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Yeah. Live. All right, so Hi, guys. Um, my name's, uh I'm a Dooney doctor, F one working in Northampton Hospital right now. Um, and, yeah. So this is gonna be a short tutorial. I don't imagine it'll take too long an hour at the most. Um, just about tips of pieces. And, um, I'll also try to go through a couple of the history that I did. I don't think the examinations are going to be that useful for me to talk through. Um, but the history is definitely I'll try and go through a couple of examples from the ones that I had in my paces last year. Okay. So in terms of general advice, most important thing is to practice, um, like, practice with different people as well. Your roommates. Um, you know, even on the wards, you can ask, like the f ones if they have time, February to practice with you. Um, have a look at what previous year stations were. Um, I'm not sure if you guys are aware of the drive. The imperial. Finally, if Google drive that has a lot of the past years, um, reports that people have written up from paces, and they go back from, like 2019 to 2011. Some land common conviction. So essentially any condition that you learn in women can be a case. They don't necessarily always do the most common ones. And it's very important to use a structure, uh, preventing answering fibers. And it's also very, very important to remember that this is not the same as third year. It can be kind of like easy to fall into the trap of being like, Okay, this is just a it's. But because now you've done all in med school, you know the conditions. They're going to expect you to be up history, too. Not just tick. All the boxes of okay, she's asked to our social history. She asked about past medical history. They're going to expect you to be working towards the differential diagnosis, and that needs to be clear in your history. Um, fine. It's not Facebook group. It's a Google drive. I can post the link in the chart at the end. Um, if that will help. But yeah, it's just got a lot of like resources from past years. Um, I think people in a couple years above us made it. Um, yeah. So, uh, working towards towards a diagnosis in your kind of history. Um, And even when you're presenting your examination should clearly be like, you know, saying things to rule out conditions rather than just saying things because you've memorized just view. And the most important to remember is, um they're looking for safe doctors, so they're not looking for you to get every single differential you to get, like, the most rare diagnosis. It doesn't even matter if you don't get the diagnosis, because we have some pretty road conditions in ours. Um, the most important thing is, if your safety netted, you ruled out the red flag things. And you, um, have escalated to a senior appropriately, um, you can practice by making your own histories and examination findings. Um, so you can you know when whenever you learn a condition, you can essentially practice as a case with someone else. So the group work is really key to final year as a whole. Okay, so examination stations remember to practice on each other. And also, uh, do you guys have real patient's in yours, right? Someone took it firm. Um, okay. Cool. So, um yeah. So we had a simulated patient's for every all of them because they still weren't sure about what the Covid situation is going to be when they were planning the exam. Um, but yeah. So in terms of real patient's, you have to go and listen to Real Patient's and examine Real patient's because they're it's very different from an actor. Um, I remember in my third year, I think third year was the only exam that we had that had real patient's in it. There was like a really sweet 90 year old guy for my cardiology exam, and he would not shut up about how, What kind of doctor do I want to be? Where do I wanna work? Do I want to do medicine or surgery or G? P? And I didn't want to lose the sympathy points by telling him to, but sometimes you just have to like the It's an examination station. They're not testing you on like the sympathy points as much. The main thing is to make it look sick slick in your history. Um, try and identify what the main signs are and summarize them so that you form a differential before saying them out loud. So don't finish your examination and immediately go into the presentation. Take a minute to think about what you've examined and what that means. Um so, for example, a murmur. If you can't identify exactly what the memory is, um, can you You maybe identify whether it's systolic or diastolic and at least to say, I had a systolic murmur or I had a diastolic murmur. Um, and if if it's a solid mamma, they just guess aortic stenosis or Michael Rigas, you'll probably be right. Crackles and wheeze. Um, that's very important. Try and identify. Um, if you it's an ad Abdo station, then appendicitis can be a really common one. That patient's can fake very easily. Um, so they I'm not sure if they have, like, a mixture of both. So they have, like they don't have a key appendicitis. Obviously, they might have some kind of, um, appendectomy scar. So make sure you kind of, um, go through that diagram. You're the one with all the different types of abdominal scars. Um, yep. And then for for us for neuro exam, we were told it would only be upper motor or lower motor neuron. We we were told we wouldn't have for anyone else. I'm not sure if it'll be the same for you guys. Um, for for us. We also had M S K, which was either we were told it was gonna be hip. Handle me. They're not gonna do anything else. Uh, it likely would be the same for you. They'll probably only do hip handle me. Um, so don't bother learning like the whole, you know, gal screening and spine tests and all of the elbow joint tests that they're not. They're probably not going to come up. It's going to be hands, hip or knee. Um, okay. Yep. So for each of the common presentations, when? When in in your examination station. You don't want the Examiner to be doing too much talking, You want to look like you're You're slick. You know what you're doing? You're you've examined the patient. Then you immediately start presenting like, Okay, So this is a patient, um, by, uh, you know, these are the positive signs. Then you list those first rather than going the order. The order of the examination that you did. You don't You don't want. What you don't want to do is look like a third year where you just kind of list Remembering the examination that you did and trying to recall the order that you did it in because what you want to be doing is listing the positive signs first and then telling them what the differential list, because they will cut you off like very, very quickly. They won't let you, like, ramble on for your presentation. They'll