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Ok. Just sort of. Yeah. Yeah. Yeah. Ok. There you go. All right. Are we ok to stop? Hi. All. So, um, we're continuing our sessions and thanks for coming in today. Um, today's session would be presented by Sara and, um, Joselyn. Um, and they would, it would cover, uh, it would cover quite a bit about how to present patients and how to manage a consultation. Very important for your risk case cause that's the bread and butter. Um, yeah. Um, can anyone hear me? Yeah, we can hear you. Ok. So, um, let's crack on so that we, we get the session done, um, in time for everyone and, uh, today evening. So my name is Sarah. I'll be doing the first half of the, the presentation today and hand over to Joslin to do the management aspect and the sbar handover aspect of it as well later on. Um, so initially we'll just look at how to sort of top tips on how to get most of the information out of consultation and go through how to, um, gauge what investigations you would do on each patients as well. So the first line, it looks a bit daunting in terms of the amount of text that's on it. But it's just mostly um examples of sentences that we can use. That sounds a little bit nicer to the examiner gives you professionalism points in the exam itself. So the the first thing is just make sure you have um a regular thing that you say. So my name is Sarah Ra Chandra, I'm a medical student and then gain consent to make sure you're confirming the patient's name and date of birth and things like that. And then for the 1st 30 seconds, just don't say anything, let the patient talk and don't be afraid of silence because as awkward as it might be for you, it is also awkward for the patient or the actor. So they're gonna give you more information in order to get rid of that silence. So try and stay as quiet as you can for the 1st 30 seconds after an open question and followed up with even more open questions. Um The biggest tip I can give you for a skis would be do ice as early as possible. Um Cos it's basically a cheat code if you ask what the patient's idea of what's going on is um you're basically asking the examiner what they were thinking when they were writing that case. So you're gonna get at least one of your top differentials from that one question. So do it as early as possible. So in case you've missed something you can ask follow up questions later on in the consultation. Um, same thing with expectations and concerns. So, if your patient wants some painkillers and you've completely ignored that aspect of, of the history, um, it, it kind of doesn't manage what the patient's expectations are. So do ice as early as possible. It's one of the best things you can do in an exam. Um, in terms of systems have, um basic ones that you do for all of your history. So, nausea, vomiting and fever, I tend to group together. It's a good way to say whether the patient's condition is systemic or localized. So if someone's come in with cellulitis and they're fine, completely, no nausea, vomiting or fever, you can get away with treating them uh in the community as opposed to someone who's come in with a raging fever. So that's a good indicator of systemic versus localized condition. Uh It changes to bowels or urine. It's a good double whammy. So in terms of bowels, constipation and diarrhea can be caused by a whole host of things, not just gi conditions. So keep that in mind. So if your patients on antibiotics, they're bound to have some, some diarrhea. Um If your patients taking opioid painkillers, they're found to have some, some level of constipation. So asking changes about bowels um can be quite a good question. Second thing is urine. So, again, not only specific to the urinary tract area itself. Um, if your patient hasn't passed any urine in the last 12 hours and they have an infection, gives you an idea of, um, whether they're going into AK I or how severe their infection in itself is as well. Um, another question is eating and drinking so that not only assesses your appetite and whether they're thirsty and drinking too much, but also tells you whether they are able to swallow. So it checks for um the more red flaggy things like unable to swallow with an upper gi metastases kind of thing. Headaches. If your patient's unwell, they're bound to have a little bit of headache. But it's a good sort of screening question to ask, especially when it comes to things like man, painkillers or your patients on cop and they have migraines as a result and things like that. Uh shortness of breath goes through two systems, at least the cardiovascular and respiratory. So if you ask that one question, you can sort of cover two separate s uh systems. So it's a good question to, to ask and don't forget rashes, especially in pee if the baby comes in feeling a bit unwell, not really eating. Um You think it's viral illness, but you've missed a rash that's nonblanching. You've missed a meningococcal um meningitis or septicemia at that point. So, always ask flashes, especially in Pete's cases. Um These are just the, the basic ones that you wanna ask. Almost every patient really, um, and then cater the more, um, red flags specific to your system um based on, on what your history is. So, if it's a gi type history, then you'd wanna ask for Melina or hematosis type of thing. Um And if they're coming in Quino, you wanna check for sudden anesthesia, that type of thing as well. Um Psych histories can be a bit daunting, especially for me. I, I'm not particularly good at psych at all. Um, but keep in mind you wanna do three main things. Firstly, you wanna normalize. Um, so there are a couple of sentences there that you can, you can use to make it easier. Um, you want to normalize so that your patient gives you the information to begin with. Um, so they feel comfortable enough to give you that information. Secondly, you wanna assess their risk. So are they thinking