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Summary

This on-demand talk focuses on helping medical professionals control the consultation and present patients in terms of management and investigations. We'll cover important points like the golden minute where you should just shut up and listen, responding to cues and asking the patient ideas, concerns and expectations. We'll also go over the importance of avoiding leading questions, multiple questions at once, and constant use of 'um's. Preparation is an important point and you will practice with your friends. Finally, we'll look at presenting a patient with a helpful format and rule of thumb for deciding on differentials, investigations and management techniques to use.

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Description

This webinar is designed to assist you in approaching acute care stations in your ISCE and useful formats to follow when presenting patient cases to examiners. We will also be going over SBAR formatting and top tips for passing on the day

Learning objectives

Learning Objectives:

  1. Understand the importance of allowing the patient to lead and give their history of what brought them in during the first few minutes.
  2. Learn how to recognize and react to cues from the patient's words or body language.
  3. Identify key points when presenting patient stories, such as recognizing positive findings and red flags.
  4. Define effective communication techniques such as avoiding leading questions, speaking slowly and using pauses, and using proper terminology.
  5. Recognize the process of bedside investigations, as well as other investigations and management techniques for different cases.
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Computer generated transcript

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

Hello, everyone. Welcome to the talk. Just people who have missed it. My name is Ronan. Um, today I was going to be doing a talk on how to kind of control the consultation, Um, and also how to present, like, patient's, both in terms of, like, management and investigations, um, to adopt who's examining you and the S K. Um, and also kind of just a general way of going through management investigations when you're practicing how to to order things and structure them in your head. So you get comprehensive breakdown of what you need to do leading forward to manage a patient. So, firstly, to just go into kind of some important points and tips that I can give you, Um, the first kind of minutes. They usually say it's the golden minute. Um, varies. Obviously, a patient won't be talking for, uh, you know that length of time, but usually 30 minutes, 30 seconds to a minute. You should allow the patient to kind of tell you about what brought them in. So a generic question that's broad allows them to to lead the history, don't interrupt them. Don't interject with a singular question or things that you want to know about the history. It should be the chance for the patient to tell you what's been going on. That's a very important kind of period. That's your golden minutes. You just shut up and listen. Really, Um, always respond to kind of cues. So either it can be something the patient has said or something, or how the patient actually looks. So if a patient said that they've been feeling a bit down, it's accu for you to ask. Well, what do they mean by that? And they might kind of tell you about them not doing as many hobbies as they used to do. Um, their actual mood has just been a deep in a decline. Um, they might tell you that it it all started because of a particular event. So it's very important to respond to those particular triggers. Um uh, those particular cues. I mean, um, the same thing can go if you're taking a history, and then a patient, you know, starts looking a bit careful. That's your cue to, you know, specifically ask them, Is everything OK and acknowledge you look a bit upset? Um, and that can work for most kind of, uh, consultations where emotions can can sort of be involved even if you're dealing with an angry patient, you know, And obviously don't, um, uh, say why you're angry or something, but acknowledging you look, you look a bit upset or you look a bit annoyed because at least it's kind of acknowledging that you know that there's something wrong the next most important thing, obviously, as I've mentioned it before, but I mention it again ice. So always ask your ideas, concerns, expectations. It's very important. And I've kind of phrase done it in a particular way that you can phrase these questions without it coming across us. Do you have any? Any ideas? Do you have any concerns? It's to kind of generic, whereas this has a bit of a more unique way to kind of including the consultation while still asking those kind of things, uh, with your cyclist we mentioned in the last, um, talk. But it's another good kind of tip to just mention is normalizing a certain thing, particularly if it upsets