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Hey guys. So I'll start in um a couple more minutes. Um Just to let you know, people join. All right, so I'll make a start and can someone just tell me that they can hear me and can see the slides as well, please? Yeah, we can hear them and see them. I like cheers. Thanks. Um OK, so, um just doing, I know it's Sunday night. So I'm gonna keep this um quite short. So I'll be skipping through some slides but you'll get them and um there's some MC won't go through them. I'll leave them and just send you them in an email. Um We're just gonna do a little bit on cancer studies and palliative. So it's quite a probably one of the easier topics in final in fourth year. Um You can get lots of marks through the MC Qs and the stations with the OSK also all chat, but are relatively, I would say the easier ones of v. Um So first of all, just I put in some tumor markers, so common tumor markers. So, um ovarian ca 125 pancreatic is C 19.9 and I'm not going to go through them all, but um they often come up in MC Qs, so kind of day before the exams. Um It's good to kind of just go through them and could kind of be asked in Os as well as like one of the last questions. Um So they're good to know um quite high yield and yeah, just like very short term memory. Um I'm just going to go through some terminology for Kansas City as part of the portion. Um So the TNM TNM staging consists of the tumors eyes and that's created from one to fall. And you've got lymph nodes, um which is which lymph nodes are present if there are any. Um And whether or not it's above or below. Um The diaphragm gives you um an indication of whether or not it's um like um lymphatically spread. Um And then um whether or not there are METS um as well. Um And that's from 0 to 1. So if there are any mets or if there isn't, and then in terms of treatment, so when you're looking at treatment, um radical means that it can be completely cured. So, um the patient would then be in remission. Um neoadjuvant treatments are given before. Um So things that chemo might be given before and then surgery may be given um in order to remove the tumor adjuvant is after. Um So things like radio radiotherapy can be given after um surgery in order to make sure that um any remaining cells or cancer or tumor is destroyed and then palliative um is a little section in itself. Um And that's quite like high yield in terms of the exams and the sys um but that is kind of from your attachment and stuff you'll know, um just extends life slightly. But um there's like the understanding with the patient and the family that the patient will be passing at some point. And then, so just looking at a couple of um treatment options. So radiotherapy is ionizing radiation and damages the DNA of the cells. Um the cancer cells have um poor mechanisms and so they, once they are damaged, it's harder for them to replicate. Um It's unable to prepare as well. Um It's measured in grades and fractions. Um but that's kind of, I don't think you really need to know that. Um but I'll just put in an extra detail, um these slides from last year as well. So, um I thought they were quite good and I about things and taking things out that I thought were relevant or not. Um And then there's different types of radiotherapy as well. Um It can be more directed or um more. Um Also I didn't like um like m less local and then in terms of there's some benefits and um negatives there in terms of comparing it to the surgery. Um So questions that you can kind of get um in exams and things could be, uh, like side effects of radiotherapy. So, in the next slide I've got, when you're thinking of, um, side effects, think about where the cancer is in the patient and where they're having the radiotherapy. So, for instance, if it was in, um, a man with prostate cancer and he's having radiotherapy, it's likely that we'll end up with some bladder and urinary, um, symptoms or things like incontinence or retention. Um, because you're damaging the cells around the prostate and then around the bladder as well. Um So there's some with radiotherapy, there's early and late um side effects which patients need to be aware of. So, if you have a consent in a patient, um for radiotherapy, these are the sort of things that you'd be going through. And so in terms of short term, and there's inflammation in the area of where the radiotherapies occur. And so you end up with skin reactions, so it's penetrating the skin. Um, so that the skin is become dry and potentially inflamed. Um Then you also have general fatigue, nausea, vomiting, things like that. Um, hair loss at the sight and then more long term effects, you're thinking of um, secondary cancers can occur. Fatigue can be a long term, um, a long term effect of radiotherapy and then other things like dry mouth, dry cough. And that's if you um were having radiotherapy around the neck region or, and lungs and things like that as well. Um There's a few other ones there that you can look at on time as well. Um And then chemotherapy. So I think one that everyone knows the most about probably um so or cytotoxic therapy. So it works by destroying rapidly dividing cells. So it's given kind of systemically and um the side effects are easy to remember of chemotherapy because you have to just think