of harming themselves? Are they thinking of suicide itself? Try and avoid the word suicide itself? Um, think of it. Uh uh Similarly to the word cancer, you don't really want to outright say, are you thinking of suicide? Um, so just dance around that word a little bit. Um And the third thing is you wanna see if there's a safety factor there, if there's someone or something like I have a dog and I wouldn't wanna leave the dog and, um, you know, harm myself in a way that the dog isn't taking care of that kind of thing. So look for safety factors there as well. Um, don't ask leading questions. Don't, you know, if you're suspicious that someone's not taking their medications, don't say, oh, you haven't taken your medications? You say that in a real consultation? So, don't do that in an exam, basically. Um, you can ask, how do you take your medications regularly? And if you're not convinced that they do, then follow it up with AAA question, like are there ways in which you make sure you take your medications regularly? So do you set alarms? Do you have a to set box type of thing? Ok. And the most important thing is confidence. If you sound confident, your examiner is gonna think you've done this a million times before and you're a safe practitioner. So it's gonna take you half of the way through. So try and even if you're not confident inside, try and appear as confident as you can. It, it takes you a long way, especially in a skis. So presenting a patient can be a bit daunting, try and do it as distinct and short as possible. Um Follow the same sort of structure as you do for your history, always mention patients age and sex at the start of the presentation. So 56 year old female presenting with so and so, um presenting complaint, history of presenting complaint and then your eyes past medical history and all of that. So the same way you would do a normal history, present it in the, in the same sort of order, give the positive findings first cause that's going to give you an indication of what your your differentials are gonna be. So that the examiner has an idea of what you're thinking and always make sure to give the important negative. So red flag symptoms. So if someone's come in with back pain, lower back pain, we want to make sure you're saying they don't have that anesthesia, they don't have bilateral sciatica. Um just to make sure you're ticking those boxes. Um And in terms of giving differentials at the end of your um presentations, always give at least 2 to 3 differentials. Um There should always be a top differential that you think the condition is. The second one would be, it could be that differential, but I'm not really sure. So I want to investigate for that differential and the third one would be your red flag one. So one that you really don't want to miss out and you want to investigate for regardless um try and do at least two systems. So it gives the examiner the idea that you, you don't have tunnel visi vision. So someone comes in with shortness of breath and you've only given respiratory um differentials, then it kind of comes across that you have a little bit of a tunnel vision and you've, you've set your mind on one differential and you're not really thinking broader. So give something like a respiratory and a cardiac differential as well just to cover your own basis. Um, in terms of investigations and managements that you want to suggest, um, you don't need to suggest them unless your examiner asks you to do so. So unless they ask, don't waste your time to, to, um, to give investigations and management. So I'll run through investigations first. Um, there are a few ways in which you can sort of structure yourself. And the one that I would, um, go with would be the boxes, uh, which stands for bedside investigations, bloods, orifices, x-rays and other radiological, um, investigations, E CG. And the final one that everyone read special test, which is more to do with whatever your patients come in with. So the first one bedside investigations, um, so if you've just done a history station, always mention that you would do a relevant examination and if you've just done an examination station, so you would take comprehensive history. Um, and the rest of it, I would go through the way you would do an ABCD assessment. Um, the w that's the way I sort of wrap my head head around it because ABCD E is done mostly at the bedside. So you would cover most of the investigations you wanna do by doing just that the first thing I wanna do is get a set of basic observations and fill out a new chart. So there'll be a respiratory rate, oxygen saturation, heart rate, BP, monitoring temperature. And don't forget your A pus if you're in a neuro station, always mention you would do au initially and once the patient is stabilized, you would calculate A G CS as well. So if you look at ABCD E um following that initial news um chart filling for a, you could do a peak flow um only on relevant patients, obviously. So if someone's come in with a D VTI wouldn't be doing a peak flow. So for someone like an asthmatic uh exacerbation, peak flow could be quite useful. Moving on to be um don't underestimate the usefulness of an ABG. Anyone who's come in with an acute problem, always do an ABG. It's got lactate, it gives you a basic idea of all of the electrolytes. Give you a basic idea of the level of hemoglobin. The patient has oxygen and carbon carbon dioxide levels as well. So it's a really good test to do very quickly, to get a very quick, quick understanding of um how the patient is doing. Basically moving on to C doing E CG uh practically done on every patient really. Um Unless it's a very acute uh moment where you can't do a full 12 lead E CG, you'd do uh you'd fall back onto the three leads, but I'll go through that later. Moving on to D. Don't forget to do glucose and ketones, especially if someone's come in uh a little bit comatose. You're not really sure