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Hello, good evening, everyone. Welcome back to our session. Five of plap two mindedly run by, um, run by us, a group of junior doctors in the UK. I would like to just quickly introduce myself. My name is Dennis. I'm one of the fy ones currently working in Queen Hospital as one of the IM GS and um, I've recently passed plat not too long ago, so I was quite fortunate to pass every station. So, uh, hence I feel that I would need to share the tips with everyone and just guide everyone through what Plav is about. And tonight I've got my team with me. Um, would you like to introduce yourself everyone? Hello, everybody. My name is Anthony. I'm an F two based at the Royal London Hospital. Um, I did my pla exams in 2021 and 22 so not too long ago. Um, so hopefully I'll be able to help you guys out a bit if I can. Um, otherwise I'm just excited to be here. So I hope it's a good session. Hi, everyone. My name is Rajni and I'm the F one, stepping in hospital in Stockport. I did my pla exam early last year. Um, and I did it without attending an academy. So, just by self study. So, sessions, like these are really helpful because you don't have to pay for them. It's free and you're getting live feedback as to what improvements do you need. So, I'm glad you can join today. Mhm. So, I'm quite glad that we've got quite a small group tonight and it's just a few of us. So please please feel free to be a volunteer and we'll be, you'll receive feedback at the end of the session and I will be talking a bit of about the UK MLA and the PLP two transitions and I will move into a combined stations which seems to gain popularity nowadays and we've got a few tips around that, how to ace them just because of um how pe how ma how people find it tricky just because of the time constraint, given eight minutes and you have to perform so many things during the exam. So, um if you, for those who would like to volunteers, please do pop um in the group chat and we will sort it out for you. Um We've got Raza there as our moderator tonight. So I'm gonna start with um just a quick run through about what PLP and UK Mra is. I've spoken to a few people and they have very clear guidelines, the content map on the GMC website, which you can have a look. Literally, I've copied and pasted the entire thing from the, uh, for the GMC website. It's about, it's gonna be exactly the same thing, but it's just how they assess you will be different. So, it's the, it's gonna make more difference to the examiner than the candidates. You still have. You still have to be a junior doctors in the UK. You still have to, um, practice safely. You still have to finish the cases. It's gonna be eight minutes and there will be 16 stations. So everything is gonna be the same. So not to worry, I know a lot of people start to get a bit nervous about the transitioning and how it's gonna affect them. So um it's about readiness for safe practice, managing uncertainty such as um you have to manage unwell patients in Sin Men or you deliver person center. OK? So it's the three domains which you have practiced on and on about history, taking management and interpersonal skills. So it's still gonna be the three main domains and this is the MLA content maps in the six domains. It's nothing new. And every university in the UK now would have to follow this content map. And even though um for their own os, they are run differently in each university. So they just have to follow the content map like what used to do. So it's nothing new. So not to worry and we'll carry on with our combined stations tonight and normally for combined stations. Um I think we've got a few, sorry, I think we've got a few new candidates who joined us tonight. So I'm gonna run through. Um, the first very important bits of tips that I find useful during the exams first would be read the prompt again and again during the one minute 30 seconds prep and secondly, try to be empathetic towards the patients not to write, not to say the same things over and over again. This is what a lot of people struggle with. When they go to an academy, they will get, they were given a, a few script to memorize and then they sort of like regurgitate every single bit from that script alone. So you will be saying, I'm sorry whenever the patient say that in pain, you will be saying thank you. Whenever the patient tell you something or you go in there always ask them. Can I ask you the question? So you don't have to do that. You just have to be yourself and practice the cases. So let's focus on the combined stations tonight, combined stations for the prom itself. You will see, please talk to the patients, take a focused history. What would be the most important bit is take focused history. I don't want you to spend too much time asking unnecessary questions because you have got only roughly 2 to 3 minutes to gather the history to roughly know what's going on and then you have to move on to doing the examinations or doing the procedure. So let's only take focused history and in terms of focused history, what you can ask is just presenting complaints and most importantly is just to ask them, um how can I help you? I've got pain. So do a quick pain run through the sots but not to ask anything else for do a quick differential diagnosis as well. Ask about the red flag that you're worried about any weight loss or anything that you feel is warranted. Uh question. So if social history is not important, don't ask it this. If do if you think smoking is not relevant to the case, which you are doing, you don't have to ask. So past medical history is important because sometimes they will have some hint in it and for examinations. Um if you've got roughly about 2 to 3 minutes to ask to do the focus history, then you have to move on. Even though if you feel like you've missed a few questions, that's fine. So in terms of examinations, um during the exam itself, you will have a mannequin set at the site and you will have the cat, you have that simulator or the patients there to talk to you. What most people struggle is with is you didn't talk to the patients. So you will lose points in interpersonal skill. So examinations before you do any examinations, even in real life or be it in an ay stations, you have to explain to them what you're gonna do. Mister Smith. I'm just gonna do a quick examinations on you if this, ok, I'm gonna examine, I'm gonna examine um, your foot, for example, I'm, I'm gonna examine your breast and you give them a brief history of what you're gonna do. Like I'm gonna have a look, have a few and have a listen if it's auscultations is needed and then you need to give them some privacy. Um I'll give you some privacy for you to get changed, but normally the patient will have already get changed anyway. So you look at the patients while you're talking and then while you move on to the man because they will be at the site where you have to perform them. But keep looking at the patients to check if they are. All right. So just say some just say like I will get a chaperone here with me or just to ensure your privacy or just get a chaperone over here with me today. Is that all right with you? The consent is very important. So, ok, always ask a quick question. Is that all right with you? So let's begin. Just say, oh, so I'm just gonna perform the examinations. Now, I'm gonna expose you and you can do the rest bits of examinations like inspection, palpation, percussion auscultations again, only do the necessary examinations if auscultations is not needed. For example, if it's a breast examinations, you only need inspection, you don't have to tell the examiner what you're doing. So it's more important to get the patients involved in your examinations. Just say, is there any pain? Is there? All right. So