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Okay. Hello, everyone. I hope this is all share ing live. Is it all going live now? Yeah. There we go. Should be fine. Um, welcome to Asia of skis. I think we're gonna wait a few more minutes just to make sure that everyone can get in and get a cup of tea like heart down. Uh, for this evening, Hopefully it won't be too long of an evening. Um, but yeah, we should be started in a few minutes. Yeah. Yep. Tim just had the same thought as you there. That's perfect. Thank you, Carla. Okay, well, I'll just get over with some of the preamble. Just while we're waiting for a few more people, I think we'll probably leave it a couple more minutes before until everyone can get in. But just so everyone knows Hi, I'm Catherine. I'm vicepresidente of G P Society. We've also got Tim in the chat as well. He said to hide in with you all, and I won't say a huge thank you to Hannah and Catherine are two lovely doctors who are going to be talking to you this evening. It's actually been quite a ride to get this one sorted, but we hope that you'll all enjoy. Really? I think for us this is kind of more of an excuse for you guys to air. All of your questions that you have just kind of in the run up to ask is I know, you know, it can be a bit panicky, but hopefully not. And that's what this masterclass is for. Unfortunately, one of our speakers had to drop out for personal reasons just last minute. So it will just be, uh, Doctor Hannah and Doctor Catherine today, and Dr Bettes does say sorry, but she's unable to make it. Um, yep. As Tim has said, uh, this is all about asking questions. So if you can just pop all of your questions down into the chat and we'll be able to get to them after the short presentation. Um, really, this is all for you guys. So please make the most of it. And good luck with everything. I think we should, uh, so do we want to start now? I think we've got Yeah, we've got quite a few people on, So if you guys want to introduce yourselves Perfect. Yes. Hopefully everybody can hear me OK as well. Um, and thank you. To Catherine and Tim for for organizing this. Um, So, yes, I'm Catherine, and Hannah is here as well. We're both and ct once and probably still not used to being called doctor. Or maybe that's just me. Um, but yeah, here to talk a little bit about oscopies. Um, I guess, um, at the start, just a couple of things. Obviously, we don't know what's coming up. We're not in any way affiliated of queens. And we don't know all the answers night for our our answers. The perfect answer. But we wanted to go through a kind of a few examples of some of the common types of all ski stations and how you might approach them. And I think the reality is you guys, by the time you got to final, you're you're good at all skis, and you know, you've done the the exams before. Probably still feel you. You have that bit of dread if you're anything like me, I don't think there's anything like anoscopy for that kind of sympathetic response. Um, but at the end of the you know, you do know what you're doing and it's following that format to get those, um, those tick boxes ticked off, and really a lot of it is, um is about that kind of tick box exercise. Um, so I guess the kind of if you think about it when you break things down, what are your off skis out there to S s. So it's looking, um, at your different kinds of skills. So history taking which you've been doing, you know, since first year, communication skills and counseling, your examination. And then I guess probably the difference more coming into you Probably noticed this in fourth year, but especially, um, in finals is really that kind of shift up to getting you to data interpretation. There will be, you know, different forms, you know, kind of medical paperwork sitting around the stations that you'll be looking at. You might have results to interpreting things like that, and they might ask you to do some prescribing. And I guess everything is is that some of it might be your kind of knowing your your first steps in emergency management. Um, So what we're gonna do is chat free, free, different Noski stations, okay? And and just I guess how we might think about approaching these. Um, well, you know, please ask away questions, put them in the chat box, and we'll chat at the end, Really happy to help in any way we can. And, you know, just ask the questions now, because this is the time to do it. And and hopefully, if we can help with that, we will. Um, So I'm going to hand over to Hana. Okay, Gram. So the very first, we've kind of done this in a couple of stations and, um, try to simulate instructions that might be something like you would see outside the station. Um, so this particular example is you're an f on on your care of the elderly rotation. And Mavis Smith is an 83 year old lady with Parkinson's disease. And please review her chest x ray and answer the examiners questions. Okay, so hopefully you'll go into the station, and this will be appearing on the wall, hopefully big enough to be able to see it. Um, And, um, what we're gonna do is sit, sit, sit for a second and have a look at it. Try not to panic. Take your time you've got loads of time to do interpretation in a station like this. And then once you're ready, the very first thing you're gonna do I don't know if I can control you. Probably. I'm sorry if you're gonna start with the same sentence every single time, even though you really, really just want to get almost, like at the chest X ray. But it's really important to get this bit right. And this is where you pick up marks. So you describe what you can see. So this is a P a chest X ray. It's an erect chest X ray of me a business. Her health and care is this. Her date of birth is this I was taking on this day at this time, and I would like to see if there's any previous imaging if available, and that's what you do in real life as well. Next thing to look at is technical quality. So you've probably heard the pneumonic a ripe before, but it is actually really useful to have a little work through, and and I would make it really obvious that you're looking at technical quality when you're in this station. So you're gonna say I'm looking First rotation on the chest section We were looking at the medial ends of the cackles in relation to whether the spinous processes are, um, and your comments on that you want to make sure that this is, uh, adequately inspired chest X ray and I make a good show of county nine Ontario chest ribs and this exams you're looking for sort of six complete, um, anterior chest ribs. And but you can see your whole way down like penetration. So this is kind of where the radio over comes in, but you should be able to see and the verbal column through the cardiac shadow and then extend. So you're looking all the embassies all the way. I do kind of tubal