GP Lecture
Summary
Join us for an insightful on-demand teaching session which provides an overview of topics that could potentially come up within a medical finals exam, focusing particularly on general practice (GP). The course will touch upon a range of specialties and conditions relevant to primary care. These include respiratory disorders (emphasizing asthma and COPD), hypertension, diabetes, minor ENT issues, neuro issues (such as migraines and Bell’s palsy), gynaecological aspects (contraception and HRT), dermatology, and rheumatology (focusing on polymyalgia, gout and arthritis). The objective is to equip medical professionals with a well-rounded understanding of these topics, albeit at a relatively superficial level, to help them get a grasp of the main points. The course also reviews certain aspects related to the diagnosis and management of asthma and COPD, providing insight into current NICE guidelines, test thresholds, and treatment pathways. Get ready to enhance your understanding and application of these crucial areas in a clinical setting.
Learning objectives
- Participants should be able to understand and interpret diagnostic criteria for asthma including the importance of spirometry and the Fraction of Exhaled Nitrous Oxide test.
- Participants should be able to identify the symptoms and potential triggers of asthma and differentiate them from symptoms of other respiratory conditions.
- Participants should gain a comprehensive understanding of the Nice guidelines for treatment and management of asthma.
- Participants should be able to diagnose and understand the causes of COPD, particularly the relationship between chronic smoking and COPD.
- Participants should be familiar with a range of medical conditions presented in general practice, including respiratory conditions, cardiovascular conditions, endocrine conditions, and ob-gyn complaints, and understand the primary care approaches to these conditions.
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Hi. So there'll probably be another you join in the next few minutes. But, um, we could start shortly and then you should have got a wee email hopefully over the weekend and we kind of change in the way we send out the sides. So instead of the med portal, I'll send a wee feedback link into the group, chat up the, to the chat on this at the end. Um, and then if you feed it and fill it and then you'll get, um, an attendance Ceric and you'll get the slide sent out to you. Um, so hopefully you'll get an email about that over the weekend. So I'll send that in at the end. But, um, we'll make a, we start now and then sure if anyone else is joining, they can join and join it. That's you, Kitty. Yes. Thank you, Mairead. Um, so yeah, I'll just get a, I'll make a start now and then if anyone else joins, that's fine. So, yeah, I'm doing the talk on general practice this week. So I don't think it's a topic that anyone is really, or should be really that stressed about. So, it's something that is kind of covered in every other specialty as you will know. So I thought I would just give like a good overview, kind of, of everything to touch on, but it's really hard to be exhaustive. Um So yeah, this is like a overview of all the topics in finals and you'll see that there's a little bit of everything in GP in different kinds of degrees. So I decided I would look at the, I think this is like the GP gems that was on the portal. And I saw that this is, I think Helen Reid, who's the lead for GP. She highlighted a lot of topics I think from the um UK MLA content map that I think that she thought maybe should be focused on and I know they're not setting the, your writtens this year, but like your acies, I think this is like a good overview, especially based on what we got. I think in our past fourth year and fifth year exams, the ones that I've highlighted here that were highlighted across those two lectures are a really good place to start and kind of focus on. But anything there could come up as a GP topic, but there's nothing I'm going to do to tonight that you won't have covered in the other specialties and won't be probably mentioned in the other talks. So everything that I'm going to talk about is probably quite um service level on what you could go into in other ways. So this is what we'll be covering. So you can see it's like a wide range of different specialties that, um, will, will all have peer share talks in different ways as well. But I just thought I would cover like the main topics to know, um, from each of these. So you'll see, like respiratory asthma and COPD are the big ones, cardiovascular really hypertension in terms of GPI think they love their antihypertensives and things like that. Um Endocrine, I just went for diabetes because it's such a big topic in itself. Ent um you know, just sore throat and painful ear are the main things that you'll see in primary care, neuro, just um migraine as the main headache thing that you'll see. And Bell's palsy as the main facial palsy, you'll see obs and gynae mainly contraception and H RT and mostly focusing on how you would counsel those in a, in an ACY. And then Derm, there's so much to cover, but um just a lot of this is just being aware of the kind of treatment and management of them. And then M SK and rheumatology. Um these are three, three conditions that you see a lot. Um So that's polymyalgia, moa gout and arthritis. So I won't be talking through all the details on each of these topics, but just kind of touching on the main things to know and then you can do your own further reading I also didn't, um, put in like cancer red flags, which I know is a big topic for GP, which is just too much to go into, but I could add onto the slides if they're going to be sent out. But it just would be too much to go into tonight because I know it's, um, still Easter holiday. So I know you wouldn't want to listen for too long. So I'll try to make this kind of short and sweet. So the first topic is respiratory and decided to focus on just asthma and COPD, which is obviously the big ones and there's probably nothing I'm going to say that you won't already know about to a certain extent. So first of all, there's diagnosing asthma. So there's kind of the three main age groups that have different um criteria criteria, sorry for diagnosing asthma. Um But the main thing to see here is that in under fives, you won't be doing really any objective tests. You'll mainly just be treating symptomatically. Um So kind of just your own clinical judgment and usually that will just be given on Children a reliever if they're short of breath. Um And then you'll see that for 5 to 16 year olds, you'll usually be using the spirometry and the bronchodilator reversibility. And then in the next slide, I'll now go into adults. So 17 and over and kind of the different objective tests you can use to diagnose asthma in them. So this is the nice guidelines for diagnosis of asthma and it looks kind of complicated, but I'll simplify it in the next slide. But you can see in this blue box in the bottom, I thought it was good to focus in on it. So it's part of that nice guideline and it has the positive test thresholds. So even if you just learn those in terms of what to watch out for, so you'll see um the different things. So for the spirometry, knowing the F EV one F EC ratio being less than 70% for the um for the fraction of exhaled nitrous oxide, knowing just the number 40 for the bronchodilator reversibility knowing 12% and for peak flow variability, being aware of 20% just it makes kind of any questions that where you'd be diagnosed with asthma in someone a lot easier. So this is kind of the way I've simplified the different tests. So you'll see that at the top we have if someone's symptomatic, so you'll be aware that the main symptoms of asthma will be someone with a cough, a wheeze shortness of shortness of breath, particularly if there's kind of a daily or seasonal variation, um history of op in themselves or family history. And then if they have any known triggers for the symptoms they are having. So there's four different um tests that you can do. So you can do the spirometry, which you'll know is the, is the obstructive picture of a ratio less than 0.7. There's also the bronchodilator reversibility. Um So you should see that um with a bronchodilator, um their F EV one should improve by at least 12% or increase or their fe one increases in volume by at least 20 MS um peak flow variability. You