keep checking with them and always, always just talk to them, see uh what the findings are and you have to explain it to them rather than examiners. I know os in some countries, for example, where I was trained, you have to talk to the examiner, tell we have to run them through what you're gonna do. But that's not the case in part two. So in part two, talk to the patients so that you can get that interpersonal skill in. I know it's quite nerve wracking. You've got eight minutes to run everything through. So just keep practicing if you and go in, if you have got an academy that you normally go to go to the academy practice with a study partner and run through every single bit of examinations, which I will talk about later and then you move on. Ok. So about four minutes, I would say it's sufficient for you to do any examinations or procedure that you want to do. Even if you don't try to finish it when the, when, when the ring comes out. So when it's like two minutes remaining, when you hear that, try to wrap it up as quickly as you could because management still cost you four points. So for management as a junior doctors anyway, we're not coming out with some brilliant management. We normally just do a quick symptomatic management, painkillers, give them antiemetics, give them fluids and then you have to decide whether you admit them or not. You can always assess the red flags. Ask them even when you want to admit them, just tell them, we'll have to admit you for further investigations. Is that all right? And then you have to speak to a senior. So you don't have to spend too much time on management. You just have to explain to them what your examination was and what you thought the diagnosis was and then you treat them symptomatically and meet them or speak to a senior and that's all. So in terms of examinations, oh, these are the things that I was talking about. So explain it to them getting consent chaperone, ask if there's any pain, always start with us. If there's any pain so that you don't want like a testicular torsion. You don't want to just go in and start squeezing, then that's not very nice and you're not gonna pass. So explain the findings while you can run them through while you were doing it. Just gonna have a feel of your tummy. Is there any pain over here, sir? That so, so you don't actually would need to spend too much time even for inspection. Just I'm just gonna have a quick look at your tummy. So for a surgery case based, you can ask them if they have had previous surgeries for that, you can look for scars, you can look, look for any skin changes and things like that. And these are the examinations part of the exams where they will come through as a combined stations will be procedures such as be dissection, taking bloods, um paracetamol overdose cannulations, ABG catheterizations. And I've got previous uh candidates who ask me, how are they running these kind of things? So they will come in. Patient has got pain. Please do take blood from the patients but you still have to go into the stations, sit down, speak to the patients, take a focused history and then say um for this purpose, Mr Smith, I will need to take some blood from you. If that's all right, if you, it's a blood culture, you can say we need to take something called a blood culture just to see if grow any bugs in it. Normally patient will come in with a fever. So your focus history should focus around identifying the source of infection. If you could any cough, any burning sensation in the urine, just try to identify the source of the infection. And abdominal exam is quite a popular one. And most I would say all of them are surgical case basis. So you just have to know uh if you get an abdominal exam, just know where the pain is. And it's that there's a little tip there. Um, if it's acute cholecystitis, you know, the very typical sign and normally prep two exam is not here to trick you. It's quite a simple exam. They will give you the most typical sign. So if it's tender, a patient will tell you it's very tender on the right upper quadrant doctor. And then you, you roughly know what it is even if you don't, you can always say you can be honest with them. If it's uh some of the cases, which is, which is quite unclear, you can be honest with them. Um um So at the end of the cases when during management time, so I've examined your abdomen, Mister Smith, and you've got a little bit of um tenderness on your right upper quadrant or your epi gas or your upper abdomen. But unfortunately, I'm not too sure. So what it is, but I will find out for you. We need to do further investigation. They will not fail you just because you don't know the diagnosis. But if you can do the rest of the case as well, you will still get a pass like you still get an eight or a nine because just because you did a good interpersonal skill, you did a good history taking, but you lose some points on management. But if you manage them symptomatically, there's no reason why they will fail you in that stations, you can always be honest with them rather than just guessing any random diagnosis I would say so. Just say, unfortunately, I don't know what it is, but we need to do more investigations or possibly a scan to find out what could be happening. And I will speak to my seniors and that's so just be honest with them and I'm sure the examiner will appreciate it as well because as a junior doctors, patients come in with abdominal pain, I would say eight out of 10 cases, you don't know what the exact causes is. So you can just do the basic, always do the basic and that's enough. And the next one will be breast examinations, which is rather popular nowadays and testicular exams. And these two, I would say they would take quite a lot of time like otoscope and ophthalmoscope. So what I would suggest is when you go to the academy try to play around with the instrument that they have got the ophthalmoscope or the otoscope. And normally in an academy, they have got the exact similar model or if not um similar ones to the one that you're using during the exam. So make sure you familiarize yourself with, with how to use them so that you won't panic during exam. Oh, no. How do I turn it on? Like I've seen candidates who struggle during the exam and they, they were nervous, they don't know, they forgot how to turn it on. So it will waste a lot of time while you're trying to f, fiddle around with the instruments and the Antenatal exam as well. But they're not, I haven't seen them for a few months now, actually for quite some time. So for examinations do focus on the first beat of this. I would, I would advise you. So, anything that you want to add team? Um, no, I think you covered pretty much everything that is. Ok, cool. So who is the volunteers for tonight's case? Mhm Is it so the first case, would it Patricia? Would you, would you want to be the volunteers or we've got someone who asked, do we start by asking open questions? You always start by asking open questions. So you go in and say how can I help you today or you can just what brought you into the hospital? That will be the same in any case I would say just because most of the can most of the stimulators, most of the patients would tell you what they're in, they're not there to torture you. So they will give you a lot of information. If you're nice to them, they'll give you more information than they're supposed to be anyway. So who want, who would like to be the volunteers? Um Patricia? Ok. Uh Rosas, do you mind adding um Patricia onto the stage, please? Uh Of course. One second. Yes. Yes. You're in the stage now, Patricia, I believe. Uh, hi, Doctor. Uh, and you see me? Hi. Hello. Hello. Hello. Ok. So for those who have not attended the session, attended session, um, we will use this, um, pr which is exactly the same during