervix, epithelium. Okay. But your best shot. Yeah, I'll just give you a few seconds. Okay. Uh Seconds. All right. So, uh let's have a look. So the correct answer was he, which is what the majority of you did say so well done. Let's see what the explanation is. So the echo Cervix, as you might be able to tell by the name is what is on the outside of the cervix. And this is lined by stratified squamous, nonkeratinized epithelium. And then the endocervix just inside the end cervical canal is with simple Colombiana. So this is quite an important concept clinically because where you got this area transition, it's called the square um oh Columbus junction. And this creates an increased risk of cervical cancer. Um sort of similar to the bladder. You might even the transition zone. Anyway, you've got two different cell types transitioning. Um You've got, you know, different DNA types going on. So you've got an increased risk of cancer. So, well, I'm done. Definitely got that. Okay. Great. So let's go to this one. So a seven year old boy who presents with rapid growth investigation reveals height in the 19th center pubic hair, axillary hair and penile growth investigations reveal he has a benign tumor of a specific cell within a test use responsible for producing testosterone. Which cell is this? Give it a go which I was responsible for producing testosterone. Mhm Skippy a bit more time. Okay. Funeral seconds. Okay. Well, so the correct answer was the which the vast majority we've got. Right. That's the laid XL. So well done. So let me just explain what's going on there. So the lady excels are responsible for producing testosterone. What I see a sort of brothers in this uh histology with the testes is the fetal cells and the lady Xl's. So that's totally cells. Um uh the lining of the seminiferous tubules. This is within test is as you can see here on the left. Um So the so totally cells line is seminiferous steuby als and they mature the sperm and the lady cells outside the seminiferous tubules in the international space and they produce testosterone and this is sort of replicated in the ovaries as well because you've got bigger cells and granulosa cells which all have similar functions in the ovaries. So I will see them as brother and sisters. Um like cells produce um helped mature the ovaries and the granite. Sorry, go around. Yeah, seeking help produce, help, help. Um I'm sure the ovaries and granulosa cells helped produce the eastern in the female. So we'll see them connected. Okay, great, well done guys. Um Okay. I think this is the last one of this SBA. Uh oh sorry. So a 12, your 12 month old boy presents to his GP with the right scrotal mass, the masses trans illuminated when a light is shown on the scrotum suggesting it is fluid filled. He is diagnosed with Hydrocele which is a collection of fluid in the scrotum in which layer of the scrotum does this occur? But again, give it your best shot. Okay. Just a few more seconds. Give it a shot. Okay. Wonderful. So I'm going to end the poll. They're fantastic. So, uh so the correct answer was be that she's the tune of Cabbage Alanis. So well done. Everyone who got that right, which is the majority of you. So just go through quickly the layers of the scrotum. So the tunica vaginalis is um where fluid, for example, Hydrocele would collect. Um And then above that also blocks below that. Sorry, you have the tunica Al Virginia. Uh And then you have the cremasteric muscle, which is the one uh which you can elicit in the cremasteric reflex where if you uh gently stroke up the inner thigh, the cremaster muscle should contract so you can test reflexes like that. Uh And then the darkest muscle surrounds the whole of the scrotum. So that is just your basic scrotal histology. It's so well done guys. Okay. So that's it for that L0 you guys to do really well. So now we're going to go on to a third L0 of the evening, is that hopefully I'm not going too fast, that paper ones sort of doing. All right, let me know if I need to slow down or you got any questions or anything. Okay. So now we're going to talk a bit about the menstrual cycle and reproductive hormones. Okay. So, ah, first L0 A woman who is trying to conceive, use as a testing kit to track her hormones. Honest lesson day. The kit measures a much increased level of LH from the day before at which day in the menstrual cycle was this measurement taken? And let me just re launch the pole. Okay. Give it a go. Okay. Just a few more seconds. A lot of your answering this one seem to get it right. So well done. I'm not making this too easy. Um, So well done. That's in the poll, the majority of you got that right. And the date is day 14. So as you should know, the LH surge coincides with coincides with ovulation. So this ovulation happens at day 14. Technically, I could have said day 13 is when the L A church actually begins. Um sort of between 13 and 15, but 14 is the day that you're going to see at the highest because this is when ovulation occurs. So the LH increases and this stimulates ovulation. So that's just the basic concept to remember and it seems like you guys got it. It wasn't okay. Next L0 A medical student is studying for their exams and notices that estrogen uh increases in the follicular phase of the menstrual cycle along with the growth of the folic you'll follicle. They know that the follicle releases estrogen but cannot recall. Uh sorry, as I should say, a spell in a follicle releases estrogen but cannot recall the specific cell. Which cell is this OK, let me really want support. So you might remember I was talking about this a little bit earlier if you're paying attention. Okay. Give it a go. Hey, I'm gonna finish in just a few seconds. All right. Fantastic. Well done to the majority. Who got that right? Which is the granulation cells? So yes, it seems like you guys have been paying attention. So the granulosa cells reduced release estrogen and progesterone. So as I mentioned earlier, you can imagine this to be like brother and sister with the lady cells which produce testosterone in the testes and the T cells which help mature the uh the US site. So this is like your follicle inside. You got the inside should eventually become the egg. Um The bigger cells line the outside of the follicle and the granulated side cells on the inside of the follicle. Uh So fantastic. Well done. We just trying to get screenshot. Okay. Give me two secs. Okay. Wonderful. So let's move on to the next question. You have to do it. Amazingly, I'm so happy with. Ok, fantastic. So a medical student is studying the menstrual cycle and notices that in the luteal fail phase, there is an increased level of progesterone as it serves an important function in this phase. What function does it serve? Uh Let me just free loans to poll. There you go. Okay. Just a few more seconds. Okay. Well done. So yes, again, you guys are doing amazingly, I feel like a lot of you. Hopefully, I have looked at these questions beforehand at the pre release and have come to this. So that's fantastic. So, the correct answer is the, which is maintenance of the endometrium or if you haven't loaded them previously, then prosecute. Fair enough. That's brilliant. So let me just explain that. So the progesterone causes proliferation of the endometrium that is completely correct. So pedestrian is really skeptical TTM, which is what the follicle becomes after ovulation that it starts to sort of degenerate. And we call that ct um um So you another function of the progesterone is also the secretion of uterine milk. Um And so the way to differentiate progesterone in Eastern is that estrogen is more about the the maintenance of uh the endometrium. Um And then sorry, like the maintenance in terms of blood vessel and then progesterone. Uh the proliferation weight. Does that make sense? Hopefully said that right. Yeah. Oh Did I mess this up? I think I, I filled out the wrong way round. I'm so sorry. Hang on. Like I think the progesterone is the maintenance and then engineer and the estrogen is the proliferation. So I think I messed up on the second slide but you don't know. So it wasn't okay. Um So is our next question. A gynecologist is explaining the H P G access which controls the menstrual cycle to one of her patient's. She explains the graphene follicle releases a hormone called inhibin, which inhibits another hormone in the access, which hormone does it inhibit. I just want to go okay, few more seconds. Give you a minute to actually okay. Just a few more seconds. Well done, just okay. Something. And the pole there, well done. So again, the majority of you got that right. So the correct answer is FSH. Uh So yeah. So as you can see a little diagram here, which is a bit blurry. Um FSH and LH both released from the anterior territory. FSH acts on the granulosa cells. Uh And then Inhibin then goes back and inhibits FSH. So if you've got too much FSH, being released and Inhibin will come, come back in a positive maybe feedback loop and stop it from being overproduced. So let me enter from what I've done is a good thing to remember. Okay. Fantastic. So I think this is the last one of this alot. Um So this is a 21 year old woman is reaching, researching follicular development and is wondering at what stage her follicle is her current point in the menstrual cycle. She is currently on day 18 of her cycle and its not sexually active at which stage is the follicle? Let me just relaunched this poll, okay. Just a few more seconds. Try and give it. Okay. You have an R D sort of mentioned this a bit earlier. Okay. So I'm going to end it there. Well done. Some of the few who are that right. So the correct answer is the call for sleep team. So as I mentioned earlier, the follicle um after ovulation starts to sort of degenerate and this is what we call the corpus luteum. Um So, stages in order to go primary follicle, secondary follicle, graphia follicle or sometimes you can see it called tertiary follicle. Um and this is what we will release the other site for the and then afterwards it comes the corpus luteum and then eventually the corpus alba cans before it pretty much disappears. So well done to you guys. All right. So that's it for that fellow. We've just got one more from me and then you'll hear from the lovely U N. So this is our final L0 for this five part. So this is relating the physiology of puberty um including the development of sexual function. They're all about puberty. Okay. So our first L0 R first SBA sorry, a six year old girl is diagnosed with hypogonadotropic hypogonadism. Uh leading pro sorry, I'm messing up all my work today, leading to precocious puberty, which hormone in the H P G axis is over produced in the hypothalamus in this condition. Is it okay? Okay. A lot of you answering this one very quickly. 