just cut you off after, like, a minute or so. Um, and you also want to immediately list, um, the investigations that you do to complete the examination. So any X rays, Um, I'm not sure if you guys you guys have been told the pneumonic boxes. So it stands for, like, bedside investigations like E C G. Um, like your analysis like basic obs. Um oh, is okay. And what? It was going Where is, um, the A is like X ray, um, and CT of town, all of those things. And then any other investigations? Um, I've actually believe well, Monica, so completely ignore that, but you want to go from bedside onwards? Observations? Yeah. Yeah, like you're actually observations observations? Um, yes. And then Oh, yeah, X ray e C G s. That's what was X and useful. Um, and s was for scams. That was it. So, bedside observations. X ray E T G. Yes, ma'am. Um, cardiology. So for us for cardiology because we didn't have real patient's, they played us an audio recording of a murmur. Likely for you. They'll have a real patient with a murmur. Um, and you'll have seven minutes of examinations, but ideally, you should be sick enough. You can do it in six minutes. Um, and you want to really make sure that you identify the murmur properly because that's what the main problem they're probably gonna have is it's unlikely they're going to have a patient with, you know, acute aortic dissection or something. It'll be something chronic. Um, Also, they might have a valve replacement one. So make sure you've listened to at least a few patient with a valve replacement. I remember when I think I there was a Makowski that I did that had a patient with a valve replacement, and I literally didn't say it because I thought it was a clock in the room, not the actual valve that you can often hear. Valve replacement, patient from bed, the bedside? Um, yeah, and any edema you want to properly press and make sure that it's not just they have fat legs. They have actual Adama. And if whether or not it's pitting and how high it goes, Um, e C G s. Also, you don't want to forget to suggest that as an investigation for a cardiology exam. Um, any potential scars that they might have, For example, where there with a cardiology exam, you'll be looking at the groin. Any ephemeral scars, they might have had an angiography. Um, and you want to check the medial legs specifically. So if you see that you have a, you know, midline start not to be stuck. Scar. Then you want to also make sure you look at the media leg and make a big show of it so that they know that you're looking for the media media leg harvest scar. Um, the insect, the precordium closely, they might have a midline, so not too mean they might have a left or Khatemi Um and oh, yeah. Another thing is, in past years, they have had patient's with dextrocardia. So if you can't hear heart sounds or you can't hear, and if you can't palpate in Apex beat, then feel on the other side because there is a patient that's floating around. The has dextrocardia, and they use them to catch patient's Catch their students out. Um, so yeah, if if you don't palpate the apex, be don't just say it was palpable because often if the patient's been, you know, you're the last person in the whole circuit. Patient's been sitting down for a long time. It might not be palpable, and that's fine. If it's not, you can just say it wasn't palpated, um, but don't lie. Don't lie. Your presentation Just because you've learnt issue, uh, yeah. And also make sure you examine the neck and listen for buoys because that's very important part of the cardiology exam. Another thing is, don't forget to pay the pulse while you're listening, because that's a very common mistake as well. Um, so investigations you might suggest a urine dip. Do you know what you'd be looking for on the urine dip? Anyone? Um, so, yeah, urine dip. You'd be looking for protein urea. Um, you know if someone has Yeah, protein. Exactly. Um, if someone's got diabetes or, um, you know, you might also want to check the BP as well for hypertension an e c g you'd be looking for Basically, they won't feel that if they give you an E c g, they won't give you a very complicated E c g. You know, they'll give you one that you can look at and be like a half a stemi. Or you can look at it and be like, That's a f. They'll give you a very obvious thing. They won't give you like this whole ventricular ectopics or whatever. Um, yeah, and then blood's Obviously, um, whenever you lift these investigations say, Well, you're doing them to rule out. So I'd be I want to do urine dipstick protein urea. I want to do E, c, g and, uh, for to look for abnormal heart rhythms like a F or, um, if they're having a stemi. If you have chest pain and I want to do bloods, I want to look at and you do a CBC to check for anemia to check for, you know, whatever it is you're checking for? For each each station. You want to say why you're doing the investigation So the examinant nose doesn't think that you're just doing them because they're the normal investigations. For example, FBC USER needs You might do them for a lot of stations, but you're doing them for different reasons. With every station, like in a cardiology station, you'll be doing using these. Sure, but you'll be doing the user needs because you won't check if the potassium's I if there's calcium is low. If there's any electrolyte abnormalities that can cause an arrhythmia, would you also be peeing examination on the presentation do at the end? Um, so I know other universities do it differently, but in in Imperial, they prefer you to just pretend the examiners, not even there and just just you and the patient doing the whole examination. And then at the end, you'd suggest it. Um, that's for the cardiologists ation. It's different for the acute care station, so I'll get to that when we get to the acute care bit. But for for for like cardio abdomen, euro, Um, M s K definitely. Just do the examination as a whole. First present and then say you any investigations you'd like to do? Okay. Yeah. Practice presentation of cardiac exam. Um, so, for example, if you heard a pansystolic murmur, then you know, if you're sure it's pansystolic, then you know where where it should be. Her best heard loudest and say like where it's heard Loudest. Where if it radiates the axilla. If it's a if it's a rejection systolic murmur it does it radiate to the carotids, um, and give you a differential at the end, so they don't have to ask you for it and give any other differentials that you have as well. At the end, I don't have to ask you for it. Um, And when you present something like, for example, this picture has irregularly irregular pulse of 100 and 20 BPM suggestive of atrial fibrillation in keeping with the picture of mitral regurgitation. Um, so you're kind of linking the patient signs