the examinations you will hear. Um, you'll be given to you. You, you, um, I can hear you twice. Is it an echo from me? Is it better though? Ok. Sounds better though. So you will be given one minute 30 seconds to read the pro. I think it's the echo coming from Patricia. The echo coming from? Oh, ok. Hello. Hello? OK. I think, can you still hear my? I can hear my echo. Yes. Unfortunately, on my own, on my own. Um um Patricia, can you mute yourself for a second? Mute yourself for a second? OK. All right. Let's test it out. I think you'll be OK though. Uh I think the echo is coming from Patricia speaker. Is that right? Yeah. Yeah. Sounds like it. OK. Then maybe I can try to join again. Yeah, let's try that. OK. So let me, um Patricia has joined our session before, but let me just have a quick run through of how our scenario works. So you'll be given one minute, 30 seconds to read the pro. I want you to utilize it. Try to formulate what questions you want to ask what you want to do in terms of examinations. I want you to talk to the patient. So, talk to our moderator tonight. What you are gonna do and you don't actually have to do it. But in your mind, I want you to run through what you are, what you are doing? Hi. Hello. Is it still sounding weird? Yeah. Yeah. Um, yeah, it's still, it still echo. Oh, have you got an ear that you, that you? Yes. Um, uh, but, um, I need to go and pick them up so maybe someone else take the first case and then I'll do the second one. Yeah, of course, of course. Yeah, let's do that. Thank you. Let's do. Sorry about that. Sorry about the technique issue just now. Can I put you? I'm gonna invite you to stage if that's all right? Ok. Are you happy to start first? I know you wanted the second case but just yeah, I have perfect. Thank you. So are you familiar with how we are gonna run the cases tonight? Are you quite happy? Yeah. Ok. So you'll be given one minute 30 seconds. Um Yeah. Are you ready? Yeah. Yeah, again? Ok. So yeah, enter the room. Hello. I'm one of the doctors in the emergency department today. I am Missus Smith. Yes. Hi doctor. Yes, I am Peter Smith. Right. Uh Could you please confirm your date of birth for me? Uh My date, I'm 30 years old. Ok. All right. All right, Mister Smith. Um Could I see that you're here with the pain in tummy. Yeah, that's right. Could you please tell me more about this pain? Um, I've just got this pain in my tummy, which started like a couple of days ago. Mhm. And, uh, where exactly is it? It's just in my whole, whole abdomen, whole tummy. It's just very painful. Ok. Ok. Um, can I ask how did it first start? It just, just appeared on its own. Mhm. Just a couple of days ago. Ok. It, uh, just, uh, it started suddenly and it's the whole of the tummy. Um, how's the pain? Is it, uh, you know, sharp or it's like dull and it's kinda like colicky? Ok. That's so right. Uh, have you noticed anything which was increasing the pain or something? No. No, it's just, nothing is nothing. It's, it's just there and nothing is sort of, um, increasing the pain. Ok. Uh, have you noticed something which was relieving it, you know, like when you were sitting or while you were laying, lying down? Uh, no, no, it's just constantly there. Oh, gosh. Um, so have you noticed any other symptoms along with the pain, you know, like vomiting or, you know, changes with your bowel? Um, yes, I've been vomiting since yesterday. Oh, that's fine. Mhm. But I'm not having any bowel changes because I'm not opened my bowels. Ok. Um, do you feel that that means you're feeling a bit constipated at the moment, is it? Yeah, I would say so, yeah. Right. Ok. Um, are you running any temperatures by any chance, do you feel chills or? No? No. Ok. It's all right. Uh, I, uh, how many times if I may ask, you know, how many times have you vomited since the pain? I think that 4 to 5 times yesterday, since yesterday it's bad. Ok. Um, so, you know, just a background check with your, uh, medical, you know how you're doing before this? Did you ever have this pain or was this the first time? This is the first time doctor, right? Ok. Uh, so have you noticed any changes with your weight? Uh No, no. Ok. Any lumps or bumps anywhere else have you? No, not that I've noticed. No, by any chance have you hurt yourself? I mean, you know, like falling or no. Absolutely not. No, that's ok. Ok. Um, was there anything, I mean, have you noticed if the food is triggered any outside food or if you did eat? No, I just ate my dinner at home. II don't usually eat outside? Ok. That's all right. Um, and so you said this is the first time, you know, a couple, uh, please bear with me while this, you know, you know, background check may have an impact on this. So do by any chance is there any long term medical conditions with you that I should be aware of? Um, no. Ok. II mean, you know, I'm 30 years old, I'm quite fit. No, that's good. That's good to know that you are fit and healthy, but not that. Um, uh, so right now the Smith, you know, what are you more worried about? It's just this pain or the pain vomiting? Yeah. Right. And the fact that I feel very, very cause I'm not open the bowels and just feel it's just so uncomfortable. Uneasy. Yeah. Yeah. Like that. Yeah. Have you had any thoughts about what's all going on regarding this? No. Is that ok? It's all right. Uh So since you're on the pain, if I may ask, could you please score the pain for me? Say zero being the least and 10 being the highest, I think it's around like four or five, I would say. Ok, 45. Ok. Um So since you're in pain, have you had any issues with um, you know, breathing and difficulty because you know, you feel a bit. No doctor? No. Ok. Right. Uh Is it ok if I go on to examine you by which I mean, you know, I may 1st I'll do a couple of numbers by checking your BP, your heart rate, your respiratory and of course, record your temperature or the just to see if everything is ok there. And also I may have to feel your tummy, just look, feel and it is, if there is something going on, I'll listen to your bowel sounds. That's ok. I may have to, you know, just expose you with the belly to see what's going on and I would have a chaperone with me. Is that, that's fine. That's fine doctor. Yeah, I'll give you the findings now. So on examination, the abdomen is distended. It's tympanic sound on percussion of the abdomen due to air free stomach and high pitch bowel sounds. All right. Um uh Thank you Mister Smith for letting me examining you. Um, it looks like, you know, there is quite an acute thing and by which, I mean, there's, there is tenderness in the abdomen and it looks like something emergency and uh we may have to admit you at this point. What do you mean by emergency doctor? What's, what's going on? Uh So right, um, you feel your stomach, you mentioned that this feeling constipated and your it's but uh, you know, the stomach looks bulging and you did, you know, come up with a couple of times, I'm suspecting there is something called as acute pancreatitis going on with you, but I'm not uh convinced at this point. Um So this is something which we need to worry about. Are you still with me, MS Smith? Yes, doctor I am. I'm just trying to understand what's going on. That's all two remain. Uh So at this point, the, the reason I wanted to admit you was to see what's going on with you by which I'll be doing a couple of blood tests while you're here and, uh, you know, I might involve my team, my colleague to see, uh, you know, help understand um, with your symptoms. But meanwhile, I would give you a painkiller and since you vomited a couple of times and, um, we may give you an antiemetic, I mean, to control the sickness. Ok. Doctor. Thank you so much. Um All right, at this point, have you any questions or are you expert? No, I don't have any questions, doctor. Thank you. Thank