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one of the ups and downs registrars in Chesterfield. And whenever you're ready, I've got the slides. But I will need to switch over from this to your next few cases, so you might have to bear with me. Yeah, that's fine. Um, so Hi, my name is Pepe, and I'm one of the s t five in a box and gynie Chesterfield. Um, I was trying to make up our point today, but no Microsoft offered stuff seemed to work on these computers, so I just kind of hand written out some sort of case studies. Um, and now I have, like, never worked in a Andy. But it's just things that I imagine will come through, um, that could be related to abs and gynie. So, um, there's just some case studies to discuss. Um, if you want to shout out any answers or write them in the chat, we can go through it. And if you have any questions or any patients that you've seen that seemed obstetric gynecology that you want that as well, then that's fine. We'll do that. Okay, So get my sheet. Yeah. So the first case we've got, um, the initial presentation is just a 24 year old lady, uh, complaining of right iliac fossa pain. So if you were presented this in A and B, what would you want to do? So we've got on the chat on ultrasound abdomen. Yeah, so, I mean, that's one thing to do at some point. Is that something that you would do in things there? So I'm just saying, Yeah, she definitely will have an ultrasound. But I don't know if that's something you would do maybe able to do on A and E unless you were doing sort of a fast scan. Um, yeah, exactly. So start off with taking a history and examining the patient. Um, so basically, I mean right, iliac fossa pain. Obviously, it will be gynecological because of our presentation, but it could be anything really coming through the door. So you want to take a bit of a history of the pain? Um, for a woman then interested in is she using, uh, and when was her last period? And also a bit of a sort of obstetric history in terms of how many pregnancies has she had before? And what were the outcomes there? Um, and then also examine the abdomen as well. So if we go over to the next slide, I think it gives it all away. But yes, so this lady's history is she's got really bad, constant pain in the right iliac fossa. And she's someone who doesn't really know when her periods were. I think maybe it's late. I'm not sure she uses condoms as contraception. She's never been pregnant before. It's very tender in the right lower quadrant. On examination, she's also tachycardic and to kidney ick BP. I probably wouldn't worry about that BP in a young woman, but the heart rate and the respiratory rate are concerning. I'm sure you always check in women from sort of age 11 2 55 a pregnancy test if they have abdominal pain. Um, and that can be either through the urine or a beta hCG level. Um, doesn't really matter what the beta hCG level is. It's just to know, is she pregnant or not? Um, and it's also worth just doing a your analysis as well for pain in case it's a UTI. So this lady is definitely pregnant. Her HPI is also 100 which is obviously on the low side. Um, so you request the guy any doctors to come and see her? Uh, they do a speculum examination to see if there could be a miscarriage. We take triple swabs because she's got pain. There is still a chance of P i D or an S t i n, which obviously in pregnancy, we want to get on and treat the do by manual palpations, which is positive for cervical excitation. So that would would suggest kind of puritanism in the adnexa. So if there's a mass there, such as an ectopic pregnancy, you may see those signs and then usually something that can be very helpful done in A and B that you have sometimes have before is the ent. Doctors have done a fast scan and said that there is blood in the, um as well um, so positive pregnancy test and blood in the peritoneum. We've got to consider a ruptured ectopic, Um and then she needs to go to theater. So she needs to be done by mouth. She needs to have some good IV access. So, like at least a green cannula, really. And the group and save sent off in case she needs blood, and then we take a pill. A process copy. This is not very common where we would kind of need to take someone to fear to straight away. Usually people will be tender, but their blood's are stable. Their observations are stable. Um, so we can usually wait a bit. Um, and we might just admit them to the ward and arrange an ultrasound scan in the morning as long as they stay stable. Do you all work? Does everyone here work at Chesterfield? A handy Oh, let's go. Sorry, I'm just going to Okay, so do your work in Chesterfield or even different