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Hi guys, I think we'll just wait, um, five more minutes or 10 more minutes till seven or 705 until we start. Um, if you can hear me, which I really hope you can. Um, just let me know in the chat. That's great. Thank you. I just wait um, a couple more minutes and then get it started, right? Um Sorry, I just saw your question there. So, um, this session it's essentially gonna be, I'm gonna quickly cover, um, history taking and two examinations and then we'll have an opportunity to sort of do cause I don't think it's gonna be a very big group. So just kind of, um, hopefully go through two, a two E scenarios hands on. Um, and so I'm happy for like anyone to volunteer and depending on, you know, sort of the amount of volunteers we have, we can kind of break it up, um, in terms of the a to itself so someone can do one part of it and the o someone else can do another part of it just so that everyone gets a chance to practice as well. Um But yeah. Ok. Um, I think people are joining. So, um, we might as well just start just so that we can all get away on time. I know it's Monday. Um, slight slightly to the left. Ok. Let me, let me see that better. Or are you able to see the slides now or? Ok, hopefully that's fine. Um, but yeah, we'll just get a start on. So, um, my name is Hema, I'm an fy one at, um, the Glasgow Royal. Um And so today I'll be covering nephrology or renal medicine. Um So if you have any questions or if you know, you can't hear me or something's going aro uh going wrong whilst um the presentation is going on, just let me know. Um and hopefully we can get that started. So, um this is just um our partners here at Code Blue. Um and just a disclaimer that the teaching here today does not replace any sort of formal teaching that you're gonna have from university where an independent platform led solely by medical students and um for the final year series, junior doctors. So, um don't take anything here, you know, as formal teaching. Um So as I said earlier, what we're gonna cover today is um just very quickly uh renal slash urology sort of history taking. Um We're gonna talk about two sort of renal general examinations. It's more sort of focused to its final year. So I was just thinking about, you know, sort of patients that you could get, um, I studied at Belfast and one of them was actually one of my final lawy, um, similar to my final lawy um stations. So I'm not saying you might get it, but you could get these kind of stations in your final exams and then we're gonna go through two a, two e scenarios and hopefully get you guys involved in that. Um, so we'll see how that goes. Um, so firstly, we're gonna talk about history taking now, I know that, you know, you guys are mostly finals. So I would hope that, you know, you would sort of be comfortable with the whole general structure of a history. So presenting complaint, history of presenting complaint past medical history, family history, drug history, social history and things like that. So I'm not exactly gonna go go through that sort of structure. I'm just gonna focus um in zero in zero in and focus more. So on the kind of questions you wanna be thinking about or asking for someone who presents with um a urological or renal um condition or issue. So, um I think these are sort of the more important aspects of um a history in terms of this specialty. So I think the one thing that like is always good to ask a patient is are they in any pain? Um And so when you're asking about pain, I'm sure you guys are experts at the whole Socrates acronym. Um But when you're thinking about sort of your differential diagnoses um in terms of the site of the pain. So, is it um like sort of flank or loin pain? Is it suprapubic? So when you know, when you're thinking about the flank or the loin, then you're thinking about the whole loin to groin which goes into the radiation, which is the next part. Um And that could be a stone, it could be um pyelonephritis if your patient is pyrexial, um or it could be renal colic if your patient is apyrexial. Um and then you wanna think about if it's suprapubicly located your pain, um It could be a lower urinary tract infection, um cystitis urethritis, things like that. And then in terms of associated symptoms of, obviously, you go through your whole Socrates, but I'm just picking up points of your Socrates. So if you think about your associated symptoms, when you're talking about dysuria or frequency, very likely could be a uti, but you might also kind of wanna think about um an sti and always never feel shy about asking about, you know, your patients set of um sexual history or possibility of having an sti um just because there probably is a mark for it in your exam and it's always just good to so that you get sort of a whole more holistic view of your patient. Um And then the next sort of symptom that you wanna be thinking about is um hematuria So you wanna think about whether, so obviously, I think it'll be quite hard for a patient to sort of tell you whether it's non visible hematuria. So, in terms of visible hematuria, what you wanna think about is could it be a tumor like Frank hematuria or sometimes um hm IGA nephropathy, post, uh upper respiratory tract infection um could also cause um branch hematuria. So you want to refer to you think about referring to urology for further imaging and further investigations. Um likely you could get like a hematuria presentation in sort of a GP history taking station and they might ask you about next steps. Um And always one of the most important things is always rule out your red flags, always rule out, you know, any signs or any possibilities of malignancies. Um when you especially in like a GP setting. Um and then in terms of non visible, that's something that sort of might be more so towards um if an investigation was done and then like a urinalysis and then you need to take a history after. And so firstly, when it's non visible, very simple, especially with a female patient. Um so this could also be on your wards but rule out um possibility of uh menstruation cause it could, it could just be menstruating. Um and then possibility of infection as well because UTI S are quite common. But um regardless both visible um and persistent or non visible hematuria needs to be investigated. Um So in non visible, I sort of put there, they are over 40 you're a little bit more worried about an underlying malignancy. Whereas if they're under 40 you're gonna sort of query a glomerular cause of the hematuria such as glomerulonephritis or something like that. And then the next thing, um you can just always ask your patient any serious, any burning sensation, um, when they're passing urine and most likely it's infection could be neoplasia, but infection or neoplasia are both important causes. Um So the next thing that we're gonna cover is um just a little bit more of the symptoms. So, oliguria or anuria and so you wanna know, you know how much urine they are passing and if they are passing or if there's complete absence of urinary flow, so passage of less than 500 mils of urine a day, um that will be known as oliguria. So essentially a reduction in your urinary flow rate. Now, this can be something that is physiological. So that means, you know, your patient may not be drinking as much. Um And so they can't, obviously they're not, they're not producing enough urine. However, sometimes when your patient is maybe unwell or maybe they're vomiting a lot, there's just a reduction in the amount of fluid that they're taking in. Um this then leads to sort of a significant reduction in your extracellular fluid compartment. So your E CF and that then will give, you know, hypoperfusion to your kidneys. So, a decrease in renal blood flow and that leads to