100%. Well done. Fantastic. Okay. So, yes, that's right. The correct answer is the GNRH because this is the only hormone in this list that is well related to the menstrual. It's related to puberty and release from the hypothalamus. So, yes, uh, hypothalamus releases GNRH. Um This can be caused by a number of things. This could be, uh, they've got their hands on some GNRH medication have been exposed to it. Um, taking it accidentally or it could be a hypothalamus tumor like because this precocious puberty. So this is quite a rare form of precocious puberty, but it's more about just understanding alleging Rh is produced from the hypothalamus kicks this whole process off. Um And normally this is recent a pulse it'll matter um throughout childhood and puberty. Okay. Well done guys. 100%. Fantastic. Well done. Go team. All right. So our next SBA on puberty, a 16 year old boy comes into the GP with concerned about his appearance. He is much shorter than his friends, has a higher pitch voice and lacks pubic hair and auxiliary hair. After running some tests, you find that he has a bone age of a 12 year old but does have elevated FSH and LH levels though a low levels of estrogen and progesterone detected in the blood, which is the which of the following is the most likely diagnosis. This one it goes well okay. I'll give you a minute to, ok, nearly done a few more seconds. OK. Bit more of a mixed answer for this one but well done to the majority of you who got it right. So the correct answer is B which is hypergonadotropic hypogonadism. I know it's a really long word, but we'll try and break it down for the next slide. So hyper gonadotroph, it hypergonadism. Um I don't know if I hang on top of that. Right in the thing. Oh Yeah. Sorry. In the answer, I meant to put um sorry in this side, I meant that hypogonadism. So I've got the hypo there. So, hypergonadotropic hypogonadism is caused when you've got an increased level of uh GNRH coming from the hypothalamus as in the previous question. So this leads to an increased level of LH and FSH. Um And then eventually um you've got away actually. So it's not caused by, that's all right. Let me just re track. So you've got a um an issue in the gonads. So, like test in your test needs which causes um these androgens and in here and not to be released, then that leads to an increase of GNRH and FSH. So you've got no of these sex hormones being released. You've got all this FSH and LH and G R H being built up if that makes sense. Um So yes, you've got very limited sex hormones. So you got no negative feedback. Like here, no negative feedback from the sex hormones acting on the hypothalamus are acting on the act anterior pituitary. You've got a build up of FSH and LH. Um that's why it's called hypergonadotropic because you've got all this stuff coming from the hypothalamus. But hypo in the cone ads, I hope that makes sense because I mean, if you need any clarification in the comments and we'll move on to the next one. So a 30 year old female who is struggling to conceive attends a fertility clinic where blood tests show that she is infertile due to hypergonadotropic hypogonadism who were just talking about which of the following conditions could be the cause of this. Let's relaunch the pole. Okay. I'll just give you a minute or two. Okay. Give it a go. Even if you're not sure because I'll explain it okay. I'll just give you a few more seconds anyone. He hasn't answered. Yes. Okay. Great. So about it was a bit, we've had a bit of an even split between the correct answer and another answer, which is okay. So, um the correct answer is c which is kind of syndrome and I understand why a lot of you say Klinefelter syndrome because this could also be a cause of hypogonadotropic hypogonadism. But the answer is that this patient is a female. So Kleinfeld syndrome would only occur in males, whereas tennis syndrome only cuts in females. That's the freaky difference. So let me talk a bit about Turner Syndrome. I'm not sure if you guys would have covered this yet, but hopefully, um, this rings a bell. Um So Turner syndrome is characterized by having one X chromosome, one sex chromosome missing in a female. So it's a 45 X. Um it's characterized by having a short stature, broadly, space nipples, um a low hairline heart shaped face, this causes complications such as cooptation of the aorta. And most importantly, in this case, the infertility um issues in the ovaries. So this would cause again as we've been talking to talking about for the last question, hypergonadotropic hypogonadism because you've got these issues in the ovaries. You're not releasing any sex hormones is a big xia, not really see any sex hormones. So this acts. Um So normally the sex hormones would inhibit Axion in the hypothalamus and the anterior pituitary. But again, you're not getting any inhibition here. So the anterior pituitary and hypothalamus releasing all this GNRH, all the FSH and LH, it's not having any effect on the gonads. So that's why tennis syndrome can cause hypergonadotropic hypogonadism. Uh Okay, wonderful. Again, if any of this goes, you know, if you're confused about any of this, we're fully accepting questions at the end. Just put anything in the chat, that's absolutely fine. So our next question, a five year old boy presents to his G P with his parents as he has shown signs of precocious puberty, including auxiliary hair and testicular growth. Blood tests reveal he has high levels of testosterone, FSH and LH, which of the following could be the cause of his precocious puberty. So, yes, it's a bit of the opposite sort of thing. Now. Okay. Give you a minute or two. Okay. Just a few more seconds for anyone who hasn't answered. Okay. I'm gonna end the poll there. So, welcome to everyone. Got to go and to the majority of you who did get that correct again. The fabulous. So the correct answer is the Church tumor. And the clear to this is because he has high levels of FSH and LH. So if you got any of the other answers, that's okay because all of these can cause um precocious puberty, all these causes of pressure duty. But the clue is in the blood test. So only the Patricia acute tumor would lead to increased levels of FSH and LH because FSH and LH are released from the anterior pituitary. So as you can see, Mr Graham here, um uh the beauty can be controlled from two of these accesses. So the one we're talking about all the time has been the H P G access, which is a autonomous pituitary going ads. But also there is involvement from the H P A which is Thomas pituitary, adrenal Gland. So that is if you said, you know, adrenal adenoma or anything like that, that is um that can be a cause of the security and you can see the aps of um adrenal hormones can read to the development of Utica and I'm put her. Um but in this case, because of the increased LH and FSH, um it was the pituitary adenoma, so well done guys. Okay. I think we've got one more question. That's right. So a 14 year old girl is concerned that she hasn't had her first period yet and wants to know if this is normal. You explain that the range of ages that are normal for girls to experience puberty. What is this range? Let me just re launch the pole. Get this go. Okay. Just a few more seconds. You haven't tried already. This is our last question for this particular section. Okay. I'm going to end up there so well done to the majority. Who did get that right? There was a bit of a mixed response in this one, but that's okay. It is a little bit more subjective on this one. So the correct answer was A B which is 8 to 15 and I'll just go through this now. So, uh so in girls, uh puberty does happen earlier. So the normal range is 8 to 13 to start puberty and then uh puberty can go up until 15. So in this particular case, she's worried about her period. So if you're getting a period from 8 to 15, that's completely fine. Um but puberty can continue, for example, growth can continue a bit, a little bit longer. Girls probably about 17 and then then boys, it's a little bit longer, takes a little bit, a little bit more delayed. So 9 to 14 and boys. So anyone who said 9 to 14. Um That's fine just for boys. So these are just the numbers that you can remember. So, anything before nine or eight in girls is precocious puberty and would require investigation and anything. So, if you have absolutely no symptom of puberty, no signs of puberty before 13, girls before 14 P M boy, that would be considered delayed puberty. But this particular question, sorry, it was a bit mean it was asking about like when puberty can occur. So, um yeah, 15, 16, 17, that's okay as well to be experiencing puberty. But if you've got no puberty signs before 13 or 14, that's the late puberty. I realize I enlisted down. Um It's just about common infection to the common infections of the urinary tract and the defense is basically so first question. Um So a male patient has presented to the G P with pain on urination, described as a burning sensation, they're able to pass urine. They have a low grade pyrexia and record that they have frequent infections on their waterworks. They work as a solicitor and mentioned that they will spend long hours of sitting and being a workaholic only to take rare breaks to top up their coffee. What is the single most important risk factor of developing the uti for this patient? So, is it a current urinary tract infection? Um, frequent hospital emissions seldom about emptying being a male or seldom avoiding Sharples. So my part of the yellow is going to be slightly more clinically relevant. Um, it will apply to like progress tests and stuff, but of course your s ones as well. Um, I'm sure they had a few questions in there. Interesting. Okay, I'll end it that nice. Um, so the answer, um, there's, there's a bit of a split so the majority have gone for a, which is true. It is a, uh, it is a risk factor. However, there's one here is seldom voiding. So does anyone know avoiding means? Um, I'll give you guys like 15 seconds appointment in the chart, you know, avoiding means any ideas. Nice. Yeah. So not urinating basically. So that is probably the biggest risk factor um, in this patient. Um, so yeah, recurrent UTIs do play a role in the precipitation of the next uti but it's obviously not the single best answer here. Um, freaking