the stomach, but got a frantic angles are what you need included. If that's not there, ask if there's a second film and they might produce one for you. And once you've done that, you kind of have two options. It depends. Maybe if you see something straight off, and if you see something which is distracting you because you really want to comment on it, I would go ahead and do that and say the most obvious abnormality is this. If you don't see it or it's not your style, that's fine. It's time for the systems, and you work through a B C D. Like always. Um, I'll look at that right comment on whether it's central or not. If it's not, check your rotation again, because normally that's probably what it is if it's not rotated and the airways moved or it's irritated a little bit. But the airways still isn't where you'd expect it to be. Try and figure out if it's being pushed or pulled, and you'll become a kind of you can get some clues and not later on as well. And the other thing is to make sure that there's no massive sort of masses or anything that should pushing into the tricky and making it look abnormal in terms of its side line. Um, and then kind of naturally worked out into breathing. You kind of follow the bronchi down. Well, I think zones is usually the easiest thing to comment on whether things are symmetrical or not, whether there's opacities where you'd expect them whether and things more Lucent than you would expect to see and just you don't have to use fancy words. You just describe what you can see. Um, and all these the puzzle kind of come together, and I would also have to look at highlight so they should be roughly the same size left to be higher than right. And that can also give you clues times. And you're looking at cardiac shadow. Just remember that they will want you to know that in an AP you don't just announced that you can't comment on the size of the cardiac shadow. And if it's a PA, I would sit and try and work out. And you ask if they've got a ruler, they'll probably produce one. And if you really aren't sure whether you got 50% or more than that and kind of have a little look around heart size as well, just in case you say that the shape isn't quite right or the aortic arch is very prominent or unfolded in any way. And sometimes you can see really obvious, um, kind of aneurysms on a chest X ray as well. And diaphragm is an expert, so you should listen before right side of the left. Sorry. Before we start on the diaphragm, we've had a little message about your mic, so I can hear you. Fine, I think. But maybe there's something a little bit wrong with it. Is there any way that you can kind of unplug? It will be okay. Or is it in your computer? It's, uh, okay. Uh, yeah, it's coming going a little bit, but I think we can I can still hear what you're saying. So I think that should be fine. Just to let you know I haven't got a huge amount of options there without. That's fine. I'll just try and move a little closer. Almost. Yeah. Okay, So diaphragm right should be higher than left and have a look for a gastric bubble. And there's not always one, but they're often this one just hiding under left and hemidiaphragm and really important to comment that there's no signs of any free air. Um, it can be quite subtle. And I have a really close look, um, and and then the other really something and is to have a look at cost around again, cause which should be really sharp and pointed. And if they're not it's really worth important. Commenting on that and then e is everything else, and there's quite a bit under everything else for a chest X ray. Um, I have my system and everyone does as well. But I tend to start with bones and I work my way of the world down from capitals and I look at all the ribs. It's really easy to miss a test like a fracture of a rib, and and that's that's fine. But official thing of this sort of space, you would be expected to spot it. Um, other things will notice that sort of soft tissue changes, particularly breast tissue. Um, if there's an asymmetry in terms of what looks like lung fields, I would always have a weight check if it's a female to make sure they haven't had a mastectomy on one side, because that's the sort of thing I'd like to try and catch you out on as well. Um, other things to look at kind of artifacts on top of things that could be clothing. It could be hair, It could be piercings and look at kind of where it is and what you think is going on and then the next kind of big category of things are medical things. So bits of tubing lines, monitoring equipment. Hopefully, you're seeing what most common types of things are. When you see people in hospital, try and think through anatomically where it is and what it's likely to be doing. If there's any clinical information given that also usually helps a little bit and hopefully be able to see that I know that's very small, but hopefully get bigger on the next slide. Um, there is a line on this particular chest X ray. Um, and you Hopefully we also notice that's an N G tube and, well, okay, well, talk. When I was in medical school, I think I have gone a bit better now. And but there's a really specific way you check it. An N G tube is. I've got on a chest X ray, and and this is the phrase that I use and have always used to document whether an N G tube is in the correct position and it's kind of four criteria you have to meet. So I would literally sit entree, stone, the n g tube and say, Look, it's dissecting in the midline through the diaphragm bisects the carina on the way down, and that deviates to the left, and it was clearly visible under the left hemidiaphragm, which would correspond with being in the stomach. And you say I want I want to measure from the tip to the gastroesophageal junction as well. And and that should be sort of 10 centimeters on the screen. And you then summarize back. I would really it's really worth practicing, summarizing both histories like essentially everything and and image interpretation because really, you want to sit in one sentence. So to summarize, this is an erect just actually made the Smith, which reveals no acute pathology, but there is an anti tube in place, and it appears to be in the correct position. The Examiner will probably have a few questions for you because this is finals. Um, the nurse asks you if they can use the N G tube. What would you say? What other method exists to confirm N G tube placement? Can you explain to me how you met your aunt? Insert an n g tube? Um, so the first question can they use the anti tube? The answer is yes, this is in the correct position that can go ahead. What other method exists to confirm? And so that's aspirating for Ph. Most trust the policy is a pH of less than 5.5. Um, and most of the time the nurses will not be able to give an anti feed without that, unless you have just confirmed that it's