them. Um, so if someone's been feeling low, it's very important to say some people who have this feeling of, um, low mood can sometimes have thoughts of hurting themselves, even ending their life and say, Have you ever had any of these thoughts? It normalizes it and then ask them whether they, like so many others who possibly can have these symptoms, Um, or or thoughts? Really? Um, going back again to the psych histories that we talked about in the last one. Uh, if a site patient's, like, suspicious of you for instants, you know, just stating that is from a point of concern is a healthcare professional that you're kind of looking out for them. That's a good way of showing that you care, and also that you're not coming from a point of maliciousness or bad intent. Your intent is good. Um, the ones at the end, which you're the three big ones that I always state is an avoid leading questions. So never assume something in the question and then say, Have you so I've given an example that you haven't missed any doses of your medication, have you? It almost kind of makes a statement and then just asks, Is that the case? Because it kind of, uh, it just isn't a good way of asking a question. Also, it attaches like assumption behind it. Um, so try and avoid those. Avoid asking multiple questions in one Go. That's a big one. So, do you have any chest pain or shortness of breath? Try and stick to. Do you have any chest pain? Do you have any shortness of breath? It doesn't take that long and it structures it better. And then my biggest pet peeve and just try to avoid it is, um ing and Irving buh bye. It doesn't come across well, if a doctor as they're kind of asking you, those are questions, uh, so take a breath, take a pause. It looks much better because it looks like you're thinking about what you're doing. And it's the does the exact same thing. Only one sound. One looks better than the other. And even saying If you really need to take a good pause saying in the middle of that, I often said in my my, um, kind of stations. Uh, just one second, I'm just pausing to think about think about what you just told me. It shows that you're acknowledging what they've said and, you know, gives you time on the spot. Just adding to that, um I think the best way to prepare literally be practicing with your friends. And, um, I remember the same thing that rodent did while we were practicing that, um every time I said, um, and when it became too much, he literally asked me to stop and redo the whole thing. And that's how I realized that I was, um, in quite a bit. So, um, that's the best way to practice. Replace the um's with a breath. It's just as effective, and it shows that you're thinking it just it just looks more professional. Um, you know, it's it's difficult. I won't deny that, but it is. It does sound and look much better. Um, see, even I did it that, uh, so presenting a patient, you want to follow kind of the same format as how you take histories. So you're presenting complaint, then following up with past medical history. Family history. The most important thing is stating the positive findings of what you came across in the history structure it how you kind of compartmentalize it. So if it's pain, you're going to follow Socrates. If it's another presenting complaint. I use that sick car pneumonic so you can use a different thing, but that still gives you structure. You don't want to just state every negative finding that you asked about. But you do want to acknowledge the red flag ones. So I always just kind of think about the general red flags because those are generic and they're easy to kind of list off if they're not there. So fever, malaise, weight changes in appetite changes. You can. It depends on what the kind of station is. If you've got an abdominal pain, you're very much wanting to to say there's no blood in the stool. That's important, so it varies dependent on station. But don't get too caught up in that, Um, try and just think about which are the most important ones, and maybe list one or two after you've presented it. After you've presented the kind of presenting complaint, you then want to say what the pertinent bits of a past medical history, drug history, whatever and if there aren't any, so if there wasn't anything family history, then just say no significant family history. That's fine. Um, social history, much the same. So it's already dependent. And then when you get to the end, offer your most likely differential from your history. So my most likely differential based off the history I took was a heart attack and then follow up with just just two or three other differentials just to show you that you're thinking kind of about other things, even if it doesn't like. This is the pitfall people fall into where Let's say it's let's say it's a pa and the person has been on a long haul flight. They have swelling in their legs, pain in the chest. It's pleuritic in nature, and they're also having a bit of a cough as