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just checking homes that. Can you hear me? Yeah, I can hear you. Perfect. Try to shoot the introduction. Alba. Yeah. How did everyone? People enjoying the weather. Welcome to our fourth month of people have been on. And I want survival Guide 10 part series. Today's talk breaks down discharge. That is especially referrals. And it's going to be delivered by my colleague Doctor. Hands and feet are his nephew. I want soon to be, uh, 42 in the West Midlands. Just a reminder that this weapon are you recorded on Uploaded to the mind of a huge in channel as well as middle. Please remember to ask questions in the chart and make sure that's that's the end. Also be available in the chart throughout, What? An artwork. Any questions? Um, but you can also sign of free reading levels opposed to link in the shop. Well, supposedly the fee, but form in the chart at the end of the webinar, which will enable you to get a certificate of attendance. People failure without further ado are 100,000. Thank you. Know so as anyhow said my name is harms them. One of the junior doctors working in the West Midlands. This talk today will be a disjointed summaries and specialty referrals, so that's get started. So the content of the session today woop speak about the importance of discharge summaries. The different components of a discharge summary will also run for examples of discharge summaries, both good and bad, and we'll have a brief discussion about them. The second part of this talk will be about specialty referrals and lastly was summarized at the end. So distraught summaries. So we're going to talk about the importance of discharge summaries. But before we do that, we're going to talk about two terms, which you'll hear quite a lot. So the difference between this John summaries and T T. O. So this John summary is the main document which cheapies and patients receive, and this will include a summary of what has happened in the hospital, said That's the main part of your discharge. Summary was T T o means to take out T T. O is usually the section following discharge summary, which includes any medication changes or any list of medications which the patient is on both on a patient and for the GP is to be a well. So, usually teachers are they come off automatically following when you print a discharge. Summary. Uh, so why are discharge summaries important? So discharge summaries are the primary motive. Communication between the hospital, which will be yourself in a in a few months, time and after care provider. So that's usually GP is district nurses or anyone in the community who will be taking over the care of this patient So fruit, your discharge summary. You'll be able to tell the GP when you want in the community. What has happened to this patient? Any changes to the management plan, any changes to the medication? Or what's the future plan in in terms of the care for this patient discharge summaries? Also a good summary for the patient and their family members to receive about any events which happened in hospital or the management plan they received. So a lot of the time, some patients are quite elderly or they they might forget about things you've explained to them. So distraught summaries conserve. That's a good reminder, um, for the family members or for themselves, about the treatment they received in hospital. Lastly, this John summaries are good reference toe have for past medical and parcel surgical history. A lot of the time when you you guys will be will be clocking in new patients. You can refer to previous discharge summaries for the same patient to know about the past medical history to know about previous presenting complaints, uh, for this patient and what has been done for them in the past in the hospital, because a lot of patients will often present with the same things that they've had over the last few years. So distraught, some reason important to know how we have managed this patient in the past. So they're different components of it is John Summary. Usually it will depend on each trust, but in across the UK uh, all trust will use a A software for discharge summaries, and this software will have different components. It will break it down, so it won't be one long document where you have to write all of it. You actually have different sections to fill in, but these sections included here, so at the top you have the patient identifiable details, so that's usually the patients name their date of birth. The hospital number the NHS number there. GP name. This is usually automatically filled out from this software. When you search up the patient at the top, you have the reason for admission or they're presenting complaint. So that's usually a few words about why the patient came in. Uh, it's not really to details just one or two words about any symptoms that came into hospital with what they were admitted with, Uh, next that you have the diagnosis. So the provisional diagnosis you've reached and there might be instances where you discharge patients and you're not quite clear what the diagnosis was, but you're right. The provisional diagnosis that lease. So it's really important to have a diagnosis for your GP and for your patient to be aware off a swell of what they were treated for in hospital. Another section of the discharge summary is a co existing medical conditions or pasta medical history. So, uh, usually it's quite it's important to list any any past medical history. This patient may have because, as I mentioned earlier, you could use this discharge summary in the future when clocking in this patient. So that's why it's important to list all the past medical history Onley less relevant stuff. So I wouldn't really list Uh, for instance, a patient had a UTI in the year 2000 and 11 in the urine tract infection. I would list stuff such as a patient, Hard s tummy in 2016 or hot and understands Fitted. So that's relevant stuff. Another section of the distraught sarees investigations in the investigation section. You usually mention any blood tests and the scan results. Yeah, in this section and following that, you have the procedures section of the discharge summary. So in procedures, you can include any operations they've had. Um, the date of these operations as well by operations, I mean surgical operations or any any other procedures such as chest ring inserted, paracenteses, colonoscopy, Oh, gee d stuff like that. So that's useful to have the procedures list useful for the patient to remember and for the GP to know off a swell the clinical features is next to the clinical features is a main bulk of your discharge summary in the clinical features. You'll give a brief summary of why the patient came in, so they're presenting complaint how you manage this patient. You also include any investigations and, uh, what the follow up plan is. So this picture, for instance, you how you managed this patient, What medications? You started them on how they progress for out there. Stay in the hospital and you usually write up the end. This patient with team fit for discharge. You also have a section about allergies. Allergies for any medications in this section is really important, too, to remember that you should write any reactions to any medications. For instance, if a patient is allergic to penicillin, just say what? What do they have? What sort of reaction do they get when they take penicillin so it could vary from a small rush to another? Relaxes Winstons. So this is important because, uh, in the future, you can use this to know whether analogy is actually analogy or just a mild reaction. Other components of a discharge summary. You have the plant management notes. So in the plan management notes. So that's usually where you're right. Any, uh, the plan for any management in the community. For instance, uh, this patient will be reviewed by district nurses to change their wound dressing, or they'll have an outpatient appointment with this specialty to follow up on this. So this is important because, uh, the patient is aware off any, uh, any care that they will be receiving the community. The GP is also aware of this, but also because war clocks when you print the discharge summary, they can use this section to book outpatient appointments with the consultants for this plan Specialty. Another section is the information given to the patient section. So in this section you can usually safety net the patient. So any red flag symptoms to watch out for and who to contact if they do have