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Summary

In this on-demand teaching session, Ms Bands, a consultant orthopaedic surgeon from Stevenage in the UK, will cover emergency management of ankle-related issues, initial management and assessment of sore throat, management of epistaxis, and recognizing and managing acute phase of sore throat. Initially, the session will involve participants writing down any thoughts or questions regarding sore throat that were already known, followed by a review of the anatomy of the oropharynx, indications for admission, how to examine the patient, tips on how to open the mouth with trismus, and atypical presentations of sore throat with differentials. Participants will also gain skills in recognizing what is normal, so they know when to seek help.

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Learning objectives

Learning Objectives:

  1. Identify signs and symptoms of sore throat and how to manage them.
  2. List methods of examination for sore throat and related anatomy.
  3. Explain the management of acute tonsillitis and peritonsillar abscess.
  4. Understand the differentials of sore throat and how to diagnose Mononucleosis.
  5. List appropriate medications and methods of fluid resuscitation for acutely unwell patients.
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Computer generated transcript

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

so Good afternoon, everybody. Um, I hope you are well or was. It was. Well, she can be. Um I'm very humbled to be allowed to come in to help with your teaching today. And I spoke to Al, um, a little bit. And I think you have a curriculum body anti That's all covered partly your surgeon curriculum and partly in your primary care or your family medicine. And some of you will be going on to do general jobs involving some on call service for ent. So I thought I would focus my lecture on emergencies related to the ankle, and you recently had some coverage on a tightness and external otitis media. So I I I took that off my lecture. My name's Ms Bands, Limber consultant, anti surgeon, working up list hospital and Stevenage in the UK, and we're going to go through some initial management and assessment off sore throat. We'll talk a little bit about the management of epistaxis or nose bleeds on. We'll focus a little bit on the anti emergencies and how to recognize and how to manage them. Initially, if you were the first on call looking after these patients, so I'm just for the first, the second or so If you could all take a minute, I have You've got pen and paper there or even something to drop down on. Just write down any thoughts that you know or anything you already know regarding sore throat. What the potential diagnoses, what the signs and symptoms you might be looking for. I'm making me make a drop down of any questions you think you already have about sore throats. Obviously, I'll hopefully address them drawing the lecture. But if not, you can ask me them at the end or the appropriate points during the next year. We'll just give you a few seconds to do that. This is leaving all so really this all for it that you're going to see and you're cute setting either really urinated department or in the primary care. A general practice setting are going to include tonsillitis, laryngitis and farengitis, and tonsillitis can evolve into a Quincy, which is a bit more of an urgent thing to consider it a bit more serious, but we'll cover that in a minute. Rarely do sore throats on their own required mission contact, which you might want to think about. Admission is those patients who are unable to drink and swallow because they're at risk of dehydration. Journal. Acute phase. So somebody is have severe and of tonsillitis that we can't swallow. Liquids they need to be admitted know eating is not really nice for the patient, and but isn't that worrying in the first couple of days? But if they're unable to drink that, that's a risk for dehydration of the patients, particularly Virex yellow by correction in a fever, obviously over 38.5 or they're generally very unwell. They're looking bit clapped out there. They're very tachycardia, any of those features, then it's worth thinking about admitting. And because actually, that might be the start of the signs of dehydration due to being unable to swallow liquids this external next welling on. Initially, the presentation was suggestive of tonsillitis. You may be reasonably worried about the possibility of of abscess in the rectum firings for the parapharyngeal, the retro flying from power frank. So basically, the walls of the throat, the retro fact is the water, the throat at the back between sort of the fascia lining the spinal column. On this, the muscles of the throat, on the parathyroid, to the space on the side of the throat and in the same sort of fascial spaces. I haven't covered the anatomy of the's. But if they are, if you are, if a patient is developing either of these abscesses, you'll notice that they may have some restriction of neck movement. They'll start to show feet to the hearing and upsets it, just spiking temperatures or just feeling very unwell. Ongoing. You look in the mouth. You might notice that there's bulging. I'm off the side walls of the throat or from the back of the throat. So any suggestions of that you will think about admitting this patient and if it crosses your mind to admit the patient and, as a safety measure, always admit. And then if there's any difficulty breathing. And by this, I mean, do they have evidence off Strider or stirred or which they've not had before? And do they have any difficulty getting air in, other than to sit forward to breathe comfortably? In that case, you might be worried that this is actually something more like a super back itis, which is ah more emergent, you anti diagnosis in the acute phase. I'll cover Symbicort Titus later on in Electra. So how are you gonna examine these? Patient's initial examination was always a safer first on call particular. You've not got much. Didn't experience will be limited to the oral cavity and the neck. Do you need a good light? And you need to turn the pressure. You're looking at the or if I want to look up prominent tonsils, you're looking for any asymmetry off these prominent tonsils and you're looking for evidence of passed on or from the tonsils. So just a reminder of some of the anatomy. This is a very nice picture which shows all the different structures of the top off the oropharynx on. Really, What you're looking for is the Palatine tonsils, which sits here between the palate. If I and d alarm or what we call the posterior pillar off the tonsils on here, the power to colossal article we call the anterior pillar of the tonsils. If there's tonsillitis, these tonsils will be large and inflamed from often have a coating of permanent coating on it. This is what I might look like in the photo on this is a photo showing rather prominent tonsils. The anterior pillar, the posture, a peeler on this particular photo and enlarged even. And I'll talk about that in a second. So that picture that I've just shown you could be a normal constant, the normal appearance in a patient this may be a patient just happens to have a large tonsils. Some patients have a chronically enlarged tonsil, a sorry chronically night, even if they happen to be heavy Sonoras and things like that. So it's difficult to tell. But if the patient is acutely store and they said they're not normally got a large tonsil, a large regular, then do you consider whether this is actually farengitis? Maybe not. Bacterial pharyngitis might be far viral farengitis. If the tonsils are large, the general appearance of the pharynx is very red, and on our therapist on the patient is very sore. But without this sort of Axid, a tip deposit in the possibilities of a viral fine writers rather than acute 20 litis or even a viral tonsillitis. In the viral picture, you're really giving supportive measures, lots of fluids, lots of pain relief, and usually they don't need admission unless It's a hepatic viral farengitis, in which case it's so painful the patient result might be able to swallow, and we'll need admission for IV fluids. So once you have examined that, once you got to the point of examination, sometimes you find the patient is unable to open their mouth, and this is a feature called trismus. Trismus occurs because of inflammatory changes to the masticated muscles. Those are the muscles that open and close the door on in the cute tonsillitis or any infection in the apparent in the tonsil A on the currency Oropharyngeal area can give rise to trismus. If you have a patient with Christmas is going to limit your ability examined, but you do need to examine them. So my take is that if you're seeing a patient who has come in with a sore throat or is it presented to our clinic with a sore throat that unable to open their mouth enough for you to get a view, give them some good analgesia. Give them a max dose of person to know if they're able to tolerate give them a dose of anti inflammatories. 