oliguria and then that leads to reduction of your glomerular flurate. Um And so that is what you would sort of then go down the course of a prerenal ak. So you sort of decrease in your perfusion to the kidneys. And that is something that's pathological. And so that's going down your AKI route. Um And then your anuria is also something that you wanna be thinking about. We're gonna cover more so about AK I later in the presentation. So II won't really go into that much, you feel right now, but in terms of anuria and something that can also be used to sort of stage or classify you your AK I as well. So you just wanna make sure that, you know, if someone's describing a decrease in the amount of urine they're passing, you're sort of keeping an eye, like, you know, how much is it and um whether they are passing anything at all and if this is a patient sort of when you're in f one next year and it's an inpatient in the hospital, you would want to keep an eye out for sort of the inputs and the outputs. So how much they're taking in and how much they're taking out. Um And sometimes in some cases, the patient is not catheterized, you might want to get them catheterized just so that you can sort of get a more, um, a better idea, a better picture about um, the ins and outs. So, the next thing is, um, polyuria, um, which is essentially a high urinary fluorate. So it's just an overproduction of urine. Many causes for this could be psychogenic polydipsia where someone just feels very thirsty and they keep drinking a lot of water, type two diabetes, mellitis of the patients on diuretics. They'll be just peeing a lot because I guess that's the sort of mode of action of diuretics. Um chronic renal failure or like diabetes insipidus, sorry. But yeah, um whereas, and so this is sort of where you wanna sort of differentiate between polyuria and then increased frequency cause polyuria. You're going a lot of times, but you also you have, you're producing a lot of urine, whereas with increased frequency, you may go to the toilet. Um a lot of times, however, you may not be producing as much urine. So you can go maybe five times a day but only very little comes out each time. Um So I just wanted to make sure that you guys are quite clear on the difference between these two symptoms. Um And so in terms of increased frequency, which is our next um symptom, um you're not producing as much urine. So that could be sort of due to reduced functional bladder capacity. So that could be like B bh benign prostatic hypertrophy. Um UTI S sometimes patients with neurological um pathology or diseases. Um like MS could also cause that symptom. So, um the next thing, next thing is um nocturia, which means um sort of increased. Um you know, they're going to the toilet more. So at night. And now in health, normally, um there is like a substantial diurnal variation in terms of the urinary flow rate. And so you normally would tend to go to the toilet less at night or while you're sleeping. So, like the cause of the nocturia could be polyuria of any cause. So, so all the causes that are listed above or um reduced functional capacity of the bladder um could cause the nocturia. And then the next sort of symptoms that we're looking at is um urgency incontinence and enuresis, enuresis is like bed wetting. Um So urgency is basically your loss of like the normal ability to postpone micturition of like, you know, hold your bladder. Um And incontinence is sort of the involuntary passage of urine. So you can think about urge incontinence or stress incontinence. This sort of is going into sort of the urogynecological kind of area. Um or for enuresis, it could be like pediatrics, nocturnal enuresis, things like that, that you could be thinking about. And then the last things are slow stream hesitancy, which is like difficulty starting your urine flow and terminal dribbling. And these are all things that you should probably think about in some more. So, older men um with B ph where your like bladder is partially obstructed by the prostate gland. Um So those are the important factors of um a urinary history. So next, what I'll be going on to is um examination of an A v fistula. Um This is um you know, something that you may see on the wards, um especially if, where you go to medical school is near a kidney transplant center or honestly any patient. Um anywhere um in the region is something that you could um possibly come across. And so firstly, we'll talk about what an A V fistula is. So an A V fistula is a surgically created anastomosis between an artery, an A and so the main purpose of it is to dilate the vein because your artery has obviously much higher flow for easier access um during hemodialysis. So I'd say if you were ever faced with an examination that, you know, you were uncomfortable with or um didn't sort of know how to begin, always go back to your basic. So always go back to your inspection. Palpation, percussion is not really needed for this examination, but you know, it could be for something else and auscultations always go back to your basic four and you should be fine. So in terms of your ev um fistula, um you wanna look at sort of the type of fistula that there is and I've sort of put in this picture, the different types of fistulas is sort of where it's located on your arm. So it could be between your cephalic vein and your radial artery, which is a radiocephalic fistula. Um your um cephalic then and um sorry, your basilic vein and your um baso basilic. Yeah. And your cephalic artery which is basal phallic um fistula. And I think this is your brachial artery and your um cephalic vein which is a brachiocephalic fistula. Um And sorry, I meant regular artery and basilic be, which is a brachial basilic fistula. So if you look at the picture and sort of the location as to where the fistula is, um, you'll be able to sort of deduce that. Um, so then next, you'll just look around the fistula site for any scarring, any signs of inflammation. So, is it red, is it like hot to touch? It shouldn't be if it's in, if it's in an exam, but if it's in an inpatient on the ward, it could be. Um, then the next thing you wanna do is um, an arm elevation test where you basically get your patient to lift your arm up and this is to sort of assess for outflow obstruction and the fistula is patent, there's no obstruction that fistula, it's kinda like the bump, but then it will collapse and so you can feel it collapse when they raise the arm up. Um The next thing you wanna do is just look at your hands um, on both sides. So you compare like with like, so look for any signs of edema or any signs of vascular insufficiencies. So you can kind of go through your six peas or almost your six P. So like whether it's pale, pulselessness, paresthesia, painful, perishing, be cold, things like that. Um There's something known as Steel syndrome, which is um vascular insufficiency secondary to an A V fistula. Um And so you can just mention that you're checking for that as well. When you're examining the hands, the next thing you wanna do is move on to palpation. So because of the sort of turbulent blood flow through the fistula, because of the artery, you will feel a thrill. So when you touch your fistula, especially with, you know, active, you'll feel the thrill. Um and then it shouldn't be like hard, it should just be soft and easily compressible. It should not really cause your patient any pain. The next thing you wanna do. And I think honestly, the best way if you wanna know how to do this is once the slides are sent out to actually look at that video properly. Um because you know, I feel like me describing it is not gonna be um the best, but essentially when you get your, when you see your fistula, you just kind of follow the vein. And if you occlude the vein about 1 to 2 