to a diagnosis. You don't want to just list the signs by themselves. You want to, like, make sure they're kind of synthesized together in a logical order. So that's why I'm saying make make sure you take a minute to kind of sort them out in your head. Um, and also, make sure you take a minute before you even start the exam outside the room to think of differentials there. Because often what happens is if you go into the examination or you go into the history, you notice things, and you forget what you're differentials were at the very beginning because you want to remember the differential so you can rule them out. In your examination, you don't want to just kind of forget them and get sidetracked by one specific sign. You want to still keep a lookout for everything else as well? Um, Respiratory. Um, again, this one, we had an audio recording for us. Um, you may or may not have an audio recording, but I think the ones that are live load on YouTube you can listen to. I think they're still very useful to listen to them. Just so you know, the difference between what we sounds like and Strider sounds like in what polyphonic we sounds like versus like course, crackles and fine crackles. Um, they're very different sounds and they're quite distinguishable. So I I would also just recommend that you go around the rest board and try and listen to patients' chests. Um, because often, like rest is one where you can very clearly hear the signs. Um, yeah. So and any investigation they want this is this is quite basic things because the examinations are quite straightforward. Our examinations weren't very kind of wild. They weren't They didn't have, like, any broke diagnostic toward these nominations that she's something. And even the IV either wasn't wasn't too bad. I remember. I don't remember any of anyone commenting on the examination sessions to any of the baby, Really? So don't worry too much about the examinations and generous, um, a neurology. So yeah, you might. You might also get the medial and knock. It sounds so yeah. Hello. Is it okay now? I'm assuming it's okay now, um, I'm not covering the mic anymore. Um, so, uh, yeah, neurology, if you get cranial nerves, um, then it will just be kind of straightforward. Go through the presentation. I mean, the presentations be very straightforward because the cranial nerves, you can just say 1 to 1 through 12. Normal, apart from six or seven or whatever ones were abnormal. Um, you this for this one. You want to be very wary of very specific science. For example, Parkinson's. That's an obvious one that can easily give you because they can find patient with Parkinson's. Um, and you want to know very well the difference between upper motor neuroscience and lower motor neuroscience, cause that's a very easy by the question that they can ask you. And that's also a very easy kind of way to show off to the Examiner. Almost, Um, like, for example, say like, you noticed some sort of facial drooping or, um, some sort of sign. You can say it's full head sparing. Then they know what you're thinking about. Or you can say, there's fasciculation in, um, you know, which is suggestive of, like lower motor neuron signs, uh, suggestive of low emotional pathology. Then, like you, you want to link kind of what your differential is to the sign that you're presenting. Essentially. Um, like I said before, you basically want to show them that you're working towards a diagnosis. Um, m s M s is a good one to think of. If the signs just seem very, very random, you can't tell how they fit together. Um, because that's kind of what my whenever I've had m s come up is kind of been the ones where I'm like, What the hell is this? And then it turns out to be a mess because M s can present some kind of differently. Um, strokes know the different types of strokes, like, um, the total anterior circulation's rogue. The partial like no, the criteria for them because that's also a very easy Viber question. And it's also a very easy way of you. Distinguishing yourself is different from, like, a higher level to all the other students. Because if you can look at a patient and not just say that they've had a stroke, because the stroke is quite obvious clinically, um, if you can say what type of stroke they've had based on symptoms that then that sounds very impressive. Um, yeah, and the in terms of investigations don't forget to mention neuro obs for neurology. So if anything like, um, you know, meningitis first presentation of seizure. You always want to do regular neuro obs. Um, depending on how acute situation is from every 15 minutes to every like hour or four hours. However, often it is depending on how acute situation is. Um, A M T s and MMSC Um, remember they did an empty s station. I was like, just just They just told you during the M T exam is one of the stations in the one previous years. Um, I can't remember if that was for the final year or one of the I think it's finally Yeah, they just got you to do an M. T s exams. They do learn kind of what the MTs involves. Um, and again, the normal bloods and MRI scans are also very important for neurology. So learn the difference between a CT and MRI scan. If they show you a scan, you don't need to be like go into details and, like, learn exactly how to analyze MRI scans. If they show you a scan, you need to be able to confidently say whether it's CT or MRI, um, our neurons different basic cops. Yeah, So in your obs are like, um, checking the people's recon reactive checking reflexes, those kind of things checking the DCs blood sugar. So things related to neuro Um, yeah, and we kind of often do them for patient's with Like Like I said, a seizure or a stroke just to monitor their neurological function is deteriorating quickly or for suspecting a bleed like hemorrhage. Um, muscular skeletal. So for us, we were told that this is one of the only ones that we might get an X ray in, Um, so you might get an X ray of the hand or the foot or the knee. Um, and it might just show Just just be kind of be very careful when you examine it. Essentially, don't kind of try and jump to a conclusion like have a very good look trace around the outer edge of each of the bones. Check if there's any fractures. Um, check if there's any kind of different opacities because you know, with bones, sometimes there's like, um, osteo fights or things like that that you can see if you kind of look very closely. So take your time with the X ray. Don't rush, because if they give you an X ray, they're not going to give you too many viable questions because they they want you to take some time looking at the X ray and a very big thing. Don't forget to warn the patient about pain before you start feeling the hands. Um and yeah, that's kind of all I have to say about mask. Oh, yeah. There's also