about the fact of that. Um you're destroying cells that are rapidly dividing and there's other cells that are also rapidly dividing in the body. So you'll have Foles um rapidly, you like lose hair a lot throughout your life. And that means that when you're damaging cells that are rapidly dividing, you're also going to damage the healthy ones that you want to keep. So you end up with hair loss, um the cells in the gut quickly. So you can end up with bowel habits and that can be constipation, diarrhea, and then the bone marrows. And that's how you get some of the side effects and more serious side effect of neutropenia and thrombocytopenia, which we'll talk about and then general side effects um as well. Um in terms of when people get chemotherapy, it's important to have a large ball cannula and make sure that it is blushed and blush in. Um if it exerts, which means if the um kind of notice the tissue and then to get into the general system, um it reduces it um affects the area on the skin and um as it is a like toxic and causes toxic reactions to the skin. Um So some of them species and uh which is probably seen on boards and things like that. And um Robo specialist and work uh for delivering um chemotherapy. I'm just going to talk about the um oncology emergencies. So this is probably north high yield part of um cancer studies. Um So questions on this nature, come up all the time. They really easy marks and it's really easy to learn. Um You also, so for last year, Os we had um neutropenic abscess. So any of these could also come up in an osk um as well. So there's one in sepsis. So, as I said, we had our um last year um for cancer. So was on this and it was a patient who um was presenting, had had, had had chemotherapy um a week before and then was unwell. We were given blood test results and we were given, I think a new shot and it was her temperature was high. So there was signs of infection. There was also um right there is also um Yep. So here we were given a chart um which gave observations and they were kind of on the, on AP literature and then um blood test that we were given was a neutrophil. So, what you're looking for is um a neutrophil count of less than um one point times like one basically. And then um there's a low threshold for treating and suspecting someone with sepsis. So, normally, um, a patient would come in into with, um having had cancer treatment a week or two prior and then they would feel unwell, they'd be confused, um, have a headache, um, have a high temperature and it would be significantly high as well. Um, and generally systemically unwell. So hypertensive um tacky and would have potentially a sign or a place of, of source of infections that could be like a chest infection. Um Alternatively, that could be um an infection of the gi tract or anything like that. And then in order to manage this, um you want to do an at assessment like always, um you want to do blood cultures and then you want to start with sepsis, sepsis six. And um the main kind of stay of treatment is given broad spectrum of antibiotics. So, um you give, sorry, give tazocin and um if, if it's, it's a more severe case or if they've had like repeated episodes of sepsis. And then the important thing also is if you got this like anoscopy or something like that is to ask about penicillin allergy because I think that and um then granulite uh colony stimulating factor GCSF is given. But that's more, I think questions rarely come up on that. It's given as prophylactic, but you don't give it when you give the treatment it's after that. So, yeah. Yeah. Ok. So then thrombocytopenia. So that's, um, a low platelet count. Um, so that's when the platelets are less than 20. And, um, so symptoms, you can have the main symptom kind of would be bleeding. Um, you'd have maybe a more bruising as well. Um, bleeding from the gums when kind of, they brush their teeth, things like that. So this is things that also that you would ask patients to be aware of and um you'd be doing PC, you'd be a G to check the hemoglobin as well. Um Let's check what type of anemia they have if they have a type of anemia as well. Um You wanna coag, you wanna grip and hold them in case they need to be um transfused or anything like that. And then treatment would be group and cross match and um a platelet transfusion. And when, whether they get a platelet transfusion, it's just based on the criteria of if it's less than 10 or if it's less to sepsis, you could have a thrombocytopenia with a neutropenic sepsis as well. Um The things can occur um together, not just in isolation. The next one is hypocalcemia, so high calcium. Um So you've got um this is often caused by um meds and uh symptoms include like dehydration is so the patient would have an cup refill and um you probably heard of the uh bones, bones drones and grows. I think it is um as a little like you want to remember the symptoms. So, and that's quite useful as well. If you have a patient and a stem, you kind of pick up those few things um that could have a high calcium. And so you need an ECG, you need a bone profile and magnesium as well in bloods. And then between bloods, you want to have a look um at the ECG to check if they got a short qt involved. And then the treatment for that is 4 to 6 L or, you know, kind of certain chloride. Um