in the correct position, and then in terms of how you measure and put an end YouTube, I mean that could come up as a part of a station. Actually, to do that, it only takes a minute or two, so I could easily do that. But you're measuring from nose around the back of a year, which is the and to the safety sternum, and you take that measurement, and that's where you want to insert your anti tube into and kind of steps. Why, it's kind of quite straightforward. You're gonna consent the patient. That explains why they need the anti tube and not obviously, there's a few indications for anti tubes. It's worth having to think about why somebody might need one and the differences and consent for that and working through culture indications So there's absolute things in terms of trauma to your face, particular Max facts stuff or basic skull fracture and then more relative things. If somebody is known to have a bit of a coagulopathy, and if they've got a structure in their esophagus or they've got, um, other esophageal issues, it's maybe not the best plan. Um, but it obviously depends on the indication, and whether they really need it, Um, and put it in the N G. Tube is simple enough. A little bit of lubrication patient did not look at you really important to get them to work with you while you do it, and then straight back and as far as you measure it, trying to get them to swallow with if they're able to and and you can offer them a drink as well. If that's something that's safe for that patient, um, you secure it and then you confirm that that's in the correct position, using one of the two things and then you document kind of, exactly as I said, Repeat them on paper. And the documentation is really important for N G tubes. Um, and it's something that's definitely come up before We've got a couple of X rays just how we look at just in case you haven't seen what can go wrong with an energy chip. So giving something down an energy tube that's in the wrong position is a never event, and having an N g tube itself in the wrong position is not a problem. The important thing is that you catch it before anything happens. Um, that's kind of one of the really important reasons to make sure you got definitely got the correct test actually, that you're looking at. Um, it's incredibly easy to get caught out. Some of these patient's um so here. We've always got one on the left with an N G tube that's gone down into the right main bronchus, and that's in the lung. And so that would be a disaster if a patient got fit during that energy tube and the middle one, we've got an N G tube that's gone down in the right place. It's gone in the stomach, and then it's done a loop and it's on its way back up. So if you already use that n g tube, there's a risk that certainly the patient's lying flat, they're gonna have aspirated through their energy tube. Um, the third one. Hopefully, you'll see there's a big see in the end of that n g tube. So it's actually going around the jadine. Um, and so that, to me, is like an N J tube, which is not what you've intended to do. Your pH is are not going to make any sense. Um, and and if the patient doesn't medically need that, that's not where you want it to be, so that needs pull back by a fair bit. Um, yeah. So those are the kind of three ways that things can look like. Um, so just to make sure everyone knows to run through when you're looking at an X ray of anything, you're going to do a who, what, when and where of what happened with this X ray, you can make sure it's technically usable. Some of them aren't, and you need to get more, and that's fine. I would usually do the most obvious abnormality if you see one. If you don't, don't worry and then systematically work through it. So chest X rays are the most likely thing to come up because there's so much that you can see on the chest X ray. They have given abdominal X rays. There are a few different pneumonic some people use for Abdo X rays. Um, this one that we've got here. Is it kind of easy to remember? So A for air, Is it where it's supposed to be? Is it where it's not supposed to be? Be looking at boil terms, cheap size, diameter. Um, any concerns in terms of the wall? Um, days for for dense things sort of got bones like a classification and it clips or anything like that that you can see um oh, organs the soft tissue things you should be able to see kind of where liver, kidneys and things like that are might not get a huge amount of detail on that, but you'll be able to get rough idea, and then X is sort of extra things on top. So that's again all our medical equipment, um, lines, artifacts, um, anything else, Which is not where it's supposed to be, um, with joints and bones not as common in the city and of skis, but alignment, bone, cartilage, soft tissue. If they find a problem. You'll you'll see it if you work through the system. And then it's really important to have a good way to summarize back. Actually, what you've seen and on an X ray and what the implications of that are, Um it might be that you can't see anything, and that's fine. You just report back that this is a normal chest, actually, um, and and kind of the main areas that you've looked at because, actually, if you're able to summarize your findings even if you haven't got it right, you get marks felt too. Yeah. So, um, I guess moving on the next thing we wanted to think about was a kind of history taking, um, station. So you're you're guaranteed that you'll definitely have a few histories to take, um, during your finals and and so, you know, if you're outside the station and this is the the blurb a half. So Mrs Brown is a 67 year old woman who has come to respiratory clinical shortness of breath. Your instructions are to take a history and then interpret the investigations provided and answer the examiners questions. So I guess I think one of the things is to try and make use of that minute when you're outside. So you've got a couple of clues there, so she's come to a respiratory clinic and shortness of breath. So just be thinking in your head, right key things in a respiratory history, What do I need to take off? And it just gives you a little bit of time to start thinking through, you know, have your you're always going to start with your same things, but knowing the things that you need to take off during that that station as well. Um, so you know your general approach. Everybody's You know, you've been taught to do this since first year, and I know everybody can take a good history. So you know just all of your things again to take your boxes introduction. Wash hands, consent your open question to begin. Everybody's got something that rolls off there, their tongue. You know, whether that's what's brought you here for today, or how can I help you? Or but just make sure it's a nice open question. And as difficult as it is an