some if you look on pain up to if you just search up Muscular excuse, for example, and upto Doctor Chen, makeup does got, like, three videos. Um, they're very, very good. He goes through the examination in a lot of detail. Um, he does it like, really slowly explaining to step first and then quickly, all the way through. I think if you follow his steps exactly as he does them it, that's fine. Because there's a lot of different ways you can do a neuro exam. And, you know, I I know how I know geeky medics does it a bit differently and other things to do it differently. But you just follow it and make up those one. I think, then you'll be good. Um, Yep. So breast and vascular, uh, I'm pretty sure this it'll be the same for you, but for us, we had essentially the breast. Um, vascular is one station, and we had both of them. Um, have you guys had that talk here where you know where I am with, um, Exam goes through exactly what stations you're gonna have, how the time is going to be distributed. Have you guys had that talk yet? Yes. OK, cool. Yeah. Um, so for it, we're having both. Yeah, Cool. Um, so yeah, so we and it will be actors. Yeah, I thought so. Because they don't have time to kind of make you look for actual signs. We had, like, we had some lumps on our breast model. Um, but I think that was pretty much the only sign that we had in the whole that whole station. Um so work fast. This is not our station where you want to be working really hard for the empathy points and talking too much of the patient. Just You just want to get them quick, because you want to do each exam in three minutes. So really, practice this one, make sure you get all the steps down. And don't forget burgers test, because that's one that I forgot my real exam. Um, so you know the word where you raise the legs patient's legs and see if they turn blue and then on the other side of the head, um, side of the bed. Yeah, So just don't forget the basics and make sure you still do general inspection. Even though you're doing a very quick exam, you still want to make sure you're having a look from the edge of the bed first and then going closer? Um, yeah, that's my only thing. And also, yeah, for breast as well. Don't forget at the end to cover the patient back up when you're presenting, it just looks a bit weird. If you've left the patient exposed and then you start presenting to throw away. Um, so even though I said, Don't don't worry about the empathy, points do still maintain the patient's dignity. A divider for that one? I don't I don't think it's very, very straightforward. They didn't kind of mess up too much with that station History stations. So relax, kind of. You know how to take a history. Now you're finally medical students you've done all of third year. You've probably been sent a clock. So many patient's on firms and everything. So you've got this and they might throw road conditions at you because they definitely didn't are you? But just take a deep breath. Let them tell you the story first, cause they'll tell you a lot of the important things first and every single symptom. You don't want to let the patient jump around like you want. Once you've given them their golden minute, then then after that, they're no longer directing the history. You don't wanna kind of get distracted by what they're saying. So just if, say, for example, you're asking your patient in, um, history about vomiting and then they suddenly emerge in, uh, how many times a day, How big are they? Well, what color? Any blood, Like all of those kind of questions, you want to make sure you clump them and explore each symptom individually and make it clear that you're leading the history, not the patient. Um, and also, you wanna group symptoms together. So, for example, um, taking the Abdo pain history and again as an example, um, you want to ask you about together about nausea, vomiting, pain in the abdomen and, um, anorexia have they've eaten, and then that way you can clear. So you ruled out like appendicitis, and then you can ask about? How have you had previous bouts of constipation? Diarrhea? Um, those kind of things, Uh, any blood in the stool, any mucus in the stool, And then you can clearly see you've ruled out like IBD. So you want to, like, clumped the symptoms together in a logical way so that you're ruling out certain differentials and you can come up with this list of differentials when you're at the door. So when you're you got that one minute before you go in, you're looking at the case. That's when you want to be thinking about all of these different, um, differentials. And what symptoms? Each of them you're gonna rule out and stick to that plan that you make If anything happens or the patient mentioned something and you're kind of very confused. Go back to that plan that you made the start and, um, just be methodical and how they how you explore it, even if you think you have no idea what the hell this condition is, you still you're not. You're not being tested on your ability to diagnose. You're being tested on a how if, whether or not you're a safe doctor. So whether or not. You've ruled out the red flags and whether or not you've, um, kind of made sure you've got taken a good, comprehensive history. Um, so, yeah. Uh, remember, to your systems review assistance review is a very important part of the history. I mean, you don't want to miss it, So Yep. Um, yeah. And I says, Well, don't forget to ice. Um, that's a very important thing. Because that will also illicit a lot of information. Especially if they've tried to talk a bit of cycling, then given them, like, I don't know, alcohol addiction or something like that. Um, in terms of the Viber, Uh, like I said before present, the case make give, maybe, like, three diagnoses, or, like, three categories of diagnoses and some risk factors that the patient themselves has. We can't hear again. Anything. Oh, is has it completely gone? Hello. Okay, um, so what was that all about? Um, just gonna respect respect, respect, uh, suggestion, respect because, um, for the patient that you have examined, and if you remember at the end, you've forgotten some key questions. It's fine. You can just say in your presentation I would have also like to ask about, for example, calf tenderness. I would also like to ask about travel history, that kind of thing in terms of the treatment again, go in stages. Don't just jump to like, uh, I don't know Hartman's procedure based off of one history like That's not how medicine works you want to be, you're going to go from conservative. So just the investigations. Um um, any conservative Freeman wait and watch approach and then medical and then surgical. So you don't kind of jump to the most extreme thing first. Especially if your history doesn't kind of if it's a clinical