well. You're thinking, Oh, this is definitely Pa and they don't think it could be anything else. And so really, you're differentials. There should just be other chest pain differentials, even if it's not fitting. So this could possibly be a pneumonia or an M. I highly unlikely, but just throw some out there for the sake of it, and then, uh, go onto your investigations and management. Now, really, after you've presented a case, it should be you volunteer your differentials, but you shouldn't then go on to just starting listing off all your investigations and management that should be only prompted by the Examiner to do so. So pause. Then they'll follow up with either giving you an investigation or even asking you about these things. And that's when you can go onto these steps. So investigations eyes pneumonic called be boxes, which I'll go through and management. I often just went through conservative medical surgical. And if it was a psych station, then biopsychosocial, which was my went through in the last, um, presentation. So be boxes, um, handy little pneumonic. It works well, so your first B is for bedside investigations. Your next B is blood's, then orifice tests, and it's a bit of a weird one, but it just works then X rays and other imaging, you know, e c g. Just because I always seem to forget that one and then the s for special tests. So anything that's just a bit outside the box. Pardon the pun, um, important point. If the examiner asks, how would you like to manage the patient? That usually means give them both the investigations and the actual treatment itself. Really? Um, it should be kind of the work up that you're thinking to getting both the official proper diagnosis and also making sure the patient is treated. Um, if the patient is acutely unwell, then really your, uh, your answer to that should always be the you know. Eight. I want to take an eight or e approach. I would like to stabilize the patient, which I'll go through, Um, but if it's kind of a chronic case or it's not really something emergency related, then you can be a bit more systematic and the bee boxes and the conservative medical surgical approach. So bedside investigations These are just want to kind of think of. I always used to think of what's in the news chart. So it's all your oxygen SATs, heart rate, BP temp. You also have to remember that, actually, if you've taken a history, you haven't done any examinations. So always mention your bedside investigations. A bedside investigation technically also includes an examination, so there's no harm in saying that. So I would say your examinations, then your kind of classic news chart ones, and then think about things that you I I like to think about it in the way of what would I do in a GP setting? So I'd like to check the year and or I possibly would do some peak flows or even think about, you know, some swabs that I might want to do, and then things that you do it at the bedside, which they do in hospital. They sometimes use those score ing systems. So Ace three is a cognitive exam that they can do for someone with, like, delirium or dementia. Another example. If it was like an ammonia case, you could say the Curb 65 score. That's a very good one, Um, things that they do in hospital. They do like a stool chart, possibly, uh, and maybe even a swallow swallow screen. If they've had a stroke, for instance. And if you have any others, then, yeah, please put them in the chat because I would appreciate it. I'll be putting a compilation of some together fuel to prompt you, um, so blood's this is the next be in the bee boxes, so basically there's there's loads of them, but the the green up highlighters, the ones that you should just list off straight off the bat, and you can't really go wrong and saying these three. So you're FBC you Annie's and the LFTs. Just say them, Throw them out there and then think about the things that you want to add on. So coag studies. I'll go on to the yellow ones so I'll miss these out. Initially, your bone profile crest and Kayani's maybe tumor markers. Iron studies amylase. The list can go on. Yeah, the yellow ones I've prompted because really, those are your emergency ones, which you just shouldn't forget. So any shortness of breath you're always doing an A B J. Any pain or shortness of breath and preferably ordering a troponin. Same thing for a d dimer, a cross match for a group and save. Just think about that. If they've got any blood loss, that's the one of the big ones that you want to do. And then any time when infection could be in the back of your mind. So that's really any, uh, unwell patient. You know, infection could always be a cause. Blood culture is not a bad a bad suggestion, I think, Um, so those are some good blood's to kind of think about, but you're green one. That's the one you should just throw out there straight away or a fist test. Now I think of our fist as being anything where there's just an opening in the body. It's a bit of a weird way to