places. Okay. No one's answered the chat as of yet, but I'm from North Yorkshire. Oh, you're from North Yorkshire. Oh, wow. Okay, fine. Okay. I don't know if this was just Chesterfield specific. Um, but if not, that's okay. I was just going to talk a bit about the admissions at Chesterfield. But I won't bother because it probably won't be relevant to all of you, so we'll move on to the next one. Um So again, this lady comes into a and, uh, she's 25 year old lady, and she's got a free day history of pelvic pain. So what would you How would you assess her in a and E? Shall I Shall I be horrible and pick someone from the group? Uh huh. Matthew Littler. Do you want to say or right in the chat how you would approach this patient? So what, you would be doctor if you saw this? Yes. Yeah. Always of history and examination. And what kind of specific things are you trying to get? Um What What differential diagnoses. Are you trying to rule in or out from your history and examination? Yeah. Perfect. That's really good. Um, so go any wise top pelvic inflammatory disease? Um, did an ovarian cyst accident, which I've got something on later as well. And you also want to ask about other potential problems as well, So yeah, Any urinary symptoms? Any problems with bowels? Basically, Um, and then abdominal examination. Yes. So I want to also ask about their periods again, Like with the ectopic. We want to know when the last period was and what contraception they're using, um, in terms of menstrual problems. So sometimes if they started to have some unusual bleeding associated with the pain that can be linked to P. I. D. Um, as can postcoital bleeding as well. Things like this pyromania that tends to be a sign of endometriosis, which you do get in A and E. And it's a bit of a tricky one is not really an acute problem, but, yeah, they're in a lot of pain. So that's that's sort of just pain management going from there. So if you're suspecting P, I D. As well. So maybe they give a history of kind of funny discharge. Um, it's important to take a history for risk factors of that, Um, so that includes a bit of a sexual history. So ask them if, when they last had sex, do they have a regular partner? Or was it sort of with a casual partner? And when was the last time they had sex with someone other than the regular partner? That's how I normally ask them. So just Yeah, you can try and keep it sort of professional and short and get a quick sexual history. Um, that will help help work out if P. I. D. Is high risk or not. Um, any investigations you would like to do so I think. I mean, normally I see any people. Everyone just has blood stone, so Yeah. Inflammatory markers. Full blood count. Pregnancy test, of course. Yes, sir. She will need vaginal swabs. I'm not sure. Is that something that you guys would do? Yeah. Yeah, George, that's perfect. Your analysis definitely is a vaginal swap. Something you would do is that a And the doctors. Do you tend to do that? Or do you just kind of refer to GI any anyway, from when I was in And we don't tend to do vaginal swabs? Yeah. Yeah, that's what I thought. And I mean, I think that's fair enough. If aquarium p i d they need a speculum assessment anyway, and then they need triple swabs or, you know, in different hospitals, they do the swab differently sometimes, but they need a full set of swabs that will check for chlamydia, Gonorrhea? Um, as well. So I think that's, um, for you guys. Not to long. You've taken the history, done a pregnancy test, um, sent off some bloods and thought about P i d. That that is fine. So if we go on to the next one. It'll just finish off that case. Yep. So this lady, um, she's got bad pain. She's complaining of offensive green discharge. She doesn't have periods because of her contraception, and she's got the Mirena, and that was recently changed three weeks ago. So that is a risk factor for P ideas of Mirena. Yeah, change in the last uterine instrumention intimate instrumention. So if they've had, like, a biopsy or a hysteroscopy or something, that is a risk factor as well. Um, she's been with one partner fairly new for six months now. In terms of her observation, she is scoring for sepsis. So, like anyone scoring for sepsis, we would start sepsis. Six. Um, and she's not pregnant, So you prefer to go in and they would do a speculum and swabs and then for P i D. So if the woman is well, if she doesn't have a fever, if she's not, septic is able to tolerate oral input. You can send her home with oral antibiotics, so they need an I am dose of kept Rituxan and then oral doctor cycling and metronidazole for 14 days. If the swabs come back positive for anything. Then