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Hi, guys. Thanks for joining. We'll probably wait for another 23 minutes just to give a chance for the rest of the audience to join the meeting and then start. Right. Okay, so it's 5.7, So let's just make a start. Thanks, everyone, for joining our session. I'm Josh from the Events team of W PMN. Um, so, once again, thanks a lot. This is our fourth session of the national teaching series. The foundation pills like our previous three sessions. Um, today we'll talk about practical tips and surviving, um, your medical wards rounds and on cause we'll explore some of the common clinical scenarios and talk you through these using a systemic approach. Um, so hopefully this will give you a better understanding of the many roles and responsibilities of an F one and help you to develop that skills to prioritize and triage your jobs, as well as carrying out an effective clinical assessment for sick patients and knowing where to escalate your senior colleagues. Um, so for those who are new here, we will be recording this session by continuing to be in the meeting. You're consenting to be recorded. Uh, we would also like to ask the audience to switch off your camera and mutual microphone during the event to ensure that has run smoothly. Uh, would also encourage everyone here to post and inquiries you have chatter box will try to answer them at the end of the top as well. The chapel function also allows interactions between the speakers or as the audience. So, please, do you use it just so you can keep it as interactive and informative as possible. Uh, further talk will post more details about upcoming events, the remaining sessions of this weapon series. We have received really good feedback from you guys from the previous sessions. So hopefully we can continue to trend and create and create information and practical tips that will help you guys to succeed in your, uh if one or two or in your kind of new journey in the NHS. Um, so, uh, just one last thing please still feel in our feedback from at the end. It will be really helpful to us. Uh, you also get a certificate in the end. Uh, and we'll also talk about how you could use these certificates in the end. Uh, but as a separate session. Um, uh, in order for you to, you know, uh, progress on your medical career or apply for any such as your training? Um, yeah. So let me just see if you guys have put anything on the check box. Perfect. Yeah, thanks, Jeremy, for posting the sign of links for the remaining sessions. Okay, so I'll just do a very brief introduction of our speaker today. Today's session will be delivered by Page and myself. Page is a junior doctor with interest in geriatric acute medicine Community Health. She graduated from the University of Little Medical School before beginning her foundation training. Um, in the northwest at the entry university hospital, which is a very busy territory center was myself. I am Josh. I'm currently F one working in Nottingham. Uh, so we're trying to tackle some of the company encountered cases, and, uh, what are the approach that we would take? Uh, and what sort of expected from you as a as a newly qualified junior doctor, as someone who is trained in a in a foreign country and coming to the UK So hopefully you will learn something and and be able to apply some of the tips and skills and knowledge that we have talked about today. Um, just a bit of this claim and the content that we're covering up by no means an exhaustive list. So it's not a check list of everything that you need to do for, uh, for when you're approaching a patient. But by discussing these scenarios, we would like to share some experience as an inside of you guys from last year working as a junior doctor in the six s. But just remember, it's not intended to be relied upon for patient care. You should always consult your senior and local or national guidance when it comes to the actual patient care. Perfect. Thanks for sharing your screen. So, uh, let's just move on to the next night so I'll just start off by talking about some, um, practical tips and and general advice. Um uh, that I find it really that that I find it really helpful, and hopefully it will be beneficial to you guys as well. I'll share some of the useful resources for, uh, for the foundation training, and then I'll move on to some of the coming election right imbalance. Talk about cooking the injury. And lastly, just very brief overview of fluid prescription that would be expected. And from us, A junior doctor covering, of course, I drink water rounds next time, please. Yeah. So I'm aware that we have already talked about quite a few, uh, medical emergency, common medical scenario, you know, three in the previous three sessions. So why not? Let's just quickly touch on some of the tips. Uh, I found it really, really handy, helpful when it comes to my ward running on course, and hopefully you guys will find it helpful as well. So typically, walk around during the course of my first thing would be, perhaps to when you're doing wood around Saturday with printed a written list of, uh, of your patients. Um, sometimes I do use the clip. Or just to make sure I don't lose the list of just to make sure I don't lose the patient list. Also sometimes use highlight in order to, you know, high at the top and bottom bit of the paper. Just so you know, it stands out. It's harder for you to lose weight. You know, when you have a cycle notes in front of you, and things don't get lost during that process. Uh, I sometimes also use a different colored paper again in order to make you stand up, too, so I don't lose them because it's also useful. Just to, you know, have have some multi colored pens, because in that way you can customize your own color preferences and prioritize your jobs based on the urgency of the task. For me, I use a red pen, too. Circle the most urgent task, followed by a blue pen and the black pen. But yeah, feel free to, you know, try out and find your own way of working around things like that. So the other thing is, sometimes your registers will do an afternoon board round, Uh, most medical wards around in most medical wards. I think it's also useful that you guys are kind of disciplined and self motivated in the sense that you know, among amongst yourself among the junior team. At the end of each day before you go home just very quickly, go through all your patients on the list and make sure that all the jobs are completed. All that are selling task our head over to the 19, uh, and also pay specific attention to the request referrals or scans, or was that you have made during the day? Um, just remember that when you are asked to request something, the job is not close until you get the results and you act upon it. And so just by requesting the scan, just requesting the blood. But it's not It's not equivalent to, you know, completing the job and also just, you know, every time before I go home, I also asked myself a question of you know, whether the patient whether everyone that I've looked after are stable. Am I happy? Just, you know, uh, am I happy for the rest of the night that you know, if there's no doctors, are they going to be stable? And if the question is not, then you probably need to handle this is a specific patient to the 90 more to the out of our service team. Uh, yeah, and sort of next. My next thing would be, you know, just to use the clinical reason when it comes to treating your jobs, Uh, for instance, you know, when you are doing nights the kind of main purpose of Nice just to make sure that patients are alive. So you have to constantly ask yourself the question of whether you know all all these 2030 jobs and sent your device or all these sleeps. Can they be done by the day team, or do they have to be done urgently? Otherwise, the patient might die or might deteriorate really badly in that sense. So things like, you know, can you prepare, uh, t t o for tomorrow at nine. AM Because transport spoke. Can you put an N g tube at 12 PM? Sorry. At 12 midnight. Can you prescribe some IV fluids at three. In the morning? Just think about it. Like I mean, do you Do you drink at three. In the morning? So these are the things that you need to consider. Uh, can you please update the family again? So trying to be, you know, reasonable and think about what other things are important. And what are the things that matter to? The care of the patient out of our setting is something that you will learn as you progress. But it's just it's just really important, really. useful tips you could have ever had. Uh, for when you start your F one and then you realize that as we talk more about some of the common cases, there's always a repetitive set of investigations that we use for almost all of my patients. For instance, you know, Phoebe G BCG, um, blood, urine, chest X ray for one patient aesthetic. Um, ABG if they meet certain criteria indication such as hypoxia, increasing requirements, these are the things that you probably learn more, uh, become more experience. But then, you know, just have a have a list of have a set of favorite investigations, uh, try to try to develop that kind of practice. Um, and then, yeah. The other thing is, when you're on call, people will come to you and just say, Oh, I've got a patient. Perhaps BP is 95 or 45. Uh, it can be worried just just by hearing her hearing these values. But then it's really important that you look at the trend, the overall trend, which I discussed in my first session last week. You know, you will be probably less worried if someone has been, you know, fluctuating between 9200 systolic since admission. Versus you know, someone is based on the 230. And suddenly drop the pressure to 95 now. Yeah, And then the other tip is, you know, uh, during world around during your core is always useful just to get contact number of your seniors or you're registered during your core shift. Just so if anything happens, if you have any questions, it's easier to, you know, uh, call them rather than keeping them. Or, for instance, if you are in certain specialties the register, maybe reviewing outlying patient, they may be somewhere else. It was just useful just to get get the work number and and have that kind of contact detailed, uh, next to you. Um, just a few tips as well. Just try not to have lunch breaks in the office because people will still come into the office and ask you to do certain tasks trying to make sure that you are separated that you work and break. Um, and, uh, yeah, if you're going somewhere else, If you're going out of the war, please make sure you leave with a phone number just so If anything happens, the team can contact you and also used for just to learn some of the common drug doses. For instance, if you're an award round, um, it will be real helpful if you know the drug daughter's such as paracetamol some laxatives that are coming to prescribe just so you don't have to go back to the patient, go back to the drug after the world around and do it later where that will take up quite a bit of the time. But obviously that will come with more experience. So don't worry too much about it Next time, please. Yeah, so just some very, very general brief generic advice for your effort. And I've got this question so many times. So I need to study for meditation. I think it's really good to read around topics, um, you know, related to the specialty that you're working in. Uh, it's going to help for you to know what what, like you know what's going on with the patient and why are they requesting these investigations and why are we treating the patient in this way again? It will come of experience, but I think what's more important is to, you know, know the kind of base practical procedures like Blood Canada's catheters, a BG and know how to do a thorough, uh, to the assessment and some basic parking skills. And I think it's also important just to know, your know, you're kind of conflict competency level when to escalate. And that's why we are holding these sessions just to make you to be more confident. We're confident when it comes to these these sort of emergency or situations. Um, and the other thing, you know, from a work like minus point of view trying to get your annual leave early as early as possible because you become a lot harder later on to