these symptoms, Um, but also anything that you've told the patient and you want to remind them off. For instance, if someone has had an intervention and the legal requirement is not to drive for one week so you would have verbally told the patient this. But just for legal purposes, it's good to inform to write it in your discharge summary, but also to remind your patient as well about any information you could have given them. Lossy. You have any actions for the GP, so that's usually where you request GP to do any blood tests review any medications or anything that wasn't what that you weren't able to do us in hospital that the GP could follow up on. So I appreciate this sounds quite big, like all the different components of a discharge summary. But I'll run through a few examples, and you'll see it's not actually that hard. So once you have this software to write your discharge summary, it's mostly just getting used to it. And, yeah, so we'll run through a few examples to give you guys a night year. So what are the key points when writing it? Discharge summary. So remember, the the key term is summary, so you don't want to write a long essay. It discharge summary should be written in around 15 to 30 minutes. Remember, you guys will be F once in a in a few weeks or a few months time. You have plenty of discharge summaries to write for, uh, the day. On top of that, you'll be busy doing war jobs such as blood Scandalous. You have to do wardrobes so you have plenty of jobs to do. You can't spend all your time writing one discharge summary, so it's important for it to be concise and but that having been said it should be concise but should include the relevant information, and it should be easy to understand. For the patient, remember that your patient is going to receive a copy of this system. Summary. Uh, it's also important to know the fine balance because this is the discharge summary is aimed both at the patient and for the GP. Uh, because it's a not a patient, you don't want to include too many medical jargon. Zenit. You want to make it. You want to keep it quite simple, but the same time because the GP will be receiving. This is, well, you don't want it to be too simple, so you don't want to use like to lay terms for. For instance, if a patient, harder and and stemi you can write patient Mr X presented with an n Stamey because remember your patients they can google a lot of this stuff, the medical terms. So yeah, it has to be simple, but it should also be medical because it's going to your GP a swell. Avoid any appreciation XYZ far as possible, because this can be confusing for the patient will run through a few examples, so you guys will see what I mean by examples of appreciation. Again, your colleagues or the GP might know, understand his appreciation. So you wanted to be asclera spots a ball so the discharge summary should be concise and relevant on include relevant information. Uh, we don't want to know about a patient. Uh, it was hard, Let's say, for instance, if they've had a fall and nothing has become off this fall. So yeah, so little things that have happened on the Ward's. We don't really want to know about it in the district. Sorry where you only really want to know about stuff that will change our management plan. So if the patient has fallen, they've hit their head. They have a subarachnoid hemorrhage, Dennis Important, including in a discharge summary. But if it's minor stuff, a minor rashes patient has developed on the ward, which has been treated, and it's now gone. That's not important to include in your discharge summary in your discharge summary. It's a really important thing to explain the rationale for any medication changes, so the GP can understand. Remember, your GP is going to look after your patient in the community, the other ones who look after this patient there. So if you've made any changes to medication, it's important for them to know why. A lot of the times you get GP is writing. They actually right back to your consultants and say, Why has did this being started this stuff where you can save this by just explaining it in your discharge summary? It's important to safety, not your patient as well. So in the information to the patient section, right about any red flag symptoms the patient should watch out for and who to contact and be courteous to the GP. Remember GPS or basically consultants, so you use your F one. You can't really demand GP to do blood testing in a week or GP to please GP. To refer to cardiology, you can kindly request GPS will be considerate in your choice of words when things out that when asking GPS to do stuff and again try to do is most a Z can, uh, in the hospital. Because GPS don't have as many as many resource or access to resource is as we do in hospitals so try. Refer to specialties on discharge if you can, and even blood test try bring blood forms and give them to patients. But, yeah, you can request GPS to do some stuff, but requested kindly, please. So now we're going to run through an example of it. This John surgery, Uh, so the first example I've provided this is a good example of it distracts. And we said that this is how you guys should aim to write your discharge summaries and then we'll run through some not so quick examples. A swell so as the top at the top, you can see you have the patient name, the date of birth, and the address a patient identifiable details. As I'm I mentioned earlier this their software you will be using. We'll fill this out automatically, so you you won't have to worry about filling this in in the reason for admission section. Uh, as I said, only a few words about why the patient came in chest pain. Because remember new clinical features. You'll describe more about the presenting complaint. So the reason for admission is just one or two symptoms. Why the patient came in in the diagnosis section the diagnosis, which you and the consultant and the medical team or surgical team have reached for this patient. So, for instance, and standing on I've not. I've included an abbreviation, but I've also explained it in here. No, Nestea elevated my cardio unfortunate. So that's for the patient to know is well, So if the patient wants to know what that is taken quite easily, use the Internet or, yeah, to find out what the diagnosis was. Obviously, we would have explained it to them. What's the one hospital in terms of coexists co existing medical conditions? I've included a for a list off their past medical history, but only if it's relevant. And the year. That's because that's quite useful. So as you can see, this patient had an end standing in the year 2000 and 10. They have a history of hypertension type two diabetes and uridine. Oh, also is well so. As I said, if someone is to refer back to this discharge summary to clock, it's quite easy to get the past medical history from this discharge summary as I've included all the past medical history in it. In the Next section investigation section. Uh, I've included any investor relevant investigations which have been done because this is a cardiology patient S e gs are important, and I've not gone on to write a massive essay about the findings of these investigations. Know, have I gone to copy the reports of radiology call reports? So just a brief summary wanted to one line should should be enough so that for this patient, the EKG showed first degree heart block troponin because the Internet and then stem it's important to record that troponin levels so first reported, with 48 2nd proponent with 60. So there's been a rise in troponin. They had a low ferritin which was discovered. What's in hospitals. Everything included included the results of the ferritin level for the cheap into nose well, and or or the other blood tests were normal, so I don't go on to list the normal blood test. I just summarize it by saying, or blood tests were normal. Chest sexually with clear as well was normal. So I just a chest x ray was clear and they had an echo whilst we went hospital. So again, just one sentence summarizing the results of this echo so mild aortic records, but no more systolic function in the procedure section. I go onto least any procedures this patient might have had. So for this particular patient they've had PCI is the percutaneously intervention again? I've included an abbreviation in brackets by Go on to explain it in full for the for the patient's purpose. And so they've had PCI to the left anterior descending artery. Uh, so that's not really relevant to the patient. But it's relevant to the