what's going on glucose would be a really good test to go for. Uh same thing with ketones, especially in a young patient. And e would be everything else, which is the, the annoying bit cause you have to really base it on the patient in front of you. So that would include things like urine dipstick. So if someone's come in with dysuria type of symptoms, then you would do uh urine dip to see if they have an infection or something going on pregnancy test, anyone with the childbearing age. Um Generally we tend to do a pregnancy test anyway. Um not just for the differentials but also for the management. Some of the the medications that we give will have to be altered if someone is pregnant and um not pregnant. So we suggest a pregnancy test in someone of childbearing age. Um there a stool chart, especially in a gi patient. So things like inflammatory bowel disease. Um the way we monitor whether the treatment we're giving is working is through a stool chart. So, um it's a, it's a pretty good test to suggest it's not normally recommended by med students. So if you do it, you you sort of chart those higher marks really. Um there are other things like scoring systems for um cognition. So like the markers of A three and also you can do a swallow screen as well if your patients um, looks like they might need it. We're moving on to blood. This looks like a pretty disgusting looking slide with a lot of, um, blood tests. But I would focus mainly on the top three rows here because that's the one that you're gonna do on practically every patient, um, that you come across. So you've got the basics. That would be your F EC UN ES and ce RP F PC gives you an idea of whether they have an infection anemia. What type of anemia? It's a very good test to do on everyone. Same thing with um urea is a really good test for gi conditions as well. So if someone's got an upper gi bleed, urea is the first thing you want to look at more. Even hemoglobin electrolytes is very important for arrhythmias and things like that as well. So you need for practically everyone and C RP. Very good inflammatory marker um tends to be higher in infections, but it goes up with both infection and systemic inflammatory conditions that it's got nothing to do with infection. So it just gives you an idea of how unwell the patient is. Basically the next step up from basics would be your LFT S and T FT S. Remember you can do LFT S not only for GI conditions. So if you have someone with cardiac failure doing an LFT can be quite useful to see how much blood is backing up into the liver um gives you an idea of how, how much fluid, what the fluid status of the patients is as well because you've got the albumin that comes under LFD S as well. Anyone with vague symptoms, like anemia, feeling tired all the time. I would do ATF D on. Um If they've got arrhythmias do at SDS as well. The next step up would be blood cultures, especially if you're in the hospital and your patient has a temperature or looks like they might have an infection, go for blood culture. Um The rest of them are subgroups of patients. So if your patient looks like they're surgical, they're about to go into surgery or they've just had surgery or they've got a bleeding risk or they've just had a bleed, could have a bleed, then you want to do these three. So coag screen and ir if your patient is on Warfarin group and save and cross match just so that you know what kind of blood you need to give the patient and you're not wasting own egg. Um unnecessarily, the next group would be intoxication in acute comatose patients. So if someone comes in pinpoint pupils, they're not really responding, do a tox screen on them, see um what kind of um bloods they have at that time doing paracetamol levels is also generally recommended, just make sure it's, it's within that four hour uh period of time postingestion as well. Um especially because paracetamol um levels is so time sensitive in terms of administering the management, which is NAC, um, you want to do that test, um, within a certain time, uh, timeframe. Next set would be cardiovascular troponins would be the main one to focus on there just to check for sties and end sties and things. I've put D dimer in bracket there because it's a pretty useless test and practically no one really does it anymore. Um, and we tend to go by um how the patient is presenting. But if you have a patient that looks like they have a DVT or a PE in your risky and you don't suggest ad dimer is going to come across a little bit dismissive. So for exam purposes still suggest that you do ad dimer. If you're suspecting things like these and DVTs, next subset is a pretty big group or patients, anyone coming in with a fracture, whether you've been through trauma or pathological, whatever elderly patients and patients who use suspecting electrolyte abnormalities, um especially things like hyper and hypokalemia that you can't really explain, then your bone profile gives you calcium phosphate and P th as well because that can affect your calcium and phosphate. Um Remember magnesium doesn't come under any of the panels. So you're gonna have to um request that separately. And magnesium also affects the levels of your other electrolytes, especially um potassium. So if you're suspecting your patient might be hypo hyperkalemic, doing a magnesium on top would give you those higher marks in your exam. And CK pretty self-explanatory. If your patient has had a full and a long life, you wanna check for rhabdomyolysis and the way you would do that is to through a CK anemia in neuro. So if someone's come in with glove and stocking kind of distribution of neurological symptoms or generally just anemic, we wanna do iron studies B12 and FOLATE because they can cause anemia as well as neurological symptoms. HBA1C and glucose things to keep in mind for those. Remember, random glucose is the way you diagnose diabetes, HBA1C on that regard is completely