would see a variation of at least 20% particularly night slash early morning. And you should see, as I said before, the um fractional exhaled nitric oxide of about 40 to diagnose um asthma. Then by the nice guidelines, you would want to have someone having symptoms and at least two of these four tests being positive. So having meeting the threshold and at least two of those, so you'll be aware of this from at least first year. Basically that just to remind you being familiar with this graph, you could be presented with it in an OS maybe if someone had done the test just to recognize. So that kind of curved picture you'll see in an obstructive picture that you see in someone with asthma. So you can see in the, in the top right, the graph is the dark blue line as the normal person and then um the red kind of meeting the same, meeting the same um volume eventually, but um just from the very start teetering off to be lower. Um and then the other one on the left is just it by itself, you can see how you measure the F EC um with the dash line at the top and how you can measure the fee one with the dash line at the bottom. So this is another nice guideline. This is for treatment and management of asthma. So you can see just um you can look at this in your own time in more detail. But the gray boxes on the left are the maintenance therapy that a patient is going to be on. And then the blue box is going to be the symptomatic relief they're on. So you can see that um from the very start, they're gonna be um started with um a Saba as symptomatic relief and a low dose um I CS as their maintenance therapy. But I've simplified this again on the next slide. So a good way to think about it is um in someone with asthma, they're gonna be as an adult, they're going to be started on a low dose, inhaled corticosteroid and a sad that as required. And then at each step here, you're going to be reassessing their effectiveness every 48 weeks usually. So then um you can move on to, then try if that's not effective, try a leukotriene receptor antagonist. And then you want to see if they're responsive to that, you can go down the left hand side and if they're not, that's not really effective and they're unresponsive to that going down the right hand side and you can see in a GP question, you're really not going to be going past probably that third step before you're thinking about um referring to respiratory or needing specialist help. So I think um this applies to most GP questions. It's going to be the 1st 2 to 3 steps of care before it's kind of beyond the threshold of of probably GP management when they're first starting a patient on any treatment. So then um the other big hitter for respiratory is CO PD. So the main way as you're um diagnosed CO PD is usually gonna be in a smoker, um who's over 35 and is symptomatic. So the you're usually gonna see exertional breathlessness, a chronic cough for longer than six months, someone having regular sputum production, winter bronchitis or wheeze. And in, actually, in our um 1st 4th year exam had a history from someone with a respiratory symptoms and they were short of breath. And I think this scale that I found on nice um is a good way of thinking about, you know, if someone's short of breath trying to quantify it because I think it's not enough really to say it, someone's short of breath, you want to know a bit more about it. So you can see like grade one is someone who's not um trouble about breathlessness at all with strenuous exercise. And then right up to grade five is someone who's too breathless to leave the house or breathless when they've been doing like their ID LS like dressing or undressing. Um You'll see then that a person with COPD is gonna have a, the obstructive issue of less than 70%. And also if you do a full blood count on someone with CO PD, they're often gonna have polycythemia as well. So another way, um you could pick up CO PD is in a chest X ray. So three main ways you can notice that if someone has hyperexpansion on a chest X ray. So if you want to count the anterior ribs, you, I always find it quite a bit awkward to count anterior ribs. But if you go by the ones that are going diagonal, slanting downwards, that's your, that's what you count. And if you count from the mid ocular line, that's how you're gonna see, you know, what is able to um be counted as an anterior rib. And then you'll see here, at least the seventh is hitting the diaphragm there that you can count to the midclavicular line. If that makes sense, you'll see the dia, the diaphragm is a lot flatter than you would see in a typical patient. And the green line is where it would usually be sitting there. And then you can also just see general chronic changes in the lung fields. Um So first ay tip I thought I would put in would be on teaching someone how to use a peak expiratory flow meter. So I'm sure everyone's done this before, but it's one of those things you could just forget how to do and think you remember how to do it and then get caught out in the day. So just remembering the different steps like attaching the mouthpiece before um setting it to zero, asking the patient to stand up straight, stand up straight, taking that really deep breath and then doing that fast blast, not a slow blow. Um And then repeating that about three times at least and taking the highest of that. And um and whenever you, if you were in an ACY, you'd be comparing this to a chart for the patient's um height and age and remember to always um show them how to do it yourself and then ask them to repeat it back and then if they're making any mistakes, correct that and ask them to do it again. So for um CO PD management, there's, this is the nice guidelines as well. So I'm sure everyone's quite familiar with this as well. So remember just um you're Saba or Saa reliever. Um and then when you're moving down the um treatment pathway, think about their asthmatic responsiveness. So if they have no asthmatic features, you're going with a laba or a Lama and if they have asthmatic features, you're going more laba or an I CS. Um So you can, you're probably familiar with that, but making sure for any G PMC QS that is probably gonna come up at least once um because they love to test people on it. Um And then just another um OSK Q tip very similar to the peak flow meter about um the different ways to um show people how to use their inhaler. Um And remember that it when you're a safety net, someone who has a diagnosis of asthma, um how to use their inhaler, remember to tell them that if they're needing to use their inhaler, um you know, and it's not working and it's not helping after they've used maybe taken 10 puffs, they need to call an ambulance because they're having an asthma attack that, you know, is refractory to inhaler and they need to go to the hospital. Um But then there's all the different things for to remember that are very similar to the peak flow meter. And remember and if it's a um steroid inhaler to rinse their mouth out after because they can get oral thrush if it's a COPD patient that you're counseling and then something that um can be um forgotten about a bit as a potential GP station. Um I don't know if it's ever come up but it's something me and my friends were a bit worried about and really had to look into. How would you do that is smoking cessation counseling because I think Helen Reid mentions it a lot about the importance of um as part of management for anyone with CO PD, making sure they get their, their flu vaccine and making sure that they, if they're smoking, that is one of the biggest things you can do is to convince them to stop smoking in terms of their like, um morbid, improving the morbidity and mortality, mortality. So a good way of structuring and this, this is taken directly just from geeky medics. I find really helpful if you're ever counseling someone on smoking cessation is these five A to give you a bit of a structure. So the five A are ask, advise, assess, assist and arrange. So you would start obviously with any counseling is taking a history of the um the patients, see where they're at, see what um products they're using. Is it, is it um cigarettes, the kind of tobacco? So, and then their smoking status, how much they're currently smoking? And then you also want to want to ask them other questions um to get a gauge of where they're at in terms of what their, their understanding is of the risks of smoking to their health. Then you can advise them with