hospital emissions. Um Also it does play a role because if they've been to hospitals quite a lot chances that they've been catheterized. So it is once again a risk factor but probably not the single, um, most strongest risk factor. Um, solid bowel emptying. Um, it's not really associated with UTI S. Um, being female is more of the risk factor because of that shorter urethra anatomically as Rachel alluded to. So, yeah, seldom voiding is the biggest risk factor. So, as, um, someone has said, avoiding is emptying the bladder and if people don't do this bacteria will build up and cause an infection of the of the bladder, which is known as cystitis. So just a bit about lower urinary tract infections. Um as I said, there cause cystitis. Um and that's infection of the bladder and the most likely causes of agent is going to be e coli. Um that's a bacteria that normally resides in the gi tract. So some of your clinical features are going to include so your urinary frequency with this area. So this area just means pain on urination. Patient's tend to report a kind of burning sensation, urgency. So the need to go to the toilet more often, um foul smelling urine, um super pubic pain and patient's could actually present with normal uh normal clinical examination um where they have no pain or uh no pain in the flank or the loins. And that's going to be the key differential here. So the differential to pylon pylon nephritis, that's an infection of the kidneys. Um And with the investigations, you're going to get um pretty much the same thing. So, urine dipstick with positive leukocytes and nitrites and the mystery and urine sample. Um So in terms of management, it'll be all try oral nitrofurantoin or trimethoprim. So, these are your first two first lines. Um There's advice on conservative care um to avoid risk of further infections. So, regular fluids and postcoital fluid, voiding, sorry and postcoital avoiding is just peeing off the sex fine. Um right, exports. So pile on the fighters is going to be that key differential and it's defined as, as I said, the infection of the kidneys. Um once again, the most slightly causative agent is E coli and this happens when it ascends the ureters. Um So clinical features are going to be more severe. Um So it's gonna be your fever, malaise um loin and flank pain, which is going to be that key differential, vomiting. Um And the clinical examination will obviously reveal loin and loin flank tenderness. Nice. Um So in terms of management on before that, so the investigations for this is the urine dip will be positive for leukocytes and nitrates. If there's blood in the urine or there's colicky pain, this will point you more towards a renal stone. So colicky pain needs sort of coming and going. Um So other investigations are going to be your full blood count. Your user needs your CRPS and blood cultures. A mystery. Um urine sample is analysed and the renal ultrasound is used to rule out something called hide hydronephrosis. Management of this pylon arthritis is going to include IV antibiotics um which will include the following. So your broad spectrum cephalosporins, um your quinolones. So, quinolones beings, things like ciprofloxacin and your aminoglycoside. So, gentamicin and you use gentamicin normally in your oh sepsis and this is just an algorithm for it. So this sort of tells you when to use what antibiotic in the uti it looks quite extensive. But do you have a read through this in your own time? It's quite useful, especially when it comes to your progress tests, especially this page as well because there's a lot of things like what the contraindications, what are the side effects and when to prescribe for what situation? Fine. So the next question is a six year old female presents with a uti, she notices pain on urination two weeks ago and has begun a course of antibiotics. So she has a past medical history of diabetes and a week to choose a Muslim. Two weeks ago, she was admitted to hospital for previous uti and sepsis and she doesn't recall being catheterized. So many risk factors of you tell that she elicit. Oh, also okay. I'll stop it then now. So it's mixed results. Um So a lot of you have gone for four. So I would argue that there is actually six. Um So I've highlighted most of them. So 60 year old female um diabetes is another one week, the trees a muscle, previous uti and catheterization. So age is going to be one risk factor. Um Sex is one diabetes, week, detrusor muscle means that she isn't going to be um urinating previous uti. So the recurrent uti s and catheterization from hospital admission, that is your six risk factors. So once again, I've made up the list of the risk factors that you could possibly encounter. So our patient has these risk factors. So, pretty much just think what predisposes you to getting bacteria in your urinary tract. Essentially fine. Next question. So, a 22 year old female patient has a two week history of burning urine and a temperature of 38 degrees. She has no, no sexual partners and it's not aware of any changes in voiding. Analysis of a serum shows low man and binding lectin. She's otherwise well and it's not on any contraception. She mentioned that her family is prone to recurring UTIs. What is the most likely cause? Okay, we'll call it that nice. So the majority of you have gone to see and that is the correct answer. So low complement. So this is gonna be a revision of case one basically. So the complement cascade um it does have relevance in other parts of the body. So for example, the defense of your urinary tract research does show that the complement system does play quite a pivotal role in this. Um and that but the man the man and binding lectin, so you're MBL is involved in that cascade, especially for your complements. So MBL is here. So that involves with your classical path all, sorry, that's a spoiler uh with the classical pathway and your optimization information and your mac proteins. Um So your mac complex and that is all involved in the defense of the urinary tract. So this is just, this is quite confusing, but this is just sort of what each um complement does. This is obviously more high I took this from my hypersensitivity notes. Um So this is more targeted to a hypersensitivity, but you can sort of see what each of them does. So C five B C 67 8 C six, C seven C A N C nine, they'll form your mat complex. Um There's some stuff in optimization to see one attached to the F C PRO FC portion. Um C three A C four A C five A L chemo taxes. So that's just a bit um of case one revision, but I will move on from that because that wouldn't be relevant to this case. Fine. So you are studying about defense and defense defense is defense mechanisms of the urinary tract. And you come across a bacteria bactericidal product called defense. Since what cell secrete defenses shut the pools. Okay. So I'll give you guys about 30 seconds, 20 seconds to do this. One, five more seconds. Nice. So there is quite a nice split in between A and D. So the honest answer is most cells, a lot of cells will secrete defenses. But the one I was looking for was in terms of the urinary tract. Um So I do apologize. Actually, the question stem might seem a bit vague. However, in relation to the urinary tract, it will be the epithelial cells. So the common split was between A and D. Endothelial cells are going to be found in your vasculature. So, like your, your vessels basically, and that wouldn't be relevant to your urinary tract as such. Um It's more epithelial cells in the and they actually urinary tract. Nice. So that's that done. So, we're moving to L 07. This is going to be about the common causative agents of um urinary tract infections. So there's a lot of his is a histology, there's some histology in this as well. Fine. So a 32 year old female presents to the gum clinics with a one week history of white frothy vaginal discharge. She describes as a fishy odor that impact his self esteem. She reports having multiple sexual partners and is currently on the C O C P. She has no notable past medical history. She reports Volvo itching and burning sensation on urination. What is the most likely organism? 85 more seconds. Nice. Okay. So we have the majority on C and someone be the answer is actually c so the key determinant here is going to be the white, the white frothy fishy discharge and a sexual history um with most likely unprotected sex. And that's going to lead to your diagnosis of trichomoniasis, vaginal iss the other differential for white frothy fishy swelling discharge is bacterial vaginosis. However, Volvo itching and burning on urination present as well in this case. So, in terms of E coli, as I said, is more common as a urinary tract infection. Um, but trichomoniasis is more of a sexually transmitted infection in ST I. So, in terms of chlamydia, it is another ST I but patient will present with pain, discomfort and a green discharge, um with uh, Neisseria, gonorrhea. Um, it is also not the ST I but it will present quite similar to chlamydia. Um E is um treponema pallidum. It's also known as syphilis as some of you might know it. Um, your present with sort of painless ulcerations of the genitalia. Um A rash, white patches in the mouth, a flu like illness and balding or swollen glands. So quite systemic rather than just isolated to your to the genital region. Fine. Next one, a 22 year old patient presenting with burning sensation, urination um has the urge to void often. She's been feeling under the weather and recently been quite feverish. She would like to have this investigated. She has multiple sexual partners and it's on the C O C P. She also notices increasing pain during sexual intercourse and heavier periods. The lab report comes back with gram negative diplococcus. What is the most likely cause it'd agent? I think these questions have come up quite often. So, and this is quite high yield. So I would uh the next series of questions would be more interesting. Yeah, I'll call it there. Um But yeah, that's a lot of you have gone body and that is correct. So when you think gram negative diplococcus, I think gonorrhea. Um and this is obviously one of the key determinants of the ST I cause between chlamydia and gonorrhea. Um And it looks a bit like this basically your difficult. So it's two coke eyes um and his grand negative fine spoiler a lot. So a 22 you're a patient presenting with the burning sensation on urination has to devoid often should be feeling under the weather and been quite feverish. Um However, here is gram negative cocky. Um