GP to know, because remember, GPS or medical is, well, the medical personnel. So it's important for the GP to know where this stent was fitted and then the next section. So, as I said previously, the bulk of your discharge summary will be your chemical features. So I refer to the patient by the name Mr or Mrs X, presented to hospital with breathlessness and central chest pain on exertion. So that's the presenting complaint. He had an end stage in 2000 and 11, and it is. He describes his symptoms similar to his episode. He had them, so I talked a bit about the past medical history, relevant pas medical history, which is hey, had an instant me and his symptoms were similar to when he had it and steady. I go on to speak about troponin levels. Been 44 60 on admission and the CT showing first degree heart block. No chewing any signs of ST elevation. So again, this is a MDAX. The GP is important for the GP to know the results of any interventions we did. All other blood tests were no more chest. That's true. It's clear, and echo showed mild aortic regurg with normal systolic function. I next go on Teo to tell the GP and the patient about the management plan we started for this We've initiated for this patient patient Watson Hospital. So we treated for acute acute coronary syndrome. Uh and we referred them for a PCI. And I go on to mention where this stent was inserted said to the left anterior descending artery. So next time I want my next light. So this is a clinical features section continued. I go on to explain any changes to medication and why the rationale why we've chosen a certain medication, not a lot, and not another so as that, as this patient could not tolerate atorvastatin at times does He was started on rosuvastatin instead. And as it in my so that's important for the GP to know. Because in the future of the GP, I was considering switching this patient over to it over a statin. They can refer to my discharge summary and they'll know that this page patient it is not. It is not tolerating this medication, so the GP will find an alternative for it. I go on to say this patient was started on clopidogrel and you antiplatelet therapy with aspirin, which he already takes for one year as the protocol for PCR. And then I talk about any relevant things that have happened to this patient Waas. They were in the hospital. So what's in the hospital? It was discovered that this patient had a low fare it in a 27. So I mentioned the blood test results. And I say we've discussed with the gastroenterologist who have agreed to see this patient in our patient setting. So this let's the gp No, that this pick this patient's low ferritin will be followed up about by the gas true team and they will, uh, they will decide on a treatment plan for it. It's important to say your patient was deemed medically fit for discharge because I know it's, uh, yeah, it's it's common sense that if your discharging a patient, they're usually fit for discharge or they've calmed the other end of their treatment care. But it's important to mention for the GP as well. Just that they're aware of how this patient waas just before you're about to discharge them. And I go on to mention any, uh, outpatient tests we we've organized for this patient. So this patient, for instance, will have 48 hour telemetry do two changes found on his easy G. So that's for the patient and again for the GP to to be aware in the allergy section night. As you can see, I've included any allergies to medications, so this patient's allergic to penicillin. But as I said, it's important to list any reactions to any allergies because some patients will say they have a mild rush to a certain medication, and that's not really analogy. So that's why it's important to risk to list the reaction to any medications is well, in the general comments again, I say the gastro team will see this patient in 14, which time? So I've included the timeframe in my destroy summary. So the patient's aware that in 14 4 weeks' time they will be seen by someone from the gas routine. And the GP is also where, in case they want to follow up on this and in the management notes, uh, I've said again mentioned about the gastro appointment and that they will be seen in clinic following PCI in the information to give in to the patient section. So that's when we talked about any safety netting for this patient or any information you've given verbally to this patient. But you wanna write it in a legal for more just to remind the patient. So I I've told the patient, please seek medical advice if experiencing further chest pain or shortness of breath. So I've told this patient in my discharge summary what symptoms to watch out for. So yeah, this is the This is the end of the example for distance Jon summary as is this a legal document this drawn some result need to be signed off a swell, but a lot of the time Whoever gives a patient of distraught summary will sign it off. So it does not necessarily have to be, You know, it can be The nursing stuff is well, but you will have your name. Whoever prepares the district summary will have their name at the bottom of the discharge summary written automatically with the software your your hospitals will use, along with the responsible consultant in charge of this patient's care. Okay, so now we're going to go through, uh, other examples of discharge summaries. Eso We'll go for this example, and then I just want you guys to write in the chart if you think this is an example of a good or a bad discharge summary compared to the one I've showed you. So the one I showed you is I get a reference discharge summary. So a reference for a good, distraught summary. So we're going to go through this one, and then you guys will have a chance to judge on your own. Uh, if you think it's it's a good or bad one, and then the how would just tell me at the end? Uh, what the majority of you guys think? So here we have a patient, a 72 year old lady. So the reason for admission, the off of this destruction re has written difficulty swallowing. So fair enough. So the symptoms, uh, this patient came up with, uh, and in the diagnosis section, me. How can you see this light now? Um, yeah. Can you I which started you on a, um, slide eight. Is it? Oh, yeah. Eight reason for admission is different Swallowing. Can you see that? I can't see. Um, check. And you see the slide. You know, I continue it. Should I just It seems to be a general consensus. They can see it might just be my screen. You carry on, comes up. All right. Okay. Yeah. Okay. Corey. Yeah. Sorry about that. So, uh, yeah, let's get back to this example of a discharge summary. Uh, so this one, a patient, 72 year old patient came in with difficulty swallowing. So the reason for admission, the office returned difficulty swallowing, uh, the diagnosis. The offer has written difficulty swallowing. Uh, so again, I don't think that's that's not really a diagnosis. That's more of a symptom symptom, but work will come back to this after. Let you guys decide on that. In terms of past medical history, the over goes on to this, uh, a different, uh, different medical condition. Dissipation house. So again, difficulty swallowing asthma, cataract. I'm hypertension for a khatemi lumber this circumcision and gout and asbestos related lung disease. So it doesn't really specify what type of lung disease just says it's better Asbestos related lung disease. The investigation section, where you'd usually include any blood tests or scans is left empty. Procedure section again is left empty. So I don't know, maybe this patient didn't have any procedures done. But if empty like I would, I would, right, Neil personally. So let's go into the clinical features section. Let's see what this office written. 