And so it's quite a simple measure to you rehydrating the patient and you'll um offload on the calcium and then you get bisphosphonates as well and then just do a cardi review as well and then tumor lysis syndrome. So, if you're destroying lots of cells and those cells um release all the electrolytes and that causes abnormalities. Um So you end up with high phosphate, high um potassium and high urea. Um And again, with this, you do an at management. Um Raspberry Rica is, is the um drug they can give that would clear the uric acid. And then if the hyperkalemia, um the hyperkalemia of course, um and you treat any kind of as you go and as you find things um and you're treating basically the individual all of this. Um So then moving on to the kind of the other set of um emergencies. So you've got spinal cord compression. So this is caused by met. So often with patients with prostate cancer would be in the stem um or not you or anything like that. Um All these questions come up quite a lot. I'm sure you will come across someone like ques and pasted and they're very, I think really easy because it's always the same treatment. And even if it comes up a oscopy um learning, this is like, ii would say really high yield and it did me well to learn all these um and kind of maybe even coming up with like a table of what the treatments are because a lot of them are just the exact same treatment. Um So you want an MRI of the whole spine that often comes up um in an obviously situa situation, you want to ask about things like um loss of bowel control, um or loss of urinary, um lot of power as well. And then the immediately as it is an emergency. So you want obviously to go the management and all that stuff, but you give DEXAmet dexamethazone eight migs and give that by daily and, and A PPI is so omeprazole and that's the treatment for a lot of things. So it's also for superior vena cava obstruction. So that's when a tumor often in the um lung like lung, lung tumor causes um uh an obstruction of flow to the upper upper, the head, the neck and then the upper limb as well. Um I'll put in a picture here of Pemberton Sign. Um So that comes up, I think in questions. So if you have a patient and you get them to and you slack this, you get them to lift their arms up and then they end up with a very, like a, I think it's, they kind of use a temp of tha um you get facial swelling so nuts um assigned to like look out for um and questions and things like that. And then um the patient obviously is on getting enough blood, they will be dizzy, have headaches, um shortness of breath, things like that as well. Um A CT chest is the investigation. And then again, the management is dexamethasone, eight MGS B and A PPI as well. And then uh definite management would be um but I think you often will get questions about this is like an emergency. What are you gonna do then again? So Brain Mets, um this could also be a an osculation. So I maybe just briefly touch on that. So, um you could get an A which is basically breaking bad news and you go through spikes, um which I'm sure you have all gone through and um you are, you might get a situation or a station where there's a patient who has cancer has been found out that they've now got Brain Mets and you need to kind of break that news. Um So it's about being apathetic. It's quite an easy station if you get it because you don't need to actually know anything really. Um which is quite good, I think. Um it doesn't require very much knowledge or anything like that. It just requires you to kind of be empathetic and kind of know like a full meal um of how to break on you. And the thing with this one also is it's really important that if you do have a patient who has brain Mets, so it has been found to have brain Mets, they cannot drive. Um So you'd be telling them that that's normally mark in the op and things like that. Um And so in terms of how they would present, um they would have headaches, nausea, vomiting, confusion. So if you just think that if there's anything like within the um cavity of the brain or tumor or anything like that, um Just think of what, what does that normally cause visual disturbances. Um You can in like severe severe cases, you can get personality changes. Um You could also get um a change in neurology. So um a loss in power, things like that as well. Um And then investigations you want a CT brain and then again, the uh management like really easy to learn all these next matters. I understand. Um with the P and then also often with brain Mets, it isn't as tends not to be really like a definitive kind of management of it. It, it is then I think at that stage often on it once it's got to that stage a bit more palliative. Um but yeah, and then um pulmonary embolism. So I think everyone kind of knows more like a lot about that. So that's fine from like a a and stuff like that. So um I'll just go through a couple of things. So um the most often ECG finding is a sinus tachy and then you want to do a CTP, of course, um do well do and DNP, then um I think the thing to be aware of with the P if they are on and you know, or um yeah, going through cancer treatment, you treat them with um like way it happened. Uh So in the, in this slide, the slides on um kind of the different types of cancer that you could be asked questions