What is the most likely organism? I'm hoping that you guys didn't see the answers. It's re Notre falls. Okay. Nice. So majority of gone for B and that is correct. So it's chlamydia. So E coli is going to be um you know, I said that like that, sorry, um E coli will be a rod like they can also be cocky. Um So that is technically another differential but it is more likely to present as a UTI rather than an S T I. Um So trichomoniasis is a protozoa um with the flu gela basically. Um and these symptoms will also be quite different compared to um familia. So the syphilis is a con pronounce this one. It's like spiro Chatur. So it's like it's like a spiral pasta basically is a spectator bacteria. It's gram negative and we'll have a different presentation to the patient. As I said, it's more systemic further than localized. It is genetic and this is um a picture of chlamydia. Nice. Ok. So another stem. So a 22 year old patient presents with burning, urination, burning sensation on urination and the urge to void. Often she's been feeling under the weather and in quite feverish recently, she would like to have this investigator. She has multiple sexual partners and it's on the C O C P lab report comes back with a gram negative. Sorry, with the grand negative cocky given the most likely diagnosis, what is a major complication of this? Say five more seconds? Okay. Right. We'll call it that. So majority of gone for D and that is correct. Somebody had gone for e so, infertility, I'll explain why. That is the case why D is the most likely complex, most major complication. So we've established that the most likely diagnosis is chlamydia in terms of the complications. It's because it's going to most likely be public inflammatory disease. So, in terms of ovarian cysts, there's going to be two types. So you're functional and you're pathological. So, functional cysts are linked to the menstrual cycle. They are benign and don't really need treatment. The pathological cyst however, are sort of caused by abnormal cell growths. Um This can be either from endometriosis or a disease called Pecos. So, Polycystic Ovarian syndrome, soapy causes linked to insulin resistance, hormonal imbalance and genetics. So, ovarian torsion, um it's sort of when the ovaries twists on itself and it's most likely due to assist because when the ovaries become imbalanced, they start, you know, it can twist on itself basically. Um and risk factors for this will include your hormonal therapies and pregnancies. So, infertility, this is the interesting one. So, um it is, it is a complication of chlamydia but it is one further down the line. Um and it's not directly caused by chlamydia itself. So B D and er correct, but I think in terms of the most, the single best answer here it's going to be d um fine. Another question. So a six year old male has been admitted to hospital for severe pneumonia for which they score four on the curb 65 scoring system. They've been catheterized and managed and the management is carried out to treat the pneumonia. On review, the urine bag has become cloudy and the patient reports pain in the super pubic region. Morphological analysis shows shows gram negative bacilli and cocaine. What is the most likely cause it'd agent expect 100% on this one because I mentioned if you uh right also not to worry if you make mistakes, this is a is a safe space to make mistakes and learn lessons, state, making less, nothing nice. Okay. I'll call it there. So um there has been a majority of a which is correct. Um Yeah, as I mentioned earlier, so equal, I will either appear as a rod shaped bacilli or sometimes as a round shape. Cocky brilliant. Um fine So a 34 year old male patient has a two week history of left flank pain for which they rate in nine out of 10 severity in nature. They describe it as an initial intermittent pain, but now the pain is constant. They are federal and nauseous with an episode of vomiting A C T K U B. Um So ct kidney ureters and bladder shows a sty cone calculi, there is blood in the urine um and there is no varicocele on examination of the genitalia. They have a past medical history of recurrent UTIs. So what is the most likely cause of the patient's deterioration? Bad? Okay, everybody. One. Okay. So majority have gone for be. Now, I'm gonna change up the session slightly. So I'm gonna ask a separate question. Now, I'm gonna ask a different question. This might relate to case for as well. So, what is the most likely underlying cause of this deterioration? So, what's the cause of this pilot nephritis? Um Okay, I'll give you guys, this is, this is quite an interesting question. Um It is, this one is quite, this one is very relevant to your program tests. So, okay, just giving it away. Brilliant. So um majority have gone for d um This is a, so it is pyelonephritis. Basically, you've got an infection of the kidney, which is correct. Um in terms of the underlying cause, um it's going to be your struvite stones. So, struvite stones do encompass for about 1% of kidney stones. But they are quite an important differential because when you get this classic Staghorn calculi, you want to think struvite stones. Um and I think only Staghorn calculus really cause this and that um changes the treatment option because you need to do like a percutane iss um nephrostomy or something. So that is quite important differential. Um So calcium oxalate. So option d it is a very good um It's very good for you to hazard a guess calcium oxalate because it is encompasses about 80% of kidney stones. Um But as I said, the Staghorn calculus is that Hallmark of struvite stones and will be needed to taken out percutaneously. Urate stones is another good differential, but there is no increased risk of um sorry, there is no increased your rates in the body. Um from the question stem, fine renal cell carcinoma. Um Not likely there's not really a suspicion of cancer apart from blood in the urine. Um But this once again will be quite low in the differentials, competitive others. Nice. So finally onto my last set of Ellos. Um So patient is being prescribed an antibiotic which works on the 50 years. Rubber Zoom. What is a class of this antibiotic? So this is a bit about antibiotics. Now, there's a lot of PT stuff here. Okay. We'll wait for about 10 more seconds. Right. We'll call it there. Brilliant. So majority have gone for B and that is the correct answer, macrolides. So, um in terms of glycopeptide, um they would target the cell wall synthesis. Um An example of that is Vancomycin that's used in the treatment for gram positive bacteria is um such as MRSA and C difficile. So one way to remember that is you think, you think glycopeptide and peptidoglycan cell walls, think glycopeptide um that's one way of remembering it. So for macrolide, um they target the 50 S rib a zoom. Um And that's the larger ribosome, a sub unit um of the bacteria. So you want to think macro, you think big, you think 50 s instead of 30 S for penicillin. Um They target the cell wall synthesis and it's a beta lactam antibiotic. Um for cephalosporins is also involved in targeting cell wall synthesis. And aminoglycoside is the one that targets the smaller ribosomes subunits. So you're 30 s um ribosomes. So you want to think, you know, amino acids, you think ribosomes because the ribosomes produce your protein chains from amino acids or the other way around. Nice. Um So you would like to prescribe antibiotics for a patient eliciting an upper respiratory tract infection. The patient has no known allergies and analysis of the microbe shows that illicit beta lactivists enzyme production. What is the best antibiotic to prescribe in this case? Okay. I'll give you guys 10 more seconds. Okay. Right. Then we'll call it there. So brilliant. And the majority of have you, have you have gone for e and that is the correct answer. So, for a Vancomycin that's going to be reserved for patients with like C diff for MRSA. Um and um so be is a possible alternative if the patient was allergic to penicillin. Um in terms of C for gentamicin, that's more likely to be prescribed in things like your oh sepsis. Um and it's not a first choice in respiratory infections for Clarithromycin. Um That is also a possible alternative. The patient was allergic to penicillin. And yeah. So in terms of co amoxiclav, it is a combination of your clavulanic acid and amoxicillin. So because this microbe illicits your beta lactamase enzyme. If you, if you need to first cleave that beta lactamase is in order for your amoxicillin to work. Otherwise this enzyme will cleave your beta lactam, which is your amoxicillin. Um And yeah, that's how it works brilliant. So these are more tailored towards antibiotics itself rather than UTIs. So I saw one to the expand the scope more clinically. So the 25 year old patient presents with a two week fever, they have a respiratory rate of 26 they're being prescribed an antibiotic for community acquired pneumonia. They have a penicillin allergy for which there anaphylactic. What is the first line treatment for this patient? Mhm. But this one if you don't know, just hazard a guess. And um I'll give you guys um stay longer on this one. Okay. Um Fine. We'll call it that. Actually, I'll wait for maybe two more visa answer. Okay. We'll call him back. Fine. So this has very mixed results. So we've got the majority of people say Metronidazol. So a rule of thumb is metroNIDAZOLE is pretty much used for parasitic infections. Um protozoa as um helicobacter pylori. And so is the answer would be seeing the doctor cycling. So a nice guidelines are gonna suggest that you patient's are generally prescribed amoxicillin, 500 mg twice daily. But because this patient is anaphylactic to penicillins, um you need to give them a second line. So doctor cycling or a macrolide such as Clarithromycin is going to be prescribed um as the best alternative. So, metroNIDAZOLE as it has a role in C diff H pylori um and prevention of perianal disease in Crohn's disease. Um but this hasn't really got a role in community community acquired pneumonias level floxacin um isn't first line, this is a third line treatment in case doxycycline doesn't work. Co Amoxiclav is reserved for bacteria that are resistant to amoxicillin alone. And furthermore, the patient is anaphylactic to penicillin. So it would not be ideal to prescribe them. Call Moxie Club. Nice. So a 28 year old patient, uh 28 year old female patient has come to the G P with this area, mild fever, foul smelling urine. Um and she's diagnosed with type one diabetes and has been