swap, you know, sudden shift like long days nights we can shift. Yeah, just just bear in mind. And again my second point would be, You know, you need to look after yourself before you look after other people. So make sure that you're getting regular breaks, you know, prioritize your jobs over your health, for instance. Um and yeah, and please make good use of your induction period as well. Um, so, um, just better in mind. Um um, during the induction period. Just remember that you're no longer a finally a student. You are actually effort and try to have a check list of things that you want to achieve from that from the remaining two days of the induction period. Try to be as proactive as possible and just see yourself as an f one. Um, so just try to ask you and everyone to let you take the lead to let you do these things, like let you request those scans and speak to the relevant specialties. Just so you know, you get the experience while there is someone that watching your giving you some feedback, so that will be really, really helpful. So just be proactive and just try, you know, just to type into it. Um And, uh, yeah, one last step just to, uh, you know, learn about the requirements of your portfolio early on and start working towards it. Um, if you're not aware of that, the ercp for everyone, it's normally in around during time. Uh, so that's, you know, two months before your before your final day as an F one. So it can be quite rush if you're not prepared for the sound of it, But don't worry too much. I'll give you another talk in a in a couple of days time. So if you do find these sessions, you so please sign up for that next please. So he's just a slide of some of the use of resources. The first few ones are the ones that I personally use. It quite often, uh was the bottom for ones are the ones that I I've heard from my friends or I found it online. So I think that if you think that these are useful, Yeah, next, like things. So, yeah, let's just quickly talk about the electrolyte imbalance, which is the main name of the sessions for my part. So, uh, hyponatremia is a very common encountered, uh, electrolyte abnormalities in the hospital. I think the main message for this, despite all these words here, is that no one expects you to know how to manage hyponatremia on your own. Please do always try to involve your senior and get advice from from different people on the appropriate investigations, especially when you're starting out as an F one. Very common encountered case will be, you know, 70 80 year old female admitted with confusion, treated for a UTI now. So it was 126. So I'll just briefly talk through What are the things that you know I would do when? When? When I get a task like that during my shift. Uh, so again, as I mentioned before, the most important thing is the trend 126. You know, if that's been the number or if you know, the patient has had this value between 100 2527 for the past few weeks, and it's probably less concerning. However, if yesterday the value is normal and now it's dropped 126 and I will be a lot more worried about this. So the trend is very important when it comes to any kind of abnormalities as discussing the first session, um, and then try to kind of take a very brief history. So, uh, why did the patient come into the hospital for this case? The patient came in with UTI. Uh, could that hint to us? You know, could there be any science, science and symptoms of dehydration? Reduce your intake? Uh, stuff like that You could point to a specific courses of, uh, low sodium, uh, other patients thirsty and trying to assess the symptoms of hyponatremia. Has the patient got any headache? Nausea? Confusion can be subtle. Um, And then, you know, the symptoms of, uh, of hyponatremia can range from headache, nausea to really severe. Such as, uh, cerebral edema, herniation, death. So So it's really important that, you know, when you see this patient, just make sure they're not having any hyponatremic emergency, um, to find out the courses of hyponatremia. Think about the common ones. The common causes, such as any medications, diuretics, PPI. So this is our eyes. Um, other patients on any IV fluids at the moment. Uh, dehydration. Any electrolyte loss is nausea, vomiting, storm a loss. Is any underlying cardiac renal liberty? See things like that when it comes to examination. So outside and systemic examination. Um, So look at the fluid status. Is the patient dry you to limit or overloaded? Um, look for signs of confusion. As I said, it can be quite subtle. Use collateral history if needed. Um, investigations. So there there are lots of investigations for hyponatremia. But as I mentioned your job here, is not to do all this investigation as the perhaps part of our doctor. You should always try to do the basic ones to make sure the patient is stable and speak with your senior SNF one. So if you see hyponatremia, feel free to repeat some routine blood. Repeat, Um, for instance Um, check the B. M. Because sometimes high IBM can kind of give you that sort of relative force Hyponatremia picture. Um, at a very basic level. Sometimes you will be asked to do things such as serum. Uh, and you're in a similarity as well as urine sodium. Uh, so but please, once you've done this, always refer to your local trust guidelines and speak to your senior. Because once you've got this result, you will have a really clear flow chart of what you should do based on the value of these results. And then you can make a management plan based on that, uh, while discussing the proscenium so treatment of hyponatremia are they stable? Um, if they are, if the hyponatremia is acute or if they are symptomatic, please do speak to your senior immediately because they can deteriorate really, really quickly and Do they need any higher level care? Uh, such as you. Um, so the guidelines usually the trucks guidelines divide them into my motor. Severe it varies, but please, do, you know, consult the local guidance. Um, and the treatment also depends on your history examination. If they're drying out there, hopefully may consider giving them some slow, uh, fluids. So some slow, normal state light. Correct the B m. Um, if they overloaded, you need to consider full restrict again. Speak to your senior, please. Before doing any of these, uh, review the medications, try to stop or, you know, hold any unnecessary medications. Uh, the other thing is, you probably learn it from medical school. Something about hyper tonic saline in Sophia hyponatremia. Just please. You know, don't try to put this in your plan. It's an F one. Yes, they may be used in some critically ill patients, but as an f one, please always involve your senior. Uh, these are not These are not the drugs that you should be prescribing at your level of training. Yeah. Please. Yeah. Uh, second, very common. Encountered, probably quite scary. Electrolyte abnormality would be hypochelemia. Um, I have encountered that yesterday. Actually, um and I still remember the first time I saw that on my job. It was it was definitely very frightening. But I think the first thing is just to try to stay calm, knowing that you have done your training. And hence you were here. Um, yeah. So there's a There's a wide range of variations of hyperkalemia. Very generally, uh, when it's more than 5.5, protecting more than 5.5 classes as hyperkalemic. Um, if the value is above six from 6 to 6.5, that's very worrying. A lot of courses of hyperkalemia you probably learn from medical school. Could be has a cycle humanized any acute kidney injury, Any chronic kidney disease? Uh, any medications now for toxins, eight inhibitors, things like that. And you also be surprised that some patients might be prescribed and okay on the drug cards without a review date. And hence they have been getting suffocated for Perhaps, you know, more than the required days. Uh, yeah. So please do look at the record properly. There are obviously somewhere, of course, is which you can also look up. So just remember, this is not a diabetic lecture. You have all gone through medical school. So we're just really about, you know, knowing what are the common things and the rest You can look it up, but knowing what are the sort of important things to consider when you're approaching a patient with hypochelemia? Um, so, yeah, when you're putting the patient initially, think about whether the patient is stable. Uh, unh reassessments. Uh, making sure the patient doesn't have any signs of cardiac arrhythmia or any any hemodynamically instability. Look at the urine output. Could that indicate any early signs of A I usually get the venous access as well, when you can take some blood too. Perhaps you can also give you some medications. Uh, if the blood's demonstrate, uh, quite a high potassium mandating certain treatment as about symptoms. Have they got any palpitation, chest pain, muscle weakness, cramps, things like that. Although most of the patients are asymptomatic, um, some questions to ask yourself as well as the patient got a background CKD again, Any particular risk factors is just any medications. Is that new or potassium? Look at the trend again, as I mentioned previously, please always refer to the trend. Um, investigations e d would be the first one. Um, and things look for perhaps, are the ones that you've learned in medical school to attend to t waves. Uh, loss of the wave, Uh, increased pr interval, things like that. Um, and and also, as I mentioned, repeated blood. Um, so if you think the patient is stable or if you think it's very likely the blood humanized, for instance, if the patient's blood was yesterday was completely normal and there's a high suspicion of, uh, sampling error, then please just repeat a CABG. That would be the quickest way. Sorry. Repeat the blood gas. That would be the quickest way to know the, uh, most up to date on your potassium level. But if the patient is unstable, please to initiate treatment urgently as well to your senior as soon as possible. Apart from blood, guess you can repeat the U. N. D s. Some just recommend doing a whole bit potassium as well. Um, so, uh, yeah, treatment of hyperkalemia. Usually again. Please refer to your local trust guidance. Usually, calcium gluconate is 90. To stabilize the endometrium. Um, sorry. The myocardium and, uh, incident extra uh, sometimes albuterol as well. Um, and, uh, make sure that you try to remove sources of high potassium so low potassium diet Review the drug cards. Um, And if the patient is on treatment, they need to have repeat the BG and blood in a sort of cereal integral basis. So please check your guidelines for that and make sure that we are. We are slightly monitoring the patient's blood to make sure there's blood out for tomorrow, just to make sure the patient doesn't happen. Rebound cholemia Recurrence. Uh, and if in doubt, please do get involved with senior as soon as possible. There are certain treatments. Things like calcium was only, um, dialysis. These are the things that you know you shouldn't be making decisions or always involved in senior. So please don't you know, put it in your plan or or, you know, try to consider that as your first time management, uh, next place, uh, so the next thing is hypochelemia again, very common encountered. We are constantly reminded about how hyperkalemic acute patients, But sometimes I do forget that hyperkalemia is equally dangerous. It's even worse because it's it's unfortunately under recognized and under treated in the hospital generally, anything less than 3.5. And the potassium is just hypokalemia. However, there are classification of that from mild to moderate to severe. So the common courses of, uh, hypokalemia such as, uh, poor intake, Any job losses, high school, my output nausea, diarrhea, vomiting. Um, uh, if someone is new my mouth, could it be in adequate, uh, fluid replacement, Inadequate advocate replacement? Um, certain medications, diuretics. Uh, and the other thing is magnesium. Please remember, um, you probably, like, not very familiar with this, but hypo magnesium low magnesium could also contribute to low potassium. So in order to treat low potassium in a patient with low magnesium, please make sure that the mechanism is corrected first. They're also rare courses, of course, but you can always pick up afterwards assessment of these