some um advice on the long term risk to smoking. Um Maybe whatever something they might not be aware of, particularly, maybe if they have concerns about a friend or a relative that's been recently diagnosed with COPD or lung cancer, you know, um advising them maybe on what their risks are relevant to that relative to that and also how it's increased being a smoker, then you want to, um, understand where their, you want to understand and assess their understanding of the consequences after you've maybe had that chat with them and their level of motivation in terms of, um, stopping smoking because you might tell them all that and they're still really a bit hesitant and then it's hard to get anywhere with someone if they're not really, you know, on board with um stopping smoking. So you want to see where they're at and then you can kind of tailor the advice and assistance you, you're going to give them based on that. So this then brings you to assist. So, Gig Me also had a good way of remembering how to do this, which is star. So that's set a quit date, t tell family and friends, uh anticipate challenges. So that's like, um someone might think, oh, you know, on Monday, whenever I used to have that um project at work, it's going to be really hard to, um, not, you know, buy a pack of cigarettes then or I've got this thing coming up. It's really stressful and I don't know how I'm going to go over that. So you want to know in advance what those difficulties will be and then r would be removing all tobacco products. So, you know, if they have any cigarettes in the house, getting rid of them, it makes it a lot easier for people to quit smoking. And then um you want to assist with things like nicotine replacement products, products. So like patches gum. And then also you can refer to someone if they would be interested on smoking cessation counseling where they could have um mediums once, twice a week in a group setting. Um and that can help some people a lot as well. And then to end um a consultation like this, you would want to arrange a follow up. So you could say you can um give them this plan and then say, OK, I'll see you in a week or two and we'll see how you're doing. So it's always great with any counseling to arrange a follow up appointment at the end of the station. So that's the end of respiratory. So we've move on now to cardiovascular. So the main thing I just thought I'd focus on is hypertension because um it's a big one with GP that you'll see all the time. So everyone's probably familiar as well with this algorithm. So knowing whether to start someone on an Ace or ARB or a calcium channel blocker. So, you know, if someone's Caucasian um less than 55 and often forgotten um diabetic, you start them on an ace inhibitor or an ARB. Um And then if someone is uh um a black patient or over 55 you want to start them on a calcium channel blocker. And then I'm sure you're familiar with the, um, working down that. Um, and then, um, something that can be a bit tricky is at the bottom there. You see about checking someone's potassium. So, um, once you're on to that, when you're adding 1/4 drug, knowing that if the potassium is over 4.5 the fourth drug you want to add is an alpha beta blocker. And if it's less than 4.5 you can add the spironolactone because you don't want to add spironolactone, which is potassium sparing if someone's potassium's already a bit on the higher range. So, um that's definitely something to know for your MC QS with anything GP, it could definitely come up. Um And then just knowing your hypertension diagnosis. So the cutoffs. So if someone's in clinic, the cutoff is 100 and 40/90. But if, um and then if they have two elevated readings in clinic, so you wouldn't really diagnose hypertension just based off 11 off um recording of their BP in clinic. So if you, you've seen them twice and it's in clinic and it's been um 140 or above systolic, then you might want to give them the ambulatory or the home BP monitoring and then your threshold for diagnosis and hypertension at that point would be over 100 and 35/85. But then if it's um over 180 or symptomatic, you're on just like some of the warning signs of malignant hypertension, then you want to send them to the hospital because that's malignant hypertension. So then another OSK station that could come up in terms of hypertension is the anti hypertensive counseling. So you're probably quite familiar with this as well. So, you know, the athletics um way of remembering counseling, I don't really use it, but a lot of people like it for structuring an Osk station um for counseling. So you know that um how to explain for hyper antihypertensives that controls BP by reducing hormone action in the kidneys. You take one once a day and it's a tablet. So the length of time someone takes it will usually be lifelong. They wouldn't really um ever really stop it and you'd be reviewing them and doing bloods every 1 to 2 weeks at the start. Um You want to check their kidney function um because you want to stop it if their creatinine rises by over 30% when they first start it. Um And then you want to um counsel them on potential side effects such as the dry cough, um potential harm to their kidneys and hyperkalemia and then they shouldn't take it if they're pregnant or breastfeeding. Um But then you are probably quite familiar with that and you would obviously always give a leaflet as well. Um But that would be probably a um a station that would be led by patient questions as well. So I wouldn't be too concerned with the structure. So then we move on to endocrine. So, the big one there I just thought was diabetes because it's on type one and type two is a big enough topic in itself and you would see all the time in primary care. So, um, I thought I'd start with diabetes type two as it's a very common one that they like in GP. Um, so obviously if you're managing anyone with diabetes, first thing you're gonna, um, try is lifestyle advice and don't, um, just jump the gun straight to drugs. Um, Metformin, um, initially would be your first drug, um, 500 mg once daily with breakfast and then you would titrate that up as needed. You'd be targeting, um, H A HBA one C of 48. And then if that rises to 58 or above, then you would start adding, uh, sulf sulfonylurea, SGL T two, pioglitazone or DPP four. And then I'll talk a bit more about those on the next slides. Um, but remember, um, to consider, um, the risk, the risks with the ST LT two and the glipiZIDE. Um, and then you'll be choosing that third drug just based on the patients, um, themselves. And there are different risks. And then for the fourth drug, you'll be adding another one, but that's, um, dependent on the patient. And then just that last star at the bottom is remembering that, um, patients when they put on Metformin can have some gi side effects. So they can get a unhappy stomach kind of um, nausea gi symptoms. And then you can sometimes, um, change them to modified release instead. Um, if they're not tolerating, um, the Metformin at first. So for diagnosing that um, diabetes, I'm sure you're quite familiar with the differences between the type one and type two. And if someone is symptomatic, so this is someone who's having polydipsia polyuria recurrent infections. Um you want to check their fasting glucose, which would be um seven or above ran glucose, 11.1 or above. If you're doing an oral glucose tolerance test, um it would be 11.1 or above as well. And then, as I said before, the HBA1C is um 48 or above. Um And remember that if you're a patient is pregnant or any condition that raises their um turnover of red blood cells such as hemolytic anemia, HBA1C can't be used to diagnose diabetes in them. So this is quite a busy slide, but this is just um the main, the most common way you're gonna see type one diabetes be um managed is with the basal bullous regime of insulin. So the long acting ones to be aware of, the main ones are Lantus or Tresiba and the long acting and a basal bullous um regimen is usually given at night and, and just remember to not stop that ever um in A DK. And then also the short acting ones you should know is mainly novorapid. That's the most common one you're going to see and that's given with meals. Um, and, um, remember that if their blood glucose is low, you're gonna be reducing their insulin and if their blood glucose is high, you're going to be increasing their insulin. So a way that you could see this in OS is being given this insulin