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Basic Course on Small Animal Neurology Webinar 2: Part 2: "How To Do The Neurological Exam? — Transcript

by Oriheal By A Vet For The Vets · 8,130 words · 1,373 segments · language en · Watch on YouTube

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0:20[Music]
0:34[Music]
0:54Finally, in your hands of neurological
0:57examination, You are checking gate.
1:00Okay. When you observe the gate, look
1:04for two things. Atexia or paresis or
1:07plegia. A taxia is you can have three
1:12types of atexia. Sensory atexia,
1:15cerebellaraxas
1:16or vestibular attackas. And then in your
1:20paresis and your Now what's paresis and
1:23what's pleia? Paresis means there is you
1:28know a reduction in the voluntary
1:30movement of your limbs. Whereas plegia
1:33is a complete loss of voluntary
1:36movement. So your paresis or plegia can
1:40be mono affecting one limb. It can be
1:42para affecting both for limbs or both
1:46hind limbs. It can be hemi meaning that
1:49it can be on the right side or the left
1:50side or it can be tetra
1:53affecting all four limbs. So when you
1:56look at the gate look if there is a
1:59taxia or look if there is paresis or
2:02pleia. Okay. So for example if you
2:05observe this video can you tell me what
2:08type of an atexia this is?
2:25I notice notice the hind limbs. Suddenly
2:28there is a loss of voluntary movement of
2:30the hind limb and he still attempts to
2:33move.
2:35So this is like a very obvious ataxia if
2:38you pay attention to how the hind limbs
2:40are moving.
2:42Sensory Sensory.
2:44Excellent. Excellent. Excellent. Yes,
2:47this is a sensory or propriceptive
2:50ataxia. There is a taxia because the
2:53legs are not able to propriceptively
2:56function. So, this is a propriceptive
2:58atexia.
3:01Please look at this video and tell me
3:04what type of anaxia this could be.
3:07So here we have a kitten
3:11that is attempting to move little bit of
3:15a of like a an intentional tremor over
3:19there. See that there? And then he
3:22attempts to move forward
3:27but slightly wobbly and incoordinated.
3:36atexia.
3:39This is cerebellar at taxexia.
3:42Fantastic. Yes, this is a cerebellar at
3:45taxia. Not very very clear over here.
3:47It's very sub subtle, but if you are
3:49able to pick up a cerebellar at taxia
3:52here, seriously well done. Very well
3:54done.
3:56Here you'll be able to see a very
3:58obvious atexia.
4:00And this whoever sat the previous
4:02lecture will know for certain what type
4:04of an atexia this is.
4:08So just observe the video very closely.
4:13Let's try and put the pet down. There we
4:16go. There we go.
4:20So here notice the legs are so
4:24incoordinated
4:27and then you have there we go
4:30incoordinated gate
4:33a little bit of hypertria in the for
4:36limbs. See there how the limbs lift up
4:38and walk.
4:43And then you'll also see over here
4:52intentional tremors.
4:55There we go. There. There. There we go.
4:58Those are intentional tremors. So you
5:01see intentional tremors. You see an
5:03incoordinated gate. You see hypometric
5:07forlims.
5:09Can you see the phone?
5:13No, this is cerebral.
5:15Brilliant. Yes. So, this is a classic
5:19beautiful like very very obvious
5:22cerebellar attack at taxia. So, how do
5:25you know if this is cerebellar atexia?
5:27Look for intentional tremors. Look for
5:30an incoordinated gate. There won't be
5:32any coordination with how the front
5:34limbs and the hind limbs are moving. See
5:36that? So random, right? Incoordinated
5:39gate and hypertria. So not see that. See
5:44the see how exaggeratedly lifted the
5:47pet's forlims are when he attempts to
5:50walk. There we go. So hypometric
5:54gate, hypometria,
5:56sens uh intentional tremors and
5:59incoordinated gate all point towards a
6:02cerebellar atexia.
6:05What type of an atexia could this be?
6:12So the pet
6:14here has sort of like a drunk walk. Uh
6:20not a not able to maintain balance.
6:29Very good. This is a vestibular atexia.
6:33unable to maintain its equilibrium.
6:36Yeah, very good. Yes, unable to maintain
6:39equilibrium. So, basically in very
6:41simple terms, when you see a pet walk
6:44like he's drunk, it's a vestibular
6:46atexia.
6:49Okay.
6:51What do you think is happening here? Is
6:54the pet pariticlegic?
6:57What type of anaxia could this be?
7:00Sorry, second. Yeah, there we go.
7:04There we go.
7:08So again, um can anyone tell me what is
7:12the mistake I am doing here?
7:16Slippery flow.
7:18Exactly. So do not do this. Okay. Don't
7:21assess patients on slippery flows.
7:34Okay. So, this pet attempts to walk very
7:36well with the four limbs. Notice the
7:39back legs.
7:41Suddenly, there's loss of strength
7:47and there's a bit of paresis on the
7:51left hind limb. So, what's happening
7:54over here? How would you describe the
7:55gate?
7:57drop
7:58looks like sensory.
8:00Sorry.
8:04This looks like sensory at taxexia plus
8:06der d des dereelate rigidity.
8:09Okay. Okay. So, uh bear in mind d
8:13cerebellate rigid cases they can't walk
8:15with the forlims.
8:18Okay. They are like they're very rigid
8:20on the for limbs. So if you would have
8:22said ship sharington maybe but here
8:25definitely no deserebate rigidity. So
8:28how would I describe this? I would say
8:30this pet has propraceptive ataxia with
8:33paraparesis of the hind limbs.
8:36Okay. So there is paraparesis of the
8:39hind limbs. He's paritic. He's
8:41definitely not plegic. He can still
8:43voluntary move his legs but it is weak.
8:46So you see here
8:58so he's able to move forward.
9:02Okay. But the back legs
9:07they lose strength and function.
9:12And you'll notice both the hind limbs he
9:14is paraparetic. The left is worse than
9:17the right. And this is how you would
9:19describe his gate in your neurological
9:22report.
9:25How would you describe this gate?
9:36paraplegic.
9:41Notice how the left leg has some
9:43movement
9:47but the left leg is also weak.
9:52Hind limbs are totally criss-crossing.
9:55Good. Yes. How would you describe that
9:57gate?
9:59Paraplegic.
10:01Parapleic.
10:02Okay. But there's some, if you notice,
10:04there's still a little bit of function
10:06on the back leg.
10:11So, see the left support
10:15unable to support his body. Yes.