patients quite similar to hypochelemia. So any symptoms of low potassium e g. Any particular any changes in the new wave and the depression flattening of t wave. Uh, etcetera, Uh, repeat the blood, uh, again, Having a blood gas would be handy will give you the most up to date and accurate reading of your latest potassium repeated routine blood. And also please remember to check magnesium as well, because if you constantly replace potassium and if you're not seeing any effects and probably you need to make sure that you have checked your magnesium, correct it accordingly. If you needed treatment again, referred to your trust guidelines. Um, if it's mild to moderate case is noisy changes or symptoms you can consider oral supplements. Uh, if it's severe, symptomatic ongoing loss is, uh, the patient can't take anything, or we can consider IV fluids. Please also check the rate of IV replacements for especially when you're putting potassium in your back. Uh, there's a certain rate limits to that again consulted local guidance again. Correct. Correct. Any hypo magnesium, uh, daily blood, just to make sure that you're monitoring that as well, Next means. Okay, so the next thing is, uh, so thank you again. You will see this very often during your own course during the war. Drowned during the regular shift. Um, so in terms of a K, I sort of too many things that you're looking at is the extent of changes of creating it in the baseline. And the second thing is the four in the urine output. The presence of oliguria is the kind of most sensitive markers to that because we know that created a delay to rise and creatinin. Uh, please do not use the CFR. As a matter of fact, I I, um So we've talked about all the urine in our first session. If you would like to learn from that, please go back to the recording and have a look. Any questions? You can email because my email address is there any way. But today we'll focus on, you know, maybe the biochemical abnormalities. Um, for instance, you'll probably get a task like 73 year old male, three POSTOP right hip replacement. Now, blood demonstrates, uh, 82. So what you do so again, the first thing I look at the trend is an acute thing or is an acute and chronic thing is important because for patients who have CKD, especially, they are under the renal team, Uh, transplant. If you need regular dialysis, you probably want to discuss that with the readings. Register after your assessment, because they may have certain expectations in these patients. Um, and also in these patients, please assess any complications of CKD? Uh, hypokalemia. Any accident OSIs any? Any signs of, uh, popular demand overloading uremia things that you learned in medical school? Uh, let me just give you a chance to, uh, yeah. Okay. All right. Perfect. Sorry. Please go back to the previous. Um, so, yeah, your assessment would, you know, include the history examination, Um, looking for underlying respective. So history was the reason for admission in this case is a replacement hip. You can also help you to identify any courses of achy I. Any apparent bleeding? Which is? Or intake paying G I losses. Abdominal pain, urinary symptoms. Um, any signs of infection? Sepsis, for instance. They've been started on the new medications. Any infection that required gentamicin, for instance. Eight inverters for people control. Have they fall on the floor recently? Um, have they been? Have they been on the floor for a long time? Later models and things like that. Examination wise. Look at the observation signs of shock temperature, uh, maintaining the BP. Look at the fluid status. Um, any any kind of drains? Tubes, things like that. Any IV fluids, any storms, Any catheters? Look at the skin to get that pulse is GDP. Things like that. Uh, listen to the chest. Any, uh, stones? Any signs of prominent Dema again that could indicate to be a course of consequences of the, uh, um, abdomen. Particularly if you're looking for for Serena courses. Any kidney, any pain tenderness, any, uh, and you got the retention? Probably bladder, things like that. So the three quarters of a k which all of us would know. Um but I think you know, I was just trying to keep it brief. So when you're assessing a patient with a K I from a practical perspective, the first thing you would consider is currently arena course. Um, any risk factors of hyperkalemia census shock or any particular medication? Proscar That could indicate that if not, then probably consider post renal course. Um, any Any history of benign or malignant tumor? Bladder cancer, prostate cancer, BPH Are they on any medications that could contribute to a urinary retention constipation? Any kidney stones, strictures inside that and not considered an intrinsic causes. Have you got any respect? Is any rashes any sore throat? Any autoimmune issues? Any atypical infection? Any bacterial viral fungal infection, etcetera. So your plan for these patients again, please consult to trust guideline. Generally please do a urine dipstick and MCPs. If you have any infection, do a self screen to review the medication to stop any nephrotoxic ins. Uh, people, uh, make sure you have daily blood out. Um, yeah, because you to make sure that you are tired of monitoring, uh, the renal function to make sure the patient doesn't develop any. Any consequences of complications from that. Just typically, make sure you have a tight input output. Yeah, and then a b c d e. So it's a very simple know Monix, um, that we use in the UK Yeah, I'm going. I'm going to next slide, please. Yeah. So it's the 80 year approach to a eye. So a sense for just medication be to boost BP, see capital fluids, fluid balance d to dipstick urine and need to exclude an obstruction experience. Everything we have covered just now, but in a in a simplified way, it's just so it's easy to remember when you're on cause, um, so eight is to address the medications, make sure that you are withholding, uh, toxins and keeping an eye on the blood test as usual. Long, um, if the patient is dry, uh, consider holding BP tablets. The BP is low, considered cautiously giving them IV fluids as well. Obviously, they will be complicated cases where patients, renal failure or patient overloaded. So you need to you need to consider speaking to your senior before you either give them fluids cautiously or your diaries Them. Uh, see, Make sure there's a tight input output. The dipstick urine. Um, looking for any hematuria has been infection UTI or any kind of intrinsic courses of that exclude obstruction a very easy head size. Investigations would include just as bad as just to make sure patients not retaining. If you have a catheter, please just make sure that it's draining properly. Uh, urine looks all right to you. Uh, if there are suspicions of close, please do flush it to tell the nurses they're really good at doing this. Flush the catheters to make sure there aren't any clots or anything that could block the catheters, uh, et cetera. And also, uh, if the patient, um, uh, doesn't improve with with the kind of management consider doing a renal ultrasound is an urgent basis or if there is any kind of clinical findings suggestive of, of, of, of sorts, of things such as obstructive obstructive uropathy. Then you should consider doing an urgent A renal ultrasound. But you can always speak to your senior when you're considering things like that. Yeah, So, um and it's like this so very, very quickly. Just the last bit of that is the out of our full prescriptions or, um or just IBI. In general, it's probably like the most common job in the hospital as an F one, especially when you're on course you will be asked to do to prescribe fluid so many times. Um, so the first thing to consider is what the indication of that is it for full resuscitation was the BP of the patient again? Look at the trend. What the cause is of that, and it is the bleeding. Is the sepsis things like that? In that case, please, please consider. Have we actually addressed the course of that? Are we are we giving antibiotics to the patients? Are we treating the sepsis or have you stopped the bleeding, or is it for maintenance, or is it for other kinds of medications such as new by mouth videos or intake D K a. Etcetera, etcetera, etcetera. Um, and the thing about is appropriate. Um, um, I have discussed before, you know, consider the timing of that. Someone's going to come to your three. AM just asking. You prescribe some fluids. Just think about do you drink, uh, three or four in the morning? Or just make sure that you know every time you give some fluids to assess the patient to give another one sufficient fluid. Overloaded is a patient frail, so yeah, so, leading up to that, please assess the age weight mobilities of the patients. Look at the new score fluid status, and there are certain patients, certain special groups of patients that you need to pay extra attention or be cautious when you're prescribing fluids. Treat fluid as a drug place. Um, for instance, the frail patients patient with renal colic impairment, including electrolytes, closest diarrhea, vomiting. Yeah, in this group of patients, do not afraid to ask for help for advice from the senior colleagues. And please put your bloods or please, please check the Bloods from previous stage is to make sure that you know. You know what other electrolytes before you're prescribing to avoid any worsening of the electrolyte imbalances and things like that, it always review and reassess, Uh, when you get the next bag's so sort of the same thing fluid balance was indication. Is it appropriate dissipation belong to a special groups of patients? Uh, things like that. So this isn't the right answer. For every case, too full prescription, it can be very subjective sometimes. But one thing for sure is like this skill and the confidence when it comes to your prescription will come with practice. If in doubt, please speak to your senior and refer to trust guidelines. So that's pretty much my part of the presentation. So I will let Page to talk about hers now. Thanks very much for listening. Uh huh. Oh, hi, everyone. Yeah, I'm Paige. Thanks, Josh. Um, so I'll be covering some other areas which I don't think have been covered so far this week. Um, it's quite attractive, so I'll ask questions. And you can always put your answers on the chat box, which I'll keep checking. Um, so I'll just go through what I'll be covering. Um, so I'm going to focus on some on call things mostly common things that you'll get bleeped about or called about. So that includes falls, analgesia, delirium and CCGs will be quite brief. Um, but it'll just become things that you might see on call. So the first scenario is a really common one, which you'll see across all specialties. So medicine and surgery. Um, Hey, Doc, I got a man who's fallen on the way back from the toilet. Can you come and review him, please? So, does anybody know or can you think If you put in the chart box, what do you think you want to know? First off over the phone from the person that's calling you? I'll just give you a couple of minutes. So anything that you would like to know before you even go and see the patient so she wants to know when they fell. So have they just fallen now? Did they fall a couple of hours ago? How have they been in the interim? You want to know who's fallen, so get the patient details. That's basic so that you can have a look at the notes before you go up there. and have a bit of an idea about who they are. Where did they fall? So did they fall in the toilet? Did they fall out of bed and they fall in the middle of the bay? Did anybody see them fall? What are their jobs? That's a really basic question, and it's something that it doesn't really matter what someone phones me up for over the phone. Um, I always ask what the patients are. These are what the most recent labs are. And then don't you know they need to be on after they fall and it doesn't matter what they were before. Um, and does anybody know how they fell? So, you know, did they hit their head? Is the main question that I'm going to ask, Did they hurt themselves in any way and why they felt so That's something that you can't answer over the phone. Obviously, you will have to go and see these patients that have fallen. Um, So what I would suggest is if the patient's stable, um, then what