centimeters, this anastomosis occlude your vein 1 to 2 centimeters above and then you can still, and then you put your finger over and if the arterial pressure is adequately conducted, you can feel like a pulsation in the vein. Um And you can see the pulsation as well. Um which means that there's sort of no stenosis between the anastomosis, but I would recommend you watch the video cause um it's a good video and you could probably, it's probably easier once you sort of have, have the full picture of the patient in front of you. Um Versus me trying to show you online. Um The last thing you wanna do is just auscultate your fistula and because of the turbulent blood flow, the blood flow, you should feel uh Brey. Um So yeah, that's examination of an A V fistula. So the next thing is just a renal exam, which is a slightly modified version of a abdominal examination. So, with a renal exam, um do you just wanna look for sort of signs of any sort of renal disease? So get your patients to put your, their hands out. Look for any tremor, a postural tremor, like a race light tremor could be a side effect of like calci urine. So if they are like a transplant patient and they're on calci urine, that could be a side effect. Um I always like to get the patients to do that first and then if they cock their risks back, um you can look for asterixis or a flapping tremor which you can notice in like uremic encephalopathy or even like sort of, it could be hepatic encephalopathy in a patient that has like hepato renal syndrome, which is, it's a very complicated um thing. But it could also be that and then um you wanna look at their nails. So, leukonychia or koilonychia signs of iron deficiency or low, I'm sorry. So, leukonychia is low albumin konia is iron deficiency, but I'll show pictures on the next slide as well. You wanna look at their fingertips um for any like capillary blood glucose monitoring because a lot of renal patients tend to be um diabetic and that could, that's probably a a contributing cause to their renal disease. So you wanna see um there's another way that you can sort of see if they're diabetic. You wanna check their pulse, always check rate, rhythm, uh volume is a little bit as uh difficult to assess radially. You can always go to the carotids for that and then also just check for um symmetry as well. You wanna look at your arms, look if they have a fistula, any bruising, they may have high BP um any skin lesions if they aren't immunosuppressants. So next, you wanna move up and always say when you're doing your inspection, step back, look at your patient at like look at the patient itself, like whether they look well, whether they look unwell around your bed and then go in and then go in from like down to like down to your hands and then just up the arm to the neck, the face and then down the abdomen or chest. Um What I find the best way that works for me. Obviously, you can do whatever you like as long as you don't, you know, miss anything. Um And I always think inspection is probably one of the biggest parts, especially in like uh patients is a, that's actually, you know, unwell versus Aus, but you never know what you may get in your aus as well. Um So then moving up to sort of the head and neck or just in general, but whether the patient has any like yellow tinge, so uremia or salow com um complexion, um any like periorbital edema, um which could be a sign of nephrotic syndrome. You wanna look at the mucous membranes in terms of the hydration cause going back to sort of the ins and outs and the urinary production. You wanna see whether they are dehydrated or whether they are, you know, fluid overloaded. Um Things like that you want gingival hypertrophy in their gums could be a sign of immunosuppressants. You can look at their GBP whether it's raised are they like fluid overload, nephrotic syndrome, that kind of thing. They may have a central line scar from like previous dialysis. You can look at the abdomen, make sure that you get your patient to sort of sit up. So you can look sort of at the back as well for any scars at the back of them. Um So you can look for a lo scar. There's a picture of the Rutherford Morrison scar on the next slide, but that's sort of your renal transplant um scar. It's in the iliac fossa. And then if there is a transplanted kidney, you would also kind of feel the smooth mass anteriorly in front of the abdomen And then you know, on your palpation, you would want to describe that um which I think I'm going on. Yeah. So this is your renal exam findings in terms of inspection. So, um that's coil onychia, your spoon shaped nails, iron deficiency, leukonychia, white, um albumin deficiency, the yellowish complexion, it's quite a good picture. Um So you can see the AV fistula in this um over here, this is a transplanted kidney. This is sort of um like a near the umbilicus like a scar um from like previous um hemodialysis. Uh Yeah. So make sure you keep an eye out for that. This is your uh Retford Morrison scar. Sometimes you may have bilateral scars in the iliac fossa and that could be suggestive of a previous renal and pancreatic um transplant, which is uh done for patients most of the time for type one diabetes could be for other causes as well. But um yeah, and if there's a scar on the flag, it could be like a previous nephrectomy. So then you're gonna move on to palpation. So you'll always begin with your superficial palpation of your nine quadrants of your abdomen. Always look at your patient's face when you're palpating just so that, you know, you're not missing the fact that they're in pain. I've always find superficial palpation important to rule out um peritonitis or peritonitic picture. Um And then you can begin your deep palpation. So your deep palpations, probably when you can sort of feel your transplanted kidney, you wanna use your three S S3 C S3 TS cause it's kind of a lump, but to describe it. So like the contours are smooth. Um The color, is it the same as skin, any scarring, the size, the shape, that kind of thing to sort of describe what you feel, but most likely is the transplanted kidney. And then in terms of blotting, would anybody know if a kidney is Belot? What is the most likely cause you can like put it in the trap? Ok. I'm fine. Yes. PC KD. Yeah. So you, you'll be looking for um polycystic kidney disease and you just wanna place your hand sort of on the um anteriorly and then at the back and then you can sort of flick up and flick down, flick up and flick down and you'll be able to block the kidneys transplant the kidney most of the time, it's not really blot because it's sort of just very anteriorly located. Um, the elect fossa. So you can sort of just feel it when you palpate, you actually don't have to blot it. Um P CD, you tend to be able to blot because they're so much bigger because of all the cysts. Um And then you can percuss across the abdomen. So that's for ascites and coexistent liver disease. And then you would do your normal abdominal examinations, auscultate for your like abdominal irrita, but you can also auscultate for your um renal arteries which are five cm superior and lateral tri g on both sides. But yeah, so that's the history and examinations done, went through it very quickly. So we can have um as much time for the A two S. So is anyone willing to volunteer um to sort of start off the first at E um kind of a bit? Um So we have two scenarios. So we'll try and get as many of you as possible. Um I'd say it's always, it's always good to volunteer. I know you might feel a little bit nervous. But um this is the first scenario. Um you might feel a little bit nervous but we can do it together and practice is always good. So it's definitely much better than me sort of talking to you and going through it. Um So anyone willing to volunteer