remember it, but it just works. So you've got your mouth, your nasal, your air, your rear passage and also your kind of genital system. And I would just think about it as any test that I would do in those kind of areas in effect. So all your swabs, you know your possible stool culture. You know you've got unique ones like fecal calprotectin and year and one that's kind of a bit more of an it in, um, uh, specific. One way. It's the year and it might microscopy culture and that, and maybe even a pregnancy test well, as well if it's a woman who might have some abdominal pain or something. A top tip that I would state is if you get given results that you need to interpret, and it's like a urine dipstick result. Don't assume that they've done things like microscopy, culture and sensitivity. They're just giving you the year and dip results, so that should prompt you if they ask what other investigations you know, go through your be boxes still, but always remember that they haven't done that other step to it. You want to send them off to culture them, especially if there's an infection showing. And then I've obviously put if you're asking something like a vaginal swab. You know, with most investigations and management, you will be awarded or you'll be acknowledged for, you know, going that one step further. So if you're offering a swab, what type of swab you can even differentiate and get it right, that's even better. Um, so the next step your your X so X rays and other imaging. So your chest X rays, abdominal X ray also ones, and then you get a bit more specific. So, really, I should have put like ultrasound a bit further up because that's a quite easy one to get. Um, so think about it in terms of what easier and what's more difficult to get in these situations, So an ultrasound would be pretty easy. A bladder scan would be relatively easy. Endoscopy and colonoscopy. They're quite easy to get as well, then you're getting onto the bit more difficult ones to order, so you have to justify justify them a bit more so ct, MRI, and then even some radio fluorescence imaging. If you've got, like, swallowing difficulties, you want to do like a barium swallow or something, or even like a swallow, uh, kind of an IV contrast study, for instance. Always remember when you're stating an imaging like a c T u N R I what type of what region do you want to to do it for and if there's going to be contrast and then obviously mentioned that there'll be contrast? Um, a good tip is, for instance, the MRI. Um, there was a station once where it was a quarterback whiner, and you didn't get awarded the mark for saying MRI unless you said an MRI of the whole spine. So you actually have to specify that it's got to be that whole region, you know? Um, really, if you're doing an MRI of the spine, it should be an MRI of the whole spine. Um, See ya. So your B boxes you've gone past the first to be is the office test the X rays. And now you want to A so e c g um, the reason why I've put what type is extra marks if you can say whether you want a three lead e c g or 12 e d c g or even a holter monitor. You know, I think a bit more specific. And it'll get you, you know, it makes you seem more professional and whether and then finally, your s. So this is, you know, very niche. And I couldn't really come up with much, Um because sometimes they fit into the different categories, but and as well, the, um it's quite quite difficult to think about them all, Um, but big ones that come to mind is things like spirometry. You might want to do a biopsy of something. And if if a patient comes in unwell and it's quite out of the blue, sometimes they usually just do an HIV test just to be certain. So, um, you know, if it's a new sepsis, you wouldn't be wrong and possibly suggesting HIV testing, you know? Um, yeah. So this is what this is a good way to actually think about the, um, investigations in a different way. Um, so particularly when you were in hospital, you can actually order specific investigation panels. And these basically touch all the bases of what I've kind of discussed. So, you know, you've all heard about the septic septic sex. That's the sepsis screen. So you do the three and three out? Um, I used pneumonic buffalo. So blood cultures You want to monitor the urine output? You want to give them fluids, start antibiotics. You want to check a lactate, and you also want to give them oxygen. So three and three out. Um, but yeah, that would be a sepsis screen, hyponatremia screen. It's, you know, the blood tests involved there. Um, you have a myeloma screen, you have a confusion screen, anemia screen, hypercalcemia screen and a liver screen. So what I would suggest is, let's say that you're really thinking this is hyponatremia, that the person's dehydrated. They haven't been drinking for the last seven days there, confused and agitated. And you're thinking this could be some kind of, uh, I pandemia than in your work up investigations. Rather than listing off you