sexually active with three partners. Um She mentions that she's on the combined oral contraceptive pill but is adamant on using barrier methods. So, on your, on your analysis, there's nitrates and leukocytes positive. So what is the best single, what is the best initial management for this patient? I'll give you guys 15 seconds on to this, I think. Yeah. The interesting thing is the antibiotics is quite easy until you start throwing numbers in and then it gets a bit more confusing. Um Fine. We'll call it that. So the majority of gone for B but the answer is actually a now, this question is quite difficult because you have to read into, you have to read into that nice um algorithm that I sent you guys. I'm not send you guys and I put earlier. Um So is the correct answer. So be is actually reserved for pregnant women or male patient's to note for pregnant women. Nitrofurantoin is actually um contra indicated in the third trimester. So you can only prescribe it for your 1st and 2nd trimester. Um In terms of um pivot message piva Masilela Piven Bacillinum. Um That's going to be your second line. If your first line option fails or if symptoms don't improve in 48 hours fossil mycin. Once again, the second line same sc and for is actually second line for pediatric patient's. So you're 12 to 15 year olds. Fine. And just a reminder of the algorithm um is actually mentioned there. Yes, I did. No, it's fine. So next question. So a 30 year old male patient has severe abdominal cramps and diarrhea for which there pyrexic. So 39 degrees there tachycardic and the BP of 100 and 50 115 over 65 mg of mercury, a stool sample reveals cluster cluster diem actually share the polls again. So these are quite difficult questions but they are quite relevant especially in the progress test. Um OK. Brilliant. So the majority of gone for beam and that is the correct answer. So fit up phylaxis medicine is going to be a second line treatment. So, yep, that is correct. Vancomycin 100 25 4 times daily for 10 days. Um in terms of options, C is actually um if the 1st and 2nd effect in effective. So you add metronidazol after that, um cefTRIAXone isn't actually indicated in C diff is only in respiratory infections. Um And for option is actually first line in H pylori infections. And finally, from me, it's just an antibiotic, pneumonic that you can remember. So hopefully this helps because it sort of helped me when I try to remember this stuff. So, antibiotics can terminate protein synthesis for microbial cells like germs. So a for aminoglycoside, see for carbapenem tea for tetracycline's people, penicillins as for sulfonamides, air for flora quinolones and for macrolides, see for cephalosporins, alpha Lincocin mites and G for glycopeptide. Now the best way to remember it is from the, there's, there are certain stems in these words that will point you to what antibiotic it is. Now, I've highlighted most of them. Hopefully they should help because it definitely helped me. So, yeah. And the last, oh, actually I was on the last slide. Sorry. So a 35 year old female patient presents with a productive cough and a fever. She has no past medical history and has never been admitted to hospital before. She's a strong believer that she shouldn't take any medications at all. But on this occasion, she allows for a prescription of amoxicillin, 500 mg, she has no known allergies. Um She does however, begin to deteriorate and it's now gasping for breath. She is also developing rashes all across the trunk and it's also going blue. So what is the best single, best initial management for this patient? Almost? There are just about two more questions, I think actually one more question. Ok. Brilliant, fine. We will call it the there's a very good split here, there's a very, very good split. Um It's between A N C. So is either, you know, you got to think there's patient's in anaphylactic shock, right? So, you know, you either administer the adrenaline or you assess the airway. Now, in in this case, everything happens very quickly. So you obviously might do A N C simultaneously. But in terms of the algorithm, you want to assess for airway obstruction first. So you want to conduct an 80 approach to this. So your airway breathing circulation, um D for disabling features and e for examination. So the reason we do A two E is because it's sort of triage is what kills you first. So, airway obstruction is what's most likely to kill you first. Um So first you want to just assess the airway for any obstructions that could be the cause And then you would in this the I am adrenaline. But yeah, so that's the drink, sorry, like after she died, okay. And this is just a bit about what they do. Um I don't know why I put this slide here. Um It's meant to accompanied the other slides fine. So a 40 year old female patient has presented with your oh sepsis. So the conducted sepsis six and she's now stable in the wards. But the patient complains of a new nausea. Um, an episode of vomiting and a sense of imbalance. They know that relatives that visit needs to talk louder than before, which causes mild embarrassment due to the neighboring patient's being disturbed by this. She works at 9 to 5 in. Can we do not support? Okay. We'll call it there actually. All right, we'll call it there. So majority have gone for C and that is good. Oh, hold up. Uh Apologies. It is. It is, see, it is anti. So Presbycusis, it's um, so press it accuses means natural hearing loss, but it's to acute and isn't the right age. So there's no occupational history. Um She was 95 office job, which I thought points away from that differential. Uh Ciprofloxacin is notorious for tendinopathy. So your achilles tendonitis, so it's not likely to be that. So see is the correct answer. I do apologize. Gentamicin is notorious for auto toxicity and nephew toxicity. Um Patient's on gentamicin must be carefully regulated. So, so to not have a toxic dose of this um for metronidazol, um one notable side effect is your peripheral neuropathy and that sort of tingling sensations in your peripheries and a gradual loss of sensation, it is very much reversible. So, so long as the patient reduces the dose, well, curriculum ison, it's notorious for prolonging the QT interval and that causes drug induced long Qt syndrome and this will put patient at risk of developing arrhythmias um such as close to the point. But I think you only learn that in case 12. So we'll leave that alone for now. Um So home stretch now you don't have too much longer to go and where you guys have life. So I'll try to finish somewhat quickly. Um But we'll just get straight into it. So this L0 is this different forms of contraception and then modes of Axion. We're going to be going through barrier and pharmacological. All right. Your first question. A third year old woman presents to you in clinic seeking contraception. Her B M I is 28 she smokes 20 cigarettes in a day. She doesn't drink alcohol and there's no significant past medical history. Which of the following contraception options is contra indicated for this woman. Is it the copper? IUD the C O C P. The progesterone only pill, the intrauterine system or condoms. Mhm. Just pre launch. Don't lose the Pope. Mhm. You just put any answer down even if you get it wrong, it's fine. All right, we're gonna call it okay. So most people have put be Yeah, so most people put be uh that is it's gonna work. Yeah. So these correct the reason why the C O C P is contra indicated in this woman is because she's smoking over 15 cigarettes in a day. So if somebody smokes or if the one smokes over 15 cigarettes in a day, it's an absolute contra indication. Uh copper IUD is not contra indicated should be offered to this woman. Actually, it's the most effective of all of these that are listed and it lasts up to 10 years. Uh progesterone only pill has very few contraindications, not contraindicated for this woman at all. Uh Marina us again, not contraindicated last five years. And uh condoms have again, very limited contraindications if only allergies, but that's not listed here. Um Other kind of risk factors for uh C O C P. If she was above 35 that would also be um contra indication. Absolute contra indication. If her B M I was over 35 that's also another contra indication. Um And I think we'll get a, I don't want to spoil it, then we're gonna get into it a bit later. Okay. Next 14 year old woman presents you in clinic so you can contraception. She tells you that she wants to go on the combined pill. She smokes 25 cigarettes a day, consumes 30 units of alcohol in a week has a past medical history of migraines with an aura. Her B M I is 36 kg. Which of the following is not a contra indication for the C O C P. Okay. So which one is not a contra indication? Because we're not again, just try your best. Go with your gut. Give you a few more seconds. I'm going to all of them. All right, good. So most people have per seen which is correct. Um So her age, so uh actually show you the answers you go. So her age is a contra indication. She's above 35. She's 40. Okay. So that's a contra indication for the C O C P. Um 25 cigarettes a day. Remember 15 is your cut off. So um she's someone wants to join. There we go. Um So yeah, so 15 cigarettes a day is a calf. She's smoking 25. So it's contra indicated alcohol, alcohol is not linked. Alcohol consumption is not linked as a contra indication for the combined pill. So that was the correct answer. Um migraines with an aura. The reason why that's a contra indication um is because when you have a migraine with aura, think about those blood vessels, those uh you've basically got a cerebral vasospasm. Um The combined pill inherently gives you an increased chance of forming a thromboembolic clot. So imagine a blood vessel with blood that is more prone to clotting. Now having a spasm, that's why it's an absolute contra indications the U K M E C four, which is the highest grade of contra indication. Um So that's contraindicated. It basically increases the risk of x chemical stroke. BM is 36 that's above 35 again, is contra indicated. So the correct answer here was alcohol consumption so well done to most of you. Okay. Next one. So a 24 year old patient presents to seeking contraception. She's got no Children and tells you that she's not planning to have Children in the next 10 years. She doesn't mind which contraceptive you give her but tells you that she's afraid of needles. She does not have any past medical history or history of menorrhagia. What contraception is the most appropriate for her? It's almost