for the first A two E, we can read through the scenario. So you're an F one in Ed and you've just started your shift uh, so you've just been handed over a patient, assess to use your a to e kind of uh format to assess the patient and just voice everything as you go along and perform an ESPA at the end. So that's your handover. Anyone willing to, um, willing to sort of participate, don't be afraid. It's a very safe space here. Ok. Um I'm just going to faze, I think, I hope I'm saying your name right. But you can tell me, um, I'm just gonna invite you to stage so that you can sort of talk through it and thank you for, um, volunteering. I don't know if your, are you able to, I think you may have to accept. Hello. Hi. Uh, before we can you tell me how should I do it? Um, so are you familiar with the A two E format? Yes. Ok. Um, do you want me to kind of talk through it? Just that, that I, um, ok. So, I, it's, it's, it's a little bit difficult because it's only just me here today. Um, so I'm your examiner and I'm gonna be your patient as well. Ok. Ok. Um, what, um, you can do is, yeah, sort of just start. Um, so are you happy with the handover? So, Missus Green, 75 year old, admitted to Ed. Um, and then she has a past medical history of, um, high BP type two diabetes and she recently completed a course of antibiotics for a uti. Hello. Can you hear me? Yes. Yes, I can hear you fine. Uh, ok. Hello. My name is, I'm one of the doctors working on the ward today. Is it ok if I speak with you? Yeah. Yeah, that's fine. Ok. Uh, my colleagues kind of updated me about why you are in hospital. And do you want me to say, uh, do you want me to tell me how you're feeling? Now? I just don't feel very well doctor. Ok. And can you tell me a little bit more about it? Uh I just, I just feel um quite rubbish. Um I'm just in, you know, I just feel like I have a lot of fluid everywhere. I just don't feel very well. Ok. Ok. So should, should I like continue or just do it? Um So like, so the first thing is you're examining your airway? So talking to me, so the airway is patent and then you can also mention if you have a patient that is, um, you know, not so responsive that you're looking, listening and feeling for sort of, you know, air like, you know, whether you can look, whether you can see the rise and fall the chest, you're listening to any sort of additional sounds such as Stridor or, you know, the difficulty in breathing and you're feeling for short of breath. So you can sort of check whether you, whether, you know, you can continue with your A two e whether you need to sort of then go down a different route if your patient was unconscious. So you can mention that as well. Ok. So in this case, the patient is talking to me is patient and they seems to be well orientated in time and place and they are not drowsy. Mhm. So, so, yeah. Ok. I don't hear any additional sounds or? Yeah. Yeah. Ok. So you've done your uh your A so we're next moving on to breathing. Yeah. So what would you assess in breathing? So, in breathing, I want to check the oxygen saturation. I want to check tracheal deviation. I want to do the chest expansion and precaution. Very good. OK. Anything else you wanna do in me? Um mm No. OK. This is something else that you can sort of think about um with an A two E something that was to, that was told to me by a doctor. OK. And work through all of it. But it kind of work if you think about it, you, so you have no sort of, you have no sort of numbers in A B. This is your second one. You are thinking of two numbers you mentioned one, your um gen saturation. Is there another number that you are very right? I always forget. Yeah. No, but so think about it. B is the second I forget you want two sort of numbers for B OK. So in terms of your breathing. So her respiratory rate is 22. Her oxygen saturation is 94. So is there anything else you want um to do for me? Is there any tracheal deviation? No, no tracheal deviation. Um lung function is fine is fine. You don't hear any extra additional sounds on cult. Ok. So the respiratory rate is slightly high. Mhm. And the oxygen sack is on the lowest border kind of normal. Mhm I would prefer it to be higher. So there might be in some kind of respiratory distress but you said that there is no additional kind of sounds in the long term. No, no additional sounds. So what's another thing? You know, some patients may be sort of on scale two. So she could be a COPD patient. Um but most of the time if your if your oxygen saturation is low and this this is an eight week scenario, just say that you're gonna put on a 15 L non reveal mask and reassess. In this case, would you put them on oxygen because it they're still normal or would you just go for a nasal cannula? Maybe? No, you could still you could still put them on oxygen just because this is a this is a a scenario. It could be, you know, they could deteriorate further. So you wanna put it now and then you could reassess later and see what what they're doing. Sometimes I know sometimes people say if there is sort of COPD, you wanna sort of be wary about it and I was a little bit mean by giving you sort of a borderline um, oxygen saturation. Um, but I think as well if you were to rationalize what you were thinking and say that, OK, because you know, it's borderline, I'm not gonna intervene. Now, I'm going to continue with my um assessment and then reassess you could also do that. I think whichever you feel is right. It should be fine. As long as you justify it to your examiner, I think it should be ok. Is that fine? Yes. Ok. Uh So are we happy with V uh Yes, so sorry. Um I just had a question there. So if the oxygen saturation is normal and you know, they're not in respiratory distress, you don't exactly have to give your um 15 L non rebreather. Um because then there, there would be no point. Um You could if you are scared but that, that you can, and as long as you sort of justify it to your examiner, you should be fine if you really want in um this sort of scenario, you can say you wanna do an EB ABG to sort of assess whether they're retaining or not and then decide after um as well is another thing you could do. Um especially with COPD, you wanna be, you wanna be sort of cautious about over oxygenating them. However, I would wanna say if it isn't a, if they are like, you know, acutely unwell, you might as well just give, even though they might be a COPD patient, you might as well just give because your main thing is sort of just saving their life and you're just, this is the whole thing about an 82 weeks acute. So you wanna intervene as soon as you can and then whatever happens you can deal with later, but you just wanna make sure that they're stable. Is that ok? Ok. So are we happy to continue to see? Yes. Ok. So what would you be looking for? So I would like to measure the BP. Mhm. Capillary refill time. Mhm. And uh just check the J BP. Mhm. Heart sounds. Mhm. Um Some people they do abdominal examination and see but it depends. Ok. Um So once again, so I said v you have two numbers that you're looking for and c you're looking for three numbers. So you've told me your CRT is a couple of refill time. You've told me um BP. So there's one more number that you're still sort of thinking about and see. Um So that's just your pulse or your heart rate? Oh Yes. So as I said, always, and I think this is always the easiest when it comes to at e always start from the fingertips and then go up and just so that you sort of don't miss anything. So. Ok. Ok. I'm gonna check, you know the CRT, is it delayed? Is it not delayed? If your CRT peripherally is delayed, always then check centrally. OK. It's delayed as well. Mhm Yeah. Then from there then move to your pulse. So then say OK, I'm gonna check her pulse for rate, rhythm, character, as I