Oscar, you get marks for giving them that kind of uninterrupted time. to tell their story can be really difficult when you've got 50 things to take off in your head. And we've all been in a Noski with a really chatty, simulated patient and absolutely some point you might, you know, need to interrupt. But a well trained, simulated patient should kind of, you know, talk for 2030 seconds, give you a couple of things to pick up on. And it's a good way to start. And it just shows that, you know, you're an active listener. You're letting them tell their story. Just make sure that you explore it symptoms. So this is a respiratory history. So, you know, you want to think about cough, shortness of breath, sputum, hemoptysis, chest pain ways, you know, And just make sure that in your head that, you know, you know, if this was going to be a G I history water, the things that you need to cover and that you just have those kind of so they'll trip off your tongue. Um, I think generally in on skis are quite good. And you can kind of say, um, you know, I would ask about systemic symptoms and often, you know, they will tell you to, um, you know, to to move on and not do your your complete systematic questioning. But at the same time, I think there are a couple of things that I probably do ask in nearly every history. So just wait energy levels. You know, things like that shows that you're thinking about this patient and kind of their whole setting. So that you, you know, asked a couple of things temperatures maybe as well. And then just your other bits of your your history. So make sure you've asked about drugs, allergies, your past medical history, your family history. And I guess in this situation is particularly in social history, you're always going to have smoking, um, and alcohol. But make sure it's respiratory. So it is that place where asking about pets or animals and what they do, they do. You can be particularly relevant. Um, so this is our kind of, you know, history of somebody who's come. So I'll just read, read it free and have highlighted in in bold, important things. So this might be what you know. This simulated patient has. So you're 67 year old women. You've been referred by your G P. You're quite worried about what might be go have gone wrong. You've been a bit short of breath for a long time, but it's getting worse. You get short of breath walking up the stairs or to the end of your driveway. You've annoying, dry cough you've never smoked. You'll see there that the answer to a lot of those questions is no, and often that will be the case in a Noski. But you've shown that you've asked them. You know, you tend to be tired, and you've never been someone who puts on weight past medical history. There's something to do with your joints. You think it's called rheumatoid drug history, which is not really sure what they all are. But there's one called methotrexate and then social history and, you know, so they're retired. Used to be a teacher nonsmoker, and they've got it. They've only got a dog. Okay, and then so you might have taken that history. And then you get to the end on the Examiner, hand you something, and I guess I think anything that you're handed again go back to those basics. So I would just say it gives you a little bit of time as well. Take a couple of seconds to look at it and say Okay, so I can see this is a spirometer is result for a brown date of birth, health and care number. And this barometer is performed whenever and again just scraped by you that little bit of time. And, you know, they should always give you the predicted value she can't interpret. Um, spirometry reported. And then you've got your results there. So you can hopefully both. I'll see that this lady's f E V one and the FEC are richest, but her ratio is preserved. Um, so you know, again, just what I've said. So you're going to comment on the results? Just as I've gone through you get marks for saying F E V one f u z are decreased, the ratio is preserved. I think that this is a restrictive pattern. Okay. And then they might ask you a couple of other questions. So what imaging investigations would you like to request? And you've hopefully got to the stage you're thinking Okay, So this is a woman with rheumatoid arthritis, and she's on methotrexate. She's got a dry cough and restrictive spirometry. So you're wondering about pulmonary fibrosis, and you're kind of gold. Standard investigation, for that is a high resolution CT chest. And although obviously getting a chest X ray will probably happen along the way as well, and and then if we're thinking about that, just know in your head it's one of those things that you know. Your classical examination finding is those fine end inspiratory crepitations, And it's just something that if it trips off the tongue and you know when it's there and to answer those questions, um, so I guess when we're approaching history stations and hand and I kind of thinking about what are our top tips? So make sure that you started with that open question. Do you know it's really, really difficult You want to jump in, but give them the time. Make sure you don't ask questions in a negative way of, you know, no cough, no shortness of breath. You know, just say any cause any shortness of breath. It's still quick. It won't it. You know, I know there's that kind of time pressure under it, but you're not leading the patient and they really will, you know, pick up on it. If you're saying, you know none of this, none of that because, you know, it's technically harder for for a patient to disagree with you and make sure you've thought about all the associated symptoms and you need to cover. And I think that is just taking that minute. You know, when you're out there, if you can work out what kind of specialty this history falls into, think about what other symptoms you need to ask about and make sure that you've covered all subheadings. Um, I genuinely, fairly early and medical schools. Sakhnovski couldn't work out why I had finished so early and then realized a minute left. Of course, I haven't asked about past medical. I've only done the history of presenting complaint. So don't don't be like me and make sure that you've asked all those subheadings and it was definitely the quickest rest of the history ever. But just make sure that you keep yourself collected, and I've asked a few questions about them, and I guess the reality is if you're in a history station and you're like, I really don't know what is going on I need more information to try and put together and work out what's going on. Do just start with your systematic questioning and, you know, and hopefully you'll get somewhere and you'll show that you've got a method and you know you're doing that systematic inquiry, and it is always something that you can fall back on. And so it's history taking okay back to