10:19Okay.
10:20Left hand leg.
10:22Very good. Yes. Yes.
10:26That's right. It's per the pet is
10:28peritic. So here I would describe this
10:31as the pet uh as as so he needs support,
10:34right? So he's not ambulatory on his
10:37own. So if you want to sound a little
10:40bit more fancy, you can say
10:42non-ambulatory
10:44paraparesis of the hind limbs.
10:48And here you can say the right is worse
10:50than the left. So non-ambulatory
10:53paraparesis of the hind limbs. If the
10:56pet is ambulatory like for example in
10:58this video you can say ambulatory
11:01paraparesis of the hind limbs but here
11:04it is non-ambulatory paraparesis of the
11:08hind limbs.
11:11How would you describe this gate?
11:21Paraplegia
11:23paralysis paraplegia
11:27nonambulatory
11:29paraplegia the highs.
11:31Brilliant. Yes. Yes. That's the most
11:34perfect way to describe this video. The
11:36pet has non-ambulatory paraplegia of the
11:39hind limbs. Very good.
11:44How would you location?
11:47Where is the location for previous
11:50video?
11:52Can you can you tell the location
11:54location of uh
11:56non-ambulatory paraparasis and
11:58non-ambulatory paraplegia?
12:02Okay. How would you describe this?
12:24terribel.
12:30How would you describe this gate?
12:35No. Watch the whole video.
12:39And you'll see parts where the pet
12:42cannot fully bear weight on the back
12:44legs.
12:47See that? There we go.
12:53Arthrosis of ambulatory parapasis.
12:58What type of an attackia is this?
13:02Ambulatory
13:05or taxia.
13:10This is sensory taxia. Ambulatory
13:12paraparis.
13:12Brilliant.
13:14Brilliant. This is a sensory atexia with
13:17ambulatory paraparesis of the hind lips.
13:20Okay. So this is how you need to
13:21describe the gate. Is there an atexia?
13:24Describe the atexia and then describe
13:27the gate neurologically with
13:29neurological terms. This is an
13:31ambulatory paraparetic pet.
13:36Okay. So this table helps you actually
13:40um further neuroloize and summarize your
13:44learning. So for example if you have a
13:48lesion in the forbrain you may have so
13:52if you will have contraateral
13:54hemiparesis or conscious propreceptive
13:57deficits. Okay, meaning if you have a
13:59lesion in the right side, your CP and
14:02postural reaction will all be deficit on
14:05the opposite side which is the left
14:07side. Now the gate in forbrain cases are
14:10mostly normal. It is rare to see atexia
14:14in forbrain cases. The behavior is
14:17changed.
14:19The consciousness may vary anywhere from
14:22octandid to coma. the spinal reflexes
14:25are intact and you may see other
14:28neurological or non-neurological issues.
14:31Okay, your brain stem produces
14:36postural reaction deficits or CP
14:38deficits on the same side. So if it's on
14:41the right side, it will be on the right
14:42side only, not like the forebrain where
14:44it's the opposite side. Your gate will
14:47have a sensory atexia specifically with
14:51upper motor neuron signs. The next
14:53lecture will explain to you what these
14:55upper motor neuron signs are. The
14:57behavior is not changed. The
15:00consciousness may be severely affected.
15:02If the aras part of the brain stem is
15:05affected, the spinal reflexes are
15:08intact. You may see other neurological
15:13neurological issues. Okay? Like for
15:15example, there may be a change in the
15:17heart rate, BP, respiratory rate and
15:20rhythm. You may see cranial nerve
15:22deficits. Cerebellum also it produces
15:26same side deficits but bear in mind no
15:30paricesis. Cerebellaraxias
15:33they often present with a hypertric
15:35gate. So the gate has a cerebellaraxic
15:39gate. No change in behavior. No change
15:42in consciousness. Very important. And
15:45your spinal reflex is intact. And there
15:49you may have other neurological or
15:51non-neurological issues. Okay. So with
15:55your handsoff neurological exam, this
15:58table helps you summarize from your
16:00hands off neuroindings where the lesion
16:04could be
16:06[Music]
16:17Heat. Heat.
16:48So you finished your hands off
16:50neurological exam. Now you go on to the
16:53hands on neurological examination.
16:57Your hands on neurological exam. It
17:00consists of checking five of these
17:04parameters. postural reaction, cranial
17:07nerves, thoracic reflex, pelvic reflex
17:11and other reflexes.
17:13But for today we will only touch on the
17:16postural reactions, cranial nerve,
17:19thoracic reflex, pelvic reflex and other
17:22reflexes. It will be part two of the
17:25neurological examination.
17:28So postural reaction
17:30please remember in your hands-on
17:33neuroexam when you check your postural
17:36reaction it is a non-specific test. It
17:39is merely a screening test to tell you
17:43if the pet is neurological or not. It is
17:46a screening test to tell you if there
17:48are abnormalities in the nervous system.
17:51It does not tell you where. Okay. So for
17:55example, if you have a problem in the
17:57forebrain, it will produce opposite
18:00postural reaction deficits. If it is in
18:03the brain stem, it will prod
18:07postural reaction deficits. If it's in
18:09the cerebellum
18:11and throughout the spinal cord, you will
18:14have same sight postural reaction
18:16deficits.
18:19Now if the pro but when you do your
18:21postural reaction to some extent you can
18:25gauge where the problem could be. Okay.
18:28So forbrain will produce contraateral PR
18:31deficits. Brain stem will produce same
18:33site. If your problem is at C1 to C5 all
18:37four limbs will be affected. If your
18:40problem is at T3 to L3 L4 to S3 only
18:45pelvic limbs are affected. So to some
18:47extent your postural reactions may tell
18:50you where the problem could be. Now
18:52these are all the postural reaction
18:55tests that you can perform. Conscious
18:59propreception CP basically in short
19:02terms hopping wheelbarrow hemi stand
19:06hemi walk extensor postural thrust
19:10visual placement tactile placement. So
19:13these are all postural reaction tests.
19:16Meaning that you are you are putting the
19:18pet in abnormal postures to see if the
19:22nervous system corrects the abnormal
19:24posture. That's all. That's why it's
19:26called postural reaction. Where in the
19:29nervous system is the problem that you
19:31cannot tell just by checking postural
19:33reactions. Okay. Now conscious
19:36propreception. Is the pet conscious when
19:40you put the paw in an abnormal position?
19:45So see when you flip it abnormally the
19:47pet consciously places it back. Now
19:51notice with
19:59this leg there is a delay.