useless. So if someone's come in undiagnosed and you think it might be um diabetes go for glucose and if someone has an established diagnosis of diabetes, then go for HBA1C GI symptoms. So IG att G, make sure you're doing IG A with it as well because if a patient has general deficiency of their IG A levels, which is very common, um you're gonna get a false negative even if the patient has celiac. So if you're suggesting doing ATT G, always make sure you're suggesting IG A as well on the side, aminase and lipase. That would be if your um your patients coming in with epigastric kind of pain and you're suspecting pancreatitis, then you'll do amylase or lipase depending on the timing and how accurate you want it to be really tumor markers for the fancier stuff. So if someone's come in with sort of IBS type symptoms, um, later on in life, um, then you'd wanna do something like AC A 1 to 5. Um, for prostate, you do P SA and all of those more specific tumor marker tests. It's also a good idea to have a, a basic list of married therapeutic range drugs in your head. Not all of them. This list is by no means exhaustive. Um, but these are the ones we use very regularly and test the levels for in hospital as well. So lithium, you tend to see them in psych patients as a mood stabilizer. The off um used in asthmatic patients were quite poorly controlled digoxin and heart failure patients and gentamicin for infections. The reason to have these ones in mind would be if you're out of range. These patients tend to present with specific toxicity type symptoms if you know that basic presentation and you know that this patient is on one of these drugs, you've already got your top differential. So having a basic list can be quite helpful at moving on to the orifices. Um So the expense of sounding quite lew it's basically in and out where you can stick in and what you can take out. So in terms of in, so we can do swabs. So nasal, no. So testing for things like M RSA wound swabs. So whether it'd be self infected or surgical wound, whatever it is, if it looks infected, you're gonna take a swab of it and send it to the labs and, and same thing with vaginal swabs and you get the more higher marks if you um suggest which specific kind of swab you're taking as well. For example, natural chlamydia gonorrhea testing and you've got your charcoal test, high vaginal swabs and things as well. Um And in terms of taking out, you've got the cultures so you can take a culture of any kind of fluid. Really. Um So things like sputum stool, urine, um remember if you have a central line and you, you're suspecting infection, you're not going to just pull that line out. You're always going to test um uh the cultures from that line first before doing that. So, so Lyme test can be a pretty useful one amniotic fluids, not really done all that commonly anymore. It's just ones to put out there. Really? Someone's got chorioamnionitis, you're probably going to get that baby out and treat both mother and baby rather than waiting for the cultures to come back. There are some special ones specific to your patient, pre patient presentation. This is where your PT knowledge is going to come in. So if your patient is coming in with a persistent diarrhea of six months or whatever, they're quite young and you're suspecting IVD, then you do a fecal calprotectin to check for inflammation within the bowels. So really this is where your knowledge would be coming in. Next one up would be the radiological investigation, the x-rays and other imaging, basically, um, a good way to wrap your head around. This one would be working from the least expensive causes the least amount of hassle to the most expensive causes the most amount of hassle cause that's the way the NHS works and that's how you're going to do it when you're, you're practicing as an F one. So we start with bedside ones like ultrasound. So you've got the fast scan that you're gonna do on practically every A V patient that's coming in to recess, um to check for internal bleeding quite quickly. Uh You've got your bladder scan, especially in patients who are coming in quite confused and you're not really sure what's happening. You've got generalized abdominal pain, likely to be retention and easily. So for the bladder scan and catheterization. Mm Good. You've got your echos for cardiac patients, doctors and things like CBC S and uh pregnancy as well. Um Moving on, you've got your x-rays. So you've got your soft tissue x-rays and your orthopedic x-rays. So the soft ones would be your chest x-rays and abdominal x-rays, chest x-ray. Practically everyone that comes into the hospital gets it. Uh in terms of your examination though, um uh exams though, uh give an indication. So if you're suspecting a chest infection or you're suspecting heart failure and you want to look at the size of the heart, then you do a chest X ray. Um abdominal X ray is not really done very often anymore. Um Mostly because we just tend to stick patients to see a team. Um because that gives more information to the surgeons who are going to operate regardless anyway. Um but if you want to mention abdominal x-ray for perforation, for example, make sure you're mentioning that it's going to be an erect abdominal x-ray, then you've got your orthopedic x-rays, especially if you're looking at the joints, make sure you also say you look at the joints above and the joints below as well for any abnormalities moving on to your CT scans. Then um CT and MRI are classed together to be honest. Um because the rules really are the same specify the region um that you're looking at and if you want to do vascular or not, so regions can be CTA PCT taps, ct thorax, ct head, whatever it is. And in terms of vascular, something like A C PPA um looking at um pulmonary vasculature, especially in when you're investigating things like pe moving on, you've got your scopes. So things that you can put a camera down