said, character volume can't really assess radially. So rate rhythm symmetry, any ra radial delay um and then move up. So you correctly, you said you wanna assess the BP and then move to the neck. Um So you can assess carotid pulse and then yes, you're right. Assess J BP. You can look at the face, see if you see anything there move down. Um So you um you mentioned yes, heart sounds, you also wanna sort of check for the apex B, whether it's well present and whether it's displaced? Ok. Thank you. Yeah. And is there any sort of investigations you would like to do at this point? And see? Well, I'll give you, I'll give you what you know, this is what you have so far. Mhm. So BP is low. Mhm. Heart rate is high and capillary refill time is increased. Mhm So I would like to give them IV fluid at this stage. Mhm And also I would take some bloods before that. So because they, they were in some a bit of respiratory distress, I would take an ABG. OK. Yeah, E BG it depending. Yeah, you could do an E BG. That's fine if they are septic, for example. Yeah. Yeah. Full blood count. U NE. Mhm. Um C RP. OK. This is it. Yeah. OK. Um Yeah, I think that's fine. I think when, when you come to see, I think it's always important and I know sometimes it may sound like you're reciting things but sometimes it is important to say it. So you would like two large bore cannulas in um both antecubital fossa one you would like to most of the time it's a 500 M um over 15 minutes because given that her BP is low and she is tachycardic and you're thinking shock, what kind of shock, but you just wanna sort of resuscitate her with the fluid and then through the other one, you wanna sort of take your blood blood. So you can take, yes, you, so you could take an ABG, not really a rest scenario because we'll do it. Um You do a VBG um And then you wanna take so your, your full blood count C RP. Sometimes I just say LFT S um it's just monitoring bloods that you would do. Um And then if you're sort of thinking about other kind of conditions, like, you know, if say someone came in with like epigastric pain and you're like occurring like pancreatitis, it's more surgical, but you could take an amylase as well. It depends on like sort of what presentation they come in with, but most of the time, yes, you would take your, um, you would take your full blood count using these C RP, um, LFT S and we go on from there if you're thinking, you know, once again, if they're gonna go for surgery, you think it's like an upper gi bleed or anything like that, you might wanna take coag group and save as well. So just as long as you're, you know, thinking about what kind of bloods you're taking from your patient and the reason for it um you should be good but yes, good job. Um Anything else you would like to do at this point and see. Yeah. Mhm Yeah. Is informing seniors uh thing and everything. Yeah, you could always always inform your seniors um at every point. Yeah. Um but also uh e Yeah. Yeah, she's um she's tachycardic and then once again, it's not really needed in this patient but say if someone had a new oxygen requirement is acutely like breathless and things like that you would wanna consider like a chest X ray in B but in this patient not really necessary at this point. OK. Yes. OK. So um we're gonna look at the eu so these are her eu you wanna tell me what you and so anyone anyone else in the chat also you're happy to kind of type in at any point as well. Uh sodium and chloride are normal but potassium is high. Mhm uh bicarbonate is still normal within the lower range. Mhm Urea is increased. Creatinine is increased. EGFR is reduced. Yeah. Ok. What are you sort of thinking when you look at, look at like a, look at a blood result like this? Like what is sort of jumping out to you? And what are you were most worried about um acute kidney injury because of the perirenal cause like hypoperfusion? Ok. What else are you very, very worried about? I'm worried about the high potassium and the ECG changes and the damage it can cause that. Yeah, the hyperkalemia as well. Yeah. Yeah. So potassium is 6.5. So you'll be concerned about hyperkalemia and then of course, she has an AKI as well. So you're sort of worried about that whole aspect. And then once again, I'm just gonna say if anyone wants to join in and um participate as well in the at um feel free you can get, as I said, it's very good practice. So, um if you want to just let me know. Um so this is your ECG. So if you're given this in an ay, what would you do? This is uh like, so in an eight week, so you're not, you don't necessarily have to like sort of go through it one by one. But like if you're given it in the se what would you do? So there is E CD changes along with the high potassium. So I need to do, is it like calcium gluconate injection or something? But do you wanna, do you wanna tell me what you sort of see first in the ECG, the changes? I hate the ECG. Sorry. So, when you think about hyperkalemia? Yeah. Ok. There's, um, sort of three things. So, p thing would be your tall tented PWA, as you can see right there, like your flattened P waves. So you can see your P waves are very hard to discern from sort of the normal thing. They're very, they're very flat, they're very hard to discern and then your widened QR S complexes. But then obviously as a spot diagnosis, yes, this is, this is hyperkalemia. This is E CG changes of hyperkalemia. But yes, always tell your examiner what you're seeing as well to justify what you're gonna sort of diagnose or like say what the, what the cause of the E CG is. And then always, even with the, I know it's hard because obviously this is a online thing, but with any sort of investigation, like a news chart or any blood result, they give you if your patient details are there, always say you're reconfirming patient details. So I know I didn't put it here cause it's hard. It's an online thing. But if they were giving it to you in the exam, always say I'm just gonna reconfirm patient details and then continue. OK. Yes, thank you. No worries. Um OK. So yes, this is your ecg um hyperkalemia. So, I don't know about other universities. I know for my university when it came to hyperkalemia, we don't exactly have to remember the entire thing. We just had to be able to sort of diagnose it and then if we asked for the protocol, they would provide it to us. Um, so I'm unsure if your university. Oh, sorry, your university. Um, you know, go through that. But yes, we'll go through essentially the hypokalemia management. Um What would you think that would involve thinking the first step is to inject calcium gluconate? Yeah. Um OK. I'm not gonna ask you how much because I do think that's what it mean. Like it is, it is, it is in the protocol. Um So yes. So you, why do you know why you would do the calcium gluconate protection? Yeah. Yeah. Um Yeah, you're right. So it's to stabilize your cardiac membrane then. Um So as I said, there is an algorithm um most of the time if your potassium is more than um 6.5 or 6.5 and more, um you would still give your potassium gluconate to avoid um chance of arrhythmia. So sometimes they may not necessarily be any changes to your CG, but you will still go through with your um calcium gluconate. Um If I'm not mistaken, I think it's not 30 mils of um 10% calcium gluconate. So, yeah, um you can still give even though. Um There are no changes in your E CG. If you ask for the algorithm, it should be provided. It was at my university. I don't, I, once again, I can't really say for other universities. Um And then what else? Yes, you're right. Calcium gluconate plus insulin and salbutamol. Essentially, you're just trying to get your potassium back into your cells. Um We'll whistle on the A two E. So we'll follow that sort of algorithm but we'll go through sort of