400 mg of ibuprofen on give them a start dose of steroids. So in our practice, who would give a starter dose of 8 mg of dexamethasone? But your your local hospital might have different steroid availability. Ideally, give it in liquid form so they're able to swallow it and leave it about 20 minutes half an hour. These two in particular the anti inflammatory and steroids, should have a benefit on inflammation the masticator and allow you to open the mouth and have a good look. Then you'll be able to assess. Is this a Quincy? Quincy is typically features trismus in a Quincy that picture that I showed you previously. Where you've got this area off Perry tonsil a cellulitis, it becomes more diffuse. You'll see bulging more around in the anteroapical around the tonsils, and it looks a bit like a bag. It looks like it wants to pop. If it looks like it wants to pop, you want to try and aspirated to try and get the pus out of Quincy is a parent wants of absence. A period once in a connection of puss in your junior time was an ent doctor. You may not have experience in aspirating what's important for you to recognize that this is going to be Quincy. I'm not. You need to get someone in to help you aspirated. One of the most important things for your time, as as medical students and is doing your doctors when you first qualify is to look in a many miles to look at everything as much as know possible to recognize what's normal in your early stages. And it's not specific to the anti. This is for any of the practice that you'll be doing in the future. You're most important Rule when you first start is to be able to recognize normal because then you can identify when you need to get help to help with abnormal. So that's a review on the identification off. Cancel itis or related and diagnosis off. Quincy. What are you going to do about the patient if there are unwell enough to admit that means that great you did IV fluids. So you're going to put an IV access for fluid resuscitation after medications, particular because they're not able to swallow the necessary medications by mouth? Do you perform a full blood count? Are using these and a CRP CRP in the phonebook and obviously related to the inflammatory and infection markers. But you wanted to the user knees because you want to know the baseline hydration status on particularly somebody has got any comorbidity is. With that answer. Lightest transmitters can occur and older patients with other medical issues did you do a test for granted a fever or infections. Mononucleosis. I'm not necessarily at the immediate admission because it's not going to change your management. However, do you think about the possibility of a diagnosis of grandeur? A fever or infection on the nucleus is if your patients presented after several days of cancel itis despite antibiotics. Now picture makes me think immediately, or whether they got a bunch of the fever and and often you'll see with those patients got much more prominent neck lumps, neck lymphadenopathy when you palpate compared to the other patients that you'll see with a normal council itis other signs that you will see in a patient with infections, mononucleosis tonsillitis is they may have a teacher. The spots in the palate on the appearance of the inflamed tonsils, bit different than what the x a day. It's very thick and coated on the tonsils. I had one cup consultant who told me that just looks like cheese on post, which slightly put me off cheese on toast. But it's it's a good thing to remember as a as a as a future on As I mentioned, they will have very, very gracious and find nothing. So this is, ah, picture just to show you those features intellectually, if you don't want to like this, that is the coated exudate on the twenties, as opposed to the spotted Patrick doctor accident that you saw in the other protein on This is an example of, particularly on the palate. Okay. And if you see these features, you're more like in the back lines of a fever. Yeah, the two forms of storage. And so it's all throughout that. My present to you is laryngitis and far enjoy. It is laryngitis. Main features paid, voice loss complete, voice lost. I'm obviously a little bit of a painful right. But generally speaking, with laryngitis, patients are still able to swallow and eat and drink. I shouldn't need admission. They just need to be reassured on wonder about any red flag symptoms that just difficulty breathing fire. Enjoy it is can be difficult for you to diagnose without explanation. Endoscope. If it's not evident in the order for it when you're looking through the mouth, so what will make you think about the drivers and requesting a nasal endoscopy? Either if you're able to form yourself or by getting when you go seeing is in is the patient is really struggling to swallow? If the pain and discomfort there have there, suffering appears to be disproportionate to the appearance of the chances in the throat, so you will need to do it escape for that to assess if I run ritis. The other reason is that actually, Paronychitis obviously is a diagnosis that you should be made. But more importantly, the diagnosis of super got tightness or people kind of has to be ruled up. And you will need to do it with a fax from laser and a scope. And I'll come on to that in a little while. Essentially, was any of these features of any of the sore throat. If you are concerned that there is more systemic future, the patients more on well in their throat is there or France looks when you look in, or you think there's a risk of a progression to come away. Compromise, admit the patient and get supportive measures on board. And for your senior on call for the ent. So that's me for sore throats. Other Any questions at this point, our ocean and carry on No questions and the types of you know we can curry. Thank you. So we're going to talk now about news nose, please. I'm some of you may or may not have chemicals nose, but if you're doing the clinical placement, just spend a couple of seconds again writing down your thoughts about nose please. Your anxiety's about them. Any questions you might have about nosebleeds and we'll come back to those I'm in a few few few minutes. We have covered the topic, so I'll give you a few seconds if you want to write anything down. Okay, so first thing I say about Epistaxis is is that it is a potential hemorrhage that your early stage when you started junior doctors, that's the kind of principal I want you to take forward. I don't want you to be too worried or too scared about managing epistaxis, but I want you to hold onto the main principle first principles off, making sure you are doing all that's needed to manage potential coverage, as you would with any other bleeding if you were doing any of the surgical and rotations. So don't cut corners with these patients that don't let your colleagues in presumptive major department to cut corners. You must be the pressure in a safe place, depending on the set of where you're working that might be in the emergency department. That might be a treatment room with all the kids that you need at the bedside For the patient, they must have normal observations they should have. They're reaching observations recorded. Ideally, you're looking for recording off heart rate and BP. This principle applies to any patient that you're worried about hemorrhage with. So you will be applying this principle in the future when you're dealing with general surgical or orthopedic trauma, all those kind of