post. So you got options between the C O C P, the P O P A cup of IUD the marina us and injectable contraceptives. It's a big clue in the question. By the way, if you got a few more seconds again, just go with your gut. No one's gonna know your answers. So most people have gone with, see, she's the correct answer. Okay. Um So the reason why is because the Copper IUD is more so the reason why it's not C O C P Copper IUD is the reason a couple ideas better. Um First of all, she's not planning on having Children in the next 10 years. It's a hypothetical question. People can change their minds up. But this stem this person, she's not planning to have any Children the next 10 years. Copper IUD is more reliable than the C O C P. Um And yeah, it lasts 10 years. So it's far better. It's also far more effective than the P O P as well. Marina us, the reason why it's not that Marina us last five years, couple IUD lasts 10. Again, that's just a big clue in the question. Um And then it's definitely not injectable contraceptives. That would be not contraindicated, but it would be inappropriate because she's afraid of needles. So you wouldn't give her an injection, not when there's other options. Okay. Next 1, 33 year old mother of one presents to seeking contraception. She tells you that she is not planning to have any more Children. She also tells you that she does not get on well with the P O P pill, progesterone only pill pill, the po people as she accidentally became pregnant with her child two years ago when she was on it, she has past medical history of stroke and she complains of heavy periods. What is the most appropriate of the below contraception to give her really launched the pulse the option C O C P P O P couple I D marina us and uh injectable contraceptives again, just go with your gut. Give you a few more seconds. I'm calling it that. So most people have gone to be uh he's the correct answer. Okay. Let's go through them one by one. This was not an easy question. So C O C P she's got past medical history of stroke. So instantly that's contraindicated. You're not going to give the C O C P uh progesterone only pill, not contra indicated, but there's a better option later. Um In this question, couple, IUD, you wouldn't give her the cup of IUD because she's got heavy periods or menorrhagia and a cup of IUD can actually make that worse. So you wouldn't give her a couple, IUD. You be inappropriate. Um Marina are us is the single best um answer here because it actually helps with patient's who have heavy periods or menor Asia and some patient even become amenorrhea. So they just don't have periods anymore when they're, when they have the marina us in them. So anytime see someone who's got menor Asia or heavy periods in this type of question, just pick the Marina R Us. Okay. Um, an injectable contraceptives again, the Marina Us is just farther. Far better answer. Okay. Oops. Oh, yeah. I know you wouldn't give her the P O P be inappropriate because she doesn't want to go on the P O P. Okay. Uh, 31 year old mother has just given birth to her first child. She intends to bottle feed her baby for how long postpartum does his mother not require any contraception? Is it one day? Seven days, 21 days, one month or six months again, go with your gut and just put an answer down okay with that quarter. So we had a split between BND. It was generally a mixed bag, but split was between B and D. Um Guys answer is actually 21 days. Um So for three weeks, postpartum, her mother doesn't require any contraception, whether or not she's going to breastfeed her baby or if she's gonna bottle feed her baby, she doesn't require any contraception for those first three weeks after those three weeks. Um Every mother should be given contraception. Um And that's just because you don't want to have back to back births kind of like within the same year because that's linked to lower health outcomes for the baby like preterm birth and low birth weight. Um So it's 21 days postpartum regardless if she's going to bottle feed or breastfeed. Um One day, it's just a made up number seven days again, it's just something that looks appealing. So you can press it one month, same thing, six months does have significance. So you might have heard of uh lactic amenorrhea or lamb for short. So that's if mothers exclusively breastfeed their baby postpartum, don't use any bottle feeding like supplementation, just exclusively breastfeeding that can act as a contraceptive for up to six months. It is however, 98% effective, which it might sound amazing, but it's not as good as some of the contraceptive options that we have available. So it's up to the patient to make an informed decision, but it won't be uncommon that you see somebody who is exclusively breastfeeding their baby also on contraception for those first six months after 21 days, if that makes sense. Okie Dokie. Right. So, um next, hello. So discuss the social and psychosocial aspects of life changes in adolescence and how it contributes to health. Just a quick note, I think I've got it down in a much later slide. Don't ignore your social learning outcomes. They will be on every single exam that you say in medical school, they'll be in your S one us to and every single progress test, there's always a dedicated section for or dedicated percentage or proportion uh for social learning outcomes. Um And although SBS and the university is recognized, SBS isn't the best way to assess social learning outcomes. Um And you are going to be assessed on it more later down the line in medical school, like in your skis. Um, they are still assessed anyways in your written exams. So that's why we've made these for you. Okay. So let's get to it. All right. A 16 year old female presents to you. A symptom suggestive of an S T I following unprotected sex. She discloses an abuse experience to you, which occurred in her early childhood which prompts you to ask about any other aces she may have experienced. You find that she has a total of six aces. You advise the use of contraception in the future as a result of her abuse experience. What may lead to difficulties in negotiating contraceptive use for this patient poem? I should say that the advice of contraception is not in relation to abuse experience, but her presenting complaint again, just pick an answer. Okay, we're gonna call it. So most people went for d see what we got. Yeah, so you're right. Um So yeah, so people with a significant number of aces which will be in the layer question um on what that number is. Um But people with a significant number of aces tend to have low assertiveness, sense of powerlessness, low self esteem and those kind of all attribute to difficulties negotiating contraception with these patient's. Unfortunately, so they do need an extra level of care and they need that to be recognized. Um in terms of this as an S B A none of the above is, um, is incorrect because, well, they are all correct. And the reason why D is correct, even though A B and C are all, um, sort of attributes is because it's just the single best answer. It just has all of their merit. So that's why that is the correct answer because they can only be one. Um, but if you pay A B C or D, you are technically correct. Okay. Was a teenage pregnancy associated with an increased risk of I hope you should all get this. Um Is it poor health and well being for mother and baby improved health and well being for mother and baby, social inclusion, increased social support or all of the above me is the pools be a nice cool down question for you guys before the later ones again, just pick an answer. Got that. So mostly went for a we did have somebody go for C and I'm actually glad that you did that because that does hold some sort of significance. Um talk about in a second. So it is poor health. Well being for mother and baby that is evidence based. Um It should be in your lectures as well. Um Teenage pregnancy is just associated with that increased risk. Um Sentence doesn't really sort of make sense. They increased risk of improved health and well being that is just, that's just wrong. People who have teenage pregnancies actually tend to have less social support as opposed to more social support. Um And then social inclusion, they are actually more prone to be um like shunned from society. So, so is that it could technically come under the social exclusion apart from social inclusion. Um but it does sort of come under the social determinants of health later, so it could give you that one. But I have been looking more social exclusion as opposed to inclusion. Okay. This is a fun question. Adolescents have a great involvement in risk taking behavior more than any other age group. This is thought to be due to, is it a irrationality? 40 calculations, delusions of invulnerability, ignorance or emotional and social factors rather than the above, relaunched the pole. Tell me what you think. Give it a few more seconds. Okay. So the reason why I said this is a fun question. Um So is correct. Um A B C and D are widely health widely health, widely held beliefs by society that actually not supported by evidence. Um And evidence actually suggests that it's the emotional and social factors rather than these widely held beliefs with no supporting evidence that actually contributes to why adolescent partaking risk taking behavior. Um definitely important for an SBA oops. So some examples of what those uh emotional and social factors could be just could be insufficient ties to community living in societies without formal rites of passage, being isolated from society. If your lives are overly regulated or circumscribed, suffering from discrimination, those social status or suffering effect of inequalities could kind of come under discrimination there as well. And then also being born into risk taking habitants as well. All of those are to be thought attributing to adolescents partaking risk taking behavior apart from as opposed to those widely held beliefs that don't have any evidence supporting them at all. Ok. So we found evidence for these instead. Okay. So adolescents have a greater likelihood, a greater likelihood than adults over 25 to be involved in which of the following risk taking behaviors, smoking, binge, drinking, violence, casual sex partners or all of the above pulp. Again, just pick one. You can't go wrong if you pick one. Okay. We got to call it that. So mostly one for e uh, the reason I said you can't go wrong, um, if you pick one is because they are all correct, that's what, like they