they'll be referred to come for follow up and for contact tracing if their septic, if they need to stay in, then they get IVF. Try Axon. Uh, and the so the bash guidelines says oral doctor cycling or IV doxycycline if they can't take orally. But I've never I mean, I've never really seen IV doxycycline. I don't think you'd really be able to get a hold of it. Um, we give IV metronidazole as well at this hospital. So if their septic, they will be admitted on IV antibiotics. Um, as gynecologists will arrange an old sound scan to look for an abscess if they're very unwell. If they're not too bad if they start to recover very quickly of antibiotics, you don't necessarily need to do a scan because you know you're not. You're not going to do surgical management if they're getting better on antibiotics anyway from a tumor, A very an abscess. Uh, if she has a Mirena in, uh, and she's got an infection, you can take it out. But you need to make sure that they've not had intercourse in the last seven days because they could still get pregnant if they're really unwell, you could potentially take it out with emergency and cover. And then we would also send that to microbiology because sometimes they can get, uh I don't know if you've ever heard of acting, um, IOC's infection from the coil and that just requires treatment with a really long course of antibiotics. Basically, any questions about that or the other lady was spoken about? No. Okay, we'll go on to the next one. But if any questions come up, just ask or put them in the chat any time. That's fine. Okay, So I got a 35 year old lady and she's come to any. She tells you that she's pregnant and she thinks she's about eight weeks and she's just vomiting really badly. So I'm going to just pick someone again. We could do that now. Uh, Olivia Jasur, Do you want to either right in the chat or say how you would approach this lady as an A and the doctor? Yeah, that's good. I like what you're putting in. Yeah, fine. So basically, we've probably got someone with either hyperemesis gravidarum or just nausea and vomiting. Crazy and yes, definitely. Do a pregnancy test if they're not had a scan or you don't have, like, a recent beat hcg um, people can be mistaken or lie about being pregnant. They do do a pregnancy test. Absolutely. And while you're at it, do a urine analysis because a UTI could trigger vomiting as well. And we can obviously treat that, um, so it's either hyperemesis or just nausea and vomiting in pregnancy. Hyperemesis is so to meet that criteria, they need to be clinically dehydrated. Have deranged You sneeze and have lost 5% of their body weight since pregnancy began. Um, so it's quite severe. And nausea and vomiting in pregnancy is basically nausea and vomiting without being that bad. Okay, Um, so you mentioned pregnancy test as an investigation. Any other investigations you would arrange in A and B for her? Yeah. Perfect. Um, so we do blood tests. Uh, the standard ones would be a full blood count. You sneeze. Um, LFTs. In case they've got some of the liver problem going on that's causing vomiting. Um, if they've got epigastric pain as well might be worth doing an amylase just to check. We don't have pancreatitis. Um, and any treatment that you had given a any. Yeah. Perfect. Yeah. Cyclizine is great. Give them something we did. We get a lot of people come over to the guy in a ward from A and B with nausea and vomiting. They've been in any quite a long time, and obviously, because I wait for a long time, but they're not had any treatment and just giving them starting a bag of fluid and giving them one anti emetic can make them feel so much better. So, yeah, just give them something. If we go on to the next side, we can see, um, what we give so again with nausea and vomiting and pregnancy in your history and examination, you want to make sure there's no other cause of them vomiting. Um, so we want to like, I make sure constipated that could be making me feel sick. Um, and any other kind of surgical cause that could make them vomit. So usually if they have quite a lot of pain in the abdomen, that's a bit usual for premises for nausea and vomiting and just maybe have a bit of muscle aching, but they're not really like in a lot of pain. Abdominally um also pregnancy associated nausea and vomiting that first presents after the first trimester is really unusual. Um, usually, it will be bad in the first trimester and then improve after the first trimester. So I'm in this country, Mr. They've never have nausea and vomiting and see before it just jumped to think, Oh, it's like hyperemesis. Think of other causes. Vomiting. Um, so, yeah, this lady is very classical