I normally do is so if I'm in the mess and I get a phone call back like that, then I look up the patient. Yeah, Exactly. Yeah. So I just check the check box again. A brief history and patient details. Great. So once you get the patient details, you can do some research. So why are they in hospital? So are they in hospital because they have recurrent falls? Are they in hospital with pneumonia, or are they in some hospital with something completely unrelated, like acute cholecystitis or something like that? Because it might all impact why they fell. So you want to know a little bit more about them? Like I say, you know, have they got any past medical history? So either things that would make them more susceptible to falls like any visual impairment, um, or balancing, you know, difficulties, Or have they got past medical history like a f? So then you're thinking are the anti coagulation. You want to know what the baseline is? So see if you can see that from the notes or ask the nurse before you get there. Because if you're going to assess someone, say you go and assess someone that's just fallen say they've hit the head and they've got, you know, some disaster or the you know dysphasia. That might be a completely new finding to you because you've never met the patient before. But actually, if you look at the notes and if you see that, that's, you know, their baseline and you're less worried about it. Um, you know, try and understand who you're going to have an idea in your head about what the patient is going to be like before you get there, so you can then make that judgement about if that fall has changed anything, um, you can have a little look about If they've had any recent blood, they might have blood that day or the day before, and you can have it if they've had a chest X ray or CT head recently. And you can just have a little look at those just to give you an idea about what you might want to do and medications. So that's the key thing that I want to know before I go and see someone. And that is, are they on blood thinning medications? So warfarin does attacks, etcetera. I'm less worried about anti platelets, and I'm less worried about low molecular weight heparin, But the big thing is digoxin warfarin. Usually it's an older person that's fallen, and so it's a high possibility that they could be on one of those medications, in which case I have a lower threshold to investigate with imaging and things like that. But we'll get onto that. Oh, okay, so history. And you might have heard this before. History is 80% of the diagnosis, so it's really important to take a good history. Falls Histories for reviews can take a while because there's a lot of information that you should get out of patients or whoever has seen them fall. This is obviously just the way I do it. It's the way I was taught, and I think it comes. You know, I liked geriatrics, so it's often old people that fall. So this is the way that I take my history and separate it, and I think you tend to forget, um, questions less if you do it like this. So I break it up. So before they fell, so does the patient recall what happened before they fell? Can they tell you about what they were feeling like before? So can you remember what they doing? Do they have any amnesia, anything like that? Any preceding symptoms? So worrying proceeding symptoms would be things like dizziness, chest pain, anything like that. Did they have any blackouts or visual disturbance? Anything that might think that might lead you down. The path that actually may be may be something else has caused this fall rather than an imbalance. Um, feel free to jump in on the shot box. Um, with any other information that you think you might ask, I'll keep checking periodically. So the next thing is during the fall. And what I mean by that is, you know, as they fall as they hit the ground, come to rest on the floor. Um, what they remember. So these are the things that I'm interested in. Um, so did they have any loss of consciousness? Um, did they hit their head? Did they hit any part of their body? So the head is obviously the main thing, because that's the biggest worry when someone has a fallen hospital. Um, but the other things as well common things are common, you know, have the broken. Their hip is an older person. They're at risk of breaking their hip. Have they hit their shoulder or any other part of the body. So have you know when an older person falls, they have usually weaker bones, so they're more likely to break things. So I have a lower threshold to image them, especially if they've got pain over an area. And the other thing you want to know is, Is this neurological? So, you know, did they have any jerky limb movements? Did they have any abnormal movements during the full during their loss of consciousness? Was there any tongue biting or any incontinence? Because those kinds of things might lead you down a different path. Is this a seizure? Is this something not quite just a full. It's something else. Oh, sorry. And then after the fall. So how do they feel after the fall? Um so can they recall before the fall during the fall and after the fall? If they can recall of those things, I'm less worried. Um, if they struggle with that, then that's where that baseline information comes into play. So do they have a baseline of confusion and recall difficulties? Or is this new? Have they got amnesia after a head injury and fall? Um, do they have any nausea and vomiting particularly important again if they hit their head, Are there any pain anywhere? So, like I say, if they're complaining of pain in the shoulder and they've fallen on that side, you're going to have to x ray that, aren't you? Because they might have dislocated it or broken and something. You know, simple things are simple. If they've got pain somewhere, examine it. Uh, and you might need to image it. Uh, the other thing that I always check with the fall, um, slash any kind of head injury that, you see is this kind of classic things. You see, a medical school, any basal school fracture signs. So that's raccoon eyes, Any CSF for blood from the ears or nose. Um, things like that battle sign, which is bruising behind the ears, more into the neck. Um, and what I do what I tend to do is document that when I'm writing up my review in my examination, I will write, you know, no sign of any basal school fractures at the time of review, because if they do have basal school fracture, those signs can take time to develop. So it's important to say that when you review them, you either did or didn't see any signs because it's all about timing with falls. So, um, on examination. So is there any specific examination points or or anything like that that you would do in the fall? That might be different, too. When you review a different patient, How would you approach this? So I'll give you a clue. It's the same as any other patient that I would review. It's always an A B C D approach, and that's because it stops you from forgetting things. Um, exactly yeah, A B c D. And that's just the safest way to do it. That's how I examine most patients that I see on call because then I don't miss anything. So a is their airway patent? Is it their own? Are they struggling? Think that's really easy to assess? Be due? The house symptoms? Are they puffing away? Are they wheezy? Do they have any localized signs of infection like crackles at the base or anywhere else that might lead you to think is an infection causing this fall there might be a precipitant to the fall. Cardiac is always, obviously very important. When someone falls, all the heart sounds regular. Is there any murmurs? Could this have been syncope? How are their peripheral pulses and things like that? Uh, obviously is as arrhythmias potentially might be. The only thing you probably feel or hear and when you're assessing the pulses is irregular or regular, and that might lead you to do an EKG. So obviously it was full and especially if they hit their head. I think neurology is very important. So it's not something that I would do it whenever I collect someone, unless they've got an indication for a neurology example. Fall, I think is an indication for a neurology exam doesn't have to be very detailed. It just has to be quite pragmatic, you know? Have they got power in all four limbs? Have they got retained sensation? And they got cranial nerves intact, especially things like vision and hearing. Are they orientated? Do they know they're in hospital? Are they aware of you know who you are and what day it is? What is their GCS? So you know, I think one else has already gone over GCS and how to score it. It's also very easy to look up if you forget. And I often do look it up just to make sure that I've scored it. Right. But GCS is something specific to a head injury. Um, I know we use it all the time, but it actually is very specific to head injury. Um, so that's I definitely would use it if they hit their head and then e so everything else So abdomen is soft. Nontender Do they have abdominal pain? Have they call them because they're in pain with the abdomen? Uh, calves, you know, hips. I think they're very even. If someone says tells me they have not hit their hip or no pain in the hip, especially in an older person, I always examine their hips. So, you know, I press on their pelvis, do a straight leg raises. Can they move them? Do they have any tenderness in the groin? Because if someone's burning the hip, they normally have pain in their groin, not actually on their hip. Um, so yeah, and then obviously you would examine any other areas of injury, whether that's, you know, shoulder, elbow of money, um, and then G. And it's not quite the alphabet but get glucose. So if someone has fallen, you know, simple things are simple. Do they have a how they're having a hypo have their fault because they got low blood sugar and they're a bit woozy. So a BM is always important to do, and it's a really easy test, and the nurses will do it very quickly. And also, it's very easy to correct very quick. So does anybody know a system for categorizing investigations? What investigations would you do in someone that has fallen? Say, it's, um, an older person that's fallen Have they might have hit their head, but they're not on any anti coagulation. What what investigations might you do in a false review? I'll just give you a few minutes, okay? I'll keep checking back. So the way I break up investigations because I think it's in medicine is always It's always good to have a system like a B, C D. And in my my system for investigation. So I tend not to forget things and miss things is that I use, um, well, I first start with the bedside or any any easy investigations I can do at the bedside. I can tell me some information, so examples of a bedside test would be lying. Standing BP. I think. I think you know everybody that falls should have lying standing BP because it's something that's very common and easy to find out and easy to fix or mitigate. Another bedside example. The test is a mess. You or CS. You've got a catheter. Um, what I would say is, if in patients over 65 there's no point dipping their urine because it's going to be positive. And you shouldn't treat based off a positive urine dip in and over 65 so I would just send it for culture. Um, and if they've got clinical symptoms and signs of a UTI, then you would treat clinically not based on the dip and then another red side test that you can do and that is important for falls is an E C G. Are they having an arrhythmia that's causing them to fall? Um oh, are they having an ischemic event that's causing them to fall? So, um, their bedside, And then I would go on two bloods, um, bloods. It's difficult. So, you know, maybe not everyone that falls needs blood. But, you know, Are you worried about something else that may have caused me to fall? Did you hear signs or see signs were localized infection. When you're accessing them, do they feel generally unwell? Have you spoken to them? And they say, Oh, no, just something's not quite right, Doc is something that's often heard. Um, so is it worth doing some routine bloods to see? If maybe have they got an infection? That's quite knock them off their baseline and then I end with imaging. Imaging in falls is important, but sometimes not necessary. So, um, you know, like I said, I