you. I would just ii suppose I'll get admitted tonight. That's all right. I mean, I would, I would suggest if that's ok. So is there anyone else with you? I mean, yeah, my girlfriend is here with me. Ok. That's good. Good to have someone around when especially, you know, you're getting to the hospital. So, um, while we go through this, I could just run through your lifestyle if that's ok because there are certain things which can affect your present situation. Yeah, of course, while, while we are waiting for the ambulance. Ok. Yeah. So can I ask if you smoke or if you drink alcohol? Um, yeah, I smoke around 20. I would say like a couple of packs 20 cigarettes. Ok. Uh, that's a lot. And have you had any thoughts about cutting this down? Uh, not at this moment. I've got a very stressful job doctor. So it, that's what really keeps me going. So I have, I have no intention of quitting at the moment. Right. We can talk about this and going forward. Uh Do you also drink? Uh Smith? Um Yes, I do. Yeah. Ok. And how, how much do you drink? I would say like between 5 to 10 pints a day comes up. So how did you feel about the case? How, how you did? I think I rushed to the management without taking the psychosocial history because I was just focused. I need to get to the management. Yeah. Oh, but you did finish. You did finish. I mean, you did technically get to the management but I will give more time during the exams for you to actually walk to where they put the Manikin and actually perform the examinations because you can't rush through the examine, you can't rush through the examinations. But how about our patients? How do you feel how these doctors, how's the consultations gone? Do you feel like if you listen to um OK, I'll start with the positive first. But you were very attentive. You were polite in the way you spoke to the patient made you asked open ended questions, you gave me opportunity to answer. It was not just yes and no, which is really good. Um You forgot about lifestyle, but you went back to it in the end. So it still counts. Um Only thing I would say is in terms of your history, just think of it being a tiny bit more organized in terms of asking about all the pain related history, think of an acronym, which you find you'll be able to remember in the exam start when you start with the pain, start with, where is the pain? When did the pain start? Um Are you taking any pain relief? Is it helping? What are the symptoms which you obviously asked already? And then you can, is the pain radiating because that's gonna help you with the differentials as well. If the pain is radiating somewhere, it might. Yeah, but it's fine. I mean, obviously this was the first time practicing. Um but apart from that, yeah, I would say um it doesn't matter that you didn't, you didn't reach diagnosis. That's just one part of it. But collectively your communication skills were great, interpersonal skills were great. You asked lots of questions. II imagine that is, would you agree there lots of check, check check you did achieve? Yeah. But what do you think the diagnosis was based on these findings that you can see on the screen? I just thought it was an acute abdomen but I don't know what the tympanic sound could be. Um Maybe I, when she said uh when um doctor said colicky pain, I'm not sure about the diagnosis. There are lots of things going on in my mind. Sorry about that. Yeah, it's all right. Acute abdomen. What would be the very classical sign you will see quite a lot if you're working in surgical, um, pain, tender, everywhere, generalized pain, all over vomiting, no opening gout, so, obstruction, all right. So acute abdomen, you are, there is acute abdomen is correct. But for pancreatitis kind of pain, it will be more epigastric and it will, will radiate to the back. Sort of like we normally very dry patients who present very dry and the causes, I mean, so for acute abdomen, you, you've got, you've always need to give the painkillers, um, and you have to decompress them. That will be the most important management, but you have to confirm it first. Ok. But I like how you actually, you, you've done, um, like you've done, um, quite a good history taking. But if not, I would say you spent a bit too much time on it, I will take a even more focused history. So, pain, I've got pain, focus on pain. You finished pain, any other symptoms? I've got bowel, I've, I hope I haven't opened my bowels. I've got vomiting. So, how long has it been? That's it? Not too many questions. Move on to past medical history. Um, what other medical history do you have? Do you take medications? That's it done? So you could do a quick ice to get your interpersonal viewpoint in. Have you had any ideas what this can be drop down? So, always go back to the examinations because during the exams, you actually need to spend time examining the patients. I know this virtual scenarios is not the most ideal, but spending time examining the patients will also score you interpersonal skill because you'll be talking to the patients at the same time telling them what you're doing and you have to guide them through what it, what it can be and you have to, you did reassure them. So I think you did very well on interpersonal skill and history taking. But you just have to be a bit more confident in your diagnosis. If you think what that is, it is what it is because you've practiced enough and I'm sure you have done enough cases to know what could be the diagnosis. It's not the end of the world if you don't come to the diagnosis anyway. All right. Um Can I ask one question? So, uh here, I, although I said acute abdomen, then I went on to say acute pancreatitis, would I lose a mark because technically it was not pancreatis and it is an obstruction case. Um You, you would, if, if you got the management, like I've mentioned, like I said previously, if you got all the management, right, even though you've got the wrong diagnosis, diagnostic can penalize you based on that? It's still an acute abdomen, but um you will not score very high or you'll be sort of like borderline because uh in terms of history taking, you will have gotten the more ideas of what it is based on the history taking. So they will cost you some points of history taking and your management as well because you haven't decompressed and you're not going to decompress and if it's the pancreatitis, is it? Yeah. Yeah. Also I wanted to add one other point because there was acute abor tender and I did not want, I wanted to advise the patient that she, she shouldn't be taking anything orally. And, uh, I want, we would put her on IV fluids. That's the reason we wanted to admit her. Yes. Yes. Oh, you know, the management, you've, you know, the management. So that's no problem. Uh I'm very confident in the, during the exam, I'm very confident that if you got the diagnosis right, you will get the management. It's about the confidence coming to make a decision of what you think the diagnosis is. Ok? Ok. Thank you. All right. No problem. Thank you. Right. Second case actually hang on. I had a few, I took some notes down. Um, at one point, sorry if I'm not trying to be mean. Um You said you said words like antiemetic and acute pancreatitis and you didn't actually explain them, I think, yeah, I think you need to use more layman's terms or, you know, just like, even if you use these words, just explain yourself a little bit. And when the patient said that they smoked, I think 20 cigarettes a day, you said that's a lot. Um, maybe keep back to yourself. Um, just fine. Honestly, you did really? Well, it's just, that was one thing that I noticed. Um, you were a bit nervous, weren't you? Um, yeah. Was that everyone's nervous? Don't worry about it. We, it's fine. I was, I was so nervous during my exam. Um, but I think if you practice the, um, order