really um you would be suggesting things like endoscopy and colonoscopy, that would be the most common. Um the ones in the bracket you as an F one will not be suggesting you could when you're doing your exam, say the patients would benefit from something like a cystoscopy or a laryngoscopy and definitely a bronchoscopy. But you wouldn't say I would request these things because you wouldn't do that as an F one yourself. Um Then you've got your more fancy stuff. So radio fluorescence imaging and pet scans uh which are used for metastasis testing and uh cancer testing. Basically, you've got your Dexa scans for someone who's come in with fragile bones really. So things like osteoporosis um cautions to keep in mind um for this aspect would be radiation exposure. Top one. So that would be in pregnant ladies. So you don't want to stick a pregnant lady in a CT scanner unless it's absolutely necessary. Second one would be young Children, so you don't really want to expose a child to too much radiation while they're still developing um for MRI S, it would be metal. So any kind of metal, whether it be jewelry or implant of metal prosthesis, um prosthesis. Now, the newer one tends to be quite good in terms of being not attracted to magnet, but always good to sort of mention it. Um to make sure that the examiner knows that you're aware of these things. Moving on to EEC G is pretty self explanatory. We want to do an E CG practically on everyone really. Um Just uh a good thing to mention for the top mark would be whether you want the three lead or a 12 lead E CG on an acute patient. As a rule of thumb, initially do three lead EC GS and get cardiac monitoring so that you know what's happening. Um And then once the patient is stabilized, you can request a 12, 8 E CG when you have a little bit more time to fiddle around. But on a stable patient, if you're in a GP setting and they're completely fine, do a 12 week E CG because that gives you more information. And there's also things like stress testing, rarely done anymore. It's not really done unless to torture med students predominantly. But it's a good thing to sort of mention for testing for things like Angina. And finally, the special test, which is the annoying part, part of boxers really because you have to cater this one very specifically to your patients. Um So if your patients come in with gi type symptoms, I wouldn't feel fiddle around too much with something that's completely unrelated. Um So some examples can begin spirometry. So if your patient is having asthmatic or co bt type symptoms, then you want to refer them for spirometry biopsy, especially if you recommended something like an endoscopy or a colonoscopy. Or if your patients come in with a dermatological presentation, biopsy can be a pretty good one. And also for patients where you're suspecting cancer. E eg even neurologists don't really care for eee GS cause it doesn't really give too much information. And as an F one, you're not going to be requesting too many EE GS as well. So it, it really depends on how much knowledge you have yourself on an E EG. So don't recommend a test that you don't yourself know enough about, um, think about occupational hazards as well. So if your patients come in, who's a farmer and you want to come up with differentials that's more catered to that the same way you would do for someone who works in a hospital with patients. So for someone who works in a hospital, you'd wanna test for things like HEP B and TB and HIV testing, especially if you, if they're coming in with multiple weird and wonderful infections. So they really shouldn't be getting. Um there are also some special blood tests that you can do for specific conditions. So things like my brothers have specific antibodies um that you can test for, that's quite specific um for those conditions. So this is where your p knowledge again comes in and gives you those higher marks by no means are you're going to fail. And if you, because you have failed to mention a couple of these things, um but it will give you the higher marks. There's also something like a biologic screen. So if you're, if you've got an IVD patient and you want to start them on a biologic, you want to make sure you're testing for, for viral infections that can be triggered by starting those biologics. So things like HIV or rubella or even TBS. OK. So there are also some panels that exist. Um II won't go through all of them with you today. Um So things like sepsis six hypernatremia screen, these are existing panels. What I would say is don't mention the panel without saying, oh sorry, don't mention the panel without saying what's in the panel in your exam. So if you just say I would do a myeloma screen without saying I do un and blah, blah, blah in an exam, your examiner could not, they wouldn't know whether you yourself know what's within that panel to make sure if you're recommending a panel, you also mentioned what's within that panel and why you're testing for it. And finally, we've got the surgical spiel. So if someone going into surgery, there are certain things you have to do before they go into surgery, um, obviously not in the case of an emergency, have to try patients and make sure they're not going cos if they're going under general anesthetic and they're not gonna have continence. So you want to have to try them. Um, you want to keep them no by mouth, especially for elective surgeries and make sure that the nurses are aware of it and it is documented, um, drip and suck, especially in gi patients, especially if you're sort of querying, um, bowel obstruction kind of picture. So drip would be in the patient and giving them IV fluids maintenance and the suck aspect would be popping an ng in and taking out whatever contents there is within the gas, um, within the stomach still medication with you because you're gonna need to stop certain medications prior to um to surgery. So things like