me. Um, so we've kind of done interpretation of something we've done. The mystery taking and the last thing we thought we would focus on is kind of communication, because, actually, I'm sure you've noticed. But it's become a much bigger thing that you've gone through medical school but communication. And the reason for that is literally that we We spend Catherine, uh, most of our days actually communicating one thing or another, whether that's giving information, counseling somebody about something or other. It comes into everything, and it's something that you will get much better at as time goes on. But it's nice to have a little system for how you go about doing things, and this is very much personal to how I go with doing things, and it's not the same as yours. That's okay. But I quite like it. And And we thought we'd chat through what is probably quite a complex thing for finals for communication. But it kind of captures quite a lot of what they kind of like to focus on. And And I always think it's good to prepare for the worst case scenario, and then that would be better than that. Um, so this station is you're an F two doctor working in general practice. Please. Council this 48 year old lady, Mrs Smith, about HRT. So you're gonna open the consultation like a wise you're gonna wash your hands. In the current climate, you're going to put on it burn and gloves, Um, and you're gonna come introduce yourself to the patient with your name and your role. You wanna confirm who you're talking to and date of birth? And that's really important when you think about why we're here for this particular consultation and patient might start talking at this point and explain why they're there. But it's always used to make sure everyone's on the same page and and an Oscar and in real life, just to explain why, why you were expecting to be there or to just check why you're here today. Um, what were you hoping we would discuss today is a really nice way to open that up. Sometimes if you've got somebody who isn't gonna necessarily promptly give you all this information, which is what you need in a Noski and and then you try to get them to open up a bit more. So this is kind of your fact finding. Why are they actually here? And what way do your symptoms affect you? And let them do their 30 seconds of talking About what? Why they come to the doctor. And then there's a few things that are really important to clarify. And with your symptoms. Obviously, people get HRT. So you're talking about hot flashes energy, but their skin talk about mood. And if you get something which is a low mood, it's really important to do a little a little risk assessment screen when you get to it. Um, talk about bleeding is really important. So you want to know if they're still having periods? When was the last one or any unusual bleeds that are happening? Anything abnormal? Um, anything that's changed um so you kind of done a little bit of an indication screen as that part. And the next thing you have to do is to make sure there's no contraindications, because actually, there's no point going any further, Um, unless they can actually have it. So sometimes you have to stop people on the tracks, and they actually before we talk any further, can we just check that you haven't got any other medical problems which can interfere with this? Um, are you on any regular medication? Have you ever been in hospital that sort of screen and and then this list of questions. Unfortunately, you just have to kind of learn off a little bit. Um, you need to know if they've ever had a clot in their leg or their lung or anywhere else. Um, they've got a history of stroke. If they've got history of liver disease, if they've got liver disease, what type of liver disease, and have they ever had any issues with chest pain? Remember that women don't necessarily present with cardiac disease in the same way as men as well, and this is something that's increasingly recognized. And if they're talking about chest pain. You need to try and dial into that a bit and really important to know if they still got a woman if you've ever had breast. And I can, um, endometrial cancer. Um, and to make sure that they're definitely not pregnant, um, as well, um, I often do it like an ice. At this point, I don't know whether anyone has actually gone through with you how to do an ice. Well, um, you just have to get a way that you're comfortable asking it. So Ideas. It's kind of What have you heard about this? What have you heard about the HRT? What? What do you know about it? Do you know why people take it? Is there anything that would worry about taking HRT? And what do you think that HRT could do for you? Because actually, expectations are not necessarily what medication can deliver sometimes. And then that's your moment to say. Actually said Okay. I talked to you a bit About what HRT is like. Anything specifically you want to know? Um, if there's something specific on their sheet, they will ask it then and and then this is kind of how you talk about what HRT does. So this is where it comes into being able to explain anything medical in a way that is not medical. Um, so when you're talking about HRT, it's good to start chatting about. The menthol is really so you say Bye ovaries of stop producing eggs. As a result of that, those reduced levels of the hormones estrogen and progesterone, the female hormones and in your body. And that means for some people that can have symptoms when they get hot hot flashes. And they have a general dryness and the longer term things like weakened bones. Um, NHRT works by replacing these hormones and with the name of reducing the symptoms and the health problems associated with menopause. It's worth thinking about indications here. So a lot of people take HRT for symptomatic relief and where the risk benefit ratio is favorable. Um, there's also women who take it because actually, they had a fracture, which is osteo product under under 60 and this is what they can't have other treatments. So this is what's recommended for them, so you could have different circumstances as a reason for presenting. Um, you need to think about short term things. So this is symptom relief. Um, flushing energy levels, middle ability, things like that. But gentle dryness and then longer term. There are benefits in terms of reduced risk of thin bones and colorectal cancer. Um, but in turn, there are risks as well, because there's risks to everything that we do. Um, and the risks that are important to talk about are sort of stickiness of blood and increased risk of clots, and they need to know what that could present, like so in terms of the DPT or, UM P um, there are increased risks of stroke and heart disease, a slight increased risk of breast cancer, endometrial cancer and ovarian cancer. And the risks are very small, and some of them actually