on, but this is all very, this is quite a lot of detail I think. Um So I'm gonna skip kind of through these, but they're in the slides that will be sent. Um And you just can have a look at them and I would kind of, I didn't particularly learn most of this but things like three yearly mammogram at the top there is quite useful to know. Um I just think it's a lot of them in for something that comes up with like one or two persons. So um there's some breast cancer there that's called rectal and then prostate as well and then non cancer, that's all. Um So this is just about where meds are often found. So, bone Mets, um if you think about kind of location, it kind of um kind of explains itself almost. So prostate often uh Mets the b the bone, I'm sorry. Um And then brain mets often goes is from the lung or the breast. Um And again, if you just think about where that kind of travels to and then if you ever see a, an X ray, I should have put on in actually of cannibal mets, it's very distinctive. And once you've seen it, I don't think, don't forget it. So, um such a picture of that. Um and that's the most often renal. Um And so, so if you see someone kind of all met and you would then suspect renal um a renal primary. So then moving on to palliative. Um so it's five main thing to treat um at the stage at the end stages of life. Um So in palliative medicine, they do anticipate rep prescribing, which is giving prescribing P RN medication. This is an example of what someone could be um prescribed. So, analgesia um often morphine, um an antiemetic is given an antilytic um which is often midazolam and then patients in the end of life get um secretions build up as they're unable to kind of clear it themselves. So you get medication for that and you can also the Midazolam can also act um kind of twofold. It can like kind of calm someone down and also be anesthesia if they, especially if they got things like brain Mets and things like that. Um So then when it comes to pain management, you wanna do a history, you wanna work out if it's physical pain or what type of pain they have. Um So in terms of categorizing pain syndromes, is it um neuropathic or is it um a physical pain? Um Is that pain also then causing anxiety, which can also then need to be treated as well. And then you do go through your ladder step by step, which I got on the next slide and then if you need adjuvant. Um but things like neuropathic pain, amitriptyline pre are often given um or gabapentin as well. And then again, with bone pain, uh which is often quite common in cancers and end of life and bypass funs are given and also radiotherapy can sometimes be given palliatively. Um So the part of that isn't necessary to then treat the cancer, you're just um kind of giving them symptom relief. Um And then, so some, I have to know if I can, can I hold up? Ok. All right. I'm sorry, I did have some old seem to come up. Um So just some tips on prescribing um analgesia. So, um to look out for any contraindications. So check if they've been, had any, like any pain relief themselves before they come into the hospital, things like that. Um You need to check the EGFR and check the renal function and see if that's um lower or, and for EGFR, you need to have a look at a trend rather than just like at an isolated um blood test because um someone can have an EGFR of 45 for instance, and that could just be their EGFR for, for a long time. So that might not be a dip for them. And then with um laxatives, you so with um with opioids, things like morphine and things like that, you also prescribe laxatives and naloxone because they'll get constipated and also um naloxone is often needed. Um If they, they get become opioid um toxic and then when you work another breakthrough, break breakthrough dose, um you calculate the total amount of um pain relief or morphine or whatever they are on and then divide it by sex um to find out they break a breakthrough dose. Um So just gonna go through the analgia ladder here. Um So you start with simple measures, things like paracetamol check that they haven't had the name themselves, then Ibuprofen as well. That would be in the same ladder. Um And then in terms of you then wake you up solo not to be prescribed paracetamol because then they would um over dose some Paracet and traMADol as well. Also in that and then step three, you go on optimal uh stronger pain release like morphine, um MST and short, short tech, long tech, things like that. And so these are some of the examples and so kind of when you're looking at that kind of third stage of that ladder, um you've got morphine, oxyCODONE, Alfentanil and fentaNYL and that's gonna go up in kind of some kind of, yeah, kind of you go start morphine and if you needed to move up, um Beyl and Alfentanil often use in um anesthetics, often use them as well. Um So you've got long acting, short acting preparations and they're all subcut um um show actin, I guess preparations. So, and those are the kind of examples and kind of the um brand names and things like that, which often come up, which is good to know whether or not belong acting or short tech. And um obviously like long tech and short tech is obvious, but things like MST and things like that. Um This is a diagram that was in last year slides and so this is comes up all the time, um