20:12Okay. And always bear in mind when you
20:14are checking the hind limbs, you must
20:17support the abdomen. When you're
20:19checking the for limbs, you must support
20:21the chest. Okay. And you should just
20:24support. You shouldn't lift the pet up.
20:27So notice the difference in the
20:28conscious propreception between the
20:30right leg and the left leg.
20:55delayed in the right leg.
20:59Exactly. So here we have a delayed
21:02conscious propressive in the right leg.
21:07Now observe hopping. Notice how Lahonta
21:12he does hopping a little differently in
21:14cats compared to dogs. Now checking
21:17postural reaction in cats can be
21:19incredibly frustrating because they
21:22don't cooperate and sometimes they like
21:24to roll over and so they give you a
21:27false uh presentation that postural
21:30reaction is abnormal. So when you hop a
21:33pet, make sure you lift and hop them.
21:36Lift, hop.
21:38Lift hop. Lift hop. So that's how you're
21:42supposed to hop cats. Okay. This is a
21:45wheelbarrow.
21:47So this is wheelbarrow.
21:50This is another way you can wheelbarrow
21:52cats.
21:53See that?
21:55So there is no wheelbarrow.
21:58So you notice hopping and wheelbarrow in
22:00cats is done here.
22:03So there we go. Hopping.
22:12And then there's wheelbarrow.
22:27Okay. So that's hopping and wheelbarrow
22:30in cats.
22:32Here you can see a clear hopping video
22:34in a dog. Now remember the side you want
22:38to hop the pet. That is the side you
22:41will support the pet's abdomen and hawk
22:44them by lifting the opposite leg. Okay,
22:48there we go. Like that. That's how
22:49you're supposed to hop your patient.
22:52Support from the same side and hop the
22:55same limb.
22:58Now this is
23:00another way you can hop your patient by
23:03testing the leg alone.
23:08This is a hemi walk. Notice he's only
23:12walking the right side.
23:15So here you can see hopping and a hemi
23:18walk.
23:21Okay. So that is hopping.
23:24[Music]
23:26Then he's coping the patient.
23:32Hopping just the singular limb.
23:38And here you have a hemi walk.
23:46Okay. So this is how you check postural
23:48reactions.
23:50This is a wheelbarrow. So this is how
23:53you wheelbarrow your patient. Now let's
23:56say there is a resistance in your
23:58wheelbarrow or the patient is not able
24:00to wheelbarrow. You're in the four
24:03limbs. Your neuroloization is cranial
24:07part of the cervical spinal cord or
24:11further cranially up to the forbrain.
24:14That's your neuroloization.
24:16If you are resistant in your wheelbarrow
24:20or the pet is not able to wheelbarrow
24:22with a poor limbs, your neuroloization
24:25is anywhere from cranial cervical spinal
24:28cord forward to the brain stem to the
24:31brain sorry. So this is how you wheel
24:34barrow.
24:42Okay,
24:49this is an extensor postural thrust. You
24:53will lift the pet's hind limbs, place it
24:55on the ground, and the pet should
24:57correct the hind limbs properly for
24:59balance.
25:01That's an extensive postural thrust.
25:08This is visual placement. Okay, this is
25:11tactile placement. Okay, tactile
25:14placement is where you completely remove
25:17the visual field. That is by blinding
25:20the pet and then you get the pet to
25:24place the paw based on tactile stimuli.
25:28That is by helping the pet feel the paws
25:31against the edge of a surface to
25:33initiate movement. So this is tactile
25:36placement. Now remove the visual stimuli
25:39the visual obstruction and allow the pet
25:42to see the object and place the paw
25:46accordingly and that is visual
25:48placement. So tactile placement here is
25:51no sight and here just by using sensory
25:56stimuli of placing the paw against the
25:58edge of the table there is a response
26:00there is conscious placement of paws.
26:06Okay, that is tactile placement. You are
26:09removing the visual stimuli. Now when
26:12you remove the obstruction and the pet
26:15is able to see the surface and the
26:19placement of the paw on that tests the
26:22visual pathway and its coordination with
26:25the four limbs.
26:29I'll get this video to play. So now when
26:33you
26:35have a large dog, how will you test the
26:38visual and tactile placement? You
26:41obviously cannot carry a 50 kilo dog,
26:43right? And you can't put them against
26:46the table this way. You can do this for
26:48medium-sized dogs, small dogs, and cats.
26:51How would you check your visual
26:52placement and tactile placement in a
26:55very large dog?
26:58Maybe by placing a stepper. by placing
27:00obstacles
27:02on the ground.
27:03Brilliant. Yes, absolutely. So, you take
27:06the pet to the staircase and you allow
27:09the stairs to become a uh basically a
27:12stimuli for um initiating visual or
27:15tactile placement.
27:18[Music]
27:42Heat. Heat.
28:00Next lecture which is part two I'll
28:03teach you how to test your cranial
28:05nerves your thoracic reflexes your
28:08pelvic reflexes and other reflexes
28:12okay and for now I would like to thank
28:16life sciences especially Dr. Vishal
28:18Sharma for his trust in me both my
28:21teachers Dr. Voger and Dr. Paul and two
28:24universities that have helped
28:26tremendously especially with the videos
28:28Cornell University and University of
28:30Georgia.
28:32Thank you very much everyone. I'll be
28:34happy to answer questions.
28:37Um could you go back to the video uh
28:40played just before the hands on exam
28:44caucus Daniel and can you walk me
28:47through it?
28:48Yes. Um which one?
28:51This the last video in this
28:53sensory the one with this uh sensory
28:56attacks here.
28:58Sure.
29:04Okay. this guy.
29:08Now if we look at this pet's gate, okay,
29:12we will see that so sensory atexia can
29:15also be called propreceptive attacksia
29:18because there is there is an issue with
29:21propriception and there is an ataxia
29:24because of that. So let's look at this
29:27video where this pet
29:32notice the placement of the back legs
29:35the quality of the gate in the back legs
29:38when you compare it to the front. The
29:40front is normal but notice the notice
29:43the sway the attack in the back legs.
29:47There we go. See that? So that
29:52see how choppy it kind of looks. So that
29:55gate
29:59is a propreceptive atexia. So it is at
30:02taxic because of propreceptive issues in
30:06the back legs. See that? And then you'll
30:10notice that there are occasions where
30:12the pet drops down, right? There is a
30:15lack of um muscle strength or muscle
30:19function. So there is a temp there is a
30:22loss in muscle involuntary movement of
30:25the leg but it's not completely lost.