72 years old. Patient admitted with difficulty, pain in swallowing ongoing S O. B. So they've used Ah, an abbreviation. They've not really explain what this abbreviation is about. Again. The patient is not used to my medical terminologies of this patient is receiving a copy of this discharge summary. Uh, it might know. Understand what s o. B. Means? Um, I think it's a swear word. Yeah. So patient had a gastroscopy that showed but savage itis He was started on fluconazole. So they've listed any medication this patient was started on and the management plan to complete seven days Course again, this grammatical mistakes lansoprazole b d patient doesn't know what he dean's So BG means twice a day for you. For those of you who don't know, biopsy was taken on GPS again. Grammatical mistakes. Oh, G d not really explained to the patient. What a no g d means So, uh, these abbreviations such as S O B o g d. Your GP would understand it, but your patient won't understand it. Results will be chased by the gastro team, so it doesn't really say when the gastro team well see this patient in so once. The timeframe in which those see this patient So any allergies identified nose of this patient's not allergic to any medications. Okay, fair enough. And any plan Management nodes. So on top, they say the gastro team will review the results of the EKG. But here they say, there's no follow up plan at the end, So it's quite conflicting in terms of the information, any information given to the patient, so they have said he had no information given to the patient. So they've not really safety netted this patient about any red flags symptoms to watch out for or you to contact. Yeah, so that's also that's Yeah, that's this discharge summary. So I just give you guys maybe a minute or so just to write in the chart. Do you think this is an example of a good discharge summary or no? And anyhow, can tell me what you guys think in general anyhow, you that I am. So I'm here. I think the general consensus is it's a very, very poor discharge summary. Yeah. You guys are running. Yeah. Yeah. I don't think anyone thinks it's very good. Chloe's mentioned that. It's very poor competitively example. Yeah, I think you will see that. Yeah, I agree with you guys. So, um, let's move on to a few more, because we have a few more examples to get fruit. Uh, yeah. All right. Can you guys see this one? Uh, so this is another example of a discharge summary. The reason for admission is shortness of breath and tachycardia. So again, shortness of shortness of breath is not really explain. It's written out the abbreviation S o B in tachycardia. In terms off the diagnosis of this patient, the diagnosis that was reach once in hospital was chronic liver disease, Alcohol withdraw a k I said they don't go on to explain what in a k i e s o u g p again, we'll know what's what the naked eye stands for. But your patient doesn't really know what an A k I means, uh, they go on to list coexisting medical conditions of the particle history this patient has suffered. Giant. It's a f, uh, fatty liver disease. Liver has been written twice a fatty liver, liver disease in terms of investigation. So they do mention what investigations have been done, What's in hospital. So this patient had a CT head and an ultrasound abdomen and blood steak and once in hospital, but again, they failed to mention the results of this these tests, But I assume they must will be normal in the clinical future. Get the procedure section has been left blank, and the clinical features section we only have two sentences. So shortness of breath and tachycardia, an alcohol excess. So I don't I don't really understand, uh, what they mean that I'm sure the patient or the GP one really understand is destroying somebody as well. And this's done automatically. So at our trust, if a patient has an a k I, it prompts you to review them medications. So this patient has an achy I. But as we can see, has it been resolved now on discharge? But they have not made any changes to, uh, to any medications. They have also GP to repeat your a a an electrolyte to check the Jeff Oh, in the community as well. But again, there's no formal documentation asking the GP to do those. So that's all about this discharge summary. So that's a very brief discharge summary, actually, two lines. Five words? Yeah. Do you guys think that's an example of a good discharge summary or a poor discharge summary again, Put you on's is in the chart, and then I need I will tell me when you guys think off in general again. Hum zero. I think the general consensus is that it's a very poor discharge summary. Um, yeah, not much detail in there. A tall is, uh, I don't even know what's going on to be honest. So they're short of breath Tachycardia on the bottle of alcohol. Well, that doesn't really spend anything. Yeah, neither do I. I don't really understand what's going on. A Z a g p. I wouldn't be very happy with this. I can't email the consultant just to find out what's been going on with my patient. I agree. Okay, then let's move on to another exam. Yeah, So just bear in mind was writing discharge summaries. So we're critiquing discharge summaries. But bear in mind the situation you will be on when you're working on the ward's, You won't have a lot of time. You have nurses asking you to write discharge summaries for multiple patients. You have other jobs to do so you won't have a lot of time. So discharge summaries need to be concise. Uh, again, The example I gave you is an example of a good destroyed summary. But I don't think you have as much time to write all this this much detail. But that having been said, eso keep that in mind, and then we're just gonna judge dis discharge summary. So in this one, we have a patient presenting with abdominal pain and vomiting. So reason for admission. The diagnosis irritable bowel syndrome on the offer goes on to this, uh, the past medical history. So they give a good description of any pasta medical history. So this patient has menorrhagia anxiety depression for post traumatic stress disorder, so they avoid using any abbreviation such as PTSD for the patient Understand as well. In the investigation section, they go on to list any relevant investigation. So this patient has not had any radiological scans, but they have had blood tests taken on admission. And they offer does go on to say the results of these blood tests, even if it is normal. So no significant in full blood, count your air and electrolytes. Unfortunately, the procedure section has been left blank, but I assume this patient has not had any procedures. So let's go on to read the clinical Features section. Ms Be was admitted to hospital with abdominal pain and a two day history of vomiting. So again, very concise. Presenting complaint. Uh, it's not wordy. It's to the point and includes relevant symptoms. Ultrasound, abdomen and pelvis was normal. So it goes on to this. Any uh, imaging radiological imaging That was done. Ms. Be was started on gentamicin, metronidazole and amoxicillin for two days. That tells the GP any The treatment this patient has received once in hospital and the patient was reviewed by the gastroenterologist is you started her on amitryptaline 10 mg. So it states the dose of the medication and the frequency of it and how long she should take this medication for so 12 to 18 months. So that's important for the both the patient and the GP to be a well, for how long to take this medication. And it goes on to say at the end she was medically safe with discharge. So that lets the GP know that the medical team that's over we're happy with the current state for to be able to discharge her in terms of the allergy sanction, they list any allergies to medications, or this patient is allergic to codeine and the reaction to any allergy. So the patient experiences vomiting what's taking codeine, and then the plan management notes. This patient will not have any outpatient followup. So they say no follow up. They go on to this, uh, amitryptaline, which should take the decision should take for 12 to 18 months for irritable bowel syndrome on in terms of information given to the patient, they say above has been explained. So what they mean by that is they explained the diagnosis to the patient on the medication. They should take some me triptolin for 12 to 18 months, and their safety net did the patient as well. They say. If symptoms worsen or persist, please seek medical attention. So that would mean contacting your GP or 111 so their safety net in this patient. So bear in mind, this is a brief discharge summary, and like that, once you won't will be on the ward, you'll be really busy. You won't have a lot of time. Do you guys think in general this is an example of the good discharge summary or it's not that good again? Post your comments in the chart about it. What's the general consensus now? What are they thinking? So, um, that the general consensus is that this is a very good discharge summary. I think we can all see that it's very detailed. It's given a good break down of the co existent medical conditions. We know exactly what's happening with the patient. I think the management summary is very clear. Yeah, so we know that the patients on a trip to lean 10 mg once nightly for 12 to 18 months and also it's very important to safety net the patient