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The people are waiting. Ok, cool, perfect. Ok. Hello, everyone. I hope you can hear us. Can you just message in the chat so we can be sure that you can hear us, that you can hear me? Ok, cool. Thank you. Ok. Hi, everyone. Really nice to see you all. Um We're just gonna wait for a few minutes just so that people join and then we'll crack on and stop. Ok. Should we start then? Doctor? Let's make a hi everyone. Welcome to our webinar today. Uh This is our introduction to our new series About Medical Clark. Um So thank you for joining us. Um So I'm gonna hand over to Doctor Marcus in a bit. I just wanted to go through a few housekeeping rules. So if you have any questions, um, please do, just type them in the chat and then we'll get back to them at the end once he's finished presenting and then we'll go through those and also we have a feedback form that we'd like everyone to fill out if that's ok. So you can get your attendance certificate. Um So yes, so this is Doctor Marcus Dawson. He's an IMT three now um as of recent um and he works in the east of England in Colchester. So thank you doctor and you can take it away Joni. Thank you very much Jim and welcome everybody. Um So yeah, really excited to be with you guys um to go through some aspects of me, Medical Clark and this will be uh an introduction into the series and we delve into a lot more cases um over the next few weeks. Um and this introduction is aimed at those who are either new graduates or new um or soon to be graduates. I myself graduate from Sophia University uh in 2019. And I've now just become a new medical registrar. So I want to pass on sort of any tips and tricks I have uh to you guys who are looking to come to the UK or any hospital for that matter in the near future. Um So for this talk, if I, if we look at what we're going to be mentioning, so it's where Clark is in the process of the admission process within hospital. Um We're gonna mention what you do before you see the patient um using the electronic notes, key features of the presenting history and the social history. Uh just having a brief run through of the a week examination that you need to carry out. Uh a few words on the drug chart mentioned in both new and existing medications, the patient might be on and on the right side of the screen. So what we have is our learning objectives for this talk and indeed the series and really, it's all about building confidence in taking a history, er what to look out for examination and how to formulate initial management plans um mentioned in things that may not have been covered in international universities. So that's things like social circumstances which are a very big part of our work here. So things around alcohol, tobacco use and social care needs as our population in the UK gets older. Um And without for a do, we'll, we'll delve into things. So firstly, what is clogging and what is the larking process? So it's for patients who have been admitted to hospital and accepted by the medical team, whether that's from A&E or a GP practice or, or anywhere really. Um what it entails is taking the history of the patient examining, doing the first examination of the patient, uh interpreting any blood tests or other tests, requesting investigations, your cells, whether that's xrays CT scans or anything else and then formulating an initial management plan. Um Typically this takes the average sho anywhere from like 1.5 to 2 hours. Although it's not a race, it very much depends on complexity. Um There's no real target initially, but as you will speed up as, as time goes by, uh often you're seeing patients who are in A&E or in our hospital, um the emergency assessment unit where we have a day unit for patients referred from GP practices and we have a bedded unit as well. So I had a, a medical student follow me recently and she was really interested in how long it takes until a consultant next comes along. So what I said is that your initial management plan uh needs to keep the patient safe until the consultant sees your patient, which can be anywhere from just a few minutes if it's in the middle of a daytime shift and lots of consultants are on or it could be as late as overnight or even a day later. So no one will routinely review your patient unless they become further unwell. So that's the sort of time frame in which your your management plan so needs to hold the patient really. So I got a few tips on how to see the patient and what to do before we even go to the bedside. Uh Here in the UK, we have lots of electronic note systems. Um not all of it is joined up, but it, it serves a good purpose nonetheless. And what we look at is previous discharge summaries, particularly if something's really recent. It's um a treasure trove of information and no doubt you can get really great history that way. Other things we have access to is GP summary care records which will include the last few consultations. Um The, the continuous medicines that the patient's on and any recent meds like antibiotics that are being prescribed in the last week or so. Um depending on the what case you pick up, um using previous scans. So if someone's in heart failure, you know, the most recent echo would be really helpful if they have a malignancy, sort of the most recent ct scan that shows the extent of metastatic disease would be, be really important for infections. Um Previous microbiology reports definitely have a look into them before you ever see your patient. See