30:29That's why I call this an ambulatory
30:31paresis with a propreceptive attacks
30:34here.
30:36Madam
30:37no intentional tremor in this video.
30:41No no no intentional tremors here.
30:44Thank you so much.
30:45Where could be the lesion? Where could
30:47be the reason located in this case?
30:49Right? So if you you remember the
30:53initial part of the lecture where I
30:55spoke about the intumisence that
30:58provides to the front legs and the back
31:00legs. You'll notice here that there is a
31:03reduced weightbearing capacity. Here the
31:06lesion is L4 to S3 because there you can
31:10see that the PET drops down and usually
31:12when there's a reduced weightbearing
31:14capacity the sciatic nerve is
31:17responsible for that and the sciatic
31:19nerve comes out from L4 to S3. So the
31:23localization is L4 to S3.
31:28Thank you. Thank you.
31:29Welcome. Unless you uh you mentioned
31:32about the postural abnormalities
31:34covering scoliosis, kyphosis, cloudosis
31:37etc.
31:38How do we account for torticololis?
31:40Toricololis.
31:42Okay. Yes, very good question. So
31:45toolis,
31:46thank you.
31:47Um we have replaced the toricolis with
31:51the word oppos.
31:54Okay. So toolis is predominant. We have
31:58predominantly used that term in farm
32:00animals. And here in small animals the
32:04term that has replaced torticololis is
32:07oppos.
32:09And so what is oppos? Oistoonis is
32:13basically the hyper flexion of the neck
32:16backwards.
32:18And so this is
32:21what we would call as oppos
32:27Nick.
32:28There we go. So this is an opposic
32:32posture. And so yes, I do have so I do
32:36have my professors who still would call
32:39this tool.
32:41Now we we have we have replaced the term
32:44with opposis.
32:51I hope that answers the question.
32:55Can you elaborate on cattoplex and
32:57narcolexi?
32:59Yes. So catyplexi is basically the
33:03complete loss. Um I am going to show um
33:08one second.
33:12It'll help you understand better.
33:16Yes.
33:27Complete loss of muscle strength with
33:30consciousness is the catalyp.
33:33Absolutely. Yes. I actually would like
33:36to show you all a video. Um
33:40Dr. Vishal, are you here with me?
33:44Yes, I'm there. Doc,
33:47um, will I be giving the seizure and
33:48epilepsy lecture soon?
33:51Yes. Yes, definitely.
33:53Okay. So, that
33:54we will be having just a mandatory break
33:56for the next week and then for the this
34:00was kochi and then we'll be continuing
34:03all the rest of the lectures.
34:05Okay. So when I am going to give the
34:07seizure and epsy lecture, please um
34:10please attend that lecture because I'm
34:12going to show youall seizure mimics and
34:16the seizure mimic videos have plenty of
34:20narcoleptic videos which I'm going to
34:22show you all including catyplexic videos
34:25as well. But for now what is the
34:28difference between narcolepsy and
34:30catyplexi? Basically catyplexi is a
34:34complete loss of muscle function with
34:38retaining consciousness. Narcolepsy is a
34:41complete loss of muscle function with a
34:44loss of consciousness also. So catyplexi
34:48consciousness is there but loss of full
34:51muscle function. Narcolepsy loss of
34:54function and loss of consciousness.
35:00Ma'am, what is HT strips?
35:04Sorry.
35:06HTT strips.
35:09Oh, so that's the shmear tier test.
35:12Basically, we'll get to that. We'll get
35:14to that when uh we do
35:16Okay. Thank you.
35:17when we do the u advanced neurology
35:20lecture in opthalmology. That time we'll
35:24be I'll teach you what's ST and why do
35:26we use it and how it's related to the
35:28nervous system. So it's a test and check
35:31your production docu till then Dr. S can
35:35refer to our opthalmology uh webinars
35:39that is already available on the YouTube
35:41with Dr. Romani there you will find ST
35:44and FDT both and other tests also.
35:49Perfect.
35:50Hello ma'am.
35:52Hello.
35:54Yes. Hello sir.
35:55Uh ma'am can you uh explain vestibular
35:58and cerebellar attacks you once again if
36:00you don't mind.
36:02Sure. Sure. Okay. So vestibular attacks
36:08imagine it this way. Okay. We will
36:10simplify it.
36:12Your vestibular atexia is an atexia that
36:15looks like that of a pet who is drunk.
36:19Okay, there basically there is a loss of
36:22balance and the pet is trying to
36:24maintain balance and move forward. Now
36:27your cerebellar taxia it will come with
36:31other signs. So the cerebellum can also
36:35present with a little bit of
36:36incoordination but it comes with other
36:39signs like hypometria
36:41complete incoordination of movement. The
36:44pet will still move but there is an
36:47incoordinated placement of the legs to
36:50move forward and there is an intentional
36:52there may be an intentional tremor.
36:55Intentional tremor meaning the pet wants
36:58to move forward but there's a little bit
37:00of a tremor before the the movement is
37:03initiated. So you see intentional tremor
37:07hyperactria
37:08and um a ser and an incoordinated gate
37:12in cerebellar issues. In vestibular
37:15issues it's more of balancing issues. So
37:19leaning more towards one side, falling
37:21off towards one side, sort of not losing
37:25a bit of balance when the pet moves
37:27forward. It's more like a drunk gate.
37:30Excuse me, everyone. Please mute your
37:32mute your mic.
37:34Thank you ma'am.
37:39[Music]
37:41Ma'am,
37:41in the signal you mentioned something
37:44about B and Q. May know what is it
37:47about? Sorry,
37:49in the signalment slide you have
37:51mentioned something about B and Q R.
37:55Oh, bright alert responsive quiet alert
37:58responsive. That is just how the pet
38:01presents to you. Is he bright alert,
38:03responsive, quiet and responsive? So
38:06that's B A R and Q A R.
38:12Doc,
38:14Dr. Nisha can you come to the chat box
38:17also there are certain questions
38:20I would request everyone to mute your
38:22mic it is creating a big
38:25hello
38:26Mr. Ben. Hello everyone.
38:29I request you to please mute your mic
38:31and write your questions in chat box.
38:34That will be very easy for us and will
38:37not disturb other people because most of
38:39the mics are unmuted right now and the
38:42person who already posted a question is
38:45unable to understand the answer. So it's
38:47better you write down your questions in
38:49chat box and let the Dr. Nisha take them
38:53one by one. Dr.