monitoring chart, um, and you could see that they're going high or low and you may need to alter their, um, insulin. It wouldn't be anything too difficult. It would be something very, probably glaringly obvious that they're going very high or they're going or they're having high both. Um, but just remember that if their levels are high or low, um, before breakfast, you want to increase or decrease the bedtime, long acting insulin. And if they're um, high or low before lunch or dinner or bed, you want to increase or decrease the rapid acting insulin given um, before the meal. And if you're ever changing someone's insulin, it's always safest to adjust by around 10%. So don't make any big drastic changes either way. Um And then you want to be, um, in an ACY, you would be saying you'd be close monitoring them after um, any changes that would be made to insulin. But for example, if they're on um, a dose of, say 20 you would only want to change, um, down to 18 maybe lowest you'd want to go is maybe 16. And then up to 20 or 24 I wouldn't be making any changes more than 20%. Um, but I would stick to about 10% as a rough rule for if you're ever changing someone's insulin. So, oh, and then just to remember on your diabetes, sick day rule, so, never insulin went unwell. So it could be, you could get an OS station where someone's been sick, um, and admitted their insulin and just, um, counsel them on that. So if someone's type one, remember to always continue your insulin as usual if you're sick and check your blood glucose more often than usual. So at least every four hours and if someone's type two, they should continue as normal on their medication, but just be careful um, with their Metformin if they're quite dehydrated, um, ensure to ha always have adequate fluid intake and um, consider sugary drinks if they can't keep down solids. And it's um, the sick day rule should always be something that you're um mentioning if you're ever counseling someone on their diabetes because it is something that people with diabetes need to remember. Um, and then I mentioned before about the drugs, um, the type two diabetes. So, um, sorry, I think the slides are a little bit mixed up here in this diabetes section, but these are just the different, um, drugs that you could be using for type two. And some of the things to watch out for or I've mentioned just there. So that's a nice guideline, which is, there's a lot of information, but um I've just highlighted to warn people about acute metabolic acidosis risk with Metformin. Um There's a contraindication if anyone's ever had bladder cancer not to give them pioglitazone. Um There's a risk of weight gain with pioglitazone and sulfonylurea. So if someone has a very high BMI, I wouldn't put them on those and there's also an increased risk of hypoglycemia on um sulfona. So if someone's taking that, I think they need to their blood sugar monitored more because there's the risk of that hypo. Um But I remember finding that um half me was quite good with the questions on getting the hang of which of these drugs to give people because I find it quite hard to get my head around. Um And then for counseling anyone on diabetes, you would know just to mention the different microvascular and macrovascular complications. Um So, you know, like the retinopathy, the neuropathies, um the nephropathy for the microvascular and then the macrovascular being the peripheral arterial disease, cerebrovascular events and um ischemic heart disease as the big ones to um always counsel people on there need to know. And then another ay that um we definitely come up for you guys is the diabetic foot exam, probably not as much. Um As 1/4 year, I wouldn't think I wouldn't, I would think of it as definitely for finals, it could come up as like a nasty GP station, but it's something that you could just forget to go over. But um, it's something you should definitely be aware of. So, the diabetic foot exam, I'd like to think of it as inspection, looking for arteriopathy, looking for neuropathy and then checking the footwear and gait. Um So for inspection, you're looking to see, um, hairless in the skin being hairless, pallor fissures, ulcers, signs of dystrophy or ingrown nails. We're looking in between the toes of the web spaces for cracking or ulcers and then also just general deformities of the foot. So the Charcot joint, which is the picture you'll see on the top right there. So that's only deformity of the foot, usually during the neuropathy that um forms over time, people having claw toes and also checking their bony prominences. And then looking for arteriopathy, you're gonna feel their the temperature. So you're gonna go from um about the knee down, you're feeling temperature. If it's symmetrical, you want to feel their pulses and you want to check their cap refill. And then for neuropathy, you want to do just your their touch sensation, then you want to do um test on their sensation of the 10 g monofilament. So that's that picture there on the left. So that's um using that device and you're pressing those um those points highlighted in blue and seeing if they can feel that checking the vibration sense with the tuning fork and then also proprioception and then you can do this at the start or the end of the consultation depending on what you prefer. But you want to look at their feet. Um, you want to look at their footwear, what they're wearing on their feet. So, are their shoes appropriate? Are they symmetrically worn down? So you might notice there's a bit of a wearing down asymmetrically in their feet and you might think they may, may need a referral to podiatrist to get on different footwear. And then also you want to have a look at them walking to see their speed steps and turning and then to complete any diabetic foot exam, you would want to say you would do a full neurovascular exam, their ankle brachial pressure index, stop their arterial pulses, get the blood, their blood glucose and HBA one C to see how their diabetes is generally being um managed. So, oh and then just for ent and just um lightly touching on just sore throats and painful ears because they're the things you see all the time in GP. So for sore throat, I think the a good thing to be aware of is the two scores, the fever, pain score and the center score because you want to know really if someone has a sore throat do they need antibiotics is the big thing to be aware of. And in our fourth year exam, we had to score them. I can't remember. I think it was the fever pain score. Um You'd have score someone with the fever pain score and prescribe um the, the pen V in um their cards. So you could use either of these and you'll see for the fever pain. So whether they have uh there's one point for each of if they have a fever, the pee is purulent to, to tonsillar exudate, which you see in the picture at the top, if they've attended within three days of onset, if they have severely inflamed tonsils, and if they have no cough or cry, sometimes people forget it's no cough. Um and then for the center score, it's also one point each of for um tonsil exudate, tender anterior cervical lymphadenopathy, a history of a fever over 38 degrees and also no cough. So they are, they are quite similar and ii don't know if you would need to learn them off, but definitely be aware of each of them. But you can see in the nice guidance that they say using fever pain or central scoring. And this is to help you with knowing whether to prescribe an antibiotic for someone. So um remember if it was ever talking to someone with a sore throat, you want to tell them that a sore throat normally can last about one week and you can manage a lot of the symptoms with self care. But then if you are considering an antibiotic to just be aware of a score of or one, you're not going to offer them antibiotic. If it's two or three, you can either can um not prescribe them antibiotic or prescribe them a delayed prescription. Maybe to say if it's not improving in the next few days to pick it up. Um But that's probably depending on your own clinical judgment of the patient along with that score. And if they're scoring a fever pain of four or five or center score of three or four, then you want to prescribe them the phenoxymethylpenicillin. Um So usually you prescribe most often 10 days of it. And then if they have a penicillin or allergy, you can give them Clarithromycin or Erythromycin for five days. And then another sore throat just to be aware of as