guys. So in discharge summaries, we always safety net. Are patients were discharging patients on. It's always good to, um, right in the notes what you said to the patient terms of coming back in if symptoms persist or get worse or specific symptoms too powerful. Yeah, I agree with Union. Agree with you guys as well. This is an example of a good discharge summary. What's It's quite breathe, and it contains all the relevant information you need to know and for the patient as well. So, uh, it doesn't have a lot of medical jargon on it's a good summary, both for the patient and for the GP. So the first example in this example of, uh, standards you guys should aim for. But then again, when you do start so you will get used to it. Didn't writing this John summaries is a skill you pick up on the job. So at the start you will take a lot of time writing. You're destroying summaries for patients, but then you will get used to it. And it's a skill you will learn as an F one because you will be doing a numerous discharge summaries as the left one eso My next slide is just about the TT. Oh, so to take out. So just to give you guys a general idea of how it appears at the end of the discharge summary in terms of TT Oh, you guys don't really need to write this up right this down. Pharmacists will usually tweak any medications or on yourself. Software yourself. You make any changes to medication, but then it will automatically come out like this. Uh so it will have a section about any drug started in hospital for the example of this patient had been started on furosemide, 20 mg eso the dosage and how often to take it. So take 1 20 mg tablet daily at midday. So why it's important to have this much details is because the patient will receive a copy of this so it will have instructions on when to take your medications and how often any cancel pre admission medications or rivaroxaban was stopped. Stop and the reason we stopped it stopped due to bleeding risk. And and you have information for the GP to consider restarting that if the patients hematuria is controlled, and then in the pre admission section is any medication this patient came into hospital with which you have not changed on discharging them. So this patient's on bisoprolol or the jobs in doxazosin furosemide and the list of other medications, and how often to take them. So that's just, uh, for your general knowledge about how T t O will appear. But there's nothing much for you guys to know about changing them, because this all done this will be done automatically by your software, where you write discharge summaries or by the pharmacist. Uh, so a brief summary about discharge summaries, which we've done so discharge summaries should be concise and should only contain the relevant information concise both for the GP because GP don't have all the time in the world to read it This chance on me, they just have a few minutes before each consultation to read the discharge summary. But also because it will help you as an F one. You'll be really busy on the ward. You don't want to spend hours writing a discharge summary because you have other shots. Do a swell, so it should be concise but contained. The relevant information both of the patient and for the GP should be easy to understand. No grammatical mistakes as far as you can help it and should include a clear management plan and any outpatient followup with the expected time frame again as needed. I said, Don't forget to safety net your patients, including any symptoms to watch out for and who to contact. So next we're going to move on to the second part of our talk, which is specialty referrals. So by specialty referrals, I mean, when you're working on a ward and you need to refer to different specialties such a cardiology, respiratory or gastro gastroenterology to get opinions or to get you're trying your patients transferred across to receive the proper care. So when referring to a specialty, it's important to know the reason why you're referring to this specialty. Uh, so usually as an F one, you the most junior member of the team, and a lot of the time you won't be aware of it. You won't know why you consultant, once a referral done. That's why it's important to clarify with your consultant or your registrar why they want this patient referred. This will help you understand. Um, this will also help you refers. So then, when explaining to the other specialty why you want their opinion, it's important to be important to use that s ball approach, which you guys would have learned in medical school, and I'll speak more about especially later on. But I won't go into too much detail because you guys would have a wealth of experience about it, having been taught in medical school with your last easily. Or it's also important have any relevant information at hand about this patient when referring. So these could include a patient, identifiable details, results of any blood tests or investigations which this specialty would want to know. So usually it's a good idea to have when referring tough. This patient's of blood tests or scans on this system as you're making the referral so you can quickly refer to in case you miss any information out and after referring it's important to documentary Ferral and the outcome of your referral, whether your referral has been accepted, declined when he advice, they've given you and update your seniors about the outcome of the referral so they can change their management plan accordingly. Or we will re refer the patient themselves if it's in the client. So, as I said so it's balsa stands for situation. So, uh, when you call the relevance specialty, you tell them who you are below my sister, for instance, I'll be like, Hello. My name is Hamza. I'm an F one working in the surgical department. The background. So the background about this patient So Mrs X is a 78 year old lady, uh, who presented following a full on a urine culture showed a growth of E. Coli, for instance. Assessment. So what did you find on assessing this patient? Uh, that, for instance, you can say this patient had super pubic tenderness and any recommendation. So what you think is going on, uh, and what treatment plan you started on as well. So, for instance, you can say us the medical team think this patient has a urinary tract infection. So we've started on antibiotics for the unity tract infection. So that's your s ball. But I won't go on more to speak about it because you guys would have had experience about doing Esparza's. But it's important just to practice us bars and to use this esport framework when referring to a specialty. Now you guys will ask yourself, How do you refer to two different specialties? So again, this will be trust abandoned? We have people watching the store cool, who will be going to different hospitals across the country so different hospitals will do it differently, but also according to different specialties. For instance, for Needle and I, we're both at the same hospital, but according to different specialties. So for some specialties, we do paper referrals for others. We send emails, two secretaries or to the relevant consultants off or for some for some of them. We just call the on call consultant at that time to get opinions or to refer this patient so it will depend on your trust. Hand on the specialty that to find out more, you will get to know about it during your induction or your learn about it. as you start the job according to your trust, it will be different, different according to different trust. And so I'm just awesome. The hall. If you could kindly post uh, the referral cheat cheat sheet, which is available on the mind, please. A page. So again I would prompt you guys to refer to this, so this is quite useful. But, yeah, I'm just going to go through some common specialities, which you might be asked to refer to, and some useful information to have it handy when referring to the specialties. So when referring to cardiology, it's important to, uh, including your referral. Any information about any E c G suspicion might have had and comparing this E c g two any previous Easy Jesus, because the cardiologists want to know if there's any. Each PCG changes if you're referring a patient with chest pain and stand on your stomach to have the troponin levels at hand. So that's the 1st and 2nd troponin levels and the trend whether the troponin is going up or it's going down and any relevant symptoms such as chest pain, shortness of breath or any Peter Peter edema, which could, such as heart video if the