hyperkalemia management once um we finished the A two E. Um So are we now happy with C? Yes. OK. And so we're gonna move on. So what are we doing next? What's um after cy, so D Yeah. And what are we assessing in D I will check the pupils. Mhm uh Glucose levels. Mhm. And the temperature at this stage you could you get your temperature and C you got your temperature and E depends um if I, when I do disability, I like to go through another pneumonic A A GED. So you're looking whether they are alert. So that could be your ask whether they are, you know, alert, whether they alert to voice, whether they alert to pain, not thing or you could do their G CS sometimes a little bit hard to do in the SG most of the time the patient is alert anyway. Um and then next you wanna go to G which is the glucose? So, yes, you wanna check their capillary blood glucose? See what that gives um you wanna do your eyes? You're right. So you wanna check whether the pupils are equal and reactive or dilated or pinpoint pupils? And then um d you wanna do um drug cardi or what drugs they're on? Yeah. Yes, thank you. Ok. So if we're gonna, so in terms of this patient, she's alert um her glucose was in range. Her eyes were equal non reactive and this is, oh sorry, this is her drug codes. Is there anything you wanna do with this? So I would like to stop Metformin, an ace inhibitor, Enalapril just because they may be in AKI when they have a and yeah, basically those two needs to be stopped. Anything else you wanna stop uh furamide? Yes. So with N Ati, you're looking to stop nephrotoxic drugs. So that's your the other acronym Dam da Mn. So any diuretics furamide, any sort of like um aspirin uh M for Metformin and N for NSAID. Sorry A is for not Aspirin, A is for ace inhibitors or ARB sn for Metformin and N for Nsaids. So she's on Metformin, Fura and Enalapril which are all sort of nephrotoxic given her EGFR and kidney function. Um You'd want this to be um suspended for now and then reevaluate once her kidneys get better? OK. Are we happy with D uh Yes. OK. And what do we move on to next? Uh A exposure and anything that you see. So if we didn't do abdominal examination, we can check it here. We can just check for any bleeding, sort of ble bleeding, any rashes, anything that we might have missed. You don't see anything. Anything else you wanna do in e thank you. I'm not sure if you check your temperature. I Yeah, that's something that I always used to forget. Um So you can Yeah, so she's apar so, so is there um anything else you wanna do now? Are we like happy with e or I think so? Yes. Um so are you sorry? Um in terms of aspirin, low dose, aspirin is normally still? Ok, to be continued in AKI if it's high dose, they tend to stop it. Um it's not routinely recommended. So yeah, but if it's low dose, it should be fine. Um Yes, so we we e is there anything else you'd like to say or do at this point? Yeah, so you wanna think about you calling a senior and reassessing? Um So are you happy to do an sbar? Um um Yes, thank you. Ok. Um just try. Ok, so um do you wanna, so I'm the med reg so you're calling me? Ok. Can I just have a minute to think? Thank you. So, hello, my name is Pfizer. I'm one of the junior doctors on the ward. I'm calling about a patient uh named this whatever I don't remember. 72 years old. I'm concerned about them because they seem to be having an AK I and uh they have a low BP. Mhm. And uh we have started uh IV fluid for them and taken some blood samples. Mhm. And stop, uh, the Metformin and Ace inhibitor and diuretics they were on and I think they, they need a senior review so I would really appreciate if you can come and review them as soon as possible. Ok. Ok. Thank you. Um Sorry, I just got a question there. Um So a the agent acronym A is for like AU or G CS. So whether your patient is alert, G is for glucose, E is for eyes equal and reactive and D is for drugs, drug cards or what drugs they came in on things like that. Um Yeah, so in terms of as good job, um I always found them quite tricky to do. Um I think when you call, it's always important that you're checking who you're speaking to. Um So you, you said you correctly introduced yourself, um say you're the junior doctor on say ward eight. Can I just confirm who I'm talking to? So then they'll give you their um sort of the like Salai and um ex soma the med reg something like that. Um And then yeah, you very rightly said I'm calling about this patient's name at the first bit in terms of your concern, you kinda wanna use keywords to sort of grab their attention so that they can come to you very quickly. So say that the patient is hypotensive uh tachycardic, uh most likely in uh in an inpatient scenario, you'll have your news ops a news with you or even in an o, they may give you a news. So say that their new score is whatever number it is. And um I'm concerned that this patient is in septic shock and is also um hyperkalemic and then you wanna give the background. So this patient was admitted with, you know, I feeling like a fall or feeling generally unwell, whatever brought them in. Um And what you think the problem is, I think the problem is that the patient is uh septic and I think uh um has an achy eye due to dehydration. Um and what you've done so far, so I've given them fluids, I've given them, I've restarted the hyperkalemia protocol, things like that. Um I'm very concerned about this patient given um you know, the AKI and the um ecg changes for the hyperkalemia. And um I would really like you to come and see this patient now. Is that ok? Um But I think you did very well as far is always very hard to do, especially when it's a very high, which it is uh very high stressful, like a very high stre like a stressful situation. So it's always very hard to do. But I think you did very well. Um, I think overall in terms of your A two, you did very well. As long as you stick to a structure, it'll always be, um, sorry, let me get my slides. It'll always be ok. Um Oh, sorry, I actually had a urinalysis. I forgot about that. Um, but yeah, um that's, that's urinalysis. It's fine. You don't have to interpret it now, but it's something that you could consider in a, um, in an at as well, depending on the patient's presentation. But I think you did very well. I think um always make sure you're introducing yourself at first checking the patient's details, checking the patient's details for sort of um every um investigation and then always say that, you know, once you sort of hit a problem, like say the uh BP is 90/60 so hit a problem, you're gonna treat them and then always say that you're gonna reassess after always mention reassess, call for senior help early. Um Just so that they know that you're thinking about it. Um They obviously it's not gonna come in and it will come in a, in a sort of f one situation. Um But yeah, uh but I think you did very well and I think as long as you sort of stick to a structure and practice as many A two es as you can, um you'll do very well. So thank you um for volunteering. Thank you. Um So I'm just gonna quickly go through um the hyperkalemia sort of protocol. This is from my hospital. I think each hospital has its own. Um I mean, es es essentially it's the same, there's, there's nothing that's gonna be like very different about it. Um So you wanna sort of look at what your serum like um potassium is and depending on that, what kind of um uh branch you're gonna go down in terms of the algorithm. Uh So, yeah, so any ECG changes. Um So those are the things that you wanna look for. Um And then most of the time with the E CG changes, you're gonna give them uh calcium gluconate 10%. Um And then that's uh IV 30 ml over 10 minutes, always ask for senior help. You wanna start the glucose infusion, insulin glucose infusion. So you're giving their