cases patient should have IV access, particularly if they're in this bit older. If you've been bleeding for a long time and it's a good idea to get an allergy on board for these patients, especially that you're going down the route of possibly needing to pack the nose on. To be honest, be mindful that if you have been contacted as the ent uncle, it's usually because in most centers, primary cares are either in the mansion department or general practice, have not been able to control the bleeding, so you're going to have to intervene a little bit further. One of the main risk factors for nosebleeds. Isn't there any blood thinning Publix? I don't coagulate so antiplatelets to find out if that's the case and find out when the last dose was taken. If your patient is on warfarin or any of the dough acts like Apixaban a big Suburban, then you should stop those in the immediate setting straightaway regarding, uh, spinach with a girl. It's a bit difficult about these ones because they stay in the system for at least seven days for aspirated on, I think, a little bit short of the copper doctoral. I'm If you think they are under con fighting effect, for example, a patient is bleeding heavily and they're on several birth in this. It might be worth stopping them to give you set your patient a bit of rest, fight What's an impatient do bear in mind stopping these two are not going to have much benefit in the 1st 24 to 36 hours. So stopping the dough up for a warfarin will. Does that need to be taken? Are for blood count for any hemorrhage and for you, using east particular to look for any dehydrated evidence of dehydration on in the older patients, which are tend to be who presents with an expected that is controlling the baseline renal function, it is worth doing calculations screen, particularly if they are on warfarin. Uh huh. Do you have to do a group? And safer All epistaxis is depends on what your clinical accident says. My feeling is that your early years, when you first start out and you're approaching this as a potential hemorrhage, it is working a group in screen. As you become a bit more experience. The group of screens are probably more useful in those patients who are going to have other comorbidities. Example. The older patient with heart pain. Yeah, so patients with known and Neemia? Obviously anybody has been bleeding for a long time. You, Mr Agreement safe. But in the first instance, when you're building your confidence in office patients, it's not a reason for the aspirin group and say for everyone. As you get more experience, you'll recognize when the nose has been severe enough to need a group and savor whether whether you could hold off for sure. Been talking now about packing your nose with those be starts. There's a step wise approach to this, and it's a very nice video, which, if I have time, I will show you. But if not, I've got the link to share all I can ask. Sorry to share in the in the chat link for you guys to copy and paste it. So initially, when somebody presents with a nosebleed, always try local pressure. This is firm hard pressure on the soft, fleshy, fleshy part of the nose. So that's over. This area you're gonna percentile is you can't pretend to 15 minutes. Sometimes you might need to get the patient to do that, which is absolutely fine, but there aren't will get tired to tell them to hold the nose with the elbows tucked in India on maybe even pressing or two times a resting on the table like so that way the elbows won't get tired of the acute. The pressure of the nose for a good 10 to 15 minutes. Pressing on that support. No supplies. Direct pressure on the little area, which is the orchestra backs plexus. This is area in case of blacks. Plexus are the area in the front of the nose on the septum. Who had a lot of our materials that supplies on those beads come together in a sort of spaghetti junction of vessels and a very pro to having a high pressure, sudden bursting of readings beating. So that's why you want to put pressure of my area. If in your department isis available, get the patient. Either suck on a piece of ice or place a bag of ice over the name of the neck, the back of the head, the bridge of the nose. Top of that. Any weather was some calling. Cooling has a visa constricting effects and never was slightly slow down. The nose bleeds whilst they're compressing the same time, ideally, before you start to compress. But if you try this for five minutes and it hasn't worked in the next 10 to 15 minutes you're going to spray local anesthetic into the nose. You should have some local anesthetic available in your immunity department or in the kit that you carry for image for ent on call preferably it should be a local anesthetic with adrenaline on it. Both of these have a very good effect from the nose in terms of both local anesthetic, but also raise a constriction and again applied pressure. Putting the cart. Um, well, certainly with the local anesthetic, a needle in into the nostrils and then again, the pressure off of those with things. Leave that for about 10 to 15 minutes. That should start to slow the please breathe leading whilst the patient is doing holding their nose. You should go with the open to get him to over the mouth on exam in the back. If you can see blood dripping down the back of the throat behind the tonsils, there is a suggestion that this is leading despite it not coming up front, and there's a possibility that this is a posterior of another in the story. This is likely to be a posterior than an anterior bleed on. To be honest, most nosebleeds that are a traumatic off posterior bleeds, Um, all from the antiviral from little area least are related to the anterior. Eat right after a tense occur off the trauma, and you'll find that they're much more difficult to control with these measures. So, generally speaking, the a traumatic noticeably to tend to be either from little area or from a vessel that's first posterity in the nostril. So after those 10 to 15 minutes of compression was local anesthetic and face remedial cotton, we'll have a look at the nose. This may be an option you'd you'd apply. Courtroom was silver nitrate. If you've had experience is applying so often I drink water, then you could give yourself, If not, get your senior ent person to come down while they're you've left the patient waiting with the tape, topical pressure and the topical you can set it arranged for your senior to come down a place for overnight right coronary. I'm not coming, sugar, not reculturing this talk, but if we have time at the end of anybody wants me to ask a drawer, crack it, then they can ask me once you remove the culture in wall. If it's bleeding too much either. For court reorder, it's still being very heavily 92. Right nasal packing Nasal packing comes in the form of, generally speaking, a rapid rhino in the NHS hospitals, but it might be different in the hospitals that you'll be working in. Another alternative is a mirror cell, which is a simpler and pack. They're rapid rhino on. It's a stiff for him Tampon that expands from being very thin or compressed and the expanse to becoming a pressure of playing camp. On within the nose you get a four centimeter short and fat one or a slimmer, longer a centimeter. One. These are still available in most invention departments in the UK in the NHS, however, the general preference to choose a rapid rhino. This is a balloon device with external component of an internal component. The accident internal component is both self lubricating with it, but you can find little bit of water if you want. You're okay. Why jelly jelly is water base. It will activate this mesh, which is a human static mash on within. It is a balloon. Once this is in certain, you're then inflate the balloon using Excel components And that's how you apply temporal the bread, the principle behind both of these or behind any packing in the nose is stuffed by tapping are on prevent further bleeding. Same principals he would use use for any other surgical reading. Once you have pap the nose, always document what you have done. So document which blood test you've taken. Document the top that have used the time it was inserted under size of it. And also, if you use drops Greiner how much you used to inflate it back and start with