well is um I thought infectious mononucleosis, it was in that GP Js lecture and I thought maybe it would be a good one to be aware of. So it's the trial of the sore throat fever and lymphadenopathy to diagnose this, to diagnose this. You're going to um use the monospot and test and see um lymphocytosis in their full BP. Um be aware that they can have splenomegaly and then they have a risk of splenic rupture. So you um you want to advise them to keep away from contact sports. Um and then uh one kind of fact that is very examinable and comes up in TQ SA lot is that if someone has um this and you give them amoxicillin, they'll come out with this maculopapular rash. So either that can be very good for seeing what it is and then also knowing not to give them amoxicillin if you know that they have it. And then something to keep in mind as a wee point is if someone has a sore throat and they're on either carbimazole or cloZAPine, think about the risk of agranulocytosis with these two. And then whether they need that's dangerous, they need to be referred if they have a sore throat because there could be, you know, a sinister infection happening there. So, and then just lightly touching on this, the painful ear, you see all the time in GP, I'm sure it's been fully fully covered in um ent, but just remember in both Otitis media and Otitis Externa. Um So the Otitis media usually, yeah, you recover resolves in 3 to 7 days and usually all you'll be doing is giving someone on paracetamol or ibuprofen for their pain or fever. But if you are going to give them antibiotics, it's usually because they're systemically unwell or they're not improving after at least three days. So usually first line for this is the amoxicillin for 5 to 7 days and you can give them Clarithromycin if they have a penicillin allergy. And then also just keeping in mind the Otitis externa or um often especially come up in M CQ as a swimmer's ear. Um, common, um, causative organisms are the pseudomonas, aeruginosa and staph aureus. And if it's mild, you can treat it, treat it with 2% acetic acid and if it's moderate, you can give a combined topical antibiotic with a steroid. And that's most often the given as the IZED ear spray and then the picture you see there is just being aware for, um, your acies being familiar with what the Otitis media looks like. So you'll see the left is a normal ear. Um So just being familiar with where you see that cone of light, um and whether that's still visible and then on the right, you'll see the the difference really. So you'll see the bulging membrane, the prominent dilated vessels and the opacification. And then you can often also see that fluid level if it's a blue ear as well. So, and then just something to keep in mind, this would be covered thoroughly in your peds lecture. Um But just in primary care, being an aware of an unwell child who needs to be referred to hospital. So mainly that's being aware of everything in that red column on the right. So the high risk patients. So, um and then also as a as a nugget for primary care, if you're suspecting meningitis in an unwell child, um you want to immediately transfer them to hospital. Um But in primary care, while you're awaiting that transfer, you can give them a single stat dose of um, benzyl penicillin, but it shouldn't, um, delay transfer to hospital at all. Yeah, just being aware of that red, red column mainly for an unwell child, but you'll be completely covered on that within your repeats um, lecture. So then just moving on to neurology. So the main two things for this in primary care that you're going to see all the time is just migraine and Bell's palsy. So, um obviously, you can, there's a lot to cover in terms of headaches. Um and there's different ways to think about how to categorize different headaches that you might see present. And this would be very common in acies as well as MT Qs, but just migraine is that typical one to definitely be familiar with. Um as you see all the time in GP. So that's your unilateral headache, which is throbbing can last from hours to days, typically has a prodrome of a warning that someone's going to have it. And it's most common in ages 20 to 50. So, um for differentiating the different headaches, you can see the picture at the bottom. Typically, your migraine is going to be the unilateral. If it's a type a band across the head, forehead, you're thinking more tension and then if it's centered around the eye, you're thinking more of the cluster headache. And then also that picture on the right with the patterns I thought it was really good. That's from almost a doctor.com for your different timings. So you'll see that the migraine will come on, you know, really bad and then slowly tailor off over the hours today's. But, um, there's different kind of patterns you'll see with the other ones. So they're all quite different. So, if you're familiar with those, it tends to be a lot easier to identify what kind of headache you're dealing with, even outside of all the different things that you can use to differentiate them. But if you are thinking this is a migraine, um for acute management, typically you would give an oral triptan um with an NSAID or you can give the oral triptan with the paracetamol. And if they're also having vomiting, you can give them an antiemetic but be careful not to give them opiates because that can make a headache much worse. Um And then for preventing migraine in people that get them regularly. Um It's good if people can identify and avoid triggers things like chocolate and alcohol and poor sleep and stress. The drugs that are typically given for prevention of migraine is topiramate pol or amitriptyline. And then if you're advising um someone um like S and Oy who's having headaches, you want to encourage sleep hygiene, adequate hydration, eating regular meals, um limiting caffeine um to a max of two cups per day, regular exercise and relaxation. And then always keep in mind your red flags for any headaches. So, um this kind of differentiates all the different headaches. You're thinking if you, even if you're thinking that someone is having a migraine, um if you're taking a history with the headache, always ask all of these questions cause you don't wanna be missing something like a subarachnoid hemorrhage or raised intracranial pressure caused by um cancer like meds. So you wanna check if they have fever, photophobia or neck stiffness and you're mainly thinking probably meningitis, um any new new neuro symptoms at all, any visual disturbance. So that's the giant cell arthritis, glaucoma. Um And if it's a sudden onset, you're obviously thinking about your subarachnoid. If it's worse on coughing or straining, you're thinking that raised intracranial pressure and, and then the same with, if it's postural worse on standing in line or bending over, um and vomiting um is something I always would forget for raised intracranial pressure and also carbon monoxide poisoning as well. So that's just kind of a, a overview of headaches, particularly migraine, particularly migraines. Um And then facial palsy, I just thought I'd focus on particularly Bell's palsy because that's the most common one that you're gonna see in GP. So I'm sure you're all familiar with the that picture there that you see. Um and remember that um an upper motor neuron um lesion spares the forehead. So in this, the entire, the entire side of the face um has a palsy. So if someone for managing it if someone presents within 72 hours, you can give you a course of prednisoLONE. So that's usually 50 mg, which would be given as 25 mgs twice daily for 10 days. Or you can give them um 60 mg daily for um for five days. Um and then weaning it down over time. And then also remember um for, if someone can't close their eye, you need to um focus on eye care because they can get a lot of um eye damage like corneal ulceration and irritation if they're unable to close their eye. And if they're, if they present already with some of the eye damage, you may need to refer to an ophthalmologist. Um but you can get also prescribed eye drops and then just taping their eye overnight can help to prevent a lot of that damage. Then on to OBS and Gyn, this is mainly going to be focusing on contraception H RT, which I'm aware are very, very big topics. So I'm mainly thinking of it in terms of um like a counseling. So I just thought I'd start on contraception counseling because it's such a big one in fourth year to think about. Um, so