if there's any blood cultures or urine cultures or any antibiotics to avoid, that have proven to be resistant to the bugs that are typically found in that patient. Um Blood tests, historic blood tests are freely available. And more importantly. Now, since COVID, we've been a lot more focused on ascertaining what the resuscitation status should be for our patients and any advanced directives. Um So this is all stored in electronic notes or can be seen from scans of the paper notes from previous admissions, but it does vary from hospital to hospital. Um So we'll show our Clocking booklet in just a moment, but you, you need to be summarizing or jotting down those tests that you see from, from what you've cleaned and then looking to take a focused history from the patient based on their admitting complaint. So a really thorough respiratory exam, if they have a chest infection or if they're in heart failure, a good fluid status examination would be the the key part um with history. So in our, in our book, we have a Social History and a Collateral history section. If that's relevant for your patients, um you've got a space to document your examination findings. And regardless of the omitting complaint. As soon as they've been referred into medicine, every patient should have a basic examination of uh auscultation of heart sounds, auscultation of the lungs. Um, palpation of the legs. If there's any peripheral edema or wounds of any nature, then with all that you're forming an impression of what you think is going on or differential diagnosis. If you're, if you're competent and then formulating a, a management plan and we'll, we'll touch on that later, but really important that you're not starting from a blank slate. There's always some preceding information that you should hear. And if the patient's been brought in by ambulance, you've got the ambulance admission notes as well. And that's a great source of information if they've been in the patient home. So this is an example of our Clocking booklet that we fill out for every patient that gets referred. So we've got any special tests, uh, blood tests, any ECG S or comment on or comment on any chest x-ray that may already be done. Um And on the next page, your examination findings, any observations that the Ed Department have already done really important to get the allergies and any reactions to the allergies. So, allergic to penicillin is one thing. But can you be more clear and say this is a anaphylactic reaction or it's something less severe, like diarrhea or flushing or something? Um, and I will just head back to our management plan. So, differential diagnosis up here and a multi step management plan and this can be simple things like antibiotics, fluids. Um, do you need to catheterize the patient? Do you need extra blood tests? Um And this is where you're gonna, the nurses are gonna act on that until the patient is next seen by the consultant. From which time there'll be a second plan in place. So, something that I found wasn't well taught so much in Sophia University and that was really looking into the social history and looking at frailty and it is something that a lot more focused on in the NHS. Um always document any smoking history and pack history. So one pack is 20 cigarettes for. How long have they been smoking? The equivalent of one pack a day? Uh Alcohol in estimated units be as precise as you can. Um, don't let the patient get away with. Oh, yeah, it's a little bit more, it's a little bit less really try and get, push them for a number and if appropriate to ask any recreational drugs. Um, if so how often and how are they taken? Uh Obviously it's not appropriate for every patient, but it, it can be very important in information and then looking at frailty, um questions that are really important to ask can be. What's the patient's walking distance? Are they able to walk miles? Only a few 100 yards, stopping for breathlessness or chest pain with angina or just uh musculoskeletal issues like arthritis. And some patients have really frail to the point where they, they could be just walking room to room in the house or, or even bed balance and not walking at all. And it's really important to get those details down. Um early on in the admission process, lots of our elderly patients have carers in the UK. We can have carers come to the home as much as four times a day, as little as once. Um otherwise, anything further than that, they may be needing a care home or a residential home. And all this can be scaled on a clinical frailty score. Something that's quite passionately used here at Colchester where the very fit grade is one, those who are extremely frail is eight and terminally ill is nine. And that just quantifies how frail your patient is and what sort of treatment and escalation of treatments they may be indicated for, for instance, if your patient were to then deteriorate and the a clinical ty score of eight, they wouldn't necessarily be the best candidate for intensive care treatment. And that'll be really clear from your notes. If anything in the future were to happen. Uh One of my key questions I almost always ask for elderly patients is who does your food shopping? Because it shows that you're cognitively intact. We're able to manage money and either you're mobile enough to go around a shop or you can drive a car, which all just gives you so much information about how the patient is managing at home before coming into hospital. And that's without knowing anything about their, their