Annie's TFTs, I'm gonna do a serum osmolality. You can just say I'd like to do a full hyponatremia screen, and if they ask you to specify what that is, then you obviously can go into it. Um, but some examiners might actually award you for all of these investigations just because you said you'd like to do the full screen work up. So it's also a good way to just think about ones that kind of outside the box. I mean, particularly the liver screen. You know, it's got all the autoimmune antibodies, your test immunoglobulins and for one under trips and so on. Um, so I put this and I always called it the surgical spiel. Um, this is for any patient who's either going to surgery or likely going to need surgery. Um, and it's something that you should just throw out there as soon as you get an acute abdomen, case or station coming in so you want to catheterize them. You want to make sure they're know by mouth, possibly consider drip and suck, particularly if they're, um, so drip and suck. By the way, drip is your fluids. Suck is an N G tube that's basically there to remove any food and gunk. That's building up. They particularly use it if you have, like, an obstruction in your colon. So any bowel obstruction, basically, that needs surgery. They're gonna have drip and suck, forehand. Um, and then finally throwing in, Consider any meds that needs stopping. And also some vte prophyl access. And that can be either pharmacological or mechanical. Like ted stockings. Uh, there are. Oh, sorry. We're talking about management, but there are a couple of things you can add to acute stations like oxygen. Um, and, uh uh oh. Um, an investigation with acute stations. Just make sure you always stop, start, do with a I'm going to do an A two e. Uh, it's okay. Where's my was? Actually, I've actually got a bit on acute acute investigations management. Um, but yeah, this was quite right. Like, you know, that it's it's a different kind of set up for the whole. What investigations do you want to do? And what management do you kind of want to do for, uh, an acutely unwell patient? Um, so yeah. Anyway, management in a general sense, you've got three blocks. The one the left is conservative. The one in the middle is medical or your your drugs, And then the one on the right is your surgical so conservative treatment? Think about anyone who can get involved in the patient's care. Physios O t s. Um, they might even benefit from, um, uh, CBT for instants. Uh, just think about anyone you can get involved. Really? Diet and lifestyle modification. You can't really go wrong in suggesting that if they're a smoker, then obviously adding smoking cessation specifically, if there are alcohol dependent, then throw in alcohol cessation support services. And then I, uh, there's the other ones that you can get in hospital. So, like, 1 to 1 nursing barrier nursing, um, and then other things you can think about infectious control measures, um, walking, aids, bed alarms, and even sometimes vaccinations if they're not, if they've not had their vaccinations. So, you know, chronic condition patient's. They'll often need their annual influenza vaccine in there. B c G vaccines. So that's a good one to throw in road. Uh, we've got a couple of people asking, what is value in nursing? Right. So barrier nursing is, um it's a way to basically stop transmission. Um, no, I believe it is, um I believe it's a way to stop transmission to other patient's if you're acutely, uh, if you're infectious, um, so what it usually means is they have extra hygiene measures in place. Um, they'll normally be a specific nurse designated to that patient to make sure that they're kind of taken care of. And they'll normally be following strict protocols to avoid spreading that infection. You normally see it in like C diff patient, um, other kind of cases if you think about something that is kind of going to cause an outbreak, if it wasn't being controlled in a room, it's probably going to require barrier nursing. But C diff is the big one. So any patient with that, it's Barry nursing and uh, a point to note. You'll know if it's a C diff case. Obviously, the history will be quite important that the history is very important. But the biggest indicator is have they been on a very long course of antibiotics, Particularly careful ISP. Oren's like Kev, try accident or something, because that will instantly make you think. Oh, this isn't just a classic gastroenteritis. This is very likely cdiff. Um, is that the only question Wisma Or was there others? Yeah. No, that's it. That's it. Fine. So, um, very important medications. I mean, I'm not going to go through every medication of the sun you should possibly think about, because that that's just impossible. But these are ones that you know any person can just throw in, and it's very valid. So analgesia, any pain, any patient who has pain, you should always mention analgesia. It's something that can easily slip your mind. Um, but it's really important to say, because