start with getting your background on doing like a, a brief but, you know, thorough, um menstrual history, the previous contraceptive use if they currently have any chance of pregnancy and then just key on point in their past medical history and drug history, they're already on for any of these, you want to do their ideas, concerns and expectations. So usually they'll have some awareness of contraceptives already and already have an idea of what they would want to start on and they might already have some concerns. So it's good to elicit those at the very start. So you kind of know where you're going with your conversation and then you'll usually find, um, in an ak the patient will direct you towards one that they're, they're interested in. So they might say they definitely don't want a coil or they might say they're interested in the combined contraceptive. And if they don't have any contraindications, then you can start to counsel them on it and something to keep in mind for all the counseling as well is, yeah, giving them a leaflet. Um is something that is always covers you. Um I always start with giving the leaflet just because, you know, you're going to be giving them so much information and I find it's quite a tight for time station. So then you can go into the different types. So I won't go into this all in full detail because I'm sure it'll be covered in the um Gynae lecture. But just being aware of the different types, there are the mode, there are mode of actions, their side effects and risks and importantly there. Um Oh, sorry, there are contraindications. Um So I think it's important to know um the contraindications of different ones, especially for when you're choosing maybe in a conation which one to, to, um suggest to people. Um And then also knowing their side effects. Um It's a good way of differentiating. Sometimes I find difficult to know which one to get people and um T Qs, um people will have different past medical histories that will put you away from specific ones. So it's good to be aware of those. Um And then this page is just the um the intra system. So the marina coil and then the copper. Um So just as well, being aware of those and the um the main complications for those is the um recent pelvic inflammatory disease, undiagnosed PV, bleeding. And if they have any abnormal uterine anatomy, um and then the emergency contraception is a whole another topic in itself which is hard to um get your head around all the different ones. But um keeping in mind for people the different contraindications. So for example, the L1 membrane that um it's contraindicated if they have um poorly controlled asthma is a big one to keep in mind in a potential os station um that you would want to know not to prescribe that one if you find out your patient has that as a in their past medical history. Um then when it comes to prescribing in um primary care, knowing the differences between the UK ME threes and UK MC fours are important because the UK Mac four S, it is completely unacceptable to give um someone if you're gonna be prescribing, prescribing them contraception. So if you, if you know either side of this, definitely know in the UK Mac Four because it is completely unacceptable to prescribe um in these patients. So you want to know if any, um, any prescribing of a contraception, you want to know if they have a migraine with aura. You want to know if they have a personal history of stroke or vte, you want to know if they um, are breastfeeding. You want to know if they're less than six weeks, postpartum if they have or have had breast cancer. And if they have uncontrolled hypertension and then um similar to the contraceptive osk counseling, you wanna know about um their menopause history and then before you even start prescribing it for H RT. So a good way of categorizing, this is um, asking them a bit about their periods. So when their last one was how regularly they were and if they had had any spotting since their last period, and then for you want to know, um, for whether they need contraception. If they're less than 50 they need it for two years. And if they're over 50 they only need it for a further year. If they have any current, any, um, vaginal symptoms such as dryness or itch or dysuria, if they're having any vasomotor symptoms, such as hot flushes, night sweats or disturbed sleep and how their mental health is if they've had any mood changes or any loss of libido. And then for explaining what H RT is, um I'm sure you are familiar with how estrogen and progesterone hormones regulate the cycle and that this production is reduced um when you go through the menopause, um and then that HRT is replacing those hormones to um control the symptoms they've been having and then being aware that it comes in many different forms such as patches, gels, tablets or implants. So, um for prescribing the different HRT types, it can be quite overwhelming. But this flow diagram from the GP notebook, I find really helpful. Um So there are main questions to kind of get you to kind of flow through your head. You can look at that um flow diagram in your own time thoroughly. But the main things to keep in mind are whether they have a uterus. So that's the first thing kind of cover it. If they have a, don't have a uterus, they only need estrogen. Um But then obviously, if they still have their uterus, then they need both. Um And then also if they're perimenopausal. Um So they have, it's been um less than 12 months since their last period, you give them. Um Sorry, I think I typed this wrong. So if they're perimenopausal, you're giving them cyclical because um you're still giving them the cycles of hormones. So um you can see below the box here, the combined sequential monthly cyclical regime. So, Estrin is taken daily and then the progesterone is given at the end of the cycle for 10 to 14 days. And then in the combined continuous, you're giving the estrogen and progesterone daily. So um for further, just another point on on counseling someone in H RT and this actually did come up in our finals is then you remember that when you're counseling someone on anything, you are always kind of giving them all the information, but they're still um gonna make decisions in the end themselves on whether they'll take it or not. So, um it's good to um present it to patients as the pros and cons. So um the pros in the plus box are, you know, the vaso vasomotor symptoms. So the hot flushes and things and the urogenital control. So if they're having incontinence, um cardiovascular protection and then also bone protection and then the side effects, if you think of them as progesterone related side effects such as the PMS like symptoms, breast tenderness and the estrogen related side effects such as the headaches, cramps. Um and also being aware of the um increased risk of vte breast and endometrial cancer and stroke. And then this box on the top, right is just a good way if you're ever explaining um risk, increased risk of breast cancer in patients taking HRT. Um it can be a bit scary if you tell people that if they're a bit worried about breast cancer, so, a way of presenting it is, um, you know, making people aware that if you think of it, like 23 cases of breast cancer are diagnosed in the UK population. If someone's on H RT, um there's an additional four cases in um, a population like that. So if you kind of have um, an understanding of the relative effects of HRT, it's not, you know, making it catastrophically worse. But if you're people are already aware of their current risk, you can see it's just increasing, um it's slightly increasing what the typical um risk is of the average population. And you can see how the risk is um affected as well by different um different categories of people. So it's a good of having a look at that. Just if you're ever explaining H RT to someone or any kind of risk is a good way of explaining it to a patient that isn't as daunting, I think. Um And then we're coming, I think towards the end. So we have dermatology. So um starting with a history of it. Um So taking it as Socrates. So being really good with your dermatology history is really important. So starting um with Socrates, I think is a good way of categorizing it in your head. So it's not only just for pain, if you think of it like sight onset character relapses, associated features, quality of life, exacerbating, relieving factors and systematic features. So, um you want to know where it is? Um