38:55Please if you can refer to the chat box
38:58uh you can uh you know you can uh uh
39:01stop sharing now and then you can
39:04properly check your chat box and then we
39:07can discuss all the questions one by
39:08one.
39:10Yes. Okay. So we have
39:16Hello.
39:17Yes. Yes dog.
39:19Okay. So we have a question here.
39:21Suppose hemiparesis in a dog then
39:24location of the lesion is where? Now
39:26when the pet is hemiparetic meaning that
39:29it is they are paritic on one side
39:32either it is on the opposite side of the
39:34forebrain or the same side of the brain
39:37stem
39:38[Music]
40:20significance. Now the more questions are
40:22there. What is the significance of
40:25opismus
40:26in neuroexam?
40:29Okay.
40:31Very good question. It is an indicator
40:34that intraranial pressure may have
40:37increased or it's an indicator that
40:40there could be transentorial herniation
40:44because of that intraraanial increased
40:47pressure. So that's the neur that's
40:49mainly the neurological significance
40:52and it is a neurological emergency.
40:56Okay.
40:57Cat shows uh ventroflexction when they
41:01have hypocalemia.
41:04Does this have a neuro component or it
41:06is differentiated based on history lab
41:10findings?
41:14Yes. So hypocalemic pets they basically
41:19have a myopathy associated with
41:21hypocalemia right there is a weakness of
41:24the cervical muscles is why there is a
41:26ventroflexion. So here we do have a
41:29neuromuscular
41:31muscular issue due to nonneurological
41:35causes but it is still an abnormal
41:38posture.
41:40It's not necessary. When you see
41:42abnormal postures, it is because of a
41:45neurological cause. There can be
41:48non-neurological causes presenting with
41:52neuromuscular issues.
41:55Now, twitching and mild tremors, how to
41:58differentiate?
41:59Very good. Uh, attend the seizure and
42:03epilepsy lecture. That's where I'll be
42:06able to explain the difference.
42:09Difference between myoclonus and tremors
42:13again
42:14again. Yes. So this also the myoclonus
42:17it I I need you all to stay for the part
42:20two of the neuro exam because then we
42:23will be doing some case studies and
42:25that's where I'll be show you these
42:28myiokemic and myoclonic cases.
42:31Okay. Uh ma'am what are the
42:33differentials if 45 days puppy presented
42:36with circling
42:38in a lecture after the next one you
42:42yourself will be able to come up with
42:44the differentials I will so the lecture
42:48the the the
42:50lecture after the next one is that
42:53lecture how do you come up with the
42:55differentials based on your history your
42:58neuro findings and your signalment ment
43:02and so remind me ask me this question
43:05again in that lecture and you and me
43:08will be able to come up with the
43:09differentials together.
43:12Great. Uh good evening ma'am. How about
43:14metanidazole toxicity and how to
43:17differentiate it from other conditions.
43:21Very good history taking very good
43:23history taking and comp and relying on
43:25the accuracy of your neurological
43:27examination. Of course, screening tests
43:30for infectious causes may need to be
43:32done, but that's basically a diagnosis
43:35of exclusion. So, if you are able to
43:38derive this from your history itself,
43:40you have probably made a diagnosis. It
43:43has a classic presentation of central
43:45vestibular disease.
43:48If the patient is already on the
43:50treatment of metronidazole for last 5 to
43:527 days, I believe then this is the
43:54already already a differential. We can
43:57think about it.
43:57Definitely. Yes. Yes.
43:59Yeah. The lesion localization in
44:02paraplegic dogs.
44:05Okay. So, it depends on where the
44:07paraplegia is. If it's in the fold
44:10again, this I'll be able to teach you in
44:12the next lecture, the upcoming lecture
44:14because then we will look at spinal
44:16reflexes.
44:18Yes. And there this is the most
44:20important lecture where people get
44:21confused. I believe I get confused in
44:23that particular lecture. Yes.
44:25The aim of this lecture is to just
44:28absorb it blindly. I know it is uh you
44:32know it is like a dictator's type of
44:34teaching but for now just absorb it
44:36blindly.
44:38Both the lectures will together will
44:40make a proper you know some summary.
44:44Even the next lecture, it's part two and
44:47it will complete your neuro exam. But
44:49the lecture after that is when we'll
44:52gather all the information and I promise
44:56you you will be able to function like a
44:58neurologist.
45:00Great. Discussing about uh deserebrated
45:05and deserated rigidity. Can a
45:08unconscious dog with FL extended forlim
45:11extended and high limb flexed have
45:16derebrated rigidity?
45:18Yes, absolutely. That is decelbrate
45:20rigidity. No consciousness with extended
45:24forlims and sometimes extended hind
45:27limbs also is decelbrate rigidity.
45:30Still uh today attendance was 300
45:33vinarians were there in the lecture.
45:36Even 188 veterinarians are there in this
45:39lecture right now. So ma'am there are
45:42times recently when dog with loss of
45:45appetite and limping of one leg either
45:48left or right are presented to me. Can
45:51it be classified as neurologic or other
45:54type of case?
45:56Very difficult to tell. Very difficult
45:59to tell because you have to share videos
46:01with me.
46:03Yes. And maybe all the history and the
46:05rest of the examination done, blood
46:07works done, everything is needed.
46:10Yeah. Okay.
46:12You know, we'll have to the orthopedic
46:13conditions.
46:15Yes. First of all, no longer orthopedic
46:17conditions. Yes. Very true. Very true.
46:20Absolutely.
46:21Neurovse. One word is neurovse. Uh maybe
46:25someone is describing this lecture. Not
46:28able to do wheelbarrow test. What do you
46:33told leion would be? What?
46:36Okay,
46:38good, good, very good question. Now,
46:41when you have a spinal fracture case,
46:44please do not do all of that. You will
46:48destabilize the spine. You are only
46:50allowed to do your postural reaction
46:53testing if your if there is no history
46:57of trauma. There's no history vehicle
47:00accident. There's no history of fall.
47:04Okay? Because you have a risk of
47:06seriously destabilizing the spine by
47:08doing your postural reactions during
47:10that time. Also, if the pet is in severe
47:13pain, do not do it. This compromises the
47:17safety of the patient. your wheelbarrow.
47:20Same thing. That's what my lecturer told
47:22me. If you cannot do it, don't do it.