also comes up in the PSA as well. So for next year, I like went back to this table and I kind of just learned it the day before and the exams um comes up all the time. So you just, yeah, just kind of learn this by heart um, I kind of wrote it out loads of times and made sure that I knew it. Um, you'll definitely get at least small question and yeah, it's such an easy mark. Um, so just know how to convert, um, from one to another and kind of the other way as well. You sometimes get and yeah, that also will probably could be a question in the PSA as well. Um, you do have the drug conversion table um in the BNF when you do the PSA. So you don't have to kind of learn it off by heart, but it is just easy to know. Um It's not too often. Um This is kind of a table that is given in the guidance for palliative medicine prescribing. Um So again, I wouldn't be like a li this or anything like that, but it's just there if you want um reference you then in terms of uh with renal failure. So if someone has an EGFR of above 60 you can use it, uh you can use morphine and then if someone has an EGFR as it reduces, you kind of then are changing your medication. So then an egfr 30 of 50 you then use oxyCODONE and then if it's less than 30 then I'll turn it off. Um And this is just to do with um the metabolism. So morphine's excreted mainly, but then oxyCODONE is more xrayed by the um is metabolized by the liver and So it's less of a, it's kind of putting less of a strain on the kidneys, for instance. Um And then, for instance, fentaNYL and ALK and all are metabolized mainly in the liver. And so you're using um less of the kidney function to kind of clear that medication, um which is important, um especially in patients who are palliative, who are probably going to be on um morphine of this pain really for a very long time. So, um you know, trying to kind of hasten the death, you're just kind of trying to symptom manage. Um And if there are other options, um you're able to then go down that um a all will often also be used um kind of, it's much more specialist. So you could get questions. I definitely, I don't know if it was in our exams, the ci or it was in the PSA or something like that, but we definitely got all questions on kind of prescribing or choosing a medication based on kidney function. So this is quite important, you know, um and um toxicity. So a rest. So ba basically, if you get some more, you can obviously um cause them to become toxic. Um so that these are some of the um symptoms of toxicity. So things like with pupils myoclonus apparently is the reaction to the other day and uh it's more significant or the most um trustworthy kind of measure of set and so on. Um and you also have things like micro sleeping as well. So in the middle of a conversation, people will um kind of just fall asleep and then they'll wake back up. Um and you'll be able to wake them up. But um that'll happen like again, like I kind of like really, really high and like you fall asleep and then wake back up. Um and then respiratory depression is on everyone know research of less than eight. would also be an indication of like opioid toxicity. Do you want to check what caused it? So, were they dehydrated or they aseptic? Um have they had an increased dose? Have they been prescribed it twice? You want to have a look at the card, things like that. Um You want to give them oxygen um go through a man. Um The thing that people often forget is the kind of that day to step, which is stop it so often if it is a PC and that need to be stopped, um which is a patient um controlled analgesia, they can just and keep going that but often if that's not stopped, that can still be running or a syringe driver as well. Um A syringe driver works continuously over 24 hours. And so if you treat um your toxicity, if you don't stop it, um you'll, you have kind of the implant and, and uh Yep. And then so in order to treat with um palliative medicine rather than in A&E, you give just a bolus of noone and you're trying to get that. Um you trying to kind of treat you, trying to treat the, the fact that I've had like an overdose of an opioid in palliative medicine. You want to reverse the effects of the toxicity, but you don't want to um reverse effect of the pain relief because the patient will still be in pain. Um You give, um you give it in kind of a, not a bolus, but you give need to titrate up the dose. Um So yeah, and then you need to go back to the causes of why they became toxic. And, and so if there's anything that can be reversed, it can reverse that. Um And then, so the other things that we said that are important to prescribe, so these um kind of screenshots are from, again, the guidance given to um palliative care doctors which we had teaching on, which is quite good. Um So in terms of nausea and vomiting, often cyclizine is given. Um it's quite hard to work out which um an and to be honest, like I saw someone's got confused with it, so I wouldn't get too bogged down with kind of which anti emetic, but it does come up quite a bit. So, um yeah, I've got in the next slide kind of the reasons why you'd give different ones so we can go through that a little bit Um But yeah, but often cyclizine is given. Um and it, it depends on whether they've got symptoms at the moment. So, are they, are you