it will definitely be worth a mark. Um, and you've got your your who? Pain ladder Bonus marks. If you can actually say this specific dosing for some, so I I should have put usually paracetamol 500 mg 46 hourly. Um, if you just say 500 paracetamol, 500 mg, uh, max days 44 g, then that's fine. And morphine is kind of your heavy hitter, uh, 5 mg if they're having much stronger pain. It's like an acute abdomen case, for instance, or even like an m. I, um, don't sign antiemetics. That's a big one. So you obviously have your, uh, one's like histamine antagonists, dopamine antagonists and your serotonin antagonists. I'm pretty sure little antagonist, um, on Dan's Atran is is quite a good one. I was, um it fixes most nausea cases. And also, it's got a very low side effect profile. So that's quite a good one. Um, but it is dependent on the nausea itself. Uh, but on Dan's Atran is is quite a good one. But I wouldn't say Throw out an, uh, an anti emetic without making sure it's appropriate. Um, so, yeah, if if you don't know the anti emetic, it's better to say I'd like to prescribe an ANTIEMETIC and check which one would be best for the patient in that case, and if you know it even better. But don't don't just guess with medications, other important things to mention oxygen. If you mention the delivery system great, that's even better fluids. Same thing again if you mention how much I'd like to give this person to find mill bolus over 15 minutes. Great. Um, and then thromboprophylaxis, uh, and that one's a bit difficult to judge, so usually it's It's more dependent on kind of what the surgeons and what the senior doctors would want to do in those cases. So, um, important tips. I can say you don't forget the obvious things to actually say in your management. So if someone's having allergic reaction, you actually get a mark for saying I'd like to remove the trigger or stop the treatment. It seems so obvious and so stupid to to not think about doing that. But it's very easy in those moments to actually forget to say that obvious thing because you think, Oh, I would, uh, immediate do that anyway, So that's a big one that often has missed, um, and something I always say at the end of listing off my medications to put you in the safe side. Uh, and it does kind of safety net you to avoid Possibly getting a red flag is saying I'd like to check the B N f before starting these treatments to ensure there's no contraindications. So even if I mean, that's the thing. If the patient's in their in their history, you forgot to ask about allergies, and then you've gone on to prescribe them. You said, Oh, I think that it's a pneumonias, so they'll need a amoxicillin, and the examiners like, okay, right This is definitely looking like a red flag. And then you said at the end, and I'd like to check with the patient, So actually, I should have put that there. But I'd like to check with the patient whether they have any allergies. And I'd also like to check the PNF to make sure there's no contraindications to any of the drugs instantly. Then the examiners like, Well, I can't give them a red flag in any of these. It's a really good way of safety netting you, um right, so a keep management. It's a bit different to what we kind of discussed. So rather than, you know, I'd like to take a conservative medical surgical approach instead. This is like, right, I need to stabilize this patient. So first thing you have to say, I'd like to take an eight. We approach, and when you're thinking eight, we approach that. It's not sufficient to just say that you should also back it up with what things are particularly important in particular stages, and that's why he depended on the presentation. You can never go wrong for saying the oxygen you can never go wrong for saying I'd like to set up to your wide or cannula in each are. And if they need fluids and they need pain relief, then those are also very valid. To mention the other things to mention kind of in the A to a depends on the snow. And I've given you a scenario there with anaphylaxis. I wouldn't want to say, Oh, I'd like to check their glucose at D because it's not. It doesn't really have any relevance renflexis. But when I'm going to a I'm definitely wanting to make sure that I'm going to check. Their airway is stable and if it's not, then perform airway maneuvers and possibly use adjuncts. So it shows the Examiner that you're definitely predicting where you're going to have to intervene, which is good. Once you've gone through the A to A, you should always back up with the senior support as well. Um, you shouldn't just mention senior support, and that's it. You should always mention who you actually want to have help from. It will normally be your Reg, because obviously you're an F one and these scenarios, so if your medical, then it'll be the medical Reg. If you're on the surgical ward. It will be the surgical Reg and that those are your seniors. So it won't be the gastroenterologist or the anesthetist. It