patient has any any previous echoes, you can include this in your referral. And what did you hear on auscultated for heart sounds? So you can remember or with a normal heart sounds. And it's also important to list any to tell the referring clinician about any a relevant past medical history. If it's cardiac related, for instance, it has this patient had an end stem us stem in the past off they known to have heart failure, or they known to have angina. For instance, if referring to someone to spend two respectfully, uh, it's important to mention the oxygen saturation and their oxygen requirement. So, for instance, if someone has new onset oxygen requirement, it's important to let's the consultant or register on know when referring this patient across and how much oxygen they're requiring. So, for instance, you can say Mrs exes and eating, UH, two liters of oxygen. And she's maintaining sorts of 90% on those, uh, important to let them know about the baseline mobility about this off this patient as well. So this patient gets short of breath by walking across the room, or this patient gets short, short of breath by walking two blocks. So usually. But what I mean by that is when the patient is well, uh, how far are they able to walk before getting short of breath? If you're suspecting any chest infection treating for chest infection, have you sent any sputum culture and has the sensitivity come back yet? And it's also important to mention to check on the system whether the patient has had any growth microorganism growth, uh, in the past for any previous medical for any previous hospital admission. Because a lot of the time the patients will come in with the same, uh, might grow the same microorganisms, which I have grown in the past, so that can be quite useful when we again. When referring to respiratory important to let them know of any really a radiological investigations. You've done such a chest X ray or CT for us and what the findings are, whether there's any new findings or even if it's clear so they can have an accurate picture. Or if you've done in a BG just to let them know of the results of this ABG when referring to microbiology, uh, the microbiologists might want to know about any inflammatory markers. Any blood tests, including White Cell count neutrophil, Count CRP or those rays. Are they going down? And the trend in those any blood cultures taken and has the blood culture growing anything, any allergies to any antibiotics and any reaction to those? As we mentioned previously? Some patients might say they're allergic to penicillin, but when you actually go off them, what happens when you take penicillin? They might be like, Oh, half of Mars Rush eso. That's not really an anaphylactic anaphylactic reaction. So you could potentially give this patient penicillin if it comes to it and any trust guidelines, It's important to know what the trust says about starting patients on, uh, what the guidelines say. So which antibiotics Your trust wants you to start on for. Relevant infection. Uh, yeah. Before you speak to Micro, just to make them aware that you've checked the guidance that you're being proactive if you're referring to neurosurgery or neurology, uh, you might want to tell them about this patient's baseline functions of before coming to hospital. For instance, is this patient usually fit and well, or the wheelchair bound, or or the tetraplegic for instance, the nature of off the injury. The patient has had an injury. So if a patient has had a road traffic accident and you're referring to your surgery, you want them to know, uh, what left? How severe this accident waas So they can have that they conform a picture when you're referring this patient across the GCS off this patient and the findings of any neuro observations again, the results of any radiological tests or a CT head or MRI reports. What does it show? Even if it's normal, I would simply mention it. Any medications this patient is on So this could be relevant, for instance, of the patient has signed a subarachnoid hemorrhage and they're on a do work a blood thinner so they might tell you to stop it. So that's why it's important to know about any medications. This special is, um, and again any past medical history or family history. Eso Then they could be aware of any neurological conditions which run in the family. So just MSV, for instance, or this this for this. This patient have a pre disposability for stroke because they're they have a strong family history of stroke when referring to surgery. The surgeons might want to know about the baseline function of this patient. So it's just patient usually fit and well, the reason they want to know about this is, uh, so that they know, Is this patient gonna be fit? Are they going to be a candidate for surgery? Because if this patients usually frail, they wouldn't tolerate, uh, general anesthesia very well. So hence they wouldn't be a candidate for surgery. And hence you surgeons wouldn't really except these patients, any relevant post surgical history, any operations they had in the policy, the blood test and the any results of any radio large course guns this patient has had. And lastly, any examination finding. So when examining the up abdomen, what did you find on the Is this patient parrot in it IC, for instance, so it will help them decide the urgency off them having to assess this patient. The last example is referring to Reno. Serena, The Reno team might want to know about any renal blood tests you've done so the e jafar, the ground in in level. And is it rising, or is it going down the urine output off this patient. So are they only go uric or how much urine have the past in the last 24 hours? The fluid status off this patient. Do you think this patient appears dry or do they appear wet? Any scans which have been done so ultrasound K U B is quite a useful want to have if it's been done. So this can potentially excludes some, uh, re, uh, re know courses off AKI, for instance, medication history for this patient on the on any nephrotoxic six. And has this been withheld And again, the baseline function of this patient. So the recently might want to know this is, with this patient, be a candidate for dialysis if they all considering it. So this has this has been quite a ways through about some common specialities you could refer to. But again, I would a point you to the direction off the mind of sleep cheat sheet referral page just to get a better idea. The next, uh, I'm just going to run through a few examples off specialty referral. So just so you guys can appreciate about how we would really usually refer a patient. So we're going to pretend Needle is the relevant consultant at the other end of the phone. And I'm an F one, and I'm going to refer few of my patients to him. Two different specialties. So my first example is, uh, a respiratory patients on the surgical F one. As you can see on this one, I'm sending an email to me. How so? This will be an email referral. Hollies, uh, is a respiratory consultant and that I'm referring. And 89 year old ladies, as you guys conceive from my email, I've included patient, identifiable detail, and I've said I would like a respiratory referral, please. Some referring an 89 year old lady. And the reason I'm referring is for new onset oxygen requirement. I go on to list the relevant past medical history of Type two diabetes. Uh huh. Perfect vascular disease and I in deficiency anemia and some blood tests and the trend in those. So this patient has a normal white cell count in a normal neutrophil count, but they have a race crp of 135 and it has actually gone up from 65 on admission. I go on to tell me. How is the respiratory consultant about the results of my examination? So on auscultated the chest, I heard by basal crackles with no wheeze and no evidence of pitting edema. So this tells me how this is more like a respiratory condition and not no, not heart failure, because there's no signs of pitting edema. This patient has also gone to have a a chest X ray would showed all changes in the left lung, but no new, no new on, but increase pacification, the right lower and middle zones. And this patient is coughing up white phlegm. I then go on to tell me how about the impression. So I think this is hospital acquired pneumonia. And I tell the Risperdal treat Eames the management plan we've initiated. Just so they're well. So we started this patient on IV amoxicillin Asper, the trust guideline for hospital acquired pneumonia. We've sent a sputum culture, and we'll also send