true medical complaint and the past medical history. So what's important here is listing down all the past medical diagnoses that are available and making sure that the drug list that you can find for the patient corresponds accurately with all the past medical conditions. So it's absolutely fine to list them off one by one. And often patients are multi morbid and have multiple diagnoses at the same time. Um It's really helpful if you can be slightly more accurate and contextualize things. So heart failure just saying heart failure is is one thing but to take your history and your clocking sort of the next level, um documenting any previous echo findings or the ejection fraction. So how bad is that heart failure and getting that accurate information early if available? Of course, um is super helpful, particularly if your patients going to cardiology ward where they're going to want a lot more information. Um Noting down any recent microbiology results is really helpful for infections. Um or for instance, with COPD patients, uh certainly get the smoking history in there. But alongside do they have any spirometry or specific tests to define how severe their COPD COPD is? Um So for instance, on the left, we got the table of medicines. So if your patient had af atrial fibrillation, you'd expect to see certain medicines. So a rate control medicine, bisoprolol and an anticoagulant, Apixaban, we commonly use COPD. You have the inhalers for heart failure. You got a combination of medicines and for BPH, benign prostatic hyperplasia in men, uh often you see finasteride and tamsulosin as, as common medicines. So it's just making sure that the admission medicines sort of match your past medical history of your patient. So at that point, we just take a small break just to, I'll just check the chat here, see if there's any burning questions, but having that brief overview of where clocking sits and, and what we tend to do and the booklet that we're filling out to make sure we're not forgetting any, any parts of our checklist. I'll run through a case that I saw a little while ago, er, just a, a month or so ago when I was doing one of my, um, my clerk in shifts recently. So our first case is quite a typical case for this area in this region of the country. So it's an 85 year old gentleman admitted after being found on the floor of his home by his carers in the morning who then raised the alarm and called the ambulance. So from the ambulance notes, you know that he's got no significant injuries, the crew assistant to his feet and he was then able to walk. It was unclear and he wasn't able to give a history about how long he'd been on the floor for. Um, but he did say he was walking to the bathroom at night and he was found, tumbled at the bath with a walking stick by his side. That's typically the very the amount of information you'd get from the ambulance notes and you may have some observations and some, some other things. So you have a past medical history that you get from the electronic notes and you can see his GP records. So he's got high BP, which he's on two medicines for. He's got benign prostatic hyperplasia. He's on tamsulosin, which I'll explain is an particular drug is an alpha selective alpha blocker that eases the urinary tension that can come about. Uh He's a type two diabetic. He's on Metformin and glipiZIDE, which is a sulfa and to go alongside that very unclear history. So he's got an element of cognitive impairment, but he hasn't got a formal diagnosis of dementia, at least not yet. So this is the point where I'd, I'd start to make my way to the patient. Um But before even seeing the patient, what you want to have a look at is so what could have caused this gentleman to fall. Um, he's on some anti attentive, he's on a lot of medicines and Jemima has helpful, put up our poll, um, which I'd love for you to get involved in. Just have a think about what you might think is the most likely cause of, of this elderly gentleman's fall. So I'm just the results of our, our chat and we've got some, a really good spread of ideas with 11 winner being hypotension. It's probably a good shout but not to mention the other ones could be a factor as well. We haven't quite done enough digging. So if I go a little bit more into things, if I tell you the drugs that he's on and the doses, so amLODIPine and Ramipril. AmLODIPine can go as high as 10 ramipril again, can be 10 mg. Uh Bisoprolol is at max dose of 10 BPH. She's on tamsulosin standard dose. He's on a sulfonylurea uh 80 mg and his Metformin is just a gram twice day daily. Um So his observations, he's been in A&E they've taken some s and they've probably done some bloods by now. Um So he's got a respiratory rate of 18 heart rate of 59 BP. 100 and 5/64. He's 95% on a sats and he's AFIB. Well, uh his blood glucose is a little bit on the low side. 3.9 but not, not too low and he's perfectly coherent. His G CS score was 15. So looking at those odds, you know, would anyone want to change their answer or does it give them more confidence into their answer? Um It's a, it's not really possible to be sure at the moment, but you wanna be having those ideas in your head. So when you're asking the questions to the patient, you wanna think about symptoms of hypoglycemia, ask about hypotension, ask about symptoms of a slow heart rate. So if you can see the cha so hypertension is our clear winner, hypoglycemia and then a a few other answers for, for the other causes. So if we skip on and if I tell you that there's, there's