will be your Reg as your senior and now contact anyone else who need help, who they need help with. Um, if the patient is actually going to crash. So it's a scenario where they've told you. So this patient's now gone into cardiac arrest and you've not even gone through your management then that instantly kind of it doesn't negate the A to A You should say I'd like to take an eight. We approach. Then once you've established that, they're in cardiac arrest. Oh, sorry. You take the eight we approach, but as you're doing that, you should state that you would like help. So pulling the alarm to bring help to you and then asking them to put out to to to call Sorry, I'm trying to think because all these things actually happen simultaneously. There's not really stages to it, but in a cardiac arrest, it's you come to the patient, you've immediately pulled the alarm. You'll be doing your A to a and normally you've got to a you've got to be. The person is not breathing. And as you've been doing that assessment, a nurses run over and you're like, right put out to to to call and instantly. Then they'll go away and you'll basically be doing your, you know, chest compressions and everything. And then the whole cardiac arrest team will come to you. That's the stages. So really, your job in what the state is A to a putting out to to to call and starting just compressions. If the patient as an arrest, Um, and then if they want you to add, if they're waiting for you to add extra stuff, obviously you can, you know, go through your whole cardiac arrest management. But that's kind of your own independent learning if you want to. Wow, the examiner on the day. Um, okay, so s bars. You get them in your acute your inter professional communication stations. It's normally a acute history that you'll take so four minutes, and then you'll get given most likely something. You found some things you found on examination and also Sorry, something's you found an examination and also a news chart s bar stands for your situation. Battleground assessment recommendation, and I go through each one of these, by the way, before you actually do your rest bar, you can write down certain things that you want to mention your ESP are they allow you to do that on a piece of paper? So, um, I don't think you just have to remember all the stuff in your head, but definitely think, How will I want to document this for myself? You know, how can I write things shorthand for instants. So when I'm kind of referencing this while I'm referring, you know, will it kind of prompt me and make me get through it quickly, but also succinctly. Okay, so your first is s situation. So it always should be who you are, where you're phoning for. And, uh, if you can't remember where you're phoning from, then you know it's just sufficient to say hi. This is Rhona fits child, one of the F one doctor's phone phone from the ward. Okay. They're not gonna mark you down on it. Um, it just means that you know, you're not remembering where you are. You have to remember those insignificant details. Then you should confirm you're speaking to you know, do it in a polite way. So can I confirm that I'm speaking to They'll say who they are and then always ask them, Do you do you have time to discuss a patient and dependent on how you ask? This is quite, um, person into the case. If they're acutely unwell, which most likely a four minute history, they always are. You should always follow it. You always should kind of say, Within this there's a patient I'm a bit concerned about. Do you have time to discuss this patient? Because then you've added the concern, and also you've asked, Do they have times you're being polite in that sense, and then once they most likely said they might, there might be a bit resistant and say, Yeah, I'm a bit busy at the moment, but go on, set the scene. So you know this is a patient called Rhys Jones. He's a 65 year old male who was presented of abdominal pain. This has been going on for the last two weeks. I believe this means in toxemia so really from your history. You already have your differential diagnosis. Yeah, So you should first set the scene in terms of patient name, age, gender, obviously presenting complaint. Maybe add on how long it's been going on for so differentiate. Whether it's acute or chronic, it will always be acute. Yeah, and then state your differential And your differential is the the attention grabber. Because as soon as they hear that, that's when they're like, Okay, right, this is serious. And that's when you go onto your background. So give the whole history. You know, it's much same when you're presenting to an examiner, there's no real difference. So pain is in the writer, and it doesn't you know, I've This isn't actually fitting of amusing Turks scheme. Yeah, I kind of just through some stuff in here because it means that they might actually pick apart your history and say, Oh, you sure about that which, in that case, then they might actually