you Naree antigens for legionella and new, more cocoa. Um, we've started this patient on saline nebs four times a day as well. And then at the end, I just say would be grateful that you could please review my patients So this is an example off a respiratory referral had put fruit. Uh, yeah, by email. So the next example of Ah, referral. I'm going to put a prostate me house. I'm going to pretend me How is Ah, it's from the cardiology team, and I'm going to refer, going to refer him one of my patients to be transferred to the cardiology would. So, uh, the hollow you there. Hi, it's Neo, the cardiology consultant. Hi there. My name is hams on one of the surgical F ones. I was just wondering whether you're free to talk so that I could just, uh, refer one of my patients who came in with a cardiology complication. Would that be okay with you? Yeah, that's fine. Yeah. Thank you. So I'm just referring. Mr. X, Mr. X is a 70 year old gentlemen. He has a background of type two diabetes, hypercholesteremia and angina and had an end stem in 2018 with two stents fitted to the left circumflex artery. So Mr X came in with a one day history off sudden onset central crushing chest pain radiating down his left arm manager and his jaw and the pain was relieved by morphine given by the paramedics, but it was not relieved by his GTM screen. Mr. X is Hemodynamically stable of President. He has a BP of 125 over 80 and a heart rate of 76. You see, GI showed new a T wave inversion inlayed V two to be four, and his troponin is were 54 200 respectively, showing an upward trend taken six hours apart. So we as part of the medical team, the medical Clocking team, we've been treating Mr X for a C S S 04 and stemi. So we've started him on the A. C s pathway. And we started him on FONDAPARINUX Asper. The trust guidance. Uh, so, uh, is that all you wanted me to do for Mr X? Would you agree with the current management plan on Do? If so, would you be happy to review Mr Eggs whenever you have time just to check that be okay with you? Thank you, homes. Uh, yeah. I think you've told me everything. I need to know that referral That was a very thorough for so thank you. And i'll come on. Review Mr X Thistle after you. Enough to my clinic. All right. Thank you. All right. So yeah. Yeah, That was an example of a referral to cardiology. Uh, now guys were just run through a last example. So I'm going to pretend the how is the on call consultant? Microbiologist. And I'm just this time I'm referring. Uh, I'm gonna do a referral just to ask for some advice on some antibiotics. Hello. Is this the uncle microbiologist? Yes. It stopped the champion. The uncle microbiologist. Hi, Doctor China. And my name is homes on one of the surgical ones. I'm just calling with regards to advice for one of my patients today. With that Okay with you if I just run it past you, that's absolutely fine. Go ahead. Okay. Thank you. So I'm just calling with regards to Ms Is Dorothy Price a hospital number 1234 on. She's a 92 year old lady with a history of recurrent UTI. She came in with a presenting complaint, was full and she was found to be quite confused as well. On admission, she had reason. Family. What markers? With the white cell count of 14.0 and a CRP off 79. Uh, urine M CNS taken on admission. Should a group a growth off protease mirabilis sensitive to gentamicin and amoxicillin but resistant to traumatic brain and neutral if you're enjoying it, The reason I'm calling you today is because I just wanted your advice on any antibiotics I could start this patient on for the UTI. According to trust, guidance and the sensitivity, it would have been gentamicin and followed by taxes. And given that they have a low each year for and they're quite old is well, but unfortunately, given that this patient has a knee jerk off 45 they're allergic to penicillin, and I'm not quite sure what biotics I could start And, uh, the allergy, which I have documented for in terms of pen, it's penicillin It It says that this patient has quite a severe rash when they take penicillin. So I don't think it would be advisable to start them on any antibiotics which contained pen insulin. So I just wanted some advice on any antibiotics. You advised me starting this patient on and did your a shin That's all right? Yeah. Yes, some. So that's absolutely fine. What did you say the easier for? Uh, this patient was so the easier far was 45 and the allergic. Okay. Okay. And have you access the local cross guidelines? Yes. We've had access the local trust guidance. Eso According to that, it would be taxes status in with the status of gentamicin. But unfortunately, I can't give taxing as this patient is allergic to penicillin. So would you suggest maybe meropenem them? Absolutely. I think Mary pen and we'll be out next. Best bet Cover all the bacterium that we are looking Teo kill. Um, yeah, Essentially, if you start the patient on IV American, um uh, let's say, uh, 400 mg TDs. Yeah, Yeah. 400 mg TVs on. If you recall for the gentleman or the lady in a couple of days time and let me know the results of those cultures. That would be great. Thank you very much. All right. Thank you, Doctor. China. And thanks for your time by know where is all right. So these are free examples off referrals. I've just put a cross so as you can see my s Bob, But it has to be quite brief. You don't want to give too much information as well. Because remember at the other end of the phone or the other end of this email you have really busy consultants and register. They don't have all day. They just want to hear the relevant information and you as well. You just want to find out what you can do for this patient, what they would advise you on. So next we go into the last section of this talk so requesting radiological tests. So this will include anything's anything from chest X ray to see TPS to CT four AKs. So when going to request radiological images, it's important to know the reason why you're requesting for these guns and the symptoms of your patients because your radiologist might want to know why you why you want to do these guns and, uh, how the results of the scan will change your management plan. So, for instance, if you have a patient who has a pulmonary embolus and you start them on treatment for pulmonary emboli, and it's now one week down the line and you want to get a CT pa now, it wouldn't really be advisable because you've already gone down this line, you've already treated them for this. The results of the city off this CT pa wouldn't really change your management plan. But for instance, if you're suspecting lower respiratory tract infection for patient who is has a new onset of shortness of breath a few hours ago, a chest X ray would be really useful because it would confirm your diagnosis off lower respiratory tract infection. So it's important to know why. Your risk with why you're requesting these guns, the symptoms of your patients as well, and how the results of these kind would change your management plan when requesting for radiological scans. Important to know to note, uh, how urgent you want these scans. For instance, if your patient is critically unwell, you need to tell them I want this chest. X ray Attorney is a spots a bulk, please, because of this patient's quite critically on well, and we're suspecting a respectful course. So this one help in our management plan or if it's something which can wait. For instance, if a patient is, uh, if it's an ultrasound scan, we can wait a few days, then you can let them know about this a swell, because they will be quite busy as well. Uh, if you are requesting for scans which involved, like, contrast or dyes, it's important to know the patient's last See Jeff. Oh, because these contrast and dyes can be detrimental to the patient's kidneys. And if, uh, requesting for an MRI to know if this patient has had any metal has any metal work in place. So that will be any contra indication for an MRI. Um, to note, if you're requesting for a CT pa, uh, it's important to put on there the well school, which you can quite easily calculate using some up, such as MG cow and the D Dimer, because this will make your room your referral like more genuine, and we'll back it up, especially if they have a high well score in a raised a dime er. So this will help get your scan accepted, and lastly, you should specify whether you want the scan portable or non portable. In general, most of your scans will be known possible, and the few exceptions will be for critically on well patients who would require a