antidiabetic medications and anticoagulation and the main one that most people tend to forget is VT prophylaxis. So whether it be mechanical in the form of Ted Stockings or something or pharmacological like flexing, um just make sure you say I would provide VT prophylaxis for this patient. So you don't have to go into specifics if you're unsure. Um mentioning VT phylaxis already ticks that box, right? So I will now hand over to Joslyn who would go through management and sbar with you guys. Yeah, thanks Sarah. So, um could you go on to the next slide for me? Thank you. So, it's quite a lot of information on this slide. But essentially what I want you to know is that um other than medical management, there's actually quite a lot to do for conservative management as well. So for example, if someone had a neck or femur fracture or a stroke, they would definitely need a physio ot input and then we can talk about that. Um And then also for everyone, um they probably need some sort of diet or lifestyle modification. So, um for stroke patient, they will need a safe swallow assessment. And um if anyone let's say have been eating a lot of um fatty food or for their alcohol intake, you could refer them to dietician or also refer to the alcohol liaison service as well. Um So for some patients, you might want to have 1 to 1 nursing care. So for example, for those that who kept on falling or if it's a kid having a DK A, you probably want a nurse to be there to just look after them. Um in terms of patients having C diff or COVID or CF patients, um you would be um worried about um cross um ec um infection. So you want them to have a side room and that's what we meant by barrier nursing in here. So you want to put these patient in a separate way to keep them safe from other patients, but also keep the sort of infections control. Um There are also some disease that you might want to um call the um infectious disease. Um what's it called? Um the um like monitoring. So for example, a meningitis scarlet fever, you definitely have to um make referrals for those ones and for vaccination. So for um heart failure and CO PD, you want to recommend for the annual flu vaccine, any one of pneumococcal. Just remember for the celiac, you'll need a booster as well. So I remember when I was in my ki there some um um peat station and you definitely want to remember to um explain the condition to both the Children and the parents as well. And I think there's always something that you should remember is provide anyone with a leaflet and just um ask them to call back um if they have any questions and also um refer them to sort of community or local support group so that they could like, get help from there as well. Um Last, but not least if someone had a fall um always have some sort of regular neuro observations. So if sorry, you can go on to the next slide. Um There are some indications on like when you want to do a neuro observation. So you could read that um when you get the slide. So this is taken from um one of the guidelines in one of the trust in London. So yeah, and then next slide for me, please. Um So these are some of the important medications that I think would be applicable for quite a lot of conditions. Um So for analgesia, you always want to start with these sort of pain ladder going from paracetamol and then go to your strong opioid like morphine. Um But also remember to give them laxatives as well cause they tend to get quite constipated. And then you also want um some antiemetics. Um So cyclic is quite good. Um It has quite a low side effect profile. Just remember for me, Promide, you want to um um prevent that in using in sort of Parkinson's disease patient. And then for oxygen. Um, is anyone is acute, you always want to start with 15 L non rebreath. Um, even with CO PD patients as well because you could always um lower the oxygen level down. But normally you start from the nasal speck for just um anyone feeling slightly shortness of breath for fluids, you want to give them um, 0.9% normal saline and just replace any sort of electrical imbalance if there's any um for VT prophylaxis, nearly, I think all the patient in the hospital will need them if they are admitted. So, Clexane will be one of the good ones if they have sort of renal impairment, maybe unfortunate happen. But I think if you say Clexane, you'll always get the point. Just three little things. I want to remind you if someone is on Warfarin, you always have to stop the Warfarin and you have to reverse it. So as um Apixaban or any sort of anticoagulations, if anyone is on Parkinson's, um if they can't, if they are being capn no by mouth and they can't take the sort of um medications like um Levodopa Carbidopa, you always need to give them a patch or else they will um get really, really ill. And for diabetic patients, they always need a insulin sliding scale. And if you're not sure what to say, you could always just say you'll consult a diabetic specialist nurse and that could cov cover you up quite good as well. So next slide for me, thank you. So there are some three important things that I would like to tell you. Um So if anyone is having an Anaplex reaction, always remember to remove the trigger. And a lot of people always forget to say that in their management thing because essentially that's actually the most important thing is to remove the trigger. So what I meant by that is stop the IV drug running. It doesn't matter if, if the patient is allergic to this drug or not, if they are having a reaction, just stop anything that's running through because you want to like stop the reaction as soon as possible or you could keep the allergen away from the patient. If you're in acute situation, you always want to do your at approach, do your crash call, refer to senior and then keep reviewing your ABCD again until the patient is all stable or your help has arrived. Um And then, and medications wise, always