prescribing it? And just in terms of anticipatory medication um here and, or other simple and then you kind of just go down this um kind of algorithm. Um So, yeah, and also it can be put within to a syringe driver as well. Um Yeah, sounds good. So, yeah, and this is the table I was on about there. Um So this just kind of goes through the different um classes and types of an emetics and you kind of based on the calls. So, you know, working out what's most appropriate but, and often that isn't necessarily a wrong answer. Um This also does come up in uh the PSA as well, just I have future revision. Um But again, this is something I wouldn't like kind of come to long term memory, kind of learn the night before sort of thing. Um But yeah, I know there's the doses there, but you definitely don't need to learn those, just kind of learn um type of drug and the classes and um the specific um reasons that you give them and then you can just work out from questions and stands um important to know that not to give haloperidol in Parkinson's as well. Um So then you could go for low dose Domperidone as well. Um rather than um you can inhale paradols. Thanks for that. Um And then the next um medication that you, the next thing that you want to prescribe for is secretions. So, as I was saying earlier, um palliative patients are unable to kind of get their secretions. And so often um they're given, this is also kind of P RN that's given. Um And again, it depends if they've got symptoms or not, but if they don't, um you're given glycopyrronium, um There's other things that you can also give, which is high hydrobromide or hyo butylbromide and that can also be used for cramping. Um So Buscopan is often used for abdominal cramping and things like that, which is also occurs in end of life care as well. Um But yeah, so those are the ones those are the medications are often given. Um it's given for um And then also simple measures as well. Um Things like just uh regular mouth and things like that as well also helps um to kind of ensure that um secretions are less likely to build up and things of that. Um and things also like to the patient and if they are all like kind of palliative and in like hospice and things like that or um bedbound, um send them up, things like that very like simple measures as well. So helps, I'm on breakfast fast. Um So often this doesn't necessarily need to be prescribed for again because it's already you're already given kind of morphine or you're already given often like pain relief, morphine, sulfate. So you're already kind of prescribed that. So this will also have like a twofold effect. Um But that is also what is given for breathlessness as well. Um And then at the end of at the end of life again, um anxiety, delirium and agitation are very common. Um And so for that, you're given Midazolam 2 to 5 mg, um 2 to 4 hourly. Um and that would be prescribed pone and the nurses will then give that when required. Um with Midazolam, you would start at a lower dose. Um And then if you need more, you can always give more rather than giving um either way. So start at 2 mg and then go up. Uh Yeah, so that's all the content um that I have to go through. Um Does anyone I've kept as quite short? So does anyone have any questions or anything like that? I do have Mc Qs and I can go through those as well if you would find that helpful, I was just gonna show it, but I finished it quicker than I thought so. So I will, I'll just go through those like a few of those and I mean, that will be helpful as well and I'll just check it as well. Give me one second. Yeah. OK. So um I'll just go through some of these um Mc Qs as well. Um And I feel like people won't be interactive. So I'll just kind of just go through them. Um And you can just kind of think of all the questions, what the answers and stuff like that. Um And I'll just go through the answers and stuff. And so this question is a 60 year old patients, even palliative and chemo chemotherapy and presents on day 10 of her um chemotherapy cycle with a heart rate of 130 So tachy and elevated rate of 20 sat of 87. So a and um hypertensive 85 and a temperature of 85. Uh what would be the most appropriate um management plan? Would people like to um unmute themselves and give an answer or anything like that? Or would you like me to just go ahead and see what the answer is and go through it like that anyone black kids people who don't want to? Oh the chart and yeah. So, yeah, yeah. Use chart guys. Um So eight. So yeah. Um So the answer is b um so this patient is, has neutropenic sepsis. So they are the kind of the key in this question is having palliative chemotherapy. And so it would be kind of the correct answer. If someone wasn't potentially having palliative chemotherapy, it was more um curative. Um And so that's why those kind of um that terminology from it comes in. So um the patient is clearly um has neutropenic sepsis and so you'd want to give ibupro specs, which is right. Um And then you want to stop the chemotherapy because it's palliative. Um and you should be s is quite a serious um, incident. So that is probably a little benefit I'll continue up. Um ok. And the next one, so 83 year old woman with an asymptomatic breast lump that is increasing in size, she has a history of COPD congestive heart failure, diabetes, KD