Is it in the flexures, extensors? And then always remember to ask, I always would forget about the scalp growing in and back areas when, when they first noticed it and if it's changed over time, the character of it. Um So you want to ask people open questions for this, describe it in their own words, if they have any photographs of it, the color of it, if it's rough or flat and what the borders are like, you want to ask about if this rash has appeared before and if they used anything before for the rash and if it helped you want to um know about pain, itchiness, burning and flakiness and then always make sure if anyone has any um dermatological issues, you want to know how it's affecting their mood. Um Are they avoiding social activities? Are they not going to work? How is it affecting, um you know, their self esteem, are they embarrassed about it? And then you want to know about triggers? So, um it can be occupational if they're um dealing with certain chemicals. Have they used any new skincare products? Are they stressed, um heat and cold intolerance, uh sunlight affected it and any drugs they've taken recently and then any treatments that have helped um that they've tried in the past and also covering your systemic features because it could be related to a systemic issue. So you want to know about fevers, sweats and weight change. So, um I won't dwell too long on this because I'm sure you can look at this in your own time, but just being aware of the different um presentations of eczema and psoriasis and acne because if they're going to come up, especially in the a these are the most likely ones to come up. So just knowing about the differences um for like a spot diagnosis and then um in Table two, just knowing um the different things to be aware of, especially um for complications or emergencies if you're ever counseling any of those to be aware of. Um So for example, with eczema, being aware of risks, um the symptoms of infection such as oozing, crusting blisters or fever. Um but you can look at that in your own time. And then also, um maybe if I send the slides out, I could add pictures to these as well, but I'm sure you are very familiar. Um Then in terms of um management, this came up in our finals. So, um it was counseling over the telephone, a mother with their child's eczema and they were asking some questions. So, um being aware of triggers knowing about wet wrapping, which is um overnight using emollients and then you can see in the picture wrapping, um wet wraps over the emollients overnight can really help with maintaining moisture and preventing itchiness overnight. Um and then knowing the different treatments. So the knowing about steroids and immunomodulators as a further um stepwise treatment further on in terms of um eczema management, if the first kind of greasy emollients and trigger avoidance aren't working at first. So you can see that um that kind of stepwise approach is definitely important to get across in eczema management. Um And likely they're gonna have acute flares and remissions of the condition. Um But emollients obviously is first line and then you can kind of step up with the topical steroids. If they're having the red and inflamed skin about making sure to um affirm to anyone that you're going to be using the lowest potency and the lowest amount of a topical steroid necessary to control. So maybe telling people about the fingertip rule, which is knowing that um a fingertip worth of uh steroid creams should be covering about an adult size palms, amount of skin. Um And then different things like if it's affecting their sleep, you can use a short course of a sedative antihistamine. Um And then talking about if it's severe or extensive, then you're going more into the short course of oral corticosteroids as well. And then being aware, you know, at the end there, um that if it it to be aware of weeps or crusted skin, you may need antibiotic treatment as well. Just one second here. Ok. Um Sorry. So then you're going into the psoriasis So lifestyle change is a good thing to keep in mind for this because I think it's something you can always forget when you're counseling someone on a dermatological condition. Um But the same kind of points to um similar to eczema. So trigger avoids trying to use soap substitutes, um which can be prescribed and um advised to patients as some um soap can really irritate the skin and make the condition worse then similar kind of treatments. So your topical steroids, but you can also give um move on then to like Vitamin D analogs and tacrolimus. If you're going a bit further with the treatment, um you can still give oral steroids or um immune modulators, um such as the methotrexate. And then also further on this would be wouldn't be in primary care, but more um referral to specialist care um would be kind of things like your biologics and your UV light therapy and then Acne management. Um So being aware of how to classify acne is very important because that um is very important to how you're treating it. So being aware kind of with the pictures you could be presented in os with a photo of Acne, asked to describe it and then also asked to um grade it in terms of mild, moderate and severe. So, um you know, in that mild, in that picture on the bottom left is just kind of some blackheads or whiteheads, not too much inflammation and is tend to be confined to kind of one area, mild, doesn't tend to be on, you know, like the back, um or the back of the neck or the chest. Um, then moderate, you're going more, you'll have a lot wider area. It can start to spread off the face. Usually, um more pustules, more inflammation and then severe is, you know, more nodular cystic lesions lesions. So you'll see a lot of scarring with the face, you'll see that they tend to be more cystic under the skin and tends to be more um if someone's describing very severe mental health effect or thinking severe, um and then severe is when you'll be referring past um primary care to a specialist dermatology um clinic or potentially going on rutin. But in mild and moderate, just knowing about for mild topical retinoids and benzyl peroxide or a topical antibiotic. But you're never given the topical antibiotic just by itself. And then the moderate, you want to give a oral antibiotic for at least three months. And if you're um advising anyone to take that, make sure to tell them that um if you're not seeing a difference after six weeks, not to stop taking it, give it the full three months to take effect. And then if they're female thinking about it, you can try the um combined oral contraceptive, um depending on if the patient would be willing to try that and then you can still keep going with the topical retinoid and benzoyl peroxidase in moderate shingles is also something I thought I'd add because you see it a lot in GP. I'm sure you're very familiar with, you know how it presents with that dermatomal distribution that never crosses the midline, which I think is shown very well in that picture there and often remembering that it can present with pain first so someone can have pain um for about 1 to 3 days before the actual rash shows up. And then you'll see that kind of fluid filled vesicles in clusters, um which is good to use that kind of terminology if you're describing a picture of it. Um and then for a diagnosis, it's usually like um a clinical diagnosis, you'd be able to spot it um clearly. But if you're unsure, you could use viral um PCR swabs and then for treatment usually on just your oral antiviral therapy. So the Acyclovir 800 mg five times a day for seven days and then make sure um if you ever noticed in like an M TQ, if it's involving the eye, they may need um referral to ophthalmology as it's dangerous. Um thing to keep in mind is herpes er ophth ophthalmicus. So you'll see, you maybe could see in a picture of the, the shingles rash on the, on the forehead um or across the cheek and then if it's heading into the eye, that's something definitely to be alarmed about um and then also there's gonna be a complication of post herpetic neuralgia where people can continue to have pain for many months afterwards. Um, after their shingles, which can be, which can be quite distressing for patients and then sure you'll be glad to hear. The last topic is MS Ks. So three things that I think are quite common is the polymyalgia, rheumatica, gout and arthritis. So, first one, polymyalgia, rheumatica is something that can um I kind of forgot