like the sequence of, um, uh, things to us during the history, um, it will just come more naturally because you don't have to think about it. You'll like, it'll come. Um because it felt a bit disorganized because like you, right, like you asked about, I think you forgot to ask about family history. Did you ask? I might have, no, I did not. No, II just thought to rush to the examination and then probably that's where i it, it is a matter of time management, but also felt a bit disorganized, but like your practice just makes perfect, I guess. Um And then at one point, you did ask some leading questions for an example, the character of the pain you asked, is it dollar sharp? How does it feel? Um I think you could have just said, how could make relevant? What, like you could make an open question and be like, what did you feel was the like, how would you describe the character of your pain? And then if they couldn't answer, you could give them a few examples. But now immediately the patient is thinking is it do or is it shop? You know? Yeah, but you did really well, honestly, really good. Uh Thank you. I just get a lot of, you know, I start with my open ended question and then get back to the co with just becoming great. And that's what I think about my struct is, yeah, that's, it's just practicing will make it better, but honestly, you great. Just keep trying. Thank you so much for the feedback. I mean, it was very valuable and one more question since you mentioned about the smoking, uh should we reflect then and there about the smoking or can we just say that we uh we can come on to that but let that's such a good question, right? Um The thing is that is correct me if I'm wrong. Um And even regin smoking is like the patients in an acute emergency case. Should we reflect on the, how should we be going? Like i it's been some time. I might remember counseling if it's counseling. Yes, certainly. If it's combined stations, you don't have time to move on. Yeah. Yeah, you can just mention in the end cause you always mention the plan to the patient in the end. So you say to them um uh what you have right now is something, it's an emergency. We'll do, we'll give you, we'll give you some IV fluids. We, we put an NG tube down your nose to decompress your stomach. We're gonna give you some pain relief. And you mentioned about that you smoke so, so many cigarettes. That is something obviously, we would like to have a discussion with you because we've got a very good team here who can tell help you suffer with quitting smoking. If you just throw it there, then you've acknowledged patients smoking problem and you acknowledge that in ideal scenario, you would deal with it because you only got 10 minutes. You can't do it now, which we do it day in, day out when you know, practice, we say, ok, um Have you considered quitting? They say, oh, well, not at the moment. Ok, that's something we can discuss later and then we make a referral and there's some care team, whatever team we have, they come back and you know, see the patient, but it's good to acknowledge because you acknowledge something a lifestyle modification that needed, especially in this patient, smoking is kind of like a respective or um uh what this patient presents with, um which is the bowel obstruction. So it's definitely something that you would need to very, just very, very, very briefly because you don't want to waste too much time. It's not a counseling. I said the station is about completely different thing. So just acknowledging that you probably just get your, your check box tick box that you need. And also I feel like it might be safer to just not give a diagnosis if you're not very sure and keep it vague instead of going a pan, just, you know, better to be sort of right than completely wrong. You can always say in the end, I'm not quite sure what's going on, but you can give them like a generic management. Even if you don't know any abdominal pain, it's always safe to keep the nil bem out and just say we're just going to keep the nil bem out for now. And I'm going to get help from a senior doctors who might be able to help you reach a diagnosis here and just say we might be order some imaging and just leave it there. It could, it could be x-ray, it could be CT scan, which in that sense, you have acknowledged that you're a safe doctor. You will ask the senior help when you don't know what the diagnosis is, but you still know the basic management for acute abdomen. That that's because I've had this scenario, but I didn't know what the diagnosis was. But I just said, well, I will do this, this, this and I will get a senior help, a senior involved and that was in a past that station. So yeah, I feel like it's really important to understand that you're not expected to know everything you're supposed to work at the level of an F two. I'm an F two. I don't know what I'm doing half the time. Um You're supposed to ask for help. That's why there are grades in training. So it's fine to not know they're looking for safe doctors more than anything. To be honest, they, you would rather fail if you didn't say I would involve a senior for advice or for a senior review than to say I will involve them. Great. Thank you so much for your feedback. Really helpful. Thank you. Thank you. Thank you very much. So we'll move on to the second case. Um Patricia, are you ready? Do you uh Rosas? Do you mind just inviting her onto the stage, please? I did um de hello. Uh we can't hear you. Um What about now? Yep, perfect. It sounds good. Yeah. Yeah. Ok, good. Ok, cool. Yeah. Right. Are you ready? Yeah. Yeah, that's fine. Let me just get the timer ready. So it's 1.5 minutes uh for examinations. Try to talk us through what you're gonna do like for not us. I mean to the patients. Ok. Again, see, thanks. Thanks into the room. All right. Um um Patricia, my ac number is 12345. Hello. Hello. Hello, I'm Patricia. I'm one of the unit doctors working in this department. Uh Can I confirm your name and age, please? Hi, my name is Martin Atkinson. I am a 60 year old. Ok, nice to meet you, Martin. How can we help you today? I've got a really bad tummy pain doctor. It's sort of up on my right side and it's really bothering me. Ok. So, um, Martin, I know this is very frustrating for you to be experiencing these symptoms. But, uh, you did very well to come to see us and we're here to help you. Um, are you in, um, is it ok for you to talk? Yeah, I'm happy to answer some questions. Ok. That's good. Uh, so could you tell me a little bit more about this pain? This, um, I don't know. It's just, it's, it's on my right hand side, um, up on top and it started, I wanna say this morning. Ok. It's just, uh, yeah, I don't know what it is. Ok. Were you doing anything with it when it started? It kind of, it just kind of started, it just showed up. It wasn't doing anything. Ok. The pain is always there or comes and goes in waves. It's kind of always there. Yeah, it's like that. Ok, since it started. Do you feel like it's getting worse? Yes. And is it going somewhere else? No, it's not really traveling anywhere. It's just kind of there. Ok. Um, and, um, is, is there anything that makes it better? Nothing's made it better? No. Ok. Anything that makes it worse? Yeah, I feel like it gets worse when I try to take a deep breath. Ok. Ok. Um, have you taken anything for this pain? No, I haven't tried any. Ok. Um, and uh, if you have to score your pain from 1 to 10 being one, the lowest pain and then the worst pain you ever felt. How would you score it? An eight or a nine? It's quite bad. And, yeah. Oh, I, I'm, I'm, I'm sorry. Um, I know, like I said, frustrating but we're here to help you just bear with me. Um, and any other symptom apart from this pain, I don't know. What kind of symptoms are you thinking of? Doctor? Um, um, have