no one obvious clear cause. But one thing you can say, um yes, I I'd agree with the majority, the 58% of our audience saying that hypotension is, is a key factor here. It could be the the most likely diagnosis. Um But there's also a few risk factors alongside that in his medicines and how he's managed. Um But really, this is a classic old person falling over with multiple reasons to be having a fall in the home, multiple comorbidities, advanced age, physically, quite frail, um and possibly over medicalized as well, and we'll touch on that in just a moment. Um So let me just roll through. So if hypotension being the key one, So let's dig into that a little more. So, taking his history, uh what you wanna be asking? So, key questions amongst a whole host of others. What time did you fall? How long have you been on the floor? Um Typically with uh long injuries, long falls. Um What you can have is rhabdomyolysis. If you've been in a certain position for far too long, patients can be on the floor for 12, 14, however many hours, um, they typically get a muscle breakdown and then a secondary kidney injury. Um, how many falls has he had? And that's trying to ascertain. Is he fell once ever or is this something that keeps happening over and over? Um, although he's elderly, you might not think he's a drinker of alcohol, but it's best not to approach anything with any bias. Um, and just ensuring that he's taking his medicine regularly, for instance, if he's got a bit of cognitive impairment and he's taking too much of one medicine or not enough of another. Uh, medicine misuse can be a, a key feature for his fall and just getting a grip of his social situation at home. So does he have someone nearby that you can call for help or is he home alone where he won't be looked in on, on a regular basis? So with the examination, um for this gentleman, I've touched on a few things, I won't go too heavy on examination. It's as best, best done um as a bedside teaching ideally but really a fluid status examination. So feeling his peripheries. Is he cool? Really clammy? Yeah, capillary refill time anywhere less than two seconds is, is the normal 2 to 3 seconds is leading yourself to dehydration. Uh looking at the all mucosa for again, fluid status, checking the JVP. Um putting the patient to one side, pressing on the abdomen. Does it raise? Can you see it? Um other things as part of our general medical examination for someone falling over like this and a a lower BP, you could easily have a mist or or never previously diagnosed aortic stenosis. That's you can then hear a murmur and that's leading you towards your diagnosis. Obviously, his dementia is in the background. Um in our Clark in booklet, we have a, a 10 point score that we assess confusion on asking questions like how to remember a street address your age, date of birth. Really simple questions. But you'll be amazed that some people can sometimes answer zero out of them correctly. Um And then the mobility. So this man's fell over. Um Common things are common. So fractured hips in the elderly. So just a a brief test. Can they move their leg as a straight leg up and down on the bed? Can you lean it out to the side and do you, can the patient do that themselves as an active movement or is there any pain when you take the, the weight of the leg and you move it for them. Is there pain there, pain on passive movement is a big worry for um any broken bones and it'd be really prudent at that point to get an x-ray of the pelvis and the hip, either left or right. So some key tests that we want and importantly, these aren't fancy scans and lots of complicated tests. A lot of them are at the bedside or, or simple blood tests. So, for this man, the line of standing BP is, is the absolute key. Um So having stand up for 30 seconds, then two minutes, then five minutes is his BP dropping. Does he have a an autonomic instability that's leading to low BP when he stands up naturally, that'll be uh aggravated by the amLODIPine and the Ramipril and even the bisoprolol that he's taking. And if he's lying, standing BP, there's a big drop. Anything over 20 millimeters of mercury of the systolic is clinically significant. You'd have your evidence then to say that this man's over medicated, you'd want to cut down on his uh antihypertensives um quite significantly the next. So he's on glipiZIDE. So, the interesting thing about glipiZIDE rather than Metformin is that it can cause active hypoglycemia. Um If this man's getting restless throughout the night or he's taking his medicine at the wrong time, Sulfon, I urea can be a really dangerous drug. Um Metformin, not so much because Metformin won't cause active hypoglycemia. It'll just prevent um the higher end of the scale. So what you want to do for that is add on, you can do add on blood. So this de chaps had a full blood count and a use and or renal function you can add on previous tests. The lab will keep the sample for a later date and you can test his HBA A one C to see if his glycemic is control is too tight. Um And that'll be super helpful and for, for changing his medicines in the near future. Um FBC is a standard blood test just again, ruling out he's not anemic and if you did have even a mild anemia that's quite common, um then adding on a an iron studies later on would be helpful to ascertain if he's iron deficient anemic. And that's something you can correct with uh iron replacement tablets or an infusion and find out a more particular cause. And then looking at um his