about in fourth year as a potential GP station or GP um topic to think about. Um which is where you're thinking about your long term steroid therapy. So you could get a steroid counseling station. Um and the patient could be on the long term steroids because they have PMR. So keeping in mind, the kind of typical app presentation of the bilateral shoulder pain or pelvic girdle pain are usually something to kind of definitely make you think about on PMR. They can have morning stiffness for about 45 minutes each morning and it typically your patient is going to be probably over 50 maybe fifties and sixties is probably the most likely age range. You'll see they need to have their symptoms for at least two weeks. So if it's less than that, I don't think you can diagnose it. Um and you usually will see raised CRP or ASR, but it's not necessary to diagnose it. So then for the treatment for polymyalgia, Grammatica you're thinking you had the long term steroid therapy, um, and making sure to taper it over months. So, if you're ever counseling this, making sure to really reaffirm with people to never stop it suddenly because you're risking a crisis. And I think the risk is that patients can start to feel better and think, oh, I don't need this anymore and just stop taking it. But you definitely want to cover that, um, that in people to make sure that um once they start to feel the effect, um you're tapering it down over time and then be aware of the different complications of taking long term steroid therapy, which are your bone disease, skin thinning, bruising and sleep disturbance. Um And then gout I think is a really common topic. I feel like I saw like it definitely came up last year in RMC QS. Um And I feel like um they just like to ask it as a GP topic. So it's your acute monoarthritis, which is your head red hot, swollen, tender joint. Most likely you're going to see it in the N TP of the big toe, just seeing that picture there. So kind of the base of the toe being red hot and swollen and usually a flare lasts about seven days. You're going to diagnose it. Um Usually using a joint aspiration. We're going to see your monosodium urate crystals which are needle shaped and negatively bret. So you probably know that from M CQ revision and they usually have a raised serum urate level as well on an X ray. Um I thought zero to finals had a good um good um diagram here of how it appears. So you'll see their joint space will be maintained but they'll have the lytic lesions punched out erosions with sclerotic borders and overhanging edges. And then in terms of your management, remember the difference between managing an acute flare and then also your urate lowering therapy for recurrent episodes and make sure not to get those mixed up. So for your acute flare, first line is nsaids with always remembering to give them PPI cover um and then you can give them colchicine. But um keep in mind that people who have very bad diarrhea when they're on that. And then if neither of those are working, then you can try a short course of steroids. If you're then going to start um treating for recurrent episodes, you want to make sure it's been at least 2 to 4 weeks after the acute flare is settled before you prescribe them their urate lowering therapy. And this is going to be allopurinol or FOXO. And when they're all this, make sure to monitor their serum ur every three weeks. But also for anyone with gout, you want to be moderate, moderate, fine, the risk factors which are losing weight and then avoiding purine rich foods. So this is your red meat and seafood and also avoiding alcohol. And then I think this is the last topic here. Um, so arthritis is something I'm sure you are very familiar with. So, just knowing about, um, managing people with osteoarthritis and rheumatoid arthritis in primary care because a lot of your patients, especially with an aging population are gonna have, um, have arthritis. So, just knowing, um, osteoarthritis, you can diagnose without an X ray. Um, if they're having um, activity related pain and no stiffness and then the rheumatoid consider referring, if they have persistent sinusitis. Do you want to order your anti CP and X rays and um, being aware of treatment side effects? So things like if you, if you have a patient that's on methotrexate, um monitoring their lung function because there's a risk of pulmonary fibrosis when they're on methotrexate. Um, long term. Um, and then just something I thought I would add at the end for kind of like a topic, um, a topical thing to think about with, um GP in terms of Aussies, which I didn't, wasn't really aware of is the telephone history, um, or just speaking to anyone over the telephone in NAS because I found it was something, it came up in our fourth year and our finals. Um, each time one, at least one station where you're talking to someone over the phone and it'd be a bit off putting. I kind of surprise you if you weren't really expecting it. So I thought good things to keep in mind if you're ever talking to a patient over the phone and that will usually be, um, really in and off. They'll have a phone in front of you and they usually tell you it's on speaker. So you might not actually need to hold the phone up to your ear. It depends probably on the marker and they'll have like a board just between you and the simulated patient. So you kind of just imagine you're talking to someone over the phone. So things to keep in mind that kind of just look really good and very confident if you're speaking to a patient in a consultation and it's over, the phone is asking them just um are you free to talk at the moment? Can you hear me? OK. Is there anyone else present on the call? Because obviously when you can't see, you don't know if they're with a phone, family member at the time or with, you know, a friend or if they're at work. So, yeah, um their location, you know, where are they at the moment? Are they in public? Um Can they talk about sensitive information if they're, you've called them and they're in the middle of a crowded shopping center um and ask them if they've sent any photographs. So the one we got in our finals was the um the mother talking about eczema and she said that she had sent you photographs as well. So you had those to look at um while talking to them over the phone and then for the end of a um patient consultation, you want to think about safety netting when it's on the phone. So just you need to think about, depending on what they've told you. Is this something that needs a follow up with face to face? Do you need, is it something like um it sounds like a stroke and you need to call an ambulance while you're still on the phone with them or do you need to tell them to attend A&E, um, and you want to ask them if they've taken any medications maybe before calling you such as taking their inhaler, if they're having, they think they might be having an asthma attack, they're taking their EpiPen or if they've taken an aspirin you're thinking about, um, if there's a risk of having a stroke. So that's everything I know that was all very, very fast. But I thought, um, on your Easter holidays you don't want to be listening to me for more than an hour and there's definitely a lot more to cover in GP. But I would say it's something to not stress about at all because if you do all your other revision of all your other topics, you're probably covering most things that will come up in GP. Anyway. So I think it's just something to kind of always refer back to when you're doing any topic. Think, how could this come up as a GP station or how could this come up as a GP question? But don't worry too much about doing much GP revision by itself because you'll usually be fine and it's something I kind of thought about more towards getting closer to the exams on covering. So I wouldn't stress too much about it at all. And if you have any questions, just send me an email um, with any questions you might have. Um if you have any questions about A or Mc Qs. Um, but hopefully that helped and thank you for listening. You're good. Thank you so much, Katie. Um, and then I'll send in the we back on there as well. So, um, if you speak a lot and then you able to get your sides not there. Ok. And thank you very much. No problem. I can hang around for a minute or two if anyone has any questions. Thank you. Ok. No problem. Bye. Yeah, I can. But um, thank you very much and I've got your sides and I put on the thing. So that's good. Thank you.