hypertension, unfit for surgery. She's diagnosed with a three centimeter left breast, which is, I'm gonna skip this question because I didn't go over the content for it. So it, we'll leave that one. This 1, um 50 year old woman presents to the GP with a 12 week history of episodic diarrhea, constipation blow and a ad and weight loss. So those are the often like key words, um constipation blow and a ad weight loss um would be quite common like buzzwords for uh malignancy and then which tumor marker is it most likely? Um But I like to put in the um group chat in the chat box. Don't worry it all. So, yeah, I am currently. So, um yeah, so let's say 125. And um in terms of this often kind of in a woman with um say like and all those symptoms, um it often is um ovarian cancer and then that's say 125, he and then a 78 year old um male with a 40 year pack history. Um, presents with six weeks of constipation, increased urinary frequency shortness of breath and weight loss. On examination. He has dry mucous membranes and postural hypertension. What is the initial investigation that is most likely to help you with your diagnosis? I know again, someone just puts a and so in the chat. Mhm. So, um, I'll just go with that one. I understand. So that one is you and eve. Um, so that would help you. Not because as they have a, um, a as they likely have hypercalcemia with those symptoms or constipation, urinary infrequency, shortness of breath or weight loss. Um It's likely and they are a smoker, they likely have a tumor that's secreting um PDH and then that causes you to have uh heart. Uh So what's the most important prognostic factor for, um, prostate prognostic indicator for prostate cancer? Um This is a question that comes up quite a lot. I feel like I saw it in my finals as well. Um I'll just call you um, a high Gleason score. Um Is this question often comes up and there's another question that also comes up, which is in, related to skin cancer and it's about re laws that often that's the most um important prognosis. In fact, the skin cancer and that comes up quite a bit and I think that also came up by laws as well. Um 36 year old presents with a throbbing headache on bend over, associated with swelling of both arms. Um He's finished chemo four months ago, has distended veins over his neck and chest. What's the most important in immediate management? So this um is a man with super superior color obstruction. So you wanna give dexamethasone and again, so stenting is an option here. Um but um in the stem, it's the immediate management. So you go on for dexamethasone rather than stenting if it asked for the definitive management and then it would be stenting. Um A 47 year old has left mastectomy with axillary node clearance. Um for breast cancer histology shows it's er negative ph er negative as well. What is the most appropriate management? So these are the sorts of questions that are, I think are a bit harder because so those slides that I kind of skipped over um kind of if you go through those, you would get these sort of questions um what you have. Um And a 50 year old man has been admitted to the hospital with nausea and an episode of vomiting um appetite chemo. He feels nauseous, complains of a dry mouth. Um and you decide he needs antiemetic and which one would you prescribe. So, in that instance, you would prescribe metoclopramide. And again, if you think about um he's had chemo and he also has a dry mouth and what um would help. So again, uh I'm unable to go back to the other side if that table helps with that. So you just kind of um lay on that table um of which anemic go with, which kind of um symptom and help that. Um I think I only have a couple more questions. I have a 65 year old. So this is from, I think one of the um uh 65 year olds with the trans of the breast with cerebral and lemax is rapidly deteriorating as if you die. And um she become confused and agitated, what would be the more seeable initial management. So, in this case, oh, maybe they did not put out for them. So in that case, it would be Midazolam. Um So she is recognized to be diet and, and she's confused and agitated. And so for that, um Midazolam would um 75 year old with me, bowel cancer is dying. He's semiconscious being treated with morphine and haloperidol vs his breathing becomes increasingly rattly. Um What's the, what's the most important and what is the most appropriate drug management? Um And so in this one, it would be, I don't think so. Um in this case, it would be hyacin. Um and that would help the secretions and stop that ra rattle um noise. Um people often call it the death rattle. Um And so it's quite unsettling for um patients and their relatives. And so that's why it's important to kind of treat that as well. Um ok, so that's everything that I've got, I will, I don't think my read or anyone else is in the chat, so I will, um, work out. I'll send her these slides and try and just get them sent to you even just in the email. Um, I probably have a list of everyone. Um, if anyone has any questions, um, feel free to email me, I'll probably see some of these at the Mo on Wednesday for an. Um, does anyone have any questions at the moment? You can send it in the chat or you can email me or anything like that? Um If not, I will let you go. Ok, great. Uh Thanks guys.