nausea and vomiting in pregnancy. She can't keep anything down, but she's not really got any pain. Uh, no problems with her bowels or urine and examination's normal. Uh, she does. So she has lots of ketones in her urine, which is a sign of starving. And pregnant women get ketones kind of much easy, much more easily than non pregnant women. Um, so it's just a sign of starvation and dehydration. Really, If they have just one key tone or less, then they probably don't admitting you could probably be able to give them like an I am anti emetic and then oral antiemetics to go home on, and they can go home. If they've got more than that, they'll probably need some IV fluids. Uh, yeah, I do all the bloods that we mentioned. Um, TFT s. Sometimes people get very excited sending them off, But you only really need to do it if they're coming in lots of times or something. And then I don't know if you've heard of something called the Puke School very aptly named. Essentially, it's free questions. How many times in the last 24 hours have you vomited? How many times have you retched? And for how many hours of the day have you felt sick? And then there's numbers, and depending on what the answer gives them a score out of 15. If that score is less than 13, then they're okay to go home and have oral anti emetics. If it's 13 to 15 and then they need something IV, they can usually go home the same day. So that's why it's good if you know and you can start the treatment because once they get feeling better and keep some food down, then they'll be able to go home. Um, in terms of treatment. So the guidelines are guidelines. Chesterfield suggest giving normal saline with potassium in, um, you can give that over like four hours or so. But if you can't get that any D, then just Hartmann's is fine. Cyclizine is usually the first line anti emetic, um, or prochlorperazine. And then if if they found that that doesn't work, you can also give metoclopramide or promethazine as well. The only thing we don't really want you to give is on done in the first trimester. Because there's some week evidence that it has been associated with cardiac anomalies in the baby after the first trimester is totally fine, though, So yeah, any questions about nausea and vomiting? Like lovely. We'll do the next one. I don't know what it will be see. Oh, yes. Uh, so first you look year old lady, come to an e. Were very. She tells the triage nurse that she's got an ovarian cyst. Um, site if we get someone to this one. Uh huh. Winterton. You want to have a go, or are they not the, um Michelle? Are you there? Okay. From A and B point of view. Yeah. Definitely went to, um What? What sort of different diagnosis. Would you be thinking of this? Yeah, Perfect. That's really good. So we get this a lot. Where? Which we get a hit, A referral from a day and say, Oh, the ladies known to have a cyst. Um, but still consider other causes of abdominal pain. Same area. So that definitely would include a pregnancy if it's left iliac fossa pain as well, Possibly constipation or some bowel issues. Um, and then in terms of gynecological causes, um, there are three types of cyst accident basically. And one is a variant or shin. The other is just cyst rupture. And then there's hemorrhoids as well. Um, so all those three things can cause acute pain and also also p i d as well to consider. Um so those are all the differentials you would be thinking of? What investigations would you request to try and help you work out what was going on? Yeah. So, yeah. Pregnancy test. Definitely need to rule that out. Um, an ultrasound again. Probably not going to get like a really good guy in the ultrasound in A and B, but it's definitely something that would be done if they say they have a cyst. I would look back at the old labs and see where this has come from because people like to. I don't know if they get told they've got a follicle, and then it blows up to like being a big ovarian cyst and stuff essentially for women who are premenopause or a simple cyst of less than for their cycle. So if they've had that before the previous scan, yeah, it might. It might have ruptured and cause pain. It's not going to talk or do anything scary. Um, if they have polycystic ovaries, polycystic ovaries is just tiny little follow. That's not going to talk, either. Um, so, yeah, I have a look at the old scan. Just see exactly what what they mean by cyst. Um, if you can get a hold of it, Uh, so, yeah, let's go to the next one and then we'll find out about that. Yeah, so she feels really rubbish. Had horrible pain. No appetite is vomiting, which is pretty common in to wash in. She's had one child before her