bleeding. Make sure your patient has IV access and husband adequate. He's I'm resuscitated. Remember, this is a bleeding patient. This is a potential hemorrhage. Generally speaking, once you packed the patient with that route providers or Mary cells, they don't he could be nailed by mouth surgery. However, when you're starting out, you might be reasonable for you to keep them know by mouth overnight, just in case they have further bleeding. Or if you think this is a patient who had a traumatic nose bleed, it's worth keeping them. Look. I'm up because they may need to go to the theater to stop the nose bleed if you can. Or if you have an idea of what is the cause of the X axis document That as well. For example, has the patient had a four and this has caused the traumatic nose be? Has the patient been sneezing a lot recently on? So there's an effective or damage because as the patient got any underlying blood ones such as a lot of these already on four for in his arm. You document now, when it comes to packing the nose, whether you're using this for a package for this for in the future, you have some experience, I hope, with making an N G tube. The same principle of putting an N G tube is what he used. Inserting these packs. Stay low in the nose, keep the patients had supported a busy force. It can't fall back to stay low in the nose ain't straight, you know, with the nasal blockage. This isn't then additions. Functional knows this is bony structures and scabbing the nose. So, in truth, straight them straight back into the back of the head. The video that I've got will be very helpful for you to wash that. That's this video here. I won't play the video now, but I'm sorry. I don't know if you want to copy the link, or I can transfer it in the chat. Um, for you guys, Any questions about stocks that this point, or should I? Maybe one. Well, you do have a couple of questions in the top. There are cup around five or six. But do you like to go through them now? Yeah. I don't mind whatever suits you guys. So So, uh, I'll just write them out now. Uh, the fast one is, Why do we observe every sex is in the tumors of the brain. Well, so, uh okay, so that depends on whether the tremors of the brain do you mean actual primary cranial intracranial treatments? They haven't specified, but I'm hoping they can. Not a new book. Okay, so a primary intracranial tremor shouldn't really cause nosebleeds unless it's causing intracranial pressure. That's affecting the blood supply to the nose, so they shouldn't really cause them. The other reason it might cause it if they're actually brain. Seems that I involving either the olfactory cleft or extending into the nose on, then that's a tumor bleeding. That's different, so hopefully you won't see too many of those. But if you do, same principles will apply in terms of trying to manage a hemorrhage and control you can. You know tamponade will still help to some extent with those, and you still need to do flu. It's a sedation for those, but you're right that at your stage, if you have a patient that's bleeding from a on intracranial Truman through the nose, that suggest is a breach of the break base of skull. And that's why the blood coming through. And it's going to be much, much larger involvement of sort of your resurgence and on the anti skull base surgeons for that. So probably outside of the beam of what you guys need to know what you're stating when you started your doctors. But the if there's bleeding from an intracranial brain human, the suggestion is that has been breached or the base of skull. Thank you, Doctor. Uh, we have another question from a med, which asks, What is the patient position when you try to pack her nose? So just a Zionist trying to demonstrate if I'm the patient, you want it sitting straight up in a chair or if they're on a bad, bring the back of the bed up forward. You're a with your pack to go into the aspirin a straight because of that for you. And then I got It's difficult to try and keep them sitting up right. You may need to get a nurse or calling to help you just to support her head so that you can put the nasal packing and that that's the position that you wanted to be in a very similar thing. When you put it in and you cheat when you guys get raunchy, then you have to do that. Thank you, Doctor. We've question from Earner. How could you deal with a patient with a nosebleed with the risk over thrombus forming when we stop warfarin and other blood billions. Okay, so it depends on why they're on the blood thinness. So, for as I mentioned for something like aspirin ical pretty girl, particularly in somebody's, I'd reach recent cardiac spankings. So in my practice, in my experience of us, it's a little kind of stand. In the last six months, I generally don't stop the aspirin clopidogrel it is worth stopping warfarin on down the dose packs the dose in particular because the reversible their their effect was often put in 24 hours. So you're not actually narrowing the therapeutic window for too long. So you just give yourself a 24 hour window for bleeding to stop for clots to stabilize we're packing to work on. Then you can restart the door and you haven't missed the window. Generally do acts and warfrin a given patient A f or with recent T V. Finally, recent DVT's or be teens. Now, if somebody has got a current BTE or current DVD, then that's a complex situation. And then what I would advise you to do is to get your seniors involved in the decision making about stopping, and there were actually warfarin for them. On the other thing that you can get patients when the graph of bleeding is trying. Examine acid. You could prescribe that that could be given systemically and the drip you've already IV. You've got an IV after the patient being mindful, though, that the only contract get indication for chronic stomach acid. Is anybody with an active problem bolic events or anybody with active peeing or active gvt, they won't be able to have chronic stomach acid. Everybody else is fair. Game on. I want to start. Dose isn't going to cause much home, but it will help you get stability of the clock. I'm slow down or prevent further bleeding, I hope. 1000 Question. Think it does there? Um, we do have a few more. I think there's about four more, but I didn't quickly. Why does the teacher need to suck on ice? I guess that's because of the beta contracted. So, yeah, you wanted your own question. Um, the next question is, how could nosebleed be induced by stress? What is the mechanism it's to do? It is a phase of dilation and strong vessel bursting. I'm there's not a There's not a really solid, evidence based stress causing nosebleeds, but hypertension is one of the risk factors for a nosebleed. Somebody has got uncontrolled hypertension. Make about nose, please. So you could you could take the two of those together. That stress is contributing to peek in and blood pressure that would contribute to university. That's that's a tenuous link. You feeling good? We've got, um, another one Concertante Foods instigate nose bleeds. Not that I've seen any evidence for. No, it's not going to change your management when you're dealing with them as a doctor, right? You don't understand You going Don't need this other. This particular moment of patients bleeding in front of you you need to deal with the bleeding. Doesn't matter what they be in previously. Um um I think the next question just says pediatric taxes, but it doesn't really It's best five. So I think we could leave that for now a while. I'm going to say just from you for you. So, given that my theme is what you guys are gonna do was junior doctors looking at these patients in a pediatric epistaxis. First incidents always go for the most conservative measures, so it's always going to be the nasal pressure. You're gonna have to get a moment after help with that. Most pediatric nosebleeds will stop with local pressure and don't need any further intervention. But in your case, if you got a child who is beating profusely and engulf your seniors early and involve the pediatric team in terms of IV access, that would be my first principles for monitoring pediatric stuff. This thank you dot There we did have a comment for imagine. In regards to the stress instigating nose bleeds, I would just really out in case