are all correct. The reason why A B and C and D are all red and E is green is for the same thing I said before is just the single best answer. It holds A B C and D is merit and because they're all correct, it just makes it a single best answer. But adolescents are more likely to, uh, to partake in these risk taking behaviors. Another one that's not listed in here is, um, stuff like car accidents and vehicle accidents as well. Unfortunately, uh, that's what the evidence says. Okay, moving on. Uh so demonstrate knowledge of the social determinants of health and how these are reflected in the communities in which we work. All right. So a 19 year old man presents in clinic with anxiety and low mood. He explains that his colleagues off the banter Banter about him being gay, that he thinks they'll stop eventually. So he doesn't want to report them to his manager. What social determinants of health is being implicated in this scenario? Launch a pulp. So your options are unemployment and job insecurity, early childhood development, social inclusion and nondiscrimination, income and social protection or education. Give it a few more seconds, you can recall it there. Good. So most of you put C which is the correct answer. Reason why a is not the correct answer is because there is no uh kind of threat to his employment status. Let me just show you the stuff. So yeah. And although that C is written in somewhat of a positive way, social inclusion of social exclusion, that is what the social determinant of health is written as, but as I said before, it encompasses both social inclusion and social exclusion and nondiscrimination is part of it. And again, that incomes is discrimination as well as under it. So if you see social determinant of health, understand that it's a category um instead of like a direct description um that should help you answer it. Um I said there's no threat to his employment status, early childhood development. There's nothing in the stem to indicate that he's got any problems with his childhood development or any aces. Um, income and social protection and education. Again, they're not implicated in this scenario. There's no mention of it, but most of you got it right. So well done. Okay. This is the question I was referring to before. So adverse childhood experiences abbreviated two aces can significantly impact an individual throughout their life. How many aces is an individual said to be at an increased risk of developing health harming behaviors in the future? Is it one? Is it too? Is it three, is it four or more or aces are not linked to developing health harming behaviors? See what you think? I'm gonna want to pull, just pick one. I don't mean that literally pick, pick number one, just pick an answer. Okay. Um So I think the results here are my fault because I said pick one. I would add that poorly should have just said, pick an answer. I'll say that from now on just just in case. Um So let me stop sharing Pope. The answer is four or more. So for is the significant cut off when it comes to aces or adverse childhood experiences? Um If someone's got four or more aces, they are said to be at a significantly higher risk of developing health harming behaviors. Um in the future over a third of the population has at least one a space. Um So it's not one. Um And then again, two or three, it's uh to the guidelines. That's not what it says for is the calf. And there is as for ye's incorrect, there's evidence to the significant evidence to suggest that it's all linked developing health harming behaviors in the future. Um So that's wrong. So the answer was four. So remember that number? Aces four is a significant number. Okay, which are the following are risk factors for teenage pregnancies and young women. Is it a unemployment be poor education? See in care of homeless d living in areas with high social deprivation or all of the above the launch of pole pick an answer. Okay, looking very good, good. So everybody went for e what do you guys think? Think you're correct. So yeah, unemployment, poor education incur homeless living hires with social deprivation. Unfortunately, all risk factors for teenage pregnancies in young women. Um and they're all avoidable as well and they can all be fixed. Um um but a lot of them um are left unfixed or unaddressed. Um But yeah, that's the important thing that these are all risk factors for teenage pregnancies and young women. Okay. So something to be aware of. Okay, this is a fun question. Social determinants of health are nonmedical factors that improve health outcomes. What are they sought to influence? Read it carefully? Okay. Health, equality or inequality, health equity or inequity, education, employment status or all of the above. I'm gonna put a poll just picking also. But think about it. Cafferty and you definitely won't forget the answer after this ago. A few more seconds. Okay. We're gonna call it that. So most people want to be um, B is the correct answer? Okay. So let's go through it because there's a good chance at least some of your confused as to what the difference is. So first let's just say C N D they are social determinants of health. Okay. So the question is asking what are the social determinants of health sort to influence CND our social determinants of health? Okay. So by that same token is also wrong. Okay. The reason why it's health equity and not health equality is because the difference between them is subtle but significant. Okay. Health equality is equal treatment, equal health treatment for everybody. Health equity is recognizing that certain proportions or individuals or groups of people require extra care to achieve the same health outcome. Okay. So the social determinants of health are sort to improve health equity and health inequity also to influence that promote more health equity. But yeah, not health equality. Do you guys understand that it's a very subtle difference but it's significant and it makes a big, big difference. Okay, but good. Most of you got it. Ok. 17 year old girl presents to looking for contraception, she's sexually active and admits to never using contraception before you spend some time discussing with her, the different forms of contraception available to her. She tells you that she's not sure if she wants to go on the pill yet. And the condoms are expensive. What social determinant of health is negatively affecting her ability to control uh access contraception is education? Is it income? Is it social inclusion and nondiscrimination, urge childhood development or employment status? Put a pool um pick an answer. So what's negatively affecting her ability to access? The contraception should also be said? And the university has said this reason why social um like learning outcomes and social questions are quite hard because they can often appear quite abstract and a lot of time there is no absolute right or wrong answer, which is why they are just not great to be put into SBS, but they're in SBS anyway because that's the best way to assess students is progression currently. Um But yeah, sometimes the lines can be a bit blurred but they'll always often be something that's just slightly bear or just the best answer compared to some others. But that doesn't mean that others are completely wrong. Um It just means that something might hold a little bit more merit or just be a bit more likely. Okay. And that's important because obviously we're talking about real scenarios, but they're putting their dumbed down into little text blocks. Okay. So most people put be the answer okay. Let's go through them one by one. Right. We'll start with the correct answer. Income. So, in the stem it tells you that she, she doesn't know if she wants to go on the pill yet. And that condoms are expensive. So she hasn't been using contraception before, but she probably would have if they weren't so expensive. That's been holding her back. So that's kind of related to kind of like income and kind of like, again, like her disposable income of what she can and cannot afford. So income is what's being um holding her back here. Education again, as I said before, like these are abstract questions. It can have some merit. Yeah. Um Income is the better answer. It could be education. Maybe she doesn't uh sort of like assess the importance of um protected sex. Maybe she doesn't fully understand that like the the difference you don't know because all you're given is just the step. Um But the reason why I would say it's not education is because she's come to you seeking contraception. And to me that's a recognition of the importance of contraception. So she recognizes that she needs contraception, but she hasn't opted for condoms because they're expensive. So I won't go for education then uh social inclusion and um nondiscrimination. Again, there's nothing to um suggest that any discrimination or exclusion is stopping her from accessing contraception in here. Um early childhood development or yeah, there's nothing to mention any aces in the stem. So I wouldn't go for that. And employment status. So, here's the interesting thing, employment status and income. They are closely connected but they are different. So, depending on someone's employment styles, their income could also vary. Right. Um, but just because somebody is unemployed doesn't mean they have a high income. Right. Just because somebody is employed doesn't mean they don't perceive certain things as expensive or affordable. Okay. That's highly dependent on their income. And as I said, it is linked to employment status, it depends where you're employed. But with such a binary thing as employment status, are you employed or not employed? Again, it's very different and often it's down to the individual. So wouldn't be employment status, more income. Okay. Hope that makes sense. Whoops. Yeah. Okay. Uh Last cello from me. Um and home stretch for the day. So it has done really well, stuck it out. So explain competence in relation to contraception and an underage adolescent patient. So super important industry, everything you'll do in medicine. So let's get into it. This is what I was saying before. Yeah. Also exam hot topic. It, it'll be on every single exam that you can think of in medical school, social outcomes because it's a people job. Okay. Give this a go a 15 year old girl presents the clinic on her own seeking contraception. She tells you that she's afraid of becoming pregnant and does not want her parents know she's sexually active. You want to assess her competency in accordance