insulin, you're giving your patients insulin to sort of bring the potassium into the cells. Um And then you're gonna give them glucose because the sugar in the blood is also gonna go into the cells so that you wanna make them hypoglycemic. Um And then another good thing that you might wanna check is sort of their pretreatment blood glucose. So whether you need to sort of follow them up with more glucose and then you give them um salbutamol as well. And then a, another, another thing that you give them is uh leukoma um using like acute life-threatening um hyperkalemia. And then there's sort of a protocol as well at the back of um whatever your hospital uses kinda tells you that, you know, the serum glucose and the serum potassium needs to be monitored every like one hour, things like that. Um And to sort of see whether there's any signs of refractory hyperkalemia as well, which is hyperkalemia that's not responding to the treatment. So, um moving on. So we're just gonna go through very quickly. Um AKI, so we're gonna talk about just your diagnostic criteria for your AKI. Um This is very common in terms of like what you'll see as a medical f one, a lot of people um sort of when they come into hospitals, their kidneys sort of go off. Um So there's a rise in creatinine of 26 micromoles in 48 hours, um which is what I tend to use. Um Or these are the other sort of criterias that you can used to classify. What an API is that in terms of your staging, this is a little bit more complicated in terms of like exam situations. I tended to just memorize the creatinine in terms of how much it sort of increased from baseline to kind of stage it. So I just tried to remember it's like from 1.5 to 1.9 stage one, then 2 to 2.9 stage two and more than three like stage three cause it's kind of intuitive. But um hopefully they won't really give this to you in an exam because it is a little bit unfair and it's a little bit um sort of difficult to remember. Um And then with an AKI as well, when you're treating it, always stop your nephrotoxic rehydrate your patient, then you sort of want then be thinking about the causes of AKI. So whether it's prerenal, which is basically decreased blood flow to the kidneys, um whether it's like intrinsic to do with the kidney itself. So, like have they recently been on like any antibiotics, any illnesses like acute tubular necrosis or inflammation? Nothing like that. And then postrenal. Um So kidney stones or um B ph tumors, this is where like imaging may be able to help. So you could do an ultrasound to see if there's like, you know, any hydronephrosis in the kidney or anything like that. Um That might be causing um an urinary outflow obstruction and causing your AK I um but most of the time it's quite simple fluid rehydration and then just think about your causes most of the time it is prerenal, but it could be anything else. So just wanna keep an eye out. Um So yeah, IV fluids, stop all your damn drugs. Um You might want to relieve an obstruction. So it's postrenal, inserting a catheter will be very helpful and always, you know, then that also gives you a very good sort of baseline for your ins and outs and then another thing that was very good. This is also another pneumonic if you look at it ei ou indications for dialysis in a patient. So, acidosis, metabolic, acidosis, electrolyte, imbalance, refractory hyperkalemia, intoxications of this like drug overdose or poisoning, edema, edema. So, refractory, pulmonary edema and uh uremia, it's like encephalo like so uremic encephalopathy or pericarditis or things you wanna look out for. Um that may be an indication for dialysis in a patient with an AK I um, so we have another scenario. I know it's eight o'clock. Um, if anybody wants to volunteer, um, I'd be very grateful. Um, I think to be fair, this might be a little bit easier. Um, but yes, if anyone would like to volunteer. Yeah. Ok. Um, I will invite you to this stage. Mm. I don't know if you can, you were able to join. Well, let me know if you need another invite. Are you there? Ok. There's sorry, there's more people. Um. Ok. What we'll do is all right, I didn't see you. So, um I've invited that would, I think so he can do the first bit and then all right, you can do the second bit as well just so that you guys get practice. Ok. Um, that would, is that right? Yeah. Ok. Um, do you wanna start by just? Ok. Ok. Um I was happy to let you do the whole thing. Um, so, but let me know if you want your practice. Cause as I said, it's always good to practice eight weeks. Um So just start by taking your history, uh, like a focus history and then we'll move on to the at. Ok. Ok. Uh, hello, my name is, do I with the doctors? Uh I've just been called because you, you've been quite unwell. Could you just tell me a bit about what's going on? Um, hi there. My name is uh Laura Green. Uh, sorry, my name is, I'm a man. Sorry. My name is, um, Edward Green. And, um, yeah, I've just been feeling very unwell doctor. I've had this terrible pain in my back. Ok. Can you kind of just tell me when did the pain start? And how did it develop? Uh, it just started a couple of hours ago but it's very, very severe. Yeah. Where, where, where about exactly? Is the pain, is it center of your back or sort of, sort of like at the, like at the back, like my flanks? Ok. And does it spread anywhere? Yeah. Maybe it just goes down to, like, my groin region there and because of the severity, has it caused you to have like, a fever or vomit or anything like that? No, I just, yeah. Yeah, I, I've, I've been sick. I just, I just feel really, I feel really, really ill. Ok. And how about you, how about you urinate? Has that changed that frequency? The frequency of that? Was it painful? When you go and urinate. Yeah, it really burns when I go doctor and I have to go so many times as well. It's so uncomfortable. Mm. Anything else? So that's fine and can I just um again just confirm your uh age please if that's all right? Yeah that's fine. I am 8181. Ok now thank you for letting me know that would it be ok if I just did the top to toe assessment of you just to see how you are? Yeah, that's fine. Yeah. Ok. So do you wanna start? Yeah, so start my et assessment. So patients talking to me so I can to look to see if they can chest rise and fall if there's any additional breathing sounds or anything like that. So a patient. Ok. Very good. Also um I think what I forgot to mention earlier but what you could mention when you're doing your airway as well in an ay is you could mention that uh the airway is pa for now, but I'd like to place an airway adjunct near the patient just in case they deteriorate as I continue my assessment. But yes, very good. So moving on to b Yeah. So in terms of the breathing, especially exacerbations, oxygen saturations, heart rate and do like my focus respiratory exam of chest expansion uh and auscultation. Ok. So your respiratory rate is 19, your sp two is 89%. Um and then your focused respiratory exam looks normal, there's no tracheal deviation, chest expansion is normal, percussion is normal and auscultation is normal. Anything else you wanna do at this point? So the refrigerate is within normal levels of patients, severe hypoxic. So I'd start him off 15 L of oxygen or two straight away. And I think because he's up some saturations start low. Maybe an ABG see if, see if he's retaining as well at this stage. OK. Uh could be useful. OK. Very good. Um And then you want to move on. Yeah, I think I move on to circulation then and so checking capillary refill time, heart rate, BP, GBP heart sounds and if there's any signs of edema and then I'll take GLU glu as well. Yeah. So this is your BP your heart rate for a refill time. And then once again, as I said, when you're checking your pulse, um always say rate rhythm and then