fever. Um, yeah. Yeah, I think, II don't know, II haven't measured my temperature but I've been feeling a bit hot and cold. Ok, since, uh, this morning. Oh, yeah. Ok. Um, apart from this, any other symptom, no, that's it. That's it. Ok. Nausea, vomiting. No, not really. No. Ok. Um, and, uh, just, um, another question is, um, do you have any medical conditions by any chance? No, I'm fit and, well, I'm a six year old, nine year old. Ok. And, um, do you have any idea yourself what could be the cause of this pain? I have no idea. That's what. Yeah. Yeah. So, um, Martin, if it's ok for you, I would like to examine you. Yeah. Yeah. So, um, so we are going to take some bedside tests, uh, that will include your BP, your breathing rate, oxygen temperature. Uh, and we also going to take, um, um, I would like to, sorry, I would like to examine, uh, your chest. We have a listen to your heart and your lungs. Uh, but mainly I would like to, uh, have a feel on your tummy if that's all right. Yeah. Ok. So, what I'm going to do is, um, well, we're, you know, um, sorry, uh, so we are going to, uh, we need to expose your, your tummy all the way to the, uh, just below your chest. Uh, And uh I will have a chaperone with me and I will try to be very gentle if there's any pain at all. Please let me know. OK. Is that ok for you, Martin? Yeah, that's great. Thank you. Uh So first I will start with having a look. Um And um if there's any changes in color or uh any changes in the shape or uh um anything that could be visible, uh then I will proceed with uh with gentle palpation like, and I would try to start away from the uh right side, which is the painful area. Um Sorry. Is that ok? Sorry. That's great. Yeah. Yeah. Uh And then um if the patient tolerates, uh I will slowly go down to the uh painful area. Uh And then I would do a little bit of deeper palpation um and I will do it um clockwise uh and trying to keep that system uh with a superficial part patient and then with the t out patient. Oh, sorry. It's just I feel like I'm just a kid in my brain. Um And then, uh I would like to ask what date as well. Oh. Mm. And I would like to do a special test. Um, so Ma uh Martin, I will have to palpate very deep um, on the right side where the pain is. Uh, but I need you to take a big deep breath. Uh, and then, um, if it's unbearable, just let me know. Yes. Uh And then I will proceed with my special test. All right. Uh And then I two minutes remaining just one second. Um So Martin just bear with me one second. Um ok. Um Martin, I would also like to do some more um some um like initial blood test uh just to have a check on your uh cell count. Look for any signs of uh anemia, uh inflammation or signs of infection. I will also have a li uh I would like to see um your kidney function, liver function, uh have a look in your uh sugar levels. Uh I will also would like to do a urine test. Yeah, I care for you. Uh And uh yeah. So do you have any idea what might be wrong with me, doctor? Um And uh this is a very bad concern. So, Martin, from what we have done so far and why we have discussed it seems to me that you are having um an infection. Uh My impression is that it might be related. Um Well, I know it might be with the A but, um, uh I'm, I'm thinking about a sort of infection that it comes from the urinary, uh uh from um urinary in a urinary infection. Um, so, but we need to run further test uh to begin, uh get to the right diagnosis. Um uh How does it sound to you, Martin? That sounds great. Thank you. Ok. So what I would like to do is uh if you are happy, uh we would like to admit you to keep up with us for a little bit. Uh We would like to observe you keep uh checking your vitals. Uh well, your BP and temperature mainly. We're also going to thank you. Done. Thank you. Mhm. Thank you. So how do you feel? II don't wanna start with asking you. Yes. Yeah, that's ok. It's uh I think I got a bit confused online. I think it's not it and, and how to explain my uh abdomen examination. Uh ignore that with it. I think it was hard to imagine that I was doing it and then explaining to the patient at the same time. Um So maybe uh yes, I do need more practice with that. Uh how to explain to the pain like every step of the way without sound too doctor. Yes. Mhm. Ok. Yeah. And also diagnosed as well. Um Do you wanna carry on? Yeah. Oh, you are a very kind doctor. Um, I first listened to, um, I don't think you covered all of the history. Um, I don't think you did all of the Socrates. I wanted to tell you my pain was sharp but I didn't get a chance to. Um, and then in terms of all the other aspects of history taking, I'm not sure how you got to the UTI because, you know, you got my urine. Yeah, I was thinking of that like, oh, yeah. And also if I tell you that the breathing gets difficult when I take like it, the breathing makes it worse. Um, I think you need to sort of narrow down your differentials a bit. Are we thinking abdomen? Are we thinking like pe, it's not a pe but I feel like it might have helped to like just rule that out a bit. Mhm. Um, I don't think you asked me for any allergies, regular medications. You did ask me for any medical conditions. Um, you didn't ask me for family history or if I smoke or drink how my diet is. I don't think you asked me. Did you ask me about my bowels? I'm not sure if you did. Uh mm Yeah. Um And then when it came to the examination, I'm not sure you need to go so far in depth saying, you know, uh superficial palpation, deep palpa, you can just say I'm going to put my hand on your tummy and feel around a bit. Let me know if anything hurts and then just do your thing. I don't think you need to spend as much time on the examination because this wasn't an examination station. It was a history taking, uh, station. Um, I think that's all I can think of right now. But I'll get back to you. Right. Um, so, yeah, sorry, it's supposed to be a focus. Uh, so, so it's supposed to be a combined station. Sorry, I didn't make that quite clear. So if it's a combined stations, you did the right thing. Focus history of you've asked enough history. But um how do you come? You started very strong. I would say you started the case. Very strong. You're very confident in your pain, taking history like your Socrates, you move on really well, very confidently move on and you've got um but on the examination part, I think that's the point where you don't know what you want to, to what, what do you want to explain to the patients? Like when I say talk to the, talk to the patients about your examinations, I would just a simple one. I'm gonna have a look at your tummy. I'm gonna have a quick few and let me know if there's any pain. So when you are laying your hands on the tummy, just do a palpations like what you do, you don't have to explain to them, but you can let them know, let me know if there's any pain or just ask them quickly. Is there any pain when I press on here? So you don't have to explain to them what superficial palpation is what the palpation is. You will be essentially wasting too much time. And that's the reason why you didn't come to the management be. But if you shorten that bit out, you will have about one or two minutes. I was looking at the timer, you will have about one or two minutes, which is very comfortable for you to finish your management. But again, coming to coming to diagnosis, a lot of people struggle with that because under exam pressure, especially uh also like session like this where you have to perform in the crowd in public. So you will struggle with. What diagnosis can it be? And then you would, because sometimes due due to pressure, you will, you feel obligated to come up with a diagnosis and you would just guess. So it's not gonna help if you come up with a completely wrong um different diagnosis. But if it's