everyone else wants to read Theatre Nation. That he's given simply tress increases BP, which makes the blood vessels contract. And also stress increases heart rate this least the increase in blood flow and results in more bleeding. It's all the systemic effect of stress, and it's all related to BP on because your colleagues said heart rate to some extent. But it's difficult with heart rate. Is heart rate going in in epistaxis know and stress in life? But at the stacks is, is the heart rate going up because the patient's stress because of the rectus faxes and it's not making the the big foot worse? Or is the heart rate up for any other reason, for example, trauma. And that's why it is contributing to the nosebleeds. So I says it, prime recalls. It's It's a bit of a Catch 22 with heart rate. I put pressure, actually, patients in pain. The BP will go up a swell that make sense. Thank you so much dot So I think that any thought of the questions and we can carry on thanks so much so hopefully no, I'm sorry, learning a little bit later, but I'll just go through now. The ent emergencies. Um I know you're all from different years, so some of you won't have come across this, But those of you that have felt with any emergency basics teaching either in B l S o l s or 80 or less just remind yourself of the basics right down quickly. What What does the A B C D stand for in any emergent situation? Surgical medical. Now I'm like this in a second. So in any air, and it's a medical situation, the first thing you assess is a for airway. The second thing is B for breathing. See the circulation? Do you for disability on the for exposure. If defense ability basically means things like their neurological status in a trauma setting, for example, you look forward there you have, like the last coma scale post procedures. If they're a lost consciousness, you too. You too. Grade, gastric own scale on exposures. Things like making sure you've exposed the whole chest than the whole legs and look for any Excel trauma or evidence of injuries. But from an ent perspective, often most of the things that you're going to be assessing focus on these three areas. You need to be a conscious off airway breathing and circulation. So, uh, post office, like, maybe can happen. Um up for patients who had a tonsillectomy and again a bit like stocks is this is a potential hemorrhage, so don't cut corners. There is a slight difference in your approach for potential and management of personal. Switch your feet and Children and adults. However, to start off with the both Children and adults, you need to identify if they're spitting up fresh blood or copious fresh blood because that's a little bit more worrying that if they're bringing up occasional blood or blood stains spit that is less worrying unless urgent on. But it might represent something called a Harold Bleed. We are concerned by even occasional on spitting up of blood because the Herald leader can occur 24 hours before. More significantly so generally, the practice in the UK is that if anybody is having new fresh blood, even a couple of spits. We admit him for 24 hours for observation. Case of develops into a more formal bleed. If, however, it's just look at a blood stain spit on, they're not bringing a pretty fresh blood. You may be able to reassure them 11 hands, so long as they don't live too far from the hospital. And I'm able to come back and easily. Broadly speaking, same principle for you guys is juniors with anything else. If you're worried, he's admit, don't take any gambles. Take any risks and necessarily, I'm. It's also useful for your from your history point of view. And for documenting is whether this is something that to begin a primary post tonsillectomy bleed or post constectomy hemorrhage or a secondary post transfer that to be hemorrhage. Primary personal. Strictly hemorrhage occurs within the 1st 24 hours of the surgery and essentially is related to the fact that that contact me said, Really, it's a raw surface of the back of the or firings on that. That stuff is concerned. We start leading secondary personal second bleed usually happens more than 24 hours later in the surgery, at which point there there should be some scab and slept forming over the 20 of bed. But this could be disrupted, or it can become infected, and then this causes a second rebleed. So for adults with POSTOP switch me bleed, as I mentioned, admit, if you're concerned because it's fresh blood and you think it might be a Herald leader or because of bleeding a lot, these patients have any of the hemorrhage in active observation is being recorded. They should have IV access on all the suitable that's taken. Make sure there having regular basic Mississippi, a shinin place on and are they are in a safe place for this on. I would always start antibiotics. If you think this is a second repeat, I am patient is coming up more than 24 hours after the first and off the surgery because, uh, we mentioned most secondly, 100 Design, affection, leakage. The patient is bleeding a lot. They're going to need theater, and if that crosses your mind that they might need theater. You need to contact your senior ent on call and you need to anyone the hospital. How it was quite coordinate with emergency theater manager on the on call and do the tests. Let them know that you got a patient with bleeding. I'm actually getting into the our weight and used to come pick it urgently. They will have you come down and see the patient very quickly. Whilst you do all the other management on your ent seen you should be on their way in to take a patient back to the evening. Last patient is bleeding. Please start some tranexamic acid that helps stabilize and clot. We start hydrogen peroxide gargles. If you got access to those in the heart in your unit, they stopped. That starts to you and wash away. Any slept, has become infected and encourages new slept, perform and and and sort of cut down and encourage the bleeding to stop and me culture for in Children. I want you to be extra cautious and extra careful. And the reason for this is actually in decompensated extremely quickly in hemorrhage or hyper billion. Yet this is a first principle that you will take forward in any of your other practice. Even if you're not doing any anti Children can really, really well with a low volume or having lost a lot of blood, and then they suddenly decompensates. You mustn't wait for them to look for the because that's about sign. As with adults, make sure they've got basic resuscitation in place. They should have monitoring of their heart rate and the BP. But this varies at different ages. For Children, there's not a standardized number that you can have for a three year old that you can for an eight year old They cover on a 16 year old, so please involve your pediatric team. You start the antibiotics, as you would have for the adult, but always include the pediatric on call team with any child that's coming with post tonsillectomy. Believe I was at your early stages. Always informed the any therapists on caller, even admission. This child. Even if you think I'm not going out to the attorney, it's important for them to be aware of the patients admission. I always inform your ent senior on call. There's your lane during this. The tip. You know, delay if you're worried about a child, if you think they're going to you and have to go back to the attorney. But even if the child is stable, make sure you do all the other prep work and measures. But then, do you also inform your senior on call that you've admitted this child is really important, that these cases are not taken lightly or taken dismissively? Okay, you want to make sure everything's and say the hat is safely in place. Everybody who needs to know nose in case things go the wrong way. Generally they don't, but when they do, you want everyone to be available and ready straight away. And I've mentioned already that if you think a child or adult with pistols might need used to go up the a time, make sure you've been coordinating that is required in your particular center. The next emergency would talk about a Superbowl tightest. This is an infection off the super botanists, so the super glass is part of your Lawrence. This is a cross section or picture of your lungs. On the surgical