diagnosis, fine. But if it's not clinical diagnosis, if you need some kind of imaging or something else to confirm your diagnosis, then just suggest it. Don't say that's exactly what you would do. And if you're not sure if you think it's an emergency, then always state that you would, um, cause I had to call a senior consultant senior first, Um, yeah, and and and And be aware of, like backing up his statement like, for example, each Yeah, you know, when I when I said before about the blood tests and the imaging why you want it? Check to check what you're looking for. Um, don't go completely harm and like, spend five minutes listening to investigations, but do explain, like, the most important ones what you're looking for. So, for example, like when you with your differentials just list how that example investigation leads to your differential for the ones that do for the ones that don't, Then it's quite just listing. So, diabetes an endo, um, this one's can be a tricky station. Um, just make sure your systems review is really, really good with this one. Um, remember to flaws with this one, that's a very important part of the station. And, um, this one might have some sort of patient counselor explaining the management to the patient aspect to it. They might have some data interpretation where they give you, like a range of lab values, um, and ask you to interpret them. They will have. They will have the normal ranges. Don't worry about that, but they will. They might give you some kind of data to interpret in the station. Also, remember to ask about neurological symptoms. Um, because often a lot of endocrinology can involve the brain. Um, and you know, like, bilateral hemianopia. Um, for a pituitary gland tumor, those kind of things. They're very important to remember the neurological symptoms, even if they don't, like, you know, link to the presenting complaint and learn the different types of insulin. If it's gonna be a diabetes case, it'll probably be a case of like, they're not using the insulin rye or their insulin regime needs to be changed, that kind of thing. So but the basal bolus regime, um, the basic one learn like insulin aspart no rapid the different types. And, like, how long they last for that kind of thing. Uh, yeah. Okay, so this is for surgical history. I've got a little example to go through. Um, So, for example, a 20 year old female presents with the right lower abdominal pain, and then you present the case. So this is a 20 year old female with two days of worsening. Um, right, lower abdominal pain, constant nature migrating towards center, um, and unable to move without pain, worsening one day of vomiting. Um, I mean, you can read the history. Um, and then you'd give a few basic like, acute few basic, uh, differentials. Any chance of any psych people it can. So because, you know, finally, they will expect you to know kind of all of medicine so they can include, like, a component of the historical side. Equestria, for example, might be that they're having any symptoms. Um, and you'd like you still need to ask about the gynie, you know, rule out any issues. So, for example, this case with lower abdominal abdominal pain, but for a lower abdominal pain, you will still need to rule out ectopic. You will still need to rule out P. I. D. Um, So in the sense that they won't have, like, you know, a mother coming to you with a, like a further follow up scan or something that they might have had 1/5 year or they might they won't come to you with, like, there's a kid that you're examining, um, and that kind of thing. But what they can they will do is expected to rule out the conditions from those, uh, topics. If that makes sense for diabetes. And, uh, do you have any advice for structure in the history to make it fit in the shorter time. Um, I think I'd just say, go ahead to talk, like, start from neurology, then go down, um, to like, Are you eating well, um, that kind of thing. What your diet like, then go down to any problems with swallowing, then go down to, like, any chest pain. Just work logically your way through, because sometimes with the dye, but with not not too much diabetes, but with endo, it might not be very clear what your diagnosis is from the start. And like a lot of endocrinological endocrinological problems presented wide array of symptoms, and you'll only be able to piece them together if you have all the pieces. Um, so don't don't make sure you don't get kind of tunnel vision and focusing on the one presenting complaint, because likely, they'll have a lot of different things and rheumator ice because icing will get illicit a lot of things quicker sometimes. Especially if the actors very kind. Um, yeah, and again, like like I said for the other stations, they're testing the euro safe. Doctor, you're not going to be in a technologist, so just make sure that you've, um, asked the floors symptoms. Um, yeah, so just make sure you flaws. You've iced and you've, um, safety netted the patient. Um Okay, So acute care. So, this one, um, for us, they gave us, like, a whole scenario with, um, like, this is the history of the patient. This is the investigations. This is what the nurse called you for, Um, and this is how the condition has changed since they were admitted. And it's like a whole a full page full of the patient info. Um, and we have three minutes to read that. So really, take your time looking through it. Um, not just to read it, but to figure out a diagnosis. They'll ask you to summarize what they've just given you. And what you don't want to do is just parrot the same information back to them because they know what's on the street you don't need. You need to kind of read it out to them again. What you need to do is pick up the important facts and bunch them together to point to a diagnosis. So if they give you like, um tachycardia and the investigations and they've given you chest pain and presenting a plane, and they've given you. Um oh, he's recently returned from Rome in the other thing in the other, like, bit of the history in the social history. Then you want to put all those together to this is a patient presenting with chest pain. Um, on a we were the recent travel history and, uh, tachycardia. So my, uh, re concerned about ruling out of pe first and foremost, and this is investigations I would do. You don't want to, like, summarize the whole thing all over again. You want to kind of pick out key things, And that's why I'm saying to make sure you do take the whole time that they give you for that bit to read it. Um, because I think my mistake when I did my station was that I, um I went to quick. I tried. I I kind of It seems every minute seems longer when you're in the exam, as you know. So I kind of read it very quickly, and I was like, Okay, um, and I finished my