bradycardia, so he had a heart rate of 59 which technically is bradycardic, although it's absolutely on the border. Um looking into that further, is that because he's on bisoprolol or is that because he's got something in his ECG? So has he got a, a certain type of block or any other reason to be bradycardic? And as part of the standard blood you often see from A&E so you get the FPC S, you get the ene and that's to look at his um renal function. And in this case, can you rule out an A K I, can you rule out that he's not dehydrated? So, dehydration on the blood tests sky high urea, in comparison to the creatinine would suggest a dehydration as a possible cause but not the only cause and some further tests. So for patients admitted to medicine of this particular type, for instance, who are comorbid um getting a chest x-ray as a baseline investigation can be really helpful. There's lots of uh incidental findings that that come about from admission chest x-rays. Uh So a bladder scan, just a very quick bedside um ultrasound scan that the nurses can do and that's to, to rule out that he's not retaining lots of urine. Um And in fact, he's in a overflow of urine and that's what's causing his frequent urination at night. Um And if there's any on the blood tests, say we mentioned you can do add on blood. So shortens our time and iron studies in someone like them, a vitamin D and a calcium. So a bone profile um as they can all be supplemented to good effect. So it's just about thinking. So not only the acute admission and the immediate presenting complaint, but looking a bit further as well into things and trying to correct what you can correct whilst he's in hospital. So the plan how we investigate him. So, what we have to do on every patient who come in is prescribed their regular medicines and make any changes that you need to make. So, if he's hypotensive bradycardic, he can't have such a high dose, at least of bisoprolol and the antihypertensives that he was on uh, fluid rehydration. You've identified that he's dehydrated on a clinical examination. Is he someone who can just drink all fluids or does he need an IV fluid boost? Um with the urine, you've done a bladder scan. If he's in urinary retention, you could catheterize and make that in your plan. Um If not, you can rule it out as a problem and no need for a catheter and then other things that we're thinking about, not so immediately but flagging, flagging this patient up to other multidisciplinary colleagues who we have it available. So, does this gentleman need physio? So physios can get involved. He's someone who's been walking with a stick at home, but does he need something that's a bit more secure, like a walking frame or could he benefit from even a wheelchair? Um And your occupational therapist there in phase five. So that's thinking about when this chap goes home. What could he need? So you can have false alarm, a bracelet around the wrist that can detect a fall or you press a button to raise, raise the alarm. Um Does he need any increased care? Does he need more frequent care visits knowing that he's at risk of falling or in fact, is he so frail that maybe he would be best off in a care home. And this is the thing that the sort of the occupational therapist and the physiotherapy team can help and advise on. So to conclude this case, um this 65 year old man ended up going home. Three days later, his standing BP was normal only once we gave some IV fluid. Otherwise he had a, a symptomatic drop. He was dizzy when he was standing for anything longer than 50 seconds. His bradycardia so common thing of geriatricians and those in elderly care medicine often stopping medicines rather than starting them. So we reduced his bisoprolol. Um His amLODIPine was just stopped altogether. And in addition, the glipiZIDE was stopped as he was hitting his target range of glucose in hospital, which was anywhere from 5 to 15. Then looking at what our MDT multidisciplinary team colleagues, er suggested for us, they said he should have four times a day care rather than twice and he was still too, too fit and well in himself to need a care home at this stage. Um In addition, the blood test, we did. So not only we did a diagnosis by getting our ruling blood test, which was the the li standing uh BP, but in fact, we ruled out that he didn't have any renal dysfunction. We disproved that he didn't have any bladder dysfunction, he wasn't in excessive attention. So lots of tests then became negative, but they're equally helpful to making sure we haven't got um, further problems on our hand. So that concludes the, the main point of this talk. Um So as a really brief starting to this whole series, so where does Clark really sit in the hospital process and what your job as a, as a junior doctor or as an F one, what you'll be expected to do? Um paying particular attention to his drug chart, prescribing any new and existing medicines with any modification that you need to really important to use. The previous sources of information that you can as there's lots of information now online before you ever see the patient, um I want to try and get across that you want to go to your patient with a little bit of agenda in mind rather than be sort of clocking and asking the history from a complete blank slate. Just having a little indication as to what might be going on is really good. So you can ask specific questions um and conduct the the patient interview on, on more your terms getting the simple bedside test. So lying and stand blood