office is the area below the vocal cords. The Glottis is the area immediately. Correspondent to the vocal chords, which is you can see in this picture would be behind the thyroid. Cartilage is the picture of the thyroid cartilage, and then the super got. This is all this area, but it's so the false cause. The epic office is the powerful fossil. Either side of the vote. All of this area could become inflamed. I have. This becomes inflamed or infected. Essentially, it closes off the airway. Here. You can't get air through on their four. This is This is why this is an emergency situation. The Super Bowl parties is an information off the epic office or supermarket tissues on it can affect both Children and adults. They're It's basically the form of sell. Your life is steady. Life's means infection off the information off the Cozaar so you could get facial cellulitis skin. Say that. Is this the skin because of being affected? But in this case is gonna be a pft CLOtest. The area pathetic falls on the adjacent tissues in the Supraglottic area. It is a result of a battery. Me, I have a bacterial infection on sometimes these bacteria or these pathogens, their record invade the apathy, a layer off the larynx. And that's why you get such a sort of sort of sort of diffuse in such a worrying swelling on rapid swelling. Usually the um, microbiology that originates. That course of these infections are from the nasal pharynx to the common bugs that cause upper respiratory tract infections can also give rise to a super good titers. But the difference is that those books have not just stayed as a local infection, the bloodstream and after lunch to get into the because of your feeling layer off the apricot healthy super got is areas. So this is a normal view off the larynx. And for those of you that well, about you starting that monitor and Oscar peas, you will be standing in front of the patient, looking down, looking into their Lawrence from with a laser to agree for the nose. So facing you, you will see anti relate the glottis on the anterior part of the larynx. This is the I'm curious larynx. That's the posterior nights there behind the postural Lawrence in the insert into the esophagus. These little funnel areas, either side of large circle that perform faucet on in front of the epiglottis is the basic time, As I mentioned earlier, if you when you start doing these, what you need to get used to is recognizing normal, not so much abnormalities because that's when you call someone when he realized something was about, like the normal that you're used to. So this is a useful picture of you to bear in mind in the future. If you're doing and you're doing Testim is endoscopy on. You can see the difference here in a nice painting. CLOtest on this view is, um, different than when you saw before. Because this is not a flexible nasal endoscope. You This is the anesthetic teams you to the patient is not facing the other way. And you've lifted the tone based out of the way. This is the breast lifted up the way on the epiglottis in our facing away from the wall in towards you because of patients now. So that's the epiglottis. They're very swollen. You can see all the structures and back of the town. This is the go down to the beautiful falls at all the structures a very red and everything so you can see that there's a demon and erythema off a supercross that I got this on. This is what it's going to obscure obstruct the airway in terms of Super Bowl titles. The pediatric population usually presents with you isolated epical fighters. However, in the UK, this has become extremely rare. That's the Hib vaccination in Mesa Locker, though, and not just in the UK but in any other parts of the Europe or any other parts of the world. But you may be working in the adult population. You see more often a form of Super Piper's, where a lot of supraglottic soft tissue is inflamed on. This is what we see more often in the UK, so much so that most ent department in this UK see one case per month. So it's not uncommon and it is something that you need to recognize. It is happening. So if you think somebody may have super good fight this, you will be worried because the patients had strider or the ent sort of the image department doctors been referring the child of the patients to We'll set up the patient's tried or maybe an acute airway. This patient used to be seen in the emergency department. We suspected that is the safest place of them. You see the anesthetic doctors in your unit need to be a form of this patient's as present always coming in, and there is a concern about your hepatitis on your first line. Management, um, last you are going, What's you? A week of the acid It came to come down, and also your your senior ent person to come in is to make sure the patient sitting up you're not lie these patients back. They will struggle even more with the breathing if you life and that's a cute themselves up. Make sure they've got a high flow oxygen with a non revealing bass cancer. Not just a simple nasal kind of need a proper mask. Oxygen. Get IV access for these patients. They need to be able to have IV antibiotics, and it's worth taking blood cultures at the same time they start sticking things in their mouth or throat. See if you can just get it to open them up and you can try and life and see. And that's just to make sure, really, that you're looking for any evidence of any more a Deemer or any more erythema up in the or France Well, that you can see. But generally speaking, the situations look sick. I was sitting forward that be working very hard breathing that breathing will be noisy. So even if you look at them up, you don't see anything. Particular worry. You know that just from the way they are over all of the in the bed, where you're looking at them, you know that they maybe they're very sick and you need to help us. As part of their initial management. You're going to give them a stat steroid, ideally dexamethasone eight or 16 mg through the drip that you already put in. Start them on nebulizer. Grenell in your nursing team will be able to make sure that's administered alongside the oxygen. I start antibiotics. Generally speaking, we give a third generation capital sporin for the for separable titers. But your hospital trust where you were, we'll have guidelines. On what? It's a specific antibiotic. To get in your particular trust, start that straight away. Don't wait for cultures. Don't waive your registrar of you. Don't with anything. Just start the antibiotic as soon as you think this might be a super tight. This is a very nice and flow chart which is a little bit busy, but actually very sensible going through what you will do if you think your patient they have to provide us. And I am happy for these slides to be shared. You I think this is being recorded so you can take a car. Drove this and you can take a photo of it on your phone. How If you want to keep a copy of it. But this is a very helpful algorithm on The most important thing I want to remind you is that you're looking for whether the patient is having airway distress world in the spirit. You distressed? So what I'm talking about here is stride off difficulty breathing, and I wouldn't this They may have things like happy cardio on behind attention, as your colleague mention. This is a stress response, so those speeches might be present. If that is present, they need to be seen by ent on. There's a possibility that they're going to end up meeting intervention. Crack your story. That's why you need the anesthetic on the senior year teaching to be involved. If this starts to reverse with the measures for in, Are you the on daily and nebulizers start steroids? Or is the immediate antibiotics on board on? They really do on very quickly to knees. Then it might be that you simply need to monitor the patient. And so this is why it's very important at this stage. Should get the medications on board because you're going to take a patient down one of these two properties very quickly. They respond very quickly. The treatment of the grain tick on. You might get the patient stables on, may be able to avoid any surgical intervention. Okay, so that is my lecture part from he saw says that I think really help with those of you that continue with your Yankee studies. I'm