similar, that's fine. So like I've mentioned in the first part of teaching, we it's fine to be completely honest with them. And in this case, you did well by doing urine dip because abdominal pain, you need a urine dip test. This is the most basic one where even a lot of F one F two nowadays don't even request for or look at it when um, patients present with abdominal pain. So I think you did very well, but it's just about coming to diagnosis and get the management in at this, in this case itself, you didn't get any points for management because you didn't address who's got pain. Just painkiller, simple painkiller, you can request more scan, give some IV fluids, patients if it's nauseous. Uh, if, if patients vomiting normally in patients pre, if patients present it with cases that acute cholecystitis, you patient will be vomiting or have been very nauseous. So you could address those things and that's it. Very simple management and you'll be done. So it was two minutes maximum for management. I'd say will be enough. All right, but you've done, you've done well. I mean, I can see that confidence kicking, you've attended our previous session. I can actually see that confidence. You're very laid back, which would actually help, trust me, it would actually help do an exam. Like if you can do this during the exam, be laid back, be confident structure. You've got really structured history taking, which I think is a strong point. You started the case really. Well, you have left a good impression to the examiner, I would say. So that that was my impression when you started the case but you just sort of um sway a bit um towards the end of the stations. Alright, but carry on you did, you did, well, I do just wanna say, I agree with Dennis. You came across as very confident, which was very reassuring as a patient. So well done. Yeah, and very nice to the patients. You've, I've, I've, I, I'm quite happy to give you four points as interpersonal skill because you sound very sincere. You just don't, you won't you, you're not the kind of candidate who say I'm sorry every time. So you sound very sincere. That's what's different with. That's what makes you different from other candidates. Have you got anything to add Roney? Um Not specifically, I think you both got pretty much everything. You, you sounded very confident and you're quite empathetic towards the patient's pain. Uh Just a general um comment, it's nothing. So this both cases, this and the one before but for male patients. So if you get a female patient instead, always bear in mind, you will have to ask the gynecology history as well. So bear in mind you might be in an extra minute because you want to rule out all the gynecology causes as well. For pain. It is good. Is it P ID? Things like discharge and stuff. It's P ID thinking more like with menstrual cycle, things like that. It's always worth keeping in mind whether your patient is male or female because sometimes you forget when you start taking the history and you realize, oh, halfway through, it's actually a male patient or a female patient. So it, it's just worth keeping that in mind to give yourself a little bit more time. Uh, if, if you get a female patient exam with abdominal pains then your differential is widely changes as well. But, yeah, apart from that, um, yeah, it was, it was really good. Thank you very much. Thank you. Well done. Um, anyone else would like to volunteer for the next case? I was gonna ask Patricia again if she wanted to be here. Mhm. Would you like to? Uh, one second? Hi. Hi. Hello. Uh Yeah, I mean, it's really good. We can actually see you. We were actually talking about you at the beginning of our session. You, we can actually see you improving from session to session, which is brilliant. Thank you. Have we, I see two more people. Do they not want to volunteer with us? I did write in the comments section. They have not said anything to me, right? Ok. No worries. Um There's a problem. Uh There's a, there's a, there's a question I uh Vash said, ask if there's a problem. I think there is an infection in your gallbladder. That's it simple. No. So you don't just, you don't have to come up with very difficult term. Just explain in layman terms. It's not an M RCP exam, it's just a PAP two exam, right? So case three, let's get everything ready. Um Just before we begin, I was not actually planning on being um uh acting for this case. So II also have to remind that I am a plap examiner and I cannot actually give any feedback. I'm just being an actor for this session. That's all we've got the rest of us to give feedback. Don't worry. Thank you. Right begin again. This will be uh combined stations, hold on into the room. Um Doctor, my number is 12345. Hello. Hi. Hello, I'm Patricia. I'm one of the unit doctors working in this department. May I confirm your full name and age, please? My name is Rachel. Um, uh, I'm, I'm 45 years old. Ok. Uh, nice to meet you, Rachel. I can see that you are in pain. Um, is it ok for you to talk? I II can talk but I, I'm just in a lot of pain. I've taken some paracetamol but it hasn't helped. Ok. Ok. Uh, Rachel. Uh, I know this is very difficult for you and, uh, I try to be very quick but I need to ask you a few questions so I can be in a better position to help you. Uh, so if I'm correct, you came here with because of pain. Can you tell me? Could you tell me a little bit more about this? It started yesterday but it wasn't this bad. Um, it just gotten worse and worse overnight and this morning it just, it was, it was really bad. Ok. Uh, could you tell me, um, a little bit more about this pain. Like what? Oh, so you said I started yesterday. Uh, do you remember how this has started? Just suddenly? I was watching TV. Ok. And, uh, WW how could you describe the pain for me, please? Um, it's sharp. Ok. Uh, is he going somewhere else? It goes to my back weirdly. II don't know why. Ok. Uh, apart from your back, does it go somewhere else? No. anything that makes it better? No. Ok. Anything that makes it worse. No. Uh, come to think of it. If I lean forward a little bit, it actually feels a bit better. Ok. Ok. And, uh, is, um, well, I, II know it might be a little bit obvious but, uh, since he started to do things, it's getting worse. Yes, it got much worse than yesterday. Yeah. Uh, and, uh, if you could score your pain for me being zero, no pain. And then the worst pain you ever felt? How are you the worst pain I've ever felt? Ok. Uh, um, I'm sorry to hear this. Uh, but like I said, we're here to help you just bear with me a few more, um, moments. Uh, apart from this pain, do you feel anything else? No. Ok. Any fever? No, no, no. Ok. Any, uh, nausea, vomiting. I have been really nauseous but I haven't vomited. Ok. Uh, and it started with the pain. Yeah. Yeah. Um, uh, and anything else, um, very long thing, uh, feel shortness of breath. No. Ok. Um, so, um, uh, I would like to ask you a few more questions. Um, this, um, does your, uh, when was your last, uh, period, um, a week ago? Ok. And, um, have you had any problems, um, with your periods or they're always regular? Ok. Any discharges? No. Ok. That's good. Um, any, uh, problems with your urine. No, it's fine. No, it's ok. Uh, ok. Um, and, um, do you, um, uh, do you have any medical conditions by any chance? No, I haven't been diagnosed with anything. Ok. And apart from the painkillers that you mentioned that you take, uh, do you take any other medications? No. Ok. Uh, any other allergies? Uh, sorry, any allergies? Ok. That's ok. Um, I think that's what I'm gonna ask you right now. I don't want to, uh, um, disturb more. Um, is it ok, uh, for you, uh, basically if I examine you? Yeah. Ok. Yeah. So to God, I will try to be very, very careful. So, what I'm going to do is, uh, we are going to examine, uh, examine your