pressures, ecg simple bloods, they don't cost a lot of money they're quick to do and then really helpful is there's a good turnaround time. Um We mentioned about prescribing regular medicines with caution, not just blindly copying down what his admission medication was and that's what he should still be on. You have to use your own judgment as to edit his, his medical chart and something that wasn't much touched on in medical universities where I studied, but involving multidisciplinary teams. So, physios, occupational therapists and anyone else who would be important to involve in a sort of a discharge process. And I think that's all we have for tonight. So I just wanna thank you very much for your time and, and your attention. Um And I'm happy to take any questions and I'll just see one quick question in the chat, but I'll be happy to um answer any questions that people may have. Ok, so we have um some comments. Uh mm ok. Last question is how far into the past medical history should you ask about? Or do you only ask about the relevant history? Um I ask about definitely start off by asking about the most relevant history. Um And if you find you have time, you can ask the patient. If they, if they're a good historian, they can be really helpful. Um But if they give you really vague information that maybe isn't that useful? I was on some red pill or blue pill that doesn't really help you at all. So I think it depends on what information they can give you. Um and more use them to fill in the information that you haven't got yourself so often. Scans of blood tests are all online beforehand. Um Maybe just go to the patient and, and ask what you don't already know and they may not know the answer and that's fine. You can leave that as a as something to be discovered later on. Ok, perfect. And then the next question was um how do you handle patients who are unable with a clear history? Let's stay with this patient that he wasn't coherent or that he did have um like diagnosed dementia. Yeah. Um So in that case, it all that we spoke about the extent of online notes is probably the key source. Um A&E if I seen the patient already and the patient's been brought in by ambulance, you'll have the ambulance notes and you may have some very, very brief A&E notes, but really it's gonna be rather than the history, you're gonna go more on your examination findings, you're gonna go more on um the patient's background. So if he's on those medicines, your differential diagnosis, you can only formulate one without needing him to say anything much at all. If you're really stuck, you can ask, you can ring the care home or ring family members as long as it's not too early in the morning or late at night. Um and getting that collateral history, it takes a bit of time, but no doubt you get a really good picture of what's going on. Um So if you're really stuck calling the next of kin. Um It is definitely the next best shout. OK. Um Another question is, what do you do if you can't come to a diagnosis? Yeah. So really good question is actually um so there's a few things you can do if there's something that you feel that you should be able to diagnose or you have a list of things, but you're not sure what is sort of diagnosis. Number one. there's no harm to ask the medical who or the consultant who's coming around after you to either see your patient first or to just ask some advice from the mere who can talk you through the case as they'll be somewhat familiar with all the patients on the list. Anyway, they should be able to guide you. And I guess the other thing is we don't always get to a diagnosis. So lots of things are either really complicated or really rare and we don't come to an immediate diagnosis. So as an acute hospital admission, um you may have to then just progress the patient's case further forwards without coming to a firm diagnosis. So you could, let's say chest pain really important to rule out that it's not a cardiac um cardiac event. So you get an ecg get a troponin. So if it isn't a heart attack and it isn't a pe or isn't something else, well, it's probably something that isn't very dangerous and can be addressed at a later time. So ruling out the really important things, keeping the patient safe and looking at the detail later on once, you know that it isn't something, um, something to worry about. Yeah, that happens quite, quite often is the case. I'd say that makes sense. Um, ok, this person asked Maria said, um, for surgical cla do you have any advice? And are there any particular things to be tested, investigations, medication changes, I guess specifically for like um lots of the same process is very much the same with surgical ing. It's often a lot briefer. Um You're naturally not too worried about um things that medics are worried about. You wanna get detail any previous operations and scars. Um So examining the abdomen is the more, more of the focus more often um knowing your surgical scars. Um it is a really helpful one. and a lot of it say follows the the very same process, but your examination is going to be different, for instance, you know, identifying any right upper quadrant pain Murphy's test all your clinical tests. Mc Burney Point for appendicitis just having those basics of the the clinical examination. So when the surgeon comes round later on, all the basics have been done and they're just filling in any details. So it it generally follows the same, the same format. Ok. And um Toyo asked, what advice do you have to form a