portable chest X ray because they cannot be moved to the radiology department due to their high oxygen demand. So usually for patients on 15 liters, non reprieve mass, you can't really Well, then down to the radiological department, you need to get a portable chest security, but for the majority of your patients will be non portable scan, so they will have to be brought in by the porters to the radiological departments. So to summarize, for artist. Or we've talked about the importance of discharge summaries, we've gone through examples of discharge summary support good and bad. And you guys have had have had an opportunity to I'll give you a pin, you is about when you think about them. We've gone from specialty referrals, and lastly, it's important to practice. So I wouldn't be too overwhelmed by the amount of information I've given today because a lot of these are things you learn on the job. But, uh, you guys, uh, it's good that you've had this information and that you've attended this talk now, so we'll, uh, get you a bit more prepared for when you do start on the job. Just a reminder. If you have enjoyed this talk, we have other talks upcoming A spot of I F. Y one survival guide. So our next talk will be held by Dr Pamela Search. So she will be talking about organization skills and seeking supporters. And therefore and so that's really important, because if one as an f find, it can be quite difficult and quite overwhelming, having finished medical school. So it's important to know how to organize your jobs and hard to seek support if you do need them. But then we have other talks about understanding that eat portfolio. Some talks about PE and finances and common bleep scenarios, and managing the deteriorating patient, which will be delivered by medical registrar. So keep your eyes open for these, so I'll just redirect you guys to this's barcodes. If you do scan this, you'll be able to fill out your feedback form so your feedback forms. After filling those, you'll get a certificate, which you can use for your non call teaching hours, as as part of the F one. Uh, yeah, so then our policy on back to me on, and we'll both will have a Q and a session about any questions you guys might have so feel free to put any questions in the chat and would answer those. Thank you very much for that insightful talk comes up. I I certainly learned too low, so I think it was definitely You talk. Um, Well, just make sure that anyone who wants to ask any questions in the chap go ahead and we can ask them the cure. Codus blurry. So should I. Just Don't worry, liver. I composed the link to the feedback in the chart. Okay. This year, um, just give me one second. Okay? Um, here we go. That's great. Yeah. Thank you, Neil. There's your link is very important, guys that you give us feedback only does it help us improve our webinars and get better teaching sessions? But also, you get a certificate when she can use as part of your portfolio for F one. So this would cut Was a non court thing over. Um, yeah, that's ah, it's father larger. Let's see, a large amount of work that goes into the portfolio is every little bit helps. Okay, guys, any questions about the talks or any questions about referring to certain specialties or any questions about the writing a very good discharge letter can answer those. No, I don't think there's any questions. Um, so I think you've given that comprehensive of the talk that everyone knows exactly how to refer to the radiologists and the mark apologists, and they'll know exactly how to write a excellent discharge letter. So just give you another minute or so to see if anyone has the questions, but yeah, After that, we can call it a day. Oh, here we go. Is a question from after Balham. Does it matter if a discharge letter is delayed? Hum. Uh, yeah, So it does. Because, technically, most of your patients won't be able to leave hospitals without a discharge letter. That's why, as part of your F one, you you often get nurses nagging you about Oh, my patient is a district summary, especially when you have a critically on, well, patient nurses work. You can consistently remind you that you need to write a destroyed summary for their patient because patients can actually leave without a discharge summary. But that having been said that if your patient is usually fit in, well, they can actually believe and then you composed of discharge that's at the end. But for the majority of patients, they do need the discharge summary and the T t o, which I mentioned before there able to leave. S. So that's for pharmacists to arrange for medications as well. That's mostly why they're either the discharge summary and teach you so your patient won't be able to leave the hospital. That's why, uh, it's really important to do your destroyed some ways on whenever you have time. Yeah, so it doesn't matter if it's delayed. If it's delayed, this patient stays on the ward longer. There no able to arrange transport to the patient, stays in for another day, and then it creates a backlog because any consent new patients to the ward to replace this better. Just to add to that exactly. I agree with everything Holmes's said. Um, this shows that is, ideally, that should be delayed normally. If you do a morning walk around, discharge letters will be the last thing you do in terms of your jobs. You know, if you got more patients, you need to prioritize. If you got scanned, you need to request, um, but it's always important that you finish all your discharge letters for the day so that those patients could get home to their families at a reasonable time on so that new patients coming in from and you can take the beds on the Lord's um, Hamas on a med odor tourer asks if there is any particular resource you could remember recommend I'm assuming for Let's split it up into discharged letters and also for special to your phones. Uh, so for discharge letters, I'd say, mostly learning through examples have not seen many resource is available online. That's why I decided to include examples off. Just joined some reason I've seen in this talk eso refer to this talk about their mind. The Sleep and Kiki Medic pages on writing discharge summaries, although just to point out the key key Medic article seemed a bit quite long, but it's mostly things you will learn on the job discharge summary so you'll see you learn through reading the destroying summaries of your other colleagues, and it's a skill. Both needle and I have learned what's on the job. So two skill you perfect as you get along, uh, in terms of specialty referral, so again I would practice, Espo. So, uh, mind the sleep and Kiki medics have useful page. Page is on how to practice your s four, but that's about it. Really. And referring to that, uh, mindedly cheat sheet but again, learning it's mostly learning on the job. I don't know whether you have anything to add to this, Neal. I agree. I think if you want to look into this shows, um is a bit more you can reflect back on this video. Um, well, posted to the metal page and also to him on the beauty General, you could just click paws on the good examples and read through and see, you know, try emulate, die in your own work essentially on for special referrals, the best resources, the mind, the sleep fell jeeps, she which I've just posted linked to in the job. Any more questions, guys? Or come, you wrap it up and go to enjoy this lovely weather? We'll just get another minute. Also, you know, anyone go? Any questions? I think not sitcoms. I think everyone's good. It was a very comprehensive talk. So I think you did cover everything. Um, should we call it a day? Yeah, All right. Thank you, everyone. So I wish you guys, although best Well, you're F one and again. Just remember, like, both me Holla and I were in the same situation. But you learn on the job, and, like, I'm sure you guys will enjoy it exactly. Guys, you guys have got this far. You've gone through five or six years of medical school. Passionate Sam's very tough exams. You guys prepared for this? I know it seemed daunting, you know, having to speak to different specialists over the phone. Um, but it's It's a skill you learn with time on every time you get more comfortable with it. Um, unless you're referring to, certain radiologists are grumpy. Uh, but yeah, we'll leave that talk for another day. Good. Look, guys, I'm sure you can. We'll do it. Yeah, well done for passing medical school and good luck. You're finally getting paid now, so you should look forward to it. Exactly. Thanks, guys. Bye. Thank you. Bye.