during your your You see the difficult circumstances of your medical school of the movement, and I highly recommend them. For those of you is trying to keep on top of clinical skills as well these websites and physically good for those. And so, please, do you take a photo of this? And as I said, I'm happy to share things later on with you all. And I think that is just over our our But I'm happy to take any further questions. If anybody has any crying, open the cat as well. Yes. So what? I'll do is I'll look, if anyone wants, um, you and ask the question, we can do that first. If no one, uh, would like to do that, I can just read out the ones on the chart. So doesn't if it a couple of seconds to see if someone would like the art over the mic. Okay, so when do we suspect most strip the coke or Glomerulonephritis? Um, do we screen all the patients who have strep throat for such complications on? Not in my practice, but I'm I think you know, I I don't think you scream for grammarian that writers and my card itises that you look for if this clinical evidence of changes. So you Yeah, I guess if you signed a very severe renal dysfunction or if a patient was starting to have new members of things, that's when you start screaming. I'm afraid I'm not. I'm not that up to date with post streptococcal complications, but that would be my advice. You suspect it was clinical evidence for it. I don't know that there is a specific group that are more predisposed to that than any other group. Apart from your normal immunocompromised type patients, So anybody who's had, um, everybody's got severely poorly controlled diabetes. Anybody who's on immunosuppressants for transplant and systemic conditions like HIV, you might think about it more of those patients. But it's not going to be your primary concern when you're managing an acute until itis or acute streptococcus infection. Ah, I got a question here, but what is the best antibiotic to administer? So here, for several life is generally it's a third generation capitalist. Boring. So we use Cath rocks in. But you need to check that you need to check your local practice allergy status. You should always ask. I mean, generally speaking, they're always trying to find out allergy stages of any patient. Before you start any medications, particularly antibiotic based, and those of you that are a bit more senior in your in your medical school, you may remember that there's a cross across allergy response between the keppra. Careful, it's boring on the penicillin. So if someone does have a history penicillin, true allergy, you may not wish to give Catholics boring. However, if it's a very mild history or they're not clearly, you know, it's just a rash, something probably going with cataracts in is the best option. And the patient should be being managed in a in a multi disciplinary setting in a safe setting such as the any recent need it is there. So, you know, God forbid you're so unlucky that you've got somebody to pick a tightest that you then give the correct antibiotic to a Catholic before it on. They also then get an allergic reaction that would just have to be addressed at that time with intervention and support. But I don't bring up saying, Well, that's good. You really can we get into trouble? I think you get trouble if you hadn't asked about when they have allergies. But if they have a very mild allergy or they don't have any evidence of allergy, then you're right. You know you need to give the right thing that's gonna treat the infection. Having said that, if they've gotten known, in fact known, severe allergy to penicillin. And generally speaking, you go to the macrolide antibiotics for this. But again, you'd want to check with your local microbiology guidance for what is the best coverage? Uh, what is the difference between airway distressing respiratory distress? So this is about a road. I just it up airway Lower airway respecting dresses and stress patients of those with a severe pneumonia or lower spacecraft infection there Basically having a problem with what we call ventilation profusion. Mismatch. So you'll cover that. Hopefully, when you do cover, respond tree medicine topics in a row way. Distress is all about the top and being blocked so they can't actually get Arian. So they'll develop a cycle strider, which is usually inspiratory so as the breathing they make. A very no, he's not struggling to get away. And I said, Sign of upper airway distress rather than the where we distressed. And you can also get something called state, already basically like a snoring noise, and that is much more of the high, even higher. Enter about the back of the tongue around the house is there, and that's more like a noise that you get with trying to get air moving I/O. So so you that that the difference is where the problem with getting Aaron is happening with Upper airway. It tends to be the fact that the larynx were above the larynx or just a little drop into the trachea is for some reason lot more compressed and not getting air way through those when you've got respiratory distress. This is much more about the smaller and the albuterol and the smaller airways not being able to exchange there. And I hope that helps. Oh, I'm losing track of the questions. Just give me a second. That's okay. I can tell that you don't need to differentiate between from your your state. You don't need to differentiate between ethical titers and super cryptitis because essentially clinically, they're going to manifest the same way. The thing for you to be aware of is the epical tightest can manifest as a part of super glue. Titus I you the epiglottis in plain as well, Everything else in the Super Bowl office or in Children particular. It might be just the epiglottis that's inflamed. Doesn't matter is going to obscure the airway, so you need to be able to manage that on gift need to get you are seeing, you know, if need be, always get you're seeing is involved. And there is some stuff about the difference of how the pathogenesis of ethical titers happens competitive. The more that you provide us, and that's to do with the bacterial source, as I mentioned to you earlier, generally, and Children used to it and him awful is's the bacteria that causes it. But this is you're getting into nitty gritty off microbiology and biochemical reactions to the microgestin. You don't need to worry about that and the slide resources again. I will spring up for you in a second. Please send a link again. I think that might be to use our about the just sticks about them beating. That's better. Figure out what the feedback thing, Um, in a primary care setting of patients ending about your chest infection. Sore throat isn't common to avoid penicillin based on tibiotalar, I think I think that's a difficult one to answer in Terms off. It'll be dependent on your local microbiology picture because I know where I work. The first line antibiotic for a chest infection is cool amoxiclav, which is penicillin based anyway, so we'll give you some degree of coverage if somebody's got cancel items. But bear in mind no. Also throats a bacterial for somebody who's got a chest infection that is bacterial but also a sore throat They probably got a viral sore throat, a viral tonsillitis on. Do you need to target the chest of that? Something that's making them more sick? I hope that makes a bit of sensory. These are things that your guys will become more affair with us. You get more clinical experience, but the first thing you want to address it, the thing that's making the patient than most sick. Okay, so if it's a chest infection that's really quite west and chesty and they're really struggling to breathe on, they happen to have a bit of a sore throat. You're focusing on treating the chest rather than this often you mentioned quarterized a shin. Yeah, I will talk to you about tradition in a second. Them in this great picture. Don't keep in my Can you please get back to that image? Okay, so let me talk about polarization. First of all, and cauterization probably needs a whole other session because it's a technical skill that you need to learn. The what you're using is ah, little bud with a silver nitrate chemical tip on it on. The idea is to court arise. Remember I said, let me show you the slide. Actually, just