have a low threshold to x ray people, especially if they were complaining of localized pain and then ct head. That's the big question. I think that that's just something that I not that I had to get my head around when I first started doing falls. Reviews do a CT head, Everyone. What are the indications for a CT head? It's quite stressful. You think? What if I miss something but actually there are very clear guidelines for CT Head, which are useful and which I use all the time. So like I said, That's That's the main question. When someone falls and it's the head, are you going to see ti their head or you're not? So you have to bear in mind that CT is is quite a lot of radiation. Um, so that is something important to understand. Um so actually, nice guidance have really good guidelines for people that presents with head injury. Obviously, it's in the emergency department, but it's fine. It's still. I still use the guidelines because it's still an acute fall with the head injury. So this is what I tend to do. So that's why I'm assessing. GCS is so important when you examine someone because obviously, if they've got an initial GCS, which is less than 13, and that's new post fall, Um, that's, you know, indication for a CT within one hour, Um, and then that's why it's important to continuously reassess DCs in someone that's hit their head because obviously, if it drops, then that could be an indication for another CT head. Um, as then we go to basal school fractures. That's why it's important to look at, because if you do see signs of it, then you should see ti them, Um, have they had a seizure? Whether I think whether before or after, you know, if it's a new seizure or if they hit their head and then they've had a seizure, then that's the CT, isn't it? But basically, I just follow the guidelines. I won't read them out completely because it's very easy to get a hold of. And it it says that there on the side. So, um, so there there are indications for a CT had within one hour, which obviously is is very quick. Um, so but you might be able to get a CT head within eight hours for other reasons. So there we go. The next question. Are they currently on Anticoagulation treatment? And that's the key, I think, for for you to take home from this session about CT heads. So, yes, they are an anti coagulation treatment, so everybody that falls and hit their head if they're on anticoagulation treatment, so that counts as dopamax and warfarin. They would need a CT scan. Obviously it's within eight hours, and normally on call you would get it done quite quickly because it's pretty standard because obviously the risk is so much higher. I tend not to worry about anti platelets and then like heparin, but obviously that's in the context of the clinical picture. So you have to make your own judgment about that. Um, and if they're not on treatment, then the next thing to worry about is loss of consciousness and amnesia. Um, and then obviously there's. There's some other risk factors. Um, so are they older? That's automatically a high risk factor. Do they have a dangerous mechanism of injury? So obviously, when you're on the ward and it maybe it's someone that's walking along with eczema frame and they lose balance and fall, I fall from standing height, not in someone that's younger might not be a dangerous mechanism of injury, but for someone that's quite frail, if they've fallen from standing height, but they've hit their head quite hard, that could be a dangerous mechanism. So you just have to take it into context about how do they call What did they hit the head head on? You know, is there any outside injury and you can see and you kind of have to judge from that? And as we've said previously, you can always ask you some questions and I encourage you to because you don't have to know all the answers and nobody expects you to. So this is just to give you a little bit of confidence when you do go to see them initially. Um, but yeah, And so it's important to have a look at that guidance in your own time. But the next thing I would do is if you're not going to ct the head or if you're waiting for a CT head. One thing that I always do if someone's hit their head and they fall and then they're in the hospital is neuro jobs. So this is also from the nice guidance. So it's about observation. So don't forget that, actually a medicine, quite a lot of what we do is is observing the patient, and that's okay because you are allowed to observe the patient and see if anything changes. Um, so this is what I do, and I just go straight off the guidance and I write the guidance in the notes. So say, for example, I got an 80 year old gentleman. He's fallen. He has in his head, but he's all right. He doesn't have any neurology. He's not on any anti coagulation. He's just on aspirin. Um, you know, he feels very well on himself, and he just happens to have hit his head. And he doesn't have any nausea or vomiting or anything like that and can have complete recall. Um, so that is someone that I would put on your arms for 24 hours. Um, so and then it goes through exactly how to do it. Um, so half hour early for two hours and then hourly for four and then two hour leave thereafter. And I usually say for 24 hours if another doctor comes along in the warning and says no need for your abs, that's fine with me. You know, I think 24 hours is in the guidance, and that's what I use. So and that's just handy to have in your in your arsenal supporting your plans, because if there was any drop in the GCS, then you would be re alerted. The nurses would call you up again, and then you can continuously reassess do the new CT head now because maybe they didn't need one before. And so that's just observation is important, and I think that's always good. So what is my usual plan look like when I've been to see someone that's had a fall? Well, it can vary, but mostly everybody that I see that has a fall. I normally do a lying standing BP because, you know, postural hypertension is like I say, very common. It's easy to identify, and it's relatively easy to treat or mitigate. Um, so I tend to always ask for a longstanding BP if they fall, and then it's just easier to do that and you can see it. And so it's not difficult to do so. You might not need it that day. That said, it's the middle of the night. You can, you know, it doesn't have to happen right then and there. It can happen the next day, so long as someone's checking it. Um, do I do blood? Like I say, I tend to do bloods. If if the patient themselves feels generally unwell, um or, you know, I can assess signs of a of a focus of infection, or I might have a suspicion that maybe they, you know, they could have to say they've got high output stone. Maybe they've got an electrolyte disturbance, that kind of thing. Then I would do blood, but I would I would have to have an indication to do blood for myself. Um, X rays. Like I said, low threshold. If you've got any injury, any pain anywhere, just x ray, it's that easy to do. It doesn't mean you have to interpret it yourself. They'll, they should usually get reported. It might be in a couple of days, but you can have a good look at it yourself. And that's why. And also it's important to keep looking at things. You can always ask you to look at it with you, but like I said, you know, you don't want someone to fracture their hip and and not know about it for a couple of days. So just X ray it neuro jobs. Like I said, if they've got a head injury, I'll always put them on your own labs. Um, because I just think that's the safest thing to do. An on call. It's about being safe and then see, see, had we've gone through the guidance and I would I just follow the guidance. And if there's any, if you're ever wondering, you know I shall, I shall. I shall not just ask you, seeing you, they'll be easily and you know, they'll easily answer that question. And then the last thing, um, is so so do they need to be an attack today? So I don't know if you know much about how what tag debate is, but in in the NHS, we use tagged base as so that that's a bay that has people in it, that high risk of falls or high risk of, um, you know, dangerous behaviors, I guess. Um, so that means that a member of staff has to be in that day at all times watching the patient's not doing something else. You have to be watching the patients at all times, and that's because then they can, you know, say a patient stands up and they're falls risk that member of stuff can go over and ask them to sit down or help them up and things like that, it's meant to reduce the risk of falls. So say, you know, say someone calls. I've been to review someone that's fallen twice in one day and they're obviously a falls risk. So I tend to say in my plan, they need to be in a tag debate or they need to be watched by someone because otherwise they would continue to fall if nobody's watching them. So, um, it might be a staffing issue for the nursing staff, but if that's your recommendation, that's your recommendation. So, um, I do tend to say that if they've had multiple falls, although I think there are high falls risk, I'll ask for them to be an attack today. So I hope that's covered. Falls. Um, and obviously, if you've got any questions about falls at the minute you feel free to put them in the chat box, I'll give you a few minutes because then I'll move on to the next scenario, which won't necessarily be about falls. Um, so I think the key things take away as a B c D low threshold to x ray. Use the guidance for head injuries and, um, yeah, simple things with them. Simple, you know, Have they slipped? Have they not got the right slippers on or have they got they? Have they not got the anti slip socks on things like that. Okay, Okay. So that one's got any questions. You can ask questions at the end as well. But if you've got any, nobody's got any questions at the minute I'll move on. So the next scenario. Hey, doc, I've got a lady in agony. Can she have any more pain relief? So this is a really common bleep. That answer, and you will get asked a lot. So I think initially, on the surface, it seems like a very simple one to answer. Um, and it's probably is it something that you need to be there for face to face? Or is it something that you can do remotely? Um, So again, as with anything you've been called what you want to know immediately after the phone over the phone, you wanna put in the chat box? What kind of things do you want to know over the world about someone that's in pain? Okay, so I want to know again. Why are they in hospital? Do they have a reason to be in pain? So, you know. Is this acute? There we go. Okay. Great. So I'm just saying some of your comments now. Yeah, So why are they on pain? Relief? What have they already been given? Last time they had any pain relief? Yeah, really good. So what have you tried so far? What so far again? And like I said before, what you know, Are they scoring high? You know, do they have a tachycardia? Have they got another reason why they might be in pain? So, you know, just yeah, they generally unwell. Um, so it's always important, I think, to have jobs. And what is that? Access. So that's important because, you know, they're obviously several different routes of pain relief. So do they have IV access or are we limited? So again, do your research. So I think this will impact you. Um, this will influence you as to whether you remotely prescribe or you go and review the patient yourself. So the biggest factor for me when I when I'm called about pain, Is it acute pain or is it a chronic pain? Is it something that the patient's been struggling with for a number of days? Or is it something that's just knew this evening or just new tonight? If it's new tonight, obviously this is up to you. And if anything, I would always encourage to review patients if you're gonna prescribe things for them. But also, I understand that this is quite a pragmatic presentation. So on calls are busy, nights are busy. If you can prioritize things, then that's the best way to do it. So the way I prioritize things is in terms of pain relief. Is it an acute pain that is new this evening or new today? And therefore I will go and review that pain because that's a new pain. They might not be an explanation for that. Is it a chronic pain? If it's chronic pain, they're already