47:25Okay? Because when you wheelbarrow and
47:27you can't do it, that means that animal
47:29is way too big for you to do it or you
47:32just don't know how to do it. Do not do
47:35it. Postural reactions, you can you can
47:38do harm. So if the pet is in pain,
47:41there's history of trauma or being hit
47:43by a vehicle or has fallen, just avoid
47:46your postural reactions. Doing your CP
47:49and hopping will give you a lot of
47:51information.
47:53Line of treatment for metronidazold
47:55induced vestibular disproportion
48:00I believe someone is facing really
48:02experiencing this case. So he badly
48:06wants the treatment right now. What are
48:08what are the treatment available?
48:11Withdraw the drug and the moment the
48:13toxicity signs set in, you can attempt
48:16to reverse it with dasopam and very good
48:19supportive care. Okay? Sometimes it can
48:22be permanent and you can't do anything
48:24about it. But if you have induced
48:26metronidazol toxicity, I feel for you.
48:30I'm so sorry. But I have seen like in
48:33metronidazol toxicity and ivormectin
48:35toxicity 90% of the cases they
48:38definitely respond in 48 to 72 hours.
48:41Yes absolutely
48:43they do respond. Uh how to differentiate
48:46shift sharington to other postural
48:49defect.
48:51Your shift sharington
48:53presents like your d cerebellate cases
48:56in lateral recumbancy but move them make
48:59them stand and see because in your ship
49:02sharington cases they are paritic or
49:04paralyzed on the back legs. Your other
49:06cases are not going to do that to your
49:08pet. You have to see paresis or
49:12paralysis with the ship sharington
49:14posture for you to say this is ship
49:16sharington.
49:19A case of twitching of the temporal
49:21reason in canine distemper case but the
49:24test kit came to be negative.
49:27What could be the differentials? Where
49:29can the le be located?
49:32I would still consider distemper. I
49:34would only consider this negative is if
49:38the CSF sample is negative for
49:40distemper.
49:42Oh,
49:42the nasal swab and the I'm sorry, the
49:45ocular swab has an incredibly high uh um
49:50false negative.
49:53So, are we going to learn how to take
49:55the CSF sample in these lectures or any
49:59videos any any video you know
50:03referential video we can see that how to
50:05take that because that is going to be
50:07one of the important diagnostic tool I
50:10believe.
50:11Yes. So you know in how in TV series
50:14they'll say stay tuned. So I'm going to
50:16say stay tuned. You must attend my
50:18lectures to find out.
50:20Definitely.
50:21Whether whether uh tuberculosis
50:25infection can cause parasis.
50:29Absolutely. Yes. Yes. Yes. Absolutely it
50:33can.
50:35Now
50:36we have collect we have actually
50:38diagnosed tuberculosis cases in the
50:40spinal cord and in the brain.
50:42Yes. Uh ma'am can be besiosis anoplasma
50:46only cause paraplegic
50:49reason?
50:50No. No. No. No. You may have cerebral
50:54beesiosis. You may have myitis because
50:57of early kiosis. But babyiosis causing
51:00plegia I highly doubt or maybe I'm not
51:03geneneralally in general. I don't think
51:05so.
51:06Yeah. And head turn in neurogenic KCS
51:12is it common symptom or is it there
51:14underlying other neurological
51:16conditions? Head turn in neurogenic KCS.
51:20Yeah. So means we are dealing with a
51:23multif focal lesion isn't it? Because
51:25then we have a head turn and we're also
51:27having one of the brain stem deficits
51:29over there. So
51:32we the lesion here is multif focal.
51:35Uh there is a question for me Dr. Vishal
51:38when would the first lecture be
51:40available on YouTube please? Uh
51:42respected uh everyone actually these are
51:45the lectures which are containing some
51:48copyright stuff from different
51:51universities and some pet owners are
51:53also there. So we discussed with Dr.
51:56Nisha and there are certain issues in
51:58those sharing those kind of uh videos
52:02and the problem is these lectures are
52:04useless unless and until you can
52:06correlate with the videos. So we are
52:08coming up with a solution where we will
52:11have a restricted entry to these
52:14lectures and definitely we don't want
52:17put them to uh put them on YouTube for
52:20free access. So wait for some time let
52:23the course complete. We will uh put all
52:25these lectures in the form of a course
52:28in our website and the entry will be
52:30restricted to the registered
52:31veterinarians only so that it is not
52:33freely available on the web. So there we
52:37only we can uh solve this copyright
52:39issue I think. So please be patient and
52:43attend all lectures and definitely the
52:45recording will be available for you. But
52:47uh we are we we are really sorry that we
52:50are not able we won't be able to put it
52:52on a free web uh link where can I find
52:56the first okay same how much effort does
53:01curvature abnormalities have on dog and
53:04how can it be managed.
53:09So discussing treatments is beyond the
53:11scope of this lecture. Again, no case is
53:14so straightforward where you just manage
53:17the case. You have to find out what's
53:19causing it.
53:21[Music]
54:02And that is the same thing. One more
54:04question is there. What is the immediate
54:06treatment when a spinal injury cases
54:08with paraplasia?
54:10Again, what's causing the plegia?
54:12Because the moment you discover what's
54:14causing the plegia, you know the
54:16treatment. So, it's I'm afraid it's not
54:19that straightforward.
54:21Now, one more uh question is there and
54:24uh this you have to answer that
54:27recommendation of gabapentin for
54:29neuropathic pain. Gavapentine is also
54:32being used for sedation of ferocious
54:35anxious dogs before bringing them to
54:39clinic. Can neuropathic pain dose of
54:41gabapentin cause sedation?
54:45Yes. Yes. Absolutely. So one of the side
54:47effects of gabapentin is actually
54:50sedation. So for pain it's ideally
54:52between 5 to 10 mg per kg twice to
54:55thrice a day. And I often tell my
54:57clients that it it may cause sedation.
54:59If that's the case, you just reduce the
55:01dose or you reduce the frequency.
55:04And for everyone's knowledge, Oryhill
55:07Life Sciences right now produces 50 mg,
55:10300 mg and 600 mg of the GAVA pentin
55:13that is available in Indian market. So
55:15if you are having any trouble in getting
55:17the vitary specific gava pentin so you
55:20can contact us.
55:23So next is uh please I need your
55:27previous videos as I miss them.