just check the allergies with patient and go on to Welsh Clinical Portal to double check. You can always use the B NF for the um root dosage or indication or if you're not sure, always just ask the um pharmacist and you will get the points as well. So next slide for me, please. So in terms of like acute management, your goal is actually to stabilize the patient and make sure they're safe. So there's some standard stuff that you always have to do. So your at approach oxygen depending on the saturation, you want to do two white ball cannulate on each arm, start the fluids and pain relief and then you um do senior support, remember your crash score, double two, double two. And then um um always mention like who you want to um wish to get help from. Um So it could be your medical or your surgical reg and for the top students aiming for the highest mark, you could say that I want to refer to the neurosurgical registrar or like a general surgeon. And remember um there's always guidelines and protocol to help you. So for anyone who's having a bleeding, we'll do the major hemorrhage protocol. So that will con um con um that will um get to the blood bank and then they could do all the two units of blood transfusion or if someone is in a um postpartum hemorrhage, then it will be a major obstetric um hemorrhage protocol as well. Um So next slide for me, please. So we're gonna go through the sbar. So I think you probably know what sbar means. So situation, background assessment and recommendation. So um we're now gonna um go through each of them. So next slide for me, please. So for situation you wanna confirm who you're speaking with? So I'll start with, hi, can I speak to the medical or surgical reg or the um peed or whoever that you think will be um a applicable in your case. And then you always want to ask for the name as well. Just so you know who you're speaking with. Um and then you introduce yourself. So I am Jocelyn, I am a final year medical student. I am calling from M AU and I'm concerned about a patient. So, um if they're acutely unwell, you want to get them here as soon as possible. So you want to give them the headline. So, um this patient is um Jocelyn, she is 16 years old and she presented with um let's say, um abdominal pain or um any sort of conditions that let's say appendicitis. So it's very severe abdominal pain and I believe this is appendicitis. So, because if know appendicitis, ok, then they might think, ok, they probably need like a surgery. So in an M I, they will probably need a PC. So a stroke, um they will need like thrombolysis. So these are all very um time sensitive conditions. So you want to like give the conditions as soon as possible and then you can go on to their history, what assessment you have done. So, going to the background for the next slide. Um So I'll give the history of the presenting complaints. So essentially you can use your Socrates. So, or how you've taken the history and you'll mention um anything that's important in history. Um Any sort of red flags in it as well and then you, you'll give the background patients. So you don't need to mention every single thing in the background. Just mention what are these sort of important medical history? For example, if someone is having, um, you think someone having a bowel obstruction, then mention any sort of surgical history if they have any, if they have any, or, um, in terms of like social history, if they are like a smoker, if there's anyone having a um sort of asthma attacks or maybe mention if someone is having um like in their family history, someone is having asthma as well. And always remember even though it's, it sounds not relevant, but always mention any sort of drug allergies they may have because um they might need that drug. Um You never know. So just mention any sort of like drug allergies in this case. And then next slide for me, please. So in terms of assessment, um normally the school will give you a news chart or any sort of examination findings and you, you'll have um some time to read the results before you um do your sbar. So if they give you a news, um you don't have to sort of mention every single thing. Um If everything is sort of normal and there is zero, I'll just say the new zero and the Afebrile. But if there's some sort of important stuff in there. So for example, the it's tachycardic technique, um you definitely mention these kind of things. And if there are like two sets of observations, you want to mention what have changed. For example, the temperature has increased. Um There have been more tachycardic, they have became more hypertensive cause that's quite like a septic picture. But the um sort of assessment that the school could give, you are not limited to a new chart or examination findings, they could give you a uti results. It could be just a bunch of changes in BP um in some preeclampsia or it could be a chest x-ray, E CG or a x-ray. So um it could be anything in here really. And then lastly, we're going to recommendations. So in here you talk about um what you think is the um diagnosis again and give out a couple more differentials. But um maybe mention why you think the top one is the one that you're suspecting and then you will state what you've done for the patient. For example, um I have taken, I referred them for a chest X ray and then um you will ask the doctor um is there anything else that you would like um that they would like you to do at the meantime, but also remember if it's emergency, you will tell them that for, for example, you would say, I think this patient is having appendicitis. I would like you to see the patient in the next 10 minutes. Um because I think it's very urgent um or like a mesenteric ischemia, you would like a senior review. So you'll be like I would like to see them within the 1010 minutes and the school, the doctor will always say I'm sorry, I'm busy. Um II can I see you in like three