on quite a bit of pain relief. They're just struggling. It's like an acute exacerbation. And then, you know, the labs are okay and the nurse says, you know, actually, I think they're all right. You know, they just were not quite on top of their pain yet because it can take a few days to titrate pain relief. Um, then that's different. I think I would be more likely to re prescribe remotely, but there are risks when doing that. It's just up to you. But, um so acute versus chronic is going to influence me. What's the past medical history? So, you know, Are they a patient that perhaps got metastatic cancer? And he's on a whole load of pain relief? Or are they someone that's actually generally fit and well doesn't normally suffer with pain, And that might lead me to, um, influence whether I go up or not. So the things that are important to always consider with pain is Is it reversible? So, like I said, Is this a new pain today? If this is a brand new pain today, can we do anything to immediately reverse that pain? Because obviously I liked geriatrics, and I just finished four months on geriatrics. So I always think about old people. And I think that actually, if you're working in a chair, actually work in any kind of health care, the majority of your patients, whether you're on geriatrics or whether you're in, you know, cardio, gastro surgery, whatever. They're going to be old people. And that's why I focus on So the most common cause is, I think, for paying acute pain. On call is things like that can be reversed is like constipation and urinary retention So I've literally had this today on on my award. Um, there was a lady she's been struggling with a couple of the past two days with new pain. It's not normal for her. She she was completely out of character for her. And, um so we did a few investigations. We are not open the bowels in a couple of days. So we gave her a suppository yesterday, and then she opened her bowels and things seemed to ease off. So we thought, Okay, maybe it's that. And then today it was way off the charts again. Her pain. She was crying. She was really, really in a lot of pain. And we well, she had open the bowel, so it can't be the bowels. So we did a bladder scan, very easy investigation, and one that I have again a low threshold to do. Even if someone is catheterized do a bladder scan. And this lady had 500 miles in the bladder. So she was in retention. So that can be so painful. So then that's an easy fix. So you catheterize the patient, and then it's immediate pain relief, and you don't have to actually give any pharmacological pain relief? Um, so, yeah, this lady had 500 miles in the bladder, and then as it was draining, it was Frank Hematuria. So she was definitely in clot retention, and we ended up putting a three way catheter in starting irrigation. And actually, she's so much better now that we have irrigated the bladder and get rid of those clots. We didn't actually have to give any extra pain relief that she would, you know, because we we basically reversed the cause of the pain. And and that's what you always want to do If you can reverse the cause, that's better than just yeah, mitigating it with medication. So I always think, Are they in retention? Ah, they constipated. They're very common causes for pain. Um, and then obviously, I'm not going to go into the medication too much because you have learned this in medical school. But, um, again, I'm one for guidance. And, um, you can't go wrong with the who pain ladder, so they have pain. So, you know, try a non opioid. So that's normally a paracetamol. Anything I would say is just a quick message about paracetamol is that it's important the party tomorrow, obviously a really common drug, and it is a safe drug. Um, but there are things to consider when you're prescribing party tomorrow. And that's, you know, is this someone is important? I think when you prescribe any medication for someone, do they have an up to date weight? You know, people are extremes of body weight will be riskier to prescribe for. Um, so if you're one end of the weight scale and you're overweight if some If a patient is massively overweight, then you know the pain relief that you're prescribing actually might not be enough. Um, but equally if you are prescribing for someone of extreme low body weight. So, you know, we're thinking less than 50 kg. You need to think about you're dozing. So especially even with party tomorrow. Yeah. Thanks, Jilani. Um, so if someone weighs 50 kg or less, you could consider reducing the oral. Um, this is just this is just our trust guidance. Obviously, you just go off your own trust. Guidance? Um, but we would normally consider reducing the oral paracetamol to 500 mg and anyone less than 50 kg for IV dose. Um, is always reduced. That's national guidance that's in the TNF. So if you're 50 kg or less, your max dose for IV paracetamol four hours or six hourly is 15 mg times your weight. So, um, that's per dose. So, um yeah, so it's just something to bear in mind, especially if you're going to remote prescribe at extremes of body weight. And don't just automatically think that because part of you tomorrow is a simple common drug, it's a safe drug because it obviously can be harmful if we use too much of it. So just something to bear in mind. But it would be my go to first one. Um, And then, you know, you can use things like NSAID, but they have their own risks. We tend to avoid them in hospital because, obviously, um, um that, you know, risk of bleeding and things like that and also acute kidney injury, because the people in the hospital they risk of acute kidney injury anyway. So if you're going to give them and said it's just increasing that risk, so we tend to avoid it, Um, the only times when I actually I think that I have prescribed and said. And they're very effective is in patients that have. When I was doing a surgical job and it was renal colic, um, sounded like renal colic. Um, and I tend to only use it in in sort of young, younger patients whose kidney functions are okay. But PR Diclofenic suppositories really, really good pain relief for renal colic or renal type of pain. So and I tend to just use them as starts not regularly, Um, if you know, if they were really struggling with pain. But that's something to consider. But it is a patient by patient, um, basis. So it's just whether you know, your patients and, um, things like that. So and obviously, if they still got pain at simple analgesics with policy tomorrow or ibuprofen, then you would maybe opt for an increase. So a mild opioid. So what we would normally do is codeine. So, um, we were in our choice. We tend not to prescribe cocoa them all just because it's it's more difficult to titrate pain. It's much easier to titrate if things are separate so they can have regular party tomorrow and prn codeine that would be able to go to And then when I can see how much codeine they're using, PRN then if they're using it quite often, I can switch parties more to switch codeine to regular. So you have regular parties, more regular codeine, and they could also have more codeine, p r n. So I tend to prescribe it for 30 mg again in elderly patients, I tend to be safe and go for the lowest dose first. So I tend to prescribe 30 mg of codeine. Um and then obviously it depends on how much they use. Um, if they've still got pain after that, then you can think about opiates. So obviously the go to opiate is morphine. But I'd be mindful if someone's renal function isn't great. If they've got renal impairment, I tend to go for oxycodone. Um, so either oxycodone, morphine or UM or or liquid oxycodone, and I tend to use that prn first and again. If they're older, you just start with the lowest dose. Just it's just safer to start with the lowest dose, see how much they're needing, and then you can always titrate it up, and you can always give more stats. I think your cough is a good drug. It's like two hours. You can use it, so obviously, based on their tolerance of it. But you get more confident with prescribing things like opiates as you go through F one. So you will get there. And then if someone is obviously requiring, like, four p r N s of morphine a day, then you can consider, um, switching the PRN to an immediate release to modified release and making that regular. So, um uh, yeah, So you would start with that, um And then because then you have a more If you start. If you do the modified release, then you have a gradual, um, control of pain. And you can always have prn's on as well. Um, so I guess the tips with analgesia is no your patient. Think about extremes of body weight. Think about simple analgesics, thinking about things like renal impairment and hepatic impairment. Um, and I think the key to it, especially in older people, is to titrate pain relief. And it might not be something that happens overnight. You might not be able to do it in one war ground, but it's something that is much safer to do if you titrate it. Okay, So has anyone done any questions about pain or analgesia? Because I've had quite a few different things there. So if you've got any questions, you just pop them in the chat. July. Thanks, Johnny. We put some more information on the chat as well. Okay, so if there's no questions, I'll move on. So the next scenario. So Hey, doc, I've got one that's very confused, and he's shouting out. He doesn't know where he is. Um, so again, if you want to put in the chart box if you get this call, say you're on call or say it's at night, what would you want to know over the phone? Um, any information that you would ask the person calling you? You can stop it in the chat. I'll just give you a few minutes, Okay? Yeah. Brilliant. So I guess that's the key question, isn't it? Is this new? Yeah, exactly. Is this new? So Yeah, great jobs. That's my favorite. I definitely would ask the obs as well. So is this a new confusion? So are they known to be confused? Have they previously been confused? Or is this brand new. It's brand new. Well, either way, you're going to have to go and see this man because he's confused. He shouting now he doesn't know where he is, and the nurse wants you to review him. So is this new? Does the patient have a doll? So, um, if for those of you who don't know why dolls is it, it stands for deprivation of liberties. Um so basically, that's a piece of paper work legal document which nurses can put in if a patient is deemed not to have capacity, then they can put the dolls in place. And that means that as it says they can, you can deprive some one of their liberties. So that would be, you know, calling security. You could restrain a patient if they're at risk of hurting themselves or others. And you could potentially use sedation against against their will. They will basically, um, So I think that's an important question to ask, because also to you, if they already have a doll's, then, um, you still have to go and assess whether they've got capacity or not. But it suggests that at one point they didn't have capacity, so they may have been confused previously, and if they don't have the dolls, then that's important to know as well because you're obviously going to go up and assess this person. Um, it's important to assess your lung capacity when they're confused, especially if you think you may have to escalate. Uh, things. Um, if they don't have dolls and you don't think they've got capacity, then they may have to put the dolls in. So what else would you want to know? So, yeah, so I guess I just asked for a basic, you know, example example of what's happening So you know, are they are they sat in bed and they're chatting out because they want attention Or they need the toilet or something like that or they may be confused. But they're you know, they're still quite happily in bed, and they're not really at risk of anyone. Or are they pacing up and down the ward going into other people's rooms and be's? Are they threatening people? Are they being violent? Things like that obviously, is going to affect the way that you think about things. Have they ever been violent? That's just the nurse will probably tell you if that's been, you know, Are they known to have episodes like this? And obviously you need to be wary and and as staff, we all need to look after each other. We have to also need to look after the patient, so