last period was two weeks ago, but you're not using any contraception on examination. She's tachacardic and kidney her. Your analysis shows us know like you're an infection and she's not pregnant. And then blood. So for this would do full blood count and a CRP. And also it would be helpful to have a lactate as well. A raised lactate would make you very suspicious. So very, very important because obviously it's kind of tissue dying. Um, also with a torsion, you would have raised inflammatory markers. If we're worried about hemorrhage from a cyst, then the foot the HB may drop as well. Uh, yeah, and then management. So basically, I mean for caution is to go to theater. And ideally, we want to go as soon as possible, uh, to help preserve the ovary. But it's quite difficult decision to make to go to the theater with this kind of thing with no imaging, because it's such a m. I don't quite know what you're going to go in and do it once where we you know, a woman was in a lot of pain, a young woman. So we went in and actually it looked like a malignancy. Um and then if you try and do anything fancy surgically, you are at risk of causing that spreading that and causing upstaging. So if we can, it's good to get some imaging like an ultrasound scan before we go to the theater. Unlike testicular torsion were very, very important, even if it's been for quite a while. So even it's been for a day or more. We go in. Even if the ovary looks like completely dead, we just untwist it and leave it and then do follow up surgery after, and usually the ovary will recover. Um, and then the follow up surgery. We would just remove the cyst that had caused the torsion in the first place. Um, we tend not to do a cystectomy in the acute phase in the acute surgery because it's all horrible and bleeds loads and really messy, so we just don't twist it, leave them and go back in later. Um, so mainly for this, you're gonna admit them to the ward. Keep them know by mouth, if you are quite suspicious that you will go to it and try and get an ultrasound as soon as you can. Obviously, if they're bleeding from a cyst, uh, and they're becoming clinically unstable with that, they will then need to go to theater to manage the bleeding. Sometimes if it's bleeding and they seem stable. We'll just sort of sit on them and keep an eye on them. And usually the bleeding can settle and then re absorb. And if it's a cyst rupture, it's just really pain relief, um, and supportive management until they feel better. And if you then do an ultrasound. If it's been a ruptured cyst, you might just see some free fluid in the pouch of Douglas and no cyst at all. Um, and this this lady. And when you look back at her old scan, it shows that she had a six centimeter dermal exist, which she's just having conservative management for. So that's follow up scans. So Dermoid Cyst is one of the most likely to talk, and it's more than five centimeters, so six less than five centimeters probably won't talk. But more than five centimeters are at risk of that. Say that that's the case. We'll go on to the next one. But if you have questions, just just shout. Okay, Uh, so this is very common gynie case. I don't know how how often you guys as like doctors in, and he would really see that. So I feel like we often just get these referrals straight through the nurse, Um, a 30 year old female with some heavy bleeding. So who we picked? Um, Ahmed. Oh, Doctor. Oh, do you want to talk about what you would do for this case? Yeah. Okay. I think from a and B point of view, the most important thing to determine is is she pregnant or not? So that that's quite a bit of how we would manage them, Um, as gorgeous. And then just to work out in terms of the bleeding, is she stable enough to go to, like, you know, a guy in the triage service, or, like, outpatient service? Or, you know, issue bleeding really heavy. Does she need to kind of be seen in a and a, um, and be stabilized there. So the main things we really expected to do a pregnancy test again. Either urine or blood is fine. Um, do observations. So look for any signs of shock. Um, get IV access and do a full blood count to see if there's been a drop in a HB and agree can save as well. If she is pregnant. Absolutely. Need gynie review. We would do a speculum to see if she is actively miscarrying. So if there's a pregnancy tissue in the cervix, we can remove that, Um, and if if not, we'll need to do a scan for her. If she's pregnant and bleeding heavily, we may need to just go to theater, um, to remove the pregnancy tissue. So it's not that straight theater from A and, um for that. And that's why it's really important that we know if