give me a second. So remember I said to you about it, but you see, it is now. Zarah, is this on the screen? Yes. We can see it right there. Um, rested you. But you keep your backs plexus or Littles area. Okay. When you look in the nostril, it doesn't not like this. You don't see all the vessels, obviously. But this area on the side of the nose is what you will see in terms off. He's a wax plexus at the front of the nostril or a little area. So if you're going to do silver nitrate core trade, you need to have a good head lights. You could look in the nose. You need to have something called a third consecutive so you could stretch the nostril up on essentially what you will do. Let's imagine for the sake of demonstration for description. What? The demonstration description. Let's imagine it Here. You can see the nose is actively bleeding. Cave is a little spurt in blood vessels coming up right here on the 90 on the septum of the nose. What you will do The silver nitrate is make a ring off core treat around it. That's to catch all these little vessels that might be feeding into the obvious bleeder on, then your political the metric quarter directly over the bleeding vessel, and you may need two or three sticks to do that on that chemical silver nitrate. Basically access chemical ceiling over those vessels and stop the bleeding. It can cause damage to the skin if it seeps out. It's a chemicals and cause a chemical burn till, especially when you guys first start out. If you're going to do silver nitrate Kortrijk, please apply and Asselin or K y jelly or something for the skin over this area on. Then when you're done, wipe it away so that it doesn't spread anywhere else. Always tell your patients if their nose is going to run and any black stuff runs up. Don't wipe it across. The nurse is going to stay in the skin that bit like so. So in terms of courtroom, what I would advise you guys to do is I will look at this website. I'm www dot e n t s h o dot com. That will have a nice description, a nice picture of have to do Kortrijk. You can also look up things on you keep. I would say this is a good resource for that. Eso that's about That's a much I think I can cover court date and a PSA introduction rather than actually have to record. Or you can have a look at that. More of the internal, more of the Internet. Um, I have lost my place. Where was I? The endoscope picture. So he you can you come off of you and tell me a little more what you need to know, and I'll talk you through it. Well, Doctor, it's not about what I wanted to know. I just don't want to miss anything when I look at it. For example, in radiology, they told us there are steps. Do not, For example, Mr Peripheries are the specific steps that we you know, we don't miss anything on the syringe. A scope. Well, first of all, you're only been doing there's a lower endoscopy once you've practiced doing it and can get a view. So once you helped the most important thing for you from that point, if you will be practicing that I should get the scope to get this view. Once you've got that view, my tip is always to system. Actually have a list in your in a mind of what you're going to look at. So I always go from front to back. So you start off looking at the base of tongue on to do the basic plan assessment. When the patients in front of you ask them to stick out the tongue like that, that full debate of tongue into your view of your camera. So first things look at the basic one. Then look at the epiglottis on between. When the tongue is out between the at the glass in the base of plan, you'll see something called the molecular. You can check that space is well, okay, so you don't. This is the 1st 2nd confronted that. Then you look at the larynx itself. The Lawrence, your best ago. These the vocal cords. You can look at the vocal chords. You're going to look at the false cords. Okay, so that's going to be your assessment. Your next stage, then you look at the size, the paraffin faucet, you the side. Sometimes you can get that more open. But like with the camera in the nose. Little open. So if you turn your head sorry if the patient turns their head to the left it open the perform Foster on the on the right. He 10 patients had also on the left hand side. You have a look at that on these are the this in the posterior pharynx said postural vocal cords here, the arytenoid cartilage It here on the softer Deal Inlet. You're not really gonna be looking for anything here, but what you do want to see if the posterior pharyngeal wall make sure there's no bulging forward? Remember I mentioned to you guys about if there was an abscess, either in the retro firings or in the power of a parapharyngeal space? What you'll see is that this space is not open like this. There's something bulging in the sense involved again. So if you want a systematic approach of our endoscopy from an e ent perspective, it will be different if you don't ask that text book from ent perspective. Go from front to back. So you're gonna do the base of turn the alecky alert the epiglottis, the larynx In quitting the vocal cords on the false cords. Then you do, besides the peripheral loss that you decide on the posterior pharyngeal wall. Is that okay? Here? That's perfect. Thank you. Okay, on, uh, have I missed anything else? That's our, uh I don't think there is a final question. What is the first? Or I think you may have answered that, But what is the first line for tonsillitis and what implications for the in patients for consul acting. Okay, First line for Consul itis is usually a penicillin V, if you're giving it already and penicillin G, if you're getting it IV, but always penicillin based. Sorry, I should have mentioned that a lecture indications the tonsillectomy there aren't really at the only indication for a hot tonsillectomy. Really? And I've never had to do is have never seen it. But in theory, on the hot concept means a concept that you do when someone is actively infected. Is it? The cancers are so extremely inflamed that they're closing off the airway. Or that you've had a Quincy that isn't able to be drained. The UK, the tonsil out to be able to access bringing the Quincy and through the throat and indication the tonsillectomy are not on emergency discussion. There are something that you would manage in your clinics or as an outpatient on in the UK The indications that Trans elected me are based on the nice guy lives with signed guidance on, But we require patients have had more than seven episodes of translate. Life is in one year or five months, like a superior over two years to have transferred back to me for constant itis. The other indication for tonsillectomy is or it's knowledge. If you're worried about once the cancer, then we can do transfers out for violin first diagnosis. That was great. Thank you so much, Doctor. I just want to point out a few students have left some feedback for you in the chart. If you like to read it. Um, that's very kind. Thank you. The I think that's all. Um, I just read out of the comments because I feel like everyone would appreciate uh, most I had said thanks so much to learn so much and now have been infused pursuit An antique around many things. Please come. Very welcome. You're welcome to join our off. Our group will be happy. Happy to have you. Then. We've got another comment from East. I saying thanks so much, Doctor. That has been quite in lightning lecture. And I hope to be able to further learn more about the anti infusion session. So I think definitely looking forward to seeing more of you, Dr. I hope it was useful. And I heard it was clinical enough for everyone. It definitely was. I just want to point out. Then we have to add the feedback link into the chart. So if everyone concludes, fill that out. I'm sure Doctor would really appreciate that. And it would be great for you as well as you do. Receive a certificate at the end. I think that concludes all of the questions, but let you, Ah, her and into, if you'd like. Yeah, that's great. Thank you so much. I'm good luck to you all on, but yeah, if I get a chance that you again, I'd be delighted to you. But if not all the best on the coffee yourself Stay safe. Okay, everybody. Thank you. Much remind. Thank you so much like there. I thank you. The coupons Welcome. Take care