differential? Sometimes I find it hard and tend to focus heavily on one potential diagnosis instead of having a short list to narrow down probably because of how practice questions work. Yeah. Um yeah, often practice questions can be quite leading. Um So it's often fine to say you may have one, you know, very clear differential or diagnosis or impression of what's going on. But it's often the case you see later on you have query that this could be, you know, chest pain of unclear cause or you can be even more broad than that um unclear cause for symptoms if they have recurrent chest pain and, and know what you've done all the the key tests in the past or dis amis and no one's come to a diagnosis. So there's no harm in keeping it broad. Um What you probably don't want to do is rule out things that haven't truly been ruled, ruled out. So let's say this chest pain patient hasn't yet had a chest x-ray, potentially it could be a pneumo. So I think rather than um listing lots of different things, it's important, maybe don't rule out things that you haven't fully ruled out and you can leave things open for discussion later on. So chest pain unlikely to be cardiac given the ecg and trop in a normal um and then focused on the respiratory system or just directing the, the consultant to the work that you have done and you then shift their attention on on to what you want to focus on. So there's no harm in giving a really broad list. Um, but just make sure you're, you're not misleading, you're not ruling out things that you haven't truly ruled out. Yeah, that makes sense as well. Um, ok, another question is how would you go about on call, patient reviews? So slightly off the, the topic of medical clocking. But, um, the other role of F ones in our hospital at least is to go see patients on the ward with high or abnormal observations that we have in a new score that's anywhere from 0 to 20. Um, the higher the score, the, the worse the observations there, it can be a lot more complicated as the, the note taking is usually a lot larger and you've got a lot more information to read through. So it's not uncommon if patients been in for weeks to have stacks of medical notes that you need to sort of get to grips with. Um, but ti it about following an A T assessment, um, keeping things as, as simple as you can and on call work. So you don't have much available to you overnight. You don't have specialist teams. You've got, you may get a blood test back in a few hours. Um, you can do investigations. You got s you got a chest x-ray and you've got blood gasses and you haven't really got a lot else except maybe ECG S. So it's about stripping it back and just taking it to a t assessments. Um, simple treatments and, and uh, and simple investigations. Really? Ok. I have two more questions. It says, will you only be cla in patients who have already been admitted by an ed or will you be making the decision about if they will be admitted and which they'll be under? Yeah. So no, the A&E they decide which team the, the patient should be under and then they refer to the medical registrar, the medical reg either accepts or says something else. So if they've been accepted the medicine, they've been accepted for admission already. Um Your job, not as an F one, but as an F two, you can discharge patients. But let's say the admission is you're waiting for a second troponin and the troponin is fine. Patient doesn't have any chest pain. Yeah, potentially that patient could go home. Um So you can't discharge without as, as an F one without a senior advice. Um And yeah, the patient has definitely been admitted to the hospital by that point. Um But you can discharge him early if you either seen enough to do so, or you've had some uh senior advice that you feel that this patient's safe to go home. Um Very rarely happens. I've probably sent home a handful of people straight from the, the medical take without waiting for a consultant the next day. And that's usually been overnight with young people typically with chest pain? I think that's everything. Uh Does anyone else have any other questions for Doctor Marcus? Thank you. No, thank you. Really good questions actually. Um Yeah, I hope you enjoy the talk. Um Yeah, I look forward to giving a few more talks in the next few weeks and months. Ok. There's another question actually, it says if you receive a patient referred from Ed, for example, the internal med ward, do you have to repeat the cla down by the Ed? Yeah. So what I didn't show is the Ed Clock book which is stretches over two sides of a four and often is just really scrappy words and a lot of things you can't really understand um as the handwriting is off bad. So yeah, you pretty much do have to repeat it and in this hospital they need to do a very brief um clerk in booklet of their own other hospitals. I've worked at it has been more extensive. Um But yeah, you do have to repeat what's done and also you can't not say you can't trust what other people have said, but you wanna confirm it yourself really. Um So if the abdomen is soft, non tender, you wanna feel the abdomen yourself, you can't just jot down someone else's findings. Um So yeah, best to be on the safe side and, and make yourself satisfied that you're happy that that um that is in fact the case. Yeah, that makes sense. Ok. Do you have any other questions before we wrap up? No, good, great. Ok. All right. Thank you, Evan for your time. Thank you doctor. Thank you very much. We'll see you very soon. See you soon. Take care. Bye bye bye.