with Gillick competency? Which of the below will A's your assessment in determining if she's Gillick competent? Would it be asking her if she smokes her drinks regularly? Would be assessing her understanding of the advantages and disadvantages of the contraception would be asking her why she does not want her parents to know she's sexually active. Would it be a conversation about stopping sexual activity until she reaches the legal age of consent? Or is there no need to test galex competency? You tell me what you think, I'll put a boat during a bit tight on time. So I'm gonna end it a bit early. Um, right. Most of you have gone for B which is the correct answer. So somebody can be some reason why is wrong. Somebody can be Gillick competent and they can spink, spink, they can smoke or drink regularly. So that's not really a factor. Um, quite independent. Uh, see asking what she does not want her parents know if she's sexually active. Again, that's like, like those of her wishes they have to be respected. Um, and it's not really gonna age your assessment in determining if she's Gillick competent or not. Um, I could give a bit of merit to a conversation about stopping sexual activity until she reaches the legal age of consent. You can give a little bit of merit to that. Um But again, it's more about the treatment because she needs to uh understand the advantages and disadvantage of the treatment so that she can give true consent to the treatment. Um And then there's no need to assess Wikileaks. Competency is wrong. She's under the legal age of consent. So there is absolutely a need to assess for Gillick competency to the law. Okay. All right. A 14 year old girl presents the clinic seeking contraception. She tells you that she wants contraception just in case and has never engaged in sexual intercourse before. She has a boyfriend who's also 14. She asks you not to tell her parents that she has a boyfriend or that she's seeking contraception. So what is the best form of Axion inner corners with the phrase of guidelines? I'll put the pole up, then I'll talk through it. So I don't waste time. So, would you assess the Gillick competency? Then give her contraception if she's competent, would you call her parents and ask them for consent to give the child contraceptive advice treatment or both? Would you refuse to give her contraception? And she's below the legal age of consent? Would you try your best to convince her to abstain from sexual activity until she's 16? Would you try to persuade her to tell her parents first? Okay. Find uh so most people have gone for a, is the correct answer. So, yeah. Um The, yeah, so there's no safety. Uh There's no safeguarding uh kind of concern here. So you don't like, it's not even an option. Uh But yeah, the general rule of thumb, somebody's under the age of consent, they're coming in, seeking contraception, they're sexually active. Um, you need to assess for Gillick competency, right? If she's competent, then you can give her the contraception because that's now a true informed consent to the treatment. In this case, the contraception. So is the correct answer. Uh, call her parents ask for consent to give the child concept of advice, a treatment for both. Um So no, because you haven't, you need to assess for Gillick competency. If she's Gillick incompetent, that might be the best answer here. But you need to assess for Gillick competency first because if she is competent, you don't need to ask for parental concern. And as a side know a parental concern, it's usually the mother um as opposed to the father, if they ever ask you that question, uh refused to give her conception. She's below legal age of concern again, like if she's good at competent, you can give her the contraception. And if she's getting incompetent, you can call the parents. And if you get consent from there, um she can, she can have contraception, try to give it to exchange sexual activity until she's 16. She has a boyfriend, she's seeking contraception, she's probably going to have sex. You need to treat her or give her the treatment that she's requesting. Only some sort of advice. So just trying to commit to abstain isn't going to accomplish anything. Um Probably actually gonna work against her, try to persuade her to tell her parents first again. Like you don't, you don't, she has the right not to okay. So you need to treat the patient in front of you. So these are the fraser guidelines. Um I know it's right on time but this will be in the slides that will be released to you later. But you can just have a read of these. Um 15 year old girl presents into clinic with her 15 year old boyfriend. She's sexually active. She's seeking contraception, but you don't find her to be Gillick competent was the next best form of Axion in regards to her contraception so much the polls. So would you give the contraception anyway, would you call the police? Would you tell her to go to the pharmacy and buy barrier contraceptives? Would you get parental consent to proceed with treatment as you can't give consent? Or would you assess the boyfriend for Gillick competence? They can answer. Give you a few more seconds. Let's just pick one. Okay. So most people said D and Good. Yeah, you're, you're clearly paying attention cause I gave you the answer about two minutes ago. Um So yeah, so if she's getting incompetent, you can't give her the contraception anyway because it's not true consent. If she's getting incompetent, she hasn't, it's not true. Informed consent. Call the police. There's no safeguarding concern here. The boyfriend's also 15. Um, there's, there's no safeguarding concern in the stem, uh, at all. So you wouldn't call the police and that wouldn't be how you pursue a safeguarding concern. Anyway, um, tell her to go to the pharmacy by Bharat Contraceptives. Again, there's no guarantee she'll do that and she might not be able to either. Um, and there's another option in another system in place, which is de where you can, if she's getting some competent, you can call the parents and get parental consent to proceed with treatment. Obviously, you have to inform the patient that you're gonna do that. You can't just do that behind their back or without letting them know. Um, they can make an informed decision on that as well. They need to be kept in the loop, the same dose for safeguarding as well. If you're going to raise the safeguarding concern, patient has to be in the loop as well that you're about to do that. Um, and it's, it's in the boyfriend for killer competence is wrong because the boyfriend isn't the one who's getting treated. I think this is one of the last questions. So you guys have stuck it out really? Well, a 14 year old girl presents seeking contraception. She's sexually active with her boyfriend who's 23 years old. Okay. So she's 14, he's 23. She's worried that her parents might find out that she's seeking contraception but explains that her boyfriend convinced her to see you for contraception. You don't find her to be Gillick competent. So what is the next best step to managing this patient pole? So would you immediately raise the issue as a safeguarding concern and escalate the concern by following the local safeguarding guidelines? Would you call her parents, let them know what's happening so they can help? Would you give her the contraception? Anyway, would you ask her to break up with her boyfriend as it's illegal because he's 23 or no management needed? Pick any answer. Get a few more seconds. Okay. Really good. You guys all smashed that. So yeah, you immediately raised issues sick on it. So there is a safeguarding concern here. Um Is she's under the legal age of consent. Um And well, he's well above it. There's a, it's a safeguarding concern. Um The stem ells suggest that as well whether or not, if she was going to be Gillick competent or Gillick incompetent wouldn't actually change this outcome. So, if she was Gillick competent, you'd still raise the issues of safeguarding concern. Um I'm calling her parents, let them know what's happening so they can help you follow the local safeguarding guidelines and sometimes that's not in the best interests of the patient. Um So you wouldn't do that and calling the parents wouldn't be you, you're the health professional, you're not the one who informs the parents that would be either the local authorities or the police give her the contraception. Anyway, um You got to intervene. There's a safeguarding concern, ask her to break up with her boyfriend as a typical cause. He's 23. Uh You have no idea what's gonna happen when she walks out of that door. You don't even know if that's going to be achieved. Um And you need to raise a safeguarding concern and no management needed is very, very wrong. These, you're safeguarding concerns. Again, I'll let you read this in your own time when you get these slides, but I've basically summarized it. Okay. I think this is the last one, 16 year old girl presents Stuart Clinic. She's pregnant though, she was previously advised by her doctor to stop smoking and drinking alcohol during the pregnancy. She tells you that she knows the risks and now only smokes and drinks in moderation of the factors listed below which best explains the pregnant woman's behavior. More simple, straight away. So poor education, coercion, different pain to the doctor as to what is and it's not risky behavior, depression or poor self discipline. Give it a few more seconds. Okay. Good. So yes, so really good. So most people have picked, see that is the correct answer. Um This is another one of those kind of like evidence based things, but it's also kind of suggestive by the stem. So there's nothing to suggest depression in the stem per education she's presented to you in clinic, um, like already. And she says that she knows the risks. So I wouldn't really say that it's, it's education. I mean, you could argue it. Um, it does have some merit. But I think, see is the better answer. Um, it's her interpretation of the degree of the risk because she's made modifications. But you can see that she still smokes and she still drinks, which is not good in a pregnancy. But that's her interpretation of, uh, the risky behavior. That's her opinion. So, um, see, would be the correct answer. Again, I think suggests that she's depressed. Yes, smoking is very addictive. So you could put it down to poor self discipline. But again, c is the single best answer here and she has reduced her consumption as well. Uh, coercion. Nothing to suggest that she's been coerced. Okay.