55:29Definitely sir definitely ma'am it will
55:31be available soon. Does CD nervous
55:35science man uh does CD nervous science
55:38managed ma'am? Somebody wants to ask I
55:41think can it be managed nervous science
55:44can be managed or not? CD
55:46right? So CD is mainly supportive
55:48therapy unfortunately
55:50um and uh you know so there's there is a
55:54lot of research currently that is going
55:56on in terms of actually um preventing
56:00any further neurological damage. So
56:02that's still going on. However, the only
56:05treatment for CD is supportive. Um and
56:08then with regard to the neurological
56:10symptoms, I'm afraid muscle relaxance is
56:13the way to go forward. If those myoconic
56:15tremors are a bit too much, but then
56:18again even that if it leads to a serious
56:21compromise in the quality of life, then
56:23I'm afraid our options are very very
56:25limited. However, there is some novel
56:28research that is going on in even rabies
56:30for example, you know, on how they could
56:33be treated and cured,
56:36right? And one question is can we use
56:39ammentadine in pets
56:43for what
56:44amantadine? I don't know.
56:46Um no but I I want to know why does this
56:50person want to use amantadine? Um
56:53whoever has asked that question if you
56:55can let me know what do you why do you
56:58want to use so if you tell me I want to
56:59use gavapentin for neuropathic pain you
57:02know so why do you want to use
57:04amantadine under for which case
57:08uh any unidentified shivering cases like
57:11in convulsion or
57:14incoordination moment we are able to
57:16find exactly what it is exactly
57:19giving a maintaining along with the gapa
57:21I hope It is giving proper uh
57:23neuropathic pain control as well as uh
57:27management.
57:28Absolutely. Yes. So I use amantadine and
57:31gava combined for neuropathic pain
57:34especially severe neuropathic chronic
57:36pain and it works. It works beautifully.
57:40Yeah because I am handling all wild
57:41animals. So it's very difficult to do
57:43all the type of test which you are
57:45mentioning. However, I'm trying my best.
57:47So in the type of condition to manage
57:49the situation and pick the control. So
57:51go for a and carap in combination is
57:53going better. Thank you.
57:55Yes or you can call me there doc. I can
57:58run the test for you.
58:00Exactly.
58:01Uh now thank you people are saying thank
58:03you to ma'am uh for such a wonderful
58:06lecture.
58:06Thank you so much.
58:08And uh one is uh is Korea treatable?
58:15Uh again depends on the underlying
58:18cause. If it's because of distemper, no.
58:21And here, majority of the cases are due
58:24to distemper. But if it's due to any
58:26other underlying cause, then it it may
58:28be treatable.
58:30Okay. And the last thing I would like,
58:32thank you very much everyone for your
58:36genius questions. Uh uh doc if you can
58:39suggest us any books or reference books
58:42which uh because you have already
58:43sparked the sparked the energy and spark
58:46you know people are now curious about
58:48the neurology and I believe this is the
58:52first line of series of lectures in
58:54India happening on neurology and you
58:58will be as the pioneer of in this field.
59:01So please guide us which are the books
59:05uh which can be crisp and direct to
59:07Indian Indian you know references like
59:10our Indian speakers if some authors from
59:14India or abroad in a small format if
59:17they have made something which which is
59:20understandable.
59:21Um I actually I have it with me. Can you
59:24just give me a second? I can show you
59:26all which
59:27Sure. Sure. uh we will try to find out
59:29the PDF format of that uh book and then
59:33we will make it available on our uh
59:35telegram channel.
59:37Please show us please show us
59:39one second. One sec.
59:56Thank you Dr. Visal for arranging this
59:59nice lecture.
1:00:01Thank you sir. You all are very
1:00:03enthusiastic and I believe I was also
1:00:05facing this issue in my practice that I
1:00:09was very much scared of neurological
1:00:11cases and neurology is very big taboo
1:00:15for us has been a big taboo for us for
1:00:18long but when I attended first lecture
1:00:22of Dr. Nisha and that was so simple and
1:00:25so great. So I also got you know
1:00:29confident that this can be learned at
1:00:31this stage. So if I can learn anybody
1:00:34can learn and uh that also depends on
1:00:36the speaker how good she can tell you.
1:00:40So thank you very much everyone. Doc
1:00:43please share that book.
1:00:45Yeah. So doc as of now these are the
1:00:48books I have read. Okay. Now if you have
1:00:51to if you have to start with neurology
1:00:56this is the one I would recommend your
1:00:58BSAVA manual of K9 and feline neurology.
1:01:02Okay. And it also has
1:01:05this is
1:01:05this is in PDF format. Yes. And I'm
1:01:08happy to share this with you all. So you
1:01:11have your PDF format here and then you
1:01:13also have in data or content you have
1:01:16videos. So you can see those videos and
1:01:19correlate it with your BSABA manual.
1:01:23Um
1:01:23that's great.
1:01:24There is also uh yes the second book
1:01:29which every new neurologist must read is
1:01:33the D Costa Practical Guide for K9 and
1:01:36Feline Neurology. Okay. And you need to
1:01:39concurrently combine that information
1:01:42with Luna's veterary neuroanatomy and
1:01:45clinical neurology. these three books is
1:01:48enough. If you are still into neuro then
1:01:52fundamentals of neuroanatomy and
1:01:55neuroysiology is another book that I
1:01:57recommend. And of course it's very
1:02:00important you know what are the small
1:02:02animal neurological emergencies but you
1:02:05cannot you can't understand this you
1:02:08can't uh unless you go through your
1:02:10BSABA manual along with D Costa's book
1:02:15and Lunta's neuroanatomy book um you
1:02:19also have veterary neuroanatomy a
1:02:22clinical approach so if you find lonta's
1:02:26book too complicated Then you can just
1:02:29then combine D Costa's book along with
1:02:32the veterary neuroanatomy book and this
1:02:36is what's required for the in the
1:02:38beginning and then you can you know once
1:02:40you have understood neurology then you
1:02:43can go on to read your canine and feline
1:02:45epilepsy books your CT and MRI books
1:02:49your of course other animal neuro other
1:02:52species neurological diseases
1:02:54electrodiagnostic books um Yeah,
1:03:01doc please share these books with us and
1:03:03we will help all this community our
1:03:06community with that. Uh there are
1:03:08certain uh small questions. One is uh
1:03:14u one doc was asking about the combined
1:03:18dose of amantine and gapentine if you
1:03:21can recommend any combined dose of those
1:03:24two medicines.
1:03:25Right.
1:03:27Uh are we allowed to discuss those
1:03:28treatments here?
1:03:30Uh we are allowed. If you don't have any
1:03:33problem, you can discuss this thing.