they're pregnant or not. Um, yeah. Another thing that's quite important to do in A and E is to try and quantify the blood loss because this is something we often get get quite vague reports on, um, and again, it does make a big difference to our management of whether we think we can bring the patient to a gynecology, um, sort of a case place or if they need to stay on A and E. And no one's expecting to kind of do speculums or anything. But if you just have a look at their pad, if they've had a pad on for under an hour, it's completely saturated in blood. Or if there are large clots sort of bigger than a golf ball. That's pretty heavy bleeding. And if you told me that over the phone, I would say Leave them in and then I'll come to you. If it's lighter than that, then that's fine. They can come to the outpatient. Um, so, yeah, let's go to the next one and just see what we said about this lady. So again, it's part of the history really important to check her periods and her cycles. She's got a regular, Um, it was about four weeks ago. It could be a very early pregnancy, but a pregnancy test is negative, she reports, changing her pad every three hours with clots. Um, and she's never been pregnant. Observations are all normal, and her blood count is also normal. Um, so if they're not pregnant and having heavy bleeding, we can manage it medically. So in a and B, you can give them 1 g of trans tranexamic acid stat, and that really does help settle bleeding. If, as I said, if the bleeding isn't that heavy, if they're stable there HB stable, they can just go home. And as gynecologist would normally give them three days of tranexamic acid and you can give them some progesterones if they're not taking any other contraception, that will just set all the bleeding. So either norethisterone or a course of Provera, because I think there's a norethisterone shortage at the moment. I heard, um, so they can go home with that just to settle things, um, and then follow up with the GP. If if the bleeding doesn't settle, um, if they're bleeding really heavily, give them a gram of tranexamic acid IV. Resuscitate them if you need to, and we will come and see them. Any questions about bleeding? Yeah. I think the most important things are to determine if they're pregnant or not and determine how bad is it? Are they stable or not? Basically, that's the main things we want to know. And if they're not pregnant, given some tranexamic acid usually settles things down. No, it doesn't look like there's any questions. So but the last last case Don't worry, Uh, and then we're done. Would anyone like to have a go at this, Uh, Asian? Yeah. How are you? Do you want to say how you would approach this 33 weeks, lady coming to A and B because she's got chest pain. Mhm okay, or fine. Um, so it will vary from hospital to hospital, but pregnant women with what would be considered non pregnant issues, um, may not necessarily go toward or antenatal. Triage might go to any, and they might get admitted under the medical team. It it varies from the hospital hospital. Um, so you may well see women who are pregnant, but they have other problems. Um, such as chest pain. Basically, you want to do pretty much what you would do in a non pregnant person, So that is an E c G. We are getting pregnant women who are older now who have complex medical problems and high risk factors. So we do get a C s in pregnancy. Um, you can also do a troponin that's not affected by pregnancy. So, you know, if it's raised or negative, it will be an accurate reflection. And of strain on the heart, Uh, chest X ray do that? Um, don't do a d dimer. It will be positive if it's negative. It's incredibly reassuring, but it almost certainly will be positive. And then you just a bit of a situation like, What do we do now? um so pregnant women don't bother doing any edema. It's pretty helpful, but tcg troponin chest X ray absolutely do all those things. Um, so, yeah, if we go on to the next, But that kind of just finishes everything. So she gives a history of a stabbing pain that's worse on inspiration. So it sounds like quite a pleuritic chest pain. It's not going to cough, but she is becoming more short of breath. Let me examine her. Everything's fairly normal. She's tachacardic. And to keep me out, though, she's got a stable BP. That's all. Normal, normal TG it shows some tachycardia. Uh, troponin is normal. As I said, no deed. I'm, er we don't want to do that. Chest X ray is clear and you want to do a full set of bloods as well. So I think Obviously the main thing going for here is this a p um so still, the commonest direct cause of death in pregnancy definitely need to think about