only last administration of your own HRT. But some of them do confirms that increased risk after as well. You can also have side effects, which are, um, more benign things. But some people can be troubled by breast tenderness like cramps, and they may have bleeding, and particularly if they're on a cyclical and make sure that's to be expected, they should have a bleed. Um, and some people think that actually start feeling that don't bleed. That's not what happens. Um, and it's really important. People know that, actually, they might still need to use contraception. So the lady who presented in this story is 48 so she's under 50. She would need to continue contraception for two years, and after her last period, if she was over 50 would be one year. The last thing I kind of talk about is practicalities of what we're doing with the medication. So HRT comes in lots of formulations, but usually you start with a tablet and kind of see where you go and you can go from there. Um, if it's under one year since the last period, you're talking about psychical combined preparation more than one year, you can do continuous combined preparation. If I had a hysterectomy, they can have estrogen only, um, HRT. And usually what ends up happening is you give a trial for a few years to see if it relieves symptoms and then you try without, um, anything. You see how you go at that point and there aren't really many alternatives, actually, for symptoms of the menopause, apart from HRT and I don't think you'd be expected to talk about them and so I wouldn't go there. So, uh, counseling sessions can be really hard because they can throw basically anything. Actually, um, and what I would say is that it's almost worth thinking of the things you definitely don't want to be asked about things that make you feel uncomfortable or you don't aren't quite sure how to explain. And those are the ones to prepare for because easy things will come to you. And that's fine and but kind of important things in terms of big diagnoses like Addison's disease and things like that. Eczema, things that come up all the time are worth having to go out and then things you don't like thinking about as possibility, I would think are worth the practice to, um, I would get really familiar with using ice or something that you like like that to make sure you are asking all the questions that the similar to patient wants asked. You'll get loads of marks for doing that. If you do it well, um, always check that you've answered all the questions, asked them, like three times, like in different ways, just to make sure you've got all the marks, because actually, in this sort of station, generally there's several marks for each question. Um, the patient has and they usually have at least two or three, um, offer information leaflets. There's one for literally everything. There's no risk in saying that you can print something out from somewhere and and kind of resisting the temptation to use medical jargon, especially when you're anxious. It can be really hard, but it's important. Um, and you kind of remember you're aiming for something if somebody who might only have an educational level you know of, um, early, like secondary school. That's the kind of level you're aiming for, somebody who might have no understanding of any scientific principle ever. Um, and you can't go wrong if you do that. Yeah. No, I guess just, uh, off the back of what you're saying about the counseling stations. Um yeah, I'm I think so. We coming up to our finals, we had gone through a lot of different ones, and we did have we had quite a lot of counseling in our final. So as Hannah mentioned, So we had eczema, um, in a child we had Addison's disease, which was partly a data interpretation. So when you're just, if this is useful, When you were outside the station, they had a uni and it must have been a course all as well. Uh, and you had to work out what you thought the diagnosis was and then council a patient on it. So that kind of brought in a whole load of things. You know, if your steroid sick day rules and everything like that. And But I guess one thing I don't think that we've ever thought about preparing was our office in Guinea endocrinology station was preconception diabetic counseling. So it's a type one diabetic. You had a very high HBA one C. But if you and I think I must have asked that patient about, you know, 20 times if they had any other questions, but and I think that but they do they ask you the questions that you want to answer. And actually, you'll be surprised how much knowledge is in there and that you can answer their questions. And if you make them feel comfortable and yeah, I'm a big fan of leaflet. I'm working in GP at the minute and I give everybody leaflets. And actually, to be honest, one of the ways that I do actually go through HRT or some of the contraception with patient's is by I print. I have leaflets that I like and I print out. And I'm like, Let's go this through this together. Um, you know, because I think that's also the leaflets are not something that you can necessarily do enough Yassky, but are laid out quite nicely. Um, so I guess we've not talked at all about examination stations. Um, you like, you just need to practice examinations and do things as you're meant to for the of skis. So, you know, making sure if you're examining lymph nodes that you go around to the back of the patient, you know, just making sure that all of those things are done. How queens want it. Um, obviously, everybody's situations are different. We, um, looked a group of us who were friends between written and Kaskey finals, uh, you know, kind of had sounds very sad, had this kind of boot camp on north coast, which did involve food and beach walks, but also involved practicing a lot of our ski stations on each other, and I think that is that's really what you need at that point as well. I was just getting practice with each other. And, you know, all of the basics. All of you can take a history, do an examination and all of those kind of transferrable skills that will stand you in, you know, in good stead for lost keys. But I guess for the kind of general on the day, um, are kind of thing for for how to do it is, you know, right. Make sure you've taken to a deep breath. Settle yourself, Read the blurb carefully. Um, you know, it will tell you what they want you to do. It might say wherever they want you, you know, to take a focused history. Or it might say, particularly what they want you to examine. So just make sure that you've read that carefully, and we all know of adrenaline. God, Roy, that's not a good thing. And, you know, for your kind of performance to take that minute. Remember all of those basics. If you've gone in, you know, wash your hands consent confirmed the patient identity, you know, that gives you 10 seconds that start to