station so early, and I was like, Okay, I could have taken my time with that a bit more, um, mentally prepare for the likely questions they're gonna ask with acute care, there's not a lot of different conditions that they're going to ask about. There's kind of your main cardio rest conditions that can be acute. And you, they're going to test you on your eight. We approach. So really, practice your way to approach practice how you'd say it and practice how you adapt the A to you approach for different cases. So, um, medications at each step, for example, chest, chest pain history, then you would for a seizure history. So you don't want to just memorize one a two year approach feel you want to, like, tailor it to each history, um, can consider strategy for stratifying risk. Uh oh, are we, um, surgery. And now they've got Molina. Then you might want to think about adding, which is what they do when before Endoscopy. So certain schools like that, like the a pack to pancreatitis, like the Q risk or something else. I think they're not using any one's called, um, but schools like that you want you want to kind of you'll do them after you ate We They're not gonna be first and foremost, but it's still good if you mentioned them. Um, and this one, you cannot forget to say you'd escalate to a senior. Because as an f one, you will not be dealing with this by yourself. Um, if you think the patient's having a GI bleed, you will put our major hemorrhage cool. You would immediately escalate to your Reg if you think this patient deteriorating, um, and mentioned that if there's some sort of infective process or any other protest, really, you'd follow hospital guidelines. Um, so if you there's a lot of your condition so you can just learn the antibiotics. But I would also suggest adding to like, whatever anti meticulous test. And I would, um, check check the trust guidelines first. Firstly, but usually it's CO. Most are, for example, like I'd say it like that. Um uh, extra points. You might Also, if you have enough time at the end of your station, um, then you can list and list any complications or risk factors or long term management of that condition. Can you refer back to the paper during the summarize thing, or do we sort of them, um, you can refer back to the paper he didn't take the paper away from me during that during the entire station, so I could refer back to the paper. Um, but But like I said, you when you refer back to the paper, uh, on the page and that's not what you want to be doing. You wanna be synthesizing that information to former diagnosis? Um, so I wouldn't look back at the paper while you're presenting, but I might look at it back at it later if they ask me more questions. Um, like like, you know, the investigation or things like that. So don't don't take don't be afraid to take your time answering the questions in the acute care station, because for this one, they're not gonna ask you they're not going to have a real patient. They're they're not going to, like, make you do the things in real life. They'll tell they'll ask you about scenario and what you would do if that makes sense. Uh, so this is I just added in like the A to be kind of thing here. So, for example, um, we just go through it first. The first thing you first thing I do on approaching is um, see, if the patient can speak. If they can speak to me, then I can realize that the airway is patent. Then I'll take a look. Listen and feel approach I would assess for chest rise, um, breath sounds and equal air entry. If they're not breathing, I would check the pulse, um, while calling for help, shouting for a two to a double two, double to crash ball to be put out. Um, I would then start CPR. The patient is not quite arrested. Yeah, but you you'd still want to call for help. At this point, you might put out Perry arrest call which some hospitals have, Um, or you just stay in this in this. But if you think it's not very, very urgent that I would ask the nurse to call my Reg. Either way, At this point where it does call for help, you will be calling for some form of help. Um, okay. And and then, if you if they're not breathing, and then I had to have a pulse, Uh, then then you start CPR. So in terms of airway maneuvers, don't forget these ones, so I'd do a head chill. Chill head tilt chin lift. Um, with with or without a jaw thrust if necessary. Um, I would suction or ask the nurse to arrange suction. Um, while I, uh, carry on for the next, The next part they to be, um, you'd remove any fluid collections, but only where you can physically see in the mouth. You wouldn't be reaching into the mouth to scoop out kind of, you know, anything that's by the bag. You might just push it further in any airway, add junks. So no, really? Well, what each of these will look like because they will come and use for the image of instrument station. Um, but, yeah, some Some of the guidelines for these have changed. If you if you use kind of very, very old books, um, they they might they might not have eye gel is high up, but not now. But nowadays I gel is used a lot more than it was previously. Um, so if you're not, if you're not sure, there's no harm in putting a good Eleanor Vandal airway if they're not conscious, um, or if they're like, you know, mumbling. But they're not really very conscious. You can Still, there's no harm in putting Goodell in. Uh, yeah. Neither found you'll. If they're conscious, you can do, um, we often use Now, if these are found you like online. And, you know, you're kind of, uh what's it called? Where, Where? The cases where you shouldn't use each of these. So for another found you'll If the patient's presentation is any kind of trauma or you think they might have a basilar skull fracture, you wouldn't use a nasal pharyngeal away. Um m a r l m a as needed as a f one. You probably wouldn't be putting in an LMA. You'd probably be putting in an eye gel. Um, the only difference is the cuff is not inflatable. You Nigel breathing. Um, check the rate in the rhythm. Oxygen saps, um, respiratory examination, a B G. So these investigators mhm you tailor them to your presenting complaint, and then any other investigations? Um, and remember to repeat the 80. So, um, once you've kind of finished from a to E, you'd want to go back to a or even before you finish. If anything changes. If if the examiner tells you Oh, now the patient's doing this, Then you want to say I want to start again from a from A and go down to eat, But you wouldn't wanna You don't need to explain again to examine of what ABC involves. If you already explained it, just say tell them you start getting a If they tell you like the patient's now, I don't know slurring his feet or something. Um uh huh. Um, you just say I want to get a repeat one. Um, because it might change very