we want to know about risk. It's it's important to know about risk. So I guess what I'm getting at here is delirium. So it's really common for patients in hospital to have delirium be delirious. Um, and so delirium is is defined as this is defined. A nice guidance. Um, you might have been heard of it called Acute Confusional State. It's a common clinical syndrome characterized by a disturbed consciousness, cognitive function, or perception, which has an acute onset and fluctuating course. And that's what's key to delirium is. It's an acute change. It's an acute confusion. It's not just some of the dementia, um, and it fluctuates. Very fluctuate in nature, and it can take days. It can take weeks to months to resolve completely, so they might be fine when it's either on ward around in the morning and be very with it and coherent and then by five o'clock or seven o'clock when they sundown, they can be completely, um, off the wall, not know where they are being arrested themselves or others. So it's important to understand that delirium is different to chronic chronic things like dementia. Um, it has risk factors which are important to consider. Um, so yeah, So again, older people are more at risk of developing delirium. Pre existing cognitive impairment puts you at a greater risk of developing a delirium. So if someone comes in with who already has a past medical history of dementia, they're much more at risk of being delirious. Um, and you would need to know what your baseline was in order to understand whether this was just their baseline or this is actually an acute change, and they're more, more, much more confused than normal, and therefore they would be delirious. Um, having a hip fracture puts you at risk of delirium and obviously any kind of severe illness. Whether it's a cap or UTI or or anything like that, you can be delirious with it. Um, so I guess the thing to take away from delirium is that actually, it's mostly multifactorial. Um, it could be age, illness, pre existing cognitive impairment and also just a change in environment. So they've come into the hospital. They don't know where they are. They have no idea what's going on. It's all new faces, and then that just makes them much more confused. So these are the first things, and these are the things that are going to prevent someone from becoming delirious and actually can reduce the episodes of delirium if someone already has one. So, um, it's basically things like adequate lighting. Can they see a clock? Can they see a calendar? Do they know what time of day it is? Um, you know, having the lights off at night and making you making sure that they are in a good sleep cycle. Reorientation techniques are very important, too. So there are things like reminding a patient that they're safe. They're in hospital. Which hospital there in remind them who they are, remind them who you are. Remind them that you know they're in hospital because they've got pneumonia. I got bad chest. They need to be on antibiotics and things like that. It's just talking to them and reminding them that this is what's happening and that It's not a scary thing that's going on. Um, the other thing that's very helpful for delirium is regular visits from family and friends. Obviously, that's that's difficult if there's coded on the ward and things like that modified, visiting. But, um, it is really helpful for people, and they often brighten up, and they are much better when they know who is around them. Also things like regular stuff. So having the same staph in that day is also quite important because, obviously, then that's some continuity as well. Obviously, as we said, it can be multifactorial, but well, there might be underlying causes that contribute to delirium. And if they are reversible, it's very important to treat them again, often with older people. Common things are common. So are you constipated? Have the open the bowels. Constipation can make them really confused, and I've seen it on my own ward. So is there about other bowels regular? Do they need any help with that? Equally common things are common. Are they in retention? Um, constipation can cause retention so the two can come hand in hand. Glad to scan them. It's an easy test, and it gives you a clear answer. Um, are they in pain? Pain can make you delirious. Do they have adequate pain relief? Um, they might not tell you. They're in pain if they've got dementia, and they don't realize they've got pain, But having a good examination of someone can you know, if you press on your tummy and there screaming in pain, then you can assume that they're in pain. So for people like that, using regular regular pain relief so they don't have to ask for it because they will forget to ask for it is important. Um, is there online infection? Have they developed a new infection, or is this a sort of resolving infection? Um, infection is just the key one to think about. And obviously, you kind of have to go off the patient and go off the blood and things like that. Um, medications can cause delirium. So are they on strong pain relief? And actually, they require it. Are they taking, um, benzodiazepines? People can come in in the hospital on all sorts of stuff that might be taking sleeping tablets at home, Things like that. These can all contribute to delirium, especially anticholinergics as well So you just have to do a good review of the medication. Can they cope without some of it? Can you suspend some of it? See if they improve, see if they still need it. If they don't, then just, you know, obviously, you would do this with your consultant in your edge. But it's important to look at medication because it's often causes for things and also, you know, are the hypoxic basic things. That's why you want to know OBS Hypoxia can cause profound delirium, and so can you know equally the other way. If you over oxygenate someone, they can become quite drowsy and you know they Are you switching off the hypoxic driver? They actually see you have two retainer. So you know, delirium is a lot of multi factors, but also it's important to do medicine as well as in it. And if they're hypoxic, they need to investigate that. And also do they have an impairment of the vision or hearing? Are they just confused because they don't know where they are? Because you can't see and they can't hear. So make sure that people have got working, hearing aids and their own glasses things can get lost in hospital. So we just need to make sure that we are giving people the correct hearing aids and glasses. Okay, so that's why I just touch briefly on sedation in the other day because I think that was actually covered it already. But it's something to it's always the last resort because it's not nice to have to sedate someone and actually really risky. Um, so the only way the only time when I would prescribe sedation is if I thought that someone was at risk to themselves, you know? Are they jumping up and down the ward? They look like they're going to fall. They look like they're going to hurt themselves. Are they going to fall out of bed? Are they going to, you know, or are There are risks. The others are there are risks of the patients. Are they risk to staff? You have to look after your own staff. And, um, you know, if they if you hear if they if you if they hit out of staff already, um, you know, and caused injury, then that's really something to bear in mind. And actually, you know we can't be having that. Have you tried the escalation techniques already? That's what you need to try first. So, um, it's also important to remember that you've got hospital security and in situations like this, and I think it's important, actually, as doctors not to get involved in the sort of restraining of patients because, you know, you actually need to be able to prescribe the medication, and if needed, you would also be trained to give it. So, um, that's why we're actually not trained in restraints restraints, so I wouldn't get involved in that. That's why you need hospital security and things like that. So if they are a risk themselves and others, then you can think about prescribing. So what are you going to prescribe? So your hospital trust will will usually have guidance for, um, sedation in the elderly. Um, so we have a guidance as well Aintree and I think what they use actually first line is haloperidol. Um, but for some reason, the guidance is higher at all. But for some reason, most people use lorazepam, which is actually second line. But the the same doses. Obviously, just check your guide your guidelines and check the VNS before you would prescribe something. But I personally, if I'm going to prescribe sedation, I tend to prescribe the lowest dose first because you don't want to knock people out because you have to bear in mind that whenever you prescribe anything sedating, it can actually deliver them worse. And, um, it definitely falls risk. So consult your own guidance in your own trust. And also, you know, if if you're not sure about it, um, then ask your senior it's okay to actually see if you've never prescribed sedation before and not really comfortable doing it. Or you just want to check that Actually, your thought thought processes and your assessment is correct, Then it's okay to escalate to a senior and just ask if this is quite, you know, Is this the right thing to do and things like that? Um, okay, so has anyone got pins in delirium or sedation or anything like that again, I'll give you a couple of minutes. Okay, so I'll move on then. So this this is just going to be There's only a couple more minutes and it's going to be very quick. Look at the C GS, and it's Like I said at the beginning, it's going to be quite pragmatic, so I'm not going to go into a niche BCGs. And I'm not going to go into, um, the full guidance of how to manage arrhythmias and things like that. But what I am going to talk about is common things that you might see and times when you should escalate that to a senior. Because often, if you're worried, if I'm worried about a BCG, even if I just think that just looks a bit odd, I've got low threshold to check with a senior, and then they can check it and and things like that. So it's just a brief overview, basically. So yeah. So Hey, Doc, I've done an EKG on my patient. Please, can you check it? This is actually a really common thing that I get bleeped for, um, which I find sometimes frustrating because I haven't asked for the C G. But they've done one. And now if someone has to check it and that someone is me, um, so but they're usually done it for, you know, a decent reason. So, um so again, you've been bleeding about it, you know, What do you want to know? Over the phone. So obviously it's a bit different because you can't see the EKG. But they just told you that they've got a patient and they done an EKG on it on them. So what kind of things would you want to know over the phone about, perhaps, why they've done the BCG If you want to. Just use the chatter box. Yeah. Okay. Okay. So what do I want to know? So why why have they done the BCG? Yeah, exactly. Yeah. What other robs are they say? Well, are they unstable? Exactly. Do they have chest pain? That's the big question, isn't it? So, um, I want to know why do they do the EKG? When did they do the EKG? Was this from hours ago? If it's from hours ago, it's It's probably useless. And you'll need a new one. Um, uh, is there any history of chest pain? Correct. So, um, that's the big one, isn't it? If they've got chest pain, that kind of makes things a bit different. And then so what's the what's? What's the first thing that you would do if when you're faced with BCG. So what? What would you do in the first instance? So you're giving an EKG? What do you look at? Yeah, absolutely. Yeah. So make sure it's for the correct patient. Are you looking at the correct patient's E c g? And are you looking at today's BCG And is it the most recent E c g. And then what? I would always say And this actually is just a general rule of thumb for any kind of investigation like Joshua talking about earlier the trend basically, you know, compare it to the previous I would always compared to a previous. Even if you're comparing to the previous from from 1997 it's still a previous. If that's the only one they've ever had were actually compared to. I think it was