hours? You will say no, I would like you to see them in 10 minutes. Like you have, you just have to reinforce it because that always happen. In this case, they will always try to trick you to see if you're so strong on your stents to be like, I would like you to see the patient as soon as possible. So this is sort of like how you would do an sbar handover and um I'll recommend you to do it with your friends. Um Just every now and then um because it's, it's not that hard, but sometimes you have to filter information to make sure like you get the most relevant information in your sbar to like score the highest mark or to get a pass. Um So that's the end of the presentation today. So if you have any questions, please put in the chat and we'll um send a feedback form and then you can get the slides. Thank you. I think that was very, very well done. Well done guys. Thank you. If you haven't, has anyone got any questions? T Yeah, me and cat will put a lot of quite useful information in the chat. Some of it I have put in is like extra like high yield stuff if you really want to impress, but just get the basics down. Alright, absolutely. We'll pop the feedback form in on the chat. So if you could do that too, that would be great. The headline of this talk, I was, it was absolutely fantastic talk. My things would be remember to say a to e senior review, say that and they'll just tick tick. That's more important than the, the, the niche kind of investigations management plans. Because at the end of the day, remember you're an F you, well, you will be in F one. That's all you need to know. You don't need to know the 10th line things you just need to know at E senior review C EPA six. that stuff we got a question. So in terms of medications to be stopped before surgery, right? Ok. So I'm currently on surgery. Um, so medications we worry about before surgery. So any of the, an like oral anti, like diabetic drugs, your, your sort of g uh glycosides, Metformin, et cetera. Some of them can be admitted on the day of the surgery. I wouldn't worry about a whole list. Usually antidiabetics, not insulin. Now, insulin's a different one. Unless they're on a sliding scale. Um, anticoagulants. That's the big one. Warfarin is usually five days before do, is do like two or three or something. Like that 24 or 48 like that or something like that short term because, oh, there we go. Very good. There we go in, well done the pill twice. It's so important. And the reason of this, I wouldn't say just cos the C OCP, it's because of the estrogen. So you're more likely to get clots. Um That's why that's there lithium. Um because you're more likely to get an AKI I um ace inhibitors for the same reason. So sorry, you're more likely to get an AKI i when you're having surgery or dehydrated and then lithium levels can become toxic. Ace inhibitors. Same thing, you're more likely to get um an AKI I anticoagulation, obviously because you're going to be bleeding. So you don't want to be bleeding more. There, there is a, there is a kind of risk benefit, you know, if they're on it for a specific indication, they might, they might, I was looking after a patient actually today. Um who was on who has it for um antiphospholipid syndrome? And so she had to have inr between three and four. So she had to have like bridging plaque saying, don't worry about that. That's, that's niche, niche niche, don't worry. Um anticoagulation, you want to stop that. Um And yeah, potassium uh diuretics, I'm guessing that means like spir spironolactone again, for the same reason, you, you can get an AK potassium shoots up. You don't want to be shooting it more up. Sorry, Jack. You go. Yeah. So for any of the weird blood stuff, like anticoagulation, VT E stuff, you can always ring hematology or even pharmacy and they're very, very good at telling you what to do. Ok, so don't worry about it. Um So yeah, that's really good. Sorry if you're not sure. I just say I would check the B NF to go to. You do not need to, I agree with, with pharmacology. Just anything and everything. Even if you know, it just say I would still check on B NF which we do. Same, same goes with Micro Guide. Um, that's the anti local antibiotic guideline in all the hospitals. So they'll have a specific one and also say, I'll check the local guidelines and how to manage the condition. Yeah, these three guide applies for everything. Pretty much micro guide is a specific welsh thing as well. When I went to England, there's no such thing. So just saying, no, it's all local guidelines. So it's very specific to Wales. So just, yeah, it's a good thing to say. Yeah, obviously if you're from Cardiff as in graduate, all medical school, say just to warn you. Yeah. Ah, interesting. Do they look at you silly Jack where they're like, what are you on about? Yeah, they haven't. What's Micro Guide? I know local guidelines. Any other questions? More than happy we're doing, um, blood results and ABG next week and it will be me doing it. So yeah, just to let you know. Awesome. And yeah, don't, don't underestimate the importance of an ABG as mentioned that is your like if anyone desaturates or if you want immediate point of care testing, you can literally get a HB you can get a lactate, you can get a potassium, you can get a lot of like your basic stuff if you're doing on weight. So do an ABG or even a VE BG. Cool. Have we, have we stand in silence? I feel like we've answered every single possible question that could possibly come out. Um Yeah. Well, thank you for coming to be honest. I mean, we me and just have put both our emails of the staff of the presentation as well. So if you have more specific questions, you can always just email us or um 0101 email address, the the generic one as well. So feel free to email us whether you have any kind of questions really. Um And we'll get back to you. Thank you. Cool. Bye everyone. Well done, everyone. Bye. Thanks for coming.