quickly. And consider catheter after you finish a to eat for fluid balance monitoring, um, disability. You don't forget to do a quick GCS after two. Um, school. You can probably tell that from the history. Like, if not, you see, s at least after you can tell from the school from the history we're talking whether or not, um And don't forget to mention glucose because glucose can cause a lot of weird and wonderful sentence. Yeah, And don't forget temperature as well. Uh, and to fully expose and examine the patient for any rashes, um, or truer. And again, when you do the e part, your listing everything else as well. So at this stage. You want to be kind of in the Examiner? All right. These are differentials I'm thinking about. This is what I do for my top differential. You do want to kind of go down that kind of route? Um, yeah. So practice, you're 80. Presentation. This is a practice one that I thought we could kind of do together. So you've been asked to the 50 year old male patient on the surgical admitting unit who's coming to hospital with abdominal pain, which came on two days before he arrived. He has no vomiting. Um, What's that? Your numbers, Actually, um, he has no vomiting. Um, the nurses, uh, worried that he looks quite well, she tells you that he was just And then she gives you these obs and you look at the blood. So what would you do next? Change in bowel habit. Oh, is that what happens? Okay. Call. No. No change in bowel habit. Um, So what? What? Do you know what you're needing next? Any ideas? I'll give you a time to read the results. The normal one is not on there. But I'll just tell you, this is a high white cell count. Um, and this is a high neutrophil neutrophil count. Well, pancreatitis, yeah, could be pancreatitis. But what would your next step to be? Yeah, history exam A B G. Exactly. Um, if you're selecting prostatitis, you can also do like either in a pack school or a Glasgow Glasgow school. Glasgow Emory School A To be exactly a to be, um, ct. Exactly. Yep. The pancreatitis. If you're suspecting that specifically, then you'd want to get fluid in very quickly and analgesia as well. For a lot of these kind of surgical histories. Analgesia, You might kind of forget to mention it, but it's actually very important for the patient. Um, so for a prank, Titus, for example, if you don't get analgesia in time, then it can worsen the necrosis. Um, because the pain kind of stimulates actually Anthology. But can I can worsen the necrosis and that kind of outcome of the patient. So allergies is a very important one to mention. Okay, So then, um, you do you 80 approach airways patent and be shows increased work of breathing some infusions on auscultation They They look shocked. Cardiovascularly um so they're alert. Glucose is normal. No, fever and everything else is kind of here. Um, just the A B. G. So what do we think from this? A B G? Can anyone tell me what's kind of what jumps out as being abnormal in the I V g. So that takes a bit high. Basic classes are low metabolic acidosis with hylecta. Yeah, um, the pH isn't on there, so I'm not sure if it's acidosis or if it's compensated. Um, but yeah. So the whole act, it's high in the by carbs. Um, hello. So a malaise is also 1200. So you're right at the beginning. Pancreatitis. Um and then you did an ultrasound scan. There was no gallstones. And Perry pancreatic standing was seen suggestive acute bronchitis. And as we saw before, the patient was in the previous, um, bit, you mentioned that the patient had been seen with open bottle of vodka, so it might be alcoholic pancreatitis. Um, yeah. So that's kind of the example of a case you might have. So, like I said, they won't be very complicated conditions for the acute care scenario. They'll that bed, just checking to make sure that you do. All of the kind of investigations as you would, um, in a real life scenario, and you'd call for help at the right time and you escalate to the right person. So you want to know when it's appropriate to put our crash call when it's appropriate to put out a Met call or just call your registrar, um, or put a needle major hemorrhage call as kind of. It depends on the scenario. Um, another thing is, when they give you that scenario, they might give you a scenario of like, Oh, the nurse calls you with X y Z. Um, then you'd want to. You'd want to tell the Examiner also what you do while you're kind of walking to the ward. So there's a lot of things you can tell the nurse to do while you get there. So I'll tell the nurse to repeat the observations. I'll tell the nurse to, um, put on oxygen and, um, get notes ready so I can review them quickly. Like those kind of things you want to tell the nurse to do while you're walking to the ward. So images and instruments this station gave people a lot of grief when we were advising for it, but actually wasn't too bad. Um, so, um er Sam did like a session where he went through all the emergency management. Essentially, And that was a very good session. Um, he probably has done one for you guys already. Um, if not, you can go through last year and upto um, but there's also the drive that I will put the child at the end. Um, has lowered the slides of practice. Um, I think a lot of people have made slides of images. Instruments. Um, so there's no need for really, like going into going ham on trying to figure out different types of instruments, um, and images. Now, I'd probably recommend doing it closer to pace is because then you remember more, and it's not very kind of detailed, difficult stuff. The common instruments. They'll have max, like, five instruments on the table. Um, and it doesn't matter if you talk about anywhere from 3 to 5 instruments, but what you want to do is just carry on talking until they stop you, um, for the instruments. So name the instrument, describe what it does. Um, when you'd use it when you wouldn't use it. So like I mentioned earlier for or for a nasopharyngeal hair way, he'd say, this is the Nasopharyngeal airway. It comes in multiple, different sizes. Um, you would use it when the patient is conscious to gain airway support. Um, and, uh, it would be it would be contraindicated in a patient with the basilar skull fracture or any kind of recent ent surgeries. Um, any complications include, uh, kind of trauma, putting it in that kind of thing on other complications. We just wanna list kind of ramble about the instrument as much as you can. Um, they'll also guide you through it. They'll ask, like from I wanna remember they ask specific questions for each each instrument. Um, but everything else is basically this. So if you just carry on talking about this, then they won't need to ask you the images. We have three images. The first image we were asked to present to a patient or two. A relative of the patient. Um, So