yesterday on the ward. We're looking at a BCG, and the only see the patient had before was one from 1982. So it was different, but so So we still compared to it because that was the other one that they had. So I would always say that. So check the patient details is correct. Is it the right one from today and is it the most recent one. And can you compare it to the previous? So I would do that for chest X rays and any kind of extra any kind of imaging and investigation. I would do that as well. Okay, so the nurse tells you over the phone, they were a bit tacky. That's what I've done in the C. G. So they were going about They were going at a rate of 105 or 120. So I did the C G. Can you look at it? So let's have a look. So mark it be where would you look? So this is the e c G. That you get handed for someone that's a bit tacky. So does anyone wanna take a stab at what this rhythm shows? Don't worry. If you don't know, it's just guess is it doesn't matter. Just want to know if you want. If you wanna put in. Okay, so this this is a science, So that's really common. You know, there's lots of reasons why someone could be in Sinus tacky. You know, it's Sinus because they've got P waves before every QRS complex, every QRS complex is regular and they've got T waves. And then there's, you know, there's no other kind of, you know, So like I said So reasons for Sinus Tacky Is the patient in pain? That's a really common cause for Sinus tacky. It's pain related. Um, you might need to go down the rabbit hole Or is it a pea if someone maybe drops the sat's or has a chest pain or anything like that? But in this instance, they were just a little bit tacky. So I guess in the absence of a good reason why, um, then you just know that it sounds like if it's obviously depends on the rate going. If someone's running like 106 and it's a Sinus tacky and they the other labs are fine and they're just in a bit of pain, then I wouldn't be too worried about it. I just monitor it and prescribed them. Say, Well, obviously you can always check with a senior. Um, so the next BCG is this. Does anybody want to take a stab at what this is in the context of attacking as well? Oh, Okay. So this one, this one's just a F So you know it's a F because the QRS complex is are irregular and they are irregularly irregular, so there's no clear pattern to them and they're not predictable. There is also an absence of P waves. So if someone has and irregularly yeah, great. Yeah, if someone has an irregularly irregular heart rate, oh, trace but has P waves, that's not a F. That's a Sinus arrhythmia, which is just obviously slightly different. So the key thing with with a F is an absence of P waves unless a SED has an absence of P waves. So obviously, with a f you can be rate controlled, so you might just see a F and they have a rate of 80 or 70. And that's fine. Um, but what you might see is this. So, um, has anybody you know? Well, it's a f. I'll give you that, um, might also be known as fast a F. But actually, it's, uh, some people might get bothered if you say fast A f. It's a f with rapid ventricular response. So, um, it's also got, uh, the here just that big. I don't if you can see my mouth, but that big, strange looking QRS complex. It's just a ventricular ectopic, so you have to worry about that too much. But you can tell there's no P waves. It's really fast, irregularly irregular. So that is a F with a rapid, rapid ventricular response. So you know if they're running, too, that it's probably, you know, that's probably like, 140 or something. Um, if they're running at that rate and they've got it in a F, then then you would just either speak to a senior or look at the guidance. But normally, what I would do in the first instance, If the BP is okay and it's stable, it's not too low. So I think the cardiologist say, If it's over 100 and 10 systolic, um, then I'll give you a small dose of metoprolol. You obviously look at what they already had in the day because the max dose of by stop in one day is 10 mg, so you can start off someone with, like, 2.5 mg of by stop. And but be aware that you know that's going to take like, an hour to kick in, and maybe an hour and a half. So it's okay to monitor someone like I said before, It's okay to observe. So if you initiate treatment and observe and see if it's coming down, if it's not coming down, then you have to reassess. You could give a further stop by stop, or you could give you something like the Digoxin. But when you get into things like that, and if it's not, come down with the first thing that you've given. I have a low threshold to ask my senior and just ask their advice, especially, you know, you have to take it into context with someone's previous, you know, past medical history. So, um, the basics are you can identify that someone is in a half with rapid ventricular response, and you might consider a beta blocker. Um, yeah, yes. So that's a half with rapid ventricular response. You might see it written like that. So the other chest pain to the chest pain The other GI you might see, is a nurse that's done an EKG on a patient because they've got chest pain. So I'm only going to look at the important things to look for, and that is a schematic changes in someone with the chest pain. Um, so I have a low threshold for doing drops on people with chest pain. If it sounds cardiac, and I haven't even lower threshold if someone has any kind of chest pain with new EKG changes that appear ischemic, um, so first kind of change or ischemic change in this one, Does anybody want to put in the chat? What kind of change? This this shows, or what can you see on the CCG that might indicated scheme? Yeah. So this is t wave inversion, so you can see it in, uh, B one B two V three and the four. There is also a little bit of the five, um, so T wave inversion is a sign of ischemia. Um, yeah, exactly. Yeah, t wave inversion. So, um, if someone had new or evolving t wave inversion, um, worsening t wave inversion and with the context of chest pain, then it's probably there might be an ischemic event going on. So you take Trump's, um and obviously, if you see ischemic changes on the BCG, I just tell my senior, um, just to make them aware that you might have someone having a cardiac event. Um, so this is the next CCGs, and we want to put in the chart. What? The changes they can see on that. It's not the best CCG. There's some arrows there that might help you. So this is ST Depression. So, um, again, that's an ischemic change. Um, it could be old if it was previously C G. But if it's new, then obviously that's an ischemic change. So you what you want to look at is the baseline. Um, so you know where the traces and is that s t segment below the baseline of where the line of where the baseline is. If it is, then it is ST Depression. And so you'd be worried. It's an even worse ET de Sorry, but this is the last one that I'm looking at. So someone's got central crushing chest pain radiates to the left arm. Uh, clammy, sweaty. They feel nauseous. Um, you know, there are a 60 year old male that has hypertension and smokes. What changes can you see in this EKG? Okay, so this is ST Elevation. So you'd be really worried if you saw ST Elevation on the ward. Um, I immediately call my senior and say, You know, I think someone's got ST I can see ST Elevation in the CCG. They've got chest pain. So that's the stemi, isn't it? So I'd always consult my senior with the CGM, especially chest pain, especially if you think you can see changes. Um, I'm not going to go into the management of stem Stem is, but it's important to do the basics. So drops and things like that. And if you're worried about it and you think that it is a stimulant and stemi, I asked my senior before I started. This is what I do. I had asked my senior before I started to high dose aspirin, so just double check, but yeah, so I hope that's like a refresher of some of the EKGs. Um, just another tip that I would say for the CGs Um, sorry, which is another type I would say about EKGs if it looks like completely different to the previous CCG, and it's grossly abnormal and it doesn't quite fit like you have no idea what it is, and it doesn't quite fit with the clinical picture. It's worth repeating an e c g. And making sure that whoever did the EKG has actually got the leads on the correct way because I've looked at a few EKGs on call and been extremely worried about them and just not known what they were. And it was completely abnormal. And it's because the leads were on the wrong way around. So it's always important. Like blood tests, like anything like in medicine to repeat things if you're if you're just not sure that they're quite right, because it could be error. So I have a low threshold to repeat CCGs as well. Um okay, so that's my end of my talk. Um, we covered falls, allergies or delirium and a little bit on the cogs. Um, So if you have any questions, please either speak up or put them in the trap box. Um, or I'm sure Gilenya Josh can pass on my email. Um, but yeah, I hope that was okay. And I hope that covered some things for you. Thank you. Very, very, very much. Ph is very thorough. Very, uh, I think you covered a wide base of things. Yourself and Josh think you give a lot of really good advice to, uh, new doctor started. And the NHS whether it be f one F two s h o level register A. We apologize for the bit of delay today. I think we just were keen to cover thoroughly give you a bit more solid foundation to start at, uh, and there was a lot of information to actually, uh, go through. I hope you all enjoy this session. Understood everything. Um, there will be some catch up, which you can request. You can revisit the sessions at a later date. Um, unfortunately, they released on a delayed schedule, which is why we encourage you to attend the sessions live. Um, upcoming in the series. We have a few more sessions. Uh, next week, there are two radiology sessions as part of your training. Um, as part of your everyday work on awards and on call, you frequently have to look at, uh, chest X rays, abdominal X rays. You have to request them as well. Sometimes you may require some interpretation because they aren't all reported urgently. You may see some CT scans as well. Uh, occasionally. So the sessions next week, uh, will be on the second and, uh, 2nd and 4th of August. Sorry. I think those are typos. Radiology is with you in a 2nd and 4th of August. Um, And essentially, what, uh, will be delivered at those sessions will be understanding of how to interpret these different imaging modalities and how to interpret, uh, essentially the reports that come with them. And I think we're also going to cover how to effectively request because sometimes you may request these scans and get rejected by the radio. Just the session will be delivered by, uh, essentially, it's over. Seen by our radiology, uh, colleague who is the founder of W PMN. Her name is Jade. Um, and she is very, very qualified. Very experienced radiology registrar working in Oxford greenery, um, with very different background. And she will be sharing her expertise with us. And she would also have some of, uh, colleagues. Um, that will deliver some of the sessions as well. So we definitely encourage you to attend those two sessions next week on the second of August and the fourth of August Radiology one and two. To help give you a better foundation to prepare you for the ward's, uh, when it comes to radiology, and then the following week, we have a session on the 10th of August, Uh, which will be, uh, session on the portfolio. Um, uh, we're aiming to deliver one session that covers both auras and tourists. The portfolio for, uh, foundation years in, uh, UK and Scotland. This is quite important because it's what determines your progression from F one to F two and on completion of F two. So we do encourage you to join that session as well. Um, so you can have all the keys to having an effective portfolio. We've sent a link in the chat. Um, I'm going to send it again. The request that you fill out the feedback form. It helps us improve our sessions. It also gives you a certificate at the end of it all, um, which you can put into your portfolio and continue to improve your learning. Thank you for joining us. And we look forward to seeing you next week. Tuesday at already All do one session