prompting you to say something different and, uh, come up with the right differential within the realms of the examination, if you will. So give the description quickly. Say, uh, you know, they're they're red flags that you've ruled out then kind of tacking the most important bits of their past Medical history and I would normally say just one or two is fine. Think about the big ones. So if it's mesenteric ischemia and they said they've got a that's really important. If they say they're a smoker again, that's a big one. If they're a lorry driver and when they when you were taking a social history, if you had the time, it's not as important. Then you go onto a, which is assessment. So this is what the Examiner obviously gives you possibly. Um, so you'll state what you think of important details in the examination and the news chart. And, um, if they've given you more news charts, so one from before they were not and well and then one where they are. And well, then obviously you want to mention the changes that you're seeing. If you're looking at two, then firstly state what they are at that moment. So they're scoring a news at the moment and then say which one's actually have worsened since they kind of weren't admitted. So if they always had a high BP and now their BP is still high, But it's at the same level, you're not as worried. But if their temperature has just gone through the roof, then you're possibly thinking this is like infection or sepsis. And then finally, your are is your recommendations. So, um, this is where you should reinforce your provisional so kind of go back saying so I do think this is, um, use enteric ischemia. But other things that I am possibly thinking are XY Zad, Um, state what you have done if you have done anything on the scenario, But if you haven't done anything, then this is a good opportunity to show the examiner that you're actually, you know, thinking about things already. So say I'm going to do a full work up for the patient, so I'll order, so I'll do some bloods for them. I'll also do a urine dipstick. And, um, do you want me to also refer them for an abdominal X ray? Um, just throw some things in, and then very, it's very dependent what your next step is. But normally it's either to ask them to come review the patient if they're acutely unwell. If they're acutely unwell, it should always be there coming. You want them to come review that patient themselves. If they're it's a chronic thing, then it's more asking them what their opinion is, whether they think it's the same kind of diagnosis, whether there's any investigations, that they can prompt you to order and then go from there, um, with them coming to review the patient always tack on at the end. It's a good thing to kind of show that you're working within the team and helping them along the way is Oh, is there anything that you'd want whether you want me to do in the meantime, while I'm asking while I'm waiting for you to come down and most likely they'll say they'll say no. But if they do, then it's them just playing into the snow. Yeah, when you reference them, uh, I'd I'd like you to come down to review the patient. Always kind of follow up with what time frame You'd like them to do it because they'll be busy. So, you know, if it's a cute I'm thinking within the next 10 to 15 minutes, Um, but yeah, uh, yeah, that's that's the whole presentation, guys. So actually, that went much quicker. So we have a lot of time for questions. If you do have any, um, and then I'll go on to this. Talk about the things I've mentioned her. Any questions? Um, Roden, can I share my feedback for this? Like, Yes, yes. Absolutely. Sorry. Hold on. Stop. Uh, there we go. Yeah, if you guys could do the feedback, that would be much appreciated. I'm sorry. My laptop, this bit snow. Uh, right. Um, yeah, we were going to mention it. Um, so I've got a question regarding the 1 to 1 session. So if time permits, if you guys are quite keen, uh, we'll try and see if we can make slots in if, um for, like, 1 to 1 session. So maybe you can even practice your s bar from based on what? Running and talk today? Um, or it could be CBD help, whatever you want, but, uh, we will send you more details about that. Uh, once we sort out our calendar and everything, uh, you will have to sign up separately because, um, it is 1 to 1, and I think, uh, everyone wants to join in. So, um, you you will have to sign up for it, but I'll send you the instructions later on. Um, yeah. Mhm. Any more questions? Anything that you want me to go back over. I mean, I finished earlier than expected, but my mouth is moving at 100 miles per hour, so that's probably why no silence is usually good. Oh, actually, I should probably mention that. Was there anything else that I need to mention for the reminders? Uh, we'll send the recordings for everything. Um, or Christmas as well. So that's fine. Uh, can you Can you stop the recording? Yes. Yeah. Um, I think I think that's about it. Um, yeah, just