settle yourself. Know that you're getting the marks for that. I guess. Just try and approach everything with a framework so ever that's your examination with your inspect pulpy It percuss, um, auscultate or you're kind of joints with Luke feel moved Special tests. You know, you'll have something and again for your histories and your counseling. Just have something so that when actually, you know, you are stressed, you can fall back on it. And I think that in reality, that stash in good stead when you're working as well because it's all of that that you go back to your routines and your frameworks and that you have and make sure you're nice to patient. Um, you know, smile, be very nice to them. They are marking you as well. And, you know, make sure you learn to the other thing is like learn a way to interrupt people without being rude, because sometimes you'll have to Actually was just thinking in our finals we had a similar patient. My similar patient was very, very good, who was manic and had pressure of speech, and it was really difficult. But you're very conscious of your time and how much you need to get through. And actually, we didn't have time to talk about how nice my shoes were or how do the sky was outside and which is what they were trying to do. Um, and actually, you need to have little ways of how you you managed to slip in your questions and stop them in the trucks. Actually, sometimes and which I do an awful lot, actually. My work, unfortunately, um, polite ways to a drop People is a skill. And I think the thing is as well, you know, when you come out of that station, the way our brains work is to try and replay what's gone. You'll walk out the bell, the bell will go and you'll remember. I didn't say that or I didn't say lover, but try Easier said than done. Take another deep breath. You can't do anything about that one now, but you can do something about the next one. Um, you know, so just kind of take take that moment and, you know, and there was a couple of seconds deep breath, really standing, uh, in good stead for the for the next station. Um, so I think that was kind of all that we had formally prepared to talk to you about. But please should any questions about editing, You know, we were finally years not that long ago. And if there's anything that we can help with, um, you know, or it wasn't clear. Um, please, please ask. Yeah, I just want to say thank you so much for preparing this and for having to talk. I'm sure everyone really appreciates it, and I just want to say and yet please ask questions. So even if they're not related with the specific stations that were mentioned today, if anyone has any questions at all, this might be your last opportunity just in the run up to ask them. There's no such thing as a silly question, especially at this stage. And you'll be surprised how many people were asking the same question. Uh, so we have one question here from Melinda, so she's asking if we know any resources where we can get a good idea of the conditions and treatments that may come up for counseling. So do you guys know any resources? I guess there's always those websites out there, which I'm sure you all know, like Gigi medics and things which will have sort of specific counseling pathways to work through for some things. And some of the Oscar books do have sort of a sections and counseling with common things on them. The problem is that actually, they could ask anything. Um, and I believe Dr Colin is still in charge of finals, and she quite likes the idea of crossing demeans of different things together, which I think have made finals a bit more of a curve ball in the last few years than they were before that, um, what I quite like to do and before finals was using, like patient dot org dot UK has got lots of things, even for inspiration of things to work through as, like, broad categories. Um, because really, actually, for communication, your options are to explain a diagnosis, um, to counsel about a treatment or consent somebody for something. Um, you can have a sort of bit of a diagnosis slash bad news type thing, thing going on and conversations with relatives that are difficult. Managing lots of emotions kind of tends to come up and really, that's actually the scope of what they can ask you to do. Um, a lot of those sort of ladder things were about getting the person you're with to open up and talk about things and calm down. Um, unless actually about you giving information. So I think that's probably less likely, because actually, they're kind of trying to test knowledge and interpretation and communication all at the same time. What do you think, Katherine? Yeah, no, I think definitely the kind of, um, the combination of specialties is definitely something that goes on. Um, you know, we Yeah. The askey stop looking stuff does have good, good ideas of things. And I know people. There's certain things that people do talk about, you know, coming up. And that might come up. I guess if you feel that you've practiced the I think Hannah's advice of practicing the common ones. And if there's something that you're going Oh, goodness. Imagine that came up. I wouldn't know what to do. Do you know what, uh, sit down with even just of a piece of a four paper and and think through it and and try and think through it? under, You know that kind of headings that gives you a framework for how you're going to how you're going to talk to a patient about it. But I think in no set, I think counseling stations, the patient will have nearly more questions than I do in a lot of things. And so if you are really you know, if you're stuck, you actually can't go far wrong by just asking them. Was there something else you were wondering about that? Or, you know, I'm just making sure that you're using the the kind of ice framework as well. As I guess the reality is that in our day to day, people ask random questions, and sometimes you actually just have to rule that you get through it in the end and it's all fine. I think one other thing I'd have to say on that is, um, on the med portal, they also have and the rundowns of previous, um, final exams. And so it might be worth having a look and seeing what other counseling stations have previously been done. How well they've been done, was it a counseling station hasn't been done too well by a previous cohort. Then they are likely to recycle those, uh, potentially. It might be a good place to start. I've definitely find um So we've got another question here from Emma. And do you have any examples of how to politely interrupt? Um oh, I guess I don't know. Some of them may be. Don't transfer well out of the when you're at work, you can use it. Well, I think in general. So I apologize and saying, Oh, I'm I'm very sorry to interrupt. Um, you know, sometimes I might say, but I want to make sure that we're getting to the