it. Um, look for signs of a DVT as well, if you're suspecting a P and then for treatment. So I put I put what we give at Chesterfield. But what you give will depend on where you work. Um, And if you can't get it on the hospital guideline, then the Royal College guideline of V T treatment will tell you for all the different types of low molecular happening what to give. You can give a give a dose of that provided they're not bleeding. But like, um, and then you need to do some more investigations to actually confirm a P. So if they do have signs of a DVT, then the first step is a leg Doppler. If they don't have signs of DVT or the leg doctor is negative, then we need to image the lungs either a CT pa or a VQ scan. Uh, people who are pregnant and your radiation stop. But we do need to have a diagnosis. Um, and some some hospital asked for a little consent form before they have the scan, so C G P. A. Is really full. If the chest X rays abnormal because it gives you more detail of the lungs, Um, and also a CTPE is usually easier to get out of hours, so it's probably something that could happen in A and B if you really, if we needed it quickly, um, compared to if you think there's less radiation two liters. But it does give an increased dose of radiation to the breasts, and that increases the risk of breast cancer. So it's quoted at 13.6% above. So you're already every woman is kind of low risk of getting breast cancer is 13% higher than that low risk. Um, the VQ scan is safer for the maternal breasts, but does have a higher, um, dose of radiation to the foetus for the foetus. Um, the doses for these scans are not going to cause teratogenicity There is a risk of childhood cancer, and that risk in the guideline is given given us one in 100,000. So pretty low. Okay, so if they need the imaging, then we do it. Um, so, yeah, that's how we would expect you to approach a pregnant woman with chest pain if she comes in through E. D and kind of a little obstetric system review, I would do if you do get pregnant woman in a and you would just be to ask them about any reduced fetal movements. Any pain in the abdomen, particularly tightening pain or crampy pain, any bleeding from the vagina and any sort of fully discharge or fluid coming from the vagina. And that could be the water's going Nothing like that. Definitely get in touch with the obstetric team, usually in obstetrics. It's the labor board coordinator who sort of runs the show rather than the doctors. Um, you can call the labor ward and speak coordinator. Usually they'll be able to sort things out pretty quickly. Um, if we're worried that a woman is medically uh, but also has upset concerns, then they can take a C t G monitor for baby to A and A, uh, and and do that there. And then, um so, yeah, basically my main point for this Don't be scared of pregnant. Just approach them with whatever they're presenting. Complaint is, assess it, approach them, ask them some simple questions that pregnancy, and you can get in touch with us if there's any concerns. And don't be scared about doing imaging in pregnant women if they need it. Um, because all those radiation, it's still a pretty low, low dose. That was all my cases and something a bit rubbish. It's been a bit like D. I. Y, uh, does anyone have any questions or any patients that you've seen that you wanted to, like, mention or ask about? I don't know if it stops and I need something you see in any or very little really compared to all the other stuff. I think personally speaking, when I did four months in and I saw probably about 4 to 5 cases of jobs and genotype presentations, so it's probably one of the are the ones that would honest It's pretty straight forward. Really, um, obscene guinea. And yeah, I think I think most of it goes to the triage nurse and then comes up straight to us. So yeah, you probably don't see quite so much of it. But yeah, it's not. It's not too hard. I don't be scared of pregnant women. Give them, give medicine if they need it image that if they need it and speak to us. We are nice people on board is crazy so that we can be a little bit short on the phone. But we are. We are nice, actually underneath all that to say, uh, just have to check the chat. There's no comment since the fine. Yeah, if if questions come up after that, then either I or promise we'll pass them on to you, if that's all right. Yeah, them on. To me, that's fine. And I'll get back to you if any. You know, if anything comes up that you weren't sure about, it's eight o'clock. So let you go. Yeah. And another Thank you for hosting the, um, session. And I think we'll leave it there. Thank you very much for coming. Bye.