abdomen. Um, well, first, sorry, we're gonna take your, uh, BP and breathing rate, temperature, oxygen, uh, level. And, uh, I would like to examine your abdomen and for this, um, I will ask a chaperone to be with me. Um, it, is that ok for you Rachel? That's, yeah. So, so I would like to, um, um, so we would need to expose you, uh, your tummy and, uh, I will try to be very gentle but I will need to palpate. Ok. Ok. Yep. Um, ok. And then I will to the examination. Ok. Yeah. Right. Oh, see, very well. So, um, very well. So, um, mm, do you have, um, well, uh, so we have done, uh, after this admission I would like to also do more investigations. Um. Mhm. So sorry. That is so two more minutes. Sorry. Carry on. Ok. Uh, I would like to do more investigations. Uh, so we, I would like to, um, order some blood tests to see, uh, for it to look for any signs of anemia to check, uh, for any signs of infection, inflammation, check your kid, kidney liver, uh function and um, and some inflammatory uh, in inflammation. In my case, we're gonna do a urine test as well if that's OK. A urine dipstick. Yeah. Ok. So, uh, Rachel, uh, from what we have done, uh, so far, what we have discussed on what we have done so far, it seems to me that, uh, what you, uh, have in this moment is, uh, something that requires admission. So we need to keep you today and it seems to be, um, some infection. Ok. All right. Yeah, the pain. That's fine. Mhm. So, um, we are going to admit you, uh, we are going to put, uh, a cannula. So we need to give you, uh, some medication to the drip, uh, mainly pain. Uh, well, sorry, we're gonna give you some painkillers. Ok. Ok. Yes. Um, we also need to do further investigations. Um, we need to do some imaging test, uh, so we can, uh, um, I better, I better figure out what's going on. Ok. Is that ok for you, Rachel? That's fine. Yeah. Yeah, I will also discuss this case with my senior. Uh And um thank you. Thank you. Thank you, Patricia. Were you, are you able to see the screen? Yes, I didn't ask you about jaundice, but I was seeing it. Ok, fine. I just wanted to make sure that you were seeing the screen. Fine. Perfect. Well, the uh the rest of the team can give you lovely feedback. Thank you. That was very nice. Yeah. Right. So what do you think the diagnosis is one? It's either hepatitis or? Yeah, exactly. How would you explain pictures what she has? Sorry, what, how would you explain? Oh, sorry. Well, how would you explain to the patients about the diagnosis? Um um I will say um that it is an in Well, I guess I would say II will do a simple, that's an infection. Oh, it seems to be um uh infection in your uh liver or in your pancreas. OK? With an elevated amylase. It's normally there's like 90% chance um it's pancreatitis. So um you've asked perfect pain, like focused pain history. You have rule out, um, pregnancy, you have ruled out urinary symptoms, which is brilliant. Uh, you have rule out all the red flags as well. So it's, I've got no problem with your history taking, but just towards the end again, be more confident in your, but I think you're very nice, very well. There's no problem with passing this case in general, but it's just about getting a better score. But I think you've done well. Um But you what you've OK, just a few important bits about pancreatitis is in terms of history, you will need to have some idea about the causes of it. Most common causes would be gallstone. That's why this case patient will have jaundice and you've requested additional scan, which is brilliant. Um alcohol will be important bit. So that's the social history that you have to ask during the focus history taking. And there's other medications if you have time, you need to ask any previous surgeries. So abdominal pain, you have to ask, um it's more, if it's a more surgical based cases, that's in general. If you are coming across a more surgical based cases, always ask about any previous surgeries because sometimes patients will represent with adhesions or patients who have had recent surgery will present themselves again with abdominal pain. So it's important to know sometimes they have got complications after this. So they will tell you, but in not in this case, but in general, sometimes they will tell you I've had a surgery last week. So you sort of have more idea what is happening. But again, you're confident you've got interpersonal skill, you do address what the patients, uh, what the patient's concerned about. And I think you've done well, well done, but always in pancreatitis give a lot and a lot of fluids, they are normally very dehydrated and they will need very strong painkillers as well. But like this case, the patient told you, I've had some paracetamol, so you can address this. I know you've had some paracetamol. It doesn't help with the pain. So I'm gonna start you on really strong painkillers to get the pain under control. I will give you some fluids with uh through the drip and then we'll look into what is the cause of the pain. But if you already know, just say I will order more scan, I will order some scans, some imaging to find out the cause of this uh pancreatitis. In terms of pancreatitis, you can explain as uh there can possibly an infection or an inflammation of the gland in your tummy. So, yeah, that's pretty much it. Any other comments. Um I thought you had great interpersonal ski. I really enjoy your history taking. You do really well. Um You used layman's terms this time around which was great and you came across as more confident and feel like your history was a bit more organized than the last case, which was good. Um Just as a fun fact, there is a mnemonic you can use for acute pancreatitis. You probably know this um get smashed. You could just like go through everything. Yeah, but I was happy with you just now. Thank you. All right. Any comments. Um No, I think you pretty much covered everything. Only one thing I would add is if it's acute pancreatitis, just make sure to add the ABG in the plan as well. Um That's all otherwise you covered covered everything. Your history was much, much better than before. And then uh you kept in mind that it's a female patient. Um It's just good to rule out the other things as well. Although some all the MRI is, is kind of like a giveaway is that was, was this Mr visible in the beginning? Sorry, I wasn't uh I wasn't sure. Yeah. Yeah. Yeah. So I mean uh it's not ideal but I've put it, put them all on the slide just so. Yeah. OK. It's fine. Yeah. But during exam again, you if you don't ask for them, you will, you're not going to get it. Yeah. Also and during the exam, there's another thing which I kind of like got caught out. So if you don't say what test you will do, they won't give the results. So you won't be able to move on to the next day. So you have to make sure you specify test you will be doing so they, they can give you the results with. Oh, ok. That's what the test. So then you could rule and do a lot of things. Yeah, I think a, a apart from that, yeah, it was, it was much better than the first one. Um, much, much improvement. Yeah. Sure. Thank you. All right. Then I think that's all our three cases tonight. Thank you very, very much for everyone who's attended the session and it's been a pleasure delivering all these sessions. If you need to refresh um, any previous, any other cases, you can always go back and watch again. Uh There are all, all the videos are on demand on metal. Um I think I've pretty much covered every bit of it and if you've got any questions, um you can get my email address. Um I would be happy to answer them for you. I'm just going to put it on the comment box below. There we go. Right. And thank you teams for organizing this and facilitating it. It's been very nice. Have a good evening everyone. Thank you very much. Thank you. Take care. Bye bye bye.