symmetry as well. Call you when you're checking your carotids. OK. So from that, he's like hemodynamically unstable. He's tachycardic um hypertensive, couple of refill times over two seconds. So he needs to start IV fluids, 500 mils for 15 minutes and then um all regular blood. So two large for Cannulas and fossor, one for the fluid that we've prescribed and then um full blood count. CRP LTs your knees and lactate a possib possibility of a blood culture as well if it's considering aseptic. Very good. OK. Um So this is your ABG BG sort of thing. So, what are you looking at here? Uh Yeah. So he's acidotic. Yeah. Oxygen seems ok. I think carbon is right. I think it's metabolic acidosis. Um, it doesn't seem to be any sign of compensation at the moment. Anything else that you're concerned about the, I mean, it's metabolic but like the lactate is raised does, yeah, the lactate is raised again, concerned about like ischemia at this point. Ok. Um Fine and anything else you wanna do at this point? Um So we've given him fluids, oxygen, I guess I'd reassess to see if it's ox oxygenation has improved. Um but so your patient is tachycardic a type anything quick that can be done by maybe one of the like nurses or anyone else on the ward? Mm E CG. Oh yeah, sorry. Yeah. Um so that's your E CG mm two. Is it like a sinus tachycardia picture? Yeah. Yeah. So it's just sinus tachycardia? Ok. Um and then what are we doing next? Um So I'll be moving on to DD. Yeah, so yes. Um patients. Yeah. Um checking the patient's blood glucose. Well, we don't have to kind of help. This is fine and then see if there's equal and responsive to light uh people and you can do a medication review. Yeah. Uh at this stage as well. Um Yeah. Ok. Very good. Um There's nothing really of concern in his card. Um So we're moving on. What next? So exposure. So we want to check his temperature. We want to do abdominal examination if there's any guarding, rigidity, tenderness. Very good. Um And having a G look to see if there's any sort of like signs of bleeding, rushes, any like stones or drains in, input in. Uh So that's your patient's temperature. Yeah. So temperatures got raised, I mean, I think in consideration of all this and going on with the sepsis six, a broad spectrum antibiotics at this case, you know, at, at this time. Uh Very good. Um Yeah, so you say you mentioned your sepsis six men, your G three take three. So you're giving them IV antibiotics, giving them IV fluids, giving them oxygen. You're measuring the serum lactate, measuring the urine output and taking blood cultures to make sure that you make that very clear, like especially once you've finished your um examination. So anything else at this point? Um So was he, was he tender any sign of like guarding or rigidity or? Sorry? Sorry. Yes, he was very tender in his um sort of right flank like fossa region? Yeah. Um So I think at this stage probably give him like pain relief as well. Um Like I II cause of the pain. Yeah. OK. Um And then reassess PT and cough help. Very good. Um Do you wanna, this wasn't related to but do you wanna perform an a for um like practice Yeah. Yeah, I can do that. Ok. Give me just one minute and then no worries. Mhm. Ok. Yeah. Yeah, I can give it a go. Yeah. Ok. I'm some reg. Ok. Uh, ok. Hello. My, I'm down far back for one. can I just confirm who I'm speaking to? Yeah, my name is him. I'm the medical registrar on call. Ok. I was hoping to speak to you in regards to an 81 year old gentleman who I believe is set uh set take on the line to read on stones. Would it be OK if I could discuss this patient with you? Yeah, that's fine. Yeah. So this patient uh has presented because he's, he's been experiencing uh plank pain, radiating to the groin fever and vomiting. Um Therefore, we do an at assessment of him. Um main findings being his, his saturations are 89% making hypoxic. He was, he was he hemody stable tachycardic. 100 and five bes a minute, hypertensive BP. 92/63 his time was raised. Um and he had a temperature of 39 degrees uh with uh tenderness and gardening in the right flank area. Um Due to this uh we've started sepsis six protocol. So we've given him IV fluids for both back to antibiotics. Um We've taken all necessary blood uh bloods. Uh in addition, his ABG display metabolic acidosis um as well. And we were provided an IV morphine pain relief we were waiting to see how he responds um to just uh to uh to these interventions. I just want to ask, is there anything more I should do uh for the management of this patient? Yeah, very good. Um Thank you. Um Yeah, very well done. Um As I said, I think practice makes perfect. Um always mention sort of like the big like name. So like you mentioned, so like hypoxic peril, um things like that mention like what the new score is and everything just so that you can sort of get who your seniors is attention. Um And yes, sorry, you actually mentioned that um just now, but I forgot to mention it earlier, but always say um I would really appreciate if you could come and assess this patient. And is there anything you'd like me to do in the meantime, which is what you said? So that's very good. Um very well done. Um As I said, with a CS practice makes perfect. Always mention reassessing, always follow your structure which make sure that, you know, you don't really forget anything. What do you think, you know, this patient sort of had? No. So I was thinking either pyonephritis or renal stone or something in the sepsis. Yeah, you were sepsis essentially. Um I think sometimes it's, I think it's university dependent. Um Sometimes in my university, we really sort of focused on history taking. This is another acronym that we used to use So it's called samples. It depends on, I don't know where you go to university, but sample is essentially s for um, signs and symptoms. Um A for any allergies. M for like medication that the patient is on p for past medical history. L for like their last meal, which is relevant if your um, patient is like a surgical patient and may need to go for surgery. You wanna see whether they've been fasted and then e is for um events leading up to where like to the presentation in hospital depends. I know, I understand that some of the like Manchester students, I think you guys have a mannequin. So there's no real like history to take. But um that's a very easy way to quickly get a and but like I'm saying, in like, in terms of an F one scenario, that's a very easy way to get um a quick history from an acutely unwell patient just so that you can sort of move on to your assessment quickly and kind of figure out where you go to from there. Um So yes, this patient had sepsis. Um So you're very right in getting routine bloods. Um urinalysis, blood cultures, you may also wanna consider urine cultures. These are all things you can say sort of the end of your assessment, your A three assessment in terms of um radiological stuff. Um ultrasound, any like Calculi A or Hydronephrosis, consider Act K UB and then obviously the big thing initia initiation of your es is six. which is very good. You did that all very well. Um Something that, you know, it's quite common as an F one when you're on call or um just in terms of A as well, so very well done. Thank you. Thank you. So, um I think that's it, that's us. Um So I hope that this was helpful for you. I couldn't really generate a um cure code, but I can send, I think I'm gonna send a feedback from through the chat. Um So hopefully that works. Um If you guys have any questions, let me know um or my email is there. So I'm happy for you to email me as well. Um I think once you complete the feedback form, we'll send the slides out to you. So thank you all for attending and thanks guys for participating as well in the A two A and I really hope this was helpful, but thank you.