bottom of what's brought you here today. Um, you know, and then try and ask some of your you know your questions. And I guess in real life, you probably do often say, because it's true. You know, I'm really sorry, but I want to make sure that we've dealt with what's brought you here today. But I need to be fair to my other patient's here. Waiting as well is something that I kind of end up maybe saying a little bit in GP. Um, but I think in general, if you have acknowledged that you're interrupting and apologizing for it. But just kind of gently saying, Would you mind if I asked you about ex? Um, I don't see how they could mark you down for that. Or sometimes it's a case of, actually. Can we go back to that? Because I just want to make sure I have things clear in my head and you make it very much. Oh, this is I'm confused. There's nothing to do with you. Um, people tend to respond quite well to that. That's perfect. I think we've got one more question here, Uh, about introducing yourself as an F one or an F two. I think we've actually got some confirmation from G P Society. So we've had an email from, um Cathy Cullen. Just in regards to, like, some questions that we had in our mini Markowski is that we're, uh and so actually she did. She does recommend that you do introduce yourself as a doctor and not a medical student specifically for finals. That would be the kind of recommended, But if it does say on the outside of the station, you're completely fine to go with whatever is said on there. But if you're not given a specific role, then it would be encouraged for you to introduce yourself as a doctor. Yeah. Can I just jump in on that, Catherine? So just for everybody, um, Cathy Cullen got back to the G P Society following a little bit of feedback from one of the Oscar examiners last weekend. Um, and Doctor Cullen has said that in finals, uh, the stations will be written. You are a foundation doctor in such and such, Um, that's in contrary two years, three and four. Um, where it says you're on placement then. So they actually encourage us, um, to introduce yourselves as a foundation doctor or junior doctor or, you know, whatever variation of that tickles your fancy. Perfect. Well, if does anyone have any further questions for doctors? We think we've got just a couple minutes left until we've, uh, decided to have it out for tonight. I'm sure everyone has got different things to do with their evening. Right. Well, if we don't have any further questions, is there any kind of wrap up statements that you guys want to say or we should relieve it there? No, I think just more to say good luck. All the best. Um, and certainly if you come across Hannah, I either this year while you're students or, um, next year as colleagues. Um, please introduce yourselves. Look forward to to working with you guys. Um, so yeah, yeah, you'll be fine. It will all be grand and no finals. It's It's fairly. It's really stressful time. There's a lot going on. There's a lot of change happening, and they do really pile the pressure on. Um, um, it's tough, but it will all be fine and you'll get through the other side. And then life will be a bit more like what, what it's going to be like at work, and it starts to get a bit more fun. Yeah, I'm just saying there's another re questions coming about the Oscars in hospital, Um, which is now back. And I don't know, Katherine want to say I did my final third day in Antrim Hospital, and actually, we had a great time, and the hospital tends to be really, really good to you, and we'll provide snacks on all sorts of things and and they do kind of take on like, personally, it kind of feels like to make sure you have a good time. I guess the reason why they have got patient's there is these are gonna be patient's with pathology or with a really good history. Um, you do tend to run into more issues. I was running over time, and actually, they want to tell you about their 50 year history of something, and you really don't have the time for that. And and I guess that's certainly when I find myself having to move things along quicker than in a proper simulated patient setting. Um, and obviously, you're going to try and find signs when you're examining people. But they should be things that are easy to find. They're not going to choose something, at least subtle. Um, and there should be clues in other parts of the station as well to kind of help. You know what you're looking for? Yeah, I think, um, I think absolutely echo what Hannah said about the hospitals. Treat you really well. I was an alter Galvin, and we had Percy pigs that are rest stations, so, you know. Excellent. Um, good feedback for queens would be Percy. Pigs, please. Um I think The one thing is, so I'm trying to think back over because we were So we must be the last year that had Oscars in the finals or like actual patient's. Um, I think the thing is to be really careful and make it sounds really stupid, But be honest about what you find on examination. Um, so a lot of in our cardiology patient, the only finding was that they had an irregular pulse and you got shown an E C G. And they were an A F. But I'm sure Hannah heard you had to report back on your findings before the CT appeared. Yes, So there's something you have like, It must be a murmur. Yes, and said that there was a murmur and things like that, you know, because they're like, Oh, it's going to be I or tick stenosis or, you know, So just make sure that you are, you know, honest about what you find and like we didn't have an awful lot. The other examination we had was a respiratory examination, but there wasn't much to find on my patient anyway, so it's just being honest, and some of that is just making sure that you can interact in that kind of slightly more real environment than actually an off ski, you know? And I think there's a lot of grace for the fact that the the patient's aren't properly and they're not trained the same way the simulative participants are. And so if they do talk a little bit more, I think the examiners are quite understanding of that. And but it is genuinely the hospitals will treat you really well. And, yeah, a different way to finish off. That's great. Thank you so much. You've been really great. I just want to say good luck to everyone. I'm sure everyone would do really well. I've had plenty of time to practice and plenty more time as well. So don't be panicking. And I think it's always important to remember, as I've been told so many times, uh, that this is the one of the last exams you'll have where the examiners really want you to pass And, uh, you know, especially with queens. Everyone's really you know, voting's for you. So don't worry. Take a deep breath. Follow. Hannah and Catherine have so eloquently said to us this evening, and I'm sure everything will be fine. Good luck, guys. Thank you so much for coming