1:03:35Okay. Only reason being it really
1:03:38depends on what your clinical parameters
1:03:40are also. You can't use it on severe
1:03:43cardiac patients and you know so just be
1:03:46a little cautious with using these drugs
1:03:48if you have not screened your patients.
1:03:50Ideally your mantadine dose is 3 mg per
1:03:53kg once a day and your gabapentin dose
1:03:57is 5 to 10 mg per kg twice to thrice a
1:04:00day. Again they come with their side
1:04:02effects and it must be tailor made to
1:04:04the patient based on their clinical
1:04:06parameters. Okay.
1:04:09Right. Uh which muscle relaxant is very
1:04:11useful to treat tickness in cattle under
1:04:15field condition? Do you have any idea?
1:04:17in cattle um
1:04:19tet tetas for tetas.
1:04:21Yeah. Uh in cattle muscle relaxants I
1:04:24will need to look it up but as far as I
1:04:26know the ones that work is your dasipam
1:04:29your midazzylam to some extent
1:04:31mtocarbamol
1:04:33but these three drugs are the only ones
1:04:35that I am aware of that exists in the
1:04:37veterary market to treat tetanus as a
1:04:40for muscle relaxation.
1:04:42Okay.
1:04:42But if I'm not mistaken large animals
1:04:44they are often put down. I have never
1:04:47ever
1:04:47Yes. Yes.
1:04:48At least my my uh teachers attempt to
1:04:52treat those cases.
1:04:54Okay. And uh one is at what extent laser
1:04:58therapy will help in ambulatory
1:05:00paraparis
1:05:01cases.
1:05:03It does. So laser is anti-inflammatory
1:05:05to some it does to some extent. It it
1:05:08helps um it just helps bring down any
1:05:10inflammation in the spinal cord and so
1:05:13I've seen improvements. So yes, laser
1:05:15therapy can very much it's
1:05:17contraindicated if you suspect there's
1:05:20neoplasia involved or a coagulopy
1:05:23involved.
1:05:23I think one doctor is facing tetanas in
1:05:26dogs. So he's asking what is your view
1:05:29on tetanus toxide to be used human
1:05:32tetanus toxide can be used in dogs and
1:05:35what you can throw a light on this
1:05:36tickness thing in dogs. So we have
1:05:40actually used intrammal toxoids of
1:05:42various kinds. Um and so we see ideally
1:05:45we see if there is an anaphylactic
1:05:47reaction to the intrammal test. No
1:05:50anaphylactic reaction then we actually
1:05:52do administer the drug. Uh but I usually
1:05:55would do an intrammal test to see if
1:05:57there is any analysis towards that.
1:06:01Okay great. I think here we should
1:06:03finish our session because uh it's
1:06:05already 5:15 and all vetinarians are
1:06:08also busy and definitely you have to
1:06:10take your evening session and thank you
1:06:12very much Dr. Nisha this was a wonderful
1:06:15session again as usual and I think this
1:06:19has already ignited the slides and more
1:06:22and more neurologist will come up in
1:06:25future and we are all ready to become a
1:06:28beginner of neur neurologist smallcale
1:06:31neurologist and I hope even last day
1:06:34also I received a case that was having a
1:06:38neurological science I will show you
1:06:40with the show you the video that was a
1:06:44uh that was a uh Shihu breed 7.5 kg and
1:06:49that was having this type of wide trans
1:06:53kind of uh movement and when I saw the
1:06:57treatment done it was already being
1:06:59treated for skin infection that was a
1:07:01high dose of ketoonazole was being done
1:07:04and ivormectin dose was literally very
1:07:06high that was the pet was consuming so I
1:07:10just recommended him to ate and watch.
1:07:13And then we recommended a small dose of
1:07:16this pheninobital.
1:07:18Pheninobital we gave and we just put
1:07:22unless and until you know it took time
1:07:24to summarize the whole thing but as soon
1:07:28we put this uh IV manitol also if there
1:07:32is something to detoxify and release
1:07:34pressure on the brain and by tomorrow
1:07:37morning we saw a good improvement in
1:07:40that patient. So I think the neurology
1:07:43is a very tough thing and we have to
1:07:45rule out all the other things before we
1:07:48jump to proper treatment of uh
1:07:51something.
1:07:52Absolutely. Absolutely. No, I'm really
1:07:54glad I'm very glad that whatever you're
1:07:57able to get from these lectures and
1:07:59apply it, it means I've done my job. It
1:08:01means I've served my purpose. Hey,
1:08:03definitely you are teaching those things
1:08:05which can be applied from the very next
1:08:07day and we can correlate things now that
1:08:09these are the symptoms we learned
1:08:11yesterday lecture and what are the
1:08:13things and if we able to differentiate
1:08:15one symptom from the other symptom the
1:08:17thing I think half work is done.
1:08:20Yes absolutely absolutely
1:08:23so thank you very much once again Dr.
1:08:25Nisha and we will be desperately waiting
1:08:28for the next lecture.
1:08:29So I was just saying a big thanks to
1:08:32you.
1:08:33Thank you
1:08:33and uh
1:08:34and and all the lectures and other
1:08:36things like if some written material or
1:08:39some you know the material you were
1:08:41saying that we can take a screenshot if
1:08:44something in the PDF format or some
1:08:46lecture format we can have
1:08:48study material if you can have
1:08:50so that will also help us
1:08:52to understand things better. Absolutely
1:08:55doc. So I I'm very happy to share these
1:08:58books uh that I have. Um I'm happy to
1:09:01actually so if we can so what I have
1:09:04done previously is sort of remove the
1:09:07videos and put the powerpoints with
1:09:09their information and then as a quick so
1:09:12we started using cheat sheets. So you
1:09:16know so we can make cheat sheets out of
1:09:18these and make it into PDF formats and
1:09:20people can download print them and put
1:09:22it in their practices and refer
1:09:25it help us a lot.
1:09:28Yeah.
1:09:29Okay. Right. Thank you. Thank you very
1:09:31much.
1:09:31Thank you so much doc. I'm very very
1:09:33grateful for the opportunity and what
1:09:35you're doing is tremendous and it's
1:09:37important and uh it's only through you
1:09:40that we get to do what we do and I
1:09:43seriously want to thank you for that.
1:09:44So, thank you.
1:09:46Thank you, man. Thank you. And have a
1:09:48great day.
1:09:49Thank you. Thank you, everyone. Thank
1:09:50you for staying.
1:09:52[Music]
1:10:07Heat. Heat.
1:10:17[Music]

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