don't just practice presenting to an examiner practice presenting the image of the patient. Um, and also don't make the mistake of presenting the same way you would have been third year where you spend a lot of time talking about rotation, inspiration and penetration exposure. You can just say, um, the images of adequate quality or just rotation, inspiration, penetration, exposure adequate. And then move on to the rest of the kind of main finding of the image. Um, talk about the most prominent. Think first. So don't you know how you learn? Like, for example, an X ray to go from, like, a two E or from like, I'm not sure how you've learned kind of learn to do an X ray, but I was always taught to go a B c d e. So, like, look at the airway first. Then look at the lung fields and look at the cardiac borders. Then look at the diaphragm and then look at everything else and doing bones or breast tissue. Um, so you want to examine the actual image in that order to make sure you don't miss anything, but you don't necessarily want to present it in that order. You want to present it as, um, this is an image taken on this day of this patient. Um, and there is an opacity in the left uh, lower lobe, which is suggestive of a pneumonia. Um, two for this patient I would like to do, uh I don't know this or that. I'd like to start them on, like to do a curb school. I'd like to start them on, um, antibiotics. Or like to carry on talking about the presentation. If it's presenting to the Examiner. If it's not presented in the Examiner, then you can, um and you talk to the patient instead. Then you want to explain in more basic terms, obviously. Um, so this is this is your lungs. This is the kind of, I don't know. There's a. As you can see, this part of the lungs looks less kind of more blurry than the rest of the lung. This could be what's called a pleural effusion. So that's when fluid builds up in the sacs around your lungs. So you want to kind of explain things in a very simple and straightforward way and focus more and explain the pathology behind what's causing that issue rather than the image itself. Um, yeah, so they could show you a chest X ray, abdominal x ray ct. They could also show you an MRI, but if they show you an MRI, it'll be a very straightforward box down MRI. They won't be getting you to interpret anything too fancy. Um, and yeah, like I said, practice presenting to the patient and the Examiner. Uh, we just went through this. Um, yeah. So in terms of revisions, strategies, in general, collaborative work is best be harsh and time yourselves strictly So, your final years now, now is not the time to be nice to each other and do the whole approach where you're like, Oh, that was a good history. Like, if it wasn't a good history, then you just want to kind of go home and tell each other what was wrong with it. What they could have added to it. Um, and cut cut people off. Like if you're examining each other and you get to six minutes, cut them off, um, and be like a present now, um, Or if they get to seven months and present now, like, don't don't let yourselves go too long, because now is not the time to be doing that. Um, practice the M S K examinations more than you think. You need to because And they're ones that you probably haven't done before in med school. Um, do and and do, Do you do question books you can do pass med past test question. Uh um, like, it doesn't really matter which questions you do. They all kind of test the same sort of things. Um, all you want to do is make sure that you're not doing it in Kind of like you're sounds very close now, Like they're in a few months, so you don't want to do it. You don't wanna go topic by topic. You don't want to be doing like, Okay, I'm going to do cardiology now, and I'm going to do a breast. And I'm going to do this and that, Like, you want to get to more of a doctor mindset where all of these things can present together. And you want to know what it is, no matter what. What are you doing them in? Um, so yeah, Britain revision takes a revision. They kind of go hand in hand. Uh, what you can do is if you're rising by yourself. You know, you look over a condition you can kind of practice. How you do it as a pacers or question you don't want to ask that kind of thing. So on the day of these, um, and make sure you dress smartly, bring a stethoscope, bring a watch, bring your i d. Which I forgot. Um, And like you are Imperial College I d or like, a driver's license or something. Um, and don't worry if you don't know the answers. Like, we had some very, very rogue diagnoses, but we all still past we had cavernous Sinus thrombosis as one of ours. Um, so don't don't worry about that. Like, don't worry. If you can't get the diagnosis they frozen really wrote you. They're looking for safe doctors more than diagnosticians. They're looking food that you're, um okay to be, like, allowed to go off this, Um, just go back to your main structure, You know, your main history, you know, from third year, if you're not sure what to say next. Um and if you kind of a bit, you know, confused about what to do, Just do assistant review in your history practice makes perfect practice, practice, practice, practice with different types of people. Um, yeah. And practice on real patient's as well. Um, you don't even need to ask. Like the you know, if if no doctor on the wards giving you any kind of time to practice with you, then just ask them. Okay? Which patient's got good science? Which patient's got good? A good history or will talk to me without yelling at me? Um, and just go talk to patient's and practice taking histories from them within the time limit. Um, so that's the end of my little tutorials. Any questions about any of that? I'll put the link to that drive in the chat now. Uh, so this is the drive. Um, so you just got loaded. Different resources for different things. Um, in the folder that says Paces Final Resources. Um, in paces notes. There's one, um, I'm not sure where where it really is, But a student called Guild Pete's notes. Um, she's Yeah, it's in. It's in the one that's like labeled a student, notes a Z I s notes, the very first one in paces notes. And there's one called Kieran Kieran Pred gills notes, and she's got very, very comprehensive notes about kind of all of the cases that you can possibly have. And if you know all of that, then that's more than enough. Like her notes are very, very comprehensive. And I would just go. I just went through them the day before my exam in there. Very good. So I'd highly recommend those anyone have any other questions? Cool. That's my tutorial. Done. Then please lend the feedback. I don't know where the feedback link is, but he's still in the feedback. Isn't charcoal okay? Thank you so much. Yeah. Okay. I'm just gonna end.